C H A P T E R 4
Adhering to Healthy Behavior
Lecture Outline
I. Issues in Adherence
Two requirements are necessary for medical advice to be beneficial; first, it must be
accurate and second, it must be followed. Two meta-analyses indicate a large difference in
outcome for people who were adherent to their medication compared to those who were not.
A. What Is Adherence?
B. How Is Adherence Measured?
C. How Frequent Is Nonadherence?
D. What Are the Barriers to Adherence?
II. What Factors Predict Adherence?
A. Severity of the Disease
Severity of the disease is actually a poor predictor of adherence, but the person’s
perception of severity, especially pain associated with a disease, is a better predictor of
adherence.
B. Treatment Characteristics
Treatment characteristics include unpleasant side effects of the medication and
complexity of the treatment.
1. Side Effects of the Medication
Early research found little evidence to suggest that unpleasant side effects are a major
reason for discontinuing a drug or dropping out of a treatment program. Recent research
indicates that patients who have concerns about severe side effects are less likely to take
their medication than those individuals who do not have concerns about side effects.
2. Complexity of the Treatment
In general, the greater the complexity of treatment, the lower the rate of adherence.
Adhering to Healthy Behavior
C. Personal Factors
Several personal characteristics relate to patient adherence.
1. Age
Age shows a curvilinear relationship with adherence, with older and younger adults
showing lower adherence. Older individuals have more barriers to adherence because
2. Gender
Few overall differences exist in adherence rates for women and men for most
3. Personality Patterns
No single personality trait shows any consistent relationship to adherence. Rather,
4. Emotional Factors
Anxiety that is specific to the disease may improve adherence, but more general
D. Environmental Factors
Environmental factors exert an even larger effect on adherence than personal factors do.
1. Economic Factors
Income and socioeconomic status are important factors for health; those with more
2. Social Support
Social support, a concept that refers to both tangible and intangible help a person
3. Cultural Norms
Cultural beliefs and attitudes are related to adherence. Cultural traditions that are not
consistent with Western medicine lead to lower adherence. Cultural factors and ethnicity
may also influence how patients are treated; when Hispanic American and African
American patients feel discriminated against, their adherence rates are not as high as
when they feel treated with respect.
E. Interaction of Factors
Many of the factors identified above related to adherence are not independent from
one another, but, in fact, act interactively with one another. Researchers realize this and
examine the complex interactions that affect adherence.
II. Why and How Do People Adhere to Healthy Behaviors?
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A. Continuum Theories of Health Behavior
Continuum theories are a class of theories that attempt to explain adherence with a
single set of factors that should apply equally to all individuals, regardless of their motivations
for adhering.
1. The Health Belief Model
2. Self-Efficacy Theory
Albert Bandura proposed a theory that assumes that individuals’ actions result from
an interaction of behavior, environment, and person factors (such as cognition). These
three concepts are referred to as reciprocal determinism. One important person
factor is self-efficacy, or the belief that individuals have control of their own
behavior. According to self-efficacy theory, whether an individual believes that they
can do a behavior predicts whether they will have success at accomplishing that
behavior. One part of this is the idea of outcome expectations, or people’s beliefs
that those behaviors will produce valuable outcomes. Combining self-efficacy and
outcome expectations plays an important role in predicting behavior. Self-efficacy
theory has been shown to predict good adherence and good medical outcomes. A
limitation of self-efficacy theory is that it concentrates on self-efficacy and omits
other factors, such as social pressure or social norms.
3. Theory of Planned Behavior
4. Behavioral Theory
5. Critique of Continuum Theories
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Continuum theories have generated a significant amount of research to aid in our
understanding of adherence. These models do predict adherence better than chance.
However, predicting behavior is challenging and past behavior is often a better
predictor of future behavior than any of the beliefs or factors the continuum models
identified.
B. Stage Theories of Health Behavior
Stage theories propose that people pass through a series of discrete stages as they attempt to
change behavior. Stage theories suggest then that people in different stages should benefit from
different types of interventions and attempt to tailor information to the specific stage a person is
in.
1. The Transtheoretical Model
2. The Precaution Adoption Process Model
Neil Weinstein’s precaution adoption process model assumes that when people begin
new and relatively complex behaviors aimed at protecting themselves from harm, they
move through as many as seven stages of belief about their personal susceptibility. In
Stage 1, people are unaware of the hazard. In Stage 2, they are aware of the hazard but
believe that they are not at risk but others are; that is, they have an optimistic bias.
People in Stage 3 acknowledge their personal susceptibility and accept the notion that
precaution would be personally effective. Action occurs in Stage 4, whereas in the
parallel Stage 5, people decide that action is unnecessary. In Stage 6, people have already
3. The Health Action Process Approach
4. Critique of Stage Theories
Stage theories have generated a significant amount of research to aid in our
understanding of adherence, though the newer models of the Health Action Process
Approach and Precaution Adoption Process Model have generated less research than
the Transtheoretical Model. One strength of these models is that they tailor the
intervention to the person’s stage of behavior change. However, they also fail to
integrate other factors, such as an individual’s beliefs or perceptions.
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III. The Intention-Behavior Gap
Research has shown that intention does not always lead to behavior change.
A. Behavioral Willingness
Behavioral willingness refers to a person’s motivation at any given moment to
engage in a risky behavior. People with strong intentions are less likely to report a
willingness to engage in risky behaviors.
B. Implementational Intentions
Implementional intentions are specific plans that people can make that identify not
only what they intend to do, but also where, when, and how. Research has confirmed that
implementation intentions are useful in promoting adherence.
IV. Improving Adherence
Health care providers have attempted to improve patient adherence through the use of
both educational and behavioral strategies. Educational procedures that impart information
boost knowledge but do not usually result in increased adherence. Behavioral strategies are
Exploring Health on the Web
Adherence to medical advice is a compelling topic for professionals, but the Internet has
relatively few sites devoted to this topic.
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Suggested Activities
Personal Health Profile — What Factors Relate to Nonadherence?
Unless your students are exceptional, they fail to comply with some aspect of exemplary
health behavior—that is, they are noncompliant in some way. They may fail to follow medical
orders when ill, deviate from preventive health behaviors such as having regular medical check-
ups, or engage in risky health behaviors such as smoking or riding with a driver who has been
drinking. Therefore, almost everyone does something (or fails to do something) that meets the
criterion of nonadherence, and everyone can analyze the factors that contribute to such
behaviors.
Health Care Professionals’ Views of Adherence
Contrast the views of health care professionals on the topic of adherence by having your
students interview a physician and a nurse about their views of patient adherence to medical
regimens. Do the two types of health care professionals agree with each other concerning the
frequency of nonadherence? Do their views agree with the research findings about the frequency
of the problem?
Cell-Phone and Driving Use among College Students
In Chapter 16, the textbook highlights that college students are far more likely to use their
cell phone while driving than other groups.
Explore the adherence rate of college students by conducting a naturalistic observation
study of cell phone use while driving. Assign your students to be observers in campus parking
lots and instruct them to note the frequency of cell phone use and nonuse in people driving.
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Attempt to get a representative sample of parking lots and times of day. With these data, you can
have your students research the state and national rates of cell phone use and driving write a
story for the campus newspaper. How do these figures compare to the numbers of students in the
class who admit to using a cell phone while driving. Encourage the writers to focus on the
number of injuries that could be prevented and the number of lives saved if all students did not
use cell phones while driving.
Technology and Adherence
Technological advances have certainly been helpful in determining whether patients
adhere to medication regiments (e.g., Medication Event Monitoring System). Have students
brainstorm ways in which current barriers to adherence could be reduced by either using current
technology or by imagining what future technology could do. What barriers could be eliminated
by use of technology aids and what barriers are unlikely to be solved by technology?
Technology such as text messages can also help researchers increase adherence by
reminding participants to adhere to healthy behaviors (see Prestwich, Perugini, & 2010 from the
“Would You Believe…?” box). Have students think like health psychologists and design an
intervention, being mindful to combine theory with technology in a meaningful way. For
example, during which stage or stages of the Transtheoretical model might such an intervention
be most successful for health behavior change?
Health-Related Persuasion
Most college students were not born yet in the 1980s and missed the ubiquitous “Just Say
No” campaign. The following three links are from TV commercials or shows during the 1980s
that tried to convince children and teens to “Just Say No” to drugs.
Have students attempt to identify psychological constructs (e.g., self-efficacy, subjective norms,
attitudes) in these commercials. Though later in the text, we will discuss drug use in more detail,
you may want to ask students how they would design more effective health communications—
possibly by targeting different psychological constructs.
Later, anti-drug campaigns benefitted from help from major advertising professional, as part of
the Partnership for a Drug Free America. This group created several slick anti-drug
advertisements, including the famous “This is your brain on drugs” advertisement:
For each of these clips, have students think about a few issues. First, who is the intended
audience? What constructs, from the health behavior theories described in the text, do the
advertisements seem to target? Do you think the advertisements would be effective? Why or why
not?
Relevant Citations:
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o Paglia, A., & Room, R. (1999). Preventing substance use problems among youth:
A literature review and recommendations. The Journal of Primary Prevention,
20(1), 3-50.
▪ This article summarizes the many different approaches possible to
preventing drug abuse.
o Trost, M. R., Langan, E. J., & Kellar‐Guenther, Y. (1999). Not everyone listens
when you “just say no”: Drug resistance in relational context. Journal of Applied
Research 120-138.
▪ This article makes an important point that possibly students will bring up
themselves after watching the PSA—it is much easier to “Just Say No” to
strangers rather than close friends. How could planning (part of the HAPA
model) or implementation intentions help teens be more willing to say no
to friends?
Changing People’s Health Behaviors
This chapter examines a number of psychological concepts that can be targeted in
advertisements or PSA to promote adherence to health behaviors. However, often when we see
popular advertisements, they don’t necessarily target psychological constructs. Have students
read a research based article (see below for a possible example) that examines which
psychological constructs help predict health behavior change. Then have students examine
magazine advertisements or TV commercials targeting that behavior to see what type of
psychological constructs are being highlighted. Finally, ask students how they would design an
effective PSA to promote health behavior change.
Health Behavior Change Project
Have students pick a specific health behavior they would like to change, then have them
use theories and techniques from the text to develop and implement a plan to change this
behavior.
Some important components to have students include in their plans are (a) specific behavioral
goals, (b) knowledge of when the behavior is most (or least) likely to occur, (c) concrete plans to
change the behavior, (d) self-monitoring of the behavior, and (e) periodic evaluation of whether
the plan is working.
Students can pick a health behavior early in the semester, monitor their behavior for a week or
two to understand the contexts in which the behavior is most likely to occur, then use the
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following weeks to develop and implement their behavior change plans.
Video Recommendations
Super Size Me (2004) is an entertaining documentary that follows one man as he consumed
solely fast food for one month and documents the physical effects on his body. This film can
provide a good introduction to the importance of adherence, as well as some of the
environmental factors that make adherence to a healthy diet a difficult task for many people.
Available for DVD rental.
From Films for the Humanities & Sciences:
Prescription Medications: A Patient’s Primer (2003) focuses on taking prescription drugs
correctly. The program also presents the problem of drug interactions and stresses the importance
of a cooperative relationship between patient and health care professionals.
Video from the Web:
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Multiple Choice Questions
1. The LEAST accurate method of assessing rate of adherence is to
a. ask the practitioner.
b. ask the patient.
c. ask the patient’s family.
d. monitor medication usage.
2. Patients’ records of their own rate of adherence may lack validity because
a. patients sometimes lie to avoid the displeasure of their physicians.
b. patients may be unaware of their own rate of adherence.
c. neither a nor b
d. both a and b
3. Patients’ self-reports of adherence
a. are valid but not reliable.
b. have questionable validity.
c. are less valid than physicians’ reports.
d. are more valid than examination of biochemical evidence.
4. Using hospital personnel to monitor patient adherence
a. is the only currently approved method of assessing adherence.
b. creates an artificial situation that may result in higher rates of adherence.
c. violates regulations of the American Medical Association.
d. both b and c are true.
5. The pill cap microprocessor is an improved variation of which method of assessing
adherence?
a. physician judgment
b. patient judgment
c. examination of biochemical evidence
d. monitoring medication usage
6. The major advantage of the pill cap microprocessor as a means of assessing adherence is
its
a. cost effectiveness.
b. ability to count the number of pills removed with each bottle opening.
c. ability to count the number of bottle openings and record the time of day for each
opening.
d. nearly perfect validity.
7. Of all methods used to assess patient adherence,
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a. only pill count is both reliable and valid.
b. examination of biochemical evidence is clearly superior.
c. examination of biochemical evidence is least valid.
d. no single method is sufficiently reliable or valid.
8. Economic factors may exert a negative effect on adherence by
a. limiting access to screening tests.
b. preventing people from getting prescriptions filled or refilled.
c. increasing social support.
d. both a and b
9. Which type of social support is beneficial for adherence?
a. living with a family
b. belonging to a large family, even one that experiences a lot of conflict
c. being married
d. both a and c
10. Economic factors may exert a negative effect on adherence by
a. limiting access to screening tests.
b. preventing people from getting prescriptions filled or refilled.
c. increasing social support.
d. both a and b
11. Those who do not share the cultural beliefs of Western medicine
a. are just as likely as those who do to comply with the advice of a physician.
b. may not comply with a physician’s advice but may comply with a practitioner
from the same cultural tradition.
c. are likely to be members of ethnic minorities and are less compliant than
European Americans.
d. are more likely to comply with the advice of a nurse than a physician.
12. Which of these personal characteristics is generally the most accurate predictor of patient
adherence?
a. age
b. sex
c. social class
d. A combination of the above factors is more accurate than any one.
13. A person’s willingness and ability to follow recommended health practice is known as
a. behavior.
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b. intention.
c. adherence.
d. perceived behavioral control.
14. Practitioners’ accuracy when judging adherence of patients is
a. very reliable.
b. very valid.
c. only slightly better than chance.
d. the best report of patient’s adherence.
15. In a study that examined medication adherence in heart failure patients,
adherence was measured by both a Medication Event Monitoring System (MEMS) and
by patient self-report. ______ predicted survival over a 6-month period, whereas ______
did not.
a. Patient self-report; MEMS
b. MEMS; patient self-report
c. Practitioner self-report; MEMS
d. Exercise; MEMS
16. Some chronic conditions, such as HIV and arthritis, show _____ adherence rates where
diabetes and pulmonary disease show ______ adherence.
a. low; high
b. high; low
c. low; low
d. high; high
17. Angela is a heavy smoker and knows that smoking increases one’s chances of lung
disease. However, she believes that she is not at an increased risk for lung cancer. This is
because Angela has a(n) _____________.
a. high self-efficacy
b. high self-esteem
c. optimistic bias
d. pessimistic bias
18. For individuals who are depressed, their risk of nonadherence is ____ greater
than individuals who are not depressed.
a. four times
b. five times
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c. two times
d. three times
19. _______ is the concept that refers to tangible and intangible help a person
receives from friends and family.
a. Self-efficacy
b. Self-esteem
c. Social support
d. Self-concept
20. In studies with patients recovering from heart problems and patients with diabetes,
_________ was a better determinant of adherence than ______________.
a. practical support; emotional support
b. emotional support; invisible support
c. emotional support; practical support
d. practical support; invisible support
21. Older studies found a general rate of nonadherence around _______; more recent studies
show a rate of about _______.
a. 25% . . . . 50%
b. 50%. . . . 25%
c. 75% . . . over 90%
d. 10% . . . . nearly 40%
22. The following disease characteristic is the MOST accurate predictor of patient adherence:
a. severity of the disease as seen by the attending physician
b. patient’s perception of the severity of the disease
c. severity of the medication’s side effects
d. a medication with no side effects
23. Nonadherence rises abruptly when the prescription requires the patient to take one pill
a. once a day.
b. twice a day.
c. three times a day.
d. four times a day.
24. The relationship between adherence and age is complex. For example, one study
(Thomas et al., 1995) found that age had a(n) ______ relationship with adherence to
colorectal screening.
a. inverse
b. direct
c. curvilinear