Journal of Community Health Voh 6, No.

2, Winter 1980

S T R A T E G I E S FOR E N H A N C I N G
PATIENT C O M P L I A N C E

Marshall H. Becker, Ph.D., M . P . H . , and

Lois A. Maiman, Ph.D.

ABSTRACT: Patient noncompliance is a substantial obstacle to the

achievement of therapeutic goals. This paper reviews a number of practical
interventions with demonstrated efficacy in enhancing patient adherence,
including (1) improving patients' levels of information concerning the
specifics of their regimens, reinforcing essential points with review, discus-
sion, and written instruction, and emphasizing the importance of the
therapeutic plan, (2) taking clinically appropriate steps to reduce the cost,
complexity, duration, and amount of behavioral change required by the
regimen and increasing the regimen's convenience through "tailoring" and
other approaches, (3) obtaining a compliance-oriented history of the patient's
prior experiences and present health beliefs and, where necessary, employing
strategies to modify those perceptions likely to inhibit compliance, (4)
improving levels of patient satisfaction, particularly with the provider-patient
relationship, (5) arranging for the continued monitoring of the patient's
subsequent compliance to treatment, (6) increasing staff awareness of the
magnitude and determinants of the noncompliance phenomenon and
attempting to develop an "active influence orientation" in each member of
the health care team, (7) using such techniques as patient-provider contracts
to involve the patient in therapeutic decisions and in the setting of treatment
objectives and creating incentives (through rewards and reinforcements) for
achieving these objectives, (8) arranging for as much continuity of provider
(and other staff) as possible, (9) establishing methods of supervising the
patient, including involvement of the patient's social support network, and
(10) involving fully the assistance of all available health care providers,
assigning specific roles and responsibilities for activities directed at improving
adherence to treatment.

The problem of enlisting patient cooperation is a critical aspect of all

recommended and prescribed therapies requiring self-administration; some
authorities count it the most serious problem facing medical practice today.1
Depending upon characteristics of the condition, the treatment, the patient and
the setting, estimates of noncompliance rates typically range from 30% to 60 %
and the situation worsens markedly where the patients are symptom-free. 2-7As
one reviewer notes, " I n an era when efficacious therapies exist or are being
developed at a rapid rate, it is truly discouraging that one-half of patients for
whom appropriate therapy is prescribed fail to receive full benefit through
inadequate adherence to treatment. 8

Dr. Becker is Professor, Department of Health Behavior and Health, Education, University of
Michigan, School of Public Health, 1420 Washington Heights, Ann Arbor, Michigan 48109. Dr. Maiman
is Assistant Professor, Department of Pediatrics, University of Rochester, School of Medicine, 601
Elmwood Avenue, Rochester, New York 14642. Work for this review was supported in part by Grant No.
5K04-HD00237 from the National Institute of Child Health and Human Development.

0094-5145/80/1600-0113500.95@1980 Human Sciences Press 113

114 JOURNAL OF COMMUNITY HEALTH

Patient noncompliance interferes with the provider's therapeutic

efforts in a variety of ways: by neutralizing the benefits of the preventive or
curative services offered; by (potentially) involving the patient in additional
unnecessary diagnostic and treatment procedures, thus generating further
costs and possible iatrogenic consequences; by negatively influencing the
client's perceptions of the services received (e.g., some suggest that poor
medical outcomes resulting from noncompliance may account for much of the
general dissatisfaction currently expressed towards the delivery of health care);
and by making it difficult for the practitioner or organization to perform
accurate evaluations of quality of care. 9-11
Many research efforts have been devoted to identifying the "determin-
nants" of patient noncomplianceS; and, more recently, a smaller number of
investigations have attempted to evaluate the efficacies of different strategies
aimed at increasing the level of patient adherence to recommended and
prescribed therapies. Thus, while no all-purpose solution to the noncompliance
enigma has been discovered, enough practical knowledge and technique has
evolved to provide a foundation for programs to improve compliance. This
paper presents summaries of published reports on some of the more commonly
employed (and promising) approaches to increasing patient cooperation,
emphasizing feasible interventions that different members of the health care
team might implement.

PROVISION OF INFORMATION

One contributor to poor compliance is the patient's inadequate under-

standing of, or knowledge about, various aspects of the regimen. For example,
recent research on clients of a neighborhood health center serving a low-income
population revealed that: 50% of patients studied could not correctly report
how long they were supposed to continue on their medication; 26% did not
know the dosage prescribed; 17 % could not report how often they were to take
their medications; 16% believed their drugs marked " p r n " were to be taken
regularly; and 23% could not identify the purpose of every drug they were
taking. 1~ Examining these conditions in relation to compliance showed that,
while 73% of those correctly identifying their physician's instructions adhered
to their regimen, only 16% of those making one or more mistakes about their
physician's instructions adhered to their regimen. Of those receiving high-level
instruction, 62% understood and 54% complied; for patients who received
relatively lower level instruction, 40% understood and only 29% complied.
Unfortunately, data regarding knowledge and compliance are, in the
aggregate, neither consistent nor clear-cut; some studies have found no
relationship between levels of patient information and adherence to
t h e r a p y ? . 8,13,14 One approach to reconciling these seemingly conflicting results
is: (1) to view knowledge about certain details of the regimen as a sine qua non
 Becker, Maiman 115

for correct compliance, but also to recognize that such information may, under
particular circumstances, be insufficient to produce adequate patient
cooperation; and (2) to look at other variables that may be associated with
communication of " b e t t e r " information to the patient.
A study by Tagliacozzo conducted at a large urban hospital's out-
patient clinic relates to the first point and concerns follow-up visit compliance
by patients with chronic conditions. 15 Although patients with considerable
disease experience showed no association between knowledge and compliance,
such association became quite significant both for patients with little prior
experience and for those cases where social factors interfered with making
clinic visits. Thus, providing information for individuals motivated to comply
but ignorant of the correct procedures should be beneficial; however,
additional information about the regimen is less likely to enhance compliance.
An experiment by M c K e n n e y and associates illustrates the second
point. 16 Twenty-five of 50 hypertensive patients had monthly half-hour educa-
tional visits with the pharmacist in addition to their regular physician visits.
During the period of study, compliance rates for those in the "pharmacist"
group increased from 25% to 79% while rates in the control group did not
change. However, during the six-month period after the special education
effort was completed, compliance in the experimental group fell back to pre-
intervention levels. The transitory effect of the educational program suggests
that the pharmacist's extra interest and exhortation probably improved com-
pliance more than additional knowledge did. While either variable yields better
compliance, the particular interpretation is important, since each explanation
suggests a different focus for future attempts at intervention.
In any medical setting, some patients will not understand well what is
expected of them after the visit, and these patients naturally have much higher
rates of noncompliance than others do. Poor recall is part of the problem.
Studies have shown that, after five minutes, patients forget about half the
doctor's instructions,17 and remember best the material in the first one third of
the presentation.l~ Further, they recall the diagnosis better than they do the
prescribed therapy. 19 Such findings suggest that the provider speak briefly and
selectively, emphasizing information necessary for compliance clearly and
early in the communication, and then repeat that information, both orally and
through simple written instructions to which the patient may later refer (a
combination of oral and written instructions results in the highest levels of
patient information-retention). 17,~°,2ICarefully organizing the information also
seems important; in one study, the simple reorganization of a list of 15 medical
statements into labelled categories enhanced recall by 50 %. 17Specific and indi-
*idualized instructions are associated with better compliance.I°.22
O f course, patients differ widely in terms of how much they know (and
want to know), and they sometimes experience "information overload". 23,24
This difficulty can be overcome to some degree by focusing on absolutely ne-
cessary aspects of the treatment plan, and by avoiding more general
116 J O U R N A L OF C O M M U N I T Y H E A L T H

discussions of the disease, the action of the medication, and so forth, since this
type of information has not been shown to be related to compliance. On the
other hand, physicians frequently underestimate their patients' knowledge. ~5
However, these considerations aside, it is remarkable how much simply
modifying features of the communication can often raise patient compliance
levels. For example, in an experiment conducted with female subjects on a
weight-loss diet, Ley discovered that the group given a highly readable, well-
organized and repetitious leaflet experienced mean weight reductions
averaging about twice those achieved by their peers (who had received the
more usual type of leaflet). ~6
Similarly, one often observes a breakdown in doctor-patient communi-
cation when the patient does not know the relevant vocabulary. ~7 For example,
a study of communication between pediatricians and mothers demonstrated in-
adequate comprehension of such terms as "follow", "incubation period", and
" w o r k u p " , suggesting that even commonly used medical terms may require
explanation or substitution. 9 And, in a study of patients' interpretations of
written prescription instructions, Mazullo and associates found that 25 % of the
subjects interpreted the phrase " e v e r y six hours" as meaning " t h r e e times a
d a y " (since they sleep at night); " a s needed for water retention" was thought
to mean that the pills would be used to cause water retention. 28 Avoidance (or
full explanation) of medical terms is therefore strongly encouraged.
Health education can also successfully influence appropriate use of
medical services. Thus, for example, several studies found that education
resulted in a greater number of clients making use of a multiphasic screening
program in an H M O , ~9 and in more self-referrals to a venereal disease clinic? °
Similarly, such approaches have also accomplished desired decreases in utiliza-
tion. Egbert and associates randomly assigned 97 patients scheduled for
elective intra-abdominal surgery into experimental and control groups. 31 The
experimental subjects were told about the pain they would likely experience
(cause, location, duration, severity), and about how, through special breathing
exercises, they could reduce the pain; the controls were not told about post-
operative pain (the surgeons were unaware of any patient's study group
assignment). Results showed that patients in the experimental group requested
50% fewer narcotics for pain relief, and were discharged, on the average, 2.7
days sooner than the controls. Levine and Britten showed 45 hemophiliacs and
their families how to recognize symptoms requiring infusions and instructed
them in venipuncture techniques; they found a resultant reduction in total days
hospitalized from 432 in the previous year to 42 in the first poststudy year, as
well as 75% reductions both in absenteeism from work or school and in
outpatient visits? 2 By transmitting relevant instructions via a special telephone
hotline, one group reduced the diabetic coma rate by two-thirds? 3 Other
education efforts have effected lower utilization rates and improved regimen
compliance for patients with congestive heart failure34; for "worried well"
patients35; for asthmatics36-3a; and for persons with colds.39 O n the basis of these
 Becker, Maiman 117

and other investigations, a strong case can be made regarding the potential of
education for enhancing cooperation and for reducing health care costs. 4°
Supervised practice of the activities that the prescribed therapy demands
also increases adherence. 41 This is true even for modification of such risk
factors as smoking or inappropriate eating behaviors, where the individual may
already be motivated to alter his/her lifestyle, but lacks the skills needed to
begin or to continue an appropriately altered behavior pattern. In such cases, it
appears necessary to train the individual in self-discipline through such means
as practice sessions and providing reinforcements. 42
Finally, simply reminding patients of upcoming appointments can
enhance compliance. Mail and telephone reminders have been used
successfully in such diverse areas as prenatal and well-child visits, medical and
dental checkups, and in obtaining annual Pap smears, 4~-47and have a clear,
beneficial influence on appointment-keeping behavior. 48-51 Foote and Erfurt
achieved a considerable increase in blood pressure control among hypertensive
patients through a program using mail and telephone follow-up 52

A L T E R I N G C H A R A C T E R I S T I C S OF T H E R E G I M E N

Often a particular therapy cannot be modified; but, whenever possible,

results from the m a n y studies examining the relationships between various
characteristics of the treatment plan itself and the likelihood of patient
cooperation should be capitalized on (Dunbar and Stunkard view "the
regimen itself" as "the single most important determinant of patient ad-
herence"1). In general, one may expect to achieve an improved level of
compliance with decreases in the regimen's complexity, duration,
requirements for changes in lifestyle (i.e., degree of behavioral change), in-
convenience, and cost. 8,13,53These findings have led m a n y reviewers to suggest
a multiplicity of compliance-improving tactics.
First, the provider should simplify the treatment plan to whatever ex-
tent is possible. Perhaps the most extreme simplification would be to use
prolonged-action injectable medications (when available and appropriate),
thus making the compliance question irrelevant, s4 Other approaches involve
reducing the n u m b e r of daily administrations and/or different medications by
utilizing, if clinically acceptable, fewer but larger doses, pharmaceuticals
designed for once-a-day oral administration, and combinations in single
tablets; by synchronizing doses; and by avoiding the routine prescription of such
additional medications as vitamins and tranquilizers that add considerably to
the overall complexity of the total regimen. (However, Weintraub cautions
that these methods may involve a n u m b e r of dangers, especially in the patient
who is capriciously compliant; he points out that large-dose tablets make ac-
cidental and suicidal overdoses easier, and notes that more serious therapeutic
consequences may result from missing a single dose if the one omitted is the
only one prescribed.)
118 J O U R N A L OF C O M M U N I T Y H E A L T H

Second, one should try to reduce the length of therapy and bring the
condition under control as early as possible. Follow-up visits should be sche-
duled soon after the initial visit in those instances where progress can be
demonstrated to the patient. This would provide the patient with a feeling of
accomplishment and a sense of the treatment's importance.
Third, if alterations of critical behaviors (e.g., diet, exercise, smoking)
are to be requested, the practitioner should attempt making these changes
gradually over the course of several visits, taking the behaviors one at a time,
reinforcing whatever compliance is achieved, and only then adding the next
objective, s6 In this " s h a p i n g " process, the patient "proceeds in a stepwise
fashion to build his behavior repertoire, achieving a series of interim criteria
until he has attained full performance of the therapeutic tasks".1
Fourth, several investigations have improved compliance by "tailor-
ing" or linking the medication schedule to the patient's regular daily activities,
thus increasing its convenience and making it more difficult to forget.~4,~7.58For
example, Hallburg found that tailoring prescribed medication regimens to the
living patterns, habitual behaviors, and physical functioning abilities of elderly
ambulatory patients was effective in reducing serious medication errors59; and
Haynes and associates significantly improved compliance of hypertensive men
with their medication regimens by employing a multidimensional strategy that
included matching medication administration times to daily patterns and
habitual behaviors. 6° The practitioner should also seek other ways to make
compliance easier, such as convenient "dose-packaging" of the medication, or
the possibility of dispensing a medication directly from the clinic so that the pa-
tient can avoid a lengthy wait at the hospital pharmacy. 13
Fifth, one may wish to employ "graduated regimen implementation",
which successively introduces treatment procedures in an increasing order of
difficulty as the patient demonstrates proficiency in each prior component. An
example of this procedure would be gradually increasing medication doses
(i.e., n u m b e r of times a day and/or the quantity of medication taken) or
systematically increasing self-management requirements (e.g., gradually in-
creasing urine testing by diabetic patients from once a day to the desired fre-
quency). Dunbar has used this strategy in an experimental study of
cholestyramine administration. 61 Using a baseline diagnosis of daily
medication-taking over the three-week period, and obtaining prior information
concerning number of medication packets taken, time of administration, and
enhancing or inhibiting situational factors related to taking the medicine, Dun-
bar instructed each experimental subject to take a number of packets equal to
or slightly less than the baseline average and to administer the daily medication
at the most frequent baseline time. By gradually increasing the dosage and ad-
ministration times, she eventually placed the subjects on the full dose regimen;
by this procedure, Dunbar achieved a 75% compliance rate (and lowered
cholesterol levels).
 Becker, Maiman 119

Sixth, the physician may be able to reduce the cost of the treatment
plan to the patient by such procedures as prescribing generically, avoiding un-
necessary or over-the-counter prescribing, checking for possible coverage by
the patient's health insurance, and encouraging the patient to compare pre-
scription rates at different pharmacies.

MODIFYING HEALTH-RELATED ATTITUDES

All physicians and other health professionals sometimes employ moti-

vating strategies, whether consciously or unconsciously. Unfortunately, cur-
rent medical training places little emphasis on the necessity for promoting ade-
quate patient education and motivation, and few schools provide any exposure
to information on the conditions under which patients will follow advice, on
methods for communicating with clients, or even on interview skills for finding
out what the patient knows, believes, or is concerned about.
Within the past few years, a number of studies have consistently shown
that a patient's beliefs about his health, and about his particular illness and its
treatment, have a strong influence on the likelihood of compliance. These
beliefs can operate independently of levels of information, objective features of
the condition and the regimen, and so forth. A large body of evidence has ac-
cumulated supporting a " H e a l t h Belief Model," which proposes that an in-
dividual's following professional advice often depends on four factors: (1) health
motivation: degree of interest in, and concern about, health matters in general;
(2) susceptibility." perceptions of vulnerability (or resusceptibility) to the par-
ticular illness (or to its sequelae), including acceptance of the diagnosis," (3) severity:
perceptions concerning the probable seriousness of the consequences, on both
physical and social dimensions, of contracting the illness or of leaving it un-
treated; and (4) benefits and costs." an evaluation of how effective the advocated
health behavior might be in preventing or treating the condition, weighed
against an estimate of what barriers might be involved in undertaking the
recommended action (e.g., financial expense, physical and/or emotional
discomfort, inconvenience, possibility of adverse side effects)62
Although the Health Belief Model was originally developed to account
for preventive health actions, 63,64it has been employed successfully to explain
compliance relative to seeking diagnosis and to following prescribed medica-
tion, diet, and other regimens, 65-72and even as a predictor of general clinic
utilization. 73
O f the patient health beliefs described above, the one which seems to
surprise practitioners most is "acceptance of the diagnosis". Why would a per-
son seek out and subject himself to expert examination and consultation (often
costly and uncomfortable), only subsequently to reject that professional's con-
clusions? At least three kinds of situation can undermine belief in diagnosis.
First, the patient may possess powerful, well-defined (albeit scien-
tifically erroneous) health beliefs that conflict with the physicians's assessment
120 JOURNAL OF COMMUNITY HEALTH

of the problem (e.g., " I can't have high blood pressure because I ' m not the
nervous type," or " m y child can't have the flu because he's had it before and
you don't get that twice--it's like measles"). These beliefs have multiple
origins (e.g., from cultural subgroups, parents' beliefs, prior experiences with
an illness, misinterpretation of factual information or acceptance of erroneous
information from nonmedical sources), and the existence of a great variety of
problematic health beliefs is well established. 74
Second, incidents may occur during the history-taking or physical
work-up that the patient interprets in such a manner as to weaken his con-
fidence in the diagnosis (e.g., " I came in complaining of a sore throat, but the
doctor spent a lot of time checking my ears and decided I have an ear infection;
well, he's wrong--it's my throat that hurts"). And then there is a well-
documented difficulty most persons have in being totally candid with their
physicians about everything worrying or bothering them. Patients frequently
are reluctant to trouble a busy professional with their minor aches and con-
cerns (embarrassment, fear of being labelled hypochrondriacal, and the social
distance between the professional and the lay patient also play roles in en-
couraging reticence); nonetheless, these problems and symptoms continue to
worry the patient. Thus, if the physician arrives at a diagnosis without happen-
ing upon the undisclosed concern, the patient sometimes feels that the
diagnosis must be inaccurate or incomplete, since it did not include (and
therefore did not explain) the withheld problem.
Third, not infrequently patients reject an unanticipated diagnosis too
painful to accept. They often react initially to a life-threatening illness by deny-
ing they have it 75 (a similar denial process leads to delay in seeking care for
symptoms related to serious diseases76). A national study of health beliefs has
shown that people accord to others a greater risk of contracting illnesses than
they are willing to estimate for themselves. 77
The degree to which a provider can modify health beliefs is more dif-
ficult to assess than the extent to which more (and better) information can be
transmitted or characteristics of the regimen changed. Nonetheless, research
has demonstrated that these attitudes and perceptions can be altered; and, by
learning which of these beliefs is below a level presumed necessary for com-
pliance, the provider can tailor intervention to suit the unique needs of each
patient. Thus, it is recommended that more attention be paid to both monitor-
ing and motivating the patient along these belief dimensions. (e.g., does the
patient care about health; agree with the diagnosis; perceive the condition as
very serious, or not at all serious; feel the recommended therapy will work; fear
medication side effects; feel the regimen will be too hard to follow?) ~3 Such a
"compliance-oriented history" should be viewed as a critical extension of the
usual medical history and be made a routine part of the examination process.56
Jenkins suggests that "attention to the 'health belief model' during the
diagnostic phase will identify what content should be emphasized in teaching
about the specific diseases to be prevented or treated and the specific health
 Becker, Maiman 121

behaviors to be encouraged."78 O f course, knowing why m a n y patients do not

follow their regimens does not imply any particular strategy for changing their
behavior. Sometimes merely providing corrective factual information will pro-
ve sufficient; in other cases, motive-arousing appeals (e.g., fear, parental or
family responsibility, pride), recommendations from other sources of informa-
tion that have greater credibility to the patient (e.g., another patient for whom
the same treatment was successful), and other interventions will be necessary.
An encouraging example of the positive effects that such physician
awareness has on patient compliance may be found in a controlled trial by Inui
and associates in which one of two groups of physicians was given special
tutorials (one to two hours in length) whose content emphasized both com-
pliance difficulties of patients with hypertension and possible strategies for
altering patient beliefs and behaviors (based on the belief dimensions described
above). After only a single session, physicians in the experimental group were
observed to spend a greater proportion of clinic-visit time on patient teaching,
and their patients later exhibited higher levels of knowledge and appropriate
beliefs about hypertension and its treatment; moreover, the patients of tutored
physicians were subsequently more compliant with the treatment regimen and
demonstrated better blood pressure control than did other patients. 79
It is perhaps worth noting that attempts to change health-related at-
titudes and behaviors have most frequently employed "fear-arousal" techni-
ques, which often do have a positive influence on compliance. 8°,81 However,
while low levels of concern about the threat of some illness or condition are not
likely to motivate action, too much fear can serve to inhibit undertaking the ap-
propriate behavior--as, for example, is often the case in delay in seeking care
for cancer symptoms. 76 In general, the literature suggests that fear appeals
work best with persons initially little concerned about the disease, and who are
already convinced of the benefits the recommended action would provide.
Also, fear appeals are more likely to affect compliance positively when they are
used at the beginning of the effort to influence the patient, and when they are
accompanied by specific behavioral recommendations that the patient can easi-
ly and quickly undertake to reduce the threat. 8244

MODIFYING THE PROVIDER-PATIENT RELATIONSHIP

In recent years, m u c h attention has been given to developing com-

pliance-improving strategies that depend upon changing health care providers'
behaviors and attitudes. 79,85-87 Coe and Wessen have suggested numerous
aspects of the contemporary physician-patient interaction (such as impersonali-
ty and brevity of encounter) that negatively affect patient behavior, 88 and the
compliance literature supports this conclusion. 89 Lack of " c o m m u n i c a t i o n "
(particularly of an emotional nature) is usually held to be the problem. Davis
found that "patterns of communication which deviate from the normative
122 JOURNAL OF C O M M U N I T Y HEALTH

doctor-patient relationship will be associated with patients' failure to comply

with doctors' advice"9°; such deviations include circumstances where tension
in the interaction is not released, and where the physician, formal, rejecting,
and controlling, disagrees completely with the patient or interviews that patient
at length without subsequent feedback. Francis and others report that a
mother's compliance with a regimen prescribed for her child is better when the
initial contact satisfies her and she feels the physician is friendly and
understands the complaint; further, they found that "the extent to which pa-
tients' expectations from the medical visit were left unmet, lack of warmth in
the doctor-patient relation, and failure to receive an explanation of diagnosis
and cause of the child's illness were key factors in noncompliance. ''91
M a n y other investigations have also shown positive correlations be-
tween compliance and patient satisfaction with the visit, the therapist, or the
clinic, including perceptions of convenience and of waiting times before and
during appointments. Adherence is greater when patient expectations have
been fulfilled; when the provider asks about and respects all the patient's con-
cerns and provides responsive information about the patient's condition and
progress; when sincere concern and sympathy are shownag; and when provider
and client substantially agree about the specifics of the regimen. 92
The degree to which the therapist supervises the patient is another im-
portant compliance factor. Thus, hospitalized patients exhibit better com-
pliance than day-patients, who, in turn, are more compliant that outpatients.
A variety of "before-after" studies have demonstrated increased patient
cooperation when: frequency of outpatient visits is increased and when home
visits are added; when patients receive negative feedback concerning their non-
compliance and when patients receive continuity of care. ~,93Furthermore, cer-
tain techniques can extend supervision beyond the patient's time at the office
or health facility. For example, a provider can make telephone calls about the
regimen, request that pill bottles be brought to the next clinic visit, or ask the
patient to keep a record of when (and how many) pills were taken each day.
The provider~'s orientation towards the patient, and his desire to in-
fluence patient comPliance, are important factors. Schulman found, for in-
stance, that hypertensive patients who received medical care "oriented to con-
sider patients as active participants in the treatment process" ("Active Patient
Orientation") were significantly more likely than other patients to have their
blood pressures under control and to display more favorable cognitive and
behavioral responses to the management of their illnesses. (Her data also imply
that this productive orientation can be substantially increased by effecting in-
cremental alteration in the system for delivering ambulatory clinic care.) 94
Glanz was able to show that dietitians with relatively greater predispositions
toward actively influencing their patients ("Orientation to Social Influence")
tended to employ more influence strategies, to involve patients in the counsel-
ing sessions, and to have patients with more appropriate health attitudes and
compliance behaviors. 95
 Becket, Maiman 123

Some have argued that, other things being equal, patient acceptance of
physician-recommended modifications in lifestyle (e.g., smoking cessation,
weight reduction) is less likely when the patient sees the physician setting a
poor personal example. 96 Others concerned with physicians as role models for
lay persons have found that physicians often tend to seek medical-interventive
solutions to their own health problems even when they are common ailments,
normally expected to disappear without treatment. 97

PATIENT-PROVIDER CONTRACTS

A relatively recent development that attempts to capitalize upon (and

in some ways, improve) the relationship between provider and patient is the
"contingency contract" wherein both parties set forth a treatment goal, the
specific obligations of each party in attempting to achieve that goal, and a time
limit for its achievement. Lewis and Michnich argue that, as a compliance-
enhancing intervention, the contract is supposed to work by "(1) clarification
of the relative responsibilities of both provider and consumer in achieving an
agreed-upon goal by explicit exchange of information about what is required in
the act of treatment by the patient; and (2) a perceived (or real) transfer of
power from provider to consumer that affects certain health-related expectan-
cies. ''98 Data are now available supporting the provider-client contract as a
tool for increasing the likelihood of patient compliance.
Recent position papers have urged the use of a contract between pa-
tient and physician as a means of enhancing the therapeutic relationship and
promoting patient compliance. 99 And promising evidence exists from both
single subject experiments and experimentation with small groups of in-
dividuals that contingency contracts can be employed to alter existing medical-
ly relevant behaviors and/or to establish new ones. Case studies with multiple
baseline and reversal designs have shown how applicable contingency contract-
ing is for changing behavior relative to such diverse conditions as obesity,
juvenile diabetes, cardiovascular disease, renal failure, and drug abuse.~°°,l°l
For example, Low and Lutzker reported using written instructions and
a system by which the patient could earn points (which could later be
exchanged for daily and weekly reinforcers) to enhance performance of the
multiple behaviors required by a juvenile diabetic's regimen (e.g., urine
testing, dietary regulation, foot care).1°' In this single-case study, a 9-year-old
diabetic with a prior history of serious noncompliance (including four hospitali-
zations due to diabetic acidosis in the year prior to the study) attained a
compliance level of nearly 100% when the instruction and point systems were
introduced. Similarly, a therapist-administered incentive system was an
effective behavioral program for controlling blood, urine, nitrogen, and
potassium levels, and fluid weight gain between treatments, in pediatric
dialysis patients, lo3
124 JOURNAL OF COMMUNITY HEALTH

In single subject reversal designs, Mann used material incentives to aid

weight reduction in obese adults, t°4 Eight subjects deposited money and a
number of personally valuable objects with the researcher and signed a
contract stating that the valuables would either be returned or permanently lost
depending upon whether or not specified weight reduction goals were met.
Three levels of contingencies were negotiated: immediate, two-week, and
terminal weight goals. The findings for weight loss are some of the strongest
reported for outpatient techniques (mean weight loss was 32 pounds, with five
out of eight subjects losing 20 pounds or more, and five subjects reaching their
goals for weight loss). However, it should be noted that some of the subjects
used extreme measures to lose weight rapidly (including taking laxatives,
diuretics, and engaging in vigorous exercise just before being weighed). This
may have resulted from both the conditions of the contract (which specified
weight change as the goal rather than the behaviors that would produce weight
change) and the lack of an education or counselling program for appropriate
weight loss practices.
Contingency contracting increased adherence to a complex regimen of
multiple medications, diet, additives, and therapeutic exercise in an elderly
heart attack patient, t°° The reinforcements were explicit praise and tokens,
which could be exchanged for privileges (e.g., selection of the dinner menu for
an evening meal and dinner at the restaurant of his choice). When
reinforcement stopped during the reversal condition, target behaviors
decreased to base-line levels; however, they returned to high levels when
reinforcement was subsequently reintroduced. Although the study
demonstrates the positive effects of contingency contracting, no measurement
of the long-term efficaciousness of this intervention was obtained, nor was any
attempt made to transfer the patient from the reinforcement system to personal
responsibility for the target adherence behaviors.
Other studies of contingency contracting have had promising results.
Several controlled experiments involved small groups of individuals being
treated for such diverse conditions as obesity, 1°5-1°7cigarette smoking, 1°8,1°9hy-
pertension, 6° and influenza. ~° Therapist-administered incentive systems based
on small monetary deposits have been employed with overweight adults (56
cents to $1 per pound),1°6 and negotiated with the parents of overweight girls
five to eleven years of age ($1 to $2.50). 1°5
One investigation compared contracts with a different approach for ob-
taining weight reduction. 1°6 After receiving individual counseling concerning
weight loss, subjects were randomly assigned to two levels of experimental
treatment (a self-control behavior modification group and a contract group)
and to a control group (which was ultimately excluded from the analyses due to
a high rate of attrition). Short-term results (i.e., weight loss over a 12-week
period) showed that both experimental groups lost a significant proportion of
body weight, with the contract group losing a significantly larger proportion of
initial weight than did the self-control group. With respect to long-term follow-
 Becker, Maiman 125

up, no significant differences were found in the maintenance of weight loss

among the groups.
In a study of overweight girls, Aragona and associates found that, at
the end of a 12-week treatment period, the two experimental groups (response-
cost plus reinforcement and response-cost only) lost significantly more weight
than did the control group, although the experimental groups did not differ
significantly. Unfortunately, with regard to long-term effects of the interven-
tions, all the groups regained weight, although the response-cost plus reinforce-
ment group remained significantly below the weight levels of the control group
by the end of an 8-week no-contract period. 1°~
Jeffrey and colleagues describe the effectiveness of contracts involving
substantial monetary sums on weight reduction for 31 severely obese adults
over a ten-weekperiod.107 The subjects, each of whom deposited $200 with the
experimenter, were assigned to three contracting situations: a "weight loss
contract" specifying an overall weight loss of two pounds per week; a "calorie
contract" specifying maintenance of a mean daily caloric intake equal to or less
than the amount estimated to produce two pounds of weight loss per week; and
an "attendance contract" specifying attendance at the 10 weekly sessions. The
high dropout rate that occurred for the control group (individuals with no
financial commitment) necessitated their removal from the study analyses.
Weight loss data revealed a significant treatment effect for the three contracting
groups, with intergroup comparisons yielding no difference in weight loss be-
tween the weight and calorie contract groups, but showing a significantly
greater weight loss for both of these groups as compared with the attendance
contract group. An informal follow-up of weight loss over a four-month period
demonstrated the long-term efficacy of contracting in maintaining weight loss.
It also showed that the continued use of financial contracts by interested sub-
jects had resulted in additional weight reduction.
There is also evidence that contingency contracting can alter smoking
behavior.~°B.l°9 Winnett tested an interesting variation of an incentive system
based on monetary deposits. 1°9 All subjects were required to deposit $55.
However, while one group received their money in installments contingent on
smoking cessation, the deposits were returned to a second group regardless of
their smoking behavior. Results at six-month follow-up showed approximately
50% of the contingent-deposit-return group were not smoking, as compared
with only one in four in the noncontingent-deposit-return group.
Haynes and associates report using a modified contracting procedure
successfully to improve adherence in a clinical population of 38 Canadian steel:
workers who did not comply with medication regimens. 6° The contracting in-
volved a verbal agreement, and the reward contingencies provided by the
researchers did not include a punishing component as part of the treatment.
Subjects in the experimental group were loaned devices for self-measurement
of blood pressure and were asked to record their blood pressure and pill taking
daily. In addition, the subjects agreed to take medications immediately prior to
126 JOURNAL OF COMMUNITY HEALTH

an individually identified daily behavior pattern. The self-recorded daily ac-

counts of blood pressure and pill taking were reviewed every two weeks, and
experimental subjects displaying appropriate compliance and decreases in
blood pressure received praise and monetary credit ($4) applied toward pur-
chase of a blood-pressure cuff and stethoscope. Results indicate that 70 % of the
experimental subjects showed both increased compliance and decreased blood
pressure. Furthermore, long-term compliance (at 12 months) among ex-
perimental subjects exceeded their six-month measure by 20% and exceeded
that of control subjects by 20% or more.
Since the deposit of funds and/or the requirement of punishments
(e.g., forfeiture of deposit, loss of funds) are generally not practical ar-
rangements in large-scale clinical settings, it m a y be more appropriate to view
such "contracts" in another way. They could be negotiated agreements be-
tween patient and practitioner regarding the relative and absolute authority
and responsibility for achieving a defined and agreed upon treatment objective.
However, review of the literature reveals few experimental studies on the ef-
fects of using contracting with large clinic populations.
Steckel and Swain randomly assigned 115 hypertensive outpatients to
two experimental groups and one control group. 111 One experimental group
received routine care and an education program with counseling; the second
experimental group received routine care, an education program, and con-
tingency contracting; and the control group received only routine care. The
subjects contracted for two types of goals: the target behavior (or final goal),
and intermediate goals (or smaller behavioral objectives) leading toward the
achievement of the target behavior. Reinforcement was in the form of tangible
rewards suggested by the patient; while some wanted lottery tickets, books,
money, and magazines, others requested more time and/or assistance from the
health care provider. The study found a statistically significant reduction in
blood pressure and weight for the contracting group.
Levy and associates found that verbal commitment enhanced com-
pliance when subjects particpating in a flu inoculation program were asked to
return a postcard indicating the occurrence of any symptoms.l l° The verbal-
commitment group (269 subjects) mailed back significantly more symptom-re-
port postcards (and required significantly fewer days for return of the cards)
than did those subjects (434) who had not been asked if they would comply with
the request. Of course, this is a one-time behavior contract situation (as com-
pared to other repetitive behaviors in this review), and reinforcers were not
used.
Patient-provider contracts thus appear to increase the likelihood of pa-
tient adherence to prescribed therapy; in addition, they offer the following ad-
vantages1: (1) a written outline of behavioral expectations is created; (2) the pa-
tient becomes involved in the decision-making process concerning the regimen,
and thus has an opportunity to discuss potential problems and solutions; (3)
formal commitment to the program is elicited; and (4) the reward/rein-
forcement components create incentives for achieving compliance goals.
 Becker, Maiman 127

ENLISTING SOCIAL SUPPORT

Evidence is growing that social support (particularly support provided

by the patient's family) plays an important role in influencing compliance.
Thus, in a review of six studies that examined the relationship between patient
adherence and family influence, Haynes concluded that "the influence of the
family appears to be considerable", with "supportive" families being
associated with greater compliance in five of the six investigations ~ Dunbar and
Stunkard suggest that family support " m a y well be one of the more promising
routes for the improvement of adherence",1 and go on to link this concept with
that of contingency contracting by noting that " w h e n family members can be
helped to utilize behavioral contingencies in a systematic manner, the effec-
tiveness of both may be increased, perhaps in a synergistic as well as in an ad-
ditive m a n n e r . " Some illustrations are provided from this literature in the
areas of obesity, hypertension, arthritis, and coronary heart disease.
Obesity
Brownell and associates have found spouse involvement to be an effec-
tive factor in weight control.~l~ They compared two groups: subjects receiving
treatment that included training of spouses in techniques to assist the
overweight husband or wife and subjects whose spouses were not assigned to
the experimental group, whether or not they were willing to be. Significantly
greater weight loss occurred in the spouse training group at three- and six-
month follow-ups than in the other group. Saccone and Israel attempted to
assess combinations of different target behaviors selected for reinforcement
(i.e., eating behavior or weight loss) and type of individual providing the rein-
forcement (i.e., therapist or "significant other' '--family member or friend) in
facilitating weight change, lj3 Although all the treatment groups showed a
statistically significant weight loss over the nine-week program, the group
receiving reinforcement from a significant other for.change in eating behavior
demonstrated the greatest weight loss. A long-term follow-up at 3 and 12
months after program termination found that maintenance of weight loss re-
mained superior in this group. 114
Building on the positive effect of including family members in weight
reduction programs, Zitter and Fremouw compared the weight loss of pairs of
overweight friends randomly assigned to two treatment groups and a control
group: (1) a partner "consequation" group, in which partners were instructed
to work together on eating and exercise behaviors and were rewarded
monetarily for both their own and their partner's weight loss and attendance at
the six-week treatment program; (2) an individual "consequation" group, in
which no explicit instructions to work together were given, and subjects were
rewarded monetarily for their own weight loss and attendance; and (3) a con-
trol group, which emphasized individual self-control with monetary reward for
attendance. At the end of the program, weight loss in both experimental groups
involving treatment of pairs of overweight friends was greater than that ob-
tained in the control group. However, the long-term effectiveness of individual
 128 JOURNAL OF COMMUNITY HEALTH

"consequation" was superior to that of partner "consequation"; at the six-

month follow-up subjects in the former group had maintained their post-
treatment weight loss while subjects in the latter group had not. 1~5
Finally, Stuart and Davis reported that far more persons receiving aid
from another family member in cueing or reinforcement of proper eating
behavior lost weight (and maintained that reduction) than did those not receiv-
ing such assistancC 16 (see also Mahoney and Mahoney, 117 and O ' L e a r y and
Wilson118).

Hypertension
Findings from a diagnostic baseline survey of outpatients with primary
hypertension revealed that the respondents indicated confusion about their
therapeutic regimens and difficulty fitting the regimens into their daily living
patterns. Further, the majority (70 %) reported a lack of family understanding
and support, and felt the need for a family member to know more about
hypertension. The data provided Green and associates with the basis for con-
structing a three-stage sequential intervention program consisting of an exit in-
terview to clarify the therapeutic regimen, a home visit to increase family sup-
port and understanding (using an adult 16 years or older identified as having
the most frequent contact with the patient), and small-group discussions to in-
crease patient feelings of self-control over their blood pressure. 1~9,~2°The in-
tervention program was used with 400 patients and was evaluated for its effect
on three behaviors (compliance with medication regimens, weight reduction,
and appointment keeping) assumed to be associated with blood pressure
control.
Analyses revealed the combination of exit interview and family-
support intervention to be the most effective strategy for enhancing compliance
with the medication regimen; however, the home visit alone achieved almost
the same level of compliance. 1..,1 With respect to weight reduction, the exit in-
terview proved to be the most effective intervention, w h i l e the home visit
(social support training) demonstrated only a modest effect on weight loss. A
ratio of appointment-keeping at the hypertension management clinic was
calculated for each subject by dividing appointments kept by appointments
scheduled during the study period. For this outcome measure, the social sup-
port training most effectively increased the number of patients keeping their
appointments. The greatest improvement in blood pressure control occurred in
the groups assigned to all three interventions. Looked at individually, the fam-
ily support intervention achieved a modest increase in control and the small-
group approach exhibited a slightly greater impact; the exit interview failed to
demonstrate any change in blood pressure control.

Arthritis
Oakes and associates retrospectively studied the contribution of family
expectations of compliance with actual use of a hand-resting splint regimen by
 Becker, M a i m a n 129

rheumatoid arthritis patients; they found that, regardless of age, sex, or social
class, patients who felt their family members expected them to wear the hand-
resting splint were more likely than other patients to comply with the treatment
regimen. 122 Ferguson and Bole have also demonstrated the complex ways in
which family support influences compliance by arthritis patients with recom-
mendations about aspirin, exercise, and splints. 123

Coronary Heart Disease

A supervised physical activity program was designed as a preventive
health program for sedentary men 45 to 59 years old at risk of coronary heart
disease (based on blood pressure readings and cholesterol levels). 12~ The iden-
tified population (N = 381) was interviewed prior to participation in the pro-
gram and at three- to four-month intervals during the 18 months of the pro-
gram. An attempt was made to identify factors influencing participation.
Although respondents reported that they decided to participate regardless of a
desire to please their wives, the investigators found that 80 % of husbands with
wives positively disposed toward the program had good or excellent compliance
with the activity program, while only 40% of husbands with wives having
neutral or negative attitudes exhibited such patterns of adherence. The find-
ings imply that the reactions and attitudes of persons close to a participant in a
preventive health program influence initial participation in, and continued
adherence to, the recommended program. Consequently, the development of
preventive health programs should focus upon significant family members as
well as on the participant.
Additional research has documented the influence of family members
on compliance with recommendations for immunizations and other preventive
measures, 125 and on taking medications for outpatient management of
psychiatric disorders. 126.127Finally, m a n y studies of family-level variables have
shown the relationships between extent of patient compliance and family
members' (1) assumption of responsibility for the sick member's care; (2)
evaluation of the illness and the recommended treatment; (3) health beliefs; (4)
sympathy, support, and encouragement; (5) compatibility of normal roles and
patterns with the patient's sick role or regimen,122,128-x35; and (6) willingness to
engage in making changes in the environment. 136
The patient's family remains a largely unexploited means for remind-
ing, assisting, encouraging, and reinforcing the patient with respect to follow-
ing medical advice. In light of our current heightened concern with chronic
conditions, and the concomitant shift in emphasis from direct medical care to
patient self-management, the effect of the family (and other social support
systems) on the patient's adherence to regimen is likely to be of tremendous im-
portance. The family can, of course, exert a negative as well as a positive im-
pact on a member's willingness to initiate or continue care; thus, the practi-
tioner should be encouraged to evaluate cautiously the role of the family in the
patient's therapy program and to attempt both to maximize its potential con-
structive contributions and to minimize its possible destructive influences.
130 JOURNAL OF COMMUNITY HEALTH

UTILIZING VARIOUS HEALTH CARE PROVIDERS

The bulk of the compliance-intervention literature has focused upon

actions that the physician might undertake to improve the patient's cooperation.
It seems apparent, however, that other personnel could and should be brought
into the compliance picture to provide additional assessment, instruction,
clarification, and reinforcement. For example, M arston argues that, "Nurses ,
by virtue of their numbers and amount of patient contact, have the greatest
potential of any group of health professionals for exerting an impact on patient
health behavior, ''137 and she goes on to list such important compliance-related
activities as diagnosis and/or monitoring of adherence levels, implementing
clarifying health education and/or attitude change strategies, enlisting the sup-
port of significant others, patient contracting, and behavior modification.
A good deal of attention has recently been paid to the potential roles for
the pharmacist in enhancing patient compliance. Canada describes several
studies that found pharmacist intervention to be worthwhile: (1) pharmacist
consultation, given to the patient before he left the hospital, led to 75%
reduction in the previous high rate of deviation from prescribed drug regimens;
and (2) pharmacist counseling of outpatients (which included written
reinforcement of the counseling and a reminder system whereby patients were
contacted by telephone or letter near the time that their supply of the
prescribed medication should have been running out) was very successful in
increasing the percent of prescriptions refilled on time and in decreasing the
proportion of missed refills. 138 Canada also notes what the pharmacist might do
if the patient fails to pick up the initial prescription and also mentions issuing
written instructions about special precautions to be taken with various types of
drugs. Schwartz favors the pharmacist's maintaining a patient medication
profile, which could be used both as a preventive to overdosing, allergic
reactions, and adverse drug interactions and as a tool to monitor
compliance. 139 Sharpe would extend the pharmacist's role even to helping
identify previously undiagnosed hypertensives and to actually monitoring
blood pressures, drug regimens, and drug-taking behaviors. ~4° A number of
recent investigations provide strong empirical support for the value of
involving pharmacists in trying to increase patient cooperation with prescribed
therapies. 16.~4~

CONCLUSION

Despite Osler's observation that, " T h e desire to take medicine is

perhaps the greatest feature which distinguishes man from animals," 142patient
noncompliance remains a most significant threat to the efficacy of
recommended and prescribed therapies. Green correctly emphasizes that
individual health-related behaviors are multicausal,m. 144involving at least three
classes of determinants, which any education strategy should attempt to
 Becker, M a i m a n 131

influence: predisposing (motivating), enabling, and reinforcing factors. It is

unlikely that any intervention attempt which ignores the multidimensionality
of the problem will accomplish long-run alterations of health behaviors.
This paper has suggested a multifactorial approach to employing
strategies for increasing patient adherence to health and medical care advice.
Major interventions discussed included raising information and skill levels,
altering characteristics of the regimen, assessing and modifying health-related
attitudes, improving various aspects of the relationship between provider and
patient, increasing provider awareness of (and need to monitor) compliance,
employing contingency contracts (including rewards and reinforcements),
enlisting social support, and utilizing all members of the health care team. In
each instance, relevant literature was reviewed, and specific suggestions for
implementation were offered.
The interventions presented above do not, of course, exhaust the list of
possible techniques for increasing compliance; however, they represent feasible
and practical approaches for which substantial empirical support is available.
One hopes that implementing these strategies will bring the degree of patient
cooperation closer than it is now to that described by Lord Byron in Don Juan."

A little still she strove, and much

repented,
And whispering, " I will n e ' e r c o n s e n t "
.... con sented.

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