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Chronic nonadherence to therapeutic regimes : an in-depth analysis of male arthritis patients Adam, Paul Marcel 1988

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CHRONIC NONADHERENCE TO THERAPEUTIC  REGIMES:  AN IN-DEPTH ANALYSIS OF MALE ARTHRITIS PATIENTS by PAUL MARCEL ADAM B.S.W., The U n i v e r s i t y A THESIS SUBMITTED  o f W e s t e r n O n t a r i o , 1983  IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF MASTERS OF SOCIAL WORK in THE FACULTY OF GRADUATE STUDIES S c h o o l o f S o c i a l Work  We  accept  this  t h e s i s as  conforming  to the r e q u i r e d standard  THE UNIVERSITY OF B R I T I S H COLUMBIA August,  1988  ® P a u l M a r c e l Adam, 1988  In  presenting  degree freely  at  this  the  available  copying  of  department publication  thesis  in  partial  fulfilment  University  of  British  Columbia,  for  this  thesis  or of  reference  by this  for  his  and  scholarly  or  thesis  for  her  of  j£oC\d  kJarl*—  The University of British C o l u m b i a 1956 Main Mall Vancouver, Canada V6T Date  DE-6(3/81)  1Y3 f ) ^  If  /flft  I  I  further  purposes  gain  the  shall  requirements  agree  that  agree  may  representatives.  financial  permission.  Department  study.  of  be  It not  is be  that  the  for  Library  an  advanced  shall  permission for  granted  by  understood allowed  the that  without  make  it  extensive  head  of  copying my  my or  written  i ABSTRACT  Chronic the  part  nonadherence  of a  i s t h e complete l a c k  patient  to at  therapeutic  regime  nonadherence  i s s i m i l a r to other  it for  f o r extended  i s a phenomena w h i c h  unlike  known a b o u t In  this  order  nonadherence patients  other  t o a home  Eight  seven p a t i e n t s o f male  comparison  to the chronic  chronic,  were  arthritis  factors  responsibility, others,  related  patients  system. little is  program.  chronic  15 m a l e  arthritis structured  identified  chosen  from  i n order  i n this  to chronic  model,  overall satisfaction,  to  by t h e  among t h e  to provide  a  population. study  i n t h e hopes o f  nonadherence. The H e a l t h  nature  p r a c t i t i o n e r  use o f unorthodox  home e x e r c i s e  i n that  treatment nonadherents.  demographics,  explanatory with  were  nonadherent  as f o l l o w s :  patient's  satisfaction  very  an i n - d e p t h  randomly  Ten v a r i a b l e s were examined  Model,  Chronic  care  related  program,  patients  as being  population  were  to the health  underwent  of these  The  variables  their  forpatients, frustrating  factors  exercise  ages  Society  determining  of time.  o f nonadherence,  to determine  Arthritis other  of  subject.  of varying  interview.  periods  i s dangerous  forms  one a s p e c t  forms o f n o n a d h e r e n c e  p r a c t i t i o n e r s , and c o s t l y  However,  least  o f a d h e r e n c e on  These Beliefs  of the i l l n e s s ,  attributes,  shared  attitudes of s i g n i f i c a n t  treatments,  and problems  with the  ii Data  analysis  significant interesting  findings,  recommend  an  practitioners from  this  nonadherent  on  how  chronic  this  group  is  a  nonadherents.  did point  to patient's the  study  small  number adherent  e x p l a n a t i o n s have  might  have  been  to  Health  Beliefs  goes  can A  some  study i s that  then  which  adherence.  actually  Several  statistically  from t h i s  intervention  that  any  study  finding  patient  were  these patients  the  finding  t o enhance  study  produce  related  appropriate  e x e r c i s e programs. to  One  seems t o be  Based  to  however  associations.  nonadherence Models.  failed  be  on  to  used  by  second  finding  the  chronic  of to  been  falsely  their  home  provided  as  labelled  as  iii TABLE OF CONTENTS  ABSTRACT  i  L I S T OF TABLES  vi  L I S T OF FIGURES  ix  ACKNOWLEDGEMENTS  . .  x  INTRODUCTION  1  ARTHRITIS AND NONADHERENCE - BACKGROUND Arthritis  INFORMATION  . . . .  - What I s I t ?  2 2  Adherence vs Compliance  4  The I m p o r t a n c e o f Nonadherence  5  T y p e s on N o n a d h e r e n c e  6  Nonadherence Control  - Deviance or J u s t i f i e d  - An E s s e n t i a l F a c t o r  A MODEL FOR UNDERSTANDING NONADHERENCE Pre  - Interaction  Interaction  Phase  Post - I n t e r a c t i o n METHODOLOGY Subjects  Phase  Reaction  . . . .  8 10  17 18 28  Phase  37 43 43  iv Procedures  45  Measures  46  Adherence  49  Demographics  52  The H e a l t h B e l i e f s Model  52  P a t i e n t ' s E x p l a n a t o r y Model  54  Nature of the I l l n e s s  54  Satisfaction  with P r a c t i t i o n e r  Attributes  . . . .  55  Shared R e s p o n s i b i l i t y  56  Overall  56  Satisfaction  Attitudes  of S i g n i f i c a n t  Use o f A l t e r n a t i v e Problems with Enhancement  Others  .  58  Treatments  58  t h e Home E x e r c i s e P r o g r a m  of Questionnaire  Validity  59 and  . . . .  Reliability  59  Data A n a l y s i s  61  RESULTS  63  A n a l y s i s Using  S e l f - R e p o r t e d Measures o f Adherence. . .  64  Demographics  64  The H e a l t h B e l i e f s Model  65  P a t i e n t ' s E x p l a n a t o r y Model  69  Nature o f the I l l n e s s  72  Satisfaction  with Practitioner  Attributes  . . . .  72  Shared R e s p o n s i b i l i t y  75  Overall  81  Satisfaction  V  Attitudes  of Significant  Others  . . .  81  Use o f A l t e r n a t i v e T r e a t m e n t s Problems w i t h  82  t h e Home E x e r c i s e  Program  82  DISCUSSION  85  Variables Related  to Self-Reported  Measures o f  Adherence  85  L i m i t a t i o n s o f t h e Study Implications  for Social  88 Work  Practice:  The  Contracting  Process Contracting Future  91 - A Technique f o r Enhancing C o n t r o l  . . . .  Outlook  97 100  BIBLIOGRAPHY  102  APPENDIX 1  I l l  Structured  Interview  Schedule  I l l  APPENDIX 2  141  Sample I n t e r v i e w  Tape T r a n s c r i p t  .  APPENDIX 3  141  147  Analysis using  Arthritis  of a c h r o n i c Demographic The H e a l t h  Society  categorization  nonadherent group Factors  B e l i e f s Model  147 . . .  147 151  vi P a t i e n t ' s E x p l a n a t o r y Model Nature of the Satisfaction Shared  Illness  153  with P r a c t i t i o n e r  Attributes  . . . .  154 157  Satisfaction  163  Attitudes  of S i g n i f i c a n t  of A l t e r n a t i v e  Problems with  t h e Home E x e r c i s e P r o g r a m  Phenomena Deviant  Others  Treatments  P o s s i b l e E x p l a n a t i o n s f o r the  Labelling  152  Responsibility  Overall  Use  .  166 167 170  Misidentification 171  Behaviour  174  vii  LIST OF TABLES  Table  Table  Table  1  2  Health Strategic  Interaction  Phase V a r i a b l e s ,  page  Health  3  Strategic  Table  Table  4  Interaction page  Health Strategic  Interaction  5  6  7  Model:  Phase V a r i a b l e s ,  Schedule Questions,  page  Cross-Tabulations:  Patient  T-Test  Analysis page  8  page  9  Other M e d i c a l Respondents,  Table  10  T-Test  11  12  Interview  Demographic page  Health  66.  Beliefs  Model  with  The  Health  Beliefs  Model  by  Nature  of  the  Illness  by  73.  page  R e p o r t e d by  Study  74.  of P a t i e n t  Attributes  Cross-Tabulations: 78.  S a t i s f a c t i o n With  with Adherence,  Patient  Attributes  A d h e r e n c e , page  and  70.  Cross-Tabulations: Practitioner  Table  40.  68.  Problems  Analysis  Practitioner Table  Post-  47.  the  Cross-Tabulation: A d h e r e n c e , page  Table  of  Cross-Tabulations: A d h e r e n c e , page  Table  Interaction  C o r r e s p o n d e n c e between S t u d y V a r i a b l e s  Adherence, Table  Model:  30.  C h a r a c t e r i s t i c s by A d h e r e n c e , Table  Pre-Interaction  22.  Phase V a r i a b l e s ,  Interaction  Model:  page  Satisfaction  by A d h e r e n c e ,  page  Shared R e s p o n s i b i l i t y  76.  with 77. Models  by  viii Table  13  Cross-Tabulations: Adherence  Table  14  Table  15  Analysis  Characteristics  T a b l e 16  17  o f Problems w i t h  t h e Home  Patient  83.  Demographic  by A r t h r i t i s  Society  Categorization,  148.  T-Test A n a l y s i s Society  Table  79.  P r o g r a m w i t h A d h e r e n c e , page  Cross-Tabulations:  page  R e s p o n s i b i l i t y M o d e l s by  ( M e d i a n S p l i t ) , page  Median T e s t Exercise  Shared  T-Test  of Health  Categorization, Analysis  B e l i e f s M o d e l by  page  Arthritis  151.  of S a t i s f a c t i o n with P r a c t i t i o n e r  A t t r i b u t e s by A r t h r i t i s  Society  Categorization,  page  155. Table  18  Cross-Tabulations: Practitioner  19  Table  20  page 21  22  Society  R e s p o n s i b i l i t y M o d e l s by  Categorization,  page  159.  S h a r e d R e s p o n s i b i l i t y M o d e l s by Categorization  (Median  Splits),  161.  T-Test A n a l y s i s Society  Table  Society  Society  157. Shared  Cross-Tabulations: Arthritis  Table  page  Cross-Tabulations: Arthritis  S a t i s f a c t i o n with  A t t r i b u t e s by A r t h r i t i s  Categorization, Table  Patient  o f O v e r a l l S a t i s f a c t i o n by  Categorization,  Cross-Tabulation: Service  Offered"  Categorization,  page  164.  S a t i s f a c t i o n with by A r t h r i t i s  page  165.  Arthritis  Society  "Kind  of  ix Table  23  Cross-Tabulation: Met" by A r t h r i t i s  Table  24  Cross-Tabulation: Arthritis  Society  Satisfaction Society  with " H a v i n g  C a t e g o r i z a t i o n , page  Needs 167.  Use o f A l t e r n a t i v e T r e a t m e n t s C a t e g o r i z a t i o n , page  168.  by  X  L I S T OF FIGURES  Figure  1  A  visual  representation  I n t e r a c t i o n M o d e l , page Figure  2  Classification of  of  the H e a l t h  Strategic  20.  matrix o u t l i n i n g  the four  t h e S h a r e d R e s p o n s i b i l i t y M o d e l , page  categories 35.  ACKNOWLEDGEMENTS  I  would  have h e l p e d  like  t o give  t o g e t me t h r o u g h t h i s  - t o D r . Mary Patrick  t o those  people  McGowan f o r t h e i r  who  year:  R u s s e l l , Dr. K a t h r y n n M c C a n n e l l ,  encouragement -  consideration  a n d Mr.  bountiful store of  and a d v i c e  t o Dr. Nancy  Waxier-Morrison  f o r her l a s t  minute  rescue - to Micheal latter In  f o r h i s concern  and g r e a t  patience  i n the  days o f the s t r u g g l e  addition,  recognition  should  be  given  to the  following: - t o UBC cinnamon  buns  which  sustained  me  t h r o u g h many a  lecture - to that  which  to s t r i v e  i s i n a l l o f u s , a f o r c e w h i c h p u s h e s us  f o r knowledge  THANK YOU, ONE AND A L L  and u n d e r s t a n d i n g  1  INTRODUCTION  Patient continues  adherence  t o be  profession patients  the  i s free to  be  physicians  social the  work  that  at  workers in who  are  the  &  Gray,  document  the  a  modicum  of  the  health  care  Within  or  any  t h i s modality  they  bring  This  provides  a as  encompassing dimensions only  social  research  physiological,  (Stone,  useful  shows  influence  1979).  This  i n developing  are to  to state,  on  uses  professionals  This  a  approach be  Social  nonadherence  other  out-patient  i t to  and  adherence  exists.  perspective  apt  1980),  1970),  applies  mental  team  w o r k e r s have an i m p o r t a n t  particularly  of  studies  safe  team.  s e t t i n g which  a unique p s y c h o s o c i a l  nonadherence  not  other  shown  care p r a c t i t i o n e r s ,  p r a c t i c e s , but a l s o t o a s s i s t  part  no  client  health  hospitals, psychiatric institutions, centers,  of  only  No  occupational  & Moody,  nonadherence  i n a p o s i t i o n t o not  own  1976),  i t i s probably  of  have  Nugent,  Although  o f the f i n d i n g s o f other least  studies  &  Klauber  degree  which  recommendations  Davis,  1986).  issue  practitioners.  as  Carnahan,  Ward,  (Trepka,  to  i s an  care  i t s influence  recommendations,  are  their  health  (Carpenter,  (Oakes,  which  basis  from  of  (Nessman,  psychologists available  bane  therapeutics  nonadherent  physiotherapists therapists  to  to the  health  modality. role,  complex  psychological psychosocial  and  as  problem.  for dealing a  to  with issue  social  perspective  is  treatment i n t e r v e n t i o n s , but i s  2 also  invaluable i n continuing  many  unanswered  aspect  of  research lack  this  study  of  questions  relating  phenomena  which  i s that  adherence  at  time.  By  In  with which  What I s to  as  to  to  includes  more  than  as  Some  of and  ankylosing  prevalent.  affect  understand  have  osteoarthritis, such  the  structures Society, One rheumatic  of  in  the  this  complete  treatment  for  this  study  i s hoping  to  population  BACKGROUND INFORMATION  It?  they  diseases.  explored  The  l o o k i n g a t a number o f v a r i a b l e s  nonadherence  i t i s necessary  which  phenomena.  nonadherence; aspect  the  f r o m a random sample o f male a r t h r i t i s p a t i e n t s .  order  patients  being  one  ARTHRITIS AND NONADHERENCE -  -  this  to explore  t h e ways i n w h i c h a c h r o n i c n o n a d h e r e n t  different  Arthritis  efforts  to  is  chronic least  associated with  distinguish is  of  to  extended p e r i o d s of normally  research  the  know s o m e t h i n g  live.  gout  Arthritis  100  these  different  such  are  These d i s e a s e s joints  (eg.  muscles,  and  as  well  spondylitis  body's  behaviours  can  tendons  about  the  kinds  of  while  arthritis, other  divided into  which a f f e c t  term  rheumatic  R e i t e r ' s Syndrome  and  disease  umbrella  rheumatoid  be  those  arthritis  i s an  known,  and  of  types  are  those  not  which  joint-support  ligaments)  (Arthritis  1986). commonality diseases  amongst  a l l these  i s that there  i s no  different  known c u r e .  kinds  of  T h i s means  3 that  once  rest  of  people  their  disorder.  get  lives.  That  available  well,  disease  accord.  At  often  those  the d i s e a s e  symptom  exacerbation faced  fatigue,  and  by  to  i t will words,  say,  to help  present,  symptoms  In o t h e r  i s not  treatments the  arthritis  with  them  for  arthritis  is a  chronic  however,  fluctuates in of  time  i s said  t o be  in  are  that  there  keep symptoms u n d e r  periods  known as  arthritis  swelling.  be  no  not  control.  As  on  patients  The  are  symptoms  its  most  pain, are  A  deformity  second  diseases  commonality  i s that  know what  (Arthritis  being  amongst  researchers  causes  the  and  disease.  noted  as  likely  birth  d e f e c t s , t r a u m a , and  Society,  causal  types  viral  factors are  common  stiffness,  left  untreated  of  practitioners  agents  of  range  of  1980).  most  Some  are  Periods  t h e y p r o g r e s s i v e l y l e a d t o m u s c l e weakness, d e c r e a s e d m o t i o n , and  own  symptoms  'remission'.  'flares'.  I f these  are  severity  when  the  rheumatic  still  which  do  have  not been  heredity, congenital  activity  (Arthritis  Society,  1986).  Thus,  arthritis  unanswered disease  questions.  are  not  ineffectual. does  not  have or  American  study,  of  of  and the  which  underlying  fact  that many  practitioners  had  and used  s t i l l  treatments  answers,  Kronenfeld sample  disease  Definite  a l l the  unorthodox  their  a  known,  Because  remedies  94%  is  at  causes are  people help.  one  the  sometimes  turn In  medicine to a  (1982) d e t e r m i n e d  least  many  of  traditional  for  Wasner  has  type  of  folk recent that folk  4 treatment. the  lack  have  In of  a d d i t i o n to  conventional  varied  personal  the  use  wisdom  of  alternative  a l s o encourages  explanations  as  to  why  therapies, patients  they  to  have  the  disease.  A d h e r e n c e vs  Compliance  Current the  literature  patient's execution  seems d i v i d e d on  whether  of  therapeutic  as c o m p l i a n c e  or adherence.  distinction  highlights  responsibility should  be  for  for  (1979) s u g g e s t s as  one  of  they  be  hand,  implies a  patient Litt,  to  and  1986).  breakdown on  the  the  than  i s beginning primary  1979).  For  on  that  p a t i e n t does  care  and  with not  between of  indicate  cause  of  poor  these  reasons  the  the  the  for  heed  blame Taylor  this  on  (Turk,  the  role  expert's advice  the  other  between  responsibility  principal this  patient term  the  Salovey  practitioner  that  the  behaviour  patient  cooperation  the  this where  patient.  Adherence,  or  to  t h a t the  ideal  practitioner  either to  the  regimen  control  the  acquiescence  interaction  Research  (Stone,  see  as  prescribed  with  T h i s p o i n t of view p l a c e s  rather  the  staff  and the  rests  working-together health  a  implies  noncompliant.  patient,  indeed  of  consider  picayune,  views  the p r a c t i t i o n e r ,  that medical  When  seemingly  differing  i n some way  passiveness  said  the  with  recommendations. are  Although  Compliance  lies  noncompliance  recommended  follow-through  placed.  decision-making  a  to  and  &  for the  characters.  interaction  is  follow-through nonadherence  is  5 deemed  t h e more  s u i t a b l e , and w i l l  therefore  be u s e d  i n this  paper.  The Importance of Nonadherence Adherence  i s the degree  regimen  given  Failure  t o adhere  frustrating cost  set  fold  link  for patients,  represents  help  Services  how  may  elsewhere  lead  to patient  of patient  practitioners.  Considerable  and  of a  development  that  This  resulting in a and  time the p a t i e n t  her  condition  will  twonew  are contraindicated Lack  of  treatment  dissatisfaction,  which i n  nonadherence.  behaviour  frustrating for  c a n be  t i m e may  therapeutic  returns  may  the  be s p e n t  plan  to then  f o r subsequent  i n assessment find  that  f o r help  have worsened,  i t is likely  such  that  the  appointments, or  t h e recommendations w h i c h have been g i v e n .  the  can  degree o f p a t i e n t  e i t h e r does n o t r e t u r n  does n o t f o l l o w  initially  duplicated,  treatments  can  of consequences.  nonadherence  are  r e s u l t i n a higher type  large  nonadherence  number  p r a c t i t i o n e r ' s treatments.  effectiveness  a  e f f i c a c y of the treatment.  may p r e s c r i b e  the f i r s t  patient  i s dangerous  resulting in a  t o seek  effect.  This  practitioner.  (1980) d e s c r i b e  to medications,  the p a t i e n t  t u r n may  advice  the  system.  the therapeutic  practitioner by  care  a n d Maiman  respect  nullify lead  to health  follows  care  f o r p r a c t i t i o n e r s , and a l s o  up a c a u s a l  With  a patient  t o him o r h e r by t h e h e a l t h  t o the h e a l t h Becker  t o which  that  treatment  By  h i s or becomes  6 more d i f f i c u l t In  to c a r r y  an a t t e m p t  calculated admission  the  to determine  that  20%  was  of  due  the  Marston  idea  of  (1970)  the  studies.  Statistical  median o f  42%  figures  appointments,  and  nonadherence ramifications  Her  estimates  probably  due  to  regimes.  33  of  analysis  large  the  problem  surfaced  p r e v i o u s l y conducted  nonadherence,  represent a  were  (1981)  p a t i e n t s whose  to nonadherence.  extent  reviewed  c o s t , Ausburn  hospitalized  admissions  nonadherence to m e d i c a t i o n Some  financial  p r o p o r t i o n of  to h o s p i t a l  suggest  out.  across these  with  a  number  treatment  range  widespread,  4  to  of medication  but  for a l l h e a l t h care  i t  nonadherence  studies revealed a  of  drop-outs.  when  92%.  These  errors,  missed  Thus,  also  not  has  only  is  important  practitioners.  Types o f Nonadherence According "the  extent  medical far  or  as  to  i t goes,  unable  order  distinction  to to  a  (p.2).  to For  behaviour  a  clearer  example,  between  be  the  defined  coincides  This d e f i n i t i o n  to provide the  get  can  advice,  but  are  picture  why  definition  i t s occurrence.  The  of  client  as  nuances which  involuntary  i s unaware  as  with  i s good  and  of fails  this who  to  voluntary  I n v o l u n t a r y n o n a d h e r e n c e o c c u r s when t h e  follow stop  compliance  person's  i t fails  occurs.  nonadherence. fails  but  in  nonadherence a  which  (1976),  health advice"  necessary  make  t o Haynes  client  failure,  does  not  or  come  to  h i s appointment  illustrates when  follow  the  the  can  calls  patient as  there  and  from  their  deliberately  these  given. into  what  on  patients  not  insulin ones  medical  can  f o r the rational  the  part  of  the  regime.  For  diabetic  individuals  o r who who  advice  In r e f u s i n g be  nonadherence  in describing  are  rather  (p.11).  on  therapeutic  state  their  to follow  "capricious  this rational basis.  "these  but  to  Weintraub  i s that  i s based  decision  (1986)  not  Voluntary  and  these  adhere  lacks  t o take  managing t h e i r d i s e a s e " advice,  not  t o h i s or her  diet,  refuse  been  between  conscious  Popkin  forget  has  nonadherence  decision  i s s i m i l a r to voluntary  nonadherents,  occasionally  conscious  noncompliance"  the l a t t e r  t o not adhere  chronic  to  Voluntary  subdivided  difference  is a  a  s/he  further  nonadherence  Boehnert  stray  be  decision  reasoning, while  that  which  The  the  Chronic  makes  "intelligent  compliance".  in  client  advice  nonadherence  former,  he m i s u n d e r s t o o d t h e p r a c t i t i o n e r  t h i s type of nonadherence.  occurs  (1976)  because  who  at times  may  consistently  and  with  respect  to follow  considered  to  medical  voluntarily  nonadherent. The d i f f e r e n c e between v o l u n t a r y nonadherence degree chronic  of  nonadherence  voluntary on  nonadherence o n l y  nonadherence. her  i s that  exercises  For half  n o n a d h e r e n c e and  nonadherence  the part  of  the  r e f e r s t o extreme  example, as o f t e n  an  to  any  i n d i v i d u a l whereas forms of  i n d i v i d u a l who  a s she was  refers  chronic  voluntary  decides  recommended  t o do  to  do  them  8 would be be  v i e w e d as v o l u n t a r i l y  s e e n as  cease  a chronic  exercising.  whereas  n o n a d h e r e n t , she From  chronic  nonadherent.  this  a  i s c h r o n i c a l l y nonadherent  of  adherence  regimen about  to at  for  this  least  extended subject,  been i d e n t i f i e d  one  periods  the  of  study  in previous  true.  aspect  of  is  i s any  will  considered  t o be  norm i s d e f i n e d as (p.1221). a  the  on  recognized  a  fairly  physiological i n d i v i d u a l may in  the  role  of  the  hallmark  of  her  lack  therapeutic  little  is  known  v a r i a b l e s which  have  nonadherence.  differs  from  that  t o Webster  which  (1979),  for a  a  group"  b e h a v i o u r which d e v i a t e s  from  practitioner-patient relationship  defined  symptoms decide  course.  or  of  the  patient  or  client.  whatever  practitioner, This  and  Upon  experiencing  sociopsychological  t o see  presence  supplying  given.  voluntary  complete  model, or p a t t e r n  i s any  that  pattern.  Traditionally followed  As  According  "a s t a n d a r d ,  Thus, d e v i a n c e  the  seen  Reaction  which  norm.  Thus,  i s the  use  research  behaviour  of  h i s or  completely  be  form  time.  Nonadherence - Deviance or J u s t i f i e d Deviance  i t can  a  the  who  i s not  is  nonadherence, person  reverse  t h i s woman t o  would have t o  discussion  nonadherence  For  a health care  expert,  the  This  information  following  d e s c r i p t i o n of  practitioner.  whatever normative  takes  entails  is  certain  problems  individual role  the  required  advice patient  has  s/he  the Once  on  the  patient by  the  has  been  behaviour  is  similar  to  (1951).  the  of  felt  that  Parsons  obligated  to  cooperate the  notion  seek  with  expert.  adherence  any  By  as  a  help  "sick  a  treatment this  normative  described  when p e o p l e  from  stating  role"  became  by  sick  Parsons  they  trained practitioner,  recommendations responsibility,  behaviour  and  to  prescribed  Parsons  expected  were  of  by  enshrined  anyone  who  is  sick. The  notion  (1960).  He  individual  of  social  suggests  that  i s conscious  violated.  With  regard  behaviour  i s only  behaviour.  Involuntary  would  be  because  A  is  that  behaviour  i s often  each his  type  actor or  of  cooperative  must  her  act  allotted  interaction  one  patient  follow  to  subsequent perceived has  not  fact,  of  outcome  there  a  the  followed exists  when  fact  interaction  In  reasons  being  and the  the  be  attempt  proposed  fashion  only  seen to  by  as  engage Johnson  In  order  smoothly,  according  to  the p a t i e n t - p r a c t i t i o n e r  why  advice  earlier  not  an  deviant  to progress  i t is is  advice.  physician  possibility  important  due  recommendations  the  as  dysfunctional.  predictable  medical  of  second p o i n t  role.  therapeutic  been  patient.  in  would  i t lacks a wilful  conduct.  any  in  considered  nonadherence  non-normative  for  Johnson  deviant  c e r t a i n norms are  in  deviant  by  t o a d h e r e n c e , t h i s would mean t h a t  nonadherence  behaviour  i s discussed  that  voluntary  deviant  deviation  of  to  will  the  be  If  harm  fact  based  previous  i s not  for  aware  the that  on  the  advice of  befalling  this the  10 In the  this  s i t u a t i o n the  patient  and  the  dysfunctional  p r a c t i t i o n e r could  patient's  deviant  nonadherent  sense,  patient  would  the  normative fully  sick  with  some q u e s t i o n of  the  for  role  the  reason  a  norm  to  for  to  be  what  Thus,  its  indicating traditional  traditional  practitioners  Control  is  that  by  the  is  be  Brody  i n the  which  of  to  the  the  are  a of  wrong One  that a  itself. may  be  with  the  possible  people  inherent  are in  not this  potentially  power  the  Part  enjoy  behaviour  healthy  is  indicating is  although  wrest  part  fact  i t must  that  power  as  cooperating  nonadherence  is  Thus,  following  Today t h e r e  something  (1980)  considered  c o n t r o l on  not  from  such,  the  traditional  not  realtionship.  attempt  Essential  point  comes  prevalence, there  to  interpretation.  nonadherent  imbalance  the  could  l o s s of  - An  The  the  relationship.  dysfunctional,  perceived  that  proposed with  this  However, what s t u d i e s is  a  for  i s , for  as  patient-physician  explanation satisfied  fact  In  physician.  of  considered  increasing  the  the  uncertainty  i s widespread  by  attributed  fault  That  validity  this  widespread consensus. that  have been a t  behaviour.  the  be  behaviour.  m i n i s t r a t i o n s of as  r e l a t i o n s h i p between  away  reaction  from to  a  patient.  Factor  underlies  traditional  little  control.  Parsons  o f the  institutionalized  much o f  the  current  medical system the (1951) n o t e d  expectations  this of  the  discussion  patient in his sick  has  very  discussion  r o l e when  he  11 stated,  "the sick  himself  together'  In  this  sense a l s o  in  a  condition  mentioned  person  to get well  that  must  which  recommendations relationship  be  taken  the p a t i e n t by  expected  from  Parsons  made  be  care  also  i n fact,  have p r i n t e d validate  their  Brody because the  'Dear  Brody  close  only  psychological The (1980)  this  and who i s m a l i n g e r i n g .  that  this  employees  still  can use t o  power d i f f e r e n t i a l  and s o c i a l  gap w h i c h e x i s t s  feel  that  this  information  Other  occurs between  anxious,  regard  and  barriers to receiving this of a s o c i a l  evidence  that  shows  knowledge reasons  gap may  too time-consuming,  patients  existence, from  As a g a t e k e e p e r t h e  forms w h i c h  p r a c t i t i o n e r s may  as b e i n g  make  this  P r a c t i t i o n e r s have many y e a r s o f e d u c a t i o n  a s t o why  education  In  illness.  t r a i n i n g , a n d may  i s that  with  but a l s o  complex t o be u n d e r s t o o d by p a t i e n t s . by  only  and a t r e a t m e n t ,  who i s i l l  Employer'  o f an i n f o r m a t i o n  clinical  to cooperate  many h o s p i t a l emergency d e p a r t m e n t s  (1980) s u g g e s t s  two s i d e s .  the  As  not o n l y  s/he l e g i t i m i z e s t h e s i c k n e s s .  a point  a diagnosis  will.  a l o t o f power,  because  As  that  the practitioner.  s/he p r o v i d e s  by d e c i d i n g  or  o f " ( p . 437 ) .  felt  h a d was  the p r a c t i t i o n e r holds  acts  'pulling  r e s p o n s i b i l i t y - he i s  because  physician  by  by a n a c t o f d e c i s i o n  he i s exempted  previously,  obligation  cannot  assume  that  suggested  of  that  i t will have  information.  raised  physicians  to  patient  patients  type o f  g a p has b e e n  i s too  be d i f f i c u l t  the task  that  and  by B r o d y  provide  more  information T h i s may  to  be  patients  due  of a higher  to the  social  more e d u c a t i o n the is  that  of  physicians  turn  lower  may  receive  by  of  Parsons,  a  for  to  the  typology  by  The  physician  still  the  of  but  would  hold  her  patients  more e d u c a t e d .  Having  understanding  r a i s e d by  t o ask  fewer  Brody  questions  less  assertive.  This  fact  that  lower  class  patients  r o l e behaviour  outlined  in  of  of  (1956) b a s e d on  the own  Their  these  the  out  of  of  the  disease  which (1980)  come under to  a  together. patient illness.  or  the  patient  states this  this  i s at  category. which  a  This  i s most  mutual  of  authority  fall  Trauma into  of  least  patient The the  partnership  control  and  this  s i t u a t i o n s that  that  take  includes:  injury.  would  describes  of  s i t u a t i o n s when  position  attention  partnership In  to  a  to  was  degree  typology  refers  act  immediate  in  relationship  guidance-cooperation,  to  refers  sick  physician-patient  first  Brody  relationship  empowers  that  class.  be  Guidance-cooperation  infectious  tend  participant.  nature  i n need  cooperate.  h i s or  has  the  acute,  patient  also  Hollender  each  participation.  category.  feel  second p o i n t  model o f  activity-passivity,  patients  A  generally  S z a s z and  held  of  social  p r o b a b l y more c a p a b l e o f  account  contrast  because  higher  information.  d e v e l o p e d by  the  a  t e n d t o be  medicine.  to  of  that physicians  class also  and  also  control  are  class patients  less  In  idea  they are  complexities  who  the  last  able  to  who  is  type  of  physician the  and  physician  management  f e a s i b l e with  are  of  diseases  13 which  are  of  diabetes).  a  chronic  nature  The  benefit  of  relationship according capable of  to of  h i s or  a  the  her  this  i n order  i n t e r a c t i o n . In  relationship  the  described  by  be  Fiske react  and  to  loss  responses stress,  t a k e n by Taylor of  include  individuals  patient only  who  illness, making  but  Information predictive is able what  experience  to  on  of  function.  because  equitable,  rigid  limits  that  variety  seeking,  loss with  in  the  that  actions  individuals  of  ways.  increased  a of  prevalent  may  Common  reactions  to  control  events as  Coping  as  in  necessary they  is  the  a  coping  the  guidance.  Not  patient  with  assist  going  them  because  to plan  the in  through.  function  them.  a  symptoms,  the  symptoms mean, and to  of  r e s u l t of  to deal  to  are  improved  response  i t allows  a  inexplicable  i t has  what v a r i o u s  take  reaction  practitioner for  i s also  important  to  and  part  physician-patient  need t o know what t o do  the  recognize  a  is  the  information  is  actions  beneficial  Faced  patient  sense  indicate  in  seeking  dependent  does t h e  the  are  helplessness.  illness. is  a more  i s much more  patient,  (1984)  information  r e a c t a n c e and  modified  actor.  control  Information  medical  either  be  the  When p a t i e n t s  about  comparison,  Parsons  to  i t sees  practitioner yields  to b r i n g  t a k e s c o n t r o l away f r o m t h e  which c a n  illness. the  hypertension,  i s that  arrangement  more c o n t r o l ,  power  arthritis,  framework  flexible  s e v e r i t y of  taking  satisfying  it  as  (eg.  and  a  patient therefore  Prediction  is  ahead f o r  the  14 future.  When  information  practitioner, elsewhere  (Fiske  television, disease danger does  friends,  inherent not  have of  enough  knowledge  A  second  response  individuals difficulty  face  events  with  existence  this  factor  comes  from  participants  to  uncontrollable to g e n e r a l i z e the  other  noise, these  hand,  control  of  or  part  of  include  most  to  probably  judge may  an  be  the made  increased  physiological  reduction  of  the  pain  or  when  control.  The  supporting  which  submit  controllable  i t would seem life  expect to  in  occur  evidence  studies  everyday  i t seems l o g i c a l a  is  t h e y have no  Thus,  to  patient  s e l f - r e p o r t s of  levels  findings  The  decisions  laboratory  shock.  information.  control  i s that  varying  same  the  with  These r e a c t i o n s  which  met  information.  increased  over  need  the  activity),  1984).  the  magazines,  accurately  faulty of  popular  of  from  this  others  to  reactions  and  (Fiske & Taylor,  and  result,  adrenalin  get  Books,  i s that  loss  These  increased  a  of  to  concentrate,  discomfort  its  basis  stress.  (eg. to  the  As  to  sources  activity  on  ability  in  potential  patient  effects  1984).  advice.  forthcoming  attempt  in this  this  to  not  relatives,  the  reaction  will  & Taylor,  a l l become  validity by  patients  is  be  difficult  situations.  p e o p l e who  their  life  more  indicated  by  Fiske  the  of  reactance  and  On  are  not  anxious  and  impatient. The that two  of  third  response  reactance.  which are  Of  most r e l e v a n t  forms to  this  & Taylor  (1984)  mentioned,  s i t u a t i o n are  anger  is the  and/or  15 aggression,  and e x h i b i t i o n o f b e h a v i o u r s  Taylor demands reacts  (1979) d e s c r i b e s  information, angrily  Although  troublemakers, are  only  degree with  to the calming  reactance same  efforts  t o an e n v i r o n m e n t  i s dependent  people  as  i s that which  Taylor  respond  a s t h e one who  of staff  staff  of the matter  patients  control.  of treatment,  hospital  for self-control.  t o which  these  by  the fact  reacting  opportunity  t h e "bad p a t i e n t "  i s suspicious  l a b e l l e d  to regain  and  members.  disruptive  these  patients  i s devoid  (1979) s u g g e s t s  to the h o s p i t a l  o f any that the  environment  on t h e amount o f c o n t r o l  normally  have  i n  who  their  which  everyday  environments. An  example  reassert found are  control  that  dissatisfied  inadequate, attempt  most o f t e n The  effort  They  changes  f i t .  t o when t h e f o r m e r to loss  c a n be r e c o g n i z e d  i n a state  may  attempt  s t r a t e g i e s " , such that  response  patients  o f s t r a t e g i e s when  are necessary.  sees  who  treatment i s  Or p a t i e n t s  strategy is  by an i n a c t i v i t y  are compliant  they  "convincing  The l a t t e r  Taylor  He  may  changes a r e made t o  of control  of helplessness.  designed to (1976).  the p r a c t i t i o n e r that  as t h e p a t i e n t  last  two t y p e s  t o change one's s i t u a t i o n .  hospital effect,  and t h a t  by H a y e s - B a u t i s t a  care.  to persuade  resorted  Helplessness  attempt  with  "countering  regimen  e x h i b i t i n g behaviours  i s provided  patients  strategies"  the  of patients  strategy i s  has f a i l e d . helplessness. or a  lack  (1979) s u g g e s t s and p a s s i v e  At f i r s t  this  of  that  are, in state i s  marked by a n x i e t y  as t h e p a t i e n t  more i n f o r m a t i o n ,  yet being  afraid  caught  Tagliacozzo  of  t h e p a t i e n t s h a d needs and c r i t i c i s m s felt  helplessness  unable may  to  between  t o ask f o r i t .  by  they  and Mauksch  feels  (1972) i t was shown t h a t  vocalize.  lead to depression.  wanting  In a  study  two-thirds  of the h o s p i t a l which  Over  time  continued  17  A MODEL FOR UNDERSTANDING NONADHERENCE  S e v e r a l models understanding  of  models  list  which  {Green, also  1980;  attempt  dimensions  to  i s that  a  line  nonadherence  variables  occurs.  t o more  behavioral,  1982;  Dracup  &  with  are  over  nonadherence  between  being  200  (Stone, 1979). enough  i n the The  this  model  &  by Stone  described  and  1966;  on  of the p a t i e n t  that and  the  Stone,  S t r a t e g y Model,  (1979)  responsible  in this  i s based  Cobb,  Interaction  which  affective Kersell  &  of a  which  have  been  T h u s , models  must  to provide that  one  a broad becomes  details.  author  (Kasl  from  development  overview o f t h e s u b j e c t , y e t n o t so i n t r i c a t e lost  and  1982;  variables  detailed  models  cognitive, Meleis,  range  an  nonadherence  complex  The p r o b l e m w h i c h c o m p l i c a t e s there  to gain  These  associated  1980)  include  (Cox,  associated with walk  why  McGuire,  Milsum, 1 9 8 5 ) . model  have been p r o p o s e d i n an e f f o r t  paper  Health  1979).  i t follows  nonadherence  been  developed  Transactions Called  the  by  Model Health  the premise put f o r w a r d  arises  the p r a c t i t i o n e r .  f o r a d h e r e n c e as  has  from  the  Neither  a cooperative  interaction  party  effort  is  fully  i s required  from b o t h . Stone behaviour  (1979)  comments  i s t h e end  result  beginning development  stage or  the  on  that  notion  of a multi-stage  patient  realizes  the  detects  there  some  that  adherence  process. sort  i s a problem  of  In t h e symptom  i n h i s or her  18 life  f o r which  taken  place,  they  a decision  practitioner. interaction health model  or s e r i e s  takes  place  exhibits  therapeutic  may  The m i d d l e  professional  either  a r e needing  help.  be made  stage  Once  regime.  the patient  This  Strategy  In keeping  interaction,  Pre  - Interaction Stone  each health only  this  idea,  into three  Figure  stresses  brings  h i s o r h e r own and u n s t a t e d  to this  of the  home, a n d  a t any s t a g e o f t h e  the Health  (see Figure  1 about  Interaction  pre-interaction, 1)  here  the importance encounter.  of r e a l i z i n g As  f o r being  b e l i e f s and e x p e c t a t i o n s  he s t a t e s ,  " i n a sense,  in  the l i v e s  o f the expert  everything and c l i e n t  that  what  the expert, the  b e l i e f s and e x p e c t a t i o n s ,  As  interaction"  stage  t o t h e recommended  stages:  care p r a c t i t i o n e r i s responsible  stated  between t h e  Phase  (1979)  person  occur  on t h e  outcome c a n be t h e r e s u l t o f one, o r  and p o s t - i n t e r a c t i o n  Insert  focuses  has r e t u r n e d  or nonadherence  with  Model i s d i v i d e d  care  The l a s t  a m u l t i t u d e o f f a c t o r s w h i c h have o c c u r r e d process.  a health  o f t h e model  and the p a t i e n t .  adherence  has  to v i s i t  o f i n t e r a c t i o n s which  once  recognition  aware o f n o t but a l s o the  of the p a t i e n t . has e v e r  i s relevant  occurred to their  (p.45).  Four o f t h e s t u d y v a r i a b l e s  a r e predominant  i n t h i s phase  19 of  the  model.  As  demographics,  can  The  be  seen  Health  e x p l a n a t o r y m o d e l , and  Table  s t u d i e s have  relationship whole,  between  however,  factors  such  status,  correlate  adherence  with  which  elderly  may  be  involuntary The  might  associated  Beliefs  with  The  and  sex,  & Gammon, is  (Ley,  determine  the race,  found  1981).  that  1982),  been  the  On  education,  not  and  the  i n that both  are  concerned  an  individual's  difference the  individual's  belief  Health  Maiman & B e c k e r ,  The  to only  p a t i e n t s who and  thus  between  importance  of  patient's  beliefs the  two  are  prone  to  explanatory  with  the  effects  about  his  or  models  different  i s that  aspects  her each  of  the  structure.  Beliefs 1974)  Model  was  (Becker,  originally  1976;  of preventive health behaviours,  Becker  predict  adherence  the b a s i s o f v a l u e - e x p e c t a n c y  behaviours. theory  Hochbaum,  developed  acceptance to  to  adherence.  Model  highlights  The  out  have  considered  patient's  here  age,  (Zisook  the  are  nonadherence.  similar  illness.  as  variables  illness.  carried  income  more f o r g e t f u l  Health  model a r e  be  and  Model,  1 about  been  1 these  of the  demographics  socioeconomic  factor  Beliefs  the nature  Insert  Numerous  i n Table  and  to p r e d i c t was  adapted  T h i s model  (Kersell  1958;  works  & Milsum,  the by on  1985).  20 Figure  1.  Interaction  A  visual Model  representation  of  the  Health  Strategic  Patient's  Pre-Interaction Variables  Demographics  t  t  +  4-  Patient's  Nature  Health  t  Beliefs  of  -»•  +•  4-  the  Model  Illness  t  +  4,  +  Patient's  Explanatory  Model  4Patient's  S a t i s f a c t i o n With  Practitioner Interaction Variables  t  t  4,  +  Overall  Shared  Patient  Respon-  Satisfaction  Attitudes Post-  Attributes  «-  -*•  sibility  of S i g n i f i c a n t Others  f +•  + 4-  Interaction Patient's  Use  Patient's  Problems  Variables of Unorthodox Treatments  with •«- -+  Exercise  t h e Home Program  1  Table Health  S t r a t e g i c I n t e r a c t i o n Model:  Pre-Interaction  Phase  Variables  Demographics  Age Living  Situation  Marital Ethnic Level  Status Origin  of  Education  Income Employment  The H e a l t h  Status  Beliefs  Model  Perceived  Severity  Perceived  Susceptibility  Perceived  Benefits  Perceived  Costs  (table  continues)  Patient's Explanatory  Nature of the  Severity Impact Duration  Illness  Model  T h i s means t h a t t h e p a t i e n t ' s a d h e r e n c e b e h a v i o u r according  to  the  the e x p e c t a t i o n will  produce  suggests  value the  the  that  desired  adherence  perceived  evaluation  of  the  Perceived  his  or  her  such as but  which  the  advocated  or  a  The  medical  health  about  reoccur  of  fear  of  behaviour of  or  must  or  treatment,  include  client's  and/or  the  on  four  a  cue  to  Perceived  of  with  the  d i a g n o s i s , or  with  ( i . e with is in  of  extent  to to  complexity  the  from  the  of  element, cues to m o t i v a t i o n ,  refers  barriers  with  (Becker, to the  of  to  include  patterns  treatment,  capability  the  individual's  new  associated  treatment  of  nonadherence, which  future  follow-through  benefits, also linked in  the  Evaluation both  disease  severity is  Some p e r c e i v e d  linked  a  remission,  Perceived  perceptions  side-effects  efficacy  the  benefits accruing  adopted,  belief  of  disease.  s t u d i e s have  and  1976).  Model  severity,  and  concerned  encompasses  discomfort,  (Becker,  depends  perceived  and  behaviour  Beliefs  is  future).  her  behaviour  be  regimen  which at p r e s e n t  i n the  o f c o s t s and  pain  the  Health  resusceptibility  subjective  his  which  individual,  behaviour,  accuracy  o f a recommended h e a l t h b e h a v i o u r . treatment,  the  t o whether  susceptibility,  arthritis  health  perceptions  to  i n the  individual's  seriousness  as  susceptibility  beliefs  may  has  to  1976).  belief  cancer  outcome  outcome.  advocated  (Becker,  individual's  the  individual  factors:  motivation  of  is predicted  of  duration treatment  to  adherence,  the  physician  1976). idea that  The  last  some  type  25 of  a  stimulus  or t r i g g e r  appropriate  health  individual  conscious  facing that a  sufficient  Rosenstock is  levels force  cue.  points  of health  this  point  a  preferred  cues  the idea  that  severity  behaviour. highlights  catalyze  which  they a r e  Davidhizar  suggests  This  visible  behaviours. when  by  symptomatology  Rosenstock  (1974)  states,  " t h e combined  and s e v e r i t y p r o v i d e d  the energy or  path  he  disease i s  i s corroborated  of benefits  of  action"  (less  element,  some c o m b i n a t i o n  of perceived  are necessary  i n order  of the b e n e f i t s  the powerful e f f e c t  barriers)  (p. 332).  a r e not a separate  One  to  to a severe  out that  t o a c t and t h e p e r c e p t i o n  motivation  and  susceptibility  of s u s c e p t i b i l i t y  provided  threat  F o r example,  motivational  (1966) who  i n order  t r i g g e r a c t s by making t h e  of the health  o f one's  clarifies  This  1983).  a common s t i m u l u s  further  to  behaviour.  (Davidhizar,  awareness  i s necessary  but r a t h e r  model  which b e l i e f s  point  susceptibility  to catalyze  of this  Thus,  health  i s that i t  have on a d h e r e n c e  behaviour. The  importance  discussion term  beliefs  of the explanatory  developed  beliefs  which  beliefs  or  fair  Caucasian,  by  (1980)  i n d i v i d u a l s hold  male  develop  the h e a l t h  executive  their  a  i n Vancouver  These  result  experiences. beliefs  is a  the set of  illness. as  i n any  model  to describe  and c u l t u r a l  to say that  evident  Explanatory  about  explanations  familial  i s also  model.  Kleinman  personal  interpersonal, probably  of  of a  would  of  It is young, differ  26  significantly  from  the b e l i e f s  i m m i g r a t e d , J a m a i c a n woman l i v i n g Kleinman differentiate as  (1980)  processes.  These  cope our  model.  symptoms, who  Byron,  clinical aid  we  disease  which  of disease,  called  beliefs  i s the and t h e  (Kleinman,  the p a t i e n t ' s  should  In  the  How  These  the p r a c t i t i o n e r  t o some  we  understand  look  like  (Kleinman,  same  way  that  on  degree  we  and  give to  and t h e e x p e c t a t i o n s  practitioners  a r e based  experience.  also  i n f l u e n c e s t h e meaning  go t o f o r h e l p ,  models, which  to  and/or p s y c h o l o g i c a l  the disease  to disease.  i n turn  1978).  frameworks  He d e f i n e s  illness  experience  cultural  that help  explanatory  city.  I n a d d i t i o n t o p r o v i d i n g a framework f o r  responses  disease,  with  to explain  recently  i t i s necessary  are c o l l e c t i v e l y  disease,  have o f what &  a r e used  coping  with  that  i s contrasted  meanings  understanding dictate  contends  psychosocial  which  explanatory  i n t h e same  i n one's p h y s i o l o g i c a l  This  individual's  1980).  elderly,  between d i s e a s e and i l l n e s s .  an a b n o r m a l i t y  meanings  o f an  also  theoretical  frameworks  Eisenberg,  patients have  and  have  cognitive  training  or e x p l a n a t o r y  i n the diagnosis  we  and  models  treatment  of  disease. Kleinman degree  (1980) s u g g e s t s  t o which  converge. likelihood With  The  t h a t adherence  p a t i e n t and p r a c t i t i o n e r closer  to the  explanatory  models  the convergence,  of the p a t i e n t e x h i b i t i n g respect  i s related  t o both  the g r e a t e r  adherent  the Health  Beliefs  the  behaviour. Model  and t h e  27 patient's as  explanatory  a r e s u l t of these  nonadherence. from  either  and/or  a  agreement factors  health  lack  of motivation  and/or  model,  between  beliefs  last  interaction  perceived  t o be  (Sackett actually  that  show t h a t  treatment  increases  Cerkoney  & Hart,  patients  the degree  and by  o f the i n i t i a l combined  demographics, explanatory production  model,  i s higher  lack  the time  than  of  when  (1986)  key  the p r e In  general,  i t i s chronic  1981).  Studies  as t h e d u r a t i o n o f decreases studied  She f o u n d  that  dramatically.  d i d not attend  treatment  population  of  when t h e i l l n e s s i s  o f adherence  decreased q u i t e  (Bloom,  118  out-  over  time  Her f i g u r e s the  had been  initial  completed,  had d r o p p e d o u t . these  variables;  Beliefs  and t h e n a t u r e  i n the c l i e n t  a  from  & Gammon,  clinic.  the Health  ( i . e few  the p a t i e n t ' s  from  discussed  Trepka  effect  With  population,  11% o f t h e p a t i e n t s  assessment,  result  susceptibility  of the i l l n e s s .  with a given  1980).  may  and t r e a t m e n t .  and a c u t e ,  at a psychology  that  be  1976; Z i s o o k  appointment-keeping  The  to  adherence  severe  voluntary  of d i r e c t i o n  results  occur  and t h e p r a c t i t i o n e r a l o n g  i s the nature  & Haynes,  lack  diagnosis  variable  has been f o u n d  ( i . e low  nonadherence  the patient  phase  a  as  nonadherence  many b a r r i e r s ) .  related to disease  The  40.7%  c a n be c o n s i d e r e d  With  benefits  explanatory  show  factors  low s e v e r i t y ) , o r f r o m  perceived  it  m o d e l , any n o n a d h e r e n c e w h i c h may  Model,  the  that i s , patient's  of the i l l n e s s ;  of a set of a f f e c t i v e ,  i s the  behavioral,  28 cognitive  and  constantly  i n t e r a c t i n g with  with  ongoing  practitioner) adherent To  sure,  inputs form  illustrate  was  of a  an e a r l y  be  able  are  i n combination  interaction  congenital  i n sports  with  the  subsequent  being  able  anxious  to  dealing  receive In t h i s with  a  he help  i s not e n t i r e l y  have  been  and  the r e s u l t  of  cause  the  by  strain  his active  (cognitive appraisal). by h i s d e b i l i t a t i o n  the A r t h r i t i s  (cognitive  a relatively  Society  appraisal).  normal l i f e  i s i n a l o t of pain, i n dealing  scenario  gentleman  will This  with  i n the  and t h u s i s his  illness  the p r a c t i t i o n e r i s going who  is likely  t o be  to  highly  s u g g e s t i o n s a r e made t o him.  Phase  pre-interaction  the p a t i e n t  understood,  of  ( a f f e c t i v e r e s p o n s e ) b e c a u s e he c a n  motivated t o f o l l o w whatever  Interaction  that  to lead  At the present  He  may  ( a f f e c t i v e response)  future.  (motivation).  as  h i s symptoms  t h e example  deformity,  as a young man  a g e , he b e l i e v e s  to control  see h i m s e l f  professional.  his arthritis  makes him somewhat h a p p i e r  which  These  f o r the c l i e n t ' s  his joints  he i s u p s e t  at  The  and  i n t e r a c t i o n consider  that  p u t on  participation  be  other,  the  the basis  this  but b e l i e v e s  Although  each  (eg.  i s a middle-aged  combination  which  manifestations.  behaviour.  Mr. A. who  the  motivational  brings  phase  looks  at the c h a r a c t e r i s t i c s  to the interview.  i t i s important  to understand  Now  that  the dynamics  this i s of the  29 i n t e r a c t i o n w h i c h o c c u r s when t h e p a t i e n t meet.. this  This  i s aptly  phase  three  called  elements  facilitating  patient  practitioner  attributes,  satisfaction  the i n t e r a c t i o n  have  been  adherence. shared  related  communication,  are s a t i s f a c t i o n and  with  overall  Table  2 about  here  attributes  relationship  to adherence.  affective  care,  refers  These  and  to three  which a r e  attributes  technical  are  competence  1979).  Ley  (1982)  relationship three  During  necessary f o r  responsibility,  of the p a t i e n t - p r a c t i t i o n e r  t o be  (Stone,  considered  These  S a t i s f a c t i o n with p r a c t i t i o n e r  felt  phase.  (see Table 2).  Insert  elements  and t h e p r a c t i t i o n e r  factors  transmission recall,  who  conducted  between which  extensive  communication are c r i t i c a l  of information  from  and t h e t r a n s m i s s i o n  research  and adherence  to effective doctor  on t h e  indicates  communication:  to patient,  of information  from  patient  patient  to  doctor. Commonsense d i c t a t e s all  aspects  inevitable. knows what of  these  of  that  the therapeutic  As w e l l ,  errors  t o do, b u t t h e n factors  i f a patient  have  been  will  forgets  i s not c l e a r  regime, also those  identified  errors  occur  will  i f the  Svarstad  be  client  instructions. by  about  Both  (1976).  30 Table  2  Interaction  Phase  Variables  S a t i s f a c t i o n with P r a c t i t i o n e r  Communication Affective  Care  Technical  Competence  Shared  Responsibility  Moral  Model  Medical  Model  Compensatory Enlightenment  Overall  Model Model  Satisfaction  Attributes  31 She of  found  that  one week  the patients  doctor's also  occur  i f the  patient  does  information treatment  a  treatment  could  a voluntary  two  to lack  places  I n one s t u d y  without  decision  regimen.  because  the may  found  The  &  and  undisclosed feel  that the  i s involuntary  of  knowledge  with  problem  As m e n t i o n e d  unsure  c a n be  case,  and  due t o h i s o r  current  on b o t h  i s responsible  and  thinking  the patient  and  f o r asking  for  practitioner.  The p r a c t i t i o n e r i s r e s p o n s i b l e and i n p r o v i d i n g  cause  of the diagnosis  earlier,  o f what  previous  case nonadherence i s  of the patient  the adequacy  patient  because  i n the f i r s t  In the l a s t  on t h e p a r t  i n the  when  from,  and  Gozzi  the withheld  clarification  information  full  i t was  (Korsch,  described  r e s p o n s i b i l i t y f o r adherence  practitioner.  will  expectations,  taking  the p a t i e n t  instances  i n the second.  dissatisfaction  treatment  errors  ( B e c k e r & Maiman, 1 9 8 0 ) .  nonadherence  forgetfulness  their  communicate  main w o r r i e s  n o t be c o r r e c t  the f i r s t  attributed  not  65% o f t h e i r  into consideration,  paragraph  Lastly,  52%  When t h e p r a c t i t i o n e r makes a d i a g n o s i s  remains u n e x p l a i n e d In  to the doctor, i n describing  f o r treatment.  d i d not mention  1968).  prescribes  her  one e r r o r  t o i n d i c a t e 76% o f t h e i r  Francis,  a visit  to the p r a c t i t i o n e r .  patients  failed  at least  recommendations  information that  made  following  has been  stated  by t h e  for eliciting  c l e a r , concise  information  back t o t h e p a t i e n t . The  second  p r a c t i t i o n e r a t t r i b u t e which  has been  linked  32 to  adherence  level  of  is  Is  or  to  to  and  understanding,  is  the the  and  of  patient" ability  reducing The  a  of  the which  that  last  element of  of  the  (1980) s t u d i e d  to  number  is  of  the  also  may  arousal  reassurance  the  and  is  the  and  "an  care  negative  experiencing. be  work  respect  affective  can  air  sympathy,  which  reduce be  an  practitioner  interest,  to  evince  brusque?  mentions  second f e a t u r e of  of  practitioner  and  approachability,  patient  practitioner  entails  friendliness,  the  of  give off  cold of  which  practitioner  first  practitioner  s/he  He  by  The  the  practitioner  of  to  of  the  interaction  practitioner's overall  practitioner  competence.  perception difficult  the  defined  carried  other  Cox out  anxiety-  interventions.  Hays  technical  on  reduction  combination  perception  a  or  Is  importance  ( p . 2 2 0 ) . The  arousal  states  through  the  of  been  parameters.  Does  support  signs  practitioner's  has  informal?  Does the  done  the  atmosphere w h i c h t h e  encouragement.  has  of  care  main  discussion?  states  (1974)  affective (1982)  type of  emotional  amalgamation  two  friendliness,  (1981)  offering  for  to  impatience?  warmth  Svarstad  Affective  t o n e f o r m a l or  closed  Garrity  the  the  p a t i e n c e or of  care.  according  relates  creates. open  c l i e n t ' s perception  affective  researchers these  the  patient  competence.  Their  from the  client's  DiMatteo  s a t i s f a c t i o n with  characteristics,  practitioner  separate  phase i s the  findings  suggest  competence patient's  one  is  of  respect  which  that  was  client's  important,  perception  and  of  but  33 affective  care.  The  second  element  responsibility. attempts  of  the  Basically  made by  the  interaction  shared  practitioner  form  of  (1982),  patients  sharing  control.  control  is  outcome"  (p.160).  beneficial  in  satisfaction  a  adherence  to  number  to medical  1975),  indicate  that  promotes  i t (Thompson,  factor  to  control  be  has  individual after  taken for  may  his/her  defined to  by  control  i t  into  the  problems,  and  and  an  to  be  patient  associated  i t also increases  suggests  others  on  Emery, L a z a r e &  consideration  that  stress  stress,  individual.  believe  the  Rodin  shown  increases  advantageous,  than m i t i g a t i n g She  to  is a  and  impact  been  the  (Eisenthal,  1981).  an  has  ways:  i s usually  in  process  Schorr  have  i t reduces  regimes  refers  patients  decision-making  (Thompson, 1981),  control  rather  of  include  shared  control.  ability  Perceived  (Liem,  Although  As  "the  w i t h an a v e r s i v e e v e n t  1979).  i n the  is  responsibility  d e c i s i o n - m a k i n g p r o c e s s or to s h a r e Including  phase  control that  i s the  In are  some  an  studies actually  important  meaning  some  Udin,  which  situations  better  able  to  an look  thus l e s s p e r s o n a l c o n t r o l w i l l  be  desired. One developed Kidder is  theory by  to  elaborates  Brickman,  (1982).  used  which  Rabinowitz,  Known as  explain  on  this  Karuza,  explanation Coates,  t h e m o d e l s o f h e l p i n g and  the  r e c i p i e n t s of a i d . Brickman  behaviours et a l . f e l t  of that  both  was  Cohn  &  coping, i t  helpers  individuals  and  could  34 be  classified  take  t o the degree  problem.  The c o n c e p t  for their  sub-divided the  according  into  problem,  solution  the extent  aged woman who has j u s t that in  she h a s b r o u g h t  the r a i n  might had of  of control  the c o l d  taken  the p r e v i o u s  day  consider  herself (High  of  for finding  with a cold.  upon  i s then  f o r the o r i g i n  As an example,  become s i c k  they  from  a  a  middle-  She may having  Self-Blame),  feel stood  or she  t h i n k t h a t she i s n o t t o blame a s e v e r y o n e a t t h e o f f i c e  a cold them  that  this  she  c a n make  distinctions  i t go  a four  cell  t o one o f t h e s e  Similarly, they  solution.  by  helpers  place By u s i n g  made  not o n l y  (e.g  A.A,  taking  i t from  she may  Vitamin  t h a t she has no c o n t r o l  matrix  i n time  Insert  where  away  i t has r u n i t s c o u r s e  A t any p o i n t  according  I n t h e same way,  o r she c o u l d f e e l  away o n c e  2).  week, and s o she must have c a u g h t  (Low S e l f - B l a m e ) .  Control), go  on  of r e s p o n s i b i l i t y  of self-blame  and t h e e x t e n t  t o the problem.  of r e s p o n s i b i l i t y  an  (Low C o n t r o l ) .  individual  believe C  (High  as i t w i l l From  c a n be d e v e l o p e d  one  these  (see F i g u r e  c a n be c a t e g o r i z e d  f o u r models.  F i g u r e 2 about  can a l s o  be c l a s s i f i e d  responsibility the term  to individual  here  according  f o r problem  'helpers',  practitioners,  w e i g h t w a t c h e r s ) , and s y s t e m s  blame  to and  reference  i s being  but a l s o  programs  (i.e hospitals,  social  35 Figure of  2.  Classification  m a t r i x o u t l i n i n g the four  the Shared R e s p o n s i b i l i t y Model.  categories  36  Degree o f  self-responsibility  for High  solution Low  Moral  Enlightenment  Degree  Model  Model  of selfblame  Compensatory  Medical for  Model  Model problem  37 agencies, the  government  degree  of concurrence  practitioner's outcome  of  Rabinowitz most  adopted  & Brickman  compatibility  and  helper.  seeking  reaction  been  last  only but  what  occurred. studies Taylor  they  Overall  1983).  match  or  the r e c i p i e n t  A  be  Zevon,  that  when  may  less  some  react severe  degree  of  evaluation.  about  phase  and S t r e u n i n g  combines Thus,  feels  about  has been  adherence  both  a  (1985), thought  satisfaction  i s not  the p r a c t i t i o n e r ,  the i n t e r a c t i o n  to c l i e n t  i s overall  which  shown  has  just  i n previous  behaviours  (Haynes,  1979; L e y , 1 9 8 2 ) .  Phase  t h i s p h a s e two b a s i c  a l l , the client  level  is a  the c l i e n t  might  which  satisfaction  t o be r e l a t e d  Post - I n t e r a c t i o n  of  there  the  are solved  suggested  to Linder-Pelz  the p a t i e n t  think  & Sackett,  In  problems  of the i n t e r a c t i o n  i s an a t t i t u d e  on how  predict  of the p a t i e n t .  According  and a f f e c t i v e  based  (Conn,  incompatibility  element  satisfaction.  further  elsewhere  n o n a d h e r e n c e on t h e p a r t  process  when  that  and t h e  Karuza,  that  models a r e i n c o m p a t i b l e ,  help  satisfaction  to help  relationship.  (1982) s u g g e s t  I t has  t o model  The  the i n d i v i d u a l ' s  c a n be u s e d  effectively  suggests  between t h e a d o p t e d m o d e l s o f b o t h  recipient/helper by  The t h e o r y  between  model  the helping  quickly,  and  ministries).  of motivation  i s leaving  processes are occurring. the p r a c t i t i o n e r  with  t o adhere t o t h e p r a c t i t i o n e r ' s  a  First certain  38 recommendations. be  considered  and  Cox  in  affective  of  the  the  and  these a  three which  the  may  have  i n combination  physiotherapist  a male p a t i e n t . exercise  in  Therefore, patient  when t h e may  (affective exercise will  not  be  is a  motivation include  Table  3).  of  as  his  process  further to  set  exhibit with  others,  to  to  the  deal  state  with  that  found  the  For  type  i t  health health  of  these  response,  of  knows someone who who  status,  their  each  affective  certain  appraisal  health  to motivation. a  trying  he  of  to  to  and  example,  exercise  has  tried  be  and  in  of  the  occurring variables  in  how  to  this  painful.  past.  of  the  behaviour.  himself pain  As  result  a  the he  himself.  post-interaction the  These  program,  unorthodox  the  much  influencing  home e x e r c i s e use  exercise  try this exercise  adherent the  this  thinks  friend  very motivated  problems  significant  afraid  caused  second  to  p r a c t i t i o n e r recommends t h i s t r e a t m e n t  response)  has  The phase  be  but  due  r e l a t i o n s h i p with  related  past,  also  appraisal  make a c o g n i t i v e  attendant  patient  cognitive  their current  on  recommend  must  factors.  their  an  may  the  these  goes  motivation  situation  available  of  are  The  the  patients  are  She  that  client's  elements;  nature  practitioner.  cognitions  the  the to  each of  suggests that  treatments  care  of  following  state,  r e l a t i o n to response  interrelatedness Cox  (1982) a r g u e s  client's variables  attitudes  treatments  of (see  39  Insert  With Schultz  regards (1980)  treatment  3 about  to problems with  outlines  regimen  nonadherence.  Table  which  She  a  number  various  states  Similarly,  as c o m p l e x i t y  increases,  adherence  associated  with  adherence  an  support  integral  (1975) s u g g e s t  to  that  are  regarding  the  degree  treatment  the  related  to  of  behaviour  i n c r e a s e s , adherence  decreases.  Lastly,  will  severe  also  of  been p r o p o s e d adherence  cause  friends  and  dependency dependent  regimen  side-effects a  decrease  in  and  p r e s c r i p t i o n s would b o t h assistance.  Formation  the be of  many  researchers  to  (Blackwell,  1983).  Becker  and  f a m i l y provide support  and  on  by  behaviour  Levy,  formation  their  assistance in f a c i l i t a t i n g  appointments  beliefs  factors  as  decreases.  has  part  levels:  individuals direct  of  d u r a t i o n of the treatment  Haynes, T a y l o r & S a c k e t t , 1979;  major  home e x e r c i s e p r o g r a m ,  behaviour.  Social be  the  and  the  r e s e a r c h e r s have  that  change r e q u i r e d o f t h e p a t i e n t  here  social  of  lending  of  h e l d by v a r i o u s members o f  t h e s e norms a r e t r a n s m i t t e d t o t h e  refers  money  to  on  to  the  the s o c i a l individual.  to  two Many  provide  behaviour.  c o n s i d e r e d types of norms  Green  norms.  network  adherence  1979;  Rides  pay  for  direct attitudes  and  n e t w o r k , and  how  Thus,  the  40 Table 3 Post-Interaction  Attitudes  Phase  Variables  of S i g n i f i c a n t  Others  Use o f U n o r t h o d o x T r e a t m e n t s  Problems with  t h e Home E x e r c i s e P r o g r a m  41 reactions  of s i g n i f i c a n t  important  because  patient  the health  to  reward  last  treatments.  factor  circumstantial  t h e r a p i e s as  evidence  points  variables.  that  many  arthritis  because  ineffectual  on a  long-term  a  basis.  This  more t h a n related  therapies after  one y e a r . to  disillusioned  summary,  literature  review  of  these  alternative are  often  medicine  does  elsewhere.  the Kronenfeld  the p a t i e n t s  and  physician. who  sought  i n a p h y s i c i a n ' s care f o r findings  i t would  seem  are not d i r e c t l y plausible  that  became more  forms o f t r e a t m e n t .  ten variables as b e i n g  (1982)  o n l y 5% o f t h e p a t i e n t s  i n c r e a s e as p a t i e n t s  with orthodox  to  to contacting a  being  Although  nonadherence,  nonadherence might  In  showed t h a t  t o 83%  connection  treatments  from  identify  nonadherence,  look f o r h e l p  comes  therapies prior  i s i n comparison  alternative  poor  unorthodox  a n d Wasner  As o r t h o d o x  phenomena  (1982) s t u d y w h i c h  of  resort  medical  Evidence  alternative  to extinguish  cause  patients  answers, p a t i e n t s  used  view  the p o t e n t i a l  t o the p o s s i b l e  not have d e f i n i t i v e  Wasner  and  Kronenfeld  traditional  for this  have  of the of  no s t u d i e s c o u l d be f o u n d w h i c h  two  therapies  families  the point  are  1979).  these  indicate  the response  From  behaviour,  regimen  t o be d i s c u s s e d i s t h e u s e o f  Although  of alternative  between  treatment.  self-care  (Blackwell,  The  t o shape  care p r a c t i t i o n e r ,  good  behaviour  t o the treatment  can h e l p  t o h i s o r h e r own  of  use  they  others  have  related  been  identified  t o nonadherence.  i n the By o r d e r  of  occurrence  variables Model,  are  the  illness  in  the  as  follows:  patient's  exercise  be  factors of  treatments  each  of  a  with  in  chronic  patients  nonadherents, arthritis  previous  and  patients  has  by a  of the  Health  Beliefs  and  nature  of  as  interview  shown  i t was  shared the  and  to  thus  home  use  of  a as  seven  related that  a l l  contributory  formed  which  Society  be  felt  possible  patients;  group of  with  and  others,  the  Phase).  been  They  Arthritis  comparison  the  problems with  studies,  arthritis  these  satisfaction  significant  consideration  exploratory  Model  satisfaction,  nonadherence.  populations defined  of  variables  equal  structured, two  Phase);  (Post-Interaction  these  given  to  model,  ( I n t e r a c t i o n P h a s e ) ; and  nonadherence  should  explanatory  program, a t t i t u d e s  unorthodox  Strategy  demographics,  attributes, overall  responsibility  to  Interaction  (Pre-Interaction  practitioner  As  Health  was  the  basis  conducted  group of being randomly  eight  chronic chosen  43  METHODOLOGY  Subjects Two The  populations  first  the  were  was a s m a l l  A r t h r i t i s  nonadherents.  examined  group o f people  Society As d e f i n e d  as  earlier,  aspect  periods  comparison  lack  had s i m i l a r  except  that  treatment  nonadherent i s  o f adherence regimen  population  which  to at least  f o r extended was u s e d  as a  c h a r a c t e r i s t i c s as t h e  treatment  adherence  by  first  behaviours  were  known. The  chronic  Arthritis criteria: of  The s e c o n d  group  population, not  a chronic  study.  identified  chronic,  of h i s or her therapeutic  o f time.  research  who were  being  someone who e x h i b i t s a c o m p l e t e one  i n this  nonadherent p o p u l a t i o n  Centre  personnel  male, l i v i n g  was h a n d - p i c k e d by k e y  according  i n Greater  program  Centre  could  t o t h e home  identified  Arthritis  Society  participants  these  given  program.  a home  Fifteen  criteria.  a t the exercise  because  from  the study  four  whom t h e '  of a d d i t i o n a l  ten patients  Unfortunately  are  patients  Of t h e s e ,  was a p a t i e n t  The r e m a i n i n g  dropped  physiotherapy  a n d by s e l f - a d m i s s i o n  ineligible  i n the study. was  year,  and the f i f t h  deemed  complications.  participate  exercise  as meeting  n o t be l o c a t e d ,  medical  the past  by t h e p h y s i o t h e r a p i s t ,  nonadherent were  within  following  V a n c o u v e r , between t h e a g e s  21 a n d 65, f l u e n t i n E n g l i s h , r e c e i v e d  Arthritis  to the  agreed to  one o f  these  because  he  44 consistently findings results  failed  from  a second  nonadherent As  Society.  group  was b a s e d  respondents  excluded  from the  by t h e r e s p o n d e n t i n This  left  assignment  the chronic  to the  on an a s s e s s m e n t  t o check were  and the  respondents.  indicated,  In o r d e r  were  questions.  group w i t h e i g h t  nonadherent  the interviewer,  encountered  and a n s w e r i n g  previously  with  participant  due t o d i f f i c u l t i e s  understanding  all  t o meet  the v a l i d i t y  asked  for a  chronic  by the. A r t h r i t i s  of this  assignment  self-report  of  their  adherence b e h a v i o r s . A from the As  comparison  the t o t a l ages  this  was  the only  patients  was drawn  i n English,  an a d d i t i o n a l i n case  located.  an  Arthritis  identified  After  Society  as meeting  t h e s e , two p a t i e n t s  although fluent  able  refused some  between  of  Vancouver.  from  Arthritis pool  o f 20  members were n o t  physiotherapy i n the past  exercise  program,  telephone member,  calls  English,  respondents.  or c o u l d not were made by  ten patients selection  to participate  i n the research  group w i t h seven  a r e male,  sample  the aforementioned  t o speak  to p a r t i c i p a t e  comparison  staff  chosen  r e s e r v e sample  had not r e c e i v e d  introductory  who  randomly  available  original  a home  was  i n the C i t y  information  had n o t r e c e i v e d  be  Of  of patients  o f 21 a n d 65, a n d l i v i n g  records,  year,  o f 10 p a t i e n t s  population  Society  fluent  group  was  were  criteria.  and one p a t i e n t , not  study.  sufficiently This  left  the  45  Procedures Potential group, staff  respondents  and t h e c o m p a r i s o n  group  member a t t h e A r t h r i t i s  patients  that  research  study.  from  i n both  they  the A r t h r i t i s  confidentiality,  were  Society  had been  I t was f e l t  the chronic  Society  originally i n order  selected  that  i n order  were the  sent  followed  study,  a second  researcher  explaining  telephone  i n order  call.  t o answer  that This  the study.  letters  t h e n p a r t i c i p a t e d i n a 1V2 h o u r , As also  part  .required  department  purpose  department, short At  from  contact  they  would  call  In order  was e x p l a i n e d was  a t t h e next  then  i n the study interview.  to obtain  t o t h e manager  physiotherapy  t h e t h e r a p i s t s were g i v e n  was  physiotherapy  the department  received  be  potential  of information  i n the  made w i t h  soon  participation  interest  amount  Society.  was f i r s t  and p e r m i s s i o n  meeting  a small  which  was made by t h e  in-home, t a p e d  the therapists  of the study  questionnaire  this  study  of the A r t h r i t i s  information, The  of this  from  the d e t a i l s of  any q u e s t i o n s  R e s p o n d e n t s who e x p r e s s e d  patient  Society.  r e s p o n d e n t s m i g h t have h a d , a n d t o a s k f o r t h e i r in  come  contacts  by i n t r o d u c t o r y  and i n d i c a t i n g  these  should  to maintain  subsequent  t o p o t e n t i a l respondents  research  receiving  was  by a  to p a r t i c i p a t e i n a  the i n i t i a l c a l l  and t o l e g i t i m i z e  contact  called  to notify  someone who was n o t an employee o f t h e A r t h r i t i s This  nonadherent  this head.  of the  to distribute staff  a brief  a  meeting.  explanation  46 of  the  After  study  prior  completion  to t h e i r  completion  of  q u e s t i o n s were a n s w e r e d ,  e x p l a n a t i o n o f t h e s t u d y was  the q u e s t i o n n a i r e . and  a more  in-depth  provided.  Measures The both  i n t e r v i e w schedule  qualitative  reason  for  Strauss types  using  (1967)  of  provide  and  together  quantitative  the  state,  methodology different  for this  two  a  that  Table  are  study v a r i a b l e s  and  4  questions.  research used on  process  verification.  in the  of  indicates  the  which  have  attempt not  was  always  information constructed  been  both  Together  data,  and  they  thus  and  act  mutual  correspondence  between  interview schedule questions.  of items  here  i n the  made t o f i n d possible was  reliable,  due  to  the  required.  f o r the study  interview schedule  from p r e - e x i s t i n g  constructed s p e c i f i c a l l y  which  and  i s e n r i c h e d when  same  of  primary  Glaser  supplementation  q u a n t i t a t i v e q u e s t i o n s used  are a combination  The  i s as  unison.  I n s e r t T a b l e 4 about  The  c o n t a i n e d a mix  methodologies  outlooks  through  study  valid  scales,  for this scales,  specific Interview  f o l l o w as c l o s e l y  and study.  but  as  An  this  was  of  the  which  were  nature items  items  possible  47 Table  4  C o r r e s p o n d e n c e Between S t u d y V a r i a b l e s and  Interview  Schedule  Questions  Independent V a r i a b l e s  Relevant  Questions  Demographics  ( 51) ( 5 2 ) ( 5 3 ) ( 5 4 ) ( 5 5 ) ( 5 6 ) ( 5 7 ) (58)  Health  Beliefs  Perceived  Susceptibility  (2)(4)  Perceived Severity  (6) ( 1 1 ) ( 1 5 ) ( 1 7 )  Perceived  (8)*(9)(13)*(14)*  Barriers  Perceived Benefits Patient's Explanatory  Model  (7) * ( 1 0 ) ( 1 2 ) ( 1 6 ) (18)(19)(20)(24)(25)(26)(27) (28)(30)(31)  Nature of the  Illness  S a t i s f a c t i o n with  (1)(3)(21)(22)*(23)  Practitioner  Attributes Communication  (80)(83)(86)*(87)*(92)(93)* (95) *  (table  continues)  48  Independent V a r i a b l e s  Affective  Relevant  Care  Questions  (79)*(81)(82)*(84)(85)(88)* (91)*(94)(96)*  Technical  Competence  (89)(90)(97)*  Shared R e s p o n s i b i l i t y  (59)  Overall  ( 29) (32) (98) (99_)*(100) ( 1 0 1 ) *  Satisfaction  (78)  (102)*(103)(104) A t t i t u d e s of Use  Significant  of Unorthodox  Problems w i t h Exercise  Others  Treatments  t h e Home  Program  (46)(47)(48) (49)*(50) (33)*(34)*(35)*(36)*(37)* (38)*(39)*  Dependent V a r i a b l e  Adherence  * denotes q u e s t i o n s  (40)(41)(42)(43)(44)(45)  w h i c h were r e v e r s e d  in scoring  49 variable order  definitions  as  p r o v i d e d by  theorists  t o enhance c o n t e n t v a l i d i t y .  schedule  c a n be  found  i n Appendix  The  i n the  complete  field  in  interview  A.  Adherence Adherence group The  and  the  former  validity The  behaviours comparison  latter  the  was  determine time  of  No by  the  results  and  to  measure  Studying  how  measures.  of  adherence  an  arthritis  hospital,  they  and  Davis  p a t i e n t s adhered  and  a  scale  Davis  (1976)  p a t i e n t s who  used  e x e r c i s e regime  Carpenter  well  by C a r p e n t e r  rheumatoid  from to  out  behaviours,  the  had  scale  p r e s c r i b e d at defined to  both  to the  adherence exercise  format.  authors,  indicating although  measure  was  reliability they  state  tested  by  information obtained indication  the a d h e r e n c e  Society.  g r o u p were n o t p r e v i o u s l y known.  figures  with  Arthritis  the  adherence behaviours  to  However, no  check  as  discharge.  adherence  to  taken  adherence  frequency  i n order  study.  measurements were  released  according  taken  in this  the  i n a study c a r r i e d  been  were m e a s u r e d  nonadherent  by  utilized.  just  chronic  made  order  developed  were  the  assignments  the comparison In  both  group  measurements  of  of  scale  i s given  performed  by  and  that  validity the  validity  cross-checking from  three  the authors  in relation  are  to these  of  the  other as  given the  scale  sources.  t o how  well  additional  50 This  p a r t i c u l a r measure  reasons.  First  of a l l ,  the  type  of  same  p r o g r a m ) , and the  the  two  criteria  the  only  the  quantity  (adherence  the  scale and  and  deletion  to  do  to i n d i c a t e the  their  patient  files  As  do  noted  variable  it  is  patients  exercises,  not  The is  respondents  will  are  often with  socially to  watch  scale and  a  has  been  type of is  ways  to  patients  a  1985). possible  complete  As  their  on s e l f - r e p o r t  measure  behaviour,  underestimate  as  difficult  treatment.  to r e l y of  told  information.  usually  desirable  the  added  is  not  be  slight  asks  Hilbert,  type  to  involved  19 7 6;  forced  this  seem  nonadherence  is  and  that thus,  behaviour  1976).  Because occurs  to  face  w h i c h t h e y were  this  in different  easily  good  added q u e s t i o n  adherence  criteria  and  as  adherence.  this  question  (Gordis,  possible  tend  to  exercise  patients)  have  exercise  The  authors,  respond  problem a  This  outcome  researchers  measures. adherence  many  to  of  to measure  home  single questions,  usually include  measure of  also  (Gordis,  by  to  Measurement because  not  a  exercise  frequency with  exercises.  number  i s short  q u a l i t y of  re-wording of e x i s t i n g q u e s t i o n s . respondent  a  (arthritis  appears  were made  of  to  scale  which d e f i n e proper which  for  been p r e v i o u s l y u s e d  Secondly,  changes  addition  chosen  same p o p u l a t i o n  Lastly,  i n that  The  the  study.  understood. validity  behaviour  with  current  i t has  was  when  positive self-presentation a  person  feels  (social  threatened,  a  desirability) counteractive  51 strategy 1982). that  an a s s u m p t i o n  'following always their  easy, home  may  and thus  t h e q u e s t i o n i n s u c h a way  a majority of people  already  F o r example, p r i o r  to the questions  was i n c l u d e d  read as f o l l o w s :  many  exercises  attempted have  people  exactly  which  n o t been  find  as they  to give people  further  totally  difficulty  nonadherent  i s not  i t difficult were  t o do  taught'.  This  p e r m i s s i o n t o admit  adherent,  i f this  their  exercise  Thus,  i t is difficult  regime  has made m o d i f i c a t i o n s  was  that  indeed  made  alterations  physiotherapy  told  to  a respondent  to their  whether exercise  or nonadherent,  department.  respondents program  is still who h a d  should  h e l p was e n l i s t e d  Working  who  as a group,  be  from three  patient information:  t y p e o f home e x e r c i s e s g i v e n , f r e q u e n c y o f e x e r c i s e  completion, program.  are often  whether  p h y s i o t h e r a p i s t s were g i v e n t h e f o l l o w i n g diagnosis,  adherent  i f excessive pain i s experienced.  to ascertain  as adherent  patients  between  t o h i s or her e x e r c i s e program  In order  classified  i s that  t o determine  adherent. minor  i n distinguishing  behaviour  alter  the  (Bailey,  case. A  and  a statement  that  threatening  t h e recommendations o f one's p h y s i o t h e r a p i s t  statement  the  i s made  i n the behaviour.  adherence,  they  less  T h i s c a n be done by w o r d i n g  engage on  i s t o make q u e s t i o n s seem  and q u a l i t a t i v e  Using  this  then asked  to discuss  t o whether  respondents  changes  made  to the exercise  i n f o r m a t i o n the p h y s i o t h e r a p i s t s  were  t h e c a s e and come up w i t h a c o n s e n s u s were e x h i b i t i n g  adherent  or  as  nonadherent  52 behaviours.  Based  categorized  on  this  as b e i n g a d h e r e n t  decision, or  patients  were  then  nonadherent.  Demographics This  study  their  age,  living  level  o f e d u c a t i o n , income, and  The  asked  situation,  Health Beliefs The  Health  measured Condon  using  scale  developed  a  Although  of  diabetic  adapted  to  make  towards  some  is a  for  use  was  the  selected  measures.  For  q u e s t i o n n a i r e uses  severity,  statistics. issue  second  thereby  by  using  were  Given  et  large  number  to  a l . (1983) of  easily  the  arthritis because  been  et  it  directed  scales to a l .  have  measure (1983)  of the s u b s c a l e s o f and  Champion  operationalized  analysis  been  items  barriers, by  and  health  study  Given  been  the  previous two  has  Gallin  an  have  f o r each  c r i t i c i s m mentioned  limiting  a  or The  perceived  concepts  The  one  numerous i t e m s  with  which  example,  1984).  (Champion,  has  for this  criticisms  concept  level,  measure  i t pertinent scale  previously  to  scale  each  that  origin,  which  Given,  the  only  A  Given,  designed  c r i t i c i z e d for using  benefits.  variable  by  been  perceived  ethnic  status.  patients,  of  earlier  status,  employment  Model  beliefs  addresses  marital  Beliefs  The  for information regarding  Model  (1983).  population.  respondents  use  scale  at of  perceived (1984) i s a  nominal  elementary  addresses  q u e s t i o n s , and  by  this  scoring  items  on a 5 - p o i n t  Likert  appropriate  to interval  by  (1984) w h i c h  Champion  not meet i s t h a t l i k e  scale.  level  This  data.  e t a l . (1983)  Health Belief  been w e l l - t e s t e d f o r v a l i d i t y credit,  they  validity  through  the use o f a three  questionnaire.  do d i s c u s s a t t e m p t s  These  stages  adaptation  of previous  education  m a t e r i a l s , and  diabetic  scale  does  i t has n o t  However, t o t h e  t o improve c o n s t r u c t  stage  process  included:  instruments,  mentioned  scales,  or r e l i a b i l i t y .  authors'  the  for analysis  One c r i t i c i s m  the Given  earlier  allows  (1) a r e v i e w  (2) a r e v i e w  (3) i n - d e p t h  to develop and  of p a t i e n t  interviews  with  25  patients.  Changes w h i c h were made t o t h i s q u e s t i o n n a i r e i n a d a p t i n g it a  t o the c h r o n i c nonadherence number  four  of questions  items  each.  study  i n order  This  was  t o pare  done  Items w h i c h were k e p t  were s e l e c t e d  cluster  These  to two  correlation.  make  them  items  chronic  question  added  i n order  a r e not u s u a l l y  illness  were t h e n  may o c c a s i o n a l l y  However,  go i n t o  asked  sample  of a  couple  population.  Lastly,  a  fourth  types  i t was f e l t  o f the items  concept,  relating  o f symptoms  as c e r t a i n  remission,  item-  slightly  of patients with  these p a t i e n t s regarding s u s c e p t i b i l i t y A  brevity.  reworded  Questions  as t h e presence  redundant.  of  down t o  on t h e b a s i s o f h i g h  t o measure  s u s c e p t i b i l i t y .  susceptibility or  items  the subscales  f o r the sake  a p p l i c a b l e t o an a r t h r i t i s  were  perceived  included the deletion of  an a c u t e  makes  of that  to  this  arthritis querying  would be a p p r o p r i a t e . related  to the Health  54 Beliefs helped  Model my  includes;  arthritis',  my a r t h r i t i s  may  and  health  developed  care  'I w o r r y when I t h i n k  measured u s i n g  by K l e i n m a n  practitioners  Although  purpose,  only  four  questions  were  not i n c l u d e d  the interview,  because  they  nonadherence. patients to  control  think  how  bad  of  these  were  felt  Two  and/or  questions  cure  included  used  because  t o be  they  extraneous were  added  disease.  your  for  Two  elsewhere  were  eliminated  t o the subject to find Society  Two  and  being  of the  'why  of  out whether  a r e as f o l l o w s ;  arthritis?',  this  study.  were a s k e d  two q u e s t i o n s  i n the interview  has c a u s e d  i n this  and  explanatory  developed  o f the A r t h r i t i s  their  qualitative  patient's  were  were  and t h e l a s t  of  (1980) t o a i d r e s e a r c h e r s  questions  had e x p e c t a t i o n s  which were you  eight  a number  in eliciting  models.  in  about  have  Model  v a r i a b l e was  questions  t h e home e x e r c i s e s  get i n the f u t u r e ' .  P a t i e n t ' s Explanatory This  'In g e n e r a l ,  able  questions 'what  do you  do  think  t h a t was t h e c a u s e ? '  Nature o f the I l l n e s s As  no  standardized  variable a l l questions of  this  review current  v a r i a b l e which of  questions  of  found  t o measure  were d e v e l o p e d by t h e a u t h o r . were  the l i t e r a t u r e  severity  were  the  felt  included  t o be  important  current  illness,  perceived  Elements based  disease  this  on a  activity,  impact,  and  55 perceived, future  duration  e l e m e n t s was measured w i t h respondents point your  were  i n time  asked  of the disease. a single  question.  Each  these  As an e x a m p l e ,  the f o l l o w i n g question,  how much o f an i m p a c t  of  'up t o  has your a r t h r i t i s  this  had on  life?'.  S a t i s f a c t i o n with P r a c t i t i o n e r A t t r i b u t e s The  respondent's  communication, measured  using  satisfaction  affective  researchers  family 329  physicians.  t o be h i g h e r  f i g u r e s being test-retest The this  adapted  study  item  items  from  know what  with  their  consistency  reliability.  The  exact  = .92 (n=287), and  = .63 (n=22).  high  internal  (1980) was u s e d i n  of brevity,  being  consistency.  general  i n order  satisfaction,  t o change  easily  The o n l y a  five  and the  the o r i e n t a t i o n o f  from p h y s i c i a n s t o p h y s i o t h e r a p i s t s .  this  these  on a sample o f  internal  Cronbach's alpha  measuring  of questions  the q u e s t i o n s  that  study  was  a n d Hays  were made t o t h e s c a l e i n v o l v e d d r o p p i n g  subscale  rewording  found  of i t s q u a l i t i e s  and h a v i n g  changes which  by D i M a t t e o  s c a l e o f D i M a t t e o and Hays  because  understood,  this  test-retest  as f o l l o w s :  reliability  competence  The s c a l e was u s e d by  In conducting  than  practitioner's  patients' satisfaction  p a t i e n t s , the researchers  tended  to  measures.  to assess  their  and t e c h n i c a l  a s c a l e w h i c h was a d a p t e d  (1980) f r o m two e a r l i e r two  care  with  Two  sample  s c a l e a r e , 'the p h y s i o t h e r a p i s t a l w a y s  seemed  s h e was d o i n g ' ,  and 'the p h y s i o t h e r a p i s t g a v e  me  56 suggestions  on  what I c o u l d do  t o manage my  arthritis  better'.  Shared Responsibility Shared measured and  responsibility  using  Zevon  measure  to  consistency  scale  developed  This  scale  has  age  on of  variable  of  the  validity  the  d e p e n d i n g on  scale  is  not  i s said  which of  ( J . Karuza J r . , p e r s o n a l  target  the  which  by  been  p r a c t i t i o n e r ' s choice  the  information  a  20-item  (1981).  whether  related  .8,  a  is  Gleason,  previously  of  helping  population.  available,  to  has  used  to  model  is  the  internal from  h e l p i n g models i s b e i n g 20,  Karuza  Although  r a n g e anywhere  c o m m u n i c a t i o n , May  been  .6  to  measured  1988).  Overall S a t i s f a c t i o n Satisfaction an  eight  developed This study  item by  (Pascoe  of  First  was  a  found  previous .92,  selected  been m e a s u r e d  questionnaire  that  for  s c a l e has service  have  and  found  high  Zwick internal  Thirdly, Attkisson  been u s e d  over  other  in a  number  client  types  questionnaire  values (1982)  of  Zwick  has  internal  indicate  consistency and  (1979).  nonadherence  i t holds  the  using  (CSQ-8)  Nguyen  chronic  different  Secondly,  repeatedly  Attkisson  the  advantages  1983).  have  .87.  of  a l l , the  settings  studies and  satisfaction  number  of  to  has  A t t k i s s o n , H a r g r e a v e s and  & Attkisson,  consistency.  .93,  Larsen,  because  different  been  client  questionnaire  measures. of  i s a v a r i a b l e which  that  values (1982)  of have  57 shown  that  t h e CSQ-8 a l s o  reliability. has  been  The f o u r t h  enhanced  critiquing  by  administrators this  scale  (Nguyen,  is  unreasonably attempt  when  ( A t t k i s s o n & Zwick,  high  to limit  that  answering  interview resulted  levels  of c l i e n t  style.  the  Thus,  adapting  equivalent  levels which  this  change  i n order  Society  lower  study. between  was u s e d  number  mode  the s a t i s f a c t i o n  both  of these  to tap this  need o f s i m i l a r h e l p ,  one q u e s t i o n .  studies. was  and  This  study was  questionnaire  i n an e a r l i e r  comparison  variable  unanswered  nonadherence  t o make  allow  of  mode  format.  to delete  will  an o r a l  advantages  made was  This  i t was  (Nguyen, A t t k i s s o n &  are both  used  I n an  administration  t o the c h r o n i c  t o the questionnaire  show  of s a t i s f a c t i o n  mode v e r s u s  an i n t e r v i e w - s t y l e scale  with  scale,  desirability, level  the o r a l  there  correlated  repeatedly  a written  significantly  1983).  only  done  using  Lastly,  satisfaction.  a lower  Conversely,  disadvantages t o using In  scales  a s compared t o t h e w r i t t e n  Stegner,  1983).  and  1982).  the a f f e c t s of s o c i a l  questions  in a  questions  these  reported  r e v i e w and  or any s a t i s f a c t i o n  using  respondents  validity  professionals  has been shown t o be s i g n i f i c a n t l y  studies  split-half  construct  & Stegner,  this,  of  of literature  health  Attkisson  o f the problems with  that  found  of  degree  i s that  a process  variety  service utilization One  benefit  through  a  has a h i g h  of  Arthritis  satisfaction  One o f t h e  questions  ' i f a f r i e n d were i n  would you recommend your  physiotherapist  58 to  him  or  her?'.  A t t i t u d e s of S i g n i f i c a n t This which were  variable  attitudes  of  behaviours. question,  by  the  and  significant  'what  information  one  author  F o r example,  treatments  Use  measured  were q u a n t i t a t i v e developed  this  was  Others  were  with  w h i c h was  to  others  might  reactions  recommended  by  the  regarding v a l i d i t y  qualitative.  determine  respondents  the  t h r e e q u e s t i o n s , two  how  the  of  family  These  advice  affect  were a s k e d  of  adherence  the  following  members  to  the  physiotherapist?'.  and  reliability  or  No  i s known f o r  variable.  of Alternative The  use  qualitative These  of  unorthodox  question,  questions  alternative  Treatments  and  sought  t h e r a p i e s was a  single  to determine  treatments  which  have  measured  quantitative the  numbers  been  with  one  question.  and  types  of  used  by  might  be  previously  respondents. It afraid upon  was of  by  effect,  felt  by  admitting  the  the the  Arthritis  in  socially  responsibility behaviour  up  i s present  use  of  that  used  respondents  treatments  Society.  a t e c h n i q u e was  engages  author  which  In  order  implies  which  the  (Bailey,  participant 1982).  frowned  to counteract that  u n d e s i r a b l e behaviour to  are  to  the and deny  F o r example,  this  respondent leaves that instead  the the of  59 a s k i n g - if_  respondents  were  asked  how  with  one o f t h e a v a i l a b l e  first to  form  many  had t r i e d  alternative  previous point  this  commonly c i t e d  being  As  an example,  patients  were a s k e d  With the  f o r respondents i n i t a t some  statement, A  whether  were  asked  question  respondents  program  o f each  'treatment  seventh  t o respond  w i t h home e x e r c i s e  the salience  respondents  afterwards'.  previously  tried,  Program  problems a s s o c i a t e d  t o determine  following  had  'none'.  e v e n i f t h e y have engaged  variable  order  As  they  they  i n time.  in  exercise  treatments  responses  P r o b l e m s w i t h t h e Home E x e r c i s e  discover  treatments,  o f t h e q u e s t i o n , i t i s much e a s i e r  deny t h e b e h a v i o u r ,  With  unorthodox  was  problems.  to respond me  added  had a n y p r o b l e m s  i n addition  programs  of these  made  t o t h e ones  to s i x  to the  feel  worse  i n order  with  to  their  home  had  been  which  mentioned.  these  information  questions  i s available  were  developed  regarding v a l i d i t y  by  the author,  or  no  reliability.  Enhancement o f Q u e s t i o n n a i r e V a l i d i t y a n d R e l i a b i l i t y In data  o r d e r t o improve  were g a t h e r e d  suggests  that  respondents respondent  validity  f o r t h e whole q u e s t i o n n a i r e ,  u s i n g an i n t e r v i e w f o r m a t .  an i n t e r v i e w f o r m a t non-verbal  spontaneity.  allows  behaviour, Access  Bailey  (1982)  f o r access  to the  as w e l l  to non-verbal  as  increasing  behaviour  allows  60 the  Interviewer  being. in  The  first  these than  first  truthful  i n other  to r e f l e c t  t o what  come  to  mind.  respondent  the  thinks  fact  likely  first  state  feels  that rather  thoughts  really  the  is that  to  informative  what t h e r e s p o n d e n t  the  the  Bailey  t o be  words,  respondent  to  a r e more  a r e more l i k e l y  Or  the  spontaneity refers  which  thoughts  normative.  compared  of  how  q u e s t i o n s , respondents  thoughts  more l i k e l y  to  estimate  advantage  answering  the  to  are  believes,  interviewer  as  wants  hear. One  fear  which  would  get  being  nonadherent,  form  of  assuage  back  to  the  interview strictly  Arthritis  Society  had  i t was  i f they  or otherwise  stressed  a l l interview  at  i s that  the  admitted  engaged  In  an  attempt  to  to  i n some  beginning  i n f o r m a t i o n was  word  of be  to the  kept  confidential.  Miller  (1986)  what  i t i s supposed  free  of  random  states, to)  " i f a measure  i t must  error)"  t o improve  effect  on  the  reliability  addition,  one  technique  reliability. available  then  had  an  validity  the  responses  could  responses  For  also  (p.59).  techniques  they  have  undesirable behaviour.  fear,  that  may  dissatisfied,  socially this  respondents  choose  Thus,  of  was  the  the  used  (assesses (relatively  aforementioned  interview  a  positive  schedule.  specifically  In  to  improve  questions, cards  listing  given  to  their  answer.  e q u a l chance  reliable  s h o u l d a l s o have had  closed-ended  were  be  is valid  the  respondents By  of being chosen;  using  from  which  cards a l l  whereas,  i f the  61 a n s w e r s were  read  aloud  t o the respondent,  the f i r s t  and l a s t  a n s w e r s may have had a d i s p r o p o r t i o n a t e c h a n c e o f b e i n g due  t o the primacy  or recency  chosen  effect.  Data Analysis One  of the d i f f i c u l t i e s  research other  i s that  words,  variety order  the methodology  analysis  also  this  study  as a supplement  was c a r r i e d  example,  o u t by c o d i n g  i f any m e n t i o n  Similarly,  transcripts  variables  affected  notations made  important f o r  compiled  t r a n s c r i p t s were t h e n  interview Appendix 2.  then  used  of the q u a n t i t a t i v e  transcript,  been  primarily  analysis.  prior  i n this  respect  made  This  according  study.  t o how  For  aspects  a notation  was  i n the i n t e r v i e w  r e f e r e n c e t o any o f t h e o t h e r  tape  results  data  adherence  were  in this  were  have  used  was made w i t h  variables being considered  the  Thus, i n  the i n t e r v i e w t r a n s c r i p t s  i f respondents  quotations  data  to the q u a n t i t a t i v e  the patient's illness  These  in a  analyzed.  the q u a l i t a t i v e  to t h e v a r i o u s independent  made.  scientists.  i t i s not o n l y  t h e means by w h i c h t h e d a t a was  used  applied  In  r e s e a r c h e r s t o know t h e q u e s t i o n s w h i c h were a s k e d , b u t  In  of  are often  social  t o occur  qualitative  i s not s t a n d a r d i z e d .  techniques  o f ways by d i f f e r e n t  for replication  future  a s s o c i a t e d with  study.  Quotations  categorically  to either data  by v a r i a b l e .  verify  or dispute  analysis.  to analysis,  from t h e  c a n be  A  sample  found  in  62  The  quantitative  univariate central for  was  tendency,  each  factors  associated  comparison interval In members  As  of dispersion  the study  nonadherent  For variables tests  the a c t u a l found  that  which  adherence some  g r o u p were, i n f a c t ,  finding,  conducted. rearranged behaviours. would  a second For into  this  second  I t was  felt  p r o v i d e a more a c c u r a t e  a s s o c i a t e d with adherence.  were  determined  to  ascertain  t-test any  of  analysis  differences  group  and t h e  d i d not  produce  of  the  group  chronic  a d h e r e n t , and some members o f nonadherent. and m e d i a n  analysis  according that  measures  behaviours of  members  s e t of t - t e s t s  groups  process of  were c a r r i e d o u t .  t h e c o m p a r i s o n g r o u p were c h r o n i c a l l y this  a  s e t up  t o o b s e r v e whether  d a t a , median  i t was  was  nonadherence,  i n the chronic  measuring  underwent  the frequencies,  with chronic  group.  level  nonadherent  whereby  out i n order  evident  first  a n d measures  variable.  carried  were  analysis  data  this  to  tests  respondents actual  second  indication  Because o f were were  adherence  set of  analyses  of the f a c t o r s  63 RESULTS  When  t h e s t u d y was o r i g i n a l l y  set up  t o compare  d a t a between t h e c h r o n i c  comparison  group  with  chronic  analyzed,  i n order  i n the chronic  their  exercise  respondents  nonadherent  Once  that  nonadherent  programs.  group  nonadherent.  Although  this  was  a second  s e t of analyses  felt  that  only  group  began  program,  two o f t h e s e v e n  were  represents  original  Arthritis  analysis  which  those  factors  behaviours.  that  Thus,  chronic and  first  found  a 25% e r r o r , i t  should  be c a r r i e d o u t  the e f f e c t s  i ti s this  analysis  the randomly 3.  home  of the  I t i s this  because  related  second  i t points to  to patient  a n a l y s i s which w i l l  which  compares  group as d e f i n e d chosen  adherence  be d i s c u s s e d  of l a b e l l i n g  of the design  t h e d a t a between t h e  by t h e A r t h r i t i s  comparison  A d i s c u s s i o n which  Before presenting limits  importance  are actually  to their  d i d not, regardless  categorization.  t o be  pages.  nonadherent  Appendix  Society  i s of primary  on t h e f o l l o w i n g The  a n d t h o s e who  t o be  were a d h e r e n t t o  between t h o s e r e s p o n d e n t s who r e p o r t e d a d h e r e n c e exercise  associated  two o f t h e e i g h t  Similarly,  i n the comparison  was  group and t h e  the data  i t was d i s c o v e r e d  respondents home  the intention  t o determine the f a c t o r s  nonadherence.  however,  f  group  c a n be f o u n d i n  looks at deviant  h a s been appended  the r e s u l t s  Society,  behaviour and  to this  analysis.  i t i s important t o note the  in its ability  to detect  statistically  64 significant  findings.  d a t a a n a l y s i s was Thus,  the  This  carried  analysis  possibility  of  c a n be a t t r i b u t e d  o u t on a v e r y  was  prone  rejecting  a  to  However,  although s t a t i s t i c a l l y  lacking,  the  which  study  ideally  examining  should  the  significance  did point be  mean  level  which  sample Two  (N = 1 5 ) .  interesting  analyzed  with  a  nature of the study (Blalock,  larger  between  chosen  due  the to  true.  findings  some  was  the  i s , in fact,  to  .10  that  Error";  significant  differences of  small  "Type  finding  to the f a c t  are  findings  sample. two  the  In  groups  a  exploratory  1972).  A n a l y s i s U s i n g S e l f - R e p o r t e d Measures  o f Adherence  Demographics Many and both  of  nonadherent groups  situation, differences age,  group  were  and  or  lower  shown  educational  Thus,  older,  were  characteristics t o be  well-matched  included  same c a t e g o r y a  demographic  nonadherents  adherents. age  the  age  level.  and  tended 62.5%  while  of  only  (see Table  percentage of  to the  42.9% 5).  be  which  status.  slightly  nonadherents of  With  the adherent For  respect  Factors  to  respect are  are adherents  living  showed  With  than  46  to marital married (57.1%).  minor  regard  older are  example,  the a d h e r e n t s are  nonadherents  compared t o t h e p a t i e n t s who  similar.  with  marital  of  the  years in  to  of  this  status,  (37.5%)  as  65  Insert  As  i n d i c a t e d i n Table  differences tended  The  Health  These  each  a n d employment  individual's  perceived  health  active  model.  questions  the heading  instance  adherents tended  benefits.  separately,  As  single  mentioned  they  can  unit,  the  earlier,  a r e not u s u a l l y asked as  which  the presence  showed  of nonadherents  s e v e r i t y (see Table  Insert  perceived  of of  redundant.  v a r i a b l e s , one  i n the scores  of health  severity,  of a  symptomatology  symptoms makes t h e q u e s t i o n  this  Nonadherents  and p e r c e i v e d  dimensions  beliefs  with  In  under  barriers,  as v a r i o u s  patients  perceived  considerable  and unemployed.  h a s been a n a l y z e d  susceptibility  difference  show  status.  variables are perceived  perceived  these  do  Model  of these  considered  here  f a c t o r s that  v a r i a b l e s a r e subsumed  susceptibility,  Of  5 about  low income e a r n e r s  Beliefs  beliefs.  Although  5,  a r e income  t o be b o t h  Four  be  Table  Table  a  significant  and a d h e r e n t s  was  6 ).  6 about  here  the cross-tabulation  t o have a s t r o n g e r  belief  indicates  i n the f u t u r e  that  Table  5  Cross-Tabulations:  Patient  Demographic C h a r a c t e r i s t i c s  by  Adherence  Demographic  Nonadherents  Characteristics  No.  Adherents  %  No.  n = 8  Age  (Median =  Under 46  % n =  7  46)  years  3  37.5  4  57.1  5  62.5  3  42.9  Alone  3  37.5  3  42.9  Other  5  62.5  4  57.1  Married  3  37.5  4  57.1  Other  5  62.5  3  42.9  3  37.5  3  42.9  5  62.5  4  57.1  46 y e a r s and  Living  Marital  over  Situation  Status  Education High  School  Post-High  or l e s s  School  (table  continues)  67  Demographic Characteristics  Nonadherents No.  %  Adherents No.  n = 8  %  n = 7  Income under  20,000  6  85.7  3  42.9  1  14.3  4  57.1  Employed  2  25.0  5  71.4  Other  6  75.0  2  28.6  20,000 and above  Employment  68 Table 6 T-Test A n a l y s i s  Perceived  of the Health B e l i e f s  Severity  nonadherents  Model w i t h  Mean*  SD  12.3  3.0  9.9  3.0  Adherence  t  -1.36 adherents  * Means were o b t a i n e d by f i r s t items r e l a t e d  to perceived  the average t o t a l  summing  severity.  score o f each  2-Tail  Prob  0.197  t h e s c o r e s on t h e f o u r The mean t h u s  respondent i n each  represents group  69 severity  of their  disease  than  d i d nonadherents (see  Table 7).  Insert  Patient's Explanatory The  Explanatory  explain showed  their that  Table  Model  a majority  of people  result  the  e x i s t e n c e o f some t y p e  heredity  (50%),  experiences standard likely  two-stage  arthritis.  i n a combination  that  events  making of  first  by  and  and  the A r t h r i t i s  study  smaller  These p a t i e n t s h e l d life  previous  diseases,  poor  and f o r a n o t h e r  food  habits,  individual  life  of  are as  a  large  in  these  patients  explanations to the n o t i o n them,  Some  respondents  improper  improper  early  Society  somehow weakened  r e f e r r e d t o by  them t o were  belief  percentage  involves  light  i s evident,  had a  was  injury  o f one o f t h e s t a n d a r d  early  experiences  disease  previous  As  use t o  data  stage  them more s u s c e p t i b l e t o t h e a r t h r i t i s .  the e a r l y  child,  A  experiences.  i n their  their  (19%),  disease.  in this  believed  early l i f e  people  factors i n this  heredity  of rheumatic  explanations.  that  The  injuries  espoused  standard  and  mentioned  Both  of patients  felt  process.  previous  explanations  percentage  a t the reasons  o f f a c t o r which p r e d i s p o s e s  Often  (31%).  causes  looks  A n a l y s i s of the q u a l i t a t i v e  the  getting  here  Model  illness.  of a  7 about  thus  examples include  c l o t h i n g as a  c l o t h i n g as an  70 Table  7  Cross-Tabulations;  Health  Beliefs  The H e a l t h  Beliefs  Nonadherents No.  %  Model  by  Adherence  Adherents No.  n = 8  Perceived  %  n = 7  Severity  High  4  50.0  6  85.7  Low  4  50.0  1  14.3  High  3  37.5  4  57.1  Low  5  62.5  3  42.9  Perceived (Median  Severity  Split)  71 adult.  Only  one  e x p e r i e n c e was The of  the sole  second  some  type  respondent  stage  of  arthritis.  Only  activating  their  factor  believed  which  two f a c t o r s disease.  an  early  p r e d i s p o s i n g him t o  of the process  event  that  requires  triggers  These  arthritis.  the occurrence  development  were m e n t i o n e d  life  of  the  by r e s p o n d e n t s  were s t r e s s  as  (58%) and  illness  arthritis  was t h e  (42%). Not result  a l l respondents of  a  two-stage  explanations disease,  able did  as  not  believe  arthritis. both  that  a l l four  they the  were  to  hoping  agency's  these  were  listing  arthritis of  were  by p a t i e n t s  were  ( 1 5 % ) , and  treatment  have  prone  (21%) were  to  respondents  but  getting  (66%) to  factor  felt note  as t h e  nonadherents.  patients  care.  exercise  explored  Treatment  the A r t h r i t i s  in their  might  the a r t h r i t i s ,  triggering  of treatment  t o get from  the  It i s interesting a  had  towards  patients  somehow  expectations.  types  (13%)  that  t h e e x p l a n a t o r y model  involvement  medication)  four  triggered  necessary.  treatment  to s p e c i f i c  mentioned (e.g  was  part  events  the m a j o r i t y of  respondents  patients  predisposed  o f any  they  were  of t h e i r  second  patients  that  were  which  their  Two  Conversely,  factors  factors  s o l e cause  refer  not aware  However,  that  A  they  the disease.  to pinpoint  that  process.  t o why  b u t were  activated  believed  expectations remember  Society Types  of  (35%), other  information (50%).  expectations, adherents  with  prior  to  treatment treatments  With  were  that  regards  much  more  72 likely  t o have e x p e c t e d  the procurement of  t h a n were n o n a d h e r e n t s The  second  patients  felt  possible. with  No  respect  Society  cure  their  Illness  The  factor  only  relation  problems. more  adherents  to  the have  (42.9%)  belief  9  lists  respondents  their  to  was  findings other  in addition  Table  and  adherence.  indicates  the the  show  to t h e i r  the  ability  illness presence i s that  problems  8 about  medical  S a t i s f a c t i o n with P r a c t i t i o n e r 10  their  disease  the  of  whether  two  the  was  groups  Arthritis  itself of  which  other  had  medical  nonadherents  were  (75.0%)  were  than  8).  Insert Table  Table  of  was  disease.  medical  (see T a b l e  other  control  i n the  related  Insert  component  were e v i d e n t between  to adherence  What  likely  Table  and/or  t o c u r e or c o n t r o l  Nature of the  some  expectation  differences to  (100%),  (42.9%).  treatment  that  information  here  problems primary  9 about  experienced  by  a r t h r i t i s diagnosis.  here  Attributes  relationship  between  satisfaction  73 Table  8  Cross-Tabulation:  Presence of other Medical  Problems  Nature of the I l l n e s s  by  Nonadherents No.  %  Adherence  Adherents No.  n = 8  %  n = 7  Yes  6  75.0  3  42.9  No  2  25.0  4  57.1  74 Table  9  Other M e d i c a l  Medical  Problems Reported  Problem  by S t u d y  Respondents  Number o f P a t i e n t s R e p o r t i n g  Depression  3  Reiter's  2  Syndrome*  Hypertension  2  Fibrositis*  1  Bronchial  1  Back  Asthma  Injury  Hiatus  1  Hernia  1  Episcleritis* denotes medical  1 problems  that  a r e a form o f  arthritis  Problem  75  Insert  As  c a n be  seen,  significance  T a b l e 10 a b o u t  the only  factor  i s a f f e c t i v e care.  point  out that  nonadherents  their  physiotherapists  which  shows  any d e g r e e  Cross-tabulations  were  level  here  somewhat  of  more  affective  (Table unhappy  care  than  of 11)  with were  adherents.  Insert  Table  11 a b o u t  here  Shared R e s p o n s i b i l i t y Table shared  12  illustrates  13  illustrates  tabulations. that the  the  T a b l e 12 a b o u t  t h e same d a t a  I t was  found  i n d i v i d u a l accumulated low  actual  of the  four  r e s p o n s i b i l i t y m o d e l s by a d h e r e n c e .  Insert  Table  the c r o s s - t a b u l a t i o n s  or  high  ends  differences  split-median  of  between  with scores  here  with  the f i r s t were  t h e two  thus  groups.  these  cross-  cross-tabulation  tending  the continuum,  cross-tabulation  median-split  By  to c l u s t e r at blurring  the  carrying  out  differences  were made  T a b l e 10 T-Test A n a l y s i s of Patient Attributes  Affective  with  Satisfaction  with  Practitioner  Adherence  Care  Mean*  SD  nonadherents  18.1  3.4  1.07  0.302  adherents  21.3  7.5  1.07  0.302  * Means were o b t a i n e d by f i r s t items  related  average t o t a l groups  2-Tail  Prob  summing t h e s c o r e s on t h e n i n e  to a f f e c t i v e care. s c o r e o f each  T  The mean t h u s r e p r e s e n t s t h e  respondent  i n each o f t h e two  77 Table  11  Cross-Tabulations; A t t r i b u t e s by  Patient S a t i s f a c t i o n with  Practitioner  Adherence  Practitioner Attributes  Nonadherents No.  %  Adherents No.  n = 8  Affective  %  n = 7  Care  Satisfied  6  75.0  7  100.0  Dissatisfied  2  25.0  0  0.0  Satisfied  5  62.5  3  42.9  Dissatisfied  3  37.5  4  57.1  Affective (Median  Care  Split)  78 Table  12  Cross-Tabulations:  Shared R e s p o n s i b i l i t y  Shared R e s p o n s i b i l i t y Model  M o d e l s by A d h e r e n c e  Nonadherents No.  %  Adherents No.  n = 8  Moral  %  n = 7  Model  (High B l a m e / H i g h  Control)  Low  3  37.5  1  14.3  High  5  62.5  6  85.7  Low  7  87.5  6  85.7  High  1  12.5  1  14.3  Low  0  0.0  0  0.0  High  8  100.0  7  100.0  Low  7  87.5  5  71.4  High  1  12.5  2  28.6  Medical  Model  Low Blame/Low  Compensatory  Control)  Model  (Low B l a m e / H i g h  Enlightenment  Control)  Model  (High Blame/Low  Control)  79 more  distinct. I n s e r t T a b l e 13 a b o u t  It  can  be  seen  themselves (low  that  t o be  blame/high  both  solid  control).  i s evident  i s that  their  choice  adopted  addition  of  to  scoring  nonadherents control)  also  and  that  nonadherents  adherents  for  a d h e r e n t s and model  (low  strongly  these  blame/high  of  medical (high  the  differences uniform i n  adherents.  compensatory model  (low  blame/low  blame/low  median c r o s s - t a b u l a t i o n s considerably  models.  lower  This  scores  shows  control),  the  indicate the  although  compensatory  nonadherents  o t h e r models w h i c h  model  than  that  were p r o p o n e n t s o f t h e  In  model,  control)  to theory, shared r e s p o n s i b i l i t y  s h o u l d be  between  the l i t e r a t u r e  whom  the  the  were more  than  on  paired  with  the p h y s i o t h e r a p i s t s  a match  hold  of  model  were  more  propound  low  control.  respondents  who  two  nonadherents  According  is  one  uniform i n rejecting  l e v e l s of  scores  However,  low  had  showed  compensatory  model,  the s p l i t  adherents  the  nonadherents  enlightenment  In f a c t ,  and  of  high  had  scores. the  nonadherents  proponents  which  here  the  they  the  two  are  working.  shared  adopted  model  models.  of  the  responsibility  i n order to determine  review, adherence same a d o p t e d  the  scores  As  i f there  discussed  in  s h o u l d be h i g h e r f o r p a t i e n t s as  the  Unfortunately  physiotherapist for  this  study  with two  80 Table  13  Cross-Tabulations: (Median  Shared  Responsibility  M o d e l s by A d h e r e n c e  Split)  Shared R e s p o n s i b i l i t y Model  Nonadherents No.  %  Adherents No.  n = 8  Moral  Model  (High  Blame/High  n = 7,  Control)  Low  5  62.5  3  42.9  High  3  37.5  4  57.1  Low  6  75.0  2  28.6  High  2  25.0  5  71.4  Low  4  50.0  4  57.1  High  4  50.0  3  42.9  Low  5  62.5  2  28.6  High  3  37.5  5  71.4  Medical  Model  (Low Blame/Low  Compensatory  Control)  Model  (Low B l a m e / H i g h  Enlightenment (High  %  Control)  Model  Blame/Low  Control)  81 f a c t o r s prevented patients  have  treatment,  this  had  and  more thus  physiotherapist  could  were  not  models  be  of  follows: model at  nine  This  to  should  be  one  was  at  For  impossible  the the  Society  Arthritis of  feel  blamed f o r t h e i r  the  that  to  which  Secondly,  three  for  thus  adopted were  as  compensatory  physiotherapists  important  there  these  and  tested  (4),  whole,  i t is  the  decide  care  were  the  providing  Society,  model  However,  members as  Some o f  i n t e r e s t , the  who  moral  t h a t , on  control.  staff  provided  sake  (1),  to  comparison.  physiotherapists model  place.  physiotherapist  originally  suggests  have  these  i t  longer  Arthritis  patients among  no  medical  (4).  the  who  tested.  the  than  to choose f o r the  physiotherapists patients  p a i r i n g from t a k i n g  for  their  are  mixed  feelings  to  which  patients  degree  problems.  Overall Satisfaction T-test between  analysis  the  indicates  o v e r a l l  that  few  satisfaction  differences of  exist  adherents  and  nonadherents.  A t t i t u d e s of No  relationship  significant to  note  S i g n i f i c a n t Others  others  that  adherence. previously  For  and  advice  was  adherence. from  example,  adherent  indicated  until  one he  between  However,  others  will  respondent talked  with  attitudes  of  i t is interesting sometimes  states a  that  f r i e n d who  affect he had  was a  82 similar  medical  amount  of pain  stopped  doing  respondent  problem. as a  result  had t o e n d u r e  a  of exercising, h i s  exercises.  Upon  hearing  significant friend  this  had  news, t h e  d e c i d e d t o do t h e same, a s he was a l s o f i n d i n g t h e  exercises painful  Use  Having  to carry out.  of Alternative  Treatments  No d i f f e r e n c e s  were f o u n d  between  the use o f a l t e r n a t i v e  t r e a t m e n t s by a d h e r e n t s and n o n a d h e r e n t s .  Problems  w i t h t h e Home E x e r c i s e  When  patients  problems exercise that  previously program,  asked  found  adherents  (see Table  are equal  t h e median  to a  14).  with their Analysis  t o o r below  indicates  relative  of  t h e home  test  analysis  exercises  than d i d  shows  t h e median,  a r e i n t h e same  variety  with  i t was d i s c o v e r e d f r o m median  the nonadherents  below  t o respond  t o be a s s o c i a t e d  a d h e r e n t s had l e s s problems  nonadherents  of  were  Program  that  while  position. freedom  71.4% o f  o n l y 37.5% A  from  position exercise  problems.  I n s e r t T a b l e 14 a b o u t  One hard  o f the problems doing  exercises  mentioned on one's  here  by r e s p o n d e n t s own.  This  was  was a p t l y  that  i t  is  described  83 T a b l e 14 Median T e s t A n a l y s i s o f Problems w i t h t h e Home E x e r c i s e Program w i t h  Adherence  Home E x e r c i s e Program Problems  Nonadherents No.  %  Adherents No.  n = 8  Few  ( L E Median)  3  Many (GT Median) Exact P r o b a b i l i t y  5 .3147  37.5 62.5  %  n = 7  5 2  71.4 28.6  84 by  one p e r s o n  rope. rope  You've around  reference stated, week and by  when  you j u s t  "I think  worse,  exercises  tend  painful we u s e d  too sore. and I j u s t  respondents  "It's  g o t one, but i f t h e r e  t o how  I was  he s t a t e d ,  were  to forget exercises  like  having  i s nobody about  could  a  skipping  else  skipping  i t " .  I n making  be, a n o t h e r  a  patient  t o go e v e r y week and a f t e r t h e f i r s t  Things quit  going".  the lack  were u n i n t e r e s t i n g ,  needed t o do t h e e x e r c i s e s .  were  getting  worse,  Other  problems  o f improvement, and t h e f r e q u e n t  and w o r s e , mentioned  the f a c t lack  that  of energy  85 DISCUSSION  Variables Related What which  the  show  of  the As  two  study  and  problems with  the  situation  to  perceive  the  surprising, also  the  high  be  of  disease  suggests, the  variables  made are  between  perceived and  nature  fact  most  high  if i t  perceived  that  neither  in their  exercise  and  left  not the  their  engaging  in  which  b e n e f i t s of adherents  to  behaviours.  each  or of  However,  what  disease  perceived of  active  future severity As  Rosenstock  susceptibility type  i s chosen of  and was  was  must  the  nonadherents risks  likely  supports  presence  some  be  This  only  the  the  susceptibility  untreated.  s e v e r i t y and  perceptions  program.  of  also perceive  behaviour  risks  nature  respondents.  The  felt  health  that perceived  for  health  of  of  a d h e r e n t s were more  through  is  s e v e r i t y i s one  Model which a r e  that  motivation  study,  difference  finding  p a t i e n t s must  perceived  home  is  three  initiation  (1974) c o n t e n t i o n  but  this  the  across  symptoms,  behaviour.  Beliefs  future problematic  susceptibility  In  These  three  home e x e r c i s e program,  c o n s i d e r i n g the  Rosenstock's  their  Health  f o r c e s behind  this  the  the  are  comparison  discussed previously, perceived  In  provide  when  there  Adherence  illness.  motivating  (1974)  Measures of  i s that  nonadherents.  elements of  was  shows  differences  adherents severity,  to Self-Reported  of  only  health  depends  on  alternatives. showed  b e n e f i t s of evident  was  much the the  86 s i g n i f i c a n c e o f a. s i m i l a r v a r i a b l e w h i c h a s k e d p a r t i c i p a n t s t o respond with  t o a v a r i e t y of problems p a t i e n t s  their  that  home e x e r c i s e  adherents  exercises, of  than  the Health  patient will costs the  reported  engage  perceived  i n those  t o them. risks  t o home e x e r c i s e  their  t o engage  i n health  i s that  choosing  they  their  In  were  alternative  therapies.  nonadherents  use unorthodox  form  was  found  of treatment that  therapies  might  be e x p l a i n e d  found  t o be u s i n g  the l e a s t  to explain  up w i t h  why  t h e same related  and was  thus  m i g h t be h a v i n g  with  was  found  therapies,  by e i t h e r  that  both t r a d i t i o n a l  options  a r e they  on t h e i r  was  that  this  use o f  62.5% o f  a n d 37.5% do n o t u s e  existed  adherents  by t h e f a c t  because o f t h e  Interestingly  difference  i s that i f  of answering  t o remark  whatsoever.  little  what  t h e hopes  asked  What  findings  home e x e r c i s e s  are experiencing,  respondents  any  must a  but they  the v a r i a b l e  w h i c h i s r a i s e d by t h e s e  i n i t s stead.  question,  home  programs.  nonadherents a r e f o r s a k i n g which  was  the v e r a c i t y  have  reason  d i d n o t come  variable,  their  not only  which  possible  found  behaviours,  t o p a r t i c u l a r problems p a t i e n t s  One q u e s t i o n  marginal  that  p r o b l e m s was much more s p e c i f i c ,  home e x e r c i s e  problems  One  with  supports  behaviours  variable  as t h e o t h e r  sensitive  problems This  experience  the study  B e l i e f s Model w h i c h a s s e r t s  attached  findings  less  What  d i d nonadherents.  be m o t i v a t e d  only  programs.  normally  enough, i t  i n the use of  or nonadherents.  some o f t h e p a t i e n t s  This were  and n o n t r a d i t i o n a l f o r m s o f  87 treatment  i n attempting  to control  nonadherents  who t u r n e d  a  experience  negative  countered in  echoed  to their  orthodox The  last  variable  primary  this  may  used  arthritis.  occurrence attention as b e i n g  other  medical  finding i s  noticed  point  more s e r i o u s .  i n time  Even  nonadherents  has a s i n g l e attention medical  i s necessary  multiple  medical  to  What  medical  to treating the illness,  they a r e  to i t scare. problem problem  may  The  deflect  i s perceived  i f i t i s not p e r c e i v e d as b e i n g  each  suggestions  research  were  i n addition  of other  attached  i f t h e second  between  these  many  were a d h e r e n t s .  the presence  full  the f i r s t ,  t o be a l l o t t e d  that  As d e s c r i b e d  more i m p o r t a n t , m u l t i p l e m e d i c a l p r o b l e m s means t h a t has  were  treatments,  This  problems,  the importance  their  that  d i a g n o s i s , than  o f an a d d i t i o n a l  from  program.  i t was f o u n d  When an i n d i v i d u a l  to devote  exercises,  alternative  (1982) who  having  a l s o made u s e o f a c o m b i n a t i o n o f  i s that  diminishes  home  i s nature of the i l l n e s s .  arthritis  suggest  Thus, t h e  therapies.  section,  t o have  their  problems  study  and unorthodox  likely  able  who a l s o  arthritis.  therapies after  their  home e x e r c i s e  i n their  the previous  more  with  by K r o n e n f e l d a n d Wasner  participants  in  to alternative  by a d h e r e n t s  addition  their  of the i l l n e s s e s . are speculative.  t o determine  problems  how  increases  attention At  this  Further  the presence  of  the l i k e l i h o o d  of  nonadherence. From  the f i n d i n g s  of t h i s  study  i t i s apparent  that the  88 Health  Beliefs  Model  nonadherence  which  patients.  discussed  is  As  f o u n d , one  One  can  Limitations  of  Some o f section this  paper.  present  in  earlier,  which  to  this  the  of  once a cause f o r rectify  i s p a r t i c u l a r l y apt  arthritis  nonadherence  the  for  the  situation.  working  with  contracting.  Study  shortcomings  been For  explaining  sample  b e l i e f s i s a process c a l l e d  the  have  was  closest  then begin e f f o r t s to  intervention  people's health  comes  discussed  of  t h i s study mentioned  at  greater  the  sake  of  l i m i t a t i o n of  most  import  length  brevity  they  in  this  elsewhere  will  be  in  briefly  reiterated. The lack  of  a  large  significant situation remain  findings  now  stands,  obscured  analytic  This  statistical  sample that  to  may  findings  of  is  a  result  present.  of  Error.  the  findings  significance  been  detection  that  of As  the  any the  power  of  the  size  of  the  However, l a c k can are  the  significance  weakened  a Type Two  potential  has  statistical  The  direct  the  been  any  analysis.  i s known as  of  ensure have  s i g n i f i c a n c e aside,  variables  further  from  techniques  sample.  to  enough  i n t h i s study  still  of  point  deserving  of  attention.  A second retrospective respondents reporting  on  l i m i t a t i o n of in  nature.  difficulties Kinsey's  sex  t h i s study This  with  can  memory  research  i s the be  f a c t that  problematic  recall.  findings,  Bailey states  it  was  due  to  (1982)  that  the  89 most d i f f i c u l t y of  people  frequency,  have w i t h  and r e p o r t i n g  However,  little  reporting  types of behaviour  to  that  state  recall,  two  are that  salience the  difficulty  when  the f a l l i b i l i t y  meaning,  remember  than  a short  with  first  o f memory  began.  respondents  in.  respect  to the i n d i v i d u a l  He g o e s on  to behaviour  increases  as t h e  d e c r e a s e s , and as  increases.  Thus, a b e h a v i o u r o f  ago, w i l l  be more d i f f i c u l t t o  while  a behaviour  i s i n terms  evident with  t h e y h a d engaged  rules-of-thumb  o f the behaviour  recall  a behaviour  seemed  time p e r i o d o f the r e c a l l  little  behaviour  o f some  import  which  took  place a  number o f y e a r s a g o . The chronic are  difficulty nonadherence  behavioral  questions beliefs,  adherence  i n the study thoughts  be f o u n d  With  regard  salience  study  i s that  behaviours. a r e aimed  and f e e l i n g s .  which  addressed  to adherence,  o f the event  individual  varying  degrees  veridicality prospective caused  views  recall  would  of the  respondent  i n these  suggest  the  govern  the  Since i t i s probable  that  would  exercise  i t i s difficult  o f any one r e s p o n d e n t . decrease recall.  areas.  that  h i s o r h e r home  by v a r i a b l e memory  most  at uncovering  to the i n d i v i d u a l  would  to determine  Instead  memory  Bailey  of importance,  design  attempt  which  U n f o r t u n a t e l y no i n f o r m a t i o n  accuracy o f h i s or her s e l f - r e p o r t . each  information to the  the only questions  i n n a t u r e , a r e t h o s e which  respondent's  could  i n transposing this  program  with  to assess the  In t h e f u t u r e , the v a r i a t i o n  use o f a  i n accuracy  90 A  third  impossible  limitation  t o measure  of this  study.  As i n d i c a t e d  the  shared  responsibility  adopted  of both  model.  measurement  in  fact,  successfully  o f models  because  test  this  shared  responsibility,  which  control  respondent  both  variable  and  the  measurement  patient's  With  i t was d i f f i c u l t i n patient  accurate  practitioner's  adopted  of the i n a b i l i t y  a prospective  an  interfered  a r e mute w i t h  with  of the shared  out.  respect  Thus,  to shared  of the design  little  information  to ascertain  would  on  with  ensure  variable  models c o u l d  to  the r o l e As  help  responsibility  and p h y s i o t h e r a p i s t ' s  the  models, the  nonadherence.  design  in  measurement o f  n o t be c a r r i e d  variable.  plays  recall,  could  t o be  variables  required  complications  the f i n d i n g s  responsibility  accurate  discussion,  of a l l the physiotherapist's  pairing  actual  i n prior  the patient's  Since  necessary  i t proved  one o f t h e more i m p o r t a n t  the  assessment  s t u d y was t h a t  an as  be a s s e s s e d  concurrently. The lack  last  shortcoming  of a clear  choosing confusion  respondents nonadherent  prior group  some members  to  their  to define  of the c h r o n i c  admission  of  was  that  group.  Thus,  selection  variable.  nonadherent  nonadherence  on  to  i s some  admitted  of  was a  prior  there  f o r the  as the l e v e l this  there  nonadherence  the nonadherence  i s t h e same  chosen  study  of chronic  nonadherent  to whether  which was l a t e r  their  definition  the chronic as  of this  t o by  chronic  nonadherence F o r example,  g r o u p may  have  based  the fact  that  they  91 occasionally w h i c h was be  forgot  later  considered  t o do  their  chosen f o r the  exercises. study,  By  the  definition  these p a t i e n t s would  not  nonadherent.  Implications  for  Social  Work  Practice;  The  Contracting  Process Contracting increase  an  r e g i m e s by three  allowing  useful  the  model. use  which  to  this  process  place  to  begin  an  for care.  are  Beliefs  which  help  Model  and  h i s or  An  to the  individual  Wiggins of  i s s e e n as  itself  the  (1986)  systems  and  essential for  limit  for  with  the  illness.  Two  examine t h e s e patient's  which  they  is  the  form  thoughts  explanatory  practitioner their  the  can  illness.  basis  of  an  behaviour.  and  perspective  between  important  i n t e r e s t i n g approach  Schwartz  The  assessment,  her  t o d e t e r m i n e t h e meaning t h a t p a t i e n t s g i v e  individual's  to  therapeutic  assessment  f e e l i n g s about  B o t h m o d e l s have q u e s t i o n s  are  i s meant  their  self-responsibility  in  formulations  Health  Meanings  are  process  contracting.  t h o u g h t s and  theoretical are  greater  involved  n e g o t i a t i o n and  person's  multi-stage  i n d i v i d u a l ' s adherence  steps  A  is a  an  to who  theory.  subject  look From  at a  comes  meaning  systems  growth,  Although  i t i s necessary  quantity  of m a t e r i a l s  from  from  approach  open s y s t e m w h i c h e x c h a n g e s  i t s environment.  q u a l i t y and  the  these  the an  material materials  for  the  system  to  that  are  taken i n .  For  example,  o u r body  carbohydrates,  sugars,  manner,  t h e body  between  itself  environment  only  must  needs  certain  minerals, also  and v i t a m i n s .  limit  t h e exchange  and t h e e n v i r o n m e n t .  which  assimilable.  h a s much  The  means  amounts  more  This  about  through  the use of m e a n i n g - s t r u c t u r e s .  Wiggins  (1986)  of  complexity  they  state, that  u n b u r d e n human l i f e  r e m a i n o v e r w h e l m i n g a n d unmanageable" Meaning-structures they  a r e formed  personal means  caution,  does  examples culture adult  a n d r e d means  familiar  which  in a  a c t by  and  small  example  stop.  Schwartz  effect  unfamiliar.  n o t make  o f a method  place  sense  order  and  reduction because otherwise  the world,  and  of s o c i a l i z a t i o n  and  mean  go,  yellow  When one has a f e v e r i t When o n e ' s  see a doctor. which  most  may  be  i n India.  the world Information in this or  a  existence  lights  but which  village  ordering  d i s c a r d e d or ignored. an  with,  has a d e f i n i t e  does  we  traffic  of information  are familiar  structures  reduction i s  go t o bed and g e t p l e n t y o f r e s t .  of pieces  i s readily  w h i c h would  a combination  Green  i n an  (p.1216).  t o how  n o t go away, one s h o u l d  living  familiar  through  experiences.  means one s h o u l d fever  refer  similar  information  than  As  f o r human  of a complexity  of  this  "meaning-structures  i s necessary  In a  i s necessary  information  to bring  df p r o t e i n ,  of  people  i n our  foreign Thus,  t o an  meaning-  experience  with  which  structure.  f i t into  These a r e  this  we  into are  Information structure is  D e n i a l as a common d e f e n s e mechanism i s humans employ  to disregard  information  93 which does n o t This need  to  fit.  provides  assess  one  the  explanation  as  t o why  patient's health beliefs  practitioners  and  explanatory  model.  As p a r t s o f t h e p a t i e n t ' s m e a n i n g - s t r u c t u r e ,  factors  determine  will  disregarded.  Mr.  be 'Z ,  Mr.  t h e major At  the  'Z'  has  joints  hesitant  his health.  that  One  active  exercise  him  they  two  he  that  was  were not active. having  was  In  of  situation.  I n t h e p a s t Mr.  do  to  he  one  him  how  has  respect  to  for his  that  states,  him big  health to  the  "they shrivel  them anyway".  important  i n order found  not  'Z' i t  e x e r c i s e s and from  the  are  will  referring he  of  years. at  of  v a l u e h e l d by Mr.  information  ten  important  In  their  i n many  w i t h Mr.  feel  values.  second  'Z'  that  fact,  not  this  practitioners  i t i s very  of  as a c h r o n i c  strong values with  understanding  importance  to  what  in  patient  talking  the o p i n i o n I got  The  a  that  In  given  to just  was  i t is felt  does  his  five  two  case  participated  past  means  and  i n the  been i d e n t i f i e d  i s that  that  supposed That  t o remain  has  accepted,  involvement  he  independent.  is  program  die.  now  because  understand  I was  h i s mind  illness  him  he  who  f o r the  This  of these  and  practitioners  40's  recommendations.  frustrations  up and  his  t o work w i t h  treatment  thought  of  be  i s borne out  osteoarthritis  nonadherent.  became a p p a r e n t  be  had  S o c i e t y , b u t he has  treatment  to  This point  i n h i s body  beginning  Arthritis  follow  information w i l l  a gentleman i n h i s l a t e  1  study.  what  these  that  to  i t was 'Z'  cope  In for  i s the with  a  i t is difficult  94 getting  accurate  practitioners,  and  recommendations. trust  h i s own  and  went  are  back  t o work 'Z's  not.  beliefs these  t a k e them i n t o In  how  the  of  forth  with  The  upon  negotiation the  written  up  these  which  and  adherence  that  for  which  to  the  activity,  he  had  their  effective  had  found  assessed  she  would  c o u l d have  and  Mr. have  tried  to  practitioner  is  offer  by  contingency rewards  h i s or  the  has  and  with  illness  current  so  begins  some  type  plan.  possible at  an  back  of  also  Some  included  contracting.  1979;  the  this  problems (Becker  the  plan  r e s e a r c h on use  Mann,  and  mutually  During  solutions  on  medical  a  agreement,  patient.  and  t h e n comment  to d i s c u s s p o t e n t i a l  & Lutzher,  or  her  can on  treatment  arriving  (Lowe  the  based  responds,  i s able  contracting  of  once  thoughts  and  signed  for  use  and  about  concludes  Upon  of  the  problems  are  h i s need  model,  of  learned  found  the p r a c t i t i o n e r  patient  efficacy  that  he  self-reliance  process,  treated,  treatment,  known as  when  thoughts  the p a t i e n t  1980).  is  has  treatments  explanatory  diagnostic  Maiman,  good  and  potential  of  dialogue  agreed  of  he  I f the p h y s i o t h e r a p i s t  client's  validity  knowledge.  which  health  mistrustful  mistrust  understanding  contracting  the  him  be  from  consideration.  i t s h o u l d be  the  not  to  this  Thus,  t o a method  health  aware  was  information  tends  of  to t e l l  i n the p a s t .  recognized  he  Because  physiotherapist he  thus  body  which  medical  of  & is  the  rewards  1972).  This  T h i s r e s e a r c h has  shown  r e i n f o r c e m e n t s has  been  effective  95 in  modifying  behaviour  cardiovascular  disease,  Maiman, 1 9 8 0 ) . long  term  move  an  related  renal f a i l u r e  the  i n d i v i d u a l from to  obesity, and  However, what does not  e f f i c a c y of  rewards,  to  personal  For  these  reasons the  has  been d e l e t e d  changes,  on  diabetes,  drug abuse  seem t o be  behaviour reliance  juvenile  an  (Becker  known i s  or  how  external  r e s p o n s i b i l i t y for  treatment  contingency part  the  of  from f u r t h e r d i s c u s s i o n s  this  the  one  can  system  of  adherence.  contract  of  &  process  intervention  strategy. Using the  a  process  of  is  no  longer  recognized  that  developing  a  held  both  with  the  treatment  exercise  treatment. this,  w h i c h was  and  The so  discussed  the  Using  was  until  (1978) when he  the  of  part  negotiation his  an  he  could  had  Mr.  'Z'  as to  i t  is  play  in  with  given.  had  footing.  Mr.  ' Z'  dissatisfaction He  would  preferences  then  agreement  puts  have  been  responded  worked  would have  been h e a r d , and  for  that  left his  out this  needs  physiotherapist.  contracting  discusses  Boston.  equal  originally  physiotherapist  f e e l i n g that  example  an  a c h a n c e t o s t a t e h i s own  on,  were u n d e r s t o o d by  a more e q u a l  chance to v o i c e he  above  practitioner  have  s a t i s f a c t o r y to both.  interaction  An  the  plan.  program  t h e n have been g i v e n  by  parties  would have a l l o w e d him  to  as  p r a c t i t i o n e r - p a t i e n t r e l a t i o n s h i p on  Power  the  negotiation  Hospital  in  solving,  decision-making,  a  at  program  Designed and  to  work set  is up  given at  facilitate  education,  the  the  by  Barofsky  Beth  mutual program  Israel  problemworks  by  96 focussing meeting  on t h e p a t i e n t ' s with  personal  the physician,  the patient  which  s/he h a s been e x p e r i e n c i n g .  these  symptoms  decided then both  upon.  signed  or  plan  have because  written  a  commitment  down  plan  treatment  of action i s and i s  transaction  plan.  now has a c l e a r  the plan  symptoms  interaction  of this  and the p a t i e n t  to follow  Prior to  by t h e p a t i e n t  As a r e s u l t  the p a t i e n t  her r e s p o n s i b i l i t i e s ,  jots  joint  i s recorded  negotiated  record.  In the ensuing  and a  by b o t h p a r t i e s .  sides  beneficial  are discussed, This  medical  This  record  of h i s  has a l s o  outlined  i s  made  a  i n the medical  record. In  summary,  contracting a of  o f treatment  information  f u l f i l l  states,  discussions  beneficial  a n d how  precise  approach  benefit  of contracting  greater  sense  contracting made  and  of  process  adherence  any  control. relates Levy  i s more l i k e l y  out i n order  to  states  From  this  as a  highly  The s e c o n d  the p a t i e n t  with a  benefit  of the  last  to the p u b l i c  As  be  (p.217).  i t provides  (1976)  exchange  might  may be v i e w e d  The  i s that  involves  that  reward.  education"  i s that  process  be c a r r i e d  claim  in a  of the patient.  behaviours  contracting  to patient  by t h e p a t i e n t .  shown t h a t  i s required  must  benefit  an e x p l i c i t  "the contracting  they  contingency  the patient  The f i r s t  requires  of s p e c i f i c  the contract  perspective  goals  a s t o what  (1981)  concrete  of engaging  process are t h r e e - f o l d .  discussion  Garrity  the benefits  commitment that  t o occur  which i s  studies  have  i f patients  make  97 an o v e r t  commitment  Contracting As an  - A Technique f o r Enhancing  j u s t mentioned,  growth  number o f Taylor  decision  (1984).  steps  Barofsky  and/or  charge  of  It  then  ask  &  end,  can  by  as  result  control.  at  o u t l i n e d by ones most  in  This  looking  control, information  alter  behaviour  recording presumed  the  transaction assembly is  the  a  Fiske  relevant  control,  and  In  that  to  the  follow  create.  to comply.  i s analogous  to  the  workers  have  only  to  of  program  visiting  would  the  an  take  described  be  patient  were  their  opinions  Additionally, which  contrasted is told  What i s l a c k i n g  what i n the  one  criticism  small  part  of to  they  with  d e f i c i e n c i e s inherent The  in  physician.  treatment plan can  by  opportunities  the  voice  the  aversive  of a l l , p a t i e n t s  to  l i n e method o f p r o d u c t i o n . that  ability  timing  interview.  This the  the  a number o f  First  patients  during  or the  were g i v e n  symptoms p r i o r  as  l i k e l i h o o d , decrease  duration  1984).  i n t e r a c t i o n i n which  i s then expected  defined  control.  were e x p e c t e d to  be  reduce  Taylor,  themselves helped  lines  understood  interventions  behaviour  questions  patients  and  better  (1978), p a t i e n t s  to e x e r c i s e  normal  can  r e s p o n s i b i l i t y and  those mentioned, the  control to  (Fiske  was  process  control.  intensity, event  be  Of  are  Behaviour active  can  regimen.  Control  contracting  control-enhancing  to c o n t r a c t i n g  and  the  enhanced sense of p a t i e n t  potential  and  to a p a r t i c u l a r treatment  to  the do,  latter in  an  assembly fasten  to  98 the  c a r , and thus  product. play  little  attachment  I n t h e same manner, most  i n the development  attachment the  feel  other  hand,  have a p a r t  i n the Beth  Israel  to play i n every  a b l e t o take ownership Decision  patients  of a treatment  t o the recommendations  that  decision this  ultimately  to the p a t i e n t  informing the  with  room  arrangement.  them  a number  and cons  the e a s i e s t  to follow.  The b e n e f i t s  was  illustrated conducted  by L a n g e r  between  the former  were  given  choose  which  a plant  night  they  t o take wanted  On  (1976)  1984).  the f i n a l However, choices  may  feel  study  allow  will  control  i n a study  In t h i s  do i s  treatments,  and then  they  type  i s legally  t o make  of decision  a number  be  have which  one o f t h e  and c o n t r o l  of choices  group  t o make.  o f the d e c i s i o n - m a k i n g p r o c e s s as  t o how c o m p l a i n t s w o u l d be h a n d l e d to  & Taylor,  o f each,  the experimental  They were a l l o w e d t o be p a r t  no  patients  some  the p h y s i c i a n  which  and R o d i n  a t a n u r s i n g home.  differences  that  (Fiske  of alternative  the treatment  major  t o make  the practitioner  t o choose  was  program,  f o r the patient  patient  been  given.  the p r a c t i t i o n e r .  What  of the pros  feel  to  plan.  the a b i l i t y  relationship  rests  l e a v e s ample  this  suggest  been  f o r t h e p a t i e n t ' s m e d i c a l c a r e , and thus  still  within  have  Hospital  of c h o i c e r e g a r d i n g the a v e r s i v e event  responsible  no p a r t  s t e p o f the p r o c e s s , and thus a r e  concerns  In t h e p a t i e n t - p h y s i c i a n  have  finished  p l a n , and thus  o f the treatment  control  to the  care  i n t h e home, t h e y were a b l e  o f , and t h e y  t o see movies.  had a c h o i c e o f  In t h e c o n t r o l  group  99 these  choices  outcome  of  these  experimental and  by  were  more a c t i v e .  improvements  was  a  to  slight by  look  by  one  of  being  of  plants  they  the  staff  members.  improvements  of  the  environment  it  types  last  category,  Based  of  rated  by  on  and  previously  how  order,  in  control of  the  themselves  group  chose,  attributing  i s that  there  control  members were  allowed  while  control  this  study  when  group  given, cared f o r  Nevertheless, i n spite  possible  and  behaviour  of  is a  people  this  powerful  are  in  an  refers  to  powerless. simply  i n f o r m a t i o n about d i s c u s s i o n of  experiences As  with Fiske  the  aversive  meaning-structures,  information helps  unfamiliar.  that  both  information control,  the e a r l i e r  was  The  h a p p i e r , more a l e r t ,  amount  control,  obtaining  i s understandable of,  of  i n which they are  importance  sense  control  t h e p l a n t s t h e y were a r b i t r a r i l y  example  event.  residents.  the d i f f i c u l t i e s  i n the  of  the  were  the  in decision  differentiation  The  of  Experimental  the  for  significantly  t o changes  group.  after  members had  respondents  manipulation  each  made  tokens  However, one  the  held  small  group  o t h e r s as  already  patients  which and  they  t o make  have  Taylor  been  state,  " i n f o r m a t i o n c o n t r o l p r o v i d e s a schema f o r t h e e v e n t , t h a t i s , a g e n e r a l u n d e r s t a n d i n g o f what w i l l happen and why. A c c o r d i n g l y , when p e o p l e f a c e t h e e v e n t , t h e y can make s e n s e o f each i n d i v i d u a l s t e p , and t h e y know when s o m e t h i n g signals a p o t e n t i a l p r o b l e m " (p.122) In  this  Arthritis  study  i t was  Society  were p r i m a r i l y  for  found  that  treatment  rather or  cure,  than many  s e e k i n g i n f o r m a t i o n r e g a r d i n g how  going new their  to  the  patients illness  100 works, a n d what t h e y c a n do t o cope w i t h t h e a r t h r i t i s .  Future  Outlook  As  t h e scope o f t h i s  much t h a t  s t u d y has been v e r y  needs t o be done i n t h e f u t u r e .  much o f a "hands-on" p r o f e s s i o n , should  have  nonadherence  study  possible  causes  population. this  findings  meets  of chronic  of research  are tentative.  Lack  should  be t h e  by p o i n t i n g  that  to  arthritis  the r e s u l t s o f  of s t a t i s t i c a l l y  i n v i t e s p r u d e n c e on t h e p a r t  of  adherence.  i n a male  be s t r e s s e d  research  the case  patient  obligation  nonadherence  work  In  t o enhance  this  However, i t must  study  and t h u s s o c i a l  outcome  of interventions partially  S o c i a l work i s v e r y  implications.  one p r a c t i c a l  development This  practical  l i m i t e d there i s  significant  o f anyone r e v i e w i n g  this  research. Nevertheless,  two m a j o r  study.  One o f t h e f i n d i n g s  Beliefs  Model  within  this  and  deal  sample.  potential  In other  proactive  rather  chronic future  to assess  to beginning  occurs.  i s that  than  a  treatment,  beliefs  before  practitioners  reactive  stance.  was  conducted  with  should  determine  i f this  Health  i s that  of  their  to pinpoint nonadherence  need As  this  occurring  finding  i n order  factors  from the  n o n a d h e r e n c e was  the health  causal  words,  nonadherence researchers  why  study  The i m p l i c a t i o n o f t h i s  need  prior with  of t h i s  seems t o e x p l a i n  practitioners patients,  f i n d i n g s have d e v e l o p e d  to adopt  this  a male  study  a of  population,  finding  i s also  101 valid  with a female The  second  Appendix some  3)  i s that  nonadherents. the  being  was  deviant  most  process  assessed.  discussed  a t work w h i c h  research  correct.  of  labelling  the  as  were p r o v i d e d ,  However,  the  been  in  of  patient's  viewed  as  with  sign  dysfunctional  and  a the  which  the  labelling  these of  respect it the  needs  to  area  of  dispensation  of  new  future  researchers  labelling  setting,  was  that  and  whole  interesting for  medical  it  than seeing  a  in  and  process  of  to  on  deviant  study  the  patient  and  behaviour. technique  contracting  contracting voluntary  a  the  intervention  the  be  introduces  to  but  implication  Rather  in  chronic  to a s c e r t a i n which of  theory  be  degree  occurs  ramifications  One  finding  I t would  identify  practitioner  i t should  resulted  inappropriately  i s temporarily  This  that  behaviour  is  that  i t  is  interested  this  The  well  which  particular health on  explicated  process.  nonadherence  been c a r r i e d out  and  this  behaviour,  therapeutics.  be  labelled  analysis  p r a c t i t i o n e r s view nonadherence.  study,  to  some f a c t o r was  scope of  therapeutic be  the  f i n d i n g i s t h a t a c h a n g e needs t o t a k e p l a c e  t o how as  ( r e l a t e d to  Numerous e x p l a n a t i o n s  explanations this  finding  patients  outside  population.  has  beliefs.  e f f i c a c i o u s technique.  whether  this  reason  suited  intervention,  in determining  in  been As  for  paper  choosing  for  dealing  the  result  little  future  has  with of  a  research  has  researchers  may  contracting  is a  useful  102  BIBLIOGRAPHY A n d e r s o n , R. 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My  name i s P a u l Adam.  the U n i v e r s i t y about to  how  talk  of B r i t i s h  people to  experience  react  you  about  with  the  with the treatments During  Interview  this  I am  Columbia.  to  a graduate  I am  arthritis.  your  hoping  with  S o c i e t y , and  I am  going  t h e n w r i t e down y o u r  answers.  to  what  of  understand  and  I will  seek  to  right  repeat  find  or  strictly  what  your  answers.  like  you,  beliefs A l l your  experience  disease. you  a  I f you please  number are  thus  answers  know  questions  there will  of  unable  l e t me  Many o f t h e are,  your  are be  no  kept  confidential. Do  you  have any  questions?  (1)  What t y p e o f m e d i c a l  (2)  Many p e o p l e  which  asked  t h e q u e s t i o n f o r you.  out  wrong  i s being  I would  your  t o ask  q u e s t i o n s and  at  more  arthritis,  have r e c e i v e d f o r the  interview  student  to l e a r n  Therefore,  experience  Arthritis  you  Schedule  their  your  have d i f f i c u l t y  doctor  has  agree  (c) I don't (d)  given  diagnosis i s correct?  (a) s t r o n g l y a g r e e (b)  problem(s)  disagree  know  do  you  believing them.  Do  have? the  diagnosis  you  believe  that  112 (e) For  strongly disagree  respondents with o s t e o a r t h r i t i s ,  (3)  I s your a r t h r i t i s  currently  skip  t o Q.5  active?  (a) y e s (b) no if  a, s k i p  t o Q. 5  i f b, (4)  Do you t h i n k  i t is likely  that  your a r t h r i t i s  will  flare  up a g a i n i n t h e f u t u r e ? (a)  strongly  agree  (b) a g r e e (c)  I don't  know  (d) d i s a g r e e  (5)  (e)  strongly disagree  How  long  ago were you d i a g n o s e d  as having  this  type o f  arthritis? (a)  less  (b) 1 - 5 (c)  than 1 year years  5 - 10 y e a r s  (d) more t h a n 10 y e a r s (e) The feelings  I don't  know  following y o u may  statements have  about  refer your  exercise  program.  F o r each  to  you a g r e e  or disagree with  which  that  these  a r e your  to various arthritis  statement  l e t me  t h o u g h t s and  and your know  the statement.  personal beliefs,  and t h a t  home  the extent Remember  t h e r e a r e no  113 right  o r wrong  (6)  I  answers.  believe  I  will  always  need  to  do  my  home  exercises. (a)  strongly  agree  (b) a g r e e (c)  (7)  I don't  (d)  disagree  (e)  strongly  know  disagree  My e x e r c i s e s  do n o t make me f e e l  (a)  agree  strongly  better  (b) a g r e e (c)  (8)  I don't  (d)  disagree  (e)  strongly  know  disagree  D o i n g my e x e r c i s e s  i n t e r f e r e s w i t h my n o r m a l  daily  work  activities (a)  strongly  agree  (b) a g r e e (c)  (9)  I don't  (d)  disagree  (e)  strongly  know  disagree  I t has n o t been d i f f i c u l t that (a)  was g i v e n strongly  (b) a g r e e  t o me  agree  following  the e x e r c i s e  program  114 (c)  (10)  I d o n ' t know  (d)  disagree  (e)  strongly  I believe (a)  disagree  t h a t my e x e r c i s e s  strongly  will  c o n t r o l my  arthritis  agree  (b) a g r e e (c)  (11)  I d o n ' t know  (d)  disagree  (e)  strongly  disagree  My a r t h r i t i s  will  (a)  agree  strongly  c a u s e me many p r o b l e m s i n t h e f u t u r e  (b) a g r e e (c)  (12)  I d o n ' t know  (d)  disagree  (e)  strongly  Doing hard (a)  disagree  exercises  i s something  I must  do no m a t t e r  i t is strongly  agree  (b) a g r e e (c)  (13)  I d o n ' t know  (d)  disagree  (e)  strongly  disagree  I t takes a l o t of e f f o r t (a)  strongly  agree  (b) a g r e e (c)  I don't know  t o do t h e s e  exercises  how  115  (14)  (d)  disagree  (e)  strongly  I would  have t o change t o o many h a b i t s  exercise (a)  disagree  program  strongly  w h i c h was g i v e n  to follow the  t o me  agree  (b) a g r e e (c)  (15)  I d o n ' t know  (d)  disagree  (e)  strongly  disagree  My a r t h r i t i s  will  (a)  agree  strongly  c a u s e me t o be s i c k  a lot  (b) a g r e e (c)  (16)  I d o n ' t know  (d)  disagree  (e)  strongly  In g e n e r a l , (a)  disagree t h e home e x e r c i s e s  strongly  have h e l p e d my  arthritis  agree  (b) a g r e e (c)  (17)  I don't  (d)  disagree  (e)  strongly  I worry in (a)  know  disagree  when I t h i n k  the future strongly  agree  (b) a g r e e (c)  I don't  know  about  how b a d my a r t h r i t i s  may g e t  116 (d) d i s a g r e e (e)  strongly disagree  (18)  What do y o u t h i n k h a s c a u s e d y o u r  (19)  Why do you t h i n k  that  was t h e c a u s e ?  (20)  Why do you t h i n k  your  illness  (21)  How  would  you r a t e  this point (a)  arthritis?  s t a r t e d when i t d i d ?  the s e v e r i t y  o f your  arthritis  at  i n time  1 - no e f f e c t ,  whatsoever  (b) 2 (c)  3 - minimal  (d) 4 (e)  5 - average  (f)  6  (g) 7 - s e v e r e (h) 8 (i) (22)  9 - very severe  How much  l o n g e r do y o u t h i n k  your  arthritis  i s going to  last? (a)  the rest  o f your  life  (b) more t h a n 5 y e a r s (c)  1 - 5  years  (d) 6 months t o 1 y e a r  (23)  (e)  less  t h a n 6 months  (f)  I don't  Up t o t h i s arthritis  know point  i n t i m e how much o f an i m p a c t  had on y o u r  life  has your  117 (a) no  impact  (b) m i n i m a l  impact  (c)  know  I don't  (d) m o d e r a t e (e) g r e a t (24)  Before any  impact  impact  going  to the A r t h r i t i s  treatments  Society  d i d you  receive  f o r the a r t h r i t i s  (a) y e s (b) no if  no, s k i p  t o Q. 27  i f yes, (25)  To what  controlling  e x t e n t were  your  (a) v e r y  effective  (c)  I don't  (e) t o t a l l y type  effective  know ineffective  ineffective  of treatments  the A r t h r i t i s  d i d you r e c e i v e  What t y p e o f t r e a t m e n t s were you h o p i n g  (28)  What d i d you want t h i s  (29)  D i d you r e c e i v e get?  (a) y e s (b) no  before going t o  Society?  (27)  to  in  effective  (b)  What  treatments  symptoms?  (d) m i n i m a l l y  (26)  these  treatment  the type  to get?  to accomplish?  of treatments  you were  hoping  118 (30)  Do y o u f e e l  that  treatments  from  the A r t h r i t i s  Society  the A r t h r i t i s  Society  c a n h e l p t o c u r e you a r t h r i t i s ? (a)  strongly  disagree  (b) d i s a g r e e (c)  I don't  know  (d) a g r e e (e) (31)  strongly  agree  Do you f e e l  that  treatments from  can h e l p t o c o n t r o l (a)  strongly  your  arthritis?  disagree  (b) d i s a g r e e (c)  I don't  know  (d) a g r e e  (32)  (e)  strongly  To  what  extent  been  satisfied  the  Arthritis  Society?  (a)  very  received  the from  satisfied  indifferent  or unsure  dissatisfied  (e)  dissatisfied  mostly  variety  with  satisfied  (d) m i l d l y  A  (33)  you  o f t h e t r e a t m e n t s y o u have  (c)  of reasons  n o t happy w i t h t h e i r  extent  have  effectiveness  (b) m o s t l y  are  agree  are often  given  home e x e r c i s e  t o which each o f the f o l l o w i n g  as t o why  program.  Indicate the  a p p l y to you.  t r e a t m e n t was u n c o m f o r t a b l e o r p a i n f u l  people  (a)  strongly  agree  (b) a g r e e (c)  indifferent  or unsure  (d) d i s a g r e e (e) (34)  strongly  t r e a t m e n t was (a)  strongly  disagree too involved agree  (b) a g r e e (c)  indifferent  or unsure  (d) d i s a g r e e (e) (35)  strongly  disagree  t r e a t m e n t made me (a)  strongly  feel  worse a f t e r w a r d s  agree  (b) a g r e e (c)  indifferent  or unsure  (d) d i s a g r e e (e) (36)  strongly  disagree  treatments required (a)  strongly  t o o l a r g e o f a change i n my  agree  (b) a g r e e (c)  indifferent  or unsure  (d) d i s a g r e e (e) (37)  strongly  t r e a t m e n t was (a)  strongly  (b) a g r e e  disagree going to l a s t agree  too long  life  120  (38)  (39)  (c)  indifferent  (d)  disagree  (e)  strongly  or unsure  disagree  t r e a t m e n t d i d n o t seem (a)  strongly  (b)  agree  (c)  indifferent  (d)  disagree  (e)  strongly  other,  Following always  effective  agree  or unsure  disagree  please  indicate  t h e recommendations  easy,  and thus  some  o f one's p h y s i o t h e r a p i s t people  find  their  home e x e r c i s e s  (40)  What e x e r c i s e s d i d y o u r p h y s i o t h e r a p i s t do  (41)  as part  How o f t e n  e x a c t l y a s t h e y were  i t difficult  o f your home e x e r c i s e do you do e a c h o f t h e s e  (a) more t h a n once  (42)  daily  (c)  5 - 6  times/week  (d)  2 - 4  times/week  (e)  weekly  (f)  less  your  d i d the p h y s i o t h e r a p i s t  exercises?  daily  t o do  taught. suggest  that you  program? exercises?  than weekly  (a) more t h a n once (b)  not  daily  (b)  How o f t e n  is  daily  recommend  that  y o u do  121 •(c)  5 - 6  times/week  (d) 2 - 4 times/week (e) w e e k l y (f) (43)  less  than  A r e you d o i n g by  weekly your  exercises  exactly  a s y o u were  taught  the p h y s i o t h e r a p i s t ?  (a) y e s (b) no (44)  What changes have you made?  (45)  Why d i d you make t h e s e  (46)  What  were  treatments (a) v e r y  the reactions  family  members  to the  satisfied satisfied  indifferent  (d) m i l d l y - (e) q u i t e (47)  of  recommended by t h e p h y s i o t h e r a p i s t s ?  (b) m o s t l y (c)  changes?  dissatisfied dissatisfied  What were t h e r e a c t i o n s o f f r i e n d s t o t h e t r e a t m e n t s recommended by t h e p h y s i o t h e r a p i s t ? (a) v e r y  satisfied  (b) m o s t l y (c)  satisfied  indifferent  (d) m i l d l y (e) q u i t e  dissatisfied dissatisfied  (48)  What a d v i c e d i d t h e y g i v e  (49)  Many  people  often  you a b o u t  t r y other  types  the e x e r c i s e s ? of t r e a t m e n t  other  122 t h a n what i s recommended i n t h e hopes o f f i n d i n g for  their  disease.  treatments  How many a l t e r n a t e  t h e r a p i e s or  have you t r i e d ?  (a) more t h a n  4  (b) 3 - 4 (c) (d)  1-2 none  if  d, s k i p  if  a - c  t o Q. 51  (50)  What o t h e r  (51)  What i s y o u r  (52)  types  o f treatment  current l i v i n g  (a) l i v i n g  alone  (b) l i v i n g  with  a partner  (c)  with  children  living  (d) l i v i n g  with other  (e) l i v i n g  with  (f)  with other  living  What i s y o u r  have y o u t r i e d ?  situation?  family  friends than  f a m i l y or f r i e n d s  marital status at this  (a) m a r r i e d (b)  commonlaw  (c)  divorced  (d)  separated  (e) widowed (f) (53)  never  married  What i s y o u r if  ethnic  one c o u n t r y  origin?  given, skip  t o Q. 55  a cure  time?  123 if  two o r more  countries,  (54)  Which one o f t h e s e c o u n t r i e s  (55)  What and  i s the highest received  level  credit  o f e d u c a t i o n you have  (b) c o m p l e t e d u n i v e r s i t y (c) some u n i v e r s i t y  (e) some h i g h (f) l e s s (56)  What  with?  finished  for?  (a) p r o f e s s i o n a l o r g r a d u a t e  (d) c o m p l e t e d h i g h  do you most i d e n t i f y  school  or c o l l e g e  or c o l l e g e school  school  than 9 y e a r s o f s c h o o l  i s your  sources l a s t (a) under  approximate  personal  income  from a l l  year  10,000  (b) 10,000 - 14,999 (c) 15,000 - 19,999 (d) 20,000 - 24,999 (e) more t h a n 25,000 (57)  What  i s your  last  year?  (a) under  approximate  family  10,000  (b) 10,000 - 19,999 (c) 20,000 - 29,999 (d) 30,000 - 39,999 (e) more t h a n 40,000 (58)  What  i s your employment  (a) employed, f u l l  time  status?  income f r o m a l l s o u r c e s  124 (b)  I  will  employed,  (c)  unemployed  (d)  receiving  (e)  student  (f)  retired  read  ourselves, me  how  face  i t describes  statements  how  well  There  describe  does  how  fault.  The o n l y i s me.  solution  each  you  ways we s e e  statement p l e a s e  a r e no  feel  right  of  tell  when y o u or  wrong  ways.  the following  see the s i t u a t i o n  I  upon m y s e l f .  p e r s o n who alone  four  you  find  am  1 - not a t a l l  (b)  2  (c)  3 - a little bit  (d)  4  (e)  5 - moderately  My  problems  a r e my  can solve  the problems  I  responsible  for finding  a  t o my p r o b l e m s by f a c i n g  (a)  My  For each  life.  the problems  (g)  different  t h e way you g e n e r a l l y  I bring  •(f)  describe  i n when you a r e c o n f r o n t e d w i t h a p r o b l e m  have  (60)  i n your  pension  Each p e r s o n d e a l s w i t h problems i n d i f f e r e n t  general,  (59)  a disability  and o u r p r o b l e m s .  problems  yourself  time  20 s t a t e m e n t s t h a t  well  answers.  In  part  them head o n .  6 7 - very problems  much a r e n o t my  fault.  I have  no c o n t r o l  over  125 t h e c a u s e o f my p r o b l e m s . solving for  them.  I am  I a l s o c a n do n o t h i n g  dependent  on o t h e r s  about  to solve  them  me.  (a) 1 - n o t a t a l l (b) 2 (c)  3 - a little bit  (d) 4 (e) 5 • ( f )  (61)  moderately  6  (g) 7 - v e r y  much  My  problems  a r e n o t my  of  circumstances,  solving myself  my  fault.  b u t I do p l a y  problems.  i f other  I am an i n n o c e n t  people  an important  I can solve work  with  victim  role i n  the problems f o r me  and g i v e  me  a  chance. (a) 1 - n o t a t a l l (b) 2 (c)  3 - a little bit  (d) 4 (e) 5 -  moderately  (f) 6 (g) 7 - v e r y (62)  much  My p r o b l e m s a r e my own f a u l t . inability  to control  p r o b l e m s by m y s e l f .  They a r e due t o my  myself.  I need  own  I  cannot  solve  t o devote  myself  t o some  h i g h e r g o a l or a u t h o r i t y t o f i n d  a solution  the  and g e t t h e  126 support (a)  I need  1 - not a t a l l  (b) 2 (c) 3 - a l i t t l e b i t (d) 4  In  (e)  5 - moderately  (f)  6  (g)  7 - very  general,  statements a  much  how  well  describe  does  what k i n d  each  of  of person  the  following  four  you a r e when y o u f a c e  problem.  (63)  L a z y and s t u b b o r n . and  pig-headed  Someone who i s sometimes  but b a s i c a l l y  a strong  inflexible  person  who c a n  f a c e p r o b l e m s head on by m y s e l f (a)  1 - not a t a l l  (b) 2 (c) 3 - a l i t t l e b i t (d) 4  (64)  (e)  5 - moderately  (f)  6  (g)  7 - very  much  A weak p e r s o n . often  i l l .  Someone who  One who i s n o t t o be blamed  Someone who o f t e n many (a)  i s h e l p l e s s and p a s s i v e and  things 1 - not a t a l l  finds oneself  f o r my  problems.  d e p e n d e n t on o t h e r s f o r  127 (b) 2 (c) 3 - a l i t t l e b i t (d) 4 (e) 5 (f)  (65)  moderately  6  (g) 7 - v e r y  much  An  victim.  innocent  person  b u t has. been g i v e n  the o p p o r t u n i t y can  Someone who  t o develop  a raw d e a l ,  or just  one's s t r e n g t h s .  l e a r n and grow i f o t h e r s  with  i s basically  a  good  not g i v e n  Someone who  gave me a c h a n c e and worked  me.  (a) 1 - n o t a t a l l (b) 2 (c) 3 - a l i t t l e b i t (d) 4 (e) 5 (f)  moderately  6  (g) 7 - v e r y (66)  A  bad  much  person.  Someone  Someone who f e e l s searching. authority,  lost,  Someone  discipline,  (a) 1 - n o t a t a l l '(b) 2 (c) 3 - a l i t t l e b i t (d) 4  who  alone, who  feels  out of  control.  and ashamed and i s  needs  and s u p p o r t  to  submit  of others.  to the  128 (e) 5 -  moderately  (f) 6 (g) 7 - v e r y much In  general,  statements your (67)  how  well  does  each  d e s c r i b e what you s h o u l d  of  the following  typically  four  do t o c o p e  with  problems Work h a r d e r wrong,  and g e t myself  head o n . myself  t o s o l v e them.  Pick myself  motivated  to face  U l t i m a t e l y s o l v e t h e problem  - not r e l y  up, a d m i t  I'm  the problems  f o r myself.  Help  on o t h e r s .  (a) 1 - n o t a t a l l (b) 2 (c)  3 - a little bit  (d) 4 (e) 5 —  moderately  (f) 6 (g) 7 - v e r y much (68)  Depend  on o t h e r s  who  know what  them t o do t h e t h i n g s t h a t any  chances  on my  own.  Let  other  people  who  control. (a) 1 - n o t a t a l l (b) 2 (c)  3 - a little bit  (d) 4  need  Respect know  they're  doing.  t o be done.  Rely  Don't  on  take  what o t h e r s s a y and d o .  what  they  are doing  take  129 (e) 5 -  moderately  .(f) 6 (g) 7 - v e r y (69)  Work  with  others  much  others  give  competence solution.  to find  me  to  a solution.  the  fullest.  and p o t e n t i a l s . Stand  Be  Use t h e c h a n c e s Develop  serious  up f o r what i s r i g h t f u l l y  my  own  in finding  a  mine.  (a) 1 - n o t a t a l l (b) 2 (c) 3 - a l i t t l e b i t •(d)  4  (e) 5 -  moderately  (f) 6 (70)  Submit  to the support  a sense of belonging Admit  that  and d i s c i p l i n e with  others  of others.  Develop  i n t h e same b o a t  I'm b a d and d e v o t e m y s e l f  t o something  a s me. larger  t h a n me and my s e l f i s h d e s i r e s . (a) 1 - n o t a t a l l (b) 2 (c) 3 - a l i t t l e b i t (d) 4 (e) 5 -  moderately  (f) 6 (g) 7 - v e r y In  general,  statements  how  much well  does  d e s c r i b e what o t h e r  each people  of  the f o l l o w i n g  should  four  do t o h e l p y o u t o  130 cope w i t h (71)  your  problems.  E n c o u r a g e and myself.  motivate  G i v i n g me  going.  Give  me  a  me  towards f i n d i n g  a solution  a good k i c k i n t h e p a n t s pat  on  the  shoulder  to get  for a  for  me  "job  well  done". (a) 1 - n o t  at a l l  (b)  2  (c)  3 - a little  (d)  4  (e) 5 (f)  bit  moderately  6  (g) 7 - v e r y much (72)  Doing  things  solving  the  for  me  problem  comfortable.  Taking  problem.  blaming  me  t o do  Not  that for  charge me  what I c a n ' t  need me  to and  be  done.  make  o f g e t t i n g me  f o r my  Actively  me  feel  out  of  limitations  or  more  the  expecting  do.  (a) 1 - n o t a t a l l (b)  2  (c)  3 - a little  (d)  4  (e) 5 (f)  bit  moderately  6  (g) 7 - v e r y much (73)  Understanding abilities  where I'm  I have.  coming  G i v i n g me  from  and  be  aware o f  a chance to s o l v e  the  the  131 problems myself. can d e v e l o p my c o u l d use  Placing  themselves  potentials.  in finding  a t my  T e a c h me  a solution  new  service  skills  so I  that  I  myself.  (a) 1 - n o t a t a l l (b) 2 (c)  3 - a little bit  (d) 4 (e) 5 (f)  moderately  6  (g) 7 - v e r y much (74)  Being  t h e r e and  f o r c i n g me  t o see m y s e l f  who  i s out  the  realization  life and  making me  of  control. that  b e s i d e s my obedience  the problems (a) 1 - n o t  feel as  that  I'm  I really  Shares  not  am,  with  alone  a guilty  me  the  t h e r e a r e more i m p o r t a n t  selfish  desires,  to  higher  ideals  I am  guilty  of.  and  but  that  my  i s necessary  person  true  way-  things i n submission to  control  at a l l  (b)  2  (c)  3 - a little  bit  (d) 4 (e) 5 (f)  moderately  6  (g) 7 - v e r y much In  general,  statements  how  well  does  d e s c r i b e the b a s i c  each  of  the  s t r e n g t h s you  following must have t o  four cope  132 with (75)  your  problems.  Having  a sense  who i s n ' t  of p r i d e  d e p e n d e n t on o t h e r s .  v a l u e and worth. able  and b e i n g  Being  ambitious.  Feeling  like  Someone  a person of  s e l f - a s s u r e d , hard-working,  t o s o l v e a p r o b l e m by m y s e l f  without  and  others.  (a) 1 - n o t a t a l l (b) 2 (c)  3 - a little bit  (d) 4 (e) 5 (f)  moderately  6  (g) 7 - v e r y (76)  Being not  much  careful taking  and n o t making waves.  any  risks  o n my  own.  t h i n g s a r e now and t h e way t h e y w i l l  Being  c a u t i o u s and  Accepting  t h e way  be.  Letting  people  give  others  do what h a s t o be done. (a) 1 - n o t a t a l l (b) 2 (c)  3 - a little bit  (d) 4 (e) 5 (f)  moderately  6  (g) 7 - v e r y (77)  Effectively  much u s i n g the chances other  Working w e l l w i t h o t h e r s . have  to offer  me.  L e a r n i n g and u s i n g what  so I c a n d e v e l o p  and work  out a  they  solution  133 to  my p r o b l e m s .  achieve  Feeling  competent  and knowing  I can  i f I am o n l y g i v e n a c h a n c e .  (a) 1 - n o t a t a l l (b) 2 (c)  3 - a little bit  (d) 4 (e) 5 (f)  moderately  6  •  (g) 7 - v e r y much (78)  Being so  able to accept  I can take  nature  and  something  support  the right  not being  larger  than  and d i s c i p l i n e  path.  afraid me.  from  Accepting to dedicate  Being  o t h e r s who need t h e same d i r e c t i o n  able  my  others guilty  myself  to i d e n t i f y  to with  a s me.  (a) 1 - n o t a t a l l (b)  2  (c)  3 - a little bit  (d)  4  (e) 5 -  moderately  6  (f)  (g) 7 - v e r y much The  next  set of questions  about y o u r (79)  most  I feel with  refer  t o your  thoughts  and  feelings  recent p h y s i o t h e r a p i s t .  t h e p h y s i o t h e r a p i s t d i d n o t spend  me  (a) s t r o n g l y a g r e e  enough  time  134  (80)  (b)  agree  (c)  indifferent  (d)  disagree  (e)  strongly  The  physiotherapist  I could  (81)  explained  perfectly  e v e r want t o know a b o u t my  strongly  (b)  agree  (c)  indifferent  (d)  disagree  (e)  strongly  The  physiotherapist not  t o me  medical  everything  condition  agree  or  unsure  disagree  just  part  (a)  strongly  (b)  agree  (c)  indifferent  (d)  disagree  (e)  strongly  The  unsure  disagree  (a)  I was  (82)  or  r e a l l y cared of  their  a b o u t me  as  a  person.  job  agree  or  unsure  disagree  physiotherapist  acted  like  I  didn't  have  any  feelings (a)  strongly  (b)  agree  agree  (c) i n d i f f e r e n t  (83)  or  (d)  disagree  (e)  strongly  The  physiotherapist  unsure  disagree gave me  suggestions  on  what  I  could  135 do  (84)  (a)  strongly  (b)  agree  (c)  indifferent  (d)  disagree  (e)  strongly  respect  disagree  (a)  strongly  (b)  agree  (c)  indifferent disagree  (e)  strongly  me  with  a great  deal  " t a l k e d down" t o me  or unsure  always  relieved  my w o r r i e s  about  my  told  me  condition  strongly  (b)  agree  (c)  indifferent  (d)  disagree  (e)  strongly  agree  or unsure  disagree  therapy,  the physiotherapist  what s h e was d o i n g (a)  strongly  (b)  agree  (c)  indifferent  (d)  treated  disagree  (a)  During  always  agree  The p h y s i o t h e r a p i s t medical  (86)  or unsure  and n e v e r  (d)  better  agree  The p h y s i o t h e r a p i s t of  (85)  t o manage my a r t h r i t i s  disagree  agree  or unsure  hardly  ever  136 (e) (87) The  strongly  disagree  physiotherapist  was  on my  (a)  strongly  d i d not g i v e  me  a chance  t o say  what  mind agree  (b) a g r e e '(c) i n d i f f e r e n t  (88)  or  (d)  disagree  (e)  strongly  The  physiotherapist  unsure  disagree d i d not a c t l i k e  I'm  important as a  person (a)  strongly  agree  (b) a g r e e (c)  (89)  indifferent  or  (d)  disagree  (e)  strongly  The  physiotherapist  unsure  disagree always  seemed t o know what she  was  doing (a)  strongly  agree  (b) a g r e e (c)  (90)  indifferent  (d)  disagree  (e)  strongly  strongly  unsure  disagree  I have a g r e a t (a)  or  deal  of confidence  agree  (b) a g r e e (c)  indifferent  or  unsure  i n the  physiotherapist  137 • (&) (e) (91)  disagree strongly  I feel  disagree  the p h y s i o t h e r a p i s t  d i d n o t t a k e ray p r o b l e m s  very  seriously (a)  strongly  agree  (b) a g r e e (c)  (92)  indifferent  or  (d)  disagree  (e)  strongly  The  physiotherapist  to (a)  unsure  disagree always  listened  to everything  I  had  say strongly  agree  (b) a g r e e (c)  (93)  indifferent  (d)  disagree  (e)  strongly  or  disagree  The p h y s i o t h e r a p i s t plans (a)  unsure  d i d not t e l l  me  very  much a b o u t  very  kind  and  her  f o r me  strongly  agree  (b) a g r e e (c)  (94)  indifferent  or  (d)  disagree  (e)  strongly  The  physiotherapist  o f my (a)  disagree  feelings  strongly  unsure  agree  was  always  considerate  138 (b) a g r e e (c) i n d i f f e r e n t  (95)  (d)  disagree  (e)  strongly  or unsure  disagree  When t h e p h y s i o t h e r a p i s t  gave me t h e e x e r c i s e s  home,  me  she d i d not t e l l  know a b o u t (a)  a s much  t o do a t  as I would  like  to  them  strongly  agree  (b) a g r e e (c)  (96)  indifferent  (d)  disagree  (e)  strongly  or unsure  disagree  The p h y s i o t h e r a p i s t better (a)  usually  when I was u p s e t o r  strongly  d i d n o t t r y t o make me  feel  worried  agree  (b) a g r e e (c)  (97)  indifferent  (d)  disagree  (e)  strongly  I  have  or unsure  disagree  some  doubts  physiotherapist (a)  strongly  agree  (b) a g r e e (c)  indifferent  (d)  disagree  (e)  strongly  or unsure  disagree  about  the  a b i l i t y  of  the  139 The  next  set of  with your l a s t (98)  How  7 questions  also  refer  t o your  experiences  physiotherapist.  would  you  rate  the q u a l i t y  of the s e r v i c e  you  have  received?  (99)  (a)  excellent  (b)  good  (c)  fair  (d)  poor  D i d you g e t t h e k i n d (a)  no, d e f i n i t e l y  (b)  no, n o t  (c)  yes, g e n e r a l l y  (d)  yes,  (100) To what  o f s e r v i c e you  wanted?  not  really  definitely e x t e n t d i d t h e p h y s i o t h e r a p y program meet y o u r  needs? (a)  a l m o s t a l l my  (b)  most  (c)  o n l y a few o f my  (d)  none o f my  o f my  (101) I f a f r i e n d  needs have been  needs have been  (a)  no, d e f i n i t e l y  (b)  no, I d o n ' t t h i n k  (c)  yes, I think  (d)  yes,  How  satisfied  met  met  i n need o f s i m i l a r  recommend y o u r p h y s i o t h e r a p i s t  (102)  met  needs have b e e n  needs have been  were  met  h e l p , would you  t o him o r h e r ?  not so  so  definitely a r e you w i t h  t h e amount o f h e l p you  have  140 received? (a) q u i t e (b)  dissatisfied  indifferent  (c) mostly (d) v e r y (103)  satisfied  D i d t h e s e r v i c e s you r e c e i v e d h e l p you t o d e a l more with  your  problems?  (a) y e s , t h e y  helped  a great  (b) y e s , t h e y  helped  somewhat  really  (d) no, t h e y  seemed t o make t h i n g s  I n an o v e r a l l ,  didn't  deal  (c) no, t h e y  with  general  help  sense,  worse  how  satisfied  were y o u  t h e s e r v i c e you r e c e i v e d ?  (a) v e r y (b) m o s t l y  satisfied satisfied  (c) i n d i f f e r e n t (d) q u i t e (105)  dissatisfied  satisfied  effectively  (104)  or m i l d l y  dissatisfied  dissatisfied  In r e f e r e n c e questions  or m i l d l y  t o t h e whole i n t e r v i e w , a r e t h e r e any  w h i c h made y o u f e e l  uncomfortable?  Explain.  141  APPENDIX 2 Sample Interview Tape Transcript  I  What do you t h i n k has c a u s e d your  R  What  I know o f a n k y l o s i n g  t o some d e g r e e don't  hereditary  know what  i t is.  c h i r o p r a c t o r s and s t u f f it  was.  ankylosing  spondylitis possibly, I went  like  t o know what  R  I'm  about  was f i r s t  diagnosed, and then I r e a l l y  s o much.  believe  So  ankylosing don't  other back  know  I  i t is.  I  think  b i t about haven't  about  I c a n ' t even  what  I  read  i t when I k e p t up on i t is.  I  remember, b u t my  But t h e n t h e y s a y t h a t  h a s m a i n l y 90% male t a r g e t  i f she s u f f e r s  k i n d s o f back  from  trouble  i t o r what.  a l l her l i f e .  groups.  She's h a d I t ' s i n the  o f my mind.  Evidence that  R  She l i v e s never  to  b i t foggy  pain.  spondylitis  I  one  a  t h e r e i s some l i n k ,  mother h a s had back  I  I read a f a i r  I'm  is  i s a cause?  that.  something  it  that.  about  i t  b e f o r e I e v e r knew what  I n your v i e w , how do y o u t h i n k h e r e d i t y positive  that  and o t h e r t h a n t h a t  I  not even  i s just  f o r ten years, going t o  that  So i t ' s a b i g r e l i e f  spondylitis?  i t might  up near  followed  ? .  be h e r e d i t y ! I don't  t h r o u g h on why s h e ' s had t h a t  o f t h o s e p e o p l e who d o e s n ' t be  that  Obviously  s e e h e r v e r y much.  way,  o r up u n t i l  f o r ten years  with  seek this  pain.  out answers. point  having  this  She's She's I tend  I was  anyway.  pain  and not  142 knowing what was c a u s i n g i t . I  Do you have any i d e a why i t m i g h t did or  R  happen?  Why  i t didn't  why i t d i d n ' t  When I f i r s t ankylosing said  having  back  just  I never  went  to  temporarily, this I  was  I was  even  and then  No, very  rapid  came when  and  started that  In f a c t , i n 'well  i t as being  i t would  I  first  about  related.  thinking,  I  I  don't  arthritis.  they  I  fixed i t  g e t bad a g a i n .  I  kept  on  at the  time.  nothing  i t just  just  pursued  really  t i m e w h i c h y o u t h i n k might R  when  to Toronto  the c h i r o p r a c t o r ' s  up f o r a l o n g  There  moved  they  comes o u t i s a r o u n d  B u t y o u s e e , when  i t was h u m i d i t y  mind  because  and t h a t ' s e x a c t l y  I had j u s t  o f my  before,  now.  i t was v e r y a p p a r e n t  problems.  problems  know'.  y e a r s from  years  h a v i n g , when I f o u n d o u t i t was  or n i n e t e e n ,  t i m e , and I t h o u g h t the  you f i v e  t h e age a t w h i c h i t u s u a l l y  eighteen  having  started  affect  for five  spondylitis  that  started  wait  have happened when i t  going  have c o n t r i b u t e d  on r e a l l y I started  i n your  life  to i t a l l ?  o u t o f nowhere. having  pain  I t was  i n a very  so  short  time. I  You s a i d and  attaching  explain R  What had  that  that  you have t o d e a l w i t h y o u r cause  What e x a c t l y ,  can you  a little bit.  I was, when really  to effect.  own m o t i v a t i o n ,  I first  marked  started  results.  doing  It really  the e x e r c i s e s I felt  good  and  everything. got  into  weight  And you s e e a t t h e same t i m e  quite  a whole  and a l l t h i s .  self-improvement  I had a l w a y s  I d i d that, thing.  I  been o v e r w e i g h t  I  lost  a l l my  life. You  sound l i k e  you were r e a l l y  I got very motivated. you  know.  total weight  those  know  really,  fitness  and t h a t  definitely of  The two s o r t  I got i n t o  physical  a correlation who  I've j u s t  hand-in-hand  uh, y o u know, n o t i n t o  h e l p s t h e back p r o b l e m  people  Now  o f went  or anything l i k e  that, too.  lets  things slide  like  There  back  that  was  I'm one  slide.  t o almost  g o t back on an u p s u r g e  You  where i t  of motivation.  But a s f a r a s t h e e x e r c i s e s , what happened was t h a t s u c h good r e s u l t s . about Sort of  a year  I t took  of doing  them  every  sort  o f when I t h i n k o f them, and s o r t  doing  don't  them.  Rather  p a i n went away. gradually  about coming  than,  Like  I had  i t ' s been  o f now  and  then.  o f s l a p - d a s h way  you know, a l l t h e t i m e .  I  t h i n k i n terms o f p r e v e n t i v e m e d i c i n e .  Okay, s o i t sounds l i k e  I  a long time.  like  but I l o s t  there, but I l e t t h a t ,  I've l e t the weight  was.  motivated!  once t h e y were s o e f f e c t i v e t h e  So t h e r e f o r e t h e p a i n wasn't -  started  decreasing  them a l t o g e t h e r . back  t o me  ago  I just  and  you know  It's sort  i n spades  had t h e w o r s t I just  and then  of l i k e ,  of pain ever.  'this  I  forgot  like i t ' s  a l l o f a sudden.  onset  went,  them  i s ridiculous,  Two  weeks  Prolonged, I got t o  144 get I  on t o t h i s  and s t a y  do, so t h a t ' s  It's and  thinking nights  that  I have  I tend  t o do.  that  I'm  now  looked  no.  I work  evenings  I come home.  I sleep  about  very  simple.  i n a year  wasn't  program i t s e l f the  screw-up  recently music be  that  any I f o r g o t ,  that  mechanics,  the other  helps  them.  my  One t h i n g motivation  I like though  In f a c t  day t o make s u r e  I t ' s me  of distracts  The  that's  I've s t a r t e d d o i n g i s that  I  there  a l l o f them.  i t , so i t ' s not n e a r l y  I t sort  even I have  Even  I know. them.  i s quite, adequate I t h i n k .  when I'm d o i n g  doing  much  and I was d o i n g  (laughs).  That  o r two.  Even a c e r t a i n s e q u e n c e t h a t  at the chart  like  program  I haven't  them  looked  Feel  have been d i f f e r e n t ?  I  just  a n hour  the e x e r c i s e  I t ' s q u i t e e a s y t o memorize.  done  stuff  t o go do i t .  t o do them i n . haven't  with.  f o r y o u t o keep a t i t ?  o f them  them a l l m e m o r i z e d .  to deal  wake up p r o p e r l y .  could  I, they're  at the chart  o f what  t r y i n g to set aside  i s anything  t h e y gave y o u t h a t  really,  I have  h a l f and hour  w o u l d have made i t e a s i e r Not  i s typical  t o g e t up and go o u t and do  and t h e n s e t a s i d e there  o f what  and s t u f f .  I c a n g e t up. R e a l l y  Do you t h i n k  That  day I g e t up, c a u s e  i n the clubs  I g e t up.  it,  the angle  every  in.  where  on i t ' .  just  I p u t on some so b o r i n g  t h e mind  to  from the  the r e p e t i t i o n of doing i t .  Are  you d o i n g  the e x e r c i s e s  the  physiotherapist?  e x a c t l y as you were t a u g h t by  R  I'm  not  chart  sure.  and  I  Can  you  think  R  No,  not  really  I  It  sounds of  R  No,  they're  I  The  s e n s e I'm  you  was  the  made  the  them?  too  much  in  the  that  that  just  have  think  told  for  up.  A g a i n , whose j o b  I'm  I  visualize being  personal to  do  quite  there,  but  that  once  quite  more  f o r you you  to  done  t o do do  you  effective,  flexibility,  There  Is  that  the that  them.  them.  here  regimentation, a  I  there  might  recall,  have  things  fire  and  could  can't of  control, is  certain  that diet  do  to  tell  what so  keep i t with  happened. I  couldn't  change me that  things.  sure  brimstone  in general,  they  I'm  i f I didn't  have u n d e r s t o o d  those k i n d  weight  As  reoccur  i s i t t o be  They  about  follow  second.  i t would  that  way.  with  a  with  anything  lackadaisical  were  had  been  I must  that  that  I  that  think  like  you  somehow?  I was  somebody.  you  pushing  could  i s that  got  important  was  forward.  were r e a l l y  away, and  that  forms  on  head.  haven't  you  exercises  that  prevented  thing  them  have made t o  o f my  f r o m you  help  become as  nothing  me  the  going  anything  But  top  really  getting  with  didn't  Let  o f f the  reviewed  variations.  c h a n g e s you  a l l pretty straight  found that  R  I  changes.  satisfied  was  o f any  like  way  it  recall.  w i t h a c o u p l e of minor  I  pain  don't  I'm  from very  Possibly  one  this  i s my  own  little  I print  up  little  daily  or  do  weight  control  146 e x e r c i s e s or t h i n g s e v e n making run I  a checklist  i t o f f on my  have  It's  a  blank,  R  Exactly, with.  a  thing  it  definitely  do  i t .  I'm  comes  i n my  several it's put  this  head  things  like  to apply  visual  own  I have  first  way  there.  'Hey, t h i s  things  of that  time.  one t h i n g  I ' v e come  i t to the a r t h r i t i s  cue l i k e  the o l d g u i l t .  t o do.  shuffling card  That's  one o f t h e most  a s f a r a s my  And t h a t  just  It'ssitting  f o r me.  i t .  I can think  world  them up.  there.  I'm g o i n g  prods  You s e e I  conscience.  Any l i t t l e that  i t .  anything'.  exactly  I think  exercises. only  like  that's  print  reminder  you h a v e n ' t done  It's a l i t t l e  And I'm t h i n k i n g o f maybe,  and p r i n t i n g  clipboard  a visual  I  up  that.  computer,  little  like  like  '  that.  That's the  works f o r me Finding  unstructured  the time t o  people  I ' v e g o t t o do  i n the  whatever  I u s u a l l y g e t up and t h e r e i s  t o do, b u t I c a n do them  cards,  because  i n any o r d e r .  everyday.  i n any,  I have t o j u s t  147 APPENDIX 3 Analysis using A r t h r i t i s  Society  categorizatiorv  of a c h r o n i c nonadherent Demographic  Factors  T a b l e 15 i l l u s t r a t e s  t h e breakdown o f p a t i e n t  characteristics  according  comparison group  comparisons.  Insert  With to  regard  be younger  than  whereas  only  group  i s also  a tendency  the c h r o n i c nonadherents  seen  that  group.  the c h r o n i c  nonadherent  to education,  higher  p e r c e n t a g e o f members  less.  Thus, school  comparison  the c h r o n i c  education have  or  falls  been  o f 46,  while  school  similarly  t r e n d h o l d s f o r income and employment.  only  to the  i t c a n be inclined  (85.7%).  group  nonadherent  the  percentage of  i s much l e s s  with a high  tended  under  status,  nonadherent  less,  age  a l o n e a s compared  group  62.5% o f t h e c h r o n i c  group  group  than the comparison group  regard  and  62.5% o f t h e  the median  for a larger  t o be l i v i n g  group  Thus,  Looking a t the m a r i t a l  t o be m a r r i e d (12.5%)  high  group.  28.6% o f t h e c o m p a r i s o n  There  group  here  nonadherent  i s under  demographic  nonadherent  T a b l e 15 a b o u t  the comparison  nonadherent  comparison  to chronic  t o age, the c h r o n i c  chronic  median.  group  With  h a s a much  education or group 14.3%  educated.  have  a  of the  This  same  Members o f t h e c h r o n i c  148 Table  15  Cross-Tabulations: Arthritis  P a t i e n t D e m o g r a p h i c C h a r a c t e r i s t i c s by  Society Categorization  Demographic  Chronic  Characteristics  Nonadherent  n  (Mdn Under  Group a "6  No.  Age  Comparison  :  = 8  Group No.  %  n == 7  46) 46  years  5  62.5  2  28.6  3  37.5  5  71.4  alone  4  50.0  2  28.6  other  4  50.0  5  71.4  married  1  12.5  6  85.7  other  7  87.5  1  14.3  5  62.5  1  14.3  3  37.5  6  85.7  46 y e a r s and o l d e r Living Situation  Marital  Status  Education high s c h o o l or post-high  less  school  (table continues)  149  Demographic Characteristics  Chronic  Comparison  N o n a d h e r e n t Group No.  %  Group No.  n = 8  %  n = 7  Income <20,000  7  100.0  2  28.6  20,000 o r above  0  0.0  5  71.4  employed  2  25.0  5  71.4  other  6  75.0  2  28.6  Employment  150 nonadherent  group tend t o r e c e i v e  employed.  Thus,  receiving  incomes  the  100% o f t h e c h r o n i c of less  comparison  Likewise,  l o w e r i n c o m e s , a n d t o n o t be  group  nonadherent  group a r e  t h a n $20,000, whereas o n l y  a r e i n t h e same  25% o f t h e c h r o n i c  nonadherent  income group  category.  a r e employed,  w h i l e 71.4% o f t h e c o m p a r i s o n g r o u p a r e i n a s i m i l a r From chronic  these findings  nonadherent  alone,  i t c a n be s e e n  g r o u p i s more l i k e l y  and n o t m a r r i e d .  This  One have result  dimension  chronic their  difference  analysis  enough,  considering would  than  between  t e n d t o have  a  employed.  that  was shown t o as a  here  there  acting  to the fact were  group.  i t was e x p e c t e d  rather  than the comparison  than  fewer  as b a r r i e r s  d i d the comparison  the fact  Model  t h e two g r o u p s  pointed  felt  program  e x p e r i e n c e more  performance  also  Beliefs  T a b l e 16 a b o u t  group  exercise  performance,  living  (see Table 16).  the study  nonadherent  home  t o be y o u n g e r ,  a n d t o n o t be  of the Health  Insert  Curiously  of the  Model  a measurable of t-test  position.  a member  person w i l l  lower e d u c a t i o n , a l o w e r income,  The H e a l t h B e l i e f s  that  28.6% o f  less  group.  that  barriers  that  the  aspects of to exercise This  i s odd  nonadherents to exercise  Table  16  T-Test  Analysis of Health  B e l i e f s M o d e l by A r t h r i t i s  Society  Categorization  Perceived  Barriers  Chronic  Mean*  N o n a d h e r e n t Group  SD  t 2-Tail  9.4  1.3  10.9  3.0  -1.26 Comparison Group  *  Means  items the  were o b t a i n e d  related  average  groups.  by f i r s t  to perceived  total  score  summing  barriers.  of each  the scores  T h e mean  respondent  thus  i n each  Prob  0.228  on t h e f o u r represents o f t h e two  152 Patient's  Explanatory  Findings when t h e  were  d a t a was  of adherence. treatment to  note  much  second  types  difference  is  of  the the  to f e e l  that  a c u r e was  nonadherent  group  received  from  hope t h a t  these p a t i e n t s  their  the  disease.  wanted a c u r e would do right have  and a  be  Nature of The  Another able  normal  breakdown o f  that  example,  to  life.  but  patient  ride  a  With  r e s p o n s e s was  the  had  bicycle respect  both  the The  analysis,  nonadherent i n the their  group  ability disease.  group  was  more  (85.7%) t h a n was  group  patient no  clue  that  he  again  so  to  i n both  the  which  were  illustrate  Arthritis  one  other  group.  Some r e s p o n s e s  stated  evident  by  first  comparison  the  interesting  held  control  nonadherent  for his disease,  this.  or  impossible  had,  For  the  to  (exercise,  to b e l i e f  (50.0%).  chronic  I t was  chronic  cure the  found  respect  comparison  unlike  Arthritis  chronic  cure  the  between t h e  that  with  similarly  respect  shows  were  to s e l f - r e p o r t e d measures  comparison group w i t h  Cross-tabulation likely  and  to  which  expectations  were  that,  Society  those  patients.  of  group  d i f f e r e n c e s were e v i d e n t and  by  information)  nonadherent  as  d i f f e r e n c e was  held  three  and  same  according  However, one  the  treatments,  the  analyzed  expectations  that  chronic  Model  Society said as  to  wanted that  control,  could  that how  he they  to he  a  the  walk could  similar  groups.  the I l l n e s s nature of  the  illness  i s a v a r i a b l e which g e t s at  the  • 153 effect  of  the  behaviour.  disease  Two  itself  factors  were  when compared a c r o s s g r o u p s . of  current  on  the  shown These  disease severity,  and  t o have  amount o f  Median  test  analysis  nonadherents  tend  have  known a b o u t  shorter the  period  of  comparison  time  group  (100%  (66.6%  well,  chronic  nonadherents  less  severe  (87.5%  comparison All  group  respondents  arthritis  as  occurrence, ankylosing and  factor  which  that,  also  lives  their  illness  or  has  As  disease i s than  different In  types  of  order  of  A  a minimal  was  had  impact  great  (20.0%)  and  only on  illness group  Frequency  most  a  evident  with  illness. that  (20.0%),  second  relationship  impact,  (40.0%),  arthritis  relationship  has  the  median).  smaller percentage  had  median).  osteoarthritis  indicate  a moderate  than  their  problem.  the  illness  chronic  median)  median)  category.  of  since  diagnosis for a  that  four  No  a  elapsed that  below  rheumatoid  show  variable  A  had  arthritis  not  their  (66.7%).  of  follows:  group  association  below  below  medical  impact  date,  has  one  (13.3%).  did  was  or  (26.7%),  and  for this  to  their  their  as  arthritis  distributions  that  were  spondylitis  categorization  felt  main  diagnosis,  to  e q u a l t o o r below  listed  their  they  psoriatic  between  (42.9%  their  to f e e l  to  time  t o or  equal  equal  mild  indicates  equal  tend  adherence  f a c t o r s are the p e r c e p t i o n  diagnosis.  to  patient's  respondents impact  on  felt  that  13.3%  felt  their  lives.  154 S a t i s f a c t i o n with P r a c t i t i o n e r Although distinct,  they  research  has  distinguish of  their  each  of  these  will  be  discussed  shown  that  between  the  evidence  variables  i t is  for  together  the  comes  interviewed  patient,  three  the  the  the  ability  communicate.  technical  Although, findings  chronic  as  stated  were  of  ability  competence,  difference  nonadherent  care  a  the  In  g r o u p and  for  in  study.  patients  these  of  one  the the  of to  this  comfortable, he  and  is  and  referring  communication.  shows  significant  there  satisfaction comparison  the  practitioner  statistically  analysis  aspects  grouping  words,  care,  to  1980).  respects in a  no  previous  According  feel  and  & Hays,  statement  affective  between  since  (DiMatteo  other  t-test  separate  socioemotional  t o make him  earlier,  achieved,  and  t h a t he  knowledge,  group  usefulness  in  factors  a  are  difficult  from  are  to  as  technical  respondents  degree  variables  health practitioner's  Further  to  Attributes  was  held  group  some  by  (see  the Table  17).  Insert  What seemed e v i d e n t was somewhat  more  communication, was  Table  about  here  t h a t the c h r o n i c nonadherent group  dissatisfied affective  the comparison group  17  care  with and  (see T a b l e  their  physiotherapists  technical 18).  was  competence  than  155 T a b l e 17 T-Test A n a l y s i s of S a t i s f a c t i o n with P r a c t i t i o n e r by A r t h r i t i s  Affective  Society  Attributes  Categorization  Care  Mean*  C h r o n i c Nonadherent  Group  SD  21.4  6.5  17.6  4.3  t 2-Tail  1.32 Comparison  Group  Communication  Mean*  C h r o n i c Nonadherent  Group  SD  17.1  6.0  14.0  5.2  Mean*  SD  5.5  2.3  4.4  1.3  t 2-Tail  1.08 Comparison  Group  T e c h n i c a l Competence  C h r o n i c Nonadherent  Group  t 2-Tail  1.08 Comparison  Group  Prob  0.210  Prob  0.300  Prob  0.300  * Means were o b t a i n e d by s e p a r a t e l y summing t h e s c o r e s on t h e nine items r e l a t e d t o a f f e c t i v e c a r e , t h e seven items r e l a t e d t o communication, and t h e t h r e e i t e m s r e l a t e d to technical competence. The mean t h u s r e p r e s e n t s t h e a v e r a g e t o t a l s c o r e o f each r e s p o n d e n t i n e a c h o f t h e two g r o u p s .  156  Insert  As  one p a t i e n t  me m o b i l e  T a b l e 18 a b o u t  d e s c r i b e d i t , " I had t o have s o m e t h i n g  and a t t h e same  was n e c e s s a r y . r e a s o n he f e l t  here  time  t o n o t do any more damage  So I had t o j u s t he had t o f i g u r e  physiotherapists  were  t o keep  figure  than  i t out myself".  The  i t o u t h i m s e l f was b e c a u s e t h e  not h e a r i n g  h i s expressed  need  t o do  more e x e r c i s e s t h a n what he had been g i v e n t o do.  Shared  Responsibility  Table four  19  shared  Society  shows  the condensed  responsibility  models  according  to  Arthritis  categorization  Insert  Table  c r o s s - t a b u l a t i o n s of the  20  illustrates  Table  t h e same  19 a b o u t  data  here  with  median-split  cross-  tabulations.  Insert  As  Table  20 a b o u t  here  a p o p u l a t i o n , the c h r o n i c nonadherent  group  tended  to  157 Table  18  Cross-Tabulations: Attributes  Patient  Satisfaction  by A r t h r i t i s S o c i e t y  Practitioner  Attributes  with  Practitioner  Categorization  Chronic Nonadherent  Comparison Group  %  No.  Group No  n = 8  Affective  Q.  .  n  O  = 7  Care  Satisfied  6  75.0  7  100.0  Dissatisfied  2  25.0  0  0.0  3  37.5  4  57.1  .5  62.5  3  42.9  Satisfied  6  75.0  7  100.0  Dissatisfied  2  25.0  0  0.0  Satisfied  4  50.0  4  57.1  Dissatisfied  4  50.0  3  42.9  Affective  Care  (Median  Split)  Satisfied Dissatisfied  Communication  Communication  (Median  Split)  (table  continues)  158  Practitioner  Attributes  Chronic  Comparison  Nonadherent Group  Group  No.  %  No.  n = 8  Technical  %  n = 7  Competence  Satisfied  9  100.0  7  100.0  Dissatisfied  0  0.0  0  0.0  Satisfied  3  37.5  5  71.4  Dissatisfied  5  62.5  2  28.6  T e c h n i c a l Competence  (Mdn  Split)  159 Table  19  Cross-Tabulations:  Shared R e s p o n s i b i l i t y  M o d e l s by  Arthritis  Society Categorization  Shared R e s p o n s i b i l i t y Model  Chronic Nonadherent  Comparison Group  %  No.  Group No.  n = 8  %  n = 7  Moral Model (High B l a m e / H i g h  Control)  Low  3  37.5  1  14.3  High  5  62.5  6  85.7  Low  6  75.0  7  100.0  High  2  25.0  0  0.0  Low  0  0.0  0  0.0  High  8  100.0  7  100.0  Medical  Model  (Low Blame/Low  Compensatory  Control)  Model  (Low B l a m e / H i g h  Control)  (table  continues)  160  Shared  Responsibility  Model  Chronic Nonadherent  Comparison Group  No.  %  Group No.  n = 8  Enlightenment  %  n = 7  Model  ( H i g h Blame/Low C o n t r o l ) Low  6  75.0  6  85.7  High  2  25.0  1  14.3  161 Table  20  Cross-Tabulations:  S h a r e d R e s p o n s i b i l i t y M o d e l s by  S o c i e t y C a t e g o r i z a t i o n (Median  Shared  Responsibility  Model  Arthritis  Splits  Chronic Nonadherent No.  Comparison Group  O,  "6  Group  %  No.  n = 8  n = 7  M o r a l Model (High B l a m e / H i g h Low  5  62.5  3  42.9  High  3  37.5  4  57.1  Low  5  62.5  3  42.9  High  3  37.5  4  57.1  Low  3  37.5  5  71.4  High  5  62.5  2  28.6  Low  4  50.0  3  42.9  High  4  50.0  4  57.1  Medical  Model  (Low Blame/Low  Compensatory  Control)  Model  (Low B l a m e / H i g h  Enlightenment (High  Control)  Control)  Model  Blame/Low  Control)  162 be  difficult  the  to categorize.  compensatory  tended  model  t o show  a  comparison  group.  the  (high  moral  blame/high blame/low models,  (low  While  the only  group  control)  models,  with  showed  control)  and  which  score.  chronic  not  t o blame f o r t h e i r  disease,  for  dealing  On  comparison important,  group  i t .  signify  regardless  that  than  scored  the  high  blame/low  member  was  a high  (low  compensatory  that  should  i s that  they  were  be i n c o n t r o l  the scores  level  (low  control)  indicates  to believe  hand,  on  of the c h r o n i c  a high  this  and t h e y  of the l e v e l  group  the medical  (high  What  the other  this  and compensatory  every  nonadherent group tended  excepting  scores  group  low on  agreement  the  with  of  the comparison  and e n l i g h t e n m e n t  area  control),  dispersion  blame/high  control)  blame/high  (low blame/high  greater  control)  nonadherent  With a l l o f t h e models,  f o r the  of control  o f accompanying  was  blame.  Overall Satisfaction One  of the c r i t i c i s m s  previous  studies  i s that  obscure  specific  areas,  dissatisfaction not  dissatisfied. is  important  with  t o know  which  brought  a patient  & Attkisson,  t o know In order  has been  against  g l o b a l measures o f s a t i s f a c t i o n  (Pascoe  sufficient  which  whether  f o r these  which  1983).  someone results  aspects  may That  be  often  feeling  is, i t  is satisfied  is or  t o have meaning i t  of care  are causing  the  dissatisfaction. In  this  study,  t-test  analysis  indicated  that  some  163 d i f f e r e n c e s were e v i d e n t i n t h e t o t a l the  two  groups  nonadherent  group  comparison  group.  (see  Table  tended  Insert  In  looking  that the many  of  the  kind  of  service  their  that  offered'  cross-tabulation was  respondents  was  not  wanted, and  were  being  equally  revealed  nonadherents were  not  comparison  the were  met.  with  met  (28.6%)  Insert  the  chronic than  the  i t was  d i d not  d i d not  chronic  feel  of  both  second  groups  to  than  as  feel  that  were  members  ( s e e T a b l e 22 and T a b l e  here  as  group group.  chronic  their  23).  to  service  nonadherent  element  get that  interesting  'kind  between  T a b l e 22 about  the  found  than the comparison  likely  (62.5%)  they  I t was  with  the  that  46.6%  spread  that  much more  getting group  case  the  questions  felt  o n l y s l i g h t l y more d i s s a t i s f i e d  This  that  of  here  satisfaction  dissatisfaction  almost  such  T a b l e 21 about  they  needs  the was  total  21)  of s a t i s f a c t i o n  t o be much more d i s s a t i s f i e d  specific  40%  of  note  at  level  of  needs the  164 Table  21  T-Test A n a l y s i s of O v e r a l l  Satisfaction  by A r t h r i t i s  Society  Categorization  Satisfaction  Mean*  C h r o n i c Nonadherent  Group  SD  t 2-Tail  14.3  5.7  11.0  3.5  1.32 Comparison  *  Group  Means were o b t a i n e d by f i r s t  items  related  to satisfaction.  average t o t a l score o f each  summing  the scores  T h e mean  thus  respondent i n each  Prob  0.210  on t h e s e v e n  represents  group.  the  165 Table  22  Cross-Tabulation:  Satisfaction  by A r t h r i t i s S o c i e t y  Satisfaction  with  "Kind  of Service  Offered"  Categorization  Chronic Nonadherent No.  Comparison Group  %  Group No.  n = 8  %  n = 7  Satisfied  4  50.0  5  71.4  Dissatisfied  4  50.0  2  28.6  166  Insert  T a b l e 23 about  here  A t t i t u d e s of S i g n i f i c a n t Others The  next  variable  significant  figures.  two  as  groups  others  were  home e x e r c i s e  Ose  second  treatments unorthodox the  looking that  by  satisfied  i s the  were e v i d e n t  reported  with,  reactions  or  at  last  variable  patients.  the  and  is  relationship  the  significant  i n d i f f e r e n t to  the  Alternative medicines  but  results  which  of  the  nonadherents treatments  (14.2%) out  of  between  that  use  of  their  t h a t a r e not are  used  by  refers  to  recommended  by  patients  on  (see  this  i s not  cross-tabulation are  (87.5%)  Table  variable,  24).  much than  more are  This  therefore  the  T a b l e 24 about  here  in  disease. i t was  likely  the  to  In  use group  only  strength  the  found  comparison  was  known.  Insert  alternative  treatments  f i n d i n g a more e f f e c t i v e c u r e f o r t h e i r  alternative  carried  differences  respondents  Society,  chronic  members  discussed  Treatments  therapies  Arthritis  hopes o f  be  program.  of A l t e r n a t i v e The  No  most  either  to  of  test this  167 Table  23  Cross^Tabulation: Arthritis  Satisfaction  with  "Having  Needs Met"  by  Society Categorization  Satisfaction  Comparison  Chronic Nonadherent No.  Group %  Group No.  n = 8  %  n = 7  Satisfied  3  37.5  5  71.4  Dissatisfied  5  62.5  2  28.6  168 Table  24  Cross-Tabulation: Society  Use o f A l t e r n a t i v e  T r e a t m e n t s by A r t h r i t i s  Categorization  Use o f A l t e r n a t i v e Treatments  Chronic Nonadherent No.  Comparison Group  %  n = 8  Group No.  %  n = 7  None  1  12.5  6  85.7  1 o r more  7  87.5  1  14.3  169 The  various  alternative  therapies  r e s p o n d e n t s a r e as f o l l o w s : (2),  relaxation  number  teas  in brackets  r e s p o n d e n t s who  indicates  comparison  by  ( 3 ) , massage ( 2 ) , yoga  ( 1 ) / and V i t a m i n C ( 1 ) .  the  number  of  different  the  problems  used each type of t r e a t m e n t .  differences  experienced  mentioned  (5), meditation  (1), colonics  P r o b l e m s w i t h t h e Home E x e r c i s e No  were  (2), naturopathy (2), v i s u a l i z a t i o n  (1), Chinese herbal The  diet  which  by  group.  the  were  Program  evident  chronic  between  nonadherent  group  and  the  170 Possible Explanations Upon mind  looking  i s why  Several  a t the f i n d i n g s  one  a r e 25% o f t h e c h r o n i c  adherent.  Or  identified  f o r the M i s i d e n t i f i c a t i o n  i n other  words,  question  nonadherent  what  causes  as n o n a d h e r e n t when, i n f a c t ,  explanations  provide  Phenomena  a  this  which  comes t o  group  actually  someone  to  be  i s not t h e c a s e .  possible  answer  to  this  question. The based  first  on  a  accounted small  very  the  size  chronic  happening patients  since  these  research  error  has  results  findings  i n measurement.  A  i s that may  be  s t u d y may  have  actually  that  Because  the p o s s i b i l i t y  one  of  are  may  be  of  the  greatly  second  different  felt  used  from  the  be  considered  third  possibility  this  for  what  definition  lapse  Thus,  study,  adherent  by  used  in  be some this  nonadherent  of t h e i r  exercise  the d e f i n i t i o n  these  to  of  could  u s e d by  i n the c h r o n i c  an o c c a s i o n a l  criteria  self-admission  of nonadherence  nonadherence. for  was  explanation  some p a t i e n t s that  of the s e l e c t i o n  group  the d e f i n i t i o n  constituted  nonadherence  stated  nonadherent  F o r example,  routine  sample,  error  any  i t was  nonadherence.  study.  an  i s that  the f i n d i n g s of the study.  Earlier for  small  f o r by  sample  altering  explanation  patients  their  home  of  would  exercise  programs. A  i s that  the adherence  some o f t h e c h r o n i c  n o n a d h e r e n t g r o u p may  the  self-admission  time  of  their  of  have  behaviours of  changed  nonadherence,  between  and  when  171 adherence behaviours members recent  of  the  he  A  the  may  is a  in  possible,  group,  a  a l l of  may  mention  of  changes  are  possible  is  seems  have  stated  their  ashamed  to  not  the  being  behaviours  thus  admit  that  some o f  that  behaviour.  they  Although  seem f e a s i b l e c o n s i d e r i n g  had  freely  occasions. to counteract this  as  suggest  and  to  in  study  adherence  behaviour,  felt  Thus,  respondents  i n the  undesirable  other  techniques  the  reasonable  respondents  self-presentation.  He  to h i s e x e r c i s e program  identified  e x p l a n a t i o n does  on  made  g r o u p members.  that  desirable  socially  the  nonadherent  It  socially  this  incorporated  is  have m i s r e p r e s e n t e d  respondents  engaged  that  no  of severe pain.  explanation  interviewer.  adherence  fact  Although  group  became a d h e r e n t  o f an o n s e t  nonadherent  adherent,  that  nonadherent  of the comparison  recently  fourth  chronic  the  by one  only  as a r e s u l t  to  chronic  m o d i f i c a t i o n s , the  exemplified that  were measured f o r t h e s t u d y .  As the  admitted well,  effects  the of  e x p l a n a t i o n does  being study  positive not  seem  likely. In  order  explanations findings  to  i t might  i n the  looking  the  the  One  the  clue  those  of  these  to look a t  T h e s e may  difference  group membership, and  validity  prudent  some o f  adherent. at  be  study.  the q u e s t i o n o f why actually  assess  help  to  some o f shed  between  this  puzzle  variables  associated with  other  the  other  some l i g h t  c h r o n i c nonadherent to  and  may  group  on are  come  from  associated  with  adherence.  172 One d i f f e r e n c e w h i c h becomes a p p a r e n t i s t h a t nonadherent  group  speaking. alone, lower  is relatively  Members  of this  and not m a r r i e d . education,  income.  This  same  homogeneous, d e m o g r a p h i c a l l y  group  tend  As w e l l ,  t o be  t o be y o u n g e r ,  they are l i k e l y  unemployed,  degree  the chronic  and  t o have  to receive  o f homogeneity  was  living  a  a  lower  not found  when  a d h e r e n t s were compared t o n o n a d h e r e n t s . In  addition  communicators, tended  members  t o be more  quality  of  technical these  to perceiving  A  competence.  chronic  factor  This  alternative treatments  seems  nonadherent  group  characteristics, of  arthritis  dissatisfaction unorthodox  seems  that  more  emerging  has  and  who  conventional  i s that  o f an e x t e n s i v e group.  upon  by  picture  similar  use o f  These a r e  the  therapeutic  is a  i n an  group.  important t o mention  questionable  patients,  dissatisfied,  the comparison  which  with the  reasonable considering  a r e more d i s s a t i s f i e d  with  also  and  a r e n o r m a l l y frowned  t o be  group  care  t o the comparison  treatments than which  poor  affective  t o be more  make much  S o c i e t y because o f t h e i r What  seems  tended  which  nonadherents  as  to express d i s s a t i s f a c t i o n  sense, i n r e l a t i o n third  nonadherent  physiotherapist's  respondents a l s o  overall  practitioner's  of the chronic  likely  their  their  Arthritis  value. of  a  chronic  demographic  than a comparison  possibly medicine  express  by m a k i n g  group their use of  remedies.  Based on t h i s  information  a possible  fifth  explanation i s  173 that  adherents  deviants as  the  were  because  other  labelled  they  shared  That  dissatisfaction  with  espoused  Arthritis  support why  the  respondents  i n the  f i t into  the  nonadherents. dissimilar,  interest  they  may  t o know d e c i s i v e l y group  were  not  to  consideration. deviance  has  be b e n e f i c i a l  that  Gove  (1980)  because  this,  identified  been or  to  they them  be did as  demographically been  t h e y may  enough  Thus, as  to  not  dissatisfied  have  expressed  information  available  since  the  one  most  valid  now  i t will  For  a l l explanations  However,  choose  being  premature.  should  notion  up as a p o s s i b l e  to explore t h i s  Deviant  out  some members o f t h e c h r o n i c n o n a d h e r e n t  been brought  Labelling  have  vocalized  i s not  explanations  say  have  explain  remedies.  there why  vocalized  turned  That  express  practices  instead  who  such.  S o c i e t y , and/or  s p e c u l a t i v e and  suffice,  may  to  medical  group,  as  characteristics  T h i s might a l s o  would  have  adherent.  aforementioned  deviant  they  Society  tended  S o c i e t y , and  which  i n marginal  Unfortunately  highly  traditional  p e r c e i v e d as  Thus,  same  i s , they  comparison  mold  w i t h the A r t h r i t i s ah  the  Arthritis  the  f o r more u n c e r t a i n t h e r a p i e s .  n o n a d h e r e n t , were n o t not  the  many o f  nonadherents.  by  by  be  of  of  the  would  be  have  to  given  equal  labelling  explanation, i t  subject i n greater  and may  detail.  Behaviour states they  that  either  people engage  are  often  i n deviant  labelled  as  behaviour,  or  174 have, c h a r a c t e r i s t i c s w h i c h make them a p p e a r d e v i a n t .  As  Schur  (1980) s t a t e s , "the reference to the 'perceived' deviator is i m p o r t a n t b e c a u s e a p e r s o n can be r e a c t e d t o , e v e n ' p r o c e s s e d ' as d e v i a n t , r e g a r d l e s s o f w h e t h e r he o r she a c t u a l l y committed t h e o b j e c t i o n a b l e a c t . Here, as i n t h e c o l l e c t i v e p e r c e p t i o n o f t h r e a t , i t i s t h e p e r c e p t i o n t h a t c o u n t s " (p. 1 2 ) . Thus, as t o as  Schur  deviant  i s saying,  someone can  when, i n r e a l i t y ,  the  be  l a b e l l e d and  t r u t h of  the  reacted  matter  can  be  in  health  much d i f f e r e n t . Evidence profession patients  are  often  to by  on  these  labelling some  ( 1980  occurs  type  of  behaviour. order  to  example, is  that  people  because  )  Certain  by the  from  defining  or  undertaking  is  are  seeks  of  the  highly non-  (p.168). the  bad  attention  the  reasons  set  and  why  maintain  appropriate  l a b e l l e d as  their  criminal  is  that  constitutes  behaviour to  'bad  compliant,  indicates  one  what  limit  or  hospitalized.  passive"  for a s o c i e t y to to  hospital  non-compliant.  that  criminal  attached  she  Taylor  that  patient'  generally  activities  contain  stigma  as  while  'good  the  patients'  i s o f t e n angry,  suggests  i s i n order  states  'good  or  i s frequently  standards  help  he  and  complains e x c e s s i v e l y ,  Schur  She  as  "the  behaviours,  i n a p p r o p r i a t e l y , and  labelling  actions  (1979),  staff  of  (1979).  non-demanding,  to  use  their  Taylor the  complaining, Contrary  current  categorized  based  According regarded  the  comes f r o m T a y l o r  patients'  patient  for  deviant  in  proliferation. as  label  deviant, will  activities.  the  prevent  For hope other  Similarly,  by  175 looking is  to  upon  n o n a d h e r e n c e as  encourage  other  regimes.  Although  labelling  has  One that  of  people  are  doing  directed  points  to  the  their  mentions  discharge responses, on  an  the  the p a t i e n t discussion  prevent cause of  the  In  not  in  people.  members due  who  from  they  described  However,  (1979)  are  both  p r a c t i t i o n e r from t a k i n g  an  often  them, She  or  also  include  over-  and  premature  of  collective dealt  label  blocks  In  with the of  i t i s important  to  be  the  the  result  Likewise,  cases,  that p a r t i c u l a r i n d i v i d u a l ' s deviant  causes  labelling  in-depth  look  of  previous  t o a number o f p o s s i b l e in  i t is  case  may  control.  those  being  are.  Taylor,  behaviour  use  the  really  by  to a l o s s of  i n t h i s paper p o i n t s  words,  as  Taylor  which  problems  than  because  attention.  the  is  collective,  ignore  allowing  Schur  allows  hospital patients  other  objectionable  reacting  nonadherence.  engage  practices  By  s e e n as  patient the  to  than  prevents  from being  that  rather  psychiatric services,  hospital.  by  depersonalization  staff  less  to  labelling  difficult  realize  of  referral  therapeutic  mentioned  category  difficult by  individual basis.  individual  a  l a b e l s and  that  intention  have a b e n e f i c i a l r o l e ,  labelling  discriminatory  from  their  discrimination i s permitted  complaints  medication,  of  labelling  against  other  to  the  ramifications.  of  The  fact  seem t o  process  towards  discriminated give  would  as  the  behaviour,  to adhere  treated  This  discrimination. being  this  outcomes  are  individuals. who  patients  many n e g a t i v e the  deviant  into  behaviour.  can the  176 A second  ramification of labelling  self-fulfilling a  behaviours.  juvenile delinquent  originally of  brought  rectifying  may  intensify  the l a b e l  on  the s i t u a t i o n ,  i n the entrenchment  Likewise,  i f someone  i s unjustly  themselves the  label.  has never  labelled  as d e v i a n t ,  i t may  F o r e x a m p l e , someone  resulted  but  i s that  as  the process of  place.  the deviant  they  may  a n d t o a c t i n a manner  as  which Instead  of l a b e l l i n g  exhibited deviant such,  labelled  the a c t i v i t i e s  i n the f i r s t  lead to  has  behaviour. behaviour,  begin  to see  appropriate  to  

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