In all fields of medicine, compliance to treatment is considered a “key link between process and outcome” (Vermeire et al., 2002). Yet, one of the greatest challenges therapists face in their clinical practice every day is patient compliance. Whilst adherence to therapy is a key determinant of a successful outcome; non-compliance rates to exercise have been documented as being as high as 70%; and failure to return for a follow-up review following an initial outpatient appointment is estimated to be upwards of 14% (Jack et al., 2010). Given that non-compliance is multi-dimensional in nature with personal, social, and environmental factors contributing to it, poor adherence is known for being particularly hard to address (Meade et al., 2021; McLean et al., 2010).
All too well known is the feeling of providing a patient with a meticulously planned program; only for them to return the following week having forgotten- or ignored- the education, recommendations, and their exercises. With so many variables and factors at play, it is important to understand the barriers- and facilitators- to therapy adherence amongst patients. Whilst many factors are outside of the control of the practitioner, barriers to compliance must be identified, and every effort must be made to ensure barriers are not accidentally put up by the practitioner themselves. Early identification of barriers is key so that steps can be made to reduce these, and factors facilitating adherence be implemented immediately, for the sake of positive patient outcomes.
What are some of the barriers that our patients face when it comes to adhering to their treatment program plan?
Bachmann et al. (2018) found in their systematic review a number of factors affecting patient compliance, including poor self-efficacy, fear of pain during or after completion of exercises, perceived inability to fit exercises into daily life and lack of time, high level of depression and anxiety, forgetting exercises, and a low baseline physical activity level.
Whilst many of these intrinsic barriers may seemingly be outside of the hands and even scope of practice of the therapist, there is a lot to be said for the power of early recognition, and early referral as part of a multi-disciplinary approach. Outcome measures assessing self-efficacy, self-motivation, and the presence of depression/anxiety, should be used early, and quick referrals should be made.
For example, the Self-Motivation Inventory (SMI) outcome measure, is used to measure self-motivation, and valid correlations between SMI scores and exercise adherence have been found (Dishman et al., 1980). In particular, psychology referral should be highly considered when appropriate, with there being moderate evidence suggesting motivation cognitive-behavioural therapy may be effective in improving attendance to exercise therapy (McLean et al., 2010).
How can we as healthcare professionals help to remove or reduce these barriers?
In respect to what therapists can do specifically to promote adherence, there have been several studies that have assessed the facilitators to patient adherence to their therapy, much of which the therapist has a great deal of control over. Bachmann et al. (2018) and Peak et al. (2020) found higher rates of program adherence when no more than 2-4 exercises were prescribed, verbal information supplemented with written handouts (2.72 times more likely to adhere), patients given positive feedback from their physiotherapist (rather than having their technique overly scrutinised), and a good social support network. Additionally, asking patients to repeat the details of their program in full has also been found to be effective, with these patients being 6.54 times more likely to be adherent (Peek et al., 2020).
How can we as healthcare professionals help to create an environment that promotes and supports facilitation?
‘Keep It Simple, Stupid!’ Do not overcomplicate things, give simple instructions and provide no more than 2-4 exercises. Provide these exercises in several different ways- verbal, video, and written. Provide lots of support, and give positive feedback. Check understanding – ask the patient to demonstrate their exercises in full. Be aware of the barriers patients may face and be ready to address these, or refer on when appropriate. Finally, encourage patients to meet basic activity guidelines.
Final thoughts on Barriers and Facilitators to Program Adherence
Healthcare professionals play a critical role in helping patients adhere to their treatment program plan. By understanding the barriers that our patients face and providing support through facilitation, we can help create an environment that promotes adherence and leads to better health outcomes for our patients.
Have you tried using any of these techniques in your practice? What has been the outcome?
Bachmann, C., Oesch, P., & Bachmann, S. (2018). Recommendations for improving adherence to home-based exercise: a systematic review. Physikalische Medizin, Rehabilitationsmedizin, Kurortmedizin, 28(01), 20-31.
Dishman, R.K., Ickes, W. and Morgan, W.P. (1980), Self-Motivation and Adherence to Habitual Physical Activity. Journal of Applied Social Psychology, 10: 115-132. https://doi.org/10.1111/j.1559-1816.1980.tb00697.x
Jack, K., McLean, S. M., Moffett, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual therapy, 15(3), 220-228.
McLean, S. M., Burton, M., Bradley, L., & Littlewood, C. (2010). Interventions for enhancing adherence with physiotherapy: a systematic review. Manual therapy, 15(6), 514-521.
Meade, L. B., Bearne, L. M., & Godfrey, E. L. (2021). “It’s important to buy in to the new lifestyle”: barriers and facilitators of exercise adherence in a population with persistent musculoskeletal pain. Disability and Rehabilitation, 43(4), 468-478.
Peek, K., Carey, M., Mackenzie, L., & Sanson-Fisher, R. (2020). Characteristics associated with high levels of patient-reported adherence to self-management strategies prescribed by physiotherapists. International Journal of Therapy And Rehabilitation, 27(1), 1-15.
Peek, K., Carey, M., Mackenzie, L., & Sanson-Fisher, R. (2018). Patient-perceived barriers and enablers to adherence to physiotherapist prescribed self-management strategies. New Zealand Journal of Physiotherapy, 46(3).
Vermeire, E., Hearnshaw, H., Van Royen, P., & Denekens, J. (2001). Patient adherence to treatment: three decades of research. A comprehensive review. Journal of clinical pharmacy and therapeutics, 26(5), 331-342.