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V 3:: “v '2”? ~. . a w f-‘gaxg x...- -."-‘ij°gg} Qt c1; 9 ‘8 «ls-433:5 59‘“ L _,_ - ——"—-~~—“--‘~-- ~-—~——“~J This is to certify that the dissertation entitled CORRELATES OF MEDICAL COMPLIANCE WITHIN A MEDICAID SCREENING CLINIC POPULATION presented by Alison w. Jones has been accepted towards fulfillment of the requirements for Ph.D. degreein Psychology /: \h’ _: ,A/ M/\ Major professor Date 8/2/83 MSU is an Affirmative Action/Eq ual Opportunity Institution 0-12771 bVIESI.) RETURNING MATERIALS: Place in book drop to ngkARIES remove this checkout from .a-I-zs-E-L your record. FINES will be charged if book is returned after the date stamped below. no N91 datum: ROOM USE ONLY " 2r?- Wit!“ finest! r r CORRELATES OF MEDICAL COMPLIANCE WITHIN A MEDICAID SCREENING CLINIC POPULATION By Alison w. Jones A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1983 ABSTRACT CORRELATES OF MEDICAL COMPLIANCE WITHIN A MEDICAID SCREENING CLINIC POPULATION By Alison Williams Jones This study examined the relationship between compliance and personality, demographic features, and attitudes towards health care systems. Subjects were mothers of children aged 6-12 who were eligible to use a Medicaid Screening Clinic. It was hypothesized that the complying mothers (67%e100% of appointments kept) would score highest on internal control, self-esteem, and social desirability. Non-compliers (0-33% of appointments kept) would score lowest, and semi-compliers (34%-66% of appointments kept) would be intermediate. Instruments were the Multidimensional Health Locus of Control Scale, the Rosenberg Self-Esteem Scale, the Physical Self Subscale of the Tennessee Self-Concept Scale, and the Marlowe-Crowne Social Oesirability Scale. It was also hypothesized that compliance would be positively associated with severity of the child's disorder and with the mother's positive attitudes towards the health care System. The hypotheses were not supported. However, there were results of interest. Compliers were most satisfied with Alison W. Jones cost/convenience aspects of health care, but non-compliers were more satisfied than were semi-compliers. Both compliers and non-compliers had more positive attitudes towards doctors than did semi-compliers. Non-compliers had a more internal locus of control than did compliers or semi-compliers (opposite to prediction), with compliers being more internal than semi-compliers. Compliers were more worried about their child's health than were semi-compliers. The lack of association between demographic variables and compliance may be due to the lack of variability on demographic variables. A salient finding was that persons utilizing the clinic were generally quite pleased with the quality of care received and expressed very positive attitudes towards the clinic. Subjects were also very willing to participate in the study. ACKNOWLEDGMENTS I wish to express deep appreciation and gratitude to the people who made this investigation possible. During all phases of this research the excellent guidance and suggestions of Elaine Donelson were invaluable and made this work not only possible but also a richly rewarding experience. I wish to extend to her very special thanks for these important contributions. I would also like to thank George Fairweather for his role in helping to enable the execution of this project through facilitating contacts with the appropriate persons. Again, I would like to extend thanks to Elizabeth Seagull and Norman Abeles for their input and their willingness to serve on the committee. Very special thanks is also extended to my very dear friend, Janis Elmore, research and statistical consultant who spent valuable time without compensation helping with the necessary statistical analysis and computer work. TABLE OF CONTENTS LIST OF TABLES ........................................ Chapter I. INTRODUCTION ...................... — ............... Review of the Literature ...................... Compliance ..... - ............................. Criteria of Compliance .................... Variables Associated with Compliance ........ Demographic Variables ..................... Features of the Disease ................... Features of the Therapeutic Regimen ....... Features of the Therapeutic Source ........ Features of the Patient—Health Care System Interaction ............................. Socio-Behavioral Characteristics .......... Situational and Personality Variables ..... Screening Programs .......................... Hypotheses .................................. Pilot Study ................................. II. METHOD.. ........................................ Subjects .................................... Instruments ................................. Procedure ................................... III. RESULTS ......................................... Overview .................................... Internal Consistency and Norms .............. Characteristics of the Sample ............... Demographic Features ...................... Health Related Attitudes .................. Hypothesis Testing .......................... Followup Data ............................... IV. DISCUSSION ...................................... Evaluation of Hypotheses .................... First Hypothesis .......................... Second Hypothesis ......................... Third Hypothesis .......................... ii Page iv Chapter Page Fourth Hypothesis ....................... 97 Fifth Hypothesis ........................ 97 Demographic Results ........................ 100 Other Relevant Variables ............ ' ...... 100 MethodologiCal Issues ................ ‘..... 102 V. SUMMARY AND CONCLUSIONS .................. ..... 105 BIBLIOGRAPHY ........................................ 110 APPENDICES Appendix A. Tests and Satisfaction Scale Scoring Procedures ........... . .................... 119 1. Informational and Demographic Questionnaire ......................... 120 2. Rosenberg Self-Esteem Inventory ....... 121 3. Tennessee Self Concept Scale .......... 122 4. Marlowe-Crowne Social Desirability Scale ................................. 124 5. Psychological Scale ................... 126 6. Multidimensional Health Locus of Control Scale ......................... , 127 7. Satisfaction Scale .................... 129 8. Scoring Method for Satisfaction Scale. 131 9. Followup Questionnaire ................ 133‘ B. Cover Letter, Research Consent Form, Administrative Agreements, Screening Clinic Medical Forms .................. 134 iii LIST OF TABLES Table 1. Studies Reviewed by Haynes (1976) and Marston (1970) ........................................ 2. Alpha Coefficients for all Scales ............... . Alpha Coefficients for Subscales ................ . Table of Means .................................. (TI-#00 Normative Data: Marlowe-Crowne Social Desirability Scale and Multidimensional Health Locus of Control Scale ........................ 6. Demographic, Informational Frequencies .......... 7. Chi-Squares: Association between Items in Demographic, Informational Questionnaire and Compliance Categories .......... i ............... 8. Chi-Square: Analysis of Mothers' Reported Worry About Child's Health .......................... 9. ANOVA for Multidimensional Health Locus of Control Scale ................................. 10. ANOVA for Subscales of the Multidimensional Health Locus of Control Scale ................. 11. ANOVA for Tennessee Physical Self Scale ......... 12. ANOVA for Rosenberg Self-Esteem Scale ........... 13. ANOVA for Marlowe-Crowne Social Desirability Scale ......................................... 14. Number of Referral Appointments Kept for Varying Medical Conditions, by Compliance Groups ........................................ 15. Follow Thrdugh Patterns for Infectious Diseases. 16. ANOVA for Satisfaction Scale ............. ' ....... iv Page 14 64 65 67 68 69 76 77 78 80 81 82 83 85 86 87 Table Page 17. ANOVA for Subscales of Satisfaction Scale. ..... 88 18. ANOVA for Psychological Scale ........... ....... 90 19. ANOVAfor Subscales of Psychological Scale ..... 91 20. Return Rate Information and Reasons Provided for Nonattendance ............................ 92 INTRODUCTION Advances in medicine have resulted in cures for many diseases previously incurable. However, if patients do not receive proper medical care, grave losses in money and human resources result. In addition professional time and services are wasted. Compliance has been used in the medical research literature to refer to patients following through with medical regimens prescribed by a health care provider. The impact and extent of patient non-compliance with medical regimens has been well documented in the research literature. According to one review of the literature the estimates of rates of patient non-compliance ranged from 25-50% (Blackwell, 1973). More recently, Becker and Maiman (1980) note rates'between 30-60% with a worsening of the situation when patients are symptom free. In addition, it has been shown that doctors notoriously underestimate non-compliance rates within their own patient populations and are inaccurate in guessing which patients are compliers and which are not (Kasl, 1975). Many variables affecting compliance have been intensively examined. HoweVer, methodological differences within the studies and lack of adequate, Standardized methods of collecting data have resulted in confusing and contradictory findings. Further confusion results from the fact that the operational definition of compliance and criteria used to assess it have varied between studies. Stone(1979) reports that estimates of the extent of patients following through with medical regimens appears to be negatively related to the objectivity of the method used to assess compliance. Asking patients directly about their adherence and following through results in the lowest levels of non-compliance, whereas testing urine samples to determine traces of medication results in the highest rates of non-adherence. The inconsistencies between studies make accurate comparisons difficult and also obscure understanding of the issues involved. The proposed study is designed to examine and better understand medical compliance within a medicaid screening clinic population. The emphasis of this study is upon understanding personality characteristics and dynamics of complying and non—complying mothers of children attending the clinic. The mothers are designated as being compliers or non-compliers on the basis of following through with scheduled appointments for their children. This is an important area to study because it is thought that there is a direct relationship between early detection of disease and mothers' following through with health Screening for their children. While previous studies have examined different variables associated with adherance behavior, very few have investigated personality traits or characteristics associated with compliance behavior (Marston, 1970). Related areas of study have included the relationship between personality variables and amount of knowledge about a disease, and haste or readiness to seek treatment for diseases. For example, using Cattell's 16 PF Questionnaire to assess anxiety, Ley and Spellman (1965) found that those patients with an average level of anxiety remembered more of the instructions than did those with low or high levels of anxiety. 0n the other hand, with anxiety measured by an MMPI Scale, Hellmuth (1966) found no relationship between level of anxiety and distortion in memory of medical recommendations by patients with heart disease. Cobb et. al. (1954) administered the Rorschach and T.A.T. tests to cancer patients who reported quickly for treatment and those who delayed seeking help. The patients seeking treatment more promptly coped with the fear in a more active and constructive manner and were co-operative about their treatment. The delayers, on the other hand, were at times more openly hostile and aggressive and demonstrated a more childlike dependance upon their physicians. There have been few studies investigating the relationship between various personality traits and adherance behavior. Some researchers have administered a variety of rating scales to patients to attempt to establish a predictive index for adherance behavior. Charney et. al. (1967), having doctors use an adjective Checklist to describe mothers of children being treated for strep infections, found that 12 of the 62 adjectives employed were useful in predicting compliance of the mothers. Further, Davis (1968) reported that those patients characterized as responsive, co-operative, grateful and "able to articulate their problems in an intelligent way", were more likely to comply with the doctors' advice than were those characterized as being obstructive, demanding, authoritative, or overbearing. However, the personality profiles were based upon the physicians' ratings of patients rather than upon more objective test data. According to Wilson (1973), mothers complying with a Penicillin treatment regimen for their children were described as being "responsible", " organized", "efficient", and "mature". They also found that a mother's concept of her own health and her own social role, and the severity of the childfls illness largely determined whether or not the children received medication. While these studies point out certain subjective insights into overt characteristics and behavior of compliant versus non- compliant women, they are not comprehensive and do little to help to elucidate more subtle, underlying dynamics and characteristics. This study will attempt to explore and gather information about more extensive, indepth personality characteristics of those persons designated as compliers, semi-compliers and non-compliers. It may shed light in an area that has not been studied well. Through better understanding the characteristics of those persons who comply and those who do not, we may become able to change the behavior of non-compliers. Three groups of subjects will be examined: Compliers (those persons who keep between 67-100% of the scheduled appointments for their children); Semi-Compliers (those persons who keep between 34-66% of their scheduled appointments); and Non-Compliers (those persons who keep between 0-33% of their scheduled appointments). For these three groups, personality variables, demographic data, medical concerns and attitudes towards health care professionals, will be compared. If significant differences were found between the mothers in the three groups on particular variables, it might be possible (in a future study) to set up a predictive index of compliance to help to improve compliance rates. Review of the Literature Compliance Compliance has been used in the literature to refer to patients showing up for appointments, taking medication or generally following through with the regimen as prescribed and dictated by a health care provider. In recent times the term compliance has been heavily criticized and discarded as a useful and descriptive construct reflecting the notion of patients co-operating with doctors' orders. The concern has been that somehow the patient is at fault or to blame for not following through with instructions. "This unfortunate term both reflects and perpetuates ill-conceived notions of the health providers role. The term evokes images of a passive, subservient, and unfeeling patient. On the other hand, it creates the expectation that the practioner is omniscent and omnipotent." (Friedman and Dimatteo, 1979,p.5). The controversy surrounding the use of the term compliance has become of central importance because it has recently been recognized that whether patients adhere to doctors' adVice and prescriptions is a complex issue dependant upon a great number of factors. The patients' personality and other characteristics influence behavior. Also influential are aspects of the relationship with the health care provider and broader issues including satisfaction with clinic visits and positive feelings towards health care services. According to Stone, "viewing compliance as a property.of the transaction between expert and client, it is appropriate to see the responsibility for establishing compliance as shared between expert and client." (1979,p.34). In the present research, the term compliance is used as a more_6bjective behavioral description than before, denotingthe behavior of not following the doctors' orders, for whatever reason. It is not intended to indicate blame or responsibility for this action on anyones' part; rather, it simply denotes the fact that the recommended behavior has taken place. Criteria 9: Compliance Five different criteria have been used in the research studies to measure the behavior of compliance. These are the urine excretion test, pill counts, patient reports, and follow-up on referrals. Combinations of these methods can elucidate the strengths and weaknesses of each one, as well as clarify the methodological issues relevant to compliance studies. The urine excretion test enables detecting medication in the urine. Through collecting and examining the patients' urine, it is possible to ascertain to what extent patients are taking their prescribed medication. According to Marston's (1970) extensive reveiw of the literature, this technique of measuring compliance has been the most frequent one. Non-compliance rates, measured by urine excretion tests, have varied from four percent (in a group of out- patients with T.B.) to ninety-two percent (in children with strep infections). One methodological problem with this measure stems from the fact that the amount of expected scrutiny varies between studies. For example one study might collect urine specimens routinely upon the patients' visits to the doctor's office, and another might collect samples during unannounced home calls. Morrow and Rabin (1966) reported a higher non-compliance rate when urine samples were obtained in unannounced home visits as opposed to during clinic hours. However, Maddock (1967) found no differences between samples collected in the two settings. Another problem is that some studies have based compliance estimates on the test result of one urine specimen whereas others have used repeated measures to derive an estimate of compliance. A further difficulty revolves around the variations between studies on the percentages of positive findings used as a criterion to label a patient as compliant or non-compliant. One study might classify patients as being compliant who had 50% or more positive tests (i.e., traces of the medication in their urine), whereas another study might classify patients as non-compliers by the criterion of only 10% negative tests. Further problems with this method result from the fact that patients might take their medicine sporadically or until their pressing symptoms disappear; their urine samples might be collected at a time when they have taken their medication. With pill count measures, the physician either asks the patient to bring the medication to the next appointment, or checks with the pharmacy to see if the patient has filled or refilled the prescription. One methodological problem 'with this technique, as with the previous one, is that criteria vary; in this case, percentages of remaining pills indicating compliant behavior differ greatly from study to study. Another problem with this method is that patients sometimes forget to bring their medicine to a follow-up appointment. Even if they do bring it and a substantial amount is gone, it is difficult to state with certainty that the patient has in fact consumed the medication. With 'this measure it might be apparent to the patient why the physician has requested bringing in the medication. If for example, the patients' social desirability or approval needs were high, and the patients did not want to disappoint the physician, they could simply pour out remaining medication and lie about its consumption. With the procedure of checking with the pharmacy, patients might refill their prescriptions, but this does not mean that they will follow through with taking the medicine. The method of patient report is perhaps the simplest way to get an estimate of compliance but of necessity subject to human error and distortion. With this method the physician simply asks the patient about following through with the treatment regimen. According to Marston's (1970) literature review, rates of non-compliance from studies using patient reports have ranged from 9% (Gordis et. al., 1969) to 59% (Neeley and Patrick, 1968). Although few studies exist comparing patient self-reports with other criteria of compliance, it would seem that with this measure, compliance rates would be inflated. The literature in fact bears this out. Feinstein et. al. (1959) found a discrepancy of 18% between compliance rates using a pill count measure and patient reports; patients reported a non-compliance rate of 27% but pill count demonstrated a rate of 45%. When Gordis et. al. (1969) made a comparison of self-reports with results from excretion tests for children on Penicillin for Rheumatic Fever, non-compliance rates for self-reports ranged from 9-15% compared to 22-35% for excretion tests. People do forget, and patients not wanting to disappoint or lose the approval of their doctors might tend to distort their reports about the extent of their following through, even when they do not realize they are doing so. 10 With the method of direct observation, health care providers go into the homes of patients and observe first hand the administration of medications or other prescribed regimes. This method was used to evaluate the effectiveness of self-care with a diabetic group (Watkins, 1966). Non- compliance rates judged by this method were extremely high, indicating that 80% of patients administered their insulin inadequately, and 73% had inadequate diets and spaced meals in a manner that would affect their disease adversely. Problems with this method result from having an observer present whom the patient knows is there for that purpose. Compliance rates under'these conditions could be inflated. It would be of interest to examine compliance using direct observation when the patients were unaware of the real purpose of the observer's presence or of the nature of the study. With the final major method of determining compliance, compliance is assessed as maintaining prolonged contact with the physician or clinic or following through on any recommended referrals. Patrick (1963) found patients leaving against medical advice from a tuberculosis sanitorium to be younger, to be in an infectious state and to have more potentially susceptible dependants living within their homes. The major problem with this method of measuring compliance is that if a patient does not remain under medical supervision with a particular provider or clinic, this does not mean that the patient is not being cared for medically. 11 Perhaps the patient has sought care from another physician at a different setting because of specific dissatisfactions. Similarly, although less probable, if a patient does not follow through on a referral, this might be because the problem for which the patient was seeking help has disappeared. Some researchers have assessed compliance rates with a combination of methods. For example, Johnson (1965) and Davis (1968) used patients' and physicians' reports about extent of compliance, and medical charts. With a combination method, the meaning of inconsistencies is not clear. For example, both patients and physicians tend to view patients as being more compliant than they are according to more objective criteria (Marston, 1970; Davis, 1966). Another issue is whether averaging results from two measures gives a more accurate estimate of the true compliance rating than does one alone. In sum, there are numerous methodological problems with each of the criteria used to measure compliance. These problems make it difficult to obtain accurate compliance rates. Methodological differences account for some reported variation in compliance rates reported in studies. In the present study compliance is defined as showing up for appointments. This method was selected because of the relative ease and directness of getting the measure and the related consistency and accuracy. A deficiency of previous studies using this criterion of compliance is lack of follow-up data about reasons for not showing up for 12 appointments. For example, subjects might not keep a scheduled appointment because they chose to go to.a different physician or agency or because the problem cleared up. In the present study, follow-up data were collected to determine reasons for non-compliant behavior. Thus, the truly non-compliant can be separated from those who do not show up for legitimate reasons. Variables Associated with Compliance Numerous contradictory findings are reported across medical compliance studies. The contradictions are in part attributable to methodological problems inherent in the criteria of compliance and the lack of standardized methods. For example, one study might measure compliance as keeping appointments, whereas another might define compliance in terms of patients taking pills as determined by pill counts. Even with studies using the same operational definition of compliance (such as keeping appointments), one study might use a 50% criterion, whereas another uses a 90% criterion. The following review of the literature will be presented in terms of variables which have been studied in relation to compliance: (1) Demographic features of patients, (2) Features of the disease, (3) Features of the therapeutic regimen, (4) Features of the therapeutic source, (5) Features of the patient-health care system interaction and (6) Socio- behavioral features of the patients (Haynes, 1976). Two major reviews of compliance, by Marston (1970) 13 and Haynes (1976), are particularly relevant. Table 1 shows the numbers of studies reviewed by Haynes and Marston for each major variable, and the number of studies covered by both reviews. Demographic Variables Age. A negative association between age and compliance was reported in 2 studies and a positive relationship in 10 studies while there was no relationship in 35 studies. Blackwell (1973) hypothesized that compliance with young patients was poor because of the bad taste of the medicine. With geriatric patients, non-compliant behavior seemed due to general senility, lapses of memory or self-neglect. Gender. Females were reported as more compliant than males in 3 studies, and less compliant in 7 studies; 27 studies reported no association between gender and compliance. In one of the studies that showed females more compliant, Nathanson (1977) found that healthy men were more likely than healthy women to engage in activities with health risks, and were less likely than the women to take preventative health measures especially where medical intervention was required. Nathanson attributed the differences to general socialization patterns, including differences in the effects of interpersonal influence, and to the historical view within the medical profession that women are especially vulnerable to illness. He concluded that women are more likely than men to conceptualize and define their problems in medical terms and to seek help within the health care system. 14 oocowpoeoo cooo ou Ups—30.... mcome FQLLoocmx. ooee_oe .m.m.m 2o; e o o o o m o m o o mpoomom oovm m o o N_ m P m o o zuexePQEQU o o o o o N o o _ :o_poc=o o o m P o m F m m zgwco>om o o m m rem FF o _ m magnum Fopwcoz o o p o n o o o o xoopo .m> ou_zz oooz o o o o o e o _ N ee_mepom o o N N o m o em op zo_ .m> eo_e .m.m.m o o n o m mm P o op cowuoozom o o w m m om o o _P oPos .m> oFoEow coocow o o o o N on N m __ o_o .m> mesa» om< o>wuommz coppopoz o>wpomoz copuopoz o>wpomoz :o_uo_om opoowco> \o>wuwmoo oz \oowvwmoo oz \o>wuwmoa oz . mopco>o mocxo: copmcoz . Amem_v eeewtez oee zoempv mezzo: so oe3o_>om meeoeom P m4m<~ 15 Education. Haynes (1976) and Marston (1970) reported 12 studies with a positive association and 1 study With a negative association between level of education and compliance; in 26 studies reviewed, there was no association. Although the majority of studies reported no association between education and compliance, caution seems in order. It appears that level of education would affect the assimilation of information related to health care issues. Methodological problems may have prevented significant differences from becoming apparant. Also, the reasons for not complying may vary with education level. "SdCioéEcdnomic Status. Of the studies reviewed by Marston (1970) and Haynes (1976), 23 found no association of socio-economic status and compliance. A positiVe association was reported in 4 studies reviewed by Haynes and 8 studies reviewed by Marston. Marston notes that the relationship between socio-economic status and compliance is difficult to assess because the ranges of socio-economic status in many of the studies were quite small. A further difficulty is the fact that socio-economic status is not independent of education. In fact, several of the studies reviewed used the Hollingshed Two Factor Index of Social Position, which used education as one of the indices of socio-economic status. In general, although compliance ratings do not vary across socio-economic levels, use of health services does, with poorer persons tending to use physician services less 16 frequently. Richardson (1969) and Ross (1962) reported that poor persons are sicker than are other groups but tend to use health services less frequently. 0n the other hand, however, Kadushin (1964, 1967) reported that while there is no difference in organic illness across socio-economic status, persons from the lower classes have a greater tendency to express anxiety in physical or somatic terms; therefore, health surveys show a greater frequency of illness and disease among the poor. Anderson (1968) and Richardson (1970) demonstrated that when illnesses occur, both high and low socio-economic groups tend to seek out physician services at the same rate. Gray, Kessler and Moody (1966) found that persons in lower socio-economic groups have their children immunized less frequently than do those in higher classes. However this pattern was shown related to mothers behaving according to their friends' expectations; when the variable of friends' expectations was held constant, the differences in use of health services disappeared. Newer methods of financing health care should help to lessen any gap between classes in the use of health care services. Marital Status. Haynes (1976) and Marston (1970) reported 13 studies with no association between marital status and compliance. Haynes found an association between marital status and compliance in 6 studies reviewed. An additional study noted by Marston, showed married patients being more likely to follow medical recommendations than were either separated or divorced patients (Morrow and 17 Rabin, 1966). Race. Eleven studies reviewed by Marston (1970) and Haynes (1976) found no association between race and compliance. However, in 7 studies reviewed by Haynes, whites had higher compliance rates than blacks. Religion. Although less frequently studied than other variables, religion was considered in 7 studies. In 4 studies reported by Haynes (1976) and in 2 different studies reviewed by Marston (1970), religion was not related to compliance. However, in one study, Protestants had the highest rates of compliance compared to other religious denominations studied. "thclUsion about Demographic Variables. Both Haynes (1976) and Marston (1970) concur in stating that the vast majority of studies found no association between demographic variables and compliance. However, the subjectsused in most of the studies had entered the health care system. Demographic variables might be more relevant when groups who have not entered the health care system are considered. Another problem is that in most studies, many extraneous variables are uncontrolled. For example, using a clinic sample in a poor neighborhood serving primarily a black clientele,it would be difficult to separate race from socio-economic status. Extraneous variables could have been confounded in many studies. For example, if the physicians in the clinic were white middle class persons who felt uncomfortable dealing with persons of different 18 socio-economic status or race, or if the physicians had stereotypes regarding poor people or blacks, the physicians' attitudes could intefere with service and adversely affect the patients' compliance ratings. Features of the Disease The major factors of disease relevant here are diagnosis, severity, duration and degree of disability. While the studies are described in terms of simple effects of the factors, clearly the factors do not operate independantly. Diagnosis of the Disease. Haynes (1976) reported 9 studies finding no association between diagnosis and compliance and 4 studies with an association. However, the studiesfinding associations dealt exclusively with psychiatric illness. Psychiatric patients had poorer compliance ratings than did those with physical or organic diagnoses. Compliance was lowest for those with a diagnosis of schizophrenia and personality disorders. Perhaps the schizophrenics' tenuous contact with reality intefered with full understanding and execution of doctors' orders. With psychopathic types, perhaps faulty superego development and hostility towards authority figures intefered with the adequate formation of a relationship. Severitygj Disease. Haynes (1976) and Marston (1970) found 10 studies showing no relationship, 2 with a negative relationship and 3 with a positive relationship between compliance and disease severity. Marston reported conflicting findings with variations across illnesses. For example, in 19 one study she reviewed, patients with active T.B. were more likely to be taking their medication than were patients with inactive T.B. Another study found patients with serious illnesses more likely to obtain care than were those with less serious ailments. Conversely, however, Marston reported little evidence relating severity of disease with compliance for patients who were children with Rheumatic Fever, or patients with arthritis, ulcers or cardiac problems. Similarly, in another study, compliance was poorer for those patients having serious illnesses than for those with less severe ailments. Gillum and Barsky (1974) found that non-compliers are more likely to feel that their disease is less serious than a group of compliers similarly diagnosed. What seemed important was patients' perception of severity rather than the doctors' perception of severity. Further, Becker and Maiman (1975) stressed that it is the mothers' perception of the severity of the child's disease at the onset that determines her likelihood of complying by giving medication and keeping appointments. It also seems that perceptions of the disease as very serious could result in non-compliant behavior when the prognosis is poor. Such patients might perceive that efforts to comply with the medical orders are futile, and give up with a sense of hopelessness. According to Charney (1972), "If the patient is fatalistically convinced of the inevitability of the disease and its consequences, he may choose to 'tune out' advice " (p.272). 20 Duration of the Disease. In none of the 7 studies reviewed by Haynes (1976) was there a relationship between disease duration and compliance. Six different studies reviewed by Marston found that compliance was lower for patients with a longer history. Blackwell (1973) reported that patients with chronic conditions are prone to relapses if their symptoms are mild or if consequences of stopping medication are not apparent immediately, as is the case for anemia and pregnancy, for example. In contrast, when the relapses occur immediately or the repercussions of ceasing to comply are intense or severe (e.g. heart failure), patients are much more likely to follow through. Compliance over time was constant for a group of school children on Penicillin for Rheumatic Fever (Gordis et. al., 1969), while mothers tend to cease giving Penicillin to their children once symptoms subside (Bergman and Werner, 1963). Similarly, Luntz and Austin (1960) found over time increasingly higher non-compliance rates for adult T.B. patients on chemotherapy; and after five years of treatment, excretion tests showed no medication had been taken by any of the patients. Another study demonstrated a 30% incidence of errors in the dosage taken by diabetic patients having had the disease for one through five years; there was an 80% dosage error for those who had had it for twenty years or more (Charney, 1972). The research about duration of disease is contradictory. Some confusion is due to the fact that duration is related to severity of the disease, degree of disability, and perceptions 21 of the disease. Degree gfi Disability. The only 2 studies about this are consistent. In 2 studies patients with severe disabilities were more likely to follow through with doctors' orders than were those with less severe disabilities (Haynes, 1976, Marston, 1970). Persons having more severe disabilities might want to follow doctors' orders regularly to help in living a more normal, functional existence. For those with less disruptive disabilities, following doctors' orders is of less importance in their everyday lives. Features gfi the Therapeutic Regimen The category “features of the therapeutic regimen" includes type of medication, degree of behavioral change, complexity of the therapeutic regimen, cost and side effects from the medication. Types 2: Medication. There are differences in compliance rates for different drugs designed to treat the same ailment and for different procedures of administration of the same drug (Haynes, 1976). For example, compliance with oral medications has been worse than for intramuscular injections administered by doctors for treatment of strep prOphylaxis, T.B. and psychotic disorders (Haynes, 1976). Degreegj Behavioral Change Required. Reports are consistent that the greater the change required in a treatment plan, the greater the likelihood of non-compliance with the regimen. Compliance rates are highest for therapies requiring passive co-operation on the part of the 22 patient, such as drugs being administered by professionals within a clinic or hospital setting. Compliance is less for subjects who must acquire new habits such as taking medication on their own. Compliance is poor also for those who must change old behaviors such as those involving dietary or vocational patterns. Compliance is worst when smoking, drinking, or using addictive drugs must be given up (Haynes, 1976). According to Gillum and Barsky (1974), profound changes of habits are extremely difficult for patients to cope with. They point out that patients tend to pick out the portion of the regimen which is easiest for them and toacomply with that. Similarly, Davis and Eichorn (1963) estimate that patients conform to two-thirds of the I medical regimen prescribed and choose what is easiest to do. ‘ Complexity f‘a Therapeutic Regimen. Overall, more complex procedures have a lower compliance rating. Francis et. al. (1969) reported that compliance was significantly lower for a large group of pediatric patients for whom three or more medications were prescribed than for a similar group taking fewer drugs. Similarly, Hulka, et. al. (1976) found that with patients having diabetes mellitus or congestive heart failure, errors were fewer than 15% when just one drug was prescribed; errors increased to 25% when two and three drugs were involved, and increased to over 35% when five or more drugs were requested. According to Marston, compliance is lower in those patients prescribed 23 to take drugs and.follow other recommendations than for those with fewer, easier requirements. C233. Some of the available evidence suggests that cost is negatively associated with compliance, with more expensive regimens having a lower compliance rating (Haynes, 1976). The significance of this variable might become lessened with more comprehensive insurance programs; Medicaid and Medicare. Side Effects. Overall the research suggests that the 'more the side effects, the lower compliance. According to 5 studies mentioned by Haynes (1976) and three different ones by Marston (1970), drugs with unpleasant side effects were less likely to be taken than drugs without unpleasant side effects. Blackwell (1973) reported that side effects were associated with non-compliance especially when the effects are unexpected or alarming. Curiously, when non- compliers were asked the reasons for not taking medicine, side effects were listed at the bottom of the reasons given. Generally, the efficacy of a drug and seriousness of the disease seem important factors to consider in evaluating the impact of side effects. FeatUres g: the Therapeutic Source Relevant factors of therapeutic source include the therapists' prediction of compliance, treatment under a regular versus a substitute physician, clinic convenience and clinic waiting time. 'Therapist's Prediction gj_Compliance. It is clear 24 from evidence that there is no association between therapist's prediction of compliance and actual compliance on the part of the patient. In the only 5 studies reviewed by Haynes (1976), there was no association between these variables. According to Gillum and Barsky (1974), physicians have tended to greatly underestimate non-compliance rates in their own clinics and have been inaccurate in identifying non-compliant persons. Clearly patient non-adherence is a complex problem. The many variables that impinge upon compliance must be untangled if health care professionals are to increase compliance. Regular Versus Substitute Physician. Patients tend to comply more frequently when they are treated by their own doctor than by a substitute physician. Becker and Maiman (1975) found that mothers were more compliant in giving their children medication and keeping follow-up appointments if they were treated by the same physician at each visit. Further, Blackwell (1973) demonstrated that children in a pediatric clinic were more likely to take their medication if they were seen by a family physician whom they knew rather than by another physician. Continuity of care increases compliance. Clinic Convenience. Clinics that are more conveniently located are more frequently used. For example, in one case, decentralization of clinic sites into the community was implemented in an effort to improve compliance ratings. (Curry, 1968). Before and after ratings showed that the move was extremely successful in improving attendance. In 25 this case, compliance improved also because of the development of specialized district teams and the changed attitude of the professional staff. Although further research is needed, convenience seems especially important for less affluent populations where money and transportation are problems. ‘Clinic Waiting Time. The literature overwhelmingly shows that longer waiting times are associated with lower compliance rates. Long waiting times (both before getting an appointment and while in the waiting room) are often listed by patients as being main reasons for not keeping appointments (Haynes, 1976). Badgley and Furnal (1961) examined 77 appointment breakers in an outpatient pediatric clinic and found that 24% of the upper classpatients and 12.5% of the lower class patients reported they had broken later appointments because they had to wait to long to see the physician. ‘Features 2: the Patient-Health Care System Interaction The factors considered here bear upon patients' satisfaction with the health care system, including relationship with the physician, satisfaction with clinic visit, and the extent to which expectations have been met. Much research recently has emphaSized the importance of "quality of care," or patient satisfaction with the clinic visit and with specific interactions with a physician. Research shows patients are satisfied with the quality of care received. According to a 1962 survey conducted by the Opinion Research Corporation (Cahal, 1962) using 26 535 persons representing a cross section of the U.S. population, attitudes towards personal physicians were quite favorable, whereas the general image of the medical profession was less positive. Complaints about personal physicians centered around excessive expense. Similarly, Apostle and Oder (1967) with a sample of the general population in Rochester, New York, found a high level of satisfaction with personal physicians, although the general profession was viewed less favorably. Sampling a low income clinic population, Alpert et. al. (1970) found that satisfaction with care was high; the most dissatisfaction was with lengthy waiting times for the physician. In a study examining satisfaction with pediatric care, almost all (98%) of 136 mothers reported very high levels of satisfaction with the medical care their children were receiving (Deisher et. al., 1965). Most satisfying were the high quality of care and the personal qualities of the physician. Some discontent was expressed over fees, problems with making house calls, and time spent waiting to see the doctor. Conversely, Koos (1955) surveyed a random sample of urban families and found that the greatest criticism of 64% of the respondants was about the quality of the relationship with the physicians. Certainly, the importance of the specific relationship between doctor and patient is coming to be increasingly recognized. Doyle and Ware (1977) reported that the treatment of the patient by the physician was the most 27 important factor in determining satisfaction with health care services. Further research has demonstrated that patients have a tendency to leave and change primary care physicians because they are dissatisfied with the interpersonal relationship. According to Stone (1979), the quality of interaction between physician and patient is consistently related to compliance with medical regimens. He reported that success in giving and assimilating the information and the emotional impact of the interaction are important. The communication aspect of the interaction was emphasized also by Boyd et. al. (1974). They found that more than 60% of the patients in their study misunderstood the doctor's verbal instructions for taking prescribed drugs. Similarly, Svarstad (1976) found that over half the patients made one or more errors in recalling and describing the physicians' instructions one week following their visit to the clinic. He also found that the patients who recalled accurately their doctors' orders and expectations did follow through with them over three times as frequently as did those making at least one mistake in recollection. Gillum and Barsky (1974) found that when messages were not clearly communicated, patients were less likely to understand or remember the doctor's orders. Studies examining the emotional impact of the doctor- patient relationship have looked at compliance as related to perceived expectations and perceived attributes and affect associated with the relationship, as well as personality and 28 behavioral characteristics of the physicians and their influence upon compliance. Generally, when patients' expectations have been met and they are satisfied with their interaction with the health care provider, compliance is increased. For example, higher non-compliance rates occurred when mothers expected to receive information on the nature and cause of the child's illness and did not, than when they did not have the expectations (Francis et. al.,1969). Similarly, poor compliance was typical of patients who felt that doctors did not meet their needs, either through asking them many personal questions without adequate feedback or through not establishing good rapport and open channels of communication. Gillum and Barsky (1974) also reported that non-compliance was associated with the failure of doctors to give patients feedback after eliciting a great deal of information from the patients. Some studies also suggest that compliance can be favorably influenced by having the physician use part of the interview to elicit questions and problems the patient may be having in complying as well as teaching and reinforcing the importance of follow through (Strecher, 1983). The relationship, however, is not simple. Korsch et. al. (1972) found that patients' perceptions of warmth and friendliness on the part of the physician were not associated with increased compliance; yet, unfriendliness on the part of the physician, as well as feelings that the physician did not understand their concerns regarding their children, were 29 associated with higher rates of non-compliance. Too, Davis (1971) found that the presence of antagonism, tension and confrontation was associated with non-compliance, but there was no effect of a friendly and relaxed atmosphere on compliance. Geersten et. al. (1973) found that the arthritic patients who described the physician as being "personal" complied more frequently than did those describing the doctor as being "business like". However, diabetic patients complied more often when their preferred physician behaved in a more authoritarian fashion (Williams, et. al., 1967). Compliance has also been found to be positively associated with the patients expressing agreement with the physician, attempts to seek the physician's opinion, and releasing tension within a session (Davis, 1968). Again, two studies examining non-verbal skills of physicians found that those doctors with greater sensitivity to body movement and posture cues were given higher care ratings than were physicians who were less sensitive to these qualities (Zastowny et. al., 1983). Further, patients perceiving their doctors to be basically uninterested in them have sought medical care elsewhere (Gray and Cartwright, 1953; Kasteler et. al., 1976). Strecher (1983) emphasizes that the situational aspects of the interaction are important in eValuating the doctor-patient relationship. He describes three interaction models which differ according to the condition being treated and the degree to which the patient is able to participate in the decision making process. 30 He categorizes these as follows: (1) "the active physician- passive patient interaction”, (2) "the guiding physician- cooperating patient", and (3) "the mutual cooperation interaction." He reports: "A person experiencing a heart attack probably would not want a physician to take time to be patient-oriented and participative" (p.132). In sum, there are complex effects of doctor-patient relationships, but generally a positive relationship is conducive to compliance. ‘SOCiOéBehaVioral Characteristics Within this category, the relevant features for compliance are components of the Health Belief Model (Becker, 1976), knowledge about the disease, and the influence of social support systems and family stability upon compliance behavior. Health Belief Model: (Becker, 1976). This model deals with the relationship between patients' specific beliefs and attitudes regarding health issues and their subsequent health related behaviors. The model examines the patients' perceptions of the disease as serious, succeptibility to disease, and beliefs about the efficacy of the treatment including the fact that the benefits of the therapy outweigh its detriments. There seems to be a positive relationship between patients' perceptions of their disease as serious and compliance. The research also indicates a positive relationship between perceived succeptibility to disease and compliance. 31 More recently a study by Greene et. al. (1982) indicates that within their sample, patients seeing themselves as being more succeptible to illness or perceiving their disease as being more severe are less likely to follow the recommended advice. In interpreting this finding they indicate a positive correlation found between numbers of drugs prescribed and succeptibility and severity of illness and speculate that patients being given many drugs perhaps assume that this reflects upon the severity of their medical problem. They also note the possibility that persons viewing their illness as severe may become fatalistic and ultimately non-compliant. In a related vein, an important area of research that is relevant to the relationship between a patient's belief system and compliance, centers around the existence of folk-medical beliefs and their impact upon health related behavior. Basically folk medical beliefs are a system endorsed by certain low income, ethnic subcultures including groups of Black Americans, Mexican Americans, Puerto-Rican Americans and southern Whites. It combines special elements of ancient African custom, remnants from the folk and formal medicine of a century ago, and particular beliefs stemming from modern scientific medicine (Snow, 1974). Included in the system are beliefs about preventing illness categorized as "natural" or "unnatural," and beliefs about home remedies, cures and preventatives. Illnesses categorized as being "unnatural" are believed to be caused by Witchcraft, and cannot be treated by regular physicians. A prime proof of 32 the fact that you are suffering from one of these ailments is that going to a traditional doctor results in a worsening of the medical condition. Persons endowed with the gift of healing are ranked into various categories depending upon the estimation of their ability, their methods of curing, and the types of illnesses which they can cure. Under this system of beliefs, practioners are ranked into three classes according to the extent that their believed ability to cure has been bestowed upon them by God. The lowest ranked group consiSts of those persons learning the craft of healing from another individual or institution. Here are included traditional medical doctors, herb doctors, and neighborhood healers. According the Snow (1974): "The conferring of expertise by education is, of course, a particularly middle and upper- class phenomenon, and is relatively meaningless to those who have little education or for whom education does not guarantee upward mobility. There is marked ambivalence on the part of informants concerning education. On the one hand, it is highly valued and seen as the key to success-realistically, however, most poor people do not have any expectations of advanced training and both envy and resent the 'higher ups' who have it " (p.93). Ranked second are the persons perceived as having healing powers bestowed by God during a religious experience occurring later in life. Oral Roberts is an example. The individuals with the greatest perceived ability to heal are those who are blessed with this gift from birth. "To be born with the power of curing is a sign of God's highest approval, a sign that the individual is to have special powers throughout life " (Snow, 1974,p.94). 33 The view of the efficacy of various appointed health practioners by those endorsing the folk medical belief system has far reaching implications. Because the etiology of organic illnesses as well as their cures are viewed in ways which are at variance with scientific medicine, their practical solutions to health problems differ from standard acceptable practices of modern medicine. According to Snow (1974), "The presence of an alternate medical system which at best is different from and at worst is in direct conflict with that of the health professional can only complicate matters.... Deeply ingrained beliefs about how to attain and maintain health affect behavior whether or not the individual ever becomes a patient in a modern health setting. These beliefs about the intricate network linking man to the natural and supernatural world may greatly color the doctor/patient relationship and influence the decision to follow - or - not the doctors orders" (p.94). In attributing the ability to heal to the will of God, it is implicitely understood that following the advice of medically trained personnel will not necessarily produce cures. Motivation to adhere the regimes prescribed by standard medical persons is greatly lessened. ' Patients' Knowledge 2: their Disease and Treatment. No association can be claimed between patients' knowledge of disease or treatment and subsequent compliance. Although some studies report a positive relationship, those studies are less sound methodologically than those finding no association (Haynes, 1976). More recently, a study by Greene et. al. (1982) found a positive relationship 34 existing between patients knowledge of disease and compliance. Specifically, they report that although the general knowledge of an illness is not significantly related to compliance, knowledge about its cause as well as knowledge about the treatment regimen are each correlated highly with compliance. Significant aspects of the treatment regimen include the patients' ability to state the names of or describe the medications as well as knowing the functions of the drugs. Here, common sense dictates that knowledge of an illness or of its treatability or consequences of the disease if left untreated must certainly have a bearing upon subsequent compliance. These variables do not seem to be independant of severity of disease. One can imagine that if a patient were told that untreated glaucoma would result in permanent blindness, this patient might behave in a compliant fashion and obtain treatment. "Sdcial~Support Systems. Compliance has been found influenced by the behavior of family and friends (Haynes, 1976, Becker and Maiman, 1980). When the people in a patient's social support system feel positively about the person following through with doctors' orders and encourage this behavior, compliance is more likely to result. For example, Oakes et. al. (1970) sought to determine the effects of family expectations upon medical compliance within a group of rheumatoid arthritis patients. They found that when age, sex, and social class were controlled, family expectations were strongly related to compliance. Patients who perceived 35 that their families expected them to follow through with the prescribed regime did so to a greater extent than did others. Similarly, Donabedian and Rosenfeld (1964) reported that the successful care of chronically ill patients discharged from a hospital required a high degree of sustained cooperation of their families. Heinzelman and Bagley (1970) randomly divided men at risk for coronary heart disease into an exercise program group and a control group. For the men in the exercise program group, the wives' attitudes about the project were significant. The proportion of husbands adhering to the prescribed regime was much greater when the wives had positive attitudes about the program than when wives expressed neutral or negative sentiments. Conversely, the support system can intefere with- compliance. With a sample of Mexican American women residing in a barrio in Texas, Hoppe and Heller (1975) found that a greater degree of frequency of visitation with relatives was associated with a lower frequency of consulting with a physician. The women who had stable support systems turned to their relatives in times of stress and trouble. In contrast, those who were more alienated and less supported and assisted by their family unit turned to medical personnel to seek help for various crises arising within their lives. Friends as well as relatives can influence compliance and the utilization of health services. Merrill et. al. (1958) studied women who had their children vaccinated as well as those who did not. They reported that all mothers interviewed 36 tended to act in accordance with their perceptions of_the way members of their peer group acted. Over half of the mothers not having their children vaccinated believed that most of their friends had not had their children vaccinated. Conversely, the majority of mothers having their children vaccinated believed that most of their friends children had been vaccinated. Johnson (1962) noted similar findings: (For polio) "Belief that one's friends had taken the new vaccine had a particularly strong association with the respondents' own vaccine status" (p.97). Gray, Kesler and Moody (1966) found that their lower class subjects had a greater tendency to feel that their friends did not expect them to have their children immunized and they immunized their children less frequently than a corresponding sample of higher socio-economic group persons: "These findings suggest- that one of the reasons why lower social class persons tend to have lower immunization rates is that there are. proportionately more people in the upper and middle social classes who believe their friends expect them to be immunized than there are in the lower socio-economic class." (p.2032). In sum, research consistently supports the fact that a person's social network group strongly affects use of medical services. While it might appear that persons who can effectively meet their needs through relying upon a support group might be less likely to seek medical services, the research strongly suggests that they use health services 37 when family and friends expect that. Situational and Personality Variables Personality and situational variables also seem salient although there has been very little research about the impact of personality variables upon compliance behavior. The following section includes a review of the situational and personality variables that seem to have a clear bearing upon the compliance process. The specific instruments to measure these variables and the related methodological issues will be discussed in the Methods section. Satisfaction with Health Care Systems. The literature, as previously reviewed, has clearly demonstrated a positive relationship between overall satisfaction with important elements of health care and patient cooperation with prescribed regimes. A satisfaction scale was used in the present study. If there is a positive relationship between keeping appointments and being satisfied with the health care setting, then the clinic can work towards improving compliance through increasing satisfaction with various elements of the health care environment. L2£!§.9: Control. Locus of control construct refers to beliefs in personal control over personal destiny or fate (Rotter, 1966). Individuals who believe that reinforcements are contingent upon their own behavior, or that they are in control of their fates, are viewed as having an internal locus of control. Conversely, those individuals who do not believe that reinforcements are contingent upon their 38 own behavior but rather see their destiny as determined by luck, chance, or fate, are viewed as having an external locus of control. Following the development of Rotter's Internal-External Locus of Control Scale, the Health Locus of Control or HLC Scale was devised to assess locus of control specifically related to health. While many of the earlier studies done in this area used the Rotter Scale, later ones employed the HLC Scale. A methodologically superior instrument to the HLC, the Multidimensional Health Locus of Control Scale, or MHLC Scale, was used in the present study. A number of studies have demonstrated that persons with an internal locus of control orientation are more likely than those with external control to behave in ways that promote their physical well being. -For example, James et. al. (1965) found that non-smokers were more likely to have an internal locus of control than were smokers. They also found that males who stopped smoking because they believed the Surgeon General's Report were more internally oriented than males who believed the report but did not quit smoking. Similarly, Platt (1969) found that it was easier for internals to change their smoking behavior than for externals, and Steffy et. al. (1970) demonstrated a greater likelihood for internals to reduce their smoking than for externals. Other studies haVe failed to find a relationship between locus of control and smoking behavior. The research findings about birth control also giVe 39 some evidence that internally oriented persons are geared towards protecting their well being. Several studies demonstrate that sexually active persons who utilize contraception are more likely to have an internal locus of control than are those who do net use contraception. MacDonald (1970) showed that with single female college students, 62% of the internals reported using contraceptives while only 37% of the externals reported doing so. Lundy (1972) reported that sexually active women who were i contraceptive users were more internal than were sexually active non-users. However, more recent studies have not found relationships between internal orientation and contraceptive usage. Seeley (1976) found no control differences between the five groups of women differing in success of family planning. Similarly, Fisch (1974) did not find differences in locus of control between effective and ineffective family planners, with women in both of these groupings tending to be highly external. Internal-external control has been shown relevant to weight loss. Manno and Marston (1972), using two treatment groups and one control group, demonstrated no relationship between locus of control and weight loss with the two treatment groups. However, within the control group, externally oriented subjects weighed more initially and lost less weight than did internally oriented subjects. The research suggests that normal weight persons are more likely to depend upon internal cues for hunger recognition than 40 are overweight persons, who are more responsive to external cues related to food (Bruch, 1961). In another study, O'Bryan (1972) found that overweight women were more externally oriented than were thinner subjects. Further, externals and internals in the sample differed on several self-report measures, although they did not differ on behavioral indices of seeking and learning information. Regarding locus of control and seeking information, Seeman and Evans (1962) reported that with T.B. patients who had been matched for occupational status and education, internals in general knew more about their condition than did externals, and asked more questions about their illness from the hospital personnel. DuCette (1974) found that for recently diagnosed diabetics, internals knew more about their illness than did externals; however, for long term diabetics this difference was not found. He also found that internal long term diabetics were more likely to have missed doctor appointments and to ignore their diets than were externals. In trying to account for this, he speculated that internals realistically recognize that there are aspects of the disease which are out of their control, and respond to a sense of helplessness through relinquishing control and not following through with treatment. Results about the relationship between compliance and locus of control are inconsistent. Williams (1972), for example, found that internal locus of control was associated with a greater utilization of preventative dental services. 41 Further, Dabbs and Kirscht (1971) found that for motivational items of the locus of control scale, internal college students were more likely to be innoculated against influenza than were the external students. However, using expectancy items of the scale, internals were found to have been less likely to have received the shots. Weaver (1972) found that with a sample of kidney patients on a dialysis machine, internals were more likely to adhere to dietary restrictions and keep appointments than were externals. However, using a sample of working class Black females who were hypertension patients, Key (1975) found externals complied more with diet and medication; however, there was no relationship between locus of control and keeping appointments, clinic discontinuance, or self-report of medication. Kern (1974) reported that external elderly subjects used more outpatient physician services but did not differ from internals in patient initiated visits. Darrow (1973) found that internal females with venereal disease were more likely to return for treatment with the onset of new symptoms than were externals. ' Social Desirability. The construct of social desirability is particularly important. Edwards (1957) defined social desirability as being "the tendency of subjects to attribute to themselves, in self-description, personality statements with socially' desirable scale values and to reject those with socially undesirable scale values" (p.6, preface). In the present research study, the Marlowe-Crowne Social 42 Desirability Scale was used. It was designed to assess the extent to which persons need to obtain approval through responding in culturally defined appropriate and acceptable fashions. Social desirability seems important for compliance behavior. Gray, et. al. (1966) examined the impact of friends' expectations upon health related behavior and found that following through with immunizations for their children was highly contingent upon friends' expectations that this behavior would occur. This may indicate an influence of. social desirability. Most mothers were greatly swayed and influenced by their peer group's view of vaccinations for their children and tended to act in accordance with their perception of the way their peer group acted (Merrill et. ale, 1958). These data suggest that if persons perceive that a certain behavior is socially desirable to their friends, they will be more likely to show the behavior. Also, compliance behavior is greater for people being treated by their own regular physician than those being treated by a substitute physician. Social desirability might be operating in this process. It is speculated that the persons in this study with high social desirability needs will be more compliant, assuming that the subjects perceive compliance as socially desirable. ConverSely, those persons with low social desirability needs will not be influenced by what they perceive as socially acceptable or unacceptable behavior. 43 A concept related to social desirability, that of acquiesence, deserves mention. The concept of acquiesence refers to the tendency to have an agreeing response set or tendency to agree with items regardless of their content. It is a relevant concept because several of the instruments used in the present study are questionnaires requiring response alternatives ranging along a continuum from strongly agree to strongly disagree. Acquiesence is relevant also because of its possible relationship with compliance. Those persons having a tendency to comply might be more likely also to attempt to be cooperative or present themselves in a certain light through responding “true" to authoritative statements or items on questionnaires. The literature tends to approach the concept of agreeing response sets in two different manners. According to one view, response sets are a source of error. According to the other view, acquiesence is a manifestation of an individual's personality dynamics, or style of reacting by agreeing. Bass (1956) views this response set as representing "social acquiesence." Leavitt et. al. (1955) feel it represents basic "agreement with things authoritatiVe". More recently, Kenniston and Couch (1960) have viewed acquiesence as being “ a manifestation of a deep-seated personality syndrome whose underlying determinants serve to explain the phenotypical phenomenon of 'acquiesence' or 'agreement'" (p.151). They found that persons who demonstrated agreement responses, 0r "yeasayers," were persons with weak 44 ego controls who have few reservations about their impulses and who 'agree' and respond readily and easily to stimuli confronting them. "Naysayers" on the other hand, inhibited or suppressed their impulses and rejected emotional stimuli impinging upon them. In the present study, the acquiesence response set could present particular difficulties for several scales using a five point Likert type response format or a true-false answer. However, changing the format of the instruments could weaken their validity; further these instruments have been used in previous research studies and have been demonstrated to have construct validity. In considering a broader relationship between acquiesence and compliance or follow-through behavior, it must be noted that expressing agreement with particular items upon a questionnaire does not necessarily imply a positive or casual relationship with following through behaviorally. Because a person might report a belief that when ill one should seek assistance, this does not mean that the person will do this. More broadly, because a person expresses an attitude of willingness to do what the doctor says, the patient might not carry out the doctors'orders. There is no necessary relationship between a persons verbalized beliefs and subsequent actions. Also, since a medical regimen preScribed may consist of several components, an individual may be amenable to complying with none, some or all of the recommendations offered, and the behavior may 45 vary with time. Davis (1968) found consistency between attitudinal and behavioral measures of compliance in 55% of 154 subjects; attitudinal compliance was accompanied by behavioral non-compliance for 22%; for 8%, attitudinal non-compliance was accompanied by behavioral compliance; and for 15% attitudinal non-compliance was accompanied by behavioral non-compliance. ”Self-Esteem. Very little formal research has been done examining the association between self-esteem and compliance. However, there is information on the relationship between various disease states and self-esteem. Some research demonstrates that persons with more severe illnesses tend to have lower levels of self-esteem, although the direction of causation is not clear. Ray (1977) found that patients undergoing masectomy operations for cancer had lower levels of self-esteem than did a control group of cholecystectomy patients. The difference was interpreted as attributable to a loss of the breast and also the fear of the possibility of the recurrence of the cancer. Further, patients with chronic obstructive lung disease had higher levels of disintegration on their figure drawings, reflecting poorer self-esteem, than did patients with chronic renal disease and on dialysis machines. Higher self-esteem generally was correlated with overall, high general levels of functioning (Abramson et. al., 1975). Persons with high self-esteem may have more of a tendency to do what is necessary to keep themselves in good physical shape and fitness: Leonardson (1977) reported 46 that perceived physical fitness was related to positive self-concepts, measured by the Piers-Harris Self-Concept Scale. In the present study, the Rosenberg Self-Esteem Scale was used. Compliance is predicted to occur more frequently by those persons with higher levels of self-esteem because they will care more about themselves and so will do what they think needs to be done to care for themselves., "Body'Concept. Little research has been done regarding the effects of body concept upon compliance. However, Mahoney and Finch (1967) reported a positive relationship between body-cathexis and self-esteem utilizing the Rosenberg Self-Esteem Scale (1965). This suggests that those persons viewing their bodies in a positive manner care about themselves. Thus, they may be more likely to take better care of themselves through complying. The Physical Self Subscale of the Tennessee Self Concept Scale was used in the present study to ascertain subject views regarding their bodies, state of health, physical appearance, and sexuality. A positive relationship between viewing one's body in a positive manner and following through with doctors' orders is predicted. Having a positive concept of one's body is assumed associated with care of the body, Which includes complying with doctors' orders. Screening Programs The Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) came into existence in the State of Michigan 47 in 1973 through a court order issued by a federal judge mandating the screening of Medicaid children. This mandate was issued as a result of the awareness that the health care received by low income children was inadequate. The project is a joint venture between the Michigan Department of Public Health (M.D.P.H.) and the Michigan Department of Social Services (M.D.S.S.). The responsibility of overseeing the screening aspects is allocated to M.D.P.H.; the responsibility of outreach work through which eligible families are obtained is done by M.D.S.S. The stated objectives of the program are two fold: first it is to focus upon preventative health care and second, it is to focus upon the early detection and treatment of diseases and illnesses with the aim of averting chronic and disabling conditions before they intensify. Screening is designed basically for healthy as opposed to sick individuals and is a way to detect problems that are not readily apparent so that a referral for early diagnosis and treatment can be made. At this point, there is some evidence to justify the screening program in terms of cost effectiveness criteria. For example, the time and effort required to measure blood pressure is minimal compared with the catastrophic effects of untreated hypertension. According to Bailey et. al. (1974), hearing tests demonstrate that one out of 1000 children have severe hearing loss; between 15-30 out of 1000 children have an impairment in hearing sufficient to result in learning problems. Early detection of these problems will result in financial as well as human gains. 48 Moreover, Bailey et. al.(1974) report that sickle cell anemia is foundin one out of every 650 American Blacks at birth, and the trait is found in 8% of the Black population of this country. The only way to prevent the disease is through genetic counseling. Early identification allows counseling to take place and can ultimately result in the saving of many lives at a very small expense. Bailey et. al (1974) report that routine screening is very effective for detecting small amounts of lead, which result in brain and nerve tissue damage, subsequent retardation of the developmental and learning processes, and, in severe cases, death. Because damage from lead poisoning occurs without obvious specific isolated symptoms, and because of its prevalence in urban populations (20-28% of children screened have 40 micrograms of lead per millileter of blood), screening to detect its presence becomes extremely relevant. A study done at the University of Texas Health Service Center in 1974 utilizing national statistics showed that substantial savings would be gained through the national implementation of an EPSDT program (Currier, 1977). The report listed five major areas in which savings would be gained: (1) the mortality of infants, (2) the mortality of young persons, (3) rehabilitation costs for chronic diseases,’ (4) costs of physician visits and (5) hospitilization costs. Gains or saVings were estimated through comparing the cost of the health services against the loss of productivity due to impairments which could have been prevented through prior 49 health screening. The total dollar savings for.preventative screening within the five major areas listed over a 20 year period were predicted to be 43 billion dollars in 1976 currency. The savings was based on rough cost estimates since actual data are not yet available. Preliminary evidence predicting the likely success and merit of the EPSDT program is provided by an overview of the EPSDT program in Michigan (Currier, 1977). In this program, outreach endeavours have proven very successful in attracting minority group members and drawing them into the health care system, and in enabling overall health status to be improved. For all groups within this program there was a decline in referrals for tests involving measurements of height and weight, blood pressure, vision, venereal disease, hematocrit, lead in blood and sickle cell trait. This means that problems were detected through the screening- and remedied at an early stage so that further referral and intervention were unnecessary. The local health department reported the largest drop in referrals resulting from rescreenings. There was also a significant reduction in referrals to private doctors and dentists for persons who were screened two or more times. Overall, a drop of 13% occurred in the referral rate for health problems during the period of January through June of 1976 for those persons who were screened two or more times. A more recent evaluation provides conflicting evidence of the actual success of this program in Michigan. Keller 50 (1981) attempted to assess the overall impact of the EPSDT program in Michigan by examining the effects on the health status of participants. It was speculated that referral rates and medical costs would decline. The results showed that referrals did decrease over time. Although medical costs of EPSDT participants were significantly lower than were those of EPSDT non-participants, when actual costs of the screening program were also taken into account, differences in favor of the participants were outweighed by slightly greater costs attributable to program participation. Overall, the researcher concluded "the program is achieving modest gains at modest coSts" (p.192). 3 Hypotheses Based upon the review of the literature of variables which seem related to the compliance process, the following hypotheses were generated. Hypothesis 1: Compliers will score significantly more internal on the locus of control scale than will semi- compliers, and semi-compliers will in turn score significantly more internal than will non- compliers. Locus of control is measured by the Multidimensional Health Locus of Control Scale. The reasoning is that with an internal locus of control orientation, some control over one's life is experienced, and therefore a greater sense of personal responsibility is assumed. With this sense of personal responsibility, persons will be more likely to do what is necessary to keep themselves or others healthy, including following through on regular health screening checkups. 51 ' HypotheSis‘2: Compliers will have higher levels of self- esteem than will semi-compliers, who in turn will have higher levels of self-esteem than will non-compliers. Self-esteem will be measured by the Rosenberg Self-Esteem Scale and the Tennessee Physical Self Scale. It is assumed that persons with higher levels of self- esteem will care more about themselves and their overall well being, and will be more likely to take better care of themselves and their children medically. "Hy‘p‘dt’he’Sis‘ g: Compliers will have greater social desirability needs than will semi-compliers, who in turn will have greater social desirability needs than will non-compliers. Social desirability will be measured by the Marlowe-Crowne Social Desirability Scale. It is assumed that to take care of oneself and one's body as well as to follow recommendations made by an authority would be seen as a socially desirable action. Therefore those persons having the need to obtain the approVal of others would be more likely to follow the physician's recommendations. ‘HypdtheSis 4: Severity of illness in the child will be positively associated with compliance. For illnesses of equal severity, those with more pronounced symptoms will have greater compliance. It is assumed that with illnesses of greater severity, parents will perceive that it is more important to comply with the doctor's orders to maximize chances for recovery. 52 Hypothesis.§: Compliers will have more positive attitudes towards health care systems than will semi- compliers, who in turn will.have more positive attitudes than will non-compliers. The Satisfaction Scale and the Psychological Scale will be used to assess attitudes towards health care systems. It is assumed that more positive attitudes towards health care systems will facilitate a person attending appointments because of pleasant feelings surrounding the experience. ' In the present study, compliers are operationally defined as being those persons keeping between 67-100% of their scheduled appointments; semi-compliers are those keeping between 34-66% of their appointments; and non- compliers are those keeping between 0-33% of their appointments. Appointment records were observed over one and one half years and include both appointments for initial screening at the clinic and referrals to other sources for follow-up of specific medical concerns. This compliance categorization was an improvement over that which had been initially proposed, and was implemented because of constrictions imposed externally as well as to insure a sounder methodological design. Originally, one group of subjects was to be eligible mothers who, when contacted by the clinic outreach staff, refused to make a screening appointment. However, the Department of Social Services would not grant permission to obtain the information needed to identify those mothers. Also the time span was, 53 increased beyond a single appointment to provide a more stable and accurate rating of compliance. Pilot StudV. Pilot data were collected to help estimate the feasibility of the study and to refine the instruments and procedure. Results indicated a high level of subject cooperation and only a few problems with reading and comprehending the instruments. Although some persons felt that the questionnaire was too long, they seemed willing to complete them. It was decided to not omit any instruments or specific items. The procedure for collecting the data was retained for the regular study with one exception. During pilot work, the efficacy became apparent of arranging home visits by phoning first, when possible, rather than simply making unannounced home visits. Several issues arose during the pilot study which could influence generalizability. First,.although subjects' willingness to complete the questionnaire was impressive, certain subjects refused to participate; this could bias results and limit generalizability. The people who were more willing to participate appeared younger, somewhat neater in apparance, and of a higher socio-economic level. Also of concern is that persons who were approached in the clinic may have felt an obligation to participate. This observation is based upon the fact that overall, persons seemed more amenable to participation when other persons were in the waiting room and were also filling out instruments. 54 The few refusals to participate seemed to occur when people were in the waiting room by themselves or with very few others, Or when they were in a hurry and stated clearly that they were unable to remain to fill out the forms. The manner in which subjects were asked to participate in the study also seemed to affect their decision. Specifically, when it Was emphasized that they did not have to participate, subjects were much less likely to participate than if they were simply asked if they would be willing to participate. In the main study subjects were simply asked if they would be willing to participate. METHOD Subjects Subjects were mothers of children aged 6-12 who were eligible for participation in the Early Periodic Screening, Diagnosis and Treatment Program (EPSDT) in Ingham County, Michigan. Patients were children whose mothers were on the case load for the Department of Social Services because they were considered to be financially indigent by legal criteria. All subjects were Medicaid recipients. A portion of the population were selected as they came to the clinic for a screening appointment and were offered an opportunity to participate in the study. Although 80 subjects were to be selected from this setting, many more questionnaires were administered, which were later discarded because the mothers did not fit the criterion of having children within the proper age bracket. Individuals who had not shown up for their screening appointment (n=20) were approached within their homes to participate. The data were collected from subjects over a period of five months beginning in June, 1980. However, clinic records were examined for a period of a year and a half prior to the study. 55 56 Instruments Tennessee Physical Self Scale. This is an 18 item subscale from the 100 item Tennessee Self-Concept Scale. The subscale assesses attitudes towards one's body, state of health, physical attractiveness and sexuality (Fitts, 1965). The items are rated on a one through five scale with extremes ranging from completely false to completely true. Fitts (1965) found high two week test-retest reliabilities (r=.92) for the overall self-concept scale as well as for the Physical Self Subscale (r=.87). In addition, items from the test correlated adequately with comparable scales of other measures such as the MMPI and EPPS. Further, the test scales predicted differences in such areas as psychological status and changes in personality as a result of psychotherapy. "Marlowe-Crowne Social Desirability Scale. This instrument was designed to assess the extent to which persons tend to or need to obtain approval through responding in culturally defined appropriate and acceptable fashions (Crowne and Marlowe, 1960). The scale is comprised of 33 items to be rated as true or false. The items focus upon personal reactions to various situations, such as, "I have never intensely disliked anyone," "I never resent being asked to return a favor.“ The items are scored according to whether the answer is more likely to be a false socially desirable response rather than a true one. In this manner, an estimate of a persons need to appear in a socially desirable light is obtained. 57 The items of the Marlowe-Crowne Social Desirability Scale were selected from other instruments or constructed to reflect social desirability but with minimal association with pathology. Fifty items were rated for social desirability by ten judges (faculty members and graduate students from the psychology department of Ohio State University). The judges were instructed to assume the point of view of college students. One hundred percent agreement was obtained on 36 of the items and 90% agreement on 11 more items. These 47 items were given to 76 students in introductory psychology courses and an item analysis was conducted. The 33 items that discriminated between high and low total scores at the .05 level or better were retained for the final version. Rosenberg Self-Esteem Scale. This is a ten-item scale devised to measure the construct of self-esteem (Rosenberg, 1965, Johnson, 1976). It is easy to administer, brief, and unidimensional. The developers of the instrument report that it has face validity and items were selected which openly and explicitely dealt with the self-esteem construct. Both positive and negative statements about self are presented alternately to reduce the effects of respondant set. The developers defend the adequacy of the scale on the basis that it is related to other data and constructs in a theoretically meaningful fashion. Satisfaction Scale. The Satisfaction Scale used in the present study is a version of an earlier scale devised to measure attitudes towards physicians and primary medical 58 care (Zyzanski et. al., 1974). Both scales were developed on a varied sample to measure feelings about three distinct elements of medical care: (1) Professional competance of the physician, (2) personal qualities of the physician, and (3) cost convenience of health care. The original questionnaire had two serious flaws; lack of clarity about subjects' interpretation of some items, and inadequacy of a dichotomous response categorization of agree-disagree. The revised scale used a Likert scoring with five response alternatives, ranging from (1) strongly agree to (5) strongly disagree. Total reliability across all scales for the new scoring method was .90. Multidimensional Health Locus 9: Control Scale. The Multidimensional Health Locus of Control Scale (MHLC) (Wallston and Wallston, 1978) is considered conceptually and methodologically superior to the Health Locus of Control Scale (HLC). The HLC Scale is a unidimensional measure of the degree to which good health is perceived determined by the subject's own behavior. In contrast, the MHLC Scale provides a multi-dimensional measure taping beliefs that the source of reinforcement for health related behavior is primarily determined by the individual (IHLC), is a matter of chance (CHLC), or is under the control of powerful others (PHLC). In addition, the MHLC Scale was developed on a more diverse, representative sample of respondants than the college Students used in the development of the HLC, and there are two equivalent forms. 59 ’- Preliminary data related to the reliability and validity of the MHLC Scale are available. Alpha reliabilities for each of the two forms of the scale ranged from .673 to I .767; when combined, the reliabilities increased to .830 to .859. The IHLC (individual health locus of control) and the PHLC (powerful others health locus of control) scales are statistically independant. However, the IHLC and the CHLC (chance health locus of control) scales are negatively correlated, and the PHLC and the CHLC are positively correlated. None of the three MHLC scales of either form are significantly correlated with sex, and only the first form of the PHLC correlated significantly with age or level of education. Psychological Scale. This scale was developed by Inez Tillman and originally consisted of six subscales assessing maternal attitudes, social responsibility, social distance, interpersonal processes, self-esteem and awareness, and attitudes and feelings of women about various issues. For this project, selected items were chosen to elicit relevant information not covered by other instruments. Medical Records Questionnaire. This questionnaire is filled out routinely upon a mother's visit to the clinic. It contains information about demographic factors, and childhood medical and social histories of the patients. Informational and Demographic Qgestionnaire. The Informational and Demographic Questionnaire was designed for this study to obtain desired information not found in other 60 instruments. Demographic information as well as feelings towards the child's health and behavior, and attitudes towards the clinic, are elicited through this instrument. A semi-structured format is provided, allowing some degree of flexibility in answers. Followup Questionnaire. .This questionnaire was intended to provide information about reasons for non-compliant behavior. It was mailed to participants who did not keep an initial clinic appointment. Those subjects not returning it by mail were contacted over the phone or in person to ascertain the information. Followup data were also obtained from the medical records and checking referral sources when appropriate. I Procedure The data were collected in the health screening clinic or in subjects' homes, by myself and three undergraduate female assistants. Females were specifically selected to avoid confounding gender. The assistants were selected also because of their interest in the project and their general desires to work directly with people and to have a field experience involving interviewing skills. They observed the primary researcher administer the questionnaires both in the field and in the clinic. Then, they were observed at the task and given feedback. The instruments were administered in the clinic to those subjects who showed up for their clinic appointment. One of the data collectors approached mothers sitting in 61 the waiting room and explained briefly that we were conducting a study with the goal of helping to improve health care services for people using the clinic. The mothers were informed that participation would entail filling out forms and questionnaires and were asked if they would be willing to participate in the study. Subjects who agreed to participate were handed a questionnaire which included a cover letter explaining the study, and a consent form. It was explained that the consent form was a statement of the fact that they had understood the conditions of the research and were willing to participate. Even though the study was specifically concerned with mothers of children. aged 6-12 years, participation was offered to all mothers within the waiting room at a given time of testing to insure that persons did not feel left out, excluded or suspicious for any reason.. To avoid inconveniencing the clinic personnel, mothers who were preoccupied with other activities such as helding an infant or filling out clinic forms were not approached unless they became unoccupied. Subjects were instructed to ask questions if anything was not clear to them. i The data of subjects who did not show up for their scheduled clinic appointment were collected through home visits. The names were obtained through the daily clinic appointment sheets. When possible they were contacted over the phone. For those persons not having telephones, unannounced home visits were made. Two persons went together 62 on the home visits for safety and security reasons. Having two researchers rather than one could threaten the subjects. However, subjects were generally willing to have us enter their homes. A judgement was made that our safety justified pairs of researchers. During the exploratory pilot data collection phase of this study, two Of the assistants described an experience of feeling intimidated by persons encountered in the streets of a neighborhood where they were making a home visit. RESULTS Overview The data analyses proceeded through several steps. Frequency scores on the demographic and informational data were computed to help describe the sample. Chi-Square tests were used to measure association between compliance and demographic and informational responses. Internal consistency was calculated for all instruments and subscales. ANOVA was used to examine differences between the three compliance groups with respect to scores on the personality measures and health care satisfaction. Internal Consistency and Norms 1 Internal consistency was measured by Chronbach's coefficient alpha. The alpha coefficients for total scale scores are listed in Table 2. Alpha coefficients for subscales of the Multidimensional Health Locus of Control Scale, the Satisfaction Scale, and the Psychological Scale are listed in Table 3. The subscales for the Psychological Scale seemed to fit most naturally into three groupings descriptive of attitudes towards community agencies, attitudes towards socio-economic groups and attitudes towards doctors. The internal consistencies of the subscales are lower than those for total scales, with the exception of 63 64 TABLE 2 Alpha Coefficients for all Scales Scale Alpha Coefficients Number of Items Tennessee Physical Self Scale .87 18 Rosenberg Self- Esteem Scale .81 IO Marlowe-Crowne Social Desirability Scale .73 33 Multidimensional Health Locus of Control .66 18 Satisfaction Scale .84 , 42 Psychological Scale .55 12 Alpha Coefficients for Subscales 65 TABLE 3 Multidimensional Health Locus of Control Scale Subscale Internal Locus Chance Locus Powerful Others Alpha Coefficients .74 .51 .48 Number of Items Satisfaction Scale Subscale Alpha Coefficients Number of Items Cost/Convenience- Personal Qualities Professional Competence .35 .60 .33 14 14 14 f Psychological Scale Subscale Attitudes Towards Community Agencies Attitudes Towards Socio-Economic Groups Attitudes Towards Doctors ‘ Alpha Coefficients .10 .16 .78 Number of Items 66. attitudes towards doctors from the Psychological Scale, and the internal locus subscale from the Multidimensional Health ' Locus of Control Scale. The means for the present population are within the limits of those obtained from prior populations sampled. Means for the present population are listed in Table 4. Table 5 lists norms for the Marlowe-Crowne Social Desirability Scale and the Multidimensional Health Locus of Control Scale. Characteristics of the Sample Frequency data from the Demographic and Informational Questionnaire is presented to assist in characterizing and describing the present population. The questionnaire (Appendix A ) eliciting this information is divided into three subcategories: Specific demographic patterns, attitudes towards the child and the child's health, and feelings towards the Medicaid Screening Clinic. Chi-Squares were computed to determine the association between the information from the Demographic, Informational Questionnaire and compliance categories. While general trends are reported upon in the writeup, more specific information is listed in Table 6. ‘Demographic Features The majority of the mothers sampled are either currently married or divorced (37% and 33% respectively). A smaller proportion are separated (14%) and a slightly higher proportion (16%) reported being never married. Almost half of the mothers described themselves as being housewives 67 TABLE 4 Table of Means Semi- Non- Scale Compliers Compliers Compliers Tennessee Physical Self Subscale 67.68 61.74 66.96 Marlowe-Crowne _ Social Desirability 19.47 17.49 20.46 Rosenberg Self- Esteem 18.3 17.6 18.5 Psychological 39.72 36.12 41.28 Attitudes Toward Doctors 23.38 19.60 23.31 Attitudes Towards Community Agencies 5.94 5.34 6.62 Attitudes Towards Socio-economic Status 10.68 11.28 23.1 Satisfaction 38.64 2.52 29.82 Professional Competence 1.29 .55 1.17 Personal Qualities .91 .10 1.17 Cost/Convenience .74 -.22 .05 Health Locus of Control 72.54 73.26 75.60 Internal Locus 25.44 24.06 28.56 Chance Locus 24.96 25.98 24.60 Others Locus 22.02 23.22 22.62 68 TABLE 5 Normative Data: Marlowe-Crowne Social Desirability Scale and Multidimensional Health Locus of Control Scale Normative Current Means Means Marlowe-Crowne Social Desirability Scale females Northwestern University 13.5 (n=86) compliers: 19.47 University of North Dakota 16 (n=59) semiecompliers 17.49 Lesley College 14.2 (n=60) non-compliers 20.46 Secretarial School ' Insurance Company 7 15.4 (n=88) 24.6 (n=88) applicants told scores to be used in making decisions about hiring Psychiatric Out-Patients 11.5 (n=46) Multidimensional Health Locus of Control Scale Internal Health Locus of Control Form A 25.10 compliers 25.44 Form B 25.30 semi-compliers 24.06 Forms A and B 50.40 non-compliers 28.56 Powerful Others Locus Of Control Form A 19.99 compliers 22.02 Form B 20.97 semi-compliers 23.22 Forms A and B 40.97 non-compliers 22.62 Chance Locus of Control Form A 15.57 ' compliers 24.96 Form B 15.46 semi-compliers 25.98 Forms A and B 31.04 non-compliers 24.60 Demographic, Informational Frequencies 69 TABLE 6 Absolute Relative Adested** Category Label Frequency Frequency Frequency Marital Status Single 15 15.3 15.5 Married 36 36.7 37.1 Divorced 32 32.7 33.0 Separated 14 14.3 14.0 Blank 1 1.0 Missing Mothers.0ccupation Temanad* 1 1.0 1.3 Professional 3 3.1 3.8 Secretarial 1 1.0 1.3 Crafts 1 1.0 1.3 Operator, Laborer 1 1.0 1.3 Transportation 1 1.0 1.3 Service 3 3.1 3.8 Student 13 13.3 16.5. Unemployed 7 7.1 8.9 Housewife 47 48.0 59.5 Domestic Help . 1 1.0 1.3 Blank 19 19.4 Missing Fathers Occupation Temanad* 6 6.1 10.5 Sales 1 1.0 1.8 Crafts 5 5.1 8.8 Operator, Laborer 20 20.4 35.1 Transporation 1 1.0 1.8 Service 3 3.1 5.3 Student 3 3.1 5.3 Unemployed 15 15.3 26.3 Military 1 1.0 1.8 Disabled 2 2.0 3.5 Blank 41 41.8 Missing * Technical, Managerial, Administrative **Frequencies adjusted for missing data 70 TABLE 6 (cont.) Absolute Relative Adjusted Category Label Frequency Frequency Frequency Number of Sons None , 21 21.4 21.4 One 23 23.5 23.5 Two 31 31.6 31.6 Three 13 13.3 13.3 Four 4 4.1 4.1 Five 5 5.1 5.1 Six 1 1.0 1.0 Number of Daughters None 19 19.4 19.6 One 35 35.7 36.1 Two 27 27.6 27.8 Three 10 10.2 10.3 Four 4 4.1 4.1 Five 1 1.0 1.0 Eight 1 1.0 1.0 Blank l 1.0 Missing Education Elementary 3 3.1 3.6 Middle 6 6.1 7.1 High 27 27.6 32.1 H.S. Degree 32 27.6 32.1 Some College 15 15.3 17.9 Graduate Degree 1 1.0 1.2 Blank 14 14.3 Missing Religion Protestant 54 55.1 67.5 Catholic 15 15.3 18.8 No Religion 10 10.2 12.5 Other 1 1.0 1.2 Blank 18 18.4 Missing Relevance of Religion Yes 60 61.2 64.5 No 33 33.7 35.5 Blank 5 . 5.1 Missing TABLE 6 (cont.) 71 AbsolUte Relative Adjusted Category Level Frequency Frequency, Frequency Status of Mother Alive ‘85 86.7 86.7 Dead 13 13.3 13.3 Status of Father Alive 71 72.4 74 Dead 25 25.5 26 Blank 2 2.0 Missing Child I11 Past 3 Mos. Yes 22 22.4 22.7 No 75 76.4 77.3 Blank 1 1.0 Missing Responsibility for Medication Yours 84 85.7 89.4 Theirs 4 4.1 4.3 Both 6 6.1 6.4 Blank 4 4.1 Missing Difficulty Controlling Childs Behavior Yes 11 11.2 12.0 No 59 60.2 64.1 Sometimes 22 22.4 23.9 Blank 6 6.1 Missing Child a Burden? Yes 7 7.1 7.3 No 89 90.8 92.7 Blank 2 2.0 Missing .Wgrried about Child's Health Yes 29 29.6 30.5 No 56 57.1 58.9 Somewhat 10 10.2 10.5 Blank 3 3.1 Mi551ng 72 TABLE 6 (cont.) Absolute Relative Adjusted Category Label Frequency Frequency Frequency Opinion of Clinic Great 27 27.6 29 Good 54 55.1 58.1 Okay 12 12.2 12.9 Blank 5 5.1 Missing Satisfied with Visit Yes 87 88.8 97.8 No 1 1.0 1.1 Sort of l 1.0 1.1 Blank 9 9.2 Missing Too Long a Wait? Yes 14 14.3 ' 16.1 No 72 73.5 82.8 Sort of 1 1.0 1.1 Blank 11 11.2 Missing At Ease with Clinic Staff? Yes 81 82.7 86.2 No 4 4.1 4.3 Somewhat 9 9.2 9.6 Blank 4 4.1 Missing Treated with Respect Yes 88 89.8 97.8 No 2 2.0 2.2 Blank 8 8.2 Missing 73 (48%), with 7% proclaiming to be unemployed. It is possible that the terms "unemployed" and "housewife" were used inter- changably. The next highest proportion (13%) stated that they were students. There was a greater degree of variability in occupations of the children's fathers than for mothers. Most of the fathers were employed in operator-laborer type occupations (20%) with the next highest proportion being categorized as unemployed (15%). A higher proportion of men than Women were in the technical, managerial and administrative professions (6% as compared to 3%) and more than twice as many (15% as compared with 7%) were described as being unemployed. It must be noted that for 41 subjects, the item about fathers occupation was left blank. ' One person reported a graduate school degree and 15% had completed some college. 33% of the respondants had graduated from high school and a slightly smaller proportion (28%) had completed some high school. Fifty-five percent of the respondants said they were Protestants and 15% 7Catholics; 10% indicated no religious affiliation. Sixty-one percent of the mothers responding reported that religion was personally important to them and 34% stated that it was not. Health Related Attitudes Seventy-seven percent of the respondants reported that their children had not been ill within the past three months, with 22% noting the presence of illness. Fifty-seven 74 percent of the subjects expressed not being worried about their child's health in general, 10% stated they were somewhat concerned and 30% stated that they were definitely worried about their child's health. The majority of the mothers (86%) felt that when their child was ill, it was the mother's responsibility to remind the child to take medicine. Most of the mothers (60%) did not feel that their child's behavior was difficult to control. Hewever, 22% said that behavior control is sometimes a problem and 11% indicated a definite problem in this area. Similarly, the overwhelming proportion (91%) of the mothers did not feel that their child was a burden. Within this same questionnaire, opinions about the Project Health Clinic and the quality of care received within this setting were elicited. The feelings overall were quite positive. Twenty-eight percent of the respondants reported feeling that the clinic was "great“, 55% felt that the clinic was "good", and 12% stated that it was "o.k.". No one expressed explicit dissatisfaction with the clinic. When asked whether they had gotten what they were looking for from the clinic, 89% responded that they had. Ninety percent of the population felt that they were treated with respect by the clinic staff, 83% felt at ease with the personnel. The area of greatest dissatisfaction was amount of time required to wait before being screened, although only 14% stated that this was a problem. 75 Chi-Square Analyses Chi-squares were computed to determine the association between the information contained within the Demographic and Informational Questionnaire and compliance categories (Table 7). There were no significant associations between compliance categories and demographic variables. For the informational items, a significant relationship was found between compliance categorization and expressed worry about child's health. Compliers expressed a greater degree of worry about their child's health and semi-compliers expressed less worry about their child's health than expected by chance (Table 8). Hypothesis Testing ANOVA'S were used to test hypotheses about variations in scores between the three groups; compliers, semi-compliers, and non-compliers. Hypothesis 1 The first hypothesis stipulated that persons designated as compliers would score significantly more internal on the MHLC than would those designated as semi-compliers, and that semi-compliers would in turn score significantly more internal than non-compliers. This hypothesis was not supported by the ANOVA on the total score (Table 9). Neither were there significant differences for the subscales of Powerful Others Locus of Control or Chance Locus of Control. The groups did differ significantly on the Internal Locus of Control subscale 76 TABLE 7 Chi-Squares: Association between Items in Demographic, Informational Questionnaire and Compliance Categories Marital Status Occupation of Child's Mother Occupation of Child's Father Number of Sons Number of Daughters Religious Affiliation Importance of Religion Mother Alive Father Alive Child Ill in Past 3 Months Responsibility for Medication when Child Ill Difficulty Controlling Child's Behavior Is Child a Burden? Worried About Child's Health Opinion About Clinic Satisfied With Clinic Too Long a Wait? At Ease With Personnel? Treated With Respect? Chi-Squares 6. 25. 19 12. 10. 4 dNN-h-‘O Raw 83 69 .67 01 14 .42 .264 .67 .47 .38 .38 .80 .16 .99 .05 .61 .48 .31 .10 DF 6 20 18 12 12 N-b-D-P-P-h Significance .336 .176 .351 .444 .603 .619 .876 .717 .480 .829 .117 .433 .925 .027* .902 .330 .648 .679 .578 77 TABLE 8 Chi-Square: Analysis of Mothers' Reported Worry About Child's Health Observed Frequencies Yes No Somewhat Sum Total Complier 24 28 5 57 Semi-Complier 0 13 2 15 Non-Complier 4 13 3 19 All 28 54 9 91 Expected Frequencies Yes No Somewhat Sum Total Complier 17 34 6 57 Semi-Complier 5 9 1 15 Non-Complier 6 11 2 19 A11 28 54 9 91 78 TABLE 9 ANOVA for Multidimensional Health. Locus of Control Scale 26.36 90 SS df ms F P Between Groups .46 2 .23 .77 .46 Within Groups 25.90 . 88 .29 79 (Table 10). However, the pattern of means was not as predicted. The non-compliers were more internal than the semi-compliers or the compliers (means are in Table 4). Hypothesis 2 The second hypothesis stipulated that compliers would have higher levels_of self-esteem than would semi-compliers who in turn would have higher levels of self-esteem than would non-compliers. Two instruments were used to assess different dimensions ' of self-esteem: The Physical Self Scale of the Tennessee Self-Concept Scale, and the Rosenberg Self-Esteem Scale. There were no significant differences between the groups on either instrument (Tables 11 and 12){ Hypothesis 3 The third hypothesis stipulated that compliers would have greater social desirability needs as measured by the Marlowe-Crowne Social Desirability Scale than would semi- compliers, who in turn would have greater needs to appear in a socially desirable fashion than would non-compliers. This hypothesis was not supported (Table 13). Hypothesis 4 The fourth hypothesis stipulated that severity of illness within the child would be positively associated with compliance. The medical records of the subjects showed that only three had what could be considered serious health problems: Cystic fibrosis, epilepsy, and suspected Down's Syndrome. Because of the lack of serious illnesses ANOVA for Subscales of the Multidimensional Health 80 TABLE 10 Locus of Control Scale Internal LoCus Source SS df ms F P Between Groups 5.40 2 2.70 3.17 .04 Within Groups 74.76 88 .84 Total 80.16 90 Powerful Others Locus Source SS df ms F P Between Groups .57 2 .28 ‘ .40 .67 Within Groups 62.02 88 .70 Total 62.59 90 Chance Locus Source SS df ms F P Between Groups .50 2 .25 .35 .70 Within Groups 62.17 88 .71 Total 62.69 90 81 TABLE 11 ANOVA for Tennessee Physical Self Scale .Source SS df ms Between Groups 1.34 2 .67 2.68 .07 Within Groups 22.04 88 .25 Total 23.38 90 82 TABLE 12 ANOVA for Rosenberg Self-Esteem Scale Source SS df ms F Between Groups .08 2 .04 1.13 Within Groups 3.05 89 .03 Total 3.12 91 83 TABLE 13 ANOVA for Marlowe-Crowne Social Desirability Scale Source SS df ms F P Between Groups .07 2 ' .04 1.30 .28 Within Groups 2.43 90 .03 Total 2.50 92 84 within the sample the hypothesis could not be tested. The medical records also gave information on the types of conditions which resulted in referrals to outside sources. As shown in Table 14 there dees not appear to be a pattern differentiating compliers from non-compliers in terms of tendencies to follow through with referral appointments. Infectious diseases could be viewed as being more critical and hence more worthy of medical attention. No pattern differentiating the groups was noted here either (Table 15). It could be argued that some of these ailments were viewed by mothers as self-limiting and thus not requiring additional medical attention. Hypothesis 5 The fifth hypothesis stipulated that compliers would have more positive attitudes towards health care systems than would semi-compliers, who in turn would have more positive attitudes than would non-compliers. The Satisfaction Scale was one instrument used to measure this dimension. It has three subscales: Professional competance of physicians, personal qualities of physicians, and cost/convenience aspects of health care. There were no significant differences between groups for the professional competance of physicians or personal qualities of physicians subscales (Tables 16 and 17). However, there was a significant difference in cost/convenience. Compliers ranked highest in satisfaction, with semi-compliers ranking lowest. 85 TABLE 14 Number of Referral Appointments Kept for Varying Medical Conditions, by Compliance Groups . Semi- Non- Medical Compliers Compliers Compliers Condition *5 N.S. S N.S. S N.S. Total Dental Problems 10 3 3 3 (cavities, decay, fillings) Routine Eye 8 2 1 2 (eye muscle, hyperopia) Infectious 6 1 l 1 Diseases (eye, ear, throat, urinary tract infections) Orthopedic 8 1 2 Disorders (leg and feet problems, scoliosis) Skin Diseases 3 1 (Dermatitis, warts) Fecal 1 Incontinence Enuresis 1 Headaches 1 Anemia 1 19 13 11 Show No Show * S NS 86 TABLE 15 Follow Through Patterns for Infectious Diseases Disease Appointment Kept Sore Throat Eye Infection Ear Infection Urinary Tract Infection Yes No complier 1 semi-complier complier compliers 1 complier 1 non—complier complier 87 TABLE 16 ANOVA for Satisfaction Scale Source SS df ms F Between Groups 9.30 2 4.65 2.88 Within Groups 143.57 Total 152.66 .06 ANOVA for Subscales of Satisfaction Scale 88 TABLE 17 Professional Competence Source SS df ms F P Between Groups 6.81 2 3.40 1.18 .31 Within Groups 248.54 86 2.90 Total 255.35 88 Personal Qualities Source SS df ms F P Between Groups 10.87 2 5.43 2.16 12 Within Groups 215.96 86 2.51 Total 226.82 88 Cost/Convenience Source SS df ms F P Between Groups 14.71 2 7.36 5.60 .005 Within Groups 115.78 88 1.32 Total 130.50 90 89 The Psychological Scale provided a measure of attitudes towards specific aspects of community service agencies, iticluding health care settings. A significant difference was found between-groups on this dimension (Tables 18 and 19). thawever, the semi-compliers had lower mean scores than did iflie compliers or non-compliers. An interpretation of this srignificant result is obscured by the fact that the alpha coefficient for this scale was quite low. There were no ssignificant differences for the subscales measuring attitudes 'towards community agencies and the rights of women in 'lower socio-economic groups. Significance was found for 'the subscale measuring attitudes towards doctors. However," 'the lowest means were obtained for the semi-compliers, with compliers and non-compliers having means which were slightly higher and quite similar. The alpha coefficient for this subscale was higher than for the other subscales of this instrument. *F0110wup Data Approximately two months after the data had been collected, followup questionnaires were sent to those persons not showing up for the regularly scheduled appointment to ascertain reasons underlying their non-compliant behavior. Those who did not return their questionnaires were contacted by phone or home visit. Return rate information and reasons provided for nonattendance are given in Table 20. When the followup questionnaire was mailed to the respondants, the questions were inadvertently phrased in 90 TABLE ANOVA for Psychological Scale 18 Source SS df ms P Between Groups 1.16 2 .81 3.93 .02 Within Groups 17.86 87 .21 Total 19.48 89 91 TABLE 19 ANOVA for Subscales of Psychological Scale Attitudes Towards Community Agencies Source SS df ms F Between Groups 3.38 2 1.69 2.17 Within Groups 67.61 87 .78 Total 70.99 89 Attitudes Towards Doctors Source SS df ms F Between Groups 3.77 2 1.89 3.67 Within Groups 44.75 87 .51 Total 48.53 89 Attitudes Towards Socio-Economic Groups Source SS df ms F Between Groups 1.41 2 .70 1.50 Within Groups 40.90 87 .47 Tota1 42.30 89 92 TABLE 20 Return Rate Information and Reasons Provided for Nonattendance RetUrn Rate ‘19 Questionnaires sent. 6 Returned through the mail. 8 Information obtained over the phone or through home visit. Persons could not be reached. lm ‘ReaSOns Provided for Nonattendance ' N Reasons 2 Don't remember. 1 Problems with transportation. 1 Kids healthy and hence saw no reason to come. 2 Other family member ill. 1 Had to leave town. 1 Had called to reschedule and when she did they were no longer on Medicaid, and hence ineligible. 1 No ride and something else came up. 5 Reported had not been scheduled. 93 such a way as to permit the subjects to report that they had not missed an appointment. In retrospect, it would have been best to have asked questions differently. Instead of stating "If you had an appointment and didn't come for it please list the reason(s) why you didn't show up," it would have been better to state "we noticed that you missed an appointment and were wondering if you could remember why." Five out of six persons returning the followup questionnaire through the mail responded that they had not been scheduled for a screening appointment. In general, reasons provided for non-attendance suggest priority given to other concerns. Twelve out of fourteen respondants reported feeling that screening appointments were important and ten out of fourteen respondants reported having a family doctor. DISCUSSION The present research study was designed to examine the relationship between compliance within a health care setting and some personality traits, demographic features, and attitudes towards health care systems. Compliance was defined in terms of percentage of appointments kept. The sample consisted of Medicaid mothers having children who were eligible for screening at a Medicaid Screening Clinic. Evaluation Qj Hypotheses First Hypothesis The first hypothesis predicted that compliers would score significantly more internal on the locus of control scale than would the semi-compliers, and that semi-compliers would in turn score significantly more internal than would non-compliers. The results did not support the hypothesis. Contrary to the prediction, the results suggest that non-compliers have a greater internal locus of control than do compliers, who in turn are more internally oriented than are semi- compliers. One possibility is that non-compliers feel more in control of determining their fate, and less ruled by external constrictions and obligations. Therefore, they experience less of a need to comply with prearranged 94 95 appointments. It also might be that because they experience a greater degree of control over their lives, they feel a greater sense of confidence in being able to deal with health care issues on their own without seeking assistance through preliminary screening. Compliers, who have a slightly more internal locus of control orientation than do semi-compliers, might be more diligent at keeping appointments for different reasons. An obvious explanation might be that since they feel in control of their fate or destiny, they realize their responsibility in following through with appointments to maximize health care benefits. It also makes sense that since the internal compliers think that they have control over what happens to them, they will set up goals which they can meet. If their goal is better health, it seems reasonable that they will take action that will lead towards fulfillment of that goal; showing up for appointments. The semi—compliers, feeling that their fates are determined by factors outside of their control, might be erratic in their attendance patterns because of a belief that keeping appointments will not make much difference in determining an ultimate health outcome. That is, they might believe that remaining in good health has little to do with their efforts. ‘Second Hypothesis The second hypothesis predicted that compliers would have higher levels of self-esteem than would semi-compliers, 96 who in turn would have higher levels of self-esteem than would non-compliers. This hypothesis was not supported by the data. It seems reasonable that persons with high self-esteem would _ tend to do what is necessary to preserve good health, simply because they do care about themselves. Other factors may have overriden or counteracted the effect of self-esteem. These factors might include such things as perceptions of seriousness of disease, vulnerability to illness in general, or beliefs about the efficacy of the screening process in detecting early illness. “Third HypOthesis The third hypothesis stipulated that compliers would have greater social desirability needs than would semi- compliers, who in turn would have greater needs to appear in a socially desirable fashion than would non-compliers. This hypothesis was not supported within the present study. Other factors may have masked any effects of social desirability. The literature suggests that mothers are strongly influenced in their compliance behavior by their friends' behavior and expectations (Oakes et. al., 1970: Heinzelman and Bagley, 1970; Merrill et. al., 1958; Johnson, 1962). This might reflect a desire to appear in a socially desirable light. Although the groups did not differ in social desirability, the social desirability Scores for the entire sample were high compared with published norms. This indicates higher than average social desirability needs 97 in this sample as a whole. Fourth Hypothesis The fourth hypothesis stipulated that severity of children's illnesses would be positively associated with compliance. Because of the lack of severe illnesses it was not possible to test this hypothesis. Previous research suggests a curvilinear relationship between perceived severity of illness and compliance. For example, Becker and Maiman (1975) stressed that it is the mother's perception of the severity of the child's disease at the onset that determines her likelihood of complying in terms of giving medication and keeping appointments. It has also been found that for serious diseases with poor prognosis, patients may give up, feeling that attempts at a cure are hopeless (Charney, 1972; Greene et. al., 1982). Similarly, compliance of patients with chronic diseases is apt to decrease over time, especially if the consequences of ceasing compliance are not immediate or readily apparant (Blackwell, 1973). Fifth Hypothesis The fifth hypothesis predicted that compliers would have more positive attitudes towards health care systems than would semi-compliers, who in turn would have more positive attitudes than would non-compliers. Two scales were used to measure satisfaction with the health care setting: The Satisfaction Scale and the Psychological Scale. There was partial support for this hypothesis. Compliers were clearly more satisfied with cost/convenience (measured 98 on the Satisfaction Scale) than were semi-compliers or non-compliers. However, contrary to the prediction, non- compliers reported more satisfaction with cost/convenience than semi-compliers. It may be that compliers were financially better off than were semi-compliers or non- compliers and so feel less overwhelmed by the prospect of large medical bills. Previous research documents an inverse relationship between high medical costs and compliance. Although the participants within the Medicaid Screening Clinic are all on Medicaid and receive financial support for health care services, it is possible that their health care expenses were not subsidized previously. Both non-compiiers and semi-compliers were less satisfied with the cost/convenience aspect of health care than were compliers. This may be a reason why they are more reluctant to show up consistently for appointments in general. A possibility relevant to why non-compliers are more satisfied than are semi-compliers, is that because they show up so infrequently for appointments they less often have to deal with the issue and so have less concern. It is also possible that persons within the semi-complier and non-complier categories have the perception that health care services in general discriminate against the poor through being overpriced; thus, they are reacting through attending sporadically. Results on the Psychological Scale were also not in the predicted direction. The means for compliers and non-compliers were quite similar and significantly higher 99 than the means for the semi-compliers. Although the alpha level for this total scale was low, there was a much higher level of internal consistency for the subscale dealing with attitudes towards doctors. The pattern of significant differences between groups on this subscale was similar to that for the total scale. That is, the means for the compliers and non-compliers were quite similar and higher than the means for the semi-compliers. These results suggest that compliers and non-compliers generally have more positive views towards community agencies, attitudes towards doctors, and towards the rights of women in lower socioeeconomic groups, than do semi-compliers. Most salient seems to be the factor of attitudes towards doctors. 1 Because they do show up so infrequently, non-compliers might get special attention when they do come to the clinic. This would increase their positive feelings towards doctors. On the other hand, since they show up so infrequently, they may have had limited experiences with doctors and thus answered more on the basis of idealistic notions rather than actual experience. For compliers, positive sentiment towards doctors would make it easier for them to comply with health care appointments in general. A possible reason for the erratic attendance records of the semi- compliers is that they have had negative experiences with physicians in the past. Because of this, although they may wish the help which a doctor might provide, they may also 100 fear that the doctor will not provide the desired help or even act in a way which is experienced as negative. Thus they are ambivalent about treatment and inconsistent in keeping appointments. “DemographiC'Results Demographic features did not differentiate between people in the different compliance categories at a statistically significant level. The present sample consisted of lower income women, all on Medicaid, the majority of whom were housewives. Most of them had finished some high school or received only their high school degree, and seemed not to be upwardly mobile in terms of professional aspirations or achievement. They had children (as was reqUired to be a subject) and the majority were either married or divorced. The lack of variability within the sample on demographic features made this a poor sample to study relations between demographic variables and compliance. The lack of significant associations between demographic variables and compliance is consistent with some previous research (Greene, et. al., 1982). There has been limited variability in demographic variables in other samples as well(Haynes, 1976; Marston, 1970). Other'Relevantvariables Several other interpretations are suggested to assist in explaining the lack of differences between the compliance groups. First, because this study examined mothers' compliance for their children rather than for themselves, 101 different variables might contribute to this process. A mother's attitude toward compliance about her child's health might be quite different from when her own health is involved. For example, personality variables might be important for mothers' compliance for themselves. However, the compliance for their children might be more influenced by such factors as attachment to their children and views associated with mothering. These might overshadow personality correlates. Although a mother's feelings of low self- esteem might be associated with reduced self-care, her self-esteem might have little to do with her behavior towards her child's health, particularly if there were a strong positive bond between them. Also salient might be issues involving the child's frustration or pain tolerance, in conjunction with immediate dangers from an ailment or expectations of spontaneous cure. This study was carried out in a screening clinic rather than in a medical setting dealing primarily with sick individuals. A mother's views about preventative health screenings for her child might overshadow the effects of personality variables in influencing compliance behavior. Mothers' awareness of the value of preventative screenings in detecting illness is likely an important variable in this context. A mother who has an internal locus of control orientation or a very high level of selfeesteem might believe that it is a waste of time to consult with health care professionals if signs of disease are not apparent. 102 Clearly, the anticipated benefits of compliance for screening must compensate for the trouble and effort involved in keeping screening appointments. A related factor is perceived vulnerability to disease and illness. The previously discussed Health Belief Model (Becker, 1976) deals specifically with the relationship between patients' beliefs and attitudes regarding health issues and subsequent health related behavior. Research indicates a relationship between perceived succeptibility to disease and compliance. Perceived vulnerability may be a more important determiner of a person's health related actions than are personality variables. This study was not designed to test this model. However, the item in the informational questionnaire "Are you worried about your child's health?" did differentiate between groups. Compliers reported more worry about the child's health than expected by chance, and semi-compliers reported less worry about the child's health than expected by chance. This suggests that concern about health may influence compliance behavior. MethodolOgical Issues Some methodological issues need to be mentioned and could have contributed to a lack of measured differences between groups. One factor is the time period of the study. The appointments.kept were considered only over a period of one and one half years because the clinic had disposed of previous records. A period of one and one half years 103‘ involves only about two appointments, on the average, and as few as one for 37 of the subjects. This may have prevented making reliable distinctions between compliers, semi-compliers, and non-compliers. The distinctions between the categories might be more reliable and salient if records for a longer time had been available. Another methodological issue involves the fact that the number of appointments used to assess compliance varied across subjects. The procedure used equates a person attending one appointment out of one scheduled with a person attending four appointments out of four scheduled; both were considered compliers. Similarly, a non-complier may have been scheduled for six appointments and kept only two, while a complier was scheduled for one appointment which was kept. More is being asked of the person who is scheduled for more appointments. However, using proportions Seemed a sound method for assessing compliance. An alternative strategy is to categorize compliers as persons who had shown up for a screening appointment and followed through on a referral; semi-compliers as those who followed through on a screening clinic appointment but misSed a referral; and non-compliers as those who missed even.their screening appointment. This procedure, however, does not incorporate a measure of behavior over time. It also seems that looking at compliance over time would reduce the influence of non-compliant actions resulting from a resolution of the medical problem that prompted 104 referral. When only one appointment is considered for compliance categorization, it is possible that the condition of concern has cleared up and the person sees no reason to follow through. Another factor which should be considered is whether or not subjects have their own personal physicians. Having a private doctor could certainly influence use of the screening clinic. A Department of Social Services spokes- person provided information that those persons who did not attend screening appointments had higher Medicaid bill payments than other persons, suggesting a use of health care services other than through the clinic. The subjects seemed a representative sample of persons attending the clinic. However, no record was kept of the numbers of persons refusing to fill out the questionnaires. Also, certain persons were not asked to participate because they were engaged or preoccupied with other activities. SUMMARY AND CONCLUSIONS Compliance has not been systematically researched but is an important area because of the ultimate objective of improving compliance and health and longevity. This research suggests that the factors contributing to the compliance process are numerous and interact in potentially complex ways. Although the hypotheses of the study were not supported, several significant results emerged which merit future attention. Compliers were most satisfied with cost/ convenience aspects of health care, but non-compliers were more satisfied than were semi-compliers. Both compliers and non-compliers had more positive attitudes towards doctors than did semi-compliers. Non-compliers also had a more internal locus of control orientation than did the compliers or semi-compliers, with compliers being more internal than semi-compliers. Although some personality variables did not differentiate between compliance groups, they may have been overshadowed by other factors such as attitudes towards health screening, anxiety about illness, and perceived vulnerability to disease. There was an indication that compliers were more worried about their children's health than were semi-compliers. It is possible that if other factors were controlled, the effects of 105 106 personality might be more salient. Similarly, the lack of associations between demographic variables and compliance may have been due to the lack of variability within the sample demographic dimensions. Previous research shows relationships between some demographic variables and use of health care services. A salient finding emerging from this study was the fact that all persons were quite pleased with the clinic. The area of greatest dissatisfaction centered around long waiting times, a factor which had previously been shown related to non-compliant behavior (Haynes, 1976).. The subjects also seemed quite willing to fill out the questionnaires, suggesting that further research with this population would be feasible. “PraCtiCa1 Problems Encountered While Conducting StUdy. While field studies are needed, there are problems with this method. In conducting this study several occurences took place which intefered with data collection. At the outset of the study the clinic secretary was instructed to note on the daily appointment sheets those subjects who called to cancel their appointments, so that these subjects could be differentiated from those who simply did not show up. However, the secretary ceased recording this information midway through the stage of collecting the data without saying she did so. Thus, some of the people selected for home interviews because they were designated non-compliers may have called to cancel an appointment. 107 This problem was remedied when the head of the clinic agreed to obtain the information from the Department of Social Services. Another problem encountered during the study centered around difficulty obtaining aceess to confidential information. The Project Health Clinic is a joint venture between the Department of Social Services and the Public Health Department. Approval for the study was granted by the Public Health Department and access to their records was permitted, but the Department of Social Services would not allow access to their files and records. For this reason it was not possible to find out the names of those persons not agreeing to come for screening appointments, those who might be considered to be truely non-compliant. Thus one group intended for the study could not be obtained. It was also true that the initial attempts to obtain approval to conduct the study brought much resistance and opposition from the relevant agencies. At the Department of Social Services where contact was initially made, I was sent to several different persons within the agency. When the final person was consulted, I was informed that the proposal would need to be approved by a committee which could take much time, and even then it was not guaranteed that access to their confidential information could be granted. The Public Health Department was contacted next. Personnel in that agency immediately granted approval for the study and contacted appropriate clinic personnel. Although 108 an administrative agreement was drawn up to protect both the clinic and myself, this was never signed by the clinic co-ordinator. Upon entering the clinic for the research, clinic personnel seemed reluctant to provide space for operation and to have a negative attitude when approached with questions. One of the clinic staff who was responsible for keeping a record of the appointments also seemed to resist cooperation. The reasons for their behavior are not known. Perhaps this type of problem could be remedied by having clearer, more definite committments agreed to by all parties involved. It might also be useful to have an informal meeting of all clinic personnel to brief them about the study and to elicit their input to allow them to become more invested in the project and ultimately more interested in helping. Recommendations. Several recommendations for future research emerge from examining problems encountered during this study. First, it would be useful to have a greater degree of supervision of personnel within the clinic setting. Because the clinic staff were aware of the research being conducted and had agreed to assist through performing certain functions, it was assumed that they would meet their committments. They did not always do what they were expected to do. Support from supervisors seems essential. Second, it would be useful to collect followup data shortly after the subjects complete individual questionnaires 109 rather than waiting until all data for all subjects is collected and then collecting followup data. When attempts were made to collect the followup data long after subjects had filled out the initial instruments, some subjects were hard to locate. When subjects were contacted after a long period of time, some had forgotten their reasons for not showing up for appointments. The recommended procedure requires additional research personnel. Systematic measurement of the Health Belief Model (Becker, 1976) seems desirable. Such factors as perceived vulnerability to disease and susceptibility to illness may play a role in determining medical compliance. The finding from the present study that compliers were more worried about their child's health than were semi-compliers, suggest that such concerns about illness may be more important than personality attributes or general satisfaction with health care systems. Also important for future research is to ascertain knowing whether or not persons attending the clinic had a private physician. Finally, an improved methodology would involve studying behavior over a longer period of time. 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APPENDICES [-4 O LOCDNO‘U‘l-hwm APPENDIX A TESTS AND SATISFACTION SCALE SCORING PROCEDURES Informational and Demographic Questionnaire Rosenberg Self—Esteem Inventory Tennessee Self Concept Scale Marlowe-Crowne Social Desirability Scale Psychological Scale Multidimensional Health Locus of Control Scale Satisfaction Scale Scoring Method for Satisfaction Scale Followup Questionnaire 119 M‘- CDVO‘ 11. 12. 13. 14. 15. 16. 17. 18. 19. 120 INFORMATIONAL AND DEMOGRAPHIC QUESTIONNAIRE Marital Status: Single Married Divorced Separated Occupation of child's mother Mother and father: Father Number of children and their boys, ages ages: girls, ages Child's place of birth: City State Highest grade of school completed: Religious affiliation: Is religion very important to you personally? Yes No Are your parents currently alive or dead? Mother: alive dead Father: alive Has your child been ill in the past 3 months? Yes dead No Do you feel that when your child gets ill that it is responsibility to remind him/her to take his/her medi or his/hers? Yours Theirs Do you have a hard time controlling your child's behavior? Yes No Do you often feel that your child is ' a burden to you? Yes No Are you very worried about your child's health? Yes What did you think of this clinic? Great Good O.K. Did you get what you came here for? Yes No No your cine, Poor Did you have to wait too long? Yes No Did you feel at ease with the people Yes No you talked with? Somewhat Were you treated with respect and concern? Yes What more could the clinic do to be helpful to you? No 121 ROSENBERG SELF-ESTEEM INVENTORY Usingithe following scale, darken the space of the number which best represents your feelings about each of the following statements: - 1 2 3 4 Strongly Agree Disagree Strongly Agree Disagree 61. I feel that I'm a person of worth, at least on an equal basis with others. 62. I feel that I have a number of good qualities. 63. All in all, I am inclined to feel that I am a failure. 64. I am able to do things as well as most other people. 65. I feel I*do not have much to be proud of. 66. I take a positive attitude toward myself. 67. On the whole, I am satisfied with myself. 68. I wish I could have more respect for myself. 69. I certainly feel useless at times. 70. At times I think I am no good at all. Instructions: you to yourself. alternative responses. a black mark Completely false = 1 Mostly true = 4 Responses Completely true I have a healthy body. I am an attractive person. I consider myself a sloppy person. am a decent sort of person. I am an honest person I am a bad person. I am a cheerful person. I am a calm and easy-going person. I am a nobody. I have a family that would always help me in any kind of trouble. I am a member of a happy family. My friends have no confi- dence in me. I am a friendly person. I am popular with men. I am not interested in what other people do. I do not always tell the truth. I get angry sometimes I like to look nice and neat all the time. I am full of aches and pains. am a sick person. am religious person. am a moral failure. am a morally weak person. have a lot of self- control. am a hateful person. am losing my min am an important person to my friends and famil I am not loved by my family. I feel that my family doesn't trust me. I am popular with women. DI HHu—ur—cu—tv—‘u—cp—a I am mad with the whole world. I am hard to be friendly with. Once in a while I think of things too bad to talk about. Sometimes, when I am not feeling well, I am cross. Mostly false Please respond to these items as if you were describing Read each item carefully, then select one of the five Do not omit any item. in the chosen response. On your answer sheet put If you want to change any answer after marking it, erase the old answer completely. 2 *35. *36. *37. *Physical Self Subscale Partly false and partly true = 3 I am neither too fat nor too thin I like my looks just the way they are. I would like to ychange some parts of my bod I am satisfied with my moral behavior. I am satisfied with my rela- tionship to God. I ought to go to church more. I am satisfied to be just what am. I am just as nice as I should be I despise myself. I am satisfied with my family relationships. I understand my family as well as I shou I should trust my family more. I am as sociable as I want to be. I try to please others, but I don' overdo i I amt no good at all from a social standpoint. I do not like everyone I know. Once in a while I laugh at a dirty joke. I am neither too tall nor too sho rt I don' t feel as well as I should. I should have more sex appeal. I am as religious as I want to be. I wish I could be more trust- worthy. I shouldn't tell so many lies. I am as smart as I want to be. I am not the person I would like to be. I wish I didn't give up as easily as I do. I treat my parents as well as I should (use past tense if parents are deceased 62. 63. 64. 65. 66. 67. 68. *69. *70. *71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. *85. *86. *87. 88. 89. 90. 91. 92. 93. 94. I am too sensitive to things my family say. I should love my family more. I am satisfied with the way I treat other people. I should be more polite to others. I ought to get along better with other people. I gossip a little at times. At times I feel like swearing. I take good care of myself physically. I try to be careful about my appearance. I often act like I am "all thumbs.“ I am true to my religion in my everyday life. I try to change when I know I'm doing things that are wrong. I sometimes do very bad things. I can always take care of my- self in any situation. I take the blame for things without getting mad. I do things without thinking about them first. I try to play fair with my friends and family. I take a real interest in my family. \ I give in to my parents (use past tense for deceased parents). I try to understand the other fellow's point of view. I get along well with other people. I do not forgive others easily. I would rather win than lose in a game. I feel good most of the time. I do poorly in sports and games. I am a poor sleeper. I do what is right most of the time. I sometimes use unfair means to get ahead. I have trouble doing the things that are right. 123 95. 96. 97. 98. 99. 100. I solve my problems quite easily. I change my mind a lot. I try to run away from my problems. I do my share of work at home. I quarrel with my family. I do not act like my family thinks I should. I see good points in all the people I meet. I do not feel at ease with other people. I find it hard to talk with strangers. Once in a while I put off until tomorrow what I ought to do today. 124 THE MARLOWE-CROWNE SOCIAL DESIRABILITY SCALE Personal Reaction Inventory Listed below are a number of statements concerning personal attitudes and traits. Read each item and decide whether the statement is true or false as it pertains to you personally. 1. Before voting I thoroughly investigate the qualifications of all the candidates. (T) 2. I never hesitate to go out of my way to help someone in trouble. (T) 3. It is sometimes hard for me to go on with my work if I am not encouraged. (F) 4. I have never intensely disliked anyone. (T) 5. On occasion I have had doubts about my ability to succeed in life. (F) 6. I sometimes feel resentful when I don't get my way. (F) 7. I am always careful about my manner of dress. (T) 8. My table manners at home are as good as when I eat out in a restaurant. (T) 9. If I could get into a movie without paying and be sure I was not seen I would probably do it.1 (F) 10. On a few occasions, I have given up doing something because I thought too little of my ability. (F) 11. I like to gossip at times. (F) 12. There have been times when I felt like rebelling against people in authority even though I knew they were right. (F) 13. No matter who I'm talking to, I'm always a good listener. (T) I4. I can remember "playing sick" to get out of something. (F) 15. There have been occasions when I took advantage of someone. (F) 16. I'm always willing to admit it when I make a mistake. (T) 17. I always try to practice what I preach. (T) 18. I don't find it particularly difficult to get along with loud mouthed, abnoxious people. (T) 19. I sometimes try to get even rather than forgive and forget. (F) 20. When I don't know something I don't at all mind admitting it. (T) 21. I am always courteous, even to people who are disagreeable. T) 22. At times)I have really insisted on having things my own way. F 23. There have been occasions when I felt like smashing things. (F) ' 24. I would never think of letting someone else be punished for my wrongdoings. (T) 25. I never resent being asked to return a favor. (T) 26. 27. 28. 29. 30. 31. 32. 33. 125 I have never been irked when people expressed ideas very different from my own. (T) I never make a long trip without checking the safety of my car. (T) There have been times when I was quite jealous of the good fortune of others. (F) I have almost never felt the urge to tell someone off. (T) I am sometimes irritated by people who ask favors of me. F I have never felt that I was punished without cause. (T) I sometimes think when people have a misfortune they only got what they deserved. (F) I have never deliberately said something that hurt someone's feelings. (T) 126 PSYCHOLOGICAL SCALE I think women who belong to lower socioeconomic groups should not expect community agencies to help them and their children. 2. I think community agencies do not provide the services for mothers and children that they should. 3. I think women in lower socioeconomic groups should not feel guilty about asking community agencies for help. 4. I think women in lower socioeconomic groups deserve more from doctors, community agencies, etc., than they receive. 5. Most doctors talk above my head when I go to them with my problems. 6. In general, most doctors seem to understand me when I go to them with my problems. 7. Most doctors tend to talk down to me when I go to them with my problems. 8. Most doctors make recommendations to me without really listening to my problems. 9. I feel at ease consulting most doctors about my problems. 10. Most doctors are very formal toward me. 11. If I had other ways of solving my problems, I would not visit most doctors at all. 12. Most community agencies are very formal toward me. Strongly Agree Agree N Disagree Strongly Disagree 12. 13. 17. 10. 14. 18. 127 MULTIDIMENSIONAL HEALTH LOCUS OF CONTROL (MHLC) SCALES Internal Health Locus of Control (IHLC) If I get sick, it is my own behavior which determines how soon I get well again. I am in control of my health. When I get sick I am to blame. The main thing which affects my health is what I myself do. If I take care of myself, I can avoid illness. If I take the right actions, I can stay healthy. Powerful Others Health Locus of Control (PHLC) Having regular contact with my physician is the best way for me to avoid illness. Whenever I don't feel well, I should consult a medically trained professional. My family has a lot to do with my becoming sick or staying healthy. Health professionals control my health. When I recover from an illness, it's usually because other people (for example, doctors, nurses, family, friends) have been taking good care of me. Regarding my health, I can only do what my doctor tells me to do. Chance Health Locus of Control (CHLC) No matter what I do, if I am going to get sick, I am going to get sick. Most things that affect my health happen to me by accident. Luck plays a big part in determining how soon I will re- cover from an illness. 128 11. My good health is largely a matter of good fortune. 15. No matter what I do, I'm likely to get sick. 16. If it's meant to be, I will stay healthy. 129 Scale Items in "Satisfaction" Questionnaire by Content Area . Transformed Affect Scale of Value Item 1. Professional Competence 2.26 1. People do not know how many mistakes doctors really make. Neg 3.32 2. Today's doctors are better trained than ever before. Pos 1.77 3. Doctors rely on drugs and pills too much. Neg 1.01 4. Given a choice between using an old reliable drug and a new experimental one, many doctors will choose the new one. Neg 1.96 5. No two doctors will agree on what is wrong with a person. Neg 2.85 6. Doctors will not admit it when they do not know what is wrong with you. Neg 1.14 7. When doctors do not cure mildly ill patients, it is because the patients do not cooperate. Pos 3 04 8. Doctors will do everything they can to keep from making a mistake. Pos 3.30 9. Many doctors just do not know what they are doing. Neg .56 10. Doctors spend more time trying to cure an illness you already have than preventing one from deve10ping. Neg .21 11. Doctors are put in the position of needing to know ‘ more than they possibly could. Pos 1.92 12. Even if a doctor cannot cure you right away, he can make you more comfortable. Pos 2.59 13. Doctors can help you both in health and in sickness. Pos 1.38 14. Doctors sometimes fail because patients do not call them in time. Pos II. Personal Qualities 1.21 1 You cannot expect any one doctor to be perfect. Pos 1.77 2 Doctors make you feel like everything will be all right. P05 .70 3. A doctor's job is to make people feel better. Pos 1.63 4 Too many doctors think you cannot understand the medical explanation of your illness, so they do not bother explaining. Neg 2.52 5. Doctors act like they are doing you a favor by treating you. Neg 2.29 6. A lot of doctors do not care whether or not they hurt you during the examination. Neg 2.03 7 Many doctors treat the disease but have no feeling ' for the patient. Neg 1.04 8. Doctors should be a little more friendly than they are. Neg 2.34 9. Most doctors let you talk out your problems. Pos 2.13 10. Doctors do their best to keep you from worrying. Pos 3.68 11. Doctors are devoted to their patients. P05 .08 12. With so many patients to see, doctors cannot get to know them all. ‘ Pos 3.11 13. Most doctors have no feeling for their patients. Neg 3.28 14. Most doctors take a real interest in their patients. Pos 130 Transformed } Affect Scale of Value Item III. Cost/Convenience 2.21 1. Nowadays you really cannot get a doctor to come out during the night. Neg 1.86 2. You may have to wait a little, but you can always get a doctor. Pos 1.93 3. It is easier to go to the drugstore for medicine than to bother with a doctor. Neg 2.81 4. The more money you have the easier it is to see the - doctor. Neg 1.11 5. A doctor has a right to charge what he does since he struggled for years to become a doctor. Pos 2.96 6. In an emergency, you can always get a doctor. P05 04 7. There just are not enough doctors to go around. Pos 1 59 8. Doctors try to have their offices and clinics in convenient locations. Pos 1.42 9. More and more doctors are refusing to make house calls. Neg .57 10. People complain too much about how hard it is to see a doctor. P05 .90 11. It is hard to get a quick appointment to see a doctor. Neg .39 12. Doctors should have evening office hours for working people. Neg 2.91 13 Most doctors are willing to treat patients with low incomes. Pos 3 63 14 A doctor's main interest is in making as much money as he can. _ Neg 131 SCORING METHOD FOR SATISFACTION SCALE For items expressing a positive sentiment (those with original scale values greater than 5), the multiplication factor is as follows: strongly agree (2), agree (1), uncertain (0), disagree (-l), and strongly disagree (-2). On the other hand, for items expressing a negative senti- ment (original scale values less than 5), the multiplication factor is strongly agree (-2), agree (-1), uncertain (0), disagree (1), strongly disagree (2). Considering as examples the two items previously mentioned, if the respondent strongly agress with the positive item (new scale value 2.96), 5.92 will be contributed to his total score. If his responses are consistent and the attitude dimension linear, he would strongly disagree with the negative item (new scale value 2.26), which would add another 4.52 points to his score. If, however, a respondent strongly agreed with the latter negative item, 4.52 points would be subtracted from his total score (or more precisely, a value of (-) 4.52 points would be added to his score). In this fashion, persons with negative attitudes get scores with negative values and persons with positive attitudes get scores with positive values. The respondents' total score is merely the algebraic sum of the products for each item divided by the number of items to which the respondent replied. The latter division 132 is necessary because of the possibility of skipped items, e.g., missing data. A comparable approach, using the appropriate 14 items, is undertaken to derive a score for each content area. 133 FOLLOW-UP QUESTIONNAIRE NAME: 1. Have you been scheduled for appointments at the Medicaid Screening Clinic within the last six months? Yes ‘ No ' Not Sure A. If yes, did you come to these appointments? Yes No B. If you had an appointment and didn't come for it, please list the reason(s) why you didn't show up. C. If you had an appointment and kept it what were your reasons for doing so? 2. Do you feel that it is worth your while to have screening appointments for your child? Yes No Not Sure 3. Has your child been ill within the past six months? Yes No If yes, what was the illness or illnesses? 4. Do you presently have a family physician? Yes No We noticed from the records that you had missed an appointment over the summer and we were wondering if you could remember your reasons for missing this. APPENDIX B Cover letter, Research Consent Form, Administrative Agreements, Screening Clinic Medical Forms 4". 134 COVER LETTER I am finishing my graduate work at Michigan State University in Lansing, Michigan and am conducting a study at the Medicaid Screening Clinic to help us to learn more about ways to improve health care delivery systems so that we can better meet the needs of people such as you. The clinic recognizes the value and importance of this research and hopes to use the general results to improve their delivery of health care services. The main goal of this study is to improve our understanding of people using the Medicaid Screening Clinic and through doing this be better able to help them through responding to their needs, concerns and dissatisfactions. For this study I will be asking people to fill out some forms and questionnaires. The information from these forms will help me to better understand you and your needs and desires. It is your choice whether to help with this research or not. If you decide to participate, you may stop at any time without any bad consequences. None of the health care providers or clinic personnel will know about your answers on the forms. All results will be strictly confidential and your name will not appear anywhere in the published study. Whether you decide to participate or not participate will also have no bearing upon the screening clinic or the service that you get at the clinic now or in the future. > When the study is finished, you may have a complete explanation of the purpose and results. If you want this kind of followup information about the study, please contact me at the address below. If you are interested in taking part in this study please sign the consent form which is attatched. Thank you. Alison Jones, graduate student Department of Psychology 135 Snyder Hall Michigan State University East Lansing, Michigan 135 RESEARCH CONSENT FORM 1- I have freely consented to take part in a scientific study being conducted by Alison Jones under the supervision of Dr. Elaine Donelson. Academic Title: Associate Professor, Department of Psychology, Michigan State University. 2- The study has been explained to me and I understand the explanation that has been given and what my participation will involve. 3- I understand that I am free to discontinue my participation in the study at any time without penalty. 4- I understand that the results of the study will be treated in strict confidence and that I will remain anonymous. Within these restrictions, results of the study will be made available to me at my request. I also understand that no clinic personnel will have access to my responses or answers, and that my responses will in no way affect the nature or availability of future health care to me. 5- I understand that my participation in the study does not guarantee any beneficial results to me. 6- I understand that, at my request, I can receive additional explanation of the study after my participation is completed. Signed: Date: 136 Administrative Agreements The following administrative agreement between Alison Jones, graduate student in psychology at Michigan State University and the Project Health Clinic, Lansing, Michigan, is designed to insure understanding and expectations of the roles and responsibilities of all persons involved in the study on medical compliance at the Project Health Clinic. The main objective of this study is to better understand medical compliance and what factors and personality variables seem to be associated with this phenomenon. Through ascertaining this information it will be possible to construct a predictive index to ultimately make changes in the screening program to help better meet the needs of those persons designated as non-compliers. To insure the successful implementation and completion of the study without interruptions or misunderstandings‘ the responsibilities of all parties involved in the project are hereby agreed to: On the part of the Project Health Clinic: 1- Permit Alison Jones (researcher) to conduct a study on medical compliance at the Project Health Clinic from June 1980- January 1981, or until such time as 120 subjects have-been selected and interviewed. . 2- Allow access to lists of clients so that subjects for study can be selected. 3- Agree to permit the researchers questionnaires and instruments to be administered to all of the subjects participating in the study. 4- Allow access to medical recores by the researcher so that data necessary to the implementation of the study can be obtained. 5- Provide space within the clinic for administration of the testing. On the part of the researcher: 1- Agrees to assume responsibility for implementation of the study project including its design, analysis and dissemination of results. 2- Agrees that complete confidentiality of subjects shall be maintained. Under no circumstances will the names of the subjects participating in the study be disclosed. 3- Agree to share with the Project Health Clinic staff the results of the study in writing upon termination of the project. 137 4- Agree to try to insure that.the results of the study are used to try to help improve compliance within the clinic setting. 5- Agree to assume responsibility for research assistants helping with the project. “Signatures Researcher Project Health Clinic Coordinator Medicaid Screening Program Department of Public Health: M&CH HEALTH HISTORY - FOR INDIVIDUALS SIX and OVER Child's Name Birthdate Name Child Answers To(nickname) Race Address 6 County Phone Parent or Guardian Address (Circle one) No. of brothers What number is How many people live Gsisters this child? in your home? Who spends the most time caring for this child? Physician's Name Address Phone Dentist's Name Address Phone PERMISSION: I hereby give my permission for the above-named child to receive health screening, immunization(s) and tuberculin testing as needed. Signature Date IMHUNIZAIIONS and DAIES 1. Circle any of the following diseases that the above-named person's parents, grandparents, aunts, uncles, brothers, or sisters have had: Tuberculosis Seizures Inherited Diseases or Family Diabetes Cancer Disease Asthma Epilepsy Heart Problems Allergy Nervous Breakdown High Blood Pressure Birth Defect H-636 PHS/MDPH 10/77 138 Z. 3. 4. S. 6. 7. 8. 9. 10. Has above person had any trouble with his/her eyes or vision? . . . . . . . . . . . . . . . . . . Are the above person‘s parents both in good health? Do any brothers and/or sisters have a health problem? Have any brothers or sisters died?. Does above person feel good most of Is there a history of ear trouble?. Circle which: Does above person usually have more than three colds or throat infections with fever a ye the time? Has above person ever had wheezing or asthma? Is above person able to keep up physically with others? Ear aches, draining ears, deafness 11. Has above person had any allergies or reactions to any 12. Does above person usually eat or drink the following daily? oods, medicines, or injections?. List which ones: Vitamin D fortified milk. . . . . Iodized salt. Juices and fruit containing Vitamin C such as oranges, tomatoes, fruit drinks with added Vitamin C . Enriched bread and cereal products. Protein foods such as meat, eggs, fish, cheese, dried beans, peanut butter Candy, pop, potato chips, pretzels, etc.. 13. Has above person ever had eczema or'hives?. . 14. Does above person complain frequently of headache leg h. 15. Does above person often have diarrhea (very loose or 16. Does person have difficulty with bowel movements? l7. l8. ache, stomach ache, or other pain? runny bowel movements Does above person have any trouble with passing urine?. Does above person have any trouble hearing or understanding other person' 5 speech?. Circle whi ic 139 e . No No No No No No No No No No No No No No No Circle any of the following that above person has now or had: "Red" or ”Hard" Measles Epilepsy Tonsillitis German or "3-day" Measles Severe anemia (thin blood) Ulcers (Stomach) Scarlet Fever Meningitis Shortness of Breath Mumps Heart Trouble Bone or Joint Tuberculosis Rheumatic Fever Problems Diabetes Pneumonia Skin Problems Seizures Kidney Infection Other illnesses or diseases?. . . . . . . . . . . . . . . . No Yes If yes, what? Has above person ever been hospitalized?. . . . . . . . . . No Yes If yes, for what? Has above person had any operations?. . . . . . . . . . . .' No Yes If yes, for what? Has above person had an(y) accident(s)? . . . . . . . . . . No Yes If yes list injuries Any broken bones? . . . . . . . . . . . . . . . . . . . . . No Yes If yes, list Has person been under care of physician the past 12 mos.‘ . No Yes If so, for what Does above person have to limit his physical activities for health reasons? (Such as being excused from gym class). . No Yes If yes, in what way and why? Does above person have any trouble sleeping now?. . . . . . No Yes Are there any problems with his/her teethl. . . . . . . . . No Yes Is above person taking any medicines or drugs howl. . . . . No Yes If yes, list 140 28. 29; 30. 31. 35. Does above person get along well with others of own age group 2 e e e e e e e o e e a Q s e e e e e e e a e o e a e . Does above person get along well with his parents? . Does above person do well in school or on the job? . Circle any of the following which the above person has or does: Feels depressed Bites Nails Speech Problems Lonesome Sucks Thumb Nightmares Jealous Chews Hair Bad Temper Irritable Wets Bed wen't Mind To be answered by Females 32. Has menstruation begun? . . . . 33. Are periods regular ? . . . . . . . . . . . . . . . How frequent? 34. Date of last menstrual period, or approximately how long ago? List any health problems or concerns not mentioned. 141 Yes Yes Yes Yes Yes No No No No g2: '62": MEDICAID SCREENING SUMMARY MARK THESE IOX' IF AREA ASESSED mamas: sexes": FOLLOW-UPI: NEEDED (Thus- I M.,...” ABM“ mum mun-an £ Ingham County Health Dept 95 3301 001 J ocean sen-an meme mum t.“ mm: mum Mflflm [ hue-nun..- J 1 1 I [:1 1 _ :11 1' J h” :15“ 3 E! :1 31:12:] C1213 1 ,3 HEAD Clmwb’fiflw , ”711—1 1:] #— DDQD mm: D DD D ("Nil 1511 11 I;;[§:a qmmmrfiffEr—*\ “IS 7] D _ D n D we smmrrmotsumencane U . - ”g 1‘ I ' D I D D 1 FOLLOW UP NEED” ................. rfimmlnmn ‘ ' g Hiram IMCTIOI CW1". EARS EYES IOUTH FACE HAIR NECK SKIN CHESTIIACX BEIITAUA . WIDE DDDDDDDDDDDDDD DDDDEDDDDDDDDDD AMALEBS storm. [Lama/“W [MM-O1 I 1491 [:1 ,Cl,’ DD . SONATUIE 0F SCREENING NURSE: flan D 213131 33 31:1 E SIGN b NDM 0 IL T M.D.SS. > 142 REFERRAL FOR SERVICES EARLY PERIODIC SCREENING DIAGNOSIS AND TREATMENT Michigan Department of Public Health (new! no aoaetss or peovuon or newer . , [out or urine“ W APPOINTMENT OAT! DAY 0' YNE WEEK TIME 0' DAY PIOVIOII'! FHON! NUMOEN (nut or cunt/“rum emu-cont fleoanu. cu: mum" surru unmet umr “MW 1 CLIENT I INFO. I 4 CLIENT/PAYIENY'S ADDRESS CLIEN7/PAYIENT'S ”ION! NUMIER IWNIIE PATIENVICLIEN‘I' CAN 0! RIACHCD IV PHONE) \ season roe eerennAL: resumes Cme ment. mouse. 11'. non: names: P 2 C 9. o ‘ '- P1 ‘ a 2 g 9 u. 5 E d sueuruu or ntreneu . riru fi :5 k J 9 c' g o I authorize the release at medical information on the named individual to the screening clinic specified above. 1 O n’ E Lsmuruer or punt on cue-nun out or neuron J J &\ ( 0A?! or EXAMINAYIOI on new“ nucleus/ll z 9 )- a O a I! a E g I W - .1 ragga—u up CARE:1 E 9 J1 Y _ f r cum". "run; ,0 D 'sncmn naennuzniau amen . In an omcg morn" g t F ;. nuoeo cur D sucuuv D D o 3 can “run curnr «to ASSISI’ANCE no“ not LOCAL U nnun ounro rauov voue neceuunonuons: 31‘ E C no [3 was w as (nun. 3 i .1 w E I 5E J III 9 > .1 8 8 (x If APPLICAOL‘I alauruu or pnavuou ran: a “ a noun. J K '5‘ng on non J PROVIDER: Pleaee return this copy to the Local Health Department clinic. “3&5 l'fi‘j‘rfia' 7;“ ,, - WASSISTANCE REQUESTED FROM MICHIGAN DEPARTMENT OF SOCIAL SERVICES .- rlunseonrn'lou D 1 [wanna g Ewan" v Dear Provider, in a on." Would you please return the attached white ”we 3 g [:1 D referral form to us after the patient's 5 < L . mitial visit. We have enclosed a. stamped. ; g ‘_ ‘Xeelr-addreeeed envelope for your convenience. J - I- < 5 E Thank you 0 a W___ _ n o ———_. —-~-~--—---- .. u E k / 143