of Health (2008) report notes that adherence among people with LTIs is poor and
that people with LTIs want more health care services delivered in the community and
in their homes. The report also notes that providing people with greater control over
the services they use is likely to increase adherence, self-efficacy and quality of life.
Cognition and coping is critical to adaptation to LTI. For example, Scharloo et al.
(2000) found that the five categories of beliefs about symptoms identified by Leventhal
and colleagues (as discussed above) predicted coping and adaptation in COPD patients,
emphasizing the importance of cognitive care and intervention for these patients.
Qualitative methods can reveal the details of patients’ of illness-related thoughts,
including the burden that LTIs place on people’s self-image. For example, Dovey-
Pearce, Doherty and May (2007) show how diabetes can affect young people’s self-
concept, highlighting the desire to be ‘normal’, the additional adult responsibilities that
diabetes places on young people and the importance of peer support. Similarly, Smith
and Osborne (2007) illustrated the crushing effect that chronic pain can have on self-
concept. Interviewees described how their pain led to social behaviour that they were
ashamed of and wanted to distance themselves from their public persona. They
expressed nostalgia for a past, pain-free self and were anxious about the self that others
attributed to them as a result of their pain-directed behaviour. Patients with LTIs may
also find engagement with traditional health services, which focus on diagnosis and
treatment, challenging and alienating. For example, in a qualitative study of stories
written by women with chronic pelvic pain, McGowan et al.(2007) found that women
found consultations unsatisfactory especially when medical tests failed to validate their
experience of pain. The failure to find a physiological explanation left women feeling
powerless and devalued and concerned that they were not believed and perceived to
be neurotic or depressed by health care professionals. In some cases this led to
complete disengagement from health care services, despite ongoing pain.
Behaviour change interventions in long-term illnesses
Behaviour change interventions have much to offer people with LTIs. For example,
in a systematic review, Glazier et al. (2006) found that 11 of 17 interventions improved
diabetes care with intervention being associated with delivery by community educators
or lay people, one-to-one interaction with individualized assessment, a focus on
behaviour change, provision of feedback, use of 10 or more sessions and a duration
of 6 months or more. While such interventions are expensive they are likely to be
cost-effective because they could reduce visits to general practitioners by a quarter and
hospitalization by a half among those with LTIs, while also enhancing participants’
QoL (Department of Health, 2008). Note too that behaviour change interventions
can prevent some LTIs. For example, Knowler et al.(2002) found that a lifestyle change
programme including weekly exercise targets was more effective than medication in
preventing diabetes onset over a 3-year period.
We noted above that clinical evidence of recovery may not always be the most
important outcome measure, for example, in relation to interventions designed to
increase adherence or patient involvement in consultations. In a classic paper, Kaplan
(1990) argued that mortality and quality of life are always the most important outcome
measures in health care and, certainly, quality of life improvement is a key measure
of success in helping people with LTIs. There are a variety of quality of life and health-
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