Compliance with Hand Therapy Programs:

Therapists and Patients Perceptions

Theresa Kirwan, BOccThy
ABSTRACT: Aim: This study explored patients and hand therapists perceptions of compliance with hand therapy and compared these perceptions. Method: Forty-one patients attending hand therapy at a large metropolitan hospital and 69 hand therapists, all members of the Australian Hand Therapy Association, were interviewed by telephone using a questionnaire developed for the study. Demographic data were analyzed descriptively and patients and therapists perceptions compared using chi-square. Results: Patients and therapists perceptions differed at a statistically significant level (p < 0.01, adjusted alpha rate) for 24 of the 33 items measuring perceptions of compliance with hand therapy. Conclusions: Therapists and patients have differing perceptions of compliance. J HAND THER. 2002;15:3140.

Occupational Therapist Melbourne Extended Care and Rehabilitation Melbourne, Victoria, Australia National Health and Medical Research Council Research Fellow School of Population Health The University of Queensland Brisbane, Queensland, Australia Occupational Therapist EKCO Hand and Upper Limb Rehabilitation Unit Brisbane, Queensland, Australia

Leigh Tooth, PhD, BOccThy

Catherine Harkin, BOccThy

The best-constructed rehabilitation program can be only as effective as the degree to which the patient complies with the treatment recommendations of the health care professionals.1,2 Compliance, which has been identified as the most unpredictable, least controllable variable in a medical intervention, can strongly sway the outcome of any treatment.3

al abilities of patients but also wastes health care resources by increasing the costs of hospitalization, physician services, laboratory work, and medications. In addition, noncompliance may result in ongoing disability and can lead to decreased labor productivity and loss of wages.4

LITERATURE REVIEW
Although many studies have examined compliance with a variety of medical treatments, limited literature addresses compliance in the area of hand therapy. This is surprising, given the degree to which hand therapists rely on patients to follow strict exercise and splint regimens. In many conditions treated by hand therapists, the regular performance of a home-based exercise program is a critical component of the rehabilitation process, preventing disuse and subsequent stiffness and disability. A home exercise program also encourages patient self-management and responsibility and enables therapists to have more time to treat others. Noncompliance not only affects the recovery and function-

Factors Affecting Compliance

More than 200 factors have been identified as being related to compliance.5 Broadly, these include characteristics of the patient, characteristics of the treatment regimen, features of the disease, the relationship between the health care provider and the patient, and the clinical setting.2,6,7 Considerable research has attempted to identify the sociodemographic variablessuch as age, gender, social support, educational status, and locus of control 816that may cause or affect noncompliance. Less attention has been directed to organizational or structural variables and variables related to the therapist patient relationship. For example, seeing different therapists on repeated visits, waiting a long time to see a therapist, having no individual appointment times, and reaching a clinic in an inconvenient location may also contribute to noncompliance.2,6 The patienttherapist relationship and the clinical environment, including noise levels, appearance and comfort of the clinic, and the number of people present, may also have a substantial effect on the degree to which patients follow the advice and instructions of their therapists.6,17
JanuaryMarch 2002 31

Dr. Leigh Tooth was supported in part by Public Health Fellowship 997032 from the National Health and Medical Research Council of Australia. Correspondence and reprint requests to Theresa Kirwan, BOccThy, 43 Donald Street, Brunswick, Victoria 3056, Australia.

Most compliance research has attempted to identify the characteristics of the noncomplying patient, assuming that the responsibility for poor compliance lies with the patient.1,4,17,18 From the perspective of the health care professional, noncompliance may arise from a patient deficiency, such as ignorance, laziness, forgetfulness, or lack of motivation, skills, resources, and social supports.2 In one of the only studies that have addressed this issue, Davis19 found that faculty physicians and fourth-year medical students perceived compliance as predominantly a patient problem and did not feel responsible for it. Surprisingly few studies have investigated whether patients and clinicians differ in their perceptions of compliance. According to Ludwig et al.,20 the health care professionals definition of compliance may be different from the patients. For example, the patient may enter treatment with certain expectations about its duration and course and about what will, and should, take place for a successful rehabilitation outcome. It is possible that these expectations will not coincide with those of the therapist. According to Groth and Wulf,3 the perceptions of patients have significant effects on their readiness to actively engage in a rehabilitation program. Patients perceptions may be based on misconceptions and faulty information; they may believe, for example, that their pain has an organic source and, consequently, that doing exercises will not make any difference. Ruffalo et al.21 stated that a physician must have a good relationship with the patient and must have a thorough understanding of the patients individual traits to enable open communication and mutual goal setting to take place. Without an open channel for communication, a patients beliefs can not be elicited and clarified by the therapist and a therapist cannot modify his or her approach to effectively convey knowledge and experiences to ensure the patients best effort at participation.5 In summary, then, high levels of compliance depend on the health care professionals and the patients acceptance of responsibility for the rehabilitation process, and the active involvement of the health care professional is as important as that of the patient. However, there appears to be little literature that explores therapists beliefs about their patients reasons for noncompliance or whether these two groups share the same perceptions about compliance.

What are hand therapists and patients perceptions of factors that affect compliance with appointments and do they differ?

METHODS
This was an exploratory and correlational study.

Participants
Participants were 41 patients receiving hand therapy and 69 Australian hand therapists. Patients. All patients referred to an occupational therapy hand therapy program at a public metropolitan hospital in Queensland, Australia, were invited to participate in the study over a five-month period. Patients were eligible if they were over 15 years of age, had been given a home exercise program, and had attended therapy for a minimum of two visits. Non-English-speaking patients and those with significant cognitive impairments were excluded because to their inability to give informed consent and answer questions accurately in the interview. Fortytwo patients (16 women and 26 men) with upper extremity and hand conditions consented to participate. One male patient later withdrew for unknown reasons, leaving 41 patients. Hand Therapists. All hand therapists who were full members of the Australian Hand Therapy Association (AHTA) were invited to participate in the study. A paragraph in the AHTA newsletter and a letter to the seven Australian state representatives informed hand therapists about the study. Eleven of the 80 members could not be contacted during the data collection phase because of maternity and holiday leave and overseas work commitments. The 69 who were contacted by telephone agreed to participate.

Data Collection and Instruments

Patient and Therapist Variables Demographic information for patients was retrieved from medical charts and from personal detail sheets completed by patients at the time they consented to participate. Patient demographic variables were age (years), gender, education level, and occupation.22 Injury variables were type of hand injury (soft tissue or overuse, fracture, acute laceration, or chronic condition), weeks attending hand therapy, number of appointments, previous hand injuries (soft tissue or overuse, fracture, acute laceration, or chronic condition), weeks attending therapy for previous hand injuries, number of appointments for previous hand injuries and whether the patient was attending treatments for other medical conditions. Demographic information for therapists was recorded during the individual telephone interviews and included age (years), gender, type of health pro-

Study Aims
This study aimed to identify and compare patients and hand therapists perceptions of compliance with home exercise programs. The specific research questions addressed in this study were:
!

What are hand therapists and patients perceptions of factors that affect compliance with a home exercise program, and do they differ?
JOURNAL OF HAND THERAPY

32

FIGURE 1. Structure of patient and therapist questionnaire.

fessional (occupational therapist or physiotherapist), years practicing as a hand therapist, total years practicing as a health care professional, and predominant work setting (private, public, or both). Compliance Variables Patients and hand therapists perceptions of compliance with home exercise programs were obtained by telephone interview using the Patient/Therapist Perceptions of Compliance with Hand Therapy Questionnaire. The questionnaire was developed following discussion with an experienced hand therapist and following comprehensive review of compliance literature. The style of the questions in this questionnaire was adapted from that of the Manchester Cystic Fibrosis Compliance Questionnaire.13 The questionnaire consisted of two versions, one for patients and one for therapists. The original patient questionnaire consisted of 41 items. These items addressed patient, treatment, therapistpatient relationship , and organizational/structural variables contributing to noncompliance. The therapist questionnaire was also made up of these 41 items. Although the 41 questions on both versions of the questionnaires addressed the same content, they were worded slightly differently. For example, patients were asked how they viewed a particular compliance issue, whereas therapists were asked how a particular issue might affect patient compliance. The 41 questions on the patient and therapist questionnaire were scored using a nominal scale of yes, no, or maybe. Each question was assessed separately, and no subscores were calculated.

ments were removed, leaving a total of 33 questions. As expected, redundancy was found among items that were similarly worded. Two questions about compliance with home exercise programs duplicated others that assessed patients not believing the home exercise program helped and patients could not be bothered and were removed. Of six removed questions about compliance with therapy appointments, four concerned the appointment interfering with other commitments, one duplicated a question about the distance needed to travel to appointments, and the last concerned the patients not believing it did them any good. Figure 1 shows the overall structure and organization of the 33 items of the questionnaire.

Procedure
Ethical approval for the study was obtained from one of the University of Queenslands Ethics Committees and from the hospital. Patients were given an information sheet and consent form by the treating occupational therapist at their hand therapy appointment between April and August 1999. Hand therapists, who were contacted using the AHTA membership directory, consented verbally over the telephone. Consenting patients and therapists were contacted by telephone at a mutually convenient time, and the questionnaire was administered during the telephone interview. The interview included a general introduction to the study, elicitation of hand injury or condition information from patients or demographic information from therapists, and administration of the questionnaire.

Reliability Analysis
After the questionnaires had been administered, internal consistency analyses were conducted to identify redundancies within the questions, and redundant questions were removed from subsequent analysis. Only data from the 69 therapists were used, because of the extreme splits in the patient responses for most items. Two questions concerning perceptions of compliance with home exercise programs and six concerning compliance with therapy appoint-

Statistical Analysis
Data were analyzed using SPSS version 8 (SPSS Inc., Chicago, Illinois). All data were screened for missing values and errors prior to analysis. Demographic and questionnaire data were analyzed using descriptive statistics. The yes and maybe questionnaire categories were combined in the statistical analysis to simplify reporting of results, thereby creating a dichotomous variable of Yes/Maybe and No.
JanuaryMarch 2002 33

TABLE 1. Patient Demographic Variables (N = 41)

Age: Mean SD Range Gender: Male Female Education*: No schooling Did not complete primary school Completed primary school Did not complete junior certificate Completed junior certificate Did not complete senior certificate Completed senior certificate TAFE or apprenticeship Did not complete tertiary education Completed tertiary education Still studying at school or university Occupation*: Professional Tradesperson Clerk or service worker Home duties Student Retired 43.2 yr 19.4 yr 1577 yr 61.0% 39.0% 2.4% 2.4% 2.4% 2.4% 9.8% 2.4% 4.9% 39.0% 2.4% 12.2% 14.6% 24.4% 19.5% 14.6% 4.9% 14.6% 19.5%

in their respective professions, on average, for 16 years. Forty-four (63.8%) hand therapists worked predominantly in private practice, 19 (27.5%) worked chiefly in the public system, and six (8.7%) worked equally in both settings.

Perceptions of Compliance with Home Exercise Programs

Tables 3 and 4 show patients and therapists responses to questionnaire items before Yes and Maybe response categories were combined. Patient Variables. Table 5 shows the percentage differences in patients and hand therapists Yes/Maybe responses, and the corresponding p values. The degree to which hand therapists and patients perceptions differed in this category was statistically significant (p < 0.01) for four of the six items. Treatment Variables. The difference in patients and hand therapists perceptions of the effects that treatment variables had on noncompliance with home
TABLE 2. Injury Variables (N = 41)
Injury: Soft tissue/overuse Fractures Acute lacerations Chronic conditions Surgical Nonsurgical Weeks patient has attended hand therapy appointments: Mean SD Range Number of hand therapy appointments: Mean SD Range Currently attending treatment for other medical condition? Yes No Attended hand therapy previously (n = 8)? Yes No Previous hand injury for those who attended hand therapy previously (n = 8): Fracture Acute lacerations Chronic conditions, nonsurgical Previously, average number of weeks attended hand therapy (n = 8): Mean SD Range Previously, number of hand therapy appointments (n = 8): Mean SD Range 12.2% 41.5% 26.8% 7.1% 2.4%

ABBREVIATION: TAFE indicates technical and further education. * Some values are missing.

Comparisons of hand therapist and patient results were analyzed using the chi-square test. Results were reported in terms of percentage differences between therapist and patient answers of Yes/Maybe to questionnaire items. Because of the numerous statistical calculations, consideration of type 1 error was needed. Using the Ottenbacher formula, the percentage of family-wise error rate was calculated and the alpha rate subsequently adjusted from p < 0.05 to p < 0.01.

6.63 wk 5.76 wk 232 wk 5.65 3.98 2172

RESULTS
Demographic and Injury Variables
Patients. The mean age of patients was 43 years. Patients had attended a mean of ten treatment sessions and had received therapy for an average of six weeks. Eight patients had attended hand therapy previously for an upper extremity or hand condition for a mean of 19 weeks. The most common injuries were fractures of the wrist and hand, followed by acute tendon, nerve, or artery lacerations. Table 1 summarizes demographic information for the patients, including level of education and occupation. Table 2 summarizes injury variables. Hand Therapists. The mean age of hand therapists was 38 years (range, 23 to 60 years). Ninety-seven percent were female. The 44 occupational therapists and 25 physiotherapists who participated had worked in hand therapy for a mean of 11.7 years and
34 JOURNAL OF HAND THERAPY

19.5% 80.5% 19.5% 80.5%

25.0% 50.0% 25.0%

19.6 wk 22.3 wk 268 wk

10.1 9.5 230

TABLE 3. Responses of Therapists and Patients to Home Exercise Program Compliance Questionnaire Items Before Yes and Maybe Response Categories Were Combined Question
Patient variables: Simply forget Do not have enough time Resent having to do the program Do not believe that it helps Do not think they have the ability to carry out the program properly The program interferes with family or social life Treatment variables: It causes too much discomfort or pain Have to rely on someone to help carry out the program Therapistpatient relationship variables: Do not understand the therapists instructions and are not sure what they have to do Do not understand their hand condition and therefore what to do They are told different things to do by different therapists and doctors They forget the therapists instructions They have difficulty reading and understanding the program instructions

Therapists (%) Yes

21.7 39.1 5.9 4.3 4.3 26.1 18.8 4.3

Patients (%) No
36.2 30.4 75.0 52.2 75.4 31.9 42.0 62.3

Maybe
42.0 29.0 19.1 43.5 18.8 42.0 39.1 31.9

Yes
22.0 39.0 2.4 0 4.9 14.6 22.0 0

Maybe
7.3 7.3 4.9 2.4 2.4 14.6 14.6 0

No
70.7 53.7 92.7 97.6 92.7 70.7 61.0 100

17.4 11.6 10.1 34.8 7.2

55.1 42.0 37.7 36.2 36.2

27.5 46.4 50.7 29.0 56.5

0 2.4 4.9 2.4 0

0 2.4 2.4 2.4 0

100 95.1 92.7 95.1 100

TABLE 4. Responses of Therapists and Patients to Appointment Compliance Questionnaire Items Before Yes and Maybe Response Categories Were Combined Question
Patient variables: Feel well without treatment Not enough time Simply forget Believe their hand condition is not very serious Interferes with family commitments Interferes with work schedule Interferes with daily routine Not always bothered Do plenty of exercise, so do not need to do hand therapy Treatment variable: Feel worse after attending appointments Therapistpatient relationship variables: Do not understand therapists instructions Do not know how to do home exercise program Not enough treatment time with therapist Hand therapist does not spend enough time responding to concerns The therapist does not give enough positive feedback The hand therapist is not competent or experienced Organizational/structural variables: Rely on someone to get to appointment Transport to the hand clinic is inconvenient Financial cost of attending therapy is expensive Not enough appointments so attending appointments is futile Have to wait for long time to see the hand therapist for treatment

Therapists (%) Yes

11.6 27.5 49.3 24.6 24.6 47.8 23.2 31.9 11.6 0 7.2 2.9 1.4 1.4 1.4 1.4 44.9 36.2 30.4 0 0

Patients (%) No
44.9 34.8 10.1 30.4 33.3 18.8 46.4 21.7 52.2 82.6 58.0 82.6 88.4 85.5 88.4 89.9 4.3 24.6 24.6 97.1 89.9

Maybe
42.0 36.2 39.1 43.5 42.0 31.9 29.0 46.4 36.2 17.4 33.3 14.5 10.1 13.0 10.1 8.7 50.7 37.7 43.5 2.9 10.1

Yes
0 9.8 0 0 7.3 14.6 9.8 0 0 0 2.4 0 0 0 2.4 0 14.6 9.8 7.3 2.4 0

Maybe
2.4 0 0 0 7.3 0 2.4 2.4 0 0 0 0 2.4 0 2.4 0 0 9.8 0 0 4.9

No
97.6 90.2 100 100 85.4 85.4 87.8 97.6 100 100 97.6 100 97.6 100 95.1 100 85.4 80.5 92.7 97.6 95.1

JanuaryMarch 2002 35

TABLE 5. Differences in the Perceptions of Therapists and Patients Regarding Compliance with Home Exercise Programs (HEPs) Reasons Patients Do Not Do HEPs or Let Their Usual Exercise Sessions Lapse
Patient variables: Simply forget* Do not have enough time Resent having to do the program Do not believe that it helps* Do not think they have the ability to carry out the program properly* The program interferes with family/social life* Treatment variables: It causes too much discomfort or pain Have to rely on someone else to help carry out the program* Therapistpatient relationship variables: Do not understand the therapists instructions and are not sure what they have to do* Do not understand their hand condition and therefore what they have to do* They are told different things to do by different therapists and doctors so are not sure what to do* They forget the therapists instructions* They have difficulty reading and understanding home program instructions* * p < 0.01

Percentage Difference Between Therapists and Patients Who Said Yes

34.4 21.8 17.7 45.4 15.8 38.9 21.3 36.2

p Values
0.001 0.026 0.023 0.000 0.002 0.000 0.048 0.000

72.5 48.8 31.5 65.8 43.4

0.000 0.000 0.000 0.000 0.000

TABLE 6. Differences in the Perceptions of Therapists and Patients Regarding Appointment Compliance Reasons Patients Miss Hand Therapy Appointments or Find It Difficult to Attend
Patient variables: Feel well without treatment* Not enough time* Simply forget* Believe their hand condition isnt very serious* Interferes with family commitments* Interferes with daily routine* Not always bothered* Do plenty of exercise, so do not need to do hand therapy* Treatment variables: Feel worse after attending hand therapy* Therapistpatient relationship variables: Do not understand therapists instructions* Do not know how to do home exercise program* Not enough treatment time with therapist Hand therapist does not spend enough time responding to concerns The therapist does not give enough positive feedback The hand therapist is not competent or experienced Organizational/structural variables: Rely on someone to help get to appointment* Transport to the hand clinic is inconvenient* Financial cost of attending hand therapy is expensive* Not enough appointments so attending appointments is futile Have to wait a long time to see the hand therapist for treatment * p < 0.01

Percentage Difference Between Therapists and Patients Who Said Yes

51.2 53.9 88.7 68.1 52.0 40.0 75.9 47.8 17.4 38.1 17.4 9.1 14.4 6.6 10.1 81.0 54.3 66.6 0.50 5.5

p Values
0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.003 0.150 0.013 0.316 0.044 0.000 0.000 0.000 1.00 0.480

36

JOURNAL OF HAND THERAPY

exercise programs was statistically significant for one of the two items (Table 5). TherapistPatient Relationship Variables. The degree to which hand therapists and patients perceptions differed in this category was statistically significant for all items (Table 5).

Perceptions of Compliance with Appointments

Patient Variables. The degree to which patients and hand therapists perceptions differed was statistically significant for all patient variables (Table 6). Treatment Variables. The degree to which hand therapists and patients perceptions differed was statistically significant for the treatment variable (Table 6). TherapistPatient Relationship Variables. Patients and hand therapists perceptions differed at a statistically significant level for two of the six therapistpatient relationship variables (Table 6). Organizational/Structural Variables. Hand therapists and patients perceptions differed at a statistically significant level for three of the five organizational/structural variables (Table 6).

DISCUSSION
The aim of this study was to explore patients and hand therapists perceptions of compliance with hand therapy home exercise programs and appointments and to compare these perceptions. The results of this study indicated that perceptions of compliance in hand therapy differed greatly between hand therapists and patients. Although both patients and hand therapists tended to identify the same types of reasons for noncompliance, more hand therapists than patients reported their occurrence. This discrepancy may be partly due to hand therapists generalizing to the whole hand therapy population or taking into consideration a range of hand conditions requiring treatment regimens of varying complexity and duration. This might be why hand therapists tended to answer the questionnaire items using the Yes/Maybe response categories. They may have considered each item a potential occurrence. Patients, on the other hand, may have related questions directly to their own injury and life situation and thus answered questions more emphatically (Yes or No).

with their family or social life, and forgetting to do the program. Hand therapists identified these same reasons but reported them as occurring more frequently than did patients. These perceptions of hand therapists are similar to those of physicians in a study by Davis,19 in which physicians viewed noncompliance predominantly as reflecting attributes of the patient, such as ignorance or forgetfulness. In this study, the hand therapists generally viewed their patients as being less motivated and committed than the patients viewed themselves. Also, the hand therapists did not rank pain and discomfort caused by the home exercise program as high in contributing to noncompliance as patients did. Hand therapists may have certain expectations about the quality and quantity of exercises a patient with certain injuries can perform, and may not take into account the varying pain thresholds of individual patients. Patients, on the other hand, may believe that pain is a sign of damage to healing tissue and subsequently avoid home exercise. Hand therapists might then need to educate patients about the ill effects of avoiding activity and encourage positive coping strategies.23 The main reasons for noncompliance reported by patients in this study are similar to those documented by Abbott et al.,13 who surveyed patients with cystic fibrosis about reasons for noncompliance with exercise. Sluijs et al.12 found that less compliant patients reported not enough time and interference with their daily routine as reasons for not carrying out their physiotherapy exercise program. In contrast, patients with arthritis in a study by Jensen and Lorish24 cited different reasonsnamely, that they got out of the habit of exercising and that the exercises did not produce the desired results, were tiring or boring, and made their joints feel worse. These issues (except boredom) were addressed in the current study, although questions were worded slightly differently. Different results may have been obtained in the current study because of the larger number of people experiencing chronic disease in the Jensen and Lorish study.24 Similarities in Perceptions Hand therapists and patients perceptions of the degree to which lack of time, resentment of the home exercise program, and discomfort or pain caused by the program contributed to noncompliance with the program were statistically similar in this study. Abbott et al.13 found that resentment was not a reason for patient noncompliance. These authors also found that lack of time was a common reason for noncompliance with exercises.13 Hand therapists in the current study seemed to be aware of the prevalence of this problem and reported the use of strategies to overcome it. A number of patients in the study reported pain and discomfort caused by the home exercise program
JanuaryMarch 2002 37

Perceptions of Compliance with Home Exercise Program

Differences in Perceptions In this study, the main patient variables cited by patients for noncompliance with the home exercise program were not enough time, discomfort or pain caused by the program, the programs interference

as a reason for noncompliance. There are, however, contradictory findings about the effects of pain on compliance. Sluijs et al.12 and Ekes et al.25 both found that perceived pain was positively associated with noncompliance. However, Friedrich et al.26 suggested that compliance was not correlated with subjective pain but was related to the influence of pain on activity and lifestylethat is, perceived functional disability.

Perceptions of Compliance with Appointments

Differences in Perceptions The most common reasons for appointment nonattendance reported by patients in this study were mainly of an organizational/structural nature namely, that transportation was inconvenient, patients needed assistance with transportation to the clinic, and appointments interfered with family commitments and daily routines. Hand therapists identified these same reasons but believed them to occur much more frequently. In addition, they believed that patients did not attend appointments because they couldnt be bothered or forgot. Patients may not have reported such reasons for missing appointments, as they may not have wanted to be viewed negatively. On the other hand, hand therapists may have underestimated the importance that patients attributed to appointment attendance. The most common reasons for nonattendance reported by patients in this study contradict those reported in other studies. Abbott et al.13 found that the most common reasons patients did not attend physiotherapy appointments were that they felt well without treatment, did not have enough time, could not be bothered attending all appointments, believed their condition was less serious than others, and felt that physiotherapy interfered with their social life. It is difficult to further compare the present study with that of Abbott et al., since their study did not elicit patients perceptions about the effects of transportation and clinic location on appointment attendance. Similarly, Gleeson et al.6 found that interference with commitments and transportation difficulties were reasons for nonattendance. In contrast to findings in the current study, Gleeson et al.6 also found appointment nonattendance was a result of forgetfulness. Similarities in Perceptions Hand therapists and patients agreed that six factors contributed minimally to compliance with appointments. These were that the hand therapist does not spend much time with the patient at the appointment, the hand therapist does not spend much time listening to and responding to the patients questions
38 JOURNAL OF HAND THERAPY

and concerns, the hand therapist does not give much encouragement and positive feedback, the hand therapist is inexperienced or not competent, the patient does not have enough appointments and attending hand therapy is futile, and the patient has to wait a long time at the clinic to see the hand therapist. These similarities may stem from both hand therapists and patients directly observing and experiencing these variables in the clinical setting. In contrast, areas in which perceptions differed may have been related to variables external to the therapist, such as patients beliefs, lifestyle, ability to learn, social supports, and mode of transportation. Frequent contact with a treating health care professional has shown to improve compliance rates,10 although Brand et al. (as in reported in Groth and Wulf3) found that more treatment appointments were associated with lower compliance. It seems that health care professionals have an important role in ensuring that patients are satisfied with the frequency of their contact with treating professionals. It has also been found that perceived length of time spent waiting to see a health care professional and patient irritation over being kept waiting is also related to noncompliance.6,7,27 Geertsen et al.27 suggested that good scheduling of appointments, to avoid excessive waiting, may improve patient compliance. One-on-one supervision time with patients has also been shown to improve compliance. Geertsen et al.27 found that 51% of patients who perceived that their doctors spent enough time with them were compliant, compared with 22% of patients who felt their physician did not spend enough time with them. Although there is a paucity of research into hand therapists and patients perceptions of compliance, other studies have examined differences in health care professionals and patients perceptions of other aspects of health care. Merkel28 studied the ability of physicians to gauge their patients level of satisfaction with medical care. Although the physicians were able to accurately predict their patients satisfaction with the technical quality and humaneness of care, they had difficulty predicting satisfaction with variables such as cost of care, payment mechanisms, convenience, and continuity of care. The authors suggested this was because physicians are better at predicting aspects of satisfaction related to a direct episode of care and to the physicianpatient relationship than they are at predicting external influences like office policies, scheduling of appointments, and administration. These results indicate that health care professionals may be aware of the problems experienced among various patient populations, but not the extent to which individual patients experience these difficulties and who these specific patients are. The findings also emphasize the importance of inquiry into patients

perceptions regarding not only their illness and treatment program but all areas of their lives that may have a bearing on the effectiveness of hand therapy.

Recommendations for Research

It is recommended that future research be conducted to establish the psychometric properties of the questionnaire used in this study. The questionnaire should be examined and tested by a panel of experts. In particular, wording of questions should be analyzed for ambiguity, content comprehensiveness, and relevance. The appropriateness of the response categories would also benefit from such an analysis. Factorial analysis of the items on a larger sample may assist in further reducing the length of the questionnaire. Because of the scarcity of literature in this area, future research comparing patients and therapists perceptions of compliance would be valuable. A matched therapistpatient study with participants from a number of different health care settings, including public and private settings as well as metropolitan and rural settings, may yield results with better generalizability. It would also be interesting to simultaneously measure actual compliance. Analysis of the relationship of demographic characteristics of hand therapists and patients and the relationship between patients disease characteristics and perceptions of compliance with hand therapy was not in the scope of this study. Future studies could use the data obtained in this study to explore these relationships. The examination and comparison of the perceptions of specific patient populations (according to hand injury or condition) with the perceptions of therapists might also yield more clinically useful results. Further research is also needed in the development of an assessment tool for use in health care settings to enhance therapists awareness of possible difficulties that may impede compliance with rehabilitation. Therapists could use knowledge gleaned from the assessment of patients characteristics and environmental barriers to create the kind of interaction style and strategies that will enhance the likelihood of increased compliance with treatment regimens.17

Limitations
This study has several limitations that may have affected the conclusions that were drawn. These include the questionnaire design and administration and the recruitment of participants. Apart from internal consistency analysis, the questionnaire did not undergo other validity and reliability testing prior to the study and was not pilot tested. Consequently, the wording of questions may have been ambiguous and its content may not have been as comprehensive as it could have been. It is likely that hand therapists answered the questionnaire in relation to all patients as a group and considered each item as something that could potentially occur, which may have accounted for the high percentage of Yes/Maybe responses. In contrast, patients may have related questions directly to themselves and been more emphatic (Yes or No) in their answers. This study used participant self-report. Previous research has suggested that self-report may be unreliable because of its reliance on participants memory and the possibility of social desirability bias.7,20 It has been reported that, because they want to be viewed positively by their treating health care professionals, patients tend to overestimate their performance of specific behaviors and their levels of compliance with home programs.2 It is also possible that hand therapists over-reported the frequency with which they used certain compliance-enhancing strategies. Although hand therapists were recruited from a number of public and private settings throughout Australia, patients included in this study were from the one location, a public metropolitan hospital in Queensland, Australia. These patients were not only treated in the same setting but by the same hand therapists, thus limiting the generalizability of their responses to other settings. The normality of this Australian patient sample could not be established, since prior research was not available for comparison of demographic and injury characteristics. It was also not possible to compare patient perceptions with their actual compliance. Despite these limitations, the collection of data via telephone interview ensured a very low drop-out rate, with only one participant changing his mind after consenting to participate in the study. All patients and hand therapists were interviewed by the same person, promoting consistency in the administration of the questionnaire. Although the interviewer was not involved in participants hand therapy and participants were assured that all disclosures would remain confidential, there was still a risk of respondent dishonesty.

CONCLUSION
This study has shown that patients and therapists may have very different perceptions about compliance to home exercise programs. It was recommended that therapists assess and monitor patient, treatment, and organizational factors that may affect compliance. It is further recommended that, when attempting to improve compliance, therapists consider balancing their treatment goals with their patients goals and abilities. Acknowledgments
The authors thank the 69 hand therapists and 41 patients who participated in this study.

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