Adhering to Medical Advice

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Adhering to Medical Advice

• Chap 4

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Issues with Adherance

• 125,000 people in US may die to adherence issues
• Page 77

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Theories that Apply to Adherence

• Why do people fail to follow the advice of a
  health care provider? Several theoretical models
  that apply to behavior in general have also been
  applied to the problem of adherence and
  nonadherence.

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Table 4.2Reasons Given by Patients for Not
Complying with Medical Advice
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Table 4.1aPredictors of Patient Adherence
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Table 4.1d
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Table 4.1b
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Table 4.1c
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Behavioral Theory

• The behavioral model of adherence is based on
  principles of operant conditioning, especially
  positive and negative reinforcement.
• With positive reinforcement, a positively valued
  stimulus is added to the situation, thus
  strengthening that behavior and increasing the
  probability that it will recur.

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Behavioral Theory

• With negative reinforcement, behavior is
  strengthened by the removal of an unpleasant or
  negatively valued stimulus. Both types of
  reinforcers strengthen behavior, whereas
  punishment inhibits or suppresses behavior.
• Advocates of the behavioral model use cues,
  rewards, and contracts to reinforce compliant
  behaviors. Some research supports the
  effectiveness of this approach.
•  

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Behavioral Theory

• Advocates of the behavioral model use cues,
  rewards, and contracts to reinforce compliant
  behaviors. Some research supports the
  effectiveness of this approach.

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Self-Efficacy Theory

• Bandura's social cognitive theory is a general
  theory of behavior that stresses the interaction
  of behavior, environment, and person factors,
  especially cognition. Bandura used the term
  reciprocal determinism to describe this model
  (see Figure 4.1).

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Self-Efficacy Theory

• An important component of the person factor is
  self-efficacy, or people's belief that they have
  the ability to perform specific behaviors that
  will lead to desired consequences.
• For example, self-efficacy was the best predictor
  of adherence to an exercise rehabilitation
  program.
• Research has generally supported the importance
  of self-efficacy in health-related behaviors,
  especially the two difficult behaviors of diet
  and smoking cessation.

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Theories of Reasoned Action and Planned Behavior

• Ajzen and Fishbein's theory of reasoned action
  and Ajzen's theory of planned behavior both
  assume that the immediate determiner of behavior
  is people's intention to perform that behavior.
• The theory of reasoned action suggests that
  behavioral intentions, in turn, are

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Theories of Reasoned Action and Planned Behavior

• (1) a function of people's attitudes toward the
  behavior, which are determined by their beliefs
  that the behavior will lead to positively or
  negatively valued outcomes, and
• (2) their subjective norm, which is shaped by
  their perception of the value that significant
  others place on that behavior and by their
  motivation to comply with those norms (see
  Chapter 3, Figure 3.1).

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Theories of Reasoned Action and Planned Behavior

• The theory of planned behavior includes an
  additional determinant of intentions to act,
  namely, people's perception of how much control
  they have over their behavior (see Chapter 3,
  Figure 3.2). Both theories have been used to
  predict adherence to a number of health-related
  behaviors.

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Theories of Reasoned Action and Planned Behavior

• A meta-analysis of studies on the usefulness of
  the theory of reasoned action and the theory of
  planned behavior found that both theories had
  some value in predicting who will adhere to an
  exercise program and who will not, but these
  theories are only modestly successful

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The Transtheoretical Model

• The transtheoretical model of James Prochaska
  and his colleagues assumes that people progress
  through five stages in making changes in
  behaviorprecontemplation, contemplation,
  preparation, action, and maintenance.

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The Transtheoretical Model

• The precontemplation stage precedes intention to
  change behavior, and people in this stage may
  fail to see that they have a problem.
• The contemplation stage involves awareness of
  the problem and thoughts about changing behavior,
  but the person has not yet made an effort to
  change.

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The Transtheoretical Model

• The preparation stage includes both thoughts and
  action, with people in this stage making specific
  plans about change. The modification of behavior
  comes in the action stage, when people make overt
  changes in their behavior.
• During the maintenance stage people try to
  sustain the changes they have made and to resist
  temptation to relapse (see Figure 4.2). People in
  these various stages need different types of
  assistance in making changes. Research on this
  theory has indicated that these stages of change
  apply to a variety of health-related behaviors.

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Figure 4.2The transtheoretical model and stages
of changing from a high-fat diet to a low-fat
diet.
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II. Issues in Adherence

• Two conditions are necessary for medical advice
  to be beneficial first, it must be accurate and
  second, it must be followed. A meta-analysis
  indicated a large difference in outcome for
  people who were adherent to their medication
  compared to those who were non-adherent.

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A. What Is Adherence?

• Because compliance connotes reluctant obedience,
  many psychologists prefer the terms adherence,
  cooperation, or collaboration.

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A. What Is Adherence?

• In an ideal world, the best definition of
  adherence would be cooperation, a word that
  implies a relationship in which both the health
  care provider and the consumer are actively
  involved in the restoration or the maintenance of
  the patient's health.

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A. What Is Adherence?

• However, cooperation is neither a common practice
  nor an accepted label for this relationship. The
  terms compliance and adherence are used
  interchangeably.

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B. How Is Adherence Measured?

• Researchers have used at least six methods to
  assess patient compliance
• (1) ask the clinician,
• (2) ask the patient,
• (3) ask other people,
• (4) count pills,
• (5) examine biochemical evidence
• 6) combine two or more of these procedures.
•  

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B. How Is Adherence Measured?

• All approaches have limitations, but the least
  valid method is to ask the clinician about rate
  of patient compliance.

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C. How Frequent Is Nonadherence?

• The rate of noncompliance to medical or health
  advice varies with a number of factors, but a
  meta-analysis of over 50 years of studies
  indicated that the average adherence rate was
  about 25, but the rate was higher for some
  conditions such as HIV and arthritis but the rate
  was lower for conditions such as diabetes.

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III. What Factors Predict Adherence?

• Many factors that would logically seem to lead to
  compliance, such as severity of the disease, are
  in fact, poor predictors of adherence.
  discomfort.

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III. What Factors Predict Adherence?

• People with a serious disease are, in general, no
  more likely than people with a mild disease to
  seek medical treatment or to comply with medical
  advice.

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III. What Factors Predict Adherence?

• Although severity of the disease is a poor
  predictor of adherence, pain associated with the
  illness does seem to increase people's level of
  adherence.
• When people suffer great pain, they have strong
  motivation to comply with treatments that might
  reduce their

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A. Treatment Characteristics

• Treatment characteristics include unpleasant side
  effects of the treatment and complexity of the
  treatment.
•  

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1. Side Effects of the Medication

• Early research found little evidence to suggest
  that unpleasant side effects are a major reason
  for discontinuing a drug or dropping out of a
  treatment program.

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1. Side Effects of the Medication

• Recent research on taking drugs for HIV found
  that patients who experience severe side effects
  are less likely to take their medications than
  those with less severe side effects.
•  

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2. Complexity of the Treatment

• In general, the greater the variety of
  medications a person must take, the greater the
  likelihood of nonadherence.
• Doses that cannot be cued to meals or bedtime
  (such as four or five doses per day) result in
  lower compliance than those that can be cued to
  meals or bedtime.
• In summary, the simpler and shorter the treatment
  schedule, the higher the level of adherence.

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B. Personal Characteristics

• Five personal characteristics relate to patient
  compliance

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• 1. Age
• Age shows a curvilinear relationship with
  adherence, with older and younger people showing
  lower adherence. Older individuals have more
  barriers to compliance because they tend to have
  more complex medication schedules. As they grow
  into adolescence, children with chronic
  conditions such as diabetes tend to become less
  compliant.
• 2. Gender
• Few overall differences exist in compliance rates
  for women and men, but women are more likely to
  adhere to a diet that includes fruits and
  vegetables.
• 3. Personality Patterns
• No single personality trait shows any consistent
  relationship to adherence. Rather, non-compliance
  is more closely related to situational factors.

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• 4. Emotional Factors
• Anxiety that is specific to the disease may
  improve compliance, but more general anxiety and
  stressful experiences tend to decrease adherence.
  Depression, however, presents a more serious
  problem for compliance.
• 5. Personal Beliefs
• When patients have high self-efficacy, they are
  more likely to adhere with medical
  recommendations. In addition, those who believe
  that they are personally responsible for their
  own health are more likely to be compliant.

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• C. Environmental Factors
• Environmental factors exert an even larger effect
  on compliance than personal factors do.
•  

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1. Economic Factors

• Income and socioeconomic status are important
  factors for health those with more resources
  have advantages in access to health care and
  often have the education to understand the
  advantages of adherence.

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2. Social Support

• Social support is one of the strongest predictors
  of adherence. People with a network of friends
  and family are more likely to adhere to medical
  advice compared with people who lack social
  support. Also, married patients are more likely
  to be compliant than those who are not married.

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D. Cultural Norms

• Cultural beliefs and attitudes are related to
  compliance. Cultural traditions that are not
  consistent with Western medicine lead to lower
  compliance.

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D. Cultural Norms

• Cultural factors and ethnicity may also influence
  how patients are treated when Hispanic American
  and African American patients feel discriminated
  against, their compliance rates are not as high
  as when they feel treated with respect.

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E. Practitioner-Patient Interaction

• Although personal characteristics are only
  marginally predictive of compliance, the
  relationship between patient and practitioner is
  a relatively strong indicator of patient
  adherence.
• This factor includes verbal communication and the
  practitioner's personal characteristics (as
  perceived by the patient).

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1. Verbal Communication

• Perhaps the best predictor of patient compliance
  is the quality of communication between
  practitioner and patient. Physicians often begin
  their report with a diagnosis, which is likely to
  interfere with the patient's understanding of any
  advice that follows. Patients either fail to
  remember or misunderstand about half the
  information they hear.

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1. Verbal Communication

• Patients are most likely to comply when they
  receive reasons for their particular treatment as
  well as information about their illness. Health
  care professionals can improve adherence by
  giving information about the disease and about
  specific treatment requirements.

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2. The Practitioner's Personal Characteristics

• Patients' compliance improves when they see their
  providers as warm, caring, friendly, and
  interested in their welfare. On the other hand,
  when patients perceive practitioners as
  authoritarian or uncaring, adherence decreases.

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2. The Practitioner's Personal Characteristics

• Female practitioners generally exhibit more
  friendly behaviors, listen better and longer, and
  make more partner statements, all of which are
  positively related to high rates of adherence. \

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IV. Improving Adherence

• Failures to adhere to medical advice are common,
  making the goal of improving adherence an urgent
  one.

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A. What Are the Barriers to Adherence?

• Failures in adherence occur for a variety of
  reasons.
• Following a doctor's advice is complicated by a
  number of factors, such as not correctly hearing
  that advice, failing to understand the advice,
  seeing the regimen as too difficult,
  time-consuming, or expensive, and stopping
  medication when the symptoms go away.

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A. What Are the Barriers to Adherence?

• Many patients have an optimistic bias, believing
  that they will be spared the serious consequence
  of noncompliance.
• Considering a broad definition of adherence that
  includes a healthy and safe lifestyle, complete
  adherence is difficult most people fail in some
  ways to eat a healthy diet, refrain from smoking,
  drink alcohol moderately, participate in physical
  activity, keep medical and dental appointments,
  participate in appropriate health screening and
  tests, and so forth.

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B. How Can Adherence Be Improved?

• Health care providers have attempted to improve
  patient adherence through the use of both
  educational and behavioral strategies.
  Educational procedures that impart information
  boost knowledge but do not usually result in
  increased compliance.

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B. How Can Adherence Be Improved?

• Behavioral strategies are more effective. These
  strategies include prompts that serve as
  reminders, such as emails or telephone calls.
• Tailoring the regimen to fit the patients
  schedule is another strategy, and the technique
  of motivational interviewing fits into this
  approach.

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B. How Can Adherence Be Improved?

• A gradual implementation of the regimen can help
  shape people toward compliance, and a written
  contract clearly specifying behaviors for both
  patient and provider can be effective.

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B. How Can Adherence Be Improved?

• Clear instructions are the single best approach
  to improving adherence, but combinations of
  techniques are even more effective in boosting
  compliance.