Health Psychology CHAPTER OUTLINE LEARNING OBJECTIVES INTRODUCTION

Health Psychology 19 CHAPTER OUTLINE LEARNING OBJECTIVES INTRODUCTION HEALTH BELIEFS AND BEHAVIOURS Behaviour ad mortality The role of health beliefs Itegrated models ILLNESS BELIEFS The dimesios of illess beliefs A model of illess behaviour Health professioals beliefs THE STRESS ILLNESS LINK Stress models Does stress cause illess? CHRONIC ILLNESS Profile of a illess Psychology s role FINAL THOUGHTS SUMMARY REVISION QUESTIONS FURTHER READING

By the ed of this chapter you should appreciate that: Learig Objectives health psychologists study the role of psychology i health ad wellbeig; they examie health beliefs as possible predictors of health-related behaviours; health psychology also examies beliefs about illess ad how people coceptualize their illess; a health professioal s beliefs about the symptoms, the illess or the patiet ca have importat implicatios; stress is the product of the iteractio betwee the perso ad their eviromet it ca ifluece illess ad the stress illess lik is iflueced by copig ad social support; beliefs ad behaviours ca ifluece whether a perso becomes ill i the first place, whether they seek help ad how they adjust to their illess. INTRODUCTION Health psychology is a relatively recet yet fastgrowig sub-disciplie of psychology. It is best uderstood by aswerig the followig questios: What causes illess ad who is resposible for it? How should illess be treated ad who is resposible for treatmet? What is the relatioship betwee health ad illess, ad betwee the mid ad body? What is the role of psychology i health ad illess? Huma beigs are complex systems ad illess ca be caused by a multitude of factors, ot just a sigle factor such as a virus or bacterium. Health psychology attempts to move away from a simple liear model of health ad looks at the combiatio of factors ivolved i illess biological (e.g. a virus), psychological (e.g. behaviours, beliefs) ad social (e.g. employmet). This reflects the biopsychosocial model of health ad illess that was developed by Egel (1977, 1980). Because, i this model, illess biopsychosocial the type of iteractio betwee biological factors (e.g. is regarded as the result of a combiatio of factors, beliefs) ad social factors (e.g. class) a virus), psychological factors (e.g. the idividual is o loger simply see as a passive victim of some exteral force, such as a virus. Ackowledgig the role of behaviours such as smokig, diet ad alcohol, for example, meas that the idividual may be held resposible for their health ad illess. Accordig to health psychology, the whole perso should be treated, ot just the physical chages that occur due to ill health. This ca iclude behaviour chage, ecouragig chages i beliefs ad copig strategies, ad compliace with medical recommedatios. Because the whole perso is treated, the patiet becomes

410 Health Psychology partly resposible for their treatmet. For example, she may have a resposibility to take medicatio, ad to chage beliefs ad behaviour. No loger is the patiet see as a victim. From this perspective, health ad illess exist o a cotiuum. Rather tha beig either healthy or ill, idividuals progress alog a cotiuum from healthiess to illess ad back agai. Health psychology also maitais that the mid ad body iteract. It sees psychological factors as ot oly possible cosequeces of illess (after all, beig ill ca be depressig), but as cotributig to all the stages of health, from full healthiess to illess. The aims of health psychology ca be divided ito two mai aspects: 1. Uderstadig, explaiig, developig ad testig theory (for example: what is the role of behaviour i the etiology of illess? ca we predict uhealthy behaviour by studyig beliefs?). 2. Puttig theory ito practice (for example: if we uderstad the role of behaviour i illess, ca uhealthy behaviours be targeted for itervetio? if we chage beliefs ad behaviour, ca we prevet illess oset?) Health psychologists study the role of psychology i all areas of health ad illess, icludig: 1. what people thik about health ad illess; 2. the role of beliefs ad behaviours i becomig ill; 3. the experiece of beig ill i terms of adaptio to illess; 4. cotact with health professioals; 5. copig with illess; 6. compliace with a rage of itervetios; ad 7. the role of psychology i recovery from illess, quality of life ad logevity. This chapter will provide a overview of health beliefs ad behaviours, idividuals illess beliefs, the role of health professioals beliefs, stress ad chroic illess. HEALTH BELIEFS AND BEHAVIOURS Over the last cetury health health behaviours examples are exercise, food itake ad goig to the doctor behaviours have played a icreasigly importat role i health ad illess. This relatioship has bee highlighted by McKeow s book, The Role of Medicie (1979), which discusses the declie of ifectious diseases i the ieteeth cetury, which forms the focus for medical sociology. It also highlights the icreasig role of behaviour i illess i the twetieth cetury. The latter represets the focus for health psychology. The commoly held view is that the declie i illesses such as TB, measles, smallpox ad whoopig cough was related to the developmet of medical itervetios such as chemotherapy ad vacciatios. For example, atibiotics are see as resposible for the declie i illesses such as peumoia ad TB. But McKeow showed that the declie i ifectious diseases had already begu, before the developmet of medical itervetios. He claimed that, lookig back over the past three ceturies, this declie is best uderstood i terms of social ad evirometal factors. McKeow also examied health ad illess throughout the twetieth cetury. He argued that cotemporary illess is caused by a idividual s ow behaviours, such as whether they smoke, what they eat ad how much exercise they take, ad he suggested that good health was depedet o tacklig these habits. McKeow s emphasis o behaviour is supported by evidece of the relatioship betwee behaviour ad mortality. BEHAVIOUR AND MORTALITY It has bee suggested that 50 per cet of mortality from the te leadig causes of death is due to behaviour. If this is correct, the behaviour ad lifestyle have a potetially major effect o logevity. For example, Doll ad Peto (1981) estimated that tobacco cosumptio accouts for 30 per cet of all cacer deaths, alcohol 3 per cet, diet 35 per cet, ad reproductive ad sexual behaviour 7 per cet. Approximately 75 per cet of all deaths due to cacer are related to behaviour. More specifically, lug cacer (the most commo form) accouts for 36 per cet of all cacer deaths i me ad 15 per cet i wome i the UK. It has bee calculated that 90 per cet of all lug cacer mortality is attributable to cigarette smokig, which is also liked to other illesses such as cacers of the bladder, pacreas, mouth, laryx ad oesophagus, ad to coroary heart disease. Ad bowel cacer, which accouts for 11 per cet of all cacer deaths i me ad 14 per cet i wome, appears to be liked to diets high i total fat, high i meat ad low i fibre. As health behaviours seem to be importat i predictig mortality ad logevity, health psychologists have attempted to icrease our uderstadig of health-related behaviours. I particular, based o the premise that people behave i lie with the

Health Beliefs ad Behaviours 411 Health locus of cotrol health locus of cotrol where the cause of health is see to be located either iteral ( due to me ) or exteral ( due to others ) The issue of cotrollability emphasized i attributio theory has bee specifically applied to health i terms of the health locus of cotrol. Idividuals differ i their tedecy to regard evets as cotrollable by them (a iteral locus of cotrol) or ucotrollable by them (a exteral locus of cotrol). Wallsto ad Wallsto (1982) developed a measure to evaluate whether a idividual regards their health as: Figure 19.1 Behaviour ca have a major effect o logevity: for example, aroud 90 per cet of deaths from lug cacer are attributable to cigarette smokig. health beliefs examples are perceptios of risk or beliefs about the severity of a illess way they thik, health psychologists have tured to the study of health beliefs as potetial predictors of behaviour. THE ROLE OF HEALTH BELIEFS Attributio theory The origis of attributio theory lie i the work of Heider (1944, 1958), who argued that idividuals are motivated to uderstad the causes of evets as a meas to make the world seem more predictable ad cotrollable (see chapter 17). Attributio theory has bee applied to the study of health ad health behaviour. For example, Bradley (1985) examied patiets attributios of resposibility for their diabetes ad foud that perceived cotrol over their illess (is the diabetes cotrollable by me or a powerful other?) iflueced their choice of treatmet. Patiets could either choose a isuli pump (a small mechaical device attached to the ski that provides a cotiuous flow of isuli), itese covetioal treatmet or a cotiuatio of daily ijectios. The results idicated that the patiets who chose a isuli pump showed decreased cotrol over their diabetes ad icreased cotrol attributed to doctors. I other words, a idividual who attributed their illess exterally ad felt that they persoally were ot resposible for it was more likely to choose the isuli pump ad to had over resposibility to doctors. A further study by Kig (1982) examied the relatioship betwee attributios for a illess ad attedace at a screeig cliic for hypertesio. The results demostrated that if the hypertesio was see as exteral but cotrollable, the idividual was more likely to atted the screeig cliic ( I am ot resposible for my hypertesio but I ca cotrol it ). cotrollable by them (e.g. I am directly resposible for my health ); ot cotrollable by them ad i the hads of fate (e.g. Whether I am well or ot is a matter of luck ); or uder the cotrol of powerful others (e.g. I ca oly do what my doctor tells me to do ). It has bee suggested that health locus of cotrol relates to whether we chage our behaviour (by givig up smokig or chagig our diet, for istace), ad also to our adherece to recommedatios by a health professioal. For example, if a doctor ecourages someoe who geerally has a exteral locus of cotrol to chage his or her lifestyle, that perso is ulikely to comply if she does ot deem herself to be resposible for her health. However, although some studies support the lik betwee health locus of cotrol ad behaviour (e.g. Rose & Shipley, 1983), several other studies either show o relatioship or idicate the reverse of what is expected (e.g. Norma, 1990; 1995). Urealistic optimism adherece (or compliace) the extet to which a patiet does as suggested (e.g. takig medicie or chagig behaviour) Weistei (1983, 1984) suggested that oe of the reasos we cotiue to practice uhealthy behaviours is our iaccurate perceptios of risk ad susceptibility. He gave participats a list of health problems to examie ad the asked: Compared to other people of your age ad sex, are your chaces of gettig [the problem] greater tha, about the same as, or less tha theirs? Most participats believed that they were less likely to experiece the health problem. Clearly, this would ot be true of everyoe, so Weistei called this pheomeo urealistic optimism. Weistei (1987) described four cogitive factors that cotribute to urealistic optimism: 1. lack of persoal experiece with the problem; 2. the belief that the problem is prevetable by idividual actio; 3. the belief that if the problem has ot yet appeared, it will ot appear i the future; ad 4. the belief that the problem is ifrequet.

412 Health Psychology Research close-up 1 Stages of smokig cessatio The research issue Traditioally, addictive behaviours have bee viewed as either/or behaviours. Therefore, smokers were cosidered either smokers or o-smokers. But DiClemete ad Prochaska (1982) developed a tras-theoretical model to examie the stages of chage i addictive behaviours. This model is ow widely used i health psychology to both predict ad uderstad behaviour, ad it is cetral to may itervetios desiged to chage behaviour. I particular, idividuals are assessed at the begiig of ay itervetio to idetify which stage they are at. The cotet of the itervetio ca the be tailored to match the eeds of each perso. The stages of chage model describes the followig stages: 1. precotemplatio (ot seriously cosiderig quittig i the ext six moths) 2. cotemplatio (cosiderig quittig i the ext six moths) 3. actio (makig behavioural chages) 4. maiteace (maitaiig these chages) 5. relapse (retur to old behaviour) The model is described as dyamic, ot liear, with idividuals movig backwards ad forwards across the stages. For the preset study, the authors sub-categorized those i the cotemplatio stage (stage 2) as either cotemplators (i.e. ot cosiderig quittig i the ext 30 days) or i the preparatio stage (i.e. plaig to quit i the ext 30 days). Desig ad procedure The authors recruited 1466 participats for a miimum itervetio smokig cessatio programme from Texas ad Rhode Islad. The majority were white, female, started smokig at about 16 years of age, ad smoked o average 29 cigarettes a day. The participats completed the followig set of measures at baselie ad were followed up at oe moth ad at six moths. The participats were classified ito three groups accordig to their stage of chage: precotemplators, cotemplators ad those i the preparatio stage. 1. Smokig abstiece self efficacy (DiClemete et al., 1985), which measures the smoker s cofidece that they would ot smoke i 20 challegig situatios. 2. Perceived stress scale (Cohe et al., 1983), which measures how much perceived stress the idividual has experieced i the last moth. 3. Fagerstrom Tolerace Questioaire (Fagerstrom, 1978), which measures physical tolerace to icotie. 4. Smokig decisioal balace scale (Velicer et al., 1985), which measures the perceived pros ad cos of smokig. 5. Smokig processes of chage scale (DiClemete & Prochaska, 1985), which measures the idividual s stage of chage. Accordig to this scale, participats were defied as precotemplators ( = 166), cotemplators ( = 794) ad those i the preparatio stage ( = 506). 6. Demographic data, icludig age, geder, educatio ad smokig history. Results ad implicatios The results were first aalysed to examie baselie differece betwee the three participat groups. The results showed that those i the preparatio stage smoked less, were less addicted, had higher self efficacy, rated the pros of smokig as less positive ad the costs of smokig as more egative, ad had made more prior quittig attempts tha the other two groups. The results were the aalysed to examie the relatioship betwee stage of chage ad smokig cessatio. At both oe ad six moths, the participats i the preparatio stage had made more quit attempts ad were less likely to be smokig. The results provide support for the stages of chage model of smokig cessatio, ad suggest that it is a useful tool for predictig the outcome of a itervetio. DiClemete, C.C., & Prochaska, J.O., 1982, Self-chage ad therapy chage of smokig behaviour: A compariso of processes of chage i cessatio ad maiteace, Addictive Behaviours, 7, 133 42.

Health Beliefs ad Behaviours 413 These factors suggest that our perceptio of our ow risk is ot a ratioal process. I a attempt to explai why idividuals assessmet of their risk may go wrog, ad why people are urealistically optimistic, Weistei (1983) argued that idividuals show selective focus. He claimed that we igore our ow risk-icreasig behaviour ( I may ot always practise safe sex, but that s ot importat ) ad focus primarily o our risk-reducig behaviour ( At least I do t iject drugs ). He also argued that this selectivity is compouded by egocetrism idividuals ted to igore others risk-decreasig behaviour ( My frieds all practise safe sex, but that s irrelevat ) ad focus o the risk-icreasig behaviour of those aroud them ( My frieds sometimes drive too fast ). The stages of chage model The stages of chage model (also kow as the trastheoretical model of behaviour) was origially developed by Prochaska ad DiClemete (1982) as a sythesis of 18 therapies describig the processes ivolved i behavioural chage. These researchers suggested a ew model of chage which has bee applied to several health-related behaviours, such as smokig, alcohol use, exercise ad persoal screeig behaviour such as goig for a cervical smear or attedig for a mammograph (e.g. DiClemete et al., 1991; Marcus, Rakowski & Rossi, 1992). If applied to givig up cigarettes, the model would suggest the followig stages: 1. Precotemplatio: I am happy beig a smoker ad ited to cotiue smokig. 2. Cotemplatio: I have bee coughig a lot recetly; perhaps I should thik about stoppig smokig. 3. Preparatio: I will stop goig to the pub ad will buy lower tar cigarettes. 4. Actio: I have stopped smokig. 5. Maiteace: I have stopped smokig for four moths ow. optimism focuses o perceptios of susceptibility ad risk, ad the stages of chage model stresses the dyamic ature of beliefs, time, ad costs ad beefits. These differet perspectives o health beliefs have bee itegrated ito structured models. The health belief model The health belief model (figure 19.2) was developed iitially by Rosestock i 1966 ad further by Becker ad colleagues throughout the 1970s ad 1980s (e.g. Becker et al., 1977). Their aim was to predict prevetative health behaviours ad the behavioural respose to treatmet i acutely ad chroically ill patiets. Over recet years, the model has bee used to predict may other health-related behaviours. Accordig to the health belief model, behaviour is a product of a set of core beliefs that have bee redefied over the years. The origial core beliefs are the idividual s perceptio of: susceptibility to illess My chaces of gettig lug cacer are high ; the severity of the illess Lug cacer is a serious illess ; the costs ivolved i carryig out the behaviour Stoppig smokig will make me irritable ; the beefits ivolved i carryig out the behaviour Stoppig smokig will save me moey ; ad cues to actio, which may be iteral (e.g. the symptom of breathlessess) or exteral (e.g. iformatio i the form of health educatio leaflets). The health belief model suggests that these core beliefs are used to predict the likelihood that a behaviour will occur. I respose to criticisms, the model was revised to add the costruct health motivatio to reflect readiess to be cocered about health matters ( I am cocered that smokig might damage my health ). More recetly, Becker ad Rosestock (1987) The model describes behaviour chage as dyamic, rather tha beig all or othig, so the five stages do ot always occur i a liear fashio. For example, a idividual may move to the preparatio stage ad the back to the cotemplatio stage several times before progressig to the actio stage. Eve whe a idividual has reached the maiteace stage, they may slip back to the cotemplatio stage over time. The model also examies how we weigh up the costs ad beefits of a particular behaviour. I particular, idividuals at differet stages of chage will differetially focus o either the costs of a behaviour ( Givig up smokig will make me axious i compay ) or the beefits ( Givig up smokig will improve my health ). Demographic variables Susceptibility Severity Costs Beefits Cues to actio Health motivatio Perceived cotrol Likelihood of behaviour INTEGRATED MODELS Figure 19.2 Attributio theory ad the health locus of cotrol model emphasize attributios for causality ad cotrol, urealistic The health belief model. Source: Ogde (2000), after Becker et al. (1977).

414 Health Psychology suggested that perceived cotrol ( I am cofidet that I ca stop smokig ) should also be added to the model (see chapter 17). Whe applied to a health-related behaviour such as screeig for cervical cacer, the health belief model predicts that someoe is likely to have regular screeig if she perceives that: she is highly susceptible to cacer of the cervix; cervical cacer is a severe health threat; the beefits of regular screeig are high; ad the costs of such actio are comparatively low. There will also most likely be relevat cues to actio either exteral (such as a leaflet i the doctor s waitig room) or iteral (such as pai or irritatio, which she perceives to be related to cervical cacer). The ew, ameded model would also predict that a woma is more likely to atted for screeig if she is cofidet that she ca do so, ad she is motivated to maitai her health. The protectio motivatio theory Rogers (1975, 1983, 1985) developed the protectio motivatio theory (figure 19.3), which expaded the health belief model to iclude additioal factors. The origial protectio motivatio theory claimed that healthrelated behaviours are a product of, ad therefore predicted by, five compoets: severity Bowel cacer is a serious illess ; susceptibility My chaces of gettig bowel cacer are high ; respose effectiveess Chagig my diet would improve my health ; self efficacy I am cofidet that I ca chage my diet ; ad fear Iformatio about the liks betwee smokig ad lug cacer makes me feel quite frighteed. The protectio motivatio theory describes severity, susceptibility ad fear as relatig to threat appraisal (i.e. appraisig a outside threat), ad respose effectiveess ad self efficacy Severity Susceptibility Respose effectiveess Self-efficacy Fear Figure 19.3 Behavioural itetios Behaviour The protectio motivatio theory. Source: Ogde (2000), after Rogers (1985). as relatig to copig appraisal (i.e. appraisig the idividual themselves). Accordig to the theory, there are two types of iformatio source: evirometal (e.g. verbal persuasio, observatioal learig) ad itrapersoal (e.g. prior experiece). This iformatio iflueces the five compoets listed above, which the elicit either a adaptive copig respose (a behavioural itetio) or a maladaptive copig respose (such as avoidace or deial). If applied to dietary chage, the protectio motivatio theory would make the followig predictios. Iformatio about the role of a high fat diet i coroary heart disease would icrease fear, icrease the idividual s perceptio of how serious coroary heart disease was (perceived severity) ad icrease their belief that they were likely to have a heart attack (perceived susceptibility). If the idividual also felt cofidet that they could chage their diet (self efficacy) ad that this chage would have beeficial cosequeces (respose effectiveess), they would report high itetios to chage their behaviour (behavioural itetios). This would be regarded as a adaptive copig respose to the preseted iformatio. The theory of plaed behaviour The theory of plaed behaviour (figure 19.4) was developed by Ajze ad colleagues (Ajze, 1985; 1988; Ajze & Madde, 1986). It emphasizes behavioural itetios as the outcome of a combiatio of several beliefs (see chapter 17). The theory proposes that itetios should be coceptualized as plas of actio i pursuit of behavioural goals (Ajze & Madde, 1986), ad that these are a result of the followig composite beliefs: Attitude towards a behaviour composed of a positive or egative evaluatio of a particular behaviour, ad beliefs about the outcome of the behaviour ( Exercisig is fu ad will improve my health ). Subjective orm this represets the beliefs of importat others about the behaviour, ad the idividual s motivatio to comply with such beliefs ( People who are importat to me will approve if I lose weight, ad I wat their approval ). Perceived behavioural cotrol comprisig a belief that the idividual ca carry out a particular behaviour based o a cosideratio of iteral cotrol factors (e.g. skills, abilities, iformatio) ad exteral cotrol factors (e.g. obstacles, opportuities) both of which are related to past behaviour. These three factors predict behavioural itetios, which are the liked to behaviour. (The theory of plaed behaviour also states that perceived behavioural cotrol ca have a direct effect o behaviour without the mediatig effect of behavioural itetios.) Applied to alcohol cosumptio, the theory would predict that someoe will have high itetios to reduce alcohol itake (behaviour itetios) if he believes that:

Illess Beliefs 415 Beliefs about the outcome of the behaviour ( If I exercise more, I will lose weight, feel fitter ad improve my health ) Evaluatios specific to the expected outcomes of the behaviour ( Beig healthy, slim ad fit is desirable ) Normative beliefs ( My family ad frieds thik I should get more exercise ) Motivatio to comply ( I wat to do what they wat me to do ) Attitude towards the specific actio Subjective orms Behavioural itetio (itetio to get more exercise) Behaviour (exercisig) Levethal ad colleagues (Levethal, Meyer & Nerez, 1980; Levethal & Nerez, 1985) defied illess beliefs as a patiet s ow implicit, Pioeer Howard Levethal (1931 ) is Professor of Psychology at the State Uiversity of New Jersey at Rutgers. He has carried out extesive research ito the experiece of beig ill, which has iformed much work o illess perceptios, ad he developed the self-regulatory model of illess behaviour. He places emphasis o the role of symptom perceptio i triggerig illess behaviour ad the liks betwee emotio ad health. ILLNESS BELIEFS illess beliefs examples are how log the illess will last ad what impact it will have o the patiet s life commosese beliefs about his or her illess. They proposed that these beliefs provide a framework, or schema, for copig with ad uderstadig a illess, ad for tellig us what to look out for if we believe that we are becomig ill. Cotrol beliefs ( How likely is it that I will maage to get more exercise if I try? ) Perceived behavioural cotrol THE DIMENSIONS OF ILLNESS BELIEFS Usig iterviews with patiets sufferig from a variety of illesses, Levethal et al. idetified five dimesios of illess beliefs: Figure 19.4 The theory of plaed behaviour applied to the itetio to egage i physical exercise. Source: Ogde (2000), after Ajze (1985) ad Stroebe (2000). reducig his alcohol itake will make his life more productive ad be beeficial to his health (attitude to the behaviour); the importat people i his life wat him to cut dow (subjective orm); ad he is capable of drikig less alcohol due to his past behaviour ad evaluatio of iteral ad exteral cotrol factors (high behavioural cotrol). The model also predicts that perceived behavioural cotrol ca predict behaviour without the ifluece of itetios. For example, a belief that the idividual would ot be able to exercise because they are physically icapable of doig so might well be a better predictor of their exercisig behaviour tha their high itetios. 1. Idetity refers to the label give to the illess (the medical diagosis) ad the symptoms experieced; for example, I have a cold... (the diagosis)... with a ruy ose (the symptoms). 2. The perceived cause of the illess this may be biological (e.g. a virus, i the case of a cold, or a ijury or lesio, i the case of aother type of illess) or psychosocial (e.g. stress or health-related behaviour). Patiets may also hold represetatios of illess that reflect a variety of differet causal models; for example, My cold was caused by a virus versus My cold was caused by beig ru-dow. 3. Time lie refers to beliefs about how log a illess will last, whether it is acute (i.e. short term) or chroic (i.e. log term); for example My cold will be over i a few days. 4. Cosequeces refers to the patiet s perceptios of the possible effects of the illess o his or her life. These may be physical (e.g. pai, lack of mobility), emotioal (e.g. loss of social cotact, loeliess) or a combiatio of factors; for example, My cold will prevet me from playig football, which will prevet me from seeig my frieds. 5. Curability ad cotrollability refers to the patiet s beliefs about whether their illess ca be treated ad cured, ad the extet to which its outcome is cotrollable (either by

416 Health Psychology themselves or by others): for example, If I rest, my cold will go away, If I get medicie from my doctor, my cold will go away. Evidece for the dimesios The extet to which beliefs qualitative research uses methods about illess comprise these such as ope-eded iterviews, focus differet dimesios has bee groups or observatio, where the data studied usig both qualitative are aalysed without resortig to ad quatitative research. umber Levethal ad colleagues carried out iterviews with idividuals who were chroically ill (havig bee recetly quatitative research uses methods such as questioaires, experimets diagosed with cacer) ad ad structured iterviews, where the healthy adults. Participats data are aalysed usig umbers descriptios of their illess ideed suggested uderlyig beliefs made up of the above dimesios. Other studies have provided support for these dimesios usig more artificial ad cotrolled methodologies. Lau, Berard ad Hartma (1989) asked 20 people to sort 65 statemets ito piles that made sese to them. These statemets had bee previously made i respose to descriptios of your most recet illess. The researchers reported that the piles of categories that people produced reflected the dimesios of idetity of the illess (diagosis/symptoms), its cosequeces (the possible effects), the time lie (how log it would last), the cause (what caused the illess) ad cure/cotrol (how ad whether it could be treated). A series of experimetal studies by Bishop ad colleagues provided further support for this framework. For example, Bishop ad Coverse (1986) preseted participats with brief descriptios of patiets who were experiecig six symptoms. The participats were radomly allocated to oe of two sets of descriptios a high prototype, i which all six symptoms had bee previously rated as associated with a give disease, ad a low prototype, i which oly two of the six symptoms had bee previously rated as beig associated with the same disease. It was foud that those idividuals i the high prototype coditio labelled the disease more easily ad accurately tha did those i the low prototype coditio. The authors argued that this provides support for the role of the idetity dimesio (i.e. diagosis ad symptoms) of illess represetatios, ad that this also suggested that there is some cosistecy i people s cocept of the idetity of illesses. Participats were also asked to describe i their ow words what else they thought may be associated with each patiet s situatio. Bishop ad Coverse reported that 91 per cet of the associatios fell withi the aforemetioed dimesios of illess beliefs. Withi these, the dimesios of cosequeces (the possible effects) ad time lie (how log it will last) were the least frequetly metioed dimesios. There is also some evidece for a similar structure of illess represetatios i other o-wester cultures (Lau, 1995; Weller, 1984). Measurig illess beliefs I order to delve further ito beliefs about illess, researchers i New Zealad ad the UK have developed the Illess Perceptio Questioaire (IPQ). This asks people to rate a series of statemets about their illess. These statemets reflect the dimesios of idetity (e.g. symptoms such as pai, tiredess), cosequeces (e.g. My illess has had major cosequeces o my life ), time lie (e.g. My illess will last a short time ), cause (e.g. Stress was a major factor i causig my illess ) ad cure/cotrol (e.g. There is a lot I ca do to cotrol my symptoms ). A MODEL OF ILLNESS BEHAVIOUR Levethal icorporated illess beliefs ito a self-regulatory model of illess behaviour (figure 19.5) to examie the relatioship betwee someoe s cogitive represetatio of his or her illess ad their subsequet copig behaviour. Represetatio of health threat Idetity Cause Cosequeces Time lie Cure/cotrol Stage 1: Iterpretatio Symptom perceptio Social messages deviatio from orm Stage 2: Copig Approach copig Avoidace copig Stage 3: Appraisal Was my copig strategy effective? Emotioal respose to health threat Fear Axiety Depressio Figure 19.5 The self-regulatory model. Source: Ogde (2000), based o Levethal et al. (1980).

Illess Beliefs 417 The model is based o problem solvig ad suggests that we deal with illesses ad their symptoms i the same way as we deal with other problems. The assumptio is that, give a problem or a chage i the status quo, a idividual will be motivated to solve the problem ad re-establish his state of ormality. I terms of health ad illess, if healthiess is your ormal state, the you will iterpret ay oset of illess as a problem, ad you will be motivated to re-establish your state of health. Traditioal models describe problem solvig i three stages: iterpretatio makig sese of the problem; copig dealig with the problem i order to regai a state of equilibrium; ad appraisal assessig how successful the copig stage has bee. These three stages are said to cotiue util the copig strategies are deemed to be successful ad a state of equilibrium has bee attaied. This process is regarded as self-regulatory because the three compoets of the model iterrelate, i a ogoig ad dyamic fashio, i order to maitai the status quo. I other words, they regulate the self. The three stages of Levethal s model ca be applied to health as follows: Stage 1 Iterpretatio A idividual may be cofroted with the problem of a symptom perceptio how a idividual experieces ad makes sese of potetial illess through two their symptoms chaels symptom perceptio ad social messages. Symptom perceptio ( I social messages iput from a rage have a pai i my chest ) of sources such as frieds, family ad iflueces how a idividual media regardig the ature of symptoms iterprets the problem of illess. This is ot a straightforward process, perceptio beig i tur iflueced by idividual differeces, mood ad cogitios. The factors cotributig to symptom perceptio are illustrated by a coditio kow as medical studets disease, described by Mechaic (1962). A large compoet of the medical curriculum ivolves learig about the symptoms associated with a multitude of illesses. More tha two thirds of medical studets icorrectly report at some time that they have the symptoms they are learig about. This pheomeo might be explaied i terms of mood (i.e. medical studets becomig quite axious due to their work load), cogitio (the studets are thikig about symptoms as part of their course) ad social cotext (oce oe studet starts to perceive symptoms, others may model themselves o this behaviour). Iformatio about illess also comes from other people, perhaps as a formal diagosis from a health professioal or a positive test result from a routie health check. But we also ofte access such iformatio via our lay referral system (i.e. seekig iformatio ad advice from multiple sources, such as colleagues, frieds or family). For example, coughig i frot of oe fried may result i the advice to speak to aother fried who had a similar cough, or a suggestio to take a favoured home remedy. Or it may result i a lay diagosis or a suggestio to seek professioal help from a doctor. Social messages like this will ifluece how we iterpret the problem of illess. Oce we have received iformatio about the possibility of illess through these chaels we become aware that somethig has deviated from the orm ad that there has bee a chage i our health status. Accordig to this framework we are the motivated to retur to a state of problem free ormality. This ivolves assigig meaig to the problem. Accordig to Levethal, we may do this by accessig our illess beliefs. So the otio is that the symptoms ad social messages cotribute towards the developmet of illess beliefs, which will be costructed accordig to the five dimesios metioed earlier. These cogitive represetatios of the problem will give the problem meaig ad eable us to develop ad cosider suitable copig strategies. Accordig to Levethal, the idetificatio of the problem of illess will result i chages i emotioal state as well as i our cogitive represetatio. For example, perceivig a) the symptom of pai ad receivig b) the social message that this pai may be related to coroary heart disease may result i deviatio from the orm, ad resultat axiety. So ay copig strategies have to relate to both our illess beliefs ad our emotioal state. Stage 2 Copig Copig ca take may forms, but two broad categories have bee defied approach copig (e.g. takig pills, goig to the doctor, restig, talkig to frieds about emotios) ad avoidace copig (e.g. deial, wishful thikig). Whe faced with the problem of illess, we develop copig strategies i a attempt to retur to a state of healthy ormality. I a alterative model of copig, Taylor ad colleagues (e.g. Taylor, 1983; Taylor, Lichtma & Wood, 1984) looked at how we adjust to threateig evets. I a series of iterviews with rape victims ad cardiac ad cacer patiets, they foud that copig with threateig evets (icludig illess) cosists of three processes: a search for meaig Why did it happe to me? a search for mastery How ca I prevet it from happeig agai? a process of self ehacemet I am better off tha a lot of people. Taylor ad colleagues argued that these three processes are cetral to developig ad maitaiig illusios, ad that these illusios costitute a process of cogitive adaptatio. Stage 3 Appraisal Appraisal is the fial stage i Levethal s model. At this poit people evaluate their copig strategy as either effective or ieffective. If it is appraised as effective the they will cotiue with it ad

418 Health Psychology the same set of copig strategies will be pursued. If the copig strategies are appraised as ieffective the people are motivated to thik of alteratives which will the be put ito place. The appraisal stage clearly illustrates the self-regulatory ature of the model as the process of iterpretatio, copig ad appraisal is ot a liear pathway but dyamic ad ogoig. Accordigly, the idividual self-regulates by a costat ogoig process of appraisal, which assesses whether copig is effective ad whether the idividual is successfully maagig to achieve a reewed sese of equilibrium. HEALTH PROFESSIONALS BELIEFS Early research regarded health professioals as experts ad assumed that doctors with similar levels of kowledge ad traiig would act i similar ways. But there is, i fact, cosiderable variability i differet aspects of medical practice. For example, Aderso et al. (1983) reported that doctors differ i their diagosis of asthma. Mapes (1980) suggested that they also vary cosiderably i terms of their prescribig behaviour, some doctors givig drugs to oly 15 per cet of their patiets ad others offerig prescriptios for up to 90 per cet. Buckall, Morris ad Mitchell (1986) reported sigificat variatio i doctors measuremet of blood pressure, ad Marteau ad Baum (1984) reported that doctors differ sigificatly i their treatmet of diabetes. It is ow geerally accepted that health professioals may behave ot just accordig to their educatio ad traiig, but also accordig to their ow lay beliefs. This meas that ay evaluatio of the iteractio betwee health professioals ad patiets should ot oly focus o the persoal beliefs of the patiet ad the kowledge base of the professioal, but also o the persoal belief system of the professioal. Figure 19.6 Iteractio betwee patiet ad doctor ca be iflueced by the health professioal s beliefs about the patiet ad the disease, as well as by their kowledge. Beliefs that ifluece practice Research idicates that the followig beliefs ifluece the developmet of a health professioal s origial diagosis. The ature of cliical problems If a health professioal believes that illess is determied by biomedical factors (e.g. lesios, bacteria, viruses), they will develop a diagosis that reflects this perspective. But a professioal who places the emphasis o psychosocial factors may develop a differet diagosis. For example, if a patiet reports feelig tired all the time, the first professioal might poit to aaemia as the cause, ad the secod to stress. The probability of the disease Health professioals also have differet beliefs about how commo a health problem is. For example, some doctors may regard childhood asthma as a commo complait ad hypothesize that a child presetig with a cough has asthma. Aother doctor who believes that childhood asthma is rare might ot cosider this diagosis. The seriousess of the disease Health professioals are motivated to cosider the pay-off i reachig a correct diagosis, which is related to their beliefs about the seriousess ad treatability of a illess. For example, if a child presets with abdomial pai, the professioal may diagose appedicitis, as this is a serious but treatable coditio. I this case, the beefits of arrivig at the correct diagosis for this coditio far outweigh the costs ivolved (such as time wastig) if the diagosis is actually wrog. The patiet The origial diagosis will also be iflueced by the health professioal s existig kowledge of the patiet, icludig medical history, degree of support at home, psychological state, ad beliefs about why the patiet came to see the doctor. Similar patiets We kow that stereotypes ca cofoud a decisio-makig process (see chapter 17). Yet without them, cosultatios betwee health professioals ad patiets would be extremely time cosumig. Stereotypes reflect the process of cogitive ecoomy. They play a cetral role i developig ad testig a hypothesis ad reachig a maagemet decisio. So a health professioal will typically base their decisio partly o factors such as how the patiet looks/talks/walks, ad whether they are remiiscet of previous patiets. Commuicatig beliefs to patiets Health professioals ow health-related beliefs may be commuicated to patiets. A study by McNeil et al. (1982) examied the effects of health professioals ow laguage o patiets choice of treatmet. They foud that patiets are more likely to choose surgery if they are told it will icrease the probability of survival rather tha decrease the probability of death. The phrasig of a questio like this teds very much to reflect the beliefs of the idividual doctor. So the results idicate that the subjective views of health professioals may be commuicated to the patiet, ad subsequetly ifluece the patiet s choice of treatmet.

The Stress Illess Lik 419 stress egative emotioal experiece resultig from a mismatch betwee the idividual s appraisal that the stressor is stressful ad their ability to cope with ad therefore reduce their respose to it THE STRESS ILLNESS LINK The term stress meas may differet thigs to may people. A lay perso may defie stress i terms of pressure, tesio, upleasat exteral forces or a emotioal respose. Psychologists defie stress i a variety of differet ways. Cotemporary defiitios of stress regard the exteral eviromet as a potetial stressor (e.g. problems at work), the respose to the stressor as stress or distress (e.g. the feelig of tesio), ad the cocept of stress as somethig that ivolves biochemical, physiological, behavioural ad psychological chages. Researchers have also differetiated betwee stress that is harmful ad damagig ( distress ) ad stress that is positive ad beeficial ( eustress ). The most commo defiitio of stress was developed by Lazarus ad Lauier (1978), who regarded it as a trasactio betwee people ad the eviromet. Withi this defiitio, Figure 19.7 O the stock exchage floor, it is easy to see how stress arises from a trasactio betwee people ad their eviromet.

420 Health Psychology stress ivolves a iteractio betwee the stressor ( My job is difficult ) ad distress ( I feel stressed by it ). So a stressful respose might be the feelig of stress that results from a mismatch betwee a) a situatio that is appraised as stressful ad b) the idividual s self-perceived ability to cope ad therefore reduce the stress. STRESS MODELS Throughout the twetieth cetury, stress models have varied i terms of their defiitio of stress, their emphasis o physiological ad psychological factors, ad their descriptio of the relatioship betwee the idividual ad their eviromet. Cao s fight or flight model Oe of the earliest models of stress was developed by Cao (1932). The fight or flight model suggested that exteral threats elicit the fight or flight respose, icreasig activity rate ad arousal. These physiological chages eable the idividual either to escape from the source of stress or fight. Cao defied stress as a respose to exteral stressors that is predomiatly see as physiological (see chapters 5 ad 6). Selye s geeral adaptatio sydrome Developed i 1956, Selye s geeral adaptatio sydrome describes three stages i the stress process: alarm, which describes a icrease i activity ad occurs immediately the idividual is exposed to a stressful situatio; resistace, which ivolves copig ad attempts to reverse the effects of the alarm stage; ad exhaustio, which is reached whe the idividual has bee repeatedly exposed to the stressful situatio ad is icapable of showig further resistace. Life evets theory I a attempt to depart from models that emphasize physiological chages, the life evets theory examies stress ad stressrelated chages as a respose to life chage. Research has show liks betwee life evets ad health status, i terms of both the oset of illess ad its progressio (Yoshiuchi et al., 1998). These results were obtaied usig Holmes ad Rahe s (1967) Schedule of Recet Experieces (SRE) a extesive list of possible life chages or life evets. These rage i supposed objective severity from serious evets, such as death of a close family member ad jail term, through more moderate evets, such as so or daughter leavig home ad pregacy, to mior evets, such as vacatio ad chage i eatig habits. Each evet has a predetermied poit score to reflect its impact, with the combied score reflectig the adjudged stress ratig of the assessed idividual. For example, death of spouse would result i more chages to a idividual s life schedule tha trouble with boss, ad is therefore allocated a higher poit score. The difficulty with this sigificace weightig is that it was devised by psychologists, ot the research participats. For example, whilst a divorce may be very stressful for oe perso, it might be liberatig for aother. The model of appraisal ad trasactio Both Cao s ad Selye s early models of stress preseted it as a automatic respose to a exteral stressor a perspective that is also reflected i life evets theory, with its use of expert rather tha idividual ratig schemes. By cotrast, more recet models allow for active iteractio betwee the idividual ad exteral stressors, rather tha passive respose. This approach provides a role for psychological state. It is epitomized by Lazarus s trasactioal model of stress ad his theory of appraisal. I the 1970s, Lazarus itroduced the psychological dimesio ito our uderstadig of the stress respose (1975; Lazarus & Cohe, 1973, 1977). He argued that stress ivolves a trasactio betwee a idividual ad his or her exteral world, ad that a stress respose is elicited if the idividual appraises a evet as stressful. Lazarus defied two forms of appraisal: 1. Primary appraisal: the idividual iitially appraises the evet i three ways as (a) irrelevat, (b) beig ad positive or (c) harmful ad egative. 2. Secodary appraisal the idividual evaluates the pros ad cos of his or her differet copig strategies. So primary appraisal is essetially a appraisal of the outside world ad secodary appraisal is a appraisal by the idividual of himself (figure 19.9). DOES STRESS CAUSE ILLNESS? The relatioship betwee stress ad illess is ot straightforward, ad there is a lot of evidece to suggest that several factors mediate the stress illess lik, icludig exercise, copig styles, life evets, persoality type, social support ad actual or perceived cotrol. Stress ca affect health through a behavioural pathway or through a physiological pathway. Behaviours that may chage as a result of stress iclude sleep, food itake ad alcohol cosumptio. Stress ca also iduce chages i the body s biochemicals, such as catecholamies ad corticosteroids, ad chages i activity, such as heart rate. Stress ad behaviour appraisal a idividual s assessmet of both the outside world ad their ability to cope with this world Recet research has examied the effect of stress o specific health-related behaviours, such as exercise, smokig, diet ad alcohol cosumptio, i terms of iitiatio, maiteace ad relapse. It has also highlighted the impact of stress o geeral

The Stress Illess Lik 421 Pioeer Primary appraisal Is this stressful? Potetial stressor STRESS Secodary appraisal Ca I cope with this? Copig Figure 19.9 The role of appraisal i stress. Source: Ogde (2000), based o Lazarus (1975). Stress ad physiology The physiological cosequeces of stress have bee studied extesively, mostly i the laboratory usig the acute stress paradigm. This ivolves brigig participats ito a cotrolled eviromet, puttig them ito a stressful situatio (such as coutig backwards, completig a itelligece task or givig a uprepared speech) ad the recordig ay chages. This research has highlighted two mai groups of physiological effects: Figure 19.8 Richard Lazarus developed the role of psychological factors ad appraisal i the study ad treatmet of stress. Richard Lazarus (1922 2002) was Professor of Psychology at the Uiversity of Califoria, Berkeley. His origial work explored theories of emotio, which led him to focus o stress ad copig. I particular, he itroduced ad developed the role of psychological factors i stress ad emphasized the importace of appraisal. He established the UC Berkeley Stress ad Copig Project, i which he exteded his ideas o the importace of appraisal to explai exactly what stress is ad what copig ivolves. This project culmiated i the publicatio i 1984 of Stress, Appraisal, ad Copig, oe of the most widely cited ad read books i psychophysiology ad health psychology. behavioural chage. For example, research suggests that idividuals who experiece high levels of stress show a greater tedecy to perform behaviours that icrease their chaces of becomig ill or ijured (Wiebe & McCallum, 1986) ad of havig accidets at home, work ad i the car ( Johso, 1986). For example, whe uder stress a perso may smoke more, sleep less, drive faster ad be less able to focus o the task i had, which, i tur, may result i heart disease, cacer or accidets. 1 Sympathetic activatio Whe a evet is appraised as stressful, it triggers resposes i the sympathetic ervous system. This results i the productio of catecholamies (adreali ad oradreali), which causes chages i factors such as blood pressure, heart rate, sweatig ad pupil dilatio. These chages are experieced subjectively as a feelig of icreased arousal. This process is similar to the fight or flight respose described by Cao. Sympathetic activatio ad prologed productio of adreali ca result i: blood clot formatio icreased blood pressure icreased heart rate irregular heart beats fat deposits plaque formatio immuo-suppressio These chages may icrease the chaces of heart disease ad kidey disease, ad leave the body ope to ifectio. 2 Hypothalamic-pituitary-adreocortical (HPA) activatio Stress also triggers chages i the HPA system. This results i icreased levels of corticosteroids (cortisol), leadig to more diffuse chages, such as the icreased use of carbohydrate stores ad a greater chace of iflammatio. These chages costitute the backgroud effect of stress, ad caot be detected by the idividual. They are similar to the alarm, resistace ad exhaustio stages of stress described by Selye as they show how chroic ogoig stress ca be damagig to the body i the loger term. HPA activatio ad prologed productio of cortisol ca result i: decreased immue fuctio damage to euros i the hippocampus These chages may icrease the chaces of ifectio, psychiatric problems ad losses i memory ad cocetratio.

422 Health Psychology The role of hormoes Kiecolt-Glaser ad Glaser (1986) argued that stress causes a decrease i the hormoes produced to fight carcioges (factors that cause cacer) ad repair DNA. I particular, cortisol decreases the umber of active T cells, which ca icrease the rate of tumour developmet. This suggests that experiecig stress whilst ill could exacerbate the illess through physiological chages. So if the illess itself is appraised as beig stressful, this itself may be damagig to the chaces of recovery. Psychoeuroimmuology (PNI) This relatively ew area of research is based o the predictio that psychological state ca ifluece the immue system via the ervous system. This perspective provides a scietific basis for the mid over matter, thik yourself well ad positive thikig, positive health approaches to life. It suggests that ot oly ca psychological state ifluece health via behaviour, but beliefs may ifluece health directly. I particular, research has focused o the capacity of psychological factors (such as mood, thought suppressio ad stress) to modify immue fuctioig. Positive mood is associated with better immue fuctioig, whereas egative mood is associated with poorer immue fuctioig (Stoe et al., 1987). Humour appears to be particularly beeficial (Dillo, Michoff & Baker, 1985). Certai copig styles (such as suppressio ad deial) may relate to illess oset ad progressio (e.g. Kue et al., 1991), while thought expressio through writig or disclosure groups may improve immue fuctioig (Peebaker et al., 1988; Petrie, Booth & Peebaker, 1998; see also chapter 6). Everyday Psychology Life ad stress Most of us would like to be better at maagig stress, especially if we cope through potetially damagig habits such as smokig or drikig. Robert Sapolsky is oe of the foremost authorities i the field of stress. I his book, Why Zebras Do t Get Ulcers, Sapolsky argues that we evolved for a very differet stress eviromet tha that which faces us today. He argues that i our evolutioary past we regularly faced serious, life-threateig situatios (such as a predator attack or hostility with a eighbourig tribe over a importat resource). Today our lives are much safer ad our stressors much milder, but there are may of them cotiual, recurrig ad irritatig. We may fid it hard to escape from these stressors ad their effects may build up over time. Sapolsky explores the role of stress i heart disease, diabetes, growth retardatio, memory loss ad auto-immue diseases such as multiple sclerosis. I attemptig to decide why zebras do ot get ulcers (or heart disease, diabetes ad other chroic diseases), Sapolsky suggests that people develop such diseases partly because our bodies are ot desiged for the costat stresses of a moder-day life (like sittig i traffic jams or dealig with multiple coflictig demads). Istead, we seem better equipped to deal with the kid of short-term stress faced by a zebra, such as outruig a lio! So why do we adapt to some stressful emergecies, while others make us sick? Ad why are some of us especially vulerable to stress-related diseases? Is this related to features of our persoalities? If so, are these features leared or iate? Humas today live log eough ad are itelliget eough to egage with ad eve geerate all sorts of stressful evets. Sapolsky suggests that stress-related disease emerges, predomiatly, from our chroic activatio of a physiological system that has evolved to respod to acute physical emergecies. We seem able to tur o the stress respose ot oly i respose to physical or psychological isults, but also by just thikig about potetial stressors. Stress may be characterized by o-costructive frettig ad agoizig, ad may geeralize ito more serious freefloatig axiety ad paic attacks, which ca iterfere with daily livig. Sapolsky highlights studies that suggest we do have some cotrol over stress-related ailmets. Oe strategy is cotaimet. Simply set aside about 10 20 miutes each day for worryig! It is the easier to dispatch cocers from your mid for the remaider of your wakig hours. Aother techique is to put some costructive thought ito how to better deal with problems durig this worry period rather tha frettig i a ufocused maer. Aother idea is to focus o livig life i the preset. Accordig to this priciple (related to Ze philosophy), we should strive costatly to ejoy each momet to its fullest. If you caot live i the momet, there will always be other cocers o your mid. Fially, our overall attitude or midset ca ifluece our resposes to stressful situatios. Realistically, life is ever as bad as it seems durig our darkest ad most depressed momets, or as woderful as it seems durig our happiest, most ecstatic momets. It is somewhere i betwee. A sage piece of advice might be: istead of worryig about relatively trivial matters, save your emotioal eergy for the really big problems i your life, because it is likely that there will be more tha eough of those. Sapolsky, R., 2003, Tamig stress, Scietific America, 289 (3), 86 95.

Chroic Illess 423 Pioeer CHRONIC ILLNESS Chroic illesses, such as asthma, AIDS, cacer, coroary heart disease ad multiple sclerosis, are aother importat focus for health psychologists. This sectio uses coroary heart disease (oe of the leadig causes of death i the preset day) to illustrate the role of psychology at every stage, from predictig risk factors through to rehabilitatio. PROFILE OF AN ILLNESS Figure 19.10 Jamie Peebaker foud that writig ad talkig ca reduce time spet visitig the GP ad improve work performace. Jamie Peebaker (1950 ) is Professor of Psychology at the Uiversity of Texas at Austi ad has bee ivolved i explorig the role of psychological factors i symptom perceptio. He has also promoted research ito the impact of psychological factors o the immue system, ad he has a particular iterest i the liks betwee traumatic experieces, laguage, ad physical ad metal health. His studies fid that time spet i simple writig ad/or talkig (icludig self-disclosure) ca reduce time spet beig see by a physicia, medical costs ad alcohol use, ad ca icrease work performace. Coroary heart disease (CHD) is caused by hardeig of the arteries (atherosclerosis), which are arrowed by fatty deposits. This ca result i agia (pai) or a heart attack (myocardial ifarctio). CHD is resposible for 33 per cet of deaths i me uder 65 ad 28 per cet of all deaths. It is the leadig cause of death i the UK, killig 4300 me ad 2721 wome per millio i 1992. It has bee estimated that CHD cost the Natioal Health Service i the UK about 390 millio i 1985/86. The highest death rates from CHD are foud i me ad wome with a maual occupatio ad me ad wome of Asia origi. I middle age, the death rate is up to five times higher for me tha wome, but this eves out i old age, whe CHD is the leadig cause of death for everyoe, regardless of geder. May risk factors for CHD have bee idetified, some less modifiable (e.g. educatioal status, social mobility, social class, age, geder, family history ad race) tha others (e.g. smokig behaviour, obesity, sedetary lifestyle, perceived work stress ad type A behaviour). PSYCHOLOGY S ROLE Psychology has a role to play at all stages of CHD (figure 19.11): 1. Psychological factors ifluece the oset of CHD. Our beliefs about both behaviour ad illess ca ifluece Beliefs: Susceptibility I wo t have a heart attack Seriousess Lots of people recover from heart attacks Costs Takig exercise would be a effort Beefits Smokig helps me deal with stress Copig with illess Rehabilitatio: Behaviour chage Belief chage Behaviours: Diet Exercise Smokig Screeig Type A behaviour Illess oset: CHD Illess represetatio Heart attack Illess as stressor Outcome: Logevity Recovery Quality of life Figure 19.11 The role of psychology i coroary heart disease. Source: Ogde (2000).

424 Health Psychology whether we become ill or stay healthy. For example, someoe who believes that lots of people recover from heart attacks may lead a iactive ad sedetary lifestyle; ad a belief that smokig helps me deal with stress is hardly likely to help someoe give up smokig. Beliefs such as these therefore result i uhealthy behaviours that ca lead to CHD. 2. Oce ill, people also hold beliefs about their illess ad will cope i differet ways. Psychology therefore cotiues to play a role as the disease progresses. For example, if someoe believes my heart attack was caused by my geetic makeup, they may cope by thikig there is othig I ca do about my health; I am the victim of my gees. Beliefs like this are likely to ifluece the progressio of the illess either by affectig behaviour or by havig a impact o the immue system. 3. Psychology also has a role to play i the outcome of CHD. For example, believig that a heart attack is due to a geetic weakess rather tha a product of lifestyle may mea that a perso is less likely to atted a rehabilitatio class ad be less likely to try ad chage the way they behave. People also differ i other ways regardig their Research close-up 2 Patiet expectatios ad the placebo effect The research issue For a log time, medicie has regarded adherece to (i.e. compliace with) medical recommedatios as importat for patiet recovery. This might be expressed i simplified forms such as: Take these drugs ad you will get better. Implicit withi this assumptio is the belief that a active drug is better tha a placebo. This is why trials to explore the effectiveess of a drug should compare it with a placebo. But it is possible that simply takig medicatio (whether active or iert) may also be beeficial if the patiet expects to get better. This perspective is i lie with the focus o beliefs foud withi health psychology, ad the predictio that positive expectatios may result i improvemets i health. This paper (Horwitz et al., 1990) presets a reaalysis of the data from a drug trial that explored the effectiveess of beta blockers followig a heart attack. The paper asks whether simply adherig to medical recommedatios to take pills was beeficial to recovery followig a heart attack, regardless of whether the pills take were active pills or placebo pills. Desig ad procedure The origial study icluded 3837 me ad wome aged 30 to 69 who were reassessed every three moths for a average of 25 moths. For this paper, data were aalysed from 1082 me i the experimetal coditio (who had received the beta blocker) ad 1094 me i the placebo coditio. Follow-up data were aalysed for 12 moths. Measures were take of psychosocial factors, adherece ad cliical characteristics. Results ad implicatios Compared to patiets with good adherece, those with poor adherece were twice as likely to have died at oe year follow-up. This was true for both the experimetal group ad the cotrol group. Eve takig ito accout psychosocial factors (e.g. stress, depressio, smokig, alcohol use, exercise) ad cliical factors (e.g. severity of heart attack), this fidig was the same. So, regardless of whether the drug was a beta blocker or a placebo, takig it as recommeded halved the participats chaces of dyig over a 12-moth period. These results idicate a strog lik betwee adherece to medical recommedatios ad mortality, regardless of the type of pill take. This effect does ot appear to be due to psychosocial or cliical factors (for example, the o-adherers did ot simply smoke more tha the adherers). So doig as the doctor suggests appears to be beeficial to health, but ot ecessarily because the drugs are good for you. Istead, the fidigs idicate that simply by takig (what is believed to be) medicatio, the patiet expects to get better. The authors cocluded that perhaps the most provocative explaatio for the good effect of good adherece o health is the oe most perplexig to cliicias: the role of patiet expectacies or self-efficacy. The researchers suggest that patiets who expect treatmet to be effective egage i other health practices that lead to improved cliical outcomes (Horwitz & Horwitz, 1993). The authors also propose that the power of adherece may ot be limited to takig drugs; it may occur with other forms of health itervetio such as recommedatios for behaviour chage. Horwitz, R.I., Viscoli, C.M., Berkma, L. et al., 1990, Treatmet adherece ad risk of death after a myocardial ifarctio, Lacet, 336 (8714), 542 5.

Chroic Illess 425 experieces of illess ad their ability to adjust to such a crisis i their lives. For example, whilst some people cope by takig defiite actio ad makig plas about how to prevet the illess gettig worse, others go ito a state of deial or cope by idulgig i uhealthy behaviours, makig the situatio worse. Such factors ca impact upo their quality of life, possibly eve ifluecig how log they live. Behavioural risk factors The risk factors for CHD ca be uderstood ad predicted by examiig a idividual s health beliefs. Psychology s role is to both uderstad ad attempt to chage these behavioural risk factors. Smokig is estimated to be the cause of oe i four deaths from CHD. Smokig more tha 20 cigarettes a day icreases the risk of CHD i middle-age threefold. Givig up smokig ca halve the risk of aother heart attack i those who have already had oe. Diet ad exercise (especially cholesterol levels) have also bee implicated i CHD. It has bee suggested that the 20 per cet of a populatio with the highest cholesterol levels are three times more likely to die of heart disease tha the 20 per cet with the lowest levels. We ca reduce cholesterol by cuttig dow total fats ad saturated fats i our diet, ad icreasig polyusaturated fats ad dietary fibre. Other risk factors iclude excess coffee ad alcohol ad lack of exercise. High blood pressure is aother risk factor the higher the blood pressure, the greater the risk. Eve a small decrease i the average blood pressure of a populatio could reduce the mortality from CHD by 30 per cet. Blood pressure appears to be related to a multitude of factors, such as geetics, obesity, alcohol itake ad salt cosumptio. Type A behaviour is probably the most extesively studied risk factor for CHD. Friedma ad Rosema (1959) iitially defied type A behaviour as excessive competitiveess, impatiece, hostility ad vigorous speech. I 1978, usig a semi-structured iterview, they idetified two types of type A behaviour. Type A1 is characterized by vigour, eergy, alertess, cofidece, loud speakig, rapid speakig, tese clipped speech, impatiece, hostility, iterruptig, frequet use of the word ever ad frequet use of the word absolutely. Type A2 was defied as beig similar to type A1, but ot as extreme, ad Type B behaviour was regarded as relaxed (for example, showig o iterruptios of others speech) ad quieter. Stress has also bee extesively studied as a predictor of CHD. I the 1980s Karasek developed a job demad/job cotrol model of stress. He proposed the job demad cotrol hypothesis, which icludes the cocept of job strai (see chapter 20). Accordig to Karasek ad colleagues (e.g. Karasek & Theorell, 1990), there are two aspects of job strai: i) job demads (which reflect coditios that affect performace) ad ii) job autoomy (which reflects the Figure 19.12 The risk of heart disease ca be reduced by cuttig dow o saturated fats ad icreasig polyusaturated fats ad fibre i our diet. perso s cotrol over the speed or the ature of decisios made withi the job). Karasek s hypothesis suggests that high job demads ad low job autoomy predict CHD. More recetly, Karasek developed the hypothesis further to iclude the cocept of social support. This is deemed to be beeficial for CHD, ad is defied i terms of emotioal support (i.e. trust betwee co-workers ad social cohesio) ad istrumetal social support (i.e. the provisio of extra resources ad assistace). Rehabilitatio programmes Modifyig exercise Most rehabilitatio programmes emphasize exercise as the best route to physical recovery, o the assumptio that this will i tur promote psychological ad social recovery, too. But whether, more geerally, these programmes ifluece risk factors other tha exercise (such as smokig, diet ad Type A behaviour) is questioable. Modifyig type A behaviour The recurret coroary prevetio project was developed by Friedma et al. (1986) i a attempt to modify type A behaviour. It is based o the followig questios: Ca type A behaviour be modified? ad Could such modificatio reduce the chaces of a recurrece? The study ivolved a five-year itervetio ad

426 Health Psychology 1000 participats who had all suffered a heart attack. They were allocated to oe of three groups: (i) cardiology cousellig, (ii) type A behaviour modificatio, or (iii) o treatmet. Type A behaviour modificatio ivolved: discussios of beliefs, values ad ways to reduce work demads ad icrease relaxatio, ad educatio about chagig the idividual s cogitive framework. At five years, the type A modificatio group showed a reduced recurrece of heart attacks, suggestig that such itervetio programmes may reduce the probability of reifarctio i at risk idividuals. Modifyig geeral lifestyle factors Other rehabilitatio programmes have focused o modifyig risk factors such as smokig ad diet. For example, va Eldere, Maes ad va de Broek (1994) developed a health educatio ad cousellig programme for patiets with cardiovascular disease after discharge from hospital, with weekly followups by telephoe. Although this study ivolved oly a small umber of patiets, the results seemed to provide some support for icludig health educatio i CHD rehabilitatio programmes. FINAL THOUGHTS Doctors ofte express surprise at the behaviour of their patiets. They ask, why do they cotiue to smoke eve whe they kow the risks?, why do patiets come to see me whe othig is really wrog?, why do patiets ot come to see me whe somethig is seriously wrog? ad why are people so differet i the ways they maage the stress i their lives ad respod to illess? Health psychology addresses these questios ad highlights the role of psychological factors i uderstadig the issue at their core, amely variability. This chapter has explored the beliefs people have about health behaviours ad illess, the beliefs that might ifluece health professioals ad the impact of stress upo our lives. I additio, it has illustrated how psychological factors have a role to play at all stages of a chroic illess. Cetral to all this is the study of variability. Health psychology provides a meas to uderstad this variability ad helps to explai why people differ both from each other ad from how other people would sometimes like them to be. Summary Health psychologists study the role of psychology i health ad wellbeig. They highlight the importace of both a) developig ad testig psychological theory ad b) relatig theory to health practice. Health psychology examies health beliefs as possible predictors of health-related behaviours, such as: a) the costs ad beefits of a behaviour, b) susceptibility ad severity of a illess, c) self efficacy i chagig behaviour, d) a perso s past behaviour ad e) the beliefs of importat others. Health psychology also examies beliefs about illess ad suggests that idividuals coceptualize their illess i terms of its time lie, its symptoms, the causes ad cosequeces of the problem, ad whether it ca be cotrolled or cured. The self-regulatory model of illess behaviour highlights how symptoms are a perceptio, how people are motivated to make sese of their illess, how they cope with illess i differet ways, ad how these factors ca ifluece how they behave i relatio to their illess. A health professioal s beliefs about the symptoms, the illess or the patiet may ifluece their diagosis, how patiets are treated ad the effectiveess of ay commuicatio betwee patiet ad professioal. Stress is see as a iteractio betwee the perso ad their eviromet. It ca ifluece illess, either through chagig health-related behaviours such as smokig ad exercise or via a physiological pathway, ad it is mediated by copig ad social support. Beliefs ad behaviours ca ifluece whether a perso becomes ill i the first place, whether they seek help ad how they adjust to their illess.

Revisio Questios 427 REVISION QUESTIONS 1. Medicie suggests that people become ill because they catch bacteria or viruses or develop somethig wrog with their bodies. What other factors might ifluece whether someoe becomes ill? 2. Medicie takes resposibility for makig people well agai. What ca the perso themselves do about their ow health? 3. Most people kow that smokig is bad for them but may cotiue to smoke. Why might this be? 4. Eve after beig asked by their doctor, may wome do ot atted for their regular cervical smear. What factors might ifluece their decisio ot to atted? 5. Whe ill, some people take to their bed, take time off work ad eed lookig after. For others, illess simply gets i the way ad they try to carry o as usual. Why do people differ i this way? 6. If you took the same symptoms to five differet doctors, you might get five differet diagoses ad five differet treatmets. Why do you thik this is? 7. Stress has bee liked with a rage of health problems. How do you thik that stress iflueces illess? 8. Some people die from heart attacks, whilst other people recover ad have log ad happy lives. Oce someoe has had a heart attack, what do you thik they could do to prevet aother oe? FURTHER READING Beett, P. (2000). A Itroductio to Cliical Health Psychology. Buckigham: Ope Uiversity Press. A useful itroductio to how the theories ad research of health psychology ca be put ito practice. Bowlig, A. (1995). Measurig Disease. Buckigham: Ope Uiversity Press. A overview of the theory behid measurig quality of life ad a clear review of the existig scales for assessig health status. Coor, M., & Norma, P. (eds) (1995). Predictig Health Behaviours. Buckigham: Ope Uiversity Press. A thorough descriptio of social cogitio models ad the extet to which they predict health-related behaviour. Ogde J. (2004). Health Psychology: A Textbook. 3rd ed. Buckigham: Ope Uiversity Press. This book has formed the basis for this chapter ad provides a groudig i health psychology at a more advaced level. Pey, G., Beett, P., & Herbert, M. (1994). Health Psychology: A Lifespa Perspective. Amsterdam: Harwood. A examiatio of health psychology with a focus o the lifespa, ad a assessmet of childhood, adolescece, adulthood, mid life ad the elderly. Stroebe, W. (2000). Social Psychology ad Health. 2d ed. Buckigham: Ope Uiversity Press. Recetly updated editio of this authoritative ad clear text applyig social-psychological priciples to topics such as modificatio of health behaviour, stress ad health, ad health promotio. Taylor, S. (1999). Health Psychology. 4th ed. Bosto: McGraw-Hill. A thorough overview of health psychology with a emphasis o health care delivery ad work from the US. Cotributig author: Jae Ogde