Research has also explored the relationship between illness cognitions and recovery from MI. From a broad perspective research suggests that beliefs about factors such as the individual’s work capacity (Maeland and Havik 1987), helplessness towards future MIs (called ‘cardiac invalidism’) (Riegel 1993) and general psychological factors (Diederiks et al. 1991) relate to recovery from MI as measured by return to work and general social and occupational functioning. Using a self-regulatory approach, research has also indi- cated that illness cognitions relate to recovery. In particular, the Heart Attack Recovery Project, which was carried out in New Zealand and followed 143 first time heart attack patients aged 65 or under for 12 months following admission to hospital. All subjects completed follow-up measures at 3, 6 and 12 months after admission. The results showed that those patients who believed that their illness had less serious consequences and would last a shorter time at baseline, were more likely to have returned to work by six weeks (Petrie et al. 1996). Furthermore, those with beliefs that the illness could be controlled or cured at baseline predicted attendance at rehabilitation classes (Petrie et al.
1996). In a recent study authors did not only explore the patients beliefs about MI but also the beliefs of their spouse to ask whether congruence between spouse and patients beliefs was related to recovery from MI (Figueiras and Weinman 2003). Seventy couples in which the man had had an MI completed a baseline measure of the illness cognitions which were correlated with follow-up measures of recovery taken at 3, 6 and 12 months.
The results showed that in couples who had similar positive beliefs about the identity and consequences of the illness, the patients showed improved recovery in terms of better psychological and physical functioning, better sexual functioning and lower impact of the MI on social and recreational activities. In addition, similar beliefs about time line were related to lower levels of disability and similar cure/control beliefs were associated with greater dietary changes. Beliefs about illness therefore seem to be associated with recovery. Further, congruence in beliefs also seems to influence outcomes.
A self-regulatory approach may be useful for describing illness cognitions and for exploring the relationship between such cognitions and coping, and also for understanding and predicting other health outcomes.
T O C O N C L U D E
In the same way that people have beliefs about health they also have beliefs about illness.
Such beliefs are often called ‘illness cognitions’ or ‘illness representations’. Beliefs about illness appear to follow a pattern and are made up of: (1) identity (e.g. a diagnosis and symptoms); (2) consequences (e.g. beliefs about seriousness); (3) time line (e.g. how long
it will last); (4) cause (e.g. caused by smoking, caused by a virus); and (5) cure/control (e.g. requires medical intervention). This chapter examined these dimensions of illness cognitions and assessed how they relate to the way in which an individual responds to illness via their coping and their appraisal of the illness. Further, it has described the self-regulatory model and its implications for understanding and predicting health outcomes.
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
The literature examining illness cognitions highlights some of the assumptions in health psychology:
1 Humans as information processors. The literature describing the structure of ill- ness cognitions assumes that individuals deal with their illness by processing the different forms of information. In addition, it assumes that the resulting cognitions are clearly defined and consistent across different people. However, perhaps the information is not always processed rationally and perhaps some cognitions are made up of only some of the components (e.g. just time line and cause), or made up of other components not included in the models.
2 Methodology as separate to theory. The literature also assumes that the structure of cognitions exists prior to questions about these cognitions. Therefore, it is assumed that the data collected are separate from the methodology used (i.e. the different components of the illness cognitions pre-date questions about time line, causality, cure, etc.). However, it is possible that the structure of these cognitions is in part an artefact of the types of questions asked. In fact, Leventhal originally argued that interviews should be used to access illness cognitions as this methodology avoided
‘contaminating’ the data. However, even interviews involve the interviewer’s own
? Q U E S T I O N S
1 How do people make sense of health and illness?
2 Discuss the relationship between illness cognitions and coping.
3 Why is Leventhal’s model ‘self-regulatory’?
4 Discuss the role of symptom perception in adapting to illness.
5 Illusions are a central component of coping with illness. Discuss.
6 Illness cognitions predict health outcomes. Discuss.
7 Design a research project to evaluate the role of coping in adaptation to illness.
F O R D I S C U S S I O N
Think about the last time you were ill (e.g. headache, flu, broken limb, etc.). Consider the ways in which you made sense of your illness and how they related to your coping strategies.
preconceived ideas that may be expressed through the structure of their questions, through their responses to the interviewee, or through their analysis of the transcripts.
F U RT H E R R E A D I N G
➧ Bird, J.E. and Podmore, V.N. (1990) Children’s understanding of health and illness, Psychology and Health, 4: 175–85.
This paper examines how children make sense of illnesses and discusses the possible developmental transition from a dichotomous model (ill versus healthy) to one based on a continuum.
➧ de Ridder, D. (1997) What is wrong with coping assessment? A review of conceptual and methodological issues, Psychology and Health, 12: 417–31.
This paper explores the complex and ever-growing area of coping and focuses on the issues surrounding the questions ‘What is coping?’ and ‘How should it be measured?’
➧ Leventhal, H., Meyer, D. and Nerenz, D. (1980) The common sense representa- tion of illness danger, in S. Rachman (ed.), Medical Psychology, Vol.2, pp. 7–30.
New York: Pergamon Press.
This paper outlines the concept of illness cognitions and discusses the implica- tions of how people make sense of their illness for their physical and psycho- logical well-being.
➧ Petrie, K.J. and Weinman, J.A. (1997) Perceptions of health and illness.
Amsterdam: Harwood Academic Publishers.
This is an edited collection of projects using the self-regulatory model as their theoretical framework.
➧ Taylor, S.E. (1983) Adjustment to threatening events: A theory of cognitive adaptation, American Psychologist, 38: 1161–73.
This is an excellent example of an interview based study. It describes and analyses the cognitive adaptation theory of coping with illness and emphasizes the central role of illusions in making sense of the imbalance created by the absence of health.
4
Doctor–patient communication and the role
of health
professionals’
health beliefs
C H A P T E R O V E R V I E W
This chapter first examines the problem of compliance and then describes Ley’s (1981, 1989) cognitive hypothesis model of communication, which emphasizes patient understanding, recall and satisfaction. This educational perspective explains communication in terms of the transfer of knowledge from medical expert to layperson. Such models of the transfer of expert knowledge assume that the health professionals behave according to their education and training, not their subjective beliefs. The chapter then looks at the role of information in terms of determining compliance
and also in terms of the effect on recovery, and then reviews the adherence model, which was an attempt to go beyond the traditional model of doctor–patient communication. Next, the chapter focuses on the problem of variability and
suggests that variability in health professionals’ behaviour is not only related to levels of knowledge but also to the processes involved in clinical decision making and the health beliefs of the health professional. This suggests that many of the health beliefs described in Chapter 2 are also relevant to health professionals. Finally, the chapter examines doctor–
patient communication as an interaction and the role of agreement and shared models.
This chapter covers:
➧ What is compliance?
➧ The work of Ley
➧ How can compliance be improved?
➧ The role of knowledge in doctor–patient communication
➧ The problem of doctor variability
➧ Explaining variability – the role of clinical decision-making
➧ Explaining variability – the role of health beliefs
➧ Doctor–patient communication as an interaction
W H AT I S C O M P L I A N C E ?
Haynes et al. (1979) defined compliance as ‘the extent to which the patient’s behaviour (in terms of taking medications, following diets or other lifestyle changes) coincides with medical or health advice’. Compliance has excited an enormous amount of clinical and academic interest over the past few decades and it has been calculated that 3200 articles on compliance in English were listed between 1979 and 1985 (Trostle 1988).
Compliance is regarded as important primarily because following the recommendations of health professionals is considered essential to patient recovery. However, studies estimate that about half of the patients with chronic illnesses, such as diabetes and hypertension, are non-compliant with their medication regimens and that even com- pliance for a behaviour as apparently simple as using an inhaler for asthma is poor (e.g. Dekker et al. 1992). Further, compliance also has financial implications as money is wasted when drugs are prescribed, prescriptions are cashed, but the drugs not taken.