Drug compliance and identity: reasons for non-compliance

Abstract

The aim of the study was to describe patient experiences of medication. Patients with asthma/allergy were interviewed in depth twice with 8 years between. The interviews were analysed according to the phenomenographic approach and three categories, one with four sub-categories, were identified: ‘access to medicine is important to relieve discomfort and to avoid fear’, ‘medicine damages your body and your identity without curing the illness’ (because ‘you can become immune or addicted’, ‘the ability of your body to heal itself is weakened’, ‘your body’s own signals are camouflaged’ and ‘you become stigmatised’) and ‘production and distribution of medicine is a profit-seeking commercial undertaking which is not primarily aimed at curing the patient’. Medication experiences were stable over time. Sociological and biological survival must be compared in an open discussion along with the patient’s and health professional’s different reasons for how they take or prescribe medication.

Introduction

Low rates of compliance have been seen as one of the most serious problems facing medical practice [1]. They pose a major challenge to effective management of most chronic diseases, including asthma [2]. About 50% of patients who suffer from chronic diseases are not compliant regarding the taking of medication [3]. Within the asthma field, estimates of compliance range between 20 and 80% of prescribed therapy [4], [5]. The great variety is largely due to methodological problems when measuring compliance [6].

Compliance is originally a military term [7]. Within the health and medical care sector it generally means following a recommended treatment regimen. It is grounded in the communication between doctor and patient where the patient is obedient, trustful and passive, while the doctor is paternal, authoritarian and active. The term compliance is criticised especially from social scientists [8], [9] and health care ethicists [10] as being judgmental: there is something wrong with non-compliant patients.

No absolute answers as to why patients do not comply have been found and there is little evidence of sustained success from the many efforts to improve compliance [11]. In a review, it is concluded that optimum benefits of medications cannot be obtained at currently achievable levels of compliance. Prevalent methods of improving compliance are not sufficient and there is a need for new methods [12]. A new relationship between patient and prescriber as equals, who have established a true partnership, a ‘therapeutic alliance’, has been advocated [3]. Such a relationship should be based on respect for the patient’s beliefs and wishes, without diminishing the doctor’s, and on openness, ‘so that both doctor and patient together can proceed on the basis of reality and not of misunderstanding, distrust or concealment’ ([3], p. 8). The aim is to attain a negotiated agreement, ‘concordance’. Though this relationship is mutual, the decisions made by the patient are regarded to be the most important. Marinker [13] points out that by respecting the patient’s autonomy when inviting to discussion, a negotiation about the appropriate intervention is possible, which may end up in a sub-optimal treatment. But he continues that a negotiated consensus is more likely to result in behaviour change than paternalistic direction. Also in the asthma field, partnership has been recommended [14]. Instead of a doctor-oriented communication, partnership requires patient orientation [15], [16], [17], i.e. not only the medical but particularly the patient’s experiences are to be attended to.

Patient experiences of medication have been the focus of several studies, showing that non-compliance is not a disobedient behaviour, but an adequate, rational act from the meaning the patient ascribes medication [18], [19], [20], [21], [22], [23], [24].

The beliefs that people hold about drugs are suggested to be of utmost importance for medicine taking, and as they often not are in line with the stance of medical science they consequently receive minimal attention from the prescriber [3].

The present study was grounded in the assumption that people have good reasons for being non-compliant, grounded in their own experiences of medicine and medication. The purpose of the study was to find out how those with asthma/allergy experience prescribed medicine and medication, and to investigate any changes to these experiences over time. Unlike most studies within this field, this study has a longitudinal design. The ultimate goal is to bring about learning by making the patient’s concrete sensory experiences and reasons for how to take medicine as important as the prescribing professional’s reasons for the prescription. Thereby, it might be possible to attain concordance and hopefully bring about an improvement in the individual patient’s life situation.