Académique Documents
Professionnel Documents
Culture Documents
1-10
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).
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.
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)
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.
Clinical psychology
Clinical psychology is concerned with mental health and the diagnosis and treatment of
mental health problems using behavioral and cognitive principles.
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
this.
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
alone
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.
Prevalence
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.
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.
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).
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.
Obesity
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.
Causes
- 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
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
Healthy diet
Diet has direct and indirect links with illness.
Exercise
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
restored.
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
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.
Personality
- 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)
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.
Attitudes
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.
Self-efficacy
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.
Situation outcomes
Connecting situation to outcome
Outcome
X would cause Y
Behavior
Self efficacy
Believing you can do it
HBM (Health Belief Model) Rosenstock (1974), Becker (1974), Becker & Rosenstock
(1984)
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)
Outcome
Attitude towards
expectancies X
behavior
outcome value
Demographics
Normative beliefs
Personality X motivation Behavior Behavior
Subjective norm
to comply intention
Past Experience
Perceived internal
and external Perceived
control factors behavioral control
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
planning.
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.
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.
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.
D
Task self- Maintenance Recovery i
efficacy self-efficacy self-efficacy s
e
n
g
Outcome Action Action control
a
expectancies planning
Intention g
Coping e
Action
Risk planning m
perception e
n
Barriers and resources, e.g. social support t
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
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
phases:
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?
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
overwhelming.
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
failure).
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
session.
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
changes.
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
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.
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.
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.
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).
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
managed.
- 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.
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).
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.
Blood
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 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.
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.
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
acceptable.
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
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.
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.
Delay behavior
Refers to ones delay in seeking health advice. Safer et al. (1979) described 3 decision-making
stages:
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
delay)
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)
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
usual.
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.
- Professional-centered approach:
Health professional keeps control (e.g. asking direct/closed questions to gain
information)
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.
Patient factors
- High levels of anxiety or distress
- Lack of familiarity
- Failure to actively engage
- Not having considered issues to be discussed
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
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