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Healthcare Utilisation - Coggle Diagram
Healthcare Utilisation
Who seeks medical care?
- Can be broken down by age, gender, etc
- As people age, they visit physicians more times per year. Young children go a fair amount.
- Women tend to report more symptoms than men.
- It could be because of actual physical symptoms, but also because of the stereotype that men should be tough and ignore symptoms.
- Those who are struggling financially will see physicians less.
Illness perceptions:
- Schemas
- Hold a set of beliefs about an illness > have it, are aware of, etc. > can be precise and clear or fuzzy (don’t know a lot, only have vague ideas). Can be accurate or inaccurate.
- How do they develop?
- Experience > you or your family develop an illness.
- Information > from medical staff, information in the media, information from the internet
- Cultural and social factors
Five belief dimensions
Timeline: how long will the illness last? Is it acute, chronic, cyclical, etc.
- Mismatch between timeline beliefs and prognosis.
- Asthma: perceived as a cyclical condition even though it’s chronic
- The best treatment is a daily prevention medication and a supplementary medication for flare-ups.
- Those who believe their asthma is cyclical are less likely to adhere to their prevention medication schedule.
Consequence: how will it impact your life? Does it require annoying or complicated treatment? Will it cause death?
Cause: What caused the illness?
- Often a wide range of beliefs- emotional stress, health behaviours, hormones, genetics, luck, etc
- Patients develop ideas about the cause of their illness, which can influence treatment decisions.
If a heart attack is caused by lifestyle, stress, or high cholesterol, each pathway can lead to different treatments/delays.
Causal beliefs and treatment decisions
- Breast cancer: chemotherapy, radiotherapy, surgery, mastectomy
- Hard to tell > some will have genetic/hormonal contributors, but more people think that’s what’s causing their treatment compared to the actual number.
- People who believe it has a genetic or hormonal cause are more likely to opt for a partial or bilateral mastectomy compared to those who think their cancer is caused by bad luck.
Control-cure: can it be treated, controlled, managed, or cured? Beliefs may or may not match medical knowledge.
Identity: What is the illness? What are the symptoms associated with it? What do you know about it?
- often asked about the burden of illness and symptoms
Heart attacks
- What do people expect (illness identity)?
- Collapsing, chest pain, arm pain
- What don’t people expect?
- Dizziness, fever, shortness of breath, nausea or vomiting
- Most people experienced the unexpected symptoms > if there is a mismatch between expectations and actual symptoms, it takes much more time to seek treatment. Shorter delays if you have more expected symptoms, especially chest pain.
- Intervention:
- Target the people most at risk, and who are most likely to delay treatment.
- Target symptoms appraisal, to increase accurate illness perception and illness identity.
- Useful for diseases that have signs or symptoms in early stages.
- Symptoms in women:
- Different from symptoms in men, which are the most reported ones.
- Discomfort, but not as much pain
- More nausea and indigestion
- Mismatch from prototypical symptoms causes women to have worse outcomes from heart attacks > including treatment delay, die more, etc.
The common-sense model of illness
- Health threats get filtered through our perceptual systems into two pathways, matching the belief dimensions
Why should we care?
- Perceptions of illnesses are better predictors of health and well-being outcomes compared to objective disease severity
- Perceptions of illness are often responsible for delays in accessing treatment.
- Noticing symptoms does not automatically lead to treatment.
- Appraisal delay > waiting to see if the symptoms persist, get worse, etc.
- Illness delay > time between waiting for symptoms and knowing you should get checked out
- Behavioural delay > time between acknowledging you need to get checked out, and actually booking appointments
- Scheduling delay > time between booking appointments and getting to the doctor (outside of patient control)
- Treatment delay > time between first presentation to the doctor's office and receiving treatment.
- People need to make a concerted effort to take each step
- Patient delay (appraisal, illness, behavioural) and symptoms account for approx 60% of total delay
- Mismatch between expected and experienced symptoms > challenge because symptoms don’t always indicate disease, and disease processes don’t always cause symptoms.
- Consequences of patient delay:
- Disease progresses further than is ideal (breast cancer and tumour size)
- Causes further physical harm because treatment was delayed (STIs leading to infertility)
- Transmission to others (tuberculosis)
- Can impact the effectiveness of treatment (myocardial infarction treatments are most effective during the first 1-2 hours)
Seeking healthcare
- Notice symptoms > interpret as signs of illness > decide to seek care > examination or diagnostic testing
- Leads to negative test results (reassurance) or positive test results (adherence)
Reassurance
- Common for test results to come back negative
- Probably the most widely used but poorly understood psychotherapeutic intervention
Who is not reassured?
Non-cardiac chest pain:
- Presented at the hospital with pain, went through tests, which came up negative > leave with no answer. A lot of people’s chest pain does not go away because of a lack of reassurance.
- Belief that symptoms = not healthy, not feeling reassured continues symptoms.
Health anxiety
- hypochondriasis > hypochondriac: Fear of a serious medical condition
- Worry about minor symptoms
- Catastrophic thinking about symptoms: rumination about (irrational) worst case scenario
- Level of reassurance may be mismatched with patient concern.
- Getting a negative result works short-term, but anxiety rebounds shortly after.
- Will get more testing and seek more medical care > repeated presentation in medical settings may result in serious, unneeded treatments that may worsen anxiety again in the long run
Why does reassurance fail
- Don’t do a good job at communicating the results
- Don’t do a good job at addressing patient concerns
- Not a lot of people have an understanding of the relationships between symptoms and diseases
- Symptoms are common, and often have alternate causes besides disease
Improving reassurance
- Good communication is key
- Clear and unambiguous information
- Ask about patient beliefs, thoughts, and fears
- Diagnostics tests
- Only those that are necessary
- Reduces delays between symptom onset and treatment
- Prepare patients for the possibility of normal findings beforehand.
Adherence
- The extent to which patients follow the instructions they are given for prescribed treatments.
- It might look like a unitary behaviour, but there are complicated reasons behind why someone might or might not adhere to treatment.
What does adherence involve?
- Following lots of medication instructions
- Being able to get to a pharmacy
- Having money to pay for medications
- Going to a doctor to renew prescriptions
- Have to take the med in the form it’s prescribed > creams, big pills, etc
- Specific storage instructions
- Treatments can be embarrassing
- Might change your diet > some foods reduce the effectiveness of medications
Non-adherence
- Patient's inability or unwillingness to take medications as prescribed
- Partial > taking meds sometimes, at incorrect times of day, taking some treatments but not others, etc
- Total > nothing
- Non-adherence is high in those with chronic illnesses (30-50%) > clinicians underestimate this.
Unintentional non-adherence
- May have the intention to take medication but face barriers:
- Poor recall of instructions, poor understanding of instructions, difficulty administering treatment, forgetting, cost > based on resources
- Improving unintentional non-adherence:
- Using clear pictorial instructions instead of difficult written instructions
- Simplifying the regimen so it’s not as complicated.
- Change route of administration > using liquid instead of pills for certain people (not always possible)
- Training for self-dialysis, self-injection, and self-administration of asthma medication.
- Reminders
- Tailor regimen to their daily routine.
- Subsidies
Intentional non-adherence
- Patient decides not to follow treatment recommendations
- Necessity-concerns framework:
- People form beliefs about their illness and the treatment
- People are considering the necessity of a treatment (how much will it help?) and beliefs about their illness, weighed up against their concerns (medicines are toxic, dangerous, etc)
- Often the belief dimensions of consequences and control-cure that influence this
- Improving intentional non-adherence:
- Education about the illness and about how the medication treats the illness
- Increasing the perceived necessity of the medication and addressing concerns about the medication.
Where is non-adherence the highest?
- Long-term treatments
- Treatments for asymptomatic conditions
- Treatment interferes with life
- Complicated treatments
Measuring non-adherence:
- Objective measures: biochemical measures, pharmacy records, pill counts, electronic monitoring.
- Subjective measures: medication diaries, self-report questionnaires.