Representations of illness: their relationship with an

Psychology, Health & Medicine

ISSN: 1354-8506 (Print) 1465-3966 (Online) Journal homepage: http://www.tandfonline.com/loi/cphm20

Representations of illness: Their relationship with an understanding of and adherence to homoeopathic treatment A. Searle & S. Murphy To cite this article: A. Searle & S. Murphy (2000) Representations of illness: Their relationship with an understanding of and adherence to homoeopathic treatment, Psychology, Health & Medicine, 5:2, 179-191, DOI: 10.1080/713690179 To link to this article: http://dx.doi.org/10.1080/713690179

Published online: 19 Aug 2010.

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Date: 15 March 2017, At: 02:40

PSYCHOLOGY , HEALTH & MEDICINE, VOL . 5, NO. 2, 2000

Representations of illness: their relationship with an understanding of and adherence to homoeopathic treatment A. SEARLE1 & S. MURPHY2 MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol & 2Department of Psychology, University of the West of England. Bristol, UK 1

Abstract The aims of this study were twofold; to test the reliability of the illness Perception Questionnaire (IPQ; Weinman et al., 1996) with a sample receiving homoeopathic treatment and to examine its predictive utility concerning the extent of understanding and adherence to treatment. Thirty adult patients presenting with ‘chronic’ conditions to homoeopathic practitioners completed the IPQ prior to their initial consultation. At their next consultation (4–6 weeks later), a further questionnaire was completed concerning their understanding of and the extent of adherence to the treatment. The IPQ yielded reliability coef cients of 0.89, 0.78 and 0.64 for time-line, consequences and control/cure, respectively. Causation beliefs appeared as the best predictors of both understanding and adherence. The severity and duration of the condition was associated with an understanding of the principles of homoeopathy and the extent of adherence to it. However, they were not associated with an understanding of the practitioners’ explanations of the illness, awareness of its consequences and the extent of perceived ef cacy of the treatment, the implications of which are discussed in relation to practice.

Introduction There has been much health psychology research guided by the self-regulatory model of illness behaviour (SRM), where the patient is seen as an active participant in the health care process (Weinman & Petrie, 1997). The SRM postulates that an individual experiencing illness may give rise to a range of problems which are pertinent to that individual while others experiencing the same condition may have their own unique experiences. It has been demonstrated that in order to make sense of and respond to these problems, patients create their own models or representations of their illness which then in uence their coping and care-seeking behaviour (Cameron et al. 1993). The process is regarded as self-regulatory because the three components of the model, interpretation, coping and appraisal, have been shown to interrelate in order to maintain the status quo, therefore if an individual’s normal state of health is disrupted by illness the model proposes that they are motivated to regain the balance (Leventhal & Diefenbach, 1991; Leventhal et al., 1984). It is posited that each patient will have their own beliefs about the Address for correspondence : Aidan Searle, MRC HSRC, Department of Social Medicine, University of Bristol, Whiteladies Road, Clifton, Bristol BS8 2PR: UK E-mail; A. [email protected] ISSN 1354-8506 print/ISSN 1465-3966 online/00/020179-13 Ó

Taylor & Francis Ltd

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identity, cause, time-line and consequences of their illness; while Lau (1982) has argued that patients’ models may also incorporate beliefs about the controllability of the condition, the extent to which they perceive they will make a recovery or limit its course of progression. The theoretical implications of the SRM suggest that the framework could have considerable scope in health research, particularly for understanding the psychological impact of illness. To date, studies have focused on differences between individuals and health practitioners regarding illness perceptions (Baumann et al., 1989; Skelton & Croyle, 1991), its treatment (Leventhal & Cameron, 1987), as well as explaining patterns of care seeking and adherence to treatment (Bishop, 1991; Cameron et al., 1993; Horne, 1997). A literature search (PsycLit and Medline) revealed that there has been scant investigation, from a psychological perspective, of the illness behaviour of those seeking complementary medicine. However, existing studies have suggested that complementary treatments are primarily chosen for the belief in their ef cacy and the rationale underlying the particular treatment (Furnham & Forey, 1994). In addition, homoeopathic patients may be dissatis ed with allopathic medicine or the attitude and behaviour of conventional practitioners (Furnham & Smith, 1988; Patel, 1987). However, these observations are not unequivocal, later ndings have shown homoeopathic patients to be more strongly in uenced by the ineffectiveness of allopathic medicine for their particular condition and thus more likely to try an alternative, a fact largely accounted for by the chronicity of their complaints (Vincent & Furnham, 1996). With regard to causation, Furnham and Kirkcaldy (1996) have reported that patients using complementary treatments believe signi cantly more than orthodox users that psychological or mental factors play an important role in the causation of illness. Thus it is argued that those seeking alternative therapies have a tendency to perceive that psychological factors play a major role in the causation of illness. This phenomena may be in uential in the choice of treatment; where a strong belief in causation through psychological factors exists, it may be more likely that a treatment which takes these factors into consideration will be sought. Recent research within the self-regulatory framework has focused on the development and utilization of the Illness Perception Questionnaire (IPQ; Moss-Morris et al., 1996; Weinman et al., 1996). The IPQ examines the dimensions of illness cognitions with the supposition that an individual will have perceptions concerning the identity, time-line, cause, consequences and controllability of the conditions. The identity of illness is related to the label or diagnosis given to it and the symptoms associated with it. It has been demonstrated that patients with stronger illness identity are more likely to perceive their illness as lasting longer and thus having more serious consequences. Those with higher time-line scores may be less likely to perceive that their condition is potentially controllable or curable and thus have more severe personal consequences as de ned by the impact on the social and psychological functioning of that individual (Weinman et al., 1996). Previous research with the IPQ has focused on patients within the allopathic domain with conditions such as chronic fatigue syndrome (CFS; Moss-Morris et al., 1996), diabetes, rheumatoid arthritis and chronic idiopathic pain (Weinman et al., 1996). As the IPQ to date has only been applied as a measure of illness perceptions to those patients receiving allopathic treatment it may prove useful to apply the tool within the domain of complementary medicine, particularly in view of the fact that alternative treatments are growing as treatment options (British Medical Association, 1993; Furnham & Kirkcaldy, 1996; Sharma, 1992). Therefore the present study is unique in attempting to apply the IPQ within the domain of complementary treatment. Thus, comparisons can then be made with the results obtained by Moss-Morris et al. (1996) and Weinman et al. (1996). As the IPQ was developed with patients suffering with chronic conditions it may be

ILLNESS REPRESENTATIONS AND HOMOEOPATHIC TREATMENT

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conceivable that its use as a research tool with those seeking homoeopathic treatment is a feasible application. Research with the SRM has paid little attention to patients’ beliefs about treatment (Horne, 1997) however, patients new to this form of ‘holistic’ treatment may experience illness cognitions that are pertinent to homoepathy with regard to the perceived ef cacy and appropriateness of this treatment for their particular condition. It may then be tentatively suggested that the SRM framework will be useful in attempting to delineate the extent that these cognition are associated with the level of adherence behaviour in patients receiving homoeopathic treatment. The present study, therefore, has two principal aims. The rst of these is to investigate the cognitive representations of illness of patients presenting to homoeopathic practitioners for treatment with the employment of the IPQ. The reliability of the components of this tool may then be assessed within the domain of homoeopathic medicine. In addition, the study will examine the relationship these illness perceptions have with the patients’ understanding of the treatment and recovery beliefs and to determine the extent of their adherence to the advised course of treatment. In particular, the predictive utility of the IPQ will be determined with reference to the ndings of previous research of those seeking complementary treatment conducted by Furnham and Smith (1988). Furnham and Forey (1994). Furnham and Kirkcaldy (1996) and Vincent and Furnham (1994; 1996).

Method The practitioners The register of the Society of Homoeopaths (1997) and the Yellow Pages were used to contact homoeopaths practising in the Bristol, Bath and Birmingham districts of the UK. A total of 22 private practitioners were approached, with eight female and two male private homoeopathic practitioners consenting to undertake the study having read the research proposal. However, there were three practitioners who failed to recruit any clients to the study, resulting in a practitioner response rate of 32%. Each practitioner was given questionnaires and asked to distribute them to all new clients over a ve-month period. This would have given a total potential response of 80 participants; however, 30 completed questionnaires were obtained (38% response rate).

Participants Thirty new adult patients presenting to the participating homoeopaths consented to take part as requested by their practitioner; the demographic details and characteristics of this group are reported in the results section.

Design This study was a prospective self-report questionnaire survey undertaken in two parts. The independent variables (IV) were the ve sub-scales of the illness perception questionnaire (IPQ; identity, time-line, consequences, cause and control/cure). In addition, age, education, marital status and previous homeoepathic treatment were included in the analysis as predictor variables. The dependent variables (DV) were the items contributing to the follow-up questionnaire developed to measure understanding of and adherence to treatment.

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Measures Demographic details. The rst part of the initial questionnaire measured age, gender, occupation, educational attainment and whether or not patients had tried homoeopathic treatments prior to the present consultation. All these variables with the exception of gender were used as predictors in the analysis of the data. Patients were also required to state the nature of their condition (or allopathic diagnosis if applicable). Illness perception questionnaire. The IPQ is a method for assessing cognitive representations of illness (Weinman et al., 1996). It consists of ve components that have been found to underly the perception of illness. The ve scales assess identity—the symptoms the patient associates with their condition; cause—personal beliefs concerning the aetiology of their condition; time-line—the perceived duration of their condition; consequences—expected effects and outcome; and control/cure—beliefs concerning control of or recovery from the condition. The identity component consisted of a list of 12 core symptoms that the patient/client was asked to rate on a four-point scale ranging from ‘all of the time’ (4) to ‘never’ (1) according to how often each symptom is experienced as a consequence of their current condition. All scores above ‘are summed, the total score being indicative of the severity of the condition. The time-line, consequences and control/cure scales are also rated on Likert scales ranging from ‘strongly disagree’ to ‘strongly agree’ (scored 1–5, respectively). The time-line scale consists of three items, consequences has seven items and control/cure has six items. After reverse scoring the appropriate items, nal scores are obtained by summing the scores for each of the scale items and then dividing by the number of items. For example, higher scores for time-line are indicative of stronger perceptions that the illness will be long lasting. The internal reliability (Chronbach’s alpha) of these scales has been demonstrated with two distinct cohorts: patients with chronic fatigue syndrome and myocardial infarction (MI; Weinman et al., 1996). The reliability alpha coef cients for the time-line, consequences and control/cure sub-scales are 0.58, 0.73 and 0.63; and 0.82, 0.69 and 0.73, respectively. The cause component consists of ten independent items relating to the perceived causation of the patient’s condition. These items are scored in the same way as the other sub-scales, with the patient indicating on a scale of 1–5 the extent to which they are in agreement with the statement. It is not appropriate to sum all of these items as each represents a speci c causal belief. However, Weinman et al. (1996) suggest that it may be useful to combine items according to research needs. Follow-up questionnaire. The questionnaire was devised in consultation with the participating homoeopaths with the intention of covering aspects pertinent to homoeopathic treatment. All the participating practitioners were given the opportunity to read the questionnaire and their comments were incorporated into the item design. The questionnaire was divided into two parts; the rst, understanding of treatment, covered the patient’s condition and consisted of ve items. The questions were: (1) To what extent do you understand your practitioner’s explanation of your condition? (2) To what extent are you aware of the possible consequences of the condition? (3) To what extent do you feel your practitioner has given reassurance that there will be improvements in your condition? (4) To what extent do you believe in the philosophy underlying homeopathy (5) To what extent do you feel that there are effective homoeopathic treatments?


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The second section covered adherence to the practitioner’s advice and prescription of remedies (four items). The items were: (6) Have you been consistent in taking the prescribed remedies at the times speci ed by your practitioner? (7) To what extent have you adhered to any dietary restrictions speci ed by your practitioner? (8) Have you used any other medicines during the course of receiving homoeopathic treatment? (9) To what extent have you taken steps to reduce anxiety and stress in your daily life? All of the items were scored on a Likert scale of 1–10, where the respondent was required to indicate the extent to which they agree with each item. For example, a score of 1 would be indicative of low agreement or low belief, and a score of 10 would be indicative of high agreement or high belief. The exception to this was item 9, Have you used any other medicines during the course of receiving homoeopathic treatment? Thus a low score for this item would be indicative of high adherence as it indicates low usage of non-prescribed treatments.

Procedure All new clients presenting over a ve-month period (November 1997 to March 1988) to the homoeopathic practitioners were requested by the practitioner to complete the initial questionnaire booklet while they were waiting prior to the consultation. On completion, the respondent sealed the questionnaire booklet in the envelope provided and then handed it back to the practitioner. The Follow-up questionnaires were distributed to the respondents of the initial questionnaire at a subsequent appointment between four and six weeks later. As before, they were required to provide demographic details in order to match the ‘follow-up’ questionnaires to the data they had previously provided at their rst consultation. Again, envelopes were provided and the completed questionnaires were handed back to the practitioner for collection.

Results Sample characteristics The seven participating practitioners recruited 33 new patients, but three respondents were excluded as they did not complete the follow-up questionnaire, leaving a sample of n 5 30. The respondents were predominately female (n 5 26), which is consistent with previous studies of homoeopathic patients (Amor & Todd, 1989; Vincent & Furnham, 1996). The mean age was 39 years (SD 5 11.7, range 5 24–69 years). The majority of respondents were either married or co-habiting (66%, n 5 20). Fifty-three per cent were educated to degree level (n 5 18) and their occupations were largely ‘professional’, thus they were typical of those seeking complementary therapies (Sharma, 1992). Finally, 36% (n 5 11) respondents had presented to homoeopathic practitioners prior to responding in the present study. The patients presented with conditions which were largely ‘chronic’ rather than acute including skin complaints (psoriasis and eczema), rheumatoid arthritis, respiratory problems (asthma), those associated with menopause, and there was one case of ME. In addition, anxiety, depression, stress and ‘nervousness’ were commonly associated with their primary

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Table 1. Means and standard deviations for subscales of IPQ IPQ scales

Mean

SD

Identity Time-line Consequences Control/cure Cause 1. Virus 2. Diet 3. Pollution 4. Hereditary 5. Chance 6. Stress 7. Own behaviour 8. Other people 9. Poor past care 10. State of mind

13.7 3.12 3.37 3.76

7.5 0.97 0.94 0.64

2.37 2.80 2.37 2.30 2.27 3.50 2.67 2.17 2.17 2.97

1.22 1.13 1.07 1.12 1.14 1.07 1.12 1.09 1.09 1.43

complaint. All of these conditions are typically representative of patients seeking homoeopathic treatment and are consistent with the ndings of Vincent and Furnham (1996). Illness perception questionnaire The mean score was 13.7 (SD 5 7.54) for the perceived severity of illness of the group. As the respondents presented with a wide range of conditions it was deemed inappropriate to determine the reliability alpha of this sub-scale. However, the high standard deviation suggests that responses varied widely (range 5 4–32). The mean scores for the cause sub-scale are shown in Table 1. Weinman et al. (1996) suggest that these items may be grouped as external and internal factors; however, the employment of Chronbach’s (1951) alpha for internal reliability yielded weak correlation coef cients when this method was attempted. Both ‘internal’ and ‘external’ causal factors failed to exceed and alpha above 0.3. Thus it was decided, due to the range of mean responses, that these items were best treated as independent predictors. Scores for each of the items that combine to make the time-line, consequences and control/cure sub-scales of the IPQ were summed taking account of reverse scored items and then divided by the number of items in each scale. These scores were then summed to determine a mean score for each sub-scale. Also, the internal reliability of these sub-scales was determined by employing Chronbach’s alpha. The coef cients can be seen in Table 2, where comparisons are made with the results of Weinman et al. (1996). It can be seen from table that the homoeopathic cohort show high comparative internal consistency for these sub-scales, particularly when compared with the CFS. cohort. Loewenthal (1996) has suggested that scales which do not exceed ten items can be deemed to be reliable if correlation coef cients are above 0.60. Follow-up questionnaire The raw scores for each of the items contributing to the two sections of the follow-up


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Table 2. Components of the IPQ; internal reliability scores (Chronbach’s alpha) for homoeopathic (Hom), Chronic fatigue syndrome (CFS) and myocardial infarction (MI) cohorts IPQ sub-scale

Hom

CFS

MI

Time-line Consequences Control/cure

0.89 0.78 0.64 n 5 30

0.58 0.63 0.69 n 5 115

0.73 0.82 0.73 n 5 91

Table 3. Means and standard deviations for items on the follow-up questionnaire (n 5 30) Item Section 1 To what extent do you feel … 1. you understand your practitioners explanation of your condition? 2. aware of the possible consequences of your illness? 3. your practitioner has given reassurances that there will be improvements in your condition? 4. you understand the rationale/philosophy underlying homoeopathy? 5. there are effective homoeopathic treatments? Section 2 6. Have you been consistent in taking the prescribed remedies at the time speci ed by your practitioner? 7. To what extent have you adhered to any dietary restrictions speci ed by your practitioner? 8. Have you used any other medicines during the course of receiving homoeopathic treatment? 9. To what extent have you taken steps to reduce anxiety and stress in your daily life?

Mean

SD

7.07 7.27 7.97 8.07 9.00

2.91 2.29 2.19 1.80 1.41

9.03

1.85

2.70

4.22

2.80 5.43

3.18 2.8

questionnaire were summed. The mean scores and standard deviations can be examined in Table 3. Stepwise regression analysis To determine the strength of associations between the independent and dependent variables, stepwise linear regression analysis was employed. The sub-scales of the IPQ (identity, time-line, consequences, control/cure and causes, 1–10) and demographic information: age, education, marital status and treatment were entered as the independent variables. Gender was not entered as the sample was heavily weighted in favour of female respondents. The independent variables were entered in the regression equation if the F ratios for their inclusion were signi cant at and below the 5% level. Each of the items on the follow-up questionnaire were treated as dependent variables in their own right; thus, a separate analysis was conducted for the nine items within the two sections. The regression analysis tables (Tables 4 and 5) display the nal gures for the equations for each of the follow-up items as predicted by the IPQ sub-scales and demographic variables. The beta weights and percentage of explained variance are shown for the associated predictors at each step of the equation for the items of the follow-up questionnaire. At the base of

F 5 9.74*** 5.52

48 43

36

0.56***

0.32*

24

0.48***

2

12

0.32**

2

42

%

0.27*

1

2

b

2

2

F 5 9.55*** 5.52

0.63***

39 42

34

0.40***

47

%

27 44

2

0.27* 0.48**

0.27*

b

3

16

%

15 F 5 11.4** 1.56

0.41**

b

2

2

4

F5

18

42

48

36

27

%

43 9.60*** 5.52

0.34*

0.33**

0.26*

0.22*

0.26*

b

2

5

F 5 8.76** 2.55

0.31*

0.35**

b

21

24

14

%

Note. DVs 5 1. practitioner’s explanation; 2. awareness of consequences; 3. practitioner’s reassurance; 4. understanding of rationale; 5. ef cacy of homoeopathy. b 5 beta weight. % 5 percentage of explained variance (per step). *p , 0.05; **p , 0.01; ***p , 0.001; n 5 30.

IV Marital status Identity Time-line Consequences Control/cure Cause 1. Virus 2. Diet 3. Pollution 4. Hereditary 5. Chance 6. Stress 7. Own behaviour 8. Other people 9. Poor past care 10. State of mind Adj R squared F df

DV

Table 4. Stepwise linear regression analysis—IPQ sub-scales (predictors) on understanding of treatment (items 1–5) (demographic variables not entered in equation except marital; n 5 30)

186 A. SEARLE & S. MURPHY


187

Table 5. Stepwise linear regression analysis—IPQ sub-scales (predictors) on adherence to treatment (items 6–9) 6 b

DV IV Marital status Identity Time-line Consequences Control/cure Cause 1. Virus 2. Diet 3. Pollution 4. Hereditary 5. Chance 6. Stress 7. Own behaviour 8. Other people 9. Poor past care 10. State of mind Adj R squared F df

7 %

b

8 b

%

9 b

%

2

2

0.42**

0.43**

10.5

0.27*

43

0.31*

19

0.25*

49

0.64*** 0.27*

31 38

26 15 2 2

31

0.29*

27 F 5 8.31*** 3.54

0.43**

14

0.27*

0.25*

%

7 12

F 5 4.97* 2.55

F5

45 12.8*** 4.53

F5

16 6.45*** 2.55

Note. Key to DVs 5 6. adherence to remedies; 7. dietary restrictions; 8. other medicines; 9. reducing stress. b 5 beta weight. % 5 percentage of explained variance. * p , 0.05; **p , 0.01; ***p , 0.001; n 5 30.

the tables, the adjusted percentage of variance (adj R squared), F ratio and the level of statistical signi cance are shown collectively for each regression equation. Relevant con dence intervals (95% level) for regression results can be found in the text. The adjusted variance was utilized as this provides a more conservative estimate that takes into account the number of cases and independent variables involved (Bryman & Cramer, 1997). Understanding. Regression results for items measuring understanding of treatment show a similar amount of variance accounted for in relation to client understanding of practitioner’s explanations of their condition (43%), understanding the rationale/philosophy underlying homoeopathy (43%) and an awareness of the possible consequences of the illness (42%). These were followed, some way behind, by a belief in the ef cacy of homoeopathic treatment (21%) and feeling the practitioner had given reassurance that there will be improvements in their condition (15%). Turning rst to an understanding of practitioners’ explanations, Table 4 shows that four items measuring perceived causation and perceived control of their condition appeared as predictors. Greater understanding was associated with a belief in stress (0.56, CI 5 2.77–4.23) and heredity (0.48, CI 5 1.78–2.82) as causes of ill health and lack of belief in both viruses ( 2 0.32, CI 5 1.88–2.86) and state of mind ( 2 0.32, CI 5 2.42–3.52) as causes. A lack of control over their condition ( 2 0.27, CI 5 2.69–4.65) was associated with greater understanding. For an understanding of the rationale/philosophy underlying homoeopathy three items representing causation beliefs, perceptions of control and identity appeared as predictors. Table 4 shows that a lack of control over their condition ( 2 0.22, CI 5 3.1–4.42) and a lack of belief in viruses as a cause of ill health ( 2 0.26, CI 5 2.04–2.7) again appeared as

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predictors. In addition, greater understanding was associated with a belief in poor past care (0.34, CI 5 1.78–2.56) and pollution (0.33, CI 5 2–2.74) as causes of ill health and higher levels of perceived severity of their condition (0.26, CI 5 13.7–14.17). Awareness of the consequences of their illness was predicted by ve items relating to causation. Greater awareness was associated with a belief in stress (0.48, CI 5 2.89–4.11), other people (0.40, CI 5 1.74–2.6) and chance (0.27, CI 5 1.76–2.58) and a lack of belief in state of mind ( 2 0.63, Cl, 5 2.5–3.44) and diet ( 2 0.27, CI 5 2.37–3.23) as causes of illness. A belief in the ef cacy of homoeopathic treatment, on the other hand, was predicted by one causation belief and the perceived consequences of their condition, with greater perceptions of ef cacy associated with a lack of belief in viruses as causative agents ( 2 0.31, CI 5 2.1– 2.64) and more severe consequences associated with their condition (0.35, CI 5 3.02–3.72). Finally, feeling the practitioner had given reassurance that there will be improvements in their condition was only predicted by longer perceived duration of illness (0.41, CI 5 2.59–3.65). Adherence. Regression results for items representing adherence show the greatest amount of variance was accounted for in relation to non-adherence (45%), followed by adherence to prescribed remedies (27%), attempts to reduce anxiety and stress (16%) and then adherence to dietary restrictions (12%). Turning rst to non-adherence, Table 5 shows that three items relating to the perceived causation of illness and consequences appeared as predictors. In order of importance these were, a low belief in one’s own behaviour ( 2 0.64, CI 5 2.1–3.24) and other people ( 2 0.27, CI 5 1.6–2.74) as causes of illness, but a higher belief in chance (0.25, CI 5 1.7–2.84). In addition, non-adherence was predicted by greater perceived consequences of illness (0.25, CI 5 2.70–4.04). Adherence to prescribed remedies was predicted by two items relating to perceived causation and by perceived identity. Table 5 shows that greater adherence was predicted by a low belief in pollution ( 2 0.43, CI 5 1.96–2.78) but a higher belief in poor past care (0.25, CI 5 1.76–2.58) as causes of illness. Greater symptom severity (0.42, CI 5 13.7–14.3) was also associated with improved adherence to remedies. Adherence to dietary recommendations was predicted by two items measuring perceived causation. Like adherence to remedies, a belief in the in uence of poor past care appeared as a predictor (0.29, CI 5 1.23–3.11), as did a belief in chance (0.27, CI 5 1.39–3.15); which, as noted above appeared as a predictor of non-adherence. Finally, reducing anxiety and stress was predicted by only one IPQ item, with those perceiving their illness to have longer duration (0.31, CI 5 2.39–3.12) taking greater steps. Interestingly, reducing anxiety and stress was the only measure of adherence to be in uenced by demographic factors, with those who were not married exhibiting more success ( 2 0.43, CI 5 0.78–2.12). Discussion The present study is based within the framework of the self-regulatory model of illness behaviour (SRM), which to date has focused its attention in the domain of orthodox (allopathic) medicine. The principal aims were twofold: to investigate the reliability of the components contributing to the IPQ in a population receiving homoeopathic treatment for a range of ‘chronic’ conditions and to determine the predictive utility of the IPQ in relation to an understanding of and adherence to homoeoepathic treatment. There are limitations regarding the extent to which the present results can be generalized to the wider domain of homoeopathy. Of particular concern is the ‘self-selected’ sample: although the demographic characteristics of the sample closely resemble those of previous


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studies with patients seeking complementary treatments (Vincent & Furnham, 1996). The relatively low response rate of 38% for participating clients may be partly accounted for by the prospective design of the study that required patients to complete questionnaires on two occasions. Also, practitioners may have been concerned that valuable consultation time would be lost through this administration procedure. However, the strength of this design is in the sanctioning of 4–6 weeks for the follow-up; it allowed more scope for the respondents to appraise their experiences and beliefs concerning homoeopathic treatment in addition to any amelioration of symptoms experienced. Given these reservations, the IPQ has provided comparative internal reliability scores for the time-line, consequences and control/cure sub-scales with the alpha coef cients reported by Weinman et al. (1996) and Moss-Morris et al. (1996). The present study’s sample size is relatively small in comparison to the aforementioned previous work and the results may have been in uenced by the response rate. However, the present results suggest that it may be acceptable to use the IPQ within the domain of homoeopathy. The mean scores for each of the sub-scales may be described as being ‘mid-ranged’; however, this may be explained by the diversity of conditions that the respondents presented with. Although patients tended to present with ‘chronic’ rather than acute conditions, they could not be described as being particularly life threatening. It should be noted that it was not appropriate to include the Identity sub-scale in this analysis as the homoeopathic cohort were presenting with a range of conditions and the list of 12 symptoms contributing to the identity sub-scale may not have been general enough to cover the range of respondents’ conditions. Stepwise linear regression analysis showed that IPQ components were most predictive of non-adherence to homeopathic treatment, followed by some aspects of understanding, namely practitioner explanations, the underlying philosophy of treatment and the consequences of their condition. IPQ measures were less successful in predicting adherence and measures of understanding covering perceived reassurance from practitioners and beliefs in the ef cacy of treatment. Causation beliefs consistently appeared as the best predictors of measures of both understanding and adherence. Understanding of practitioner explanations and the consequences of illness, as well as adherence to dietary recomendations, were predicted exclusively by them, and the appeared as the majority of predictors for non-adherence, an understanding of the underlying philosophy of treatment and adherence to remedies. Examining causation beliefs in more detail shows that a number of items, whilst predicting measures of understanding, failed to predict adherence behaviour. A low belief in viruses not only predicted greater understanding of explanations, but greater beliefs in both the philosophy and ef cacy of treatment. This re ects lay perceptions of homoeopathy which perceive it as less successful in treating disease believed to be caused by such external agents (Vincent and Furnham, 1994) and suggests that those seeking such treatment are responsive to its’ philosophy, if not adherence. Interestingly a lack of belief in the mind was associated with greater understanding of both the philosophy of treatment and practitioner explanation. Conversely, a higher belief in stress as a cause of illness predicted greater understanding of both the consequences of their condition and practitioner explanations. Previously, Furnham and Kirkcaldy (1996) have shown that users of complementary therapies have a stronger belief in psychological and mental factors having a fundamental causal role in disease onset than those being treated by GPs. The present results suggest that these factors, although ‘psychological’ in nature, must be regarded as distinct perceptions. For items predicting both understanding and adherence, poor past care was associated with a greater belief in the philosophy of treatment as well as adherence to both remedies and

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diet. This supports Vincent and Furnham’s (1996) observation that those seeking homoeopathic treatment are strongly in uenced by the ineffectiveness of allopathic medicine for their particular condition and that the standard of care was inadequate. Similarly, Furnham and Smith (1988) suggested that rather than having a true conviction for the rationale of homoepathy, frustration and dissatisfaction with conventional medicine is the initial impetus for trying homoeopathy. Those who saw illness in uenced by chance seem to make a variety of responses to treatment. A greater belief in chance, whilst predicting more understanding of illness consequences, was associated with both adherence to dietary recommendations and also non-adherence to the remedies. Unsurprisingly, a low belief in ones’ own behaviour as a causative factor was predictive of non-adherence, highlightin g the need for practitioners to identify and challenge such beliefs to improve adherence. Turning to other IPQ components shows that those with more severe perceptions of their illness may be making a greater investment in improving their state of health by adhering more closely to taking the remedies and seeking to understand the underlying principles. Greater perceptions of severity were associated with not only more understanding of the philosophy of the treatment and a greater belief in its ef cacy, but with higher levels of adherence to prescribed remedies. Similarly, perceptions of a longer duration of illness predicted not only higher levels of perceived reassurance from practitioners, but greater adherence to reducing anxiety and stress. Interestingly, marital status, the only demographic variable which appeared as a predictor, was negatively associated with adherence to stress reduction. This may suggest a lack of spouse support which has been shown to positively in uence recovery from illness and levels of adherence (Doherty et al., 1983; Ley, 1988) and the need to include the development of such support within treatment programmes. Opposed to this, those with greater perceived consequences of their illness, rather than adhering to treatment, were more likely to be non-adherers. This suggests such respondents may have adopted a more universal approach to their treatment, with perceived bene t to be gained from other treatments in addition to the homoeopathic remedies. To an extent this is consistent with SRM theory. Indeed, Leventhal et al. (1992) postulate that treatment is a dynamic process and that the patient is an ‘active problem solver’, with their own ideas about treatment. Finally, it would appear that within the domain of homoeopathy, the IPQ has been shown to have good internal reliability when used as a measure of the illness representations of those seeking homoeopathic treatment. However, in the present context it was not appropriate to include the identity sub-scale due to the range of conditions the patients presented with; future studies should endeavour to include this.

Acknowledgements The authors would like to thank all the homoeopathic practitioners and their clients who kindly participated in this research.

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