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Assessment of factors which influence compliance to diet revision therapy for food allergy in a pediatric… Harris, Elizabeth Dorothy 1987

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ASSESSMENT OF  FACTORS WHICH INFLUENCE COMPLIANCE T  DIET REVISION THERAPY FOR  F O O D ALLERGY  IN  A  PEDIATRIC POPULATION by ELIZABETH B.Ed. (Elem.), The  DOROTHY  University of  A THESIS SUBMITTED  IN  HARRIS  British Columbia,  PARTIAL FULFILMENT  1972  OF  THE REQUIREMENTS FOR THE DECREE OF MASTER OF ARTS  in THE FACULTY OF GRADUATE STUDIES (Department of  We  Educational Psychology  and  Special  accept this thesis as conforming to  the  required standard  THE UNIVERSITY  OF BRITISH  OCTOBER,  © ELIZABETH  COLUMBIA  1987  DOROTHY  HARRIS,  1987  Education)  In  presenting  degree  at  this  the  thesis  in  University of  partial  fulfilment  of  of  department  this or  publication of  thesis for by  his  or  requirements  British Columbia, I agree  freely available for reference and study. I further copying  the  that the  representatives.  Library shall make  It  this thesis for financial gain shall not  is  granted  by the  understood  Educational Psychology and Special Education  The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 D a t e  DE-6G/81)  October, 1987  it  that  head of copying  my or  be allowed without my written  permission.  Department of  an advanced  agree that permission for extensive  scholarly purposes may be her  for  ABSTRACT Failure to of  treatment  compliance children.  comply with  programs.  with  This  prescribed  Forty-five  prescribed regimens is a major study  diet  investigated  revision  children, aged 6 to  therapy  factors for  reason for  which  food  12 years, w h o were  are  allergies  the  failure  related  in  to  school-aged  under a physician's care  for f o o d allergies, formed the sample. The to  Health  measure  these  Questionnaire 38  items  Belief  M o d e l was  factors.  The  involved a pilot  used as the  development  test  of  into  4  considered  optional.  The  38-item  reliability of  .87, and a composite reliability of  subtests,  of  4  subtests  variables.  A  discriminant  discriminating  diet  is  .80,  with  function  therapy  which  DRTPQ  The canonical correlation between the  the  and revisions; the  organized  and  basis for  of  dropouts  a  instrument  7-item  subtest  scale  internal  .61 for the four  shared  subtests  from  full  subjective  variance of  the  continuing  devised  Revision Therapy  resulting one  3 types of  64% 3  has  Diet  a questionnaire  consists of is  to  be  consistency  subscales. ratings  between  DRTPQ  subjects  Parent  of  compliance  these  proved  with  sets  of  capable  of  88.9% accuracy.  These three subtests measured: 1. 2.  3.  Parent and family life factors, such as the amount interference in normal routines, Child's attitudes to the treatment and his/her normal respect to cooperation with parental demands, and Belief in the A  condition  fourth and  benefits to category  perceived  of  be derived from items  susceptibility  compliance in this sample, although Suggestions for interventions  the  measured to  illness  of  perceived  behavior  treatment. perceived  but  proved  severity not  of  to  it may be useful in clinical practice. to  ii  with  aid compliance are outlined.  the  predict  TABLE OF Abstract  CONTENTS  .  »  List of Tables List of  vi  Figures  v  Acknowledgements I.  »  viii  Introduction  1  A. Background to the Problem B. Research Context C. Statement of the Problem  1 3 6  II.  Review of the Literature A. Introduction B. Measurement of Compliance 1. Types of Measurement 2. Sources of Error a. Laboratory Tests b. Direct Observation c. Pill Count d. Treatment O u t c o m e e. Clinical Judgment '. f. Self-Report g. Summary 3. Selection of Methods a. Population Characteristics b. Condition Characteristics c. Characteristics of the Regimen 4. Conclusion C. Factors Which Influence Compliance a. Population Variables b. Condition Variables c. Treatment Variables d. Summary D. The Health Belief M o d e l 1. Components of the Health Belief M o d e l 2. Criticisms of the Health Belief M o d e l 3. Research Using the Health Belief M o d e l a. H B M and Antibiotics b. H B M and Asthma c. H B M and Diet 4. Summary  7 7 7 7 8 8 9 9 9 10 11 12 12 13 14 15 15 16 17 19 23 26 27 27 29 30 31 31 33 34  III.  Instrumentation A. Sample B. Ratings C. Initial Questionnaire  36 36 37 38  Construction iii  1. Item Generation 2. Pilot Administration and Analysis D. Test Revision and Administration 1. Revision Procedure a. Subtests b. Items 2. Administration Procedure E. Analysis and Final Revision F. Summary  39 40 43 43 43 44 45 46 52  IV. Analysis and Results A. Cluster Analysis B. Dropout Analysis C. Subjective - Objective Correlations D. Test - Retest Correlations E. Demographic Variables F. Summary  53 53 58 62 65 66 69  V. Summary and Conclusions A. Summary of instrument Development Results B. Summary of Analysis 1. Results of Analysis 2. Factors Which Influence Compliance a. Parent and Family Life b. Child Positive Factor c. Belief in Treatment and Benefits d. Perceived Severity and Susceptibility C. Recommendations for Further Research D. Suggestions for Use and Clinical Interpretation E. Conclusion  71 71 72 72 73 73 74 75 75 77 78 79  References  81  Appendix  A: Diet  Revision Therapy  Parent Questionnaire  90  Appendix  B: Researcher Questionnaire  Appendix  C: Initial Version: Diet  Appendix  D: Dropout's  Appendix  E: Subtest Structure  Rating Protocol  108  Appendix  F: Squared Multiple  Correlations  111  98  Revision Therapy Parent Questionnaire  Parent Letter  Appendix G: Subject Profiles: DRTPQ Variates and Discriminant Functions  100 106  Scores,  iv  Dropout  Status,  Cluster,  Canonical 113  Appendix H: Guide to Parent Questionnaire Appendix  I: Subject  Administration  Recruitment  and  Article  Scoring  of  the  Diet  Revision  Therapy 116 120  v  List  Table  3—1:  Means,  Standard  of  Deviations  Tables  and  Intercorrelations  Ratings and DRTPQ Scores Table  3-2:  Analysis of  Table 3—3: Summary of Table 3—4:  Compliance 37  Pilot Data by Subtest  41  Core Item Test by Subtest  Intercorrelation Matrix  of  of  Core Item Test  42 43  Table 3—5: Summary Item Statistics by Subtest: All Items  47  Table 3—6: Summary Item Statistics by Subtest: Final Version  50  Table 3—7:  51  Intercorrelation Matrix  of  Final Version  Table 4—1: Summary of  the  Differences  Between Clusters  Table 4—2: Summary of  Canonical Correlation  Table 4—3: Core Test Summary Statistics: Time Table 4 — 4: Test - Retest Correlations Table 4—5: Correlations  Analysis 1 and Time 2  of C o r e Test  of Subtests and Ratings with Age  vi  53 64 67 67 69  List  Figure 4 — 1 : Subjective Figure 4 - 2 :  of  Figures  Compliance Ratings by Cluster  Standardized  DRTPQ Scores, by Cluster  Figure 4—3: Standardized Test Scores and Ratings by Dropout Status  vii  55 57 60  ACKNOWLEDGEMENTS  I would casual  though  like it  to  was  research. Thank you project  was carried To  the  thank at  Dr.  Julianne Conry for  inception,  also to  and  for  her  allowing  Dr. Stephen Cislason, the  'inspiration' me  to  of  this  study,  participate  physician through  in  her  whom  our  out.  graduate  student  Eng, and Maria laquinta, w h o  researchers, Wendy  collected a large  Bidgood, Jennifer  portion  of  the  Birtwell,  Karen  data, a special thank  you. I  would  consideration  of  also my  like  to  numerous  express drafts  my  appreciation  which  Conry and Dr. Robert Conry, gave me.  viii  my  for  committee  the  helpful  members,  and Dr.  speedy Julianne  I.  INTRODUCTION  Keep a watch also on the faults of the patients, which often make them lie about the taking of things prescribed. For through not taking disagreeable drinks, purgative or other, they sometimes die. (Hippocrates, " O n D e c o r u m " , cited in DiMatteo & DiNicola, 1982)  If the participants don't like the treatment then they may avoid it, or run away, or complain loudly. And thus society will be less likely to use our technology no matter how potentially effective it might be. (Wolf, 1978)  A. BACKGROUND TO THE Whereas medical  the  science  PROBLEM  problem  since  of  compliance  Hippocrates  to  (Gordis,  prescribed  1979;  DiMatteo  has  &  scienctists have only  recently  treatments  by the  psychological services (Garfield, 1983).  Estimates 93% (Rapoff care  of  failure  1974).  result  The  cost  treatment's treatment  project,  are  when to  tests and treatments, research  comply  with  concerned about  health  care  advice  & Christopherson, 1982). The consequences of  recommendations  frequently  to  antibiotic  the  post-treatment  failure  followed, effects,  health  serious.  treatments care  or  to  comply  lack  followed of  of  them,  not  is high  Unless  a  the  range  1982),  acceptance of  from  15% to  and  infections  resistant (Mattar  appointments,  procedure  researcher  prescribed,  can  be  can  he  attributed  to  noncompliance  &  health  Yaffe,  repetition  (Becker & Maiman, 1975).  as  1  the  completed  missed  complicates  immeasureably. and  Recurring  are  system  and unused medication  effectiveness was  potentially  concerned  DiNicola,  behavioral  consumer of  become  regimes  the  In a  of  determining  be  sure  cannot to  of  be  that sure  treatment.  a the that  When  Introduction / 2 attempting treatment  to  prove  term  "compliance"  behavior  (in  changes)  coincides  of  (1982)  the  describe 8),  care  conceptualization  derived  through  through  reflects  a  between  "the  extent  to  in  "compliance"  recent  as  it  cooperation"  is yet  "compliance"  and  described  these  by  plan, attending  literature,  is  felt  another  "adherence" terms  appointments,  DiNicola and DiMatteo or also the  not"  ignores,  includes  as  forgets,  or  eventual treatment.  success  Wacker, of  and  term  "adherence"  in  be taking  used  Acceptability  is  defined  and  add must  to be and  chooses behaviors  that  been  connotation.  literature.  interchangeably. following  substituted  In  "Patient  this  research,  Specific a  diet  for  behaviors or  exercise  previous behaviors such as smoking, etc.  who  (1987)  are directly by  the  medication,  misunderstands  a treatment  (1982)  describe a noncomplier as one w h o  patients  shared  patient  has  used  Koeppl  is  regimen  professional  individual  DiMatteo  31).  the  them  clinical  choose  prescribed regimen, including the choice of Reimers,  Meleis the  lifestyle  practitioner-patient  and  that  person's  2)  compliance  frequently  (1984)  p.  for  judgmental  restricting  noncompliers  of  a  executing  the  care  an  or  goal  less  include  is crucial that  which  1979,  a  will  it  (Haynes,  Dracup  health  to  diets,  requirement  have  term  "the  which  the  to  extent  responsibility  the  coincide with a clinical prescription" (p. Often  as  patient.  compliance  outcome,  following  that  and the  "the  advice."  compliance  giver  of  as  health  implying  negotiations  compliance  defined  or  treatment  & DiNicola, 1982).  medications,  medical  (p.  health  is  taking  with  process"  between  that  terms  DiNicola  influence  their  efficacy  compliance is proven (DiMatteo  The  and  treatment  no  a different  Haynes  regimen  or  (1979) amend  treatment.  state  that  influenced as  prescription.  "purposely  "the  both by  the  likelihood  compliance acceptability of  a  and  the  of  that  recommended  Introduction / 3 treatment  being attempted"  Kazdin clients,  (1981, p.  and  others  reasonable for the Although  appropriate. embodies selection care  (Elliott, of  regime, totally, Witt between  in  as "judgements  procedures  are  by lay persons,  appropriate,  of  1986)  is inherent  literature its  treatment  treatment  to  behavioral  application to  selection in  the  Elliott  use, use  (1985) use,  is  been  felt  a  patient  the  of  to  interventions  concept  of  be  the  province  comply  theorize  integrity,  prerequisite  to  a and  sequential  therefore,  and is a determinant  includes  but  effectiveness,  of  with  integrity  (how  elements  is  the  health  prescribed selection. relationship  which  closely the  the  a  reciprocal in  in  acceptability  compliance. Traditionally,  chooses to  followed), which in turn influences the treatment's Compliance,  and  medical recommendations  which  problem  has  when  refers  partially, or not at all, he is involved in fact, in treatment  and  fair,  client."  issue  However,  acceptability  treatment  school settings,  acceptability,  determines  whether  acceptability  a medical  professional.  refers to  problem or  or  The  493.)  of  most  clinical settings  and as such is clearly a prerequisite to compliance.  acceptability  treatment  plan  is  effectiveness. of  acceptability,  use,  and  integrity  of effectiveness.  B. RESEARCH CONTEXT The with  present  study  involves  a medically prescribed diet  being  sufferers  whose  parents  project  in  behavioral  of  food  the  difficulties  to  a  relationship was  to  the  revision therapy  allergies.  responded  which  assessing  Subjects newspaper between  be  were  factors for  food  investigated  influence  children w h o  drawn  article  which  from  allergies and (Mullens,  are suspected  among  describing  a  of  those  children  proposed  research  learning  1986).  compliance  difficulties  (This  article  or is  Introduction / 4 presented in Appendix food  I.)  The children were  allergies and a thorough  evaluated by a physician specializing in  medical history was taken. All subjects who  physician's symptom criteria indicating probability of food allergy were The  treatment  consisted  common  allergy  gradually  reintroducing  of  this  diet  selection  provoking  are  as long  restrictive,  of  food  allergen  to  distress,  headaches, rhinitis  (Cislason,  the  child's  symptomatic  as symptoms  consisting  of  diet  did  not  rice,  eliminating  was  obtained,  all then  return. The early stages  poultry,  subjects, some dietary  eligible.  by  remission  the  fish,  restriction  and  will  a  limited  be necessary  1986b).  Symptoms  allergen  emotional  revising  until  of vegetables. For most  lifelong (Cislason,  and  foods  foods  very  of  met  allergy  within  1986a).  each and  disturbance,  vary  person.  otitis  and  from  person  Common  to  person,  reactions  are  media, muscle pain, fatigue,  an  Reactions vary  widely  inability  from  to  concentrate  imperceptibly  mild  to  and  from  gastrointestinal  rashes, behavioral  and fatally  learn  efficiently  severe  and  can  be either chronic or acute. Although an  individual  required. both foods.  all subjects  pattern  of  Each subject  type  and  When  ingests  from  symptoms  comes to  intensity  he  suffer  --  and  the  and  same condition, f o o d  sensitivity:  individually  physician with his own  is  a food  the  found  that  is  to  be  allergic  an  allergen  "safe"  food  allergy, each has  prescribed  pattern to  a  of  diets  symptoms --  particular  for  him,  he  list  is  matter  are  will  array  react  in  of a  unique way. Determination calculated week new  trial  period foods  of  and  of  each  error.  strict  are added  subject's  Symptoms  adherence to  are the  and symptoms  initially "core  are  cleared  diet"  a  through  two  carefully to  three  described above. At this  point,  carefully monitored.  a  of  Those which  provoke  Introduction / 5 a reaction subject;  are considered allergens and  those  which  create  no  symptoms  guides the subject and his parent of  regularly  spaced  nutritional  status  clinic  is  placed on  through  "unsafe"  considered  food  "safe".  list  Throughout  through  blood  this  procedure,  tests  and  for  The  this systematic trial procedure  appointments.  monitored  are  the  physician  in a series  the  food  that  subject's  diaries,  and  supplements are prescribed as necessary. Support student  for  the  family  was  researcher responsible for  status  and  by  two  parent  provided  by  regular  assessment of  meetings  the  contact  the  graduate  learning  and  behavioral  included  educational  and  feedback  treatment  regimens,  which  child's  with  components. Because children, treatment the  the  is important or to  degree  important  to  is  By  possible  compliance  in determining  which  the  each  to  whether  subject  identification  of  in order to  determining to  of  remission of  some other factor, it is important  presents difficulties, diet.  issue  design  the a  maintained those  provide  factors  compliance  which  to  undertake  for  intervention are  symptoms  compliance with  patients  whom  enhancement  to  program  is due  the  to  the  treatment. to  assist them 1  these  which  with  some assessment of  compliance  designed to  contributing  especially  Also  therapy on  this  difficulties,  will  address  it  is  these  factors. The  elements  of  this  treatment,  which  must  be  considered in  designing an  assessment of compliance, are: 1.  This  is  others. and the family.  a The  pediatric  population  behavior  subject  child  of  the  must  so  parents be  the of  viewed  treatment the in  is  largely  administered  actual subjects must terms  of  by  be surveyed,  his membership  within a  Introduction / 6 2.  This  is  a  long  term  chronic  condition  requiring  a  change  in  family  eating  behaviors. 3.  There  is  no  generalizable,  condition  for  all  subject  to  symptoms  subjects.  subject. by  A  reliable,  Consequences  subject  discovering  and  may  a new  direct of  comply  link  between  noncompliance with  his  allergen  among  compliance  to  diet  foods  treatment  vary  and  and  widely  from  still  experience  previously  considered  "safe". 4.  It  is  not  measurable  possible means  whether a patient  to as  infer there  are  no  this  laboratory  treatment  tests  which  by  physically  will  indicated  is compliant with diet revision therapy.  C. STATEMENT OF THE PROBLEM The families food  present  study  complied with  allergy.  This was  factors  derived from  health  care  likely  to  intervention  with  the  factors  an individually  prescribed  done  the  through  a review of  professional comply  investigated  to  the  influencing  diet  revision  development  literature.  the  of  therapy  an  whether  or  not  treatment,  thereby  facilitating  program to aid and encourage compliance.  a  particular an  for  instrument  Such an instrument  predict  degree  would patient  appropriate  to  which  suspected based  on  enable a would and  be early  II.  REVIEW OF THE  LITERATURE  A. INTRODUCTION The following compliance  in  this  chapter describes literature research  context.  The  divisions. In the first section, methods a view to  selecting the  most  the  assessment instrument  the  factors  which  have  is  been  then  into general theories. The content  to  pertains to  two  assess compliance are reviewed  with  The  on  the assessment of into  technique  derived.  found  literature  used to  appropriate  which  for this  second  influence  compliance  project.  section  falls  The structure  is  concerned  compliance, and their  of the assessment instrument  of  with  organization  is derived from  this  literature.  B. MEASUREMENT A variety to which  of  patients'  1. Types of  indirect  measurement techniques  medication  prescribed to  compliance in a number  used to  assess the  degree  recommendations.  be taken by a patient,  it is possible  of ways. These can be categorized into direct  to and  methods. include:  Measuring the variety  2.  is commonly  behavior coincides with medical  Direct methods 1.  COMPLIANCE  Measurement  In cases of estimate  OF  amount  of laboratory  medication  present  in a subject's body using a  tests.  Directly observing the Indirect methods  of  patient  include four  taking the  techniques:  7  medication.  Review of the 1.  Physically counting the amount of should be left at that time  2.  Measuring the treatment  3.  Using clinical judgment.  4.  Self-report of the  2. Sources of All sources and  above  error.  regimens  than  drugs  in  prescribed  methods  amount  outcome.  of  others.  In  compliance  are more  general,  assessment are  appropriate  direct  for  methods  indirect methods are often  the  tests, such patients'  medication.  Error  as drug  bodies can  among individuals. The amount of the  treatment.  subject  to  multiple  particular patient  may  yield  somewhat  groups more  more practical (Cordis, 1979).  Tests  Physiological of  in the  what  patient.  Some methods  accurate results, but  a. Laboratory  medication left and comparing to  Error  the  of  Literature / 8  of  time  can result  assays, be  the  used  drug  appropriate to  because  drug found  elapsed since  are  the  infer  when  that  metabolism  the  they of  presence  have  taken  drugs  varies  in b l o o d or urine can also vary with was  taken,  and  is  also  intervening factors such as f o o d , exercise and stress. (Epstein & Cluss,  affected  by  1982; Cordis,  1979: Olson, Zimmerman, & de la Rocha, 1985). Laboratory tests are not  applicable to  the  present  research as no  prescribed and biochemical assessment cannot reflect dietary compliance.  drugs  are  Review of the b.  Direct  / 9  Observation  Direct  observation  influence  compliance.  methods,  where  of  patient  Cordis  the  patient  study  entailed  involved  daily  unannounced  behavior  (1976)  has  becomes  and changes his behavior in order this  Literature  aware  habits,  families  an  obtrusive  commented that  to appear  eating  visits to  is  his  on  timed  the  to  is  to  being  Since compliant  observation  would  coincide with  and  reactivity  compliance  compliant.  direct  procedure  may direct  assessed  behavior  have  to  in  have  meal times. This was  impractical.  c.  Pill  Count  The pill count, not  in  points and  the  bottle;  out is  dispenser monitor  it  that this  subject  easily quantifiable, not  prove  information  to  the  Norell  time  a medication  that, as sophisticated  Treatment  pin  each  method  taken down  of  that the  as directed. patterns  devised  use for  proves  a  an  of  medication Cordis  (1979)  noncompliance,  mechanical  eyedropper  glaucoma.  medication  in  order  Epstein and Cluss  appears, it  actually  is  to  (1982)  measures use  of  medication.  Outcome  Measurement of compliance.  it was  regime  as this  simply  (1979)  of  the dispenser rather than use of the  d.  that  does little to  falsification.  records  compliance  comment  does  to  which  while  When  treatment  there  outcome,  compliance with  treatment  outcome  DiMatteo,  1984).  outcome  is a direct treatment  and this  inference  and  is a highly proven  can be must  connection  inferred, be  suspect method  but  between  not  interpreted  It should be noted that a high degree of  with  of  measuring  treatment  proven, caution  and  by successful (DiNicola &  correspondence  between  Review of the treatment out  to  and  outcome  even then,  and  Cluss  (1982,  p.  968)  note  under clinical control, and some w h o Taylor (1979) found  their  intervening  variables must  be  ruled  prove compliance. Epstein  not  is rare, and  Literature / 10  regimes  Therefore, negative  and  positive outcome  that  that 88% of 34%  of  should  controlled  can  used  not as  "many  patients  who  are under clinical control  uncontrolled  outcome be  that  be  an  adhere  are  do not adhere."  hypertensives were compliant  hypertensives  used  were  also  as a compliance  indication  that  compliant.  measure;  compliance  with  needs  rather, to  be  investigated.  e.  Clinical  Judgment  Clinical judgment compliance. and  in  1967;  some  cases,  Caron &  to  Roth,  (1983),  antacid  (objective that  22 of  regimen,  physicians'  be  and  judgments  better  Norell,  their  study  ratings)  ratings) 27  no  1968;  in  impressions (subjective  found  to  Physicians have been shown to  McGoldrick  results  has also proven  of  doctors that of  of  be  Witenberg,  renal  dialysis  compliance were  was  compliance  a  and  patient  of  compliance,  Blanchard, M c C o y , patients,  significantly  would  overestimated  there  estimator  chance (Biackwell, 1973; Charney et al,  1981).  compliance  unreliable  regularly overestimate  than  of  a somewhat  suggest.  compliance of  median  correlation  objective  that  higher than  Caron  the  an  found  Suls,  and  their of  measure  of  clinical  laboratory  Roth  (1968)  patients  just  and  .01  to  an  between  compliance  (pill  count). However, . Cummings, nurses were  provided  compliance with more  with  Kirscht, results  of  Becker patients'  and  Levin  (1984)  lab tests, they  found  were  accuracy than either biophysical assessments or  that  able to  when predict  self-report.  Review of the f.  Self-Report  Self-report of  Literature / 11  unreliability  over-report (Cordis,  of  inherent  1976;  Yoos, are  actual proportion  least  in  the degree to  noncompliance  higher  compliance to  than  1984).  Zimmerman,  the and  at  least  de  methods  la  any  is subject  behavior.  Rocha  (1981)  as  found  noncompliant  patients may be  Cummings et  three  of  Norell  noncompliant  reported.  valid of  self-report  regime  The  which he is compliant and to  usually  of  a medical  al. (1984)  of  (1985)  refer  patient  under-report  as they  report  as much as two patient  self-report  is  likely  who and  report that  or three  self-report  to  least  the times  be  investigated.  as the  to  noncompliance  patients  compliance they  to  all the sources  that  found  assessing  to  the  Olson,  consistently  reliable method of assessing adherence to a medical regime. Gordis patient  (1979)  interview  makes  data,  deliberate attempt to  the  there  is  point no  mislead on the  that  when  evidence part  of  to  considering  suggest  the  patient.  that  the  inaccuracy  there  has  It could be the  of  been  a  result  of  lack of memory for past actions, or because the patient actually thinks he has been compliant when in fact he has not clearly understood the regime. On  the  hypertensive compliance  positive  steel workers, measured  side,  Taylor  found  against  (1979)  in  that self-report  pill  count.  his  study  of  compliance  explained 52% of  This  is  compared  a correlation  of  .91  to  the  15%  in  variance in of  variance  explainable through other sources. Radius drug  et  al (1978)  report  between  parental  report  of  administration and blood tests revealing the presence of that drug in asthmatic  children. Dunbar prediction  and  Stunkard  (1979,  techniques, "The best  p.  method  415)  feel  currently  that,  when  is still  to  compared with simply ask the  other patient  Review of the what  he or she expects to  which  revealed that when  advice  of  their  sample of  doctors,  patients were 70%  of  would  not  comply  while  23%  said  they  noncongruent  them  and  did  would  Maiman  they would  and  A  In  Kirscht  be able to  as they  cite  they  Davis'  intended  predicted  (1968) to  they  total  both to  (1977)  of  cases,  follow  would.  said  they  congruent  Of  his  15% said  would  subjects  the  comply,  outnumber  one. found  keep their  77%  study,  that,  by  asking  mothers  obese children on their  if  they  diets, they  were  loss.  Summary  The implication with  the  combat  et  did  not.  not.  able to significantly predict weight  to  this, they  asked whether  subjects approximately two  Becker,  g.  for  154 clinic patients, 55% said they would comply and did, while  they  thought  d o . " As support  Literature / 12  sources the  unreliability  use multiple al,  of  1984;  of  this review of  compliance measurement techniques, is that,  error  inherent  in  all  of  each of  the  above  methods. This is supported Dunbar  &  Agras,  the  1980;  techniques methods  of  by major writers  Cordis,  1979;  presented, assessing  the  to  compliance is  in the field  Marston,  way  (Cummings  1970;  Rapoff  &  Christophersen, 1982; Sackett, 1979).  3. Selection of Although possible  to  considering  Methods all  methods  select methods the  of more  characteristics  of  assessing  compliance  appropriate the  to  population  which they are being treated, and the treatment  are  a particular being regimen  subject  to  project  studied, itself.  the  error,  than  it  is  others  by  condition  for  Review of the a.  Population  Characteristics  The  present  their  homes.  quite  different  other  study  The  populations  and  patients'  compliance  1973; not  beliefs  the  of  obtain  'unsafe'  such  &  of  Sackett,  with  their  away  parents' the  home.  in  in  a  population  is  or  risk  must  efforts  population  at  The  pediatric  the the  for  For children, as for  disabled,  Research  greater We  a pediatric  often  1975).  at  1979).  are  to  populations.  elderly  others"  are  from  adult  the  Green,  age  &  foods  as  applied  compliance  compliance in  "responsible  extremes  cooperative  a treatment  estimating  (Becker  Haynes, Taylor be  of  estimating  attitudes,  at  involves  problem  from  dependent  patients  Literature / 13  major has  the  determinants  demonstrated  noncompliance  also  consider  that  diet  revision  therapy,  children's  behaviors,  attitudes  of that  (Blackwell,  children  may  and  must  may  also  be  considered. Witenberg renal  dialysis  home-based  et  patients. patients  compliance  level  treatment  in  treatments  is  the  regime,  one  administering mother  were  subject , to  doctor-patient Deaton  "doing than  The  and the the survey  that  regime.  compliance that,  better," that  in  the of  the  objective  patients of  because of  home-based vs. hospital  despite  estimation  error  must  (Litman,  found  lower  clinic.  determine  studied  They  was  between the patient To  al (1983)  data  who  compliance  a lack  prevalent  of  with  frequent  feeling  showed  received  clinic that  that  their  their  dialysis  home-administered and  regular  contact  staff.  factors the This  which  influence  characteristics is  1974). Cuskey and  usually  of the  a child's compliance to the  person  child's  who  parent  Litt (1980)  describe the  that  parents  is  and  a medical  responsible most  often  parent  as mediating  asthmatic  children  for the the  relationship. (1985)  has  found  the  of  make  Review of the compliance and  decisions based on  abilities,  that  and  parents'  that  their  expert  noncompliance  expertise  and  is  knowledge  not  awareness  always  of  their  children's  maladaptive.  regarding  their  Literature / 14  Her  conditions  suggestion  children's  conditions  is be  considered in compliance research.  b.  Condition  Characteristics  Characteristics of the  methods  conditions sort  of  term,  have  compliance  example lifestyle  reliably  (Deaton,  cure  than  acute  results  in  1985;  Assessment  Conditions hypertension,  positive  Becker et  account  in  results  in  swift  direct  way  noncompliance to over of  prematurely  a  in  feedback  often  for  design  which  the  patient  cite  discontinuing  day  treatment.  of  allergy)  the  that  treatment  condition:  influence  essentially different  (or  their (Cuskey  antibiotic  order  to  children's &  Litt,  term  behavior by  such  as  in  which  consequences. The  patient  effects  in  asymptomatic  must  of  take  maximally  symptoms 1980;  must  effective,  as the  Mattar  into  compliance  medications, which be  for  difference  conditions  instrument  the  short  treatment.  noncompliance)  experiences  term  symptom-free,  from  a compliance  direct,  long  this  of the  different  require  reflect  nature  a  media,  short  to  Chronic  otitis  require  severe negative  in  is  conditions  feels  of  require  conditions  case of  course  remission  is prescribed  Chronic  compliance  The  ten  in  long term  1973).  to  which  problem  his regimen. In the  seven  patients  and  food  designed  patient  compliance  (Blackwell,  the  the  acute be  and the  which  for  change  for  must  a treatment  diabetes,  al, 1978).  a  receiving  conditions  lifestyle  which  measure compliance to that treatment.  (asthma,  present  noncompliance is not  for  conditions  methods  addressing the family  parents  no  changes, whereas treatment  change.  taken  condition  that can be applied to  which  and  the  &  be  many  reason Yaffe,  or  for  1974;  Review of the Literature / 15 Yoos,  1981,  1984).  Charney et  al (1967)  report  that  a child  who  is  has a less than 50% chance of completing the prescribed course of  c.  Characteristics  of  Perhaps the itself  (Dunbar  regimes which  are  &  with  diet  to  the  1980;  important Dunbar  increase least  determinant  &  noncompliance  amount  of  requires adding a behavior,  with than  proscription,"  and  to  which  regimens  a point  patients  lives in order to  It  in  a  &  Complex Cluss,  patient's  follows  that  such as taking  it  be  life  Padrick (1986).  have been able to  It  incorporate  regimen  long  are  is more  term  Treatments most  likely  often that a  medication, is more  a previous  designed  or  1982).  habitual  notes that a "prescription  should  echoed by  compliance is the  1979).  a regime that requires restricting  that  established routine,  of  (Epstein  change  change, for example. Hingson (1977)  degree  Stunkard,  (Davis, 1967; Haynes, 1979).  regime which complied  single most  shown  antibiotic.  Regimen  Agras,  necessitate  complied  the  asymptomatic  to  fit  behavior --  is easier than a  within  a  is necessary to the  easily  regime  patient's  assess  into their  the daily  truly assess compliance.  4. Conclusion Several methods of compliance assessment were examined and considered use  in  this  concluded  research. that  a  Because  each  combination  of  technique methods  has  would  its  flaws  and  benefits,  produce  the  most  for  it  was  valid  and  reliable estimate of a patient's level of compliance. Direct observation, laboratory be  ruled  out  compliance,  as  for the  this  treatment.  treatment  tests, and pill count Treatment  procedure  is  outcome diagnostic  are methods which  cannot and  be  used  designed  had  to  to  estimate  to  establish  Review of the whether  the  directly  subject  linked to  allergen.  A  is  allergic  symptom  patient  to  a variety  patterns  might  of  foods.  as a reaction  comply  strictly  yet  Treatment  is possible to still  Literature / 16  is  therefore  not  a newly discovered  experience  negative  treatment  judgment.  outcome. Remaining The  self-report  are  indirect  measures  assessment was  involving  accomplished  for  administering the treatment,  for  assessing factors which have been found The  self-report derived  from  compliance  as  the  There were  did  no  was  clinical  on  student  the  to  clinical  questioning  the  parent  of direct  responsible  and indirect  means  influence compliance.  treated  judgment.  graduate  restrictions  and  and was a combination  assessment  compliance  by  self-report  in  The  combination  physician  researcher  information  each  with  estimated  who  worked  rater  could  estimates each  with  patient's  the  use in  of  family.  coming  to  studies  of  their estimates.  C. FACTORS WHICH INFLUENCE In  this  section  of  COMPLIANCE  the  review,  literature  reporting  general  compliance with medical regimens was outlined, and integrated with factors found influence general  the factors  condition. Model.  acceptability  behavioral  is a series of  These  This  of  factors  model  and  factors  have and  been its  treatment  programs.  In  concerned with  patients'  organized  a  into  research literature  will  model, be  addition  to  perceptions the  these  of  Health  to  their Belief  reviewed, and discussed  relative to this research. The  catalogue  to  medical  regimes  In  general  terms,  of  variables which  is lengthy  three  groups  and of  have  been  overlapping variables  can  found  (Cummings, be  said to  to  influence  Becker, & determine  compliance  Maile, how  1980). well  a  Review of the Literature / 17 particular treatment  is carried  out:  1.  The nature of the patient  2.  The nature of the condition  for which the treatment  3.  The nature of the treatment  prescribed.  a. Population  population, was prescribed, and  Variables  Demographic have proven  to  variables  such  be surprisingly  as  education,  uninformative  income,  in predicting  marital  status,  a patient's  and  age  compliance  to  a medical regime (Davis, 1967, 1968; Dunbar & Stunkard, 1979; O l s o n et al,1985). Age  is  concerned.  predictive  Blackwell  when the patient the  likelihood  discussed  of  (1973,  compliance p.  250)  only  reports  so  that  previously.  treatment  Cuskey  and  will  have to  Litt  (1980)  as  extremes  noncompliance  is "extremely young or extremely  that the  far  be  is  of  age  more  are  common  o l d . " This may be influenced administered  agree  that  by  by  a third party as  pediatric  noncompliance  is  more c o m m o n than adult noncompliance, but Mattar and Yaffe (1974) disagree. They posit that pediatric compliance is high, as parents value the more  than  they  less likely to Since twelve,  value their  to  the  subjects  in  likely  survey the  Education it is related to et  their  children  health. Adolescents have been demonstrated  to  this  parents  level has been the  al (1978)  ability of found  research  predict  their children's adherence to the  Radius  of  to  be  comply than other young patients (Litt & Cuskey, 1980).  age is not  necessary  own  health  of  all  between  the  compliance in  these subjects,  these  regarding  subjects  ages  factors  but  of it  which  six  and  would  be  influence  treatment. shown to  a patient  that  are  mothers'  (or  influence  compliance to  his parent)  education  to  (more  the  understand the than  extent  that  treatment.  8 years versus  less  Review of the Literature / 18 than  8 years) was  positively  correlated  with  compliance to  regimens  prescribed  for  their asthmatic children. Radius  and  her  associates,  in  the  same  study,  also  between marital status and compliance. Mothers who  were  to  results  be  compliant  Maiman  et  positive  influence  members  with  their  al (1979)  can  in  their  may result  exert  child's  in  regimen.  study from  of  the  encouraging  Similar  juvenile  obesity.  found  a  married were were  more  found  likely  by Becker,  Radius speculates that  "various beneficial impacts which  medication  correlation  adherence"  as  other  this family  discussed in  Becker  and Green (1975). Family support compliance  to  alcoholism 1978; &  is widely held to  positive  treatment  health  and  be important  regimes  prescribed  such  in encouraging and  as  weight  exercise (Becker &  control,  Green,  maintaining  dental  care,  1975; Becker et  al,  Davis, 1967, 1968; Dunbar & Stunkard, 1979; Haynes, 1976; Norbeck, Lindsey,'  Carried,  1983).  The  positive  increased supervision of the including "unsafe"  "environmental foods;  the treatment;  by  the  influence  of  family  regime's administration  control" family  techniques  member  acting  support  may  be  the  by the supportive family  such  as  restricting  as a "stimulant"  or simply by helping in day-to-day administration  the or  result  member,  availability  of  encouragment  to  of the regimen.  Wallston, Magna, DeVellis and DeVellis (1983) consider social support from sources  -  family  and  conceptualize support  clinical  -  as quantitative  as  important  versus qualitative  the perception of the " g o o d n e s s " of the support) (material aid versus emotional Such perceptions  psychological have  been  facilitators (the  of  of  adherence.  all  They  amount of support versus  and instrumental versus expressive  support). characteristics  found  to  of  influence  patients compliance  as and  beliefs, are  attitudes  reviewed  in  and the  Review of the section below on the  b.  Condition  significant  in of  of  the  the the  disease  prediction disease,  consequences of  of  the  compliant  at the fifth day while and  regimens  Blackwell  (1973)  boredom  can all  months, with  one  remaining been  Snow  of  they  list that  62%  54%  as average chronic  al  (1978)  found  with  of  compliance  an  their  for  the  the  to  be  disease,  the  nature  of  the  a  81% of  patients  were  medication  on the  ninth  compliance  long  term  rate  for  treatment  forgetfulness,  hypertensive  short  regimens.  complacency,  their  subjects  one  third  distributed  over  being other  studies  and  treatment  for  acute  the  appears  conditions, relief  conditions,  which  conditions is not  a proscribed  for  rest to  of  be  or  may  be  the  was  being  that  after  roughly  U-shaped  compliant,  continuum.  This  a generalizable finding  12  and  the  result  has  (Cuskey  &  1979). compliance  and is therefore treatment  is  available. Compliance is not food)  steelworkers  among  third  reinforcement  of  and  that  average  illness,  noncompliant,  usually produces symptomatic  eating  as  "in  found  still taking  completely  or  duration  symptoms  give  Litt, 1980; Sackett & Snow, 1979; Taylor, In  themselves  is that compliance decreases over time. Within  third being  in  shown  contribute."  distribution  found  the  the  56% were  (1979)  states  et  the  are  have  regimen, Charney et al (1967)  while  Taylor  compliance  consistent finding  antibiotic  term  which  salience  short-term  Sackett  process  noncompliance.  The most  day.  Model.  Variables  Features  severity  Health Belief  Literature / 19  immediately  with  the  reinforced.  prophylactic reinforced,  reinforcing  prescribed In long term  in but  (Olson  nature,  regimen chronic  this  noncompliance et  al, 1985).  direct (eg. This  Review of the is  perhaps  asthma  an  even  more  where,  even  though  possible  to  generally  avoid  pronounced a  asthmatic  difficult  to  problem  in  may  be  completely  (Becker  et  al,  patient  attacks  maintain  long-term  acceptability  effectiveness. treatments thereby  Witt  being  and  treatment treatment)  a  is  a  treatment  Elliott  (1985)  acceptable,  contributing  effectiveness  of  and  to  effective  major  factor  and that the strength are  determinants  has  been  a  that  compliant,  it  like  is  1985).  with  regimes  which  thought  Yeaton  and  consultant  being  must  The  be  related  used  Sechrest  not It  is  have  (as it  research  to  its  with  effective  with  integrity,  (1981)  consider  administration  effectiveness.  to  relationship  treatments  and ease of  of  conditions  Deaton,  a reciprocal  acceptable  that  of  in chronic conditions.  propose  results.  case  1978;  compliance  uncertain efficacy, a characteristic c o m m o n The  the  Literature / 20  suggest  that  when  selecting  a  affects  integrity  of  on  this  connection  between efficacy and acceptability has, however, produced mixed results. Kazdin treatment histories  (1981,  Experiment  acceptability. followed  a  statement  outcomes.  They  were  then  significant  effects  were  found  and severity of Shapiro three no  group  significant  clearly The  more  students  studied  Undergraduate  by  (Von Brock & Elliott,  1)  asked for  1987; Witt,  the  effect  psychology indicating to  rate  treatment 1986) for  of  therapeutic  students either  the  were  strong  treatments  efficacy. restriction  This of  effects  given  or  brief  weak  for  has  range of  been  both  case  treatment  acceptability.  study  on  No  criticised  effectiveness  problem. and  Goldberg  contingency  (1986)  programs  for  studied  improving  difference  in  effectiveness  acceptable  to  the  were  judging  the  students  acceptability  among who on  effectiveness  acceptability  of  spelling in sixth graders. There was the had  a  and  three  treatments,  experienced  treatment  all  but  three  characteristic  one  was  programs. other  than  Review of  the  Literature / 21  efficacy. VonBrock  and  Elliott  (1987)  addressed  the  relationship  between  acceptability  could  differentiate  between  acceptability  Behavior  Intervention  Rating  and effectiveness. They found  first that they  and  using  perceived  effectiveness  provided written case studies to problem and  either  between  a  general  or  no  unexpected  which  interventions  were  new  treatment  the  with  The  when  mild  three  gave  by  results  implication  of  mild  problems,  case of  this study  severity  higher  problems.  teacher perceives the VonBrock as less  reason.  Witt  is that treatment  of  or  acceptability  problem (1987)  effective  those  interventions  suggests  acceptability  that  relationship  is considered, but  information  perhaps  relying  a  significant  less  rather  particular  past  these  effects  were  choose a  to  consider  experience. An  (and, by extension, which  to  when  likely to willing  on  ratings  in  outcome)  is best done  before  as severe.  Elliott  also  found  in  that  they  "perceived"  this  study  view  that  as less  effectiveness  may  teachers  tend  acceptable for be  more  to any  important  acceptability than actual data.  Reimers et analogue  are  that  acceptability  No  effectiveness information,  and  (1986)  in determining  but  a severe problem,  may be influenced by providing  They  interventions),  indicated  effectiveness  behavior  classroom  effectiveness  problem  teachers  accompanied  linked  usual  information.  The  were  for  in the  rate  to  of  for severe problems, indicating that teachers may be more  alternatives  the  as  used (one  and acceptability  direction.  interventions  noted  statement  effectiveness  effectiveness  Scale.  216 teachers. The case studies described a behavior  (mild or severe), the treatment  treatment  an  the  al (1987)  pretreatment depends  see the  studies to  primarily  on  above  phenomenon  as a concern when  assess acceptability. They state: "If the  outcome  (effectiveness)  of  a  using  treatment's  treatment,  then  Review of the assessing acceptability treatment  will  before  undoubtedly  the  fact  influence  may be irrelevant" eventual  instances. They suggest that acceptability in  progress  determine  and  treatment  severity  his parents)  of  or the  (Rapoff  acceptability  should  as the  its acceptability, integrity,  The  likely  after  (p.221). of  effects  the  of  the  / 22  Experience using a treatment  be assessed both  interim  Literature  while  in  other  treatment  treatment  will  is  likely  and further effectiveness.  a condition  influences  physician feels that the  compliance  condition  & Christopherson, 1982; Cuskey &  that,  if  the  is severe, compliance  Litt, 1980; O l s o n et  al, 1985). This  was severe was associated with high compliance levels. Haynes et  compliance, severity  but  does  estimates  that physician's perception  of  Becker predict  severity  recommendations. condition  to  mixed  appears to the  predicts  This  authors  case of The  acceptability  state  Deaton  by  of the  compliance when  with  et  not  the  demonstrated  of  but  the  perception  correlate  patient's  medications  well  perception that  not  severity  with  physicians'  with of  of  behavioral the  child's  suggested that  severity  Belief M o d e l . al, 1985)  Olson the  that  parent  Health  compliance.  does  (1985)  the  (Yoos, 1981; O l s o n in  severity  parent's  et  al  have  (1985)  state  illness is assumed to  that be  severity  terminal,  only as  in  cystic fibrosis. severity  of  of treatment  school setting. W h e n  a  behavior  programs  teachers and  severe, they are more likely to find demonstrated  (1980)  compliance  perception  results  influence  Maiman  compliance.  is an integral feature  Other leads  and  of  that the  more  that the  found  found  is  (or  by Charney et  al (1979)  who  patient  was demonstrated condition  al (1967)  in  problem designed to parents  has  also  modify  perceive  the  been the  behavior of  child's  a proposed treatment  shown  behavior  to  influence  a child in a problem  as  acceptable. This has been  in analogue studies by Frentz and Kelly (1986),  Kazdin (1980),  Martens,  Review of the Literature / 23 Witt, Elliott, and Darveaux (1985)  c. Treatment  and Witt, M o e , Gutkin, and Andrews (1984).  Variables  Features determinants  of  regimen  which  schedule  and  of  the  treatment  regime  compliance  (Dunbar  have  shown  been  complexity  of  the  have  been  called  &  Agras,  1980).  to  effect  compliance  regime,  the  the  most  Components of  type  are  of  the  duration  regime  important treatment  of  therapy,  (medication,  diet,  exercise, etc.), and side effects. Duration treatment has  of  regime  continues,  the  been discussed in  long term treatments Complexity Blackwell (1973) less  likely  frequently  to the  has  poorer  been the  linked level  2.  The  compliance.  compliance (Olson  of  the  adhere  treatment  that patients than  medication  complex  patients  is to  be  is  regimen  also  taking  three  taking  fewer  taken,  is  negatively  the  or more  al,  1985).  This  et  for  which  (Blackwell,  per day are  regularly  will  be  less  it  the  more  taken.  Two  learn  and  effect:  more  and  medications  that  difficult  for  problem are that the  1979),  compliance.  and  the  complex regimen is more disruptive to the combat this  to  medicaitons,  The more  possible  the  related  and  wherever  longer  chronic conditions  remember,  Recommendations to  The  are prescribed.  reports  more  of  poor  a previous section dealing with  factors could be operating to create this 1.  to  should  be  patient  patient's  regimen tailored  to  daily  routine.  should be to  fit  the  simplified individual  (Becker & Maiman, 1980; Dunbar & Stunkard, 1979; Hingson, 1977). In  their  review  of  behavioral  state: " A s a general rule, treatment  treatment  acceptability,  integrity appears to  Witt  and  Elliott  vary as an inverse  (1985) function  Review of the of  treatment  responsible them are  for  more less  complexity"  (p.  266).  administering  treatment,  acceptable; complex  acceptable  than  simple  They tend  suggest to  that  modify  teachers,  treatments  regimens  require  much  regimens  which  require  Literature / 24  teacher less  and  others  in order time  time  to  and  and  make  skill  skill  and  (Elliott,  Witt, Galvin & Petersen, 1984; Witt & Martens, 1983; Witt, Elliott, & Martens, 1984). A  related  finding  severity  and treatment  in  instance)  this  problem  by  Elliott  complexity,  being  (destroying  rated  et  with the  the  property).  most  Also,  considered most acceptable for the Happe treatments.  (1983)  He  uses  an  problems  moderate  "the  'energy'  plan in  requires  relation  to  the  least costly  plan  will  be  programs, comment other  types  of are  behavioral that  words,  behavior.  much  effective,  --  in  least  treatment complex  metaphor which  require  problems. 'energy' (p.  in  34),  (token  for  the  different  a high  level  an  absolute  sense  suggests  time,  analogous  to  tailoring  was  behavioral  of  time,  skill,  acceptable for severe behavior this  of  severe  (praise)  discuss  interprets  terms  economy,  (daydreaming).  He  and  problem  most  treatment  behavior  to  plans) are more  mild  between  skill,  and  the  that  to  either  too  much  or  consultants  resources  medical  mean  -  regime  should  intervention to  fit  the  lifestyle.  The type regimen  the  problem"  the  patient's  or  too  recommend which  acceptable  "energy"  energy treatment  for  interaction  most complex treatment  suggests that interventions  than  is the  least severe problem  and resources (high  that  al (1984)  regimen drugs  in  Davis  various  modifications,  "prescriptions" adding  prescribed for various conditions varies widely.  a new  (1967)  noted  forms  and  are more behavior that,  (pills,  lifestyle  liquids,  changes.  easily complied is easier than  among  three  injections), Hingson  with than  eliminating  Common  diets,  (1977)  makes  "proscriptions".  a previously  recommendations  exercise  made  to  the In  habitual cardiac  Review of the patients, with.  change  His  reduce  in  personal habits  cognitive  dissonance analysis of  dissonance, an individual  necessitate the  compliance  of  and  (1979)  with  Snow  "lifestyle"  just such a lifestyle dietary  regimens  features  of  restrictive  are  previous  for  have  leads  The  from  various  would with  snacks,  sources. It  influence directions  his  (b)  of  noted  treatment  generally  of  the  long  toward  Side effects are often  &  relationship Agras,  is not  1980),  low  comprising  (Sackett,  side  when  (c)  noncompliance.  Yoos  only  are  (1984)  Diets  5  still  to this  able  to  survey the treatment:  amount  to  to  Blackwell severe,  found  of  side  (d)  of  project  is  report  that  to  be:  intrusive  (a) into  and  by preparing  eat  'unsafe'  characteristics of the  levels  way  he  pressure  the  he  foods  child  normally  the  that  complies  feels to  'cheat'  things.  have a negative impact on compliance, but  10  expect (Cuskey & Litt, %  (1973) play effects  of  the  on  the  an  may  a socially acceptable  reasons other  important  were  though,  be  which  relief.  obtain  peer  for stopping antibiotics treatments  this  this  tend  revision therapy  given by mothers that  "To  enumerates several  complex,  the diet, among other  thought  1979).  they  that  regimens  in  (1979)  compliance.  duration,  as strong as one w o u l d  noncompliance effects,  is  parents, the  on his diet, and his attitude  this  child  is important  his  complied  state  lower  question  compliance. Glanz  administers diet  compliance with  from  to  be  Becker, Maiman, and Kirscht (1977)  poor  Although the child's mother meals and  to  those  family lifestyle, and (e) unlikely to produce dramatic symptom  child's  last  him  comply with  also  are associated with habits,  the  change in his life."  regimens.  notable  compliance  choose to  regimen: a diet.  diets which of  will  least amount  Sackett  such as smoking was  Literature / 25  the  response. (A  patients  hand, role  reason  for their  1980; Dunbar cite  believes  for that  in  influencing  most  frequently  children. She suggests, more  pertinent  study  Review of the would  be to  discontinue  determine  what  proportion  of  the  people who  Literature / 26  experience side  treatment.)  Side  negatively  influence  the  behavioral programs as well. Kazdin (1981, Experiment  2) found  that, as the  of  effects  side effects  described throwing  of  have  shown  a treatment  included  Witt  effects  Side  of  reactions  effects  found  by  Forehand,  1985).  Children who  behavior were present  found  found  treatment  of  on  had to  such  effects  as  crying  or  one  setting  were  been  in  two  appear (1981,  target  child  and  may  be  seen  in  to  inappropriate  to  be  factors  negatively  another  cited  a home-based program  have increased levels of  the  in classroom situations.  may  Davies  risk to  in  context  Witt  eliminate  &  as  Elliott,  oppositional  behavior at school.  improving  in  school,  In  but  their  have  been  subjects'  age,  or vice versa.  Summary  shown which  the  of  children  M c M a h o n and  research, children  There  term  aggressiveness,  that amount other  in  behavior ar h o m e may deteriorate,  d.  and  of  severity  acceptability was reduced. Side  behavioral interventions  treatment Breiner,  acceptability  was administered.  (1983)  acceptability of  to  increased, the  emotional  and Martens  influencing the  the  been  things when treatment  negative  effects  in  are several features  other  studies  determines  that  to  the  influence treatment  and habit changing nature of symptoms:  variations.  and  the  inherent  in  this  research project  compliance. A m o n g must  be  provided  these by  their  which are:  parents:  the regimen: the subtlety and variety of  complexity  of  the  program  in  its  individually  the  long  most  of  prescribed  Review of the  Literature / 27  D. THE HEALTH BELIEF MODEL The the  Health  1950's  having  TB  presently with  and  an  is  valuation  care  (HBM)  explaining and  theory  in  upon  social  concepts,  an  outcome  is  an  individual  taking  much  and  behavior  is  and  expectation  response to health  (Rosenstock, of  the  based (Becker et  psychology  the  in  preventive  "wherein  behaviors  1974),  research  This into  al, 1979). The  behavioral predicted that  concern  theory from  a specific  action  formulated,  preventive  action  to  avoid  2. 3. 4.  the severity of the particular disease, the benefits to be derived from preventing the barriers to preventing the disease, and  5.  some stimulus to  To  extend  illness.  treatment of HBM  to 1. 2. 3.  the  is  Belief  incorporates  the  individual's  will  is concerned with predicting the  his level of personal susceptibility,  was  model  result  in  349).  1.  model  as  Health  a  particular  provoke the  directed theory  at to  the  likelihood  disease  (Rosenstock, 1974) and as such is comprised . of the individual's perceptions  This  such  compliance  and  both  in  Health Belief Model  The H B M , as originally of  developed  certain  which  that o u t c o m e " (Becker et al, 1977, p.  1. Components of the  was  immunizations  recommendations  founded  of  for  Pap smears  important  decision-making  Model  1960's  tests,  health  Model  Belief  threat  of:  disease,  individual to take a preventive action.  explaining explain  an already diagnosed condition,  an  individual's  compliance  with  desire  to  avoid  an  recommendations  to  Becker and Maiman (1975)  revised  the  include general health motivations, the value of illness threat reduction, and the probability that compliant behavior will reduce that threat,  as factors indicating  an individual's  "readiness to  undertake  recommended compliance  Review of the behavior"  (Becker  and  Maiman,  1975,  p.20).  They  identified  Literature / 28  several  modifying  and  enabling factors: 1.  demographic variables,  2. 3. 4. 5.  structural variables of the regime, attitudes including satisfaction with the treatment interaction with the health professional enabling variables such as prior experience and support,  Examining all these factors, of  compliance  Taylor,  with  they  prescribed  program,  regimens  be  possible to  (Becker  it  H B M suggests that, in order  is necessary for  them  and  be willing  to  follow  are  vulnerable  or  susceptible  poses a threat  to  them.  treatment,  will  they  et  al,  predict  1977;  the  Becker  likelihood  et  al,  1978;  the  to  be  the  reduce the  treatment.  illness  Finally, they  patients  concerned  course of to  for  must  likelihood  or  about  to  undertake  health  They must condition  being  treatment  matters  in  general  also believe that  in  question  believe that, by following of  a  and  the  adversely affected  they  that  it  prescribed  by  the  illness  condition. At  factors for  it w o u l d  1979). Thus, the  or  felt  etc.  this  point,  once  readiness  has  been  established, modifying  are called into play. These are the factors  patients  to  have decided to Age influences  follow  the  regimen  that  has  and  enabling  that influence how easy it will  been  suggested  to  them  once  be they  do so.  has  been  compliance,  shown with  to  be  extremes  the of  main age  bio-demographic and  youth  variable  predisposing  which to  less  compliance (Blackwell, 1973; Haynes, Taylor & Sackett, 1979). Level of  education, as it  (Becker,  Drachman  conform  to  &  treatment  Kirscht, regimens.  affects 1972),  understanding will  Reimers et  influence al (1987)  of the  the  regime to  ability  regard  of  good  the  be  followed  patient  understanding  to as  Review of the Literature / 29 prerequisite to compliance in their proposed model for The structural involve  the  variables of  complexity  of  the  the  regimen which  regimen  and  be accommodated in the patient's daily  2. Criticisms of the Controversy the  HBM  article,  in  regarding  exists  an  this  low  to  theory.  explain  doctor-patient change 1978; that HBM  ease  with  which  on  the  compliance regimen  can  routine.  the  compliance.  Their  the  much  theoretical  Indeed,  outlining  the  importance  Dunbar  and  disagreement  disagreement  rests  on  and  clinical  Stunkard, between  Dunbar's  in  the  utility  their two  feeling  that  variables  involving  non-belief  1979 authors  that,  H B M variables and compliance are significant, they variance,  of  items  while  are  too  such  as  relationship and prior experience are more significant, and that attitude  following Dracup  much  regarding  addendum  correlations between  have an impact  Health Belief Model  predicting  include  the  acceptability.  behavior  &  of  Meleis,  Dunbar's  as a theoretical  change is more 1982)  than  argument  framework  is for  prominent  attitudes  predicting  tenable future  in the  while  research (Taylor  behavior.  maintaining  research that  may  Stunkard  the be  need  amended  et  al,  agrees for  the  in  the  process. Stone are  not  (1979)  specified;  comments  that  therefore  it  the  is  functions  not  possible  predictions based on the  H B M , only relative  is  for  increased  (or  higher  one  group  specification  of  and Wallston the  (1984)  relationships  echo  between  to  than  another),  make  the  H B M variables  absolute is "If  likelihood  (Stone, 1979, p.  Stone's (1979) the  relate  predictions. That  increase (or be higher for the appropriate group)." Wallston  which  quantitative  perceived threat of  action  73.)  concern regarding  variables and add  their  will  own  lack  of  concerns  Review of the regarding lack of  consistent operationalization  of  Literature / 30  the variables. They regard the  HBM  as a catalogue of variables rather than a model. Cummings, by  14  upon  models  Becker, and Maile (1980)  of  evaluation  variables  into  framework. health  by  six  multidimensional  health  behavior  expert  broad scaling  characteristics,  of  determinants  the  include of  knowledge  noted,  (1)  about  which  the  of  health  and threat  disease,  to  agreement  accessibility to  symptoms  the  them  Remarkable  was  perceptions (5)  judges.  subjected  groups  "The six factors  care, (3)  and  investigated  and  109 variables described Smallest on  the  authors  cite  behaviors  Space  clustering as into  health care, (2) of  (6)  disease,  Analysis  (4)  supporting a  unified  evaluation social  demographic  of  of  network  characteristics"  (Cummings et al, 1980, p. 138). There  is considerable overlap  the  H B M . 'Evaluation  and  benefits  this  research as all the  due to  of  of  health  care'  treatment. 'Access subjects  between  to  these factors  incorporates health  saw the  elements  and the of  components  belief  in  treatment  care' can be considered a constant  same  doctor  and  cost  was  of  not  a  in  factor  universal medical insurance.  3. Research Using the The  Health Belief Model  Health Belief M o d e l has been tested  in a variety of  contexts to  predict  compliance with many different types of  medical recommendations, among them  studies  regimens. These will be discussed in  involving  children and long term  of their applicability to the present research.  are  terms  Review of the a. HBM  and  Drachman, and  in a random  sample of  Kirscht  125 otitis  (1972)  10 years, were  charge,  return  and  the  requested after  regimen  unannounced assay  of  home  the  measure: (a)  this visit to prescribed.  indicated  40.7%  a  complied  49.1%  knowledge  a  Urine  of  rate.  H B M variables regimen  would  the  child, and to  perceived antibiotic  b. HBM  regimen  (medication  believe that the  mentioned severity  previously,  of  compared  and (b)  knowledge  an  were  a dual drug  of  interviewed  subjects  Results of  with  free  during  antibiotic kept  by  compliance assay  results  the  predictive  and  of  compliance.  appointments)  were  more  Mothers likely  who to  feel that the present illness was a threat  physician was competent  and that the  be to  treatment  things. Charney et  child's  illness  al  (1967)  positively  determined influenced  that  the  compliance  parents' to  an  regimen.  and  Asthma  Asthma treatment Both are long term often  59  appointments  assessed at interview  H B M variables were  be beneficial, among other As  were  mother's  from  the treatment.  were  regimen  Mothers  collected  compliance  care clinic. The  an antibiotic  visit.  Follow-up  and  child  H B M variables and the  fifth day of  concerned about their child's health, to their  follow-up  beliefs  a hospital  placed on  samples were  compliance  at  health  keeping.  general, the with  for  assess the  visits on the  sample. The  and appointment In  to  studied  media cases  children, aged 6 weeks to  of  31  Antibiotics  Becker,  immediately  Literature /  is similar to  treatments  treatment  involving  for  food  fairly complex  allergy  lifestyle  in several respects.  modifications  and are  of uncertain efficacy. The severity of symptoms and episodes ranges from  mild  Review of the Literature / 32 to  severe and  that  asthma  childhood.  is variable  "may (A  treatment  is  serve  possible that  on  within  individuals  and  as  prototype  for  a  difference a  food  between  allergy  over other  food  diet,  time.  Deaton  chronic allergy  children  (1985)  illnesses"  (p.  treatment  often  suggests 3)  and  administer  of  asthma  their  own  treatment!) Becker with  et  regimens  of the  al (1978)  prescribed for  months  attack to  17  during years  asthmatic. A parent self-reported  of  compliance. to  the  does  a  the  asthmatic  month =  interview  prevent  give  period.  The  to  of  this  not  result  in  complete  and to  attacks  in  objective  been  compliance  consisted of  ranged  the  these  in  children)  an 9  diagnosed  as  determine  theophylline  (a  were  performed  on  the  self-report  of  to  correlated  of  111  from  beliefs and  presence of  corroboration  age  previously  assess health  survey reveal that, even in  levels. Significant  remission,  the  associations were  r=.913,  (b)  illness two  threat of  (c) the  a situation  HBM noted  and variables grouped under the  only  had  determine  and subjective)  expected,  their  lending  validity  reports.  results  perceived  and  sample  children  compliance measures were  The  compliance  tests  beliefs  an emergency facility for treatment  years)  asthmatic  to  These two  7.7  to  health  children. The  was conducted  Blood  children  mothers'  5  (mean  compliance.  prescribed to  80%  their  mothers'  117 children who were brought  asthmatic  drug  investigated  variables between  where are  predictive  compliance  topics (a) general health  perceived  benefits  demographic  and  and  (d)  perceived  predisposing  education and marital status) were associated with compliance.  compliance  variables  of  (objective motivations  barriers.  As  (mother's  Review of the c. HBM  and  Diet  The Morse,  Health  Belief  Model  has  and  Guthrie  (1979)  investigated  Sims,  mothers' found  compliance with  the  HBM  bottle feeding mothers,  to  be  generally  associated  with  interpreted  by  inspecting  to  have the  Becker,  but  pediatric  on  nature  responses of  of  is  were  best more  of  and  Kirscht  (1977)  practices  interview. An intervention,  following  'threat' the  outcome  obesity  of  weight  compliance to  measures  are  compliance was a ratio than  form  likely  studied  to  dietary  ranged in age from  was  of  given  a pamphlet to  dietician's  loss diet,  not of  at  each  related  long range (12  appointments.  A  dropout  feeding  of  four  to  rate  of  follow-up  This is  and  health  a clinic dietician to  17 years.  visits  criticism A  was  low  groups  of  hour  or  high  parents  pamphlet. were  of  the  second  clinic appointment 38%  feeding,  (1985).  compliance  selected  be  which  a standardized one  compliance.  month)  can  adhere to.  presenting either  randomly  breast  positively  infant  19 months  and represent a potential  reliably  and  advice  interview:' Control group subjects received no intervention  Measures estimates of  of  in the  feeding  finding  in  182 mothers whose children were referred to  obesity. The children  and  bottle  nutritional  The health beliefs of the mothers were determined through  of  This  to  infants  nutrition and  "adaptive noncompliance" discussed by Deaton  beliefs in a group  levels  breast  not.  physicians'  current  mothers  their  regard  are positively correlated, while  the  consonant with  regimens.  with  It appears that for  knowledge  of  dietary  feeding  concern and importance nutritional  the  been  Maiman  of  in  H B M components  The  knowledge  breast feeding  an instance of the  treatment  the  supported.  nutritional  compliance,  practices which  for  studied  mothers were analyzed differentially.  compliance and  not  been  physicians' recommendations  feeding mothers scores on health  appears  Literature / 33  used  study as  analogue  keeping,  encountered  as  in  of  other the  Review of the course of  the  study but  available on the Indices severity,  supported  the  indices.  the  diet  more  but  Of  demographic  loss, the  not  positively  the  fear  of  weight.  overweight,  diet  although  susceptibility,  and  demographic  and, with  the  being  least  the  variables,  only  exception  of  the  perceived  variables of  strongly  age  keeping. The finding  was  not  expected  the social desirability of  mothers  This  perceived  were  demographics,  associated child  and  of  the  mother's  associated with compliance as measured by success  arousal intervention  children  most  barriers  by appointment the  operating.  barriers  variables  perceived  responding to The  perceived  information  attrition factor  motivations,  model,  successful on  children  health  compliance  the  claim that statistical analyses of the  reveals no differential  benefits,  marital status were the  authors  general  perceived with  HBM  dropouts of  correlated  the  Literature / 34  who  could  this was not  to  seen  as  could  be  due  a positive  high  children  were  to  older  effect  fear arousing  increasing  discussed in the  older  the  weight.  have  received the  be  but  losing  appeared  that the  on  their  on  weight  pamphlet  perceived  losing  severity  of  study.  4. Summary Research components tailored  to  susceptibility the  the  fit  the  allergy  examples  the  model  of  of the  the  therapy  Health to  be  individual  and severity,  generalizability Use  food  of  using  Belief  supported. research  etc. must  has  generally  However,  context.  each  Thus  found  the  component  questions  be changed for each piece of  major  has  of  been  perceived  research, limiting  model across situations.  Health  Belief  Model  was  thought  likely  examined. The  Model  health  beliefs  to to  of  predict be  the  compliance  effective parents  of  levels  based  upon  the  children  in  pediatric  the  research  involved  in  Review of the Literature / 35 this  treatment,  specifically their  perception  of  the  severity  of  their  children's  allergies along with the benefits they believe are to  be derived from  are  the  expected  to  be  expected  are  subjective  perception  their  family  amount  in  are  to  parents.  the  of  and  support  personnel likely  relationships  life  of  associated with  the  study,  facilitate  between  the  the  compliance to compliance  difficulty  cooperation parents and  from  compliance  feel their as  they or from  to  find  in  resistance their  the  the  revision  diet  and  integrating  this  they  in  find  contact  social contacts are  diet  general  in  with  health  treatment,  therapy. the  their  to  child.  doctor, this  motivations  Also  parents'  treatment  the  regard  this  food  into The other  treatment of  the  III. In  order  construct to  to  an instrument  believe w o u l d  allergy.  fulfill  This  chapter reliability  in  study,  pilot  readministration  purposes  which would  influence  establishing a  the  the  of  of the instrument  to  collected from  Chapter  to in  I,  diet  the  or  necessary to  literature  revision  leads us  therapy  the  for  food  instrument  and  of  the  construct  instrument  validation  and  sample prior to final revision.  parents, researchers and the of  was  administration  subtest  the entire  it  developing  through  instrument,  each subject's compliance. The method First, the  taken  validity  the  in  compliance  steps  construct  revision  outlined  assess the factors which  a family's  outlines and  Ratings were  INSTRUMENTATION  physician concerning  collecting these ratings is described.  research sample is described.  A. SAMPLE The who  sample used  responded to  would  investigate  difficulties. physician distractible  the  found  were  this  study  was  drawn  from  among  those  200  parents  a newspaper article describing a proposed research project  (Appendix and  in  relationship I) to  invited  The  first  exhibit to  between  food  forty-eight symptoms  participate.  allergies  subjects of  food  Participating  and  who  learning  were  allergy parents  and  which  behavior  examined  by  the  reported  to  be  permission  for  and granted  psychological and educational testing of the child. All subjects lived within a large from  both  the  doctor's  office  and the  metropolitan university.  lived approximately one and a half to two At months  to  the 11  start years  of 9  the  study,  months.  the  The  area, within commuting There were  hours dirve both children  mean  36  age  ranged of  the  two  distance  exceptions:  they  facilities.  in  age  subjects  from was  6  years  4  9  years  6  Instrumentation months.  All  but  one  subject  were  in  attendance  at  elementary  / 37  schools.  The  exception was receiving tutoring at home. The sample was c o m p o s e d of 33 boys (73%)  and 12 girls  (27%).  B. RATINGS In  addition  to  the  questionnaire  responses, ratings  of  each child's  estimated  compliance level were obtained from three sources: 1.  the child's parent (parental self-report) (SR),  2.  the graduate student or psychologist researcher who worked with the family (RQ), and, the physician who prescribed the diet revision therapy and treated all the subjects (MD).  3.  All parents  ratings  were  were  asked  to  made  on  respond  a scale to  the  with  item  points  below  ranging  as the  from  last  0 to  item  on  10. the  The Diet  Revision Therapy Parent Questionnaire (DRTPQ); (Appendix A):  "If  0  represents  follows  the  diet  'never  follows  exactly,'  how  the well  diet' does  and your  10 child  represents follow  'always  the  diet,  overall?"  The  researchers and the  physician were  given a rating  protocol, presented  in  Appendix B, with the question:  "How  Also points Table  along 3-1.  well has this subject complied with all aspects of this study?"  provided the  on the rating  0 - 1 0  scale.  protocol  Results of  are general descriptions of this  rating  procedure  are  four  anchor  presented  in  Instrumentation / 38 Table  3-1  Means, Standard Deviations and Intercorrelations  of Compliance Ratings  and DRTPQ Scores  Rater  Mean  S.D.  Parent  Researcher  Physician  DRTPQ Total  Parent  7.4  2.4  100  73  66  68  Researcher  5.8  3.1  100  63  63  Physician  6.2  3.5  100  56  Note  1.  The entire range of rating scale points (0 - 10) was used by all three categories of raters. Correlations are presented with decimals omitted and rounded to two places. Correlations with the DRTPQ Total are based upon the final 38-item version of this test which has a mean of 112.11 and a standard deviation of 13.23.  Note 2. Note  3.  The total  Diet  treated  ratings Revision  are  moderately  Therapy  highly  Parent  correlated  Questionnaire  with  one  another  (DRTPQ). The  three  and  with  ratings  the were  as separate variables in subsequent analyses.  C. INITIAL QUESTIONNAIRE The  construction  of  CONSTRUCTION the  test  consisted  previous step. The five steps were: 1.  item  2. 3. 4. 5.  pilot administration and analysis, test revision, administration, analysis and final revision.  generation,  of  five  steps,  each  building  on  the  Instrumentation  / 39  1. Item Generation Items Model  were  written  to  assess  different  components  of  the  Health  Belief  (Becker & Maiman, 1975), as well as other facotrs logically derived from  literature.  The  initial  item  pool  consisted  of  47  statements  drawn  up  to  the  fit  the  following general categories: 1.  Social  Support  Systems - The  extent  to  which  the  parent  has  support  from  family and friends in using this diet. (7 items) 2.  Relevant  Health  Beliefs -  The  regular  health  promoting  beliefs  and  habits  Lifestyle Congruence - The ease with  which  the  can accommodate  of  the family. (5 items) 3.  diet revision therapy within 4.  Belief  in  Treatment  treatment 5.  -  the  their day-to-day life. (7 items)  The  will be effective  family  extent  to  which  the  family  believes  that  the  in helping their child. (8 items)  Perceived Severity - The severity the  parent ascribes to the child's allergies. (2  items) 6.  Optimism,  Ease,  regarding the  and  Committment  outcome  of  the  diet,  the  on the diet, and their opinion as to  The  optimism  the  parents  express  ease they feel in keeping their  child  how successful he or she will be on  it.  (7 items) 7.  Positive Child Attitude  8.  Locus of in their  9.  - The attitude  of the child toward the diet. (7 items)  Control - The degree of control the parents assume over the events lives. (4 items)  Estimate of parents to  Compliance - Items estimate the  child are able to  also included in other subtests which  degree of  maintain. (3  compliance to  items)  the  diet that they  ask the and their  Instrumentation Items  were  knowledgeable  revised  in  test  writing and reviewing (1986, p. 80) were The different  47  the  construction Likert or  of  and/or  the  critiques project  statements  of  items  from  interest. from  persons  Guidelines  for  Crocker and Algina  were  arranged  in  questionnaire  prevent the formation  format  of  with  items  from  a response set. A series  scales were devised because items could be best answered by  describing  grouped under the  frequency,  appropriate  quantity,  agreement,  scale. Twenty-eight  were  negatively  worded.  While  it  positively  and  negatively  worded  items  (Crocker  d o without sacrificing clarity of  is  etc.,  and  items were  nineteen  possible to  received  followed.  Likert-type  responses  basis  agree-disagree format  categories interspersed to  of 4-point a  on  / 40  desirable &  to  the  items  were  positively worded  balance the  Algina,  1986)  number  of  was  not  this  content. The resulting initial  and  form  of  the  questionnaire is presented in Appendix C.  2. Pilot Administration and The meeting the  parents  at  the  children to  researcher  was  difficult from  for  the  1974)  British the  the  of  the  from  questionnaire finding  to  follow  the  with  regard  to  study  Columbia on  diet  in  families  22  of  on  interested  parents  The (Nelson,  been  complete  problems they  twenty-two  University  had  requested  of  Analysis  out diet  the  one at  February  to  six  that  of  17,  They  factors  revision  attended  weeks.  time.  "what  effect  children  make  1987. At These were it  the  on  their  time,  parents  were  easier  Comments  evening  that  told  therapy." diet  an  that or  were  child  the more  invited  and  any  may have been experiencing with the diet revision therapy. completed to  determine  questionnaire the  item  protocols  means  and  were standard  analyzed  using  deviations,  item  LERTAP validity  Instrumentation (point  biserial  correlations  with  subtest  Anova, a measure of  internal  Cronbach's  a composite.)  Table  Alpha for  total  test),  subtest  consistency) and total test reliability The  results  Table  3-2  of  this  reliability (Hoyt's  analysis are  (Hoyt's  Anova and  summarized  in  3-2.  Analysis of  Subtest  1. 2. 3. 4. 5. 6. 7. 8. 9.  and  / 41  Social Support Relevant Health Beliefs Lifestyle Congruence Perceived Severity Optimism, Ease, Commitment Belief in Treatment Positive Child Attitude Locus of Control Estimate of Compliance*  Total Test  Pilot Data by Subtest  N o . of Items  Mean  S.D.  Hoyt's Rel.  7 5 7 2 7 8 7 4 3  19.18 9.41 19.14 5.91 19.41 27.09 19.00 12.00 9.36  2.08 1.62 2.55 1.19 2.72 3.49 3.94 1.07 2.34  .09 .00 .38 .00 .27 .67 .68 .00 .46  2.11 1.57 1.87 .92 2.15 1.86 2.06 1.00 1.40  140.40  9.27  .59**  5.89  50*  S.E.M.  This subtest was c o m p o s e d of three items also included in other subtests. The items ask parents to estimate whether or not their child is complying with the diet. The 47 items, therefore, are counted as 50 items in the total test. The Hoyt's reliability for all 50 items as a single subtest is .59. Cronbach's Alpha for reliability of a composite is .37.  The originally  subtest  internal  consistency  designed was weak.  This  items in each subtest, or to the The individual items were 1. 2.  may  content  figures have  suggest been  and wording  due  that to  of the  the the  subtest small  structure  number  of  items themselves.  inspected with regard to the following  criteria:  at least moderate correlation (> .3) with subtest or total test, moderate degree of distribution over the four scale points.  (That  is,  Instrumentation / 42 responses spread over at least 2 or 3 points and no the respondents choosing one response point), and apparent contribution to content validity.  3.  Twenty form  the  core  Appendix  items  20  subtests  were  subtests  from  parents'  and  treatment  based the  first  families'  (CF), and  are  hereafter  subsequent  were  on  selected to  revised version. These items  three  these  the  grouped  of  version  parents'  summarized  as  then  feelings  substantial improvement to  the  items  responses to  results  of  these criteria and were  remain  are  that 80%  in the test  marked  with  of  and  a (*)  in  C.  These  The  items met  more  the and  most are  about  beliefs  into three  that  diet the  into (PF),  again subjected  in  3—3  below.  'Core  Item  over the  Test',  as  The  to  was  consistency)  relate  to  the  reactions  to  his  their  child  (BT).  LERTAP analysis and  new  used  which  benefit  organization  initial version of it  subtests. The  internal  child's  treatment will  were  in reliability  items the  20 items Table  derived  successful (greatest  divided  the  logically  to  the test; form  the  the  represents it  is  core  a  referred of  the  revisions.  Table Summary of Core  Subtest  3-3  Item Test by  Subtest  S.E.M.  N o . of Items  Mean  S.D.  Hoyt's Rel.  1. Parent and Family (PF) 2. Child Factors (CF) 3. Belief in Treatment (BT)  5 9 6  14.77 23.64 19.77  2.99 5.08 3.37  .70 .75 .75  1.48 2.38 1.53  Total Test  20  58.18  9.16  .84*  3.54  *  Hoyt's  Reliability  =  .84; Cronbach's  Stratified Alpha  =  .68;  Instrumentation Table there  are  3—4  presents the  moderate  correlations  associations among test  is strong.  them  subtests and the  total  which contributes  to the total test variance.  Intercorrelation  the  subtests and  and that the  Each subtest  Table  1. P F 2. C F 3. B T Total  between  correlation  is tapping  unique  / 43  indicates  that  between  the  subject  matter  3-4  Matrix of Core  Item Test  1. P F  2. C F  3. B T  (.70)  .364  .482 .502  (.75)  Total .705 .857 .803 (.68)*  (.75)  Figures in italics represent subtest and total test reliabilities. * Cronbach's Alpha = .68; Hoyt's Reliability = .84.  D. TEST REVISION AND  1. Revision  a.  ADMINISTRATION  Procedure  Subtests  A areas,  and  new  subtest  reflects  structure  further  review  valuable items and subtests from 1.  was of  designed the  using  literature,  a  framework  as  well  the core item version of the  Parent and Family Life Factors (PFL): The attitudes,  revision. (11  the  six  content  retention  of  instrument.  characteristics, and behaviors  of the parents and other family members which will the target child comply with the diet  as  of  affect items)  their  ability to  help  Instrumentation 2.  Child Positive Factors (CPF): The degree to  which the  with  environment  the  diet,  doing so. (11 3.  and  support  from  from  his  which  cooperates  assists  him  in  items)  Medical and Social Support feel  the  personnel  involved with their 4.  has  child himself  / 44  Factors (MSS): The degree in  the  study  child; their faith  Belief  in  Treatment/Benefits  (diet)  is  good  for  their  in the  (BTB): The  children  and  support  other  that  parents the  have  results  the  individuals  medical profession. (5  belief  and  the  of  who  are  items)  that  will  parents  the  be  treatment  beneficial.  (11  items) 5.  Related Health  Beliefs (RHB):  The  regular  health-promoting  that the family engages in which make following beliefs and lifestyle. (5 6.  habits  this diet  and  consonant with  their  their  items)  Perceived Severity and Susceptibility (PSS): The severity with which view  practices  child's condition  and the  likelihood  they  see of  the  parents  a reoccurrence  of  symptoms. (7 items)  b. Items The 20 core items were retained as written in the subtest with  structure  changes,  literature, Maiman  family  fourteen  new  along  structure  of the similar  the  items  original  were  test.  items were  added  after  questionnaire lines  variables  to  were  the  al, 1978; therefore first  asked  as  Morse,  Sims,  further  &  an  Questions  introduction  review  Guthrie,  on to  new  included of  the  populations (Becker,  included a pool of  edition.  Using the  revised and  Health Belief M o d e l tests using pediatric  Kirscht, 1977; Becker et  edition  designed  and  especially the &  second  as a base, sixteen of  pilot  1979;).  The  50 items and was demographic the  and  questionnaire.  Instrumentation / 45 Comments  regarding  estimates were  perceived  results  requested after the  of  the  therapy  and  self-reported  compliance  items were rated.  2. Administration Procedure The  revised  administered to Those  parents  weeks after time.  the  diet  (n  =  Therapy  all children who  15) w h o  attended  first meeting, were  were  determining  Revision  parents of  the  They  Diet  the  told  that  factors which  revision  therapy.  this  Parent participated  meeting  requested to  complete  was  part  of  involved  in  who  the  did  study  (n  clinic when they brought Parents w h o disability  study  They were of  the  or  were  sent  Parent  preparation  for  also  the  informed  asked to  had  their  stopped  call  telephone items  following  were One  from  but  complete  never  parent  It  actually  the  asked  the  the  researcher  diet  1987, seven  project  aimed  families to  other  at  follow  parents,  not  questionnaire. children  the  were  questionnaire  food  allergy and  were  contacted  cooperation  peruse  was decided not on  9,  therapy.  still  in  the  session.  diet  to  revision  was  questionnaire at that  whose  D) requesting their  the  the  that  (DRTPQ)  April  difficult for  children from the  were  at that time.  on  complete the  meeting  diet  continuing  their child for a post-testing  a  who  in this  19) were  They  two  doctor.  =  Questionnaire.  the  with the  attend  a letter (see Appendix  responses t o children  not  had withdrawn who  a  make it easier or more  They  in the  a parent  attending the meeting, would also be asked to Parents  Questionnaire  who to  despite  the  learning by  mail.  and a copy  questionnaire  would  obtain  survey the making  their  parents  initial  was unavailable. Eleven questionnaires were  in  of  contact  completed  manner. Of  an original sample of 48 subjects in the  overall study, data was collected  Instrumentation / 46 from 45, a participation  E. ANALYSIS AND  FINAL REVISION  Responses LERTAP.  The  to  the  LERTAP  order  45  questionnaires  program  subtest configuration. In  rate of 93.75%.  was  set  up  were to  subjected  include  Percent original  items  to  validate  the  subtest  structure  of  this  the  using revised  the  above  20 raters along with a copy of  The protocol for the  agreement, defined as the  placement  correct  raters is included as Appendix E.  of  ratings  the  by  the  number  test  factors  greater  the content  were  retained  to  was  calculated for of  ratings  retained  each item  received. in  the  An  between 50% and 70% was considered for retention to  or  was  raters w h o  agreement contribution  70%  item,  percentage of  of  test.  agreed with  by  dividing  item  with  An  item  a  means  of  investigating  sum  a  percent  with  percent  if it made  of the test. All 20 core items from the provide  the  the  significant  pilot version of  the  stability  of  the  being studied. Items were  test  in  instrument,  agreement  the  analysis  items. The raters were requested to choose the subtest in which they felt each  item best fit.  of  50  item  Item statistics arranged by subtest are presented in Table 3—5.  description of the subtests was given to a panel of the  all  to  results  contribute  (item (mean  correlations (<.3)  also evaluated discrimination), and  standard  in terms and the  deviation).  of  their  amount As  in  relationship  to  subtest  of variance between the  pilot  version,  and total  subjects  items  with  they low  or with a narrow range of responses were deleted.  This evaluation took place concurrently with the percentage agreement analysis procedure.  Instrumentation / 47  Table  3-5  Summary Item Statistics by Subtest: All Items  Subtest  Item N o .  Core  PFL  1 2 6 7 13 15 18 27 33 40 47 (Subtest)  C1 C3 C7  Hoyt's Rel. = 0.73 S.E.M.= 2.43  CPF  Hoyt's Rel. = .89 S.E.M.= 2.09  MSS Hoyt's Rel. = 0.56 SEM=.96  5 8 14 20 22 24 28 29 32 34 36 (Subtest) 3 10 11 12 35 (Subtest)  C40  C6 C8 C13 C19 C20 C14 C25 C30 C27 C32  C31  Mean  S.D.  3.178 3.000 2.311 2.667 3.422 2.200 2.556 2.844 3.200 3.311 2.422 (31.11)  .834 .739 .949 .798 .500 .869 .918 .737 .944 .874 1.138 (4.92)  .394 .626 .390 .680 .296 .301 .483 .283 .132 .234 .450  2.844 2.400 2.778 3.022 2.800 2.422 2.489 2.978 3.044 2.822 2.756 (30.36)  .903 .809 .951 .690 .991 .917 .895 .783 .825 .912 .802 (6.53)  3.867 3.578 3.178 3.778 3.773 (18.13)  .405 .543 .684 .420 .580 (1.62)  r  *  r  *  P.A.*  Decision  .527 .658 .326 .544 .411 .235 .435 .201 .180 .325 .297  95 60 85 85 80 80 75 85 80 85 65  Retain Retain:A Retain Retain Retain Retain Retain Delete:B DeIete:B Retain Retain:C  .668 .683 .518 .744 .604 .634 .695 .416 .653 .838 .265  .782 .640 .295 .573 .691 .638 .521 .150 .433 .734 .247  75 100 85 95 65 95 100 95 95 100 90  Retain Retain Retain Retain Retain: A Retain Retain Retain Retain Retain Retain-.A  .424 .473 .494 .165 .131  .415 .384 .438 .241 .378  95 100 50 65 20  M o v e to M o v e to M o v e to Delete:B M o v e to  ST  TT  BTB BTB BTB PFL  .continued.  Instrumentation / 48  Table 3—5 continued Mean  S.D.  3.222 2.978 2.867 3.578 3.533 3.578 2.867 3.800 3.200 3.44 3.178 (36.24)  876 .965 1.140 .657 .548 .657 1.120 .405 .919 .755 .960 (4.36)  .551 .660 .227 .305 .643 .200 .061 .244 .336 .572 .280  .502 .457 .230 .377 .533 .267 .266 .086 .545 .313 .350  85 95 45 10 35 80 65 35 85 90 70  Retain Retain Delete:E M o v e to PSS M o v e to PSS Delete:B Delete: B Delete: B Retain Retain Retain  16 30 31 45 50 (Subtest)  3.311 3.689 3.689 3.422 2.333 (16.44)  .557 .514 .701 .812 .953 (1.47)  -.266 .120 .040 -.074 -.223  .177 .261 .339 .362 -.292  85 60 85 20 70  Delete:B Delete:B M o v e to PFL M o v e to PFL Delete:D  19 21 23 25 26 44 49 (Subtest)  1.467 2.711 1.733 2.467 3.600 2.600 1.578 (16.16)  .548 1.014 .963 .944 .780 1.176 .866 (3.57)  .138 .437 .470 .437 .343 .203 .383  .200 .234 .146 .455 .371 .068 -.001  15 65 80 90 65 60 70  Delete: B Retain Retain Retain Retain Delete:B Retain  Subtest  Item N o .  Core  BTB  4 9 17 37 38 39 41 42 43 46 48 (Subtest)  C5 C9  Hoyt's Rel.= .69 SEM = 2.44  RHB Hoyt's Rel.= 0.0 SEM = 1.48 PSS Hoyt's Rel.= .63 SEM = 2.02  C38  C44  r  ST  *  r  TT  P. A . *  Decision  Total Test 148.44 14.44 Hoyt Reliability = .85 Cronbach's Alpha = .59 Standard Error of Measurement = 5.48  Decision Comments: A - Core Item; B - Insufficient Discrimination; C - G o o d Discrimination; D - Negative Discrimination; E - Low Percent Agreement. * r<..j. = Item-subtest correlation r ^ = Item-total test correlation P.A. = Percent Agreement  Instrumentation / 49 Seven items were deleted and five were transferred basis  of  percentage  inadequate  (<.3)  they  left  were  agreement  item in  scores.  discrimination.  very  small  of  Related  logical Health  subtests,  analysis Beliefs  and were  of  lost  A  subtests  These items were placed in the basis  Five  further (3  items  three  items  or  item  content.  many  combined with  items  to  less)  were  most and  and  due  moved  a result  of  Social  Benefits and  to  deletions. on  Support  viable  the  because  appropriate  considered  Belief in Treatment  deleted  were  as  Medical be  other subtests on  items  subtest which seemed the  the too  further  to  as  the and  separate  Parent and  Family Life respectively. In 44,  and  all, twelve 50).  The  items resulting  were  deleted  (12,  test  consists  of  Twenty-seven items are positively worded The final item  statistics  describes  the  questionnaire.  38 items were  for  the  resulting  relationship  between  and the  38  items,  combined  into  4  subtests.  and eleven are negatively worded.  subjected tests,  16, 17, 19, 27, 30, 33, 39, 41, 42,  to  item it  analysis. Table  summarizes  subtests  in  the  this  3—6  subtests. final  presents Table  version  of  the 3—7 the  Instrumentation / 50 Table  3-6  Summary Item Statistics by Subtest: Final Version  Subtest  Item N o .  Core  PFL  1 2 6 7 13 15 18 31 35 40 45 47 (Subtest)  C1 C3 C7  Hoyt's Rel.= .75 SEM = 2.45  CPF  Hoyt's Rel.= .89 SEM = 2.09  BTB Hoyt's Rel.= .75 SEM = 1.77  5 8 14 20 22 24 28 29 32 34 36 (Subtest) 3 4 9 10 11 43 46 48 (Subtest)  C15  C31 C40  C6 C8 C13 C19 C20 C14 C25 C30 C27 C32  C5 C9  C44  Mean  S.D.  r  3.178 3.000 2.311 2.667 3.422 2.200 2.556 3.689 3.733 3.311 3.422 3.422 (35.91)  .834 .739 .949 .798 .500 .869 .918 .701 .580 .874 .812 1.138 (5.13)  .511 .646 .364 .638 .357 .326 .459 .350 .230 .296 .169 .387  .558 .693 .319 .553 .443 .251 .417 .347 .398 .321 .360 .329  2.844 2.400 2.778 3.022 2.800 2.422 2.489 2.978 3.044 2.822 2.756 (30.36)  .903 .809 .951 .690 .991 .917 .895 .783 .825 .912 .802 (6.53)  .668 .683 .518 .744 .604 .634 .695 416 .653 .838 .265  .798 .681 .300 .587 .697 .672 .531 .145 .437 .763 .268  3.867 3.222 2.978 3.578 3.178 3.200 3.444 3.178 (26.64)  .405 .876 .965 .543 .684 .919 .755 .960 (3.81)  .207 .556 .665 .608 .332 .390 .630 .300  .419 .513 .442 .370 .417 .566 .300 .344  ST  *  r  TT  *  Comments  From RHB From RHB From RHB  From MSS  From MSS From MSS  .continued.  Instrumentation / 51 Table 3—6: continued  Subtest  Item N o .  PSS  21 23 25 26 37 38 49 (Subtest)  Hoyt's Rel.= .66 SEM = 1.82  Core  C35  Mean  S.D.  2.711 1.733 2.467 3.600 3.578 3.533 1.578 (19.20)  1.014 .963 .944 .780 .657 .548 .866 (3.37)  Total 112.11 Hoyt's Reliablility = .87 Cronbach's Alpha = .61 Standard Error of Measurement = 4.66  Tg-j. =  Item-subtest  r^-,.  Item-total test  =  r  *  r -j-j.*  .354 .457 .436 .431 .160 .261 .474  .219 .134 .420 .376 .351 .518 -.028  ST  Comments  13.23  correlation correlation  Table Intercorrelation  3-7  Matrix  of Final Version  Subtests  1.PFL  2.CPF  3. BTB  4.PSS  Total  1.PFL 2.CPF 3. BTB 4.PSS Total  (.75)*  .455  .386 .336  .193 .071 .313 666;  .773 .785 .684 .455  (.89)*  (.75)*  (.87)* (.61)**  Figures in italics represent subtest and total test reliabilities. Hoyt's Reliability Cronbach's Alpha  Instrumentation / 52 F.  SUMMARY The  final  version  subtests  which  survey  revision  therapy.  The  believed  to  an  high reliability (.61) The than  a  four  The  subtests  contains  of  parents  provide  compliance with has high  of  reliable  the  diet  reliability  of  as  twelve  a of  items  result  of  resulted  (.87)  making  in  factors  which  are  scores  range  from  mean  to  be  believed  of  to  (2.28  of  between  compliance  standard  following of  the  four  in  diet  factors and  which  combine and  are into  moderately  increase in reliability, This  items -- made  deviation  of  the  definite  13.23,  between subjects on the  compliance  the  that  test.  standard  deviations  signifies  rather  to  diet  below  the  distribution  revision mean)  are  basis of  therapy.  Total  to  (1.65  is slightly  134  skewed,  it  shape. ratings  of  subjective estimates  between these different types of  members  therapy,  placement of  and  mean); although  questionnaire. The use of three  The  into  participating  measures of  shorter.  of the  112.11  influence  above the  collection  made  available  82  have normal  The  arranged  as a total test,  test  items and changing the  instrument's  appears to  children  a slight  the  in the psychometric properties  deviations  items  revision  evidence of the ability of this test to differentiate  standard  38  as a composite score.  revisions -- deletion improvements  DRTPQ  reactions  which  deletion  decrease  the  the  influence  overall instrument  of  chapter  sample in  estimated perceptions  in  clinical  of  compliance,  practice,  and  the  most  the  commonly  subtests  different raters provides evidence of  the  of  the  relationships  information.  outlines this  compliance levels enabled comparisons  study  which influence compliance to diet  the  use of  the  are differentiated  revision  therapy.  DRTPQ with  to  describe how  respect to  the  the  factors  IV. This chapter food  in  chapter the  outlines  analysis of  ANALYSIS AND  the  use  factors  of  the  which  RESULTS instrument  influence  developed  compliance to  in  the  the  previous  treatment  of  allergy. To  who  study  exemplify  compared dropped ratings  factors  both  on  the  out of  the  good  the  respect to  and  participated  their  of  treatment  compliance  subjects w h o  and  subtests  of  which  responses to  poor the  compliance,  compliance instrument.  are  the  in the  influence  made.  subtest pilot  based o n Analyses  A  was  of  the  of  the  ten  between  carried  the  sample  ratings  were  subjects  who  the  out.  instrument  the core items at both  of  subjective  comparison  scores  testing  members  The  subjective group  are compared  administration  of with  times.  A. CLUSTER ANALYSIS Subjective (RQ),  and  similar  compliance  physician (MD)  patterns  of  ratings  were  ratings.  The  by  parent  (parental  analyzed in  order  Statistical  Package  to  self-report,  form for  groups  the  SR) researcher of  Social  subjects  Sciences  with (SPSS,  1986) Cluster routine was used for this analysis. Clusters The were  program  were  divided the  as many  between group  groups  on  the  basis of  sample first  into  two  the  average linkage  groups, then  as subjects; that is, until there  members. The four  lowest coefficient A  formed  group  solution  was no  between  three, error,  etc. or  groups.  until  there  dissimilarity,  was chosen as it resulted in  the  of error without single member groups.  description of  the  groups  selected through  Table 4 - 1 .  53  this  procedure  is presented  in  Analysis and Results / 54 Table 4 - 1 . Summary of the  Cluster  Differences Between Clusters  n  Mean SR  Mean RQ  Mean MD  Mean DRTPQ  s.d.  Mean Age  A B C D  24 8 10 3  8.8 7.1 6.4 0.3  7.6 6.1 2.6 0.3  8.8 2.0 5.3 0.0  118.2 110.2 105.3 90.3  9.8 14.0 12.0 1.2  115.3 111.1 111.4 122.3  Total  45  7.4 p<.0001  5.8 p<.0001  6.2 p<.0001  112.1 p<.001  13.2  114.2  The also  clusters, chosen on the  illustrated  compliance other  (SR)  three  standard  in  4—1.  fairly  tightly  means  have  are  cluster  deviation  self-report  Figure  above  measures in which  By contrast, the three The  The  three  cluster with  a  of  range the  subjects  8.8  often  of  parental  exception to  6.4,  group  portray  of  This  is  of  D.  The  one  half  typical  of  light.  almost total noncompliance.  dispersed among the  Cluster C, are similar to the  Cluster  approximately  mean.  are  self-reports  themselves in a favorable  members of Cluster D admit to (RQ) are well  compliance ratings,  groups and, with  self-reports.  physician's ratings (MD) also show a wide span among the clusters, with  Cluster  A  is  characterized  by  high  Cluster D is characterized by uniformly Cluster  below  the  total  low ratings given to Cluster B as well as to  slightly  subjective  means  grouped  below  researchers' ratings  the exception of The  and  basis of  below these.  C the  is  distinguished total  Researchers  group made  by  low mean  mean, their  but  Cluster D.  ratings  by  all three  types  of  raters  and  estimates  only  ratings. self-reports researcher  ratings  on  the  and  doctor's  reports basis  which of  fall  regular  markedly telephone  Analysis and Results / 55  Cluster A Cluster B Cluster C Cluster D Total Group:  Compliance Rating  1 0  T B  SR P<.0001  RQ P<.0001 Figure 4-1  Subjective Compliance  Ratings by Cluster  MD P<.0001  X • n A  Analysis and Results / 56 contact  with  and with  the  parents  such frequent  had concealed from  and  at  least two  contact  the  testing  parents  may  sessions with  have  the  subject  revealed problems  child,  that  they  the physician. In some cases, the children told researchers h o w  they acquired and ate unsafe foods. Cluster compliance were  B  members  were  estimated  levels than estimated for  generally those  subjects w h o  them had  by  the  by the  not  doctor  to  researchers or  been to  the  have  much  lower  by self-report,  doctor's  office  for  and some  time. The of  the  total  three  group  ratings  are  fairly  means, as expected; the  than  the  physician's  ratings.  both  the  researchers'  and  The  similar,  with  self-report  researchers' ratings  self-report  physician's  were  having only  ratings  are  significantly  while  the  latter  ratings  two  the  highest  slightly  lower  different  from  did  not  differ  appreciably. The  clusters were  analyzed in  terms  of  their  member's  scores on  subtests and their total DRTPQ scores. Figure 4—2 presents the subtests  earned  by  the  members  of  each  cluster  and  the  mean score on  tested  for  four the  significant  differences with an analysis of variance, using the SPSS:X Breakdown routine. O n two Factors  of the four subtests, Parent and Family Life (PFL), and Child Positive  (CPF),  significant subtest  the  difference or  on  clusters  differ  between  clusters on  Perceived  Severity  significantly  and  the  from  one  another.  Belief in Treatment  Susceptibility  (PSS).  There  and  The  was  no  Benefits (BTB)  clusters  differed  significantly o n the total score (DRTPQ Total). The  lowest  received  the  subtests.  Cluster  scores were  lowest A,  obtained  compliance with  the  ratings, highest  by Cluster D, the and  this  subjective  cluster  members was  compliance  low  ratings,  of  which  on  all  received  also four the  Analysis and Results / 57  Z-Score + 2.0  Cluster Cluster Cluster Cluster  A B C D  X • n A  + 1 .0  0.0  -1 .0  -2.0  PFL  CPF  BTB  PSS  P<.01  P<.0001  ns  ns  Figure 4-2 Standardized DRTPQ Scores, by Cluster  -w-  DRTPQ Total P<.0001  Analysis and Results / 58 highest  mean subtest  scores. Cluster B, characterized by  ratings, appears to  have subtest  CPF which  Cluster C also has  is low.  scores near the low  low  physician's compliance  mean total group  CPF scores as well  score on all  but  as moderately  low  scores on PFL. The subtest. diet,  widest  range  of  mean  scores  earned  by  the  clusters  Low scores on this subtest may indicate that the  and  sneaks  between  different  parents'  and  unsafe  foods.  The  other  subtest  clusters, PFL, is comprised of  families'  attitudes  toward  the  is  on  the CPF  child resists being on  which  discriminates  the  significantly  items which are concerned with  diet  and  the  amount  of  the  change  it  represents in their daily lives. On (p<.003). standard  the  total  DRTPQ  score,  the  difference  Cluster A, as expected, scored above the deviation,  and  Cluster D  standard  deviation  between clusters formed  B. DROPOUT Ten  below  of  the  forty-five  subjects  either  intention  declared  their  significant  Thus,  deviations  one-half  below  the  Cluster C is approximately  the  instrument  differentiated  compliance ratings.  doctor  regularly  stop  the  began  following  also deemed to (an  important  participated in the post testing at the members of  who  the  diet  revision  therapy  months. They were thus classified because they to  already done so. Subjects were  The  mean while  mean.  is  ANALYSIS  after four  the  standard  according to subjects' similarities on the  classified as dropouts  seeing  the  clusters  mean by approximately  scored nearly two  mean. Cluster B scored approximately at the one-half  between  dropout  the  diet  revision  have dropped out  part  of  the  therapy, if they  therapy)  or  were had  or  had  had  quit  had  not  university clinic. group  did  not  differ  from  the  total sample in  Analysis and Results / 59 age or sex, being 70% male and having a mean age of 9 years 6 months. The  parents  administered dropping difficult  the  out to  of  these  ten  questionnaire  varied  but  prepare, or  subjects  either  common not  were  by  mail  themes  effective  in  interviewed  or  of  by  the  telephone.  finding  producing  by  the  diet  symptom  researcher  Reasons too  restrictive,  remission or  improvement,  and having difficulty keeping the child happy on the diet  Two  were  subjects  modified  their  following  child's  diet  a different  treatment  for  food  slightly  a  result  of  their  the  four  as  given  allergy, diet  for too  behavioral  were  and  and  noted.  most  revision  had  therapy  experiences. The expressed  in  performance  of  each  standard  scores,  group  are  on  presented  in  subtests  Figure  4—3  below.  mean score on the total test was 96.9 (s.d. 11.1), significantly mean of the remaining subjects of In discriminate completely  order  to  determine  between and  those  analysis was performed.  subjects who  and  three The  (p<.0001)  ratings, dropouts'  below  the  116.7 (s.d. 9.7).  if  the  who  remained  four  subtests  dropped  out  on  the  diet  of of to  the the  questionnaire diet  some  revision  extent,  would therapy  discriminant  Analysis and Results / 60  Z-Score  + 2.0  Dropouts : • Remaining: n  PFL  CPF  BTB  PSS ns Figure  SR  RQ  MD  4-3  Standardized Test Scores and Ratings by Dropout  Status  -\\-  Total  Analysis and Results / 61 The function  discriminant  which  correctly  sample. The group the  remaining  function  subjects  of  discriminant  classified  means of  coefficients  deviations  analysis based upon  the  this  versus  are  86.7% function  -2.03  designed  independent  to  the of  4 subtests produced a discriminant  the  subjects  applied to  for  the  adjust  variables  and  applied  subtest z-scores were  dropouts.  for  when  the  Standardized  unequal  combine  means  to  form  to  the  .58 for  discriminant and  the  standard following  function:  Y' =  .70  This function  PFL  is to  Since the  .38  CPF  be applied to  +  produced  correlations,  and  low  decided to  perform  resulting function over  the  .52  .30 PSS.  subtest  equation.  negative  variation  analysis using the  proved capable of correctly 4  -  an unexpected  nonsignificant  discriminant  the  BTB  individual's subtest scores expressed as z-scores.  PSS subtest  coefficient,  improvement  +  discriminant  between  groups,  function it  was  first three  subtests only. The  classifying 88.9% of  subjects - a slight  The  revised,  3  subtest  discriminant  function,  Y' =  .68  yielded group By  PFL  +  .40  CPF  +  .44  BTB  means of .55 for the remaining subjects and -1.95 for the  deleting  one  variable  was encountered. Rather, a slight gained by shortening the test is  from  the  analysis,  improvement noteworthy.  no  loss  of  dropouts.  predictive  accuracy  was noted. The increase in  efficiency  Analysis and Results / 62 C. SUBJECTIVE - OBJECTIVE The  compliance  data  collected  four  'objective'  subjective  ratings  degree  of  association between  analysis  was  performed.  between the  two  analysis  provides  variables  within  using the  and  CORRELATIONS  In  these  about  subjects  questionnaire  two  addition  the  to  sets of  is  derived  subtests.  To  from  determine  variables, a canonical  providing  an  estimate  three  of  the  the  correlation relationship  sets of variables and the significance of that relationship, canonical a method each  BMDP6M  set  of  determining  (Kerlinger,  (Dixon,  1983)  the  1979).  program  relative  The  importance  canonical  with  the  three  of  analysis  the  separate  was  subjective  performed  ratings  as  the  not  to  first set of variables and the four subtests as the second set. The  relatively  compromise other  this  subtests  canonical  high  correlations  analysis. Squared multiple  were  sufficiently  analysis; Although  somewhat  higher,  indicating  The squared multiple  significance. was  .32  (10%  significant  (  the  of  sets  of  first of  to  stronger  three  correlations  indicate  squared  were  the  the  multiple  between  enough  were  correlations among  to  felt  each subtest  heterogeneity  relationships low  ratings  for  required the  for  ratings  ratings,  allow the  and all  than  the were  among  analysis to proceed.  correlations are presented in Appendix F.  pairs The  low  the  questionnaire subtests, they t o o  Three  among  canonical  canonical variance).  p<.0001)  and  variable.  The  variates  correlation Only  the  necessary for other  two  were  generated  was  .80  (64%  first  canonical  interpretation canonical  of  of  and  variance);  correlation the  correlations  evaluated  is  the  not  second  considered  relationship were  for  between statistically  significant (p2 = .58; P2 = .86). Results  of  the  first  canonical correlation  are  includes: correlations between the variables and the  presented  in Table 4—2,  which  canonical coefficients; percent  of  Analysis and Results / 63 variance  accounted  applying a cutoff Fidell,  1983, p.  which  was  for  value of 170),  not  PFL,  CPF, and  parental three  correlations  subtests,  with  There one  similarly  weighted.  In the high  <  effect  intercorrelated  very  of  of  the  correlation.  performance  between  in the  In  (Tabachnick &  7 included  relationship  analysis that those would  the  first  .80.  PFL and  set  of  this  Indeed,  likely  is the  to  physician's  in  the  the  analysis  sets.  discriminant  This  is  analysis and  subjects w h o  scored high  on  the  also  high  ratings  on  the  compliance.  Of  the  canonical  receive  estimates  contributed  most  variable  variables.  PSS was not among  that  their  three  the  of  BTB  .96  to  the  and  a  equation,  standardized  significant  squared  multiple  approached  an  acceptable  three  subjective  significant. correlations  standardized  ratings,  of  strongly  CPF demonstrated  ratings  homogeneity  of  be  and  .09) while  is marked  ratings;  canonical  of variable coefficients  variable  the  CPF scores  with  the  significance level (p  only  uncertain  researchers'  coefficient  interpretation  the  among clusters.  correlation  canonical  redundancies; and  explaining  from this  self-report,  a  in  BTB subtests  significant  having  .3 for  subtest's  lack of differentiation is evident  sets;  PSS was the  useful  consistent with that  It  within  as  raw  of  the  canonical scores,  coefficients are  quite  are highly  (.624, .662, and .729). first set of  within-set  variables, the  variance  50%, meaning that there  (78%).  ratings, the  This,  canonical variate  accompanied  by  a  accounts for  redundancy  figure  is a 50% overlap of subtest variance accounted for  by  a of the  ratings' canonical variates, indicates a very potent solution for this set. The  more  correlations  and  moderately standardized  correlated canonical  subtest  scores  coefficients  produce  a set  with  larger  a  of  canonical  range.  standardized coefficients for this set of variables range from .80 for CPF to  -.11  The for  Analysis and Results / 64  Summary of  Table 4 - 2 Canonical Correlation* Analysis  Variables  Variable/Canonical Correlations  Subjective Ratings Self-report Researcher rating Physician's rating  .91 .85 .89  Percent of variance Redundancy  Canonical  40% 26%  Correlation  .80  is restricted  to  the first (and  PSS. The  canonical variates  of  this  set. The  redundancy  of  26% indicates  variation  figure in the  ratings  more  efficient  for  the  canonical variates with their of shared variance between  the  only significant)  set account  for  40% of  that variation  canonical variate.  the on  variation  this  within  this  set accounts  for  set.  Percent of variance and redundancy is  .27 .80 .13 -.11  .66 .96 .47 .04  Percent of variance Redundancy  26% of the  .43 .27 .44  78% 50%  Subtest Scores PFL CPF BTB PSS  *This summary  Standardized Coefficients  first  set  figures of  variables.  canonical correlation sets of variables.  indicate  of  .80  that the  Taken  as  indicates  canonical analysis a that  pair, there  the  first  is  64%  Analysis and Results / 65 D. TEST - RETEST CORRELATIONS Twenty-two phase  of  this  instrument. the  subjects  research.  As there  instrument,  it  and  structure  factor  was  are  20  in  subjects  core  the  pilot  also  items  in  stage  completed  common  analyze the  of  the  the  final  between  responses of  test  construction  version  the  two  of  the  versions  these twenty-two  of  parents  time.  20 core  Family  These  is possible to  to these items over The  participated  items of  (PF), the  maintained  the  test  Child  in  the  are organized into three  Factor  (CF), and  test-retest  analysis  Belief and  in  the  subtests, the Treatment  test  was  Parent  (BT).  This  analyzed  by  subtest. The first administration the  earliest  administration  1987. At that time, core  sample  Three  of  the  9 of  completed  these  the  the  the  the  subjects  standard test-retest took  of  of  core items took  retest  took  second  were  later  administration  this  the  took  interval,  in the  place when  and their  is adapting for  the  over  the  subsequent  to  poorer  in  diet  others.  -- will  the  the  had  the effect  BT (Belief in Treatment)  no  and  been stabilized  extent.  subjects  which is designed to  observe  weeks.  administration  pertinent  responses to the  have changed; for  six  9, the  revision therapy  diets  a large  place within  As parents  child, their responses to the  children's  have influenced the  PF subtest -  the  the  April  There was, therefore,  initial stages of diet  symptoms to  change took  test, and this will  particularly likely that the family  on  retest. The balance of  classified as dropouts.  and they had achieved control of their  of  later  interval. What can be said, though, is that the first  second administration  content  Feb. 17, 1987, and  seven weeks  22 subjects completed the  place when the children were  During  place  place on  to  the  items. It is  measure how well better of  the  in  some  the cases  treatment  on  subtest may change. It is  Analysis and Results / 66 therefore retest  expected that there will  scores.  predictive  Evidence of stability  device,  but  sensitivity of the  group  and  variety  of  however,  high  to  test-retest  to  the  means o n subtest  different  the  of  two  use of  coefficient  the  would  the test  and  instrument  cast  doubt  as a  on  the  that  reliability  two  administrations  of the  core  occasions.  occasions were very similar. Reliability for  the  in  the  diminished  experiences  types  between  changes in the subjects.  questionnaire o n both  Family  both  lends support  relationship  presents the subtest results of the  item version of the  Parent  a very  instrument  Table 4-3  The  be a moderate  the  the  retest  families  showed  a  interval,  had  slight  while  perhaps on  increase,  due  the and  to  diet. the  Overall, range  of  responses widened. The total  test  tested  obtained reliability  and  the  over time  fact  period. Attitudes  The  CF subtest  the  test-retest  scores were  E. DEMOGRAPHIC  VARIABLES  The  demographic  having some influence on the  of  .82  is  expected  changing other  high  (see  Table  4-4).  and  at  different  traits,  rates  The being  during  such as intelligence. stability  of  and behaviors. Lower correlations  for  expected, as these  are  points  factors  to  that  the  are  sensitive  to  review  as  diet.  variables  which  compliance of  are mother's . marital status, mother's the  likely  children's attitudes  change with experience on the  Seven of  as  .65 is g o o d considering the type of attribute  reliability  BT subtests were  three  are  are generally less stable than  perceptions of their  PF and  coefficients  of  that true  this  parents'  test-retest  emerged pediatric  in  the  literature  patients with dietary  regimens  eductional level, and child's age.  45 subjects in this  research lived with their single mothers.  Of  Analysis and Results / 67  Table 4 - 3 Core Test Summary Statistics: Time 1 and Time  Subtest  Characteristic  Time n =  Parent and Family 5 items  Mean s.d. rel. SEM range  14.77 2.99 .70 1.48 6 - 18  15.32 2.28 .48 1.46 8 - 18  Child Factors 9 items  Mean s.d. rel. SEM range  23.64 5.08 .75 2.38 17 - 33  25.23 5.27 .88 1.70 15 - 35  Belief in Treatment 6 items  Mean s.d. rel. SEM range  19.77 3.37 .75 1.53 10-24  20.14 3.48 .88 1.08 12-24  Total 20 items  Mean s.d. rel. SEM range  58.18 9.16 .84 (.68)* 3.54 40 - 71  60.68 9.30 .90 (.72)* 2.83 42 - 75  *  Hoyt's  1 22  2  Time n =  Reliability (Cronbach's Alpha)  Table 4 - 4 Test - Retest Correlations of  Subtest Parent and Family (PF) Child Factors (CF) Belief in Treatment (BT) Total  Core Test  Correlation  Significance  .4029 .8247 .4091 .6516  .063 (ns) .000 .059 (ns) .001  2 22  Analysis and Results / 68 the  seven,  two  (or  28%)  were  treatment  dropouts  as  compared  to  22% of  the  whole sample. Four (or 57%) were in clusters other than Cluster A as compared 47%  of  the  whole  sample.  These  considering the limited size of the Only graduation the  of  as their  the  secondary  not  mothers  in  Twenty-three education  subject recruitment  the  study  of  as the  the  45  and twenty  are  mothers high  -.2963  test,  are  the  the  proportion,  than  high  lack of  at  least  using  school  useful, since  education becomes one  year  making this  of a  post  relatively  a newspaper article  as a  same as the  significant  mean age of  difference  the  other  two  the  total  in mean age for  clusters by less than  the a  11 year olds and a 7 year  support generalizations. negatively with  the coefficients  (BTB), are  correlates  of  member cluster, c o m p o s e d of  Age was correlated of  less  school graduates,  Cluster D which was older than  old, and does not  two-tailed  have  a result  (9 years, 6 months). The only  two  in  technique.  year. This is a three  Although  reported  level at which  The mean age of the dropouts was the  clusters was for  differences  education level, making analysis by this variable not  educated sample. This is probably  population  significant  group.  research indicates grade eight  significant.  well  two  are  to  coefficients  so  low  two  as to  variables  all the  subtests and  most  attain statistical significance at the of  correlation,  lack any which  ranging  practical  were  The correlations are presented in Table 4 — 5 ,  least  from  of  .0346  in  the  ratings.  .05 level with a  significance. (The efficient  the  (MD  rating)  to  two  significant  other  analyses.)  Analysis and Results / 69 Table Correlations of  Subtests and Ratings with Age  Subtest  Correlation  Significance  -.0734 -.1139 -.2863 -.2942 -.2335 -.1164 -.0710 0.0345  PFL CPF BTB PSS Total Self-Report Researcher Physician  F.  4-5  .316 .228 .024 .049 .061 .224 .321 .411  (ns) (ns) (ns) (ns)  SUMMARY In  used to diet  this  chapter,  investigate  revision  levels  and  the  the  Diet  differences  Revision  Therapy  Parent  between  subjects on their  were  compared  clustered  according  on  DRTPQ  their  to  subjective  clusters, as did  other  the  total test  determination  calculation  has  been  ability  to  of  their  compliance  subtest  and  Family  Life  between  the  ratings  scores. The  (PFL) and Child Positive Factors (CPF) subtests discriminated  the  Questionnaire  comply  with  therapy.  Subjects  in  (ns) (ns)  than  of  score. Researcher ratings  cluster  parental  membership,  self-report  which  were  tended  and  more to  have  Parent  significantly  physician's ratings, heavily less  weighted variance  used  in  this  than  the  ratings. Dropouts  scores,  and  membership  a  were  discriminant  in the  Belief  in  while  Perceived  compared  Treatment  dropout and  Severity  with  function group.  Benefits and  remaining of  three  subjects subtests  on was  mean  questionnaire  derived  to  predict  Parent and Family Life, Child Positive Factor, and (BTB)  were  Susceptibility  significantly  (PSS)  yielded  related an  to  dropping  unexpected  out  negative  Analysis and Results / 70 result and was deleted from the  calculation. In this  function,  PFL was more  heavily  weighted than CPF and BTB. A canonical analysis was performed to subjective  ratings  between ratings  the  and  two  and  sets of  subtests.  component  of  the  scores.  variables accounts  On  the  questionaire  determine the  this  equation  analysis, and  for  the  the  The  relationship between  canonical  64% of  the  CPF subtest  PSS  subtest  correlation  of  .80  variance between  the  was  again  the  the  most  added  powerful  little  to  the  relationship. Appendix score,  cluster  function  of  membership,  adapts  overall results a  represent  family  to  a  change  Factors,  routine  to  these factors  Positive  and  Benefits, as  presents  profiles  dropout  for  the  status,  45  subjects,  including  canonical variate  total  scores and  DRTPQ  discriminant  scores. The  ability  C  well  which as  differentiate  comply  in  he  style  with  of  refers or  questions  their  the  strength diet  of  three  revision  factors  therapy.  in  The  influencing subtests  the  which  are: Parent and Family Life, which asseses h o w well a family  which  how  point to  faith  to  she the that  a  about  parents  on  the  and  child's  feels  between subjects w h o  between subjects judged to  eating  methods  normal the  the  treatment  of  level  meal of  compliance  diet;  and  Belief  results  they  expect  is  preparation;  beneficial.  in  and those judged to  be  the  three  continue treatment and those w h o  be compliant  with  Treatment  from  These  Child  in  basis of  detecting the  change  final version of  also has these characteristics.  in the  a  subject's  condition.  questionnaire, it  Since  these  and  therapy subtests  drop out,  and  noncompliant.  The core subtests are relatively stable over time and sensitive enough to useful  daily  items  form  be the  is presumed that the final version  V. SUMMARY This address  chapter  the  summarizes  factors  school-aged  which  child  with  AND  the  development  influence  food  CONCLUSIONS  compliance  allergies.  of with  The  and limitations Results  families of f o o d  The organized Factor, greater.  formed  study  into  traits  be  4  subtests.  Three  Belief  in  Treatment  fourth  to  a  analyze  research are also made,  relate  to  high  is  with  and  clinical  have  Severity  somewhat  consists  Family  subtest  and  practice  lower.  The  38  Child  reliabilities  four  of  of  Life,  Susceptibility  a Cronbach's Alpha reliability  with  Positive  of  (PSS),  subtests  .61. The  items  .75  or  had  a  combined  Hoyt  internal  score over 38 items is .87.  have  moderately  correlations  to  Parent  Benefits  .66  with  concluded that the  combine  and  Perceived  which  Questionnaire  subtests,  subtest, of  subtests  Parent  reflect  an  the  subtests overall  low total  correlations  test  score, not  measure different attribute.  performed less well than the other three total  used  for  parents.  in further  discussed as they  Therapy  consistency of the total  may  instrument  was  therapy  identified.  Revision  a composite  moderately  revision  to  allergic children.  coefficient  The  are  diet  designed  OF INSTRUMENT DEVELOPMENT RESULTS  The  reliability  this  Diet  and  the  of this research are of  A. SUMMARY  use of  instrument  instrument  compliance differences among treated subjects and their Suggestions for the  an  with  corrected  traits,  Perceived  one  but  Severity  another for  overlap.  that the and  71  It  different  Susceptibility  subtests, having lower correlations with  test and with the other subtests.  and  the  Summary and Conclusions / 72 B. SUMMARY  OF ANALYSIS  1. Results of  Analysis  The  Diet  the  original  who  had  Revision Therapy  48 subjects w h o  dropped  experience with for  a  few  out.  the  As the  diet  was of  in  effectively  differentiated  contribute  significantly to the differentiation  regimes  analysis  parents,  on  were  Members  of  their  upon  and  was  and  Belief  in  the  and  on the Total  Treatment  ratings  Four  and  using  as  distinct  raters  B  C  not  by their  to  be  judged  Benefits  and  on  with  in to  is  basis  subjective  A  composed  was  compliance  who which  medical  Therefore, ratings  identified,  with  of  the  noncompliant  by all three  Clusters the  did  not  Perceived  not  participants.  judgment.  were  diet  did  with  clusters  be  the  those  clinical a  subjects  function  compliant  of  subjects'  PSS subtest  by  by then  subjects treatment.  either  raters. The four  Parent and Family Life subtest, the score.  been  45  parents. Cluster D was composed of  be noncompliant  DRTPQ  and  were  the  a patient  by  subjects who were judged to  subtest,  whether  performed  three  had  the  of dropouts from continuing  responses. Cluster  all  reflect  discriminant  but  to  including ten  compared  a  groups,  subjective  physicians.  researcher or physician, but  significantly  formed  two  they  were  questionnaire  Clusters  differed  the  determining  subjects  judged of  in  heavily  researchers,  compared who  practice  depends  cluster  between  subtests  administered  designed to after  dropouts  remained  Current  Three  was  administered  the  was  revision therapy,  questionnaire  it  Responses  treatment.  Questionnaire  began the  therapy,  weeks.  Parent  the three  clusters  Child Positive Factors  differ  significantly  Severity  and  on  the  Susceptibility  subtests. A  canonical correlation was employed to  investigate  the  relationships  between  Summary and Conclusions / 73 subjective  ratings  and  sixty-four  percent  of  questionnaire shared  scores.  variance  The  between  results  were  ratings  significant:  and  there  questionnaire  was  subscales  (IR] = .80). Moderate the  two  (The the  test-retest  administrations  core  items  development  was expected to  20  core  items  the  items  which  moderate  CPF subtest over  an  but  to  and  instrument  was  demonstrated  through  during  test  development  process.  the  remained  in  subjects  was  nonsignificant  showed  interval  a larger  which  the  questionnaire  under  mothers'  marital  correlations degree  of  status  a period of 7 to and  education  were  throughout  treatment, so change  over  diet  change in  time  stability.  encompassed initital  to the maintenance phase of treatement, Age  the  occur. The subtest scores were sensitive enough to  BTB,  .65  the  of  process.) The sample of  indicate  correlated  of  are the  subjects to while  reliability  for  Total  the  PFL and  test  experiences  scores through  10 weeks. not  significantly  related  compliance in this sample.  2. Factors Which Influence Compliance Of  four  subtests developed, three  appear to  measure factors which  influence  compliance.  a. Parent and  Family  Life  The Parent and Family Life (PFL) subtest is comprised of  items such as:  "This diet is harder to prepare than our previous way of "We "I  eating",  can usually control the things that happen in our lives", and  have been able to  appealing meals".  help my child stay on the diet by  preparing  Summary and Conclusions / 74 Health habits, like taking children to from  family  had  the  also  had  and  other  highest a  people  coefficient  in  high  coefficient  PFL  subtest  in  the  who  deal with  the  discriminant  the  dentist the  regularly,  child  function  determination  of  and social support  are  included. This  for  detecting  the  subtest  dropouts;  canonical variate  for  it the  questionnaire. The components variables  of  such  barriers  items to  as support  can  be  compliance,  and  the  related related  to  the  health  Health  beliefs  concordance between  the  Belief  and  diet  and  the  Model enabling  the  family's  lifestyle.  fa. Child  Positive  Factor  The Child Positive Factor (CPF) subtest consists of assessing  whether  or  not  the  subject  is  upset  child  is  items which  cooperative  and  are aimed at  compliant.  Typical  items are: "My  child  that  his  food  is  different  from  his  friends'  food", "My  child monitors  "My  child generally does what he is told".  This subtest  deals with the  his diet,  and appears to  succeed  in  test-retest it  was  the  interval;  important  his own diet  it in  program.  also had the the  day-to-day  have a strong  treatment  highest  at .89.  behavior  of  the  child  relationship with the ability  This  discrimination  internal consistency coefficient  and refuses 'unsafe' f o o d " , and  of  subtest  was  coefficient dropouts.  the  most  in the Also,  as it of  relates  to  the family  to  over  the  canonical function,  and  this  stable  subtest  had  highest  Summary and Conclusions / 75 c.  Belief  in  The  Treatment  and  Benefits  Belief in Treatment  and Benefits (BTB) subtest taps the  have in the medical profession and their belief that the treatment "I  try to d o what  "This diet will Controlling  faith the will  my doctors tell me to do no matter  help my child behave and pay attention  food  allergies  will  significantly  reduce  parents  be beneficial:  what," better,"  the  and  number  of  colds my child gets." This subtest  contributed  the  discrimination  among the  clusters. This subtest was also fairly sensitive to  condition  It  over  Treatment,  Perceived  The Health  the  while  the benefits of  d.  is  course  parents  who  saw  would  did  not  not  significant  in  improve  differentiating  change over the  improvement  increase  their  in  scores  would  cease  course  their on to  child's  Belief  in  believe  in  Susceptibility  and  Susceptibility (PSS) subtest  PSS is considered a cornerstone  my  was  requirement  derived  from  the  in the  motivation  child  eats  something  child is more susceptible to  is, who  he  shouldn't,  his  symptoms  are  and  subtest  problems, were  child  was  weighted  take health action. Sample items from this subtest are:  severe," "My  parents  treatment  whose  Perceived Severity  "When  that  of  and  Belief M o d e l .  This  that  it  and was  diet revision therapy.  Severity  of a person to  test,  logical  but  dropouts,  in  treatment.  canonical correlation,  of  significantly  of  the  to  provided  surprising  saw their  children  more  likely to  drop  illness than other  results. as  out  more  People  with  susceptible  of treatment.  children." higher  and  scores  with  more  on  this  severe  Similarly, a negative canonical  Summary and Conclusions / 76 coefficient linked  was observed: higher  with  significantly  lower  of  is  criticism that  of  the  research context  the  components  the  Like  on the  Health  and may not  may have prevented  perceptions of severity and susceptibility  compliance.  among clusters formed  One derived  ratings  parents'  this  subtest  basis of subjective  Belief  must  BTB,  Model  be  from  generalize due to  this  defined  difficulties  not  differ  ratings.  which  operationally  did  are  construct anew  was  for  each  in operationalization. This  Perceived Severity and Susceptibility subtest from  performing  better. Another be a  possible explanation  that parents who home-based  to  be  effective.  Elliott's  (1987)  consider  thought  about  subtests  analyzed actually  There  is  as  of  some  diet  new  problems  revision  shots and  evidence  behavioral  treatments  PSS subtest's equivocal performance  treatment  for  mild  treatments  when  after  with  to its ambiguity a  having  increased  from  Hoyt's  to  a  of the  It  .66. test  PSS subtest be administered and interpreted  in  were  reliability  that  technical enough  VonBrock were  not  and  willing  to  open  to  can  be  as  severe.  This  treatment.  PSS is also the  When  is therefore  were  a  be strong  teachers  but  problems  not  may  believe  than  finding  acceptability:  the  =  rather  similar  problems  PSS, total .88.  therapy  interpretation,  coefficient  deleted .87  of  as serious may  pills, could  of  of as a problem with the face validity In addition  the  such  the  children's  perhaps including  study  different  information  perceive their  treatment  medical intervention,  for  the was  suggested  separately from  full  least reliable  questionnaire  not  diminished  that,  the other  in  practice, subtests.  of was  --  it the  Summary and Conclusions / 77 C. RECOMMENDATIONS The limitations  main  recommendations  in the present  The most the  same  should  be  both  predicting  the  canonical correlation  A  self-report  instrument  between  which  the  compliance  combination  of  an  largely  out  of  two  the present study  development  and  is the  validation  use of  analysis.  sample. The discriminant  The  function  sample as should  subtest scores and subjective ratings. With a larger  was  the  might  lack  instrument criteria,  have been delineated  absence  arise  should be tested on such an independent  limitation  used  research  in the design of  sample, the subtest structure  against  commonly  this  dropouts  further  compliance  further  cross-validated using another  for  independent  element  for  for  study.  limiting  sample  instrument  the  FOR FURTHER RESEARCH  and  be validated using factor analysis.  of  a  can  be  concrete validated.  arguments  against  in Chapter Two. The fact  objective  criterion  for  objective  criterion  for  ratings  are  Subjective clinical  judgment  and  remains, however, that  compliance  with  this  in  treatment,  a  of  subjective  criteria provides a reasonable sustitute. A n improvement  in  composite  subjective  criterion  to  the combination, and that might A  separate  concepts  derived  Adaptations parent children  of  training,  the  might  this DRTPQ  diet for  be written and validated.  or  for  futher  therapy other  classroom interventions,  such as diabetic  component  be a self-rating by the subject child.  recommendation in  be made by adding another  research  research  treatments  context  involves into  — behavioral  counselling, etc.  and  obesity diets, asthma treatment  extending other  programs  the  contexts. such  medical  programs  regimens,  etc. -  as with  could  Summary and Conclusions / 78 D. SUGGESTIONS The  FOR USE AND  38-item  CLINICAL INTERPRETATION  4-subtest  version  of  Questionnaire should be administered to therapy allow  early for  in  the  brief  intervention  course  of  experience  with  the  of the  diet  is becoming stabilized and the  This  point  in the treatment  is not  rewarding. The  toward  family's  with  problems  intervention Family  lifestyle,  including  early  enough  meal  be  to  timed  to  provide  for  out.  should take place when  the  phase of  is entered.  maintenance  for  that  this  the  treatment  patients  in their condition  who  child's  may find  that,  are experienced, continued  diet  is a lifelong  requirement  and resistance may be provoked in some subjects. in reducing symptoms, may actually dispose the  in  different  subtests, require individually tailored  and  but  should  noncompliance.  Families  An  Revision  administration  instrument  realization  Thus, the success of the treatment,  Parent  revision  is likely be a problem  will be encountered at this point  different  parents of children involved in diet  diet,  since no further dramatic improvements  patient  Parent  This  Diet  before a family becomes discouraged and drops  A further administration  compliance  Therapy  treatment.  the  program  Life  subtest  providing plans),  to  and  a  help  would  evidenced  intervention family  focus  training  providing  a  areas,  on  program support  demonstrating  in  low  scores  on  programs.  tailoring  and  by  the  deficiency regime  administering  the  encouragement  to  diet  to  the  on  the  fit  the  (possibly parent  in  less structured ways. The important intervention  nature part are  in  of  the  patient,  determining  strong.  If  the  the the  child  allergic child in this success is  resisting  of  the the  instance, clearly plays an  treatment.  diet,  resulting  Implications in  a low  for Child  Positive Factor score, the parents may need assistance in winning the cooperation  of  Summary and Conclusions / 79 the  child. Parenting classes, family counselling, or  assistance with simple  management  techniques are indicated by relatively low scores on this subtest. An  educational  consequences they  of  can expect  program  untreated from  designed to  food  allergies  compliance to  increase the and  the  of  the  parents' wide  awareness of  ranging  treatment  is an indicated  failed  discriminate  the  improvements intervention  for  families with low BTB scores. It  is  possible  'educational parents'  function'  belief  in  that  this  had  already  treatment  subtest  was  been  to  accomplished  insufficiently  strong  for  even  these  motivation  though  subjects.  to  the Some  overcome  the  barriers they encountered in family lifestyle or in gaining their child's cooperation. The PSS subtest and low  is best dealt with  scores have been linked to  between the A  physician and  guide  for  in an individual  manner,  noncompliance. This topic  since both  high  should be discussed  patient.  administering  and  scoring  the  Diet  Revision  Therapy  which  influence  Questionnaire is presented in Appendix H.  E.  CONCLUSION This  compliance parents'  study to  diet  and  derived from By  that  the of  there  for  food  intrusiveness the  are  of  child, and  several  factors  allergic children. A m o n g them the  the  treatment  parents'  into  belief  in  their the  family  are  the  life,  the  benefits  to  be  treatment.  measuring  Questionnaire to  of  behavior the  shown  revision therapy  perceptions  attitudes  likely  has  these  developed  experience  in  difficulty  variables this  study,  following  with it the  is  the  Diet  possible to diet  therapy  Revision predict and to  Therapy  which provide  Parent  patients  are  appropriate  Summary and Conclusions / 80 intervention and support for them. The use  both  DRTPQ  has been shown to  early in treatment  and in the  possess  sufficient  reliabililty  maintenance phase of  diet  and validity  for  revision therapy  to enable such identification of potential problems. 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(1978).  regimen  Rapoff,  for  M.A.  (Eds.),  Drachman,  mothers'  R.H.  Schuberth,  compliance  with  a  children. Journal of Asthma Research, 15(3),  A  Adherence,  I.M.,  influencing  Christopherson,  regimens:  79-124).  Rosenstock,  Factors  asthmatic  &  medical  Reimers,  M.H.,  E.R. (1982).  review  and  Compliance  Compliance  evaluation.  and  In  in  Generalization  in  &  medication  133-149.  pediatric  R.B. Stuart  K.C.,  patients  and  P.O.  Behavioral  with  Davidson  Medicine  (pp.  New York: Brunner/Mazel.  T.M.,  Wacker,  interventions:  A  D.P.,  &  review  Koeppl,  of  the  G.  (1987).  literature.  Acceptability  School  of  Psychology  behavioral  Review,  16,  212-227.  Rosenstock,  I.M.  (1974).  Historical  origins  of  the  health  belief  model.  Health  Education Monographs, 2, 328-335.  SPSS Inc. (1986) SPSS:X user's guide (2nd ed.)  Sackett,  D.L.  and  (1979).  D.L.  Methods  Sackett  Johns Hopkins  for  (Eds.),  University  compliance  Compliance  in  Haynes,  (pp.  11-22).  Shapiro,  E.S.  increasing  &  D.W.  Health  Care  Taylor,  &  D.L.  of  Sackett  (Eds.),  University  Goldberg,  comparison  R.  (1986).  performance  546-557.  R.B. Haynes, D.W. (pp.  compliance  Baltimore: Johns Hopkins  spelling  Review, 15„  research. In  323-333).  Taylor,  Baltimore:  Press.  Sackett, D. & Snow, J. (1979). The magnitude R.B.  N e w York: McGraw-Hill.  A in  sixth  grade  and  noncompliance.  Compliance  in  Health  In  Care  Press.  of  group  students.  contingencies School  for  Psychology  / 88 Stone,  G . C . (1979).  Psychology and the  N. E. Adler (Eds.) Health  Tabachnick, &  Taylor,  system. In G . C . Stone, F. C o h e n ,  Psychology: A Handbook.  B.C. & Fidell, L. S. (1983).  &  San Francisco: Jossey-Bass.  Using multivariate  statistics. N e w York:  Harper  Row.  D.  W.  (1979).  Haynes,  D.W.  A  test  Taylor,  of  S.  (1978).  VonBrock,  M.B.,  &  information  of  Sackett,  model  (Eds.)  in  hypertension.  Compliance  in  with  In  R.B.  Health  Care.  Press.  antihypertensive  drug  therapy.  Annals  Roberts, of  the  Science, 304,, 390-403.  Elliott, the  D.L.  belief  Haynes, R. B., Johnson, A.L., Gibson, E.S., &  Compliance  New York Academy of  health  University  D. W . , Sackett, D.L., R.  the  and  Baltimore: Johns Hopkins  Taylor,  health  S.N.  (1987).  acceptability  of  Influence  classroom  of  treatment  interventions.  effectiveness  Journal  of  School  Social  support  Psychology, 25, 131-144.  Wallston,  B.S., Alagna,  S.W.,  and physical health.  Wallston,  B.S.  Health  &  Wallston,  An  examination  (Eds.)  Handbook  behavior: Singer,  DeVellis, B.M., &  DeVellis,  R.F. (1983).  Psychology, 2,(4), 367-392.  K.A. and of  (1984).  Social  integration. Psychology  psychological In  A.  and  Baum,  Health  models  of  S.E. Taylor, (Vol.  4,  health and J.E.  pp.  23-53).  M.D.  (1983).  patients.  Health  Hillsdale, N.J.: Lawrence Erlbaum Associates.  Witenberg,  S.H.. Blanchard,  Evaluation  of  E.B., M c C o y ,  compliance  in  C,  home  Suls,  and  J., &  center  McColdrick,  hemodialysis  Psychology, 2;3, 227-237.  Witt,  J.C.  (1986).  Teachers'  resistance  to  the  Journal of School Psychology, 24, 37-44.  use  of  school-based  interventions.  / 89 Witt, J.C. & T.  R.  Elliott,  S.N. (1985).  Kratochwill  (Ed.)  Acceptability  Advances  in  of  classroom management  School  Psychology  (Vol.  strategies.  4,  pp.  In  251-288)  Hillsdale, N.J.: Lawrence Erlbaum Associates.  Witt,  J . C , Elliott, of  the  acceptability  problem  Witt,  J.C.  S.N., &  &  Martens,  J.C, Moe, same  of  C,  interventions:  intervention.  (1983)  Cutkin, T.B., &  in  (1978).  applied  Factors affecting Time  Assessing  different  Social  behavior  Andrews,  ways:  The  Journal of  validity:  analysis  is  The  teachers'  the  L.  behavior  15, 204-207.  acceptability  of  behavioral  Schools, 20, 510-517.  (1984).  problem  judgments  involvement,  Behaviour Therapy,  used in classrooms. Psychology in the  thing  M.M.  of  B.K.  school-based consultation.  Wolf,  B.K. (1984).  behavioral  severity, and type  interventions  Witt,  Martens.  The  of  effect  language  of  saying  the  and  jargon  in  School Psychology, 22, 361-367.  case  finding  its  for  subjective  heart.  Journal  measurement of  Applied  or  how  Behaviour  Analysis, 11, 203-214.  Yeaton,  W.H.  &  maintenance  Sechrest, of  L.  (1981).  successful  Critical  treatments:  dimensions  Strength,  Journal of Consulting and Clinical Psychology, 49,  Yoos,  L.  (1981)  Practitioner,  Yoos,  L.  (1984).  Compliance:  Philosophical  and  in  the  integrity,  and  choice  and  effectiveness.  156-167.  ethical  complications.  The  Nurse  6,(5), 27-30.  Factors  influencing  Pediatric Nursing, 10, 141-147.  maternal  compliance  to  antibiotic  regimens.  APPENDIX A: DIET REVISION  THERAPY  PARENT  90  QUESTIONNAIRE  91 APPENDIX A DIET REVISION THERAPY  PARENT QUESTIONNAIRE  Child's Name  Birthdate  Name of person completing questionnaire Relationship to  child  Diet started Please list the  people living in your  Name  home.  Age  Relationship to  Mother's occupation Education:  Less than high school grad High school graduate Years of post secondary education Degrees  yrs  What hours are worked?  Father's occupation Education:  Less than high school grad High school graduate Years of post secondary education Degrees  What hours are worked? Where does your child eat lunch? Where is the  child cared for after school?  W h o supervises him/her there?  yrs  child  92 Who  does the family food shopping?  Who  prepares the family meals? Breakfast? Lunch? Dinner? Snacks?  Please answer all the following corresponds to your answer.  To the following series of this true for you?"  questions,  Not at all 0 1.  2.  3.  4.  5.  6.  7.  8.  please  Just a Little 1  O u r whole 0 I have meals. 0  questions. Below each item, circle the  family is supportive 1  been  able  to  help  answer  the  question,  number  "How  Pretty Much  child  1  3  stay on  the  diet  by  preparing  2  appealing 3  The people involved in the study have been pleasant and friendly. 0 1 2  3  M y child has been better since we started this 0 1 2  3  I believe that my we have noticed. 0  child  This diet is harder to 0 O u r family 0  will  stick  1  with  this  diet  treatment.  to  maintain  the  2  adapting to this new way of 2  M y child objects to being on this 0 1  diet. 2  improvement 3  prepare than our previous way of eating. 1 2  is having difficulty 1  is  diet. 2  my  much  Very Much 3  2 of this  which  3  eating. 3  3  93  Not at all 0 9.  Just a Little 1  Pretty Much 2  This diet will help my child behave and pay attention 0 1 2  10.  The people we've dealt with in this study 0 1  11.  I try to 0  d o what  my doctors tell 1  12.  The reasoning behind the 0  13.  O n c e I've 0  14.  15.  Very Much 3  me to 2  to  d o , no matter  has been made clear to me. 3  go off 2  his  "safe" foods o n restaurant menus. 1 2  3  Even before we started this diet, I suspected a connection my child eats and his behaviour and symptoms. 0 1 2  21.  22.  Other members of our family 0 1 M y child's food I need to do. 0  about  bed early enough to get a complete rest. 2 3  are following 2  the  allergies and allergic reactions 1  M y child understands the 0 I worry 0  3  3  17.  20.  it.  diet.  I make sure my children go to 0 1  19.  competent. 3  3  16.  18.  and  what.  d o something, I usually do 2  M y child's friends encourage him to 0 1 I can find 0  3  have been efficient 2  diet revision therapy 1 2  made up my mind 1  better.  benefit 1  my child's health. 1  M y child has probably 0  been off 1  the  food  3  diet. 3 keep me from  2  doing the 3  of this new way of 2  eating.  2 the core diet  between  3  3 this 2  week. 3  things  94  Not at all 0 23.  24.  25.  26.  Just a Little 1  28.  29.  30.  31.  32.  33.  34.  illness than other children. 2  M y child is upset that his food is different 0 1 2  from  Sometimes Little 1  3  M y child monitors 0  his own 1  . 3  question " H o w often  2 treats. 2  3  he is told. 2  I am conscious of the nutritional 0 1  my children to the  3  3  value of different 2  1  is this true in  Always or Nearly Always 3  diet and refuses "unsafe" f o o d . 2  M y child generally does what 0 1  I am used to taking year. 0  2  Often or Usually  W e like to reward ourselves with food 0 * 1  food.  his symptoms are severe.  Food allergy can be a serious health problem. 0 1  statements, please answer the  his friend's  3  3  When my child eats something he shouldn't, 0 1 2  Never or Seldom 0  Very Much 3  2  M y child is more susceptible to 0 1  To the following your family?"  27.  Pretty Much  dentist  for  2  foods. 3 regular check-ups twice 3  M y child probably sneaks "unsafe" foods. 0 1 2  3  W e like to eat in restaurants at least once a week. 0 1 2  3  M y child resists staying on the 0 1  3  diet. 2  a  95  To the following  statements,  please answer the  None 0 35.  36.  Few 1  I have informed 0  Some  39.  M y child has found 0  some treats within his 1 2  Slightly Disagree 1  Food allergy difficulties. 0 Diet  may  be  at  the  revision can help  but  not 1  W e can usually control 0  diet. 3  question  "How  much  do  W h e n I first heard about the recognized my child. 0 1 This is a healthy diet 0 M y child's f o o d athletic activities. 0 If you wait 0  root  probably 1  and  of  my  child's  learning  and  1  behaviour 3  cure f o o d 2  allergies. 3  that happen in our lives. 2  3  improve even if his allergies are not 2 symptom  pattern  attributed  to  food  2  allergic  agree  3  and my child is getting 1 2  allergies  you  Definitely Agree 3  2  the things 1  42.  45.  3  2  M y child's health will 0  44.  diet.  Slightly Agree  1  41.  43.  this  Food allergies are a lifelong problem. 0 1 2  0 40.  Many 3  others w h o deal with my child about 1 2  Definitely Disagree 0  38.  " H o w many?"  2  To the following statements, please answer the or disagree with these statements?"  37.  question  allergy,  I  3  everything  reactions  controlled. 3  he needs. 3  interfere  with  his  social  2  3  long enough, children will get over most any illness. 1 2  3  and  96  Definitely Disagree 0 46.  47.  48.  49.  50.  Slightly Disagree 1  This diet will improve 0  Slightly Agree 2  Definitely Agree 3  my child's academic performance. 1 2  3  If we cheat once, it is difficult to 0 1 Controlling child gets. 0  food  allergies  will  get  back on the 2  significantly  1  My child generally enjoys g o o d 0 1  reduce  diet. 3 the  number  of  colds  2  3  health. 2  3  I usually take my child to the doctor at the 0 1 2  first sign of  my  any illness. 3  COMMENTS We're interested in hearing how you and your child are doing been on the diet for some time. have you  noticed  in  your  child  1.  What changes therapy?  2.  Have his/her teachers made any relatives? What have they noticed?  3.  H o w was his/her recent  4.  Have there been any other changes in the way your child has been treated, at home or at school? For example, have you used different parenting strategies, special help at school, tutoring, etc. Please explain.  comments?  report card compared to  since you  now that he/she has  What  began  about  diet  revision  neighbours  and  previous resports?  97 5.  Sometimes parents can't bring their child back to the clinic or doctor's office for the next appointment. What are some of the things that might make you miss an appointment?  6.  Have you ever gone on a diet for some health or fitness reason?  H o w successful do you feel you were?  7.  Do you know any other  people outside this study w h o  have food allergies?  Have you discussed your experiences on this diet with them?  If so, h o w  8.  helpful do you feel this was?  Do you ever have trouble  What d o you do to  9.  keeping your  deal with this?  H o w much of the time does your child follow Less than Half  10.  0  child on the diet?  Half  the diet? Most  All  If 0 represents "never follows the diet" and 10 represents "always follows diet exactly," how well does your child follow the diet, overall?  1  2  3  4  5  6  7  8  9  the  10  Thank you for your cooperation.  If you have any further comments, please feel free to  use the rest of this page.  APPENDIX B: RESEARCHER  QUESTIONNAIRE  98  99 APPENDIX B RESEARCHER QUESTIONNAIRE POST TEST RATING Please rate the subjects named below on the  II  SCALE  following  0 to  10 point rating  scale.  " H o w well has this subject complied with all aspects of this study?"  0  Very poor try.  compliance: never follows  3  Fairly poor compliance: frequently involved any more.  7  Fairly g o o d compliance: only occasional or minor deviations from the probably continue to some extent.  10  Very g o o d compliance: always follows the diet exactly, under g o o d control, still very involved, has incorporated this way of eating into their lifestyle.  All statements on what is required.  each rating  point  off  need  the  diet,  diet,  not  dropped  stuck to  be  true.  it  out  for  Your  early, didn't  a while,  general  not  diet,  really  really  will  impression is  Please make your rating immediately after your post testing session with each family and deposit the rating slip in my folder in the clinic. Thank you very much for your help. Liz  POST TEST RATING  CHILD'S  NAME  SCALE  RESEARCHER  DATE Very p o o r Compliance 0  1  Very g o o d Compliance 2  3  4  5  6  7  8  9  10  APPENDIX C: INITIAL VERSION: DIET REVISION  THERAPY PARENT QUESTIONNAIRE  100  101 APPENDIX C INITIAL VERSION: DIET REVISION THERAPY PARENT QUESTIONNAIRE  Name Child  Please mark.  answer all questions.  Beside  each item  To the following group of questions, please answer the question, " H o w m u c h j s this true for you?" 1.*  Our whole family is supportive diet.  2.  This diet is a major change of for us.  3.*  I have been able to help my child stay on the diet by preparing appealing meals.  4.  The people involved in the study have been pleasant and friendly.  5.*  M y child has been better since we started the treatment.  6.*  I believe that my child will stick with this diet long enough for improvement to be apparent.  7*  This diet is harder to prepare than previous way of eating.  8.*  M y child objects to diet.  being on  of  this  lifestyle  our  this  9.* This diet will help my child behave and pay attention better. 10.  I understand the reasoning behind diet revision therapy.  the  indicate  (0) Not at All  your  response with  (1) Just a Little  (2) Pretty Much  a check  (3) Very Much  102  (0) Not at All 11. O n c e I've made up my mind to something, I usually do it.  do  12. I, or someone close to me, has had a successful experience with a diet. 13.* My child's friends encourage him go off his diet.  to  14.* My child is upset that his f o o d is different from his friend's f o o d . 15.  I can find "safe" foods on menus.  restaurant  16. Exercising is a regular routine family.  in our  17. I have suspected a connection between food and my child's behaviour and symptoms. 18.  I'm paying more for food since my child started on this diet.  19.* My child understands the this new way of eating.  benefit  20.* My child has probably been off core diet this week.  of  the  21. W h e n your child eats something he shouldn't, his symptoms are severe. 22.  Food allergy is a serious health problem.  (1) Just a Little  (2) Pretty Much  (3) Very Much  103  To the following statements, please answer the question, " H o w often is this true in your family?"  23. W e like to treats.  reward ourselves with  24. W e like to week.  eat out at least once a  25.* M y child generally does what told.  (0) (2) (3) (1) Never or Sometimes Often or Always oi Seldom Nearly Usually Always  food  he is  26. I am conscious of the nutritional of different foods. 27.* M y child resists staying on the  value  diet.  28. I am used to giving vitamins and/or flouride to my children daily. 29. I find  it difficult to  keep  appointments.  30.* M y child probably sneaks "unsafe" foods. To the following group of statements, please answer the question, " H o w many?" 31.* I have informed others w h o deal with my child about this diet. 32.* M y child has found some treats within the core diet. 33. I know other  people on allergy diets.  (0) None  (1) Few  (2) Some  (3) Many  104  To the following group of statements, please answer the question, " H o w much do you agree or disagree with these statements?" 34. Kids usually outgrow  food  allergies.  35.* Food allergy may be at the root of my child's learning and behaviour difficulties. 36. It is possible to term.  live on this diet  37. M y friends think I'm to try this. 38. Just a little bit won't hurt.  of  wasting my  an "unsafe"  39. Eating (snacking) is socially for kids. 40.* W e can usually control happen in our lives.  long  time  food  important  the things  that  4 1 . * W h e n I first heard about the symptom pattern attributed to food allergy, I recognized my child. 42. This is a healthy diet and my child is getting everything he needs. 43. Changing habits is very difficult. 44.* This diet will improve my academic performance. 45. If we cheat once, we go all out.  child's  might  as well  46. M y child's f o o d allergies keep him from doing as well as he could. 47. It is possible for a person to modify his behaviour and learning style.  (0) Definitely Disagree  (D Slightly Disagree  (2) Slightly Agree  (3) Definitely Agree  105 Name Child COMMENTS:  We're interested in hearing how your child or she has been on the diet for a while.  is doing ,  now  that  he  What changes have you noticed?  Have his or her teachers made relatives? What have they noticed?  any  comments?  What  about  neighbours  H o w long did it take before you noticed any changes?  Are you having any problems? Are there any questions we can help you with?  and  APPENDIX DROPOUT'S  D:  PARENT LETTER  106  APPENDIX E: SUBTEST STRUCTURE  RATING  108  PROTOCOL  109 APPENDIX E SUBTEST STRUCTURE RATING  PROTOCOL  Dear Colleague, I would like to request a few minutes of your time validation project I am doing as part of my thesis.  to  help  me  with  the  test  The attached questionnaire is part of an instrument being developed to assess the degree to which parents are compliant with a medically prescribed diet revision therapy for suspected food allergy in their children. The parent is required to respond to each statment by circling a number from 0 to 3 which corresponds most closely to the scale points given that is true for them. In the parent version, the 0 to 3 rating numbers are placed in the space below each statement. In this version of the questionnaire, they have been replaced with letters which stand for the subtests which formed the basis of the instrument's design. The following definitions describe the concepts behind the subtests e m b e d d e d within the attached questionnaire. Please read the descriptions of each subtest and then decide to which subtest each item belongs. Some items are negatively w o r d e d , but most are positive. Please item.  mark your  choice by circling the  appropriate  letter  in the  space below each  Thank you for your assistance, Liz Harris  PFL Parent and Family Life Factors The attitudes, characteristics, and behaviours of the parents and other family members which will affect their ability to help the target child comply with diet revision. CFP Child Positive Factors The degree to which the child himself cooperates with from his environment which assists him in doing so.  the  MSS Medical and Social Support Factors The degree of support the parent feels from the personnel other individuals who are involved with their child; their profession. BTB Belief in Treatment/Benefits The belief the parent has that the treatment the results will be beneficial.  diet,  and  has  support  in the study and the faith in the medical  (diet) is g o o d for their  child and that  110 RHB Related Health Beliefs The regular health-promoting habits and practices that the family make followig this diet consonant with their beliefs and lifestyle.  engages in  PSS Perceived Severity and Susceptibility The severity with which the parent views their they see of a reoccurence of syptoms.  and  child's  condition  the  which  liklihood  APPENDIX F: SQUARED MULTIPLE CORRELATIONS  112 APPENDIX F S Q U A R E D MULTIPLE CORRELATIONS  A.  Squared  Multiple  Correlations of Each Variable in the Variables in the First Set  Variable Self-Report Researcher Physician  B. Squared Multiple  Set  With  All  Other  Second Set With All  Other  R-Squared .60 .57 .48  Correlations of Each Variable in the Variables in the Second Set  Variable PFL CPF BTB PSS  First  R-Squared .28 .24 .24 .11  APPENDIX G: SUBJECT PROFILES: DRTPQ SCORES, DROPOUT STATUS, CLUSTER, CANONICAL VARIATES AND DISCRIMINANT  113  FUNCTIONS  114 APPENDIX C Subject Profiles: DRTPQ Scores, Dropout Status, Cluster, Canonical Variates and Discriminant  Functions  DRTPQ Z-Score  Subject  Status  Cluster  Canonical Ratings Variate Score  Canonical Subjects Variate Score  Dropout Discriminant Score  1.65 1.45 1.35 1.25 1.25 1.25 1.15 1.05 0.95 0.95 0.95 0.95 0.95 0.65 0.55 0.44 0.34 0.34 0.24 0.14 0.14 0.14 0.14 0.04 0.04 0.04 -0.06 -0.16 -0.16 -0.36 -0.36 -0.56 -0.66 -0.76 -0.86 -0.86  5 14 4 8 21 36 28 34 1 3 19 39 43 23* 42 17 12 33 10 2 13 20 35 11 18 31 44 30 32 37 40 29* 41* 7 6 27*  + + +  A A A A A B C A A A A A A B A B A A B A A C A A A B C C C A A A A B C B  0.608 1.009 1.175 0.834 1.175 -0.851 0.618 0.834 0.834 1.200 0.774 0.793 0.530 -1.217 0.458 -0.075 1.009 0.443 -0.112 0.305 0.834 -0.184 0.433 1.200 0.618 0.079 -0.628 -0.375 -0.046 0.721 0.289 0.608 0.417 -0.836 -1.019 -0.528  1.415 1.808 1.386 1.319 1.395 0.844 0.967 1.004 1.134 1.429 0.880 1.018 0.551 -0.396 0.513 -0.063 0.140 0.136 0.075 -0.800 0.597 -0.079 -0.375 0.653 0.724 0.228 -0.280 0.052 -0.215 0.495 -0.699 -0.121 -0.799 -0.723 -1.378 -1.636  2.895 1.762 1.381 1.977 1.689 1.427 1.497 0.957 1.429 1.244 0.887 1.077 1.518 0.323 0.582 1.073 0.466 -0.030 0.377 -0.328 0.012 0.363 0.844 -0.208 0.578 0.391 -0.009 0.151 -0.511 0.852 -0.484 -1.069 -1.012 -1.300 -0.427 -0.782  + + + + + + + + + + + + + + + + + + + + + + + + + + + + -  + +  115 Appendix  *  DRTPQ Z-Score  Subject  -0.86 -0.97 -0.97 -1.07 -1.57 -1.57 -1.77 -2.07 -2.28  38 15 16 25* 9 45 24 26 22  Status  Canonical Ratings Variate Score  Canonical Subjects Variate Score  Dropout Discriminant Score  C C C A D D D B C  -0.585 -1.054 -1.142 0.305 -2.625 -2.625 -2.347 -0.485 -1.367  -0.829 -0.964 -0.964 -0.507 -2.029 -1.183 -1.753 -1.427 -1.541  -0.956 -1.924 -1.924 -1.104 -2.104 -2.027 -2.610 -3.147 -3.795  + -  Subjects misclassified by discriminant = =  continued  Cluster  -  + -  G  remaining dropout  function.  Note  1:  Status:  subjects  Note  2:  Five subjects were misclassified on the basis of the dropout discriminant function. O n e subject, Number 23, was a false positive. That is, she was classified on the basis of subtest scores as a remaining subject but in actual fact had dropped out. This family had not been to see the study physician for some months and the mother, while commenting that they were following the DRT, told the researcher in interview about many "unsafe" foods and eating practices that they used. The four false negatives (25, 27, 29, & 41) represent subjects who, while still classified as remaining subjects, are experiencing compliance difficulties. Their questionnaire scores suggest that intervention to aid compliance would be appropriate. Two are significantly low on the CPF subtest and three are low on BTB.  APPENDIX GUIDE T O ADMINISTRATION DIET REVISION  H: AND SCORING OF THE  THERAPY PARENT QUESTIONNAIRE  116  117 APPENDIX  H  GUIDE T O ADMINISTRATION A N D SCORING O F THE DIET REVISION THERAPY PARENT QUESTIONNAIRE  reflects  The parents are asked to read each item and circle the their current experience with the treatment.  number  which  best  The scores for the subtests are obtained by referring to the Scoring Table below. The subject's score on the subtest is the total of his item scores for that subtest. The subtest scores were compared with the sample's mean score and standard deviation. In the discriminant function analysis, a score one standard deviation below the mean was typical of the dropout group. The Perceived Severity and Susceptibility subtest interview format rather than as a standardized score.  is best  interpreted  in clinical  PFL S C O R I N G TABLE  Item #  0  1 2 6 7 13 15 18 31 35 40 45 47  1 1 4 4 1 1 1 1 1 1 1 4  Item Responses 1 2  3  Scores  Subtest Total Mean  =  +  =  35.91  2 2 3 3 2 2 2 2 2 2 2 3  Standard Deviation  =  5.13  3 3 2 2 3 3 3 3 3 3 3 2  +  4 4 1 1 4 4 4 4 4 4 4 1  +  118 CPF S C O R I N G TABLE Item Responses Item #  Scores 5 8 14 20 22 24 28 29 32 34 36 Subtest Total = Mean  =  30.36  —  1 4 4 1 4 4 1 1 4 4 1 =  —  Standard Deviation  =  2  3 2 2 3 2 2 3 3 2 2 3  3 3 2 3 3 2 2 3 3 2 +  —  +  4 1 1 4 1 1 4 4 1 1 4  —  +  —  6.53  BTB S C O R I N G TABLE  Item  #  0  Item Responses 1  2  3  Scores 3 4 9 10 11 43 46 48 Subtest Total = Mean  =  26.64  —  1 1 1 1 1 1 1 1 =  Standard Deviation  — =  2 2 2  3 3 3 3 3 3 3 3  2 2 2 2 2 + 3.81  —  +  —  4 4 4 4 4 4 4 4 +  —  PSS SCORING TABLE Item Responses 1 2  Item #  Scores 21 23 25 26 37 38 49 Subtest Total Mean  =  Total Test  Mean  =  =  19.20  =  112.11  + Standard  Deviation  PFL  +  —  +  =  3.37  CPF  Standard Deviation  +  +  +  BTB  +  +  —  +  = 13.23  PSS  APPENDIX  I:  SUBJECT RECRUITMENT ARTICLE  120  121 APPENDIX I  Subject Recruitment The following  article appeared in the  Article  Vancouver Sun, Page B6, November 22,  1986.  Learning problems could  begin with diet  By Anne Mullens Sun Medical Reporter  whether  Two Vancouver doctors are undertaking a study to determine food allergies are a cause of children's learning disabilities.  Dr. Stephen Cislason, w h o specializes in allergies and nutrition, and Dr. Julianne Conry, of the University of BC.'s education clinic, have proposed a study of children w h o are performing below expectations at school or have behavioral problems coupled with any number of recurring physical symptoms such as constant colds, headache or skin irritations. "It is my belief that these children's problems are rooted in food allergy, and that through diet revision, they will see a dramatic improvement," said Cislason. Although many have speculated in the past that hyperactive children can be better controlled through diet, Gislason said studies have not conclusively linked learning disabilities to food allergies. He hopes to  d o just that.  "In talking with teachers, there is a consensus that too many children are dysfunctional for no apparent reason and that existing remedial methods are not that effective...These illness patterns are prevalent and I suspect that everyone has f o o d allergy in one degree or another." Gislason and Conry propose to first screen about 50 children w h o are having trouble in school to see if there is an improvement following diet revision. Gislason hopes to follow the initial study with a controlled study, in which some children receive diet revision and others do not, in an effort to determine whether diet revisions can become a primary treatment for learning disabilities.  122 Instead of traditional "elimination" diets in which various items are slowly removed from the diet to determine the allergy, Cislason says he revises the diet, eliminating all food additives and usually the two staple food groups, dairy products and cereal grains. "The diet revisions will be tailored to the child," he said. "Dairy products and grains have the highest incidence of idiosyncratic reaction." Gislason is looking for children five to 12 years of age to take part in the study with the following symptoms: • Difficulty or failure in school as a result of behavioral problems or underachievement. • Chronic and recurring physical symptoms such as frequent colds or flu-like illness, skin rashes, hearing loss, headache, abdominal or limb pain, diarrhea, bed-wetting, moodiness, sleep disturbances. • Normal or above average IQ. • N o defined neurological handicaps or diagnosed psychiatric illness. • N o current use of behavior-modifying drugs or parent willingness to discontinue use. • Parental willingness to revise child's diet. Parents interested in their children taking part in the study are asked to call  (Mullens,  1986)  


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