Title, Health Psychology. Author, Dimatteo. Publisher, Pearson Education, ISBN, X, Length, pages. Export Citation. A comprehensive, yet engaging book, that covers both the clinical aspects of health psychology with the research related to important health issues. Integrating. Now in. its second edition, this book's biopsychosocial health psychology approach is contrasted and compared to traditional biomedical views of health and.
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Health psychology / M. Robin DiMatteo, Leslie R. Martin. Author. DiMatteo, M. Robin. Other Authors. Martin, Leslie R. Published. Boston: Allyn and Bacon. chrisfalgocaput.cf: DIMATTEO: HEALTH PSYCHOLOGY _c (): M. Robin DiMatteo, Leslie R. Martin: Books. Health Psychology M. Robin DiMatteo, Leslie R. Martin. A comprehensive, yet engaging book, that covers both the clinical aspects of health psychology with the .
Questioning research assumptions The notion that the world we experience, and our understandings of reality and people, comes from social life. Thus, our reality is a product of social life and does not exist in a straightforward, taken-for-granted manner. Some major critiques have been made of social psychology since the s, and many of these critiques are relevant to health psychology.
Researchers began to question the nature of reality positing ontological questions , how we can know that reality positing epistemological questions and what methods we can use to study that reality positing methodological questions Chamberlain et al.
Some writers have convincingly argued against the supposedly natural character of certain phenomena, and have described how these phenomena arise from particular historical, discursive, social and cultural realms. This has been achieved on a general level by Michel Foucault e.
Foucault, , and on a more specific level for psychology by Kenneth Gergen e. From this perspective, a person with asthma will experience pain and suffering, but how this is interpreted and treated will depend on the historical time and place in which it occurs. This perspective is known as social constructionism. Social constructionists argue that we come to understand our reality through our ideas and paradigms. Social constructionism has developed alongside postmodernism.
This is set apart from modernism, in which matters are straightforward, reality can be tested, defined, described or at least approximated. In modernism, progress is assumed to be linear, coherent and relatively unified. As with most paradigms, social constructionism does not provide a unified perspective, and debates continue to rage between people who call themselves constructionists.
One such debate is the realism—relativism debate. This debate concerns the extent to which an external world exists independently of our representations of it. Despite this, most social constructionists take a critical realist perspective Edley, From this view, the existence of bodies, diseases and poverty is accepted, but how we know them are as socially constructed entities; furthermore, we can only know them in this manner.
For example, while no one would deny the reality of the physical constriction and inflammation of the airways during an episode of asthma, the meaning of this event as an attack, as an illness, as a limitation, as an embarrassment, etc. Knowledge gained in different disciplines highlights how our ideas about health, illness, disease and the body can vary by social, cultural and historical location. Foucault, Joralemon, Diseases have been shown to reinforce the particular social structures and political struggles of the time.
For example, women in the nineteenth century who wanted to further their education were labelled as suffering from hysteria Smith-Rosenberg, , cited in Nettleton, Such findings reinforce the notion that biomedicine, although authoritative and powerful globally, is culturally specific and that its practices and knowledge are social in origin Nettleton, It is important to note here that saying our knowledge is socially constructed is not at all the same as saying that our knowledge is worthless Nettleton, Social constructionists try to put forward different ways of understanding how knowledge comes to be created.
This task has been taken up recently in health psychology, and some researchers have begun to study language and discourse as topics in their own right.
Such research has a number of aims, and includes consideration of how situations, facts, ideas, knowledge are constructed and used in language and everyday talk. Our meanings, sense of selves, understandings of health, illness and the body, arise from our social and cultural worlds.
They arise from social interaction, through language 25 26 Health Psychology or other forms of meaning-making. Reflexiveness Reflexiveness involves taking an explicit look at the broader consequences of practices within a discipline. Critical examinations of the assumptions and practices of health psychology as a discipline have very recently begun to develop, involving considerations of how it functions to sustain established notions, how its practices limit understanding and how it legitimates or marginalises particular groups or institutions in society.
Health psychology is a discipline formed at a particular social and historical moment. It has been argued that the theoretical assumptions of health psychology have actually hindered attempts to improve health. This has come about, it has been argued, because health psychology directs its attention to an individual level of analysis in terms of health-related behaviour.
There is little discussion about the implications of individualism in health psychology and little discussion of the implications of the field of health psychology itself. The sorts of questions that could be asked of the discipline are whether it contributes to the status quo. Is health psychology beneficial for health?
Whose health does health psychology benefit? Furthermore, as Marks and colleagues have pointed out, psychologists also need to be fully aware of the social and economic context in which they and other professionals Locating the field 27 live and work if they are to make genuine improvements to health and health care.
Summary Theories in health psychology have mostly developed within the Englishspeaking cultures of the USA, Europe and British commonwealth Marks et al.
The emphasis on the individual in health psychology has focused primarily on factors within individuals such as cognitions and between individuals such as personality attributes and rarely on the social worlds of individuals. Ironically, this is apparent in the almost complete absence of theorising around the body and embodiment in health psychology: the individual is treated as a thinking, cognitive being, but not one that is and has a physical body see ch.
At this point it would be useful to review some of the evidence which shows that health is not simply an individual phenomenon: health and illness vary across some major social categories. To highlight how health and illness are intertwined with social life, we outline how they vary across different social groups. Mutual collaboration fosters greater patient satisfaction, reduces the risks of nonadherence, and improves patients' healthcare outcomes.
Keywords: patient adherence, health outcomes, physician—patient relationship Introduction For most medical conditions, correct diagnosis and effective medical treatment are essential to a patient's survival and quality of life. A significant barrier to effective medical treatment, however, is the patient's failure to follow the recommendations of his or her physician or other healthcare provider. Patient nonadherence sometimes called noncompliance can take many forms; the advice given to patients by their healthcare professionals to cure or control disease is too often misunderstood, carried out incorrectly, forgotten, or even completely ignored.
Nonadherence carries a huge economic burden. Yearly expenditures for the consequences of nonadherence have been estimated to be in the hundreds of billions of US dollars DiMatteo b.
In addition to the most obvious direct costs, nonadherence is also a risk factor for a variety of subsequent poor health outcomes, including as many as deaths each year Smith ; Burman et al ; Christensen and Ehlers ; Kane et al The corpus of literature on patient adherence is large, and there are many conceptual models that attempt to integrate a large number of complex factors that affect adherence Bowen et al To manage the size and complexity of the empirical findings of this massive research enterprise, reliance on meta-analytic work is necessary to provide the building blocks for data-driven models of patient adherence.
Currently, ongoing meta-analytic studies at the University of California, Riverside, USA, are beginning to identify a number of stable and consistent factors that affect patient adherence DiMatteo a , c ; DiMatteo et al , Syntheses of the literature, along with new empirical advances, highlight the complexities inherent in understanding and effecting changes in patient adherence and suggest solutions to common problems in medication management.
Much that has been learned from recent research on the communication between healthcare providers and their patients can lessen the economic burden of nonadherence and improve healthcare processes and outcomes for patients. Studies exploring simple versus complex dosing schedules have found that adherence falls off appreciably when regimens become more complicated and affect patients' lifestyles Chesney Adherence to recommendations involving lifestyle changes such as exercise frequently poses significant difficulties for patients.
Such programs, of course, tend to be more successful in supervised rather than home-based programs McKelvie et al The health consequences of nonadherence can be quite severe.
Nonadherence compromises patient outcomes in many different ways but is most obvious when patients fail to take medications that likely would cure or at least effectively manage their illnesses Miller ; Chesney et al ; Weir et al For patients suffering from or those at risk of coronary heart disease, nonadherence to medication treatments can jeopardize survival McDermott Among diabetic patients, adherence to medication for controlling hypertension is essential to preventing mortality from diabetes and myocardial infarction Elliott et al Further, aside from direct biomedical benefits, studies show that health may depend partly upon the act of adhering to a regimen.
Some research suggests that adherence, even to a placebo, is itself beneficial to health outcomes McDermott ; Irvine et al The clinical picture in a patient's treatment can also be confused by nonadherence with patients' risk profiles increased as a result. Thus, not only do nonadherent patients fail to benefit from effective medication, they also risk being harmed by less than ideal medication and dosage choices Joshi and Milfred ; Salzman ; Bedell et al Relatedly, the risk of new illness may increase in the context of nonadherence, such as when antibiotic-resistant bacterial infections develop because patients have not taken their full, prescribed doses of antibiotics Harrison ; Lutfey et al ; Graham ; Rao ; Raviglione et al Thus, it is clear that nonadherence often results in a combination of wasted medical care dollars Johnson and Bootman ; Rizzo and Simons ; DiMatteo b , wasted time and energy for patients and healthcare providers alike DiMatteo et al , and frustration and dissatisfaction for all interactants.
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Research on patient adherence The research literature on patient adherence is extensive. Over the past 50 years, there have been 32 adherence related citations in PubMed and 10 in PsychLit.
Of these citations, more than represent empirical research articles that involved the assessment of medical patients' adherence to a variety of physician-prescribed regimens medication, diet, exercise, lifestyle changes, etc.
These various methods are used in the context of a vast array of disease conditions both chronic and acute. With technologies such as these, every removed dose of medication sends an electronic signal to the physician with the date and time the bottle was opened Eisen et al , providing a very reliable indicator of medication access despite the remaining possibility that the dose was removed but not actually taken as prescribed.
Direct observation of a patient taking medication is another, albeit more energy-intensive, method for assessing adherence Volmink et al In the treatment of latent tuberculosis infection, for example, measurement of adherence to isoniazid INH can be direct, using an assessment of INH metabolites in patients' urine Perry et al ; Eidlitz-Markus et al Pharmacy records represent another resource for measuring adherence.
Recent studies have analyzed pharmacy claims databases involving large numbers of patient records and indicating such data as when the medication was obtained and whether prescriptions were refilled on schedule Tai-Seale et al ; Bieszk et al Understanding adherence requires a multi-method approach to give a clear and accurate picture of whether and how medical recommendations are being followed.
Adherence needs to be measured using multiple tools. For example, adherence to antidepressant medication might be assessed by pill count, patient self-report, and MEMS Thompson et al ; Hamilton Just as studies of adherence vary greatly in the way they measure the construct, they also range widely in scope and application.
Some studies focus on variations in rates of nonadherence DiMatteo c , some on particular types of nonadherence and their associations with patient outcomes DiMatteo , others on the correlates of adherence DiMatteo , a , and still others on the ways clinicians can improve adherence rates for their patients Roter et al ; Atreja et al Meta-analytic techniques are now being used as well Macharia et al ; DiMatteo et al , ; McDonald et al ; Peterson ; Ismail Their goal is to synthesize and summarize what we currently know about adherence and to develop data-driven models for understanding the phenomenon and initiating interventions.
Health Psychology: A Critical Introduction
Such an approach requires careful organization and assessment of the research findings on adherence, seeking evidence for convergence, and stability in research findings. It is clear from the research to date that as we compile and analyze the empirical evidence on patient adherence, we approach an enhanced understanding of this complex and important issue. In this article, we review some of the most robust findings on patient adherence, identifying what we currently know about how to manage and reduce its associated clinical risks in the context of medical practice, as well as what we have yet to determine.
Factors that affect adherence Cognitive factors It goes without saying, perhaps, that patients must understand what they are supposed to do before they can follow medical recommendations.
Thus, patients' health literacy is central to their ability to adhere. Studies show that the risk of nonadherence is very high when patients cannot read and understand basic written medical instructions. Misunderstanding of this type is not as uncommon as one might imagine. One large study of over patients found that nearly one third had marginal or inadequate health literacy. Language barriers contributed somewhat to these limitations, but even when patients could understand the language of their medical instructions, many could not comprehend the medical information.
Further, older patients in this study had significantly more problems understanding their medical regimens than did younger patients. Other studies confirm these trends and indicate that our current interventions aimed at increasing health literacy to improve patient adherence have, so far, been disturbingly ineffective Williams et al ; Gazmararian et al ; Schillinger et al Patients' health beliefs are affected by their health literacy, and these beliefs are also contributors to non adherence.
In practice, patients' low health literacy has been linked to ineffective physician—patient communication and, in particular, physicians' failure to assess recall and comprehension of new concepts with their patients Schillinger et al Low health literacy has been associated with patient depression Kalichman and consequently with the manner in which patients communicate with their doctors. Patient health literacy issues may also be tied to ethnic disparities in screening, such as mammography, probably because of reduced access to and understanding of written cancer prevention materials Peek and Han Another important factor influencing nonadherence is patients' ability to remember the details of the recommendations made to them.
Studies have repeatedly shown that forgetting to take or how to take medications is a major contributor to nonadherence Kravitz et al ; Cline et al ; Brekke et al ; Shemesh et al ; Zaghloul and Goodfield Even when information is communicated effectively and comprehension is initially high, much of what is conveyed during the medical visit is forgotten within moments of leaving the doctor's office.
Healthcare providers need to explain the specific steps of the regimen, review the most important details, use written instructions, and encourage their patients to ask questions about the regimen for adherence to occur Becker and Maiman ; Carter et al ; Wolf ; Frank et al Not surprisingly, when patients are presented with a very large amount of information, they tend to forget a large proportion of it Ley ; Rost et al High anxiety also contributes to patients' lower levels of recall, and increases the risk of nonadherence Ley ; Shapiro et al ; Montgomery On the other hand, research suggests that the risk of nonadherence is reduced when patients know their doctors well and are in more familiar, and less anxiety-provoking, physician—patient relationships Rost et al ; Heffer et al Finally, it has been shown that when patients are more satisfied with their medical visits, they tend to experience better recall of information Falvo and Tippy Empathic communication involving a thorough understanding of the patient's perspective, improves adherence.
Patients who are informed and affectively motivated are also more likely to adhere to their treatment recommendations Squier Interpersonal factors The interpersonal dynamics of the physician—patient relationship play an important role in determining a variety of patient outcomes including patient adherence to their treatment recommendations.
Patients who feel that their physicians communicate well with them and actively encourage them to be involved in their own care tend to be more motivated to adhere Frankel ; Safran et al ; Martin et al ; O'Malley et al Additionally, when physicians and patients agree on how involved patients should be in their care, adherence is improved Jahng et al Cohesive partnerships and effective interpersonal communication make it possible for patients and physicians to work together to help patients follow mutually agreed-upon recommendations Jahng et al Successful communication between physicians and patients promotes greater patient satisfaction with medical care, which in turn fosters higher levels of adherence.
Patients' trust in their physicians is essential to their emotional disclosure and is therefore a crucial component of the patient—physician relationship. Finally, clearly written materials that patients can take home with them can enhance their ability to remember, and therefore to adhere to, their recommended treatments. But these things are difficult to ascertain in the absence of effective communication and a healthy relationship between clinician and patient.
Recalling the importance of medical communication to the overall PCC model, it is recommended that clinicians formally evaluate their communication skills and receive training to strengthen those abilities, as training is generally found to be effective. One of the most widely used of this latter type of training program is Motivational Interviewing MI. Meta-analytic findings indicate that patient adherence is significantly influenced by clinician communication skills training, with adherence being 1.
They suggest that using simulated patients may not be worth the extra cost when the more economical role-playing approach appears equally effective. With proper communication skills training, health care professionals are well-equipped to foster the type of trusting clinical relationships that are consistently shown to relate to better outcomes.
Multiple studies have shown that patients are more motivated to adhere when they are in partnering relationships — that is, their physicians communicate effectively and welcome their involvement in care.
Another — more direct — approach to improving adherence is to explicitly incentivize the behavior; smaller incentives may be provided to every adherent patient, or periodic opportunities for a larger incentive may be given through a lottery system.
Financial incentives have been shown to improve adherence especially in cases where the treatment itself is onerous eg, depot medications and for patients who are at high risk for nonadherence.
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Meta-analytic findings show that when incentives are larger, more frequent, and given over a longer period of time they tend to exert more influence on adherence.
Engage social supports Just as a supportive relationship with the clinician is important to patient adherence, the support of family and close friends can also play a vital role in encouraging adherence. Meta-analytic findings verify the value of social supports, with practical support — for example, providing transportation to medical appointments or picking up a prescription from the pharmacy — being the most important.
When the social support system is engaged, adherence challenges related to social, economic, or lifestyle barriers can often be more effectively addressed. In addition, some data suggest that when social supports are stronger patients experience less negative affect which in turn predicts adherence self-efficacy and actual adherence.
Part of helping patients to adhere to treatment involves working with them to develop goals that are attainable and linking patients with resources and tools that will help them to meet the challenges they will inevitably encounter. Much of the goal-setting literature relating to improving adherence is focused on lifestyle recommendations for example, dietary changes or increased physical activity — and these data are clear that step-by-step changes are generally more do-able than are large-scale changes made all at once.
But other aspects of the adherence-improvement regimen may be modified according to this strategy.
For example, one adherence-related goal may be to improve self-monitoring behaviors, but these are sometimes perceived as onerous by patients, eg, 92 and thus personal record-keeping may be phased in more slowly, making it manageable for the patient and enabling them to experience successful self-monitoring. This experience of success is the most powerful method for improving self-efficacy for a behavior and is consistently superior to either vicarious experiences or simple attempts to verbally persuade one that they are capable of making a change.
The simplest reminder devices — digital timer caps and pill bottle strips with toggles — seem unhelpful when utilized as the sole intervention. With the PCC framework in mind, it is easy to see that technologies that facilitate the delivery of medical care with less human-to-human interaction may sometimes ostracize already-isolated patients; further, some technologies may be confusing to even the most tech-savvy clinicians.
Because forgetting is a widespread reason for failing to adhere, interventions to remind patients of their dosing schedule are common.
Some of the simplest and most economical interventions involve telephones calling, texting, and apps 97 but the effectiveness of these approaches varies. Although simple telephone reminders and SMS have been found to increase medication adherence, 96 — some data suggest that electronic reminders alone are ineffective.
Telephone counseling is more effective than simple reminders by phone and can be supplemented with short text messages to prompt adherence over time. When using reminder messages and apps, best practices require these to be as focused on individual patient needs as possible.
For example, the MEssaging for Diabetes MED program sends messages that are tailored to address specific adherence barriers identified by patients eg, beliefs that medications might be harmful, or lack of information about their medications , in addition to providing a reminder.
And, a smartphone app for HIV patients provides real-time feedback about plasma concentration of the antiretroviral medication based on adherence, thus helping patients to better understand how their medications are working and fostering a sense of personal control.
Van Mierlo et al reviewed a wide range of digital health tools including social networking and videos, but concluded that most interventions had only moderate effects, and in some cases were more burden than help to clinicians.
This review noted, however, that a substantial number of patients prefer communication with their physicians electronically such as by email which suggests that continued effort to improve the ease-of-use for these types of technologies may be worthwhile. Another review 53 highlighted the usefulness of electronic monitoring systems for improving adherence in diabetic patients and suggested the importance of these technologies for helping clinicians identify patients in need of extra support.
In addition, this review 53 notes that electronic monitoring data has been shown to help physicians and patients to make more appropriate adjustments to treatment plans, as compared to making plan-adjustments based solely on laboratory data, because electronic data differentiates between missed doses and under-prescription, thus avoiding unnecessary changes in dosing or medication switching.
Taken together the data on technology-based adherence aids suggests that they are useful, but not uniformly so. To the extent that these tools are used to inform treatment decisions and are used in conjunction with other strategies they are likely to be more successful. If, however, they are used instead of relationship-based strategies there may be little benefit.
Create tailored, coordinated, multifaceted plans Evidence consistently points to the importance of using multi-pronged approaches to improve adherence — this is not surprising because the multifaceted nature of the nonadherence problem is well-recognized.
Combining educational, self-management, motivational, and practical elements in an adherence-improvement plan will yield the best outcomes. For example, some patients may not have knowledge-based barriers but may experience financial constraints — in this case, it would make little sense to spend time and energy on informing the patient about the disease process and value of medication for controlling it, since it is the financial aspect that is creating the problem.
Tailoring multifaceted interventions to individual needs not only maximizes efficiency but it also makes it more likely that patients will feel engaged, in control, and as if they are in genuine partnership with their clinicians — all of which make medication adherence more likely. This means that team members must communicate with each other regularly, ensuring that instructions given to patients are consistent and that the strategy is cohesive.
This, in turn, helps improve patient trust and active partnership, leading to more self-advocacy and problem-solving and ultimately better adherence. Depending on the nature of the medication regimen, the context within which it is embedded, and the patient her- or himself, the most efficacious approach will vary.
As a general rule, multifaceted interventions work most effectively, with elements of these multi-pronged approaches including simplification of the medication regimen; personalizing and tailoring both medication regimens and interventions to improve adherence; involving patients in medication decisions; utilizing social support systems to support adherence; and using technology selectively, taking patient preferences into account, but not attempting to replace the interpersonal relationship with electronics.
Footnotes The authors report no conflicts of interest in this work.
Health Psychology by Dimatteo Robin Martin Leslie
References 1. National Health Expenditure Data.Non-compliance and knowledge of prescribed medication in elderly patients with heart failure. Patient centered experiences in breast cancer: Predicting long-term adherence to tamoxifen use. With proper communication skills training, health care professionals are well-equipped to foster the type of trusting clinical relationships that are consistently shown to relate to better outcomes.
It advocates a straightforward 3-ingredient model: Before a person can change, they must 1 know what change is necessary information ; 2 desire the change motivation ; and then 3 have the tools to achieve and maintain the change strategy.
Med Care Res Rev. Another review 53 highlighted the usefulness of electronic monitoring systems for improving adherence in diabetic patients and suggested the importance of these technologies for helping clinicians identify patients in need of extra support.
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