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The Effects of Patient Communication Skills Training on Compliance
Donald J. Cegala, PhD;
Terese Marinelli;
Douglas Post, PhD
Arch Fam Med. 2000;9:57-64.
ABSTRACT
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Objective To examine the relationship between communication skills training for patients and their compliance with recommended treatment.
Design A randomized control design was used, with patients nested within physicians. Each physician was audiotaped with 6 patients, 2 patients in each of the 3 intervention conditions: (1) a trained group (n = 50) received a training booklet in the mail 2 to 3 days prior to the scheduled appointment, (2) an informed group (n = 49) received a brief written summary of the major points contained in the training booklet while in the waiting room prior to the scheduled appointment, and (3) an untrained group (n = 51) did not receive any form of communication skills intervention.
Setting Participants included physicians and patients from 9 different primary care, family practice locations. Two locations were clinics associated with a large, university-based medical school and hospital, while 7 were private practice offices in the community.
Participants The sample included 25 family physicians (averaging 11 years postresidency) and 150 patients. Patients were randomly selected from appointment records and randomly assigned to 1 of 3 intervention conditions.
Intervention A training booklet designed to instruct patients in information seeking, provision, and verification.
Main Outcome Measure Patients' compliance with medications, behavioral treatment (eg, diet, exercise, smoking cessation), and/or follow-up appointments and referrals.
Results Trained patients were more compliant overall than untrained or informed patients. Training positively influenced compliance with behavioral treatments and follow-up appointments and referrals.
Conclusion Training patients in communication skills may be a cost-effective way of increasing compliance and improving the overall health of patients.
INTRODUCTION
INFORMATION exchange between physicians and patients is central to the quality of health care.1-5 However, considerable research indicates that physicians sometimes do not meet patients' information needs.3, 6-12 Although effort has been expended to address communication issues in medical school curricula and resident training programs,13-15 this only speaks to half of the physician-patient dyad. Little attention has been given to patients' communication skills during medical interviews.16
The purpose of this research is to test the effectiveness of patient communication skills training on compliance with physicians' treatment recommendations. This report is based on a subset of data from a larger project investigating patient communication skills training. The following sections provide a brief review of research into patient communication skills training and a rationale for examining training's impact on patient compliance.
PATIENT COMMUNICATION SKILLS TRAINING
While considerable attention has been given to patient education in general, very little work is directed specifically to communication skills training.16-19 However, studies consistently show that many patients could benefit from such training. For example, patients typically engage in little information seeking during medical interviews, even though virtually all patients claim they want as much information as possible.10, 20-23 Other research shows that when patients do seek information they often do so indirectly.24-26
Although relatively few studies have examined the effects of patient communication skills training, findings suggest that such training is potentially valuable.16 For example, some research indicates that trained patients participate more actively in medical interviews.27-31 Other studies report that trained patients elicit more factual information from physicians per controlling act spoken by patients.30-32 In related research, Robinson and Whitfield28 found that trained patients had more accurate and complete recall of physicians' treatment information and recommendations.
Some researchers30-31,33 report a positive relationship between patient training and physiologically measured health outcomes (eg, blood glucose control, blood pressure control). Greenfield et al30-31 also found higher self-reported health assessments on the part of trained patients. They speculate that these enhanced health outcomes on the part of trained patients may have been because of closer adherence to the treatment plan. In a related finding, Roter34 reports that trained patients had a higher ratio of appointments kept to appointments made over a 4-month period after training. Together, these results suggest that training may have a positive effect on patient compliance and other health outcomes.
In this study, we chose to focus on the relationship between patient communication skills and compliance. Our decision to do so was based on 2 reasons. First, patients' noncompliance with treatment recommendations is costly in terms of both poorer health and financial strain on the health care system.35-37 Yet, despite considerable effort to improve patient adherence, noncompliance continues to be a significant problem.38-39 Thus, to the extent that enhanced communication between physicians and patients can reduce noncompliance in ways that do not infringe on patients' autonomy or decision making,40 communication skills training may offer a relatively inexpensive and effective way of addressing problems associated with noncompliance. Second, several other health outcomes, such as disease control or disappearance of symptoms, are indirectly related to patients' compliance with recommended treatment. Thus, we viewed patient compliance as a fundamentally important outcome to examine and chose to begin our research program there.
While a limited number of studies suggest that patient communication skills training may positively affect compliance, additional research is needed to determine what communication skills are most important to include in interventions and how best to instruct patients.16-19 Our research to date has provided needed guidelines for determining what communication skills to teach patients, particularly with respect to information exchange.41-44 Other previous work assessed the effects of a 30-minute, face-to-face communication skills training procedure.45 In this study, we tested the effectiveness of printed material designed to instruct patients in effective information exchange skills.
RATIONALE AND HYPOTHESES
Some research suggests that patients who ask questions, state preferences, and generally more actively participate in medical interviews have measurably better health outcomes than less-active patients.46 Previous research into patient communication skills training shows that trained patients typically are more active participators in medical interviews.16, 45 This was also the case for trained patients in this study, as they asked more questions, elicited more information from physicians per question asked, used more summarizing utterances to verify information, and provided more detailed information to physicians than patients in control groups.47 As a result of participating more actively in their interviews, we expected that trained patients would obtain more desired information about diagnosis and treatment options and, therefore, acquire a better understanding of the rationale and purpose of treatment recommendations. Given this enhanced understanding of recommended treatment, it is hypothesized that trained patients will demonstrate greater overall compliance than either informed or untrained patients. We also believe that trained patients will be more compliant with medication, behavioral treatments, and follow-up appointments/referrals than either informed or untrained patients.
MATERIALS AND METHODS
DESIGN
A nested design was used, such that patients were nested within physicians. Each physician was audiotaped with 6 different patients, 2 patients in each of the 3 intervention conditions. Those in the untrained group (n = 51) did not receive any intervention prior to their scheduled appointment. Those in the trained group (n = 50) received a training booklet in the US mail 2 to 3 days prior to their scheduled appointment, while those in the informed group (n = 49) received a brief written summary of the major points contained in the training booklet in the waiting room prior to seeing the physician.
PARTICIPANTS
Participants for this study included 25 family practice physicians and 150 patients. The physicians and patients were recruited at 9 different locations in and around a large metropolitan area in central Ohio. Nine of the physicians practiced in a large clinic that is part of a university hospital complex, while the remaining 16 physicians practiced in private offices with 2 to 4 physicians per site. Table 1 contains demographic information relevant to the patient sample.
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Table 1. Frequency Demographics for Patients in 3 Intervention Groups*
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Among physicians, 17 were men, 8 were women. Twenty-two physicians were white, 3 were African American. On average, physicians were 11 years postresidency (range, 1 month to 36 years).
PROCEDURES
Data collection was completed at one location before moving to another site. The data were collected from July 15, 1997, to November 7, 1997. All participants signed an institutional review committee consent form.
Patient Selection and Assignment
Each patient listed on the appointment records for a given day was assigned a number. Patients were randomly assigned to an intervention condition, then randomly selected from the list and telephoned. Patients were told that their physician had agreed to participate in a study of physician-patient communication and that they were being contacted to determine if they had interest in participating in the study as a patient. Overall, 84% of the patients contacted agreed to participate in the study.
Physician Selection
Physicians agreed to participate in the study prior to data collection. They were told they would be audiotaped with 6 different patients. They knew that a portion of the patients would receive an educational intervention of some kind, but they did not know any of the specific content or objectives of the intervention. To further mask intervention conditions, untrained patients were given a copy of the consent form with a cover exactly like the cover of the training booklet and brief summary given to trained and informed patients. In most instances, physicians did not know which interviews were being taped because they had no way of knowing if the microphone in the examination room was operational or not, and taping usually was done over the course of several hours while physicians saw a mixture of patients who were and were not part of the study.
Administration of Materials
All patients were met in the waiting room by one of us (D.J.C. or T.M) or an assistant. They were given a preinterview questionnaire to complete and were asked to sign a consent form.
Trained patients were then asked if they experienced any problems using the training booklet (they also returned a completed evaluation form that was sent with the booklet), and the booklet was briefly examined for evidence of usage (eg, written notes, underlining). In all but 5 instances, there was both written and oral evidence that the booklet had been read. Five patients forgot to bring the booklet with them to the appointment, but each of these patients reported having read the booklet. Informed patients were given a brief summary of key points covered in the training booklet and were encouraged to read the summary before seeing the physician. Untrained patients were simply told that they would soon be taken to an examination room to await the physician.
Two examination rooms at each site were equipped with wireless microphones. The recording equipment and base of operations at each site was not visible. The recording equipment was turned on when patients were taken to the examination room. When the physician arrived, recording began and a stopwatch was started to record the length of the interview.
The entire interview was monitored as it was recorded. As soon as the interview ended, patients were taken to the waiting room and given 2 postinterview questionnaires to complete. When they completed the questionnaires they were paid ($30 for trained patients, who were asked for a greater time commitment, and $20 for untrained and informed patients), and all patients were given a copy of the training booklet. They were encouraged to use it for their next physician appointment or consider sharing it with family or friends.
At the end of the day's taping, physicians were given a folder for each taped interview. Within the folder were 2 postinterview questionnaires and a consent form. The items on the 2 questionnaires were parallel to the items constituting the patients' questionnaires.
Telephone Survey
Approximately 2 weeks after the taped interview patients were telephoned and engaged in an interview designed to assess compliance with recommendations made during the taped interview.
TRAINING INTERVENTIONS
Training Booklet
The 14-page training booklet was based on previous work in physician-patient communication24, 41-45 and results of an assessment of earlier versions of the training materials.44 The booklet was designed to instruct patients in information provision, seeking, and verifying. It was formatted like a workbook, with examples and space for notes.
Regarding information provision, patients were first instructed to list the topics they wanted to discuss with the physician. Additionally, they were encouraged to consider any psychosocial issues relevant to their medical condition, such as worries, stress, or feelings of depression. Next, they were instructed to list items of personal and family history relevant to the topics they wanted to discuss (eg, Had the patient seen a physician about the problem before? How was the problem treated?). Then, patients were instructed to respond to a series of questions regarding symptoms (eg, What symptoms were experienced? How long had they experienced them? How often did they occur?). In addition, patients were asked to specify anything that helped to alleviate symptoms and what they expected the physician to do about their medical condition.
The next section of the booklet addressed information seeking. The following topics were covered, each with several sample questions: diagnosis, recommended medication(s), behavioral treatment recommendations (eg, exercise, diet), and prognosis. This section ended with space for patients to write any additional questions they wanted to ask that were not already covered by the topics and sample questions.
The last section of the booklet was designed to instruct patients in information verifying. They were reminded that, when necessary, they could check on their understanding of information they received from the physician by asking questions of clarification, repeating what the physician had just said, or summarizing their understanding of what was said. Each of these strategies was illustrated by examples.
The booklet was analyzed for readability using the Flesch Reading Ease and Flesch-Kincaid Grade Level indices. The reading ease score was 68.96, which falls within the range for standard reading difficulty. The Flesch-Kincaid score was at the fifth grade level.
An evaluation form was mailed with the booklet, which trained patients were asked to complete after using the booklet to prepare for their appointment. The evaluation form was developed for and used in previous research that pilot-tested an earlier version of the training booklet.44 Overall, the booklet was evaluated highly, indicating that trained patients found it useful and informative.
Brief Summary
The informed group received a brief summary of the major points covered in the training booklet. Although they received information on major points, informed patients were not given sample questions or other examples to illustrate the ideas presented. However, they were encouraged to engage in such behavior as organizing their thoughts, writing down important items, expressing their concerns, asking questions, and using information-verifying strategies to make sure they understood information that was given to them. In virtually all instances, informed patients had adequate time (eg, 20 minutes or more) to read and think about the recommendations provided, as they usually had to wait several minutes before seeing the physician.
COMPLIANCE MEASURE
A self-report measure of compliance was used in this study because it was most appropriate for assessing the varied forms of treatment characteristic of a primary care setting. Although self-reports of compliance are not free of problems, there seem to be key factors that improve their validity. For example, Hayes and DiMatteo,48 Sackett,49 and others suggest that patients' self-reports are more valid if they are asked about their compliance with treatment in a nonthreatening way. In addition, Hayes and DiMatteo48 and Thompson50 suggest that patients' self-reports of compliance are likely to be more accurate when data are gathered by a person unconnected with the medical establishment. The data-gathering procedure used here met both of these conditions.
Following Gordis,51 a distinction was made between noncompliance caused by the patient's intent not to follow treatment recommendations and noncompliance resulting from factors other than the patient's intent (eg, forgetfulness or lack of understanding about treatment procedures and/or their rationale). Unintentional noncompliance was assessed with 2 sets of items. Patients were first asked a series of questions designed to assess their recall of treatment recommendations regarding medications, behavioral changes, follow-up appointments, and referrals. Patients' responses to these questions were assessed against transcripts of the interviews to determine the accuracy of their recall of treatment information. The logic of this procedure was based on the assumption that if a patient could not correctly recall treatment information, he/she was not likely to have followed the recommendation, or, at minimum, did not follow the treatment as prescribed. In either instance, it was assumed that lack of recall about treatment information was indicative of unintentional noncompliance. Second, patients responded to 2 unintentional noncompliance items based on work reported by Brooks et al52 and DiMatteo et al.35 Finally, intentional noncompliance was assessed with 12 items based on work by Becker and Maiman53 and Donovan and Blake.54 The recall probes and unintentional and intentional noncompliance items are listed in Table 2.
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Table 2. Recall Probes and Unintentional and Intentional Noncompliance Items
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Data Collection
Patients were contacted by telephone approximately 2 weeks after their taped appointment. They were asked if the physician had recommended any of 4 treatment categories at the taped interview: prescribed medication(s), behavioral recommendations (eg, diet, exercise, smoking cessation), follow-up appointments, or referrals to another physician. For each category indicated with a yes, the interviewer first asked the patient the recall probes, then the set of unintentional and intentional compliance items. One of us (T.M.) conducted all of the compliance interviews. This person was blind to the intervention condition of each patient.
Patients' responses were relied on to determine compliance with medication and behavioral recommendations, but patients' charts were checked approximately 4 months after the taped interview to verify their responses to telephone interview questions about follow-up appointments and referrals.
Compliance Scores
Computation of the compliance scores involved 2 related data sets that were gathered during the telephone survey. A recall proportion score was computed for each patient by dividing the number of facts about the treatment recommendation correctly recalled by the total number of facts provided by the physician. These proportion data were used to score patients' recall along a 0- to 4-scale (0, 100% recall; 1, 76% to 99% recall; 2, 51% to 75% recall; 3, 26% to 50% recall; 4, 1% to 25% recall). This scale is comparable with the 0- to 4-scale used for recording patients' responses to the unintentional and intentional items.
The 3 compliance subscores (all ranging from 0 to 4) for each treatment category were added up to compute a compliance score for each treatment (where 0 indicated 100% compliance). Because so few patients received a referral recommendation (n = 7), these scores were combined with follow-up appointment scores to produce a single compliance score for follow-up appointments/referrals. In addition, an overall compliance score was computed by summing the compliance scores for medications, behavioral changes, and follow-up appointments/referrals.
DATA ANALYSIS
Approximately 11% of the sample reported that they did not receive a recommendation for any of the 4 treatment categories (verification against the transcripts indicated that 2 patients erred in their reporting). Thus, compliance was not an issue for these patients. Of the remaining 89% of the sample, approximately 75% were noncompliant with 1 or more of the 4 treatment categories. Ideally, data would have been analyzed with a nested analysis of variance (ie, using the physician x treatment mean square as the error term). However, this method of analysis was precluded because of missing cell data for individual treatment category scores (ie, medications, behavior treatments, follow-up appointments/referrals). As an alternative, the noncompliance scores of patients within each physicianx intervention cell were averaged. In instances in which there was a datum for only 1 patient in a physician x intervention cell, just that single datum was used. Paired t tests were then computed on these scores (ie, physicians were matched across the 3 intervention treatments). This procedure resulted in an ultraconservative test, since the sample sizes and associated degrees of freedom were reduced considerably. However, this procedure retained the advantages of the nested design and it accounted for the potential lack of independence across intervention conditions. Although it is customary to adjust the initial  level when conducting multiple t tests, this was not done here because the procedure used already resulted in conservative tests. An of P .05 with 1-tailed tests was used to assess the hypotheses. For large effect sizes, the power of statistical tests ranged from 0.75 (n = 11) to 0.98 (n = 25).
RESULTS
The first hypothesis predicted that trained patients would be more compliant overall than either informed or untrained patients. The pattern of means reported in Table 3 is consistent with the hypothesis. Trained patients were significantly more compliant overall than either untrained or informed patients. It should be noted that informed patients were also more compliant overall than untrained patients. However, the effect of training was much more dramatic than merely informing patients. Training accounted for more than 60% of the variance in noncompliance scores, while informing accounted for only 22% of the variance. Overall, there is substantial support for the first hypothesis.
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Table 3. Means (SDs) and t Test Results for Compliance Scores
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The second hypothesis predicted that trained patients would be more compliant than informed or untrained patients in each of the 3 categories of compliance. The data relevant to medications are reported in Table 3. While the pattern of means is consistent with the hypothesis, none of the test results is significant. However, trained patients were significantly more compliant with behavioral treatments than untrained patients, although the difference between trained and informed patients was nonsignificant. There was no difference in behavioral compliance between informed and untrained patients. Similarly, trained patients were significantly more compliant with follow-up appointments/referrals than untrained patients, but there was no reliable difference between trained and informed patients. Informed and untrained patients did not differ in their compliance with follow-up appointments/referrals.
This study was not designed to address possible interactions between patient characteristics, training, and compliance. However, relevant data were examined for possible implications for future research. A moderate but significant correlation was obtained between overall compliance and patients' education, such that more educated patients were more compliant (r = -0.29; P = .001, 2-tailed). This relationship was consistent within the intervention groups, although it was slightly less strong in the trained group (untrained: r = -0.28, P = .06; informed: r = -0.29, P = .07; trained: r = -0.23, P = .11; all 2-tailed).
The correlation between patients' race and overall compliance was nonsignificant (r = 0.16; P = .07, 2 tailed). Correlations within intervention groups revealed a significant correlation for the untrained group, such that minority patients were less compliant overall than nonminority patients (r = 0.33; P = .03, 2-tailed). There was no relationship between patients' race and compliance among informed or trained patients (informed: r = -0.01, P = .94; trained: r = 0.07, P = .65; both 2-tailed). For a follow-up analysis, an analysis of variance was computed on overall compliance scores across intervention groups consisting of only minority patients. The results indicated that trained and informed minority patients were more compliant overall than untrained minority patients (F2,35 = 5.48; P = .008;  2 = .31). No significant correlations were obtained between patients' overall compliance and sex, status (ie, new vs returning patients), age, or illness severity.
COMMENT
Our study examined the impact of printed materials designed to instruct patients in communication skills. In light of research indicating that many patients do not competently engage in information exchange during medical interviews, training was designed to enhance patients' information exchange skills. The results provided some support for the training booklet as an effective tool.
Hypothesis 1 received the most support. Trained patients were more compliant overall than untrained patients (P<.001) and were also significantly more compliant than informed patients (P = .03). These results suggest that providing patients with instruction in communication skills relevant to information exchange may enhance their compliance with treatment recommendations.
The results concerning compliance with specific treatment recommendations were mixed. Training did not have a significant effect on compliance with medications, but the pattern of compliance score means was consistent with the expectation that trained patients would be more compliant than informed or untrained patients (Table 3). The conservativeness of the statistical test used to assess this hypothesis should be kept in mind in interpreting these results. Additionally, the proportion of patients in each intervention condition who were compliant with medications suggests that training had a noticeable effect (ie, trained, 0.52; informed, 0.24; and untrained, 0.33). Still, the effect of training on patients' compliance with medications was not significant. Additional research is needed to determine if communication skills training can enhance immediate and long-term compliance with medications. Such research will likely need to account for other factors that may affect compliance with medications, such as patients' age and severity of illness, which were not controlled systematically by the research design for this study.
Results pertinent to behavioral treatment recommendations and follow-up/referral appointments were more supportive of training effects. This was most evident for behavioral recommendations. Trained patients were more compliant with behavioral recommendations than untrained patients (P = .004), accounting for 37% of the variance in compliance scores. Trained patients were also more compliant than informed patients, although the difference was not significant (P = .07). Given the conservativeness of the statistical test, this result may be meaningful, as it accounts for 16% of the variance in compliance scores.
Overall, the results concerning compliance with behavioral treatment recommendations are encouraging. Researchers have noted that compliance with lifestyle changes, such as diet, exercise, and smoking cessation, is the most difficult for patients,38, 55 especially if they are not motivated to make such changes.56-57 The results of this study indicate that trained patients were especially compliant with treatment recommendations involving lifestyle changes. While this may suggest that the training booklet was particularly effective with these patients, it may also reflect differences in patients' readiness for important lifestyle changes. Although we did not directly assess patients' readiness, 6 patients reported not being ready or not wanting to make appropriate lifestyle changes as the reason for noncompliance. Of these 6 patients, 3 were in the informed group and 3 were in the untrained group. Thus, patient readiness may have contributed to at least some of the trained patients' compliance with lifestyle changes beyond any effects of the training booklet.
Finally, the results concerning follow-up/referral appointments indicated that trained patients were significantly more compliant than untrained patients (P = .02). However, there was no reliable difference between trained and informed patients' compliance (P = .11), even though the sample means were in the predicted direction. On the other hand, perhaps the communication skills training examined herein is less relevant to compliance with this category of treatment recommendations, especially follow-up appointments. Approximately 61% of the patients who received a recommendation for a follow-up appointment were return patients. If patients have already made a commitment to see a particular physician on a regular basis, especially for chronic illnesses, the extent of information exchange within a single visit may not be an overriding factor in determining whether they keep a follow-up appointment. Perhaps future research should examine the role of communication skills training in patients' decisions to continue seeing a physician or their adherence to follow-up appointments over an extended period.
Although the results of this study show reasonable support for the effectiveness of the training booklet, it should be recognized that patients receiving only a brief summary of key points in the booklet also were more compliant overall than untrained patients (P = .02), and they did not differ significantly from trained patients in compliance with separate treatments. On the surface at least, this suggests that even minor efforts to encourage patients to be more active in medical interviews can potentially have positive effects on health outcomes. On the other hand, our previous research45 and some other work in patient communication skills training16 suggest that more extensive, face-to-face training may have dramatic effects. Following social learning theory, a face-to-face training component could be used to emphasize modeling and practice as a means of promoting learning and self-efficacy.58 While researchers have advocated multiple-component interventions,38, 55, 59 relatively few studies have actually examined the effects of such interventions, particularly within randomized control designs.39, 55 To our knowledge, no studies have been conducted on multiple-component communication skills interventions.
Although most private practices and many small clinics are not likely to have the resources to hire a person exclusively for extensive patient training, our observations of both clinics and private practices in this study suggest that staff nurses often perform training-like functions in their normal dealings with patients prior to the physician's appointment. Nurses could be instructed to engage patients in conversation relevant to topics covered in printed or videotaped materials and, as such, provide a version of face-to-face instruction. This may be especially effective if patients are given printed material, such as the training booklet we used, well in advance of their appointment. Along these lines, several of the physicians who participated in this study asked for copies of the training booklet after receiving a summary of the results. Some of these physicians indicated that they had certain patients in mind for whom training would be especially beneficial. This suggests an efficient distribution strategy for targeting patients and disseminating instructional materials where they may do the most good.
Training patients in communication skills seems to be a potentially effective way of facilitating health outcomes that are important to both physicians and patients. A fruitful direction for future research into patient communication skills training is determining the most efficient and effective ways of delivering such instruction. Another topic for future research is to access the possible effects of training on various clinical outcomes. Along these lines, future research may be especially informative through examining the effect of training on clinical outcomes when patients are not formally participants in a study. It is possible that at least part of the impact of the training booklet we used was related to the fact that patients knew they were participants in a study (eg, perhaps they devoted more time to reading the booklet). Observing the effects of training materials on patients' clinical health outcomes in a more natural setting would provide valuable insight into the limitations and promise of patient communication skills training.
AUTHOR INFORMATION
Accepted for publication June 2, 1999.
This research was made possible by grant R03 HS90110-01T from the Agency for Health Care Policy and Research, Rockville, Md (Dr Cegala).
The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Health Care Policy and Research.
Corresponding author: Donald J. Cegala, PhD, 3016 Derby Hall, 154 N Oval Mall, Columbus, OH 43210 (e-mail: cegala.1{at}osu.edu).
From the School of Journalism and Communication (Dr Cegala and Ms Marinelli) and the Department of Family Medicine (Drs Cegala and Post), Ohio State University, Columbus.
REFERENCES
| |
1. Frederikson LG. Development of an integrative model for medical consultation. Health Commun. 1993;5:225-237.
2. Makoul G, Arntson P, Schofield T. Health promotion in primary care: physician-patient communication and decision making about prescription medications. Soc Sci Med. 1995;41:1241-1254.
3. Waitzkin H. Information giving in medical care. J Health Soc Behav. 1985;26:81-101.
FULL TEXT
|
ISI
| PUBMED
4. Frederikson LG. Exploring information-exchange in consultation: the patients' view of performance and outcomes. Patient Educ Couns. 1995;25:237-246.
FULL TEXT
|
ISI
| PUBMED
5. Ong LM, DeHaes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med. 1995;40:903-918.
6. Strull WM, Lo B, Charles G. Do patients want to participate in medical decision-making? JAMA. 1984;252:2990-2994.
FREE FULL TEXT
7. Waitzkin H. Doctor-patient communication: clinical implications of social scientific research. JAMA. 1984;252:2441-2446.
FREE FULL TEXT
8. DiMatteo MR, Reiter RC, Gambone JC. Enhancing medication adherence through communication and informed collaboration choice. Health Commun. 1994;6:253-265.
9. Joos SK, Hickman OH, Borders LM. Patients' desires and satisfaction in general medicine. Public Health Rep. 1993;108:751-759.
ISI
| PUBMED
10. Ley PL. Communicating With Patients: Improving Communication, Satisfaction and Compliance. New York, NY: Croon Helm Ltd; 1989.
11. Matthews JJ. The communication process in clinical settings. Soc Sci Med. 1983;17:1371-1378.
12. Williams S, Weinman J, Dale J, Newman S. Patient expectations: what do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction? Fam Pract. 1995;12:193-201.
FREE FULL TEXT
13. Evans BJ, Kiellerup FD, Stanley RO, Burrows GD, Sweet B. A communication skills programme for increasing patients' satisfaction with general practice consultations. Br J Med Psychol. 1987;60:373-378.
14. Kern DE, Grayson M, Barker LR, et al. Residency training in interviewing skills and the psychosocial domain of medical practice. J Gen Intern Med. 1989;4:421-431.
ISI
| PUBMED
15. Smith RC, Lyles JS, Mettler J, et al. Effectiveness of intensive training for residents in interviewing skills: a randomized, controlled study. Ann Intern Med. 1998;128:118-126.
FREE FULL TEXT
16. Anderson LA, Sharpe PA. Improving patient and provider communication: a synthesis and review of communication interventions. Patient Educ Couns. 1991;17:99-134.
FULL TEXT
|
ISI
17. Sharf BF. Teaching patients to speak up: past and future trends. Patient Educ Couns. 1988;11:95-108.
FULL TEXT
|
ISI
| PUBMED
18. Simons-Morton DG, Mullen PD, Mains DA, Tabak ER, Green L. Characteristics of controlled studies of patient education and counseling for preventive health behaviors. Patient Educ Couns. 1992;19:175-204.
FULL TEXT
|
ISI
| PUBMED
19. Webber GC. Patient education: a review of the issues. Med Care. 1990;28:1089-1103.
FULL TEXT
|
ISI
| PUBMED
20. Beisecker AE, Beisecker TD. Patient information-seeking behaviors when communicating with doctors. Med Care. 1990;28:19-28.
FULL TEXT
|
ISI
| PUBMED
21. Beisecker AE. Patient power in doctor-patient communication: what do we know? Health Commun. 1990;2:105-122.
22. Parrott R. Exploring family practitioners' and patients' information exchange about prescribed medications: implications for practitioners' interviewing and patients' understanding. Health Commun. 1994;6:267-280.
FULL TEXT
23. Street RL Jr. Information-giving in medical consultations: the influence of parents' communicative styles and personal characteristics. Soc Sci Med. 1991;32:541-548.
24. Cegala DJ. A study of doctors' and patients' patterns of information exchange and relational communication during a primary care consultation: implications for communication skills training. J Health Commun. 1997;2:169-194.
FULL TEXT
|
ISI
| PUBMED
25. Frankel R. Talking in interviews: a dispreference for patient-initiated questions in physician-patient encounters. In: Psathas G, ed. Interaction Competence. Washington, DC: International Institute for Ethnomethodology and Conversation Analysis, University Press of America; 1990:231-262.
26. Quill TE. Recognizing and adjusting to barriers in doctor-patient communication. Ann Intern Med. 1989;111:51-57.
27. Anderson LA, DeVellis MB, DeVellis RF. Effects of modeling on patient communication, satisfaction, and knowledge. Med Care. 1987;25:1044-1056.
FULL TEXT
|
ISI
| PUBMED
28. Robinson EJ, Whitfield MJ. Improving the efficiency of patients' comprehension monitoring: a way of increasing patients' participation in general practice consultation. Soc Sci Med. 1985;21:915-919.
29. Roter DL. Patient question asking in physician-patient interaction. Health Psychol. 1984;3:395-409.
FULL TEXT
|
ISI
| PUBMED
30. Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patients' outcomes. Ann Intern Med. 1985;102:520-528.
31. Greenfield S, Kaplan S, Ware JE, Martin-Yano E, Frank HJ. Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3:448-457.
ISI
| PUBMED
32. Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27(suppl 3):S110-S123.
33. Kaplan SH, Greenfield S, Ware JE. Impact of the doctor-patient relationship on the outcomes of chronic disease. In: Stewart M, Roter D, eds. Communicating With Medical Patients. Newbury Park, Calif: Sage; 1989:228-245.
34. Roter DL. Patient participation in the patient-provider interaction: the effects of patient question asking on the quality of interaction, satisfaction and compliance. Health Educ Monogr. 1977;5:281-310.
ISI
| PUBMED
35. DiMatteo MR, Hays RD, Sherbourne CD. Adherence to cancer regimens: implications for treating the older patient. Oncology. 1992;6(suppl 2):50-57.
36. Hammond SL, Lambert BL. Communicating about medications: directions for research. Health Commun. 1994;6:247-251.
FULL TEXT
37. Hayes RB, Taylor DW, Sackett DL. Compliance in Health Care. Baltimore, Md: Johns Hopkins University Press; 1979.
38. Burke LE, Dunbar-Jacob J. Adherence to medication, diet, and activity recommendations: from assessment to maintenance. J Cardiovasc Nurs. 1995;9:62-79.
39. Miller NH, Hill M, Kottke T, Ockene IS. The multilevel compliance challenge: recommendations for a call to action. Circulation. 1997;95:1085-1090.
FREE FULL TEXT
40. German PS. Compliance and chronic disease. Hypertension. 1988;11(3, pt 2):II56-II60.
41. Cegala DJ, Socha-McGee D, McNeilis KS. Components of patients' and doctors' perceptions of communication competence during a primary care medical interview. Health Commun. 1996;8:1-28.
42. Cegala DJ, McNeilis KS, Socha-McGee D, Jonas AP. A study of doctors' and patients' perceptions of information processing and communication competence during the medical interview. Health Commun. 1995;7:179-203.
43. Cegala DJ, Coleman MT, Warisse J. The development and partial test of the Medical Communication Competence Scale (MCCS). Health Commun. 1998;10:261-288.
44. Cegala DJ, Drummond D, McCartney W, Marinelli T. The development and partial assessment of a patient communication skills training procedure. Paper presented at: annual meeting of the National Communication Association; November 22, 1997; Chicago, Ill.
45. Socha McGee D, Cegala DJ. Patient communication skills training for improved communication competence in the primary care medical consultation. J Appl Commun Res. 1998;26:412-430.
46. Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE. Characteristics of physicians with participatory decision-making styles. Ann Intern Med. 1996;124:497-504.
FREE FULL TEXT
47. Cegala DJ. Communication Skills Training for Primary Care Patients. Rockville, Md: US Dept of Health and Human Services, Agency for Health Care Policy and Research; 1998. AHCPR publication 99-139511.
48. Hayes RB, DiMatteo MR. Key issues and suggestions for patient compliance assessment: source of information, focus of measures, and nature of response options. J Compliance Health Care. 1987;2:37-53.
49. Sackett DL. A compliance practicum for the busy practitioner. In: Hayes RB, Taylor DW, Sackett DL, eds. Compliance in Health Care. Baltimore, Md: Johns Hopkins University Press; 1979:286-294.
50. Thompson J. Compliance. In: Fitzpatrick R, Hinton J, Newman S, Scrambler G, Thompson J, eds. The Experience of Illness. New York, NY: Tavistock; 1984:109-131.
51. Gordis L. Conceptual and methodologic problems in measuring patient compliance. In: Hayes RB, Taylor DW, eds. Compliance in Health Care. Baltimore, Md: Johns Hopkins University Press; 1979:23-45.
52. Brooks CM, Richards JM, Kohler CL, et al. Assessing adherence to asthma medication and inhaler regimens: a psychometric analysis of adult self-report scales. Med Care. 1994;32:298-307.
FULL TEXT
|
ISI
| PUBMED
53. Becker MH, Maiman LA. Strategies for enhancing patient compliance. J Commun Health. 1980;6:113-135.
FULL TEXT
| PUBMED
54. Donovan JL, Blake DR. Patient non-compliance: deviance or reasoned decision-making? Soc Sci Med. 1992;34:507-513.
55. Dunbar-Jacob J, Burke LE, Pyczynski S. Clinical assessment and management of adherence to medical regimens. In: Nicassio PM, Smith TW, eds. Managing Chronic Illness: A Biopsychosocial Perspective. Washington, DC: American Psychological Association; 1995:313-349.
56. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Am Psychol. 1992;47:1102-1113.
FULL TEXT
| PUBMED
57. Botelho RJ, Skinner H. Motivating change in health behavior: implications for health promotion and disease prevention. Prim Care. 1995;22:563-589.
58. Bandura A. Self-Efficacy: The Exercise of Control. New York, NY: WH Freeman & Co; 1997.
59. Rudd P. Clinicians and patients with hypertension: unsettled issues about compliance. Am Heart J. 1995;130:572-579.
FULL TEXT
|
ISI
| PUBMED
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