Editorial: The practitioner and the compliant patient

Treating tuberculosis: the essential role of social work

The resurgence of tuberculosis gives cause for alarm. Compliance with an effective medication regimen leads to cure; yet, many patients fail to comply. This paper discusses factors affecting compliance and the essential role of social work, from an ecological perspective, when intervening to increase compliance. The authors relate comments made by patients at the only hospital originally and still serving as a TB sanatorium in relation to literature on compliance. Changes at the hospital include the development of a social work department which uses the ecological perspective in working with patients whose histories include non-compliance, as well as alcoholism, homelessness, loneliness, joblessness, and AIDS. The content of interviews with patients reveal and identify problems for future research.

Patient treatment adherence. Facility design and counseling skills

OBJECTIVE

To describe the essential facility characteristics for a model patient counseling area: (1) activities that should be accommodated by the facility; (2) special environmental and interior design features, with a discussion of their impact on the healthcare provider-patient interaction; (3) storage and equipment requirements; and (4) determination of space requirements for the counseling area. A second objective is to suggest a strategy to follow when justifying an adherence clinic.

DATA SOURCE

Primary and secondary sources of literature were reviewed in the areas of pharmacy, psychology, and architecture to identify design specifications for the patient counseling area.

CONCLUSIONS

The design of a counseling area can indirectly affect the quality of the interaction between the patient and healthcare provider, primarily in terms of its effect on communication. The key features that should be included in the design of the area are different levels of privacy (visual and auditory), "soft" interior decoration, and accommodation of people with disabilities. There are several design-related barriers to communication that should be avoided in the facility. The space required for a counseling area is dependent upon the scope of services provided--approximately 100-130 square feet may be necessary.

Management of tuberculosis in urban homeless indigents

Tuberculosis patients who are homeless, indigent, and alcoholic infrequently complete a course of chemotherapy, risking treatment failure, recurrence, and continued spread of infection in the community. Obstacles to successful treatment include an erratic schedule, mistrust of authority, and uncooperative or aggressive behavior. Successful management of this problem requires the use of proven case holding techniques, a correct choice of drug regimen, and a prompt and appropriate response to the patient who is lost or refuses treatment. Nine- and six-month drug regimens with proven success are now available; however, the direct observation of medication-taking should be maximized. Patient default may be further minimized by encouraging prompt notification of the health department. Occasionally, the threat or use of existing public health laws on confinement for purposes of treatment are required for noncompliant patients.

Consensual norms regarding patient involvement

A stratified sample of 72 nurses, physicians and members of the general public met together in small tripartite dialogue groups each month for 20 months, in order to mutually identify health care behaviors that effectively involve patients in their own health care. Content analysis of 200 hours of verbatim transcripts from the dialogue sessions yielded 1245 patient involvement behaviors. These behaviors were rated by all subjects for their degree of importance within the normative health care relationship through use of a Likert-type inventory. Analysis of the 656 behaviors from the inventory which were classified as essential for effective patient involvement produced 44 clusters, with inter-item correlations ranging from 0.80 to 0.95. Further reduction of the 44 clusters indicated six core clusters, suggesting key norms that existed regarding effective involvement of patients in their own care. Salient norms centered on overt contracts in health relationships, egalitarian communication between patient and professional, patient access to broad-based information, tailoring of treatment programs, self-care and lifestyle modification. The lack of congruence between these norms and the realities of health care is discussed.

Compliance and the health belief model: a challenge for the liaison psychiatrist

Noncompliance or nonadherence to prescribed medical regiments is a widespread problem. The behavior of noncompliance is complex, requiring an analysis based upon theoretical constructs. We review the Health Belief Model (HBM) as one such construct that may aid in understanding the problem. The four essential ingredients of the model include (1) a perception of susceptibility to disease, (2) a belief that the impact of this disease will affect him/her biologically and/or psychosocially, (3) a belief that the potential benefits of the regime outweigh the risks of the disease and its treatment, and (4) an ability to surmount barriers to treatment. The HBM has been shown to have construct validity and has provided a means of exploring practical and cost effective methods for reducing noncompliance and perhaps morbidity and mortality associated with failures to follow up on recommended medical procedures. Moreover, the general problem of noncompliance provides a unique opportunity for students of human behavior to interact constructively with their medical and surgical colleagues.

Knowledge of and compliance with drug regimens in the elderly

In an interview study of 545 patients recently discharged from The Johns Hopkins Hospital, data were collected on the patients' knowledge of their diseases, knowledge of drug purpose, and compliance with the prescribed drug regimen. The interrelationships of these variables were compared in patients under age 65 and patients aged 65 or older. Age-related factors and trends were sufficiently important to warrant further investigation. Knowledge of and compliance with drug regimens may reflect doctor-patient relationships. Understanding the patterns of drug use offers a potential for appropriate strategies in clinical practice.

Intentional prescription nonadherence (noncompliance) by the elderly

Prescription drugs are not always taken as directed. When there is a discrepancy between the use of a drug and the prescription directions, the drug-taking behavior is considered "nonadherent." To determine the extent of prescription non adherence by old persons and the reasons for nonadherence, an in-home survey was made of 111 elderly subjects who were taking prescription drugs. Drug-taking behavior was compared with the behavior implied by the prescription instructions, the reasons for the differences were sought. Of the study sample, 43 per cent showed such differences in use of one or more prescription drugs. The chief type of discrepancy was underuse (90 per cent of nonadherence). No difference was observed in most of the psychosocial variables studied between those who took drugs as directed and those who did not. Hypertensive subjects did not differ from those without hypertension. A large proportion of nonadherence (73 per cent) was intentional. Intentional nonadherence was more likely to occur in subjects who used two or more pharmacies and two or more physicians. Traditional efforts aimed at reducing the incidence of forgetting to take medicines would not seem to be helpful in cases of intentional nonadherence.

Effect of patient education on medication compliance

Noncompliance is a major contributing factor to therapeutic failure. Many complex variables hae been reported to interfere with patient compliance. Though there are exceptions, educational techniques have been shown to be of value. Patients with diagnoses of schizophrenia, and bipolar and unipolar affective disorders were separated into control and experimental groups and studied to determine the factors associated with poor compliance and the potential value of educational techniques. Following a course of lectures and data sheets, the "educated" patients tended to be more compliant on outpatient follow-up. They were also less fearful of side effects and addiction. Factors associated with poor compliance were related to severity of illness, social isolation, fear of dependency and side effects (extra-pyramidal).