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Running head: PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN

Patient Adherence to Healthcare Treatment Plan Jacques Kriel and Chrys Quiroz Touro University Nevada

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Patient Adherence to Healthcare Treatment Plan

When looking at your own medical care, one would think that the many years of theoretical and practical knowledge that doctors have would be enough to convince you of the power of healing that the doctors advice imparts. Additionally, doctors endure many different types of tests that continuously assess their ability to perform and apply, as necessary, any treatments you might need. Yet, people insist on not following well-established health practices. Both authors of this research paper have background experiences in the healthcare setting and have witnessed patients not adhering to set treatments plans by their healthcare professionals. While survey studies are ubiquitous in the literature, the patients perspective simply by itself is rarely considered. Our purpose was to explore what the reality of the patient-physician relationship is, while taking into account the actual life experiences of the patient that can most uniquely be gathered through interview--- focusing on people in their early 20s to early 30s, a subset of the population that generally has been neglected, and specifically looking at adherence. Our initial hypothesis was that patients should equally regard doctors of equal skill level, since such doctors would be able to provide the correct treatment specifically tailored to their patient. The authors assumed that if qualitative reports indicated the same finding as studies grounded in quantitative tests, these findings could be considered relevant to the occupational therapist or other healthcare staff that see the patient on a regular basis. Literature Review Many research articles talk about adherence, each sharing their own perspectives--- yet marked similarities exist. However, the literature by and large reflects patient responses based on surveys, which talk about aspects that patients find important. These studies neglect to indicate why patients prefer some interactions compared to others, even though they reveal general

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN trends. We thought our findings could clarify, more specifically, what approaches would better satisfy the patients that are seen.

Daele, Metsemakers, Derckx, Spreeuwenberg and Vrijhoef (2008) look at the differences between Dutch general practitioner physicians or specially trained nurse practitioners in a randomized control study. They used data from questionnaires and from the computer documentation system. Notably, participants were included only if they participated in all parts of the study, with patients meeting the characteristic of being significantly older. They noted that on average nurses spent 12.2 minutes providing information to patients while physicians would spend 9.2 minutes with patients. Additionally, nurses seemed to indicate an interactive relationship with their patients, to more of an extent, than physicians. Patients also seemed to return more to the nurse practitioners and reported being healthier based on their visits, compared to the clients of the general practitioners. These responses were gained from a questionnaire constructed from discussion with two general practitioners with a background in research, were tested on a group of 40 patients, with additional refinements during these steps. Additionally, this information was used for documentation purposes because of its reliability and adjustments were made prior to the start of the study to ensure that. Patients from both nurse practitioners and general practitioners had no significant differences in satisfaction, equally regarded their respective professional as the right one for their illness, equally came back to their respective practitioner in the future, and both equally would recommended the professional to their friends. Otani, Waterman, and Dunagan (2012) wanted to look at how seriously ill patients differ in their mental assessment of the hospital stay compared to less seriously ill patients. They also used questionnaires with the average age in this study being 56.7 years old. They took the

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN perspective that certain attributes may contribute more to a satisfying experience than others. They also found that nursing care was most influential in determining patient quality of care, with staff care of secondary importance and physician care of the least importance. Patients see nurses a lot more frequently than they see their doctors, therefore this ranking may seem obvious. Additionally, their results indicate that patients are less likely to rate the hospital negatively if the doctor shows careindicated by whether he or she is available to you, communicates with you, gives you adequate instructions, and involves you in decisions about your health care. However, these categories do not provide what people felt like were adequate

instructions, or what involvement meant to participants. This is significant because each of these positive ratings may not be indicative that the doctor is fully including the patient. Rogers et al. (2012) looked at the difference of patient satisfaction survey scores between patients sent to the trauma service compared to those who had general surgery. While at this time the doctors served on both units at this particular hospital, they served as their own internal controls, with the only variable being whether patients were being seen in the trauma unit or the general surgery unit. Patients sent to trauma care reported a lower satisfaction rating of their surgeons than those who had general surgery. While the authors indicated that the severity of their conditions was the primary agent of these results, this may not completely be true. The authors noted that doctors rotated weekly, time constraints related to taking care of life threatening circumstances overruled being courteous or keeping the patient well informed, and that there was an unrewarding nature of the emergency room for physicians. All these factors may have influenced the poor patient satisfaction during their hospital stay. They also noted that the literature indicates that mental status may have an effect on quality of care perceptions, which was similar to Pecks findings (2011).

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN

Peck (2011) examined age related differences of patients that impact the client-physician relationship in a qualitative study. In a time period spanning over 11 months, the author collected data from patients at a large family medicine practice who consented to take part in the study. This population had a median age of 60 years, with almost 1/3 being over the age of 65. After consenting, a patient participated in a pre-visit questionnaire, went to his or her appointments, and then filled out a post-visit questionnaire. While the majority of studies only consisted of surveys, this study also included patient perspective by audiotaping their visits. This allowed data to be collected more aligned with the patients needs during a visit, which additionally was strengthened by the RAIS coding system, a well-known coding scheme in the literature. Authors also assured accuracy of the data by training coders, having multiple coders who did not interact with each other, and checking the coding scheme afterwards. Thus, great measures were taken to give a true picture of what happened during the physician encounter. They found that physician interactions consisted of biomedical information giving, psychosocial exchanges, and questions after using cluster analysis to identify groups of cases that were similar, and found that these have often been used to measure the physician patient relationship. Their findings, first of all, note that there were few patient complaints of the doctors, which would seem to indicate that the doctors had the training to appropriately administer treatmentand, according to our hypothesis, should all be as likely to be chosen. They noted that patient age does attenuate whether patients experience the visit as patient centered, but other characteristics also affected their satisfaction. The patients visit was more negatively affected if the physician was white or if it was the patients first visit to the hospital. They also noted a disturbing aspectthat white patients were more likely to report a higher quality assessment. It seems like physicians are lacking cultural

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN competence, according to these researchers. This result may indicate that therapists are not listening to other verbal cues of their patients, a relationship we tend to explore in this study. Methodology Research Design The rationale behind choosing a qualitative research method for our study is because we

felt like our research question would be best explained through observation and explanation. It is appropriate to gather our findings through language rather than numbers. Furthermore, we wanted to represent the participants in a more holistic fashion by including as much information as possible regarding their responses, and felt it would be most successful through the means of qualitative research. The research approach that we took was the grounded theory approach. First, we gathered data by interviewing and observing our participants. Next, we coded the data by extracting meaning from the interviews that were held. From there, we were able to group the coding into concepts and categories in order to form a theory regarding our research question. Finally, we confirmed the categories among each other to ensure their appropriateness. Participants There were six total participants in our research study, three females and three males. They were all given pseudonyms to protect their identity which will be further discussed in the data analysis section. Sophia, Emma, Isabella, Ethan, and Mason were in their 20s, while Jacob was in his early 30s. Jacob and Ethan were working professionals, while Sophia, Emma, Isabella, and Mason were currently university students. Jacob, Ethan and Isabella have no relation to the medical field while the other two females, Sophia and Emma and one of the males, Mason, are going to school for medical related studies. The participants were chosen using a convenience and purposive sample. For each researcher, there was at least one familiar

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN participant and another unfamiliar participant to be interviewed. All participants were readily accessible to the researcher. Data Collection The types of data that were collected were interviews and observations. It was felt necessary to choose interviews in order to gain as much perspective from the participants and observations were duly noted in order to provide stronger evidence and feedback regarding the data. Data were collected, face to face, on January 1, 3 and 6 at a local coffee shop and a study room at a privately funded university in the Southwestern region of the United States. Each location was isolated, away from distractions and within a semi-formal setting. The participants were approached informally and given ample time to decide whether they would like to participate in the study. Once agreeing, the participants were debriefed about the study and informed of the working definition or jargon that they may hear during the interview. Before starting, they were encouraged to ask questions if clarification was needed and asked for permission to be recorded using an iPhone 4 and a Sony ICD-P520 device provided by the researcher. Confidentiality and privacy was discussed during the debriefing. 3 out of the 5 participants agreed to being recorded. Debriefing took approximately 5 minutes while the actual interview occurred within the span of 10-20 minutes each. The types of questions that were asked involved the history of the participants regarding their reasons for a medical visit, adherence to a medical practitioner, adherence to the treatment plan, qualities of a competent

practitioner, and the types of services that were sought. The interview was semi-structured in that questions were decided upon before the interview process but guided questions were also asked and were participant specific. Each participant mutually agreed to be interviewed and observed, and convenient times were chosen by both parties.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Data Analysis Data were organized using programs on a Dell Software computer. Microsoft Word was used for the process of transcription and Microsoft Excel to organize the data and create a matrix. We implemented aspects of the grounded theory approach. We felt that the grounded theory approach was the most applicable for our research question because we sought to use the codes, concepts and categories to develop a theory. We applied very thorough data analyses for our qualitative research paper. After transcribing the data from the interviews, we created files

for each of the interviews and made sure to read through the data multiple times. From there, our first analysis consisted of color coding the data into categories. Next, we created pseudonyms using a Social Security website that listed popular names. For the second analysis, we coded the categories into a matrix and established a more appropriate chart to organize the data. After, we individually verified the coding groups to the original transcription document. Lastly, we came together and analyzed the finished product simultaneously to ensure that each code correlated with the original quote and that nothing was misconstrued or that no meaning was stretched. All five of the verbatim transcripts can be found in Appendix A-F and the two coding documents are attached in Appendix G-H. An example of the type of coding we used was convenience related factors. This code pertained to explanations provided by the participants that suggested lack of adherence due to things such as distance, office location, and accessibility. An example of the text that was applied to the code of convenience related factors was that the doctor retired and it had to do with my dads insurance and with the military, it was wherever you were stationed. It is important to note that observations were made during the interviews and the researchers were able to note nonverbal cues and emotional reactions though it may not have been explicitly stated by the participant. For example, a code was entitled emotional reactions. A participant

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN stated that somehow in the conversation, he asked me if I went to church. Somehow that

crossed a line between the doctor relationship between medical and not medical. The researcher documents that the participant had a higher pitched tone of voice towards the end of the sentence and categorized this quote as an emotional reaction during the coding process. Findings While participants were going to school and had a medical background or were simply working professionals, they seemed to agree that all doctors, despite their feeling of the interaction, had the necessary skills needed for their particular treatmentwhatever that actually entailed. The general sentiment of the group was indicated by one female, who expressed that it seemed like she was knowledgeable and it felt like you said all doctors that go through graduate school almost all of them are well equipped to do the job. However, one patient thought that a general practitioner might not have the full breadth of knowledge to answer his questions about a specific condition compared to a specialist. All participants, however, thought that the practitioner answered all their questions and did not feel like any more detail was necessary. Participants strongly considered the time the physician spent with them during their session. If he was willing to spend the time with the patients, this led to a number of other thingsbut simply the fact that he would spend more time seemed to result in one patient coming back and other patients listening to their doctor. Evidence for this is shown by the unanimous agreement by all participants of the need for doctors to spend more time with them. Emma, 26 years old, said I was able to voice questions I had and feedback-wise he would tell you. This would lead to an interaction where the doctor would assess whats going on, what are the issues, whats going on in your life. More time also meant more detail would be gathered by the physician, including the extent of how their issue would affect them in a variety

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of contexts. When the doctor did not ask how the participants experience the issue in their daily life, the response can be exemplified by Isabella, he made me feel awkward. [Pause] He just rambled on and didnt seem to ask me exactly what was wrong. like he would just assume what was wrong. If the doctor confirmed responses with the patient, the patient felt like he addressed all the areas of unknowing, according to Jacob. While half of the patients expressed a similar concern of voicing their questions, it seemed like this strategy helped patients determine what part of the treatment is most necessary for them to be healthy. More body language seemed to accompany patient-physician interactions that were longer lasting and would gather additional information, indicated by when Emma, said a lot of it is about the topic of what it is too and the personality too. The doctor I just saw was easy to talk to and shes a timid or shy personso its harder to talk to her than with this provider. So it depends. Thus, body language was important, but not as important as involving the patient in their treatment. In summary, more time spent meant considering all aspects that may affect or aggravate the medical issue. It may be helpful to note times when doctors or medical professionals, who are all appropriately certified, did not put their patient firstdespite years of training telling them to do so. This can be exemplified by a general attitude that put off the patients from following his advice or returning to the same practitioner, like when Jacob said so if your appointment is at 3:30, its almost like they want to get you out as soon as possible so that they can take a break before their next appointment In one case, a doctor used his religious philosophical theoretical base to argue for improvement----known to be a hot button issue. In another case, a doctor answered his phone during a participants appointment. Some doctors just provided one way communication. Doing so led one of the participants to immediately start a search for a new

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health care practitioner. Another doctor felt like his authority as a practitioner was threatened by a client just trying to understand the timeline for treatments. Patients also considered convenience in regard to healthcare decisions. All patients found this important, but not as important as spending time with the doctor. For example, Sophia explained that when taking care of a minor health issue, her home practitioner lived in another city and therefore wasnt able to go home for this visitit wasnt worth going home. In addition, Emma noted switching doctors because her sister would be able to set up quicker appointments. Sophia seemed really frustrated by how long it took to make a first appointment. Additionally, Isabella postponed looking for a practitioner due to the amount of effort it would take to see if a practitioner was evaluated positively. Another patient, Ethan, seemed to be satisfied with whatever doctor was available to him when he was stationed in the Air Force, or was previously satisfied with being on his fathers insurance. When a doctor did not spend enough time with the patient, Jacob sacrificed convenience, in terms of geographic location, to have a doctor spend time with him. Other times, Ethan switched doctors due to him retiring. Some barriers to adherence occurred due to doctors suggestions not incorporating participant routines. Half of participants responded to this factor influencing adherence. This can be exemplified by Sophia saying that so I usually followed what they said. But with resting, I hate it so I over do it because I dont like to rest. I will get up and do way too much and afterwards I wished I didnt do it enough. When asked about diet, she simply asked me why would you get rid of comfort food and indicated that some foods were simply part of her sensory diet. Other patients had other routines, whether it was playing a sport even though it was not recommended by the doctor, or even having a certain kind of diet instead of vitamins.

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Thus, half of participants indicated lifestyle routines prevented them implementing the treatment plan requested by their doctor for their own personal health. A consideration that participants often took into account was the benefit that a treatment would have on their lifethat is, they essentially did a cost benefit analysis. If a participant did not see any risk of not following the treatment, they would not adhere to the doctors advice. Four out of six participants followed treatment in this way. This was exemplified when Sophia was saying this is actually common for most people: What I do follow: When Im given antibiotics I take it for the whole time, and a lot of my friends dont do that, and the antibiotics doesnt kill it and the antibiotics wont cure it cause it stronger now. I actually do follow that advice. Mason reflected on his decision to play football, saying I did not have any injuriesso it was good. He actually quit the following year, maybe seeing the actual reality of being injured in others, since he said high school football was too intense. Finally, Emma may not have included vitamins in her diet long term, even though it was part of the treatment plan, because of the lack of negative effect on her life, but we do not know this for sure. The impact of social networking sites like Yelp should not be neglected, even though only important to one participant, Isabella. One person considered the following criteria, somebody with a medical degree and good reviews on Yelp. Yelp, specifically, allows people to say how timely service was provided, or to what extent it was not delivered. Yelp only shows reviews from task related comments and filters out opinion dominated reviews. The increasing use of online social networking may cause a more frequent use of these types of reviews. Clinicians should be aware that this resource is open access and available to everyone, even though it is not used by everyone.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Overall, some observations should also be noted about how participants conducted themselves during the interview because it reflects on the impact that the physician-patient

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relationship has. Emma talked about a doctor judging her from his own philosophical standpoint when she remarked that he was like a typical doctor. As far as professional wise, that did sort of make me second guess the things he was recommending to me? Like youve been practicing for so many years shouldnt you know that has nothing to do with health care for you to be asking that? In this case, her tone of voice went higher and she increased the speed of her speech. Sophias tone of voice and tense neck contraction increased when she talked about the doctor that talked on his phone when she went to see him about a medical issue. Ethan became angrier and did not speed up his tone when he remarked he just was giving his professional opinion and I disagreed with him and it made me mad. It was interesting to see these different reactions and made the interviewers realize that recalling a memory partially allows one to relive it. Our study adds to the literature in numerous ways. It shows that time spent was not the only necessary component of a client centered interaction. In fact, one physician spent the appropriate time with a client and only used one way communication, which resulted in simply patient frustration. Physicians had to interact with patients and see how the condition affected them in their life experiences to help them determine what part of the treatment plan was important for their well-being. Half of the patients did not follow a treatment if it did not fit with their life schedule, so this is an important consideration for clinicians to weigh in making a treatment plan. Thus, patients did not adhere to doctors of equal skill and more satisfaction did not occur just because of more time spent. These latter two aspects have been well indicated in rigorous studies in the literature, but lack of patient perspective has led to slightly skewed results. Conclusions

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Our study shows that it is not uncommon for patients to lack in follow through with the

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recommended treatment plan that their healthcare practitioner recommends to them. In an ideal world, all patients would adhere to their treatment plan considering their provider has undergone a rigorous curriculum to reach the level of competence to be a practitioner in their field. Previous literature made it apparent that patient expectations have a tremendous influence on their perceived experience with their healthcare provider. This research study contributed to the conceptual framework because we were able to gather some of the underlying reasons that patients consider whenever they make a visit to their doctors office. Since our population was very diverse, we feel like if we had a larger sample size, we would be able to generalize our findings to the public. However, since we only gathered six interviews from the participants, we do not feel like our findings are transferable. Our small sample size is a limitation to our study. Another limitation to our study is that the interview skills used to gather the data could have been stronger. Therefore, lack of experience in interviewing may have affected how much information the participants shared during their interview. Future research can explore specific populations (based on factors such as age, ethnicity, and socio economic status) and their expectations of medical care. Further exploration in varying experiences based on the specific populations can also be completed in the future. A general consensus can be extrapolated from the interviews as a whole. The golden rule of treating others the way you want to be treated should be implemented regardless of the situational component--- in a healthcare setting or within ones family. It is important to note that despite what is found within qualitative research regarding patient and practitioner interaction, basic social norms will always be apparent. As one participant noted, in summary, interactions do have a lasting effect on a person, no matter how much time has passed. Therefore, it is always important to be cognizant and aware of how one is

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coming across through their interactions with people because like the well-known saying states people will forget with you did, but they will never forget how you made them feel.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN References

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Dierick-Van Daele, A.T.M., Metsemakers, J.F.M., Derckx, E.W.C.C., Spreeuwenberg, C., & Vrijhoef, H.J.M. (2009). Nurse practitioners substituting for general practitioners: randomized controlled trial. Journal of Advanced Nursing, 65(2), 391-401.

doi:10.1111/j.1365-2648.2008.04888.x Otani, K., Waterman, B., & Dunagan, W.C. (2012). Patient satisfaction: how patient health conditions influence their satisfaction. Journal of Healthcare Management, 57(4), 276292. Peck, B.M. (2011). Age-related differences in doctor-patient interaction and patient satisfaction. Current Gerontology and Geriatrics Research, 2011, 1-10. doi:10.1155/2011/137492 Rogers, F.B., Krasne, M., Bradburn, E., Rogers, A., Lee, J., Wu, D.,... Osler, T. (2012). Acute care and trauma surgeons: we cant get no satisfaction--- what do satisfaction surveys measure? The American Surgeon, 78, 731-734.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Appendix A Interview #1 Q: Ok, (cough) sothe purpose of this thing was just that we wanted of this researchthis

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study that were doing as part of a project was just to get some views on peoples perceptions of what makes a professional qualified. And so theres not a lot of...a lot of a lot ofresearch about peoples views...theres a lot of questionnaires out there and stuff. So... but theres not a lot about asking peoples opinionswhich isthats also an important part to consider. Like their opinions about what makes atheir opinions to stay with a practitioner by their own choice rather than...um...just being forcedum...working with a medical practitionerlike most commonly its a doctorwhether you choose a doctorumand thatsand I want to see how if.. Umhow you feel like what makes a person adequately trainedlike you dont need to know the knowledge behind it like when you come in to visit, what makes you feel that they are like adequately trained. Like that they know what theyre doing and that youre going to be safe when theyre treating you. So... for the first question I only really have one question and then we're just gonna take it from there andjust for like 10 minutes. So (cough) so do you have a primary care physician that you go to if you have the flu or if you haveum A: Not currently Im in transition. Q: but you have seen an umI mean you have seen physicians before, right? A: Yes Q: and you have... you have... seen like a physician for a long period of time? A: Yes Q: Like over many years or whatever

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A: My pediatric doctor was my doctor all the way until I was twenty years of age and now I am 31. Q: Yea but after that did you also have a doctor you went to (um)...likefor just like regular stuff... (for checkups) yea just for checkups or whatever? A: Yes but I have moved quite a few of times in the last eleven years. Thats why I am currently in transition. I havent gone to see a...I havent had another check-up so I havent picked a doctor in this area yet. Q: Yea... so that would be interesting to see why you chose each practitioner. So I guess just keep in mind like those different experiences youve hadand if one... you know... sticks out you can elaborate on thatyou know I wontwe will use likewe will make you anonymous so no one willcause I know medical care is something really personal, so wanna make sure you know you can tell us, you can feel comfortable telling likeme this information A: So I can be honest. Q: Basically yea, because we want to make sure we get good data. Q: So were you able to speak about problems and receive attention? The attention that you neededMaybe if you can mention maybe some examples that stick outlike maybe like if you werent able to maybe um to speak about your problems or receive attention...or times when you could speakand you dont have to mention the problems if you dont wantI guess I just wanted to see what your experiences were so more you can give us the better it would be. A: Well, I stayed with my pediatric doctor... which I didnt know is a common thing...for like a young adult to stay with a pediatric doctor until theyrelets say I stayed with him until I was twentyI heard from another doctor since I mentioned it to them that its more of a common

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thing and I didnt know I just felt comfortable talking w my doctor, Dr. ___, because he was very nice and trustworthy. So whatever issue that I had that I spoke to him aboutand I did have a problemand he would go into detail about it and what I can do to prevent it from being worse or things I can do also to make it betterand what to expect. AndI would say overall the reason that I stayed with him as long as I did was the comfort level and the amount of respect I felt that he gave meand isnt he was very personableuminstead of just feeling youre sort of being rushed and they dont have time.. very often other doctors that Ive seen are like... they treat you likethey only have a certain amount of time they have allotted to you. So if your appointment is at 3:30 its almost like they want to get you out as soon as possible so that they can take a break before their next appointment... or somethingbeing rushed or being less personableit almost feels like theyre in a rush in those select cases. So something that they are personablethat they smilethat they shake your handthey reassure you Q: So I just want to make sure Im following you correctlysome of the things you just mentioned was that theyre trustworthythat theyre personableand you can correct me if Im wrongthey recognize the emotions youre going through as youre hearing about a diagnosis or a reason why youre coming to see them and maybe its better news or worse news than you expect but they react and they dont just assume that you will have the same reaction as they would as a medical professionalI know sometimes that theres a lot of jargon in the medical fieldand so like people who are doctors may know that something is not a big deal but its a very lengthy word and it sounds very complicated and then someone else might think then whos not in the medical field may think this is something thats really going to affect my lifeIs that kind of what you were talking about when you were talking aboutwhen you said they were recognizing your emotions likethat he made sure thatyou understood what he was talking

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN aboutthe diagnosis that he was giving you. Like, and he didnt just assume that you would react the same way he did. Or to what extent do you think he did that? Like, that he recognized your emotions? Because you show... likewere talking about to phases of your lifeone portion where you stayed with a doctor for a really long time by your own choice...and another portion of your life where you switched doctors many times

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A: There wasup until I was twenty. So I would say my decision to change doctors would be at some point around when I was maybe 15 or 16 so the next four years I was aware that I could switch doctorsand that some other boys my age may have switched to general care instead of a pediatricyou know like a general family doctorI didnt mean so much emotional even though there were emotions involved. Um so if you find out that theres something wrong medicallyso whenever I would ask my first doctor what to expect and how it would affect me he covered all the areas of unknowingand so, uhhe would present the information in a kind manner I guess. And he would cover everything, and... so he would ask me if I have any questions so he would take the time instead of giving me like a packet of information, instead he would do it on a personable level to where he would answer my questions whereas someone else might do that. Since then I would not stay with any physician because according to my opinion I had such a good doctor growing up that I would compare the next doctors that I visited and I was never really too satisfied with their care. Since then I would go occasionally but, I have been occasionally, but I havent really been to one in a few years now really havent looked for one because Ive been to so many impersonable doctors in the lastsince I was twentyso for the last twenty years Q: So um- it seems like youre almost talking about he was moremaybe just reactive tobecause the difference between giving someone just information and making sure all their

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questions is answered you need to be aware of what the person is communicating to youeven if theyre not directly saying oh I have another question So do you feel like he maybe did that more? Because you said that your practitioners after that, they kind ofto put it kind of in more of an extreme way, they just gave you a packet of informationwhereas he did not just give you a packet of information. He kind ofkind of answered your questions. He seemed like possibly he was more interacting with you I seemed to be more interactive like back and forth rather than one way A: Yes. And then if I wanted more information he would provide it but he would want to answer all my questions that I had at that momentand knew sort of the topicthe way he approached it he would cover I guess all of the bases. This is what this is, this is how to treat it, this is what to expect. And then after that do you have any questions Q: So just a recap.you said you mentioned trustworthinessyou saidwhat else did you mentionkindnessand feelings that you werent rushedand feeling of an interactive session versus one way communication by a practitionerso can you tell me more about whatabout specific behaviorsmaybe nonverbal communication or maybeactually just specific behaviorsnot necessarily the knowledge of the professionals because we all know theyre accredited, they all went to grad schools. So we all know they get the training. But so maybe just things you noticed about the sessions with the people you didnt stay for long. A: I would say just from the greeting that they would say: hello, how are you and they would have a smile on their face, those are things that are nice, especially when you have to share personal information with a stranger. If they seem caring, that theyre gentle, that theyre not moving with too much haste because youre a person and not a thingthose are initial things that I would notice. I think a lot of it has to do with eye contact and with smiling to where you

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN feel like it is a pleasant experience instead of something youre not looking forward to because youre not treated like with respect or dignity that you would expect better service if you went

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out to eat and you have a waiter and you take their business to them and they smile and ask you how youre doing and have you been there beforetheres interaction there and theres eye contact and everything. So if you go to a doctor thats even more expensive and they want you to come back they have to be at some level genuine and caring. I mean that doctors are in theI mean they care for people. Q: SoI feel like weve talked about a lot of topics and weve covered a lot of ground... which this is my first interview so thats really good. So I guess I was wondering if you could provide maybe an examplemaybe a personal example.from you went to see the doctor for something and like this is what happened and then he reacted in a certain waybut more like an example from your lifeyou know one that you actually talked about what you went in for. And Again I wont be sharing your name or anything with anyone. This will be in an essay format and this will be what we are writing and sharing the details in. and we will use aand make you anonymous and no one will know it is youit would really add some personality and depth to our paper. I was just hopI was just wondering do you feel comfortable doing that? A: Yea I do. Does it matter what type of doctor I went to, like a chiropractor, is that ok? Q: We were kind of thinking more in terms of going to an md or something like that. Because its just a slightly different environment A: So like a yearly examination would be fine? Q: Yea, a yearly examination. And that would kind of wrap up our interview. A: I could use the yearly examination that was about five years ago and I would be 27 at the time. This was a female doctor that I hadnt been to before. And it was over here, actually in this

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area. Even though I live close enough to go see her I do not. The first time I met her when I had the examination. I filled out a form of my previous history, once she asked me some questions and after the examination was finished, I had felt like that even though she had gave me a greeting, she was not really friendly. Q: What was she looking for? Because I remember I had a physical before I had a physical before they looked for A: Check my weight, height, prostate cancer(on cuing), she asked me like if I take medications or smoke, how often I drink, if I have sexual intercourseso um Q: So what were the things? A: She checked my reflexesand thats really all I can think of at the moment. Q: What were the good things and the bad things or you can say the reverse A: I was mentioning like what I noticed that really sort of made me feel like I wouldnt go back and see her that even though she gave me a greeting it wasnt, it didnt seem like a very good one. It was just more like a hello my next patient how you is doing nice to meet youlike it wasnt a happy toneI felt like I was just another patient Q: Like going through the motions maybe A: Going through the motions (confirmatory) Q: And so maybe going through the motions she maybe didnt pause to make sure you were ok A: I feel like she did everything she was supposed to do... it was just that the service was just not very personable. Just smiling and being personable I think it means having eye contact. Those things for me are I guess, (cough) if I dont feel comfortable with someone, usually it means its lacking something like they dont smile. Id like to be around someone, like a doctor when Im

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN needing to feel comfortable in getting like a prostate examination, Id like them to be a happy person if that makes me feel more comfortable Q: Did she also seem like she was in a bad mood, or was it just like she was rushed? A: Maybe Q: Like she had a bad day or a bad patient A: No, I thought it was her personality, that she didnt like being real personable Q: Do you remember anything good from the session? A: It seemed like she was knowledgeable and it felt like you said all doctors that go through graduate school almost all of them are well equipped to do the job.

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PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Appendix B Interview #2

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Q: Our studies looking at how, to what extent, people follow the advice of their doctor when they go homehow they adhere. Our question is what are the factors that affect your desire to, or your desire not to, follow your practitioners advice. We know theyre all board certified so we know they are all able to be a doctor, so were looking at more the behaviorslike the mood, maybe its sitting or standing, or maybe its not those things and its something else. Maybe sitting or standing has no impact and it never changed how you view your practitioner. Maybe their tone of voice also did not affect you. What Ive also noticed is that people have also switched their practitioners and so I might also ask why you eventuallyhave you had the same doctor your entire life? Or have you ever switched? A: Ive had my practitioner since I was a teenager, I dont even remember when I stretched, for many years. Wont get a new doctor here. Example of what happened today. I wasnt able to go home for this visit it wasnt worth going home (to my doctor). New doctor. Doctors going over information with her and he gets a phone call. Im like, are you really going to answer that? He says excuse me and starts talking in Indian, trying to get off phone and then he leaves and then doesnt come back for another 10 minutes. Q: Thats interesting that he did that A: Yea (laugh) A lot of it is about the topic of what it is too and the personality too. The doctor I just saw was easy to talk to and shes a timid or shy person so its harder to talk to her than with this provider. So it depends

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Q: So you were kind of saying earlier that you would have some interesting things to bring up since you said you had experience w healthcare more than another person

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A: I have a lot of medical issues so Ive had (I dont mind sharing) Ive had an endoscopy and a colonoscopy and Ive done all these things and I still dont know. The only thing they could come up with was acid reflux but theyre leaning more towards diverticulitis but Im still undiagnosed. I also have endometriosis and have had surgery for that too. Each care provider is different because those are all specializations since Ive seen several doctors. One of them was a little different, you asked him questions and he didnt like it, (thought you were challenging him) so he wasnt easy to talk to. Q: It seems like youre implying that you were not maybe leaning as much on his advice because youre not clear what he's telling you? IS that what you were saying? A: All these doctors are specialists so its easy to follow their advice so they have a lot of information. Just for surgeryIts a lot of prep time. Most guys there were 50 Q: I recently had a colonoscopy. I didnt trust my doctor because its extreme A: Its invasive A: Reason why I had to get one because my mom has ulcerative colitis so I had to get one when I was twenty so that was more of a genetic thing you dont get them till youre 40 A: With all my doctors theyve had really good advice because they give many handouts and they prep you for everything because when I went in for my surgery I had to appointments before, then I had my surgery, then I had an appointment after so they follow up with you and make sure youre doing fine. So I usually followed what they said. But with resting [aka do nothing and heal) (a lot of it) I hate it so I over do it because I dont like to rest. I will get up and do way too much and afterwards I wished I didnt do it enough.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Q: Maybe you dont rest enough likeyou walk around and youre not supposed to

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So it seems like youre activeyou know everyone has routine like for studying to walk around to study I have did that with people last year. It helps me sometimes the building makes me claustrophobic when I dont do that. IT seems like youre saying theyre asking you to do something thats contrary to your lifestyle routine and that youre saying your lifestyle routine would normally be to be really active, walking around or how would you describe your lifestyle routine. Or would you like to sit and just be in one place for a long time A: Have to switch. So those kinds of ties to being ADD. I am a sensory seeker. I need to be doing stuff all the time. What I found this is actually common for most people. What I do follow: When Im given antibiotics I take it for the whole time, and a lot of my friends dont do that, and the antibiotics doesnt kill it and the antibiotics wont cure it because its stronger now. I actually do follow that advice. Q: What about anything that, anything that. Things that made you particularly follow advice were that they gave you handouts? A: Talked through things for me, this is what happens before, this is what happens after, heres what it does Q: By sitting down going over it with you one stream or did you mean more interactive, i.e. say something and see how you respond and depending on how you respond they react. Dont want to put words in your mouth, Ive been told I do that A: Im the person that talks about anything, so since Im usually comfy around people doctors may give me more advice than other people like endometriosis deals specifically w girl parts; some people may not be comfortable talking about those things Q: So you ask them questions?

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A: I'm very comfy with asking questions. Whats going to happen after this? Will it come back? And it does Q: Sometimes do the questions get off track and they redirect you and then the relationship continues. Is that one thing you noticed maybe? So since obviously not a doctor you wont know every diagnoses like when Ive gone somehow I got some kind of bacteria and I got it taken care of so thats why I got a colonoscopy. It was also me being lactose intolerant and that made it so much worse and now its kind of taken care of. I noticed I would ask questions and sometimes I would get off track and the reason I actually switched practitioners during this process in finding out what was wrong was because I was more comfortable with a male doctor than a female doctor. And also this doctor like he would listen to my questions and even if they were off track he would say thats not really important but this is important and this is what you really need to know; you said your doctor was a female at home A: Definitely I would prefer to have a female so when I did need to go to see a specialist I did originally want a female but it didnt end up working this way but I was fine w my doctor since it didnt work out that way. I do have a really good relationship with my doctor at home (esp. since women need to get an annual pap smear) and she asks how school and how are things going on; shes someone I can talk to and doctors need to have that kind of relationship. Females might be a little more understanding (laughs w relief) Q: And also, questions, the questions you ask, is that another reason why you stay with this one practitioner because she allows you to ask questions even if theyre not relevant, thats the point I was trying to get at in a long winded way A: Yes, half the questions I asked off topic but I can ask her whatever. If you need to come back in but ask me now if you need to

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Q: It seems like she participates in asking you about, I mean because, shes your practitioner, shes trying to get a social history A: Its built over the years (in response to social history) Q: That makes you comfy (yes) thats part of the relationship (yes) that your sad (yes) that youre in a bad mood (yes) Q: Another thing doctors will help with even though she might not be a psychiatrist or

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psychologist, they can still help with that, too and I went to her for my own separate issues where I could have gone to a different doctor but I felt comfy enough going to her and she was able to prescribe me some too Are there any other things that have influenced your adherence, willingness to follow up on a treatment, follow the advice of a doctor? A: No Q: What about more mundane things, like cholesterol check, and I did listen to the doctor but she said I shouldnt eat so much meat but because I love meat I eat meat every meal A: Diet eats healthy, for acid reflux; dont eat fast food certain acidic foods; you need to cut it totally out is what they recommend. Q: Is the reason why you dont do it you built a lifestyle, dont have chocolate or milk based thing (she agrees) sensory diet? A: Comfort food so why would you get rid of comfort food (sarcastically) but yes, like eating ice cream? Q: Do you want to reflect on an emotional experience with a doctor? A: The best one is what we just talked about, like you should exercise more. Do I? No. They want you to be healthy doesnt mean youre always going to do it.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Appendix C Interview #3

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Q: So were looking at how you follow doctors advice; how people follow doctors advice if they follow it or if they dont follow it after they see their doctor and anything related to that I should have started last time with an opening question last time. Were you able to speak about problems and receive appropriate attention, w an experience that really stands out. A: Last time I went to doctor was before school for a physical. My blood work came back and he told me this is kind of high and you should do this. You should take this vitamin because youre lacking in these areas and you should start working out. I was definitely able to voice questions I had about it and feedback wise he would tell you. As far as following through with me following through w exercise and vitamins I did in the beginning but as far as keeping it up now I dont. Everything sounds good and because you know his a doctor and you know more about it you, me personally, I follow his instructions. After a while you get lazy Q: Have you always had the same doctor? A: I switched over a couple years ago. Q: Is there a specific reason that you switched? Were you not comfortable w practitioner anymore? What is the difference between the practitioner you use to have and the switch, something caused you to switch? A: I switched because my sisters job she works for a primary care physician and I thought it was easier to call my sister and schedule my appointments thru her because she worked w/ this other doctor. There wasnt anything that I didnt like about the doctor before the switch Q: I guess if you could just point out some things about youre mostum---I assumehow old are you?

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN A: 26 Q: What are the most experiences that made you not follow the doctor? Out of all those years you saw doctors, do you recall behaviors, like specific things that recurred and every time you decided that because this happened I am not going to follow this advice? A: I know that one time I went to the doctor and I know the doctor himself was a religious person but it wasnt medical advice. You know how the doctor would ask you a number of

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questionssomehow in the conversation he asked me if I went to church. Somehow that crossed a line between the doctor relationship between medical and not medical. AS far as medical wise, I cannot think of medical advice I did not follow Q: I remember when right before the fire alarm went offwhen you went in for the physical for your school. You said some of the things you liked about your visit that time? What specific things did you say? A: Doctors very personable, spend the time to talk to you, he treats you like family. Whats going on what are the issues whats going on in your life versus (in contrast my words) in and out i.e. doctor has too many patients and does not try to get to know you or all the aspects of what could be causing the sickness or the illness or whatever ex: sore throat take this Q: Most memorable experience because of the quality of the treatment: A: A good visit and thing that stands and tells you Q: Behaviors, what he says, how treats you, kind of like a way someone described it to me; how are they providing the service to you? Trying to figure out what the behaviors are? A: For the most part, they are in good moods, using like the big medical terms, like it when they break it down be calm and be patient with you. Never had a doctor thats grumpy but one that is rushed so their quality of care is not as great versus not laid back but more time to spend on you

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Q: Is there anything else you can think of that affected whether you followed through on the treatments? Maybesomeone else mentioned to me they thought the doctor was competent because of this and this Was competencyplaying a role inwhat behavior made you feel one doctor was more competent than another one? Talked about the one experience where the doctor crossed a boundary where he shouldnt have? Any other behaviors that occurred during your visit with him. Curious about his body language? A: His mannerisms wise, there was nothing too weird not too close or too far. He was like a typical doctor. As far as professional wise, that did sort of make me second guess the things he was recommending to me? Like youve been practicing for so many years shouldnt you know that has nothing to do with health care for you to be asking that? Q: Are there any other mannerisms or physical behaviors that doctors produced or somehow communicated or somehow it was present in the clinical situation that made you follow the advice less or follow it considerably more? A: When the doctors spent the time, sat down, kind of showed you the results and recommendations and gave you info to more read up on it and ask more questions about, ex exercise more your blood work came back and it shows you have higher triglycerides and then he gave you the reading? This is shown to lower that and its a good idea for this vitamin.

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Showing you evidence, examples and the research to why its good and why it would benefit me Q: So they justified it, showing you the evidence, showing (no) A: Trust what the doctor is saying more versus not saying the benefits to it ; whats the benefit of lowering it; Whats the benefit in the long run and whats the bad side of not doing it in the long run?

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Q: Is there something about sitting down? You mentioned sitting down? Was the other one not sitting down? A: Most doctors actually sat down. Q: Did that make you more open to share your experience; have a continued relationship w the provider? A: More time= continued patient versus if theyre not really willing to do that

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Q: Anything else that has altered whether you follow doctors advice or dont? I s there anything else that stands out for you? Did any of them stand up and did that make a difference to you? (no, dont go too much, not an experience that I can remember off the top of my head, all sat down for a little bit of time) A: Time spent, more eye contact, more vested, more justifications and explanations for certain protocols Q: By vested you mean more reactive? A: Yes, I personally want a doctor that has a conversation you have with anybody. One thing at a time is better and makes sure you understand that.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Appendix D Interview #4 Q: Ok...so...Im doing a study with Chrys. Were doing a project for qualitative research its were looking at how people follow the advice of their doctor when they go homeshow how people adhere to their doctor rather than like their doctor says take these pillsthe example is

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the doctor says take these pills and the ideal situation is that they take those pillsthe opposite would be the doctor says take those pills and they dont take those pills at all. So thats basically what were talking about but were not just talking about pills or medication but about any advice theyve given you. And I mean were doing it on people who have just had normal doctors appointments so its not like by doing this were saying you like a big medical condition or whatever. It all applies. I am going to start with a starting question and then Ill just guide the interview like I wont have any more questions Ill just be asking you about what you said. Do you have any questions? Are you clear what Im asking about or do you have any questions about it? A: No Q: So were good? A: Yes Q: So when you were at the doctor the last time do you feel like you feel like you received appropriate attention or not? And like I mean I guess it would be best if you could think of an example?and you dont have to mention the doctors names because we know theyre all like board certified you know were talking about those other aspects A: I got a basic physical last time I went to the doctor and I didnt have any questions but I felt like she did a good job.was thorough, was nice.

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Q: Why I mean like why do you think it went well specifically. For example, was it that shefor example some people have said (and I mean you might not think this at all so this might not apply to you at all): some people like it when your doctor sits down; they like it when the doctor talks like in a he is not rushed when hes talking to you. But I mean You might like it when hes rushed when hes talking to you or when hes standing up or whatever. So I guess Im kind of talking about those kinds of things like. A: What I liked specifically that she did? Q: Yea About the wayher approach to you? A: Shes knowledgeable and willing to answer questions if I had any but I didnt have any so she just a good job and was time efficient. Q: Have you had the same practitioner for---or have you had various---have you had various doctors or have you had the same doctor? A: Various doctors Q: So I guess can you give me a timeline of um how long youve had this one doctor and then--um I guess starting from when you are a teen till now. Like how your doctors visitsI stayed with this one doctor for 10 years A: I have had different doctors depending on what my parents insurance was also in the military I have had various doctors. Q: Was that more related to money; like one insurance company was cheaper than another one sometimes? A: It had to do with my dads insurance and with the military it was wherever you were stationed. Wherever youre at you just get a different doctor thats just working there

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Q: So you said when you were with your dads insurance was that just because his insurance was related to the job he had or something. A: Yea Q: Can you tell me maybe aboutdid you ever go see the doctor for the flu or something else where you had maybe a longer interaction with a doctoror maybe you can tell me more about that doctors visit in terms of that approach. Like was the doctor looking at you was the doctor calm, like the tone of voice that you had. (Last time we met?) Yea so at your physicalthe last time you saw your doctorso what about like the way the doctor was composing themselves or if the doctor was closer or further away from you or you know like all thoseyou know you get creped if someones like super close to your face( I laugh)? I mean like things like that cause to make a good description in the paper I write I need to talk about that kind of stuff so I need you A: She was just seated at her chair and I was just seated at the little table things and she just did some basic measurements and some other thingsand yea she was just seated and I was seated on the thing and she just did some little measurement things Q: What does a---Do you remember what a physicalI remember having a physical a while agolike you said they take your blood pressure dont they weigh you too? A: She weighed me, took measurements. Q: What kind of measurements, again? A: More like height measurements Q: Height measurements? (He agrees.) oh yea check your blood pressure, did your test for colon cancer (no) Isnt that where youwhy they reach under (no thats for a hernia). A: This was more a simple health screening questionnaire

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Q: Do you remember what else she asked you? A: She asked me questions like health history questions and some other stuff Q: You said she did some reflex testing? A: Yea

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Q: And socan you recall an experience where you had a really bad experience with a doctor like one that really bothered you? A: I remember in high school I was mad so I wanted to play football but the doctor did not want me to play football and I was mad at him for that because he said it was too dangerous of a sport and I was mad because I was 15 and I wanted to play Q: ButumWas that anything to the way he provided the services A: No. He did a good job and everything he just was giving his professional opinion and I disagreed with him and it made me mad Q: Ok. Then did you listen to him? A: No I ended up playing football that season. I didnt have any injuriesso it was good. Q: So it seems like one of the reasons you didnt listen to him is becauseumwhat do you think was the reasons you didnt listen to him? A: Because I wanted to play football. Q: Was he maybe just not convincing enough or something? A: No I was going to play football regardless. I was 15 I wanted to play so I was going to play. Q: Yea. Ok. Had you been playing before then? Like I know there is little league football or whatever?

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN A: I had been playing flag football but that was for the freshman team. (Ok). After that year (sophomore year) I didnt really like football not high school football. It was too intense and political. Q: So, it was kind of part of your life already? It was like daily you would go play flag football or whatever with your friends or whatever? A: I wouldnt say daily cause I would play other sports too but it was just that season I was gonna play. (when was this?) I was in ninth grade and I was fifteen. Q: So like 6th, 7th, and 8th grade, lets say, would you play like flag football with your friends like is that an activity that you would play then often? A: Yea, if it was in the fall. Q: So basically what Im getting at is if it was in like youre a routine? because it seems like

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youre saying all your friends were playing it so you wanted to play it so you wanted to play it so you didnt really care what the doctor was saying? (yes) What Im getting at Im asking all these questions and basically just trying to find out if playing footballbecause you said you wanted to play football regardless of what the doctor was saying (sports was in my routine) So was football part of the sports that was in your routine? (yea you could say that) But then for some reason after you played for 1 season you decided you were not interested in playing it anymore? (I was not interested in playing competitive; I just wanted to play for fun). Ok so that was more like a personal decision, right (yea).um so is there anything else that you canwhat about anythingdo you remember anything else from that experience with the doctor that specifically like made you pay attention more or less to certain things he was saying A: I cant really remember it was eleven years ago. Thats all I remember from that visit.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Q: It seems like one of the it was like part of your routine but you said it was likewere your friends doing it too: playing flag football and playing football during that particular time (yea) So, like, when you went to play football you went to also play with your friends (yea) besides

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just the sport. So your friends were on the team (yes). Is there anything else that you can think of in any of your doctors visits that have influenced you to listen to your doctor? A: I think now I would be more willing to listen to them than when I was a teenager. It depends on if theyre knowledgeable if they know what theyre saying Q: But I mean shouldnt every single one (every doctor that is a doctor I emphasize) should be knowledgably because they have a degree. They passed their certified board examination A: They might not be very knowledgably about a certain subject. Compared to a generalist, a specialist would have more in depth knowledge about a certain condition. Q: So, have you ever seen specialists? A: No Q: But you feel like your general practitioner may not be able to give you advice on some things that are really specific because they only have general training? A: Yes Q: Thanks for helping me out, thats about everything.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Appendix E Interview #5 Q: Were you able to speak about the reasons for your visit to the medical practitioner and did you receive appropriate attention? A: Yes, I told them what was happening to me. [Pause] I guess they did ask me more detailed

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questions that were appropriate unless I already did a good job of explaining. They do a good job at asking for clarification when I come in for a visit. Q: Have you switched or jumped around to different practitioners and if so, why? A: I have jumped around, and when I did it was because of geographic reasons [pause] like the doctor retired, [pause] or the insurance plan changed to where it would be cheaper if I went to a different doctor. [Pause] The longest that Ive stayed with one practitioner would be about 5 years. Q: Can you think of any factors that made you follow the advice of the practitioner during your own time after your visit? A: Im pretty sure they are credible since they are a doctor. I dont really notice things about them individually. [Pause] Yeah, I dont really look too into it. [Pause] I paid them for their advice so its only logical to follow through. Q: What do you look for in a practitioner? A: They have to be personable seem to genuinely care about their patients and licensed. [Pause] I guess you could also say that I make sure they have a good front desk personnel and I look at the facility and make sure it is a clean environment. Q: What types of practitioners have you seen? A: Podiatrist, pediatrics, general physician, nurse practitioner, and a dentist.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Appendix F Interview #6 Q: Were you able to speak about the reasons for your visit to the medical practitioner and did you receive appropriate attention? A: No the doctor wasnt very sociable. He made me feel awkward. [Pause] He just rambled and didnt seem to ask me exactly what was wrong like he would just assume what was wrong. Q: Have you switched or jumped around to different practitioners and if so, why? A: [Pause] I havent yet but I am thinking about it. Q: What has held you back from switching, if you dont mind me asking? A: Um, I havent really taken the time to do the proper research to feel comfortable enough to switch.

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Q: Can you think of any factors that made you follow the advice of the practitioner during your own time after your visit? [I had to clarify] Like following through after you went home. A: Um, I dont know of course I followed through. Who doesnt? Q: What do you look for in a practitioner or competent doctor? A: I dont know somebody with a medical degree and good reviews on Yelp. Q: What types of medical practitioners have you visited? A: Um, a gynecologist, dermatologist, psychiatrist, rehabilitation counselor.

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Appendix G First Analysis- Axial Coding spending the time

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I was definitely able to voice questions I had about it and feedback wise he would tell you.-3 very personable, spend the time to talk to you, treats you like family-3 spend the time to talk to you, he treats you like family. Whats going on what are the issues whats going on in your life-3 has a conversation you have with anybody; One thing at a time is better and makes sure you understand that-3 more vested, more justifications and explanations for certain protocols-3 explanation is that you can have a conversation with them (above)-3 time spent-continued patient, showed you the results, "blood work came back shows you have high triglycerides" explaining medical procedures-3 some people may not be comfortable talking about those things-2 she asks how school is and how things are going on; shes someone I can talk to and doctors need to have that kind of relationship. Females might be a little more understanding (laughs w relief)-2 half the questions I asked off topic but I can ask her whatever-2 doctor that has conversation with anybody-3 so they follow up with you and make sure youre doing fine-1 P: its built over the years (in response to social history) P2Me: It seems like she participates in asking you about, I mean because, shes your practitioner, shes trying to get a social history Me: that makes you comfy (yes) thats part of the relationship (yes) that your sad (yes) that youre in

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN a bad mood (yes)

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P2: Another thing doctors will help with even though she might not be a psychiatrist or psychologist, they can still help with that, too and I went to her for my own separate issues where I could have gone to a different doctor but I felt comfy enough going to her and she was able to prescribe me some too good job at clarification when I come in for visit-5 I had felt like that even though she had gave me a greeting, she was not really friendly/good one.-1 like it wasnt a happy tone-1 going through the motions (confirmatory)-1 (after being asked about her greeting)-1 no, I thought it was her personality, that she didnt like being real personable-1 Id like to be around someone, like a doctor when Im needing to feel comfortable in getting like a prostate examination-1 Id like them to be a happy person if that makes me feel more comfortable-1 theyre gentle, that theyre not moving with too much haste because youre a person and not a thing1 theres interaction there-1 I felt like I was just another patient-1 doctor wasnt very sociable. He made me feel awkward. [Pause] He just rambled and didnt seem to ask me exactly what was wrong-6 when I went in for my surgery, I had appointments before, then I had an appointment after, so they follow up with you and make sure youre doing fine-2 doctors may give me more advice than other people like endometriosis deals specifically w girl parts-2 scope of practice

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doctor would ask you a number of questionssomehow in the conversation he asked me if I went to church-3 did sort of make me second guess the things he was recommending to me? nothing to do with health care for you to be asking that-3

antecedent consequence whats the benefit of lowering it; Whats the benefit in the long run and whats the bad side of not doing it in the long run?-3 As far as following through with me following through w exercise and vitamins... you get lazy-3 I didnt have any injuriesso it was good-4 I remember in high school I was mad so I wanted to play football but the doctor did not want me totoo dangerouswhen 15-4 But then for some reason after you played for 1 season you decided you were not interested in playing it anymore?-4 I was not interested in playing competitive-I just wanted to play for fun (happened to occur after doctor said it was too dangerous) When I am given antibiotics, I take it for the whole time. A lot of my friends dont do that, and the antibiotics doesnt kill it and wont cure it-2 But with resting [aka do nothing and heal) (a lot of it) I hate it so I over do it because I dont like to rest. I will get up and do way too much and afterwards I wished I didnt do it enough -2

body language eye contact-3 eye contact-1

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN usually it means its lacking something like they dont smile-1 sat down-3 then contradicted herself and said all doctors sat down interactive-1 skill his mannerisms wise, there was nothing too weird not too close or too far-3

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I got a basic physical last time I went to the doctor and I didnt have any questions but I felt like she did a good job.was thorough, was nice-4 All these doctors are specialists so its easy to follow their advice so they have a lot of information.-3 they might not be very knowledgable about a certain subject. Compared to a generalist, a specialist would have more in depth knowledge about a certain condition.-4 guess they did ask me more detailed questions that were appropriate-5 it seemed like she was knowledgeable and it felt like you said all doctors that go through graduate school that go through graduate school almost all of them are well equipped to do the job-1 Everything sounds good and because you know his a doctor and you know more about it you, me personally, I follow his instructions-3 somebody with a medical degree and good reviews on Yelp-6

age I was going to play football regardless. I was 15 I wanted to play so I was going to play.

convenience related factors doctor retired-5

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It had to do with my dads insurance and with the military it was wherever you were stationed -4 Even though I live close enough to go see her I do not-1 good staff and clean environment-6

easier easier to call my sister and schedule my appointments thru her because she worked w/ this other doctor-there wasnt anything I disliked about the doctor before the switch-3 After a while you get lazy

routine But with resting [aka do nothing and heal) (a lot of it) I hate it so I over do it because I dont like to rest. Il will get up and do way too much and afterwards I wished I didnt do it enough.-2 lazy-3 Is the reason why you dont do it you built a lifestyle, dont have chocolate or milk based thing (she agrees) sensory diet? P: comfort food so why would you get rid of comfort food (sarcastically) but yes, like eating ice cream?2 The best one is what we just talked about, like you should exercise more. Do I? No. They want you to be healthy doesnt mean youre always going to do it-2

What Im getting at; Im asking all these questions and basically just trying to find out if playing footballbecause you said you wanted to play football regardless of what the doctor was saying (sports was in my routine) So was football part of the sports that was in your routine? (yea you could say that)-4

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN

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so like 6th, 7th, and 8th grade, lets say, would you play like flag football with your friends like is that an activity that you would play then often? P: Yea, if it was in the fall. Its a lot of prep time-2 not spending time get you out as soon- as possible so that they can take a break before their next appointment... or something-1 ask me if I have any questions so he would take the time instead of giving me like a packet of information-1 he gets a phone call. Im like, are you really going to answer that?-2 you asked him questions and he didnt like it,(thought you were challenging him) so he wasnt easy to talk to-2 did sort of make me second guess the things he was recommending to me? nothing to do with health care for you to be asking that-3 reviews the time to do the proper research to feel comfortable enough to switch-6 good reviews on yelp-6

gender Females might be a little more understanding (laughs w relief)-2

emotional reactions You know how the doctor would ask you a number of questionssomehow in the conversation he asked me if I went to church. Somehow that crossed a line between the doctor relationship between

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN medical and not medical. -3

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higher tone of voice toward end of sentence

doctor did not want me to play football and I was mad at him for that because he said it was too dangerous of a sport and I was mad because I was 15 ---4 increasing aggressive tone towards end of sentence she wasnt trying to get to know me-irritated-1

cheaper Example of what happened today. I wasnt able to go home for this visit it wasnt worth going home (to my doctor). -5 be cheaper if I went to a different doctor-5 ] I paid them for their advice so its only logical to follow through.-5

gender 1-male 2-female 3-female 4-male 5-male 6- female

PATIENT ADHERENCE TO HEALTHCARE TREATMENT PLAN Appendix H Second Analysis- Matrix Coding Regarding Adherence
Column1 spending time body language not spending time skill convenience routine price age antecedent consequence scope of practice 1-Jacob* 2-Sophia 3-Emma 4-Mason 5-Ethan 6-Isabella 8 4 7 1 1 1 3 1 2 0 0 0 2 2 1 0 0 1 1 1 2 2 1 1 1 1 1 1 1 1 0 3 1 1 0 0 0 1 0 0 2 0 0 0 0 1 0 0 2 2 3 2 0 1 2 0 0 0

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*adherence to staying with a particular practitioner and not with following a treatment; the data points followed a similar trend as the others and were therefore included

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