Psychology

ZNOTES.
ORG
UPDATED TO 2021-23 SYLLABUS
CAIE A2 LEVEL
PSYCHOLOGY
(9990)
SUMMARIZED NOTES ON THE PSYCHOLOGY AND HEALTH SYLLABUS
CAIE A2 LEVEL PSYCHOLOGY (9990)
Participants were also asked general questions about

doctor’s attire
1. Patient-Practitioner The interviewer sampled patients at different times of
day on five
occasions at each surgery, seeing an average
Relationship of over 70% of
available patients
Results:
1.1. Practitioner and Patient Patients significantly preferred male doctors wearing
a formal
suit and tie
Interpersonal skills Patients also preferred female doctors wearing a
white lab
coat
Non-verbal communication (Mckinstry & Wang, Older patients, as well as higher class patients
1990) preferred traditionally dressed doctors
28% reported that they would be unhappy seeing
Investigated the role of practitioner’s appearance as a informally
dressed doctors
form of
non-verbal communication Some patients also disliked their doctor wearing a
white
lab coat
A total of 475 patients, seeing 30 doctors from five 64% of patients said that the way their doctor dresses
general medical
centres in Scotland were recruited
was quite or very important
Procedure: Interviews were given to the participants Female doctors received higher ratings than male
regarding
their opinions on eight photographs doctors
The photographs consist of five male doctors and three 41% of patients were confident about the formally
female
doctors, wearing different attire dressed doctor’s ability

Mckinstry and Wang observed that it would have been

useful to
include a female doctor in a formal suit
This has been included in the preference for the female in
the white
coat might have not been so apparent
Verbal Communication (Mckinlay, 1975; Ley, 1988)
Investigated the communication barriers between

patients and doctors
Specifically focused on doctor-based errors, which can
have
methodological flaws such as not using independent
raters
Mckinlay (1975)
Conducted a pilot study into the words which the
doctors
used in a Scottish maternity hospital
These words were classified as commonly used
among patients,
incomprehensible to patients or
in between these two
brackets
Of the 57 words tested, only 13 fell into the middle
bracket
These 13 words became the focus of the study as
they
represented the ‘gray area’ of verbal
comprehension
Participants were interviewed to test their
understanding of
the words
They were asked to read the word, hear it being
They were asked:
used in a
sentence and were asked to define the
Which doctor they would feel happiest seeing for the first word
time
(0-5 rating scale) Patients’ responses were verbatim on a standard
Whether they would have more confidence in the ability identified
by the patient’s number and then
of one of
these doctors scored by two independent
doctors (male and
Whether they would be unhappy about consulting any of female)
them These scorers were working ‘blind’
Which doctor looked most like their own doctor They were unaware of individual participants or
the other
doctor’s score
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One year after data collection, the group of As the interview assured that only the doctors would
doctors working
on the ward were asked to be
“tested”, this ensured that participants are not
indicate the words’ level of
understanding they psychologically harmed by being reassured
would expect for a typical patient to
have for each Ley
word Ley’s proposals have great application into improving
The scale used ranged from A (not understand at doctors’ practices
all) to D
(understand pretty well)
The scorers were reliable, giving the same or Issues and Debates:
similar
ratings
In the scores obtained, patients who underused General
the medical
services were less likely have an Doctor’s beliefs will have a deterministic effect on
adequate understanding of
the words in patients’ behaviour
comparison to regular users By underestimating their comprehension, doctors
Regular users had worse comprehension for may bring a
situation at patients may have a hard
‘navel’ and
‘rhesus’ time understanding
Women who had at least one child were slightly Mckinlay
more likely
to comprehend words than those Mckinlay’s findings have great application to everyday
attending the hospital in
their first pregnancy life,
suggesting that doctors should use
Only for ‘purgative’ was the women’s understandable terminology to
their patients, as
comprehension score
lower in both groups some patients may not understand some terms
The women did have some knowledge, such as This study also displays individual and situational
claiming that
‘rhesus’ was about ‘your blood group’ explanations as there are individual differences in the
which was not deemed
to be an adequate patient’s knowledge, as well as situational factors that
understanding the
doctors may expect when consulting with patients
Ley (1988) Mckinstry and Wang
Reported on the frequency at which patients Mckinstry and Wang’s findings show individual and
forget the
verbal advice given to them by doctors situational explanations, as some patients may have
This forgetting is linked to several factors such as individual
preferences on their doctor’s attire
the
amount, order, perceived importance and
nature of the
information given 1.2. Practitioner Style and Diagnosis
Age, anxiety and medical knowledge also
contributed to
forgetfulness Practitioner style: Doctor and patient-centred
To improve relationship, Ley suggested that a
(Byrne and Long, 1976; Savage & Armstrong, 1990)
practitioner
must use simple language, state the
key information
first, advice which is categorised Focused on the interactions between patients and
and repeat the key
points practitioners
Evaluation: Byrne and Long (1976)
Mckinstry and Wang Investigated the interactions between patients and

This study utilized a wide representative sample from practitioners
different doctors and clinics. Tape recorded and analysed about 2,500 medical
This reduces demand characteristics, as shown by the consultations in
several countries
fact
that some patients claimed that the doctor’s They found that each practitioner tended to use a
attire was not
important. consistent
style for all patients being treated
However, if a photograph of a female doctor in a
Most of the styles were classified as either doctor-
formal suit
was part of the choices, the preference for centred
or patient-centred
the female doctor in
the white coat to be less They commented that few doctors could cold reflect
apparent on the
dynamics and process of the consultation
There could be pressure for women to conform to a From the tape recordings, they recognised six phases
stereotype, for example, there were more objections that
doctors went through in this consultation
towards a
female in jeans over a male. process:
Mckinlay Establishes a relationship with the patient
The usage of blind scorers and clear interviews Attempts to discover the reason for the patient’s
ensured
the validity of the data gathered attendance
The procedure is also standardized, which can Conducts a verbal or physical examination or both
increase
reliability The doctor, the patient or both of them consider
the
condition
WWW.ZNOTES.ORG
The doctor, and occasionally the patient, details Testing is a much more expensive and mostly, invasive
further
treatment procedure
that are given to those who manifest clinical
Ends the consultation indications of
disease, and are most frequently applied to
confirm a suspected
diagnosis
Most of the 2,500 consultations underwent this process
Doctor-centred consultations tend to ask closed Disclosure of Information (Robinson & West, 1992)
questions
that require brief answers such as ‘yes’ or
‘no’ Investigated on whether computerization leads to greater
They also focused on the first problem the patient disclosure
compared to paper questionnaire
gives Recruited 33 male and 36 female participants from a
Doctor-centred doctors also tend to ignore any other Genito-urinary
(GU) clinic in England
problems
that the patient might have had Ages ranged from 15 to 49 years with a mean of 27 years
Patient-centred doctors had a less controlling role They were randomly assigned to either computer
They tend to ask open-ended questions such as ‘Can interview or paper
interview
you describe
the situation when pain occurs?’ It consists of a comparison of the data collected from the
These questions allow the patient to relate more computer
interview and the patient questionnaire
information and
introduce new facts that can be Due to withdrawal and computer errors, 37 participants
pertinent are in the
computer condition and 32 in the paper
They also avoided medical jargon and allowed the condition
patient to
participate in decision making Participants were asked to complete their case histories
through
either a computer or paper-based questionnaire
Savage and Armstrong (1990) After this, the patients underwent a consultation with
their doctor,
complete with a physical examination
Compared the effect of directing and sharing styles of Data collected were from the doctor’s interview, with
consultation three specific
data:
They used randomised allocation to conditions to test Number of symptoms reported
how
satisfied patients felt when undergoing these Number of reported previous attendances at GU clinic
approaches Number of sexual partners the patient had in the last
A random sample of 359 participants between the 12 weeks
ages of
16 to 75 presenting any symptoms were Found that both paper and computer interviews yielded
eligible more symptoms
than doctor’s interview
Each patient was asked for their consent to have their Mean number of sexual partners increased in the
consultation recorded computer condition
Patient satisfaction was measured by two Data is not statistically significant
questionnaires that
asked about the quality of Computer interviews will elicit more information from
communication in the consultation and
any thoughts, patients than
paper questionnaire with regard to
immediately and one week later personal symptoms
From 200 results, they found that both consultation Suggests that patients are unwilling to disclose all their
styles had
high ratings symptoms
within a consultation
However, directing consultations had reported more Computer-based interviews are elicited to support
satisfaction
with their doctor’s explanation doctor’s diagnosis
This implies that authoritarianism and certainty are
elements of
the doctor’s style that satisfy the patients Evaluation:
the most
Byrne and Long
Practitioner Diagnosis: Type I and II errors The usage of tape recordings only recorded the usage
of
verbal cues. This ignores non-verbal cues such as
Type I Error: the practitioner diagnoses a patient as bodily
gesture and interpersonal skills
healthy
when he is actually ill. As there was a large amount of recordings used
Type II Error: the practitioner diagnoses a healthy patient around the world,
Byrne and Long’s study is
as
ill generalizable to different
populations
Type I and II errors may occur at any point throughout a As all consultations are recorded, the researchers can
patient’s
illness from screenings, consultations and gather a
lot of qualitative data to be analysed, but it
treatment stages can be too
subjective and reduce reliability
Screenings involve cheap tests that are given to large Savage and Armstrong
populations, many of whom will not manifest any clinical This research used an independent measures design.
indications
of disease, such as smears This
means that participants are in either of two
conditions. This
may introduce confounding variables
WWW.ZNOTES.ORG
as other patients may

prefer using computers over People with this disorder believe that normal sensations
paper as a form of disclosing
information or minor
symptoms as a sign of illness with negative
outcome
Issues and Debates: For example, a person may fear that perspiring can lead
to heart
attack
For both Byrne and Long & Savage and Armstrong’s It is often accompanied by several mental illnesses such
studies as
obsessive-compulsive disorder, phobias and
The findings for Byrne and Long, as well as Savage somatisation disorder
and Armstrong
have relevance to everyday life, Hypochondriasis is a chronic illness that can begin at any
suggesting that doctors
should be aware of their time of a
person’s life, especially within the age range of
communication style when dealing with a
patient 20 to 40 years
These studies display individual and situational Despite being classified as a somatoform disorder
explanations on why patients can prefer different
styles of
their doctors’ consultation styles
There is also cultural bias when considering the
findings of
communication techniques. Some cultures
could prefer a direct
approach when handling a
doctor. Both studies conducted were
conducted in the
West.
1.3. Misuse of Health Services

Patients may sometimes misinterpret their illnesses or delay
their
treatment or seeking of medical advice. This section will
also deal with
two disorders: hypochondriasis (a fear of
illness) and Munchausen
syndrome.
Delaying Treatment (Safer et al, 1979)
Investigated the likely factors that can influence delays in Munchausen Syndrome (Aleem & Ajarim, 1995)
seeking
medical treatment
Conducted a study in waiting rooms of four clinics in large Characterised as physical or psychological symptoms that
inner-city hospital are
intentionally produced in order to assume sick role
Interviewers approached patients waiting for a doctor or Named after Baron Munchausen, a famous German
nurse aristocrat, known for
telling unbelievable tales of his
They were asked if they were going to tell the doctor exploits
about a new
symptom People with this condition intentionally produce or
If patient was presenting new symptom, they were asked pretend to have
physical or psychological symptoms of an
to take part
in the study illness
93 patients (38 males, 55 female) with an average age of Their main intention is to play sick and have others care
44 years
were interviewed for them
They were asked about their symptoms and their Patients suffering from Munchausen Syndrome may
reactions to the
symptoms, as well as the length of their spend years going
from one doctor to another while
delay pretending to have an illness
The interview lasted for 45 minutes They may pretend to have psychological symptoms
Safer et al identified three stages of delay: (hearing voices),
physical symptoms (pain and aches), or
Appraisal Delay – defined as number of days that try to make themselves ill by
infecting themselves
elapsed
from the day the patient first noticed their There are four ways in which these patients behave:
symptom up till the
day that they concluded they
Lying about symptoms
were ill
Tampering results
Illness Delay – the time it takes between realizing that
Self-infliction (cutting or burning)
patient is ill and deciding to seek medical advice
Aggravating pre-existing symptoms
Utilisation Delay – the time it takes between seeking
medical advice and actually doing so
Aleem and Ajarim (1995)
Misuse: Hypochondriasis (Barlow & Durand, 1995)

Case study of a 22-year-old female university student who
Persistent fear of serious medical illnesses was
referred with painful swelling over the right breast
WWW.ZNOTES.ORG
From the age of 17, she had been seen by hospitals

regularly for
issues relating to her menstrual cycles 2. Adherence to Medical
She developed symptoms similar to deep vein
thrombosis and was
referred to medications, which did Advice
not work
Soon after the swelling, she reported swelling in her groin A major issue to consider with adherence to medical
area requests is the type
of behavior we are asking somebody to
Following physical examinations and investigations, she do. These types of requests can be
categorized into:
was
diagnosed with hematoma
She was treated with antibiotics, but surgical drainages Requests for short-term compliance
were needed
as she developed abscesses Requests for positive additions to lifestyle
At this stage, doctors were suspicious of the cause of Requests to stop certain behaviours
abscesses Requests for long-term treatment
Upon finding a syringe with faecal matter, the woman Adherence: following advice given by a medical
was confronted
and left the hospital angrily practitioner
Evaluation 2.2. Types of Non-adherence and why

Delaying Treatment
patients don’t adhere
Safer’s study uses self-reports to explain why patients
There are many reasons on why patients could not always
delay their treatment. There are issues with validity as
adhere to
medical advice. Non-adherence can fall into two
patients can answer desirably
categories:
patient-based and doctor-based behaviours.
The sample used in this study is large and
represented both
male and female populations. This
Types of Non-adherence and problems caused by
has high population
validity which can allow the
researcher to generalize the
findings to the general non-adherence
population
Non-adherence to medication is complex health-care
problem.
Issues and Debates:
The causes can be related to the patient, treatment and
Delaying treatment the type of
health care provided
Safer et al’s findings have good application to As a consequence, patients do not benefit from correct
everyday
life as practitioners can put interventions to diagnosis and
treatment, increasing morbidity and
stop such
delays mortality
Hypochondriasis Morbidity: incidence of disease across a population
Mortality: rate of death in a population
Understanding hypochondriasis can further support
the
development of treatment programmes that can Here are some possible ways that a patient may not
reduce the
number of times a patient presents adhere to medical
requests
himself to a medical check-up
Before treatment Poor description of treatment programme
This reduces costs and prioritizes those who really
need
medical attention During Takes more or less of a drug than has
For both Hypochondriasis and Munchausen Syndrome treatment been prescribed
Mental illnesses such as Hypochondriasis and Take the drug at a different time from
Munchausen Syndrome
may have individual and that instructed
situational explanations towards
their origin. For May not complete prescription
example, there have been suggestions stating
that Only attend some clinics and follow-up
childhood trauma, as well as personality disorders appointments
may
cause these illnesses.
Not completing exercises (physical
The Nature versus nurture debate is also considered,
therapies)
as
there could be biological and psychological triggers
(e.g.
hormone release) to these illnesses May end their course of treatment early
After treatment
Majority of research on hypochondriasis and or fail to attend sessions
Munchausen Syndrome
have been conducted on May revert straight back to behaviours
Western patients, which can lead into
cultural bias in that were changed through the treatment
understanding these disorders and the
development
of these treatment programmes. Non-adherence can also be influenced by the patient’s
context of the
treatment provided.
WWW.ZNOTES.ORG
Patient decides that they don’t need Perceived Seriousness

Patient
treatment Perceived Susceptibility
Patient does not understand treatment Cues to Action
The cost-benefit analysis looks at whether the perceived
Patient decides the cost of treatment
benefits
exceed the perceived costs
are more than benefits
The barriers may include:
Social support and demographic factors Financial (e.g. prescription charges are too expensive)
Treatment Treatment programme is time Situational (e.g. difficult to access clinic)
programme consuming and expensive Social (e.g. don’t want to face ageing)
Access to treatment programme is not Benefits can include:
easy Improved Health
Health care Doctor does not stress importance of Relief from anxiety
provider treatment Reducing health risk
Doctor does not give adequate details ‎

on how to administer the drug
Rational non-adherence (Bulpitt, 1994)
Rational Choice Theory is a framework for understanding

and
modelling why an individual will behave in particular
way
Rational: based on or in accordance with reason or
logic
Claims that people weigh the costs and benefits of a
certain
treatment
If costs are higher than benefits, an individual would not
change
their behavior to adhere to medical requests ‎
Bulpitt (1994) reviewed several studies involving a cost-
benefit
analysis when deciding on the course of action In 1974, Becker developed the Compliance Model,
that patients would
take building heavily
on the Health Belief Model
Drug treatment for hypertension in elderly patients was It was used to explain why a patient might comply with
considered
by the researcher medical
requests
Found that both the EWPHE AND SHEP studies had many The model can predict factors that would influence the
health
risks to drug treatment in the elderly such as gout, likelihood of
a patient adhering to medical request
changes in bowl
movements and chest pain Perception of the patient’s mother are examined as it was
The MRC trial for elderly patients found that coronary believed
that the mother would usually be the one who
events
reduced by 44% with a mixture of prescribed will decide on whether
the child is sick or not
drugs The Compliance Model introduces the concept of health
Bulpitt concluded that the benefits from treating motivation
combined systolic
and diastolic hypertension in elderly It considers both negative (physical threat) and positive
patients outweigh the
disadvantages aspects
(awareness of health concern)
When considering the benefits of antihypertensive The second concept introduced is that of incentive value
treatment, it is
important to consider benefits other than of
adherence
stroke reduction These are factors about the illness that contribute to the
He also referred to the difficulty in measuring cost-benefit decision
to adhere such as the child’s vulnerability and
interactions in individuals the degree of harm
This model is supported by a study conducted in 1971
Health Belief Model (Becker and Rosenstock, 1974) where a random
sample of 125 cases were drawn from a
population of children being
treated in the
Aims to predict when a person will engage in preventive Comprehensive Child Care Clinic at a large teaching
health
behaviors hospital
The likelihood that individuals will follow medical advice The children were aged from six weeks to ten years and
depends
on two assessments that they make: evaluating were all
placed on a course of liquid oral antibiotics and a
the threat and a
cost-benefit analysis follow up visit
When evaluating a threat, there are several factors that An hour-long interview was conducted with each patient
can
influence a person’s perceived threat of illness, after the
doctor’s appointment
including:
WWW.ZNOTES.ORG
Adherence was operationalised by asking the name of the Both adolescents and parents were given a further
medication, the number of times a day it should be given questionnaire
to be completed at home with a self-
and the
date of flow-up appointment addressed return envelope
The results showed that mothers who adhered to various If the questionnaire was not returned within ten days
aspects of
prescribed treatment were more interested in of the
interview, the family was called once to remind
their child’s health
and were concerned about the them
present illness 80 out of 94 families consented to participate in the
They perceived illness as a substantial threat to the child, study,
took part in the adherence interview and
but had
confidence in the physician’s ability and completed the
demographic questionnaire
medication to reduce the
threat 52 of these families had at least one family member
return to
the follow-up self-report questionnaires
Issues and Debates: Medical records were reviewed for each participant to
Individual-Situational Debate: reasons on why gain
information about the number of blood sugar
patients could
not adhere may vary between tests taken per day
as a measure of adherence
individual and situational
explanations The families were categorised into three groups,
Situational explanations would often revolve on participants
(52), non-returners (28) and non-
environmental factors that can affect adherence, consenters (14)
such as
levels of educations, income and family The results showed significant differences in
networks adherence levels
between study participants and
Individual factors put more emphasis on the those who did not return their
self-reports
personality
factors of the individual, as well as a The families who returned their questionnaires had
cost-benefit
analysis adolescents
with higher adherence interview scores
Applications to everyday life: and blood sugar tests
more than those who did not
Doctors can use these reasons to stress the return their questionnaires
patient’s gains
by following the medical advice by Evaluation:
reducing the costs Self-reports are a good way to identify adherence to
Cultural Bias medications
There can be different factors exclusive to other It is most applicable for both drug-based and physical
countries
that can affect adherence to medication therapy
(e.g. economic
status)
Objective: Pill Counting (Chung & Naya, 2000)
2.3. Measuring Non-Adherence
Tested compliance with treatment featuring an oral
Self-reports (Riekart & Droter, 1999) asthma medication
using the MEMS Track Cap
57 patients (32 male) formed the sample
Self-report measures involve asking the patient or the The sample had a history of asthma
doctor if the
patient if he is following their treatment An initial screening of two to three weeks was followed by
programme a 12-week
treatment period
The validity of self-reports is limited because of the Participants were instructed to take the asthma
challenges
associated with gaining information without medication twice a
day
response bias At the start of treatment, they were given 56 tablets with
one-week
supply to spare
Riekart and Droter (1999) Tablets were dispensed in screw-top bottles fitted with
Investigated the implications of studies using self- TrackCap
medication event monitoring system (MEMS)
report
measures to investigate adherence to medical device
treatment for
adolescents suffering from diabetes
It was felt that participants who refused to be involved The MEMS composes of two parts:
in the
research might have less adherence than those A standard plastic container
who took part of
the study A lid containing a computer chip that registers the
The participants were adolescents between the ages time of
opening and closure of the container
11 to 18
years old who were living with at least one
Patients were then scheduled to return to the clinic every
parent
three
weeks for four more visits
Participants were excluded if they were diagnosed
During these visits, comparisons of tablet counts and
with diabetes
within the last year, had an additional
TrackCap
monitoring
chronic illness or had
evidences of a learning disability
Each patient was told “Take one tablet in the morning and
An interview was conducted after their appointment
one
tablet in the evening approximately 12 hours apart.
at the clinic
while the parents answered a
Do not take the
tablets at mealtimes.”
demographic questionnaire
WWW.ZNOTES.ORG
Median adherence was 89%, according to TrackCap Issues and Debates:

events Applications to everyday life: Understanding the
On days when patients took two tablets, mean time effectiveness of such measures of non-adherence can
between doses was
12 hours and 34 minutes with tablets allow us to
identify the most reliable methods for
taken eight to 16 hours apart
on 86% of treatment days investigating adherence
On tablet counts, median adherence was 92% Validity: Self-reports can be questioned as patients
can
sometimes be prone to lying about their
Biochemical Testing (Roth & Caron, 1978) adherence levels
Physical measures of adherence are more objective,
Considered the relative merits of a variety of methods as they
use biological characteristics (e.g. levels of
that can be
used to investigate adherence drug in the
blood) as a form of measurement
Suggests that self-reports from patients are correct when Riekart and Droter uses children as participants. This
they say
that they are taking little or no medicine means
that their data may be more prone to demand
Self-reports are overly estimated when patients say that characteristics
by answering in a desirable manner.
they are
taking their medicine regularly It is important to question the ethical concerns
Doctors usually overestimate patient’s intake of medicine within
the study, most notably, protection and
Reliability in keeping appointments is not a good measure informed consent
of
adherence Evaluation:
States that pill counts provide an indication of self-intake Self-reports
but it
cannot presume that the pills were taken Self-reports are a quick way to identify adherence
Medication monitors indicate when as well as whether levels.
the medication
was removed from container These are applicable for both drug and treatment
Blood and urine testing usually provide a reasonably programmes
good indication
of amount of medicine taken However, self-reports can be prone to social
Clinical responses or side effects can be indications that desirability
medicine
is taken Pill Counting
Biochemical tests that measure drugs can be used to Reliable method for measuring the amount of pills
monitor drugs
and metabolites can be used to monitor taken per
interval
plasma concentrations of a
number of drugs used on However, it does not track what the user does to
cardiovascular system the drug,
whether if they consume it or dispose it
Biochemical testing can be used to monitor adherence to Biochemical
medical
treatment and empirical evidence has shown Subjective method of measuring adherence
that adherence for
prescriptions are higher with frequent However, it can be very costly and time-consuming
urine monitoring It may also involve invasive procedures if blood,
These measures are reliable and objective saliva or
urine are needed
Repeat Prescriptions
Repeat Prescriptions (Sherman et al, 2000) Using this measure only informs the researcher
that the
pills are collected from the pharmacy
Investigated on how obtaining a prescription refill history
could
identify poor adherence with asthma medications
116 children with asthma were interviewed with their
2.4. Improving adherence
parents or
caregivers on a visit to the clinic
One of the questions asked to them were if measures of Improving Adherence (Ley, 1988; Atreja et al, 2005)
estimated
adherence on a checklist and a question on
Reviewed a selection of studies of practitioners and
where they obtained the
medications
Adherence was operationalised by calculating the hospital
patients
number of dosages
refilled divided by the number of Found that 28% of patients in the UK had low satisfaction
ratings of
the treatments they received
doses prescribed over up to a
period of 365 days
Dissatisfaction was even higher in hospital patients, with
The patient’s doctor was asked to make a judgement
41%
giving low satisfaction ratings of their treatment
about their
adherence by estimating if patients were
taking the required dosage
of their inhaler based on case Ley suggested that patients are “information seekers”
history and clinical judgement who want to
know the details of the treatment and their
disorders
Information provided by pharmacies were 92% accurate
He suggested that dissatisfaction came from a lack of
Mean adherence was 72%, 61% and 38% for the three
emotional
support, as well as the doctor’s understanding,
different inhalers
prescribed to patients in the study
Doctors were able to identify 21 of 49 patients who lack of information
when prescribing drugs or the failure
refilled less
than 50% of their dosages to explain the patient’s
disorder
The more information the patient receives, the more that
Three of 11 patients used their inhalers excessively
he can be
satisfied
WWW.ZNOTES.ORG
Despite research on non-adherence being conducted, asthmatics on inhalers

there were no
reported changes in adherence level. They wanted to investigate the effectiveness of the
“Funhaler”
as a form of adherence to child asthmatics
Atreja et al (2005) reviewed the current literature The Funhaler consisted of several features that
regarding
adherence and developed the SIMPLE distract
children’s attention from the drug delivery
mnemonic that brings all the
elements of successful and a form of
self-reinforcement through the use of
adherence methods that an intervention should
have effective breathing
techniques
Simplifying regimen characteristics These distractions can include: a whistle and a
Imparting knowledge spinner that
activates as the child breathes
Modifying patient beliefs 32 Australian children participated in this study and
Patient and family communication were
either given the Breath-a-tech inhaler for a week
Leaving the bias and the
Funhaler for the second week
Evaluating adherence 38% more patients were found to have medicated
their children
the previous day with the Funhaler
Behavioural Techniques 60% more patients took the recommended four or
more cycles of
aerosol delivery when using the
Behavioural techniques can be used to increase
Funhaler
adherence to
medications.
These techniques, according to behaviourists offer a
number of
suggestions to improve adherence, such as
changing habits using
classical conditioning, positive
reinforcement to encourage positive
behaviours and
using role models to show importance of adherence to
medical requests
Monetary Incentives (Yokley & Glenwick, 1984)
Evaluated the impact of four conditions for motivating
parents
to take their children to be immunized
These conditions include:
Mailed General Prompt (n = 195)
Specific Prompt (n = 190): received a personalized ‎ ‎
message containing the exact details of the An image of the Funhaler used in Watt et al (2003)
immunizations
the child needed
Increased access (n = 185): received the specific These studies display the effectiveness of behavioural
prompt
and a second page that included the techniques
that can be used to increase adherence.
mention of two off-hours
clinics being opened
Monetary Incentive (n = 183): received the specific Issues and Debates:
prompt with a second page that opened with the Practical Applications:
mention of a
raffle with a $175 prize The concepts and theories discussed have good
This condition received a lottery ticket at the end of application to
doctors
the mail. Longitudinal Research: Yokley & Glenwick’s study
Parents in this condition were told on how to join the takes a
longitudinal approach of research into
lottery
that provided 3 prize pools, worth 25,50 and studying adherence to
medical requests. This allows
$100 researchers to see the impact of
an intervention over
The impact of the different prompts was measured a long period of time
over the
following of 12 weeks to assess how many of Usage of children: Watt et al illustrates how
each group would
attend the immunization psychological
reinforcers in the form of turning an
Results show that the monetary incentive condition inhaler into a fun
experience can improve the child’s
had the
biggest impact on attendance, followed by use of their inhalers
the increased access,
specific prompts, and general Evaluation:
prompt groups, respectively Yokley & Glenwick’s study was conducted on a large
It appears that monetary incentives provide sample.
This gives out high population of validity
immediate adherence,
but specific prompts were a Participants in Yokley & Glenwick’s study may also
cost-effective option bring ethical
concerns, relating to informed consent
Funhaler (Watt et al, 2003) and deception.
Making children’s medical treatments “fun” can have As the researchers asked parents to come in an actual
positive
consequences on adherence setting,
this can give ecological validity and can be
Watt et al stated that poor adherence to prescribed generalized to
other populations
frequency
remains a major problem for paediatric
WWW.ZNOTES.ORG
Caused, increased or prolonged by mental, emotional or

3. Pain behavioral
factor
Caused by psychological pain
Headaches, back pain and stomach pan are the most
3.1. Types and Theories of Pain
common types of
psychogenic pain
Phantom limb pain refers to ongoing painful sensations
Acute and chronic organic pain
that come
from a removed limb
Acute pain begins suddenly and is usually sharp in quality After amputation, the amputee may continue to have
This can be a warning for disease or a threat of the body awareness that
the removed limb is still part of them and
experience sensations
linked to it
Acute pain can be caused by many events including: These sensations are also present when children are born
Surgery without one
of their limbs, suggesting that phantom limb
Broken bones pain is ‘hard wired’
Dental work
Burns or cuts Melzack (1992) reviewed evidences on phantom limbs
Labour or childbirth and noted
several remarkable features:
Phantom limbs have a vivid sensory quality and
They can either be temporary and not severe or severe precise location
in space
and can last
for weeks Phantoms have a wide range of sensations such as
Chronic pain persists regardless of the healing of the warmth and
itchiness
injury A phantom arm would hang down when the person
Pain signals remain active for a long time sits or stands but
moves in coordination with other
Physical effects include tense muscles, limited mobility, a limbs
lack of
energy, and changes of appetite Sometimes, a limb gets stuck in an unusual position
Emotional effects include anxiety, anger, fear of re-injury Patients perceive phantoms as an integral part of
and
depression their body
These can interfere with a person’s life Phantom are also experienced by some people with
spinal injuries
Common chronic complaints include: Wearing artificial arms or legs enhances the phantom
Cancer pain
Headaches Occurs in 90% of amputees with itching as the most
Low back pain common pain
Arthritis pain
Psychogenic pain (pain not due to past injury) 3.2. Measuring Pain
Neurogenic pain (pain due to nerve damage)
Chronic pain can be caused by trauma, injury or infection. Self-report measures (Clinical interview)
This method is the preferred approach to pain

Specificity Theory (Descartes)
measurement
The body has a sensory system for perceiving pain There are multiple tools used to reliably assess pain but
It contains its own special receptors for detecting pain there is
no accepted criterion standard
stimuli and
its own area of the brain Pain intensity, pain quality and pain location must be
When a noxious event stimulates pain, a signal travels to considered
when discussing a patient’s experience of
the centre
in the brain where pain is perceived pain
Pain location is measured by asking patients to identify
Gate Control Theory (Melzack, 1965) the
area of the body where they are experiencing pain
For those who have difficulties verbalizing the location of
Suggests that pain is a combination of sensory pain
such as children, an outline of the body can be used
experience and
psychological gates that can increase or on which the
patient marks the location of pain
decrease the perception of
pain An example of this can be seen in the Pediatric Pain
Argues that the nerve impulses that produce pain passes Questionnaire
through a
series of gates on their way to the brain Pain Intensity can be measured through several different
These gates are influenced by the messages descending means
such as psychometric measures, observations or
from the brain
and other information measuring the impact
of pain (counting the number of
painkillers the person is taking)
Psychogenic pain (Phantom Limb Pain) Pain Quality is measured by self-report measures which
consider
the level of unpleasantness of two measures
(deep and surface pain)
and several descriptions
WWW.ZNOTES.ORG
The second part of the McGill Pain Questionnaire uses Children are first asked to encircle words that best
this method of
measurement describe their
pain and must choose three words that
best describe the experience
of their pain
Psychometric measures and visual rating scales The child was also asked to rate how they feel at the time
(McGill Pain Questionnaire) on a
continuum as well as rating the worse pain they had
on the same
scale
Visual Analogue Scale (VAS): Usually appears as a 100mm Finally, they are asked to pick four colours to mark the
line
with descriptors at either end severity of
pain and colour the part of their body that
Scores can be measured through recording the distance hurts depending on their
colours picked
from the
starting point to the mark
This allows scores to be compared over time Wong-Baker Scale
As pain is subjective and internal experience Uses six faces to measure pain
measurement is usually
carried using patient self-reports The faces ranged from 0 (no hurt) to 10 (hurts worst)
such as the McGill Pain
Questionnaire (Melzack, 1975)
The McGill Pain Questionnaire is the first proper

self-
report pain-measuring instrument
Patients are asked to tick the word in each of the 20
sub-classes that best describes their pain
Based on this, a Pain Rating Index (PRI) is calculated
Patients are also asked to indicate the location of pain
on a
body chart Garra et al (2010) were able to demonstrate significant
difference in the visual analogue scale for each of the
Behavioral and Observational Methods (UAB Pain Wong-Baker
FACES Scale
Behavior Scale) The visual analogue scale was found to have an excellent
correlation
in older children with acute pain and had a
Observations of patient’s behavior when he experiences uniformly increasing
relationship with Wong-Baker FACES
pain Scale
Behaviorists claim that people can behave in certain ways
when they
are in pain Issues and Debates:
Specificity theory is reductionist, as it only explains
Sample behaviors can include: the
source of pain biologically
Complaints All theories of pain have good applications to
Gestures everyday life as
they can help practitioners
Postures understand why we perceive pain and
develop
As a result, they developed pain behavioral scales, such treatment programmes that can help patients
as the UAB
Pain Behavior Scale
Tracks the severity of chronic pain over time 3.4. Managing and Controlling Pain
There are ten types of questions that note certain
behaviors and
each item is rated through a three-
Medical Techniques
point scale (0, 0.5, 1)
The higher the score, the more marked the pain Surgical treatments are used whenever medications do
associated
behavior and the greater the level of not relieve
pain
impairment Such treatments can involve cutting nerve pathways or
Patients can get a score of between 0 and 10 making lesions
in certain areas in the brain
Surgical treatment is usually recommended for people
3.3. Pain Measures for Children with terminal
illness
There are also several physical therapies that can be used
Pediatric Pain Questionnaire (Varni and Thompson, to ease
and manage pain
1987)
These include:
Manual Therapies such as massages
The PPQ is a multidimensional questionnaire for
Mechanical Therapies such as ultrasound
assessing childhood
pain, with separate forms for the
Heat Treatments such as microwave diathermy
child, parents and doctor
Cold Treatments such as ice packs
This questionnaire is heavily based on McGill Pain
Electrotherapy such as electrical nerve stimulation
Questionnaire and
assesses the perceptions of patient’s
pain experience in a
child-friendly format Biochemical treatments such as analgesics and painkillers
can be
used to manage pain.
WWW.ZNOTES.ORG
An analgesic or pain killer is any member of a group of Patients suffering from chronic pain reportedly claim that
drugs used
to achieve analgesia engaging
in an enjoyable activity is the most effective
Analgesia – relief from pain method of diversion
Analgesics act in various ways on the central nervous
systems Morley, Shapiro and Biggs (2004) developed a training
The type of medicine to use depends on the location of program
which taught patients how to use attention
the pain diversion strategies such
as:
All painkillers have side effects Usage of imagery and mindfulness: creating a vivid
For pain associated with inflammation and headaches, and pleasant
image to concentrate
paracetamol or
anti-inflammatory pain killers. Basic attention management: brief relaxation, internal
Pain caused by sensitive nerves can be treated with and
external attention focus
depression
medications Pain coping strategies: coping self-statements, signal
The most popular chemical treatment is aspirin. breathing
Aspirin and other similar drugs such as ibuprofen have Discussion on dealing pain and relationship to pain
three
therapeutic actions: and its
chronic nature
Against pain Attention diversion and mindfulness: focus on the
Against inflammation details of the
experience, mindfulness, breathing
Against fevers exercises
They work on the damaged tissue causing the pain Intense pain and flare-ups
They also have no known effect to the nervous system Pain transformation images
The only drawbacks of aspirin is the number of side
In the first time period until a three month follow up, pain
effects such as
gastric irritation and bleeding, as well as
intensity reduced significantly
deafness
Opiates inhibit pain messages from raveling to the brain Alternative Techniques
They close the gate, preventing pain signals from getting
to the
brain Acupuncture
Morphine and similar drugs such as fentanyl are the Is derived from Ancient Chinese medicine
strongest
painkillers Fine needles are inserted into certain sites of the body
Some medications come in a patch but they all work in for
therapeutic or preventative purpose
similar ways Western acupuncture is the use of acupuncture after
Opiates can only be prescribed after consultation with a a medical
diagnosis
general
practitioner and dosages would be closely Research has shown that acupuncture can stimulate
monitored nerves under
the skin and in muscle tissue
This leads into the production of pain-relieving
Psychological techniques: cognitive strategies substances such
as endorphins
Traditional acupuncture is based on the belief of Qi
There has been a growing acceptance of the value of Qi is said to be a ‘life force’ that flows through the
psychological
interventions body
in channels called meridians
These can include relaxation, biofeedback, cognitive When Qi cannot flow freely in the body, sickness can
coping skills,
mental imaging and counselling result
Cognitive redefinition is where an individual attempts to They believe that acupuncture can restore the flow of
alter
their thinking to replace the thought of Qi
apprehension
This approach is related to distraction therapies Transcutaneous electrical nerve stimulation (TENS)
Cognitive redefinition involves the patient replacing pain- Battery-operated device that has leads connected to
related
thoughts with more positive thoughts sticky pads
called electrodes
Attention management is often included in cognitive When the machine is switched on, the electrodes
behavioral
treatments (CBT) passes small
impulses to areas of the body where you
Patients may have different responses to attention experience muscle pain
strategies and
individual differences in what diversion These impulses can reduce pain signals passing along
techniques are effective as
pain relief methods nerves and
can help the individual relax
The core method of attention diversion to divert attention It is also suggested that electric impulses can
from pain
by refocusing or directing attention to stimulate
endorphins
something unrelated to pain Health care professionals have reported that TENS
According to the Gate Control Theory, attention diversion can help some
people, although it depends on the
can help
close the gates and reduce the perceptions individual and the condition
being treated
Deliberately using imagery, attention diversion and Issues & Debates:
mindfulness to
cope with pain can take many forms Methods of controlling pain must not be reductionist
WWW.ZNOTES.ORG
For example, the biomedical approach explains and Adaptation Syndrome

(GAS)
treats pain in
a simplistic way GAS is a term describing the body’s short and long-term
The most useful application that comes from our reactions
and adaptations to stress to restore
understanding of
pain relief will come from combining homeostasis
both physiological and
psychological techniques. Homeostasis: the control of internal conditions, e.g.
Cognitive techniques are the most useful, as patients temperature and blood conditions
can apply
these techniques anywhere.
The three stages of Selye’s GAS are:
Alarm: prepares the body’s resources for the stressful
4. Stress response
Resistance: the body adapts to the stressor and
Happens when we feel that we are not in control of events in physiological arousal declines but is still above normal
our lives
and can come in many forms, either positive or Exhaustion: the body’s energy reserves are depleted
negative. There are
multiple causes and sources of stress. and the
ability to resist can decline
4.2. Sources of Stress 4.4. Causes of Stress
There are many factors that can trigger stress in the Work (Chandola et al, 2008)
person
One way to investigate the causes of stress is through Investigated which biological and behavioral factors link
investigating
environmental changes which can cause work
stress to coronary heart disease (CHD)
stress 10,308 civil servants from Whitehall, London were
For many people, stress is so common, that that it has recruited
in this study
become part
of their life Data was gathered through questionnaires and clinical
Positive effects of stress can include motivation, as well assessments
as
assisting in performing well under pressure Participants were classified as being under work stress if
The top five sources of stress, according to the American the
report job strain, felt job control was low and felt
Psychological Association include: socially
isolated at work
1. Money (76%) Various follow-up measures were taken, including:

2. Work (70%) Fatal and non-fatal CHD episodes
3. The economy (66%) Biological risk factors (e.g. morning rise in cortisol,
4. Family responsibilities (59%) blood
pressure, waist circumference, etc.)
5. Relationships (55%) Behavioral risk factors (e.g. alcohol, smoking, activity,
diet)
4.3. Physiology of stress and effects on Results indicate that cumulative work stress is a high-risk
health factor
for developing CHD, especially at the younger,
working aged
population
Concerns to the responses of the person to the stressor 32% of effect of work stress on CHD can be explained by
Based on arousal the effect
of work stress on health behaviors such as low
physical activity and
poor diet
Arousal refers to a general physiological state in which Chronic work stress was associated with CHD and this
the
sympathetic division of the autonomic nervous association is
stronger among participants under 50.
system is activated.
Sympathetic nervous system: the autonomic nervous Life Events (Holmes and Rahe, 1967)
system
that controls the internal organs and plays a
role in keeping
the body’s internal environment stable Investigated on what makes a life event stressful
Used case histories and interviews to study a large
The sympathetic division rouses the body to action amount of people
who suffered extreme stress
through
activating physiological mechanisms which Developed a social readjustment scale from these case
produce and maintain
alertness and energy material
Using 394 participants, researchers were able to rank 43
GAS Model (Selye, 1936) events on
their scale
The events ranged from most stressful (death of spouse,
Immediate responses to stressful events generate a high
n = 100) to
least stressful (minor violations in law, n = 11)
arousal
level
Selye observed that long-term adaptation to stress Personality (Friedman and Rosenman, 1974)
followed a
three-stage pattern, known as the General
WWW.ZNOTES.ORG
Believes that stress comes from the individual’s Reductionism: sources of stress may vary between
personality individuals. For example, Selye’s research claims that
Type A and B models are used to explain this theory stress is
a result of a depletion in physiological
These models were developed to explain why some resources
people are prone to
CHD
People who seemed to be particularly susceptible to CHD 4.5. Measures of Stress
tended to
have certain similar personalities
As a result, the Type A and Type B personalities are
Physiological Measures (Wang et al, 2005; Evans
developed
and Wener, 2007)
TYPE OF INDIVIDUAL CHARACTERISTICS
Functional Magnetic Resonance imaging (fMRI) is a
TYPE A Competitive
neuroimaging
procedure using MRI technology to
Works fast measure brain activity by using
MRI technology to identify
Strong desire to succeed changes in blood flow
Likes control In the simplest fMRI study, a participant alternates
Prone to stress between
completing a specific task and control or rest
state to measure
baseline activity
TYPE B Non-competitive
fMRI data is then analysed to identify brain areas in which
Works slowly the
signal changed between activity and rest state
Less desire to succeed
Wang et al (2005) used an fMRI scanner and a technique
Does not enjoy control
called
arterial spin-labelling perfusion MRI
Less prone to stress
Arterial spin-labelling perfusion MRI: arterial blood is
labelled and, after a delay, moves the imaging plane,
In a longitudinal study, 3000 healthy men between aged during
which time there is decay of the label.
39 and 59
were assessed to determine their personality
Snapshot images are
acquired in labelled and control
type and then followed
up for the next nine years conditions and subtracted
The men were then split into two groups depending on
whether they
were assessed as Type A or B In Wang et al’s research, 32 participants were split into a
70% of the 257 men who died were from the Type A stress
condition (n = 25) and control condition (n = 7)
group Participants were asked to perform a mental task,
Concluded that people who are of Type A are more responding
verbally while in the fMRI scanner
susceptible to
stress because of their behaviour traits Throughout, participants were prompted for faster
Type A people are also more likely to suffer from stress- performance and
were required to restart if an error
related
illnesses occurred
Evaluation High-stress condition was preceded with the low-stress
Work (Chandola et al., 2008): use of longitudinal condition
where participants counted aloud backward
research
allows researchers to see how different from 1000 (to control
activation of verbal and auditory
sources of stress impact
individuals centres)
Chandola et al. gives an insight on how a large Self-reports of stress and anxiety levels (1-9 scale) and
population of
over 10,000 people respond to life saliva
samples were collected straight after each task
events, as well as the impact
it had on their risk of Regression analyses were carried out to search for the
developing CHD specific
brain regions associated with individual
participants’ experience of
stress
Issues and Debates The results provided neuroimaging evidences that
Application to everyday life
psychological
stress induces negative emotion and the
It is unlikely that an individual explanation of stress ventral right prefrontal
cortex plays a key role in stress
will be
able to take account for everyone’s experience response
of stress
following a trigger event They also suggested that psychological scans can be used
Thus, it is important that we consider how
as a
measure of stress
reductionist
explanations of stress are when trying to
Cortisol is released in response to fear or stress by the
explain the sources. adrenal
glands as part of the ‘fight or flight’ mechanism
Cultural Differences: different cultural expectations Measuring salivary cortisol is often used as a biomarker
and
beliefs may have a significant impact on what in
psychological stress and is a technique preferred by
they perceive as a
trigger to stress
researchers as
a non-invasive method of measuring
Nature vs Nurture: suggests that stress is caused by stress
both
biological and environmental factors
In addition, saliva collection does not require the
collaboration
with skilled personnel, allowing trouble-free
WWW.ZNOTES.ORG
sample collection ‘’Has your partner or friend ever told you that you eat
However, one issue with measuring salivary cortisol is too
fast?”
that stress
mechanisms can be indirectly assessed by Type As are likely to say “Yes, often”.
salivary cortisol measures Type Bs are likely to say “Yes, once or twice” or
Evans and Wener (2007) conducted research looking on “No”
how
frequently personal space can be intruded upon and The idea that people can be categorised is desirable to
how this can be
one of the key underlying factors that can doctors as
it allows them to predict their patients’
underlie stress when
travelling behavior based on the
results of a personality test
A total of 139 adult commuters (54% male) who are Such simplistic approach can be criticised for trying to
commuting from New
Jersey to Manhattan, New York City explain
human personality in such basic terms
were recruited A major issue with Type A and B theory is determining
Each participant was provided a free monthly rail pass for which factors
are influencing stress and CHD
their
participation Some research focused on hostility, arguing that Type A
Participants had been on the same commuting route for personalities are characterised by underlying hostility
an average of
82 months, with a 12-month minimum
Their average duration of the commute to work was 83 Evaluation:
minutes Self-reports
Two measures of crowding were taken for each journey: Can be prone to social desirability as patients can
Car density – measured through dividing the total sometimes lie about their responses
number of
passengers within the train car with the Physiological measures: considered as objective
total amount of seats measures
to stress.
Seat density – more proximal measure of crowding to This can be achieved by looking at brain activity, or
the
participant’s location and was calculated by levels
of hormones produced
dividing number of
people sitting on the same row However, it is time consuming and expensive
with 5 (number of seats in the
row)
Issues and Debates:
Salivary cortisol was collected through a chewable swab
Psychometric Tests: allows practitioners to better
They found that the density of the train car was
understand the person’s feelings and perceptions of
inconsequential for
levels of stress, whereas the seating
anxiety
density near passenger
affected self-reported stress and
Application to everyday life: measures of stress are
cortisol levels in the
participant’s saliva
useful
in both medical and home settings. If we can
identify potential
triggers of stress, we can collaborate
Psychological Measures (Self-reports) (Holmes
with practitioners early
enough to prevent any future
and Rahe, 1967; Friedman and Rosenman, 1974) instances of stress/illness
Holmes and Rahe (1967) investigated the causes and

sources of
stress and focused on life events as stressors 4.6. Managing Stress
The scale consisted of 43 life events that each had a
stress
score Medical Techniques (Biochemical)
Respondents would add up the scores that they had
experienced
within the last 12 to 24 months to obtain Commonly used as a quick and easy way to deal with
their score stress,
especially at short term
Rahe et al. (1970) Anti-depressants that are most widely prescribed are
Tested the SRSS’ reliability selective
serotonergic reuptake inhibitors (SSRIs) such as
2500 US Military sailors were asked to rank stressful Prozac
events
in their lives with the scale These work by regulating serotonin levels in the brain
The sailors were tracked for six months, noting their to
elevate mood and have been used to treat panic
visits to
the dispensary to identify a correlation disorder, GAD,
and OCD
between their visits to
the doctor and the stressful Benzodiazepines are used to treat anxiety and work by
events that they reported releasing
inhibitory transmitters
Rahe et al. proven the reliability of the scale, with the Inhibitory Transmitter – makes brain less aroused,
exact
same positive correlation between reported more calm
and less anxious
stress and illness Kahn et al (1986)
It is also possible to categorise individuals under Type A Gave a group of patients benzodiazepines, as well as a
or Type B
personalities (Friedman and Rosenman, 1974) placebo
to a control group
Classifying these behaviors are usually done by interviews They followed 250 patients for eight weeks
or
questionnaires They found that benzodiazepines reduced stress
Example questions include: significantly
more than the placebo
WWW.ZNOTES.ORG
Psychological Techniques: Biofeedback (Budzynski Participants were randomly allocated into either three
et al, 1969) conditions,
relaxation, relaxation plus imagery or a
control condition
Biofeedback: technique in which electromechanical There were no significant differences in the Leeds
device
monitors physiological processes such as heart General Scales
but the mood disturbance score on the
rate or muscle
tension profile of mood states
differed significantly than the
The device reports the information predicted way
The information enables the person to gain voluntary This indicates that relaxation positively affected mood
control over
these processes through operant state and
that this effect was further increased when
conditioning relaxation was combined
with imagery
Principles of biofeedback:
The patient has electromyography (EMG) electrodes Preventing Stress (Meichenbaum, 1985)
attached to
the skin surface over a particular muscle
The patient hears a tone with a pitch proportional to Proposed Stress Inoculation Therapy which follows three
stages:
the
electromyographic activity in a muscle group
Conceptualisation: education emphasising
As the patient gets better, they have to maintain their
relaxation level. development of a
warm, collaborative relationship
Budzynski et al (1969) wanted to assess the effect of through which a careful
assessment and problem
biofeedback in reducing tension headaches reconceptualization are finished.
Skills acquisition and rehearsal: coping strategies, as
Tension headaches are associated with sustained
contraction of scalp
and neck muscles well
as new skills are learnt by the patient to apply in
stressful
situations. These can include relaxation and
Each participant had electrodes attached to their head,
one inch
above the eye across their forehead emotional
regulation skills
There were three conditions and each of the 15 Application and follow through: focuses on
participants were
randomly allocated to one of these transferring
coping mechanisms to the real life and
prevent relapse
conditions
The experimental group were told that the pitch of the
Evaluation
tone would
vary with level of muscle tension on the
forehead Imagery
Control groups were told to relax deeply, especially the Bridge’s sample is heavily focused on women who are
forehead
muscle undergoing
cancer therapy. This biased sample may
They were told that the constant tone should help them reduce the study’s
generalizability to male
relax and
deeply as possible and to do this in silence populations
The results were gathered over five sessions and the The usage of random allocation as a control
mean level of
muscle tension technique is a
strength
They found that participants in feedback group saw a But as participants were aware that they are taking
significant
reduction in muscle tension over five sessions part in a
study regarding pain management, this can
lead to demand
characteristics
Psychological Techniques: Imagery (Bridge, 1988)
Biofeedback
Involves the systematic practice of creating a detailed of Budzynski’s research only used a small sample of 15
an
attractive and peaceful setting or environment participants. A size of 15 people cannot generalize a
There is no single correct way to use imagery for stress population
as a whole
relief There are many controls in this study, namely the
Used to promote relaxation which can lower blood standardized
procedure which can make the
pressure and reduce
other problems related to stress researcher think that his study is
reliable
Bridge et al (1988) wanted to see if stress can be As Budzynski’s study is a snapshot study lasting for
alleviated in
patients being treated with radiotherapy for five weeks,
the researcher must take note of any long-
early breast cancer
using randomized control trials (RCT) term changes in
behaviours
lasting for 6 weeks
A sample of 139 women at Middlesex Hospital, London Issues and Debates:
Patients completed the Leeds General Scales Measure,
The most useful application that comes when developing
which gives the
severity of depressive and anxiety
methods
for managing stress occurs when we combine
symptoms in patients who have not
receive a primary
both physiological and
psychological methods of stress
diagnosis of an affective illness
management
They also completed a mood scale, the profile of mood
that uses 65
items to assess depression, vigor, fatigue,
tension, anger or
confusion
WWW.ZNOTES.ORG
This model focuses on three aspects of communication:

5. Health Promotion The Communicator: this aspect focuses on the
credibility, as
well as sources for the message given.
This can be achieved
through using academic advice,
5.1. Strategies for promoting health
appropriately qualified people,
as well as personal
This is a report of a study conducted by Cowpe (1989) experiences and trustworthiness (e.g.
group-based
drug therapies led by ex-drug user)
Chip-pan fires were the major cause of domestic fires and
accidents
in 1976-1984 The Communication: This focuses on the arousal
Approximately 1/3 of all domestic fires were caused by given by the
message promoted.
The Audience: This focuses on considering the proper
chip pans
This study aimed to test the effectiveness of an demographic and type of issue that is being
promoted.
advertising
campaign warning people about chip pan
fires
This can be understood as a quasi-experiment
Health Belief Model
Two sixty second advertisements involving the usage of
States that people are motivated by fear to protect their
chip pans
were made, as well as advertisements
health
dedicated to avoiding chip pan
fires
Leventhal (1967)
These advertisements were screened in UK Television
Demonstrated the health belief model with an
between 1976 and
1984
experiment
involving cigarette smokers
Ten regions were shown the advertisements
Participants who were exposed to high fear appeal,
Effectiveness of these campaigns were measured through
involving
watching a film of a lung surgery changed
the usage of
fire brigade statistics.
their intentions
regarding smoking more than those
Cowpe reports an overall 12% decrease in fires (7-25%
exposed to moderate fear
appeal
depending on
area)
High awareness levels and recall of the adverts existed Issues and Debates:
for a
considerable time
He concluded that the advertising campaign was proved Yale Model of Communication
effective as
shown by the reduction of chip pan fires Has good application to everyday lives as they can
model
strategies that can be employed by marketing
Fear Arousal (Janis and Feshbach, 1953) campaigns
Janis and Feshbach’s Fear Arousal Model
Aimed to test if a level of fear would have a behavioral Has good application to everyday life as they can
consequence
in relations to tooth-brushing model
strategies that can be created, although it is
Four groups consisting of 50 students each were shown a best used for
addictive negative health behaviors such
film about
dental hygiene. as smoking and drinking
Depending on their group, they either received a strong Individual and Situational Explanation
fear
message, a moderate fear message or a low fear
message involving
tooth decay All strategies must tackle both individual and situational
An additional control group was screened a video factors as people could adhere to these strategies
involving the
functions of the human eye depending on
what target group the strategy aims to
Questionnaires were also administered, asking how promote healthy behaviours.
Factors such as age and
tooth-brushing
behavior had changed behaviour must be considered so that these
theories
76% of the high fear group worried (42% increase after become deterministic.
watching the
video) about tooth decay Application to everyday life:
46% of the low fear group felt worried (24% increase after Both Fear Arousal and Yale Model of Communication
watching
the video) about tooth decay can be used to
create strategies that marketing
28% of the high fear group reportedly changed habits companies and practitioners can
use to change health
after being
exposed to the video behaviours.
50% of low fear group changed their tooth-brushing Prevention of illness is a more effective way to deal
habits after
being exposed to the video with
illnesses
They concluded that minimal fear arousal was an Campaigns that promote healthier lives (such as
effective method of
promoting health encouraging
exercise) helps not only an individual,
but the entire medical
community.
Yale Model of Communication
Providing Health Information (Lewin, 1992; 2002)
Hovland et al (1953) conducted many studies at Yale
University
which helped to form a model of persuasive Giving patients’ information to make them informed
communication. decisions could
be a good way to promote healthy
WWW.ZNOTES.ORG
behaviors. before the programme.

Lewin (1992) wanted to find out if home-based
programmes would
reduce psychological distress in Workplaces (Fox et al, 1987)
making decisions
176 patients who had suffered a heart attack to either a Implemented a token economy on an open pit mine to
self-help
program or informed counselling reduce accidents
The self-help programme consisted of a heart manual Workers from two mines, the Shirley Basin and Navajo
given to
participants Coal mines
participated
Psychological adjustment, was assessed by the Hospital The number of workers in the Shirley Basin mine was at
Anxiety and
Depression Scale, was better in the 197 when data
collection began (1972)
rehabilitation group at one year The number of workers in the Navajo Coal mine was at
They also had less contact with general practitioners 450 workers
when data collection began (1975)
during the
following year and significantly fewer were Stamps were rewarded to employees if:
readmitted in the first
six months They worked without lost time injuries
Clinically anxious or depressed patients had the most They were in a work group in which all the workers
significant
improvements. had no lost
time injuries
The cost-effectiveness of the home-based programme is They were not involved in equipment-damaging
yet to be
compared with a hospital-based program accidents
They making adopted safety suggestions
And if they show unusual behavior that prevented
5.2. Health Promotion in schools,
accidents
workplaces and the community Stamps were removed if:
A worker or group gets injured
Schools (Tapper et al, 2003) Causing equipment damage
Failing to report accidents
Developed a “Food Dudes” program that aimed to
promote healthy
eating in schools The number of days lost without accidents, as well as
This program focuses on three aspects: costs for
accidents were recorded
Taste Exposure: Increasing the exposure to a new Both the number of days lost due to accidents, as well as
food group
over a period of weeks the costs
of covering accidents reduced significantly, after
Modelling: Certain factors such as imitation and the token economy
has been implemented
observational learning make modelling more effective
Rewards: Positive reinforcement for eating the food, Communities (Farquhar et al, 1985)
as well
as rewards for implying the importance of the
healthy eating
behavior Focuses on the Stanford Five City Multifactor Risk
Reduction
Project (FCP)
The programme is implemented by staff through: Long-term field study assessing the feasibility and
Six Food Dudes episodes effectiveness of
community-wide health education
A set of Food Dudes rewards directed at lowering cardiovascular
disease risks
A set of letters from the Food Dudes that praised the
The FCP is originally planned to include:
children
Six years of education
A Food Dudes home pack to encourage children to eat
fruits and
vegetables at home Four independent (cross-sectional) population surveys
Four surveys of cohort
A staff manual and briefing video to help teachers
Continuous surveillance for CHD episodes
implement the
programme correctly
A set of education support materials to help teachers Population surveys provide major source of data relating
meet
curriculum targets with the Food Dudes
to CVD risk
The main intervention phase lasted for 16 days Randomly selected sample from 12-74 years old used
During the intervention period, children were exposed to
episodes of
the Food Dudes and listen to their teacher, Cities involved include Monterey and Salinas (treatment
who read the Food Dudes
letters cities),
Modesto, San Luis Obispo and Santa Maria
Children were also rewarded with Food Dudes stickers (control cities)
and prizes if
they tasted fruits and vegetables
Both teachers and parents evaluated the program. The main goals of the population surveys include:
Children were enthusiastic about the curriculum work To develop or adopt appropriate measurement
using the Food
Dudes instruments and
procedures for the survey
Even after four months, the children were still eating To hire, train and supervise staff to operate the
significantly
more fruit and vegetables, compared to centres
WWW.ZNOTES.ORG
To establish survey centres in each of the four All methods of promoting health listed have great
communities application
to everyday life as it provides evidence for
To identify and recruit randomly selected samples supporting the
implementation of mass health
from each
community with an objective of achieving campaigns to encourage healthy
behaviours
at least a 66% response
rate
To conduct surveys in a manner that provides 5.3. Individual Factors in Changing
accurate and
reliable data, and to maintain an
effective relationship with
general public and Health Beliefs
healthcare professionals
Unrealistic Optimism (Weinstein et al, 1980)
As well as surveys, physiological measures were used.
These include: Investigated unrealistic optimism about future life events
Body height and weight Unrealistic optimism: an error in judgement where
Blood pressure by two methods (mercury manometer people tend to
believe that they are invulnerable and
and
semi-automated machine) expect others to be victims
of misfortune
Resting heart rate This research attempted to test six hypotheses:
Non-fasting blood samples analyzed for plasma People believe that negative events are less likely to
thiocyanate
(measure of smoking rate) happen to
them than to others and vice versa for
Expired air carbon monoxide positive events
Urinary sodium potassium and creatinine (index of The more undesirable the negative event is, the
prior sodium
chloride intake) stronger the
tendency that one’s own chances are less
Low level bicycle test (measure of fitness) than average
The greater the perceived probability of an event, the
Short term impact saw knowledge of CVD risk factors
stronger
the tendency for people to believe that their
increasing in
both treatment and control groups own chances are
greater than average
Improvement in treatment group was more noticed Previous personal experience with an event increases
There is a significant decrease in blood pressure and
the
likelihood that people will believe that their own
cholesterol chances are
less than average
Net decreases in resting heart rate favored intervention
When a stereotype exists of a particular type of
participants person to whom
a negative event is likely to happen,
Dietary saturated fat intake declined significantly in
people would tend to
believe that their own chances
women, but
not in men for the 24-hour diet recall are less than average
Long-term impact found that both CHD and all-cause
In the first study, 258 college students estimated how
mortality risk
scores were maintained in intervention much
their own chances of experiencing 42 events
cities while levelling out in
control cities differed from the
chances of their peers
A follow-up in 2014 found that frequent, regular, Instructions from the questionnaire stated:
systematic contact
with media professionals influence
“Compared to other students – same sex as you –
newspaper coverage of
health-related topics what do you
think are the chances that the following
events will happen to
you?”
Issues and Debates:
There were 18 positive and 24 negative life events cited in
the form
At Schools
Beneath the description of each event, there was a 15-
Tapper used children as participants for her study on
point rating
scale in which participants had to choose
promoting healthy eating in schools. Researching
their relative probability
of this happening to them
about healthy
eating in childhood can support
The lowest possible choice was 100% less than average,
positive adult health
behaviours. It must be important
as this
indicated a probability of 0
that the parents are also
informed
Overall, participants rated their own choices to be above
At the Workplace average
for positive events and below average for
Fox et al. used a longitudinal study that allowed the negative events
effectiveness of the token economies implemented in The present data provide evidence of unrealistic
both mines optimism for both
kinds of events
Results showed that despite supporting all six
At communities hypotheses, different
factors managed to govern
Farquhar uses a longitudinal study to identify the responses to positive and negative events
long-term
effects of implementing mass media For negative events, optimism and perceived
campaigns in communities, to
which is still being controllability had an
impact on participants’ judgements
measured as of 2014. When an event was judged as controllable, a stereotype
For all methods of health promotion existed in
participants’ minds of the kind of person to
WWW.ZNOTES.ORG
whom the event

generally occurred Helping relationships: Develop relationships with
caring,
trust, openness and acceptance for the healthy
Transtheoretical Model (Prochaska et al, 1997) behaviour change
Suggests that individuals follow a six-stage model that To help individuals progress through these stages,
involves the
changing of health behavior practitioners
must need to understand the processes of
The six stages include: change.
Pre-contemplation: People do not intend to take Prochaska et al (1992) believe that the future of health
action in
the foreseeable future (next six months) promotion programmes lies with stage-matched,
Contemplation: People intend to start the healthy proactive and
interactive interventions.
behavior
in the foreseeable future (usually the next
six months).
However, people may still feel Health Change in Adolescents (Lau, 1990)
ambivalent toward changing their
behaviour
Preparation: People are ready to change their action Longitudinal study aimed to explore the sources of
within
the next thirty days. They start to take small stability and
change in young adults’ health beliefs
steps towards the
behavioural change and believe The data collected in this study was part of a larger piece
that changing their behaviours
would make them of
research of students enrolled at Carnegie Mellon
healthier University, for
classes ending in 1983
Action: The person changes his behaviour within the Out of 1,106 students who were sent questionnaires, 947
last six
months and intend to keep moving forward of these
provided data which included responses from
with that behavior students and their
parents
Maintenance: The person has sustained his behaviour The data collected via questionnaires over a period of
change
in a while, usually more than six months, and three years
were collated to investigate six questions:
intend to main the
behaviour change going forward.
1. Is there a link between the health beliefs of parents
Termination: The person has no desire to continue
and students
when they initially leave home for
the
unhealthy behavior and are sure that they will not
college?
relapse.
2. How do parents exert their influence on children?
Processes of change are the actual activities that can be 3. How much do young adults’ health beliefs change
done in
order to move through different stages of during the first
years of their college life?
interventions 4. How strong is the association between the health
There are ten stages of intervention: beliefs of the
young adults and their peers at this
Consciousness raising: Increases awareness about the time?
causes,
consequences and cures for a particular 5. How do peers exert their influence on these young
problem behaviour adults?
Dramatic relief: Initially produces increased emotional 6. How strong is parental influence compared to peer
experiences followed by reduced affect if appropriate influence?
action can
be taken
The results found that there was a substantial change in
Self-re-evaluation: Combines both cognitive and
the
performance of health behaviours during the first
affective
assessments of one’s self image with and
three years of
college
without a particular
habit
Parents’ influence is much more significant than that of
Environmental re-evaluation: The belief that one can
peers
change
the commitment and recommitment to act on
Lau suggested that direct modelling of behaviour is the
that belief
most
powerful influence on health beliefs
Social Liberation: Requires an increase in social
Issues and Debates:
opportunities in demonstrating the new, positive
Application to everyday life: Understanding the
behaviours
individual
factors that can identify whom could
Counter-conditioning: Requires the learning of
change their behaviours
following a health promotion
healthier
behaviours that can become substitutes for
campaign
problem behaviours
There can be cultural bias in the individual factors
Stimulus control: Removes cues for unhealthy
that
can influence a person’s change in health
behaviours and
prompts healthier alternatives
behaviours
Contingency management: Provides consequences
for taking
steps in a particular direction
WWW.ZNOTES.ORG
CAIE A2 LEVEL
Psychology (9990)
Copyright 2022 by ZNotes

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ZNOTES.

UPDATED TO 2021-23 SYLLABUS

Participants were also asked general questions about

Mckinstry and Wang observed that it would have been

Verbal Communication (Mckinlay, 1975; Ley, 1988)

Investigated the communication barriers between

Evaluation: Byrne and Long (1976)

Mckinstry and Wang Investigated the interactions between patients and

as other patients may

1.3. Misuse of Health Services

Delaying Treatment (Safer et al, 1979)

Misuse: Hypochondriasis (Barlow & Durand, 1995)

From the age of 17, she had been seen by hospitals

Evaluation 2.2. Types of Non-adherence and why

Patient decides that they don’t need Perceived Seriousness

Doctor does not give adequate details ‎

Rational non-adherence (Bulpitt, 1994)

Rational Choice Theory is a framework for understanding

Median adherence was 89%, according to TrackCap Issues and Debates:

Despite research on non-adherence being conducted, asthmatics on inhalers

Caused, increased or prolonged by mental, emotional or

This method is the preferred approach to pain

The McGill Pain Questionnaire is the first proper

For example, the biomedical approach explains and Adaptation Syndrome

4.2. Sources of Stress 4.4. Causes of Stress

1. Money (76%) Various follow-up measures were taken, including:

Holmes and Rahe (1967) investigated the causes and

This model focuses on three aspects of communication:

behaviors. before the programme.

whom the event

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