Adhering to Medical Advice
Chap 4
Issues with Adherance
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125,000 people in US may die to
adherence issues
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Page 77
Theories that Apply to Adherence
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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.
Table 4.2
Reasons Given by Patients for Not Complying
with Medical Advice
Table 4.1a
Predictors of Patient Adherence
Table 4.1d
Table 4.1b
Table 4.1c
Behavioral Theory

The behavioral model of adherence is based on principles of
operant conditioning, especially positive and negative reinforcement.
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With positive reinforcement, a positively valued stimulus is added
to the situation, thus strengthening that behavior and increasing the
probability that it will recur.
Behavioral Theory
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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.
Behavioral Theory

Advocates of the behavioral model use
cues, rewards, and contracts to reinforce
compliant behaviors. Some research
supports the effectiveness of this
approach.
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).
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.
Theories of Reasoned Action and Planned Behavior
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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
Theories of Reasoned Action and Planned
Behavior
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(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).
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.
Theories of Reasoned Action and Planned
Behavior
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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
The Transtheoretical Model
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The transtheoretical model of James Prochaska and his
colleagues assumes that people progress through five stages in making
changes in behavior—precontemplation, contemplation, preparation, action,
and maintenance.
The Transtheoretical Model
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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 Transtheoretical Model
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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 healthrelated behaviors.
Figure 4.2
The transtheoretical model and stages of
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.
A. What Is Adherence?

Because compliance connotes reluctant
obedience, many psychologists prefer the
terms adherence, cooperation, or
collaboration.
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.
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.
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?
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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
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.
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.
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.
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

A. Treatment
Characteristics
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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.
1. Side Effects of the
Medication
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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.
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.

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.
C. Environmental Factors
 Environmental factors exert an even larger
effect on compliance than personal factors
do.
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1. Economic Factors
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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. Also, married patients are more
likely to be compliant than those who are
not married.
D. Cultural Norms
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Cultural beliefs and attitudes are related to
compliance. Cultural traditions that are not
consistent with Western medicine lead to
lower compliance.
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.
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).

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.
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.
2. The Practitioner's
Personal Characteristics
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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.
2. The Practitioner's
Personal Characteristics
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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. \
IV. Improving Adherence
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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.

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.
B. How Can Adherence Be
Improved?
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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.
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 patient’s
schedule is another strategy, and the
technique of motivational interviewing
fits into this approach.

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.
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.