Monday, June 6, 2011

Health Reform and the Great Unmentionable : Lack of Patient Compliance as One Cause of Poor Outcomes

The typical attempt to solve a social ill focuses on giving people information, or it tries to motivate people through fear. But these strategies tend to fail…The more important and deeply rooted the behavior, the less impact information has the more people close their minds to messages that scare them.

Tina Rosenberg, Join the Club: How Peer Pressure Can Transform the World, W.W. Norton and Company, 2011

June 6, 2011 - U.S. health system critics and health reform zealots often close their minds to a major cause of poor outcomes – lack of patient compliance. Instead , they attribute poor outcomes to lack of universal coverage, socioeconomic distress, or the profit-seeking medical industrial complex.

To say bad outcomes stems from bad behavior to cultural and peer conformity is unmentionable and therefore unspeakable because patients are sacred. Criticism of patients as a source of bad results is off-limits. It is viewed as bad politics. These are potential voters you are criticizing.

Health professionals and the capitalistic system in which they practice, not patients or population factors, are said to be responsible for the bad health of the nation, even though abundant evidence exists that other things – life style, poverty, income differences, inferior education, lack of family cohesion, violence in the streets and homes, clean water, adequate energy sources, culture, and simply following the crowd – are more responsible (1, 2).

The “Social Cure”

In her new book, Join the Club, How Peer Pressure Can Transform the Word (3), Tina Rosenberg, a Pulitzer-prize winning author , does us a favor by reminding us that patient behavior, dictated by the culture in which they live and their desire for social acceptance by peers, plays just as great a role as most other factors combined . Rosenberg reminds us, again and again, that the “social cure” – people responding positively to peer pressure and new social norms – may be more important than health reform itself.

No amount of information she asserts, or warnings from government expert or from doctors “can budge us when we refuse to be budged…We often lie to others about our bad behavior, but the more interesting and powerful excuses come when we lie to ourselves.” People do not like to be lectured to about their health. They prefer to listen to their own inner demons, no matter what the consequences, To them, it is short-term gratification, not long-term consequences, that count.

Patient Non-Compliance

In the paragraph that follows, she gives these examples of what she is talking about.

“Take, for example, patient adherence – failure to carry out a doctor’s orders. Poor patient adherence is a serious problem; dozens of studies have shown this. Only a fourth of the people on blood-pressure drugs in one study took their pills correctly. Only 13 percent of diabetes patients taking certain drugs complied with their regimens for a year. Three-quarter of patients in a study did not keep follow-up appointments and 50 percent of patients with chronic illnesses dropped out of a treatment within a year.”

Failure of Alternative Approaches

Alternative approaches have been tried to help patients comply – counseling, group therapy of patients with common diseases, patient information brochures, electronic beeping pillboxes, automated –reminder phone calls, DOTS (Directly Observed Treatment, Short-Course) by loved ones, a nurse, or a community worker) – may work temporarily but in the long-term none of these approaches can get people to take their pills more than half the time.

Innovative "social Cure" Programs

The point of Rosenberg’s book is this. People do not respond to what authorities or doctors tell them to do, but to what their peers approve of or what they do. Creating innovative peer groups to respond to health problems, whether these groups be similar to alcoholics anonymous, to maverick organizations persuading teenagers it is manipulative tobacco companies not adult do-gooders that are trying to get them to stop smoking, peers telling gays and HIV-positive individuals that condom use is a good thing – creates positive social change and the “social cures.” These programs , she says, are what we ought to be concentrating upon.

Summing Up

In summary, the health of society may depend more on social and peer conformity than its national health system. People will do what they want to do and what they think pleases their peers rather than following the advice or warnings of harm from health experts or doctors.


1. L. Sagan, The Health of Nations: The Cause of Sickness and Well-Being, Basic Books, 1987.

2. D. Satcher, and R. Pamies, Multicultural Medicine and Health Differences, MacGraw Hill, 2006.

3. T. Rosenberg, Join the Club: How Peer Pressure Can Transform the World, W, W. Norton and Company, 2011.


Anonymous said...

Absolutely 200% correct. 60-80% patients are non compliant with instructions,followup,taking their medications, diet and exercise

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