Health Psychology Notes Ch.9 Becoming Ill and Getting Medical Treatment
Compliance: Adhering to Medical Advice - Extent of the Nonadherence Problem
Adherence and compliance are terms that refer to the degree to which patients follow doctor's advice. Patients may not take medication, skip appointments, not do exercises, cheat on dietary restrictions. People will violate in unique ways and there are problems in determining who has complied and who hasn't. How do you measure compliance? 1. You can ask the practitioner to estimate the level of compliance, but in general they overestimate compliance and are not good at recognizing which patients are more compliant than others 2. You can ask the patient but people tend to overestimate their compliance either through self-deception or not wishing to look irresponsible The overall ballpark figure for compliance is estimated at 60%. But of course there are variations in compliance levels across conditions. Acute treatment regimens run around 67% whereas chronic regimens drop to 50 - 55 %. Adherence tends to be higher in the days before and after a doctor's visit. Lifestyle changes smoking and diet are variable and generally low. Percentages may be overestimated because they show results from voluntary participation which may attract more adherers than shirkers. They also do not indicate the range of compliance, how completely the regimen is followed. Nonadherence can have serious consequences and nonadherers are more likely to die in the months and years following a heart attack.
Using and Misusing Health Services - Who Uses Health Services?
Age and Gender Children have more contact with doctors than adolescents and young adults. As age increases the number of contacts increases as the level of chronic diseases increases. Women tend to consult doctors more and this difference remains even when gender specific health care needs are accounted for. Women also take more medications and have more acute conditions. But the underlying cause may be socially reinforced sex roles that encourage men to endure pain. Sociocultural Factors in Using Health Services People are more likely to fill prescriptions and seek medical care the higher their income. Disadvantaged groups are more likely to use outpatient clinics and emergency rooms for medical care. Even people with insurance often pay part of the cost of care and so tend to delay seeking treatment. People in the lower classes tend to see themselves as less susceptible to illness than people in higher income groups. In immigrant situations, language can be a barrier to help seeking as most medical facilities do not staff translators.
Using and Misusing Health Services
Americans visit doctors on average 3.2 times a year. In the EU it is 6.27 times.
Using Complementary and Alternative Medicine
CAM methods are diverse but fall into several categories: 1. manipulative and body-based methods - moving the body parts, massage and chiropratic procedures 2. nature products - herbal products and natural dietary supplements 3. mind-body interventions - progressive relaxation and meditation and other techniques to manage body function and symptoms 4. energy fields like acupuncture 5. homeopathy which involves the use of diluted substances Some CAM treatments require a trained practitioner and some do not. Many patients do not inform their doctor that they are using CAM techniques. But about a third of Americans do use CAM methods but there is almost no science behind them and most work at the level of placebos. Chiropratic and deep-tissue massage does appear successful in treating back pain. When CAM methods are shown to be beneficial scientifically, they are adopted by traditional medicine.
Compliance: Adhering to Medical Advice - Patient - Practitioner Interactions
Communicating with Patients Many patients leave their doctors offices not knowing how to follow their regimens. This is often a communication problem. A study found 1. many patients were deficient in basic medication knowledge like size of dose and length of regimen 2. the poor knowledge often resulted form the physicians having given inadequate info 3. the clients asked few questions 4. the more explicit the physician's instructions the better the level of compliance Good communication is more likely to occur in a patient centered style than a doctor centered style Adherence and the Patient-Practitioner Relationship Patients who are satisfied with their relationship with their doctor - who find them warm and communicactive - are more likely to follow their advice.
Compliance: Adhering to Medical Advice
Compliance involves three characteristics: 1. the illness/regimen 2. the person 3. interactions between practitioner and patient
Focusing on Prevention
Health care systems have generally focused on secondary and tertiary prevention. This is called the chronic care model. Can this model be adjusted to emphasize primary prevention? Research says yes if six conditions are met: 1. organization of care - priority has to be given to identifying at risk people and getting health providers to work toward changing their behavior 2. clinical information systems - access to data so professionals can review performance and send reminders 3. delivery system design - providing preventative info 4. decision support - help in deciding who should receive interventions 5. self-management support - families support the targets of the interventions and receive support from the health care system 6. community resources - the health care system makes use of existing community organizations
Problematic Health Service Usage
Hypocondriacs tend to interpret real but benign bodily sensations as symptoms of illness. Hypochondriasis is the tendency of individuals to worry obsessively their health and monitor their bodily sensations closely and make frequent unfounded medical complaints. It is considered a psychiatric disorder when it lasts six months and causes functional impairment and significant emotional distress. Costa and McCrae have shown a link between neuroticism and hypochondriasis. There are real health problems that medical technology cannot confirm. One example is chronic fatigue syndrome which is persistent fatigue for more than six months. There are no medical tests to detect it. Psychotherapy can reduce the symptoms of CFS.
Using and Misusing Health Services - Why People Use, Don't Use and Delay Using Health Services
Ideas, Beliefs and Using Health Services Medical mistakes account for 100,000 deaths in the US yearly. Sometimes treatment makes people worse. These are called iatrogenic conditions and are part of the reason people avoid help seeking. Some people are concerned about confidentiality. Many adolescents have health concerns they do not want repeated to their parents. LGBT folk may avoid doctors for the same reason. Some minority groups may belief they will suffer from discriminatory practices like the Tuskegee study. The Health Belief Model and Seeking Medical Care According to the health belief model symptoms initiate a decision making process about seeking medical care. How much threat people perceive depends on three factors: 1. cues to action: this can include the symptoms themselves, advice from lay people, mass media health information 2. perceived susceptibility: 3: perceived seriousness: The threat people feel grows the greater numbers two and three are. Then people will weigh the perceived benefits against the perceived barriers to getting treatment. If the benefits outweigh people are likely to seek attention. People report that transportation costs and medical bills influence their treatment seeking. So does their perceived medical knowledge. People who think cancer cannot be treated successfully will delay treatment. But some studies have found only weak correlations between help seeking and this model. Social and Emotional Factors and Seeking Medical Care The role of emotions when symptoms appear can vary. If people are already depressed they will have trouble mobilizing the energy to seek treatment. But people who are frightened by symptoms may seek treatment very quickly. However if they expect pain from the disease and its treatment the fear of that pain may cause them to delay treatment. Fear plays a large role in dental treatment about 5 % of Americans avoid it altogether. Sometimes embarrassment plays a role. People may fear making an issue out of nothing or discussing a medical problem like bladder control. Urging from others can tip the balance toward seeking help. Stages in Delaying Medical Care Treatment delay refers to the time that elapses between the first awareness of a symptom and the seeking of medical care. In many cases of heart attacj this can be only a few minutes. Delay occurs in three stages: 1. appraisal delay - the time a person takes to interpret a symptom as a sign of illness, here the sensory experience has the greatest impact on taking action, the more severe the pain or bleeding the sooner it is recognized as illness 2. illness delay - the time taken between recognizing one is ill and deciding to see attention, people will seek attention more quickly if the symptom is new rather than familiar 3. utilization delay - the time after deciding to seek medical care until actually going to use that health service, delay will be less for people not worried about cost, who are sure it can be treated and who have experienced sever pain Many people delay treatment when the pain is minimal but pain not a major symptom of many major diseases like hypertension or cancer. Heart attacks do involve pain and some drugs must be administered within three hours to prevent myocardial damage.
Types of Health Service - Health Care Systems in Other Countries
In many wealthy countries health services are paid for with tax dollars and coverage is universal. In poorer nations care is available on a pay as you go basis and many people have little or no access to care. Each nation's system is different in terms of structure and coverage. For ex: - some plans cover drugs some don't and some do for certain age and income groups - some encourage supplemental insurance for uncovered expenses - some require citizens to contribute to medical savings accounts which contributors and family use to pay for services - in Italy and Britain most doctors a re civil servants - in Australia and the Netherlands the primary care physician is a 'gate keeper' for more specialized care
Types of Health Service - The American Health Care System
In the US Medicare covers most of the elderly, Medicaid covers low income people. Private insurers cover the rest but 16.7 % of Americans have no private insurance. These figures are worse for minorities. Laws passed in 2010 will widen coverage so that only about 5 % of people are not covered but it is clear that uninsured people have higher mortality rates and that each widening of the coverage net decreases mortality. There are two broad options in paying for health care: 1. Fee for service where each office visit/procedure has a fee and the user or insurer pays a fixed or negotiated amount. Insurers often pay 80% of the costs and Medicaid pays less. 2. Managed care programs place restrictions on what is covered and most charge annual fees to their members or the members employers. Some programs include incentives for doctors to send fewer patients to hospitals. HMOs or health management organizations are plans where members can use the services of any affliated hospital or doctor. HMOs bargain with service providers to get the best prices for services. PPOs or preferred provider organizations are affiliated doctors and hospitals that offer discounted fees to members.
Compliance: Adhering to Medical Advice - Why Patients Do and Do Not Adhere to Medical Advice
Medical Regimens and Illness Characteristics Some regimens require people to change long standing habits. Patients are less liking to change habits than they are to take medication. Some regimens are complicated and difficult to follow. Compliance tends to fall over time if the regimens make large time demands, are in force for extended periods, have side effects or are expensive. Part of the problem is that some conditions like hypertension manifest not symptoms. Patients who rate their illnesses as serious are more likely to adhere to their regimes. Age, Gender and Sociocultural Factors Generally each of these factors exerts a very small influence on adherence and compliance. But together, say an elderly, male on social assistance will have noticable differences in their level of compliance Age can be seen as an influence in these cases: a) childhood cancer patients had more difficulty adhering to drug regimens even though they were helped by their parents b) adolescents were less adherent to special diabetic diets than children were c) among adult arthritis patients middle aged patients made more errors than elderly sufferers In some cultures, like First Nations the idea of cure is inherent in the healing process so long term medicatice regimens seem ineffective. Special efforts are also needed to help communities with low literacy rates. Psychological Aspects of the Patient The health belief model as helps explain why people do and do not follow treatment regimens. Sometimes non-compliance appears rational. If a) it appears the medication isn't helping b) the side effects are unpleasant c) are confused about dosages d) can't afford refills e) interrupt their regimens to test if the illness is still there But most non adherence is a result of simple forgetting. Adherence is often affected by cognitive and emotional factors that impact a patient's memory of their instructions and even if the instructions are in writing, if the level is above the fifth grade it can cause problems for some patients. Negative affect has been linked to low levels of adherence. In general higher self-efficacy and social support promote following a regimen but in some cases where there are dietary and alcohol free aspects to the regimen social support increase the level of temptation.
Compliance: Adhering to Medical Advice - Increasing Patient Adherence
Noncompliance and Health Outcomes In general, people who adhere have far better outcomes than people who do not. But the critical level of adherence varies from disease to disease. For some conditions 80 % to total compliance is necessary, for other conditions 50 % may be sufficient. Improving Physicians' Communication Skills In the past, doctors have focused more on correcting non-compliance than preventing it. They often tackled non adherence by repeating the instructions in greater detail. So why wasn't that done in the first place? But studies have shown that improving practitioner communication skills is not hard to do. Improvements brought about by training programs have proved durable. Interventions Directed at Patients Follow up letters describing the regimens were found to increase adherence as did simply making the parents of sick children promise to follow instructions. Motivational interviewing can be used to emphasize the benefits of adherence. Several behavior models have been used to enhance adherence. 1. Tailoring the regimen to make them part of the person's habits and routines 2. Prompts and reminders including post its or followup phone calls 3. self monitoring of the regimen 4. behavioral contracting where a contract outlining behavior is negotiated and signed But these methods are not fully successful and new methods must be developed.
Perceiving and Interpreting Symptoms - Interpreting and Responding to Symptoms
Often previous experience leads people to correct assessments about their symptoms but this is not always so. Anecdotal evidence, experiences, readings can give us cognitive representations or commonsense models about illnesses. They often seem to involve four components of how people think about disease. They are: 1. Illness Identity - which consists of the name and the symptoms of the disease 2. Causes and underlying pathologies - these are ideas about how diseases are transmitted and what follows from exposure 3. Time Line - prognosis ideas, how long before symptoms manifest and how long will they last 4. Consequence - involves ideas about the seriousness effects and outcomes of an illness Prevalence is often a standard in judging the seriousness of a disease, rare diseases are often assumed to be worse. Two Negative By products of Commonsense Models People with incorrect ideas about illness are less likely to adopt preventative strategies and are less likely to seek treatment. Also, if a disease becomes chronic people's expectations will often become more negative and lessening their sense of self control. Lay Referral System These are non medical members of the patients circle who give information. They may: 1. Interpret symptoms 2. Give advice about seeking treatement 3. Recommend a remedy 4. Refer to another lay person who manifested similar symptoms
The Patient's Behavior and Style
Patients can do things doctors find unsettling: 1. not following prescribed treatments 2. waiting too long to seek treatment 3. insisting on tests/treatments the physician sees as unnecessary 4. requesting bogus certification of disabilities 5. making sexual remarks toward the doctor Why do people give unclear descriptions of symptoms? 1). Well people differ in the degree to which they monitor internal states and associated them with health problems. 2). People will often describe only the symptoms they believe are relevant to the condition they think they have 3). They may under or over state the importance of a symptom they think reflects a serious illness 4). They may not have sufficient command of the language to communicate their symptoms Communication can be improved with better interviewing techniques being taught to doctors and by having patients list their symptoms before the interview. Also, doctors often do not hear back from patients and the do not know for sure that this means their diagnoses have been correct.
The Patient-Practitioner Relationship - Patient Preferences for Participation in Medical Care
People differ in the amount of participation they want in the treatment process. Some want little info about the illness and treatment while others want substantial information and participation in treatment. In general women want more involvement than men do, young adults want more than older adults and Whites want more than Blacks and Hispanics. People who receive their desired amount have better outcomes than those who don't Those who prefer an active role usually recover more quickly than those who prefer a passive role. Practitioners differ in the level of participation they are inclined to offer. Mismatches in levels between patients and doctors can have three outcomes which are significant. 1. clients will experience more stress during unpleasant procedures 2. clients will be less likely to follow the practitioners advice 3. dissatisfaction and internal discomfort can lead to switching doctors
Perceiving and Interpreting Symptoms - Perceiving Symptoms
Perceiving symptoms is more complicated than it sounds as we do not assess our internal states well and our judgments about heart rate, BP, breathing and congestion do not correlate well with physiological measures. A number of factors affect our perception of symptoms: Individual Differences: Almost all people begin to experience heat as pain when it gets to around 44-46 degress C. This suggests that individual standards of pain do not vary as greatly as is often thought. Many internally focused people believe they can sense negative changes in their internal states but they have been shown to overestimate the importance of these changes and underestimate the speed of their recovery. Competing Environmental Stimuli: When the environment is supplying a great deal of competing input people are less likely to notice pain. (that explains why some athletes continue to play hard after experiencing serious injuries). People who live alone and hold boring jobs tend to report more symptoms and take more aspirin and sleeping pills. Psychological Influences Perceptions of wellness and illness and recovery are greatly influenced by cognitive processes. Placebos are the best known example of this. Sometimes these are accompanied by nocebo side effects like fatigue and dizziness. In a study of people in a neighborhood about to be sprayed with insecticide it was found that people who were itentified in self reports as having more concerns about health reported three times the number of symptoms after the spraying. Medical student's disease appears in med students as they imagine they suffer from the diseases they are studying, two thirds at some point self diagnosis with a condition they are studying. Mass psychogenic illness involves widespread symptom perception across individuals when no medical basis exists any illness. Usually this is preceded by an unusual odor or someone fainting that triggers the expectation of illness. Why do these things happen? 1. those involved already have high stress or negative emotions 2. the symptoms involve common events like headaches or dizziness that care real but vague 3. expectations and other cognitive factors support the illusion 4. modelling of the symptoms occurs Gender and Cultural Differences Women report feeling pain at lower levels of intensity than men do and ask for relief sooner. This may be explained by several factors including hormones and social roles. Cultural norms about displaying pain vary. 1. people from Asian cultures report more physical symptoms that have psychological bases than people from other cultures 2. in studies of patients in six countries with similar back problems Americans were found to complain the most followed by Italians and New Zealanders and then the Japanese, Colombians and Mexicans 3. in the US Blacks will delay treatment seeking longer than Whites
The Practitioner's Behavior and Style
Research has identified several styles: Doctor centred: Practitioners usually ask yes no questions and focus mainly on the first problem mentioned. Patient centred: Tend to ask more open ended questions and allow patients to relate more information. Female physicians tend to spend 10 % longer with patients and are more likely to be patient centered in style. Some practitioners use jargon that is not well understood by patients particularly those from low income backgrounds. A study showed that lower class women only understood about 39% of the jargon the physicians used but that the physicians rated their understanding as below that. Only 57 % of patients surveyed knew their diagnosis and fewer reported their had been informed of drug side effects though doctors rated their patients knowledge much higher. People also like to feel their doctors are emotionally involved in their treatment and are warm and sensitive. Not all doctors are equally skilled at interviewing and some elicit much more patient information than others.
Types of Health Service - Specialized Functions of Practioners
Specialized Functions of Practitioners There are hundreds of types of health care professionals. Because the amount of training and skill needed is vast few people can specialize in more than one field. But this division of labor means that many people may be involved in a patient's care and they may not 1. communicate fully 2. have so little direct contact with an individual that their time together is cold and impersonal
Types of Health Service - Office-Based and Inpatient Treatment
The first place ill people go is to see their family physician who either treats, refers to a specialist or hospitalizes. People with serious illnesses or complex treatment needs often end up in hospitals or nursing homes. Hospitals offer the most sophisticated services with wide ranges of diagnostic facilities and treatment choices. Nursing homes provide relatively long term care for people with treatment needs that go beyond what a patients support system can meet and for people who have trouble meeting daily self-care needs. In many countries out patient services have grown in importance because technological advances have made it possible to bring treatment to people and because in hospital care is so expensive. Out patient care can be more convenient for people with limited transportation resources. Pace makers and insulin pumps provide of out patient care.
