Posted at 10.15.2018
The cognitive theories and models associated with adherence to medical advice including the Health Idea Model, Rational Choice Theory, Ley's Cognitive Theory and Protection Desire Model are investigated in this expanded article. The factors influencing medical non-adherence are explored through the cognitive methodology and the research question of: 'to what degree do cognitive models and theories offer an explanation for why people do not abide by medical advice' is examined and deconstructed. Research from various magazines and studies have been used in an attempt to examine the level that cognitive models and ideas can offer a conclusion for why people do not adhere to medical advice. The research allowed the final outcome to be produced that cognitive models and theories work in explaining the cause for non adherence but it would be reductionist to disregard the various other factors that donate to a patient's non-adherence to medical advice such as cultural factors and biological factors. These other factors are also central to answering why adherence occurs as cognitive factors are connected to both cultural and natural factors
What is medical adherence? Based on the World Health Company, this is of long -term medical adherence is 'the degree to which someone's behavior - taking medication, following a diet and/or executing changes in lifestyle, corresponds with agreed recommendations from physician. ' Haynes et al. stated that compliance and adherence are interchangeable terms but recently, there has been argument about whether conformity is really the same as adherence. The term compliance indicates the unaggressive and obedient nature of a patient whereas adherence takes into account the self-reliance of an individual. Thus, if an individual can take control of their own treatment to improve their health, how come non-adherence occur? In the strictest sense, Taylor (1990) suggested that 93 percent of patients didn't adhere to some type of their treatment. However, Sarafino (1994) used a far more lax explanation of adherence allowing customisation of treatment and proposed that patients were moderately adherent with 78 percent adherence in short term treatments. THE ENTIRE WORLD Health Organisation says that in developed countries, there can be an average of 50 percent adherence to long-term therapy of chronic diseases such as hypertension and diabetes. Out of all the American patients with hypertension, 85 percent 'remain undiagnosed, untreated, or inadequately treated. ' In McKenney's study, fifty members were studied and assessed over five a few months and the results revealed that the patients approximately needed only 65 percent of the recommended hypertensive medication and only 20 percent of the individuals had taken as much as 90 percent of their recommended drugs.
From these figures, it is clear that the definition of adherence is open to subjective interpretation and degrees of adherence may vary according to the definition adopted. Therefore, the many studies discussed in this article are limited as the interpretation of adherence is very wide thus generalisability and effectiveness are negatively afflicted. So what can be defined as non-adherence? Essentially, forgetting to have a dose, absent a dose deliberately, periodic alleviation of remedy and a full stop to treatment can all be described as non-adherence. There are many triggers that can contribute to insufficient adherence but focusing on the cognitive procedure might provide a far more concise answer to the question: To what extent do cognitive models and ideas offer a conclusion for why people do not stick to medical advice.
According to Cooper, Love, and Raffoul (1982), intentional non-adherence occurs 73 percent of the time.
Figure 1 Diagram depicting Health Opinion Model.
Source: (Hayden, 2009)
Source: Stretcher, V. , & Rosenstock I. M. (1997). MEDICAL Belief Model. In Glanz K. , Lewis F. M. , & Rimer B. K. , (Eds. ). Health Behavior and Health Education: Theory, Research and Practice. SAN FRANCISCO BAY AREA: Jossey-Bass.
The Health Idea Model (HBM), suggested by Rosenstock (1974) and later assessed by Janz and Becker (1984), advised that the likelihood of compliance to health advice relates to the patient's understanding of how severe the condition is and the amount of susceptibility. The foundation of perceived risk of the condition can appear from previous medical knowledge or the patient's perception of the implications of the disease. The probability of preventive action is set through some steps. If the individual recognises the condition as a danger, they will proceed to consider perceived obstacles against identified benefits, followed by a cue to action (any event that leads to altered behavior). However, as Physique 2 signifies, the HBM contains communal factors, such as ethnical upbringing; and cue to action can be associated with interpersonal factors such as media and peer pressure so in relation to the research question, cognitive models can make clear adherence to a certain extent, but social factors can be found also.
One can consider the Turner et al. (2004) research describing the utilization of HBM by the Osteoporosis Protection Programme on female patients to illustrate the HBM. Generally, there was a low level of perceived threat of osteoporosis amongst the women because of the common misconception that osteoporosis occurs in elderly females. To increase identified susceptibility, the participants were shown a standard healthy bone of an 75 12 months old female against a slide of osteoporotic bone in a 47 calendar year old woman and also images of an fractured back, hip and waistline. It was also emphasised that osteoporosis often demonstrated no symptoms and was only realised whenever a fracture took place. To imbue cues to action, a massive amount of information was made available to participants to improve awareness of the threats of osteoporosis, along with bone nutrient density screening and discussion classes for eating alterations and recommended physical activity. In addition, Turner et al. attemptedto reduce common identified barriers. Convenient program times, each prolonged one hour, were organised to assist in busy schedules and classes occurred in a 'centrally located, state-of-the-art community centre. ' Furthermore, free childcare services were provided at the city centre so that members would not have to stress about their children and the condition of cost was taken out by offering the program for free. Turner et al. figured involvement in health campaign programs was increased when identified threat, susceptibility and benefits were increased and identified barriers were lowered.
Turner et al. 's review had a relatively large test with 342 women completing the entire programme so research of such intricacy requires a large amount of time, work and money. However, as the focus of the study was on women, there would be difficulty generalising to guys but it could be said that more females have problems with osteoporosis so generalisation to guys had not been the intention.
In regards to the study question, medical belief model supports the effect of cognition but simply considering cognitive factors with disregard of other levels of analysis is reductionist. Many perceived barriers are related to cultural factors and the Turner et al. analysis shows that one of the main problems was financial situation, that will be linked to cultural class. Another communal barrier could be peer pressure. If one of the individuals were mocked by co-workers to be a hypochondriac, the perceived hurdle would be reinforced and obedience could be influenced negatively by the social group. Moreover, media or family members expressing their problems could supply the cue to action.
Perceived Benefits versus Perceived Costs to Patient
The Rational Choice Theory offers an description for non-adherence in which patients feel that there may be rationale to improve the suggested treatment scheduled to justifications that are believed to be true by the individual, though may well not actually be true or helpful to the patient's health. A conclusion because of this phenomena could be anticipated to negative side ramifications of treatment that alter the patient's standard of living so that they feel that it might be more reasonable to discontinue treatment. An example of non-adherence due to dissatisfaction associated with the side ramifications of medication is the Bulpitt (1988) review which aimed to investigate the study on results and difficulties of medication for hypertension. Antihypertensive medication may be linked to impaired intimate function such as erection dysfunction and it has been reported that the frequency of erectile inability was 6. 7 percent by age 55 and 24 percent by the age of 70 in Kinsey et al. 's work. Bulpitt reported a analysis by Curb (1985) found that 8 percent of males taking antihypertensive treatment finished the utilization of medication credited to impotence and ejaculation difficulty that emerged after taking the antihypertensive drugs. Notably, it was found by the Medical Research Council (1981) that 15 percent of patients halted medication scheduled to other area results such as headaches or dizziness. Though these studies have attributed undesired side effects with failed conformity, this was appropriate to only a tiny portion of the test, thus other factors must be looked at to attain a more wholesome notion of adherence and avoid reductionism. In addition, these studies are limited in generalisability to females as the studies only involved males and usefulness is doubtful as only hypertensive medication were included. Ethics could also be an issue in these studies because exploration in to the participant's erectile problems could be humiliating for the topic and may cause emotions of inadequacy that could be categorized as mental injury to the participant.
The existence of practical obstacles could contribute to a patient's decision to disregard medical advice. Financial hurdles such as low income of patients may cause not being able to manage expensive treatments not payed for by Country wide Health Techniques. Karter et al. (2000) concluded from other study on the partnership between financial obstacles and adherence to treatment for diabetes that 'removal of financial obstacles by giving more complete coverage for these costs may boost adherence to suggestions for SMBG [self-monitoring of bloodstream blood sugar]. ' The study was cross-sectional which provided a snapshot of the frequency of adherence to SMBG so it was less frustrating than a longitudinal study. A huge amount of data was attained from 44, 181 members so the analysis was highly generalisable to the mark population of Northern Californian diabetics, although ethnocentricity of the analysis restricts generalisation to the rest of the world.
The patient might also fail to comply because they have reason to mistrust the effectiveness of the treatment. A study on arthritis patients by Arluke (1980) advised that if the conditions of the disease worsen even although patient has implemented prescribed training, adherence will be influenced negatively. Furthermore, the Handbook of Clinical Mindset in Medical Adjustments states that 'the most usual reason given for intentional non-adherence was that the individual did not assume that the drug was needed in the dose approved by the physician. ' The individual might stop treatment out of attention to see whether the illness is still present because the patient may be sceptical about the usefulness of recommended treatment. This lack of rely upon the physician's advice could arise from concerns on the competency or professionalism of these doctor that can be connected with the patient-practitioner relationship. The trust imparted on the physician is somewhat dependent on how the doctor functions or dresses and a study by McKinstry and Wang (1991) where patients were shown pictures of male or female doctors dressed up in either formal or informal clothing. For example, a picture of any traditionally dressed doctor would depict the physician wearing a formal white jacket whereas an informally dressed doctor would be shown putting on jeans. When asked, the patients scored that they had the most self-assurance in the doctors that were formally dressed which preference was especially prevalent in elderly patients. Though members were approached at surgeries, this research was lower in ecological validity because patients aren't normally shown pictures of doctors and questioned when they go to a surgery. The patient-practitioner romance can be reliant on the patient's understanding of the medical professional, but can be reliant on the social situation and the interpersonal connection between them and the way in which of communication could impact the level of understanding of prescribed treatment. Thus, in relation to the study question, we can already observe how not only cognitive factors have an effect on adherence, but cultural aspects including the communicative skills and the practitioner's clothing could impact adherence.
A lack of understanding of the medication and/or the procedure schedule that is recommended is also a hurdle. This problem can not only lead the individual to possibly perform the treatment improperly, but can hinder the patient's ram of the procedure because of their treatment. Hadlow and Pitts (1991) reported that around 33 percent of patients do not have proper understanding of popular medical terms and as a result, 40 to 80 percent of advice distributed by the medical professional is instantly overlooked. Moreover, in a study by McKinlay (1975) of the knowledge of information directed at women by health employees in a maternity ward, only 39 percent of women actually realized 13 chosen medical terms. Interestingly, the health personnel expected even lower degrees of understanding but used specialized jargon no matter this. Only female participants were researched therefore the gynocentrism restrictions generalisation as well as perhaps a less gynocentric test could be gained in a new ward of the hospital, such as physiotherapy. Medical staff could be utilising technological jargon on patients to you shouldn't be asked questions and assert a sense of authority. In cases like this, ethics would be an issue as it's the patient's right to be fully enlightened about the procedure and their condition. It is unethical to send patients away with the probability that they don't grasp how to use their medication as it might lead to auspicious repercussions and there's a greater likelihood that the patient will fail to adhere, as is defined in Ley's Cognitive Model (1988).
Ley's Cognitive Model state governments that understanding and storage area of information affect adherence and lead to satisfaction that have a positive effect on adherence (see Figure 1).
Figure 2 Diagram depicting Ley's Cognitive Model (1988)
Source: (Kessels, 2003)Ley et al. (1973) conducted a study on patients with a control group of students and assessed their recall of the set of medical assertions in a structured or unstructured condition. The patients exhibited twenty five percent more recall in the categorised condition with structured information and students exhibited 50 percent more recall. These results suggest that providing patients with organized information would raise the levels of adherence as there will be a lower possibility of forgetting the medical advice. However, this review could be criticised because of the lack of ecological validity as it is strange for an individual to try and recall a list of apparently unrelated words when they go to a GP surgery. Also, students tend to be accustomed to learning and keeping in mind information it is therefore questionable whether using a college student control group is ideal and a possibly better group will be a diverse sample of patients instead. Furthermore, it might be reductionist to simply believe that the organised dynamics of information was the sole contributor to increased degrees of recall as other factors can have influenced recall, for example, the emotional state of the individual. A report on patient information recall by Anderson et al. (1979) figured stressed patients tended to remember better than the ones that were relaxed. This conclusion suggests that arousal could help ram which is possibly due to the patient's concerns about their health, thus making an extra effort to recall information given to them.
In a more ecologically valid research on the recall of real consultations (rather than list recall) by Ley (1988), it was found that less than 55 percent of information given by the physician was recalled. Ley concluded some main movements that occurred:
The primacy impact: Patients tended to recall the first information given to them best.
Structured information was better recalled than when non-categorised.
Prior medical knowledge improved upon recall of information.
The higher amount of information given, the higher amount forgotten
There was no influence on recall when the physician repeated instructions.
Ley's study was very useful as once reasons for impaired recall were diagnosed, amendments could be produced to the appointment process. A later review exhibited that doctors that got adopted advice from a booklet based on Ley's findings demonstrated an average of 70 percent of information was appreciated by the individual. However, demand characteristics could be present as the individuals were aware of the necessity to recall information that could have affected the patient's focus on details directed at them. Therefore, ecological validity, though higher than the previous study, would still not be very high as the situation is still different to a normal surgery visit where patients could be turning over questions to ask the physician and therefore not pay all the attention to instructions being given.
Figure 3 Diagram depicting Safeguard Motivation Theory
Source: Norman, P. . B. H. &. S. E. R. , 1996. Protection Motivation Theory. In Predicting Health Behaviour. Buckingham: Open College or university Press. pp. 84.
The Protection Drive Theory (PMT) suggested by Rogers (1983) indicates that the procedure of taking action to safeguard oneself, i. e. to adhere to medical advice, uses some cognitive decisions. PMT refers to the intention to adhere to the advice of the health worker and would depend on adaptive (positive response) and maladaptive response (modified negative response) that influence the chance of survival. Maladaptive responses are inspired by threat appraisal and can be prompted by intrinsic and extrinsic rewards. For instance, regarding complicated and time consuming treatments, an intrinsic award that could take action against adherence is to avoid the procedure to diminish stress. An extrinsic compensation stemming from this scenario would be that missing treatment allows time for contribution in interpersonal gatherings. When understanding of severity and vulnerability are high, maladaptive responses will decrease and likewise, greater degrees of dread arousal will elicit increased identified severeness and vulnerability and therefore the patient will make a judgement that degrees of threat are high.
Conversely, an adaptive response can be brought about by coping appraisal which is related to how the patient perceives the ailment can be handled. Coping appraisal can be increased with higher response efficacy which is the belief that approved medication will impact the illness. Another explanation could be that self-efficacy can increase coping appraisal. Adaptive response is also afflicted by response costs that are, perceived obstacles which can inhibit the emergence of adaptive behavior of sticking with medical advice.
A research on outpatient treatment adherence by Grindley et al. examines the PMT by it as a verification tool to assess sports injury treatment adherence. Factors of PMT were integrated in the analysis by various means. The generation of threat appraisal was reliant on the patient's belief that the uncomfortableness or even disability of these condition would persist or exacerbate and the fear arousal from pain, medical diagnosis and disability further increased threat appraisal. Coping appraisal was dependent on the patient's belief in the potency of their treatment and also their capability to successfully complete treatment, which accounted for response efficacy and self-efficacy. Response costs relevant to the situation had taken the proper execution of anxiety about the required timeframe for treatment, possible experience of pain and financial implications. The data was gathered utilizing a 7-point Likert range which assessed aspects of PMT such as recognized intensity, vulnerability etc. , thus there was reduced researcher bias than self-reports as it eradicates the necessity for researcher interpretation of participant reviews. Grindley et al. concluded that drop out behaviour from the analysis was related to the recognized seriousness, self-efficacy and response barriers and this higher self-efficacy was related to higher treatment efficacy.
The study required into consideration that the severity of the patient's condition could be a confounding variable in order a control, individuals that were prescribed treatment treatment for 4 to eight weeks were used in order to eradicate patients with slight accidental injuries or chronic health problems anticipated to dissimilar treatment requirements. Due to this control, the severity of the problem could not affect results and for that reason increased the consistency of results. Another durability is that honest guidelines were followed and prepared consent was attained, without physical harm imparted on the individuals. Issues with generalisability is the ethnocentric nature of the study as only one rehabilitation facility was used in the sample thus the results may have limited generalisability probable when put on other areas. However, the large sample of 229 members comprising 149 females and 80 guys was a strength as the results could be generalised to both genders. Another restriction is that the study measures behaviour inside the clinic during attendance but didn't look at the patient's behavior with home physical therapy which behavior could be different so there is not a wholesome point of view, thus negatively impacting on usefulness. Additionally, extraneous variables that may have occurred could are the fact that patients may well not have necessarily known the treatment or the negative implications that could result from failing to adhere. In addition, the option of pain killers means that the perception of pain is less severe thus decreasing protection motivation. Feelings and mood of the individual could have a poor influence on adherence because they are maladaptive reactions as DiMatteo et al. concluded of their study on the partnership between major depression and noncompliance, stressed out patients were 3 times much more likely to be non-adherent to medical advice than non-depressed patients. Thus other than cognitive factors, the affective condition of a patient can have a significant effect on adherence and might limit the amount to which cognitive models explain adherence.
It is apparent from the theories examined that there surely is no ultimate reason or level of examination that can clarify non-adherence and a holistic analysis is required for a sensible conclusion. The reasons for non-adherence evaluated in this essay merely focus on the cognitive perspective toward non-adherence and it would be reductionist to claim that any solitary factor is the sole reason for non-compliance. Many factors intertwine and the cognitive level of analysis can only explain non-adherence up to certain magnitude. Evidently, even within the ideas discussed in this essay, the social degree of analysis has been surreptitiously present because of the many social relations to the theories. To illustrate this aspect, one can consider the HBM. It consists of cues to action but press campaigns and advice are both interpersonal factors that cause the process. Also, in both the HBM and PMT, a potential response cost can form part of sociable norms. For instance, a diabetic might avoid taking an treatment at a restaurant since it goes against interpersonal norms. Another exemplory case of a social hurdle could be how supporters of Jehovah's Witness faith refuse blood vessels transfusions due to their belief that the Bible forbids the ingestion of blood vessels and so even in emergencies, they'll not accept blood transfusions. In addition, self-efficacy (which is a feature of PMT) is linked to interpersonal factors as Bandura stated that judgements of self-efficacy are based on lots of interpersonal constructs such as the individual's own accomplishments, effect of themselves and society, scrutiny of mental claims and observations of others.
Many other possible cognitive reasons for non-adherence never have been mentioned in this essay such as biological factors. Genetics are an example of how natural factors could effect non-adherence to medical guidance. For instance, if a person has inherited aggressive qualities through genes from their parents, the hostility might bring about negative conformity as the individual does not reply well to advice. A severe brain accident in the recollection centres of the brain would also have an impact on adherence but one would claim that the specialist will consider this and treat the individual accordingly.
Furthermore, there are extensive limitations to studies on adherence which leaves the validity of studies doubtful. Most studies on medical adherence use self-reporting methods which are extremely subjective and are available to demand characteristics as well as researcher bias because the participant could try to report so to assist or sabotage the study and the researcher may become biased because of their enthusiasm or seeks. On top of that, the participant may be influenced by public desirability bias because they would like to report in a way which they understand is the 'right' way. Additionally, it is difficult to accurately assess adherence, i. e. if the different approach to measuring adherence was implemented like counting the amount of pills the patient has remaining in the container to observe how many pills have been taken, it would still not be exact even as we only know that a certain range of pills have been taken out but we do not know how many pills have been taken by the patient.
In conclusion, although models and ideas of cognition offer some description as to why people do not adhere, they cannot provide the ultimate answer. Cognitive ideas and models can certainly help prediction of how well an individual will adhere but people are in the end unpredictable numerous individual dissimilarities therefore there are numerous facets to the incident of non-adherence. To simplistically give attention to only cognitive factors of non-adherence can only just give a one-sided take on non-compliance. With regards to the research question, it can only just be said that non-adherence is because cognitive factors up to a certain scope as there is absolutely no hesitation that cognitive factors do play a part in influencing adherence, but factors from the biological and socio-cultural degree of analysis are significant in the incident of non-adherence to medical advice. To get an ultimate understanding of why people do not stick to medical advice, studies in behavioural, cultural, physiological developmental etc. mindset will have to be examined to come to a more holistic conclusion.