Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
A behavioral approach to patient compliance James P. Schmidt To cite this article: James P. Schmidt (1979) A behavioral approach to patient compliance, Postgraduate Medicine, 65:5, 219-224, DOI: 10.1080/00325481.1979.11715152 To link to this article: http://dx.doi.org/10.1080/00325481.1979.11715152
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [University of Calgary]
Date: 04 August 2017, At: 15:31
A behavioral approach to patient compliance
James P. Schmidt, PhD
Downloaded by [University of Calgary] at 15:31 04 August 2017
Consider What are the three components ofa behavior sequence? How con a medication-taking pattern be programmed into a patient's /ife-style? What three attributes must a reward have to be useful in reinforcing a behavior?
A behavioral approach to increasing a patient's compliance with a drug regimen uses manipulation of the three components of a behavior sequence: the antecedent, the behavior, and the consequence. Success of a behavioral program depends on a cooperative relationship between physician and patient. The recurring problem of patient noncompliance continues to hamperthe implementation of drug therapy. While the subject of noncompliance bas been examined extensively,1-3 research into methods of overcoming it bas been relatively neglected. To date, the method used most often is that of educating patients about their disease, the reasons for taking medications, and how the drugs should be taken.4,5 While this approach bas met with sorne success, many patients still fail to adhere to a treatment program. Behavioral procedures are the basis of a new strategy to increase patient compliance. 6 The behavioral model views every behavior sequence as having three components: an antecedent, a behavior, and a consequence. Manipulation of these three components increases the likelihood that a given behavior will resuit. This article presents a behavioral model that may be used by physicians or their assistants to increase the likelihood of patient corn pliance. Each of the three components is discussed in turn as it specifically applies to compliance. The antecedent In regard to a therapeutic regimen, the antecedent to compliance is the
eue or signal that reminds the patient when it is time to take the prescribed medication. In my experience, most patients rely on memory rather than on an external eue. Reliance on memory is chancy, at best, especially because memory of the illness is often unpleasant. The behavioral model for compliance focuses on strengthening the external eues to the timing of medication, thus reducing dependence on memory or other internai signais. To do this, the physician must first assess the life situation of the patient, a task that may be brief or extensive depending on the drug regimen and the patient. A regimen containing only one drug or a drug that is to be taken only once a day is much easier to program into a patient's life-style than is a regimen containing several drugs or one drug that must be taken several times a day or under special conditions, such as on an empty stomach. Programming a medication-taking pattern into a patient's life-style by the modification of eues is accomplished in three steps: l. Identification and use of events that occur regularly in the patient's life-style. The regularity of certain events should not be taken for granted. For example, the patient may not eat three meals a day or go
continued VOL 65/NO 5/MAY 1979/POSTGRADUATE MEDICINE
219
Downloaded by [University of Calgary] at 15:31 04 August 2017
A medication·taking pattern can be programmed into a patient' a lite-style by identifying regular events and then establishing a link between one of these and medication ta king.
James P. Sehmidt At the time this article was written Dr Schmidt was a staff psychologist and member of the teaching staff of the department of psychiatry, Letterman Army Medical Center, San Francisco. He is nowa staff psychologist with the division of psychology, University Hospital, University of Saskatchewan CoUege of Medicine, Saskatoon. He received his PhD in clinical psychology and is interested in applications of psychology to medical problerns, the hospital treatment of psychiatrie patients, and teaching.
220
to bed at the same time each night; th us, if the medication schedule specifies "take at mealtime" or "take at bedtime," the regimen may be disrupted. Likewise, many habits practiced during the week are not carried over into the weekend or into vacation time. Activities that might provide a regular environmental eue include eating and other oral habits (eg, smoking, chewing gum, eating an evening snack), bowel and elimination habits, television-viewing habits (eg, the evening news), reading habits (eg, the daily paper), hobbies, work habits, bedtime habits (eg, showering, turning down bed, checking locks), waking habits (eg, shaving, dressing), religious habits (eg, daily prayer, reading of the Bible), habits involving other people (eg, a regular cali to family or friends), sexual habits, ànd established health habits (eg, exercising, taking vitamins, brushing teeth). 2. Establishment of a link between a regular habit and medicine taking. This may be done directly or indirectly. In the direct method, the medicine is used as the eue and its eue value is increased by placing the medicine in the area where the habituai action is repeated. Thus, it might be left on the television set if it is to be taken when the patient watches the evening news, or beside the milk in the refrigera tor if it is to be taken with meals and the patient drinks milk with every meal.
In the indirect method, a novel eue or signal is substituted for the medicine and built into a habit. The indirect method is especially important if the medicine must be stored in the refrigerator or if there are children in the home. Thus, tape is placed over the saltshaker as a reminder of a mealtime regimen, or a small circle of paper is attached to one corner of the television screen as a reminder that the medicine is to be taken during a certain show. 3. Building in of eues if regular habits cannot be identified or if a link cannot be established. Examples include setting an alarm dock each day to signal medication time, placing reminder signs in the bathroom or kitchen, or carrying reminder cards in the wallet or purse. Built-in eues are most effective if each one preprograms the next in a cyclic fashion. For example, a patient who must take medication mornings and evenings places the pill bottle inside the pillowcase in the morning. Removing the bottle from the pillowcase in the evening reminds him or ber to take the medicine and to leave the bottle in a shoe. Seeing it in the shoe in the morning is a reminder to take the medicine and to put the bottle back inside the pillowcase, and so on. The behavior The importance of educating patients about their illness and the necessary medication cannot be overemphasized. In addition, sorne re-
VOL 65/NO 5/MAY 1979/POSTGRADUATE MEDICINE
Downloaded by [University of Calgary] at 15:31 04 August 2017
A suitable reward for compliance must be immediate, neither too strong nor too weak, and continuously rewarding.
education often is necessary. When patients enter the physician's office they already have been "educated" by friends, family members, and the various media to have certain expectations regarding physician, illness, and medication. lt is important for the physician to identify and challenge expectations that are unrealistic or inaccurate, for these often interfere directly with compliance. Examples of counterproductive beliefs include "1 should stop the medicine when 1 feel better." "If 1 were a better, smarter, or stronger person, 1 wouldn't need the medicine." "If 1 miss my medicine once, l'Il take twice as much the next time to catch up." "If 1forget to take the medicine, I'd rather not come back at ali than to come back and get the doctor mad at me." Unrealistic or inaccurate beliefs often can be elicited by asking how the patient feels about being ill and about taking medicine. Refutation of such beliefs is important, especially of those that might prevent the patient from retuming to the physician or that might cause the patient to lie about degree of compliance. Unrealistic statements are best dealt with nonthreateningly. First, the patient should be asked if he or she sees any reason why the belief might be untrue or counterproductive. Then a more realistic view can be pointed out. A conversational, relaxed manner is best: The patient who perceives the physician as being angry or authoritarian may be reluctant to
VOL 65/NO 5/MAY 1979/POSTGRADUATE MEDICINE
openly examine the belief in question.
The consequence Patients often report that, while they know the medicine will help in the long run, they do not take it because it is inconvenient to do so or because they dislike the side effects. These reasons for noncompliance often can be overcome by helping the patient to establish a self"'reward system for taking the medicine. For example, a patient mi~ht agree not to have dessert or watch a favorite television program until the medicine has been taken. While such an agreement easily can be broken or ignored, most persons a bide by it once they have made a commitment to the physician. To be effective the reward must have three qualities: lt must be immediate, it must be of appropriate strength (neither too strong to resist nor too weak to be effective), and it must continue to be rewarding when used repeatedly. Thus, a personal gift would be a poor reward because the time interval between compliance and purchase might be too long, the object rnight be irresistible and th us be purchased even without compliance, and the reward might cease to have value after several gifts had been acquired. On the other band, a piece of candy rnight be a good reward in that it would be immediately available, neither too strong nor too weak for most people, and repeatedly gratifying.
In helping the patient to establish a self-reward program, it is best to write out a contract or agreement. In it the patient should specify the rewards he or she is to receive for a particular behavior.
Other aspects of the behavioral program Three other points about the behavioral program are important. One is the need for follow-up monitoring. Routine monitoring by the physician of the degree of patient corn pliance can be critical. Monitoring is best viewed as a way not of "catching" the patient but of ascertaining whether the program is working, and if it is not, of understanding why and correcting the problem. If compliance is treated as a problem which both physician and patient must address, the chance of success is greatly increased. When noncompliance does occur, there is a good chance that the patient will retum to the physician and try to deal with the problem in other ways. Monitoring may be done by subjective report by the patient, a calendar record of medicine intake, pill counts, a check of physical signs, or sorne combination of these. Reliance on subjective recall is the easiest method but also the most unreliable, in that it depends heavily on the patient's memory. When a treatment pro gram is planned by physician and patient together, the likelihood that it will be followed is increased if the physician continued 221
P+S
A behavioral compliance program usually can be planned and implemented in 15 to 20 minutes by any trained health care worker.
PROBLEMS+SOLUTIONS
May we help you?
Downloaded by [University of Calgary] at 15:31 04 August 2017
Do you need another opinion? When you want consultation about a problem case- its diagnosis, probable course, possible complications, treatment, or potential sequelaese nd us your query. Be as succinct as possible, but be sure to include ali pertinent details. We cannot publish photographs or tracings, but these may be included with the query if essential to an understanding of the case. We shall try to return ali such material but cannot assume responsibility for its loss. We will submit your question to one or more of our consultants -ali outstanding specialistsand promptly forward the reply to you. Selected problems are published anonymously each month.
records the compliance plan in the medical record. When the patient retums for follow-up visits the physician inquires how specifie parts of the plan have gone, to insure that the patient bas been dealing with eues, beliefs, and rewards correctly between visits. A second point is that the program need not be administered or planned by the physician to be effective-it can be supervised by a nurse, technician, or physician's assistant. Because the behavioral procedures given in this article are conceptually simple and straightforward, they can be leamed and used relatively rapidly. A comprehensive compliance program can be planned and implemented in 15 to 20 minutes with most patients. A final point is that compliance, both to a medication and to a behavioral program, is greatly increased if the physician bas fostered a cooperative rather than an authoritarian relationship with the patient. The program is a method of increasing the patient's self-control rather than the physician's control over the patient. As such, it requires a cooperative relationship that leaves
the patient with a desire to apply self-control techniques to the task of compliance. Summary A behavioral program for increasing a patient's compliance with a drug regimen can be administered by a physician or by trained health care personnel. The program focuses fJrst on the development of a strong extemal eue to the timing of medication and then on hëlping the patient to have realistic expectations and to establish an appropriate selfreward for compliance. Monitoring of degree of compliance is essential to the success of the program, as is development of a cooperative, rather than authoritarian, relationship between physician and patient.
The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
Address reprint requests to James P. Schmidt, PhD, Psychology Division, University Hospital, Saskatoon, Saskatchewan S7N OW8, Canada.
References
Send queries to: Problems+Solutions POSTGRADUATE MEDICINE
4530 W 77th St
Minneapolis, MN 55435
224
1. BlackweU 8: The drug defaulter. Clin Pharmacol Ther 13:841-848, 1972 2. Boyd JR et al: Drug defaulting. 1. Determinants of compliance. Am J Hosp Pharm 31:362-367, 1974 3. Matthews D: The noncompliant patient. Primary Care 2:289-294, 1975 4. Hecht AB: Improving medication compliance by teaching outpatients. Nurs Forum
13:112-129, 1974 S. Sackett DL et al: Randomized clinical trial . of strategies for improving medication compliance in primary hypertension. Lancet 1:1205-1207, 1975 6. Zifferblatt SM: Increasing patient compliance through the a pp lied analysis of be havior. PrevMed4:173-182, 1975
VOL 65/NO 5/MAY 1979/POSTGRADUATE MEDICINE
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
A behavioral approach to patient compliance James P. Schmidt To cite this article: James P. Schmidt (1979) A behavioral approach to patient compliance, Postgraduate Medicine, 65:5, 219-224, DOI: 10.1080/00325481.1979.11715152 To link to this article: http://dx.doi.org/10.1080/00325481.1979.11715152
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [University of Calgary]
Date: 04 August 2017, At: 15:31
A behavioral approach to patient compliance
James P. Schmidt, PhD
Downloaded by [University of Calgary] at 15:31 04 August 2017
Consider What are the three components ofa behavior sequence? How con a medication-taking pattern be programmed into a patient's /ife-style? What three attributes must a reward have to be useful in reinforcing a behavior?
A behavioral approach to increasing a patient's compliance with a drug regimen uses manipulation of the three components of a behavior sequence: the antecedent, the behavior, and the consequence. Success of a behavioral program depends on a cooperative relationship between physician and patient. The recurring problem of patient noncompliance continues to hamperthe implementation of drug therapy. While the subject of noncompliance bas been examined extensively,1-3 research into methods of overcoming it bas been relatively neglected. To date, the method used most often is that of educating patients about their disease, the reasons for taking medications, and how the drugs should be taken.4,5 While this approach bas met with sorne success, many patients still fail to adhere to a treatment program. Behavioral procedures are the basis of a new strategy to increase patient compliance. 6 The behavioral model views every behavior sequence as having three components: an antecedent, a behavior, and a consequence. Manipulation of these three components increases the likelihood that a given behavior will resuit. This article presents a behavioral model that may be used by physicians or their assistants to increase the likelihood of patient corn pliance. Each of the three components is discussed in turn as it specifically applies to compliance. The antecedent In regard to a therapeutic regimen, the antecedent to compliance is the
eue or signal that reminds the patient when it is time to take the prescribed medication. In my experience, most patients rely on memory rather than on an external eue. Reliance on memory is chancy, at best, especially because memory of the illness is often unpleasant. The behavioral model for compliance focuses on strengthening the external eues to the timing of medication, thus reducing dependence on memory or other internai signais. To do this, the physician must first assess the life situation of the patient, a task that may be brief or extensive depending on the drug regimen and the patient. A regimen containing only one drug or a drug that is to be taken only once a day is much easier to program into a patient's life-style than is a regimen containing several drugs or one drug that must be taken several times a day or under special conditions, such as on an empty stomach. Programming a medication-taking pattern into a patient's life-style by the modification of eues is accomplished in three steps: l. Identification and use of events that occur regularly in the patient's life-style. The regularity of certain events should not be taken for granted. For example, the patient may not eat three meals a day or go
continued VOL 65/NO 5/MAY 1979/POSTGRADUATE MEDICINE
219
Downloaded by [University of Calgary] at 15:31 04 August 2017
A medication·taking pattern can be programmed into a patient' a lite-style by identifying regular events and then establishing a link between one of these and medication ta king.
James P. Sehmidt At the time this article was written Dr Schmidt was a staff psychologist and member of the teaching staff of the department of psychiatry, Letterman Army Medical Center, San Francisco. He is nowa staff psychologist with the division of psychology, University Hospital, University of Saskatchewan CoUege of Medicine, Saskatoon. He received his PhD in clinical psychology and is interested in applications of psychology to medical problerns, the hospital treatment of psychiatrie patients, and teaching.
220
to bed at the same time each night; th us, if the medication schedule specifies "take at mealtime" or "take at bedtime," the regimen may be disrupted. Likewise, many habits practiced during the week are not carried over into the weekend or into vacation time. Activities that might provide a regular environmental eue include eating and other oral habits (eg, smoking, chewing gum, eating an evening snack), bowel and elimination habits, television-viewing habits (eg, the evening news), reading habits (eg, the daily paper), hobbies, work habits, bedtime habits (eg, showering, turning down bed, checking locks), waking habits (eg, shaving, dressing), religious habits (eg, daily prayer, reading of the Bible), habits involving other people (eg, a regular cali to family or friends), sexual habits, ànd established health habits (eg, exercising, taking vitamins, brushing teeth). 2. Establishment of a link between a regular habit and medicine taking. This may be done directly or indirectly. In the direct method, the medicine is used as the eue and its eue value is increased by placing the medicine in the area where the habituai action is repeated. Thus, it might be left on the television set if it is to be taken when the patient watches the evening news, or beside the milk in the refrigera tor if it is to be taken with meals and the patient drinks milk with every meal.
In the indirect method, a novel eue or signal is substituted for the medicine and built into a habit. The indirect method is especially important if the medicine must be stored in the refrigerator or if there are children in the home. Thus, tape is placed over the saltshaker as a reminder of a mealtime regimen, or a small circle of paper is attached to one corner of the television screen as a reminder that the medicine is to be taken during a certain show. 3. Building in of eues if regular habits cannot be identified or if a link cannot be established. Examples include setting an alarm dock each day to signal medication time, placing reminder signs in the bathroom or kitchen, or carrying reminder cards in the wallet or purse. Built-in eues are most effective if each one preprograms the next in a cyclic fashion. For example, a patient who must take medication mornings and evenings places the pill bottle inside the pillowcase in the morning. Removing the bottle from the pillowcase in the evening reminds him or ber to take the medicine and to leave the bottle in a shoe. Seeing it in the shoe in the morning is a reminder to take the medicine and to put the bottle back inside the pillowcase, and so on. The behavior The importance of educating patients about their illness and the necessary medication cannot be overemphasized. In addition, sorne re-
VOL 65/NO 5/MAY 1979/POSTGRADUATE MEDICINE
Downloaded by [University of Calgary] at 15:31 04 August 2017
A suitable reward for compliance must be immediate, neither too strong nor too weak, and continuously rewarding.
education often is necessary. When patients enter the physician's office they already have been "educated" by friends, family members, and the various media to have certain expectations regarding physician, illness, and medication. lt is important for the physician to identify and challenge expectations that are unrealistic or inaccurate, for these often interfere directly with compliance. Examples of counterproductive beliefs include "1 should stop the medicine when 1 feel better." "If 1 were a better, smarter, or stronger person, 1 wouldn't need the medicine." "If 1 miss my medicine once, l'Il take twice as much the next time to catch up." "If 1forget to take the medicine, I'd rather not come back at ali than to come back and get the doctor mad at me." Unrealistic or inaccurate beliefs often can be elicited by asking how the patient feels about being ill and about taking medicine. Refutation of such beliefs is important, especially of those that might prevent the patient from retuming to the physician or that might cause the patient to lie about degree of compliance. Unrealistic statements are best dealt with nonthreateningly. First, the patient should be asked if he or she sees any reason why the belief might be untrue or counterproductive. Then a more realistic view can be pointed out. A conversational, relaxed manner is best: The patient who perceives the physician as being angry or authoritarian may be reluctant to
VOL 65/NO 5/MAY 1979/POSTGRADUATE MEDICINE
openly examine the belief in question.
The consequence Patients often report that, while they know the medicine will help in the long run, they do not take it because it is inconvenient to do so or because they dislike the side effects. These reasons for noncompliance often can be overcome by helping the patient to establish a self"'reward system for taking the medicine. For example, a patient mi~ht agree not to have dessert or watch a favorite television program until the medicine has been taken. While such an agreement easily can be broken or ignored, most persons a bide by it once they have made a commitment to the physician. To be effective the reward must have three qualities: lt must be immediate, it must be of appropriate strength (neither too strong to resist nor too weak to be effective), and it must continue to be rewarding when used repeatedly. Thus, a personal gift would be a poor reward because the time interval between compliance and purchase might be too long, the object rnight be irresistible and th us be purchased even without compliance, and the reward might cease to have value after several gifts had been acquired. On the other band, a piece of candy rnight be a good reward in that it would be immediately available, neither too strong nor too weak for most people, and repeatedly gratifying.
In helping the patient to establish a self-reward program, it is best to write out a contract or agreement. In it the patient should specify the rewards he or she is to receive for a particular behavior.
Other aspects of the behavioral program Three other points about the behavioral program are important. One is the need for follow-up monitoring. Routine monitoring by the physician of the degree of patient corn pliance can be critical. Monitoring is best viewed as a way not of "catching" the patient but of ascertaining whether the program is working, and if it is not, of understanding why and correcting the problem. If compliance is treated as a problem which both physician and patient must address, the chance of success is greatly increased. When noncompliance does occur, there is a good chance that the patient will retum to the physician and try to deal with the problem in other ways. Monitoring may be done by subjective report by the patient, a calendar record of medicine intake, pill counts, a check of physical signs, or sorne combination of these. Reliance on subjective recall is the easiest method but also the most unreliable, in that it depends heavily on the patient's memory. When a treatment pro gram is planned by physician and patient together, the likelihood that it will be followed is increased if the physician continued 221
P+S
A behavioral compliance program usually can be planned and implemented in 15 to 20 minutes by any trained health care worker.
PROBLEMS+SOLUTIONS
May we help you?
Downloaded by [University of Calgary] at 15:31 04 August 2017
Do you need another opinion? When you want consultation about a problem case- its diagnosis, probable course, possible complications, treatment, or potential sequelaese nd us your query. Be as succinct as possible, but be sure to include ali pertinent details. We cannot publish photographs or tracings, but these may be included with the query if essential to an understanding of the case. We shall try to return ali such material but cannot assume responsibility for its loss. We will submit your question to one or more of our consultants -ali outstanding specialistsand promptly forward the reply to you. Selected problems are published anonymously each month.
records the compliance plan in the medical record. When the patient retums for follow-up visits the physician inquires how specifie parts of the plan have gone, to insure that the patient bas been dealing with eues, beliefs, and rewards correctly between visits. A second point is that the program need not be administered or planned by the physician to be effective-it can be supervised by a nurse, technician, or physician's assistant. Because the behavioral procedures given in this article are conceptually simple and straightforward, they can be leamed and used relatively rapidly. A comprehensive compliance program can be planned and implemented in 15 to 20 minutes with most patients. A final point is that compliance, both to a medication and to a behavioral program, is greatly increased if the physician bas fostered a cooperative rather than an authoritarian relationship with the patient. The program is a method of increasing the patient's self-control rather than the physician's control over the patient. As such, it requires a cooperative relationship that leaves
the patient with a desire to apply self-control techniques to the task of compliance. Summary A behavioral program for increasing a patient's compliance with a drug regimen can be administered by a physician or by trained health care personnel. The program focuses fJrst on the development of a strong extemal eue to the timing of medication and then on hëlping the patient to have realistic expectations and to establish an appropriate selfreward for compliance. Monitoring of degree of compliance is essential to the success of the program, as is development of a cooperative, rather than authoritarian, relationship between physician and patient.
The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
Address reprint requests to James P. Schmidt, PhD, Psychology Division, University Hospital, Saskatoon, Saskatchewan S7N OW8, Canada.
References
Send queries to: Problems+Solutions POSTGRADUATE MEDICINE
4530 W 77th St
Minneapolis, MN 55435
224
1. BlackweU 8: The drug defaulter. Clin Pharmacol Ther 13:841-848, 1972 2. Boyd JR et al: Drug defaulting. 1. Determinants of compliance. Am J Hosp Pharm 31:362-367, 1974 3. Matthews D: The noncompliant patient. Primary Care 2:289-294, 1975 4. Hecht AB: Improving medication compliance by teaching outpatients. Nurs Forum
13:112-129, 1974 S. Sackett DL et al: Randomized clinical trial . of strategies for improving medication compliance in primary hypertension. Lancet 1:1205-1207, 1975 6. Zifferblatt SM: Increasing patient compliance through the a pp lied analysis of be havior. PrevMed4:173-182, 1975
VOL 65/NO 5/MAY 1979/POSTGRADUATE MEDICINE
