Unit 4: Health enhancing behaviours and its implication for well-being: psychological

factors: resilience, hope, optimism, exercise, safety, nutrition.

DEFINITIONS OF HEALTH BEHAVIOR

There are many questions about health-related behavior, or health behavior, that are not yet
well understood. Therefore, both public health workers and scientific researchers continue to
attempt to understand the nature and causes of many different health behaviors. Health
behavior encompasses a large field of study that cuts across various fields, including
psychology, education, sociology, public health, epidemiology, and anthropology. In the
broadest sense, health behavior refers to the actions of individuals, groups, and organizations,
as well as the determinants, correlates, and consequences, of these actions—which include
social change, policy development and implementation, improved coping skills, and
enhanced quality of life. This is similar to the working definition of health behavior that
David Gochman proposed, which includes not only observable, overt actions but also the
mental events and emotional states that can be reported and measured. Gochman defined
health behavior as "those personal attributes such as beliefs, expectations, motives, values,
perceptions, and other cognitive elements; personality characteristics, including affective and
emotional states and traits; and overt behavior patterns, actions, and habits that relate to
health maintenance, to health restoration, and to health improvement." Interestingly, this
definition emphasizes the actions and the health of individuals. A public health perspective,
in contrast, is concerned with individuals as part of a larger community. These perspectives
are interrelated, as the behaviors of individuals determine many of the social conditions that
affect all people's health. Gochman's definition is consistent with the definitions of specific
categories of overt health behavior proposed by S. Kasl and S. Cobb.
In two seminal 1966 articles, Kasl and Cobb define three categories of health behavior:
Preventive health behavior involves any activity undertaken by individuals who believe
themselves to be healthy for the purpose of preventing or detecting illness in a asymptomatic
state. This can include self-protective behavior, which is an action intended to confer
protection from potential harm, such as wearing a helmet when riding a bicycle, using seat
belts, or wearing a condom during sexual activity. Self-protective behavior is also known as
cautious behavior.
Illness behavior is any activity undertaken by individuals who perceive themselves to be ill
for the purpose of defining their state of health, and discovering a suitable remedy.
Sick-role behavior involves any activity undertaken by those who consider themselves to be
ill for the purpose of getting well. It includes receiving treatment from medical providers,
generally involves a whole range of dependent behaviors, and leads to some degree of
exemption from one's usual responsibilities.
UNDERSTANDING AND IMPROVING HEALTH BEHAVIOR
The best way to design programs to achieve positive changes in health behavior is to have an
understanding of why people behave as they do and what might motivate them to change.
Theories and models of health behavior have been developed for this purpose. A theory is a
set of interrelated concepts, definitions, and propositions that present a systematic view of
events or situations by specifying relations among variables in order to explain and predict
the events or situations. Theories can be useful during the various stages of planning,
implementing, and evaluating interventions. They can, for example, be used to guide an
exploration of why people are or are not consuming a healthful diet or adhering to a
therapeutic dietary regimen. Theories can guide the search to understand why people do or do
not follow medical advice; to help identify what information is needed to design an effective
intervention strategy; and to provide insight into how to design an educational program so it
is successful. Thus, theories help to explain behavior, as well as suggest how to develop more
effective ways to influence and change behavior. A theory about why a person chooses the
foods he or she eats is one step toward successful nutrition management, but some type of
change model will also be needed to guide the person toward a healthful diet.
The most widely accepted theories about health behavior have been tested in research and
found to be helpful in understanding or predicting health behaviors. Health behavior is,
however, far too complex to be explained by a single, unified theory, and some professionals
have devised models that draw on a number of theories to help understand a specific problem
in a particular setting or context
THEORETICAL MODELS OF HEALTH BEHAVIOR
No single theory or model dominates research or practice in health-related behavior. Four of
the most frequently mentioned theories of health behavior in the late 1990s were the health
belief model; social cognitive theory; the stages of change model; and community
organization. These theories focus on a range of factors influencing behavior determinants,
including factors within an individual (such as thoughts, feelings, and beliefs), factors in
groups or relationships, and factors that exist in organizations, communities, and
governments (such as structures, regulations, policies, and laws).
A. The health belief model was originally developed to explain why people did or did
not take advantage of preventive services such as disease screening and
immunization. The health belief model suggests that people's beliefs about health
problems, perceived benefits of action and barriers to action, and self-efficacy explain
engagement (or lack of engagement) in health-promoting behavior. A stimulus, or cue
to action, must also be present in order to trigger the health-promoting behavior.
Perceived severity
Perceived severity refers to the subjective assessment of the severity of a health problem and
its potential consequences. The health belief model proposes that individuals who perceive a
given health problem as serious are more likely to engage in behaviors to prevent the health
problem from occurring (or reduce its severity). Perceived seriousness encompasses beliefs
about the disease itself (e.g., whether it is life-threatening or may cause disability or pain) as
well as broader impacts of the disease on functioning in work and social roles. For instance,
an individual may perceive that influenza is not medically serious, but if he or she perceives
that there would be serious financial consequences as a result of being absent from work for
several days, then he or she may perceive influenza to be a particularly serious condition.
Perceived susceptibility
Perceived susceptibility refers to subjective assessment of risk of developing a health
problem. The health belief model predicts that individuals who perceive that they are
susceptible to a particular health problem will engage in behaviors to reduce their risk of
developing the health problem. Individuals with low perceived susceptibility may deny that
they are at risk for contracting a particular illness. Others may acknowledge the possibility
that they could develop the illness, but believe it is unlikely. Individuals who believe they are
at low risk of developing an illness are more likely to engage in unhealthy, or risky,
behaviors. Individuals who perceive a high risk that they will be personally affected by a
particular health problem are more likely to engage in behaviors to decrease their risk of
developing the condition.
The combination of perceived severity and perceived susceptibility is referred to as perceived
threat. Perceived severity and perceived susceptibility to a given health condition depend on
knowledge about the condition. The health belief model predicts that higher perceived threat
leads to higher likelihood of engagement in health-promoting behaviors.
Perceived benefits
Health-related behaviors are also influenced by the perceived benefits of taking
action. Perceived benefits refer to an individual's assessment of the value or efficacy of
engaging in a health-promoting behavior to decrease risk of disease. If an individual believes
that a particular action will reduce susceptibility to a health problem or decrease its
seriousness, then he or she is likely to engage in that behavior regardless of objective facts
regarding the effectiveness of the action. For example, individuals who believe that wearing
sunscreen prevents skin cancer are more likely to wear sunscreen than individuals who
believe that wearing sunscreen will not prevent the occurrence of skin cancer.
Perceived barriers
Health-related behaviors are also a function of perceived barriers to taking action. Perceived
barriers refer to an individual's assessment of the obstacles to behavior change. Even if an
individual perceives a health condition as threatening and believes that a particular action will
effectively reduce the threat, barriers may prevent engagement in the health-promoting
behavior. In other words, the perceived benefits must outweigh the perceived barriers in order
for behavior change to occur. Perceived barriers to taking action include the perceived
inconvenience, expense, danger (e.g., side effects of a medical procedure) and discomfort
(e.g., pain, emotional upset) involved in engaging in the behavior. For instance, lack of access
to affordable health care and the perception that a flu vaccine shot will cause significant pain
may act as barriers to receiving the flu vaccine.
Modifying variables
Individual characteristics, including demographic, psychosocial, and structural variables, can
affect perceptions (i.e., perceived seriousness, susceptibility, benefits, and barriers) of health-
related behaviors. Demographic variables include age, sex, race, ethnicity, and education,
among others. Psychosocial variables include personality, social class, and peer and reference
group pressure, among others. Structural variables include knowledge about a given disease
and prior contact with the disease, among other factors. The health belief model suggests that
modifying variables affect health-related behaviors indirectly by affecting perceived
seriousness, susceptibility, benefits, and barriers.
Cues to action
The health belief model posits that a cue, or trigger, is necessary for prompting engagement
in health-promoting behaviors. Cues to action can be internal or external. Physiological cues
(e.g., pain, symptoms) are an example of internal cues to action. External cues include events
or information from close others, the media, or health care providers promoting engagement
in health-related behaviors. Examples of cues to action include a reminder postcard from a
dentist, the illness of a friend or family member, and product health warning labels. The
intensity of cues needed to prompt action varies between individuals by perceived
susceptibility, seriousness, benefits, and barriers. For example, individuals who believe they
are at high risk for a serious illness and who have an established relationship with a primary
care doctor may be easily persuaded to get screened for the illness after seeing a public
service announcement, whereas individuals who believe they are at low risk for the same
illness and also do not have reliable access to health care may require more intense external
cues in order to get screened.
Self-efficacy
Self-efficacy was added to the four components of the health belief model (i.e., perceived
susceptibility, severity, benefits, and barriers) in 1988. Self-efficacy refers to an individual's
perception of his or her competence to successfully perform a behavior. Self-efficacy was
added to the health belief model in an attempt to better explain individual differences in
health behaviors. The model was originally developed in order to explain engagement in one-
time health-related behaviors such as being screened for cancer or receiving an
immunization. Eventually, the health belief model was applied to more substantial, long-term
behavior change such as diet modification, exercise, and smoking. Developers of the model
recognized that confidence in one's ability to effect change in outcomes (i.e., self-efficacy)
was a key component of health behavior change.
 B. The stages of change model concern an individual's readiness to change, or to try to
change, unhealthful behaviors. Its basic premise is that behavior change is a process
and not an event, and that individuals are at varying levels of motivation, or readiness,
to change. This means that people at different points in the process of change can
benefit from different programs for change, and the programs work best if matched to
their stage of readiness. The Transtheoretical Model (also called the Stages of Change
Model), developed by Prochaska and DiClemente in the late 1970s, evolved through
studies examining the experiences of smokers who quit on their own with those
requiring further treatment to understand why some people were capable of quitting
on their own. It was determined that people quit smoking if they were ready to do so.
Thus, the Transtheoretical Model (TTM) focuses on the decision-making of the
individual and is a model of intentional change. The TTM operates on the assumption
that people do not change behaviors quickly and decisively. Rather, change in
behavior, especially habitual behavior, occurs continuously through a cyclical
process. The TTM is not a theory but a model; different behavioral theories and
constructs can be applied to various stages of the model where they may be most
effective.
The TTM posits that individuals move through six stages of change: precontemplation,
contemplation, preparation, action, maintenance, and termination.
Precontemplation - In this stage, people do not intend to take action in the foreseeable future
(defined as within the next 6 months). People are often unaware that their behavior is
problematic or produces negative consequences. People in this stage often underestimate the
pros of changing behavior and place too much emphasis on the cons of changing behavior.
Contemplation - In this stage, people are intending to start the healthy behavior in the
foreseeable future (defined as within the next 6 months). People recognize that their behavior
may be problematic, and a more thoughtful and practical consideration of the pros and cons
of changing the behavior takes place, with equal emphasis placed on both. Even with this
recognition, people may still feel ambivalent toward changing their behavior.
Preparation (Determination) - In this stage, people are ready to take action within the next
30 days. People start to take small steps toward the behavior change, and they believe
changing their behavior can lead to a healthier life.
Action - In this stage, people have recently changed their behavior (defined as within the last
6 months) and intend to keep moving forward with that behavior change. People may exhibit
this by modifying their problem behavior or acquiring new healthy behaviors.
Maintenance - In this stage, people have sustained their behavior change for a while (defined
as more than 6 months) and intend to maintain the behavior change going forward. People in
this stage work to prevent relapse to earlier stages.
Termination - In this stage, people have no desire to return to their unhealthy behaviors and
are sure they will not relapse. Since this is rarely reached, and people tend to stay in the
maintenance stage, this stage is often not considered in health promotion programs.
 C. Social cognitive theory (SCT) is very complex. From this theory's perspective,
people and their environments are thought to interact continuously. A basic premise
of social cognitive theory is that people learn not only through their experiences, but
also by watching the way other people act and the results they achieve. SCT also takes
the view that, while people are influenced by the world around them, they can also
actively change that world. SCT provides a foundation for several strategies for
behavior change, for example the use of role models who carry out a behavior and
achieve good results. Another way SCT applies to behavior change is by emphasizing
that individuals change their situations by changing their own behavior. This theory
describes the influence of individual experiences, the action of others and
environmental factors on individual health behaviors. SCT, provides opportunities for
social support through instilling expectations, self-efficacy and using observational
learning and other reinforcements to achieve behavioural change.

For eg : Healthy relationships, a programme implemented by CARE: a small group

intervention for people living with HIV/AIDS. The programme is based on the Social
Cognitive theory and uses skill- building exercises to increase independence and develop
healthy behaviours among participants.
D. Community organization articulates the process by which community groups
identify problems or goals, mobilize resources, and develop ways to reach their goals.
It includes several ways of bringing about change, including developing resources and
skills; getting specialized help from outside experts; and social action, which involves
people joining together for a cause, especially one that involves a particular group that
is being greatly affected by a particular problem. Examples of this are AIDS activists,
women's health activists working for more research on breast cancer prevention and
treatment, and youths developing coalitions to fight the tobacco companies' efforts to
attract customers among teenagers.
IMPLICATIONS FOR PUBLIC HEALTH AND WELL-BEING
Understanding and improving health-related behavior is critical to the future of public health
and to the well-being of individuals, and has become central to public health activities. While
policies, laws, and regulations can affect health behaviors, there are also many individual
factors that must be considered in these public health efforts.
Change is incremental. Many people have practiced a lifetime of less than optimal health
behaviors of one sort or another. It is unreasonable to expect that significant and lasting
changes will occur during a short period of time. Public health programs need to identify and
maximize the benefits of positive change, pull participants along the continuum of change,
and consider changes in educational programs and environmental supports to help people
maintain changes over the long term

Exercise:
What is exercise?
Aspects of exercise have been defined in different ways according to intention, outcome and
location.
1 Intention: Some researchers have differentiated between different types of behaviours in
terms of the individual’s intentions. For example, Caspersen et al. (1985) distinguished
between physical activity and exercise. Physical activity has been defined as ‘any bodily
movement produced by skeletal muscles which results in energy expenditure’. This
perspective emphasizes the physical and biological changes that happen both automatically
and through intention. Exercise has been defined as ‘planned, structured and repetitive bodily
movement done to improve or maintain one or more components of physical fitness’. This
perspective emphasizes the physical and biological changes that happen as a result of
intentional movements.
2 Outcome: Distinctions have also been made in terms of the outcome of the behaviour. For
example, Blair et al. (1992) differentiated between physical exercise that improves fitness and
physical exercise that improves health. This distinction illustrates a shift in emphasis from
intensive exercise resulting in cardiovascular fitness to moderate exercise resulting in mild
changes in health status. It also illustrates a shift towards using a definition of health that
includes both biological and psychological changes.
3 Location: Distinctions have also been made in terms of location. For example,
Paffenbarger and Hale (1975) differentiated between occupational activity, which was
performed as part of an individual’s daily work, and leisure activity, which was carried out in
the individual’s leisure time.
These definitions are not mutually exclusive and illustrate the different ways that exercise has
been conceptualized.
Who exercises?
The Healthy People 2000 programmes in the USA show that only 23 per cent of adults
engage in light to moderate physical activity five times per week and up to a third remain
completely sedentary across all industrialized countries (Allied Dunbar National Fitness
Survey 1992; United States National Center for Health Statistics 1996). The results of a
survey in 2003 in which men and women in the UK were asked about their exercise
behaviour over the past 12 months are shown in Figure 7.1. They suggest that the five most
common forms of exercise are walking (46 per cent), swimming (35 per cent), keep fit/yoga
(22 per cent), cycling (19 per cent) and snooker/pool/billiards (17 per cent). Overall, 75 per
cent of adults had taken part in some sport/game/physical activity in the past 12 months but
men were generally more likely to have done so than women and activity generally decreased
with age.
Why exercise?
Research has examined the possible physical and psychological benefits of exercise.
The physical benefits of exercise:
a. Longevity:
Paffenbarger et al. (1986) examined the relationship between weekly energy expenditure and
longevity for a group of 16,936 Harvard alumni aged 35 to 70. They reported the results from
a longitudinal study which suggested that individuals with a weekly energy expenditure of
more than 2000 kcals on exercise reported as walking, stair climbing and sports, lived for 2.5
years longer on average than those with an energy expenditure of less than 500 kcal per week
on these activities.
The possible reasons for the effects of exercise on longevity are as follows:
1 Reduction in blood pressure: physical activity has an inverse relationship to both diastolic
and systolic blood pressure. Therefore increased exercise decreases blood pressure. This
effect is particularly apparent in those who have mild or moderately raised blood pressure.
2 Reduction in weight and obesity: overweight and obesity are related to certain cancers,
hypertension and coronary heart disease. Exercise may help promote weight
loss/maintenance.
3 Reduction in diabetes: exercise may be related to improved glucose control, resulting in a
reduction in the possible effects of diabetes.
4 Protection against osteoporosis and thinning bones: exercise may be protective against
osteoporosis, which is common among older women.
5 Reduction in coronary heart disease: the main effect of exercise is on the occurrence of
coronary heart disease and rehabilitation following a heart attack.
b. Coronary heart disease: The effects of exercise on coronary heart disease have been
examined by assessing the consequences of both occupational activity and leisure activity.
Regarding occupational activity, Paffenbarger and Hale (1975) followed up 3975
longshoremen for 22 years. Longshoremen have occupations that involve a range of energy
expenditure. The results showed that at the end of this period, 11 per cent had died from
coronary heart disease and that those longshoremen who expended more than 8500 kcal per
week had a significantly lower risk of coronary heart disease than those in jobs requiring less
energy. This difference remained when other risk factors such as smoking and blood pressure
were controlled. This relationship between occupational activity and coronary heart disease
has also been shown in samples of both men and women (Salonen et al. 1982). Research has
also evaluated the relationship between leisure-time activity and coronary heart disease.
Morris et al. (1980) followed up a group of middle-aged sedentary office workers over 8.5
years and compared those who engaged in sport with those who reported no leisure-time
activity. The results showed that those who attempted to keep fit showed less than half the
incidence of coronary heart disease at follow-up compared with the other subjects. This
association has also been reported in students in the USA (Paffenbarger et al. 1978, 1983,
1986). Regardless of the location of the activity, research indicates an association between
physical fitness and health status. Blair (1993) has carried out much research in this area and
has argued that increases in fitness and physical activity can result in significant reductions in
the relative risk of disease and mortality (see also Blair et al. 1989, 1995, 1996). For example,
Blair et al. (1989) examined the role of generalized physical fitness and health status in
10,224 men and 3120 women for eight years and reported that physical fitness was related to
a decrease in both mortality rates (all cause) and coronary heart disease. Blair has also
explored the relationship between fatness and fitness. The data from one study are shown in
Figure 7.2. This study indicated that overweight men and women who showed low fitness
scores had a high risk of all-cause mortality. Those overweight individuals, however, who
showed either medium fitness scores or high fitness scores showed a substantial reduction in
this risk. Fitness was therefore protective against the effects of fatness.
Exercise may influence coronary heart disease in the following ways:
1) Increased muscular activity may protect the cardiovascular system by stimulating the
muscles that support the heart.
2) Increased exercise may increase the electrical activity of the heart.
3) Increased exercise may increase an individual’s resistance to ventricular fibrillation.
4) Exercise may be protective against other risk factors for coronary heart disease (e.g.
obesity, hypertension).
The physical benefits of exercise have been summarized by Smith and Jacobson (1989) as:
(1) improved cardiovascular function; (2) increased muscle size and strength and ligament
strength for maintaining posture, preventing joint instability and decreasing back pain; (3)
improved work effort; and (4) changing body composition.

The psychological benefits of exercise:

Research also indicates that exercise may improve psychological well-being. These effects
are outlined below.
Depression
Research using correlational designs suggests an association between the amount of exercise
carried out by an individual and their level of depression. Many of the reviews into this
association have stressed the correlational nature of the research and the inherent problems in
determining causality (e.g. Morgan and O’Connor 1988). However, McDonald and Hodgdon
(1991) carried out a meta-analysis of both the correlational and experimental research into the
association between depression and exercise. They concluded that aerobic exercise was
related to a decrease in depression and that this effect was greatest in those with higher levels
of initial depressive symptoms. In an attempt to clarify the problem of causality, McCann and
Holmes (1984) carried out an experimental study to evaluate the effect of manipulating
exercise levels on depression. Forty-three female students who scored higher than the cut-off
point on the Beck depression inventory (BDI) were randomly allocated to one of three
groups: (1) aerobic exercise group (one hour of exercise, twice a week for ten weeks); (2)
placebo group (relaxation); (3) no treatment. After five weeks, the results showed a
significant reduction in depressive symptomatology in the exercise group compared with the
other two subject groups, supporting the relationship between exercise and depression and
suggesting a causal link between these two variables, that is, increased exercise resulted in a
reduction in depression. However, the authors report that subsequent exercise had no further
effects. Hall et al. (2002) also used an experimental design to explore the relationship
between exercise and affect with 30 volunteers rating their affective state every minute as
they ran on a treadmill. The results showed improvements in affect from baseline to follow-
up which supports previous research suggesting that exercise is beneficial. However, the
results also showed a brief deterioration in mood mid-exercise. The authors suggest that
although prolonged exercise may improve mood, this dip in mood may explain why people
fail to adhere to exercise programmes.
Anxiety
Research has also indicated that exercise may be linked to a reduction in anxiety. Again,
there are problems with determining the direction of causality in this relationship, but it has
been suggested that exercise may decrease anxiety by diverting the individual’s attention
away from the source of anxiety.
Response to stress
Exercise has been presented as a mediating factor for the stress response .Exercise may
influence stress either by changing an individual’s appraisal of a potentially stressful event by
distraction or diversion (e.g. ‘This situation could be stressful but if I exercise I will not have
to think about it’) or may act as a potential coping strategy to be activated once an event has
been appraised as stressful (e.g. ‘Although the situation is stressful, I shall now exercise to
take my mind off things’).
Self-esteem and self-confidence
It has also been suggested that exercise may enhance an individual’s psychological well-
being by improving self-esteem and self-confidence. King et al. (1992) report that the
psychological consequences of exercise may be related to improved body satisfaction, which
may correlate to general self-esteem and confidence. In addition, exercise may result in an
improved sense of achievement and self-efficacy.
Exercise and smoking withdrawal
Many people experience withdrawal symptoms such as agitation, craving and the desire to
smoke, irritability and restlessness when they have stopped smoking, even for just a few
hours. Some research has explored the effectiveness of exercise at reducing withdrawal
symptoms following smoking cessation. For example, Ussher et al. (2001) explored the
impact of a 10-minute period of exercise of moderate intensity on withdrawal symptoms
caused by an overnight period of smoking cessation. The results showed that those who had
exercised reported a significant reduction in withdrawal symptoms while exercising which
lasted up to 15 mins post-exercise. In a similar vein Daniel et al. (2004) examined the impact
of either light intensity or moderate intensity exercise and reported that only moderate
intensity exercise reduced withdrawal symptoms. As a means to explore why exercise might
have this effect, Daniel et al. (2006) compared exercise with a cognitive distraction task to
see whether the benefits of exercise were due to exercise per se or just the process of doing
something to take one’s mind off smoking. The results showed that exercise was still more
effective when compared to the distraction task. In addition, this effect was not just due to the
impact of exercise on mood
How does exercise influence psychological well-being?
Many theories have been developed to explain the factors that mediate the link between
exercise and psychological state. These reflect both the physiological and psychological
approaches to the study of exercise. For example, it has been argued that exercise results in
the release of endorphins, the brain’s natural opioids (Steinberg and Sykes 1985), and
increases in the levels of brain norepinephrine, reductions of which can cause depression. It
has also been suggested that improved psychological state is related to the social activity
often associated with exercise and the resulting increased confidence and self-esteem. Any
reduction in levels of depression may be related to greater social contact, improved social
support and increased self-efficacy.

Nutrition:
Nutrition is the intake of food, considered in relation to the body’s dietary needs. Good
nutrition – an adequate, well balanced diet combined with regular physical activity – is a
cornerstone of good health. Poor nutrition can lead to reduced immunity, increased
susceptibility to disease, impaired physical and mental development, and reduced
productivity. Nowadays, there is, however, a consensus among nutritionists as to what
constitutes a healthy diet (DoH 1991a). Food can be considered in terms of its basic
constituents: carbohydrate, protein and fat. Descriptions of healthy eating tend to describe
food in terms of broader food groups and make recommendations as to the relative
consumption of each of these groups. Current recommendations are as follows:
■ Fruit and vegetables: A wide variety of fruit and vegetables should be eaten and preferably
five or more servings should be eaten per day.
■ Bread, pasta, other cereals and potatoes: Plenty of complex carbohydrate foods should be
eaten, preferably those high in fibre.
■ Meat, fish and alternatives: Moderate amounts of meat, fish and alternatives should be
eaten and it is recommended that the low-fat varieties are chosen.
■ Milk and dairy products: These should be eaten in moderation and the low-fat alternatives
should be chosen where possible.
■ Fatty and sugary foods: Food such as crisps, sweets and sugary drinks should be eaten
infrequently and in small amounts.
Other recommendations for a healthy diet include the consumption of fluoridated water where
possible, a limited salt intake of 6g per day, eating unsaturated fats from olive oil and oily
fish rather than saturated fats from butter and margarine, and consuming complex
carbohydrates (e.g. bread and pasta) rather than simple carbohydrates (e.g. sugar). It is also
recommended that men aged between 19 and 59 require 2550 calories per day and that
similarly aged women require 1920 calories per day although this depends upon body size
and degree of physical activity (DoH 1995).
How does diet affect health?
Diet is linked to health in two ways: by influencing the onset of illness and as part of
treatment and management once illness has been diagnosed.
Diet and illness onset: Diet affects health through an individual’s weight in terms of the
development of eating disorders or obesity. Eating disorders are linked to physical problems
such as heart irregularities, heart attacks, stunted growth, osteoporosis and reproduction.
Obesity is linked to diabetes, heart disease and some forms of cancer. In addition, some
research suggests a direct link between diet and illnesses such as heart disease, cancer and
diabetes. Much research has addressed the role of diet in health and, although at times
controversial, studies suggest that foods such as fruits and vegetables, oily fish and oat fibre
can be protective while salt and saturated fats can facilitate poor health.
Diet and treating illness: Diet also has a role to play in treating illness once diagnosed. Obese
patients are mainly managed through dietary-based interventions. Patients diagnosed with
angina, heart disease or following a heart attack are also recommended to change their
lifestyle with particular emphasis on stopping smoking, increasing their physical activity and
adopting a healthy diet. Dietary change is also central to the management of both Type 1 and
Type 2 diabetes. At times this aims to produce weight loss as a 10 per cent decrease in weight
has been shown to result in improved glucose metabolism (Blackburn and Kanders 1987;
Wing et al. 1987). Dietary interventions are also used to improve the self-management of
diabetes and aim to encourage diabetic patients to adhere to a healthier diet.

Hope:
Hope is an optimistic state of mind that is based on an expectation of positive outcomes with
respect to events and circumstances in one's life or the world at large. As a verb, its
definitions include: "expect with confidence" and "to cherish a desire with anticipation.
According to “Richard Snyder’: Hope is defined as “An individual’s perceptions regarding
one’s own ability to clearly conceptualize one’s goals, develop specific strategies to reach
them, initiate and sustain the activities in support of those strategies.”
Professor of Psychology Barbara Fredrickson argues that hope comes into its own when crisis
looms, opening us to new creative possibilities. Frederickson argues that with great need
comes an unusually wide range of ideas, as well as such positive emotions as happiness and
joy, courage, and empowerment, drawn from four different areas of one's self: from a
cognitive, psychological, social, or physical perspective. Hopeful people are "like the little
engine that could, [because] they keep telling themselves "I think I can, I think I can". Such
positive thinking bears fruit when based on a realistic sense of optimism, not on a naive "false
hope".
The psychologist Charles R. Snyder linked hope to the existence of a goal, combined with a
determined plan for reaching that goal: Alfred Adler had similarly argued for the centrality of
goal-seeking in human psychology, as too had philosophical anthropologists like Ernst Bloch.
Snyder also stressed the link between hope and mental willpower, as well as the need for
realistic perception of goals,] arguing that the difference between hope and optimism was that
the former included practical pathways to an improved future. D. W. Winnicott saw a child's
antisocial behavior as expressing an unconscious hope [. for management by the wider
society, when containment within the immediate family had failed.
Hope theory
As a specialist in positive psychology, Snyder studied how hope and forgiveness can impact
several aspects of life such as health, work, education, and personal meaning. He postulated
that there are three main things that make up hopeful thinking:
Goals – Approaching life in a goal-oriented way.
Pathways – Finding different ways to achieve your goals.
Agency – Believing that you can instigate change and achieve these goals.

In other words, hope was defined as the perceived capability to derive pathways to desired
goals and motivate oneself via agency thinking to use those pathways.
Snyder argues that individuals who are able to realize these three components and develop a
belief in their ability are hopeful people who can establish clear goals, imagine multiple
workable pathways toward those goals, and persevere, even when obstacles get in their way.
In healthcare
Major theories
Of the countless models that examine the importance of hope in an individual's life, there are
two major theories that have gained a significant amount of recognition in the field of
psychology. One of these theories, developed by Charles R. Snyder, argues that hope should
be viewed as a cognitive skill that demonstrates an individual's ability to maintain drive in the
pursuit of a particular goal. This model reasons that an individual's ability to be hopeful
depends on two types of thinking: agency thinking and pathway thinking. Agency thinking
refers to an individual's determination to achieve their goals despite possible obstacles, while
pathway thinking refers to the ways in which an individual believes they can achieve these
personal goals.
Snyder's theory uses hope as a mechanism that is most often seen in psychotherapy. In these
instances, the therapist helps their client overcome barriers that have prevented them from
achieving goals. The therapist would then help the client set realistic and relevant personal
goals (i.e. "I am going to find something I am passionate about and that makes me feel good
about myself"), and would help them remain hopeful of their ability to achieve these goals,
and suggest the correct pathways to do so.
Whereas Snyder's theory focuses on hope as a mechanism to overcome an individual's lack of
motivation to achieve goals, the other major theory developed by Kaye A. Herth deals more
specifically with an individual's future goals as they relate to coping with illnesses. Herth
views hope as "a motivational and cognitive attribute that is theoretically necessary to initiate
and sustain action toward goal attainment". Establishing realistic and attainable goals in this
situation is more difficult, as the individual most likely does not have direct control over the
future of their health. Instead, Herth suggests that the goals should be concerned with how the
individual is going to personally deal with the illness—"Instead of drinking to ease the pain
of my illness, I am going to surround myself with friends and family".
While the nature of the goals in Snyder's model differ with those in Herth's model, they both
view hope as a way to maintain personal motivation, which ultimately will result in a greater
sense of optimism.

Why is Hope Important?

•Hope plays a predictive role in academic and job performance.
•Hope mediates the relationship between socio-economic status and academic achievement
•For adolescents, hope has a positive impact on grade point average even with low socio-
economic status.
Higher levels of hope equate with:
• Seeing barriers as obstacles to be overcome
• Having the will to achieve one’s goals
• Finding pathways and strategies to get there
• Having more grit, perseverance, and a growth mindset.

Hope and Resilience

The concept of resilience, i.e. the ability to bounce back to healthy functioning after stressful
experiences, is closely connected with many notions addressed within the field of positive
psychology, namely subjective well-being, positive adaptation, effective coping in the face of
adversity, and healthy functioning (Cefai et al., 2015; Joseph, 2011; Joseph & Linley, 2008a;
Lemay & Ghazal, 2001; Masten, 2001; Seligman, 2011). The importance of retaining hope in
adverse circumstances was demonstrated by Frankl in his book Man’s Search for Meaning.
Hope is described as an essential factor that sustained the prisoners throughout their time in
the concentration camp (Frankl, 1992). According to Rutter (1993), coping strategies based
on hopeful thinking are important for resilience to psycho-social adversity. McCubbin et al.
(1997) list a realistic hope and positive outlook among family resilience factors. These act
protectively in adaptation to chronic stress, and also help in overcoming a crisis and restoring
family functioning (McCubbin et al., 1997; Slezackova & Sobotkova, 2017). Wu (2011)
investigated the protective effects of hope and resilience on the quality of life of the families
coping with criminal traumatisation of one of its members. The results showed that resilience
and hope significantly mitigated the impact of a post-traumatic stress disorder and depression
in the victims of criminal acts and in their family members. Higher hope levels also increased
the probability of receiving social support, which encouraged the people to nurture a positive
view of themselves and to maintain or re-create a hopeful attitude towards their goals.
Horton and Wallander (2001) studied the impact of hope and social support on resilience and
psychological distress in mothers of chronically ill children. The mothers with higher-quality
social connections and higher hope scores were found to show greater resilience in stressful
and mentally demanding situations.
Hope and Well-being
A lack of hope is an important indicator of a malfunction of some sort (Bernardo &
Estrellado, 2014). Previous studies (Bailey & Snyder, 2007; Ciarrochi et al., 2015) have
established a positive relationship between hope and subjective well-being. High-hopers tend
to be better at achieving their goals (including academic achievement, coping with stress,
sport) than low-hopers, which in turn has a positive impact on their well-being and self-
evaluation (Snyder, Rand, & Sigmon, 2002).
Kato and Snyder (2005) focused on the connection between hope and subjective well-being
when testing the reliability and validity of the Japanese version of the Dispositional Hope
Scale. Their results confirmed the hypothesised correlation between hope and well-being.
Hope was also negatively correlated with hopelessness, anxiety and depresssive tendencies.
In two studies by Bailey, Eng, Frisch, and Snyder (2007), hope and optimism served as
unique predictors of life satisfaction. The strongest unique predictor of life satisfaction was
the agency component of hope.

Strategies to Enhance Hope:

Hope is one of the most beautiful feelings available to us humans. Even when things are at
their worst, hope can always pull us through. It is the promise of better things to come –
whether rational or not. Having hope for the future is essential to being at your best on a daily
basis. We all go through tough times, and we all need feelings of hope deep within to keep
moving forward.
– Pamper Yourself. It is easy to lose track of hope when you are slogging through
unenjoyably hard days. Even if you are not happy with your routine (a job you hate, for
example), you can take time during the day to do something you enjoy. 10 minute breaks to
have a cup of your favorite coffee or read a great book will do wonders for your outlook, and
your hope for the future.
– Turn it off. Let’s be honest – the news can be downright depressing sometimes. If you are
always plugged in to the news via TV or mobile device, you can easily be drug down into a
hopeless frame of mind. Thankfully, there is an easy solution to this problem. Just turn it off.
Limit yourself to a set amount of time each day where you catch up on the news, and leave it
at that. To start, try 10 minutes in the morning and 10 minutes in the evening. That will be
enough to keep you ‘in the loop’, but not so much as to damage your attitude.

– Be Nice. Sometimes, the simple lessons we learn as kids are the most powerful even as
adults. Try going through your day being nice to everyone you come across. Say hello, thank
them for their help, or whatever else the situation calls for. You will soon find that people are
more than ready to return those niceties, making everyone’s day a little bit brighter. As this
attitude becomes your normal approach to life, you will find feelings of optimism and hope
naturally increase along the way.

– Pitch In. Hope often can be found in feeling good about the society around us. When we
feel kinship with our fellow humans, we can’t help but feel positive about the future. To tap
into those feelings, volunteer your time to help with a cause outside of yourself. There is
certainly countless organizations right within your own city that would love to have your
help. Choose one that calls to you in a personal way, and build time into your schedule to
help that cause in some way. You will be making your community a better place, and
building your own capacity to hope at the same time.
– Laugh. The act of laughter is great for many psychological processes, and hope is no
different. Seek out something that will give you a good laugh, whether it is a TV show or a
particularly funny friend. Make time for laughter each day and find your views on the future
suddenly looking better than they did before.

– Meditate. It is easy to spiral into negative thinking when you get caught up in the chaos that
is modern life. Take time to meditate and slow that spiral down until it is well under your
control. Meditation re-organizes your brain and allows it to function properly again. You will
be untangling the mess that the world around you has created and finding your way back to
your true self. During this process, you will see how much you are still capable of, and how
many reasons you have for hope.