The paper reviewed here is ‘The Role of Theory in Increasing Adherence to Prescribed Practice’ by Hanna and colleagues and freely available here. I selected this paper as it refers to the self-efficacy construct which featured in a previously reviewed paper on determinants of healthy eating behaviour (see here). For this reason I was mainly interested in the understanding adherence behaviour and subsequent sections. However in the introduction the authors cite an important paper in which one author calculated an estimated 24.8% of patients will not adhere to medical treatment although this was a passing reference and the original paper will be interesting to look at in closer detail. Moving onto the ‘understanding adherence behaviour’ section the authors describe 5 relevant theories.
1. The Health Belief Model (Rosenstock, 1966).This is outlined in the article as a number of factors combining to influence goal-directed behaviour. These factors are the perceived vulnerability, perceived severity, ‘stimulants to behaviour’, self-efficacy and what I would term a risk-benefit judgement. Essentially it seemed to be a model in which advantages and disadvantages associated with the behaviour are combined to influence behavioural outcome although I wasn’t clear on the weighting associated with each of the factors.
2. Protection Motivation Theory (Rogers, 1983). This theory incorporates threats, rewards and coping mechanisms to arrive at a judgement. While there is some overlap with the previous model there are independent factors also. It is interesting to speculate on whether these would be occurring as simultaneous or sequential psychological processes.
3. The Theory of Reasoned Action (Ajzen and Fishbein, 1980). The original theory incorporated a perception of how others viewed the effectiveness of the action and also how effective the action was going to be. This theory seems to suggest that the social milieu is an important aspect of actions being undertaken.
4. Self-efficacy Theory (Bandura, 1977). The belief a person has in being able to undertake a task. These beliefs are further influenced by physiological state, ‘mastery experiences’, ‘vicarious experiences’ and ‘verbal persuasion’.
5. Social Cognitive Theory (Bandura, 1986). The mediating factors for influencing goal directed behaviours include self-efficacy, sociostructural factors (impediments and facilitators) and expectations of outcome.
The authors compare the theories and argue that the concepts including outcome expectations in social cognitive theory encompass the concepts contained within the other models. They then look at some experimental support for the theories in physiotherapy. What I found particularly interesting about the conclusions from their analysis was the need to operationalise a theory in order to facilitate the experimental investigation of that same theory. This reminds me of the top-down versus bottom-up debate. The attachment of the finer details to the top level constructs enables assessment to take place and is similar to some of the discussion that takes place in computational biology (e.g see the blue brain project).
In summary, this was a brief paper which outlines a number of theories relevant to adherence to treatment regimens and a consideration of the experimental support in a very specific area of physiotherapy. However there is also an application of this same approach to the area of medication adherence and the concepts have a wider relevance to health related behaviours. There are enough models considered here to provide a useful starting point for further reading.
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