Health Behaviour Change/Cancer Screening Flashcards
CHANGING HEALTH BEHAVIOURS
The Need to Change Behaviour
Components of Behaviour Change Interventions:
•Theory – How the intervention is supposed to work
•Behaviour Change Techniques (BCTs) – what the intervention includes.
•Form of Delivery – How the intervention is being delivered.
Chronic conditions (asthma, HIV/AIDS, high blood pressure, fatigue and headaches, heart disease, cancer diabetes and obesity etc.) illustrate a key role for behaviour and why changing health behaviour is central to health care management:
- to prevent illness - behaviour change is key to preventing chronic conditions. for example, stopping smoking can prevent lung cancer, eating a healthier diet can prevent bowel cancer and doing more exercise can prevent heart disease. this is sometimes called primary prevention.
- to manage illness - once diagnosed with a chronic condition, behaviour change is also key to illness management. for example dietary changes, increased exercise and encouraging medication adherence can a a central role in managing the illness which is called secondary prevention.
- to reduce physical symptoms - chronic conditions can result in a multitude of physical symptoms such as fatigue, pain, nausea and bowel problems which might be prevented through dietary changes and exercise
- to improve wellbeing - having a chronic condition can reduce a person’s wellbeing and quality of life. therefore behaviour change can also improve wellbeing such as being more active which can lead to more social support, and eating a healthier diet can help you feel more in control of your lives.
behaviour change can involve conscious and effortful (making decisions about how/whether to change behaviour, for example joining the gym) or unconscious and effortless (buying brown bread as that is all that is on offer) processing.
CHANGING HEALTH BEHAVIOURS
Learning and Cognitive Theory
learning theory forms the basis of much psychological work with its emphasis on associative learning, reinforcement, and modelling.
examples,
associative learning - we eat chocolate when we are fed up as we associate it with feeling special from when we were children
reinforcement - because our parents commented how lucky we were when they gave it to us
modelling - because we saw them eat it
LEARNING THEORY APPROACHES
explores ways on how to change behaviour
Reinforcement:
positively reinforcing the desired behaviour and ignore or punish the less desired behaviour. Barthomeuf et al. (2007) found that emotion expressed on people’s faces can influence food preferences. Harne-Britner et al. (2011) were able to improve health care workers hand hygiene by 15.5% using positive reinforcement with a sticker reward system. negative reinforcement can involve medication need to be taken. for example, consuming alcohol can cause sickness when taking Antabuse, and fatty foods can cause anal leakage when taking Orlistat. Also, people often change their behaviour in the longer term when the old unhealthy behaviour is no longer functional. for example, changing their diet when they find different foods more enjoyable.
Incentives:
financial incentives can change behaviour; changing the costs of cigarettes, fatty foods and fizzy drinks or directly paying people to lose weight, stop smoking, or be more physically active. Marteau et al. (2009) concluded that;
- the greater incentive, the greater the likelihood of behaviour change.
- incentives are better at producing short-term changes. the impact of incentive depends upon the financial state of the individual.
- incentives are more effective if the money is paid as close as possible to that target behaviour.
- incentives work better for discrete and infrequent behaviours such as vaccinations rather than repeated habitual behaviours such as diet or smoking.
- consequences of incentives includes undermining an individuals motivation to change their behaviour, undermines an individuals informed consent and autonomy, and may change the doctor-patient relationship if the patient is paid by the doctor to behave in certain ways.
Therefore, incentives change behaviour through a crude version of reinforcement and may have unintended consequences which may undermine changes in behaviour in the longer term.
Modelling:
research shows that children are likely/unlikely to smoke if there parent’s do/do not smoke, this also is seen in how much physical exercise a child sees there parents do. therefore, humans behaviour is influenced by their parents. this can have an impact on their diet, physical activity, emotional regulation, risk-taking behaviours.
Associative Learning:
involves pairing two variables together so that one variable acquires the value or meaning of the other. for example, Pavlov’s dogs heard a bell ring whenever they were given food which results in salivating when they hear the bell even without the food. one form of associative learning is evaluative conditioning whereby an attitude object is paired repeatedly with an object which is either positively or negatively as a means to make the attitude object either more positive or negative. this method is seen in marketing perfume, cigarettes, pet food, air freshener and pairing it with something inheritently attractive such as people, green fields, romantic music etc.
Exposure:
one of the best predictors of future behaviour is past behaviour, as having already performed a behaviour makes that behaviour seem familiar and can increase an individuals confidence that they can carry out that behaviour again. Research shows that we eat what we are familiar with and have been exposed to. daily exposure to vegetables for example can result in children eating more vegetables and having a preference for them. therefore simple exposure can change intake and preference. actually performing a behaviour once can increase the chances that this behaviour will occur again in the future. not only does past behaviour predict future behaviour but it also predicts and changes cognitions that then predict behaviour (Gerrard et al. 1996). for example, if i think ‘condoms are difficult to put on’ and my behaviour is ‘i don’t use condoms’ and then i put one on a banana during a skills training sessions, my cognition will shift to ‘actually i can use a condom’ and my behaviour will change as well to ‘i now use condoms’.
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ADDING COGNITIVE THEORY
Cognitive Behavioural Therapy:
Freeman (1995) describes how CBT emphasises the link between thoughts and feelings; therapy as a collaboration between patient and therapist; the patient as a scientist and the role of experimentation; the importance of self-monitoring and regular measurement; the idea of an agenda for each session set by both patient and therapist; the idea that treatment is about learning a set of skills and the therapist is not the expert who will teach the patient how to get better; the importance of regular feedback by patient and therapist.
CBT can use the following cognitive and behavioural strategies,
- keeping a diary
- gradually trying new behaviours (that have been avoided)
- cue exposure (clients exposed to triggering situations to help them learn new coping responses and extinguish old unhealthy reactions to these situations)
- relaxation techniques - music, relaxing muscles, recording soothing voices or messages as a means to aid relaxation which can reduce anxiety and negative thoughts.
-distraction techniques - for example, if a person feels the need to smoke when with certain friends, they can be taught hoe to focus on other aspects of their lives at these times or encouraged to use a telephone helpline.
- cognitive restructuring - central to CBT that behaviour is maintained through distorted cognitions and a vicious cycle between thoughts and behaviours which is perpetuated by irrational self-talk. cognitive restructuring involves challenging and changing these distorted thoughts and replace them with more helpful ones.
CBT and Chronic Illness:
CBT can be used on patients with HIV and cancer to change cognitions and promote behaviour change (Antoni et al, 2001, 2002). for example, beliefs that HIV or cancer are terminal illnesses and that nothing can be done will change a persons help seeking and feelings of hopelessness will change their mood and quality of life. They outline a detailed system for changing irrational thoughts using rational thought replacement, which they call the ABCDE system (awareness, beliefs, challenge, delete, and evaluate). CBT has also been used to treat mental health problems such as panic disorders, OCD and eating disorders.
Relapse Prevention:
CBT describes a number of cognitive and behavioural strategies to help people change their behaviour. Marlatt and Gordon (1985) developed a relapse prevention model to explore the process that occur when a change in behaviour fails to last and people relapse. main concepts based in this model are of addictive behaviours:
- addictive behaviours are learned and therefore can be unlearned
- addictions are not ‘all or ntohing’ but exist on a continuum
- lapses from abstinence are likely and acceptable
- believing that ‘one drink-a drunk’ is a self-fulfilling prophecy
They examined the process from abstinence to relapse and the mechanisms that may explain the transition from lapse to relapse.
Processes of addictive behaviours:
baseline state - if an individual sets total abstinence as the goal, then this stage represents the target behaviour and indicates a state of behavioral control
pre-lapse state - high-risk situation (any external/internal situation that may motivate the individual to carry out the behaviour); coping behaviour - once exposed to high-risk situations the individual engages the coping strategies (behavioural strategies such as avoidance, a substitute behaviour like eating, or cognitive such as remembering why they are attempting to abstain); positive outcome expectancies - according to previous experience the individual will either have positive outcome expectancies if the behaviour is carried out or negative outcome expectancies
No Lapse or Lapse?
Marlatt and Gordon (1985) argue that when exposed to a high-risk situation, if an individual can engage good coping mechanisms and also develop negative outcome expectancies, the chances of a lapse will be reduced and the individuals self-efficacy will be increased. However, if the individual engages poor copings strategies and has positive outcome expectancies, the chances of a lapse will be high and the individuals self-efficacy will be reduced.
- no lapse - good coping strategies and negative outcome expectancies will raise self-efficacy, causing the period of abstinence to be maintained
- lapse - poor or no coping strategies and positive outcome expectancies will lower self-efficacy, causing an initial use of the substance (the cigeratte, a drink). this lapse will either remain an isolated event and the individual will return to abstinence, or will become a full-blown relapse. Marlatt and Gordon describe this transition as the abstinence violation effect (AVE) which involves cognitive dissonance and internal attributions that lead to relapse..
The Abstinence Violation Effect (AVE):
the transition from initial lapse to full-blown relapse is determined by dissonance conflict and self-attribution. dissonance is created by a conflict between a self-image as someone who no longer smokes or drinks and the current behaviour (e.g. smoking/drinking). this conflict is exacerbated by a disease model of addictions, which emphasises ‘all or nothing’, and minimised by a social learning model, which acknowledges the likelihood of lapses. the techniques used to help the individual deal with the transition involves (Marlatt and Gordon developed this):
- self-monitoring
- relapse fantasies
- relaxation training/self-management
- skills training (‘how will i say no to a drink?’)
- contingency contracts (‘when offered a cigarette i will’…)
- cognitive restructuring
Learning theory forms the basis of many interventions to change behaviour.
- behavioural strategies (reinforcement, modelling, and associative learning)
- cognitive and behavioural strategies (CBT and relapse prevention)
CHANGING HEALTH BEHAVIOURS
Social Cognition Theory
Social cognition theory emphasises expectancies, incentives and social cognitions. expectancies includes beliefs, incentives relate to the impact of the consequences of any behaviour and are closely aligned to reinforcements, and social cognitions reflect an individuals representations of their social world in terms of what other people around think about any given behaviour.
Social Cognition Model Based Interventions:
Sutton (2002b, 2010) described a series of steps to develop an intervention based upon the TPB, although he argued that the steps could also be applied to other social cognition models,
Step 1 - identify target behaviour and target population
Step 2 - identify the most salient beliefs about the target behaviour in the target population using open-ended questions
Step 3 - conduct a study involving closed questions to determine which beliefs are the best predictors of behavioural intention. choose the best belief as the target belief
Step 4 - analyse the data to determine the beliefs that best discriminate between intenders and non-intenders. these are further target beliefs
Step 5 - develop an intervention to change these target beliefs
The Theory of Planned Behaviour can be used as a framework for developing a behaviour change intervention, however the intervention itself remains unclear. A behaviour changing programme is also the causal modelling approach which involves the following frameworks: persuasion, information, increasing skills, goal-setting and rehearsal of skills (TPB also has these frameworks). there is also the ‘elaboration likelihood’ model which involves the presentation of ‘strong arguements’ and time for the recipient to think about and elaborate upon these arguments.
Evidence for Social Cognition Model Based Interventions:
some problems identified in using social cognition models for interventions as follows,
How to change beliefs?
many interventions are based upon theories which is often used for the design of process and outcome measures and to predict intention and behaviour rather than to design the intervention itself. using TPB for behaviour change interventions describes which beliefs should be changed but not how to change them
Does behaviour change?
studies indicate that there is an attenuation effect whereby any changes in beliefs are attenuated by other variables in the model to reduce their impact upon behaviour. the use of theory and the success of the intervention still remains unclear.
Do they miss other important factors?
Sniehotta (2009) described the ‘bottleneck’ whereby interventions using TPB assume that all changes in behaviour will be mediated through intentions. this, he argues, misses the opportunity to change other relevant factors that may influence behaviour directly, such as changes in the environment, and which do not need to pass through behavioural intentions.
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Making Plans and Implementation Intentions
much research indicates that although an individual may make an intention to carry out a behaviour this intention is not always translated into practice. this is known as the intention-behaviour gap and appears to result from intenders who do not act rather than non-intenders who do act.
Research highlights ways that this gap can be closed and in 1993 Gollwitzer defined the notion of implementation intentions which involve the development of simple but specific plans, after intentions, as to what an individual will do given a specific set of environmental factors. Therefore, implementation intentions describe the ‘what’ and the ‘when’ of a particular behaviour. For example, the intention ‘i intend to stop smoking’ will be more likely to be translated into ‘i have stopped smoking’ if the individual makes the implementation intention ‘i intend to stop smoking tomorrow at midday when i have finished my last packet’. Implementation intentions are quite similar to the notion of SMART goals that are used in other disciplines, and which stand for goals that are Specific, Measurable, Achievable, Reasonable and Timebound.
Evidence for implementation intention interventions:
experimental research has shown that encouraging individuals to make implementation intentions can increase the correlation between intentions and behaviour for a range of behaviours. Gollwitzer and Sheeran (2006) carried out a meta-analysis of 94 independent tests of the impact of implementation intentions on a range of behavioural goals and concluded that implementation intentions had a medium to large effect on goal attainment. they provide a simple way to promote and change health-related behaviours. However, critisicms include,
- do people make plans when asked to?
- the impact of existing plans
- do people own their plans?
- is all behaviour change volitional?
- not all plans are the same
Information Giving:
If a person believes ‘i smoke but i am not at risk of getting lung cancer’, then to change their behaviour the starting point would be to improve their knowledge about their health. their has been information provision through leaflets, billboards, campaigns, TV advertisements and group-based seminars and lectures. O’Brien and Lee (1990) found in their study that increased knowledge was related to future healthy behaviour. Hammond et al. (2003) also found that labels on cigarette packets are effective with more people intending to stop smoking or attempt to. Information giving can be more complex for interventions such as CBT, relapse prevention and psychoeducational interventions with people in rehabilitation. information giving is useful and necessary but is not sufficient enough to change behaviour. Therefore, social cognition theory has informed much on predicting and explaining health-related behaviours and the basis for behaviour change interventions.
CHANGING HEALTH BEHAVIOURS
Stage Models
Stage-Matched Interventions
a stage model approach to behaviour highlights how people show different levels of motivation to change their behaviour at different stages. A stage approach has often been combined with many strategies derived from learning and cognitive theory or social cognition theory described above so that interventions can be targeted to people according to where they are in the process of change. This has taken the form of either tailored or stage-matched interventions. This approach tends to be more affective as the intervention provided makes more sense to the individual.
Motivational Interviewing (MI)
if people are at a stage when they are unmotivated to change their behaviour, then their seems little point in offering them an intervention to including them in a study, particularly as motivation is a consistently good predictor of behavioural intentions and behaviour. MI was developed by Miller and Rollnick (2002) as a way to help people consider changing their behaviour and to increase their motivation to change. MI doesn’t show how to change but encourages them to think about their behaviour in ways that may make them realise they should change.
CHANGING HEALTH BEHAVIOURS
The Role of Affect
Using Fear Appeals:
in recognition of the role that emotion plays in behaviour many health promotion campaigns include fear appeals which are designed to raise fear as a means to change how people behave. Fear appeals typically provide twp types of message relating to fear arousal (there is a threat or risk and its serious) and safety conditions (the action is easy and effective, its a recommended protective action). They are designed to generate an emotional response (i.e. fear) and offer a simple way to manage the threat (i.e. change behaviour).
The Problem with Blocking:
the key problem with fear appeals and the process of arousing strong emotions is that when aroused, people tend to block the information they are hearing. Therefore, when presented with messages trying to change their behaviour, many people resist, using a number of strategies such as avoidance, ignoring and finding fault in the arguments used, or criticizing the mode of presentation (Jacks and Cameron 2003; Harris and Epton 2009). this create a problem in those trying to change behaviour as the message cannot get through. research has highlighted two potential strategies to counteract this tendency to block: the use of visual images and self-affirmation.
Using Visual Images:
visual images may be more effective at conveying information or changing beliefs compared to language-based measures. this forms the basis of advertising, marketing and health education campaigns and is central to the use of diagrams and illustrations throughout education. some research has explored the impact of visual images in health research (higher intention to change behavior, higher self-efficacy and a change in beliefs, cognitions and behaviour).
Using Self-Affirmation:
self-affirmation theory is grounded on the idea of ‘self-integrity’ and argues that people are inherently motivated to maintain their self-integrity and their sense of self as being ‘adaptively and morally adequate’. If a persons integrity is challenged by information indicating that their behaviour is damaging, then they resist this information as a means to preserve their sense of self. This perspective provides a framework for understanding the process of blocking. It also highlights a way to encourage people to stop blocking and respond to the message in the desired way. In particular, self-affirmation theory indicates that resistance can be reduced if the individual is encouraged to enhance their self-integrity by affirming their self-worth by focusing on other factors that are core to how they see themselves but unrelated to the threat.
Using Affect Effectively:
Fear appeals use emotion to change behaviour yet can be met with resistance with people blocking the information as it challenges their sense of integrity. Visual images and self-affirmation are useful approaches to limit this process of blocking. How fear appeals, visual images and self-affirmation can work together is shown below, with the example of someone who is obese,
- fear appeal: ‘being overweight can cause heart disease’
- emotional response: ‘anxiety’
- resistance: ignoring the message/thinking ‘research is always wrong’ or ‘that leaflet isn’t very well designed’
- self-affirmation intervention: ‘think of times when you have been kind to others’
- visual image: here is an image of fatty deposits on an artery
- emotional response: ‘i am reassured’, ‘i am a good person’
-reaction to fear appeal: ‘maybe i should lose some weight’
Affect can be used to change behaviour. this can involve fear appeals which generate strong emotions, the use of visual images and the use of self-affirmation.
CHANGING HEALTH BEHAVIOURS
Integrated Approaches
Creating a Science of Behaviour Change Interventions
there has been a call to improve intervention research in the following ways,
- to improve the reporting of interventions to make the process more transparent and easier to synthesise and replicate;
- to identify which aspects of behaviour change interventions are effective;
- to improve the design and therefore effectiveness of behaviour change interventions
this call for a science of behaviour change interventions has involved two key approaches; the integration of theories of behaviour change and the development fo a taxonomy of behaviour change techniques (BCT’s)
- The Integration of Theories of Behaviour Change:
The COM-B - created to reflect a comprehensive and parsimonious approach to behaviour and the factors necessary for behaviour change to occur. COM-B highlights the key role of Capability, Opportunity, Motivation and Behaviour to predict and explain a multitude of behaviours.
The Theoretical Domains Framework (TDF) - Michie and his colleagues developed the TDF as a means to synthesize across the different theories that psychologists us to predict behaviour and design and evaluate behaviour change interventions. researchers have identified 33 theories and 128 theoretical constructs which have been groups into 14 domains and a guide has been developed for the use of TDF in the development of interventions.
- The Development of a Taxonomy of Behaviour Change Techniques (BCT’s):
Michie and colleagues developed a taxonomy of behaviour change techniques (BCT’s) which is an active ingredient of the interventions and mechanisms of change. to achieve this, they have coded and classified the components of a vast range of protocols and interventions to label which strategies are being used. this process has gone through permutations and has generated a long and comprehensive list of all the different actions that can be carried out to bring about behaviour change. the ultimate goal is that these techniques can be matched to their target behaviour and populations so that researchers can calculate which techniques are most effective at producing change in which behaviours and populations.
•Common language for designing, reporting and evaluating behaviour change interventions which improves fidelity.
•Observable and replicable.
•Used alone or in combination with other BCTs.
•Can have a measurable effect on a specified behaviour. Michie & Johnston (2012)
Challenges in identifying BCTs
•Need a standardised language to describe BCTs and the content of behaviour change interventions.
•This would make it easier to see what intervention content is effective.
Example of BCT Taxonomy - Abraham & Michie, 2008:
•The taxonomy was designed to provide standardised, theory-linked definitions of BCTs (what theories you can use for any one of the 26 BCTs).
This was with the aim of:
•Facilitating the identification of techniques used in interventions from intervention descriptions.
•Providing standardized definitions of intervention techniques to be used for published pieces of work.
•26 BCTs were identified in intervention manuals and intervention descriptions using a coding manual.
•Resulted in standardised definitions for 26 BCTs alongside their theoretical underpinning.
BCTs and Theory
•Efficacy of interventions is not predicted by number of BCTs but by having a theoretical underpinning (Dombrowski et al., 2012).
•Interventions which used BCTs that were consistent with Control Theory had better results for weight loss in an obese adult population than interventions which used less BCTs that were consistent with Control Theory.
The Behaviour Change Wheel (BCW):
Bichie and colleagues have integrated existing theories of behaviour change to produce the COM-B and TDF. they have also identified and coded a wide range of BCTs as a means to improve both the reporting and effectiveness of interventions and also to target specific techniques at specific behaviours and populations. In 2011, Michie et al. carried out a synthesis of all the different types of taxonomy as a means to identify essential conditions for behaviour change and how these could be turned into actual behaviour change. Took 19 intervention development frameworks that they didn’t believe to work in isolation and integrated them into one holistic framework which could aid the development of behaviour change interventions. from this process, the researchers created a behaviour change wheel with three levels illustrating the translational process from essential conditions, through intervention functions, to policy.
- essential conditions - the researchers identified 3 conditions which are deemed essential for behaviour and behaviour change: capability, motivation and opportunity. the constructs reflect the COM-B.
- Intervention functions - changing behaviour requires a change in these essential conditions and that a series of intervention functions can bring this change about. the nine functions reflect a synthesized version of the many strategies that are used to change behaviour and were derived from a detailed coding process. these reflect the BCT’s.
- Categories of policy - the researchers argue that policy changes are needed to enable the interventions to occur. Interventions can be designed with the view of making new policy in addition to being linked to policy.
Form of Delivery (FOD)
•Relevant delivery features of interventions.
•Inclusive of, but not limited to, intervention provider, duration and intensity of intervention, intervention setting and materials.
•Multiple FOD elements will be present in each intervention (e.g. delivery style, communications style, communication techniques, visual styles and complexity), Dombrowski, O’Carroll and Williams (2016).
Why is FOD important?
•Can be used to translate theory into real world.
•Can influence effectiveness of BCTs.
•Can influence participant engagement in interventions.
•Intervention content may be understood differently depending on FOD.
•Can directly influence intervention effectiveness.
•Can support sustained behaviour change.
Dombrowski, O’Carroll and Williams, (2016)
Why do you think interventions are complex?
•Interventions have a number of components.
•They can act independently from one another or inter-dependently.
•Active ingredients of interventions can be hard to define and identify.
•Interventions can be delivered to a wide variety of people:Individuals, Organisations, and Population level
•People delivering and receiving interventions.
•Fidelity
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Developing Behaviour Change Interventions
Medical Research Council (MRC) Framework (2000):
•A framework to develop and evaluate RCTs for complex interventions to improve health.
•Interventions are evaluated using this framework so the recommendation is that we also design them with these factors in mind.
•The Framework recommends that interventions follow this process:
1.Preclinical – theory.
2.Phase 1 – modelling.
3.Phase 2 – exploratory trial
4.Phase 3 – definitive RCT
5.Phase 4 – long-term implementation
TIDieR Checklist:
•Template for Intervention Description and Replication (TIDierR).
•Checklist was developed to improve the reporting and replicability of interventions.
•This resulted in a 12-item checklist; Name, rationale, materials, procedures, provider, modes of delivery, locations, duration and intensity, tailoring, modifications, assessing fidelity.
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What is MAP?
•A behaviour change toolkit designed by NHS Education for Scotland.
•Provides practitioners with the skills to support behaviour change that are relevant to their patients stage of change and practitioners level of competence.
•MAP is a mnemonic which stands for – Motivation, Action and Prompts and Cues.
•Designed to be used by those who do not specialize in delivering behaviour change interventions.
•Specific evidenced based BCTs , known for their efficacy in changing key health behaviours were mapped onto one of the three routes outlined in MAP.
MAP Routes of Behaviour Change
•Motivation – the BCTs in the motivation route are designed to support individuals in the pre-intentional phase of behaviour change.
•Action and Prompts and Cues – the BCTs in these stages focus on the post-intentional phases of behaviour change and aims to reduce the intention-behaviour gap.
Dixon & Johnston (2020)
MAP BCTs:
Motivational Stage - Pros and Cons, comparative imagining of future outcomes, social support
Action Stage - Goal setting (outcome), goal setting (behaviour), action planning, coping planning, review goals, self-monitoring, social support
Prompts and Cues - Rewards, adapt the social and physical environment, habit formation, social support
How does MAP cover the core components of interventions?:
Theory - Dual process theory
•Incorporates 12 evidenced-based BCTs.
•Form of Delivery - Intensity, Style, Participant materials, Provider of intervention, and Delivery format.
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Health Inequalities and Behaviour Change Interventions
What is the Scottish Index of Multiple Deprivation?:
•SIMD - A measure of multiple deprivation.
•Doesn’t only consider low income but the things that communities identify as being important to them: Income, Employment, Education, Health, Access to services, Crime, and Housing
•SIMD was published in January 2020.
•Scottish Index of Multiple Deprivation highlights areas that would benefit from receiving greater support and intervention.
Model Technologies
Ecological Momentary Interventions (EMIs):
the term EMI refers to treatments provided to people during their everyday lives and in natural settings. such treatments/interventions have been used for a wide range of behaviours such as smoking cessation, weight loss, anxiety, alcohol use, dietary change and exercise promotion. They have also been used on different chronic illnesses but are particularly useful for hard-to-reach groups such as adolescents who would usually avoid contact with health professionals. Affective text messaging has been shown to be affective in changing behaviour and promoting physical activity. This intervention is easily and successfully delivered, is acceptable to patients, and effective at changing a wide range of behaviours including smoking. are also cost-effective.
Web-Based Interventions:
patients who are unable to or unwilling to attend face-to-face consultations can now engage in a range of therapeutic strategies from their own home to fit in with their own time frame. this kind of intervention can reach a large amount of people, however, there can be high-level dropout rates over time as they may not want to or are unable to come into a consultation. they may be effective but still seem to require therapist involvement to be more successful.
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The Mass Media
The Media as a Negative Influence:
although cigarette and alcohol advertisements have been banned across the USA and most of Europe, food adverts are still considered acceptable. Unhealthy foods have been shown to be on air twice as much as healthy foods for children under 5 (Radnitz et al. 2009). Halford et al. (2004) found that obese children recognised more of the food adverts and that the degree of recognition correlated with the amount of food consumed. Furthermore, all children ate more after exposure to the food adverts.
The Media as a Resource for Positive Change:
media can also promote health behaviour. there is little evidence on the effectiveness of campaigns, and debates on whether to raise awareness rather than change behaviour. Ongoing campaigns over many years may cause change through a ‘drip drip effect’ as successive generations gradually become accustomed to a new way of thinking or behaving. This is particularly apparent in the reduction in drink driving over the past decade. No one campaign may have made this happen but negative attitudes towards drink driving in the new generation of drivers may be a response to always having been aware that this was not an acceptable thing. Memorable campaigns over recent years include,
- ‘five a day: just eat more’
-‘most people are killed by someone they know’
- ‘sharing your mate’s work means sharing with everyone he’s ever shared with’
Understanding Media Campaigns:
media campaigns use several psychological strategies described above to encourage us to change our behaviour. these include modelling, fear appeals, visual imagery, targeting a specific audience, and encouraging people to focus on the negative aspects of what they do. The elaboration likelihood model (ELM) was developed as a model of persuasion and provides a framework for understanding why some media campaigns might be more successful than others and how they could be improved.
The ELM argues that in order for people to change their beliefs and behaviour, they need to be motivated to receive the argument and centrally process the argument. this will occur if the message is congruent with their existing beliefs, the message is personally relevant to them and the individual can understand the arguement.
The ELM offers another route if others are not motivated in changing their behaviour/beliefs called ‘peripheral processing’. this involves using direct cues and information, maximising the credibility of the source of the message and maximising the attractiveness of the source of the message.
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Understanding Sustained Behaviour Change
even though there has been much research and a multitude of interventions, many people continue to behave in unhealthy ways. Rates of sustained behaviour change are poor, with many people reverting to their old habits. If real changes are to be made to peoples health status, then research needs to address the issue of behaviour change in the longer term. To date, however, most research has focused on the onset of new behaviours or changes in behaviour in the short term due to the use of quantitative methods, with prospective designs that have follow ups require greater investment of time and cost. some research however, has addressed the issue of longer-term behaviour change maintenance, particularly for weight loss, smoking cessation and exercise.
In general it seems that there is a role for a range of demographic, psychological and structural factors in understanding longer-term changes in behavior and that, while some changes in behaviour may result from the ‘drip drip’ effect illustrated by stages and plans, other forms of change are the result of more sudden shifts in an individuals motivation. Further, the existing research tends to focus on behavior-specific changes rather than the factors that may generalise across behaviours.
CHANGING HEALTH BEHAVIOURS
Thinking Critically About Changing Health Behaviours
Problems with Theories and Models
Stage Models - these assume stages are qualitatively different to each other rather than seeing behaviour as a continuum
Social Cognition Models - these suffer from issues of whether they measure or change beliefs, whether the constructs they describe are separate from each other or tautological and whether the theories can ever be rejected
Problems with Research Methodology
Research Design - due to funding issues, time and the involvement of researchers much research in this area is limited by poor research designs which use only short-term follow-ups, cross-sectional or longitudinal designs. Randomised controlled trial can only tell us what works for some of the people some of the time and cannot highlight which component of any intervention is particularly effective and which adds nothing to improving health outcomes.
Sampling - research aims rarely involve representative samples so that the results can be generalised beyond the study.
Problems with the Assumptions Behind this Research Area:
research exploring behaviour change also makes assumptions which are problematic,
- the science of behaviour is the same as that of behaviour change
- behaviour is rational
- people change their behaviour because of what is done to them
- professionals do what they are told to do by the protocol
ACCESSING HEALTH CARE
A Brief History of Health Care
The Role of Medical Interventions
research indicates wide variability in health care professionals, the distances needed to travel to access health care and the availability of free health care vs. the need for health insurance.
New Medicines:
In the western world, HIV/AIDS is now considered a chronic illness with many people living with the HIV virus having a normal life expectancy. This change has been attributed to the antiretroviral medication HAART. In sub-Saharan Africa, however, where HAART is less available, HIV/AIDS still shows the pattern of an acute terminal illness. The life expectancy of a person in non-african countries with AIDS is similar to a person without AIDS. In contrast, African countries sees a huge gap between the life expectancy of these two populations.
Availability of Vaccinations:
there is also worldwide variation in vaccinations for illnesses such as measles which could be due to the presence of a skilled professional at the birth.
Availability of Skilled Health Professionals:
child mortality rates also vary by geographical region which could be due to the presence of a skilled professional at the birth.
Not Just Medical Interventions: Thomas McKeown (1979) examined the impact of medicine on health in the 17th century and argued that there was a commonly held view that illnesses was related to medical intervention however, the reduction in such illnesses was already underway before the development of the relevant medical interventions. Therefore he claimed that the decline in infectious diseases seen throughout the past 3 centuries is best understood no in terms of medical interventions, but in terms of social and environmental factors ' prediction improved nutrition, better hygiene and contraception' (McKeown 1979:117).
Environmental Factors:
environmental factors include food availability, food hygiene, sanitation and sewage facilities, and clean water. these basic requirements vary by country and may contribute to health inequalities. In 2009, WHO reported defecating in the open which raises risks of worm infestation, hepatitis, cholera, trachoma, and environmental contamination. The use of improved sanitation facilities by WHO region indicates that the lowest rates of use of improved sanitation facilities were in the African and South-East Asian regions.
Poor water also relates to illnesses such as vomiting, sickness, diarrhoea and cholera. WHO data shows the lowest levels of drinking safe water are in the Africa and South-East Asian regions.
There are variations in key environmental factors contributing to health, with a focus on the quality of food available,e asy access to fast unhealthy food, working environments that encourage a sedentary lifestyle, town planning which makes walking hard and using the car the norm, the absence of walkways or cycle paths and poor street lighting.
ACCESSING HEALTH CARE
Health Care Systems
Self-Care:
many symptoms and illnesses are managed through self-care with no need for professional input. this includes having plasters creams, pain relief pills, over-the-counter medicine, internet and self-help books. Therefore many symptoms are not taken tot he doctor. when they are, however, in most countries across the world, they are met with a two-tiered system of primary and secondary care.
Primary Care:
primary care is the first contact with the health service and the patient is free to make an appointment whenever they feel they need one. In primary care they are met by generalist practitioners who have been trained to recognise and cope with whatever problems come through their door. However places such as the USA have some doctors who are both generalists and specialists. Including chats relating to social problems (like housing issues), chronic illnesses, and common mild symptoms (like a cold). The role of the primary care team is to diagnose and manage whatever problems a second opinion and further tests. The primary care team are therefore the gatekeepers into secondary care. this process prevents secondary care being inundated with less serious medical problems, but errors inevitably occur as minor problems are referred on and serious problems are missed.
Secondary Care:
if referred by their GP, a patient is then permitted to see a specialist in secondary care. In most countries access to secondary care can only occur via a referral letter from the GP although this is changing as patients are increasingly becoming consumers of health care and demanding their right to see whoever they want. Private practice also changes this division as patients can choose to pay to see secondary care specialists if they have the money or health insurance. professionals in this sector work in teams relating to body systems and tends to be based in a hospital with outpatient and inpatient systems.
ACCESSING HEALTH CARE
Help Seeking and Delay
According to the medical model perspective, help-seeking relates to two factors:
- symptoms - the patient has a headache, back problem or change in bowel habits that indicates that something is wrong
- signs - on examination the doctor identifies signs such as raised blood pressure, a lump in the bowel or hears rattling when listening to a patients chest which indicates that there is a problem.
From this perspective the doctor is a detective and the patient is required to bring them the problem. However, help-seeking is not as simple as this, as many people go to the doctor with very minor symptoms and many patients don’t go to the doctor when it is something serious. This is known as the ‘clinical iceberg; to reflect the vast number of problems that never reach the doctor.
A Series of Thresholds:
Help-seeking is more complex than the detection of symptoms and the identification of signs and can be understood in terms of a number of thresholds that need to be reached,
- is it a symptoms?
- is it normal or abnormal?
- do I need help?
- Could a doctor help?
these thresholds can be understood in terms of four processes which have been explored within both psychological and sociological research,
- symptom perception
- illness cognitions
- social triggers
- costs and benefits of going to the doctor
Symptom Perception: our perceptions of having symptoms is influenced by four main sources of information, - bodily data - mood - cognitions - social context
Illness Cognitions:
once a symptom has been perceived as such, a person then forms a mental representation of the problem. this can be called their ‘illness cognitions’. this consists of dimensions relating to identity (what is it?), time line (how long will it last?), causes (what caused it?), consequences (will it have a serious effect on my life?), and control/cure (can i manage it or do i need treatment?). this will be helped by social messages from friends, family or the media to decide whether or not a symptom is serious, abnormal or manageable by self-care. it will also be influenced by the persons own health history and may be less surprised by a symptom. this process is called normaisation which can pose problems for both patient and doctor (once in a consultation) as a heavy smoker might say they are always breathless and have become used to it.
Social Triggers:
How the symptoms might have an impact on their daily lives, social triggers are as follows,
- perceived interference with work or physical activity
- perceived interference with social relations
- an interpersonal crisis
- sanctioning
Together symptom perception, illness cognition, and social triggers take the idnviidual up the thresholds towards help-seeking for a particular problem. the final set of factors influence this process are the perceived costs/beenfits of going to the doctor.
Costs and Benefits of Going to the Doctor:
- Therapeutic (access to treatments/doesnt like to take medication, physical and potentially embarrassing tests or conversations)
- practical (time away from work/family/fare and effort)
- emotional (reassurance from doctor, caring vs. feeling embarrassed or a nuisance)
- the sick role (doctors can legitimise their symptoms which comes with two benefits/obligations - excuses normal roles and duties and no longer responsible for their illness; they must want to get well and adhere to what the doctor says)
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Delay
Definitons of Delay:
refers to the time between detecting a sign or symptom and the first contact with a health professional. Although the notion of delay is quite complex. It is difficult to measure whether a patient has delayed their help-seeking and, if so, for how long.
Predictors of Delay:
predictors of delay include,
symptom perception - ‘i am too busy to think about my symptoms’
Illness cognitions - ‘it will go away soon’
Social Triggers - ‘my friends have reassured me that this is normeal’
costs and benefits of going to the doctor - ‘doctor’s can’t do much for indigestion’/’I don’t want to bother a busy doctor with my problems’
Interventions for Delay:
interventions for adherence encourage patients to take their medications and interventions for behaviour change encourage people to eat more healthily or stop smoking (the outcome is clear). however interventions for delay are more complex, serious illness are often the same as symptoms for minor illnesses. The system would collapse under the weight of demand if everyone seeks help whenever they experienced a symptom and as soon as the symptom started. Inteventions to prevent delay need to be extremely specific in terms of the advice they give and who they give it to, and should only intervene if early intervention has been proven to be both cost-effective and therapeutically effective.
ACCESSING HEALTH CARE
Screening
What is Screening? screening programmes (secondary prevention - interventions aimed at detecting illness at an asymptomatic stage of development so that its progression can be halted or regarded) take the form of health checks, such as measuring weight, blood pressure, height, urine, carrying out cervical smears and mammograms and offering genetic tests for illnesses such as Huntington's disease, some forms of breast cancer and cystic fibrosis.
Three broad definitions of screening were defined: opportunistic screening which involves using the time when a patient is involved with the medical services to measure aspects of their health, and population screening which involves setting up services specifically aimed at identifying problems. Self-screening, for example, is when people are encouraged to practise breast and testicular self-examination and it is now possible to buy over-the-counter kits to measure blood pressure, cholesterol and blood sugar levels.
The aim of all screening programmes is to detect a problem at the asymptomatic stage, this results in discovering a risk of the disease (primary screening) and can detect the illness itself (secondary screening).
Guidelines for Screening:
The disease
- an important problem
- recognisable at the latent or early asymptomatic stage
- natural history must be understood
The screen
- suitable test/examination
- test should be acceptable by the population being screened
- screening must be a continuous process
Follow-up
- facilities must exist for assessment and treatment
- accepted form of effective treatment
- agreed policy on whom to treat
Economy
- cost must be economically balanced in relation to possible expenditure on medical care as a whole.
More recently, the criteria have been developed as follows:
- disease must be sufficiently prevalent and/or sufficiently serious to make an early detection appropriate
- the disease must be sufficiently well defined to permit accurate diagnosis
- there must be a possibility (or probability) that the disease exists undiagnosed in many cases (i.e. that the disease is not so manifest by symptoms as to make repid diagnosis almost inevitable)
- there must be a beneficial outcome from early diagnosis in terms of disease treatment or prevention of complications
- there must be a screening test that has good sensitivity and specificity and a reasonably positive predictive value in the population to be screened
The Predictors of Screening Uptake:
vary enormously according to factors such as the country, the illness being screened and the time of the screening programme. Marteau (1993) suggested that there are three main factors that influence uptake of screening; patient factors (demographics, beliefs, emotions, context), health professional factors (belief in effectiveness, communication process) and organisational factors (means of invitation, place of screening, giving choice, and media campaign).
The Psychological Impact:
these can be a result of the various different stages of the screening process,
- the receipt of a screening invitation - feeling worried and anxious
- the receipt of a negative result - anxiety, not enough reassurance by their negative result, beneficial to use the word ‘normal’ instead of ‘negative’ result.
- The receipt of a positive result - worry, anxiety, shock, however psychological changes may only be maintained in the short term and quickly return to baseline levels.
- The receipt of an inadequate test result - women report more anxiety and concern, perceived themselves to be more at risk and less satisfied with the information they had received immediately following the result.
- Being involved in a screening programme - no evidence for raised levels of depression, anxiety or reduced quality of life in the longer term.
- The existence of a screening programme - can influence social beliefs about what is healthy and may change society’s attitude towards a screened condition.
Risks of screening:
•False negative result: No test is perfect and cancer may be missed. Have screening when invited and report and bodily changes to your GP.
•False positive result: The test may also suggest that cancer is present when it is not.
•Overdiagnosis: Screening may find cancers that are so slow growing that they wouldn’t cause a person any problems in their life time.
•Side effects/complications: The test themselves may cause problems e.g. perforated bowel during a colonoscopy.
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What is cancer screening?
•At the early stages, cancer can be asymptomatic
•Aim is to find cancer at an early point of growth in an otherwise healthy population
•Screening can also prevent cancer by identifying and treating pre-cancer cells/growths.
•Screening programmes in the UK need to meet certain criteria:
Condition - Focus on a condition that is common and/or severe
Test - A test is available that is safe and validated showing adequate efficacy
Intervention - Have suitable intervention/treatment options available
What are the 3 cancer screening programmes offered by the NHS?:
Cervical screening - For those with a cervix (entry to the womb) aged between 25 and 64. Test is offered every 3 years up to age 49 and then every 5 years after that. Attendance at GP practice required. A smear test is performed with cells first tested for Human Papillomavirus (HPV).
Breast screening - For females (and transgender man if breast tissue) aged between 50 and 70. Screening is offered every 3 years. Attendance at a clinic or mobile screening unit required. Mammography is the test; x-ray of breast tissue.
Colorectal (bowel) screening - For everyone with a bowel aged between 50 (60 in England) and 74. The screening test is offered every 2 years. The test is completed at home and if positive a colonoscopy takes place at a hospital or screening centre.
A Role for Health Psychology:
•Screening participation is a health behaviour
•Understand decision making in relation to screening
•Develop interventions to enhance informed choice
•Promote health communication across health literacy levels
•Reduce health inequalities in cancer screening
•Assess the impact of psychological implications of screening and a cancer diagnosis
•Develop interventions to minimise negative implications/support patients
•Understand and promote medication/treatment/surveillance adherence
•Promote cancer prevention/recovery strategies e.g. healthy lifestyle
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Bowel (Colorectal) cancer (1)
•Small bowel (based on diameter; is around 6 metres long); breaks down food and absorbs nutrients.
•Large bowel is 1.5 metres long and is made up of the colon and the rectum
•Large bowel absorbs water from food before passing out as waste.
Bowel (Colorectal) cancer (2)
•4th most common cancer in the UK (3rd in males and females separately; 3rd most common in Scotland)
•2nd most common cause of cancer deaths
•If diagnosed early (stage 1), 95% chance of surviving next 5 years
Age is a risk factor (between roughly 65 to 85 mostly)
Symptoms: •Blood in poo / faeces •A persistent change in bowel habits •Abdominal pain •Lump in abdomen •Extreme tiredness for no obvious reason •Unexplained weight loss
NHS Colorectal Cancer Screening Programme (England):
- In August 2018, ministers agreed that in the future bowel cancer screening in England will start at the age of 50. The NHS is starting to reduce the age range for bowel cancer screening from April 2021.
- Everyone aged 60 to 74 who is registered with a GP and lives in England is automatically sent a bowel cancer screening kit (Faecal Occult Blood Test)every 2 years.
Types of Bowel Screening Tests:
- Bowel Scope; Flexible Sigmoidoscopy
- Guaiac Faecal Occult Blood Test; gFOBt
- Faecal Immunochemical Test; FIT
Uptake of bowel cancer screening (gFOBt) (1):
Inequalities in participation in an organised national colorectal cancer screening programme: results from the first 2.6 million invitations in England
Von Wagner et al. (2011)
Results:
•Uptake overall was 54%
•Significant gender difference: Females = 56%; Males = 51%
•Ethnically diverse areas: High = 38%; Others = 52-58%
Uptake of bowel cancer screening (gFOBt) (2):
Uptake of the English bowel (Colorectal) Cancer Screening Programme: an update 5 years after the full roll-outHirst et al. (2018)
•Overall uptake for first time invitees 52%
•Overall uptake goes down from 2010 (53%) to 2015 (49%)
•The gender divide remains: higher for women(56%) than men (47%).
•Uptake remains socially graded: most deprived quintile (43%) to in the least deprived (57%)
•Are-based ethnic diversity remains: least diverse (mainly white-British)(56%) compared to most diverse (41%)
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Ethnicity (1):
Attitudes to colorectal screening (FS) among ethnic minority groups in the UK
Robb K. et al. (2008)
•No significant ethnicity differences in interest in screening
•Peace of mind was a facilitator for screening (across all groups)
•Lack of knowledge about causes of colorectal cancer; more pronounced in ethnic minority groups compared to white-British
•Embarrassment/shame for ‘others in their community’ was a particular barrier for ethnic minority groups
Ethnicity (2):
Understanding low colorectal cancer screening uptake in South Asian faith communities in England - A qualitative study Palmer et al. (2015)16 Key Informants (covering Islam, Sikhism and Hinduism) interviewed
•Limitations posed by the English language
•Limitations posed by any written language
•Reliance on younger family members
•Low awareness of cancer and screening
•Difficulties associated with faeces
Hot off the Press!
•Community survey in an ethnically diverse area of London; representation from South Asian, Chinese, Afro-Caribbean, Somalian, Arab etc
•Survey completed in a community pharmacy (n = 1013); Cancer Awareness Measure (CAM)
•Symptom awareness lower across all ethnic minority groups; lower if main language is not English
•Risk factor awareness low overall (4/10), particularly for Somalian and Afro-Caribbean individuals
•One in 3 people did not know there was a bowel screening programme
•Need targeted interventions
Models within Health Psychology: likelihood of being screened, - Perceived Susceptibility - Perceived Severity - Perceived Benefits - Perceived Barriers - Cues to Actions - Self-Efficacy - Health Motivation
Narrative information: •Health communication research suggests that narrative information can be more easily remembered, engaging and acceptable to those living in more deprived areas (as compared to factual, didactic information). - Transportation - Reduce counterarguing - Provide role models
ASEND study - Reducing the social gradient,
Development:
•Interviews with those who had attended screening
•Focus groups with people approaching the age of eligibility
•Literature review
•Expert opinion (health psychology, public health, social marketing)
Pilot work
Questionnaire study with 1256 people approaching the age of gFOBt screening; recruited through GP practices in London and Carlisle.
2 groups:
Control – Standard 16-page information booklet
Intervention - Standard 16-page information booklet + Narrative leaflet
Questionnaire:
IV: Perceived susceptibility, disgust, self-efficacy, response efficacy, symptom absence, peace of mind
DV: Intention to be screened
Results
•Overall, intention was lower in younger people, males and those living in more deprived areas (no difference in ethnicity but 86% white)
•The intervention group:
- Had lower levels of perceived disgust
- Had higher expectations for peace of mind
- Felt more vulnerable to bowel cancer
- Had a stronger belief that doing the test would reduce their chances of getting bowel cancer
•Intervention group had stronger intentions to complete the test kit when they were invited
•Mediation analysis: The intervention changed beliefs which in turn changed intention
National Trial
•73,722 people in England sent their invitation with the supplementary narrative leaflet
•No influence on uptake of screening
Reminders in London
•An intervention to increase uptake of Bowel Scope screening in a ethnically diverse area in London
•A leaflet (and reminder letter) sent to those who did not attend bowel scope screening one year after their invitation
ACCESSING HEALTH CARE
The Medical Consultation
the core component of any interaction with a health care system is the consultation between patient and health professional as this is the context within which key decisions about diagnosis and management strategy are made.
The Problem of Doctor Variability:
considerable variability has been found among doctors in terms of different aspects of their practice. some variability is good as research indicates that patients prefer different styles of consultation. some variability has implications for patient safety for example, doctors differ in their diagnosis, methods used to measure health related behaviours and symptoms, in their treatment, and their adherence to guidelines regarding suicide prevention. However, this variability can also be understood by examining the other factors involved in the clinical decision-making process.
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How Doctors Make Decisions
Their role is to decide what the symptoms communicated to them mean. this involves differentiating between the pain in the chest that means indigestion and the one that means heart disease. Once a problem has been diagnosed,, they then have to decide on an appropriate management strategy which could range from ‘do nothing, it will go away’, to calling an ambulance. therefore a doctors role is highly skilled and complex. it is further complicated by the number of people coming through their doors with other issues. therefore the process of clinical decision-making has been understood within the framework of problem-solving.
A Model of Problem-Solving:
it is often assumed that clinical decisions are made by the process of inductive reasoning, which involves collecting evidence and data and using these data to develop a conclusion and hypothesis. However, doctors decision making are generally considered within the framework of the hypothetico-deductive model of decision making. this perspective emphasizes the development of hypotheses early on in the consultation and is illustrated by Newell and Simon’s (1972) model of problem-solving, which emphasises hypothesis testing. They suggested that problem solving involves a number of stages that result in a solution to any given problem. The stages are as follows,
- understand the nature of the problem and develop an internal representation
- develop a plan of action for solving the problem
- apply heuristics (rules) to the given situation
- determine whether heuristics have been fruitful
- determine whether an acceptable solution has been obtained
- finish and verify the solution
Clinical Decisions as Problem Solving:
Models of problem solving have been applied to clinical decision making by several authors, who have argued that the process of formulating a clinical decision involves the stages shown below:
1) accessing information about the patient symptoms
2) developing hypotheses
3) search for attributes
4) making a management decision
Explaining Variability:
- access different information about the patients symptoms
- develop different hypotheses
- access different attributes either to conform or to refute their hypotheses
- have differing degrees of a bias towards confirmation
- consequently reach different management decisions
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Health Professionals’ Health Beliefs
The beliefs involve in making the original hypothesis can be categorised as follows,
1) the health professionals own beliefs about the nature of clinical problems
2) the health professionals estimate of the probability of the hypothesis and disease
3) the seriousness and treatability of the disease
4) personal knowledge of the patient
5) the health professional stereotypes
Other factors that may influence the development of the original hypothesis include the following,
1) the health professionals mood
2) the profile characteristics of the health professional
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Communciations Beliefs to Patients
the choice of words health professionals use towards their patients can influence the patients choice of hypothetical treatment. if the ways in which presenting the risk varies, this will result in a variation in patient uptake. weight bias is common amongst health professionals and can influence how they interact with patients and deliver health care through their interpersonal behaviour within consultations, judgements and medical decision-making. this in turn can influence the patients own beliefs and their subsequent behaviour.
Patient-Centredness:
this is recommend to improve patient outcomes such as their satisfaction, compliance and health status. it consists of 3 central components,
- a receptiveness by the doctor to the patients opinions and expectations, and an effort to see the illness through the patients eyes
- patient involvement in the decision making and planning of treatment
- an attention to the affective content of the consultation in terms of the emotions of both the patient and doctor.
this is comparable to other components and dimensions described by other researchers. Patient-centredness is now the way in which consultations are supposed to be managed.
Agreement Between Health Professional and Patient:
it is important to understand the extent to which these two individuals speak the same language, share the same beliefs and agree as to the desired content and outcome of any consultation. if health professional-patient communication is seen as an interaction, then it may well be an interaction between two individuals with very different perspectives
The Role of Agreement in Patient Outcomes:
it is possible that disagreement may result in poor compliance to medication, to any recommended changes in behaviour, or low satisfaction with the consultation. to date little research has explored these possiblities.
ACCESSING HEALTH CARE
Adherence
Defining Adherence:
adherence is mostly explored in the context of medication-taking and the extent to which patients take their drugs as recommended but also related to other behaviours such as smoking, dietary change and exercise.
As a means to understand why some patients fo not adhere, researchers have further defined non-adherence,
- unintentional non-adherence - an individual simply forgets or has misunderstood the instructions
- intentional non-adherence - chooses not to take their medication or engage in risk-reducing behaviour
Measuring Adherence:
Objective measures,
1) observation
2) blood or urine samples
3) pill counting
4) electronic monitors
5) assessing prescriptions
Subjective Measures,
1) self-report
Why is Adherence Important?
primarily because following recommendations of health professionals is believe essential to patient recovery.
Models of Adherence:
Cognitive Hypothesis Model,
an early model of adherence was developed by Ley (1989) who described a cognitive hypothesis model of compliance (as it was then). from this model it was predicted that a patient would adhere to their doctors recommendations if they understood these recommendations, could recall the instructions and were satisfied with the consultation
The Perceptions and Practicality Approach,
Horne (2001) developed a model of adherence that emphasise perceptions and practicalities and focused on the predictors of unintentional non-adherence and intentional non-adherence. From this perspective adherence is seen as relating to motivation, resources, perceptual barriers, and practical barriers which are deemed to prevent the adherence from happening.
Predictors of Adherence
Patient Satisfaction:
patient satisfaction elated to a range of professional (use of light humour) and patient (personalised style to the content of the consultation) variables and is increasingly used in health care assessment as an indirect measure of health outcome based on the assumption that a satisfied patient will be a healthier patient. It is possible that in line with Ley’s (1988) model, increased satisfaction may predict increased adherence.
Patient Understanding:
not many people understand the the content of the consultation which gets worse the older the patient. if the doctors advice to the patient or suggests that they follow a particular treatment programme and the patient doe not understand the causes of their illness, the correct location of the relevant organ or the process involved in the treatment, then this lack of understanding is likely to affect their compliance with the advice.
Patients’ Recall:
patients can forget the name of the drug, the frequency of the dose, and the duration of the treatment as well as the treatment regime recommended by the doctors. information not recalled during the consultation can also be related to compliance
Belief About the Illness:
research shows that patients hold beliefs about their illness and that these consistently relate to key dimensions of cause, consequences, time line, control and identity. Research indicates that these beliefs (whether the illness is serious) predict adherence.
Beliefs About the Behaviour:
people also hold beliefs about their health-related behaviours and within the framework of social cognition models adherence can be predicted by beliefs about the costs and benefits of taking medication, perceptions of risk for illness, self-efficacy for taking drugs, the norms of those around the patient and their attitudes to medication.
Beliefs About Medication:
Horne (1997) identified two key sets of beliefs labelled ‘necessity’ beliefs (‘How much do I need this medicine?’) and ‘concern beliefs’ (‘I worry about side-effects’). these are good predictors of adherence.
Can Adherence Be Improved?
The Role of Information:
- oral information - primacy effect, stressing the importance of adherence, simplifying the information, using repetition, being specific, and following up the consultation with additional interviews
- written information - increases knowledge, compliance and outcome, to make information clearer and easier to remember. However good information can be argued to not be sufficient enough to improve adherence
- changing beliefs and emotions - can involve behaviour strategies sich as reinforcement, incentives or modelling; social cognition theory-based interventions such as implementation intentions; the use of stage models and motivational interviewing; changing affect or drawing upon integrated models such as the COM-B and BCTS.
ACCESSING HEALTH CARE
Thinking Critically about Access to Health Care
Problems with…..
Help-Seeking Research:
- lead times
- health anxiety
- increased consultation rates
- clinical decision making
- uneccesary treatments and false hope
- Quantity vs. quality of life
Screening Research:
- Conflicting outcomes
- patient autonomy
- do more harm than good
- costs to the health service
- politics
The Consultation Research:
- a clash of ideology
- understanding what happens between people
Aherence Research:
- financial cost
- side effects
- not effective
- weighing up risk
- optimism bias
- immortality
Health Belief Model
believe behaviour is more likely to occur if people believe there is
- perceived susceptibility
- perceived severity
- perceived benefits
- perceived costs
- cues to action (prompt them to action to the their behaviour)
- health motivation
- self-efficacy
This kind of theory might be used when we are trying to design interventions. there are various different overlaps with the models entailed and so perceived behavioural and self-efficacy, outcome expectancies, and goals are present in all 3 of the social cognitive models. and these are the different constructs that we think about when designing interventions to be able to tackle that and eventually improve health.
