Specialist Option 3: Health Psychology A2
- Syllabus
- 9990–2028–2029
- Section
- —
- Level
- A2
Health Psychology A2 overview and key studies
- Syllabus
- 9990–2028–2029
- Topic
- —
- Level
- A2
Health psychology links behaviour, care and community outcomes
| Health-psychology job | Core question | Evidence example |
|---|---|---|
| Explain | Why do people experience/respond to health risk, pain or stress differently? | Cognitive appraisal, learning, social context and biology |
| Assess | How can pain, stress, satisfaction or adherence be measured validly? | Self-report, behavioural record, observation and physiological/objective data |
| Manage/treat | Which psychological or service intervention changes experience/behaviour? | Communication style, relaxation, access, prompts or positive-psychology programme |
| Prevent/community | How can environments increase healthy action before illness worsens? | Immunisation access/incentives and school intervention |
| Recurring Health area | Behavioural relationship to learn |
|---|---|
| Practitioner–patient | Communication and decision style influence satisfaction, information and adherence |
| Adherence/community care | Prompts, access, reinforcement and beliefs alter following medical advice |
| Pain | Pain is subjective; child, parent and clinician ratings may diverge |
| Stress/illness | Appraisal and coping can affect mood and quality of life during treatment |
| Health promotion | School/community systems can build protective behaviour and well-being |
For every claim use the same chain: define the construct → explain the proposed mechanism → identify how it was operationalised → state the observed result → restrict the conclusion to the sample, setting and outcome. An application is justified only when that chain supports it.
| Debate/method lens | Health-specific question |
|---|---|
| Individual–situational | Is behaviour driven by beliefs/person differences, or by practitioner, access and environment? |
| Reductionism–holism | Does one variable isolate a mechanism while omitting social/biological context? |
| Determinism–free will | Does an intervention bias behaviour while preserving informed agency? |
| Ethics | Can treatment, deception, incentives or vulnerable samples be justified and consented? |
| Validity/generalisation | Does a score/clinic/school predict actual health and transfer across groups/cultures? |
Health psychology neither replaces biological medicine nor treats behaviour as blame. It studies how psychological and contextual processes influence health experience and action, and evaluates interventions on the outcomes they actually measured.
Five key studies connect communication, adherence, pain, coping and prevention
| Savage & Armstrong (1990) | Evidence map |
|---|---|
| Question/design | Directing versus sharing GP style; randomised controlled study with one inner-London GP |
| Sample/measure | 359 randomly selected patients; satisfaction with understanding, explanation and help immediately/one week later |
| Result | Directing style produced higher satisfaction overall, especially physical problems/prescriptions; no significant style difference in longer, advice, psychological or chronic consultations |
| Limit | Satisfaction/self-report and one GP are not adherence or health outcome; heavy one-week attrition (58% response) |
| Yokley & Glenwick (1984) | Evidence map |
|---|---|
| Design/sample | 1,133 families of under-immunised preschoolers randomly allocated to general prompt, specific prompt, specific+access, specific+monetary incentive, contact control or no-contact control |
| Result | All except general prompt showed improvement; incentive largest, then access, then specific prompt; specific prompt alone was most cost-effective |
| Limit | Clinic attendance/immunisation is objective and applied; incentives raise equity/ethics and one public-health context may not transfer |
| Brudvik et al. (2017) | Evidence map |
|---|---|
| Design/sample | Cross-sectional Bergen emergency outpatient study, 243 children aged 3–15; age-adapted child scales and independent parent/physician numeric ratings |
| Result | Mean pain: child 5.5, parent 4.8, physician 3.2; child–parent agreement moderate κ=.55, child–doctor .12 and parent–doctor .17 |
| Conclusion/limit | Physicians underestimated pain across conditions; disagreement was smaller for fractures. Subjective pain lacks a single external ‘correct’ observer score |
| Bridge et al. (1988) | Evidence map |
|---|---|
| Design/sample | Six-week randomised controlled trial, 154 women with stage I/II breast cancer during radiotherapy; 15 dropped out |
| Conditions | Weekly supportive talking control; muscle relaxation; relaxation plus peaceful-scene imagery; intervention groups practised ≥15 min/day with tapes |
| Result | Mood disturbance lower in interventions, combined group more relaxed, control worsened; ≥55 benefited most; no group difference on Leeds depression/anxiety scales |
| Limit | Self-report mood benefit does not mean cancer cure; researcher attention/practice and age interaction matter |
| Shoshani & Steinmetz (2014) | Evidence map |
|---|---|
| Design/sample | Two-year repeated-measures comparison: 537 Israeli grade 7–9 students in one-year whole-school positive-psychology programme versus 501 in similar wait-list school |
| Result | Intervention distress, anxiety/depression and interpersonal sensitivity decreased while controls increased; self-esteem, self-efficacy and optimism strengthened |
| Limit | Large longitudinal applied evidence, but schools were not individual-randomised; school/culture/history and self-report constrain causality/generalisation |
Match each conclusion to its outcome: consultation satisfaction, immunisation attendance, pain-rating agreement, mood during radiotherapy, or adolescent well-being. None of these alone proves a universal clinical cure or one best intervention for every person.
A key study is a linked evidence chain, not a fact list
| Reconstruct in this order | What must be connected | Diagnostic question |
|---|---|---|
| 1 Context/theory | Prior problem, mechanism and relation to other work | Why was this study needed? |
| 2 Aim/hypothesis | Exact predicted question/direction if stated | What comparison or association was tested? |
| 3 Design | Method, design, IV/conditions, DV/outcomes, controls | What permits causal or only correlational inference? |
| 4 Sample | Size, demographics, setting, sampling/allocation | Who supplied the evidence and who may it represent? |
| 5 Procedure | Ordered experience, materials, timing, instructions | Could another researcher reproduce it? |
| 6 Results | Direction plus useful numerical evidence/significance | What was observed—not merely expected? |
| 7 Conclusion | Bounded answer to aim | Does it stay within measured outcome? |
| 8 Discussion | Applications, alternative explanations and next questions | What changes after this evidence? |
| Evaluation move | Evidence-linked form | Weak generic form |
|---|---|---|
| Validity | ‘Physician rating may underestimate private child pain; independent child scale improves construct coverage’ | ‘The study is valid’ |
| Reliability | ‘Standardised prompts/ratings improve replication, but consultation context varies’ | ‘It can be repeated’ |
| Generalisation | ‘One London GP/Israeli schools restrict practitioner/cultural transfer’ | ‘Small sample’ |
| Ethics | ‘Children/clinical patients require consent, protection and no denied essential care’ | ‘It may be unethical’ |
| Application | ‘Specific reminders are cost-effective for this under-immunised clinic population’ | ‘It helps society’ |
To compare studies, keep the dimension constant: field realism, control, outcome objectivity, timescale, allocation, vulnerability or application. Then explain the trade-off. For example, Yokley’s random allocation and objective attendance strengthen causal inference; Shoshani’s whole-school longitudinal implementation improves realism but leaves school-level confounds.
| Issue/debate | Evidence question |
|---|---|
| Individual–situational | Does the result arise from person characteristics, consultation, treatment or institutional access? |
| Reductionism–holism | What did isolating one component reveal, and what health system did it omit? |
| Determinism–free will | Does manipulation change probabilities while people retain informed choice? |
| Nature–nurture | Which biological vulnerability and learned/social experience interact? |
| Usefulness | Is benefit clinically/behaviourally meaningful, feasible, equitable and sustained? |
Do not memorise methodology as detachable labels. Random allocation supports causal comparison only for the manipulated contrast; a significant self-report change remains a self-report outcome; an applied field result remains bounded by its sample, setting, implementation and follow-up.
3.1 The patient-practitioner relationship
- Syllabus
- 9990–2028–2029
- Topic
- 3.1
- Level
- A2
Practitioner communication works only when patients can interpret it
| Channel | Signal and possible effect | Risk |
|---|---|---|
| Non-verbal | Clothing, posture, eye contact and distance can signal role, attention, authority or warmth before words are processed | Meanings vary by age, class, culture, setting and individual preference |
| Verbal | Questions, diagnosis and treatment explanations can build shared understanding | Medical terminology, closed questioning or assumed knowledge may conceal misunderstanding |
| Repair | Explain terms in plain language, invite questions and check understanding in the patient's own words | Repetition alone does not repair language or power barriers |
| McKinstry & Wang (1991) | Evidence |
|---|---|
| Aim/sample | Test acceptability of doctors' clothing and appearance-based confidence; 475 patients from five Lothian general practices |
| Procedure | Patients judged standardised photographs of one male and one female doctor in different outfits and answered closed attitude questions |
| Results | Formal dress was generally favoured; suit/tie for the male and white coat for the female drew many high ratings. Preference was stronger among older/higher-social-class patients; practices varied. 64% called dress quite/very important and 41% said appearance could increase confidence |
| Evaluation | Standardised images and quantitative ratings aid comparison/reliability, but photos are not real consultations, clothing was confounded with gender/outfit details, and one Scottish area limits cultural generalisation |
| McKinlay (1975): terminology | Teaching implication |
|---|---|
| Problem | Practitioner vocabulary and assumptions can make patients appear ‘ignorant’ even when the information was not made accessible |
| Mechanism | Technical terms, compressed explanations and status differences reduce opportunities to disclose uncertainty |
| Safer practice | Use concrete ordinary language, define unavoidable terms, ask open questions, and verify comprehension rather than asking only ‘Do you understand?’ |
| Boundary | Plain language supports understanding; it does not guarantee adherence, trust or an accurate diagnosis by itself |
Apply evidence conditionally: dress recognisably and professionally for the patient group and setting, but prioritise respectful behaviour and comprehension checks. A communication recommendation should specify the channel, how it changes interpretation, and the patient outcome it is expected to improve.
McKinstry and Wang found an overall preference with subgroup and practice variation—not a universal dress law. Technical vocabulary may signal expertise yet still fail if the patient cannot use the diagnosis or treatment information.
Diagnosis accuracy, presentation and consultation style are distinct outcomes
| Diagnostic pathway | What can go wrong | Consequence |
|---|---|---|
| Patient disclosure | Embarrassment, anger, misunderstanding, closed questions or sensitive face-to-face disclosure may hide/distort information | Clinician reasons from incomplete evidence |
| Evidence interpretation | Symptoms overlap; training/tests may be incomplete or unavailable | Healthy patient classified ill = false positive (Type I); ill patient classified healthy = false negative (Type II) |
| Action | Error is carried into testing/treatment or reassurance | False positive risks anxiety/unneeded procedures; false negative delays needed treatment |
| Presenting a diagnosis | Evidence and implication |
|---|---|
| Choice of channel | Cooke & Colver's 77 skin-cancer patients chose letter 48%, phone 37%, face-to-face 11%, combined 5%; 94% of those receiving their chosen method were happy |
| Quality over channel alone | Schofield et al. found no significant phone–face-to-face difference in satisfaction/anxiety/depression; preparation, explicit/clear/full information mattered |
| Application | Explain pros/cons, offer feasible choice, communicate clearly, check support and next steps—especially for serious/uncertain diagnoses |
| Boundary | Skin-cancer preferences do not automatically generalise to every condition, urgency, literacy level or culture |
| Consultation style | Practitioner behaviour | Possible strength/risk |
|---|---|---|
| Doctor-centred / directing | Doctor defines problem, gives diagnosis/instructions and takes expert control | Efficient/clear and may reassure; can suppress patient priorities or shared agency |
| Patient-centred / sharing | Doctor elicits concerns/preferences and shares options/decisions | Supports voice and tailoring; may feel less decisive and needs time/information |
| Savage & Armstrong (1990) | Evidence map |
|---|---|
| Design/sample | 359 randomly selected patients aged 16–75 from one inner-London GP; randomised directing versus sharing style during treatment/advice/prognosis |
| Outcome/result | Immediate satisfaction and one-week follow-up; directing scored higher on most satisfaction outcomes, especially physical problems/prescriptions. No significant style difference for longer, advice, psychological or chronic consultations |
| Strength | Random allocation and scripted contrast support a causal test within this GP's consultations |
| Limits | One GP, self-reported satisfaction, 89% initial and 58% one-week response; satisfaction is not adherence, diagnostic accuracy or health improvement |
False positive = illness diagnosed when absent; false negative = illness missed when present. Savage and Armstrong support a context-bound satisfaction effect of directing style—not ‘doctor-centred is always medically better’.
Delay has three stages; fabricated illness must be distinguished by motive
| Safer et al. (1979) stage | Interval | Predictors/examples |
|---|---|---|
| Appraisal delay | Notice symptom → decide it signals illness | Well-defined/painful symptoms shortened delay; reading/research and attempts to interpret or self-treat could lengthen it |
| Illness delay | Decide ‘I am ill’ → decide to seek professional care | Perceived severity, imagined consequences, beliefs about treatment benefit/discomfort |
| Utilisation delay | Decide to seek care → attend/use service | Cost, appointment effort, childcare/life barriers, pain and belief that the condition is curable |
| Study architecture | Evidence/evaluation |
|---|---|
| Sample/procedure | 93 first-time patients (38 men, 55 women; mean age 44) with mostly mild complaints in waiting rooms of four clinics at a large inner-city hospital; 45-minute interview/questionnaire |
| Result/conclusion | Different variables predicted each stage; painful symptoms and no competing personal problem predicted shorter total delay. One total-delay score hides distinct decisions |
| Strength | Detailed stage model has practical value: information targets appraisal, belief support targets illness decision, and access reform targets utilisation |
| Limits | Retrospective self-report is vulnerable to recall/reconstruction; severe cases were excluded and one hospital context restricts generalisation |
| Pattern | Symptoms/illness behaviour | Primary motive |
|---|---|---|
| Munchausen syndrome / factitious disorder imposed on self | Deliberately feigns, exaggerates or induces illness and repeatedly seeks the patient role | Internal psychological need to occupy the sick role, without an obvious external reward |
| Malingering | Deliberately feigns/exaggerates illness | Clear external incentive such as money, avoiding work/duty, drugs, shelter or legal advantage |
| Genuine illness/somatic presentation | Symptoms are not intentionally fabricated | Distress or disease; absence of a quick physical explanation does not prove deception |
| Munchausen diagnostic evidence | Examples |
|---|---|
| Essential pattern | Pathological lying, travelling between services, recurrent feigned/simulated illness |
| Supporting—not individually decisive | Multiple admissions/scars, unusual dramatic presentation, medical knowledge, willingness for tests/operations, evidence of self-induced signs, deprivation/personality history |
| Diagnostic caution | Corroborate records, observations and biological tests; assess motive and alternatives. Lists vary across classifications and overlapping features do not establish intent alone |
| Aleem & Ajarim (1995) | Evidence map |
|---|---|
| Case | 22-year-old woman repeatedly treated since age 17, presenting with bodily swelling and complaints without a coherent physical cause |
| Critical observation | Ward staff found a needle containing faecal material; it was believed she had injected breast tissue. When confronted she became angry, left and did not return |
| Value | Rare, detailed clinical evidence reveals a possible method of symptom induction and repeated service use |
| Limits/ethics | One case cannot estimate prevalence or universal cause; retrospective records and clinician interpretation risk bias, and confrontation/confidentiality require care |
Both Munchausen syndrome and malingering can involve intentional symptom production; the key distinction is motive. Never infer either merely because tests are negative, and never treat a supporting feature—such as scars or repeated admissions—as a diagnosis by itself.
3.2 Adherence to medical advice
- Syllabus
- 9990–2028–2029
- Topic
- 3.2
- Level
- A2
Non-adherence can be intentional, unintentional and rational
| Behaviour | Examples | Problems |
|---|---|---|
| Treatment non-adherence | Never starts, wrong dose/time, stops early, changes diet/exercise, or uses device incorrectly | Reduced benefit, relapse/resistance, avoidable harm and misleading clinical decisions |
| Appointment non-attendance | Misses diagnosis, monitoring, treatment or follow-up | Delayed care, wasted capacity and disrupted continuity |
| Intentional vs unintentional | Deliberate preference/concern versus forgetting, misunderstanding, access or practical failure | The same observed missed dose needs a different intervention |
| Laba et al. (2012) | Evidence map |
|---|---|
| Aim/design | Online discrete-choice experiment testing which medication attributes influence stated continuation |
| Sample/task | 161 Australian community adults, age/gender matched to census; hypothetical medicines varied on eight attributes |
| Result | Immediate/long-term harms and benefits, cost and regimen significantly influenced choice; private insurance reduced cost sensitivity; side-effect framing often outweighed benefit framing |
| Boundary | Shows reasoned stated preference, not observed pill-taking; 10% participation and hypothetical non-disease-specific choices limit generalisation |
| Health Belief Model component | Adherence question / support |
|---|---|
| Susceptibility + severity | ‘What is my risk and what happens untreated?’ Give accurate, non-alarmist personalised information |
| Benefits | ‘How will this treatment reduce risk/symptoms?’ Make outcome and timescale concrete |
| Barriers/costs | Side effects, money, complexity, transport, stigma: solve or renegotiate them |
| Cues to action | Prompts, follow-up, symptom/action plans |
| Self-efficacy | Can the patient perform the regimen? Demonstrate, simplify and check skill |
First identify whether the barrier is preference, belief, memory, comprehension, access or regimen design. Shared decisions may customise timing/cost/side effects; information alone cannot fix transport or an unaffordable prescription.
‘Rational’ means understandable from the patient's perceived attributes and priorities, not medically optimal. HBM is useful but reductionist if family, service access, habit and practitioner communication are ignored.
Every adherence measure observes a proxy, so triangulate
| Measure | What it records | Strength | Validity threat |
|---|---|---|---|
| Clinical/semi-structured interview | Patient/caregiver account, routine and reasons | Rich context; semi-structure balances comparison and probing | Recall/social desirability; participating families may differ (Riekert & Drotar) |
| Pill count/refill | Tablets missing or prescriptions collected | Cheap, quantitative and practical | Dumping/sharing; collection does not prove ingestion |
| Electronic dispenser/TrackCap | Date/time bottle opened | Detailed objective event record | Opening ≠ swallowing; other containers and monitoring reactivity |
| Blood/urine | Drug/metabolite or expected biological marker | Harder to fake; confirms recent exposure for suitable medicines | Snapshot misses timing/occasional omission; metabolism varies; invasive and not universally available |
| Chung & Naya (2000) | Evidence map |
|---|---|
| Sample/regimen | 57 adults with asthma (32 male, 25 female; 18–55), 47 completed; zafirlukast 20 mg twice daily, 12 hours apart, away from meals |
| Procedure | After screening, 56 tablets supplied every three weeks across 12 weeks; bottle TrackCap recorded openings; returned pill count compared with cap data |
| Control/limit | Participants knew adherence was monitored but not exactly how. Standardised longitudinal records aid reliability, yet cap/pill proxies still do not prove ingestion and awareness can improve behaviour |
| Decision | Best response |
|---|---|
| Need reasons/barriers | Semi-structured interview |
| Need daily timing pattern | Electronic cap/dispenser |
| Need inexpensive clinic screen | Pill count/refill plus questions |
| Need recent physiological confirmation | Valid drug-specific blood/urine test with consent |
| High-stakes inference | Combine methods; investigate disagreement instead of declaring one ‘true’ |
Objective means less dependent on the researcher's or patient's judgement, not perfectly valid. A cap opening, missing pill or biomarker is evidence about a different part of adherence; agreement across methods strengthens inference.
Improve adherence by matching the intervention to the barrier
| Barrier | Technique/mechanism | Evaluation |
|---|---|---|
| Forgetting/weak cue | Timed text, call, sticker or specific prompt | Low cost; fatigue and ignored prompts reduce durability |
| Vague goal/accountability | Collaborative behavioural contract with exact action, monitoring, review and feasible reward | Supports commitment; honesty and clinician time constrain monitoring |
| Complex/unacceptable regimen | Customise timing, formulation, device, cost or side-effect plan through shared decision | Targets rational barriers; clinical safety/choice limits remain |
| Child finds treatment aversive | Developmentally appropriate device, play/reward and caregiver routine | Engagement may not equal correct dose; caregiver report is biased |
| Access/community barrier | Specific prompt plus transport/opening/access support or incentive | Can change attendance; cost, equity and external-reward maintenance matter |
| Chaney et al. (2004) Funhaler pilot | Evidence map |
|---|---|
| Intervention | Asthma spacer added toy-like incentive features to make correct use rewarding for young children |
| Method | Matched questionnaire-based survey; two home interviews of each caregiver by the same interviewer, plus random telephone checks about previous-day medication |
| Finding | Funhaler was associated with greater child/parent acceptance, willingness and reported adherence than the existing spacer |
| Limits | Small pilot, caregiver self-report and novelty; association/short follow-up cannot establish durable medication delivery or health improvement |
| Yokley & Glenwick (1984) | Evidence map |
|---|---|
| Sample/design | 1,133 families of under-immunised preschoolers randomly assigned by family to six conditions, avoiding different prompts within one household |
| Conditions | General prompt; specific prompt; specific+access; specific+monetary incentive; contact control; no-contact control |
| Result | All except general prompt improved immunisation; incentive largest, then access, then specific prompt. Specific prompt alone was most cost-effective |
| Evaluation | Random assignment and objective clinic behaviour support causality/application; one service context, incentives/equity and attendance versus broader adherence limit transfer |
Specify who receives the intervention, the exact cue/support/reward, the barrier it changes, an objective adherence outcome, baseline/comparison condition, follow-up and ethical safeguards. For children, obtain guardian consent and age-appropriate assent without coercive rewards or withholding necessary care.
The intervention with the largest immediate effect is not automatically best: compare cost, feasibility, equity, generalisation and maintenance. Fun or rewards can cue behaviour, but only valid measurement can show whether the prescribed regimen was actually followed.
3.3 Pain
- Syllabus
- 9990–2028–2029
- Topic
- 3.3
- Level
- A2
Pain signals tissue threat, but the experience is modulated
| Pain type/function | Pattern | Important boundary |
|---|---|---|
| Protective function | Warns of actual/potential harm, promotes withdrawal/rest and learning | Pain can persist after protection is useful, and damage can occur with little pain |
| Acute | Rapid onset, usually identifiable source/location and short duration; often resolves with healing/treatment | Intensity can be high but duration, not severity alone, defines it |
| Chronic | Persists beyond expected healing/for an extended period and can affect mood, relationships and quality of life | May begin as acute pain; biological, cognitive and social processes maintain it |
| Phantom limb | Pain is experienced as located in an amputated limb | The experience is real although the peripheral limb is absent |
| Theory | Mechanism and prediction | Evaluation |
|---|---|---|
| Specificity | Specialised pain receptors/pathways carry signals to a pain centre; more noxious input should produce more pain | Explains sensory transmission but is reductionist: damage and reported pain often diverge |
| Gate control (Melzack & Wall) | In the spinal dorsal horn, relatively greater small-fibre activity opens transmission while large touch/pressure fibres inhibit it; descending attention, emotion and expectation can also modulate perception | Explains rubbing an injury and psychological strategies, integrating nature/nurture; ‘gate’ is a model, not a conscious door |
| MacLachlan, McDonald & Waloch (2004) | Evidence map |
|---|---|
| Problem/method | First reported therapeutic mirror treatment case for ongoing lower-limb phantom pain in a conventional clinical setting |
| Procedure | The intact leg and its mirror reflection created visual feedback of two limbs while repeated movements were performed; practice later progressed without the mirror |
| Result | Phantom pain reduced significantly during intervention, perceived motor control increased, and aspects of the phantom changed |
| Inference/limit | Congruent visual–motor feedback may alter phantom experience. One male case gives rich idiographic/process evidence but cannot prove efficacy, mechanism or generalisation |
Specificity emphasises biological nature and determinism; gate control is more holistic because sensory input interacts with learned attention, expectation and emotion. Mirror treatment gives the person active control, but improvement still depends on neural and situational processes rather than free will alone.
Pain is neither ‘only in the tissue’ nor ‘only in the mind’. Gate control explains modulation of genuine nociceptive experience; MacLachlan supports treatment potential for one lower-limb case, not a universal cure.
Pain measures capture different perspectives, not one perfect score
| Measure | What it captures | Strength | Limitation |
|---|---|---|---|
| Clinical interview | Patient's location, quality, timing, triggers and meaning through questions | Flexible, idiographic qualitative detail and clarification | Vocabulary, memory, social desirability and practitioner bias; no standard precise score |
| McGill Pain Questionnaire | Sensory, affective and evaluative descriptors; pain-rating index, words chosen and present intensity 1–5 | Multidimensional yet quantitative; standardised comparison | Fixed descriptors may not fit language/culture or unique experience |
| Visual/faces rating scale | Child/adult marks a line, number or age-appropriate face for intensity | Quick, repeatable and directly self-reported | Scale understanding and anchors differ; number remains subjective |
| UAB Pain Behavior Scale | Observer rates categories such as vocal complaints, grimacing, posture, mobility and guarding | Adds visible behaviour and standardised observation | Pain can be hidden/exaggerated; observer inference and context affect score |
| Brudvik et al. (published 2016/2017) | Evidence map |
|---|---|
| Design/sample | Cross-sectional Bergen emergency outpatient study of 243 children aged 3–15 with independent child, parent and physician ratings |
| Measures | Age-appropriate child scales (faces/colour for younger children; visual analogue for older children) and parent/physician numerical ratings |
| Results | Mean child pain 5.5, parent 4.8, physician 3.2; child–parent agreement moderate (κ=.55), child–doctor .12 and parent–doctor .17. Underestimation was less marked for fractures |
| Conclusion | Physicians commonly underestimated paediatric pain; child self-report plus parent assessment can improve decisions |
| Strength | Limitation |
|---|---|
| Real emergency setting and three independent perspectives improve ecological/construct coverage | Cross-sectional ratings cannot reveal which estimate caused treatment or which is an objective ‘truth’ |
| Age-adapted standard scales and quantitative agreement support comparison | Scales differ by age; illness mix, Norwegian setting and observer expectations constrain generalisation |
| Exact disagreement has direct pain-management application | Severe pain can impede completion, and hardly half of severely affected children received relief—rating alone does not ensure action |
Choose by purpose: interview for quality/context, McGill for multidimensional standard scoring, visual scale for rapid self-rated intensity, and UAB for observable behaviour. Combine them when decisions are high-stakes; investigate disagreement rather than averaging away the patient's voice.
Quantitative does not mean objective, and observational does not mean accurate. Pain has no simple external gold standard: validity improves when age, language, behaviour, self-report and clinical context are considered together.
Pain management targets chemistry, attention or sensory modulation
| Route | Mechanism/use | Strength | Risk/boundary |
|---|---|---|---|
| Biochemical | Analgesic/anti-inflammatory or neuropathic-pain medicine changes peripheral/CNS signalling; e.g. gabapentin may help some nerve/phantom pain | Convenient, standardisable and may act quickly | Side effects, tolerance/dependence for some drugs, interactions; suppresses pain rather than every cause |
| Attention diversion | Actively (singing/task) or passively (picture/TV) focus limited attention away from pain | Portable, active patient control, no drug side effects | Severe/chronic pain may dominate attention; relief varies |
| Non-pain imagery | Generate a vivid safe/pleasant scene incompatible with sustained pain focus/arousal | Can reduce distress and descending amplification | Requires concentration/practice; not tissue repair |
| Cognitive redefinition | Reframe sensations as manageable, temporary or non-threatening rather than catastrophic | Alters appraisal, anxiety and coping | Unsupported reassurance may invalidate danger signals |
| Alternative | Procedure/proposed mechanism | Evaluation |
|---|---|---|
| Acupuncture | Fine sterile needles placed at selected points; biomedical accounts propose sensory/endorphin modulation while traditional accounts use qi/meridians | Some patients report benefit; practitioner skill, culture/expectancy and condition matter. Bruising/bleeding, infection if unsterile, cost/time and rare injury are limitations |
| TENS | Skin electrodes deliver mild low-voltage current near pain; competing large-fibre input may inhibit transmission and stimulation may recruit endogenous analgesia | Non-drug, adjustable and self-administered for some conditions; placement/dose matter, benefit is not universal, and misuse can irritate/burn skin |
| Clinical need | Reasoned combination |
|---|---|
| Acute injury with continuing danger | Diagnose/protect tissue first; biochemical relief plus brief cognitive support |
| Persistent neuropathic/phantom pain | Specialist review; appropriate medicine and sensory/psychological rehabilitation may be combined |
| Anxiety amplifies procedural pain | Clear information, attention diversion or imagery alongside necessary analgesia |
| Patient seeks acupuncture/TENS | Discuss evidence, contraindications, qualified use, cost and measurable follow-up |
Evaluate the measured outcome: reported intensity, distress, behaviour, function or medication use. Control/placebo comparisons help separate specific mechanism from expectation and attention; objective function can complement self-report, but subjective relief is itself a relevant outcome.
Psychological treatment does not imply unreal pain, and ‘alternative’ does not imply harmless or mechanism-proven. Pain management can be holistic: combine compatible methods while retaining diagnosis, safety and evidence boundaries.
3.4 Stress
- Syllabus
- 9990–2028–2029
- Topic
- 3.4
- Level
- A2
Stress links prolonged demands to physiological and behavioural health risk
| GAS stage | Adaptive response | If demand persists |
|---|---|---|
| Alarm | Sympathetic/adrenal activation releases adrenaline and cortisol; heart rate, breathing, glucose and alertness rise for fight-or-flight | Repeated activation increases physiological load |
| Resistance | Overt alarm falls while the body maintains resources and remains ready; the person may appear to cope | Irritability, poor concentration, sleep/appetite disturbance and sustained cardiovascular/endocrine activity can emerge |
| Exhaustion | Resources and recovery capacity are depleted after prolonged demand | Fatigue, anxiety/depression, weakened immunity and increased hypertension/metabolic/CHD risk—not an inevitable fixed endpoint |
| Source model | Stress mechanism | Boundary |
|---|---|---|
| Holmes & Rahe life events | Social Readjustment Rating Scale sums life-change units: greater accumulated readjustment predicts higher illness risk | Events differ in meaning, desirability, culture and coping; correlation does not prove events caused illness |
| Work stress | High demands with low control/justice and sustained effort can activate physiology and encourage unhealthy coping | Job, grade, prior health and personality confound associations |
| Friedman & Rosenman Type A | Time urgency, competitiveness, hostility and control orientation increase frequent threat/challenge appraisal | Nomothetic label varies within people; hostility may be more relevant than the whole type |
| Chandola et al. (2008) Whitehall II | Evidence map |
|---|---|
| Sample/design | Longitudinal cohort of 10,308 London civil servants aged 35–55 at baseline; repeated work-stress exposure and CHD outcomes across phases |
| Outcomes | CHD death/non-fatal myocardial infarction/angina, health behaviour, metabolic syndrome, heart-rate variability and morning cortisol rise |
| Results | Chronic work stress predicted CHD, especially under age 50 (RR 1.68); it also related to poorer behaviour, metabolic risk, lower HR variability and higher morning cortisol. About 32% of the association was attributed to behaviour/metabolic syndrome |
| Inference/limit | Supports behavioural and neuroendocrine pathways, but an observational civil-service cohort cannot establish manipulation-level causality or represent every occupation/culture |
Use a person–situation account: demands and life change create conditions, while control, appraisal, coping, resources and personality alter response. GAS describes a broad physiological trajectory; it does not decide which source is stressful for one individual.
Stress can raise probability of illness without making illness inevitable. Life-event scores, Type A and work strain are risk explanations; they do not diagnose a person or prove a single cause.
Stress measures capture arousal, brain response, hormones or appraisal
| Measure | Proxy | Strength | Validity limit |
|---|---|---|---|
| Heart rate/device | Autonomic arousal over moments/time | Objective, continuous, repeatable | Exercise, caffeine, illness and excitement also raise rate |
| Perfusion fMRI | Regional cerebral blood-flow change during/after task | Spatially localises stress-related brain response | Indirect, expensive, artificial and motion-sensitive; does not read thoughts |
| Salivary cortisol | HPA-axis hormone in saliva | Non-invasive, quantitative, repeatable in field settings | Strong circadian/food/medication differences; sampling time matters |
| Type A questionnaire | Self-reported time urgency/competitiveness/hostility | Standardised trait comparison | Response bias and broad labels reduce construct validity |
| Holmes–Rahe questionnaire | Weighted recent life change | Fast nomothetic risk index | Weightings omit appraisal, context, culture and positive/negative meaning |
| Wang et al. (2005) | Evidence map |
|---|---|
| Method | Perfusion fMRI measured cerebral blood flow while participants completed a psychologically stressful arithmetic/performance task and comparison periods; behaviour and physiological responses were also recorded |
| Finding | Ventral right prefrontal activation was specifically associated with psychological stress and persisted beyond the task; a wider network supported stress responses |
| Evaluation | Repeated objective brain-flow measurement links task and response, but small controlled samples and scanner/task artificiality restrict generalisation; activation is a correlate, not a unique stress centre |
| Evans & Wener (2007) | Evidence map |
|---|---|
| Sample/procedure | 139 urban rush-hour train commuters; saliva collected after the journey and at home on a comparison weekend, alongside self-report and performance aftereffects |
| Result | Overall carriage density did not predict stress indices, but immediate seating density/personal-space invasion significantly affected cortisol, self-report and aftereffect performance |
| Evaluation | Natural commute and converging measures improve ecological/construct validity; no random allocation, self-selection/routine differences and sampling timing constrain causality |
Match measure to the claim: momentary arousal (heart rate), regional task response (fMRI), HPA activity (cortisol), personality style or accumulated life change (questionnaires). Convergence across physiology, self-report and behaviour is stronger than treating any one proxy as ‘stress itself’.
Biological data are more objective in recording, not automatically more valid for the person's experience. Standardisation supports reliability; validity still depends on timing, confounds, construct definition and ecological context.
Stress management makes arousal, imagery and coping skills controllable
| Biofeedback loop | Learning job |
|---|---|
| 1 Measure | Sensor records a normally hidden response such as forehead EMG, heart rate or skin conductance |
| 2 Translate | Device gives immediate sound/display proportional to the response |
| 3 Try strategy | Person relaxes muscles/breathing and observes whether feedback falls |
| 4 Reinforce/transfer | Successful control is practised until it can be used without the device |
| Budzynski & Stoyva (1969/1970) | Evidence map |
|---|---|
| Design | 15 tension-headache patients randomly allocated to contingent forehead-EMG tone, constant irrelevant tone or silent relaxation; all tried to relax forehead muscles over five sessions |
| Result | Contingent-feedback group significantly reduced muscle tension relative to controls; early patients also showed reduced headache activity |
| Evaluation | Contingent versus irrelevant/silent controls support feedback-specific learning, but tiny specialised sample, expectancy and muscle tension as a proxy limit generalisation to all stress |
| Bridge et al. (1988) | Evidence map |
|---|---|
| Sample/design | 154 women under 70 receiving six weeks of early breast-cancer radiotherapy at one London hospital; 139 completed; randomised relaxation (47), relaxation+peaceful imagery (44), supportive talking control (48) |
| Procedure/outcomes | Weekly ~30-minute sessions; interventions practised from tapes ≥15 minutes daily. POMS and Leeds depression/anxiety scales measured mood |
| Results | Six-week total mood disturbance was lower in interventions; combined group was more relaxed, control worsened and women ≥55 benefited most. No group difference on Leeds depression/anxiety scales |
| Boundary | Supports mood benefit during treatment—not cancer cure or direct proof that ‘stress’ fell. Field realism/randomisation are strengths; self-report, demand/practice and one female clinical sample limit transfer |
| Stress inoculation training phase | What happens |
|---|---|
| 1 Conceptualisation | Collaboratively identify stressors, thoughts, physiological/behavioural responses and explain the stress model |
| 2 Skills acquisition/rehearsal | Learn and practise relaxation, coping self-statements, cognitive restructuring, problem-solving/assertiveness matched to the person |
| 3 Application/follow-through | Rehearse increasingly realistic stressors, use skills between sessions, review outcomes and adapt/maintain the plan |
The device does not relax muscles by itself, imagery did not improve every measure, and SIT is more than relaxation. All require active practice/free choice within situational constraints; evaluate benefit, distress during therapy, access, maintenance and population fit.
3.5 Health promotion
- Syllabus
- 9990–2028–2029
- Topic
- 3.5
- Level
- A2
Effective health messages pair manageable threat with achievable action
| Message component | Needed inference | Failure mode |
|---|---|---|
| Susceptibility/severity | ‘This relevant harm matters to me’ | Too little threat is ignored; extreme threat can trigger denial, avoidance or helplessness |
| Response efficacy | ‘The recommended act reduces the harm’ | Fear without a useful response leaves anxiety rather than change |
| Self-efficacy/instructions | ‘I know exactly what to do and can do it’ | Information that is complex, costly or inaccessible stays as knowledge |
| Ethical delivery | Accurate, proportionate, age/culture appropriate, with support | Deception, stigma and traumatic imagery can cause harm |
| Janis & Feshbach (1953) | Evidence map |
|---|---|
| Design | About 15-year-old high-school students received equal-length dental-hygiene talks with minimal, moderate or strong fear; a control group and pre/immediate/one-week questionnaires enabled comparison |
| Result | Strong appeal produced most fear, but reported conformity was greatest after minimal fear: 36% versus 22% moderate and 8% strong |
| Interpretation | High fear may promote defensive avoidance; tolerable fear leaves recommendations usable |
| Limits | Short follow-up and self-reported hygiene do not prove durable brushing/clinical health; minors, frightening material and consent raise ethics/generalisation issues |
| Lewin et al. (1992) | Evidence map |
|---|---|
| Design/sample | 176 post-myocardial-infarction patients randomly allocated to a home self-help rehabilitation/heart manual or standard care plus placebo information/counselling |
| Intervention | Manual gave structured exercise, relaxation and risk-management information; facilitator contacted patients at 1, 3 and 6 weeks to review progress, encourage adherence and solve problems |
| Results | At one year psychological adjustment was better; intervention patients had fewer GP contacts and fewer hospital readmissions in the first six months, especially those anxious/depressed at discharge |
| Boundary | Information was bundled with follow-up/problem-solving, so the manual alone cannot receive all causal credit; one cardiac population limits transfer |
A defensible campaign states a credible consequence, immediately shows a small effective action, removes practical barriers and measures behaviour over time. Tailor intensity and delivery to age, culture, prior experience and perceived control rather than assuming one external message affects everyone equally.
The strongest emotional reaction is not the same as the strongest behaviour change. Janis/Feshbach supports low over high fear in that dental context; Lewin supports a supported self-help package, not passive information as a universal solution.
Schools and worksites change health through repeated cues and consequences
| Setting | Behavioural levers | Outcome to measure | Risk |
|---|---|---|---|
| School healthy eating | Peer/media role models, repeated tasting, availability, small rewards, teacher/parent consistency | Observed fruit/vegetable selection and consumption at school/home | Consent/assent, allergies, coercion/stigma, reward dependence and home inequality |
| Worksite safety | Clear rules, hazard redesign, feedback, group/individual reinforcement and reporting culture | Injuries, lost days, equipment damage, near misses and safe actions | Under-reporting, blame, inequitable incentives and reward removal |
| Tapper, Horne & Lowe (2003): Food Dudes | Evidence map |
|---|---|
| Programme | Hero role-model videos/letters, repeated fruit/vegetable exposure and small rewards; designed for primary ages 4–11 and delivery by school staff |
| Evidence | Longitudinal field work across nursery/classes/whole schools found large increases in school fruit/vegetable consumption, some home transfer and maintenance; a five-month experimental–control comparison reported substantially higher school/home intake in intervention children |
| Mechanism | Modelling prompts tasting; reinforcement establishes repetition; repeated exposure can make the food intrinsically liked and alter school norms |
| Limits | Programme components are bundled, schools/classes are not equivalent to individual randomisation, observation can be reactive, and UK child/cultural transfer needs testing |
| Fox, Hopkins & Anger (1987) | Evidence map |
|---|---|
| Setting/intervention | Workers at two dangerous open-pit mines earned trading stamps for injury-free individual/group performance, no equipment damage, adopted safety ideas and exceptional prevention; awards were lost after injuries/damage/non-reporting |
| Outcomes | Introduction was followed by large, multi-year reductions in lost-time injuries, days lost and accident/injury costs; savings exceeded programme cost |
| Strength | Long-term objective operational outcomes in a high-risk real workplace show practical maintenance/cost value |
| Limits | Before/after field evidence cannot isolate tokens from concurrent culture/procedure changes; incentives may suppress reporting and mining does not represent every worksite |
A strong institutional programme changes the environment as well as the person: make the healthy/safe act easy and visible, model it, reinforce early success, monitor objective outcomes and fade rewards while maintaining opportunity and norms.
Observed change after a multi-component programme does not identify one active ingredient. Rewarded performance may start behaviour, but maintenance, intrinsic value, accurate reporting, ethics and transfer determine whether promotion is genuinely successful.
Health beliefs improve when realistic risk and well-being resources develop together
| Unrealistic optimism | Mechanism/consequence |
|---|---|
| Comparative judgement | ‘My negative outcome is less likely—and positive outcome more likely—than for similar others’ without adequate evidence |
| Bias sources | Focus on one's protective factors but neglect others', little personal experience, perceived control, low estimated probability and stereotype distance |
| Health effect | Advice is discounted, screening/lifestyle change delayed, warning signs minimised; optimism may still support hope/coping when evidence-calibrated |
| Weinstein (1980) | Evidence map |
|---|---|
| Study 1 | Rutgers students judged 42 future events: own positive outcomes above average and negative outcomes below average |
| Study 2 | Students generated factors affecting eight events; another group shown those factors displayed less unrealistic optimism |
| Conclusion | Bias partly arises from egocentric focus—people know their own favourable circumstances but fail to consider that peers also have advantages |
| Limits | Hypothetical self-report and US college samples support comparative judgement, not actual health behaviour or every culture/age |
| Positive-psychology focus | Core route | Example/boundary |
|---|---|---|
| Pleasant life | Frequent positive emotion and savouring everyday enjoyment | Enjoyable activity; pleasure alone can be brief/adaptive only in context |
| Good life | Use personal strengths in absorbing, connected and satisfying activities/relationships | Skilled work, learning or relationship engagement—not merely ‘more positives than negatives’ |
| Meaningful life | Belong to and serve a purpose larger than oneself | Family/community/service; meaning can involve effort, not constant happiness |
| Shoshani & Steinmetz (2014) | Evidence map |
|---|---|
| Design/sample | Two-year repeated-measures school comparison: 537 Israeli grade 7–9 students received a one-year whole-school intervention; 501 attended a similar wait-list school. Initial wider sample 1,167; 1,038 completed data |
| Programme/measures | Teacher training plus 15 positive-psychology lessons using activities/discussion/media; BSI distress/symptoms, self-esteem, self-efficacy, life satisfaction and optimism scales |
| Results | Intervention distress, anxiety/depression and interpersonal sensitivity decreased while controls increased; self-esteem, self-efficacy and optimism strengthened |
| Limits | Applied longitudinal multi-measure evidence, but schools—not individuals—were randomised; self-report, school/history/culture and attrition restrict causality/generalisation |
Positive psychology studies strengths and well-being; it does not require constant positivity, blame distressed people or replace clinical care. Realistic optimism keeps hope while updating risk from evidence; pleasant, good and meaningful routes may overlap but are not synonyms.