1. Using and Misusing Health Services
Health psychology

2. Overview

3. Perceiving and Interpreting Symptoms
Our perceptions are not very accurate
There are individual differences:
Some people have more symptoms
There are differences in what people can tolerate
Differ in how much attention is paid to internal states
Internally focused people overestimate bodily changes and experience slower recovery
Some people experience more symptoms or are aware of more symptoms (e.g., repressor notice less, bluntor vs. monitors, neuroticism). Talk about my hypertension study again and the work by Cochrane in the uK who found a linear relationship between neuroticism on the EPI and having one’s BP measured. Thos who did not come to GP in last two years were least neurotic, next were those who came but did not have their BP measured, and highest were those who came and happened to have their BP measured. Interpretation was that people who are more neurotic report more symptoms that prompt the doctor to measure their BP.

4. Symptoms Awareness
Background stress is associated with greater reports of symptoms
Mood - positive mood associated with fewer symptom reports than negative mood.
Stress may contribute to greater symptom reporting because people misinterpret stress symptoms as illness symptoms and because people under stress have more nonspecific symptoms that are stress-induced.
The mood effect may relate to “States of Mind”. States of Mind are where certain memories are linked to like mood and memories. Thus, when in a negative mood people recall more illness-related memories than when in a positive mood.

5. Expectations
Prior experience, beliefs, and knowledge influence expectations about symptoms.
Ignore unexpected symptoms and amplify expected symptoms
Beliefs about the disease label, causes, time course, and consequences influence symptom awareness and experience.
Disease label such as hypertension connotes a sense of tension and anxiety. You are more likely to pay attention to symptoms that you believe are caused by serious illnesses or that affect highly valued parts of the body (e.g., face). People can also hold quite inaccurate disease models of their condition. For example, hypertension is generally a symptomless condition that is chronic. However, people will report stop taking their high blood pressure medication when they feel better. In other words, they hold an acute rather than a chronic model of their blood pressure condition.

6. Placebos Inert substance or treatments
People can experience real symptom relief.
Furthermore taking placebos faithfully is associated with a lower likelihood of death.
Turn to our study on adherence to placebo therapy in CAMIAT.

7. Medical student’s disease -
Studying symptoms leads to greater focus on one’s own symptoms (e.g., of fatigue) that then get interpreted as indicative if disease.
As medical students learn about the symptoms of various diseases, more than 2/3 of them come to believe, incorrectly, that they have contracted one of these diseases at one time or another.

8. Mass Psychogenic Illness
Widespread symptom perception among a large group of individuals, without any evidence for physical or environmental cause.
Factors contributing to this effect are:
Cognitive exaggeration of common symptoms
Modeling
Emotional distress (e.g., anxiety)

9. Cultural Factors
Social-cultural influences shape how one appraises and responds to physical symptoms.
Cultural differences have been seen in what symptoms people recognize and tolerate. For example, a study by Sanders et al. (1982) study compared the behavioural and emotional functioning of low-back pain sufferers from six different countries. They found that Americans reported the greatest overall impairment, Italians and New Zealanders reported the second largest impairments, followed by Japanese, Columbian, and Mexican pain patients.

10. Help-Seeking – Lay Referral Network
Help interpret a symptom
Give advice about seeking medical attention
Recommend a remedy
Recommend consulting another key referral person

11. Who Uses Health Services?
Age: young children and elderly use more
Gender: women use more
Sociocultural: use increases with income

12. Why People Don’t Use Health Services
Iatrogenic conditions: medical problems resulting from a practitioner’s error or as a normal side effect of treatment.
Not trusting practitioners
Worry about confidentiality
Worry about discriminatory practices
Talk about DNA testing and the potential discrimination of employers and insurance companies.

13. Why People Don’t Use Health Services
Emotional factors:
fear of serious disease
embarrassment
Social factors
Not wanting to appear weak
More likely to use health care system if lay referral system encourages it
Talk about DNA testing and the potential discrimination of employers and insurance companies.

14. Misusing Health Care Services
Hypochondriacs: people who tend to interpret real but benign bodily sensations as symptoms of illness
Associated with neuroticism
Does not increase with age

15. In a little more detail

16. Delay in seeking help
A study of 800 elderly patients with newly diagnosed cancer found that 48 per cent had sought help within two months of noticing the symptoms, 19 per cent had delayed for over three months, and 7 per cent had delayed for a year (Samet et al. 1988).

17. Delay in seeking help
A study of heart attack survivors in Glasgow found that only 25 per cent had called for help when the symptoms started, and 60 per cent waited four hours before calling (MacReady, 2000).
In fact, 12 per cent of the patients waited a full day before seeking help.

18. Delay can occur at a number of decision points en route to the surgery.
Some psychologists suggest that delay occurs in a three stage process (Safer et al. 1979):
1. appraisal delay - the time it takes for a person to interpret their symptoms as a sign of illness
2. illness delay - the time it takes between realising that you are ill and deciding to seek medical advice

19. Delay can occur at a number of decision points en route to the surgery.
3. utilisation delay - the time it takes between deciding to go, and turning up at the surgery.
Different people will delay at different points in this process, and different symptoms and conditions will also bring about different patterns of response.

20. There are number of other factors that have been found to affect delay in seeking help, including;
Characteristics of the patient
Illness-related factors
Health beliefs

21. Characteristics of the patient
For example, age, gender and culture. Age can have an effect because elderly people may interpret their symptoms as being part of the ageing process. When people attribute their symptoms to ageing they are more likely to delay in seeking treatment (Prohaska et al. 1987). Some symptoms may also be less obvious in older people. For example, they report less pain than younger people with angina, and as a result might not seek help for an underlying heart condition (Day et al., 1987).

22. Illness-related factors
For example, the site of the symptoms, the type of symptoms, and the speed of development of the symptoms. Some conditions, such as sexually transmitted disease or incontinence, can create a lot of embarrassment and this may lead to delay (Leenaars et al., 1993). Also, symptoms that develop slowly or are not too severe will also lead to delay in reporting (Prohaska et al., 1987).

23. Health beliefs
For example, the frequency with which women examine their breasts for possible cancer is affected by their beliefs about the seriousness of the disease and their personal susceptibility to it (Ashton et al., 2001).

24. Overuse of health services

25. Hypochondriasis
Some people worry a lot about their health and it is estimated that worried people, some who are well and some, who are ill, place high demands on the health services (Wolinsky and Johnson, 1991). At the extreme end of the scale there are a few people who continue to visit their doctors even though there are no obvious signs of illness, and even when the doctor has taken all reasonable steps to reassure the patient.

26. Hypochondriasis
These patterns of abnormal illness behaviour are commonly given 'disease' labels such as hypochondriasis. This label, however, is commonly used in an informal way and not based on recognised tests and procedures. It is based on the health worker's belief that the patient's complaints are exaggerated or unfounded. Sadly, on some occasions, the label is made incorrectly when the health worker cannot find any explanation for the illness behaviour and comes to the conclusion that it is 'all in the patient's head'.

27. Munchausen Syndrome
A small number of people seek out excessive medical attention, often going from city to city to get new diagnoses and new surgical interventions. This is sometimes diagnosed as an illness itself - Munchausen Syndrome.
In very exceptional circumstances, individuals seek excessive and inappropriate medical contact through the 'illness' of a relative such as a child.

28. Munchausen Syndrome
This can be seen as a form of child abuse, where the parent (usually a mother) exaggerates, fabricates or induces illness in their child. The main motivation is believed to be that the parent wants to show herself to be an exceptional mother. This condition is referred to as 'Munchausen by proxy'.

29. Munchausen syndrome by proxy
The most famous case of this in the UK was the nurse Beverley Allitt. Between February and April of 1991 there were 26 unforeseen failures of medical treatment and unaccountable injuries on Ward 4 of Grantham and Kesteven General Hospital. In total four children died and nine were injured. Investigations found that nurse Beverley Allitt had altered critical settings on life support equipment and administered lethal doses of potassium and insulin to children in her care (The Allitt Inquiry, 1991).

30. Munchausen syndrome by proxy
She was diagnosed as suffering from Munchausen syndrome by proxy and was sentenced to thirteen concurrent life sentences.

31. Abuses by the health services
It is worth pointing out that the misuse of health services is not all one-way.
There is an argument to be made that medical services are bad for your health. In its extreme form this argument suggests that the major advances in life expectancy and good health are much more to do with the rise in living standards and public sanitation than to do with medics. IlIich, in his book Medical Nemesis (1975), suggests that 'the medical establishment has become a major threat to health' (p.11).

32. Abuses by the health services
In fact, it is recognised that one of the most likely places to catch a new illness in the UK is in hospital (Plowman et al., 2000) and iatrogenic (doctor-made) illness is a major cost to the health service. It is clearly not the aim of hospitals to make people ill, but IlIich's argument is that the power of the medical profession makes us helpless about our own health, and gullible to intrusive treatments that have only marginal benefits or no benefits at all.

33. Harold Shipman
On a less philosophical but more chilling note, the power of doctors can also be abused. Most famously there is the example of Harold Shipman, the Yorkshire GP who murdered an unknown number of his elderly female patients before being convicted in January He was able to operate unchallenged for many years despite there being evidence of anomalies in his death rates, a personal history of drug abuse, and a series of complaints made against him (Ramsey, 2001).

34. Harold Shipman
The question that arises is 'how could this happen?'. Although there are no easy answers, two of the contributing factors might be the trust invested in doctors by their patients, and the lack of monitoring within the health service and its professional associations.

35. The end