when they are considering a physicians' referral to a physician or hospital. People search for information from sources that are easily accessible, in location, time, and monetary costs, and they continue their searches longer when the sources of information are accessible than when the information is hard to obtain.

Releasing new information through multiple forms of the mass media increases its accessibility. The release of hospital mortality statistics by HCFA is a step in that direction. Those statistics were reported not only in the print media, but also on the radio and television (see ch. 4). Another step might be to make quality-related information continuously accessible to consumers in hard copy and through computer terminals in libraries, senior citizen centers, adult education centers, community centers, and other facilities. Hard copy information could be provided to physicians, particularly referral physicians; this would assist them to make wise referral choices and to help patients who want the information interpreted. Cable television exposures could be considered as could "hot lines" that could provide a source of continuous information.

The acceptance of information on the quality of a providers' care is increased when it is accessible in familiar settings, such as libraries and senior citizen centers, where needed social support is present. Studies of consumers' reasons for choosing health services indicate that consumers often rely on the recommendations of friends and relatives; lay opinions and social networks play an important role in the evaluation and decision processes regarding choice of physicians and hospitals. Consumers need social support from peers, family, and friends in making choices of health providers. Expert-based information may seem less foreign if it is presented in familiar settings.

Social support helps reinforce a behavior change. The sources of reinforcement, which include family, peer groups, teachers, employers, health providers and the media, vary with the change being considered (262). The particular groups needed for some choices have been identified. A review of 150 articles on nutrition found that people need not only information but also support and followup reinforcement from fam

ily, friends, and primary care physicians in making choices about nutritional intake (252). Furthermore, the relative importance of particular support groups has been established for a few behaviors in certain settings. Adolescent drug-taking behavior, for example, is most influenced by approval from friends (321), especially a best friend (338a). Sources of support when making choices about providers on quality grounds and their relative importance are other areas that need to be examined.

Provide Consumers the Skills To Use and Physicians the Skills To Provide Information on the Quality of Care

Specific skills are required for consumers to be able to use effectively information on the quality of care that they have acquired. Knowledge alone is not sufficient. If the purpose of providing information is to change health behavior, certain knowledge about how to follow the physician's advice is essential (62). If the purpose of providing information on indicators of quality is to assist consumers in choosing physicians and hospitals, consumers will need skills or assistance in interpreting the information and in asking questions about its significance in individual situations. Physicians are likely sources of such information.

Consumers who call on their physicians for assistance in interpreting the meaning and use of indicators of the quality of care need skills to ques

tion them. Although some consumers are hesitant to question physicians, two experimental studies demonstrate that patients can successfully be "coached" to ask more questions of physicians and to secure more information about their conditions and treatments (264,540). Consumers need the

'Some organizations have started to provide information to consumers on how to ask questions of physicians, e.g., the National Women's Health Network has a publication "Plaintext DoctorPatient Checklist," which lists questions to ask physicians during an appointment (458). A publisher, Krames Communications, issues a comic-book format brochure, "Asking Questions: For Only

skills to make them capable of asking the right question. In addition, physicians must be willing and able to provide help and interpretation. Some physicians might benefit from continuing education to make them aware of their patients' desire for information and to acquire the skills and resources to answer their patients' questions. Physicians need skills to ensure that the desired information has been transmitted.

the Best Health Care," with types of questions for patients to ask physicians during different types of encounters (358).