Clin Sci Compliance Adherence Handout 2011-12

7/31/2019 Clin Sci Compliance Adherence Handout 2011-12

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Social Behaviour:Conformity, Compliance

and Adherence


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AIM:To provide an introduction to aspects of social

behaviour and the role of adherence (compliance)in pharmacy

OBJECTIVES: Explain concepts of conformity, obedience andcompliance

Identify the relevance of social behaviour to

clinical health care settings Define the concept of adherence and identify

problems associated with non-adherence (noncompliance)


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Definition of Conformity

Involves a change in belief or behaviourdue to perceived pressure from others

Can be temporary or permanent

Pressure can originate from informationgained, or from a desire to fit in

Eg, convert from one religion to another/ atheist to catholic

Eg, change appearance: fashion


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Three types of conformity

Compliance: people yield to group pressure toavoid punishment for non-conformity.Agrees inpublic, disagrees in private.

Internalization: persons opinion comes toresemble group opinion; incorporate into ownvalue system. Public and private acceptance.

Identification: yield to pressure because desire toadopt group characteristics. Public and privateacceptance, but temporary.


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Findings:

Control participants who undertook thetest made no mistakes

In the experiment groups:74% of genuine participants conformed

with wrong answer on at least one trial

32% genuine participants agreed with

wrong answer on all trialsGenuine participants conformed less if

they had an ally


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Opposition of the rest of the group (grouppressure)

Desire to meet experimenters wishes Desire to convey a favourable impression

of themselves

Desire to be no different to the others

Like people in the group

Social support: helps resist conformity(ally)

Factors affecting conformity


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Wish not to make a fool ofthemselves (need for social respect)

Difficult to maintain that you see

something when others dont

Were messages given off by theexperimenter? (informational

conformity rely upon his behaviouras guidance or to test own behaviouragainst)


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Other reasons for conformity include:

Having no clear opinion in the first place Not wishing to upset people or draw attention

to yourself

Being able to see others view as well as your

own No ideal stance, so best to support the

majority

Wishing to fit in and be liked/accepted

The issue isnt seen as that important Agree for the sake of it but privately hold on to

original opinion

Feelings of discomfort at being different


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Conformity - Issues arising

Group pressure causes distortion so it ispossible that you can then see almostanything

Group size: smaller groups considered less

collusive - but pressure to conform does notnecessarily increase with rising group sizes

Are we genetically predisposed to socialconformism? ie, a co-operation gene?

Real life situations are more complex withother pressures around; things are not alwaysso cut and dry!

Collaboration may aid our survival


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Sheriff (1930s) found two important sourcesof influence of conformity:

Informational conformity

We gain information from other

peoples perspectives as a guide towhat is going on, how to answer orwhat to think

Normative conformity We conform to what we believe are the

norms of the group in order to beaccepted


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Crutchfield (1955) suggested people who tend toconform have certain characteristics:

They are intellectually less effective

Have less ego strength

Less leadership ability

Less mature social relationships Have feelings of inferiority

Tend to be authoritarian

Less self-sufficient

More submissive

Narrow-minded and inhibited

Have relatively little insight into their ownpersonalities


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1971 Stanford Prison Experiment

Mock prison

Students recruited as prisoners and guards Ended after 6 days

Guards became sadistic

Prisoners became depressed andexperienced extreme stress

Participation voluntary but acted as if realand not able to leave

Zimbardo et al (1973)


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Prisoners given a number learned torefer to themselves as numbers

Initial rebellion. Guards cruel response

Resorted to inhumane punishments,

targeted ring leaders, misuse of protectiveequipment (fire extinguishers) etc.

Uniform / sunglasses

Parents on visiting day were worried, but

conformed to system when asked certainquestions (ie, dont you think your son isup to this?)


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Advantages of conformity

Group cohesion

Social control

Use to promote health relatedbehaviour

Feel accepted and liked

Clear rules and codes of conduct


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Rebellion

Is one person alone likely to rebel?

People more likely to rebel in groups

Garrison (1982) found that

(a) Where participants have the opportunity to clarifyand define the situation they are more likely torebel

(b) In situations of conflict: urge to obey and urge to

conform to group many people delay makingdecisions as long as possible. Loyalty to a groupis a major deciding factor as to whether or not toobey


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Obedience

To obey someone who is in a

position to exert power, invokepunishments or reward behaviour.

To do as one is told


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Stan Milgram (1933-1984)

Set out in 1963 and 1974 to disprove Asch

Experiment:

Experimenter, Teacher, Student Teacher hasno idea what is going on

Student strapped into chair/electrodes on arms

Teacher reads list of 2 x word pairs and askslearner to read them back

Every incorrect answer = electric shock. Start

at 15 volts and increase each time wronganswer.

Student pretends to receive shocks. Teacherbelieves shocks being administered.


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Findings:

When the teacher learned that theexperimenter would assume fullresponsibility:

Despite feeling uncomfortable teacherscontinued to administer shocks

Two thirds of the teachers were obedient(described as ordinary people fromworking and professional classbackgrounds)

65% of teachers punished learners to themaximum of 450 volts


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Interest in Nazi behaviour during

II WW

Experiment undertaken worldwide similar findings. In Germany

over 85% ofTeachersubjectsadministered a lethal electric shockto the learner

Higher in other countries


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Milgrams conclusion

Human nature cannot be countedon to insulate man from brutalityat the hands of his fellow man

when orders come from what isperceived as a legitimateauthority.


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Why do we need some form ofsocial control?

Health care treatments require co-operation and long-term changes inpeoples behaviour:

Smoking cessation

Heart disease

Liver disease

Renal failure

Lack of co-operation will result inbreakdown of treatment


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Lack of order will result in a chaoticservice and lack of systems

Reinforce inequalities in health

Opportunities for health research lost

Behaviour in health centres / hospitals

ensure health and safety of visitors andpatients

Need to prevent ill health

Reduce costsReduce burden to NHS [waiting lists]

Improve Quality of Life


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IndividualBehaviour

- Legislation

- Police

- Criminal Justice System

- Prisons

Punishment as

a deterrent

- public humiliation

- fear

Beliefs

- right/wrong

Morals / Ethics

- empathyBig Brother

- Cameras

- Being observed (Foucault)

Role Models- Peers

- Idols

- Media

- School

- Family

Peerpressure


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Adherence to Medical Advice

In terms of health compliance can be defined asthe extent to which a persons behaviour (in

terms of taking medications, following diets etc)coincides with medical or health advice

(Haynes et al, 1979)

Why dont people follow the medical advicegiven?

Health environment very different to theexperiments of 1950s and 1960s above

People more likely to ignore health care advice


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Estimations of adherence

Studies on adherence in health vary widely inestimation of compliance to health regimes

Taylor (1990) = 93% of people do not comply (toaspects of treatment)

Sarafino (1994) suggests difference between shortterm and long term adherence; 78% of the time foracute v 54% of the time for chronic illness

Both Taylor and Sarafino looking from different

perspectives Sarafino average adherence rate fortaking

medicines was 60% (long term and short term) BUTchanges to lifestyle, eg, changing diet, quit smokingwas varied and often LOW


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Barat et al (2001) found older patients in one studywere sometimes unclear about purpose of drugsbeing taken (60%)

Kaplan et al (1993) identified 3 issues for older

people and medicines compliance: Difficulty understanding or following complex

instructions

Difficulty using medicine containers due to

dexterity (child proof caps) Taking range of medicines for different

conditions. side effects = discontinue

medicines

Older people and adherence


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Hussey and Giliand (1989) suggest 2 kinds ofnon compliance :

Unintentional pt does not have adequate understanding of

condition or treatment or fail to understandadvice being given

Intentional

when choose to find alternative treatmentor simply decide not to do anything

Different types of adherence


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Concept of Rational Non Adherence

Why might a rational patient not adhere to treatment?

Patient does not believe it is in their best interest todo so: eg:-

Treatment will not help them

Or treatment will make things worse or causefurther problems

Sarafino (1994)

Believe treatment not helping

Side-effects unpleasant or affect QoL

Confused about treatment regime

Barriers cost, access

By stopping medicines can check status of illness


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Ley (1988) non compliance for medicationdefined as:

Not taking enough medicine

Taking too much medicine

Not observing correct interval between

doses

Not maintaining correct duration oftreatment

Taking additional un-prescribed medicines

Implications serious

Can you think of implications of above?


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Factors influencing adherence

Homedes (1991) found >200 variablesaffect compliance. He categorised

them:Characteristics of patient

Characteristics of treatment regime

Features of the disease

Relationship between professionaland pt

Clinical setting


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Characteristics of patient (Leys cognitivemodel)

Knowledge pt brings to consultationUnderstanding of what is said to them

(medical vocabulary)

Cognitive functioning (memory)Satisfaction

Strategies to improve memory: wristwatches with alarms, reminder charts andaides, tear off pill calendars, specialdispensers, Rx stickers, supervision


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Leys Cognitive Model (1989)

Understanding

Memory

Satisfaction Compliance


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Implications for clinical practice?

Think about the way in which the physical, clinicalenvironment is set up and about the way in whichpatients and practitioners behave.

Curtains around a bed to talk about somethingserious. Do curtains block out the sound?

Easier to talk to someone dont know offloadpersonal life history if do not expect to see them

again Ward Rounds: opinions merge

Violence in A&E on rise (anonymity act asinhibitor?)


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Issues to consider

How we communicate withpatients

How we monitor compliance

Using in-depth assessments

Of knowledge, beliefs, values

Determine risk of non-adherence

Documents

Clin Sci Compliance Adherence Handout 2011-12