Understanding Non-Compliant Behavior


Childhood Obesity News mentioned Dr. Fred Kleinsinger, who has done a lot of work regarding NCB, or non-compliant behavior. Why do some patients knowingly sabotage their treatment and/or the scientific research they might be involved in? Why are physicians not given better preparation for dealing with patient non-adherence to protocol? Fortunately, there is a skill set that can be taught and learned.

Clinicians need to understand that psychological issues carry a big stick. Whether in ongoing treatment for a chronic condition, or in the context of a formal study, there will be participants who suffer from depression, denial, and other psychological maladies whose symptoms can clash with the health care professional’s immediate objectives. Dr. Kleinsinger gives these examples:

In evaluating depression as a cause of NCB, I do not only include patients with a clear diagnosis […] but also patients whose depressed mood and defeatist attitude sabotage their ability to deal with their medical condition. Patients with bipolar disorders are often unpredictable, and their degree of compliance varies, depending on their mood state.

Some patients feel rewarded for remaining sick. In my experience, the most common reward is being classified as medically disabled.

This concept of “secondary gain” is part of the dynamic in some families. Often, one member is compensated, with attention and deference — by being served, by being relieved of responsibility in joint efforts — for being unwell. Sometimes, they have no other sense of identity or source of self-esteem. If a person does not care about seeking her or his own happiness, the doctor’s satisfaction or lack of it will not matter in the slightest.

Every so often, a patient comes along who manifests severe psychiatric illness. Once in a blue moon, something really bizarre turns up.

The everyday interactions

Fortunately, most doctor/patient or researcher/patient relationships do not carry so much freight. The majority of interactions are benign and fruitful, and can be more so when the professional takes some pains to facilitate things. This author’s initial recommendation has to do with framing. When NCB is encountered, it is to be considered not a failure, but a challenge.

With the caveat that this is not the whole answer, but only a starting place, it is vital to doublecheck that the patient understands what is expected, and why. Listening is important.

Does the patient have any suggestions about how their self-care behavior could be optimized? Dr. Kleinsinger adds:

Using the general categories I have suggested — and any of your own creation — develop a differential diagnosis for the cause or causes of the patient’s NCB… Discussing the case with a colleague may help generate a fresh perspective and a new approach.

How to Reduce NCB

Moe Alsumidaie wrote that there is evidence that “gamification invokes intervention with patients,” and added:

Gamification essentially enables patients to visualize study progress and rewards patients for adhering to study outcomes. Gamification is typically deployed via a mobile application or a web-based platform…

Gamification does not necessarily delight older people; it’s more of a youth thing. Text messaging, however, strikes a chord with a wider demographic group. Alsumidaie says:

A recent analysis has proven that text messaging effectively increased clinical trial recruitment and enrollment, which may suggest that text messaging can also be an effective and efficient tool that captivates patients during clinical trial conduct.

On the other hand, there is some evidence that people don’t want to cope with more gadgets, even familiar or user-friendly ones. So that could go either way. Devices are definitely helpful in solving one problem, the distortion caused by time lag. Retrospective reactions (like journaling at the end of each day) are increasingly frowned upon.

Your responses and feedback are welcome!

Source: “Understanding Noncompliant Behavior: Definitions and Causes,” NIH.com, Fall 2003
Source: “Technology Tips on Improving Clinical Trial Patient Adherence,” AppliedClinicalTrialsOnline.com, 02/13/15
Photo credit: Richard Riley (rileyroxx) on Visualhunt/CC BY

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About Dr. Robert A. Pretlow

Dr. Robert A. Pretlow is a pediatrician and childhood obesity specialist. He has been researching and spreading awareness on the childhood obesity epidemic in the US for more than a decade.
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Dr. Pretlow’s invited presentation at the American Society of Animal Science 2020 Conference
What’s Causing Obesity in Companion Animals and What Can We Do About It

Dr. Pretlow’s invited presentation at the World Obesity Federation 2019 Conference:
Food/Eating Addiction and the Displacement Mechanism

Dr. Pretlow’s Multi-Center Clinical Trial Kick-off Speech 2018:
Obesity: Tackling the Root Cause

Dr. Pretlow’s 2017 Workshop on
Treatment of Obesity Using the Addiction Model

Dr. Pretlow’s invited presentation for
TEC and UNC 2016

Dr. Pretlow’s invited presentation at the 2015 Obesity Summit in London, UK.

Dr. Pretlow’s invited keynote at the 2014 European Childhood Obesity Group Congress in Salzburg, Austria.

Dr. Pretlow’s presentation at the 2013 European Congress on Obesity in Liverpool, UK.

Dr. Pretlow’s presentation at the 2011 International Conference on Childhood Obesity in Lisbon, Portugal.

Dr. Pretlow’s presentation at the 2010 Uniting Against Childhood Obesity Conference in Houston, TX.

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