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Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20
The Physician–Patient Working Alliance and Patient Psychological Attachment, Adherence, Outcome Expectations, and Satisfaction in a Sample of Rheumatology Patients a
b
b
a
Jairo N. Fuertes , Prachi Anand , Greg Haggerty , Michael Kestenbaum & Gary C. b
Rosenblum a
Derner Institute of Advanced Psychological Studies, Adelphi University
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Nassau University Medical Center Accepted author version posted online: 19 Dec 2013.Published online: 03 Sep 2014.
Click for updates To cite this article: Jairo N. Fuertes, Prachi Anand, Greg Haggerty, Michael Kestenbaum & Gary C. Rosenblum (2015) The Physician–Patient Working Alliance and Patient Psychological Attachment, Adherence, Outcome Expectations, and Satisfaction in a Sample of Rheumatology Patients, Behavioral Medicine, 41:2, 60-68, DOI: 10.1080/08964289.2013.875885 To link to this article: http://dx.doi.org/10.1080/08964289.2013.875885
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BEHAVIORAL MEDICINE, 41: 60–68, 2015 Copyright Ó Taylor & Francis Group, LLC ISSN: 0896-4289 print / 1940-4026 online DOI: 10.1080/08964289.2013.875885
The Physician–Patient Working Alliance and Patient Psychological Attachment, Adherence, Outcome Expectations, and Satisfaction in a Sample of Rheumatology Patients Jairo N. Fuertes
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Derner Institute of Advanced Psychological Studies, Adelphi University
Prachi Anand and Greg Haggerty Nassau University Medical Center
Michael Kestenbaum Derner Institute of Advanced Psychological Studies, Adelphi University
Gary C. Rosenblum Nassau University Medical Center
Over the past twenty years, the physician–patient relationship (eg, the physician–patient working alliance) has emerged as an integral component to the treatment of patients for a myriad of health conditions. Psychological, emotional, and behavioral dimensions of patients’ working alliance with their physicians, along with patients’ attachment styles, were examined in relation to rheumatology patients’ adherence to treatment plans, outcome expectations, and satisfaction. Study participants were 101 adult outpatients from a rheumatology clinic. Path analyses demonstrated that the physician–patient working alliance predicted outcome expectations (Standardized Beta [SB] D 0.27), and patient satisfaction (SB D 0.62), and that patient satisfaction in turn predicted patient adherence (SB D 0.48). Physicians’ ratings of patient adherence were significantly and positively correlated with patients’ ratings of the physician–patient working alliance. No significant paths were evident with respect to patient attachment. The physician–patient working alliance directly predicts patient satisfaction, and outcome expectations, and indirectly predicts adherence through patient satisfaction.
Keywords: adherence, attachment, physician–patient working alliance, satisfaction Over the past three decades, research in counseling and psychotherapy has shown that the working alliance between therapists and their patients is the primary factor in patient and therapist-rated outcomes, specifically pertaining to involvement in, gains from, and satisfaction with treatment.1,2,3 The working alliance has been found to be Correspondence should be addressed to Dr. Jairo N. Fuertes, Associate Professor of Psychology, The Derner Institute of Advanced Psychological Studies, Adelphi University, Hy Weinberg Center–Rm 319, 158 Cambridge Avenue, Garden City, NY 11530, USA. E-mail: [email protected]
present in all forms of therapy, and the cumulative empirical data suggests that the working alliance is of such central importance to counseling and psychotherapy that it is now universally considered in mental health as the essential aspect of effective psychological treatment.3 In a similar vein to the increased focus on the relationship between therapist and patient, the health sciences field has initiated a movement to further explore and emphasize the professional relationship established between physicians and patients.4 With greater investment in such ideas, medical professionals are attempting
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to view their work as a joint venture between patient and physician rather than as an individual endeavor by the physician. In addition, medical schools are increasing training in patient-centered care for the purpose of developing physicians’ interpersonal interactions with their patients (ie, “bedside manner”) in order to improve medical care treatment.4 As evidenced by these developments in the field of healthcare, patient-centered care has developed to be more congruent with and responsive to patients’ wants, needs, and preferences.1 Patient-centered care has evolved out of a need for a broader, more comprehensive model of treatment that incorporates psychological, social, and cultural indices, in addition to the biological factors, into patients’ treatment plans. In fact, over the past 20 years, this form of patient treatment has grown in use in modern medicine.5,6 Research indicates that patient-centered approaches improve health,7 lessen symptom burden,5 increase satisfaction with treatment,8 facilitate treatment adherence,9,10 and reduce the chance of misdiagnosis.11 The importance of physician–patient communication and of a collaborative stance between the two appears to be important in rheumatology care.12,13 Adherence to medications is a longstanding and continuing problem with rheumatology patients, with non-adherence being as low as 30% and as high as 80% depending on the patient, the severity of the symptom, and the stage of treatment.13,14 This is of concern since medications make up the primary mechanisms with which to control symptoms and improve function. Medical care researchers in this area of medicine have noted the importance of patient participation in decision making15 and of physician–patient communication directed at improving adherence, satisfaction, and patients’ expectations with treatment.16,17 In our study, “patient-centeredness” is embodied in our conceptualization of the physician–patient relationship as a working alliance, and we use a recently developed and validated measure of the working alliance in the current study.4,18,19 The other variables in our study have been shown to be important to medical care treatment, health improvement, and symptom reduction. For example, treatment adherence and satisfaction have received considerable attention in the medical field.20,21 Self-agency is a construct from psychological research that appears to be particularly relevant to patient-centered care and patient empowerment.22,23 Additionally, self-agency is also linked to outcome expectations for patients.22,23 Lastly, a great deal of research has shown that people’s attachment styles may mediate their perceptions of others as trustworthy and approachable, which may emerge in the discussions and general interactions between physicians and patients.24 In the current study, we bring these concepts together to examine their interplay with the working alliance and to see how well each explains patient satisfaction and adherence.
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The Physician–Patient Working Alliance The working alliance construct has been empirically validated as the best predictor of outcome across all modalities of psychotherapy3 and has now been adapted for use and measure in medical care treatment.4 The working alliance has been defined as the level of agreement between physicians and patients on the goals of treatment, the level of agreement on the tasks associated with pursuing and evaluating treatment goals, and the presence of an emotional bond characterized by trust and liking between physician and patient.4,25 This relationship incorporates the patients into their own care rather than making them passive recipients, which has been found to be associated with higher satisfaction18 and greater continuity of care.26 In addition, the working alliance incorporates cognitive, behavioral, and emotional dimensions of care into a “partnership” between patients and physicians.4 By creating a strong working alliance that is responsive to patients’ needs and preferences, patients’ participation in their treatment increases.27 For example, studies have indicated significant positive relationships between working alliance ratings and adherence to treatment4,18 and between working alliance ratings and adherence self-efficacy beliefs.19 Patients who endorsed a strong working alliance have also reported better quality of life.18
Attachment The current study based its conceptualization of attachment style on traditional psychological attachment theory, which states that a child constructs internal working models for his/her self and for his/her relationships with others based on his/her first relationships with caregivers.28,29 As a result, the child develops a relatively fixed attachment style by either late adolescence or adulthood.29 Social psychologists have identified two types of interpersonal attachment styles—secure and insecure.28 Individuals with predominantly secure attachment styles are generally comfortable investing in close relationships with others and trusting others.28 On the other hand, people with insecure attachment styles are likely to experience fears of rejection or abandonment in relationships with others and to have difficulty in trusting others.28 Research has shown that securely attached individuals report having significantly more coping, emotional, and social resources than insecurely attached individuals.30 Attachment style strongly impacts trust in and collaboration with others and the ability to effectively cope with stress-inducing situations. As such, there is also possibly a connection between one’s attachment style and one’s ability to develop cooperative and trusting relationships with professionals who treat illness and pain, such as health care professionals. Thus, psychological attachment is an important concept to examine in
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medical care relationships and health outcomes as it may provide an important venue by which to understand patients’ ability to cope with disease and the quality of their interactions with physicians. Further research has demonstrated that patients with insecure attachment styles view the physician–patient relationship less favorably when compared to patients with secure attachment styles.28 In comparison, patients who manifest secure attachment styles (ie, possess little to no fear of rejection or intimacy) report stronger working alliances with their physicians.18 Additionally, secure attachment styles have also been linked to greater patient satisfaction with treatment, improved health-related quality of life, greater control of physical symptoms, and greater adherence to treatment.18,28 Thus, based on the above findings, the impact of patients’ attachment styles on medical care relationships is considered to be crucial to treatment and outcome. Adherence The importance of a collaborative relationship between physicians and patients is perhaps best highlighted by current estimates of patient adherence to treatment, which indicate that up to forty percent of patients are unable to follow their treatment regimen. In chronic conditions, like rheumatoid arthritis and related diseases, patient adherence to medication is commonly about 50%.31 Inadequate patient adherence leads to complications, deterioration in health, and significant hardships for patients as well as for the healthcare system, thereby making patient adherence a key part of proper medical treatment.32 The quality of care that is provided by physicians has the potential to improve or to diminish patient adherence to treatment.31 Aspects of care that lead to improvement in adherence are as follows: physicians’ encouragement of patient involvement in the treatment plan,33 patients’ trust in the therapeutic relationship,33 physicians’ knowledge of the patient as an individual,34 and effective communication by both patient and physician.35 These factors can serve as the foundation for the eventual formation of a strong working alliance between physician and patient.18 As the working alliance develops, patients’ perceptions of the value of treatment improve.4,19 In addition, patients’ agreement with, approval for, and trust in their physician help them to view the treatment as warranted and important, thereby increasing their participation in and adherence to the recommended treatment.18,19 In order to adhere to the treatment plans that impact their daily lives, patients must also understand the purpose of the various aspects of the treatment and feel capable of accomplishing the necessary treatment procedures. With adequate levels of agreement communication and trust in place between them, the patient and the physician are better able to work on implementing, following, and monitoring the treatment.
Adherence Self-Efficacy and Outcome Expectations Self-efficacy is defined as the belief in one’s ability to organize and perform behaviors necessary to achieve one’s goals.36 Adherence self-efficacy is a patient’s belief that he/ she can follow through with specific recommendations inherent in the treatment regimen, and has been found to have a strong relationship with actual patient adherence.19,31 These findings indicate that, in order to adequately adhere to their treatment plans, patients must understand the necessary tasks associated with the plan and feel prepared and capable to carry out these tasks. Adherence self-efficacy has been found to be positively, and significantly, associated with ratings of the physician– patient working alliance.19 This association is perhaps based on the level of agreement between patient and physician on the goals of treatment and agreement on the tasks needed to meet or achieve the goals; if the patient agrees with the goals and tasks of treatment, then he/she is much more likely to believe that he/she can adhere to it. The dimensions of liking and trust in the alliance also allow for patients and physicians to address difficulties in believing that adherence is possible, and facilitate physicians interventions aimed at helping the patient deal with doubt or fear about being able to better adherence. The emotional dimensions associated with self-efficacy with respect to adherence have been greatly underemphasized in medicine, and in this study we examine if trust and liking as measured in the alliance is associated with patients becoming more confident with respect to treatment adherence.19 Belief and participation in the treatment are also likely to be affected by the patients’ expectations about the outcome. If the patient has some notion that the outcome of treatment will be desirable, then he/she would be more likely to follow the protocol associated with those outcomes. But where does the patient develop these expectations? One influential source is the physician, who can help to modify faulty outcome expectations and use the working alliance to help the patient believe in the utility and value of the treatment.37
Satisfaction Patient satisfaction with treatment has emerged as a vital aspect in the medical care field, specifically in relation to the successful implementation of a treatment plan and the improved quality of life for the patient. In many studies, patients’ satisfaction with care has been found to be correlated with higher rates of adherence,18,32,37–39 thereby granting it an essential role in improving the course and outcome of treatment. To help improve satisfaction, and therefore adherence, physicians can work toward creating stronger relationships with their patients, as the physician–patient working alliance has been found to be significantly associated
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with patients’ satisfaction levels.4,18 Furthermore, patients’ attachment styles have been found to be related to satisfaction and need to be considered as an important factor in the study of the working alliance and patient adherence.18
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Present Study and Hypotheses The current study examined the interplay between patients’ attachment styles and patients’ ratings of the physician–patient working alliance on several important factors of medical treatment, namely patient adherence, satisfaction, and outcome expectations. The study examined the level of association between these variables, and at a more complex level, we examined the role of the working alliance in mediating the relationship between psychological attachment and patient satisfaction and treatment adherence (see Figure 1). In terms of associations, based on previous research on the working alliance with different patient populations, the current team of researchers hypothesized that the physician– patient working alliance would be positively associated with patient adherence to treatment and with patient satisfaction. We also examined the relationship between the working alliance and patients’ outcome expectations, which was an entirely new link being explored, and hypothesized that the working alliance would be positively associated with expectations, which in turn would be associated with treatment adherence. Furthermore,
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since patients who are less trusting of and reliant on others are likely to have poorer collaboration with physicians and healthcare providers,28 we hypothesized that patients’ with an insecure attachment style would have more difficulty developing strong working alliances with their physicians. With lower working alliance ratings, patients with insecure attachment styles would be less likely to trust their physicians and their treatment plan.28 Therefore, we also hypothesized that insecurely attached patients would be less likely to adhere to their treatment plan or to find satisfaction with their treatment plan. In terms of the mediating role of the working alliance, we used path analysis to examine whether the working alliance offset the deleterious effect of insecure attachment on adherence and satisfaction.
Power Analysis Prior to the study a power analysis was conducted to ascertain the number of participants that would be required to adequately test the hypotheses in the study. With power set at .80, a medium effect size expected for the effect of the working alliance on the variables of interest, and with significance set at .05, we estimated that between 97 and 102 participants would be needed in order to have sufficient statistical power to adequately conduct the analyses.
FIGURE 1 Path analysis of attachment, working alliance, satisfaction, outcome expectations, and adherence. Significant paths links are present in boldface and larger type fonts. Note. Insecure D Insecure attachment; Secure D Secure attachment; PWAI D Physician–patient working alliance; Satis D Patient satisfaction with treatment; AdhereD Patient-rated adherence; Expect D Patient outcome expectations.
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METHODS
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Participants After approximately nine months of data collection, 101 participants, out of about 150 patients who were asked to participate, agreed to complete the survey for the study. All of the participants were adult outpatients who were recruited in the rheumatology clinic at Nassau University Medical Center, a hospital in Nassau County, New York. Data were collected twice a week during clinic hours (ie, between 9 AM and 1 PM). There were 17 males and 84 females, and the average age for the group was 48.57 (SD D 13.97). Thirty-four reported their marital status as married, 12 as divorced, 6 as widowed, 42 as single, and 7 as being in a committed relationship but not married. Sixteen of the respondents identified as Caucasian, 33 as African American, 45 as Hispanic, 3 as Asian American, and 4 as “Other.” Forty-three reported being born in the United States, 56 reported being born outside of the U.S., and 2 participants left the item blank. The countries most frequently represented in the sample included: El Salvador, Mexico, Honduras, Peru, and the Dominican Republic. Twenty-two of the participants reported having at least an 8th-grade education level, 32 reported having had a high school education level, 30 reported some college education or technical program, and 15 reported having completed college. Two participants left this information blank. The respondents rated their current health as follows, with the number of respondents in parentheses: very poor (5), poor (28), fair (37), good (28), and excellent (3). Most respondents reported their primary diagnoses being treated at the clinic as either arthritis or lupus. Sixty-six reported having health insurance, 34 responded as not having it, and 1 person left the item blank. In order to participate in the study, participants had to meet the following criteria: they had been diagnosed with and had been receiving treatment for a type of rheumatology disease, they were 18 years old or older, and they possessed a reading ability of 6th-grade level or better in English or Spanish. Patients were excluded from the study if they were found to be neurologically or psychiatrically incapacitated by the attending physician or if they were unable to read at a 6th-grade level. Procedure After receiving full IRB approval from Adelphi University and Nassau University Medical Center, researchers recruited participants in the rheumatology clinic of Nassau University Medical Center. Patients were told that the survey would take 30–45 min to complete. Once each participant signed the written informed consent form prior to his/ her participation in the study, the researchers asked if the participant had any questions about the study. All data
associated with the patient surveys were entered into a password-protected electronic file by one of the study personnel. Attending physicians were made aware of the study once the study was initiated and were approached to consent to the study. They were also made aware that their consent, or their refusal of consent, would not affect their employment in any way. Those physicians who consented were asked to complete a measure of patient adherence. Surveys for patients and physicians were completely anonymous. There were no names on any part of the questionnaire and no identifying information, such as those outlined by HIPAA identifiers, was used. Thus, the risk of a breach of confidentiality was extremely low. Physicians were not able to see any patient survey responses. Additionally, patients had no access to physician responses. Rather than use names on the questionnaires and associated paperwork, a unique code number was placed on top of each patient survey, with the same code number on the survey of the physician who saw that specific patient. This code number was not linked to subject identity. In this manner, a patient survey and the appropriate physician survey could be matched while still maintaining the anonymity of the surveys themselves. Measures The Physician–Patient Working Alliance Scale (PPWA) The PPWA was developed based on a measure used in psychotherapy research originally adapted by Tracey and Kokotovic.41 The three subscales of the original Working Alliance Inventory-Short (WAI-S) remain in the PPWA, and they are as follows: agreement on the goals of treatment, agreement on the tasks needed to achieve the goals of treatment, and the establishment of liking and trust between patient and physician. Participants rated their responses on a scale from 1 (strongly disagree) to 7 (strongly agree). Overall, higher scores on the PPWA indicate stronger agreement and more liking and trust between the physician and the patient. While both patient and physician forms of the PPWA have been developed, in the current study only patients rated the working alliance, using the patient form of the PPWA. A sample item from the agreement on treatment goals subscale is “My doctors and I agreed on my treatment plan.” A sample item from the agreement on treatment tasks subscale is “My doctors and I agreed on what is important for me to do.” A sample item from the therapeutic bond subscale is “I trust my doctors.” This patient form of the PPWA scale has been found to be reliable in previous studies.4,18,19 The Experiences in Close Relationship Scale-Short Form (ECR-S) The Experiences in Close Relationship Scale-Short Form (ECR-S)42 is a 12-item self-report measure of adult
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attachment. Participants rate each statement based on how they typically feel in romantic relationships. Participants are asked to rate their responses on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). There are two subscales assessing attachment anxiety and attachment avoidance. The anxiety subscale relates to fears of rejection and preoccupation with abandonment. A sample item from this subscale is “I do not often worry about being abandoned.” The avoidance subscale evaluates fears of intimacy and dependence. A sample item from this subscale is “I try to avoid getting too close to my partner.” For both subscales, a higher score signifies greater attachment avoidance or attachment anxiety. This scale has been reliable in previous research.18 Early examinations of the ECR-S across six independent samples indicated that the scales contained adequate internal consistency (coefficient alphas ranging from .77 to .86 for attachment anxiety and .78 to .88 for attachment avoidance).42 Alpha coefficients were slightly lower for the ECR-S than the original 36-item version of the scale, the ECR, but this is to be expected given that the ECR-S contains notably fewer items than the ECR. Additionally, past studies have revealed that test– retest reliabilities were strong (i.e. r > .80) over a onemonth period.42 In the current study, the 12 items in the scale were subjected to a factor analysis, which yielded two scales comprised of both attachment anxiety and avoidance items. A perusal of the factor loadings indicated that one scale assessed comfort with trust and intimacy, while the other scale included items about discomfort with and fear of intimacy and trust. Thus, we labeled these two scales secure attachment and insecure attachment and used them as such in all subsequent analyses.
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agree).A sample item from this measure is “I stick to my treatment schedule even if it means changing my eating habits.” This scale’s internal consistency has been reliable in previous studies.4,19,45 The reliability of this measure has been assessed at .89 and has been found to correlate in theoretically consistent ways with other measures, such as adherence.45 The General Measure of Expected Health Outcomes The General Measure of Expected Health Outcomes was developed by the principal investigator for the present study in order to assess participants’ expectations about the outcome of their treatment. The scale is comprised of 5 items and participants rate their responses using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). A sample item from this scale is “If I follow my treatment plan as prescribed by my doctors today, I believe that I will feel better.” Physician Ratings of Patient Adherence Measure Physicians’ ratings of patient adherence were assessed using a 5-item scale developed by the principal investigator for the current study. These statements were rated using a 6-point Likert scale as a means of assessing how physicians viewed the extent and consistency of patients’ adherence to treatment plans. Physicians responded to each statement with a rating ranging from 1 (strongly disagree) to 6 (strongly agree). A sample item from this scale is “The patient has taken all medications as prescribed.”
Medical Patient Satisfaction Questionnaire
RESULTS 4
An 11-item measure was developed by Fuertes et al. in order to assess patients’ global satisfaction with various realms of treatment (eg, appointment making, administrative and staff, and quality of physician’s medical treatment). The Medical Patient Satisfaction Questionnaire requires participants to rate their responses using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Multiple studies have found its overall internal consistency reliably acceptable.4,18,19 The internal consistency alpha coefficient has been measured at .91.4
Table 1 presents the means, standard deviations, and internal consistency reliability scores for each of the scales in the study. We would like to highlight the high level of internal consistency for most of the measures in the study, particularly the newly created measure of patient outcome expectations. The only measure with borderline acceptable reliability is the subscale of secure attachment, which may TABLE 1 Means and standard deviations for all study variables (N D 101)
Treatment Adherence Self-Efficacy Questionnaire In order to assess patient adherence we used a measure of adherence self-efficacy that has strong psychometric properties, and which has been linked with actual adherence to treatment.45 The scale indicates the extent to which participants feel that they can engage in behaviors that are in accordance with the goals of their physicians’ treatment plans. Participants rate their responses using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly
Physician–patient working alliance Satisfaction Patient ratings of adherence Outcome expectations Doctor ratings of adherence Insecure attachment Secure attachment
Mean
SD
Alpha Coefficients
70.74
11.73
.92
65.48 57.05 30.46 24.47 20.54 12.50
8.99 9.56 4.40 5.04 8.11 5.40
.88 .88 .86 .95 .87 .79
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FUERTES ET AL. TABLE 2 Intercorrelations among all study variables (N D 101)
ADH EXP PWAI SATIS INSEC SEC PRADH
Variable Label
ADH
EXP
PWAI
SATIS
INSEC
SEC
PRADH
Adherence with treatment Outcome expectations Physician—patient working alliance Satisfaction with treatment Insecure attachment Secure attachment Physician-rated adherence
1.00 .23* .46** .58** ¡.12 ¡.17 .13
— 1.00 .27* .40** .06 ¡.17 .09
— — 1.00 .62** ¡.19 ¡.15 .25**
— — — 1.00 ¡.29* ¡.19 .17
— — — — 1.00 ¡.01 .09
— — — — — 1.00 ¡.08
— — — — — — 1.00
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*p < .05; **p < .01.
have been due to the manner in which we arranged the items for the measure on the basis of the factor analyses explained above. We met the assumptions underlying our statistical tests, including normal distributions of scores, homogeneity of variance, and independence of observations. The correlations among the study variables are presented in Table 2. In terms of the associations, our first hypothesis was supported: a small, positive correlation was found between the physician–patient working alliance and patient self-reported adherence to treatment (r D .46, p < .01, or a small effect size of .21); we also found a medium correlation between the working alliance and patient satisfaction (r D .62, p < .01, or a medium effect size of .38). Our hypothesis of a significant relationship between the working alliance and patients’ outcome expectations was also supported, albeit by a very weak correlation (r D .27, p < .05, or a very small effect size of .07). We hypothesized that insecurely attached patients would be less likely to adhere to their treatment plan or to be satisfied with their treatment, and our results found partial support for this hypothesis: we found a small negative correlation between patient satisfaction and insecure attachment, (r D –.29, p < .05, or a very small effect size of .08). To test the mediating role of the working alliance between insecure attachment and adherence and satisfaction, LISREL 8.8046 was used to compute the path analysis shown in Figure 1. Overall fit of the data to the model was adequate, X2(7) D 14.96, p D .36, GFI D 0.94, RMSEA D 0.126. Although the RMSEA of 0.126 was greater than the desirable values of 0.00, it was not significantly different from the 0.05 value. The results of the path analysis also show significant links from working alliance to satisfaction (SB D 0.62) and then from satisfaction to adherence (SB D 0.48). Although working alliance significantly predicts outcome expectations (SB D 0.27), there are no direct paths from outcome expectations to adherence.
DISCUSSION The path analysis clarified the connections between the working alliance and patient adherence, satisfaction, and
outcome expectations. First, the path analyses demonstrated that the physician–patient working alliance was predictive of outcome expectations. The reader will recall that high scores on the working alliance measure are indicative of stronger agreement between patient and physician on the goals and tasks of treatment, and also are indicative of more liking and trust between the patient and physician. It is evident from this result that the positive aspects to the working alliance, such as the developed trust and liking of the physician by the patient and vice versa, help patients to feel more hopeful about their treatment and their potential benefits from the treatment. While outcome expectations did not predict adherence, this finding is in and of itself important in behavioral medicine, since positive expectations about improvement may very well lead to improvements in lifestyle and life outlook, which may lead to improvement in health and functioning. The path analysis also revealed that the working alliance predicts patient satisfaction. It is reasonable to expect that if you agree with your physician on the goals and tasks of treatment, and that if you like and trust your physician, then as a patient you are more likely to be satisfied with the treatment and care that you are receiving. This result has been replicated in previous studies on the physician–patient alliance involving other patient populations studies.4,18,19 However, the important link between working alliance, satisfaction, and patient adherence is also evident in the current set of results. There is also a strong indirect link between the physician–patient working alliance and patient adherence to treatment via patient satisfaction. Thus, adherence to treatment for the current sample is predicated on feeling satisfied with treatment, and satisfaction is predicated on a strong working alliance with the physician. A correlational result that is worth highlighting here is the significant correlation between physicians’ ratings of patient adherence and patients’ ratings of the working alliance. Physicians who made stronger alliances with their patients (as rated by the patient) reported better adherence for these patients. While the magnitude of this effect was very small (.06), it was nonetheless a significant finding, and the ratings were made independently (ie, the working alliance was rated by the
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patient and adherence was rated by the physician). Taken together, these results present a triangulation of findings that are consistent in showing that the working alliance is important to adherence, via patient satisfaction, which precedes adherence, and as evidenced by the higher ratings of patient adherence provided by physicians, which were positively associated with patients’ ratings of the working alliance. While the current study has provided potentially valuable results, there are several limitations that should be noted, First, we relied mostly on patient self-reports and did not assess the working alliance from the perspective of the physician. Second, self-reports may not necessarily reflect actual behaviors, especially on critical factors such as adherence. Third, we did not randomly select patients from the clinic, so the sample was one of convenience and comprised of patients who were willing to participate. Thus, the participants may or may not reflect the broader population of rheumatoid care patients seen in other clinics and caution needs to be taken in generalizing these findings.
CONCLUSIONS The physician–patient working alliance has a moderate effect on patients’ satisfaction with treatment and milder effects on patient adherence and patients’ outcome expectations. Additionally, the physician–patient working alliance predicts patient adherence to treatment via a path through patient satisfaction. Thus, the results of the present study highlight the impact of patient satisfaction with their physicians and their recommended treatment plan on their adherence to said treatment plan. The results also highlight the importance of physicians spending some time in fostering an alliance that encourages agreement on the part of the patient. This could be done, for example, by asking the patient something like “could you and I agree that you will try this exactly as I am explaining it to you until our next visit, and then we will evaluate if it’s helping you or whether we have to change it in some way? It also seems important that physicians make concerted efforts to develop a sense of trust and liking with the patient. This may be particularly important when patients uphold cultural values, beliefs, or practices that may need to be addressed and accounted for in the prescription and delivery of services. In rheumatoid conditions these may involve beliefs about taking multiple medications, exercise, rest, pain tolerance and management, and the use of alternative substances that are culturally prescribed. The lack of significant findings with respect to attachment is noteworthy, since a bulk of the recent theoretical and empirical work on the working alliance in psychotherapy has been linked with psychological attachment. It may be that with rheumatoid patients, psychological attachment in physician–patient interactions is not as salient or central as it is in psychotherapy or as it
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may be with other medical-patient populations. Alternatively, it may be that the way that psychological attachment was measured in the current study, via the use of a shorter measure of attachment, was limited. As noted above, the resulting factor loadings obtained with the ECR-S did not yield the two dimensions of avoidance and anxiety expected. Instead, two alternative dimensions emerged each with elements of both avoidance and anxiety, which we labeled as secure and insecure attachment. One explanation is that these new factors may have diluted the saliency of these attachment predictors leading to the lack of significant paths in our model. Clearly more research is needed on the viability of the ECR-S in medical-care interaction research, and the possible link between attachment and the working alliance in physician–rheumatoid patient communication awaits further empirical work. These results also support the use of brief, reliable, and valid measures of both the physician–patient working alliance and of patient satisfaction in measuring patients’ behaviors in medical care. The results also have implications for the way that medical students and residents are taught to communicate with their patients; for example, by actually encouraging the patients to ask more questions about their condition and the alternatives for treatment, and by encouraging patients to express their concerns and ambivalence about treatment more openly with their providers. Future research in this area might include include an analysis of the working alliance from both patients and phyisicians, and account for length and severity of the diagnosis and length of the professional relationship in examining the alliance. Future research examining the working alliance with respect to adherence and outcome should assess adherence more precisely through electronic monitors on pill bottles and lab results that more accurately assess medication intake and compliance.
REFERENCES [1] Laine C, Davidoff F. Patient-centered medicine: a professional evolution. JAMA. 1996;275:152–156. [2] Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality improvement in chronic illness care. Jt Comm J Qual Improv. 2001;27(2):63–80. [3] Wampold BE, Mondin GW, Moody M, Stich F, Benson K, Ahn H. A meta-analysis of outcome studies comparing bona fide psychotherapies: “All must have prizes.” Psychol Bull. 1997;122:203–215. [4] Fuertes JN, Mislowack A, Bennett J, Paul L, Gilbert TC, Fontan G, Boylan LS. The Physician–patient working alliance. Patient Educ Couns. 2007;66:29–36. doi:10.1080/10503300600789189 [5] Putnam SM, Lipkin M. The patient-centered interview: research support. In: Lipkin M, Putnam SM, Lazare A, Carroll JG, Frankel RM, eds. The Medical Interview: Clinical Care, Education and Research. New York, NY: Springer; 1995:530–538. [6] Swenson SL, Buell S, Zettler P, White M, Ruston D, Lo B. Patientcentered communication. J Gen Intern Med. 2004;11:1069–1081.
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[7] Anderson EB. Patient-centeredness: a new approach. Nephrol News Issues. 2002;16:80–82. [8] Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C. Observational study of effect of patient centeredness and positive approach on outcomes of general practice consultations. BMJ. 2001;323:908–911. [9] Beck RS, Daughtridge R, Sloane PD. Physician–patient communication in the primary care office: a systematic review. J Am Board of Fam Med. 2002;15:25–38. [10] McLane CG, Zyzanski SJ, Flocke SA. Factors associated with medication noncompliance in rural elderly hypertensive patients. Am J Hypertens. 1995;8:206–209. [11] DiMatteo MR, Lepper HS. Promoting Adherence to Courses of Treatment: Mutual Collaboration in the Physician–Patient Relationship. Westport, CT: Greenwood Press; 1998. [12] Treharne GJ, Lyons AC, Hale ED, Douglas KMJ, Kitas GD. “Compliance” is futile but is “concordance” between rheumatology patients and health professionals attainable? Rheumatology. 2006;45:1–5. [13] Harrold LR, Andrade SE. Medication adherence of patients with selected rheumatic conditions: a systematic review of the literature. J Semin Arthritis Rheum. 2009;38:396–402. [14] Hill J, Bird H, Johnson S. Effect of patient education on adherence to drug treatment for rheumatoid arthritis: a randomized controlled trial. Ann Rheum Dis. 2001;60:869–875. [15] Kjeken I, Dagfinrud H, Mowinkel P, Uhlig T, Kvien T, Finset A. Rheumatology care: involvement in medical decisions, received information, satisfaction with care, and unmet health care needs in patients with rheumatoid arthritis and ankylosing spondylitis. Arthritis Care Res. 2006;55:394–401. [16] Mahomed NN, Liang MH, Cook EF, Daltroy LH, Fortin PR, Fossel AH, Katz JN. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatology. 2002;29:1273–1279. [17] Carr A, Hewlett S, Hughes R, Mitchell H, Ryan S, Carr M, Kirwan J. Rheumatology outcomes: the patient’s perspective. J Rheumatology. 2003;30:880–883. [18] Bennett JK, Fuertes JN, Keitel M, Phillips R. The role of patient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment. Patient Educ Couns. 2010;85:124–133. [19] Fuertes JN, Boylan LS, Fontanella J. Behavioral indices in medical care outcome: the working alliance, adherence and related factors. J Gen Intern Med. 2009;24:80–85. doi:10.1007/s11606-008-0841-4 [20] Christensen AJ, Johnson JA. Patient adherence with medical treatment regimens: an interactive approach. Curr Dir Psychol Sci. 2002;11:94–97. [21] DiMatteo MR, Hays RD, Grtiz CR, Bastani R, Crane L, Elashoff R, Ganz P, Heber D, McCarthy W, Marcus A. Patient adherence to cancer control regiments: scale development and initial validation. Psychol Assess. 1993;5:102–112. [22] Brashers DE, Haas SM, Neidig JL. The patient self-advocacy scale: measuring patient involvement in health care decision-making. Health Commun. 1999;11:97–122. [23] Nordgren S, Fridlund B. Patients’ perceptions of self-determination as expressed in the context of care. J Adv Nurs. 2001;35:117–125. [24] Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four category model. J Pers Soc Psychol. 1991;61:226–244. [25] Bordin E. The generalizability of the psychoanalytic concept of the working alliance. Psychother Theor Res Pract Train. 1979;16:252–260.
[26] Holman H, Lorig K. Patients as partners in managing chronic disease. BMJ. 2000;320:526–527. [27] Stewart M. Patient-Centered Medicine: Transforming the Clinical Method. London, UK: Sage Publications; 1995. [28] Ciechanowski P, Russo J, Katon W, Von Korff M, Ludman E, Lin E, Simon G, Bush T. Influence of patient attachment style on self-care and outcomes in diabetes. Psychosom Med. 2004;66:720–728. [29] Bowlby J. Attachment and Loss, Vol. 2: Separation: Anxiety and Anger. New York, NY: BasicBooks; 1973. [30] Meyers LB, Vetere A. Adult romantic attachment styles and healthrelated measures. Psychol Health Med. 2002;7:175–180. [31] Eldred LJ, Wu AW, Chaisson RE, Moore RD. Adherence to antiretroviral and pneuomocystis prophylaxis in HIV disease. JAIDS Hum Retrovirol. 1998;18:117–125. [32] Barbosa CD, Balp M, Kulich K, Germain N, Rofail D. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adher. 2012;6: 39–48. [33] Martin LR, Jahng KH, Golin CE, DiMatteo MR. Physician facilitation of patient involvement in care: correspondence between patient and observer reports. Behav Med. 2003;28:159–164. [34] Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Practice. 1998;47:213–220. [35] DiMatteo MR. The role of effective communication with children and their families in fostering adherence to pediatric regimen. Patient Educ Couns. 2004;55:339–344. [36] Bandura A. Self-efficacy: The Exercise of Control. New York, NY: W.H. Freeman; 1997. [37] Iannotti RJ, Schnedier S, Nansel TR, Haynie DL, Plotnick LP, Clark LM, Sobel DO, Simons-Morton B. Self efficacy, outcome expectations, and diabetes self-management in adolescents with type 1 diabetes. J Dev Behav Pediatr. 2006;2:98–105. [38] Finkel MI. The importance of measuring patient satisfaction. Empl Benefits J. 1997;22:12–15. [39] Biderman A, Noff E, Harris SB, Friedman N, Levy A. Treatment satisfaction of diabetic patients: what are the contributing factors? Fam Pract. 2009;26:102–108. [40] Institute of Medicine. Hurtado MP, Swift EK, Corrigan JM, eds. Committee on the National Quality Report on Health Care Delivery, Board on Health Care Services. Envisioning the National Health Care Quality Report. Washington, DC: National Academy Press: Institute of Medicine; 2000. [41] Tracey TJ, Kokotovic AM. Factor structure of the Working Alliance Inventory. Psychol Assess J Consult Clin Psych. 1989;1: 207–210. [42] Wei M, Russell DW, Mallinckrodt B, Vogel DL. The Experiences in Close Relationship Scale (ECR)-Short Form: reliability, validity, and factor structure. J Pers Assess. 2007;88:187–204. [43] Hays RD. The Medical Outcomes Study (MOS) Measures of Patient Adherence. 1994. http://www.rand.org/health/surveys/MOS.adherence. measures.pdf. Accessed November 8, 2011. [44] Tarlov AR, Ware JE, Greenfield S, Nelson EC, Perrin E, Zubkoff M. The medical outcomes study. JAMA. 1989;7:925–931. [45] Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe TL. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol. 2000;19:124–133. [46] Joreskog KG, Sorbom D. LISREL 8.8 for Windows [Computer software]. Skokie, IL: Scientific International, Inc.; 2006.
Behavioral Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vbmd20
The Physician–Patient Working Alliance and Patient Psychological Attachment, Adherence, Outcome Expectations, and Satisfaction in a Sample of Rheumatology Patients a
b
b
a
Jairo N. Fuertes , Prachi Anand , Greg Haggerty , Michael Kestenbaum & Gary C. b
Rosenblum a
Derner Institute of Advanced Psychological Studies, Adelphi University
b
Nassau University Medical Center Accepted author version posted online: 19 Dec 2013.Published online: 03 Sep 2014.
Click for updates To cite this article: Jairo N. Fuertes, Prachi Anand, Greg Haggerty, Michael Kestenbaum & Gary C. Rosenblum (2015) The Physician–Patient Working Alliance and Patient Psychological Attachment, Adherence, Outcome Expectations, and Satisfaction in a Sample of Rheumatology Patients, Behavioral Medicine, 41:2, 60-68, DOI: 10.1080/08964289.2013.875885 To link to this article: http://dx.doi.org/10.1080/08964289.2013.875885
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BEHAVIORAL MEDICINE, 41: 60–68, 2015 Copyright Ó Taylor & Francis Group, LLC ISSN: 0896-4289 print / 1940-4026 online DOI: 10.1080/08964289.2013.875885
The Physician–Patient Working Alliance and Patient Psychological Attachment, Adherence, Outcome Expectations, and Satisfaction in a Sample of Rheumatology Patients Jairo N. Fuertes
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Derner Institute of Advanced Psychological Studies, Adelphi University
Prachi Anand and Greg Haggerty Nassau University Medical Center
Michael Kestenbaum Derner Institute of Advanced Psychological Studies, Adelphi University
Gary C. Rosenblum Nassau University Medical Center
Over the past twenty years, the physician–patient relationship (eg, the physician–patient working alliance) has emerged as an integral component to the treatment of patients for a myriad of health conditions. Psychological, emotional, and behavioral dimensions of patients’ working alliance with their physicians, along with patients’ attachment styles, were examined in relation to rheumatology patients’ adherence to treatment plans, outcome expectations, and satisfaction. Study participants were 101 adult outpatients from a rheumatology clinic. Path analyses demonstrated that the physician–patient working alliance predicted outcome expectations (Standardized Beta [SB] D 0.27), and patient satisfaction (SB D 0.62), and that patient satisfaction in turn predicted patient adherence (SB D 0.48). Physicians’ ratings of patient adherence were significantly and positively correlated with patients’ ratings of the physician–patient working alliance. No significant paths were evident with respect to patient attachment. The physician–patient working alliance directly predicts patient satisfaction, and outcome expectations, and indirectly predicts adherence through patient satisfaction.
Keywords: adherence, attachment, physician–patient working alliance, satisfaction Over the past three decades, research in counseling and psychotherapy has shown that the working alliance between therapists and their patients is the primary factor in patient and therapist-rated outcomes, specifically pertaining to involvement in, gains from, and satisfaction with treatment.1,2,3 The working alliance has been found to be Correspondence should be addressed to Dr. Jairo N. Fuertes, Associate Professor of Psychology, The Derner Institute of Advanced Psychological Studies, Adelphi University, Hy Weinberg Center–Rm 319, 158 Cambridge Avenue, Garden City, NY 11530, USA. E-mail: [email protected]
present in all forms of therapy, and the cumulative empirical data suggests that the working alliance is of such central importance to counseling and psychotherapy that it is now universally considered in mental health as the essential aspect of effective psychological treatment.3 In a similar vein to the increased focus on the relationship between therapist and patient, the health sciences field has initiated a movement to further explore and emphasize the professional relationship established between physicians and patients.4 With greater investment in such ideas, medical professionals are attempting
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to view their work as a joint venture between patient and physician rather than as an individual endeavor by the physician. In addition, medical schools are increasing training in patient-centered care for the purpose of developing physicians’ interpersonal interactions with their patients (ie, “bedside manner”) in order to improve medical care treatment.4 As evidenced by these developments in the field of healthcare, patient-centered care has developed to be more congruent with and responsive to patients’ wants, needs, and preferences.1 Patient-centered care has evolved out of a need for a broader, more comprehensive model of treatment that incorporates psychological, social, and cultural indices, in addition to the biological factors, into patients’ treatment plans. In fact, over the past 20 years, this form of patient treatment has grown in use in modern medicine.5,6 Research indicates that patient-centered approaches improve health,7 lessen symptom burden,5 increase satisfaction with treatment,8 facilitate treatment adherence,9,10 and reduce the chance of misdiagnosis.11 The importance of physician–patient communication and of a collaborative stance between the two appears to be important in rheumatology care.12,13 Adherence to medications is a longstanding and continuing problem with rheumatology patients, with non-adherence being as low as 30% and as high as 80% depending on the patient, the severity of the symptom, and the stage of treatment.13,14 This is of concern since medications make up the primary mechanisms with which to control symptoms and improve function. Medical care researchers in this area of medicine have noted the importance of patient participation in decision making15 and of physician–patient communication directed at improving adherence, satisfaction, and patients’ expectations with treatment.16,17 In our study, “patient-centeredness” is embodied in our conceptualization of the physician–patient relationship as a working alliance, and we use a recently developed and validated measure of the working alliance in the current study.4,18,19 The other variables in our study have been shown to be important to medical care treatment, health improvement, and symptom reduction. For example, treatment adherence and satisfaction have received considerable attention in the medical field.20,21 Self-agency is a construct from psychological research that appears to be particularly relevant to patient-centered care and patient empowerment.22,23 Additionally, self-agency is also linked to outcome expectations for patients.22,23 Lastly, a great deal of research has shown that people’s attachment styles may mediate their perceptions of others as trustworthy and approachable, which may emerge in the discussions and general interactions between physicians and patients.24 In the current study, we bring these concepts together to examine their interplay with the working alliance and to see how well each explains patient satisfaction and adherence.
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The Physician–Patient Working Alliance The working alliance construct has been empirically validated as the best predictor of outcome across all modalities of psychotherapy3 and has now been adapted for use and measure in medical care treatment.4 The working alliance has been defined as the level of agreement between physicians and patients on the goals of treatment, the level of agreement on the tasks associated with pursuing and evaluating treatment goals, and the presence of an emotional bond characterized by trust and liking between physician and patient.4,25 This relationship incorporates the patients into their own care rather than making them passive recipients, which has been found to be associated with higher satisfaction18 and greater continuity of care.26 In addition, the working alliance incorporates cognitive, behavioral, and emotional dimensions of care into a “partnership” between patients and physicians.4 By creating a strong working alliance that is responsive to patients’ needs and preferences, patients’ participation in their treatment increases.27 For example, studies have indicated significant positive relationships between working alliance ratings and adherence to treatment4,18 and between working alliance ratings and adherence self-efficacy beliefs.19 Patients who endorsed a strong working alliance have also reported better quality of life.18
Attachment The current study based its conceptualization of attachment style on traditional psychological attachment theory, which states that a child constructs internal working models for his/her self and for his/her relationships with others based on his/her first relationships with caregivers.28,29 As a result, the child develops a relatively fixed attachment style by either late adolescence or adulthood.29 Social psychologists have identified two types of interpersonal attachment styles—secure and insecure.28 Individuals with predominantly secure attachment styles are generally comfortable investing in close relationships with others and trusting others.28 On the other hand, people with insecure attachment styles are likely to experience fears of rejection or abandonment in relationships with others and to have difficulty in trusting others.28 Research has shown that securely attached individuals report having significantly more coping, emotional, and social resources than insecurely attached individuals.30 Attachment style strongly impacts trust in and collaboration with others and the ability to effectively cope with stress-inducing situations. As such, there is also possibly a connection between one’s attachment style and one’s ability to develop cooperative and trusting relationships with professionals who treat illness and pain, such as health care professionals. Thus, psychological attachment is an important concept to examine in
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medical care relationships and health outcomes as it may provide an important venue by which to understand patients’ ability to cope with disease and the quality of their interactions with physicians. Further research has demonstrated that patients with insecure attachment styles view the physician–patient relationship less favorably when compared to patients with secure attachment styles.28 In comparison, patients who manifest secure attachment styles (ie, possess little to no fear of rejection or intimacy) report stronger working alliances with their physicians.18 Additionally, secure attachment styles have also been linked to greater patient satisfaction with treatment, improved health-related quality of life, greater control of physical symptoms, and greater adherence to treatment.18,28 Thus, based on the above findings, the impact of patients’ attachment styles on medical care relationships is considered to be crucial to treatment and outcome. Adherence The importance of a collaborative relationship between physicians and patients is perhaps best highlighted by current estimates of patient adherence to treatment, which indicate that up to forty percent of patients are unable to follow their treatment regimen. In chronic conditions, like rheumatoid arthritis and related diseases, patient adherence to medication is commonly about 50%.31 Inadequate patient adherence leads to complications, deterioration in health, and significant hardships for patients as well as for the healthcare system, thereby making patient adherence a key part of proper medical treatment.32 The quality of care that is provided by physicians has the potential to improve or to diminish patient adherence to treatment.31 Aspects of care that lead to improvement in adherence are as follows: physicians’ encouragement of patient involvement in the treatment plan,33 patients’ trust in the therapeutic relationship,33 physicians’ knowledge of the patient as an individual,34 and effective communication by both patient and physician.35 These factors can serve as the foundation for the eventual formation of a strong working alliance between physician and patient.18 As the working alliance develops, patients’ perceptions of the value of treatment improve.4,19 In addition, patients’ agreement with, approval for, and trust in their physician help them to view the treatment as warranted and important, thereby increasing their participation in and adherence to the recommended treatment.18,19 In order to adhere to the treatment plans that impact their daily lives, patients must also understand the purpose of the various aspects of the treatment and feel capable of accomplishing the necessary treatment procedures. With adequate levels of agreement communication and trust in place between them, the patient and the physician are better able to work on implementing, following, and monitoring the treatment.
Adherence Self-Efficacy and Outcome Expectations Self-efficacy is defined as the belief in one’s ability to organize and perform behaviors necessary to achieve one’s goals.36 Adherence self-efficacy is a patient’s belief that he/ she can follow through with specific recommendations inherent in the treatment regimen, and has been found to have a strong relationship with actual patient adherence.19,31 These findings indicate that, in order to adequately adhere to their treatment plans, patients must understand the necessary tasks associated with the plan and feel prepared and capable to carry out these tasks. Adherence self-efficacy has been found to be positively, and significantly, associated with ratings of the physician– patient working alliance.19 This association is perhaps based on the level of agreement between patient and physician on the goals of treatment and agreement on the tasks needed to meet or achieve the goals; if the patient agrees with the goals and tasks of treatment, then he/she is much more likely to believe that he/she can adhere to it. The dimensions of liking and trust in the alliance also allow for patients and physicians to address difficulties in believing that adherence is possible, and facilitate physicians interventions aimed at helping the patient deal with doubt or fear about being able to better adherence. The emotional dimensions associated with self-efficacy with respect to adherence have been greatly underemphasized in medicine, and in this study we examine if trust and liking as measured in the alliance is associated with patients becoming more confident with respect to treatment adherence.19 Belief and participation in the treatment are also likely to be affected by the patients’ expectations about the outcome. If the patient has some notion that the outcome of treatment will be desirable, then he/she would be more likely to follow the protocol associated with those outcomes. But where does the patient develop these expectations? One influential source is the physician, who can help to modify faulty outcome expectations and use the working alliance to help the patient believe in the utility and value of the treatment.37
Satisfaction Patient satisfaction with treatment has emerged as a vital aspect in the medical care field, specifically in relation to the successful implementation of a treatment plan and the improved quality of life for the patient. In many studies, patients’ satisfaction with care has been found to be correlated with higher rates of adherence,18,32,37–39 thereby granting it an essential role in improving the course and outcome of treatment. To help improve satisfaction, and therefore adherence, physicians can work toward creating stronger relationships with their patients, as the physician–patient working alliance has been found to be significantly associated
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with patients’ satisfaction levels.4,18 Furthermore, patients’ attachment styles have been found to be related to satisfaction and need to be considered as an important factor in the study of the working alliance and patient adherence.18
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Present Study and Hypotheses The current study examined the interplay between patients’ attachment styles and patients’ ratings of the physician–patient working alliance on several important factors of medical treatment, namely patient adherence, satisfaction, and outcome expectations. The study examined the level of association between these variables, and at a more complex level, we examined the role of the working alliance in mediating the relationship between psychological attachment and patient satisfaction and treatment adherence (see Figure 1). In terms of associations, based on previous research on the working alliance with different patient populations, the current team of researchers hypothesized that the physician– patient working alliance would be positively associated with patient adherence to treatment and with patient satisfaction. We also examined the relationship between the working alliance and patients’ outcome expectations, which was an entirely new link being explored, and hypothesized that the working alliance would be positively associated with expectations, which in turn would be associated with treatment adherence. Furthermore,
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since patients who are less trusting of and reliant on others are likely to have poorer collaboration with physicians and healthcare providers,28 we hypothesized that patients’ with an insecure attachment style would have more difficulty developing strong working alliances with their physicians. With lower working alliance ratings, patients with insecure attachment styles would be less likely to trust their physicians and their treatment plan.28 Therefore, we also hypothesized that insecurely attached patients would be less likely to adhere to their treatment plan or to find satisfaction with their treatment plan. In terms of the mediating role of the working alliance, we used path analysis to examine whether the working alliance offset the deleterious effect of insecure attachment on adherence and satisfaction.
Power Analysis Prior to the study a power analysis was conducted to ascertain the number of participants that would be required to adequately test the hypotheses in the study. With power set at .80, a medium effect size expected for the effect of the working alliance on the variables of interest, and with significance set at .05, we estimated that between 97 and 102 participants would be needed in order to have sufficient statistical power to adequately conduct the analyses.
FIGURE 1 Path analysis of attachment, working alliance, satisfaction, outcome expectations, and adherence. Significant paths links are present in boldface and larger type fonts. Note. Insecure D Insecure attachment; Secure D Secure attachment; PWAI D Physician–patient working alliance; Satis D Patient satisfaction with treatment; AdhereD Patient-rated adherence; Expect D Patient outcome expectations.
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METHODS
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Participants After approximately nine months of data collection, 101 participants, out of about 150 patients who were asked to participate, agreed to complete the survey for the study. All of the participants were adult outpatients who were recruited in the rheumatology clinic at Nassau University Medical Center, a hospital in Nassau County, New York. Data were collected twice a week during clinic hours (ie, between 9 AM and 1 PM). There were 17 males and 84 females, and the average age for the group was 48.57 (SD D 13.97). Thirty-four reported their marital status as married, 12 as divorced, 6 as widowed, 42 as single, and 7 as being in a committed relationship but not married. Sixteen of the respondents identified as Caucasian, 33 as African American, 45 as Hispanic, 3 as Asian American, and 4 as “Other.” Forty-three reported being born in the United States, 56 reported being born outside of the U.S., and 2 participants left the item blank. The countries most frequently represented in the sample included: El Salvador, Mexico, Honduras, Peru, and the Dominican Republic. Twenty-two of the participants reported having at least an 8th-grade education level, 32 reported having had a high school education level, 30 reported some college education or technical program, and 15 reported having completed college. Two participants left this information blank. The respondents rated their current health as follows, with the number of respondents in parentheses: very poor (5), poor (28), fair (37), good (28), and excellent (3). Most respondents reported their primary diagnoses being treated at the clinic as either arthritis or lupus. Sixty-six reported having health insurance, 34 responded as not having it, and 1 person left the item blank. In order to participate in the study, participants had to meet the following criteria: they had been diagnosed with and had been receiving treatment for a type of rheumatology disease, they were 18 years old or older, and they possessed a reading ability of 6th-grade level or better in English or Spanish. Patients were excluded from the study if they were found to be neurologically or psychiatrically incapacitated by the attending physician or if they were unable to read at a 6th-grade level. Procedure After receiving full IRB approval from Adelphi University and Nassau University Medical Center, researchers recruited participants in the rheumatology clinic of Nassau University Medical Center. Patients were told that the survey would take 30–45 min to complete. Once each participant signed the written informed consent form prior to his/ her participation in the study, the researchers asked if the participant had any questions about the study. All data
associated with the patient surveys were entered into a password-protected electronic file by one of the study personnel. Attending physicians were made aware of the study once the study was initiated and were approached to consent to the study. They were also made aware that their consent, or their refusal of consent, would not affect their employment in any way. Those physicians who consented were asked to complete a measure of patient adherence. Surveys for patients and physicians were completely anonymous. There were no names on any part of the questionnaire and no identifying information, such as those outlined by HIPAA identifiers, was used. Thus, the risk of a breach of confidentiality was extremely low. Physicians were not able to see any patient survey responses. Additionally, patients had no access to physician responses. Rather than use names on the questionnaires and associated paperwork, a unique code number was placed on top of each patient survey, with the same code number on the survey of the physician who saw that specific patient. This code number was not linked to subject identity. In this manner, a patient survey and the appropriate physician survey could be matched while still maintaining the anonymity of the surveys themselves. Measures The Physician–Patient Working Alliance Scale (PPWA) The PPWA was developed based on a measure used in psychotherapy research originally adapted by Tracey and Kokotovic.41 The three subscales of the original Working Alliance Inventory-Short (WAI-S) remain in the PPWA, and they are as follows: agreement on the goals of treatment, agreement on the tasks needed to achieve the goals of treatment, and the establishment of liking and trust between patient and physician. Participants rated their responses on a scale from 1 (strongly disagree) to 7 (strongly agree). Overall, higher scores on the PPWA indicate stronger agreement and more liking and trust between the physician and the patient. While both patient and physician forms of the PPWA have been developed, in the current study only patients rated the working alliance, using the patient form of the PPWA. A sample item from the agreement on treatment goals subscale is “My doctors and I agreed on my treatment plan.” A sample item from the agreement on treatment tasks subscale is “My doctors and I agreed on what is important for me to do.” A sample item from the therapeutic bond subscale is “I trust my doctors.” This patient form of the PPWA scale has been found to be reliable in previous studies.4,18,19 The Experiences in Close Relationship Scale-Short Form (ECR-S) The Experiences in Close Relationship Scale-Short Form (ECR-S)42 is a 12-item self-report measure of adult
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attachment. Participants rate each statement based on how they typically feel in romantic relationships. Participants are asked to rate their responses on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). There are two subscales assessing attachment anxiety and attachment avoidance. The anxiety subscale relates to fears of rejection and preoccupation with abandonment. A sample item from this subscale is “I do not often worry about being abandoned.” The avoidance subscale evaluates fears of intimacy and dependence. A sample item from this subscale is “I try to avoid getting too close to my partner.” For both subscales, a higher score signifies greater attachment avoidance or attachment anxiety. This scale has been reliable in previous research.18 Early examinations of the ECR-S across six independent samples indicated that the scales contained adequate internal consistency (coefficient alphas ranging from .77 to .86 for attachment anxiety and .78 to .88 for attachment avoidance).42 Alpha coefficients were slightly lower for the ECR-S than the original 36-item version of the scale, the ECR, but this is to be expected given that the ECR-S contains notably fewer items than the ECR. Additionally, past studies have revealed that test– retest reliabilities were strong (i.e. r > .80) over a onemonth period.42 In the current study, the 12 items in the scale were subjected to a factor analysis, which yielded two scales comprised of both attachment anxiety and avoidance items. A perusal of the factor loadings indicated that one scale assessed comfort with trust and intimacy, while the other scale included items about discomfort with and fear of intimacy and trust. Thus, we labeled these two scales secure attachment and insecure attachment and used them as such in all subsequent analyses.
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agree).A sample item from this measure is “I stick to my treatment schedule even if it means changing my eating habits.” This scale’s internal consistency has been reliable in previous studies.4,19,45 The reliability of this measure has been assessed at .89 and has been found to correlate in theoretically consistent ways with other measures, such as adherence.45 The General Measure of Expected Health Outcomes The General Measure of Expected Health Outcomes was developed by the principal investigator for the present study in order to assess participants’ expectations about the outcome of their treatment. The scale is comprised of 5 items and participants rate their responses using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). A sample item from this scale is “If I follow my treatment plan as prescribed by my doctors today, I believe that I will feel better.” Physician Ratings of Patient Adherence Measure Physicians’ ratings of patient adherence were assessed using a 5-item scale developed by the principal investigator for the current study. These statements were rated using a 6-point Likert scale as a means of assessing how physicians viewed the extent and consistency of patients’ adherence to treatment plans. Physicians responded to each statement with a rating ranging from 1 (strongly disagree) to 6 (strongly agree). A sample item from this scale is “The patient has taken all medications as prescribed.”
Medical Patient Satisfaction Questionnaire
RESULTS 4
An 11-item measure was developed by Fuertes et al. in order to assess patients’ global satisfaction with various realms of treatment (eg, appointment making, administrative and staff, and quality of physician’s medical treatment). The Medical Patient Satisfaction Questionnaire requires participants to rate their responses using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Multiple studies have found its overall internal consistency reliably acceptable.4,18,19 The internal consistency alpha coefficient has been measured at .91.4
Table 1 presents the means, standard deviations, and internal consistency reliability scores for each of the scales in the study. We would like to highlight the high level of internal consistency for most of the measures in the study, particularly the newly created measure of patient outcome expectations. The only measure with borderline acceptable reliability is the subscale of secure attachment, which may TABLE 1 Means and standard deviations for all study variables (N D 101)
Treatment Adherence Self-Efficacy Questionnaire In order to assess patient adherence we used a measure of adherence self-efficacy that has strong psychometric properties, and which has been linked with actual adherence to treatment.45 The scale indicates the extent to which participants feel that they can engage in behaviors that are in accordance with the goals of their physicians’ treatment plans. Participants rate their responses using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly
Physician–patient working alliance Satisfaction Patient ratings of adherence Outcome expectations Doctor ratings of adherence Insecure attachment Secure attachment
Mean
SD
Alpha Coefficients
70.74
11.73
.92
65.48 57.05 30.46 24.47 20.54 12.50
8.99 9.56 4.40 5.04 8.11 5.40
.88 .88 .86 .95 .87 .79
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FUERTES ET AL. TABLE 2 Intercorrelations among all study variables (N D 101)
ADH EXP PWAI SATIS INSEC SEC PRADH
Variable Label
ADH
EXP
PWAI
SATIS
INSEC
SEC
PRADH
Adherence with treatment Outcome expectations Physician—patient working alliance Satisfaction with treatment Insecure attachment Secure attachment Physician-rated adherence
1.00 .23* .46** .58** ¡.12 ¡.17 .13
— 1.00 .27* .40** .06 ¡.17 .09
— — 1.00 .62** ¡.19 ¡.15 .25**
— — — 1.00 ¡.29* ¡.19 .17
— — — — 1.00 ¡.01 .09
— — — — — 1.00 ¡.08
— — — — — — 1.00
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*p < .05; **p < .01.
have been due to the manner in which we arranged the items for the measure on the basis of the factor analyses explained above. We met the assumptions underlying our statistical tests, including normal distributions of scores, homogeneity of variance, and independence of observations. The correlations among the study variables are presented in Table 2. In terms of the associations, our first hypothesis was supported: a small, positive correlation was found between the physician–patient working alliance and patient self-reported adherence to treatment (r D .46, p < .01, or a small effect size of .21); we also found a medium correlation between the working alliance and patient satisfaction (r D .62, p < .01, or a medium effect size of .38). Our hypothesis of a significant relationship between the working alliance and patients’ outcome expectations was also supported, albeit by a very weak correlation (r D .27, p < .05, or a very small effect size of .07). We hypothesized that insecurely attached patients would be less likely to adhere to their treatment plan or to be satisfied with their treatment, and our results found partial support for this hypothesis: we found a small negative correlation between patient satisfaction and insecure attachment, (r D –.29, p < .05, or a very small effect size of .08). To test the mediating role of the working alliance between insecure attachment and adherence and satisfaction, LISREL 8.8046 was used to compute the path analysis shown in Figure 1. Overall fit of the data to the model was adequate, X2(7) D 14.96, p D .36, GFI D 0.94, RMSEA D 0.126. Although the RMSEA of 0.126 was greater than the desirable values of 0.00, it was not significantly different from the 0.05 value. The results of the path analysis also show significant links from working alliance to satisfaction (SB D 0.62) and then from satisfaction to adherence (SB D 0.48). Although working alliance significantly predicts outcome expectations (SB D 0.27), there are no direct paths from outcome expectations to adherence.
DISCUSSION The path analysis clarified the connections between the working alliance and patient adherence, satisfaction, and
outcome expectations. First, the path analyses demonstrated that the physician–patient working alliance was predictive of outcome expectations. The reader will recall that high scores on the working alliance measure are indicative of stronger agreement between patient and physician on the goals and tasks of treatment, and also are indicative of more liking and trust between the patient and physician. It is evident from this result that the positive aspects to the working alliance, such as the developed trust and liking of the physician by the patient and vice versa, help patients to feel more hopeful about their treatment and their potential benefits from the treatment. While outcome expectations did not predict adherence, this finding is in and of itself important in behavioral medicine, since positive expectations about improvement may very well lead to improvements in lifestyle and life outlook, which may lead to improvement in health and functioning. The path analysis also revealed that the working alliance predicts patient satisfaction. It is reasonable to expect that if you agree with your physician on the goals and tasks of treatment, and that if you like and trust your physician, then as a patient you are more likely to be satisfied with the treatment and care that you are receiving. This result has been replicated in previous studies on the physician–patient alliance involving other patient populations studies.4,18,19 However, the important link between working alliance, satisfaction, and patient adherence is also evident in the current set of results. There is also a strong indirect link between the physician–patient working alliance and patient adherence to treatment via patient satisfaction. Thus, adherence to treatment for the current sample is predicated on feeling satisfied with treatment, and satisfaction is predicated on a strong working alliance with the physician. A correlational result that is worth highlighting here is the significant correlation between physicians’ ratings of patient adherence and patients’ ratings of the working alliance. Physicians who made stronger alliances with their patients (as rated by the patient) reported better adherence for these patients. While the magnitude of this effect was very small (.06), it was nonetheless a significant finding, and the ratings were made independently (ie, the working alliance was rated by the
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THE PHYSICIAN–PATIENT WORKING ALLIANCE
patient and adherence was rated by the physician). Taken together, these results present a triangulation of findings that are consistent in showing that the working alliance is important to adherence, via patient satisfaction, which precedes adherence, and as evidenced by the higher ratings of patient adherence provided by physicians, which were positively associated with patients’ ratings of the working alliance. While the current study has provided potentially valuable results, there are several limitations that should be noted, First, we relied mostly on patient self-reports and did not assess the working alliance from the perspective of the physician. Second, self-reports may not necessarily reflect actual behaviors, especially on critical factors such as adherence. Third, we did not randomly select patients from the clinic, so the sample was one of convenience and comprised of patients who were willing to participate. Thus, the participants may or may not reflect the broader population of rheumatoid care patients seen in other clinics and caution needs to be taken in generalizing these findings.
CONCLUSIONS The physician–patient working alliance has a moderate effect on patients’ satisfaction with treatment and milder effects on patient adherence and patients’ outcome expectations. Additionally, the physician–patient working alliance predicts patient adherence to treatment via a path through patient satisfaction. Thus, the results of the present study highlight the impact of patient satisfaction with their physicians and their recommended treatment plan on their adherence to said treatment plan. The results also highlight the importance of physicians spending some time in fostering an alliance that encourages agreement on the part of the patient. This could be done, for example, by asking the patient something like “could you and I agree that you will try this exactly as I am explaining it to you until our next visit, and then we will evaluate if it’s helping you or whether we have to change it in some way? It also seems important that physicians make concerted efforts to develop a sense of trust and liking with the patient. This may be particularly important when patients uphold cultural values, beliefs, or practices that may need to be addressed and accounted for in the prescription and delivery of services. In rheumatoid conditions these may involve beliefs about taking multiple medications, exercise, rest, pain tolerance and management, and the use of alternative substances that are culturally prescribed. The lack of significant findings with respect to attachment is noteworthy, since a bulk of the recent theoretical and empirical work on the working alliance in psychotherapy has been linked with psychological attachment. It may be that with rheumatoid patients, psychological attachment in physician–patient interactions is not as salient or central as it is in psychotherapy or as it
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may be with other medical-patient populations. Alternatively, it may be that the way that psychological attachment was measured in the current study, via the use of a shorter measure of attachment, was limited. As noted above, the resulting factor loadings obtained with the ECR-S did not yield the two dimensions of avoidance and anxiety expected. Instead, two alternative dimensions emerged each with elements of both avoidance and anxiety, which we labeled as secure and insecure attachment. One explanation is that these new factors may have diluted the saliency of these attachment predictors leading to the lack of significant paths in our model. Clearly more research is needed on the viability of the ECR-S in medical-care interaction research, and the possible link between attachment and the working alliance in physician–rheumatoid patient communication awaits further empirical work. These results also support the use of brief, reliable, and valid measures of both the physician–patient working alliance and of patient satisfaction in measuring patients’ behaviors in medical care. The results also have implications for the way that medical students and residents are taught to communicate with their patients; for example, by actually encouraging the patients to ask more questions about their condition and the alternatives for treatment, and by encouraging patients to express their concerns and ambivalence about treatment more openly with their providers. Future research in this area might include include an analysis of the working alliance from both patients and phyisicians, and account for length and severity of the diagnosis and length of the professional relationship in examining the alliance. Future research examining the working alliance with respect to adherence and outcome should assess adherence more precisely through electronic monitors on pill bottles and lab results that more accurately assess medication intake and compliance.
REFERENCES [1] Laine C, Davidoff F. Patient-centered medicine: a professional evolution. JAMA. 1996;275:152–156. [2] Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality improvement in chronic illness care. Jt Comm J Qual Improv. 2001;27(2):63–80. [3] Wampold BE, Mondin GW, Moody M, Stich F, Benson K, Ahn H. A meta-analysis of outcome studies comparing bona fide psychotherapies: “All must have prizes.” Psychol Bull. 1997;122:203–215. [4] Fuertes JN, Mislowack A, Bennett J, Paul L, Gilbert TC, Fontan G, Boylan LS. The Physician–patient working alliance. Patient Educ Couns. 2007;66:29–36. doi:10.1080/10503300600789189 [5] Putnam SM, Lipkin M. The patient-centered interview: research support. In: Lipkin M, Putnam SM, Lazare A, Carroll JG, Frankel RM, eds. The Medical Interview: Clinical Care, Education and Research. New York, NY: Springer; 1995:530–538. [6] Swenson SL, Buell S, Zettler P, White M, Ruston D, Lo B. Patientcentered communication. J Gen Intern Med. 2004;11:1069–1081.
Downloaded by [New York University] at 04:44 08 June 2015
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FUERTES ET AL.
[7] Anderson EB. Patient-centeredness: a new approach. Nephrol News Issues. 2002;16:80–82. [8] Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C. Observational study of effect of patient centeredness and positive approach on outcomes of general practice consultations. BMJ. 2001;323:908–911. [9] Beck RS, Daughtridge R, Sloane PD. Physician–patient communication in the primary care office: a systematic review. J Am Board of Fam Med. 2002;15:25–38. [10] McLane CG, Zyzanski SJ, Flocke SA. Factors associated with medication noncompliance in rural elderly hypertensive patients. Am J Hypertens. 1995;8:206–209. [11] DiMatteo MR, Lepper HS. Promoting Adherence to Courses of Treatment: Mutual Collaboration in the Physician–Patient Relationship. Westport, CT: Greenwood Press; 1998. [12] Treharne GJ, Lyons AC, Hale ED, Douglas KMJ, Kitas GD. “Compliance” is futile but is “concordance” between rheumatology patients and health professionals attainable? Rheumatology. 2006;45:1–5. [13] Harrold LR, Andrade SE. Medication adherence of patients with selected rheumatic conditions: a systematic review of the literature. J Semin Arthritis Rheum. 2009;38:396–402. [14] Hill J, Bird H, Johnson S. Effect of patient education on adherence to drug treatment for rheumatoid arthritis: a randomized controlled trial. Ann Rheum Dis. 2001;60:869–875. [15] Kjeken I, Dagfinrud H, Mowinkel P, Uhlig T, Kvien T, Finset A. Rheumatology care: involvement in medical decisions, received information, satisfaction with care, and unmet health care needs in patients with rheumatoid arthritis and ankylosing spondylitis. Arthritis Care Res. 2006;55:394–401. [16] Mahomed NN, Liang MH, Cook EF, Daltroy LH, Fortin PR, Fossel AH, Katz JN. The importance of patient expectations in predicting functional outcomes after total joint arthroplasty. J Rheumatology. 2002;29:1273–1279. [17] Carr A, Hewlett S, Hughes R, Mitchell H, Ryan S, Carr M, Kirwan J. Rheumatology outcomes: the patient’s perspective. J Rheumatology. 2003;30:880–883. [18] Bennett JK, Fuertes JN, Keitel M, Phillips R. The role of patient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment. Patient Educ Couns. 2010;85:124–133. [19] Fuertes JN, Boylan LS, Fontanella J. Behavioral indices in medical care outcome: the working alliance, adherence and related factors. J Gen Intern Med. 2009;24:80–85. doi:10.1007/s11606-008-0841-4 [20] Christensen AJ, Johnson JA. Patient adherence with medical treatment regimens: an interactive approach. Curr Dir Psychol Sci. 2002;11:94–97. [21] DiMatteo MR, Hays RD, Grtiz CR, Bastani R, Crane L, Elashoff R, Ganz P, Heber D, McCarthy W, Marcus A. Patient adherence to cancer control regiments: scale development and initial validation. Psychol Assess. 1993;5:102–112. [22] Brashers DE, Haas SM, Neidig JL. The patient self-advocacy scale: measuring patient involvement in health care decision-making. Health Commun. 1999;11:97–122. [23] Nordgren S, Fridlund B. Patients’ perceptions of self-determination as expressed in the context of care. J Adv Nurs. 2001;35:117–125. [24] Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four category model. J Pers Soc Psychol. 1991;61:226–244. [25] Bordin E. The generalizability of the psychoanalytic concept of the working alliance. Psychother Theor Res Pract Train. 1979;16:252–260.
[26] Holman H, Lorig K. Patients as partners in managing chronic disease. BMJ. 2000;320:526–527. [27] Stewart M. Patient-Centered Medicine: Transforming the Clinical Method. London, UK: Sage Publications; 1995. [28] Ciechanowski P, Russo J, Katon W, Von Korff M, Ludman E, Lin E, Simon G, Bush T. Influence of patient attachment style on self-care and outcomes in diabetes. Psychosom Med. 2004;66:720–728. [29] Bowlby J. Attachment and Loss, Vol. 2: Separation: Anxiety and Anger. New York, NY: BasicBooks; 1973. [30] Meyers LB, Vetere A. Adult romantic attachment styles and healthrelated measures. Psychol Health Med. 2002;7:175–180. [31] Eldred LJ, Wu AW, Chaisson RE, Moore RD. Adherence to antiretroviral and pneuomocystis prophylaxis in HIV disease. JAIDS Hum Retrovirol. 1998;18:117–125. [32] Barbosa CD, Balp M, Kulich K, Germain N, Rofail D. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adher. 2012;6: 39–48. [33] Martin LR, Jahng KH, Golin CE, DiMatteo MR. Physician facilitation of patient involvement in care: correspondence between patient and observer reports. Behav Med. 2003;28:159–164. [34] Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Practice. 1998;47:213–220. [35] DiMatteo MR. The role of effective communication with children and their families in fostering adherence to pediatric regimen. Patient Educ Couns. 2004;55:339–344. [36] Bandura A. Self-efficacy: The Exercise of Control. New York, NY: W.H. Freeman; 1997. [37] Iannotti RJ, Schnedier S, Nansel TR, Haynie DL, Plotnick LP, Clark LM, Sobel DO, Simons-Morton B. Self efficacy, outcome expectations, and diabetes self-management in adolescents with type 1 diabetes. J Dev Behav Pediatr. 2006;2:98–105. [38] Finkel MI. The importance of measuring patient satisfaction. Empl Benefits J. 1997;22:12–15. [39] Biderman A, Noff E, Harris SB, Friedman N, Levy A. Treatment satisfaction of diabetic patients: what are the contributing factors? Fam Pract. 2009;26:102–108. [40] Institute of Medicine. Hurtado MP, Swift EK, Corrigan JM, eds. Committee on the National Quality Report on Health Care Delivery, Board on Health Care Services. Envisioning the National Health Care Quality Report. Washington, DC: National Academy Press: Institute of Medicine; 2000. [41] Tracey TJ, Kokotovic AM. Factor structure of the Working Alliance Inventory. Psychol Assess J Consult Clin Psych. 1989;1: 207–210. [42] Wei M, Russell DW, Mallinckrodt B, Vogel DL. The Experiences in Close Relationship Scale (ECR)-Short Form: reliability, validity, and factor structure. J Pers Assess. 2007;88:187–204. [43] Hays RD. The Medical Outcomes Study (MOS) Measures of Patient Adherence. 1994. http://www.rand.org/health/surveys/MOS.adherence. measures.pdf. Accessed November 8, 2011. [44] Tarlov AR, Ware JE, Greenfield S, Nelson EC, Perrin E, Zubkoff M. The medical outcomes study. JAMA. 1989;7:925–931. [45] Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe TL. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol. 2000;19:124–133. [46] Joreskog KG, Sorbom D. LISREL 8.8 for Windows [Computer software]. Skokie, IL: Scientific International, Inc.; 2006.
