Compliance with advice
Follow the health worker’s advice about treatment, follow-up and referral.
Caregiver compliance with advice on treatment, follow-up and referral is often low.
This may be related to caretakers’ lack of knowledge or motivation, access (both geographic, economic and time-related) and other factors (e.g., drug side effects or improvement in child’s conditions, health provider support when giving advice, quality of referral services) (Family and community practices that promote child survival, growth and development – A review of the evidence; IMCI health facility surveys in the Region).
Compliance with advice on treatment
Compliance with advice on follow-up
Compliance with advice on referral
Compliance with advice on treatment
Household surveys supported by WHO have often shown that caretakers properly advised by health facility-based providers had better knowledge about treatment (“how much”, “how often” and “for how long”) than those inadequately or not advised (unpublished data - see also the link below to IMCI health facility surveys in the Region).
CDD (control of diarrhoeal diseases), ARI (acute respiratory infections) and IMCI (integrated management of childhood illness) health facility surveys have shown that health provider’s advice on duration of treatment is often the weakest part of the advice on treatment—i.e. advice given incorrectly or omitted—compared with the advice on the dose.
Likewise, these surveys have found that caretakers’ knowledge of the duration of treatment is usually less good than their knowledge of the amount of drug to give to the child and that there is a direct relationship between health provider’s correct advice and caretaker’s correct recall (unpublished data).
Furthermore, studies have usually found a low level of caretaker compliance with treatment.
This means that a sick child’s chances of receiving correct treatment at home can be low.
IMCI training has been associated with improved outcome: children seen by IMCI-trained health providers were more likely to receive correct treatment and their caretakers to recall the instructions correctly than those seen by health providers not trained in IMCI (IMCI health facility survey, Sudan, 2003).
Interventions have shown improved compliance with treatment as a result of improved counselling (Family and community practices that promote child survival, growth and development – A review of the evidence).
Pre-packaging of medicines has also been shown to improve compliance.
Compliance with advice on follow-up
Compliance with follow-up can improve with proper advice. An IMCI research study on compliance with referral and follow-up recommendations in Gezira State, Sudan, 2000, found that receiving the first dose of drug treatment at the facility was strongly associated with a higher compliance with follow-up, although the practice of delivering treatment at the facility was found not to be very common in a subsequent health facility survey. The study in Gezira reported that 45% caretakers, advised by IMCI-trained health providers, complied with follow-up advice and took their children back to the facility for the follow-up visit.
Compliance with advice on referral
According to some ARI health facility surveys supported by WHO in the past, intention to comply with referral was more likely to be reported in exit interviews by those caretakers who had received support and explanations about the urgent need for referral than those simply told to take the child to a hospital—although the sample size of cases needing urgent referral was usually small (unpublished data).
In the above-mentioned study on compliance with referral and follow-up recommendations in Gezira State, Sudan, 2000, a third (33%) of children needing urgent referral were actually taken to the hospital on the same day of referral. Cost was a commonly cited reason for not going to the hospital. Risk of mortality in these children taken promptly seemed to be lower than those taken later or not taken at all, although the difference was not statistically significant. Most providers reported that they were referring fewer children since they had received training in IMCI than before.
Interventions to improve adherence to treatment are feasible and have a positive impact on compliance.
They should take into consideration the many factors affecting caretaker compliance with instructions—e.g. caretaker’s comprehension of the instructions, expectations, physical and economic access to drugs, side effects or child’s early improvement, etc.—and provider’s prescribing practices—knowledge and clinical and communication skills, client demands and drug companies’ pressure, administering treatment at the facility, drug availability to give the first dose, benefits.
Related links:
IMCI health facility surveys in the Region
