CHAPTER 4 Adhering to Medical Advice

Lecture Outline
I. Theories that Apply to Adherence

Several theoretical models that apply to behavior in general have also been applied to the problem of adherence and nonadherence.
A. 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. 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.
B. 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). 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 diabetes management and smoking cessation.
C. 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 (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). 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. 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.
D. 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. 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. 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.
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. Two meta-analyses indicate a large difference in outcome for people who were adherent to their medication compared to those who were not.
A. What Is Adherence?

Because compliance connotes reluctant obedience, many psychologists prefer the terms adherence, cooperation, or collaboration. The best definition of adherence would be cooperation, implying a mutual, interactive relationship of the health care provider and the consumer, but neither this practice nor this term is accurate currently. The terms compliance and adherence are used interchangeably.
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, and (6) combine two or more of these procedures. All approaches have limitations, but the least valid method is to ask the clinician about rate of patient compliance.
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 rate for failure to adhere was about 25%. The rate was better for some conditions such as HIV and arthritis but worse for conditions such as diabetes.
III. What Factors Predict Adherence?

There are many factors that would logically seem to lead to compliance.
A. Severity of the Disease

Severity of the disease is actually a poor predictor of adherence, but the persons perception of severity, especially pain associated with a disease, is a better predictor of adherence.
B. Treatment Characteristics

Treatment characteristics include unpleasant side effects of the treatment and complexity of the treatment.
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. Recent research indicates that severe side effects are a reason for adherence failures, especially among younger patients.
2. Complexity of the Treatment

In general, the greater the complexity of treatment, the lower the rate of compliance. Medication 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. The simpler and shorter the treatment schedule, the higher the level of adherence.
C. Personal Factors

Seven personal characteristics relate to patient compliance.

1. Age

Age shows a curvilinear relationship with adherence, with older and younger adults 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 for most conditions, but women are more likely to adhere to a healthy diet that includes fruits and vegetables.
3. Personality Patterns

No single personality trait shows any consistent relationship to adherence. Rather, noncompliance is more closely related to situational factors.
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. The factor of conscientiousness shows reliable relation to adherence.
5. Personal Beliefs

When patients have high self-efficacy, they are more likely to adhere with medical recommendations. In addition, those who believe that the treatment will be effective and that they can exert control of their own health are more likely to be compliant.
D. Environmental Factors

Environmental factors exert an even larger effect on compliance than personal factors do.
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.
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. People who live with someone (spouse, family, companion) are more likely to be compliant than those who live alone.
E. Cultural Norms

Cultural beliefs and attitudes are related to compliance. Cultural traditions that are not consistent with Western medicine lead to lower compliance. 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.
F. Practitioner-Patient Interaction

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).
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. 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.

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. Female practitioners often exhibit behaviors that are positively related to high rates of adherence.
G. Interaction of Factors

Many factors show some relationship to adherence, but each factors contribution is small. These factors overlap and interact, and researchers and practitioners must consider the complex pattern of these interactions to understand and improve adherence.
IV. Improving Adherence

Failures to adhere to medical advice are common, making the goal of improving adherence an urgent one.
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. 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.
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. 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 effective strategy, and the technique of motivational interviewing fits into this approach. 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. Clear instructions are the single best approach to improving adherence, but combinations of techniques are even more effective in boosting compliance.