19.2 Patient Adherence & Psychosocial Care
Key Takeaways
- The World Health Organization groups adherence barriers into five dimensions: social and economic factors, health system factors, condition-related factors, therapy-related factors, and patient-related factors, so nonadherence is rarely just a matter of motivation.
- Adherence to removable offloading is often poor: in one study, patients with diabetic foot ulcers wore their removable cast walkers for only about 28% of their daily steps, which is why non-removable offloading improves healing.
- Motivational interviewing uses open questions, affirmations, reflective listening, and summaries (OARS) to draw out the patient's own reasons for change, and the transtheoretical model describes stages from precontemplation through contemplation, preparation, action, and maintenance.
- Teach-back, plain language, interpreters, written and pictorial instructions, and involving caregivers address low health literacy and language barriers, while screening tools such as the PHQ-9 identify depression that undermines self-care.
- Social determinants such as cost, transportation, food and housing insecurity, work demands, and caregiver burden should be screened and addressed with social work, community resources, and coverage options; for example, Medicare has covered lymphedema compression garments since January 1, 2024.
19.2 Patient Adherence & Psychosocial Care
Core Clinical Principle: Most chronic wound care happens between visits, carried out by patients and families. When a plan fails, the cause is often cost, transport, pain, depression, confusion, or a regimen that does not fit the patient's life. Finding and addressing those barriers is part of treating the wound.
The CWSP outline lists patient adherence (for example, socioeconomic factors and ability to comply) in Professional Issues, and addressing psychosocial aspects of care and educating patients, families, caregivers, and ancillary staff are listed tasks.
Language Matters: Compliance, Adherence, Concordance
- Compliance implies the patient follows orders.
- Adherence implies agreement with a plan the patient helped shape.
- Concordance emphasizes a shared plan negotiated between patient and clinician.
Labeling a patient "noncompliant" in the chart without exploring why tends to end the conversation. Documenting specific barriers and the response is more useful clinically and legally.
Why Patients Do Not Follow the Plan
| WHO Dimension | Wound Care Examples |
|---|---|
| Social and economic | Cost of supplies and copays, lost wages from visits, no transportation, unstable housing, food insecurity, limited family support |
| Health system | Long wait times, short visits, poor continuity, conflicting advice between providers, limited home health access |
| Condition-related | Neuropathy removing pain that would warn of harm, depression, cognitive impairment, visual loss, obesity limiting reach |
| Therapy-related | Complex or painful regimens, bulky casts that prevent driving or working, hot compression garments, frequent dressing changes |
| Patient-related | Beliefs about the wound, fear of amputation, low health literacy, substance use, competing priorities |
What the Evidence Shows
- Offloading: In a study by Armstrong and colleagues (2003), patients with diabetic foot ulcers wore their removable cast walkers for only about 28% of their total daily steps, mostly taking them off at home. This is a major reason non-removable devices heal more ulcers.
- Compression: Many patients with venous leg ulcers stop wearing compression after healing, and recurrence rises sharply without it.
- Depression: Depression is common in people with diabetic foot ulcers and is associated with worse self-care, recurrence, and higher mortality.
Assessing Barriers
| Area | Tools or Questions |
|---|---|
| Health literacy | "How confident are you filling out medical forms by yourself?" and teach-back |
| Depression | PHQ-2 as a screen; PHQ-9 (scores of 10 or more suggest at least moderate depression) |
| Anxiety | GAD-7 |
| Cognition | Mini-Cog |
| Social needs | Screening for food, housing, transportation, utilities, and safety |
| Substance use | Tobacco, alcohol, and drug use screening |
| Practical fit | "What would make this plan hard to follow at home or at work?" |
Strategies That Work
Motivational Interviewing
A collaborative conversation style that strengthens a patient's own motivation for change. Core skills are OARS:
- Open questions: "What worries you most about your foot?"
- Affirmations: "You came to every visit this month even with the bus schedule."
- Reflective listening: "You want the ulcer to heal, and you are also worried about losing your job if you cannot drive."
- Summaries: Pull together what the patient said and move toward a plan.
Listen for change talk (desire, ability, reasons, need, commitment) and avoid the "righting reflex" of lecturing, which often increases resistance.
Stages of Change (Transtheoretical Model)
| Stage | Patient Description | Clinician Approach |
|---|---|---|
| Precontemplation | Not considering change in the next 6 months | Raise awareness, build rapport |
| Contemplation | Considering change within 6 months but ambivalent | Explore pros and cons, resolve ambivalence |
| Preparation | Planning to act soon, often within 30 days | Set specific goals and a start date |
| Action | Actively changing (less than 6 months) | Support, problem-solve setbacks |
| Maintenance | Sustained change for 6 months or more | Prevent relapse |
Practical Measures
- Teach-back: Ask the patient to explain or demonstrate the dressing change or how to check the feet.
- Plain language and interpreters: Use qualified medical interpreters rather than family members.
- Simplify: Fewer dressing changes, longer-wear dressings, once-daily medications, and devices the patient can manage.
- Adherence by design: Non-removable offloading (total contact cast or an instant total contact cast) removes the daily decision.
- Shared decision-making: Offer realistic options when the ideal plan is not workable, and document the discussion.
- Address costs and access: Social work, patient assistance programs, transportation services, home health, and telehealth visits. Medicare has covered compression garments for lymphedema since January 1, 2024, under the Lymphedema Treatment Act.
- Smoking cessation: Use the 5 A's (Ask, Advise, Assess, Assist, Arrange) with pharmacotherapy such as varenicline or nicotine replacement.
- Treat depression, pain, and substance use as part of wound care, with referrals as needed.
Educating Families, Caregivers, and Staff
Caregivers often perform daily wound care. Assess their ability and burden, teach with demonstration and return demonstration, give written instructions and warning signs, and provide a contact for questions. Education for ancillary staff (such as nursing assistants in long-term care) should cover repositioning, heel offloading, moisture management, and reporting skin changes early.
Clinical Traps
Trap 1: Blaming Instead of Asking
A patient who "refuses" a total contact cast may be the only driver in the family. Ask what makes the plan hard and look for a workable alternative.
Trap 2: Assuming a Nod Means Understanding
Patients with low health literacy often agree politely. Teach-back reveals gaps before they cause harm.
A 55-year-old man with a plantar diabetic foot ulcer says, "I know I need to wear the boot, but I'm on my feet all day at work and it slows me down." Which response best reflects motivational interviewing?
A 62-year-old woman with a venous leg ulcer who smokes 20 cigarettes a day says, "I know smoking slows my healing, and I think I should quit sometime in the next few months, but not yet." Which stage of change best describes her?
A 70-year-old man with limited health literacy is being discharged with instructions for daily dressing changes and foot checks. He nods and says he understands. What is the best way to confirm understanding?