An implementation intentions intervention to increase uptake of mammography.

BACKGROUND AND PURPOSE: This study tested an implementation intentions intervention to increase uptake in the United Kingdom's National Health Service Breast Screening Programme. The intervention asked women to plan how they would overcome up to 3 previously identified barriers to attending. METHODS: In a randomized controlled trial, 2,082 participants were allocated to an intervention condition, an assessment-only condition, or a nonassessment control condition. The intervention condition was designed to help women plan how to change their appointment, how to arrange transport, and how to negotiate time off work. The assessment-only condition controlled for the possibility that completing a questionnaire about mammography might in itself influence attendance, and the nonassessment condition was a control against any effect on attendance that mere contact with the research team might have. RESULTS: Mean age of respondents was 56.1 years, and 99.4% were White British. In the full intention-to-treat analysis, which included all participants, attendance was found to be almost identical across the 3 conditions, around 80%. Some of the women in the intervention condition, however, failed to write their plans on the questionnaire (10.6% for changing the appointment, 2.1% for travel arrangements, and 21.1% for taking time off work) or said that planning was irrelevant to them (2.4% for changing the appointment, 1.7% for travel arrangements, and 32.4% for taking time off work). A second analysis, of planning time off work, therefore, examined the 620 respondents in the intervention condition more closely and found that those who planned were significantly more likely to attend than those who did not. A 3rd analysis, excluding the 209 respondents for whom planning time off work was irrelevant, revealed that the most likely to plan were those whose initial intentions to attend were strong but whose perceptions of control over making the necessary arrangements to attend were weak. CONCLUSIONS: Two main implications of the findings are discussed: the importance of planning in implementation intentions interventions and the validity of the theoretical distinction between motivation and volition.

Belief importance and the theory of planned behaviour: comparing modal and ranked modal beliefs in predicting attendance at breast screening.

OBJECTIVE: The objective of this study was, to compare the predictive utility of two measures of the attitude, subjective norm and perceived behavioural control constructs of the theory of planned behaviour (TPB; Ajzen, 1991) in predicting intention and subsequent attendance at breast screening. One construct was based on a modal set of underlying beliefs; the other was based on the three beliefs from each construct considered by the participant to be the most important. METHOD: We used a prospective, longitudinal design using a postal questionnaire at Time 1 and objective attendance data from screening records at Time 2. Questionnaires were sent to 1657 women from southeast England due to be invited for X-ray mammography under the UK's National Health Service Breast Screening Programme. After evaluating a set of modal behavioural, normative and control beliefs, women were asked to select the three beliefs they saw as the most important for them, and to rank them. The products of these three beliefs formed the 'important' (vs. the modal) measures. RESULTS: The 'important' attitude and subjective norm measures showed similar associations with direct measures and were equivalent to the modal measures in predicting intention and attendance at screening. The modal control construct was marginally more robust than the 'important' one in its association with the direct measure of control, and with intention. Key individual important beliefs that predicted intention and behaviour were identified. CONCLUSIONS: Measuring belief importance can help more fully identify the structures underlying attitude, subjective norm and perceived behavioural control, and can provide useful information when the TPB is used as the basis for intervention to help change behaviour.

Emotion and adherence to treatment in people with asthma: an application of the emotional stroop paradigm.

This study explored whether an emotional Stroop paradigm might represent an appropriate means of assessing individuals' emotional representations of asthma. In addition, the opportunity was taken to investigate whether emotional representations of asthma, as assessed by this method, were associated with adherence to inhaled preventative medication. An asthma Stroop task was devised which comprised three sets of stimuli: asthma symptom words, general negative words, and neutral words. Three groups of participants were compared on their performance on this task: individuals with asthma, individuals without asthma, and individuals without asthma who had been primed about the condition. It was found that individuals with asthma experienced significantly more interference when colour-naming the asthma symptom words, but not when colour-naming the general negative words. Furthermore, their performance on the asthma Stroop task was associated with self-reported adherence levels. Specifically, individuals who reported the highest and lowest levels of adherence displayed more interference when colour-naming the asthma symptom words than individuals with intermediate levels of adherence. It is concluded that the emotional Stroop paradigm might provide an objective and sensitive means of assessing individuals' emotional representations of illness. Additionally, it is proposed that emotional responses to illness should be assessed and included in research designed to explain health behaviours and, furthermore, that such research should not assume that any relationship between emotional representations and health behaviours will be linear.

Individually elicited versus modal normative beliefs in predicting attendance at breast screening: Examining the role of belief salience in the Theory of Planned Behaviour.

OBJECTIVE: To examine the influence of an individually derived versus modal subjective norm component of the Theory of Planned Behaviour (TPB) in predicting attendance at breast screening. DESIGN: A prospective, longitudinal design was employed using a postal questionnaire at Time 1 and objective attendance data from screening records at Time 2. METHOD: Questionnaires were sent to 1000 women from East Kent due to be invited for X-ray mammography under the UK's National Health Service Breast Screening Programme. The TPB constructs were used to predict attendance, with a focus on subjective norm. Two versions of the questionnaire were distributed: one assessed subjective norm using individually generated normative beliefs (individual condition) and the other provided a list of modal referents (modal condition). RESULTS: The mean number of normative referents in the individual condition was just two, almost all of whom were family members, in contrast to the modal condition where 'GP' led the rank table. The results suggest that a more senstive measure of subjective norm is attained using individually derived beliefs. Structural equation modelling revealed that, contrary to theoretical prediction, the effect on attendance of the individually derived subjective norm was not entirely mediated by intention: an independent contribution to attendance was shown. In the modal condition the construct was entirely mediated by intention. CONCLUSIONS: For health behaviours that have implications for others as well as self, measuring individually salient normative beliefs may both improve theoretical prediction and yield information of potential value for designing intervention programmes.

Persuading school-age cyclists to use safety helmets: Effectiveness of an intervention based on the Theory of Planned Behaviour.

OBJECTIVES: To design and evaluate a theory-based intervention to encourage the use of protective helmets in school-age cyclists. DESIGN: Two-by-three mixed design on 97 cyclists who did not initially use a helmet: Condition (intervention/control) x Time (pre-intervention/immediately post-intervention/5-month follow-up). METHOD: The intervention builds on a previous study using the Theory of Planned Behaviour in which we identified a small number of salient beliefs that predict intention to use a safety helmet and helmet use (Quine et al., 1998). Participants were randomly assigned to intervention or control conditions. The intervention group was presented with a booklet containing a series of persuasive messages based on the identified salient beliefs, and the control group was presented with a different series of messages concerning a cycling proficiency and bicycle maintenance course. Initial beliefs were measured just before the intervention at Time 1, by questionnaire. The immediate effects of the intervention were evaluated by questionnaire at Time 2. Five months later, at Time 3, the long-term effects of the intervention on beliefs, intentions, and behaviour were assessed. RESULTS: The behavioural, normative and control beliefs and intentions of intervention participants became more positive than those of control participants, and the effect was maintained over time. There was also a significant effect on behaviour: at 5-month follow-up, none of the 49 control children had taken up helmet wearing, while 12 (25%) of the 48 intervention children had. CONCLUSIONS: The results suggest that in order to promote lasting helmet use in young cyclists, we need to change their beliefs. The intervention reported here may present an inexpensive solution to the problem of persuading adolescents to use safety helmets. The results point to the value of social cognition theories such as the Theory of Planned Behaviour in the design of effective interventions to change health behaviours.

Attendance at cancer screening in the wake of widespread adverse publicity surrounding test results.

The largest error ever discovered in cervical smear test results was reported by an East Kent Hospitals' NHS Trust in 1996. To test whether the incident would have an impact on a separate NHS screening programme within the affected area, 1000 women who were due to be called for x ray mammography were asked how confident they would be about the accuracy of their mammogram result. Most women reported that they would be confident, but significantly fewer unconfident than confident women subsequently kept their appointment for breast screening. Attendance and non-attendance at breast screening in the area did not differ from previous screening rounds, suggesting that the error in the cervical cytology results had not adversely affected a separate screening programme.

Perceptions of risk in motorcyclists: unrealistic optimism, relative realism and predictions of behaviour.

In the first phase of a prospective investigation, a national sample of motorcyclists completed a postal questionnaire about their perceptions of risk, their behaviour on the roads and their history of accidents and spills. In the second phase a year later, they reported on their accident history and behaviour over the preceding 12 months. A total of 723 respondents completed both questionnaires. Four sets of findings are reported. First, the group as a whole showed unrealistic optimism: on average, respondents believed themselves to be less at risk than other motorcyclists of an accident needing hospital treatment in the next year. Second, optimism was tempered by 'relative realism', in that respondents who were young and inexperienced saw themselves as more at risk than other motorcyclists, as did riders who reported risky behaviours on the road. Third, there was some evidence of debiasing by personal history, in that having a friend or a relative who had been killed or injured on the roads was associated with perceptions of absolute risk of injury or death--though there were no effects on comparative risk and no effects on any of the judgments of a history of accidents of one's own. Finally, there was good evidence that perceptions of risk predicted subsequent behaviour, though generally in the direction not of precaution adoption but of precaution abandonment: the greater the perceived risk at time 1, the more frequent the risky behaviour at time 2. The implications of the findings are discussed, and possible interpretations are suggested.

The experience and impact of contacting a cancer information service.

Our objective was to review the quality of service delivered by a national cancer information service--the British Association of Cancer United Patients (BACUP)--and to consider the implications for future policy and practice. We used a sample of callers over a 10-day period, responding to a structured postal questionnaire. The sample included patients, relatives, friends, and general public who called the service with any concern relating to cancer. Of the 406 invited to take part, 282 responded (69%). The questionnaire was designed to evaluate the callers' perceptions of the information they received, their perceptions of the nurse's communication skills, the emotional impact of the call, and their overall satisfaction with the service. The results indicate that over 90% of callers evaluated the information they received and the nurse's communication skills positively, and there was no difference between the two major groups of callers, i.e. patients and relatives/friends. Both groups reported that the call had a positive emotional impact on them and that they were satisfied with the service. Emotional impact was predicted by quality of information for patients and nurse's communication skills for friends/relatives; overall satisfaction was predicted by nurse's communication skills for patients and both measures for relatives/friends. We conclude that the telephone is an effective medium for conveying information about cancer, and BACUP is meeting its needs. The needs of patients and relatives/friends are different--principally information for patients and support for relatives/friends--and it may be possible to improve training still further by focusing on those differences. The main challenge for cancer information services is to meet the ever-increasing demand.

Age and experience in motorcycling safety.

Official casualty statistics show that young motorcyclists are more likely than older motorcyclists to be killed or seriously injured on the roads. We address two main issues: might the statistics be attributable to inexperience rather than youth; and might accidents be associated with particular patterns of behaviour which may themselves be predictable from riders' beliefs? From a national prospective survey of over 4000 riders in the U.K., the data showed that youth played a much greater role than inexperience, and that accidents were associated with a particular pattern of behaviour, namely a willingness to break the law and violate the rules of safe riding, which was predictable from the riders' beliefs measured 12 months earlier. The implications of the findings are discussed both for theory and for policy and practice, and particular emphasis is placed on suggestions for modifying training courses.

First diagnosis of severe mental and physical disability: a study of doctor-parent communication.

This study investigates factors associated with satisfaction with medical communication at the time of diagnosis of a child's severe mental or physical disability. Two competing social psychological models that have been used to account for parent patient satisfaction are tested: Korsch's (1968) affective model and Ley's (1977) cognitive model. One hundred and sixty six mothers of children with severe learning disabilities were questioned about the time when their child's disability was first diagnosed. Measures included the child's age when diagnosis was made, the length of time parents had been anxious, and how satisfied they were with the way they were told the diagnosis. They were asked to rate the doctor's affective behaviour and their understanding and memory of the information they received. Fifty-eight per cent of parents reported dissatisfaction with the communication. Stepwise multiple regression analysis showed that Korsch's affective scale was much the strongest predictor, entering the equation first, and explaining 35.7% of the variance in satisfaction. Ley's cognitive scale entered second, explaining a further 1.4% of the variance. Further analysis including the other predictors found that six predictors explained 40% of the variance. The implications of the findings for the training of medical staff are discussed.

Motorcycling safety research: a review of the social and behavioral literature.

The literature on motorcycling safety research is reviewed, and it is argued that there have been two main periods. The first, spanning the 1970's, was based on accident analysis, and the main objective was to identify and control factors that contribute to the severity of motorcycling accidents. The main concerns were to reduce head and brain injuries through safety helmets, to reduce multi-vehicle collisions through daytime use of headlamps, and to reduce drink-riding. The second period, the 1980's shifted the emphasis of research to what might be called 'riding analysis'--that is, analysis of the process of motorcycle riding. Particular attention was paid to skills testing, training evaluation and perceived risk. Now, in the early 1990's, a third period is developing, in which the rider is seen as 'active agent'. The theoretical basis of the new research has come from the models of social psychology, and the main concern is to use riders' beliefs and attitudes about safe riding to predict their behaviour on the roads and so their accident involvement. The three periods of research are reviewed in turn, and the paper concludes with an outline of the key research issues that remain to be addressed.

Breast cancer screening services in three areas: uptake and satisfaction.

The objective of our study was to test whether attendance for breast cancer screening and satisfaction with the service could be predicted from a knowledge of the woman's social and psychological characteristics. In a prospective design, demographic characteristics, self-reported health status and behaviour, expectations and attitudes were examined through postal questionnaires sent out shortly before the invitation to screening, and the measures were used to predict subsequent attendance and satisfaction. The sample was taken from three areas in the South-East Thames Regional Health Authority providing a Forrest service--one rural, one provincial and one inner city--and consisted of 3160 women aged 50-64 invited routinely for screening. The main predictors of attendance were the woman's attitude to being screened and her belief that 'salient others' wanted her to attend. The main predictors of satisfaction with the service were the behaviour of the staff and the facilities at the centre. Three implications of the findings are discussed: (a) health education should include partners, relatives and friends of the target women, as their views had as much effect on attendance as did the women's attitudes; (b) staff training and development should focus on communication with the patient; (c) further research should examine the precursors of reported discomfort and pain.

Discomfort and pain during mammography: description, prediction, and prevention.

OBJECTIVE: To identify the nature of pain and discomfort experienced during mammography and how it can be ameliorated. DESIGN: Questionnaire survey before invitation for mammography and immediately after mammography. Responses before screening were related to experience of discomfort. SETTING: Health district in South East Thames region. SUBJECTS: 1160 women aged 50-64 invited routinely for screening; 774 completed first questionnaire, of whom 617 had mammography. 597 completed the second questionnaire. MAIN OUTCOME MEASURES: Reported discomfort and pain, comparisons of discomfort with that experienced during other medical procedures, qualitative description of pain with adjective checklist. RESULTS: 35% (206/597) of the women reported discomfort and 6% (37/595) pain. 10 minutes after mammography these figures were 4% (24/595) and 0.7% (4/595) respectively. More than two thirds of women ranked having a tooth drilled, having a smear test, and giving blood as more uncomfortable than mammography. The most important predictor of discomfort was previous expectation of pain (discomfort was reported by 21/32 (66%) women who expected pain and 186/531 (35%) who did not). Discomfort had little effect on satisfaction or intention to reattend. CONCLUSIONS: The low levels of reported pain and discomfort shortly after mammography and the favourable comparisons with other investigations suggest that current procedures are acceptable. Since two thirds of the women experienced less pain than expected health education and promotion must ensure that accurate information is made available and publicized.

Inequalities in pregnancy outcome: a review of psychosocial and behavioural mediators.

The purpose of this paper is to review the literature on psychosocial factors in pregnancy outcome and to present a model which attempts to integrate the findings theoretically. There are four sections. The first presents published data on the incidence of early childhood mortality and low birth weight. Changes over time and differences between countries are noted and attention is drawn to the marked inequalities between occupational groups in the British data. The second section reviews the evidence that a variety of psychosocial risk factors influence pregnancy outcome, notably social, emotional, cognitive and behavioural factors. The third section develops the theme of inequalities and examines theories which have been advanced to account for the differences in adult mortality. We argue that material deprivation goes some way towards explaining inequalities in pregnancy outcome, but that any proper account will have to explain the links between inputs and outcomes--the processes and mechanisms by which material deprivation is translated into observable mortality and morbidity. In the concluding section, we argue that some of the principal links are the psychosocial risk factors described in the second section, and we present a model which traces the pathways of mediation.

Alcohol training in south-east England: a survey and evaluation.

In 1982, the University of Kent at Canterbury introduced a multi-disciplinary diploma course in alcohol counselling and consultation. The purpose of the report which follows is to assess the existing range and level of alcohol services and training in south-east England against which the course was set up, and to appraise the course itself against its aims and objectives. The first part of the study was based on a questionnaire survey of senior administrators in Health and Social Services in London and the South East, and the examination of the course was based on student progress. The results from the first part of the study are bleak. Respondents believed that the majority of clients with alcohol problems were simply not detected, and a lack of resources to mount satisfactory training schemes was among the principal reasons. Only a minority of the organizations provided secondary-level training of any sort, and the majority placed alcohol problems at the bottom of their priorities for training and, by implication, for services overall. The results from the second part of the study were more encouraging. While there was little to suggest that students' knowledge and attitudes changed during the course, there were a number of small changes in behaviour. The most hopeful findings, however, came from students' and managers' perceptions, where one of the most positive outcomes of the course was a perceived growth in student maturity, confidence, and role security.

Do health beliefs predict health behaviour? A follow-up analysis of breast self-examination.

In a previous paper, we suggested that women who attended classes on breast self-examination showed significant improvements in behaviour, and that part of the reason was a change in their beliefs. Further analysis of our data confirms the original conclusion, and indicates that the perceived value of doing the behaviour is a more important predictor than perceived vulnerability to cancer.

Do health beliefs predict health behaviour? An analysis of breast self-examination.

The purpose of this paper is to explore the relationships between health beliefs and health behaviour. The study we report was conducted as part of a national campaign to evaluate the benefits of breast self-examination in the early detection of breast cancer, and the purpose of our analysis was to test the Health Belief Model of Becker and his colleagues. Three groups of women were investigated--278 who accepted an invitation to attend self-examination classes and were taught the techniques in detail, 262 who declined the invitation and 594 controls to whom no classes were offered--and beliefs and self-reported behaviour were measured shortly before the classes took place and again a year later. The campaign, it emerged, produced marked changes in both beliefs and behaviour, but the relationships between beliefs and behaviour were much weaker than the model had led us to expect and accounted for no more than a quarter of the variance. Alternative models are considered, notably Fishbein and Ajzen's Theory of Reasoned Action, and the paper concludes with some suggestions for improving health campaigns.

Language in schizophrenia. The structure of monologues and conversations.

Experimental research into language in schizophrenia has been guided traditionally by two main assumptions: that language disturbance is widespread among schizophrenic patients and easy to detect and measure, and that schizophrenia is fundamentally a cognitive disorder in which language disturbance is part of an inability or failure to regulate one's thoughts. However, recent findings have challenged both assumptions. Two experiments are reported here, the first based on monologues, the second on conversations, which were subjected to reconstruction and discourse analyses. Schizophrenic material is found to be harder to follow than normal, and is characterised by poor reference networks and inappropriate use of questions. While some of the results are specific to the schizophrenic group, others are found also in affective patients, but none is the product of formal thought disorder. The central problem lies less in cognition than in the social process of taking the role of the other.

Visual communication and the content and style of conversation.

Previous research suggests that visual communication plays a number of important roles in social interaction. In particular, it appears to influence the content of what people say in discussions, the style of their speech, and the outcomes they reach. However, the findings are based exclusively on comparisons between face-to-face conversations and audio conversations, in which subjects sit in separate rooms and speak over a microphone-headphone intercom which precludes visual communication. Interpretation is difficult, because visual communication is confounded with physical presence, which itself makes available certain cues denied to audio subjects. The purpose of this paper is to report two experiments in which the variables were separated and content and style were re-examined. The first made use of blind subjects, and again compared the face-to-face and audio conditions. The second returned to sighted subjects, and examined four experimental conditions: face-to-face; audio; a curtain condition in which subjects sat in the same room but without visual communication; and a video condition in which they sat in separate rooms and communicated over a television link. Neither visual communication nor physical presence proved to be critical variable. Instead, the two sources of cues combined, such that content and style were influenced by the aggregate of available cues. The more cueless the settings, the more task-oriented, depersonalized and unspontaneous the conversation. The findings also suggested that the primary effect of cuelessness is to influence verbal content, and that its influence on both style and outcome occurs indirectly, through the mediation of content.