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Indian Journal of Community Medicine

A Study on Compliance and Behavioral Responses of Patients in an out-Patient Clinic

Author(s): Mrs. J.P. Acharya, I Acharya

Vol. 28, No. 1 (2003-01 - 2003-03)

Deptt. of PSM, B. J. Medical College, Ahmedabad - 16

Keywords: OPD patients, Full, Partial and non-compliance, Behavioural responses

Research question: What is the level of compliance, the reasons of compliance failure and prevailing behaviour of OPD patients?

Objective: To assess the relationship between behavioural responses of out-patients and their various levels of compliance.

Study design: Longitudinal follow-up of patients.

Setting: An out patient clinic with basic facilities like laboratory, X-ray, minor OT etc. in Ahmedabad cantonment area.

Participants: 250 OPD patients who required follow-ups.

Study variables: Level of compliance to medical regimen, various reasons for partial and non-compliance and behaviour ot patients in relation to prescribed drugs, treating doctor and OPD environment.

Statistical analysis: Proportions.

Results: The overall compliance profile showed 59.8% to be fully compliant, 39.6% as partially compliant and 0.6% as non-compliant. Compliance failure was mostly due to side effect of drugs (28.3%), forgetting to take the doses (23.1 %), bad taste of drugs (15.2%) etc. Analysis showed that the fully compliant patient had understood the prescription properly, was prescribed less number of drugs, thought the treatment to be effective, could identify the drugs prescribed, had a good impression of the treating doctor's acumen, behaviour, way of examination and explanation ot the disease and found the waiting period in the OPD suitable, the staff skilled and helpful and sitting arrangements comfortable. The non-compliant and partially compliant were not satisfied with the drugs, doctor and OPD staff.

Introduction:

The load of illnesses in a developing nation like India, is enormous. Morbidity and mortality can be reduced markedly by the patients compliance to the prescribed regimen of drugs. This practice, however, varies from non-compliance to complete compliance through various degrees of partial compliance.

Both partial and non-compliance lead to unsuccessful treatment, a significant problem faced by the doctors, today.The non-compliance rates vary from 15% to as much as 90%1-3.

The reasons for poor compliance are mainly discontinuation of treatment, say, when the patient felt better or when the immediate expected results of therapy did not appear. Either of the reasons are based on deliberate action,misinterpretation or inadequate information 4.

Most of the studies on drug compliance have been carried out in the developed countries on patients of chronic illnesses like Rheumatic Heart Diseases 5 , Chronic Suppurative Otitis Media 6 , Hypertension 7 , etc. Very few studies have taken place in India 8, 9 .

Material and Methods:

The cantonment in Ahmedabad is located in the north-eastern part of the city, spread over 5.6 sq. km area, with an approximate population of around 14,000. The residential areas are within the cantonment as well as in adjacent localities of Sadar Bazar, Sardar Nagar and Meghani Nagar etc.

The study was carried out amongst persons residing in and around the cantonment area from Jan to Dec 1997 in one of the out-patient clinics which had basic facilities like a laboratory, X-ray, minor O.T., etc The average daily patient load varied from 60 to 80 cases a day. A Medical Officer assisted by para-medical staff including pharmacist was available. The clinic was open from 0800 hrs to 1400 hrs everyday except Sundays and holidays. Random sampling method was utilized. In the case of patients below 15 years of age, the person accompanying was interviewed (patient attendant).

Observations:

During the study period, out of a total of 6,395 new OPD cases, 250 (3.91%) were included. Their details are presented under three broad groups:

Compliance to prescribed medical regimens:

Compliance to medical regimen was based on acceptance of essential drugs prescribed to the patient with reference to his illness. If he/she consumed all the essential drugs, it was considered as Full compliance, if none taken it was considered as Non-compliance and when only few of the essential drugs were consumed it was taken as Partial compliance. For each follow up, compliance was assessed and weighted compliance for the three follow-ups was also calculated.

Table I: Distribution of cases according to compliance of medical regimen as per follow up status.

Follow up No. Examined Compliance Status
Category   Full
(no.)
% Partial
(no.)
% None
(no.)
%
First 250 145 58.0 101 40.4 4 1.6
Second 250 166 66.4 84 33.6 0 0
Third 222* 121 54.5 101 45.5 0 0
Weighted 722 432 59.8 286 39.6 4 1.6

*28 cases were lost to follow up at the third visit.

Thus, 59.8% were fully compliant, 39.6% partially compliant and only 0.6% were non-compliant.

Reasons of compliance failure:

Table II: Reasons for partial and non-compliance of cases as per follow-up status.

Reasons for Partial and
Non-Compliance
Compliance Status
First
(no.)
% Second
(no.)
% Third
(no.)
% Weighted
(no.)
%
Side Efffects 35 33.3 23 27.4 24 23.8 82 28.3
Forgot Dose 26 24.8 19 22.6 22 21.8 67 23.1
Bad Taste 13 12.4 16 19.1 15 14.8 44 15.2
No Benefits 7 6.7 4 4.8 8 7.9 19 6.5
Social reasons 5 4.8 7 8.3 4 3.8 16 5.5
Domestic commitments 4 3.8 2 2.4 8 7.9 14 4.8
Felt better 2 1.9 2 2.4 8 7.9 12 4.1
Wrong Instructions 3 2,8 4 4.8 4 3.8 11 3.8
Household Work 5 4.8 2 2.4 3 2.9 10 3.5
Miscellaneous Reasons 3 2.8 4 4.8 3 2.9 10 3.5
School Timings 2 1.9 1 1.2 2 1.9 5 1.7
Total 105 100.0 84 100.0 101 100.0 290 100.0*

*Multiple responses

Reasons of compliance failure at every follow-up were identified in those groups where partial and non-compliance were observed. The first five reasons were side effects of drugs (28.3%), foregetting the dose (23.1%), bad taste of drugs (15.2%), no benefits from drugs (6.5%) and social reasons (5.5%).

Behavioural responses:

The behavioural responses of the patients in relation to prescribed drugs, towards the treating doctor and towards ambient OPD environment were inquired at the first follow up itself. The influence of these variables on compliance was also assessed.

(a) Towards prescribed drugs:

Table III: Behavioural responses of cases/patient attendants towards prescriptions, at the first follow-up.

Reasons No. of Respondants
N=250
Full Compliance
N=145
Partial Compliance
N=105
No. % No. % No. %
Number / Variety of Drugs in Prescription
More 73 29.2 21 28.8 52 71.2
Less 177 70.8 124 70.1 53 29.9
Nature of Prescription
Complex and difficult to understand 100 40.0 27 27.0 73 73.0
Sinple and easy to understand 150 60.0 118 78.7 32 21.3
Effective / ineffective Treatment
Effective 186 74.4 135 72.6 51 27.4
Ineffective 64 25.6 10 15.6 54 84.4
Drugs Identification at home
Identifiable 20 80.4 141 70.1 60 29.9
Unidentifiable 49 19.6 4 8.2 45 91.8

This was inquired in relation to the variety of drugs prescribed, understanding of prescription/regimen, effect of treatment and identification of drugs. 177 (70.8%) cases felt less drugs than expected were prescribed as compared to 73 (29.2%) who felt that more drugs were prescribed; 150 (60%) cases conveyed that the regimen was simple and easily understandable as against 100 (40%) who found the regimen complex and difficult to understand; for 186 (74.4%) cases the treatment was considered effective as compared to 64 (25.6%) for whom it was considered as ineffective and 201 (80.4%) cases felt that the drugs could be identified by them at home as against 49 (19.6%) who reported otherwise.

The full compliance rates were high when less drugs were prescribed (124 or 70.1%), medical regimen was simple and easily understandable (118 or 78.7%), treatment was effective (135 or 72.6%) and drugs were identifiable (141 or 70.1%). On the other hand, partial and non-compliance rates were high when more drugs were prescribed (52 or 71.2%), prescription was complex and difficult to understand (73 or 73%), the treatment was ineffective (54 or 84.4%) and drug was unidentifiable (45 or 91.8%).

(b) Towards the treating doctor:

Table IV: Behavioural response of cases/patient attendants towards treating doctor, at the first follow-up.

Reasons No. of Respondants
N=250
Full Compliance
N=145
Partial and/or
Non-Commpliance
N=105
No. % No. % No. %
Approach of the Doctor to His/Her Patient
Personal 207 82.8 136 65.7 71 34.4
Impersonal 43 17.2 9 20.9 34 79.1
Examination of Patient by Doctor
Satisfactory 233 93.2 143 61.4 90 38.6
Not Satisfactory 17 6.8 2 11.8 15 88.2
Explaining about the diseaser to the patient
Satisfactory 204 81.6 132 64.7 72 35.3
Not Satisfactory 46 18.4 13 29.3 33 71.7
Capability of Doctor about judging the severity of disease
Satisfactory 210 84.0 128 60.9 82 39.1
Not Satisfactory 40 16.0 17 42.5 23 57.5

Behaviour towards treating doctor was identified as regards the doctor's approach to the patient, examination of patient, explaining about the disease to the patient and capability of judging the severity of the illness concerned. 207 (82.8%) cases felt that the approach of the doctor was personal, as compared to impersonal approach reported by 43 (17.2%) cases; 233 (93.2%) cases stated that they were satisfactorily examined as compared to 17 (6.8%) who stated that examination was not satisfactorily carried out. 204 (81.6%) cases reported that the doctor's explanation of illness and related issues was satisfactory while 46 (18.4%) cases reported it to be not so satisfactory. 210 (84.0%) conveyed that capability of the doctor in judging severity of the illness was satisfactory as compared to 40 (16.0%) cases who said it was unsatisfactory.

Full compliance was high amongst cases who felt that the approach of the doctor was personal (136 or 65.7%), patient was satisfied with the examination carried out (143 or 61.4%), when doctor explained about the disease to patient (132 or 64.7%) and where doctor's capability to judge illness was satisfactory (128 or 60.9%). The partial and non-compliance was high when doctor's approach was impersonal (34 or 79.1%), patient was dissatisfied by doctor's examination (15 or 88.2%), when he could not satisfactorily explain about the disease etc. to the patient (33 or 71.7%) and where his capability to judge severity was unsatisfactory (23 or 57.5%).

(c) Towards OPD environment:

Table V: Behavioural responses of cases/patient attendants towards OPD environment at the first follow-up.

Reasons No. of Respondants
N=250
Full Compliance
N=145
Partial and/or
Non-Commpliance
N=105
No. % No. % No. %
Time gap between reporting of the patient and being attended by the doctor
satisfactory 242 96.8 142 58.7 100 41.3
unsatisfactory 8 3.2 3 37.5 5 62.5
Educationon taking of the drugs by the dispensing pharmacists
satisfactory 143 57.2 79 73.8 28 26.2
unsatisfactory 107 42.8 66 46.2 77 53.8
Services of Para-Medical staff
satisfactory 134 53.6 81 69.8 35 30.2
unsatisfactory 116 46.4 64 47.8 77 52.2
Sitting ararngements in OPD
satisfactory 211 84.4 133 63.1 35 36.9
unsatisfactory 39 15.6 12 30.8 70 69.2
OPD timings
satisfactory 166 66.4 99 59.6 78 40.4
unsatisfactory 84 33.6 46 54.8 27 45.2

The ambient OPD environment in the present study included time gap between reporting of patient and his/her being attended by the doctor, education imparted by the pharmacists on consumption of drugs, services of the para-medical staff, sitting arrangements and the OPD timings.

It was observed that 242 (96.8%) cases were satisfied with the time gap between reporting to the OPD and being attended to by the doctor as against 8 (3.2%) dissatisfied cases; 143 (57.2%) cases were satisfied with education on drug intake given by pharmacists as compared to 107 (42.8%) dissatisfied cases; 134 (53.6%) cases were satisfied with the services of para-medical staff as against 116 (46.4%) dissatisfied cases, 211 (84.4%) cases stated that available seating arrangements were satisfactory while 39 (15.6%) cases were not satisfied with the same, and for 166 (66.4%) cases the OPD timings were suitable as compared to 84 (33.6%) cases for whom the same were unsuitable.

Full compliance observed was more when time gap between reporting of the patient to OPD and being seen by the doctor was less (142 or 58.7%), satisfactory education on drugs was given by pharmacists (79 or 73.8%), services of medical attendants were found satisfactory (81 or 69.8%), seating arrangements were comfortable (133 or 63.1%) and OPD timings found suitable. Partial or non-compliance increased when time gap was relatively more (5 or 62.5%), pharmacists gave unsatisfactory education about drug intake (77 or 53.8%), services of medical attendants were found unsatisfactory (70 or 52.2%), seating arrangements were not satisfactory (27 or 69.2%) and OPD timings were unsuitable (38 or 45.2%)

Discussion:

Compliance of medication is a relatively new area of study. Various studies have shown non-compliance to vary in a wide range. This is not too surprising when one considers various methods of data collection and variations in the definitions of compliance8. The present study rates 59.8% patients as fully compliant, 39.6% as partially compliant and 0.6% non-compliant. Francis 10 reported comparable figures of 50.6% full compliance, 38.2% partial compliance and 11.2% non-compliance. Moulding 4 reported 31% partial compliance in tuberculosis patients. Hungerbuhler 7 reported 44% partial compliance in hypertensives and Mattars 11 figures range from 5 to 51%.

Reasons for partial and non-compliance from I through III follow-ups have been noted. 28.3% cases complained of side effects which is similar to studies done by Mazzulo 2 and Anderson 12 . 23.1% cases said that they forgot to take their medicines, similar to what Linn 1 found in elderly patients. 15.2% complained of bad taste of drugs as has again been observed by Linn, mostly in younger patients. 6.5% patients said they did not benefit from drugs given to them similar to observations by Francis. Other reasons cited here for partial and non-compliance were social reasons, domestic reasons, more number of drugs,feeling of betterment, school timings of children etc.

Kasl and Cobb 13 have observed that most compliance studies focus too much on demographic variables rather than attitude and perceptions in explaining whether or not patients were compliant. A lot of stress has, therefore, been given here, on behavioural aspects of patients towards the drugs and regimen, the treating doctor and the ambient OPD environment.

When the number of drugs was more, partial and non-compliance was as high as 71.2%. With a more complex regimen, full compliance was only 27% compared to partial compliance of 73%. Though Hungerbuhler found no relationship between the number of drugs prescribed and compliance, observations of Eraker 14 were similar to the present study. When the patient thought the treatment to be effective, compliance was 72 .6% This dropped to 15. 6% if treatment was ineffective quite similar to what Arya 9 observed in a PHC in Hyderabad. If the drugs were identifiable full compliance was again high (70.1 %), similar to what Hulka 15 had observed, in her study.

More than 60% full compliance was observed when the patient felt the doctors approach as more "personal", examination of the patient satisfactory, explanation of the disease proper and acumen in judging the severity of illness satisfactory. If the doctor was impersonal, callous in examination procedures, did not satisfactorily explain the disease to the patient or had poor acumen in judging severity of illness, the full compliance dropped to 11.8% and partial and non-compliance ranged from 57.5% to as high as 88.2 %. Francis had noted that unpleasant behaviour by the doctor affected compliance adversely. Linn also observed that if the physician examined the patients properly, the latters confidence grew and he/she was more compliant. Satisfaction of the case with the doctor and clinic was also co-related to compliance. While Charney 16 established along-standing relationship between compliance and behaviour of patient towards the doctor treating him/her. Davis 1 was not in complete agreement as in his study no such relationship could be established.

As regards the ambient OPD environment, less time gap between reporting to OPD and the doctors examination of the patients, proper dosage instructions by the pharmacists during drug dispensing, helpful para medical attendants, satisfactory sitting arrangements and suitable OPD timings favoured full compliance (58.7% to 73.8%). Whenever, the OPD atmosphere (as regards the above mentioned aspect) was not favourable, partial and non -compliance increased (41.3% to 69.2%).

Linn observed that employed younger patients who had long waits in between appointments were less compliant. Jain 8 observed 40.4% partial and non-compliance when inadequate and inappropriate instructions were passed on by pharmacists to the patients. Arya noted that some 2% of her patients did not find PHC timings as suitable and hence were non-compliers.

The present study has exposed lacunae in certain areas which need to be corrected for improving patient compliance. The following recommendations may help towards achieving the same to a large extent:

  1. Patients should be prescribed simple and effective regimen consisting of adequate number of drugs which can be easily identified by them.
  2. The doctor should be more personal in his approach, examine the patients properly explaining to him/her about the type and severity of illness and, therefore, also has to keep updating his/her knowledge about common illnesses encountered in the out-patient departments.
  3. The OPD environment should be improved with sitting arrangements comfortable and medical attendants helpful. The pharmacists must explain about the drugs and their dosages preferably both verbally and by writing on the pill boxes/covers. The waiting period of patients from the time of arrival to the time of examination by the doctor must be reduced, as far as possible.
  4. Each and every patient, his/her attendant and family member has to be educated about the importance of personal health, hygiene and sanitation, besides compliance so as to prevent occurrence of disease and reduce morbidity load in the community.

Acknowledgement:

Authors are grateful to Dr. C.K. Purohit, Director PG studies and Medical Research, BJ Medical College, Ahmedabad for his constant guidance during the course of this study.

References:

  1. Linn MW, Linn BS, Stein SR. Satisfaction with ambulatory care and compliance in older patients. Medical Care 1982, XX(6) 606-14.
  2. Mazzulo JM, Lasagna L, Griner PF. Variation in interrelation of Prescription Instructions JAMA 1974,227(8): 929-31.
  3. Davis MS. Variation in patients compliance with Doctors advice. An emperical analysis of patterns of communication: American Journal of Public Health 1968,58(2): 274-88.
  4. Moulding T, Onstad 4D, Starlarlo JA Supervision of out patient drug therapy with the Medication Monitors. Annals of Internal Medicine 1970; 73: 559-64.
  5. Elling R, Whittemore R, Green M. Patient participation in a pediatric program Journal of Health and HumanBehaviour 1960; 1: 183.
  6. Becker MH, Drachman RH, Kirscht JP. Predicting mothers compliance with pediatric medical regimen. Journal of Paeditirics 1972; 81(4): 843-54.
  7. Hungerbuhler P, Bovet P, Shamlaye C et al.Compliance with medication among out patients withuncontrolled hypertension in the Seychelles. Bulletin of the World Health Organization 1995; 73(4): 437-42.
  8. Jain L, Saxena S, Sen S. The fate of your prescription. Indian Pediatrics 1985; 22: 367-70.
  9. Arya S, Naidu AN. Community awareness attitudes and utilisation of Primary Health Centre in rural Hyderabad. Indian Journal of Community Medicine 1983;VIII(2): 13-21.
  10. Francis V, Korsh BM, Morris MJ Gaps in Doctor-Patient communication. The New England Journal of Medicine 1969; 280(10): 535-40.
  11. Mattar ME, Marketta J, Yajje SJ. Pharmaceutic factors affecting Paediatric Compliance. Paediatrics 1975; 55(1): 101- 8.
  12. Anderson RJ, Krik LM. Methods of improving patient compliance in chronic disease states Archives of Internal Medicine 1982,;142: 1673-5.
  13. Kasl SV, Cobb S. Health behaviour, illness behaviour and sick role behaviour. Archives of Environmental Health 1966; 12: 246.
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