1. Using Health Services

2. 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

3. Personality and Hypertension: Effect of Hypertension Awareness Aware hypertensive > normotensive & unaware hypertensive, P < 0.001

4. 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

5. 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

6. Symptoms Awareness Background stress is associated with greater reports of symptoms Mood - positive mood associated with fewer symptom reports than negative mood.

7. 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.

8. Placebos Inert substance or treatments People can experience real symptom relief. Furthermore taking placebos faithfully is associated with a lower likelihood of death.

9. Adherence with Medication 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 Placebo Group Amiodarone Group Adherent Poorly Adherent Adherent Poorly Adherent

10. 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.

11. 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)

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

13. Help-Seeking – Lay Referral Network Help interpret a symptom Give advice about seeking medical attention Recommend a remedy Recommend consulting another kay referral person

14. Who Uses Health Services? Age: young children and elderly use more Gender: women use more Sociocultural: use increases with income

15. 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

16. 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

17. Factors influencing how people cope with health anxiety

18. 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.

19. 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

20. 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

21. 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.

22. 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

23. Medical Terms Meaning – Match terms to meanings Antibiotics Breech Enamel Glucose Mucus Suture Protein Umbilicus 1. A hard glossy coating 2. The rump or back part 3. Agent to treat bacteria 4. Secretion of body tissues 5. Sugar produced by the body 6. The navel 7. A device to join separated tissue or bone 8. Substance that makes up plant or animal tissue

24. 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

25. 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

26. 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

27. How do patients impair communications? Not indicating distress Poor communication of symptoms

28. 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)

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

30. 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).

31. 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

32. Distribution of Adherence 1/3

33. 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.

34. Forms of Non-Adherence Forgetting a dose Deliberately skipped doses Occasional day or even week off therapy Stopped therapy

35. 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

36. 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

37. Non-adherence: Characteristics of the regimen Complex regimens have low adherence Adherence decreases with duration of the regimen Expense decreases adherence

38. 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.

39. 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.

40. Non-Adherence: Psychosocial Factors  Social support  Personality - Dispositional Attitudes  Affective State  Knowledge and attitudes

41. Non-Adherence: Knowledge/Beliefs  Lack of knowledge  Denial or trivialization  Perceived invulnerability Necessary but not sufficient

42. 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.

43. 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

44. 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.

45. Haynes et al., - results Compared to pill count PPV - proportion of adherent who are adherent; NPV - proportion of non-adherent who are non-adherent

46. 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