Adherence to acute hand therapy treatment – application of a multi-dimensional model

This thesis has its foundations in my clinical work as a Senior Hand Therapist in a fast paced acute hospital setting. The literature shows that patient adherence to hand therapy treatment in acute conditions (defined as less than three months post injury) results in superior recovery and prevention of deformities in tendon, nerve, and bony injury and prevention of contractures post burns. Non-adherence with splinting in acute injury can result in increased health system costs by increasing the need for difficult secondary surgical repair procedures, medical, nursing, and allied health support. In this setting, patients who fail to follow their therapy regime have traditionally been labelled ‘non-compliant’ by the surgery and therapy team. Hand therapy literature and conference presentations confirm this thesis’ contention that most therapists perceive non-compliance as a mostly patient-driven problem, reflecting attitudes of the patient, such as ignorance or forgetfulness. This simplistic view is not supported by evidence, with newer patient health behaviour models encompassing additional influences such as socio-economic, health care system, condition-related, and therapy-related factors. There has also been a shift in conceptualising patient behaviour from compliance to that of adherence, and the difference between these terms is explained in Chapter 1. A review of the literature on adherence behaviour is also presented in this thesis, and the Multi-dimensional Adherence Model (MAM) published by the World Health Organisation in 2003 forms the central reference point for the five publications that comprise Chapters 3 to 7. These publications address five key research questions that arose from my aforementioned clinical work. A variety of methodologies have been employed to answer the clinical questions, including a systematic review, qualitative methodology (phenomenological analysis and grounded theory design), a cohort study, and a randomised controlled trial. All provide support for this thesis’ contention that ability to follow treatment for acute injury is impacted by more than one factor, and interventions to improve adherence need to address all relevant factors. The discussion chapter provides examples of interventions, with a summary of the current evidence for each.