People, regardless of the era in which they live, have the well recognized behavior of not following their provider's plan of care. Hippocrates warned his student, “Keep watch also on the faults of the patients, which often make them lie about the taking of things prescribed.”

Whether the “faults of the patient” are described as non-compliance, non-adherence, or non-concordance is not important, although hundreds of papers and articles have been written concerning the virtue of using "adherence" over "compliance." Labels are not behaviors and nothing is accomplished, relative to patient care, by debating which label best describes the problem. People are not following the plan of care and the end result is a significant increase in readmissions, morbidity and mortality.

To date, no better definition of behavior has arisen more than the poet Emily Dickinson. She wrote, at least a century ahead of B.F. Skinner, that "Behavior is what a man does [or says]. It is not what he thinks, believes, or feels." As you continue through this blog, it is important to keep this simple definition in mind. Other methods for combating non-adherence focus on feelings, beliefs, attitudes, ambivalence, and a number of internal or cognitive events.

Why Are Patients Non-Compliant?

I can understand why people in ancient Greece may have been reluctant to take some of the compounded medications of that era. Keep in mind, that every generation was "modern" in their time. In our modern time, major pharmaceutical agencies have pointed to “behavior” (see title chart above) as the most common cause for noncompliance. Take a closer look at each of the major categories described in this research (see chart below) by AstraZeneca and Frost and Sullivan. You will see that “behavior” represents only one of the eight categories described (or in my observation - mislabeled) as "behavior."

ICE IF SAD is a mnemonic I created to help me remember the most common reasons people are non-compliant. While the above researchers suggested that these factors are "behaviors," the reality is,  most of the reasons people do not follow the plan of care are related to events before (antecedents) or consequences following a medication taking behavior. Can you pick the one label that is a behavior?

One of the really inconvenient aspects of our language is that we use labels to frequently describe behavior. Patients are described as “non-compliant.” Keep in mind that not doing something is not a behavior. People are “forgetful” and forgetful is not a behavior. Describe what a person does when they are “forgetful.”  According to this study, 16% of the patient population don’t take their medications because “they forgot.” Describe the behaviors associated with “being forgetful”. Dr. Ogden Lindsley developed the dead man's test (as we discussed in a previous blog) as a way to demonstrate whether an event was a behavior or not. "If a dead man can do 'it' perfectly... it is not a behavior." A "dead man" has forgotten everything. Forgetting is therefore not a behavior.

Everything Related to Behavior is either an Antecedent or a Consequence

All behavior, things we say or do, are surrounded by cues or antecedents (things that come before the behavior) or consequences (things that follow the behavior that
increase or decrease the behavior). In the next blog I'll get into the ABC's of behavior in more detail. The desired behavior in medication adherence is taking the right medication, at the right time, by the right person, via the right route, in the right dose. From our patient's perspective, if the consequences of taking medication is punishing, you can count on non-compliance. In the coming blog "Following the ABCs of Behavior" we'll review the consequences of behaviors with a tool that will help you look at your recommendations from the patient's point of view.

Inconvenience, expense, and side effects are punishing consequences that can be easily managed by providers if they are aware that their patient is having some difficulty with them. Then there is accepting and distrust. Motivational Interviewing practitioners would most likely blend them together under the title "AMBIVALENCE." The question is, "Is ambivalence an antecedent or a consequence to non-adherence?" For the answer, check back in the next blog.

If the goal of patient education is behavior change (e.g., taking medication as prescribed) then we need to focus on behavior. Motivational interviewing (MI) has an
important role to play in addressing ambivalence and addressing feelings and thoughts. When the interviewing is done patients are discharged back to the
environment and reinforcers that got them admitted in the first place. The real question is "With who and how are you going to reinforce the new behaviors?" Thomas Edison once said, "There's a better (BeTr) way... find it."

Behavioral Education and Research Services, Inc. (BEARS) focuses on improving patient outcomes by training nurses and other health services professionals in Adherence Management (AdM) Coaching.

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