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Medical & Health Psychology Ch.


Chapter 1: What is health?

What is health? Changing perspectives
The World Health Organization defines health as: A state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity (1947).

Mind-body relationships
Hippocrates divided attributed health to 4 circulating bodily fluids (humours): If healthy, the
four would be in balance. Galen (2nd century) then argued that the body and mind were
considered as one unit (interrelated: physical and mental disturbances have an underlying
physical cause). During the Renaissance, the understanding of the human body became more
organic/ physiological, with little room for psychological explanations.
Dualism entails that the mind is considered to be non-material and the body as material. It
developed the notion of the body as a machine (mechanistic viewpoint).

Biomedical model of illness

In this model, health entails the absence of a disease, and any symptom of illness is thought to
have an underlying pathology that could be cured through medical intervention.

Challenging dualism: Psychosocial models of health and illness

There is one type of stuff (monist), but it can be perceived objectively or subjectively. Freud
redefined the mind-body problem as one of consciousness. According to this, the unconscious
conflicts which had been repressed are considered to cause the physical disturbances.

Biopsychosocial model of illness

This model emphasizes the interaction between body and mind, between biological processes
and psychological and social influences. Health is more than simply the absence of disease, as
psychological, behavioral, and social factors can add to the biological/biomedical

Individual, cultural, and lifespan perspectives on health

Lay theories of health
- Bauman (1961): People make 3 main types health:
- A general sense of well-being
- The absence of symptoms of disease
- The things that one who is physically fit is able to do

Other views on health include as a reserve, and as physical fitness and vitality, as a mental
state, and as a function (to perform ones duties).
Health is generally viewed as a state of equilibrium across various aspects of the person,
encompassing physical, psychological, emotional, and social well-being. It does seem that
health is considered differently when it is no longer present (so it is good when nothing is
wrong) or when a person is behaving in a health-protective manner.

Cross-cultural perspectives on health

What is considered to be normal health varies across cultures and as a result of the
economic, political and cultural climate of the era in which a person lives. Collectivist
cultures emphasize group needs, while cultures that promote an independent self are more
likely to view health in terms of social functioning rather than simply personal functioning,
fitness, etc.
Next to this, it is noted that Western medicine dominates.
Lifespan, ageing, and beliefs about health and illness
Growing older may be associated with decreased functioning and increased disability or
dependence. The developmental process is a function of the interaction between three factors:
- Learning (relatively permanent change in knowledge/skill/ability)
- Experience (what we do/see/hear/feel/think)
- Maturation (thought/behavior/physical growth, genetically determined sequence)

Piaget proposed a framework for understanding cognitive development:

- Sensorimotor (birth-2 yrs): sensations, movement; lacking symbolic thought
- Preoperational (2-7 yrs): symbolic thought (awareness of how they can affect the
external world through imitation and learning), simple logical thinking and language
not very sympathetic to an ill family member
- Concrete operational (7-11 yrs): abstract thought and logic, manipulation of objects
- Formal operational (12-adulthood): abstract thought, imagination, deductive reasoning

It is important for children to learn how to maintain their own health. Under-7s generally
explain illness on a magical level. Children over 7 can think logically about objects and
events, but are unable to distinguish between mind and body until age 11 (illness is within
the body).

Adulthood tends to be divided between early (17-40), middle age (40-60) and elderly (60/65).
They are less likely than adolescents to adopt new health-risk behavior and are generally more
likely to engage in protective behavior. Middle age has been identified as a period of doubts
and anxiety, reappraisal and change, some of it triggered by uncertainty of roles when
children become adults and leave home, some of it triggered by awareness of physical
changes. Positive health behavior changes may follow.

Bowling & Iliffe (2006) describe 5 progressively more inclusive models of successful aging:
- Biomedical model (physical and psychiatric functioning)
- Broader biomedical model (^ and social engagement + activity)
- Social functioning model (nature and frequency of social functioning)
- Psychological resources model (personal characteristics of optimism and self-efficacy,
sense of purpose, coping and problem solving, self-confidence and self-worth)
- Lay model (socio-economic variables of income and perceived social capital)

What is health psychology?

Psychology can be defined as the scientific study of mental and behavioral functioning.
Psychology aims to describe, explain, predict and, where possible, intervene to control/modify
behavior and mental processes (language, memory, perception etc.). Health psychology
emerged in the late 1970s and takes a biopsychosocial approach to health and illness.

Main goals of health psychology:

- The promotion and maintenance of health
- Improving health-care systems and health policy
- The prevention and treatment of illness
- The causes of illness (risk factors, vulnerability)

Psychosomatic = the mind and body are both involved in illness, they act together (not just
the mind) where an organic cause is not easily identified, the mind may offer a trigger of a
physical response that is detectable and measurable.
Psychogenic = illnesses with no physical evidence.
Illnesses are often viewed as psychophysiological with increased acceptance that
psychological factors can affect any physical condition.

Behavioral principles (classical/operant conditioning) can be applied to experimentally

evaluate techniques of prevention, rehabilitation, and treatment.

Clinical psychology
Clinical psychology is concerned with mental health and the diagnosis and treatment of
mental health problems using behavioral and cognitive principles.

Chapter 2: Health inequalities

Health differentials
Where we live can impact on our risk for disease as much, if not more than, how we live.
People in ethnic minorities still tend to be less well off than the majority population, and may
suffer adverse health effects as a result of their ethnicity + socio-economic position. Many
individuals face multiple advantages or disadvantages as a result of occupying several social

Evidence of health differentials

Almost all the countries whose populations experience the shortest life expectancy are in
Africa. Nearly 1/3 of deaths in the developing countries occur before the age of 5.
People in developing countries experience significant health risks from lack of safe water,
poor sanitation, inadequate diet, indoor smoke from solid fuels, and poor access to health
care. Major killers among the adult population include being underweight, tuberculosis, and
malaria. But also war is a big killer.

Even the haves experience health differentials

The richer people within most industrialized countries are likely to live longer than the less
well off and are healthier while alive.

Explanations of socio-economic health inequalities

There is a social explanation and a more individual one:
- Social causation model: low social-economic status causes health problems
- Social drift model: when an individual develops a health problem, it influences SES
Studies found that baseline measures of SES predict subsequent health status, while health
status is less able to predict SES.

People in lower socio-economic groups engage in more health-damaging and less health-
promoting behavior than those in the higher socio-economic groups. This does not appear to
be the result of lack of knowledge, but it is considered to be a deliberate choice based on a
evaluation of the costs and benefits of such behaviors.
In addition, the environment in which these groups live are risk factors (e.g. working in
dangerous settings and low-quality housing). Environmental factors may also work through
social and psychological pathways. For instance, negative social comparisons appears to have
a direct effect on self-esteem, anxiety, and depression, which may in turn influence health.
Next to this, differences in stress experienced as a result of various factors may contribute to
differences in health across the social groups (stress hypothesis).
Access to health care is likely differing according to personal characteristics and the system
with which the individual attempts to act. People with lower SES access health care more
frequently than those with high SES which suggests that theres no economic division in

Work-life balance and stress, and unemployment

3 key factors that contribute to work stress (Karasek & Theorell, 1990) are:
- Demands
- Degree of freedom (autonomy to make choices about how to best cope with demands)
- Degree of available social support
High levels of demand + high levels of freedom + good social support = less stress.
A combination of low SES and high-stress job increases the risk of developing for instance
CHD more than having a high-stress job and high SES. In addition, the impact of
unemployment is worst or those with little savings / financial security.

Minority status and health

Explanations for correlations:
1. The behavioral hypothesis suggests that variations in health outcomes might be
explained by differences in behavior across ethnic groups.
2. The psychosocial impact of occupying minority status (e.g. generally experiencing
more stress due to discrimination).
3. Problems accessing health care: lower quality or less desirable services.

Gender and health

Biological and behavioral differences, as well as economic and social factors

Women Men
Greater life expectancy More likely to die from CHD, violence,
(industrialized countries) death penalty (US)
Appear to have greater resistance to Contact medical services less frequently
infections (even when necessary)
Consume less alcohol across a range of Report higher levels of self-rated health
countries (and less likely to volume drinking)
More likely to be abstinent Smoke more
Eat more vegetables and fruit Eat more meat
Social isolation: Traditional masculine beliefs (independent,
- Less likely to drive / access to a car self-reliant, strong, tough)
- More likely to be widowed /live

More vulnerable to disrupted or poor social

Chapter 3: Health-risk behavior

What is health behavior?

The generally adopted view in research of health behavior is: that what is associated with an
individuals health status, regardless of current health and motivations.
Other definitions include:
- Any activity undertaken by a person believing themselves to be healthy for the
purposes of preventing disease or detecting it at an asymptomatic stage, purely to
prevent their chance of disease onset (Kasl & Cobb, 1966)
- Behavior performed by an individual, regardless of his/her perceived health status,
with the purpose of protecting, promoting or maintaining his/her health (Harris &
Guten, 1979)
- Behavioral pathogens (health-risk behavior) and behavioral immunogen (health-
protective behavior) (Matarazzo, 1984)

Key behavioral factors associated with health (Alameda seven): sleeping 7-8 hours a night,
not smoking, consuming no more than 1-2 alcoholic drinks per day, getting regular exercise,
not eating between meals, eating breakfast, and being 10% overweight. However, in re-
analyses, not snacking or not eating breakfast was not related to mortality.

Health-risk behavior
Although specific health risks may vary across the world, there are many commonalities.

Smoking, drinking, and illicit drug use

Smoking, alcohol consumption, and illicit drug use are leading risks for global deaths and
disease, and have significant addition potential as well as social consequences.
Morbidity = costs associated with illness (e.g. disability, injury).

After caffeine and alcohol, nicotine is the most commonly used psychoactive drug in society
today. Many tobacco companies and governments are provided with a vast income as a result
of tobacco tax.
As well as culture, there are age differences in prevalence. Amongst the more elderly,
smoking was initiated before the medical evidence as to the health-damaging effects of
smoking was clear and publicly available.

Alcohol is considered an integral part of many life events, therefore social use of it is
widespread. Different individuals respond differently to the same amount of alcohol intake,
depending on factors such as body weight, food intake, metabolism, the social context, and
the cognitions and expectations. The European Commission refer to safe levels as being under
40g of alcohol a day for men (4 drinks) and under 20g for women (2 drinks).

Very few go on to use illegal drugs regularly, but cannabis is the most commonly used.

Negative health effects

Smoking: Approximately 5 million deaths per year worldwide. Carbon monoxide reduces
circulating oxygen in the blood (so also less oxygen feeding the heart muscles) and nicotine
increases blood pressure and heart rate (therefore making the heart work harder). COPD is a
common disease, and also passive smoking has led to serious consequences.
Alcohol: Commonly perceived as a stimulant, but in fact it is a central nervous system
depressant. Low doses cause behavioral disinhibition, but high levels of intoxication lead to a
25x increase in the likelihood of an accident or respiratory rate (causing coma and death).
Approximately 1/3 of men and of women exceed national drinking guidelines. Amongst
students at university, drinking is a social behavior but has been associated with poor
academic performance, relationship breakdowns, and unplanned/unprotected sex.

Alcohols relationship to CHD, stroke, and diabetes mellitus is in fact a beneficial one. The
key term in experiencing any benefits from drinking is moderate ingestion of alcohol.
Moderate intake of red wine has been associated with reduced cardiovascular deaths (red
grapes contain flavonol which protects arteries from cholesterol).

Drug use: The method of ingestion (perhaps more than the substances itself) has led people to
associated some forms of drug use (injection) with serious diseases (HIV and Hepatitis C).
The health burden of addiction predominates amongst younger people.

Why do people initiate potentially addictive substances use behaviors?

- Genetics: In smoking there is some evidence of genetic factors in combination with
dopamine, it is unlikely however that any genetic influences function in isolation
- Curiosity
- Modelling, social learning, reinforcement: Family behavior and dynamics increase the
preparedness and reduce perceptions of risk
- Social pressure: Preferring to see the behavior as something they selected to do
- Image and reputation: Wanting to fit in, be seen to be sociable
- Self concept and self-esteem: What one is and ones value/worth
- Weight control: A motive for smoking initiation and maintenance
- Risk-taking propensity: In a larger array of risk-taking/problem behavior, incl. theft
- Health cognitions: Expectancies of stress relief, anxiety reduction, other benefits
- Stress: Depressive symptomatology in smoking onset

Continuing unhealthy behavior and developing dependency

Dependence model: only a small number of people will become dependent on X (e.g.
alcohol). Main aspects include:
- Genetics and family history
- Pre-existence of certain psychopathology (e.g. mood disorders)
- Social learning (something is socially acquired and learned, received reinforcement)

For smoking, few people succeed in remaining casual/social smokers. The addictive potential
derives from the biologically addictive properties (e.g. nicotine acts as a brain stimulant which
activates reward pathways). There is a need for nicotine in order to avoid withdrawal
symptoms (physical and psychological).

People who continue explain this by:

- Pleasure/enjoyment of the behavior
- Habit formation
- A form of stress self-management
- A lack of belief in ability to stop (self-efficacy)
Behavior cessation
Even people who stop smoking when 50-60 yrs can avoid most of their subsequent risk of
developing lung cancer or other smoking-related disease or disability; stopped when aged 30
leads to >90% of lung cancer risk being avoided.

Thoughts about treating dependence

In the 1800s, inability of personal control was seen as behavior of passive victims of an evil
and powerful substance: The drug was seen as being the problem. In 1960, Jellinek described
alcoholism as a disease, and pre-existing genetic and psychological weaknesses were

Unprotected sexual behavior

Negative health consequences of unprotected sexual intercourse
Approximately 36.9 million people currently live with HIV/AIDS, of which the majority is in
South-Africa, and 0.2% in Western Europe. In many countries, unprotected heterosexual sex
has to a large extent taken over from homosexual sex and injecting drug use (IDU) as a route
of infection.
There has been an increase in the prevalence of other sexually transmitted diseases/infections
(STD / STI) including chlamydia, genital herpes simplex, and genital warts most common
among adolescents and young adults. Chlamydia is curable, and the most preventable cause of

The use of condoms

Prior to HIV/AIDS, sexual behavior was generally considered to be private behavior and
somewhat under-researched. The lack of information made it extremely difficult to assess the
potential for the spread of HIV infection. Nowadays, those who use condoms more often are:
young people, females, non-white ethnicities, and members of non-Christian religions.
Condom use commonly begins to decline after 6 months within a relationship. Safer sex
practices are influenced by concerns about STIs, the type, number, and length of sexually
active relationships.
Barriers to condom use are: reduce spontaneity (m), reduce pleasure (m), anticipated male
objection (f), embarrassment in raising the issue (f), worry that suggesting implies one of the
two is HIV-positive/STD (f), lack of self-efficacy or mastery in condom use (f).

Unhealthy diet
What and how we eat plays an important role in our long-term health, as heart disease and
some forms of cancer have been directly associated with diet.

Fat intake and cholesterol

Excessive fat intake has been found to be implicated in coronary heart disease and heart
attacks, as well as to cancer. Cholesterol is a lipid (fat) which is present in our own body cells,
and normally synthesizes to produce steroid hormones and produce bile necessary for
digestion. Factors which increase cholesterol levels are for instance a fatty diet and age.
If fat molecules are not metabolized during exercise, circulating levels become high, and
plagues (fatty layers) are laid down on the artery walls (atherosclerosis), which then thicken
and restrict blood flow to the heart.
When increased blood pressure causes artery walls to lose elasticity and harden, they cannot
adapt to increased blood flow anymore (arteriosclerosis).
The detrimental effects of high salt intake on blood pressure appear to persist even when
levels of physical activity, obesity, and other health behavior are controlled. Educational
interventions have therefore attempted to modify intake. In spite of mixed findings, guidelines
still exist as to recommended levels of salt intake. High salt intake is considered to be >6g for
adults and >5g per day for children per day.

Obesity itself is not a behavior, but it is contributed to mainly by a combination of poor diet
and a lack of exercise. It is often measured in BMI (body mass index), which is calculated by
(weight in kg) / (height in m)2. 20-24.9 = normal; grade 1 = 25-29.9; grade 2 = 30-39.9; grade
3 >40.
However, BMI does not take age, gender or body frame/muscle build into account, and thus
can the index only be used as a guide in context with these other factors.

Negative health consequences

Obesity is a growing, major risk in a range of physical illnesses, such as hypertension, health
disease, type II diabetes, osteoarthritis, respiratory problems, lower back pain, and cancer.
Next to this, the disease can have psychological health problems, such as low self-esteem and
social isolation. The relative risk appears to increase proportionately with the percentage
overweight a person is. In addition, social lower class has been associated to increased obesity
for young females (but not for males). This stresses the importance of interventions starting

- An energy intake that grossly exceeds the energy output
- Genetic explanations:
Born with a greater number of fat cells
Lower metabolic rates and burn calories more slowly
Deficiencies in a hormone responsible for appetite regulation/control

Chapter 4: Health-protective behavior

Adherence behavior
Definition and measurement
- Compliance: Patient takes medicine which conforms to doctors orders
- Adherence: Patient sticks to advise about medication/behavior in a more collaborative
practitioner-patient relationship
influenced by individual and environmental factors
- Concordance: Patient knows what costs and benefits adhering to their treatment brings
about, and there are conditions in which this is encouraged

Why people dont adhere to recommendations/treatments

- Patient-related factors: Personal and cultural beliefs, attitudes, and self-efficacy beliefs
- Condition-related factors: Perceived severity
- Treatment-related factors: Frequency and dosage, expenses, presence and extent of
side effects
- Socio-economic factors: Access vs. isolation to dispensing pharmacy and its products
- System-related factors: Communication with healthcare provider regarding medicines,
necessity/function, traditional beliefs, and systems
for most, non-adherence will be a combination of these factors. It is influenced by
personality, culture and social systems (so on multiple levels: micro as well as macro
& meso)

Healthy diet
Diet has direct and indirect links with illness.

Health benefits of fruit consumption

Vitamins, folic acid, antioxidants, fibre: All are essential to a healthy body as they offer
protection against diseases (e.g. cancer, stroke, heart disease).
There is national variation in lifestyle factors and the effect of fruit: e.g. combined with
Mediterranean diet (low fat, fresh, fish>meat) there may be a stronger association between
diet and reduced disease risk.

Why people dont eat sufficient fruit + vegetables

Those with good cooking skills report higher vegetable intake. Interventions on this issue
should therefore be quite practical, such as tying up cooking skills with both appropriately
calorific and nutritious food. Preconceptions about healthy food can work against a person
making healthy food choices. Parental behavior at mealtimes have been variously associated
with child eating behavior, as food preferences are generally learned through socialization
within the family. It sets childrens future preferences by cooking methods, products, tastes,
textures, and food components.

Physical inactivity is the fourth leading risk factor for global mortality. Exercise is therefore
considered as health-protective behavior. Most countries have guidelines as to what is
considered the appropriate amount of exercise to gain health benefits. It is important to keep
in mind that these guidelines shall not be intended to be set so high as to beyond the reach of
the average individual.
Exercise does not have to be structured and formal: Simply regular walking reduces the risk
of cardiovascular disease, particularly among older people.
Psychological effects
Exercise has been associated with psychological benefits in terms of elevated mood, reduced
anxiety and depression, improved self-esteem or body image, and prosocial behavior. For
those with cognitive decline (result of ageing or dementia), exercise may also have benefits,
as it may improve some aspects of daily functioning (by virtue of neuroprotective effects).
For some people, a reliance on exercise develops to the extent that exercise becomes a
compulsion, interfering with other aspects of ones life and producing dependence (e.g. mood
reduction or irritability). Fortunately, when exercise is reinstated, the positive mood is often

Reasons to (not) exercise

- Low (cycle) awareness
- Environmental barriers (e.g. no cycle path)
- Parental activity
such findings suggest a role for parental modeling and some scope for parental intervention
with different approaches (for children and adolescents).
Screening for risk factors
Based on the principle of susceptibility, screening for risk factors aims to identify an
individuals personal level of risk for future illness. It offers advice and information about
how to minimize further health risk and plan investigation and treatment. An example is
genetic screening.

Screening for disease detection

It is based on a biomedical model, which states that by identifying abnormalities in cell/organ
functioning as early as possible, treatments can be implemented prior to the onset/
advancement of disease symptoms. The best-known examples are mammography, bone
density screening, and antenatal screening (e.g. for Downs syndrome). HIV screening
programs are not often made available on invitation, but is generally requested by individuals
who consider themselves as potentially at risk.
Criteria for establishing screening programs are:
- The condition should be an important health problem
- There should be a recognizable early stage and clear benefit of identifying changeable
- Treatment should have clear benefits to the individual
- There should be a suitable (safe, validated) test with good sensitivity and specificity
- The test should be acceptable to the general population
- Frequency and follow-up should be agreed on
- Costs should be considered

The costs and benefits of screening

Provision of a positive genetic risk result causes significant feelings of hopelessness about
future health, which can persist for several years. Family members and partners are also
affected by the identification of genetic risk. Contrary to expectations, receipt of a negative
test result does not inevitably reassure the individual: There may be other, unidentifiable risk
factors such as yet unknown gene carriers.
In terms of wider screening for disease detection, the procedure itself appears to be preceded
by some anxiety, which can in fact prevent some from returning to subsequent screening.
Thus, to make a decision the person weighs up the pros and cons of a choice and selects the
best option.
Self-screening behavior
There is a need for greater awareness and practice of testicular self-examination and skin self-
examination. A real challenge to health educations is a lay epidemiology by which the
general perception within society is that X (e.g. sun exposure) is healthy (Ness et al., 1999).
Interventions should thus address the value placed on a particular risk behavior, and also to
make a plan of action for self-examinations.

Immunization behavior
The purpose of immunization
Public health policy is to provide vaccinations that provide long-lasting protection against
specific disease without adverse consequences to the individual, and with the costs of
providing the vaccination being outweighed by the costs of having to treat the disease if no
vaccination were to be provided.
Some vaccinations use live components, while others use inactivated components. Parental
permission will of course be required, which has been controversial for instance for the HPV
vaccination (implicit acknowledgement of sexual activity).
While socio-economic variables such as low educational attainment have sometimes been
found to influence the uptake of vaccination, not all studies report this. Evidence more
consistently points to emotional and cognitive predictors of uptake.
Chapter 5: Explaining health behavior

Distal influences on health behavior

One way of considering the factors predictive of health behavior generally is to view some
influences as distal (which operate on behavior directly), and others as proximal (such as
beliefs and attitudes). The latter is a more feasible target for intervention.

Demographic influences
In terms of age, the health behaviors that receive the majority of attention from educational,
medical, and public health specialists are patterns of behavior set down in childhood/ early
adulthood. In adolescence behavior changes: Initiation of risk behavior as part of rebelling
against authority, or because the behavior is considered to be cool and grown-up. Individuals
operate in varying social worlds, each with their own systems and norms, which exert
influence on individual beliefs and behaviors.

- Eysencks three-factor model
1. Extroversion: Opposite to introversion (outgoing, social)
2. Neuroticism: Opposite of emotional stability (anxious, worried, guilt-ridden)
3. Psychoticism: Opposite to self-control (egocentric, aggressive, antisocial)

- McCrae & Costas five-factor model

1. Neuroticism
2. Extroversion
3. Openness (to experience)
4. Agreeableness
5. Conscientiousness
considered to be relatively stable and enduring

- Locus of control beliefs (LoC) (Rotter, 1966)

1. Internal LoC (place responsibility for outcomes on themselves, their actions affect)
2. External LoC (place responsibility for outcomes on external factors such as luck)

- Multidimensional health locus of control (MHLC) (Wallston et al., 1978)

1. Internal: Themselves are the prime determinant, health-protective, self-efficacy
2. External/chance: External forces such as luck, fate, and chance determine
3. Powerful others: Determined by health and medical professionals

- Self-determination theory (Deci & Ryan, 2000)

Distinguishing between intrinsic and extrinsic motivation to carry out behavior

The behavior of others in our culture or social groups creates a perceived social norm which
suggests implicit/explicit approval for certain behaviors, values, and beliefs. The credibility,
similarity to self, and the attractiveness of the source of information influences whether or not
attitudinal change/behavior change occurs as a consequence.

Goals and self-regulation behavior

Behavior tends to be goal-directed: Processes of self-regulation control, modify, or adapt the
responses to achieve desired outcomes / reduced undesired outcomes.
Cognitive regulation and emotional regulation are both required. An inability to control
thoughts and evaluate decision options and potential outcomes or to regulate emotions may
increase impulsivity and risk-taking behavior. Having a weak sense of meaning/purpose in life
has been associated with greater likelihood of risk behaviors, such as smoking.

Models of health behavior

We only reduce the statistical risks of ill health by adopting healthy habits, as we can never
provide a full explanation for the huge variations in peoples health. Humans and the
influence upon them are namely very inconsistent. Attitudes towards health behavior vary
within and between individuals. In the same individual, health behavior may be motivated by
different expectations. Differences are in part explained by life stage.
Early theories on why we change our behavior suggest: information attitude change
behavior change.

Attitudes are the common-sense representations that individuals hold in relation to objects,
people, and events. From the 1960s onwards, a three-component model of attitude gained
acceptance. It contained thought (cognition), feeling (emotion), and behavior. An individual
may hold several attitudes towards a particular object, depending on social context etc.
Contrary thoughts are referred to as dissonance, which many will attempt to resolve by
bringing their thoughts into line with one another. Attitudes alone are insufficient. An
important influence on attitude is that of personal relevance and perceived risk.

Risk perception and unrealistic optimism

Risk perceptions are biased, according to Weinstein (1984), and he named it unrealistic
optimism that some do not stop with their health-risk behavior as they perceive the risk too
low. Not everyone can namely be at low risk. He identified 4 factors associated with
unrealistic optimism: lack of personal experience, actions that might prevent, if the problem
has not emerged already it is unlikely to do so in the future, and the belief that the problem is
Schwarzer (1994) suggests that the relationship between optimism and behavior is likely to be
negative because individuals underestimate their risk and thus do not take precautions against
the risk occurrence.
The mass media is also a primary source of information about health and associated behaviors
and risks, whether it uses the scientific evidence appropriately or not.

Self-efficacy beliefs are beliefs about whether one can produce certain actions. It is likely to
generate other cognitive and emotional activity (such as the setting of high personal goals).
These cognitions and emotions in turn affect actions in order to achieve the goal.
The beliefs often emerge as an important and strong predictor of individual health behavior.
Whilst not all influences on health behavior are psychological, health and social psychologists
have developed theoretical models to examine which factors combine empirically to explain a
wide range of behavior.

Sociocognitive models of behavior change

Social cognition describes how people encode, process, interpret, remember, and learn from
and use information in social relations in order to make sense of the behavior of others and
make sense of the world in which they operate. Social cognitions shape our judgments,
attitudes, responses, and behavior.
SCT (Social Cognitive Theory) Bandura (1977, 1986)

Situation outcomes
Connecting situation to outcome

X would cause Y

Self efficacy
Believing you can do it

HBM (Health Belief Model) Rosenstock (1974), Becker (1974), Becker & Rosenstock
The beliefs encompass perceptions of threat and evaluation of the behavior. Perceiving
barriers is generally associated with low levels of preventative behavior. An important
predictor of what we do in the future is what we have done in the past.
Limitations: Insufficient attention paid to negative effect of social influences/context or mood,
and it is a static model (suggesting that beliefs occur simultaneously).

Perceived susceptibility

Perceived severity

Perceived benefits
Demographic variables Likelihood of behavior
e.g. gender, age
Perceived barriers

Cues to action

Health motivation

PMT (Protection Motivation Theory) Rogers (1983), Rogers & Prentice-Dunn (1997)
Expanded on the HBM by including response-efficacy, the emotion fear, and costs, and self-
efficacy to the coping appraisal factors they consider influence behavior change.

Subjective expected utility theory = individuals are active and generally rational decision
makers who are influenced by the perceived utility or certain actions or behavior.

TRA (Theory of Reasoned Action) derives from SCT, and the underlying principle states that
individuals behave in a goal-directed manner and the implications are weighed in a reasoned
manner before the decision is taken to (not) engage.
Beliefs about behavior
in given social context
Social perceptions Social behavior
Outcome expectations
TPB (Theory of Planned Behavior)

Attitude towards
expectancies X
outcome value

Normative beliefs
Personality X motivation Behavior Behavior
Subjective norm
to comply intention
Past Experience

Perceived internal
and external Perceived
control factors behavioral control

Behavior is thought to be proximally determined by intention, which in turn is influenced by a

persons attitude towards the object behavior, their perception of social norms and pressures
regarding the behavior, and perceived behavioral control (this is added to TRA to create TPB).
Perceived behavioral control (PBC) = a persons belief that they have control over their own
behavior in certain situations, even when facing particular barriers.
Limitations of TPB is known as the intention-behavior gap: Medium-sized changes in
intention only resulted in trivial-sized changes in behavior.

Descriptive norms (i.e. describe what others do) may operate in a different way than
injunctive norms (i.e. those that proscribe what you should do because others do and think it
appropriate you do too).

Over the past 15 years, TPB has been extended by past behavior, habits and automaticity,
moral norms, anticipatory regret (success/failure), self-identity, (type of) social support, and

Implementation intentions
Gollwitzer suggests that individuals need to shift from a mindset typical of the motivation
(pre doing) phase towards an implementational mindset, which is found in the volition (doing)
phase. Individuals need to make a specific if-then statement in order to succeed. But Ogden
(2003) argues that this method of questioning is manipulative > descriptive. De Vet and
colleagues (2011) rightly point out that much of the evidence of positive effects of II
formation on behavior comes from research studies where individuals were helped to form
their II. This face-to-face assistance is not always available in real life.

Stage models of behavior change

Weinstein and Standman (2002) suggested that a stage theory requires 4 properties:
1. A classification system to define stages: Few people will perfectly match the prototype.
2. Ordering of stages: People must pass through all the stages to reach the end point of
action or maintenance, but progression to the end point is neither inevitable nor
3. Similar barriers to change facing people within the same stage
4. Different barriers to change facing people in different stages
TTM (Transtheoretical model / Stages of Change model) Prochaska & di Climente (1984)
- Pre-contemplation: May not consider that they have a problem
- Contemplation: A person demonstrates awareness of a need of, and to consider, action
- Preparation: A person is ready to change and sets goals
- Maintenance: Keeps up with the change, resists temptation
- Termination: Behavior change has been maintained for adequate time so the person
feels no temptation to lapse and believes in their total self-efficacy to maintain the
- Relapse: A person may lapse into earlier behavior patterns and return to a previous
stage, this can occur at any stage really.

Limitations of this model are: Past behavior is a powerful predictor of future behavior, but this
model assumes that readiness/intentions are the key to change. Perhaps a continuous variable
of readiness may be more useful than discrete stages of readiness.

PAPM (Precaution Adoption Process Model)Weinstein(1988), Weinstein & Sandman (1992)

- Stage 1: Unawareness of threat to health
- Stage 2: Unengaged (aware of risks, but not believing levels they engage in is
sufficient to pose a threat to their health)
- Stage 3: Engaged for some reason (internal and external triggers, consideration stage)
- Stage 4: Decide not to act
- Stage 5: Decide to act
- Stage 6: Action (initiated what is necessary to reduce their risk)
- Stage 7: Maintenance

Limitations of this model are that it has been tested less than TTM but does progress thining
to include the issue of awareness and predecisional processes.

HAPA (Health Action Process Approach) Schwarzer (2001)

Task self- Maintenance Recovery i
efficacy self-efficacy self-efficacy s
Outcome Action Action control
expectancies planning
Intention g
Coping e
Risk planning m
perception e
Barriers and resources, e.g. social support t

PREintenders Intenders Actors

Limitations are: For middle-aged and older people it works better, and more is needed about
the volition-action processes regarding action planning, coping planning, and action control.
Insufficient attention is given to non-conscious processes.

The models differ in some aspects, but share a common goal: To aid our understanding of
correlates and predictors of behaviors associated with health, whether positively or negatively.
Chapter 6: Changing behavior: Mechanisms and approaches

Developing public health interventions

Before any intervention is developed, those involved need to determine which behaviors to
address and how best to address them. The best known framework for making these decisions
is known as the PRECEDE-PRECEED model (Green & Kreuter, 2005).

- Predisposing factors (knowledge, attitudes, beliefs, preferences, skills, self-efficacy

desired behavior change)
- Enabling factors (characteristics of the environment, such as availability of resources)
- Reinforcing factors (reward/reinforce desired behavior change, such as social support)

It takes into account any political, social, and environmental influences that may facilitate
behavior change, incl. changes in health education or social policy. It is implemented in 5
1. Social diagnosis: Planners gain an understanding of the problems that affect QoL
2. Epidemiological, behavior, and environmental diagnosis: Identification and
assessment of health issue(s) specific to the community and the related behavioral and
environmental influences
3. Educational and ecological diagnosis: How to change any behaviors, the likely impact,
and the level of acceptability to the community
4. Administrative and policy diagnosis: The program needs to be consistent with this
5. Programme implementation: PROCEED
Process: Did it do what was intended?
Impact: What impact did it have?
Outcome: What long-term effects on health were achieved?

Strategies for changing risk behavior

The stages of change model (Prochaska & di Clemente, 1986).

Motivating change
If individuals are unaware of the advantages of change, they are unlikely to be motivated.
While clear information may be of benefit when it is completely new, does not contradict
previous understandings of issues, is highly relevant to the individual, and is relatively easy to
act on, most information does not contain all of these aspects.

The NICE guidelines on behavioral change (NICE, 2014) identified 7 ways of presenting
information in order to increase the motivation of smokers to quit. Key messages should
include: Outcome expectancies, personal relevance, positive attitude, self-efficacy, descriptive
norms, subjective norms, and personal and moral norms.
Individuals are more likely to centrally process messages if they are motivated to receive an
argument when it is congruent with their pre-existing beliefs, it has personal relevance to
them, or recipients have the intellectual capacity to understand the message. Peripheral
processing involves maximizing the credibility and attractiveness of the source of the message
using indirect cues and information.

A second potential approach to increasing the influence of both mass media and interpersonal
communication is through the use of fear messages. It is more effective than humor (Biener et
al., 2000), but high levels of threat have proven relatively ineffective. Rogers (1983)
protection motivation theory explains this by suggesting that individuals will respond to
information in either an adaptive or maladaptive manner depending on their appraisal of both
threat and their own ability to minimize that threat.
Fear control seeks to reduce the perception of the risk, often by avoiding thinking about it. For
danger control to be selected, someone needs to consider that an effective response is
available (response efficacy) and that they are capable of engaging in this response (self-
efficacy). If danger control is not selected, then fear control becomes the dominant coping
strategy. Fear control involves withdrawal from the message, not the health threat, as it is too

A less threatening approach to the development of health messages involves framing the
message in positive or negative terms (stressing the outcomes associated with action or

The most effective form of persuasion in one-to-one interventions is known as motivational

interviewing. Its goal is to increase an individuals motivation to consider change, not to show
them how to change. If the interview succeeds, only then can any intervention proceed to
considering ways of achieving it. If the individual still rejects the possibility of change, they
will typically not continue in any programme of behavioral change.

Additional strategies of motivating change:

- Consideration of the disadvantages of the status quo
- Consideration of the advantages of change
- Evoking the intention to change
- Evoking optimism about change

Changing behavior
If individuals are motivated to change their behavior, then any intervention should focus on
helping them achieve the changes they wish to make.

Problem-focused interventions involve considering how > whether to change and are best
suited to individuals who want to change their behavior but do need help working out how to
do this. Egans (2013) form of problem-focused counseling emphasizes the importance of
appropriate analysis of the problem the individual is facing as a critical element of the
counseling process. The job of the counselor is to mobilize the individuals own resources to
identify problems accurately and to arrive at strategies of solution. Counselling is problem-
oriented: focusing on issues at hand, in the here and now, and has 3 phases:
1. Problem exploration and clarification
2. Goal setting
3. Facilitating action
Some people might not need to work through each stage, others may work through all in one

Banduras SCT (2001) suggests that both skills and confidence in the ability to change can be
increased through some simple procedures, such as active persuasion. There are 3 basic
models of observational learning:
- Live model: an actual individual doing the behavior
- Verbal instructural model: descriptions and explanations of a behavior
- Symbolic model: real/fictional person displaying behaviors in books, films, media
The skills required to change behavior can all be taught and practiced. The simplest forms of
intervention may involve the provision of appropriate education. At the beginning, positive
beliefs may predominate, but then the individual begins to rely on the bad behavior, more
dependent beliefs predominate. Cognitive interventions may be of benefit where such
thoughts interfere with any behavioral change.
A second strategy is to set up homework tasks that directly challenge any inappropriate
cognitive beliefs that individuals may hold. Such challenges could be realistic, and should be
mutually agreed on. Success in these tasks can bring about long-term cognitive and behavioral

As health behaviors occur in a social and economic context, Becker et al. (1977) developed
the health belief model, which provides a simple guide to key environmental factors that can
be influenced in order to encourage behavioral change.
- Provide cues to engage in healthy behaviors / remove unhealthy behavioral cues
- Minimize costs and barriers associated with healthy behavior
- Maximize costs of engaging in health-damaging behavior
Individuals/groups within the population have also been used to actively promote any targeted
changes. This is based on a theory of the spread of new behaviors through society known as
diffusion of innovations (Rogers, 1983).
- Innovators (small group, willing and able to test out new ideas from them)
- Early adopters (opinion leaders, adopting an innovational idea is crucial to its adoption
by the wider population)
- Early majority (adopts ideas reasonably early, but does not have the power to
influence the wider population)
- Late majority (after adopting by the early majority, this cautious group adopts after it
has been well tested)
- Laggards (the last do adopt, or may never adopt)

Characteristics of any innovation that may influence its likely uptake by the group: advantage,
compatibility with values and norms, ease of uptake, and evidence of effectiveness.

Getting it right
Information provision should include:
- The consequences of behavior in general
- The consequence of behavior to the individual
- Others approval of behavioral change
- Normative information about others behavior

Problem-focused approaches include:

- Goal setting
- Action planning
- Barrier planning / problem solving
- Set graded tasks
- Prompt review of behavioral goals
- Prompt review of outcome goals
- Prompt rewards contingent on effort / progress towards behavior
- Prompt rewards contingent on successful behavior
Chapter 7: Preventing health problems
Working with individuals
Motivational interviewing
This is a rather sophisticated approach, especially for those with low motivation. Another
approach to increase effectiveness of this kind of interviewing has been to integrate it within
more complex programmes of change.

Problem-focused approaches
These interventions are likely to be more effective than those simply providing information.
Based on social cognitive models of health action process approach (HAPA) and
implementation interventions, these approaches have encouraged individuals to plan
when/how/under what circumstances they will engage in their behavior of choice.
One of the barriers to attend screening for risks is anxiety about its outcome. It may both
prevent people engaging in screening, or result from screening. Therefore, people are
sometimes given a coping booklet and a medical booklet with information.

Using the mass media

The earliest media campaigns adopted a hypodermic model of behavioral change, which
assumed a relatively stable link between knowledge, attitudes, and behavior. If we could
inject appropriate information, this would change the attitudes and influence behavior. Good
sources of information may be an expert, someone like yourself, a neural individual, or
someone clearly linked to the issue (e.g. a doctor providing health information) or a particular
The cumulative effects of repeated media campaigns may influence attitudes and behavior.
Other methods to maximize effectiveness are: refining communication by peripheral cues,
using fear messages, frame information, and specific targeting of interventions.

The use of fear

Increased HIV-related anxiety did not increase knowledge about the topic, or trigger any
behavioral change. It may even increase feelings of shame and skepticism.
If fear messages are used, they need to be accompanied with simple, easily accessible
strategies of reducing the fear. Such as: free sunscreen when warning for skin cancer.

Information framing
A more neutral approach. Messages can be framed in positive (stressing positive outcomes
associated with action) or negative terms (emphasizing negative outcomes associated with
failure to act).

Audience targeting
Using the language of the target audiences, making them more effective.

Environmental interventions
To encourage behavioral change, we should consider cues to action (or remove cues to no
action) by simpler messages and reminders, minimize costs and barriers, and maximize costs
of engaging in heath-damaging behavior.

Public health programmes

Community intervention programmes
Environmental interventions such as the Minnesota Heart Health Programme included healthy
food labeling (low fat, high fibre, etc.), establishing healthy menus in restaurants, smoke-free
areas, and increased physical recreation facilities. The programme had surprisingly little
impact on health and health behavior.

Reducing risk of HIV infection

Interventions targeting sexual behavior appear to have been more successful across
industrialized and developing countries (40-54%). Why the programs were more successful
than CHD is unclear, but maybe the use of peers and working with specific groups of people >
trying to impose change from without was more effective. In addition, CHD develops over
time while risks of unsafe sex are highly salient and the consequences can be catastrophic.

Worksite public health

One response to the problems encountered by large-scale population interventions had been to
target smaller, more easily accessible and controllable target groups. These may be thought
of as interventions which reward healthy lifestyles or punish unhealthy ones.
This however mirrors the ineffectiveness found in primary care: Screening employees for
CHD risk factors has proven of no real benefit.
One way that employers can influence their workforce is to provide financial incentives for
change, to provide an external reward system for appropriate behavioral change > relying on
employees personal motivation. Successfulness is often only acquired however when there is
social support available.

School-based interventions
School provides a context in which health professionals can access students and act as agents
of change. At a higher, systematic level, simple one-target interventions may be effective,
particularly if they target pupils early in school life. The WHO health-promoting schools
initiative states that schools should prioritize the health and develop an integrated approach to
enhance it, as well as to prevent uptake of unhealthy behavior and educating about health-
promoting activities. School activities and infrastructure should be based around this.
This approach has had limited success, partly because as a result of its complexity and limited
uptake and implementation in schools.
Besides this, peer education can be effective.

Using new technology

The difficulties in measuring outcomes and conducting randomized controlled trials in this
research context means that many papers simply report usage > outcomes. Analysis of the
effectiveness of internet interventions shows their reach in terms of the number of people they
can potentially access and their effectiveness.
A second increasingly used technology is that of texting, which can be used to remind people
of the need to change, provide skills and prompts to engage in change, and record any
behavioral change (this has been proven effective!).
Technology can be attractive for modern health promoters, but the temptation to ignore more
traditional approaches must be met with caution.
Chapter 8: The body in health and illness
The behavioral anatomy of the brain
The brain is a complex organ of nerve cell bodies, and divided into 4 anatomical areas:
1. Hindbrain: necessary for life, controlling blood pressure, heart rate, and respiration.
Alertness and wakefulness, muscular and positional information.
2. Midbrain: Reticular system, sensory and motor correlation centers.
3. Forebrain: Mood and behavior (incl. thalamus for attention and memory function,
hypothalamus for appetite and emotions, hippocampus as part of limbic system for the
interaction between perceptual and memory systems, and amygdala as part of limbic
system for linking sensory information to emotionally relevant behavior)
4. Cerebrum: incl. basal ganglia for complex motor coordination and cortex.

Problems of neurological functioning

There are many causes of neurological dysfunction, most frequently encountered by a stroke
(cerebrovascular accident, CVA) which can result from a clot (thrombosis) or rupture in a
blood vessels wall causing a bleed into the neural tissue.
If someone suffers from a stroke, they have numbness/weakness in face/arm/leg (often on one
side of the body), sudden confusion, trouble seeing, walking, and severe headache. If these
symptoms are identified, FAST guides a response: Face (smile), Arms (lift), Speech (repeat),
Time (call for help immediately).

The autonomic nervous system

This system is responsible for control. Many organs have some degree of control over their
functioning. It can initiative sweating in high temperatures, blood pressure and heart rate
during exercise, and make us physiologically responsive at times of stress, distress or

It has 2 opposing networks of nerves:

- Sympathetic: involved in activation and arousal (fight-flight response)
- Parasympathetic: involved in relaxation (rest-recover response)
The activity in each of the organs depends on the relative activity in these two networks.

Endocrine processes
The activity initiated by the sympathetic nervous system is short-lived. A second system is
therefore used to provide longer-term arousal by using endocrine glands, which communicate
with their target organs by releasing hormones into the bloodstream. Some extend the activity
of the sympathetic nervous system (adrenal glands, situated above the kidneys).
A second activating system involves the pituitary gland, the activity of which is also
controlled by the hypothalamus (emotions).

The immune system

Components of the immune system
The immune system provides a variety of protective mechanisms that respond to attacks from
bacteria, viruses, infectious diseases and other sources (antigens). A number of organs and
chemicals form the front line of the system:
- Physical barriers (skin)
- Mechanical barriers (cilia, which are small hairs in the lining of the lungs)
- Chemical barriers (acid from the stomach)
- Harmless pathogens (bacteria within the body, defending their territory)
- Lymph nodes
Phagocytes (white blood cells) circulate within the circulatory system. They destroy antigens
in a process known as phagocytosis. Lymphocytes are also white blood cells which circulate in
the blood and lymph system.

Immune dysfunction
HIV (Human Immunodeficiency Virus infection) is the cause of a potentially fatal condition
known as Acquired ImmunoDeficiency Syndrome (AIDS). It belongs to slow viruses, and
infect the T helper (CD4+) cells which usually attack the pathogen. The infected cells
circulate. They will eventually die, but before doing so they may bind with healthy cells,
resulting in their death as well. So HIV replicates itself, different strains of the virus emerge,
some of which are resistant to antiretroviral drugs.

Autoimmune conditions
The immune system can identify cells that are self (part of the body) and non-self
(antigens etc.). Sometimes this process breaks down and the immune system treats all cells as
non-self and attacks them. This can result in autoimmune conditions, such as:
- Diabetes
Type 1: The body doesnt produce sufficient insulin in the pancreas. It is triggered by
an infection.
Type 2: The body produces sufficient insulin but the cells that take up the glucose
insulin molecules become resistant and no longer absorb them. It develops later in
life and is associated with obesity.
- Rheumatoid arthritis (RA)
Triggered by viruses in people with a genetic tendency for it. During flare-ups, people
experience significant pain, stiffness, warmth, redness, swelling, fatigue, loss of
appetite, fever, and loss of energy. There is no known cure, although symptoms can be
- Multiple sclerosis (MS)
A neurological condition involving repeated episodes of inflammation of the central
nervous system (brain and spinal cord), resulting in the slowing/blocking of the
transmission of nerve impulses. Onset is usually after 40 years. It causes physical
problems, cognitive impairment, and memory problems.
One approach to treatment involves a different type of interferon, which have to be
regularly injected. But they can cause fatigue, muscle aches, headaches and fever,
which is why many patients avoid using this.

The digestive system

This is the system of organs responsible for the ingestion of food, absorption of nutrients, and
the expulsion of waste products from the body. Movement between and along the different
organs is controlled by smooth muscle movement known as peristalsis.

Controlling digestion
- Hormone and nerve regulators. Hormones are produced and released by cells in the
mucosa (lining) of the stomach and small intestine at key stages in the process. Gastrin
causes acid production, secretin produces a fluid that is rich in bicarbonate and
enzymes to break down food into its constituent proteins, sugars, etc., and
cholesystokinin triggers the gallbladder to discharge its bile into the small intestine.
- A complex local nervous system known as the enteric nervous system. Sensory
neurons respond to stretch and tension after they receive information from receptors,
and motor neurons control gastrointestinal motility (peristalsis, stomach motility) and
secretion. Key neurotransmitters are norepinephrine (activating) and acetylcholine
(inhibitory role).

Disorders of the digestive system (2 examples)

- Gastric ulcer
Ulteration of the lining of the stomach (mucosa) which results in abdominal
discomfort or pain for several days/weeks, poor appetite, weight loss, bloating, nausea,
and vomiting. It is relieved by eating, and a bacterium is responsible for 70% of the
cases. It allows acid to reach the sensitive lining beneath. Stress may also be
implicated in the development and maintenance of this disorder, as it may increase risk
behaviors as smoking or alcohol consumption.
Treatment involves suppressing acid secretion and if possible eradicating the bacteria
by drugs, sometimes also surgery is used.
- Inflammatory bowel disease (IBD)
A group of inflammatory conditions of the large and small intestine. Main forms are
Crohns disease (chronic, severe disrupted digestion; drugs and antibiotics can help)
and ulcerative colitis (affecting the terminal part of the large intestine and rectum, may
develop into cancer after many years, resulting in the patient needing a colostomy..

The cardiovascular system

The main function is to transport nutrients, immune cells, and oxygen to the organs and to
remove waste products from them. It moves hormones from their point of production to the
site of action as well.
There are various types of blood vessels:
- Arteries: transport blood away from the heart (can contract/expand slightly due to
- Arterioles: small arteries, linking the large arteries to the organs
- Veins: transport blood back to the heart once the oxygen and nutrients have been
absorbed from it and replaced by carbon dioxide

The heart
2 separate pumps operating in parallel. Each side of the heart has 2 chambers (atria and
ventricles). The rhythm is controlled by an electrical system: It is initiated by an electrical
impulse which causes the muscles of both atria to contract.
An electrocardiogram (ECG) is used to measure the activity of the heart. It can detect each of
the odes firing and recharging.

The body usually contains 5L of blood, which consists of plasma and cells (exogenous which
transport nutrients and oxygen). It also produces its own cells which are manufactured by
stem cells. 3 types are produced: red blood cells (erythrocytes), white blood cells (phagocytes,
lymphocytes), and platelets which respond to damage to the circulatory system.
Blood pressure (measured in mmHg) has 2 components:
- The degree of pressure as a result of its constriction within arteries and veins (DBP:
diastolic blood pressure)
- The wave of blood pushed out from the heart flowing through the system (SBP:
systolic blood pressure)
Healthy levels are SBP < 130-140 mmHg and DBP < 90 mmHg (written as: 130/90 mmHg).
Diseases of the cardiovascular system
- Hypertension
A condition in which resting blood pressure is significantly above normal levels.
Primary/Essential seems to be the normal consequence of risk factors such as obesity
and high salt intake, while secondary results of a disease process usually involving
kidneys, adrenal glands or aorta (5% of cases). Stress may also contribute to the
development of essential hypertension. It may be present and remain unnoticed for
years, but the amount of damage it can do rises once blood pressure rises.
- Coronary heart disease (CHD)
For instance artherosclerosis where atheroma builds up on the lining of the arteries.
Low-density lipoproteins (LDLs) transport cholesterol to various tissues and cells, it is
seen as harmful. High-density lipoproteins (HDLs) transport excess/unused cholesterol
back to the liver (health-protective).

The respiratory system

Delivers oxygen to and removes carbon dioxide from the blood. 2 parts:
- Upper respiratory tract (nose, mouth, larynx, trachea)
- Lower respiratory tract (lungs, bronchi, bronchioles, alveoli). Each lung is divided in
upper and lower lobes the upper lobe of the right lung contains a third subdivision
known as the right middle lobe.

The bronchi carry air from the mouth to the longs. In the longs, they divide into smaller ones,
and then in smaller tubes called bronchioles. These contain minute hairs (cilia) which beat
rhythmically to sweep debris out of the lungs towards the pharynx for expulsion. Bronchioles
end in air sacs (alveoli) which are small, thin-walled balloons and are surrounded by tiny
blood capillaries.
The rate of breathing is controlled by respiratory centers in the brain stem which respond to
the concentration of carbon dioxide in the blood, and air pressure in lung tissue.

Diseases of the respiratory system

- Chronic obstructive pulmonary disease (COPD): a group of lung diseases
characterized by limited airflow resulting from damage to alveoli. The most common
manifestations are emphysema and chronic bronchitis.
- Lung cancer: The most common cancer among both sexes. Symptoms include: a dry
non-productive cough, shortness of breath, coughing up sputum with signs of blood,
ache/pain when breathing, loss of appetite, fatigue, and losing weight. The main cause
is smoking, but other risks involve exposure to carcinogens, and scarring from
Chapter 9: Symptom perception, interpretation and response
How do we become aware of the sensations of illness?
Illness generates changes in bodily sensations and functions that a person may perceive
themselves or maybe have pointed out to them by others. Signs include:
- Changes in bodily functions
- Emissions
- Sensations
- Unpleasant sensations
- Bodily appearance
- Function

Bodily signs are objective as they are physical sensations which can be detected and
identified, while symptoms of illness are interpretations (subjective). Peoples views about
health are shaped by their prior experience and their understanding of medical knowledge.

Illness or disease?
Illness stands for what the patient feels when he goes to the doctor, so not feeling quite well
(Cassell, 1976). Disease stands for what he has on the way home from the doctors office
(being something of the organ/cell/tissue that suggests a physical disorder or underlying
pathology, whereas illness is what the person experiences).

Symptom perception
Several models of symptom perception:
- Attentional model (Pennebaker, 1982): Competition for attention between multiple
internal/external cues/stimuli same physical sign/physiological change going
unnoticed in some contexts but not in others.
- Cognitive-perceptual model (Cioffi, 1991): Processes of interpretation of physical
signs and influences upon their attribution as systems while also acknowledging the
role of selective attention.

Characteristics of bodily signs that increase likelihood of symptom perception

The fact that only some symptoms will be detected by the person highlights that biological
explanations of symptom perception are insufficient. Often these symptoms are likely to be
painful/disruptive, novel, persistent, pre-existing chronic disease.

Attentional states and symptom perception

Individual differences exist in the amount of attention people give to their internal state and
external states. Pennebaker discovered that somatic sensations are less likely to be unnoticed
when ones attention is engaged externally than when they are not distracted. A high degree of
attention increases ones sensitivity to new/different bodily signs. Previous experience with an
illness can increase a persons attentional bias.

Social influences on symptom perception

People hold stereotypical notions about who gets certain diseases, and this can interfere with
perception and response to initial symptoms. Our motivation to attend to and detect signs/
symptoms of illness will depend on the context at the time the symptom presents itself.
Situations bring with them varying expectations of physical involvement, and setting also
plays a role (with suppression of physical discomfort by means of motivated distraction).
Individual differences affecting symptom perception
- Gender: Socialization provides women with a greater readiness to attend to and
perceive bodily signs and symptoms, and they simply talk and attend health care more.
- Life stage: With age comes experience and typically an increasing awareness of ones
internal organs, their functions, and sensations.
- Emotions and personal traits: People who are in a positive note tend to rate themselves
as more healthy and indicate fewer symptoms. Negative emotional stages (anxiety,
depression, fear) may increase symptom perception by means of its effect on attention.
But fear of being seriously ill can reduce ones attention to and consideration of
possible meanings of their symptoms.
- Cognitions and coping style: How people think and respond to events (e.g. repression).

Symptom interpretation
Symptoms not only derive from medical classifications of disease, but can also influence how
we think, feel, and behave.

Cultural influences
The extent to which differences can truly be ascribed to culture is not always clear, given that
the range of other influences are not always controlled for in studies. Cultural variations are
learned through socialization (Zborowski, 1952) based on peoples ideas of what is

Individual difference influences

- Gender: Women more often have somatization disorder (unexplained symptoms),
measures of neuroticism, and interpret a bodily sign as symptomatic/ underlying
- Life stage: Young children are distinct from adolescents in cognitive awareness of
illness, and the difference in life/illness experience and knowledge accumulated.
- Personality: Those high in Neuroticism / NA commonly exhibit heightened symptom
perception and are more likely to seek health care than those low in N.
- Self-identity: Most people have several social identities depending on context, and its
proposed that the interpretation of symptoms differs depending on a persons current
salient social identity. Attractiveness threat or threat to emotionality leads to greater
illness severity perceptions.
- Illness experience: Having a history in particular symptoms/vicarious experience leads
to assumptions about the meaning and implications of some symptoms. Symptoms
considered to be rare are more likely to be interpreted as serious than a previously
experienced/widespread symptom. These reserves of knowledge are known as disease

Illness/disease prototypes
When the symptoms one experiences fit a model of illness retrieved from their memory. A
failure of symptom to fit a prototypical image of the likely victim can lead to
misinterpretation or delay.
Self-regulatory model of illness and illness behavior Leventhal et al., 1992):
(Common sense model) Illness cognitions are defined as a patients own implicit common-
sense beliefs about their illness.

Social-cultural context

Biological characteristics
and psychological traits

Representation Coping Appraisal

of health threat responses
(internal /
Representation Coping Appraisal
of emotion responses

Mental representations of illness (IRs) emerge as soon as a person experiences a symptom or

receives a diagnostic label. This happens through the media, personal experience, and from
family and friends. People start a memory search to make sense of the symptom or diagnosis.

Leventhal found five consistent themes in the context of IRs:

- Identity
- Consequences
- Cause
- Timeline
- Curability/controllability

The Illness Perception Questionnaire (IPQ and IPQ-R (revised), also CIPQ for children): The
IPQ-R distinguishes between beliefs about personal control over illness from outcome
expectancies and from perceived treatment control. It strengthens the timeline component,
assesses a new dimension of emotional responses to illness, and examines the extent to which
a person feels they understand their condition (illness coherence).
But in the end, ones health status will affect ones beliefs regarding illness. Mismatched
perceptions have obvious implications in terms of responses to people with for instance
cancer, but they also hold implications for healthy individuals. Understanding the sources and
salience of beliefs and perceptions, and the reasons behind them, could be crucial to the
development of targeted interventions.

Illness representations have direct effects on outcomes as:

- Seeking and using/adhering to medical treatment
- Engagement in self-care behavior
- Attitudes towards the use of brand-specific vs. generic medicines and treatment choice
- Illness-related disability and return to work
- Caregiver anxiety and depression
- Quality of life

The issue of change in illness representation is also relevant when there is change possible in
the nature of treatments patients undergo. Studies highlight a need to consider patients
perceptions at important treatment transition points in order to best manage their perceptions
and optimize patient QoL and adaptation.

Attributional models consider where a person locates the cause of an event (symptoms).
Attributions are made in order to attempt to make unexpected events more understandable or
to try and gain some sense of control. Attributions can however be wrong, and thus coping
efforts can be misguided.
Culture influences how illness is perceived, understood, and experienced. Beliefs about
treatment have been shown to be associated with culture, race, and ethnicity.

Planning and taking action: Responding to symptoms

1. Recognize that you have symptoms of an illness (rest, go to bed are types of self-
2. Label the symptoms and realize that they could indicate a medical problem (ignore,
seek advice, or go to a health professional). Our response to serious symptoms may
still involve some delay to see whether things improve or whether attempts at self-care
will improve the situation.

Delay behavior
Refers to ones delay in seeking health advice. Safer et al. (1979) described 3 decision-making
1. One infers that (s)hes ill on the basis of perceiving symptom(s)
2. Whether or not in need of medical attention ( the time taken for this = appraisal
3. The time taken between deciding one needs medical attention and actually acting on
that decision by making an appointment/presenting to a hospital (utilization delay)

Many factors influence delay, such as socio-economics, demographics, personality. If the

symptom is easily visible to oneself and others, one will delay less in seeking treatment.
When the symptoms appear to be serious, unusual, or controlled/treated through medication,
people are more likely to take action. The effects of symptoms are also important: For
instance, if the symptoms threaten normal relations with others or disrupt regular activity.

A formal diagnosis can allow someone a time out from normal duties and responsibilities, but
many delay seeking medical care when money is limited or when they do not have sufficient
health insurance. Westernized cultures, younger and elderly people, and women have been
found to promote an independent sense of responsibility.
Lastly, seeking healthcare does not inevitably lead a person into the sick role, as effective
treatment may be provided that rids them of their symptoms and enables them to carry on as
Chapter 10: The consultation and beyond
The medical consultation
The nature of the encounter
Consultations are a time in which doctors and other health professionals can obtain
information to inform their diagnostic and treatment decisions, and patients can gain
information about their condition, its treatment, and discuss other relevant issues. 5 phases:
1. Establishing a relationship
2. Attempting to discover the reason
3. Examination (verbal/physical)
4. Considering the condition
5. Further treatment/investigation

Ford et al. (2003) identified 6 factors which they found important to a good medical
consultation, such as that the health professional is well-informed and able to communicate
their knowledge, achieving a good relationship with the patient, and engaging the patient.

Who has the power?

Both patient and health professional can contribute to the outcome of the consultation. All
health professionals have significant responsibility for determining the style and outcome.

- Professional-centered approach:
Health professional keeps control (e.g. asking direct/closed questions to gain
Health professional makes decision, patient passively accepts this decision
- Patient-centered approach:
Health professional identifies and works with the patients agenda and their own
Health professional actively listens and responds appropriately
Encouraging engagement of the patient (patient is an active participant)

Recently, we have moved towards a process of shared decision making (Elwyn et al., 2012),
which involves: choice (making sure patients know that treatment options are available),
option (providing more detailed information about options), and decision (supporting the
work of considering preferences and jointly deciding what is best).
However, the health professional typically has more relevant knowledge than the patient,
which is why the appearance of equality can therefore be an illusion rather than reality.

Factors that influence the process of consultation

Working together
- Health professionals gave more information to patients they liked
- Time available
- Type of problem being dealt with
- Different agendas and expectations of the consultation (possibly failing to appreciate
important aspects of any information given and received)
- Poor communication skills leads to being less aware of patients responses and level of
- The type of health professional influences the style of interaction (e.g. nurses should
provide the main caring role)
- Both men and women are more likely to report being treated disrespectfully by doctors
of the opposite gender than those of the same gender
Culture and language
- White patients discuss more emotional problems
- In the Netherlands, consultations with immigrant patients are likely to be significantly
briefer and the power distance is also greater than those with Dutch patients
- Problems in communication may result in doctors experiencing difficulties in reaching
appropriate diagnoses and patients misunderstanding information given in the

The type of information and the way it is given

- Technical or medical language can be confusing unless appropriately explained
- Of particular importance may be whether information is framed or reported in a
positive or negative way

Patient factors
- High levels of anxiety or distress
- Lack of familiarity
- Failure to actively engage
- Not having considered issues to be discussed

Breaking bad news

Despite the clear need for skills in breaking bad news, many senior doctors receive no formal
training in doing so. The model looks like this:
1. S SETTING UP the interview
Privacy, involve significant others, sit down, make connections, manage time.
2. P Assessing the patients PERCEPTION
Ask open-ended questions.
3. I Obtaining the patients INVITATION
Determine how much the patient wants to know about their diagnosis.
4. K Giving KNOWLEDGE and information to the patient
Verbal warning, non-technical language, small chunks, checks patients understanding
5. E Addressing the patients EMOTIONS with empathic responses
Supportive through the use of emphatic responses (observe, follow and identify, use
open-ended questions, reason for emotion, empathic feedback, wait until the patient is
able to reengage)
A clear treatment plan will reduce anxiety and uncertainty but should be discussed
only after patients are ready to address these issues.

Moving beyond the consultation

A key goal of the consultation is to allow health-care professionals and patients to receive and
provide information relevant to medical decision-making and treatment.

Medical decision-making
Some doctors may only be willing to treat patients who are actively involved in maintaining
their own health. Other biases may be less conscious, or may be motivated by non-health-
related issues. A key area for medical decision-making involves diagnosing the illness. A
number of ways to achieve this are:
- Hypothesis testing: Logical sequencing of establishing and testing hypotheses about
the nature of the diagnosis.
- Pattern recognition: Compares patterns of symptoms with disease prototypes.
- Opinion revision or heuristics and biases: Based on partial evidence as a result of
using rules of thumb / heuristics (least reliable: the most commonly used heuristics are
often those termed fast and frugal, so they aid quick decision-making on the basis of
minimal information).
- Availability
- Representativeness
- Potential pay off of differing diagnoses

Compliance, adherence, and concordance

A key determinant of the success of any medical intervention is whether patients actually
follow the recommended medical regime. Concordance means that both health professional
and patient reach a jointly determined agreement concerning the treatment regimen. This
requires the patient to be fully informed of the benefits and costs.

Take the tablets

This is the most frequent medical treatment. Patients need to take them at times and in
sufficient quantities to provide a therapeutic dose, which may not be easy.

Keep taking the tablets

The most effective interventions are generally complex and involve a combination of:
convenient timing of drug taking, providing relevant information, reminders to take
medications, self-monitoring, reinforcement of appropriate use of medication, and family
therapy. More complex procedures involve the use of reminders sent via the post, text or

Changing behavior
Many medical interventions require more significant behavioral change than taking
medication, which is difficult to measure. One measure of adherence is relatively simple:
Whether the patient attends clinics and other appointments.
One key issue of relevance is that of (lack of) motivation, and competing demands on time,
but also social support.

To improve adherence:
- Self-control strategies: Attribute any successful behavior to their own efforts > those
of health professionals
- Relapse prevention: Identifying high-risk situations that may result in relapse back to
previous behaviors, and planning how to avoid/cope with them
- Motivational strategies: Stepwise progression
- Make change habitual