Default clinic appointments promote influenza vaccination uptake without a displacement effect.

The majority of U.S. adults do not receive an annual influenza vaccination. Behavioral economics tools can be harnessed to encourage health behaviors. Specifically, scheduling patients by default for a flu shot appointment leads to higher vaccination rates at a medical practice than does merely encouraging flu shot appointments. It is not known, however, whether default appointments actually increase net vaccination or merely displace vaccinations from other venues. In the current field experiment, we examined the use of default appointments in a large medical practice and established that automatically scheduled appointments increased the total vaccination rate by 10 percentage points within the practice without displacing vaccinations that patients would otherwise have received in other settings. This increased vaccination rate came at the cost of a high no-show rate. These findings point to an effective way to increase vaccination rates and may offer a cost-saving measure in the scope of accountable care organizations.

Decision-making Processes among Prostate Cancer Survivors with Rising PSA Levels: Results from a Qualitative Analysis.

BACKGROUND: Prostate cancer survivors with a rising prostate-specific antigen (PSA) level have few treatment options, experience a heightened state of uncertainty about their disease trajectory that might include the possibility of cancer metastasis and death, and often experience elevated levels of distress as they have to deal with a disease they thought they had conquered. Guided by self-regulation theory, the present study examined the cognitive and affective processes involved in shared decision making between physicians and patients who experience a rising PSA after definitive treatment for prostate cancer. METHODS: In-depth interviews were conducted with 34 prostate cancer survivors who had been diagnosed with a rising PSA (i.e., biochemical failure) within the past 12 months. Survivors were asked about their experiences and affective responses after being diagnosed with a rising PSA and while weighing potential treatment options. In addition, patients were asked about their decision-making process for the initial prostate cancer treatment. RESULTS: Compared with the initial diagnosis, survivors with a rising PSA reported increased negative affect following their diagnosis, concern about the treatability of their disease, increased planning and health behavior change, heightened levels of worry preceding doctor appointments (especially prior to the discussion of PSA testing results), and a strong reliance on physicians' treatment recommendations. CONCLUSIONS: Prostate cancer survivors' decision-making processes for the treatment of a rising PSA are markedly different from those of the initial diagnosis of prostate cancer. Because patients experience heightened distress and rely more heavily on their physicians' recommendations with a rising PSA, interactions with the health care provider provide an excellent opportunity to address and assist patients with managing the uncertainty and distress inherent with rising PSA levels.

Using the common sense model of self-regulation to understand the relationship between symptom reporting and trait negative affect.

BACKGROUND/PURPOSE: Based on the Common Sense Model of Self-Regulation, we examined if the relationship of trait NA to physical symptom reporting was moderated by life events and illness representations. METHODS: This relationship was examined using a cross-sectional dataset of 554 elderly adults. RESULTS: A significant three-way interaction demonstrated that individuals who reported the greatest severity of physical symptoms were higher in trait NA, and reported more life events and a chronic illness history. CONCLUSIONS: The results of this study are consistent with the hypothesis that individual high on trait NA who have a history of a chronic illness have illness representations with both disease specific physical symptoms and symptoms from other causes, such as emotional distress. This may complicate the care of medical conditions for these patients.

Using the Common Sense Model of Self-regulation to review the effects of self-monitoring of blood glucose on glycemic control for non-insulin-treated adults with type 2 diabetes.

PURPOSE: This systematic review examined the relationship between self-monitoring of blood glucose (SMBG) and glycemic control in patients with type 2 diabetes. The Common Sense Model of Self-Regulation (CSM) served as a theoretical framework for examining how, when (mediators), and for whom (moderators) SMBG improved glycemic control. DATA SOURCES: Five databases were searched: Medline, PsychInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing & Allied Health Literature. STUDY SELECTION: Included studies had cross-sectional, longitudinal, or randomized controlled trial designs; were published between 2007 and 2011; and included patients with type 2 diabetes at least some of whom were not taking insulin; 1318 studies were screened, 119 were reviewed in detail, and 26 were included. DATA EXTRACTION: Data were collected on the relationship between SMBG and glycemic control, study design, mediators, moderators, participant characteristics, the CSM, and limitations. DATA SYNTHESIS: Twenty-six studies met criteria for inclusion: 11 cross-sectional, 4 longitudinal, and 11 randomized controlled trials. The results of the cross-sectional studies were inconclusive. Results from the longitudinal studies and randomized control trials suggested that SMBG may improve glycemic control. The few studies investigating mediators or moderators reported mixed results. Few studies effectively measured the CSM. CONCLUSION: Data suggested that SMBG may help improve glycemic control. Future trials must be designed to test hypotheses and improve our understanding of when, how, and for whom SMBG can enhance glycemic control. Rigorously controlled repetitions of current 2-arm trials will yield little new knowledge of theoretical or practical value.

Assessing theoretical predictors of long-term medication adherence: patients' treatment-related beliefs, experiential feedback and habit development.

Patient non-adherence to medication is a pervasive problem that contributes to poor patient health and high healthcare costs. Basic research and interventions have focused thus far on behaviour initiation factors, such as patients' illness and treatment beliefs. This paper proposes two processes that occur after behaviour initiation that are theorised to contribute to prediction of long-term medication adherence: 'coherence' of patients' beliefs from experiences with treatment and habit development. Seventy-one hypertensive patients reported their treatment-related beliefs, experiences related to treatment efficacy and medication-taking habit strength in a baseline interview. Patients then used an electronic monitoring pill bottle for approximately one month. Patients' medication habit-strength was the strongest predictor of all adherence measures, explaining 6-27% incremental variance in adherence to that explained by patients' treatment-related beliefs. Patients' beliefs and experiences did not predict overall adherence, even for patients with 'weaker' habits. However, patients' experiences were found to predict intentional non-adherence and habit strength was found to predict unintentional adherence. Practitioners may assess patients' medication-taking habits to get an initial view of their likely adherence to long-term medications. Future research should assess the current theoretical predictions in a hypertension inception sample and in populations with symptomatic conditions.

Why do comparative assessments predict health? The role of self-assessed health in the formation of comparative health judgments.

OBJECTIVE: Research has shown that self-assessments of health are strong predictors of morbidity and mortality regardless of format (i.e., self or comparative). In this study, the authors examined the relationship between 2 of these health assessments, self-assessed health (SAH) and comparative health (CH). On the basis of social psychological theory, they hypothesized that CH is predictive of health outcomes because it is based on SAH. Additionally, the authors examined whether motivational and dispositional factors influenced CH and whether these factors were able to account for the differences between CH and SAH. METHOD: Data were obtained from 851 community-dwelling older adults (M = 73 years). Participants responded to questionnaires assessing personality characteristics (e.g., trait affectivity, dispositional optimism and pessimism), and health status (e.g., functional limitations). All-cause mortality was tracked for a 10-year period. RESULTS: Correlation and agreement analyses revealed that both judgments had a high degree of similarity. As expected, survival analysis showed that CH predicted mortality but only until SAH was added into the model. Analysis examining the factors that influence CH showed that after controlling for SAH, high levels of trait positive affectivity, low levels of functional limitations, and low levels of fatigue-lack of energy were associated with high CH ratings. Examination of CH-SAH difference scores showed that only participants' age accounted for differences between these 2 judgments. CONCLUSIONS: These data revealed that CH judgments were, to a great extent, based on SAH. Results showed that motivational factors influence CH judgments but do not explain the differences between SAH and CH.

Heterogeneity in depression symptoms and health status among older adults.

OBJECTIVES: We assessed whether distinct classes of depression symptoms could be identified. In addition, we determined how these classes differed in terms of health status. METHODS: Data were analyzed with latent profile analysis. MANOVA tests were used to compare the health status of the various classes. RESULTS: A four-class model had the best fit. Classes were labeled according to participants' responses to the Center for Epidemiologic Studies-Depression Scale (CES-D) items and their overall score: low depression symptoms, high depression symptoms, subthreshold with anhedonia, and subthreshold with anhedonia and negative interpersonal feelings. Cross-sectional and longitudinal analyses showed that health status differed across classes. CONCLUSIONS: The results provide support for the idea that there is heterogeneity in the presentation of depression symptoms among older adults. These data showed that about a third of our sample of older adults reported increased levels of anhedonia and that negative interpersonal feelings were uncommon.

Physicians' communication of the common-sense self-regulation model results in greater reported adherence than physicians' use of interpersonal skills.

OBJECTIVES: Interventions that address patients' illness and treatment representations have improved patient adherence and outcomes when administered by psychologists and/or health educators and focused on a single chronic illness. The current study assesses the potential feasibility/effectiveness of an intervention based on the common-sense self-regulation model (CS-SRM) when administered by providers in a primary care setting. DESIGN: We designed a prospective, correlational study in order to optimize patients' and providers' time and to gain initial evidence of the CS-SRM-approach's feasibility/effectiveness. METHODS: Patients (n= 243) were recruited from a primary care waiting room and reported on objective behaviours of their providers (providers' CS-SRM-related behaviours and interpersonal skills) and other theoretically related measures directly after the medical encounter and reported on adherence, presenting problem resolution, and emergency care usage 1 month later. RESULTS: The more providers gave their patients an adaptive understanding of their presenting problem/treatment (the greater the number of CS-SRM-related behaviours they engaged in), the more adherent were patients in the month following the encounter and the better was their problem resolution 1 month later. The CS-SRM-related behaviours were more predictive of these outcomes and emergency care usage than were the providers' interpersonal skills. CONCLUSIONS: In the time-limited encounter, interventions may have to prioritize theoretical approaches for attaining patient adherence. The current study, although correlational, indicates that addressing the patients' illness/treatment representations is more important than the providers' interpersonal skills for attaining patient adherence and provides preliminary evidence that a CSM-based intervention in the primary care setting may be both feasible and effective.

Factors associated with the accuracy of physicians' predictions of patient adherence.

OBJECTIVE: Physicians are inaccurate in predicting non-adherence in patients, a problem that interferes with physicians': (1) appropriate prescribing decisions and (2) effective prevention/intervention of non-adherence. The purpose of the current study is to investigate potential reasons for the poor accuracy of physicians' adherence-predictions and conditions under which their predictions may be more accurate. METHODS: After the medical encounter, predictions of patient-adherence and other ratings from primary-care physicians (n=24) regarding patient-factors that may have influenced their predictions were collected. Patients (n=288) rated their agreement regarding the prescribed treatment after the encounter and reported adherence 1 month later. RESULTS: Several factors were related to physicians' adherence-predictions, including physicians' perceptions of patient-agreement regarding treatment. However, some factors were not related to adherence and agreement-perceptions were inaccurate overall, potentially contributing to the poor accuracy of adherence-predictions. The degree to which physicians discussed treatment-specifics with the patient moderated agreement-perception accuracy but not adherence-prediction accuracy. CONCLUSIONS: Training providers to discuss certain treatment-specifics with patients may improve their ability to perceive patient-agreement regarding treatment and may directly improve patient-adherence. PRACTICE IMPLICATIONS: Discussing treatment-specifics with patients may directly improve adherence, but providers should not rely on these discussions to give them accurate estimates of the patients' likely adherence.

Cognitive science speaks to the "common-sense" of chronic illness management.

We describe the parallels between findings from cognitive science and neuroscience and Common-Sense Models in four areas: (1) Activation of illness representations by the automatic linkage of symptoms and functional changes with concepts (an integration of declarative and perceptual and procedural knowledge); (2) Action plans for the management of symptoms and disease; (3) Cognitive and behavioral heuristics (executive functions parallel to recent findings in cognitive science) involved in monitoring and modifying automatic control processes; (4) Perceiving and communicating to "other minds" during medical visits to address the declarative and non-declarative (perceptual and procedural) knowledge that comprise a patient's representations of illness and treatment (the transparency of other minds).

Psychological factors influencing self-assessments of health: toward an understanding of the mechanisms underlying how people rate their own health.

BACKGROUND: Research in the past 20 years has shown that self-assessed health (SAH) is a consistent and reliable predictor of health outcomes. However, it is still unclear what factors are responsible for the association of SAH with mortality and other objective health indicators. PURPOSE: This study examined the impact of trait positive affect, trait negative affect, and functional limitations (FL) on SAH cross-sectionally and longitudinally. We hypothesized that changes in SAH ratings would be mainly influenced by FL, whereas affective information would have a biasing effect on SAH ratings cross-sectionally. METHODS: We analyzed longitudinal data obtained from five successive annual interviews conducted with over 800 elderly respondents (mean age = 73 years) using latent growth curve modeling. RESULTS: Results revealed that SAH judgments were related to FL and to trait affects in each of the five waves (cross-sectional data), but only changes in FL were related to changes in SAH over time. These data also showed that changes in SAH were predictive of mortality above and beyond its initial levels. CONCLUSIONS: The results suggest that the temporal trajectory of FL is a source of information that allows an individual's SAH to predict objective health measures of both morbidity and mortality.

Integrating co-morbid depression and chronic physical disease management: identifying and resolving failures in self-regulation.

Research suggests that treatments for depression among individuals with chronic physical disease do not improve disease outcomes significantly, and chronic disease management programs do not necessarily improve mood. For individuals experiencing co-morbid depression and chronic physical disease, demands on the self-regulation system are compounded, leading to a rapid depletion of self-regulatory resources. Because disease and depression management are not integrated, patients lack the understanding needed to prioritize self-regulatory goals in a way that makes disease and depression management synergistic. A framework in which the management of co-morbidity is considered alongside the management of either condition alone offers benefits to researchers and practitioners and may help improve clinical outcomes.

Using the common sense model to design interventions for the prevention and management of chronic illness threats: from description to process.

In this article, we discuss how one might use the common sense model of self-regulation (CSM) for developing interventions for improving chronic illness management. We argue that features of that CSM such as its dynamic, self-regulative (feedback) control feature and its system structure provide an important basis for patient-centered interventions. We describe two separate, ongoing interventions with patients with diabetes and asthma to demonstrate the adaptability of the CSM. Finally, we discuss three additional factors that need to be addressed before planning and implementing interventions: (1) the use of top-down versus bottom-up intervention strategies; (2) health care interventions involving multidisciplinary teams; and (3) fidelity of implementation for tailored interventions.

Health Psychology: the Search for Pathways between Behavior and Health.

This review of the current status of theoretically based behavioral research for chronic illness management makes the following points: (a) Behavioral interventions have demonstrated effectiveness for improving health outcomes using biomedical indicators, (b) current interventions are too costly and time consuming to be used in clinical and community settings, (c) translation of the conceptual models generated from studies of the problem-solving processes underlying self-management and the relationship of these processes to the self system and cultural and institutional contexts suggest new avenues for developing effective and efficient cognitive-behavioral interventions, and (d) it is proposed that integration of the conceptual developments in self-management with new approaches to the design of clinical trials can generate tailored, behavioral interventions that will improve quality of care.

Lessons from white coat hypertension: comment on Spruill et al. "The impact of perceived hypertension status on anxiety and the white coat effect".

The Implications of White Coat Hypertension by Spruill et al. (2007) are multiple and extend well beyond the domain of hypertension and cardiovascular risk. First, their excellent study indicates that theory and research need to treat emotional reactions as situation-specific events. Although traits such as Anxiety can be easily and reliably measured, their assessment may not detect the situation-specific mechanisms that link emotional responses to health risks. Second, patients' self perceptions, whether they label themselves as having a chronic disease, give meaning to the situational cues that elicit emotional reactions. Third, as Spruill et al. indicate, health behavioral research needs to examine how the clinical setting and social and cultural frameworks affect self-labeling. We add to their clinical concerns by questioning whether a clinician's words, i.e., whether they suggest a condition is related to stress, can in our contemporary culture, lead patients to treat a condition as acute rather than chronic, and how the clinicians' behavior, e.g., attention to specific areas of the body during a clinical examination, may shape the perceived cause of symptoms. The implications of this excellent study extend well beyond its focus on white coat hypertension.

Observer ratings of health and sickness: can other people tell us anything about our health that we don't already know?

After administering interviews covering health conditions, physical limitations, optimism, and affect to 851 older adults, interviewers rated the health and sickness of the interviewees. Observers' ratings of health and sickness were more highly correlated with the severity of participants' self-reported health conditions than were participants' self-ratings of health. This finding is likely attributable to participants' self-ratings of health being more highly correlated with their optimism and positive affect than the observers' ratings. Participants rated as sicker and less healthy at baseline were at a 3 times greater risk for mortality over 114 months. This association was independent of participants' self-rated health as well as demographics, self-reported health conditions, years of smoking, physical limitations, body mass index, optimism, and affect.

Living with the worry of cancer: health perceptions and behaviors of elderly people with self, vicarious, or no history of cancer.

Cancer is a major health threat that has a long-term impact on quality of life and health worries. The present study is focused on two major issues: (1) the impact that a history of cancer has on reactions to other diseases, in addition to cancer and general health worries; and, (2) the impact that having lived with someone who had cancer has on health perceptions and behaviors. All 108 participants had osteoarthritis, a symptomatic but benign disease (49 people have had cancer, 22 had lived with a cancer patient, and 37 had not had any close experience with cancer). Cancer and health worries were lowest among the people with vicarious experience, while monitoring for bodily signs was similar and highest in both cancer experience groups. Reactions to arthritis suggest more vigilance among people who have had self or vicarious experience with cancer, while reactions to ambiguous symptoms suggest vigilance especially among those with a personal history of cancer. Overall, the findings suggest that the effects of self-experience with cancer and of close experience with a cancer patient may be long-term and impact upon both health perceptions and behaviors.

Elderly people's ratings of the importance of health-related factors to their self-assessments of health.

Identifying the bases for self-assessed health (SAH) has interested researchers in their attempts to understand its validity as a predictor of future health outcomes. Quantitative approaches typically used statistical methods to identify correlates of SAH while qualitative approaches asked people to elaborate on the reasons underlying their rating of health. The current study used a quantitative methodology, asking 487 elderly people to rate the importance of 42 health-related factors as bases for their SAH judgment. Factors indicating overall functioning/vitality were rated highly by all participants. Factors indicating current disease were rated highly by people reporting poor/fair SAH while risk factors and positive indicators were rated highly by those reporting good, very good, or excellent health. Thus, there seems to be a clear distinction between poor and fair SAH that reflect levels of illness, and higher levels of SAH that reflect levels of health.

Giving up and replacing activities in response to illness.

Data from a longitudinal study of 250 older adults were used to examine activity loss and replacement as a consequence of an important illness episode. Multiple regression analyses revealed that reductions in activity were predicted by physical factors, specifically illness chronicity and severity. In contrast, replacing lost activities was facilitated by social support and optimism and inhibited by a belief in the need to conserve physical resources. An examination of the long-term benefits of replacing activities revealed that older adults who replaced a lost activity had higher positive affect levels 1 year after illness onset than those who did not replace activities. Continuing activity during illness episodes can help maintain positive well-being over time.

Trait negative affect relates to prior-week symptoms, but not to reports of illness episodes, illness symptoms, and care seeking among older persons.

OBJECTIVE: Use the commonsense model of self-regulation to generate and test hypotheses about the relationships of trait negative affect (NA) and self-assessed health (SAH) to reports of current symptoms (acute and chronic), episodes of illness, and use of health care during illness in a sample of elderly, community-dwelling respondents. Trait NA and SAH were compared with the properties of the illness episodes in models predicting the use of medical care. METHODS: Data were obtained from two successive annual interviews (N = 790 and 719, respectively) conducted with elderly respondents (mean age = 73 years). RESULTS: Both NA and SAH correlated (positively and negatively, respectively) with reports of prior-week acute and chronic symptoms at each of the two interviews. Trait NA and SAH also predicted changes in prior-week symptoms 1 year later. Neither trait NA nor SAH was related to reports of acute illness episodes, but each showed a very small relationship to reports of chronic illness episodes. Neither trait NA nor SAH predicted the average number of symptoms reported during acute or chronic episodes. The use of medical care during acute and chronic illness episodes was related to the properties of the episode: reported duration, novelty, and severity. Neither NA nor SAH predicted use of care for acute episodes; SAH was related to use of care for chronic episodes. Worry about the illness episode, but not trait NA, was related to care seeking for participants interviewed during a chronic episode. CONCLUSIONS: Trait NA does not bias elderly adults' reports of symptoms, illness episodes, symptom reports for episodes, or the use of health care. Both NA and SAH reflect independent sources of common sense and self-knowledge, and each contributes valid information about the elderly individuals' perceptions of their somatic states.