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Theories of Health Belief

Health Belief Model

A working model which ts to attempts to predict health behaviours by focusing on the attitudes and beliefs of an individual. Hockbaum developed the model and the core assumption is that someone will adopt a health behaviour if they believe that the negative health condition is avoidable by adopting the healthy behaviour. The model refers to perceived seriousness (will it kill me?), perceived susceptibility (will I get it?), benefits and barriers (cost-benefit analysis) and demographic values e.g. population characteristics e.g. age, sex, income, education etc.

Locus of Control

Refers to someone's belief about what causes the good and bad results in their life. An individual either has a hi gh internal locus of control or a high external locus of control. An individual with an internal locus of control believes that it is the individual that is the main cause of their behaviour, actions and situations. Whereas an external control believes that it is largely out of their control and is the result of powerful others, fate or chance which determines events. People with a high internal locus of control believe they can influence others with their actions, they blame themselves for positive and negative actions whereas an external locus of control often feel stressed and overwhelmed and prone to depression as they believe that is what will ultimately happen anyway. Largely reductionist and deterministic.

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Theories of Health Belief


Refers to an individual's perception of their ability in a particular situation, it means how effective a person thinks they will be at successfully adopting a healthy behaviour. It is a cognitive model developed by Bandura based upon the thought processes of an individual. People with a strong sense of self-efficacy tend to view challenges as tasks to be mastered and recover quickly from a setback, whilst those with a weak sense of self-efficacy avoid challenging tasks and focus upon failures. 

There are factors which affect a person's efficacy expectation (an individual's belief that they can successfully do something): 

  • vicarious experiences - seeing another person do something successfully 
  • verbal persuasion - someone telling you that you can do something 
  • emotional arousal - too much anxiety can reduce a person's self-efficacy

Cognitive appraisal of a situation may also affect expectations of personal efficacy, social, situation and temporal circumstances are contextual factors which could influence appraisal. Self-efficacy can alter depending on a situation. Self-efficacy is actually a person's conviction that their own behaviour will influence the outcome whereas locus of control is concerned with the cause of an outcome. 

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Becker - Health Belief Model

Aim - use the health belief model to explain mother's adherence to a drug regimen from their asthmatic children.

Method - correlation between beliefs during interviews, a blood test conducted to measure the level of medication confirming the validity of the mother's interview answers. 

Participants - 111 mothers aged between 17-54

Procedure - 45-minute interviews with questions regarding their perception of their child's susceptibility to illness, beliefs on seriousness, how asthma affected education, embarrassment etc. 

Results - positive correlation between mother's belief about child's susceptibility to asthma attacks, mothers more likely to comply with regime the greater the mother's education and if they were married (demographic values). Costs were negatively correlated with compliance were disruption of daily activities, inaccessibility of chemists, the child complaining about medication and the prescribed schedule. 

Conclusion - HBM is useful to predict and explain different levels of compliance with medical regimes. 

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Rotter - Locus of Control

Method - review article

Sample - 6 pieces of research into individuals perceptions of ability to control outcomes based on reinforcement.

Findings - participants with an internal locus of control are more likely to show behaviours that would enable them to cope with potential threats, than participants who had an external locus of control and though that chance determined the effects of their behaviours.  

Conclusion - locus of control affects many behaviours, not just health behaviours. 

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Bandura and Adams - Self Efficacy

Aim - assess the self-efficacy of patients undergoing systematic desensitisation in relation to their behaviour with previously phobic objects. 

Method - controlled quasi-experiment - patients with snake phobias

Participants - 10 snake phobia patients who replied to a newspaper advertisement, 9 females 1 male

Procedure - pre-test assessment, each participant was assessed for avoidance behaviour towards a boa constrictor, fear arousal was assessed with an oral rating 1-10 and efficacy expectations (how much they thought they would be able to perform different behaviours with snake). Systematic Desensitisation - patients introduced to a series of events involving snakes and at each stage were taught relaxation, ranged from pictures to handling live snakes. Post-test assessment, behaviours and beliefs on self-efficacy in coping.

Findings - higher levels of post-test self-efficacy were found to correlate with higher levels of interactions with snakes, 

Conclusion - systematic desensitisation enhanced self-efficacy levels, which in turn led to a belief that the participant was able to cope wth the phobic stimulus of a snake. 

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Methods of Health Promotion - Media Campaigns

Media Campaigns 

Good source of health promotion as it brings about how to lead a safe and healthy lifestyle via television adverts, posters and leaflets. They are used to communicate and interact with a range of audiences. Media campaigns would be a waste of money if there was no evidence that demonstrated the effectiveness of health promotions by the media.

A practical method of health promotion as the can reach a large population in a short period of time, they require access to resources however that some people don't have, in conjunction with this they can be avoided and ignored and they may not be seen by the full target population which reduces their effectiveness. Media campaigns are time effective however not particularly cost effective and can only reach a certain demographic.

In addition to this, just because someone has an improved knowledge does not mean that their behaviour will improve, especially if a campaign is upsetting and disturbing it can cause a person to switch off from the message. 

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Methods of Health Promotion - Legislation


Refers to the law making process, laws can be implemented to change health behaviours, this is done by promoting and enforcing positive health behaviours whilst banning unhealthy ones. Certain behaviours have been made illegal e.g. smoking in public and smoking and drinking under the age of 18. Whilst some behaviours have been made compulsory in a legal manner e.g. wearing a seatbelt.

Raises an issue of free will versus determinism and the ethical issue with forcing and banning certain behaviours. Some would argue that legislation may deny people human rights e.g. freedom of movement, whilst others would suggest, for example, smoking itself is dangerous and that it should be completely banned. 

Legislation is  far-reaching and supposed to be enforced equally wherever it applies, obedience to these laws is optional. The legislation method of health promotion is only effective if people listen and abide by the laws. 

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Methods of Health Promotion - Fear Arousal

A method of health promotion which uses fear and intimidation to persuade people into doing or avoiding certain health-related behaviours. Fear-arousing communication usually features two parts;

  • stressing the severity of the issue using fear
  • recommending an action to reduce or eliminate the health risk

The assumption of fear arousal is that if the negative consequences of an action are made clear, then it is more likely that the individual will do something about it to prevent it. High fear campaigns tend to be more successful than low fear campaigns, the idea of fear and emotional tension is to drive an action, a threatening situation will cause the individual to feel motivated and take action to reduce the threat. 

Fear arousal raises ethical concerns as causing someone to feel fear goes against protection from harm as it causes psychological harm which is against the BPS guidelines. It is arguable that fear is a basic human emotion and it, therefore, is applicable to everyone, but people do respond to fear differently so it is unlikely to be effective for large populations. Fear arousal goes against the Yale model, which outlines how too much emotion will not deliver a message successfully. Reductionist as it assumes that it will automatically change behaviour but does not consider social desirability or social pressures to conform to certain lifestyles or self-efficacy - think they cannot do it. 

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Cowpe - Media Campaigns

Aim - test the effectiveness of an advertising campaign which demonstrated a procedure and provided information about preventative actions. 

Method - quasi-experiment where media campaigns were shown in 10 UK regional TV areas from 1976 to 1984. The number of chip pan fires reported between 1976 and 1982 and two quantitative consumer surveys were used to gather data.

Participants - people living in the television areas

Results - net decline in each area over the 12 month period was between 7%-25%, the largest reduction in fires was during the campaign. Areas that received more than one television channel due to the reduced impact of seeing the campaign more than once. The questionnaire showed an increase in awareness (62% to 90% awareness after the first adverts and stayed at 96% after the campaigns). People mentioning chip pan fires as a danger in the kitchen also increased by 12% before the campaign and 28% after the campaign.

Conclusion - advertising proved effective as shown by the reduction in chip-pan fires. As time passes the effectiveness of the campaign passes away, Viewers are less likely to be influenced by the campaign if overexposed. 

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Dannenberg - Legislation

Aim review the impact of the passing of a law requiring cycle helmet wearing in children.

Method - natural experiment when laws were passed in the USA, requiring children under 16 to wear helmets when riding bicycles on roads and paths.

Participants - children from 47 schools and two control groups, aged 9-10, 12-13 and 14-15. In the control group the campaign was already in place, 7322 children were sent questionnaires

Design  - independent design where children feel into one of the three countries. 

Procedure - questionnaire containing a 4-point Likert-scale,the topics covered include bicycle use, helmet ownership and use, awareness of the law, sources of information on helmets and peer pressure.  Parents were asked to help children with the questionnaire - consent.

Results - all areas increased their helmet use. 4% wore helmets prior to the law but after the law was passed 47% wore helmets. Questionnaire response rates were between 41-53%. 

Conclusion - although people may not wear helmets daily, the law did help to improve usage. A follow-up study by Cope found similar rates of cycle helmet usage - reliable. 

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Janis and Feshback - Fear Arousal

Aim -  investigate the consequences  of fear appeals on emotions and behaviour  in communications.

Method - laboratory experiment, showed fear arousing material and collected data by a series of questionnaires on emotional reactions and changes in dental practices.

Subjects -  9th-grade freshman class at a US high school divided into 4 groups.

Design - independent measures, in one of three lectures, group 1 had strong fear appeal, emphasising consequences of poor dental hygiene. Group 2 had a moderate fear appeal with little information on consequences and group 3 had minimal fear arousal. Group 4 had a lecture on the eye (control group). 

Results - Amount of knowledge on dental hygiene did not differ between groups, strong fear arousal was seen in a more positive light, they found it interesting but it didn't affect their behaviour. Strong fear-appeal showed a net increase in conformity by 8%. Low fear-appeal was easier to follow and more people altered their behaviour.

Conclusion - Minimal fear arousal works better than strong arousal. Choosing the right level of fear is important in order to change an individual's health behaviours. Fear appeal must be appropriate for the audience. 

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Reasons for Non Adherence to Medical Regimes

Adherence to medicines is the extent to which the patients' action matches the agreed recommendations. Non-adherence includes changing the frequency or dosage of the medicine and neglecting to follow agreed actions e.g. exercise or stopping smoking. 

Non-adherence can result in deterioration of health and wasted medication, there are various reasons as to why people don't adherence, there are two categories;

  • intentional non-adherence - a conscious decision not to follow the advice, it is best understood in terms of perceptual factors e.g. believing that the medicine won't work or is against ethics (vegan) or even practical factors such as side effects.
  • unintentional non-adherence - forgetfulness, inability to pay and confusion - despite wanting to adhere they were unable to.

Trying to decipher someone's reasons for non-adherence raises issues, the most appropriate method is self-report however social desirability, demand characteristics and dishonesty distorts findings. Non-adherence may be a combination of factors which is unique to each individual so finding ways to overcome non-adherence may be difficult. The validity of research and theories is also a weakness as it is difficult to operationalise it - taking roughly the right amount of pills - is that adherence? Research lack reliability when trying to operationalise as it cannot be checked and compared with other research. 

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Measures of Non-Adherence

There are various ways that have been proposed that adherence can be measured: using self-report, looking at the therapeutic outcome , asking the doctor, counting pills and bottles, mechanical methods e.g. track cap and biochemical tests e.g. blood and urine. All of these methods have faults, methodological triangulation is the most appropriate and accurate way of measuring non-adherence. 

Self-report allows attitudes to be given and it is most convenient however it lacks internal validity, asking the doctor avoids social desirability bias but patients may have lied to their doctor about their adherence. Counting pills and bottles may appear to show adherence but someone may have taken the pills out and just not take the pill or taken more than their recommended dosage one day and nothing the following day, in addition, it also is an invasion of privacy. 

Mechanical methods are expensive but can be useful in conjunction with self-report and biochemical tests, the biochemical tests removes the issue of dishonesty, however, they are expensive, time consuming and only show adherence at one point in time and therefore it may be misleading. 

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Improving Adherence using Behavioural Methods

Non-adherence to a medical regime is sometimes not serious, the symptoms and illness may clear up by itself, non-adherence, however, can prove to be fatal and in these cases it requires health psychology to combat non-adherence.  The approach to non-adherence is the behavioural perspective, it iss practical and nomothetic viewpoint. Appropriate behaviourist techniques in combating non-adherence include direct reinforcements (positive reinforcement), modelling (imitation - support group) and contingency contracts (negotiating goals etc.) 

The main issue with improve adherence is that the method which is used is dependent upon the approach that the problem is explained in terms of, this often means that the methods are reductionist which makes it easier to understand and easy to apply but it is oversimplistic in an area; using a combination of methods is likely to be more effective.

Cultural differences complicate adherence, different cultures view medicine and illness differently so it is likely that the findings and theories from their culture cannot be generalised to different cultures. Individual differences should be taken into consideration, people differ individual to what they will adhere to and their reason behind it is based on their individual experiences. 

Focus of improving behavioural measures on behaviourism is reductionist in that behaviourism ignores free will, context and individual differences such as religion. 

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Bulpitt - Reasons for Non-Adherence

Aim - review research on adherence in hypertensive patients.

Method  - a review article of research identifying problems with taking drugs for high blood pressure

Procedure - research was analysed to identify the physical and psychological effects of drug treatment on a person's life. These included work, physical well-being, hobbies etc.

Results - anti-hypertension medication has many side effects; physical reactions e.g. sleepiness, dizziness, lack of sexual functioning. Also affects cognitive functioning e.g. work, hobbies and curtailed.  8% males discontinued treatment due to sexual problems. 

Conclusion -  When the costs of taking medication e.g. side effects, outweigh the benefits of treating a mainly asymptomatic (not showing any indications of a disease or other medical condition) problem there is less likelihood of the patient adhering to their treatment. 

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Lustman - Measures of Non-Adherence

Aim - assess the efficacy of the antidepressant Fluoxetine in treating depression by measuring glycemic control. 

Method - randomised controlled double-blind study

Participants - 60 patients, 26 type I diabetes and 34 with type II

Procedure - 8-week study, patients were randomly assigned to either the Fluoxetine or the placebo group, the randomization was completed by a computer. Patients were assessed for depression using psychometric tests and their adherence to medical regimes was measured by measuring GHb (gamma-Hydroxybutyric acid).

Results - Patients with Fluoxetine reported lower levels of depression, they also had lower levels of GHb - indicated improved adherence. 

Conclusion - Measuring GHb in patients with diabetes indicates their level of adherence to prescribed medical regimes. Greater adherence was shown by patients who were less depressed, and previous research has suggested that reducing depression may improve adherence to diabetic patients.  Fluoextine effectively reduces the severity of depression in diabetic patients. 

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Watt - Improving Adherence using Behavioural Metho

Aim - see if using the Funhaler improves children's adherence to taking medication for asthma. 

Method - filed quasi-experiment, self-reports were used to measure adherence, repeated measures design. Two conditions, one-week using normal pMDI inhaler then one week using the Funhaler.

Participants - 32 children (10 male, 22 female) average duration of asthma 2.2 years, all diagnosed with asthma and prescribed drugs delivered by a pressurised inhaler. Informed consent was given.

Procedure -  Each child was given the Breath-a-tech for one week, parents were given a questionnaire to complete and in the second week they used the Funhaler and the parents were given another questionnaire with matching questions.

Findings  - 38% more parents medicated their children the previous day with the FUnhaler in comparison to existing treatment. 

Conclusion - The spinner and the whistle on the Funhaler works as a reinforcer to children with asthma, it aids their adherence.  Making medical regime fun, adherence particularly in children can be improved. 

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