Chapter 4 Adhering to Medical Advice adherence - A patient's ability and willingness to follow recommended health practices. Many professionals prefer this term to the more often used term "compliance" which implies an unwilling giving in to medical advice. cooperation - Ideally, the physician - patient relationship should be one of cooperation. Behavioral Theory of Adherence - is based on the "operant conditioning theory" of B. F. Skinner. The likelihood of a behavior occurring in the future depends on whether it is followed by a consequence that the organism (person) finds pleasant (reinforcing) or unpleasant (punishing). positive reinforcement - If a behavior (a rat pressing a lever) is followed by "adding" something pleasant (candy) the behavior will be repeated. negative reinforcement - If a behavior (a rat pressing a lever) is followed by "removal" of something unpleasant (continuously being shocked) the behavior will be repeated (as above). punishment (positive OR negative) - If a behavior (a rat pressing a lever) leads to something "unpleasant" (either by adding or removing), the behavior will NOT be repeated. Punishment is NOT the favored method for changing behavior. Punishment induced change tends to be more "temporary" and it can induce "negative emotional responses" in the person. Self-Efficacy Theory of Adherence - Albert Bandura suggests that self regulating (adherence) behaviors are a function of (1) personal factors (personality), (2) environment (situations), and (3) the person's behaviors. reciprocal determinism - Bandura suggests that these three factors (personality, environment, and behaviors) continuously interact with each other in very complex ways. self-efficacy - The belief that one is capable of performing behaviors that will produce (situation specific) desired outcomes. Three factors increase self efficacy: (1) performance (practice), (2) "vicarious" experiences (watching others), and (3) verbal persuasion (listening to others). High levels of arousal (anxiety) usually decrease self-efficacy. the Theory of Reasoned Action - This theory (behavior enactment determined by attitude and social norms) was discussed in chapter 3. It has been applied to the study of adherence behaviors (as well as to heath enhancing behaviors). the Theory of Planned Behavior - This theory (behavior enactment determined by attitude and social norms AND perceived control) was discussed in chapter 3. It has been applied to the study of adherence behaviors (as well as to heath enhancing behaviors). adherence history People's adherence history is a better predictor of future adherence than either of the above models. the Trans-theoretical Model - This model (Prochaska et. al.) consists of five spiraling stages that lead to changing to new behaviors. Stage 5 "maintenance" seems to be the only part of the theory that really relates to "adherence." The usefulness of this theory "depends on the specific behavior" being changed. non-adherence - Failure to follow medical advice leads to as many as 125,000 deaths per year in the U. S. Failure to take prescribed medications is the most frequent cause. Robin DiMatteo's (2004) meta analysis of 500 studies indicated an average non-adherence rate of 24.8% (i.e., about 25%). assessing adherence - Physician reports are the "poorest choice" being little better than chance. Having hospital staff of family monitor and report on the patient is better. However, this monitoring tends to actually increase adherence. While this is good for the patient, it is BAD for research because we are unintentionally changing the behavior we are trying to study! side effects - negatively affect adherence. The more severe the side effects, the more adherence suffers. treatment complexity - For example, the more daily doses of a medicine one must take the lower the adherence. Specifically, with "four" or more doses per day, adherence plummets to less than 40%. The problem seems to be fitting treatments into daily routines. severity of illness - surprisingly does NOT predict adherence. Pain, in contrast, does. The more severe the pain, the greater the adherence. personal factors in adherence - There are small but complex age differences, with the very old and the very young having "poorer" adherence. No personality or gender differences have been noted. People who believe they can adhere are more likely to. Also, those who believe in, and understand, the treatment are more likely to adhere. income level and adherence - Higher income (SES) seems to be associated with better adherence. However, there are complex relationships among SES, education, and ethnicity. social support - received from friends and family is a strong predictor of adherence. Family conflict is a negative factor for adherence. cultural factors - African, Hispanic, and Asian Americans reported increased feelings of being disrespected by their physicians, leading to (1) lower adherence and (2) more missed appointments. physician factors - The "most crucial factor" in non-adherence is poor verbal communication between the physician and the patient. Adherence is higher when patients perceive doctors as more warm, caring, interested, and understanding. Female physicians appear to engage in more adherence enhancing behaviors (e.g., spending more time and asking more questions). improving adherence - Strategies fall into two basic categories: (1) educational, and (2) behavioral. Education may "frighten" a patient into compliance (hey, if it works?). DiMatteo and Dinicola (1982) have suggested four categories of behavioral strategies. The problem is that behavioral strategies are costly and time consuming. motivational interviewing - A therapeutic approach that originated within substance abuse treatment that attempts to change a client’s motivation and prepares the client to enact changes in behavior. The therapist discusses present behavior, goals, and strategies. the record - Unfortunately, according to DiMatteo (2004) health professionals put little effort into improving adherence (long term) and little progress has been made in the past 50 years! For short-term regimens, providing "clear instructions" is the best strategy for increasing adherence.