If health professional–patient communication is seen as an interaction between two individuals then it is important to understand the extent to which these two individuals speak the same language, share the same beliefs and agree as to the desired content and outcome of any consultation. This is of particular relevance to general practice con- sultations where patient and health professional perspectives are most likely to coincide.
For example, Pendleton et al. (1984) argued that the central tasks of a general practice
consultation involved agreement with the patient about the nature of the problem, the action to be taken and subsequent management. Tuckett et al. (1985) likewise argued that the consultation should be conceptualized as a ‘meeting between experts’ and emphasized the importance of the patient’s and doctor’s potentially different views of the problem.
Recent research has examined levels of agreement between GPs’ and patients’ beliefs about different health problems. Ogden et al. (1999) explored GPs’ and patients’ models of depression in terms of symptoms (mood and somatic), causes (psychological, medical, external), and treatments (medical and non-medical). The results showed that GPs and patients agreed about the importance of mood-related symptoms, psychological causes and non-medical treatments. However, the GPs reported greater support for somatic symptoms, medical causes and medical treatments. Therefore, the results indicated that GPs hold a more medical model of depression than patients. From similar perspective, Ogden et al. (2001a) explored GPs’ and patients’ beliefs about obesity. The results showed that the GPs and patients reported similar beliefs for most psychological, behavioural and social causes of obesity. However, they differed consistently in their beliefs about medical causes. In particular, the patients rated a gland/hormone problem, slow metabolism and overall medical causes more highly than did the GPs. For the treatment of obesity, a similar pattern emerged with the two groups reporting similar beliefs for a range of methods, but showing different beliefs about who was most helpful. Whereas, the patients rated the GP as more helpful, the GPs rated the obese patients themselves more highly. Therefore, although GPs seem to have a more medical model or depression they have a less medical model of obesity. Research has also shown that doctors and patients differ in their beliefs about the role of the doctor (Ogden et al. 1997), about the value of patient centred consultations (Ogden et al. 2002), about the very nature of health (Ogden et al. 2001b), about chronic disease and the role of stress (Heijmans et al. 2001) and in terms of what is important to know about medicines (Berry et al. 1997). If the health professional–patient communication is seen as an interaction, then these studies suggest that it may well be an interaction between two individuals with very different perspectives. Do these different perspectives influence patient outcomes?
The role of agreement in patient outcomes
If doctors and patients have different beliefs about illness, different beliefs about the role of the doctor and about medicines, does this lack of agreement relate to patient out- comes? It is possible that such disagreement may result in poor compliance to medication (‘why should I take antidepressants if I am not depressed?’), poor compliance to any recommended changes in behaviour (‘why should I eat less if obesity is caused by hormones?’) or low satisfaction with the consultation (‘I wanted emotional support and the GP gave me a prescription’). To date little research has explored these possibilities.
One study did, however, examine the extent to which a patient’s expectations of a GP consultation were met by the GP and whether this predicted patient satisfaction.
Williams et al. (1995) asked 504 general practice patients to complete a measure of their expectations of the consultation with their GP prior to it taking place and a measure of whether their expectations were actually met afterwards. The results showed that having
more expectations met was related to a higher level of satisfaction with the consultation.
However, this study did not explore compliance, nor did it examine whether the GP and patient had a shared belief about the nature of the consultation. Therefore, further research is needed to develop methodological and theoretical approaches to the con- sultation as an interaction. In addition, research is needed to explore whether the nature of the interaction and the level of the agreement between health professional and patient predicts patient outcomes.
T O C O N C L U D E
Traditional educational models of doctor–patient communication emphasized patient factors and considered non-compliance to be the result of patient variability. The relationship between health professionals and patients was seen as the communication of expert medical knowledge from an objective professional to a subjective layperson.
Within this framework, Ley’s model explained failures in communication in the context of the failure to comply in terms of patient factors, including patient’s satisfaction, lack of understanding, or lack of recall. In addition, methods to improve the communica- tion focused on the health professional’s ability to communicate this factual knowledge to the patient. However, recent research has highlighted variability in the behaviours of health professionals that cannot simply be explained in terms of differences in knowledge. This variability can be examined in terms of the processes involved in clinical decision making by the health professional and in particular the factors that influence the development of hypotheses. This variability has also been examined within the context of health beliefs, and it is argued that the division between professional and lay beliefs may be a simplification, with health professionals holding both professional and lay beliefs; health professionals have beliefs that are individual to them in the way that patients have their own individual beliefs. However, perhaps to further conceptualize the communication process, it is important to understand not only the health pro- fessional’s preconceived ideas/prejudices/stereotypes/lay beliefs/professional beliefs or the patient’s beliefs, but to consider the processes involved in any communication between health professional and patient as an interaction that occurs in the context of these beliefs.
? Q U E S T I O N S
1 Health professionals’ decisions are based on knowledge. Discuss.
2 What are the problems with the hypothetico-deductive model of decision- making?
3 Discuss the role of health professionals’ beliefs in the communication process.
4 To what extent is non-compliance the responsibility of the patient?
5 Shared beliefs are essential for improving patient outcomes. Discuss.
6 Describe a research project designed to evaluate health professionals’
beliefs.
A S S U M P T I O N S I N H E A LT H P S Y C H O L O G Y
Some of the research cited in this chapter illustrates the kinds of assumptions that underlie the study of health professionals and also provides insights into the assumptions of health psychology.
1 The mind–body split. Health psychology attempts to challenge the biomedical model of health and illness. This involves challenging biomedical assumptions such as the mind–body split. However, perhaps by emphasizing the mind (attitudes, cognitions, beliefs) as a separate entity, the mind–body split is not challenged but reinforced.
2 Biomedical outcomes. Challenging the biomedical model also involves questioning some of the outcomes used by medicine. For example, compliance with recommenda- tions for drug-taking, accuracy of recall, changing health behaviours following advice are all established desired outcomes. Health psychology accepts these out- comes by examining ways in which communication can be improved, variability can be understood and reduced and compliance promoted. However, again, accepting these outcomes as legitimate is also a way of supporting biomedicine. Perhaps variability is acceptable. Perhaps inaccuracy of recall sums up what happens in com- munication (psychologists who study memory would argue that memory is the only process that is defined by its failures – memory is about reconstruction). Even though psychology adds to a biomedical model, by accepting the same outcomes it does not challenge it.
3 Adding the social context. Individuals exist within a social world and yet health psychology often misses out this world. An emphasis on the interaction between health professionals and patients represents an attempt to examine the cognitions of both these groups in the context of each other (the relationship context). However, this interaction is still accessed through an individual’s beliefs. Is asking someone about the interaction actually examining the interaction or is it examining their cognitions about this interaction?
F U RT H E R R E A D I N G
➧ Boyle, C.M. (1970) Differences between patients’ and doctors’ interpretations of common medical terms, British Medical Journal, 2: 286–9.
This is a classic paper illustrating differences between doctors’ and patients’
knowledge and interpretation. At the time it was written it was central to the contemporary emphasis on a need to acknowledge how uninformed patients were. However, it also illustrates some variability in doctors’ knowledge.
F O R D I S C U S S I O N
Consider the last time you had contact with a health professional (e.g. doctor, dentist, nurse, etc.). Discuss the content of the consultation and think about how the health professional’s health beliefs may have influenced this.
➧ Marteau, T.M. and Johnston, M. (1990) Health professionals: a source of variance in health outcomes, Psychology and Health, 5: 47–58.
This paper examines the different models of health professional’s behaviour and emphasizes the role of health professional’s health beliefs.
➧ Trostle, J.A. (1988) Medical compliance as an ideology, Social Science and Medicine, 27: 1299–308.
This theoretical paper examines the background to the recent interest in compliance and discusses the relationship between compliance and physician control.
➧ Tuckett, D., Boulton, M., Olson, C. and Williams, A. (1985) Meetings between experts. London: Tavistock.
This is a classic book which describes a study involving consultation analysis.
It set the scene for much subsequent research and shifted the emphasis from doctor as expert to seeing the consultation as an interaction.
5
Smoking and alcohol use
C H A P T E R O V E R V I E W
This chapter examines the prevalence of smoking and alcohol consumption and evaluates the health
consequences of these behaviours. The history of theories of addictive behaviours and the shift from a disease model of addictions to the social learning theory perspective is then described. The chapter also examines the four stages of substance use from initiation and maintenance to cessation and relapse, and discusses these stages in the context of the different models of addictive behaviours. The chapter concludes with an examination of a cross-behavioural perspective on addictive behaviours and an assessment of the similarities and differences between smoking and drinking and their relationship to other behaviours.
This chapter covers:
➧ The prevalence of smoking and alcohol consumption
➧ What is an addiction?
➧ What is the 2nd disease concept?
➧ What is the social learning perspective?
➧ The stages of substance use
➧ Initiating and maintaining an addictive behaviour
➧ The cessation of an addictive behaviour
➧ Relapse in smoking and drinking
➧ A cross-addictive behaviour perspective
W H O S M O K E S ?
Data from the 1992 General Household Survey in the UK showed that 28 per cent of people aged 16 and over were smokers compared with 30 per cent in 1990. This decrease in smoking behaviour follows a trend for an overall decline and is shown in Figure 5.1.
However, the data also showed that, although women smoke fewer cigarettes than men, fewer women than men are giving up.
Smokers can also be categorized in terms of whether they are ‘ex-smokers’, ‘current smokers’ or whether they have ‘never smoked’. The trends in smoking behaviour according to these categories are shown in Figure 5.2. Again, sex differences can be seen for these types of smoking behaviour with men showing an increase in the numbers of
‘never smoked’ and ‘ex-smokers’, and a decrease in ‘current smokers’, whilst women show the same profile of change for both ‘current smokers’ and ‘ex-smokers’ but show a consistently high level of individuals who have ‘never smoked’.
In general, data about smoking behaviour (General Household Survey 1994) suggests the following about smokers:
I Smoking behaviour is on the decline, but this decrease is greater in men than in women.
I Smokers tend to be in the unskilled manual group.
I There has been a dramatic reduction in the number of smokers smoking middle-tar cigarettes.
Fig. 5-1 Changes in smoking, 1972–92 (after General Household Survey 1994)
I Two-thirds of smokers report wanting to give up smoking.
I The majority of smokers (58 per cent) say that it would be fairly/very difficult to go without smoking for a whole day.
W H O D R I N K S ?
According to the General Household Survey (1992), men on average drank 15.9 units a week (about eight pints of beer) and women drank about 5.4 units (about two and a half pints of beer). About 27 per cent of men and 11 per cent of women were drinking more than the recommended sensible amounts of alcohol which at this time were 21 units for men and 14 units for women. These limits have now been increased to 28 for men and 21 for women. Sex differences in drinking behaviour are shown in Figure 5.3.