Why people do not adhere to medical advice

The cognitive theories and theoretical accounts associated with attachment to medical advice such as the Health Belief Model, Rational Choice Theory, Ley ‘s Cognitive Theory and Protection Motivation Model are investigated in this drawn-out essay. The factors impacting medical non-adherence are explored through the cognitive attack and the research inquiry of: ‘to what extent do cognitive theoretical accounts and theories offer an account for why people do non adhere to medical advice ‘ is evaluated and deconstructed. Research from assorted publications and surveies have been used in an effort to analyze the extent that cognitive theoretical accounts and theories can offer an account for why people do non adhere to medical advice. The research allowed the decision to be made that cognitive theoretical accounts and theories are effectual in explicating the cause for non attachment but it would be reductionist to disregard the assorted other factors that contribute to a patient ‘s non-adherence to medical advice such as societal factors and biological factors. These other factors are besides cardinal to replying why attachment occurs as cognitive factors are connected to both societal and biological factors

What is medical attachment? Harmonizing to the World Health Organisation, the definition of long -term medical attachment is ‘the extent to which a individual ‘s behavior – taking medicine, following a diet and/or put to deathing lifestyle alterations, corresponds with in agreement recommendations from a wellness attention supplier. ‘[ 1 ]Haynes et Al. stated that conformity and attachment are interchangeable footings but late, there has been argument about whether conformity is truly the same as attachment.[ 2 ]The term conformity implies the inactive and obedient nature of a patient whereas attachment takes into history the independency of an person. Therefore, if a patient can take control of their ain intervention to better their wellness, why does non-adherence occur? In the strictest sense, Taylor ( 1990 ) suggested that 93 per centum of patients failed to adhere to some signifier of their intervention.[ 3 ]However, Sarafino ( 1994 ) used a more slack definition of attachment leting customisation of intervention and proposed that patients were moderately adherent with 78 per centum attachment in short term interventions.[ 4 ]The World Health Organisation claims that in developed states, there is an norm of 50 per centum attachment to long-run therapy of chronic diseases[ 5 ]such as high blood pressure and diabetes. Out of all the American patients with high blood pressure, 85 per centum ‘remain undiagnosed, untreated, or inadequately treated. ‘[ 6 ]In McKenney ‘s survey, 50 participants were studied and evaluated over five months and the consequences showed that the patients about took merely 65 per centum of their prescribed hypertensive medicine and merely 20 per centum of the participants had taken every bit many as 90 per centum of their prescribed drugs.[ 7 ]

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From these statistics, it is clear that the definition of attachment is unfastened to subjective reading and degrees of attachment may change harmonizing to the definition adopted. Therefore, the assorted surveies discussed in this essay are limited as the reading of attachment is really wide therefore generalisability and utility are negatively affected. So what can be defined as non-adherence? Basically, burying to take a dosage, losing a dosage intentionally, occasional relief of therapy and a complete halt to intervention can all be described as non-adherence. There are many causes that can lend to miss of attachment but concentrating on the cognitive attack might supply a more concise reply to the inquiry: To what extent do cognitive theoretical accounts and theories offer an account for why people do non adhere to medical advice.[ 8 ]

Health Belief Model

Harmonizing to Cooper, Love, and Raffoul ( 1982 ) , knowing non-adherence occurs 73 per centum of the clip.[ 9 ]

Figure 1 Diagram picturing Health Belief Model.

Beginning: ( Hayden, 2009 )

Beginning: Stretcher, V. , & A ; Rosenstock I.M. ( 1997 ) . The Health Belief Model. In Glanz K. , Lewis F.M. , & A ; Rimer B.K. , ( Eds. ) .A Health Behavior and Health Education: Theory, Research and Practice. San Francisco: Jossey-Bass.

The Health Belief Model ( HBM ) , proposed by Rosenstock ( 1974 ) and subsequently evaluated by Janz and Becker ( 1984 ) , suggested that the chance of conformity to wellness advice is related to the patient ‘s perceptual experience of how terrible the disease is and the grade of susceptibleness. The footing of sensed menace of the disease can get from anterior medical cognition or the patient ‘s perceptual experience of the deductions of the disease. The likeliness of preventative action is determined through a series of stairss. If the patient recognises the unwellness as a menace, they will continue to see sensed barriers against perceived benefits, followed by a cue to action ( any event that leads to change behavior ) .[ 10 ]However, as Figure 2 indicates, the HBM incorporates societal factors, such as cultural upbringing ; and cue to action can be linked to societal factors such as media and peer force per unit area so in relation to the research inquiry, cognitive theoretical accounts can explicate attachment to a certain extent, but societal factors are present besides.

One can see the Turner et Al. ( 2004 ) survey depicting the usage of HBM by the Osteoporosis Prevention Programme on female patients to exemplify the HBM. By and large, there was a low degree of sensed menace of osteoporosis amongst the adult females due to the common misconception that osteoporosis occurs in older females. To increase sensed susceptibleness, the participants were shown a normal healthy bone of a 75 twelvemonth old adult female against a slide of an osteoporotic bone in a 47 twelvemonth old adult female and besides images of a fractured spinal column, hip and waist. It was besides emphasised that osteoporosis frequently showed no symptoms and was merely realised when a break took topographic point. To permeate cues to action, a huge sum of information was made available to participants to raise consciousness of the menaces of osteoporosis, along with bone mineral denseness testing and audience categories for dietetic changes and recommended physical activity. In add-on, Turner et Al. attempted to cut down common sensed barriers. Convenient programme times, each enduring an hr, were organised to ease busy agendas and categories took topographic point in a ‘centrally located, state-of-the-art community Centre. ‘[ 11 ]Furthermore, free child care services were provided at the community centre so that participants would non hold to worry about their kids and the job of cost was eliminated by offering the programme for free. Turner et Al. concluded that engagement in wellness publicity programmes was increased when sensed menace, susceptibleness and benefits were increased and perceived barriers were decreased.[ 12 ]

Turner et Al. ‘s survey had a comparatively big sample with 342 adult females finishing the full programme so research of such complexness requires a immense sum of clip, attempt and support. However, as the focal point of the survey was on adult females, there would be trouble generalizing to males but it could be said that more females suffer from osteoporosis so generalization to males was non the purpose.

In relation to the research inquiry, the wellness belief theoretical account supports the influence of knowledge but merely sing cognitive factors with neglect of other degrees of analysis is reductionist. Many sensed barriers are related to societal factors and the Turner et Al. survey shows that one of the chief jobs was fiscal state of affairs, which might be linked to societal category. Another societal barrier could be peer force per unit area. If one of the participants were mocked by co-workers for being a hypochondriac, the perceived barrier would be reinforced and obeisance could be influenced negatively by the societal group. Furthermore, media or household members showing their concerns could supply the cue to action.

Rational Choice theory

Perceived Benefits versus Perceived Costss to Patient

The Rational Choice Theory offers an account for non-adherence in which patients feel that there is rationale to change the recommended intervention due to justifications that are believed to be true by the patient, though may non needfully be true or helpful to the patient ‘s wellness. An account for this phenomena could be due to negative side effects of intervention that alter the patient ‘s quality of life in such a manner that they feel that it would be more sensible to stop intervention. An illustration of non-adherence due to dissatisfaction associated with the side effects of medicine is the Bulpitt ( 1988 ) reappraisal which aimed to look into the research on effects and complications of medicine for high blood pressure.[ 13 ]Antihypertensive medicine is known to be linked to impaired sexual map such as erectile disfunction and it has been reported that the frequence of erectile failure was 6.7 per centum by the age of 55 and 24 per centum by the age of 70 in Kinsey et Al. ‘s work.[ 14 ]Bulpitt reported that a survey by Curb ( 1985 ) found that 8 per centum of males taking antihypertensive intervention ended the usage of medicine due to impotence and ejaculation trouble that emerged after taking the antihypertensive drugs.[ 15 ]Notably, it was found by the Medical Research Council ( 1981 ) that 15 per centum of patients halted medicine due to other side effects[ 16 ]such as concerns or giddiness. Though these surveies have attributed unwanted side effects with failed conformity, this was applicable to merely a little part of the sample, therefore other factors must be considered to achieve a more wholesome thought of attachment and avoid reductionism. In add-on, these surveies are limited in generalisability to females as the surveies merely involved males and utility is questionable as merely hypertensive medicine were included. Ethical motives could besides be an issue in these surveies because probe into the participant ‘s erectile jobs could be mortifying for the topic and might do feelings of insufficiency which could be classified as mental injury to the participant.

Fiscal Barriers

The presence of practical barriers could lend to a patient ‘s determination to ignore medical advice. Fiscal obstructions such as low income of patients may ensue in non being able to afford expensive interventions non paid for by National Health Schemes. Karter et Al. ( 2000 ) concluded from their survey on the relationship between fiscal barriers and attachment to intervention for diabetes that ‘removal of fiscal barriers by supplying more comprehensive coverage for these costs may heighten attachment to recommendations for SMBG [ self-monitoring of blood glucose ] . ‘[ 17 ]The survey was cross-sectional which provided a snapshot of the frequence of attachment to SMBG so it was less clip devouring than a longitudinal survey. A huge sum of information was acquired from 44,181 participants so the survey was extremely generalisable to the mark population of Northern Californian diabetics, though the ethnocentricity of the survey limits generalization to the remainder of the universe.

Patient-practitioner Relationship

The patient might besides neglect to follow because they have ground to doubt the effectivity of the intervention. A survey on arthritis patients by Arluke ( 1980 ) suggested that if the conditions of the complaint worsen even though the patient has followed prescribed direction, attachment will be affected negatively.[ 18 ]In add-on, the Handbook of Clinical Psychology in Medical Settings states that ‘the most common ground given for knowing non-adherence was that the patient did non believe that the drug was needed in the dose prescribed by the doctor. ‘[ 19 ]The patient might halt intervention out of wonder to see whether the unwellness is still present because the patient may be doubting about the utility of prescribed intervention.[ 20 ]This deficiency of trust in the doctor ‘s advice could originate from uncertainties on the competence or professionalism of their physician which can be connected with the patient-practitioner relationship. The trust imparted on the doctor is slightly dependent on how the physician acts or frocks and a survey by McKinstry and Wang ( 1991 ) in which patients were shown images of male or female physicians dressed in either formal or informal vesture. For illustration, a image of a traditionally dressed physician would picture the physician have oning a formal white coat whereas an informally appareled physician would be shown exhausting denims. When asked, the patients rated that they had the most assurance in the physicians that were officially dressed and this penchant was peculiarly prevailing in older patients.[ 21 ]Though participants were approached at surgeries, this survey was low in ecological cogency because patients are non usually shown images of physicians and questioned when they attend a surgery. The patient-practitioner relationship can be dependent on the patient ‘s perceptual experience of the doctor, but can besides be dependent on the societal state of affairs and the societal interaction between them and the mode of communicating could impact the degree of apprehension of prescribed intervention. Therefore, in relation to the research inquiry, we can already see how non merely cognitive factors affect attachment, but societal facets such as the communicative accomplishments and the practician ‘s garb could act upon attachment.


A deficiency of apprehension of the medicine and/or the intervention agenda that is prescribed is besides a barrier. This job will non merely take the patient to perchance execute the intervention falsely, but can impede the patient ‘s memory of the process for their intervention. Hadlow and Pitts ( 1991 ) reported that around 33 per centum of patients do non hold proper apprehension of normally used medical footings[ 22 ]and as a consequence, 40 to 80 per centum of advice given by the doctor is immediately forgotten.[ 23 ]Furthermore, in a survey by McKinlay ( 1975 ) of the apprehension of information given to adult females by wellness workers in a pregnancy ward, merely 39 per centum of adult females really understood 13 chosen medical footings. Interestingly, the wellness workers expected even lower degrees of understanding but used proficient slang regardless of this.[ 24 ]Merely female participants were studied so the gynocentrism limits generalization and possibly a less gynocentric sample could be attained in a different ward of the infirmary, such as physical therapy. Medical workers could be utilising proficient slang on patients to avoid being asked inquiries and to asseverate a sense of authorization. In this instance, moralss would be an issue as it is the patient ‘s right to be to the full informed about the intervention and their status.[ 25 ]It is unethical to direct patients off with the possibility that they do non to the full understand how to utilize their medicine as it could take to auspicious effects and there is a greater chance that the patient will neglect to adhere, as is described in Ley ‘s Cognitive Model ( 1988 ) .[ 26 ]

Ley ‘s Cognitive Model ( 1988 )

Ley ‘s Cognitive Model states that understanding and memory of information affect attachment and lead to satisfaction which have a positive consequence on attachment ( see Figure 1 ) .

Figure 2 Diagram picturing Ley ‘s Cognitive Model ( 1988 )

Beginning: ( Kessels, 2003 ) Ley et Al. ( 1973 ) conducted a survey on patients with a control group of pupils and measured their callback of a list of medical statements in a structured or unstructured status. The patients showed 25 per centum more callback in the categorized status with structured information and pupils showed 50 per centum more callback. These consequences suggest that supplying patients with structured information would increase the degrees of attachment as there would be a lower chance of burying the medical advice. However, this survey could be criticised due to the deficiency of ecological cogency as it is unusual for a patient to try to remember a list of apparently unrelated words when they go to a GP surgery. Besides, pupils are more accustomed to larning and retrieving information therefore it is questionable whether utilizing a pupil control group is ideal and a perchance better group would be a diverse sample of patients alternatively. Furthermore, it would be reductionist to merely presume that the organized nature of information was the exclusive subscriber to increased degrees of callback as other factors could hold affected callback, for illustration, the emotional province of the patient. A survey on patient information callback by Anderson et Al. ( 1979 ) concluded that dying patients tended to remember better than those that were relaxed.[ 27 ]This decision suggests that rousing could help memory which is perchance due to the patient ‘s concerns about their wellness, therefore doing an excess attempt to remember information given to them.[ 28 ]

In a more ecologically valid survey on the callback of existent audiences ( alternatively of list callback ) by Ley ( 1988 ) , it was found that less than 55 per centum of information given by the physician was recalled.[ 29 ]Ley concluded some chief tendencies that occurred:

The primacy consequence: Patients tended to remember the first information given to them best.

Structured information was better recalled than when non-categorised.

Prior medical cognition improved callback of information.

The greater sum of information given, the greater sum forgotten

There was no consequence on callback when the physician repeated instructions.[ 30 ]

Ley ‘s survey was really utile as once grounds for impaired callback were identified, amendments could be made to the audience procedure. A later survey showed that physicians that had adopted advice from a brochure based on Ley ‘s findings showed that an norm of 70 per centum of information was remembered by the patient.[ 31 ]However, demand features could be present as the participants were cognizant of the demand to remember information which could hold influenced the patient ‘s attending to inside informations given to them. Therefore, ecological cogency, though higher than the old survey, would still non be really high as the state of affairs is still different to a normal surgery visit in which patients could be sing inquiries to inquire the physician and hence non pay every bit much attending to instructions being given.

Protection Motivation Theory

Figure 3 Diagram depiction Protection Motivation Theory

Beginning: Norman, P..B.H. & A ; .S.E.R. , 1996. Protection Motivation Theory. In Predicting Health Behaviour. Buckingham: Open University Press. pp.84.

The Protection Motivation Theory ( PMT ) proposed by Rogers ( 1983 ) indicates that the procedure of taking action to protect oneself, i.e. to adhere to medical advice, follows a series of cognitive determinations. PMT refers to the purpose to adhere to the advice of a wellness worker and is dependent on adaptative ( positive response ) and maladaptive response ( altered negative response ) that influence the opportunity of endurance.[ 32 ]Maladaptive responses are influenced by menace assessment[ 33 ]and can be encouraged by intrinsic and extrinsic wagess. For illustration, in the instance of complicated and clip devouring interventions, an intrinsic award that could move against attachment could be to avoid the intervention to diminish emphasis. An extrinsic wages stemming from this scenario would be that jumping intervention would let clip for engagement in societal assemblages. When perceptual experience of badness and exposure are high, maladaptive responses will diminish and likewise, greater degrees of fright rousing will arouse increased sensed badness and exposure and hence the patient will do a opinion that degrees of menace are high.

Conversely, an adaptative response can be triggered by get bying assessment which is related to how the patient perceives the complaint can be dealt with.[ 34 ]Coping assessment can be increased with higher response efficaciousness which is the belief that prescribed medicine will hold an consequence on the unwellness. Another account could be that self-efficacy[ 35 ]can increase get bying appraisal. Adaptive response is besides affected by response costs which are, sensed barriers which can suppress the outgrowth of adaptative behavior of adhering to medical advice.[ 36 ]

A survey on outpatient rehabilitation attachment by Grindley et Al. examines the PMT by utilizing it as a testing tool to mensurate athleticss hurt rehabilitation attachment. Factors of PMT were incorporated in the survey by assorted agencies. The coevals of menace assessment was dependent on the patient ‘s belief that the uncomfortableness or even disablement of their status would prevail or worsen and the fright rousing arising from hurting, diagnosing and disablement farther increased menace assessment. Coping assessment was dependent on the patient ‘s belief in the effectivity of their intervention and besides their ability to successfully complete intervention, which accounted for response efficaciousness and self-efficacy. Response costs relevant to the state of affairs took the signifier of anxiousness about the needed sum of clip for rehabilitation, possible experience of hurting and fiscal deductions. The information was gathered utilizing a 7-point Likert graduated table which assessed facets of PMT such as sensed badness, exposure etc. , therefore there was reduced researcher bias than self-reports as it eliminates the demand for researcher reading of participant studies. Grindley et Al. concluded that bead out behavior from the survey was related to the perceived badness, self-efficacy and response barriers and that higher self-efficacy was related to higher intervention efficaciousness.[ 37 ]

The survey took into history that the badness of a patient ‘s status could be a confounding variable so as a control, participants that had been prescribed rehabilitation intervention for 4 to 8 hebdomads were used so as to eliminate patients with minor hurts or chronic unwellnesss due to dissimilar rehabilitation demands. Due to this control, the badness of the status could non act upon consequences and hence increased the dependability of consequences. Another strength is that ethical guidelines were followed and informed consent was acquired, with no physical injury imparted on the participants. A job with generalisability is the ethnocentric nature of the survey as merely one rehabilitation installation was used in the sample therefore the consequences might hold limited generalisability potency when applied to other countries. However, the big sample of 229 participants dwelling of 149 females and 80 males was a strength as the consequences could be generalised to both genders. Another restriction is that the survey measures behaviour inside the clinic during attending but did non analyze the patient ‘s behavior with place physical therapy which behavior could be different so there is non a wholesome position, therefore negatively impacting utility. Furthermore, immaterial variables that may hold occurred could include the fact that patients may non hold needfully understood the intervention or the negative effects that could ensue from failure to adhere. In add-on, the handiness of hurting slayers means that the perceptual experience of hurting is less terrible therefore take downing protection motive. Emotions and temper of the patient could hold a negative consequence on attachment as they are maladaptive responses as DiMatteo et Al. concluded from their survey on the relationship between depression and disobedience, down patients were 3 times more likely to be non-adherent to medical advice than non-depressed patients.[ 38 ]Therefore other than cognitive factors, the affectional province of a patient can hold a important consequence on attachment and might restrict the extent to which cognitive theoretical accounts explain attachment.


It is apparent from the theories examined that there is non an ultimate ground or degree of analysis that can explicate non-adherence and a holistic analysis is required for a reasonable decision. The grounds for non-adherence examined in this essay simply concentrate on the cognitive position toward non-adherence and it would be reductionist to claim that any individual factor is the exclusive ground for non-compliance.[ 39 ]Many factors intertwine and the cognitive degree of analysis can merely explicate non-adherence up to a certain extent. Obviously, even within the theories discussed in this essay, the societal degree of analysis has been sneakily present because of the many societal dealingss to the theories. To exemplify this point, one can see the HBM. It involves cues to action but media runs and advice are both societal factors that trigger the procedure. Besides, in both the HBM and PMT, a possible response cost could organize portion of societal norms. For illustration, a diabetic might forbear from taking an injection at a eating house because it goes against societal norms. Another illustration of a societal barrier could be how followings of Jehovah ‘s Witness religion garbage blood transfusions due to their belief that the Bible forbids the consumption of blood and therefore even in exigencies, they will non accept blood transfusions.[ 40 ]In add-on, self-efficacy ( which is a characteristic of PMT ) is connected to societal factors as Bandura stated that opinions of self-efficacy are based on a figure of societal concepts such as the person ‘s ain accomplishments, influence of themselves and society, examination of emotional provinces and observations of others.[ 41 ]

Many other possible cognitive grounds for non-adherence have non been mentioned in this essay such as biological factors. Geneticss are an illustration of how biological factors could act upon non-adherence to medical counsel. For case, if a individual has inherited aggressive traits through cistrons from their parents, the aggression might ensue in negative conformity as the patient does non react good to advice. A terrible encephalon hurt in the memory Centres of the encephalon would besides impact attachment but one would reason that the practician will see this and handle the patient consequently.

Furthermore, there are many restrictions to surveies on attachment which leaves the cogency of surveies questionable. Most surveies on medical attachment usage self-reporting methods which are really subjective and are unfastened to demand features every bit good as research worker prejudice because the participant could try to describe in such a manner to assistance or undermine the research and the research worker may go colored because of their enthusiasm or purposes. Additionally, the participant may be influenced by societal desirableness prejudice because they would wish to describe in a manner which they perceive is the ‘right ‘ manner.[ 42 ]Furthermore, it is hard to accurately mensurate attachment, i.e. if a different method of mensurating attachment was adopted like numbering the figure of pills the patient has left in the bottle to see how many pills have been taken, it would still non be accurate as we merely know that a certain figure of pills have been taken out but we do non cognize how many pills have really been taken by the patient.

In decision, although the theoretical accounts and theories of knowledge offer some account as to why people do non adhere, they can non supply the ultimate reply. Cognitive theories and theoretical accounts can help anticipation of how good a patient will adhere but people are finally unpredictable with many single differences hence there are many aspects to the happening of non-adherence.[ 43 ]To simplistically concentrate on merely cognitive factors of non-adherence can merely give a nonreversible position on non-compliance. In relation to the research inquiry, it can merely be said that non-adherence is a consequence of cognitive factors up to a certain extent as there is no uncertainty that cognitive factors do play a portion in act uponing attachment, but factors from the biological and socio-cultural degree of analysis are important in the happening of non-adherence to medical advice. To derive an ultimate apprehension of why people do non adhere to medical advice, surveies in behavioral, societal, physiological developmental etc. psychological science will hold to be examined to come to a more holistic decision.

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