Health Psych Notes Chapters 1,2,7

Health Psychology UCSSCPSY37 Spring 23’
Chapters 1, 2 and 7 (BOOK + LECTURE)

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Chapter 8 - Illness Cognitions
People’s belief about their illness influences how they behave → illness cognitions/beliefs/representations
What does it mean to be healthy?
● Beliefs about being ill exist in the context of beliefs about being healthy
● ‘Good health’ is a ‘state of complete physical, mental, and social well-being’ (WHO, 1947)
● Dimensions of ‘health’
○ Physiological/physical: i.e., good condition, to have energy.
○ Psychological: i.e., happy, energetic, feel good.
○ Behavioural: i.e., sleeping properly.
○ Future consequences: i.e., living longer.
○ The absence of illness: i.e., no sickness, disease, or symptoms.
What does it mean to be ill?

● Dimensions used to conceptualise illness:
○ Not feeling normal: i.e., ‘I don’t feel right’.
○ Specific symptoms: i.e., psychological/physiological.
○ Specific illnesses: i.e., cancer, cold, depression.
○ Consequences of illness: i.e., ‘I can’t do what I usually do’.
○ Timeline: i.e., how long the symptoms last.
○ The absence of health: i.e., not being healthy.
What are illness cognitions?

A patient’s own implicit common sense beliefs about their illness. Cognitions provide patients with a framework
for coping with and understanding their illness, and telling them what to look out for if they are becoming ill.
Five dimensions of illness cognitions/beliefs:
● Identity: label given to the illness and the symptoms experienced
● The perceived cause of the illness: may be biological or psychosocial. Can also reflect a variety of
causal models.
● Timeline: belief about how long illness will last; these can be acute (short term) or chronic (long term).
● Consequences: patient’s perceptions of the possible effects of the illness on their life. Can be physical,
emotional, or a combination of factors
● Curability and controllability: whether they believe their illness can be treated and cured, and the extent
to which the outcome of it is controllable by themselves or by powerful others.
Evidence
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Leventhal → (qualitative) interviews are the best method of accessing illness cognitions as it avoids priming
subjects and avoids subjects expected by the interviewer. However, interviews are time-consuming and can only
involve a limited number of subjects.
Lau et al., 1989 → (quantitative) card-sorting technique where piles of categories reflect dimensions.
Measuring Illness Cognitions
Questionnaires
● Measuring Illness Beliefs:
○ Illness Perception Questionnaire (IPQ) - rating statements about their illness. All five
dimensions are included.
○ IPQ-R - revised version includes additional subscales; cyclical timeline perceptions, illness
coherence and emotional representations.
○ Brief Illness Perception Questionnaire (B-IPQ) - brief version, uses single items, useful for
limited time (less time consuming) or when completing many different measures.
● Measuring Treatment Beliefs:
○ Beliefs about Medicine Questionnaire (BMQ) - four dimensions:
■ Specific to medication being taken
1. Specific necessity → is medicine taken seen as important
2. Specific concerns → is the individual worried about side effects
■ General beliefs about all medicines
3. General overuse → reflect doctor’s overuse of medicines
4. General harm → reflect damage that medicines can do
Measurement Issues
Self-Regulatory Model
Leventhal developed the SRM → based on approaches to problem-solving, suggesting illness/symptoms are
dealt with by individuals in the same way as other problems. Given a change in the status-quo, individuals are
motivated to solve the problem and re-establish their state of normality.
Three stages:
1. Interpretation → making sense of the problem
2. Coping → dealing with the problem
3. Appraisal → assessing how successful the coping stage has been
All stages continue to occur

until coping has been
successful and equilibrium is
attained.
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Why is it ‘self-regulatory’
All stages interrelate in an ongoing and dynamic fashion
1. Interpretation
Individuals are confronted with potential illness through two channels
A. Symptom perception → i.e., ‘I feel a pain in my chest’

Influenced by mood, cognitions, and social context, which can alleviate or aggravate the symptoms. They may
also create the symptoms in the first place.
Problem-solving theories state individuals are motivated to return to a ‘problem-free’ state. Cognitive
representations of the problem will give the problem meaning and will guide the coping strategies.
● Problem identification also results in changes to one’s emotional state, i.e., anxiety.
Internal/External Focus:
Focuses on variability in symptom perception between individuals. Some individuals are more
sensitive and focused on internal symptoms while others more externally sensitive and less sensitive to
internal changes.
● Internally sensitive people tend to relate to a perception of slower recovery from illness and
more health-protective behaviour.
● May result in a different perception of symptoms but not a more accurate one.
Demographics
Variability of symptom reporting by gender, time of day, day of week, and family group.
● Studies show symptoms are more likely to be reported in the morning and evenings rather than the
middle of the day. Less likely to be reported on weekend evenings than weekday evenings.
● Women reported more symptoms than men (during the day)
● Adolescents show an increase in symptoms in the evenings compared to their parents.
Attachment Style
Three attachment styles are considered: secure, anxious ambivalent, and avoidant.
● Secure attachment styles report fewer somatic symptoms as compared to the others.
● Mediating factors: higher levels of symptoms may only relate to less secure attachment in those with
negative affect, lower social support or higher levels of suppressed anger.
Mood, Cognition, and Social Context
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Anxiety shows increasing self-reports of pain experience.

Mood
Anxiety proposed as placebo for pain reduction → increases the individual’s sense of control.
Higher trait negative affect is related to higher reports of all symptoms specific to asthma.
Cognition
Association between cognitive state, symptom perception, and attention. Also related to
attentional state; boredom + absence of environmental stimuli can result in over-reporting,
whereas distraction and attention diversion can lead to under-reporting.
Social Context
Symptom severity perception and diagnosis differs across cultural backgrounds.
B. Social messages → i.e.,‘doctor has diagnosed the pain as angina’

● Formal diagnosis may occur after or before symptoms are perceived.
● Information may come from non-health professionals; people often access their social network (for
advice and information seeking) before professional consultation → ‘lay referral system’.
○ May result in lay remedy or a referral to professional help.
● Language used by the doctor is important: calling the problem by its lay term or medical term.
○ Lay terms made patients feel more ownership
○ Medical terms resulted in more professionality over their illness and greater confidence in
doctors. Manipulating the name of the problem results in shifts in people’s beliefs about the
illness.
2. Coping
Two broad categories:
● Approach coping (e.g., taking medication, doctor visits, resting, talking about emotional change)
● Avoidance coping (e.g., denial, wishful thinking).
A. Coping with the crisis of an illness
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Crisis theory: examines the impact of any form of disruption on an individual’s established personal
and social identity. Within this framework, crisis is self-limiting as individuals find a way of returning
to equilibrium → self-regulation.
● Physical illness as a crisis: represents a turning point in one’s life. Causes the following
changes/crises:
○ Change in identity: from carer → patient, breadwinner → person with illness.
○ Change in location: being hospitalised
○ Change in role: independent → passive dependent.
○ Change in social support: isolation from family and friends
○ Change in future: children, career, travel → uncertain
● Crisis nature can be exacerbated by other illness-specific factors
○ Unpredicted: illness not expected, no prior consideration of coping strategies.
○ Information is unclear: ambiguity and unclear causality or outcome.
○ Need for decision making: quick decisions often needed to be made.
○ Ambiguous meaning: ‘is it serious? How long will I be affected?’
○ Limited prior experience: individuals are healthy most of the time.
The Coping Process

1. Cognitive Appraisal
Appraising the seriousness and significance of the illness; knowledge, past experience, and social support
influence the appraisal process. Illness cognitions are related to how the illness is appraised.
2. Adaptive Tasks
Seven adaptive tasks used to cope:
Illness Related General Tasks
Dealing with pain/symptoms Preserving emotional balance
Dealing with hospital environment + treatment Preserving self-image, competence, and mastery
Developing + maintaining relationship with Sustaining social relationships

health professionals
Preparing for an uncertain future
3. Coping Skills
Appraisal focused Problem focused Emotion Focused
Logical analysis and mental Seeking information and support Affective regulation
preparation
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Cognitive redefinition Taking problem-solving action Emotional discharge
Cognitive avoidance or denial Identifying rewards Resigned acceptance
Appraisal
Individuals evaluate effectiveness of the coping strategy to determine whether it should be continued or
changed.
Implications for the Outcome of the Coping Process

Motivation to re-establish equilibrium - This desire can be satisfied by either short-term or long-term solutions.
● Crisis theory differentiates between two types of new equilibrium: healthy adaptation, which can result
in maturation, and a maladaptive response resulting in deterioration.
● In this perspective, healthy adaptation involves reality orientation, adaptive tasks and constructive
coping skills.
● According to this model of coping, the desired outcome of the coping process is reality orientation.
B. Adjustment to Physical Illness and the Theory of Cognitive Adaptation

Theory of cognitive adaptation:
● Search for meaning: can be understood as a search for causality and to understand the implications.
○ Attribution theory suggests people need to understand, predict, and control their environment.
○ The search for any cause is more important
● Search for mastery
○ Can be achieved by a sense that the illness is controllable. This is central to a state of
cognitive adaptation.
○ It is achieved through:
■ Psychological techniques; positive attitude, meditation, self-hypnosis, causal
attribution.
■ Behavioural techniques: changing diet, changing medications, accessing
information/controlling side-effects.
● Process of self-enhancement
○ Illness can lead to a decrease in self-esteem. Self-enhancement is the process by which
self-esteem is built up again.
○ Individuals make sense of the world by comparing themselves with others.
■ Downward comparisons: comparing to others who are worse off → ‘at least i’ve only
had cancer once’
■ Upward comparisons: comparing to others who are better off
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The Role of Illusions

The search for meaning, development of mastery and self-esteem involves developing illusions. They do not
necessarily have to contradict reality but involve positive representations of that reality.
● It is argued illusions are necessary and essential to cognitive adaptation and that reality orientation may
be detrimental to adjustment.
● The notion of illusions is similar to benefit-finding.
Evidence for CAT

● Has been found to improve illness progression in people with HIV/AIDS.
Implications for the Outcome of the Coping Process

● According to this model of coping, individuals cope with their illness by achieving cognitive
adaptation. Involves searching for meaning, achieving mastery, and developing self-esteem.
● These beliefs may not be accurate but are essential to maintaining the illusions that promote adjustment
to the illness. Not reality orientation.
C. Post-Traumatic Growth and Benefit-Finding
Theories of coping emphasise desire to re-establish equilibrium. Effective coping → return to normality after
illness.
● Positive consequences of traumatic events have been explored in terms of the experience of
positive-growth.
The experience of positive growth
Five main areas of growth: perceived changes in the self; closer family relationships; changed philosophy in
life; a better perspective in life; a strengthened belief system.
● Traumas can be conceptualised as external (natural disasters, bereavement…) or internal (physical
illness or injury). Different types of traumas result in different experiences.
The correlates of positive growth
● Post-traumatic growth has been associated with decreases in distress and depression and increases in
social support, optimism, positive reappraisal, spirituality, and religious coping.
● Illness cognitions relating to coherence, treatment control, personal control, and attribution to
carelessness were positively associated with PTG.
● Illness cognitions associated with timeline, consequence, identity, attribution to God’s punishment/will,
and attribution to chance/luck were negatively associated with PTG.
Predicting post-traumatic growth
Factors that predict positive growth after trauma:
● The degree of post-traumatic growth relates to symptom severity, time elapsed since the event, age,
gender, social support and a clear cause to the event.
● Available support for recovery and the +ve and -ve responses of others.
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● Spirituality and financial stability.

● Benefit-finding is associated with greater optimism, high intrusive thinking and high social support.
The Role of PTG and Health Outcomes
● Has been found to be protective against certain illnesses.
● Realistic statements were related to higher chance of death at follow-up, i.e., ‘I tried to accept what has
happened’.
Implications for the outcome of the Coping process
Post-traumatic growth and benefit-finding perspectives illustrate how at times individuals end up in a better
place than they were before the event. It is coped with in such a way that individuals find positives in the event
and incorporate those into a more fruitful future (this was cringe to type).
3. Appraisal
Individuals evaluate the effectiveness of the coping strategy and determine whether to continue with it or find an
alternative.
Predicting and Changing Health Outcomes
How Do Illness Cognitions Relate to Coping?

When exploring the link between illness cognitions, coping cognitions, and coping behaviours, they found that
illness cognitions predicted both aspects of coping.
● Perception of control over illness and problem-focused coping (neuro epilepsy)
○ Positive personal models → greater control, shorter timeline, less consequences.
○ Searle et al (2007); Important to explore not just coping cognitions but coping behaviours
(what people acc do)
● The link between illness cognitions and coping behaviours was direct and not mediated through coping
cognitions.
● If we want to change people’s behaviour, it is better to try and change their illness cognitions rather
than their coping cognitions.
○ Strong illness identity is associated with the use of avoidant coping strategies
Predicting Adherence to Treatment
● Symptom perception is directly linked to adherence to medication.
○ Asthma study: acute asthma beliefs (not chronic) were less likely to take their medication.
○ Belief that the illness has serious consequences was related to medication adherence.
● Treatment non-adherent individuals report more doubts about the necessity of the medication they are
taking, as well as greater concerns about the consequence of the medication + more negative beliefs
about the consequences of their illness.
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○ Illness treatment beliefs were better predictors of adherence than demographic or clinical
factors.
Predicting Illness Outcomes
Studies also investigate the link between illness cognitions and physical health conditions → beliefs about
illness and emotional representations were consistently most associated with outcomes like depression, anxiety,
and quality of life.
● Stroke study → perceptions of control at baseline added to the variance accounted for by both clinical
and demographic variables.
○ Individuals who received workshop intervention showed better disability recovery than the
control group.
○ Control cognitions may relate to recovery from stroke. Intervention to try and change those
cognitions seems to improve recovery.
● MI study → illness cognitions relate to the recovery from MI.
○ Patients who believed their illness had less serious consequences + would last a shorter time
(at baseline) were more likely to have returned to work by 6 weeks.
○ Those with beliefs that illness could be controlled or cured at baseline predicted attendance at
rehabilitation classes.
○ Couples who had similar positive beliefs about identity + consequences of their illness →
improved psychological recovery, physical functioning, sexual functioning, and less impact of
MI on social + recreational life.
■ Similar beliefs about timeline were related to lower levels of disability and similar
cure/control beliefs were associated with greater dietary changes.
■ Drawing exercise: increases in heart size from baseline → 3 months showed slower
return to work, activity restriction, and anxiety about MI.
■ Increases in the size of heart may reflect the extent to which their heart condition
plays on their mind.
The Central Role of Coherence

Illness beliefs and their relationship to outcome → coherent model whereby beliefs about causes of the illness
are consistent with beliefs about treatment. Role of coherence:
● I.e → If I believe that breathlessness is caused by smoking, then I am more likely to decide to stop
smoking. / I.e → If I believe that asthma symptoms are caused by bronchial constriction, then I am
more likely to adhere to my bronchial dilation medication.
● Obese individuals who believe their obesity is a hormonal problem are less likely to adhere to a stricter
diet as advised to.
Adherence is more likely to occur when illness beliefs and treatment beliefs are coherent with each other. Can
we change beliefs to be in line with each other?
● For example, providing a leaflet with information about association can change intentions by providing
a coherent model of association. It was found to be useful.
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● Changing beliefs in smokers towards a more medical cause (genetics → use of craving reducing
medication) meant that smokers are less able to change their behaviour on their own and more on
medical support.
○ Shows that coherence is important but changing beliefs may not always be beneficial to
changes in behaviour.
Interventions to Change Illness Cognitions

People make sense of their illness → form illness cognitions → health outcomes.
Changing cognitions has been practised through interventions such as face to face consultations or through
providing visual information.
Face-to-face
● Petrie et al., 2002 → three-session intervention designed for MI patients
● Change beliefs about conditions and their health outcomes
● Patients who received intervention reported more positive views about their MI in a number of
dimensions. Appears to change cognitions and improve patient’s functional outcome after MI.
○ Found evidence for importance of social support
Imagery-Based Interventions
Visual images may be effective as a means to raise awareness about the risks of behaviours (smoking, tanning)
● Images on cigarette packaging effectively drew attention to health warnings.
● Effective in reducing the intention to stop smoking.
● Tanning image experiment → personalised photo of one’s own skin was related to stronger intentions
to use sun-screen in the future.
For medication adherence/understanding → visual representation of the medication working was associated
with a more coherent understanding of their medication and greater belief in the medications ability to cure the
disease.
● Imagery has an immediate impact on illness cognitions, worry, behavioural intentions and mental
imagery relating to heart disease.
● Increased healthy diet efforts after two weeks.
● Combination of images and text are most effective in changing cognitions and behaviour.
Not always positive:
● Showing patients screens during check-ups (hysteroscopy) can lower perceptions about effectiveness of
treatment as well as raise anxiety + more negative descriptions of pain + perception that a health
professional is less receptive.
Image Superiority Theory: images not only imprint on memory better than verbal messages but also generate
changes in mood which make it more likely to become a cue to action and possibly change in behaviour.
● May also be better at changing implicit rather than explicit attitudes → may change behaviour.
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Chapter 4 - Eating Behaviours
Chapter contents: what constitutes a healthy diet, links between diet and health, who eats healthy + who doesn’t.
Psychological models of eating behaviour.
Health psychology’s take on eating: eating behaviour is far more than a response to biology, and there are many
factors influencing how we eat; modelling, reinforcement, associative learning…
What Is a Healthy Diet?
● Fruit and vegetables: wide variety should be eaten, preferably five or more servings every day.
● Bread, pasta, and other cereals and potatoes: plenty of complex carbs should be eaten, preferably those
high in protein.
● Meat, fish, and alternatives: moderate amounts should be eaten, preferably low-fat varieties. Ideally
two portions of fish each week, one of which should be oily.
● Milk and dairy products: eaten in moderation and low-fat alternatives chosen when possible.
● Fatty and sugary foods: crisps, sweets, sugary drinks only eaten infrequently and in small amounts.
Low sugar options chosen when possible.
Other recommendations are beans, pulses, less red or processed meat, and limited juices and smoothies. Women
should intake 2,000 kcal and men 2,500 kcal a day. A moderate intake of alcohol is recommended. Fluoridated
water consumed when possible, limited salt intake, and unsaturated fats like olive oil and fish are preferred over
butter and margarine. Simple carbs are preferred over complex carbs.
The Impact of Diet on Health

Diet is linked to health by influencing the onset of illness and as part of treatment once diagnosis occurs.
Diet and Illness Onset

Affects health through weight. Fruits and vegetables + oily fish and fibre can be protective, while salt and
unsaturated fats can facilitate poor health.
● Obesity
○ Diabetes, heart disease, and some forms of cancer.
● Eating disorders
○ Heart irregularities, heart attacks, stunted growth, osteoporosis, reproduction.
Diet and Treating Illness (ONCE DIAGNOSED)

Plays a role in treating illness once diagnosed:
● Obese patients are mainly managed through dietary-based interventions.
● Angina, heart disease, or heart attack patients are recommended to stop smoking, increase their
physical activity and adopt a healthy diet.
● Central to managing type 1 and type 2 diabetes.
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Who Eats a Healthy Diet?

Diets of children, adults, and the elderly.
Children
● Western diets for children do not match recommendations for healthy diets; fat over fruit and veg.
● Majority of developing world suffers from undereating, which results in physical and cognitive
problems and poor resistance to illness → lowered intakes of energy and micronutrients
○ 54% of childhood mortality is caused by malnutrition.
Adults
● Low prevalence of healthy eating practices among young adults.
● Gender differences→ women reported more healthy eating than men.
Elderly
● Often eat foods deficient in vitamins, too low in energy, and poor nutrient content.
A lot of research has explored why

people eat what they do: cognition
models, developmental and weight
concern models.
A Cognitive Model of Eating Behaviour

Focuses on the individual’s cognitions → to what extent cognitions predict and explain behaviour. Most
cognitive models have drawn upon social cognition models like TRA and TPB.
Using Social Cognition Models
Explore the role of specific cognitions in predicting intentions to consume specific foods. Examples:
○ Behavioural intentions not good predictors of behaviour: intention-behaviour gap explored.
○ Studies used TPB and TRA to understand cognitive predictors of actual behaviours.
● Attitude found to be a better predictor than subjective norms → best predictor of intentions →
intentions best predictor of actual behaviour.
○ Social norms components of models consistently fail to predict eating behaviour.
● Importance of past behaviour and habit in predicting food eating behaviours.
● Interventions to change and improve diet using cognitive perspective:
○ Interventions can change dietary behaviour in the short-term → do not persist in the long-term
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Broader Impact of Cognition

● Role for distraction: i.e → watching TV increases food intake in both current and subsequent meals.
○ Impact persists even when participants have comparable levels of hunger → estimates of food
intake are less accurate when eating and being distracted.
● Applicable to other forms of distractors like listening to music, a story, using the computer, engaging in
word counting tasks, eating on the go, and social interaction.
Distraction may interrupt the link between food intake and subsequent reduction in desire to eat.
● Role of memory; distraction interrupts episodic memory formation and prevents encoding of a meal.
○ Supported: when food intake amount is made salient (i.e., leaving food wrappers out) there is
a decrease in food intake.
○ Reminding participants of recent meals makes memory appear more recent → suppresses
subsequent food intake.
○ Lacking a memory of meals or impaired memory such as amnesia increases food intake.
Food environment can trigger overeating → makes it hard to monitor consumption
● Many factors influence overeating, as well as perceived notions of a ‘normal meal’. Research also finds
people deny that the environment has an impact on their food intake → ‘mindless eating’.
○ Mindful eating = when people are encouraged to self monitor and process what they eat.m
● Role for language on food intake → food labels.
○ People consume more when food is described as containing ‘healthy’ ingredients compared to
‘unhealthy’ ingredients.
Eating behaviour is influenced by cognitions, as well as a highlighted role for distraction, memory, and
language.
A Developmental Model of Eating Behaviour

Emphasises the importance of learning and experience → development of food preferences as a child.
Theory of ‘the wisdom of the body’ → body’s innate food preferences, concludes that children have an innate
regulatory mechanism and are able to select a healthy diet.
● Could only do so if healthy food was available to them, however preferences change over time and
were modified by experience.
● Important role of learning: development of food preferences can be understood in terms of exposure,
social learning, and associative learning.
Exposure
Neophobia → fear and avoidance of novel foodstuffs → ‘Omnivore’s paradox’
● Greater in males than females, appears to run in families, to be minimal in infants.
● AKA ‘picky eater’ → can be measured using a questionnaire.
Young children show neophobic responses to food but must accept and eat them although they originally may
appear as threatening.
● Exposure can change children’s preferences → direct relationship, minimum of 8-10 exposures
necessary before preferences shifted significantly.
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○ Impact of exposure to new foods is accumulative

○ Children can identify and are willing to taste vegetables if their parents buy them.
● Simple exposure can change intake and preference
Why does exposure work?
● Learned safety view → preference increases because eating the foods has not resulted in any negative
consequences. Neophobia also reduces with age.
Social Learning
Impact of observing other people’s behaviours on one’s own behaviour; aka ‘modelling’ or ‘observational
learning’.
Peers
Modelling study conducted on children observing models engaging in eating behaviours different to theirs:
● Greater change in child’s food preference if the model was an older child, a friend, or a fictional hero.
● Unknown adult = no impact on food preferences.
Modelling study on changing children’s preferences for vegetables:
● Shift in their vegetable preference persisting through follow-up assessment.
Other findings:
● Consumption was greatest in those who sat with siblings
● Overweight girls ate more sitting next to another overweight girl vs normal weight.
Impact of social learning using video-based peer modelling:
● Food preferences change through watching others eat.
Parents
Adolescents are more likely to eat breakfast if their parents do; emotional eating is concordant as well.
● Parental behaviours and attitudes are central to the process of social learning → positive association
between parent’s and children’s diets.
● Evidence that children and mothers are not always in line with each other
○ Mother’s rated health as more important for their children than for themselves
○ Found that mothers who restrain their own food intake may feed their children more of the
foods they are denying themselves.
Parental behaviours and attitudes may influence those of their children through the mechanisms of social
learning.
● Association may not always be straightforward
The Media
Unhealthy foods are given twice as much airtime as healthy foods. Role of social learning is also shown by the
impact of TV and food advertisements.
● Obese children recognised more of the food adverts than the other children. Degree of recognition
correlated with the amount of food consumed.
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● Children ate more food after exposure to the food adverts rather than non-food adverts.
Social learning factors are central to choices about food → food intake is largely determined by social influence,
particularly modelling. Modelling includes peers, parents and the media.
Associative Learning
Impact of contingent factors on behaviour. Food can be paired with specific places, times of day, people, and
other foods/drinks which can change what and when people eat.
● Contingent factors can be considered reinforcers in line with operant conditioning.
● Food has been paired with a reward, used as the reward, and paired with physiological consequences.
● Relationship between control and food.
Reward Eating Behaviour

‘If you eat your vegetables I will be pleased with you’ → giving children food in association with positive adult
attention.
● Increases food preference
● Rewarding vegetable consumption increases that behaviour.
● Rewarding food can encourage healthy eating either by positively reinforcing healthy foods or
negatively reinforcing unhealthy ones.
Food as the Reward
‘If you behave well, you will get a biscuit’ → food acceptance increased if the foods were presented as a
reward, neutral conditions had no effect. Using food as a reward increases the preference for that food.
● ‘if you eat your veggies you will get a chocolate’ → although this practice can induce children to eat
more vegetables in the short run, in the long run parental control attempts may have a negative effect
on the quality of the children’s diets by reducing their preference for those foods.
Food and Control
Associations between food and rewards highlight a role for parental control over eating behaviour.
● Studies indicate that parents often believe that restricting access to food or prohibiting children to eat
food are good strategies to improve food preferences → actually makes restricted food more attractive.
● Controlling the child’s environment in terms of what food is brought to the house or which restaurants
they eat at can encourage healthy eating without having the rebound effect of more obvious forms of
control to overeat/eat unhealthy foods.
● It also may well be that increased parental control causes the child to overeat. But it may also be that
parents use more parental control because their child already overeats.
Food and Physiological Consequences

Association between food cues and physiological responses to food intake.
E.g. food aversion to foods that have caused negative physiological responses (upset stomach). Additionally
children adjust their food intake according to the flavour of foods if certain flavours have been consistently
paired with a given caloric density.
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A Weight Concern Model of Eating Behaviour

The Meaning of Food and Weight
So far:
● Cognitive (attitudes and beliefs) and developmental (learning and association) models of eating
behaviour. Also associated with treats, celebration, family, etc…
● Once eaten, it can change weight and shape of the body, which is also associated with attractiveness,
control, and success.
● Women in particular show weight concern in the form of body dissatisfaction → dieting, which
changes eating behaviour.
Body Dissatisfaction
Many forms
Distorted Body Size Estimation
The perception that the body is larger than it really is. Measured by asking people to estimate people to adjust
the distance between two beams which match the width of different parts of their body.
● Consistently shows that clinically diagnosed eating disorder patients show greater perceptual distortion
than non-clinical subjects.
● Also shows that the vast majority of women (with or without an eating disorder) think they are fatter
than they actually are.
Discrepancy between Ideal versus Perceived Reality
A discrepancy between perceptions of reality versus those of an ideal → most girls and women would like to be
thinner than they are and most males would like to be either the same or larger.
Negative Feelings about the Body
Final and most frequent way in which body dissatisfaction is understood is simply in terms of negative feelings
and cognitions towards the body.
● Questionnaires such as → Body Shape Questionnaire, Body Areas Dissatisfaction Scale, and Eating
Disorders Inventory subscale.
Causes of Body Dissatisfaction
Media
Common source of body dissatisfaction → response to representations of thin women in media. Women used by
the media are generally thin, and therefore create the idea that thinness is not only the desired norm but also the
norm.
● Social comparison theory: upward social comparisons occur when an individual compares themselves
to someone perceived to be socially better than them. If a discrepancy exists between individual and
idealised figure, a motivation arises to make personal alterations in order to progress towards the
comparison standard.
● Not all body dissatisfaction is a result of media: internalisation.
○ Body dissatisfaction may be exacerbated by media images if a woman internalises these ideals
and makes favourable upward comparisons to such images.
The Family
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Role of the mother in daughter relationship in body dissatisfaction → mothers of girls with anorexia show
greater body dissatisfaction than mothers of non-disordered girls.
● However this theory holds many inconsistent results and inconclusive findings.
Dieting and Restraint Theory

● Most common consequences of body dissatisfaction are dieting and attempts to change body size by
eating less → dieters show both overeating and undereating:
Causes of Overeating
Attempts to eat less result in episodes of overeating. Some possible causes:
● Giving in: overeating can be triggered by ‘motivational collapse’, cognitive shift towards ‘giving in’.
● Rebellion: challenging and defiant cognitions which lead to ‘not caring’, and overeating.
● Mood modification: overeating enables masking of negative mood with temporarily heightened mood
by overeating. Aka → masking hypothesis, explains overeating when feeling ‘miserable’.
● Denial: thought suppression can have paradoxical effects, making suppressed thoughts more salient.
Aka → theory of ironic processes of mental control. I.e., don’t think about eating that pizza → *thinks
about pizza more*.
● Relapse: ‘what the hell’ effect is characterised by disinhibition in response to distress, intoxication, or
preloading. Similar to Abstinence Violation Effect (AVE).
● Self-licensing: ‘letting yourself off’ to indulge in moments of lowered self-control. Fine line between
effective self-compassion and self-licensing.
● Triggers: high calorie preloads, anxiety, smoking abstinence.
Dieting is related to weight variability, developing eating disorders, onset and progression of obesity.
Role of Control: from dieting to overeating
Dieting and Weight Loss

The Dark Side of Dieting: Minnesota Starvation Experiment (Keys et al., 1950)
● Classic study on restricting average food intake in half for 12 weeks in objection to the Korean War.
○ 3 months: normal eating (3500 calories)
○ 6 months: semi-starvation (1570 calories) → loss of 25% of their weight
○ 3 months: controlled rehabilitation
○ 2 months: unrestricted rehabilitation for part of the group
● Resulted in: preoccupation with food, hoarding food, stealing food, inability to concentrate, mood
changes, depression and apathy, after dieting period: loss of control, eating continuously, binge eating.
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Chapter 5 - Exercise
Defined as:
Intention: the physical and biological changes that happen as a result of intentional movements, occur
automatically and through intention.
Outcome: can be defined in terms of exercise outcome; exercise that improves fitness and exercise that
improves health.
NOTES FOR FINAL:
Chapter 10 - Stress
Stress: contemporary definitions regard stress from the external environment as a stressor (problems at work),
the response to the stressor as stress or distress (e.g. feeling tension), and the concept of stress as something that
involves biochemical, physiological, behavioural and psychological changes.
Stress → a transaction between people and the environment- described in terms of ‘person-environment fit’.
Distress → harmful and damaging stress
Eustress → positive and beneficial stress
Acute stress → exam, giving a public talk, etc…
Chronic stress → job stress, poverty, etc…
Good person-environment fit → low stress

Bad person-environment fit → high stress
Early Stress Models

● Cannon’s Fight-or-Flight Model
○ Earliest model of stress → biomedical model approach to stress
○ External threats elicit a fight or flight response involving increased activity rate and increased
arousal.
○ Enable individuals to escape from the source of stress or fight it → adaptive response.
○ Prolonged → medical issues
○ Stress is defined in response to external stressors, predominantly physiological.
● Seyle’s general Adaptation Syndrome (GAS)
○ Three stages in the stress process: alarm, resistance, exhaustion.
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○ Alarm: increased activity, occurs upon exposure.

○ Resistance: coping + attempts to reverse effects of alarm stage
○ Exhaustion: repeatedly exposed to stressor = incapable of showing further resistance
● Issues with Cannon and Selye Models:

○ Describes stress within a straightforward stimulus-response framework.
○ Did not address individual variability and psychological factors are given minimal role.
○ Both describe the physiological response to stress as consistent
● Life Events Theory
○ Examines stress and stress-related changes as a response to life experiences.
○ Schedule of Recent Experiences (SRE) → provides respondents with an extensive list of
possible life changes or events.
■ Both negative to positive life events
○ Weighting system to account for severity of event
○ Health-related (negative?) life events strongly predictive of mortality (e.g. period in hospital)
● Issues with LET
○ Individual’s own rating of the event is important → experiences should not be seen as
objectively stressful or benign (i.e., divorce)
○ The problem of retrospective assessment → an individual's present state of mind will
influence their recollection of that event that occurred in the past.
○ Life experiences may interact with each other → experiences in the checklist are often
regarded as independent of each other, however this is not always the case. One event may
counter the effect of another and cancel out any negative stressful consequences.
○ Stressors may be short term or ongoing → does not take into account ongoing chronic
stressors.
Transactional Model of Stress

Lazarus and Folkman (1984) → the most commonly used model of stress is the TMS which emphasises the key
role of appraisal.
The Role of Appraisal
● Stress involves a transaction between the individual and their external world: individual interacts with
world
● Lazarus defined individuals as psychological beings who appraised the outside world rather than
simply responding to it passively. There are two forms of appraisal
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○ Primary appraisal: individual initially appraises the event itself

1. Irrelevant
2. Benign and positive
3. Harmful and a threat
4. Harmful and a challenge
○ Secondary appraisal: individual evaluates the pros and cons of their different coping strategies
(“Can I cope with this?”)
● Primary appraisal involves appraisal of the outside world and secondary appraisal involves appraisal of
the individual themselves.
○ Form of primary and secondary appraisals determine whether the individual will show a stress
response or not.
○ The stress response can take different forms:
1. Direct action
2. Seeking information
3. Doing nothing
4. Developing a means of coping with the stress in terms of relaxation of defence
mechanisms
Does Appraisal Influence the Stress Response

Appraisal is related to the stress response.
● Sometimes it is not the events themselves that elicit stress, but the individual’s interpretation or
appraisal of those events.
● Stress response needs a degree of awareness of the stressful situation.
However, appraisal may not always be necessary.
● Could either be that appraisal is not always necessary or that the individuals themselves do not
acknowledge their level of subjective stress.
○ Repressors → a group of individuals who use selective inattention and forgetting to avoid
stressful information.
○ Such people show incongruence between their physiological state and their level of reported
anxiety. (Saying ‘I am fine’ while their body is in a state of arousal).
Which Events are Appraised as Stressful?
An event needs to be praised as stressful before it can elicit a stress response. The nature of the event is
irrelevant- it is all down to the individual’s own perception.
● However, some types of events are more likely to result in a stress response than others.
○ Salient events → stressors in salient domains in life are more stressful than those in more
peripheral domains. (i.e., a person who regards work more importantly than family- work =
salient domain, family = peripheral domain).
○ Overload → multitasking seems to result in more stress than the chance to focus on fewer
tasks at once. A single stressor which adds to a background of other stressors will be appraised
as more stressful than when it occurs in isolation.
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○ Ambiguous events → clearly defined events help efficiently develop a coping strategy.
Ambiguous events require the person spending more time and energy considering which
coping strategy to use.
○ Uncontrollable events → if a stressor can be predicted and controlled, it is usually appraised
as less stressful than a more random and uncontrollable event.
Stress and Changes in Physiology and Behaviour

Changes in Physiology
● Stressor causes
○ Sympathetic activation: release of adrenaline and noradrenaline
■ Changes in: heart rate, blood pressure, sweating, pupil dilation, immune function.
■ The experience of the feeling of arousal
○ Hypothalamic-pituitary-adrenocortical activation: release of cortisol
■ Changes in: management of carbohydrate stores, inflammation, immune function.
■ Constitute the background effect of stress which cannot be detected by the individual.
Changes in Behaviour
● Smoking
○ Link between stress and smoking behaviour in terms of smoking initiation, relapse and the
amount smoked.
● Alcohol
○ Tension-reduction theory suggests people drink alcohol for its tension-reducing properties.
● Eating
○ Two hypotheses concerning the link between stress and eating:
1. The general effect model → predicts that stress changes food intake generally
2. The individual difference model → predicts that stress only causes changes in eating
in vulnerable groups of individuals.
● Exercise
○ Stress may reduce exercise, whereas stress management, which focuses on increasing
exercise, has been shown to result in some improvements in coronary health.
○ Bi-directional relationship → stress reducing exercise and exercise reducing stress.
● Accidents
○ High levels of stress show a greater tendency to perform behaviours that increase their
chances of becoming injured.
Does Stress Cause Illness?

Direct and Indirect Pathways
● Stress causes illness through either a direct pathway (changes in physiology) or indirect pathway (via
changes in behaviour).
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Direct Pathway
Reflects changes in physiology.
Sympathetic activation → production of stress hormones and causes arousal.
● Results in blood clot formation, increased blood pressure, increased heart rate, irregular heart
beats, fat deposits, plaque formation and immunosuppression.
Hypothalamic-pituitary-adrenocortical (HPA-axis) activation → production of cortisol
● Prolonged production of cortisol can lead to decreased immune function and damage to
neurons in the hippocampus.
Indirect Pathway
Reflects changes in behaviours which in turn cause illness.
● Might increase smoking and alcohol intake, reduce exercise levels, make them forget to take their
medication, prefer high fat snacks rather than meals, not practise safe sex or encourage risk taking such
as driving too fast, not wearing a helmet.
Inter-related Pathway
The direct and indirect pathways inter-relate.
● Stress may cause changes in behaviour such as smoking and diet which then cause changes in
physiology.
● Stress may cause physiological changes such as raised blood pressure.
● Stress is linked to illness via a complex interaction between behavioural and physiological factors.
Chronic / Acute Stress Model

● Chronic stress is more likely to involve HPA activation and the release of cortisol.
● Acute stress operates primarily through changes in sympathetic activation, such as blood pressure and
heart rate.
The Chronic Process
● Chronic work stress may cause changes in physiology and behaviour which over time lead to
cardiovascular damage.
● Chronic stress is associated with atherosclerosis, a slow process of arterial damage which limits the
supply of blood to the heart.
The Acute Process
● Exercise can be protective in the long term but a danger for an at-risk individual.
Links between Acute and Chronic Stress

● Acute and chronic stress are intrinsically linked.
● Chronic stress may be the frequent occurrence of acute stress; acute stress may be more likely to trigger
a cardiac event in someone who has experienced chronic stress + may also contribute to wear and tear
of cardiovascular system
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Physiological moderators of the

stress-illness link
Not everyone who experiences stress
becomes ill → variability is due to
individual differences in
physiological factors such as stress
reactivity, recovery, allostatic load,
and stress resistance.
Stress Reactivity
Some individuals show a stronger physiological response to stress than others, known as ‘stress reactivity’ or
‘cardiovascular reactivity’. What this means is that when given the same level of stressor, regardless of
self-perceived stress, some people show greater sympathetic activation than others.
● Greater stress reactivity may make people more susceptible to stress-related illness.
● This does not mean that individuals who show greater responses to stress are more likely to become ill,
but are more likely to become ill if subjected to stress, particularly if this pattern of responding to stress
is maintained over a long period of time.
Stress Recovery
After reacting to stress the body recovers and levels of sympathetic and HPA activation return to baseline.
● Some people recover more slowly or quickly than others.
● This rate of recovery may also be related to a susceptibility to stress-related illness.
○ Some research has focused primarily on cortisol levels and recovery to normal levels
following a stressor.
Allostatic Load
Allostatic load reflects the wear and tear on the body which accumulates over time after exposure to repeated or
chronic stress.
● Body’s physiological systems constantly fluctuate as the individual responds and recovers from stress-
a state of allostasis.
● As time progresses, recovery is less and less complete and the body is left increasingly depleted.
● If exposed to a new stressor → person is more likely to become ill if their allostatic load is high.
Stress Resistance
This concept emphasises how some people remain healthy even when stressors occur.
● Includes adaptive coping strategies, certain personality characteristics, and social support.
● These factors are considered psychological moderators.
Physiological Moderators of the Stress-Illness Link

The factors are as follows:
● Health behaviours: exercise, smoking,
alcohol and eating can cause a reduction in
stress.
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● Coping styles: an individual's coping style may mediate the stress-illness link and determine the extent
of the effect of the stressful event on their health status.
● Social support: increased social support is related to decreased stress response.
● Personality: may influence an individual's response to a stressful situation.
● Actual or perceived control
Coping
What is coping?
The process of managing stressors that have been appraised as taxing or exceeding a person’s resources. ‘The
efforts to manage…environmental and internal demands’.
● In terms of stress → how an individual interacts with stressors in an attempt to return to normal
functioning.
○ Correcting or removing the problem.
○ Changing the way you interpret the problem.
○ Learning to tolerate it and accept it.
● Coping is a highly dynamic process that requires appraisal and reappraisal / evaluation and
re-evaluation (constant).
● Model of stress emphasises the interaction between person and environment. Similarly the model of
coping is seen as a similar interaction between person and stressor.
Approach versus Avoidance

Approach coping involves confronting the problem, gathering information and taking action.
● Consistently more adaptive.
Avoidance coping involves minimising the importance of the event.
● Effectiveness of the coping style depends on the nature of the stressor.
● Avoidant coping might be more effective for short-term stressors, but less effective for long-term.
Problem-Focused versus Emotion-Focused Coping (Instrumentality-Emotionality)

People can show both problem focused and emotion focused coping when facing a stressful event.
Problem Focused-Coping
● Involves attempts to take action to either reduce the demands of the stressor or to increase the
resources available to manage it.
● I.e., devising a revision plan and sticking to it, setting an agenda for busy days, etc…
Emotion-Focused Coping
● Involves attempts to manage the emotions evoked by a stressful event.
● I.e., talking to a friend about a problem, turning to drink or smoke, getting distracted by
shopping or watching a film.
Factors influencing which strategy to use:

Type of problem
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● Work problems evoke more problem-focused coping than health and relationship issues, which tend to
be emotion-focused coping.
Age
● Children use more problem-focused strategies, adolescents use more emotion-focused strategies.
Middle-aged men and women are more problem-focused, and the elderly more emotion-focused.
Gender
● Women use more emotion-focused coping than men, who are more problem-focused.
Controllability
● People use more problem-focused if they believe the problem itself can be changed. If the problem is
perceived as uncontrollable, there is emotion-focused coping.
Available resources
● Coping is influenced by external resources such as time, money, children, family and education. The
less resources, the less feeling of control, resulting in a tendency to not use problem-focused coping.
Coping training
● Intervention designed to change the coping profiles of individuals. Involves assertiveness, cognitive
restructuring, time management, relaxation, physical activities and scheduling of pleasant activities.
Strategies were successfully trained and an increase in well-being noticed.
Coping and the Stress-Illness Link

Coping styles may moderate the link → studies find problem-solving and acceptance styles are more effective at
reducing stress and distress. Approach and active coping strategies are more effective.
Coping and Positive Outcomes
Stressful life events and illness may not only result in negative outcomes but may also lead to some positive
changes in people’s lives: stress-related growth, benefit-finding, growth-oriented functioning and crisis growth.
● In line with the new movement of ‘positive psychology’
● Coping processes that involve finding meaning in the stressful event, positive reappraisal, and
problem-focused coping are associated with positive outcomes.
Social Support
What is social support?
Defined according to the number of friends supplying social support and the individual’s satisfaction with this
support. There are different types of social support:
● Esteem support: other people increase one’s own self-esteem.
● Support: other people are available to offer advice.
● Companionship: support through activities.
● Instrumental support: involves physical help.
Structural support → refers to type, size, density and frequency of contact with the network of people
available to any individual.
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Functional support → refers to the perceived benefit provided by this structure. Further classified into
available functional support (potential available support) and enacted functional support (actual available
support).
Social capital is a notion which has an impact on health. It is a broad construct that incorporates trust, social
networks, social participation, successful cooperation and reciprocity.
Does social support have an impact on health?

Some studies show that increased social support predicts a decrease in mortality rate, indicating a role for social
support in health. Social support has also been shown to have an impact on immune health and consequently
health.
Possible mechanisms that may explain the role of social support in health status
● Main effect hypothesis: social support itself is beneficial and the absence of social support is itself
stressful. Its very presence reduces the effect of the stressor and its absence acts as the stressor.
● Stress buffering hypothesis: suggests that social support helps individuals cope with stress, therefore
mediating the stress-illness link by buffering the individual from the stressor. Social support influences
the individual’s appraisal of the stressor.
○ Social comparison theory → the existence of other people enables individuals exposed to a
stressor to select an appropriate coping strategy by comparing themselves with others.
○ Stress buffering hypothesis has been described using role theory. Social support enables
individuals to change their role or identity according to the demands of the stressor.
Personality
Type A
Initially defined type A behaviour in terms of excessive competitiveness, impatience, hostility and vigorous
speech. Three types of A behaviour are identified:
● Type A1 → vigour, energy, alertness, confidence, loud speaking, rapid speaking, tense clipped speech,
impatience, hostility, interrupting, frequent use of the word ‘never’ and frequent use of the word
‘absolutely’.
● Type A2 → similar to A1 but not as extreme, regarded as more relaxed, showing no interruptions and
quieter.
Conscientiousness
Greater daily hassles were linked to a higher intake of fat snacks, a greater consumption of caffeinated drinks,
higher levels of smoking but lower intake of alcohol, vegetables and less exercise. Associations influenced by
conscientiousness.
Hostility
The Big 5 Personality Types
Big 5 include: extraversion, agreeableness, openness, conscientiousness, and neuroticism.
Control
Effect of control on the stress-illness link.
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What is control?
Attribution and control
Attribution theory examines control in terms of attributions for causality. Applying this to a stressor,
the cause of a stressful event would be understood in terms of whether the cause was controllable by the
individual or not.
Self-efficacy and control
Self-efficacy refers to an individual’s confidence to carry out a particular behaviour. Control is implicit
in this concept
Categories of control
Five different types of control identified; behavioural control (e.g. avoidance); cognitive control (e.g.
reappraisal of coping strategies); decisional control (e.g. choice over possible outcome); informational control
(e.g. ability to access information about the stressor); retrospective control (e.g. could i have prevented that from
happening)
The reality of control
Perceived control (‘I believe i can control the outcome of a job interview’) and actual control (‘I can control the
outcome of a job interview’). The discrepancy between these two has been referred to as illusory control.
Does control affect the stress response?

Subjective experience: examined relationship between controllability of stressor and subjective stress →
predictability enabled individuals to subjectively feel they have control over stressor and this perceived control
reduces the stress response.
Physiological changes: if a stressor is regarded as uncontrollable, the release of corticosteroids is increased.
Does control affect health?

Animal Research
● Controllability may influence the stress response, which may then promote illness.
Human Research
● Combination of high workload, low satisfaction and low control are the best predictors of CHD.
External locus of control is associated with greater disease severity in those with Parkinson’s.
○ Control and preventive behaviour → high control enables individuals to maintain a healthy
lifestyle by believing they are able to do something to prevent the illness.
○ Control and behaviour following illness → high control enables the individual to change
behaviour after illness. If they believe they can do something about their health, they will
change their behaviour.
○ Control and physiology → control directly influences health via physiological changes.
○ Control and personal responsibility → high control can lead to a feeling of personal
responsibility and personal blame/helplessness.
STRESS AS A COMPLEX PSYCHO-PHYSIOLOGICAL PROCESS
27
This chapter has illustrated the ways in which stress and its
impact on illness reflect an interaction between psychological
processes (appraisal, behaviour, coping, social support,
personality, control) and physiological processes (sympathetic
activation, HPA activation, immune response, stress reactivity,
allostatic load, stress recovery, stress resistance).
Chapter 9 - Accessing Health Care
Brief History of Health Care

● Prior to the 19th century average life expectancy was about 30 years old.
● Life expectancy began increasing in industrialised countries, leaving a big discrepancy in health
inequalities between rich and poor countries.
● Life expectancy now is about 70 years.
The Role of Medical Interventions

Variations in health and illness are explained with a focus on the success or failure of medical interventions and
the availability of health care.
New Medicines → Medical intervention directly impacts upon the life expectancy of people with conditions.
Availability of Vaccinations → There is worldwide variation in vaccinations for illnesses.
Availability of Skilled Health Professionals → variation in health and illness may be partly explained.
Environmental Factors
Food availability, clear water, food hygiene, sanitation and sewage facilities. These basic requirements vary by
country.
Health status varies over time, geography, and by gender and social class. Main analysis of this variability
focuses on the availability of medicines and access to skilled health professionals.
Health Care Systems

There are three levels to any health care system, although details and structure may vary between countries.
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Self-Care
Many symptoms and illnesses are managed through self-care with no need of professional input.
● Most houses have some stock of medical resources, from relief for physical injuries to pain relief.
● Internet and self-help books provide photographs and descriptions of symptoms to aid self-diagnosis
and self-medication.
Primary Care
Primary care is the first contact with the health service and the patient is free to make an appointment whenever
they feel they need one.
● Met by a general practitioner (GP) who has been trained to recognise and cope with whatever issues
may enter their door.
● GP is part of a primary care team consisting of nurses, nurse practitioners, health visitors, midwives
and receptionists.
● Their job is to manage whatever issue a patient might have and refer patients on to the hospital
specialists in secondary care for a second opinion and further tests.
● They are gatekeepers into secondary care.
● This process prevents secondary care being inundated with less serious medical issues.
Secondary Care
If referred by the GP, a patient is permitted to see a specialist in secondary care. In most countries, referral to
secondary care can only occur via a referral letter from the GP.
● Changing as patients are demanding their right to see who they want, and patients become consumers
of healthcare.
● Private practice also changes this division as patients can choose to pay to see secondary health
specialists (with money or health insurance).
Help-Seeking and Delay

Help seeking is also known as ‘illness behaviour’ and refers to the process of deciding to get professional help.
Help seeking related to two factors:
● Symptoms → recognising something is wrong.
● Signs → on examination, the doctor identifies signs that may not be visible.
Clinical Iceberg → reflects the vast number of problems that never reach the doctor. We all have symptoms all
the time that we do nothing about, so often serious issues go by unattended.
A Series of Thresholds
Help-seeking is more complex than sign and symptom detection. It can be understood in terms of thresholds that
must be reached. Thresholds are as follows:
● Is it a symptom? → pain somewhere
● Is it normal or abnormal? → pain is different from what I normally feel
● Do I need help? → this pain may be something serious
● Could a doctor help? → the doctor can help with a serious illness
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Thresholds can be understood in terms of four processes which have been explored within psychological and
sociological research.
Symptom Perception
Whether or not we perceive ourselves as having a symptom is influenced by four main sources of information:
Bodily Data
● There is a competition between internal information (our bodies) and external information (our
environment), which may explain why busy working people perceive fewer symptoms.
● Some people show selective attention to their bodily symptoms and are more aware of change.
● Symptom perception can be generated in the absence of body data (e.g.Watching a film of someone
with lice will produce an itching feeling).
Mood
● Stress and anxiety can make symptoms worse, whereas relaxation can make them better.
Cognitions
● Focusing on a symptom makes it worse, while distraction makes it better. Chronic patients are
encouraged to practise distraction through being busy, talking to people, and staying employed if
possible.
Social Context
● Medical student’s disease describes how medical students often develop symptoms of whatever
condition they are studying.
● Smiling, yawning, shivering and itching can be contagious if people watch others experience that. \
Illness Cognitions
Once the symptom is perceived, the person makes a mental representation of the problem.
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● Illness cognitions are influenced by their social environment as well as their own health history and
expectations of their own level of health.
● Individuals also undergo a process of normalisation → a patient who has recurring headaches may be
less surprised by a new headache whereas someone who is always well may react more strongly to a
less serious symptom.
● Normalisation can pose problems for both patient and doctor.
● Illness cognitions take the symptom up to the next threshold as it is deemed to be abnormal (or not) and
serious (or not).
Social Triggers
Throughout the process of identifying a problem as abnormal (or not) is also influenced by social triggers.
● Triggers relate less to the individual’s perception of the symptom and more the impact that the
symptom will have on their daily lives.
○ Perceived interference with work or physical activity. A symptom that disrupts these will be
identified as abnormal, as they are core to people’s lives.
○ Perceived interference with social relations. A symptom is perceived as abnormal if it disrupts
our ability to interact with others.
○ An interpersonal crisis. People have symptoms that they are habituated to, however, a sudden
crisis (argument, divorce, retirement…) may trigger increased attention to a long-standing
symptom.
○ Sanctioning. The notion of sanctioning is similar to social messages in that it involves other
people encouraging a visit to the doctor.
Symptom perception, illness cognitions and social triggers take the individual up the thresholds towards
help-seeking for a particular problem. Another set of factors that influence this are the perceived costs and
benefits of going to the doctor.
Costs and Benefits of Going to the Doctor

Therapeutic (costs and benefits).
● Gaining access to effective treatments and being referred on to secondary care for more specialist
advice and treatment.
● Help-seeking costs include being given medication to take (if you don’t like taking medicine),
undergoing a potentially embarrassing examination, talking about personal problems.
Practical (costs and benefits).
● Practical costs such as taking time off work, time away from the family, cost of the fare and effort of
getting to the doctor.
Emotional (costs and benefits).
● People like these doctor visits as it may give them structure to their day, as well as meet people at the
doctor which is reassuring for the patients, they can find sympathy and care.
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● There may be embarrassment or a feeling of being a nuisance to a doctor who appears to be busy and
overworked.
The sick role (costs and benefits).
● Doctors have the power of turning a person into a patient by legitimising their symptoms.
● People get more sympathy if they can say the pain they have been complaining about is diagnosed.
This comes with two benefits and two obligations.
The benefits:
● Excuses the patients from their normal roles and duties.
● No longer responsible for their illness as ‘they are ill’.
● Illness is no longer seen as self-inflicted or even as a punishment.
The obligations
● Once admitted to the sick role the patient must want to get well and see their sick role as temporary. If
the sick role goes on for too long they will be seen as ‘putting it on’ or ‘malingering’.
● They will have to adhere to what the doctor says.
Delay
The time taken since a patient first experiences symptoms to the first contact with a medical health professional.
● Patients often come to the doctor with symptoms that should have been treated months or even years
before.
● Delay in health-seeking presents problems to health professionals and patients.
Defining Delay
The time between detecting a sign or symptom and the first contact with a health professional. More complex
than it seems.
● Detecting a symptom involves all the thresholds described previously and the input of mood,
cognitions, social context, illness cognitions and social triggers.
Predictors of Delay
Factors concerning symptom perception, illness cognitions, social triggers, and costs and benefits of help
seeking.
Interventions for Delay
Poses some complications as the outcome of the intervention is less clear
● Symptoms of serious illnesses are often the same as symptoms for minor illnesses.
● If individuals are advised to seek help whenever they experience a symptom and as soon as it is
noticed, the health care systems would collapse under high demand.
● Interventions have to be extremely specific.
Screening
A screening programme picks up problems at a time when they cannot be detected by the patient on the premise
that early detection leads to better treatment success.
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What is Screening?
There are three forms of prevention:
● Primary prevention: modifying risk factors before illness onset, for example, health promotion
campaigns (smoking, diet, alcohol…)
● Secondary prevention: interventions which detect illness at an asymptomatic stage of development so
that its progression can be stopped or slowed down. For example, screening.
● Tertiary prevention: rehabilitating patients and treatment intervention once illness has manifested.
There are two types of screening defined:
● Opportunistic screening: using the time when a patient is involved with the medical services to
measure aspects of their health.
○ A patient comes in with a sore throat, and the GP decides to check blood pressure.
● Population screening: setting up services specifically aimed at screening.
○ Cervical screening and breast screening.
● Self-screening: people are encouraged to self-monitor and screen for signs that could be illness.
○ Breast and testicular self-examination, over-the-counter kits for blood pressure, cholesterol
and sugar levels.
The aim is to detect the asymptomatic phase of an illness- results in two outcomes:
● Primary screening: screening can discover the risk of the disease.
○ Cervical screening may detect precancerous cells which place the individual at risk of cancer.
○ Cholesterol screening could place an individual at high risk of CHD.
● Secondary screening: screening can detect the illness itself.
○ Mammograms may discover breast cancer.
Guidelines for Screening

Criteria have been established:
Disease Screen Follow-up Economy
An important problem Suitable test or Facilities must exist Cost must be

examination for assessment and economically
treatment balanced
Recognisable at the Test should be Accepted form of

latent or early acceptable by the effective treatment
asymptomatic stage population being
screened
Natural history must be Screening must be Agreed policy on

understood a continuous whom to treat
process
Predictors of Screening Uptake

The number of individuals who attend screening varies enormously according to factors such as the country,
illness being screened, and time of screening programme.
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1. Patient factors
Demographic factors
Health beliefs
Emotional factors
Contextual factors
2. Health professional factors
Means of presenting tests
GP’s attitudes
Screening behaviour
3. Organisational factors
Means of invitation
Voluntary vs mandatory
Place of screening
Psychological Impact
Screening can have several negative consequences such as cost and time to health services and the patient.
● ‘Intangible costs’
● The receipt of a screening invitation
○ Receiving a screening invitation may increase anxiety, however it is not always the case.
● The receipt of a negative result
○ It would be assumed that receiving a negative result would only decrease an individual’s
anxiety. Additionally it creates a sense of reassurance or no change in anxiety levels.
○ There are residual levels of anxiety which do not return to baseline.
○ The mere term ‘negative result’ may be confusing, therefore changing ‘negative result’ to
‘normal’ can decrease anxiety and possible confusion.
● The receipt of a positive result
○ Associated with a variety of negative emotions from worry, shock, anxiety.
● The receipt of an inadequate test result
○ Neither negative nor positive results- unable to confirm or disconfirm the presence of a
condition.
○ Inadequate or inconclusive results may result in greater levels of anxiety and more concern
over their result. Individuals perceive themselves more at risk for that particular condition.
The Medical Consultation

Core component of any interaction within health care is the consultation between patient and health
professional.
● Traditional notions viewed the doctor as the objectively knowledgeable person with extensive
education, and the patient as a passive person who absorbs information and suggestions and responds
accordingly.
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● Shift in narrative → ‘expert patient’ who has their own beliefs and expectations, the doctor is more
‘human’.
The Problem of Doctor Variability
How Doctors Make Decisions

The process of clinical decision-making has been understood within the framework of problem solving.
A Model of Problem-Solving
Clinical decisions are made by the process of inductive reasoning, which involves collecting data and evidence
which are used to develop a conclusion and a hypothesis.
● Doctor’s decision-making processes are generally considered within the framework of the
hypothetico-deductive model of decision-making. This perspective emphasises the development of
hypotheses early on in the consultation. See the figure below.
→ Problem solving involves a number of

stages that result in a solution to a given
problem.
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● Understand the nature of the problem and develop an internal representation. At this stage
individuals formulate internal representations of the problem → understanding the goal of the issue and
nature of the data.
● Develop a plan of action for solving the problem. There are two types of plans; heuristics (rules of
thumb, less definite and specific but provide guidance and direction) and algorithms (set of rules that
provide a correct solution if applied correctly).
● Apply heuristics. Plans applied to given situation
● Determine whether heuristics have been fruitful. If considered unsuccessful, new ones developed.
● Finish and verify the solution.
Clinical Decisions as Problem-Solving

Hypotheses are tested by the doctor’s selection of questions.
Search for attributes. Doctors test hypotheses by searching for factors that confirm or refute them. The type of
hypothesis made has been shown to bias the collection and interpretation of any information received during the
consultation.
Explaining Variability
Health professionals may access different information about the patient’s symptoms, develop different
hypotheses, access different attributes either to confirm or refute said hypotheses, have differing degrees of bias
towards confirmation, or reach different management decisions.
Health Professionals’ Health Beliefs

Patients are described as having lay beliefs, which are individual and variable. Health professionals are
described as having professional beliefs, which are assumed to be consistent and predictable.
● However: development of hypotheses involves a health professional's own health beliefs which may
vary as much as those of the patient.
● Components of the HMB, PMT have been used to examine health professionals’ health beliefs.
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Health professional’s own beliefs about the nature of clinical problems. Influences their choice of
hypothesis.
The health professional’s estimate of the probability of the hypothesis and disease. They have pre-existing
beliefs about the prevalence and incidence of any given health problem, which influences hypotheses.
The seriousness and treatability of the disease.
Personal knowledge of the patient. Hypotheses are also related to the doctor’s existing knowledge of the
patient. May include their medical history, psychological state of the patient, psychosocial environment, etc…
The health professional’s stereotypes. Stereotypes are sometimes seen as problematic and confounding of the
decision-making process. However, consultations are time-limited, so stereotypes play an important role in
developing and testing hypotheses and reaching management decisions.
● Stereotypes reflect ‘cognitive economy’ → developed through many factors such as how the patient
walks/talks/looks/ if they remind them of previous patients.
● Without stereotypes, consultations would be extremely time-consuming.
Other factors:
● Health professionals’ mood, profile characteristics, etc…
Communicating Beliefs to Patients

E.g. ‘increase the probability of survival’ or ‘decrease the probability of death’. Patients are more likely to
choose surgery if they believed it increased the probability of survival rather than if it decreased the probability
of death.
● The phrasing of such a question would very much reflect the individual beliefs of the doctor, which
in turn influence the choices of the patients.
The Modern Consultation

Variability in health professionals’ behaviour exists in the context of both the health professional and patient. In
order to understand any variability in the outcome of the consultation, both should be considered as a dyad.
● The modern consultation therefore involves two individuals and a communication process.
Patient-Centeredness
Patient centeredness is considered to consist of three central components:
1. A receptiveness by the doctor to the patient’s opinions and expectations → effort to see illness through
the patient’s eyes.
2. Patient involvement in decision-making and planning of treatment.
3. An attention to the affective content of the consultation in terms of the emotions of both the patient and
the doctor.
Patient-centeredness is now the way in which consultations are supposed to be managed. Emphasises
negotiation and places interaction as central.
● Relationship explored in terms of level of agreement and impact of such on patient outcome.
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Agreement between Health Professional and Patient
The Role of Agreement in Patient Outcomes

If doctors and patients have different beliefs about illness, different beliefs about the role of the doctor and
medication, will this lack of agreement relate to patient outcomes?
● Can disagreement result in poor compliance to medication?
Adherence
Defining Adherence
Used to be referred to as ‘compliance’ → the extent to which the patient’s behaviour (in terms of taking
medications, following diets or other lifestyle changes) coincides with medical or health advice.
● ‘Compliance’ was deemed too paternalistic and related too much to traditional models of consultation.
● DROPPED this definition
The term ‘adherence’ encapsulates a more patient empowered role. Defined as ‘the extent to which a patient’s
behaviour matched agreed recommendations from their health professional.
● Similar notion to that of compliance, however there is ‘agreement’ and ‘recommendations’ which
illustrate a shift in perspective away from paternalistic doctors towards open negotiation.
● More in line with patient-centeredness and shared decision-making.
As a means to understand why people don’t adhere a further distinction of non-adherence has been made:
● ‘Unintentional non-adherence’ → individual simply forgets or has misunderstood instructions.
● ‘Intentional non-adherence’ → an individual chooses not to take their medicine or engage in
risk-reducing behaviour.
Measuring Adherence
Issues measuring adherence:
● Self-reported adherence may be inaccurate due to issues such as memory, social desirability and the
wish to be prescribed further medicines in the future.
● Highly complex behaviour
● Measures of adherence are broadly objective or subjective.
Objective measures:
● Observation → clinician observes medication intake. Can be inaccurate, time-consuming, and
unfeasible.
● Blood or urine samples → assessing blood levels of the drug. Costly, time-consuming, varies according
to how drugs are metabolised in different individuals.
● Pill counting → patients asked to show remaining pills. Requires face-to-face, time-consuming, and
inconvenient. Not very reliable, users may throw away pills.
● Electronic monitors → expensive, assumes a pill is taken each time a bottle is opened.
● Assessing prescriptions → records made for when patients ask for new prescriptions.
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Subjective measures:
● Self-report → patients rate their own adherence during interview or questionnaire. Inexpensive, but
contaminated by recall problems or social desirability.
Why is Adherence Important?

Following the recommendations of health professionals is considered an essential part to patient recovery.
● Study found the odds of dying were halved if people took their medication.
● Adherence, regardless of whether it was to an active drug or a placebo, also halved the odds of dying.
● Adherence is related to health outcomes.
● Half of patients with chronic health illnesses are non-adherent.
Models of Adherence
Cognitive Hypothesis Model (of compliance)
Predicted that people would adhere to their doctor’s recommendations if they understood these
recommendations, could recall the instructions and were satisfied with the consultation.
The Perceptions and Practicalities Approach (of adherence)
Focused on the predictors of

unintentional non-adherence and
intentional non-adherence.
● Adherence is seen as relating
to motivation, resources, perceptual
barriers, and practical barriers.
● All those are deemed to
prevent adherence from happening.
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Predictors of Adherence
Patient Satisfaction
Patient Understanding
Important to understand the extent to which patients understand the content of the consultation. This is done by
examining beliefs about the location of organs.
● 66% of people could not locate the heart correctly, and 80% the stomach. 58% could not locate the
kidneys and 51% could not locate the liver.
● If the doctor gives advice to the patient and they do not understand the cause of their illness or the
location of the relevant organ or process involved in the treatment, then this lack of understanding is
likely to affect compliance with the advice.
Patient’s Recall
Recall is not influenced by the age of the patient, which is contrary to some predictions of the effect of ageing
on memory. Recalling information after the consultation may be related to compliance.
Beliefs About the Illness

Patients hold beliefs about their illness and these relate to dimensions of cause, consequence, timeline, control
and identity.
● Beliefs predict adherence → belief that the illness has serious consequences is related to medication
adherence.
Beliefs About the Behaviour

People hold beliefs about their health-related behaviours. Within the framework of social cognition models,
adherence can be predicted by beliefs about the costs and benefits of different health behaviours + risk
perception.
● Higher adherence was predicted by greater perceived susceptibility and lower response costs.
Beliefs About Medication

Necessity/Concerns Framework (NCF) → beliefs about the necessities and concerns of medication are good
predictors of adherence in the context of illnesses such as asthma, diabetes, cancer, and CHD.
How Can Adherence Be Improved?

Adherence is considered essential to patient well-being. Interventions to increase adherence include:
The Role of Information

Studies find that information could improve adherence if it was instructional and educational in nature.
Appeared to improve adherence from 52 to 66 per cent.
● Oral Information
○ Facilitates understanding and recall
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○ Primacy effect → patients have a tendency to remember the first thing they are told.
○ Stressing importance of adherence
○ Simplifying the information
○ Using repetition.
○ Being specific
○ Following up the consultation with additional interviews.
● Written Information
Changing Beliefs and Emotions

Knowledge is not enough to improve adherence, research turns to changing cognitions and emotions. May
involve behavioural strategies such as; reinforcement, incentives, modelling- or social cognition theory-based
interventions such as implementation intentions, the use of stage models and motivational interviewing.
Ethics of Care (EoC): Guest Lecture

● Carol Gilligan’s ‘dis-covery’: the different voices in ethics (1982)
○ She was a pupil of Kohlberg.
○ Observed men are more inclined to apply rules and principles.
○ Women are more inclined to reason situationally more, and relationally interested.
○ Moral stages masculine reasoning are much higher than for women. It depends on context,
relations, and not thinking in principles (for women) → “soft voice/focus”.
● The dominant abstract ‘principle-based’ ethical reasoning vs the soft voice of the ‘relational-based’
reasoning in ethics.
What is care?
● Not the ethics of medicine, although applied in the health domain. Is applied in politics, international
relationships and conflict, police force, etc…
● It chooses the perspective of care when you focus on a specific problem → any problem
○ We are dependent on other people to survive.
○ Does not start with the idea of autonomy but rather (inter)dependency not to perish
● Care is the normal way of being, an everyday practice (not act). Living is caring about things.
● Without care and caring no life.
Attentive and sensitive responses to actual complexities (concrete needs)
● Devoted attentiveness to concrete needs
● Being able to be focused and interested is the first step
● What morality requires in actual contexts
● Opposing abstract rules of reason or the dominance of rational calculation.
● Situation specific response.
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Conclusion
● EoC makes room for the different soft voices of care.
● Caring is essential but mundane.
● Caring is a general practice.
● All care is morally laden.
● Caring can’t do without relationality.
● Caring is only caring if it is a situationally adequate response.
1. The discourses of justice and care

Ethics of Justice (roughly) ⇔ Ethics of Care (roughly)
Separate individuals, autonomy ⇔ Relationality, inter/dependency.
Rights and duties ⇔ virtues, care, moral experiences
General principles, abstract, clear ⇔ contextual, concrete, complex, emotional reasonableness
What is legitimate ⇔ what can be accounted for
Formal reasoning ⇔ substantial reasoning
Distributive responsive ⇔ responsive (dialogical)
Rule principle as starting point ⇔ appeal, needs
Small units, acts and dilemmas ⇔ integralist oriented
E.g. Small units (eating disorder = eating or not) → too categorical, not a small binary dilemma
2. Completing the caring process

Tronto’s model of ‘complete care’ (Joan Tronto is politically oriented)
● Phases of coping (from perceiving, accepting, and deciding → feedback loop)
1. Caring about → attentiveness, people are trained to be more present, look perceptive.
2. Taking care of → virtue of responsibility, accepting it and doing it.
3. Care-giving → providing care is a virtue of competence, doing so competently.
4. Care-receiving → responsiveness (to the care receiver), accept and change to feedback.
5. Caring with → trust & solidarity (the ethics of care on a societal level)
Good care is complete care → see it through, follow the stages, feedback, and begin again.
● Care is organised in stages (a chain).
Has political and ethical consequences (who is at stake, included, excluded).
Quality of care is in the process of caring (and less in the product of caring, the problem)
3. Presence as a practice-oriented EoC

Characteristics (correspond to point/clues below)
1. Movement, place and time
2. Boundaries
3. Looking for close connection
4. Fine tuning oneself
5. Meaning for the care receiver
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Point/clue
1. After the other, not the other way around.
2. Unfragmented (‘holistic’): accessible for whatever.
3. Being with/in the lived life; avoiding professional mismatches.
4. Focal point on the emergent good of the other. (opposite of knowing in advance what you will do).
Virtue of practical wisdom.
5. To count, at least for one other human being; combating the feeling of being socially redundant.
In the relational ethics of presence less usual concepts come into the foreground like:
● Care and caring as the most fundamental category of good, sustainable life (together) → much more
than a virtue, attitude or behaviour.
● Vulnerability, frailty and precariousness as ontological status of human beings.
● Dependency as asymmetrical power in the caring process.
○ The professional has the knowledge asn knows the opportunities. They must understand,
acknowledge and accept the responsibilities of the asymmetry present in the
patient-professional dynamic.
● Solidarity, community and loyalty.
Additionally
● Contextuality vs ‘on their own’.
● Particularity vs general rules (cases under general laws).
● Perspective from within vs outside (emic/etic).
● Perception vs judgement.
● Emergent goods vs established values.
● Complexity of practices vs simple actions.
Reducing and solving the problem is not the ethics of care → it is staying with the person and caring for them.
● Patients are let alone when problem is ‘solved’
Critical insights
1. The moral relevance of recognition and affirmation
2. The moral importance of having a stage (to be somewhere and listened to)
3. The moral importance of being someone
4. The moral importance encompassing horizon (bigger picture of the patient)
5. The moral importance the political perspective (not just one to one)
EoC is a lens → it is how you approach issues, how we view them, with a lens of care. That will provide a
specific perspective or early missed things.
The ethics of capita (selecta)

There are many capita selecta:
● Patient: having problem vs suffering
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● Professionalism, from instrumental and reflective to morally and practically wise.

● Etc
Misunderstanding about relationality

Steps of relational work
1. Rough care (self-oriented) (least presence) (care receiver not taken seriously = least recognition, object
of categorising, a diagnosis) (carer is in the focus) (violent care) → old fashioned.
● Care that adds suffering; cruel care, neglecting behaviour of the carer.
2. Cold care (in between)
● Care given in an impersonal way; distant, patient is a number, a thing.
3. Okay care (task-oriented) (care task is in the focus)
● Care given adequately, rather task oriented, ‘nothing wrong’, nothing extra either.
● Passes the bare minimum threshold.
● Not good, not bad.
4. Kind care (in between)
● Care given attentively, friendly, courteously; sensitive to needs.
● At Least receiving this care in hospitals
5. Service oriented care (patient-oriented) (patient is in the focus) (compassionate care)
● Care given with willingness to serve the patient and when necessary, going the extra mile.
6. Decent care (in between)
● Care given without humiliation, honouring the knowledge and desires of the patient.
● Patients know best about the condition, they have the knowledge
7. Relational care (relation-oriented) (most presence) (care receiver taken most seriously = most
recognition, a person) (relation is in the focus) (mutually arranged care) (both poles of the relation give,
both career and receiver place equal input)
● Care steered and structured from the relational perspective.
Explaining the difference between weak and strong relationality
- There is another lens to look through, presence and EoC.
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Guest lecture Tuesday, 2, May, 2023
Well-being and Anosmia

● Awareness of smell (loss) is key.
● People are unreliable when judging their own sense of smell
○ Moein et al., 2020
Olfactory disorders: e.g., anosmia, hyposmia, parosmia, phantosmia.
● Anosmia: loss or impairment of the smell
Parosmia: a disorder of the sense of smell → (bad smells)

○ Brain trauma, bacterial and viral infections, smoking, chemical exposure, cancer treatment,
neurological diseases, COVID-19.
○ Covid-19 → Independent predictor of recovery
● Difficulty imagining losing the sense of smell → difficulty communicating the issues caused by smell
loss.
○ Limited vocabulary to communicate its disorder.
● Burges Watson et al., (2021): aim was to document the impact of post Covid-19 alterations to taste and
smell.
○ Invisible disorder, no proof of alterations to sense of smell.
How olfaction promotes well-being

Nutrition
● Orthonasal olfaction → sniffing
● Retronasal olfaction → perception of odours emanating from the oral cavity during eating and
drinking, contributes to the flavour
Main functions of smell in nutrition
1. Detecting distal location of food and identifying foods’ suitability for ingestion, based on prior
learning (humans are still able to identify the location of food,( i.e., following a trail)).
2. Large discrepancy between the perceived flavour and the expectations can lead to rejection
and avoidance.
3. Smell of food before or after a meal, and the experience of flavour during a meal can regulate
appetite- stimulation and inhibition.
4. For newborns to initiate breastfeeding.
Anosmia, parosmia and food
● Eating spoiled food, difficulties with cooking, decreased appetite, forget about the need to eat, weight
loss and weight gain.
● We also eat for pleasure and joy → no food satisfaction
Smells and environmental hazards

Chemical signals
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1. Non microbial hazards → predators, fire, poison, gas (fear related)

2. Microbial hazards → bodily fluids, expired food, decomposing matter, etc… (disgust related)
● Evolutionary beneficial to avoid pathogens of infectious nature.
● Humans can smell diseases from other people’s body odour.
● Avoidance behaviour.
Smell and Social Behaviour

‘The scented ape’ → produce the most variety of bodily odours, however we don’t tolerate the natural smells we
produce, as evidenced by the huge hygiene industries of soaps, deodorants, etc…
Use of smell in social behaviours; things we are able to detect using our olfaction:
● Sex, age, kinship (familiars), health, personality traits (especially neuroticism), emotions, phases of the
menstrual cycle, attraction, fear, stress, and anxiety.
● Often rated on valence rather than conscious recognition of factors.
Impairments to Relationships
Family → bonding with newborns, etc…
Friendships → avoiding eating out may cause withdrawal. May also cause withdrawal due to fear of smelling
bad, causes isolation and if prolonged, depression.
● Bi-direction relationship between depression and smelling disorders.
○ Depression worsens sense of smell (appear to have worst sense of smell)
○ Sense of smell may cause depression.
Romantic relationships → we get comfort from the smell of a partner. May induce feelings of distance with
partners and friends.
Relationship with yourself → not smelling yourself or not recognising it may cause a sense of disconnect with
yourself; identity issues.
Is it Possible to Recover? → yes.

● Human olfactory system is adaptive due to its regenerative nature
● Olfactory training (OT)
The role of awareness → individuals who have not become fully aware of their disorder have been found to not
be as impaired as those who have become aware of it. Maybe more psychological.
Workshop: experiencing a temporary state of anosmia
Guest Lecture - Nudging
Nudging → Any aspect of the choice architecture that alters people’s behaviours
Psychologists are familiar with this → have been trying ways to change behaviour for very long.
Exists in many forms
46
● Therapy
● Prevention Programmes
● Education Programmes
The person whose behaviour is being changed is aware that that is what's going on → being told what to do and
being aware of the problem (conscious behaviour change).
Intention-behaviour Gap: nudging comes into play → the reason for making bad decisions
What causes ‘bad’ decisions → dual system theory (thinking fast and slow)
We have two ways of operating while making decisions: impulse and rationality
● The hot system is dominant when you
○ Temporarily have low cognitive capacity (occupied mind)
○ Have had alcohol
○ Are mentally tired
○ Are in a more emotional than rational state
Impulse and fast → means taking shortcuts which we take quite often (heuristics or biases)
● A decision process that takes a shortcut is also known as a cognitive bias
● Cheerleader effect (how i met your mother) → ‘people seem more attractive in a group than when
considered individually’ → assigning the same attractiveness to every member of the group.
○ People are rated more attractive when in a group than when isolated.
● Decision making and perception can be shortcutted.
Availability heuristic → the more mentally available memories are the more you believe the event will happen
again.
Biases are used when you are somewhat compromised (tired, occupied) → e.gEnvironmental factors like
promoting unhealthy foods.
● Mindless eating: people take a lot of decisions and don't always do so while being fully aware.
Heuristics applied to behaviour

1. Consumption norms
People tend to perceive the portion offered to them to be the norm.
● Different entree sizes offered (Rolls, Morris & Roe, 2002)
○ Increased portion sizes by 73% → people still consumed the same portion.
○ Portion distortion
● Reducing portion size (sometimes) leads to decrease in consumption (Freedman & Brochado, 2010)
○ Decreased standard portion by half.
○ Less consumption of fries.
○ Students did not compensate with a second portion.
■ However: other research found no or very temporary effects
● Smaller portion sizes
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2. Environmental cues
The smell of food leads to eating (Fedoroff et al., 1997; 2003)
● Indirect evidence: people with a poor sense of smell do not like to eat as much
Seeing food leads to eating (Painter et al., 2002): availability of food nearby makes you eat.
● Playing around with availability.
○ Edwards, 2014 → putting a cardboard doctor cut-out at the entrance of a supermarket led to
more buying of fruit.
○ Papies & Hamstra, 2010 → Putting healthy recipe on the door of a butcher led to less snacking
However this can also reverse effects (Chernev 2011)
● Hamburger + carrot = healthy?
○ Estimated calories
○ Subways vs. mcdonals (Chanon & Wansink 2007)
● a) availability heuristics
3. Social Influences
Social modelling: how much someone eats is dependent on the behaviours of others
Mainly when (Cruwys et al., 2015)
● You want to be liked by others
● You identify as being similar to others
● (unhealthy) snacking is concerned
Social norm: the implicit or explicit rules a group of people has about what is acceptable in terms of behaviour,
values and options
● Injunctive norm: what others think you should do. (may make people defensive). Can have reverse
effects
● Descriptive norm: (works better) what you think others do.
Easter eggs experiment (Prinsen et al., 2014)

● Counter of the bakery uses a bowl of easter eggs. Next to it:
○ Empty bowl with wrappers
○ Empty bowl
● Or: subjects are asked to taste a healthy or unhealthy snack. The trash can in the room
○ Is empty
○ Contains mainly healthy wrappers
Eating fruit:
Changes in the choice architecture that influence’s peoples choices in a predictable way by making use of
individuals automatic decision-making processes, without forbidding any option of making an option more
costly in terms of time, money, trouble, or social sanctions.
● Education information provision is not part of this process
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● No rules and regulations

● Taking away unwanted options
Default nudge: known example → organ donation

● Default nudge is most effective
Summary
● Nudging matches with the mindless way in which people make decisions
○ Make use of biases/heuristics
○ Freedom of choice stays intact
● Nudging
Guest Lecture - Sex
The State of Adolescent Sexual Health and Reproductive Health
What is ‘normal’ sexual health development?

Normal = average
● how (statistically) often does it occur?
● Psychological: does the person suffer from it?
● Legal: is it allowed by law?
Definition: (in slide) (WHO, 2002).

● Ecompasses: body image, sexual risks, beliefs and emotions, (sexual behaviour most researched)
Young people’s sexual health in the netherlands (2017)

● 12-25 year olds, online questionnaires, representative.
● Results: included a range of sexually related activities.
○ Adolescents are having sex younger (interpret the graphs)
○ Not only in the Netherlands → neighbouring countries there is the same observed effect.
○ US (15 → 18)
Why do today's youth start having sex later?
● Qualitative study:
○ Make your life a success, make good choices → perfectionism is on the rise in younger
generations (expectations they place on themselves).
■ There are high expectations for the ‘event’
■ Perfectionism across different domains of life is increasing.
○ Insecurity due to gender norms and ideals of beauty.
○ Rather use an app than meet in real life
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■ Increases the bar for dating in real life.

○ Older when you go out → older when you kiss. Cannot isolate this trend, it's in association
with other behaviours.
■ Other behaviours have shifted, such as going out and drinking.
■ “Younger less likely to go out and drink… where a lot of the sexual tension happens”
Experiences with sexting
● Not common amongst young people.
Conclusion
● In slides
Later sexual debut = positive?

● http://content1a.omroep.nl/urishieldv2/l27m257a80c21d0fa44a006459f947000000.790bd813ebc12ccd
2bc19d89637f4eeb/nos/docs/200617_seks.pdf
Part 2: Sex education → towards a sex positive future

‘Double Dutch’
● Simultaneous use of condom and hormonal contraceptive (among youth usually the contraceptive pill)
● Protection against STDs and pregnancy
● Teenage pregnancy rates are very low
Explanatory factors for the high use of contraceptives among youth
● Demographic, economic and social factors
○ When looking at the population (relative wealth) → in NL people are relatively wealthy,
inequalities are relatively small as compared to different countries.
○ Poverty is related to teen pregnancy
● Accessibility of youth-friendly health services
○ No minimum age for contraceptive pills. No parental consent needed, completely confidential;
insurance covers the cost.
○ Free STI testing, no minimum age, no GP transfer (referral) or insurance needed.
● Quality of sex education
○ Abstinence only: purity balls (normally only girls who promise to only have sex when
married)
○ Condom use (netherlands campaigns)
Dutch lessons in love

● Start young; ensure age appropriateness.
○ From kindergarten onwards you can begin with sex education, not necessarily about sexual
acts but more about anatomy, similarities and differences between boys and girls; gender;
boundaries; consent.
● Positive approach: acceptance and rights based.
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○ Not only focusing on risks and dangers, more positive interpretations and lessons.
○ Pleasure
● Focus on competence and internal control.
○ Hormones etc…
● Tailor well to specific risk groups.
○ Different approach?
● Comprehensiveness is the buzzword.
Dutch Schools
● Primary → 92% sex education
● High school → 96% sex education
Regulation in the netherlands:
● Increasingly more attention for the positive sides of sex and sexual wellbeing
● Schools MUST pay attention to sexuality and diversity but there are NO guidelines at all
● Only for primary education and the lower grades of secondary education.
○ Inconsistency in the quality of sexual education.
● Basic education: STDs, contraception, pregnancy etc…
○ Poor coverage on other topics → score low marks when evaluated for this information.
○ Even regarding the topics that are most commonly covered there are still misconceptions.
○ Sex education in the Netherlands is not getting better → poor retention of information on
behalf of children.
○ Move beyond biological functions → dating, consent, relationships, etc…
■ Safe environment, confidence on behalf of teachers.
■ Integrate and normalise sexual and gender diversity.
■ Competence from teachers to educate children regarding these topics.
● Sexual pleasure
○ Teachers are uncomfortable bringing the topic up → only 33% of the schools discuss the idea
of sex being pleasurable.
● Importance of including pleasure in sexual education
○ Providing inclusive CSE → improves sexual autonomy → increases sexual well-being.
○ Pleasure is not trivial as it leads to more consent and a greater consensual experience.
Can prevent sexual violence, understand the orgasm gap.
51

Health Psych Notes Chapters 1,2,7

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Health Psychology UCSSCPSY37 Spring 23’

Chapters 1, 2 and 7 (BOOK + LECTURE)

Chapter 8 - Illness Cognitions

What does it mean to be ill?

What are illness cognitions?

All stages continue to occur

A. Symptom perception → i.e., ‘I feel a pain in my chest’

Mood, Cognition, and Social Context

Anxiety shows increasing self-reports of pain experience.

B. Social messages → i.e.,‘doctor has diagnosed the pain as angina’

A. Coping with the crisis of an illness

The Coping Process

Illness Related General Tasks

Dealing with pain/symptoms Preserving emotional balance

Developing + maintaining relationship with Sustaining social relationships

Preparing for an uncertain future

Appraisal focused Problem focused Emotion Focused

Cognitive redefinition Taking problem-solving action Emotional discharge

Cognitive avoidance or denial Identifying rewards Resigned acceptance

Implications for the Outcome of the Coping Process

B. Adjustment to Physical Illness and the Theory of Cognitive Adaptation

The Role of Illusions

Evidence for CAT

Implications for the Outcome of the Coping Process

C. Post-Traumatic Growth and Benefit-Finding

● Spirituality and financial stability.

Predicting and Changing Health Outcomes

How Do Illness Cognitions Relate to Coping?

The Central Role of Coherence

Interventions to Change Illness Cognitions

Chapter 4 - Eating Behaviours

The Impact of Diet on Health

Diet and Illness Onset

Diet and Treating Illness (ONCE DIAGNOSED)

Who Eats a Healthy Diet?

A lot of research has explored why

A Cognitive Model of Eating Behaviour

Broader Impact of Cognition

A Developmental Model of Eating Behaviour

○ Impact of exposure to new foods is accumulative

Reward Eating Behaviour

Food and Physiological Consequences

A Weight Concern Model of Eating Behaviour

Dieting and Restraint Theory

Role of Control: from dieting to overeating

Dieting and Weight Loss

NOTES FOR FINAL:

Good person-environment fit → low stress

Early Stress Models

○ Alarm: increased activity, occurs upon exposure.

● Issues with Cannon and Selye Models:

Transactional Model of Stress

○ Primary appraisal: individual initially appraises the event itself

Does Appraisal Influence the Stress Response

Stress and Changes in Physiology and Behaviour

Does Stress Cause Illness?

Chronic / Acute Stress Model

Links between Acute and Chronic Stress

Physiological moderators of the

Physiological Moderators of the Stress-Illness Link