Health Psychology Chapter 4 summary

Adherence behaviour
Definition and measurement
- Compliance: patient medicine taking behaviour which conforms with ‘doctor’s
orders’.
- Adherence: a person sticks to, or cooperates with, advice about medication (or
lifestyle changes, behaviours) (NICE 2009a) in a more collaborative
practitioner–patient relationship.
- Concordance: a jointly determined agreement between physician and patient as to
what is the appropriate treatment, following the patient having been fully informed of
the costs and benefits of adhering to their particular treatment. It does not explicitly
describe adherence behaviour, but more the conditions in which to encourage it.
Non adherence behaviour can be in many different variations such as not filling a prescription
to skipping a dose occasionally to not taking the medicine at all. The consensus, however, is
that a clinically relevant cut-off should be used wherever possible. So if it is not anymore
effective at a point then it is non adherence behaviour.

Do people adhere?
People always did not adhere to some degree and complaint anyways. But there are factors
which can be seen today which are similar across all illness non adherence behaviours.
adherence amongst those with cardiovascular disease averaged at 77 per cent, similar to the
taking of essential immunosuppressant drugs amongst adult organ transplant patients, where
22.6 per cent were found to not adhere (Dew et al. 2007). However, variation was seen across
many other conditions, attributed in part to treatment complexity (number, amount, type of
administration, timing of medicines, etc.) and individual beliefs about, as well as actual,
illness severity, and many other factors which we describe later in this section.

The costs of non-adherence

within the UK it has been estimated that individual non-adherence to prescribed medicines
costs the UK NHS approximately £200 million per year due to repeat admissions to hospital,
but a further £300 million may be wasted also due to not taking medicines as prescribed. This
includes an estimated £90 million worth of unused and unwanted prescription medicines
stored in individuals’ homes, £110 million returned to pharmacies, and £50 million worth
disposed within care homes.

Why do people not adhere to medical recommendations and treatments?

- Patient-related factors: like culture, age, personality, knowledge, personal and
cultural beliefs, attitudes towards illness and medicines and self-efficacy beliefs
- condition related factors: like symptom type, perceived severity (NOT actual
severity, diMatteo et al. 2007), presence or absence of pain, presence of comorbidities,
prognosis.
- Treatment-related factors: like the number, type, timing, frequency and duration of
dosage of medications, presence and extent of side affects, expense
- Socio-economic factors: low educational level, costs of treatment (relates also to
socio-economic equalities associated with ethnicity), access to dispensing pharmacy,
social isolation.
- System-related factors: communications with healthcare provider regarding
medicines, necessity or function, presence of traditional healing beliefs and systems
For most people non-adherence will be a mixture of all the factors above. Influences on
adherence can be considered as going from the micro level, which includes personality (for
example, the association between neuroticism and medication non-adherence in older adults,
Jerant et al. 2011), to the macro and meso level, such as culture and social systems.

Healthy diet
The World Health Organization (WHO 2002a) states that low intake of fruit and vegetables as
part of diet is responsible for over three million deaths a year, worldwide, from cancer or
cardiovascular disease. The World Health Organization attributes 16 million (1 per cent)
disability adjusted life years and 1.7 million (2.8 per cent) deaths worldwide to low fruit and
vegetable intake, with the highest percentage being in the developed world including Europe
and America, and the lowest attributable percentage being in high-mortality developing
countries including many parts of Africa. Furthermore, one-third of cancer deaths are
attributable, in part, to poor diet, particularly high intake of fats, salt and sugar and low levels
of fibre.

The health benefits of fruit and vegetable consumption

Fruit and vegetables contain, among other things, vitamins, folic acid, antioxidants and fibre,
all of which are essential to a healthy body. They may also offer protection against diseases
such as some forms of cancer, heart disease and stroke. For example, a recent large-scale
review and meta-analysis of data from prospective studies found limited evidence of benefits
of consumption for cancer risk, whereas all-cause mortality and cardiovascular disease risk
was significantly reduced by higher fruit and vegetable intake. Further evidence of the
beneficial effects of high fruit and vegetable intake comes from a large meta-analysis of data
involving 124,706 men and women where vegetarians had significantly lower cancer
incidence and significantly lower rates of ischaemic heart disease mortality (Huang et al.
2012) than non-vegetarians. However, vegetarians also reported lower rates of smoking and
lower levels of alcohol consumption than nonvegetarians, risk behaviours which were not
always controlled for in the analyses.
 😊
Also, this cute cow brought you a flower so maybe say thank you by not eating her and her
family or drinking the milk that is meant for baby cows for like a day in a week .

The benefits found are attributed to the presence of antioxidant compounds known as
‘polyphenols’, such as the flavonoids (specifically flavonol), and in the case of tomatoes,
lycopene (more being released when cooked than when eaten raw).

Why do people not eat sufficient fruit and vegetables?

the National Diet and Nutrition Survey (Food Standards Agency 2009) found that the foods
most frequently consumed by British young people (aged 4 to 18 years) were white bread,
savoury snacks (e.g. crisps), biscuits, potatoes and confectionery, although an encouraging
trend was seen in terms of increased fruit intake compared to previous years. Although the
average vitamin intake was not deficient, intake of some minerals was low.
These food preferences can in part be understood by the findings of another survey of British
young people (Haste 2004), which found that children gave ‘It tastes good’ (67 per cent) and
‘It fills me up’ (43 per cent) as the top two reasons for their favourite food choice, above
‘Because it is healthy’ (22 per cent) and ‘It gives me energy’ (17 per cent).
Food preferences
Whilst food preferences have a biological basis, they are also significantly determined by
social and cultural factors. Parents play a major role in setting down patterns of eating, food
choices and leisure activities inasmuch as they develop the rules and guidelines as to what is
considered appropriate behaviour. Food preferences are generally learned through
socialisation within the family, with the food provided by parents to their children often
setting the child’s future preferences for:
- cooking methods: home.cooked/fresh vs. ready-made/processed
- products: high fat vs. low fat, organic vs. non organic
- tastes: seasoned vs bland, sweet vs. sour
- textures: soft-crunchy, tender-chewy
- food components: red white meat, vegetables, fruit, grains, pulses and carbohydrates

Exercise
WHO says physical inactivity is the 4th leading risk factor for global mortality.
Recommendations to exercise
Specific recommendations regarding physical activity for adults (aged 18–64 years) suggest at
least 30 minutes of moderate intensity exercise on at least five days of each week (or as an
alternative to this, 150 minutes of moderate exercise, 75 minutes of high-intensity exercise)
and for children and young people (aged 5–17 years) the recommendations are higher,
suggesting at least 60 minutes of at least moderate to vigorous intensity exercise a day,
every day.
Within these guidelines are also recommendations for at least 2 exercise days to include
muscles strengthening exercise (3 times a week for children), and for adults, the aerobic
exercise should be done in bouts of 10 minutes plus duration. For those over 65 years of age,
the WHO guidelines are the same as for younger adults although specific recommendations
include balance-enhancing exercise for those with limited mobility.

Levels of exercise
There are suggestions that levels of childhood activity influence adult health and diseases risk,
but this might also be because the healthy lifestyle of children might adjust to a healthy
lifestyle in adulthood. While a greater percentage of younger adults (16 to 24 years) appear to
meet current recommended physical activity levels compared with older adults, the
prevalence of inactivity is high in child samples.

What are the physical health benefits of exercise

An early pointer towards the benefits of moderate to high levels of exercise came from a
longitudinal study of the lifestyles of 17,000 former graduates of Harvard University where
significantly more deaths occurred between 1962 and 1978 among those who reported leading
a sedentary life. Those who exercised the equivalent of 30–35 miles (48–56km)
running/walking a week faced half the risk of premature death of those who exercised the
equivalent of five miles (8km) or less per week. Moderate exercisers were defined as
exercising the equivalent of 20 miles (32km) per week, and these individuals also showed
health benefits in that on average they lived two years longer than the low-exercise group
In general, therefore, regular exercise is an accepted means of reducing one’s risk of
developing a range of serious health conditions. Once a relationship between behaviour and a
health outcome has been established, it is important to ask ‘how’ this relationship operates. In
terms of exercise and reduced heart disease risk, it appears that regular performance of
exercise:
- strengthens the heart muscles
- increases cardiac and respiratory efficiency
- tends to reduce blood pressure
- reduces the tendency of a person to accumulate body fat.

The psychological benefits

Exercise has been associated with psychological benefits in terms of elevated mood among
clinical populations such as those suffering from depression and elderly people. Regular
exercise has also been associated with reduced anxiety and depression and improved
self-esteem or body-image amongst non-clinical populations. Single episodes or
limited-frequency aerobic exercise appear beneficial also in terms of elevated mood,
self-esteem and prosocial behaviour, which are behavioural acts that are positively valued by
society that may elicit positive social consequences. These psychological benefits of exercise
have been attributed to various biological mechanisms, including:
- exercise-induces release of endorphins
- stimulation of the release of catecholamines such as noradrenaline and adrenaline
which counter stress response and enhance mood.
- Muscle relaxation which reduces feelings of tension
For some individuals, self-image and self-esteem may be enhanced as a result of exercise
contributing to weight loss and general fitness. Rightly or wrongly, we live in a society where
trim figures are judged more positively (by others as well as by ourselves) than those that are
considered to be overweight or unfit. However Mead and colleagues’ (2009) meta-analysis
found no significant linear relationship between the duration of exercise interventions and
reduced depression.

The negative consequences of exercise

Experimental studies have shown that depriving regular exercisers of exercise can lead to
mood reduction and irritability (e.g. review by Biddle and Murtrie 1991), with positive mood
restored when exercise is reinstated. As with eating disorders, it may be that exercise affords
an element of control to those who feel aspects of their lives are uncontrollable.

Why do people exercise (or not)?

Pros:
- Desire for physical fitness
- Desire to lose weight, change body shape and appearance
- Desire to maintain or enhance health status
- Desire to improve self-image and mood
- As a means of stress reduction
- As a social activity
Cons:
- Lack of time
- Cost
- Lack of access to appropriate facilities and equipment
- Embarrassment
- Lack of self-belief
- Lack of someone to go with to provide support
Health-screening behaviour
2 broad purposes of health screening

1. Identification of (behavioural and/or genetic) risk factors for illness to enable

behaviour change, leading to required behaviour or lifestyle change, or, in the case of
genetic risk, possibly prophylactic surgery
2. To detect early asymptomatic signs of disease in order to treat, leading to the person
possibly facing regular medication or further investigations

Screening for risk factors

- Screening for cardiovascular risk (cholesterol and blood pressure assessment and
monitoring)
- Eye tests to screen for diabetes, glaucoma or myopia
- Prenatal genetic testing
- Genetic testing for carrier status of the cystic fibrosis, Huntington’s disease gene or for
breast, ovarian or colon cancer in those with a family history
Genetic screening
A range of diseases have a genetic component: for example, cystic fibrosis which results
from mutation to a single gene; Downs syndrome which results from chromosomal disorder;
type 1 diabetes, breast and ovarian cancer, which have a multifactorial cause in that genetic
damage may have an acquired cause (e.g. diet) as well as being inherited. With advances in
the diagnostic technology for carrier status of genes predisposing to a range of conditions,
such as breast cancer

Screening for disease detection

- Screening for breast cancer (mammography)
- Screening for cervical cancer (cervical smear or Pap test)
- Antenatal screening (down syndrome or spina bifida)
- Bone density screening

Criteria for establishing screening programmes

- The condition should be an important health problem (prevalent or serious)
- There should be a recognisable early stage to the condition, or, in the case of screening
for risk factors, clear benefit to identify changeable risks
- Treatment at an early stage of a detected disease should have clear benefits to the
individual compared with treatment at a later stage
- A suitable test with good sensitivity and specificity should be available
- Adequate facilities for a diagnostic assessment and treatment should exist
- Screening frequency and follow-up should be agreed
- The individual and health-care costs should be considered in relation to the individual
and public health benefits
- Evidence based information regarding the potential consequences of testing any
potential further investigations or treatment should be provided to potential
participants in order to enable informed choice re-undertaking screening
- Any particular sub-groups to target should be identified
The costs and benefits of screening
Marteau and Kinmouth (2002: 78) suggested that the effects of screening on the individual are
not considered sufficiently. They highlight that information given to those invited for
screening tends be brief, emphasising the public health benefits of participation in terms of
reduced morbidity and mortality, rather than perhaps addressing the potential impact on the
individual. For an individual to be fully informed prior to making a decision about screening
uptake requires informing them about the possible adverse outcomes of screening and the
limited prognostic benefits of some treatments (if any are available) for some individuals.
In the case of genetic testing, for example to identify whether an individual carries the gene
that predisposes towards the development of Huntington’s disease (an adult-onset disease),
there is actually nothing that can be done to change the individual’s risk, and therefore some
question the value of screening other than as a means of preparing the individual for their
future.

Factors associated with screening behaviour

Factors that are associated with non-uptake of screening opportunities
- Lower levels of education and income
- Age (younger woman tend to not attend risk factor screening)
- Lack of knowledge about condition
- Lack of knowledge about purpose of screening
- Lack of knowledge about potential outcomes of screening
- Embarrassment regarding procedures involved
- Fear that something bad will be detected
- Fear of pain or discomfort during procedures
- Lack of self belief in terms of being able to practise self-examination correctly

Immunisation behaviour
Purpose of immunisation
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. Vaccination is the oldest form of immunisation, in which
immunity is provided to an individual by introducing a small amount of an antigen into their
body (either orally, intramuscularly or intradermally (injecting into the skin)), which triggers
the development of antibodies to that specific antigen. Public health specialists consider
vaccines both safe and successful and, at least in developed countries, vaccinations against
infectious disease have been credited with the virtual eradication of diseases that in previous
centuries caused widespread morbidity and mortality, such as smallpox, diptheria and polio.
A new vaccine has emerged which targets a sub-group of a family of viruses known
collectively as human papillomavirus (HPV) which is present in 70–95 per cent of cervical
cancers.

Costs and benefits of immunisation

Over the past century, the widescale benefits of childhood vaccination programmes have
become apparent. It is now rare for a child living in the Western world, and increasingly in
developing countries where vaccination programmes are being promoted, to die from measles,
diphtheria or polio. High hopes of achieving population immunity against measles following
the introduction of a vaccine in 1988, and high initial uptake (97 per cent), have not quite
been achieved, in part due to a now fully discredited 1998 study that reported adverse effects
of the combined MMR vaccination and received widespread publicity, leading to a downturn
in immunisation uptake, to an average 81 per cent in 2004.