Evaluating illness representations in heart transplant patients

Abstract

The aim was to see whether qualitative analysis improved quantitative measurement of illness perception after heart transplant. Two methods of evaluating illness representations were compared: one quantitative (administration of the Illness Perception Questionnaire-Revised) and one qualitative (phenomenological reduction). The qualitative analysis provided greater insight into the idiosyncratic and dynamic nature of the concept of illness representations. Adjustments to the Illness Perception Questionnaire-Revised are suggested to improve the evaluation of illness perception in terms of dispersion of scores, emotional impact, coping strategies and treatment, and social support, and ultimately to enhance interventions designed to promote treatment compliance.

Keywords

adherence health behavior heart illness perception phenomenology quantitative methods

A patient’s representation of his or her health condition comprises a key predictor of treatment compliance. Illness perception research generates critical data that can inform one of the biggest challenges in modern medicine: overcoming non-compliance with treatment. The self-regulation model (SRM) developed by Leventhal et al. (1980) is a valid model for studying illness perception.

The SRM is based on the following three basic principles: (1) the individual is an active agent in reducing the disparity between his or her actual and ideal state of health, (2) the cognitive representation of the illness guides the adoption and evaluation of an action plan, and (3) the representation of the threat is idiosyncratic and not necessarily congruent with medical norms (Leventhal et al., 1980). Individuals’ illness representations evolve from five key variables (Baumann et al., 1989)—(1) identity: the label associated with the illness (e.g. angina) and the associated symptoms (e.g. chest pain); (2) timeline: expectations about the duration and evolution of the illness (acute/chronic, cyclical); (3) consequences: anticipated impact of the illness and the expected sequelae (immediate and long-term, social, and physical); (4) causes: perception of the origin of the illness (causal attributions); and (5) control/cure: perception of control over the origin or evolution of the illness.

The most frequently used measure for evaluating illness representations is the Illness Perception Questionnaire (IPQ), developed by Weinman et al. (1996). This questionnaire is derived from Leventhal et al.’s (1980) SRM and is applicable to all populations of patients. The IPQ is divided into five subscales that correspond with the five dimensions of the SRM (identity, causes, consequences, timeline, and control/cure). The IPQ was developed using data obtained from diverse populations and has been demonstrated to be reliable and valid (Weinman et al., 1996). A revised version of the questionnaire (Illness Perception Questionnaire-Revised (IPQ-R)) was developed in 2002 (Moss-Morris et al., 2002) to address certain shortcomings in the original version. Three new subscales were added, including the cyclical timeline, emotional representations of the illness, and understanding of the illness (illness coherence). The control/cure scale was divided into two subscales: personal control and treatment control. Moss-Morris et al. reported that the IPQ-R has better psychometric properties than the original measure, although Rees et al. (2015) have offered a recent psychometric critique of four of the IPQ-R subscales.

Despite good indices of coherence and validity, certain conceptual problems with the IPQ-R remain. Although the IPQ-R is derived from the SRM, it does not seem to capture the variety of representations of health threat are idiosyncratic and are not necessarily congruent with medical norms. Steed et al. (1999) emphasized the importance of acknowledging each patient’s personal context and idiosyncratic responses to the questionnaire items. Weinman et al. (1996) proposed the addition of qualitative measures to enhance the use of the IPQ; other authors have suggested the addition of an open interview (Scharloo et al., 1998, 2000).

The objective of this study was to identify improvement in a current measure of illness representations through qualitative techniques and evaluate this phenomenon in heart transplant patients. The qualitative data were compared with the quantitative data from the IPQ-R.

Method

Participants

Recruitment took place in a university hospital specialized in cardiology. The institution research and ethics committee approved the project. Eligibility criteria for participants were as follows: (1) heart transplant received in the past 3 months, (2) over 18 years old, and (3) no psychiatric condition. In total, 12 individuals were contacted, 3 refused to participate, and 1 individual withdrew due to health concerns. Six men and two women between 22 and 66 years old were interviewed. To ensure patient confidentiality, references to participants were rendered anonymous with alphabetical labels (the first patient is referred to as participant A, the second is referred to as participant B, etc.).

Procedure

The clinical nurse contacted patients who had undergone a heart transplant in the past month. Patients who expressed interest in the project subsequently met with a research assistant. The research assistant explained the project in detail, obtained informed consent, and scheduled the evaluation appointment (interview and questionnaire). A research assistant conducted a semi-structured interview with each patient 3 months after the heart transplant. Five patients were interviewed at the hospital and three were interviewed at home, as per their preference. In both cases, a quiet, private location was chosen to ensure confidentiality. The IPQ-R was administered following the interview.

Materials

Interview

The interview was described to participants as an opportunity to discuss their perception of their health following the heart transplant. The interviews were non-directive and addressed various themes (e.g. events surrounding the illness, conceptualizations of the illness, vision of the future); participants were free to describe their experiences in their own words. The instructions were designed to position the participant as an expert on his or her condition. The interviews lasted 90–150 minutes; each interview was recorded and subsequently transcribed verbatim.

IPQ-R

The IPQ (Weinman et al., 1996) and the revised IPQ (IPQ-R; Moss-Morris et al., 2002) are based on the five dimensions of illness perception. The identity scale includes 26 questions about symptoms. The total score is the total number of symptoms that are endorsed by the participant; scores range from 0 to 26. The items on the other subscales (consequences, timeline, control, cure (treatment), emotional representations, and coherence) require responses on a five-point scale (1 = strongly disagree, 5 = strongly agree). An average overall score is calculated for each subscale except for the causes scale where items are scored individually. All of the subscales demonstrated good internal reliability, with Cronbach’s alpha coefficients ranging from 0.79 to 0.89. The IPQ-R also demonstrated good discriminant and predictive validity (Moss-Morris et al., 2002).

Measures

This study used the phenomenological approach to data analysis (Giorgi, 1985). This approach seemed congruent with the objective of the study and was therefore favored over a grounded theory approach. The phenomenological approach strives to describe a given phenomenon in the subject’s own terms, without imposing a preconceived interpretation (Fewtrell and O’Connor, 1995). The data analysis was based on Giorgi’s (1985) method, wherein the narrative is addressed in four steps: (1) creation of a “naïve” description of the phenomenon, based on the subject’s responses to open questions about his or her experience; (2) simplification or summary of the content, establishing the subject’s overall sense of the phenomenon; (3) discrimination of “meaning units” to clarify and refine the subject’s conceptualization of the phenomenon; and (4) development of an operational representation, that is, translating the subject’s terms into psychological “jargon,” all while referring back to the subject and modifying and reformulating where necessary (Blowers and O’Connor, 1996).

The research team responsible for interpreting the content of the transcriptions was composed of four doctoral level research assistants in psychology. All of the assistants had a minimum of 4 years of research experience and were trained in qualitative analysis; furthermore, all of them had participated in the pilot study. The content of each was analyzed verbatim in four steps. First, all four members of the team read through the content verbatim several times in order to familiarize themselves with the participant’s ideas and perspective. Next, two of the students separately refined the text into a descriptive summary. The first step required re-reading the content verbatim and isolating the ideas. For example, a change of theme or a particular important detail can represent a transition to a new idea. Once isolated, the ideas were recorded in a table. The main ideas were numbered and listed on one side; a brief description of each idea was recorded in the respective adjacent column. The idea was described in the participant’s original words and meaning wherever possible, without interpretation or speculation. In the second step, all four members of the research team individually determined the themes of the text, based on recurring ideas in the individual’s narrative. The themes were also recorded in a table along with excerpts from the verbatim supporting each identified theme. Next, all four members of the team re-grouped for an audio-recorded meeting to discuss the content and arrive at a consensus about their individually determined participant’s themes. Each member took a turn presenting the extracted themes that he or she considered relevant. The common themes among the four judges were retained; less relevant and non-unanimous themes were rejected or integrated into one of the principal themes. Finally, the result of the content analysis (i.e. the themes) was presented to the participant to ensure validity. To facilitate comparison between the qualitative and quantitative results, each final theme was subsequently matched with its corresponding IPQ-R subscale.

Results

The following section compares the qualitative (interview) results with the quantitative evaluation (IPQ-R). The results are presented by IPQ-R subscale. The qualitative data for each subscale is presented, followed by the quantitative data. Mean, median, and range of scores on each IPQ-R subscale are presented in Table 1.

Table 1.

Mean, median, minimum, and maximum score for dimensions of the IPQ.

Dimensions	Mean	Median	Minimum	Maximum
Identity	8.6	8	0	21
Timeline	2.6	2.4	1.7	4.3
Consequences	2.4	2.4	1.6	3.4
Treatment	3.8	4.3	2.3	5
Control	4.2	4.4	3.6	4.7
Timeline cyclic	2.8	3	1	4
Emotion representation	1.8	1.7	1	3
Coherence	1.9	2	1.2	2.6

IPQ: Illness Perception Questionnaire.

Identity

Of the eight participants, six described themselves as no longer (or not) ill (3) or as healed (2). One participant used the word “illness” hesitatingly (“I’d say it helped me fight my illness, if you can call it an illness.” (G)). In fact, despite an invasive surgical intervention, the requisite post-surgery treatment, frequent medical appointments, and certain post-surgery restrictions, the six participants no longer considered themselves “ill.” The various post-transplant medical requirements or constraints were perceived as preventive or cautionary, and “normal” rather than indicative of an illness:

I consider myself healed. Of course, someone else might say, “I don’t have to take medications, I don’t have to watch what I eat …” but actually, they have to follow the same diet as me [if they want to stay healthy]. (E)

For five participants, “no longer being sick” represented the possibility of a return to a normal life, that is, of returning to their pre-illness daily tasks and activities. In sum, participants described their present health condition (identity) partially as a function of a comparison to their former state, emphasizing an improvement in functioning and quality of life:

I’m satisfied [with my current condition] in comparison to before. Before, I had heart failure and I was really limited in what I could do. Now, once I regain my strength and muscles and everything, I’ll be even stronger. (D)

The concept of luck or of a second chance was mentioned in various contexts by four of the participants. Three participants made parallels between the transplant and a second life, a rebirth, or a second birth, or a miracle:

[Interviewer question: What is your perspective on the heart transplant?] A real miracle. A miracle, pure and simple. You know, sometimes you hear people say, such and such saint performed such and such miracle […]. But it happened to me. To me, that’s what it was. My family is convinced it was a miracle, too, because, really, the odds were against me.

Participant F described a different vision from the others; he or she said that it was important to play down the significance of the transplant and to view the surgery as a normal part of regular healthcare. On the quantitative questionnaire, identity is evaluated by the symptoms related to the condition (see Table 1).

Causes

All participants identified an objective cause responsible for their condition. Six participants reported medical reasons for the heart transplant, including cardiac events, viruses, and hereditary disease. The two other participants reported environmental or chance circumstances. Participant B reported occupational factors and participant D reported a combined work accident and medical error. Interestingly, half of the participants also added personal attributions for the development of their heart problems. Participants C and E hypothesized that lifestyle factors such as stress management problems and overinvestment at work were contributors to the health problem; participants G and H mentioned emotional factors such as fears, worries, and traumatic events:

You know, I lost my job, I basically lost my daughter. There was a lot of emotion, you know. I wonder sometimes if the heart attack was simply a broken heart that exploded. Because they don’t really know what causes them, you know [heart attack as cause of the health condition necessitating the heart transplant]. (G)

On the IPQ-R, causal attributions for the condition were evaluated by multiple choices (e.g. virus, medical errors, and so on). Participants indicated agreement or disagreement for each possible cause. Participants were also asked to identify the three most significant factors in the development of their heart condition; the factors did not have to appear on the IPQ. The frequency of causes reported by participants on the IPQ-R broke down as follows: microbe or virus (5); emotional variables (stress, emotions, attitude) (4); work overload or work context (3); heredity (2); inadequate past medical care (2); lifestyle (e.g. smoking, diet) (2); environmental pollution (1); accident or injury (1); and aging (1).

Timeline (two subscales: acute/chronic and cyclical)

None of the participants took a clear position on this dimension. Two participants provided hypotheses about the timeline: participant A jokingly declared that he would not die of heart problems and would live to be over 80 years old; participant B reported that the worst-case short-term scenario would be transplant rejection (i.e. the transplanted organ is not accepted by the recipient’s body).

Overall, the common theme in participants’ reflections on this dimension was uncertainty. Ironically, with the exception of participant H, uncertainty was not expressed by anxiety; rather, it seemed to have a motivating effect on participants. Others reported that their uncertainty inspired them to take each day as it comes and to avoid long-term plans or expectations:

I just take it one day at a time, whatever happens next will happen next […] And if things go well, that’s great. (D)

As for me, all I see in the future is me and my partner in our little straw hats, picking flowers. (G)

There was little consensus on the timeline dimension among participants on the IPQ-R: four participants viewed their condition as impermanent, three were undecided, and one participant perceived his or her condition as permanent.

The results were relatively divided; no particular trend emerged for this subscale. Two participants disagreed strongly with the cyclical timeline, two were undecided, and four agreed somewhat. Overall, the qualitative and quantitative responses to the two timeline subscales were decidedly ambivalent.

Consequences

All of the participants reported positive consequences. Six mentioned improved functioning and increased physical and mental capacities (e.g. greater endurance, better concentration). Four participants reported a positive impact on their overall perspective on life, indicating that they value and appreciate life more than they did before the transplant. Four reported positive consequences in terms of the pursuit or realization of their projects or dreams.

Participant G reported that the ordeal of the illness had strengthened the relationship with his or her partner; G further reported that his or her family members had made lifestyle changes (e.g. quit smoking) following the transplant. Participant A reported that the transplant inspired him to spend more time giving back to others (e.g. volunteering). Finally, participant H reported a decrease in fear and anxiety following the transplant and found it easier to play down problems and put things in perspective:

The difference is amazing. Psychologically, I get upset when I feel myself getting worked up over nothing again. I try to tell myself, “Think about your heart! Make the most of this moment and don’t waste your time sweating the small stuff.” (H)

The consequences subscale on the IPQ-R is composed of eight items that evaluate negative consequences only. Overall, participants seemed to perceive few major negative consequences of their condition: four participants reported none and four others were undecided. The quantitative and qualitative results for negative consequences were homogeneous; however, the qualitative results also revealed a number of positive consequences.

Personal control

None of the participants addressed the control dimension as a function of the origin of the illness; rather, the participants addressed personal control in the context of past hardships or obstacles, both related and unrelated to the illness. Participants described the personality characteristics and concrete coping strategies that helped them get through difficult times. For example, three participants reported that their tendency to be optimistic helped them resolve problems and make it through the pre-transplant waiting period. One participant even mentioned that optimism helped him or her to avoid a kidney transplant:

[Interviewer question: How did you avoid the kidney transplant?] The doctors and I figured that it was because I’m very optimistic. I left the hospital with a creatinine (measure of kidney function) of 360 and, one week later, I was down to 163 […] We don’t know how it happened … I’d been telling myself that I’d have to grow a third kidney. (F)

Furthermore, the majority of participants identified and described strategies that they used to face obstacles. Participant C spoke of the importance of adjusting, accepting, and letting go. Participant H reported that he or she tends to avoid or to flee from problems; in contrast, Participant F said that he or she is more likely to get involved or to take an active role. Participant G reported that he or she often seeks social support during difficult times. Finally, two participants mentioned spirituality as a strategy for handling problems.

The results of this subscale of the IPQ-R were clear: all eight participants reported some degree or type of control over the problem. Although the narratives were more descriptive, the quantitative and qualitative results were overall congruent.

Treatment

All of the participants mentioned the post-transplant treatment. Five participants acknowledged the importance of the treatment regimen. Some of the participants viewed treatment as protection against future health problems or as a way to maintain heart health; one participant even linked the post-transplant treatment to increased longevity:

[Regarding restrictions on alcohol consumption] I try not to touch alcohol. I have fruit juice instead. The dietician said it was fine [to drink alcohol], but I’d rather not. I was lucky to get a new heart, you know, I want to take good care of it. (E)

Whereas participant D viewed the post-transplant treatment as a new habit to adopt, participant F viewed it simply as a regular element of healthcare, rather than as a treatment designed to cure a condition.

A significant portion of the participants believed that they would benefit from the treatment; five participants endorsed this statement on the IPQ-R, whereas one participant disagreed and two were undecided. These results are relatively congruent with the qualitative results obtained during the interview.

Emotional representations

Half of the participants reported no negative feelings about their health condition. Rather, their emotional representations were positive; participants reported gratitude, contentedness, happiness, peace, and serenity. Two participants reported negative feelings indirectly related to the transplant. Participant G reported sadness and helplessness about loss of dexterity from the stroke that preceded the heart transplant. Participant B reported frustration about his or her partner’s overprotective behavior following the heart transplant. Two participants indicated that their health condition generated negative feelings. The first participant described occasional depressed moods; the second reported worry and fear related primarily to the evolution of the condition.

Participants reported very few negative emotional representations of their illness on the IPQ-R; six participants reported none at all and two were undecided. These answers are congruent with the information collected during the interviews.

Illness coherence

As a group, the participants provided coherent information about the rationale for the transplant, the surgical intervention, the risks involved in the transplant, the post-surgery convalescence, and the role and the importance of the post-surgery treatment in managing the condition. Although several, somewhat naïve, theories were presented, the information reported was overall coherent.

On the whole, the participants seemed to have a good understanding of their health condition; seven disagreed with the statement on the IPQ-R that the condition does not make sense, and one participant was undecided. The qualitative results are congruent with the quantitative results.

Additional theme: social support

Although not included on the IPQ-R, the role of social support from friends and family members emerged as a relevant theme among the participants. The two primary subthemes were the following: (1) support and (2) the role and importance of the family. For example, five participants provided detailed descriptions of the support that they had received; some participants reported that social support played a role in helping them through the ordeal. The primary sources of support were the immediate circle of loved ones (primarily family) and medical personnel. Participant B even found that medical support was more helpful than social support because support from family and friends can create worry for the patient about being an emotional burden:

The medical staff is even more important than your family members. Because when family members visit, they bring love but they also create stress. I remember being sick and my children being at the foot of my bed, saying, “Daddy, we love you, Daddy, we love you.” But Daddy, there, in the bed, what’s he thinking? He’s thinking, “God, I’m so sick!” (B)

Over half of the participants addressed the roles and responsibilities of the family, both within and outside the context of the illness:

It’s not the same as my first transplant, when the children were young. They don’t need me as much; they can fly on their own now […]. I’ve given them the best possible guidance … so, on the whole, I think I’ve succeeded. (C)

Discussion

Important differences between qualitative and quantitative information were observed on the identity dimension. Participants reported an average of 8.75 post-transplant symptoms on the IPQ-R, but the qualitative data illustrated that, despite the presence of post-transplant symptoms, six out of eight participants considered themselves “healed.” Although counterintuitive, this result becomes clearer when we consider the definition of healing, that is, an absence of symptoms and a return to health. The qualitative data revealed that patients defined “healed” in terms of a comparison to their health status prior to the transplant. A heart transplant effectively eliminates the most difficult pre-transplant symptoms (i.e. physical, functional, and cognitive limitations; decreased quality of life); although new symptoms appear after the transplant, they are often short-lived (e.g. post-operative pain) and do not limit functioning or quality of life to the same extent as the pre-transplant symptoms. Hirani et al. (2006) and Sadala and Stolf (2008) obtained similar results with cardiac patients following revascularization and heart transplants, respectively. Other authors have also suggested that angioplasty patients may mistakenly believe that they are healed following surgery (Gaw-Ens, 1992; Shaw, 1986; Wenger, 1992). The identity dimension produced the greatest differences between qualitative and quantitative results. The qualitative data highlighted the interactions between variables (e.g. past and present symptoms) to produce an overall coherent (for the patient) sense of the post-transplant condition.

For the causal attribution dimension, the data obtained was fairly similar across the two methods; the participants reported the same causes during the interviews as on the IPQ-R. However, the information gathered in interviews revealed two distinct types of causal attribution. First, objective attributions based on concrete events associated with the onset of the heart condition (e.g. heart attack, stroke), and second, more speculative or naïve personal attributions for the development of the condition (e.g. emotional problems).

The results of the IPQ-R on the two timeline subscales revealed that participants are undecided or divided on the temporal dimension of the illness (acute/chronic and cyclical). However, the qualitative results provided insight into the impact of the uncertainty; for some participants, uncertainty creates worries, whereas for others, it motivates them to pursue their goals and dreams.

The qualitative and quantitative results on the consequences subscale diverged, primarily because the IPQ-R does not evaluate positive consequences related to the condition. The interviews revealed that participants associated quite a few positive consequences with the post-transplant condition. As for negative consequences, participants reported few, both in the interview and on the questionnaire. The absence of questions about positive consequences represents a significant weakness in the IPQ-R; prior research has established that the illness experience can have a positive impact, particularly on quality of life (Affleck and Tennen, 1996; Petrie et al., 1999; Thornton, 2002).

The quantitative results on the control subscale revealed that, on the whole, participants feel some degree of control over the evolution of their condition. The qualitative data corresponded to the questionnaire results; however, the interview data provided a greater understanding of different types of control and the ways that control are perceived and exerted.

The results on the treatment subscale were homogeneous across the two evaluation methods. The majority of participants agreed that the treatment would effectively manage their condition. However, the qualitative information allowed us to identify the personal obstacles that patients face with respect to medical recommendations.

The IPQ-R does not investigate positive emotional representations (e.g. gratitude) related to the illness; this shortcoming is partially responsible for the divergence between the qualitative and quantitative results on the consequences subscale. The qualitative and quantitative results both demonstrated that participants have a good understanding of their condition. The qualitative interview also highlighted the importance of patients’ friends, family members, and other sources of support.

On the basis of the results and of the qualitative data obtained in this study, we recommend several modifications to the IPQ-R. First, the use of averages to score the subscales creates a significant problem, wherein contradictory extreme scores can be mistaken for indecision. For example, a patient who scores 1, 1, 5, and 5, respectively, on the four items of a subscale would have an average score of 3, which represents “neither agree nor disagree.” To avoid this problem and ensure that extreme scores are represented, researchers may wish to use dispersion indices.

On the identity dimension, this study confirmed previous findings: some patients consider themselves healed despite an enduring health condition. In light of this finding, we propose the addition of a preliminary question at the beginning of the identity section, designed to evaluate the degree to which the patient considers himself or herself ill (scale from “I am not ill” to “I am very ill”). Furthermore, this question could serve to orient patients prior to the administration of the IPQ-R. For example, some of the participants in this study indicated that they “do not have a problem,” and were therefore not sure how to respond to the questionnaire. The addition of questions regarding positive emotional representations of the illness on the emotional representations scale may impact illness representations and provoke compliance.

On the control subscale, the qualitative results highlighted the importance of discriminating between different types of control. For example, two participants in this study reported the use of prayer as a coping strategy. However, participant A prayed in situations that were beyond his or her control (e.g. waiting for a heart donor), whereas participant H turned to prayer in situations in which he or she retained some element of control (e.g. discouragement about the treatment). The impact of a given strategy is not comparable across contexts, and pairing the administration of the IPQ-R with measures designed to address specific coping strategies may provide information about coping.

Four additions to the treatment subscale are suggested. First, the IPQ-R evaluates treatments that heal, control, and prevent negative outcomes, but does not address treatments that delay the development of the illness. Second, the addition of a “non-applicable” response option would prevent the inclusion of non-relevant items in the calculation of the subscale average. The addition of this option would ensure that disagreement with certain items (e.g. my treatment can control, but cannot cure, my condition) would not skew the subscale average and erroneously project rejection or dissatisfaction with the treatment. Third, given that undesirable side effects of treatment can negatively impact patients’ perceptions of treatment, we propose the inclusion of a questionnaire item could address side effects. Finally, we recommend the addition of items that address other non-represented elements of the SRM, such as family and social support, the impact of culture, or the impact of religious beliefs.

Interestingly, Rees et al. (2013) in a psychometric evaluation of the diabetes version using the Rasch model reported significant issues of multidimensionality and imprecision with four subscales (timeline, personal control, treatment control, and identity). They make the point that the generic IPQ-R may need to be adapted to the concerns of specific patient groups with addition of qualitative research to target the relevance of items more to the person’s perception with improved specificity of response categories.

Several limitations of this study must be acknowledged. First, the sample size was small. The recruitment pool was limited by some patients’ poor condition after the transplant. However, despite the small sample size, the qualitative results demonstrated common themes across participants and the links with findings from prior research (Sadala and Stolf, 2008). Second, the use of a theoretical model (the IPQ-R subscales) to present the qualitative results limited the interpretation of the raw qualitative data.

Conclusion

The implications of the study are that qualitative research methods provide idiosyncratic information of patients’ sometimes perplexing behavior surrounding their treatment which permits improving the current popular quantitative instrument (Fowler et al., 2007; Prasun et al., 2012). Specifically, the use of the qualitative approach generated concrete suggestions for improving existing quantitative tools that permit research with larger populations. Suggested improvements to the IPQ-R could develop knowledge about illness representations and clarify the relationship between illness representations and treatment compliance in diverse populations.

Footnotes

Acknowledgements

The authors would like to thank Sarah Roberts for her help in translating this article from French to English.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was partially supported by standard research grant no: 410-2002-1062 from the Social Science and Humanities Council of Canada.

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