ASBHDS Session 6 - Health-related behaviour, substance misuse, adherence

Question 1

What are health-related behaviours?

Answer 1

Anything that may promote good health or lead to illness.

• Smoking
• Drinking
• Drug use
• Taking exercise
• Eating a healthy diet
• Safer sex behaviour
• Taking up screening activities
• Adhering to treatment regimens

Question 2

What were the primary causes of death in England and Wales 2015?

Answer 2

Almost 1 in 4 deaths are ‘avoidable with lifestyle and healthcare changes’

Question 3

Why is there concern about health-related behaviour?

Answer 3

• At least one-third of all disease burden in developed world is caused by tobacco, alcohol, blood pressure, cholesterol and obesity
• Behavioural risk factors, including tobacco use, physical inactivity, and unhealthy diet, are responsible for about 80% of coronary heart disease and cerebrovascular disease.

- Smoking is estimated to cause about 71% of all lung cancer deaths, 42% of chronic respiratory disease and nearly 10% of cardiovascular disease.

Question 4

What are features/behaviour of longevity

Answer 4

• Sleep 7-8 hours a night
• Don’t smoke
• Eat breakfast most days
• Are currently at or near your “ideal” weight
• Usually don’t eat between meals
• Get regular exercise
• Drink alcohol in moderation (no more than 2 alcoholic drinks each day) or not at all

Question 5

Theories to help understand people’s health-related behaviour. Outline classical conditioning as a learning theory.

Answer 5

• Behaviours can become linked to unrelated stimuli.

- Conditioned behaviours – habit

• Many physical responses can become classically conditioned E.g. Anticipatory nausea in chemotherapy
• Behaviours such as smoking, drinking can become unconsciously paired with environment (e.g. work break), or emotions (e.g. anxiety)
• Aversive techniques in smoking/alcohol misuse involves pairing a behaviour with unpleasant response – alcohol + medication to induce nausea

- Break unconscious response – Change habits

Question 6

What are the limitations of conditioning theories?

Answer 6

• Classical and operant conditioning based on simple stimulus-response associations
• No account of cognitive processes, knowledge, beliefs, memory, attitudes, expectations etc.
• No account of social context

Question 7

Outline Operant Conditioning as a learning theory.

Answer 7

• People/animals act on the environment and behaviour is shaped by the consequences (reward or punishment)
• Behaviour increases if it is:

I. Rewarded

II. A ‘punishment’ is removed

• Behaviour decreases if it is

I. Punished

II. A reward is taken away

Question 8

What are the problems with operant conditioning?

Answer 8

- Problem is…

I. Unhealthy behaviours immediately rewarding! (alcohol, smoking, chocolate, unsafe sex….)

II. Driven by short term rewards

- Changing behaviour – Shape behaviour through reinforcement (punishment or reward) e.g. money saved towards holiday by giving up smoking

Question 9

Outline Social Learning Theory as a learning theory.

Answer 9

• People can learn vicariously (observation/ modelling)

E.g. Bandura and the Bobo Doll experiment

• Behaviour is goal-directed
• People are motivated to perform behaviours:

I. That are valued (lead to rewards)

II. That they believe they can enact (self-efficacy)

• We learn what behaviours are rewarded, and how likely it is we can perform behaviour, from observing others
• Modelling more effective if models high status or ‘like us’ (value/ability)
• Influence of family, peers, media figures, celebrities as role models

Question 10

Assess the pros and cons of the social learning theory.

Answer 10

• Harmful behaviours e.g. drinking, drug use, unsafe sex
• Positives

I. Peer modelling / education (e.g. safer sex)

II. Celebrities in health promotion campaigns

Question 11

Outline the Cognitive Dissonance Theory as part of the health belief model in social cognition models.

Answer 11

Cognitive dissonance theory (Festinger, 1957)

• Discomfort when hold inconsistent beliefs or actions/events don’t match beliefs
• Reduce discomfort by changing beliefs or behaviour
• Health promotion: Providing health information (usually uncomfortable) creates mental discomfort and can prompt change in behaviour. But information alone not effective

Question 12

What are the limitations of the Health Belief Model?

Answer 12

• Rational and reasoned? – sex / chocolate
• Decisions? – habit / conditioned behaviour / coercion
• Emotional factors (e.g. fear)
• Incomplete (self-efficacy, broader social factors)

Question 13

Outline the Theory of Planned Behaviour as a part of the social cognition model.

Answer 13

Question 14

Explain the intention behaviour gap in the Theory of Planned Behaviour.

Answer 14

• TPB – good predictor of intentions but poor predictor of behaviour
• Problem is translating intentions into behaviour
• Implementation intentions

Concrete plans of action – what will I do when and where

E.g. volitional help sheet (writing if-then statements) (Armitage 2008)

Question 15

Outline the stages of change model.

Answer 15

• Aka the transtheoretical model
• The way people think about health behaviours, & willingness to change their behaviour, are not static
• Stages of change model - 5 stages which people may pass through over time in decision making / change
• Different cognitions may be important determinants of health behaviour at different times

Question 16

What is substance abuse?

Answer 16

• Substance abuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs.
• Psychoactive substance use can lead to dependence syndrome - a cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance use.
• It typically includes a strong desire to take the drug, difficulties in controlling its use and persisting in its use despite harmful consequences
• In addition, it includes a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state.

Question 17

What are the three types of substances?

Answer 17

• Stimulants
• Hallucinogens
• Depressants

Question 18

What are stimulants? Provide some examples.

Answer 18

• Stimulants: These substances make you feel more alert and like you have more energy and confidence.
• Examples include tobacco, cocaine, amphetamine (speed) and mephedrone.

Question 19

What are hallucinogens? Provide some examples.

Answer 19

• Hallucinogens: These substances are sometimes described as ‘mindaltering’ as they can change/impact your perceptions, mood and your senses.
• Examples include LSD and magic mushrooms (note that sometimes drugs have mixed effects – ecstasy for example is sometimes described as a stimulant hallucinogen).

Question 20

What are depressants? Provide some examples.

Answer 20

• Depressants: These substances make you feel relaxed
• Examples include alcohol, heroin, tranquillisers and cannabis.

Question 21

Describe the common treatment regimes for various types of addictions and withdrawal states: The Medical Model.

Answer 21

Medical Model:

• Detoxification regimes
• Substitute prescribing
• Abnormal condition that causes discomfort, dysfunction, or distress to the individual afflicted
• Focus on the physical condition i.e. tolerance, physical withdrawal symptoms, vitamin deficiency, pancreatitis.
• Pharmaceutical treatment preferred

Question 22

Describe the common treatment regimes for various types of addictions and withdrawal states: The Disease Model.

Answer 22

• Step Facilitation
• AA/NA

I. AA started in UK IN 1940s, now 3,000+ groups

II. Meetings are central to the approach

III. Individuals present must reaffirm the “starting point of recovery” that is that he/she is “an addict”

IV. 12 Steps are referred to: these involve a Higher Power (God)

V. SMART Recovery an alternative

• Also known as The Minnesota Model in treatment terms, combines in-patient with therapy and groups
• Addiction is an illness, with loss of control the primary symptom.
• Addiction is genetic & therefore predetermined.
• Abstinence/avoidance is the only viable treatment

Question 23

Describe the common treatment regimes for various types of addictions and withdrawal states: The Behavioural Model.

Answer 23

• Motivational Interviewing
• CBT

I. Use of “tools” – drink/drug diaries, decision balance sheets

II. Believes that alcohol and drugs can be used by individuals to cope with anxiety, low self esteem amongst other things

III. Therefore uses techniques to address these feelings which will in turn reduce substance use. – Eg: Relaxation training, Anger Management, Problem-Solving Skills

• Addiction doesn’t exist, excessive use is merely a ‘mis-learnt coping-mechanism’
• Excessive use/misuse is a result of social, economic & familial learned experiences.
• Alternative coping mechanisms can be taught, & past experiences addressed

Question 24

Which treatment works for addictions and withdrawal states?

Answer 24

• Miller & Wilbourne (2002) evaluated 361 controlled studies in an attempt to rate the treatment efficacy of various alcohol interventions
• The Top 5:

1. Brief Interventions
2. Motivational Interviewing
3. Acamprosate
4. Relapse Prevention
5. Naltrexone

Question 25

What if they don’t want to change?

Answer 25

Harm Reduction

• Alcohol: Vitamin B
• Opiates: Naloxone
• Injecting: Needle exchange, BBV screening, sexual health
• Other routes of administration: sharing advice BBV screening

Question 26

What if they don’t want to stop?

Answer 26

Substitute prescribing

• Opiates:

I. Methadone. Opioid.

II. Buprenorphine. mixed agonist– antagonist opioid receptor modulator

• Amphetamine: Dexamphetamine

Question 27

What if they do want to change?

Answer 27

• Detoxification:
• Alcohol Benzodiazepines: Chlordiazepoxide
• Opiates: Opiate Substitutes: Methadone, Buprenorphine

Question 28

How to stay changed?

Answer 28

Relapsed Prevention:

• Disulfiram (Antabuse) – Alcohol Deterrent (24hr after last drink)
• Acamprosate (Campral) – Anti-craving (ASAP after detox)
• Naltrexone – Opioid-receptor antagonist (after detox)

Question 29

What are the two types of non-adherence?

Answer 29

• Erratic non-adherence: unintentional non-adherence occurs when the patient wants to follow the agreed treatment but is prevented from doing so by barriers that are beyond their control.
• Intelligent non-adherence: intentional non-adherence occurs when the patient decides not to follow the treatment recommendations. This is best understood in terms of beliefs and preferences that influene the person’s perceptions of treatment and their motivation to start and continue with it.

Question 30

Using the categories of non-adherence, can you come up with any suggestions as to why a patient may not adhere to her treatment?

Answer 30

• Illness: no symptoms, not perceived as severe, no relief from treatment
• Treatment: long treatment/waiting times, inconvenience, poor reputation, medication difficult to administer and unsupervised, side effects, stigma
• Patient: lack of understanding of treatment or recall, doesn’t align with beliefs (Health Belief Model)
• Psychosocial: cognitive or mental health problems, lack of social support, homelessness
• Healthcare: setting (including follow-up appointments), doctor-patient interaction (perceived competence, own attitudes) and communication (prescriber’s instructions unclear…), lack of concordance

Question 31

Describe the multidimensional model of adherence.

Answer 31

Question 32

There is increasing recognition that the key to making better use of medicines is the involvement of patients as partners in decisions about treatment – a procedure described as ‘concordance’. Outline it.

Answer 32

Concordance involves negotiation between patient & doctor over treatment regimes, in which patients beliefs and priorities are respected, the patient is active, and can make decisions in partnership with doctor.

Question 33

Describe the steps involved in concordance.

Answer 33

• Define problem: clearly specify problem taking in your own & patient’s views
• Convey equipoise: make clear there may not be set opinions about which treatment is best
• Describe treatment options, and consequences of no treatment
• Provide information in preferred format (e.g. written)
• Check patient understanding of options
• Elicit patient’s concerns & expectations about condition, possible treatments & outcomes
• Ascertain patient’s preferred role in decision making
• Defer if necessary: review needs & preferences after patient has had time for consideration, with family/friends, if they wish
• Review decisions after specified time period