A LEVEL

8 Health Psychology
8.1 The patient–practitioner relationship
8.1.1 Practitioner and patient interpersonal skills
Non-verbal communication STUDY TIP
In medical consultations, verbal and non-verbal interpersonal skills are displayed When revising lists
by the patient and practitioner. Argyle (1975) suggested that non-verbal of factors, like the
communication is four times more powerful than verbal, but that it should match types of non-verbal
verbal communication. For example, trust is lost if a practitioner tells a patient communication, try
there is nothing to worry about, but has an anxious facial expression. making a ‘sentence
story’ to help your
Types of non-verbal communication memory: paralanguage,
» Facial expression: patients may look at their practitioner’s face for clues about appearance, gestures,
their diagnosis. Practitioners may use facial expressions to interpret how a facial expression and
personal space can
patient is feeling about a diagnosis (Silverman and Kinnersley, 2010).
become, ‘Without
» Paralanguage: non-verbal parts of speech, including ‘ums and ers’, volume, speaking (non-verbal),
speed and pitch. Voice tone can indicate to patients that the practitioner is a parachutist with a
uninterested in them (Marcinowicz et al., 2010). nervous appearance
» Personal space: practitioners often invade their patients’ personal space to gestured to the pilot
examine them, making patients feel uncomfortable. Patients reporting greater and jumped into space
invasion of their personal space were those who had more privacy at home and with a surprised facial
expression.’ Try writing
were lonelier (Marin et al., 2018).
the sentence on one side
» Gestures: these can accompany verbal/non-verbal communication to help the of a card and the list on
patient’s understanding. However, they must be used cautiously. What might be the other and see if your
acceptable in one culture may be considered rude in another. friends can guess the
» Appearance: the practitioner’s physical appearance (clothes and hair) can affect a factors.
patient’s confidence in them.

Relevant research: McKinstry and Wang (1991)

Aim: to investigate whether doctors’ clothing influenced patients’ respect for them
and how acceptable patients found different clothing styles.
Methodology:
» Involved 475 patients of 30 doctors from five Scottish practices.
» Questionnaire was administered on five separate occasions:
– five photos of male doctor – white coat, suit, tweed jacket, cardigan or jeans
– three photos of female doctor – white coat, skirt or trousers.
» Participants were asked:
– which doctor they would feel happiest about seeing for the first time
– their level of confidence in the doctor
– which photo looked most like their own doctor
– about clothes worn in the photos.
Results:
▼ Table 8.1 Percentage of top acceptability score (5) for the doctors in the different styles
of clothes

Percentage of patients
Male doctor Female doctor
Acceptability White Suit Tweed Cardigan Jeans White Skirt Trousers
score coat jacket coat
5 38% 50% 30% 16% 13% 55% 47% 22%

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 » There was a significant relationship between patient age and doctor choice.
» Older patients gave higher scores to the male doctor in a suit and white coat and SKILLS
the female doctor in a white coat. BUILDER
» Some voted in a way that matched the clothing choice of their own doctor.
» Clothing style was very important/quite important for 64 per cent of Mark is a newly
participants, and not important to 36 per cent. qualified doctor in
a small clinic in a
Conclusion: patients prefer conservatively dressed doctors. The researchers
village with a large
concluded that doctors may dress in a certain way to gain patients’ approval.
population of elderly
people. Suggest one
Verbal communication way that Mark could
Verbal communication focuses on how the practitioner questions the patient about dress, and one action
their condition and conveys information about diagnosis and treatment. that he could take, to
instil confidence in his
Factors affecting verbal communication patients. [4]
» Primacy effect: information from the beginning of the consultation is stored in
Try to include
long-term memory and remembered better than later information (Ley, 1988). research evidence
» Forgetting: patients often remember little of their doctor’s consultations. in your answer. For
Richard et al. (2016) reported patients remembering as little as 20 per cent example, McKinstry
of information and immediately forgetting between 40 and 80 per cent. and Wang (1991)
Recently, attention has turned to how practitioners communicate using medical looked at how
terminology. clothing style can
inspire confidence
Relevant research: McKinlay (1975) in patients. Argyle
Aim: to investigate Scottish working class families’ understanding of medical (1975) and Silverman
terminology. and Kinnersley
(2010) investigated
Methodology: non-verbal
» Participants were 87 unskilled working-class women attending obstetrics and communication.
gynaecology appointments. Make sure you cover
» They were split into utilisers and underutilisers. both clothing style
» Participants were presented with a 13-word list used by practitioners when and action.
speaking to patients:
– Words were spoken aloud.
– They were heard again in a sentence.
– Participants were asked to say their meaning.
– Responses were recorded verbatim and scored (‘blind’) in categories, as shown
below.
Results:
▼ Table 8.2 Percentage of the sample who showed wrong or vague knowledge compared
with adequate understanding on 5 of the 13 words

Utilisers Underutilisers
Wrong Adequate Wrong Adequate
or vague understanding or vague understanding
knowledge knowledge
Antibiotic 44.4 41.7 60.0 28.9
Breech 0.0 100 6.7 84.4
Mucus 22.2 47.2 33.3 33.3
Glucose 36.1 44.4 44.4 37.8
Enamel 30.6 61.1 40.0 51.1

» Utilisers had consistently higher understanding than underutilisers.

» Researchers also investigated the relationship between how well physicians
thought patients understood medical terminology and how often they used it.

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 8 HEALTH PSYCHOLOGY

▼ Table 8.3 Percentage of patients that doctors expected to have ‘adequate knowledge of
words’ compared to the percentage of patients who actually had adequate knowledge SKILLS
and the percentage of doctors using the word
BUILDER
% of patients % of % of utilisers % of the
that doctors underutilisers who had doctors Using research into
‘thought’ who had adequate actually using practitioner–patient
would have adequate knowledge the words with communication,
an adequate knowledge patients explain one weakness
understanding of quantitative data.
of the words Use an example
from research into
Antibiotic 5.6 28.9 41.7 44.4
practitioner–patient
Breech 22.2 84.4 100.0 38.9 communication. [2]
Membranes 0.0 44.4 63.9 44.4 This question tests
Protein 16.7 0.0 11.1 55.6 methodological
knowledge and
Conclusions: can be answered
using research into
» Physicians consistently underestimated the comprehension of working-class
verbal or non-verbal
participants.
communication.
» Many used words with patients that they assumed they had little
understanding of.
▼ Table 8.4 Methodological issues

Strengths Weaknesses
Validity – McKinstry and Wang (1991) used photographs Generalisability – McKinstry and Wang’s sample, from
of unknown doctors rather than asking participants to Lothian in Scotland, may not be representative of other
talk about their own doctors. areas. McKinlay’s participants were working-class women.
McKinlay (1975) interviewed patients at the clinic about Including patients with a wider range of conditions
words they would hear there. Understanding of these and from a wider range of backgrounds would increase
words represents their real-life understanding. generalisability.
Usefulness – McKinlay’s results may be used in healthcare Quantitative data – McKinlay’s data showed
settings to address miscommunication and improve underutilisers generally had poorer technical vocabulary;
understanding between practitioners and patients. qualitative interview data is needed to discover why.
Questionnaires – McKinstry and Wang included Validity – McKinstry and Wang used more photos of males
quantitative data reliably obtained from closed than females, with no picture of a female doctor in a suit.
questions. A white coat being voted highest for the female doctor
could just be because this was the most formal style.

Issues and debates

Application to everyday life
The research moves the responsibility for communication barriers from the patient
to the practitioner. Strategies can be used to change working practices in health
care and improve comprehension.
Idiographic versus nomothetic
The research uses a nomothetic approach, focusing on groups of people. This is
useful for generalisation of findings, but an idiographic approach using qualitative
methods would discover individual needs. For example, patients with minor problems
would require different styles of communication from those with mental health
problems or serious illness.

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 NOW TEST YOURSELF
8.1 Janis is a new doctor in a large city practice. 8.3 Outline what is meant by utilisers and
Explain how she should dress in order to underutilisers when referring to attendance
promote confidence in her older patients. [2] at health facilities. [2]
8.2 Explain why an understanding of interpersonal 8.4 Explain one strength and one weakness
skills is important for medical practitioners of research into practitioner and patient
when examining patients. Use at least one interpersonal skills. [4]
example in your answer. [4]

8.1.2 Patient and practitioner diagnosis and style

Practitioner diagnosis
SKILLS
Disclosure of information
Misunderstandings when communicating symptoms can occur because of:
BUILDER
» patients’ Valerie is giving a
– lack of vocabulary diagnosis of serious
– unwillingness to give information illness to a patient.
– mistrust of the doctor Explain one way that
» the practitioner’s gender: Hall et al. (1994) found that patients gave more Valerie could ensure
information to female practitioners, who asked more questions and conducted that the patient
longer appointments. remembers as much
as possible of the
Practitioners should correctly diagnose ill people as ill, and healthy people as information she is
healthy: relating. [4]
» A false positive is when a healthy person is diagnosed as ill when they are not. Combine your
» A false negative is when an ill person is diagnosed as healthy. This is medical knowledge of
negligence and the consequences can be serious. practitioner verbal
and non-verbal
Presenting a diagnosis communication
Non-verbal communication is more important than verbal communication when with what you have
presenting a diagnosis: learned about
diagnosis and
» Shapiro et al. (1992) found that female participants receiving mammogram
style. How might
results from a ‘worried’ practitioner remembered fewer details than those
Valerie’s style and
receiving results from a ‘not worried’ practitioner. communication
» During the COVID-19 pandemic, telephone diagnoses meant there was no non- affect the way her
verbal communication, increasing the risk of misunderstandings. patient remembers
the consultation
Key study: Savage and Armstrong (1990) and diagnosis?
Context: The question only
requires you to write
» Research has shown that a sharing style is preferred by patients and this ensures about ‘one way’.
they follow medical advice willingly. Choose your best
» A traditional directed style is seen as paternalistic and limiting patient idea and explore it in
autonomy. detail.
Aim: to investigate whether a sharing consultation style increases patient
satisfaction compared to a directed style.
Research method(s) and design: field experiment.
Variables:
» Independent variable: directed or sharing consultation style.
» Dependent variable: patient level of satisfaction.
» Controlled variables: random selection of patients; same doctor used throughout.

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 8 HEALTH PSYCHOLOGY

Sample: 200 randomly sampled patients (aged 16–75) from a London GP practice.
Procedure:
» Participants were randomly allocated to the ‘directed’ or ‘sharing’ practitioner
style by cards placed on the doctor’s desk, face down.
» The doctor also had prompts giving examples of directed and sharing styles of
consultation.
» At the end of the consultation, the participant completed a five-question
questionnaire (see Table 8.5).
» Participants received a second identical questionnaire to mail back one week
later.
» Researchers noted the length of consultation and demographics.
Ethics: participants gave consent for their appointments to be audio-recorded.
Results:
▼ Table 8.5 Results of questionnaires

Questionnaire 1 (%) Questionnaire 2 (%)

Directed Sharing Directed Sharing
I was able to discuss my problem well. 73 74 61 53
I received an excellent explanation. 45* 24* 33* 17*
I perceived the practitioner to have 62* 37* 39* 18*
complete understanding.
I felt greatly helped. 54 45 49* 28*
I felt much better 33 32 33 26
*significant difference

Conclusion:
» Patients with simple physical illnesses benefit more from a directed style of
consultation.
» Patients prefer certainty and paternalism – doctor to be the authority figure.
» Directed style did not provide greater satisfaction during longer advisory
consultations when patients had chronic or psychological illnesses.
▼ Table 8.6 Methodological issues

Strengths Weaknesses
Ecological validity – Savage and Armstrong’s (1990) Ecological validity – Shapiro et al.’s (1992) participants
study was a real-life setting, with a real doctor and their watched video clips of practitioners giving a diagnosis
patients. and evaluated them. Savage and Armstrong’s doctor
followed prompts, which may not match their normal
style, and thus may have affected patients’ experiences.
This lowers the validity of both studies.
Holistic approach – Shapiro et al.’s research focused on Cultural differences – Elwyn et al. (2002) reported how
the practitioner’s and patients’ verbal and non-verbal in the USA patients are told the diagnosis, no matter
communication. This holistic approach increases validity. how serious it is; but in Japan patients are often not told
about a serious or terminal diagnosis (Noguchi, 2007).
Cultural factors are important when presenting diagnoses.
Representativeness – participants selected by random Generalisability – in Savage and Armstrong, 11 per cent
sampling are representative of patients registered to of patients did not complete the first questionnaire and
the doctor. Opportunity sampling might have meant only 44 per cent did not complete the second. This lowers
those known well were selected. generalisability.

Issues and debates

Application to everyday life
There are significant applications to everyday life. By understanding which style of
consultation works best, practitioners can adapt to suit individual patients. This
may help with information disclosure, meaning more accurate diagnoses.
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 Individual and situational explanations
Savage and Armstrong’s (1990) research offers situational explanations for patient
satisfaction increasing with either a sharing or a directed style. This ignores
individual differences that could impact a patient’s preference.

NOW TEST YOURSELF SKILLS

8.5 Savage and Armstrong’s research offers situational explanations for
BUILDER
patient satisfaction increasing with either a sharing or a directed style, Describe the study by
ignoring individual differences that might affect a patient’s satisfaction. Savage and Armstrong
Describe two individual differences that could influence a patient’s (1990) on directed
preference. [4] and sharing styles of
8.6 Suggest one way in which non-verbal communication might affect how a practitioners. [6]
patient receives a diagnosis. [2]
8.7 Using the key study by Savage and Armstrong (1990) on the In your response,
directed or sharing style of practitioners, explain one strength try to explain the
of the method used. [2] procedure and
results clearly
8.8 Mo is very tired and fears making an error with a patient diagnosis
and show how the
because of his inability to concentrate.
conclusion links back
a Describe two possible errors Mo could make. [2] to the aim.
b Explain which one he should be most worried about, and why. [2]

8.1.3 Misusing health services

Delay in seeking treatment
▼ Table 8.7 Reasons for delay in seeking treatment

Research Reason
Safer et al. (1979) » People have different thinking and decision-making processes when first experiencing a
symptom from when first suspecting illness.
» They lack trust in doctors.
» They perceive stigma around seeking treatment for mental health concerns.
Fernando et al. » People in Sri Lanka are influenced by their own and family’s perception of stigma.
(2017) » 15 per cent of patients and carers reported delays in seeking help due to stigma-related
concerns.
Bruffaerts et al. » The median duration of delay was one year for mood disorders, but 16 years for anxiety in a
(2007) Belgian sample.
» The onset of mental disorders might be during childhood/adolescence and so viewed by
people as normal.

Health belief model

According to the health belief model (HBM), people who feel threatened by STUDY TIP
their symptoms tend to see a practitioner more quickly, whereas those who view Using your knowledge
symptoms as no threat, delay or avoid seeking medical help. of the practitioner–
▼ Table 8.8 HBM explanation for delays in seeking medical help patient relationship and
of misusing the health
Perceived… Explanation service, make yourself
a mind map of all the
Threat Extent to which someone views a health problem as being serious reasons why a person
affects cues to action might delay seeking
Susceptibility Extent to which someone thinks they are at risk of a certain illness treatment. Then expand
the map to include a
Seriousness How serious the patient thinks their health problem is study for as many as
Benefits What the patient views as the advantages of treatment possible. Work with
a friend to make this
Barriers Anything the patient thinks will make it difficult to follow a
easier.
treatment programme

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 8 HEALTH PSYCHOLOGY

Relevant research: Safer et al. (1979)

Context: most research into delays in seeking medical care focuses on the time
between noticing the symptom and the first appointment. Safer et al. investigated
whether delay can be broken into different stages and factors, involving different
decisions/processes.
Aim: to investigate factors that influence delays in seeking medical treatment.
Methodology:
» A 45-minute structured interview with an opportunity sample of 93 patients in a
waiting room of an inner-city hospital.
» If the patient was seeing a practitioner about a new symptom or illness, they
were asked to take part in the study.
» They were asked questions about symptoms and reactions, such as ‘Do you expect
the treatment will be uncomfortable?’
» Patients were given:
– a scale to measure emotional reactions to symptoms.
– a seven-item scale measuring the extent to which they imagined negative
consequences of symptoms and treatment.
– a ten-item scale measuring level of pain.
» Patients were asked length of delay at illness stages (see Table 8.9).
▼ Table 8.9 Safer et al.’s four stages of delay

Delay stage Description

Appraisal Delay from first noticing symptoms to concluding they were ill
Total Delay from first noticing symptoms to first appointment
Illness Delay from deciding they were ill to deciding to get medical help
Utilisation Delay from deciding to seek help to attending appointment

Results:
▼ Table 8.10 Length of delay at each stage

Delay stage Length of delay in days

Appraisal » Pain: severe = 2.5; none = 7.5
» Reading about symptoms = 19.6; not reading = 3.5
» Bleeding = 1.2; no bleeding = 4.8 SKILLS
Total » Competing problem/issue = 23.8; no competing problem = 7.2 BUILDER
» Severe pain = 8.6; little/no pain = 23.8
» Reading about symptoms = 50.2; not reading = 11.5 Explain one feature
of a structured
Illness » New symptoms = 2.5; old/frequently experienced = 11.3 interview as a way of
» Negative visual imagery of outcome = 4.4; no negative imagery = 1.9 investigating factors
Utilisation » Concerned with cost = 9.7; not concerned = 2.0 influencing delays in
» Severe pain = 1.6; little/no pain = 3.8 medical treatment. [2]
» Felt symptoms incurable = 4.3; felt curable = 1.8 First, bullet-
point some ideas
Conclusions: about structured
» Bleeding or severe pain reduces the delay in seeking medical help. interviews. Refresh
» Negative imagery, concerns over costs, researching symptoms and believing your memory by
symptoms are incurable all increase delay. revisiting section
5.1.5 if you need
Munchausen syndrome to. Which of these
Munchausen syndrome (factitious disorder) is when people seek out excessive features would make
medical attention, often going from city to city to get a new diagnosis and new structured interviews
surgical intervention. It is not malingering, which is when a person feigns or especially useful for
exaggerates symptoms for an obvious gain or incentive. There is no thought of gain investigating factors
influencing delays in
with Munchausen syndrome. It is thought to be very rare, but prevalence is hard to
medical treatment?
establish due to the deception involved.

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 Aleem and Ajarim (1995) developed a list of diagnostic features of Munchausen
syndrome (see Table 8.11).
▼ Table 8.11 Diagnostic features of Munchausen syndrome (Aleem and Ajarim, 1995)

Essential features Supporting features

Pathological lying (pseudologia Borderline and/or antisocial personality
fantastica) traits
Peregrination (travelling or wandering) Deprivation in childhood
Recurrent feigned or simulated illness Equanimity for diagnostic procedures
Equanimity for treatments or operations
Evidence of self-induced physical signs
Knowledge of or experience in a medical field
Most likely to be male
Multiple hospitalisations
Multiple scars (usually abdominal)
Police record
Unusual or dramatic presentation

Relevant research: Aleem and Ajarim (1995)

Aim: to present a case study of Munchausen syndrome.
Methodology:
» A 22-year-old female university student was referred to hospital with a possible
case of immune deficiency or neutrophil disorder.
» She was initially investigated at the age of 17 for menstrual cycle issues.
» She developed symptoms of deep vein thrombosis; medication to treat this was
ineffective.
» She was admitted to hospital aged 22 with a painful swelling on her breast.
» She told doctors of similar swellings previously over her abdominal wall which
had required drainage at other hospitals multiple times – there were scars.
» Later she had abscesses drained and doctors discovered suspicious bacteria in
fluid.
Findings:
» The psychiatrist diagnosed Munchausen syndrome.
» A nurse found a syringe containing faecal matter with which the patient had
been injecting herself.
» The patient became angry when informed and left hospital.
Conclusion: Munchausen syndrome diagnosed, but nothing further could be
concluded.
▼ Table 8.12 Methodological issues

Strengths Weaknesses
Case study – Aleem and Ajarim (1995) used an Validity – Safer et al. (1979) used retrospective data.
appropriate method for a condition that is difficult to Memories could be inconsistent, especially under stress.
research ethically; experimental method cannot be used.
Usefulness – from Safer et al., medical practices can Reliability – qualitative data is subject to interpretation
develop strategies to reduce patient delays. Aleem and by the researchers. For example, Aleem and Ajarim
Ajarim provides information, allowing more reliable possibly interpreted information about the first
diagnosis of Munchausen syndrome. hospitalisation differently due to already knowing about
the discovered syringe.

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 8 HEALTH PSYCHOLOGY

Issues and debates

Reductionism versus holism
The health belief model explanation is holistic, considering multiple reasons. This
makes it hard to isolate which variables have the strongest effect in delaying
seeking treatment. It is also difficult to create effective interventions. A more
reductionist approach may be necessary, but it is often impossible to manipulate
variables for practical and ethical reasons.
Idiographic versus nomothetic
An idiographic approach with rich in-depth information is appropriate in Aleem and
Ajarim (1995) as Munchausen syndrome is relatively rare and generalising from small
samples in a nomothetic manner may not be valid. Practitioners can decide whether
findings may apply to their own clients.

SKILLS BUILDER
Julia wants to conduct a case study about a client This will involve knowledge of method triangulation.
she is working with who has Munchausen syndrome. What advice would you give Julia to ensure that her
Explain how Julia might collect and analyse her findings are valid and reliable? If you need to, revisit
data. [4] the sections on case studies, validity and reliability
in Chapter 5.

NOW TEST YOURSELF

8.9 Donald decides he needs some time off work b Explain one weakness of taking a
and is going to ‘be ill’ for a few days. He will go nomothetic approach when diagnosing/
to his doctor complaining of severe backache. researching Munchausen syndrome. [2]
Donald looks at the weather forecast for the 8.11 Outline one problem with the holistic
next week and picks his days. approach taken by the health belief model
Suggest what behaviour Donald is displaying. explanation for delay in seeking treatment. [4]
Give one reason for your answer. [2] 8.12 Explain one of the factors that influences
8.10 a Outline what is meant by idiographic versus delay in seeking medical treatment. Refer to
nomothetic. [2] relevant research in your answer. [4]

8.2 Adherence to medical advice

8.2.1 Types of non-adherence and reasons why
patients do not adhere
Adherence to medical advice is when patients follow specific guidance from health
professionals.

Failure to follow treatments

» Unintentional non-adherence: the patient wants to follow a treatment but
there are uncontrollable barriers:
– not remembering
– not understanding the doctor
– unable to afford treatment
– unable to take time off work
– simply forgot.
» Intentional non-adherence: the patient decides not to follow treatment. This
may be due to their beliefs, levels of motivation or lack of faith in the treatment.

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 Laba et al. (2012) identified six intentional factors:
STUDY TIP
1 Immediate medication harms Draw a Venn diagram
2 Long-term medication harms for unintentional
3 Immediate medication benefits and intentional non-
4 Long-term medication benefits adherence to medical
5 Financial cost of medication treatment. You should
6 Regime have found that financial
issues were in the
(See ‘Relevant research’ below.) overlapping section of
the diagram. This is one
Failure to attend appointments of the factors identified
Individual failure to attend appointments is an expensive and persistent worldwide by Laba et al. (2012).
problem. Previous failure to attend appointments predicts future failure to attend. Look at the list of
reasons why people
Other predictors are:
do not attend medical
» age (either young or over 80 years old) appointments and
» work commitments see how many could
» difficulties getting to hospital be down to financial
problems. This
» feeling an appointment is unnecessary shows you the web of
» being too ill to attend connections between
» fear/mistrust of hospitals non-attendance at
» fear of serious illness being discovered. appointments and non-
adherence to advice
Parsons et al. (2021) reviewed 12 studies, reporting that work/family commitments, and medication. Draw
forgetting an appointment and transportation difficulties were most commonly yourself a diagram of
reported reasons. the links. Learning
these and thinking
Most likely to miss appointments are:
about how they apply
» those under 21 in real life helps with a
» those from low social status/class depth of understanding
that memorisation
» individuals who have missed appointments previously
cannot give.
» those who already have a mental or physical diagnosis
» minority ethnic groups.
Problems caused by non-adherence include:
» unresolved medical problems
» cost to health service
» delayed treatment, leading to:
– later need for more expensive, stronger medication
– later need for surgery.

Explanation of non-adherence
Rational non-adherence
Reasons (Sarafino, 2006):
» Believing medication is not helping.
» Feeling that the side effects outweigh the benefits.
» Being confused about how often/how to take medication.
» Not having enough money to buy medication.
» Wanting to see if they still have the illness if they stop taking medication.
Bulpitt and Fletcher (1988) researched non-adherence to medication with side
effects in patients with high blood pressure:
» Eight per cent stopped due to sexual problems.
» Fifteen per cent stopped due to tiredness, sexual problems and gout.
» Patients stopped when the side effects outweighed the benefits.
Health belief model
Taking preventative action when faced with potential illness or injury depends on:
» how much of a threat the health problem poses
» the pros and cons of taking action.
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 8 HEALTH PSYCHOLOGY

▼ Table 8.13 Health belief model explanations for action

Consideration Preventative action more likely if:

Perceived seriousness Problem considered serious
Perceived susceptibility Patient feels susceptible to problem
Cues to action Cues seen – appointment reminders,
advertisements, posters
Perceived benefits/barriers More perceived benefits than barriers

Other factors include demographic variables, personality traits and social class.
Relevant research: Laba et al. (2012)
Aim: to explore decisions that may lead to intentional non-adherence behaviour and
the relative importance of medication-specific factors and patient background.
Methodology: experiment:
» 248 Australians; median age: 57 years; 45 per cent male, 55 per cent female.
» 161 participants completed an online survey.
» The Beliefs About Medication Questionnaire (BMQ) was used to create a ten-
question discrete-choice questionnaire on two hypothetical drugs.
▼ Table 8.14 Example of a discrete-choice question

Medication A Medication B
Symptom severity 1 out of 10 7 out of 10
On medication, daily symptoms are now felt 6 days per week 2 days per week
The severity of daily medication side effects 1 out of 10 4 out of 10
For every 100 people taking this medication, the number of people who will 35 95
have unwanted effects in the next ten years is:
For every 100 people with this illness, 85 will die in the next ten years. On 65 65
medication, this number reduces to:
The medication is taken: Once a day Once a day
Can you drink alcohol? Yes Yes
Your monthly cost for the medication $10 $50
Which would you prefer?

» Six out of eight factors influenced medication choice.

» Those with medical insurance were less sensitive to costs.
» Side effects had greater influence than benefits to health.
» The ability of medication to reduce death was most important, followed by
current side effect severity and future side effect risk.
Conclusions:
» Patients make rational choices.
» Adherence could be improved by:
– reducing costs of medication
– altering regime
– educating patients on medication benefits.
▼ Table 8.15 Methodological issues

Strengths Weaknesses
Usefulness – results from Laba et al. (2012) show factors Representativeness – 1,668 people were
that influence patients’ adherence to their treatment regime. initially invited to participate. However, only 248
This could help practitioners design interventions to improve respondents commenced the questionnaire and 161
adherence. completed it = 10 per cent participation rate. Maybe
a certain type of person participated.
Reliability – objective quantitative data from discrete-choice Ecological validity – the questionnaire scenarios
questionnaire meant that the results had high reliability. were all hypothetical and may not reflect real life.

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 Issues and debates
Application to everyday life
Explanations of non-adherence are applicable to real life. If health service
professionals understand that cost and complexity affect non-adherence then
strategies to overcome this can be introduced, such as lowering the cost or making
instructions clearer.
Idiographic versus nomothetic
Laba et al.’s nomothetic approach allowed generalisable conclusions about rational
non-adherence. Quantitative data collected using fixed-choice questions and
statistically analysed led to objective and reliable findings. A lack of open questions
meant participants could not explain. Adding an idiographic approach may have
helped to gain greater insight.

SKILLS
NOW TEST YOURSELF BUILDER
8.13 Explain one weakness of questionnaires as a way of identifying why
Explain two cues
people fail to keep appointments. [2]
to action that may
8.14 Frida is puzzled why so many of her patients seem to not take the encourage patients
medication she prescribes for them. It is frustrating as then they do not to seek treatment. [4]
get better and often return to see her with the same symptoms.
Suggest two reasons why people may fail to take their medication. Check the mark
Use relevant research in your answer. [4] allocation; each
‘cue to action’ needs
8.15 Outline one strength of the health belief model. [2]
to have enough
8.16 a Plan a study to investigate non-adherence to medical treatment.
elaboration for two
Your plan must include details about:
marks. Remember,
– sampling technique
don’t just describe
– data collection methods. [10]
them, but explain
b Explain one reason for your choice of sampling technique. [2] how they work.

8.2.2 Measuring non-adherence

Subjective measures
▼ Table 8.16 Subjective measures of adherence

Method Details Strengths Weaknesses

Self-report Patients complete questionnaires regarding » Cheap and quick » Relies on memory
adherence to treatment plan, such as the » Quantitative data (low reliability)
ten-item Medication Adherence Report » Large numbers easily » Social desirability
Scale (MARS), with forced choice yes/no reached bias (low validity)
format. » Increases
generalisability
Semi-structured Focused dialogue between patient and » Detailed qualitative » Time-consuming and
clinical practitioner to help with diagnosis and data expensive
interview treatment. Medical Adherence Measure » Increases validity and » High drop-out rate
(MAM) designed to elicit details from usefulness » Lower generalisability
patients about adherence. Success of
interview based on supportive relationship
so patients feel comfortable enough to be
honest. (Zelikovsky and Schast, 2008.)

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 8 HEALTH PSYCHOLOGY

Relevant research: Riekert and Drotar (1999)

Aim: to assess implications of non/incomplete participation of adolescents with
diabetes in treatment adherence research.
Methodology:
» Fifty-two of the original 94 families (parents plus adolescents aged 11–18)
completed the study.
» Adolescents had diabetes for over a year.
» Participants were recruited through a clinic.
» They were interviewed using the Adherence and IDDM Questionnaire-R,
regarding:
– diet
– glucose testing
– preparedness for hypoglycaemia.
» Number of blood glucose tests was monitored through a reflectance meter.
» Metabolic control was measured at clinic appointments.
» Parents completed a questionnaire on demographics and the family took two
questionnaires, to be mailed back.
» Researchers reviewed medical charts of all 94 adolescents initially requested to take
part, to obtain the number of blood glucose tests per day and metabolic control
levels. Demographic data of families refusing to take part was also obtained.
Results:
» Demographics were similar for all three groups: participants completing the
study, those not returning the questionnaires (non-returners) and those not
consenting to take part (non-consenters).
» Adolescents of non-returner families tested their blood glucose levels
significantly less frequently than those of families who returned the
questionnaire, or non-consenter families.
» Adolescents of non-returner families also had significantly lower rates of
adherence than those of families who returned their questionnaires.
Conclusion: lower adolescent adherence to treatment regime is associated with
lower participation in adherence studies by adolescents and their families.

Objective measures
▼ Table 8.17 Objective measures of adherence

Method Details Strengths Weaknesses

Pill counting Typically conducted in person » Unannounced pill counts » Burden to patients as they
at clinic. by telephone or home have to attend clinic with
visits overcome patient medication.
manipulation. » Patients may manipulate pill
» Increases validity: there was count if they know date and
a 92 per cent agreement time of check, decreasing
between telephone and home validity.
pill counts and measures of
viral load in HIV+ patients
(Kalichman et al., 2008).
Medication Dispensing correct pills at set » Advantage to patient as » Lacks validity: just because
dispensers day/time; can use visual/audio they are more likely to take medicine was removed from
alarms; also record date and medicine with reminders, dispenser does not mean it
time pill leaves device, and meaning relapse less likely. has been taken.
frequency of use. » It is a reliable way to » Helps forgetfulness, but not
measure adherence. deliberate non-adherence.

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 Relevant research: Chung and Naya (2000)
Aim: to electronically assess compliance with an oral asthma medication.
Methodology:
» Forty-seven patients with asthma, aged 18–55.
» Two to three weeks of screening, then 12 weeks’ treatment; one pill twice a day.
» Tablets in bottles fitted with TrackCap recording date and time when opened.
» Patients gave informed consent but did not know about the device.
» Tablet count and TrackCap removal were both measured.
Results:
» There was 80 per cent compliance with TrackCap (taken off twice a day); 89
percent compliance with tablet count.
– Difference due to patients taking out more than one tablet at a time, maybe
to put in a dispenser.
» There was 64 per cent compliance on TrackCap and tablet count: two tablets
daily, 12 hours apart.
» Under-compliance by 20 per cent of participants: one tablet removed daily.
» No compliance for up to eight days by 10 per cent of participants.
Conclusion: monitoring systems like TrackCap measure adherence effectively.

Biological measures of adherence

» These provide assurance that medication has been taken, not just removed from
the bottle.
» They allow for a personally adjusted dose to be calculated.
▼ Table 8.18 Biological measures of adherence

Method Details Strengths Weaknesses

Urine analysis Donated in sterile jar » Chemically stable for 14 days Drug/drug and drug/food
under refrigeration interactions may interfere with
» Cheap and non-invasive accuracy of results. Cannot be used
» Objective visual results if patients are on more than one
medication.
Blood » Traditional » Reliable: Burnier (2020) found Traditional sampling is invasive
sampling » Dried blood spot that DBS testing can show and some find it unpleasant/
(DBS) testing levels of hypertension drugs as stressful, so it is not suitable for
reliably as traditional plasma all patients.
testing.
» DBS is less stressful than
traditional blood sampling.

▼ Table 8.19 Methodological issues

Strengths Weaknesses
Application to everyday life – in Riekert and Drotar Ethical issues – Reikert and Drotar used data from
(1999), the families not completing research tasks non-consenters. There are ethical issues about informed
may lack organisational skills. This allows real- consent and using information without permission.
life interventions for non-participants, increasing Chung and Naya deceived participants as to how they
adherence. were monitored.
Chung and Naya (2000) measured adherence at home
when patients would normally take medication.
Quantitative data – electronic monitoring is objective, Validity – Chung and Naya found adherence rates to be
giving quantitative analysis of adherence to medical high. However, participants knew adherence was being
advice. No social desirability bias or misremembering measured. It would have been more valid if participants
means increased validity. were blind to the true aim.

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 8 HEALTH PSYCHOLOGY

Issues and debates

Quantitative and qualitative data
Qualitative and quantitative methods have strengths and weaknesses. Reikert
and Drotar (1999) used method triangulation to gain quantitative and
qualitative data, improving the validity of results. Chung and Naya (2000) used
objective quantitative measures, which told them about adherence, but not the
reasons for this.
Application to everyday life
Research into reasons for non-adherence can be applied to improve the medical
profession’s understanding of why people may not adhere to advice or regimes, and
what they can do about it.

SKILLS BUILDER
Chris is a caring pharmacist who worries that elderly This question requires knowledge of the different
customers forget to take their medication at the methods of ensuring people take their medication
appropriate time. What one suggestion could he make and choosing one. As the question talks about
to help them to remember their medication? [2] elderly customers, the method should be one they
can use at home.

NOW TEST YOURSELF

8.17 Explain two differences between subjective 8.19 a Outline what is meant by biological
and objective measures of non-adherence to measures of adherence to medical
medical treatment. [4] treatment. [2]
8.18 Simi is planning a study on non-adherence to b Choose one biological measure and
medical treatment and cannot decide which explain one strength of it as a measure of
type of data to collect. Compare qualitative adherence to treatment. [2]
and quantitative data as ways of investigating 8.20 Suggest one application to everyday life of
non-adherence. [4] research into reasons for non-adherence. [2]

8.2.3 Improving adherence

Improving adherence in children
Strategies include:
» simple regime
» pleasant-tasting medicine
» easy-to-take liquids rather than tablets
» text message reminders for older children
» regular phone contact with parents
» involving children fully with treatment plans, considering their concerns
(Benn, 2014).
Asthma can cause breathing difficulties in all ages. Spacer devices are plastic
containers with a mouthpiece or mask at one end and a space to insert an
asthma inhaler at the other end. Fitting over the mouth, they can be scary for
children.
The Funhaler is based upon operant conditioning principles, where children
are rewarded if they use the device correctly, making them more likely to repeat
it. The rewards are spinners and a whistle activating if the device is used
correctly.

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 Relevant research: Chaney et al. (2004)
Aim: to compare the Funhaler device to currently used spacer devices.
Methodology:
» Participants were 32 children aged 1.5–6 years old diagnosed with asthma,
currently using a standard spacer device.
» They were randomly recruited through seven local clinics.
» Parents were initially telephoned before any home visits were conducted.
» Informed consent was given and parents were interviewed by questionnaire
about their child’s current asthma device.
» The questionnaire included questions about problems associated with the
delivery of the medication and parental and child adherence to using the device.
» The Funhaler device was used instead of the current device for two weeks (with
adult supervision).
» Parents were contacted once by phone randomly to see if they had medicated
their child the previous day.
» The families were visited at home at the end of the two-week trial.
» A second questionnaire regarding use of the Funhaler was completed by the same
parent.
Results:
▼ Table 8.20 Adherence to prescribed technique

Current device Funhaler

Medicated the previous day 59% 81%
Using the recommended 4+ 50% 80%
breath cycles per aerosol
delivery

▼ Table 8.21 Child’s attitude and parental approach to using the device

Existing spacer device Funhaler

Child’s attitude towards using the device
Pleasure 10% 68%
Strong fear or dislike 19% 0%
Panic or phobia 31% 0%
Parental approach to medicating their child
Completely happy 10% 61%
Dislike 16% 0%

Conclusions:
» The Funhaler could be useful in managing asthma in young children.
» It could improve clinical outcomes in children.
» Behaviourist theories (like operant conditioning) are effective in increasing
children’s adherence to medication.
▼ Table 8.22 Individual behavioural techniques

Technique Description Strengths Weaknesses

Contract Verbal/written behavioural In Neale (1991), participants » Not effective in the long
contract between patient and who signed a contract agreeing term (Bosch-Capblanch et
practitioner regarding regime to increase exercise and adopt al., 2007).
a cholesterol-reducing diet » Bosch-Capblanch et al.
made significantly more positive (2007) found research into
health changes than those contract effectiveness
without a contract. was small-scale and poorly
executed, lowering the
validity of results.

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 8 HEALTH PSYCHOLOGY

Technique Description Strengths Weaknesses

Prompts Texts (usually), phone or letter Schwebel and Larimer (2018) » Not everybody uses text
reminders of medication/ reviewed 162 studies and messages. Elderly patients
appointments concluded that prompts were may not find them
beneficial, convenient, cost- beneficial.
effective and acceptable to
patients.
Customising Tailoring treatment to best Supported by research evidence: » Costly due to the time
treatment fit with the patient’s ability Lakhanpaul et al. (2020) used invested in collaborating
and lifestyle. Heath et al. intervention mapping to improve with community groups.
(2015) looked at intervention South-East Asian families’ » Counterproductive if not
mapping: how and why the understanding of asthma. conducted with sensitivity
patient needs to change, and to cultural differences.
targeting the desired behaviour
using behavioural techniques.
(e.g. operant conditioning).

Key study: Yokley and Glenwick (1984)

Context:
» The researchers wanted to investigate behavioural psychology applied to
increasing immunisation adherence.
» At the time of the research, preventable diseases such as polio, whooping
cough, tetanus and rubella killed over five million children worldwide.
» Yokley and Glenwick (1984) reported 10,000 cases of preventable diseases in
the USA.
Aim: to evaluate the impact of four conditions on motivating parents to have
children immunised.
Research method(s) and design: field experiment; longitudinal design.
Variables:
» Independent variables:
1 General prompt to parents regarding immunising their children.
2 Specific prompt with dates, times and locations.
3 Specific prompt with extended clinic hours, drinks, movies and snacks.
4 Specific prompt with monetary incentive (three prizes of $100, $50 and $25).
» Dependent variables:
1 Number of children receiving one or more immunisations at the clinic.
2 Number of children attending clinic (for any reason).
3 Total number of immunisations received by children.
» Controlled variables:
1 Contact control group: received telephone call asking whether child was
immunised and general demographic information, but no specific prompt to
have child immunised.
2 No contact control group: received no contact during the study.
3 Parents with two or more immune-deficient pre-schoolers were assigned to
conditions as families, to prevent siblings being in different conditions of the IV.
Sample:
» Participants were 715 pre-school immune-deficient children; 50 per cent female;
64 per cent white.
» The children needed one or more inoculation for diphtheria, tetanus, whooping
cough, polio, measles, mumps or rubella.

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 Procedure:
» Participant record cards were created containing information directly relevant to
the research.
» Participants were randomly assigned to receive either:
1 General prompt: ‘Dear parent … ‘.
2 Specific prompt: ‘To the parents of … our records show … ‘.
3 Specific prompt plus extended clinic hours, with child-minding, movies and snacks.
4 Specific prompt plus monetary incentive of a lottery ticket with three prizes
worth a total of $175. To be eligible, parents had to bring their children to
the clinic for immunisation, tear off their ticket stub and put it in the clinic’s
lottery box.
» After two months, the lottery was drawn for the money-incentive group and
prizes were delivered directly to the winners’ homes.
» A further follow-up took place after three months.
Ethics:
» Parents did not consent to participate.
» They were unaware behaviour was being manipulated.
» There are questionable ethics around encouraging one group with money.
» Ethical strength: following data collection, both control groups received a
specific prompt letter ensuring parents of children in these groups were also
reminded that their children required immunisation.
Results:
40
Percentage increase children being immunised compared with the

After 2 weeks
After 2 months
After 3 months
combined results of the two control groups

30

20

10

0
General prompt Specific prompt Specific prompt Specific prompt
+ increased access + monetary incentive
Types of prompt
▲ Figure 8.1 Percentage increase in children being immunised compared with the
combined control groups

Conclusions:
» Using behavioural incentives to motivate parents to immunise children is
effective.
» A single general prompt is not enough to motivate parents to immunise children.

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 8 HEALTH PSYCHOLOGY

▼ Table 8.23 Methodological issues

Strengths Weaknesses
Experimental method – the random assignment of Generalisability – in Chaney et al. (2004), 32 Australian
participants meant that participant variables should not children is not representative of the wider population.
have biased results, increasing validity. This only showed differences with children already used
to a conventional spacer.
Yokley and Glenwick’s (1984) findings may not generalise
to other parts of the USA or other countries. The final
sample was 36.9 per cent less than the original, so the
results may also not be representative of the target
population.
Reliability – Yokley and Glenwick used standardised Validity – in Chaney et al., parents probably wanted to
procedures, meaning research is replicable. show they were doing their best for their children, so
put in extra effort to ensure adherence; this lowers the
validity of results.

Issues and debates

Use of children in research
Although Yokley and Glenwick (1984) used children in their research, the focus was
on parental behaviour. It is still important to consider the effects on children’s
immunisation. Control groups received a follow-up reminder letter after the study
ended, ensuring no group was disadvantaged. Chaney et al.’s (2004) research took
place in children’s own homes, with full parental permission and minimal researcher
contact. All ethical considerations were met.
Applications to the real world
Yokley and Glenwick’s study has practical applications. Where immunisation levels
are low and preventable diseases are returning, incentivised programmes might
increase the number of immunisations.

SKILLS BUILDER
Suggest one ethical issue Yokley and Glenwick (1984) mnemonic like DRIP will remind you to think about
would have considered when conducting their research deception, right to withdraw, informed consent and
into immunisation adherence. [2] protection from harm (including confidentiality and
privacy). As the topic is sensitive, relevant issues
Your first sentence should identify a suitable
would be informed consent, confidentiality or right
ethical issue. Bullet-point your ideas first; a
to withdraw. Be sure just to choose one.

NOW TEST YOURSELF

8.21 Outline one strength of longitudinal studies family, rather than each child being randomly
when investigating improving adherence to allocated. [2]
medical treatment. [2] 8.24 a Describe what psychologists have
8.22 Suggest two reasons why a psychologist discovered about improving adherence to
might choose a field experiment to investigate medical treatment. [6]
improving children’s adherence to medical b Evaluate what psychologists have
treatment. [4] discovered about improving adherence to
8.23 Using the key study by Yokley and Glenwick medical treatment, including a discussion
(1984), explain why families with two children about the use of children in research. [10]
were randomly allocated to a condition as a

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 8.3 Pain
8.3.1 Types of pain
Functions of pain STUDY TIP
Pain is subjective, with a sensory and affective component. Those believing pain is A good working
a threat to health will rate the affective level as higher than someone who believes knowledge of the
the same pain is just because they over-exercised. Individual response to pain is syllabus will mean you
affected by social, genetic and cognitive factors. should not be short
of ideas on some of
Pain’s function is to prevent us from further injuring ourselves. Doctors use pain as the less predictable
a clue when diagnosing. questions (e.g. Paper
4, Section B). Look at
Acute and chronic pain your revision checklists
regularly and practise
Acute pain is sudden, sharp pain lasting less than six months (ICD-11). sorting topics into their
Chronic pain: respective categories
until you can remember
» usually lasts longer than six months all the specific research
» causes high levels of anxiety and exhaustion methods and studies
» can affect sleep and impact the ability to lead a normal life. that you need to know
for each section.
Phantom limb pain
» Phantom limb pain is experienced by 80 per cent of people after limb loss.
» It is more common in women than men.
» It may be explained by mixed signals, brain adjustment or damaged nerve endings.
» It is a chronic condition, either recurrent or intractable, described as ‘shooting’,
‘burning’ or ‘cramping’ pain (Sarafino, 2006).
Mirror treatment
▲ Figure 8.2 Mirror
» Mirror treatment uses a mirror to create the illusion of the amputated limb treatment for phantom
being there, by placing the opposing limb in front of the mirror, with the limb pain
amputated limb behind it.
» The patient massages and moves the opposing limb and feels the benefit in the
phantom limb. SKILLS
» Ramachandran et al. (1995) describe how this breaks the negative feedback loop
telling the brain the limb is not moving and establishes new connections to ‘feel’ BUILDER
it again, easing the pain.
Suggest two reasons
why a psychologist
Relevant research: MacLachlan et al. (2004) might choose a case
Aim: to report the effects of mirror treatment on a person with lower limb amputation. study to investigate
Methodology: pain treatment. [4]

» Case study of 32-year-old man with leg amputation. Make a list of the
advantages of case
» He had used painkillers and a Transcutaneous Nerve Electrical Stimulation
studies, thinking, for
(TENS) machine for phantom limb pain, but it worsened.
example, about the
» He then tried mirror treatment.
idiographic approach,
Results: triangulation of
methods or type of
» Pain reduced to 0 on a 0–10 scale.
data. Then choose
» He felt more control over the phantom limb than prior to mirror treatment. two reasons that
Conclusion: are directly relevant
to studying pain
» Mirror treatment is effective for phantom limb pain. treatment.
» It avoids patients taking pain medication, giving them control over their pain.

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 8 HEALTH PSYCHOLOGY

Theories of pain
Specificity theory
This is a biological theory that suggests we have a sensory system specifically
dedicated to pain. The more the specific pain pathway (pain nerve fibres and
SKILLS
specific pain centre) is used, the more intense the pain is.
BUILDER
Gate control theory
Melzack and Wall (1965) proposed this theory of pain based on the action of T-cells Evaluate one theory
(transmission cells): of pain, including a
discussion of nature
» Small, slow fibres carry pain stimulation to the spinal cord. versus nurture. [10]
» They pass through a ‘gating mechanism’, activating T-cells to transmit the pain
signal to the brain. This question allows
» The extent to which the gate is open depends on the following: you to evaluate just
– Activity level in slow pain fibres: the more activity there is, the wider the one theory of pain
from this section,
gate opens.
focusing in detail
– Activity level in other peripheral fibres: they carry information about
on the supporting
harmless stimuli or mild irritations and close the gate.
evidence and the
– Messages from the brain to the spinal cord: neurons in the brainstem and cortex issues and debates.
send impulses relating to emotions down the spinal cord to open or close the gate: Remember to discuss
– Anxiety and boredom open the gate. nature versus
– Happiness and distraction close it. nurture.
▼ Table 8.24 Methodological issues

Strengths Weaknesses
Application to everyday life – MacLachlan et al.’s (2004) Validity – specificity theory is now outdated and
case study of mirror treatment shows how it could be discredited. There is no physical evidence of a gating
used by practitioners or even by people in their own mechanism in the spinal cord, suggesting other
homes. mechanisms might be involved.
MacLachlan et al.’s study results could have been a
‘placebo effect’ – just receiving treatment can have
positive effects. Attention from clinicians as part of the
treatment may have contributed to the results.
Case study – MacLachlan et al.’s research gave detailed Generalisability – MacLachlan et al.’s findings cannot
insight into the patient’s background and effectiveness be generalised to the wider population as individual
of treatment compared to other treatments. experience with mirror treatment differs. Pain is
subjective and varies with culture and gender.

Issues and debates

Nature versus nurture
The gate control theory of pain focuses on the nature side of the debate. However,
this ignores environmental (nurture) factors affecting pain perception, such as
hearing other patients in pain or harsh overhead lighting. It also ignores other
factors that can reduce pain, such as psychological treatments.
Reductionism versus holism
Gate control theory and MacLachlan et al.’s research take a holistic approach to pain,
accounting for both physical and psychological factors. However, neither accounts
for individual differences in pain experience.

NOW TEST YOURSELF

8.25 Explain one strength and one weakness of qualitative data, using
research from pain treatment as an example. [4]
8.26 Outline one feature of mirror treatment for phantom limb pain. [2]
8.27 Explain one weakness of the gate control theory of pain. [2]
8.28 Describe the placebo effect in relation to treatment for pain. [4]

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 8.3.2 Measuring pain
Subjective measures
Subjective measures, such as self-report, are important to understand the severity/
daily impact of patients’ pain.
Clinical interview
» Clinical interviews are used to assess patients with chronic pain.
» They allow observation and assessment of a patient’s emotional state and beliefs
about pain causes.
» They may use psychometric tests to help understand the type and intensity of the
patient’s pain, everyday functioning, emotional distress, beliefs and expectations.
Evaluation

» Strength: they are an effective way to assess pain. Although using standardised
questions, the physician can ask patients to elaborate to allow for a tailored
treatment plan. This increases adherence and likelihood of treatment success.
» Weakness: they may not be effective for all as they rely on good communication
and trust between patient and physician.

Psychometric measures and visual rating scales

McGill pain questionnaire
The McGill pain questionnaire (MPG) was constructed by Melzack and Torgerson
(1971), who asked doctors and university graduates to group 102 adjectives
describing different aspects of pain. They identified four categories, subdivided into
20 questions:
1 Sensory (questions 1–10): patients choose word describing their pain.
2 Affective (questions 11–15): looking at emotions the pain makes the patient feel,
with choices from numbered words such as tiring, sickening or fearful.
3 Evaluative (question 16): subjective intensity of pain, measured on a five-point
scale.
4 Miscellaneous (questions 17–20): various aspects of pain on three-to-five point
rating scales.
Three major results measurements:
» Pain rating index (PRI): high score = high pain levels. Total score given for all
questions, plus sensory, affective and evaluative score.
» Number of words chosen.
» Present pain intensity (PPI) at time of the questionnaire.
Evaluation
Strengths:
» Reliable: Ferraz (1990) found r = +0.96 correlation between 91 patients in a test-
retest analysis.
» Valid: Byrne et al.(1982) compared results of patients with back pain to previous
research and found similar results.
Weaknesses:
» Quantitative pain measures may limit the patient’s ability to communicate their
real experience of pain: descriptive words used in questionnaire do not fit their
experience; or may misunderstand the terms used.
Visual analogue scales
Visual analogue scales (VAS) avoid some problems with language by also using
pictures. The psychometric scale is designed to measure subjective pain along
a continuum. The patient identifies their current intensity of pain. It can be
completed on each clinic visit to monitor pain.

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 8 HEALTH PSYCHOLOGY

No pain Mild, annoying Nagging, uncomfortable, Distressing, miserable Intense, dreadful, Worst possible,
pain troublesome pain pain horrible pain unbearable,
excruciating pain

0 1 2 3 4 5 6 7 8 9 10
▲ Figure 8.3 An example of a VAS for measuring pain

Evaluation
Strengths:
» It is quick and easy to use.
» It is designed to show pain on a continuum, so no ‘gaps’ in pain intensity.
» Patients should feel their pain is represented on the scale, so it is a valid
measure.
Weaknesses:
» Patients are unable to elaborate on pain experience and its impact.
» It is a basic measurement of pain.

Behavioural measures
UAB pain behaviour scale
» The UAB pain behaviour scale measures observable pain behaviour and verbal/
non-verbal signs of pain.
» Using a three-point scale, an observer judges how frequently each behaviour
occurs across a three-week period.
▼ Table 8.25 One measure on the UAB pain behaviour scale

Body language M T W T F S S M T W T F S S M T W T F S S
(clutching, rubbing
of site of pain)
None 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Occasional ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Frequent 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Evaluation
Strengths:
» It is quick to score and easy to use.
» It can be used with a large number of patients, including those who cannot
complete a self-report.
» A wider sample makes results more generalisable.
Weaknesses:
» It is dependent on the observer’s ability to accurately record pain behaviour.
» There is a low correlation between observer scores on the UAB and self-reports
on the MPQ.

Key study: Brudvik et al. (2016)

Context:
» Research shows that hospital doctors underestimate children’s pain,
administering pain relief medication less often, later and at lower doses than for
adults.
» Parents are better estimators than nurses, yet they still underestimate their
children’s self-reported pain (Rajasagaram et al., 2009).

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 Aims: to explore
» the relationship between children’s self-reported pain and parents’ and doctors’
pain ratings
» how age, medical condition and severity of pain affect pain estimates
» whether pain assessment affects administration of pain relief.
Research method(s) and design: field study; correlational, using questionnaires.
Variables:
» Dependent variables:
– Numeric rating of child’s pain by doctors and parents.
– Three- to eight-year-olds’ responses on two visual analogue scales (e.g. see
Figure 8.4).
– Nine- to fifteen-year-olds’ responses using a visual analogue scale, with a
coloured green–red line.
Sample: opportunity sample of 243 paediatric patients aged 3–15 years old (mean
age: 10.6), their parents and 51 doctors.
Procedure:
» Participants completed scales and questionnaires as detailed in ‘Variables’ above.
» Parents answered demographic questions.
» Doctors gave details of experience, whether they were parents, pain relief given
and match between child’s rating and their own.
» Child’s diagnosis classified as infection, fracture, wound injury or soft tissue,
ligament or muscle injury.
» Each family’s total waiting time was recorded.
Ethics:
» Parents gave written consent for themselves and their children.
» The researchers ensured someone was always available to provide extra support
or guidance.
» The children’s medical condition could change rapidly, so it was important
parents knew someone was available if they wished to exercise their right to
withdraw.
Results:
» Only 42 per cent of children with severe pain (judged by doctors) were given pain
relief medication.
» Only 14.3 per cent of children self-rating pain as severe were given pain relief
medication.
Conclusion:
» Doctors significantly underestimate pain in 3–15-year-olds.
» Anxiety increases pain perception.
» Doctors should place higher value on parental reports of children’s pain.
▼ Table 8.26 Methodological issues

Strengths Weaknesses
Reliability – the MPQ was standardised. Brudvik et al. Generalisability – Brudvik et al. only looked at one
(2016) used a standardised procedure. Norwegian emergency department. They were not
specialist children’s doctors, so they did not routinely
assess pain. Doctors in other countries may have
assessed children’s pain more accurately.
Validity – Byrne et al. (1982) tested MPQ comparing Validity – in Brudvik et al., parents and children knew
results of patients with back pain to previous research each other’s answers. The children’s answers may have
and found similar results. been influenced by their parents’ reactions.
Brudvik et al. was in a natural setting, where doctors
had usual routines, with limited time to conduct
consultations.

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 8 HEALTH PSYCHOLOGY

Issues and debates

SKILLS
Idiographic versus nomothetic
BUILDER
Brudvik et al.’s (2016) research illustrates the nomothetic approach: measuring
pain numerically and using statistical analysis to determine the significance. Open From the key study by
questions would have collected qualitative data; a more idiographic approach means Brudvik et al. (2016)
they could have learned more about how/why some children experience greater pain on children’s pain,
than others. explain one strength
of the data gathered
Application to everyday life using visual analogue
The study can be used to support changes in Norwegian paediatric care. Training scales. [2]
should include listening to children/parents regarding pain levels and remembering
Think about the
individuals with the same condition may experience pain differently. This is critical
strengths of visual
due to links between pain, recovery time and long-term problems like
analogue scales
hypersensitivity.
and choose the one
that applies most
NOW TEST YOURSELF to children needing
to rate their pain.
8.29 Explain one strength and one weakness of Brudvik et al.’s (2016) Explain the strength
research into children’s pain. [4] in terms of how it is
8.30 Outline what is meant by the nomothetic approach, using an example particularly related
from research into measuring pain. [2] to children.
8.31 Explain why an understanding of cultural differences is important in
research into measuring pain. [4]
8.32 Tomas is conducting research into measuring pain. He plans to design
and then test a questionnaire on chronic pain level in people over 65,
by asking them to complete it and then comparing their answers with a
standardised self-report measure.
a Suggest one strength and one limitation of the questionnaire
method for measuring pain. [2]
b Suggest an additional method he could use to gain more data. [2]

8.3.3 Managing and controlling pain

▼ Table 8.27 Biochemical pain treatments

Type Example Description Strengths Weaknesses

Analgesics Paracetamol Very common type of painkiller Safe: serious » No better than placebo for
(painkillers) side effects chronic pain
rare (Prescott, » Only effective in small
2000) numbers of people for
acute pain (Moore, 2016)
» Exceeding dose is
extremely dangerous
NSAIDs Non-steroidal anti-inflammatory Effective for » Side effect – stomach
(e.g. ibuprofen) drugs to reduce pain, reducing fever, irritation
inflammation and temperature inflammation » Conflicting research on
and headache safety: decreased risk of
pain Alzheimer’s disease but
increased risk of breast
cancer
Opiates Strong painkillers like morphine Effective » High doses slow breathing
and codeine in treating and heart rate
acute pain » Addictive
(Rosenblum et
al., 2008)

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 Type Example Description Strengths Weaknesses
Local Novocaine Injected near to the body area Fast-acting. » Can wear off after 30
anaesthetics affected and stops nerves Acts within minutes, so often has to
sending pain signals to brain 5–10 minutes be combined with another
painkiller
Indirect Anti- The painkilling mechanism of Useful for Do not work immediately and
medication depressants antidepressants is not totally chronic pain pain relief is not total
understood; they may increase like migraines,
the neurotransmitters in the back pain and
spinal cord to reduce pain signals sciatica

▼ Table 8.28 Psychological treatments

Type Example Description Strengths Weaknesses

Cognitive Attention Using distraction to help reduce » Inexpensive, self- » Requires full belief
strategies diversion pain perception administered, effective, in the power of
no side effects distraction
» Significantly reduces
perceived pain and
increases quality of life
(Holden, 2013)
Non-pain Helps reduce moderate pain » No side effects » Less useful for
(guided) by imagining a pleasant » Patients have control long periods as
imagery scene unrelated to the pain over pain management difficult to maintain
experience; therapists ‘guide’ » Can be used whenever/ visualisation
the patient to imagine the wherever needed » Not everyone can
scene visualise things
Cognitive Through having clear » No side effects » Ineffective when
redefinition information, patients are » Positive self-statements fears are rational
helped to think fearlessly are helpful and based on past
and rationally about pain, experience
challenging irrational thoughts
Alternative Acupuncture Fine metal needles inserted » Reduce medication dose » Some people fear
treatments under skin and swivelled around and side effects needles
or mild electrical current passed » Research support with » For severe pain,
through to relieve pain; might cancer patients this needs to be
be explained by gate control (Hu et al., 2016) used alongside
theory of pain conventional drug
therapy
Stimulation/ Electrodes placed on skin near Effective during labour Effects are short-lived
TENS site of pain; mild electrical (Kaplan et al., 1998) with chronic conditions
current passed through the like phantom limb pain
skin; may also be explained by (Sarafino, 2006)
gate control theory

▼ Table 8.29 Methodological issues

Strengths Weaknesses
Usefulness – psychological treatments have no side Effectiveness – psychological treatments alone are
effects. Patients feel in control of their own pain ineffective for severe pain. Biological treatments may
management. Biological treatments are usually effective have harmful side effects or be addictive.
against severe pain.
Adherence – people are more likely to adhere to Reductionist – biological treatments are reductionist,
psychological treatments if pain is moderate and/or focusing on the biological mechanisms of pain and
short-lived, as side effects are one of the main reasons ignoring environmental factors.
for non-adherence.

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 8 HEALTH PSYCHOLOGY

Issues and debates

Idiographic versus nomothetic
Biological treatments take a nomothetic approach. Paracetamol is often prescribed
for pain despite research finding it ineffective for many, and individuals also
experience differences in side effects.
Similarly, cognitive redefinition is ineffective for some patients. Therefore, an
idiographic approach is more appropriate.
Cultural differences
Acupuncture demonstrates alternative pain relief techniques to traditional Western
drug therapy, supported by research evidence. Hu et al. (2016) found that cancer
patients receiving acupuncture alongside conventional drug therapy experienced
greater reduction in pain than those just having drug therapy.

SKILLS BUILDER
Martina suffers from chronic back pain and strong You will need knowledge of the strengths of
medication has only been partially successful. She is psychological pain treatments, and particularly of
thinking of trying acupuncture. Explain one strength of one strength of acupuncture for someone who is on
acupuncture that might attract Martina. [2] painkillers already.

NOW TEST YOURSELF

8.33 Outline what is meant by reductionist with needles. Suggest a treatment that Antonio
reference to biological treatments for pain. [2] could try as an alternative to medication.
8.34 Explain two differences between biological Explain your answer. [4]
and psychological treatments for pain. [4] 8.36 Sherif is interested in how people manage
8.35 Antonio has been experiencing some side and control chronic pain. Plan a study to help
effects from his pain medication, so he has Sherif investigate this. Your plan must include
stopped taking it. But the pain is disturbing details about:
him, though it is not severe. He is afraid of – type of data
– ethical issues. [10]

8.4 Stress
8.4.1 Sources of stress
Defining stress STUDY TIP
Stress is how our body reacts when we feel under pressure.
Use the Social
Sarafino (2006) provides three definitions: Readjustment Rating Scale
(SRRS) found at https://
1 Effect of environment on individuals. [Link]/vp4btbp6 and
2 Bodily response to stressful events. complete your own stress
3 Interaction between person and environment; individuals choose their response rating. Remember not to
using a combination of behavioural, cognitive and emotional strategies. take this too seriously, as
warned on the site. Think
Physiology of stress how many of the measures
were not relevant to you
General Adaptation Syndrome (your divorce, death of a
Selye (1936) suggests three stages of his General Adaptation Syndrome (GAS): spouse, for example). Now
look at the others. Would
1 Alarm: you rank them in the same
– Prepares body for fight or flight. way? This gives you some
– Cortisol, epinephrine and norepinephrine maintain the body’s increased good evaluation tips for the
nomothetic approach taken
arousal levels.
by this and similar scales.

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 Adrenal cortex
Stressor Amygdala Hypothalamus Pituitary ACTH
> cortisol

Adrenal medulla
> epinephrine (adrenaline)
and norepinephrine
(noradrenaline)

▲ Figure 8.4 Alarm stage

2 Resistance:
– If stress continues, the body tries to adapt.
– The body resists efforts to return blood pressure and heart rate to normal by
allowing high levels of these hormones.
– The individual may not be showing outward signs of stress but becomes
susceptible to illnesses.
3 Exhaustion:
– The body cannot maintain arousal indefinitely.
– This weakens the immune system.
– The individual is likely to experience illness and physiological damage.

Effects of stress on health

Acute (short-term) stress SKILLS
This can be protective in terms of health. For example, if you have surgery or a BUILDER
vaccination, the acute stress response alongside immune system activation enhances
the immune response. Stress can be
explained in terms of
Chronic stress deterministic factors.
Chronic stress affects the following systems: Explain two ways in
» Digestive system: which the explanations
– Chronic stress changes hormone levels and increases stomach acid, which may that you have learnt so
far in this section are
lead to stomach ulcers.
deterministic. [4]
– The behavioural response to stress can cause ulcers: smoking, drinking, use of
NSAIDs (ibuprofen) and lack of sleep. By listing all of
» Circulatory system: the ways in which
– Increased heart rate leads to strain on the circulatory system. the physiology of
– Chronic stress affects the immune system and raises coronary heart disease stress and effects of
(CHD) risk by raising blood pressure (hypertension). stress on health are
– Another risk for CHD is high cholesterol levels, which can lead to blood clots deterministic, you
and arteries narrowing. can then choose two
– CHD risk is raised by the behavioural response to stress: overeating, drinking and explain how they
alcohol and smoking. are deterministic.
» Immune system and immunosuppression: This will prepare you
for the free will side
– Chronic stress leads to immune system suppression, due to cortisol produced.
of the debate later
– Kiecolt-Glaser et al. (1984) measured natural killer (NK) cells in American
when you come to
medical students’ blood a month before exams and during exams. NK cells are
consider how people
essential to the immune system. They found lower levels in the second sample, reduce their stress.
and even more so for those reporting loneliness and/or stressful life events.

Causes of stress
Life events
Holmes and Rahe (1967) investigated the relationship between stressful life
events and illness. They developed the Social Readjustment Rating Scale (SRRS)
measuring life events experienced in the last 12 months from a list of 43 (see
page 212).

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 8 HEALTH PSYCHOLOGY

Holmes and Rahe concluded that the more life events (positive or negative) in the
previous year, the higher the likelihood of stress and ill health.
Work
Work can be stressful for three main reasons:
» Under-stimulation: Johansson et al. (1978) studied Swedish sawmill workers and
compared the finishers (preparing timber) to the sawmill cleaners. Finishers had
highly repetitive work and higher stress hormone levels than cleaners.
» High workload: in the same study, Johansson et al. found that finishers had
a high level of responsibility and demand, and higher illness/absence than
cleaners.
» Low control: Marmot et al. (1997) studied 10,000 UK civil servants. They found
no correlation between workload and stress, but lack of control was associated
with CHD in lower grade civil servants.

Relevant research: Chandola et al. (2008)

Aim: to determine biological/behavioural factors linking work stress and CHD.
Methodology:
» A 17-year longitudinal study of 10,308 London-based civil servants aged 35–66.
» Self-reported work-related stress and isolation were assessed by the Job Strain
Questionnaire.
» Incidents of CHD were noted.
» Cortisol levels were measured on waking and 30 minutes later.
» Alcohol consumption, smoking and exercise were all measured.
» The study ended with a clinical examination.
Results:
» Self-reported work stress was lowest in the highest grades of civil service.
» Among younger participants, there was a significant association between work
stress and incidents of CHD. Little association was found in older participants
(aged 50–60).
» Higher work stress was associated with poor health behaviour.
» Work stress also correlated with a morning rise in cortisol towards the end of the
study.
Conclusion:
» Chronic work stress is a risk factor for CHD.
» Approximately 32 per cent of the effect can be explained by poor health
behaviours.

Type A personality
» Friedman and Rosenman (1974) were physicians working with male CHD patients
in the USA in the 1950s.
» They compared male patients’ incidence of CHD to their partners/spouses, who
had a similar diet.
» Partners/spouses were less likely to have CHD.
» Certain behaviours associated with cholesterol levels and blood clotting time
were associated with greater risk of CHD.
» They called these behaviour patterns ‘Type A’ personality, characterised as
competitive, ambitious, work-driven, time-conscious and aggressive.
» The Type A personality was identified as a risk factor for white, middle-class men
(Friedman and Ulmer, 1985).

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 ▼ Table 8.30 Methodological issues

Strengths Weaknesses
Reliability – Kiecolt-Glaser et al. (1984) used two Validity – cannot determine which Type A personality
objective quantitative methods, measuring NK cells and aspects increase individual risk of CHD. Some research
life events questionnaire. suggests hostility levels are a leading factor, not
Friedman and Rosenman (1974) studied 3,154 healthy personality as a whole.
men between the ages of 39 and 59 for eight and a half
years. A personality questionnaire separated them into
Type A and Type B (relaxed) personalities. Almost twice
as many Type A people than Type B developed CHD. This
provides research evidence for the theory.
Research by Johansson et al. (1978) and Marmot et al.
(1997) supports Chandola et al.’s (2008) findings.
Usefulness – understanding the relationship between Correlational research – data was generated mainly
Type A personality factors and stress can help people through self-report and was correlational. This cannot
reduce their risky attitudes and behaviour. account for other factors that may be responsible for
CHD.
Longitudinal research – Chandola et al. used data Cultural/individual differences – Holmes and Rahe’s
triangulation over a long period, increasing the validity (1967) SRRS ignores individual/cultural differences.
of their findings.

Issues and debates

Reductionism versus holism
Biological, SRRS and Type A/B personality explanations are reductionist. They try
to describe complex human behaviours simplistically. Many people are a mixture
of both personality types, depending on context and current stressors. A holistic
approach may be beneficial as situational factors also impact people’s reaction to
stress.
Cultural differences
The research into work causing chronic stress was conducted in Western individualist
cultures. Busy, repetitive jobs with low responsibility and low control may be viewed
differently in other cultures.

SKILLS BUILDER
Johannes is always on the go. He works hard and Refer to psychological research in your answers.
worries a lot, but finds consolation in eating, so he is
Review the study by Friedman and Rosenman (1974)
putting on weight. He says he doesn’t have time to eat a
and research from other studies into chronic stress
healthy diet or to exercise.
and health to inform your answer. There are just
a Suggest Johannes’ likely personality type. [2] three minutes for this question; focus on just one
b Describe one health problem that Johannes may health problem to avoid running out of time.
develop if he does not change his lifestyle. [2]

NOW TEST YOURSELF

8.37 Explain two weaknesses of using rating scales too stressful. Suggest the type of employment
in research into causes of stress. [4] Sylvie should look for now in order to reduce
8.38 Outline one way in which research into her stress levels. Use psychological research
causes of stress is nomothetic. [2] in your answer. [4]
8.39 Sylvie recently gave up a job with a lot of 8.40 Explain one reason why a holistic approach
responsibility and very tight deadlines over to investigating the causes of stress may be
which she had no control, because she found it preferable to a reductionist approach. [2]

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 8 HEALTH PSYCHOLOGY

8.4.2 Measures of stress

Biological measures
Heart rate
» Hospitals often measure heart rate per minute using electrocardiography.
» Heart rate increases in acutely stressed individuals and decreases in the
chronically stressed (Schubert et al., 2009).
Heart rate variability (HRV)
» This is the variation in time between heart beats measured in milliseconds with
an electroencephalogram (ECG).
» When relaxed, HRV goes up but it goes down when stressed.
» Nowadays smart watches can measure HRV by detecting heartbeat optically
through wave of blood flow in the wrist and sending data to the phone.
Brain function (fMRI)
» Functional magnetic resonance imaging (fMRI) scanners record brain activity
using powerful electromagnets.
» The scanner recognises changes in blood oxygenation and flow that occur during
neural activity.
» Degrees of neural activity are different colours on the scan, showing active brain
areas.
Sample tests: salivary cortisol
» Cortisol released by adrenal glands as part of the ‘fight or flight’ response can be
measured non-invasively in urine and saliva.
» High levels of cortisol indicate that the individual is experiencing stress.

Relevant research: Wang et al. (2005)

Aim: to study neural circuitry of psychological stress.
Methodology:
» There were 32 participants: 25 experimental, 7 in control group.
» Participants in the experimental group were scanned using perfusion fMRI.
» There were four scans of eight minutes each, ending with a full anatomical scan.
The scans:
1 Baseline condition without task.
2 Low-stress condition: participants counted backwards aloud from 1000.
3 High-stress condition: performed verbal serial subtraction of 13 from a four-
digit number aloud; prompted to go faster during the task and if they made a
mistake, they had to restart.
4 Final baseline condition without task.
» Control group also had four scans, but no task.
» Participants in both groups completed a self-report stress scale (1–9).
» Saliva samples were collected immediately before and after each scan.
» Experimental participants reported level of effort, frustration and task difficulty
after low- and high-stress tasks.
» Heart rate was recorded every two minutes.
Results:
» The ventral right prefrontal cortex (RPFC) showed continued activation during
and after stress tasks.
» This demonstrates that perfusion fMRI is a suitable approach to measure stress.
Conclusion: the ventral RPFC plays a central role in stress response.

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 Relevant research: Evans and Wener (2007)
Aim: to investigate how density and proximity of other train passengers affect
commuter stress.
Methodology:
» During the morning commute, 208 American commuters completed five-point
Likert scales reporting their stress.
» Near the journey’s end, they completed a proofreading task to measure
motivation/persistence.
» A saliva sample of cortisol levels was taken at the end of the journey.
» Crowding was measured via observation.
» At the weekend, researchers visited participants’ homes and took another
cortisol sample, at the same time as the workday one. The participant’s spouse/
partner was asked to evaluate interactions on a five-point rating scale, using a
questionnaire.
Results:
» Proximal crowding significantly correlated with cortisol levels, self-reported
mood and percentage of proofreading errors.
» Distal crowding was not correlated with stress.
» Longer commutes were associated with significantly higher cortisol levels, poorer
proofreading performance and higher levels of perceived commuting stress.
» Spousal ratings of commuter stress were not associated with longer commuting times.
Conclusion: proximal crowding is related to commuter stress, possibly due to
invasion of personal space, but distal crowding is not.

Psychological measures
Self-report questionnaires
These are easily completed and a convenient way to measure stress.
Friedman and Rosenman’s personality test
» Friedman and Rosenman studied couples with the same diet and found men had a
higher incidence of heart disease.
» They sent 150 questionnaires to San Francisco businessmen, asking which of ten
listed habits a friend had exhibited prior to a heart attack.
» The questionnaires were also sent to hospital workers looking after cardiac patients.
» They identified consistent traits in responses.
» Structured 25-question audio-taped interviews were conducted over more than
eight years, assessing how people responded to everyday pressures.
» Participants’ personalities were rated by two researchers to ensure inter-rater
reliability.
Jenkins et al. (1979) created a pen and paper version of this personality test – the
Jenkins Activity Survey. A subset of 21 items best predicted Type A behaviour:
questions about being punctual and competitive. Using this, psychologists can
identify an individual’s personality type as either A or B.
Life events questionnaire
Holmes and Rahe (1967) created the Social Readjustment Rating Scale (SRRS):
» This included 43 life events based on the type of events that their patients had
reported experiencing.
» Holmes and Rahe asked a sample of 394 participants to rate the life events
(regardless of whether it was positive or negative). They were then ranked and a
score assigned.
» Total scores for a 12-month period:
– fewer than 150 life change units = 30 per cent chance of stress
– 150–299 life change units = 50 per cent chance of stress
– over 300 life change units = 80 per cent chance of stress-related illness.

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 8 HEALTH PSYCHOLOGY

▼ Table 8.31 Methodological issues

Strengths Weaknesses
Generalisability – the Jenkins Activity Survey is an Generalisability – Wang et al.’s (2005) fMRI research
easy-to-score self-report questionnaire; it could be was expensive and time-consuming, and there were just
completed online or sent out to large numbers of people. 32 participants, giving low generalisability.
Validity – Scully et al. (2000) reviewed SRRS 30 years Validity – Holmes and Rahe’s (1967) research was
after it was first used. They reported it was still a correlational, only looking at the relationship between
reliable measure of life events, stress and ill health, health and life events. There could be other variables
suggesting it has temporal validity. (like poor nutrition through stress) affecting health.
Objective data – Evans and Wener (2007) measured Subjective data – self-report measures of stress or
cortisol in saliva samples; this is an objective way of personality (Friedman and Rosenman, 1974; Holmes and
measuring physiological effects of stress. Wang et al. Rahe, 1967) are prone to social desirability bias.
used fMRI scans, which is a more objective and reliable
way of measuring stress than self-report methods.

Issues and debates

Individual and situational explanations
The scales used take an individualist approach to stress and illness, seeing the cases
as lying in people’s individual behaviour. This fails to consider lifelong
environmental stressors like disability or poverty.
Cultural differences
Research into biological and psychological measures of stress has taken a Western,
individualist approach. Rating scales assume that Christmas, weddings and moving
house are all highly stressful events, but this has not been tested cross-culturally.

NOW TEST YOURSELF SKILLS

8.41 Using examples of research into measuring stress, explain what is
BUILDER
meant by individual and situational explanations. [4] Suggest one strength
8.42 Outline what is meant by temporal validity. [2] of using biological
8.43 Explain two strengths of self-report questionnaires for measuring measures of stress. [2]
stress. [4]
Identify a strength
8.44 People’s stress can be personal, varying with individual age, gender and
of using biological
circumstances. Rating scales for adults may not apply to younger people,
measures and
for example.
explain why it is a
a Plan a study using self-reports to investigate stress in 16–18-year-old strength. Remember
full-time students. Your plan must include details about: just to choose one
– question format (open and closed questions) and focus on the
– scoring/interpretation. [10] reason for this being
b Describe one piece of psychological knowledge on which your a strength.
plan is based. [4]

8.4.3 Managing stress

Psychological therapies
» Biofeedback is based on operant conditioning.
» It uses technology so an individual can see/hear the physiological reactions that
occur when under stress.
» The individual is taught relaxation techniques and connected to machines
measuring muscle tension (EMG), brain activity (EEG) and sweating (SCR).
» When increased activity is identified, visual/audio feedback is given.
» Relaxation techniques used while receiving positive feedback decreases heart
rate/tension.
» The individual learns how to use relaxation techniques when stressed.

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 Relevant research: Budzynski and Stoyva (1969)
Aim: to describe a biofeedback instrument incorporating operant conditioning
principles.
Methodology:
» Fifteen participants were randomly allocated to one of three groups:
– Experimental group – correct feedback: participants were told the tone of
EMG would vary with forehead muscle tension. They were told to relax and
keep tone pitch low (high pitch = more tension).
– Control group 1 – no feedback (silence): participants were asked to relax,
especially forehead muscle.
– Control group 2 – irrelevant feedback: participants were asked to relax deeply,
especially forehead muscle, and told low monotone would help relaxation.
» EMG measured muscle action potential over 20 sessions.
» Participants were paid $1.50 for each session and told bonus would be given
according to their rank in the group of 15.
» Experimental group participants received continuous feedback about muscle activity.
Results: there was a 50 per cent mean decrease in action potential in the
experimental group; 20 per cent in the silent control group; and 28 per cent in the
irrelevant feedback control group.
Conclusion: biofeedback may be useful for people with certain psychosomatic
disorders.

Preventing stress
Stress inoculation training
There are three phases of stress inoculation training (SIT) (Meichenbaum and
Deffenbacher, 1988):
1 Conceptualisation involves two goals:
– building collaboration between client and trainer
– increasing the client’s understanding and awareness of nature/impact of
stress responses.
The client is taught how to recognise stress and anxiety through the process of
Socratic questioning.
2 Skill acquisition:
– The client is made aware of their anxious self-talk.
– They are taught specific self-statements to counter negative self-statements.
– They are taught techniques like problem-solving and self-reward for coping.
3 Rehearsal and application:
– This is the ‘inoculation’ part of training: clients work on transferring skills
across increasingly demanding levels of stressors.
– Role plays and imagery are used for assignments.
– The client feeds back to the trainer.
– Coping techniques are learnt.

Key study: Bridge et al. (1988)

Context:
» Relaxation and imagery techniques can help patients to deal with the
psychological stress of cancer diagnosis and treatment.
» Previous research with cancer patients suggests positive thought and guided
imagery can prolong life (Simonton and Simonton, 1975).
Aims and hypotheses:
» Aim: to see whether stress could be reduced in patients diagnosed with early
breast cancer and receiving radiotherapy.
» Hypothesis: women receiving relaxation training with an imagery component
would show less stress than women given relaxation training alone.

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 8 HEALTH PSYCHOLOGY

Research methods and design: randomised control trial using questionnaires.

Sample: opportunity sample of 139 women (average age: 53, all under 70) treated
either by mastectomy or lumpectomy; attending six-week radiotherapy treatment
at a UK hospital.
Procedure:
» Participants completed the Profile of Mood States and the Leeds General Scales
Questionnaire.
» All participants were seen individually by the researcher, once a week for six weeks.
» Participants were allocated to one of three conditions:
1 Control
2 Relaxation
3 Relaxation plus imagery.
» Treatment groups were taught relaxation techniques involving diaphragmatic
breathing.
» The ‘relaxation plus imagery’ group imagined a ‘peaceful scene’ of their choice.
» The control group women chatted together.
» Sessions lasted 30 minutes.
» Treatment groups had audio tapes for home practice.
» Participants repeated the same questionnaires at the end of the study.
Ethics:
» Fully informed consent was given.
» Participants were informed that results would not appear in their medical records
and they would not be penalised if they refused to take part.
» No drugs would be given.
» Confidentiality was maintained.
Results:
» No significant differences were found between groups on the initial
questionnaire scores.
» Mood before and after the study was compared. There was no significant
difference in mood disturbance of the ‘relaxation’ group; there was a small
difference in the ‘relaxation plus imagery’ group; in the control group, total
mood disturbance worsened.
» However, when the researchers divided women into under-54 and over-54 groups,
the results differed.
Conclusions:
» Relaxation combined with imagery is effective at reducing mood disturbances.
» Mood disturbances worsen in patients with no intervention.
» Intervention is more effective in older women with more time to focus on the
techniques as they are less likely to be working or have young children.
▼ Table 8.32 Methodological issues

Strengths Weaknesses
Reliability – Bridge et al. (1998) used standardised Ethics – stress inoculation training (SIT) is expensive and
procedures: the women in the treatment groups were the cost is not covered by some countries’ health services.
taught relaxation techniques in the same way. This The number of sessions needed may require unaffordable
allows replicability. time off work. Therefore, some people are excluded from this.
Mood disturbance for Bridge et al.’s control group worsened.
They needed to be offered the therapy afterwards.
Application to everyday life – in Budzynski and Stoyva Generalisability – in Bridge et al., there were only 44–48
(1969), EMG techniques gave individuals a way of participants in each group, and fewer when broken down
managing stress in different everyday situations. by age. This is unlikely to represent the target population.
SIT focuses on stress causes, not just symptoms. The skills
used in training can be applied to everyday situations.
Bridge et al.’s treatment groups used audio tapes at
home and could continue to do so.

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 Issues and debates
Determinism versus free will
The research demonstrates that training helps people manage their low mood by
exercising free will, reducing feelings of helplessness and increasing empowerment
during difficult treatments. Mental wellbeing is determined by attitudes to
treatments.
Application to everyday life
Relaxation techniques could be carried out at home. They are more effective with
women over 54. Interventions could be targeted at older women who are most likely SKILLS
to benefit.
BUILDER
NOW TEST YOURSELF Explain one strength
of an operant
8.45 Using examples of research into managing stress, explain conditioning technique
what is meant by determinism versus free will. [4] for managing stress.
[2]
8.46 Jacqui suffers from tension headaches. Suggest one way
in which biofeedback might help her. [2] First, identify
8.47 From the key study by Bridge et al. (1988): the technique as
a Explain how the participant’s age was relevant to the results biofeedback and
of the relaxation training. [2] bullet-point the
b Explain what is meant by a ‘randomised control trial’. [2] strengths. Choose
one and write about
8.48 Suggest one weakness of self-report methods when conducting
it, explaining why it is
research into managing stress. [2]
a strength.

8.5 Health promotion

8.5.1 Strategies for promoting health
Fear arousal STUDY TIP
» Fear arousal uses vivid imagery to raise public awareness of risky health There are some small
behaviours, such as the use of graphic imagery on cigarette packets. parts of the health
» Success is more likely if the individual has a high level of self-efficacy. option that could be
» If fear appeals are too anxiety-provoking, behaviour becomes defensive and easily missed, especially
people avoid the fear message or even engage more in the activity (Brown and in the last section – for
Smith, 2007). example, psychological
» Janis and Feschbach (1953) found that high fear appeals lead to a high level of therapies for managing
stress. Keep a copy of
emotional stress and the individual may:
the relevant syllabus
– ignore the message section at the front of
– become distracted/unable to concentrate each set of revision
– become aggressive to the person communicating the health message notes. This will help
– actively avoid the message. you familiarise yourself
» Low fear appeals are also ignored as they do not produce the motivation to with the exact wording/
change. phrasing of the bullet-
pointed content. This
will assist in decoding
Relevant research: Janis and Feschbach (1953) exam questions and
Aim: to investigate potential adverse effects and defensive reactions to fear including the expected
appeals. content in your answers.

Methodology:
» Participants were 200 American high school students (mean age: 15).
» They were randomly allocated to either strong, moderate or minimal fear appeal
groups on dental hygiene or a control group.

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 8 HEALTH PSYCHOLOGY

» Fear appeal groups received the same essential information.

» Independent variable – strength of fear appeal:
– strong – serious dangers of poor dental hygiene given, using the word ‘you’
frequently
– moderate – consequences of poor dental hygiene given in a factual manner
– minimal – information given on the growth and functions of teeth
– control – information given on the structure and function of eyes.
» The effects of communication were measured in four ways:
1 A general health questionnaire on dental hygiene (a week before lectures).
2 Self-reported feedback on a five-point scale, from ‘very worried’ to ‘not at all
worried’.
3 A 23-item test on the factual content of lectures.
4 A follow-up questionnaire on the effect of lectures (one week later).
Results:
» There was no difference in the amount of knowledge remembered.
» In the strong fear group, 42 per cent thought about the condition most of the
time, compared to 22 per cent in the minimal fear group.
» In the strong fear group, 74 per cent felt worried about the condition of their
mouth, compared to 44 per cent in the minimal fear group.
» Participants in the strong fear group found the lecture more interesting than
other groups.
» More people in the strong fear group said there was something they disliked
about the illustrated talk.
» Groups’ conformity to oral hygiene behaviour:
– strong fear group = 8 per cent
– moderate fear group = 22 per cent
– minimal fear group = 36 per cent
– control group = 0 per cent.
Conclusion:
» Strong fear appeals create a high level of tension and concern, but little change
in behaviour.
» Low fear appeals result in greater behaviour change.
» Level of fear appeal does not affect the amount of knowledge gained from
communication.

Providing information
» This includes giving people information they need to stop an unhealthy habit. For
example, to help people give up smoking, they could be provided with links for
buying nicotine patches or details of stop smoking programmes (Sarafino, 2006).
» Waiting rooms can have booklets on various diseases and illnesses tailored to the
specific clinic.

Home-based exercise programmes

» Myocardial infarction (MI, or a heart attack) is distressing and requires the
survivor and their family to adjust their lifestyle and recover psychologically.
» MI rehabilitation reduces distress and improves quality of life.
» Not providing programmes may lead to a loss of confidence and depression.
» Home-based interventions are uncommon, despite evidence that they are as
useful as hospital-based ones.

Relevant research: Lewin et al. (1992)

Aim: to evaluate the effectiveness of a home-based post-MI exercise programme.
Methodology: field experiment; longitudinal design.

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 » Three days after admission to a UK coronary care unit, 176 patients
(mean age: 56) were randomly assigned to one of two groups:
– Experimental group: self-help rehabilitation programme after discharge.
Spouses were given information, and invited to take part and to encourage
the patient.
– Control group: standard care plus placebo information package and informal
counselling.
» Both groups were followed up at one, three and six weeks.
» Postal questionnaires were sent at six weeks, six months and one year to measure
symptoms of anxiety and depression, general health and use of health services.
Results:
» There was a significant improvement in anxiety and depression in the
rehabilitation group at six weeks, six months and one year.
» The control group made an average of 1.8 more visits to the doctor in the first
six months compared to the rehabilitation group.
» At one year, the control group had made a mean of 0.9 more visits.
» More members of the control group were admitted to hospital in the first six
months (24 per cent versus 8 per cent of rehabilitation group).
Conclusion: self-rehabilitation programmes lead to improved psychological
adjustment, fewer cases of readmittance, fewer visits to the doctor and a lower rate
of anxiety and depression.
▼ Table 8.33 Methodological issues

Strengths Weaknesses
Application to everyday life – the fear arousal method Individual differences – Janis and Feschbach (1953)
of persuading individuals to change their behaviour is couldn’t completely predict how people will respond to
still used today in health promotion campaigns. This fear appeals. Individual factors such as personality and
shows that fear appeals are useful. prior experience could affect response.
Lewin et al. (1992) is supported by research. Campbell et
al. (1998) found an improvement in blood pressure and
28 per cent reduction in hospital admissions.
Validity – Lewin et al. ensured patients in the Validity – Lewin et al.’s funding ran out; nearly half
rehabilitation group did not talk to others about their of the participants in the experimental and control
intervention. They used a double-blind method so neither groups were not followed up at the six months and one
the cardiologist nor the nursing care team knew to which year points. This could affect the validity of long-term
condition patients were assigned. findings.
Longitudinal study – Lewin et al. were able to Ethics – fear appeals reduce the self-esteem of those
investigate long-term effects of a home-based post-MI unable to follow guidance, increasing the belief that
exercise programme. they are unable to do anything to avoid negative
consequences (Simpson, 2017).

Issues and debates

Individual versus situational explanations
Research by Wu et al. (2021) looked at the effects of fear appeals during the
COVID-19 pandemic using situational factors such as notification of proximity to
infected person and whether this would motivate individuals to make behavioural
changes. This focused on situational factors and individual factors, like how
personality and prior experience affect responses. It is important for researchers to
consider both factors when researching fear appeals.
Cultural differences
Tannenbaum et al. (2015) reviewed data from 127 cross-cultural studies on fear appeals.
They found no evidence of cultural differences in effects. However, Chung and Ahn
(2013) found cultural differences when researching South Korea and the USA, suggesting
different culturally appropriate messages should be used. This suggests that research
around fear appeals and cultural differences is conflicting, and more research is needed.

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 8 HEALTH PSYCHOLOGY

SKILLS BUILDER
Sylvie is designing questionnaires to investigate the might social desirability bias affect how participants
efficacy of health promotion strategies. Explain one answer a questionnaire about their response
way that Sylvie could ensure that the data she collects to health promotion strategies? What could the
is valid. [4] researcher do to help participants provide detailed
and honest answers? The question only requires
Combine your knowledge of research methods with
you to write about ‘one way’. Choose your best idea
what you have learned in health psychology. How
and explore that in detail.

NOW TEST YOURSELF

8.49 Outline one ethical issue with fear appeals as 8.51 Explain what is meant by individual versus
a method of health promotion. [2] situational explanations, using research into
8.50 Xavier thinks he would like to give up smoking. strategies for promoting health. [4]
His friends don’t smoke, and they are always 8.52 Plan a field experiment using questionnaires
warning him of the health risks, but that just to investigate strategies for promoting health.
makes him defensive. Suggest one way in Your plan must include details of:
which his friends may have more success, – question format
rather than relying on fear arousal. [2] – sampling technique. [10]

8.5.2 Health promotion

Schools and healthy eating
Research shows that in some countries young children do not eat enough fruit and
vegetables. The UK Department of Health (2000) found that fewer than 4 per cent of
children ate the recommended five portions of fruit and vegetables a day, with one
in ten eating none.

Relevant research: Tapper et al. (2003)

Aim: to increase consumption of fruit and vegetables through the use of ‘Food
Dudes’ in schools.
Methodology:
» A variety of studies carried out, including one in a nursery.
» Researchers used a video of the ‘Food Dudes’ – a group of four children who gain
superpowers from eating vegetables.
» The Food Dudes battle against ‘Junk Punks’, who threaten to take over the planet
by destroying all the fruit and vegetables.
» Throughout the video, fruit and vegetables were eaten regularly.
» Rewards were stickers, pens and erasers, given for eating the target amount of
fruit and vegetables.
» This modelling plus rewards approach resulted in increasing fruit and vegetable
consumption that persisted at the 15-month follow-up.
Extended research to a whole school programme:
» Children aged 4–11 in three UK primary schools.
» School staff implemented the programme:
– Food Dude video
– Food Dude rewards
– letters from the Food Dudes encouraging children and reminding them how
they get rewards
– staff manual, briefing video and support materials.
» Children watched videos and listened to letters being read out for 16 days.

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 » Rewards were given to children for tasting target food or eating a whole portion.
» A maintenance phase involved no videos but rewards and letters were used
intermittently.
» Two more schools were tested, one of which received the Food Dudes programme
and another which acted as a control and simply received extra fruit and
vegetables during the study.
» Parents completed questionnaires after the study commenting on whether their
child had enjoyed/benefited from the intervention.
» Impact was assessed four months later.
Results:
» There were significant increases from Monday to Friday in fruit and vegetable
consumption across all three initial schools.
» More fruit and vegetables were eaten at weekends but results were not
statistically significant.
» In the two extra schools, the experimental school showed significant increases
in fruit/vegetable consumption compared to the control school.
» Increases persisted at a four-month follow-up.
» Parents and teachers responded positively to the programme, suggesting children
enjoyed it, but also that they were more enthusiastic when doing work with the
Food Dudes theme.
» There was improved attendance and increased confidence among low-achieving
children.
Conclusion: behaviour modification programmes can change children’s eating
habits, in both the short term and the long term.

Worksites and health and safety

Promoting safe work practices is essential for reducing workplace accidents. South
Africa recorded 32 mining fatalities in the first six months of 2021, with many
other accidents. Behaviour modification methods using operant conditioning
principles, like token economies, have been used to try and decrease accidents (see
Organisational Psychology chapter, page 257). However, the long-term effects of
these have rarely been studied.

Relevant research: Fox et al. (1987)

Aim: to investigate whether token economies are an effective long-term way of
reducing accidents and injuries in two USA mines.
Methodology:
» Miners were divided into four hazard groups: from Group 1 – least hazardous jobs,
to Group 4 – most hazardous jobs.
» Miners who avoided lost-time and/or medically treated compensation were
rewarded with monthly stamps, to be exchanged locally for goods.
» Miners in hazardous jobs received more stamps for avoiding injuries than miners
in less hazardous jobs.
» Special payments were given to employees suggesting how to prevent serious
accidents or equipment damage.
» Injured miners lost monthly stamps depending on the number of workdays
missed.
Results: both mines showed substantial decreases in the number of days lost during
the first five years of the token economy programme.
Conclusion: token economies are a cost-effective way of reducing work-related
injuries in mining.

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 8 HEALTH PSYCHOLOGY

▼ Table 8.34 Methodological issues

Strengths Weaknesses
Longitudinal design – both Tapper et al. (2003) and Fox Validity – Tapper et al.’s questionnaires gathered data
et al. (1987) tracked changes over time and found that about children’s fruit/vegetable consumption at home and
interventions were effective over the long term. school. Parents may have given socially desirable answers.
Fox et al.’s reward incentive maybe stopped employees
reporting small accidents, so they may not have actually
decreased.
Generalisability – Tapper et al.’s findings were replicated Generalisability – Fox et al. looked at USA mining
in five schools across England and Wales. companies. Therefore, study results may not generalise to
Research by Wang et al. (2015) on Chinese middle other countries and organisations.
school children suggests similar interventions might be
effective in other countries.

Issues and debates SKILLS

Application to everyday life
BUILDER
Time off work for accidents costs organisations work time, employee morale and
money. If workplace token economies can decrease accidents, there is less chance a Describe what
of negative consequences for the employee; the cost of the programme will be lower psychologists have
than the benefit, making the study useful. discovered about
health promotion.
Use of children in research
[6]
When researchers work with children, they must design age and/or developmentally b Evaluate what
appropriate materials. Tapper et al.’s (2003) ‘Food Dude’ videos and rewards are an psychologists have
example of this. The materials were particularly important as they could have a discovered about
long-term effect on the children’s health. health promotion,
including a
discussion about
NOW TEST YOURSELF application to
everyday life. [10]
8.53 a Outline what is meant by longitudinal research. [2]
b Explain one strength of longitudinal research, using research Always look at part
into workplace health and safety. [2] b before you start
8.54 Howard is a school meals supervisor in a primary (elementary) school. writing. As part b
He would like to increase fruit and vegetable consumption in young refers to ‘application
children. Using research into health promotion, suggest two strategies to everyday life’, you
Howard could use to encourage the children to eat fruit and vegetables. [4] will need to include
at least one piece of
8.55 Outline one ethical issue with the use of children in research. [2]
research in part a
8.56 Suggest one strength and one weakness of behaviour modification that can be evaluated
techniques in health promotion. [4] in this respect.

8.5.3 Individual factors in changing health beliefs

Unrealistic optimism
This is the cognitive belief that negative events are less likely to happen to us than
other people and that positive events are more likely to happen to us. Individuals
feel invulnerable to disease and may disregard health advice and engage in risky
behaviour.

Relevant research: Weinstein (1980)

Aims:
1 To investigate whether people believe that negative events are more/less likely
to happen to them than others.
2 To investigate whether the more control people feel they have over negative
events, the more they think it will not happen to them.
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 Methodology:
Comparative rating group:
» In Study 1, a diverse group of American college students estimated their chances
of experiencing particular life events compared to their classmates’ chances.
» Researchers used 42 life events: 18 positive, 24 negative; randomly divided
between two rating forms.
» Different versions of the rating form (each listing 21 events) were handed to
alternate students.
Comparative rating forms:
» Instructions said: ‘Compared to other students … same sex as you … what do
you think are the chances that the following events will happen to you?’
» Beneath the description of each event were the choices: 100% less (no chance),
80% less, and so on – through to 90% more and 100% more (certain).
Event characteristics group:
» The same life events were rated by 120 female students.
» They were instructed to estimate ‘the percentage probability of each event
occurring to students at the university’.
» Events were rated for:
– controllability
– desirability
– personal experience.
Results:
» Participants’ scores were in the predicted direction on 37 out of 42 events
(positive events = more likely to happen to them; negative events = less likely to
happen to them).
» There were some exceptions. For example, participants did not rate themselves as
being significantly more likely to be ‘not ill all winter’.
» There was a significant positive correlation between the positive events and the
extent to which participants perceived them as being likely to happen to them.
» When negative events were believed to be controllable, participants had a
stereotypical view of the type of person to whom this type of event would likely
occur, and they deemed themselves at less than average risk.
Conclusion: unrealistic optimism appears when an event is perceived as controllable
and people have some degree of emotional investment or commitment in its outcome.

Positive psychology
In the 1990s, Seligman started looking at happiness and wellbeing, rather than
mental illhealth. This is a free will approach – we control our own lives and
happiness.
Pleasant life, good life and meaningful life
▼ Table 8.35 Seligman’s three components of a happy life

Happy life Focuses on Description Examples

components positive…
Pleasant life Emotions Having positive emotions and taking Relaxing, reading, spending time
satisfaction from daily things with friends
Good life Traits Understanding our signature strengths and A person whose signature
using them to enhance our lives strength is creativity could focus
on creative aspects of their job
Meaningful Institutions, such We will be happiest using our signature Helping neighbours, volunteering
life as democracy, strengths to help make other people’s lives with a charity or campaigning for
family and free happier too; Seligman suggests this includes people in need
inquiry developing positive connections with others

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 8 HEALTH PSYCHOLOGY

Relevant research: Seligman (2004)

Positive psychology:
» Seligman’s article is an overview of a four-week introductory course.
» It included weekly ‘real-world’ homework assignments.
» Students reviewed scientific literature, focusing on:
– the past – contentment and satisfaction
– the present – joy, comfort and pleasure
– the future – optimism, hope, trust and faith.
» They learned about:
– depressive realism: unhappy people are more accurate in their life perceptions
than happy people
– the effect of major life changes on happiness.
» They practised increasing their own optimism, to increase productivity, improve
physical health and lower vulnerability to depression.
Homework tasks:
» Gratitude night: gratitude increases happiness. Seligman organised ‘Gratitude
night’ for his students, families and close friends. Students thanked them for all
they had done for them.
» Pleasurable day: students learnt skills of ‘savouring’ – sharing good experiences
with others, through memories and mementoes. They also learnt mindfulness,
by being in the moment and slowing down. They planned and carried out a
‘pleasurable day’.
» Signature strengths: students completed a Values in Action (VIA questionnaire),
identifying their top five strengths out of 24. They then chose a boring task and
found a way of using their signature strength[s] to complete it.
Meaningful life (final part of course):
» Creating a family tree – students had family members complete a VIA
questionnaire and interviewed them about relatives who had died.
» Mentoring a younger student – with similar issues to ones they had overcome.
» Writing a positive vision – for the future of humankind and their role in it.
» Writing their own obituary – from the viewpoint of their future grandchildren.

SKILLS BUILDER
Unrealistic optimism has been researched using rating fixed-choice questions on page 42. The command
scales to measure participants’ optimism. Give one term is ‘give’, which means you do not have to
difference between rating scales and forced/fixed- describe why rating scales are better or worse than
choice questions as a way of investigating unrealistic forced/fixed-choice questions, but just describe
optimism. [4] how they differ. You could give an example of a
rating scale from Weinstein’s (1980) research and
This question tests your knowledge of the additional
show how the question would have changed if it was
research methods required for A Level compared
forced/fixed-choice.
with AS Level. Refresh your knowledge of forced/

Key study: Shoshani and Steinmetz (2014)

Context:
» Many studies into positive psychology only look at short-term immediate effects
of intervention.
» This study takes a long-term approach.
Aims and hypotheses:
» To investigate whether participants in the positive psychology intervention
group had better mental health outcomes throughout middle school compared
with a control group.
» To investigate if the efficacy of the intervention was moderated by any specific
sociodemographic factors, including gender.
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 Research method:
» Longitudinal field experiment.
» Mixed design:
– compared intervention and wait list control groups (independent measures)
– measured before and after intervention period (repeated measures).
Sample: 1038 seventh to ninth graders (age: 11.8–14.7 years) from two large schools
in Israel; 537 from one school = experimental group; 501 from the other school =
wait list control group.
Procedure:
» A wide range of self-report questionnaires was used to gather quantitative data
using rating scales.
Intervention group:
» Schoolteachers were trained in group dynamics and positive psychology
throughout the school year.
» A teachers’ textbook of lesson plans/activities was created to ensure all teachers
delivered lessons in the same way.
» Student sessions were conducted. These included activities, discussions, reading
poems and stories and watching video clips.
» Another part of the programme was gratitude – awareness and appreciation of
the positive aspects of our lives.
» An intervention group discussed five or more things for which they were grateful each
week, writing gratitude letters to people who had a positive impact on their lives.
Wait list control group:
» Teachers continued with their social science lessons, focusing on adolescents’
issues.
Ethics: by the time the intervention was introduced for the wait list control group,
the oldest students would have moved on to high school. This meant the beneficial
programme was withheld from some students.
Results:
» Both groups had slightly worse than expected mental health levels at the
beginning of the study.
» At the end of the study:
– Intervention group: significant decreases in psychological distress and
depression, and significant increases in optimism.
– Wait list control group: increased poor mental health symptoms.
Conclusions: intervention was effective for both low and high-risk middle school
students.
▼ Table 8.36 Methodological issues

Strengths Weaknesses
Longitudinal design – Shoshani and Validity – Seligman’s (2004) self-report VIA questionnaire may result
Steinmetz’s (2014) intervention ran for one in socially desirable answers, decreasing the validity of the data.
year and students were followed up over a In Shoshani and Steinmetz, students completed the same
two-year period. This allowed monitoring of questionnaires across two years. Students may have recognised that
longer-term effects. questionnaires measured success of the programme and provided the
answers they believed teachers hoped for (participant expectations).
Psychometrics – used by Weinstein (1980) Generalisability – Shoshani and Steinmetz involved two Israeli
and Shoshani and Steinmetz as self- middle schools. Positive psychology interventions may be
report measures. Operationalisation and less effective with older teenagers or primary school children.
standardisation of the concepts mean they Weinstein’s research into unrealistic optimism sampled students
can be applied objectively and research can from one American university. Therefore, these findings are not
be replicated. generalisable outside of this population.

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 8 HEALTH PSYCHOLOGY

Issues and debates

Individual versus situational explanations
There is a focus on situational explanations of happiness – for example, strong SKILLS
social networks or faith can increase happiness (Myers and Diener, 1995). This
ignores individual explanations, such as how for some people (e.g. people who are BUILDER
chronically ill) acknowledging negative aspects is important for them to be able to
adjust their behaviour. Using the key study
of Shoshani and
Cultural differences Steinmetz (2014),
Two Israeli middle schools were involved in Shoshani and Steinmetz (2014). The explain two strengths
of a longitudinal design
results may not apply to other cultures and other types of school.
field experiment as a
method to investigate
NOW TEST YOURSELF wellbeing. [4]

8.57 Explain what is meant by individual factors, using research into The best way to
changing health beliefs. [4] approach this is
8.58 Suggest why measures of individual factors in changing health to explain one
beliefs may be culturally biased. [2] strength of a field
experiment and then
8.59 From the key study by Shoshani and Steinmetz (2014) on the
one strength of a
efficacy of a positive psychology intervention programme,
longitudinal design
suggest one strength of collecting quantitative data. [2]
when using a field
8.60 Describe what is meant by meaningful life. [2] experiment.

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 Health Psychology revision checklist
Check the syllabus to ensure you have covered all required content for each
subtopic. There are typically two to three bullet points per subtopic. You should
ensure that your evaluation points for each subtopic match with the relevant issues
and debates and methodology listed in the syllabus.

Topic Subtopic Revision notes Now test Past papers

complete yourself questions
questions complete
complete
The patient– Practitioner and patient interpersonal skills
practitioner
Patient and practitioner diagnosis and style
relationship
Misusing health services
Adherence to Types of non-adherence and reasons why
medical advice patients do not adhere
Measuring non-adherence
Improving adherence
Pain Types of pain
Measuring pain
Managing and controlling pain
Stress Sources of stress
Measures of stress
Managing stress
Health promotion Strategies for promoting health
Health promotion
Individual factors in changing health beliefs

Savage and Yokley and Brudvik et al. Bridge et al. Shoshani and
Armstrong Glenwick (2016) (1988) Steinmetz
(1990) (1984) (2014)
Context (including
relationship to other
studies)
Main theories/
explanations
Aim(s) and hypotheses
Methodology
Results/findings
Conclusions
Discussion points

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