Theories of Health Belief

Theories of Health Belief

·         HEALTH BELIEF MODEL: Becker, 1978.

·         LOCUS OF CONTROL: Rotter, 1966 OR Wineman, 1980

·         SELF-EFFICACY: Bandura and Adams, 1977

THEORY: HEALTH BELIEF MODEL

The health belief model is a working model that attempts to explain and predict health behaviours by focussing on the attitudes and beliefs of individuals. It was developed in the 1950’s by social psychologists (Hockbaum et al.). The core assumptions of this model is that someone will do a health related action if they believe a negative health condition is avoidable, can be avoided by completing the health related action, and that they feel they will be able to successfully complete the action. The model refers to constructs representing perceived threats and benefits that result in the final decision: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy.

STUDY: BECKER (1978) Compliance with a medical regimen for asthma

Becker conducted a correlational study to test the health belief model on asthma prevention medication. A sample of 111 mothers aged 17 to 54, with asthmatic children aged between 9 months and 17 years, took part in 45 minutes interviews, in which the mothers were asked about compliance, perceptions of susceptibility, seriousness of conditions, interference with education, embarrassment, interference with mother, effectiveness of medication and faith in doctors. Compliance was checked by blood tests of children, taken under the precedent that it was for medical rather than research reasons. Positive correlations were found between compliance and the following factors: susceptibility to attacks, seriousness of condition, interference with own activities, education and marital status. Negative correlations were found between compliance and disruption, inaccessibility to chemists, and complaints. It was concluded that the HBM was accurate in compliance with the medical regimen for asthma.

THEORY: LOCUS OF CONTROL

The locus of control refers to someone’s belief about what causes the good and bad results in their life. The locus of control is a scale from high internal locus of control, the belief that it is the individual is the main cause of their behaviour, actions and situations, to high external locus of control, where the individual will primarily believe that powerful others, fate, or chance strongly determine events, and they are largely out of their control. Those with high internal locus of control will think that they can influence others and their own lives with their actions; they think that their efforts will be successful, and they are active in seeking information – they will blame themselves both for positive and negative outcomes. Alternatively, those at the other end of the scale will often feel stressed out or overwhelmed, and may be prone to laziness, clinical depression or obesity as they believe what will happen, ultimately will happen.  

EVALUATION: this theory has not been strongly supported by later research, especially in terms of eating habits, for example, see Wineman (1980). Therefore, this theory may be limited in its applications and is not wholly nomothetic. This is an overly reductionist theory, which may be why it does not work in terms of complex health behaviours, such as eating habits. It is situational versus dispositional. It largely relies on self-report to gain information in order to determine locus of control, and self-report has issues with internal validity such as dishonesty, memory bias and social desirability.

STUDY: ROTTER (1966)

Rotter conducted a review article study into internal versus external locus of control. Initially, he used six pieces of research into individual perceptions of ability to control outcomes. Rotter found that the studies’ findings consistently showed that participants who felt they had control over the situation were more likely to show behaviours that would enable them to cope with potential threats than participants who thought that chance or other non-controllable forces determined the effects of their behaviours. In other words, he found that those with an internal locus of control appeared to be more prepared against danger than those with an external locus of control. Rotter concluded that locus of control would affect many behaviours, including health behaviours, as those with an external locus of control were likely to be less pro-active in avoiding health risks. He included in his study research by James et al, which found that male smokers who gave up smoking and did not relapse had a higher locus of control than those who did not quit. However, there wasn’t a significant difference for female smokers.

STUDY: WINEMAN (1980)

Wineman conducted a cognitive study to investigate locus of control, body image and weight loss in a self-selected sample of 116 adult members of Overeaters Anonymous (OA). Most of these were female, all were Caucasian, and they were from a range of social class backgrounds. He conducted a self-report study using retrospective correlation. Three questionnaires were given out: a demographic questionnaire, which featured questions about age, sex and age at onset of obesity; Rotter’s Social Reaction Inventory Scale, 29 forced choice questions measuring internal and external locus of control; and Secord and Jourad’s Body Cathexis Scale, which used five-point Likert scales to measure body satisfaction. The results showed that of the 116 participants, 59% had childhood onset of obesity. Multiple regression analysis was performed at three onset age categories (childhood, adolescence and adult) separately to analyse the relationship between locus of control and weight loss. Locus of control significantly predicted body image in the adult group but there was no correlation between either body image or weight loss in the sample overall. Body image and weight loss correlated in the adolescence group. Males had overall higher body satisfaction and greater weight loss. Wineman concluded that external cues may influence a person’s eating habits specifically yet not be reflected in general locus of control beliefs, and from this she concluded the Rotter scale was not a suitable measure of locus of control with regards to eating habits.

THEORY: SELF-EFFICACY

Self-efficacy refers to a person’s perceptions of their ability in a particular situation. It is at the heart of Bandura’s social cognitive theory, and according to Bandura, someone’s attitudes (including self-efficacy), abilities and cognitive skills comprise what is known as the self-system, which plays a major role in how we perceive different situations, and how we behave in response to these situations. He described self-efficacy as a determinant of how people think, behave and feel (1994), and demonstrated that self-efficacy impacts everything from psychological states to behaviour, to motivation. Self-efficacy is believed to begin in early childhood and evolve throughout life: the four main sources are mastery experiences, social modelling, social persuasion, and psychological responses. People with a strong sense of self-efficacy tend to view challenges as tasks to be mastered, and recover quickly from setbacks and disappointments, whilst people with a weak sense of self-efficacy avoid challenging tasks, quickly lose confidence, and focus on failures.

STUDY: BANDURA AND ADAMS

This study aimed to assess the self-efficacy of patients undergoing systematic desensitisation in relation to their behaviour with previously phobic objects.

It was a controlled quasi-experiment consisting of 10 self-selected patients with snake phobias. There were nine females and one males, aged 19-57 years.

The first part of the procedure was a pre-test assessment: each patient was assessed for avoidance behaviour towards a boa constrictor, then fear arousal was assessed with an oral rating of 1-10 and finally efficacy expectations (how well they thought they will be able to perform different behaviours with the snake). Their fear of snakes was also measured on a scale, along with their own rating on how effectively they would be able to cope.

They then underwent the behavioural therapy of systematic desensitisation: a standard programme was followed where patients were introduced to a series of events involving snakes and each was taught relaxation. These ranged from imagining looking at a picture of a snake to handling a live snake. Post-test assessment: each participant was again measured on behaviours and belief of self-efficacy in coping.

The findings showed higher levels of post-tests self-efficacy were found to correlate with higher levels of interaction with snakes, and thus it was concluded that desensitisation enhanced self-efficacy levels, which in turn led to a belief that the participant was able to cope with the phobic stimulus of a snake.

Adherence to Medical Regimen

Healthy Living: explaining health behaviours

FEATURES OF ADHERENCE TO MEDICAL REGIMES

·         REASONS FOR NON-ADHERENCE: Bulpitt et al. (1988)/Lowe and Raynor (2000)

·         MEASURES OF NON-ADHERENCE: Lustman (2000)/Becker (1978))

·         IMPROVING ADHERENCE USING BEHAVIOURAL MEASURES: Watt et al. (2003)

REASONS FOR NON-ADHERENCE

Adherence to medicines is defined as the extent to which the patients’ action matches the agreed recommendations. Non-adherence can include changing the frequency or dosage of medicines, as well as neglecting to follow agreed actions such as exercise or stopping smoking. Whilst non-adherence can result in deterioration of health and wasted medication, there are various reasons why people don’t adhere to advice they’re given in terms of health. Reasons for non-adherence tend to come under two categories: intentional non-adherence and unintentional non-adherence. Unintentional non-adherence features reasons such as forgetfulness, inability to pay, and confusion, which meant that despite wanting to adhere, they were unable to. Intentional non-adherence occurs when there is a conscious decision not to follow advice, and is best understood in terms of perceptual factors such as believing that the medicine won’t work or is against their ethics (such as a vegan who will not eat meat to improve health), or practical factors, such as the side-effects the medicine produces.

EVALUATION: REASONS FOR NON-ADHERENCE

There are some issues with trying to decipher somebody’s reasons for non-adherence. The most appropriate research method into this is self-report; however social desirability bias, demand characteristics and dishonesty may distort the findings. Non-adherence may also be for a combination of factors, or unique to an individual or group, so finding ways to overcome non-adherence could be quite difficult; however, if it is achieved, the health and money benefits could be beneficial to a lot of people. Another weakness of looking at non-adherence is the validity of the research and theories, as it is difficult to operationalize non-adherence – if somebody takes roughly the right amount of pills, is that adherence? What about if they take them at slightly the wrong time of day? As researchers operationalize adherence differently, research may lack reliability as it cannot be compared and checked with other research. We must be careful when attempting to generalize adherence behaviour, as different illnesses may bring out different attitudes and behaviours in people.

STUDY: BULPITT et al. (1988)

Bulpitt et al. conducted a review article study on non-adherence to taking medication to regulate high blood pressure (hypertension). Various pieces of research were looked at to identify problems with taking drugs for high blood pressure. Both physical and psychological side effects were looked at, including problems at work and the effects on physical wellbeing. The study found that anti-hypertension medication had many side effects including sleepiness, dizziness, impotence, and weakened cognitive functioning. Curb et al.’s study that 8% of males discontinued treatment due to sexual problems, whilst the medical research council found that 15% withdrew due to side effects. It was concluded that when side effects outweighed the benefits of treating a mainly asymptomatic problem such as hypertension, there is less likelihood of the patients adhering to their treatment.

EVALUATION: BULPITT et al. (1988)

The problem with using the methodology of a review article is that it looks at dated research, which may lack temporal validity. On the other hand, this enables the researcher to look at patterns and see if attitudes towards medication and adherence change over time, which may be more useful. The use of various pieces of research allows for cross-referencing and increased reliability and generalizability of the findings. As both physical and psychological side effects were investigated, this study appears to be more holistic in its approach. It is not known, however, the depth or validity of the research that was looked at, and the review article appears to be fairly brief.

STUDY: LOWE AND RAYNOR (2000)

Another study into reasons for non-adherence is Lowe and Raynor (2000). The research was conducted on a random sample of 161 patients aged 65 years and older. The mean age of the sample was 76 years, and the mean number of medicines prescribed was 4. The cognitive study used a self-report method, whereby participants were visited and interviewed at home using a structured questionnaire. They were asked questions on which medicines they took, the dosage they take and the frequency dosages are taken. The results showed a discrepancy in 53% of cases. In 28 out of 86 cases, this was due to administrative error, 3 cases were due to confusion and the remaining cases were due to a rational decision by the patient.  92 medicines in all were involved, of which 51 were no longer being taken, 19 dosages had been adjusted and 22 frequencies were adjusted. The reasons given by the sample included side-effects, believing the drugs did not work, and adjustment to fit daily routine. The conclusion was that contrary to popular belief, very few of the elderly who do not adhere to medical regimen are actually confused about it: most make a rational decision by weighing up the costs and benefits, and their non-adherence tends to mostly be intentional. It was deemed “concerning” that patients did not communicate their decisions with their doctor, and that so many administrative errors had been made by the doctors.

EVALUATION: LOWE AND RAYNOR (2000)

The sample was fairly limited in that it looked at a vulnerable, age-biased group (the elderly), however as it was random it is likely that the sample is representative of elderly people. The use of a vulnerable sample however raises ethical issues as they may have felt pressured into giving consent, or not felt that they could have withdrawn from the study. The use of a self-report method is effective in that it enabled participants to recall what they had done and give attitudes, however self-report brings issues of internal validity due to dishonesty, demand characteristics and social desirability bias. As the report was asking for certain amounts of retrospective data, forgetfulness may also have been an issue. The use of a structured questionnaire boosts the reliability of the study, as does comparing the results from the study with medical records. This is a very useful study as it provides reasons for intentional non-adherence, and shows that the common belief about the elderly being confused about medication is somewhat fabricated. It also demonstrated the need for doctors’ surgeries to check for administrative errors, and that communication is lapse between doctors and patients in terms of non-adherence.

MEASURES OF NON-ADHERENCE

There are various ways in which it has been proposed that adherence can be measured: using self-report, looking at the therapeutic outcome (did the patient get better?), asking the doctor, counting pills and bottles, mechanical methods (such as the track cap) and biochemical tests (such as blood and urine tests). As none of these methods are without their faults, methodological triangulation appears to be the most appropriate and accurate way of measuring (non-)adherence.

EVALUATION: MEASURES OF NON-ADHERENCE

Each method of measuring adherence has strengths and weaknesses. Using self-report allows attitudes to be given and is most convenient, but may lack internal validity. Asking the doctor means that social desirability bias wouldn’t be an issue, however patients may have lied to their doctors about their level of adherence. Counting pills and bottles may appear to show what has been taken, but someone may have removed pills and not taken them, or taken more than their recommended dosage one day then nothing the next. It is also an invasion of privacy to check this. Mechanical methods are expensive but can be useful in conjunction with self-report or biochemical tests, and biochemical tests mean that dishonesty isn’t an issue, but they are expensive, time consuming and only show adherence at one point in time, so may be misleading. 

STUDY: LUSTMAN (2000)

Lustman’s study looked into using physiological measures of assessing adherence to medication and the treatment of depression in diabetics. The aim of the study was to assess the effectiveness of fluoxetine as treatment for depression in diabetics. A self-selected sample of 60 diabetic volunteers with depression was involved in a laboratory experiment, using a double blind technique. All were screened for depression and randomly assigned to two groups (the group who would take the drug, and one who would take the placebo). Participants were given daily doses of the medication for 8 weeks, and then re-assessed for depression and their adherence to their medical regimen through measuring blood sugar levels. The results showed that reduction of depression was significantly greater in the experimental group than the control group, and that these patients also had nearer normal blood sugar levels, which indicated improved adherence. The conclusion from this research is that physiological tests were an effective method of measuring adherence, and that reduced depression may improve adherence in diabetic patients. 

EVALUATION: LUSTMAN (2000)

Whilst the use of a laboratory experiment, double blind design and control group should improve the internal validity of the study due to removal of certain confounding variables (such as self-fulfilling prophecy), the use of an independent measures design (which introduces participant variables) balances this out. The participants may simply have gotten better at adherence and felt better within themselves; it may have had very little to do with the drug, however the control group did show that it was not the placebo or Hawthorne effect. The study is useful as it provides another reason for non-adherence, a way of measuring non-adherence, and suggests a way to improve adherence. The extent to which the results can be generalized is limited due to the small, biased sample.

IMPROVING ADHERENCE USING BEHAVIOURAL MEASURES

Sometimes, non-adherence to medical regimen is not particularly serious, as sometimes symptoms and illnesses clear up by themselves. However, non-adherence can prove fatal, and it is these cases which require health psychology to combat non-adherence. Potentially the most useful psychological standpoint in terms of a perspective or approach to non-adherence is the behavioural perspective, as it is a practical and nomothetic viewpoint. Some appropriate behaviourist techniques in combatting non-adherence include direct reinforcements (positive reinforcement), modelling (imitation – this could be from a support group, for example), and contingency contracts (whereby the patient negotiates with the health worker concerning goals and rewards for achievements).

EVALUATION: IMPROVING ADHERENCE USING BEHAVIOURAL MEASURES

The main issue with attempts to improve adherence is that the method used depends on the approach that the problem is explained in terms of, and this will often mean methods are reductionist – this makes them simple to understand and easy to apply to different contexts, but is also likely to be overly simplistic in an area of behaviour which is fairly complex. Combined methods are therefore most likely to be effective. Cultural differences also complicate things; different cultures view medicine and illness differently, so it is likely that findings and theories from one culture cannot be generalized to different cultures. Individual differences should also be a consideration: people differ individually to what they will adhere to and their reasons behind it based on their individual differences. For example, women have been shown to visit doctors more quickly after becoming ill than men. The focus of improving behavioural measures on behaviourism is reductionist in that behaviourism ignores freewill, context and individual differences such as religion.

STUDY: WATT et al. (2003)

Previous research had suggested that non-adherence in children with asthma could be due to boredom, apathy and forgetfulness. This study aimed to see if using a Funhaler instead of a regular inhaler could improve children’s adherence to taking asthma medication. 32 asthmatic children with a mean age of 3.2 years, who had been prescribed drugs taken via an inhaler, were involved in the study. Parental consent was gained, as the children were too young to give informed consent. The method was a field experiment using a repeated measures design, assessed through self-report. The independent variable was whether the child used the inhaler or Funhaler, and the dependent variable was the level of adherence to taking their asthma medication. For the first week, children used regular inhalers, and in the second week the Funhaler was used – a device which incorporates features to distract the child from the drug delivery and reinforces the use of the Funhaler, such as a spinner and a whistle which work best when the deep breathing required for effective drug delivery is used. After each week, the parents completed a questionnaire on adherence. The results were that 38% more parents reported higher adherence in the children when using the Funhaler, and thus it was concluded that making a medical regimen fun can improve adherence in children.

EVALUATION: WATT et al. (2003)

The main issue with this study in terms of methodology is that it was conducted over a fairly short time span. Whilst adherence may have improved with the use of the Funhaler, this may have been due to novelty which could have worn off fairly quickly after the initial week’s use, as behaviourist research has found that constant reinforcement is less rewarding that partial reinforcement. This study is useful because it tested uptake of the medication through both self-report from the parents and through calculating the volume of air in the Funhaler, and thus the amount of medication absorbed by the child. The Funhaler is widely available to asthmatic children, and may well be a lifesaver as it can help to control asthma. However, making medication regimen fun may only work for very young children, and for medication taking through an inhaler rather than orally or through injection, so the findings are unlikely to be able to be generalised, reducing how useful it is.

General points on evaluation of adherence: adherence can be affected by a wide range of patient beliefs, so a holistic approach is desirable. Ethics are potentially an issue due to the samples, and in Becker, the lack of parental consent. Physiological measures of adherence are most reliable, whilst self-report studies have questionable validity.