Annals of Behavioral Medicine

, Volume 49, Issue 3, pp 463–472 | Cite as

District-Level Primary Care Supply Buffers the Negative Impact of Functional Limitations on Illness Perceptions in Older Adults with Multiple Illnesses

  • Benjamin SchüzEmail author
  • Clemens Tesch-Römer
  • Susanne Wurm
Original Article



Illness perceptions predict important outcomes, e.g. coping, adherence and well-being. Less is known about the sources of illness perceptions, in particular the role of environmental factors such as primary care supply.


This study examines whether and how primary care supply (on district level) affects individual illness perceptions.


We conducted a longitudinal study in 271 adults 65 years and older with multiple illnesses. Functional limitations (SF-36 physical functioning subscale) at time 1 were tested as predictors of illness perceptions 6 months later. Primary care supply on district level was matched to individual data.


In multilevel models, functional limitations predicted illness perceptions. Primary care supply on district level moderated the impact of functional limitations on individual identity and emotional response perceptions, with better supply buffering detrimental effects of functional limitations.


Illness perceptions do not only depend on individual factors, but socio-structural factors also substantially contribute to individual illness perceptions.


Illness perceptions Primary care supply Older adults Physical functioning Multilevel modelling Common-Sense Model 



This study (PREFER) was funded by the German Federal Ministry of Education and Research (Grant No. 01ET0702). The content is the sole responsibility of the authors.

Authors’ Statement of Conflict of Interest and Adherence to Ethical Standards

Authors Schüz, Tesch-Römer, and Wurm declare that they have no conflict of interest. All procedures, including the informed consent process, were conducted in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000.


  1. 1.
    Hagger MS, Orbell S. A meta-analytic review of the common-sense model of illness representations. Psychol Health. 2003; 18(2): 141-84.CrossRefGoogle Scholar
  2. 2.
    Leventhal H, Nerenz DR, Steele DJ. Illness representations and coping with health threats. In: Baum A, Taylor SE, Singer JE, eds. Handbook of Psychology and Health. 4. Hillsdale, NJ: Erlbaum; 1984:219–52.Google Scholar
  3. 3.
    Leventhal H, Diefenbach M, Leventhal EA. Illness cognition: Using common sense to understand treatment adherence and affect cognition interactions. Cognitive Ther Res. 1992; 16(2): 143-63.CrossRefGoogle Scholar
  4. 4.
    Moss-Morris R, Weinman J, Petrie KJ, et al. The revised illness perception questionnaire (IPQ-R). Psychol Health. 2002; 17(1): 1-16.CrossRefGoogle Scholar
  5. 5.
    Leventhal H, Leventhal EA, Contrada RJ. Self-regulation, health, and behavior: A perceptual-cognitive approach. Psychol Health. 1998; 13(4): 717-33.CrossRefGoogle Scholar
  6. 6.
    Halm EA, Mora P, Leventhal H. No symptoms, no asthma: The acute episodic disease belief is associated with poor self-management among inner-city adults with persistent asthma. Chest. 2006; 129(3): 573-80.CrossRefPubMedGoogle Scholar
  7. 7.
    French DP, Cooper A, Weinman J. Illness perceptions predict attendance at cardiac rehabilitation following acute myocardial infarction: A systematic review with meta-analysis. J Psychosom Res. 2006; 61(6): 757-67.CrossRefPubMedGoogle Scholar
  8. 8.
    Ross S, Walker A, MacLeod MJ. Patient compliance in hypertension: Role of illness perceptions and treatment beliefs. J Hum Hypertens. 2004; 18(9): 607-13.CrossRefPubMedGoogle Scholar
  9. 9.
    Cameron LD, Moss-Morris R. Illness-related cognition and behaviour. In: French D, Vedhara K, Kaptein AA, Weinman J, eds. Health Psychology. 2nd ed. Chichester: BPS Blackwell; 2010: 149-61.Google Scholar
  10. 10.
    Baumann LJ, Cameron LD, Zimmerman RS, et al. Illness representations and matching labels with symptoms. Health Psychol. 1989; 8(4): 449-69.CrossRefPubMedGoogle Scholar
  11. 11.
    Schüz B, Wurm S, Ziegelmann JP, et al. Changes in functional health, changes in medication beliefs, and medication adherence. Health Psychol. 2011; 30(1): 31-9.CrossRefPubMedGoogle Scholar
  12. 12.
    Kaptein AA, Bijsterbosch J, Scharloo M, et al. Using the common sense model of illness perceptions to examine osteoarthritis change: A 6-year longitudinal study. Health Psychol. 2010; 29(1): 56-64.CrossRefPubMedGoogle Scholar
  13. 13.
    Kaptein AA, Yamaoka K, Snoei L, et al. Illness perceptions and quality of life in Japanese and Dutch patients with non-small-cell lung cancer. Lung Cancer. 2011; 72(3): 384-90.CrossRefPubMedGoogle Scholar
  14. 14.
    Noureddine S, Massouh A, Froelicher ES. Perceptions of heart disease in community-dwelling Lebanese. Eur J Cardiovasc Nur. 2013; 12(1): 56-63.Google Scholar
  15. 15.
    Lange LJ, Piette JD. Personal models for diabetes in context and patients’ health status. J Behav Med. 2006; 29(3): 239-53.CrossRefPubMedGoogle Scholar
  16. 16.
    Frostholm L, Fink P, Christensen KS, et al. The patients’ illness perceptions and the use of primary health care. Psychosom Med. 2005; 67(6): 997-1005.CrossRefPubMedGoogle Scholar
  17. 17.
    Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998. Health Serv Res. 2003; 38(3): 831-65.CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005; 83(3): 457-502.CrossRefPubMedCentralPubMedGoogle Scholar
  19. 19.
    Bankart MJG, Baker R, Rashid A, et al. Characteristics of general practices associated with emergency admission rates to hospital: A cross-sectional study. Emerg Med J. 2011; 28(7): 558-63.CrossRefPubMedGoogle Scholar
  20. 20.
    Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. J Am Med Assoc. 1995; 274(4): 305-11.CrossRefGoogle Scholar
  21. 21.
    McWilliams JM, Meara E, Zaslavsky AM, et al. Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: U.S. trends from 1999 to 2006 and effects of medicare coverage. Ann Intern Med. 2009; 150(8): 505-15.CrossRefPubMedGoogle Scholar
  22. 22.
    Carlton EL, Simmons LA. Health decision-making among rural women: Physician access and prescription adherence. Rural Remote Health. 2011; 11(1): 1159.Google Scholar
  23. 23.
    Wurm S, Wolff JK, Schüz B. Primary care supply moderates the impact of diseases on self-perceptions of aging. Psychol Aging. 2014; 29(2): 351-358.CrossRefPubMedGoogle Scholar
  24. 24.
    Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. Lancet. 2012; 380(9836): 37-43.CrossRefPubMedGoogle Scholar
  25. 25.
    Wurm S, Schöllgen I, Tesch-Römer C. Gesundheit. In: Motel-Klingebiel A, Wurm S, Tesch-Römer C, eds. Altern im Wandel: Befunde des Deutschen Alterssurveys (DEAS). Stuttgart: Kohlhammer; 2010: 114-7.Google Scholar
  26. 26.
    France EF, Wyke S, Gunn JM, et al. Multimorbidity in primary care: A systematic review of prospective cohort studies. Brit J Gen Pract. 2012; 62(597): e297-e307.CrossRefGoogle Scholar
  27. 27.
    Aarts S, van den Akker M, Bosma H, et al. The effect of multimorbidity on health related functioning: Temporary or persistent? Results from a longitudinal cohort study. J Psychosom Res. 2012; 73(3): 211-7.CrossRefPubMedGoogle Scholar
  28. 28.
    Kadam U. Redesigning the general practice consultation to improve care for patients with multimorbidity. BMJ (Online). 2012;345(7878):Google Scholar
  29. 29.
    Bower P, Harkness E, Macdonald W, et al. Illness representations in patients with multimorbid long-term conditions: Qualitative study. Psychol Health. 2012; 27(10): 1211-26.CrossRefPubMedGoogle Scholar
  30. 30.
    Mc Sharry J, Bishop FL, Moss-Morris R, et al. ‘The chicken and egg thing’: Cognitive representations and self-management of multimorbidity in people with diabetes and depression. Psychol Health. 2012; 28(1): 103-19.CrossRefPubMedGoogle Scholar
  31. 31.
    Schüz B, Wolff JK, Warner LM, et al. Multiple illness perceptions in older adults: Effects on physical functioning and medication adherence. Psychol Health. 2014; 29(4): 442-57.CrossRefPubMedGoogle Scholar
  32. 32.
    Engstler H, Motel-Klingebiel A. Datengrundlagen und Methoden des Deutschen Alterssurvey (DEAS) [Data and methods in the German Ageing Survey (DEAS)]. In: Motel-Klingebiel A, Wurm S, Tesch-Römer C, eds. Altern im Wandel: Befunde des Deutschen Alterssurveys (DEAS) [Ageing in Change: Findings from the German Ageing Survey (DEAS)]. Stuttgart: Kohlhammer; 2010:34–60.Google Scholar
  33. 33.
    Charlson ME, Szatrowski TP, Peterson J, et al. Validation of a combined comorbidity index. J Clin Epidemiol. 1994; 47(11): 1245-51.CrossRefPubMedGoogle Scholar
  34. 34.
    Groll DL, To T, Bombardier C, et al. The development of a comorbidity index with physical function as the outcome. J Clin Epidemiol. 2005; 58(6): 595-602.CrossRefPubMedGoogle Scholar
  35. 35.
    Schüz B, Warner LM, Wurm S, Ziegelmann JP, Tesch-Römer C, Schwarzer R. Personale Ressourcen für Autonomie trotz Multimorbidität [Personal Resources for Autonomy despite Multimorbidity]. In: Kuhlmey A, Tesch-Römer C, eds. Autonomie trotz Multimorbidität Ressourcen für Selbstständigkeit und Selbstbestimmung im Alter [Autonomy despite Multimorbidity Resources for Independence and Self-Determination in Old Age]. Göttingen: Hogrefe; 2013:83–110.Google Scholar
  36. 36.
    Maas CJM, Hox JJ. Sufficient sample sizes for multilevel modeling. Methodology. 2005; 1(3): 86-92.Google Scholar
  37. 37.
    Broadbent E, Petrie KJ, Main J, et al. The brief illness perception questionnaire. J Psychosom Res. 2006; 60(6): 631-7.CrossRefPubMedGoogle Scholar
  38. 38.
    Schüz B, Wurm S, Warner LM, et al. Self-efficacy and multiple illness representations in older adults: A multilevel approach. Psychol Health. 2012; 21(1): 13-29.CrossRefGoogle Scholar
  39. 39.
    Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992; 30: 473-83.CrossRefPubMedGoogle Scholar
  40. 40.
    McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993; 31(3): 247-63.CrossRefPubMedGoogle Scholar
  41. 41.
    Unesco. ISCED 1997: International Standard Classification of Education 1997 [cited 2010 Feb 23]. Available from:
  42. 42.
    Bundesinstitut für Bau- Stadt- und Raumforschung [German Federal Institute for Research on Building UAaSD. INKAR 2011 - Indikatoren und Karten zur Raum- und Stadtentwicklung in Deutschland und in Europa Berlin, Germany: BBSR; 2011 [cited 2012 Dec 17]. Available from:
  43. 43.
    Raudenbush S, Bryk T, Congdon R. HLM Hierarchical Linear and Nonlinear Modeling. 7 ed. Scientific Software International, Inc.; 2010.Google Scholar
  44. 44.
    Enders CK, Tofighi D. Centering predictor variables in cross-sectional multilevel models: A new look at an old issue. Psychol Methods. 2007; 12(2): 121-38.CrossRefPubMedGoogle Scholar
  45. 45.
    Aiken LS, West SG. Multiple Regression: Testing and Interpreting Interactions. Thousand Oaks: Sage; 1991.Google Scholar
  46. 46.
    Snijders TAB, Boskers RJ. Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling. 2nd ed. London: Sage; 2012.Google Scholar
  47. 47.
    Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychological Bull. 1985; 98(2): 310-57.CrossRefGoogle Scholar
  48. 48.
    Van Oort L, Schröder C, French DP. What do people think about when they answer the brief illness perception questionnaire? A ‘think-aloud’ study. Brit J Health Psychol. 2011; 16(2): 231-45.CrossRefGoogle Scholar
  49. 49.
    Broadbent E, Kaptein AA, Petrie KJ. Double Dutch: The ‘think-aloud’ Brief IPQ study uses a Dutch translation with confusing wording and the wrong instructions. Brit J Health Psychol. 2011; 16(2): 246-9.CrossRefGoogle Scholar

Copyright information

© The Society of Behavioral Medicine 2014

Authors and Affiliations

  • Benjamin Schüz
    • 1
    Email author
  • Clemens Tesch-Römer
    • 2
  • Susanne Wurm
    • 2
    • 3
  1. 1.School of PsychologyUniversity of TasmaniaHobartAustralia
  2. 2.German Centre of GerontologyBerlinGermany
  3. 3.Institute of PsychogerontologyUniversity of Erlangen-NurembergNurembergGermany

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