Principle Set #3:
The “if” of voice training
and therapy: Factors
affecting compliance
Kittie Verdolini Abbott, PhD, CCC-SLP; 2011
Communication Science and Disorders
School of Health and Rehabilitation Sciences
Compliance
• Defined: Extent to
• Aspects:
which patients
– Seeking treatment
implement health care
– Behavior in health
care setting
instructions
– Following
recommendations
after visit
– Follow-up visits
icardia.com
Terminology is problematic
• Compliance implies
hierarchical
(condescending)
health care model;
passive patient
• Alternative terms
– Adherence improves
little to my thinking, but
is widely used
– Concordance model of
health care (Bissell et
al., 1997):
Collaboration of pt and
dr; at least in the past
met resistance in
practice (Bissell &
Noyce, 1997)
Measurement is problematic
• Patients are often
unreliable reporters
• Physicians may
overestimate (e.g.
Gatchel & Baum,
1983)
• Clinical outcome is
not good indicator
• Pharmacy refill info
may be unreliable
• Blood or urine assay
may be best for
pharmaceutical Rx,
but not perfect due to
different pt responses
(Gatchel & Baum,
1983)
Measurement updates
• Electronic monitoring
increasingly used
effectively
– E.g., compliance with
isolation precautions (Ross
et al., 2011)
– E.g., compliance with voice
therapy exercises (Doyle,
personal communication;
Nanjundeswaran et al., in
preparation; Verdolini
Abbott et al., in
preparation)
techfresh.net
teenagelifestyle.com
Factors affecting compliance
DISEASE FACTORS
Severity of health
condition
– Pt’s perception of
severity increases
compliance
• Meds post stroke
(Sappok et al., 2001)
• CPAP for sleep apnea
(Hui et al., 2001)
• Incontinence treatments
in women (Alewijnse et
al., 2001)
• Psychological treatment
for insomnia (Morgan et
al., 2003)
Factors affecting compliance
• Severity, cont’d
– Rosenstock’s Health
Belief Model (1974):
Therapeutic action is
related to four or more
factors:
• Susceptibility to disease
• Perception of disease
severity
• Benefits of treatment
• Barriers to treatment
currentnursing.com
Factors affecting compliance
• Relevance for voice
therapy?
Factors affecting compliance
DISEASE FACTORS
Duration of illness
– In some studies,
negative relation to
compliance
– E.g. anorexia (Kahn &
Pike, 2001)
– Discussion? Why?
http://www.helpfulhealthtips.com/wp-content/uploads/2008/04/Anorexia-Nervosa-2.jpg
Factors affecting compliance
PATIENT VARIABLES
Demographic factors
– Gender: No effect or
males have an edge
(Kittler, Weitzdorfer,
Pehamberger, Wolff, & Binder,
2001; Maviglia, Teich, Fiskio,
& Bates, 2001; Salmon, 2001)
– Age: Varies across Dx
(e.g. Maviglia et al., 2001;
Gordillo et al., 1999; Kiortsis et
al., 2000).
– Race and ethnic
group: Variable
findings
• When income and
education was controlled,
race did not emerge as a
risk factor for
mammography utilization
(Rawl et al., 2000).
Aside
Dr. Guy Ashkenazi
Department of Science
Teaching
Hebrew University
Jerusalem
• Googled “guy”
• fh.huji.ac.il
Factors affecting compliance
• Race/culture: Study
by White & Verdolini
(in Verdolini & Ramig,
2001)
– African-American gospel
singers; Caucasian
classical choral singers;
about 50% of gospels
singers hoarse; about 30%
of classical singers hoarse
on day of survey
– Azjen & Fishbein
mathematical model
(Azjen & Fishbein, 1970,
1972, 1973, 1974; Fishbein &
Azjen, 1975):
B = IF + SN
B = behavior (intention
to seek treatment)
IF = individual feelings
about treatment seek
SN = social norms about
treatment seek
Raw-Score Regression Weights are Shown, Based on 7-Point Ordinal Scale (-3 = Extreme Negative Influence; 0 =
Neutral Influence; +3 = Extreme Positive Influence). Probability for Equations p Set at α = 0.10. (Data From White
and Verdolini, Published in Verdolini & Ramig, 2001.)
Intention to Seek
Treatment
Self
Factor
Social
Factor
Interaction
(Self x
Social)
African American
p = 0.08; N = 22
I=
S(-0.17)
SO(2.39)
IN(-0.28)
Caucasian
p = 0.01; N = 58
I=
S(0.98)
SO(-0.08)
IN(-0.04)
Factors affecting compliance
• Pt’s educational level:
Little or no effect, or
positive effect (CPAP
for sleep apnea and
heart failure; e.g.
Evangelista et al., 2001; Hui et al.,
2001).
• Income: High-income
and unemployed tend
to be most compliant
(e.g. al-Shammari et al., 1995;
Lane et al., 2001; Pan et al., 2001;
Pang et al., 2001) discussion?)
dailyclipart.net
Factors affecting compliance
• Geography: Rural may
decrease compliance (e.g.
Eaker et al., 2001; Pan et al., 2001)
• Transportation: Lack
decreases compliance (e.g.
Langkamp & Hlavin, 2001)
cars-and-trees.com
• In most studies, single
demographic factors do
not explain compliance;
combinations of factors
may
– E.g. F, adolescent, large
sibship, not accompanied by
parent decreased antibiotic
use following rheumatic fever
(Gordis et al., 1969).
Factors affecting compliance
COGNITIVE,
PERSONALITY,
ATTITUDE
FACTORS
• Forgetfulness impacts
negatively; remembering
helps (e.g. al-Shammari et al., 1995;
Chesney et al., 2000; Donohoe et al., 2001)
• Some psychiatric
conditions may decrease
compliance (e.g. (DiMatteo, 1995;
Gordillo et al., 1999; Shemesh et al., 2001)
• Positive pt attitude about
disease (I’m going to
deal with this) increases
compliance (e.g. Scherer & Bruce,
2001)
• Confidence in treatment
increases compliance
(e.g. Donohoe et al., 2001)
lost100pounds.wordpress.com
Factors
affecting
compliance
productivity501.com
•Locus of control
•Self-efficacy
http://3.bp.blogspot.com/_7YR-Rsp2dxo/TOjKdHWkPoI/AAAAAAAAADM/4-gpgyDinjg/s1600/untitled.jpg
Factors affecting compliance
• Locus of control:
– Men tend to have
external locus for
errors, internal locus
for merit; women tend
to have reverse (reference
lost to follow-up!)
– In health care, external
locus of control
negatively predicts
compliance with
medical treatment (e.g.
HIV+; Gordillo et al., 1999)
Factors affecting compliance
• Self efficacy
(Bandura, 1977)
– One’s belief in one’s
ability to carry out a
behavior
– State- not trait-specific
(varies across situations; e.g. (Kaplan,
Atkins, & Reinsch, 1984)
– Experimentally
manipulable with
affective rewards in
clinical environment
(e.g. (McAuley et al., 1999)
get-real-fitness.com
Factors affecting compliance
• Hundreds and even
thousands of studies
show positive influence of
self-efficacy on
compliance
• E.g., osteoporosis
prevention, alcoholism
treatment, renal
transplantation meds,
treatment for atopic
dermatitis, HIV retroviral
meds, asthma treatment,
exercise prescription,
drug treatment for
rheumatoid arthritis (quick lit
review largely from 2001; in Titze & Verdolini, 2011)
Factors affecting compliance
• Self-efficacy for voice
(Gillespie & Verdolini Abbott,
2011)
sptimes.com
• Fourteen teachers with selfdeclared voice problems
• Received education about
causes and treatments for
common voice problems in
teachers
• Randomly assigned to (1)
“abuse/misuse” language
educational video; (2) neutral
language educational video
(double-blind)
Factors affecting compliance
• Self-efficacy for voice
measured before and
after exposures
• Results showed subjects
in “abuse/misuse” group
did not show a reduction
in self-efficacy for voice
pre- to post-exposure
• However, subjects in
“neutral” group showed
an increase in selfefficacy for voice with the
exposure
• Conclusion: Normal
increases in self-efficacy,
expected with patient
education, was harmed
by “abuse/misuse”
language
Factors affecting compliance
• Larger-N studies
needed for verification
• Further studies also
needed to determine
effects of voicerelated self-efficacy
shifts on patient
compliance and
treatment outcome
• For now, some evidence is
shown that “abuse/misuse”
language may harm people’s
self-efficacy for voice
• We should therefore question
seriously whether we should
use the terms or not (I say
not!)
Factors affecting compliance
• “Readiness”
(Motivational
Interviewing)
– SE theory says people
don’t comply because
they feel they can’t
– MI theory says people
don’t comply because
they feel they’re not
ready
• MI techniques help
patients move
through various
stages to “readiness”
– (For background and
review relevant to
voice, see Behrman,
2006)
Factors affecting compliance
SOCIAL VARIABLES
• Social and family
support enhance
compliance, including
HIV, diabetes,
hemodyalysis (e.g. Kaplan,
Atkins, & Reinsch, 1984)
• Review study by
White (gospel
singers) (see previous discussion)
Factors affecting compliance
TREATMENT
VARIABLES
– Patient education:
May or may not
increase compliance
(however note that often pts don’t
understand what you tell them; 50% in
one study; pts also forget about half of
what you tell them quickly; Boyd et al.
1974; Spelman et al. (1967)
– Pt’s perception of
increased explanation
may be the key for
compliance (e.g. lipid-lowering
drugs; Kiortis et al., 2000)
http://bossip.files.wordpress.com/2010/10/dartmouth-old-lady-black-doctore1286646111253.jpeg?w=600&h=400
Factors affecting compliance
• Information
exchange: Match
between pt’s desire
for active participation
and information may
be key (e.g. Krantz et al., 1980)
Factors affecting compliance
• Frequency of treatment:
Negative effect (e.g.
depression, fertility meds;
de Klerk, 2001; Kruse et al.,
1993).
• Complexity of treatment
(dose number of time
consumption): Negative
impact (e.g. al-Shammari
et al., 1995; hemophilia,
Hacker et al., 2001; lipidlowering drugs, Kiortsis et
al., 2000)
• Relation to voice
therapy?
Factors affecting compliance
• Written instructions:
• Follow-up monitoring:
Possibly positive
Generally helps (e.g. alShammari et al., 1995; Atis et al., 2001).
effect (e.g. DiMatteo & DiNicola, 1982)
But note paradoxical
• Asking pts to repeat
results for smoking
back instructions:
cessation (e.g. Dornelas et al.,
2000)
May help (e.g. DiMatteo &
DiNicola, 1982)
• Self-monitoring aids
may help (e.g.
asthma treatment (e.g.
Finkelstein et al., 2001)
Factors affecting compliance
• Self-management:
May help (e.g. asthma; group had
self-treatment strategies in case of
exacerbation; greater self-efficacy and
predicted self-care behavior at one-year FU;
van der Palen et al., 2001)
• Contracts: May help
in some cases (e.g. severe
personality disorders; Miller, 1990)
blogs.forbes.com
Factors affecting compliance
TREATMENT
EFFECTS
• Side effects:
Negative effect on
compliance (e.g.Brook et al.,
2001; Kiortsis et al., 2000; Lin et al., 1995)
• Experiencing
improvement: May
help initially (“hook” in
voice therapy); but
then harm compliance
(e.g.depression; (Demyttenaere et al.)
etc.usf.edu
Factors affecting compliance
Clinician-patient
interaction
Compelling effect
– Mom’s who perceived
docs as business like
had poorer satisfaction
than if perceived as
warm and caring (e.g.
Korsch et al. (1968); Korsch & Negrete
; dissatisfaction
led to poor compliance
(1972)
(e.g. (Francis et al., 1969).
• Docs viewed as warm
and friendly were
considered nice and
competent; docs seen as
cold and aloof considered
unfriendly and
incompetent (e.g. Ben-Sira, 1976,
1980)
Factors affecting compliance
• Relevance in today’s
referral patterns?
Compliance
package?
zebrarug.com