Understanding non-compliance to improve patient behaviours

There are many beliefs and assumptions about compliance that we have come across over the years when researching patient behaviour globally. With millions of pounds a year being wasted on unused prescription drugs, finding out the motivations behind why patients do or don’t take their medication as prescribed is vitally important for health professionals.

This is not just a matter of money for an under-pressure health service, it’s about a patient’s health.  According to the Medicines Partnership the proportion of patients classified as non-compliant at six and 12 months was 61 per cent and 68 per cent respectively which is undoubtedly a huge concern.  

In an attempt to shed some light on the reasons behind non-compliance, here we outline five of the most universal myths and assumptions as to why patients don’t take their medicine.   

Myth 1: “Compliance is always linked to the severity of the condition i.e. the more severe a condition, the more likely a patient is to comply”

Despite extensive research, a definitive link between compliance and severity of condition still proves elusive. During our research, we have seen that compliance can be a significant issue in a whole variety of therapy areas including life threatening conditions such as cancer, transplant rejection, HIV and heart failure. As with much in life, reasons for non-compliance are not straightforward but multi-faceted.   

The reality of living with a severe illness, the burden of the regimen, the emotional distress and stigmatisation, among many other factors, can strongly influence compliance irrespective of disease severity. In situations such as transplant rejection, side effects of the drugs can lead to patients covertly missing doses. We see in HIV, despite the advances in treatment making it now more an area of chronic disease management, issues such as denial, stigma and many cultural and lifestyle concerns can lead to frequent missed doses.  

So although disease severity is undoubtedly a motivator towards better adherence to treatment, it is not the only factor.

Myth 2: “Compliance always improves with less frequent dosage”

As many of us have personally experienced, compliance is a lot easier when it is once daily rather than three times daily. There is a considerable volume of evidence demonstrating that reducing daily pill burden can have a significant impact on compliance. However, at what point does prolonging the dosing interval become counterproductive?

Often a daily preparation can be simpler to remember than a biweekly; it fits more naturally into a patient’s routine. In addition, we can see that fears start to increase about having a ‘foreign chemical’ in your body for such a long duration, leading to non-compliance. 

Myth 3: “A sensible patient equals a compliant patient”

Many doctors even admit to not being compliant with medication. Despite this, doctors can often make assumptions about a patient’s compliance based on their perceived class or education level.  We have seen this with our TriSight approach - where we oversee doctors observing group discussions with patients. They were surprised when they heard directly about patients’ non-compliance.  In some cases their reasons for non-compliance were deliberate but in a number of cases it was accidental i.e. the patient had simply misunderstood the instructions and their understanding hadn’t been checked. 

Evidence shows that doctors are not routinely asking patients how they are getting on with their medications that are taken in the long term. This is critical in improving compliance rates as we often see that patients may feel that it is inappropriate, feel embarrassed or feel the doctor is too busy to raise any issues and simply stop treatment or miss doses instead.  Similarly patients can feel inhibited about asking about a medicine’s side effects or raising any reservations about them.

Myth 4: “Non-compliance can be improved by simply reminding patients to take their medication”

There have been numerous compliance programmes adopted over the years that have provided a simple reminder service to patients to take their medication. These are particularly popular for chronic preventative conditions where often there was little obvious reward for taking the medication (and consequently compliance rates can be particularly poor). While some of these services did show at least some short term gain, many were destined for failure. 

Without really understanding the barriers to non-compliance, it is difficult for health professionals and the pharmaceutical industry to effectively design a programme. A reminder service is not going to overcome the feeling of ostracisation felt by a teenager who wants to fit in but has to do a blood glucose reading when out with friends or overcome the denial of some patients with high blood glucose levels or high cholesterol. 

So while in certain situations and for certain patients a reminder service may be sufficient, it is clear that a one size fits all approach is not going to be the answer given the complexity of the issues affecting compliance.

Myth 5: “More information means a more compliant patient”

As with the reminder services, the concept of providing information to improve compliance has been a highly appealing solution. Although understanding the condition and treatment is important, provision of information alone does not often provide the solution. There have been studies in chronic conditions such as asthma, hypercholesterolemia and diabetes that have seen no change in compliance irrespective of the knowledge levels of the patients (including understanding of the consequences of non-compliance).

Improving compliance often involves complementary use of educative, practical and emotionally and behaviourally supportive interventions rather than just information alone. There is evidence that regardless of specific knowledge imparted, self- management programmes which help to raise people’s sense of ownership and confidence are more effective in promoting better medicine taking. 

There is no silver bullet when it comes to compliance. It is therefore vital that health care professionals understand the products, their side effects and the reason for non-compliance to motivate behaviour change in both patients and healthcare professionals alike. Only then could we begin to see rates of non-compliance decline, patients’ health improve and in turn, less money being wasted on unused drugs by the NHS.