Tasleem Akhtar ( PMRC Research Centre, Khyber Medical Coliege, Peshawar. )
The patient compliance is a big problem in disease management which is evident from the large number of publications on the subject in the medical literature. Even in the economically advance countries with high literacy rates and adequate health care facilities, patient compliance is a serious problem faced by doctors. In a study by Bergman and Warner1 59 families having children with streptococcal phaiyngitis were studied, only 30% were found to adhere to a 10 day course of penicillin, although 95 percent of these families knew the appropriate regimen. In hypertensive patients about 50% fail to follow referral advice, over 50% drop out of care and only 2/3rd of those who remain in care comply with the therapeutic regimen prescribed. Estimates of non compliance for short term medication regimens have been as high as 92%. The average for chronic diseases is about 50%2.
Factors which influence patient compliance have been summarised by Mathews and Hingson3 Factors which consistently influence compliance are the nature of regimen offered, the belief patients hold about their illness and treatment and certain features of patient doctor interaction.
Complexity of the treatment regimen and increased duratioii of therapy decrease compliance. Regimens which require change in behaviour of the patient such as dietary habits, smoking and drinking are less likely to be followed as are regimen which disrupt the daily routine of the patient. Expensive drugs especially when prescribed for extended period of time would be less likely to be taken, particularly in developing countries like Pakistan where the major burden of therapy falls on the patient even in the so called free government hospitals4 Non compliance is high when the disease being treated is asymptomatic or psychiatric. However severity of the disease in terms of painfulness, disability or threat to life does not ensure as high a compliance as one would expect3. The possible reasons could be that severe illness requires more complex and difficult drug regimen. Also the patient may find it difficult to comply owing to limitations imposed by the illness or may be discouraged by failure of previous therapy to cure his ailment3.
The patient’s beliefs about his illness has consistently been found to influence compliance independently of his knowledge about the disease and treatment. In the studies conducted on the subject, the beliefs included in the “Health belief Model” which was originally formulated to predict compliance with preventive health measures, were applied to drug compliance2,3
When applied to compliance it was found that patients who feel susceptible to complications or further attacks of their illness, believe that their illness could have severe consequences for their health, have belief in the effectivity of the treatment regimen and do not anticipate adverse drug reactions or increased cost of therapy are more likely to comply with the prescribed therapy. Certain characteristics of patient and physician interaction have also been shown to influence patient compliance. When patients are satisfied with their physician and the care being provided, they are more likely to comply with therapy prescribed. When doctors underestimate the patients knowledge of the disease and therefore give them less information, the patients are less likely to follow instructions3.
Factors which are expected to influence compliance but have not been found to do so consistently are demographic characteristics, severity of illness and knowledge regarding illness and regimen to be followed. The latter was demonstrated by Sackett et a15 in a randomised controlled trial including 230 hypertensive men. The experimental group was given intensive instructions about the disease and although they did show an increase in knowledge as compared to the control group, the expected increase in compliance did not occur. The study of Bergman and Warner1 in the 59 families with children with streptococcal pharyngitis, mentioned earlier, also showed that families with more knowledge of the regimen, did not show increased compliance.
Having discussed the problem of patient compliance as encountered in the developed countries, it is time to look at the problem as it exists in Pakistan. As is the case with many other serious health problems, no adequate data on patient compliance is available. One small study on the prescribing patterns of Medical practitioners in Peshawar6 has shown that all categories of doctors prescribed on an average four medicines per prescription. The instructions to the patient are sketchy and generally illegible. Since in the overcrowded clinics and outpatient departments, there is not much time to explain to the patient verbally the use and timings of the many medicines prescribed, it is not surprising that the patient gets mixed up and confused. Multiple and complex drug therapy also leads to increased adverse drug reactions. Therefore although no actual figures are available, it can be safely assumed that with the prevalent prescribing practices patient compliance would be very low.
Does this matter? A leading article in the BMJ, has also posed this question for the Medical Practitioners in the developed countries. The author for the article feels that unnecessary prescribing is more of a problem than non compliance and that if all the thugs prescribed were to be taken by the patients according to instructions, there would be a tremendous increase in adverse drug reactions and the financial burden would be immense.
In a country like Pakistan, it is difficult to say which is the more important of the two problems. Patient non compliance or unnecessary prescribing. The control of diseases like Tuberculosis and Malaria depend to a large extent on case finding and treatment. Therefore patient compliance becomes very important. However it is also a fact that drugs like the antibiotics, vitamins, antacids, psychoactive drugs and steroids are prescribed in large numbers6 most of the time unnecessarily. Therefore before formulating recommendations for improving patient compliance in Pakistan, it is necessary to conduct well planned studies on the subject inorder to put the problem in its proper perspective.
1. Bergman, A.B. and warner, RJ. Failure children to receive penicillin by mouth. EngLJ.Med., 1963;268: 1334.
2. Eraker, S.A., Kirscht, J.P. and Becker, M. H. Understanding and improving patient compliance. Ann. Intern. Med., 1984; 100: 258.
3. Mathews, D, and Hingson, R. Improving patient compliance. Med. Clin. North Am., 1977; 61:
4. Nishtar, T. and Ahmad, N. Patient cost per hospital bed. Pakistan J. Med. Res., 1980; 19:60.
5. Sackett, D.L., Haynes, R.B. and Gibson, E.S. Randomised clinical trials of strategies for improving medication compliance in primary hypertension. Lancet, 1975; 1: 1205.
6. Alchtar, T., Ahmad, N., Billand, B. and Chaffar, A. Prescribing patterns of medical practitioners. PakistanJ. Med. Res., 1982; 21(1):330.