John P. Kirscht

Understanding and Improving Patient Compliance

The problem of patient compliance, as well as the ability of the physician to understand, detect, and improve compliance are described in relation to a new model of health decisions and patient behavior. The health decision model combines decision analysis, behavioral decision theory, and health beliefs. This model provides a framework for modifying general health beliefs; treatment recommendations; experience with therapeutic regimens and health care providers; patient knowledge and social interaction patterns. Physicians, guided by certain ethical restraints, are in a unique position of responsibility and opportunity to actively encourage patient compliance with treatment.

Psychosocial Factors Affecting Adherence to Medical Regimens in a Group of Hemodialysis Patients

The present research was designed to identify psychosocial correlates of adherence among patients receiving hemodialysis at two outpatient clinics. The 116 participants were interviewed concerning their knowledge of treatment, health beliefs, treatment history, social support, personal characteristics, and adherence to the medication, diet and fluid-intake aspects of the regimen. In addition, medical record data were obtained on serum phosphorus and serum potassium levels, and on between-dialysis weight gains. The magnitude of relationships between predictors and adherence measures varied, depending on the method used to measure adherence. For the self-report measures, beliefs concerning the efficacy of the behavior and barriers to the behavior, along with reported family problems, proved to be consistent predictors. Other beliefs and characteristics did not contribute significantly. For the medical chart information, however, the predictive factors were less consistent. In general, situational factors seem to be the major contributors to patient adherence, and adherence itself is seen as a complex and multidimensional phenomenon.

The Health Belief Model and Illness Behavior

What do people do until the doctor comes? A major insight into health-related behavior was provided by the recognition that many events occur between states of wellness and sickness; those events were grouped under the label “illness behavior.” “The basic problem of illness behavior is: in the presence of symptoms, what will the individual do and why will he do it?” 1 Short of initiation of professional treatment, there are many definitional and remedial behaviors taken (or not taken) in the person’s efforts to cope with episodes of distress. The illness experience is frequently assumed to comprise a set of more or less discrete stages,‘ starting with the perception of something amiss with health. Many of the episodes are transitory and minor but some eventuate in adoption of a form of the sick role and entail professional care. Critical to this process is individual initiative. This review will examine psycho-social components of that initiative, especially the health beliefs that appear useful in understanding how health decisions are made. A number of conceptual models have been proposed to explain or account for ill-health behavior some of these will be described shortly and, in each, the process of defining the health situation in the presence of symptoms is crucial for the outcome. Hence, illness behavior is seen as important for the utilization of health services, for promptness or delay in seeking care, and for the use of non-medicallyapproved remedies. Illness behavior, narrowly defined, includes only that portion of the process in which the individual attempts to discover what is wrong the transition between feeling states and undertaking some course of restorative action (or resuming ordinary behavior). But the boundaries are fuzzy, and it is not entirely clear whether some behaviors represent illness or sickness. We have used a broader definition that includes symptom experiences, self-treatment or “untreated” episodes, and seeking care. In many instances, seeking care is a mixed category that contains many types of utilization without regard to the stage of the episode. Within this broader category of illness, the potential behaviors cover a very wide range. The starting point, however, is the symptom experience. In spite of our illusions about health, symptoms apparently occur all the time in virtually all They are

Evaluation of a minimal-contact smoking cessation intervention in an outpatient setting.

We examined the ability of a provider-initiated, minimal-contact intervention to modify the smoking behavior of ambulatory clinic patients. Smokers at two outpatient sites were assigned to one of three groups: provider intervention only (PI); provider intervention plus self-help manual (PI/M); and usual care (control) group (C). The physician message emphasized the patients personal susceptibility, the physicians concern, and the patients ability to quit (self-efficacy). The nurse consultation concentrated on benefits and barriers associated with stopping, and on strategies for cessation. Telephone interviews were conducted with the 250 participants within a few days of their clinic visit and again at one and six months. Both PI and PI/M proved to be superior to usual care in motivating attempts to quit at both one-month and six-month follow-ups, and logistic regression analyses indicated that participants receiving the self-help manual in addition to the health provider message were between two and three times more likely to quit smoking during the study period than were participants in either of the other study groups.

The Health Belief Model and Predictions of Health Actions

An important role of applied social science in health has been the promulgation of theory designed to account for health behaviors of individuals and groups. Efforts to model various health-related actions have multiplied and become increasingly sophisticated. Stone (1979), in his comprehensive review of psychology and the health system, noted that “the questions of why people behave as they do and how they may be induced to behave differently have represented the core of American psychology throughout this century” (p. 70). Recent growth in the study of health behavior has significant roots in the pioneering efforts of applied psychologists and sociologists, represented in the frameworks outlined in the seminal article by Kasl and Cobb (1966). As noted by Leventhal, Zimmerman, and Gutmann (1984) in their critical review, “the health belief model is the cognitive model most frequently used in studies of health behavior and compliance” (p. 384).

Psychological functioning in a cohort of gay men at risk for AIDS. A three-year descriptive study

This study describes the mental health of a large cohort of gay men participating in the Chicago Multicenter AIDS Cohort Study/Coping and Change Study. Six biannual questionnaires were self-administered between 1984 and 1988. General mental health was determined by the Hopkins Symptom Checklist (HSCL). An abbreviated version of the Center for Epidemiologic Study Depression Scale (CESD-5) and an adapted Diagnostic Interview Schedule (DIS) question also measured depression. Suicidal ideation was assessed by one question in the HSCL. AIDS-specific distress was determined by three subscales specifically developed for this study While mean HSCL and CESD-5 scores were stable during the observational period, AIDSspecific distress increased over time. The HSCL scores for the cohort were somewhat elevated above general population norms but considerably below psychiatric outpatient norms. Fewer than 12% of the men reported elevated HSCL or CESD-5 scores three or more times. A self-reported episode of depression of two weeks or more, measured by the DIS screening question, was experienced by 40.1% of the sample. Suicidal ideation was reported on three or more visits by 18.8% of the men The younger members of this cohort exhibit greater general and AIDS-specific distress. Income was inversely associated with general distress. HIV-seropositive participants had generally higher AIDS-specific distress scores than those who were seronegative, but their scores were equivalent on the HSCL and CESD-5

Psychological and Social Factors as Predictors of Medical Behavior

Response to illness was studied in a group of 251 low-income mothers who brought a child to a pediatric clinic for treatment. Measures of illness and use of medical care services for the child constituted the dependent variables; social characteristics of the mother, and her health beliefs and attitudes served as the independent variables. The information was collected by means of personal interviews. A major determinant of seeking care was the presence of symptoms in the child. Age, number of children, beliefs about illness threat, and about the benefits of medical care also related to obtaining care. A measure of the scope of services used, however, was unrelated to illness, but positively related to both education and the mothers evaluation of physicians. With illness taken into account, situational barriers plus beliefs concerning illness threat and the efficacy of care become more important predictors of utilization of care. The beliefs are related to the mothers experience, education, and life situation. It was concluded that health beliefs interact with situational demands and constraints in relation to actions taken in the face of health threats.

Health Beliefs in a Population: The Michigan Blood Pressure Survey:

In a general population sample, we examined relationships between sociodemographic characteristics and health beliefs. Individual questionnaire measures for components of the health belief model were combined to form six scales. In analyses which adjusted for perceived levels of health, sociodemographic markers of social disadvantage (e.g., black race, or low socioeconomic status) appeared to associate with favorable health beliefs, that is, with health beliefs often associated with health promoting behaviors. Specifically, we found that blacks expressed greater concern about health. Women believed they tended to get sick more often and to suffer more severely from illness. Female and older respondents placed greater value on the kinds of services provided by members of the health professions. Female, black, older, and lower socioeconomic status respondents placed greater value on such healthful personal habits as exercise, alcohol avoidance, and proper diet. These results suggested that the poor health suffered by relatively disadvantaged members of society are not, in some manner, a consequence of funda mental beliefs about health.

INTERNAL CONTROL AND THE TAKING OF INFLUENZA SHOTS

Expectancies about ability to control the environment and motivation to exert control were assessed among 510 college students, half of whom had voluntarily taken influenza inoculations. Inoculation was more likely among students motivated to exert control but less likely among those who expected to exert control.

An assessment of different components of patient medication knowledge

Different components of drug knowledge (i.e., knowledge of the drug purpose, regimen, action if a dose is missed, and common side effects) were examined in 187 ambulatory cardiovascular patients in order to determine whether the components were similar enough to be considered interchangeable in representing drug knowledge. Patients and physicians were interviewed in a family practice setting and their responses compared for each cardiovascular drug the patient was taking. Scores were highest for knowledge of the drug regimen and purpose, fewer patients were correct about the appropriate action if a dose were missed, and only a small number could accurately identify common side effects associated with their drug therapy. The comparison of patient responses to each of the knowledge measures indicated that there was little consistency in response across the various types of knowledge. The differences in the measures were supported further by regression equations that showed different relationships between a set of independent variables and knowledge of drug purpose and regimen, respectively. The study findings suggest that a partial explanation for inconsistencies of research about drug knowledge may be the way this concept is measured.