Non-Compliant Behavior and Obesity

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Childhood Obesity News talked about non-compliant behavior, or NCB, in relationship to clinical trials, and in the context of chronic illness. There is more to say about that, because obesity is certainly a chronic condition, and so is diabetes, which frequently comes along for the ride.

In America’s past, “doctor’s orders” were almost as sacred as holy writ. Resistance surely existed, but the phenomenon of self-injury through non-compliance was not studied.

Dr. Fred Kleinsinger has written about the tendency of patients in ongoing treatment to omit certain behaviors that they have been asked to perform, even though it interferes with the effectiveness of treatment. He says:

I believe that were we able to sufficiently understand our patients, their lives, what their illnesses mean to them, and how they cope with their illnesses, every act of noncompliance would seem to make sense — at least at some level.

His early, touchingly naive belief was that the patients simply didn’t get it. If only they could be led to understand the importance of carrying out their part of the bargain, everything would work out. He says:

My solution, therefore, for all noncompliant behavior was to repeat — more emphatically — why my recommendations were important and to reiterate my explanations and dire predictions until I felt that the patient could comprehend and would comply.

Well, that didn’t work. Piling on information turned out not to be the answer. Dr. Kleinsinger became convinced that it is not patients, but doctors, who need to get a clue. He notes that few physicians have been trained to identify the causes of non-adherence, and even fewer have the skills to prevent or counteract NCB.

It appears that a study manager would also benefit from learning the same skills that can help the family physician to secure better compliance. He says:

I have found that, similar to many other problems in medicine, NCB is caused by multiple, often intertwined factors… Any patient may be influenced by more than one of these causative factors, and I am sure many other factors exist that I have not yet encountered or do not yet understand.

I found that making the effort to understand the causes of each patient’s NCB helps me tailor an approach to removing obstacles and encouraging the patient’s full participation in their own health care.

What might those obstacles be? Cultural issues, for sure. Doctors forget how intimidating they are, even when they try hard to relate. The patient might be too polite or too frightened to indicate any lack of understanding. Or they may not even know that they don’t understand. Something could be going on with the patient, like the beginning of dementia.

The ultimate non-compliance joke

(This is ancient, and paraphrased from the original, wherever it may be.)

A girl recovers from rheumatic fever, which weakens the heart and makes pregnancy a life-threatening risk. But these are the old days, and there is a cultural assumption that people don’t do the thing that results in babies unless there is a wedding first. Also, people speak in euphemisms. So when the doctor sits the girl down for a serious talk, he does not speak plainly. Instead, he asks her to promise that, for the sake of her health, she will never get married.

Years later, the doctor runs into the woman, surrounded by a passel of children, obviously her own. With bafflement and injured dignity he says, “I thought we agreed that you should not marry.”

She says, “Oh Doctor, I did follow your advice. My parents disowned me, and the church excommunicated me, and even my babies’ father doesn’t understand. But I never did get married.”

This fable illustrates the crucial need for clarity. The moral of the story is, of course, to be as sure as possible that patients and study subjects understand what they are signing up for. But even then, it’s not a complete answer — as Dr. Kleinsinger learned.

Your responses and feedback are welcome!

Source: “Understanding Noncompliant Behavior: Definitions and Causes,” NIH.com, Fall 2003
Photo credit: The Library of Congress on Visualhunt/No known copyright restrictions

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