Accountability: a missing construct in models of adherence behavior and in clinical practice

Figures & data

Figure 1 The frequency of office visits in clinical trials greatly differs compared to those seen in practice.

Notes: Clinical trials typically include assessment visits often during a study. Having a visit at baseline (week 0) and weeks 1, 2, 4, 6, 8, and 12 is common. This allows the clinical researcher to report the course and effectiveness of the intervention. In the “real world”, visits typically occur every 12 weeks. The increase in office visits seen in clinical trials might indirectly increase patient adherence to the intervention. This practice lies in parallel to the flossing before the dentist and weekly piano lesson behaviors.

Figure 2 The effect of accountability in medication adherence.

Notes: The group randomized to the Internet-based survey (accountability intervention) once a week had higher rates of adherence over the 12-week study period. Reproduced with permission from JAMA Dermatology. 2011;147(10):1223. Copyright © 2011 American Medical Association. All rights reserved. Yentzer BA, Wood AA, Sagransky MJ, et al. An Internet-based survey and improvement of acne treatment outcomes.²⁴

Figure 3 Autonomous accountability versus controlled accountability in clinical practice.

Notes: (A) A provider (top)/patient (bottom) interaction; one in which the health care provider makes demands and any accountability might drive fear or shame (controlled accountability). (B) A shared partnership model in which accountability to good adherence gives the patient the opportunity to please himself or herself and the provider (autonomous accountability). Adapted from Servier medical art [homepage on the Internet]. Powerpoint image bank. Servier; 2013 [modified August 8, 2013]. Available from: http://www.servier.com/Powerpoint-image-bank.⁷²

Figure 4 The inclusion of autonomous and controlled accountability in a modified version of Bandura’s Social Cognitive Theory.

Notes: Autonomous and controlled accountability are regulated by social interactions. The possibility of needing to account for one’s actions through a social interaction functions as a behavioral amplifier. Whether the intervention is considered a form of controlled or autonomous accountability is mediated by the individual’s personal factors (knowledge, expectation, attitudes). The dashed line in the figure justifies controlled accountability as possibly having minimal impact on long-term behavioral change. Once the individual internalizes his or her sense of accountability, self-efficacy may further aid in increasing adherence. With all these different factors assimilated, enabling factors (eg, cues to action) are included as features that could potentially augment accountability and further increase adherence rates.

Table 1 Testable accountability hypotheses

Testable hypotheses	Interventional construct
Levels of accountability differ from patient–physician, patient–nurse, patient–psychologist, or other patient–provider interactions	Accountability and social support
Gender, age, and ethnicity affect the degree of accountability between patient and provider and thus affects adherence	Accountability and personal factors
Certain types of social interactions between patient and provider carry more weight in increasing accountability and adherence	Accountability and social interactions
Autonomous accountability leads to better long-term behavioral change compared to controlled accountability	Autonomous and controlled accountability

Note: Multiple testable hypotheses are suggested to further refine and understand autonomous and controlled accountability.

Table S1 Dominant health behavior models and their constructs

Model	Developed	Key concepts mediating behavior
Andersen’s behavioral model	Andersen^Citation1	• Societal factors (eg, technology, norms)
		• Health services system factors (resources, organization)
		• Personal factors (eg, illness level, age, knowledge of disease)
Health Belief Model	*Rosenstock^Citation7,Citation8	• Perceived susceptibility of condition
		• Perceived severity of condition
		• Perceived benefits of recommended action
		• Perceived barriers of recommended action
		• Cues to action (ie, aids that remind individual)
		• Self-efficacy
Information motivation behavioral skills model	Fisher and Fisher^Citation2	• Information (eg, knowledge of condition)
		• Motivation (eg, personal attitudes toward adherence, social support for the behavior, norm of how others with condition behave)
		• Behavior skills (eg, individual has skills and tools available, self-efficacy)
Integrated Behavior Model	NIMH theorists’, 2000s^Citation3	• Attitude toward outcome (ie, belief toward an outcome, evaluation of the outcome)
		• Subjective norm (ie, belief of what others think, what experts think)
		• Motivation to comply with others
		• Self-efficacy
		• Knowledge and skills to carry out the behavior
		• Importance of behavior
		• Environmental constraints
		• Habit
Self-Determination Theory	Ryan and Deci^Citation4	• Cognitive Evaluation Theory (competence, autonomy, and relatedness)
		• Organismic Integration Theory (autonomous, controlled)
Social Cognitive Theory	Bandura^Citation5	• Personal factors
		• Environmental factors
		• Behavioral factors (reciprocal determinism)
Theory of Planned Behavior	Fishbein and Ajzen^Citation6	• Attitude toward outcome (ie, belief toward an outcome, evaluation of the outcome)
		• Subjective norm (ie, belief of what others think, what experts think)
		• Motivation to comply with others
		• Self-efficacy
Theory of Reasoned Action	Fishbein and Ajzen^Citation6	• Attitude toward outcome (ie, belief toward an outcome, evaluation of the outcome)
		• Subjective norm (ie, belief of what others think, what experts think)
		• Motivation to comply with others

Note:

* Health Belief Model was originally developed by Rosenstock, but another cited reference gives a better overview of the theory.

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