What does health protective behavior entail? - Chapter 4

What is meant by adherence behavior?

As previously discussed, our behavior influences our health. However, not all behavior is harmful. There is enough you can do to improve health.

Definition and measurement

Depending on which literature you read (medical, psychological or pharmacological), terms such as adherence' compliance and concordance are used interchangeably with different meanings. Roughly speaking, it's about the relationship between a patient and a healthcare professional. The term adherence is used here to indicate that the patient is following the advice of the expert. The meaning of non-adherence also differs between studies and books. This makes it difficult to compare studies. If 70% of a medical product has to be taken to be effective and less than this amount is taken, this is considered as non-compliance. Compliance means patient medicine taking behavior which conforms with doctor's orders. Concordance can be defined by a jointly determined agreement between physician and patient as to what is the appropriate treatment, following the patient having been fully informed of the costs and the benefits of adhering to their particular treatment. 

Do people adhere to this behavior?

About half of all prescription medication for longer-term use is not taken as directed. The numbers differ per type of condition and depend on many factors. A few examples of possible factors:

• Patient-related factors: personality, knowledge, culture, age, beliefs with regard to medication.
• Condition-related factors: the observed severity, presence or absence of pain, prognosis, symptoms, etc.
• Treatment-related factors: frequency and duration of the medication dose, presence and extent of possible side effects, type of treatment, number of treatments.
• Socio-economic factors: treatment costs, social isolation, low educational level.
• System-related factors: communications with healthcare providers regarding medicines, necessity or function, presence of traditional healing beliefs and systems.

What does a healthy diet entail?

Fruit and vegetables

Fruits and vegetables contain vitamins, fibers and antioxidants (chemicals that inhibit the oxidation process), all three of which are essential for good health. They can also protect the body against some forms of cancer, heart disease and strokes. Vegetarianism can reduce the risk of ischemic heart problems . This is a heart disease caused by the restriction of blood flow to the heart. However, some studies show that these results might be because participants smoked less and consumed less alcohol than non-vegetarians.

The daily recommended amount of fruit and vegetables is five or more servings per day (1 serving is approximately 80 grams). Less than 20% of young people adhere to this recommendation. A large proportion of adults do not adhere to these recommended amounts either. The reason for this is that people like other things better. Much more than in the past, it is common for young people to buy food themselves during the school lunch break and in most school canteens the supply is well adapted to demand.

Parents play a major role in the development of eating patterns, food choice and physical activity of their children. Children take over cooking habits from their parents. What food they eat in their youth, largely determines their later taste preference, which in turn partly determines the choice of product. Children can adopt the following preferences from their parents (through a socialization process):

• Cooking methods: warm up meals or freshly cooked meals.
• Products: for example, products that are high in fat or not.
• Flavors: mild or spicy.
• Food components: red or white meat, vegetables and fruits for example.

Various interventions have targeted the fruit and vegetable intake of young people. An effective program builds on the learning theory of increased exposure to taste of fruit and vegetables, modeling of healthy behavior through childhood cartoons and empowerment through child-friendly rewards (such as stickers) for eating fruits and vegetables. This appears to be effective for children.

What are the benefits of exercise?

What are the physical health benefits of exercise?

It is well known that exercise reduces the risk of cardiovascular disease, type II diabetes, osteoporosis and being overweight. It appears that regular performance of exercise:

• Strengthens the heart muscles.
• Increases heart and respiratory efficiency.
• Tends to reduce blood pressure.
• Reduces the tendency to accumulate body fat.

Exercise has benefits for those already with disease: for example, increasing muscular strength, function and quality of life, reducing fatigue and the side effects of cancer treatments and reducing fatigue in those with Chronic Fatigue Syndrome. Extreme exercise is sometimes associated with poor body image and with other compulsive disorders including eating disorders. Moreover, there is also a risk of injury and damage to the muscles.

Psychological benefits of exercise

Exercise has been associated with psychological benefits in terms of elevated mood among clinical populations. Research has shown that participating in aerobic training on a limited frequency is associated with reduced anxiety, more self-confidence and prosocial behavior (positive social behavior). This is because natural opiates are released during training, which act as a painkiller. Also stimulation of the release of the catecholamines (noradrenaline and adrenaline) is encouraged, they counter any stress response and enhance mood. Catecholamines are neurotransmitters in the brain. However, the relationship between exercise and a positive mood is not as simple as suggested here. For example, research has shown that when the intensity of the training increases, a negative mood arises. There are many more factors involved in this relationship, such as the area where people exercise, the help available and encouragement during exercise, and so on. Exercise can also be positive for people who experience cognitive deficits due to aging or dementia. It slows neuronal dysfunction and degeneration in Alzheimer's and it improves some aspects of cognitive functioning.

The negative consequences of exercise

For some people, the desire to excersize becomes compulsive, interfering with other aspects of life and leading to dependence. Excersizing does not solve health risks anymore and can even lead to problems. Regular exercise is better than extreme exercise. Just as with eating disorders, it may be that exercise is an element of control to those who feel aspects of their lives are uncontrollable. This can cause dependancy on sports.

Why do people exercise?

People who choose to exercise cite a variety of reasons:

• Desire to be physically fit.
• Improve body weight or body shape.
• Maintain health.
• Reduce stress.
• They see sports as a social activity.
• Improve self-image and state of mind.

Why do people not exercise? 

• Lack of time.
• Costs.
• Lack of access to good facilities.
• Shame.
• Do not believe in themselves ('it doesn't help me' or 'I can't keep that up').
• The lack of someone who wants to go with them.

People who exercise are often more aware of the positive consequences of this than people who do not exercise. They are also more convinced that they have the result in their own hands and that they will keep it up.

What is meant by health-screening behavior?

There are roughly two types of health research:

1. Research to detect early symptoms of disease in order to treat.
2. Identification of risk factors so that behavior can be changed on time.

An example of the first type is that pregnant women over 30 can be examined. For example, testing certain values ​​in the amniotic fluid whether the future baby will have Down syndrome. There is no treatment, but one may consider terminating the pregnancy early.

Examples of research in which risk factors can be easily detected are the measurement of cholesterol and blood pressure because of heart problems, eye tests for the risk of diabetes and genetic tests for Huntington's disease.

Screening for risk factors

A second goal of screening is to screen risk factors in individuals who are thought to be healthy. The goal is to detect someone's personal risk for a certain future disease, so that this person can be sufficiently informed about minimizing future health risks or planning further investigation and treatment. Examples of such primary prevention include:

• Screening for the risk of a cardiovascular disease (measuring cholesterol and blood pressure).
• Genetic testing for carrier status of the cystic fibrosis, or Huntington's disease gene or for breast, ovarian or colon cancer, in those with family history.
• Prenatal genetic testing.

Screening for disease detection

Screening with the aim of detecting certain diseases is based on a biomedical model. According to this model,  treatments can be implemented prior to the onset or advancement of disease symptoms by identifying abnormalities in cell or organ functions as early as possible. The best known examples of such a screening are:

• Screening for breast cancer (mammography).
• Screening for cervical cancer.
• PSA (prostate specific antigen) screening for prostate cancer. 
• Antenatal screening, for example for Down's Syndrome.
• Bone density screening.

Criteria for establishing screening programmes

The general criteria are that:

• The condition should be an important health problem.
• There must be a recognizable early stage to the condition or clear benefit to identifying changeable risks.
• Treatment at an early stage of a detected disease should have clear benefits to the individual compared with treatment at a later stage.
• A suitable test with good sensitivity and specificity should be available.
• The test should be acceptable to the general population.
• Adequate facilities for diagnostic assessment and treatment should exist.
• Screening frequency and follow-up should be agreed.
• Costs should be considered in the relation to the individual and public health benefits.
• Evidence-based information should be available to potential participants.

Costs and benefits of screening

According to Marteau and Kinmouth (2002), the effects of screening on the individual are not yet sufficiently known. There are also questions about the usefulness of screening and about the variation in availability and effectiveness between countries. The process can also cause stress if it appears that someone carries a gene for breast cancer, for example. Research shows that models about making decisions need to look further than simply the pros and cons of behavior. Many people nowadays also use the internet for health purposes (for example searching information), and this information is often biased: the judgments of screening are overestimated on the internet.

Self-screening behavior

It is already very common for women to check themselves regularly for lumps in their breasts. These bumps can be breast cancer, so it is important to go to the doctor when you feel something unusual. Testicles and skin are increasingly being examined by people themselves. These forms of preventive investigations are extremely useful when you consider that it costs someone nothing and is accessible to everyone. It is of course important that someone knows exactly how to examine themselves. It is really effective, because research shows that around 90% of breast cancer cases are detected by women themselves. As with many other health behaviors, a lack of self-examination is associated with a number of (social) factors: lower levels of income and education, age (young people do it less), lack of knowledge about the subject, shame about the possible following procedures, fear of something being discovered, fear of pain and a lack of confidence in the effect of self-examination. Men also do less self-screening than women. An intervention aimed at making an individual plan for action, also called 'implementation plan' with regard to self-screening, proved to be effective.

Immunisation behavior

Vaccination is the oldest form of immunization. Someone who is vaccinated receives a small amount of an antigen in his body. This can be done in three way:  orally, in the muscles or in the skin. The antigen causes the body to make antibodies against the specific antigen. This means that the body is always able to attack immediately if the disease enters the body. This form of prevention ensures that diseases, such as polio and diphtheria, no longer occur on a large scale, which means that almost no people die anymore due to these diseases. A new vaccine is available which targets human papilllomavirus (HPV), which is present in 70-95% of cercival cancers. It is effective in 90% of the alduts and children who have not already acquired infection. Emotional and cognitive predictors are present for taking a vaccination, for example fear of the risks of the vaccination or lack of knowledge about the benefits of a vaccination.