Unit 4 - Prescribing Partnerships

Compliance and Concordance


What is compliance?

Definitions of compliance range from 'patient acceptance of recommended health behaviours' (Becker et al, 1977) to 'what the patient is expected to display by paternalistic prescribers who think they know best' (Sanghani, 1998).

The literature states that 50-70% of patients comply with medication regimes (Wright, 1993), from which we can assume that 30-50% do not comply.

The concept of concordance differs from compliance in that it is more about reaching an agreement between a patient and a prescriber with regard to their illness and treatment.

Non-compliance

Stewart (1987) defined non-compliance as intentional or unintentional behaviour. Where non-compliance is intentional — sometimes referred to as intelligent or rational non-compliance — the patient is exercising control over treatment.

Reasons often cited by patients for intentional non-compliance are:

  • The patient thinks the treatment does not work, or will not work
  • The patient may be genuinely confused about the instructions for taking the medication
  • They may feel the side-effects are too unpleasant
  • There may be a lack of financial or practical resources to continue with treatment
  • There is poor communication between the professionals and the patient.

Unintentional non-compliance can be due to lack of appropriate information or lack of awareness of the importance of the medication regime. The underlying causes of unintentional non-compliance should be identified and action taken accordingly.

In addition to attribution theory and the Health Belief Model, outlined in 'The Psychology of Prescribing', the first part of Unit 4, there are other psychosocial theories of non-compliance. These explore perceptual theories that concern patients' values and beliefs and cultural theories.

Reflection

Think of three patients and consider what you have learnt about their health locus of control and attribution.

How might this affect their compliance or non-compliance with a medication regime?

From compliance to concordance

Compliance models are concerned mainly with patients being passive recipients of the prescriber's ideas, while concordance models are concerned more with giving patients information about their disease and treatment options (Misselbrook, 1998).

When patients talk with prescribers about taking medication for a particular health problem, each approaches the problem from a different perspective.

  • The prescriber usually looks for a textbook answer. Once the ideal treatment has been found — effective, fast-acting, evidence based and backed by national guidelines — the challenge is to persuade the patient of its value to ensure that the medicine is taken

  • The patient may believe that a prescription medicine is only one possible way to tackle the illness. They may not like the idea of drug treatment — the medication maybe too strong or it may be addictive. They may already be planning to talk to a friend, surf the web for more information or see a herbalist for an alternative option.

Both of them are looking for a solution that works
If neither the prescriber nor the patient knows what the other is thinking, the chances of success will be low. If they share their beliefs, experiences and understanding of the problem, there is a better chance that they will agree on a way to tackle it.

This agreement is what is meant by concordance
Thus, the issue is not one of compliance — 'will the patient do what I tell them?' — but one of concordance — 'have I understood the patient's health beliefs and negotiated a course of action both of us are happy with?'.

Make Notes

Write down examples you can recall of patients/clients who have moved from non-compliance to compliance or from compliance to concordance. Consider the factors that facilitated this. How, as a prescriber, would you become aware of non-compliance? Keep a note of any such situations in your reflective diary.

Further Reading

Further reading

The Medicines Partnership discusses the issue of taking patients from medication compliance to concordance,
www.concordance.org

Hobden, A. (2006) Concordance: a widely used term, but what does it mean? British Journal of Community Nursing, 11 (6) 257-260.

Hobden, A. (2006) Strategies to promote concordance within consultations. British Journal of Community Nursing, 11 (7) 286-289.

Britten, N. (1998) Communication: the key to improve compliance. Prescriber 9: May 19, 27-31.

Dowell, J. (1998) Achieving concordance to improve treatment. Prescriber 9: 22, 21-25.


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