Health Belief Model and Hypertension Treatment Compliance

The health belief model and compliance with hypertension treatment
Running title: Health Belief Model and Compliance in Hypertension
Pauline E. Osamor and Olanike A. Ojelabi
Pauline E. Osamor, Institute of Child Health, College of Medicine, University of Ibadan, Nigeria,
Olanike A. Ojelabi, Worcester State University, Urban Studies Department, Worcester, MA 01605, USA
Author contributions: Osamor PE, contributed to the conception and design of the study; all authors contributed to the writing and critical revision of the manuscript.
Biostatistics statement: The study was designed, analysed and data interpreted by the authors. Data available in this manuscript did NOT involve a biostatistician.
Conflict-of-interest statement: The author reports no conflicts of interest in this work.
Data sharing statement: No additional data are available
AIM: To explore the use of the Health Belief Model (HBM) in evaluating care seeking and treatment compliance among hypertensive adults in south-west, Nigeria.
METHODS: A community-based cross-sectional study was conducted using a semi-structured questionnaire to obtain information from 440 hypertensive adults in an urban, low-socio-economic community, situated in south west Nigeria. Focus Group Discussions (FGDs) were conducted with a subset of the population. The relationship between treatment compliance and responses to questions that captured various components of the HBM was investigated using chi-square tests. Content analysis was used to analyze data from the FGD sessions and to provide context to the survey responses. Data entry and management was carried out using the Statistical Package for Social Sciences (SPSS) version 11.0.

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RESULTS: The components of the HBM reflecting Perceived Susceptibility components were significantly associated with treatment compliance. On the other hand, HBM Perceived Seriousness components were not significantly associated with compliance. The main HBM Perceived Benefit of Taking Action component that was prominent was the belief that hypertension could be cured by treatment, a theme that emerged from both the survey and the FGD.
CONCLUSION: Use of the HBM as a framework is helpful in identifying perceptions and behaviors associated with hypertension treatment compliance.
Key words: Health belief model; Compliance; Hypertension; Community-based; Nigeria
Core tip: Hypertension is a major health problem in developing and developed countries, and treatment compliance for such chronic conditions is often poor. In this study, the Health Belief Model (HBM) was used to evaluate care seeking and treatment compliance among hypertensive adults. HBM proved to be a valuable framework to develop and modify public health interventions and also serves to improve treatment compliance and reduce the risk of complications.
Osamor PE, Ojelabi OA. The health belief model and compliance with hypertension treatment. World J Hypertension 2017;
Hypertension, otherwise known as high blood pressure, is a leading cause of cardiovascular disease (CVD) worldwide[1]. The proportion of the global burden of disease attributable to hypertension has significantly increased from about 4.5 percent (nearly 1 billion adults) in 2000 to 7 percent in 2010[2-9]. This makes hypertension a major global public health challenge and the single most important cause of morbidity and mortality globally. The prevalence of hypertension in Nigeria may form a substantial proportion of the total burden in Africa. This is because of the large population of the country currently estimated to be over 170 million[3,6,10]. In Nigeria, hypertension is the commonest non-communicable disease with over 4.3 million Nigerians above the age of 15 classified as being hypertensive using the erstwhile national guidelines (systolic BP > 160 mmHg and diastolic BP > 90 mmHg)[12-15].
Treatment of hypertension rests on a combination of lifestyle interventions and use of antihypertensive medication. However, poor compliance with treatment is often common in hypertension. Studies of treatment compliance have explored the role of various factors, including demographic and socio-behavioral features of patients, the type and source of therapeutic regimen, and the patient-provider relationship[16]. Yet, a common framework for evaluating such factors is often lacking. One such framework is the Health Belief Model (HBM),which has shown utility in evaluating compliance with antihypertensive medications[17-20].
Health Belief Model
The Health Belief Model (HBM) is an intrapersonal health behavior and psychological model. This model has been commonly applied to studying and promoting the uptake of health services and adoption of health behaviors[21]. Recently, a National Institutes of Health publication, “Theory at a Glance, A Guide for Health Promotion Practices” proposed that the HBM may be useful in the examination of inaction or noncompliance of persons with or at risk for heart disease and stroke[24], suggesting a natural fit for this study.
The HBM is a “value-expectancy” model [17]. It attempts to explain and predict health behaviors by focusing on the attitudes and belief patterns of individuals and groups. The modelconsists of six dimensions: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and modifying factors. While the HBM has been criticized for overemphasizing the logical order and rationality of one’s health behaviors[28], it is considered to be one of the most influential models in the history of health promotion practice[29], and has shown usefulness in predicting health behaviors among population with or at risk for developing cardiovascular disease.
With respect to care-seeking and treatment compliance, a hypertensive patient’s ability to see a physician and comply to medical treatment regimen is a function of a various factors. These include patient’s personal knowledge, benefit and perceptions, modifying factors, and cues to action[30]. Therefore, the goal of this study is to explore the use of the HBM as a framework for evaluating care-seeking and treatment compliance in hypertension in south-west Nigeria.
Uncontrolled hypertension is caused by non-adherence to the antihypertensive medication, patients understanding their drug regimens and the necessity to adhere to this regimen will help to improve their adherence, thus help prevent the complications of hypertension that are debilitating and if not prevented can increase the burden of a disease that is already on the increase[31]. Knowledge and beliefs about hypertension have been frequently examined in efforts to better understand the disparities in blood pressure control[33,34]. Relatively few studies, however, have attempted to identify individual factors associated with the adoption of hypertension control behaviors using a health behavior model as the theoretical framework. Thus, this study aims to explore the use of the HBM- an intrapersonal health behavior and psychological model in evaluating care seeking and treatment compliance among hypertensive adults in south west Nigeria.
This community-based cross-sectional study was carried out in an urban, low-socio-economic community in Nigeria. Most of the residents belong to the Yoruba ethnic group and the dominant religion is Islam. The health facilities in the community include an outreach clinic run by the Department of Preventive Medicine and Primary Care of the University of Ibadan, four private clinics and a small dental clinic. Other sources of health care in the community include Patent Medicine Vendors (PMVs) and three traditional healing homes. The study site was selected for three specific reasons: Firstly, the community has been the site of previous research studies where people were screened and therefore know of their hypertension status. Secondly, a community study approach (instead of a clinic-based approach) was chosen because selecting participants from a clinic or hospital will only select those who are attending clinic or complying, thereby introducing a selection bias and thirdly, the community has a variety of sources of healthcare located within the community, implying that residents have options when seeking healthcare.
The study is a community-based cross-sectional study which enrolled hypertensive adults (age 25 years and above) in the community. It utilized both the survey and Focus Group Discussion (FGD) to collect primary data from the respondents. The participants for this study were selected from a list of known hypertensive adults residing in the community that was developed from a previous hypertension study[35] and updated for the present study during home visits. Four hundred and forty (440) hypertensive subjects were enrolled using a consecutive sampling method.
After obtaining informed consent, subjects were administered a semi-structured questionnaire that had items on several issues, including knowledge on causes, prevention and severity of hypertension, healthcare seeking for hypertension, their beliefs and perception about hypertension and compliance with treatment including keeping clinic follow-up appointments and regularly taking their antihypertensive medications. Eight FGDs were conducted, each with 6-8 discussants. The dimensions of the HBM were operationalized as described in table 1, where each dimension was framed as a series of questions, which were asked in the survey and/or discussed as a topic in the FGD.
Data entry and management was carried out using the Statistical
Package for Social Sciences (SPSS) version 11.0[36]. Univariate analyses were employed in interpreting socio-demographic characteristics of the respondents, while a bivariate analysis was used in cross tabulating variables. The transcription of the qualitative data was carried out immediately after each FGD session. This was essential since the memory of the interviewer/note taker was still fresh and it was easier to reconcile written notes and the interview transcripts. Content analysis was used to analyze data from FGD sessions.
Socio-demographic characteristics
A total of 440 (including 287 women) respondents were studied. The ages of respondents ranged from 25 to 90 years, with a mean of 60 (SD 12) years. Most (71%) of the respondents were married and 61.4%, Muslims. Slightly over half of the respondents (51.1%) had no formal education. About half (50%) of the respondents were traders, while those who have retired and not working constituted 25.7%.
Prevalence of compliance with clinic visits and taking medication
The prevalence of self-reported compliance with clinic appointments was 77.5% and that of good compliance with treatment was 50.7% of respondents. 41.5% reported poor treatment compliance at different levels ranging from regularly missing taking their medication to fairly regularly, sometimes and rarely taking their medication.
Perceived Susceptibility to hypertension
In response to being asked what they understood by the disease “hypertension”, most respondents defined hypertension as an illness of anxiety and stress (60.9%). Nearly one in twelve (7.3%) said they did not know what hypertension meant. A few of the respondents (4.1%) believed that hypertension means “too much blood in the body”, thereby causing “tension in the blood”. Roughly two percent of respondents said hypertension “was in everybody’s blood”. A quote from one of the FGDs is illustrative:
Hypertension is in everybody’s body and blood. When we exert undue stress on our body, think too much and do a lot of wahala (stressful things), hypertension will start.
This statement clearly articulates the notion that everyone is predisposed to hypertension but the condition only becomes apparent or manifests itself when the person experiences a lot of stress. This could either mean that everyone is predisposed to having hypertension or that hypertension is hereditary.
Perceived Severity of hypertension
A large proportion 89.8% of the respondents knew that hypertension could lead to other serious health problems or complications. Only 1.1% did not affirm that it will lead to serious problem, while 9.1% did not know if hypertension could lead to other health problems. Other health problems that could result from hypertension mentioned by respondents include: stroke (47.5%); death (25.5%); severe headache (5.2%) and heart attack (5.0%). In the FGD sessions conducted, respondents were asked if they perceived hypertension to be a serious health problem. The general response was that hypertension is a serious health problem. One of the FGD discussants summed it this way:
Hypertension is a very serious sickness. It is not sickness we should take lightly. It can lead to quick death. One of my younger brothers who worked in the bank had hypertension. He suffered attacked from hypertension while in the office and before they got to the hospital, he died. Hypertension kills fast. But it has drugs that can control it and if one is not taking the drugs regularly, it will cause serious problem.
A fifty-two years old woman used her personal experience to buttress the magnitude of hypertension. She stated that:
This sickness they call hypertension is a very serious sickness. I was not taking any drugs because I did not have money to buy it and I was not worried because I was not feeling sick. In 2003, I was sick just for a week and before I knew what was happening I could not walk or move my body. I was rushed to the hospital and they told me my blood pressure was very high. I was in the hospital for almost a month and my children spent a lot of money. I am better now, but am still using walking stick because the hypertension made my body stiff. I am taking my medication always now so that I do not die quickly because it can kill.
The general perception of the respondents and focus group discussants on the complications from hypertension is that hypertension itself is a very serious health problem and that any complications arising from it could be very severe.
Perceived benefit of treatment compliance
Nearly three quarters (73.2%) of the respondents believed that hypertension could be cured with treatment. Most (72.0%) of the respondents reported that it is not good to wait until one feels sick before taking antihypertensive medication and the reason given by a large proportion (30%) of these respondents is that taking medication regularly will prevent reoccurrence of hypertension. Despite the fact that respondents believe they needed to take medication as prescribed (and not only when they are sick), only a relatively small proportion (a little above 50%) of the respondents did take their medication as prescribed.
Perceived barriers to complying with treatment
Among the respondents, 41.5% had poor compliance at different levels ranging from regularly missing taking their medication to fairly regularly, sometimes and rarely taking their medication. Of these respondents who were non-compliant with their medication, 11.4% said they felt better and therefore had no need to continue taking their medication. Only 0.5% said they were tired of taking drugs, while 6.8% stopped because of lack of funds to purchase drugs. Other factors included side effects of drugs (6.1%), forgetfulness (8.4%), busy schedule and limited medication (3.6%). A major theme from the survey and FGDs is that respondents were apprehensive of the long term effects from antihypertensive medication and the possibility of being stuck with it for the rest of one’s life or the medication causing other illness or complications. Negative feelings were elicited in some cases, as antihypertensive drugs were perceived as being damaging or “not good” for the body. The FGDs highlighted factors that hindered good compliance to treatment despite the general acceptance of the necessity to take antihypertensive medications. One of the discussant said:
I do not take my medicine every day. People do not always follow what doctor say. It is not only for hypertension, even for other sickness. If they say take medicine for five days, once we feel better by thethird day, the person will stop. Even the doctors themselves, will they swallow medicine every day?
A discussant in another session stated:
Let me tell you the truth … it is not easy to be taking drugs every day. Sometimes, we forget especially when you are rushing to go out. Sometimes we do not have the money to buy it.
Another respondent added details about what often happens as a result of the financial obstacles:
That is what we have all been trying to say. Money is the major problem. In the hospital, they will ask you to pay for ordinary card, before you see the doctor. When they write drugs for you there is no money to buy all. If you do not have money and you go to a private hospital, they will not even attend to you. That is why some people prefer to just go to chemist and buy what they can afford and some others prefer traditional medicine because you do not have to drink it every day and it is less expensive.
Cues to action
An important source of cues to action includes the individual’s cultural conditioning of available treatment options. In this study family and friends were a major source of cues to action. Overall, 19.3% of respondents reported that family members were very concerned about their hypertension while 74.8% said family members were extremely concerned about their hypertension. Also, 20.2% and 73.2% respectively reported that family members were very helpful or extremely helpful in reminding them about taking their medication. Regarding support from friends, 26.4% of respondents reported that friends were very concerned about their hypertension while 28.9% said friends were extremely concerned about their hypertension. Out of the 440 respondents, 91 and 150 (20.7% and 34.1%) respectively reported that friends were very helpful or extremely helpful in reminding them about taking their medication (Figure 1).
Hypertension is a condition of sustained high blood pressure which can only be confirmed after blood pressure measurements that meet the criteria for the condition. The cause of hypertension is not known in most cases[1] hence the term “essential hypertension”. In the present study, hypertension is perceived primarily as an illness of anxiety and stress. This finding is consistent with a previous study of hypertension in Nigeria[38] which revealed that over 60% of their respondents irrespective of the educational background believe that psychosocial stress is the main cause of hypertension. Similarly, Koslowsky et al[39] found that stress and tension were most commonly stated as causes of hypertension. Majority (more 90%) in this study believe hypertension is a serious condition and two-thirds (66%) believe that hypertension can be prevented. Contrary to findings and reports from previous studies[38,40,41], nearly three-quarters (73%) of respondents in the present study believe that hypertension is curable. Almost half of the respondents claim good compliance with respect to drug treatment and 86% claim good compliance with keeping their doctor’s appointment. Reasons for compliance to treatment include fear of the complications of hypertension and the desire to control blood pressure. Benson and Britten[42] reported that patients comply with medication regimen for a variety of reasons including perceived benefits of medication; fear of complications associated with hypertension and feeling better on medication. The latter reason is contrary to the generally held belief among physicians that hypertension is a largely asymptomatic disease[43].

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One central theme that runs through the data in this study is the issue of socio-economic status of the respondents. This suggests the importance of considering other variables that can help form individual’s perception including health care costs and some sort of lay consultation that takes place before they resolve to take a recommended health action[27]. Financial hardship is a barrier which should not be ignored as it is a contributory factor to noncompliance. This finding corroborates the observed association between poor compliance, ignorance and lack of funds for purchase of drugs[44]. Failure of patients to keep scheduled appointments is an important obstacle to the provision of effective healthcare. By missing appointments, individuals deprive themselves of professional services. Interestingly, 77.5% of the respondents in this study claim they comply with keeping their follow up clinic appointments every time. Several studies have investigated HBM and appointment-keeping for chronic disease management. Nelson et al[20] and also Landers et al[45] found HBM variables to be unrelated to keeping clinic appointments for hypertension.
Social support networks are important in the long-term management of chronic conditions such as hypertension, which require a radical and life-long change in the lifestyle of the affected person. In this study, those who had support from friends or family members (concerned about their illness, giving reminders about medication) showed better treatment compliance than those who did not, although this difference was greatest for those that had the support of friends. This is an important finding and is consistent with what has been reported for multiple chronic diseases in several parts of the world[46].
A summary of the major findings in this study in the context of interpreting compliance using the significant components of the HBM shown in Figure 1 suggests that HBM Perceived Susceptibility components tested were significant predictors of compliance. On the other hand, HBM Perceived Seriousness components were not significantly associated with compliance. The main HBM Perceived Benefit of Taking Action component that was prominent in this study is the belief that hypertension can be cured. This is a recurring theme in all the components of the study (survey and FGD) and most respondents believed that taking the medication for some time led to a “cure” and one could stop taking medication. This finding agrees with studies of Kamran et al[47], which showed a relationship between HBM constructs and treatment compliance. The constructs that were significantly showing relationship in their study were perceived susceptibility, perceived benefit of using the medicine and perceived barrier to treatment. This has major personal and public health implications because hypertension can only be controlled (not cured) and stopping medication can lead to complications. More importantly, it highlights the discrepancy between healthcare providers and their patients in the perceived goal of treatment since the former are working towards control while the latter believe compliance can lead to cure.
Most of the HBM Barriers to Taking Action components emerged during the FGD sessions. These barriers are practical issues that loom large and prevent the patients from making optimum use of the hospitals and medications that are available. In other words, the option of a university teaching hospital is available but is not accessible because of costs and inconvenience. Similarly, known medications that work well in hypertension are available but the costs are too high for the patients to comply with the prescriptions as written. It is noteworthy that believing that one can stop taking the medication after some time can also serve as a barrier to compliance because the individual now believes there is “no need” for more medication.
Another major finding from this study is that HBM Cues to Action are extremely important in predicting compliance with hypertension treatment in this community. These cues are centered on patients having family members and/or friends who are concerned about the individual’s health and treatment. This finding is important because, as noted by Harrison et al[48] in a meta-analysis, cues are often not included in Health Belief Model studies. Indeed, these authors limited their review to articles to the four major components of the HBM (susceptibility, severity, benefits and costs) because in their words: “Cues to action have received so little attention in empirical studies that we excluded this dimension”. However, the findings of this study shows that cues are an important dimension in these types of study. While the specific cues that are important may vary between locations, cultures, and environments, they emphasize the social context in which health behavior takes place. As expected, attending clinic regularly is an important predictor of compliance in the present study. It provides an opportunity for multiple cues that can improve compliance, including blood pressure checks, discussing actions to control blood pressure, and reminders to take medication.
Components of the HBM show variation in association with treatment compliance for hypertension in this Nigerian community. The findings provide useful baseline data for future studies of the Health Belief Model in hypertension and other chronic conditions in similar societies.
Strength and limitations of the study
Strengths of this study include: the use of both survey and FGD methods; inclusion of a large set of variables and focus on the components of the HBM to a non-communicable disease (hypertension) in a developing country context. A potential limitation is that the study did not formally investigate the modifying factors dimension of the HBM. Nonetheless, the findings provide clues to care-seeking and compliance issues, while suggesting potential intervention points (e.g. breaking the cost barrier, including social networks in treatment plans) that could be further studied and tested.
Ethical Approval
Ethical approval for the study was obtained from the Joint University of Ibadan /University College Hospital Ethical Committee.
The authors are grateful to the study participants and community leaders of Idikan community, Ibadan. The input of Dr. Bernard Owumi and Dr. Patricia Awa Taiwo of the Department of Sociology, University of Ibadan, is hereby acknowledged.  

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Compliance in International Relations

This paper seeks to address whether state cooperation via formal international institutions may best be understood as a spectrum of compliance rather than binary states. Prevailing perspectives on state compliance to its international obligations generally presupposes binary state of compliance – in which states adhere to its commitments – and non-compliance – in which states do not adhere to its commitments. This construction proves problematic as it disregards state intention; states may act in good faith to comply with its international commitments, yet fail to meet these commitments do to exogenous variables. While largely ignored by realists, liberal institutionalist and constructivist literature has sought to address this issue and provides a limited descriptive framework to understand non-binary states of compliance. While these frameworks are useful for understanding complexities inherent in defining non-compliance, these do not fulfill the stated objective of this paper: reframing compliance as a spectrum rather than binary states.
Intro, Research Question
Chayes, Chayes and Mitchell (1998) illustrate the limitations of a binary compliance definition through a good-faith description of the environment treaty non-complier state. Environmental treaties attempt to impose regulatory requirements, not only on states, but on subsidiary private sector actors. Exogenous factors to environmental treaties may limit a state’s ability to enforce these regulatory requirements on private sector actors, resulting in a state of non-compliance. The binary definition of compliance disregards the good-faith in which a state enters an international agreement and further ignores the exogenous factors that limit state compliance. A binary definition of state compliance provides no relevant information by which one can determine whether non-compliance is a deliberate violation of state commitment or due to exogenous factors to the agreement. In order to provide a more descriptive framework to determine the nature of non-compliance, this paper posits that it is necessary to redefine compliance as a spectrum such that the level of compliance (C) can be defined: C∈[0,1], where 0 is perfectly non-compliant, and 1 is perfectly compliant. This definition of compliance may provide greater insight into the nature of a state’s non-compliance by providing information on the extent of non-compliance to treaty obligations.

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While disregarded by realists, the nature of compliance has been explored in liberal institutionalist, and constructivist literature. This literature has provided some insight into the complexity inherent in defining compliance; yet, it falls short of providing a definition of compliance which allows for further understanding of the nature of state non-compliance. In fact, constructivist literature fails entirely in this endeavor as it proposes that compliance is a social construction impervious to a general analysis. While a compliance spectrum does not fully illuminate exogenous factors to international commitments, within this definitional framework they exist as lurking variables upon which further scrutiny can be given. Furthermore, while not a conclusive determinant of state intention, a spectrum of compliance allows for consideration of good-faith through a quantitative estimate of how compliant states are with their international commitments. This is preferable to the existing compliance binary which fully disregards good-faith in state action.
Furthermore, this research aims to provide increased context and understanding of inter-state cooperation via international institutions. The creation of a compliance spectrum allows for observation of trends both in terms of a state’s tendency towards compliance or non-compliance and in terms of a state’s historical capacity to fulfill its international obligations. This contextual understanding of a state’s compliance may inform how commitments are enforced by institutions on a state-by-state level as well as inform the formulations of new inter-state agreements to take into account trends of compliance.
Literature Review
For realists, state power is the primary factor that governs interstate relations. Consequently realists find contention in the notion that formal international institutions play substantial role in determining state behavior (Boyle, 1980). Consequently, states are assumed to successfully comply only under conditions of shared interests or hegemonic coercion, and only in so far as compliance is congruent to a state’s foreign policy interests (Morgenthau, 1985). Under this formulation, a state’s international commitments and the formal institutions present to enforce them are indeterminate of state decisions to comply with their commitments (Aron, 1981). The primary grievance realists pose to compliance and enforcement literature is the lack of coercive power of formal international institutions to ensure state compliance. Furthermore since states possess jurisdiction to interpret provisions of international agreements, realists contend that states have no incentive to comply with burdensome past commitments (Morgenthau, 1985). Realist formulations of international cooperation predominantly focus on state power and interest and generally disregard ideas concerning compliance. Since it is the aim of this paper to propose a redefinition of state compliance, it can be said that realists are pursuing an altogether different project and are consequently of no interest to our current undertaking.
Liberal institutionalists formulate international agreements as a means by which states are able address common issues which cannot be addressed through unilateral action (Bilder, 1989). Within this formulation, compliance is largely due to state reputational costs. States expect higher costs in the long term if they are non-compliant with their short term commitments. Consequently, formal international institutions can be understood to amplify the reputational consequences of non-compliance by increasing transparency of state behavior (Keohane, 1984). Greater transparency and the potential for reciprocity in international agreements serve to increase compliance through iterative engagement amongst the same state actors. These conditions stabilize a state’s expectations concerning member state behavior and increase confidence that these states will comply with their international commitments. This in turn incentivizes a state to also comply with its international commitments (Garrett & Weingastt, 1993).
Liberal institutionalist literature generally privileges the state as the sole agent of compliance. However the Downs and Rocke (1995) study of General Agreement on Tariff and Trade (GATT) rules illustrates how exogenous factors to the agreement, including domestic politics and interest group demands, play a major role in determining the degree of compliance one could expect from GATT signatories. Downs and Rocke illustrated that negotiating states agreed upon weak enforcement mechanisms due to uncertainty of future interest group demands. These uncertainties lead to the adoption short term obligations and less strict enforcement mechanisms thus reducing the cooperation demands for GATT states. In order to achieve compliance, states must address exogenous domestic factors to the agreement. This illustrates the primary failing of Liberal institutionalist literature which generally overemphasizes the roles of formal institutions and states over domestic factors.
Further literature examines domestic administrative and technical incapacities as a source for non-compliance. Jacobson & Brown Weiss (1995, 1997) illustrated that the determinant variable for successful compliance with environmental accords was administrative capacity. Domestic factors such as a skilled labor force, financial resources, and domestic legal authorization were crucial in order for a state successfully comply with environmental accords. In order to address these administrative incapacities, independent agencies may facilitate compliance by providing necessary resources to reach regulatory standards. Within this formulation state cooperation via international institutions serve not only promote compliance and enumerate state commitments, they also serve to enable states with administrative and technical incapacities to meet compliance standards (Hans et al, 1993).
While Liberal institutionalist literature considers the intentions of states engaging in international agreements as well as the exogenous factors that determine a state’s compliance success, Liberal institutionalist literature still adopts a binary definition of compliance that disregards these factors. The complexities Liberal Institutionalists perceive within state compliance do not inform and are not represented in their formulation of compliance. This paper seeks to move beyond the work of liberal institutionalists and redefine compliance such that these complexities are integrated into our understanding of state compliance.
Constructivist regime theorists formulate an understanding of state compliance in terms of international rules, norms and agreements. Rather than focusing on conditions of non-compliance constructivists posited that analysis should endeavor to understand how state behavior is interpreted by other states as well as how these behaviors are intended by the state actor. For Constructivists , the most relevant inquiry into state compliance was how states rationalized their actions and whether other states were receptive to its rationale (Kratochwil & Ruggie, 1986). By this formulation, seemingly conflicting actions of state actors could be derived from similar principles and norms. Compliance is therefore not an objective fact; rather it is a subjective social construction.
The implications of this theory are that 1) normative concepts such as fairness determine a state’s compliance decisions and 2) formal international institutions can be undermined- states become non-compliant- if they lose legitimacy with member states (Kratochwil & Ruggie, 1986).
The relationship between legitimacy and compliance has been explored multiple constructivist authors. Legro (1997) posited that understanding the attributes of a rule its specificity and durability- is the most effective way to determine the causal effect norms have on compliance outcomes. This theory argues that the clearer, more durable and endorsed a rule or norm is, the greater effect it will have in promoting state compliance. Other constructivists like Fisher (1981) argue that rules will promote compliance when they adhere to shared values and morals. Under this formulation the more widely held the rule the more compliant state actors will be to the rule. Keck & Sikkink (1998) attempting to advance compliance in the human rights theatre assert that prohibitions that will successfully engender interstate compliance are those prohibitions that embody cross-cultural norms such as protection of innocent groups nd ensuring bodily integrity.
For constructivists formal international institutions play a significant role in legitimating particular rules and fostering a sense of obligation amongst states. Tacsan (1992) exemplifies this through his discussion of the International Court of Justice, which he argues is a location where norms and normative values converge through the ICJ’s multilateral bargaining process. The convergence of norms at the ICJ has resulted in the development of norms concerning self-determination, non-intervention, and collective self-defense were the primary normative expectation that informed Central America’s peace settlements.
Constructivist literature utilizes a normative approach in its study of compliance. Constructivists assert that norms of appropriateness, ideas, and values are the determinant factor to state compliance. Furthermore, constructivists assert that international commitments, and consequently compliance, are social construction that can only be understood through an intersubjective framework, and are imperious to a general analysis. By contextualizing compliance in a case-by-case basis, you are effectively left with no standard definition of compliance by which one can determine what constitutes non-compliance. The lack of a satisfactory definition of compliance in constructivist and liberal institutionalist literature that considers both intentions and trends is in need of formulation.

Milgram and Zimbardo’s Experiments on Obedience and Compliance

The Milgram Obedience experiment, which is also known as the Obedience to Authority Study, is a very well known scientific experiment in social psychology. The concept of the experiment was first discussed in 1963 in the Behavioral Study of Obedience in the Journal of Abnormal and Social Psychology by Yale university psychologist Stanley Milgram and later in his 1974 publication Obedience to Authority: An Experimental View. The purpose of this experiment is to test the power of human nature to resist the authority of an authority who gives an order against their conscience. This experiment was regarded as a typical one about the obedience experiment, and it had strong repercussions in the social psychology circle.

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The following is some basic processes of the experiment:Milgram first advertised in the newspaper for participants and paid them $4.50 for each trial. Forty people, ranging in age from 25 to 50, were recruited to take part in the experiment. They were told they would take part in an experiment to study the effects of punishment on students’ learning. In the experiment, two people were paired, one as a student and one as a teacher. Who shall be the student and who shall be the teacher shall be determined by lot. The teacher’s task is to read the paired related words. The students must remember the words. Then the student need to choose the correct answer from four opinions after teacher presents a word. If the choice is wrong, the teacher pushes the button and gives the students an electric shock as punishment.
Due to prior arrangement, each group actually had only one participant, and the other was an assistant of the experiment. As a result, the participants were always teachers and the assistants were always students. At the beginning of the experiment, an assistant and a participant were placed in two rooms separated by a wall. Electrodes were attached to the students’ arms so that they could be given an electric shock if they made a bad choice. Moreover, the experimenter strapped the “student” to a chair, explaining to the “teacher” that it was to prevent him from escaping. “Teacher” and “student” cannot see each other directly, they use the telecommunication transmission way to keep in touch. There were buttons on a total of 30, imposing electric penalties are marked on the each button it controlled by the voltage, starting from 15 volts, increased to 450 volts in turn. In fact, no shock was actually implemented, in the next room, the experimenter turned on a tape recorder, which played a pre recorded scream paired with the action of a generator. However, to make the participants convinced, they first received a 45-volt electric shock as an experience. Although the experimenter said the shock was mild, it was too much for the participants to bear.
During the experiment, the “student” made many mistakes intentionally. After the “teacher” pointed out his mistakes, he gave electric shock immediately. The “student” groaned repeatedly. As the voltage rises, the “student” shouts and scolds, then begs, kicks and hits the wall, and finally stops yelling, seemingly fainting. At this point, many of the participants expressed a desire to pause the experiment to check on the students. Many participants paused at 135 volts and questioned the purpose of the experiment. Some went on to take the test after receiving assurances that they were not liable. Some laughed nervously as they heard the students scream. When a participant indicated that he wanted to stop the experiment, the experimenter responded in the following order:

Please continue.
This experiment needs you to continue. Please continue.
It is necessary that you go on.
You have no choice, you must go on.

If, after four times of prompting, the participants still wanted to stop, the experiment stopped. Otherwise, the experiment will continue until the punishment voltage applied by the participants increases to the maximum 450 volts and continues for three times.
In this case, 26 participants (65% of the total) obeyed the experimenter’s order and persisted until the end of the experiment, but showed varying degrees of nervousness and anxiety. Fourteen others (35% of the total) rebelled and refused to carry out the order, saying it was cruel and immoral. After the experiment, Milgram told the truth to all the participants in order to eliminate their anxiety.
Surprisingly, before the experiment, Milgram had asked his fellow psychologists to predict the outcome of the experiment, and they all agreed that only a few people — 1 in 10 or even 1 percent — would be willing to continue punishing until the maximum volt. As a result, in Milgram’s first experiment, 65 percent of the participants (more than 27 out of 40) reached the maximum 450 volts of punishment — even though they all showed discomfort. Everyone paused and questioned the experiment when the volts reached a certain level, and some even said they wanted to give their money back. None of the participants persisted in stopping before reaching 300 volts. Milgram himself and a number of psychologists around the world have since done similar or different experiments, but with similar results. Dr Thomas Blass of the university of Maryland, Baltimore county, repeated the experiment many times and came up with the result: Regardless of the time and place of the experiment, a certain percentage of participants — 61 percent to 66 percent — were willing to apply a lethal voltage to each experiment.
As Philip Zimbardo recalled, due to little awareness about the experiment, participants who didn’t reach the highest volts didn’t insist that the experiment itself should end, didn’t visit the “student” in the next room, and didn’t ask the experimenter for permission to leave.
Milgram stated in his article The Perils of Obedience (1974) that the legal and philosophical views of obedience are very significant, but they say little about the actions people take when confronted with practical situations. He designed this experiment at Yale university to test an ordinary citizen’s willingness to inflict much or little pain on another human being just because of the orders given by a scientist assisting the experiment. When the authority that led the experiment ordered the participant to harm another person, even more so than the screams of pain the participant had heard, the authority continued to order the participant most of the time, even though the participant was so morally disturbed. Experiments have shown how willing adults are to submit to almost any measure of power, and we must study and explain this phenomenon as soon as possible.
The experiment itself has raised ethical questions about the science of the experiment, which puts extreme emotional pressure on participants. Although the experiment led to valuable discoveries in human psychology, many scientists today would consider such experiments unethical. A later survey found that 84% of the participants at the time said they felt “happy” or “very happy” to have taken part in the experiment, that 15% of the participants chose to be neutral (92% of the participants did the post-survey), and many of them later thanked Milgram. And Milgram kept getting calls from former participants who wanted to help him with his experiments again, or even to join his research team. However, the experience of the experiment did not change every participant for life. Many participants were not told the details based on modern experimental standards, and exit interviews showed that many participants still did not seem to understand what was going on. The main criticism of experiments is not the ethical controversy of their methods, but the significance they represent. A participant from Yale university in 1961 wrote in the magazine of the Jewish Currents: when he wanted to stop in the middle of as a “teacher”, is a suspect to “the whole experiment may be just designed, in order to test an ordinary americans will follow orders against conscience – like Germany during the Nazi period” and this is one of the purpose of the experiment. Milgram, in his book The Perils of Obedience (1974), said, “the question we face is how the conditions we create in the laboratory to bring people to power are related to the Nazi era that we deplored.”
An ordinary person, just to get his work done, without any personal malice or enmity, can actually be a tool for a horrific process of destruction. Moreover, when their work makes the destruction process obvious, when the tasks they are asked to perform do not conform to their own moral values, most people are unable to resist the orders of leaders.
On the basis of the first experiment, Milgram further discusses what factors are involved in the generation of obedience behavior. He explored the manipulation of experimental conditions from the subjective and objective dimensions of obedience. The objective conditions of Milgram’s operation include many.
Firstly, it is the distance between “teacher” and “student”: The distance between teachers and students is divided into four grades, with 40 participants participating in each grade. After analysing the data, the result shows that the closer the “student” is to “teacher”, the more the participant refuses to obey, and the farther the distance is, the easier the participant is to obey. Secondly, it is the relationship between the experimenter and the participant. The relationship was divided into three situations: the experimenter and the participant were face to face together; the experimenter left after explaining the task and kept in touch with the participant by telephone; the experimenter was not present, and all instructions were played by a tape recorder. The results showed that in the first case, the participants obeyed three times more than in the other cases. Thirdly, it is the status of the experimenter. The results showed that the higher the status of the experimenters, the higher the number of the “students” who were tested with the strongest electric shock.
In addition, there are many factors affecting obedience, which can be summarised into three aspects:

the sender of the order. His authority, whether he supervises the execution of orders, affects obedience.
the executor of a command. His moral level, personality characteristics and cultural background will also affect his obedience to orders.
situational factors. For example, whether someone supports his refusal behavior, what is the example behavior of those around him, how is the reward structure set, how is the feedback of his refusal or execution of orders, etc., will also affect the individual’s obedience behavior.

In conclusion, just like some social psychologists believe that there are two main reasons why individuals obey behaviors. The first is legal power. We usually think that in certain situations, society has given certain social roles more power, and it is our duty to obey them. For example, students should obey teachers, patients should obey doctors, etc. In the laboratory, participants should obey the experimenter, especially the unfamiliar situation strengthens the participants’ readiness to obey the orders of the experimenter. The second is the transfer of responsibility. In general, we have our own sense of responsibility for our own behavior, but if we think that the responsibility for a certain behavior is not our own, especially when a commander takes the initiative to take responsibility, we will think that the leader of the behavior is not our own, but the commander. Therefore, we don’t have to be responsible for this behavior, so there’s a transfer of responsibility, and people don’t think about the consequences of their behavior.


Similarities and Differences between Concepts of Compliance

Compliance, obedience and conformity are the three forms of social influences processes which can affect the way an individual behaviour in a social setting, all the way from following fashions and unwritten social norms, to committing immoral acts just because the individual was ordered to do so by someone with an authority position. Compliance is when an individual gave in to an expressed request from another person or other people, whereas obedience refers to doing as told by someone and as for conformity is giving in to group pressure or going along with the majority. Conformity is peer pressure, the individual was not asked to do, he just do it to go along with everyone else because the individual wants to be accepted. Obedience on the other hand comes from authoritative people such as teachers and policemen. The individual obeys the instruction that came from these authoritative figures. This paper aims to look at the similarities and differences between the concepts of the three types of social influences. And also to look specifically at those factors that will affect each of the three. In conclusion, it was found that two of the forms of social influences are very similar to each other and almost to the stage of interchangeable, while the other stands alone with influencing factors that are different from the other two.

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Social influence is the process whereby one or more people presence, whether real or imaginary can affect thoughts, feeling and behavior of individual under extreme or no pressure at all or even persuasion. There are three areas of social influence, namely, conformity, compliance and obedience. This purpose of this paper is to compare and contrast the concepts of compliance, obedience and conformity and also to look at the factors that influence each one of them to see the differences and similarities between them. It seems that in conclusion, conformity stands apart from compliance and obedience, which share more similarities than differences.
Compliance happened frequently in everyday life, for example, when an individual performed a task when asked to, this individual is complying with a request. The unwritten law of the group and members is to stick to the rules in order to be considered as being part of the group, this is considered the most important characteristic of compliance.
Compliance refers to a form of social influence in which an individual gave in to expressed requests from another person or other people (Vaughan & Hogg, 2011). This is also known as social compliance. There were many research carried out to find out what really influence compliance.
There are five factors or strategies that influence compliance (Jones & Pittman, 1982). One of the factors, intimidation, is to generate fear in order to let the other to think that you are dangerous. The second factor is known as exemplification, in which an individual attempt to make others to look upon him as a morally respectable person. The third factor is known as supplication in which an individual make others believe that he is pitiful, helpless and needy. The fourth factor is self-promotion, in which an individual attempted to generate respect and confidence by convincing others that he is competent. Ingratiation is the last factor whereby an individual will attempt to get others to like him before subsequently making request for others to comply with him. Another strategy that increases compliance is the use of multiple requests instead of a single request. Multiple requests uses a setup or softener by first making a ‘false’ request and follow by the real request. There are three classic tactics, known as the foot-in-the-door, the-door-in-face and low-ball (Cialdini & Goldstein, 2004). In accordance to foot-in-the-door tactics, an individual would most likely to agree to a larger request when an initial smaller request has been agreed. As for the-door-in-face tactics, a person would ask for a big favour at first and then followed by a smaller second favour. The low-ball tactics is based on the principle that one will agree to accept higher increase once he committed to an action. Compliance is not only influenced by persuasive tactics used as mentioned but also by the power the requester has. There are 6 basic powers, the reward power, coercive power, informational power, expert power, legitimate power and referent power (Raven, 1993). Once there is compliance, the reward power states that rewards will be given. Coercive power states that punishment will be threaten or given when there is non-compliance. The influencer will have the informational power if the targeted individuals thought that the influencer have more information than themselves. And individual process the legitimate power if the person is an authorized person from recognized organizations with the authority give commands and make decisions. Lastly, referent power refers to the attraction to or respect the influencer (Vaughan & Hogg, 2011).
Obedience refers to a form of social influence in which a person gave in to express instructions or orders from an authority figure without question. Or simply defined as being simply acting in accordance with rules or orders (Vaughan & Hogg, 2011). Obedience started at a very young age, for example, individual tends to obey orders or instructions coming from parents or school teachers and when the individual steps into the social to work, he tend to obey his boss. There are also others who are the followers of spiritual leaders and they sees him as a legitimate authority and will tend to obey his orders even if it is wrong. The authority that these individual have are given by the society to them. In most case, obedience is a trait that human developed out of respect or fear. Obedience is a trait that allows human beings to obey laws, belief in God, and follow social norms. Obedience is a virtue that allows schools to be great learning centre as otherwise it would be difficult for a teacher to conduct a class if some students refuse to follow or take orders from the teacher.
Experimental research into this was pioneered by the US psychologist Stanley Milgram (1963) who conducted a series of experiments, in which, 65% of the participants administered what they believed to be extremely painful and possibly deadly electric shocks to an innocent victim, who was actually a confederate, when instructed to do so by an authoritative experimenter even though many of the participants became agitated and angry at the experimenter. The level of shock that the participant was willing to deliver was used as the measure of obedience (Vaughan & Hogg, 2011).
However, some factors affecting the level of obedience had been identified by the Milgram’s experiment. The of the location is one of the factors. In the experiment, when conducted at Yale University, a trusted academic institution, led to many participants to believe that the experiment would be safe and people also tend to obey others if they recognize them as ethical personality or legal authority. In this case, the experimenters were perceived as from a trusted academic institution. Obedience also increases when the personal responsibility of the carrying out the task decreases. In the study, experimenter wore a uniform or laboratory coat which symbolized higher status of the person thus influencing the increasing obedience. Peer support also influence the level of obedience, if the person have the social support of their friends or the presence of others that disobey the authority, this will reduces the level of obedience. Proximity of the authority will also affect the level of obedience. It is easier to resist orders or instruction from long distant than close by (Vaughan & Hogg, 2011).
Conformity is a trait that makes people change their behaviour to fit social norms and behave according to the wishes of others (Crutchfield, 1955). In a group, people change their beliefs and attitudes to match them to the majority of the people within the group. When an individual conform, he is also being obedient and in order for people to comply, there must be a perceived authority within the group who can influences the behavior of member of that group. Without this authority figure, it is hard to make members of a group to conform. And if a member of this group fails to conform, he faces the punishment of the authority and in turn loses his credibility which is so important for him. It is this pressure that makes people to conform (Cialdini & Goldstein, 2004).
There are much experiments (Asch, 1951; Aarts & Dijksterhuis, 2003) done to show that when confronted by social norms individuals will often adjust their behaviour to closer approximate of the perceived norm.
In the Aarts & Dijksterhuis (2003) experiment participants who were exposed to pictures of a situation where there is a social expectation of silence, a library, were later quieter on a pronunciation task than the participants who were shown pictures of a normally noisy situation, example, a railway station. This showed that the normative behaviour of being silent had been unconsciously activated in those subjects who saw the library picture.
The Asch (1951) experiment involved subjects performing a perception task, saying which of a selection of lines matched a control line in length. Unknown to the subject the other participants in the room were all confederates, and the seating was arranged so that the confederates would each give their answer to the trial in turn, with the subject giving their answer last or second to last. On certain trials the confederates would all give the same incorrect answer to the question. The experiment showed that around 76% of the subjects would conform to the incorrect answer at least once. After the experiment ended, participants were asked on why they conformed to the incorrect majority during the trials. All participants reported feeling uncertainty and doubt as a result of the differing opinions between themselves and that of the group. The majority of participants admitted knowing that they saw the lines differently to the group but thought they may have perceived it wrongly and that the group actually is right. Others simply went along with the group in order not to stand out or appeared as stupid and to avoid any conflict with the rest. A small minority reported actually seeing the lines same as what the group did. It seems that human beings conformed to avoid social disapproval and it also appeared that nobody wants to be the only outstanding person to voice a different answer or opinion (Asch, 1951).
From the study done by Asch (1951), there were factors found to influence the increase or decrease in conformity. First of all, conformity seems to increase as the size of the group grows and when the group size is small, with only four to five person, there seems to be lesser effect. And when it comes to difficult task, participants who were uncertain of the answer will almost certainly tends to look at others in the group for conformity. Conformity also increases when the status of the group is higher or more knowledgeable and almost always decreases when individuals were to provide answer privately without the presence of the rest of the group. The study suggested that individual conformed so as to go along with the majority as the individual are concern of how they appeared in the eyes of others.
It is interesting to note that while conformity emphasizes on the power of the majority to force the minority to conform their behaviour to the group’s expectations of how they should act, there are research being done recently on minority social influence (Vaughan & Hogg, 2011). Minority social influence refers to a form of social influence in which the deviant minority rejects the group norms and influence the majority to change their behaviour. Given this change in the process, researchers have begun to explore how certain kinds of minorities can persuaded the majority to change their behaviour. The research shows that a minority which presents its point of view in a confident, consistent, yet flexible manner can overcome an uncertain or uninvolved majority.
Differences between Obedience, Conformity and Compliance
The differences between obedience, conformity and compliance is that, in obedience, there is a perceived difference of status between the one who gives the instruction and the individual who obeys without question. And in conformity, it is the individual’s fear of social disapproved and being different from the group. On the other hand, it is peer pressure that brings in the conformity among the members of a group. Conformity is also affected by whether the individual’s culture is orientated towards individualism or collectivism (Bond & Smith, 1996), however, compliance and obedience are less likely to be affected by this particular factor.
Similarities in Obedience, Conformity and Compliance
The concepts of compliance, obedience and conformity, are all interrelated and shared with some similarities between them. Both compliance and conformity have shown to be improved when there are positive inter-personal attitudes (Gordon, 1996). Likewise, having attention to incidental similarities between the requester and the individual who obeys has shown to increase compliance (Burger et al., 2004) by improving the relationship between the two. Similarly cohesiveness of the group has been shown to affect the conformity (Crandall, 1988).
Compliance and obedience also have a similarity in the foot-in-the-door approach. Studies have shown that having the participant commit to a small act initially, such as accepting a taster at a supermarket, can lead to improvement in compliance to further request in the later stage (Freedman & Fraser, 1966). This is also reflected in the Milgram (1963) experiments on obedience where the subject built up from smaller shocks to larger ones.
Compliance, obedience and conformity are all subjected to the effects of informational social influence. Conformity is obviously based on informational social influence and studies (Cialdini, Kallgren, & Reno, 1990, 2000) have further provided evidence for the normative focus theory; that the saliency of the social norm has a significant correlation to conformity. Compliance is subject to informational social influence under Cialdini’s category of social validation (Vaughan & Hogg, 2011), which targeted on the individual’s desire to fit with the actions and expectations of the society. Studies have also shown that the rate of obedience to destructive commands drops sharply if the participants are reminded about the amount of responsibility that will falls on their shoulders (Hamilton, 1978).
In conclusion, there are indeed many common aspects between compliance, obedience and conformity, however, there seems to be more similarities between compliance and obedience than those shared by conformity.