Transcript Using Health Services Perceiving and Interpreting Symptoms   Our perceptions are not very accurate There are individual differences:     Some people have more symptoms There are differences.

Using Health Services
Perceiving and Interpreting
Symptoms
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Our perceptions are not very accurate
There are individual differences:
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Some people have more symptoms
There are differences in what people can
tolerate
Differ in how much attention is paid to internal
states
Internally focused people overestimate bodily
changes and experience slower recovery
Personality and Hypertension:
Effect of Hypertension Awareness
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0
Aware Hyper
Normot
Unaware Hyper
Normot
Neuroticism
Aware hypertensive > normotensive & unaware hypertensive,
P < 0.001
Personality and Hypertension:
Conclusion
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Awareness of hypertension status
confounds assessment of the
association between personality
characteristics and hypertension.
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Due to hypertension labeling effect; or
Due to self-selection bias
Perceiving and Interpreting
Symptoms
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Our perceptions are not very accurate
There are individual differences:
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Some people have more symptoms
There are differences in what people can
tolerate
Differ in how much attention is paid to internal
states
Internally focused people overestimate bodily
changes and experience slower recovery
Symptoms Awareness
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Background stress is associated with
greater reports of symptoms
Mood - positive mood associated with
fewer symptom reports than negative
mood.
Expectations
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Prior experience, beliefs, and
knowledge influence expectations about
symptoms.
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Ignore unexpected symptoms and amplify
expected symptoms
Beliefs about the disease label, causes,
time course, and consequences influence
symptom awareness and experience.
Placebos
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Inert substance or treatments
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People can experience real symptom relief.
Furthermore taking placebos faithfully is
associated with a lower likelihood of death.
Adherence with Medication
Amiodarone Group
Placebo Group
Risk of Sudden Cardiac Death
Risk of Sudden Cardiac Death
1.0
1.00
.9
Adherent
.8
Cumulative Survival
.98
.96
.94
Adherent
Poorly Adherent
.92
.7
Poorly Adherent
.90
0
200
400
600
800
Surv iv al Time in Day s
Adherent > = 66% of pills taken
Poorly adherent 66% of pills taken
RR = 2.11, 95% CI, 1.03-4.56, p < .05
0
200
400
600
800
Surv iv al Time in D ay s
Adherent >= 66% of pills taken
Poorly adherent < 66% of pills taken
RR=3.15, 95% CI, 1.34-7.44, p < .01
Medical student’s disease 
Studying symptoms leads to greater
focus on one’s own symptoms (e.g., of
fatigue) that then get interpreted as
indicative if disease.
Mass Psychogenic Illness
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Widespread symptom perception among a
large group of individuals, without any
evidence for physical or environmental
cause.
Factors contributing to this effect are:
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Cognitive exaggeration of common symptoms
Modeling
Emotional distress (e.g., anxiety)
Cultural Factors
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Social-cultural influences shape how
one appraises and responds to physical
symptoms.
Help-Seeking – Lay Referral
Network
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Help interpret a symptom
Give advice about seeking medical
attention
Recommend a remedy
Recommend consulting another kay
referral person
Who Uses Health Services?
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Age: young children and elderly use
more
Gender: women use more
Sociocultural: use increases with income
Why People Don’t Use Health
Services
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Iatrogenic conditions: medical problems
resulting from a practitioner’s error or
as a normal side effect of treatment.
Not trusting practitioners
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Worry about confidentiality
Worry about discriminatory practices
Why People Don’t Use Health
Services
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Emotional factors:
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fear of serious disease
embarrassment
Social factors
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Not wanting to appear weak
More likely to use health care system if lay
referral system encourages it
Factors influencing how people
cope with health anxiety
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Blunters, high info
80
Blunters, low info
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76
Monitors, high
info
Monitors, low info
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Pre-info
Post-info
Post-exam
Mulitvariate Predictors of Non - Adherence to
Ovarian Cancer Screening
Immediate Post
Clinic Risk
Perception
High vs. low
Odds
Ratio
95% CI
P value
0.23
0.06 – 0.81 .03
High vs. medium
0.23
0.07 – 0.73 .01
Medium vs. low
0.99
0.32 – 3.03 .99
High RP group is 4.3 times less likely to adhere than low RP.
High RP group is also 4.3 times less likely to adhere than medium.
There was also a trend for high worry (p = .057) and low adaptive
coping (p = .059) to be predictive of non-adherence.
Misusing Health Care Services
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Hypochondriacs: people who tend to
interpret real but benign bodily
sensations as symptoms of illness
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Associated with neuroticism
Does not increase with age
The Patient/Practitioner
Relationship
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People differ in the role they want to
play in their treatment
Patients who take an active role recover
better and faster
Practitioners differ in the level of
participation they are willing to give
What Happens When There is
a Mismatch?
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Although physicians and patients agree
that patients should play a role, neither
tends to act this way.
If the patient wants to participate and the
practitioner doesn’t want them to, conflict
will result.
If the practitioner wants the patient
involvement but the patient doesn’t want
to participate both are uncomfortable.
The Practitioner’s Behaviour
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Physicians tend to use a consistent style.
Two styles:
Doctor-centered
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Asks close-ended questions and focuses on first problem
mentioned.
Ignores attempts to discuss other problems
Patient-centered
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Asks open-ended questions and allows discussion
Avoids jargon and encourages participation in decisions
Medical Terms Meaning –
Match terms to meanings
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Antibiotics
Breech
Enamel
Glucose
Mucus
Suture
Protein
Umbilicus
1.
2.
3.
4.
5.
6.
7.
8.
A hard glossy coating
The rump or back part
Agent to treat bacteria
Secretion of body tissues
Sugar produced by the body
The navel
A device to join separated
tissue or bone
Substance that makes up plant
or animal tissue
Why Physicians Use Jargon
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Habit
Patient doesn’t need to know
Patient better off not knowing
Keep interactions short
Reduce emotional reactions
Reduce recognition of errors
Elevate practitioner’s status
Not aware of jargon
What to we want in a doctor?
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Competency
Expertise
Concern, warm, sensitivity
How do “good” doctors benefit?
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Patient is more adherent to treatment
Obtain more extensive diagnostic information
The Patient’s Behaviour that
Upsets the Doctor
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Expressing anger or criticism
Ignoring or not listening
Insisting on procedures the physician
thinks is not necessary
Requesting the doctor certify something
he/she does not think is true (e.g.,
disability)
Sexually suggestive remarks
How do patients impair
communications?
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Not indicating distress
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Poor communication of symptoms
Why do people describe their
symptoms differently?
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Symptom perception and interpretation
Differing common sense models of illness
Emphasizing or down-playing symptoms
Difficulties in communicating (e.g.,
language)
Compliance
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Adherence
Concordance
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Degree to which the patient carries out the
behaviours the physician recommends
(e.g., taking medication).
Extent of non-adherence
problem
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Difficulties with assessing it:
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Many different kinds of medical advice to
which one could adhere
Can violate advice in many different ways
Difficult to know if patient complied (50/50
chance that the physician’s judgment of the
patient’s adherence is accurate).
Adherence
 60% of patients may not be adhering to
long-term treatment regimen 1-2 years later
 even in cardiac patients medication
adherence over time is poor (i.e., 40%
nonadherent 3 years later)
 Good predictor of long-term adherence is
adherence at entry
 Distribution of adherence is tri-modal
Distribution of Adherence
Adherent
Partial Adherent
Non-adherent
1/3
1/3
1/3
Measuring Adherence in
Clinical Practice
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Physician impression overestimates patientadherence by about 50% (Caron, 1985).
Electronic monitors of pills taken are
impractical in routine clinical practice.
Bio-chemical measures also have limitations
Self-report methods are good at detecting
those who admit to adherence difficulties but
will miss-classify about 50% patients who
deny problems or who are unaware of a
problem.
Forms of Non-Adherence
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Forgetting a dose
Deliberately skipped doses
Occasional day or even week off
therapy
Stopped therapy
Patients’ Reasons for Not
Adhering
 Forgetfulness (e.g., restaurant, trip)
 Financial (wait until pay day, take 1/2 dose to
delay renewing prescription)
 Feeling sick
 Feel well (rare reason)
 Lazy about going to the drug store
 Too busy - forget
 Life events, stress (e.g., death in family)
 Don’t believe in the treatment
 Confused about dosage
Rational Reasons for Nonadherence
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Have reason to believe the treatment isn’t
working
Feel that side-effects are not worth the
benefits of treatment
Don’t have enough money to pay for
treatment
Want to see if the illness is still there when
they stop the treatment
Non-adherence:
Characteristics of the regimen
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Complex regimens have low adherence
Adherence decreases with duration of
the regimen
Expense decreases adherence
Non-adherence: CognitiveEmotional Factors
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Patients forget much of what the doctor
tells them
Instruction and advice are forgotten more
readily than other kinds of information
The more patient is told, the higher the
likelihood of forgetting more.
Patients remember what they are told first
and what they think is most important.
Non-adherence: CognitiveEmotional Factors
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More intelligent patients do not remember
more than less intelligent patients
Older patients remember as much as
younger patients
Moderately anxious recall more than low or
high anxious patients
The more medical knowledge the patient
has, the more he/she will remember.
Non-Adherence: Psychosocial
Factors
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Social support
Personality - Dispositional Attitudes
Affective State
Knowledge and attitudes
Non-Adherence:
Knowledge/Beliefs
 Lack of knowledge
 Denial or trivialization
 Perceived invulnerability
Necessary but not sufficient
Non- Adherence - Behaviour
 Early adherence, e.g., within first month
of initiating therapy is an excellent
predictor of later adherence, even 7 years
later (Dunbar & Knoke, 1986)
 The more similar the predictor behaviour
to the predicted behaviour, the higher the
correlation.
 Generally, little evidence for a healthoriented behaviour pattern.
Donald E. Morisky’s Questions
1. Do you ever forget to take your medicine?
2. Are you careless at time about taking your
medicine?
3. When you feel better do you sometimes stop
taking your medicine?
4. Sometimes if you feel worse when you take
the medicine, do you stop taking it?
 High adherence = all ‘no’ responses
 Medium adherence = 1 or 2 ‘yes’ responses
 Low adherence = 3 or 4 ‘yes’ responses
Brian Haynes’ Question
 People often have difficulty taking their pills for
one reason or another and we are interested in
finding out any problems that occur so that we
can understand them better.
 Do you ever miss your pills? If yes
 What is the average number of tablets missed
per day, week, and month?
 Adherence defined as taking >= 90% of pills
prescribed.
Haynes et al., - results
Compared to pill count
Measure
PPV
NPV
Accuracy
 Uric Acid
66%
66%
66%
Chlorthalidone
75%
80%
76%
Hydrochlorothiazide
DBP Control
62%
67%
67%
54%
64%
60%
Self-report
70%
91%
75%
PPV - proportion of adherent who are adherent; NPV - proportion of
non-adherent who are non-adherent
Increasing Patient Adherence
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Use clear (jargon free) sentences
Repeat key information
Recruit sources of support
Tailoring the regimen
Providing prompts and reminders
Self-monitoring
Behavioural contracting