HP_Ch. 9

PART IV BECOMING ILL AND GETTING MEDICAL TREATMENT

9 USING HEALTH SERVICES Types of Health Services Specialized Functions of Practitioners Office-Based and Inpatient Treatment The American Health Care System Health Care Systems in Other Countries

Perceiving and Interpreting Symptoms Perceiving Symptoms Interpreting and Responding to Symptoms

Using and Misusing Health Services Who Uses Health Services? Why People Use, Don’t Use, and Delay Using

Health Services Using Complementary and Alternative Medicine Problematic Health Service Usage

The Patient–Practitioner Relationship Patient Preferences for Participation in Medical Care The Practitioner’s Behavior and Style The Patient’s Behavior and Style

Compliance: Adhering to Medical Advice Extent of the Nonadherence Problem Why Patients Do and Do Not Adhere to

Medical Advice Patient–Practitioner Interactions Increasing Patient Adherence

Focusing on Prevention

PROLOGUE Jo’s life had just undergone major changes—she had been promoted by her employer and relocated to a new town with her two children. A year ago, she was diagnosed with high blood pressure and began taking a prescribed medication, which she supplements with sassafras and herbal tea that a clerk at a natural food store recommended. Now that she was settled, she decided to find a new physician soon. A coworker suggested she try Dr. Armstrong and, when asked, said that he was not like Jo’s last physician, who would sweep into the examining room, hurriedly ask very specific short-answer questions, dominate the conversation, and rush on to the next patient.

The coworker was right: Dr. Armstrong was com- petent and caring. After chatting with Jo to learn more about her and to establish a friendly relationship, he asked about her health, did some physical tests, and discussed with her a few alternatives for treating her hypertension. She felt comfortable enough with him to tell him about the supplements she was using, and he replied that she could continue them if she’d like, but the evidence for their benefit was not yet very solid. He gave her a pamphlet about hypertension and the URL for the American Heart Association Website so she could get more information if she wanted it. Jo left the office relieved and feeling secure in having found a physician whom she and her children could talk to easily and trust.

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With this chapter, our main focus in this book begins to shift from primary to secondary prevention efforts. Most health care systems engage chiefly in secondary and tertiary care, providing treatment to stop or reverse a problem or to retard damage it might cause and rehabilitate the person. In this chapter, we will see that the relationship formed between the patient and the health care practitioner, or health professional, can influence the actions they take in preventing and managing illness. The importance of this relationship will become clear as we discuss the kinds of health services available and the factors that affect when and how effectively people use these services. As we examine these topics, you’ll find answers to questions you may have about people’s use of health services. How do people decide they are sick and may need medical attention? How can patients influence their health care? Do people follow medical advice—and if not, why?

TYPES OF HEALTH SERVICES

Systems of medical care are complex in most societies, particularly in industrialized nations where the medical systems consist of an enormous variety of health services. To see the complex nature of health care systems, we will consider the specialized functions of health care workers, compare office-based and inpatient treatment, and contrast the American medical system with systems in other countries.

SPECIALIZED FUNCTIONS OF PRACTITIONERS Medical care systems have staffs of health care work- ers who differ greatly in their roles and specialties. The American system, for instance, employs millions of pro- fessionals, including physicians of many types—general practitioners, pediatricians, cardiologists, neurosur- geons, dermatologists, gynecologists, psychiatrists, and so on—as well as nurses, dentists, optometrists, res- piratory therapists, physical therapists, medical social workers, and dietitians, to name only a small number. Each type of practitioner provides a different type of health service, using specialized knowledge and skills.

Because each of these services involves an enormous amount of knowledge and skill that grows and changes very rapidly, individual practitioners cannot perform with a high degree of skill the services of several specialties simultaneously. The advantage in organizing the health care system into specialties is that patients can receive the greatest expertise available for each

aspect of the treatment of each health problem. But this great advantage has drawbacks. For instance, the many professionals who provide care for a particular individual do not always communicate with each other effectively, so that the physician in charge of the treatment may not have a full picture of the person’s condition or progress (Weiner et al., 2005). Also, because many practitioners work with a patient very briefly—performing just a few tests, for example—the contact these practitioners have with patients is often impersonal.

OFFICE-BASED AND INPATIENT TREATMENT When we get sick and seek professional treatment, the first place we usually go is to our family physician at his or her office. This practitioner can treat the illness, refer us to a specialist for treatment, or arrange for hospitalization.

People with serious illnesses who require medical attention either on a continuous basis or with complex equipment or procedures generally receive treatment as inpatients in hospitals and nursing homes. Hospitals are the most complex medical facilities in medical care systems, employing highly sophisticated equipment and skilled practitioners from almost all specialty areas (AMA, 2003). As a result, they can provide a wide variety of services, ranging from emergency care, to diagnostic testing, to curative treatment, to rehabilitation and social services. Many hospitals also offer health promotion facilities, such as wellness centers and weight loss programs. Some hospitals have specialized missions, such as in providing care for children or for certain health problems—cancer, eye diseases, or orthopedic problems, for instance.

Nursing homes provide care for individuals who need relatively long-term medical and personal care, particularly if the patients or their families cannot provide this care (AMA, 2003; USBC, 2010). The large majority of patients in nursing homes are handicapped or frail, elderly individuals who often need help in day-to-day activities such as dressing and bathing themselves. The average nursing home in the United States is a moderately sized facility, having about 100 beds. Nursing homes vary in the degree of skilled nursing and rehabilitative services they are prepared to provide. Although most American nursing homes provide high-quality care, many others do not; quality ratings can be obtained online via www.medicare.gov or state departments of health.

People with serious health problems in many nations have been relying less and less on inpatient services in recent years, using outpatient or home health care instead (AMA, 2003; NCHS, 2009a). The shift away

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Most patients in nursing homes are elderly individuals who need long- term medical and personal care.

from inpatient care has occurred because of the fast- rising costs of hospital and nursing home services and because technological advances have made it possible to maintain medical treatment with outpatients. Two examples of technological devices that provide outpatient treatment are pacemakers, which are installed in the body to send electrical pulses to regulate heartbeat, and insulin pumps, which inject insulin into the body on a specific schedule. Clients who use home care usually begin their treatment on an inpatient basis, but are then discharged in the care of a home health care service.

Outpatient care offers some advantages over inpa- tient care. For one thing, home care is less expensive. Also, people usually prefer being at home, and can often return to work or school while receiving out- patient treatment. But for some patients—particularly the elderly—home health care can present problems if they lack needed help from family or friends and do not have transportation to make periodic visits to their physicians.

THE AMERICAN HEALTH CARE SYSTEM When most Americans get sick and need treatment, their health insurance pays for most of the costs. Employers provide insurance for most working people; others buy private insurance or are covered under governmental insurance programs: Medicare covers all elderly people, Medicaid covers low-income people. But over 15% of Americans—46 million people—have no health insurance, and the percent of uninsured is much

higher for Hispanics and Blacks than Whites (USBC, 2010). These people can’t afford to get sick, and they have higher mortality rates than insured individuals (Wilper et al., 2009). The United States government enacted law in 2010 that will phase in insurance coverage so that 95% of Americans will have health insurance in a few years, but the structure of the health care system will remain much the same.

Several decades ago, private-practice physicians gave all office-based medical treatment in the United States, and each charged a fee for each service. Amer- ican health insurance now structures medical care within two broad options: fee-for-service (also called ‘‘traditional’’) and managed-care programs. People in fee- for-service programs can choose their physicians, and the insurance pays most (often, 80%) of incurred charges. Practitioners who treat fee-for-service patients generally must accept the amount of payment insurance plans specify. The amount is often lower than the practitioner requests; because Medicaid plans usually pay very low amounts, members may have difficulty finding a practitioner who will provide treatment. Managed-care programs place restrictions on their members’ choices and services. Most managed-care and fee-for-service programs charge annual fees members or their employers pay; fees are lower in managed-care plans. Over 70% of employed Americans are in managed-care plans; Medicare now offers managed-care programs (Luft, 1998; CU, 2001). Some managed care programs provide financial incentives to their physicians for cost-saving behaviors, such as sending fewer patients to hospitals, which may foster suboptimal care.

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One type of managed-care plan is the health mainte- nance organization (HMO), in which members are entitled to use the services of any affiliated physician or hospi- tal with little or no additional charges (CU, 2001; Miller & Luft, 1994). Visits to specialists or for nonemergency hospital treatment must be preapproved and referred by the primary care physician. The HMO pays for treatments it arranges or recommends and negotiates with specific hospitals and physicians for discounted rates. Another type of managed-care plan—called the preferred provider organization (PPO)—is similar to some HMOs. Each PPO consists of a network of affiliated physicians and hospi- tals that discount their fees; patients usually may go to any affiliated specialist without preapproval. Although the overall care patients in HMOs, PPOs, and fee-for- service plans is similar, HMO patients tend to use more preventive services but are less likely to see a physician quickly or to be admitted to a hospital when seriously ill (CU, 1999, 2001; Miller & Luft, 1994). Ratings of man- aged care plans are available, but are not very useful (Schauffler & Mordavsky, 2001).

What is the quality of health care in the United States and other countries around the world? We can gauge the quality with rankings by the World Health Organization of the overall health system performance and the number of physicians and nurses a country has for its population—Table 9.1 gives these comparisons. Americans receive medical care that is among the finest in the world, but the health care system has important flaws: huge numbers of people are currently uninsured, its costs are skyrocketing, and it is so complex and offers so many managed-care options that deciding to

Table 9.1 Overall Health System Performance (OHSP) Rankings and Number of Physicians and Nurses per 10,000 People in Selected Nations

Country OHSPa Physiciansb Nursesb

Australia 32 25 97 Brazil 125 12 38 Canada 30 19 101 China 144 14 10 Germany 25 34 80 India 112 6 13 Italy 2 37 72 Netherlands 17 37 146 Singapore 6 15 44 South Africa 175 8 41 Sweden 23 33 109 Turkey 70 16 29 United Kingdom 18 23 128 United States 37 26 94

aThe latest rankings available are from WHO, 2000 and include 191 countries. bData from WHO, 2009.

use these services can be intimidating to some people. Do other countries have health care systems that have solved these problems?

HEALTH CARE SYSTEMS IN OTHER COUNTRIES Many countries have universal health care systems—they provide medical coverage for virtually all of their citizens—usually funded by taxes and payroll deductions (PNHP, 2006; WHO, 2005). These nations include Aus- tralia, Canada, Germany, Italy, the Netherlands, Sweden, and the United Kingdom. The health care they provide is excellent and usually less complicated to use than America’s. People in poorer countries generally have lit- tle or no coverage, and the ability to pay for service or private insurance rations medical care increasingly, even in richer nations (WHO, 1999).

How are universal health care systems structured, and what do they cover? Each one is different—for instance:

• Many systems cover prescription drugs, sometimes only for certain age or income groups.

• Most, but not all, systems encourage the use of supple- mental private insurance, especially for types of care the system does not cover, such as dental.

• Some systems are partly funded with medical savings accounts, such as Singapore’s Medisave, which requires all employees and self-employed individuals to put part of their pay into an account that the contributor and relatives can use to pay for treatments (Drechsler & Jütting, 2005).

• In some systems, such as in Italy and the United King- dom, most physicians are employed by the government, but in others most doctors are privately employed.

• Some systems, such as in Australia and the Netherlands, have the primary care physician serve as a ‘‘gatekeeper’’ for receiving care by a specialist or hospital.

In the Canadian system, each province pays its citizens’ medical bills and determines its own policies, such as what types of care will be covered. Most Canadian physicians are employed privately, and patients may choose any doctor they wish. The fees physicians charge are set by the province in negotiation with a medical association.

Compared with the American system, universal health care systems are far less expensive in terms of costs per citizen and the percentage of each nation’s gross domestic product spent on health care (WHO, 2009). Because of steadily increasing costs in most countries, efforts are being made around the world to

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slow these increases. Sometimes funding problems in some nations, such as Canada and the United Kingdom, have led to long waits for diagnostic tests and elective surgery (CU, 2007).

In any health care system, a critical step in seeking medical attention is finding a regular physician to contact when we are sick. He or she can either cure our illness or help us find other help within the system. Now, suppose someone who has a regular physician develops some symptoms—say, nausea and a moderately high fever. Will the person go to the doctor? An important step in using health services involves deciding when we are sick enough to require medical attention in the first place. This is the topic of the next section.

PERCEIVING AND INTERPRETING SYMPTOMS

If you came down with a case of strep throat as a child, chances are the symptoms you experienced were obvious to you and your parents. You had a very sore throat, fever, and headache, for instance, and your physician prescribed a curative course of action. From experiences of this type, you learned that symptoms accompany illness, certain symptoms reliably signal certain illnesses, some symptoms are more serious than others, and when they go away, you’re well again. As an adult, you decide whether to visit your physician on the basis of the symptoms you perceive and what they mean to you.

PERCEIVING SYMPTOMS Perceiving symptoms of illness is more complicated than it may seem. It’s true that we perceive internal states on the basis of physical sensations, and we’re more likely to notice strong sensations than weak ones. But we do not assess our internal states very accurately. For example, people’s estimates of their own heart rate, breathing function, and degree of nasal congestion correlate poorly with physiological measures of these states (Pennebaker, 1983; Rietveld & Brosschot, 1999). Individuals also have trouble perceiving external symptoms, such as whether a mole-like spot is melanoma, a skin cancer (Miles & Meehan, 1995). Partly because of people’s low degree of accuracy in assessing signs of illness, the point at which people recognize a symptom can differ from one individual to the next and within the same person from one time to the next. Furthermore, people do not always notice a symptom—even a strong one—when it is there, and sometimes they may perceive a symptom that has no actual physical

basis. Let’s see what factors affect our perception of symptoms.

Individual Differences ‘‘He’s such a big baby; he notices every little ache and pain,’’ you may have heard someone say. Why do some individuals report more symptoms than others do? One reason is that some people simply have more symptoms than others, of course. Although people could differ in the sensations they experience from the same symptom, such as a specific painful stimulus, studies testing large numbers of normal individuals with stimuli of different temperatures have cast doubt on this possibility. They found that people seem to have a uniform threshold at which heat becomes painful—‘‘almost all persons begin to feel pain when the tissue temperature rises to a level between 44◦C and 46◦C’’ (Guyton, 1985, p. 302). But individuals differ in the degree of pain they will tolerate before doing something about it, such as taking medication (Karoly, 1985; Melzack & Wall, 1982).

Some individuals seem to pay more attention to their internal states than others do (Pennebaker, 1983). They show a heightened awareness of or sensitivity to their body sensations. As a result, these people notice changes more quickly than individuals who tend to focus their attention on external happenings. This doesn’t mean internally focused individuals’ perceptions of internal changes are more accurate—indeed, research has found that they are more likely than externally focused people to overestimate their bodily changes, such as in heart rate (Pennebaker, 1983). Among patients who seek medical treatment, those who are internally focused tend to have less severe illness and perceive their recovery as slower than those who pay less attention to their internal states (Miller, Brody, & Summerton, 1987). Many internally focused individuals may pay too much attention to their internal states and, in so doing, magnify departures from normal bodily sensations.

Competing Environmental Stimuli You may have heard anecdotes about athletes who were unaware of a major injury they had suffered during a com- petition until after the sporting event was over—then it hurt! The extent to which people pay attention to internal stimuli at any given time depends partly on the nature or degree of environmental stimuli present at that time.

When the environment contains a great deal of sensory information or is exciting, people become less likely to notice internal sensations. People are far more likely to report sensations or physical symptoms when the external environment is boring or lacks information than when the environment captures their attention

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(Pennebaker, 1983). For instance, when watching a movie, they are more likely to notice an itch or a tickle in their throats during boring parts. Also, people who hold boring jobs or live alone tend to report more physical symptoms and use more aspirin and sleeping pills than those who hold interesting jobs or live with other people.

Psychosocial Influences Because people are not very accurate in assessing their actual internal physical states, their perception of body sensations can be heavily influenced by cognitive, social, and emotional factors (Petrie & Pennebaker, 2004; Rietveld & Brosschot, 1999). One way researchers have demonstrated the role of cognitive factors in symptom perception is in the effects of placebos, which are inert substances or sham treatments (Rehm & Nyak, 2004; Roberts, 1995). For example, people who receive a placebo ‘‘drug’’ to reduce their pain, not knowing the drug is inert, often report that it relieves their symptoms or sensations.

Expectations can also increase the symptoms people perceive. For instance, patients who are taking an active medication sometimes show a nocebo phenomenon: they perceive side effects, such as dizziness or fatigue, that could not be the direct result of the drug (Barsky et al., 2002). They may have ‘‘manufactured’’ sensations based on their expectations. In another example, researchers recruited residents of neighborhoods that were sched- uled to receive a spraying of an insecticide by aircraft (Petrie et al., 2005). A questionnaire was used to sep- arate these people into three groups: high, medium, and low in health worries relating to aspects of modern life, such as genetically modified food and fluoridation of water. After the spraying, these people reported on the symptoms they experienced that they attributed to exposure to the spray. The people with the high health worries reported three times the number of symptoms, such as headache and dizziness, than did those with low health worries. These findings suggest that the symptoms people perceive can result not only from actual physio- logical changes that occur in their bodies but from their beliefs, too. Keep in mind, though, that worry can also make people more vigilant, such as when individuals who worry a lot about their asthma are more accurate in noticing symptoms and attributing them to their asthma condition (Mora et al., 2007).

The combined roles of cognitive, social, and emo- tional factors in symptom perception can be seen in two interesting phenomena. The first is called medical student’s disease. As medical students learn about the symptoms of various diseases, more than two-thirds of them come to believe incorrectly that they have contracted one of

these illnesses at one time or another (Mechanic, 1972). The second phenomenon, called mass psychogenic illness, involves widespread symptom perception across individ- uals, even though tests indicate that their symptoms have no medical basis in their bodies or in the environment, such as from toxic substances (Petrie & Pennebaker, 2004). Usually it begins with an event, such as an unusual odor or someone fainting—then a chain reaction occurs with person after person feeling symptoms, and some may even be taken to the hospital.

Why do such phenomena occur? Researchers have described several conditions that heighten the percep- tion of symptoms (Colligan et al., 1979; Mechanic, 1972; Petrie & Pennebaker, 2004). First, the people are already feeling negative emotions, such as high stress—that is, medical student’s disease, and mass psychogenic illness tend to occur when people have been experienc- ing high levels of anxiety, interpersonal conflict, or heavy workloads. Second, the symptoms involve common phys- ical sensations, such as headache or dizziness, that are vague and very subjective in nature. Third, expectations and other cognitive factors exaggerate the sensations, attaching to them more importance than they warrant. Fourth, modeling of the symptoms occurs. (Go to .)

Gender and Sociocultural Differences Women in research on pain report feeling discomfort at lower stimulus intensities than men and request sooner that a painful stimulus be terminated (Fillingim, 2000). Why? There is evidence for several factors, such as differences in sex hormones and sex role beliefs.

People of different cultural backgrounds seem to differ in their perceptions of and reactions to illness symptoms—for instance, displaying much more distress and disability to pain in some cultures than in others (Young & Zane, 1995). These differences may result from cultural norms for reinforcing stoical versus distressed and disabled behaviors when in pain. Let’s consider three examples of cultural differences. First, people of Asian cultures report more physical symptoms with psychologi- cal bases than people of other cultures (Chun, Enomoto, & Sue, 1996). Second, a study compared disability in patients with long-term low back pain conditions of similar severity and duration in six different countries (Sanders et al., 1992). American patients reported the most overall impairment, such as in work and social activ- ities. Italians and New Zealanders reported the second- largest impairments, followed by Japanese, Colombian, and Mexican patients. Third, of heart attack patients in the United States, Black individuals experience symp- toms that are less typical than those of Whites and delay getting treatment longer (Lee et al., 1999).

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HIGHLIGHT

Symptoms by Suggestion? Researchers studied the role of expec-

tation and modeling in symptom perception in an exper- iment (Lorber, Mazzoni, & Kirsch, 2007). They recruited students as participants who were tested in pairs (but one member was actually a confederate of the researchers). Each pair was told that the study was testing the effects of a substance that reportedly produces in some people four ‘‘known’’ symptoms—itchy skin, drowsiness, headache, and nausea—that are mild and usually last for less than an hour. And the pair was told that one or both of them would inhale the substance as a spray and that the study was also testing to see if a few other symptoms might occur. The spray was actually inert.

The participants were randomly assigned either to receive the spray or not, and these conditions were subdivided: seeing the confederate either receive or not receive the spray. Then the pair sat for an hour, free to read magazines or do homework. During this time, the confederate displayed behaviors, such as scratching and yawning, that were consistent with the known symptoms. Every 10 minutes, the pair rated their experience of the four known symptoms and four others; each of eight symptoms had been reported in prior research on mass psychogenic illness. A videotape of the sessions was used to confirm the occurrence of two symptoms, itchy skin and drowsiness, which would be reflected in the students’ behavior. Figure 9-1 shows the outcome: ratings of the known symptoms were far greater for students who received the spray, especially if they also saw the confederate receive the spray. A similar,

subsequent experiment confirmed that modeling is a critical factor in this effect (Mazzoni et al., 2010).

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In summary, people’s perception of a symptom depends on the strength of the underlying physical sensation, their tendency to pay attention to their internal states, the degree to which external stimuli compete for their attention, and a variety of cognitive, social, and emotional processes. What individuals do when they perceive symptoms is the topic of the next section.

INTERPRETING AND RESPONDING TO SYMPTOMS Psychiatrist George Engel (1980) described the case of a 55-year-old man whom he called Mr. Glover, who suffered his second heart attack 6 months after his first. He was at work, alone at his desk, when he experienced general

discomfort, pressure over his chest, and pain down his left arm.

The similarity of those symptoms to those of his heart attack six months earlier immediately came to mind … but he dismissed this in favor of ‘‘fatigue,’’ ‘‘gas,’’ ‘‘muscle strain,’’ and, finally, ‘‘emotional tension.’’ But the negation itself, ‘‘not another heart attack,’’ leaves no doubt that the idea ‘‘heart attack’’ was very much in his mind despite his apparent denial. Behaviorally, he alternated between sitting quietly to ‘‘let it pass,’’ pacing about the office ‘‘to work it off,’’ and taking Alka-Seltzer. (p. 539)

When Mr. Glover’s boss noticed his strange behavior and sick appearance, she convinced him to let her take him to the hospital.

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The role of people’s prior experiences in their decision of what the symptoms they feel reflect and whether they warrant attention can be complex. Most often, past experience probably helps people make correct judgments. For instance, one of the strongest factors in mothers’ correct decisions to seek medical care for their children is prior experience—that is, whether the child or a relative had a similar problem in the past (Turk et al., 1985). But sometimes people’s prior experiences and expectations can lead them to incorrect interpretations of their symptoms. For example, many elderly people assume that feeling weak is a symptom of old age rather than a sign of illness (Leventhal & Prohaska, 1986). And people who notice symptoms while under long-term, intense stress may see the symptoms as a stress reaction (Cameron, Leventhal, & Leventhal, 1995). Although these interpretations may sometimes be correct, they may also lead people to ignore symptoms that do, in fact, need treatment.

From direct experience and the things we read and hear, we develop ideas and expectations about illnesses—some are correct, some are not—and use this information to construct cognitive representations or commonsense models of those illnesses (Lau & Hart- man, 1983; Leventhal, Leventhal, & Contrada, 1998; Petrie & Pennebaker, 2004). These models can affect our health-related behavior and seem to involve four basic components of how people think about disease:

• Illness identity, which consists of the name and symptoms of the disease.

• Causes and underlying pathology, which are ideas concerning how one gets the disease (‘‘I got a cold because a girl sneezed her germs in my face’’) and what physiological events occur with it.

• Time line, or prognosis ideas, such as how long the disease takes to appear and lasts. For instance, symptoms of salmonella take many hours to appear after eating tainted food; some people know this, and others think the symptoms occur immediately.

• Consequence, which involves ideas about the seriousness, effects, and outcomes of an illness.

People use many types of information in construct- ing ideas about illnesses—for example, they seem to use illness prevalence in judging its seriousness (Jemmott, Croyle, & Ditto, 1988). Rare illnesses are seen as more serious. Commonsense models of illness appear to affect future health and disability in at least two ways. First, people with incorrect illness ideas are less likely than oth- ers to adopt preventive behaviors and less likely, when ill, to seek treatment, follow medical advice, and return to work quickly (Frostholm et al., 2005; Petrie & Pennebaker,

2004; Schiaffino, Shawaryn, & Blum, 1998). Second, as an illness, such as arthritis, lasts and becomes chronic, peo- ple’s expectations about their condition often worsen, leading to negative emotions and a lessened sense of personal control (Kaptein et al., 2010).

Mr. Glover’s reaction to the classic heart attack symptoms he was having was probably governed by emo- tion elicited by the memory of his earlier attack. Although fear can motivate a person toward health behavior, it can also motivate maladaptive avoidance behavior. He finally decided to go to the hospital after his boss persuaded him that his symptoms needed treatment. Before people decide to seek medical attention for their symptoms, they typically get advice from friends, relatives, or coworkers (Rothrock, 2004; Suls, Martin, & Leventhal, 1997). These advisers form a lay referral network of nonpractitioners who provide their own information and interpretations regarding the person’s symptoms (Freidson, 1961). These people may respond to a request for help or just the ill person’s appearance and might:

• Help interpret a symptom—such as, ‘‘Jim and his sister Lynn both had rashes like that. They were just allergic to a new soap their mother had bought.’’

• Give advice about seeking medical attention—as in, ‘‘MaryLou had a dizzy spell like the one you just had, and it was a mild stroke. You’d better call your doctor.’’

• Recommend a remedy—such as, ‘‘A little chicken soup, some aspirin, and bed rest, and you’ll be fine in no time.’’

• Recommend consulting another lay referral person—as in, ‘‘Pat had the same problem. You should give him a call.’’

Although the lay referral system often provides good advice, laypersons are, of course, far more likely than practitioners to recommend actions that worsen the condition or delay the person’s use of appropriate and needed treatment.

USING AND MISUSING HEALTH SERVICES

A pharmacist is often the first health professional that people consult when they have a health problem. A customer might ask, ‘‘My hands get these red patches that peel, and hand creams don’t do any good. Do you have anything that’ll help?’’ When pharmacists suggest an over-the-counter remedy, they usually recommend that the person see a physician if it doesn’t work.

Most prospective patients try hard to avoid vis- iting physicians, but they don’t always succeed, of course. Americans visit their doctors as outpatients over

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People with health problems often consult pharmacists for over-the-counter remedies before seeing their physician.

990 million times a year—3.36 visits per person (USBC, 2010), and people in the European Union visit their physi- cians more: 6.86 times per person per year (WHO/Europe, 2010). What conditions do patients commonly discuss with physicians? The conditions include ear and respi- ratory infections, pregnancy-related issues, and a variety of chronic illnesses, such as hypertension, diabetes, and cancer (USBC, 2010). Of course, these conditions are not evenly distributed across all segments of the population.

WHO USES HEALTH SERVICES? People with health risks, such as obesity and high stress, use health care substantially more than others do (Tucker & Clegg, 2002). Demographic and sociocultural factors are also related to health services use in America and probably most industrialized countries.

Age and Gender One factor in using health services is age (USBC, 2010). In general, young children and the elderly have contact with physicians more often each year than adolescents and young adults. Young children visit physicians for general checkups and vaccinations, and they develop a variety of infectious diseases. Physician contacts are less frequent from late childhood through early adulthood, but increase in the middle-age and elderly years as the prevalence of chronic diseases rises.

Figure 9-2 depicts how physician contacts vary with age and with another important factor, the patient’s gender. Through the life span, females have higher rates of physician visits than males do (NCHS, 2009a). Although much of women’s higher visit rates in early adulthood

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results from pregnancy-related care, the difference remains even when physician visits for pregnancy and childbirth are not counted (Reddy, Fleming, & Adesso, 1992; Verbrugge, 1985). The reasons for gender differences in using medical care are unclear, but there are several possible explanations. One obvious explanation is that women may simply develop more illnesses that require medical attention: they show higher rates of medical drug use and illness from acute conditions, such as respiratory infections, and from nonfatal chronic diseases, such as arthritis and migraine headache. Another reason is that men are more hesitant to admit having symptoms and to seek medical care for the symptoms they experience. In a study that asked men and women about recent experiences of various symptoms, women reported more of almost all symptoms, including ones that had no medical confirmation (Kroenke & Spitzer, 1998). Gender differences in reporting and, perhaps, perceiving symptoms probably reflects sex-role stereotypes—that is, societies often encourage men more than women to ignore pain and to be tough and independent.

Sociocultural Factors in Using Health Services Data on health service usage by different segments of the American population show sociocultural differences in

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usage rates (NCHS, 2009a). These differences lead to two important conclusions. First, the percentage of people who fail to get prescriptions filled or seek medical care at a doctor’s office decreases with family income. Second, African Americans and other individuals with low family incomes are more likely than Whites and others with higher incomes to use outpatient clinics and hospital emergency rooms for medical care. This is probably because disadvantaged people are less likely to have regular physicians (Flack et al., 1995). Although there is clearly a gap in usage of health services between social classes in America, it has narrowed since the mid-1960s, when the government introduced Medicare and Medicaid insurance programs for the elderly and poor, respectively. These programs account for much of the 25% increase in physician visits that occurred between 1968 and 1972 (USDHHS, 1985).

Despite the help these programs provide, the costs American patients must bear for medical treatment can still be substantial because public and private insurance programs generally do not cover all the expenses. Some kinds of treatment are excluded, and patients typically must pay part of the costs for those treatments that are covered, which is especially difficult for individuals with low incomes. People on Medicaid who have a heart attack are more likely than others to delay seeking treatment that could stop damage to the heart (Foraker et al., 2008). Worldwide, a lack of knowledge about prevention and poor access to health counseling and preventive services contributes to the high illness rates of low-income people (WHO, 1999).

Although medical insurance can help many low income people get the treatment they need, there are reasons besides the expense of medical care for the gap between social classes and cultural groups in using health services (Flack et al., 1995; Penn et al., 1995; Rundall & Wheeler, 1979; Young & Zane, 1995). For one thing, individuals from the lower classes tend to perceive themselves as being less susceptible to illness than those from the higher classes do. As a result, low-income people are less likely to seek out preventive care. Second, people with low incomes and from minority groups are less likely to have regular sources of health care than others are. Often this situation develops because low-income regions are less able to attract physicians to provide health services there. In addition, people in the lower classes and from minority groups may feel less welcomed by and trustful of the health care system than other individuals. Third, in many countries language can be a barrier to health care for immigrants if they do not speak the dominant language and no translators are available. These and many other factors tend to reduce the likelihood that

low-income individuals will use health services for preventive care and when they are ill. Public health informational programs need to combat cultural barriers that impede the use of health care and prevention services.

The title of this section is Who Uses Health Services? We’ve seen that the most frequent users of health services are young children, women, and elderly individuals, and in the United States they tend to be from the higher social classes. Nonusers are likely to be males, particularly in adolescence and early adulthood, and from disadvantaged groups. But almost all people use health services at some time, and many upper-class individuals fail to get medical treatment when they should. These portraits give us an image of who uses health services, but they do not explain why.

WHY PEOPLE USE, DON’T USE, AND DELAY USING HEALTH SERVICES Health psychologists and others who study health care have discovered many factors that influence whether and when individuals are likely to seek medical care. Some of these factors involve people’s ideas and beliefs about treating illness.

Ideas, Beliefs, and Using Health Services An ailing man who was considering whether to seek treat- ment thought, ‘‘Remember how the medicine Buddy’s doctor gave him made him sicker? I don’t trust doc- tors.’’ Patients sometimes develop health problems as a result of medical treatment, and these problems are called iatrogenic conditions. The condition can result from a practitioner’s error, such as giving the wrong type or dose of medication, or as a normal side effect or risk of a treatment, as when people undergo surgery or begin to take a new medication. Some errors can be prevented with technology, such as scanning bar-codes on drug packages (Poon et al., 2006). Tens of thousands of people are killed each year in the United States alone as a result of medical errors in the hospital and adverse effects of drugs, either from prescription or filling errors (Gerlin, 1999; Phillips & Bredder, 2002). The stories we hear about the treatment patients received may influence our decisions to use medical services.

Not trusting practitioners can stop people from seeking the care they need; we will consider two issues of trust. First, individuals may avoid getting care because they worry that their practitioners will not keep information confidential. For instance, a study found that most American adolescents have health concerns they want to keep private from their parents, and

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one-fourth said they would forgo treatment if their parents could find out about it (Cheng et al., 1993). Many gay men and women avoid medical care because of concerns about confidentiality or physician reaction to their sexual orientation (Mann, 1996). Second, minority group members have heard stories, some of which are true, of discriminatory practices and atrocities carried out by medical personnel against them (Landrine & Klonoff, 2001). One true story is that physicians in the United States falsely told Black men with syphilis that they were being treated for their illness and that the disease was ‘‘bad blood.’’ This unethical action was done so that a research project, called the Tuskegee Syphilis Study, could chart the effects of untreated syphilis, which include blindness, brain damage, and death.

The Health Belief Model and Seeking Medical Care In Chapter 6, we examined the role of health beliefs in taking preventive action, and saw that the health belief model provides a useful framework for explaining why people do and do not practice healthful behaviors. How does the health belief model apply to people’s seeking medical care when they notice symptoms?

According to the health belief model (refer to Figure 6-2), symptoms initiate a decision-making process about seeking medical care. Part of this process involves assessing the perceived threat suggested by the symptoms (Becker & Rosenstock, 1984; Rosenstock & Kirscht, 1979). How much threat individuals perceive depends mainly on three factors. One factor is cues to action, which can include the symptoms themselves, advice sick people receive in lay referral, and information from the mass media, such as descriptions of cancer symptoms. Two other factors, perceived susceptibility and perceived seriousness, modify the concern the cues arouse: the threat individuals feel intensifies with increases in the perceived susceptibility to the particular illness and the perceived seriousness of the physical and social consequences of contracting the disease.

The health belief model also proposes that people assess whether the perceived benefits of getting treatment outweigh the perceived barriers to doing so. People who believe treatment can cure the symptoms or arrest the progression of the illness are more likely to seek medical care than those who believe otherwise. In assessing the barriers to medical care, people consider whether the treatment will have unpleasant side effects and will be costly, painful, and difficult to obtain. Individuals who feel threatened by their symptoms and believe the benefits of receiving treatment outweigh the barriers are likely to visit a practitioner. But people who do

not feel threatened or assess that the barriers are too strong are likely to decide to delay treatment or avoid it altogether.

The results of research suggest that the factors described by the health belief model do influence people’s decisions of whether and how soon to use health services (Becker & Rosenstock, 1984; Rosenstock & Kirscht, 1979). For example, many elderly people report that medical bills, transportation difficulties, and other barriers have hindered their ability to get medical care (Fitzpatrick et al., 2004). And among people who know about and have cancer symptoms, those who believe cancer cannot be treated effectively or cured tend to delay seeking medical care much longer than individuals who believe treatment can be successful (Antonovsky & Hartman, 1974). Many Americans believe erroneously that cancer cannot be cured and that treatment can cause cancer to spread (Gansler et al., 2005). Still, some studies have found only a weak relationship between factors in the health belief model and people’s likelihood of using health services, which suggests that other variables are also important in decisions to seek treatment (Harris & Guten, 1979; Langlie, 1977).

Social and Emotional Factors and Seeking Medical Care Earlier, we considered the case of Mr. Glover, who delayed medical treatment for clear symptoms of a heart attack, and we saw that social and emotional factors can play important roles in people’s decisions about seeking treatment for their symptoms.

The role of strong emotions when symptoms appear can vary. People who are already very depressed tend to delay getting medical care for symptoms, such as of a heart attack, perhaps because they can’t mobi- lize the energy to seek it (Bunde & Martin, 2006). Fear may have different effects. People who are frightened by their cancer symptoms are more likely to seek care quickly, within several days, than are people with little fear (Petrie & Pennebaker, 2004). But if they expect and fear pain from the disease or its treatment, they may delay care (Levin, Cleeland, & Dar, 1985). Expectations of pain affect dental care, too—about 5% of Americans are so fearful that they avoid all kinds of dental treatment (Gatchel, 1980). Concerns of possible embarrassment may also lead individuals to avoid medical care. For instance, people with heart symptoms may worry that if ‘‘it turns out to be nothing,’’ they’ll be embarrassed that they created a crisis and rushed to the hospital (Dracup, 2004). Sometimes the symptoms are themselves embar- rassing, such as when adults have problems of bladder control.

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Social factors influence people’s tendencies to seek medical care for their symptoms. For example, many men believe getting medical care is a sign of weakness, violating their social role for being strong. But social factors can also encourage people to seek care, such as through the process of lay referral, which can serve as ‘‘social trigger’’ to seek treatment (Zola, 1973). One social trigger is called sanctioning, in which someone asks or insists that an ill person have his or her symptoms treated. For instance, a man who had been having problems with his vision for a while finally went to a doctor after his wife prodded him to do so. Some sick individuals seek medical care if they simply believe significant others want them to do that (Timko, 1987).

Stages in Delaying Medical Care When symptoms of a potentially serious illness develop, seeking treatment promptly is imperative. Treatment delay refers to the time that elapses between when a per- son first notices a symptom and when he or she enters medical care. In medical emergencies, such as severe in- jury or a heart attack, people often seek help in a matter of minutes or hours, as Mr. Glover did. What determines how long people wait?

On the basis of interviews with patients at a clinic, researchers discovered that treatment delay occurs as a sequence of three stages (Safer et al., 1979). As the diagram in Figure 9-3 illustrates, the three stages are:

1. Appraisal delay—the time a person takes to interpret a symptom as an indication of illness.

2. Illness delay—the time taken between recognizing one is ill and deciding to seek medical attention.

3. Utilization delay—the time after deciding to seek medical care until actually going in to use that health service.

The people’s reasons for delaying treatment revealed that different factors were important in different stages of delay. During appraisal delay, the sensory experience of

a symptom had the greatest impact on taking action—for instance, patients recognized a symptom as an indication of illness more quickly if they experienced severe pain or bleeding than if they did not.

In the illness delay stage, thoughts about the symptom had the greatest impact. Thus, individuals decided to seek medical attention more quickly if the symptom was new rather than very familiar and if they didn’t think much about the symptom and its implications. During utilization delay, perceptions of benefits and barriers were important—delay was shortest for those people who were less concerned about the cost of treatment, had severe pain, and felt that their symptoms could be cured. In addition, the researchers found that having a major nonillness problem or life event, such as a marriage or divorce, was an important factor that increased the total treatment delay.

Some people delay getting care for a long time, sometimes weeks or months, because they are not expe- riencing pain. This factor is potentially very important because pain is not a major symptom of many very serious diseases, such as hypertension. Pain is also not one of the main warning signs of cancer. Most people who notice a warning sign of cancer, such as a skin blemish or lump, wait a few weeks before seeing a physician for it, and perhaps a third delay more than 3 months (Antonovsky & Hartman, 1974; Bish et al., 2005). A heart attack often involves pain and requires treatment quickly: thrombolytic drugs can prevent myocardial damage if administered within 3 hours after the attack begins (AHA, 2010). Do heart attack victims seek treatment quickly? More than a third of them delay the decision for more than 3 hours, and those who seek treatment early are more likely to be men than women and have relatively high levels of problem-focused coping (Martin et al., 2004; O’Carroll et al., 2001; Walsh et al., 2004). People who lack health insurance or have financial concerns about being sick are more likely than others to delay (Smolderen et al., 2010). (Go to .)

DELAY

NO

YESYESYES

DELAY

NO

DELAY

NO

APPRAISAL DELAY ILLNESS DELAY

TOTAL DELAY

UTILIZATION DELAY

Is That Care Worth the

Costs?

Do I Need Professional

Care?

Am I Ill?

Enters Treatment

Notices Symptoms

Figure 9-3 Treatment delay is conceptualized as having three stages: appraisal delay, illness delay, and utilization delay. (From Safer et al., 1979, Figure 1.)

Chapter 9 / Using Health Services 237

HIGHLIGHT

A New Meaning for ‘‘Diehard’’ Sports Fan The 2004 baseball World Series play-

offs for the American League championship were in progress—and for fans, it was a big deal! The Boston Red Sox had come from behind and tied the series with their archrival, the New York Yankees, each having won three games. During the seventh and deciding game, the volume of patients at the emergency rooms of six Boston-area hospitals was about 15% below the normal or expected number (Reis, Brownstein, & Mandl, 2005). A few days earlier, when it looked like the Red Sox would not win the championship, the volume at the hospitals was about 15% above the expected number.

Deciding to go to an emergency room involves the person’s discretion, and failing to go for medical care is not unusual for diehard fans when critical games with popular teams are in progress. But we don’t know for sure why they don’t go. Do they simply not notice their symptoms? Do they notice the symptoms but appraise them as innocuous? Do they assess the barriers and benefits of going right away and decide that delaying a few hours won’t matter? As we’ve seen, delaying can matter a lot, depending on the health problem.

Reprinted courtesy of Bunny Hoest.

USING COMPLEMENTARY AND ALTERNATIVE MEDICINE When Elena feels a cold coming on, she takes echinacea, an herb that is extracted from a plant. Many people in various parts of the world, including industrialized nations, try to prevent or treat illnesses with practices or products, such as massage or herbal methods, not currently considered part of conventional medicine. As a group, these methods are called complementary and alternative medicine (CAM)—a method is complementary if used along with conventional treatments, and alternative if used in place of them. Although CAM methods are quite diverse, they can be classified into five types (NCCAM, 2006):

• Manipulative and body-based methods maneuver or move parts of the body, as occurs in chiropractic and massage procedures.

• Biologically-based methods apply materials found in nature, such as herbal products and dietary supplements.

• Mind-body interventions use techniques for enhancing the mind’s ability to manage body function and symptoms, as in progressive muscle relaxation and meditation.

• Energy therapies employ hypothesized or known physical energy fields, such as ‘‘biofields’’ believed to exist and surround the body and electric or magnetic fields.

• Alternative medical systems, such as traditional Chinese medicine and homeopathy, are complex theoretical approaches for treating illness that differ from and often preceded the development of the system of medicine practiced by professionals with MD degrees. These alternative systems often use one or more of the preceding four methods.

Although these treatments are viewed as uncon- ventional by medical societies in developed nations, many are widely used, traditional methods in other countries—such as China, Puerto Rico, and Haiti—and emigrants take these methods to their new lands (Ahn et al., 2006; Belluck, 1996; Bezkor & Lee, 1999). Some CAM procedures require the services of a practitioner, and others do not. Patients rarely tell their physicians that they use CAM treatments.

Who uses CAM? Probably most people around the world who use CAM learned to do so through their religious or cultural backgrounds. Individuals in the United States who use CAM tend to be well educated, have beliefs and values that are consistent with the method’s rationale, and have troublesome symptoms,

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such as pain or stress, that have not improved with standard medical care (Astin, 1998; CU, 2000; NCCAM, 2006). Over one-third of American adults use CAM; mind- body and biologically-based methods are the most fre- quently used types (USBC, 2010). A survey of thousands of North Americans regarding illness treatments in the prior 2 years found that most were satisfied with the medical care they received and, if they had tried CAM methods, had gotten better results from medical treat- ment for almost all illnesses (CU, 2000). Most CAM methods were not very successful, having helped the people ‘‘feel much better’’ in only 10–30% of cases, depending on the illness and method used. (Although there was no control group, a placebo would probably have gotten similar ratings.) Two alternative treatments, chiropractic and deep-tissue massage, were particularly successful for back pain.

A main issue for CAM methods is that they have little or no scientific evidence of their safety and effectiveness for treating specific disorders. Once sufficient evidence is found, they are adopted into conventional health care, as has occurred for the dietary supplements glucosamine sulfate to prevent and treat arthritis and folic acid to prevent birth defects (AMA, 2003; NCCAM, 2006). Some CAM treatments have been tested in careful experiments. At various points in this book, you will find evidence for the utility of relaxation techniques, deep- tissue massage, and biofeedback in treating pain and other chronic conditions, such as asthma and diabetes. Although spinal manipulation appears useful for treating back pain, it is not effective with tension headache (Bove & Nilsson, 1998). Many dietary supplements and herbal remedies are not very effective, and some have serious side effects (CU, 2004; Hurley, 2007), but a few have good evidence of success, such as in treating irritable bowel syndrome (Bensoussan et al., 1998). Smelling a lavender aroma does not reduce stress or pain (Kiecolt-Glaser et al., 2008). Some CAM methods have value, but others clearly do not. People who want to use a CAM treatment should look for independent information on its effective- ness and side effects and discuss it with their physicians. The National Center for Complementary and Alternative Medicine has a useful website (http://nccam.nih.gov).

PROBLEMATIC HEALTH SERVICE USAGE Sometimes health care usage becomes problematic, such as overusing it when there is no medical need because of the patients’ emotional distress. People in the general population commonly refer to these patients as ‘‘hypochondriacs’’ and think these people are either malingering or imagining symptoms, so that the illness is ‘‘all in their heads.’’

But this common view is inaccurate. Although some individuals do imagine symptoms and some malinger to get various benefits of the sick role, hypochondriacs tend to interpret real but benign bodily sensations as symptoms of illness (Williams, 2004). They may think, for example, that their gastric pains are signs of a serious disease rather than the results of eating spicy foods or amplify minor sensations, such as muscle soreness or twinges, and perceive them as very painful. Hypochondriasis is the tendency of individuals to worry excessively about their health, monitor their bodily sensations closely, make frequent unfounded medical complaints, and believe they are ill despite reassurances by physicians that they are not (AMA, 2003; Costa & McCrae, 1985; Kring et al., 2010). It is considered a psychiatric dis- order when it lasts at least 6 months and causes sig- nificant emotional distress or functional impairments. Psychotherapy with cognitive and behavioral methods can markedly reduce hypochondriasis (Kring et al., 2010; Thomson & Page, 2009).

Paul Costa and Robert McCrae (1980, 1985) have demonstrated an important link between hypochon- driasis and emotional maladjustment, or neuroticism, which involves a high degree of self-consciousness and ‘‘vulnerability to stress as well as the tendency to expe- rience anxiety, hostility, and depression’’ (1985, p. 21). Their analysis of people’s survey responses showed that somatic complaints increase with neuroticism and that the proportion of people who are hypochondriacs is not higher in old age than in earlier adult periods. Although these findings suggest that neuroticism leads to more unfounded health complaints (Costa & McCrae, 1985; Feldman et al, 1999), neuroticism has been linked also to the future development of a variety of diag- nosed illnesses, such as cardiovascular disease, arthritis, and irritable bowel syndrome (Turk-Charles et al., 2008; Lahey, 2009).

One other issue should be discussed: sometimes people may have real health problems that medical tech- nology cannot yet confirm. A clear example is a condition called chronic fatigue syndrome (CFS). The main symptom of CFS is unexplained, persistent severe fatigue for at least 6 months, but other symptoms can include sore throat and headaches (Hurwitz, 2004). Physicians had incorrectly thought this condition was an extended form of mononucleosis, which is caused by the Epstein-Barr virus, but it isn’t, and the cause remains a mystery. Although CFS has been linked with high allostatic load and low blood pressure (Maloney et al., 2009; Newton et al., 2009), there are no medical tests to detect CFS; diagnosis is based on ruling out all other diseases. Stud- ies attempting to link CFS with psychological disorders have produced inconclusive results (Hurwitz, 2004).

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To summarize, there are many reasons why people use, don’t use, overuse, and delay using health services. These reasons include the nature of the symptoms people perceive, the health beliefs they hold, and social and emotional factors. Another factor that affects people’s decisions to use health services is the quality of the relationships they have with their physicians, as we are about to see.

THE PATIENT–PRACTITIONER RELATIONSHIP

A woman who had been receiving treatment for cancer at a clinic on a regular basis began to procrastinate about going in for periodic examinations and care. When her family asked why she had not gone in on schedule, she replied, ‘‘They gave me a new doctor, and he’s not very nice. He treats me like a number, and I feel uncomfortable talking to him—he talks down to me when I ask him questions.’’ Many patients have stories about negative experiences with practitioners, and these experiences can lead people to delay or stop getting the medical attention they need. These stories often involve the practitioner’s hurried manner, insensitivity, lack of responsiveness, failure to explain the medical problem or the treatment, or unwillingness to involve the client in planning the treatment. Problems like these are likely to be aggravated if the client and practitioner have very different cultural backgrounds (Young & Zane, 1995).

When the general practitioner changes from one visit to the next, patients may have a difficult time establishing a good relationship with a physician. Reprinted courtesy of Bunny Hoest.

PATIENT PREFERENCES FOR PARTICIPATION IN MEDICAL CARE When people visit physicians about health problems, do they just want to be ‘‘cured,’’ or do they also want to know about the illnesses and how to treat them? How involved do they want to be in decisions and activities in their treatment? Physicians often misjudge the involvement patients want (Kindelan & Kent, 1987). Correctly judging the amount and type of participation they prefer can be important—patient–practitioner relationships depend to some extent on the compatibility between what the patient wants and what the practitioner provides.

People differ in the participation they want— although almost all want to know what their illnesses are and how to treat them, some want more details about the illnesses, self-administration of treatment, and involve- ment in decisions than others do. But most patients with a serious condition want substantial information and involvement (Stewart et al., 2004). Research has revealed important associations with clients’ participation pref- erences. First, gender, age, and sociocultural differences exist. In terms of the amount of information and involve- ment in medical decisions that Americans want, women want more than men do, younger adults want more than older adults do, and White people want more than Black or Hispanic individuals do (Levinson et al., 2005; Stewart et al., 2004; Turk-Charles, Meyerowitz, & Gatz, 1997). Second, receiving the desired amount and type of participation enhances individuals’ adjustment to and satisfaction with medical treatment (Auerbach, Martelli, & Mercuri, 1983; Stewart et al., 2004). Third, patients who report that they usually want or take an active role in their treatment tend to adjust to their recovery periods better and recover faster than those who prefer an inactive role (Auerbach, 2000; Mahler & Kulik, 1991).

Just as people differ in the information and involve- ment they want regarding their health, practitioners differ in the participation they are inclined to provide. Some doctors are less inclined than others to share their authority and decision making, often with the incorrect belief that clients are not able to understand medical information and make good decisions (Auerbach, 2000). What happens in the patient–practitioner relationship when the person wants a different level of participa- tion from what the practitioner gives? The mismatch has at least three important outcomes. First, the patients experience more stress during unpleasant medical pro- cedures (Auerbach, Martelli, & Mercuri, 1983; Miller & Mangan, 1983). Second, clients are less likely to follow the practitioner’s advice, such as for dietary changes, outside the medical setting and improve their medical conditions (Cvengros et al., 2009). Third, dissatisfaction

240 Part IV / Becoming Ill and Getting Medical Treatment

and interpersonal discomfort can lead to a switch in doc- tors (Haug & Lavin, 1981; Keating et al., 2002). In deciding how much information and involvement to provide each client, practitioners clearly need to assess and consider how much the person wants. (Go to .)

THE PRACTITIONER’S BEHAVIOR AND STYLE Imagine this test: you recently completed medical training and have just started a position in a clinic as a general practitioner. Your next patient this morning is waiting in an examination room, which you are preparing to enter. Your task will be to decide which one of more of the more than 1,300 disease entities known to medicine this person has (Mentzer & Snyder, 1982). Or maybe the person has no physical problem at all. You have 20 minutes.

Diagnosing and treating health problems are difficult tasks, which different physicians undertake with their own behaviors and styles of interacting with patients. Patrick

Byrne and Barrie Long (1976) identified different styles of interacting by analyzing about 2,500 tape-recorded medical consultations with physicians in several coun- tries, including England, Ireland, Australia, and Holland. Each physician tended to use a consistent style for all clients treated. Most of the styles were classified as doctor-centered, in which the physician asked ques- tions that required only brief answers—generally ‘‘yes’’ or ‘‘no’’—and focused mainly on the first problem the person mentioned. These physicians tended to ignore attempts by patients to discuss other problems. Doctor- centered physicians seemed to be intent on establishing a link between the initial problem and some organic dis- order, without being sidetracked. In contrast, physicians who used a patient-centered style took less controlling roles. They tended to ask open-ended questions, such as, ‘‘Can you describe the situations when the pain occurs?’’ that allow a patient to relate more information and intro- duce new facts that may be pertinent. They also tended to avoid using medical jargon and to allow clients to

HIGHLIGHT

Fighting for Your Life Not all victims of serious diseases

who are getting medical care receive the most effec- tive treatments available. Some physicians have dif- ficulty keeping up with rapid advances in medical knowledge or are reluctant to switch from a proce- dure that works reasonably well to one that may work better. What can people do to get the best possible treatment?

Patients and people close to them can join the fight for their lives by taking an active interest in their health care (CU, 2007; Gipson, Liskevych, & Swillinger, 1996). Let’s use a hypothetical case of a man named Morry who has a serious illness, such as heart disease or cancer. After learning the diagnosis, he and his family or friends can swing into action. They can:

• Get information about the disease and the usual courses of treatment. Information is readily available on the Internet and in books they can purchase in bookstores or use through public, college, and medical school libraries.

• Make a list of questions to ask at each meeting with physicians working on his case. Morry should have a companion accompany him and take notes in physician visits. They should ask to know all possible treatment options, what each involves, what the risks are, and the likelihood of success. Be sure

all uncertainties are cleared up before leaving each meeting.

• Broaden the sources of information. Organi- zations—such as the American Heart Association and American Cancer Society—have websites with information about support groups and treatment methods (most of these websites are included in the reference list for this book). At least one of the physicians Morry consults for treatment options should be certified in the specialty and, preferably, on staff at a major university or teaching hospital. Many people consult only the original physician on their case, and this is a mistake.

• Use reputable information sources to find out about very new medical procedures (and even some risky experimental ones). Even though many newer approaches may provide the most effective treatment, not all physicians know about them or feel comfortable about recommending them.

When patients and people close to them take an active interest in their health care, they can play an informed role in discussions and negotiations with their physicians toward making decisions. Patients who do this can be satisfied that they are getting the best treatment available and feel a sense of efficacy in themselves and in their physicians.

Chapter 9 / Using Health Services 241

Patients tend to prefer a physician who gives clear explanations about illnesses and treatments, encourages them to ask questions, and conveys a feeling of concern for them.

participate in some of the decision making. On average, physician visits take about 20 minutes, and longer visits tend to be of higher quality (Chen, Farwell, & Jha, 2009). Female physicians tend to use a more patient-centered style and spend 10% more time with patients than male physicians do (Krupat, 2004).

The patient–practitioner relationship depends on the ability of the two participants to communicate with each other. But physicians sometimes impede communication by using medical jargon or technical terms. For example, telling hypertensive patients to ‘‘reduce sodium intake’’ is an accurate recommendation, but will they know what it means? Some people will know exactly what sodium is, others won’t have any idea, and others will think it only means table salt, not realizing that there are other sources of dietary sodium. Studies have found that most patients, particularly those from lower- class backgrounds, fail to understand many of the terms their physicians use—such terms as ‘‘mucus,’’ ‘‘sutures,’’ and ‘‘glucose,’’ for instance (DiMatteo & DiNicola, 1982; IOM, 2004; McKinlay, 1975). Although jargon is useful for accuracy and for communicating among medical professionals, practitioners who use technical terms in talking with clients without explaining the terms or checking comprehension can create confusion, incorrect ideas, and dissatisfaction in them.

John McKinlay (1975) assessed lower-class women’s understanding of 13 terms their physicians used with them in a maternity ward. Although over two-thirds of the women understood the terms ‘‘breech’’ and ‘‘navel,’’ almost none understood ‘‘protein’’ and ‘‘umbilicus’’— and on the average, each of the 13 words was understood by only about 39% of the patients. McKinlay also had

the physicians indicate for each word whether they thought ‘‘average lower-working-class women’’ would understand the term. The physicians expected even less comprehension than the clients showed, yet they used these terms often with these women.

Why would physicians use terms with a patient when they do not expect the person to understand? Sometimes they may do this ‘‘out of habit,’’ that is, the terms are so familiar to them that they forget the client is less medically sophisticated. Or they may feel—perhaps in a patronizing way—that the person ‘‘doesn’t need to know.’’ Other reasons for using jargon may involve their perceptions of what would benefit the patient or the medical staff (DiMatteo & DiNicola, 1982; McKinlay, 1975). What might these benefits be? Sometimes the person’s knowing exactly what the disease or its treatment is may produce too much stress or interfere with treatment. And there can be another issue: using ‘‘big words’’ the client does not understand elevates the status of practitioners.

First and foremost, people prefer to have a prac- titioner they think is competent. But there are other important factors in the patient–practitioner relation- ship, too—especially the sensitivity, warmth, and concern the person perceives in the practitioner’s behavior. People prefer, evaluate highly, and express greater satisfaction for dentists and physicians who seem friendly and inter- ested in them as persons, show empathy for their feel- ings, project a sense of reassurance, and present a calm and competent image (CU, 2007; van Dulmen & Bensing, 2002; Weiner et al., 2005). In contrast, practitioners who seem emotionally neutral are often evaluated less posi- tively, perhaps because they appear unconcerned. People

242 Part IV / Becoming Ill and Getting Medical Treatment

assess these characteristics not just by the practitioner’s words, but by his or her facial expressions, eye con- tact, and body positions (DiMatteo, 1985; Krupat, 2004). The practitioner’s style can have important implications: greater satisfaction with the practitioner translates into a higher likelihood that patients will follow medical advice and keep medical appointments (DiMatteo, Hays, & Prince, 1986; Krupat, 2004).

Perhaps the most important implication of physi- cians’ styles relates to the diagnostic information they receive from their patients. Physicians vary greatly in their ability to elicit significant diagnostic information from their clients (Marvel et al., 1999; Roter & Hall, 1987). Physicians who ask more open- and closed-ended questions, allow clients to give a full answer, give more information about the cause and prognosis of the illness, and discuss more details about prevention and treatment receive more diagnostic facts from their clients than doc- tors who do less of these things. The additional facts doctors receive are not trivial ones, but ones other physi- cians judge to be important in diagnosing the person’s illness. The first complaint or detail the client gives is often not the most significant one, and getting a full statement of the client’s concerns takes only several additional seconds: at the start of a visit, the practitioner can elicit a list of the person’s concerns and then set

an agenda together (Mauksch et al., 2008). Findings like these have led medical schools to introduce programs to educate future physicians regarding interviewing skills and psychosocial factors in treating patients (Krupat, 2004; Weiner et al., 2005). (Go to .)

THE PATIENT’S BEHAVIOR AND STYLE It takes two to tango, as the saying goes. Although the practitioner’s behavior plays an important role in the relationship he or she forms with a patient, the client’s behavior and style are important, too. Physicians reported in surveys, for instance, that some patients do things that can be unsettling for a doctor (CU, 2007; Smith & Zimny, 1988). Some of these behaviors include:

• Not following the prescribed treatment.

• Waiting too long with symptoms before contacting the doctor.

• Insisting on laboratory tests, medications, or procedures the physician thinks are unnecessary.

• Requesting that the doctor certify something, such as a disability, the physician thinks is untrue.

• Making sexually suggestive remarks or behaviors toward the physician.

ASSESS YOURSELF

Do You Know Medical Terms’ Meanings? The following 10 medical terms were

used in McKinlay’s (1975) study of patients’ understand- ing of medical jargon, which is described in the text. Match the terms with the definitions given below: in the space preceding each term, place the number for the corresponding definition.

antibiotic mucus

breech protein

enamel purgative

glucose suture

membrane umbilicus

1. The rump or back part. 2. A small scar on the abdomen; the navel. 3. A substance that makes up plant and animal tissue.

4. A simple sugar that the body manufactures from ingested food.

5. A joining together of separated tissue or bone, or a device to achieve this joining.

6. A sheet of tissue that covers or lines a body organ. 7. An agent that works against bacterial infections. 8. A hard, glossy coating or surface. 9. A substance or procedure that causes a cleansing of

a body organ, as occurs in a bowel movement.

10. A secretion of body tissues.

Check your answers against the key below. Did you get them all correct? Would you have known as many of the definitions if they weren’t given? Would your friends— especially ones who have not gone to college—know the terms?

Answers, in order:

7, 1, 8, 4, 6, 10, 3, 9, 5, 2.

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If behaviors such as these lead to a breakdown in the relationship between the patient and practitioner, the quality of the medical care may suffer.

Do patients do things that impair patient– practitioner communication? Yes. For one thing, people who are high in neuroticism may convey too much concern about their conditions and seem less credible and less in need of medical care (Ellington & Wiebe, 1999). Also, some clients describe their symptoms in unclear or misleading ways. Let’s consider two examples. First, a patient simply said, ‘‘I can’t see to thread a needle or read the paper,’’ and didn’t clarify what the problem was—it was far-sightedness—even when asked (Zola, 1973). Second, a woman with chest pain and dizziness for a month finally went to a doctor, who had tried unsuc- cessfully to identify what symptoms had gotten worse. He tried one more time, and then became exasperated by her repeated ambiguity (Seaburn et al., 2005, p. 525):

PHYSICIAN: What’s been worse over the last month?

PATIENT: The sharpness mostly and the dullness gets a little bit …

PHYSICIAN: And you didn’t think it would be a good idea to see a doctor sooner than today for something that has been going on for a month? It didn’t cross your mind?

PATIENT: Do you think this could be serious?

PHYSICIAN: If it was serious, you’d be dead by now.

Her symptoms were ones that people with heart condi- tions often report, and her doctor was upset by her ambiguity and delay in seeking medical care. The patient– practitioner relationship was clearly strained.

Why do patients give unclear descriptions of their symptoms? Let’s look at a few reasons. One reason may lie in the way they perceive or interpret different symp- toms. As we saw earlier, people differ in the attention they pay to internal states and the degree to which they associate different sensations with health problems. Sec- ond, individuals form different commonsense models of illness. When reporting symptoms to a doctor, people may describe only or mainly those problems they think are important, based on their own notions (Bishop & Converse, 1986). Third, clients may try either to empha- size or to downplay a symptom they believe may reflect a serious illness. For example, people high in hypochon- driasis may try to maximize the physician’s attention to a sensation they are worried about, and other patients may describe a worrisome symptom very casually or offhand- edly in the hope that the doctor will agree that ‘‘it’s nothing.’’ Last, the clients may be very young or immi- grants and lack a good command of the practitioner’s primary language, making their symptom descriptions

unclear and incomplete (Giachello & Arrom, 1997). These patients are also unlikely to understand fully what their illnesses are or what they need to do to treat them.

What can be done to improve communication between patients and practitioners? Physicians’ inter- viewing skills can be enhanced with training programs that teach how and when to summarize information, ask questions, and check for comprehension (Roter & Hall, 1989; Weiner et al., 2005). Researchers have also found that a simple approach can improve clients’ communication: while patients wait for their visits, they can fill out a form that has them list any symptoms and questions they have and encourages them to ask questions when they see the doctor (Thompson, Nanni, & Schwankovsky, 1990).

One thing to keep in mind about patient–practitioner communication is that often practitioners lack feedback for their work. For example, although a patient may visit the doctor again if symptoms persist or if the illness is serious or long term, physicians cannot be certain that not hearing from a person means a diagnosis was correct or the treatment was effective. And as we are about to see, practitioners usually cannot be sure to what extent a client is following the medical regimen—the treatment program or lifestyle change—they recommended.

COMPLIANCE: ADHERING TO MEDICAL ADVICE

‘‘Now don’t tell the doctor, but I don’t always take my medicine when I’m supposed to,’’ Amy whispered to a friend in her physician’s waiting room. People don’t always adhere to, or comply with, their practitioner’s advice. Adherence and compliance are terms that refer to the degree to which patients carry out the behaviors and treatments their practitioners recommend. Most researchers have used these terms interchangeably, and we will, too. But adherence is a better term because it suggests a collaborative nature of treatment, and the dictionary definition of the word compliance—‘‘giving in to a request or demand’’ or ‘‘acquiescence’’—suggests that the person obeys reluctantly (DiMatteo & DiNicola, 1982; Wiebe, 2004). The remainder of this chapter examines the extent of clients’ failure to follow medical advice, why they do and do not comply, and what can be done to increase their adherence.

EXTENT OF THE NONADHERENCE PROBLEM How widespread is the problem of noncompliance? Answering this question is actually more difficult than

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it may seem (Dunbar-Jacob & Schlenk, 2001; Marteau & Weinman, 2004). First of all, failures to adhere may occur for many different types of medical advice. For instance, patients may fail to take medication as directed, not show up for appointments, skip or stop doing rehabilitation exercises, or ‘‘cheat a little’’ in following specific diet or other lifestyle changes advised by practitioners. Second, people can violate each of these types of advice in many different ways. In failing to take medication as directed, for example, they might omit some doses, use a drug for the wrong reasons, take medication in the wrong amount or at the wrong time, or discontinue the drug before the prescribed course of therapy ends. Finally, there is a problem in determining whether a person has or has not complied: What is the most accurate and practical way to assess compliance?

Researchers assess patient adherence to medical recommendations in several ways, and each has advan- tages and disadvantages (Dunbar-Jacob & Schlenk, 2001; Rand & Weeks, 1998; Wiebe, 2004). One of the easiest approaches for measuring compliance is to ask a prac- titioner who works with the client to estimate it. As it turns out, however, practitioners do not really know; they generally overestimate their patients’ compliance and are poor at estimating which clients adhere better than others. Another simple approach is to ask the patient. But people tend to overreport their adherence, per- haps because they know they should ‘‘follow the doctor’s orders.’’ These two methods are very subjective and open to various forms of bias, including lying and wishful think- ing. As a result, researchers who use these approaches today often supplement them with reports of family members or medical personnel and with other methods that are more objective. Table 9.2 describes three rela- tively objective approaches for assessing adherence to using medication.

Despite the complexities in assessing adherence, we can provide some general answers to the question we started with: How widespread is noncompliance?

Speaking in very broad terms, the average rate of nonad- herence to medical advice is about 40%—that is, two of every five patients fail to adhere fairly closely to their regimens (DiMatteo, 1985; Rand & Weeks, 1998). Conversely, the overall rate of adherence is about 60%. Adherence varies considerably, depending on the type of medical advice, the duration of the recommended regimen, and whether its purpose is to prevent an illness from occurring or to treat or cure an illness that has developed. An overview of the findings of research on compliance indicates the following conclusions (Dunbar-Jacob & Schlenk, 2001; Shearer & Evans, 2001; Stilley et al., 2010):

• The average adherence rate for taking medicine to treat acute illnesses with short-term treatment regimens is about 67%; for chronic illnesses with long-term regimens, the rate drops to 50–55%.

• Adherence to taking medicine is higher in the days before and after visiting a doctor than at other times.

• Adherence to recommended changes in lifestyle, such as stopping smoking or altering one’s diet, is generally quite variable and often very low.

Keep in mind three things about these conclusions. First, the percentages stated may overestimate adherence because most studies have included in their samples only people who agreed to participate (Cluss & Epstein, 1985). It’s likely that people who do not participate differ from those who do, such as by having lower health motivation. Second, the adherence rates cited do not reflect the range of noncompliance: some patients adhere exactly to a medical regimen, others do not comply at all, and probably most adhere to some degree. Third, nonadherence can have serious health effects: CHD patients with low adherence to taking their prescribed medication or making lifestyle changes are far more likely than those with high adherence to have or die from a stroke or heart attack in subsequent months or years (Chow et al., 2010; Gehi et al., 2007).

Table 9.2 Objective Methods for Assessing Adherence to Using Medication

• Pill or quantity accounting, in which the remaining medication is measured, such as by counting the number of pills left. This is compared against the quantity that should be left at that point in treatment if the patient has been following the directions correctly. Of course, this method does not reveal whether the person used the medication at the right times, and patients who expect an accounting and want to conceal their noncompliance can discard some of the contents.

• Medication-recording dispensers contain mechanical or electromechanical recording devices that can count and record the time when the dispenser is used. Although this approach is expensive to implement, it assesses compliance accurately as long as the patient does not deliberately create a ruse. If patients know about the device and want to avoid taking the medicine, they can operate the dispenser at the right time and discard the drug.

• Biochemical tests, such as of the patient’s blood or urine. This approach can assess whether medication was used recently, but usually cannot determine how much or when, and it can be very time-consuming and expensive to implement.

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WHY PATIENTS DO AND DO NOT ADHERE TO MEDICAL ADVICE Given that practitioners don’t generally know how well their clients adhere to medical advice, what do they think when they learn their patients have not followed their advice? They are concerned about the effects of noncompliance on the person’s health, of course, and they tend to place most of the ‘‘blame’’ on the patients’ ‘‘uncooperative’’ personalities, inability to understand the advice, or difficult life situations (Davis, 1966). But as we’ll see, both the practitioners and patients impact adherence, and an individual’s adherence depends on characteristics of (1) the illness or regimen, (2) the person, and (3) the interactions between the practitioner and patient.

Medical Regimens and Illness Characteristics The medical regimens practitioners advise can differ in many ways, such as in their complexity, duration, cost, side effects, and the degree to which they require changes in the patient’s habits. Let’s see how each of these factors relates to compliance.

Some regimens require clients to change longstanding habits—for example, to begin and maintain exercising regularly, reduce the calories or certain components in their diets, stop smoking cigarettes, or cut down on drinking alcoholic beverages. We have seen in previous chapters that these changes can be very difficult for people to make. Recommendations by physicians can induce many patients to make changes in such habits, particularly if the individuals are at high risk for serious illness (Dolecek et al., 1986; Pederson, 1982). But studies have consistently found that people are much less likely to adhere to medical advice for changes in personal habits than to advice for taking medication (Dunbar- Jacobs & Schlenk, 2001; Haynes, 1976).

Some treatment regimens are more complex than others—such as by requiring the person to take two or more drugs, each with its own special instructions: ‘‘Take one of these pills after meals, and two of these other pills at bedtime, and one of these other pills every 8 hours.’’ As you might expect, the greater the number of drugs and the more complex the medication schedule and dosage, the greater the likelihood the person will make an error, thereby failing to adhere to the regimen (Ingersoll & Cohen, 2008; Wiebe, 2004). Regimens also become difficult if they require a variety of complicated tasks, as, for example, individuals suffering from chronic kidney disease must do (NKF, 2010; Swigonski, 1987). Many of these patients must:

• Undergo hemodialysis, in which the blood is shunted from an artery to a filtering apparatus and returned to a vein. This procedure generally takes about 4 hours three times a week, during which complications may occur, such as an extreme drop in blood pressure.

• Take large quantities of medication and vitamins— sometimes involving dozens of pills a day—while also strictly limiting fluid intake.

• Severely restrict their dietary intake of sodium, mainly salt; potassium and phosphorus, which are found in many fruits and vegetables; and protein, especially meats and dairy products.

In general, the more a client is required to do, the more likely compliance will suffer.

The duration, expense, and side effects of a medical regimen are also factors in people’s adherence to their practitioner’s advice. Studies have confirmed the role of duration—compliance tends to decline over time (Parrish, 1986; Wiebe, 2004). Short-term regimens are usually prescribed for acute illnesses and show clear beneficial effects fairly quickly, but long-term regimens usually apply to chronic health problems and have slower

Reprinted by permission of United Feature Syndicate, Inc.

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and less obvious benefits. The expense and side effects of treatment play a role, too. Most people will adhere to treatment because they have sufficient incomes or insurance to pay for it or feel the benefits of the treatment are essential despite the cost, and most drugs don’t have noticeable or worrisome side effects. But what happens, for instance, when individuals cannot afford their medicine or its side effects do become a problem? Some patients may reduce the dosage of the drug or discontinue using it entirely. The expense and side effects of treatment can impair adherence for many people (Murdaugh, 1998; NCHS, 2009a; Piette, Heisler, & Wagner, 2004).

We might expect that individuals who have health problems that could disable them or threaten their lives would be more likely to adhere to their treatment reg- imens than people with less serious illnesses. Whether this idea is correct seems to depend on whose perspec- tive of the severity of the health problem we consider— the practitioner’s or the patient’s. When comparisons are based on illness severity judged by physicians, clients with serious illnesses are no more likely to adhere than those with milder health problems (Becker & Rosenstock, 1984; Haynes, 1976). Perhaps this is because many very serious health problems, such as hypertension and atheroscle- rosis, have no symptoms that worry people greatly or interfere with their functioning; on the other hand, many less serious illnesses do have such symptoms. In contrast, when comparisons are based on illness severity judged by patients who have the health problem, clients who rate their illness as relatively serious generally show better adherence to their treatment regimens than those who perceive their illness to be less severe (Becker & Rosenstock, 1984; Stafford, Jackson, & Berk, 2008).

Age, Gender, and Sociocultural Factors Research has found little or no association between compliance in general and clients’ specific personal and demographic characteristics, such as their age, gender, social class, race, and religion (Cluss & Epstein, 1985; Wiebe, 2004). Does this mean these factors never affect compliance? Probably not. For one thing, although each of these factors is not by itself strongly related to adher- ence, when they are joined—for example, gender plus age plus social class—their combination shows a stronger association to compliance (Korsch, Fine, & Negrete, 1978). What’s more, some of these factors may be related to adherence in some circumstances but not others.

Consider the factor of age, which seems to affect adherence in different ways, depending on the illness. For example, research found that:

• For childhood cancer patients, problems in adherence to specific care procedures, such as using antibiotics correctly, were greater for younger than for older children (Manne et al., 1993). Although the parents mainly controlled these procedures, the child’s age made a difference.

• Among child and adolescent diabetics, adolescents were less adherent to their special diets than children (Johnson et al., 1992).

• For adult arthritis patients, 47% of 55- to 84-year-olds and only 28% of 34- to 54-year-olds made no medication errors in several weeks of monitoring; middle-aged people with very busy lives made the most errors (Park et al., 1999).

Children become increasingly responsible for their own medical treatment as they get older (La Greca & Stone, 1985). Adolescents may be less likely than individuals from other age groups to comply with long- term treatments that single them out or make them different from peers. And the elderly are more likely than other age groups to suffer from visual, hearing, and cognitive impairments that may lead to noncompliance (Murdaugh, 1998).

Gender and sociocultural influences on adherence may also depend on specific circumstances. For instance, women’s concern about controlling their weight appears to interfere with using medication to control their blood sugar (Polonsky et al., 1994). Two sociocultural factors are important. First, some cultural groups may have beliefs or customs that undermine adherence. As an example, among American Indians, the idea ‘‘of taking something all the time, like an antihypertensive drug, is foreign to some cultures where ‘cure’ is inherent to the healing process, thus making medications that must be taken continuously appear ineffective’’ (Baines, 1992). Second, minority groups often have low literacy rates and high health risks; special efforts are needed to enhance regimen adherence in patients with low literacy (Marteau & Weinman, 2004; Pignone et al., 2005).

Psychosocial Aspects of the Patient We saw earlier that the seriousness of an illness and the costs of its treatment can affect compliance, depending on the point of view of the patient. Perceived seriousness and perceived costs and benefits are two psychosocial factors that should have a familiar ring by now—we have examined them more than once before as components in the health belief model. The health belief model components are as important in explaining why people do and do not adhere to medical advice as they are in explaining other health-related behaviors, such as whether people are likely to adopt health behaviors or

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use health services (Becker, 1979; Becker & Rosenstock, 1984). Thus, a patient who feels threatened by an illness and believes the benefits of the recommended regimen outweigh the barriers is likely to adhere to his or her practitioner’s advice. But individuals who do not feel threatened by the health problem or assess that the barriers of the regimen outweigh the benefits are unlikely to comply.

Sometimes not adhering to a treatment regimen may be deliberate and based on valid reasons, regardless of whether they are medically sound (Kaplan & Simon, 1990; Turk & Meichenbaum, 1991). This is called rational nonadherence. How can not adhering to medical advice be rational? Patients may be acting rationally when they fail to take medication as directed because they:

• Have reason to believe the medication isn’t helping.

• Feel that its side effects are very unpleasant, worrisome, or seriously reducing the quality of their lives.

• Are confused about when to take it, or how much.

• Don’t have the money to buy the next refill.

• Want to ‘‘see if the illness is still there’’ when they withdraw the medication.

These are not unreasonable reasons—and sometimes the clients may be medically correct in not adhering, such as when they experience symptoms they think may be serious side effects. Very common intentional reasons for not taking medication are its side effects and cost, and a preference to take as little medicine as possible (Lorish, Richards, & Brown, 1989; Pound et al., 2005). But most nonadherence in taking medication occurs unintention- ally: by forgetting (Dunbar-Jacob & Schlenk, 2001).

Adherence to medical advice is often affected by cognitive and emotional factors, and Table 9.3 describes the impact on patients’ memory when these factors operate at the time that clients receive instructions. For people to comply with a treatment regimen, they must be cognitively and emotionally able to understand and remember what they are to do. The directions patients receive are often complex and given at a time when they

may not be listening as carefully as they should. Even when health information is given in writing, most adult patients may not understand it if it is written much above the fifth-grade reading level (Estey, Musseau, & Keehn, 1994). The role of cognitive function and emotions on adherence can also be important outside of medical settings. People who have difficulty paying attention, remembering, or planning adhere less well than others to taking medications at the correct time and dosage (Stilley et al., 2010). And negative affect, especially depression, has been linked to low levels of adherence (Marteau & Weinman, 2004; Trivedi et al., 2008).

Two other psychosocial factors that are associated with adherence are self-efficacy and social support. Generally speaking, people who feel they can carry out the regimen and receive the comfort, caring, and help they need from family, friends, or support groups are more likely to follow medical advice than clients who have less social support (DiMatteo, 2004; Dunbar-Jacob & Schlenk, 2001). Self-efficacy can include the person’s confidence in being able to perform the activities or recover from lapses or other setbacks (Schwarzer et al., 2008). Social support is most effective when a cohesive family gives tangible or instrumental support in caring for the medical regimen. But for some people, such as kidney disease patients who must restrict fluid intake, social relationships can sometimes lead to nonadherence (Swigonski, 1987). This may happen because social gatherings often occur with food and beverages present—in meetings for lunch, dinner, drinks, or just a cup of coffee, for instance. Some evidence indicates that individuals who are low in con- scientiousness are more likely to be led astray by social support than people who are high in conscientiousness (Moran, Christensen, & Lawton, 1997).

PATIENT–PRACTITIONER INTERACTIONS The word ‘‘doctor’’ comes from the Latin docere, which means ‘‘to teach.’’ Two features of good teaching involve explaining information in a clear and organized fashion and assessing whether the learner has learned

Table 9.3 Cognitive and Emotional Factors in Patients’ Recall of Information from Physicians

1. Patients forget much of what the doctor tells them. 2. Instructions and advice are more likely to be forgotten than other information. 3. The more a patient is told, the greater the proportion he or she will forget. 4. Patients will remember: (a) what they are told first and (b) what they consider most important. 5. More intelligent patients do not remember more than less intelligent patients. 6. Older patients remember just as much as younger ones. 7. Moderately anxious patients recall more of what they are told than highly anxious patients or patients who are not anxious. 8. The more medical knowledge a patient has, the more he or she will recall.

Source: Cassata, cited in DiMatteo & DiNicola, 1982, p. 45.

248 Part IV / Becoming Ill and Getting Medical Treatment

or understands. Some medical practitioners are good teachers, and others are not:

for example, there are documented cases of men con- suming contraceptive drugs intended for their wives. The idea may be amusing, but the fact of an unwanted child was not. (Hunt & MacLeod, 1979, p. 315)

This example illustrates that physicians do not always make sure the patient understands what they have said. Successful communication in patient–practitioner interactions is essential if the client is to adhere to the advice.

Communicating with Patients If your physician told you to ‘‘take one pill every 6 hours,’’ does that mean you should wake up in the middle of each night to take one? Or would it be OK simply to take four pills a day, equally spaced during your waking hours? Would you ask? Sometimes the information people get from practitioners is not very clear. You might argue that the advice was clear: every 6 hours, on the dot. But practitioners need to anticipate unspoken questions—saying, for instance, ‘‘You’ll need to wake up to take one because the infection may recur if the medicine wears off.’’ If practitioners don’t do this, patients usually answer these questions themselves, often incorrectly.

Many people leave their doctors’ offices not knowing how to follow their treatment regimens. Bonnie Svarstad (1976) conducted a study in which she interviewed patients at a community health center, recorded their actual verbal interactions with their physicians, and checked their medication containers a week later. This study revealed four findings. First, the patients’ knowledge about their treatment was deficient—for example, half did not know how long to continue the medication, and about one-fifth did not know the purpose of or how often to take the prescribed drugs. Second, the patients’ poor knowledge often resulted from the physicians not providing the needed information. Third, the clients asked very few questions during the visits. Fourth, the more explicit the doctors’ directions, the more the people complied, which was measured by pill counts at the patients’ homes about a week later. Today, many pharmacies provide instructions.

Physicians spend very little time giving information to patients during a visit. The average visit lasts about 20 minutes (Chen, Farwell, & Jha, 2009; Krupat, 2004). Studies assessing hundreds of visits have examined the amount of time physicians spend giving information to clients about their illnesses and treatment: averaging across the studies, it appears that doctors spend perhaps

10% of the time, or 2 minutes, giving patients information (DiMatteo, 1985). But the doctors themselves reported a very different picture: when asked how much time they spent giving information, they gave estimates that were several times higher than the research records showed (Waitzkin & Stoeckle, 1976). A person’s adherence to medical advice depends on the practitioner’s communi- cating information. Good communication takes time and is much more likely to occur when the practitioner’s style is more patient-centered than doctor-centered.

Adherence and the Patient–Practitioner Relationship As we have seen, people generally prefer medical care that involves a patient-centered style. Research has shown that individuals who have good relationships with their physicians are more likely to adhere to the medical advice they give (DiMatteo, 1985; Garrity, 1981; Krupat, 2004). For example, researchers found that mothers who were very satisfied with the warmth, concern, and communication of information of their child’s physician were three times more likely to adhere closely to the regimens than mothers who were dissatisfied (Francis, Korsch, & Morris, 1969). It may be that doctors who succeed in fostering compliance are those who use patient-centered styles.

To summarize, the reasons why patients do and do not adhere to medical advice include characteristics of the illness and regimen, the clients and practitioners, and the way these people interrelate or communicate. While reading this material, you may have thought, ‘‘Couldn’t many of the circumstances that lead to nonadherence be changed to enhance compliance?’’ The next section examines this question.

INCREASING PATIENT ADHERENCE Implicit in our interest in enhancing adherence is the assumption that doing so would benefit the person’s health. How important is adherence to the patient’s health? If it is very important, should health care workers aim for each client to comply perfectly to his or her regimen, or would a lesser degree of adherence be acceptable? We will address these questions briefly before considering ways to increase compliance.

Noncompliance and Health Outcomes By not adhering to regimens recommended by their physicians, people increase their risk of developing health problems they don’t already have or of prolonging or worsening their current illnesses. Hospital admissions

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are substantially higher for people who fail to follow medication regimens for serious conditions, such as hypertension (Dunbar-Jacobs & Schlenk, 2001). And prospective studies of people with serious illnesses have shown that individuals who adhered poorly to their medical regimens were much more likely to die during 1- or 2-year follow-up periods than people who adhered well. For example, two studies found higher mortality rates in heart disease patients who adhered poorly to taking drugs to prevent heart attacks (Ho et al., 2006; Irvine et al., 1999); another study found higher death rates among kidney disease patients who adhered poorly to dialysis treatments (Kimmel et al., 1998). For HIV drug treatment, strict adherence to the regimen is necessary to prevent the virus from rebounding and developing drug resistance (Catz et al., 2000; Ingersoll & Cohen, 2008).

But failing to follow a practitioner’s orders exactly is not always detrimental to the client’s health. One reason is that the effect of nonadherence is greater for serious and chronic illnesses than for less serious conditions (DiMatteo et al., 2002). Another reason may be that physicians sometimes prescribe drugs or other procedures with nonmedical goals in mind, such as to avoid risking malpractice suits. But even when medically sound regimens are given—as in the great majority of cases—some people who follow their doctors’ orders closely show little benefit from the treatment, whereas others who are much less compliant show substantial improvements in their health (Cluss & Epstein, 1985; Hayes et al., 1994). The importance of following medical advice closely seems to depend on the particular health problem and the treatment prescribed: for some illnesses, 80% adherence for the medication may be the minimum level of compliance needed; for other health problems a 50% rate may be sufficient. Unhealthful noncompliance might be defined as ‘‘the point below which the desired preventive or therapeutic result is unlikely to be achieved with the medication prescribed’’ (Parrish, 1986, p. 456). Unfortunately, compliance cutoff points still need to be established for specific illnesses and treatments.

Although research is needed to determine compli- ance cutoff points, two things should be clear. First, perfect adherence may not be necessary in many cases. Second, the current adherence levels of clients are very far from perfect.

Improving Physicians’ Communication Skills Probably most physicians in the past who have dealt with the compliance problem at all did so after the fact. Rather than trying to prevent noncompliance, they tried to correct it if and when they learned about it. How did

they try to correct it? A study examined this question and found that the first step physicians used when a client failed to adhere was to give a ‘‘thorough explanation of the regimen and repeat it so that the patient understands’’ (Davis, 1966). As we have seen, explaining the regimen and making sure the person understands can prevent noncompliance in the first place.

Getting practitioners to improve their style of communicating with patients is not necessarily difficult to accomplish. One study presented a brief program to instruct physicians at a hospital clinic about the kinds of reasons hypertensive people have for not adhering to their regimens and about ways to detect and improve low compliance (Inui, Yourtee, & Williamson, 1976). Compared to doctors in a control group, the physicians who received the program subsequently spent more time giving information during patient visits—and, more important, their clients showed more knowledge about their regimens and illnesses, greater adherence in taking medications, and better blood pressure control. Oftentimes such changes in physician behavior last indefinitely (Roter & Hall, 1989). (Go to .)

Interventions Directed at Patients Other approaches to promote adherence focus on the patient. One method that seems to help at least for short-term regimens is to have the person state explicitly that he or she will comply. In an experiment with parents of children suffering from acute infections, parents who were asked to promise (all agreed) to give all of the medi- cation doses had higher compliance rates than those who were not asked to promise to comply (Kulik & Carlino, 1987). And the children of the parents who promised showed greater recovery later from their illnesses. For long-term regimens, a useful simple approach is to have the physician’s office send follow-up letters explaining why the treatment is important and the risks if the regimen isn’t followed (Smith et al., 2008). Although follow-ups and other simple methods help, they improve adherence only modestly (Haynes et al., 2008).

Social and motivational forces in a patient’s life can have important effects on adherence, particularly when the regimen is long term or requires lifestyle changes. One helpful approach that we discussed in Chapter 6 is for practitioners to use motivational interviewing methods to identify the benefits and problems of adherence and to reduce resistance to implement the regimen (Resnicow et al., 2002; Shearer & Evans, 2001). Another approach is for the practitioner or client to recruit constructive sources of social support (Jenkins, 1979; Shearer & Evans, 2001). Family and friends who are committed to the regimen can promote compliance by

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CLINICAL METHODS AND ISSUES

How to Present Medical Information Because patients often misunderstand

or forget medical recommendations, practitioners are also learning specific techniques for presenting medical information. Several methods are particularly effective (Parrish, 1986; Schraa & Dirks, 1982; Shearer & Evans, 2001). These methods include:

• Orienting patients to the disease process and rea- son for the treatment in terms they can under- stand.

• Simplifying verbal instructions by using clear and straightforward language and sentences, without con- descending.

• Using specific and concrete statements—such as, ‘‘You should walk a mile a day for the first week, and

2 miles after that,’’ instead of, ‘‘You should get daily exercise.’’

• Breaking down a complicated or long-term regimen into smaller segments. The patient might begin the regimen by doing only part of it and then adding to it later. Or the regimen might involve a series of smaller goals that the client believes he or she can achieve.

• Emphasizing key information by stating why it is important and offering it early in the presentation.

• Using simple, written instructions.

• Having the patient repeat instructions or state them in his or her own words.

• Assessing the person’s self-efficacy, motivation, and opportunities for social support in the regimen.

having positive attitudes about the treatment activities and making sure they occur. Effective social support can also come from self-help and support groups established to give information and assistance with specific health problems. Practitioners can help clients make contact with appropriate groups.

Several behavioral methods are also useful in enhanc- ing patients’ motivation to adhere to their treatment regimens (Burke, Dunbar-Jacob, & Hill, 1997; Haynes et al., 2008; Roter et al., 1998; Wiebe, 2004). These methods include:

• Tailoring the regimen, in which activities in the treatment are designed to be compatible with the patient’s habits and rituals. For example, taking a pill at home at breakfast or while preparing for bed is easier to do and remember for most people than taking it in the middle of the day.

• Providing prompts and reminders, which serve as cues to perform recommended activities. These cues can include reminder phone calls for appointments or notes posted at home that remind the client to exercise. Innovative drug packaging can also help—for instance, some drugs today come in dispensers with dated compartments or built-in reminder alarms.

• Self-monitoring, in which the patient keeps a written record of regimen activities, such as the foods eaten each day.

• Behavioral contracting, whereby the practitioner, the client, and a family member negotiate a series of treatment activities and goals in writing and specify rewards the patient will receive for succeeding.

A major advantage of these methods is that the client can become actively involved in their design and execution (Turk & Meichenbaum, 1991). Furthermore, the patient can carry them out alone or with the aid of the practitioner, family, or friends.

The procedures we have examined for increasing patient compliance are often combined into a complex program, particularly to enhance medication adherence for people with chronic illnesses, such as hypertension or heart disease. But these programs have been only moderately effective so far, and new methods are needed (Haynes et al., 2008). Some current methods are easy for practitioners to incorporate into existing ways of working with clients, but others are time-consuming to apply and involve skills that are outside the expertise of most medical workers.

FOCUSING ON PREVENTION

Health-care systems have focused mainly on secondary and tertiary prevention—that is, treating an illness to reverse the condition or to contain or slow its progress— and have developed processes for managing chronic diseases. This approach is called the chronic care model. Can the chronic care model be applied to promote pri- mary prevention and help people avoid health problems? Researchers have proposed that it can if efforts for pri- mary prevention in a health care organization incorporate six features of the chronic care model (Glasgow et al., 2001):

Chapter 9 / Using Health Services 251

1. Organization of care. The administrators of the health care system give explicit and obvious priority to primary prevention, such as identifying smokers and helping them quit, and provide incentives for staff to engage in these efforts.

2. Clinical information systems. The organization requires reg- ularly updated, easily accessed data in clients’ files regarding the need for and status of preventive services so that clients and staff can receive performance feedback and reminders.

3. Delivery-system design. Physicians initiate preventive inter- ventions, such as mailings and counseling for stopping smoking, which nonphysicians carry out.

4. Decision support. The organization provides its staff with guidelines, training, and reminders to identify clients who need intervention and to carry it out.

5. Self-management support. The health care system provides information and referrals to clients and their families help them recognize the need for preventive services and for change in unhealthful behaviors.

6. Community resources. The health care system extends its prevention efforts into the community by making use of self-help organizations, such as for quitting smoking and losing weight, and supporting public health programs and laws.

The chronic care model provides a blueprint for designing prevention programs in health care organizations, some of which have already begun to use it and improve prevention.

SUMMARY

Health care systems for the delivery and management of medical care are complex, involving professionals with a variety of specialized functions. Inpatient treatment for people with serious illnesses occurs in hospitals; nursing homes provide care mainly for elderly individuals who need long-term medical and personal care. Health care systems in many countries provide insurance for all citizens. The United States didn’t have a system of universal health coverage before 2010, but a law was passed so that almost all citizens will be insured in a few years.

People decide they are sick and in need of medical attention chiefly on the basis of the symptoms they perceive. They often consult a lay referral network before going to a physician. Some people seem to notice changes in physical sensations more than others do and to perceive these sensations as symptoms. Stimuli in the environment can interfere with or mask people’s attention to internal sensations. Because people generally do not assess their internal states very accurately, psychosocial factors can influence perceptions of symptoms, which may account for the phenomena of medical student’s disease and mass psychogenic illness. Commonsense models and other knowledge people extract from their experience generally help them to make appropriate decisions about seeking medical attention. But sometimes people’s knowledge of iatrogenic conditions and their emotions, such as intense fear or anxiety, can lead them to interpret their symptoms incorrectly and lead to treatment delay.

Young children and the elderly use health services more than adolescents and young adults do, and women use more medical services and drugs than men do. Many people use complementary and alternative medicine methods to supplement or take the place of medical care. The health belief model has been useful in helping

to explain why people use, don’t use, and delay using health services. Many individuals wait months before seeking attention for symptoms of serious illnesses, such as cancer. In contrast, some people overuse health services. Hypochondriasis involves the tendency for a person to interpret real but benign bodily sensations as symptoms of illness despite reassurances by a doctor that they are harmless. This tendency is linked to emotional maladjustment.

People generally express high levels of satisfaction with the care they receive from physicians who communi- cate with a patient-centered rather than a doctor-centered style. Patient-centered physicians tend to ask open-ended questions, avoid using medical jargon or technical terms, and allow clients to participate in some of the decision making regarding the treatment of their illness. These doc- tors are also likely to project feelings of concern and reassurance and to give clear explanations about ill- nesses and treatments. Of course, patients vary in their behaviors and styles, too, and may impair communication with their doctors because of the way they describe their symptoms.

Patient compliance with or adherence to medical advice varies greatly, and poor adherence is very com- mon. Individuals tend to be less compliant for long-term regimens to treat chronic diseases than for short-term reg- imens to treat acute illnesses, and they are particularly unlikely to adhere to recommendations to change long- standing habits. Also, the more complicated the regimen, the more likely adherence will suffer. Adherence is affected by various psychosocial factors, including rational nonad- herence decisions and the patient’s health beliefs, social support, and cognitive and emotional factors. Patients are more likely to adhere closely to a regimen when their

252 Part IV / Becoming Ill and Getting Medical Treatment

practitioners are patient-centered and explain their illnesses and treatments clearly. Behavioral methods

and communication enhancement can improve people’s adherence to medical advice.

KEY TERMS

commonsense models lay referral network iatrogenic conditions

treatment delay complementary and

alternative medicine

hypochondriasis doctor-centered patient-centered

adherence compliance rational nonadherence