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BMC Health Services Research

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Open Access 01-12-2024 | Research

Attachment styles and healthcare utilization: exploring the role of the patient-doctor relationship

Authors: I. Schmalbach, G. H. Franke, W. Häuser, B. Strauss, K. Petrowski, Elmar Brähler

Published in: BMC Health Services Research | Issue 1/2024

Abstract

Background

With the purpose of improving healthcare, past research has examined the link between healthcare utilization and attachment. It is suggested that an individual’s attachment style influences both the quality of their patient-physician relationship and healthcare utilization patterns. Nevertheless, most studies concentrate on the individual aspect, overlooking the dyadic dimension; specifically, the investigation of how insecure attachment relates to health behavior within patient-physician relationships. This gap leaves the role of the patient-doctor relationship in this process unclear. Therefore, to elucidate this complex interplay, we hypothesized that the correlation between attachment and healthcare utilization is mediated by the quality of the patient-physician-relationship.

Method

Participant selection was based on electoral districts, a random-route procedure, and the Kish selection grid. The participants were visited by a trained interviewer who collected psychometric and sociodemographic information. Participants answered the Experiences in Close Relationships-Revised questionnaire (ECR-RD8) and the Patient-Doctor Relationship Questionnaire (PDRQ-9). Additionally, participants were asked about their healthcare utilization. The final sample consisted of N = 2.275 participants.

Results

In average the participants reported consulting their primary health care practitioner M(SD) = 4.44 (4.76) times in the past 12 months. Generally, the participants rated the quality of the relationship with their primary health care practitioner close to “totally appropriate” (M = 4.12 ± .69). The degree of insecure attachment manifested towards the lower extremity of the scale. The total effect of the mediation analyses was significant. Regardless, the indirect effect indicated a trend result with minimal effect sizes.

Conclusion

The findings of the current study bridged the gap between attachment styles and healthcare utilization. Nonetheless, our results suggested insufficient support for the mediating role of the primary care physician in the relationship between attachment style and healthcare utilization. Considering the characteristics of the sample, this outcome may not apply in a clinical context. However, further research is needed to shed light in the revealed trends and indicate implications.

Bowlby J. A securebase: parent-childattachment and healthyhuman development. New York: Basic Books; 1988.

Kelly EP, Tsilimigras DI, Hyer JM, Pawlik TM. Understanding the use of attachment theory applied to the patient-provider relationship in cancer care: recommendations for future research and clinical practice. Surg Oncol. 2019;31:101–10. https://doi.org/10.1016/j.suronc.2019.10.007.CrossRef

Thompson D, Ciechanowski PS. Attaching a new understanding to the patient-physician relationship in family practice. J Am Board Fam Pract. 2003;16(3):219–26. https://doi.org/10.3122/jabfm.16.3.219.CrossRefPubMed

Strauss B, Brenk-Franz K. The relevance of attachment theory in medical care. In: Hunter J, Maunder R, editors. Improving patient treatment with attachment theory: a guide for primary care practitioners and specialists. Springer International Publishing/Springer Nature; 2016. p. 39–52. https://doi.org/10.1007/978-3-319-23300-0_4.CrossRef

Bowlby J. The making and breaking of affectional bonds. I. Aetiology and psychopathology in the light of attachment theory. An expanded version of the fiftieth Maudsley lecture, delivered before the Royal College of psychiatrists, 19 November 1976. Br J Psychiatry. 1977;130:201–10. https://doi.org/10.1192/bjp.130.3.201.CrossRefPubMed

Schmidt S, Nachtigall C, Wuethrich-Martone O, Strauss B. Attachment and coping with chronic disease. J Psychosom Res. 2002;53(3):763–73. https://doi.org/10.1016/S0022-3999(02)00335-5.CrossRefPubMed

Overall NC, Chang VT, Pietromonaco PR, Low RST, Henderson AME. Partners’ attachment insecurity and stress predict poorer relationship functioning during COVID-19 quarantines. Soc Psychol Personal Sci. 2022;13(1):285–98. https://doi.org/10.1177/1948550621992973.CrossRef

Puig J, Englund MM, Simpson JA, Collins WA. Predicting adult physical illness from infant attachment: a prospective longitudinal study. Health Psychol : Off J Div Health Psychol Am Psychol Assoc. 2013;32(4):409–17. https://doi.org/10.1037/a0028889.

Johnson W, Huelsnitz C, Carlson E, Roisman G, Englund M, Miller G, Simpson J. Childhood abuse and neglect and physical health at midlife: prospective, longitudinal evidence. Dev Psychopathol. 2017;29(5):1935–46. https://doi.org/10.1017/S095457941700150X.CrossRefPubMed

10.

Mikulincer M, Shaver PR. A behavioral systems perspective on the psychodynamics of attachment and sexuality. In: Diamond D, Blatt SJ, Lichtenberg JD, editors. Attachment and sexuality. The Analytic Press/Taylor & Francis Group; 2007. p. 51–78.

11.

Ainsworth MS, Bowlby J. An ethological approach to personality development. Am Psychol. 1991;46(4):333–41. https://doi.org/10.1037/0003-066X.46.4.333.CrossRef

12.

Hazan C, Shaver P. Romantic love conceptualized as an attachment process. J Pers Soc Psychol. 1987;52(3):511–24. https://doi.org/10.1037/0022-3514.52.3.511.CrossRefPubMed

13.

Mikulincer M, Shaver PR. Attachment theory and emotions in close relationships: exploring the attachment-related dynamics of emotional reactions to relational events. Pers Relat. 2005;12(2):149–68. https://doi.org/10.1111/j.1350-4126.2005.00108.x.CrossRef

14.

Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol. 1991;61(2):226–44. https://doi.org/10.1037/0022-3514.61.2.226.CrossRefPubMed

15.

McWilliams LA. Relationships between adult attachment dimensions and patient physician relationship quality. J Relationsh Res. 2018;9:e15. https://doi.org/10.1017/jrr.2018.13.CrossRef

16.

Ahrens KR, Ciechanowski P, Katon W. Associations between adult attachment style and health risk behaviors in an adult female primary care population. J Psychosom Res. 2012;72(5):364–70. https://doi.org/10.1016/j.jpsychores.2012.02.002.CrossRefPubMed

17.

Pietromonaco PR, Beck LA. Adult attachment and physical health. Curr Opin Psychol. 2019;25:115–20. https://doi.org/10.1016/j.copsyc.2018.04.004.CrossRefPubMed

18.

Cooper ML, Shaver PR, Collins NL. Attachment styles, emotion regulation, and adjustment in adolescence. J Pers Soc Psychol. 1998;74(5):1380–97. https://doi.org/10.1037//0022-3514.74.5.1380.CrossRefPubMed

19.

Feeney JA, Peterson C, Gallois C, Terry DJ. Attachment style as a piedictor of sexual attitudes and behavior in late adolescence. Psychol Health. 2000;14(6):1105–22. https://doi.org/10.1080/08870440008407370.CrossRefPubMed

20.

Huntsinger ET, Luecken LJ. Attachment relationships and health behavior: the mediational role of self-esteem. Psychol Health. 2004;19(4):515–26. https://doi.org/10.1080/0887044042000196728.CrossRef

21.

Ciechanowski P, Russo J, Katon W, Von Korff M, Ludman E, Lin E, Simon G, Bush T. Influence of patient attachment style on self-care and outcomes in diabetes. Psychosom Med. 2004;66(5):720–8. https://doi.org/10.1097/01.psy.0000138125.59122.23.CrossRefPubMed

22.

Brenk-Franz K, Strauss B, Tiesler F, Fleischhauer C, Ciechanowski P, Schneider N, Gensichen J. The Influence of Adult Attachment on Patient Self-Management in Primary Care--The Need for a Personalized Approach and Patient-Centred Care. PLoS One. 2015;10(9):e0136723. https://doi.org/10.1371/journal.pone.0136723.CrossRefPubMedPubMedCentral

23.

Jimenez X. Attachment in medical care: a review of the interpersonal model in chronic disease management. Chronic Illn. 2016;13(1) https://doi.org/10.1177/174239531665345.

24.

Brenk-Franz K, Strauss B, Tiesler F, Fleischhauer C, Schneider N, Gensichen J. Patient-provider relationship as mediator between adult attachment and self-management in primary care patients with multiple chronic conditions. Psychosom Res. 2017;97:131–5. https://doi.org/10.1097/01.psy.0000138125.59122.23.CrossRef

25.

Feeney JA, Ryan SM. Attachment style and affect regulation: relationships with health behavior and family experiences of illness in a student sample. Health Psychol: Off J Div Health Psychol Am Psychol Assoc. 1994;13(4):334–45. https://doi.org/10.1037//0278-6133.13.4.334.CrossRef

26.

Ciechanowski PS, Walker EA, Katon WJ, Russo JE. Attachment theory: a model for health care utilization and somatization. Psychosom Med. 2002;64(4):660–7. https://doi.org/10.1097/01.psy.0000021948.90613.76.CrossRefPubMed

27.

Adler HM. The Sociophysiology of caring in the doctor-patient relationship. J Gen Intern Med. 2002;17:883–90. https://doi.org/10.1046/j.1525-1497.2002.10640.x.CrossRefPubMedCentral

28.

Miller RC. The somatically preoccupied patient in primary care: use of attachment theory to strengthen physician-patient relationships. Osteopathic Med Prim Care. 2008;2(1):1–10.

29.

Ridd M, Shaw A, Lewis G, Salisbury C. The patient–doctor relationship: a synthesis of the qualitative literature on patients’ perspectives. Br J Gen Pract. 2009;59(561):e116–33. https://doi.org/10.3399/bjgp09X420248.CrossRefPubMedPubMedCentral

30.

Chipidza FE, Wallwork RS, Stern TA. Impact of the Docotr-patient relationship. Prim Care Companion CNS Disord. 2015;17(5) https://doi.org/10.4088/PCC.15f01840.

31.

Dinkel A, Schneider A, Schmutzer G, Brähler E, Häuser W. Family physician-patient relationship and frequent attendance of primary and specialist health care: results from a German population-based cohort study. Patient Educ Couns. 2016;99(7):1213–9. https://doi.org/10.1016/j.pec.2016.02.009.CrossRefPubMed

32.

Heje HN, Vedsted P, Sokolowski I, Olesen F. Patient characteristics associated with differences in patients’ evaluation of their general practitioner. BMC Health Serv Res. 2008;8:178. https://doi.org/10.1186/1472-6963-8-178.

33.

Potiriadis M, Chondros P, Gilchrist G, Hegarty K, Blashki G, Gunn JM. How do Australian patients rate their general practitioner? A descriptive study using the general practice assessment questionnaire. Med J Aust. 2008;189:215–9. https://doi.org/10.5694/j.1326-5377.2008.tb01986.x.CrossRefPubMed

34.

Kersnik J, Scvab I, Vegnuti M. Frequent attenders in general practice: quality of life, patient satisfaction, use of medical services and GP characteristics. Scand J Prim Health Care. 2001;19(3):174–7.CrossRefPubMed

35.

Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405–11.CrossRefPubMed

36.

Wilkinson SR. Coping and complaining: attachment and the language of disease. Routledge; 2004. https://doi.org/10.4324/9780203420881.CrossRef

37.

Hunter J, Maunder R. Advanced concepts in attachment theory and their application to health care. In: In improving patient treatment with attachment theory: a guide for primary care practitioners and specialists. Cham: Springer International Publishing; 2016. p. 27–37. https://doi.org/10.1007/978-3-319-23300-0_3.CrossRef

38.

Zaporowska-Stachowiak I, Stachowiakm K, Stachnik K. Two is a perfect number: patient–doctor relationship and patient attachment style in palliative care. J Health Psychol. 2019;24(5):549–60. https://doi.org/10.1177/1359105317721307.CrossRefPubMed

39.

Hillen MA, de Haes HC, van Tienhoven G, et al. All eyes on the patient: the influence of oncologists’ nonverbal communication on breast cancer patients’ trust. Breast Cancer Res Treat. 2015;153(1):161–71.CrossRefPubMedPubMedCentral

40.

Ciechanowski P, Russo J, Katon W, Simon G, Ludman E, Von Korff M, Lin E. Where is the patient? The association of psychosocial factors and missed primary care appointments in patients with diabetes. Gen Hosp Psychiatry. 2006;28(1):9–17.CrossRefPubMed

41.

Sullivan MD, Ciechanowski PS, Russo JE, Soine LA, Jordan-Keith K, Ting HH, Caldwell JH. Understanding why patients delay seeking care for acute coronary syndromes. Circ: Cardiovasc Qual Outcomes. 2009;2(3):148–54. https://doi.org/10.1161/CIRCOUTCOMES.108.825471.CrossRefPubMed

42.

Gerretsen P, Myers J. The physician: a secure base. J Clin Oncol. 2008;26(32):5294–6. https://doi.org/10.1200/JCO.2008.17.5588.CrossRefPubMed

43.

Naing MZ, Mohanan SA. Doctor patient relationship as a mediator between attachment dimensions and self-management in chronic patients, Yangon, Myanmar Scholar. Hum Sci. 2021;13(2):125–125.

44.

Ehrenthal JC, Zimmermann J, Brenk-Franz K, Dinger U, Schauenburg H, Brähler E, Strauß B. Evaluation of a short version of the experiences in close relationships-revised questionnaire (ECR-RD8): results from a representative German sample. BMC Psychol. 2021;9(1):140. https://doi.org/10.1186/s40359-021-00637-z.CrossRefPubMedPubMedCentral

45.

Van der Feltz-Cornelis CM, Van Oppen P, Van Marwijk HW, De Beurs E, Van Dyck R. A patient-doctor relationship questionnaire (PDRQ-9) in primary care: development and psychometric evaluation. Gen Hosp Psychiatry. 2004;26(2):115–20. https://doi.org/10.1016/j.genhosppsych.2003.08.010.CrossRefPubMed

46.

Zenger M, Schaefert R, van der Feltz-Cornelis C, Brähler E, Häuser W. Validation of the patient-doctor-relationship questionnaire (PDRQ-9) in a representative cross-sectional German population survey. PLoS One. 2014;9(3):e91964. https://doi.org/10.1371/journal.pone.0091964.CrossRefPubMedPubMedCentral

47.

Horvath A, Gaston L, Luborsky L. The therapeutic alliance and its measures. In: Miller NE, Luborsky L, Barber JP, Docherty JP, editors. Psychodynamic treatment research: a handbook for clinical practice. Basic Books; 1993. p. 247–73.

48.

Mingote Adán J, Moreno Jiménez B, Rodríguez Carvajal R, Gálvez Herrer M, Ruiz López P. Psychometric validation of the Spanish version of the patient-doctor relationship questionnaire (PDRQ). Actas Esp Psiquiatr. 2009;37(2):94–100.PubMed

49.

Mergen H, van der Feltz-Cornelis CM, Karoglu N, Mergen BE, Ongel K. Validity of the Turkish patient-doctor relationship questionnaire (PDRQ-Turkish) in comparison with the Europep instrument in a family medicine center. HealthMed. 2012;6(5):1763–70.

50.

Porcelli P, Taylor GJ. Alexithymia and physical illness: a psychosomatic approach. Alexithymia. Advances in research, theory, and clinical practice; 2018. p. 105–26.CrossRef

51.

Bellach B, Knopf H, Thefeld W. Der Bundes-Gesundheitssurvey 1997/98. Gesundheitswesen. 1998;60:59–68.

52.

Thode N, Bergmann E, Kamtsiuris P, Kurth BM. Predictors for ambulatory medical care utilization in Germany. Bundesgesundheitsblatt Gesundheitsforsch Gesundheitsschutz. 2005;48:296–306.CrossRef

53.

R Core Team. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2020. URL https://www.R-project.org/.

54.

Rosseel Y. Lavaan: an R package for structural equation modeling. J Stat Softw. 2012;48:1–36.CrossRef

55.

Ballen CJ, Salehi S. Mediation analysis in discipline-based education research using structural equation modeling: beyond “what works” to understand how it works, and for whom. J Microbiol Biol Edu. 2021;22(2):e00108–21. https://doi.org/10.1128/jmbe.00108-21.

56.

Weber R, Eggenberger L, Stosch C, Walther A. Gender differences in attachment anxiety and avoidance and their association with psychotherapy use-examining students from a German University. Behav Sci (Basel, Switzerland). 2022;12(7):204. https://doi.org/10.3390/bs12070204.CrossRefPubMedCentral

57.

RKI. Health monitoring – chronic disease – diabetes mellitus. 2016. URL https://www.rki.de/EN/Content/Health_Monitoring/Main_Topics/Chronic_Disease/Diabetes/diabetes_node.html.

58.

Bernman WH, Marcus L, Berman ER. Attachment in marital relations. In: Sperling MB, Berman WH, editors. Attachment in adults: theory, assessment and treatment. New York: Guilford Press; 1994. p. 1994.

59.

Shukla DM, Faber EB, Sick B. Defining and characterizing frequent attenders, Systematic Literature Review and Recommendations. J Patient-Centered Res Rev. 2020;7(3):255–64. https://doi.org/10.17294/2330-0698.1747.CrossRef

60.

Mimura C, Norman IJ. The relationship between healthcare workers' attachment styles and patient outcomes: a systematic review. Int J Qual Health Care : J Int Soc Qual Health Care. 2018;30(5):332–43. https://doi.org/10.1093/intqhc/mzy034.

61.

Salmon P, Wissow L, Carroll J, Ring A, Humphris GM, Davies JC, Dowrick CF. Doctors' attachment style and their inclination to propose somatic interventions for medically unexplained symptoms. Gen Hosp Psychiatry. 2008;30(2):104–11. https://doi.org/10.1016/j.genhosppsych.2007.12.002.

62.

Cox ED, Smith MA, Brown RL, Fitzpatrick MA. Assessment of the physician-caregiver relationship scaled (PCRS). Patient Educ. 2008;70(1):69–78.CrossRef

Title: Attachment styles and healthcare utilization: exploring the role of the patient-doctor relationship
Authors: I. Schmalbach
G. H. Franke
W. Häuser
B. Strauss
K. Petrowski
Elmar Brähler
Publication date: 01-12-2024
Publisher: BioMed Central
Published in: BMC Health Services Research / Issue 1/2024
Electronic ISSN: 1472-6963
DOI: https://doi.org/10.1186/s12913-023-10484-w

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Attachment styles and healthcare utilization: exploring the role of the patient-doctor relationship

Abstract

Background

Method

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Method

Results

Conclusion

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