Evaluation for Adherence to Medical Advice Reductionism: Reductionism is the argument that we can explain behavior and experiences

by reference to only one factor. The adherence to medical advice can be reductionist in a number of ways. The study conducted by Milgram in 1963 showed that 2/3 of the people gave shocks up to 450 volts which means that the obedience to authority was high but this is an reductionist approach since it does not consider other factors that could cause high obedience level and reduces the results to authority only. The other factors could be the payment given to participate in the study which strengthened the obligation and also the location of the experiment was Yale university which seemed it to be more realistic. Another study conducted by Bulpitt et al. in 1988 states that when the cost of taking the medication; side effects outweighs the benefits of the treatment people are less likely to adhere to the treatment. This is reductionist because there could be other factors that contribute to the low adherence rate such as the economical cost of the medication and the availability of the medicine in a specific area. When measuring adherence the therapeutic outcome assess whether the patient is getting better this is reductionist because the patient may not only be getting better due to the medicine but other aspects such as a change in environment could alleviate the symptoms of a viral disease or a change in lifestyle such as stop smoking could make the symptoms of diseases like bronchitis much better. Chung and Naya in 2000 said that the adherence improved because the patients had a clue that they were being observed therefor this is also a reductionist point of view since the high level of adherence could be possible if someone was reminding the patients to take their medication or the severity of their illness was enough to increase their adherence. The biochemical tests used to check the patients compliance is also reductionist since it only shows the results for drugs taken a few hours before the test therefor this approach reduces the compliance to drugs taken a particular time before the test and does not consider the regularity of taking the medication. Another study conducted by Sherman et al. in 2000 checked with the pharmacy of the patient whether they have been refilling their medications or not this method is reductionist because the patient might be visiting different pharmacies depending on preferences and location. Sarafino in 1994 said that the overall adherence is 60% and Taylor in 1990 said that 93% of the patients failed to adhere to some aspect of their treatment. This is reductionist because the people who volunteer to take part in these studies are the people who already adhere. Nessman et al. support this point of view, they found out that compliance increased from 38% to 88% however only 56 people out of 500 volunteered for the study thus their volunteers were more motivated to take part in the study and hence showed more positive results. Ethics: When looking at ethics, we need to look at consent, deception, debriefing, protectionism, withdrawal and confidentiality.

The traditional approach in social psychology is using an artificial situation i.e. lab experiment where the experimenters exert authority on the participants (Milgram 1963) to make the people adhere. when looking at lab experiments they contain many ethical issues such as deception, lack of protection which affects the natural reaction of people to adherence. However during lab experiments consent is mostly taken care of and confidentiality is maintained such as in Milgram and Zimbardo. In a more real life situation, patients however are more likely to lie about their level of adherence. This means people want to appear socially desirable and this in turn can lead to deception. The people that normally take part in the experiment are those people that adhere more than others. This distorts the final figures. In Bulpitt (1988) the results said that with a high number and intensity of side effects comes low levels of adherence. Practitioners can avoid telling the patients the whole truth about the illness and the side effects to ensure high levels of adherence but that would be breaking the ethical guidelines of deception and protection of participants because they may encounter side effects which were not in their knowledge. While talking about ethics major importance is given to children ethics too. In a study by Kent and Dalgleish (1996) came to the conclusion that a major reason for children not adhering to the doctor were their parents. They showed that by day 6 only 29% of the children were being given the prescribed medication. This shows that a major problem in children ethics is lack of children protection. In order to judge patients level of adherence doctors may want to know the daily routine of the patients. As the study by Johnson and Bytheway (2000) shows that doctors told patients to keep record of their daily routine. This invades their privacy and patients may not be comfortable in revealing so much about themselves. The adherence rates doctors give may be different to the real life rates in order to make themselves look more superior to others. This is ethically wrong because in reality they are just posing to be great. In the study by Chung and Naya (2000) there was deception in the case of the trackcaps. The patients were not told of the details of the trackcap hence, this led to deception. In conclusion, there are various ways of improving adherence. However, doctors must keep in mind ethical issues that may come up during the process. Even if the doctors reinforce and stress upon the regimens, they must not cross the boundaries of consent and withdrawal because in the end the final decision lies in the hands of the patients, themselves.

Reliability: REASONS FOR NON ADHERENCE: Adherence to medical advice can be describes as the degree to which patients carry out the behaviors and treatments their practitioner recommends. Reliability is the measure o how much the results o n experiment to prove or disprove a hypothesis can be replicated. The study done by Milgram gave measured, quantitative results that people can go to extreme measures and do something when instructed by someone they perceive as legitimate authority. Abu Gharib in 2004 carried out a study which confirmed the results found by Milgram, hence making the theory reliable. However, the fact that these studies were lab experiments and come under social psychology, which are both different from real life. Because in real life situations extraneous/confounding variables such as state of mind, company, environment, etc come into play, that pose a threat to validity, which in turn means low reliability. The results found by Sarafino about rate of adherence which, on average is 60%, is reliable in the sense that the results are quantitative, hence objectified and measurable. However, on average means that it is not generalisable, and that individual differences have not been taken into account which questions reliability, and the same goes for the study done by Taylor in 1990 which says that 93% o the people fail to adhere to some part of their treatment. These percentages are also unreliable due to the fact that the people who mainly participate in studies, are usually the ones who are already regular in adhering to medical advice (confounding variable) hence not the best sample. Nessman et al (1990) carried out a study in order to research the effectiveness of group sessions in increasing compliance. The results showed a tremendous increase in the rate of compliance by 50 percent but the sample was voluntary which decreases the reliability as the subjects who took part in this study were already motivated to adhere to medical advice. Furthermore, in the study of Banyard 1996, the reliability was quite high as the research is more doctor centered and it holds the doctor responsible to determine the patients adherence through a set of instructions about how doctors should request and warn patients against nonadherence. The study done by Kent and Dalgleish to measure adherence in a group of parents was high on reliability s it was objective. The parents either adhered by giving medication to their child or did not, and the results were quantifiable. There were a number of controls as well for example, free medication was provided to all so financial reasons or non-adherence was ruled out, all the parents thoroughly understood the diagnosis and all of them were ware that it was a study and they would be followed up. These controls ensured reliability and replication. However, because the parents were aware of the follow up, there could be a threat to validity in the form of demand characteristics which in turn lowers reliability. Another study done by Bulpitt (1988) on rational adherence proved to be low in reliability due to the sampling. There were only males with hypertension so the sample was very narrow, hence not generalisable, which in turn lowered validity. Replication of the results might have been hard I the sample was different, hence low reliability. Also, cost-benefit analysis as a reason to not adhere to medical advice is personal and different for every person (individual differences), hence not standardized, which means low reliability.

The study conducted by Johnson and Bytheway (2000) was also low on reliability because of the sampling. The sample focused only in UK, which means there was high cultural relativism. And the age group was narrow as well as the study was carried out on 75+ year olds, receiving prescribed medication or 12+ months. Only 77 participated and the sample recruited was not the one that was wanted. So the sample was not generalisable, and different results might have been produced if the age group or location were different. MEASURING ADHERENCE: Adherence can be measured by Self Report methods which include open ended questionnaires. The questionnaires can be standardized, which adds a little reliability, however self reports are mainly subjective because the criteria for healthy differs from person to person and there are many individual differences. It might not be a valid way of measuring adherence since patients overestimate adherence which leads to low reliability. Another way in which adherence can be measured is through Biochemical tests (blood/urine). These tests are a highly objectified, quantified and standardized way of measuring adherence hence they are highly reliable. However, they may provide information based on recent intake of medicine, posing a threat to validity and in turn, lowering reliability. Practitioners can also estimate if the patient has been adhering to advice or not, and this depends on objective, direct observation which means high reliability. However, Canon in 1985 proved that doctors tend to overestimate patients adherence. Therapeutic outcome can also be measured to assess the patients adherence. However this is low on reliability as there might be doctors other than adhering to medical advice that made the patient healthier. Hence, low validity and reliability on the whole. Numbers of pills present in the bottle, as opposed to the number of pills that SHOULD be left in the bottle at a certain point during the treatment can measure how much the patient has adhered to medical advice. This is a quantitative way of measuring and is high in reliability. However, due to pill dumping, validity o this measure becomes low, meaning low reliability. Chung and Naya (2000) carried out a study on Mechanical ways to measure adherence and introduced and electronic device TrackCap which recorded the number of pills taken and the time. This is a very reliable way of measuring adherence as it is highly quantitative and standardized. However, pill dumping can lower the reliability. The study done by Sherman et al (2000) was not high on reliability in terms of sample as it was only male, asthma patients who were all from the US so cultural relativism was high. It was also focused on a specific age group of children. Also, an individual can go and purchase medicines from different pharmacies, so it is not valid, hence low reliability. IMPROVING ADHERENCE: Leys methods of predicting and improving patients adherence are quite reliable as they are standardized and procedural. But some of them are immeasurable or unquantifiable, for example, a patients level of satisfaction cannot be measured which makes it unreliable. Another factor that weakens reliability is that following the same procedure for all patients will hardly result in an increase in adherence in all patients because of individual differences. Behavioral methods suggested by Burke et l (1997) are also reliable in the sense that there are specific things doctors can do in order to ensure adherence such as

repetition of information, self monitoring, patient-centered approach etc. However, individual differences my lower reliability, as well as the method of self monitoring, as patients tend to overestimate adherence. However, adherence is mostly successfully achieved through these actions, which means that they are valid, and on the whole reliability is high. Individual vs. Situational: The individual vs. situational debate focuses on whether actions are driven by individuals disposition, inherent nature or whether they are governed by the situation they are in. When discussing adherence to health, both these phenomenon influence the degree of adherence present in patients. The very idea of adherence which is to determine the degree to which patients carry out the treatment of practitioners recommend, its slightly more influenced by individual disposition that situational. Agreed, a person's situations that could be the type of ailment he is undergoing does influence the efficiency of his actions, however, ultimately depends upon that individuals inherent nature i.e. if he is responsible and serious or nonchalant and lax very imperative factor that increases the dispositional influence is the realism associated with adherence due to which individuals are not isolated from families, or arent tortured or in unfamiliar surroundings which reduces the extent to which situations govern the individuals actions. Considering the factor of non-adherence, we can deduce whether it is individual influence or situational. The duration of the regiment is likely to impact adherence, as demonstrated by Sarafino's study. Chronic illnesses, which require longer periods of medication, had a 50% till 55% rate of adherence as compared to acute illness where adherence was 67%. If situation was impacting actions then those with chronic illnesses should have showed higher rates of adherence, as the situation is more severe. But ultimately it came down to how each individual has a different perspective to health and attitude and it defers greatly. This also covers the factor of the complexity of the regimen and the intensity of the illness, which as demonstrated by Sarafino's results arent enough to make people adhere. Sometimes the financial implications of treatment can defer people from adhering however, Kent and Dalgeish conducted a study where medication was free and yet only 29% children were being given medication by parents. Here, again the different natures of parents are evident as some maybe more careful and concerned than others. Patients are also likely to not adhere when they feel that the medication may not help or side effects of consumption are too worrisome. Bulpitt conducted a study, which proved that when costs of medicines outweigh the benefits, patients do not adhere. This to a certain extent complements the situational hypothesis because every individual (rational) would want to minimize cost and maximize benefit.

Self-report methods too, can be evaluated in terms of both individual and situational explanations. It depends upon the patient whether he chooses or not to tell the truth with his response. On the hand, some people may fake their responses because they want to appear socially desirable. Same goes for the therapeutic outcome. It could be explained in terms of individual hypothesis in the sense that the patient may be true to the treatment and wants to get better. This shows the individual factor because the patient wants to get better. But the situational part comes in because of the therapist. The therapist may choose answers he wants. The mechanical methods come under the situational theory because it only looks at what kind of situation the patient is in and not the individuality of the patient. There are several ways to improve adherence. These could be either situational or individual. Individual depends on personality and differs from person to person. Fear of the illnesses worsening comes from individually within a person therefore is an individual factor. Sugar coated medicines are more preferable by patients therefore improve adherence individually. Other factors that affect adherence individually are instructions on medicine bottles and rewards that can be given to patients in result of adherence. Friends and family can promote adherence by keeping positive attitudes, it also depends on the satisfaction of a patients consultation but after all these completely depend on how active a person is in such matters therefore individual. Situational depends completely on the environment and the people around so if doctors spend more time with patients helping them understand their problem with a patient centered approach or if doctors use clear sentences without medical jargons adherence can be improved situationally. Reminders and built in alarms can also improve adherence and we can say that they are situational factors since they are to do with the environment. Generalizability: Generalisabilty is when the degree to which an experiment or theory is applicable to a wider population or group. It is affected by sample size, age, race, gender etc. A feature of generalisabilty is cultural relativism, which shows that if a certain action or behavior may be relevant may be relevant to a certain culture or country it does not does not mean it will be relevant to another culture or country. Milgram (1963) : Is not generalisable since his participants were from the New Haven area Participants were recruited/invited through newspaper ads, as a result a group of random individuals volunteered for the experiment. Abu Gharib >> Friskel (2004): The participants were hardened terrorists in maximum security cells Common mentality

Cognitive structure of the participants different to general population

Banyard (1996): The idea or concept is generalisable Varies from doctor to doctor (not all doctors are the same) Assumes that most doctors want their patients to comply and adhere and make lifestyle changes such as giving up smoking. Not all patients will be willing to change their lifestyle Kent and Dalgleish (1996): The situation is generalisable as parents are in charge of their children However the medication was free and the parents were aware of the study Sample not generalisable Johnson and Bytheway (2000): Culturally relative >> U.K Low generalisablity as there was a specific age group (75+) Furthermore those who volunteered are usually those who adhere hence we cannot generalize results on to the whole population and individual were seen which makes it even more less generalisable Johnson and Bytheway concluded that routines differ from person to person hence adherence is not generalisble to the wider population. Svarstad (1976): High on generalisabilty because one can monitor the intake of medicine. So recording verbal interactions is nothing complex Waitzkin and Stoeckle (1976): It is not certain that all doctors will take 20 minutes (can take longer or less time) Dimatteo (1985): High on generalisability because a good relationship between a doctor and patient is achievable But however not everyone can achieve it or maintain the relationship Having a good relationship can lead to more adherence Sherman et al (2000): In terms of sample it is some what generalisable to the area (100 patients) Culturally relative (US) Asthma is a common disease It is quite possible that the patient may use different pharmacies rather than frequenting the same pharmacy Parish (1986): The method is generalisable as doctors can simplify the information and instructions

However not all patients will be willing to adhere despite the simplification of verbal instructions

Chung and Naya (2000): Culturally relative >> U.K Since asthma is growing the study can be generalized The patients were aware that adherence was being measured (but not how?) Trackcap: the cap can be opened several times exceeding the prescribed duration and times the medication was supposed to be taken However adherence can be measured Reasons for non-adherence: Not everyone is willing to change their lifestyle and hence would prefer to take medication rather than make a drastic change in their lifestyle. Other than lifestyle the adherence to regime (tuberculosis medication) will differ based on the age group, elderly patients are more likely to forget to take their medication or due to a hectic lifestyle where teens or adults may forget to take their medication. It is easy to assume that all patients will have the financial mean to buy the medication or even get medical care especially when the regime is long term. Rational non adherence can be quite generalisable as patients can feel that there is no visible improvements just choose not to continue taking medication or can be confused about the intake of the medication and may not adhere to the prescribed regime not everyone can remember when to take their medication. Psychosocial factors differ from place to place hence the results of these variation factors. Knowledge and beliefs is generalisable however specific beliefs are culturally relative Weisteins explanation of unrealistic optimism is generalisable despite cultural relavatism. Measuring adherence and non-adherence: Self report measures assumes that all patients will tell the truth and not make up information however not everyone will. Therapeutic outcome, it is possible that patients gets better by not taking medication other factors can improve health, not everyone will improve with taking medication. However the method is very generalisable to doctors Practioners estimate, doctors tend to over estimate adherence (caron 1985) Pill bottle counts, cannot be generalized because it assumes that all patients take their medication as per recommendation, not everyone will be willing to adhere and may dumping pills rather than taking them. Mechanical methods, can be generalized to patients and doctors but not everyone can afford mechanical methods Biochemical tests, very objective method. How can the doctor be so sure that the patient has taken the medications regularly and not before the tests are to be conducted. The patients are aware of this method to measure adherence Pharmacy estimates (2000) Improving adherence:

The adherence will vary from country to country, not everyone can afford medical treatment, socio-economic status. Use of labels and texts may not be possible if the literacy rates are low, even if the information is simplified it would not be generalisable to the general (lesser educated population) Also age plays a factor in adherence even if the instructions and information is verbally explained it is likely that the older the patient the less likely that the patient will not recall the instructions and similarly and can be applied to younger patients. Language barriers can be a unfavorable factor as it is possible the patient may speak a different language or may not understand the instructions. This means that it can be culturally relative. Using clear jargon free sentences can be very effective as few can be educated enough to understand the information. Recruiting sources of support same sociological structures, such as in Africa and Australia group cooperation Is promoted but it is not in America. (Ley) Social support can be very useful but how is it possible that everyone has the social support.