Stress

Syllabus Question: Describe stressors.

Always refer back to this bit for questions that ask for stress.

Selye (1965) states that stress refers to a failure to respond appropriately to emotional or physical threats.

Stress can be seen in three ways.

I. II.

III.

An internal bodily response as an automatic biological reaction to external stimuli An external stimuli that exerts a destructive force upon the organism as a reaction to an environmental threat or demand. An interaction model looks at both the stimulus and response and the cognitive appraisal of the situation. A stress reaction only occurs if an individual perceives that there is a mismatch between the demands and the situation and their ability to cope with it.

Stress is a response to a stressor, a stressor is an external stimuli or threat that cause stress. When an over exposure to a stressor is experienced by someone then that stressor will eventually cause stress.

Acute stressors is stress that appear suddenly and require immediate attention but do not last long. Chronic stressors are stressors that last for a long time.

Syllabus Question: Discuss physiological, psychological and social aspects of stress.

Physiological aspects

Physiologically, stress is controlled by the nervous system and the endocrine system mainly the hypothalamus and the pituitary gland. The nervous and endocrine system transmits messages throughout the body. The nervous system uses electrical and chemical messages and the endocrine system uses hormones, which are released into the blood stream. Both of these systems are implicated in the stress response.

The hypothalamus is the main area that controls this process. For an immediate reaction towards stress the hypothalamus sends a message to the sympathetic adrenal medullary system (SAM). For long term stress, the SAM will increasingly use up bodily resources, to deal with this the hypothalamic pituitary adrenocortical axis (HPA) is stimulated to deal with the stress.

The stressor will cause activity within the hypothalamus, initially this will activate the sympathetic adrenal medullary system (SAM). This then stimulates the andrenal medulla, causing the release of adrenaline and noradrenalin. The release of these two hormones causes of the arousal of sympathetic nervous system and causing the "Fight or flight" response. This helps in cases of emergency, allowing you to run fast to escape or react quickly to something. Long term stress causes the SAM system to use too many of the body's resources to counter this the hypothalamus sends a message to the hypothalamic pituitary adrenocortical axis (HPA). This causes the anterior pituitary gland to be stimulated, releasing ACTH into the blood stream and causing the adrenal cortex to release glucocorticoids (like cortisol) into the blood stream. This suppresses the immune system and is useful in coping with long term stress and reducing the effects of the initial shock response

Selye (1976) identified the General Adaption Syndrome (GAS) which is a non-specific physiological response that occurs to a variety of stressful stimuli.

Phase 1: Alarm Reaction The physiological response triggered by stressful stimuli. This is the stage that involves the hypothalamus and the SAM and HPA systems. This is the equivalent of the fight or flight response.

Phase 2: Stage of Resistance This is the stage of adaption, the body is adapting with the demands of the environment. But as this stage proceeds the parasympathetic nervous system calls of more of the body's resources in order to cope. This causes the body to be pushed to the limits. Factors that determine how an individual can adapt to stress include: I. Behavioral coping style II. Personality factors and cognitive style III. Gender and cultural factors Phase 3: Stage of Exhaustion Eventually continued high arousal levels exhaust bodily resources producing negative physiological and psychological effects. Physiological effects included reduced resistance to infection and heart and circulatory problems. Psychologically this may cause anger, frustration, depression, helplessness and anxiety.

In evaluation of the GAS, it suggests a single, passive response to stressors whereas there is evidence that stress responses are different according to the individual, situation and stressor, and also that individual's responses are active rather than passive. Selye has also been criticized for using non-human animals to support his research on human responses to stress. Therefore, we can't fully apply the conclusions from animal studies onto humans when in the end we are different. This may also explain why the model overemphasizes physiological factors at the expensive of psychological factors such as the role of emotional and cognitive factors in stress- non human animals are less affected by emotional and cognitive factors.

Kiecolt-Glaser et al. (1984) Aim : To study the effects of stress on the immune system

Procedure They used 75 first year medical student volunteers (49 males and 26 females) during exam period. The researchers took blood samples one month before their final exams and again on the first day of their final exams and after the students had completed two of the exams. This was when stress levels should be the highest. They were also assessed using behavioral measures. On both occasions they were given questionnaires to assess psychiatric symptoms, loneliness and life events. This was because there are theories which suggest that all three are associated with increased levels of stress.Results They found that T-Cell activity declined between the two samples, confirming other research findings that stress is associated with a reduced immune response. They also found that immune responses were especially weak in those students who reported feeling most lonely, as well as those who were experiencing other stress life events.Conclusion That stress is associated with a lowered immune response in humans.

EvaluationIt was a natural experiment which means there are few ethical objections but it also means that it was not a true experiment. At best we can conclude that stress and immune response are negative correlated, we can't say that one caused the other. But the independent variable is a form of long term stress which allows stress to be looked over a period of time and is a natural form of stress. Other studies used artificial stress which may be different from natural stress.

Cognitive:PSYCHOLOGICAL ASPECTS OF STRESS Cognitive processes determine whether an event is perceived as being stressful or not If it is not, then it is unlikely that there will be a physiological stress responseLazaruss Theory of Appraisal An appraisal must be made in order for emotions to happen Emotions are influenced by personal characteristics and how these characteristics affect the appraisal Then they act according to the interpretation / appraisal Their reaction will be what they suppose to be the best response to the situation Primary appraisal An evaluation of the nature of the situation Is it relevant to my goals? Is it favourable to my situation? Who is responsible for it? Secondary appraisal Evaluation of ways of coping with the situation Changing it by making it less threatening How capable am I of coping with this?STUDY: Speisman et al. - Audio track interfering with emotionAIM:to prove the Lazaruss theory that appraisal can interfere with emotionsPROCEDURE- Participants were shown an unpleasant documentary of a traditional coming-of-age ritual of performing a circumcision on boys- Three groups:1. Trauma group~ Shown the documentary with a soundtrack emphasising the pain2. Denial group~ With a soundtrack that suggested the ritual was joyful - the boys anticipated entering manhood3. Intellectualisation group~ With an anthropological interpretation that ignored the painFINDINGS- Participants reacted more emotionally in the trauma group compared to other twoCONCLUSION- Because they evaluated the situation as being painful through the soundtrack- Thought it was appropriate to display more negative emotions - as the situation showed potential harm- Shows that through appraising the situation, different emotional responses can be displayed to the same stimuli

SocialSocial Readjustment Rating Scale used to measure psychological aspects of stress- stress is due to changes in the social environment

Rahe, Mahan and Arthur (1970)

Rahe et al. aimed to test the hypothesis that the stress of life events was correlated with illness. This followed up research by Holmes and Rahe (1967) who had observed that patients tended to have experienced critical life events in the months prior to the onset of illness. Life events were defined as positive or negative events, which disrupted normal routines and so required social readjustment.

used a sample of 2500 navy personnel and just before their tour of duty they asked them to fill in a questionnaire relating to significant changes in their life over the past six months. This meant that a life change unit (LCU represented the degree of stress caused by an event) could be calculated for each navy personnel. During the six months, a health record was kept for each participant by the ship's physician. They found a significant positive correlation of 0.118 between LCUs and illness. This figure may be small but with a sample size of 2500 it is significant. Further support comes from Rahe and Arthur (1977) where they found an increase of psychological illnesses, athletic injuries, physical illness and traffic accidents when LCUs were raised. Conclusions: The findings suggest that the stress of life events is correlated with physical illness.

The SRRS does not take individual difference into consideration. The scale assumes that each stressor affects people the same way. Not necessarily true e.g. for some people divorce is extremely stressful while for others it can be amicable or even a relief.Most people experience major life events very infrequently. Therefore a better measure of stress might look at the stresses and strains of daily life. These are called daily hassles", e.g. such as losing your keysMost 43 life changes in the SRRS arent everyday events. Kanner et al (1981) has designed a Hassles Scale which consists of 117 items, including concerns about losing things, traffic jams, arguments, disappointments, weight and physical appearance.Delongis et al (1981) Empirical StudyAim: Kanner et al (1981) were interested in investigating whether it is daily hassles, rather than major life events that are the most stressful. They developed a 117 item hassles scale and a 135 uplifts scale to examine the relationship between hassles and health.Procedure: An opportunity sample of 100 American participants, including 52 women and 48 men, all white, well-educated and middle class were asked to circle the events on both scales that they had experienced the previous month and rate each according to severity (for the hassles) and frequency (for the uplifts).Each participant was tested once a month for ten consecutive months using the two stress measures together with another two psychometric tests for psychological well-being.

Results: They found the hassles scale tended to be a more accurate predictor of stress related problems, such as anxiety and depression, than the SRRS. Uplifts had a positive effect on the stress levels of women, but not men.

Syllabus Question: Explain factors related to the development of substance abuse or addictive behavior.

ERQ:Explain factors related to the development of substance abuse and addictive behaviorSubstance: Something that is ingested into the body that has produces a cognitive and or behavioral change or effectSubstance abuse: refers to the continued use of the substance despite knowing problems associated with the substance such as persistent desire to use it and/or unsuccessful efforts to control substance use.Addiction: the state of being enslaved to a habit or to something that is psychologically or physically habit-forming to such an extent that it negatively effects daily life or causes severe traumaFactors:Genetic vulnerabilityRole of stressRole of peersGeneticsDNA inherited by the offspring from the parent and is considered responsible for the biological development of a child. Biological traits include brain chemistry which is directly linked to the physiological development of addiction. Addiction occurs in the Limbic System, the brains reward center. Neurotransmitters are used to transmit messages.Dopamine: An excitatory that is released whenever the brain decides the reward a behavior to remember it through a pleasurable experience usually from natural highs to motivate positive behavior.Drugs often assimilate an artificial high by triggering the intense release of dopamine that the body in turn learns to crave. In abusers, the brain combats this by reducing the number of neurotransmitters and receptor available to moderate the effects called tolerance. Resulting in a hypo-functioning reward system therefore without the drug, a natural/artificial high is difficult to achieve.Brains that produce more Dopamine experience a more intense pleasurable experience that the body wants to seek again and therefore may be more genetically prone to addiction.Kendler & Prescott (1998)Aim:Examined the patterns of marijuana and cocaine use by female twinsMethod:interviewed 1,934 twins, ranging in age from 22 to 62Drug "use" involved at least one nonprescribed use of a drug; "dependence" : tolerance or withdrawal or spending large amounts of time seeking, obtaining, and recovering from the effects of the drug.Results:Genetic factors play a major role in the progression from drug use to dependenceThe study found that concordance rates - both twins using, abusing, or being dependent on drugs - were higher for identical than fraternal twins. For example, for cocaine dependence concordance was 35 percent in identical twins and zero for fraternal twins.

Tsuang (1998)Aim:Studied the genetics of drug abuse likelihood for different drugsMethod:studied drug use in 1,874 identical male twin pairs and 1,498 fraternal male twin pairsfocused on gene DRD2 that codes for dopamine receptors (A person with fewer dopamine receptors is unable to 'feel' the effect of dopamine as well & needs higher levels)People with the DRD2 A1 variation of the gene have fewer dopamine receptorResults:The researchers found evidence to suggest that genetic influences contribute to a common vulnerability for abusing marijuana, sedatives, stimulants, heroin or opiates, and psychedelics.The genetic influence for abuse was greater for heroin than for any other drug.

EvaluationMuch of the research is reliant on self-reported data.Research is inconsistent - that is, there is not a high level of reliability.Is genetics the root of initiation - that is, the desire to even try the drugs - abuse or dependence?Twin are not yet clear which genes are responsible and what role they may play in addiction.Reductionist and deterministic.Different drugs seem to have different levels of concordance in twinsConsiders the biological aspect of addiction not just psychologicalTwin studies allow correlation to be drawn with genetic factors controlled in MZ twinsStressA pattern of negative physiological states and psychological responses occurring in situations where people perceive threats to their well-being which they may be unable to meet. Accompanied by various physiological, cognitive and behavioral changes and manifest in physiological, psychological and social aspects. Body reacts to stressors whether they are conscious or not Rise in stress hormone cortisol. Stress has an effect on our physiology as hormones are physical signals in the body. These effects may also have an influence on the likelihood of addictive behaviour.Morgan et al (2002)Aim:show how social factors can influence the level of dopamine receptors and probability to self-administer drugsMethod:Dopamine levels measured in monkeys that were individually housed and housed in groups for 18 monthsSelf-administered cocaine was made available to the monkeysResults:Those monkeys that were high in the social hierarchy also experienced higher levels of dopamine receptors. The monkeys that were submissive saw a decrease in their level of their dopamine.Subordinate animals took more cocaine than the dominant monkeys. This suggests that environmental stressors can produce profound biological changes that have important behavioral association, including vulnerability to cocaine addiction.

In humans there is a lot of research that shows a strong correlation between childhood abuse and later development of drug & alcohol dependency.Clerk & Blendy (2008)found that the longer the abuse continues the greater the later chances of dependency. But unlike the well controlled monkey study by Morgan et al, research on the role of abuse is solely correlational in nature and it is not possible to isolate variables to determine a cause and effect relationship. However, if we generalize the findings from animals, we can perhaps find an explanation for this correlational data.SCTSocial Cognitive Theory argues that we learn behaviour by observing the behaviour and process this dynamic with our environment. It is important that we identify with the person modeling the behaviour and that we feel that the model has received some positive outcome for the behaviour. This is the concept of vicarious reinforcement.One important set of role models is our parents.Bauman et al (1990)found that among American adolescents, if the parents did not smoke, then their children were less likely to smoke. 80% of adolescents whose parents did not smoke had never tried smoking, whereas over 50% of those with parents that smoke did. Biglan et al (1984)found that more than 70% of all cigarettes are smoked by adolescents with their peers.Unger et al. (2001)Aim: Whether adolescents smoke more if their peers doMethod:Cross-cultural survey on US adolescents (mean age 13) smokingResults:European American students who had peers who smoked were more likely to smoke than othersConclusion:individualistic cultures - adolescents create own youth, characterized with rebellion to set themselves apart from their parentsCollectivistic cultures - bond between teen and parent is important, and rebellion is not tolerated, therefore adolescents are more likely to conform to roles and norms that their parents

DiFranza et al:Aim: find out whether people get addicted to cigarettesMethod:longitudinal study of 217 adolescents (mean age of 12) in USMostly European American that have inhaled a cigarette at least onceThey performed psychological evaluations and reported history of tobacco useAnswered questions about attitudes and beliefs, social environment, family and community11 interviewedAssessing tobacco dependence based on reported cravings, time devoted to smoking and inability to quitResults:adolescents who had an immediate experience of relaxation after first puff were more likely to become addicted, learnt behavioural response to tobacco67% claimed relaxation effect after first inhale29& didnt experience such effectConclusion:Post-inhale relaxation was a big research for addictionOf those who experience relaxation ,91% were unable to quit 60% lost controlTakes far less to become addicted than what they previously thoughtStill unknown why some people are more sensitive to nicotine than others

Peer influences have been found to be among the strongest predictors of drug use during adolescence. It has been argued that peers initiate youth into drugs, provide drugs, model drug-using behaviors, and shape attitudes about drugs. However, SLT simply shows why individuals may initiate drug use. It is not a predictor of which individuals will develop abuse or addiction. In addition, when it comes to peer influence, it is important to remember that we have some level of choice of the groups to which we belong. It is possible that the use of drugs among peers is not simply because of the influence of others.

Syllabus Question: Discuss prevention strategies and treatments for overeating and obesity.

Prevention strategies

Health belief Model:The Health Belief Model argues that when an individual perceives a threat from a disease (measured by susceptibility to the disease and the severity of disease), and understands the benefits of preventive action, then the individual is likely to take preventive action. The second component of the model is that the individuals need to identify perceived barriers to a change in their behaviour. The final important aspect of the HBM is self-efficacy - an individual's belief that he or she is able to perform the advocated behaviour.According to this model, making people aware of threats or risk is an important part of nutrition education. McClure (2002) found what is called an optimism bias in which most people think that their diets are much healthier than they actually are. She found that when personalized feedback challenged this optimism, lifestyle changes took place.One implementation of the HBM was the Project Lean (Low-Fat Eating for Americans Now) Campaign (Samuels 1993). The first step was to inform the target population about the risks of high fat diets. The poster on the left is an example of the type of media campaign that was used to highlight these risks. As you can see on the poster, there was also a hot-line which people could call to get more information about the effects of a high-fat diet and to get a free brochure with suggestions for dietary change.Researchers determined the barriers to change through a series of focus groups. One of the perceived barriers to changing their diet was the fear that low-fat food was "inconvenient" and "tasteless." In order to develop self-efficacy in the community, chefs and food journalists took part in the campaign to demonstrate how to easily prepare tasty low-fat foods. The response was very strong with over 300.000 calls coming through the hotline. Evaluation: to measure success by calls is meaningless.

Social Learning Theory and Media Effect modelOn average, children in the United States view 15 television food advertisements every day, 98% of which are low in nutritional value, averaging out to 5,500 messages per year. Another study has shown that only 2% of advertisements (out of the 10,000 food advertisements that a child watches on average yearly) are about fruits and vegetables. Could media be used to a more positive effect to encourage healthy eating and fight the obesity epidemic?Social Learning Theory has been applied in mainstream television series in order to change people's behaviour. The use of soap operas for this goal became known as the Sabido Method. In a study by Valente et al (2007) the researchers measured the effect of storyline on a popular American television show, ER (Emergency Room) in which an obese, low-income African American teenage boy is diagnosed with hypertension. The show dedicated three episodes to integrating a discussion of teenage obesity, hypertension and heart disease, as well as the doctor explaining the 5 A Day plan to the young teen. The 5 A Day plan recommends five portions of fruit and veg per day. By a series of random phone surveys, the researchers found that after watching those three episodes of ER, people gained higher awareness and knowledge of 5 A Day, and were reported to engage in some change in their eating behaviors.

TREATMENTCognitive behavioral therapy aims to change cognitions and eating behavior. Beck (2005) conducted a pilot study of a new CBT based programme for weight loss. The participants were 10 women who weighed between 90 and 136kg. A year later all the women had lost weight and have kept it off. According to Beck it important to target the thoughts and beliefs that prevent the patient from losing weight when they have decided to do so. The important thing to Beck is not why the patient is overeating but to deal with the cognitions that lead directly to eating.

Further support for CBT comes from Starhe et al. (2007), they conducted a randomized trial with a group of obese women in Sweden. Half of them participated in a programme that included elements of CBT and the control group participated in a programme that included moderate intensity physical activity. The treatment lasted for 10 weeks and the participants' weight was controlled periodically over an 18 month period. Results show that in the cognitive programme, the weight loss was 8.6kg at the end of the treatment and 5.9kg after the 18 month follow up. Participants in the control group had lost an average of 0.7kg and after the 18 month follow up, they had gained 0.3kg on average. The researchers concluded that CBT seems to be efficient and it is also cost effective.

In spite of these two studies showing that CBT may have some effect on eating behaviours, the vast majority of the research shows that CBT does not have a long-term effect on weight loss. Cooper et al (2009) carried out a long-term study of 150 female participants with obesity who were randomly allocated to either CBT for a period of 44 weeks or a guided self-help program for 24 weeks. The CBT treatment resulted in an average weight loss of about ten percent of initial weight, compared to minimal weight loss in the self-help program. The participants were subsequently followed-up for three years post-treatment. The great majority regained almost all the weight that they had lost with the CBT treatment. The researchers suggest that it is ethically questionable to claim that psychological treatments for obesity work in the absence of data on their longer-term effects.

SurgeryGastric bypass procedures are surgeries leading to a marked reduction in the functional volume of the stomach. They are accompanied by an altered physiological and psychological response to food. There many variations to this type of surgery but most involve reducing the size of the stomach pouch to physically limit food intake. The resulting weight loss is dramatic but is only considered from morbidly obese patients. The aim of this type of surgery is to reduce the amount of food being consumed and to make the patient feel a level of fullness after ingesting only a small amount of food.

Maggard et al. (2005) performed a meta-analysis of effectiveness associated with surgical treatments of obesity, based on 147 studies. Surgery results in weight loss of 20-30kg, which was maintained for up to 10 years and was accompanied by general improvement in health. They concluded that gastric bypass was more efficient overall than gastric banding.

Elkins et al. (2005) found that many who have undergone the surgery suffer from depression in the following months as a result of a change in the role food plays in their emotional outlook. Severe limitations are placed on what the patient can eat and this can cause great emotional strain in individuals who are use to a certain lifestyle and food choices. But Adams et al. (2007) found that the long-term mortality rate of gastric bypass patients has been shown to be reduced by up to 40% suggesting that although some people may be depressed following their operation, they might not be even be alive have they not done so.

Health Promotion

Syllabus Question: Examine models and theories of health promotion.

Health Belief Model

The Health Belief Model is composed of five core beliefs that are affected by a range of external variables. These components interact and affect healthy behavior on the basis of external cues. I. Perceived vulnerability: The individual's assessment of the susceptibility that they will be affected by the condition II. Perceived seriousness: The individual's assessment of the severity of the condition if affected III. Perceived barriers: Aspects of the situation that disincline the individual from taking action. This could be financial, situational, social etc. IV. Perceived benefits

These four factors then allows an individual to conduct a cost-benefit analysis, where an individual sees if the benefits outweigh the costs or vice versa.

V. Cues to action: In order to exhibit a health behavior we need a cue to action, even when our cost benefit analysis judges it to be, a trigger to initiate the appropriate behavior. This could be internal or external.

Research supporting the effectiveness of the HBM

The Health Belief Model argues that when an individual perceives a threat from a disease (measured by susceptibility to the disease and the severity of disease), and understands the benefits of preventive action, then the individual is likely to take preventive action. The second component of the model is that the individuals need to identify perceived barriers to a change in their behaviour. The final important aspect of the HBM is self-efficacy - an individual's belief that he or she is able to perform the advocated behaviour.According to this model, making people aware of threats or risk is an important part of nutrition education. McClure (2002) found what is called an optimism bias in which most people think that there diets are much healthier than they actually are. She found that when personalized feedback challenged this optimism, lifestyle changes took place.One implementation of the HBM was the Project Lean (Low-Fat Eating for Americans Now) Campaign (Samuels 1993). The first step was to inform the target population about the risks of high fat diets. The poster on the left is an example of the type of media campaign that was used to highlight these risks. As you can see on the poster, there was also a hot-line which people could call to get more information about the effects of a high-fat diet and to get a free brochure with suggestions for dietary change.Researchers determined the barriers to change through a series of focus groups. One of the perceived barriers to changing their diet was the fear that low-fat food was "inconvenient" and "tasteless." In order to develop self-efficacy in the community, chefs and food journalists took part in the campaign to demonstrate how to easily prepare tasty low-fat foods. The response was very strong with over 300.000 calls coming through the hotline

Araham et al. (1992) studied Scottish teenagers who were well aware of the seriousness of the risk of HIV infection, their vulnerability to it and the benefits gained by using condoms. However, condom use by the participants was prevented because of the perceived barrier of costs; including loss of pleasure and awkwardness of use exceed the perceived benefits to avoiding infection. The HBM can be effective in that in can be used identify issues that prevent unhealthy behavior and then target that issue, in this case the barriers to using it.

Evaluation the Health Belief Model:

I. The key assumption of the HBM is that people are rational thinkers, i.e. they are capable of making and following choices that are in their best interest. But research into obesity for example have shown as that in cases like obesity that may not be the case. CBT for obesity exists to change faulty cognition in that those that are obese are not able to think properly about food and its negative effects if consumed too much. Therefore the HBM cannot be applied in cases of obesity or other disorders in fact. II. The HBM assumes people care about their health or the health of those they care for. Health apathy can be defined as a suppression of emotion towards matters pertaining to personal health or to the personal health of people for whom individuals are responsible for. This would explain why people still engage in unhealthy behavior such as eating poor feed when they are obese and feeding poor food to others who are also obese. III. The HBM ignores physiological determinism. Kessler (2010) argues that food Is deliberately designed with the use of chemical enhancers to make it more compelling for the customer to buy it. Therefore, positive rewards are artificially instilled in the food to encourage consumption above and beyond the need to eat for energy intake. IV. The HBM assumes people are active thinkers able to make choices within the realm of freewill. But it ignores the fact that food corporations use very aggressive marketing and have large advertising budgets. These advertising market foods with role models, movie tie-ins and other social learning theory techniques. Ofcom (2003) has shown that TV advertising is one of a range of factors which influence food consumption by children. Also, healthier choices are less widely advertising and so therefore advertisements of unhealthy foods dominate the media and cultural landscape, therefore making people less inclined to make healthy food choices. \

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Social Cognitive Theory

Social Cognitive Theory is the more modern term for "Social Learning Theory." Social Learning Theory suggests that health promoters act as change agents, facilitating change through modification of the social environment and the development of skills and capacities that enable individuals to make healthy changes. If you remember from the core, there are several important components of Social Learning Theory.

Observational learning is the ability to learn by observing the behaviour of others. For example, people may be more likely to follow the example of people they see as role models. Seeing someone you respect refuse to eat unhealthy foods may therefore change your attitude about what you eat.

Expectations are the value an individual places on the outcomes resulting from different behaviours. For example, if you believe that smoking will help you to lose weight and place great value on weight loss, then you may be more likely to take up smoking.

Reciprocal determinism describes the way in which behaviour and the environment continuously interact and influence one another. This is a key difference between this theory and the Health Belief Model. Social Cognitive Theory stresses the need for addressing environmental influences in order to promote change. For example, modifying social norms about smoking is considered to be one of the most powerful ways of promoting cessation among adults.

Self-efficacy is an individuals belief and level of confidence in her/his own ability to successfully make a change or perform a behaviour. Social learning theory identifies self-efficacy as the most important factor for successful change.

Health promotion campaigns that are based on Social Cognitive Theory include an informational component to increase perceptions of the risks and benefits associated with a particular behavior, teaching social and cognitive skills that can be used to initiate behavior change, building self-efficacy to promote behavior maintenance, and building social support to sustain change.

Social Learning Theory has been applied in mainstream television series in order to change people's behaviour. The use of soap operas for this goal became known as the Sabido Method. In a study by Valente et al (2007) the researchers measured the effect of storyline on a popular American television show, ER (Emergency Room) in which an obese, low-income African American teenage boy is diagnosed with hypertension. The show dedicated three episodes to integrating a discussion of teenage obesity, hypertension and heart disease, as well as the doctor explaining the 5 A Day plan to the young teen. The 5 A Day plan recommends five portions of fruit and veg per day. By a series of random phone surveys, the researchers found that after watching those three episodes of ER, people gained higher awareness and knowledge of 5 A Day, and were reported to engage in some change in their eating behaviors.

StrengthsUnlike the Health Belief Model, the SCT includes environmental factors and seeks to change social norms.Programs such as the Sabido Method have been effective in changing behaviour.

LimitationsThe theory not explain why people choose to change.It is difficult to measure levels of "self-efficacy" - and it is based on self-reported data.In many studies on the effectiveness of SCT, self-efficacy has not shown to be a valid predictor of behavioural change.

Syllabus Question: Discuss the effectiveness of health promotion strategies.

Health promotion can be defined as the science and art of helping people change their lifestyle to move toward a stage of optimal health. It is associated with achieving greater health equity and eliminating health inequalities in society.

Measuring the success of health promotion strategies

Health promotion strategies have to be assessed in order to determine their success to influence future policy. Health status should be measured before an intervention is carried out, the intervention itself should be measureable and then health status should be measured again after intervention. This is known as measurement of outcomes and is based on a scientific experimental paradigm.

This perspective uses an evidence-based treatment (EBT) approach and assumes that research into health campaigns has to product statistically significant data to show an effect of the health strategy. EBT is very scientific with a total lack of subjective and personalized approach.

The EBT approach considers the notions of efficacy and effectiveness. Efficacy is the relative improvement in health as the result of an intervention in a controlled randomized trial. Effectiveness is the relative improvement in health as the result of an intervention in a more realistic, everyday setting.

Advantages of the EBT approach are: I. Differences between efficacy and effectiveness can be identified. II. It can help identify hazardous interventions which may only show up in large datasets. III. It is used to monitor changes during treatment over time. Setting up a scientific approach to data collection negatives the effects of subjective variables.

Disadvantages of the EBT approach are: I. It requires a clearly defined population and a reasonable control of variables within it, which is quite unrealistic. II. The heavy reliance on the underlying scientific principles is also unrealistic as there are many non-measureable variables that affect health outcomes. III. Appraisals of health should always consider the everyday and personalized

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Health Psychology

variables that may influence susceptibility to campaigns and the will power to adopt healthier personal habits. These are difficult quantify.

For health promotion to work, it must produce cognitive dissonance. This is the uncomfortable feeling caused by holding two contradictory beliefs or ideas at the same time. The assumption behind cognitive dissonance is that people are driven to reduce conflicting feelings or thoughts by changing their attitudes, beliefs and behaviors or by justifying or rationalizing them.

In the sense of health promotion, this forces people to reflect on their lifestyle choices and begin a process of changing or rationalizing them. But this theory doesn't consider the cognitive and emotional processed involved in decision making.

The effectiveness of health promotion

Health campaigns are often criticized for being ineffective. Some people argue that they cannot make people change their habits and that they cannot making people change their habits and that they do not really help those who need to change the most.

Holm (2002) conducted a survey on the efficiency of health campaigns in relation to food habits in Denmark and found that health campaigns are useful but they cannot work by itself. A successful health campaign in Denmark in the 19990s aimed to decrease the use of butter on the national rye bread sandwiches that constitute the Danish people's lunch. From 1985 to 2001, the amount of people who said they did not use butter on the sandwich increased from 7% to 40%. The use of low of low fat milk also increased in Denmark after health campaigns. This shows that health campaigns can be effective.

VERB was a national, multicultural campaign that ran from 2002-2006 in the US. It used commercial marketing strategies to persuade children aged 9-13 to be physically active every day. It was almost meant to reach parents and adults professional in charge of children and give them ideas about how to promote physical activity on a daily basis.

Huhman et al. (2005) conducted a large-scale survey of children and parents to investigate the campaigns effectiveness to create awareness and promote physical activity. They found that after one year, 74% of the children were aware of the VERB

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Health Psychology

campaign. There was an increase in sessions of free-time physical activity for children who were aware compared to those weren't. The researchers concluded that commercial advertising in health promotion is promising and effective.

TRUTH was an anti-tobacco campaign in Florida in 1998-99 and aimed to prevent teen smoking by changing the attitudes of teenagers and encouraging them to form groups and spread the message in the community. The campaign included a massive advertising drive, such as TV commercials, billboards, posters, Internet, etc. One of the core components of the campaign was young people confronting the confronting the tobacco industry and accusing them of manipulating young people to encourage them to smoke.

The campaign carried out a number of telephone surveys of its target audience to measure effect and awareness of the campaign, as well as changes in attitude among adolescents. One of the findings was that teenager's negative attitude to smoking had risen and follow up surveys indicated that non-smoking teens who refrained from smoking through the campaign were more likely to say that they had been influenced by the campaign. The Florida Youth Tobacco Survey (FYTS) (1999) found that the number of middle- high school teenagers defined as smokers went down by 19.4% and 8% respectively. During this time period, 29000 teenagers from Florida made the decision not to smoke.

Sly et al. (2002) carried out a survey 22 months after the campaign to investigate if the anti-tobacco advertisements had an effect on attitude changes such that the non-smokers would remain non-smokers. They found that amount of exposure to the ads with the key message theme, that the tobacco industry manipulates teenagers' attitudes to smoking, during the campaign predicted that the person had remained a non-smoker. The findings from this campaign indicate that it is possible to change people's attitudes and behavior if the campaign is clear and focused on a target group.

Difficulties in evaluating effectiveness of campaignsEven though it appears that the TRUTH campaign was a success, we have to note that there are several difficulties in evaluating the effectiveness of a public health campaign. Here is a list of just a few problems. It is not possible to isolate variables when studying a large population being exposed to public media. Therefore, although a correlation between exposure to the campaign and change in behaviour can be observed, cause and effect cannot be determined. Levels of exposure to the media can only be measured through self-reported data. It is unlikely that the average person can accurately determine the number of times that they have been exposed, either directly or indirectly, to the campaign. Sampling is often problematic, so the results may not reflect the diversity of the population. Even if a public health campaign is judged to be effective, often the findings are not transferable to other populations. As noted above, it is difficult to measure the effectiveness over a large period of time to determine if the results are simply short-term change or a durable, long-lasting change in behaviour. Simply measuring health outcomes through hospital or work related data is not enough to determine that the campaign itself made a difference. Even if a campaign fails, it is difficult to know whether it failed because of the actual campaign or the way that it was delivered. Much of the data obtained is self-reported, leading to potential demand characteristics influencing the final outcome. Who is doing the research is very important. Often those that design the program play an integral role in its evaluation, potentially leading to a lack of objectivity and researcher bias. Strong evaluation requires triangulation. This is time-consuming and expensive.

Syllabus Question: Examine prevention strategies and treatments for substance abuse and addictive behavior.

Alcoholics Anonymous (AA) was founded in Ohio (USA) during the 1930s by Bill Willson and Dr. Bob Smith. At that time, alcoholism was seen as a moral failing and attempts to cure addicts acquired a religious significance.

According to Alcoholics Anonymous (2001) , AA is centered around "the twelve steps and twelve traditions." The twelve steps are guidelines for self-improvement. Such programmes have been adapted to suit different personal, cultural and religious needs, although there is a heavy emphasis on spirituality and surrendering of free-well, first to the power of the addiction and secondly to the power of a sponsor and notion of god.

According to VandenBos (2007) the AA treatment can be summarized as thus: I. An acceptance that one cannot control one's addiction or compulsion II. A recognition of a greater power as a source of strength III. A need to examine past errors in one's history with the help of a supportive sponsor IV. An attempt to make amends for these errors V. An attempt to commit to a new life with a code of behavior VI. A commitment to helping others who suffer from the same addictions or compulsions

A problem with AA is that the key assumptions of powerlessness and the need to adopt a higher power on the road to recovery can be seen as controversial. Professionally this could mean an individual finding strength and support in a more experienced and former addict. But this means care and addiction-expertise may be passed on by non-trained individuals who are not healthcare specialists. This may actually harm the person trying to recover instead. AA is an organization that believes in paying help forward and passing on expertise to others who need it. Healthcare professionals are not a key part of this paradigm and this had drawn both criticism and praise.

Shute (1997) argues that reliance on the medical model is too broad since not all AA attendees are full brown alcoholics but they will be forced to see themselves as such

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in the context of the meetings. Also alcohol is completely banned, suffered are asked to stop it completely. Shute argues that the disease approach and the notion of abstinence reduce the chances of all those in need receiving the appropriate help. However, not everyone has a clear knowledge on how the AA works. Some may not have even heard of such therapy treatment. This type of treatment does require some literacy knowledge, as people must be able to communicate their experiences to the rest of the groups during their meetings. It is highly important for members to respect each others privacy, as they are sharing stories that may be extremely sensitive to the members, as alcoholism not only brings physical and psychological problems to the person, it also brings financial and employment problems to their family. AA is a type of group therapy, and at times members may be intimated by the fact that they are in a group of people that are strangers to them, and this may prevent them from opening up. There is also a cultural issue to therapies, as collectivist cultures tend to depend on their own personal relationships, and they may consider seeking help as shameful to their own community. The advantage of AA is that there is no cost to the group, meaning that it gives the entire society a fair chance to prevent alcoholism. Different genders may also see this group differently, as males may have a stronger stereotype that they become alcoholics than females; this may prevent females from seeking help, as they wish to avoid being judged

Drug treatment

Disulfiram is often considered the most effective drug for dealing with alcoholism. Disulfiram blocks the enzyme acetaldehyde dehydrogenase from converting alcohol into the relatively harmless acetic acid. Alcohol is instead stored in the body as acetaldehyde and this is widely believed to be the cause of hangovers. Therefore the effect of disulfiram is to cause an instant and intense hangover in anyone who drinks alcohol while taking the drug. Krame et al. (2006) conducted a 9 year study and found an abstinence rate of over 50%.

Naltrexone is a drug that reduces the craving for alcohol while the alcoholic consumes alcohol. In other words, the presence of naltrexone in the blood acts as a negative reinforce for alcohol consumption. It does this by reducing endorphin release. This approach is called the Sinclair method and is an example of pharmacological extinction. It works on the principle that endorphins are part of the body's reward system for performing healthy behaviors. According to the principles of classical conditioning, the law of effect and social learning theory, the positive consequence for these behaviors provided by endorphins increase the likelihood of the behaviors being repeated.

Sinclair (2001) found 27% of naltrexone patients had no relapses to heavy dirnking throughout 32 weeks, compared with only 3% of placebo patients. Sinclair argues that this clearly demonstrates the efficacy of naltrexone as long as it used in conjunction with coping skills therapy. In addition that data showed a detoxification period is not required and targeted medication taken only when craving occurs is effective in maintaining the reduction in heavy drinking. Together these results make naltrexone a highly appropriate drug for alcoholics who experience highly pleasurable effects from drinking.

But, taking naltrexone before drinking will have to occur for the rest of the patient's life otherwise the endorphin conditioning, will re-establish itself. Therefore, freedom from naltrexone would only result from complete abstinence from alcohol.

Drug treatments offer an effective way for alcoholics to control their addiction but they are more effective if used in conjunction with other therapy and supported by motivation and a desire to control the behavior. Drug treatments do not tackle the negative thought processes which may lead some people to drink nor the underlying social issues which ay have caused the alcoholic to drink excessively in the first place. Cognitive behavioural therapy. Not everybody can afford the drugs that help them overcome the disease of alcoholism. It may be unethical for people to go through all the side effects of the drugs, which is why patients must contact their psychiatrists to obtain these drugs. Once again, obtaining help from psychiatrists may be unlikely for collectivist cultures as they dont wish to lose face. Alcoholics from a lower economic status may not be able to access these drugs. The extent to which the drugs would be effective on the patient would vary, as different participants may have different tolerance. Genetic factors may have allowed people to become more tolerant to alcohol.

The government also plays an important role in preventing alcoholism. The government has put a large amount of tax on demerit goods. A demerit good such as alcohol is unhealthy and harmful to the human body and the society. This tax discourages people to consume alcohol, as it would take a larger proportion of their income. This is especially effective for people who have a lower economic status, as they cannot afford to drink alcohol.

A researcher named Snyder has suggested that the more money that the government spends on alcohol advertisements, the more the young people drink. She found that the teenagers who lived in media markets with more alcohol advertising drank more. Snyder et al interviewed a random sample of young people aged 15-26 years, 4 times between 1999 and 2001.Snyder has also looked at the purchased information from the alcohol industry, as it showed the amount of money spent advertising in each state and the amount of total alcohol sold in each state. This way, she could analyze the youths drinking habits and the dollars spent. She found that the youth drank 3 % more per month for each additional dollar spent per person in the market. This shows that the government should be more aware of their actions and they should limit the amount of advertisements that are presented in their country. Based on this study, we may conclude that the more advertisement there is, the higher the number of alcoholics present in a country.