INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the tect directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type o f computer printer. The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. Each original is also photographed in one exposure and is included in reduced form at the back o f the book. Photographs included in the original manuscript have been reproduced xerographically in this copy. Higher quality 6” x 9” black and white photographic prints are available for any photographs or illustrations appearing in this copy for an additional charge. Contact UMI directly to order. UMI A Bell & Howell Information Company 300 North Zeeb Road, Ann Arbor MI 48106-1346 USA 313/761-4700 800/521-0600 ENHANCING ADHERENCE TO ANTIBIOTIC REGIMENS: A TEST OF PROTECTION MOTIVATION THEORY AND PERSUASIVE COMMUNICATIONS DISSERTATION Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University By Candace Louise Haugtvedt, M.S. ***** The Ohio State University 1998 Dissertation Advisory Committee: Approved by Suzan N. Kucukarslan, Ph.D., Adviser Catherine A. Heaney, Ph.D. Dev S. Pathak, D.B.A. Adviser Jon C. Schommer, Ph.D. Pharmacy Graduate Program UMI Number: 9833997 Copyright 1998 by Haugtvedt, Candace Louise All rights reserved. UMI Microform 9833997 Copyright 1998, by UMI Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. UMI 300 North Zeeb Road Ann Arbor, MI 48103 ABSTRACT In an era of managed care, educating patients to promote adherence to medication regimens will prevent complications and their concomitant costs to individual patients as well as to society, estimated by Johnson and Bootman to be $76.6 billion per year in the ambulatory setting in the United States. Enhancing adherence to antibiotic regimens specifically, will reduce antibiotic resistance, a growing pubhc health problem. Based on protection motivation theory, a brochure was revised to enhance self-efficacy and response efficacy components of the model and compared to neutral brochure and no brochure conditions for adherence to an antibiotic regimen. 302 participants at a large university’s Student Health Center Pharmacy were recruited upon presentation of an amoxicillin prescription for a 10-day course of three times a day therapy. Patients were randomized into the 3 conditions, completed validated questiormaires and received oral counseling by the pharmacist. Data on illness symptoms, diagnosis, pill count, a knowledge test of antibiotic resistance and a self-report of the past 5 days’ of therapy were collected by telephone on days 5 and 10. This study also tested seven different models of protection motivation theory using covariance structure modeling. A model which included consideration of future consequences was found to fit the data better than the other models when using the RMSEA and NNFI fit indices to compare them. The coping appraisal variable self-efficacy was a significant and strongly positive predictor of protection motivation in all of the models, as was the threat appraisal variable of maladaptive response rewards a negative predictor of protection motivation. The level of fear arousal was found to moderate the relationship between self- efficacy and protection motivation. The level of consideration of future consequences was found to moderate the relationship between response efficacy, self-efficacy, response costs and protection motivation. Self-efficacy and maladaptive response rewards were found to be mediating variables, explaining the relationship between consideration of future consequences and protection motivation. Protection motivation was a significant predictor of adherence behavior in all seven covariance structure models tested. The intervention of the brochure designed to enhance self-efficacy and response efficacy with verbal reinforcement during the oral counseling session did not enhance medication adherence behavior over that of a control group not receiving the brochure. In addition, those patients who received the unrevised brochure did not adhere better to their medication regimen. There was not a statistically significant difference in the mean adherence among the three groups. There was a statistically significant difference between the groups on their knowledge of antibiotic resistance, with the groups receiving the brochures scoring significantly higher than the control group. The response efficacy scores were also significantly different between the groups, with the groups receiving the brochures scoring significantly higher than the control group. Self-efficacy scores were not statistically significant between the groups, however, and since self-efficacy was found to be the greatest predictor of protection motivation in the covariance structure models, this may explain why the brochures were not effective in enhancing medication adherence behavior. Future studies should focus on techniques to enhance patient’s self-efficacy using verbal persuasion, vicarious experience, performance accomplishments and physiological states cis suggested by Bandura. Maladaptive response rewards was also found m be a iii significant negative predictor of protection motivation. Participants in this study were all counseled by the pharmacist on how to best schedule the doses of the antibiotic in order to minimize disruption to their daily routine. This may explain why the levels of adherence were so high across all of the groups. Decreasing the levels of maladaptive response rewards increases the levels of protection motivation and antibiotic adherence behavior. Future studies could manipulate maladaptive response rewards experimentally in this manner to determine its effect on antibiotic adherence behavior. Based on the covariance structure modeling results, these techniques should prove promising to enhance protection motivation and antibiotic adherence. IV Dedicated To My Husband Curtis and Daughters & ica and Andrea ACKNOWLEEXj MENTS I would like to thank my adviser, Suzan Kucukarslan, for her encouragement over the years. She has spent many hours reading and revising this manuscript and helping to see it to its completion. I would also like to thank Catherine Heaney, who first sparked the idea for testing protection motivation theory in the area of medication adherence behavior when I took her Health Promotion and Disease Prevention class in the Fall of 1994. She has remained a constant mentor through this entire process and I am extremely grateful to her for her insightful comments at every stage of the development of this dissertation. I would also like to thank my other dissertation committee members, Dev Pathak and Jon Schommer for their helpful and constructive comments. In addition I would like to acknowledge the support and encouragement of my former advisers Linda MacKeigan and Steven Birdwell in my graduate education experience at the Ohio State University. I would like to especially thank Steve Prentice-Dunn and Ronald Rogers at the University of Alabama-Tuscaloosa for being the true academics that they are. They helped immensely in assuring that the study measures were truly measuring the protection motivation theory constructs that they were designed to measure. They also provided extremely helpful feedback during the proposal stages of this dissertation and encouraged me along the way to its completion. 1 would like to thank Kevin McCaul at North Dakota State University for helping immensely in the design of the measures used to measure fear arousal in this study and for providing extremely helpful feedback at the proposal stage of this dissertation. He is a true scholar in the field of health psychology and 1 am very grateful to him for his help on this dissertation. 1 would like to thank Alan Strathman at the vi University of Missouri-Colnmbia for his helpfulness, especially for the development of the consideration of future consequences scale with his colleagues and for providing extremely helpful comments at the proposal stage of this dissertation. I also am very grateful to Duane Wegener at Purdue University for his helpful comments, especially regarding the covariance structure modeling. He also provided very constructive feedback on the dissertation along with much needed encouragemenL Thanks also to Michael Browne and Robert MacCallum in the Quantitative Psychology Department at OSU for allowing me to take their classes on factor analysis and covariance structure modeling and for troubleshooting when 1 had problems running the models using the RAMONA software program. I would also like to thank all of the people who helped me in the data collection process, especially the staff of the OSU Student