December 2003 Bulletin

Promoting patient adherence to treatment recommendations

Communication strategies that work

By Michael G. Goldstein, MD, and J. Gregory Carroll, PhD

10-year-old child and his mother return for a follow-up appointment eight weeks after surgery for an ankle fracture. The surgery was successful; the immediate postoperative course and initial follow-up care were uneventful. At this visit, however, the mother reports she is having difficulty getting her child to participate in rehabilitation exercises. “It hurts my son so much to bend his ankle…he just cries every time I suggest it is time to exercise. I hate fighting with him about this. I just don’t know what to do.”

Patient participation in physical therapy and rehabilitation is an important determinant of the outcome of orthopaedic surgery and other clinical interventions. Yet studies have consistently found that rates of patient adherence to treatment recommendations hover around only 50 percent.1,2
Though many factors influence patient adherence, including the complexity of the treatment regimen and environmental factors such as access and cost, research has also shown that physicians can improve treatment adherence through the use of specific communication strategies.2,3 These strategies are based on proven theories of patient education and health behavior change.4,5
However, many physicians are not familiar with these strategies and don’t feel confident that they can influence patients, or as in the case above, patient family members, to follow through with treatment plans.

This article will briefly review some key concepts and strategies that can increase patient motivation and adherence to treatment recommendations.

What motivates patients to adhere?
Researchers have identified several key factors that influence individuals to change behavior and, more specifically, to follow through with treatment recommendations. These factors include:

1. A strong, collaborative clinician-patient relationship, characterized by rapport, trust, support and respect for the patient’s autonomy

2. Patients’ intentions and readiness based on their knowledge and beliefs about the value and importance of the recommended treatment strategy

3. Patients’ self-efficacy, or confidence in their ability to do what is recommended (rehabilitative exercises or taking medication)

4. Access to resources in patients’ social or physical environment
In the case example above, the mother seems aware of the value of the exercises, but we are not sure about the child’s understanding. Clearly, the mother is quite frustrated and appears to have low confidence in her ability to influence her son to take action.

Applying the principles noted above, the surgeon could promote adherence by building a relationship with the mother and by exploring her—and perhaps the child’s—intentions, confidence and access to resources.

Communication model
Keller and White developed a model to help clinicians apply these research-based principles of motivation and behavior change within the context of the clinician-patient encounter.4 This model provides a compelling synthesis of the research evidence and specifies two core dimensions of motivation: conviction and confidence. Conviction refers to the values and beliefs that underlie a patient’s readiness and intention to take action, while confidence is a reflection of self-efficacy. The model also identifies three components of effective intervention: assessment, rapport building and tailoring.

Assess conviction and confidence
Use open-ended questions to explore and understand the patient’s or family member’s conviction and confidence.

In our example, to assess conviction, the physician might ask, “How convinced are you that it is important for your son to do these exercises daily?” Or, “What is your understanding of the importance of the exercises to your son’s full recovery?”

Asking, “How confident are you that you can motivate your son to do these exercises?” is a way to assess confidence.

Using a 0-10 scale may facilitate the assessment process and provide a simple way of clarifying what the patient believes and needs.

For example, “On a scale of 0-10, how convinced are you about the importance of doing this?” or “On a scale of 0-10, how confident are you that you can do this?” Follow-up questions based on the patient’s response help clarify and even enlist the patient in the process of developing a plan.

Build rapport and the relationship
Use reflective listening, a core communication skill that involves more than just attending to what the person is saying. It is an active attempt to hear and understand the meaning of what the person is trying to say. Reflective listening is accomplished by the following tasks:

Empathy is a second strategy that promotes rapport building. Simply stated, empathy is the patient’s experience of being understood, supported and accepted. The expression of empathy is strongly associated with adherence.
Empathy can be accomplished through the use of the following strategies:
Reflect feelings, concerns, and beliefs: “You sound pretty frustrated.”
Normalize or legitimize the feelings: “Many parents would feel frustrated in that situation.”

Affirm the effort; “I am impressed with how hard you have worked on this with your son.”

Once the surgeon assesses conviction and confidence and builds rapport, he or she can best promote adherence by tailoring the intervention to match the patient’s levels of conviction and confidence. When conviction is low, the surgeon provides new information and explores the patient’s reasons for pursuing or not pursuing treatment options. When confidence is low, the orthopedic surgeon reviews past experience (especially successes), identifies small steps and problem solves to address specific barriers.

Surgeons can play an important role in helping their patients adhere to treatment recommendations. Assessing the patient’s conviction and confidence, using reflective listening and empathy to build a supportive clinician-patient relationship and tailoring the communication to address the patient’s conviction and confidence will enhance adherence and lead to improved outcomes for patients and their families.

Michael G. Goldstein, MD, is associate director of the Bayer Institute, Clinical Education and Research, and can be reached at (800) 800-5907 or via e-mail at

J. Gregory Carroll, PhD, is chief executive officer, Bayer Institute for Health Care Communication. He can be reached at

1. Meichenbaum, D and Turk, D: Facilitating treatment adherence: A practitioner’s guidebook. 1987, New York: Plenum Press. 310.

2. Di Matteo, MR: Enhancing patient adherence to medical recommendations. JAMA, 1994. 271(1): pp. 79, 83.

3. Roter, DL and Hall, JA: Strategies for enhancing patient adherence to medical recommendations. JAMA, 1994. 271(1): p. 80.

4. Keller, V and White, M.: Choices and Changes: A new model for influencing patient health behavior. JCOM, 1997. 4(6): pp. 33-36.

5. Goldstein, MG, et al., Models for provider-patient interaction: Applications to health behavior change, in Handbook of Health Behavior Change, Shumaker, S.A. et al., (eds) 1998, Springer: New York. pp. 85-113.

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