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 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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1011121314

Neuroticism

Aware HyperNormotUnaware HyperNormot

Aware hypertensive > normotensive & unaware hypertensive,P < 0.001

Personality and Hypertension:

Conclusion

Awareness of hypertension status confounds assessment of the association between personality characteristics and hypertension.

Due to hypertension labeling effect; or

Due to self-selection bias

Perceiving and Interpreting Symptoms

Our perceptions are not very accurate There are individual differences:

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 Background stress is associated with

greater reports of symptoms Mood - positive mood associated

with fewer symptom reports than negative mood.

Expectations Prior experience, beliefs, and

knowledge influence expectations about symptoms. Ignore unexpected symptoms and

amplify expected symptoms Beliefs about the disease label, causes,

time course, and consequences influence symptom awareness and experience.

Placebos Inert substance or treatments

People can experience real symptom relief.

Furthermore taking placebos faithfully is associated with a lower likelihood of death.

Adherence with Medication

Adherent > = 66% of pills takenPoorly adherent 66% of pills takenRR = 2.11, 95% CI, 1.03-4.56, p < .05

Adherent >= 66% of pills takenPoorly adherent < 66% of pills takenRR=3.15, 95% CI, 1.34-7.44, p < .01

Placebo Group Amiodarone Group

Risk of Sudden Cardiac Death

Survival Time in Days

8006004002000

Cum

ulat

ive

Sur

viva

l

1.00

.98

.96

.94

.92

.90

Adherent

Poorly Adherent

Risk of Sudden Cardiac Death

Survival Time in Days

8006004002000

Cum

ulat

ive

Sur

viva

l

1.0

.9

.8

.7

Adherent

Poorly Adherent

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 Widespread symptom perception

among a large group of individuals, without any evidence for physical or environmental cause.

Factors contributing to this effect are: Cognitive exaggeration of common

symptoms Modeling Emotional distress (e.g., anxiety)

Cultural Factors

Social-cultural influences shape how one appraises and responds to physical symptoms.

Help-Seeking – Lay Referral Network Help interpret a symptom Give advice about seeking medical

attention Recommend a remedy Recommend consulting another

kay referral person

Who Uses Health Services? Age: young children and elderly

use more Gender: women use more Sociocultural: use increases with

income

Why People Don’t Use Health Services Iatrogenic conditions: medical

problems resulting from a practitioner’s error or as a normal side effect of treatment.

Not trusting practitioners Worry about confidentiality Worry about discriminatory practices

Why People Don’t Use Health Services Emotional factors:

fear of serious disease embarrassment

Social factors 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

68

70

72

74

76

78

80

82

84

Pre-info Post-info Post-exam

Blunters, high info

Blunters, low info

Monitors, highinfoMonitors, low info

Mulitvariate Predictors of Non - Adherence to Ovarian Cancer Screening

Immediate PostClinic RiskPerception

OddsRatio

95% CI P value

High vs. low 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 Hypochondriacs: people who tend

to interpret real but benign bodily sensations as symptoms of illness Associated with neuroticism Does not increase with age

The Patient/Practitioner Relationship 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?

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

Physicians tend to use a consistent style. Two styles: Doctor-centered

Asks close-ended questions and focuses on first problem mentioned.

Ignores attempts to discuss other problems Patient-centered

Asks open-ended questions and allows discussion Avoids jargon and encourages participation in

decisions

Medical Terms Meaning – Match terms to meanings

Antibiotics Breech Enamel Glucose Mucus Suture Protein Umbilicus

1. A hard glossy coating2. The rump or back part3. Agent to treat bacteria4. Secretion of body tissues5. Sugar produced by the body 6. The navel7. A device to join separated

tissue or bone8. Substance that makes up

plant or animal tissue

Why Physicians Use Jargon 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?

Competency Expertise Concern, warm, sensitivity How do “good” doctors benefit?

Patient is more adherent to treatment Obtain more extensive diagnostic

information

The Patient’s Behaviour that Upsets the Doctor

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?

Not indicating distress

Poor communication of symptoms

Why do people describe their symptoms differently?

Symptom perception and interpretation

Differing common sense models of illness

Emphasizing or down-playing symptoms

Difficulties in communicating (e.g., language)

Compliance Adherence Concordance

Degree to which the patient carries out the behaviours the physician recommends (e.g., taking medication).

Extent of non-adherence problem

Difficulties with assessing it: 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 AdherenceAdherent Partial Adherent Non-adherent

1/3

1/31/3

Measuring Adherence in Clinical Practice

Physician impression overestimates patient-adherence 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 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 Non-adherence

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 Complex regimens have low

adherence Adherence decreases with duration

of the regimen Expense decreases adherence

Non-adherence: Cognitive-Emotional Factors

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: Cognitive-Emotional Factors

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

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 health-oriented 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%

Hydrochloro-thiazide 62% 67% 64%DBP Control 67% 54% 60%

Self-report 70% 91% 75%

PPV - proportion of adherent who are adherent; NPV - proportion ofnon-adherent who are non-adherent

Increasing Patient Adherence Use clear (jargon free) sentences Repeat key information Recruit sources of support Tailoring the regimen Providing prompts and reminders Self-monitoring Behavioural contracting