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Abstract

Research problem. Patients’ low adherence to medical treatment in chronic illnesses is one of the biggest public health concerns. Hypertension in particular has a prevalence of over 20% in Chile and other western countries, with 30-60% adherence rates for medication intake, and lower for lifestyle changes. Numerous studies have helped understand different patient, treatment, illness and patient-caregiver communication factors associated with patients’ adherence. However, these studies have not been able to fully explain the ambivalence of those patients who ask for medical assistance, but nevertheless fail to follow the treatment as agreed. For this reason, these models fail to suitably predict patients’ future behaviour, only predicting their conscious intention to adhere. Also, they regard adherence as an individual phenomenon, disregarding possible interaction effects between patient and treatment/caregiver characteristics. Methods and theoretical background. This dissertation explores patient non adherence as a manifestation of resistance, using theoretical models based on constructivism and dialogical self theories. It aims to explore, describe and relate patients’ adherence to their interactional patterns with caregivers, their personality traits, their experience with the illness and their implicit constructs and schemas about adhering or not adhering to the medical treatment. In order to do this, qualitative methods were used to analyse 51 in depth patient interviews. Results and Discussion. Two different prototypes of patients emerged: those who keep control and those who give up control of the treatment. Each prototype of patient engages the caregiver in different interactional patterns, some associated with high and some with low adherence. Regarding patients’ constructs and schemas, the main implicit values associated with non-adherence were: self-esteem, autonomy, affiliation, wellbeing, or feeling that the extra effort is not worth it. Finally, almost all patients had both pro and anti adherence “voices”, and they used different implicit strategies to resolve their ambivalence: integration strategies allowed both voices to express themselves and be heard, and was associated with higher and more stable adherence. On the contrary, domination strategies aimed to reject or dismiss one of the voices, and were associated to poorer or less stable adherence. These results are discussed in relation to adherence research and intervention.