Social Behaviour: Conformity, Compliance and Adherence

AIM:
To provide an introduction to aspects of social behaviour and the role of adherence (compliance) in pharmacy

OBJECTIVES:
Explain concepts of conformity, obedience and compliance Identify the relevance of social behaviour to clinical health care settings Define the concept of adherence and identify problems associated with non-adherence (non compliance)

Definition of Conformity
Involves a change in belief or behaviour due to perceived pressure from others Can be temporary or permanent Pressure can originate from information gained, or from a desire to fit in Eg, convert from one religion to another / atheist to catholic Eg, change appearance: fashion

Three types of conformity

Compliance: people yield to group pressure to avoid punishment for non-conformity. Agrees in public, disagrees in private.
Internalization: persons opinion comes to resemble group opinion; incorporate into own value system. Public and private acceptance.

Identification: yield to pressure because desire to adopt group characteristics. Public and private acceptance, but temporary.

Conformity Asch (1950s)

Examined extent to which pressure from others can influence someones judgement. Experiment: Group of approximately 7 people (only 1 person a genuine participant rest actors who had been prepared!) Arranged so genuine participant last/last but one to answer Each participant undertook several trials Control participants also used

Findings: Control participants who undertook the test 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 trials Genuine participants conformed less if they had an ally

Factors affecting conformity

Opposition of the rest of the group (group pressure) 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)

 Wish not to make a fool of themselves (need for social respect) Difficult to maintain that you see something when others dont Were messages given off by the experimenter? (informational conformity rely upon his behaviour as guidance or to test own behaviour against)

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

Conformity - Issues arising

Group pressure causes distortion so it is possible that you can then see almost anything Group size: smaller groups considered less collusive - but pressure to conform does not necessarily increase with rising group sizes Are we genetically predisposed to social conformism? ie, a co-operation gene? Real life situations are more complex with other pressures around; things are not always so cut and dry! Collaboration may aid our survival

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

Informational conformity We gain information from other peoples perspectives as a guide to what is going on, how to answer or what to think
Normative conformity We conform to what we believe are the norms of the group in order to be accepted

Crutchfield (1955) suggested people who tend to conform 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 own personalities

Zimbardo et al (1973)
1971 Stanford Prison Experiment Mock prison Students recruited as prisoners and guards Ended after 6 days Guards became sadistic Prisoners became depressed and experienced extreme stress Participation voluntary but acted as if real and not able to leave

 Prisoners given a number learned to refer to themselves as numbers Initial rebellion. Guards cruel response Resorted to inhumane punishments, targeted ring leaders, misuse of protective equipment (fire extinguishers) etc. Uniform / sunglasses Parents on visiting day were worried, but conformed to system when asked certain questions (ie, dont you think your son is up to this?)

Advantages of conformity
Group cohesion Social control
Use to promote health related behaviour

Feel accepted and liked Clear rules and codes of conduct

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 clarify and define the situation they are more likely to rebel (b) In situations of conflict: urge to obey and urge to conform to group many people delay making decisions as long as possible. Loyalty to a group is a major deciding factor as to whether or not to obey

Obedience
To obey someone who is in a position to exert power, invoke punishments or reward behaviour. To do as one is told

Stan Milgram (1933-1984)

Set out in 1963 and 1974 to disprove Asch Experiment: Experimenter, Teacher, Student Teacher has no idea what is going on Student strapped into chair/electrodes on arms Teacher reads list of 2 x word pairs and asks learner to read them back Every incorrect answer = electric shock. Start at 15 volts and increase each time wrong answer. Student pretends to receive shocks. Teacher believes shocks being administered.

Findings:
When the teacher learned that the experimenter would assume full responsibility: Despite feeling uncomfortable teachers continued to administer shocks Two thirds of the teachers were obedient (described as ordinary people from working and professional class backgrounds) 65% of teachers punished learners to the maximum of 450 volts

 Interest in Nazi behaviour during II WW Experiment undertaken worldwide similar findings. In Germany over 85% of Teacher subjects administered a lethal electric shock to the learner Higher in other countries

Milgrams conclusion
Human nature cannot be counted on to insulate man from brutality at the hands of his fellow man when orders come from what is perceived as a legitimate authority.

Why do we need some form of social control?

Health care treatments require cooperation and long-term changes in peoples behaviour: Smoking cessation Heart disease Liver disease Renal failure Lack of co-operation will result in breakdown of treatment

 Lack of order will result in a chaotic service and lack of systems Reinforce inequalities in health Opportunities for health research lost Behaviour in health centres / hospitals ensure health and safety of visitors and patients Need to prevent ill health Reduce costs Reduce burden to NHS [waiting lists] Improve Quality of Life

Peer pressure

Punishment as a deterrent - public humiliation - fear

- Legislation - Police - Criminal Justice System - Prisons

Role Models - Peers - Idols - Media - School - Family

Individual Behaviour

Beliefs - right/wrong

Big Brother - Cameras - Being observed (Foucault)

Morals / Ethics - empathy

Adherence to Medical Advice

In terms of health compliance can be defined as the 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 advice given? Health environment very different to the experiments of 1950s and 1960s above People more likely to ignore health care advice

Estimations of adherence
Studies on adherence in health vary widely in estimation of compliance to health regimes Taylor (1990) = 93% of people do not comply (to aspects of treatment) Sarafino (1994) suggests difference between short term and long term adherence; 78% of the time for acute v 54% of the time for chronic illness Both Taylor and Sarafino looking from different perspectives Sarafino average adherence rate for taking medicines was 60% (long term and short term) BUT changes to lifestyle, eg, changing diet, quit smoking was varied and often LOW

Older people and adherence

Barat et al (2001) found older patients in one study were sometimes unclear about purpose of drugs being 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

Different types of adherence

Hussey and Giliand (1989) suggest 2 kinds of non compliance :

Unintentional pt does not have adequate understanding of condition or treatment or fail to understand advice being given
Intentional when choose to find alternative treatment or simply decide not to do anything

Concept of Rational Non Adherence

Why might a rational patient not adhere to treatment? Patient does not believe it is in their best interest to do so: eg: Treatment will not help them Or treatment will make things worse or cause further 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

 Ley (1988) non compliance for medication defined as: Not taking enough medicine Taking too much medicine Not observing correct interval between doses Not maintaining correct duration of treatment Taking additional un-prescribed medicines Implications serious Can you think of implications of above?

Factors influencing adherence

Homedes (1991) found >200 variables affect compliance. He categorised them: Characteristics of patient Characteristics of treatment regime Features of the disease Relationship between professional and pt Clinical setting

 Characteristics of patient (Leys cognitive model) Knowledge pt brings to consultation Understanding of what is said to them (medical vocabulary) Cognitive functioning (memory) Satisfaction Strategies to improve memory: wrist watches with alarms, reminder charts and aides, tear off pill calendars, special dispensers, Rx stickers, supervision

Leys Cognitive Model (1989)

Understanding

Satisfaction

Compliance

Memory

Implications for clinical practice?

Think about the way in which the physical, clinical environment is set up and about the way in which patients and practitioners behave. Curtains around a bed to talk about something serious. Do curtains block out the sound? Easier to talk to someone dont know offload personal life history if do not expect to see them again Ward Rounds: opinions merge Violence in A&E on rise (anonymity act as inhibitor?)

Issues to consider
How we communicate with patients How we monitor compliance Using in-depth assessments
Of knowledge, beliefs, values Determine risk of non-adherence