Patient compliance and satisfaction with physicianinfluence attempts: A reinforcement expectancy

approach to compliance-gaining over time.

Item Type text; Dissertation-Reproduction (electronic)

Authors Klingle, Renee Storm

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Patient compliance and satisfaction with physician influence attempts: A reinforcement expectancy approach to compliance-gaining over time

Klingle, Renee Storm, Ph.D.

The University of Arizona, 1994

U·M·I 300 N. Zeeb Rd. Ann Arbor, MI48106

Patient Compliance and Satisfaction with Physician Influence Attempts:

A Reinforcement Expectancy Approach to Compliance-gaining Over Time

by

Renee Storm Klingle

A Dissertation Submitted to the Faculty of the

DEPARTMENT OF COMMUNICATION

In Partial Fulfillment of the Requirements For the Degree of

DOCTOR OF PHILOSOPHY

In the Graduate College

THE UNIVERSITY OF ARIZONA

1994

THE UNIVERSITY OF ARIZONA GRADUATE COLLEGE

2

As members of the Final Examination Committee, we certify that we have

read the dissertation prepared by Renee Storm Klingle

entitled Patient Compliance and Satisfaction with Physician Influence

Attempts: A Reinforcement Expectancy Approach to Compliance-

gaining OVer Time

and recommend that it be accepted as fulfilling the dissertation

requirement for the Degree of Doctor of Philosophy

a~-= .. ~.

&A<I&l Date' P

h-l),o/u Date

Date' 7

1)00/93 Date I I

/2/:zc:0?2 Date7

Final approval and acceptance of this dissertation is contingent upon the candidate's submission of the final copy of the dissertation to the Graduate College.

I hereby certify that I have read this dissertation prepared under my direction and recommend that it be accepted as fulfilling the dissertation

re~t/~

D~47===- (.~(/b

3

STATEMENT BY AUTHOR

This dissertation has been submitted in partial fulfillment of requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library.

Brief quotations from this dissertation are allowable without special permission, provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproductions of this manuscript in whole or in part may be granted by the head of the major department or the Dean of the Graduate College when in his or her judgement the proposed use of the material is in the interests of scholarship. In all other instances, however, permission must be obtained from the author.

SIGNED: Ciif ~

ACKNOWLEDGEMENTS

It is a pleasure to finally acknowledge those who have allowed me to reach the completion of my degree.

4

Michael Burgoon's hands-off approach to advising has allowed me to grow tremendously as a scholar and has facilitated my abilities to work indepenrlently. His willingness to listen rather than quickly offer advice enriched my capabilities to think clearly and carefully critique my own work. Judee Burgoon's insights and careful attention to the details in this project forced me to clarify my thinking. Judee's Willingness to assist me as I pursued my degree have always gone well beyond the call of duty for a graduate director, professor, and committee member. I am eternally grateful for her willingness to loan her personal computer for more than a years worth of data collection. David Buller has always humbled me and kept me on my toes with his questions that wind down paths I never expected to travel. His willingness to assist me with statistical questions during the summer was greatly appreciated. Lawrence Aleamoni and Darrell Sabers from Educational Psychology, always seemed to bring me back to the basics with unexpected questions. Their support and kindness throughout the project were very refreshing.

I was fortunate enough to be blessed with two guardian angels during the course of this project. John Hall not only assisted me in all the technical aspects of the dissertation but was always there with a few words of support and assistance when needed. Chris Arslanian made it possible for Alice to get out of Wonderland. I'm afraid I would still be collecting data today if it had not been for her assistance and uplifting personality.

Of course the data collection process would have never even gotten off the ground if it were not for Leslie Boyer's help in developing the scripts and Denise Ahearn's and Frank Hunsaker's willingness to enact the scripts. I am also greatly indebted to the physicians, hospitals, and clinics who allowed me to setup shop for indefinite periods of time: Dr. Kligman and his staff at Family and Community Medicine at the University Medical Center, Dr. Parker and his staff at his private practice clinic, Donna Brewer, Joyce Norman, Laurel Rokowski, and the volunteers at Tucson Medical Center.

Several fellow graduate students, undergraduates, and faculty members in the Department of Communication at the University of Arizona provided assistance with the data collection process as well as emotional support throughout this project. A special thanks to Barb Walkosz, Cindy White, and Kristyn McDermot who went to great lengths to direct the undergraduates during data collection. After collecting over 700 subjects on my own, I understand the frustrations and amusements each of the undergraduates must have encountered. I thank all of you for enduring despite it all. A few students enabled me to keep my sanity through their encouraging words and concern: Mark Adkins, Sarge, Lesa Stern, and Walid Afifi. Dr. Sally Jackson also provided friendly support as well as statistical guidance during several stages of this project.

I would also like to thank a few friends, colleagues, and students in the Department of Speech at the University of Hawaii who provided an invaluable support system as well as a sounding board for my never ending complaints: Miller, Min-Sun, Raja, Basil, Krystyna, Kelly, Geoff, Levine, Rodney, Bill, Ron, Gail, Jodi, Maria, Sarah, and all the others who constantly inquired into the progress of my dissertation.

Finally, I want to thank Cal Morrill who was there for me even when I looked for signatures in the strangest places or when I became concerned that I would lose my "insanity."

DEDICATION

To the people who believed in me and believed in my ideas -­

even during the moments in life when I was unable to.

To my parents ...

Who have always believed that it was impossible for me to fail.

To Cal...

For stimulating me intellectually and for teaching me the value of good ideas. For making

me smile when I wanted to cry and for allowing me to cry when I couldn't seem to smile.

Your unconditional support and encouragement made it possible for me to succeed and

persevere. Without you, I'm afraid my parents' belief would have been falsified.

No one could have been a better teacher or a truer friend.

5

TABLE OF CONTENTS

LIST OF TABLES 11

LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 14

ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 15

I. RATIONALE AND RESEARCH HYPOTHESES ................. 16

Predictors of Patient Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19

Patient Knowledge and Long-term Compliance . . . . . . . . . . .. " 19

Physician Intercession and Patient Compliance . . . . . . . . . . . . .. 22

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 28

Conceptualization of Influence Behaviors . . . . . . . . . . . . . . . . . . . . . .. 29

Conceptualization of Verbal Compliance-Gaining Strategies . . . . .. 30

Conceptualization of Nonverbal Strategies. . . . . . . . . . . . . . . .. 33

Physician Regard Strategies as Reinforcement Stimuli . . . . . . . . .. 35

Regard strategies as conceptually recognizable . . . . . . . . . . 35

Regard strategies as universal reinforcers . . . . . . . . . . . . . 36

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 38

Factors Affecting Strategy Evaluation . . . . . . . . . . . . . . . . . . . . . . . .. 39

Patient Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 40

Expectations as a Function of Communicator Characteristics . . . . . . 40

Evaluations of Unexpected Communication: Violations of Communication Expectations . . . . . . . . . . . . . . . . . . . . . . . .. 44

Expectations as a Function of Situational Perceptions . . . . . . . . .. 48

Expectations and Assimilation Effects . . . . . . . . . . . . . . . . . . .. 51

Expectations as a Function of Prior Communication Exchanges . . .. 53

6

7

TABLE OF CONTENTS--Continued

Communication Reinforcement and Motivation . . . . . . . . . . . . . . . . . .. 56

Reinforcement Expectations . . . . . . . . . . . . . . . . . . . . . . . . .. 57

Violations of Reinforcement Expectations . . . . . . . . . . . . . . . .. 59

Frustration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 60

Net incentive value . . . . . . . . . . . . . . . . . . . . . . . . .. 61

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 62

Consequences of Strategy Usage . . . . . . . . . . . . . . . . . . . . . . . . . . .. 63

Consequences of Initial Strategy Usage . . . . . . . . . . . . . . . . . .. 64

Patient satisfaction and physician perceptions in initial encounters . . . . . . . . . . . . . . . . . . . . . . . . .. 64

Physician persuasiveness in initial encounters . . . . . . . . .. 67

Consequences of Strategy Combinations . . . . . . . . . . . . . . . . .. 68

Patient satisfaction and physician perceptions with ongoing influence attempts . . . . . . . . . . . . . . . . . . . 68

Physician persuasiveness and ongoing influence attempts . .. 70

Consequences of Future Strategy Combinations . . . . . . . . . . . . .. 72

Patient satisfaction and physician perceptions with future strategy usage . . . . . . . . . . . . . . . . . . . . .. 72

Physician persuasiveness and future strategy usage . . . . . .. 74

II. METHOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 75

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 75

Participants .............. '. . . . . . . . . . . . . . . . . . . . . . . . . .. 76

Study 1: Consequences of Initial Strategy Usage. . . . . . . . . . . . . . . . . . 78

Design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 78

TABLE OF CONTENTS--Continued

Stimuli and Manipulation of Independent Variables . . . . . . . . . .. 79

Script development . . . . . . . . . . . . . . . . . . . . . . . . .. 79

Manipulation of regard strategy . . . . . . . . . . . . . . . . .. 81

Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 82

Video production of stimuli . . . . . . . . . . . . . . . . . . . .. 83

Administration and Procedures . . . . . . . . . . . . . . . . . . . . . . .. 83

Dependent Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 85

Physician persuasiveness and motivation to comply . . . . .. 86

Patient satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . .. 86

Physician perceptions . . . . . . . . . . . . . . . . . . . . . . . .. 86

Communication evaluation . . . . . . . . . . . . . . . . . . . . .. 87

Situational perceptions . . . . . . . . . . . . . . . . . . . . . . .. 88

Study 2: Con~equences of Strategy Combinations. . . . . . . . . . . . . . . .. 89

Design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 89

Manipulation of Independent Variables . . . . . . . . . . . . . . . . . .. 89

Manipulation of strategy combinations . . . . . . . . . . . . .. 90

Manipulation of final strategy type . . . . . . . . . . . . . . . .. 92

Administration and Procedures . . . . . . . . . . . . . . . . . . . . . . .. 92

Dependent Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 94

Overall persuasiveness . . . . . . . . . . . . . . . . . . . . . . .. 94

Overall patient satisfaction . . . . . . . . . . . . . . . . . . . . .. 95

Physician perceptions . . . . . . . . . . . . . . . . . . . . . . . .. 95

Communication evaluation . . . . . . . . . . . . . . . . . . . . .. 95

8

9

TABLE OF CONTENTS--Continued

Dependent measures for evaluation of future strategies .. " 96

Assessment of Source Characteristics . . . . . . . . . . . . . . . . . . . . . . . .. 96

III. RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 99

Manipulation Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 99

Source Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 99

Order Effects of Mixed Combinations in Study 2 . . . . . . . . . . . .. 101

Reinforcement Expectations . . . . . . . . . . . . . . . . . . . . . . . . .. 101

Study 1: Initial Strategy Usage. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 103

Communication Evaluation of Regard Strategies . . . . . . . . . . . .. 103

Reinforcing quality of regard strategies . . . . . . . . . . . . .. 104

Communication expectations .. .................. 106

Perceptions of relational concern . .. .............. 106

Appropriateness . . . . . . . . . . . . . . . . . . . . . . . . . . .. 106

Communication evaluation as a function of situational perceptions . . . . . . . . . . . . . . . . . . . . . . . .. 109

Consequences of Initial Strategy Usage. . . . . . . . . . . . . . . . . .. 115

Patient satisfaction .......................... , 115

Physician perceptions . . . . . . . . . . . . . . . . . . . . . . . . 118

Persuasiveness. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 121

Study 2: Consequences of Strategy Combinations .................. 124

Patient Satisfaction and Physician Perceptions. . . . . . . . . . . . . .. 125

Persuasiveness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 128

Consequences of Future Strategy Usage . . . . . . . . . . . . . . . . . . . . . .. 129

TABLE OF CONTENTS--Continued

Communication Evaluations as a Function of Previous Communication Usage. . . . . . . . . . . . . . . . . . . . . .. 129

Effects of Previous Communication Exposure on Patient Satisfaction, Physician Perceptions, and Physician Persuasiveness . . . . . . . . . . . . . . . . . . . . . . . . . . .. 135

IV. DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 142

Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 142

Communication Evaluation. . . . . . . . . . . . . . . . . . . . . . . . .. 143

Consequences of Influence Attempts in Initial Encounters. . . . . . . . 150

Consequences of Strategy Combinations . . . . . . . . . . . . . . . . .. 151

Significance and Limitations of Claims. . . . . . . . . . . . . . . . . . . . . . .. 156

Directions for Future Research. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 160

FOOTNOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 163

APPENDIX A: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 165

APPENDIX B: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 169

APPENDIX C: ............................................ 179

APPENDIX D: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 180

APPENDIX E: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 181

APPENDIX F: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 183

APPENDIX G: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 192

APPENDIX H: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 193

APPENDIX I: ................. : . . . . . . . . . . . . . . . . . . . . . . . . .. 199

APPENDIX J: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 205

REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 209

10

LIST OF TABLES

Table Page

1. Source Manipulation Check: Observed Means on the Source Characteristic Measures for Videotaped and Transcript Versions of the Male and Female Physician . . . . . . . . . . . . . . .. 100

2. Reinforcement Expectations Manipulation Check for Study 2: Observed Means and Standard Deviations for Pure Combinations and Mixed Combinations on Reinforcement Expectations . . . . . . . . . . . . . . . . . . . . . . . .. 102

3. Intercorrelations Among Dependent Variables in Study 1 . . . . . . . . . . . .. 103

4. HI: Univariates on Perceptions of Approval and Valence. . . . . . . . . . .. lOS

5. HI: Observed Means and Standard Deviations on Ratings of Approval and Valence for Regard Strategies . . . . . . . . . . . . . .. 105

6. H2, H3, and H4: Observed Means and Standard Deviations on Ratings of Communication Expectations, Perceptions of Relational Concern, and Communication Appropriateness . . . . . . . . . . . . .. 107

7. H2, H3, and H4: ANOVA for Physician Gender, Strategy, and Session on Communication Expectations, Perceptions of Relational Concern, and Appropriateness. . . . . . . . . . . . . . . . .. lOB

B. H5, RQI, and RQ2: Multiple Regressions of Situational Perceptions and Strategy Type on Communication Expectations and Perceptions of Appropriateness . . . . . . . . . . . . . . . . . . . .. 111

9. RQ3: Multiple Regressions of Situational Perceptions, Strategy Type, and Physician Gender on Communication Expectations and Perceptions of Appropriateness . . . . . . . . . . . . . . . . . . . .. 113

10. H7 and HB: Observed Means and Standard Deviations on Patient Satisfaction in Initial Encounters with a Physician for Physician Gender and Strategy. . . . . . . . . . . . .. 116

11. H7 and HB: ANOVA on Patient Satisfaction in Initial Encounters with a Physician for Physician Gender, Strategy Type, and Consultation Session . . . . . . . . . . . . . . . . . . . . . . . . . . .. 117

12. H9 and HlO: Observed Means on Physician Perceptions in Initial Encounters with a Physician for Physician Gender and Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 119

11

LIST OF T ABLES--continued

13. H9 and HlO: ANOVA on Physician Perceptions in Initial Encounters with a Physician for Physician Gender, Strategy Type, and Consultation Session. . . . . . . . . . . . . . . . . . . . . . . . . . .. 120

14. Hll: Anova on Physician Persuasiveness in Initial Encounters with a Physician for Physician Gender, Strategy Type, and Consultation Session. . . . . . . . . . . . . . . . . . . . . . . . . . .. 122

15. Hll: Observed Means on Physician Persuasiveness in Initial Encounters with a Physician for Physician Gender and Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 122

16. Intercorrelations Among Patient Satisfaction, Physician Perceptions, and Physician Persuasiveness following Strategy Combination in Study 2 . . . . . . . . . . . . . . . . . . . . . . . . . . .. 124

17. H12 and H13: Univariates on Patient Satisfaction and Physician Perception following Strategy Combination in Study 2 . . . . . . . . . . 126

18. H12, H13, and H14: Observed Means on the Patient Satisfaction, Physician Perceptions, and Physician Persuasiveness Measures for Strategy Combination and Gender .. . . . . . . . . . .. 127

19. H14: ANOVA on Physician Persuasiveness following Strategy Combination in Study 2 . . . . . . . . . . . . . . . . . . . . . .. 128

20. Intercorrelations Among Communication Evaluation Variables following Final Strategy in Study 2 . . . . . . . . . . . . . . . . . . . .. 130

21. H6: Observed Means and Standard Deviations of Communication Expectations for Previous Communication Exposure. . . . . . . . . .. 131

22. RQ4: Univariates on Communication Evaluations for Strategy Combination, Physician Gender, and Final Strategy. . . . . . . . . .. 133

23. RQ4: Observed Means and Standard Deviations on Communication Evaluations for Physician Gender, and Final Strategy. . . . . . . . .. 135

24. RQ7, RQ8, and RQ9: Univariates on Patient Satisfaction, Physician Perception, and Physician Persuasiveness for Communication Exposure, Physician Gender, and Final Strategy Type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 138

12

13

LIST OF T ABLES--continued

25. RQ7, RQ8, and RQ9: Observed Means and Standard Deviations on Patient Satisfaction, Physician Perceptions, and Physician Persuasiveness for Communication Exposure. . . . . . . .. 140

26. RQ7, RQ8, and RQ9: Observed Means and Standard Deviatioas on Patient Satisfaction, Physician Perceptions, and Physician Persuasiveness for Final Strategy Type . . . . . . . . . . . .. 141

14

LIST OF FIGURES

Figure Page

1. Strategy Combinations Created for Study 2 . . . . . . . . . . . . . . . . . . . .. 91

2. Interaction of Physician Gender and Strategy Type on Patient Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 118

3. Interaction of Physician Gender and Strategy Type on Physician Perception. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 121

4. Interaction of Physician Gender and Strategy Type on Physician Persuasiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 123

15

ABSTRACT

Communication expectancy and reinforcement principles are systematically integrated

to explain the effectiveness of communication strategies focused on improving initial and long­

term medical adherence and patient satisfaction. Study 1 analyzed patients' evaluations of

communication regard strategies and the effectiveness of these strategies in initial encounters.

It was predicted that physician gender would play a major role in patients' communication

evaluations. As predicted, negative regard influence strategies used by male physicians were

perceived as more appropriate than negative regard strategies used by female physicians.

Results did not indicate gender differences for perceptions of expectancies or relational

concern as communicated by regard strategies. Study 1 also addressed the effectiveness of

influence attempts in initial encounters with a physician. The study supports the predicted

interaction for communication effectiveness in initial encounters. Specifically, the results

support the claim that female physicians are limited to the use of positive regard strategies

whereas male physicians are more effective persuaders using either positive or negative regard

strategies. The results also indicate that the use of negative regard strategies by male

physicians does not hinder patient satisfaction or physician perceptions, whereas the use of

negative regard strategies by female physicians is negatively related to these outcome

measures. The reinforcement expectancy framework tested in Study 2 argued that occasional

use of nonrewarding communication would facilitate communication effectiveness for both

male and female physicians in ongoing physician-patient relationships. The results supported

this assumption. Physician gender, howev,er, did not mediate the effectiveness of certain

strategy combinations as expected. Finally, the investigation found that previous exposure to

any type of physician communication style, as opposed to never having seen the physician,

facilitated a physician's influence attempts.

16

CHAPTER 1

RATIONALE AND RESEARCH HYPOTHESES

Compliance in the health care setting remains a source of concern for social scientists

and health care professionals trying to understand why patients seek expert medical advice and

then appear to ignore prescribed or suggested treatment regimens. Several researchers

(Becker & Maiman, 1980; Bergman & Wiholm, 1981; Eraker, Kirscht, & Becker, 1984;

Haynes, 1979; Klopovich & Trueworthy, 1985; Robbins, 1980) present evidence that patients

who are symptom-free and on a prevention regimen, as well as patients who are severely

discomforted and have life-threatening diseases, all demonstrate inadequate compliance to

clinical prescriptions. The consequences related to medical noncompliance may be quite

serious, including unnecessary or dangerous diagnostic and treatment procedures (Becker &

Maiman, 1980; Norell, 1980), exacerbation of the medical condition and progression of the

disease (R. B. Stewart & Cluff, 1972), and, on a broader scale, inaccurate assessment

regarding the value of specific treatment regimens (Eraker et aI., 1984; Wilson, 1973).

Because of the serious potential health consequences related to noncompliance,

researchers have expended considerable effort toward understanding the problem of enlisting

patient cooperation in prescribed treatment programs. Communication between health care

providers and consumers is widely cited as playing an integral role in adherence to medical

prescriptions. However, there has been a dearth of theory and research specifying the actual

effects of physician communication influence attempts on patient compliance. Rather,

scholarly attention has focused on indirect compliance routes such as patient satisfaction (e.g.,

Ben-Sira, 1980; Lane, 1983; Linn, Linn, & Stein, 1982) or on merely describing physician­

patient interactions (M. Burgoon, Parrott, J. K. Burgoon, Birk, et aI., 1990; M. Burgoon,

Parrott, J. K. Burgoon, Coker, et aI., 1990; Davis, 1968; Freemon, Negrete, Davis, &

17

Korsch, 1971; Korsch & Negrete, 1972; M. A. Stewart, 1984). Research (e.g., M. Burgoon,

Birk, & Hall, 1991) which has addressed the efficacy of various physician influence attempts

theoretically has been limited to one-message-and-done situations rather than sequential

message strategies . Yet, compliance-gaining episodes with patients who are chronically ill or

who are seeking lifestyle changes are frequently characterized by varying amounts of

influence attempts by health care providers. Thus, these past research endeavors have

contributed relatively minimally to explaining and improving the "actual" compliance-gaining

process in the medical setting.

The relationship between sequential message strategy choices and compliance gaining

in the health care setting is of import given the dramatic shift in the nation's health problems

this century from infectious and communicable diseases to heart disease, cancer, and chronic

illnesses (Altman & King, 1986). As a result, more patients are visiting health care

professionals on a regular basis and are often asked to comply with complicated long-term

lifestyle changes. The adherence rates for such lifelong changes are generally lower than for

short-term medical regimens, and these rates decrease dramatically with time (Bloom,

Cerkoney, & Hart, 1980; Epstein & Cluss, 1982).

Although the number of patients attempting difficult lifestyle changes is increasing,

there is a lack of theory designed to address such people. Rather, strategic suggestions to

improve chronic conditions and alter patients' lifestyles are frequently generalized from

studies associated with relatively brief rt!gimens (Turk, Salovey, & Litt, 1986). This

approach is rendered somewhat suspect because it fails to recognize the uniqueness of long­

term compliance situations. More specifically, long-term compliance situations, by definition,

contain an element of time which greatly affects the meanings attached to communication

transactions, individuals' expectations for future interactions (J. K. Burgoon & Le Poire,

18

1991), and the acceptability of communicative responses (Levinger & Huesman, 1980).

Additionally, long-term compliance situations are more likely to involve nonimmediate

positive consequences which decrease a patient's motivation to initially comply (Gross, 1987).

A more complete understanding of effective physician influence attempts can be achieved by

investigating ongoing physician communication, in addition to single strategic attempts.

The framework developed and tested in this study explicates effective communication

strategies for physicians who have repeated exposure to patients attempting lifelong, or at

least long term, behavior management. An examination of the health care context and of

compliance-gaining research provides the starting point for such an effort. Next, language

expectancy and reinforcement principles are addressed, with a particular focus on the

appropriateness and the reinforcement value associated with specific language choices.

Several researchers have argued that our language choices impact on message receptivity, and

consequently, are powerful predictors of whether our influence attempts are successful at

achieving and maintaining influence (M. Burgoon & G. R. Miller, 1985). Scholars (1. K.

Burgoon, M. Burgoon, G. R. Miller, & Sunnafrank, 1981; M. Burgoon & M. D. Miller,

1990) have also suggested the utility of applying learning theories as predictive bases for

attitude and behavioral change. A systematic integration of these two lines of research are

used in the present study to explain the efficacy of communication strategies directed at

improving long-term medical adherence.

The investigation is designed to achieve the following goals: (1) to conceptualize

potential physician compliance-gaining strategies based on their reinforcement value in a

clinical encounter; (2) to determine how physician influence attempts are evaluated, (3) to

explicate the consequences of both initial and ongoing influence attempts used by male and

female physicians on patient satisfaction, physician evaluation, and physician persuasiveness;

and (4) to provide an indication of how previous compliance-gaining strategy usage by

physicians influences the effectiveness and evaluation of future influence attempts.

Predictors of Patient Compliance

The problem of enlisting patient compliance has been examined extensively. From

the literature, it can be ascertained that noncompliant patients cannot be differentiated based

on age, social class, race, education, intelligence or even severity of illness (cf. Haynes,

19

1979; Lane, 1983). The relationship between other potential predictor variables, however, is

not as clear (M. Burgoon & J. K. Burgoon, 1990). Some of the confusion and conflicting

findings may be related to how scholars have viewed the typical noncompliant patient, as well

as the compliance situation. Specifically, researchers have often conceptualized the

noncompliant patient to be uninformed and the compliance situation to be short-term. These

conceptualizations can result in inaccurate assumptions and, consequently, inappropriately

chosen predictor variables for long-term compliance.

Patient Knowledge and Long-term Compliance

Compliance is often regarded as a multifaceted process of consensus, involving

agreement between the health care provider and the patient on performances and therapeutic

expectations (Amarasingham, 1980; Anderson & Kirk, 1982; Linden, 1981). Not surprising,

treatment models for dealing with noncompliance have espoused the importance of education

and attitudinal adjustment in order to "align" expectations (Becker, 1974; Heiby & Carlson,

1986; MCKenney, 1981). Patient education programs commonly recommend that physicians

provide necessary information, screen patient's beliefs, and stress the severity of the problems

to meet this goal (Becker & Maiman, 1980; Hartman & Becker, 1978; Webb, 1980).

Asking physicians to monitor their patients' health beliefs in order to alter patients'

attitudes is a monumental task, leaving the physician little realistic direction for intervention.

More important, a substantial amount of research (e.g., Cummings, Becker, Kirscht, &

Levin, 1982; Dunbar & Angras, 1980; Kirscht & Rosenstock, 1979; Mazzuca, 1982;

Podshadley & Schweikle, 1970; Sacket, Haynes, & Gibson, 1975; Webb, 1980) has

demonstrated that patients who become more knowledgeable are not necessarily more

compliant. Although instructional methods are certainly integral to a patient's ability to

follow prescribed treatment regimens, they do not guarantee that a patient will act

appropriately. As Gross (1987) states, "knowing what to do and how to do it in no way

insures cooperation from a patient" (p. 10).

20

Where the belief change approaches fall short is in recognizing that in many situations

patients have the appropriate belief structure but they are confronted with a number of

obstacles that impact subsequent behavior. For instance, many physicians smoke cigarettes

and many nutritionists are overweight. As Gross (1987) pointed out, it is hard to imagine that

these individuals lack the appropriate belief structure. Rather, the evidence suggests that

patients often fail to follow the clinician's expectations, as well as their own, because of the

perceived aversive consequences initially associated with compliance, not inaccurate health

beliefs (Chesney, 1984; Cummings, Becker, Kirscht, & Levin, 1981; Davis, Hess, Van

Harrison, & Hiss, 1987; Gross, 1987). Similarly, incentive theorists (e.g., Logan, 1971;

Logan & Wagner, 1965) have suggested that the probability of a patient complying is

contingent on both the patient's knowledge of the appropriate response(s) and the patient's

incentive to adhere to the prescribed treatment. Thus, if instructional strategies and belief

alteration programs are to be successful, physicians must arrange to have initial positive

consequences be associated with patient compliance and initial negative consequences

associated with patient noncompliance. The theoretical reasoning to be advanced demonstrates

the utility of communication behaviors serving this reinforcement function.

21

The provision of some form of incentive is particularly important in long-term

compliance situations since they often involve nonimmediate and nonsalient positive

consequences. This is in sharp contrast to curative approaches which have immediately

salient outcomes for the individual. As illustration, brief curative measures generally require

the patient to take medication for a brief period with noticeable results immediately occurring.

In comparison, chronic dialysis involves a lifetime of dietary and fluid restrictions, multiple

medication needs, and episodic access procedures (McKevitt, Jones, Lane, & Marion, 1990).

In diabetic regimens, patients are expected to maintain a highly regulated diet, monitor blood

or urine glucose, exercise, and take medication in the form of insulin injections or orally

administered pills (Gross, 1987). Similarly, weight loss and cholesterol programs require

patients to maintain a highly regulated and often unsatisfying diet and/or exercise regimen.

Although the potential long-term ramifications of noncompliance in these situations are quite

serious (e.g., morbidity, heart disease, blindness), many people are not motivated by foreseen

long-term consequences (Ajzen & Timko, 1986; Epstein & Masek, 1978; Evans, 1980).

Thus, conceptualizing noncompliance as a comprehension or attitudinal problem

ignores a majority of noncompliant patients who comprehend and concur with the necessity of

the medical regimen, but at some point choose not to comply. According to Altman and King

(1986), these patients are often the norm, rather than the exception, in chronic disease

treatment and prevention programs. The present study concentrates on these undermotivated

noncompliers who understand and accept the physician's advice but at some point refrain from

using it. Importantly, because patient knowledge and belief structure are usually unrelated to

the problem, these undermotivated noncompliers will not necessarily benefit from strategies

related to education or attitudinal adjustment. Rather, as pointed out by Ley (1988),

physicians must rely on motivational techniques rather than educational methods with the

22

intentionally noncompliant patient.

Physician Intercession and Patient Compliance

Although physicians could communicatively intercede in a number of ways, health

communication research has focused predominately on communication that produces satisfying

relations, rather than addressing more direct communication strategies for improving the

noncompliant situation (e.g., communicating expectancies, reinforcing desirable behaviors,

and showing disapproval for undesirable behaviors). Patient satisfaction literature suggests

that satisfaction is an important determinant in "doctor-shopping" (Kasteler, Kane, Olsen, &

Thetford, 1976) and in patients' willingness to seek care from a physician (Comstock,

Hooper, Goodwin, & Goodwin, 1982; Larsen & Rootman, 1976). However, its utility as a

compliance predictor is suspect given that positive communication has not unequivocally been

linked to compliance (cf. Kaplan, Greenfield, & Ware, 1989; Roter, Hall, & Katz, 1987) and

patient satisfaction has not accounted for a substantial about of variance as a predictor of

compliance (cf. J. K. Burgoon et aI., 1987, Ley, 1988). Further, the overconcern with

patient satisfaction has created a bias towards rewarding physician-patient exchanges which

may actually have detrimental effects on long-term compliance.

Still, many scholars persist in arguing that there should be a high correlation between

satisfaction with physician communication and adherence to clinical prescriptions. According

to prescriptions advanced by Kreps (1988), the patient-provider relationship is the primary

vehicle by which adherence to the medical regimen is achieved. Consequently,

communication which defines the nature of the relationship is presumed to be a significant

factor in determining whether a patient will comply with the suggested regimen (Matthews &

Hingson. 1977).

Given the integral role of the patient-provider relationship, the use of personal,

23

affiliative communication which coincides with a caring relationship is claimed to improve

patient satisfaction and, thus, facilitate adherence rates (Becker, 1979; Cousins, 1985;

DiMatteo, Prince, & Taranta, 1979; Hanson, 1986; Korsch & Aley, 1973; Pendleton, 1983).

Although a body of literature (Ben-Sira, 1980; J. K. Burgoon et aI., 1987; Comstock et aI.,

1982; Doyle & Ware, 1977; Larson & Smith, 1981) provides evidence that a provider's

friendly bedside manner is correlated with patient satisfaction, the correlation between

satisfaction and compliance is often negligible (cf. M. Burgoon, 1991).

Findings that threatening communication leads to patient compliance (e.g., M.

Burgoon et aI., 1991; Kaplan et aI., 1989; Lane, 1983; McArdle, 1972; Robberson &

Rogers, 1988; Schmidt, 1977) also appear to contradict the advocated relationship between a

provider's friendly bedside manner and adherence. Although few studies have explored the

effects of cornn1Unicator style on long-term compliance, the one longitudinal study (Kaplan et

aI., 1989) related to this issue found physicians' negative affect, not positive affect, to be

related to health status. Thus, rewarding exchanges do not necessarily lead to self-care

activities in chronic disease.

There are several plausible explanations for such seemingly contradictory viewpoints

that should be considered before advocating either an affiliative or a more assertive

communication approach. First, there is evidence that both affiliative and aggressive

communication can lead to relational satisfaction (Street & Wiemann, 1987). Specifically,

although aggressive communication events are generally seen as aversive communication

stimuli (i.e., ones that an individual wants to terminate or prevent), these communication

exchanges can signal concern and involvement that are relationally satisfying. Conversely,

rewarding or neutral communication exchanges used during noncompliant situations could

hinder relationship satisfaction, because in these instances nonaversive communication

24

potentially signals physician disinterest or lack of concern in the patient's progress. In other

words, interpersonal involvement and concern can be communicated through either approval

or disapproval cues (M. Burgoon & J. K. Burgoon, 1991; Street & Wiemann, 1987). Thus,

both aversive and affiliative exchanges can lead to relationship satisfaction.

Second, although patients may be dissatisfied with the occasional use of a certain

strategy, overall communication satisfaction and, thus, relationship satisfaction will not

necessarily be in jeopardy. Because many researchers operate from a short-term perspective,

satisfaction with ongoing communication exchanges has been disregarded. Yet satisfaction

with communication patterns is probably much different from satisfaction with specific

communication behaviors. Thibaut and Kelley (1959) stress that interpersonal relationships

must be recognized as dynamic processes, with individuals continuously monitoring,

assessing, and reconsidering whether the reward-cost ratio associated with the relationship is

sufficient. As Molm (1987) points out, individuals in long-term relationships expect some

exchange of aversive actions. Thus, dissatisfaction with aversive communication should only

occur if it is the main source of influence experienced in a relationship.

Consistent with this shortcoming is the fact that much of the past research failed to

consider the impact of relational histories or the impact of past communication exchanges.

Rather, each patient is treated equally prior to the communication manipulation but, in fact,

each probably is quite different. Several researchers (J. K. Burgoon & Le Poire, 1991; J. K.

Burgoon, Le Poire, & Rosenthal, 1991; Planalp, 1985; Roloff, 1987) have noted that

communication acceptability is a function of familiarity and previous communication

experiences with a communicator. Failure to build prior contact into research endeavors,

therefore, may account for the abundance of contradictory findings in the literature.

More important, the logic underlying the use of all positive exchanges ignores welI

25

established reinforcement principles that, unlike satisfaction, have been clearly linked to

behavioral change (Chesney, 1984; N. E. Miller, 1984). Several learning theorists maintain

that the potential for a behavior to occur in any situation is a function of an individual's

expectancy that the behavior will lead to a particular reinforcement or that the behavior will

avoid an aversive situation (e.g., Estes, 1971; Logan, 1971; Tolman, 1932). Similarly,

communication theorists and sociologists (e.g., 1. K. Burgoon, 1991; Dillard, 1990; Molm,

1989) have argued that motivation to act is a function of an individual's perception that a

positive state of affairs is threatened or lost. If the behavior of the target is constantly

positive then appropriate action-consequence sequences cannot develop and motivation to

restore or maintain a current state of affairs is absent. Thus, continual use of satisfying or

positive communication may inhibit patient motivation to comply.

Not only can continuous reinforcing exchanges prevent the development of motivating

action-consequence expectancies, but an over-reliance on positive communication can decrease

the incentive or reinforcement value of satisfying communication. According to Homans'

(1974) Social Exchange Theory, the more often a person receives a particular reward the less

valuable the reward becomes in the future. In other words, frequent use of communication

reinforcers by physicians can result in satiation effects where the reinforcer is no more

effective than a neutral stimulus at motivating patients. Learning theorists testing the effects

of intermittent reinforcement on humans (e.g., Boyagian & Nation, 1981; Bradshaw, Szabadi,

& Bevan, 1976; Pittenger & Pavlik, 1989; Wurster & Griffith, 1979) offer additional support

for the superiority of occasional rather than continuous reinforcement. Commodity Theory

(Brock, 1968) also assumes that less frequent use of rewards increases the incentive value of

the reward. Specifically, communication reinforcers should become more valuable as

perceived effort to receive the reward increases and availability of the reward decreases.

26

Because less frequent use of rewards should increase perceived effort and decrease perceived

availability, an intermittent use of reinforcement should increase the incentive value of the

reinforcement.

Finally, an over-reliance on warm, friendly communication could establish these

communication behaviors as expected or normative which, in turn, could limit the physician's

future persuasive success when utilizing such strategies. More specifically, repeated

occurrences of communication behaviors are represented in working memory as

"expectancies" (Abelson, 1981; Planalp, 1985; Roloff & Berger, 1982). Frequent

confirmation of these expectancies explains the maintenance of communication expectations

(M. Burgoon & G. R. Miller, 1985). Using this line of reasoning, repeated use of positive

communication strategies by a physician could confirm these strategies as normative or

expected.

Evidence from communication research (M. Burgoon et aI., 1991; M. Burgoon,

Dillard, Doran, & Miller, 1982; M. Burgoon, Dillard, Koper, & Doran, 1984) suggests that

greater persuasive success can be obtained by physicians positively violating patient

expectations (e.g., engaging in communication behavior that is better or more preferred than

that which is expected) than by meeting or negatively violating expectations. In fact, negative

violations of communication expectations have been shown to have detrimental effects on

patient compliance (M. Burgoon et aI., 1991). By combining this information with the fact

that repeated use of rewarding communication could establish these strategies as normative, it

can be concluded that continual use of rewarding communication inhibits a physician's ability

to make future positive violations and, at the same time, increases the probability that a

physician will engage in future negative violations. Thus, an over-reliance of warm, friendly

communication may actually decrease the impact of the physician's future suasory attempts.

27

In sum, because so many researchers have operated from a short-term perspective,

overall satisfaction and assumptions related to ongoing communication exchanges have been

disregarded. More important, the preoccupation with patient satisfaction and the need to

prevent "doctor shopping" has relegated patient compliance to a secondary objective of

physicians. Evidence suggests, however, that few patients are actually dissatisfied with their

physicians and that even fewer (less than 10 %) engage in doctor shopping because of this

dissatisfaction (Cousins, 1985). Instead, patients reportedly change physicians because their

condition didn't improve and the physician is unable to inspire confidence (Cousins, 1985).

Because patients expect physicians to motivate them, it is possible that compliance success

leads to satisfaction, rather than satisfaction leading to compliance. Thus, addressing the

relationship of physician compliance-gaining attempts to patient compliance, and then to

satisfaction is a more appropriate ordering of scholarly inquiry in long-term compliance

situations.

Several health researchers (DiMatteo & DiNicola, 1982; Hall, Roter, & Rand, 1981)

have attempted to outline the communication strategies used by physicians to gain compliance

because of the recognition that patient beliefs and satisfaction may account for only a small

amount of the variance in compliance. The majority of this literature, however, is either

plagued by methodological shortcomings or based on "opinion from informed sources" rather

than on "empirical work" (Pendleton, 1983, p. 11). Some communication scholars (e.g., M.

Burgoon et aI., 1991; M. Burgoon, Parrott, J. K. Burgoon, Birk, et aI., 1990; M. Burgoon,

Parrott, J. K. Burgoon, Coker, et at., 1990) have attempted recently to remedy these

problems by addressing strategy usage in the health care context empirically. According to

M. Burgoon and colleagues (M. Burgoon, Parrott, J. K. Burgoon, Birk, et al., 1990, M.

Burgoon, Parrott, J. K. Burgoon, Coker, et al., 1990), both patients and physicians report

28

that health care providers are most likely to employ expertise strategies. This research also

found that although physicians report relying on more aggressive strategies with previously

noncompliant patients or severely ill patients, patients do not perceive the use of aggressive

strategies in these situations. Regardless of which perceptual data are most accurate, the fact

that physicians rarely take aggressive or reinforcing actions to motivate patients suggests that

such non-motivating, neutral strategies are likely to be perceived by patients as normative or

expected.

Unfortunately, health communication research that focuses on strategy selection,

rather than strategy outcome, cannot explain effective strategy usage. Similarly, health

communication research that focuses on effective strategy usage in a single consultation

session (e.g., M. Burgoon et aI., 1991) cannot be applied readily to situations where

physicians have multiple contacts with a patient. Thus, conclusions regarding physician

compliance-gaining strategies as predictors of long-term patient compliance must be made

from other bodies of literature.

Summary

Evidence from the health context suggests that merely providing patients with more

information to alter beliefs will not guarantee long-term adherence to clinical prescriptions.

Instead, the evidence suggests the need for physicians to use a communication style that

increases initial positive consequences associated with compliance and decreases positive

consequences associated with noncompliance. Further, the review illustrated that an

overemphasis on short-term satisfying communication is not the most logical or advantageous

choice for improving long-term compliance and could actually be detrimental to achieving

compliance. Instead, physicians should direct their efforts toward using persuasive

communication exchanges with their patients. However, the .scarcity of investigations

29

regarding strategy effectiveness precludes the ability to draw inferences from the extant

literature regarding the efficacy of various influence behaviors or combinations of influence

behaviors over time. What is needed is a framework that addresses these undermotivated

noncompliers by taking into account time, the importance of patient expectations, and the

patient's need for immediately motivating consequences. Such a task first involves delineating

and conceptualizing potential physician influence choices which can be integrated into a

motivational framework related to sequential compliance-gaining attempts.

Conceptualization of Influence Behaviors

Although a substantial amount of communication literature has scrutinized the

production and selection of compliance-gaining strategies (for review see M. Burgoon, 1991),

limited prescriptive advice is available from this body of knowledge. Specifically, the over

reliance on compliance-gaining strategies as the dependent variable has led to a lack of

concern regarding the consequences of certain compliance-gaining strategies. Further, most

measures of influence are based entirely on verbal utterances despite the demonstrated

importance of corresponding nonverbal behaviors (Berger, 1985; Parks & Dindia-Webb,

1979). As Berger (1985) noted, failure to include nonverbal communication used in influence

processes constrains oneself to studying "the tip of a very large iceberg" (p. 483). Thus, the

consequences of influence behaviors from both channels must be indexed.

Rather than rendering this extant body of verbal compliance-gaining literature

inapplicable for the current framework, past conceptualizations of various verbal strategies

serve as a starting point for an assessment of physician influence attempts. Additionally,

nonverbal influence behaviors will be appended to the final conceptualization because face-to­

face interactions include both verbal and nonverbal behaviors. It is necessary to consider

conceptually equivalent nonverbal and verbal behaviors in order to avoid contradictions in the

30

two channels that might override or change the relational meaning of the other. Although the

effects of contradictory or opposing messages from different channels are worthy of future

attention, this study focuses solely on combinations of conceptually similar verbal and

nonverbal influence attempts.

Conceptualization of Verbal Compliance-Gaining Strategies

It was argued previously that positive consequences must be arranged for patients to

adhere to suggested treatment regimens. Although much of the medical compliance literature

deals with material rewards such as tokens or money (see Chesney, 1984). symbolic rewards

in the form of verbal and nonverbal approval cues have also been shown to be effective. and

often more effective than material rewards for motivating humans (Barringer & Gholson.

1979: Chance. 1979: Colletti & Brownell. 1982: Greenbaum. Turner. Cook. & Melamed.

1990: Spence. 1972: Spence & Segner. 1967: Stevenson, Weir, & Zingler, 1959). This has

been particularly evident for social approval cues (e.g., Bourget, 1977: Colletti & Brownell.

1982; Harris & Rosenthal, 1985; Kazdin & Klock. 1973). Thus, receivers' interpretation of a

message's reinforcing qualities is considered instrumental in determining strategy effectiveness

and guides strategy conceptualization for the present framework.

A fundamental communication assumption is that every communication message has a

relational and content component (Bateson. 1958; Bochner & Lenk-Krueger. 1979;

Watzlawick. Beavin, & Jackson, 1967), and every interpersonal transaction involves

opportunities for relational expression. Whereas the content component is the literal meaning

of the message, the relational message denotes how individuals regard the relationship, each

other, or themselves in the relationship.

Health communication researchers (Buller & Buller, 1987; J. K. Burgoon et al.. 1907:

Street & Wiemann. 1987) suggest that a health care provider's relational message may be

31

more influential than the content of the message. Communication scholars have long

recognized the importance attached to the relational meanings of messages. Le Poire and J.

K. Burgoon (1991), for example, stressed that individuals are generally more concerned with

"what is implied during any conversation" than "what is said" (p. 3). This relational message

concern is likely a function of humans' innate need for acceptance -- which is generally

implied rather than explicitly stated in any communication exchange. Given the importance

attached to the relational meanings of messages, the process of responding to a message is

assumed to be based more on its relational message than its exact content. This assumption

allows a wide range of both verbal and nonverbal messages to be categorized based on their

functional similarities or "common symbolic characteristics" (G. R. Miller, 1983, p. 129).

Potentially there are a variety of characteristics which differentiate relational messages

associated with compliance-gaining strategies (J. K. Burgoon & Hale, 1984, 1987; J. K.

Burgoon, Buller, Hale, & deTurck, 1984; J. K. Burgoon et al., 1987). Messages used in the

following theoretical framework are broadly characterized by the degree to which they

relationally signal positive, negative, or neutral regard for patients and/or patients' actions.

The logic of the categorization system is based on the assumption that a physician's influence

attempts may either signal approval or disapproval of (a) the patient's actions or (b) the

patient him or herself. Communication choices that signal approval or affect for others

and/or their actions are considered positive regard strategies. Conversely, influence attempts

that indicate disapproval or lack of affect for others and/or their actions are labeled negative

regard strategies. Finally, communication choices that are simple directives or justifications

for action are defined as neutral regard strategies. Neutral strategies used in isolation from

other strategies neither validate or invalidate the patient (see Appendix A for examples of each

strategy type).

32

Conceptualizing compliance-gaining strategies based on their reinforcing properties is

consistent with several scholars' classifications of influence attempts. For instance, G. R.

Miller (1983) argued that compliance-gaining strategies could be classified by whether the

influence attempt depicts the negative, aversive consequences of not doing what the

communicator recommends (punishment) or whether the message points out the positive

consequences for doing what the communicator recommends (reward). Roloff and Barnicott

(1978, 1979) distinguished between prosocial strategies that represent socially acceptable

modes of influence and antisocial communication strategies that are more forceful, aversive

devices. Prosocial influence attempts are similar to reward-oriented strategies since they are

conceptualized as messages that state positive outcomes will occur if the target complies. On

the other hand, antisocial strategies state that negative consequences will occur if the target

does not comply and, thus, are isomorphic with punishment-oriented strategies. Similarly,

Hunter and Boster (1987) who began with an "empathy" interpretation of the compliance

gaining message strategy continuum conceded and agreed with M. Burgoon and colleagues

(M. Burgoon, Dillard, & Doran, 1984; M. Burgoon, Parrott, J. K. Burgoon, Coker, et al.,

1990) who claimed that compliance-gaining strategies can be viewed on a continuum akin to

instrumental verbal aggression (Le., strategies vary by their degree of forcefulness). By

definition, aversive strategies are more aggressive than nonaversive strategies.

Missing from many past conceptualizations are influence attempts that are neither

rewarding nor punishing. Nearly two decades ago, Bowers (1974) argued that researchers

have progressed little beyond examining threats and promises. Consequently, some scholars

began including more neutral strategies such as justification, explanations, direct requests, and

hints into their compliance-gaining typologies (Clark, 1979; Cody, McLaughlin, & Jordan,

1980; Cody, McLaughlin, & Schneider, 1981; Schneck-Hamilin, Georgacorakos, &

Wiseman, 1982, Schneck-Hamilin, Wiseman, & Georgacorakos, 1982). Although these

strategies may appear to have little motivational utility when used in isolation, they may be

quite useful in combination with other strategies. Thus, such so-called neutral strategies

should be included as potential influence attempts.

33

Conceptualizing verbal compliance-gaining strategies as showing positive regard,

negative regard, or neither will be useful when assessing communication appropriateness and

applying reinforcement principles addressed in the framework. Additionally, this

conceptualization enables the ready generation of equivalent nonverbal strategies.

Specifically, nonverbal cues can be examined according to whether they (a) signal approval

for the patient and/or the patient's actions, (b) signal disapproval for the patient and/or the

patient's actions, or (c) are relatively ambiguous in this regard.

Conceptualization of Nonverbal Strategies

Immediacy behaviors serve as comparable communicative indices to the proposed

verbal categorization scheme because they signal positive regard, interpersonal warmth, and

approval. According to Mehrabian (1968, 1969) and J. K. Burgoon and Hale (1984),

immediacy behaviors are approach behaviors that indicate physical or psychological closeness

to another, as well as signal interest, involvement, and affect. Conversely, nonimmediacy

behaviors signal hostility, exclusion, and lack of sensory engagement. Coker and J. K.

Burgoon (1987) have argued that immediacy should be subsumed under conversational

involvement (Le., the degree to which individuals are engaged in the relationship, topic, or

situation). These scholars state that invol~ement is manifested by immediacy, expressiveness,

conversational management, altercentrism, and social anxiety. Of particular interest here is

the dimension of altercentrism, which relationally communicates friendliness, pleasantness,

interest, involvement, and warmth. Both immediacy and altercentrism would be included as

34

approval cues and, thus, are messages of positive regard.

Researchers have cited numerous nonverbal cues associated with immediacy, the most

commonly cited behaviors being close conversational distance, direct body and facial

orientation, forward body leaning, touching, positive reinforcers such as smiling and pleasant

facial expressiveness, and a high degree of eye contact (Anderson, 1985; J. K. Burgoon et

aI., 1984; Richmond, Gorham, & McCroskey, 1987). Behaviors associated with

altercentrism include more kinesic/proxemic attentiveness and more vocal warmth/interest

(Coker & J. K. Burgoon, 1987). The opposite of these behaviors communicate

nonimmediacy and egocentrism.

Although these nonverbal behaviors are typically associated with expressions of

intimacy, they can also function as reinforcement cues in the physician-patient encounter

because they are associated with warmth and approval. Based on the previous discussion,

nonimmediacy behaviors signal disapproval or negative regard and act as aversive stimulation.

A substantial amount of communication research substantiates this claim (cf. J. K. Burgoon,

Buller, Hale, & deTurck, 1984, Coker & J. K. Burgoon, 1987). J. K. Burgoon, Buller, and

Woodall (1989) have argued that, in addition to these nonimmediacy behaviors, scowls,

negative facial expressions and cold vocal tones can serve as negative feedback. Further,

although eye contact is an immediacy behavior, occasional stares when coupled with cold

vocal tones are generally viewed as aversive, threatening, or dominant behaviors (cf. J. K.

Burgoon et aI., 1989). Thus, negative regard can be communicated nonverbally by a

combination of nonimmediate behaviors and the occasional use of direct eye contact. Neutral

feedback, operationalized as moderately nonimmediate behaviors coupled with neutral

intonations, should be conceptually similar to the verbal neutral regard strategies described

early. Specifically, these nonverbal behaviors should neither validate or invalidate the

35

patients.

Physician Regard Strategies as Reinforcement Stimuli

Applications of reinforcement principles must begin by conceptually defining a priori

what is reinforcing. Here, messages of positive regard and approval are considered positive

reinforcers (motivating an individual to increase a behavior) and messages of negative regard

and disapproval are considered negative reinforcers (motivating an individual to increase a

behavior to eliminate the aversive stimuli). However, two conditions must be met for these

communication influence attempts to be labeled as reinforcers: (a) the particular

communication stimuli of interest must have conceptually recognizable meaning, and (b) the

communication stimuli must be reinforcing for all individuals. These conditions could be

construed as problematic because communication behaviors often have multiple meanings and

social acceptance cues are secondary reinforcers which generally depend upon the experience

of the individual organism.

Regard strategies as conceptually recognizable. Communication scholars acknowledge

that any communication behavior, particularly ambiguous nonverbal behaviors, may have

multiple meanings. However, the range of possible interpretations is limited by the fact that

most behaviors used with regularity among members of a given social community have

socially shared meanings. Thus, hearers should interpret certain sets of communication

stimuli in consistent ways. Several researchers (J. K. Burgoon et aI., 1984; J. K. Burgoon &

Newton, 1991; Le Poire & J. K. Burgoon, 19(1) have offered support for a social meaning

position regarding the nonverbal behaviors used in this framework. Specifically, immediacy

and involvement behaviors have consistently been associated with positive relational messages

and the opposite of these have consistently been associated with negative relational messages.

Application of a social meaning perspective has not been applied to verbal

36

compliance-gaining strategies. Rather, strategies are assumed to be unambiguous and are

conceptualized based on the content of the message (deTurck, 1985). Some support for the

social meaning perspective for verbal compliance-gaining strategies can be derived from

research which has demonstrated that individuals consistently differentiate specific strategies

(e.g., positive regard strategies) as socially acceptable and empathetic, whereas other

strategies (e.g., negative regard strategies) are viewed as socially unacceptable and

unempathetic (e.g., Hunter & Boster, 1978; Roloff & Barnicott, 1978). Further, although

verbal compliance-gaining strategies could be construed as having multiple meanings, their

ambiguity is probably a function of some contradiction found in the nonverbal channel.

Evidence indicates that when verbal messages are ambiguous, individuals generally rely on

nonverbal cues (Zahn, 1973). Thus, the verbal regard strategies previously discussed should

have conceptually recognized meaning as long as conceptually similar verbal and nonverbal

messages are used in concert.

Regard strategies as universal reinforcers. Although it could be argued that social

reinforcement depends upon the experience of the individual organism, many social

reinforcers (approval cues) and punishers (disapproval cues) are so widely used that they have

virtually become intrinsic. Harre (1980) contends that the deepest human need is for approval

and respect. J. K. Burgoon and colleagues (J. K. Burgoon & Hale, 1988; J. K. Burgoon &

Le Poire, 1991) have consistently demonstrated that immediacy and involvement behaviors

(positive regard messages) are positively interpreted and the opposite behaviors are negatively

interpreted. Research concerning patient satisfaction with nonverbal behaviors offers further

support. Specifically, numerous studies have reported that patients prefer more immediate,

involved, friendly, pleasant, receptive, and expressive nonverbal communication (Buller &

Buller, 1987; J. K. Burgoon et aI., 1987; Carter, Inui, Kukull, & Haigh, 1982; Hall et aI.,

1981; O'Hair, 1986; Street & Wiemann, 1987). Additionally, direct eye contact, forward

leans, and direct body orientations have been linked to patient satisfaction (Larson & Smith,

1981).

37

Positive and negative verbal regard messages have also been shown to consistently act

as reinforcing and aversive stimuli respectively. For instance, negative verbal messages such

as fear-arousing strategies which depict the negative, aversive consequences of not adhering to

the communicator's recommendation produce more negative arousal than persuasive appeals

which focus on the positive consequences of changing behavior (Robberson & Rogers, 1988).

Research testing Expectancy-Value Theory (Shenkel, Rogers, Perfetto, & Levin, 1985;

Tedesco, Keffer, & Fleck-Kandath, 1991) lends further credence to the reward value attached

to social approval. Specifically, individuals appear to be motivated by their beliefs regarding

what a particular referent thinks they should or should not do.

Learning theorists offer further evidence for the assumption that regard strategies are

universal reinforcers. Specifically, learning theorists (Atkinson & Wickens, 1971; Estes,

1986, Krechevsky, 1932; Levine, 1970; Restle, 1962) have suggested that knowledge of a

correct response is in itself reinforcing. Given that approval cues indicate what the physician

thinks is correct and what is incorrect, these behaviors should be universal reinforcers.

Applying these arguments to the present endeavor, verbal and nonverbal regard

strategies should be perceived by patients as reinforcing stimuli such that positive regard

strategies are viewed as relationally communicating approval and negative regard strategies

are viewed as relationally signaling disapproval. Additionally, these strategies should be

differentially valenced such that positive regard strategies are more rewarding to receivers

than neutral or negative regard strategies and negative regard strategies are the least

rewarding. Although it will be argued that a physician's previous communication usage can

38

change how reinforcing these strategies are, the linear relationship for strategy type and

reinforcing quality should remain the same. For instance, it will be illustrated that a neutral

strategy can become aversive in some situations. However, negative regard strategies used by

the same physician should be perceived as more aversive than neutral regard strategies.

Perceived differences in message interpretation for each of the three strategy types must be

met for the application of reinforcement principles. The following hypothesis regarding the

reinforcing quality of influence strategies is forwarded:

H 1: There is a direct linear relationship between the type of influence attempt and

perceptions of reinforcement such that positive regard strategies are perceived

by patients as showing more physician approval and are more positively

valenced than negative regard strategies.

Summary

Both verbal and nonverbal communication strategies can be conceptualized based on

whether they communicate positive regard, negative regard, or neither. However, the

effectiveness of these strategies in long-term compliance situations is yet to be determined.

Thus, emphasis shifts to communication expectancy and reinforcement principles to derive

influence behavior predictions.

It was argued previously that application of reinforcement principles to physician­

patient interactions, as opposed to patient satisfaction, should prove beneficial. Additionally,

a substantial amount of evidence suggests that meeting patient expectations facilitates patient

satisfaction and compliance (M. Burgoon et aI., 1991; Davis, 1968; DiMatteo et aI., 1979;

Francis, Korsch, & Morris, 1969; Freemon et aI., 1971; Geerston, Gray, & Ward, 1973;

Larsen & Rootman, 1976). It is assumed that communication expectancies are especially

pertinent in highlighting acceptable or socially appropriate strategy usage for male and female

39

physicians. It is further argued that because the use of acceptable communication impacts on

message reception and communicator evaluation, the use of expected or more preferred

communication is a necessary condition for effective influence attempts. Reinforcement

principles, on the other hand, offer insight into motivational effects of strategy usage.

However, reinforcement theorists often have ignored the impact of sociological gender

expectations and norms that have been found to significantly affect communication

acceptability and, consequently, communication effectiveness.· Thus, a synthesis of these two

lines of research is necessary for accurate predictions regarding ongoing compliance-gaining

attempts by physicians.

Factors Affecting Strategy Evaluation

Several theorists have proposed that normative and/or repeated occurrences of

communication behaviors and situations are represented in working memory, commonly

known as "schemata," "scripts," or "expectancies" (Abelson, 1981; Planalp, 1985; Roloff &

Berger, 1982). These cognitive structures allow individuals to anticipate how others will and

should act in certain contexts, with various communicators, and in specific situations (1. K.

Burgoon, 1991; D. T. Miller & Turnbull, 1986). Communication expectancies function as

perceptual filters that influence whether receivers accept or reject a communicator's messages

(1. K. Burgoon, 1991; Taylor & Crocker, 1981). Further, a substantial amount of evidence

suggests that communication violating social norms or showing inconsistency with perceivers'

expectations results in negative communicator evaluations and relational dissatisfaction (for

review, see Spitzberg & Cupach, 1984). Consequently, appropriateness of various strategies

for specific physicians (males versus females) during initial and future encounters must be

ascertained before strategic message choices can be considered from a motivational standpoint.

An examination of the research on receivers' communication expectations serves as a

foundation for determining the acceptability of various influence attempts.

Patient Expectations

40

It is generally presumed, and well documented, that meeting patient expectations by

being encouraging (Larsen & Rootman, 1976), caring (DiMatteo et aI., 1979), and

interpersonally involved (Geerston et aI., 1973; Street & Wiemann, 1987) is a determining

factor in patient satisfaction and acceptance of medical treatment (Davis, 1968; Francis et aI.,

1969; Freemon et aI., 1971; Himmelhoch, 1980). Evidence suggests that the physician's use

of communication that does not concur with a patient's expectations results in a strained

relationship and limited persuasive success (Siderris, Tsouna-Hadjis, Toumanidis, Vardas, &

Moulopoulos, 1986; Zisook & Gammon, 1981). Yet the medical research has not gone much

beyond correlational studies and often explains expectations in a teleological fashion where

patient communication expectations are defined by whether the patient is satisfied and has

complied (Bruhn, 1983; Parrott, 1989). Further, much of the research has inadvertently

disregarded the fact that different communication behaviors can represent similar relational

meanings (i.e., both aversive and affiliative behaviors can show concern) and the relational

meanings attached to certain behaviors can depend on communicator characteristics. Thus, a

more careful examination of communication expectancies from other bodies of literature is

warranted.

Expectations as a Function of Communicator Characteristics

Patients' expectations for appropriate physician communication may be either the

result of societal norms for typical physician-patient interaction or a function of past

communication experiences with the physician. Researchers generally recognize that

individuals rely on social schemas or stereotypes regarding what they already know about

communicators in general when judging the communication actions of an unfamiliar

41

communicator (Cantor & Mischel, 1979; Wegner & Vallacher, 1977). From this perspective,

patients' communication expectancies during initial exposure to a physician are dependent on

societal norms for physician behavior. Consequently, the acceptability of communication

strategies in these encounters is determined by the stereotypes associated with particular

physicians.

Hamilton (1979) noted that groupings of various communicators influenced inferences

about how a particular person should act. Similarly, Language Expectancy Theory (M.

Burgoon, 1993, 1990; M. Burgoon & G. R. Miller, 1985) shows that sociological forces

determine appropriate or normative communication usage for different classes of

communicators. A series of studies testing Language Expectancy Theory (M. Burgoon, 1975;

M. Burgoon, Dillard, & Doran, 1984; M. Burgoon et aI., 1982; M. Burgoon, Dillard, Koper

et aI., 1984; M. Burgoon, Jones, & Stewart, 1975; Wheeless, Hudson, & Wheeless, 1987)

demonstrated that communication expectations and, thus, message acceptability varied based

on communicator credibility and gender. Evidence clearly indicated that credible

communicators and men have a larger range of socially acceptable behaviors than do

communicators of low credibility and women. M. Burgoon and G. R. Miller (1985) have

contended that sociological norms allow men and highly credible communicators freedom to

use more aggressive and intense influence behaviors than women and communicators of low

credibility.

Although physicians in general are likely to be perceived as credible and as having a

large bandwidth of acceptable behaviors, M. Burgoon et al. (1991) found that female

physicians are more limited than male physicians in their language choices. As explanation

for this finding, there is evidence that some schemas or stereotypical groupings of

communicators may be more accessible to the communication perceiver (Higgins & King,

42

1981; Higgins, King, & Mavin, 1982). Crocker, Fiske, and Taylor (1984) stated that

"information may be processed with respect to one or some of the schemas that are potentially

relevant, but not all of them" (p. 209). According to these scholars, the level of accessibility

determines which cognitive organizing device is used. Consequently, the gender of the

physician is probably more of a determining factor than the general credibility of physicians

because gender expectations are more easily accessible.

Recent research in the health context (M. Burgoon et aI., 1991) has supported the

assumption that patients have different language expectations for male and female physicians.

More specifically, using the verbal aggression continuum, the research has suggested that

female physicians are expected to use nonaggressive strategies that stress commonality of

goals, communicate liking, and show concern. On the other hand, male physicians are

expected to be more neutral and use more expertise strategies. However, the research has

also indicated that patients do not find aggressive communication choices such as direct

commands, threats, or negative altercasting unacceptable when used by a male physician. In

fact, these influence behaviors are more preferred and are more influential than moderately

aggressive strategies for male physicians. This is in sharp contrast to patients' perceptions of

socially appropriate communication for female physicians. M. Burgoon et al. (1991) argued

that aggressive communication used by male physicians sends different relational messages

than aggressive communication used by female physicians. Specifically, aggressive

communication used by male physicians is interpreted by patients as expression of personal

concern. Aggressive language used by female physicians carries quite different relational

meanings because women are expected to be affiliative. Thus, although it is acceptable for

male physicians to engage in a wide range of strategies, female physicians seem limited to

approval messages or reinforcing influence behaviors.

43

Although Michael Burgoon and his research colleagues are the only group of scholars

that specifically has addressed the impact of physician gender on strategy acceptability,

several other studies offer indirect evidence corroborating the claim that physician

expectations are gender specific. These studies generally suggest that women are expected to

be more emotional, less verbally aggressive, nonassertive, affiliative, and nurturing in the way

they communicate (Bell, 1981; M. Burgoon, Dillard, & Doran, 1984; M. Burgoon, Dillard,

Koper et aI., 1984; Fitzpatrick & Winke, 1979; Haas, 1979; Weisman & Teitelbaum, 19~~"",

1989). Further, stimuli judgment research (Helson, 1947, 1964; Sherif & Hovland, 1961)

reveals that a judgment of stimuli (e.g., male and female physicians) is related to other stimuli

to which the individual has been exposed (e.g., men and women in general). Thus, it is

reasonable to believe that general gender-specific expectations transfer to the health context.

Using this reasoning, similar gender-specific predictions could be made for nonverbal

strategies which have not been empirically tested. Specifically, because women are expected

to be affiliative and nurturing, nonverbal immediacy behaviors would be expected of female

physicians, whereas either immediate or nonimmediate nonverbal displays would be

acceptable for male physicians attempting to influence patients. As further support, Language

Expectancy Theory shows that communication commonly used by various communicators

confirms and maintains these sociological expectations. Nonverbal research provides evidence

that females engage in more immediacy behaviors that males (for review see J. K. Burgoon et

al., 1990). Additionally, evidence in the health field indicates "hat female physicians utilize

more affiliative behavior than male physicians (Maheux, Dufort, & Beland, 1988; Maheux,

Dufort, Beland, Jacques, & Levesque, 1990; Weisman & Teitelbaum, 1985, 1989),

suggesting that immediacy behaviors are normative and expected for female providers. Thus,

for female physicians, high immediacy behaviors probably conform more closely to

44

expectations and are preferred by patients, whereas more nonimmediate behaviors are viewed

as unacceptable and are rejected by patients. Because male physicians are generally

nonaffiliative and affectively neutral in patient care (Maheux et aI., 1990), nonimmediacy

behaviors are probably accepted whereas immediacy behaviors are preferred but unexpected

for these communicators.

Thus, communication expectations in initial encounters with a communicator are based

on the most readily assessable communicator stereotypes (i.e., communicative behaviors most

frequently used by a particular class of communicators). Because gender expectancies are so

strongly ingrained in individuals' schemas for information processing, the following prediction

is advanced for patients' communication expectations in initial encounters with a male and

female physician:

H2: There are perceived gender differences in expected influence behaviors in

initial encounters with physicians such that male physicians are expected to

use more neutral regard strategies than any other regard strategy, and female

physicians are expected to use more positive regard strategies than any other

regard strategy.

The influence behaviors that are expected of male and female physicians should, by

definition, be perceived by patients as "appropriate" influence attempts. However, research

on violations of communication expectations suggests that unexpected communication can also

be viewed as "appropriate" if the violations are more preferred than expected. This research

also shows the adverse consequences associated with "inappropriate communication" and,

thus, highlights the importance of using influence attempts viewed as socially acceptable.

Evaluations of Unexpected Communication: Violations of Communication Expectations

J. K. Burgoon and Le Poire (1991) pointed out that "it is not expectancies per se but

45

their valences and their consequent implications for benefiting the perceiver that are doubtless

most salient for interactants" (p. 3). These violations of expectancies are generally assumed

to have arousal or attention-gaining potential which may facilitate or inhibit message

acceptance and message persuasiveness (M. Burgoon & G. R. Miller, 1985; Sherif &

Hovland, 1961), shift receivers' attention from the content level of the interaction to the

relational level (J. K. Burgoon & Hale, 1988), and influence relational outcomes such as

relationship satisfaction (Cupach, 1982; Duran, Zakahi, & Mumper, 1982; Kelley & J. K.

Burgoon, 1991) and person perceptions (J. K. Burgoon & Walther, 1990).

The efficacy of communication violations is determined by whether the language

choices are perceived positively or negatively. According to Language Expectancy Theory

(M. Burgoon, 1990; 1993) messages that are better or more preferred than that which is

expected for a particular communicator represent positive violations and facilitate a source's

influence efforts. Conversely, messages which are viewed as socially inappropriate for a

particular communicator are negative violations and can inhibit the suasory attempt. J. K.

Burgoon (1978, 1983) maintains a similar position arguing that people enter interactions with

nonverbal expectancies for specific communicators and that negative violations produce more

negative outcomes, whereas positive violations produce positive outcomes. Additionally,

Sherif and Hovland (1961) have argued that messages perceived as unacceptably discrepant

from extant attitudinal positions are rejected by the perceiver.

Because the medical communication literature (e.g., Davis, 1968; Gillum & Barsky,

1974; Himmelhoch, 1980; Korsch & Aley, 1973; Korsch, Gozzi, & Francis, 1968; Stimson,

1974) has generally argued that patient compliance and understanding are facilitated by

physicians tailoring their communication to meet presumed underlying patient expectations,

one might conclude that advocating the use of expectancy violations is incongruent with the

46

findings in the physician-patient communication literature related to physician adherence and

patient expectations. However, the medical literature has conceptualized meeting patient

expectations as equivalent to guessing what patients "hope to experience" (cf. L. S. Linn,

DiMatteo, Chang, & Cope, 1984, p. 805) and communication scholars have conceptualized

positive violations of expectations as messages that are more preferred than what is expected.

Thus, meeting expectations in the health literature is analogous to positively violating

expectations in the communication literature given that each represents a prescriptive

expectation, or what is "desired," rather than what is "predicted" to occur. Because these

definitions are conceptually isomorphic, an incongruence does not exist and a substantial

amount of evidence concurs with the notion that positive violations increase the likelihood of

accepting the position advocated, whereas negative violations decrease the likelihood of

accepting the position advocated.

Both Language Expectancy Theory (M. Burgoon, 1993) and Nonverbal Expectancy

Theory (J. Burgoon & Hale, 1988) assume that communicator characteristics mediate which

communication behaviors count as a positive versus a negative violations. Language

Expectancy Theory assumes that stereotypical communicator classifications influence the

evaluation of the violation. M. Burgoon and G. R. Miller (1985) claimed that because

normative expectations for communicator types are relatively invariant, which communication

behaviors are evaluated as more preferred (i.e., positive violation) and which communication

behaviors are evaluated as socially inappropriate (Le., negative violation) depends on the type

of communicator. For instance, stereotypical norms give men the freedom to communicate

concern for another individual through either aggressive or nonaggressive language (M.

Burgoon et aI., 1991).

M. Burgoon et al. (1991) argued recently that because males are expected to be

47

affectively neutral and show little concern, both aggressive and nonaggressive language would

be viewed by patients as positive violations of communication expectations for this group of

communicators. On the other hand, because females are expected to be affiliative, increases

in aggressive language by female physicians would result in more negative communicator

evaluations. As support, these researchers found a linear relationship between strategy type

and person perceptions for female physicians such that as verbal aggression increased,

perceptions of the female physicians became less positive. As partial support for the claim

regarding male physicians, the researchers found that male physicians were evaluated more

favorably when they used nonaggressive strategies than moderately aggressive strategies (i.e.,

affectively neutral strategies). Communicator evaluations, however, were not significantly

different between the aggressive and moderately aggressive condition. M. Burgoon et al.

(1991) argued that although these findings do not support the claim that aggressive language is

a positive violation of expectations, these findings do indicate that "an increased level of

verbal aggression does not constitute a negative violation of expectations" (p. 198).

Consequently, the evidence (M. Burgoon et aI., 1991) indicates that female physicians are

restricted to nonaggressive strategies with all other strategies negatively violating patient

expectations and favorable communicator evaluations, whereas male physicians can use either

aggressive or nonaggressive communication without negatively violating expectations or

endangering person perceptions.

This discussion of communication violations and the gender specific interpretations

attached to these violations allows predictions to be advanced regarding patients'

communication evaluations of initial strategies used by male and female physicians.

Previously it was shown that negative regard strategies could be classified as a type of

aggressive communication behavior and positive regard strategies could be viewed as

48

nonaggressive. Further, the argument advanced was that communication acceptability is

based on what patients both expect and prefer and patients prefer physicians to be caring and

interpersonally involved. Consequently, perceptions of relational concern communicated by

the use of regard strategies used in initial encounters and perceived communication

appropriateness of these strategies should be gender specific, such that:

H3: There is an interaction between physician gender and influence strategy in

initial encounters with a physician such that (a) among male physicians, a

deviation from neutral regard strategies, either in the direction of positive

regard or negative regard strategies, is perceived as showing the most concern

for the patient; and (b) among female physicians, there is a direct linear

relationship such that positive regard strategies are perceived as showing the

most concern and negative regard strategies are perceived as showing the least

concern for the patient.

H4: There are gender differences in perceived appropriateness of influence

behaviors in initial encounters with a physician such that negative regard

strategies used by male physicians are perceived as more appropriate influence

attempts than negative regard strategies used by female physicians.

Expectations as a Function of Situational Perceptions

Acceptance or rejection of non-normative communication behaviors could also be a

function of a variety of situational factors that naturally exist during established physician­

patient relationships with the chronically ill or at risk patient populations. Repeated influence

attempts in the health care context, for instance, probably transpire because of previous

patient noncompliance and because the noncompliant actions are life threatening for the

patient. Previous research has not specifically addressed the relationship between

communication expectations and the role of patient severity and previous noncompliance.

Research has shown, however, that these situational variables have a significant effect on

strategy selection.

49

Compliance research (Boster & Stiff, 1984; deTurck, 1985; Dillard & M. Burgoon,

1985; Hunter & Boster, 1978) has demonstrated that personal benefit to the individual (Le.,

patient severity) and resistance to persuasion (i.e., previous noncompliance) are significant

predictors of strategy selection. This research has consistently shown that sources select more

verbally aggressive and aversive influence strategies in situations where there is anticipated

resistance and where the source believes that compliance is in the receiver's best interest.

Additionally, research in the health context has found that physicians are more likely to report

using aggressive influence attempts when the situation is potentially severe and the patient has

been previously noncompliant (M. Burgoon, Parrott, J. K. Burgoon, Birk, et al., 1990).

Because acceptability is a function of frequent message usage (cf. M Burgoon & G. R. Miller,

1985), these situational variables have the potential to affect both expectations and perceived

message acceptability.

A substantial amount of work has also implied that communication evaluations are

different in initial versus established relationships (cf., Derlega, Winstead, Wong, &

Greenspan, 1987; Roloff, 1987). Dissatisfying communication exchanges, for instance, are

expected and tolerated more as relational familiarity increases (Roloff, 1987). Suggesting,

once again, the possible acceptability of more aversive influence attempts in established

physician-patient relationships.

Whereas negative regard strategies should become more acceptable to patients when

the situation is perceived as severe and where previous noncompliance is believed to have

occurred, neutral regard strategy, which communicate a lack of involvement with the patient,

50

should be viewed as unacceptable in these situations. The impact of these situational variables

on strategy expectations and acceptability of positive regard strategies, however, is less clear.

The increased acceptability and expectancy of negative regard strategies in these situations

might, intuitively, suggest a corresponding decrease in the acceptability and expectancy of

positive regard strategies. Tolerance of aggressive influence attempts in these situations,

however, does not necessarily equate to communication preferences. Although patients may

expect aversive influence attempts when their condition is severe and when they previously

have been noncompliant, they may prefer physicians to be sympathetic and encouraging in

these situations. Thus, positive regard strategies may be unexpected but viewed as

appropriate influence attempts because they are a positive violation of expectations.

To address the interaction pattern between strategy type and situational perceptions,

the following hypotheses and research question are advanced for communication evaluations

as a function of perceived severity and pervious noncompliance:

H5a: Patients' expectations and perceptions of appropriateness for a physician's use

of negative regard strategies are positively correlated with perceived severity

of illness.

H5b: Patients' expectations and perceptions of appropriateness for a physician's use

of negative regard strategies are positively correlated with perceptions of

previous noncompliance.

H5c: Patients' expectations and perceptions of appropriateness for a physician's use

of neutral regard strategies are negatively correlated with perceived severity of

illness.

51

H5d: Patients' expectations and perceptions of appropriateness for a physician's use

of neutral regard strategies are negatively correlated with perceptions of

previous noncompliance.

RQ 1: Is there a relationship between perceived severity of illness and patients'

expectation and perceptions of appropriateness for a physician's use of

positive regard strategies?

RQ2: Is there a relationship between perceptions of previous noncompliance and

patients' expectations and perceptions of appropriateness for a physician's use

of positive regard strategies?

The mediating effects of situational variables on gender expectations is also unclear.

The findings (M. Burgoon, Parrott, J. K. Burgoon, Birk, et al. 1990) that physicians are

more likely to report using aggressive strategies with increased severity and resistance were

based on an exceptionally small sample of female physicians (n= 13) compared to male

physicians (n=56). Additionally, M. Burgoon, Parrott, J. K. Burgoon, Coker, et al. (1990)

have found that patients do not perceive physicians as using more aggressive influence

attempts in these situations. Thus, these situational variables are probably not strong enough

to override predicted gender expectancies. However, an attempt will be made to probe

potential interaction effects between strategy type, physician gender, and situational

perceptions.

RQ3: Is there an interaction between physician gender, strategy type, and situational

perceptions on communication evaluation?

Expectations and Assimilation Effects

Although sociological expectations are extremely resistant to change (Darley & Fazio,

1980; Nisbett & Ross, 1980), evidence suggests that people do make some allowances for

52

variations as long as the discrepancy is close to acceptable behavior (Hewes & Planalp, 1982;

Sherif & Hovland, 1961). Accordingly, patients may view some communication strategies as

more closely aligned with expectations than they actually are and, thus, perceive them as

acceptable. Further, schematic research suggests that cognitive structures such as expectations

can change based on the reception of new information (Crocker et ai. 1984). Thus, repeated

use of various influence behaviors by a physician may change a patient's perception of what

communication behaviors are perceived as normative or expected for a particular

communicator.

Researchers have generally supported the notion that acceptance of a stimulus (i.e.,

communication behavior) is determined by its relationship to other acceptable stimuli (Helson,

1964; Pepiton & DeNubile, 1976; Sherif & Hovland, 1961). According to Social Judgment

Theory (Granburg, 1982; Sherif & Hovland, 1961), assimilation, or acceptance, of incoming

information occurs when discrepant information is close to one's latitude of acceptance or

what one generally regards as acceptable. Conversely, communication which is extremely

discrepant from what one views as acceptable results in a contrast effect; that is, the

information is seen as more discrepant than it actually is. In this instance, neither assimilation

nor accommodation to the existing expectancy occurs. Rather, the incongruent behavior is

rejected. Sherif and Hovland (1961) explained that discrepant communication is judged more

negatively and less impartially than communication close to a receiver's latitude of

acceptance.

Assimilation has also been shown to occur more often with ambiguous communication

(e.g., Cohen, 1981; Owens, Bower, & Black, 1979). Ambiguous communication can be

construed as communication with multiple meanings, behavior lacking clear definition, or

behavior that fits more than one schema equally well (Owens et aI., 1979). Because neutral

53

regard strategies don't clearly signal approval or disapproval, these communication behaviors

probably carry relatively ambiguous meaning. This information suggests that occasional use

of ambiguous, neutral compliance-gaining strategies by female physicians during ongoing

exchanges should be perceived by patients as fitting more closely to normative female

behavior than the behaviors actually do and, although not necessarily preferred, should be

acceptable. On the other hand, occasional use of negative regard strategies by female

physicians during ongoing exchanges would be contrasted and perceived as unacceptable.

Because neutral strategies are fairly ambiguous and close to positive regard strategies,

neutral regard strategies should be viewed as relatively appropriate influence attempts for

females in ongoing communication exchanges. Conversely, it is assumed that the use of

negative regard strategies by female physicians results in a contrast effect and are viewed as

inappropriate influence attempts in both initial and ongoing communication exchanges.

Expectations as a Function of Prior Communication Exchanges

Although it was previously suggested that non-normative communication behaviors are

either assimilated into sociological communication expectations or discounted, cognitive

structures such as expectancies can change over time. Most theorizing about cognitive

organizing structures indicates that the structures adapt to fit the events the perceiver is

exposed to (cf. Fiske & Dyer, 1982). Kelley and Thibaut (1978) proposed that individuals

develop and change their probability estimates for how an individual will act in the future by

noting past behavior. Thus, although isolated instances of non-normative communication are

generally dismissed as a "fluke," and the expectancies and person perception are left

unchanged, incongruent or non-normative communication behavior may be judged as typical

of an individual if the behavior occurs repeatedly over time (Crocker et al., 1984). Just as

societal expectations are developed and maintained through frequent confirmation of

expectations (M. Burgoon & G. R. Miller, 1985), so too are communicator specific

expectations.

54

It is generally assumed that cognitive structures change by variables being added to or

subtracted from the existing cognitive structure upon exposure to a new set of events (Crocker

et aI., 1984). Specifically, variables such as type of communication strategy will be added to

the stereotypical communication expectancy if they occur frequently, whereas types of

communication strategies will be subtracted from the stereotypical communication expectancy

if they occur rarely. For example, a physician's use of only positive regard strategies would

caUSI! other strategies to be dropped from the perceiver's communication expectancies for this

particular communicator. On the other hand, a female physician's use of negative or neutral

regard strategies in conjuncture with expected positive regard strategies would allow these

non-normative strategies to be added to the perceiver's stored communication expectancies.

Hence, communication expectations in familiar relationships are moderated by previous

communication patterns such that individuals who have been exposed to a particular influence

strategy will expect to receive that influence strategy in the future more than. those who have

not been exposed to the influence strategy. Thus:

H6a: Positive regard strategies are more expected by patients who have previously

been exposed to positive regard strategies than by patients who have never

been exposed to positive regard strategies.

H6b: Negative regard strategies are more expected by patients who have previously

been exposed to negative regard strategies than by patients who have never

been exposed to negative regard strategies.

H6c: Neutral regard strategies are more expected by patients who have previously

been exposed to neutral regard strategies than by patients who have never

been exposed to neutral regard strategies.

55

Communicator specific expectations pose a special problem for the explanatory

framework of Language Expectancy Theory. Specifically, what counts as a positive and

negative violation of expectations is probably a function of both sociological expectations and

communicator specific expectations. If a communicator continually meets a target's

expectations (female uses positive regard and male uses neutral regard) than evaluation of

communication violations in familiar physician-patient relationships should be the same as in

initial physician-patient relationships. However, if a communicator continually used both

expected and non-normative communication behaviors or uses all non-normative behaviors,

evaluations of future non-normative communication in these situations are likely to be

different from initial encounters with a physician.

The mediating effects of communicator specific expectations on evaluation of non­

normative expectations is unclear. No evidence exists to suggest what would happen if a

communication act negatively violated a communicator specific expectation (Le., a male uses

positive regard strategies and then engages in a negative regard strategy) but positively

violated a normative communication expectation. Thus, predictions cannot be made for future

strategy usage regarding (a) what influence attempts are evaluated as appropriate

communication, as well as (b) what influence attempts are evaluated as showing relational

concern. Due to the lack of evidence about how normative violations of expectations are

impacted by communicator specific expectations, the following research question is proposed

for future communication evaluations:

RQ4: Is there an interaction between previous strategy usage, strategy type, and

gender on communication evaluation?

Summary

56

Patients' conununication expectations determine communication evaluations and, thus,

which strategies can be used by male and female physicians in initial and ongoing

interactions. There is evidence to suggest that communication evaluations are a function of

communicator gender, situational perceptions, and previous communication usage.

Specifically, it was suggested that aversive communication is likely to be tolerated more when

used by male physicians than female physicians or when used in ongoing influence attempts

which involve patients who have previously not complied or whose condition is serious.

Although acceptable communication is a necessary condition for suasory success, it is not a

sufficient condition for increasing adherence rates of knowledgeable patients. Knowledgeable

patients need more than believable arguments that are appropriately and persuasively delivered

by a communicator -- they need communication which offers incentive to comply. Thus,

reinforcement principles are considered to determine which strategies or combinations of

strategies should be used to increase physician persuasiveness, facilitate physician evaluations,

and maintain patient satisfaction in initial and ongoing influence attempts of physicians.

Communication Reinforcement and Motivation

The importance of social reinforcement for motivation and behavioral change is well

accepted by psychologists and health care researchers (cf. Chesney, 1984; Glaser, 1971).

Many health enhancement models follow from Skinner's (1953, 1969) established claim that

behaviors will be emitted by an individual in relation to certain outcomes that either reinforce

the behavior or fail to do so (N. E. Miller, 1984). The administration of positive

consequences (positive reinforcement) or removal of aversive consequences (negative

57

reinforcement) increase the probability of behavior occurring. Conversely, the administration

of negative consequences (negative punishment) or the removal of positive consequences

(positive punishment) decreases the probability of behavior occurring. According to Skinner

(1969), behaviors followed by reinforcers will occur in the future and behaviors followed by

punishers will be extinguished. In accordance with these operant conditioning principles, a

patient's compliant behavior should increase or be maintained if it is followed by a physician's

message of approval or the removal of disapproval cues. Conversely, noncompliant behavior

should be decreased if it is followed by messages of disapproval or the removal of approval

cues.

Although this behavioristic view is parsimonious, several psychologists have taken

issue with such simplistic notions of human behavior. These opponents contend that human

action is not reducible to simple conditioning principles, but must take into account humans'

cognitive and motivational processes (Estes, 1971). Additionally, this Skinnerian perspective

has equated the effectiveness of reinforcement as a function of directly experienced

consequences. However, Bandura (1971) stresses that reinforcement generally occurs within a

social context in which "people continually observe the behavior of others and the occasions

on which it is rewarded, ignored, or punished" (p. 228). A similar view is taken here by

assuming that memory structures storing past reinforcement events, which are directly or

indirectly experienced, guide behavior. More specifically, it will be argued that a physicians'

communication choices influence patients' "communication reinforcement expectations" and

violations of these expectations can facilitate long-term adherence with the physician's request.

Reinforcement Expectations

Just as communication expectations are formed when an individual continually

observes a communicator's repeated communication behavior, communication reinforcement

58

expectations develop when an individual observes a communicator's use of approval,

disapproval, and neutral cues and associates them with one's own action or another's action.

Although generally used to explain stimulus-response sequences, basic principles of

association can account for the formation of reinforcement expectancies. The principle of

contiguity or association has been assumed and supported by most behaviorists (e.g., Estes,

1971; Guthrie, 1959; Hull, 1952; Logan & Wagner, 1965; N. E. Miller, 1959; Thorndike,

1949). For instance, Thorndike's (1931) early writings regarding a "representational theory"

stated that individuals' responses are based on anticipated consequences that have been

acquired through connecting outcomes to various stimulus-response sequences. In terms of

physician communication behavior, patient reinforcement expectancies develop after observing

frequently occurring patient behavior-physician communication connections. Thus,

reinforcement expectancies are formed when patients associate compliant actions with either

eliciting rewarding exchanges or eliminating aversive exchanges.

These reinforcement expectancies guide an individual's behavior by acting as

anticipatory assumptions about action-consequence covariations (e.g., Darley & Fazio, 1980;

Smith, 1982). According to some learning theorists (Daly & Daly, 1982; Estes, 1971;

Logan, 1971; Tolman, 1932), the potential for a behavior to occur in any situation is a

function of the expectancy that the behavior will lead to a particular reinforcement or avoid an

aversive situation. Thus, reinforcement expectancies allow patients to anticipate similar

responses to their actions in the future.

A critical difference between expectancy and behavioristic perspectives is in the role

ascribed to reinforcing stimuli. Behaviorists assume that a behavior occurs because it was

followed by the presentation of reinforcing stimuli, whereas a reinforcement expectancy

perspective assumes that a behavior occurs because an individual expects the behavior to be

59

followed by reinforcing stimuli. Thus, motivation is based on a perceptual process where an

individual perceives the potential for receiving a reinforcing stimuli or avoiding negative ones.

These expectancies are formed through direct or indirect observation of another's

reinforcement behavior.

That direct reinforcement and punishment is effective at motivating humans is well

established (Getsie, Langer, & Glass, 1985; Glaser, 1971). Additionally, past research has

supported the notion that people are motivated to change their behavior after witnessing the

consequences associated with another's behavior (for review, see Bandura, 1971; Podsakoff &

Todor, 1985). Research has shown, for instance, that observing another individual being

reinforced increased behavioral change of the observer (e.g., Bandura, Grusex, & Menlove,

1967; Barnwell, 1966; Liebert & Fernandez, 1970) and observing another being punished

decreased inappropriate behavior (e.g., Walters, Parke, & Cane, 1965). In the absence of

observed punishment or reinforcement, either an increase or a decrease in behavior occurs

(cf. Marlatt, Jacobsen, Johnson, & Morrice, 1970; Ross, 1971). Bandura (1971) explained

these findings by suggesting that when an individual expects to observe punishment for an

emitted behavior and the punishment is omitted, permissiveness is conveyed. On the other

hand, when an individual expects to observe reinforcement and the reinforcement is absent it

conveys to the person that a behavior is not worth performing. For this reason, continual use

of neutral behaviors by a physician should inhibit compliance. Additionally, continual use of

reinforcement could inhibit compliance in situations where noncompliance exists because

punishment was not associated with noncompliant actions.

Violations of Reinforcement Expectations

Although the establishment of communication reinforcement expectancies seems to

suggest that frequent use of rewarding communication serves to convey and confirm

60

reinforcement expectancy associations, sole reliance on reinforcement can be detrimental to

motivation. There is evidence that violations of expectations are arousing and cause an

individual to attend to the meaning of the violating act (J. K. Burgoon, 1991; Helson, 1964).

Although some learning theorists (Hull, 1952; Tolman, 1932) have suggested that discrepant

information changes the previously established association, other evidence indicates that

occasional violations actually motivate individuals to restore the desired state of affairs and

increase the value of the previously expected reward.

Studies comparing continuous reinforcement to intermittent reinforcement provide

evidence that violations of reinforcements increase behavior change. This line of research has

generally supported the belief that partial reinforcement is superior to continuous

reinforcement in long-term behavioral change (Boyagian & Nation, 1981; Eisenberger &

Leonard, 1980; Schoenfeld & Cole, 1972). Several explanations can be offered for the

superiority of intermittent reinforcement.

Frustration. According to Amsel's (1967) frustration hypothesis, nonreward of a

previously rewarded response results in primary frustration which is aversive, but motivating.

This aversive motivation which Amsel labels "frustration," intensifies an individual's

behaviors to restore the anticipated reward. Other researchers (Boyagian & Nation, 1981; J.

K. Burgoon, 1991; H. Daly & J. Daly, 1982; Dillard, 1990; Logan & Wagner, 1965) have

made similar predictions and have offered evidence indicating that when rewards are expected

and not delivered, frustration occurs which motivates the individual to try to regain the

desired behavior. Although this frustration can initially result in an avoidance response, over

time the individual comes to anticipate frustration and is motivated to try to regain the desired

behavior.

The magnitude, or importance of the rewarding behavior (e.g., social approval cue),

61

influences the degree of frustration produced by the nonreward and, consequently, the

individual's motivation to engage in action to restore the desired state of affairs (Dillard,

1990). J. K. Burgoon and Hale (1988) have suggested that an individual will only be

motivated to regain social approval from a rewarding communicator. According to Amsel

(1967), the greater the anticipation of reward (the stronger the association), the greater the

frustration produced by the nonreward. Dillard (1990) has claimed that the magnitude of the

discrepancy, as well as the importance of the behavior, determines if an individual will be

motivated to restore an expected behavior. Similarly, incentive theorists (e.g., Hull, 1952;

Logan, 1969, 1971; Spence, 1956) have argued that the motivation to perform a response is

determined by the value of the reinforcement attached to the response. Thus, patient

motivation should be facilitated when an expected and valued reinforcement does not occur in

a physician-patient interaction.

Net incentive value. Violations of reinforcement expectations can also increase net

incentive value which, according to Logan (1971), determines the degree to which a violation

will motivate an individual to perform a response. As previously discussed, satiation effects

occur with constant use of positive behaviors so they become less valuable. Additionally, it

was stated that reinforcers become more valuable as perceived effort to receive the reward

increases.

The use of aversive stimuli can also strengthen the net incentive value by acting as an

incentive to avoid a particular response (Logan, 1971). Logan (1971) explained that incentive

to act is determined by an individual's perception that a behavior will lead to the acquisition

of positive consequences and the avoidance of negative consequences. Molm (1987) has

suggested that the use of punishment turns future neutral outcomes into negative reinforcers

because the individual believes his or her actions are preventing the punishment from

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reoccurring. As illustration, individuals who expect a communicator to use combinations of

aversive and neutral stimuli are motivated to comply to avoid one stimulus and receive

another. The same is true for individuals who expect a communicator to use combinations of

aversive and reinforcing stimuli or combinations of reinforcing and neutral stimuli. On the

other hand, individuals who only expect to only receive reinforcing stimuli or only aversive

stimuli have only one motivating factor working on their behalf. Thus, individuals should be

more motivated to engage in an action associated with achieving reinforcement and avoiding

punishment than an individual who only expects behavioral reinforcement. Consequently, a

physician who only shows signs of approval or positive regard should be less effective at

motivating a patient than a physician who uses both approval and disapproval cues.

Although some have warned against the use of aversive control because it leads to

anger and aggression (Belleck & Hersen, 1977; Gambrill, 1977; Morris, 1976; Rimm &

Masters, 1979), others have taken exception to this position and have shown aversive stimuli

to be quite effective motivators (Azrin & Holz, 1966; Balsam & Bondy, 1983; Greenbaum et

aI., 1990; Premack, 1971). In a meta-analysis of feedback effects Getsie et al. (1985) report

that people are more motivated to avoid aversive stimuli than to receive reinforcing stimuli

and the combination of the two is the most effective. Further, the observation of others being

punished as opposed to the observation of others being reinforced has been shown to have a

more positive effect on motivation and performance of observers (Podsakoff & Todor, 1985).

Additionally, Balsm and Bondy (1983) have persuasively illustrated that both reward and

punishment have negative side effects and that some combination of each should be used to

counterbalance the other.

Summary

Taken together, this research indicates that violations of communication reinforcement

63

expectations by using combinations of positive regard with neutral strategies, positive regard

with negative regard, or negative regard with neutral strategies are superior to continuous

reinforcement or continuous punishment at motivating a patient. It was suggested that

although violations of reinforcement expectations are initially frustrating, patients are

motivated to avoid or eliminate aversive strategies.

Tests of intermittent reinforcement principles have generally failed to consider the

effects of sociological norms for language usage. In fact, most studies have only tested

males' use of aversive stimuli or combinations of aversive stimuli and reinforcing stimuli (cf.

Podsakoff & Todor, 1985; Podsakoff, Todor, Grover, & Huber, 1984). Research which has

examined the effectiveness of females using aversive stimuli could not establish any positive

effects for punishment (cf. Bateman, Strasser, & Dailey, 1982). This research, combined

with the expectancy literature, suggests that violations of reinforcement expectations are

mediated by gender. Thus, to understand the consequences of strategy choices expectancy

and reinforcement principles must be integrated.

Consequences of Strategy Usage

The following section integrates expectancy and reinforcement assumptions to advance

predictions regarding effective communication influence behaviors for male and female

physicians who have repeated exposure with undermotivated patients. Because ongoing

relationships begin with initial influence attempts, the consequences associated with regard

strategies used in initial encounters with a physician are examined. Next, the consequences

associated with sequential influence attempts are assessed. Finally, the consequences of

influence attempts that follow various strategy combinations will be discussed. The

effectiveness of physician influence attempts will be determined by indexing physician

perceptions, patient satisfaction, and physician persuasiveness during initial and future

64

encounters. Although the ultimate goal for physicians is patient compliance, consideration of

adequate overall satisfaction with the interaction and favorable physician evaluations determine

the reward value of the communicator which mediates suasory attempts (J. K. Burgoon,

1991).

Consequences of Initial Strategy Usage

Violations of expectations were previously discussed to assess the acceptability of

influence attempts used in the health context. This literature also can be used, in combination

with reinforcement principles, to explain the consequences of communication behaviors.

According to J. K. Burgoon (1978, 1991), violations of communication expectations cause the

receiver to focus on the relational meanings attached to the communication event. These

behaviors are then positively or negatively valenced based of both sociological expectations

for communication events and communicator reward value. Thus, the reward value of the

communicator influences the effects of a violation. Similar to Language Expectancy Theory,

if the behavior is positively evaluated then positive interactional consequences should occur

whereas if the behavior is negatively evaluated then negative interactional consequences

should occur.

Patient satisfaction and physician perceptions in initial encounters. Past research has

shown that communication that is inconsistent with perceivers' expectations results in

relational dissatisfaction (Spitzberg & Cupach, 1984). Additionally, medical communication

literature has indicated that positively violating patients' normative expectations by being

interpersonally involved is a determining factor in patient satisfaction (cf. Geerston et al.,

1973). Although men, unlike women, can communicate involvement by being either

aggressive or affiliative, aggressive attempts are aversive communication behaviors which are

not as satisfying as reinforcing influence behaviors.

65

M. Burgoon et al. (1991) have found that physicians' use of affiliative strategies result

in more patient satisfaction for both male and female physicians. Further, although M.

Burgoon et al. did not obtain a significant interaction effect between strategy usage and

physician gender for satisfaction, they did find that the use of neutral strategies by male

physicians resulted in less satisfaction than either aggressive or affiliative strategies,

supporting a nonlinear relationship with male physicians. Aggressive strategies used by

female physicians, on the other hand, was reported to lead to the least amount of satisfaction.

Thus, satisfaction should be higher for both male and female physicians when they use

affiliative communication. Additionally, aggressive communication used by a male physician

should result in more patient satisfaction than aggressive communication used by female

physicians because of the gender specific relational message associated with aggressive

communication. Hence, the following predictions regarding satisfaction with initial influence

behaviors are advanced:

H7: Patient satisfaction with physician influence behaviors is greater with positive

regard strategies than either negative or neutral regard strategies.

H8: There are gender differences in patient satisfaction following negative regard

strategies used in initial encounters with a physician such that negative regard

strategies used by male physicians result in greater patient satisfaction than

negative regard strategies used by female physicians.

According to Nonverbal Expectancy Theory (J. K. Burgoon, 1978, 1991), whether a

communicator is perceived as rewarding depends on both general, trait-like attributes (e.g.,

gender, status, expertise) and state-like attributes (e.g., communication style). Although the

reward-value of both male and female physicians should be quite high in initial encounters,

the fact that reward value is influenced by communicator style means that a physician's

66

reward value could decrease with the use of socially inappropriate and negatively valenced

communication. Evidence from communication competence research (Spitzberg & Cupach,

1984) has offered support for the notion that communication viewed as inappropriate can

endanger perceptions of attractiveness and credibility. Additionally, M. Burgoon et al. (1991)

found that negative violations of communication expectations (e.g., socially inappropriate

communication) resulted in more unfavorable physician evaluations than positive violations or

normative behavior.

Combining predicted gender expectancy predictions, results from M. Burgoon et al.

(1991), and the knowledge that inappropriate communication used by communicators results

in less favorable communicator evaluations and positive violations of expectations results in

the most favorable communicator evaluations, the following hypothesis regarding physician

evaluation in initial encounters with a physician is advanced:

H9: There is an interaction between physician gender and influence strategy in

initial encounters with a physician such that (a) among male physicians, there

is a nonlinear relationship such that positive regard strategies result in the

most favorable physician perceptions and neutral and negative regard

strategies result in less favorable physician perceptions equally; and (b) among

female physicians, there is a direct linear relationship such that positive regard

strategies result in the most favorable physician perception and negative regard

strategies result in the least favorable physician perception.

HI0: There are gender difference with physician perceptions as a result of influence

behaviors used in initial encounters with a physician such that negative regard

strategies used by male physicians result in more favorable physician

perceptions than negative regard strategies used by female physicians.

Physician persuasiveness in initial encounters. Past researchers have suggested that

patient satisfaction leads to compliance. However, it previously was illustrated that the

relationship between satisfaction and compliance is negligible. According to Language

Expectancy Theory (M. Burgoon 1990), positive violations of expectations increase the

persuasive success of the communicator. In support, M. Burgoon et al. (1991) have found

that male physicians are more persuasive when using aggressive or affiliative compliance­

gaining strategies than neutral influence attempts and female physicians are most successful

when using affiliative compliance-gaining strategies.

67

Reinforcement literature also suggests the utility of using either aversive or

reinforcing strategies to influence others. Specifically, aversive and reinforcing strategies

motivate patients to comply in order to avoid future aversive communication interactions or in

order to maintain satisfying ones. According to this perspective, the persuasiveness of an

influence attempt it dependent on whether it is interpreted as either a reinforcer or a punisher,

not whether it is a positive violation. However, physician gender dictates which motivating

stimuli (i.e., aversive or reinforcing) £rul be used to persuade patients. Hence:

Hll: There is an interaction between physician gender and influence attempts in

initial physician-patient encounters such that (a) among male physicians, a

deviation from neutral regard strategies, either in the direction of positive

regard or negative regard strategies, results in greater physician

persuasiveness; and (b) among female physicians, there is a direct linear

relationship such that positive regard strategies result in the greatest physician

persuasiveness and negative regard strategies result in the least physician

persuasiveness.

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Consequences of Strategy Combinations

Compliance-gaining episodes with patients who are chronically ill or who are seeking

lifestyle changes frequently consist of multiple influence attempts. Thus, an assessment of

strategy usage over time is necessary to determine the efficacy of regard strategies in

improving the compliance-gaining process in the medical setting. Although an infinite

number of strategy combinations could be created, an application of Arnsel's frustration

hypothesis suggests the following combinations be assessed: all positive regard, all negative

regard, all neutral regard, mixed positive and neutral regard, mixed positive and negative

regard, and mixed negative and neutral regard. Similar to initial influence attempts, the

effectiveness of strategy combinations used during physician-patient encounters will be

determined by indexing patient satisfaction, physician perceptions, and physician

persuasiveness.

Patient satisfaction and physician perceptions with ongoing influence attempts.

Communication that defines the nature of the physician-patient relationship is a critical

ingredient to relational satisfaction and communicator evaluation. Although previous research

has suggested that satisfaction and physician perceptions can be increased through the use of

reinforcing strategies, it was argued that patient satisfaction with ongoing exchanges is

considered a function of the overall communication reward-cost ratio of strategy

combinations. As Molm (1987) has pointed out, "long-term relationships involve some

exchange of aversive actions" (p. 192). She and others (e.g., Thibaut & Kelley, 1959) have

argued that dissatisfaction with the relationship should only occur if punishment is the main

source of influence used in a relationship.

Greater satisfaction with ongoing exchanges and more favorable person perceptions

are experienced when a communicator utilizes strategies or combinations of strategies that are

69

viewed as socially appropriate (Spitzberg & Cupach, 1984). Conversely, less satisfaction and

less favorable person perceptions are experienced when a communicator utilizes strategies or

combinations of strategies that are viewed as socially inappropriate. Additionally, continual

use of negative regard strategies should be viewed as inappropriate or relationally dissatisfying

because the reward/cost ratio of the interaction is negative.

Combining this information with the relationship stated in hypothesis 1 regarding

reward value of strategy types and the hypotheses regarding the effects of stereotypical gender

expectations on perceived strategy acceptability, the following hypotheses concerning patient

satisfaction and physician evaluations experienced as a result of strategy combinations used by

a physician are forwarded:

H12: There is an interaction between physician gender and strategy combinations

such that (a) among male physicians, all positive, mixed positive/neutral,

mixed positive/negative, and mixed negative/neutral combinations result in

more overall satisfaction than all negative and all neutral combinations; and

(b) among female physicians, all positive and mixed positive/neutral

combinations result in the more patient satisfaction than all negative, mixed

positive/negative, mixed negative/neutral, and all neutral combinations.

H13: There is an interaction between physician gender and strategy combinations

such that (a) among male physicians, all positive, mixed positive/neutral,

mixed positive/negative, and mixed negative/neutral combinations result in

more favorable physician perceptions than all negative and all neutral

combinations; and (b) among female physicians, all positive and mixed

positive/neutral combinations result in more favorable physician perceptions

than all negative, mixed positive/negative, mixed negative/neutral, and all

70

neutral combinations.

The difference in satisfaction and physician perceptions resulting from mixed

positive/neutral combinations and mixed positive/negative combinations is uncertain because

violations of reinforcement expectations should increase the reward value of the positive

regard strategies in both of these situations. Further, both combinations involve reinforcing

and aversive stimuli since the positive/neutral combination uses a neutral strategy that should

be viewed as aversive when used in combination with positive regard strategies. Because the

literature does not indicate clearly which specific combination is most satisfying and which

combination results in the most favorable physician perception, the following relationship will

be probed:

RQ5: Which strategy combination results in the most patient satisfaction and

favorable physician perception?

Physician persuasiveness and ongoing influence attempts. As previously argued,

motivation is based on reinforcement expectations that are developed when an individual

associates another's reinforcing or nonreinforcing behavior with one's own actions or

another's actions. Consistent use of reinforcing communication or nonreinforcing

communication by a communicator can inhibit the development of reinforcement expectations

because appropriate action-consequence sequences do not develop. In these situations,

individuals do not develop expectations that their behavior can prevent the loss of reinforcing

exchanges or that their behavior can eliminate nonreinforcing exchanges. Accordingly,

physicians who consistently use only reinforcing or only nonreinforcing communication

patterns are likely to inhibit the development of reinforcement expectations. Consequently,

continual reinforcement or continual nonreinforcement patterns should be less motivating than

occasional violations of reinforcement. As further support, Amsel's (1967) frustration

71

hypothesis suggests that occasional nonreward of a previously rewarded response motivates

individuals to restore the anticipated reward. Thus, physician persuasiveness is a function of

violations of reinforcement expectations such that negative violations of reinforcement

expectations through the use of neutral regard strategies or negative regard strategies will be

more persuasive than the use of continuous reinforcement or continuous punishment.

Additionally, it was argued that incentive value influences motivation to comply and the

greatest incentive value occurs for a combination of reinforcing and aversive stimulus.

Greater persuasiveness also should be experienced for individuals who are favorably

evaluated. According to Fishbein and Ajzen (1981), intention to perform a particular

behavior is partially a function of an individual's motivation to comply with various referents.

Further, at the core of much persuasion research is the assumption that individuals are more

likely to comply with individuals who have rewarding characteristics associated with them

(Reardon, 1981). For instance, Nonverbal Expectancy Theory (1. K. Burgoon & Hale, 1988)

assumes that rewarding individuals (attractive, competent, pleasant communicator) receive

more favorable outcomes. Finally, inappropriate communication has been shown to inhibit

persuasion and at times result in a boomerang effect for persuasiveness. Thus, the following

hypothesis states that physician persuasiveness is a function of strategy combination and

gender:

H14: There is an interaction between physician gender and strategy combination

such that (a) among male physicians, mixed positive/neutral, mixed

positive/negative, and mixed negative/neutral combinations result in greater

physician persuasiveness than all positive, all negative, and all neutral

combinations; and (b) among female physicians, mixed positive/neutral

combinations result in greater physician persuasiveness than any other

72

combination.

Similar to satisfaction and physician perception predictions, it is unclear which of the

three preferred strategy combinations for the male physician are most persuasive. Thus, the

following relationship will be probed:

RQ6: Which strategy combination results in the most persuasiveness for male and

female physicians?

Consequences of Future Strategy Usage

A final concern of this study pertains to the evaluation and, hence, effectiveness of

various strategies once communicator specific reinforcement expectations have been

established. Although the effectiveness of a single communication transaction in ongoing

exchanges is not as important as overall effectiveness, determining the impact of previous

communication usage on the evaluation and effectiveness of future strategies provides further

evidence of the benefits associated with specific strategy combinations. Further, chronic

disease management and prevention efforts could involve instances where a single consultation

session is crucial. For instance, a physician could greatly benefit from knowing which

influence technique would work the best if confronted with a chronic smoker being diagnosed

as being pregnant. Further, the potential for a certain strategy to be viewed differently due to

communicator specific expectations is of import to future researchers trying to establish

predictions based on communication expectancy perspectives.

Patient satisfaction and physician evaluation associated with future strategy usage.

Evidence suggests that previous communication exchanges with a communicator set up

pre interaction expectancies that can affect subsequent evaluations of the physician, regardless

of the way the physician actually behaved. For instance, J. K. Burgoon and colleagues (J. K.

Burgoon & Le Poire, 1991; J. K. Burgoon, Le Poire, & Rosenthal, 1991) found that

73

individuals who expect positive exchanges with another individual hold onto these favorable

impressions and that those who expect negative exchanges, despite disconfirming evidence,

maintain these unfavorable impressions. Other researchers have similarly documented the

perseverance of first impressions (Ickes, Patterson, Rajecki, & Tanford, 1982; Swann &

Snyder, 1980). Thus, initial, pleasant patient-provider exchanges enable a physician to

employ more negatively evaluated strategies in future interactions without endangering the

physician's impression. However, initial, unpleasant patient-provider interactions decrease a

physician's ability to use positively .evaluated strategies to improve the physician's impression

in the future.

Given this knowledge base and the predictions advanced in Hypothesis 12 and 13,

there should be an interaction between physician gender, strategy combinations, and future

strategy usage such that male physicians who previously used all positive influence attempts or

combinations of positive and neutral, positive and negative, or negative and neutral should

receive more favorable communicator evaluations when using negative, positive, and neutral

strategies in the future than male physicians who previously used all negative or all neutral

strategies. On the other hand, female physicians who previously used all positive strategies or

combinations of positive and neutral strategies should receive more favorable communicator

evaluations when using negative, positive, and neutral strategies in the future than female

physicians who previously used other strategy combinations. However, as stated earlier, it is

unclear whether communicator specific expectations or normative expectations have a stronger

impact on receivers' judgments and it is equally unclear if these two factors interact in some

manner. Due to the lack of evidence about how normative judgments are impacted by

communication specific expectations, the following research question is proposed for

satisfaction and person perceptions associated with future communication exchanges:

74

RQ7: Is there a difference between regard strategies used in initial encounters with a

physician's communication behaviors and regard strategies used after exposure

to a physician's typical communication behaviors for future patient satisfaction

with a particular strategy?

RQ8: Is there a difference between regard strategies used in initial encounters with a

physician's communication behaviors and regard strategies used after exposure

to a physician's typical communication behaviors for evaluation of physician

perceptions after using a particular strategy?

Physician persuasiveness and future strategy usage. Although reinforcement and

expectancy principles are useful in explaining initial physician-patient interactions and strategy

combinations, an application of these principles to future influence attempts is suspect because

it is unclear if communicator specific expectations and normative gender expectations interact.

Previously it was argued that using an appropriate interaction style in ongoing relationships

allows physicians more freedom to use negatively evaluated strategies in the future without

endangering person perceptions or patient satisfaction. However, it is unclear whether these

strategies will benefit the physician in the future. Understanding the motivational effects of

future compliance-gaining strategies is of import to physicians dealing with patients whose

previous noncompliance may make one physician-patient interaction a matter of life or death.

Thus, the following research question will be examined:

RQ9: Is there a difference between regard strategies used in initial encounters with a

physician's communication behaviors and regard strategies used after exposure

to a physician's typical communication behaviors for patient motivation to

comply?

CHAPTER II

METHODS

Overview

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The investigation used a quasi-longitudinal design to determine the effectiveness of

different physician compliance-gaining strategies in initial encounters with a physician and to

determine the effectiveness of strategy combinations used over time by a physician. Patients

from hospitals and private practice clinics were assigned to one of two interrelated studies

conducted via an interactive videotaped computer format involving one or more physician­

patient consultation sessions. Criterion measures were administered by computer to each

subject in private areas of hospital and clinical study sites.

Respondents in Study 1 individually watched 1 of 30 possible physician-patient

consultation sessions. Each session involved a physician requesting a patient to make dietary

changes. The 30 individual sessions varied according to physician gender (male or female),

strategy type (neutral regard, positive regard, negative regard), and consultation session (five

different sessions related to diabetes management). After watching the session, subjects

answered questions related to physician persuasiveness, patient satisfaction, perceptions of the

physician, and evaluation of the physician's communication.

Respondents in Study 2 watched a series of six different consultation sessions, each

involving a physician requesting dietary changes of a diabetic patient. Respondents watched

either a male or female physician and were exposed to 1 of 6 conceptually different strategy

combinations. Each strategy combination began with a neutral consultation session where the

physician reviewed the patient's initial ailments. Strategy combinations were then created by

combining four manipulated consultation sessions from Study 1 to create the appearance of an

ongoing physician-patient relationship. Following these five sessions, subjects responded to a

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number of questions related to the physician's overall persuasiveness, patient's overall

satisfaction, and overall physician perceptions. To test the impact of previous strategy usage

on future strategy usage, respondents viewed one final consultation session that contained

either positive, neutral, or negative regard messages. After watching this session, subjects

responded to the same questions used in Study 1.

Participants

Subjects for both Study 1 and Study 2 were drawn from several different clinics and

hospitals in a large southwestern city. Locations included a private practice clinic specializing

in endocrinology and cardiology en = 176), a family and community medicine clinic affiliated

with a teaching hospital en = 154), a private practice clinic specializing in oncology en =

35), an outpatient clinic, physical therapy unit, and surgery waiting area in a for-profit

hospital en = 457), and two hospital blood drives en = 27). Several patients who participated

in these study sites were recruited from diabetic clinics and diabetic support groups. Eleven

of the participants were excluded from the analyses because they reported on the survey that

they had previously visited the videotaped physician. This left 363 patients participating in

Study 1 and 474 patients participating in Study 2. Because of patient time constraints, 15

patients who participated in Study 1 were unable to complete the entire survey and 16 patients

from Study 2 were unable to complete the entire survey.

A computer-based application was created to control the assignment of subjects to

different conditions in both studies. Each condition, with a corresponding identification

number, was consecutively listed on the application program to assure that the appropriate

number of subjects were assigned to each condition. The facilitator (researcher or research

assistant) had access only to the list of subject and study identification numbers. The

facilitator, however, was blind to experimental conditions. Subjects showed up at random to

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participate in either Study 1 or Study 2 and were also unaware of the condition assigned to

them. Assignment to Study 1 or Study 2 was based on both the list of identification numbers

and the time availability of subjects. The facilitator followed the order of identification

numbers which contained both Study 1 and Study 2. However, if subjects indicated that they

would be unable to volunteer 30-minutes of their time to participate in Study 2, subjects were

asked if they would be willing to participate in a shorter study (Study 1).

Population characteristics for Study 1 and Study 2 were virtually identical. Sixty

percent of the participants in both studies were male. The majority of the patients in the

sample were Anglo (72%). Hispanics comprised the next largest group (16%) followed by

African Americans (3%), American Indians (1 %), and Asians (1 %). Three percent indicated

that their ethnic background was best categorized by some other category than the ones listed

and four percent did not indicate their ethnic origin. The majority of the individuals had at

least a high school education (96%), with 13% having a graduate degree, 19% graduating

from a 4 year college, 41 % having either some college education or trade school experience,

19% having only a high school education, and 4% having less than a high school education.

The sample had a fairly even distribution of valid age groups (at least 18 years of age)

represented with 6% less than 20 years of age, 27% between 20 and 30 years of age, 19%

between 31 and 40 years of age, 17% between 41 and 50 years of age, 12% between 51 and

60 years of age, and 19% over 60 years old. Participants yearly household incomes ranged

from under $10,000 (16%) to over $45,000 (23%). Twenty-two percent had incomes

between $10,001 and $20,000; 20% had incomes between $20,001 and 30,000; and 17% had

incomes between $30,001 and $45,000.

On the average participants reported that they could identify with the patient's

situation (M = 5, Median = 5.5, on a two-item seven-point scale) and felt that dietary

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changes were relevant to their own personal situation <M = 5, Median = 5, on a three-item

seven-point scale). Nearly two-thirds (65 %) of the participants previously had been asked by

their physicians to make dietary changes. Participants reported that dietary changes were

suggested by their physician to manage and/or treat diabetes (12%), heart disease (14%),

cancer (2%), weight problems (33%), or a digestive disorder (13%). Another 27% reported

that they had been asked to change their diet for a reason not listed on the survey. Most of

the patients (43 %) reported visiting their physician between 2 to 5 times a year. Twenty-six

percent reported visiting their physician less than 2 times a year, 18 % reported visiting their

physician between 6 to 10 times a year, and 13% reported visiting their physician 11 or more

times a year. A little over half (54%) of the participants reported that they generally visit

male physicians, 12 % of the participants reported that they generally visit a female physician,

and approximately one-third (33 %) of the participants stated that they visit both male and

female physicians.

Study 1: Consequences of Initial Strategy Usage

The first study was designed to serve two primary goals: (1) to determine how initial

influence attempts used by male and female physicians are evaluated; and (2) to assess the

consequences of initial influence attempts used by male and female physicians on physician

persuasiveness, patient satisfaction, and physician perceptions. Additionally, subjects assigned

to the session that was later used as the final session in Study 2 functioned as a no-exposure

control group to determine the effects of prior communication exposure on evaluation of

subsequent influence attempts.

Design

Study 1 employed a 3 (strategy type) x 2 (physician gender) x 5 (consultation session)

design in which consultation session was treated as a random factor. For Study 1, five

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consultation sessions were developed in which a male or female physician used either positive,

neutral, or negative regard strategies to persuade the patient to make dietary changes. This

was done to enhance generalizability across positive, neutral, and negative regard strategies

used by male and female physicians and to assess potential differences across sessions later

used in Study 2. Participants were assigned to view 1 of 30 videotaped sessions while

imagining themselves as the patient who had visited the physician. To enable patients to more

adequately imagine themselves as taking part in the consultation session, the patient's dialogue

was excluded from the videotape and the physician spoke directly to the subject. Following

the videotape, participants were asked to think carefully about how they would actually feel

and what they would actually do as the physician's patient.

This role-playing method allows for control of extraneous variables not possible in

actual dyadic interactions where such things as the patient's reactions could affect physicians'

communication behaviors. Although role-playing in hypothetical situations does not provide

an ideal level of external validity, deTurck (1985) has argued that it is justified when the

participants view themselves as the main character.

Stimuli and Manipulation of Independent Variables

Script development. A set of five one-minute consultation sessions was developed to

serve as the basis for varying the physician influence attempt (e.g., neutral regard, positive

regard, negative regard). An introductory, neutral consultation session was also developed

for use in Study 2. Development of these six sessions involved three stages. First, the

researcher spent one week observing the head of a family and community medicine clinic at a

teaching hospital during his routine consultation sessions with patients who had conditions

requiring dietary management. This observation period allowed the researcher to view, first

hand, typical patient complaints and possible medical diagnoses/recommendations that could

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serve as the foundation for developing six consultation sessions to either be rated individually

or sequentially. Criteria for choosing a medical condition to be used in the sessions included

finding a problem most people could relate to and one which necessitated ongoing behavior

management, such as dietary changes. Mild diabetes served as the medical basis for all six

consultation sessions because a majority of the approximately 50 patients observed had

complained of feeling tired and run down, which is symptomatic of individuals later

diagnosed with diabetes. This condition is also appropriate for an investigation related to

ongoing physician compliance-gaining attempts because noncompliance is generally high with

diabetic patients (May, 1991) and these patients generally meet with physicians on a regular

basis.

Once the medical condition was determined, two medical experts in clinical practice

of this kind were consulted. First, a family care practitioner at a large teaching hospital was

consulted in regards to typical conversations a physician might engage in with a patient who is

heading towards a diagnosis of mild diabetes. The researcher then wrote a script for each

session, making sure each was approximately equal length and that each followed a natural

progression of probable consultation sessions a patient might encounter who had symptoms of

diabetes and who would later be diagnosed as having mild diabetes. As a final step in

preparing the scripts, the researcher asked another physician with extensive clinical experience

to review each script for realism and authenticity. Appropriate modifications were made to

each script according to suggestions offered by this second consultant.

Six experimental conditions were created for each of the five sessions used in Study 1

by manipulating the type of regard strategy (neutral regard, positive regard, or negative

regard) used in the consultation session and the gender of the physician attempting to persuade

the patient. Thus, a total of 3D-videotaped sessions were constructed for analysis in Study 1.

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Manipulation of regard strategy. Variations in regard were operationalized following

the conceptualizations discussed in Chapter 1 (see Appendix A for definitions and strategy

examples). Each script included three conceptually similar verbal influence attempts spaced

throughout the script (see Appendix B for complete scripts). Additionally, the physicians

dramatizing the scripts were trained to enact nonverbal behaviors, as discussed in Chapter 1,

that complemented the verbal channel.

The neutral regard condition was manipulated by inserting a direct request, a

justification based on expertise, and a justification based on the patient's condition.

Moderately nonimmediate behaviors (indirect body orientation, occasional gaze aversion) and

neutral vocal intonations complemented these neutral regard strategies. The positive regard

condition was manipulated by inserting a supportive request, a validation request, and a

request stressing commonality of goals. These verbal influence attempts were complemented

with a pleasant and affiliative nonverbal interaction style that included high immediacy

(forward lean, direct body orientation, high gaze, smiling) and altercentrism (kinesic/proxemic

attentiveness, vocal warmth/interest). The negative regard condition was manipulated by

inserting a nonsupportive request, an invalidation request, and a request stating negative

consequences. The negative regard strategies were complemented with an unpleasant and

dominant nonverbal interaction style that included egocentrism (lack of kinesic/proxemic

attentiveness and cold vocal tones) and negative feedback (neutral and negative facial

expressions, reduced eye gaze with an occasional direct look).

Prior to videotaping the sessions, a manipulation check was conducted on the verbal

scripts to ensure differences in perceptions of regard (see Appendix C for manipulation check

instrument). Using a repeated measures design, 25 students from an upper division

communication class read and evaluated the 15 manipulated scripts which varied based on the

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physician-patient session (five different sessions) and strategy type (neutral regard, positive

regard, or negative regard).2 The students also read and evaluated the neutral introductory

session used in Study 2. Students were asked to read and evaluate each script individually

while imagining themselves as a patient of a physician who was approximately 45 years of

age. No mention was made of the biological sex of the physician. After each of the 16

messages, subjects completed two subscales measuring communication valence and approval.

The communication valence measure consisted of two seven-point Likert format scales and

four seven-interval bipolar adjective scales (a = .88). The approval measure consisted of a

three-item seven-point Likert format scale (a = .90). The valence items have been used in

previous investigations to assess the interpretation assigned to a communicator's behavior in

an interpersonal relationship (e.g., J. K. Burgoon & Hale, 1988). Scripts were arranged and

evaluated in their naturally occurring order beginning with the introductory episode and

ending with the three manipulated scripts of the last session. The ordering of the three

manipulations began with the neutral version and ended with the negative version.

Results confirmed the success of the manipulation. MANOV A revealed a significant

main effect for type of regard strategy, Wilks' lambda = .34, £(2,16) = 15.45,12< .001,

R2 = .66. There was a significant linear effect for communication valence such that the

positive regard manipulations were more positively valenced (M = 5.02) than the neutral (M

= 4.48) and the negative regard manipulations <M = 3.61), £ (1,17) = 31.24,12< .001.

There was also a significant linear effect for approval such that the positive regard

manipulations communicated the most approval <M = 5.45) followed by the neutral regard

manipulations (M = 5.11) and the negative regard manipulations (M = 4.00), £(1,17) =

6.54,12< .05. There were no significant main effects or interaction effects for sessions.

Sources. The male source and female source used in this investigation were chosen

on the basis of their age, ethnicity, attractiveness, and repertoire of expressiveness. The

female actor was a pediatrician who had been practicing medicine for 10 years and who had

previous experience as an actor for health care videotaped projects. The male actor was a

advanced doctoral student with interests and experience in health communication research.

Both actors were caucasian and approximately 45 years of age. These demographic

characteristics were used to represent the average physician and to enable the results to be

compared to M. Burgoon et al. (1991) who used identical physician characteristics.

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The actors participated in training sessions to standardize the nonverbal manipulations

and to enhance their naturalistic delivery of the scripted consultation sessions. Training

sessions involved rehearsing the scripts so that both the researcher and the actors could

provide feedback to one another. Additionally, one of the training sessions involved

videotaped playback to enable self-critiques by the actors of their performances.

Video production of stimuli. Professional broadcast-quality production facilities were

used to record the 30 manipulated consultation sessions and the two introductory consultation

sessions on a 3/4 inch-SP videotape (16 by each actor). A professional videographer, audio

technician, lighting director, and technical director were used during the recording session.

The videotaped sessions were sent to Crawford Communication in Atlanta, Georgia to create a

"draw" videodisc, thereby allowing the manipulated sessions to be randomly accessed for

playback.

Administration and Procedures

Patients 18 years of age or older were approached by the facilitator (researcher or

research assistant) in hospital and clinic waiting areas and asked if they would be willing to

volunteer 10 to 15 minutes of their time while waiting for their physician or after their

appointment to participate in a study looking at physician communication styles. Patients

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were informed that participation involved watching one short consultation session followed by

a series of questions related to the physician's communication style. The facilitator then went

over a consent form with the patient to explain the nature of the study (see Appendix D). To

decrease demand characteristics, the facilitator explained to each volunteer that a number of

physicians had been videotaped and that the one they would evaluate might use a consultation

session they liked, disliked, or one viewed somewhere in between. The facilitator then

stressed that all of their answers would be confidential and they should try to rate the

physician as honestly as possible.

A computer-based application was created to control the videodisc playback of the

appropriate session in the design and to automatically administer the survey items after the

subject viewed the video segment. The application was created using Asymetrix Toolbook, an

object-oriented Microsoft Windows application that allows for creation of graphical user

interfaces to control screen behavior.

The application's presentation to the subject began with an explanation of how to use

the keyboard and the computer mouse, followed by a practice screen explaining how to

indicate opinions on a Likert-type scale display for each survey questions (see Appendix E).

The facilitator also verbally reiterated the instructions for respondents because the majority of

subjects were not initially comfortable using computers. After subjects successfully navigated

the instructional screens, they were presented with a screen that asked them to put on the

earphones to test the laserdisk player. A short video segment then appeared on the computer

screen. The segment was a 5-second segment from the introductory female physician session

that stated "now looking at your physical exam, your blood pressure is a little high." The

facilitator asked the subject if the volume was comfortable and adjusted the volume

accordingly. Given the assurance of a functioning video and comfortable volume, the subject

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proceeded on to read the introductory screens.

Screen instructions informed subjects that they would be watching a videotaped

physician-patient consultation session followed by a series of questions. The description

stated that the session involved a patient who had consulted the physician because the patient

had not felt very well for a couple of weeks. The physician was described as a primary care

physician who had been practicing medicine in a large southwestern city for a number of

years. Subjects were then instructed that the patient's dialogue had been excluded so that they

could more easily imagine themselves as taking part in this consultation. Finally, the screen

instructions asked that they imagine themselves as the patient as they watched the videotaped

segment. The appropriate session was then displayed on the television monitor. After the

video segment was completed, the survey portion of the application began (see Appendix F

for complete introduction to video segment and for the survey portion of the application).

During the video segment and survey portion of the study, the facilitator moved to

another area of the room that would ensure inability to see subjects' responses while allowing

for detection of problems with the program and enabling participants to ask questions.

Because some subjects were very tentative about operating the computer, the facilitator often

stayed nearby for the first two questions and then retired to a more distant location after

reassuring the subject that they seemed to understand how to work the system. When subjects

completed the program they were thanked for their participation and given a debriefing form

that explained the goals of the study and that told participants not to disclose the details of the

study to other patients.

Dependent Measures

The computer administered survey presented after the videotaped consultation session

contained four sets of questions related to (a) physician persuasiveness and patient motivation

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to comply; (b) patient satisfaction and physician perceptions; (c) communication evaluation

and situational perceptions; and (d) patient background information and relevancy of

physician's recommendations to their own situation. Each section included an introductory

screen reinforcing the appropriate use of the scales and informing subjects of the general

nature of the questions. All items in the first three sections used a seven-point scale and, with

the exception of five items measuring communication appropriateness and communication

valence, all items were bounded by strongly disagree/strongly agree (see Appendix F for full

text of survey and Appendix I for individual scale items).

Physician persuasiveness and motivation to comply. Persuasiveness was assessed by

having subjects respond to an eight-item seven-point scale tapping motivation to comply (e.g.,

"I would be motivated to change my behaviors"), the likelihood that the subject would comply

(e.g., "I would follow Dr. Jones' advice"), and the persuasiveness of the physician's

arguments (e.g., "In this visit, Dr. Jones used effective strategies to persuade me").

Reliability for the measures using Cronbach's (1951) coefficient alpha was .96.

Patient satisfaction. Satisfaction with communication used during the consultation

session was assessed by having participants respond to eight seven-point items from Hecht's

(1978) Interpersonal Communication Satisfaction measure; Smith, Falvo, McKillip, and Pitz's

(1984) Patient-Doctor Interaction Scale; and Wolf, Putnam, James and Stiles' (1978) Medical

Interview Satisfaction Scale. Six items measured affective satisfaction (e.g., "I would feel

much better after this visit with Dr. Jones") and two items measured communication

satisfaction (e.g., "I was very satisfied with Dr. Jones' style of communication in this

session "). The satisfaction scale had a coefficient alpha of .93.

Physician perceptions. Perceptions of the physician were measured using a six-item

seven-point scale that addressed how competent the physician appeared (e.g., "Dr. Jones is a

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very competent physician"), how the physician dealt with patients (e.g., "Dr. Jones is good at

dealing with patients"), and how much confidence one would place in the physician (e.g., "I

would trust Dr. Jones to deal with my medical problems"). The reliability of this measure

using Cronbach's alpha was .94.

Communication evaluation. The physician's communication was evaluated using five

subscales measuring communication appropriateness, communication expectancy,

communication valence, messages of approval, and affect. A three-item seven-point scale

assessed the subjects' perception of communication appropriateness ("How would you rate Dr.

Jones' interaction with the patient on a scale ranging from very inappropriate to very

appropriate?" bounded by very inappropriate/very appropriate; "How would you rate Dr.

Jones' interaction with the patient on a scale ranging from very unprofessional to very

professional?" bounded by very unprofessional/very professional; and "If I were a patient, I

would object to the manner in which Dr. Jones talked to me" bounded by strongly

disagree/strongly agree). Communication expectancy was measured using a three-item seven­

point scale ("I think it is normal for Dr. Jones to respond to a patient this way"; "Dr. Jones'

communication style during this visit is what I anticipated"; "I did not expect Dr. Jones to

communicate this way") taken from M. Burgoon et al. (1991). Each of the communication

expectancy items was bounded by strongly disagree/strongly agree. Reliabilities for these

measures using Cronbach's coeefficient alpha were .83 for communication appropriateness

measure and .74 for communication expectancy.

The communication valence measure consisted of a four-item seven-point scale ("How

would you rate Dr. Jones' interaction with the patient on a scale ranging from very pleasant

to very unpleasant?" bounded by very unpleasant/very pleasant; "How would you rate Dr.

Jones interaction with a the patient on a scale ranging from very unenjoyable to very

enjoyable?" bounded by very unenjoyable/very enjoyable; "Dr. Jones interacted with me the

way I like" bounded by strongly disagree/strongly agree; "How would your rate Dr. Jones'

interaction with the patient on a scale ranging from very undesirable to very desirable:"

bounded by very undesirable/very desirable) taken from J. K. Burgoon, Newton, Walther,

and Baesler (1989).

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The communication approval measure used a three-item seven-point scale evaluating

the patient's perceptions of relational messages related to the degree of approval the physician

had for the patient or the patient's actions (e.g., Dr. Jones acted like I wasn't trying hard

enough"). A three-item seven-point scale measured the degree of affect communicated by the

physician's message (e.g., "Telling me this shows Dr. Jones cares about me as a patient").

Approval and affect items were all bounded by strongly disagree/strongly agree. Reliabilities

for these communication evaluation items were .91 for communication valence, .75 for

messages of approval, and .88 for affect.

Situational perceptions. Four measures were used to assess the subject's perceptions

of the situation: prior contact (e.g., "It seemed like this was one of the first times the patient

had visited Dr. Jones"), severity of illness (e.g., "I would consider this a serious medical

problem if I were the patient"), previous noncompliance (e.g., "I don't think this patient

generally follows the physician's advice"), and confidence in physician's recommendations

(e.g., "If I were actually the patient I would be convinced that following the physician's

suggestions would make me feel much better").3 Each scale consisted of two-item seven-point

scales bounded by strongly disagree/strongly agree. Reliabilities for these situational

perceptions measures were .70 for prior contact, .83 for severity of illness, .88 for previous

noncompliance, and .84 for confidence in the physician's recommendations.

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Study 2: Consequences of Strategy Combinations

The second study was designed to serve two primary goals: (1) to assess the

consequences of strategy combinations used by male and female physicians on persuasiveness,

patient satisfaction, and physician perceptions; and (2) to determine the effects of previous

communication exposure on evaluation of future influence attempts used by male and female

physicians. Participants watched five sequential physician-patient consultation sessions

combined to represent 1 of 6 conceptually different strategy combinations. They then

evaluated the physician's overall communication effectiveness on a computer administered

survey. Following the survey, participants watched one final consultation session that used

either positive, neutral, or negative regard strategies and then rated the physician's

communication style used in this last session.

Design

A 6 (strategy combination) x 2 (physician gender) x 3 (final consultation regard

strategy) factorial design was used, involving six conceptually different strategy combinations

used by a male or female physician and followed by a consultation session which included

either neutral regard, positive regard, or negative regard influence attempts. The strategy

combinations included three pure types (all neutral regard sessions, all positive regard

sessions, or all negative regard sessions) and three mixed combination (positive/ neutral

regard sessions; negative/neutral regard sessions; positive/negative regard sessions).

Manipulation of Independent Variables

Thirty-six experimental conditions were created by combining the 32-videotaped

sessions described in Study 1 (30-manipulated sessions used in Study 1 and two neutral

introductory sessions). The conditions differed by physician gender, strategy combination,

and type of regard strategy used in the final consultation session. Because the combinations

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were created by using the videotaped sessions from Study 1, both studies used the same male

and female physician. The procedures for manipulating regard strategies used in the

individual consultation sessions were also the same.

Manipulation of strategy combination. A computer program was developed to

combine the appropriate sessions from the videodisc to create the appearance of sequential

consultation sessions used by the same physician. Each of the combinations began with either

a male or female physician delivering a neutral, introductory session. In this first session, the

physician summarized what the patient had stated in an initial examination followed by a

series of neutral requests related to eating more nutritional foods, having some lab work done,

and seeing the physician at the end of the week. This neutral, introductory session was used

to avoid negative and positive preinteraction expectancies which have the potential to

influence subsequent communication evaluations (cf. J. K. Burgoon & Le Poire, 1991).

Following the neutral, introductory session, four sequential sessions from Study 1

were used to create the combinations. Thus, each combination consisted of five sequential

sessions. Combinations for the pure types (i.e., all neutral, all positive, all negative) were

created by using the four sessions containing the same regard strategy type (e.g., the pure

positive combination began with the neutral, introductory session followed by four sessions

using positive regard strategies). Because four sessions were also used to create the mixed

combinations (two sessions of each regard type), six possible orders existed for each of the

three mixed combinations. Although an attempt was made to assess ordering effects within

the three mixed combinations, logistical considerations for recruiting huge numbers of patients

prohibited the testing of all possible ordering effects. The theoretical rationale suggested the

efficacy of occasional violations of reinforcement or intermittent reinforcement. A skip­

pattern order (e.g., positive-negative-positive-negative), therefore, was used rather than using

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one strategy type for each of the first two sessions and the other strategy type for the last two

sessions (e.g., positive-positive-negative-negative). A skip-pattern order was also used to

prevent recency effects that could override the effects of strategy combinations. Specifically,

ending with two sessions of the same strategy type could have a stronger influence on the

participant's evaluation of a physician's communication than the strategy combination used.

Because recency effects could also exist for the skip-pattern order two different orders were

included for each of the three mixed combinations. 3 For the mixed positive/neutral

combinations, participants saw a skip-pattern order either ending in a neutral regard (Le.,

positive-neutral-positive-neutral) or ending in a positive regard session (Le., neutral-positive­

neutral-positive). Mixed negative/neutral combinations and mixed positive/negative

combinations were created in the same manner. These concerns for ordering effects resulted

in three additional combinations to the original six. Figure 1 summarizes all combinations

evaluated in Study 2.

Figure 1. Strategy Combinations Created for Study 2.

Session 1 Session 2 Session 3 Session 4 Session 5

Combination 1: Neutral Neutral Neutral Neutral Neutral

Combination 2: Neutral Positive Positive Positive Positive

Combination 3: Neutral Negative Negative Negative Negative

Combination 4a: Neutral Neutral Positive Neutral Positive

Combination 4b: Neutral Positive Neutral Positive Neutral

Combination 5a: Neutral Neutral Negative Neutral Negative

Combination 5b: Neutral Negative Neutral Negative Neutral

Combination 6a: Neutral Positive Negative Positive Negative

Combination 6b: Neutral Negative Positive Negative Positive

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Manipulation of final strategy type. Participants filled out a questionnaire following

the strategy combination and then watched one final session with the physician. This final

session either contained neutral regard strategies, positive regard strategies, or negative regard

strategies. Combined with the gender manipulation, this created a 6 x 2 x 3 factorial design.

This last session was a session developed for Study 1. Thus, operationalization of regard

strategies were identical to those previously described. Specifically, each session included

three conceptually similar verbal influence attempts spaced throughout the script. The neutral

regard condition used a direct request, a justification based on expertise, and a justification

based on the patient's condition. The positive regard condition used a supportive request, a

validation request, and a request stressing commonality of goals. The negative regard

condition used a nonsupportive request, an invalidation request, and a request stating negative

consequence (for complete scripts, see session six in Appendix B).

Administration and Procedures

Patients 18 years of age or older were approached by the facilitator in hospital and

clinic waiting areas and asked if they would be willing to volunteer 30 minutes of their time

to participate in a physician-communication study. Patients were informed that participation

involved watching five different consultation sessions, each lasting approximately one minute,

followed by a series of questions related to the physician's overall communication style. The

facilitator then went over a consent form with each volunteer to explain the nature of the

study (see Appendix G). Similar to Study 1, the facilitator explained to each volunteer that a

number of physicians had been videotaped. and that the one they would evaluate might use a

consultation style they either liked or disliked and then stressed that all of their answers would

be confidential. Finally, the facilitator informed the patient that following the first set of

questions they would view one more session with the physician and have the opportunity to

93

rate the physician's conununication style one more time.

Study 2 used the same computer-based application program with identical computer

instructions used in Study 1 (see Appendix E). Following the computer orientation, screen

instructions informed subjects that the video they were about to watch contained several

sessions involving Dr. Jones/Dr. Hansen (the name was changed for the male and female

physician conditions) and a patient she/he has been seeing for a number of years. The

physician was described as a primary care physician who had been practicing medicine in a

large southwestern city for a number of years. Subjects were instructed that the patient's

dialogue had been excluded so that they could more easily imagine themselves as taking part

in each situation. Finally, the screen instructions asked that they imagine themselves as the

physician's patient as they watched each segment.

Prior to displaying each segment on the television monitor, subjects read a screen

containing some brief background information regarding the consultation session they were

about to view. The description of the first session stated that in the first segment, the patient

had gone to see Dr. Jones because the patient had been tired, rundown, and generally not

feeling very well for a couple of weeks. The description of the second session explained that

one week later, the following discussion took place. The description of the third session

stated that several months later, the patient returned complaining that the condition did not

seem to be getting better. Additionally, to make sure the patient's noncompliant behavior did

not seem deviant, the description informed the subject that, like many patients, the patient has

not been able to make all the dietary changes that had been suggested. The fourth session

was presented as a conversation that occurred during an annual physical. The fifth session

was introduced as "one week later, the following conversation took place."

After the fifth video segment was completed, the survey portion of the application

94

began (see Appendix H for complete introductions to each video segment and for the survey

portion of the application). Following this survey, a computer screen stated that the

participant would be watching one more videotaped physician-patient consultation session.

The introduction to this final session was identical to the description provided in participants

in Study 1. The second survey began after this sixth video segment was completed.

Consistent with Study 1 procedures, the facilitator was located in another area of the

room that would ensure inability to see subjects' responses while allowing for detection of

problems with the program and enabling participants to ask questions. When subjects

completed the program they were thanked for their participation and given a debriefing form

that explained the goals of the study and that told participants not to disclose the details of the

study to other patients.

Dependent Measures

The computer administered survey presented after viewing the first five videotaped

sessions contained three sets of questions related to (a) overall physician persuasiveness and

motivation to comply; (b) overall patient satisfaction, physician perceptions, and physician

affect; and (c) reinforcement expectations, relevancy, and perceived difficulty. Each section

included an introductory screen reinforcing the appropriate use of the scales and informing

subjects of the general nature of the questions. All items used a seven-point scale and were

bounded by strongly disagree/strongly agree (see Appendix H for full text of survey and

Appendix I for individual scale items). A second computer administered survey appeared

after the sixth videotaped session and contained the same set of questions presented to subjects

in Study 1 (see Appendix F for full test of survey).

Overall persuasiveness. Overall persuasiveness was assessed by having subjects

respond to a seventeen-item seven-interval scale tapping motivation to comply (e.g., "Dr.

95

Jones made me want to change my behavior"), the likelihood of compliance (e.g., "I would

follow Dr. Jones' advice"), and the persuasiveness of the physician's strategies (e.g., "Dr.

Jones used effective strategies to get me to change my behavior"). Nine of these items were

from the persuasiveness scale used in Study 1 but were phrased to measure overall

persuasiveness (e.g., Study 1: "In this visit, Dr. Jones made me think about my behavior

very much" versus Study 1 "Dr. Jones caused me to think about my behavior very much").

Because the initial survey was too long for most patients to complete, this scale was reduced

to an eleven-item scale by removing items lacking discriminant validity. S Most of the

likelihood of compliance items suffered from poor discriminatory power and were,

consequently, deleted from the survey. The final persuasiveness scale had a Cronbach's alpha

of .96.

Overall patient satisfaction. Overall satisfaction was measured using the same eight

items used in Study 2 with slight modifications in the wording of the items. In Study 1, items

generally included the phrase "in this visit," whereas Study 2 left these items as measures of

overall satisfaction (e.g., Study 1: "This visit made me feel understood by Dr. Jones" versus

Study 2: "I would feel understood as a patient of Dr. Jones"). As in the overall

persuasiveness scale, several items were deleted from the scale because they lacked adequate

discriminant validity. The reliability of the final five-item satisfaction scale was .94.

Physician perception. Physician perception was measured using the same six items

used in Study 1 to measure perceptions of the communicator. The reliability of this measure

for Study 2 was .95.

Communication evaluation. One two-item seven-interval scale assessed the

physician's affect for the patient ("Dr. Jones cared about me as a patient"; "Dr. Jones showed

concern for me"). A three-item seven-interval scale measured reinforcement expectations.

These items measured whether the patient perceived that the physician's communication

choices were dependent on the patient's behaviors (e.g., "I think a patient's behavior affects

Dr. Jones' communication style") and was used as a manipulation check of reinforcement

expectancies. Reliabilities for these measures were .93 for affect and. 70 for reinforcement

expectations .

96

Dependent measures for evaluation of future strategies. Scale items following the

sixth consultation session were identical to the items used in Study 1. However, because the

length of the instrument needed to be shortened to accommodate the patients' schedule, nine

items were removed from the scale that lacked adequate discriminate validity (see Appendix 1

for items that were deleted). With the exception of the appropriateness and expectancy items,

the reliabilities for these items were either equal to or higher than the reliabilities reported for

Study 1.6 The expectancy reliability dropped to .66 and the appropriateness reliability was

.67.

Assessment of Source Characteristics

Several of the hypotheses were based on the assumption that physicians are viewed as

high reward communicators. Thus, a pilot test served as a manipulation check for physician

rewardingness. An attempt was also made to determine how closely initial perceptions of the

two communicators were to people's perceptions of the "average" physician who is

approximately 45 years of age. Part two of the pilot study provided an estimate of source

generalizability.

To measure the rewardingness of the male and female physician used in the

investigation, 40 patients taken from the same population pool as Study 1 and Study 2 viewed

the introductory, neutral session used in Study 2 and completed three computer administered

measures related to the physician's credibility, rewardingness, and attractiveness. Similar to

97

Study 1, participants read an introductory computer screen informing them that the

consultation session they were about to watch involved a patient who has consulted with the

physician because the patient had not felt very well for a couple of weeks. The physician was

described as a primary care physician who had been practicing medicine in a large

southwestern city for a number of years. Participants were then instructed to imagine

themselves taking part in this consultation session (see Appendix J for introductory

instructions and questionnaire).

Credibility was assessed through ratings on twenty seven-interval bipolar adjective

scales measuring the two most important dimensions of credibility: competence and

character. The items were taken from J. K. Burgoon (1976) and McCroskey and Young

(1981). Competence scale items included responsible/irresponsible, intelligent/unintelligent,

expert/inexpert, qualified/unqualified, bright/stupid, valuable/unvaluable, trained/untrained,

competent/incompetent, informed/uninformed, and logical/illogical (a = .90). Character

items included formal/informal, trustworthy/untrustworthy, virtuous/sinful,

believable/unbelievable, cooperative/not cooperative, honest/dishonest,

sympathetic/unsympathetic, admirable/unadmirable, unselfish/selfish, and reliable/unreliable

(a = .79). The reliability of the entire scale was .90.

Subjects rated overall physician rewardingness on four seven-interval bipolar

adjectives taken from Burgoon, Walther, and Baesler (1991) that evaluated the opportunity to

interact with the physician again (very undesirable/very desirable, very unrewarding/very

rewarding, very unpleasant/very pleasant, very distasteful/enjoyable). Reliability was .87.

Additionally, twelve seven-interval items adapted from McCroskey and McCain (1974)

measured physician social (a = 92), task (a = .91), and overall attractiveness (a = .81).

Five items measured social attractiveness (e.g., "I could establish a friendly physician-patient

98

relationship with Dr. Jones"); five items measured task attractiveness (e.g .• "Dr. Jones would

be a physician I could depend on"); and two items measured overall attractiveness (e.g., "I

would be happy with Dr. Jones as my primary care physician"). The reliability of the entire

scale was .96.

To determine how similar the two physicians were to physicians with similar

characteristic (Le., a 45-year old primary care physician), another set of 40 patients read the

same neutral session and were given the same instructions as the subjects who had viewed the

session. Additionally, half of the subjects were told that the physician was a 45-year old

male, and half of the subjects were informed that the physicians was a 45-year old female.

Source Characteristics

CHAPTER 3

RESULTS

Manipulation Checks

99

Initially, source characteristics of the two videotaped physicians used in Study 1 and

Study 2 were assessed to detennine whether or not the physicians chosen for the

manipulations were high reward communicators. Using a transcript of the videotaped

interaction, these ratings were then compared to patients' perceptions of a typical 45-year old

male or female primary care physician. Generalizability of the results from Study 1 and

Study 2 required that patients' perceptions of the videotaped physicians were not significantly

different from patients' perceptions of physicians in general. Additionally, several of the

assumptions leading up to the hypotheses presumed that the videotaped physicians would

initially be seen as rewarding communicators.

An examination of the mean scores for credibility, communicator rewardingness, and

attractiveness indicated that the videotaped physicians were initially perceived as relatively

rewarding communicators. Both physicians were perceived as credible <M for Male = 5.63;

M for Female = 5.18), rewarding <M for Male = 5.21; M for Female = 4.43), and above

average on social <M for Male = 5.43; M for Female = 4.39) and task attractiveness <M for

Male = 5.52; M for Female= 4.82).

Data from the patients' perceptions of the videotaped physician and the data from the

patients' perceptions of the transcript version were analyzed using a 2 (gender) x 2 (condition)

multivariate analysis of variance (MANDV A) for the dependent measures of competence,

character, social attractiveness, task attractiveness, overall attractiveness, and rewardingness.

This MANDVA revealed no significant interactions between gender and condition, Wilks'

100

lambda = .93, approximate 1:(6,71) = .84, n=.54, and no significant differences between

the videotaped version and transcript version, Wilks' lambda = .97, approximate 1:(6,71) =

.39, n=.88. A significant main effect for gender emerged, Wilks' lambda = .84,

approximate 1:(6,71) = 2.24,12< .05, R2=.16, with significant univariate effects for social

attractiveness, approximate 1:(1,76) = 6.13, n< .05, eta2=.07, overall attractiveness,

approximate E(1,76) = 9.45,12< .01, eta2=.11, and communicator rewardingness,

approximate 1:(1,76) = 6.51, n< .05, eta2=.08. Males were perceived as more socially

attractive <M = 5.17) than females <M = 4.49), had higher ratings on overall attractiveness

<M = 5.29) than females <M = 4.43), and were perceived as more rewarding <M = 5.06)

than females <M = 4.49). Table 1 summarizes the means and standard deviations for each

source characteristic.

Table 1

Source Maninulation Check: Observed Means and Standard Deviations on the Source Characteristic Measures for Videotaped and Transcrint Versions of the Male and Female Physicians

Videotaged Version Transcrigt Version

Male (n=20) Female (n=20) Male (n=20) Female (n=20)

Source Characteristics M SO M SO M SO M SO

Credibility 5.63 .63 5.18 .72 5.34 .70 5.26 .68

Competence 5.96 .66 5.55 .84 5.69 .71 5.51 .70

Character 5.21 .75 4.43 .79 4.99 .83 5.02 .72

Attractiveness 5.49 .86 4.55 1.43 5.00 .85 4.70 1.12

Social 5.43 .95 4.39 1.60 4.90 .94 4.59 1.26

Task 5.52 .83 4.82 1.36 5.09 1.00 4.85 1.06

Overall 5.58 1.13 4.25 1.60 5.00 .99 4.60 1.22

Rewardingness 5.21 .70 4.43 1.36 4.55 1.07 4.90 .70

101

Order Effects for Mixed Combinations in Study 2

Order effects were assessed for each of the conceptually similar mixed combinations

to determine if combinations 4a (neutral-positive-neutral-positive) and 4b (positive-neutral­

positive-neutral) could be collapsed into an overall mixed positive/neutral condition; if

combinations Sa (neutral-negative-neutral-negative) and Sb (negative-neutral-negative-neutral)

could be collapsed into an overall mixed negative/neutral condition; and if combinations 6a

(positive-negative-positive-negative) and 6b (negative-positive-negative-positive) could be

collapsed into an overall mixed positive/negative condition. Three separate MANOV As were

run for the dependent measures that immediately followed the combinations (persuasion,

satisfaction, physician perception, and affect). The first multivariate analysis examined

differences between combinations 4a and 4b. The second multivariate analysis examined

differences between combinations Sa and Sb. The third multivariate analysis examined

differences between combinations 6a and 6b. All multivariate and univariate tests for each

combination pair were insignificant.

As a further assessment of order effects, three additional MANOV As were run for the

dependent measures that followed the final consultation session (approval, expectancies,

appropriateness, relational concern, persuasion, satisfaction, and physician perceptions). All

multivariate and univariate tests for each combination pair were, again, insignificant. These

findings justified collapsing the conceptually similar mixed combination pairs into the three

mixed combinations of positive/neutral, negative/neutral and positive/negative combinations.

Reinforcement Expectations

An unequivocal test of the strategy combination hypotheses for Study 2 required that

there be perceived differences in reinforcement expectations between the three pure

combination types (all neutral regard sessions; all positive regard sessions; all negative regard

102

sessions) and the three mixed combination types (positive/neutral regard sessions;

negative/neutral regard sessions; positive/negative regard sessions) such that the pure

combinations would result in lower reinforcement expectations than the mixed. One way

analysis of variance revealed a significant main effect for combination, E(5,467) = 4.84,

n < .0001, eta2= .08. The direct test of this manipulation check involved a 1 degree of

freedom contrast analysis comparing the pure types (contrast weights of -1, -1, -1) to the

mixed combinations (contrast weights of + 1, + 1, + 1). This test was significant, !(467) =

4.21, n< .0001. Examination of the means in Table 2 shows that reinforcement expectations

were lower in the pure combination types than in the mixed combination types. Thus,

subjects exposed to the mixed combination types were more convinced than subjects exposed

to the pure types that the patient's behavior influenced the physician's communication style.

Table 2

Reinforcement Expectations Manipulation Check for Study 2: Observed Means and Standard Deviations for Pure Combinations and Mixed Combinations on Reinforcement Expectations

Mean SD n

Pure Types 4.16 1.34 234

All Positive Combination 4.13 1.30 80

All Neutral Combination 4.03 1.18 79

All Negative Combination 4.33 1.55 75

Mixed Types 5.00 1.25 238

Positive/Neutral Combination 4.95 1.13 81

Positive/Negative Combination 5.09 1.35 79

Negative/Neutral Combination 4.97 1.26 78

103

Study 1: Initial Strategy Usage

Communication Evaluation of Regard Strategies

Hypotheses 1 through 5 and research questions 1 through 3 concerned the relationship

between the type of influence attempt used in initial encounters with a male or female

physician and patients' communication evaluations. Although the dependent variables in

Study 1 were highly correlated, variables were only analyzed together with multivariate

analysis of variance (MANOV A) when there was a high conceptual interrelatedness between

the variables and when the measures were treated as a set in the same hypothesis (see Table 3

for intercorrelations). In all other instances, hypotheses with categorical predictor variables

were analyzed with a 3 (strategy type) x 2 (physician gender) x 5 (consultation session)

analysis of variance (ANOVA). Consultation session was treated as a replicated factor in

each analysis. Following these analyses, direct tests of the hypotheses were conducted with 1

degree of freedom contrast analyses. The contrast tests are reported as one-tailed! tests.

Hypothesis 5 and research questions 1 through 3 were tested with mUltiple regression.

Table 3

Intercorrelations Among Dependent Variables in Study 1

Valence Approval Expect Concern Approp Satis Percep Pers

Valence (Valance) 1.00 .71 .72 .84 .88 .91 .88 .81

Approval (Approval) 1.00 .61 .62 .74 .71 .63 .58

Expectations (Expect) 1.00 .63 .70 .72 .64 .60

Relational Concern (Concern) 1.00 .79 .1l4 .82 .77

Appropriateness (Approp) 1.00 .87 .83 .73

Patient Satisfaction (Satis) 1.00 .90 .86

Physician Perception (Percep) 1.00 .85

Persuasiveness (Pers) 1.00

104

Reinforcing quality of regard strategies. The first hypothesis predicted that positive

regard strategies would be perceived as the most reinforcing type of influence attempt

followed by neutral regard strategies, and then negative regard strategies. To test the

conceptualization of positive, neutral, and negative regard strategies, a 3 (strategy type) x 5

(consultation session) multivariate analysis of variance for the dependent measures of approval

and valence was performed. Consultation session was treated as a replicated factor. Bartlett's

sphericity test (203.88, R< .0001) confirmed that a multivariate analysis was appropriate.

Hypothesis 1 was confirmed. The MANOV A was significant for the two dependent

measures, Wilks' lambda = .10, E(4,14) = 7.31, R< .005, R2 = .90. As Table 4 shows, the

analysis revealed significant differences on each of the dependent variables. The direct test of

the hypothesis, using the contrast coefficients of + 1, 0, -1, was significant for both approval,

I(352) = 6.04, R< .0005, and valence, 1(352) = 5.59, R< .001. As indicated by Table 5,

patients perceived positive regard strategies as the most reinforcing, followed by neutral

regard strategies, and then negative regard strategies.

105

Table 4

HI: Univariates on Percentions of Aimroval and Valence

SS DF MS F Sig

Valence

Session (S) vs Within 15.94 4 3.98 1.90 .110

Strategy by Session (ST X S) vs Within 16.34 8 2.04 .97 .456

Strategy vs (ST X S) 65.62 2 32.81 16.07 .002

Within 712.41 340 2.10

Approval

Session (S) vs Within 9.47 4 2.37 1.22 .303

Strategy by Session (ST X S) vs Within 14.69 8 1.84 .94 .480

Strategy vs (ST X S) 72.85 2 36.43 19.83 .001

Within 661.07 340 1.84

Table 5

HI: Observed Means and Standard Deviations on Ratings of Approval and Valence for Regard Strategies

Positive

ill= 123)

Reinforcement Measure M SO

Approval 4.88 1.35

Valence 5.02 1.45

Regard Strategy

Neutral

(n= 117)

M SO

4.43 1.35

4.45 1.40

Negative

(n= 115)

M SO

3.79 1.48

4.00 1.51

106

Communication expectations. Hypothesis 2 predicted gender differences in

expectations of influence behaviors such that male physicians are expected to use neutral

regard strategies and female physicians are expected to used positive regard strategies. A 3

(strategy, type) x 2 (gender) x 5 (consultations sessions) analysis of variance with consultation

sessions as a replicated factor was performed for the dependent variable of expectancy.

Hypothesis 2 was not supported. Although patients did expect females to use positive regard

strategies more than any other strategy, patients did not expect male physicians to use neutral

strategies more than any other strategy. Rather, there was a significant main effect for

strategy, 1:(2,8) = 10.26, p< .01, eta2 =.07, with positive regard strategies the most expected

and negative regard strategies the least expected for both male and female physicians (see

Table 6 for means). The main effect for gender and the predicted interaction effect between

gender and strategy, however, was not significant (Table 7).

Perceptions of relational concern. The predicted interaction between physician gender

and influence strategy for messages of relational concern was tested with the same analysis of

variance design used for hypothesis 2. Hypothesis 3 was not supported. Patients did not

perceive both positive and negative regard strategies as showing relational concern when used

by a male physician (see Table 6 for means). There was a significant main effect for

strategy, 1:(2,8) = 13.32, p< .005, eta2 =.06, with positive regard strategies showing the

most affect and negative regard strategies showing the least affect. However, the main effect

for gender and the predicted interaction effect between gender and strategy were not

significant (Table 7).

Appropriateness. Hypothesis 4 predicted that patients' would perceive negative regard

strategies as more appropriate influence attempts when used by male physicians than when

used by female physicians. The predicted gender effect for perceptions of appropriateness

107

was initially tested with the same analysis of variance design used in Hypothesis 2 and 3.

There was a significant main effect for both strategy, E(I,8) = 17.10, I!< .001, eta2=.IO,

and physician gender, E(2,4) = 8.39, I! < .05, eta2= .02. The gender by strategy interaction

was not significant (Table 7). The direct test of hypothesis 4 used the error term associated

with the strategy by gender interaction and contrast weights of +1,0,0, -1, 0, 0 (+1 was

assigned to negative strategies used by male physicians and -1 was assigned to negative

strategies used by female physicians). Hypothesis 4 was supported, 1(8) = 2.82, I!< .05.

Table 6 shows that negative regard strategies were seen as more appropriate influence

attempts when used by male physicians (M = 4.26) than when used by female physicians (M

= 3.71).

Table 6

H2. H3. and H4: Observed Means and Standard Deviations on Ratings of Communication Expectations. Perceptions of Relational Concern. and Communication Appropriateness

Communication Evaluation

EXQectations Relational Concern AI!I!roQriateness

Condition M SD M SD M SD

Male Physician

Positive Regard (n=57) 4.71 1.20 5.20 1.13 5.37 1.37

Neutral Regard (n=54) 4.60 1.15 4.40 1.28 4.83 1.37

Negative Regard (n=61) 4.05 1.12 4.19 1.53 4.26* 1.47

Female Physician

Positive Regard (n=59) 4.50 1.16 4.89 1.37 4.94 1.28

Neutral Regard (n=61) 4.46 1.47 4.21 1.52 4.40 1.50

Negative Regard (n=62) 3.66 1.39 4.22 1.53 3.73* 1.67

Note: Higher scores on these scales represent higher perceptions that the communication was expected, showed relational concern, and was appropriate. >Ie I! < .05

Table 7

H2. H3. H4: ANOVA for Physician Gender. Strategy. and Session on Communication Expectations. Perceptions of Relational Concern. and Appropriateness

SS DF MS F

112: Communication Expectations

Session (S) vs Within 26.56 4 6.64 3.21

Strategy by Session (ST X S) vs Within 12.57 8 1.57 .76

Physician Gender by Session (P X S) vs Within 14.75 4 3.69 1.78

Physician Gender by Session by Strategy (ST X S X P) vs Within 7.61 8 .95 .46

Strategy vs (ST X S) 43.05 2 21.53 13.70

Physician Gender (P) vs (P X S) 2.57 2.57 .70

Strategy by Physician Gender (S x P) vs (ST X S X P) 3.89 2 1.94 2.04

Within 670.72 324 2.07

03: Perceptions of Relational Concern

Session (S) vs Within 16.09 4 4.02 2.41

Strategy by Session (ST X S) vs Within 17.50 8 2.19 1.31

Physician Gender by Session (P X S) vs Within 20.41 4 5.10 3.05

Physician Gender by Session by Strategy (ST X S X P) vs Within 13.69 8 1.71 1.02

Strategy vs (ST X S) 46.13 2 23.07 10.55

Physician Gender (P) vs (P X S) 4.79 4.79 .94

Strategy by Physician Gender (S x P) vs (ST X S X P) .57 2 .29 .17

Within 543.08 325 1.67

108

Sig

.013

.639

.132

.884

.003

.451

.192

.049

.238

.017

.418

.006

.387

.849

109

Table 7 (continued)

SS DF MS F Sig

H4: Appropriateness

Session (S) vs Within 19.19 4 4.80 2.22 .066

Strategy by Session (ST X S) vs Within 20.44 8 2.55 1.18 .309

Physician Gender by Session (P X S) vs Within 8.16 4 2.04 .94 .438

Physician Gender by Session by Strategy (ST X S X P) vs Within 6.95 8 .87 .40 .919

Strategy vs (ST X S) 87.35 2 43.68 17.10 .001

Physician Gender (P) vs (P X S) 17.11 17.11 8.39 .044

Strategy by Physician Gender (S x P) vs (ST X S X P) .36 2 .18 .21 .817

Within 706.26 327 2.16

Communication evaluation as a function of situational perceptions. Hypotheses 5a

through 5d, and research questions 1 and 2 concerned the interaction between situational

perceptions and strategy type on patients' communication expectancies and patients' views

regarding the appropriateness of certain regard strategies. This set of hypotheses and research

questions was tested through four fully saturated regression analyses. Because the main

concern was assessing the significant two-way interaction, the multiplicative term for each

interaction variable was forced into the model first.

The first regression analysis assessed the possible interaction between severity of

illness and strategy type on communication expectations. When the multiplicative term

composed of severity and strategy type was forced into the model first there was a significant

110

relationship, 1:(3,195) = 9.58,12<.005, R2=.05. When the main effect for severity of

illness and strategy type were entered into the equation, the interaction became insignificant.

As Table 8 shows, severity of illness accounted for most of the variance and, thus, the

significance of the interaction is probably an artifact of its relationship to the situational

percept.

The second regression analyses assessed the possible interaction between severity of

illness and strategy type on communication appropriateness. When the multiplicative term

composed of severity and strategy type was forced into the model first there was a weak, but

statistically significant relationship, 1:(3,195) = 6.07,12< .05, R2=.03. When the main effect

for severity of illness and strategy type were entered into the equation, the interaction became

insignificant. Once again, Table 8 illustrates that perceptions of severity of illness accounted

for most of the variance.

The third regression assessed the possible interaction between perceptions of previous

noncompliance and strategy type on communication expectations. When the multiplicative

term composed of noncompliance and strategy type was forced into the model first there was

a significant relationship, 1:(3,195) = 8.64,12< .001, R2=.04. When the main effect for

perceptions of previous noncompliance and strategy type were entered into the equation the

interaction became insignificant. Similar to severity of illness perceptions, perceptions of

previous noncompliance accounted for most of the variance (Table 8).

The fourth regression assessed the possible interaction between perceptions of

previous noncompliance and strategy type on communication appropriateness. When the

multiplicative term composed of noncompliance and strategy type was forced into the model

first there was a weak, but statistically significant relationship, 1:(3,195) = 4.23, 12 < .05,

R2 = .02. When the main effect for perceptions of previous noncompliance and strategy type

111

were entered into the equation the interaction became insignificant. Once again, perceptions

of previous noncompliance accounted for most of the variance (Table 8).

Table 8

H5. ROI, and R02: Multiple Regressions of Situational Perceptions and Strategy Type on Communication Expectations and Perceptions of Appropriateness

B Beta p

Expectation Regressions

Severity X Strategy .06 .18 .78 .438

Severity .19 .22 3.14 .002

Strategy .13 .08 .36 .723

E(3,195) = 6.63, &=.30, Q<.0005

Noncompliance X Strategy .07 .19 1.08 .283

Noncompliance .55 .60 10.79 .000

Strategy -.09 -.06 -.33 .742

E(3,195) = 43.59, &=.63, Q< .0001

Appropriateness Regressions

Severity X Strategy .05 .12 .53 .596

Severity .22 .22 3.09 .002

Strategy .17 .09 .41 .685

E(3,195) = 5.30, &=.27, Q<.005

Noncompliance X Strategy -.01 -.03 -.17 .864

Noncompliance .67 .63 11.44 .000

Strategy .19 .10 .61 .545

E(3,195)=47.16, &=.65, Q<.OOOI

Note: E values for each equation are listed below each set of predictor variables.

112

Research question 3 concerned the possible interaction between physician gender,

situational perceptions, and strategy type on communication evaluation. This research

question was probed through four fully saturated models similar to the ones above except that

a three way interaction term composed of the situational percept, strategy type, and gender

was forced into the model first. The three way interaction between severity of illness,

strategy, and gender on communication appropriateness was insignificant, E(7, 191) = 3.25,

n = .07, and the three way interaction between previous noncompliance, strategy, and gender

on communication appropriateness was insignificant, E(7,191) = 2.25, n=.14. The

regression assessing the interaction between severity of illness, strategy type, and gender on

communication expectations was significant, £(7,191) = 5.17, n< .05, R2=.02. The

regression assessing the interaction between perceptions of noncompliance, strategy type, and

gender on communication expectations was also significant, £(7,191) = 2.25, n< .05,

R2=.02. However, similar to before, when two way interactions and main effects were

entered into the equation, the interaction became insignificant (Table 9)

113

Table 9

R03: Multiple Regressions of Situational Perceptions. Strategy Type. and Physician Gender on Communication Expectations and Perceptions of Appropriateness

B Beta t p

Expectation Regressions

Severity X Strategy X Gender .08 .18 .55 .583 Severity X Strategy .02 .06 .19 .846 Severity X Gender -.04 -.09 -.36 .710 Strategy X Gender -.37 -.16 -.50 .616 Severity .21 .25 2.60 .010 Strategy .30 .18 .63 .531 Gender .31 .19 .51 .608

Noncompliance X Strategy X Gender -.03 -.05 -.20 .843 Noncompliance X Strategy .08 .21 .92 .359 Noncompliance X Gender .06 .02 .10 .922 Strategy X Gender -.08 -.15 -.79 .437 Noncompliance .59 .64 8.69 .000 Strategy -.10 -.07 -.29 .774 Gender .30 .12 .64 .526

Appropriateness Regressions

Severity X Strategy X Gender .01 .02 .07 .947 Severity X Strategy .04 .11 .36 .719 Severity X Gender .06 .11 .44 .661 Strategy X Gender .05 .02 .06 .952 Severity .19 .19 2.02 .045 Strategy .15 .08 .27 .786 Gender .01 .00 .01 .994

Noncompliance X Strategy X Gender -.06 -.11 -.44 .663 Noncompliance X Strategy .00 .01 .04 .967 Noncompliance X Gender .29 .11 .45 .644 Strategy X Gender -.19 -.29 -1.57 .119 Noncompliance .74 .70 9.66 .000 Strategy .13 .07 .31 .754 Gender

Note: £: values are as follows: first expectation equation, £:(7,191}=2.89, R=.29, l?<.05; second expectation equation, £:(7, 191)= 18.52, l? < .001; first appropriateness equation, £:(7,191)=2.57, R=.31, l?<.01; second appropriateness equation, £:(7,191}=20.63, R=.66, l?<.00001.

114

The analyses, as a whole, suggest that these situational perceptions do not significantly

interact with the other variables in the model. Rather, there is a main effect for situational

perceptions such that high perceptions of severity and previous noncompliance are associated

with greater communication expectations and appropriateness for any influence strategy used

by the physician. This supports hypothesis Sa and 5b which predicted a positive relationship

between situational perceptions and communication evaluations for negative regard strategies,

but disconfirms hypothesis 5c and 5d which suggested that neutral strategies are negatively

correlated with these situational perceptions. The analyses also suggest that there is a positive

relationship between perceptions of severity of illness and pervious noncompliance for the use

of positive regard strategies (research questions 1 and 2).

To more precisely determine the role of these situational perceptions in the

framework, a secondary analysis was done treating the situational variables as the dependent

measures rather than the independent measures. A 2 (physician gender) x 3 (strategy type) x

5 (consultation session) multivariate analysis of variance with sessions as the random factor

was done to determine if the independent variables in the framework influenced patients'

perceptions of severity of illness and perceptions of previous noncompliance. MANDV A

revealed a significant main effect for strategy, Wilks' lambda = .19, £:(4,14) = 4.49,

12< .05, R2 =.81, with a significant univariate effect for severity, 1:(2,8)=6.89, Q< .05.

Inspection of the means reveals that patients perceived the situation to be more severe when

the physician used negative regard strategies <M = 4.99) than neutral regard strategies <M =

4.66) or positive regard strategies <M = 4.33). There was no significant main effect for

gender and no significant interaction effect between gender and strategy.

115

Consequences of Initial Strategy Usage

Hypotheses 7 through 11 addressed the effectiveness of different influence attempts

used by male and female physicians during initial encounters. Data were analyzed using a 3

(strategy type) x 2 (physician gender) x 5 (consultation session) analysis of variance design.

Although the dependent variables were highly correlated (see Table 3), ANOV A was used

because the variables of patient satisfaction, physician perceptions, and physician

persuasiveness are conceptually different and the predictions vary slightly for each outcome

measure. Consultation session was treated as a replicated factor in each analysis. Following

these analyses, direct tests of the hypotheses were conducted with 1 degree of freedom

contrast analyses.

Patient satisfaction. Hypotheses 7 and 8 concern the effects of initial strategy usage

by male and female physicians on patient satisfaction. Hypothesis 7, which predicted that

patient satisfaction with physician influence attempts is greater with positive regard strategies

than with either negative or neutral regard strategies, was supported. There was a significant

main effect for strategy, E(2,8) = 15.90, Q<.005, eta2 =.07. Moreover, the means are in the

exact pattern suggested by the hypothesis with more satisfaction following the positive regard

strategies than the neutral or negative regard strategies (see Table 10 for means). The direct

test, comparing the positive regard strategy condition to the neutral and negative regard

condition (contrast coefficients of +2 -1 -1), was significant, 1(8) = 5.32, Q< .001.

Hypothesis 8 predicted that there are gender differences for satisfaction such that

negative regard strategies used by male physicians result in more patient satisfaction than

negative regard strategies used by female physicians. The interaction between physician

gender and strategy was significant, E(2,8) = 4.48, Q < .05, eta2 = .004. Inspection of the

means in Table 10 shows that more satisfaction is reported by patients following the male

116

physician's use of negative regard strategies than following the female physician's use of

negative regard strategies. The direct test of hypothesis 8 used the error term associated the

gender by strategy interaction and compared the male-negative regard condition to the female;-

negative regard condition (contrast coefficients of 0, 0, + 1, 0, 0, -1). The difference was

significant, 1(8) = 4.20, Jl < .005, supporting hypothesis 9. See Table 11 for ANOVA

information. Figure 2 illustrates the gender by strategy interaction for satisfaction and

demonstrates that the predicted main effects for satisfaction are interpretable.

Table 10

H7 and H8: Observed Means and Standard Deviations on Patient Satisfaction in Initial Encounters with a Physician for Physician Gender and Strategy

Strategy

Positive

Neutral

Negative

Male Physician

M SD n

4.94 1.41 57

4.05a 1.31 56

3.99&* 1.38 62

Physician Gender

Female Physician

M SD n

4.44 1.36 58

3.99 1.54 61

3.56* 1.59 64

Note: The means sharing a common subscript within a column are not significantly different from each other (Jl> .05) using the Tukey b post hoc test. * The means are significantly different at Jl < .005

Table 11

H7 and H8: ANOVA on Patient Satisfaction in Initial Encounters with a Physician for Physician Gender, Strategy Type, and Consultation Session

SS DF MS F

Session (S) vs Within 23.43 4 5.86 2.87

Strategy by Session (ST X S) vs Within 14.58 8 1.82 .89

Physician Gender by Session (P X S) vs Within 7.99 4 2.00 .98

Physician Gender by Session by Strategy (ST X S X P) vs Within 3.10 8 .39 .19

Strategy vs (ST X S) 57.97 2 28.98 15.90

Physician Gender (P) vs (P X S) 9.50 9.50 4.75

Strategy by Physician Gender (S x P) vs (ST X S X P) 3.47 2 1.74 4.48

Within 672.50 329 2.04

117

Sig

.023

.524

.420

.992

.002

.095

.049

Figure 2. Interaction of Physician Gender and Strategy Type on Patient Satisfaction.

5.0

4.9

4.8

4.7

4.6

4.5

4.4

4.3

4.2

4.1

4.0

3.9

3.8

3.7

3.6

3.5

3.4

Positive Regard Slralegies

Neulral Regard Slralegies

Male Physician

Female Physician

Negalive Regard Slralegies

Physician perception. Hypotheses 9 and 10 concerned the effects of initial strategy

118

usage by male and female physicians on perceptions of the physician. Hypothesis 9 predicted

a nonlinear relationship for male physicians and a linear relationship for female physicians.

These predictions were supported. There was both a significant main effect for strategy type,

E(2,8) = 12.03, I!< .005, eta2=.07, and the predicted interaction between physician gender

and strategy type, E(2,8) = 5.61, I!<.05"eta2=.01. Moreover, as shown in Table 12, the

means were in the direction predicted by hypothesis 9. For the male condition, physician

perceptions were higher following positive regard strategies than neutral or negative regard

119

strategies. For the female condition, physician perceptions were higher for the positive regard

strategies and decreased with the use of more negative strategies.

Table 12

H9 and HlO: Observed Means and Standard Deviations on Physician Perceptions in Initial Encounters with a Physician for Physician Gender and Strategy

Ph~sician Gender

Male Ph~sician Female Ph~sician

Strateg~ M SD n M SD n

Positive 5.44 1.01 57 4.93 1.37 58

Neutral 4.56. 1.13 56 4.49 l.34 61

Negative 4.55. 1.37 62 4.08 1.48 64

Note: The means sharing a common SUbscript within a column are not significantly different from each other (12 > .05) using the Tukey b post hoc test.

The direct test of hypothesis 9 involved two contrast tests, one for the male condition

testing for a nonlinear relationship and one for the female condition testing for the linear

relationship. Both tests used the error term associated with the strategy by gender interaction.

The predicted nonlinear relationship for males was significant, E(I,8) = 25.24, p< .001,

eta2 = .23 and the predicted linear relationship for females was significant, E(1,8) = 73.72,

HYQothesis 10 predicted that there are gender differences for negative regard strategies

such that communicator evaluations are higher for male physicians using negative regard

strategies than for female physicians Using negative regard strategies. The direct test between

these two groups (contrast coefficients of 0, 0, + I, 0, 0, -1) was significant, !(8) = 4.93,

12 < .001. As shown in Table 12, physician perceptions were higher in the male condition

120

following the use of negative regard strategies than the female condition. Table 13 contains

the ANOY A information and figure 3 illustrates the gender by strategy interaction for person

perceptions.

Table 13

H9 and HlO: ANOYA on Physician Perceptions in Initial Encounters with a Physician for Physician Gender, Strategy Type, and Consultation Session

SS DF MS F Sig

Session (S) vs Within 13.50 4 3.38 1.85 .120

Strategy by Session (ST X S) vs Within 17.79 8 2.22 1.22 .288

Physician Gender by Session (P X S) vs Within 16.21 4 4.05 2.22 .067

Physician Gender by Session by Strategy (ST X S X P) vs Within 2.41 8 .30 .16 .995

Strategy vs (ST X S) 53.50 2 26.75 12.03 .004

Physician Gender (P) vs (P X S) 10.07 10.07 2.48 .190

Strategy by Physician Gender (S x P) vs (ST X S X P) 3.38 2 1.69 5.61 .030

Within 601.45 329 1.83

Figure 3.

Interaction of Physician Gender and Strategy Type on Physician Perception.

5.5

5.4

5.3

5.2

5.1

5.0

4.9

4.8

4.7

4.6

4.5

4.4

4.3

4.2

4.1

4.0

3.9

3.8

Persuasiveness

Positive Regard Strategies

Neutral Regard Strategies

Male Physician

Female Physician

Negative Regard Strategies

Hypothesis 11 predicted that there is an interaction between physician gender and

strategy type for persuasiveness such that a male physician is most persuasive using either

121

positive regard or negative regard strategies and a female physician is most persuasive using

positive regard strategies. ANDV A revealed a significant main effect for strategy, E(2,8) =

7.82, R < .05, eta2= .05 (Table 14). The predicted interaction effect between physician gender

and strategy approached significance, E(2,8) = 4.23, R= .05, eta2 =01. The means are in the

exact pattern suggested by the hypothesis (see Table 15 for Means).

Table 14

H 11: ANOV A on Physician Persuasiveness in Initial Encounters with a Physician for Physician Gender. Strategy Type. and Consultation Session

SS DF MS F

Session (S) vs Within 21.95 4 5.49 2.95

Strategy by Session (ST X S) vs Within 19.15 8 2.39 1.29

Physician Gender by Session (P X S) vs Within 8.40 4 2.10 1.13

Physician Gender by Session by Strategy (ST X S X P) vs Within 6.82 8 .85 .46

Strategy vs (ST X S) 37.42 2 18.71 7.82

Physician Gender (P) vs (P X S) 7.55 7.55 3.60

Strategy by Physician Gender (S x P) vs (ST X S X P) 7.21 2 3.60 4.23

Within 617.93 332 1.86

Table 15

H 11: Observed Means and Standard Deviations on Physician Persuasiveness in Initial Encounters with a Physician for Physician Gender and Strategy

Strategy

Positive

Neutral

Negative

Male Physician

M

5.23

4.35

4.63

SD n

1.06 57

1.30 56

1.39 62

Physician Gender

Female Physician

M SD n

4.78 1.21 58

4.39 1.49 61

4.09 1.43 64

122

Sig

.020

.250

.343

.885

.013

.131

.050

123

The direct test of the hypothesis involved two contrast tests. The predicted curvilinear

relationship for the male physician was tested using the error term associated with the strategy

by gender interaction and contrast coefficients of + 1, -2, + 1. The predicted linear

relationship for the female physician was tested using the same error term but with contrast

coefficients of + 1, 0, -1. Hypothesis 11 was supported with both a significant curvilinear

relationship for the male physician, .E(1,8) = 17.03, Q < .005, eta2= .45, and a significant

linear relationship for the female physician, .E(1,8) = 18.37, Q < .005, eta2= .69. Figure 4

illustrates the gender by strategy interaction for physician persuasiveness.

Figure 4. Interaction of Physician Gender and Strategy Type on Physician Persuasiveness.

5.5

5.4

5.3

5.2

5.1

5.0

4.9

4.8

4.7

4.6

4.5

4.4

4.3

4.2

4.1

4.0

3.9

3.8

Positive Regard Strategies

Neutral Regard Strategies

Male Physician

Female Physician

Negative Regard Strategies

124

Study 2: Consequences of Strategy Combinations

Hypotheses 12 through 14 concern the effectiveness of different strategy combinations

represented in ongoing interactions with a male or female physician. The dependent variables

assessing the effectiveness of strategy combinations were all highly correlated (see Table 16

for intercorrelations). A 2 (physician gender) x 6 (strategy combination) MANOVA was used

to test hypothesis 12 dealing with patient satisfaction and hypothesis 13 dealing with physician

perceptions because the predictions were identical for both hypotheses. Bartlett's sphericity

test (690.95, R < .0001) confirmed that a multivariate analysis was appropriate. Persuasion is

conceptually different from patient satisfaction and physician perceptions. Additionally,

because hypothesis 14 predicted a slightly different relationship, the persuasion prediction was

tested in a separate 2 x 6 ANOV A. Research questions were probed using Tukey b post hoc

tests.

Table 16

Intercorrelations Among Patient Satisfaction. Physician Perceptions. and Physician Persuasiveness following Strategy Combination in Study 2

Patient Satisfaction

Physician Perceptions

Physician Persuasiveness

Satisfaction

1.00

Perceptions

.89

1.00

Persuasiveness

.84

.80

1.00

125

Patient Satisfaction and Physician Perceptions

Hypothesis 12 and hypothesis 13 predicted an interaction between physician gender

and strategy combination such that the pure positive combination, the mixed positive/neutral

combination, and the mixed negative/neutral combination result in more overall satisfaction

than the pure negative combination or the pure neutral combination for male physicians;

among female physicians the pure positive combination and the mixed positive/neutral

combination are predicted to be the most satisfying. The predicted interaction was not

significant (see Table 17). However, there was a significant main effect for strategy

combination, Wilks' lambda = .89,1:(10,920) = 4.99, p< .0001, R2=.05, with significant

univariate effects for both satisfaction, 1:(5,461) = 8.46, p< .0001, eta2=.08, and physician

perceptions, 1:(5,461) = 8.32, p < .0001, eta2= .08. As Table 18 shows, the means for both

the male and the female physician are in the direction of the prediction for the male condition.

This main effect for strategy combination was probed using the contrast codes originally

designed to test the male physician condition (-2, + 1, -2, + 1, + 1, + 1). These codes follow

the theoretical framework advanced in Chapter 1 if gender was not a factor. The contrast was

significant for both patient satisfaction, 1(462) = 5.61, p< .0001, and physician perceptions,

1(462) = 5.95, p < .0001.

Research question 5 asks which combination results in the most patient satisfaction

and the highest physician perceptions. The research question was probed using Tukey b post

hoc tests on the six strategy combinations. As shown in Table 18, the pure negative

combination resulted in significantly less patient satisfaction and lower physician perceptions

than all of the combinations except the pure neutral combination (p < .05). The pure neutral

combination resulted in significantly less patient satisfaction and lower physician perceptions

than the mixed positive/neutral combination, p < .05. Additionally, for physician perceptions,

126

the pure neutral combination resulted in significantly lower physician perceptions than the

pure positive combination, Q < .05. Thus, the pure negative and the pure neutral

combinations are the least satisfying and result in the lowest physician perceptions, whereas

the mixed combinations and the pure positive combination are the most satisfying and result in

the highest physician perceptions. Inspection of the means shows that the most effective

strategy was the mixed/positive combination. This combination, however, was not

significantly different from the other mixed combinations.

Table 17

H12 and H13: Univariates on Patient Satisfaction and Physician PerceQtion following Strategy Combination in Study 2

SS DF MS F

Patient Satisfaction

Combination (C) 107.27 5 21.45 8.46

Gender (G) 2.72 2.71 1.07

Combination by Gender (C X G) 7.22 5 1.45 .57

Within 1168.50 461 2.55

Physician Perceptions

Combination (C) 92.58 5 18.52 8.31

Gender (G) 5.85 1 5.85 2.63

Combination by Gender (C X G) 10.03 461 2.00 .90

Within 1026.45 2.23

Note: Combination differences on these measures are associated with a multivariate E(10,920) = 4.99, Q< .0001.

Sig

.000

.301

.723

.000

.106

.480

127

Table 18

H12, H13, and H14: Observed Means and Standard Deviations on the Patient Satisfaction, Physician Perception, and Physician Persuasiveness Measures for Strategy Combination and Gender

Patient Physician Physician Satisfaction Perceptions Persuasiveness

Condition M SD M SD M SD

All Neutral 4.10bc 1.58 4.41bc 1.56 4.36bc 1.42

All Positive 4.79.< 1.59 5.18. 1.63 4.80.< 1.46

All Negative 3.61bc 1.86 4.16bc 1.65 4.06bc 1.75

Positive-Neutral 5.08. 1.42 5.40. 1.29 5.10ac 1.30

Negative-Neutral 4.49.< 1.63 4.96.< 1.51 4.84.< 1.41

Positive-Negative 4.56.< 1.44 5.08.< 1.31 4.86.< 1.20

All Neutral/male 3.97 1.63 4.27 1.53 4.16 1.31

All Positive/male 5.07 1.55 5.53 1.44 4.95 1.52

All Negative/male 3.78 1.90 4.39 1.71 4.21 1.85

Positive-Neutral/male 5.09 1.37 5.45 1.22 5.10 1.15

Negative-Neutral/male 4.50 1.72 4.99 1.58 4.83 1.49

Positive-Negative/male 4.72 1.34 5.28 1.11 4.93 1.12

All Neutral/female 4.22 1.55 4.54 1.61 4.54 1.51

All Positive/female 4.53 1.61 4.86 1.74 4.66 1.40

All Negative/female 3.46 1.83 3.93 1.58 3.91 1.66

Positive-Neutral/female 5.08 1.50 5.36 1.37 5.10 1.46

Negative-Neutral/female 4.47 1.53 4.93 1.44 4.86 1.34

Positive-Negative/female 4.40 1.54 4.90 1.48 4.78 1.29

Note: For strategy combination means representing the main effect for strategy, those means sharing a common subscript within a column are not significantly different from each other.

128

Persuasiveness

Hypothesis 14 concerns an interaction between physician gender and strategy

combination such that male physicians are predicted to be most persuasive when using mixed

positive/neutral combinations, mixed negative/neutral combinations, or mixed

positive/negative combinations, and female physicians are expected to be most persuasive

when using mixed positive/neutral combinations. The predicted interaction was not significant

(see Table 19). There was, however, a significant main effect for combination, 1:(5,462) =

5.58, R< .0001, eta2 =.06. As indicated by Table 18, the means were in the direction of the

male condition prediction. This main effect for combination was probed using the contrast

codes originally designed to test the male condition (contrast coefficients of -2, + 1, -2, + 1,

+ 1, + 1). These codes follow the theoretical framework advanced in Chapter 1 if gender was

not a factor. The contrast was significant, 1(462) = 3.99, Q< .0001.

Table 19

H14: ANOVA on Physician Persuasiveness following Strategy Combination in Study 2

Combination (C)

Gender (G)

Combination by Gender (C X G)

Within

SS

57.49

.35

6.45

952.13

DF

5

1

5

462

MS

11.50

.35

1.29

2.06

F

5.58

.17

.63

Sig

.000

.680

.680

Research question 6 asks which combination results in the most persuasiveness for the

male and female physician. Since gender did not significantly interact with strategy

129

combination, the assessment of mean differences was limited to the six combination means.

Tukey b post hoc test revealed the pure negative combination was significantly less persuasive

than the pure positive combination, and all the mixed combinations, Q< .05. Inspection of the

means shows that, for both the male and the female physician, the greatest physician

persuasiveness occurred following the positive-neutral combination. The persuasiveness of

this combination, however, was not significantly different from the other mixed combinations.

Consequences of Future Strategy Usage

Two sets of hypotheses and research questions concerned the effects of previous

communication exposure on the evaluation of future strategy usage. The first set, hypotheses

6a through 6c, examined the relationship between exposure to various influence attempts and

expectations for those influence attempts in the future. Research question 4 also probed the

relatIonship between exposure to strategy combinations, gender, and final strategy type on

other communication evaluation variables. The second set, research questions 7 through 9,

probed the relationship of different types of communication exposure to the outcome variable

of patient satisfaction, physician perceptions, and physician persuasiveness.

Communication Evaluations as a Function of Previous Communication Usage

Hypotheses 6a through 6c indicates that previous strategy usage by physicians

influences future communication expectations. Research question 4 concerns the possible

interaction between previous strategy usage, physician gender, and final strategy type on

communication evaluation. These hypotheses and research questions were tested using Study

2 data. Direct tests of the hypotheses were conducted with 1 degree of freedom contrast

analyses. The contrast tests are reported as one-tailed! tests. Research question 4 was tested

using MANOV A. See Table 20 for intercorrelations among dependent variables that followed

final strategy type.

Table 20

Intercorrelations Among Communication Evaluation Variables following Final Strategy in Study 2

Expect Approp Approv Valence Concern Satis Persu Percep

Expectation (Expect) 1.00 .57 .40 .65 .61 .60 .54 .61

Appropriateness (Approp) 1.00 .62 .79 .70 .77 .68 .75

Approval (Approv) 1.00 .61 .54 .58 .49 .56

Valence (Valence) 1.00 .85 .92 .79 .88

Relational Concern (Concern) 1.00 .85 .78 .86

Satisfaction (Satis) 1.00 .88 .91

Persuasion (Persu) 1.00 .82

Physician Perception (Percep) 1.00

130

Hypothesis 6a predicted that positive regard strategies are more expected by patients

previously exposed to these strategies than by patients not previously exposed to these

strategies. This hypothesis was tested using patients from Study 2 who were exposed to

positive regard strategies in the final session. The direct test of this hypothesis compared

patients exposed to pure positive, mixed positive/neutral, or mixed positive/negative

combinations (contrast coefficients of + 1, + 1, + 1) to patients exposed to pure neutral, pure

negative, or mixed negative/neutral combinations (contrast coefficients of -1, -1, -1). The

contrast test only approached significance, !(146) = 1.39,0.=.08.

Hypothesis 6b predicted that negative regard strategies are more expected by patients

previously exposed to these strategies than by patients not previously exposed to these

strategies. This hypothesis was tested using patients from Study 2 who were exposed to

negative regard strategies in the final session. The direct test of this hypothesis compared

patients exposed to pure negative, mixed positive/negative, or mixed negative/neutral

131

combinations (contrast coefficients of + 1, + 1, + 1) to patients exposed to pure neutral, pure

positive, or mixed positive/neutral (contrast coefficients of -1, -1, -1). The contrast was not

significant, 1(141) = -.002, R= .99.

Hypothesis 6c predicted that neutral regard strategies are more expected by patients

previously exposed to these strategies than by patients not previously exposed to these

strategies. This hypothesis was tested using patients from Study 2 who were exposed to

neutral regard strategies in the final session. Since all patients were exposed to at least one

neutral regard strategy session (Le., the first introductory session) an unbiased test of this

hypothesis cannot be conducted. Realizing this bias, the direct test of this hypothesis

compared patients exposed to the pure neutral, mixed positive/neutral, or mixed

negative/neutral combination (contrast coefficients of + 1, + 1, + 1) to patients exposed to

pure negative, pure positive, or mixed positive/negative combination. The contrast was

significant, 1(147) = 1.84, R < .05. Table 21 shows the means for all three tests.

Table 21

H6: Observed Means and Standard Deviations of Communication Expectations for Previous Communication Exposure

Final Strategy

H6A: Positive Regard H6B: Negative Regard H6c: Neutral Regard

Exposure Condition M SO n M SO n M SO n

Previous Exposure 4.87 1.28 75 . 4.50 1.25 74 4.81 1.12 77

No Previous Exposure 4.60 1.18 77 4.50 1.49 73 4.43 1.42 76

1(46) = 1.39, g=.08 1(141) = -.002, g=.50 1(147) = 1.84, g=.03

132

Research question 4 was probed using a 2 (physician gender) x 6 (strategy

combination) x 3 (final strategy type) multivariate analysis of variance for communication

evaluations of expectancy, appropriateness, approval, valence, and relational concern.

Neither the multivariate or the univariate tests revealed a significant three-way interaction or

significant two-way interactions (Table 22). There was a significant multivariate main effect

for final strategy, Wilks' lambda = .84,1:(10,820) = 7.31, Q< .0001, R2=.16, with

significant univariate effects for appropriateness, 1:(2,414) = 16.60, Q< .0001, eta2=.07,

approval, 1:(2,414) = 24.49, Q< .0001, eta2=.1O, valence, 1:(2,414) =18.21, eta2=.08, and

relational concern, 1:(2,414) = 15.88, eta2=.06. As shown in Table 23, positive regard

strategies used in the final session resulted in the most positive communication evaluations.

There was also a significant multivariate main effect for gender, Wilks' lambda = .95,

E(5,41O) = 3.76, Q< .005, R2=.05, with significant univariate effects for expectations,

1:(1,414) = 5.46, Q< .05, eta2=.Ol, approval, 1:(1,414) = 11.37, Q< .001, eta2=.02, and

valence, 1:(1,414) = 5.15, Q < .05, eta2= .01. Table 22 shows that this is due to the male

physician being rated higher than the female physician on these communication evaluations.

Table 22

R04: Univariates on Communication Evaluations for Strategy Combination. Physician Gender. and Final Strategy

SS DF MS F

Expectancy

Combination X Gender X Strategy 26.27 10 2.63 1.59

Combination X Gender 8.16 5 1.63 .99

Combination X Strategy 14.37 10 1.44 .87

Gender X Strategy 2.63 2 1.32 .80

Combination 10.34 5 2.07 1.25

Gender 9.03 9.03 5.46

Strategy 4.27 2 2.13 1.29

Within 684.13 414 1.65

Appropriateness

Combination X Gender X Strategy 37.89 10 3.78 1.56

Combination X Gender 5.59 5 1.11 .46

Combination X Strategy 15.98 10 1.59 .66

Gender X Strategy 1.77 2 .89 .37

Combination 7.16 5 1.43 .59

Gender 2.81 1 2.81 1.16

Strategy 80.42 2 40.21 16.60

Within 1003.03 414 2.42

133

Sig

.107

.425

.562

.451

.284

.020

.276

.115

.805

.762

.690

.707

.282

.000

134

Table 22 (continued)

SS DF MS F Sig

Approval

Combination X Gender X Strategy 23.37 10 2.34 1.20 .286

Combination X Gender 3.81 5 .76 .39 .854

Combination X Strategy 26.57 10 2.66 1.37 .192

Gender X Strategy .27 2 .14 .07 .933

Combination 17.21 5 3.44 1.77 .117

Gender 22.07 22.07 11.37 .001

Strategy 95.06 2 47.53 24.49 .000

Within 803.44 414 1.94

Valence

Combination X Gender X Strategy 33.36 10 3.34 1.49 .141

Combination X Gender 8.16 5 1.63 .73 .603

Combination X Strategy 17.66 10 1.77 .79 .641

Gender X Strategy 1.50 2 .75 .34 .716

Combination 10.84 5 2.17 .97 .438

Gender 11.55 11.55 5.15 .024

Strategy 81.81 2 40.81 18.21 .000

Within 927.94 414 2.24

Relational Concern

Combination X Gender X Strategy 20.80 10 2.08 1.10 .363

Combination X Gender 13.63 5 2.73 1.44 .210

Combination X Strategy 35.79 10 3.58 1.89 .045

Gender X Strategy 1.64 2 .82 .43 .649

Combination 10.64 5 2.13 1.12 .348

Gender 2.88 2.88 1.52 .218

Strategy 60.26 2 30.13 15.88 .000

Within 785.39 414 1.90

135

Table 23

R04: Observed Means and Standard Deviations on Communication Evaluations for Physician Gender. and Final Strategy

Communication Evaluation Variables

Expectancy Appropriateness Approval Relational Concern

Condition M so M so M so M so M so

Positive Strategy 4.74 1.20 5.47 1.32 4.71 1.35 5.39 1.30 5.46 1.17

Female m=74) 4.51 1.16 5.31 1.37 4.46 1.33 5.17 1.35 5.34 1.31

Male m=78) 4.97 1.24 5.62 1.26 4.95 1.37 5.60 1.26 5.57 1.02

Neutral Strategy 4.63 1.24 4.60 1.63 4.02 1.28 4.57 1.52 4.71 1.33

Female m=76) 4.57 1.23 4.59 1.63 3.83 1.29 4.48 1.55 4.70 1.36

Male m=77) 4.68 1.25 4.61 1.63 4.21 1.26 4.66 1.49 4.71 1.30

Negative Strategy 4.51 1.32 4.53 1.68 3.57 1.50 4.40 1.62 4.66 1.56

Female m=74) 4.36 1.28 4.45 1.57 3.34 1.52 4.22 1.55 4.51 1.45

Male m=73) 4.65 1.43 4.62 1.78 3.81 1.49 4.60 1.70 4.80 1.67

Effects of Previous Communication Exposure on Patient Satisfaction. Physician Perceptions,

and Physician Persuasiveness

Research questions 7 through 9 concerned the possible differences between the

effectiveness of regard strategies used in initial encounters with a physician and the

136

effectiveness of regard strategies used after exposure to a physician's typical communication

behavior. Research question 7 addressed the effects of future strategy usage on patient

satisfaction, research question 8 concerned the effects of future strategy usage on perceptions

of the physician, and research question 9 concerned the effects of future strategy usage on

physician persuasiveness.

Data from both Study 1 and Study 2 were used to create five conditions of physician

communication exposure to probe these research questions. The first condition represented

patients without previous exposure to the physician's communication behavior. Subjects from

Study 1 exposed to the last session used in Study 2 represented the "no-exposure" group. The

second condition represented patients exposed to a physician who used a consistent positive

communication style (pure positive combination). The third condition represented patients

exposed to a physician who used a consistent neutral communication style (pure neutral

combination). The fourth condition represented patients exposed to a physician who used a

consistent negative communication style (pure negative combination). The fifth condition

represented patients exposed to a physician who used an intermittent reinforcement

communication style (mixed positive/neutral combination, mixed positive/negative

combination, and mixed negative/neutral combination). Since the dependent variables were

highly correlated, a 2 (physician gender) x 5 (previous communication exposure) by 3 (final

strategy type) MANOV A was used to probe these research questions (see Table 20 for

intercorrelations). Bartlett's sphericity test (1736.08, 12 < .0001) confirmed that a multivariate

analysis was appropriate. Significant fmdings were probed with Tukey b post hoc tests to

determine difference in the means.

The MANOV A produced a significant main effect for final strategy type, Wilks'

lambda = .92, E(6,1086) = 7.44, Q< .0001, R2= .06 with significant univariates for

137

satisfaction, E(2,S4S) = 20.07, Q< .0001, eta2 =.OS, physician perceptions, E(2,S4S) =

17.63, Q< .0001, eta2 =.07, and persuasion, E(2,S4S) =lS.44, Q< .0001, eta2 =.06; a

significant main effect for communication exposure, Wilks' lambda = .93, E(12,1437) = 3.30,

Q< .0001, R2 =.07, with significant univariates for satisfaction, E(4,S4S) = 7.S3, g< .0001,

eta2= .OS, physician perceptions, E(4,S4S) = 6.26, Q < .0001, eta2= .04, and persuasion,

E(4,S4S) = 8.08, Q< .0001, eta2 =.06; and a significant main effect for physician gender,

Wilks' lambda = .98, E(3,S43) = , Q < .OS, R2= .02 with a significant univariate only for

perception, E(1,S4S)=S.79, Q< .OS, eta2 =.01. The three-way and two-way interactions were

all insignificant (Table 24). Thus, there is not a significant difference between regard strategy

types for patients exposed to a physician's communication style and for patients not exposed

to a physician's communication style.

Post hoc comparisons using Tukey b revealed that patients previously exposed to a

physician's communication style were more satisfied, evaluated the physician more highly,

and were more persuaded than patients not previously exposed to a physician's communication

style (Q < .OS). There were no significant differences between the consistent positive,

consistent neutral, consistent negative, or the intermittent reinforcement communication style

(Table 2S). The post hoc comparisons on final strategy type revealed that patients were more

satisfied, evaluated the physician more highly, and were more persuaded if they received

positive regard strategies than if they received either negative regard strategies or neutral

regard strategies (Q < .OS) (Table 26).

138

Table 24

R07, R08, and R09: Univariates on Patient Satisfaction, Physician Perception, and Physician Persuasiveness for Communication Exposure, Physician Gender, and Final Strategy ~

SS DF MS F Sig

Patient Satisfaction

Communication Exposure by Gender by Final Strategy (E X G X S) 12.03 8 1 50 .88 .529

Communication Exposure by Gender (EX G) 4.13 4 1.03 .61 .657

Communication Exposure by Final Strategy (E X S) 17.97 8 2.25 1.32 .230

Gender by Final Strategy (G X S) 1.44 2 .72 .43 .654

Communication Exposure (E) 51.21 4 12.80 7.53 .000

Gender (G) 3.63 1 3.63 2.14 .144

Final Strategy (S) 68.24 2 34.12 20.07 .000

Within 926.54 545 2.54

Physician Perceptions

Communication Exposure by Gender by Final Strategy (E X G X S) 14.80 8 1.85 .97 .454

Communication Exposure by Gender (EX G) 4.73 4 1.18 .62 .646

Communication Exposure by Final Strategy (E X S) 23.93 8 2.88 1.52 .148

Gender by Final Strategy (G X S) 1.94 2 .97 .51 .600

Communication Exposure (E) 47.53 4 11.88 6.26 .000

Gender (G) 10.99 10.99 5.79 .016

Final Strategy (S) 66.89 2 33.44 17.62 .000

Within 1033.97 545 1.90

139

Table 24 (continued)

SS DF MS F Sig

Physician Persuasiveness

Communication Exposure by Gender by Final Strategy (E X G X S) 8.67 8 1.08 .54 .825

Communication Exposure by Gender (E X G) 6.09 4 1.52 .76 .551

Communication Exposure by Final Strategy (E X S) 20.23 8 2.53 1.26 .261

Gender by Final Strategy (G X S) 2.74 2 1.37 .68 .506

Communication Exposure (E) 64.72 4 16.18 8.08 .000

Gender (G) 1.41 1.41 .71 .401

Final Strategy (S) 61.84 2 30.92 15.44 .000

Within 1091.37 545 2.00

140

Table 25

RQ7, RQ8, and RQ9: Observed Means and Standard Deviations on Patient Satisfaction, Physician PerceQtions and Physician Persuasiveness for Communication EXl!Qsure

Patient Satisfaction Physician Perceptions Physician Persuasiveness

Condition M SD n M SD n M SD n

Exposure to Consistent 3.75. 1.35 74 5.02. 1.43 74 4.81. 1.47 75 Positive Style

Exposure to Consistent 3.74. 1.16 76 4.92. 1.28 76 4.91. 1.41 76 Neutral Style

Exposure to Consistent 3.70. 1.48 74 4.95. 1.53 74 4.92. 1.54 75 Negative Style

Exposure to Intermittent 3.91. 1.25 228 5.21. 1.30 228 5.00. 1.30 232 Reinforcement Style

No Previous Exposure to 3.12 1.31 124 4.43 1.40 124 4.15 1.45 124 Reinforcement Style

Note: Those means sharing a common subscript within a column are not significantly different from each other.

Table 26

R07, ROg, and R09: Observed Means and Standard Deviations on Patient Satisfaction, Physician Perceptions and Physician Persuasiveness for Final Strategy Type

141

Patient Satisfaction Physician Perceptions Physician Persuasiveness

Condition M SD n M SD n M SD

Positive Regard 5.17 1.50 194 5.42 1.31 194 5.23 1.29

Neutral Regard 4.28. 1.64 192 4.70. 1.43 192 4.49. 1.46

Negative Regard 4.24. 1.62· 191 4.69. 1.41 191 4.58. 1.48

Note: Those means sharing a common subscript within a column are not significantly different from each other.

n

194

195

194

CHAPTER 4

DISCUSSION

142

The theoretical framework presented in the first chapter posited that both physician

gender and communication reward value are important predictors of physician communication

effectiveness. In this investigation, physician gender was assumed to playa major role in

patients' perceptions regarding language appropriateness, whereas message reinforcement

value was presumed to determine which acceptable messages would be persuasive. The

investigation provides a more complete picture of physician influence attempts used in the

clinical setting and expands upon previous research in a number of ways. First, the

effectiveness of initial influence attempts was assessed by having patients rate one of several

different medical consultation situations. Second, the investigation provided one of the first

attempts to assess the effectiveness of influence attempts used by health care providers who

have repeated contact with patients. Third, the subject pool involved patients who were

presently utilizing health care services rather than subjects from a more general population.

Fourth, the influence manipulations included both verbal and nonverbal communication

channels rather than relying on just verbal influence attempts that are not indicative of actual

physician-patient encounters.

Summary of the Findings

Several of the communication evaluation predictions were not supported. The

reinforcement evaluation (hypothesis 1) and communication appropriateness (hypothesis 4)

predictions that are fundamental to the reinforcement framework, however, were supported.

These message evaluation findings, and lack there of, require a reexamination of message

attributes that can most parsimoniously predict persuasive success. All of the hypotheses

concerning communication effectiveness in initial encounters with a physician were supported.

143

Physician gender interacted with strategy effectiveness such that patients allowed male

physicians in initial encounters more flexibility in their influence choices than female

physicians. The hypotheses concerning gender effects and strategy combinations in ongoing

physician-patient consultation sessions received only partial support. The logic of the

reinforcement framework used to predict communication effectiveness over time was

supported. Gender, however, did not mediate the effectiveness of strategy combinations as

expected. Basic assumptions related to the role of gender in established physician-patient

relationships need more careful consideration. Finally, a physician's previous communication

style proved to have some interesting, but unexpected, effects on the evaluation of future

strategies.

Communication Evaluations

A major assumption embedded in the theoretical framework was that physician

influence attempts can be categorized based on the degree to which they signal approval for

patients and/or patients' actions and these messages of approval are differentially valenced by

patients. A test of the theory's a priori specification of what communication behaviors are

reinforcing is a necessary step for the application of reinforcement principles used in the

framework. The significant relationship found between the three strategy types and patients'

perceptions of reinforcement allowed for differences between consultation sessions to be

explained according to reinforcement principles.

Several other message evaluations were believed to be important factors in

detennining strategy effectiveness. According to Language Expectancy Theory (M. Burgoon,

1993), influence attempts that positively violate receiver's expectations are more successful

than those that do not. Perceptions of expected and positively violated influence behaviors

were used to indirectly assess what would be viewed as acceptable language choices.

144

M. Burgoon et al. (1991) found that expectancies are gender specific with male

physicians expected to use neutral strategies more than any other strategy and female

physicians expected to use positive strategies more than any other strategy. The predicted

gender expectation effect in hypothesis 2, however, was not supported. Rather, both male

and female physicians were expected to use positive regard strategies more than any other

strategy type. It is possible that this hypothesis was unsupported because subjects interpreted

the expectancy questions as what they "hoped" to experience rather than what they expected

to experience. A large number of patients commented to the researcher that they did not

understand one or more of the communication expectation questions. This misunderstanding

did not exist for any of the other scale items. Although it is unclear if the expectancy

questions were misinterpreted in the systematic fashion suggested above, these findings would

be consistent with much of the medical literature on patient expectations (e.g., L. S. Linn et

al., 1984) which views patient expectations as equivalent to Language Expectancy's

conceptualization of a positive violation of expectations. The interpretation of the expectancy

questions may have been improved if each subject rated all three types of regard strategies,

rather than only one strategy type, as was done in the study by M. Burgoon et al. (1991).

The context subjects were recruited from may also explain why the current findings

run counter to previous research. Previously, it was argued that repeated exposure to positive

communication strategies by a physician provides confirmation that these strategies are

normative or expected. Nearly half of the subjects participating in Study 1 (45%) came from

a private practice clinic involving three affiliative male physicians. Sharf (1993) has argued

that researchers need to consider the context in which physician-patient encounters occur.

Perhaps more important than the actual setting of the medical visit is the effects of previous

health care experiences on patients' perceptions of current and future medical encounters.

Future studies might incorporate subjects' previous health care experiences in an effort to

examine or control for this possibility.

145

In regards to violations of expectations, M. Burgoon et al. (1991) reasoned that

aggressive strategies used by male physicians are perceived by patients as "expressions of

personal concern and considered positive violations of expectations" (p.186). This message

evaluation assumption remained untested by these researchers since measures of relational

meanings that patients associated with physician influence attempts were not included in their

investigation. These researchers did provide an indirect test of their assumption by doing a

series of post hoc analyses to detennine if there was a significant difference between the

aggressive and moderately aggressive conditions for male physicians. No significant

differences, however, were found. According to the authors, this suggests that aggressive

influence attempts were neither positive or negative violations of expectations for male

physicians. The present investigation, using a direct test of the assumption, was also unable

to support the belief that negative regard strategies used by male physicians show relational

concern and, thus, was unable to support the claim that these strategies are viewed as positive

violations.

Lack of support for hypothesis 3 may be because the present investigation used

aversive influence attempts which are best conceptualized as somewhere between highly

aggressive strategies and aggressive strategies. M. Burgoon et al. (1993) predicted, and

found, extremely aggressive strategies to be more negatively evaluated than aggressive

influence attempts. One of the sessi<~ns tested in Study 1, however, included the same

negative, neutral, and positive strategies used by M. Burgoon et al. and also embedded them

in a similar consultation session to allow for a set of comparable manipulations (see session

six in Appendix B). Even in this consultation session, negative regard strategies used by male

146

physicians failed to show more relational concern <M = 4.09) than neutral regard strategies

<M = 4.12) or positive regard strategies <M = 4.87) used by male physicians.

Staines and Libby (1986) have suggested that it is useful to differentiate between

prescriptive and predictive expectations. Predictive expectations are one's beliefs concerning

what is likely to occur and are identical to the expectancies measured above. Prescriptive

expectations, on the other hand, are one's beliefs concerning what behaviors "should" be used

by a communicator and are isomorphic with the communication appropriateness measure used

to test hypothesis 4. Several scholars (Kelley & J. K. Burgoon, 1991; Staines & Libby,

1986; Wegner & Vallacher, 1977) have recognized the utility of prescriptive expectations

when addressing relational communication.

Measures of prescriptive expectations may provide a more methodologically elegant

gauge of people's perceptions of acceptable communication behavior. Acceptable language

choices could be measured by directly asking patients their perceptions of communication

acceptability. This avoids the semantic confusion created by labeling aggressive or aversive

strategies as "positive" violations and eliminates the need to measure both predictive

expectations and violations of these expectations.

Support for hypothesis 4, which tests prescriptive expectations, illustrates that gender

influences perceptions of communication appropriateness in initial interactions such that

aversive communication by male physicians is seen as more acceptable than aversive

communication by female physicians. Communication effectiveness predictions in the present

framework were based on the reinforcement value of communication (Le., how aversive or

reinforcing the message is) rather than on communication violations. Thus, significant gender

differences for communication appropriateness maintains the logic of the hypotheses related to

consequences of initial strategy usage.

147

With the use of multiple consultation sessions, situational attributes are bound to vary.

Previous research by M. Burgoon et al. (1990) showed that situational factors had a

significant effect on physicians' reported use of various compliance-gaining strategies.

Communication research has generally shown that communicators are more likely to use

aversive communication when the request is in the best interest of the receiver and when

resistance to persuasion is expected (Cody et al., 1986). One set of hypotheses and research

questions was concerned with the relationship between situational perceptions and

communication evaluation.

M. Burgoon et al. (1990) found a positive relationship between physicians' reported

use of negative strategies for both severity of illness and previous noncompliance. The

present study predicted that there would be a positive relationship between message

acceptability and expectations for negative regard strategies for both severity of illness and

pervious noncompliance. An inverse relationship, however, was expected between the use of

neutral regard strategies and these situational perceptions. Strategy type and situational

perceptions did not interact as expected. Rather, patients' perceptions of previous

noncompliance and severity of illness were positively related to both expectations for and

appropriateness of any strategy -- negative, neutral, or positive. It is noteworthy that this

relationship did not seem to be mediated by the gender of the physician. From this, one can

surmise that relational history has the potential to influence the acceptability of any influence

attempt -- including aversive influence attempts -- by both male and female physicians.

Specifically, when there is previous noncompliance and the situation is severe, patients seem

to allow even female physicians more flexibility in their use of negative regard strategies.

This coincides with Roloff's (1987) argument that dissatisfying communication exchanges are

expected and tolerated more as relational familiarity increases.

148

This main effect for situational factors indicates that there is not the predicted inverse

relationship between situational perceptions and communication evaluations for physicians

who use neutral regard strategies. One possible explanation for this counterintuitive finding is

that patients perceive even neutral regard strategies as persuasive influence attempts. Patients'

perceptions that a physician is putting forth an effort to change the patient's behavior -­

regardless of the effectiveness of the effort -- may be sufficient to influence expectations and

appropriateness.

Another possible explanation is that patients' expectations for clear explanations by a

physician are stronger than their desire for an involved and caring physician. The predicted

inverse relationship for neutral regard strategies was based on the assumption that appeals to

medical expertise and explanation would be inappropriate because these influence attempts do

not communicate involvement with the patient. Medical communication research (e.g., Roter,

1988) has shown that patients expect physicians to offer explanation during the consultation

process. However, because the medical communication literature generally compares what

they believe to be overall poor communication (nonaffiliative and lacking explanation) to

overall good communication (affiliative and clear explanation) there is no evidence to suggest

if nonaffiliative exchanges that offer explanation are viewed as acceptable to patients.

Manipulation of situational attributes would allow for a better understanding of the

relationship between situational variables and communication evaluations. The exploratory

analysis following the hypotheses tests showed that situational perceptions are influenced by

the type of strategy the physician used such that severity perceptions increase with the use of

more aversive strategies. Because both situational perceptions and communication evaluations

are related to physician strategy usage, it is unclear from this data set if the relationships

observed between situational perceptions and communication evaluations are spurious

relationships or if the relationship between strategy type and communication perceptions is

mediated by situational perceptions (e.g., strategy type -- > situational perceptions -- >

communication perceptions). Future studies need to manipulate situational variables to

facilitate understanding of their effects on communication acceptability.

149

A further issue addressed in this investigation was the impact of previous

communication on expectations of future communication. Some support emerged for the

belief that expectations are moderated by previous communication patterns. For the most

part, however, previous communication did not seem to influence future expectations as

predicted. The prediction that neutral regard strategies would be more expected by patients

exposed to physicians who previously used neutral regard strategies was supported. The

prediction that positive regard strategies would be more expected by patients exposed to

physicians who previously used positive regard strategies approached significance, but was not

supported. Finally, patients who were exposed to a physician who previously used negative

regard strategies did not expect to receive negative strategies in the future any more than

patients not exposed to a physician who used negative regard.

One possible explanation for these results is the measurement problem previously

alluded to for the expectancy variable. A second possible explanation for these unexpected

findings is that situational attributes influenced communication expectations. By the final

session it was clear that the patient had a history of noncompliance. The description

preceding session three even stated "like many patients, the patient has not been able to make

all the dietary changed that had been ~uggested." Given that previous strategies used by the

physician did not seem to be effective, patients may have expected the physician to try a

strategy that was not previously used. Though beyond the scope of this study, future

investigations manipulating situational attributes in ongoing physician-patient relationships

could probe the effects of actual or perceived previous noncompliance.

Consequences of Influence Attempts in Initial Encounters

150

One of the major goals of this investigation was to provide a further understanding of

the effectiveness of communication strategies used in initial encounters with a physician.

Several hypotheses indicate that gender mediates the effectiveness of influence attempts used

by male and female physicians in initial encounters. As predicted, satisfaction is greatest with

the physicians' use of positive regard strategies. Male physicians, however, seem to be able

to use negative regard strategies in initial encounters without significantly decreasing patient

satisfaction. The same was not true for female physicians in initial encounters since

satisfaction decreased with the use of less reinforcing strategies. A similar relationship was

predicted and found for physician perceptions.

A more fundamental issue concerns the relationship between influence strategies and

physician persuasiveness. Consistent with M. Burgoon et al. (1991), support for hypothesis

12 clearly illustrates that female physicians are limited to more affiliative communication

strategies in initial encounters if they are to be effective persuaders, whereas male physicians

can effectively use either affiliative or aversive communication exchanges. That this finding

could be replicated using different compliance-gaining strategies with actual patients over

several different consultation sessions is encouraging. When combined with the findings for

hypotheses 1 and 4, the data indicate that a reinforcement explanation can be used effectively

to predict strategy effectiveness in initial encounters. A reinforcement explanation may even

be preferred to a Language Expectancy interpretation when addressing strategies that are

conceptualized based on their reinforcing qualities. In fact, Language Expectancy theory

cannot be applied to the present findings unless future investigations find support for the

assumption that negative regard strategies used by a male physician communicate relational

151

concern.

In sum, the effectiveness of strategies used by physicians in initial encounters with a

patient are mediated by physician gender which influences patients' perceptions of

communication appropriateness. Male physicians in initial encounters have much more

freedom to employ a wide range of strategies to increase patient adherence rates than female

physicians. These findings suggest that scholars' (e.g., Evans, 1984; Korsch et aI., 1968)

attacks on the use of nonaffiliative communication are inappropriate -- at least for male

physicians. Training programs (e.g., Evans, Stanley, & Burrows, 1992) may also want to

rethink their stance on training physicians to avoid aversive communication at all costs.

Consequences of Strategy Combinations

Single episode interactions do not reflect physician-patient relationships experienced

by patients who are chronically ill or who are seeking lifestyle changes. Brody (1988) has

argued that communication research should differentiate between medical situations that are

longitudinal and those which entail brief or episodic service. Although the results concerning

the consequences of initial strategy usage suggest that males should use positive or negative

regard strategies and females should use only positive regard strategies, one cannot presume

that physicians will be effective if they use only one type of strategy over time. The

framework advanced in Chapter 1 argues that continuous reinforcement and strategy

combinations involving reinforcing communication and non-reinforcing communication (i.e.,

reinforcement violations) result in more satisfaction and better physician perceptions than

continuous non-reinforcement. Additionally, it was predicted that mixed strategy

combinations are superior to both continuous reinforcement and continuous non-reinforcement

for physician persuasiveness. These assumptions were supported for all three outcome

variables.

152

Exploration of the research questions asking which strategy combination is most effect

found the mixed combinations resulted in more satisfaction, more favorable physician

perceptions, and greater physician persuasiveness than pure negative combinations. The

positive/neutral combination was also superior to the pure neutral combination. The

positive/neutral combination also had the highest means overall for satisfaction, physician

perceptions, and physician persuasiveness. The means for this combination, however, were

not significantly different from the means in the other mixed combination types. The

superiority of the intermittent reinforcement styles challenges the majority of the medical

communication literature that has argued for the superiority of an all affiliative communication

style. The finding that a pure negative communication style is the least preferred

communication style for both male and female physicians also disputes the single episode

research that suggests a negative communication style by male physicians is effective. While

a negative communication style is an appropriate and effective single session influence

strategy, it is not an effective ongoing influence style.

Another assumption embedded in the framework, however, was that the effectiveness

of strategy combinations are mediated by patient's perceptions of communication

appropriateness. Given that gender has been found to influence perceptions of acceptability in

initial interactions, the framework contends that female physicians should limit reinforcement

violations to the occasional use of neutral regard messages. Thus, there should have been an

interaction between strategy combination and physician gender that over-rides the main effect

for combination. Support for the predicted gender interaction did not exist for patient

satisfaction, physician perceptions, or physician persuasiveness. Nevertheless, it is

noteworthy that the means for both male and female conditions were in the exact same

direction and coincided with the predictions advanced in the reinforcement framework for

153

male physicians. The absence of extant research on gender effects in ongoing communication

exchanges forced extrapolation from single episode interactions that proved unsuccessful.

Two recent articles (Canary & Hause, 1993; Hamilton & Stewart, 1993) have

challenged the rationale of addressing gender effects in communication research. Hamilton

and Stewart (1993) have suggested that changing social values may have rendered gender

moderator predictions as obsolete in language intensity research. The results of their recent

study, which examined the effects of gender and language intensity on communicator

persuasiveness, did not find an interaction between language intensity and source gender on

receiver attitudes. Yet Study 1 clearly illustrated that gender does mediate communication

effectiveness of intense language in the medical setting. There is, of course, the argument

that the lack of significant gender differences is due to the specific communicators used in the

manipulation. But this possibility is unlikely since the same videotaped sessions used in Study

1 --which found gender differences-- were used to create the strategy combinations in Study 2.

Further, the source manipulation check demonstrated that these physicians are not significantly

different from patients' perceptions of physicians in the general population. Given that the six

combination means are in exactly the same direction for the male and the female physician

and that the pattern observed coincides with the reinforcement expectancy framework, makes

it equally difficult to dismiss the lack of gender differences as merely a methodological

artifact. So the ultimate question needing to be addressed is why the gender differences

observed for the sessions used in Study 1 seemingly disappeared when they were combined to

create the appearance of an ongoing relationship in Study 2.

Canary and Hause (1993) have argued that "expectations for behavior developed in

specific contexts and relationships soon outweigh expectations based on cultural stereotypes"

(p. 136). Others (Crocker et aI., 1984; Deaux & Lewis, 1984) have similarly claimed that

154

once specific information is learned about a person, sex role stereotypes playa less significant

role. The framework advanced presumed that receivers would make some allowance for the

use of more aversive strategies by female physicians in ongoing communication exchanges.

However, it was suggested that females could expand their range of communication choices in

developed relationships to the use of both positive and neutral regard strategies -- not to the

use of negative regard strategies.

Perhaps the best explanation for the lack of gender differences is that communication

expectations for relationships are stronger than sex role stereotypes and the two do not

interact with one another. And, as previously discussed, some aversive exchanges are

expected in familiar relationships. This, or course, is an empirical question yet to be

addressed in the medical setting. Results from this study should be compared to future studies

-- especially those that use actual interactions.

One final issue explored in this investigation was the effects of communication

exposure to a physician's communication style and patients' evaluation of future influence

attempts. There were no significant interaction effects between communication exposure and

subsequent influence attempts on patient satisfaction, physician perceptions, or physician

persuasiveness. Additionally, there were no significant interactions between gender and final

strategy usage or between gender and previous communication exposure. There was a

significant main effect for communication exposure where patients not previously exposed a

physician's communication style reported lower satisfaction, evaluated the physician less

favorably, and reported less persuasive success than patients who were previously exposed to

a physician's communication style. This is surprising given that some of the pure

combinations (e.g., all negative and all neutral) negatively influenced patients' initial

evaluations of satisfaction, physician perceptions, and physician persuasiveness. Several

155

researchers (e.g., Ickes et aI., 1982; Swann & Snyder, 1980) have found that individuals

maintain their evaluations, even in the face of disconfirming evidence. These preinteraction

expectancy biases did not seem to exist in the present study.

An attitude accessibility explanation can be evoked to explain the differences between

those patients who were previously exposed to the videotaped physician in Study 2 and those

patients in the control group who were not previously exposed to the videotaped physician.

According to Roskos-Ewoldsen (1992), the accessibility of an attitude from memory plays an

integral role in message processing. Attitude accessibility research defines an attitude as an

association in memory between the attitude object and the individual's evaluation of the object

(Fazio, 1989). Attitudes developed by patients exposed to the physician over five sessions

could have been related to the topic of diabetes or the physician. When attitudes are

accessible, or there is a well-developed association, people are less susceptible to peripheral

cues and are more likely to be influenced by the content of the message (WU & Shaffer,

1986). Thus, patients who were previously exposed to the physician and the diabetic

consultation sessions may have focused more on the what was said in the consultation session

than patients who were not previously exposed to the physician or previous diabetic episodes.

This would allow the patients who were not in the control group to focus more on the logic of

the message. Since the information in the consultation session was not illogical, attitude

accessibility should have facilitated satisfaction, physician perceptions, and physician

persuasiveness. Further, this group of subjects had more patient history information and may

have perceived any persuasive attempt as justified. This seems especially reasonable given

that perceptions of previous noncompliance were positively related to communication

evaluations for all strategy types.

156

Significance and Limitations of the Claims

The framework provides a heuristic function of integrating various bodies of

communication and psychology literature to address a critical but generally ignored subject in

the health care context -- long-term adherence. Many of the predictions advanced, and

supported, challenge claims made from the short-term perspective and directs researchers

towards examining the noncompliance problem for what it typically is -- a problem based on

repeated communication exchanges between health care providers and undermotivated

patients. It was argued that satisfying, affiliative communication is not the most logical or

advantageous choice for improving long-term compliance and could actually be detrimental to

achieving compliance. The investigation proved successful on several fronts.

First, this investigation successfully replicated the findings of M. Burgoon et al.

(1991) and supported the claim that aversive influence attempts are an effectiveness

compliance-gaining tool for male physicians. Several important differences exist between this

research on initial compliance-gaining attempts and that performed by M. Burgoon et al.

(1991). M. Burgoon et al. embedded their manipulation in a scenario that was limited to

verbal influence attempts. The scenario they used was based on an initial encounter that was

not serious in nature and which had the physician offering advice that mayor may not have

solved the patient's problem. This scenario is not necessarily typical of noncompliance

situations in the medical context and, thus, it is unclear if results from their study could be

generalized given the uniqueness of their chosen consultation session. Here, several

videotaped consultation sessions were manipulated by including both verbal and nonverbal

influence attempts. The present investigation also had actual patients observe the videotaped

physician. This method maintained experimental control, while adding realism to the

manipulation. The videotaped procedure also eliminated the possibility of subjects re-reading

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the transcript or slowing down to examine specific aspects of the manipulation.

The fact that previous research on strategy effectiveness in initial encounters could be

replicated using a slightly different influence categorization scheme with a different population

of subjects and over a variety of consultation sessions suggests that the findings are probably

quite robust and should not be ignored by the medical community. Even though the

proportion of variance was small in both investigations, one life saved is hardly an

insignificant amount of variance accounted for by a communication variable.

This investigation extends previous research by offering tentative support for the claim

that both male and female health care providers who have repeated exposure to a patient can

strategically use nonaffiliative communication to improve adherence rates while maintaining

satisfaction and person perceptions. Specifically, it was argued that strategy combinations

involving reinforcing and non-reinforcing communication are more persuasive than continual

reinforcement or continual non-reinforcement. Although integration of expectancy and

reinforcement principles led to the prediction that acceptable nonrewarding communication is

dictated by gender expectations such that females should rely on positive/neutral

combinations, this investigation was unable to find gender differences. Rather, coinciding

with the male physician prediction, all mixed type combinations (Le., positive/neutral,

negative/neutral, negative/positive) were superior to pure types (Le., all positive, all neutral,

all negative) for both male and female physicians. The findings related to female physicians

need to be interpreted and applied with great caution, however, since gender differences were

predicted.

The application of the predictions advanced and the claims supported to numerous

health care contexts is obvious. Regarding preventive medicine, practitioners could improve

programs dealing with prenatal care, well-child exams, or cholesterol maintenance. From a

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curative standpoint, therapists could increase motivation to comply with physical therapy and

speech therapy exercises. Additionally, counselors could increase compliance rates, as well as

behavioral maintenance, with weight loss and addition programs. In chronic disease

situations, health care providers could help diabetic, cancer, or heart-disease patients deal with

the difficult, long-term management of their illnesses.

As with any investigation, a number of limitations exist for these two interrelated

studies. One of the larger methodological shortcomings of the present investigation is the use

of only one male and one female physician. This casts doubt on the ability to generalize to

the community of physicians. The investigation offered a method, not previously considered

by scholars, to assess generalizability. Comparing the videotaped version to a transcript

version was considerably less time consuming and costly than training and videotaping a

number of physicians. However, this method is not without its flaws. First, if the type of

communication style influences physician perceptions then a measure of credibility and

attractiveness using only one communication style is biased by the style chosen. For instance,

the gender difference may not have existed if the two episodes used a positive communication

style rather than a neutral style. Second, the transcript version eliminates the nonverbal

communication channel and, thus, is not directly comparable to the videotaped version.

Clearly, the chosen method to assess generalizability needs to be improved upon if used in

future research. Additionally, future work should attempt to include more than one female

and male communicator.

The measurement of communication expectancy also raised concerns. Although the

questions are worded to tap predictive expectations, the items may have been interpreted as a

measure of what patients would "prefer" to have happen rather than what they would

"predict" would happen. Perhaps the best way to address this issue is to include both types of

159

measures. Subsequent studies might also have subjects compare all types of influence

attempts to determine which ones are seen as the most typical physician influence behaviors.

The greatest strength to the present study is also related to one of the larger

methodological problems. The present quasi-longitudinal study maintains experimental

control that is difficult to achieve in traditional longitudinal studies and provides necessary

baseline data for more expensive and time-consuming longitudinal studies. This design

format, however, can only assess motivation to comply and perceived communication

effectiveness rather than actual compliance. The method is also incapable of assessing

communication effects on behavioral persistence. Scholars have long questioned the validity

of measuring compliance through questionnaires or interviews (e.g., Gordis, 1979; Marston,

1978). After reviewing the literature, Gordis (1979) claimed that "there is little or no

evidence to suggest that complying patients misrepresent themselves as noncompliers, nor is

there evidence that those who profess noncompliance in an interview are lying" (p. 38).

However, the indirect compliance measurement technique used in this investigation assumed

that subjects were not only willing to represent themselves accurately but were able to report

how motivated they would be if they were the patient.

Whether direct measurements of compliance are needed is probably not as great an

issue as being able to measure the patients' ability to maintain adherence. The extension of

the reinforcement framework to behavioral maintenance predictions has already been advanced

(Klingle, 1993). The effectiveness of the predictions, however, remains to be determined.

Measures of behavioral maintenance or behavioral persistence is a primary goal in chronic

disease management and should be included in programmatic research related to long-term

compliance.

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Directions for Future Research

The current work is one of the first to experimentally investigate the effects of initial

influence attempts over a variety of different consultation sessions using actual patients, as

well as the first to systematically examine the effects of ongoing influence attempts in the

medical setting. It is not surprising, then, that a number of critical questions remain. For

example, what is the role of situational factors in patients' judgments of communication

expectancies and appropriateness? Exploring the effects of situational attributes in a more

systematic fashion will allow researchers to more clearly understand inherent intricacies in

ongoing influence attempts. This would facilitate efforts to detennine if there are factors that

might over-ride gender expectancies in ongoing interactions. From the present investigation,

it is unclear if gender effects disappeared because of relational familiarity, situational factors,

or some unknown methodological bias in the present investigation.

Questions that are not as easily addressed methodologically or theoretically concern

when and how many times a physician should engage in a communication reinforcement

violations. That is, although this investigation demonstrated that a combination of strategies is

preferred to no combination, it is unclear what the exact ratio of positive to aversive strategies

should be or when the violations should occur. The fact that reinforcement expectations were

higher with the mixed strategy combinations than with the pure types, suggests that the

placement of the violation is not all that important. Even if there isn't a logical reasoning for

using reinforcing or aversive communication, patients seem to believe that one exists. These

issues may not be all that vital for physicians who have infrequent repeated visits with

patients. However, these issues obviously need to be addressed to apply the framework to

support group contexts where health care providers have frequent and lengthy interactions

with patients. This context raises the additional matter of how reinforcement violations

161

operate in group settings. The use of aversive and reinforcing stimuli in this context requires

an understanding of the effects of direct versus observed reinforcement/punishment. The

communication expectancies in this context may be quite different.

The impact of strategy combinations should also be examined using actual interactions

between physicians and patients rather than videotaped procedures. Because the predictions

were based on the assumption that patients are motivated to regain or maintain reinforcing

communication from a physician, an application using actual interactions rather than role

playing may increase the magnitude of the effects. Thus, a follow-up investigation could

involve a traditional longitudinal study in which patients visit a health care provider over a

number of weeks. Dietary management would serve as an ideal health care context for this

secondary test because numerous illnesses and maintenance programs require long-term

compliance with dietary suggestions and physician contact is frequent. This clinical stage

could utilize the previously tested compliance-gaining strategies and could test all the outcome

variables addressed in this study as well as behavioral maintenance.

In a special Communication Monographs issue that examined communication

scholarship into the new century, Sharf (1993) argued that future research must go beyond

looking at brief and episodic physician-patient relationships and strive to address physician­

patient relationships that are longitudinal in nature. She also pointed out that more studies

need to focus on outcome variables other than satisfaction and tap into "tough issues" such as

long-term adherence to medical recommendations. The compelling argument that health care

research must be extended to more longitudinal issues has been with us for more than a

decade (cf. Epstein & Cluss, 1982), yet generally gets ignored by communication researchers.

The present investigation was not without its methodological and theoretical limitations. This

work, however, makes an important theoretical contribution by expanding the domain of

162

medical communication research to long-term adherence situations. The claims and findings

have practical implications for practitioners desiring to engage in the most effective

communication repertoire in both short- and long-term adherence situations and has heuristic

value for scholars attempting to advance their thinking to longitudinal health care concerns.

FOOTNOTES

1 Sociological variables such as physician ethnicity might also influence message

acceptability. The relationship between message acceptability and sociological expectations

related to variables other than gender, however, is unclear given the limited empirical

grounding regarding their impact in the health care context. Future research should

investigate expectations related to other sociologically and culturally important variables

because they may change the nature of communication expectations and, consequently, the

efficacy of certain strategy combinations predicted in the theoretical framework.

163

2 Although 25 students participated in the survey, only 18 students completed all the

items. Surveys with missing data were excluded from the analyses.

3 Because of a survey design error that was not initially detected, several subjects did

not respond to the situational perception items.

4 Six different orders existed for each of the combinations. For instance the positive

neutral combination could have been constructed in the following manner: (1) positive,

neutral, positive, neutral (2) neutral, positive, neutral, positive, (3) positive, neutral, neutral,

positive, (4) neutral, positive, positive, neutral, (5) positive, positive, neutral, neutral, or (6)

neutral, neutral, positive, positive. Either of the first four combinations would have been fair

tests of the positive-neutral combination and should result in similar outcomes. However,

since logistical constraints limited the number of orders to be tested only the first two orders

depicted above were used in Study 2.

S Phi coefficients were computed for each of the items on individual scales to

determine which items were poor discriminators. The phi coefficient was used because it

measures the strength of relationship between item scores and the total scores of the scale to

which that item is a part. If the item has high discriminatory power, respondents who score

high on a particular item should also score high on the overall scale and respondents who

score Iowan a particular item should score Iowan the overall scale. Items were removed

from the survey if the phi test had a phi less than .50.

164

6 Reliabilities for the dependent measures assessing evaluation of future strategies in

Study 2 were as follows: persuasiveness (a = .96), patient satisfaction (a = .96), physician

perceptions (a = .96), appropriateness (a = .67), expectancies (a = .66), valence

(a = .93), approval (a = .73), and affect (a = .88).

APPENDIX A

Verbal Strategy Definitions and Examples

NEUTRAL REGARD STRATEGY

Definition

Communication requests which are simple directives or justifications. These verbal strategies neither signal approval or disapproval for the patient or the patient's actions.

Types and Examples

Direct Request: requests which tell the patient what to do.

"There are several changes I would like you to make in your diet. "

"You need to change your eating habits."

"I want you to have a number of tests done. "

"Make sure you are keeping an accurate log of your eating patterns."

"You need to change your present eating habits."

Justification Based on Expertise: requests based on expertise or research.

"A substantial amount of research has shown that these changes can prevent other health problems from occurring in the future. "

"In my opinion, regular eating habits are key in these situations."

"In my opinion, you shouldn't put this off."

"Since research indicates that diet is key in your situation, I want you to keep a log of your eating habits."

"I want you to start exercising regularly and continue keeping a dietary log since all the best sources indicate that dietary changes and exercise in these situations are necessary. " .

Justification Based on Patient Condition: requests made because of the patients particular illness.

"Seeing a dietitian is the best advice I can give you for your situation."

165

"If this is diabetes, the same dietary changes we've discussed will be needed to deal with the condition. "

"The food choices the dietitian discussed with you and the recommendations to avoid sweets and eat a high fiber diet are necessary to keep diabetes under control. "

"I've seen individuals who are in your same situation and eating habits are generally key. "

166

"I know from treating similar cases that these changes usually can solve the problem. "

POSITIVE REGARD STRATEGY

Definition

Communication requests which are supportive, understanding, or stress concern for the patient. These verbal strategies signal approval of the patient and/or the patient's actions.

Types and Examples

Supportive Requests: requests which reinforce, reassure, compliment, or promise good things for compliance.

"You'll feel so much better about yourself because you'll know you're doing what it takes to feel better now and prevent problems in the future. "

"Regular eating habits will make you feel so much better. "

"If this is diabetes, don't worry, you're going to be okay as long as you stick to the same dietary changes you've been working so hard on already. "

"I can tell you've been trying really hard to change your diet -- now if you can just take the extra step and eliminate all the foods we discussed you will feel better."

"Make sure you keep an accurate log so we can see all the wonderful progress you are making on your diet. "

Validation Requests: requests which acknowledge the difficulty of the compliance act and indicate confidence in the patient following the request.

"I know that changing ones eating habits is very difficult, but you're the kind of person who can do it and make it work for you."

"A lot of patients have difficulty making these changes, but with your determination I know you can do it. "

"I realize these tests sound inconvenient, but I know you'll try to fit them into your schedule and be glad you did. "

167

"If you make these changes -- which I know you can -- everyone will be so proud of you because we all know how difficult it is to make these changes."

"I know it's difficult, but I want to see you feeling good everyday, so please avoid sweets and eat a high fiber diet like the dietitian discussed. "

Commonality of Goals: requests which stress mutual concern, affect, or "we"ness.

"I really like you and would like to see you feeling better the next time I see you, so please make sure you try to make some of these changes."

"I'm really concerned about you so I want you to see the dietitian so you can get some help fitting these dietary changes into your busy lifestyle. "

"We both want to find out what could be causing you to feel so run down so please make the appointment to have the tests done. "

"We both want you to get better, so please eat right everyday, okay?"

"I care about you a great deal and want to see you get better, so make sure that you make these changes in your eating habits."

NEGATIVE REGARD STRATEGIES

Definition

Communication requests which attack or criticize the patient's past behaviors or potential future behavior, or requests that attribute primary responsibility to the patient for ill feeling. These verbal strategies signal disapproval for the patient and/or the patient's actions.

Nonsupportive Requests: requests which suggest the simplicity of the request and/or indicate disbelief in the patient's Willingness to make changes.

"You really have two choices -- change your diet or spend the rest of your life wishing you had."

"It's not going to take that much of your time to see a dietitian as recommended -- and it should make it possible for you to meet your goals."

"If this is diabetes, the solution is generally quite simple -- stick to your diet."

"Make sure you keep an accurate log so you can note when you aren't sticking to your diet. "

"There's not a reason in the world why you shouldn't change your eating habits and exercise regularly. "

Invalidation Requests: requests which criticize or attack the patient's self­concept and/or indicate disappointment in the patient's previous actions.

"Unless you want to be foolish and take the risk of developing a serious health problem like heart disease ot diabetes you have to start changing your eating habits. "

"You have to see by now that it's absolutely irrational not to make the changes we discussed. "

"And I'm not going to debate with you on this one -- you have to have these tests done. "

"You can't keep fooling around with our diet -- a responsible person would know that now is the time to take charge and make all the changes necessary. "

"There's no doubt about it. You must eat right everyday -- not just occasionally -- to get better. "

Negative Consequences: requests which suggest noncompliant actions will lead or have caused negative consequences.

"You're going to continue to feel tired unless you make these basic changes."

"Your irregular eating habits are bound to make you overeat and gain weight. "

"If you don't have these tests done immediately you could end up with a very serious situation and wish you had taken the time out of your schedule. "

"If you want to make sure you don't end up with a serious problem later in life it's as simple as ABC - change your eating habits. "

If you won't follow this advice you're going to continue to feel run down and tired -- it's that simple."

168

169

APPENDIX B

Transcripts

SESSION 1

Let me review what you've just told me to make sure I have everything. You've

been gaining some weight over the last 10 years and when you went to your high school

reunion you felt "yucky" and out of shape. However you can exercise the same as usual

without getting out of breath. You also said that you're not urinating real often, no unusual

bowel movements, no chest pains or palpitations. You said that there's no history of cancer

but you thought one of your cousins had diabetes and maybe a distant aunt had some heart

trouble. Is that correct? Now looking at your physical exam, your blood pressure is a little

high but everything else seems normal so your problem may be related to simply being

slightly overweight and out of shape and we talked about some changes you might try making

in your diet and exercise. In most situations like yours, the problem can be solved with a

change in diet and making regular exercise a part of your life. But I do think it would be

good idea to rule out the possibility that it isn't something more serious by doing some simple

screening tests. Before you leave the clinic today I'd like you to have a urinalysis, blood

count, and a standard set of chemistry tests including a look at your blood sugar, cholesterol,

and fat. These tests will only take a few minutes. In the mean time, try eating more

nutritional foods like the ones we discussed and going for regular walks. Do you have any

questions? Okay. Well, if you coul~, take this down to the lab and make an appointment to

see me at the end of the week.

170

SESSION 2

NEUTRAL

Most of the tests came back normal. Cholesterol is at the high end of normal. Your

blood sugar is borderline high at 130 -- the normal range is 80 - 120. It might be that way if

you had just eaten so it's not usually something to get too alarmed about. However, the fact

that you're overweight and the possible family history of diabetes does put you at risk. In

order to regain your energy and lose some weight, I think you should make some changes in

your eating habit. There are several changes I would like you to make in your diet. What

I'd like you to do is cut back on fat and the amount of sweets you eat. Both of these are high

in calories. I want you to try eating more foods that are natural sources of carbohydrates and

high in tiber. For instance, try to eat whole wheat bread instead of white bread. I know

from treating similar cases that these changes usually can solve the problem. Also. a

substantial amount of research has shown that these changes can prevent other health

problems from occurring in the future. You might also want to set up an appointment with a

dietitian to get some advice on meal preparation. Okay?

POSITIVE

Most of the tests came back normal. Cholesterol is at the high end of normal. Your

blood sugar is borderline high at 130 -- the normal range is 80 - 120. It might be that way if

you had just eaten so it's not usually something to get too alarmed about. However, the fact

that you're overweight and the possible family history of diabetes does put you at risk. In

order to regain your energy and lose some, weight, I think you should make some changes in

your eating habit. I know that changing ones eating habits is very difficult. but you're the

kind of person who can do it and make it work for you. What I'd like you to do is cut back

on fat and the amount of sweets you eat. Both of these are high in calories. I want you to

171

try eating more foods that are natural sources of carbohydrates and high in fiber. For

instance, try to eat whole wheat bread instead of white bread. I really like you and would

like to see you feeling better the next time I see you. so please make sure you try to make

some of these changes. Also. you'll feel so much better about yourself because you'll know

you're doing what it takes to feel better now and prevent problems in the future. You might

also want to set up an appointment with a dietitian to get some advice on meal preparation.

Okay?

NEGATIVE

Most of the tests came back normal. Cholesterol is at the high end of normal. Your

blood sugar is borderline high at 130 -- the normal range is 80 - 120. It might be that way if

you had just eaten so it's not usually something to get too alarmed about. However, the fact

that you're overweight and the possible family history of diabetes does put you at risk. In

order to regain your energy and lose some weight I think you should make some changes in

your eating habit. Unless you want to be foolish and take the risk of developing a serious

health problem like heart disease or diabetes you have to start changing your eating habits.

What I'd like you to do is cut back on fat and the amount of sweets you eat. Both of these

are high in calories. I want you to try eating more foods that are natural sources of

carbohydrates and high in fiber. For instance, try to eat whole wheat bread instead of white

bread. You're going to continue to feel tired unless you make these basic changes. You

really have two choices -- change your diet or spend the rest of your life wishing you had.

You might also want to set up an appoin~ent with a dietitian to get some advice on meal

preparation. Okay?

172

SESSION 3

NEUTRAL

From what you told me, it really seems like the way you feel is related to your eating

habits. Your chart also indicates that you've gained some weight over the last few months

and your blood pressure is a bit higher. You need to change your eating habits. It's

important that you eat the foods high in fiber and low in refined sugars and carbohydrates as

we discussed. I'd also like you to try to figure out a way to space out your eating times

throughout the day so you aren't overeating in one meal. Usually it's a good idea to make

sure your meals are about 4 to 5 hours a part. In my opinion. regular eating habits are key in

these situations. You commented that you don't have time to plan the appropriate meals.

Since you said you didn't meet with a dietitian I'm going to write down a dietitian I'd like

you to meet with. She'll give you a list of specific things that will help you fit these dietary

changes into your busy lifestyle. Seeing a dietitian is the best advice I can give you for your

situation.

POSITIVE

From what you told me, it really seems like the way you feel is related to your eating

habits. Your chart also indicates that you've gained some weight over the last few months

and your blood pressure is a bit higher. A lot of patients have difficulty making these

changes. but with your determination I know you can do it. It's important that you eat the

foods high in fiber and low in refined sugars and carbohydrates as we discussed. I'd also like

you to try to figure out a way to space out your eating times throughout the day so you aren't

overeating in one meal. Usually it's a good idea to make sure your meals are about 4 to 5

hours a part. Regular eating habits will make you feel so much better. You commented that

you don't have time to plan the appropriate meals. Since you said you didn't meet with a

173

dietitian I'm going to write down a dietitian I'd like you to meet with. She'll give you a list

of specific things that will help you fit these dietary changes into your busy lifestyle. I'm

really concerned about you so I want you to see the dietitian so you can get some help fitting

these dietary changes into your busy lifestyle.

NEGATIVE

From what you told me, it really seems like the way you feel is related to your eating

habits. Your chart also indicates that you've gained some weight over the last few months

and your blood pressure is a bit higher. You have to see by now that it's absolutely irrational

not to make the changes we discussed. It's important that you eat the foods high in fiber and

low in refined sugars and carbohydrates as we discussed. I'd also like you to try to figure out

a way to space out your eating times throughout the day so you aren't overeating in one meal.

Usually it's a good idea to make sure your meals are about 4 to 5 hours a part. Your

irregular eating habits are bound to make you overeat and gain weight. You commented that

you don't have time to plan the appropriate meals. Since you said you didn't meet with a

dietitian I'm going to write down a dietitian I'd like you to meet with. She'll give you a list

of specific things that will help you fit these dietary changes into your busy lifestyle. It's not

going to take that much of your time to see a dietitian as recommended -- and it should make

it possible for you to meet your goals.

SESSION 4

NEUTRAL

Your urinalysis showed that you tested positive for glucose. It's not very high but the

fact that you're still feeling tired and you're urinating more frequently may indicate a mild

diabetes condition. I think it's time we do some screening tests for diabetes. I want you to

have a numher of tests done. I'd like you to make an appointment to have a glucose tolerance

174

test and a hemoglobin A1C which will show us how high your sugar has been running.

You'll need to block off a whole day in your schedule to have these tests done. Your

schedule this week is very busy so schedule an appointment early next week. You'll need to

fast the day before. When you come in for the test, they'll start by taking a blood sample and

then you will drink a sugary drink that doesn't taste real good and have several more blood

tests over the next few hours. In my opinion. you shouldn't put this off. In the mean time,

you have to make the changes we discussed in your diet. If this is diabetes. the same dietary

changes we've discussed will be needed to deal with the condition.

POSITIVE

Your urinalysis showed you tested positive for glucose. It's not very high but the fact

that you're still feeling tired and you are urinating more frequently may indicate a mild

diabetes condition. I think it's time we do some screening tests for diabetes. We both want

to find out what could be causing you to feel so run down so I'd like you to make an

appointment to have a glucose tolerance test and a hemoglobin Al C which will show us how

high your sugar has been running. You'll need to block off a whole day in your schedule to

have these tests done. Your schedule this week is very busy so schedule an appointment early

next week. You'll need to fast the day before. When you come in for the test, they'll start

by taking a blood sample and then you will drink a sugary drink that doesn't taste real good

and have several more blood tests over the next few hours. I realize these teste; sound

inconvenient. but I know you'll try to fit them into your schedule and be glad you did. In the

mean time, you have to make the changes we discussed in your diet. If this is diabetes. don't

worry. you're going to be okay as long as you stick to the same dietary changes you've been

working so hard on already.

175

NEGATIVE

Your urinalysis showed you tested positive for glucose. It's not

very high but the fact that you're still feeling tired and you're urinating more frequently may

indicate a mild diabetes condition. I think it's time we do some screening tests for diabetes.

And I'm not going to debate with you on this one -- you have to have these tests done. I'd

like you to make an appointment to have a glucose tolerance test and a hemoglobin Ale

which will show us how high your sugar has been running. You'll need to block off a whole

day in your schedule to have these t~sts done. Your schedule this week is very busy so

schedule an appointment early next week. You'll need to fast the day before. When you

come in for the test, they'll start by taking a blood sample and then you will drink a sugary

drink that doesn't taste real good and have several more blood tests over the next few hours.

If you don't have these tests done immediately you could end up with a very serious situation

and wish you had taken the time out of your· schedule. In the mean time, you have to make

the changes we discussed in your diet. If this is diabetes, the solution is generally guite

simple -- stick to your diet.

SESSION 5

NEUTRAL

Some of your test results came back positive. Glucose was basically normal but your

hemoglobin Ale was slightly higher than normal. What this means is you have mild diabetes

or what's sometimes called prediabetes. Now mild diabetes isn't serious -- you don't have to

inject yourself with insulin - but you. do need to monitor your diet as we've talked about so

you don't feel run down and tired all the time. Since research indicates that diet is key in

your situation, I want you to keep a log of your eating habits. I'm going to give you a

special book which will help you keep track of what you're eating. Okay? Make sure you're

176

keeping an accurate log of your eating patterns. And think about what we've already talked

about. The food choices the dietitian discussed with you and the recommendations to avoid

sweets and eat a high fiber diet are necessary to keep diabetes under control. Do you have

any questions?

POSITIVE

Some of your test results came back positive. Glucose was basically normal but your

hemoglobin A 1 C was slightly higher than normal. What this means is you have mild diabetes

or what's sometimes called prediabetes. Now mild diabetes isn't serious -- you don't have to

inject yourself with insulin -- but you do need to monitor your diet as we've talked about so

you don't feel run down and tired all the time. I can tell you've been trying really hard to

change your diet -- now if you can just take the extra step and eliminate all the foods we

discussed you will feel better. I'm going to give you a special book which will help you keep

a log of what you're eating. Make sure you keep an accurate log so we can see all the

wonderful progress you are making on your diet. And think about what we've already talked

about. I know it's difficult. but I want to see you feeling good everyday. so please avoid

sweets and eat ~ high fiber diet like the dietitian discussed. Do you have any questions?

NEGATIVE

Some of your test results came back positive. Glucose was basically normal but your

hemoglobin A1C was slightly higher than normal. What this means is you have mild diabetes

or what's sometimes called prediabetes. Now mild diabetes isn't serious -- you don't have to

inject yourself with insulin - but you do need to monitor your diet as we've talked about so

you don't feel run down and tired all the time. You can't keep fooling around with your diet

-- a responsible person would know that now is the time to take charge and make all the

changes necessary. I'm going to give you a special book which will help you keep a log of

177

what you're eating. Make sure you keep an accurate log so you can note when you aren't

sticking to your diet. And think about what we've already talked about. If you want to make

sure you don't end up with a serious problem later in life it's as simple as ABC -- change

your eating habits. Do you have any questions?

SESSION 6

NEUTRAL

I reviewed your lab tests and there's no serious problem with them. It all comes

down to your eating habits. In looking over your dietary log it's clear that you're diet is

good some days but at other times you're eating a lot of junk food. You need to change your

present eating habits. First, I want you to include more nutritional, high fiber foods in your

diet. Second, you need to reduce the amount of high caloric, less nutritional foods you're

presently eating. If you want to snack, eat fruits and vegetables, but avoid the junk foods

you've been eating. I've seen individuals who are in your same situation and eating habits are

generally key. You told me that you enjoy going for an occasional walk. I'd like you to

continue going for walks and work towards a more regular exercise schedule. I want you to

start exercising regularly and continue keeping a dietary log since all the best sources indicate

that dietary changes and exercise in these situations are necessary. Do you understand

everything we've talked about? Okay.

POSITIVE

I reviewed your lab tests and there's no serious problem with them. It all comes

down to your eating habits. In looking Over your dietary log it's clear that you're diet is

good some days but at other times you're eating a lot of junk food. We both want you to get

better. so please eat right everyday. Okay? First, I want you to include more nutritional,

high tiber foods in your diet. Second, you need to reduce the amount of high caloric, less

178

nutritional foods you're eating. If you want to snack, eat fruits and vegetables, but avoid the

junk foods you've been eating. I care about you a great deal and want to see you get better.

so make sure that you make these changes in your eating habits. You told me that you enjoy

going for an occasional walk. I'd like you to continue going for walks and work towards a

more regular exercise schedule. If you make these changes -- which I know you can -­

everyone will be so proud of you because we all know how difficult it is to make these

changes. Do you understand everything we've talked about? Okay.

NEGATIVE

I reviewed your lab tests and there's no serious problem with them. It all comes

down to your eating habits. In looking over the dietary log it's clear that you're diet is

good some days but at other times you're eating a lot of junk food. There's no douht about

it. You must eat right everyday -- not just occasionally -- to get better. First, I want you to

include more nutritional, high fiber foods in your diet. Second, you need to reduce the

amount of high caloric, less nutritional foods you're eating. If you want to snack, eat fruits

and vegetables, but avoid the junk foods you've been eating. If you won't follow this advice

you're going to continue to feel run down and tired -- it's that simple. You told me that you

go for an occasional walk which you enjoy doing. I'd like you to continue going for walks

and work towards a more regular exercise schedule. There's not a reason in the world why

you shouldn't change your eating habits and exercise regularly. Do you understand

everything we've talked about? Okay.

179

APPENDIX C

Manipulation Check Instrument

Instructions: Based on the scenario you just read, please indicate how strongly you disagree or agree with each of the statements below by circling the appropriate number.

Strongly Strongly Disagree Neutral Agree

1. I w9u1d like being told this. 2 3 4 5 6 7

2. The physician was very disappointed in the patient. 2 3 4 5 6 7

3. I would enjoy my interaction with the physician if the physician communicated with me this way. 2 3 4 5 6 7

4. The physician showed clear signs of disapproval. 2 3 4 5 6 7

5. The physician seemed very frustrated with the patient 2 3 4 5 6 7

Based on the scenario you just read, how would you rate the physician's communication:

very undesirable 1 2 3 4 5 6 7 very desirable

very unrewarding 1 2 3 4 5 6 7 very rewarding

very unpleasant 1 2 3 4 5 6 7 very pleasant

very distasteful 1 2 3 4 5 6 7 very enjoyable

180

APPENDIX D

Study 1 Consent Form

Purpose and Benefits

This project is designed to gather information about the ways in which doctors communicate with their patients. Specifically, health researchers in the Department of Communication at the University of Arizona are interested in examining how people make evaluations about doctors' communication styles in the clinical setting. The information you provide will help researchers understand how health care providers may more effectively communicate with their patients to improve patient care.

Procedures

You will be asked to watch a video which contains an actual physician-patient consultation session. While viewing the video, you will be instructed to imagine yourself as the patient the physician is consulting. After watching the video you will be asked a number of questions concerning the physician you observed and your feelings as a patient.

The physician-patient interaction and questions will all be on a computer. A researcher will show you how to use the computer and will also assist you during the project if you have any difficulty reading or understanding the questions. Most people find using the computer for this project both easy and enjoyable. Your names will not be linked to the answer you supply in the computer so all answers will be anonymous. The study will take approximately 10 minutes to complete. You may refuse to participate or may withdraw from the study at any time without upsetting the researcher.

Risks. Stress. and Discomfort

You will not incur any physical risks by participating in this study. You will not be asked questions of a personal nature and participation should not result in any discomfort.

Confidentiality

Only researchers from the Communication Department at the University of Arizona will have access to your answers and your name will not be linked with the answers you choose. Hospitals will receive a summary of the study in statistical form but will not see individual answers.

Principle Investigator

Renee S. Klingle 621-1366

Subject's Statement

"The study described about has been explained to me. I voluntarily consent to participate in this activity. I understand that any questions I may have about the research or about my rights as a subject will be answered by the investigator listed above or the research assistant running the study. "

Signature of Subject Date

APPENDIX E

Computer Instructions

If you would like instructions for using the computer mouse, please press the letter "Y" on the keyboard.

If not, click on the "Begin" button below.

BEGIN

[new screen page]

181

During the next few minutes, you will be asked to answer a few questions regarding your opinion about certain topics. Before we begin, however, we must be sure you know how to operate the program. Please use the mouse to point to the cursor arrow (it looks like this ) at the box below labeled "Click Here." Then briefly press and release the left mouse button (this is called "clicking on a button").

If you do not understand these directions, please ask the facilitator for assistance.

CLICK HERE

[new screen page]

Good! if you prefer to use the keyboard, you can press the Enter key to continue on any screen. Press the Enter key or click on the button below to continue.

CONTINUE

[new screen page]

Most of the time you will be asked to indicate how much you agree with a statement. In this case, we use the scale below. To register your opinion, click the left mouse button while pointing the cursor arrow at the appropriate place on the scale. Try it now.

Or you can use the right and left arrow keys of the computer keyboard to adjust the marker on the scale. Try it below. When you are done, click on the "Continue" button below (or press the ENTER key).

Sample: I am comfortable using co~put~rs (indicate your agreement below).

Strongly 1 ___ 1 ___ 1 ___ 1 ___ 1 ___ 1 ____ 1

Disagree

Indicate your opinion by clicking on the scale line.

Strongly Agree

182

[new screen page]

It looks like you've got it. One important thing to remember, however, is that once you click on "Continue" for any screen, you will not be able to return to change your answer. However, until you click on the continue button, you can change your opinion on the scale as many times as you like. When you are ready to continue, click on the button below (or press ENTER).

CONTINUE

[new screen page]

In a minute 'you will be asked to view a segment of video. To make sure that the videodisc is working properly, put on the earphones now and then click on the "Test video" button below. You should see the image on the television screen next to the computer monitor.

TEST VIDEO

Did you see a picture on the television monitor and hear the audio?

YES NO TEST VIDEO AGAIN

183

APPENDIX F

Single Session Instrument: Study 1 and Study 2 (Part B)

Introduction to Study 1

This project is designed to gather information about the ways in which doctors communicate with their patients. Specifically, health researchers in the Department of Communication at the University of Arizona are interested in examining how people make evaluations about doctors' communication styles in the clinical setting.

Introduction to Video Segment for Study 1 and Study 2 (Part B)

You will be watching [Study 1: "a" /Study 2B: "one more"] videotaped physician-patient consultation session. After the segment, we will ask you a series of questions. In this session the patient has consulted Dr: Jones because the patient has not felt very well for a couple of weeks. Dr. Jones is a primary care physician who has been practicing medicine in a large southwestern city for a number of years. The patient's dialogue has been excluded so that you can more easily imagine yourself taking part in this consultation.

We ask that you imagine yourself as Dr. Jones' patient as you watch this videotaped segment. When you are ready to watch the consultation session, click on the button below.

Study 1 and Study 2 (Part B) Questionnaire

The questions you will be asked on the next few screens concern the video you just watched and your feelings as Dr. Jones' patient. The questions are worded as if you were actually the patient who visited Dr. Jones. Think carefully about how you would actually feel and what you would actually do as Dr. Jones' patient.

For each screen, you will be presented with a statement about the consultation session you just viewed. Please indicate how much you agree with the statement by clicking on the point of the scale that most closely approximates where your opinion falls in relation to the extremes of the scale.

*1. Dr. Jones' arguments in this session were very convincing.

Strongly Disagree

1---1---1---1---1---1---1 Strongly Agree

2. I would try very hard to follow the advice Dr. Jones gave in this session.

Strongly Disagree

1---1---1---1---1---1---1 Strongly Agree

3. I would be motivated to change my behavior.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

184

4. In this session, Dr. Jones used effective strategies to get me to change my behavior.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*5. I would have confidence in Dr. Jones' abilities as a physician.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

6. If Dr. Jones used these strategies on me, I would change my eating habits.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*7. I would follow Dr. Jones' advice.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

8. Dr. Jones convinced me to change my behavior.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

9. I would try very hard to please Dr. Jones by following her advice.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*10. Dr. Jones caused me to think about my behavior very much.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

11. In this visit, Dr. Iones used effective strategies to persuade me.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

185

The following statements concern your feelings about Dr. Jones. Once again, please indicate where your opinion falls in relation to the extremes.

12. Dr. Jones seemed experienced in dealing with patients' problems.

Strongly Disagree

1---1---1---1---1---1---1 Strongly Agree

*13. Dr. Jones did not take my problems as a patient seriously.

Strongly Disagree

1---1---1---1---1---1---1

14. Dr. 'Jones is a very competent physician.

Strongly Disagree

1---1---" 1 ___ 1 ___ 1 ___ 1 ___ 1

Strongly Agree

Strongly Agree

* 15. There are some things about the way Dr. Jones communicated that could have been better.

Strongly Disagree

1---1---1---1---1---1---1 Strongly Agree

16. I am perfectly satisfied with the care I just received from Dr. Jones.

Strongly Disagree

1---1---1---1---1---1---1

17. I would feel much better after this visit with Dr. Jones.

Strongly Disagree

1---1---1---1---1---1---1

*18. Dr. Jones was friendly in this visit.

Strongly Disagree

1---1---1---1---1---1---1

19. I would have confidence in Dr. Jones.

Strongly Disagree

1---1---" 1 ___ " 1 ___ 1 ___ 1 ___ 1

Strongly Agree

Strongly Agree

Strongly Agree

Strongly Agree

20. Dr. Jones seemed devoted to me as a patient.

Strongly Disagree

1---1---1---1---1---1---1 Strongly Agree

186

21. I think if I were really a patient, this visit with Dr. Jones would have relieved my worries about the problem.

Strongly Disagree

1---1---1---1---1---1---1

22. Dr. Jones is good at dealing with patients.

Strongly Disagree

1---1---1---1---1---1---1

Strongly Agree

Strongly Agree

23. I would trust Dr. Jones to deal with my medical problems.

Strongly Disagree

1---1---1---1---1---1---1

24. This visit made me feel understood by Dr. Jones.

Strongly Disagree

1---1---1---1---1---1---1

Strongly Agree

Strongly Agree

25. I was very satisfied with Dr. Jones' style of communication in this session.

Strongly Disagree

1---1---1---1---1---1---1 Strongly Agree

26. How would you rate Dr. lones' interaction with the patient on a scale ranging from very inappropriate to very appropriate?

Very Inappropriate

1 ___ 1 ___ 1 ___ 1 ___ 1 ___ 1 ___ 1 Very Appropriate

*27. How would you rate Dr. lones' interaction with the patient on a scale ranging from very unprofessional to very professional?

Very Unprofessional

1---1---1---1---1---1---1 Very Professional

187

28. How would you rate Dr. Jones' interaction with the patient on a scale ranging from very pleasant to very unpleasant?

Very Unpleasant

1 ___ 1 ___ 1 ___ 1_1 ___ 1 ___ 1 Very Pleasant

29. How would you rate Dr. Jones' interaction with the patient on a scale ranging from very unenjoyable to very enjoyable?

Very Unenjoyable

1 ___ 1 ___ 1 ___ 1_1_1_1 Very Enjoyable

30. How would you rate Dr. Jones' interaction with the patient on a scale ranging from very undesirable to very desirable?

Very Undesirable

1_1_· 1_1_1_1_1 Very Desirable

The following questions also ask you to consider the way Dr. Jones interacted with the patient. Once again, please indicate on the scale where your opinion falls.

31. I think it is normal for Dr . Jones to respond to a patient this way.

Strongly Disagree

1_1_1_1_1_1_1

32. This would be Dr. Jones' way of showing concern.

Strongly Disagree

1_1_1_1_1_1_1

33. Dr. Jones interacted with me the way I liked.

Strongly Disagree

1---1_1_1_1_1_1

Strongly Agree

Strongly Agree

Strongly Agree

34. Dr. Jones' communication style during this visit is what I anticipated.

Strongly Disagree

1---1---1_1_1_1---1 Strongly Agree

35. If I were the patient, I would object to the manner in which Dr. Jones talked to me.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

36. Dr. Jones acted like I wasn't trying hard enough to change my health problem.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

37. Telling me this shows Dr. Jones cares about me as a patient.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

188

38. If I were the patient, I would think Dr. Jones was annoyed with me during this visit.

Strongly Disagree

1_1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 Strongly Agree

39. I get the impression that Dr: Jones has faith that the patient will follow the advice given.

Strongly Disagree

1_1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 Strongly Agree

40. I did not expect Dr. Jones to communicate this way.

Strongly Disagree

1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 Stroog~ Agree

41. Dr. Jones seemed very concerned about me.

Strongly Disagree

1 ____ 1 ____ 1 ____ 1_1 ____ 1 ____ 1 Strongly Agree

42. It seemed like this was one of the first times the patient had visited Dr. Jones.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

43. The physician has probably seen this patient a number of times.

Strongly Disagree

1 ____ 1_1 ____ 1_1_1_1 Strongly Agree

44. I could put myself in the patient's shoes.

Strongly Disagree

1 ____ 1 ____ 1_1 ____ 1 ____ 1_1 Strongly Agree

45. I could actually imagine myself as Dr. Jones' patient.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

46. It seemed like the patienfs health problem was very serious.

Strongly Disagree

1_1_1_1 ____ 1 ____ 1 ____ 1 Strongly Agree

47. I would consider this a serious medical problem if I were the patient.

Strongly Disagree

1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 Strongly Agree

48. I felt contident that the physician's recommendations would solve the patient's problems.

Strongly Disagree

1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1_1 Strongly Agree

49. If I were actually the patient I would be convinced that following the physician's suggestions would make me feel much better.

Strongly Disagree

1_1_1_1 ____ 1 ____ 1_1 Strongly Agree

50. This patient probably doesn't make the changes the physician recommends.

Strongly Disagree

1_1 ____ 1 ____ 1 ____ 1 ____ 1_1 Strongly Agree

51. I don't think this patient generally follows the physician's advice.

Strongly Disagree

1_1 ____ 1 ____ 1 ____ 1 ____ 1_1 Strongly Agree

189

This last set of questions is very short. Here we ask you for some background information about yourself. These questions are just to see if our sample is like the general population. Please indicate the appropriate response by clicking on the button that corresponds to your answer, then clicking the "continue" button. Keep in mind that your answers are strictly confidential.

1. Has your physician ever recommended that you make changes in your diet?

YES NO

190

2. What condition was your physician trying to treat or prevent when recommending the dietary changes?

DIABETES/HYPERGLYCEMIA WEIGHT PROBLEM

HEART DISEASE ULCER/DIGESTIVE PROBLEM

CANCER OTHER

3. Have you ever found it difficult to follow your physician's recommendations?

YES NO

4. How important do you think it is for you to change your present eating habits?

Not at all 1_1_1_1_1_1_1 Very important

5. How often have you tried to change your eating habits?

Never 1_1_1_1_1_1_1 Very often

6. How much would you like to change your present eating habits?

Not at all 1_1_1_1_1_1_1 Very much

7. How difficult is it for you to follow a physician's advice when it requires you to make a change in your lifestyle?

Not at all 1_1_1_1_1_1_1 Very difficult

8. How similar was the patient's situation to those you have experienced?

Not at all 1_1_1_1_1_1_1 Very similar

9. Have you ever visited the physician(s) you saw in the video?

YES NO

191

to. Who do you primarily visit for your health care needs?

A MALE PHYSICIAN A FEMALE PHYSICIAN I VISIT BOTH OTHER

11. Approximately how many days each year do you visit a physician?

LESS THAN 2 2 - 5 DAYS 6 - 10 DAYS 11 - 20 DAYS MORE THAN 20 DAYS

12. What is your gender?

FEMALE MALE

13. What is your age group?

LESS THAN 20 YEARS OLD 41-50 YEARS OLD

20-30 YEARS OLD 51-60 YEARS OLD

31-40 YEARS OLD OVER 60 YEARS OLD

14. What is the highest education level of schooling you have completed?

LESS THAN HIGH SCHOOL TRADE SCHOOLl2 YEAR COLLEGE

HIGH SCHOOL GRADUATE 4 COLLEGE PROGRAM

SOME COLLEGE GRADUATE DEGREE

15. How would you describe your ethnic background?

AFRICAN AMERICAN HISPANIC

AMERICAN INDIAN WHITE/ANGLO

ASIAN/PACIFIC ISLANDER OTHER

16. What was your estimated annual household income before taxes last year?

* Note:

LESS THAN $10,000

$10,001 - $15,000

$15,001 - 20,000

$20,001 - 30,000

$30,001 - 45,000

MORE THAN $45,000

You have finished the survey. Thank you for your help.

These items did not discriminate well and were omitted from Study 2 to shorten the survey.

192

APPENDIX G

Study 2 Consent Form

Pumose and Benefits

This project is designed to gather infonnation about the ways in which doctors communicate with their patients. Specifically, health researchers in the Department of Communication at the University of Arizona are interested in examining how people make evaluations about doctors' communication styles in the clinical setting. The infonnation you provide will help researchers understand how health care providers may more effectively communicate with their patients to improve patient care.

Procedures

You will be asked to watch a computer videodisc which contains episodes from actual physician-patient consultation sessions. While viewing the video, you will be instructed to imagine yourself as the patient the physician is consulting. Following the video you will be asked a number of questions concerning the physician you observed and your feelings as a patient. You will then be asked to view one final consultation session nd asked to answer several more questions regarding the physician depicted in the tape.

The physician-patient interaction and questions will all be on a computer. A researcher will show you how to use the computer and will also assist you during the project if you have any difficulty reading or understanding the questions. Most people find using the computer for this project both easy and enjoyable. Your names will not be linked to the answer you supply in the computer so all answers will be anonymous. The study will take approximately 25 minutes to complete. You may refuse to participate or may withdraw from the study at any time without upsetting the researcher.

Risks. Stress, and Discomfort

You will not incur any physical risks by participating in this study. You will not be asked questions of a personal nature and participation should not result in any discomfort.

Confidentiality

Only researchers from the Communication Department at the University of Arizona will have access to your answers and your name will not be linked with the answers you choose. Hospitals will receive a summary of the study in statistical fonn but will not see individual answers.

Principle Investigator

Renee S. Klingle 621-1366

Subject's Statement

"The study described about has been explained to me. I voluntarily consent to participate in this activity. I understand that any questions I may have about the research or about my rights as a subject will be answered by the investigator listed above or the research assistant running the study. "

Signature of Subject Date

193

APPENDIX H

Over Time Instrument: Study 2 (Part A)

Introduction to Study 2 (Part A)

This project is designed to gather information about the ways in which doctors communicate with their patients. Specifically, health researchers in the Department of Communication at the University of Arizona are interested in examining how people make evaluations about doctors' communication styles in the clinical setting.

Introduction to Video Segments

The video you are about to watch contains several episodes of actual physician-patient consultation sessions.

Each episode involves Dr. Jones and a patient she has been seeing for a number of years. Dr. Jones is a primary care physician who has been practicing medicine in a large southwestern city for a number of years. The patient's dialogue has generally been excluded from the videotape and the session has been edited because we would like you to imagine yourself as the patient in each situation. As you watch each segment, please imagine yourself as Dr. Jones' patient.

First Episode:

Second Episode:

Third Episode:

Fourth Episode:

Fifth Episode:

In this first segment, the patient has gone to see Dr. Jones because the patient had been tired, rundown, and generally not feeling very well for a couple of weeks. The following conversation took place at the end of this consultation.

One week later, the following discussion took place ....

Several months later, the patient returns complaining that the condition does not seem to be getting better. Like many patients, the patient has not been able to make all the dietary changes that had been suggested.

During an annual physical, the following conversation took place ....

And one week later, the following conversation took place ....

Study 2 (Part A) Ouestionnaire

The questions you will be asked on the next few screens concern the video you just watched and your feelings as Dr. Jones' patient. The questions are worded as if you were actually the patient who has been visiting Dr. Jones. Think carefully about how you would actually feel and what you would actually do as Dr. Jones' patient.

194

For each screen, you will be presented with a statement about the consultation sessions you just viewed. Please indicate how much you agree with the statement by clicking- on the point on the scale that most closely approximates where your opinion falls in relation to the extremes of the scale.

1. I would try very hard to please Dr. Jones.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*2. I would see the dietitian Dr. Jones' recommended.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*3. I would follow Dr. Jones' advice to keep a log of my eating habits.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

4. Dr. Jones used effective strategies to persuade me to follow her recommendations.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

5. Dr. Jones made me want to change my behavior.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*6. I would be motivated to change my behavior.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

7. I would think of Dr. Jones whenever I was tempted to cheat on my diet.

Strongly Disagree

1_1_1_1 __ 1_1_1 Strongly Agree

*8. I would follow Dr. Jones' advice.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

9. If a physician used these strategies on me, I would change my eating habits.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

10. Dr. Jones used effective strategies to get me to change my behavior.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

11. Dr. Jones was a very motivating physician.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

12. Dr. Jones caused me to think about my behavior very much.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

13. Dr. Jones' arguments were very convincing.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*14. I would be willing to make changes in my behavior for Dr. Jones even if it was inconvenient for me.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*15. I would try hard to win Dr. Jones' approval.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

16. I think I would make all the changes Dr. Jones recommended.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

17. Dr. Jones convinced me to cbangemy behaviors.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

195

196

Again, these questions concern the video you just watched. Please indicate what your feeling would be if you were actually the patient who had been visiting Dr. Jones.

18. I am perfectly satisfied with the care I have received from Dr. Jones.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*19. Dr. Jones was friendly.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

20. I was very satisfied with Dr. Jones' style of communication.

Strongly Disagree

1_1_' 1_1_1_1_1 Strongly Agree

21. I would feel understood as a patient of Dr. Jones.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

22. Dr. Jones would have relieved my worries about my problems.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

23. Dr. Jones cared about me as a patient.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*24. There are some things about the way Dr. Jones communicated that could have been better.

Strongly Disagree

1_1_1_1_1 __ 1_1 Strongly Agree

*25. My problems, as a patient, were not taken seriously by Dr. Jones.

Strongly Disagree

1_1_1_' 1_1_1_1 Strongly Agree

26. Dr. Jones showed concern for me.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

27. I would feel much better after each visit with Dr. Jones.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

28. Dr. Jones is devoted to me as a patient.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*29. Dr. Jones is a very competent physician.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

30. I would have confidence in Dr. Jones' abilities as a physician.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

31. I would trust Dr. Jones to deal with my medical problems.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

32. Dr. Jones seemed experienced in dealing with patients' problems.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

33. Dr. Jones is good at dealing with patients.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

197

198

The following questions are designed to assess your reactions to the situation you were asked to imagine yourself participating in. Again, please indicate your level of agreement or disagreement with the following screens.

34. I could put myself in the patient's shoes.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

35. Dr. Jones would give the patient a compliment if the patient deserved one.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

36. I could actually imagine myself as Dr. Jones' patient.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

37. I think a patient's behavior affects Dr. Jones' communication style.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

38. It would be easy to follow Dr. Jones' recommendations.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*39. I think Dr. Jones would be very disappointed in me if I didn't follow the suggestions given.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

40. People can change Dr. Jones' communication behavior towards them by following or not following the advice given.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

41. I think it would be difficult to actually make the changes Dr. Jones suggested.

Strongly Disagree

1_1_1_1_1_1_1 Strongly Agree

*Note: These items did not discriminate well and were omitted from Study 2 to shorten the survey.

199

APPENDIX I

Individual Scale Items

STUDY 1 AND STUDY 2 (PART B) SCALES Persuasiveness Scale

Motivation to Comply Items

1. I would be motivated to cbange my behavior

... 2. Dr. Jones caused me to think about my behavior very much.

3. I would try very hard to follow the advice Dr. Jones gave in this session.

4. I would try very bard to please Dr. Jones by following her advice.

Likelihood of Compliance Items

5. If Dr. Jones used these strategies on me, I would change my eating habits.

* 6. I would follow Dr. Jones' advice.

Physician Perceived Persuasiveness Items

... 7. Dr. Jones' arguments in this session were very convincing.

8. In this session, Dr. Jones used effective strategies to get me to change my behavior

9. Dr. Jones convinced me to change my behavior.

10. In this visit, Dr. Jones used effective strategies to persuade me.

Patient Satisfaction Scale

Affective Satisfaction Items

... 1. Dr. Jones did not take my problems as a patient seriously.

2. I would feel much better after this visit with Dr. Jones .

... 3. Dr. Jones was friendly in this visit.

4. I think if I were really a patient, this visit with Dr. Jones would have relieved my worries about the problem.

5. This visit made me feel understood by Dr. Jones.

6. I am perfectly satisfied with the care I just received from Dr. Jones.

200

Communication Satisfaction Items

* 7. There are some things about the way Dr. Jones communicated that could have been better.

8. I was very satisfied with Dr. Jones' style of communication in this session.

Physician Perception Scale

1. Dr. Jones seemed experienced in dealing with patients' problems.

2. Dr. Jones is a very competent physician.

3. Dr. Jones is good at dealing with patients.

4. I would trust Dr. Jones to deal with my medical problems.

5. I would have confidence in Dr. Jones' abilities as a physician.

6. Dr. Jones seemed devoted to me as a patient.

Communication Appropriateness Scale

1. How would you rate Dr. Jones' interaction with the patient on a scale ranging from very inappropriate to very appropriate?

* 2. How would you rate Dr. Jones' interaction with the patient on a scale ranging from very unprofessional to very professional?

3. If I were a patient, I would object to the manner in which Dr. Jones talked to me.

Communication Expectancy Scale

1. I think it is normal for Dr. Jones to respond to a patient this way.

2. Dr. Jones' communication style during this visit is what I anticipated.

3. I did not expect Dr. Jones to communicate this way.

Communication Valence Scale

1. How would you rate Dr. Jones' interaction with the patient on a scale ranging from very pleasant to very unpleasant?

2. How would you rate Dr. Jones' interaction with the patient on a scale ranging from very unenjoyable to very enjoyable?

3. Dr. Jones interacted with me the way I liked.

201

Communication Valence Scale (continued)

4. How would you rate Dr. Jones' interaction with the patient on a scale ranging from very undesirable to very desirable?

Approval Scale

I. Dr. Jones acted like I wasn't trying hard enough to change my health problem.

2. If I were the patient. I would think Dr. Jones was annoyed with me during this visit.

3. I get the impression that Dr. Jones has faith that the patient will follow the advice given.

Affect Scale

I. This would be Dr. Jones' way of showing concern.

2. Telling me this shows Dr. Jones cares about me as a patient.

3. Dr. Jones seemed very concerned about me.

Situational Perception Scales

Prior Contact Items

1. It seemed like this was one of the first times the patient had visited Dr. Jones.

2. The physician has probably seen this patient a number of times.

Severity of Illness Items

1. It seemed like the patient's health problem was very serious.

2. I would consider this a serious medical problem if I were the patient.

Previous Noncompliance Items

1. This patient probably doesn't make the changes the physician recommends.

2. I don't think this patient generally follows the physician's advice.

Confidence in Physician's Recommendations Itemli

1. I felt confident that the physician's recommendations would solve the patient's problems.

2. If I were actually the patient I would be convinced that following the physician's suggestions would make me feel much better.

Personal Relevancy Scales

Identification with Patient Items

1. I could put myself in the patient's shoes.

2. I could actually imagine myself as Dr. Jones' patient.

Relevancy of Physician'S Advice

1. How important do you think it is for you to change your present eating habits?

2 How often have you tried to change your eating habits?

3. How much would you like to change your present eating habits?

STUDY 2 (pART A) SCALES

Overall Persuasiveness Scale

Motivation to Comply Items

1. I would try very hard to please Dr. Jones.

2. Dr. Jones made me want to change my behavior.

* 3. I would be motivated to change my behavior.

4. Dr. Jones was a very motivating physician.

5. Dr. Jones caused me to think about my behavior very much.

* 6. I would try hard to win Dr. Jones' approval.

Likelihood of Compliance Items

* 7.

* 8.

* 9.

* 10.

11.

12.

I would see the dietitian Dr. Jones' recommended.

I would follow Dr. Jones' advice to keep a log of my eating habits.

I would follow Dr. Jones' advice.

I would be willing to make cbanges in my behavior for Dr. Jones ~ if it was inconvenient for me.

If a physician used these strategies on me, I would change my eating habits.

I think I would make all the changes Dr. Jones reconmlended.

202

203

Physician Perceived Persuasiveness Items

13. Dr. Jones used effective strategies to persuade me to follow her recommendations.

14. I would think of Dr. Jones whenever I was tempted to cheat on my diet.

15. Dr. Jones used effective strategies to get me to change my behavior.

16. Dr. Jones' arguments were very convincing.

17. Dr. Jones convinced me to change my behaviors.

Overall Patient Satisfaction Scale

Affective Satisfaction Items

* 1. My problems, as a patient, were not taken seriously by Dr. Jones.

2. I would feel much better after each visit with Dr. Jones.

* 3. Dr. Jones was friendly.

4. Dr. Jones would have relieved my worries about my problems.

5. I would feel understood as a patient of Dr. Jones.

6. I am perfectly satisfied with the care I have received from Dr. Jones.

Communication Satisfaction Items

* 7. There are some things about the way Dr. Jones communicated that could have been better.

8. I was very satisfied with Dr. Jones' style of communication.

Physician Perception Scale

1. Dr. Jones seemed experienced in dealing with patients' problems.

* 2. Dr. Jones is a very competent physician.

3. Dr. Jones is good at dealing with patients.

4. I would trust Dr. Jones to deal with my medical problems.

5. I would have confidence in Dr. Jones' abilities as a physician.

6. Dr. Jones is devoted to me as a patient.

204

Affect Scale

1. Dr. Jones cared about me as a patient.

2. Dr. Jones showed concern for me.

Reinforcement Expectations Scale

1. Dr. Jones would give the patient a compliment if the patient deserved one.

2. I think a patient's behavior affects Dr. Jones' communication style.

3. People can change Dr. Jones' communication behavior towards them by following or not following the advice given.

* 4. I think Dr. Jones would be very disappointed in me if I didn't follow the suggestions given.

Perceived Compliance Difficulty Items

1. It would be easy to follow Dr. Jones' recommendations.

2. I think it would be difficult to actually make the changes Dr. Jones suggested.

* Note: These items did not discriminate well and were omitted from Study 2 to shorten the surveyS

205

APPENDIX J

Physician Characteristics Instrument for Episode 1

Instructions Prior to Video Viewing

This project is designed to gather information about the ways in which doctors communicate with their patients. Specifically, health researchers in the Department of Communication at the University of Arizona are interested in examining how people make evaluations about doctors' communication styles in the clinical setting.

You will be watching a videotaped physician-patient consultation session. After the segment, we will ask you a series of questions. In this session the patient has consulted Dr. Jones because the·patient has not felt very well for a couple of weeks. Dr. Jones is a primary care physician who has been practicing medicine in a large southwestern city for a number of years. The patient's dialogue has been excluded so that you can more easily imagine yourself taking part in this consultation.

We ask that you imagine yourself as Dr. Jones' patient as you watch this videotaped segment. When you are ready to watch the consultation session, click on the button below.

Instructions for Questionnaire

The questions you will be asked on the next few screens concern the video you just watched and your feelings as Dr. Jones' patient. The questions are worded as if you were actually the patient who visited Dr. Jones. Think carefully about how you would actually feel and what you would actually do as Dr. Jones' patient.

Credibility Scale

For each screen, you will be presented with a rating scale like the practice scale you saw earlier. Each scale uses two descriptive adjectives representing the extremes of a judgment about Dr. Jones. Please indicate the point on the scale that most clearly approximates where your opinion falls in relation to these extremes.

1. Irresponsible 1_1_1_1_1_1_1 Responsible

2. Unintelligent 1_1_1_1_1_1_1 Intelligent

3. Inexpert 1_1_1_1_1_1_1 Expert

4. Informal 1_1_1_1_1_1_1 Formal

5. Trustworthy 1_1_1_1---1_1_1 Untrustworthy

6. Sinful 1_1_1_1---1_1---1 Virtuous

206

Credibility Scale (continued)

7. Qualified 1---1---1---1---1---1---1 Unqualified

8. Unbelievable 1---1---1---1---1---1---1 Believable

9. Cooperative 1---1---1---1---1---1---1 Not Cooperative

to. Dishonest 1---1---1---1---1---1---1 Honest

11. Unsympathetic 1---1---1---1---1---1---1 Sympathetic

12. Bright 1---1---1---1---1---1---1 Stupid

13. Unvaluable 1---1---1---1---1---1---1 Valuable

14. Unadmirable 1---1---1---1---1---1---1 Admirable

15. Trained 1---1---1---1---1---1---1 Untrained

16. Incompetent 1---1---1---1---1---1---1 Competent

17. Unselfish 1---1---1---1---1---1---1 Selfish

18. Uninformed 1---1---1---1_1_1_1 Informed

19. Unreliable 1---1---1_1---1_1---1 Reliable

20. Logical 1_1---1_1---1_1_1 Illogical

Physician Rewardingness Scale

21. Based on the video you just watched, how would you rate the opportunity to consult with Dr. Jones in the future, from undesirable to desirable?

very undesirable 1 ___ 1 ___ 1 ___ 1_1 ___ 1 ___ 1 very desirable

22. Based on the video you just watched, how would you rate the opportunity to consult with Dr. Jones in the future, from unrewarding to rewarding?

very unrewarding 1 ___ 1 ___ 1_' _1 ___ 1_1 ___ 1 very rewarding

23. Based on the video you just watched, how would you rate the opportunity to consult with Dr. Jones in the future, from unpleasant to pleasant?

very unpleasant 1 ___ 1 ___ 1 ___ 1_1_1 ___ 1 very pleasant

207

Physician Rewardingness Scale (continued)

24. Based on the video you just watched, how would you rate the opportunity to consult with Dr. Jones in the future, from distasteful to enjoyable?

very distasteful 1_1_1_1_1_1_1 enjoyable

Physician Attractiveness Scale

For the next few screens, you will be presented with a statement about the consultation session you just viewed. Please indicate how much you agree with the statement by clicking on the point of the scale that most closely approximates where your opinion falls in relation to the extremes of the scale.

25. I could discuss personal medical concerns with Dr. Jones.

Strongly Disagree

1_1_1_1---1_1_1

26. I think Dr. Jones could solve my medical problems.

Strongly Disagree

1_1_1_1---1---1---1

Strongly Agree

Strongly Agree

27. I could establish a friendly physician-patient relationship with Dr. Jones.

Strongly Disagree

1---1---1_1---1---1---1

28. I would like to have a physician like Dr. Jones.

Strongly Disagree

1---1---1---1---1---1_1

Strongly Agree

Strongly Agree

29. I would have confidence in Dr. Jones' abilities as a physician.

Strongly Disagree

1_1---1---1---1_1_1

30. Dr. Jones seems like a very competent physician.

Strongly Disagree

1_1---1_1---1---1_1

Strongly Agree

Strongly Agree

Physician Attractiveness Scale (continued)

31. I would find it difficult to talk to Dr. Jones.

Strongly Disagree

1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 Strongly Agree

32. Dr. Jones would be a physician I could depend on.

Strongly Disagree

1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 Strongly Agree

33. I would feel comfortable around Dr. Jones.

Strongly Disagree

1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 Strongly Agree

34. I could never establish a good physician-patient relationship with Dr. Jones.

Strongly Disagree

1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 Strongly Agree

35. I would trust Dr. Jones to deal with my medical problems.

Strongly Disagree

1_1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 Strongly Agree

36. I would be happy with Dr. Jones as my primary care physician.

Strongly Disagree

1_1 ____ 1 ____ 1 ____ 1 ____ 1 ____ 1 Strongly Agree

208

209

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