Adherence to medical advice

🧠 Health Psychology: Adherence to Medical Advice (Syllabus 3.2)

Hello future Psychologists! This chapter is incredibly practical. You’ll learn why people often struggle to follow doctor's orders—whether it’s taking medication, changing their diet, or attending check-ups—and what health professionals can do about it. Understanding adherence (or lack thereof) is vital because treatments only work if people use them correctly!

Don't worry if this seems like common sense at first. Psychology gives us frameworks (models and theories) to explain these behaviors scientifically, which is essential for your exams.

3.2.1 Types of Non-Adherence and Reasons Why Patients Do Not Adhere

What is Non-Adherence?

Adherence is the extent to which a patient follows the recommendations of a health provider (e.g., taking medicine, lifestyle changes, attending follow-up appointments).

Non-adherence (or non-compliance) is the failure to follow these recommendations. This is a massive global issue, often leading to worse health outcomes and wasted resources.

There are two main types of non-adherence:

• Failure to follow treatments: This includes not taking medication as prescribed (e.g., stopping early, taking the wrong dose), or not following lifestyle advice (e.g., quitting smoking).
• Failure to attend appointments: Missing check-ups, follow-up consultations, or therapy sessions.

Explanations of Non-Adherence

Psychologists distinguish between two key reasons for non-adherence:

1. Unintentional Non-Adherence: This is when the patient wants to adhere but fails due to external factors (e.g., forgetting, complex schedule, medication confusion).
2. Intentional Non-Adherence: This is when the patient chooses not to adhere. This leads us to Rational Non-Adherence.

Rational Non-Adherence

This explanation suggests that patients make a conscious, logical decision to ignore or alter medical advice based on their own assessment of the costs versus the benefits of the treatment.

Think of it like this: A patient might stop taking a blood pressure tablet because they feel fine and the pill causes unpleasant side effects (like dizziness). Rationally, they decide the cost (side effect) outweighs the immediate perceived benefit (since they feel healthy anyway).

Reasons for rational non-adherence include:

• Believing the medication is not working.
• Experiencing negative side effects.
• Financial concerns (medication is expensive).
• Fears about dependency or long-term risks.

Key Study: Laba et al. (2012) – Rational Non-Adherence and Financial Barriers

Context: Laba et al. conducted a discrete choice experiment using a community sample in Australia to investigate how patients make trade-offs regarding prescription medication attributes.

Finding: They found that financial factors and out-of-pocket medication costs significantly influenced choices to take or skip medications. When costs are perceived to outweigh benefits, patients make a rational choice to alter or stop taking their treatment.

Key Takeaway: Non-adherence isn't always stubbornness or forgetfulness; it is often a reasoned decision based on practical trade-offs like medication cost, efficacy, and side-effect profile.

The Health Belief Model (HBM)

The HBM is a psychological model used to explain and predict health behaviors, including adherence. It assumes that a person's decision to act (or adhere) is based on several core beliefs or perceptions about their health condition and the proposed treatment.

To adhere, an individual evaluates these key components:

1. Perceived Susceptibility: How likely the person believes they are to get the illness or condition.
   (e.g., "I smoke, but lung cancer only happens to heavy smokers, not me.")
2. Perceived Severity: How serious the consequences of the illness are believed to be.
   (e.g., "A cold is unpleasant, but it’s not serious enough to warrant medication.")
3. Perceived Benefits: The positive outcomes expected from following the advice.
   (e.g., "If I take my antibiotics, I will get better faster.")
4. Perceived Barriers: The perceived obstacles or negative aspects of the treatment (these drive non-adherence). This includes cost, pain, side effects, and inconvenience.
   (e.g., "The pill makes me nauseous, so I'm stopping.")

The model also includes modifying factors:

• Cues to Action: Internal (like pain or symptoms) or external (like a poster campaign, appointment reminder, or a doctor's warning) triggers that prompt behavior.
• Self-Efficacy: The belief in one's capability to successfully execute the required health behavior.
  (e.g., "I am confident I can stick to this inhaler routine.")

3.2.2 Measuring Non-Adherence

How do psychologists and doctors know if a patient is actually following their advice? They use several methods, categorized as subjective, objective, or biological.

1. Subjective Measures

These methods rely on the patient's own reporting. They are generally inexpensive but suffer from issues like social desirability bias (where patients alter answers to look compliant).

• Clinical Interviews: A practitioner asks the patient directly about their adherence.
• Semi-structured Interviews: These use a mix of fixed questions and follow-ups to explore detailed responses, yielding richer qualitative data.
• Self-Reports/Questionnaires: Patients fill out forms about their behavior.

Study: Riekert and Drotar (1999) – Subjective Measurement in Children

Procedure: Riekert and Drotar examined adherence in children and adolescents with chronic conditions such as Type 1 Diabetes, evaluating participation in research and the validity of self-reports and interviews.

Finding: They confirmed that self-reports and interviews often overestimate adherence rates compared to objective tracking, but they provide valuable qualitative data on psychosocial barriers (such as daily routines and family dynamics) that objective measures cannot capture.

2. Objective Measures

These methods measure adherence directly and physically, without relying purely on patient recall.

• Pill Counting: The practitioner counts the remaining medication at a follow-up visit.
• Medication Dispensers: Electronic devices record the exact date and time the medication container was opened.

Study: Chung and Naya (2000) – Objective Measurement using Medication Dispensers

Procedure: Chung and Naya investigated adherence to oral asthma medication using Medication Event Monitoring Systems (MEMS)—special electronic caps that record when the bottle is opened.

Finding: They found that electronic monitoring provided an objective, quantitative record of medication compliance, revealing patterns of irregular dosing and demonstrating that adherence measured objectively was notably lower than what patients typically report.

3. Biological Measures

These methods test biological samples to verify whether the prescribed substance has actually entered the patient's body.

• Blood Samples: Measuring the concentration of the drug or its metabolites in the bloodstream.
• Urine Samples: Analyzing urine for traces of the medication.

Limitation: Biological measures generally only confirm recent usage (e.g., over the preceding hours or days), not consistent long-term adherence. They can also be invasive and costly.

3.2.3 Improving Adherence

Since non-adherence is a major challenge, health psychology explores behavioural and community strategies to help patients follow medical recommendations.

Individual Behavioural Techniques

These focus on changing specific actions of the patient using learning principles such as operant conditioning and reinforcement.

• Customising Treatment: Tailoring the medical regimen to fit into existing daily routines (e.g., linking pill-taking with brushing teeth).
• Prompts and Reminders: Providing external cues (e.g., automated texts, visual charts, pill organisers) to prevent unintentional forgetting.
• Behavioural Contracts: Establishing a clear, explicit agreement between patient and practitioner specifying adherence targets and agreed rewards.

Study: Improving Adherence in Children (Chaney et al., 2004)

Aim: To test whether operant conditioning via a fun, rewarding inhaler spacer (the Funhaler) would improve adherence to asthma medication in young children.

Procedure: The Funhaler incorporated incentive toys—specifically a spinning disk and an auditory whistle—that only activate when the child breathes in with the correct, deep inspiratory effort.

Finding: The Funhaler significantly increased both parent and child compliance compared to a standard spacer. Positive reinforcement made taking asthma medication rewarding and enjoyable, reducing resistance and improving technique.

Community Interventions

These interventions focus on influencing health-related behaviors across entire community groups or public health clinic populations.

Key Study: Yokley and Glenwick (1984) – Improving Immunization Adherence

Context: Yokley and Glenwick evaluated community-based interventions to increase preschool child immunization clinic attendance in Akron, Ohio.

Aim: To compare the effectiveness of different prompts and incentives on attendance at public health pediatric immunization clinics.

Interventions Compared:

1. General Prompt: A general mailed reminder sent to parents.
2. Specific Prompt: A personalised mailed reminder naming the child and specific missing vaccinations.
3. Expanded Clinic Hours: A specific prompt combined with extended clinic opening times.
4. Monetary Incentive (Lottery): A specific prompt combined with a monetary lottery incentive (entry to win cash prizes).
5. Control Group: Received no intervention.

Results and Conclusion: The combined specific prompt with a monetary incentive produced the largest increase in immunization attendance. Specific prompts were more effective than general ones, demonstrating that targeted behavioral prompts and incentives substantially enhance adherence at the community level.