PSY_C19.qxd 1/2/05 3:52 pm Page 408 Health Psychology 19 CHAPTER OUTLINE LEARNING OBJECTIVES INTRODUCTION HEALTH BELIEFS AND BEHAVIOURS Behaviour and mortality The role of health beliefs Integrated models ILLNESS BELIEFS The dimensions of illness beliefs A model of illness behaviour Health professionals’ beliefs THE STRESS–ILLNESS LINK Stress models Does stress cause illness? CHRONIC ILLNESS Profile of an illness Psychology’s role FINAL THOUGHTS SUMMARY REVISION QUESTIONS FURTHER READING PSY_C19.qxd 1/2/05 3:52 pm Page 409 Learning Objectives By the end of this chapter you should appreciate that: n health psychologists study the role of psychology in health and wellbeing; n they examine health beliefs as possible predictors of health-related behaviours; n health psychology also examines beliefs about illness and how people conceptualize their illness; n a health professional’s beliefs about the symptoms, the illness or the patient can have important implications; n stress is the product of the interaction between the person and their environment – it can influence illness and the stress–illness link is influenced by coping and social support; n beliefs and behaviours can influence whether a person becomes ill in the first place, whether they seek help and how they adjust to their illness. INTRODUCTION Health psychology is a relatively recent yet fast- reflects the biopsychosocial model of health and growing sub-discipline of psychology. It is best illness that was developed by Engel (1977, understood by answering the following questions: 1980). Because, in this model, illness biopsychosocial the type of inter- n What causes illness and who is responsible is regarded as the action between biological factors (e.g. for it? result of a com- a virus), psychological factors (e.g. n How should illness be treated and who is bination of factors, beliefs) and social factors (e.g. class) responsible for treatment? the individual is no n What is the relationship between health and longer simply seen as a passive victim of some illness, and between the mind and body? external force, such as a virus. Acknowledging the n What is the role of psychology in health and role of behaviours such as smoking, diet and illness? alcohol, for example, means that the individual may be held responsible for their health and Human beings are complex systems and ill- illness. ness can be caused by a multitude of factors, not According to health psychology, the whole just a single factor such as a virus or bacterium. person should be treated, not just the physical Health psychology attempts to move away from changes that occur due to ill health. This can a simple linear model of health and looks at include behaviour change, encouraging changes the combination of factors involved in illness – in beliefs and coping strategies, and compliance biological (e.g. a virus), psychological (e.g. behavi- with medical recommendations. Because the ours, beliefs) and social (e.g. employment). This whole person is treated, the patient becomes PSY_C19.qxd 1/2/05 3:52 pm Page 410 410 Health Psychology partly responsible for their treatment. For example, ness, can unhealthy behaviours be targeted she may have a responsibility to take medication, for intervention? if we change beliefs and and to change beliefs and behaviour. No longer is behaviour, can we prevent illness onset?) the patient seen as a victim. From this perspective, health and illness exist Health psychologists study the role of psycho- on a continuum. Rather than being either healthy logy in all areas of health and illness, including: or ill, individuals progress along a continuum from healthiness to illness and back again. Health psy- 1. what people think about health and illness; chology also maintains that the mind and body 2. the role of beliefs and behaviours in becom- interact. It sees psychological factors as not only ing ill; possible consequences of illness (after all, being 3. the experience of being ill in terms of adap- ill can be depressing), but as contributing to all the tion to illness; stages of health, from full healthiness to illness. 4. contact with health professionals; The aims of health psychology can be divided 5. coping with illness; into two main aspects: 6. compliance with a range of interventions; and 1. Understanding, explaining, developing and 7. the role of psychology in recovery from ill- testing theory (for example: what is the role ness, quality of life and longevity. of behaviour in the etiology of illness? can we predict unhealthy behaviour by studying This chapter will provide an overview of health beliefs?). beliefs and behaviours, individuals’ illness beliefs, 2. Putting theory into practice (for example: if the role of health professionals’ beliefs, stress we understand the role of behaviour in ill- and chronic illness. McKeown’s emphasis on behaviour is supported by evidence of HEALTH BELIEFS AND BEHAVIOURS the relationship between behaviour and mortality. Over the last century health health behaviours examples are exer- behaviours have played an BEHAVIOUR AND MORTALITY cise, food intake and going to the doctor increasingly important role in health and illness. This It has been suggested that 50 per cent of mortality from the relationship has been highlighted by McKeown’s book, The Role ten leading causes of death is due to behaviour. If this is correct, of Medicine (1979), which discusses the decline of infectious dis- then behaviour and lifestyle have a potentially major effect eases in the nineteenth century, which forms the focus for med- on longevity. For example, Doll and Peto (1981) estimated that ical sociology. It also highlights the increasing role of behaviour tobacco consumption accounts for 30 per cent of all cancer deaths, in illness in the twentieth century. The latter represents the focus alcohol 3 per cent, diet 35 per cent, and reproductive and sexual for health psychology. The commonly held view is that the behaviour 7 per cent. Approximately 75 per cent of all deaths decline in illnesses such as TB, measles, smallpox and whooping due to cancer are related to behaviour. More specifically, lung cough was related to the development of medical interventions cancer (the most common form) accounts for 36 per cent of all such as chemotherapy and vaccinations. For example, antibiotics cancer deaths in men and 15 per cent in women in the UK. It has are seen as responsible for the decline in illnesses such as pneu- been calculated that 90 per cent of all lung cancer mortality is monia and TB. But McKeown showed that the decline in infec- attributable to cigarette smoking, which is also linked to other ill- tious diseases had already begun, before the development of nesses such as cancers of the bladder, pancreas, mouth, larynx medical interventions. He claimed that, looking back over the and oesophagus, and to coronary heart disease. And bowel can- past three centuries, this decline is best understood in terms of cer, which accounts for 11 per cent of all cancer deaths in men social and environmental factors. and 14 per cent in women, appears to be linked to diets high in McKeown also examined health and illness throughout the total fat, high in meat and low in fibre. twentieth century. He argued that contemporary illness is caused As health behaviours seem to be important in predicting by an individual’s own behaviours, such as whether they smoke, mortality and longevity, health psychologists have attempted to what they eat and how much exercise they take, and he suggested increase our understanding of health-related behaviours. In par- that good health was dependent on tackling these habits. ticular, based on the premise that people behave in line with the PSY_C19.qxd 1/2/05 3:52 pm Page 411 Health Beliefs and Behaviours 411 Health locus of control The issue of controllability health locus of control where the emphasized in attribution cause of health is seen to be located – theory has been specifically either internal (‘due to me’) or external applied to health in terms of (‘due to others’) the health locus of control. Indi- viduals differ in their tend- ency to regard events as controllable by them (an internal locus of control) or uncontrollable by them (an external locus of control). Wallston and Wallston (1982) developed a measure to evaluate whether an individual regards their health as: n controllable by them (e.g. ‘I am directly responsible for my health’); n not controllable by them and in the hands of fate (e.g. Figure 19.1 ‘Whether I am well or not is a matter of luck’); or Behaviour can have a major effect on longevity: for example, n under the control of powerful others (e.g. ‘I can only do around 90 per cent of deaths from lung cancer are attributable what my doctor tells me to do’). to cigarette smoking. It has been suggested that health locus of control relates to whether we change our behaviour (by giving up smoking or changing our diet, for way they think, health psy- instance), and also to our health beliefs examples are perceptions adherence (or compliance) the extent chologists have turned to the adherence to recommenda- of risk or beliefs about the severity of an to which a patient does as suggested study of health beliefs as poten- tions by a health professional. illness (e.g. taking medicine or changing tial predictors of behaviour. For example, if a doctor behaviour) encourages someone who generally has an external THE ROLE OF HEALTH BELIEFS locus of control to change his or her lifestyle, that person is unlikely to comply if she does not deem herself to be responsible Attribution theory for her health. However, although some studies support the link between The origins of attribution theory lie in the work of Heider (1944, health locus of control and behaviour (e.g.