Marston: Discussion 405

resulted in the development of voice stress analyzers. These devices provide information concerning the truthfulness of responses based on the quality of speech. Results obtained from the use of voice stress analyzers are said to parallel the results of lie detector tests. Research using instrumentation of this sort should be undertaken to determine whether these data could provide the researcher or clinician with accurate information concerning noncompliance, on the bases of which more appropriate interventions could be devised.

Future Directions for Compliance Research That Have Potential for Translation into Practice

Haynes has shown conclusively that demographic factors, illness featu-xs, and source of care show little relationship to compliance behavior. Complex regimens are generally associated with noncompliance. Knowledge concerning diagnosis and its treatment has not fared much better."

According to Becker and Haynes,? the theoretical approach which, to date, shows the most promise for explanation and prediction of compliance behavior is the Health Belief Model, formulated by Hochbaum,lo Rosenstock,ll and others, and further elaborated by Becker.12 Originally the Model was used pri- marily in correlational studies (e.g., Heinzelmann l:{), and to explain certain health-seeking or early detection behaviors (Hochbaum l o ) . Becker has postu- lated motivation for health, a concept not a part of the original Model. Becker urges testing of the Model in prospective studies, since there is a question as to whether the belief system precedes or follows the behavior, an issue not resolved by correlational studies. The five essential ingredients of the Health Belief Model, as revised by Becker, are 1. perceived vulnerability to illness, 2. per- ceived seriousness, 3. perceived efficacy of treatment, 4. presence of cues to action, and 5. a relative absence of impediments to accomplishing the recom- mended behavior. Demographic and cultural variables, social support systems, and patient-provider relationships are treated as moderating variables. Various elements of the Health Belief Model are manipulable. One major example is the work of Leventhal and his co-workers lJ* 11 on the use of fear communica- tions to manipulate perceived vulnerability. It remains for future research to demonstrate whether perceived control over what happens to the individual, also a manipulable variable ( MacDonald 1 6 ) , will complement other elements of the Model to potentiate compliance behavior. Health education. The traditional health-education approach to enhancing patient compliance has two assumptions: 1. patients are rational beings with respect to their health behavior; and 2. adequate knowledge concerning illness and treatment regimens (which includes attitude change following health- education efforts) is associated with compliance. For the most part, reviews of the literature are in agreement concerning the lack of a positive association between patients' knowledge of their disease and/or therapy and compliance

An important distinction must be made between knowledge, per se, and health education, defined more broadly. For example, Maccoby and Farquhar 2"

have been engaged in a large-scale field investigation in three northern California towns. This investigation is aimed at testing the effectiveness of various health- education techniques in changing target behaviors known to be predisposing factors for coronary heart disease. Preliminary findings demonstrate that health

behavi0r.G. 8 . 17-19

406 Annals New York Academy of Sciences

education via the mass media plus one to one and small group discussions with certain high risk groups are effective in reducing, significantly, cigarette smoking, and in initiating dietary changes. This study employs certain behavior modifica- tion techniques such as modeling, as well as traditional health education ap- proaches. Most of us are aware of television vignettes that advocate continuance of antihypertensive drugs by black males who, especially, are at risk for hyper- tension and its sequelae. The passage of PL94-317 (Health Information and Health Promotion) in 1976 provides further endorcement for the widely held belief that health-education theories and techniques, defined broadly can have a positive impact on this nation’s health. Need for carefully planned, randomized designs for field investigations o f coin- pliance. Sackett and the McMaster researchers ?’. ?? make an eloquent plea for carefully constructed, randomized designs for the conduct of future studies of compliance behavior. It is important to do field investigations patterned on Sackett’s and Maccoby’s paradigms to learn conclusively which approaches are effective in potentiating compliance with particular populations and diagnostic groups. Without research of this sort we may discover that what we thought were sound findings are not reproducible. The approaches used by Sackett and Maccoby should be undertaken with diagnostic groups which exert major impact on our population as evidenced by morbidity and mortality statistics. Traditional epidemiologic data include prevalence of the diagnostic entity, as much informa- tion as possible about it, and how it may be prevented or its effects ameliorated. Data such as perceived susceptibility, seriousness, effectiveness of usual treat- ment, etc. (elements of the Health Belief Model) should be included also. These latter data should be taken into consideration in devising intervention strategies to the same extent as are traditional epidemiologic data. Need for congruence between perceptions of patients and professionals concern- ing compliance behavior. The compliance literature reflects, predominantly, the attitude that the professional knows best what the patient should do about health and illness issues. This one-sided kind of approach, with the primary onus on the patient, appears more like coercion, or conformity for the sake of con- formity, than like cooperation of patient and professional in joint effort to optimize the patient’s health status. We are faced with a 50% noncompliance rate, on the average. In many cases we have lost sight of the end point, the patient’s health status, in stumbling over the impediment of patient noncompli- ance. A few investigators have suggested and provided limited data to support the notion that certain elements of the patient-provider relationship may be more conducive to compliance than are 0 the r s .~3 -~~ It is imperative that we learn more about the patient-provider relationship before concluding that workers without health training are as effective in persuading patients to comply as are professionals. Aspects of the relationship, per se, yet to be identified, may be a more important factor than the issue of lay versus professional helpers. Use of behavior modification techniques. A number of re~earchers,*~-?~ have suggested and/ or tried various behavior modification approaches via tailoring of regimens, use of contracts, etc. Empirically, these approaches “work and theoretically may, in turn, alter the attitude and belief system, so that the desired sequence of events, namely compliance behavior followed by improved health status, ensues. Increased utilization of support systems. Theoretically, patients’ compliance behavior should be influenced by their perceptions of how they think persons

Marston: Discussion 407

most significant to them think they should act. It must be made clear that patients’ perceptions of what their significant others think they should do may not be congruent with what the significant others actually think. An early study by Gray, Kesler and Moodyao demonstrated that mothers who thought that their neighbors thought they should have their children immunized against polio were significantly more likely to have their children immunized than were mothers who did not hold these beliefs. Two more recent efforts to provide social support for patient compliance have been those of Fass 31 who taught a family member concerning the patient’s illness and medical regimen, and Caplan’s work at the University of Michigan32 on the use of a buddy support system. Research is needed to determine whether the professional’s selection of a person to provide support to a patient in complying with his medical regimen is as effective as determining who the patient himself believes is his most significant other, and working with this duo. Need for identifying whether critical periods exist for the onset o f noncompli- ance with specific medications. There may be so-called “critical periods” when patients discontinue taking specific medications. For example, there is an assumption that the greatest decrement in pill taking for women on oral contra- ceptives is at the end of the first month. If critical periods can be identified for the onset of noncompliance for other medications, such information could be utilized to change or otherwise tailor the regimen, or some other type of intervention could be devised.

Surnrnary

The major points of this discussion are:

1. There is a need for research aimed at developing better criterion measures of noncompliance so that professionals can direct scarce resources where they are most needed. The specific suggestion made concerned one type of instru- mentation that may be potentially useful in identifying noncompliers.

2. Research should be undertaken to determine whether critical periods exist when patients are at risk of discontinuing particular medications. Such information could be utilized in devising appropriate interventions.

3. An eclectic approach, utilizing the Health Belief Model, health education and behavior modification strategies, and social supports should be undertaken in large scale epidemiologic-type field investigations in keeping with the format of the McMaster studies.

4. Much work remains to be done to identify elements of the client-provider relationship which are associated with compliance behavior.

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