Toward a better understanding of treatment adherence: incorporating accountability explicitly into the social cognitive theory of adherence behavior

Introduction

Non-adherence to medication is a major cause for treatment failure and could lead to worsening of diseases (1). Up to one-third to one-half of the dermatology patients are non-adherent to prescribed medication regimens (2). Dermatological diseases are especially challenging because of the many dosage forms for common medications in addition to their various treatment modalities (3).Topical agents consist of a large portion of dermatologic prescriptions, but adherence to use of topicals is particularly poor due to reasons including patient concern about side effects, the inconvenience of application, or even forgetfulness. Considering other factors such as long-term treatment durations and complex treatment regimens, adherence to medications is understandably difficult for patients with chronic skin diseases. There are multiple interventions to potentially increase adherence, such as educational workshops, written action plans, telephone counseling, and text message or automated phone calls (4–6). Despite these interventions, adherence is often poor.

Accountability is the willingness to take responsibility for your actions. It is a theoretical concept apparent in many aspects of human behavior yet is not explicitly present in many health behavior models. Interventions that promote accountability may provide a relatively inexpensive and feasible method to promote better adherence. The utilization of health behavior models may help incorporate accountability into patient care, as these models can improve the understanding of adherence issues in chronic conditions (7,8). However, there is limited literature assessing the efficacy of health behavior models that incorporate accountability to assess adherence.

Health behavior models have been used in the past to help understand issues with adherence in chronic conditions, such as hypertension and HIV (7,8).Particularly, health behavior models help elucidate the underlying factors for human health behaviors and allow for the development of interventions to change such behaviors. The core constructs of health behavior models—such as the Health Belief Model, the Social Cognitive Theory (SCT), and the Transtheoretical model—help to explain human attitudes and beliefs that drive behaviors such as medication adherence (9). Bandura’s SCT can incorporate the concept of accountability (10). Bandura’s SCT is a behavioral model based on the idea that human expectations, thoughts, and values can alter behavior and are molded by a person’s social environment (11). Bandura utilizes key social concepts such as self-regulation, observational learning, and self-efficacy to describe a reciprocal deterministic association between individuals, their environment, and behavior (12).One of the purported core weaknesses of Bandura’s SCT is that it ignores the concepts of emotion and motivation, the latter of which is closely related to accountability. Therefore, adding this construct could potentially strengthen Bandura’s theory. We examine Bandura’s SCT as a health behavior model of adherence, the use of the model to develop and assess the impact of adherence interventions, and how accountability relates with Bandura’s SCT’s core concepts of self-regulation and self-efficacy (Figure 1).

Figure 1. The inclusion of accountability in Bandura’s Social Cognitive Theory model.

Adherence, accountability, and the SCT

Adherence is “the extent to which a person’s behavior corresponds to the prescribed medical advice of the healthcare provider.” (13) This includes actions such as following both diet and fluid intake per physician instructions and taking medications at recommended times and intervals. There are variety of factors that influence adherence such as socioeconomic status, concerns about adverse effects, and the complexity of instructions (14).These factors are often included in health behavior models. Accountability is not commonly addressed in these models.

Accountability is the perception that an individual is implicitly or explicitly held responsible for his or her actions or inactions (15). Accountability requires the expectation of being held to account either by oneself or by others. This concept can be divided into two separate categories: controlled and autonomous accountability (10). Controlled accountability is when there is a sense of pressure leading someone to accomplish a task (10). Autonomous accountability is when there is an internal desire or intrinsic motivation leading a person to accomplish a task (10). According to Bandura’s SCT, a person can engage in cognitive, vicarious, self-reflective, and regulatory processes to achieve a goal. People change themselves proactively by controlling their behaviors through thoughts, motivations, and actions (8). The expectation of “account-giving” is important in changing a patient’s behavior in the days prior to an anticipated social encounter (10).

Self-regulation leads to greater adherence

SCT focuses on one of its core concepts, self-regulation, as a source of behavioral change (16). Self-regulation is the ability to manage your behavior, thoughts, or feelings in response to the demands of a given situation. In one study involving patients with acne, a mobile application was combined with a self-regulation-based patient education module. The app served as a platform offering real-time problem solving through a live chat bot and real-time feedback from patients in between their hospital visits. This shared decision making led to increases in the Acne Self-Regulation Inventory (ARSI) scores and overall acne treatment outcomes, affirming that these patients attained better behavioral modification (17). Successfully adhering to a new behavior requires one to self-regulate by replacing a well-established behavior (e.g. lying on the couch in the morning) with a more favorable one (e.g. walking two miles in the morning) (18). Accountability may enhance the self-regulation needed to adopt these behaviors. More specifically, it could be an inherent part of maintaining assigned exercise regimens when expected to follow up weekly with researchers involved in a study. Adults in a study were asked to report their use of self-regulatory behavioral strategies on a Physical Activity Regulation Scale within the first month of a 12-month exercise program monitored by researchers (18). Reported strategies included seeking social support, time management, and self-monitoring (18). Higher usage of self-regulatory strategies was associated with greater adherence to weekly exercise classes over the following 11 months (18). Although self-regulatory strategies led to better patient adherence, this study did not assess accountability’s role. An expectation to report back to researchers after a task assignment may have given subjects an accountability which encouraged utilization of the self-regulatory strategies. Thus, incorporating accountability into the SCT as an augmentation to self-regulation and measuring accountability and its effects may help us better understand the relationship between accountability and adherence.

In another study relating self-regulation and adherence, patients who survived cancer were asked to evaluate what aspects of SCT’s self-regulation concept influenced their recommended post-treatment physical activity patterns (19). Broad, value-based goals were stated as important factors related to self-regulation (19). As a result, patients reported setting exercise goals based on personal values in their life (ex. being healthy so they can live long enough to see their grandchildren graduate from college) (19).Although not explicitly defined in this study, accountability formed from setting these goals may have helped these patients accomplish the self-regulatory process of maintaining their long-term post-treatment survivorship care plans. In the real world, patients may share their treatment plans and goals with their healthcare providers (or with friends and family). There are behavioral commitment benefits that come from announcing your goals to someone perceived as being relatively important (20). If after sharing, these patients feel that they are being held accountable to report the results of their progress to their providers, they may be further motivated to self-regulate (19). Increased understanding on how accountability supplements self-regulation may allow providers to collaborate with patients and create health-related goals that are realistic and attainable for them.

The importance of self-efficacy in promoting adherence

Self-efficacy is a person’s belief in their own ability to follow through with a task and is a strong predictor of health-promoting behaviors in populations suffering from chronic conditions, such as HIV (21). In a study analyzing the connection between self-efficacy and medication adherence in HIV positive patients, a 12-item HIV adherence self-efficacy scale (HIV-ASES) was used to assess patient confidence to adhere to medication regimens and nutritional plans (22). Higher scores on the HIV-ASES were associated with better patient medication adherence, lower CD4 counts, and viral load, when compared to patients with lower scores, suggesting the positive association between self-efficacy and patient adherence (22). The more confidence someone has in their ability to perform a task, the more likely they may be to have the confidence to simultaneously hold themselves accountable in completing the task. Another study evaluated the effects of a web-based education program on mothers with kids who have atopic dermatitis. Parent knowledge and medication adherence were evaluated through use of online quizzes and self-checklists. Ultimately, there was an increase in the mothers’ feelings of self-efficacy in treating AD, revealing the benefits of this educational intervention tool on improving adherence (23).

A patient’s self-efficacy may be enhanced through social interactions and social support (10) . A supportive social interaction between a patient and provider may also increase a patient’s sense of accountability. For example, a health care provider who encourages a patient to complete a task with regular follow-up visits could implicitly be holding a patient to account when doing so. A short time to the next follow up visit may make it seem easier to be adherent over that time interval compared to trying to be adherent over the long term, while the expectation of reporting at the follow up visit may increase accountability. Thus, increased accountability may also contribute to increased motivation to adhere. Motivation encourages more planning and strategizing which in turn could cause patients to feel more efficacious. However, whether accountability affects perceptions of self-efficacy is not well characterized (10).

In a cross-sectional study, 252 outpatient heart failure patients were asked to complete self-report questionnaires at the end of one of their cardiology checkup visits (21). The questionnaires assessed factors such as perceived social support, self-efficacy, and treatment adherence. Greater perceived social support and self-efficacy were associated with better adherence to medication, diet, and exercise (21). Providers offer emotional and informational support when they educate their patients on how to manage their chronic conditions. Offering this support could lead to a strong doctor-patient relationship that could strengthen a patient’s self-efficacy as well as their feelings of accountability toward their healthcare providers.

Limitations of interventional studies that attempt to apply concepts from the SCT

Patient adherence is a major hurdle for treatment efficacy in dermatology, and there is very limited literature explicitly assessing the role components of the SCT may have on adherence. Furthermore, studies using the SCT as a conceptual framework also tend to only address certain concepts of the theory. Our review aims to provide rationales for explicitly adding accountability into the SCT. Utilizing a validated measure of accountability in intervention studies may provide an objective measure to assess the impact of accountability on treatment adherence (24).

Conclusion

Improving adherence to medication can increase treatment efficacy in real-world settings. Basing adherence interventions on health behavior models, such as the SCT, may be a promising approach to identifying, testing and refining methods to promote adherence. Bandura utilized key social factors in the SCT theory (self-efficacy, outcome expectations, self-regulation, and observational learning) to describe how personal experiences, social experiences, and the environment influence behavior. Behavior intervention studies that measure accountability could be done to assess how accountability affects adherence in dermatology and core SCT concepts.

Patients are expected to have followed through with some form of instruction from their healthcare provider. The anticipation of a social interaction with a provider may promote patients’ sense of accountability, thus influencing adherence. More specifically, accountability could influence the self-regulatory behaviors (e.g. utilizing value-based goals) patients use to follow through with a task. Additionally, social support from providers may help give patients the accountability and self-efficacy needed to adhere to medication. Further studies utilizing a validated measure of accountability could help assess its role in different health interventions and influence on medication adherence. Ultimately, incorporating accountability into a SCT framework could facilitate development of new, more effective adherence interventions and help our patients achieve more treatment success.

Acknowledgements

None

Disclosure statement

No potential conflict of interest was reported by the author(s).

Contents of the manuscript have not been previously published and are not currently submitted elsewhere.

Additional information

Funding

Feldman has received research, speaking and/or consulting support from Sun Pharma, Amgen, BMS, Helssin, Arcutis, Dermavant, Alvotech, Galderma, Almirall, Leo Pharma, Boehringer Ingelheim, Pfizer, Ortho Dermatology, Abbvie, Samsung, Janssen, Lilly, Novartis, Regeneron, Sanofi, UpToDate and National Psoriasis Foundation. He is founder and majority owner of www.DrScore.com and founder and part owner of Causa Research, a company dedicated to enhancing patients’ adherence to treatment.