Medical Teacher, Vol. 26, No. 4, 2004, pp.

359365

An introduction to patient education:

theory and practice

Med Teach Downloaded from informahealthcare.com by ${individualUser.displayName} on 01/28/15

For personal use only.

RICHARD BELLAMY
Kintampo Health Research Centre, Kintampo, Ghana

SUMMARY Patient education is the process of enabling individuals to make informed decisions about their personal health-related
behaviour. It aims to improve health by encouraging compliance
with medical treatment regimens and promoting healthy lifestyles.
Behavioural change for patients is a complex process and requires
more than the simple acquisition of knowledge. Several educational
models based on behavioural theories have been developed to
explain individuals health-related behaviour. The health belief
model is the one most commonly used in research. The four
principal components of this model are the individuals perception
of his or her personal susceptibility to disease, perception of the
severity of the disease and perception of the benefits from
and barriers to modifying behaviour. The health belief model can
be used to design educational interventions that are most likely to
be effective. Patient education is a duty for all health practitioners
and it should be a core component of medical school curricula.

The importance of patient compliance

Healthcare workers (HCWs) often find it difficult to believe
that patients do not follow their advice. It seems surprising,
if patients make the effort to seek medical help, that they
will not adhere to the treatment recommended. However,
a substantial number of studies have now shown that a
large percentage of patients do not take the medications
they are prescribed. Non-compliance with lifestyle advice,
such as stopping smoking, taking more exercise and eating
a healthy diet, is also a major problem. Non-adherence to
medical treatment and advice is now recognized to be so
widespread that it has been described as the most significant
problem facing medical practice today (Eraker et al., 1984).
Non-compliance can take many forms. In 1979, Sackett &
Snow reviewed 537 studies that reported on non-compliance
rates. They found that most of these studies were of poor
methodological quality. Only 40 studies were based on a
random population sample or a sample that was likely to be
representative of the general patient population. They
summarized the results of these 40 studies providing a
catalogue of poor compliance with a wide range of medical
advice and interventions. Appointment keeping for preventive activities (e.g. screening tests) varied from 10% to 65%
and for treatment 55% to 84%. Compliance with short-term
medication for treatment was 7778% and that for immunizations 6064%. Compliance with long-term treatment was
even poorer with rates for medication taken for prevention
varying between 33% and 69% and for treatment 41%
and 69%. Compliance with behaviour modifications such
as diet (870%) and seat belt use (559%) was also poor
(Sackett & Snow, 1979). Non-compliance is therefore
an important public health issue. Non-compliance in its

broadest definition can be considered in respect of any

form of health behaviour. The term should not purely be
restricted to failure to follow direct advice from a HCW.
For example if a person chooses to smoke when he or she
has heard government warnings that this is unhealthy, this is
a form of non-compliance, even if he or she has never been
personally advised not to smoke.
Previously many HCWs viewed compliance as entirely
the patients own responsibility. When a patient did not
comply with medical advice they were regarded as a poor
patient and often blamed for any resultant adverse consequences (Lerner et al., 1998). However, compliance should
not be seen as the patients duty but a joint responsibility
of the HCW and patient working in partnership (Lerner et al.,
1998). Some authors have avoided the term compliance
altogether as it implies that the HCW makes the decisions
and the patient must then follow them (Heath, 2003). Terms
such as therapeutic alliance and adherence have been
adopted as replacements (Say & Thomson, 2003). However
as compliance is widely used in the literature, this term
will be retained throughout this paper.
Maximizing compliance involves identifying barriers to
patient understanding, identifying barriers to compliance
and assisting the patient to develop his or her own treatment
plan (Falvo, 1994). Anderson & Kirk (1982) remind us that
the word doctor is derived from the Latin docere, which
means to teach. Doctors and other HCWs have a duty to
educate patients to enable them to make informed decisions
regarding their own health behaviour. Therefore the ability
to understand and apply the principles of patient education
are essential competences for all health practitioners. Medical
schools should therefore carefully consider how they will
teach the core principles of patient education and how they
will assess whether students have developed the competences
to educate patients effectively. This review is therefore
intended to be of relevance to both healthcare practitioners
and medical educators.
What is patient education?
The objectives of patient education differ from those
of educating students. When educating students we are
attempting to transfer knowledge and skills whereas in patient
education we are attempting to facilitate behaviour change.
Patient education is therefore not just the provision of
information, or of an intervention such as counselling or
behavioural instruction. Patient acquisition of knowledge is
Correspondence: Richard Bellamy, MRCP DPhil, Obaapavita Trial Director,
Kintampo Health Research Centre, Kintampo, PO Box 200, Ghana. Tel: 233
61 27304; fax: 233 61 24145; email: bellamyrj2000@yahoo.co.uk

ISSN 0142159X print/ISSN 1466187X online/00/000359-7 2004 Taylor & Francis Ltd
DOI: 10.1080/01421590410001679398

359

R. Bellamy

often an essential component of patient education but it

should not be limited to this. Falvo (1994) tells us that
before education can be said to have occurred, learning
must take place. . . and that learning implies some change
in behaviour, skill or attitude. . .. This implies that education
has not taken place unless some benefit can be demonstrated.
Three popularly quoted definitions of health education
can help us to understand its purpose:

Med Teach Downloaded from informahealthcare.com by ${individualUser.displayName} on 01/28/15

For personal use only.

[the purpose of health education is] . . . bringing

about behavioral changes in individuals, groups
and larger populations from behaviors that are
presumed to be detrimental to health, to behaviors
that are conducive to present and future health. . ..
(Simonds, 1976)
[health education is] . . . any combination of learning experiences designed to facilitate voluntary
adaptations of behavior conducive to health. . ..
(Green, 1980)
[health education is] . . . the process of assisting
individuals, acting separately or collectively, to make
informed decisions about matters affecting their
personal health and that of others. . .. (National
Task Force on the Preparation and Practice of
Health Educators, 1983)
Health education was initially developed as a public health
tool and focused on topics such as sanitation, immunization
and maternal and child health. During the 1950s the concept of health education broadened and started to include
chronic conditions such as tuberculosis. During the 1960s
health education (of the public) and patient education
(of individuals) were seen as distinct topics. The United
States Department of Health, Education and Welfare (1971)
unified these concepts with a document that advocated
educating patients about their disease and on how to stay
healthy. The difference between the terms health education
and patient education is not always made clear. The term
patient education is sometimes used when advice is given to
an individual and is matched to his or her own individual
health problems and health education is used when nontargeted advice is given to groups. However, if advice
regarding smoking is given to a group of diabetics is this
really health education rather than patient education? The
distinction between health education and patient education
is unclear and they are probably best regarded as two ends
of a continuous spectrum. Many authors now use these
terms interchangeably as the theoretical principles underlying health and patient education are essentially the same.
Therefore this review does not attempt to distinguish
between education of patients and education of well people.
The principles of patient education have been developed
from behavioural models that are based on a synthesis of
several theories on health behaviour. These theories and
models will be discussed before considering how patient
education can be used in day-to-day clinical practice.
Theories underlying health-related behaviour
Self-efficacy, learned helplessness and attribution theory
Self-efficacy is ones own belief in ones ability to cope
with certain stresses. It suggests that whether one is able to
360

achieve something is strongly dependent on whether one

believes one can do it (Bandura, 1977; Bandura & Simon,
1977; Bandura, 1982). For example, if a patient believes
he/she will be able to give up smoking then he is more likely
to succeed when he/she attempts to do so. Learned helplessness is essentially having very low self-efficacy, where
one believes that ones own actions will not have any effect on
the outcome of an event. The theory of learned helplessness
was developed to explain the behaviour of animals after
receiving traumatic shocks over which they had no control
(Seligman & Maier, 1967; Seligman, 1975). Learned helplessness can probably explain the failure of many people
to follow health advice. For example a man who has had a
heart attack may say he will not give up smoking because
he will probably die anyway or someone who has failed
to lose weight on several occasions may say that he cannot
prevent himself from eating.
Attribution theory recognizes that self-efficacy and learned
helplessness are not fixed aspects of personality (Lewis &
Daltroy, 1990). Heider (1958) suggested that failure to
achieve something on one occasion is more likely to affect
ones self-efficacy if one believes that the cause of failure
was due to internal (i.e. due to oneself ) rather than external
factors. This is sometimes called the locus of causation.
Other factors that influence self-efficacy include locus of
control (can one really influence outcome), stability (does
failure occur only once or on repeated occasions) and
globality (does failure in one area suggest failure in other
areas is also likely) (Weiner, 1979, 1985). These concepts
can be applied to health-related behaviours. For example:
does one have a myocardial infarct because of bad luck or
because of smoking? (locus of causation); does stopping
smoking depend on personal will-power or assistance
from social contacts? (locus of control); does failure to stop
smoking on one occasion indicate one will always fail?
(stability); does failure to stop smoking mean that one will
also fail to lose weight and take more exercise? (globality).
For each of these questions it is the patients perception of
the chances of success that is important rather than any
true probability value.
Fear arousal and coping theory
Leventhal (1971) hypothesized that fear is a prime motivator
of behaviour. When placed in a situation that induces fear the
individual will take action to reduce the fear. Simplistically
this suggests that we should use fear-inducing messages
in health education to ensure that our patients comply
with our recommendations. For example, we might tell a
man who has just had a heart attack that he must stop
smoking or he will be at high risk of death. In order to reduce
his fear he may choose to follow our advice. However,
Leventhal warns us that it is the perception of risk that is
important, not the true risk. If given a fear-inducing message
a patient may act in a way that reduces the fear without
actually reducing the risk. For example we may tell a woman
she must have regular mammography to prevent death
from breast cancer. The screening mammogram may then
be seen as fear inducing because it could detect the cancer
she is afraid of. Her solution to reducing her anxiety may
be to avoid having a mammogram and to block the issue from
her mind.

An introduction to patient education

Med Teach Downloaded from informahealthcare.com by ${individualUser.displayName} on 01/28/15

For personal use only.

Lazarus & Folkman (1984) suggest that individuals

use many different behavioural and cognitive strategies to
cope with stressful situations. These coping strategies are not
fixed and each person employs different methods at different
times and in response to different stimuli. The coping
strategies they list are confronting, distancing, self-control,
seeking social support, accepting responsibility, escape
avoidance, problem-solving and positive reappraisal. Each
of these strategies can be beneficial in some health situations
but they can also be used to the detriment of ones health.
For example seeking social support might help one to give up
smoking but it could also lead to inappropriate dependence
on others. The sick role, as described by Parsons (1951), is
a complex coping strategy. In this role patients are not
expected to fulfil their normal roles and are not expected to be
able to overcome illness by voluntary effort.
Social learning theory
Social learning theory was originally developed to explain
how animals and humans learn by imitating the behaviour
of others. The basic principle has been summarized by Perry
et al. (1990) as attending to others responses when
motivated by an acquired drive. . .. This theory was adapted
to clinical psychology by Rotter (1954). He hypothesized
that our behaviour is influenced by observing the actions of
others. Positive or negative reinforcement of behaviour
occurs depending on the outcome of the observed actions.
Social support theory states that our interactions with
others influence our behaviour in more ways than simple
observation and imitation. We receive several forms of
support from others including emotional, informational
(e.g. advice), instrumental (e.g. practical help) and appraisal
(e.g. feedback) (Israel & Schurman, 1990). In the maineffects model of social support theory it is suggested that we
benefit from social relationships regardless of whether we are
under stress. In contrast, the buffering model hypothesizes
that we primarily benefit from social interactions when we are
under stress. There is some evidence to support both the
main-effects and buffering models (Gonzalez et al., 1990).
Other theories
Several other theories that have been postulated to explain
health-related behaviour have been reviewed by Glanz et al.
(1990). These theories include:
 Theory of reasoned action: behaviour is determined by a few
desired outcomes that an individual views as important
(Fishbein, 1967; Carter, 1990).
 Multiattribute utility theory: behaviour can be understood
by the breakdown of complex decisions into smaller units
(Sayeki, 1972; Beach et al., 1976).
 Information processing: internal and external sources of
information are sorted by cognitive processes and behaviour is determined by simple or complex decision-making
rules (Bettman, 1979; Simon, 1979; Rudd & Glanz, 1990).
 Protection motivation theory: threat provides the motivation
to act but coping appraisal determines how to act (Beck &
Frankel, 1981; Rimer, 1990).
 Self-regulation theory: the aim of behaviour is to close the
gap between ones current state and ones perceived ideal
state (Leventhal & Cameron, 1987).

 Transtheoretical model: four stages are necessary for

effective behaviour change: contemplation, commitment
to change, initiation of change and maintenance of
therapeutic gains (Prochaska & DiClemente, 1985).

Health education models

The theories discussed in the preceding section have been
used as the basis for two well-known models of health
behaviour: the PRECEDE model and the health belief
model. Although a simple MEDLINE search will identify
many articles referring to these two models (2617 articles
referring to the health belief model were identified by the
authors search in November 2003), a thorough examination
of the articles indicates there are few clinical trials providing
a valid representation of the models. In 1992, the authors
of one meta-analysis were only able to identify 16 controlled
trials in adults that met the criteria for the health belief
model (Harrison et al., 1992). There is therefore a need for
more controlled trials to assess the validity of these models.
PRECEDE model
The PRECEDE model is a practical model used in improving compliance on a one-to-one basis. The model involves
assessing the patients readiness for behavioural change in
three phases (Green et al., 1975; Green, 1979; 1999):
 Phase 1: predisposing factors: The patients motivation to
change is assessed by asking three questions. Does the
patient believe he or she is susceptible to the disease if
the health behaviour is not adopted? Does the patient
believe that the problems associated with non-compliance
are severe? Does the patient perceive that the benefits of
compliance exceed the risks? Unless the answer to all three
questions is yes, the patient requires education and
support before moving to the second phase.
 Phase 2: enabling factors: The patients skills and resources
are assessed in addition to any barriers which he or
she must overcome. If the skills and resources are not
adequate the patient will need further support before
moving to the third phase.
 Phase 3: reinforcing factors: The patients expectations of the
intervention are assessed to ensure that these are realistic.
If they are not the patient will need further education
before behaviour change is attempted.
Following initiation of the attempt at behaviour change, the
HCW must assess whether self-monitoring will be adequate
to maintain the new health behaviour.
Health belief model
The health belief model developed from the work of several
social psychologists during the 1950s, who were trying to
explain why individuals failed to participate in preventive
healthcare such as tuberculosis screening, immunizations
and dental health (Rosenstock, 1960). The model is derived
from Lewins theories on behaviour. Lewin et al. (1944)
hypothesized that an individuals behaviour depends on the
value that he or she places on an outcome and on the
individuals estimate that a particular action will result in that
361

R. Bellamy

Individual perceptions

Modifying factors

Likelihood of action

Demographic variables (e.g. age, sex, race)

Perceived benefits of
preventive action

Sociopsychological variables
(e.g. personality, social class, peer pressure)

minus
Perceived barriers to
preventive action

Perceived susceptibility to
disease X

Perceived threat of
diseaseX

Med Teach Downloaded from informahealthcare.com by ${individualUser.displayName} on 01/28/15

For personal use only.

Perceived severity of
disease X

Likelihood of taking
recommended health
action

Cues to action
(e.g. mass media campaigns, advice from others
reminder postcard, illness in family member or friend,
newspaper or magazine article)

Figure 1. Original formulation of the health belief model as described by Becker et al. (1979).

outcome. In adapting this to health behaviour, it was believed

that an individuals actions would depend on the following
factors (Becker, 1974b; Becker et al., 1979; see Figure 1):






perceived personal susceptibility to disease;

perceived severity of disease;
perceived benefits of preventive action;
perceived barriers to preventive action;
modifying factors such as demographic variables and social
influences;
 cues to action such as advice from others and media
reporting.
This model rapidly became very popular and in 1974 a book
was published summarizing the evidence supporting the
model (Becker, 1974a). Although the model was initially
developed to explain preventive health behaviour, it was
found that it could equally be applied to illness behaviour
and sick-role behaviour including acute and chronic illness
(Haefner & Kirscht, 1970; Becker, 1974b; Kasl, 1974;
Kirscht, 1974; Rosenstock, 1974; Becker et al., 1977a; 1977b;
1979). A further review 10 years later summarized 24 studies
on preventive health behaviour, 19 studies on sick role
behaviour and three studies on clinic utilization. This
review found strong evidence in support of the health belief
model ( Janz & Becker, 1984).
Beckers group compared the health belief model with 13
other models that had been developed to explain individual
health behaviour (Cummings et al., 1980). They used the
authors of the original models as judges to group 109
variables from the models on the basis of similarity. This
demonstrated that many of the models used very similar
variables even though they were labelled differently. This
study proved helpful in developing a unified model for
explaining health behaviour. Four years later Beckers group
published a model, which they called the health decision
model, incorporating health beliefs, behavioural decision
362

theory and decision analysis (Eraker et al., 1984). The

components of the health decision model are:
 General health beliefs: This relates to how concerned a
person is about his or her health in general, willingness
to accept medical direction and his/her satisfaction with
his/her interaction with healthcare advisers.
 Specific health beliefs: This relates to perceived susceptibility
and perceived severity of the illness.
 Patient preferences: The individual has to weigh up the
perceived barriers and benefits. It is the patients perceptions that count rather than the real risks and benefits
and these perceptions may be influenced by biases.
 Experience: The person may have experienced disease,
treatment or other health behaviours previously. His or her
perceptions of that experience and of his/her healthcare
providers can alter future decisions.
 Knowledge: Specific knowledge of a disease and the
diagnostic and therapeutic interventions to be considered
can be important influences.
 Social interaction: Supervision by others, social support
and social networks can influence our experience and
knowledge.
 Sociodemographic factors: Age, sex, income, educational
level and possession of health insurance may influence
knowledge, experience and social interaction.
 Previous health decisions, health behaviour and the resultant
health outcomes: The results of previous health decisions
can affect knowledge and experience.

Patient education in day-to-day practice

A basic understanding of the preceding educational theories
can assist healthcare workers in their day-to-day communication with patients. Communication is important because
it improves patient compliance and produces health benefits

Med Teach Downloaded from informahealthcare.com by ${individualUser.displayName} on 01/28/15

For personal use only.

An introduction to patient education

(Lipkin, 1996). Patients who are given more information

about their illness have fewer problems (Rosenberg, 1971,
Hermiz et al., 2002; Ryan et al., 2003) and report greater
satisfaction with the HCW (Ley et al., 1976). Patients
who are warned of likely side effects from medicines are
less likely to stop taking them when they occur (Seltzer et al.,
1980). Non-compliance is often linked to the physicians
failure to communicate the purpose of the treatment (Mohler
et al., 1955; Wilson, 1973). Higher rates of patient compliance occur when the doctor has better communication
skills (Schmidt, 1977) and when the patient perceives
himself or herself as an active participant in treatment
planning (Chambers et al., 1999). Doctors who show concern
for the patient achieve better patient satisfaction, which is
related to compliance to therapy (Korsch et al., 1968; Francis
et al., 1969; Falvo et al., 1980).
It is important that the clinician establishes rapport
with the patient in order to earn his or her trust (Di Matteo,
1975). Studies suggest that patients remember only 50% of
what they are told in a clinic visit (Ley, 1972). Patients must
therefore be given sufficient time to understand the information they are given. Information may often need to be
repeated and the patient should be encouraged to ask
questions. There is a tendency for doctors to spend less
time on health education of patients with lower educational
achievements (Stirling et al., 2001, Furler et al., 2002).
However, research shows that patients with less formal
education have a greater need for health education and
therefore additional effort should be made to meet these
needs (Hatcher et al., 1986).
Szasz & Hollender (1956) describe three models of
doctorpatient interaction. In the activitypassivity model
the doctor gives instructions for the patient to follow. In the
guidancecooperation model the patients cooperation is
sought but the doctor remains in charge. In the mutual
participation model joint decisions are made. This latter
model is what doctors should be aiming to achieve. Mutual
participation forms the basis of doctorpatient contracts
where patients are seen as active members of the health
care team. . . (Etzwiler, 1973). In these contracts both
doctor and patient must be willing to negotiate and both
should gain from the encounter (Quill, 1983). Although
some physicians have reservations about active involvement of patients in decision-making, there are considerable
benefits for patient compliance (Schwartz, 1979; Brody,
1980). The aim should be to make the patient less dependent
on the HCW by increasing his or her knowledge, skills
and self-reliance (Green, 1987). The patient then feels
ownership of the decisions reached so that he or she is
more committed to them.
Conclusions
Patient education is an essential component of effective
healthcare delivery. Educational models based on behavioural theory can help us to understand patients actions
and to plan effective educational interventions. If doctors
are to deliver high-quality patient education in the future it
is important that this subject is incorporated into medical
curricula. As health and teaching professionals, medical
teachers are in an ideal position to educate students on how
to educate their patients. Medical education and patient

education have many similarities. In my opinion patient

education would benefit from being incorporated into the
discipline of medical education. Patient education could
then benefit from the significant advances that are taking
place in medical teaching. Rigorous studies on patient
education are as essential as those on the education of
health professionals. The effectiveness of patient education
interventions can be assessed in similar ways to educational
interventions for students. The published studies can then be
evaluated using an approach similar to the best evidence
medical education approach. This will assist HCWs who
wish to plan and implement educational interventions of
proven effectiveness.

Practice points
 Compliance with medical advice on treatment and
lifestyle modifications is often poor.
 Non-compliance can adversely affect patients health.
 Patient education aims to improve health by enabling
individuals to make informed choices regarding their
own health-related behaviour.
 The health belief model can help us to understand
patients behaviour and to design effective educational
interventions.

Notes on contributor
RICHARD BELLAMY is an infectious disease physician and epidemiologist
with a strong interest in medical education. He is currently based in
Ghana directing a clinical trial on the effects of vitamin A supplements
on maternal mortality.

References
ANDERSON, R.J. & KIRK, L.M. (1982) Methods of improving patient
compliance in chronic disease states, Archives of Internal Medicine, 142,
pp. 16731675.
BANDURA, A. (1977) Self-efficacy: toward a unifying theory of behavior
change, Psychological Review, 84, pp. 191215.
BANDURA, A. (1982) Self-efficacy in human agency, American Journal of
Psychology, 37, pp. 122147.
BANDURA, A. & SIMON, K.M. (1977) The role of proximal intentions in
self-regulation of refractory behavior, Cognitive Therapy and Research, 1,
pp. 177193.
BEACH, L.R., TOWNES, B.O., CAMPBELL, F.L. & KEATING, G.W. (1976)
Developing and testing a decision aid for birth-planning decisions,
Organizational Behavior and Human Performance, 24, pp. 1928.
BECK, K.H. & FRANKEL, A. (1981) A conceptualization of threat
communications and protective health behavior, Social Psychology
Quarterly, 44, pp. 204217.
BECKER, M.H. (Ed.) (1974a) The Health Belief Model and Personal Health
Behavior, Health Education Monographs No. 2 (New Jersey, Charles B.
Slack).
BECKER, M.H. (1974b) The health belief model and sick role behavior, in:
M.H. Becker (Ed.) The Health Belief Model and Personal Health
Behavior, Health Education Monographs No. 2, pp. 8292 (New
Jersey, Charles B. Slack).
BECKER, M.H., HAEFNER, D.P., KASL, S.V., KIRSCHT, J.P., MAIMAN,
L.A. & ROSENSTOCK, I.M. (1977a) Selected psychosocial models and
correlates of individual health-related behaviors, Medical Care, 15,
pp. 2746.

363

Med Teach Downloaded from informahealthcare.com by ${individualUser.displayName} on 01/28/15

For personal use only.

R. Bellamy

BECKER, M.H., MAIMAN, L.A., KIRSCHT, J.P., HAEFNER, D.P. &

DRACHMAN, R.H. (1977b) The health belief model and prediction
of dietary compliance: a field experiment, Journal of Health and Social
Behavior, 18, pp. 348366.
BECKER, M.H., MAIMAN, L.A., KIRSCHT, J.P., HAEFNER, D.P., DRACHMAN,
R.H. & TAYLOR, D.W. (1979) Patient perceptions and compliance:
recent studies of the health belief model, in: R.B. Haynes,
D.W. Taylor & D.L. Sackett (Eds) Compliance in Health Care,
pp. 78109 (Baltimore, Johns Hopkins University Press).
BETTMAN, J.R. (1979) An Information Processing Theory of Consumer Choice
(Massachusetts, Addison-Wesley).
BRODY, D.S. (1980) The patients role in clinical decision-making,
Annals of Internal Medicine, 93, pp. 718722.
CARTER, W.B. (1990) Health behavior as a rational process: theory
of reasoned action and multiattribute utility theory, in: K. Glanz,
F.M. Lewis & B.K. Rimer (Eds) Health Behavior and Health
Education: Theory, Research and Practice, pp. 6391 (San Francisco,
Jossey Bass).
CHAMBERS, C.V., MARKSON, L., DIAMOND, J.J., LASCH, L. & BERGER, M.
(1999) Health beliefs and compliance with inhaled corticosteroids by
asthmatic patients in primary care practices, Respiratory Medicine, 93,
pp. 8894.
CUMMINGS, K.M., BECKER, M.H. & MAILE, M.C. (1980) Bringing
the models together: an empirical approach to combining variables
used to explain health actions, Journal of Behavioral Medicine, 3,
pp. 123145.
DI MATTEO, M.R. (1975) A social-psychological analysis of physician
patient rapport: toward a science of the art of medicine, Journal of Social
Issues, 35, pp. 1233.
ERAKER, S.A., KIRSCHT, J.P. & BECKER, M.H. (1984) Understanding
and improving patient compliance, Annals of Internal Medicine, 100,
pp. 258268.
ETZWILER, D.D. (1973) The contract for health care, Journal of the
American Medical Association, 224, p. 1034.
FALVO, D., WOEHLKE, P. & DEICHMANN, J. (1980) Relationship of
physician behavior to patient compliance, Patient Counselling and Health
Education, 2, pp. 185188.
FALVO, D.R. (1994) Effective Patient Education: A Guide to Increased
Compliance, 2nd edn (Maryland, Aspen Publishers).
FISHBEIN, M. (1967) Attitude and prediction of behaviour: results of a
survey sample, in: M. Fishbein (Ed.) Readings in Attitude Theory and
Measurement (New York, Wiley).
FRANCIS, V., KORSCH, B.M. & MORRIS, M.J. (1969) Gaps in doctor
patient communication: patients response to medical advice,
New England Journal of Medicine, 280, pp. 535540.
FURLER, J.S., HARRIS, E., CHONDROS, P., DAVIES, P.G.P., HARRIS, M.F. &
YOUNG, D.Y.L. (2002) The inverse care law revisited: impact of
disadvantaged location on accessing longer GP consultation times,
Medical Journal of Australia, 177, pp. 8083.
GLANZ, K., LEWIS, F.M. & RIMER, B.K. (Eds). (1990) Health Behavior
and Health Education: Theory, Research and Practice (San Francisco,
Jossey Bass).
GONZALEZ, V.M., GOEPPINGER, J. & LORIG, K. (1990) Four psychosocial
theories and their application to patient education and clinical practice,
Arthritis Care and Research, 3, pp. 132143.
GREEN, L.W. (1979) Educational strategies to improve compliance
with therapeutic and preventive regimens: the recent evidence,
in: R.B. Haynes, D.W. Taylor & D.L. Sackett (Eds) Compliance
in Health Care, pp. 157173 (Baltimore, Johns Hopkins University
Press).
GREEN, L.W. (1980) Health Education Planning: A Diagnostic Approach
(California, Mayfield).
GREEN, L.W. (1987) How physicians can improve patients participation and maintenance in self-care, Western Journal of Medicine, 147,
pp. 346349.
GREEN, L.W. (1999) What can we generalize from research on patient
education and clinical health promotion to physician counseling on
diet?, European Journal of Clinical Nutrition, 53, pp. S9S18.
GREEN, L.W., LEVINE, D.M. & DEEDS, S.G. (1975) Clinical trials of
health education for hypertensive patients: design and baseline data,
Preventive Medicine, 4, pp. 417425.

364

HAEFNER, D.P. & KIRSCHT, J.P. (1970) Motivational and behavioral effects of modifying health beliefs, Public Health Reports, 85,
pp. 478484.
HARRISON, J.A., MULLEN, P.D. & GREEN, L.W. (1992) A meta-analysis
of studies of the health belief model with adults, Health Education
Research, 7, pp. 107116.
HATCHER, M.E., GREEN, L.W., LEVINE, D.M. & FLAYLE, C.E. (1986)
Validation of a decision model for triaging hypertensive patients to
alternate health education interventions, Social Science and Medicine, 22,
pp. 813819.
HEATH, I. (2003) A wolf in sheeps clothing: a critical look at the ethics
of drug taking, British Medical Journal, 327, pp. 856858.
HEIDER, F. (1958) The Psychology of Interpersonal Relations (New York,
Wiley).
HERMIZ, O., COMINO, E., MARKS, G., DAFFURN, K., WILSON, S. &
HARRIS, M. (2002) randomised controlled trial of home based care of
patients with chronic obstructive pulmonary disease, British Medical
Journal, 325, pp. 938942.
ISRAEL, B.A. & SCHURMAN, S.J. (1990) Social support, control and
the stress process, in: K. Glanz, F.M. Lewis & B.K. Rimer (Eds) Health
Behavior and Health Education: Theory, Research and Practice, pp. 187
215 (San Francisco, Jossey Bass).
JANZ, N.K. & BECKER, M.H. (1984) The health belief model: a decade
later, Health Education Quarterly, 11, pp. 147.
KASL, S.V. (1974) The health belief model and behavior related to
chronic illness, in: M.H. Becker (Ed.) The Health Belief Model
and Personal Health Behaviour, Health Education Monographs No. 2,
pp. 106127 (New Jersey, Charles B. Slack).
KIRSCHT, J.P. (1974) The health belief model and illness behavior,
in: M.H. Becker (Ed.) The Health Belief Model and Personal
Health Behaviour, Health Education Monographs No. 2, pp. 6081
(New Jersey, Charles B. Slack).
KORSCH, B., GOZZI, E.K. & FRANCIS, V. (1968) Gaps in doctorpatient
communication: doctorpatient interaction and patient satisfaction,
Pediatrics, 42, pp. 855871.
LAZARUS, R.S. & FOLKMAN, S. (1984) Stress Appraisal and Coping (New
York, Springer).
LERNER, B.H., GULICK, R.M. & DUBLER, N.N. (1998) Rethinking
nonadherence: historical perspectives on triple drug therapy for HIV
disease, Annals of Internal Medicine, 129, pp. 573578.
LEVENTHAL, H. (1971) Fear appeals and persuasion: the differentiation
of a motivational construct, American Journal of Public Health, 61,
pp. 12081224.
LEVENTHAL, H. & CAMERON, L. (1987) Behavioral theories and
the problem of compliance, Patient Education and Counselling, 10,
pp. 117138.
LEWIN, K., DEMBO, T., FESTINGER, L. & SEARS, P.S. (1944) Level of
aspiration, in: J.M.V. Hunt (Ed.) Personality and Behavior Disorders:
A Handbook Based on Experimental and Clinical Research, pp. 333378
(New York, Ronald Press).
LEWIS, F.M. & DALTROY, L.H. (1990) How causal explanations influence
health behavior, in: K. Glanz, F.M. Lewis & B.K. Rimer (Eds) Health
Behavior and Health Education: Theory, Research and Practice, pp. 92114
(San Francisco, Jossey Bass).
LEY, P. (1972) Comprehension, memory and the success of communications with the patient, Journal of Instructional Health Education,
10, pp. 2329.
LEY, P., BRADSHAW, P.W., KINCEY, J.A. & ATHERTON, S.T. (1976)
Increasing patients satisfaction with communications, British Journal
of Social and Clinical Psychology, 15, pp. 403413.
LIPKIN, M. JR (1996) Physicianpatient interaction in reproductive
counselling, Obstetrics and Gynecology, 88(Suppl.), pp. 31S40S.
MOHLER, D.N., WALLIN, D.G. & DREYFUS, E.G. (1955) Studies in
the home treatment of streptococcal disease, I: Failure of patients to
take penicillin by mouth as prescribed, New England Journal of Medicine,
252, pp. 11161118.
NATIONAL TASK FORCE ON THE PREPARATION AND PRACTICE OF
HEALTH EDUCATORS (1983) A Framework for the Development of
Competency-based Curricula for Entry Level Health Educators (New
York, NTFPPHE).
PARSONS, T. (1951) The Social System (New York, Free Press).

Med Teach Downloaded from informahealthcare.com by ${individualUser.displayName} on 01/28/15

For personal use only.

An introduction to patient education

PERRY, C.L., BARANOWSKI, T. & PARCEL, G.S. (1990) How individuals,

environments and behavior interact: social learning theory, in: K. Glanz,
F.M. Lewis & B.K. Rimer (Eds) Health Behavior and Health Education:
Theory, Research and Practice, pp. 161186 (San Francisco, Jossey Bass).
PROCHASKA, J.O. & DI CLEMENTE, C.L. (1985) Common processes of selfchange in smoking, weight control and psychological distress, in:
S. Shiffman & T. Wills (Eds) Coping and Sbstance Use, pp. 345364
(Orlando, Academic Press).
QUILL, T.E. (1983) Partnerships in patient care: a contractual approach,
Annals of Internal Medicine, 98, pp. 228234.
RIMER, B.K. (1990) Perspectives on intrapersonal theories in health
education and health behaviour, in: K. Glanz, F.M. Lewis & B.K.
Rimer (Eds) Health Behavior and Health Education: Theory, Research and
Practice, pp. 140157 (San Francisco, Jossey Bass).
ROSENBERG, S.G. (1971) Patient education leads to better care for heart
patients, HSHHA Health Reports, 86, pp. 793801.
ROSENSTOCK, I.M. (1960) What research in motivation suggests for public
health, American Journal of Public Health, 50, pp. 295302.
ROSENSTOCK, I.M. (1974) The health belief model and preventive health
behavior, in: M.H. Becker (Ed.) The Health Belief Model and Personal
Health Behavior, Health Education Monographs No. 2, pp. 2759
(New Jersey, Charles B. Slack).
ROTTER, J.B. (1954) Social Learning and Clinical Psychology (New Jersey,
Prentice-Hall).
RUDD, J. & GLANZ, K. (1990) How individuals use information for
health action: consumer information processing, in: K. Glanz, F.M.
Lewis & B.K. Rimer (Eds) Health Behavior and Health Education:
Theory, Research and Practice, pp. 115139 (San Francisco, Jossey
Bass).
RYAN, S., HASSELL, A., DAWES, P. & KENDALL, S. (2003) Control
perceptions in patients with rheumatoid arthritis: the impact of the
medical consultation, Rheumatology, 42, pp. 135140.
SACKETT, D.L. & SNOW, J.C. (1979) The magnitude of compliance and
noncompliance, in: R.B. Haynes, D.W. Taylor & D.L. Sackett (Eds)
Compliance in Health Care, pp. 1122 (Baltimore: Johns Hopkins
University Press).

SAY, R.E. & THOMSON, R. (2003) The importance of patient preferences

in treatment decisions: challenges for doctors, British Medical Journal,
327, pp. 542545.
SAYEKI, Y. (1972) Allocation of importance: an axiom system, Journal of
Mathematical Psychology, 9, pp. 5565.
SCHMIDT, D.D. (1977) Patient compliance: the effect of the doctor as a
therapeutic agent, Journal of Family Practice, 4, pp. 48534856.
SCHWARTZ, W.B. (1979) Decision analysis: a look at the chief complaints,
New England Journal of Medicine, 300, pp. 556559.
SELIGMAN, M. (1975) On Depression, Development and Death
(San Francisco, W.H. Freeman).
SELIGMAN, M. & MAIER, S. (1967) Failure to escape traumatic shock,
Journal of Experimental Psychology, 74, pp. 19.
SELTZER, A., RONCORI, I. & GARFINKEL, P. (1980) Effect of patient
education on medication compliance, Canadian Journal of Psychiatry,
25, pp. 638645.
SIMON, H.A. (1979) Information processing models of cognition, Annual
Review of Psychology, 30, pp. 363396.
SIMONDS, S.K. (1976) Health Education in the mid1970s: State of the Art
(New York, Prodist).
STIRLING, A.M., WILSON, P. & MCCONNACHIE, A. (2001) Deprivation,
psychological distress, and consultation length in general practice,
British Journal of General Practice, 51, pp. 456460.
SZASZ, T.S. & HOLLENDER, M.H. (1956) A contribution to the philosophy
of medicine: the basic models of the doctorpatient relationship,
Archives of Internal Medicine, 97, pp. 585592.
UNITED STATES DEPARTMENT OF HEALTH, EDUCATION AND WELFARE.
(1971) The need for patient education, American Journal of Public
Health, 61(7).
WEINER, B. (1979) A theory of motivation for some classroom
experiences, Journal of Educational Psychology, 71, pp. 325.
WEINER, B. (1985) An attributional theory of achievement, motivation
and emotion, Psychological Review, 92, pp. 548573.
WILSON, J.T. (1973) Compliance with instructions in the evaluation of
therapeutic efficacy: a common but frequently unrecognised major
variable, Clinical Pediatrics, 12, pp. 333340.

365