Elaine A. Leventhal

Illness cognition: Using common sense to understand treatment adherence and affect cognition interactions

We summarize basic empirical themes from studies of adherence to medical regimens and propose a self-regulatory model for conceptualizing the adherence process. The model posits that self-regulation is a function of the representation of health threats and the targets for ongoing coping (symptom reduction, temporal expectancies for change) set by the representation, the procedures to regulate these targets, and the appraisal of coping outcomes. The underlying cognitive mechanism is assumed to function at both a concrete (symptom-based schemata) and abstract level (disease labels), and individuals often engage in biased testing while attempting to establish a coherent representation of a health threat. It also is postulated that cognitive and emotional processes form partially independent processing systems. The coherence of the system, or the common-sense integration of its parts, is seen as crucial for the maintenance of behavioral change. The coherence concept is emphasized in examples applying the model to panic and hypochondriacal disorders.

Self-regulation, health, and behavior: A perceptual-cognitive approach

Abstract Self-regulation systems are designed to adapt to threats via coping procedures that make efficient use of resources based upon valid representations of the environment. We discuss two components of the common-sense model of health threats: illness representations (e.g., content and organization) and coping procedures (e.g., classes of procedure and their attributes - outcome expectancies, time-lines, dose-efficacy beliefs, etc.). Characteristics of each of these domains, and the connection between the two, are critical to understanding human adaptation to problems of physical health. Rather than posing a barrier to factors outside the person that control behavior, an emphasis on subjective construal involves a view of the person as an active problem-solver embedded in a bidirectional system of sensitivity and responsiveness vis a vis the social, physical, and institutional environments in which health threats occur and through which intervention efforts may be directed.

Symptom representations and affect as determinants of care seeking in a community-dwelling, adult sample population.

The cognitive and emotional determinants of health-care utilization were assessed for middle-aged and older adults matched on age, gender, and health status. Both members of a pair were interviewed when either initiated a medical visit. Interviews were based on a self-regulatory model that assumed that Ss would use symptoms to create and update representations and coping procedures. Care seekers reported more symptoms than did matched controls but did not report more symptoms than did matched controls with new symptoms. The mere presence of atypical symptoms was insufficient to trigger care seeking. Care seeking is driven by well-developed representations of a serious health threat, perceptions of inability to cope with the threat, advice to seek care, and life stress.

Gender differences in processing information for making self-assessments of health.

Objective This study proposes that women’s greater inclusiveness of various sources of information when making self-assessed health (SAH) judgments accounts for the finding that SAH is a weaker predictor of mortality in women than in men. Methods Data from a sample of 830 elderly residents of a retirement community and a 5-year mortality follow-up study were used to examine the bases for women’s and men’s reports of negative affect (NA) and judgments of SAH. The degree to which each health-related measure accounts for the SAH-mortality association in each gender group was examined. Results The findings support two possible explanations for the lower accuracy of SAH as a predictor of mortality among women: 1) In both men and women, NA is associated with poorer SAH, but in men, NA is more closely linked to serious disease in conjunction with other negative life events, whereas in women, NA reflects a wider range of factors not specific to serious disease. 2) Men’s SAH judgments reflect mainly serious, life-threatening disease (eg, heart disease), whereas women’s SAH judgments reflect both life-threatening and non–life-threatening disease (eg, joint diseases). Conclusions Women’s SAH judgments and NAs are based on a wider range of health-related and non–health-related factors than are men’s. This difference can explain gender differences in the accuracy of SAH judgments and may be related to other documented differences in women’s physical and mental health and illness behavior. The findings emphasize the need to study the bases of NA and other self-evaluations separately for women and men.

Medication Adherence in Rheumatoid Arthritis Patients: Older Is Wiser

OBJECTIVES: To create a profile of individuals nonadherent to their medications in an age‐stratified sample (ages 34–84) of community‐dwelling rheumatoid arthritis patients. The relative contributions of age, cognitive function, disability, emotional state, lifestyle, and beliefs about illness to nonadherence were assessed.

Seeking medical care in response to symptoms and life stress.

Analyses tested the following contrasting hypotheses:a) The occurrence of a new symptom in the presence of ongoing life stress increases the attribution of symptoms to illness and increases the use of health care; b) new symptoms occurring in the presence of ongoing life stress are attributed to stressors if they are ambiguous indicators of illness, and they are unlikely to motivate care-seeking if the stressor, i.e., the perceived cause, is of recent onset. The 43-to-92-year old subjects in this longitudinal study were less likely to seek care for the ambiguous symptoms they experienced during the previous week if there was a concurrent life stressor that began during the previous 3 weeks; these symptoms were attributed to stress rather than to illness, and subjects tolerated the emotional distress caused by the combination of a stressor and an ambiguous symptom. Subjects were less willing to tolerate the combined distress of an ambiguous symptom and a concurrent life stressor if the stressor onset was not recent; under such conditions, subjects were more likely to seek health care. Current life stressors did not affect care-seeking for symptoms that were clear signs of disease; these symptoms were readily identified as health threats in need of medical attention. The findings contribute to a better theoretical understanding of how individuals perceive their physical states and how they cope with stress. Practical implications of these findings for increasing efficient use of health care services are also discussed.

Self-Assessments of Health: What Do People Know that Predicts their Mortality?

Factors reflecting current experience—for example, number of medications used, poor function, negative affects, and positive affect—had stronger associations with self-assessments of health (SAH) than factors related to prior events (medical history, prior smoking) in baseline data from 830 elderly retirement-community residents (mean age = 73). Participants appear to have implicit knowledge of the factors affecting their SAH: The rank order of the beta weights relating factors to SAH was correlated with the rank order of participant ratings of the attention given to each factor when making SAH judgments. Relationships of SAH and each of the factors to five year mortality showed that subjectively salient factors such as function and lack of energy predicted five-year mortality, reduced the relationship of SAH to mortality, and accounted for most of the relationship of medical factors to mortality. Affective variables, however, had no relationship to mortality despite their impact on SAH.

Elderly people's ratings of the importance of health-related factors to their self-assessments of health

Identifying the bases for self-assessed health (SAH) has interested researchers in their attempts to understand its validity as a predictor of future health outcomes. Quantitative approaches typically used statistical methods to identify correlates of SAH while qualitative approaches asked people to elaborate on the reasons underlying their rating of health. The current study used a quantitative methodology, asking 487 elderly people to rate the importance of 42 health-related factors as bases for their SAH judgment. Factors indicating overall functioning/vitality were rated highly by all participants. Factors indicating current disease were rated highly by people reporting poor/fair SAH while risk factors and positive indicators were rated highly by those reporting good, very good, or excellent health. Thus, there seems to be a clear distinction between poor and fair SAH that reflect levels of illness, and higher levels of SAH that reflect levels of health.

Using the common sense model to design interventions for the prevention and management of chronic illness threats: From description to process

In this article, we discuss how one might use the common sense model of self-regulation (CSM) for developing interventions for improving chronic illness management. We argue that features of that CSM such as its dynamic, self-regulative (feedback) control feature and its system structure provide an important basis for patient-centered interventions. We describe two separate, ongoing interventions with patients with diabetes and asthma to demonstrate the adaptability of the CSM. Finally, we discuss three additional factors that need to be addressed before planning and implementing interventions: (1) the use of top-down versus bottom-up intervention strategies; (2) health care interventions involving multidisciplinary teams; and (3) fidelity of implementation for tailored interventions.

In Sickness but Not in Health: Self-ratings, Identity, and Mortality∗

Self-rated health as a predictor of mortality has been studied primarily in large, representative populations, with relatively little progress toward understanding the information processing that individuals use to arrive at these ratings. With subsamples of National Health and Nutrition Examination Survey (NHANES) Epidemiologic Follow-up Study (NHEFS) data for respondents with circulatory system disease (N = 3,709) and respondents with no diagnosable disorders (N = 1,127) at baseline, we test the idea that individuals with experience of chronic disease of the circulatory system will have more predictive self-ratings of health than healthy individuals. Poor or fair self-rated health increased the adjusted hazard of all-cause mortality for respondents with circulatory system disease, but not for respondents who were healthy. Additional analyses confirm that poor or fair self-rated health is particularly predictive for respondents with self-reported history of circulatory system diagnoses and perception of symptoms, but not for respondents without symptoms or diagnoses prior to the NHANES physical exam.