Psychology HEALTH Paper Four

Question 1

Types of non-adherence include:

Answer 1

• Failure to follow treatment (e.g. to take tablets every 12 hours)
• Not engaging in preventative measures linked to health (e.g. stopping smoking)
• Failing to attend further appointments or interviews

Question 2

Problems caused by non-adherence include:

Answer 2

• Wasted money on drugs
• Worsening of health
• Financial costs when appointments are not kept and they are unavailable for others to take

Question 3

Rational non-adherence (Bulpitt)

Answer 3

Rational non-adherence refers to the patient making a reasoned decision due to undertaking a cost-benefit analysis. This means that a reason for non-adherence could be as a result of a well-considered and reasoned thought process that leads the patient to believe non-adherence is more beneficial.

Question 4

Bulpitt Study

Answer 4

Bulpitt looked at the risks and benefits of a drug treatment for hypertension (high blood pressure).

Risks included increased diabetes, gout, and dry mouth but these were either not serious or at a very low rate.

Benefits included reduction in strokes by 40% and coronary events by 44%.

Bulpitt concluded that the benefits from treating hypertension in elderly patients far outweigh the disadvantages. It seems people rationally decide not to take the medication because of the risks whilst ignoring the benefits.

Question 5

The Health Belief Model (Becker and Rosenstock)

Answer 5

The model outlines the factors that explain the beliefs and consequent decisions people make about their health. It assumes that the likelihood that individuals will follow medical advice depends directly on two assessments that they make: Evaluating the threat and a Cost-Benefit Analysis.

Question 6

First belief of The Health Belief Model

Answer 6

The first stage is the evaluation of the health threat which includes:

• the perceived seriousness (the more serious, the more likely adherence)
• the perceived susceptibility (the more vulnerable, the more likely adherence) and cues to action.

Demographic factors e.g. age, socio-psychological variables and cues to action are all modifying factors that influence the perception of the problem. For example, an obese person may be in danger of developing a heart condition, however since they are young they believe they are less susceptible reducing the risk to minor.

Question 7

Second belief of The Health Belief Model

Answer 7

A cost-benefit analysis influences the likelihood of taking action. For example, comparing the perceived benefits (being healthier) against the perceived costs (financial, situational, social). All these factors as well as cues to action interact to predict the likelihood of taking preventative health actions.

Question 8

Self-reports to measure non-adherence

Answer 8

Self-reports involve asking the patient if they adhere to treatment requests. These are subjective and susceptible to response bias.

Question 9

Subjective: self-reports (Riekart and Droter) Aim

Answer 9

Looked at the implications of non-participation in studies using self-report measures to investigate adherence to medical treatment for adolescents with diabetes.

Question 10

Riekart and Droter procedure

Answer 10

• Adolescents with diabetes for more than one year (total of 94 families).
• The adolescents completed a series of questionnaires and interviews while their parents also completed a questionnaire.
• They both had a questionnaire to complete at home with a self-addressed return envelope - if not done within 10 days, they were called to remind them.
• Families were divided into three groups: participants/returners (52), non-returners (28) and non-consenters (14).

Question 11

Riekart and Droter findings

Answer 11

• Significant differences in adherence levels between participants and non-returners.
• Those who returned the questionnaire had higher adherence scores and tested blood sugar more frequently.
• This suggests that when self-report measures are used the results may be distorted if only the results of those that completed the self-report are considered.

Question 12

Objective: pill counting (Chung and Naya) Aim

Answer 12

To investigate if you can electronically assess adherence to oral asthma medication by using a trackcap.

Question 13

Chung and Naya procedure

Answer 13

• 57 with asthma patients
• Underwent a screening period of three weeks and a 12 week treatment period in which they were told to take their medication twice a day, one in the morning and one in the evening approximately 12 hours apart and not at mealtimes.
• They received a three week supply with a week to spare.
• They were dispensed from a bottle fitter with a TrackCap medication monitoring system that registers when the bottle is opened/closed.
• Participants returned every three weeks to have their tablet counts measured.

Question 14

Chung and Naya findings

Answer 14

• On days when patients took exactly 2 tablets, the mean time between doses 12½ hours.
• Median 89% compliance was found from Trackcap, but Median 92% from tablet counts. - Concluded that it is possible to electronically assess adherence with an oral medication using an event monitoring system.
• Compliance was measured by the number of times the cap was opened, the number of days the cap was opened 8 hours apart and number of pills left at the 12 week period.

Question 15

Biochemical tests (Roth and Caron)

Answer 15

Roth and Caron suggested non-adherence could be measured through blood and urine samples.

Question 16

Roth and Caron procedure

Answer 16

• They conducted a study with 116 patients whose antacid regime was monitored.
• Patients estimated their intake average 89%, however actual intake averaged 47%.
• They found that pill counting was inaccurate and that patient self-reports often overestimated when they said they took medicine regularly.

Question 17

Roth and Caron Conclusions

Answer 17

Therefore, Roth and Caron concluded the best measure of non-adherence is objective, quantitative tests, such as biochemical tests to measure non-adherence. They suggested that urine and blood tests taken over a number of months will give a more accurate indication of adherence.

Question 18

Repeat Prescriptions (Sherman et al.)

Answer 18

Investigated if prescription refill history identified poor adherence with asthma medications more frequently than the doctor’s assessment.

Question 19

Sherman et al. Procedure

Answer 19

• 116 children with asthma were interviewed with their parents on a clinic visit.
• Adherence was checked by telephoning the patient’s pharmacy to assess the ‘refill rate’.
• It was assumed that if the medication (the ‘refill’) was not collected from the pharmacy, then it could not have been taken, whereas if it was collected then the original prescription must have been taken.
• Patient adherence was operationalised by calculating the number of doses refilled divided by the number of doses prescribed over a period of up to 365 days.

Question 20

Sherman et al. findings

Answer 20

Adherence was 72%, 61% and 38% for the three different inhalers prescribed to the children.
Checking refills is an accurate way of measuring adherence. Also found doctors are not able to tell if a patient is using their inhaler from consultation alone.

Question 21

Improve Practitioner Style: Ley

Answer 21

Improve practitioner style by changing information presentation techniques. Ley Prepared a booklet of guidelines for doctors on how to communicate more clearly with patients.

Satisfaction: including listening to the patient and finding out what their worries are, etc

Understanding and memory: avoiding jargon, encouraging feedback to increase recall of instructions, etc

C:selecting Content - being aware of the effect of what they say to the patient (e.g. will it cause fear, is the patient particularly vulnerable), etc.

Use simple language, state the key information first, repeat key points (by summarising).

Question 22

Behavioural Techniques: Yokley and Glenwick

Answer 22

Investigated the relative impact of four conditions for motivating parents to take their children to be immunised.

Question 23

Conditions

Answer 23

Four experimental
Two Control
General prompt
Specific prompt
Increased access prompt
Money incentive prompt
Contact control group
No contact group

Question 24

Yokley and Glenwick: Procedure

Answer 24

The participants were an entire population of a medium-sized midwest city (approx. 300,000). The target population consisted of children five years or younger who needed a vaccine. Each condition differed in the type of message on the postcard. Impact was measured over 12 weeks.

Question 25

Yokley and Glenwick: Findings

Answer 25

• The results showed the money incentive group had the biggest impact on attendance, followed by increased access, specific prompt and then general prompt.
• Money incentives have a powerful and immediate impact, however may not be cost-effective, so a specific prompt would be the more cost-efficient.

Question 26

Behavioural Techniques: Watt et al.

Answer 26

Making medical treatment programmes fun and engaging can have positive consequences on the levels of adherence. The Funhaler incorporates incentive toys into a child’s inhaler. If the correct breathing technique is used, the child is rewarded with a fun whistle sound and a spinning toy within the inhaler.

Question 27

Watt et al. procedure

Answer 27

• 32 children with asthma
• Questionnaires were completed after the use of the Breath-a-Tech and then after two weeks of using the Funhaler

Question 28

Watt et al. findings

Answer 28

• Found it was associated with improved compliance compared to a Breath-a-Tech
• 38% more parents medicate their children the previous day and 60% more children took the recommended four or more cycles. This provides support that behavioural techniques can be developed to reinforce positive health behaviours and improve adherence with children.

Question 29

Pain

Answer 29

A sensory or emotional discomfort which tends to be associated with actual tissue damage or threatened tissue damage.

Question 30

Acute

Answer 30

Mild OR severe pain that comes on quickly but lasts only for a brief time. Acts as a warning of damage to tissue or disease. Short duration, less than 6 months. For example, bruise, burns or cuts.

Question 31

Chronic Pain

Answer 31

Constant, recurring pain that lasts for more than 6 months. May be associated with illness or disability. This gets progressively worse and reoccurs intermittently. People experience high levels of anxiety and have feelings of helplessness and depression as the pain doesn’t dissipate. An example would be migraines.

Question 32

Psychogenic Pain

Answer 32

A type of pain that refers to episodes where there is not an organic cause for the pain, but the person is still experiencing it. For example phantom limb pain.

Question 33

Phantom Limb Pain

Answer 33

Pain perceived by the body of a limb is no longer present. It is psychogenetic as the pain is imagined by the mind

Question 34

Specificity Theory (Descartes)

Answer 34

Specificity theory believes the body has a separate sensory system for perceiving pain.

It believes that specific pain receptors transmit signals to a “pain centre” in the brain that produces the perception of pain.

When the body feels pain via one of the senses (e.g. on the skin), this then travels down the neural fibres to the brain where pain is registered in the brain.

The intensity of the pain is directly related to the amount of tissue damage (e.g. a prick from a needle is not as painful as a burn across the entire hand). It therefore believes pain is purely a sensory experience.

Question 35

Gate Control Theory (Melzack)

Answer 35

The nervous system is made up of the central nervous system (the spinal cord and the brain) and the peripheral nervous system (nerves outside of the brain and spinal cord.

In the gate control theory, the experience of pain depends on an interplay of these two systems as they each process pain signals in their own way.

Upon injury, pain messages originate in nerves associated with the damaged tissue and flow along the peripheral nerves to the spinal cord and on up to the brain.

Before the pain messages can reach the brain these pain messages encounter ‘nerve gates’ in the spinal cord that open or close depending upon a number of factors (possibly including instructions coming down from the brain).

When the gates are opening, pain messages ‘get through’ more or less easily and pain can be intense. When the gates close, pain messages are prevented from reaching the brain and may not even be experienced.

Question 36

Self-report measures (clinical interview)

Answer 36

A self-report technique involving a dialogue between practitioner and patient to help with diagnosis. They will discuss the intensity, quality, location and duration. This can be in the form of a semi-structured or unstructured interview. The patient is able to elaborate on their symptoms and describe them in their own words.

Question 37

McGill Pain Questionnaire

Answer 37

Location: diagram of body, mark location of pain

Feel: patient selects one word from each of 20 sub-categories to describe pain (e.g. spreading, radiating, penetrating or piercing)

How does the pain change - selecting words and open questions about what relieves/increases the pain (brief, rhythmic, constant)

How strong is the pain - likert rating scales to describe strength of pain (mild, distressing, excruciating)

Types of pain:
Sensory: burning
Affective: emotionally: frightening
Evaluative: overall intensity: unbearable

Question 38

VAS

Answer 38

Used over a continuum of values. A 10 cm line with descriptors at either end showing alternative ends of the spectrum. The patient marks on the line the level of pain they are experiencing. VAS score can be calculated by measuring the distance from the starting point to the mark.

Question 39

UAB pain behavioural scale

Answer 39

Observers observe target behaviours (body language, mobility, posture, vocal complaints: verbal, vocal complaints: non-verbal) and record how frequently each occurs. There are ten types of target behaviours, each item being scored on a three-point scale (0, 0.5, 1). The higher the score, the more pain. The patient can score between 0 and 10.

Question 40

Paediatric pain questionnaire: Varni and Thompson

Answer 40

Multi-dimensional questionnaire for assessing pain in children with separate forms for patient, parent and clinician.

It measures perceptions of pain intensity, location, affective factors etc. in a child-friendly format.

Firstly, the child circles words that best describes the pain and then the three that describe the pain they are in at the time of completing the questionnaire.

They then rate how they feel on a continuum alongside rating the worst pain they had that week.

They then use four different colours relating to different severities of pain and colour in a picture of themselves.

Question 41

Wong-Baker Scale

Answer 41

Wong-Baker FACES Rating Scale uses a series of faces ranging from a happy face at 0 (no hurt) to a crying face at 10 (hurts worst). Child chooses the face corresponding to their perceived pain.

Face 0: is very happy because he doesn’t hurt at all

Face 2: hurts just a little bit

Face 4: hurts a little more

Face 6: hurts even more

Face 8: hurts a whole lot more

Face 10: hurts as much as you can imagine, although you do not have to be crying to feel this bad

Question 42

Medical techniques to manage pain

Answer 42

Surgical treatments are used when medication doesn’t relieve pain. Surgical treatments include cutting nerve pathways or making lesions in special centres in the brain. This is only recommended for people with terminal illnesses.

Question 43

Drugs

Answer 43

One treatment is analgesic/painkillers which are a group of drugs used to achieve relief from pain (analgesia). The drugs act in various ways on the central nervous system. For example, peripherally acting analgesics act on the peripheral nervous system e.g. ibuprofen

Question 44

Attention Diversion

Answer 44

Diversion of attention from the pain by refocusing (e.g. listen to music) or directing attention to something other than the pain. This will help close the gates and reduce the perception of pain.

Question 45

Non-pain Imagery

Answer 45

The patient thinks of a scene far removed from the situation they are currently in that is where they are experiencing the pain. This could be a relaxing environment, somewhere like a park or beach that they can immerse themselves in and this acts as a distraction against the pain.

Question 46

Cognitive Redefinition

Answer 46

An individual alters their thinking to replace thoughts of apprehension about the pain with other more positive thoughts. For example, the patient may replace thoughts like “this is really going to hurt” with “this is not the worst pain in the world”. It suggests the brain has a significant impact on how pain is perceived.

Question 47

Acupuncture

Answer 47

Fine metal needles are inserted under the skin at certain sites.

The therapist will have a ‘map’ of the body and use this to guide the placement of the needles.

This results in the body producing pain-relieving substances, such as endorphins.

Question 48

Stimulation Therapy/TENS

Answer 48

A mild electric current is passed between electrodes which are placed on areas of the body where you are experiencing muscle pain.

The impulses reduce the pain signals passing along nerves which helps an individual relax.

This helps to reduce the perception of deep muscle pain or pain in muscles due to anxiety and stress.

Question 49

Janis and Feshbach Aim

Answer 49

Janis and Feshbach (1953) conducted a laboratory experiment on fear arousal to promote oral hygiene. The aim was to test if level of fear would have a behavioural consequence in relation to the participants’ brushing of teeth.

Question 50

Janis and Feshbach Procedure

Answer 50

There were four groups: a minimal fear group, a moderate fear group, a strong fear group and a control group with 50 students in each.

They assessed the effectiveness of a dental hygiene lecture in which each varied in terms of the level of fear. Emotional reaction + conformity measured through self-report questionnaires given before, immediately after, and 1 week after the fear presentations

Question 51

Janis and Feshbach Findings

Answer 51

It was found that although the immediate impact was strongest in the high-fear group as it aroused the most fear, the minimal fear presentation was most effective in conformity to dental hygiene behaviour.

The minimal fear presentation group showed 50% increase in conformity to recommended dental hygiene recommendation whereas 28% in the high-fear group reported change, suggesting that low levels of fear are best.

Question 52

Fear arousal: Cowpe Aim

Answer 52

Aim was to test the effectiveness of advertising campaigns that combined both fear arousal and providing information on highlighting the dangers of chip-pan fires.

Question 53

Cowpe Procedure

Answer 53

Two 60 second adverts made showing the cause of chip pan fires (overfilling and inattendance). Shown in ten UK regions between 1976-1984.

Question 54

Cowpe Findings

Answer 54

Between 7% and 25% drop (measured through fire brigade statistics) in fires and high levels of awareness of the dangers of chip pan fires reported via questionnaires.

Question 55

Yale model of communication

Answer 55

Several factors that influence how likely one is to change behaviour: three aspects of communication: communicator, communication and audience. Also: source, message, medium, target, situation.

Question 56

Yale model of communication Factors

Answer 56

The source of the message - is the presenter of the message credible, an expert, trustworthy?

The message itself - is it clear and direct; colourful and vivid; is it one-sided or two-sided?

The medium - is the message personal; done via television, radio or printed?

The target audience - who is the target audience? School children; communities?

The situation - where will the message be presented? In the home; a medical surgery?

Question 57

Providing information: Lewin Procedure

Answer 57

The effect providing information has on health behaviours.

Believes that if people want to live healthier lives, they need to know what to do by being provided with information.

176 patients who recently suffered a heart attack were randomly allocated to either a self-help rehab programme focused on improving cardio-vascular health or the control group (standard care plus a placebo package of information and informal counselling).

Patients were assessed at 6 months and 1 year.

Question 58

Providing information: Lewin Findings

Answer 58

Psychological adjustment was better in the rehabilitation group at one year. They also had significantly less contact with their general practitioners during the
following year and significantly fewer were readmitted to
hospital in the first six months (less than 10% readmission compared with 25%).

Question 59

Health Belief Model

Answer 59

People are likely to practise healthy behaviours if they believe by not doing so they are susceptible to serious health problems. Leventhal demonstrated this with an experiment on cigarette smokers who were exposed to a high-fear appeal. They changed their attitudes and intentions regarding smoking more than those shown a moderate-fear appeal.

Question 60

Schools (Tapper et al.): What was included in the package

Answer 60

A Food Dude adventure video with six 6-minute adventure episodes

A set of Food Dude rewards

A set of letters from the Food Dudes (for praise and encouragement)

A Food Dude home-pack (to encourage children to eat fruit and vegetables in the home context as well as at school)

A teacher handbook and support materials.

Question 61

Tapper Aim

Answer 61

To evaluation the effect of a whole school Food Dudes programme on healthy eating.

Question 62

Schools (Tapper et al.): Procedure

Answer 62

The main intervention lasted 16 days during which the children watched the Food Dudes episodes and listened to their teacher read out the Food Dudes letters. Children received rewards when they eat fruit and vegetables presented to them: sticker for tasing, sticker or small prize for eating a whole portion. This was followed by the maintenance phase where there are no videos/letters and the rewards are more intermittent.

Question 63

Schools (Tapper et al.): Findings

Answer 63

Teachers and parents evaluated the programme positively and the children were enthusiastically engaging with the curriculum and had improved attendance alongside lower achieving children becoming more confident.

At a four month checkup, the children were still eating significantly more fruits and vegetables than before.

Question 64

Worksites (Fox et al.) Aim

Answer 64

Fox et al. studied the use of a token economy at two open-pit mines (coal and uranium)

Question 65

Procedure Fox et al.

Answer 65

Workers could earn tokens for working without time lost injuries, not being involved in equipment damage and for making adopted safety suggestions.

They lost tokens for injuries, damages or failure to report injuries/accidents.

The tokens could be exchanged for thousands of items in a store.

Question 66

Fox et al. Findings

Answer 66

This resulted in a large decline in lost days due to injuries, lost time injuries and costs of accidents/injuries.

The reduction in costs far exceeded the cost of running the token economies.

The system continued to be used at one mine for 12 years (until closure) and used at the other for at least 11 years where improvements were maintained.

Question 67

Communities (Five city project; Farquhar et al.) focus

Answer 67

Longitudinal (6 years) programme investigating the feasibility and effectiveness of a community-wide education programme at reducing cardiovascular disease.

Question 68

Farquhar et al. Procedure

Answer 68

There were two treatment communities: Salinas and Monterey. There were three control cities: Modesto, San Luis Obispo and Santa Maria where only morbidity and mortality events were monitored.

Those who resided in randomly selected households in the 4 surveyed cities were eligible to participate with each survey comprising approximately 1800 - 2500 participants.

Questionnaires given (e.g. health attitudes, knowledge and behaviour, measures of CHD risk) and physiological measures taken (e.g. height, weight, blood pressure, heart rate, etc.).

Urine samples were also taken to assess cholesterol levels.

During the six years, the Community Education Programme was given to the two experimental cities via the media (television + radio) and community education (e.g. classes, seminars and group projects).

Question 69

Farquhar et al. Findings

Answer 69

Knowledge of CVD risk increased in all four groups, improvements in the treatment groups was significantly greater.

CHD and all-cause mortality risk cores were maintained or continued to improve in intervention cities whilst levelling out/rebounding in the two control cities.

Results showed reductions in cholesterol levels (2%), blood pressure (4%), resting pulse rate (3%) and smoking (13%).

Question 70

Weinstein Aim

Answer 70

Investigated the impact of unrealistic optimism on health beliefs.

Question 71

Weinstein First Study Procedure

Answer 71

• 258 college students rated their own chances of experiencing 42 events (18 positive/24 negative).
• Positive events included ‘owning your own home’ and negative events were ‘developing cancer’.
• The events were scored ‘compared to other students studying here and the same sex as you’ on the following scale: 100% less, 80% less, 60% less, 40% less, 20% less, 10% less, average, 10% more, 20% more, 40% more, 60% more, 80% more, and 100% more.

Question 72

Weinstein First Study Findings

Answer 72

Overall, the participants rated their own chances to be above average for positive events and below average for negative events.

Question 73

Weinstein Second Study Procedure

Answer 73

The second study used 120 female college students to list factors they thought would influence their own chances of experiencing 8 future events. When a second group of students read it they reported less unrealistic optimism for the same 8 events.

Question 74

Weinstein conclusions

Answer 74

This led the researchers to conclude that the unrealistic optimism was only experienced people focus on their own chances of achieving these outcomes and don’t realise that others may have just as many factors in their favour

Question 75

Transtheoretical model: Prochaska et al.:

Answer 75

Model of behavioural change that assesses, through a series of six stages, whether a person is ready to change to a new, healthier behaviour.

Question 76

Six Stages

Answer 76

Pre-contemplation: no intention in next six months
Contemplation: intends to change in six months
Preparation: intend in near future (30 days) have plan of action
Action: taken action
Maintenance: behaviour sustained 6+ months
Termination: 100% changes, no chance of relapse

Question 77

Processes of change

Answer 77

Activities a person can complete to move through the different intervention stages - there are ten processes.

Consciousness raising: Involves increased awareness about the
causes, consequences, and cures for a particular problem behaviour

Self re-evaluation: Combines both cognitive and affective
assessments of one’s self-image with and without a particular unhealthy habit

Self-liberation: The belief that one can change and the commitment and recommitment to act on that belief

Question 78

Health change in adolescents: Lau et al.: Aim

Answer 78

Investigated the stability and change of health beliefs and behaviour in adolescents.

Question 79

Lau et al. Procedure

Answer 79

Baseline questionnaires on alcohol consumption, eating habits, exercise, sleeping, smoking and wearing seatbelts were gathered.

The study required the questionnaire to be completed again after 1, 2 and 3 years - this resulted in the sample dropping from 947 parent-child pair participants to 532.

Question 80

Lau et al. Findings

Answer 80

Results showed a substantial change in health behaviour while at college. Found that peers have a strong impact on the performance of health behaviours, but parents were more important as sources of influence over beliefs and behaviours.