Posted at 10.02.2018
The cognitive theories and models associated with adherence to medical advice such as the Health Perception Model, Rational Choice Theory, Ley's Cognitive Theory and Cover Motivation Model are looked into in this expanded article. The factors impacting on medical non-adherence are explored through the cognitive way and the research question of: 'to what amount do cognitive models and theories offer an explanation for why people do not stick to medical advice' is examined and deconstructed. Research from various publications and studies have been found in an attempt to examine the magnitude that cognitive models and theories can offer an explanation for why people do not adhere to medical advice. The study 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 ignore the several other factors that contribute to a patient's non-adherence to medical advice such as public factors and natural factors. These other factors are also central to answering why adherence occurs as cognitive factors are linked to both social and biological factors
What is medical adherence? Based on the World Health Company, the definition of long -term medical adherence is 'the level to which someone's behaviour - taking medication, carrying out a diet and/or executing changes in lifestyle, corresponds with agreed recommendations from physician. ' Haynes et al. stated that conformity and adherence are compatible terms but recently, there's been controversy about whether compliance is really exactly like adherence. The word compliance signifies the passive and obedient character of a patient whereas adherence takes into account the independence of an individual. Thus, if an individual can take control of their own treatment to improve their health, why does non-adherence occur? In the strictest sense, Taylor (1990) suggested that 93 percent of patients failed to adhere to some type of their treatment. However, Sarafino (1994) used a more lax definition of adherence allowing customisation of treatment and proposed that patients were moderately adherent with 78 percent adherence in short term treatments. THE PLANET Health Organisation claims that in developed countries, there is an average of 50 percent adherence to long-term therapy of serious diseases such as hypertension and diabetes. Out of all the American patients with hypertension, 85 percent 'stay undiagnosed, unattended, or inadequately cared for. ' In McKenney's research, fifty individuals were studied and examined over five a few months and the results demonstrated that the patients about got only 65 percent of the prescribed hypertensive medication in support of 20 percent of the members had taken as many as 90 percent of the prescribed drugs.
From these reports, it is clear that this is of adherence is open to subjective interpretation and degrees of adherence may vary in line with the definition used. Therefore, the many studies discussed in this article are limited as the interpretation of adherence is very extensive thus generalisability and usefulness are negatively affected. So what can be explained as non-adherence? Essentially, forgetting to have a dose, lacking a dose deliberately, periodic alleviation of therapy and a complete stop to treatment can all be referred to as non-adherence. There are various causes that can contribute to lack of adherence but focusing on the cognitive strategy might provide a far more concise response to the question: From what magnitude do cognitive models and theories offer a conclusion for why people do not adhere to medical advice.
According to Cooper, Love, and Raffoul (1982), intentional non-adherence occurs 73 percent of the time.
Figure 1 Diagram depicting Health Belief Model.
Source: (Hayden, 2009)
Source: Stretcher, V. , & Rosenstock I. M. (1997). The Health Opinion Model. In Glanz K. , Lewis F. M. , & Rimer B. K. , (Eds. ). Health Habit and Health Education: Theory, Research and Practice. San Francisco: Jossey-Bass.
The Health Opinion Model (HBM), proposed by Rosenstock (1974) and later evaluated by Janz and Becker (1984), advised that the probability of conformity to health advice relates to the patient's conception of how severe the disease is and the degree of susceptibility. The basis of perceived threat of the condition can occur from previous medical knowledge or the patient's understanding of the implications of the disease. The probability of preventive action is set through a series of steps. If the individual recognises the condition as a danger, they will proceed to consider perceived barriers against perceived benefits, accompanied by a cue to action (any event that leads to altered behaviour). However, as Shape 2 implies, the HBM features public factors, such as ethnical upbringing; and cue to action can be linked to interpersonal factors such as advertising and peer pressure so with regards to the research question, cognitive models can describe adherence to a certain degree, but social factors can be found also.
One can consider the Turner et al. (2004) research describing the use of HBM by the Osteoporosis Protection Programme on feminine patients to demonstrate the HBM. Generally, there was a low degree of perceived threat of osteoporosis amongst the ladies because of the common misunderstanding that osteoporosis occurs in old females. To improve recognized susceptibility, the individuals were shown a normal healthy bone of your 75 yr old female against a glide of your osteoporotic bone in a 47 12 months old female and also images of the fractured spine, hip and midsection. It had been also emphasised that osteoporosis often proved no symptoms and was only realised whenever a fracture occurred. To imbue cues to action, a vast amount of information was distributed around participants to improve awareness of the hazards of osteoporosis, along with bone mineral density trials and discussion classes for dietary alterations and suggested physical activity. In addition, Turner et al. attempted to reduce common recognized barriers. Convenient programme times, each prolonged an hour, were organised to help in busy schedules and classes occurred in a 'centrally located, state-of-the-art community centre. ' In addition, free childcare services were provided at the city centre so that members would not have to worry about their children and the situation of cost was eliminated by offering the program for free. Turner et al. concluded that contribution in health promotion programs was increased when recognized menace, susceptibility and benefits were increased and identified barriers were lowered.
Turner et al. 's research had a relatively large test with 342 women concluding the entire program so research of such complexity 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 maybe it's said that more females suffer from osteoporosis so generalisation to guys had not been the intent.
In regards to the research question, the health belief model supports the impact of cognition but simply considering cognitive factors with disregard of other levels of analysis is reductionist. Many perceived obstacles are related to sociable factors and the Turner et al. research implies that one of the key problems was financial situation, that will be linked to public class. Another interpersonal hurdle could be peer pressure. If one of the individuals were mocked by acquaintances for being a hypochondriac, the perceived barrier would be strengthened and behavior could be affected negatively by the public group. Moreover, media or family members expressing their worries could supply the cue to action.
Perceived Benefits versus Perceived Costs to Patient
The Rational Choice Theory provides an description for non-adherence where patients believe that there is rationale to improve the suggested treatment anticipated to justifications that are thought to be true by the individual, though may not actually be true or helpful to the patient's health. An explanation for this phenomena could be credited to negative area effects of treatment that alter the patient's quality of life so that they feel that it would be more sensible to discontinue treatment. An example of non-adherence credited to dissatisfaction from the side effects of medication is the Bulpitt (1988) review which aimed to investigate the study on results and problems of medication for hypertension. Antihypertensive medication is known to be linked to impaired intimate function such as erectile dysfunction and it has been reported that the consistency of erectile failure was 6. 7 percent by the age of 55 and 24 percent by age 70 in Kinsey et al. 's work. Bulpitt reported a study by Curb (1985) discovered that 8 percent of men taking antihypertensive treatment concluded the utilization of medication scheduled 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 anticipated to other aspect effects such as head pain or dizziness. Though these studies have attributed undesired side effects with failed conformity, this was appropriate to only a tiny part of the sample, thus other factors must be considered to attain a far more wholesome notion of adherence and avoid reductionism. Furthermore, these studies are limited in generalisability to females as the studies only engaged males and effectiveness is questionable as only hypertensive medication were included. Ethics may be a concern in these studies because research in to the participant's erectile problems could be humiliating for the subject and might cause thoughts of inadequacy which could be categorised as mental harm to the participant.
The occurrence of practical barriers could donate to a patient's decision to disregard medical advice. Financial hurdles such as low income of patients may lead to not being able to find the money for expensive treatments not payed for by National Health Plans. Karter et al. (2000) concluded using their company 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 enhance adherence to suggestions for SMBG [self-monitoring of bloodstream glucose]. ' The analysis was cross-sectional which provided a snapshot of the occurrence of adherence to SMBG so it was less frustrating than a longitudinal study. A massive amount of data was bought from 44, 181 participants so the study was highly generalisable to the prospective population of North Californian diabetics, although ethnocentricity of the study limits generalisation to the rest of the world.
The patient may also neglect to comply because they have reason to doubt the effectiveness of the treatment. A study on arthritis patients by Arluke (1980) recommended that if the conditions of the disease worsen even though the patient has followed prescribed teaching, adherence will be affected negatively. In addition, the Handbook of Clinical Psychology in Medical Configurations state governments that 'the most usual reason given for intentional non-adherence was that the patient did not believe that the medicine was needed in the dosage recommended by the medical doctor. ' The patient might stop treatment out of curiosity to see whether the illness continues to be present because the patient may be sceptical about the effectiveness of recommended treatment. This insufficient trust in the physician's advice could arise from concerns on the competency or professionalism of the doctor which can be connected with the patient-practitioner marriage. The trust imparted on the physician is somewhat based mostly on how the doctor works or dresses and a report by McKinstry and Wang (1991) in which patients were shown pictures of female or male doctors dressed in either formal or informal clothing. For instance, a picture of your traditionally dressed up doctor would depict the doctor putting on a formal white coating whereas an informally dressed doctor would be shown using trousers. When asked, the patients scored that that they had the most self confidence in the doctors which were formally dressed and this preference was particularly prevalent in old patients. Though members were contacted at surgeries, this research was low in ecological validity because patients are not normally shown pictures of doctors and questioned when they attend a surgery. The patient-practitioner relationship can be dependent on the patient's perception of the physician, but may also be reliant on the cultural situation and the cultural connections between them and the manner of communication could affect the level of understanding of approved treatment. Thus, in relation to the research question, we can already see how not only cognitive factors have an impact on adherence, but communal aspects such as the communicative skills and the practitioner's attire could influence adherence.
A lack of knowledge of the medication and/or the procedure routine that is prescribed is also a hurdle. This problem can not only lead the individual to possibly perform the treatment incorrectly, but can impede the patient's ram of the procedure because of their treatment. Hadlow and Pitts (1991) reported that around 33 percent of patients don't have proper understanding of widely used medical terms and as a result, 40 to 80 percent of advice distributed by the physician is instantly forgotten. Moreover, in a study by McKinlay (1975) of the understanding of information directed at women by health workers in a maternity ward, only 39 percent of women actually comprehended 13 chosen medical terms. Interestingly, medical employees expected even lower degrees of understanding but used specialized jargon no matter this. Only woman participants were researched therefore the gynocentrism limitations generalisation as well as perhaps a less gynocentric test could be obtained in another type of ward of the hospital, such as physiotherapy. Medical employees could be utilising specialized jargon on patients to don't be asked questions and also to assert a feeling of authority. In cases like this, ethics would be an issue as it's the patient's to be fully informed about the procedure and their condition. It is unethical to send patients away with the possibility that they don't grasp how to use their medication as it could lead to auspicious results and there is a greater possibility that the patient will fail to adhere, as is defined in Ley's Cognitive Model (1988).
Ley's Cognitive Model areas that understanding and recollection of information affect adherence and lead to satisfaction which have a positive influence on adherence (see Number 1).
Figure 2 Diagram depicting Ley's Cognitive Model (1988)
Source: (Kessels, 2003)Ley et al. (1973) conducted a report on patients with a control group of students and assessed their recall of a set of medical claims in a set up or unstructured condition. The patients showed 25 percent more recall in the categorised condition with organized information and students demonstrated 50 percent more recall. These results suggest that providing patients with structured information would increase the levels of adherence as there will be a lower probability of forgetting the medical advice. However, this analysis could be criticised because of the insufficient ecological validity as it is abnormal for an individual to try and recall a set of apparently unrelated words when they go to a GP surgery. Also, students are usually more accustomed to learning and keeping in mind information therefore it is questionable whether utilizing a student control group is ideal and a possibly better group would be a diverse sample of patients instead. Furthermore, it might be reductionist to simply presume that the organised mother nature of information was the sole contributor to increased levels of recall as other factors might have damaged recall, for example, the psychological state of the patient. A report on patient information recall by Anderson et al. (1979) concluded that stressed patients tended to recall better than those that were calm. This conclusion suggests that arousal could help ram which is possibly because of the patient's problems about their health, thus making an extra effort to remember information directed at them.
In a more ecologically valid review on the recall of real consultations (instead of list recall) by Ley (1988), it was found that significantly less than 55 percent of information given by the doctor was recalled. Ley concluded some main movements that took place:
The primacy result: Patients tended to remember the first information given to them best.
Structured information was better recalled than when non-categorised.
Prior medical knowledge improved recall of information.
The increased amount of information given, the higher amount forgotten
There was no effect on recall when the physician repeated instructions.
Ley's research was very helpful as once reasons for impaired recall were discovered, amendments could be made to the appointment process. A later study proved that doctors that got adopted advice from a booklet predicated on Ley's findings confirmed that an average of 70 percent of information was appreciated by the patient. However, demand characteristics could be present as the individuals were alert to the need to recall information that could have inspired the patient's focus on details directed at them. Therefore, ecological validity, though greater than the previous review, would still not be very high as the problem is still dissimilar to a standard surgery visit where patients could be turning over questions to ask the physician and for that reason not pay the maximum amount of focus on instructions being given.
Figure 3 Diagram depicting Safeguard Motivation Theory
Source: Norman, P. . B. H. &. S. E. R. , 1996. Safety Drive Theory. In Predicting Health Behavior. Buckingham: Open College or university Press. pp. 84.
The Protection Desire Theory (PMT) proposed by Rogers (1983) shows that the procedure of taking action to safeguard oneself, i. e. to adhere to medical advice, practices a series of cognitive decisions. PMT refers to the intention to stick to the advice of any health staff member and would depend on adaptive (positive response) and maladaptive response (modified negative response) that affect the chance of success. Maladaptive responses are inspired by threat appraisal and can be inspired by intrinsic and extrinsic rewards. For instance, regarding complicated and frustrating treatments, an intrinsic prize that could take action against adherence could be to avoid the procedure to decrease stress. An extrinsic pay back stemming out of this scenario would be that skipping treatment allows time for participation in social gatherings. When perception of intensity and vulnerability are high, maladaptive responses will decrease basically, greater degrees of fear arousal will elicit increased recognized severeness and vulnerability and therefore the patient will make a judgement that degrees of hazard are high.
Conversely, an adaptive response can be brought on by coping appraisal which relates to how the patient perceives the ailment can be handled. Coping appraisal can be increased with higher response efficacy which is the belief that recommended medication will impact the illness. Another description could be that self-efficacy can increase coping appraisal. Adaptive response is also affected by response costs which can be, perceived barriers which can inhibit the introduction of adaptive behaviour of sticking with medical advice.
A review on outpatient treatment adherence by Grindley et al. examines the PMT by using it as a verification tool to evaluate sports injury treatment adherence. Factors of PMT were integrated in the analysis by various means. The era of threat appraisal was reliant on the patient's belief that the pain or even disability of their condition would persist or exacerbate and worries arousal originating from pain, prognosis and disability further increased threat appraisal. Coping appraisal was dependent on the patient's perception in the effectiveness of their treatment and also their capacity to successfully complete treatment, which accounted for response efficacy and self-efficacy. Response costs relevant to the situation needed the form of panic about the mandatory amount of time for rehabilitation, possible connection with pain and financial implications. The info was gathered utilizing a 7-point Likert size which assessed aspects of PMT such as recognized seriousness, vulnerability etc. , thus there was reduced researcher bias than self-reports as it gets rid of the need for researcher interpretation of participant information. Grindley et al. figured drop out behaviour from the study was related to the perceived intensity, self-efficacy and response barriers and that higher self-efficacy was related to raised treatment efficacy.
The study needed into account that the severity of an patient's condition could be a confounding variable in order a control, members that had been prescribed rehabilitation treatment for 4 to eight weeks were used in order to remove patients with minimal injury or chronic illnesses due to dissimilar treatment requirements. Due to this control, the severe nature of the problem could not impact results and for that reason increased the consistency of results. Another strength is that ethical guidelines were used and informed consent was attained, with no physical damage imparted on the members. A problem with generalisability is the ethnocentric nature of the analysis as only 1 rehabilitation center was found in the sample thus the results might have limited generalisability probable when applied to other areas. However, the large test of 229 individuals consisting of 149 females and 80 men was a strength as the results could be generalised to both genders. Another restriction is that the analysis actions behaviour inside the medical clinic during attendance but didn't verify the patient's behavior with home physical remedy which behavior could be different so there isn't a wholesome point of view, thus negatively affecting usefulness. Additionally, extraneous variables which may have happened could include the fact that patients may not have necessarily recognized the procedure or the negative outcomes that could result from inability to adhere. Furthermore, the option of pain killers means that the conception of pain is less severe thus minimizing protection motivation. Emotions and disposition of the individual could have a negative influence on adherence because they are maladaptive reactions as DiMatteo et al. concluded from other study on the partnership between depression and noncompliance, depressed patients were 3 times more likely to be non-adherent to medical advice than non-depressed patients. Thus apart from cognitive factors, the affective condition of a patient can have a substantial effect on adherence and might limit the degree to which cognitive models make clear adherence.
It is apparent from the theories examined that there surely is not an ultimate reason or degree of examination that can describe non-adherence and a all natural analysis is required for a wise conclusion. The reasons for non-adherence analyzed in this essay merely concentrate on the cognitive perspective toward non-adherence and it might be reductionist to claim that any one factor is the only real reason for non-compliance. Many factors intertwine and the cognitive degree of analysis can only just explain non-adherence up to certain degree. Evidently, even within the theories discussed in this article, the social level of research has been surreptitiously present due to many social relationships to the ideas. To illustrate this aspect, you can consider the HBM. It will involve cues to action but press campaigns and advice are both social factors that result in the process. Also, in both the HBM and PMT, a potential response cost could form part of cultural norms. For instance, a diabetic might refrain from taking an injections at a restaurant since it goes against public norms. Another exemplory case of a social barrier could be how enthusiasts of Jehovah's Witness faith refuse bloodstream transfusions because of the idea that the Bible forbids the ingestion of bloodstream and so even in emergencies, they'll not accept blood transfusions. Furthermore, self-efficacy (which is a feature of PMT) is linked to interpersonal factors as Bandura explained that judgements of self-efficacy derive from lots of sociable constructs such as the individual's own accomplishments, influence of themselves and modern culture, scrutiny of psychological states and observations of others.
Many other possible cognitive reasons for non-adherence never have been mentioned in this article such as biological factors. Genetics are an example of how natural factors could influence non-adherence to medical direction. For instance, if a person has inherited aggressive attributes through genes using their company parents, the aggression might cause negative conformity as the individual does not act in response well to advice. A severe brain harm in the memory space centres of the mind would also affect adherence but one would claim that the practitioner will consider this and treat the individual accordingly.
Furthermore, there a wide range of limits to studies on adherence which leaves the validity of studies doubtful. Most studies on medical adherence use self-reporting methods which are incredibly subjective and are open to demand characteristics as well as researcher bias because the participant could try to report so to aid or sabotage the research and the researcher could become biased because of their enthusiasm or seeks. Also, the participant may be affected by cultural desirability bias because they would like to report in ways which they perceive is the 'right' way. Moreover, it is difficult to accurately evaluate adherence, i. e. when a different approach to calculating adherence was implemented like counting the amount of pills the individual has remaining in the bottle to observe how many pills have been considered, it would still not be appropriate even as we only know that a certain amount of pills have been taken out but we do not know just how many pills have been taken by the patient.
In conclusion, even though models and ideas of cognition offer some description as to the reasons people do not adhere, they can not provide the ultimate answer. Cognitive theories and models can aid prediction of how well a patient will adhere but people are eventually unpredictable numerous individual dissimilarities therefore there are numerous facets to the occurrence of non-adherence. To simplistically focus on only cognitive factors of non-adherence can only just give a one-sided take on non-compliance. In relation to the study question, it can only just be said that non-adherence is because cognitive factors up to certain level as there is no question that cognitive factors do play a role in influencing adherence, but factors from the natural and socio-cultural degree of examination are significant in the event of non-adherence to medical advice. To gain an ultimate knowledge of why people do not stick to medical advice, studies in behavioural, public, physiological developmental etc. psychology should be examined to come to a more all natural conclusion.