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Issues in Patient Adherence to Health Care Regimens Dr. Stanislav V. Kasl Ph.D.
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Department of Epidemiology and Public Health , Yale University School of Medicine , New Haven, Connecticut, USA Published online: 09 Jul 2010.
To cite this article: Dr. Stanislav V. Kasl Ph.D. (1975) Issues in Patient Adherence to Health Care Regimens, Journal of Human Stress, 1:3, 5-48, DOI: 10.1080/0097840X.1975.9939542 To link to this article: http://dx.doi.org/10.1080/0097840X.1975.9939542
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ISSUES IN PATIENT ADHERENCE TO HEALTH CARE REGIMENS
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STANISLAV V. KASL. Ph.D.*
This paper examines an important area of personal health behavior in which the possible link between stress and health status is not primarib a biological one but a behavioral one. The review oj* empirical literature is organized around four topics: I ) the limited payofljivm the search f o r stable sociodemographic and personality correlates oj. adherence: 2) the inadequacy of our current theoretical formulations; 3) the role of the doctor: and 4) the doctor-pa tien t interaction , which emphasizes mutual expectations rather than a one-way transfer of injormation. The concluding remarks address themselves to the need-for afirmer linkage with the conceptual and empirical literature on stress and coping.
It is easy to forget that the role of human stress in health and illness is not exhaustively represented by a single perspective, namely the etiological link from stress to disease via altered biological processes. Also to be considered is the role of personal health behavior - all those activities which relate to health maintenance, disease risk reduction, and treatment regimen. Such activities, which can have considerable and direct influence on health status, may in turn be affected and altered by the presence of +Dr. Kasl is Professor of Epidemiology in the Department of Epidemiology and Public Health at Yale University School of Medicine, New Haven, Connecticut.
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stress. In this latter persp,ective, a better understanding of the role of stress is achieved by paying attention to the personal health behaviors rather than the biological processes. And it behooves each investigator and each clinician to determine the optimal “mix” of these perspectives for the problem he is studying or the patient he is treating. If we accept the catchall definition of stress as a “demand which taxes the adaptive resources,”‘ we can readily see that the presence of the disease and the prescribed treatment regimen (either or both) can represent stressful circumstances - above and beyond other demands which also may be impinging on the patient. Thus, in examing the dynamics of patient adherence behavior, we are seeking to understand a problem which has both practical implications for patient management and theoretical implications for behavior under stress. The selective review which follows is intended to illuminate some of the issues which make it such a difficult area of patient behavior to understand and manage. However, as the reader will soon discover, the adherence literature does not provide many direct linkages to the literature on stress. Thus the present review can only spell out ‘and analyze some of the issues, but it remains for future studies to provide a firm empirical base for the link with behavior under stress. Journal of Human Stress 5
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ISSUES IN PATIENT ADHERENCE THE SEARCH FOR STABLE CORRELATES OF ADHERENCE Adherence or compliance encompasses a great variety of categories and types of behavior: a) entering into or continuing a treatment program, b) keeping follow-up or referral appointments, c)' taking prescribed medication, and d ) restricting or changing one's activities, including smoking, diet, and exercise. (Some might argue that participation in screening and in periodic health exanainations also are forms of adherence behavior with strong implications for health maintenance, though the recommendation which is being adhered to is a somewhat nebulous one as far as source and content are concerned. The present review will not deal with these forms of health behavior in order to delimit the scope, and because they are less likely to represent behavior under stress. The reader is referred to other reviews2 for an examination of their correlates.)
General reviews of the compliance literature ' l o suggest that the traditional (and perhaps easiest) approach of searching for stable characteristics of the person which would predict compliance is not going to enhance our understanding of the dynamics of this class of behaviors. There is little evidence that different forms of compliance are more than modestly correlated with each other, and that compliance of any one type is stable over time. There is even one study" which showed that a patient's intentions to comply are poorly correlated with his actual compliance.
related consistently to adherence across the board, and neither the practicing physician nor the investigator should make a priori assumptions about their importance. The search for a "defaulter type"b has not met with success. The above comments should not be interpreted to mean that sociodemographic characteristics are always irrelevant; rather, the point is that they do not lead to a general understanding of the adherence phenomenon. However, in specific instances, one or another of these variables may be related. For example, the Detroit studyI2 of dropping out from a hypertensive clinic revealed a strong social class gradient: the dropouts were more likely to be non-white and lower on education, occupation, and income. Similarly, regular (middle class) members of a comprehensive prepaid group practice program were found to have lower rates of broken appointments (8 percent) than urban indigent families who later joined such a program (25 percent). ''
In fact, there is a lot of evidence that when sociodemographic variables are related to adherence, it is in fairly specific ways which represent interaction withi other variables. The following studies illustrate this point: 0 In a study of male NASA employee^'^ who were followed up after cardiovascular screening, achieving adequate therapeutic control was more often found in older employees in the case of hypertension and in younger employees in the case of hypercholesteremia. Patients' sociodemographic charac- 0 Among individuals trying to stop s m ~ k i n g , ' a~ wife's disapproval of teristics, surprisingly, offer very little smoking increased chances of success promise as reliable predictors of poor for the husband, but women smokers adherence. Age, sex, race, social class, were unaffected by their husbands' and marital status - none of these is 6 Journal of Human Stress
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KASL patient with that condition, rather than by his expectations of good or poor adherence. And even small changes in the regimen which would likely improve adherence -such as setting up as simple a medication regimen as possible - may not be acceptable to clinicians who want to juggle medicines in order to effect a Other studies of tuberculosis pa- better control of the problem and to t i e n t ~ ’ ~suggest , ’ ~ that poor compliance monitor better the possible side reacis especially common among those liv- tions. ing alone; however, a study of diabetic In short, our limited understanding of patientslVsuggested that poor control adherence behavior does not lead to any of the disease was especially common easy ways of modifying and enhancing among members of larger households. the patient’s compliance. As noted Characteristics of medical regimen before, intentions to comply are poorly remain fairly reliable predictors of correlated with actual cornpliance,l’ and adherence. Coming back to a clinic as compliance may show very little stability requested and having tests done which over time,’5 thus suggesting that the have been ordered tend to have high dynamics of compliance are evercompliance rates,s while abiding by changing. Noncompliance may depend restrictions and changing personal habits on variables in the social environment, have low rates of compliance.s.20.21such as family expectations26 or social Multiple’ recommendations or restric- isolation,27which may be largely beyond tions lead to greater noncompliance. the physician’s control. Lifelong work atHigher drug defaulting is found if the titudes and habits may make compliance doctor prescribes multiple drugs or with some regimen more difficult.25.2* multiple daily doses of one drug,22.23.24 or. Highly anxious and defensive patients if the drug has side effects. Patients who may distort or forget the recomhave been on a medication regimen mendations almost as soon as they hear longer tend to default more, especially if them.2v And noncompliance may inthe chronic condition is not serious or crease as soon as the patient “feels painful. Compliance is generally better if well.”3o Perhaps the one area where one the medication provides some relief from can expect some improvement in symptoms and poor when it is taken for adherence would be as a result of the prophylactic reasons or when symptoms physician (or some other health belie the need for medication. professional) helping the patient to set up Overall, these results suggest that com- some system for the latter to monitor his pliance can be predicted better from the medications. Several ~ t u d i e s ~ . have ~‘.~~ characteristics of the medical regimen shown more drug defaulting among than from the characteristics of the patients who have no method for remempatients. However, such a conclusion is of bering to take medication, while another limited value since the physician’s choice study” has shown that a home monitor of the medical regimen is dictated which automatically records the primarily by his judgment of what con- regularity with which medication is stitutes optimal treatment for that removed can lead to high levels of com-
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disapproval, -and disapproval from friends and relatives actually increased their chances of failure. A study of tuberculosis patients on home medicationsl6 showed poor compliance among older men and younger women.
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ISSUES IN PATIENT ADHERENCE pliance among tuberculosis patients. Also instructive are the results of two studies,333 4 both of which were done in the context of a hypertension detection and follow-up program and both of which involved outreach programs of stepped-up care to maintain patients in treatment and to improve medication behavior - one via public health nurses,33 the other via clinical pharmacy serv i c e ~ .Both ~ ~ studies obtained the same result: the usual dismal picture of hypertension 3 5 3 b led to a striking improvement in adherence, which lasted only for the duration of the intervention program (two years) and then it was back to the old, dismal picture. The lesson from these studies is that, given our present limited understanding of adherence, such services and interventions don’t seem to succeed as health education efforts, and the activities must be maintained indefinitely if the better adherence is to persist. How can we enhance our understanding of adherence behavick? The following sections of this review will deal with three areas which I believe call for a closer scrutiny: our theoretical formulations, the role of the doctor, and the doctor-patient interaction.
closure. However, in spite of this vigorous and extensive activity of conceptualizing the behavioral aspects of the health-illness-treatment-recovery cycle, it does not appear that such formulations are ade; quate to deal with the many aspects of the problem of adherence behavior. This is because adherence becomes an issue precisely in those circumstances which are neglected by the above-mentioned formulations.
There appear to be three major areas of inadequacy of current formulations to deal with compliance: 1) The person’s “at risk’‘ status, in which he feels well but knows that one or more risk factors are present (as revealed at screening, or because past episodes of illness such as tuberculosis or rheumatic fever put the person at higher risk), does not fit the conceptual definition of either health behavior (“any activity undertaken.by a person believing himself to be healthy, for the purpose of preventing disease or detecting it in an asymptomatic stage”I5) or illness behavior (“any activity, undertaken by a person who feels ill, to define the state of his health and to discover a suitable remedy”*s), but falls somewhere in between. Hence, the understanding gained THE INADEQUACY OF OUR from a large number of studies of health TH EOR ETICAL FORM ULATIONS and illness behavior2.3.40.51.52.53 is not The whole area of personal health be- directly applicable to “at risk” behavior. havior has been the target of many theo2) Staying in treatment and complying retical formulations, including those of with treatment regimen in order to bring Parson,‘7 M e c h a n i ~ . ’4o~ S ~ c h n i a n . ~ ’about reduction of risk (e.g., keeping on and Z ~ l a 4 ‘. ~In~ addition to these au- antihypertensive medication) requires thors, many others have offered reformu- sick-role behavior from a person who lations, elaborations, formalizations, and does not feel sick, requires medication consolidations of this large set of in- even though no concomitant changes in sights, ideas, and 45 4b 4 7 48 health status generally are taking place, 4 q so with the work on the Health Belief and requires being in treatment indefiModel5’ perhaps representing the nitely. Moreover, the sick-role behavior most persistent attempt at theoretical takes place in a treatment setting which
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has minimum social visibility and minimum social and institutional support. In short, it is a far cry from the classical Parsonian conceptualization of the sick roIe.37. 3 8 . 4 9 3) A doctor who prescribes treatment which consists of alteration of personal habits (smoking and eating) is prescribing treatment which is less obviously medical, where his authority to insist on it may be more marginal, and where the sanctions available to the doctor are weaker. Again, then, the whole matrix of sick-role expectations, norms, and sanctions involving the doctor, the patient, and the significant others around him, is much less clear (and probably quite different) from the traditional description of the sick role. These comments suggest the need for some modifications and elaborations of the concepts of health, illness, and sickrole behavior. A first step in this direction has been taken by who int6oduced the concept of “at risk” role. He points out that, in contrast to the sick role, the “at risk” role: a) is not institutionalized; b) has only. duties attached to it, but no privileges, such as reduced social obligations; c) has an indefinite time span; d) lacks continuous reinforcement from health professionals and the social environment; e) lacks the feedback provided by changes in symptomatology and in treatment procedures.
THE ROLE OFTHE DOCTOR The vast majority of studies of compliance are studies of patient behavior only; the physician remains a shadowy figure in the background, only seldom caught in the investigator’s net. Thus, our information about what physician characteristics and behaviors contribute to good or poor compliance is extremely limited. Nevertheless, the empirical
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literature can be organized to make the following points. First of all, patient compliance clearly is important to the practicing physician; in fact, the most important source of dissatisfaction in the physician’s professional life is his inability to exercise control over his patient because of the patient’s uncooperative behavior.ss So we are talking about a problem which is ostensibly important to the physician. Secondly, several studies have shown that physicians overestimate the amount of patient compliance and cannot detect the patients who are complying p o ~ r l y . ~ . ~ . ~ . S b . 5 7 ’ 5 8 Moreover, physicians are unlikely to think of anything other than patient characteristics as reasons for noncompliance.8.5 5 There is also some evidence that clinical experience does not necessarily provide the physician with more skills and sensitivity to deal with this problem. In a comparison of senior physicians with fourth year medical students,8 it was the student group who: a) had a more realistic estimate of patient noncompliance; b) saw a greater variety of patient characteristics as potentially having an influence on compliance; c) were less likely to invoke the patient’s personality or difficult life situation as major reasons for noncompliance; and d) were less likely to suggest that they might manage noncompliance by withdrawing from the case and referring the patient to another physician. Finally, there is pretty good evidence that physicians are reluctant to get involved in medical regimen which are likely to lead to adherence problems. For example, in the Chicago cardiovascular screening only about 30 percent of cigarette smokers who were referred to physicians because of some other cardiovascular risk factor revealed at Journal of Human Stress
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ISSUES I N PATIENT ADHERENCE screening (high blood pressure, ECG abnormality) were advised by their doctors to quit smoking. In a study of charts of a public outpatient clinic,s9 among those patients who were independently identified as severely overweight, only one half of them had their weight noted in their charts, and in only one quarter of the cases was a weight management program proposed. And in another study of medical records,’’ it was found that within three months the physicians had lost track of 56 percent of their hypertensive patients. A possible conclusion from this last finding is that physicians are reluctant to take on an activist, outreach role in this area of adherence behavior. This lack of studies on the doctor’srole in the patient’s adherence suggesls not only that the physician is a very elusive subject, but that the very perspective from which the studies are carried out (i.e., the position that the locus of the problem is with the patient) appears to make it unnecessary to study the physician in the first place. Thus we have a modest paradox here: as Stimsonbohas pointed out, the problem is almost exclusively investigated from the physician’s, and not the patient’s, perspective; but it is the patient, not the physician, who is invariably studied. Yet,as we have seen so far in this review, an exclusive focus on the patient doesn’t get u s very far. We must pay attention to the doctorpatient relationship, to their mutual expectations, and to the social aspects of the setting in which medication is prescribed and, later, taken. THE DOCTOR-PATIENT INTERACTION
The doctor-patient relationship is the aspect of medical service which is under greatest criticism from the patient.“’ The 12 Journal of Human Stress
most frequently investigated component of this relationship is the communication process in this dyad; there is no question that communication is inadequate and that many social, motivational and structural barriers exist which prevent a free exchange about the disease, the treatment, and the relationship itself.62. 6 3 6 4 However, in view of other evidence that possessing correct information about the disease and the medical regimen is by itself, at best, weakly related to patient’s adherence.b ’ l o l 9 *‘l4 6 5 6 6 it would seem that the crucial element in the doctor-patient relationship is probably not the exchange of information and facts, but the nature of the expectations each one has about his own role and the role of the other person in the dyad, the congruence and mutuality of such expectations, and the potential for exploring and revising these expectations. What do we know about the patient’s expectations and how they influence adherence? Most fundamentally, the patient expects (hopes for) good medical care which, as Friedsonb7 has shown, translates into a) technical competence of the physician and b) his taking interest in the patient. But both these elements are really a set of subjective expectations about what the doctor will say and what he will do - as well as what will be the later consequences in terms of improvements in health status. There are a number of studies which suggest that unfulfilled patient expectations lead to poorer compliance.8 bn b9 Lowered patient satisfaction is probably one of the intervening variable~,’~ but it is not frequently studied simultaneously. (In any case there are other studies7’7 2 7 3 which have established the association between patient safisfaction and compliance.) For example, whether a doctor is “friendly” (vs. “businessSeptember, 1975
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KASL like”) doesn’t influence satisfaction near- dered, than when a patient has more time ly as much as expecting reassurance, and to prepare for the hospitalization and for not getting it, or expecting an explana- whom the usual number of tests is ortion, and not getting it;70and such dis- dered. satisfied patients have lower compliAs we noted before, there is no ance.68 Another studyb9found that pa- adequate agreement that that aspect of tients who say “Yes” to the question doctor-patient communication which in“Does the doctor spend enough time creases the patient’s knowledge of the with you?” are more likely to comply disease and the treatment leads to better than those whose answer is negative. And ~ o m p l i a n c ePerhaps .~~ one reason for this since the actual time .spent with the may be the modifying role of patient’s expatient was unrelated to compliance, this pectations: communicating information finding reveals the effect of the patient’s and explanation to the patient improves expectation (about how much is compliance primarily in those who expect “enough”) rather than of the physician’s such doctor behavior. Another reason behavior. may be that the patient’s knowledge about disease interacts with other There is also .some evidence42.43.74.7s variables in influencing compliance. In a that unfulfilled expectations at initial study of diabetic and hypertensive contact may threaten continuation of the patients.77 better knowledge about illness therapeutic relationship. Zola” has showed an overall association with better noted that when the physician pays little compliance (staying in treatment); attention to the specific trigger which however, the association was much brought the individual to see the doctor, weaker among subgroups of patients: a) then there is a greater likelihood that the who had had a broad range of experience patient will eventually break off treatwith their illness and the medical care ment. also has suggested that this system; b) who were high on anxiety; c) should even be applied to checkup visits: whose illness entailed many problems in the patient may declare that he has come for a checkup, but the timing of the visit self-management, but d) whose illness is such that the patient has something did not interfere markedly with their specific he considers worth checking daily activities. upon and unless the physician explores While increasing the patient’s this “hidden agenda” the patient may knowledge about the disease may not not keep the appointment for the next have much of an effect on compliance, checkup. Vincent7s found that out- increasing his knowledge about treatpatients at a glaucoma clinic show less ment and what to expect does seem to compliance with medication (taking eye have the expected association with drops) if they came initally for a com- adherence. Several studies have linked plaint of vision loss, than if they pre- noncompliance to the physician’s failure sented signs and/or symptoms o r came to communicate the purpose of the treatfor a routine examination. And Davis7‘ ment‘o.30or the need for follow-up aphas reported that self-discharge from p o i n t m e n t ~ . And ~ ~ above all, the hospital (against medical advice) is more physician needs to find out about the likely when a patient is admitted on an patient’s expectations and about emergency basis and for whom an “obeying doctor’s orders,” as seen by the unusually large number of tests is or- patient. For example, Stimson60has emSeptember, 1975
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ISSUES IN PATIENT ADHERENCE phasized the fact that patients generally have some ready-made preconceptions about taking medicines: “You only take medicines when you are ill, not when you are better.” “You need to give your body some ‘rest’ from the medicine onoe in a while or otherwise your body becomes dependent on it or immune to it.” Such preconceptions have to be inquired about and modified, as necessary. Morleover, the patient may have some expectcations about the visit to the doctor (concerning what complaints will get discussed: what the doctor will say is “wrong”; and what the doctor will prescribe or say th.at the patient will have to do). Again, inquiring about such expectations and modifying them may lead to much better patient compliance. CONCLUDING REMARKS It should be apparent that the above review is a highly selective one: it is limited to adherence behavior among outpatients and only the physician, among several possible health professionals, is considered. Such a limitation is appropriate since (in addition to considerations of length of the review) the bulk of the studies are concerned with this narrower formulation of the issue. Nevertheless, we may note some of the other issues which this review leaves out: 0 adherence among hospitalized or institutionalized patients (which can also be a problem);’8 role of other health professionals and 0 of the way the medical care delivery system is organized; viewing most adherence problems as 0 issues of self-care and taking them out of the domain of the doctorpatient relationship; the role of the lay referral system4” 4 2 . 0 4 5 . l9 in enhancing or interfering with adherence: 14 Journal of Human Stress
the use of nonmedical per~onnel.’~. All of these are important problems in their own right. It also may be noted that this review does not have many direct linkages with the literature on stress. This latter limitation, however, is not a matter of choice: such linkages as yet do not exist. At the moment there is no way of taking one or another of the current theoretical formulations or approaches to stress, coping, adaptation, and decision makinga’ 8 2 8 3 8 4 8 5 and applying it rigorously to the just reviewed frndings on adherence behavior. Most of the studies which one way or another invoke the concept of stress (and mostly assess some form of distress in the patient) are studies of illness behavior;8b 8 8 8 9 q o on the basis of these studies it is reasonable to conclude that certain forms of distress, especially depression and low self-esteem, enhance in some persons the readiness to seek medical attention (however, the literature on anxiety and delay in seeking diagnosis of cancer9’ 9 2 does not lend itself very well to this generalization). But these studies of illness behavior deal primarily with initial contacts with the physician and we d o d t have any evidence that continued contact (staying in treatment) or other forms of adherence are similarly enhanced by distress. In fact, it is quite possible that patients whose initial contact with the physician is motivated primarily by psychological distress may subsequently be poor on diverse forms of adherence behavior. This review has provided ample documentation that the dynamics of patient adherence are as yet poorly understood and that certain traditional but limited approaches have had only limited payoffs. More broadly-based studies need to consider systematically the whole issue of stress (demands on adaptive
0
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KASL resources) and coping. In particular, future studies need to pay attention to the interaction of five possible sources of demands: the medical regimen itself, the disease state, the social environment at home and at work, the doctor-patient relationship, and the medical care setting.
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This paper was presented, in part, at the American Heart Association Conference on "Applying Behavioral Science to Cardiovascular Risk." Seattle, June 17-19,1974.
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INDEX TERMS patient adherence, patient compliance, doctorpatient reiationship, medical regimen, patient expectations, at-risk behavior.
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REFERENCES 1.
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Editorial. J. Hum. Stress. Vol. 1. March, 1975, p. 3. Rosenstock. I.M.. "Why People Use Health Services." Milbunk Mem. Fund Q.. Vol. 44. July, 1%6. p. 94. Rosenstwk. I.M. "The Health Belief Model and Preventive Health Behavior." Health Educ. Monogr.. Vol. 2. Winter, 1974, p. 354. Becker. M.H. "The Health Belief Model and Sick Role Behavior." Heulth Educ. Monogr.. Vol. 2. Winter, 1974. p. 409. Berkowitz. N.H.. M.F. Malone. M. W. Klein. et al. "A Patient Follow-through in the Outpatient Department." Nurs. Rrs.. Vol. 12. Winter, 1963. p. 16. Blackwell, B. "The Drug Defaulter." Clin. Phurmucol. Ther.. Vol. 13. NovemberDecember. 1972, p. 841. Charney. E. "Patient-Doctor Communication: Implications for the Clinician." Pediutr. Clin. North A m . . Vol. 19, May, 1972. p. 263. Davis, M.S. "Variations in Patients' Compliance with Doctors' Orders: Analysis of Congruence Between Survey Responses and Results of Empirical Investigations," J. Med. Educ.. Vol. 41, November, 1966. p. 1037. Marston. M. "Compliance with Medical Regimens: A Review of the Literature." Nurs. R ~ s .VOI. . 19, July-August. 1970. p. 312. Wilson, J.T. "Compliance with Instructions in the Evaluation of Therapeutic Efficacy." Clin. Pediutr.. Vol. 12, June, 1973, p. 333. Davis, M.S. "Physiologic. Psychological, and Demographic Factors in Pa!ient Compliance
September, 1975
17.
18.
19.
20.
21.
with Doctor's Orders," Med. Cure, Vol. 6, March-April. 1968, p. 115. Caldwell. J.R.. S. Cobb. M.D. Dowling, et al. "The Dropout Problem in Antihypertensive Treatment." J. Chronic Dis.. Vol. 22. February, 1970. p. 579. Greenlick. M.R.. D.K. Freeborn, T.J. Colombo. et al. "Comparing the Use of Medical Care Services by a Medically Indigent and a General Membership Population in a Comprehensive Prepaid Group Practice Program." Med. Cure. Vol. 10. May-June. 1972. p. 187. Villafana. C.. and J. Mackbee. "The Value of Continued Follow-up in a Preventive Medicine Program,'' Industr. Med. & Surg.. Vol. 40, July, 1971. p. 11. Guilford. J.S. "Group Treatment vs. Individual Initiative in the Cessation of Smoking." J. Appl. Ps.vcho1.. Vol. 56. April, 1972. p. 162. Luntz. G.R.W.N., and R. Austin. "New Stick Test for P.A.S. in Urine." Br. Med. J.. Vol. I. June4, 1960. p. 1679. Berry, D.. A. Ross, and K. Deuschle. "Tuberculosis Patients Treated at Home,'' A m . Rev. Respir. Dis.. Vol. 88. December, 1963. p. 769. Pragoff. H. "Adjustment of Tuberculosis Patients One Year After Hospital Discharge." Public Heulth Rep.. Vol. 77. August, 1962. p. 671. Williams. T.F.. D.A. Martin, M.D. Hogan, et al. "The Clinical Picture of Diabetic Control. Studied in Four Settings." A m . J. Public Heulrh. Vol. 57. March, 1%7. p. 441. Davis, M.S. "Predicting Non-compliant Behavior." J. Health Soc. Behuv.. Vol. 8. December, 1967, p. 265. Johannsen. W.J.. G.A. Hellmuth. and T. Sorauf. "On Accepting Medical Recommendations.'' Arch. Enviroti. Heulth. Vol. 12. January. 1966, p. 63.
22. Clark, G.M.. and R.C. Troop. "One-tablet Combination Drug Therapy in the Treatment of Hypertension." J. Chmnic Dis.. Vol. 25, February. 1972. p. 57. 23. Malahy. B. "The Effect of Instruction and Labeling on the Number of Medical Errors Made by Patients at Home." A m . J. Hosp. Phurm.. Vol. 23. June. 1%6. p. 283. 24. Neely. E., and M.L. Patrick. "Problems of Aged Persons Taking Medications at Home." Nurs. Res.. Vol. 17, January-February, 1968. p. 52. 25. Davis, M.S.. and R.L. Eichhorn. "Compliance with Medical Regimens: A Panel Study," J. Health & Hum. Behue.. Vol. 4. Winter. 1963. p. 240.
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ISSUES IN PATIENT ADHERENCE 26. Oakes. T.W.. J.R. Ward. R.M. Gray, et al. “Family Expectations and Arthritis Patient Compliance to a Hand Resting Splint Regimen.” J . Chrotrir Dis.. Vol. 22. April, 1970. p. 157. 27. Porter. A.M.W. “Drug Defaulting in General Practice.” Br. Med. J . . Vol. 1, January 25. 1969. p. 21 8. 28. Willis, F.N.. and N.M. Dunsmore. W o r k Orientation, Health Attitudes and Compliance with Therapeutic Advice,” Nurs. Res.. Vol. 16. Winter, 1967, p. 22. 29. Hellmuth. G.A.. W.J. Johannsen. and T. Sorauf. “Psychological Factors in Cardiac Patients,” Arch. Environ. Health, Vol. 12, June, 1966, p. 771. 30. Mohler, D.N., D.G. Wallin. and E.G. Dreyfus. “Studies in the Home Treatment of Streptococcal Disease. 1. Failure of Patients to Take Penicillin by Mouth as Prescribed,” N. EngI. J . Med.. Vol. 252. June 30. 1955. p. 1116. 31. Mclnnis, J.K. “Do Patients Take Antituberculosis Drugs?” A m . J. Nurs.. Vol. 70. October, 1970. p. 2152. 32. Moulding, T.. G.D. Onstad. and J.A. Sbarbaro. “Supervision of Outpatient Drug Therapy with the Medication Monitor.” Ann. Intern. Med.. Vol. 73. October, 1970, p. 559. 33. Wilber, J.A.. and J.G. Barrow. “Reducing Elevated Blood Pressure,” Minn. Med.. Vol. 52. August 1969, p. 1303. 34. McKenney. J.M., J.M. Slining, H.R. Henderson, et a1 “The Effect of Clinical Pharmacy Services on Patients with Essential Hypertension,” Circulation, Vol. 48, N(wember. 1973, p. 1 104. 35. Stamler, I.. J.A. Schoenberger, H.A. Lindberg, et al. “Detection of Susceptibility to Coronary Disease.” Bull. N.Y.Acad. Med.. Vol. 45. December, 1969, p. 1306. 36. Wilber, J.A., and 1.G. Barrow, “Hypertension - a Community Problem,” A m . J . Med.. Vol. 52. May, 1972, p. 653. 37. Parsons, T. ”Illness and the Role of the Physician: A Sociological Perspective.” A m . J. Orthopsychiatry. Vol. 21, July, 1951, p.452. 38. Parsons, T. “Definitions of Health and Illness in the Light of American Values and Social Structure,“ Patients, Physicians, and Illness. E.G. Jaco. ed.. p. 165. The Free Press Glencoe. Ill., 1958. 39 Mechanic, D. ”The Concept of llllness Behavior,” J. Chronic Dis.. Vol. 15, February, 1%2. p. 189. 40 Mechanic, D. Medical Sociology. The Free Press, New York. 1968.
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41.
Suchman, E.A. “Stages of Illness and Medical Care.” J . Health & Hum. Behav.. Fall. 1965. p. 114.
42. Zola, I.K. “Studying the Decision to See a Doctor,” Psychosocial Aspects of Physical Il111ess. Vol. 8. Advances in Psvchosomatic Medicine. Z. J. Lipowski, ed., p. 216. S. Karger. Basel, Switzerland, 1972. 43. Zola, I.K. “Pathways to the Doctor - From Person to Patient,” SOC. Sci. Med.. Vol. 7. September, 1973, p. 677. 44. Fabrega, H., Ir. Disease and Social Behavior: A n Interdisciplinary Perspective. The MIT Press, Cambridge. 1974. 45 Friedson, E. Profession of‘Medicine: A Study of‘theSociology ofApplied Knowledge. Dodd. Mead, & Co.. New York. 1970. 46. Gordon. G. Role Theory and Illness. College and University Press, New Haven, 1%6. 41. Kasl. S.V., and S. Cobb. “Health Behavior, Illness Behavior. and Sick Role Behavior,” Arch. Envirm. Health. Vol. 12, February, 1%6. p. 246, and April 1%6, p. 531. 48. Pflanz. M., and J.1. Rohde. “Illness: Deviant Behavior or Conformity,” SOC.Sci. Med.. Vol. 4, December. 1970, p. 645. 49. Twaddle, A.C. “The Concept of the Sick Role and Illness Behavior,” Psychosocial Aspects of Phvsical Illness, Vol. 8. A d v a n c e s in Psvchosomatic Medicine, Z. J. Lipowski. ed., p. 162. S . Karger, Basel, Switzerland, 1972. 50. Twaddle. A.C. “Illness and Deviance,” SOC. Sci Med. Vol. 7. October, 1973. p. 751. 51. Becker, M.H., ed. “The Health Belief Model and Personal Health Behavior.” Health Educ. Monogr., Vol. 2. Winter, 1974. p. 326. 52. Anderson. O.W.. and R.M. Andenen. “Patterns of Use of Health Services.” Handbook of Medical Sociofogy, H.E. Freeman, S . Levine. and L.G. Reeder. eds.. p. 386. Prentice Hall. Inc.. Englewood Cliffs, N.J., 1972. 53. McKinley. J.B. “Some Approaches and Problems in the Study of the Use of Services - An Overview,” J. Health Soc. Behav.. Vol. 13. June 1972, p 115. 54. Baric, L. “Recognition of the ‘At-risk’ Role: A Means to Influence Health Behavior.” Int. J . Health Educ.. Vol. 12, 1969, p. 24. 55. Ort. B.S., A.B. Ford. and R.E. Liske. “The Doctor-Patient Relationship as Described by Physicians and Medical Students,” J. Health Hum. Behav., Vol. 5, Spring, 1964, p. 25. 56. Caron, H.S., and H.P. Roth. “Patients’ Cooperation with a Medical Regimen,” J.A.M.A.. Vol. 203, March 11,1%8. p. 922. 57. Charney, E., R. Bynum, D. Eldredge. et al.
September. 1975
KASL “How Well Do Patients Take Oral Penicillin?
A Collaborative Study in Private Practice,” Pediatrics. Vol. 40.August 1967. p. 188.
58. Roth, H.P., H.S. Caron, and B.P. Hsi.
59.
Downloaded by [University of New Hampshire] at 11:15 05 March 2015
60.
61.
62.
63. 64.
65.
66.
“Estimating a Patient’s Cooperation with His Regimen.” A m . J. Med. S c i , Vol. 262, November. 197 1, p. 269. Maddox, G.L.. C.F. Anderson, and M.D. Bogdonoff. “Overweight as a Problem of Medical Management in a Public Outpatient Clinic,” A m . J. Med. S c i . Vol. 252, October, 1966, p. 394. Stimson, G.V. “Obeying Doctor’s Orders: A View from the Other Side,” SOC.Sci Med.. Vol. 8. February 1974, p. 97. Kms, E.L. “‘Metropolis’- What City People Think of Their Medical Services,” A m . J. Public Health. Vol. 45, December, 1955, p. 1551. Cartwright, A. Human Relations and Hasptial Care. Routledge & Kegan Paul, London. 1%4. Ley. P., and M.S. Spelman Communicating with the Patient. Staples Press, London, 1967. Pratt, L.. A. Seligman, and G. Reader. “Physician’s View on the Level of Medical Information Among Patients,’’ Am. J . Public Health, Vol. 47. October, 1957, p. 1277. Finnerty. F.A., Jr.. E.C. Mattie. and F.A. Finnerty. Ill. “Hypertension in the Inner City. 1. Analysis of Clinic Dropouts.” Circulation. Vol. 47. January, 1973, p. 73. Stewart, R.B.. and L.E. Cluff. “A Review of Medication Errors and Compliance in Ambulant Patients,” Clin. PharmacoL Ther.. Vol. 1 3 , J ~ l y - A ~ g1972, ~ ~ t p. . 463.
67. Friedson. E. Patients‘ View of’Medical Practice. Russell Sage Foundation. New York. I%]. 68. Francis, V., B.M. Konch. and M.J. Morris. “Gaps in Doctor-Patient Communication: Patients’ Responses to Medical Advice.” N. Engl. J . Med.. Vol. 280. March 6, 1969. p. 535. 69. Geertsen, H.R.. R.M. Gray, and J.R. Ward. “Patient Noncompliance within the Context of Seeking Medical Care for Arthritis.” J. Chronic Dis.. Vol. 26, November, 1973. p. 689. 70. Korsch, B.M.. E.K. Goui. and V. Francis. “Gaps in Doctor-Patient Communication. I. Doctor-Patient Interaction and Patient Satisfaction.” Pediatrics. Vol. 42. November, 1%8. p. 855. 71. Alpert. J.1. ”Broken Appointments.” Pediatrics. Vol. 34. July, 1964, p. 127. 72. Becker. M.H. R.H. Drachman, and J.P. Kirscht. “A New Approach to Explaining Sick-
September. I9 75
Role Behavior in Low-Income Populations,” Am. J. PublicHealth. Vol. 64. March, 1974, p.
20.5. 73. Diamond, M.D., A.J. Weiss, and B. Grynbaum. “The Unmotivated Patient,” Arch. Phys. Med. Rehabil.. Vol. 49. May, 1968. p. 281. 74. Davis, M.S. “Discharge from Hospital Against Medical Advice: A Study of Reciprocity in the Doctor-Patient Relationship,” SOC. Sci Med.. Vol. 1. September. 1967. p. 336. 75. Vincent, P. “Factors Influencing Patient Noncompliance: A Theoretical Approach,” Nurs. Res.. Vol 20, November-December, 1971. p. 509. 76. Davis, M.S. “Variations in Patients’ Compliance with Doctor‘s Orders: Medical Practice and Doctor-Patient Interaction,” Psychiatry Med.. Vol. 2. January, 1971. p. 31. 77. Tagliacozzo. D.M.. and K. Ima “Knowledge of Illness as a Predictor of Patient Behavior.” J. Chronic Dis.. Vol. 22. April 1970, p. 765. 78. Roth. H.P.. and D.G. Berger. “Studies on Patient Cooperation in Ulcer Treatment. 1. Observation of Actual as Compared to Prescribed Antacid lntake on a Hospital Ward.” Gastroenterology, Vol. 38, April, 1960, p. 630. 79. Suchman. E.A. “Health Orientation and Medical Care,” A m . J. Public Health. Vol. 56. January, 1966, p. 97. 80. Kms, E.L. The Health oj’Regionvdle. Columbia University Press, New York. 1954. 81. Coelho, G.V., D.A. Hamburg, and J.E. Adams. eds. Coping and Adaptation. Basic Books. New York, 1974. 82. Janis, 1.L.. and L. Mann. “A Conflict Theory Approach to Attitude Change and Decision Making,” Psychological Foundations of Attitudes. A. Greenwald, T.C. Brock. and T.M. Ostrum. eds., p. 327. Academic Press, New York. 1%8. 83. Lazarus. R.S. Psychological Stress and the Coping Process. McGraw-Hill. New York. 1966. 84. Levi, L. “Psychosocial Stress and Disease: A Conceptual Model,” Life Stress and Illness, E.K.E.Gunderson, R.H. Rahe,eds.. p.8. C.C. Thomas, Springfield, Ill., 1974. 85. Levine, S., and N.A. Scotch, eds. SocialStress. Aldine, Chicago, 1970. 86. Kasl, S.V.. and S. Cobb. “Some Psychological Factors Associated with Illness Behavior and Selected Illnesses,” J. Chronic Dis.. Vol. 17. April 1964, p. 325, Continued on page 48
Journal of Human Stress 17
more detailed data collection and analysis. Holmesv Rahe .and their co-workers have done a great deal to stimulale activity and research in the life-events field. Their research has often titilated arid intrigued us, but the processes that explain the relationship between life events and illness require considerable exploration. Refinements of such instruments as the Rating Scale is a necessary step in attempting to test native theoretical conceptions of the
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u
2. Mechanic, D. Medical Sociology: A Selective Vim*.pp. 294-301. Free Press. New York. 1968. 3. Holmes. T.H.. and M. Masuda. "Life Change and lllness Susceptibility." Stressfir1 Lit? Events: Their Nature arid E#iects. B.S. Dohrenwend and B.p. Dohrenwend. eds., pp. 45-72. Wi~ey-~nterscience. N~~ Yo&, 1974.
4.
s. Selye. H. The stress r?/.LjtP. McGraw-Hill, New York. 1956. 6. Lazarus. R.S. Ps.vchologica1 Stress and the Coping Process. McGraw-Hill. New York. 1966.
op. cit.. pp. 135.149.
INDEX TERMS
sm* social Rnthg change, adaptive behavior, -oremeat
liie of stress.
REFERENCES 1. Holmes. T.H.. and R.H. Rahe. "The Social
Readjustment Rating Scale." J. Psychos. Res.. VOI. I I , 1967. pp. 213-218.
8. Brown. G. W.. and J. L. T. Birlev. "Crisis and Life Changes and the Onsei of Schizophrenia." J. H d t h Soc. Bchuv.. Vol. 9, 1968. pp. 203-214. 9. Holmes and Masuda. op. cit.. p. 57. 10. Brown. G.W. "Meaning, Measurement, and Stress of Life Events." In Dohrenwend and Dohrenwend. eds.. op. cit.. pp. 217-243.
KASL - REFERENCES I7 Mechanic, D., and E.H. Volkart. "Stress, Illness Behavior and the Sick Role. A m . Sociol. Rev.. Vol. 26. February 1%1. p. 51. 88. Roessler. R., and N.S. Greenfield. "Per91. sonality Determinants of Medical Clinic Consultation," J. New. Ment. Dis.. Vol. 127. August. 1958. p. 142. 89. Shuval. J.T.. A. Antonovsky. and A.M. 92. Davies. Social Functions qt' Medical I'racticc~. Jossey-Bass. Inc.. San Francisco. 1970. 90. Stoeckle. J.D.. I.K. &la. and G. E. Davidson. "The Quantity a n d Significance of
Continued,ti.ompage
87.
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Psychological Distress in Medical Patients: Some Preliminary Observations About the Decision to Seek Medical Aid," J. Chronic Dis.. Vol. 17. October 1964. p. 959. Antonovsky, A., and H. Hartman. "Delay in the Detection of Cancer: A Review of the Literature." Heulth Educ. Monogr.. Vol. 2, Summer. 1974, p. 98. Green. L.W., and B.J. Roberts. "The Research Literature on Why Women Delay in Seeking Medical Care for Breast Symptoms." Health Educ. Monogr.. Vol. 2. Summer. 1974. p. 129.
September. I975
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Issues in Patient Adherence to Health Care Regimens Dr. Stanislav V. Kasl Ph.D.
a
a
Department of Epidemiology and Public Health , Yale University School of Medicine , New Haven, Connecticut, USA Published online: 09 Jul 2010.
To cite this article: Dr. Stanislav V. Kasl Ph.D. (1975) Issues in Patient Adherence to Health Care Regimens, Journal of Human Stress, 1:3, 5-48, DOI: 10.1080/0097840X.1975.9939542 To link to this article: http://dx.doi.org/10.1080/0097840X.1975.9939542
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ISSUES IN PATIENT ADHERENCE TO HEALTH CARE REGIMENS
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STANISLAV V. KASL. Ph.D.*
This paper examines an important area of personal health behavior in which the possible link between stress and health status is not primarib a biological one but a behavioral one. The review oj* empirical literature is organized around four topics: I ) the limited payofljivm the search f o r stable sociodemographic and personality correlates oj. adherence: 2) the inadequacy of our current theoretical formulations; 3) the role of the doctor: and 4) the doctor-pa tien t interaction , which emphasizes mutual expectations rather than a one-way transfer of injormation. The concluding remarks address themselves to the need-for afirmer linkage with the conceptual and empirical literature on stress and coping.
It is easy to forget that the role of human stress in health and illness is not exhaustively represented by a single perspective, namely the etiological link from stress to disease via altered biological processes. Also to be considered is the role of personal health behavior - all those activities which relate to health maintenance, disease risk reduction, and treatment regimen. Such activities, which can have considerable and direct influence on health status, may in turn be affected and altered by the presence of +Dr. Kasl is Professor of Epidemiology in the Department of Epidemiology and Public Health at Yale University School of Medicine, New Haven, Connecticut.
September, I 9 75
stress. In this latter persp,ective, a better understanding of the role of stress is achieved by paying attention to the personal health behaviors rather than the biological processes. And it behooves each investigator and each clinician to determine the optimal “mix” of these perspectives for the problem he is studying or the patient he is treating. If we accept the catchall definition of stress as a “demand which taxes the adaptive resources,”‘ we can readily see that the presence of the disease and the prescribed treatment regimen (either or both) can represent stressful circumstances - above and beyond other demands which also may be impinging on the patient. Thus, in examing the dynamics of patient adherence behavior, we are seeking to understand a problem which has both practical implications for patient management and theoretical implications for behavior under stress. The selective review which follows is intended to illuminate some of the issues which make it such a difficult area of patient behavior to understand and manage. However, as the reader will soon discover, the adherence literature does not provide many direct linkages to the literature on stress. Thus the present review can only spell out ‘and analyze some of the issues, but it remains for future studies to provide a firm empirical base for the link with behavior under stress. Journal of Human Stress 5
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ISSUES IN PATIENT ADHERENCE THE SEARCH FOR STABLE CORRELATES OF ADHERENCE Adherence or compliance encompasses a great variety of categories and types of behavior: a) entering into or continuing a treatment program, b) keeping follow-up or referral appointments, c)' taking prescribed medication, and d ) restricting or changing one's activities, including smoking, diet, and exercise. (Some might argue that participation in screening and in periodic health exanainations also are forms of adherence behavior with strong implications for health maintenance, though the recommendation which is being adhered to is a somewhat nebulous one as far as source and content are concerned. The present review will not deal with these forms of health behavior in order to delimit the scope, and because they are less likely to represent behavior under stress. The reader is referred to other reviews2 for an examination of their correlates.)
General reviews of the compliance literature ' l o suggest that the traditional (and perhaps easiest) approach of searching for stable characteristics of the person which would predict compliance is not going to enhance our understanding of the dynamics of this class of behaviors. There is little evidence that different forms of compliance are more than modestly correlated with each other, and that compliance of any one type is stable over time. There is even one study" which showed that a patient's intentions to comply are poorly correlated with his actual compliance.
related consistently to adherence across the board, and neither the practicing physician nor the investigator should make a priori assumptions about their importance. The search for a "defaulter type"b has not met with success. The above comments should not be interpreted to mean that sociodemographic characteristics are always irrelevant; rather, the point is that they do not lead to a general understanding of the adherence phenomenon. However, in specific instances, one or another of these variables may be related. For example, the Detroit studyI2 of dropping out from a hypertensive clinic revealed a strong social class gradient: the dropouts were more likely to be non-white and lower on education, occupation, and income. Similarly, regular (middle class) members of a comprehensive prepaid group practice program were found to have lower rates of broken appointments (8 percent) than urban indigent families who later joined such a program (25 percent). ''
In fact, there is a lot of evidence that when sociodemographic variables are related to adherence, it is in fairly specific ways which represent interaction withi other variables. The following studies illustrate this point: 0 In a study of male NASA employee^'^ who were followed up after cardiovascular screening, achieving adequate therapeutic control was more often found in older employees in the case of hypertension and in younger employees in the case of hypercholesteremia. Patients' sociodemographic charac- 0 Among individuals trying to stop s m ~ k i n g , ' a~ wife's disapproval of teristics, surprisingly, offer very little smoking increased chances of success promise as reliable predictors of poor for the husband, but women smokers adherence. Age, sex, race, social class, were unaffected by their husbands' and marital status - none of these is 6 Journal of Human Stress
September. 19 75
KASL patient with that condition, rather than by his expectations of good or poor adherence. And even small changes in the regimen which would likely improve adherence -such as setting up as simple a medication regimen as possible - may not be acceptable to clinicians who want to juggle medicines in order to effect a Other studies of tuberculosis pa- better control of the problem and to t i e n t ~ ’ ~suggest , ’ ~ that poor compliance monitor better the possible side reacis especially common among those liv- tions. ing alone; however, a study of diabetic In short, our limited understanding of patientslVsuggested that poor control adherence behavior does not lead to any of the disease was especially common easy ways of modifying and enhancing among members of larger households. the patient’s compliance. As noted Characteristics of medical regimen before, intentions to comply are poorly remain fairly reliable predictors of correlated with actual cornpliance,l’ and adherence. Coming back to a clinic as compliance may show very little stability requested and having tests done which over time,’5 thus suggesting that the have been ordered tend to have high dynamics of compliance are evercompliance rates,s while abiding by changing. Noncompliance may depend restrictions and changing personal habits on variables in the social environment, have low rates of compliance.s.20.21such as family expectations26 or social Multiple’ recommendations or restric- isolation,27which may be largely beyond tions lead to greater noncompliance. the physician’s control. Lifelong work atHigher drug defaulting is found if the titudes and habits may make compliance doctor prescribes multiple drugs or with some regimen more difficult.25.2* multiple daily doses of one drug,22.23.24 or. Highly anxious and defensive patients if the drug has side effects. Patients who may distort or forget the recomhave been on a medication regimen mendations almost as soon as they hear longer tend to default more, especially if them.2v And noncompliance may inthe chronic condition is not serious or crease as soon as the patient “feels painful. Compliance is generally better if well.”3o Perhaps the one area where one the medication provides some relief from can expect some improvement in symptoms and poor when it is taken for adherence would be as a result of the prophylactic reasons or when symptoms physician (or some other health belie the need for medication. professional) helping the patient to set up Overall, these results suggest that com- some system for the latter to monitor his pliance can be predicted better from the medications. Several ~ t u d i e s ~ . have ~‘.~~ characteristics of the medical regimen shown more drug defaulting among than from the characteristics of the patients who have no method for remempatients. However, such a conclusion is of bering to take medication, while another limited value since the physician’s choice study” has shown that a home monitor of the medical regimen is dictated which automatically records the primarily by his judgment of what con- regularity with which medication is stitutes optimal treatment for that removed can lead to high levels of com-
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disapproval, -and disapproval from friends and relatives actually increased their chances of failure. A study of tuberculosis patients on home medicationsl6 showed poor compliance among older men and younger women.
September. 1975
Journal of Human Stress 9
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ISSUES IN PATIENT ADHERENCE pliance among tuberculosis patients. Also instructive are the results of two studies,333 4 both of which were done in the context of a hypertension detection and follow-up program and both of which involved outreach programs of stepped-up care to maintain patients in treatment and to improve medication behavior - one via public health nurses,33 the other via clinical pharmacy serv i c e ~ .Both ~ ~ studies obtained the same result: the usual dismal picture of hypertension 3 5 3 b led to a striking improvement in adherence, which lasted only for the duration of the intervention program (two years) and then it was back to the old, dismal picture. The lesson from these studies is that, given our present limited understanding of adherence, such services and interventions don’t seem to succeed as health education efforts, and the activities must be maintained indefinitely if the better adherence is to persist. How can we enhance our understanding of adherence behavick? The following sections of this review will deal with three areas which I believe call for a closer scrutiny: our theoretical formulations, the role of the doctor, and the doctor-patient interaction.
closure. However, in spite of this vigorous and extensive activity of conceptualizing the behavioral aspects of the health-illness-treatment-recovery cycle, it does not appear that such formulations are ade; quate to deal with the many aspects of the problem of adherence behavior. This is because adherence becomes an issue precisely in those circumstances which are neglected by the above-mentioned formulations.
There appear to be three major areas of inadequacy of current formulations to deal with compliance: 1) The person’s “at risk’‘ status, in which he feels well but knows that one or more risk factors are present (as revealed at screening, or because past episodes of illness such as tuberculosis or rheumatic fever put the person at higher risk), does not fit the conceptual definition of either health behavior (“any activity undertaken.by a person believing himself to be healthy, for the purpose of preventing disease or detecting it in an asymptomatic stage”I5) or illness behavior (“any activity, undertaken by a person who feels ill, to define the state of his health and to discover a suitable remedy”*s), but falls somewhere in between. Hence, the understanding gained THE INADEQUACY OF OUR from a large number of studies of health TH EOR ETICAL FORM ULATIONS and illness behavior2.3.40.51.52.53 is not The whole area of personal health be- directly applicable to “at risk” behavior. havior has been the target of many theo2) Staying in treatment and complying retical formulations, including those of with treatment regimen in order to bring Parson,‘7 M e c h a n i ~ . ’4o~ S ~ c h n i a n . ~ ’about reduction of risk (e.g., keeping on and Z ~ l a 4 ‘. ~In~ addition to these au- antihypertensive medication) requires thors, many others have offered reformu- sick-role behavior from a person who lations, elaborations, formalizations, and does not feel sick, requires medication consolidations of this large set of in- even though no concomitant changes in sights, ideas, and 45 4b 4 7 48 health status generally are taking place, 4 q so with the work on the Health Belief and requires being in treatment indefiModel5’ perhaps representing the nitely. Moreover, the sick-role behavior most persistent attempt at theoretical takes place in a treatment setting which
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KASL
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has minimum social visibility and minimum social and institutional support. In short, it is a far cry from the classical Parsonian conceptualization of the sick roIe.37. 3 8 . 4 9 3) A doctor who prescribes treatment which consists of alteration of personal habits (smoking and eating) is prescribing treatment which is less obviously medical, where his authority to insist on it may be more marginal, and where the sanctions available to the doctor are weaker. Again, then, the whole matrix of sick-role expectations, norms, and sanctions involving the doctor, the patient, and the significant others around him, is much less clear (and probably quite different) from the traditional description of the sick role. These comments suggest the need for some modifications and elaborations of the concepts of health, illness, and sickrole behavior. A first step in this direction has been taken by who int6oduced the concept of “at risk” role. He points out that, in contrast to the sick role, the “at risk” role: a) is not institutionalized; b) has only. duties attached to it, but no privileges, such as reduced social obligations; c) has an indefinite time span; d) lacks continuous reinforcement from health professionals and the social environment; e) lacks the feedback provided by changes in symptomatology and in treatment procedures.
THE ROLE OFTHE DOCTOR The vast majority of studies of compliance are studies of patient behavior only; the physician remains a shadowy figure in the background, only seldom caught in the investigator’s net. Thus, our information about what physician characteristics and behaviors contribute to good or poor compliance is extremely limited. Nevertheless, the empirical
September, 19 75
literature can be organized to make the following points. First of all, patient compliance clearly is important to the practicing physician; in fact, the most important source of dissatisfaction in the physician’s professional life is his inability to exercise control over his patient because of the patient’s uncooperative behavior.ss So we are talking about a problem which is ostensibly important to the physician. Secondly, several studies have shown that physicians overestimate the amount of patient compliance and cannot detect the patients who are complying p o ~ r l y . ~ . ~ . ~ . S b . 5 7 ’ 5 8 Moreover, physicians are unlikely to think of anything other than patient characteristics as reasons for noncompliance.8.5 5 There is also some evidence that clinical experience does not necessarily provide the physician with more skills and sensitivity to deal with this problem. In a comparison of senior physicians with fourth year medical students,8 it was the student group who: a) had a more realistic estimate of patient noncompliance; b) saw a greater variety of patient characteristics as potentially having an influence on compliance; c) were less likely to invoke the patient’s personality or difficult life situation as major reasons for noncompliance; and d) were less likely to suggest that they might manage noncompliance by withdrawing from the case and referring the patient to another physician. Finally, there is pretty good evidence that physicians are reluctant to get involved in medical regimen which are likely to lead to adherence problems. For example, in the Chicago cardiovascular screening only about 30 percent of cigarette smokers who were referred to physicians because of some other cardiovascular risk factor revealed at Journal of Human Stress
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ISSUES I N PATIENT ADHERENCE screening (high blood pressure, ECG abnormality) were advised by their doctors to quit smoking. In a study of charts of a public outpatient clinic,s9 among those patients who were independently identified as severely overweight, only one half of them had their weight noted in their charts, and in only one quarter of the cases was a weight management program proposed. And in another study of medical records,’’ it was found that within three months the physicians had lost track of 56 percent of their hypertensive patients. A possible conclusion from this last finding is that physicians are reluctant to take on an activist, outreach role in this area of adherence behavior. This lack of studies on the doctor’srole in the patient’s adherence suggesls not only that the physician is a very elusive subject, but that the very perspective from which the studies are carried out (i.e., the position that the locus of the problem is with the patient) appears to make it unnecessary to study the physician in the first place. Thus we have a modest paradox here: as Stimsonbohas pointed out, the problem is almost exclusively investigated from the physician’s, and not the patient’s, perspective; but it is the patient, not the physician, who is invariably studied. Yet,as we have seen so far in this review, an exclusive focus on the patient doesn’t get u s very far. We must pay attention to the doctorpatient relationship, to their mutual expectations, and to the social aspects of the setting in which medication is prescribed and, later, taken. THE DOCTOR-PATIENT INTERACTION
The doctor-patient relationship is the aspect of medical service which is under greatest criticism from the patient.“’ The 12 Journal of Human Stress
most frequently investigated component of this relationship is the communication process in this dyad; there is no question that communication is inadequate and that many social, motivational and structural barriers exist which prevent a free exchange about the disease, the treatment, and the relationship itself.62. 6 3 6 4 However, in view of other evidence that possessing correct information about the disease and the medical regimen is by itself, at best, weakly related to patient’s adherence.b ’ l o l 9 *‘l4 6 5 6 6 it would seem that the crucial element in the doctor-patient relationship is probably not the exchange of information and facts, but the nature of the expectations each one has about his own role and the role of the other person in the dyad, the congruence and mutuality of such expectations, and the potential for exploring and revising these expectations. What do we know about the patient’s expectations and how they influence adherence? Most fundamentally, the patient expects (hopes for) good medical care which, as Friedsonb7 has shown, translates into a) technical competence of the physician and b) his taking interest in the patient. But both these elements are really a set of subjective expectations about what the doctor will say and what he will do - as well as what will be the later consequences in terms of improvements in health status. There are a number of studies which suggest that unfulfilled patient expectations lead to poorer compliance.8 bn b9 Lowered patient satisfaction is probably one of the intervening variable~,’~ but it is not frequently studied simultaneously. (In any case there are other studies7’7 2 7 3 which have established the association between patient safisfaction and compliance.) For example, whether a doctor is “friendly” (vs. “businessSeptember, 1975
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KASL like”) doesn’t influence satisfaction near- dered, than when a patient has more time ly as much as expecting reassurance, and to prepare for the hospitalization and for not getting it, or expecting an explana- whom the usual number of tests is ortion, and not getting it;70and such dis- dered. satisfied patients have lower compliAs we noted before, there is no ance.68 Another studyb9found that pa- adequate agreement that that aspect of tients who say “Yes” to the question doctor-patient communication which in“Does the doctor spend enough time creases the patient’s knowledge of the with you?” are more likely to comply disease and the treatment leads to better than those whose answer is negative. And ~ o m p l i a n c ePerhaps .~~ one reason for this since the actual time .spent with the may be the modifying role of patient’s expatient was unrelated to compliance, this pectations: communicating information finding reveals the effect of the patient’s and explanation to the patient improves expectation (about how much is compliance primarily in those who expect “enough”) rather than of the physician’s such doctor behavior. Another reason behavior. may be that the patient’s knowledge about disease interacts with other There is also .some evidence42.43.74.7s variables in influencing compliance. In a that unfulfilled expectations at initial study of diabetic and hypertensive contact may threaten continuation of the patients.77 better knowledge about illness therapeutic relationship. Zola” has showed an overall association with better noted that when the physician pays little compliance (staying in treatment); attention to the specific trigger which however, the association was much brought the individual to see the doctor, weaker among subgroups of patients: a) then there is a greater likelihood that the who had had a broad range of experience patient will eventually break off treatwith their illness and the medical care ment. also has suggested that this system; b) who were high on anxiety; c) should even be applied to checkup visits: whose illness entailed many problems in the patient may declare that he has come for a checkup, but the timing of the visit self-management, but d) whose illness is such that the patient has something did not interfere markedly with their specific he considers worth checking daily activities. upon and unless the physician explores While increasing the patient’s this “hidden agenda” the patient may knowledge about the disease may not not keep the appointment for the next have much of an effect on compliance, checkup. Vincent7s found that out- increasing his knowledge about treatpatients at a glaucoma clinic show less ment and what to expect does seem to compliance with medication (taking eye have the expected association with drops) if they came initally for a com- adherence. Several studies have linked plaint of vision loss, than if they pre- noncompliance to the physician’s failure sented signs and/or symptoms o r came to communicate the purpose of the treatfor a routine examination. And Davis7‘ ment‘o.30or the need for follow-up aphas reported that self-discharge from p o i n t m e n t ~ . And ~ ~ above all, the hospital (against medical advice) is more physician needs to find out about the likely when a patient is admitted on an patient’s expectations and about emergency basis and for whom an “obeying doctor’s orders,” as seen by the unusually large number of tests is or- patient. For example, Stimson60has emSeptember, 1975
Journal of Human Stress
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ISSUES IN PATIENT ADHERENCE phasized the fact that patients generally have some ready-made preconceptions about taking medicines: “You only take medicines when you are ill, not when you are better.” “You need to give your body some ‘rest’ from the medicine onoe in a while or otherwise your body becomes dependent on it or immune to it.” Such preconceptions have to be inquired about and modified, as necessary. Morleover, the patient may have some expectcations about the visit to the doctor (concerning what complaints will get discussed: what the doctor will say is “wrong”; and what the doctor will prescribe or say th.at the patient will have to do). Again, inquiring about such expectations and modifying them may lead to much better patient compliance. CONCLUDING REMARKS It should be apparent that the above review is a highly selective one: it is limited to adherence behavior among outpatients and only the physician, among several possible health professionals, is considered. Such a limitation is appropriate since (in addition to considerations of length of the review) the bulk of the studies are concerned with this narrower formulation of the issue. Nevertheless, we may note some of the other issues which this review leaves out: 0 adherence among hospitalized or institutionalized patients (which can also be a problem);’8 role of other health professionals and 0 of the way the medical care delivery system is organized; viewing most adherence problems as 0 issues of self-care and taking them out of the domain of the doctorpatient relationship; the role of the lay referral system4” 4 2 . 0 4 5 . l9 in enhancing or interfering with adherence: 14 Journal of Human Stress
the use of nonmedical per~onnel.’~. All of these are important problems in their own right. It also may be noted that this review does not have many direct linkages with the literature on stress. This latter limitation, however, is not a matter of choice: such linkages as yet do not exist. At the moment there is no way of taking one or another of the current theoretical formulations or approaches to stress, coping, adaptation, and decision makinga’ 8 2 8 3 8 4 8 5 and applying it rigorously to the just reviewed frndings on adherence behavior. Most of the studies which one way or another invoke the concept of stress (and mostly assess some form of distress in the patient) are studies of illness behavior;8b 8 8 8 9 q o on the basis of these studies it is reasonable to conclude that certain forms of distress, especially depression and low self-esteem, enhance in some persons the readiness to seek medical attention (however, the literature on anxiety and delay in seeking diagnosis of cancer9’ 9 2 does not lend itself very well to this generalization). But these studies of illness behavior deal primarily with initial contacts with the physician and we d o d t have any evidence that continued contact (staying in treatment) or other forms of adherence are similarly enhanced by distress. In fact, it is quite possible that patients whose initial contact with the physician is motivated primarily by psychological distress may subsequently be poor on diverse forms of adherence behavior. This review has provided ample documentation that the dynamics of patient adherence are as yet poorly understood and that certain traditional but limited approaches have had only limited payoffs. More broadly-based studies need to consider systematically the whole issue of stress (demands on adaptive
0
September. 1975
KASL resources) and coping. In particular, future studies need to pay attention to the interaction of five possible sources of demands: the medical regimen itself, the disease state, the social environment at home and at work, the doctor-patient relationship, and the medical care setting.
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This paper was presented, in part, at the American Heart Association Conference on "Applying Behavioral Science to Cardiovascular Risk." Seattle, June 17-19,1974.
12.
13.
14.
INDEX TERMS patient adherence, patient compliance, doctorpatient reiationship, medical regimen, patient expectations, at-risk behavior.
15.
16.
REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Editorial. J. Hum. Stress. Vol. 1. March, 1975, p. 3. Rosenstock. I.M.. "Why People Use Health Services." Milbunk Mem. Fund Q.. Vol. 44. July, 1%6. p. 94. Rosenstwk. I.M. "The Health Belief Model and Preventive Health Behavior." Health Educ. Monogr.. Vol. 2. Winter, 1974, p. 354. Becker. M.H. "The Health Belief Model and Sick Role Behavior." Heulth Educ. Monogr.. Vol. 2. Winter, 1974. p. 409. Berkowitz. N.H.. M.F. Malone. M. W. Klein. et al. "A Patient Follow-through in the Outpatient Department." Nurs. Rrs.. Vol. 12. Winter, 1963. p. 16. Blackwell, B. "The Drug Defaulter." Clin. Phurmucol. Ther.. Vol. 13. NovemberDecember. 1972, p. 841. Charney. E. "Patient-Doctor Communication: Implications for the Clinician." Pediutr. Clin. North A m . . Vol. 19, May, 1972. p. 263. Davis, M.S. "Variations in Patients' Compliance with Doctors' Orders: Analysis of Congruence Between Survey Responses and Results of Empirical Investigations," J. Med. Educ.. Vol. 41, November, 1966. p. 1037. Marston. M. "Compliance with Medical Regimens: A Review of the Literature." Nurs. R ~ s .VOI. . 19, July-August. 1970. p. 312. Wilson, J.T. "Compliance with Instructions in the Evaluation of Therapeutic Efficacy." Clin. Pediutr.. Vol. 12, June, 1973, p. 333. Davis, M.S. "Physiologic. Psychological, and Demographic Factors in Pa!ient Compliance
September, 1975
17.
18.
19.
20.
21.
with Doctor's Orders," Med. Cure, Vol. 6, March-April. 1968, p. 115. Caldwell. J.R.. S. Cobb. M.D. Dowling, et al. "The Dropout Problem in Antihypertensive Treatment." J. Chronic Dis.. Vol. 22. February, 1970. p. 579. Greenlick. M.R.. D.K. Freeborn, T.J. Colombo. et al. "Comparing the Use of Medical Care Services by a Medically Indigent and a General Membership Population in a Comprehensive Prepaid Group Practice Program." Med. Cure. Vol. 10. May-June. 1972. p. 187. Villafana. C.. and J. Mackbee. "The Value of Continued Follow-up in a Preventive Medicine Program,'' Industr. Med. & Surg.. Vol. 40, July, 1971. p. 11. Guilford. J.S. "Group Treatment vs. Individual Initiative in the Cessation of Smoking." J. Appl. Ps.vcho1.. Vol. 56. April, 1972. p. 162. Luntz. G.R.W.N., and R. Austin. "New Stick Test for P.A.S. in Urine." Br. Med. J.. Vol. I. June4, 1960. p. 1679. Berry, D.. A. Ross, and K. Deuschle. "Tuberculosis Patients Treated at Home,'' A m . Rev. Respir. Dis.. Vol. 88. December, 1963. p. 769. Pragoff. H. "Adjustment of Tuberculosis Patients One Year After Hospital Discharge." Public Heulth Rep.. Vol. 77. August, 1962. p. 671. Williams. T.F.. D.A. Martin, M.D. Hogan, et al. "The Clinical Picture of Diabetic Control. Studied in Four Settings." A m . J. Public Heulrh. Vol. 57. March, 1%7. p. 441. Davis, M.S. "Predicting Non-compliant Behavior." J. Health Soc. Behuv.. Vol. 8. December, 1967, p. 265. Johannsen. W.J.. G.A. Hellmuth. and T. Sorauf. "On Accepting Medical Recommendations.'' Arch. Enviroti. Heulth. Vol. 12. January. 1966, p. 63.
22. Clark, G.M.. and R.C. Troop. "One-tablet Combination Drug Therapy in the Treatment of Hypertension." J. Chmnic Dis.. Vol. 25, February. 1972. p. 57. 23. Malahy. B. "The Effect of Instruction and Labeling on the Number of Medical Errors Made by Patients at Home." A m . J. Hosp. Phurm.. Vol. 23. June. 1%6. p. 283. 24. Neely. E., and M.L. Patrick. "Problems of Aged Persons Taking Medications at Home." Nurs. Res.. Vol. 17, January-February, 1968. p. 52. 25. Davis, M.S.. and R.L. Eichhorn. "Compliance with Medical Regimens: A Panel Study," J. Health & Hum. Behue.. Vol. 4. Winter. 1963. p. 240.
Journal of Human Stress 15
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ISSUES IN PATIENT ADHERENCE 26. Oakes. T.W.. J.R. Ward. R.M. Gray, et al. “Family Expectations and Arthritis Patient Compliance to a Hand Resting Splint Regimen.” J . Chrotrir Dis.. Vol. 22. April, 1970. p. 157. 27. Porter. A.M.W. “Drug Defaulting in General Practice.” Br. Med. J . . Vol. 1, January 25. 1969. p. 21 8. 28. Willis, F.N.. and N.M. Dunsmore. W o r k Orientation, Health Attitudes and Compliance with Therapeutic Advice,” Nurs. Res.. Vol. 16. Winter, 1967, p. 22. 29. Hellmuth. G.A.. W.J. Johannsen. and T. Sorauf. “Psychological Factors in Cardiac Patients,” Arch. Environ. Health, Vol. 12, June, 1966, p. 771. 30. Mohler, D.N., D.G. Wallin. and E.G. Dreyfus. “Studies in the Home Treatment of Streptococcal Disease. 1. Failure of Patients to Take Penicillin by Mouth as Prescribed,” N. EngI. J . Med.. Vol. 252. June 30. 1955. p. 1116. 31. Mclnnis, J.K. “Do Patients Take Antituberculosis Drugs?” A m . J. Nurs.. Vol. 70. October, 1970. p. 2152. 32. Moulding, T.. G.D. Onstad. and J.A. Sbarbaro. “Supervision of Outpatient Drug Therapy with the Medication Monitor.” Ann. Intern. Med.. Vol. 73. October, 1970, p. 559. 33. Wilber, J.A.. and J.G. Barrow. “Reducing Elevated Blood Pressure,” Minn. Med.. Vol. 52. August 1969, p. 1303. 34. McKenney. J.M., J.M. Slining, H.R. Henderson, et a1 “The Effect of Clinical Pharmacy Services on Patients with Essential Hypertension,” Circulation, Vol. 48, N(wember. 1973, p. 1 104. 35. Stamler, I.. J.A. Schoenberger, H.A. Lindberg, et al. “Detection of Susceptibility to Coronary Disease.” Bull. N.Y.Acad. Med.. Vol. 45. December, 1969, p. 1306. 36. Wilber, J.A., and 1.G. Barrow, “Hypertension - a Community Problem,” A m . J . Med.. Vol. 52. May, 1972, p. 653. 37. Parsons, T. ”Illness and the Role of the Physician: A Sociological Perspective.” A m . J. Orthopsychiatry. Vol. 21, July, 1951, p.452. 38. Parsons, T. “Definitions of Health and Illness in the Light of American Values and Social Structure,“ Patients, Physicians, and Illness. E.G. Jaco. ed.. p. 165. The Free Press Glencoe. Ill., 1958. 39 Mechanic, D. ”The Concept of llllness Behavior,” J. Chronic Dis.. Vol. 15, February, 1%2. p. 189. 40 Mechanic, D. Medical Sociology. The Free Press, New York. 1968.
16 Journal of Human Stress
41.
Suchman, E.A. “Stages of Illness and Medical Care.” J . Health & Hum. Behav.. Fall. 1965. p. 114.
42. Zola, I.K. “Studying the Decision to See a Doctor,” Psychosocial Aspects of Physical Il111ess. Vol. 8. Advances in Psvchosomatic Medicine. Z. J. Lipowski, ed., p. 216. S. Karger. Basel, Switzerland, 1972. 43. Zola, I.K. “Pathways to the Doctor - From Person to Patient,” SOC. Sci. Med.. Vol. 7. September, 1973, p. 677. 44. Fabrega, H., Ir. Disease and Social Behavior: A n Interdisciplinary Perspective. The MIT Press, Cambridge. 1974. 45 Friedson, E. Profession of‘Medicine: A Study of‘theSociology ofApplied Knowledge. Dodd. Mead, & Co.. New York. 1970. 46. Gordon. G. Role Theory and Illness. College and University Press, New Haven, 1%6. 41. Kasl. S.V., and S. Cobb. “Health Behavior, Illness Behavior. and Sick Role Behavior,” Arch. Envirm. Health. Vol. 12, February, 1%6. p. 246, and April 1%6, p. 531. 48. Pflanz. M., and J.1. Rohde. “Illness: Deviant Behavior or Conformity,” SOC.Sci. Med.. Vol. 4, December. 1970, p. 645. 49. Twaddle, A.C. “The Concept of the Sick Role and Illness Behavior,” Psychosocial Aspects of Phvsical Illness, Vol. 8. A d v a n c e s in Psvchosomatic Medicine, Z. J. Lipowski. ed., p. 162. S . Karger, Basel, Switzerland, 1972. 50. Twaddle. A.C. “Illness and Deviance,” SOC. Sci Med. Vol. 7. October, 1973. p. 751. 51. Becker, M.H., ed. “The Health Belief Model and Personal Health Behavior.” Health Educ. Monogr., Vol. 2. Winter, 1974. p. 326. 52. Anderson. O.W.. and R.M. Andenen. “Patterns of Use of Health Services.” Handbook of Medical Sociofogy, H.E. Freeman, S . Levine. and L.G. Reeder. eds.. p. 386. Prentice Hall. Inc.. Englewood Cliffs, N.J., 1972. 53. McKinley. J.B. “Some Approaches and Problems in the Study of the Use of Services - An Overview,” J. Health Soc. Behav.. Vol. 13. June 1972, p 115. 54. Baric, L. “Recognition of the ‘At-risk’ Role: A Means to Influence Health Behavior.” Int. J . Health Educ.. Vol. 12, 1969, p. 24. 55. Ort. B.S., A.B. Ford. and R.E. Liske. “The Doctor-Patient Relationship as Described by Physicians and Medical Students,” J. Health Hum. Behav., Vol. 5, Spring, 1964, p. 25. 56. Caron, H.S., and H.P. Roth. “Patients’ Cooperation with a Medical Regimen,” J.A.M.A.. Vol. 203, March 11,1%8. p. 922. 57. Charney, E., R. Bynum, D. Eldredge. et al.
September. 1975
KASL “How Well Do Patients Take Oral Penicillin?
A Collaborative Study in Private Practice,” Pediatrics. Vol. 40.August 1967. p. 188.
58. Roth, H.P., H.S. Caron, and B.P. Hsi.
59.
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60.
61.
62.
63. 64.
65.
66.
“Estimating a Patient’s Cooperation with His Regimen.” A m . J. Med. S c i , Vol. 262, November. 197 1, p. 269. Maddox, G.L.. C.F. Anderson, and M.D. Bogdonoff. “Overweight as a Problem of Medical Management in a Public Outpatient Clinic,” A m . J. Med. S c i . Vol. 252, October, 1966, p. 394. Stimson, G.V. “Obeying Doctor’s Orders: A View from the Other Side,” SOC.Sci Med.. Vol. 8. February 1974, p. 97. Kms, E.L. “‘Metropolis’- What City People Think of Their Medical Services,” A m . J. Public Health. Vol. 45, December, 1955, p. 1551. Cartwright, A. Human Relations and Hasptial Care. Routledge & Kegan Paul, London. 1%4. Ley. P., and M.S. Spelman Communicating with the Patient. Staples Press, London, 1967. Pratt, L.. A. Seligman, and G. Reader. “Physician’s View on the Level of Medical Information Among Patients,’’ Am. J . Public Health, Vol. 47. October, 1957, p. 1277. Finnerty. F.A., Jr.. E.C. Mattie. and F.A. Finnerty. Ill. “Hypertension in the Inner City. 1. Analysis of Clinic Dropouts.” Circulation. Vol. 47. January, 1973, p. 73. Stewart, R.B.. and L.E. Cluff. “A Review of Medication Errors and Compliance in Ambulant Patients,” Clin. PharmacoL Ther.. Vol. 1 3 , J ~ l y - A ~ g1972, ~ ~ t p. . 463.
67. Friedson. E. Patients‘ View of’Medical Practice. Russell Sage Foundation. New York. I%]. 68. Francis, V., B.M. Konch. and M.J. Morris. “Gaps in Doctor-Patient Communication: Patients’ Responses to Medical Advice.” N. Engl. J . Med.. Vol. 280. March 6, 1969. p. 535. 69. Geertsen, H.R.. R.M. Gray, and J.R. Ward. “Patient Noncompliance within the Context of Seeking Medical Care for Arthritis.” J. Chronic Dis.. Vol. 26, November, 1973. p. 689. 70. Korsch, B.M.. E.K. Goui. and V. Francis. “Gaps in Doctor-Patient Communication. I. Doctor-Patient Interaction and Patient Satisfaction.” Pediatrics. Vol. 42. November, 1%8. p. 855. 71. Alpert. J.1. ”Broken Appointments.” Pediatrics. Vol. 34. July, 1964, p. 127. 72. Becker. M.H. R.H. Drachman, and J.P. Kirscht. “A New Approach to Explaining Sick-
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Role Behavior in Low-Income Populations,” Am. J. PublicHealth. Vol. 64. March, 1974, p.
20.5. 73. Diamond, M.D., A.J. Weiss, and B. Grynbaum. “The Unmotivated Patient,” Arch. Phys. Med. Rehabil.. Vol. 49. May, 1968. p. 281. 74. Davis, M.S. “Discharge from Hospital Against Medical Advice: A Study of Reciprocity in the Doctor-Patient Relationship,” SOC. Sci Med.. Vol. 1. September. 1967. p. 336. 75. Vincent, P. “Factors Influencing Patient Noncompliance: A Theoretical Approach,” Nurs. Res.. Vol 20, November-December, 1971. p. 509. 76. Davis, M.S. “Variations in Patients’ Compliance with Doctor‘s Orders: Medical Practice and Doctor-Patient Interaction,” Psychiatry Med.. Vol. 2. January, 1971. p. 31. 77. Tagliacozzo. D.M.. and K. Ima “Knowledge of Illness as a Predictor of Patient Behavior.” J. Chronic Dis.. Vol. 22. April 1970, p. 765. 78. Roth. H.P.. and D.G. Berger. “Studies on Patient Cooperation in Ulcer Treatment. 1. Observation of Actual as Compared to Prescribed Antacid lntake on a Hospital Ward.” Gastroenterology, Vol. 38, April, 1960, p. 630. 79. Suchman. E.A. “Health Orientation and Medical Care,” A m . J. Public Health. Vol. 56. January, 1966, p. 97. 80. Kms, E.L. The Health oj’Regionvdle. Columbia University Press, New York. 1954. 81. Coelho, G.V., D.A. Hamburg, and J.E. Adams. eds. Coping and Adaptation. Basic Books. New York, 1974. 82. Janis, 1.L.. and L. Mann. “A Conflict Theory Approach to Attitude Change and Decision Making,” Psychological Foundations of Attitudes. A. Greenwald, T.C. Brock. and T.M. Ostrum. eds., p. 327. Academic Press, New York. 1%8. 83. Lazarus. R.S. Psychological Stress and the Coping Process. McGraw-Hill. New York. 1966. 84. Levi, L. “Psychosocial Stress and Disease: A Conceptual Model,” Life Stress and Illness, E.K.E.Gunderson, R.H. Rahe,eds.. p.8. C.C. Thomas, Springfield, Ill., 1974. 85. Levine, S., and N.A. Scotch, eds. SocialStress. Aldine, Chicago, 1970. 86. Kasl, S.V.. and S. Cobb. “Some Psychological Factors Associated with Illness Behavior and Selected Illnesses,” J. Chronic Dis.. Vol. 17. April 1964, p. 325, Continued on page 48
Journal of Human Stress 17
more detailed data collection and analysis. Holmesv Rahe .and their co-workers have done a great deal to stimulale activity and research in the life-events field. Their research has often titilated arid intrigued us, but the processes that explain the relationship between life events and illness require considerable exploration. Refinements of such instruments as the Rating Scale is a necessary step in attempting to test native theoretical conceptions of the
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u
2. Mechanic, D. Medical Sociology: A Selective Vim*.pp. 294-301. Free Press. New York. 1968. 3. Holmes. T.H.. and M. Masuda. "Life Change and lllness Susceptibility." Stressfir1 Lit? Events: Their Nature arid E#iects. B.S. Dohrenwend and B.p. Dohrenwend. eds., pp. 45-72. Wi~ey-~nterscience. N~~ Yo&, 1974.
4.
s. Selye. H. The stress r?/.LjtP. McGraw-Hill, New York. 1956. 6. Lazarus. R.S. Ps.vchologica1 Stress and the Coping Process. McGraw-Hill. New York. 1966.
op. cit.. pp. 135.149.
INDEX TERMS
sm* social Rnthg change, adaptive behavior, -oremeat
liie of stress.
REFERENCES 1. Holmes. T.H.. and R.H. Rahe. "The Social
Readjustment Rating Scale." J. Psychos. Res.. VOI. I I , 1967. pp. 213-218.
8. Brown. G. W.. and J. L. T. Birlev. "Crisis and Life Changes and the Onsei of Schizophrenia." J. H d t h Soc. Bchuv.. Vol. 9, 1968. pp. 203-214. 9. Holmes and Masuda. op. cit.. p. 57. 10. Brown. G.W. "Meaning, Measurement, and Stress of Life Events." In Dohrenwend and Dohrenwend. eds.. op. cit.. pp. 217-243.
KASL - REFERENCES I7 Mechanic, D., and E.H. Volkart. "Stress, Illness Behavior and the Sick Role. A m . Sociol. Rev.. Vol. 26. February 1%1. p. 51. 88. Roessler. R., and N.S. Greenfield. "Per91. sonality Determinants of Medical Clinic Consultation," J. New. Ment. Dis.. Vol. 127. August. 1958. p. 142. 89. Shuval. J.T.. A. Antonovsky. and A.M. 92. Davies. Social Functions qt' Medical I'racticc~. Jossey-Bass. Inc.. San Francisco. 1970. 90. Stoeckle. J.D.. I.K. &la. and G. E. Davidson. "The Quantity a n d Significance of
Continued,ti.ompage
87.
48 Journal of Human Stress
Psychological Distress in Medical Patients: Some Preliminary Observations About the Decision to Seek Medical Aid," J. Chronic Dis.. Vol. 17. October 1964. p. 959. Antonovsky, A., and H. Hartman. "Delay in the Detection of Cancer: A Review of the Literature." Heulth Educ. Monogr.. Vol. 2, Summer. 1974, p. 98. Green. L.W., and B.J. Roberts. "The Research Literature on Why Women Delay in Seeking Medical Care for Breast Symptoms." Health Educ. Monogr.. Vol. 2. Summer. 1974. p. 129.
September. I975
