This article presents a critique of current models of preventive behavior. It discusses a variety of factors that are usually overlooked-including the appearance of costs and benefits over time, the role of cues to action, the problem of competing life demands, and the ways that actual decision behavior differs from the rational ideal implicit in expectancy-value and utility theories. Such considerations suggest that the adoption of new precautions should be viewed as a dynamic process with many determinants. The framework of a model that is able to accommodate these additional factors is described. This alternative model portrays the precaution adoption process as an orderly sequence of qualitatively different cognitive stages. Data illustrating a few of the suggestions made in the article are presented, and implications for prevention programs are discussed.

The precaution adoption process.

ContextMany clinicians have called for an increased emphasis on the patient's
role in clinical decision making. However, little is known about the extent
to which physicians foster patient involvement in decision making, particularly
in routine office practice.ObjectiveTo characterize the nature and completeness of informed decision making
in routine office visits of both primary care physicians and surgeons.DesignCross-sectional descriptive evaluation of audiotaped office visits during
1993.Setting and ParticipantsA total of 1057 encounters among 59 primary care physicians (general
internists and family practitioners) and 65 general and orthopedic surgeons;
2 to 12 patients were recruited from each physician's community-based private
office.Main Outcome MeasuresAnalysis of audiotaped patient-physician discussions for elements of
informed decision making, using criteria that varied with the level of decision
complexity: basic (eg, laboratory test), intermediate (eg, new medication),
or complex (eg, procedure). Criteria for basic decisions included discussion
of the nature of the decision and asking the patient to voice a preference;
other categories had criteria that were progressively more stringent.ResultsThe 1057 audiotaped encounters contained 3552 clinical decisions. Overall,
9.0% of decisions met our definition of completeness for informed decision
making. Basic decisions were most often completely informed (17.2%), while
no intermediate decisions were completely informed, and only 1 (0.5%) complex
decision was completely informed. Among the elements of informed decision
making, discussion of the nature of the intervention occurred most frequently
(71%) and assessment of patient understanding least frequently (1.5%).ConclusionsInformed decision making among this group of primary care physicians
and surgeons was often incomplete. This deficit was present even when criteria
for informed decision making were tailored to expect less extensive discussion
for decisions of lower complexity. These findings signal the need for efforts
to encourage informed decision making in clinical practice.

https://jamanetwork.com/journals/jama/articlepdf/192233/joc91394.pdf

Informed decision making in outpatient practice: time to get back to basics.

In a three-path mediational model, two mediators intervene in a series between an independent and a dependent variable. Methods of testing for mediation in such a model are generalized from the mor...

/pdf/tests-of-the-three-path-mediated-effect-4lsls0umh7.pdf

Tests of the Three-Path Mediated Effect:

Patients with chronic illness often receive care from multiple providers in multiple settings and require coordination of their complex care. This report assesses the quality of the coordination of care, describes barriers to coordinated care, and discusses some solutions to improve care coordination in the United States.

/pdf/coordinating-care-a-perilous-journey-through-the-health-care-1igh9lgl3a.pdf

Coordinating Care — A Perilous Journey through the Health Care System

The problem of patient compliance, as well as the ability of the physician to understand, detect, and improve compliance, are described in relation to a new model of health decisions and p...

Understanding and Improving Patient Compliance

Objectives.The authors determined patients' report of prescription drug counseling activities after withdrawal of the pilot program to require patient package inserts in 1980 and implementation of Omnibus Budget Reconciliation Act of 1990 counseling requirements in 1993.Methods.Four cross-sectional

Counseling patients about prescribed medication: 12-year trends.

A nationwide telephone survey of 1,223 individuals investigated the nature and source of information provided to patients regarding prescription drugs. About half of the respondents said that they had received information from their doctor about the purpose and directions for use for their most recent prescription. Only a few people (11 per cent) said that they had been informed about the drug's side effects and 19 per cent said that they had been told nothing by their doctor. Most (72 per cent) related that nothing had been said to them at the pharmacy. Written information (stickers on the medicine container, leaflets or brochures) were said to be infrequently provided at the pharmacy. About 12 per cent of the respondents said they had expected they might get a drug side effect, but only 9 per cent said that they had experienced one. The most frequently cited action in response to side effects was to consult the physician (40 per cent); however, a sizeable percentage of people stopped the medicine completely or temporarily (36 per cent) or kept on taking the drug as prescribed (32 per cent).

A survey of patients' receipt of prescription drug information.

A nationwide survey of 1,720 current and 949 former oral contraceptive (OC) users gathered information about receipt, readership, knowledge, opinions, and reported behavioral changes induced by two forms of patient-oriented OC information. A substantial majority of women said they received and read the patient insert dispensed with the drug. However, only about one third of pill users said that they received the longer informational brochure supplied by physicians on patient request. Directions for use and side effects were the most often recalled information. Physician-patient contact patterns were reported as generally unaffected by written patient information. Respondents preferred the longer informational brochure to the insert. Survey results have implications for recently proposed changes in required OC patient information and for the development of patient information on additional prescription drugs. ( JAMA 238:2504-2508, 1977)

A Survey of the Effects of Oral Contraceptive Patient Information

Two hundred forty-nine newly diagnosed hypertensive patients prescribed thiazide medication were recruited for study. Two-thirds were given a leaflet or patient package insert (PPI) that described the drug and its possible side effects, and one-third were not. At a revisit about 1 month later, patients were asked whether they had experienced any of 17 different “health problems.” For each problem that they experienced, they were asked whether they thought the problem was related to the medicine they were taking. Ten of the health problems were taken verbatim from the PPI's list of possible drug side effects. Patients who received the PPI reported experiencing about the same number of side effects as the non-PPI subjects. However, those who recieved the PPI were more likely to attribute experienced reactions to the drug. This was true both for reactions specifically listed in the PPI and for similar reactions not listed. Results support the notion of an “attribution-labeling” process rather than a “suggestion” effect.

Informing patients about drug side effects

A national telephone survey of 1,104 adults who had recently obtained a new prescription was undertaken to determine the nature and amount of drug information obtained. Sixty percent stated that physicians provided directions for use information with the pharmacy reported as about half as active. Only 3 to 6 per cent said they asked the physician or pharmacist for information. However, one in six respondents said they looked up the prescription in a drug reference book such as the Physicians Desk Reference.

Louis A. Morris

Papers

Counseling patients about prescribed medication: 12-year trends.

A survey of patients' receipt of prescription drug information.

A Survey of the Effects of Oral Contraceptive Patient Information

Informing patients about drug side effects

A survey of patient sources of prescription drug information.