Adherence versus Compliance:

Rethinking our Role in Patient Behaviors

Carrie (Potts) Tamayo, MA, CCC-SLP

Sarah Ginsberg, Ed.D., CCC-SLP
 Learner Objectives
• Explain key differences in terms
• Identify adherence factors
• Generate strategies for enhancing
adherence
• Describe benefits/limitations of
measurement methods
• Incorporate adherence goals into
treatment plans
 Adherence

What are we talking about?

 Adherence
• Up to 80% of patients
• Changes over time
• SLP: voice, stuttering, dysphagia,
acquired cognitive impairments……
• Consequences
Background
Recalcitrance

Compliance

Adherence
 Conceptual Shift
Compliance:

Patient

Adherence:

Patient Provider
 Adherence “Myths”
• Adherence is simple

• Treatment outcomes as indicators

• Provider predictions

• We can’t influence behavior

 Adherence Factors

Patient Treatment Provider

Characteristics Program Characteristics

Adherence
 Small Group Discussion
• Generate a list of factors that you think
influence patient behaviors:
– Patient characteristics
– Treatment program characteristics
– Provider characteristics
Patient Characteristics
Most Relevant:
•Understanding
•Past adherence
•Self-efficacy
•Barriers to Implementation
•Social support**
•Satisfaction with care
•Avoidance coping
Least Relevant:
•Demographics
• Personality

Dunbar-Jacob, Burke, & Puczynski (1995)

Treatment Program

Complexity
Frequency/Duration
Consistency
Continuity of care
Aversive/non-reinforcing events
Cost (financial, emotional, social)

Meichenbaum & Turk (1987)

Dunbar-Jacob, Burke, & Puczynski (1995)
Provider Characteristics

Communication skills
Attitudes
Procedural aspects
(e.g., wait time….)

Dunbar-Jacob, Burke, & Puczynski (1995)

 Factors: Dysphagia
• Low et. al (2001)
- Setting
- Age

• Factors related to compliance (speculation)

– Taste
– Less “thirst-quenching”
– Less gratifying
– Poor awareness
 Factors: Dysphagia
• Factors related to compliance
- Denial
- Dissatisfaction
- Calculating risk
- Rationalization
- Minimization

Colodny (2005)
 Factors: Cleft Palate
• “Best predictors”
– Age
– Proximity
– Visits
– Type of cleft
– Financial
– Severity perceptions
– Understanding perceptions
– Self-efficacy expectations
– Attitude

Paynter, Jordan, & Finch (1990)

 Factors: Acquired Cognitive
Impairment
• “Barriers to Compliance”
– Difficulty of task
– Structure of program
– Reliance on others
– Difficulty initiating tasks, recalling

Lemoncello, Sohlberg, & Fickas (2008)

 Strategies
• Designing Intervention
– Education
– Tailor/adapt
– Pairing
– Self-monitoring
– Pacing
– Self-efficacy

Dunbar-Jacob, Burke, & Puczynski (1995)

 Strategies
• Providing Instructions/Education
– Environment
– Caregivers
– Language
– Repetition
– Follow-up
– Consistency
– Modeling
Clark & Becker (1998)
Dunbar-Jacob, Burke, & Puczynski (1995)
 Strategies
• Behavioral Techniques
– Self-monitoring
– Goal setting
– Feedback
– Contracting
– Reinforcement
– Cueing/Reminders
• Provider-initiated follow-up

Dunbar-Jacob, Burke, & Puczynski (1995)

 Strategies
• Self-efficacy enhancement
– Cognitive-social learning theory
– Exercise and diet
– Spousal involvement

Dunbar-Jacob, Burke, & Puczynski (1995)

 Strategies
• Enhancing HCP-Provider Relationship
– Communication
– Patient satisfaction with visit
– Willingness to adhere

Clark & Becker (1998)

Improving Communication: HCP
Behaviors
1. Attentive
2. Patient concerns
3. Reassuring
4. Addresses concerns
5. Engages patient
6. Tailors regimen
7. Non-verbal and verbal encouragement
8. Goal-setting
9. Reviews long-term plan
10. Advanced planning
Clark & Becker (1998)
 Strategies: Voice Therapy
• Motivational Interviewing
• Self-study?

Behrman (2006)
Behrman, Rutledge, Hembree, & Sheridan (2008)
 Strategies: Home Programs
• Personal Motivation
• Social Support
• Ongoing feedback
• “Enhance Program Characteristics”
– Instructions
– Scheduling
– Ongoing re-assessment
• Assistive Technology?
Lemoncello, Sohlberg, & Fickas (2008)
 Strategies: Speech Sound
Disorders
• Computer-led practice?

Nordness (2008)
 Measurement Tools
• HCP judgment
• Self-report
• Electronic monitoring
• Biological measures
• Directly Observed Therapy (DOT)

Rand & Weeks (1998)

 Pros/Cons
Method + -
HCP judgment Cost Reliability

Self report Cost Accuracy

Ease Time concerns
Patient Characteristics Interviewer skills
Electronic Self-monitoring Availability
monitoring Cost
Biological Physiologic measures Potential for false positives
measures Yes/No only (not degree)
DOT Effective Logistics
Ethical issues
 Measuring Adherence
• Bottom Line
– Multiple measures
– Individualized
– Sensitive
– Encourage self-monitoring
– Interview methods

Dunbar-Jacob, Burke, & Puczynski (1995)

Rand & Weeks (1998)
 Small Group Discussion
• Pick an area of clinical practice (e.g.,
dysphagia, voice, articulation, etc.)
– How could you modify your care plan to
promote adherence?
– What measurement tools might you use?
– Barriers?
 Dealing with Slips
• Regular and ongoing follow-up
• Identification of factors
• Adjustment of program/Behavioral
interventions
– Contracting
– Self-monitoring
– Education
 Final Thoughts
• Conceptual Shift
• Future Directions
• Questions?
 Selected References
• Behrman (2006). Facilitating behavioral change in voice therapy: The relevance of
Motivational Interviewing. American Journal of Speech-Language Pathology, 15, 215-225.

• Behrman, A., Rutledge, J., Hembree, H., & Sheridan, S., (2008). Vocal Hygiene Education,
Voice Production Therapy, and the Role of Patient Adherence: A Treatment Effectiveness
Study in Women with Phonotrauma. Journal of Speech, Language, and Hearing Research,
51, 350-366..

• Clark, N. M., & Becker, M. H. (1998). Theoretical models and strategies for improving
adherence and disease management. In S. A. Shumacher, E. B. Schron, J. K. Ockene, & W. L.
Mcbee (Eds.), The Handbook of Health Behavior Change (2nd ed.; pp. 3-32). New York, NY:
Springer Publishing Company.

• Dunbar-Jacob, J., Burke, L. E., & Puczynski, S. (1995). Clinical assessment and management
of adherence to medical regimens. In P. M. Nicassio& T. W. Smith (Eds.), Managing Chronic
Illness: A biopsychosocial perspective. (pp. 313-350). Washington, D. C.: American
Psychological Association.

• Garcia, J. M., Chambers, E. & Molander, M. (2005). Thickened liquids: Practice patterns of
Speech-Language Pathologists. American Journal of Speech-Language Pathology, 14, 4-13.
 Selected References
• Lemoncello, R., Sohlberg, M.M., & Fickas, S. (2008). Maximizing home exercise program
completion for adults with acquired cognitive impairments. Poster session presented at the
ASHA Annual Convention, Chicago, IL.

• Low, J., Wyles, C., Wilkinson, T. & Sainsbury, R. (2001). The effect of compliance on clinical
outcomes for patients with dysphagia on videofluoroscopy. Dysphagia, 16, 123-127.

• Miller, L. G., & Hays, R. D. (2000). Adherence to combination antiretroviral therapy:

Synthesis of the literature and clinical implications. The AIDS Reader, 10(3), 177-185.

• Nordness, A.S. (2008). Effects of Parent- vs. Computer-led Home Practice Compliance.
Poster session presented at the ASHA Annual Convention, Chicago, IL.

• Paynter, E.T., Jordan, W.J., & Finch, D.L. (1990). Patient compliance with cleft palate team
regimens. Journal of Speech, Language, and Hearing Research, 55(4), 740-750.

• Rand, C.S., & Weeks, K. (1998). Measuring adherence in clinical care and research. In S.A.
Schumacher, E.B. Schron, J. K. Ockene, & W.L. McBee (Eds.), The handbook of health
behavior change. (2nd ed.). (pp. 3-32). New York, NY: Springer Publishing Company.

• Wilson, L., Onslow, M., & Lincoln, M. (2004).Telehealth Adaptation of the Lidcombe
Program of Early Stuttering Intervention: Five Case Studies. American Journal of Speech-
Language Pathology, 13, 81-92.