PERSONALITY PREDICTORS OF POST-TRANSPLANT HEALTH OUTCOMES

IN SOLID ORGAN RECIPIENTS

by

Sophie Mankowski

B.Sc., Universis. of Moneeal, 1995

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE DEGE2EE OF

MASTER OF ARTS

in the Department of Psychology

O Sophie Mankowski 1998

SMON FRASER UNTVERSITY

April, 1998

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Abstract

The role of psychosocial factors in assessing transplant patients has been to aid

allocating the scarce and costly transplant resources based on the probability of a

successfid outcome. To date there is very little research concernkg the relevance of

normal personality traits to health outcomes in organ recipients. This study addressed the

role of nomal personality traits in predictiag successful post-transplant outcome in order

to better understand which aspects of ongoing personality style are associated with

enhanced surgery outcome. Participants were organ recipients who had completed the

Revised NE0 Personality Inventory before the transplantation. Four broad personality

predictors (Neuroticism, Agreeableness, Conscientiousness, Opemess) were examined in

. relation to three outcome vanables measured after transplantation (treatment cornpliance,

physical health, and mental heatth). Preliminary analysis showed that age was sipiflcantly

correlated with cornpliance. Results when controlling for the eEect of age showed that 1)

patients scoring higher on Neuroticism were rated by the transplant nurse as having poorer

physical health than patients scoring lower on Neuroticism; 2) organ recipients scoring low

on both Opemess to experience and Conscientiousness were more likely to report being

happy and caim after the surgery. Results are discussed in t e m of the implications of

these hdings in helping transplant teams to iden*- patients in advance who may be at

higher risk for poor outcome.

Acknowledgments

I am grateful to rny supervisor Marilyn Bowman not only for her assistance and

patience throughout this projecf but also for showing so much enthusiasm and putting so

much trust in me. Thank you to Steve Hart for his valuable statistical suggestions. 1

would also like to thank John Soos for his enormous support, as well as clinical and

intellectual contribution to the present project.

I would like to thank my classrnates Agnieszka, Jocelyn, Corina, and Gary for

their continual encouragement and support. A particular thank you to Darek Dawda and

Nichole Fairbrother for their precious advices and many feedbacks dl the way through

my project. Thank you to John Mitchell for his patience, continuing encouragements, and

good humour in times of hstrations.

Finally, a word of gratitude to the B.C Transplant Society and Soiid Organ

Transplant Outpatient Unit for allowing me to conduct this project.

List of Tables

Table Page

................................................................ 1 Description of Participants.. 11

2 Kendall Rank Order Correlations for Cornpliance, Health, Number of Missed

Appoùitments, Length of Hospitahtion, Nurnber of Rejection, and Number of

Hospital Admission. ...................................................................... -13

3 Means, Standard Deviations, Ranges, and Sample Size for Neuroticïsm,

Agreeableness, Conscientiousness, Opemess, Compliance, Health and Menta!

Heaith. ..................................................................................... -20

4 Pearson Product Moment Correalations for Age, S tatus, Neuroticism,

Agreeableness, Conscientiousness, Openness, Compiiance, Health, and Mental

health ........................................................................................ -2 1

5 Summary of Multiple Regression Analysis for Variables Predicting

Cornpliance. .............................................................................. -23

6 Summary of Multiple Regession Analysis for Variables Predicting

Physical Health. ............... .. .......................................................... -24

7 Summary of Multiple Regression Andysis for Variables Predicting

Mental Health. ............................................................................ -25

8 Sumrnary of Hierarchical Regression Andysis for Variables Predicring

Compiiance while Controhg for the Effects of Age.. ............................... 26

9 Sumrnary of fierarchical Regression Analysis for Variables Predicting Health

while Controhg for the Effects of Age.. ............................................ -27

10 Sumrnary of Krerarchical Regression Analysis for Variables Predicting Mental

Heakh while Controhg for the EEects of Age.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . -28

1 1 Kendall Correlations for Neuroticism, Nurnber of Days in Hospital, Number of

Rejeaion Episode, Number of Admission.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . -29

List of Appendixes

Appendix

A The Nuning Rating Scale.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -45

Personality predictors of post-transplant health outcomes

in solid organ recipients

Outline of the Studv

Because the need for organ transplants continues to exceed the availability of

organ donors, carefid patient selection remains an important, if unfortunate, necessity .

Successfùi patient selection depends on our ability to accurately predict health outcomes

for these patients.

Psychological factors have been used to select organ transplant candidates and to

predict health outcomes in transplant patients for many years. However, other than

anecdotal evidence, there is little objective support for the reliability or valiaity of these

variables in predicting outcome. In addition, due to the paucity of scientific data, selection

criteria are not currently standardized, and continue to Vary in centers across Canada. The

purpose of the proposed study is to examine the effectiveness of normal personality traits

in predidng post-transplant outcome.

INTRODUCTION

With recent imrnunological and surgical advances, organ transplantation has

become an important method of treatment for pztients with end-stage organ disease.

Despite scientific advances however, organ transplantation in Canada is hindered by its

inability to provide adequate supply to the ever-increasing demand. Approximately one-

third of organ transplant candidates waiting for a transplant die because of the

insufficiency of donor orgzns (Riether & Mahler, 1995).

The current gap between organ recipients and organ donors has forced health care

professionals to deal with the ditlicult task of allocating limited resources. This situation

has served as an impetus to consider both medical (eg., advanced age, presence of CO-

rnorbid disease) and psychosocial cntena (eg., social support, psychopathology) in carefid

candidate selection as a way to s t ra te risks (Freeman, Westphai, Davis, & Libb, 1995).

A transplant tearn's priority is to select patients who will benefit the most from the nirgery

because they have the best estimated post-transplant health outcomes (Olbrisch &

Levenson, 1995).

The process of seiecting candidates on the bais of psychosocial exclusion cnterïa

raises important ethical issues regarding the question ofjustice and fainiess (Caplan, 1987;

Robertson, 1987). Medical and psychological variables are regularly used to predict

transplant outcomes, and to determine a referred patient's psychological readiness for and

Likely benefit fkom surgery. These variables can, however, easily be confounded with

appraisals of a patient's social worth (Loewy, 1987). The percentage of transplant

candidates across settings and organs who are refused surgery on the bais of psychosocial

criteria ranges firom 0% to 37% (Olbrisch & Levenson, 1991). Health care workers are

not devoid of subjective feelings towards assessed patients which may impede theû ability

to objectively select the most suitable candidates. Because of a lack of empirical data

systematically Linking psychosocial criteria and post-transplant outcomes, hedth care

workers may overly rely on their cluiical impressions to guide their decision with respect

to whom they think is the "good" candidate.

Psychosocial Variables in Redictin~ ûutcomes

No national standards egst for the selection of organ transplant recipients.

Currently, psychosocial critena are inconsistently used across transplant teams (Olbrish &

LevensonJ995). Transplant programs across Canada rely on a senes of preoperative

assessments conducted by a transplant team. Assessrnents are conducted collaboratively

by surgeons, nursing staff, psychiatrist or psychologia, and social workers. Their role is

to evaluate the transplant applicant in order to determine which patients may be at greater

risk for poor surgicd outcorne. In addition, these assessments are used to evaluate the

candidate's strengths and wlnerabilities in order to recommend or guide the patient toward

the most appropriate treatment to enhance their preparedness for transplantation (Soos,

1992).

The most common psychosocial criteria used in predicting problematic organ

transplant outcornes include the presence of ongoing non-cornpliance, major p syc hiatric

ihess unresponsive to treatment, alcohol and dmg abuse, severe and irreversible

neurocognitive impairment, lac k of available social support, poor CO ping style, CO-morbid

obesity, and personality disorders (Craven, 1989; Freeman et ai., 1992; 1. Soos, personal

communication, May 17,1996).

Research has show that the presence of these psychosocid factors places patients

at increased post-operative risk as they have been associated with noncompliance with

medical regimens and thus poorer medical and psychological outcorne (Breman, Davis,

Buchholz, Kuhn L Gray, 1987; Chacko, Harper, Kunik & Young, 1996; Fnerson &

Lippmann, 1987). The impact of demographic factors on post-transplant compliance has

also b e n investigated, considering the effects of sex, educational level, or marital status,

but results have been contradictory and of limited utility in predicting long-terni

adjustment (De Geest, 1995; Kilbrands et al., 1995; Schweitzer et al., 1990).

Pre-ooerative Mental Disorders

Studies have also examined the relationship between psychological disorders seen

in the preoperaîive assessrnent, and postoperative problems such as noncompliance and

dissatisfaction with Me. In a recent project, a history of substance abuse and/or the

presence of a personaiity disorder has been associated with the development of compliance

problems foilowing heart transplantation (Shapiro et al., 19%). Other recent findings have

suggested that poor psychosociai adjustment and health status outcome mesures tend to

be associated with major mental disorders (Chacko et al., 1996) referred as Axis-1

disorders in the DSM-IV (Diagnostic and statistical manual of mental disorders, 4th ed.,

1994). Further, they found that noncompliance was related to personality disorders coded

on Axis II in the DSM-IV. These hdings are consistent with the study of Breman et al.

(1987) which found that patients with personality disorders were more likely to be at high

risk for poor medical outcome because they did not comply with the medical regimen.

Finally, Saravay and Lavin (1994) reviewed 26 outcome studies of organ transplantation

selected for their rigorous methodology and found that 89% of these showed a sigdlcant

relation between psychiatric comorbidity and length of hospital stay.

Noncornpliance with the medical regirnen has been shown to be a major cause of

gr& fidure and therefore a nsk factor for post-transplant complications (Didlake,

Dreyfus, Kennan, Van Buren & Kahan, 1988; Hilbrands, Hoitsma & Koene, 1995). In

their study, De Geest, Borgermans, and Gemoets (1995) reported a higher rate of acute

rejection episodes in the noncornpliant group, which suggests that compliance could play

an etiologicat role in ailograft rejection and gr& survival. Cornpliance with the post-

operative meâical regimen is a highly relevant behaviour because discharged patients must

take the initiative to go to chic appointments and take their immunosuppressant

medications daily for the rest of their lives. In addition, they have to follow a strict diet

and make other major lifestyle adjustments such as maintenance of smoking cessation and

abstinence fiom alcohol or other substances, especidy if organ fdure was associated with

dnig dependence. In their study, Didlake et al. (1988) found that major noncompliance

among 2.8 % of a large sample of kidney recipients resulted in graft loss, and in 1.9 %

resulted in rejeaion episodes when they had only partially complied with the c y c l o s p o ~

regimens.

Although the iiterature on the determinants of noncompliance is inconclusive,

psychiatric disorders, alcohol abuse, and other psychosocial factors such as lack of

available support, have ofien been associated with noncornpliance in organ transplant

recipients (Schweitzer et ai., 1990; Swanson et al., 199 1; Kiley, Lam, L Pollack, 1993).

While waiting for more robua predictors of compliance, clhicians are still relying on the

pre-transplant history of past medical compliance as their best currently available indicator

of fiiture cornpliant behaviour. Nonetheless, noncornpliance may still develop &er

surgery arnong people who have been compiiant in the past (Armstrong et al., 198 1). It

rernains unclear whether psychological variables, behavioural variables, environmental

variables or combinations of these are the most reliable and valid predictors of post-

surgery cornpliance.

Personality Variables

Traditional psychoanalyticaf personality theory argued the presence of a

relationship between personality and illness (Freud, 1955), but many of its formulations

were found inadequate, and were increasingly abandoned over the past three decades. In

their place, new formulations derived h m studies in normal personaiity, stress, and

coping have developed to provide an alternative way of studying these connections.

Although controversial for many years, there is now substantial evidence showing that

personality variables have an impact on the process of coping with illness and on the

development and the course of disease. For example, in their review of the literature,

Friedman and Booth-Kewley (1987) demonstrated a consistent positive association across

studies between personality and iUness, parîicularly in the case of disorders of the

wdiovascular system. Studies looking at the personality predictors of the development of

heart disease have shown that some aspects of Type A personality traits (e.g., hostility,

impatience, achievement striving) are usudy a significant risk factor (Eysenck, 1988;

Matthews, 1988; Shoharn-Yakubovich, Ragland, Brand, & Syme, 1988). Other research

looking at the relationship between personality, immune function, and the development of

cancer have s h o w that traits such as unassertiveness, helplessness, and rigid defensiveness

were more characteristic among cancer patients and among those patients who presented

with a less favorable couse to their iUness (PersS., Kempthorne-Rawson, & Shekelle,

1987; Eysenck, 1988; Kavan, Engdahl, & Kay, 1995).

Although there is a tradition in heaith psychology research to investigate Mages

between personality and disease outcorne, to our knowledge, there are no reliable data

conceniing the impact of personality traits on post-transplantation outcomes. Results are

not consistent because both personality and outcome measures vary fkom study to study.

Higher level of self-care "agency" and perceived self-efficacy were associated with better

compliance rate among 150 rend transplant recipients (De Geest et al., 1995). Passive

and avoidant coping style were correlated with noncornpliance with the medicai regimen

(Dew, Roth, Thompson, Kormos & M t h , 1996). Neuser (1988) investigated the

innuence of personality factors on survival time in patients with bone marrow

transplantation and found that higher scorers on the factor "strive for recognition and

help" were more Ee1y to survive one year after the surgery. Because these patients were

subject to many behaviord and medical restrictions after discharge, compliance with the

medical regimen was fundamental to Sufvival. For those patients who were more

dependent on social recognition for their behavior, it may be that by complying they were

more iikely to be recognized and helped. Similarly, De Jager and Shuda (1990)

investigated the links between certain personality styles and kidney transplant survivd

rates. They fomd that 12 unsuccessful rend patients were characterized by greater

conservativeness, as weli as a tendency to go dong with the group. Although, it is not

clear in these studies how personalify might have affected Survival t h e , it may be that

certain personality characteristics play a role by their contributions to overali cornpliance,

which of course fùrther iduences medical outcome (Neuser, 1985).

Ma-ior Mental Disorder and Orean Transr>lant

The number of transplant candidates diagnosed with a major psychiatrie problem is

fairy low. They are usuaiiy not inciuded on the waiting List, as research indicates that

ongoing major psychopathology unresponsive to treatment places these patients at a

greater risk for poor nirgery outcomes. For this reason, transplant candidates are

psychologically relatively intact and are hctioning within the normal range. The

emotional distress they experience is cornmennirate with the extraordinary challenge of

coming to face with end-stage organ disease, and because of this signincant stress, these

patients remain at risk for post-transplant medical, psychological, and behavïord

complication despite their basically sound psychological tùnctioning. Each patient is

characterized by unique maiadaptive and adaptive traits and by unique ways of coping with

this stressfiil event.

Nomd Person* and Heaith Behaviors

The utility of a five-factor taxonorny of personality has been demonstrated in that it

organizes the many adjectives found under the term "personalilty" into rneaningfid clusters.

1t has facilitated the study ofspecified domains of personality traits as well as the

communication of empincal results (John, 1990). This mode1 originated korn analysis of

the naîural language and has been shown to be useful in predicting health outcornes (Smith

& WiUiams, 1992). The NE0 Personalïty Inventory, or revised version, (Costa &

McCrae, 1992) has been a good attempt at operationalizing the five dimensions of normal

adult personality, and it has been used in shidies of health behaviors.

The Revised NE0 Personality Inventory (NEO-PI-% Costa & McCrae, 1992) is a

self-report inventory composed of five dornain scales: Neuroticism, Extraversion,

Op enness to Expenence, Agreeableness, and Conscientiousness.

Although the NEO-PIR has not been used in the area of organ transplantation,

previous research has demonstrated its utility in predicting outcome in behavioral medicine

and hedth psychology (Costa et al., 1992; Miller, 199 1) and, because of its breadth, is a

usefül instrument in detecting personality strengths or weakness that could othemise be

overlooked (Widiger & Frances, 1994).

Using this test with an outpatient clinical samples, Miller (1 99 1) suggested that the

trait Conscientiousness has an impact on a person's willingness to work hard in

psychotherapy and to tolerate discornfort and fnistration. This trait refers to the ability to

control impulses, and it assesses determination, reliability, and the ability to plan, organize,

and carry out various tasks. Muten (199 1) described the implication of the dornain

Conscientiousness by saying that patients higher on this trait tend to make better patients

in that they are more likely to show up for appointments or work on their assigned clhicai

work. He descnbed them as more self-reliant and self-disciplined. Using a similar

rationale, Christensen and Smith (1 995) showed that Conscientiousness was sigdicantly

associated with rnedical compliance in patients undergoing rend didysis. Other recent

studies (Friedman et al., 1993; 1995) reported that conscientious children were more likely

to live longer than less comcientious children. Individual differences in health habits and

adherence to medical treatment have been hypothesized to mediate the relationship

between conscientiousness and health complications or longevity.

In their study, Booth-Kewley and Vickers (1 994) found that the trait

Agreeableness was a predictor of heaith habits and hypothesized that one interpretation for

these fïndings may be that agreeable people are less likely to be conf?ontationai, to infringe

on people's rïghts, or be hostile. These quaiities may influence risk taking and health

behaviours. The trait Agreeableness has also been shown to facilitate the formation ofa

treatment alliance with the therapist (Costa et al., 1992).

Neuroticisrn is defined as the overall tendency to experience negative affects. An

elevated score on this domain is not always an indicator of the presence of

psychopathology. Nevertheless, it may suggest that someone is at higher risk for

psychiatrie ~ c d t i e s (Costa & McCrae, 1992). It has been suggested that people with a

high score on Neuroticism rnay be more susceptible to irrational beliefs, be more

impulsive, and may have more difnculties coping with stressfbl events (Costa & McCrae,

1992). It is also Lely that Neuroticism rnay intense and infiuenced the length of one's

degree of distress (Costa et al., 1992). Finally, Muten (1991) found that people scoring

higher on the trait Opemess to Expenence are more open to psychological services to

assist them in coping, such as developing self-regdation and relaxation slolls.

Although personality seems to exert an influence on surgical outcome, it is not yet

clear through which pathway it is iduencing the nature of the outcorne. However, if

personality traits are indeed associated with treatment outcome, then psychologists are

further encouraged in their role in detecting those patients who may be more prone to

post-transplantation distress. Also, by understanding the candidate's strengths and

vulnerabilities, the clinician may be able to guide and encourage the patient to seek

treatment in order to be better prepared for surgeqc This process of eariy intervention

and preventive psychological interventions should enhance the possibility of successful

outcome.

In an attempt to r e k e our understanding of factors which contribute to good

transplant outcomes, this study aimed to rneasure the role of normal persodty factors in

predicting the nature of surgery outcome.

Research Hypothesis

This study tested the hypothesis that specific personaky traits assessed

prospectively during the psychological evaluation of organ transplant candidates predicted

subsequent medical, behaviord, and psychological outcomes. Four broad personaiity

domains (Neuroticïsm, Agreeableness, Conscientiousness, Opemess) measured before

surgery were examùled in relation to three outcome variables measured &er

transplantation (treatment compliance, physical hedth, and mental hedth).

It was predicted that

1) Conscientiousness will be positively correlated to later compliance, and physical and

mental heaftfi, and

2) Neuroticism will be negatively correlated to compliance, health, and psychological weU-

being .

It is fiirther predicted that

3) Agreeableness will be positiveiy correlated to compliance, health, and overall weIL

being, and that,

4) Openness wiU be positively correlated to compliance, hedth, and overall well-being.

Partici~ants

The sample consisted of 37 ber , 16 heart, and 12 lung transplant patients (&F65),

with a total of 23 females and 42 males. Archival data on patients and a 2-item Nursing

Rating Scale were obtained in collaboration with the BC Transplant Society and the Solid

Organ Transplant Outpatient Unit at Vancouver Hospital.

Age and severity of illness (medical status) pnor to transplantation were coiiected

through the Health Wonnation Division of the BC Transplan: Society. Age was

controiled for as it may play a role in surgical outcome. For example, older patients rnay

have additional medical problems both before and after transplantation and hence this rnay

anect the relationship between personality and outcome.

Mean age of subjects was 52 years and age ranged fiom 22 to 68 (==10.93).

Patient's medical stahis while waithg for the transplantation was rated on a scale of 1

@est) to 4 (worst) (see Table 1) and the mean level of the patient's medical status was

1.37 @=. 74). 76 % of the patients in the sample were at a relatively hi@ level of

bctioning (Le., Medical status 1) before being trmsplanted. A description of participants

is provided in Table 1.

Measues

1) Personalitv Predictors

a) The Revised NE0 Personality Inventory (NEO-PI-R). The NEO-PI-R (Costa &

McCrae, 1992) is a self-report inventory used to assess basic dimensions of normal

personality. The NEO-PI-R was used by the transplant psychologist as previous research

has demonstrated its utility in predicting outcome in health fields. It is a 240-item

questionnaire composed of five domain scales: Neuroticism, Extraversion, Opemess to

Experience, Agreeableness, and Conscientiousness. Each domain is M e r constituted of

Table 1

Description of Particioants M=65)

Variable

Liver

Heart

L w 3

Male

Fernale

Medical status prior to transplantation

1 (at home)

4 (KU-Intubated and

52 (10.93 years)

1.37 (.74)

ventiiated)

6 facets assessing specific aspects of each dimension. The underlying assurnption of this

measure is that by assessing these traits, one can obtain a global picture of a person's

ongoing personality style (Costa, 199 1). It has good psychornetric properties with intemal

consistency for the facets scales ranging from -56 to -81, and long-term retest reliability

ranging from .63 to .8 1 for the five domains. In addition, there has been ample evidence

supporting the convergent, discriminant7 and constmct validity of the NE0 dimensions.

For the purpose of the study, ail domains were included with the exception of the trait

Extraversion. in order to limit the number of variables used in the study, and to focus on

major factors, the facets were not included in the hypothesis testing. Items answered for

each domain were coded on a scale fiom 1 (very low) to 5 (very high), and summed scores

for each dornain were expressed in standardized T scores. A T score of 50 indicates that

the patient scored average on a personality trait, cornpared to a patient with a low or a

high score.

2) Outcome Variables

a) Cornpliance Rating. Overaii compliance was rated by the recipient's primary nurse-

coordinator, describing the patient on a 5-point Likert scale. This two-item questionnaire

asked the nurse to rate £kom 1 (exceptionally cornpliant) to 5 (very poorly cornpliant) the

extent to which the patient has been cornplying with the medication regimen, and, with the

clinic visits.

A test of the validity of the nurse ratings was done by correlating the score with an

objective meanire of compliance defined as the number of missed scheduled appointments

at the Solid Organ Transplant Outpatient Unit. The nurse's rating of patient's compliance

level was significantiy correlated with the number of missed scheduled appointments =

3 O 1 This result suggests that convergent validity exists for this measure. Results

are presented in Table 2.

The munber of missed scheduled appointments at the Solid ûrgan Transplant

(SOT) Outpatient Unit was collected for the first year post-operative penod, as an

Table 2

Kendall Rank Order Correlations for Corn~liance. Health Number of Missed

Appointment. Lenoth of Hospitalizatioa Number of Reiection and Nurnber of Hos~ital

Admission.

1. Cornpliance (nurse rating)

2. Heaith (nurse rating)

3. Number of rnissed appointment

4. Length of hospitalization

5. Number of rejection episode

6. Number of hospital admission

Note. *p S.05; **p S O I .

objective index of post-operative compliance. Mer the surgery, each patient is required

to adhere to scheduled appointments at the SOT Unit for folfow-up purposes including

m o n i t o ~ g medication and coilecting blood analysis. Patients visit the clinic on a weekly

bais for the fh t 12 weeks, and once monthly fiom three to nine months post-operatively.

Following that period, they corne to the clinic whenever it is suggested by the nurse and

treating physician. This objective rneasure was assessed in order to examine the validity of

the nurse rathg of compliance.

b) Phvsical Health Status Rating. Patient health was assessed by mirse-ratings, and by

three objective indices. The recipient's p m nurse-coordinator dso rated the patient's

overall heaith status for a period of 1 year after the surgery, using a 5-point scale. The

Iowest number (1) refmed to exceptionaily good health and the highest (S) , very poor

health. The two nurse's rating questions may be seen in Appendk A

The validity of this health rating was assessed by correlating the nurse's score with

three objective rneasures of physicd hedth, dehed as a) the length of hospitaiization, b)

the number of rejection episodes and c) the total number of hospital admissions. Because

the variables Length of stay in the hospitd, and Number of admissions were positively

skewed, nonpararnetric statistics were used. Kendall's correlations examined the

relationship between the objective variables and the subjective ratings of health. Results

showed that the objective measures were highly correlated among themselves. Two were

positively correlated with the nurse's ratings of health (Tau= .29, .28, p<.0 1), while the

nurnber of rejection episodes was not sigdicantly related to health ratings completed by

the nurse (Tau= . 1 1, p>.05). Results are sumrnarized in Table 2.

c) HeaIth SeIf-re~ort

Short-Fom Health Survev (SF-36x Self-descnption of health was measured using a 36

item self-report questionnaire (Ware & Sherboume? 1992). It rneasures quality of Me and

medicai outcome. It is made up of 9 subscales ident-g various health domains such as

physicd and role hctioning, bodily pain, vitality, social and psychological functioning,

and generai health perception. This questionnaire bas demonstrated good reliabiiity and

validity through a range of medicd conditions (Ware, Snow, Kosinski, Gandek, 1993).

The SF-36 has a test-retest reliability ranging fiom -60 to -81 and an intemal consistency

ranghg nom -78 to -93 (McHorney, Ware, Raczek, 1993). Hïgh scores for each health

domain represent better health compared to low scores.

The SF-36 has been used as part of an ongohg project on quality oflife at the B.C

Transplant Society. The SF-36 is sent to each patient every 2 years. The patients who

completed the SF-36 and were admuiistered the NE0 Personality hventory before their

transplantation were included in the study. The last batch of questionnaires was sent out

in June, 1996. Patients who were transplanted &er this date have not yet completed the

SF-36, and therefore were not part of this data set.

Psychologicd outcome was inferred nom the scde Mental Health, based on items

located within the SF-3 6 subscales of psychological weU-being. The scale Mental Heaith

has demonstrated to be the most valid measure of the psychological portion of the hedth

survey (Ware, Snow, Kosinski, Gandek, 1993). It is made up of 5 questions assessing

feelings of anxiety and depression. Sample items inchde " have you felt so down in the

dumps that nothing could cheer you up?", " have you been a very nemous person?", or

"have you been a happy person?". Responses on the Mental Hedth scale are provided on

a 1-6 scde in which a low score on this scale reflects overali feehgs of anxiety and

depression. The highest and lowest possible scores are converted to O and 100 using the

Transformed Scale Formula, and any scores between these values represent a percentage

of the totd possible score achieved. A score of 100 reflects excelIent mental heaith.

Mean mental health for the general U. S. population is (SD=18) 74.7 (Ware, Snow,

Kosinski, Gandek, 1993).

3) PhvsicaI Health: obiective indicators

Three aspects of the patients' medical condition were used as objective indicators of health

status. These included length of hospitaiization (initiai admission and readmissions

included), number of rejection episodes (counted as the number of doses of antirejection

medication needed for 3 consecutive days between the period of one week to one year

after the surgery), and number of admissions. Each of these measures was routinely

recorded and coded on an ongoing base at the Kealth lnformation Division of the BC

Transplant Society. For the purpose of this study, data conceming these variables was

coliected f?om the records for the year following the surgery. These variables were used

to assess the validity of nurse ratings.

The Trw~splant Process

Patients are first identified by their family physicianç as being potential organ

transplant candidates. They are then referred to the B.C Transplant Society for a

comprehensive rnedical and psychological evaluation in order to determine their suitability

for transplantation. If there are no medical contraindications, the patient's psyc hological

status is evahated to idenw possible psychosocial contraindications which may othervvise

d e out transplantation. In addition, salient psychological factors are identified to assist in

patient management, in an extensive interview. Areas of concem amenable to

psychological interventions are pinpointed with the aim of rnaxhkkg the patient's coping

ability. The i n t e ~ e w is conducted by a clinical psychoIogist who is specialized in the

psychologicd evaluation and treatrnent of transplant patients. The psychological

assessrnent evaiuates the presence of potential contraindications to transplantation,

including such feahires as the presence of major psychopathology unresponsive to

treatment, ongoing aicohol and drug abuse, irreversible and severe neurocognitive

impairment, ongoing medical noncornpliance and lack of availability of social support. In

addition to using a semi-structured clinical interview, psychological tests are admlliistered

and interpreted.

Data used in the study were prùnarily archival except for the 2-item Nursing

Rating Scale which was used to assess each patient's overd cornpliance with the medical

regimen and overall physical health. Archival data were supplieci ffom the B.C. Transplant

Society and the Solid Organ Transplant Outpatient Unit at Vancouver Hospital. Data

coILection is an ongoing normal part of the clinical assessrnent and treatment process. AU

files of transplant patients since 1990 were reviewed, and cases were uicluded if they had

completed the main psychological test, the NE0 Personaiity Inventory, before obtaining

their transplantation.

The NEO-PI-R questionnaire was used by the transplant psychologist fiorn 1990

up to the present. The sample used in this study did not constituted the entire population

of patients transplanted in Vancouver since 1990. A total of 297 patients were

transplanted between January 1990 and February 1997. Among these 297 transplanted

patients, a sample of 69 subjects had completed the NEO-PI-R and had lived at least six

months after the surgery . When deemed necessary, other questionnaires had occasionaiiy

been used in place of the NEO-Personality Inventory, or no questionnaires were used

because of pragmatic reasons. Out of these 69 potential subjects, 4 patients were not

included in the study. Three files had been tramferreci to and one patient died

two weeks &er his transplant. Data for each of the outcome variables were coliected for

a period of one year d e r the date of the patient's transplant surgery. Out of the 65

selected patients, 8 subjects had missing data on the objective health measures as they had

been transplanted within the fast six to nhe months f?om the time of data collection. For

this group, scores had to be pro-rated. For each variable, total scores were divided by the

total number of months that had elapsed since these patients had their surgery, and were

rnultiplied by the number of months left to make up a whole year.

Cardiac transplant patients required special data tramfer because a major

reorçanization of cardiac transplants took place during the penod of data collection.

While the new S t. Paul's Hospital cardiac transplant clinic was being set up, no records

were taken of patients' clinic attendance, although the ch ic was in use. For that reason,

the variable Missed clinical visits was not included in the study with regards to the 19

cardiac patients. Finaiiy, in June 1996, the B.C Transplant Society sent SF-36 questions

to 260 patients out of the total pool of 297, and 50 % responded. 55 questionnaires were

sent to patients included in the present data set, and 33 out of these 55 patients completed

the questionnaires.

RESULTS

Preiiminary Analysis

The means, standard deviations, ranges, and sample size for each variable hcluded

in the hypothesis are summarized in Table 3. The mean values on each of the 4 penonality

traits were in the center ofthe normal range with T-scores n o d y distributed within

three standard deviations fiom the mean. Generally, transplanted patients were

moderately compiiant with the medical regimen and schedded post-

transplant chic visits, and they scored average to below average in their overd health

status as rated by the transplant nurse coordlliator. The means, standard deviations,

ranges, and sample size for variables number of missed appointments, total length of

hospitakation, number of total rejection, and nurnber of admission for one year followuig

the surgery are presented in Table 3.

Distributions. At a univariate level, all variables were normally distibuted with the

exception of length of hospitabation and number of admission. Nonparametric statistics

were used where necessary to correct the positive skew of these variables. At a

rnuitivariate level regression diagnostic measures were performed to evaluate nomality

and equality of variances.

Controls. A number of steps were taken to make sure that the type of organ did

not interfere with the relationship between personality and outcornes. An analysis of

variance on the absolute values of the residuals was first perfonned with organ type as the

between-participants factor in order to see if the factor Organ had a main effect on the

outcome variables. To achieve this, nine separate regressions were conducted where each

outcome variable was regressed on the predictors independently for each organ group.

With the exception of the cnterion Health, the results of these analyses indicated that the

residuals for each organ group were comparable and therefore that each group had similar

regression equation for each variable. The potentid existence of an interaction was further

examined by creating two extra predictors with dummy code variables. Subsequently an F

test was performed on the mean square's change between the residuds nim of squares of

the combined groups including the 6 predictors and the sum ofeach organ residuai sum of

square. None of the F tests were significant. The three types of organ groups were

pooled together for the Pearson product moment correlations, multiple regression, and

hierarchical regression analyses.

Pearson product moment correlations were conducted to d y z e the zero-order

relationships between the predictors and outcorne variables used in the hypothesis-testing.

Results, as presented in Table 4, showed a negative correlation between age and

cornpliance (g = -3 1; E S.0 1 .). Older transplanted recipients were more cornpliant with

the medical regùnen than younger aansplanted patients. Patients with higher scores on the

trait Neuroticism were rated by the nurse coordinator as having poorer health than patients

s c o ~ g lower on the neuroticism domain (r = -28; p < -05.). Patients who were more

open to experiences were more agreeable but less conscientious = -3 1; 4-26; g .OS).

FinaUy, the less conscientious patients obtained higher scores on the mental health scde (1

= -.35; E s.05.); that is, patients with low scores on conscientiousness or, in other terms,

who were in general less motivated and more disorganized, report feeling happier and

calmer than conscientious recipients. All other results were not sigrificant.

The conventiod indices for small., medium, and large effea sizes for product

moment correlations are .IO, -30, and -50 (Cohen, 1992, p. 157). The correlations

described in Table 4 represent smai! to maidy medium effect size. According to Cohen

(1992) a medium effect size would be discernible to the "naked eye" of the attentive

observer.

Table 3

Means. Standard Deviatioas. Rances. and Sample Size for Neuroticism Apeableness.

Conscientiousness. Openness. Compliance. Health and Mental heaith

Variable

--

Range - n

Predictor variable (NEO-PI-R)

Neuroticisrn 50.77 (1 1.03)

Agreeableness 52.94 (9.88)

Conscientiousness 47.26 (10.71)

ûpenness 50.68 (10.49)

Outcome variable

Cornpliance (rated 1-5) 2.52 (1.05)

Physical Health (rated 1-5) 3.38 (-80)

Mental Kealth (SF-36) 77.22 (16.93)

Index of vatidity for cornpliance and physical health indices

Number of missed appointments 1.02 (1 -00)

Number of days in hospital 46.33 (39.32)

Nurnber of rejection episodes 1.30 (1.35)

Number of admissions 2.80 (1 -77)

Table 4

Pearson Product Moment Correlations for Age. Status. Neuroticism. A.greeableness,

Conscientiousness. Openness. Compliance. Health and Mental heaith.

1. Age

2. Status

3. Neuroticism

4. Agreeableness

5. Conscientiousness

6. ûpenness

7. Compliance

8. HeaIth

9. Mental heaIth

Note. *g 5 -05; * *E 1 .O 1.

Rewession Analyses

Three multiple regression analyses were performed in order to assess the amount

of total variance contributed by the four predictor variables for each of the three outcome

variables. The results of the regression analyses are summarized in Tables 5 to 7. None of

the three regressions were si@cant. However, the outcome variable mental heaith was

the best predicted by personality (F = 2.3; ~5.08). Twenty-four percent of the variance in

mental health was predicted by personality. More specitically, there was a tendency for

low cooscientiousness and high agreeableness to predict improved psychological statu

@S10). Finally, although the regression equation for cornpliance was not si@cant, the

Beta weight for agreeableness was moderately related to compliance.

a') Type of orean and outcome

Preliminary analyses showed a main eEect of organ (heart) on physical health. The

regression analyses were repeated to assess the best predictors ofhealth, controlling for

organ. Regressions for the liver and heart group showed the identical pattern of results.

In these two groups, neuroticism was the best predictor ofphysical health. These results

did not hold for the Lung group.

b) Effects of aee

In addition to the theoretical prediction that health may partly depend on the age of

the recipient, prelirninary analysis also showed that age was signincantly correlated with

compliance. In order to control for potential nuisance variables, the amount of unique

variance for each outcome variable contributed by the four personaiity predictors was

estimated using three hierarchicd regressions while controlling for the effect of age. In

order to assess the amount of variance accounted for by the predictors, as a first step, age

was entered in the regression equation. In a second step analysis, the predictors were

entered in a randorn order. The results of these three hierarchicai regression analyses are

show in Tables 8 to 11. Analyses showed s i d a r patterns of results to those perfomed

Table 5

Summaq of Multiple Remession Anaiysis for Variables Predictinp Cornpliance @Mis)

Variable

Neuroticism

Agreeableness

Conscientiousness

Opemess

Note. R ~ = -06 * g i 10

Table 6

Sumrnary of Multiple Remession AnaIvsis for Variables Predictinp Phvsical Health (N=65)

- - - - --

Variable B SE B P

- - -- -

Neuroticism -.O2 .O L .29*

Agreeableness -.O0 .O 1 .O 1

Conscientiousness -. O0 .O1 -.O7

Openness .O0 .O 1 -01

Note. ~ ~ = . 0 8 . * p 1 -05.

Table 7

Sumrnary of Multiple Regession Anaiysis for Variables Predicting Mental Health M=33)

Variable - B -- SE B P

Neuroticism .23 -22 -17

Conscientiousness

Opemess

Note. IX2=.24. *p L -10.

Table 8

Summary of Hierarchical Remession Anal~sis for Variables Predicting Comvliance while

Controllhg for the Effects of Aee

Step 1

Age -.O3 .O 1 -.3 1"

Step 2

Neuroticism -.O 1 .O 1 -. 09

Agreeableness -.O2 .O1 -. 19

Conscientiousness -.O I .O 1 -.O7

Opemess .O 1 .O 1 . I l

Note. R ~ = .O9 for Step 1; m2= -13 for Step 2 @s 2 .OS). * g 1 -05.

Table 9

Summarv of fierarchical Regsession Analvsis for Variables Predicting HeaIth while

Controllina for the Effects of Age (N=65)

Variable

Step 1

Age . O0 .O 1

Step 2

Neuroticisrn .O2 .O 1

Agreeableness .O0 -01.

Conscientiousness -.O0 .O 1

Openness .O0 .O1

Note. R ~ = -00 for Step 1; m2= .O9 for Step 2 @S > -05).

Table 10

S u r n m q of Hierarchicd Remession Analvsis for Variables Predictina Mental Health

while Controlhe for the Effects of Ane CN=33)

Variable

Step 1

Age .O6

Step 2

Neuroticism -26 -24

Agreeableness .54 -3 1

C onscientisusness -.46 -26

Opemess -.45 .28

Note. R'= -00 for Step 1; A&= -25 for Step 2 @s 2 -05). * p 1 -10.

Table I l

Kendali Correlations for Neuroticism. Number of D a ~ s in Hospital, Number of Reiection

Episode. Number of Admission.

Neuro ticisrn

1. Number of days in hospitd

2. Number of rejection episodes

3. Number of admission

Note. *E -05.

without controifing for age. Medical status was not controlled for because of the lack of

variability in the scores. 75 % of the patients were at a high level of health fllnctioning

when they were placed on the waiting list-

DiSCUS SION

The goal of this study was to understand the relationship between personality and

organ transplant nirgery outcome, and to d e t e d e what aspects of personality were rnost

useil in predicting surgery outcornes. By i d e n m g in advance the patients at higher risk

for poor outcome because of certain personality characteristics, hospital staff could more

closely monitor and prepare the patient for the surgery, and hence increase probability of

successfùl outcome as well as ensuring the effective use of a scarce resource.

Contrary to predictions, personality did not significantly predict cornpliance rate in

organ recipients d e r the transplantation, nor did it signillcantly predict level of health or

mental health. No more than 25% of the variance in mental health could be predicted by

personality. The patient's age accounted for a significant proportion of the variance in

cornpliance. When age was controlled through hierarchical regressions, the pattern of

results did not signifïcantly change. Multiple regression analyses performed separately for

organ type on health outcome did not reveai any difZerent results, and in general, the

regression analyses did not clan@ the relationship between personality and the outcorne

variables. Pearson correlation analyses however showed that different personaiity

dimensions have dzerent patterns of association with the measures of outcome.

With respect to the relation between neuroticism and nurse's rating of health,

results showed a sigdïcant positive correlation between these two variables. Organ

recipients who tended to have a higher neuroticism score had higher symptom scores on

the nurses' rating of health measure. One interpretation is that patients with high

neuroticism tend to wony and be more irritable, and therefore are more Likely to report

any symptoms to the nurse-coordinator when coming to the outpatient chic. In other

words, the nurse's rating may have been affected by the patient's perception of his or her

health, and not by his or her actual health. This interpretation may also explain why there

were no relationships between neuroticism and the objective rneasures of health (see Table

1 1 ). A study by Costa and McCrae (1992) supports this interpretation They found that

neurotic patients may be more likely to have somatic concem because their anxiety makes

them more sensitive to physiological cues and they interpret these as sign of ilhess. This

would ais0 make them more prone to report symptorns and to seek help. This

interpretation only explains one portion of the results.

The nurses' rating of health was significantly correlated with the objective

rneasures of physical heaith, total number of days spent in the hospital, and total number of

admissions. These significant correlations not only validate the subjective rating scale for

health, but also suggest that the nurse was iduenced by both the personality of the patient

and the actud heaith of the recipient in making her ratings. In a shidy by Gibson and

Cook (1996), the role of p e r s o d t y in answering health questionnaires was emphasized.

They concluded that these questionnaires may be more often an indirect measure of health,

and therefore, it is important to develop health questionnaires with good extemal

validation through the use o f objective meanires The present study seems to have been

successful in discrimùlating health nom personality features of psychosornatization.

Future decisions regarding organ transplant should include both subjective and objective

means in order to assess health.

Previous studies looking at the association between neuroticism and health have

also shown that another part of the explmation for this relationship could be that

neuroticism puts patients more at risk to engage in unhealthy behaviors (Costa & lMcCrae,

1987). In the present study, cornpliance was operationalized as adherence to medications

and scheduled visits to the outpatient unit. The measure did not assess more remote

health-related behaviors such as failure to quit smoking or to follow diet regimens. Not

aitendhg ciinic appohtments may not have as serious implications as fading to quit

smoking or abstaining f b m drinking, or not looking after one's physical and emotional

health. Research looking at the cause of the iink between neuroticism and ilhess should

use meanires that better discriminate between this range of behaviors.

Pearson correlations revealed a sigdicant association between age and

compliance. Older organ recipients adhered more with the medical regimen and scheduled

outpatient visits. In the organ transplant literature, studies have proposed that

demographic factors, nich as age, may play an etiological role in compliance. However,

because results have been inconclusive regarding these variables, research attention has

moved to psychosocial and situational factors as possible etiological explamtion of

cornpliance. In te- of the present study, one possible expianation is that older patients

had more tirne available to attend the visits on a regular base, and hence were less likely to

miss their scheduled visits. However, this study was not able to mess the reason why

people missed their visits, and did not examine ifthere were dinerences in compliance

between the first three months after the surgery, which requires patients to attend the

ch i c on a regular basis, and the foUowing nine months. In addition, missed scheduled

visits may not always reffect poor compiiance. There were no records of patients

notification of canceliation of theû appointments at the SOT, nor any notes regarding the

nature of the cancellation. In fiture studies, it would be valuable to obtain more

information on the reason for patients missing clinical appointments. This would allow

better discrimination between those who tmiy codd not make it and those who had no

valid excuse.

An interestirtg f inhg was the tendency for patients with higher agreeableness

scores to be rated as more cornpliant by the nurses' rating. While the research fiterature has

rnainly looked at the effect of conscientiousness on compiiance, it seerns that

agreeableness could alsu play a role in treatment adherence because agreeable patients wiil

conform to other's wishes and be cooperative. For example, Neuser (1988) proposes the

ex-planation that by cornplying with the medical regimen and clinical visits those patients

who depend more on social recognition are more Wely to be helped and recognized.

Other studies have suggested that agreeableness predicts good health habits because

agreeable patients are less hostile and less Likely to be confiontational. These qualities may

facilitate the development of a treatment alliance (Costa, 1992; Booth-Kewtey & %ckers,

1994). To evaiuate this interpretation, future research lookîng at the predictive role of

agreeableness on compliance could assess the hospital staff in order to evaluate the quality

of the treatment alliance between each patient and his or her treating physician or nurse.

Finally, this study relied on a global rating of compliance whîch rnay not have

discriminated potential pro blems in complying with treatment regimes. In addition, less

conscientious patients may have been reminded more ofien by their caretaker or the

hospital staff to attend the outpatient unit or th& take medication. For these reasons,

M e r investigation of the possibility that health behaviors may implicate different

etiological factors or distinct personality traits should increase our understanding of the

influence of personality on compliance.

Among these patients, there were interesthg relationships between some general

personality traits and overall mental health. Patients who scored lower on the

Conscientious and Openness to experience scales were more likely to report better overd

mental health. That is, those who were less conscientious and less open to expenence

reported feeling calmer and happier than those who were more conscientious and more

open to experience. In psychoanalytic theory, too much conscientiousness is viewed as

being detrimentai to one's psychological health because it indicates the presence of a

powerfd punitive superego (Hogan & Ones, 1997). Despite this, more generally,

conscientious Uidividuals are often characterized as better at planning, organizhg and

compleiing tasks, whereas unconscientious inaividuals as more careless, disorganized, and

unreliable (Costa & McCrae, 1992), wfüch should relate to mental health. The

relationship between mental health and conscientiousness, as defhed by Costa and

McCrae, was investigated recently in a study showing that low conscientiousness

predicted depression (Anderson & McLean., 1997). The explmation was that low

conscientiousness tended to be related to poor task performance which would lead to a

higher incidence of expenencing performance failure, further leading to negative self-

perception and hence depression. Because this study did not use a prospective design it is

not clear if the low levef of conscientiousness among the depressed played an etiological

role in the depression or instead resulted ftom the cognitive distortions which tend to

characterize depressed patients. In the present study, patients scoring lower on

conscientiousness may have been more relaxed and less achievement-onented and these

characteristics may be more compatible with Life after the transplant, which is fidl of

uncertainty because of the continual presence of health nsks such as grafk rejections,

infections, immunosuppressants side effects, or secondas, ihess. The surgery itself may

have infiuenced patient's level of conscientiousness. Change in conscientiousness as a

result of going through a Me-saving surgeq would have been useful to assess. People

may change their attitude toward We, which may then have an impact on conscientious

behaviors.

Patients who scored lower on Opemess to experience tended to report better

mental health. In general low-openness individuals tend to prefer the familiar and do not

need to constantly try different activities. They may therefore feel less challenged or

hstrated by a treatment regimen which imposes many restrictions on behavior. In

contrast, people scoring high on Openness to experience may experience more hstrations

in the face of a restricted post-transplant treatment regimen. Costa and McCrae (1980)

have also proposed that "being open is a double-edged sword" in that open individuals

ampli@ both positive and negative emotions and are therefore more prone to affective

variability. Because people s c o ~ g higher on Opemess to experience tend to question

and explore ideas more deepfy, this questionhg may lead them to feel less satisfïed with

themselves or less able to fom a coherent picture of the world. This last explanation rnay

provide an alternative explanation to why high Openness is correlated to more fiequent

self-report of anxiety and depression in the present study.

Limitations of Present Researc h

This study is huidered by Limitations in its design and methods. First, personality

data were obtained through self-report measures. The Revised NE0 Persodty Inventory

does not include validity scales to test for confounds such as social desirabifity or

inconsistency. D u ~ g the transplant procedure, clear statements are made regarding the

purpose of the psychological assessrnent in trying to evaluate patient's suitability for

transplantaiion, and patients are £ùlly informed about the nsks and benefits of the nirgery

Within that context, patients' self-report of their personality may have been afEected by a

deliberate attempt to bias the results in order to increase their chance ofbeing placed on

the organ transplant waiting List, and may as a result lack validrty. Aithough Costa and

McCrae (1997) are fairly skeptical about the use of validity scales among normal

populations, they do recognize that in selection and some clinical settings the motivation

to make a good impression is more powerfil. In the present study, the distribution for

each personality domain was normally distnbuted, suggesting the absence of a major

source ofbias. The validity of the NEO-PI-R was also indirectly controiled because it was

administered in conjunction with a semi-stnictured i n t e ~ e w by the transplant

psychologist, and any discrepancies between the personality profile and the clinical

impression would Likely have b e n detected. Overall, 1 beiieve that the NEO-PI-R is a

valid questionnaire for the purpose of tbis study.

Another feature of the study that could have been improved concem the outcorne

variables. Multiple sources for outcorne ratings woufd be expected to increase the

reliability and validity of these measures. Although the nurses' rating of compliance was

fairly valid, as show by its correlation with the number of missed scheduied

appointments, it was a single score, and a more complex measure might have provided

more complex detail about compliance. Compiiance is a complex construct constituted of

many domains and there is no standardized m u r e . Transplant patients are required to

comply with many treatment orders. Discharged patients must take immunosuppressant

rnedications, attend outpatient ch ic appointments, follow a strict dietaxy reojmq

exercise, and when needed, stop smoking and drinkuig. These behaviors c m be

operationalized in dinerent ways, &OM medical record review, caregiver or nurse

practitioner interview, to piiicount or biological assays. The nurses' rating of compliance

focused on only one general judgment of cornpliance and therefore did not discriminate

compliance problems in one area versus another. This study therefore may not have

recognized those patients who were noncornpliant in other important domains. Future

research on currpliance could include multiple measures of compliance and broader

coverage of the constnict in order to include a more representative sample ofthe

noncom pliant population

A lirr?itation to the design of the study was the potential confounding variables that

were not controlled by Wtue of the nature of this study. For example, in addition to an

increase in overail compliance rate because of better patient setection over the las several

years, the hospitai stafYhave been more closely m o n i t o ~ g patients' behaviors, to seek to

i d e n e those who may be at risk for noncornpliance. For patients scoring low on

conscientiousness, social support becomes more crucial. As they may be l a c h g in the

trait promoting treatment adherence, extemal reminders, prompthg and encouragement

provided by sigdicant others becorne aii the more important. It is possible that low

conscientiousness patients who lack the intemal structure associated with treatment

compliance were cornpensated by extemal structure suppiied by a stable form of social

support.

Because of its bias in screening patients to select those most probable to be

successfùi and the use of only liver, heart, and lung recipients, this shidy has limited

extemal vaiidity. Patients who were suspected to have more extrerne persomiity features

or psychopathobgy and pathology were not given the NEO-PI-R and therefore were not

included in this sample. However, this decision did not exclude them fkom being

transplanted. The rationale for this transplant team decision was that a questionnaire such

as the NEO-PI-R tests normal personality and would not detect more serious

psychological and personality problems. Ot her f o m of questionnaires were given to

patients suspected to have more senous psychological problems. In the future, it would be

important to include aü transplant patients, includmg those suspected to have more

problematic personality, in order to study the effects of personaiity features on surgery

outcornes. In addition, it would be valuable to include patients who had more complex

surgeries, such as heart-lung or double-lung surgery, so that the results could be

generalized to other populations of organ recipients. Findy, each hospitd has its own

screening process and characteristic staE For that reason, fhre research should examine

personality predictors of transplantation outcome across settings. These changes wouid

increase the extemal validity of research done in this area.

A third Limitation relating to the design of the study is the mail sarnple size. Due

to the limited nurnber of patients being transplanted every month, and the recent

introduction of personality testing at the B.C Transplant Socîm, this sample size was

srnalier than would have been ideal and did not include heart-Iung and double-lung

patients. A total amount of 297 patients were transplanted between the period of 1990

and February 1997, including 13 8 liver, 10 1 heart, 27 single Img patients. Out of this

number, only 65 patients were included in the study as only that number had cornpleted

the NEO-PI-R

Although there were some associations between certain personality traits and

outcorne variables, personality did not significantly predict surgery outcomes within this

smdl group. As already mentioned above, better measures and control of nuisance

factors, a more heterogeneous group, and a Iarger sample could increase the power of

h r e research done in this area.

Conclusion

The ever-widening gap between the needs of potentiai organ recipients and

available donor organs has forced the medical community to engage in carefùl transplant

candidate selection. By detecthg personality factors associated with post-transplant

outcome, appropriate psycho-educational interventions can be hplemented to help

maximize favorable treatment outcornes. Better predictive data codd help ensure that

patients who need more intensive attention and foiIow-up Eom the transplant team could

be detected early. Patients at higher risk for poor outcome d e r the transplant could

therefore be beîter prepared to cope with the surgery, codd be more closely monitored by

health care providers and sources of social support, in order to help them cope with the

inevitable pre and post-transplant stresses. Such findings would allow health care workers

to design interventions that wiU promote heaith-enhancing behaviors, whüe reducïng high

nsk behaviors, therefore ma>amizing the effective use of a scarce and precious resource.

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Patient Name: File Number: Name of patient's transplant nurse-coordinator:

A) Please, rate the extent to which you feel this patient has been cornpliant with the medical regimen and scheduled post-transplant clinic visit s :

1 2 3 4 5 Exceptional& Highiy Modzrateiy Pcmriy Very Poorly

cornpliant coqliant compliant cotapliant cornpliant

B) Please, rate the patient's overall hedth status for a period of 6 months d e r the surgery:

1 2 3 4 5 Exceptional Good Moderate Poor Very Poor

C) In the following space, please write any comments you may have regardhg your a m e r to question A) and/or B):

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