Different terms have been used to describe patient behaviour when advised by a practitioner to take medication or make significant changes to their lifestyle. Compliance refers to the patient following the practitioner’s orders obediently without question, whilst adherence implies that the patient follows the request with more negotiation. More recently the term concordance has been used to describe treatment related behaviour, particularly in the UK. Concordance implies a complete power balance between the clinician and the patient in which they work on equal terms to reach an agreement regarding treatment. Rates of non-concordance vary, depending on the nature and duration of the illness as well as a number of patient variables. However, non-concordance in chronic wounds is similar to other chronic illnesses, standing at around 50 %. According to Ley’s (1989) cognitive hypothesis model, concordance is predicted by the patient’s understanding of the information provided during the consultation, how well they can recall this information, and overall satisfaction with the consultation. The way information is communicated can have an impact on the way the patient recalls and understands what has been communicated. To ensure that information is communicated effectively it should be clear, simple and jargon free. Furthermore, using more than one mode of communication will enhance patient recall (for example using written as well as spoken information). A patient’s health beliefs and perceptions about the causes and consequences of their wound may also influence treatment concordance. In addition social support can also have a positive influence on concordance, however the most effective support seems to be that provided by family and peers. The clinician can also provide social support to the patient, however, the most successful type is informative or educational support. Finally, there is an important link between patient-centred consultations and good concordance; clear communication within a therapeutic, non-judgmental relationship appears to hold the key to good concordance (see Box 7.1).

The terms compliance, adherence and concordance have all been used to refer to the extent to which a patient follows treatment protocols. Sometimes they are used interchangeably, however whilst these terms are related, they are not synonyms and each has a very specific meaning. Compliance was the term used during early work that investigated whether or not patients followed their practitioner’s instructions. Compliance has been defined as ‘the extent to which the patient’s behaviour matches the prescriber’s recommendations’ (Horne et al. 2005). The term compliance implies that the patient will follow the clinicians orders without any question; its use is therefore declining because of an implied lack of patient involvement.

Indeed, the term compliance has been heavily criticised in the literature for its paternalistic view of the practitioner–patient relationship, in which the patient is perceived as passive and expected to obey the clinician’s orders (Snelgrove 2006). Many clinicians feel uneasy about the use of the label compliance, as it places all blame for departures from prescribed treatment on the patient (Russell et al. 2003). For example, labelling the patient as non-compliant, suggests deliberate, deviant behaviour. Thus the term compliance does not allow the clinician to distinguish between patients who have intentionally decided not to take medication and those who have perhaps misunderstood what the treatment requires and as a result have not followed the prescribed treatment correctly. It has therefore been argued that the notion of compliance fails to take sufficient account of the social context of patients’ lives (Russell et al. 2003) and the patient perspective on treatment (Snelgrove 2006).

This shift in perspective regarding compliance is part of a much broader change in models of patient care (DOH 2010; Coulter and Collins 2011). Thus in the past 20 or so years there has been an increasing move from clinician–patient consultations which are heavily dominated by the practitioner, who instructs the patient in ‘what to do’, to consultations which are more patient-centred. Patient (or person) centred care is a model of care in which patients are seen as equal partners in the planning and evaluation of their care, in order to ensure they have the most appropriate treatment plan for their needs. As a result, there is more emphasis on patients being encouraged to ask questions and the consultation focusing on a patient’s individual needs. The term adherence has been used to reflect this shift in thinking. Adherence is defined as ‘the extent to which the patient’s behaviour matches agreed recommendations from the prescriber’ (Horne et al. 2005). The use of the phrase ‘agreed recommendations’ moves away from the idea of the patient as a passive recipient of health care who needs to obey the directions given by all-knowing professionals; adherence implies greater patient commitment to treatment, introduces an element of reasonable negotiation, and reflects increased patient empowerment.

The term adherence has, however, been criticised for not moving far enough away from traditional paternalistic models of care. Snelgrove (2006) suggests that whilst the reference to adherence acknowledges the negotiation between patient and clinician, it still suggests a certain degree of patient passivity, and implies that the power in the relationship remains predominantly with the clinician. In a response to this, some clinicians and researchers have used the term concordance in place of either compliance or adherence. The advantage of this term is that it suggests that the patient is an equal partner, one who shares in the decision-making process (Weiss and Britten 2003). Metcalfe (2005) succinctly summarises the similarity between compliance and adherence and their difference to concordance noting that whilst compliance and adherence can refer to behaviour by one person, concordance cannot – by definition concordance requires an active discussion, and therefore involves more than one individual. The idea of patient concordance is very much in line with the current ethos in modern heath care which puts a high value patient autonomy, self-regulation and self-management, particularly in relation to long-term conditions and chronic illness. The emphasis is on shared decision making, which takes into account a patient’s circumstances, wants and desires. Concordance also demands that the clinician focuses on the consultation process, ensuring they adapt it to suit the needs of the individual patient (Metcalfe 2005).

There has however, been some criticism of concordance as a concept and the terms adherence and compliance continue to be used in preference by some clinicians and researchers. Segal (2007) for example, has suggested that the use of the term concordance is a sham, and that this new focus on joint decision making has not made any difference to the extent to which patients follow prescribed treatments. Indeed Segal (2007) goes further, suggesting that concordance is simply compliance by another name. She argues that clinicians use this concept as a guide for asking how best to persuade patients to do as they say, rather than for asking how they can ensure they demonstrate respect for the patient perspective. Whilst it is true that the need for concordance puts emphasis on the communication between clinician and patient, this should not be about the power of persuasion. Communication, as discussed throughout this chapter, is about listening as well as talking. As Metcalfe (2005) notes, there will always be some determined patients who will choose their own course of action even in the face of good evidence which contradicts said action. In these cases, the clinician should make their opinion and advice clear, but may have to accept they can do no more. Likewise at the other extreme, there will be patients that simply want to be directed by their clinician – in these instances clear communication will still be essential, and if that is the patient standpoint, such an approach remains concordant. However, for those patients (the majority) who do want to engage in meaningful discussion about their treatment plan, involving them in planning and decision making is essential; for these patients, simply telling them what they must do is likely to be counter-productive (Metcalfe 2005).

Various models have tried to explain why patients choose to follow medical advice. The most enduring of these is the Cognitive Hypothesis Model (Fig. 7.1) developed by Phillip Ley (1981, 1989). According to this model, the extent to which a patient follows prescribed treatment can be predicted by:

This perspective explains concordance by focusing on the communication between clinician and patient, with the most important part of this communication concerning the transfer of knowledge from expert to layperson. According to Ley’s model, concordance will depend on both the clinician’s skill as a communicator and the cognitive skills of the patient. Poor concordance is therefore often a product of failure to understand or recall instructions and advice, rather than a deliberate strategy of avoidance. Indeed, research from wound care practice has highlighted lack of patient understanding as one reason for poor concordance (e.g. Flanagan et al. 2001; Hallett et al. 2000). Furthermore, studies have shown that:

According to Kessels (2003) there are three factors which can influence how likely a patient is to forget treatment instructions. The first of these relates to the mode of communication which is used. For example, if patients are provided with both oral and written information, the more likely they are to remember to follow those instructions (McDonald et al. 2002). This is because information that is received by more than one sense is more likely to be registered within memory and retained for a longer period of time. Furthermore, the written instructions will act as a memory aid, a resource which can be returned to as and when necessary. Written instructions do however present difficulties to patients with literacy problems and other options to support the oral information provided by a clinician have therefore been explored. One method which seems to be beneficial for patients with low education is the use of illustration. For example, cartoons have been used to improve patient concordance with wound-care advice after treatment in an emergency department. Those patients who received the cartoon instructions showed better understanding of what was required of them and better concordance (Delp and Jones 1996).

The second factor which may increase patient forgetfulness and so decrease concordance also concerns communication. This time however, the focus is on the behaviour of the clinician – for example the over use of medical jargon. There is substantial evidence that ineffective communication between patients and health care providers is a major determinant of poor treatment concordance (Levinson and Chaumeton 1999). Furthermore, communication is often the aspect of care with which patients are least satisfied (Aharony and Strasser 1993). For example, Stewart et al. (2000) found that 44 % of the burns patients he interviewed reported not understanding the instructions they were given in the use of pressure garments; 90 % of their consultants, however, believed the instructions were clear and the patients had understood. It is suggested that the personal backgrounds of health care providers and the norms, beliefs, and practices intrinsic to their professional training, affect their communication and interaction with patients, which ultimately affects the treatment they provide (Bates et al. 1997).

Finally Kessels notes that there are features specific to each patient which can impact on what a patient remembers about treatment needs. This includes factors such as low education that, as noted earlier, can limit a patient’s understanding of instructions. It also includes a patient’s own expectations of the consultation process, and their beliefs about health and healing. Indeed, individual factors such as this have been found to be very important in determining patient concordance (Snelgrove 2006). Ley’s model has been criticised for not taking the possible influence of patients’ pre-existing knowledge and beliefs, or life context, into account. Thus whilst Ley’s model is important because of it focuses on the dialogue between patient and health care provider, it has been argued that it is an educational model, which assumes that the clinician is the expert and the patient is a novice who needs to be taught what to do (Snelgrove 2006). Any consideration of concordance however, must recognise issues such as a patient’s health beliefs, their personal circumstances including social support, and their sense of control, as these are all factors which have been shown to affect the extent to which patient’s will follow a treatment plan (Stanton 1987).

Concordance acknowledges that whilst the health beliefs of the patient may be different to those of their clinician, they are just as relevant when making treatment choices (Dickinson et al. 1999). This is important, since the extent to which someone will engage in a health related behaviour (e.g. wound treatment) depends upon the value they put on the goal of the behaviour (e.g. wound healing) and their estimate of the likelihood that the behaviour will achieve that goal (Janz and Becker 1984). Thus according to the health belief model (HBM) (Janz and Becker 1984; Rosenstock et al. 1988) concordance with treatment will occur when a patient is:

According to the HBM, by weighing up the pros and cons of taking therapeutic action such as wearing compression bandages, people arrive at a decision as to whether the perceived benefits (e.g. wound healing, or prevention of recurrence) outweigh the perceived barriers or cost (e.g. Compression causing pain and discomfort at night; Crookes 1997). As Moffatt (2004a, b) notes, it is important to understand the patient’s beliefs about compression during consultation, particularly if there have been previous episodes of failed treatment. Research into the extent to which burns patients wear the pressure garments which they are prescribed also supports the HBM; Stewart et al. (2000) found that 56 % of burns patients were uncertain about the ability of their pressure garments to reduce their hypertrophic scars with almost a third of the sample not wearing the pressure garments they had been prescribed for the full 20–24 h that were recommended.

Self-care can be an important part of wound management, as it was for the burns patients in the study by Stewart and colleagues (2000). One of the barriers to wearing the pressure suit which was described by patients, concerned the difficulty of putting on and taking off the garment they had been prescribed. Another barrier related to the challenge of coping with the itching and discomfort created by the suit. Those patients who described difficulties donning and wearing the suit could be said to lack self-efficacy – that is the belief that they can cope with, or carry out particular behaviours. Patients who felt unable to cope with the discomfort would be less likely to wear their suit for the recommended length of time; those finding it difficult to get the garment on and off might stop wearing it all together. Self-efficacy therefore has important implications for concordance in cases where self-care is required. Low levels of self-efficacy have been also been implicated in patients with leg ulcers who do not engage in physical exercise (Heinen et al. 2007), poor concordance with compression bandaging (Finlayson et al. 2010), and poor foot-care in people with diabetic neuropathic foot complications (Vileikyte et al. 2004).

Patient beliefs are also central to the self-regulatory theory or ‘common sense’ model of illness, put forward by Leventhal and colleagues (Leventhal and Cameron 1987; Leventhal et al. 1997, 2003). According to this model, ‘common-sense’ beliefs about illness and their remedies shape our response to threats to our health. Thus we expect aspirin to cure a headache, antibiotics to clear infection, ointment to soothe an itchy rash and so on (Leventhal et al. 2003). When our expectations are fulfilled (e.g. the ointment soothes the itch), behaviours are reinforced and we are more likely to repeat them in the future. However, if our expectations are thwarted then we will reassess the situation, questioning the relevance of the remedy (perhaps this rash is more serious than first imagined) or its efficacy. Concordance behaviours are therefore heavily influenced by these common-sense beliefs, and the patient’s ‘illness perceptions’, that is their representations of their illness. Illness perceptions differ from person to person (Cameron and Leventhal 2003) and even patients with the same medical condition can hold very disparate views of their illness. The way that patients think about their illness is structured around five cognitive dimensions: