Cognitive models and theories


The cognitive theories and models connected with adherence to medical tips such as the Health Belief Unit, Rational Decision Theory, Ley’s Cognitive Theory and Protection Motivation Version happen to be investigated in this extended essay. The factors affecting medical non-adherence will be explored through the cognitive approach and the research question of: ‘to what extent do cognitive designs and theories offer an explanation for why people usually do not adhere to medical guidance’ can be evaluated and deconstructed. Research from several publications and studies have already been used in an effort to examine the degree that cognitive types and theories will offer a conclusion for why people do not stick to medical advice. The research allowed the conclusion to be made that cognitive styles and theories work in explaining the reason for non adherence nonetheless it will be reductionist to ignore the several other factors that donate to a patient’s non-adherence to medical information such as social elements and biological factors. These other elements are likewise central to answering why adherence develops as cognitive factors are connected to both cultural and biological factors

Table of Contents


What is certainly medical adherence? According to the World Health Organisation, the definition of lengthy -term medical adherence is certainly ‘the extent to which a person’s behaviour – taking medication, carrying out a diet and/or executing lifestyle changes, corresponds with agreed advice from physician.’ [1] Haynes et al. explained that compliance and adherence happen to be interchangeable terms but recently, there’s been debate about whether compliance is really the same as adherence . [2] The term compliance implies the passive and obedient characteristics of an individual whereas adherence takes into account the independence of an individual. Thus, if an individual may take control of their very own treatment to improve their health, how come non-adherence arise? In the strictest impression, Taylor (1990) advised that 93 percent of clients didn’t adhere to some kind of their treatment. [3] Even so, Sarafino (1994) used a far more lax definition of adherence permitting customisation of treatment and proposed that people were reasonably adherent with 78 percent adherence in short term treatments. [4] The World Health Organisation claims that in designed countries, there is an average of 50 percent adherence to long-term therapy of chronic conditions [5] such as for example hypertension and diabetes. Out of all the American sufferers with hypertension, 85 percent ‘remain undiagnosed, untreated, or inadequately treated.’ [6] In McKenney’s study, fifty participants were studied and evaluated over five months and the benefits showed that the sufferers approximately took only 65 percent of their recommended hypertensive medication and only 20 percent of the participants had taken as many as 90 percent of their recommended drugs. [7]


From these statistics, it is clear that the definition of adherence is available to subjective interpretation and degrees of adherence may vary according to the definition adopted. Therefore, the various studies discussed in this essay happen to be limited as the interpretation of adherence is quite broad therefore generalisability and usefulness happen to be negatively affected. Just what exactly can be defined as non-adherence? Essentially, forgetting to take a dose, missing a dose deliberately, occasional alleviation of remedy and a complete end to treatment can all come to be described as non-adherence. There are several causes that can contribute to insufficient adherence but concentrating on the cognitive approach may provide a more concise answer to the question: From what extent do cognitive products and theories offer a conclusion for why people usually do not adhere to medical advice. [8]

Health Belief Model

According to Cooper, Love, and Raffoul (1982), intentional non-adherence arises 73 percent of that time period. [9]

Figure 1 Diagram depicting Health Belief Model.

Source: (Hayden, 2009)

Source: Stretcher, V., & Rosenstock I.M. (1997). The Health Belief Unit. In Glanz K., Lewis F.M., & Rimer B.K., (Eds.). Health Behavior and Well being Education: Theory, Study and Practice. San Francisco: Jossey-Bass.

The Health Belief Style (HBM), proposed by Rosenstock (1974) and after evaluated by Janz and Becker (1984), suggested that the probability of compliance to health advice is related to the patient’s perception of how severe the condition is and the amount of susceptibility. The basis of perceived risk of the disease can arrive from prior medical understanding or the patient’s perception of the implications of the condition. The probability of preventive action is determined through a series of steps. If the individual recognises the illness as a threat, they’ll proceed to consider perceived barriers against perceived benefits, followed by a cue to action (any event that leads to altered behaviour). [10] However, as Figure 2 signifies, the HBM includes social factors, such as for example cultural upbringing; and cue to actions can be associated with social factors such as for example mass media and peer pressure consequently in relation to the study question, cognitive designs can describe adherence to a certain extent, but social factors can be found also.

One can consider the Turner et al. (2004) study describing the utilization of HBM by the Osteoporosis Prevention Programme on female individuals to illustrate the HBM. Generally, there is a low level of perceived threat of osteoporosis amongst the women due to the common misconception that osteoporosis arises in older females. To increase perceived susceptibility, the participants were shown a normal healthful bone of a 75 year old girl against a slide of an osteoporotic bone in a 47 year outdated woman and also photos of a fractured backbone, hip and waist. It had been also emphasised that osteoporosis quite often showed no symptoms and was simply realised when a fracture took place. To imbue cues to actions, a vast amount of information was made available to participants to raise awareness of the threats of osteoporosis, along with bone mineral density tests and discussion classes for dietary alterations and suggested physical activity. In addition, Turner et al. attemptedto reduce common perceived barriers. Convenient programme times, each lasting one hour, were organised to facilitate occupied schedules and classes occurred in a ‘centrally located, state-of-the-art community center.’ [11] Moreover, free childcare providers were provided at the city centre to ensure that participants would not have to worry about their children and the condition of expense was eliminated by supplying the programme for free. Turner et al. figured participation in health advertising programmes was heightened when perceived threat, susceptibility and benefits were increased and perceived barriers had been decreased. [12]

Turner et al.’s study had a relatively large sample with 342 women of all ages completing the entire programme so study of such complexity takes a large amount of time, effort and funding. However, as the target of the analysis was on females, there would be difficulty generalising to men but it could possibly be said that even more females suffer from osteoporosis so generalisation to males was not the intent.

In relation to the research question, medical belief style supports the effect of cognition but simply considering cognitive factors with disregard of various other degrees of analysis is reductionist. Various perceived barriers are related to social factors and the Turner et al. study demonstrates one of the primary problems was financial situation, which might be linked to social class. Another cultural barrier could possibly be peer pressure. If among the participants were mocked by colleagues to be a hypochondriac, the perceived barrier would be reinforced and obedience could be influenced negatively by the sociable group. Moreover, press or family members expressing their concerns could supply the cue to action.

Rational Choice theory

Perceived Benefits versus Perceived Costs to Patient

The Rational Choice Theory provides an explanation for non-adherence where patients feel that there is rationale to alter the recommended treatment because of justifications that are believed to be true by the patient, though may not necessarily be authentic or helpful to the patient’s health. An explanation for this phenomena could possibly be due to negative side effects of treatment that alter the patient’s quality of life so that they feel that it would be more reasonable to discontinue treatment. A good example of non-adherence because of dissatisfaction associated with the side effects of medication is the Bulpitt (1988) review which aimed to investigate the research on effects and issues of medication for hypertension. [13] Antihypertensive medicine is known to be linked to impaired sexual function such as for example erectile dysfunction and it’s been reported that the rate of recurrence of erectile inability was 6.7 percent by age 55 and 24 percent by the age of 70 in Kinsey et al.’s function. [14] Bulpitt reported that a study by Curb (1985) found that 8 percent of males taking antihypertensive treatment finished the utilization of medication due to impotence and ejaculation problems that emerged after choosing the antihypertensive drugs. [15] Notably, it was found by the Medical Exploration Council (1981) that 15

percent of individuals halted medication due to other unwanted effects [16] such as head aches or dizziness. Though these analyses have attributed undesirable side effects with failed compliance, this was applicable to only a little part of the sample, thus other factors should be considered to attain a more wholesome notion of adherence and prevent reductionism. In addition, these studies are limited in generalisability to females as the research only involved men and usefulness can be questionable as only hypertensive medication were included. Ethics may be a concern in these analyses because investigation in to the participant’s erectile problems could be humiliating for the topic and might cause emotions of inadequacy which could be classified as mental harm to the participant.

Financial Barriers

The presence of sensible barriers could donate to a patient’s decision to disregard medical advice. Personal obstacles such as for example low income of clients may lead to not being able to afford expensive treatments not paid for by National Health Schemes. Karter et al. (2000) concluded from their study on the partnership between financial barriers and adherence to treatment for diabetes that ‘removal of financial barriers by providing more comprehensive insurance policy coverage for these costs may boost adherence to tips for SMBG [self-monitoring of blood glucose].’ [17] The analysis was cross-sectional which provided a snapshot of the rate of recurrence of adherence to SMBG so that it was less time consuming when compared to a longitudinal study. A vast amount of data was acquired from 44,181 participants therefore the study was highly generalisable to the target human population of Northern Californian diabetics, although ethnocentricity of the study limits generalisation to all of those other world.

Patient-practitioner Relationship

The patient might also fail to comply because they possess reason to doubt the effectiveness of the treatment. A study on arthritis people by Arluke (1980) advised that if the conditions of the disease worsen even though the patient has followed prescribed instruction, adherence will come to be affected negatively. [18] Furthermore, the Handbook of Clinical Psychology in Medical Settings states that ‘the most common reason granted for intentional non-adherence was that the individual did not think that the drug was required in the dosage recommended by the medical doctor.’ [19] The individual might quit treatment out of curiosity to find whether the illness continues to be present since the patient may be sceptical about the usefulness of approved treatment. [20] This lack of rely upon the physician’s advice could arise from doubts on the competency or professionalism of their doctor that can be connected with the patient-practitioner relationship. The trust imparted on the physician is somewhat dependent how the doctor acts or dresses and a report by McKinstry and Wang (1991) where patients were demonstrated pictures of male or female doctors dressed up in either formal or informal outfits. For example, a picture of a traditionally dressed doctor would depict the physician wearing a formal white layer whereas an informally dressed doctor would be shown wearing denim jeans. When asked, the patients rated that they had the most self confidence in the doctors that were formally dressed which preference was particularly prevalent in older clients. [21] Though participants were approached at surgeries, this study was lower in ecological validity because individuals are not normally demonstrated pics of doctors and questioned when they attend a surgery treatment. The patient-practitioner relationship can be reliant on the patient’s perception of the medical professional, but may also be dependent on the social scenario and the social interaction between them and the manner of interaction could affect the amount of understanding of recommended treatment. Thus, with regards to the research question, we can already see how not only cognitive elements affect adherence, but social aspects like the communicative expertise and the practitioner’s attire could influence adherence.


A lack of knowledge of the medication and/or the procedure schedule that is approved is also a barrier. This problem will not only lead the patient to possibly perform the treatment incorrectly, but can hinder the patient’s memory of the task for his or her treatment. Hadlow and Pitts (1991) reported that around 33 percent of people don’t have proper knowledge of commonly used medical terms [22] and as a result, 40 to 80 percent of advice given by the physician is immediately forgotten. [23] In addition, in a report by McKinlay (1975) of the knowledge of information given to women by health personnel in a maternity ward, simply 39 percent of ladies actually understood 13 chosen medical terms. Interestingly, medical personnel expected even lower levels of understanding but used technical jargon irrespective of this. [24] Only feminine participants were studied so the gynocentrism limits generalisation as well as perhaps a much less gynocentric sample could possibly be attained in a several ward of the hospital, such as for example physiotherapy. Medical workers could be utilising complex jargon on patients in order to avoid being asked questions also to assert a sense of authority. In cases like this, ethics would be an issue as it is the patient’s right to be fully informed about the treatment and their condition. [25] It really is unethical to send clients away with the likelihood that they do not fully understand how to use their medication as it could bring about auspicious consequences and there is a greater probability that the patient will neglect to adhere, as is described in Ley’s Cognitive Model (1988). [26]

Ley’s Cognitive Model (1988)

Ley’s Cognitive Model claims that understanding and recollection of details affect adherence and result in satisfaction that have a positive influence on adherence (see Figure 1).

Figure 2 Diagram depicting Ley’s Cognitive Model (1988)

Source: (Kessels, 2003)Ley et al. (1973) conducted a study on clients with a control band of pupils and measured their recall of a list of medical statements in a structured or unstructured condition. The patients showed twenty five percent extra recall in the categorised state with structured data and students showed 50 percent extra recall. These results suggest that providing individuals with structured data would increase the degrees of adherence as there would be a lower probability of forgetting the medical advice. However, this study could possibly be criticised due to the lack of ecological validity since it is unusual for an individual to try and recall a set of seemingly unrelated words if they go to a GP surgery. Also, pupils are more accustomed to learning and remembering facts it is therefore questionable whether utilizing a college student control group is ideal and a perhaps better group will be a different sample of patients rather. Furthermore, it might be reductionist to simply believe that the organised mother nature of information was the only real contributor to increased levels of recall as other factors could have damaged recall, for instance, the emotional state of the patient. A study on patient facts recall by Anderson et al. (1979) concluded that anxious sufferers tended to recall much better than those that were calm. [27] This conclusion shows that arousal could aid memory space which is possibly due to the patient’s worries about their health, hence making a supplementary effort to recall facts given to them. [28]

In a far more ecologically valid review on the recall of actual consultations (rather than list recall) by Ley (1988), it was found that less than 55 percent of details given by the doctor was recalled. [29] Ley concluded some main trends that occurred:

The primacy effect: People tended to recall the earliest information given to them best.

Structured facts was better recalled than when non-categorised.

Prior medical expertise improved recall of facts.

The greater sum of information given, the greater amount forgotten

There was no influence on recall when the physician repeated guidelines. [30]

Ley’s study was very helpful as once known reasons for impaired recall were recognized, amendments could be designed to the consultation method. A later study showed that doctors that acquired adopted advice from a booklet based on Ley’s findings showed an average of 70 percent of facts was remembered by the patient. [31] However, demand attributes could be present as the participants were aware of the need to recall information which could own influenced the patient’s focus on details given to them. Accordingly, ecological validity, though greater than the prior study, would still not really be very high as the situation continues to be different to a standard surgery visit in which patients could be considering inquiries to ask the physician and therefore not pay as much focus on instructions being given.

Protection Motivation Theory

Figure 3 Diagram depicting Protection Motivation Theory

Source: Norman, P..B.H.&.S.E.R., 1996. Protection Determination Theory. In Predicting Health Behaviour. Buckingham: Open up University Press. pp.84.

The Protection Determination Theory (PMT) proposed by Rogers (1983) shows that the process of taking action to protect oneself, i.e. to adhere to medical advice, follows a series of cognitive decisions. PMT identifies the intention to adhere to the advice

of a health worker and is dependent on adaptive (confident response) and maladaptive response (adapted unfavorable response) that influence the opportunity of survival. [32] Maladaptive responses are influenced by threat appraisal [33] and will be encouraged by intrinsic and extrinsic benefits. For example, in the case of complicated and frustrating treatment options, an intrinsic award that could act against adherence is to avoid the treatment to diminish stress. An extrinsic prize stemming from this scenario would be that skipping treatment would allow period for participation in cultural gatherings. When perception of severity and vulnerability are large, maladaptive responses will decrease and likewise, greater levels of dread arousal will elicit raised perceived severity and vulnerability and therefore the patient can make a judgement that degrees of threat are high.

Conversely, an adaptive response could be triggered by coping appraisal which is related to the way the patient perceives the ailment can be handled. [34] Coping appraisal can be increased with bigger response efficacy which is the belief that approved medication will have an impact on the condition. Another explanation could possibly be that self-efficacy [35] can boost coping appraisal. Adaptive response is also afflicted by response costs which are, perceived barriers which can inhibit the emergence of adaptive behaviour of adhering to medical advice. [36]

A analysis on outpatient rehabilitation adherence by Grindley et al. examines the PMT by it as a screening instrument to measure sports harm rehabilitation adherence. Factors of PMT were incorporated in the analysis by several means. The era of threat appraisal was dependent on the patient’s belief that the irritation or even disability of their state would persist or exacerbate and worries arousal from pain, analysis and disability further increased threat appraisal. Coping appraisal was reliant on the patient’s belief in the effectiveness of their treatment and in addition their capability to successfully complete treatment, which accounted for response efficacy and self-efficacy. Response costs highly relevant to the problem took the form of anxiety about the required period of time for rehabilitation, possible experience of pain and economic implications. The info was gathered utilizing a 7-point Likert level which assessed areas of PMT such as for example perceived intensity, vulnerability etc., thus there is reduced researcher bias than self-reports as it eliminates the necessity for researcher interpretation of participant reviews. Grindley et al. figured drop out behaviour from the analysis was linked to the perceived severity, self-efficacy and response barriers and that bigger self-efficacy was linked to higher treatment efficacy. [37]

The study took into consideration that the severity of a patient’s state could be a confounding variable so as a control, participants that were prescribed rehabilitation treatment for 4 to eight weeks were used in order to eradicate patients with small injuries or chronic illnesses because of dissimilar rehabilitation requirements. Because of this control, the severity of the condition cannot influence results and therefore increased the reliability of results. Another strength is that ethical rules were followed and informed consent was acquired, without physical harm imparted on the participants. A difficulty with generalisability is the ethnocentric nature of the study as only 1 rehabilitation facility was used in the sample thus the results may have limited generalisability potential when applied to the areas. However, the large sample of 229 participants comprising 149 females and 80 males was a strength as the results could be generalised to both genders. Another limitation is normally that the study measures behaviour inside the clinic during attendance but did not analyze the patient’s behaviour with residence physical therapy which behaviour could possibly be different so there isn’t a wholesome perspective, therefore negatively affecting usefulness. Furthermore, extraneous variables that may contain occurred could are the fact that patients might not have necessarily understood the treatment or the negative outcomes that could result from failure to adhere. Furthermore, the availability of pain killers signifies that the perception of discomfort is less severe thus lowering protection motivation. Emotions and mood of the patient could have a negative effect on adherence as they are maladaptive responses as DiMatteo et al. concluded from their analysis on the partnership between unhappiness and noncompliance, depressed people were 3 times much more likely to become non-adherent to medical advice than non-depressed individuals. [38] Thus other than cognitive factors, the affective state of an individual can have a substantial effect on adherence and may limit the degree to which cognitive products explain adherence.


It is evident from the theories examined that there is not an ultimate reason or degree of analysis that can describe non-adherence and a holistic evaluation is necessary for a sensible bottom line. The reasons for non-adherence examined in this article merely focus on the cognitive perspective toward non-adherence and it could be reductionist to claim that any single factor may be the sole reason behind non-compliance. [39] Many elements intertwine and the cognitive level of analysis can only describe non-adherence up to a specific extent. Evidently, actually within the theories mentioned in this essay, the social level of analysis has been surreptitiously present due to the many public relations to the theories. To illustrate this aspect, you can consider the HBM. It involves cues to action but media campaigns and guidance are both social elements that trigger the process. Also, in both the HBM and PMT, a potential response cost can form part of sociable norms. For example, a diabetic might avoid choosing an injection at a cafe since it goes against sociable norms. Another example of a social barrier could possibly be how followers of Jehovah’s Witness faith refuse bloodstream transfusions due to their belief that the Bible forbids the ingestion of blood vessels and thus even in emergencies, they will not accept blood transfusions. [40] Furthermore, self-efficacy (which is a feature of PMT) is linked to social elements as Bandura stated that judgements of self-efficacy derive from a number of social constructs such as the individual’s own achievements, impact of themselves and contemporary society, scrutiny of emotional states and observations of others. [41]

Many other conceivable cognitive known reasons for non-adherence have certainly not been mentioned in this article such as biological factors. Genetics are a good example of how biological elements could influence non-adherence to medical guidance. For instance, if a person has inherited aggressive traits through genes from their parents, the aggression might bring about negative compliance as the patient will not respond well to assistance. A severe brain personal injury in the memory space centres of the brain would likewise affect adherence but you might argue that the practitioner will consider this and treat the individual accordingly.

Furthermore, there are several limitations to analyses on adherence which leaves the validity of analyses questionable. Most research on medical adherence make use of self-reporting methods which are incredibly subjective and are open to demand characteristics and also researcher bias because the participant could attempt to report in such a way to assist or sabotage the research and the researcher could become biased as a result of their enthusiasm or aims. Additionally, the participant could be influenced by public desirability bias because they would like to report in a way which they perceive is the ‘right’ method. [42] Moreover, it really is difficult to effectively measure adherence, we.e. if a distinct method of measuring adherence was adopted like counting the number of pills the individual has still left in the bottle to see how many pills have been taken, it would still not be exact as we only know that some number of pills have already been taken out but we have no idea how many pills have actually been taken by the patient.

In summary, although the styles and theories of cognition give some explanation as to why people usually do not adhere, they cannot provide the ultimate reply. Cognitive theories and types can aid prediction of how very well a patient will adhere but persons are finally unpredictable with many specific differences therefore there are lots of facets to the occurrence of non-adherence. [43] To simplistically give attention to only cognitive factors of non-adherence can only give a one-sided view on non-compliance. With regards to the research question, it can only be said that non-adherence is because cognitive factors up to a particular extent as there is absolutely no doubt that cognitive factors do play a part in influencing adherence, but elements from the biological and socio-cultural level of analysis will be significant in the occurrence of non-adherence to medical information. To get an ultimate knowledge of why people usually do not adhere to medical advice, studies in behavioural, social, physiological developmental etc. psychology will have to be examined to come quickly to a far more holistic conclusion.

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