Thesis--Wisconsin. / Includes bibliographical references (leaves 34-35).

Adult literature has shown that quality of patient-physician relationships is associated with better patient adherence to treatment recommendations across chronic illnesses. However, few studies have examined this in youth with type 1 diabetes, particularly those of Hispanic origin. Evidence indicates that minority youth with type 1 diabetes are at higher risk for poorer metabolic control and experience less satisfaction in patient-provider relationships compared to their white, non-Hispanic counterparts. This study examined the association between satisfaction with the physician-patient relationship and regimen adherence and glycemic control in 120 Hispanic youth with type 1 diabetes. Most caregivers who participated were mothers (82.5%) and youths were primarily female (51.7%). Children ranged in age from 10 to 17 (M age = 13.63 ± 2.18 years). Mean duration of diabetes was 6.26 ± 3.72 years. Most caregivers were married (64.7%). Mothers? highest level of education included 35.3% who had a high school education or less, 34.5% who had some college, and 30.2% who completed college. Mean HbA1c level on recruitment date was 7.68 ± 3.56. Adolescents and their parents independently completed an adapted version of the Medical Interview Satisfaction Scale (MISS-21) (Meakin & Weinman, 2002), which assessed their personal satisfaction with their endocrinologist?s consultation, and the Diabetes Self Management Profile (DSMP) (Harris et al., 2000), which measures adherence over the past 3 months across multiple self-care domains. Spanish translations of both forms were used when appropriate in obtaining caregiver report. Also, physicians rated their patients? regimen adherence using an average of eight items concerning patient adherence. Youth and parents shared similar perceptions concerning youth regimen adherence, as measured by the DSMP (r=.68, p<.001). Youth and parent report of their relationship with their endocrinologist was modestly correlated (r=.27, p<.01). Due to high concordance between parent and child adherence scores, further analyses used a combined DSMP score, while separate scores were used for parent and child reports of satisfaction. Age, mother?s education, and single parent status were used as control variables and were correlated with parent and child satisfaction and a combined DSMP score. Including control variables, parent and child satisfaction did not significantly predict glycemic control (R2∆=.02, p<.10). Parent and child satisfaction also did not significantly predict adherence (R2∆=.02, p=.06). Due to these unexpected findings, further exploratory analyses were conducted. Parent and child satisfaction did not predict physician report of adherence. Interestingly, parent and child report of satisfaction with communication comfort with the physician predicted physician report of adherence (R2∆=.05, p<.01). More specifically, child report of communication comfort predicted physician report of adherence (ß=.26, p<.01), while parent report did not. No subscales of the satisfaction measure (MISS) or the adherence measure (DSMP) predicted glycemic control. Findings suggested that more positive patient-physician relationships are associated with better physician-reported regimen adherence, but not with family report of adherence. However, it is unclear whether better patient-physician relationships enhance adherence or whether more adherent patients are likely to be satisfied with their provider. Further studies are needed to prospectively examine the directionality of these relationships, as well as examine methods to improve the quality of physician-patient relationships in order to increase positive health outcomes.

Background: In South Africa, tuberculosis (TB) is the leading cause of death, and Cape Town is among the three cities in the country with the highest TB burden. Despite implementation of Directly Observed Treatment Short-Course (DOTS), and improvements in the organisation and delivery of TB care, poor treatment adherence challenges treatment outcomes and the health system's ability to reach international targets. TB requires long-term care, where the relationship with healthcare providers is one of the important influences on decisions to seek care and adhere to treatment. This study sought to explore and deepen insight into how trust is built and experienced between patients and healthcare providers for TB treatment in primary care settings from a gender perspective. Methods: The research was located in three local government-managed clinics in the City of Cape Town's Metropole health district, similar in TB patient load and performance indicators, but differing in level of TB-HIV integrated services. A case study design employing qualitative data collection approaches (non-participant observations in clinics, focus group discussions and in-depth interviews with patients and providers) was applied. Findings: Trust plays a central role for both patients and providers in treatment for TB. On the part of patients, many expressed a deep desire and motivation to complete their treatment. However, patient vulnerability, a complex outcome of intersecting factors at all levels (personal, community and health service level), across which gender was an underlying influence, emerged as a critical influence over patient trust in providers and the health system, with consequences for a range of outcomes including treatment adherence. The ability of providers and the health system as an institution to recognise and respond to patient vulnerability and needs beyond the illness, including to access socio-economic and psycho-social support for the patient, was critical for building trust and enabling adherence. On the part of healthcare providers, vulnerability was a consequence of a range of factors, including professional status and gender, with implications for how trust was built in patients and managers and its outcomes. Patient trustworthiness was based on judgements of competency, integrity and recognition. The ability of managers to mitigate the challenges healthcare providers faced, through providing a supportive and enabling work environment, had implications for providers' experiences and judgements of institutional trustworthiness. Conclusion: Reflecting on the findings within broader national, provincial and global health policy reforms, specific strategies for building patient and provider trust in each other, and in the health system, are proposed. Recommended strategies addressing both patient and provider vulnerabilities rooted in the personal, community and health facility environment are considered. While many of the recommendations are specific to the TB and TB/HIV model of care, they have wider relevance for building mutual trust between patients and providers and enhancing the responsiveness of the health system as a whole. This is important in the context of South Africa, where the vision espoused under proposed National Health Insurance reforms towards universal coverage is transformative, even revolutionary, but its implementation and ultimate achievements are likely to be dogged by challenges of patient and provider trust in the health system, unless themselves addressed. Globally, the study's conclusions also offer important insights about patient-provider trust relevant to health system development, as well as ideas for future, related research.

Mental illness affects 1.2 million children and youth in Canada. Female adolescents, in particular, suffer significant consequences associated with this. While family physicians are often the first line of contact for a health-related concern, little is known about how the promotion of lifestyle medicine to enhance the mental wellbeing of female adolescents is being communicated. Using a qualitative content analysis approach, a survey about counseling on lifestyle medicine was completed by 126 Hamilton Family Physicians giving a response rate of 25.2%. Key informants discussed with the highest agreement the following three themes: lifestyle medicine factors, barriers, and improvements for communication to female adolescent patients. The global prevalence of female adolescent mental health issues in combination with the use of screening tools was showcased within this study population. Results indicated that Hamilton family physicians integrate global recommendations into their line of care with patient-centered dialogue, awareness of patient needs, and lifestyle medicine education. / Thesis / Master of Science (MSc)

The medical profession in recent decades has made culture and cross-cultural competence an issue for patient – physician relationships. Many in the profession attribute the necessity of cross-cultural competence to increased diversity, globalization, and health disparities; however, a historical analysis of medicine indicates that culture’s relevancy for health care and outcome is not new. The rise of clinics, which can be traced to 17th century France, the professionalization of physicians in 18th century U.S., and the civil rights movement of the 20th century illustrate that medicine, throughout its history, has grappled with culture and health. While medicine has a history of discussing cultural issues, the profession has not defined culture cogently. Medicine’s ambivalence in defining culture raises questions about how effectively medical educators prepare residents to be cross-culturally competent. Some medical educators have expressed that many didactic and experiential efforts result in stereotyping patients. Definitions of culture and their impact on stereotyping patients are the central problems of this study. Specifically, this study hypothesized that cultural beliefs impact ones willingness to accept stereotypes. Thus, this study sought to learn how faculty members and residents define culture. Faculty members also were compared to residents to glean the impact of cross-cultural education. This study used an explanatory mixed method design where quantitative and qualitative methods work complementarily to examine a complex construct like culture. A valid and reliable survey provided quantitative data to compare the two groups, while open-ended questions and interviews with faculty members provided context. The statistical results reveal that faculty members and residents share a philosophy of culture; however, when the two groups’ definitions are contextualized, they have many different beliefs. Differences also emerged with respect to predictability; cultural beliefs predict stereotyping among residents, but not faculty members. Faculty members attribute these differences to experiences, while residents believe that they do not learn about culture during their professional education.

The patient's failure to cooperate effectively in the patient/physician (patient and physician) interaction has been shown to be a problem of significant magnitude. In the present study, an attempt was made to identify specific, patient behaviors which might be related to physician judgment of a good patient and progress of treatment. A checklist of 37 behaviors was compiled. A series of 100 patients was observed during their interaction with physicians and occurrences of behaviors from the checklist were noted by an experimenter. Physicians also indicated whether the patient was considered to be a good patient and whether treatment was progressing as expected. For every third patient, physicians noted the occurrence of behaviors from the checklist. An association was found between some behaviors from the checklist and the physicians' judgment. There was also shown to be a difference in the ability of the experimenter and the physicians involved to detect these behaviors.

The purpose of this thesis is to identify common themes presented in several illness narratives with specific attention paid to the relationship between patients and their physicians and patients and their families. Only illness narratives written in America and Western Europe were used for this thesis so the topic could be narrowed to the experience within the western biomedical field. While most research on illness narratives focuses on defining illness and illustrating the importance of introspective work, this thesis identifies patterns in a way that can shape the future treatment of chronically ill patients. This thesis also allows me to creatively explore a personal illness narrative, reinforcing these themes and contributing to the discussion of what physicians and families can do to make the illness experience more bearable for the patient.

In Sweden and elsewhere there is evidence of poorer cancer survival for patients of low socioeconomic status (SES), and in some settings differences in treatment by SES have been shown. The aim of this thesis was to explore factors which influence cancer treatment decisions, such as knowledge reaped from clinical trials, patient-related factors, and physician-related factors. In a register study of colorectal cancer, all stages, patients were stratified for SES-factors. Differences were seen with regards to clinical investigation, surgical and oncological treatment and survival, with the highly educated group being favored. Survival was better for highly educated patients in stages I, II and III but not in stage IV. In a Scandinavian cohort of newly metastasized colorectal cancer patients, recruitment to clinical trials was studied. Patients entering clinical trials had better performance status and fewer cancer symptoms than those who were treated with chemotherapy outside of a clinical trial. Median survival was 21.3 months for trial-patients and 15.2 months for those treated with chemotherapy outside a  trial. Those not treated with chemotherapy had a median survival of just 2.1 months. Patients in clinical trials are highly selected and conclusions drawn from studies cannot be applied to all patients. In the same cohort, treatment and survival were stratified for education, smoking and indicators of social structure. Highly educated patients did not have a survival advantage. Patients who lived alone were offered less combination chemotherapy and surgery of metastases than other patients and had 4 months shorter survival than those who lived with a spouse or child. In a fourth study, 20 Swedish gastrointestinal oncologists were interviewed on which factors they considered when deciding on oncological treatment. Oncologists feared chemotherapy complications due to lack of social support, and ordered less combination chemotherapy for patients living alone. Highly educated patients were seen as well-read and demanding, and giving in to these patients’ requests for treatment was regarded as a way of pleasing patients and relatives and of avoiding conflict.

The overall aim of this thesis was to characterize patient-physician communication in oncology care with focus on the content and quality of the consultations from the perspectives of patients, oncologists and observer. Further, the aim was to explore oncologists’ perceived barriers against psychosocial communication in out-patient consultations. Finally, the aim was to evaluate different methods for evaluating communication in this setting. Routine oncology out-patient consultations from two different hospitals were audio-recorded. After the consultations, patients and oncologists perceptions of the content and quality of the communication were assessed using a self-report questionnaire. A nation-wide survey was performed to assess oncologists’ perceived barriers against psychosocial communication. Finally, the audio-recorded consultations were used for evaluating inter-rater reliability and feasibility of two different communication analysis instruments. Patient-physician consultations in oncology care are focused on the physical aspects of disease and treatment, both in terms of how often these issues were discussed and in terms of the amount of time spent on discussing them. Psychosocial issues, such as the disease’s effects on patients’ emotional or social functioning, are not always discussed during consultations, and the time spent on such discussions is limited. When psychosocial issues are discussed during the medical consultations, they are most often patient-initiated. Reasons for why psychosocial aspects are seldom discussed during the medical consultations can be the barriers concerning this kind of communication perceived by a large majority (93%) of the oncologists. Barriers against psychosocial communication were identified at organizational levels (including guidelines, routines, and resources) and individual levels (including physicians’ knowledge and attitudes). Furthermore, this thesis shows that there are methods with high feasibility and reliability for evaluating the content of patient-physician communication, in large study samples in oncology care. The method (observation/self-report) and perspective (patient, physician, and observer) used when evaluating communication affects the results. This needs to be considered when choosing evaluation methods in intervention studies. There are reasons to continue to evaluate, promote and implement promising ways of achieving better communication in clinical practice. Research should focus on how to overcome barriers against psychosocial communication.

Information in the transition to the late palliative phase is not a well-studied area, especially not from the perspective of patients and family members. The aim of this thesis was to describe how cancer patients, family members and physicians experience information during the transition from a curative or early palliative phase to a late palliative phase, i.e. when tumour-specific treatment could not be offered. Cancer patients (n=30) admitted to palliative hospital based home care, family members (n=20) of cancer patients, and physicians (n=30) working with cancer patients in different settings were included in order to create a maximum variation sampling. Tape-recorded, semi-structured interviews and qualitative, phenomenographic analyses were done in all the studies. Patients described the physician as an expert (study I), an important person during this event, despite characterising him/her in different ways ranging from the empathetic professional to the rough and ready expert. Their relationship with the physician was also stressed. Their own resources, i.e. a sense of well being, a sense of security and individual strength, and their previous knowledge, were important components regarding their ability to take part in the communication (study II). Patients interpret words and phrases carefully and can perceive them as forewarnings, as being emotionally trying, and as fortifying and strengthening (study III). The overall message could be interpreted as either focused on quality if life, on treatment or on death and threat. Family members wanted to protect the patient during this period and could be very active and prominent in their protective role (study IV). However, other family members described themselves as being in the background more or less involuntarily. Family members also felt that there were expectations regarding their behaviour, either that they should take over in terms of communication, or that they should restrict their participation. When giving information, the physicians had a clear goal - to make the patient understand while being as considerate toward the patient as possible. However, the strategies for reaching this goal differed and included: explaining and convincing, softening the impact and vaguely suggesting, preparing and adapting. Some physicians had a main strategy while others mixed different strategies depending on the context. The experience of receiving and providing information about discontinuing tumour specific treatment is like crossing a border, where patients experience the behaviour of the physician and the words they express of great significance. Family members assume the role of protectors. Physicians use different strategies in order to help patients cross the border. / On the day of the public defence the status of the article II was: In press and the title was: Patient interpretation of verbal expressions when given information about ending cancer treatment.; the status of article V was: Submitted.