Wk. 7. Adherence .

Social Isolation

Adherence - Bissonnette (2008)

o Adherence is a complex and multifaceted
concept.
o It is a dynamic concept and is influenced by the
social context in which it is used.
o Adherence rates to prescribed regimes in chronic
illness average 50% and range from 0-100%
o Adherence context-
 Ex- Fluid restriction;
 medications; diet;
 exercise; life style modifications.

The Evolution of Terms- Adherence(cont.)

The Evolution of Terms- (cont.)
 In the early 1970’s- The phenomenon of
following directions from health care providers
was thought of as “compliance” .
 In early literature, the term compliance was used
to describe patients' obedience to
recommendations with prescribed treatment( p.
636)
 Compliance research was mostly performed by
physicians until Marston (RN) suggested that
nurses and other disciplines participate in
understanding this complex phenomenon

The Evolution of Terms- Adherence(cont.)

 Compliance was later thought to be paternalistic
and led to blaming the patient for not following
directions (not being obedient) .
 Linked to ideology of professional power of HCP
over the patient.
 Marston advocated for a more holistic approach
to client care in nursing.
From compliance to Adherence (cont.)
 In 2003, The WHO (World Health Organization)
suggested that Adherence was a better concept.
 With adherence, the patient is not passively
obeying, but rather making a decision from the
options that are offered by the HCP.
 Most common understanding- Haynes et al
(2005) defines adherence
• “ as the extent to which patients follow the
instruction they are given for prescribed
treatments” ( as cited in Bissonnette. p 636)

Nursing and adherence- Bissonnette. (cont.)

Definition of Adherence
Rose et al(2000)
‘ a collaborative effort between health care
providers and consumers to achieve mutually
derived health goals”. (Pg. 638).
Since 1970, Nursing has sought to remove non-
compliance from nursing literature because of its
paternalistic obligations.
From Adherence to Concordance (cont.)
Concordance suggests an alliance between patient
and healthcare provider based on realistic
expectations.
Concordance suggests that the patient and HCP
participate in a mutually agreed regime through a
process of negotiation and shared decision making.
An attempt to equalize power imbalance between
HCP and clients.
Interventions- MI ;

A concept analysis of adherence- Bissonnette

• Nursinag and Adherence
A concept analysis of adherence (cont.)
Attributes- predictability of disease trajectory,
personal experience, power imbalance,
agreement and pervasiveness.
decisional conflict
Antecedents-Ex-prescribed medications;
smoking cessation; fluid restrictions,
weight loss etc..
Consequences-
1.Patient related-improved morbidity; reduced
mortality, client empowerment.
2.HCP consequences-EX- ambivalence
towards client adherence behaviour
3.Health care system-Decrease in cost in
health care services

Herrera, etal (2017) Understanding Non-

Adherence From the Inside: Hypertensive
patients’ motivations for Adhering and Not
Adhering
 Adherence is understood as
- “a complex process that includes patient, HCP,
health system, illness and factors such as self-
efficacy…and visibility of symptoms” ( p 1023)
-
 Authors state that non-adherence or resistance
is not necessarily irrational but an expression of
“conflict between different internal motivations or
voices” (of the pt. (p. 1024). Some pt. voices are
coherent with adherence; others are not .

 Associated with patient values and must be

acknowledged and expressed.
 Pt focused approach.

Theories emphasizing adherence as a rational

choice -Herrera (cont.)
Many Theories-
1. The Health Beliefs Model –Most common. Tries
to understand the reason that pts do not adopt
preventative behaviours. Includes 4 key elements-
the client’s understanding of
a. perceived threat of a disease,
b. perceived benefits of health behavior,
c. perceived barriers to that behavior and
d. cue to action
2.Leventhal’s common-sense model-
Explores the clients subjective experiences of her\
his illness to understand the way they cope and
adapt to their illness

Herrera et al(2017) Understanding Non-

Adherence From the Inside: Hypertensive
patients’ motivations for Adhering and Not
Adhering (cont.)
 Patient non-adherence is not a manifestation of
irrational beliefs but an expression of conflict
between different internal positions.
 Pro-adherence Explanations-
1. self-worth
2. Fear of consequences

Herrera et al(2017) (cont.)

Anti-Adherence voices and their Adaptive
function:-
 Quality of life.
 Autonomy

The Transtheoretical Model (TTM)of Change-Paul

& Sneed
  Results from Herrera et al study indicate that
almost 96% of participants had a degree of
ambivalence.
 This support Noia and Prochaskas’s
Transtheoretical model of behavioural
change(TTM )that patient ambivalence persist
after the initial contemplation phase is resolved.
 However ongoing change requires the
motivation towards change to outweigh the
reason for against change.

The Transtheoretical Model of Change- Paul &

Sneed (cont.)
Nursing Assessment-Prochaska’s TTM model (Paul
& Sneed; Kramer-Kile. Pg. 297)
Not linear but spiral . The stage construct represents
a temporal dimension.
An approach that focuses on the client’s
understanding of his disease, illness experience;
situational circumstances etc.
Behaviour change is a process( and not an event)
and occurs over time. Ex diet modification,
HCP could use this understanding of behavior
change to guide pts adhere to treatment plans.

The Transtheoretical Model of Change- Paul &

Sneed (cont.)
A model to assess the client readiness for change in
behavior.
TTM consist of 3 dimensions
1. The 6 stages of change-.
2. The processes of change on which interventions are
based.
Experiential
behavioral.
3. The action criteria for actual behavior( Outcome)
TTM consists of behavioral and experiential processes of
change. (pg. 308)

The Transtheoretical Model of Change- Paul & Sneed

(cont.)
TTM consist of 6 stages of change.
1. Pre-contemplation.
2. Contemplation
3. Preparation
4. Action
5. Maintenance And
6. Termination

Transtheoretical Model (cont.)

1. Pre-contemplation – person not currently
considering change (in the next 6 months)
 Nurse Strategies include using Motivational
interviewing techniques;
o validating lack of readiness
o encouraging re-evaluation of current behavior
o encouraging self-exploration rather than action
o explaining and personalizing the risks

2. Contemplation Phase – person is ambivalent

about change (not considering change in the next
month)
 Strategies-
 Encourage evaluation of the pros and cons of
behavior change
 Re-evaluate group image through group
activities
 Identify and promote new, positive-outcome
expectations

Transtheoretical Model (cont.)

3. Preparation – actively making attempts at
change (within the next month)
 Encouraging the evaluation of the pros and cons
of behavior change
 Identifying and promoting new positive outcome
expectations
 Encouraging realistic, practical and small initial
steps
 Offering refers to support of action oriented
programs, (smoking cessation, weight loss,
exercise

4. Action – is actively working toward behavioral

change, modifying environment and experiences
 Helping the patient with restructuring cues and
triggers and solidifying social support
 Enhancing self-efficacy for deal with obstacles
 Dealing with feelings of loss and frustration

Transtheoretical Model (cont.)

5. Maintenance – maintain changes and prevent
relapse
 planning for follow up support
 Reinforcing internal rewards
 Discussing strategies for coping with triggers
and relapse.
6. Termination- the client has reached 100% self-
efficacy
In sum….
Ambivalence is normal (96% of pts)
Resistive behaviours aims to preserve important
personal values-self-worth, well being, autonomy
and affiliation.
Resistive behaviours linked to adverse effects of
medications , distrust of HCP, fear of stigma
associated with some diseases and client’s
perception that their problems were not to severe.
Adherence is not dichotomous but complex(pts can
adhere to one aspect of treatment but not to another
aspect.)
 Social Isolation
Social Isolation
 Definition-
 ‘as a state in which the individual lacks a
sense of belonging socially, lacks
engagement with others, has minimal
number of social contacts and they are
deficient in fulfilling quality relationships’
(Nicholson pg. 1)

 Isolation may be voluntary or involuntary.

 Involuntary- pts with MRSA;
Coronavirus(2020)

 Social isolation can be characterized by feelings

of boredom, marginality, or exclusion.
 Social isolation could be found in a variety of
illnesses and across the life cycle.

Social Isolation and Chronic illness

 Factors that contribute to social isolation include
diseases and social situations.
 Social isolation includes the client and her\his
family and requires intervention. Ex- client with
moderate stage Dementia.

 Clients experience with chronic illness is unique,

therefore interventions vary to meet the needs of
the client and\or family.

Social Isolation
We actively seek human companionship or
relationships.
 Solitude is also necessary.
 Individuals need to balance solitude with
social engagement.
 “Belonging” is a multidimensional social
construct of relatedness to persons, places or
things and is fundamental to personality and
social well-being” (Hill, 2006. pg. 121)

Issues of Social Isolation

 Basic needs for authentic intimacy remain unmet.
 Typically perceived as alienating or unpleasant

 Predisposing factors-altering physical disabilities

or illnesses etc.

 Can lead to:

 Depression
 Loneliness
 Other social and cognitive impairments-
worsening dementia, increased mortality; re-
hospitalization; increased falls.

Issues related to Social Isolation

Stigma-
The older adult
Culture
Demographics and socio-economic factors; negative
relationships with family members’
Illness factors
Healthcare perspectives
Isolation Process
The isolation process-
 Withdrawal of family\friends from client or vice –
versa.
 Self-perception of the client.

Social Isolation(SI)-Nicholson
The authors conducted a literature review. The
themes that emerged are;-
1. Variables\Factors associated with SI
2. The negative health aspects of social isolation.

Social Isolation(SI)-Nicholson
Variables\Factors that contribute to SI
a.Physical – visual \hearing impairment; health
problems; older adult population
b.Psychological- Living alone; depression; Small
social networks; Relationships with others that
contribute to negative outcomes-Ex abusive
relationships.
c. Economic-
d.Changes in roles
e.Environmental.

Social Isolation(SI)-Nicholson
Negative impact of SI on Health -Nicholson (2012)
1.Health Behavioural-
1.poor nutritional intake; ↑alcohol intake

2.Psychological-
1.cognitive decline; increased risk of suicide

3.Physiological-
1. rehospitalization, Increase falls risk; issues
related to poor body image(overweight; vision
impairment) and stigma

Social Isolation(SI)-Iovino etal

 SI captures a dense multi-dimensional construct
reflecting the structural and functional aspects of
social engagement or relationships.

 It includes
o Social Disconnectedness and
o Loneliness

Social Isolation(SI)-Iovino etal

SI consists of
Antecedents
o Predisposing factors-Age gender
o Precipitating Or risk factors-Loss, grief, stigma
Outcomes
o Psychological responses-Depression
o Clinical responses-
o Health related Behaviour-Poor self-care
Social Isolation(SI)-Iovino etal
Interventions: Counteracting Social Isolation
1. Assessment of social isolation
2. Integrate client’s culture into health care
3. Respite care
4. Support groups and other mutual aid
5. Promote Spiritual well-being
6. Rebuild family networks and appropriate use of
Communication technologies
Interventions
• Aims of Interventions:-
1.Increase moral autonomy of the client. (p 137)
2.Increase social interaction to meet the
individuals’ needs.
3.Use of repetitive strategies that are client
centered.

Outcomes
o Reduction of social isolation

o Maintenance of integrity of:

 Chronically ill person
 Caregiver(s)

o Build solutions that best deliver culturally and

personally competent care.