A patient suffering from diarrhoea for 2 days with passage per rectum of necrotic mucous and blood consults a physician. The physician prescribes medication for five days against patient's complaints. The patient is further asked to consult again with clinical investigation report. The patient has not improved and developed similar symptoms after a couple of months. The physician has prescribed metronidazole 500 mg three times a day for five days. However, the patient has stopped medication on second day once he felt better. Therefore, lack of compliance on the part of patient has resulted treatment failure. In fact, he is serious risk for complications of development of drug resistance.

Patient compliance means taking the correct amount of the prescribed medication(s) at the proper time. The concept of patient compliance as defined in reliable web site, is "patients who correctly follow all the instructions about a course of therapy as directed by their physician are considered to be 'compliant' with a treatment protocol". Compliance with therapy implies an understanding in which patient is motivated to prescriber's direction in a manner intended for the benefit of the recipient of medication. Problems concerning patient compliance have been recognized for decades and, indeed, it constitutes to the major hurdle today to achieve the desired outcomes of a therapy.

Negative effects of non-compliance
The problems of non-compliance as significant cause of morbidity and mortality have been demonstrated by several recent studies. Several studies on patient compliance statistics have shown non-compliance causes 125,000 deaths annually in the USA, and estimates that up to 10 per cent of hospital admissions and 23 per cent of nursing home admissions are directly related to non-compliance. Another study in the USA finds approximately 50 per cent of the 2 billion prescriptions filled each year are not taken correctly. These result in increased burden on health care expenditures. Apart from many reasons, one important factor is known to be widespread development of resistance in bacterial infections consequent upon non-compliance of antibiotics regimen. In India clear statistic is not available on non-compliance. However, the situation is qualitatively similar across the globe. Therefore, non-compliance can worsen the quality of life as well as add to the cost of medical care.

Why non-compliance?
Numerous factors have been established over time that contributes to non-compliance. In studies of non-compliance in Indian scenario, the most common reasons given for noncompliance are illiteracy and financial concerns. Compliance is poor with chronic diseases requiring complex, long-term treatment. Forgetfulness is also one of the significant factors of non-compliance. According to recent studies, patients forget about half the information given by the physician 15 minutes later. The rule of thumb related to non-compliance: one-third of patients take all their prescribed drugs as directed, one-third take some, and one-third doesn't take any at all. Several other established reasons are listed in table 1.
Patient related Drug related
Forgetfulness Complex dosage regimen
Failure to comprehend therapy Side effects
Disappearance or reduction of symptoms Adverse effects (real or imaginary)
Lack of confidence Unpleasant taste or smell
Confusion to follow instruction(s) Inconvenient precautions
Apathy Administration difficulties
Physical difficulties Similar marketed brands

The way out
Patient compliance is an ongoing challenge for the health care institution of every country. In addition, non-compliance has major complications for patients with HIV infections, epilepsy, TB, diabetes, filaria, hypertension etc. And therefore, compliance to a therapy is a primary determinant of treatment success. The priority of health care providers is to take proper steps to ensure that patients will use medications on time, in the proper doses and in the appropriate manner. Education is one of the critical ways to help patients become more conscious to manage their illness. Doctors with much-talked rational prescribing can make a perceptible difference in improving compliance. Pharmacists have a greater responsibility to encourage compliance. Pharmacists may detect and help solve compliance problems. Pharmacists' initiatives in disease programme such as diabetes support and heart disease support in many advanced countries have resulted positive impact on compliance. A few industries in the west have initiated patient-focused/patient-support programmes that provide to increase awareness and help patients understand the importance of medication adherence. These programmes focus on consumer education (in association with drug retail outlets) and one-on-one communication with emphasis on how to learn to manage their condition. Recent WHO/HAI survey on "new report on price, availability and affordability of medicines for chronic diseases" has interesting facts from India: (a) most of the private pharmacies did not have any trained pharmacist even though it existed on paper and (b) maximum sale in private pharmacies was observed to be without proper prescriptions and cash memos (source: e-drug Digest, Vol 3, Issue 55). Though patient compliance is not entirely in the hands of pharmacists, it is hoped that by following strict guidelines vis-à-vis the WHO/HAI report mentioned above can go a long way to improve compliance. Indian drug manufacturers by embracing the patient-support programme discussed earlier, besides the pharmacists have even a greater responsibility in improving compliance.

(The author is Reader in Pharmacy, Annamalai University, Annmalainagar 608 002, Tamil Nadu,Email: cdl_scbasak@sancharnet.in)