Copyright © 1998 Elsevier Science Ltd. All rights reserved.

8.03
Health Care
JOHN WEINMAN
United Medical and Dental Schools of Guy's and St. Thomas's
Hospitals, London, UK

8.03.1 INTRODUCTION 79
8.03.2 THEORETICAL BACKGROUND 80
8.03.3 PERCEIVING SYMPTOMS AND ENTRY INTO THE HEALTH-CARE SYSTEM 81
8.03.3.1 The Nature and Experience of Symptoms 81
8.03.3.2 Factors Influencing Symptom Perception 82
8.03.3.2.1 Attentional focus 82
8.03.3.2.2 Knowledge and expectations 83
8.03.3.2.3 Disposition and emotions 83
8.03.3.2.4 Contextual factors 83
8.03.3.3 Summary: Symptom Perception 84
8.03.3.4 Symptom Perception and Help Seeking 84
8.03.4 HEALTH-CARE PROFESSIONAL±PATIENT COMMUNICATION 86
8.03.4.1 Input Factors in Communication 86
8.03.4.1.1 Patient input factors 87
8.03.4.1.2 Health-care professional input factors 89
8.03.4.2 The Consultation Process 91
8.03.4.3 Outcomes of Health-care Communication 92
8.03.4.3.1 Cognitive outcomes 92
8.03.4.3.2 Affective outcome: patient satisfaction 92
8.03.4.3.3 Behavioral outcome: adherence 94
8.03.4.3.4 Consultation outcomes: an overview 98
8.03.4.4 Improving Health-care Communication 98
8.03.5 HEALTH CARE IN HOSPITALS 100
8.03.5.1 Psychological Effects of Hospitalization 100
8.03.5.1.1 Physical and social environment 100
8.03.5.1.2 Communication in hospital 101
8.03.5.2 Children in Hospital 102
8.03.5.3 Psychological Aspects of Specific Hospital Treatments 102
8.03.5.4 Stressful Medical Procedures in Hospital 104
8.03.5.5 Psychological Interventions for Stressful Medical Procedures 104
8.03.6 CONCLUSION 106
8.03.7 REFERENCES 107

8.03.1 INTRODUCTION sense of and respond to symptoms, leading up

This chapter is concerned with a range of
psychological processes involved in the entry
into, experience of, and outcome from health
care. It begins by considering how people make
to the decision to seek health care. Following
this, a large part of the chapter is concerned
with the process and outcome from medical
consultations. Finally, it considers some very
specific health-care settings such as hospital

79
80 Health Care
environments and surgical treatments where
psychological factors can play an important
role in adaptation and recovery.
Thus, the chapter covers the three following
broad areas, which form its major subsections:
(i) perceiving symptoms and entry into health
care, (ii) health-care professionalÐpatient com-
munication, and (iii) health care in hospital.
It is important to note at the outset that this
chapter does not deal with the nature of health-
care systems and the ways in which these are
organized and accessed. Health-care systems
vary greatly from country to country and there
can be considerable differences in the ease of
access to health care, the relative roles of the
primary and secondary care sectors, and the
ways in which health care is funded and
delivered. All these are extremely important
contextual factors which can directly influence
the experience of health care for the individual
but a consideration of their influence is beyond
the scope of this chapter. The focus here will be
on those psychological processes involved in the
entry into and use of health services, and which
may be seen across different health-care systems.
8.03.2 THEORETICAL BACKGROUND
Although this chapter focuses on a range of
psychological processes and issues, there is a
general model which unifies many of the various
themes, particularly from the patient's perspec-
tive. This is the self-regulatory approach (e.g.,
Carver & Scheier, 1990; Leventhal et al., 1997).
The core concept here is that the individual
attempts to make sense of threats to health using
preexisting knowledge or schema which give rise
to behavioral responses (e.g., taking nonpre-
scribed medicines, deciding to seek medical help,
following medical advice, etc.). Thus, many of
the individual's behaviors within the health-care
setting can be understood from the perspective
of their own thoughts and ideas. These are not
static but may well change and develop with the
experience of new symptoms or information.
Self-regulation is therefore a dynamic process in
which the individual attempts to preserve the
Cognitive representation
of illness/health threat
Internal and
environmental
stimuli
Representation of
emotion (fear/distress)
Figure 1 Leventhal's self-regulatory model (adapted from Leventhal, Diefenbach, & Leventhal, 1992).
sense of self and to solve the problem of what is
happening to their health.
The individual's initial representations of a
health problem (e.g., ªthis stomach pain is a
temporary problem brought on by something
specific such as over-eatingº) give rise to specific
coping procedures (e.g., not eating, taking
antiacids) which are appraised for their effec-
tiveness (see Figure 1). If the appraisal process
results in the view that the mode of coping is not
working, then another coping procedure may be
selected or the individual may change their view
about the nature of the problem (e.g., ªthis
stomach pain has lasted for the whole day and
has not responded to indigestion medicationÐit
must be something more seriousº) and their
response to it.
The core of the self-regulatory approach is the
individual's own understanding or representa-
tion of their situation. Work by Leventhal and
colleagues (Leventhal et al., 1997; Leventhal,
Nerenz, & Steele, 1984) has shown that this
representation is built around five distinct but
interrelated themes, namely identity, cause,
time-line, consequences, and cure/control. On
experiencing a new symptom, the individual
typically will provide a label or description and
possibly search for or link this with other
symptoms which they are experiencing. These
aspects constitute their perceived identity of the
problem, and typically this is linked with a
causal explanation, as well as some expectations
about how the problem will last (time-line), its
likely effects (consequences) and the extent to
which it is amenable to cure or control. These
representations will influence how the indivi-
dual responds to the problem in the short-term
and the longer-term, if it persists. They will also
provide the conceptual framework for provid-
ing and making sense of information within
consultations with health-care professionals, as
well as for evaluating the appropriateness and
efficacy of recommended treatment or advice.
In some of the following sections (e.g.,
symptom perception), this self-regulatory,
schema-based approach will be very obvious
but in others it will be less clear or less pertinent.
Coping Appraisal
Coping Appraisal
 Perceiving Symptoms and Entry into the Health-care System
Nevertheless, it is a central tenet in this chapter,
just as it is in many other areas of psychological
research. Just as individuals actively interpret
and make sense of their physical (Eysenck &
Keane, 1995) and their social environment
(Fiske & Taylor, 1991), it will be shown that
the psychological processes involved in experi-
encing symptoms and utilizing health care can
be understood in a similar way (Weinman &
Petrie, 1997).
8.03.3 PERCEIVING SYMPTOMS AND
ENTRY INTO THE HEALTH-CARE
SYSTEM
There are many reasons why people gain
access to health care. Increasingly people are
encouraged to attend on a regular basis for
check-ups or for screening or preventive
purposes, but by far the most common reason
for seeking medical help is the experience of a
symptom. At first sight, the relation between
symptoms and entry into health care might
appear straightforward. A simplistic model of
the relation between symptom experience and
health-care utilisation would probably involve
the idea of a threshold of symptom severity, and
that individuals would only seek care when this
notional threshold is exceeded. As we shall see,
this simple model is untenable and it is necessary
to understand first how symptoms are perceived
and then to examine how they influence
behavior, including help-seeking behavior.
8.03.3.1 The Nature and Experience of
Symptoms
There are continuous changes in bodily
functions but individuals have limited aware-
ness of these. In a series of studies, Pennebaker
(1982) examined the awareness of a number of
changing bodily processes (e.g., heart rate,
finger temperature) and showed that this
process is neither direct nor accurate The
awareness and interpretation of bodily pro-
cesses has been found to involve a range of
factors, as will be outlined below, and an
understanding of these is a basic first step in
explaining why people seek help for health
problems. A fundamental issue here concerns
the point at which the individual decides that a
particular change in bodily functioning might
constitute a symptom and may therefore be
indicative of a medical condition. Symptoms are
experienced quite frequently. This has been
found by asking people to recall symptoms
experienced in the preceding days or weeks or by
getting them to record their symptoms, by
keeping a health or symptom diary. Typically
people recall experiencing between two and
81
three symptoms per week and very often
symptom diaries reveal the presence of daily
symptoms. Most of these are transient and,
while they may make the individual wonder
about their nature and cause, they may not give
rise to any further behavior such as taking
medication or seeking medical help. One study,
of people keeping health diaries, found that
while symptoms were recorded on 38% of the
days in the study period, medical care was
sought for only 5% of those symptoms
(Verbrugge, 1985). This ªclinical icebergº has
been reported elsewhere (e.g., Last, 1963) and it
is clear that neither the experience nor the
severity of a symptom provides an adequate
explanation of why people seek medical help.
There are many people who seek help for
symptoms which doctors consider to be ªmin-
orº or ªtrivialº and there are also people who
delay or do not seek help for symptoms which
may reflect serious or life-threatening condi-
tions, and some examples of this will be
discussed in Section 8.03.3.4. In order to
understand the relation between symptoms
and help-seeking behavior, it is necessary first
to examine how symptoms are perceived and
then to examine their role, alongside other
factors, in initiating access to health care.
The studies of Pennebaker (1982) and others
show clearly that symptom perception shares
many characteristics of other perceptual pro-
cesses, such as those which are involved in the
recognition of objects and sounds in the external
world. Thus, there is considerable evidence that
bodily changes are not perceived accurately and
that there can be large variations in what is
attended to and how it is perceived and
interpreted. Just as attentional processes and
ªtop-downº influences in the form of knowl-
edge and prior experience can determine how
objects are perceived (Eysenck & Keane, 1995),
the same factors play a critical role in influen-
cing our awareness of and interpretation of
bodily changes.
Physical symptoms are often ambiguous and
their interpretation involves a number of
cognitive-perceptual processes which are subject
to both psychological and social influences
(Cioffi, 1991; Pennebaker, 1982). The experience
of a bodily symptom initiates an active memory
search in order to generate comparisons between
current stimulus and the concrete and abstract
knowledge contained in the person's illness
schemas. These cognitive structures are the
dominant source of information for the apprai-
sal of health threats (Leventhal et al., 1997).
According to Bishop (1991), the information
contained in illness schemas forms a stable
knowledge base or prototype which acts as a
standard for the comparison and interpretation
82 Health Care
of bodily symptoms. Current symptoms are
compared with prototypical patterns of illness
retrieved from long-term memory. If there is a
close enough resemblance between the illness
prototype and the current symptoms, then a
congruent interpretation will be made. How-
ever, H. Leventhal and Diefenbach (1991)
propose that comparisons are made not with
illness prototypes but with specific illness
episodes. They suggest that matching to proto-
types is likely to result in an ambiguous outcome
and that the resulting uncertainty will initiate
additional, more specific searches. Croyle and
Barger (1993) comment that both types of
matching may occur. Frequently experienced
illnesses such as flu may promote the formation
of prototypes, whereas unusual symptom clus-
ters may give rise to matching with specific illness
episodes. Cioffi (1991) has described a model of
symptom interpretation which is compatible
with the self-regulation model. Her model
proposes that symptom interpretation is a
function of interactions between ªbottom-up,º
stimulus-driven processes, situational cues, and
ªtop-downº processes which reflect the influ-
ence of higher level cognitive structures (e.g.,
knowledge, expectations) on other cognitive
functions such as attention and memory.
According to Cioffi (1991), ambiguous physio-
logical changes compete with other events for a
share of our fixed attentional capacity. If the
stimuli are strong enough, or if there is little
competition from other sources, the sensations
are noticed and given a somatic label. An
attribution is then made regarding the cause of
the change and its consequences. Causal attribu-
tions reflect the relative influence of the
procedures involved in the interpretative process
and may be symptomological (e.g., muscle pain
as a symptom of illness), or nonsymptomologi-
cal (e.g., muscle pain due to exercise). Sympto-
mological attributions can reflect preexisting
hypotheses such as particular health concerns
which may bias both attention to bodily stimuli
and choice of attribution. Alternatively, in the
absence of a prior hypothesis, a memory search is
launched in order to generate plausible attribu-
tions. These processes, along with subsequent
behavioral responses, are mediated by factors
such as mood, coping repertoire, available
choices, and both situation-specific and general
goals. A schematic of this model is shown in
Figure 2.
8.03.3.2 Factors Influencing Symptom
Perception
The appraisal of health threats may be
influenced by a range of personal, psychological,
social, and cultural factors (Croyle, 1992). While
many of these factors interact, they can be
loosely categorized into those which affect or are
a part of the self-system and those which stem
from external, social, and cultural influences.
8.03.3.2.1 Attentional focus
Symptom perception is subject to the same
limits and biases as other types of sensory
processing, where there are well-demonstrated
limits in attentional capacity which can be
influenced by internal states, perceiver's inten-
tions, and environmental stimuli and contexts
(e.g., Kinchla, 1992). Similarly, a number of
studies have shown that symptom perception
depends on what the individual is attending to
as well as what is happening in the perceiver's
environment. For example, Pennebaker (1982)
reports a study in which the symptom reports of
fatigue were compared in two groups of joggers,
one running around a track and the other on a
cross-country run. The cross-country group
report less fatigue, presumably because of the
more varied and interesting surroundings.
Similarly it has been reported that, while
watching films, people are more likely to notice
itchy/tickly throat sensations and then cough
during boring parts of the film.
Attention to symptoms is to some extent
under strategic control and a number of studies
have examined the effects of attention to or
distraction from physical sensations (Cioffi,
1991). Experimental studies examining the
effects of various unpleasant stimuli (e.g., loud
noise, pain induced by immersing one's hand
into iced water) on tolerance and arousal, have
shown that active distraction can have short-
term advantages over more direct attention to
the stimuli (Mullen & Suls, 1982). However,
focused attention results in more favorable
outcomes than distraction when the noxious
stimulus is chronic and when the attentional
strategy involves focusing on concrete aspects of
the sensation (Suls & Fletcher, 1985). This raises
the question as to whether focusing on aversive
symptoms such as pain could have any positive
or negative effects which could be utilized in the
clinical situation. Work by Leventhal, Le-
venthal, Shacham, and Easterling (1989) in-
dicates that focusing on sensory properties of
sensations can result in reduced levels of
distress. This type of sensory focusing or
monitoring serves to direct attention to more
objective, sensory properties of the stimulus and
away from the more negative, emotionally
arousing aspects, resulting in a more neutral
interpretation and response. This can be used to
good effect in providing sensory information to
patients prior to stressful medical procedures
and surgery (see Section 8.03.5.5).
 Perceiving Symptoms and Entry into the Health-care System
Behavior
Mediators
Prior
hypothesis
Attributions
Somatic
label
Physical
state
Figure 2 A model of symptom perception (adapted
from Cioffi, 1991).
8.03.3.2.2 Knowledge and expectations
The knowledge contained within illness
schemas imposes meaning on internal and
external events (Leventhal et al., 1984). A
powerful illustration of the influence of schema
contents on the interpretation of somatic stimuli
comes from studies of patients suffering from
panic disorder and hypochondriasis whose
catastrophic illness-related interpretations of
benign bodily stimuli reflects their current
health concerns (Warwick & Salkovskis,
1990). Similar influences of catastrophic inter-
pretations on symptoms can be seen in patients
with chronic fatigue syndrome (Moss-Morris,
1997) and with chronic pain disorders (e.g.,
Keefe, Brown, Wallston, & Caldwell, 1989). In
all these situations the catastrophizing indivi-
dual will be likely to interpret a bodily symptom
in a very negative way (i.e., perceive it as
indicative of a serious problem), which then will
generate even higher levels of anxiety and an
increased focus on and negative interpretation
of related symptoms.
In addition to personal illness experience,
illness schemas are derived from illness infor-
mation current in the culture and from social
83
communication with other people, particularly
medical practitioners (Leventhal et al., 1984).
The body or self schema also affects the
interpretation of health threats as it provides
a basis for comparing deviations from the norm
and for discriminating normal age-related
changes from illness (Keller, Leventhal, Proha-
sha, & Leventhal, 1989). Indeed, with older
people there is evidence of a bias towards age-
related attributions (i.e., ªit's because I am oldº)
which can serve to delay seeking help or prevent
taking appropriate action (E. Leventhal &
Crouch, 1997).
8.03.3.2.3 Disposition and emotions
The content and activation of illness schemas
may also be influenced by dispositional factors
such as psychological traits and emotions (H.
Leventhal & Diefenbach, 1991; Leventhal,
Diefenbach, & Leventhal, 1992). For example,
Leventhal et al. (1992) propose that personality
factors such as repression-sensitisation (Byrne,
1964) may affect illness representations by
influencing attention to and interpretation of
somatic states. Also, high levels of negative
affectivity, which is highly correlated with
neuroticism (Watson & Clark, 1984), have been
found to predict symptom reporting and health
complaints, but not actual health status (Wat-
son & Pennebaker, 1989). Laboratory studies
involving experimental induction of a negative
mood state in volunteer subjects results in more
negative judgements of health status and higher
levels of symptom reporting than is reported by
comparison subjects who had undergone posi-
tive mood induction (Croyle & Uretsky, 1987).
Similarly, when individuals are asked to keep a
diary of symptoms and moods, they report
higher levels of symptoms during negative
mood states (Verbrugge, 1985).
8.03.3.2.4 Contextual factors
Social information and the environmental
and cultural context also affect symptom
perception (Croyle & Barger, 1991). When
intrapersonal memory searches aimed at estab-
lishing the meaning of symptoms fail to provide
an answer, social information becomes an
important factor. In particular, the social
comparison process, in which illness informa-
tion is shared within the social network, has a
significant influence on symptom appraisal
(Leventhal & Diefenbach, 1991). Medical
sociologists describe the way people use ªlay
referralº networks in trying to make sense their
symptoms. These reflect the use of advice given
by family and friends, who may often refer the
individual to others who are known to have
knowledge or experience which could help in
84 Health Care
throwing some light on the nature of the
problem (see Armstrong, 1989).
Situational and contextual cues can play an
important role in interpreting symptoms and in
the generation of illness representations. For
example, Baumann, Cameron, Zimmermann,
and Leventhal (1989) found that, in the presence
of a stressful life event, participants were more
likely to interpret ambiguous symptoms as signs
of stress than signs of illness. However, in the
absence of stress, an illness interpretation was
more likely. While external factors affected
judgements about ambiguous symptoms, the
effect was constrained by prior knowledge since
context did not influence judgements about
symptoms representing familiar illnesses.
8.03.3.3 Summary: Symptom Perception
The interpretation and response to symptoms
is guided by illness schemas and involves several
cognitive procedures. Typically, it begins with a
search of long-term memory for comparable
illness episodes, which promotes comparisons
between the current state and previous experi-
ence. The outcome of the comparison process
influences judgements about illness status and
the identity of symptom clusters. These judge-
ments can be mediated by the self-system and by
external factors. The influence of the self-system
reflects personal illness experience, the cultural
knowledge base, the body schema, and person-
ality traits. Symptom appraisal may also be
biased by motivational processes aimed at
minimizing health threats (Croyle, Sun, & Hart,
1997). For example, in an experimental study,
Croyle, Sun, and Louie (1993) found that
students who had been told that they had a
potentially risky cholesterol level actually rated
high cholesterol as less serious than those who
were informed that theirs was in the normal
range. Contextual and situational cues may also
modify symptom interpretation, by the provi-
sion of specific local information (e.g., other
people with similar symptoms) or via selective
attention to specific aspects of the symptom
experience (Cioffi, 1991).
8.03.3.4 Symptom Perception and Help Seeking
From a population perspective, the experi-
ence of symptoms is widespread and it is clear
that the majority of these are transient and
benign. For the individual, each symptom is
evaluated in terms of its potential threat and
decisions will be made on how best to respond
on the basis of past experience and the present
context. Thus, the perceived identity and cause
of the symptom and its anticipated timeline and
consequences will give rise to particular health-
related behaviors. The most common initial
response is to anticipate that the symptoms will
be short-lived and can be attributed to a specific
situational factor but there are important
individual and cultural differences in this
respect (Robbins & Kirmayer, 1991; Kirmayer,
Young, & Robbins, 1994). These authors have
carried out studies in which they presented
various imaginary symptoms (e.g., dry mouth)
to participants and asked them to choose the
most likely cause from three alternatives, of
which one was situational (ªI need to drink
more liquidsº), one of which was physical
(ªthere is something wrong with my salivary
glandsº), and the other was psychological (ªI
must be scared or anxious about somethingº).
Situational explanations were chosen most
frequently but some individuals showed clear
biases towards selecting more physical or
psychological explanations.
A bias towards opting for physical explana-
tions for symptoms could lead to potential
conflicts in health care, when tests fail to reveal
any organic cause for a problem. To some extent
this can be observed in people with chronic
fatigue syndrome since they commonly attri-
bute their symptoms to a physical cause in the
absence of any confirmatory evidence (Moss-
Morris, 1997). This, in turn, may reduce the
perceived relevance of any psychological treat-
ments which may be offered and have adverse
effects on treatment adherence (see Section
8.03.4.3.3).
Seeking medical help is a relatively uncom-
mon response since the majority of individuals
wait, do nothing, or self-medicate (Freer, 1980).
However, there has been considerable interest in
understanding the responses of two groups of
individuals: those who persistently seek help for
what appear to be quite minor symptoms and
those who delay seeking help while experiencing
serious or life-threatening symptoms. Studies of
frequently attending patients reveal that they
are typically high in trait anxiety (Banks,
Beresford, Morrell, Waller, & Watkins, 1975).
This is consistent with the finding that trait
anxiety is associated with a stronger attentional
focus on internal bodily states, as well as higher
levels of symptom reporting (Watson & Penne-
baker, 1989). Also, these individuals are more
likely to make more negative interpretations
and attributions for particular symptoms than
their less anxious counterparts (Sensky, Ma-
cleod, & Rigby, 1996). Given the negative
cognitions which accompany anxiety (Lucock,
Morley, Peaks, & White, in press), it is therefore
not surprising that there will be greater concern
and an accompanying need for reassurance but,
as is discussed more fully at the end of this
section, the rather minimal reassurance which is
 Perceiving Symptoms and Entry into the Health-care System
very often provided by the doctor is not likely to
be effective in reducing anxiety or preventing
further help-seeking.
Delay in seeking help for serious symptoms is
a complex process which depends critically on
the individual's perception of their symptoms as
well as contextual factors, such as barriers to
health care. Three stages of delay can be
identified and have been described by Safer,
Tharps, Jackson, and Leventhal (1979) as
appraisal delay, illness delay, and utilisation
delay. Appraisal delay involves the decision as
to whether one is ill, given the particular pattern
of symptoms which are being experienced. This
stage is very much a function of the sensory
properties of the symptoms as well as the way in
which these are interpreted either from past
experience, from reading about one's symp-
toms, or from discussion with others. The
appraisal stage can be understood easily in
terms of the models of Leventhal et al. (1997)
and Cioffi (1991) which were outlined earlier in
the chapter, since symptoms which do not
activate threat-related illness schema are not
interpreted as serious or potentially serious and
are very unlikely to instigate help-seeking.
Illness delay describes the delay between
recognising that there is an illness and deciding
that professional help should be sought, whilst
the time taken from that point to actually
seeking help is referred to utilisation delay.
Different factors contribute to the various
stages of delay, including past experience of
symptoms, their perceived consequences and
concerns about the possible costs, and negative
aspects of the treatment and outcome. One
condition where delay can have very serious
consequences is myocardial infarction (MI),
since early utilization of medical care is
associated with improved changes of survival.
Death following MI typically occurs within a
few hours of symptom onset, yet the evidence
shows there is a large variation in utilization
delay times and that some individuals put
themselves at much greater risk as a result
(Dracup et al., 1995). This work also shows that
symptom severity and interpretation are im-
portant since those who perceive their symp-
toms as indicative of MI are less likely to delay.
Problems caused by patient delay over a longer
time period are also found with other condi-
tions, including cancer (Facione, 1993), sexually
transmitted diseases (Leenars, Rombouts, &
Kok, 1993), and mental health problems
(Clausen, Pfeffer, & Huffine, 1982).
From the health-care professional's (HCP)
perspective it is therefore important to know
what symptoms the individual has experienced
and the way that these have been interpreted as
a basis for understanding the decision to seek
85
help. In view of this, it is noteworthy that
guidelines for good patient interviewing in
primary care include an encouragement to
focus on why the patient has come (Pendleton,
Schofield, Tate, & Havelock, 1984). Thus, in
addition to eliciting signs and symptoms,
doctors are expected to develop an interviewing
approach which allows patients to express their
own ideas or concerns about their condition.
From the HCP's perspective, patients may
appear to be seeking help for relatively minor
symptoms (e.g., transient pain from indigestion)
whereas specific contextual factors (e.g., a close
relative with a heart problem) may cause the
patient to hold a much more serious representa-
tion of their problem.
A further implication for HCP's lies in the
issue of reassurance. As will be outlined in
Section 8.03.4.1.1, one of the most common
patient expectations for a primary care con-
sultation is to be able to have a better under-
standing of a current complaint (Williams,
Weinman, Dale, & Newman, 1995). Since the
majority of symptoms will not be found to be
indicative of any underlying problem, as the
result of a physical examination or diagnostic
test, it is not surprising that the HCP will expect
this to be sufficient to reassure the patient. For
some patients being told that there is no
underlying or serious problem is effective in
providing reassurance but there is consistent
evidence that this is not always so. For a
significant minority, there is continued concern
about their health status (Channer, James,
Papouchado, & Rees, 1987; Lucock et al., in
press).
This continued anxiety following reassurance
from the HCP may then result in further
needless consultations or investigations, and is
one of the factors involved in frequent atten-
dance for health care. The key issue here seems
to be the nature of the reassuring message which
typically consists of reporting that no pathology
can be detected and so there is no need to worry
(McDonald, Daly, Jelinek, Panetta, & Gutman,
1996). Although apparently comforting from
the HCP's perspective, this message only
provides negative information and fails to
contribute a positive explanation for the
symptoms which the patient had or is experien-
cing. According to Lucock et al. (in press),
reassurance in the form of negative information
will only provide a short-term reduction of
health concern. If symptoms persist or reoccur,
then the health concern will also return since the
patient still lacks a satisfactory explanation
which would enable them to interpret the
symptoms as benign. For reassurance to be
effective, patients' concerns need to be elicited
and appropriate information provided for
86 Health Care
explaining the symptoms. These findings can be
understood in terms of Leventhal's self-regula-
tory model, which was outlined at the beginning
of this chapter. If the patient's cognitive
representation of a problem is that it is serious
(e.g., heart disease) and the diagnostic test fails
to provide any evidence for this, then an
adequate alternative explanation and discussion
of the symptoms will probably be necessary for
the patient to generate a more benign repre-
sentation and therefore be reassured by the test
results.
8.03.4 HEALTH-CARE PROFESSIONAL±
PATIENT COMMUNICATION
The consultation between the patient and the
HCP lies at the centre of health care. The
information which is transmitted during the
consultation is very often critical in the
formulation of diagnoses and in the organisa-
tion of treatment. Effective communication is
necessary to ensure not only that the patients'
problems and concerns are understood by the
HCP but also that relevant information, advice,
and treatment is received and acted upon by the
patient. Since the late 1960s there has been
considerable research on the medical consulta-
tion, prompted to a large degree by the fact that
there has been consistent evidence that not only
are the process and outcome often unsatisfac-
tory for patients but also there is widespread
noncompliance with subsequent treatment re-
commendations. Early research revealed quite
high levels of patient dissatisfaction which was
often associated with insufficient information,
poor understanding of the medical advice, and
subsequent reluctance or inability to follow
recommended treatment or advice (e.g., Korsch
& Negrete, 1972). These early findings showed
that many patients complained that they were
not given sufficient information about the
nature of their problem, the treatment, and
the likely outcome. For example, in the Korsch
and Negrete (1972) study, which involved
mothers taking their children to a paediatric
outpatient clinic, about 20% of mothers were
not informed clearly about the diagnosis and
nearly 50% were uncertain afterwards as to the
course of their child's illness. Similar findings
have been produced in more recent studies in a
variety of health-care settings and it is notable
that these problems are unrelated to the length
of time spent with the HCP (Korsch & Negrete,
1972).
A related problem involves the use of
information, such as medical jargon, by the
HCP which the patient misconstrues or cannot
understand. Korsch and Negrete (1972) found
that jargon was used in about half the
consultations in their study. Other studies have
shown how much this ªcommunication gapº
reflects differences in biomedical knowledge
between patients and HCPs. A good example is
seen in Figure 3 which shows some data from a
study by Hawkes (1974) who investigated
patients' and doctors' interpretations of anato-
mical terms. Not only did this study show that
patients' understanding of anatomical terms is
often quite different from that of their doctor
but also that doctors may also differ in their use
of some terms. Another complaint from
patients is that the HCP does not appear to
be interested in their presenting problem or in
their concerns or worries about it and this is
associated with lower levels of satisfaction with
the consultation (Williams & Calnan, 1991).
Moreover, patients often report feeling that
they have not been sufficiently involved in the
decision-making which may have occurred in
the consultation. Hence, Roter and Hall's
(1989) overview of research in this area revealed
that patient satisfaction was higher following
consultations in which the HCP engaged in
more social conversation, positive verbal and
nonverbal behavior, and partnership building.
The development of relatively unobtrusive
audio and video-recording techniques has
allowed researchers to investigate the consulta-
tion and many studies have analyzed the process
of the consultation and attempted to relate
process variables or characteristics to outcome.
While these studies have identified important
themes, they have not always been successful in
making clear links between process and out-
come (Stiles, 1989). In the absence of simple
relations between consultation process vari-
ables (e.g., duration or style of consultation)
and various outcomes (e.g., satisfaction, ad-
herence, etc.), more recent studies have begun to
examine what HCPs and patients bring to the
consultation, as well as the importance of
contextual factors. As a result, many current
frameworks for understanding doctor-patient
communication tend to be based on the
relations between inputs (i.e., the attitudes,
beliefs, expectations, etc. which patient and
doctor bring to the consultation), process (the
nature of the encounter), and outcome (the
short- and longer-term effects on the patient).
An example of one such framework is provided
by Friederikson (1993) and is shown in Figure 4.
An overview of input, process, and outcome
factors follows.
8.03.4.1 Input Factors in Communication
Input factors which influence the consulta-
tion include not only aspects of the doctor and
 Health-care Professional±Patient Communication 87

In the picture below put a tick underneath the drawing that shows
the correct position of the brain

Total Rating
Doctors 0 0 0 53 (100%) 0 0 53 Good
Patients 11 (5.9%) 9 (4.8%) 17 (9.2%) 122 (66.3%) 4 (2.1%) 21 (11.4%) 184 Fair

In the picture below put a tick underneath the drawing that shows
the correct position of the sciatic nerve

Total Rating
Doctors 0 1 (1.8%) 2 (3.7%) 29 (54.7%) 21 (39.6%) 53 Fair
Patients 37 (22.8%) 25 (15.4%) 8 (4.9%) 36 (22.2%) 56 (34.5%) 162 Poor

Figure 3 Examples of the differences in the use of anatomical terms by patients and doctors (from Hawkes,
1974).

patient but also the context and setting in which
the consultation occurs. For example, for many
primary care consultations in the UK, patients
are booked in for 10-minute appointments
whereas similar consultations in other countries
may typically last two to three times longer.
Although longer consultations do not inevitably
result in better patient outcomes (Morrell,
Evans, Morris, & Roland, 1986), the resulting
process may well be different. Similarly, the
layout of the consulting room, including the
proximity and positioning of the HCP and
patient, can also influence the communication
process.
8.03.4.1.1 Patient input factors
When considering patient ªinputº factors
which can influence the medical consultation, a
number of studies have shown that patients
cope with health threats in diverse ways and
show consistent differences in how they want to
be involved in the health-care process (Krantz,
Baum, & Wideman, 1980). These studies also
show that patients differ in the amount of
information which they would like to receive
about their health problem. Similarly, a dis-
tinction has been made by Miller, Brody, and
Summerton (1988) between ªmonitorsº and
ªblunters,º with the former being more inclined
to need and seek out information about their
problem and treatment, whereas the latter
group prefer consultations in which relatively
limited information is provided. This is similar
to the repression-sensitisation classification,
described in Section 8.03.3.2.3, and reflects
the extent to which patients choose to cope with
their health problems in a problem-focused or
an avoidant manner.
Patients come into the health-care setting with
different levels of biomedical knowledge, based
on their past experience. There is also consistent
evidence that patients have differing expecta-
tions for specific consultations (Williams et al.,
 INPUT PROCESS OUTCOMES

Initialization S
P Frame of A
Perceptions
Reference T
A
Compliance I
T S
Motivations,
F
I goals, needs, Concern
A
expectations C
E
Information exchange Understanding T
N I
Personal
Relationship O
T information
N

Acknow- S
Frame of Physical Perceptions A
D ledgement Questions
Reference exam T
of problem
O Diagnosis I
Motivations, Diagnosis S
C Prognosis F
goals, needs,
T Treatment/Action A
expectations C
O Treatment option T
Understanding
Medical I
R Relationship O
information
Termination N

Figure 4 Information processing model of medical consultation (adapted from Friedrikson, 1993).
 Health-care Professional±Patient Communication
1995), and an awareness of these can be helpful in
understanding not only why they are seeking
help at that time but also in being able to respond
effectively to their needs. Following the self-
regulatory model, described at the beginning of
this chapter, it has been found that patients'
illness representations will influence their deci-
sion to seek help (Cameron, Leventhal, &
Leventhal, 1993) and hence their expectations
of the consultation.
Patient expectations have been conceptua-
lized and defined in a range of different ways. In
their review of the literature, Thompson and
Sunol (1995) have proposed working definitions
for four types of expectations that are used
frequently:
(i) Ideal. This may be referred to as an
aspiration or desire;
(ii) Predicted. The realistic, practical, or
anticipated outcome which therefore reflects
what users actually believe will happen in an
health care consultation;
(iii) Normative. What should or ought to
happen and could be equated with what users
are told, or led to believe, or personally deduce
that they ought to receive from health services;
and
(iv) Unformed. This state occurs when users
are unable or unwilling to define their expecta-
tions, which may be because they do not have
any, or find it too difficult to express, or do not
wish to reveal their feelings, due to fear anxiety,
conformity to social norms, etc.
The term ªexpectationsº itself therefore
needs to be clearly defined and one reason for
the lack of consistency in the research in this
area is that many studies have failed to do this.
An example of this problem can be seen in a
study carried out to investigate the relationship
between patients' expectations and HCPs' ac-
tions (Webb & Lloyd, 1994). Primary care
patients' expectations were measured using
questionnaires which asked each patient
ªHow do you think the doctor will be able to
help you with your problem?º and instructed
the subjects to tick as many of the following
actions: ªgive you a prescription,º ªrefer you to
hospital,º ªgive you advice,º ªhelp you in some
other way.º By this method it would not be clear
to the patients whether they should respond
according to what they themselves want (i.e.,
ªidealº expectations) or what they merely
expect that they will be given by the doctor
(i.e., ªpredictedº or ªnormativeº expectations).
One method of measuring patients' expecta-
tions is to categorize their informational needs
into distinct categories such as information in
relation to aetiology, diagnosis, prognosis,
treatment, and social effects (Kindelan & Kent,
1987). However, the measurement of patients'
89
expectations by the simple categorization of
needs according to the medical condition can be
inadequate since patients may require varying
levels of information about the presenting
symptoms. The range of psychosocial and
medical expectations of primary care patients
has been investigated by Good, Good, and
Nassi (1983). They have developed a scale
(Primary Care Patient Request Scale) from the
responses of North American primary care
patients and it requires patients to rate the
extent to which each item on the scale reflects
their needs prior to the consultation. The results
of a principal components analysis to investi-
gate underlying components on the types of
consultation requests of primary care patients
revealed five distinct dimensions: treatment of
psychosocial problems, medical explanation,
supportive communication, test results, and
ventilation and legitimation. A simpler version
of this scale, developed by Salmon and Quine
(1989), measures four components: explanation
and understanding, support, medical treatment,
and information-seeking. Using this scale,
Williams et al. (1995) have shown that the most
common expectation in primary care patients is
for explanation and understanding of their
problem, with much smaller numbers wanting
tests, diagnoses, or support. Thus,patients do
not always want or expect diagnosis or treat-
ment since they may be looking to the
consultation to gain more understanding of
their health problem or may be hoping for
support or understanding from their doctor.
These prior expectations can be important in
determining outcomes, since consultations in
which patient expectations are met have been
shown to result in greater satisfaction and an
increased willingness to follow advice or
treatment (Williams et al.).
8.03.4.1.2 Health-care professional input factors
It is important to acknowledge that health-
care professionals can vary considerably in the
attitudes and beliefs which they have not only
about their own and the patient's role, but also
about the function and conduct of the con-
sultation. Doctors have been categorized in
various ways according to their role perceptions
and the extent to which they concentrate on the
technical or more psychosocial aspects of
patient care, as well as their beliefs about
whether patients should be actively involved in
the consultation and in decision-making about
the management of the clinical problem (e.g.,
Grol, de Maeseneer, Whitfield, & Mokkunk,
1990). Inevitably, these broad attitudinal differ-
ences are reflected in differences in the way in
which the consultation is conducted and in
90 Health Care
other aspects of professional behavior, includ-
ing decision-making, prescribing, and manage-
ment of clinical problems (McGee, 1997).
Similarly, other HCPs have also been found
to vary in their beliefs and attitudes in ways
which impact on the way they manage their
encounters with patients (Marteau & Johnston,
1990). In clinical psychology, one very obvious
HCP input factor is the theoretical orientation
of the practitioner, since this can have a major
influence on the way in which clients' problems
are conceptualized and managed. It has also
been shown that personal characteristics of the
practitioner can have significant effects on the
process and outcome of psychological therapy
(e.g., Strupp & Hadley, 1979).
A few studies have attempted to examine the
interaction of clients' and therapists' values in
psychological therapies (e.g., Kelly, 1990).
There is evidence that strong initial differences
between client and therapist may have signifi-
cant negative effects on the early stages of
therapy (Kelly & Strupp, 1992) and may be a
contributory factor to client dropout (Vervaeke,
Vertommen, & Storms, 1997).
Although HCPs undergo a common training
and share a common body of knowledge and
skills, wide variations in their clinical behaviour
have been noted (e.g., Marteau & Johnston,
1990). Part of this variation is a by-product of
personality differences and can be seen in
differences in interpersonal aspects of clinical
practice but part is a reflection of differences in
the approach to clinical problems. Some of
these are between-individual differences,
whereas others reflect factors which can vary
within the same individual, such as changing
mood, time pressure, and various other con-
textual influences. In their overview of clinical
decision-making, Schwartz and Griffin (1986)
point out that there are often substantial
disagreements between doctors when interpret-
ing the same clinical information (e.g., X-rays).
They also note that doctors may be inconsistent
and disagree with their own previous judge-
ments.
Clinical decision-making has been the subject
of psychological research for a number of years
and there is accumulating evidence of inter- and
intra-individual differences in both the process
and the outcome (Schwartz & Griffin, 1986). A
detailed account of medical decision-making is
beyond the scope of this chapter and so what
follows is a brief outline of the process together
with a focus on some factors which are
associated with variation in decision-making
performance.
In responding to a new patient, the doctor will
first try to solve the problem of what is wrong,
based on the various signs and symptoms, and
then will have to make a decision about the best
approach to treatment. Both these processes
occur under conditions of uncertainty and, for
much of the time, the doctor's thinking will be
based on the use of probabilistic information.
The signs and symptoms may be ambiguous and
there is often a margin of error in test results.
Also, treatment decisions, whether they involve
waiting to see what will happen or the
prescription of treatment, can involve risks of
complications or side-effects.
During clinical decision-making, the doctor is
often faced with having to process a large
amount of information about the patient and
the possible diagnoses and treatment options. In
this they are subject to the same limits of
information-processing capacity which affect
all of us (see Eysenck & Keane, 1995). Thus,
there are limits in what can be attended to and
how much information can be held in working
memory. In view of this it is not surprising to
find that all doctors acquire heuristics, or
general strategies, for processing diagnostic
and treatment information and these are subject
to a range of influences.
Kahnemann, Slovic, and Tversky (1982) have
described a number of the heuristics which are
used during clinical decision-making. These
include the representativeness heuristic (deci-
sions based on the similarity between the
present situation and known previous ones)
and the availability heuristic (judgments made
on the basis of information which is most
readily available). The influence of representa-
tiveness heuristics can be seen in the initial
hypotheses which doctors generate for newly
presented symptoms and availability heuristics
can be inferred from the influence of such
factors as recent or emotionally salient events
which readily come to the doctor's mind during
the clinical judgment process. Christensen-
Szalanski, Beck, Christensen-Szalanski, and
Keopsell (1983) have demonstrated an avail-
ability bias in doctors' estimates of the risk of
different diseases since their overestimates of
risks were found to be biased by encounters with
people with the disease. Similarly, attitudes and
beliefs about the doctor's and the patient's role
can influence the weighting given to informa-
tion from patients (e.g., the relative attention
given to physical and psychosocial informa-
tion). The doctor's mood can affect
information-processing in a number of ways
by directly influencing the speed and accuracy
of clinical problem-solving (Isen, Rosenzweig,
& Young, 1991) or possibly by constraining
access to mood congruent semantic informa-
tion, as has been demonstrated on more general
studies of the effect of mood on cognition (e.g.,
Power & Dagleish, 1997).
 Health-care Professional±Patient Communication
8.03.4.2 The Consultation Process
There are a range of methods and frame-
works for analyzing and describing the process
of the consultation. One of the broadest
distinctions made has been between consulta-
tions which are described as patient-centered
and those which are HCP-centered, reflecting
the extent to which the HCP or patient
determines what is discussed (Grol et al.,
1990). HCP-centered consultations are ones in
which closed questions are used more often and
the direction is determined by the HCP,
typically with a primary focus on medical
problems. In contrast, patient-centered encoun-
ters involve more open-ended questions with
greater scope for patients to raise their own
concerns and agendas. Related to this are
consistent differences in the extent to which
the HCP responds to the emotional agendas and
the nonverbal cues of the patient (see Roter &
Hall, 1989). Although there has been a tendency
to consider the more patient-centered/emotion-
focused approach as preferable, what appears to
be more important is for HCP and patient to be
in agreement over the nature of the problem and
the best course of action (Starfield et al., 1981).
A number of specific methods have been
developed for carrying out detailed analyses of
the social interaction between HCP and patient
based on audio or videotapes or transcripts of
the consultations but, as yet, there is no real
consensus as to the best method for this. One of
the earliest of these was the Bales's (1950)
process analysis system which distinguishes
verbal statements into those which are task or
emotion-focused and then into more specific
categories and this approach has been adapted
and extended by a number of other investigators
(see Roter & Hall, 1989).
With Bales's system, the coding can be carried
out using transcripts, audiotapes, or first-hand
observations (Bales, 1950; Korsch & Negrete,
1972). Verbal behavior is usually studied,
although nonverbal behavior may also be
coded. A unit can be as short as a single word
or as long as a lengthy sentence; compound
sentences are usually divided at the conjunction
and sentence clauses are scored as separate units
when they convey a single item of thought or
behavior. The rationale underlying this ap-
proach is that all interpersonal statements can
be classified as falling into one of two domains,
the task and the socioemotional. Interaction is
described in terms of 12 mutually exclusive
categories: six ªeffectively neutralº in the task
dimension (e.g., doctor gives suggestion) and six
equally divided into positive and negative
affective categories in the socioemotional
dimension (e.g., doctor agrees or disagrees).
91
Wasserman and Inui (1983) have noted that a
strength of Bales's system is that it deals with
both the content and relationship levels of the
communication and that it is particularly strong
on the relationship level, where it is sensitive to
the feelings of each communicator. Moreover, it
has been shown to be reliable and applicable in
diverse situations. Its main weakness is the
treatment of information transfer, that is, the
transfer of information from the patient to the
doctor as well as in the reverse direction. With
this system there is a difficulty in categorising
statements that involve both information
transfer and affective components. As a result,
a number of investigators, including Roter
(1977), have modified the system to allow direct
coding from audiotapes, assessment of the
affective aspects of the clinician's behavior,
and a more finely tailored categorisation of the
clinical encounter.
An alternative approach, known as the
Verbal Response Mode (VRM), has been
developed by Stiles (1978) and which classifies
each statement made by the HCP and patient
into one of eight basic categories (e.g., ques-
tions, giving interpretations, etc.). Good over-
views of these different approaches are
available elsewhere (e.g., Roter & Hall, 1989)
and attempts have been made to define a
number of more general ways of classifying
HCP-patient interactions. For example, one
can distinguish between verbal and nonverbal
information and, within the verbal domain, six
broad categories can be defined: information-
giving, information-seeking, social conversa-
tion, positive talk, negative talk, and partner-
ship building. From a meta-analysis of these
broad categories (Roter, 1989) it has been
found that for the doctor, information-giving
occurs most frequently (approximately 35% of
the doctor's communication) followed by
information-seeking (approximately 22%), po-
sitive talk (15%), partnership building (10%),
social conversation (6%), and negative talk
(1%). In contrast, the main type of patient
communication consists of information giving
(approximately 50%) with less than 10%
involving information seeking.
A comparative study of process analysis
methods was carried out by Inui, Carter,
Kukull, and Haigh (1982). The Bales, Roter,
and the VRM system were applied to 101 new
patient consultations at a general medical clinic.
The outcome measures were patient knowledge,
satisfaction, recall of prescribed medications,
and compliance. The findings revealed that the
explanatory power of the three systems differed.
Roter's system was found to explain 28% of the
variance in adherence to prescribed medicines,
compared to 19% for the Bales system and none
92 Health Care
for the VRM. The Roter and Bales systems were
also better than VRM in explaining variation in
satisfaction.
More recently, Roter et al. (1997) have used
cluster analysis with the Roter Interactional
Analysis System (RIAS) to describe doctor's
communication patterns in a study of 127
doctors and 537 patients. Their results revealed
five distinct patterns: (i) ªnarrowly biomedical,º
(ii) ªexpanded biomedical,º (iii) ªbiopsychoso-
cial,º (iv) ªpsychosocial,º and (v) ªconsumer-
istº (see Table 1). They found that ªbiomedicalº
approaches were used more often with more
sick, older, and lower income patients by
younger, male doctors. Patients and doctors
completed a satisfaction questionnaire imme-
diately after the consultation. The highest levels
of doctor satisfaction were found in those using
the consumerist approach and the lowest levels
were found in those using the narrowly
biomedical approach. In contrast the highest
levels of patient satisfaction were found with
those who had seen doctors using the psycho-
social communication pattern whereas the
lowest satisfaction scores were recorded in
those who had experienced either of the two
biomedical patterns.
A very different approach to process analysis
can be found in the studies of Ley and
colleagues (Ley, 1988), who have concentrated
on the informational content of the consulta-
tion and the quality of information provided
by the doctor. In particular they have analyzed
the content in terms of its level of complexity,
comprehensibility, and the extent to which the
information is organized. They and others have
found that medical information may be too
detailed or complex with the result that
important information may not be understood
or retained by the patient. Ley's studies have
shown patients' understanding and recall of
the consultation can have a direct influence
on treatment adherence or can influence ad-
herence via their effects on satisfaction (see
Figure 5).
There is even evidence that patients and
doctors may interpret the same information in
different ways and this communication gap can
occur around anatomical information or other
technical terms which are used to describe illness
or treatment (see Figure 3).
These various ways of conceptualizing and
analyzing the consultation process have given
rise to a large number of indices or categories
which have been related to outcomes, often in
quite a limited fashion. Outcomes, such as
patient satisfaction or adherence to treatment,
are likely to be determined by a range of factors,
reflecting a complex interaction of input,
process, and situational variables.
8.03.4.3 Outcomes of Health-care
Communication
The efficacy of any communication needs to
be evaluated in terms of its effect on outcome.
For health-care communication, the ultimate
outcome is health but only relatively few studies
have measured short or longer-term health
outcomes following consultations and these will
be mentioned briefly. However, a range of other
outcomes have been assessed and these fall into
three broad groups, namely cognitive, affective,
and behavioral.
8.03.4.3.1 Cognitive outcomes
These can be assessed by evaluating changes in
patients' knowledge, understanding, and recall
of the relevant information provided in the
consultation. Ley and colleagues have carried
out a number of careful studies of patient recall
and these have been summarized (Ley, 1997).
Studies which have assessed how much patients
are able to recall from consultations have shown
that about half the information is retained but
there is considerable range. This variation partly
reflects the type of setting and sample used and
partly the method which is used to test for recall.
There are a number of other factors involved
including the content of the information, the
patients' prior knowledge, and their level of
anxiety. With regard to the content and structure
of the message, information which is presented
early in the consultation is recalled better (the
primacy effect) as are statements which are
perceived as being important or relevant. More-
over, if the HCP makes an effort to present
information in an organized way based around
specific themes (e.g., the nature of the problem,
the details of the treatment, etc.), then recall is
improved. Not surprisingly, the more informa-
tion which is presented, the smaller proportion is
remembered.
8.03.4.3.2 Affective outcome: patient
satisfaction
One of the broadest indicators of the patients'
affective response to a health-care consultation
is their overall level of satisfaction. Fitzpatrick
(1997) has commented that the concept of
patient satisfaction is important because it
focuses on the need to understand how patients
respond to health care. As a result, it is
increasingly being assessed in surveys of health-
care settings as a marker of quality of care,
along with such other dimensions of quality as
access, relevance to need, effectiveness, equity
and efficiency.
Patient satisfaction is also considered im-
portant since it is associated with patient
 Health-care Professional±Patient Communication 93

Table 1 Communication patterns and their frequency of use in primary care consultations.

Type of pattern Characteristics Consultations % of doctorsa

Narrowly biomedical Low % of talk on psychosocial topics; high % 32 68

of biomedical information given by dr. & pt.;
high % of question asking by dr.
Expanded biomedical High % of question asking by dr.; moderate 33 61
levels of biomedical and psychosocial
exchange for dr. & pt.
Biopsycho-social Balance between biomedical and psychosocial 20 42
exchange in dr. & pt.; fewer questions than in
the two biomedical patterns
Consumerist High frequency of question asking by pt. and 8 23
information giving from dr.; low levels of
question asking by dr. and of psychosocial
exchange
Psychosocial Dominated by psychosocial exchange; dr. talk 7 19
divided between psychosocial and
biomedical; high % of pt. psychosocial talk;
lowest levels of question asking by dr. & pt.;
dr.- very positive and accepting of pt. input

a
percentage of doctors with at least one of their consultations falling in the pattern Source: Roter et al. (1997).

cooperation (Hall, Roter, & Katz, 1988; Roter,
Hall, & Katz, 1987), improved health status
(Eraker, Kirscht, & Becker, 1984), and fewer
malpractice suits (Vaccarino, 1977). Increased
levels of satisfaction have also been found to be
related to other important outcomes from the
consultation, particularly adherence or com-
pliance with treatment or advice.
Although the concept of satisfaction has
good face validity, there is a singular lack of
good theory or consensus about its nature or
structure. Some approaches are based around
the anxiety surrounding illness and equate
satisfaction with the adequacy with which this
is dealt with by HCPs. Stimson and Webb
(1975) have suggested that patient satisfaction is
related to the perceptions of the outcome of
treatment and the extent to which treatment
meets the patient's expectations. This can be
related to the self-regulatory model, in that
greater satisfaction would be predicted if the
patient's own representation of the problem is
taken into account by the HCP and if the
information which is provided allows the
patient to develop a representation of the
problem and the treatment which reduces their
uncertainty and facilitates their coping, includ-
ing their adherence to treatment (Leventhal &
Cameron, 1987).
More recently Fitzpatrick (1997) has pro-
moted the idea of patient satisfaction as a
multidimensional concept, since patients have
been found to have differing views about
different aspects of their health care, such as
the HCP's behavior towards them, the informa-
tion provided, the technical skills of the HCP,
and the access to and quality of the health-care
setting. Despite this, there is evidence that the
behavior of the HCP is the critical determinant
and one which can significantly influence
ratings of all the other aspects of health care.
Although patient satisfaction appears to be a
relatively straightforward concept, there remain
a number of difficulties in measuring it. Results
from most satisfaction surveys reveal very
skewed data, apparently indicating very high
levels of satisfaction across patient samples,
particularly amongst older patients (Hall &
Dornan, 1988). Part of this problem seems to lie
in the reluctance of patients to criticize health-
care services and part of it is due to the structure
of the questionnaires which have been used to
assess patient satisfaction. Comparative studies
of different methods have shown variability in
satisfaction across measurement approaches.
Wide variation in satisfaction scores between
three commonly used methods has been
reported (Counte, 1979). For example, consis-
tently lower rates of satisfaction are found when
the same respondents use a five-point rating
scale ranging from ªpoorº to ªexcellentº
compared to a six-point rating scale ranging
from ªextremely satisfiedº to ªvery dissatisfiedº
(Ware and Hays, 1988). In addition, the use of
more in-depth methods which require patients
to describe their experiences of health from their
own perspective, typically give rise to a more
critical view (Fitzpatrick & Hopkins, 1993).
94 Health Care
Understanding
Satisfaction
Recall
Figure 5 Ley's cognitive model, showing the relations between the patient's understanding, recall, and
satisfaction with the consultation and subsequent treatment adherence.
Although these do not provide a quantitative
measure, they can be used to highlight areas of
dissatisfaction.
There are many patient satisfaction ques-
tionnaires that have been developed for use in
different health-care settings. For assessing
patient satisfaction with the consultation, one
of the most widely used measures is the Medical
Interview Satisfaction Scale (MISS) (Wolf,
Putnam, James, & Stiles, 1978). This scale
measures satisfaction with three aspects of the
medical consultation. First, it assesses the extent
to which the patient feels that the doctor listens,
understands, and is interested (affective). Sec-
ond, it assesses the patient's evaluation of the
doctor's competence in the consultation (beha-
vioral) and the third aspect is concerned with the
amount and quality of information provided
(cognitive).
Bowman, Herndon, Sharp, and Dignan
(1992) have identified a number of important
structural and measurement criteria for an
adequate patient satisfaction scale and have
reported that the MISS meets all of these.
Moreover, it has good internal consistency and
correlates highly with other equivalent mea-
sures (Kinnersley, Stott, Peters, Harvey, &
Hackett, 1996).
8.03.4.3.3 Behavioral outcome: adherence
The most widely studied behavioral outcome
from health-care consultations is reflected in the
extent to which the patient adheres to the advice
or treatment offered by the HCP. Many
consultations result in the prescription of
treatment or advice by the HCP and the
appropriate adoption of self-care behaviors,
including use of medicines, is a key aspect to the
self-management of most chronic illnesses.
However, many patients fail to do this and
low rates of adherence to recommended treat-
Adherence
ment are seen as problematic in most chronic
diseases including asthma (Yeung, O'Connor,
Parry, & Cochrane, et al., 1994), diabetes
(Glasgow, McCaul, & Schafer, 1986), heart
disease (Horwitz & Horwitz, 1993; Monane,
Bohn, Gurwitz, Glynn, & Avorn, 1994), cancer
(Lilleyman & Lennard, 1996), and kidney
disease (Cleary, Matzke, Alexander, & Joy,
1995), as well as in psychological treatments,
such as relaxation training for anxiety-related
disorders (Taylor, Agras, Schneider, & Allen,
1983).
The incidence of reported medication non-
adherence varies greatly from 4±92% across
studies, converging at 30±50% in chronic illness
(Haynes, Taylor, & Sackett, 1979; Meichen-
baum & Turk, 1987). In the area of primary
prevention, it has been found that many
participants drop out of lifestyle change
programs designed to improve diet or reduce
health risk behaviors (Dunbar & Agras, 1980).
Even patients who have experienced major
health problems, such as heart attacks, may
show low levels of uptake of rehabilitation
programs as well as considerable variation in
the adoption of recommended lifestyle change
(Petrie, Weinman, Sharpe, & Buckley, 1996). In
the area of mental health, there is also evidence
of significant rates of nonadherence to various
recommendations from HCPs. For example,
about half of those undergoing intake in a
mental health clinic were found to fail to attend
for the first arranged interview and something
like three-quarters of psychotherapy patients
have been found to drop out by the fifth session
of treatment (Phillips, 1988).
There has been a major interest in patient
adherence for many years since it has been
found that many so patients fail to follow
advice or treatment. In view of the importance
of this topic, the following section will present
an extended overview of it, focusing on the
 Health-care Professional±Patient Communication
nature of the concept and its causes, as well as
ways in which it can be influenced by specific
interventions.
Although adherence may be simply defined as
ªthe extent to which the patient's behavior
coincides with the clinical prescriptionº (Sackett
& Haynes, 1976), there are several conceptual
and methodological issues (Gordis, 1976). It is
neither usually possible nor desirable to define
nonadherence as an ªall or nothingº response in
which the patient either completely follows the
HCP's instruction (adherence) or deviates from
it in some way (nonadherence). For most
treatments, the need for total adherence is
questionable and this has led Gordis (1976) to
define nonadherence as ªthe point below which
the desired preventative or desired therapeutic
result is unlikely to be achieved.º The percen-
tage adherence necessary to achieve the desired
effect varies between treatments and between
and within individuals. Many individuals,
particularly those with chronic health problems,
are required to adhere to a variety of recom-
mendations from their HCPs. For example,
diabetic patients are required to take medica-
tion, control their diet, and check their feet and
blood glucose levels on a regular basis but it has
been found that these behaviors are not highly
correlated (Glasgow, McCaul, & Schafer,
1987).
Nonadherence behaviors may be categorized
as either active or passive. Active nonadherence
arises when the patient makes a strategic
decision not to take the treatment as instructed.
An example of this type of behavior was found
among hypertensive patients who believed that
they could judge when their blood pressure was
high by the presence of symptoms such as stress
or headache and thus took antihypertensive
medication only when these symptoms were
experienced (Baumann et al., 1989; Meyer,
Leventhal, & Guttman, 1985). Active nonad-
herence behavior has been noted among several
chronic illness groups including those with
asthma (Becker et al., 1978; Woller, Kruse,
Winter, Mans, & Alberti, 1993), rheumatoid
arthritis (Lorish, Richards, & Brown, 1990),
epilepsy (Conrad, 1985), and hypertension
(Morgan & Watkins, 1988), and may be
particularly influenced by the patients' percep-
tion of their problem as well as their level of
satisfaction with the HCP and the consultation.
From a self-regulatory perspective, the level of
treatment adherence may be indicative of a
strategic coping response which is entirely
consistent with the patient's view of their
problem (Leventhal & Cameron, 1987). Thus,
patients who believe that their problem will not
last for long have been found to be less likely
than those with a more chronic timeline
95
representation to adhere to their medication
over a long period of time (Meyer, Leventhal, &
Guttman, 1985).
Passive nonadherence may be unintentional
when the patient's intentions to follow treat-
ment recommendations are thwarted by bar-
riers such as forgetting, and inability to follow
treatment instructions because of a lack of
understanding or physical problems such as
poor eyesight or impaired manual dexterity.
Thus, if the quality of communication is poor
and patients receive information which is
difficult to understand or recall, as has been
outlined above, then this makes it less likely that
treatment will be adhered to (Ley, 1988).
(i) Measuring adherence
Adherence measures can be divided into two
broad categories according to whether the
assessment is direct or indirect. Direct measure-
ment entails observing the required adherence
behavior such as the ingestion of the drug or by
detecting its presence in body fluids. Indirect
measures assume ingestion based on proxy
evidence such as the patient's report or the
number of dosages removed from a container.
The strengths and weaknesses of available direct
and indirect methods have been reviewed
extensively (e.g., Rudd, 1993). At first sight,
direct methods might appear to be the best way
to assess adherence as other methods do not
directly confirm that the medication has been
ingested (Caron, 1985). However, these techni-
ques are problematic partly because they may be
difficult to carry out and partly because there is
not a one-to-one relationship between the
amount of medication or tracer taken and the
concentration found in body fluids. Further-
more, a major drawback of direct methods is
that they are invasive, expensive, of question-
able reliability, and provide no indication of the
type or time-course of nonadherent behavior. A
commonly used indirect method for assessing
adherence is to count the number of dosage
units left in the container and compare this to
the number which would have been left had the
patient followed the instructions. This method
has the advantages of being technologically
simple and inexpensive. However, some studies
have shown that pill counts may under-estimate
the true level of nonadherence (Kruse, Niko-
laus, Rampmaier, Weber, & Schlierf, 1993;
Rudd, Ahmed, Zachary, Barton, & Bonduelle,
1990). For example, patients may remove
medication for reasons other than to use it.
They might give the medication to someone else,
or transfer it to another container, or may
deliberately discard doses prior to monitoring
to create an impression of high adherence.
96 Health Care
In the 1990s, technological developments
have allowed the incorporation of electronic
devices into the medicine container to record the
time and date of usage. The major advantage of
these devices is that potentially they provide a
profile of medication taking rather than simply
detailing how much was taken (Kruse et al.,
1993; Rudd et al., 1990). However, as with the
pill count method, a dose removed is not
necessarily a dose taken. Furthermore, if
inclusion of the monitoring device changes
the appearance of the medicinal product, this
will alert the patient to the fact that they are
being monitored and may change behavior.
Similarly studies assessing adherence to beha-
vioral treatments, such as the use of relaxation
tapes, have required the users to keep diaries
recording their daily use of the tapes (e.g.
Bennett & Millard, 1985) and it is very likely
that this self-monitoring process will influence
rates of adherence.
One of the most widely used methods of
assessing adherence is patient self-report which
is held to be a valid indicator of treatment
adherence that is practical and useful in a wide
variety of research settings (Ley & Llewellyn,
1995; Meichenbaum & Turk, 1987). One
problem with self-reported adherence is that
questions about medicine taking are often
presented at a time and place which is quite
distant from the actual event and so reports are
subject to recall effects. In particular, even when
they admit to nonadherent behavior, people
tend to overestimate the extent of their
adherence (Ley & Llewellyn, 1995). The
accuracy of self-report as a measure of
adherence has been assessed by comparison
with other, more objective, methods or eval-
uated on the basis of correlation between self-
reported adherence and clinical outcome mea-
sures. In the main these studies show that the
accuracy of self-report varies according to the
type of adherence behavior (e.g., medicine
taking vs. lifestyle change) as well as the type
of self-report measure used. Nevertheless Mor-
isky, Green, and Levine (1986) have shown that
a four-item scale of adherence to antihyperten-
sive medication had acceptable internal con-
sistency and was moderately predictive of blood
pressure control at two and five year follow-ups.
(ii) The determinants of nonadherence
The search for causal factors to explain
patients' adherence or nonadherence to their
recommended treatment or advice has pro-
gressed through different phases since the 1960s.
Much of the early work focused on the possible
contribution of demographic or personality
factors, as well as particular characteristics of
the treatment or the disease which might
influence adherence levels. More recent studies
have tended to concentrate on cognitive factors,
particularly patients' beliefs and attitudes, since
these are potentially modifiable.
In an early systematic review of 185 studies
(Sackett & Haynes, 1976), no clear relationship
emerged between race, gender, educational
experience, intelligence, marital status, occupa-
tional status, income, and ethnic or cultural
background and adherence behaviors. More-
over, there is little evidence that adherence
behaviors can be explained in terms of person-
ality characteristics (Becker, 1979; Bosley,
Fosbury, & Cochrane, 1995; McKim, Stones,
& Kozma, 1990). Also, the idea that stable
sociodemographic or dispositional characteris-
tics are the sole determinants of adherence is
discredited by evidence that an individual's
levels of adherence may vary over time and
between different aspects of the treatment
regimen (Cleary et al., 1995; Hilbrands, Hoits-
ma, & Koene, 1995; Rudd et al., 1990). This
limitation also applies to the search for disease
and treatment characteristics as antecedents of
adherence since there are wide variations in
adherence between and within patients with the
same disease and treatment (e.g., Cleary et al.;
Lilleyman & Lennard, 1996).
One very obvious explanation for nonadher-
ence arises from the poor cognitive outcomes
outlined above, particularly poor understand-
ing and recall of information presented in the
consultation. Many patients lack basic knowl-
edge about their medication (Al Mahdy &
Seymour, 1990; Cartwright, 1994; Eagleton,
Walker, & Barber, 1993) but the relationship
between this and their adherence is neither
simple nor clear-cut. In a review of the
adherence literature Haynes (1976) concluded
that, although 12 studies had demonstrated a
positive association between knowledge and
adherence, there were more that had failed to
demonstrate a link. Studies conducted since
then generally indicate that associations be-
tween knowledge and adherence are at best
small and inconsistent (Eagleton et al., 1993),
and interventions which enhance knowledge do
not necessarily improve adherence (George,
Waters, & Nicholas, 1983; Haynes et al., 1978).
There is increasing interest in the role of
patient satisfaction as a mediator between
information provision, recall, and adherence,
as would be predicted by Ley's model which was
outlined earlier (see Figure 5). In a national UK
survey of patients' satisfaction with medicines
information, over 70% of respondents wanted
more information than they were given (Gibbs
& George, 1990). Dissatisfaction with attributes
of the practitioner or the amount of information
 Health-care Professional±Patient Communication
and explanation provided may act as a barrier
to adherence by making the patient less
motivated towards treatment (Hall et al., 1988).
The emphasis of adherence research since the
late 1980s has moved away from attempts to
identify stable trait factors which characterize
the nonadherent patient to achieving a greater
understanding of how and why patients decide
to take some treatments and not others (Horne,
1993). Much of this research is informed by
psychological theories which conceptualize
behavior as the product of cognitions which
occur within a social framework and these are
described more fully in Chapter 8.01.
The application of social cognition models in
research indicates that medication nonadher-
ence may arise from a rational decision on the
part of the patient and identifies some of the
cognitions which are salient to these decisions.
Although there is some variation in the specific
type of beliefs which are associated with
adherence across studies, the findings show
that certain cognitive variables included in the
Health Belief Model (HBM) (Janz & Becker,
1984) and Theory of Planned Behaviour (TPB)
(Ajzen, 1988) appear to be prerequisites of
adherence in certain situations. For example,
beliefs that failure to take the treatment could
result in adverse consequences and that one is
personally susceptible to these effects tend to be
associated with higher adherence (Cummings,
Becker, Kirscht, & Levin, 1981; Kelly, Mamon,
& Scott, 1987; Nelson, Stason, Neutra, Solo-
man, & McArdle, 1978). Perceived severity of
anxiety has also been found to be related to
adherence to recommended practice of relaxa-
tion training at home (Bennett & Millard, 1985).
Additionally, adherence decisions may be
influenced by a cost-benefit analysis in which
the benefits of treatment are weighted against
the perceived barriers (Brownlee-Duffeck et al.,
1987; Cummings et al., 1981; Nelson et al.,
1978). Other studies, based on the TPB, have
shown that the perceived views of significant
others such as family, friends, and doctors
normative beliefs may also influence adherence
(Cochrane & Gitlin, 1988; Reid & Christensen,
1988). Several studies have demonstrated the
value of interventions based on the HBM in
facilitating health-related behaviors, such as
attending for medical check-ups (Haefner &
Kirscht, 1970), or using emergency-care facil-
ities in an acute asthma attack (Jones, Jones, &
Katz, 1987).
Another cognitive approach which has been
used to explain nonadherence is the self-
regulatory model outlined at the beginning of
this chapter. This model also acknowledges the
importance of symptom perception in influen-
cing illness representations and adherence as a
97
coping behavior. Confirmatory evidence for
this is provided by findings from a study of
patients with diabetes who used perceived
symptoms to indicate their blood glucose levels
and to guide self-treatment (Gonder-Frederick
& Cox, 1991). Unfortunately patients' beliefs
about their symptoms, and estimations of their
own blood glucose levels, were often erroneous
and resulted in poor diabetic control. Further
evidence of the importance of illness represen-
tations was obtained by Meyer et al. (1985) who
noted a clear relationship between illness
representations and behavior in their study of
patients with hypertension. Patients who be-
lieved that their hypertension was an acute
condition were more likely to cease taking
antihypertensive medication than those who
believed it to be a chronic condition. This study
also showed that patients' representations of
their illness often conflicted with the medical
view and provided an insight into the effects of
mismatch between the patients' representations
and those of their doctor. In a group of 50
patients who had continued in treatment, 80%
agreed with the statement that ªpeople cannot
tell when their blood pressure is up.º However,
92% believed that they could tell when their
own blood pressure was raised by monitoring
symptoms such as tiredness, headache, and
stress. Patients who believed their anti hyper-
tensive medication improved symptoms were
more likely to take it. A striking example of this
was provided by five out of 17 patients who
believed that their medication affected symp-
toms. These patients took their antihypertensive
medication only when they judged their blood
pressure to be raised. The patients had under-
stood and accepted the abstract medical view of
hypertension as an asymptomatic condition but
their concrete experience or symptoms caused
them to hold contrasting beliefs and to behave
according to these.
Illness perceptions have been linked with a
range of adherence-related behaviors other than
the use of medicines. These include various self-
management behaviors, such as dietary control
and blood glucose testing in diabetes, attending
rehabilitation, and the adoption of various life-
style changes following myocardial infarction.
A study of noninsulin dependent diabetic
patients, has shown that personal models of
diabetes are related to dietary self-management
and to exercise adherence but not to the more
medical aspects of control, such as blood
glucose testing and taking medication (Hamp-
son, 1997). Similarly, in a prospective study of
patients following first-time myocardial infarc-
tions (MI), Petrie et al. (1996) have found that
specific illness perceptions are predictive of
different post-MI behaviors. They found that
98 Health Care
attendance at rehabilitation, which is prescribed
for all patients, was predicted by the strength of
their belief in the cure/control of their MI
whereas return to work depended more on the
extent to which the patient saw their MI as
having less serious consequences
In addition to studies of the role of illness
beliefs, there is a small body of work which has
examined people's beliefs about medicines and
the ways in which these could influence
adherence (Britten, 1994; Conrad, 1985; Do-
novan & Blake, 1992; Morgan & Watkins,
1988). The negative beliefs about medicines
identified in these studies appear to be common
across several illness and cultural groups and
include worries about the potentially harmful
effects of medicines and about long-term
dependence on them. However, there are only
a few studies which have assessed medication
beliefs quantitatively and they have used
different questionnaires or have investigated
medication beliefs in the broader context of
views about the practice of medicine (Echabe,
Guillen, & Ozamiz, 1992; Marteau, 1990). Some
studies have assessed peoples' ideas about
medicines in general, whereas others have
focused on specific medication prescribed for
a particular illness.
Research by Horne (1997) indicates that four
ªcore-themesº or factors underlie commonly
held beliefs about medicines. Factor analysis of
a pool of belief statements revealed two broad
factors describing peoples' beliefs about their
prescribed medicines: their perceived necessity
for maintaining health (specific-necessity) and
concerns based on beliefs about the potential for
dependence or harmful long-term effects and
that medication taking is disruptive (specific
concerns). Two factors were also found to
describe peoples' beliefs about medicines in
general. The first relates to the intrinsic proper-
ties of medicines and the extent to which they
are harmful, addictive substances (general-
harm) and the second factor comprises views
about whether medicines are overused by
doctors (general-overuse).
Peoples' views about the specific medication
regimen prescribed for them were found to be
much more strongly related to adherence
reports than are more general views about
medicines as a whole. Moreover, an interplay
was found between concerns and necessity
beliefs which suggests that people engage in a
risk-benefit analysis and consequently attempt
to moderate the perceived potential for harm by
taking less. Patients with stronger concerns
based on beliefs about the potential for long-
term effects and dependence reported lower
adherence rates, whilst those with stronger
beliefs in the necessity of their medication
reported greater adherence to medication regi-
men (Horne, 1997).
8.03.4.3.4 Consultation outcomes: an overview
The cognitive, affective, and behavioral out-
comes of the consultation are very closely linked
and can influence each other. Patient satisfac-
tion, understanding, and beliefs can play a
major role in influencing adherence with
treatment or advice, which is obviously im-
portant in situations where nonadherence
results in adverse health consequences. Since
there is evidence of high levels of nonadherence,
this can clearly affect other outcomes including
health and well-being. The latter have not often
been studied as communication outcomes but
there are a number of studies which demon-
strate positive effects on patients' health and
well-being arising from positive experiences in
medical consultations (Stewart, 1995). These
have focused on psychological states such as
anxiety as well as changes in specific physical
variables such as blood pressure and blood
glucose control. Some of the most impressive
findings here have been found in the patient-
intervention studies, which are described below.
8.03.4.4 Improving Health-care Communication
In addition to increasing our understanding
of health-care communication and its central
role in health-care delivery, some research
findings have also provided insights for devel-
oping interventions to improve the quality of
communication. The majority of these have
been aimed at improving the communication
skills of health-care students or practitioners at
various stages of training but a few have been
targeted at patients, to enable them to get the
most from a consultation. Both types of
intervention approach will be outlined.
Communication skills training is now re-
garded as a fundamental part of the curriculum
for medical, nursing, and other health-care
students but this varies considerably in terms
of the amount and type of teaching and the stage
at which it is taught. Typically, students are
provided with an overview of the basic skills of
ªactiveº listening which facilitate patient com-
munication. At a basic level these include the
importance of developing good rapport and the
use of open-ended questions early in the
consultation, appropriate eye-contact and other
facilitatory responses to help the patient talk,
together with the ability to summarize and arrive
at a shared understanding of the patients'
problem. These skills can be taught in a number
of ways but the successful courses inevitably
 Health-care Professional±Patient Communication
involve active learning, using role-plays with
simulated patients, as well as real patient
interviews (see Kendrick, 1997; McManus,
Vincent, Thom, & Kidd, 1993). Feedback is
important to identify problem areas as well as
indicators for improvement, and increasing use
is made of videotape for this purpose. There
is consistent evidence that this type of training
can result in clear improvements in basic
communication skills which are maintained
for a number of years (Maguire, Fairburn, &
Fletcher, 1986).
In addition to these basic packages, it is also
necessary for health-care students to learn how
to communicate about sensitive or difficult
areas of clinical practice, including dealing with
distressed patients or relatives and giving ªbad
news.º Research in this area, using tape-
recorded consultations, has shown that doctors
tend to give detailed information rather than
find out and respond to patients' concerns and
informational needs. As Maguire (1997) notes,
this avoidance of patients' worries can have
negative effects in the short and longer term. An
immediate consequence is that patients may
remain preoccupied with their own concerns
and fail to take in information or advice. They
may also selectively attend to negative phrases
or messages and be unresponsive or misconstrue
more positive or neutral information. Maguire
(1997) provides the example of a surgeon who
informs a recently diagnosed cancer patient that
radiotherapy will be given ªto mop up any
residual cells,º and then adds ªI am sure that we
will eradicate your cancer.º When questioned
afterwards, the patient only recalled the phrase
ªresidual cellsº and became very distressed since
she thought that this meant that the cancer
would spread through her body.
There were are various reasons why doctors
and other health-care professionals may be poor
at ªbad newsº communication and these include
lack of training, fears about the effects of
exploring patients concerns, lack of support,
and a desire to protect their own emotional well-
being. Some of the training packages which
have been developed have taken these factors
into account and provide sufficient time for the
learners to explore and get feedback on different
strategies, using role-play situations. Many of
the component skills are those which are part of
any communication training package, such as
those outlined earlier in this section. The key
first step is to ensure that this communication
takes place in an appropriate environment and
needs to start with the patient, exploring what
they have been told and what they think and feel
about their condition. If will often be necessary
to take time to provide the patient with the
information which they want, letting patients
99
proceed at their own pace and allowing
information to be assimilated. The other key
skills involve developing the ability to recognise
distress and allow this to be expressed without
feeling discomfort or providing unrealistic
reassurance (Maguire, 1997).
There is growing evidence that the way bad
news is presented to patients can have major
effects on the patient's perception of their
condition and on subsequent coping and
adjustment (Fallowfield, Hall, Maguire, &
Baum, 1990). Effective training of health-care
professionals in this area can have significant
effects on the quality of health care for patients
with serious or terminal conditions. In addition
to improving the HCP's communication skills,
there is also considerable scope for providing
patients with more useful information, includ-
ing tape-recordings of their consultations.
Since the 1980s, there have been a number of
interesting interventions aimed at patients.
Generally, these have involved interventions
for patients prior to a consultation in order to
increase their level of participation, particularly
to ensure that their own concerns are dealt with
and that information provided by the doctor is
clearly understood. A successful development of
this approach can be seen in the work of
Greenfield, Kaplan, and Ware (1985) who used
a preconsultation intervention lasting 20 min-
utes for hospital outpatients who were helped to
identify their main questions and encouraged to
ask these in the consultation. Compared with
control patients, these patients participated
more actively in the consultation and this was
also associated with better long-term health
outcomes, including lowered blood pressure in
hypertensives and better glycaemic control in
diabetic patients. These interventions can be
quite time-consuming and a number of re-
searchers have explored the possible efficacy of
simpler patient-based interventions, such as the
use of preparatory leaflets (e.g., McCann &
Weinman, 1996), but these have not shown such
significant effects in changing the process or
outcome of consultations.
Finally, mention should be made of two
specific patient-based approaches which have
been very successful. The first by Ley and
colleagues (see Ley, 1988) involved hospital
patients and an additional short visit which
allowed them to ask for any information to be
clarified. Compared with control groups, these
patients had a much higher level of satisfaction
with communication, indicating that effective
interventions need not be of complex or time-
consuming. Hogbin and Fallowfield (1989)
describe another simple intervention which
consisted of making a tape-recording of the
ªbad newsº consultation and allowing patients
100 Health Care
to take away and keep the tape. Since this type
of consultation is often very distressing, patients
may often find it very difficult to take in all the
information. Thus, it was found that patients
welcomed the use of these tapes as something
which they could go back to and which others
could also listen to.
The importance of providing patients with
access to information in various forms, which
can be discussed and shared with family and
friends, is very pertinent in this area of health. In
this respect it is interesting to note the
development of patient support groups and
information exchanges using the ªinternetº
(Davison & Pennebaker, 1997). Providing
patients with access to others with similar or
related medical conditions may result in very
important gains in communication. For exam-
ple, patients may be able to locate and
communicate with others who have very similar
experiences and circumstances, which may not
only have a supportive function but may also
provide ways of sharing and coping with many
of the problems which are experienced.
8.03.5 HEALTH CARE IN HOSPITALS
This section of the chapter will focus on a
range of psychological aspects of health care in
hospital settings. It begins with a general
consideration of the psychological consequences
of admission to hospital and is followed by a
brief outline of some of the psychological
problems associated with the hospitalization
of younger children. Then there is a selective
overview of particular hospital treatments such
as intensive care and haemodialysis which can
produce specific emotional reactions due to the
limitations and demands they impose on
patients. Similarly, many medical procedures
are found to be painful or distressing and a
number of psychological interventions, which
have been devised to help patients cope with
these, are outlined in the final part of this section.
8.03.5.1 Psychological Effects of
Hospitalization
Hospital patients vary in many ways includ-
ing their age, personality, and social circum-
stances, as well as in the severity of their health
problems and the duration of their stay. Also,
their experience in hospital will vary greatly and
this inevitably means that there are difficulties
in attempting a general discussion of the impact
of hospital admission. Some specific issues
concerning children are presented separately
but the following account is intended to convey
some of the more general factors which have
been identified. The psychological reactions
which are described may reflect not only a
response to hospitalization but also to the illness
itself.
8.03.5.1.1 Physical and social environment
One obvious feature of hospital life which
involves a considerable change for the patient is
the physical environment. Although a number
of studies have demonstrated positive and
negative effects of the built environment on
psychological well-being and health (Spencer &
Baum, 1997), there are relatively few studies
which have directly investigated how the
physical environment of the hospital affects
the patient's condition. The hospital environ-
ment has been identified as one of a range of
stressors which people experience in hospital
(Koenig, George, Stangl, & Tweed, 1995). Even
such factors as the nature of the view from the
patient's bed have been found to affect recovery.
For example, Ulrich (1984) found that patients
with a window view of trees had a better
postoperative recovery (i.e., fewer complica-
tions, less analgesia, better adaptation, shorter
length of stay) than patients recovering from the
same type of surgery but whose hospital window
looked out on to a brick wall.
The hospital environment is frequently seen
to be drab, clinical, impersonal, and cold by
patients. Whereas in the outside world the
individual operates with a strong sense of
personal space, which is the amount of space
necessary for optimal social behavior, in
hospital this space is being constantly invaded
as part of the daily routine. The daily routine
itself is one which is very likely to be very
different from life at home and therefore may
require considerable adjustment. It is not
therefore surprising to find that studies, which
have compared home-treated and hospitalized
patients with the same condition, have shown
less psychosocial distress in those remaining at
home (e.g., Oldenburg, Macdonald, & Perkins,
1988).
Enforced life-style changes have also been
identified as a key hospital-based stressor in the
Hospital Stress Index (Koenig et al., 1995).
Admission to hospital removes individuals from
a familiar, well-ordered world and places them
in an environment which is different in every
respect. In hospital they are likely to be totally
dependent on others for most basic functions
such as washing and feeding. Usually they will
be restricted to one place, surrounded by totally
new people, whose skills are now of vital
importance to them, and it is significant that
developing good relations with hospital staff is
not only an important factor in adaptation to
 Health Care in Hospitals
hospital life but can also be a potential source of
stress for patients (Koenig et al.). Other hospital
stressors which have been identified by an older
measure, the Hospital Stress Rating Scale
(Volicer & Bohannon, 1975), include worries
about aspects of communication with staff as
well as concerns about investigations and
treatment, which are discussed in more detail
below.
On the positive side, studies by Kulik and
Mahler (1987) and Kulik, Mahler, and Moore
(1996) have demonstrated the importance of
social contact in the recovery of patients
following surgery. These studies have focused
on the effects of having a preoperative room-
mate on the anxiety and recovery of surgical
patients. In the early study they compared the
effects of sharing a room either with a patient
who was also about to undergo cardiac surgery
or with one who had already had the same
operation. The results showed clear beneficial
effects of sharing a room with someone who was
recovering from surgery. The patients who had
postsurgical room-mates were less anxious prior
to surgery, engaged in more postsurgical
physical activity, and were discharged sooner
(Kulik & Mahler, 1987). In a more recent
variation on this study, two further variables
were investigated, namely having a room-mate
or being on ones own and having a room-mate
who was about to undergo or had gone through
same type of operation. In addition to replicat-
ing the earlier findings with respect to the
advantage of sharing with a postsurgical
patient, it was also found that it was advanta-
geous to share with a postsurgical patient who
had undergone the same type of surgery and
that those who were in rooms on their own had
the slowest recovery (Kulik et al., 1996).
8.03.5.1.2 Communication in hospital
In addition to the general stresses associated
with hospital admission, some of the fear and
anxiety which is found in many hospital patients
may stem from the uncertainty and lack of
information which they may have about the
nature of their illness and its treatment and
prognosis. There are a number of studies of
hospital patients which show clearly that they
are greatly dissatisfied with the communications
aspect of hospital life (e.g., Ley, 1972). These
studies indicate that about 40±50 % of hospital
patients are critical of the communication
aspects of their stay. Many of the communica-
tion problems which were discussed in the
earlier part of this chapter (see Section 8.03.3)
are also seen in hospital settings.
There is also evidence that hospital patients
are often diffident in this respect and are
101
unwilling to ask for information. The diffidence
which seems to underlie patients' reluctance to
complain or ask for information has been the
subject of psychological study and it would
appear that patients enter hospital with ideas
about how they should behave. Lorber (1975)
has identified three categories of patient which
she labeled ªgood patientsº (about 50% of her
sample), ªaverage patientsº (about 25%), and
ªbad patientsº (about 25%) on the basis of the
ratings of their medical staff. Patients who were
labeled ªgoodº were ones who had straightfor-
ward medical problems, were uncomplaining
and docile, who took up minimal staff time, and
showed uncomplicated recovery. The ªaverageº
group were rather similar except they had some
problems, but these were manageable. The
ªbadº group consisted either of patients with
serious conditions or those without serious
conditions but who complained and put extra
demands on the staff as a result.
Interestingly, these patterns of behavior could
be detected from interviews with patients about
their views of the patient's role at the time of their
admission. Thus, it would appear that many
patients enter hospital with the expectation of
being in a relatively passive role and the pattern
of life in hospital actually reinforces this,
sometimes to the point of helplessness. Taylor
(1979) describes how helplessness can develop
when questions go unanswered and desires for
attention are not met. As a result ªgoodº patient
behavior may actually be detrimental to recov-
ery since it prevents patients from taking an
active role in their health care. Moreover ªbadº
patient behavior can be seen as a reaction against
helplessness and an attempt to gain a degree of
control, and hence could be thought of as a
healthier response.
Fortunately, these problems do not appear to
be insurmountable. For example, Ley, Brad-
shaw, Kincey, and Atherton (1976) conducted a
study of hospital patients on three wards of a
general hospital. In one ward there was an extra
visit made to patients every 10 days, in which
attempts were made to ensure that they had
understood what they had been told. These
visits were relatively brief and only concerned
with clarifying existing information rather than
raising new issues. The second ward essentially
comprised a control group, who received an
extra visit to discuss their welfare, food, and so
on and not to clarify information. Patients in the
third ward in the study received no extra visits.
The results showed that 80% of patients who
had received the informational visit were
satisfied with the communication received,
which was approximately twice the level of
satisfaction with communication found in the
other two groups.
102 Health Care
In addition to these general psychological
impacts of hospitalization, there may be specific
problems or demands which occur either as the
result of the particular health problems or the
type of treatment which the patient has to
undergo. An example of the way in which the
patient's health problem may influence their
experience of hospital care can be seen in some
of the studies of patients with AIDS who may
experience negative attitudes from staff or other
patients. These negative attitudes are closely
linked with the blaming attributions which staff
or patients may have for the cause of AIDS. In a
survey of 270 AIDS patients being treated in
either special care units or integrated in more
general hospital settings, specific stresses were
reported by those in the integrated units (Van
Servellen, Lewis, & Leake, 1990). Whereas both
groups were bothered by the same range of
general stressors identified above, particularly
loss of independence, separation from loved
ones, and problems with medicines, those who
were in integrated settings more frequently
experienced and were upset by factors asso-
ciated with ambiguity about their care and their
medical condition. Moreover, these patients
also reported higher levels of stress associated
with feelings of abandonment and impersonal
or discriminatory treatment. A number of
studies of HCPs have revealed evidence that
their attributions of patient blame for their
condition can have direct influences on their
attitudes to the care of the patient as well as their
approach to and involvement with them.
Broadly, it has been shown that where staff
see patients as instrumental in having brought
about their own condition through their own
behavior or neglect, then they may be less
committed, motivated, and sympathetic to-
wards them (Marteau & Riordan, 1992).
8.03.5.2 Children in Hospital
In many countries approaching 50% of
children will have spent a period of time in
hospital and for those with chronic conditions
many have to spend longer periods or visit
repeatedly over a number of years. There is
evidence that children's reactions to illness and
hospital treatment can be quite distinct and that
the psychological and social consequences of
separation from home can produce quite
specific problems. Older studies of the emo-
tional reactions of children to hospital (e.g.,
Illingworth & Holt, 1955) showed that admis-
sion to hospital was often very distressing for
them, particularly the younger ones, but the
situation has improved over the years. Since
that time various recommendations have been
put forward and, to some extent, implemented
to allow greater access by parents to their
hospitalized children. These have included
increased flexibility in visiting arrangements
as well as a greater provision of overnight
accommodation for parents.
Adaptation to hospital life will depend
greatly on the age and personality of the child
as well as on the family and their reaction to the
child, to disease, and to hospitals. When they
occur, emotional problems in hospital are much
more prevalent in younger children, particularly
up to and around the age of four. Older children
are more amenable to explanation and are
usually less distressed by separation from home
and by being surrounded by strangers. A more
extensive discussion of children's responses to
health issues and health care can be found in
Chapter 8.27.
There are a number of specific psychological
problems associated with the hospitalization of
children. The problems would appear to stem
from three sources:
(i) The social separations and disruptions
incurred by admission to hospital;
(ii) The emotional response to the clinical
problem; and
(iii) The lack of preparation for hospital life
and the investigations and treatments to be
carried out.
The more long-term effects of hospitalization
on children suggest that some of the traumatic
effects reported in early studies may have been
overstated. Follow-up studies of hospitalized
children indicate that serious problems are only
found in children who had psychological pro-
blems prior to admission or who come from
difficult families (La Greca & Stone, 1985).
Studies of preparation of children for hospita-
lization also show that different types of pre-
paration appear to be suitable for children of
different ages and with different amounts of
prior experience (see Schmidt, 1997 for an
overview).
8.03.5.3 Psychological Aspects of Specific
Hospital Treatments
In the same way that physical illness imposes
physical and social limitations on the individual
which can give rise to psychological reactions,
some treatments are also very restricting and
have been found to cause emotional and
behavioral changes. In particular, a number
of studies have been made of patients in specific
treatment settings such as intensive care units
(ICUs), coronary care units (CCUs), and
haemodialysis. Although these treatment en-
vironments can give rise to specific stressors,
 Health Care in Hospitals
they also offer challenging opportunities for
psychological interventions.
Experimental work with healthy volunteers
has shown that long periods of sensory
deprivation or sensory overload will often give
rise to a state characterized by increased
wakefulness, disorientation, and visual halluci-
nations (Goldberger, 1982) These states have
also been found in some patients who are being
treated in ICUs since they may be exposed to
long periods of sensory deprivation produced
by monotony and immobilization, sometimes
interrupted by periods of overstimulation, as
well as sleep deprivation. It is claimed that the
observed ªICU psychosisº is the result of all
these factors on an individual who is already
fearful of his or her life because of a serious
physical illness. Fortunately, these dramatic
psychological responses gradually disappear
when normal amounts of sensory stimuli and
sleep are restored by returning the patient to a
normal hospital environment. More important,
these changes can be avoided if the ICU
contains a more varied sensory environment
and with good contact with visitors and staff.
For example, Keep, James, and Inman (1980)
have compared patients in ICUs with and
without windows, and found that those in the
windowless units were less well oriented during
their stay and had a less accurate recall of their
length of stay afterwards. In addition to these
general problems associated with the ICU,
other studies have assessed the degree of stress
experienced by patients, staff, and visitors. For
example, in a study of a surgical ICU, patients
rated their level of stress from a wide range of
events which occurred (Pennock, Crawshaw,
Maher, Prue, & Kaplan, 1994). The ratings were
made shortly after their transfer from the ICU
and indicated relatively minimal distress asso-
ciated with many events with exception of being
intubated and not being able to communicate.
For patients' relatives there is evidence that they
find the time spent by the patient on life support
in the ICU particularly worrying. During this
time they experience considerable fear and
uncertainty but this can be resolved by seeking
information and the use of other resources
(Jamerson et al., 1996). For staff working in this
climate, it is assumed that greater levels of work-
related stress will be experienced, compared
with other hospital personnel. However, the
evidence on this is ambiguous and some studies
have shown that ICU staff show a more positive
attitude to their work and work environment
than equivalent non-ICU staff (Boumans &
Landerweerd, 1994).
In the context of coronary care, a number of
studies have identified possible areas for
psychological intervention in facilitating the
103
recovery of patients in CCUs. Using a self-
regulatory framework, one study has shown
that patients with myocardial infarction have
clear beliefs about the cause, timeline, con-
sequences, and controllability of their heart
condition during the acute phase of their
hospital stay in the CCU. Moreover, these
beliefs appear to be associated with subsequent
attendance at cardiac rehabilitation and with
later adaptive changes, such as return to work
and social functioning (Petrie et al., 1996). In
addition to these cognitive processes, there is
also good evidence that patients' mood states at
the early stages of recovery are related to longer-
term physical and psychological well-being
(Frasure-Smith, Lesperance, & Talajie, 1995)
and there is now increased awareness of the
ways in which appropriate care during the
hospitalization phase of treatment can promote
adaptive coping and recovery (see Bennett,
1994).
In contrast to the acute psychological
restrictions and demands of intensive or
coronary care, some patients are subject to
much more chronic restrictions as part of their
treatment. Many patients with renal failure are
required to spend a considerable amount of time
on renal dialysis machines, either in hospital or
at home. These patients have a uniquely
dependent relationship not only on their dialysis
machine but also with the staff involved in their
treatment. Dialysis can have major effects on an
individual's psychological and social function-
ing, particularly giving rise to vocational
impairment, reduced sexual activity, and mood
changes (Oldenburg et al., 1988). In addition to
the physical limitations and demands of
dialysis, the patients are also faced with the
need to adhere to strict recommendations
regarding diet and fluid consumption, as well
as complex medication regimens. Nonadher-
ence can be a key issue in renal failure and the
range of adherence-related factors outlined in
an earlier section are very pertinent for patients
on dialysis.
One finding which emerges from studies of
patients on renal dialysis is that psychological
dysfunction at an early stage is a predictor of
longer-term adjustment. This means that it is
not only vital that good psychological care is
available during hospital treatment but also that
ªat riskº individuals can and should be
identified at an early stage in order to anticipate
later difficulties. It is noteworthy that compara-
tive studies of patients on hospital or home-
based dialysis show that the home-treated
individuals show much less social dysfunction
(Oldenburg et al., 1988). Part of this may well
reflect the patient selection criteria for hospital
and home dialysis, with more ªproblematicº
104 Health Care
patients tending to be treated in the hospital
setting. However, part of this may also reflect
the additional negative effects of hospitaliza-
tion, outlined earlier, superimposed on the
specific limitations and demands of dialysis.
The most commonly reported psychological
difficulties found in patients on renal dialysis
are depression and anxiety but the extent of this
is unclear. There is a range in the reported
prevalence of depression from 10±100% (Levy,
1994) and this variation is partly due to the
different criteria and measures used (see Kaplan
De-Nour, 1994). Another reason stems from the
similarities between the physical effects of renal
failure, such as fatigue, apathy, and sleep
difficulties, and the symptoms of depression.
Despite these methodological problems, there
do appear to be a number of aspects of dialysis
which can give rise to psychological distress.
For example, Devins, Binck, Hollomby, Barre,
and Guttman (1981) have identified the con-
stant threat of death, dependence on the dialysis
machine, medical staff, and the stringent dietary
and liquid restrictions as key factors in the
widespread feelings of helplessness and lack of
control. Patients' perceptions of control over
their treatment have been found to interact with
treatment experiences and illness severity in
determining mood outcomes (Christensen,
Turner, Smith, Holman, & Gregory, 1991). A
belief that one's health is subject to personal
control has been found to be associated with
lower levels of depression in people who had
only been treated by dialysis whereas, for those
who had returned to dialysis following a failed
kidney transplant, higher control beliefs over
health were associated with greater depression.
In line with self-regulatory theory, patients
representations of their kidney disease, includ-
ing their control perceptions, would be expected
to influence coping and other outcomes,
including treatment adherence (Horne & Wein-
man, 1994). Studies by Christensen, Benotsch,
Wiebe, and Lawton (1995) have demonstrated
that problem-focused types of coping were
associated with better adherence to fluid intake
restrictions when these coping strategies were
used in response to stressors arising from a
relatively controllable aspect of dialysis. For
those stressors which patients perceived as less
controllable, emotion-focused coping strategies
were associated with better levels of adherence.
8.03.5.4 Stressful Medical Procedures in
Hospital
In addition to the generally stressful effects of
hospital admission, there is a range of medical
procedures which can give rise to considerable
discomfort and anxiety. These include specific
investigative procedures such as barium X-rays
(Allan & Armstrong, 1984), endoscopy (John-
son, Morrissey, & Leventhal, 1973), and cardiac
catheterization (Kendall et al., 1979) which may
not only be uncomfortable and sometimes
physically distressing but which also carry the
threat of uncovering a serious medical condition
(Weinman & Johnston, 1988). The other
obvious ªeventº in hospital which has been
found to produce significant psychological
effects is surgery. The psychological impact of
surgery will partly depend on the procedure, the
condition, and the likely outcome as well as on
such psychological factors as the patient's
expectations and coping style and the quality
of communication.
The way in which a patient reacts to a medical
procedure can also have a significant influence
on the outcome, particularly in recovery from
surgery. Patients who show the highest pre-
surgical levels of stress response will also tend to
experience adverse psychological reactions
postsurgically and will be more likely to show
poorer physical recovery (Johnston, 1986).
These patients have been found to request more
analgesia, show more postsurgical complica-
tions, and tend to recover more slowly with
delays in discharge, as compared with less
anxious or stressed patients.
8.03.5.5 Psychological Interventions for
Stressful Medical Procedures
Since studies have shown a relation between
patients' psychological state and their recovery,
it has been recognized that there could be
considerable gains from providing a psycholo-
gical intervention designed to reduce or mini-
mize the psychological impact of a medical
procedure. There is a range of interventions
which have been used to prepare patients for
surgery or other stressful procedures in the
hospital setting. In broad terms, they can help
by providing the patient with information to
reduce the uncertainty of the event, or with
specific behavioral or cognitive skills to help
with some of the discomfort or pain Mathews
and Ridgeway (1984) have provided a clear
overview of the various preparations and these
are summarised in Table 2.
Procedural information is probably the most
widely used approach and consists of providing
information about the various procedures which
will take place before and after the operation. In
short, it involves a description of what will be
done to the patient at different stages pre- and
postoperatively. Sometimes this information is
also accompanied by an explanation of the
 Health Care in Hospitals
purpose of each of the procedures which are
described. Thus, it provides the patient with a
map of the events which will occur and, in doing
so, can reduce the uncertainty of the whole
process.
Sensory information describes what patients
are likely to feel, particularly during the
immediate postoperative pain period. The
important point here is to provide matter of
fact or benign interpretations of the sensations
so that the patient can recognize them as part of
the expected postoperative process. Thus, the
patient who can recognize postoperative pain as
an expected sensation caused by the incision and
reflecting the healing process will be far less
likely to be distressed than someone who has not
been prepared for the pain and who may think
of it as problem or a complication of the
surgery.
Contrada, Leventhal, and Anderson (1994)
have outlined an interpretation of the benefits of
sensory and procedural information from the
perspective of the self-regulatory model. They
view the sensory preparation as providing a
script which describes internal sensations and
the procedural preparation as a script providing
the objective external events involved in
surgery. They maintain that it is the availability
of the script which reduces uncertainty and
worry for the patient. More specifically,
Leventhal (1985) has argued that sensory
information should be particularly helpful since
it focuses on potentially threatening sensations
(e.g., pain, discomfort) with the aim of ensuring
that these are processed as nonthreatening or
less threatening. However, evidence on the
efficacy of both types of preparatory informa-
tion indicates that procedural information is at
least, if not more, effective in producing
favorable outcomes (Johnston & Vogele,
1993, see below).
Behavioral instructions are also commonly
provided and describe different behaviors which
will help before, during, and after surgery.
These include instructions about ways to cough
and move in bed which will reduce the
likelihood of pain associated with these move-
ments. Other behavioral instructions such as
deep breathing and ambulation exercises may
also reduce the incidence of pain or complica-
tions as well as facilitating recovery.
Modeling is based on the use of filmed models
who can be seen undergoing the same procedure
as the patient. Following Bandura's social
learning theory (Bandura, 1986), modeling or
the observation of others completing a difficult
or stressful task can serve to increase the
individual's sense of self-efficacy for managing
the same task. Two main types of model have
been investigated: (i) mastery models who are
105
shown dealing with the task with ease and
ability, and (ii) coping models who are shown as
having some anticipated concerns but who
nevertheless are able to overcome these and
cope with the procedure. The coping type of
model has been found to be a more effective
preparation for children undergoing surgery.
For example, in a study of children about to be
innoculated, Vernon (1974) has compared a
group of children who saw a preparatory film
which was realistic (the child in the film is seen
to experience short-lived, moderate pain and
emotion) with a group who saw an unrealistic
film (no pain or emotional expression) and a
group who saw no preparatory film. The
realistically prepared group were found to
experience least pain when receiving their
injections. These methods have been more
widely used with children than with adults,
particularly since it may be difficult to provide
children with sensory or procedural informa-
tion or behavioral instructions in a meaningful
way.
Relaxation-based interventions can involve a
number of different techniques. These may
involve the use of deep breathing, progressive
muscle relaxation, or, less frequently, hypnosis.
Relaxation can be used both to provide a
general preparation involving anxiety-reduc-
tion and to give a specific skill which can be used
postoperatively for dealing with pain or
discomfort.
Cognitive coping procedures focus on pa-
tients' concerns and fears about the surgery and
provide ways of dealing with them in one of two
ways. First, they may make use of coping
strategies which the patient has used success-
fully in the past for dealing with stressors,
enabling the patient to rehearse and apply these
in the surgical context (Langer, James, &
Wolfer, 1975). The second cognitive approach
involves dealing with negative thoughts by
distracting attention from them and by focusing
on positive aspects of the surgery and repeating
positive self-statements (Ridgeway & Mathews,
1982).
The efficacy of these interventions has been
evaluated by examining their effects on a range
of postsurgical outcomes, including anxiety,
pain, and use of pain medication, length of stay
in hospital, and various indicators of recovery.
All the interventions have been found to be
successful in improving at least one aspect of
outcome and the majority have a positive
impact on many of the outcomes. The different
interventions have been examined systemati-
cally in a meta-analysis by Johnston and Vogele
(1993) and their findings will be outlined briefly.
The largest recovery effects were obtained for
pain, negative affect, and physiological indices
106 Health Care

Table 2 Psychological preparations for stressful medical procedures.

Type of preparation Example

Procedural information
Sensory information
Behavioral instructions
Modeling
Relaxation
Cognitive coping
ªAfter the operation, you will be taken to the recovery
room, where specialist staff will care for youº
ªIt is normal to feel a sharp, burning sensation along the
line of the incisionº
ªYou should try to cough four times each morning and
afternoon/evening to keep your chest clearº
ªThis film shows someone like you coping with the
procedures that you will be experiencingº
ªTry to breathe deeply and concentrate on relaxing the
muscles of your body whenever you feel tenseº
ªYou say that you are worried about the anaesthesia.
Try to think of ways in which you could make those
thoughts more positiveº

Source: Mathews & Ridgeway (1984).

of recovery but there was considerable variation
in the magnitude of these effects. Smaller but
more consistent advantages of psychological
preparation were found on pain medication and
length of hospital stay. The interventions which
had the most widespead overall effects on all the
outcomes were found to be procedural informa-
tion provision and behavioral instructions.
Relaxation was also found to have beneficial
effects on the various outcomes. Whereas
Mathews and Ridgeway (1984) had indicated
that cognitive coping interventions were most
likely to have the greatest efficacy, the meta-
analysis results show that their effects appear to
be restricted to specific outcomes. Thus,
cognitive interventions have been shown to
have positive effects on negative affect, pain and
use of pain medication, and clinical recovery but
do not appear to result in shorter lengths of stay
or in improved physiological indices or beha-
vioral recovery. Surprisingly, in view of the
importance attached to patient evaluations of
health care, only a few studies have examined
the effects of these interventions on patient
satisfaction but these show quite positive
results, indicating that patients view them as
acceptable and helpful.
In summary, there is considerable evidence to
indicate that different types of psychological
preparation can not only reduce the anxiety,
stress, and pain involved in many medical
procedures, but also that there are considerable
related benefits (e.g., less analgesia, better
recovery, faster discharge, etc.). Although the
above outline of approaches provided separate
descriptions of each, they can easily be used in
conjunction and often are.
What is encouraging from the research and
reviews of psychological preparation for sur-
gery is that they show that it is possible to
intervene effectively using relatively uncompli-
cated procedures. Moreover, there is now
sufficient information about their efficacy to
be confident in recommending that they should
be included as routine components of standard
medical and nursing care for all patients
undergoing surgery.
8.03.6 CONCLUSION
The outline of psychological preparations for
surgery provides a very positive endpoint for
this chapter. The development and success of
these procedures not only constitute very
concrete evidence of the importance and
contribution of psychological factors in health
care but also serves to link together some of the
other main areas covered in this chapter. For
example, the preparations can have important
effects on the way in which postsurgical
symptoms are interpreted and responded to
by patients. Indeed, the efficacy of the inter-
ventions provides additional evidence of the
role of self-regulatory processes and expecta-
tions in symptom perception since the provision
of sensory information can provide the patient
with a benign interpretation of predictable
postsurgical symptoms. Moreover, it is clear
that whatever specific mode of intervention is
used, each of them involves aspects of commu-
nication between the HCP and the patient.
At the beginning of this chapter a brief
mention was made of the variety of systems
which have evolved for the delivery of health
care in different countries. The psychological
processes and topics covered here are of equal
relevance across all these systems. It is notable
that Johnston and Vogele (1993) end their meta-
analysis with a similar observation since they
find that psychological preparations for surgery
 References
have produced similar results in countries with
both free market and public health-care provi-
sions. The ubiquitous role of psychological
processes in health care is a reflection of the
relevance and the potential of research and
practice in health psychology.
ACKNOWLEDGMENTS
I am particularly grateful to Susan Pybus for
her help in producing this manuscript. Special
thanks are also due to Rob Horne, Mary Rome,
and Sue Williams for their contribution to
specific parts of the chapter. Finally, thanks are
also due to the editors for their encouragement,
critical feedback, and patience.
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