Adhering to Medical Advice Chap 4. Issues with Adherance 125,000 people in US may die to adherence...

Adhering to Medical AdviceAdhering to Medical Advice

Chap 4Chap 4

Issues with AdheranceIssues with Adherance

125,000 people in US may die to 125,000 people in US may die to adherence issuesadherence issues

Page 77 Page 77

Theories that Apply to AdherenceTheories that Apply to Adherence

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

Table 4.2Table 4.2Reasons Given by Patients for Not Complying Reasons Given by Patients for Not Complying

with Medical Advicewith Medical Advice

Table 4.1aTable 4.1aPredictors of Patient AdherencePredictors of Patient Adherence

Table 4.1dTable 4.1d

Table 4.1bTable 4.1b

Table 4.1cTable 4.1c

Behavioral Theory Behavioral Theory

The behavioral model of adherence is based on principles of The behavioral model of adherence is based on principles of operant conditioning, especially positive and negative operant conditioning, especially positive and negative reinforcement. reinforcement.

With With positive reinforcementpositive reinforcement, a positively valued stimulus is added , a positively valued stimulus is added to the situation, thus strengthening that behavior and increasing the to the situation, thus strengthening that behavior and increasing the probability that it will recur. probability that it will recur.


With With negative reinforcementnegative reinforcement, behavior is , behavior is strengthened by the removal of an unpleasant or strengthened by the removal of an unpleasant or negatively valued stimulus. Both types of negatively valued stimulus. Both types of reinforcers reinforcers strengthenstrengthen behavior, whereas behavior, whereas punishmentpunishment inhibits or suppresses behavior. inhibits or suppresses behavior.

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


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

Self-Efficacy TheorySelf-Efficacy Theory

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

Self-Efficacy TheorySelf-Efficacy Theory

An important component of the person factor is An important component of the person factor is self-efficacyself-efficacy, or people's belief that they have , or people's belief that they have the ability to perform the ability to perform specificspecific behaviors that will behaviors that will lead to desired consequences. lead to desired consequences. For example, self-efficacy was the best For example, self-efficacy was the best

predictor of adherence to an exercise predictor of adherence to an exercise rehabilitation program. rehabilitation program.

Research has generally supported the Research has generally supported the importance of self-efficacy in health-related importance of self-efficacy in health-related behaviors, especially the two difficult behaviors, especially the two difficult behaviors of diet and smoking cessation.behaviors of diet and smoking cessation.

Theories of Reasoned Action and Planned BehaviorTheories of Reasoned Action and Planned Behavior

Ajzen and Fishbein'sAjzen and Fishbein's theory of reasoned action theory of reasoned action and Ajzen's and Ajzen's theory theory of planned behavior of planned behavior both assume that the immediate determiner of both assume that the immediate determiner of behavior is people's behavior is people's intentionintention to perform that behavior. to perform that behavior.

The theory of reasoned action suggests that behavioral intentions, The theory of reasoned action suggests that behavioral intentions, in turn, are in turn, are

Theories of Reasoned Action and Planned Theories of Reasoned Action and Planned BehaviorBehavior

(1) a function of people's(1) a function of people's attitudes attitudes toward the toward the behavior, which are determined by their beliefs behavior, which are determined by their beliefs that the behavior will lead to positively or that the behavior will lead to positively or negatively valued outcomes, and negatively valued outcomes, and

(2) their (2) their subjective normsubjective norm, which is shaped by , which is shaped by their perception of the value that significant their perception of the value that significant others place on that behavior and by their others place on that behavior and by their motivation motivation to comply with those norms (to comply with those norms (seesee Chapter 3, Figure 3.1). Chapter 3, Figure 3.1).


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


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

The Transtheoretical ModelThe Transtheoretical Model

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


The The precontemplation stage precontemplation stage precedes intention precedes intention to change behavior, and people in this stage to change behavior, and people in this stage may fail to see that they have a problem.may fail to see that they have a problem.

The The contemplation stagecontemplation stage involves awareness of involves awareness of the problem and thoughts about changing the problem and thoughts about changing behavior, but the person has not yet made an behavior, but the person has not yet made an effort to change.effort to change.


The The preparation stage preparation stage includes both thoughts includes both thoughts and action, with people in this stage making and action, with people in this stage making specific plans about change. The modification of specific plans about change. The modification of behavior comes in the behavior comes in the action stageaction stage, when , when people make overt changes in their behavior.people make overt changes in their behavior.

During the During the maintenance stage maintenance stage people try to people try to sustain the changes they have made and to sustain the changes they have made and to resist temptation to relapse (resist temptation to relapse (seesee Figure 4.2). Figure 4.2). People in these various stages need different People in these various stages need different types of assistance in making changes. types of assistance in making changes. Research on this theory has indicated that these Research on this theory has indicated that these stages of change apply to a variety of health-stages of change apply to a variety of health-related behaviors.related behaviors.

Figure 4.2Figure 4.2The transtheoretical model and stages of The transtheoretical model and stages of

changing from a high-fat diet to a low-fat diet.changing from a high-fat diet to a low-fat diet.

II.II. Issues in AdherenceIssues in Adherence

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

A.A. What Is Adherence?What Is Adherence?

Because Because compliancecompliance connotes reluctant connotes reluctant obedience, many psychologists prefer the obedience, many psychologists prefer the terms terms adherenceadherence, , cooperationcooperation, or , or collaborationcollaboration. .


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


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

B.B. How Is Adherence How Is Adherence Measured?Measured?

Researchers have used at least six methods to Researchers have used at least six methods to assess patient compliance:assess patient compliance:

(1) ask the clinician, (1) ask the clinician, (2) ask the patient,(2) ask the patient, (3) ask other people,(3) ask other people, (4) count pills,(4) count pills, (5) examine biochemical evidence(5) examine biochemical evidence 6) combine two or more of these procedures. 6) combine two or more of these procedures.

B.B. How Is Adherence How Is Adherence Measured?Measured?

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

C.C. How Frequent Is How Frequent Is Nonadherence?Nonadherence?

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

III.III. What Factors Predict What Factors Predict Adherence?Adherence?

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


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


Although severity of the disease is a poor Although severity of the disease is a poor predictor of adherence, predictor of adherence, painpain associated associated with the illness does seem to increase with the illness does seem to increase people's level of adherence. people's level of adherence.

When people suffer great pain, they have When people suffer great pain, they have strong motivation to comply with strong motivation to comply with treatments that might reduce theirtreatments that might reduce their

A.A. Treatment Treatment CharacteristicsCharacteristics

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

1.1. Side Effects of the Side Effects of the MedicationMedication

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

1.1. Side Effects of the Side Effects of the MedicationMedication

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

2.2. Complexity of the TreatmentComplexity of the Treatment

In general, the greater the variety of In general, the greater the variety of medications a person must take, the medications a person must take, the greater the likelihood of nonadherence. greater the likelihood of nonadherence.

Doses that cannot be cued to meals or Doses that cannot be cued to meals or bedtime (such as four or five doses per bedtime (such as four or five doses per day) result in lower compliance than those day) result in lower compliance than those that can be cued to meals or bedtime. that can be cued to meals or bedtime.

In summary, the simpler and shorter the In summary, the simpler and shorter the treatment schedule, the higher the level of treatment schedule, the higher the level of adherence.adherence.

B.B. Personal CharacteristicsPersonal Characteristics

Five personal characteristics relate to Five personal characteristics relate to patient compliance:patient compliance:

1.1. AgeAge Age shows a curvilinear relationship with adherence, with older and Age shows a curvilinear relationship with adherence, with older and

younger people showing lower adherence. Older individuals have younger people showing lower adherence. Older individuals have more barriers to compliance because they tend to have more more barriers to compliance because they tend to have more complex medication schedules. As they grow into adolescence, complex medication schedules. As they grow into adolescence, children with chronic conditions such as diabetes tend to become children with chronic conditions such as diabetes tend to become less compliant.less compliant.

2.2. GenderGender Few overall differences exist in compliance rates for women and Few overall differences exist in compliance rates for women and

men, but women are more likely to adhere to a diet that includes men, but women are more likely to adhere to a diet that includes fruits and vegetables. fruits and vegetables.

3.3. Personality PatternsPersonality Patterns No single personality trait shows any consistent relationship to No single personality trait shows any consistent relationship to

adherence. Rather, non-compliance is more closely related to adherence. Rather, non-compliance is more closely related to situational factors.situational factors.

4.4. Emotional FactorsEmotional Factors Anxiety that is specific to the disease may improve compliance, but Anxiety that is specific to the disease may improve compliance, but

more general anxiety and stressful experiences tend to decrease more general anxiety and stressful experiences tend to decrease adherence. Depression, however, presents a more serious problem adherence. Depression, however, presents a more serious problem for compliance.for compliance.

5.5. Personal BeliefsPersonal Beliefs When patients have high self-efficacy, they are more likely to When patients have high self-efficacy, they are more likely to

adhere with medical recommendations. In addition, those who adhere with medical recommendations. In addition, those who believe that they are personally responsible for their own health are believe that they are personally responsible for their own health are more likely to be compliant.more likely to be compliant.

C. Environmental FactorsC. Environmental FactorsEnvironmental factors exert an even larger Environmental factors exert an even larger

effect on compliance than personal factors effect on compliance than personal factors do.do.

1.1. Economic FactorsEconomic Factors

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

2.2. Social SupportSocial Support

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

D.D. Cultural NormsCultural Norms

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

D.D. Cultural NormsCultural Norms

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

E.E. Practitioner-Patient Practitioner-Patient InteractionInteraction

Although personal characteristics are only Although personal characteristics are only marginally predictive of compliance, the marginally predictive of compliance, the relationship between patient and relationship between patient and practitioner is a relatively strong indicator practitioner is a relatively strong indicator of patient adherence. of patient adherence.

This factor includes verbal communication This factor includes verbal communication and the practitioner's personal and the practitioner's personal characteristics (as perceived by the characteristics (as perceived by the patient).patient).

1.1. Verbal CommunicationVerbal Communication

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

1.1. Verbal CommunicationVerbal Communication

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

2.2. The Practitioner's The Practitioner's Personal CharacteristicsPersonal Characteristics

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

2.2. The Practitioner's The Practitioner's Personal CharacteristicsPersonal Characteristics

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

IV.IV. Improving AdherenceImproving Adherence

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

A.A. What Are the Barriers to What Are the Barriers to Adherence?Adherence?

Failures in adherence occur for a variety of Failures in adherence occur for a variety of reasons. reasons.

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

A.A. What Are the Barriers to What Are the Barriers to Adherence?Adherence?

Many patients have an Many patients have an optimistic biasoptimistic bias, , believing that they will be spared the serious believing that they will be spared the serious consequence of noncompliance. consequence of noncompliance.

Considering a broad definition of adherence that Considering a broad definition of adherence that includes a healthy and safe lifestyle, complete includes a healthy and safe lifestyle, complete adherence is difficult; most people fail in some ways adherence is difficult; most people fail in some ways to eat a healthy diet, refrain from smoking, drink to eat a healthy diet, refrain from smoking, drink alcohol moderately, participate in physical activity, alcohol moderately, participate in physical activity, keep medical and dental appointments, participate in keep medical and dental appointments, participate in appropriate health screening and tests, and so forth.appropriate health screening and tests, and so forth.

B.B. How Can Adherence Be How Can Adherence Be Improved?Improved?

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


Behavioral strategies are more effective. Behavioral strategies are more effective. These strategies include prompts that These strategies include prompts that serve as reminders, such as emails or serve as reminders, such as emails or telephone calls.telephone calls.

Tailoring the regimen to fit the patient’s Tailoring the regimen to fit the patient’s schedule is another strategy, and the schedule is another strategy, and the technique of technique of motivational interviewingmotivational interviewing fits into this approach. fits into this approach.


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


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

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