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Health Notions, Volume 1 Issue 1 (Month-Month 2017)

ISSN 2580-4936

URL of this article:

Combining Protection Motivation Theory to Predict Compliance Behaviour in

Healthcare's Medical Record

Rahmi Damayanti1(CA)
Department of Health Administration and Policy, Public Health Faculty, Airlangga University, Indonesia; (Corresponding author)


Completness of medical records is an important thing that can affects the quality of health care services. By
improving employee compliance is one step towards improving the quality of healthcare in Indonesia. This
paper focused to ensure employees compliance to complete the medical record due to improve organization
quality. This paper is a descriptive-qualitative study which explores the previous studies related to completeness
and protection motivation theory. Firstly, it collected the studies related to completness medical record,
protection motivation and other theory related compliance. Secondly, it sums up all the related studies and
explains the theory and how it can be used in healthcare organization. The next step is revealing the author
views regarding of employee compliance in healthcare organization. As a result, protection motivation is a
model which can be use to improved individual behavior.

Keywords: Protection motivation theory, compliance, medical record



Medical record completeness is a key performance indicator that is related with delivery of healthcare
services in the hospital. Patient medical record review is the most applied technique to investigate adverse
events in hospitals. The determination with which information is recorded may influence the visibility of
adverse events. Poor information quality in patient medical records may cause of poor quality of care and
associated with higher rates of adverse events (Tola, et al, 2017). Good quality data healthcare play a main role
in planning, development, and maintenance of healthcare services. Quality health records are essential for the
maintenance of optimal healthcare (Adeleke, et al, 2012). It would be able to give beneficial to organization
incorporate security behaviour, make the routine employees activity to achieve required change in culture
organization in line with the security policies of a business (Vroom, et al, 2004).
Improving the quality of healthcare data will impact on hospital management and decision making in many
ways including:
1. National and regional service delivery decision making, impacting on health economics
2. Patient safety whilst undergoing care
3. Evidence to support clinical decision making through healthcare research
4. Information provided to patients on their illness and care
5. Effectiveness of clinical care pathways
6. Movement of data across organizational departments to provide a holistic view of healthcare requirements
(Kerr, et al, 2008).
Medical record is a very important document that used to communicate and document critical information
among health professionals (Tola, et al, 2017). Employee compliance to organizational rules, or set policies and
procedures may provide a useful mechanism in modeling employees’ proper attitudes or behaviors concerning

1 | Publisher: Humanistic Network for Science and Technology

Health Notions, Volume 1 Issue 1 (Month-Month 2017)
ISSN 2580-4936

how organizational resources should be used (Sher, et al, 2017), to increase the quality of medical record.
Protection Motivation Theory (PMT) propose that past behavior strongly influences the process of assessing
threats and one’s ability to cope with them (Vance, et al, 2012).
The policy can be set very clear and detailed, but compliance may be lacking, particularly due to
information security. In incident and field survey, employee convenience day-to day routine activity used to be
the reason why employee seldom to comply with security policies and procedure (Herath, et al, 2009). Prior of
this research is to ensure that employees compliance to complete the medical record policy and procedure. To
fill this gap, this paper explains employees’ compliance to organization policy of medical record due to improve
organization quality.

Literature review
Protection motivation theory was proposed by Rogers in 1983 (Sirur, et al, 2009) deriving from the two
appraisal processes of threat appraisal and coping appraisal is defined as an intervening variable that has the
typical characteristics of a motive: it arouses, sustains and directs activitys (Haret, et al, 2009). This theoretical
model, PMT, is best known for use in health science. The goal of persuasion is to motivate or to influence an
individual’s attitude or behavior in a predetermined way (Siponen, et al, 2007). Protection motivation is
measured by behaviour intention, a comment on the relation between intention and behaviour is in order
(Rogers, 1983).
The PMT explains how delineating an individual’s protection motivation can be aroused through his or her
appraisal mechanisms whenever confronting a threat (Sher, et al, 2017). Thus employees’ non-compliance
represents a maladaptive response, while compliance with them is an adaptive response. The maladaptive
response invokes threat appraisal factors, which decrease the likelihood of maladaptive response (vance, et al,
2012). Threat appraisal relates to the perceptions of how threatened an individual feels based on an evaluation of
the components of fear appeal (Herath, et al, 2009). It is composed of the following items:
(i) Perceived vulnerability i.e. an individual’s assessment of the probability of threatening events.
(ii) Perceived severity i.e. the consequences of the event (Ifenedo, 2012)
(iii) Rewards (or benefits), which results in any intrinsic or extrinsic motivation for increasing or keeping an
unwanted behavior which in our context is an employees’ non-compliance (Vance, et al, 2012)
Coping appraisal focuses on ability to cope with these threats and factors that may increase or decrease the
probability of an adaptive response (Sirur, et al, 2009). Coping appraisals are made up of three subconstituents:
(i) Self-efficacy, the factor that may emphasizes the individual’s ability or judgment regarding his or her
capabilities to cope with or perform the recommended behavior.
(ii) Response efficacy, a main effect on intention to protect oneself and others (rogers, 1983), this factor
relates to individual belief about the perceived benefits of the action taken (Ifenedo, 2012).
(iii) Response cost, the factor that may emphasizes the perceived opportunity costs in terms of monetary, time,
effort expended in adopting the recommended behavior (Ifenedo, 2012).
Intention to comply indicate people’s willingness to try to perform the behavior, actual compliance are
based on TRA, but the intentions are the most applicable measure of protection motivation (Simponen, et al,
2007). Fear arousal, which assesses how much fear the threat evokes for an individual, is an emotional response
to threat appraisal and, in its turn, influences an individual to do protective behaviors or decide not to take such
protective behaviors (Sher, et al, 2017).
Secondly, The theory of reasoned action was renamed by Ajzen in 1985 as the theory of planned
behaviour and revised to account for a third concept determining intention: perceived behavioural control (Sirur,
et al, 2009). Accompanying TRA and PMT can be regarded more comprehensive model for predicting protective
behavioral intentions. The TRA illustrates an individual’s behavior intention is directed by his or her attitude,
and the attitude is a function of an individual’s beliefs, and can predict staff’s compliance intention (Sher, et al,
2017). PMT considers cases in which individuals can choose whether to apply a specific protective measure.
There is needs to be a baseline for which the individual can appraise the threat and a protective measure which
the individual should use to cope. This is quite different from the framework provided by the TPB. The TPB
addresses a specific behavior and does not focus on the differences between two specific alternative actions
(Sommestad, et al, 2015). The TRA model introduced two factors that affect behavioral intention: attitude
toward the behavior and subjective norms (Leonard, et al, 2004). TPB does not include response costs, that is
the estimated costs (Sommestad, et al, 2015) in thoeritical, and this is the extended model of TRA, which added
perceived behavioral control as another factor influencing behavioral intention (Leonard, et al, 2004). This
makes a slightly different between TPB and PMT. Some researches make a combine of these theories to predict
It such of our decision is made to describe why there is a compliance of medical record rule take in
place. In our study, any medical record breaches may be considered as a perceptible threat to hospitals and
health care employees because it would negatively effect on a hospital’s reputation. In that such situation,

2 | Publisher: Humanistic Network for Science and Technology

Health Notions, Volume 1 Issue 1 (Month-Month 2017)
ISSN 2580-4936

employee may responsible to their own jobs or even get ramifications of legal law case if they were unable to
complete the medical record, this is the reason which makes the PMT an appropriate theoretical underpinning
for our study.


This was an observational analytic research to determine the relationship between variables quantitatively
without giving intervention to variables studied by using cross sectional method. The study was conducted from
2 untill 29 August 2015 in health center of Sojol district. Sampling was carried out by using Total Sampling. The
population in this research was 40 health officers at Balukang and Tonggolobibi public health center. The
sample in this study was all officers who work in Balukang and Tonggolobibi. The data collected in the form of
primary and secondary data. Primary data was obtained through interviews to health officers and secondary data
obtained through document review from public health center.
Data processing techniques were as follows: before editing process, completeness of primary data was done.
After the data was complete, it was analyzed by using computer application. Furthermore, to determine the
relationship of variables, cross-tabulation with chi square statistical with a degree of confidence of 95%.


The results of this study add to the literature in several ways. First, this study contributes to the literature of
security policy by integrating PMT and TRA, which may provide a theoretical basis useful in examining privacy
policy adherence intentions (sher, et al, 2017). A recent systematic review found that this theory is
approximately as good at predicting intentions and behavior related to compliance as it is at predicting other
behaviors (sommestad, et al, 2014). According to the correlations presented by Ifinedo (2012), The research
showed that behavioral compliance intention was positively influenced by factors self-efficacy, response
efficacy, attitude toward compliance, perceived vulnerability, and subjective norms. Moreover, Sher (2017)
confirmed that perceived vulnerability and perceived severity may also be regarded as predictors of fear arousal
instead of protection motivation.
Regarding to Vance (2012), saverity and self efficacy has positive impact but respond efficacy show
opposite effect of saverity on intention to compy, vulnerability insignificant does not increase intention to
comply, and last reward has a negative influence in inttention to comply. In the original formulation, protection
motivation theory hypothesized that the components would combine multiplicatively. The results of the present
experiment not only offer additional evidence against a multiplicative combinatorial rule, but also suggest that
an additive rule may apply only up to a point (Maddox and Rogers, 1982).
In addition, simponen et al (2009) proved that threat appraisal, respond efficacy, sunction has
significant impact on intention to comply and intention to comply has a significant impact on actual compliance.
Protection motivation is the best measured for behavioural intentions, a comment on the relation betwen
intention and behavior is in order (Cacioppo and Petty, 2014).


Achievement of health center basic program is strongly influenced by the motivation factor of work of
health officer. Work motivation is a will or desire that appears in the health officer that raises the spirit or drive
to work optimally to achieve the goal. With motivation, health workers will feel a special impetus to complete a
job towards achieving organizational effectiveness. When health worker has motivation to excel and receive an
allowance, they will perform their tasks as well as possible. However, when people think that doing the job is
just a routine they tend to be static in their work.
Based on the results of the analysis using the c-square test, p = 0.025 (p≤ 0.05), indicating that there is a
statistically significant correlation between work motivation of health worker and achievement of target of basic
program of health center in Sojol. This shows that hypothesis in this study is accepted.
From the analysis, well-motivated health officers in Sojol are motivated to reach the achievement of basic
program target of health center in Sojol because of reward (salary, and promotion) received in accordance with
the workload and responsibilities given. However, support of training and support work infrastructure are still
low. Health workers with poor motivation are less motivated to achieve the target achievement of basic health
center programs in Sojol because inadequacy and inaccuracy of reward targets to accomplished health workers
and lack of support provided to officers to develop their capabilities such as procurement of training or seminars
and work infrastructure.

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Health Notions, Volume 1 Issue 1 (Month-Month 2017)
ISSN 2580-4936

Basically, motivation of Health Officer Work is influenced by two main factors: intrinsic factor (one of them
is achievement desire and satisfaction) and extrinsic factor (such as support and reward). This proves that the
importance of motivation in officer to encourage and increase work productivity (Hamzah B, 2008). Extrinsic
motivation can have a direct and powerful effect, but it will not last long. Intrinsic motivation is to care with
quality in work. Those with good motivations tend to have long-term and deeper effects because they are
attached to the individual and not forced (Frederick, 2003).
The motivation of the health worker has a positive and strong influence on the performance of the health
center. The higher the level of motivation of health personnel, the higher the level of performance of health
centers in health services. The existence of motivation in an organization is an element that can cause
performance to be better or vice versa, or as an aspect required by all organizations because it is a central
concept to improve performance in an organization (Nawawi, 2012). Someone who is highly motivated will
tend to do something differently and always have innovation for learning things with the aim of improving its
performance in the future (Hollenbeck, 2010).


Based on the result of data analysis, it can be concluded that motivation of health officer has big contribution
to the success of basic program of health center in Sojol. Increasing work motivation of health workers in
Sojol is an aspect that needs to be considered, for example is the provision of training to officers who are still
less competent and procurement of facilities and infrastructure to support the work process of every health
worker. Aspects that greatly affect the work motivation of health center health workers in Sojol that is reward
(salary, promotion positions, and awards for officers who excel at work).
Maintaining good motivation in every officer needs to be conducted by adjusting or upgraded aspects of
reward (salary, promotion and other rewards) given to health officers at health center in Sojol. More attention to
the supporting factors towards the smooth completion of work programs from health personnel such as
infrastructure facilities and training on quality improvement of human resources needs to be performed. It is
expected that the officers will have high dedication to show consistent results so that the support of quality
improvement. Infrastructure facilities can be provided by the health center and / or related stakeholders.


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