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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

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perceiving and interpreting symptoms
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
Personality and Hypertension:Effect of Hypertension Awareness

Aware hypertensive > normotensive & unaware hypertensive,

P < 0.001

personality and hypertension conclusion
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 symptoms5
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
Symptoms Awareness
  • Background stress is associated with greater reports of symptoms
  • Mood - positive mood associated with fewer symptom reports than negative mood.
  • 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.
  • Inert substance or treatments
    • People can experience real symptom relief.
    • Furthermore taking placebos faithfully is associated with a lower likelihood of death.



Poorly Adherent

Poorly Adherent

Adherence with Medication

Amiodarone Group

Placebo Group

Adherent > = 66% of pills taken

Poorly adherent 66% of pills taken

RR = 2.11, 95% CI, 1.03-4.56, p < .05

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
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
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
Cultural Factors
  • Social-cultural influences shape how one appraises and responds to physical symptoms.
help seeking lay referral network
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
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
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 services16
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
mulitvariate predictors of non adherence to ovarian cancer screening
Mulitvariate Predictors of Non - Adherence to Ovarian Cancer Screening

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
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
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
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
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








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

Medical Terms Meaning – Match terms to meanings
why physicians use jargon
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
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
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
How do patients impair communications?
  • Not indicating distress
  • Poor communication of symptoms
why do people describe their symptoms differently
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)
  • Adherence
  • Concordance
    • Degree to which the patient carries out the behaviours the physician recommends (e.g., taking medication).
extent of non adherence problem
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).
  • 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
measuring adherence in clinical practice
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 areunaware of a problem.
forms of non adherence
Forms of Non-Adherence
  • Forgetting a dose
  • Deliberately skipped doses
  • Occasional day or even week off therapy
  • Stopped therapy
patients reasons for not adhering
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
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
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
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 factors39
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
Non-Adherence: Psychosocial Factors
  • Social support
  • Personality - Dispositional Attitudes
  • Affective State
  • Knowledge and attitudes
non adherence knowledge beliefs
Non-Adherence: Knowledge/Beliefs
  • Lack of knowledge
  • Denial or trivialization
  • Perceived invulnerability

Necessary but not sufficient

non adherence behaviour
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
Donald E. Morisky’s Questions
  • Do you ever forget to take your medicine?
  • Are you careless at time about taking your medicine?
  • When you feel better do you sometimes stop taking your medicine?
  • 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
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
Haynes et al., - resultsCompared to pill count

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

non-adherent who are non-adherent

increasing patient adherence
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