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Att förstå patienters bristande deltagande i individualiserat rehabiliteringsprogram
Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Central County Primary Health Care.
2002 (Swedish)Licentiate thesis, monograph (Other academic)
Abstract [en]

The aim of this investigation was to elucidate and describe those patients who had discontinued their participation and/or paticipated infrequently in physiotherapy treatment based on their own activity and responsibility. The ambition was to understand the phenomenon of compliance/adherence from various perspectives in behavioural as well as social science.

In study I the phenomenon compliance/adherence was studied in relation to Health Locus of Control and Health Belief variables. This study was based on a questionnaire that was answered by all patients before beginning of treatment. Questions concerning the patients´conceptions about both health locus of control and health beliefs were the focus.The definitions of compliance/adherence were completed treatment period and exercise frequency, respectively. Those patients who completed the treatment were also studied regarded exercise frequency.

The results of study I showed that those who discontinued their treatment reported a higher perceived threat from their health condition (higher level of dysfunction (higher pain intensity) and a higher perceived severity of their health condition (higher level of dysfunction, worse general health) than those who completed treatment. The results also showed that those who exercised once a week or less often valued the significance of the caring situation as lower (HLC), perceived a higher threat from their health condition (higher pain intensity), a higher severity of their health condition (higher level of dysfunction, worse general health, greater distrution of impairment), more barriers to treatment (lower expectations), and had certain differences in demographic variables (younger individuals, more women) than those who exercised more often (HB).

Study II investigated patients´descriptions of their reasons for discontinuing the treatment, whether those reasons varied, and if so how they varied. Sixteen patients who had discontinued their treatment were interviewed with open-ended questions. The inteviews began with a question about the background to the physiotherapy treatment. There were questions concerning carrying out the treatment as well as concerning what they thought about their impairment. The patients were also asked about their priotities in daily life, as these wre presumed to be anobstacle to the treatment over a shorter or longer period of time. The third domain concerned how they experiebced the patient/physiotherapist relationship. The interviews were anlysed qualitatively.

Analysis of study II resulted in four different descriptions of reasons for treatment discontinuation. A) It was about time to end treatment and continue on alone. B) The treatment was not the most important activity to spend time on. C) An agreement with the physiothreapist to discontinue treatment due to lack of effect. D) No viewpoint as to why they discontinued the treatment. In further analysis of category D, this group appeared to experience varoius forms of powerlessness. They felt their trustworthiness was often questioned. They experienced frustration in their life situation as others made the important descisions and they themselves had little to say.They defended themselves by talking about their own conceptions of the reasons for their impairment and what should be done about them. In comparing category D with categories A, B, C it was found that those in the latter three categories experienced varying degrees of control in different situations, whereas those in category D did not experience a feeling of control.

Conclusion: The concept of compliance in physiotherapy is ambiguous. The concept involves one part defining what will concern the other part. It is clear that the physiotherapist and the patient do not always agree about the aim of the treatment. Instead, we should develop the concept of concordance in encounters with the patients and abandon the reasoning of compliance.

Abstract [sv]

Syftet med denna undersökning var att tydliggöra och beskriva de patienter som avbrutit sitt deltagande och/eller deltagit sällan i en behandling med sjukgymnastik baserad på egen aktivitet och eget ansvar. En ambition var att förstå fenomenet följsamhet utifrån några olika teoretiska perspektiv inom såväl beteende- som samhällsvetenskap.

I Delstudie I studerades fenomenet följsamhet i relation till beteendeaspekter avseende patientuppfattningar om styrmekanismer som påverkar den egna hälsan (HLC) och patientupplevda hälsohot och hälsohotens konsekvenser (HB). Denna delstudie bygger på frågeformulär, som besvarades av samtliga patienter innan behandlingsstart. De frågor som mäter patientens uppfattningar om vad som styr den egna hälsan och frågor som mäter patientupplevda hälsohot och hälsoerfarenheter har bearbetats. Definitionerna på följsamhet var dels fullföljd träningsperiod, dels träningsfrekvens. De patienter som genomförde träningen jämfördes med de som avbröt den. De som genomförde träningen studerades dessutom avseende träningsfrekvens.

Resultatet i Delstudie I visade att de som avbröt sin behandling, rapporterade större hot av sitt hälsotillstånd (högre smärtintensitet) och större konsekvenser av hälsotillståndet (sämre funktionsförmåga, sämre allmänt hälsotillstånd) än de som genomförde den. Resultatet visade dessutom att de som tränade en gång i veckan eller mer sällan hade värderat vårdsituationens betydelse lägre (HLC), upplevde större hot av sitt hälsotillstånd (högre smärtintensitet), större konsekvenser av hälsotillståndet (större funktionsnedsättning, sämre allmänt hälsotillstånd, större besvärsutbredning), fler hinder för behandlingen (lägre förväntningar) och uppvisade andra demografiska faktorer (yngre individer, fler kvinnor) än de som tränade oftare (HB).

I Delstudie II studerades hur patienter själva beskriver anledningen till avbrott i behandlingen, om dessa anledningar kan variera och hur de varierar. Sexton patienter som avbrutit sin behandling intervjuades med öppna frågor. Intervjun inleddes med en fråga om bakgrunden till den sjukgymnastiska behandlingen. De ställdes inför frågor som hade anknytning till genom!örandet av behandlingen och vad de trodde själva om sina besvär. Frågor om patienternas prioriteringar i vardagen ingick, vilka antogs kunna utgöra hinder för behandling under en kortare eller längre tid. Ett tredje område som ingick, rörde deras erfarenheter av patient/sjukgymnast relationen. Intervjuerna analyserades kvalitativt.

Analysen i Delstudie II resulterade i att fyra olika beskrivningar av orsaker till avbrott i behandlingen genererades. A) Det var dags att avsluta och gå vidare på egen hand. B) Behandlingen var inte det viktigaste att lägga sin tid på. C) Överenskommelse med sjukgymnasten att avbryta behandlingen på grund av uteblivna resultat. D) Avsaknad av ställningstagande till avbrott i behandlingen. Vid en fårdjupadanalys av kategori D framstod att denna grupp erfar olika former av maktlöshet. Det yttrade sig i beskrivningar av att deras trovärdighet ofta är ifrågasatt, att deras livssituation är en ständig frustration där andra tar de viktiga besluten och där de själva inte har mycket att säga till om, samt att de värjer sig mot att berätta om sina fåreställningar om vad de själva tror besvären beror på och vad man gör åt dem. Vid en jämförelse mellan kategori D och A, B, C har kategorierna A, B och C varierande grad av kontroll i olika situationer medan kategori D saknar kontroll.

Place, publisher, year, edition, pages
Institutionen för hälsa och samhälle , 2002. , 81 p.
Series
Linköping Studies in Health Sciences. Thesis, ISSN 1100-6013 ; 51
Keyword [en]
Adherence, Compliance, Gender perspective, Health-care provider/patient relationship, Physiotherapy, Longstanding pain, Primary health care, Health Locus of Control, Health Belief, Patient perspective, Qualitative inquiry
National Category
Physiotherapy
Identifiers
URN: urn:nbn:se:liu:diva-8389ISBN: 91-7373-156-0 (print)OAI: oai:DiVA.org:liu-8389DiVA: diva2:23191
Presentation
(English)
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Supervisors
Available from: 2007-03-13 Created: 2007-03-13 Last updated: 2013-07-10

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