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COMPLIANCE
Ensuring compliance, in terms of patients adhering to their treatment
programmes, is one of the major problems associated with treating asthma.
Patient non-compliance goes some way to accounting for the 2,000 or so deaths
that occur as a result of asthma each year.
Research (1,2) indicates that a successful treatment
programme (i.e. one with which the patient will comply) looks not only at
treating the physical symptoms of the disease, but also considers and satisfies
the patient's psychological and social needs. In an attempt to reduce the
number of patients whose lives are compromised by the condition, the Department
of Health targeted asthma for particular attention during 1995. (3)
Non-compliance is a major problem in all chronic diseases, but rates for
asthma are alarming. Studies indicate a rate of 30 to 70% of non-compliance
(1) for inhaled and oral therapy in both asthmatic adults
and children. (4) Compliance with regular preventative
therapy is usually worse than with reliever inhalers, because these are
perceived by patients as more effective in relieving symptoms. The key
determinants of compliance can be summarised as: the patient's understanding of
the disease, their treatment programme and possible side-effects; the
appropriate selection and correct instruction on inhaler device and technique;
and the patient's level of confidence in their nurse or doctor.
Cochrane (1992) has identified three types of non-complier (5) that the asthma practitioner will encounter in treating
patients with asthma:
- on/off compliers take their therapy, feel better and so stop the treatment,
then start again when they feel worse
- regular under-users consistently take less medication than prescribed
- patients who comply with one therapy but not another; this often means that
the bronchodilator is used regularly but a steroid inhaler is not
Nurses have a vital role in increasing patient compliance with asthma
treatment. In particular, research (6) demonstrates that
nurses must get to know their patient and address their health beliefs,
especially their "illness attribution". This is what the patient
thinks may have caused their asthma (e.g. outside factors such as atmospheric
pollution, family history).
In addition, the patient's perceptions of who is responsible for their
health (their "focus of control") will determine the success of
different styles of asthma management programmes. For example, a patient with
an internal focus of control feels responsible for their own health, may
respond well to self-management plans as they prefer to be in control, and may
be hostile that they have developed asthma.
An external focus of control causes patients to feel that their health is
the responsibility of the doctor or nurse. They may well follow advice, but
will need a lot of support before they can self-manage. Feeling that nobody has
any effect on their health is the response of the fatalist who, consequently,
is particularly difficult to manage. However, patients decide what they will
and will not do to manage their disease, and studies suggest that individuals
are more likely to comply with treatment or advice if they have been involved
in the decisions, rather than if they are passive.
Patient denial is another issue with which nurses must contend. It is
usually seen in patients who adopt an emotion-focused (as opposed to a
problem-focused) coping strategy to deal with an asthma diagnosis. Studies
(7) indicate significant underestimation by patients of the
severity of their condition. This denial is the result of the patient's fears
and concerns, which are areas that the nurse must address. If a problem-focused
strategy is adopted, patients will try to find out more about the condition,
and try to reduce it by taking medication. This may lead to better disease
management.
Essentially, management plans need to be individualised to fit in with the
patient's personality, coping strategy, lifestyle, and expectations.
Understanding what bothers the patient most about their condition will lead to
more focused consultation, and team work within the primary care unit
(including the nurse, GP, and pharmacist) will ensure that a consistent message
is communicated to the patient who can then consolidate her knowledge. Hyland
and Leg have produced the Asthma Bother Questionnaire (8)
which aims to identify those areas causing most distress to the patient. If
these concerns can be allayed, and the patient has a good understanding and
knowledge of their condition, a solid basis for good compliance has been set.
References
1. Rand CS, Wise RA. Measuring adherence
to asthma medication regimens. Am J Resp Crit Care Med 1994; 149: S69-76
2. Hussar DA. Patient non-compliance. J Am Pharm Assoc.
1975; 15 (4): 183-201.
3. Department of Health (September 1994) On the state of the
public health 1993.
4. Dekker FW, Dieleman FE, Kaptein AA, Mulder JD. Compliance
with pulmonary medication in general practice. Eur Resp J 1993; 6, 886-890.
5. Cochrane GM, Therapeutic compliance in asthma; its
magnitude and implications; Eur Resp J 1992; 5: 122-145
6. Horn CR. Compliance by asthmatic patients - how much of a
problem. Res Clin Forums 1986; 8 (2): 47-53
7. Turner-Warwick M. Nocturnal asthma: a study in general
practice J Roy Coll Gen Prac 1989; 39, 239-243
8. Hyland M, Leg a. Measurement of psychological distress in
asthma treatment programmes. Br J Clin Psychol, in press.
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