Health Psych Chapter 4 Adherence

Transtheoretical model: Preparation

Intending to take action in immediate future (next month). Plan of action. Would benefit from an action-oriented program.

Six basic methods for measuring patient adherence

1. Ask the practitioner 2. Ask the Patient 3. Ask other people 4. Objectively measure behavior 5. Examine biochemical evidence 6. Use a combination of those procedures

Behavioral Strategies

4 categories of behavioral strategies for improving adherence: 1. Using prompts 2. Tailoring the treatment regimen/information to the patient (eg motivational interviewing) 3. Using positive reinforcement to shape behavior 4. Using a contingency contract

Self-Efficacy Theory

A Continuum theory. People will adhere to behaviors if they 1. believe they can initiate and carry out this behavior (self-effiacy). A. Performance of a behavior. B. Vicarious experience. C. Verbal persuasion. D. Physiological arousal states. 2. believe that the behavior will produce valuable outcomes (outcome expectations). Strengths: Predicts adherence to a variety of health recomendations (eg ecercise, diabetes and HIV medicines). Weakness: Focus on self-efficacy and omits other factors (such as social pressure)

Theory of planned behavior

A Continuum theory. Three factors shape intentions: Attitude toward the behavior (positive or negative feelings toward the behavior), Subjective norms (perception of social pressure to perform or not perform behavior), and perceived behavioral control (similar to self efficacy). Intention then predicts behavior. Strengths: Identifies beliefs that shape behavior. Useful in guiding internet-based interventions. Most successful at predicting physical activity and dietary behaviors. Weaknesses: Not always successful at predicting risk-taking behaviors. Intention does not always predict behavior.

Health Action Process Approach

A Stage theory. Incorporates aspects of both continuum theories and stage theories. Two general stages: Motivational phase (includes outcome expectations, risk perceptions, self-efficacy, and intention) and Volitional phase (Includes planning and action. Self efficacy remains an important predictor, maintenance and relapse). Strengths: Takes into account planning (imp. for physical exercise). Weaknesses: Newer theory, not as much research support

Health Belief model

A continuum theory. Suggests four beliefs that should predict health-related behaviors (including adherence). 1. Percieved susceptibility to disease 2. Perceived severity of the disease 3. Perceived benefits of health-enhancing behaviors 4. Perceived barriers to health-enhancing behaviors Strengths: Predicts simple health behaviors, perceived barriers and perceived benefits are strong predictors of health behavior. Weaknesses: Does not predict adherence very well, does not include a belief about personal control.

Behavioral Theory

A continuum theory. Uses principles of operant conditioning to explain what behaviors will be strengthened or decreased. Reinforcement strengthens behavior. Punishment decreases behavior. Not used very often in health psychology. Two types of reinforcements: 1. Positive (positive valued stimulus increases a probability that the behavior will occur again). 2. Negative (behavior strengthened by the removal of an unpleasant stimulus, eg nagging). Strenghts: Children's reponsiveness. Weakness: Punishment not useful in improving people's adherence.

Behavioral Willingness

A person's motivation at a given moment to engage in a risky behavior. Teens especially may be prone to engage in risky behaviors.

Transtheoretical model

A stage theory. Suggests people progress and regress through five stages: Precontemplation, contemplation, preparation, action, and maintenance.

Precaution Adoption process model

A stage theory. Suggests that people move through seven stages in their readiness to adopt health behavior. Beginning new complex behaviors, people go through several stages of belief. Strengths: Captures the variable nature of beliefs and behaviors better than other models. Weaknesses: Not as extensively researched. Doesn't look at other predictors of behavior aside from risk perception. Like TTM, it is unclear whether the 7 stages truly represent different categories.

Adherence

Ability and willingness to follow recommended health suggestions. Extent to which A person's behavior coincides with medical or health advice. Eg following a medical regimen, maintaining a healthy lifestyle, going to the doctor.

Factors predicting adherence: Personal Characteristics

Age: The young and old are more likely to be nonadherent Gender: generally, women and men have same adherence rates. Personality patterns: There is no global set pattern of personality traits that lead to adherence. (Optimism and conscientiousness = more likely to be adherent) Emotional Factors: High stress and depression is related to nonadherence.

Nonadherence

Approximately 125000 people die each year due to nonadherence. Nonadherence to medication is nearly 25%. There are differences among chronic conditions regarding adherence.

Barriers to Adherence

Cost (very expensive may lead to less adherence/use), Patients see the regimen as being too difficult, patient treat regient as advice rather than orders, patients stop taking medication when symptoms disappear, optimistic bias.

Adherence Measurement: Asking Patient

Easy to do, but patient sometimes over-reports adherence. Slightly more valid measure than asking physician, but still not best.

Adherence Measurement: Asking practitioner

Easy to do, but practitioner often doesn't know if patient is adhering. Often overestimates patient's adherence.

Environmental factors

Economic Factors, social support, cultural norms

Transtheoretical model: Contemplation

Intending to change in the next 6 months. More aware of pros/cons of changing. Cost/benefit weighing can keep people stuck here (chronic contemplation or behavioral procrastination). Not ready for tradtional action-oriented programs.

Transtheoretical model: Action

Have made specific overt modifications in lifestyle (in past 6 months). Observable behavioral change, and vigilance against relapse is critical here.

Adherence Measurement: Ask other people

Hospital personnel or family. Might by physically impossible. Also, persistent monitoring can lead to an inflation of adherence.

Cultural norms and adherence

Individuals less acculturated to western medicine have poorer adherence. Japanese similar to US (doctors make decisions). Perception of disrespect by physician (9% of EA, 14% AfAm, 20% AsiAm, 19% HispAm). Using combinations may be seen as nonadherent by both healers

Adherence measurement: Using a combination of these methods

Interviewing patients, counting pills, and electronic monitering. However, poor agreement between objective and patient/clinician reports.

Adherence Measurement: Objectively measure behavior

Monitor medication use (eg counting pills). MEMS (medication event monitoring system). Chip in cap bottle. Physical activity monitoring devices.

Factors predicting adherence: Severity of Disease

More life threatening = more likely to adhere. People's perception of the severity of their disease is more predictive of adherence than objective severity of disease.

Transtheoretical model: Precontemplation

No intention of taking action in the forseeable future (next 6 months). Uninformed or under-informed about consequences about behaviors. Demoralized about ability to change. Resistant/unmotivated to change.

Improving adherence impacts/history?

Over the past 50 years, adherence rates have improved little. Little effort has been put into improving adherence. Most effective interventions are often the most costly and complex.

Stage Theories

Propose that people pass through a series of stages as they attempt to change their behavior. Includes Transtheoretical model, precaution adoption process model, and health action process approach.

Theories of Adherence

Psychologists have developed theories to identify , and then target, modifiable factors that can increase adherence. Two broad categories: Continuum theories, stage theories.

Factors that predict adherence

Severity of the disease, Treatment characteristics, personal characteristics, environmental factors.

Factors predicting adherence: Treatment characteristics

Side effects of medication: Perceived severe side effects decrease adherence. Complexity: more complex treatment decreases adherence

Intention -Behavior Gap

Some health behavior theories suggest that people's intentions are predictive of people's behaviors. Research has shown that people often intend to behave in one way but do not.

Implementation intentions

Specific plans that people make that identify what, where, when, and how they intend to engage in a behavior. May help people's pursuit of their goals become more automatic. May help people be less likely to forget their intentions.

Overall strengths and weaknesses of continuum theories

Strengths: Produced substantial amounts of research to hep understand theories. Identify beliefs that should motivate anyone to change his or her behavior. All models are better than chance at predicting behavior. Weaknesses: Some theories are better at predicting intentions than behaviors. Rely heavily on self-report. Leave out important factors such as self-identity and anticipated emotions.

Stage theories overall weaknesses and strengths

Strengths: Recognize the benefits of tailoring interventions to a person's stage of behavior change. Weaknesses: More complex than continuum theories, may be unnecessarily complex. People can skip stages. Need longitudinal research to study people throughout the stages.

Transtheoretical Model strengths and weaknesses

Strengths: Spiral movement between stages may capture behavior change progress more accurately. Can create different interventions at different stages. Works best for understanding smoking cessation. Weaknesses: Transitions from one stage to another may not be equally easy to influence. Not very successful in predicting adherence to behaviors other than smoking cessation. Fewer stages may till accurately predict behaviors.

Social support and adherence

Tangible and intangible help a person receives from friend and/or family. Those with low social support (few friends/family) are more likely to be nonadherent. Practical support is a stronger predictor of adherence than emotional support.

Improving Adherence

Two general methods for improving people's adherence: 1. Education strategies (Increasing people's knowledge, perhaps emotion arousing). 2. Behavioral strategies (more directly involved in changing behaviors)

Adherence measurement: Examine Biochemical Evidence

Urine or blood. Can be intrusive and/or expensive.

Continuum theories

Use a single set of factors to explain adherence for everyone, One size fits all. Includes health belief model, self efficacy theory, theory of planned behavior, and behavioral theory.

Transtheoretical model: Maintenance

Work to prevent relapse. Less tempted to relapse, and increasingly more confident as change continues.