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Chapter 4 Adhering to Medical Advice
adherence - A patient's ability and willingness to follow recommended health
practices. Many professionals prefer this term to the more often used term
"compliance" which implies an unwilling giving in to medical advice.
cooperation - Ideally, the physician - patient relationship should be one of
cooperation.
Behavioral Theory of Adherence - is based on the "operant conditioning theory"
of B. F. Skinner. The likelihood of a behavior occurring in the future depends on
whether it is followed by a consequence that the organism (person) finds
pleasant (reinforcing) or unpleasant (punishing).
positive reinforcement - If a behavior (a rat pressing a lever) is followed by
"adding" something pleasant (candy) the behavior will be repeated.
negative reinforcement - If a behavior (a rat pressing a lever) is followed by
"removal" of something unpleasant (continuously being shocked) the behavior
will be repeated (as above).
punishment (positive OR negative) - If a behavior (a rat pressing a lever) leads
to something "unpleasant" (either by adding or removing), the behavior will NOT
be repeated. Punishment is NOT the favored method for changing behavior.
Punishment induced change tends to be more "temporary" and it can induce
"negative emotional responses" in the person.
Self-Efficacy Theory of Adherence - Albert Bandura suggests that self
regulating (adherence) behaviors are a function of (1) personal factors
(personality), (2) environment (situations), and (3) the person's behaviors.
reciprocal determinism - Bandura suggests that these three factors
(personality, environment, and behaviors) continuously interact with each other in
very complex ways.
self-efficacy - The belief that one is capable of performing behaviors that will
produce (situation specific) desired outcomes. Three factors increase self
efficacy: (1) performance (practice), (2) "vicarious" experiences (watching
others), and (3) verbal persuasion (listening to others). High levels of arousal
(anxiety) usually decrease self-efficacy.
the Theory of Reasoned Action - This theory (behavior enactment determined
by attitude and social norms) was discussed in chapter 3. It has been applied to
the study of adherence behaviors (as well as to heath enhancing behaviors).
the Theory of Planned Behavior - This theory (behavior enactment determined
by attitude and social norms AND perceived control) was discussed in chapter 3.
It has been applied to the study of adherence behaviors (as well as to heath
enhancing behaviors).
adherence history People's adherence history is a better predictor of future
adherence than either of the above models.
the Trans-theoretical Model - This model (Prochaska et. al.) consists of five
spiraling stages that lead to changing to new behaviors. Stage 5 "maintenance"
seems to be the only part of the theory that really relates to "adherence." The
usefulness of this theory "depends on the specific behavior" being changed.
non-adherence - Failure to follow medical advice leads to as many as 125,000
deaths per year in the U. S. Failure to take prescribed medications is the most
frequent cause. Robin DiMatteo's (2004) meta analysis of 500 studies indicated
an average non-adherence rate of 24.8% (i.e., about 25%).
assessing adherence - Physician reports are the "poorest choice" being little
better than chance. Having hospital staff of family monitor and report on the
patient is better. However, this monitoring tends to actually increase adherence.
While this is good for the patient, it is BAD for research because we are
unintentionally changing the behavior we are trying to study!
side effects - negatively affect adherence. The more severe the side effects, the
more adherence suffers.
treatment complexity - For example, the more daily doses of a medicine one
must take the lower the adherence. Specifically, with "four" or more doses per
day, adherence plummets to less than 40%. The problem seems to be fitting
treatments into daily routines.
severity of illness - surprisingly does NOT predict adherence. Pain, in contrast,
does. The more severe the pain, the greater the adherence.
personal factors in adherence - There are small but complex age differences,
with the very old and the very young having "poorer" adherence. No personality
or gender differences have been noted. People who believe they can adhere are
more likely to. Also, those who believe in, and understand, the treatment are
more likely to adhere.
income level and adherence - Higher income (SES) seems to be associated
with better adherence. However, there are complex relationships among SES,
education, and ethnicity.
social support - received from friends and family is a strong predictor of
adherence. Family conflict is a negative factor for adherence.
cultural factors - African, Hispanic, and Asian Americans reported increased
feelings of being disrespected by their physicians, leading to (1) lower adherence
and (2) more missed appointments.
physician factors - The "most crucial factor" in non-adherence is poor verbal
communication between the physician and the patient. Adherence is higher
when patients perceive doctors as more warm, caring, interested, and
understanding. Female physicians appear to engage in more adherence
enhancing behaviors (e.g., spending more time and asking more questions).
improving adherence - Strategies fall into two basic categories: (1) educational,
and (2) behavioral. Education may "frighten" a patient into compliance (hey, if it
works?). DiMatteo and Dinicola (1982) have suggested four categories of
behavioral strategies. The problem is that behavioral strategies are costly and
time consuming.
motivational interviewing - A therapeutic approach that originated within
substance abuse treatment that attempts to change a client’s motivation and
prepares the client to enact changes in behavior. The therapist discusses
present behavior, goals, and strategies.
the record - Unfortunately, according to DiMatteo (2004) health professionals
put little effort into improving adherence (long term) and little progress has been
made in the past 50 years! For short-term regimens, providing "clear
instructions" is the best strategy for increasing adherence.