Health Psychology 19 - Blackwell Publishing
PSY C19.qxd 1/2/05 3:52 pm Page 408Health PsychologyCHAPTER OUTLINELEARNING OBJECTIVESINTRODUCTIONHEALTH BELIEFS AND BEHAVIOURSBehaviour and mortalityThe role of health beliefsIntegrated modelsILLNESS BELIEFSThe dimensions of illness beliefsA model of illness behaviourHealth professionals’ beliefsTHE STRESS–ILLNESS LINKStress modelsDoes stress cause illness?CHRONIC ILLNESSProfile of an illnessPsychology’s roleFINAL THOUGHTSSUMMARYREVISION QUESTIONSFURTHER READING19
PSY C19.qxd 1/2/05 3:52 pm Page 409Learning ObjectivesBy the end of this chapter you should appreciate that:nhealth psychologists study the role of psychology in health and wellbeing;nthey examine health beliefs as possible predictors of health-related behaviours;nhealth psychology also examines beliefs about illness and how people conceptualize their illness;na health professional’s beliefs about the symptoms, the illness or the patient can have important implications;nstress is the product of the interaction between the person and their environment – it can influence illness andthe stress–illness link is influenced by coping and social support;nbeliefs and behaviours can influence whether a person becomes ill in the first place, whether they seek help andhow they adjust to their illness.INTRODUCTIONHealth psychology is a relatively recent yet fastgrowing sub-discipline of psychology. It is bestunderstood by answering the following questions:nnnnWhat causes illness and who is responsiblefor it?How should illness be treated and who isresponsible for treatment?What is the relationship between health andillness, and between the mind and body?What is the role of psychology in health andillness?Human beings are complex systems and illness can be caused by a multitude of factors, notjust a single factor such as a virus or bacterium.Health psychology attempts to move away froma simple linear model of health and looks atthe combination of factors involved in illness –biological (e.g. a virus), psychological (e.g. behaviours, beliefs) and social (e.g. employment). Thisreflects the biopsychosocial model of health andillness that was developed by Engel (1977,1980). Because, inthis model, illnessbiopsychosocial the type of interis regarded as theaction between biological factors (e.g.result of a coma virus), psychological factors (e.g.bination of factors,beliefs) and social factors (e.g. class)the individual is nolonger simply seen as a passive victim of someexternal force, such as a virus. Acknowledging therole of behaviours such as smoking, diet andalcohol, for example, means that the individualmay be held responsible for their health andillness.According to health psychology, the wholeperson should be treated, not just the physicalchanges that occur due to ill health. This caninclude behaviour change, encouraging changesin beliefs and coping strategies, and compliancewith medical recommendations. Because thewhole person is treated, the patient becomes
PSY C19.qxd 1/2/05 3:52 pm Page 410410Health Psychologypartly responsible for their treatment. For example,she may have a responsibility to take medication,and to change beliefs and behaviour. No longer isthe patient seen as a victim.From this perspective, health and illness existon a continuum. Rather than being either healthyor ill, individuals progress along a continuum fromhealthiness to illness and back again. Health psychology also maintains that the mind and bodyinteract. It sees psychological factors as not onlypossible consequences of illness (after all, beingill can be depressing), but as contributing to all thestages of health, from full healthiness to illness.The aims of health psychology can be dividedinto two main aspects:1. Understanding, explaining, developing andtesting theory (for example: what is the roleof behaviour in the etiology of illness? canwe predict unhealthy behaviour by studyingbeliefs?).2. Putting theory into practice (for example: ifwe understand the role of behaviour in ill-HEALTH BELIEFS AND BEHAVIOURSOver the last century healthbehaviours have played anincreasingly important rolein health and illness. Thisrelationship has been highlighted by McKeown’s book, The Roleof Medicine (1979), which discusses the decline of infectious diseases in the nineteenth century, which forms the focus for medical sociology. It also highlights the increasing role of behaviourin illness in the twentieth century. The latter represents the focusfor health psychology. The commonly held view is that thedecline in illnesses such as TB, measles, smallpox and whoopingcough was related to the development of medical interventionssuch as chemotherapy and vaccinations. For example, antibioticsare seen as responsible for the decline in illnesses such as pneumonia and TB. But McKeown showed that the decline in infectious diseases had already begun, before the development ofmedical interventions. He claimed that, looking back over thepast three centuries, this decline is best understood in terms ofsocial and environmental factors.McKeown also examined health and illness throughout thetwentieth century. He argued that contemporary illness is causedby an individual’s own behaviours, such as whether they smoke,what they eat and how much exercise they take, and he suggestedthat good health was dependent on tackling these habits.health behaviours examples are exercise, food intake and going to the doctorness, can unhealthy behaviours be targetedfor intervention? if we change beliefs andbehaviour, can we prevent illness onset?)Health psychologists study the role of psychology in all areas of health and illness, including:1. what people think about health and illness;2. the role of beliefs and behaviours in becoming ill;3. the experience of being ill in terms of adaption to illness;4. contact with health professionals;5. coping with illness;6. compliance with a range of interventions;and7. the role of psychology in recovery from illness, quality of life and longevity.This chapter will provide an overview of healthbeliefs and behaviours, individuals’ illness beliefs,the role of health professionals’ beliefs, stressand chronic illness.McKeown’s emphasis on behaviour is supported by evidence ofthe relationship between behaviour and mortality.BEHAVIOURAND MORTALITYIt has been suggested that 50 per cent of mortality from theten leading causes of death is due to behaviour. If this is correct,then behaviour and lifestyle have a potentially major effecton longevity. For example, Doll and Peto (1981) estimated thattobacco consumption accounts for 30 per cent of all cancer deaths,alcohol 3 per cent, diet 35 per cent, and reproductive and sexualbehaviour 7 per cent. Approximately 75 per cent of all deathsdue to cancer are related to behaviour. More specifically, lungcancer (the most common form) accounts for 36 per cent of allcancer deaths in men and 15 per cent in women in the UK. It hasbeen calculated that 90 per cent of all lung cancer mortality isattributable to cigarette smoking, which is also linked to other illnesses such as cancers of the bladder, pancreas, mouth, larynxand oesophagus, and to coronary heart disease. And bowel cancer, which accounts for 11 per cent of all cancer deaths in menand 14 per cent in women, appears to be linked to diets high intotal fat, high in meat and low in fibre.As health behaviours seem to be important in predictingmortality and longevity, health psychologists have attempted toincrease our understanding of health-related behaviours. In particular, based on the premise that people behave in line with the
PSY C19.qxd 1/2/05 3:52 pm Page 411411Health Beliefs and BehavioursHealth locus of controlThe issue of controllabilityhealth locus of control where theemphasized in attributioncause of health is seen to be located –theory has been specificallyeither internal (‘due to me’) or externalapplied to health in terms of(‘due to others’)the health locus of control. Individuals differ in their tendency to regard events as controllable by them (an internal locus ofcontrol) or uncontrollable by them (an external locus of control).Wallston and Wallston (1982) developed a measure to evaluatewhether an individual regards their health as:nnFigure 19.1Behaviour can have a major effect on longevity: for example,around 90 per cent of deaths from lung cancer are attributableto cigarette smoking.health beliefs examples are perceptionsof risk or beliefs about the severity of anillnessTHEway they think, health psychologists have turned to thestudy of health beliefs as potential predictors of behaviour.ROLE OF HEALTH BELIEFSAttribution theoryThe origins of attribution theory lie in the work of Heider (1944,1958), who argued that individuals are motivated to understandthe causes of events as a means to make the world seem morepredictable and controllable (see chapter 17).Attribution theory has been applied to the study of health andhealth behaviour. For example, Bradley (1985) examined patients’attributions of responsibility for their diabetes and found that perceived control over their illness (is the diabetes controllable byme or a powerful other?) influenced their choice of treatment.Patients could either choose an insulin pump (a small mechanicaldevice attached to the skin that provides a continuous flow ofinsulin), intense conventional treatment or a continuation ofdaily injections. The results indicated that the patients who chosean insulin pump showed decreased control over their diabetesand increased control attributed to doctors. In other words, anindividual who attributed their illness externally and felt that theypersonally were not responsible for it was more likely to choosethe insulin pump and to hand over responsibility to doctors.A further study by King (1982) examined the relationshipbetween attributions for an illness and attendance at a screeningclinic for hypertension. The results demonstrated that if thehypertension was seen as external but controllable, the individualwas more likely to attend the screening clinic (‘I am not responsible for my hypertension but I can control it’).ncontrollable by them (e.g. ‘I am directly responsible for myhealth’);not controllable by them and in the hands of fate (e.g.‘Whether I am well or not is a matter of luck’); orunder the control of powerful others (e.g. ‘I can only dowhat my doctor tells me to do’).It has been suggested that health locus of control relatesto whether we change our behaviour (by giving up smokingor changing our diet, forinstance), and also to ouradherence (or compliance) the extentadherence to recommendato which a patient does as suggestedtions by a health professional.(e.g. taking medicine or changingFor example, if a doctorbehaviour)encourages someone whogenerally has an externallocus of control to change his or her lifestyle, that person isunlikely to comply if she does not deem herself to be responsiblefor her health.However, although some studies support the link betweenhealth locus of control and behaviour (e.g. Rosen & Shipley,1983), several other studies either show no relationship or indicate the reverse of what is expected (e.g. Norman, 1990; 1995).Unrealistic optimismWeinstein (1983, 1984) suggested that one of the reasons we continue to practice unhealthy behaviours is our inaccurate perceptions of risk and susceptibility. He gave participants a list of healthproblems to examine and then asked: ‘Compared to other peopleof your age and sex, are your chances of getting [the problem]greater than, about the same as, or less than theirs?’ Most participants believed that they were less likely to experience thehealth problem. Clearly, this would not be true of everyone, soWeinstein called this phenomenon unrealistic optimism.Weinstein (1987) described four cognitive factors that contribute to unrealistic optimism:1. lack of personal experience with the problem;2. the belief that the problem is preventable by individualaction;3. the belief that if the problem has not yet appeared, it willnot appear in the future; and4. the belief that the problem is infrequent.
PSY C19.qxd 1/2/05 3:52 pm Page 412412Health PsychologyResear ch close-up 1Stages of smoking cessationThe research issueTraditionally, addictive behaviours have been viewed as ‘either/or’ behaviours. Therefore, smokers were considered either‘smokers’ or ‘non-smokers’. But DiClemente and Prochaska (1982) developed a trans-theoretical model to examine thestages of change in addictive behaviours. This model is now widely used in health psychology to both predict and understand behaviour, and it is central to many interventions designed to change behaviour. In particular, individuals areassessed at the beginning of any intervention to identify which stage they are at. The content of the intervention can thenbe tailored to match the needs of each person.The stages of change model describes the following stages:1.2.3.4.5.precontemplation (not seriously considering quitting in the next six months)contemplation (considering quitting in the next six months)action (making behavioural changes)maintenance (maintaining these changes)relapse (return to old behaviour)The model is described as dynamic, not linear, with individuals moving backwards and forwards across the stages.For the present study, the authors sub-categorized those in the contemplation stage (stage 2) as either contemplators(i.e. not considering quitting in the next 30 days) or in the preparation stage (i.e. planning to quit in the next 30 days).Design and procedureThe authors recruited 1466 participants for a minimum intervention smoking cessation programme from Texas and RhodeIsland. The majority were white, female, started smoking at about 16 years of age, and smoked on average 29 cigarettesa day. The participants completed the following set of measures at baseline and were followed up at one month and at sixmonths. The participants were classified into three groups according to their stage of change: precontemplators, contemplators and those in the preparation stage.1. Smoking abstinence self efficacy (DiClemente et al., 1985), which measures the smoker’s confidence that theywould not smoke in 20 challenging situations.2. Perceived stress scale (Cohen et al., 1983), which measures how much perceived stress the individual has experienced in the last month.3. Fagerstrom Tolerance Questionnaire (Fagerstrom, 1978), which measures physical tolerance to nicotine.4. Smoking decisional balance scale (Velicer et al., 1985), which measures the perceived pros and cons of smoking.5. Smoking processes of change scale (DiClemente & Prochaska, 1985), which measures the individual’s stage ofchange. According to this scale, participants were defined as precontemplators (n 166), contemplators (n 794)and those in the preparation stage (n 506).6. Demographic data, including age, gender, education and smoking history.Results and implicationsThe results were first analysed to examine baseline difference between the three participant groups. The results showedthat those in the preparation stage smoked less, were less addicted, had higher self efficacy, rated the pros of smokingas less positive and the costs of smoking as more negative, and had made more prior quitting attempts than the other twogroups.The results were then analysed to examine the relationship between stage of change and smoking cessation. At both oneand six months, the participants in the preparation stage had made more quit attempts and were less likely to be smoking.The results provide support for the stages of change model of smoking cessation, and suggest that it is a useful tool forpredicting the outcome of an intervention.DiClemente, C.C., & Prochaska, J.O., 1982, ‘Self-change and therapy change of smoking behaviour: A comparison of processes of change in cessation and maintenance’, Addictive Behaviours, 7, 133– 42.
PSY C19.qxd 1/2/05 3:52 pm Page 413413Health Beliefs and BehavioursThese factors suggest that our perception of our own risk is not arational process.In an attempt to explain why individuals’ assessment of theirrisk may go wrong, and why people are unrealistically optimistic,Weinstein (1983) argued that individuals show selective focus. Heclaimed that we ignore our own risk-increasing behaviour (‘I maynot always practise safe sex, but that’s not important’) and focusprimarily on our risk-reducing behaviour (‘At least I don’t injectdrugs’). He also argued that this selectivity is compounded byegocentrism – individuals tend to ignore others’ risk-decreasingbehaviour (‘My friends all practise safe sex, but that’s irrelevant’)and focus on the risk-increasing behaviour of those around them(‘My friends sometimes drive too fast’).The stages of change modelThe stages of change model (also known as the transtheoreticalmodel of behaviour) was originally developed by Prochaska andDiClemente (1982) as a synthesis of 18 therapies describing theprocesses involved in behavioural change. These researchers suggested a new model of change which has been applied to severalhealth-related behaviours, such as smoking, alcohol use, exerciseand personal screening behaviour such as going for a cervicalsmear or attending for a mammograph (e.g. DiClemente et al.,1991; Marcus, Rakowski & Rossi, 1992).If applied to giving up cigarettes, the model would suggest thefollowing stages:1. Precontemplation: I am happy being a smoker and intendto continue smoking.2. Contemplation: I have been coughing a lot recently; perhaps I should think about stopping smoking.3. Preparation: I will stop going to the pub and will buy lowertar cigarettes.4. Action: I have stopped smoking.5. Maintenance: I have stopped smoking for four monthsnow.The model describes behaviour change as dynamic, rather thanbeing ‘all or nothing’, so the five stages do not always occur in alinear fashion. For example, an individual may move to thepreparation stage and then back to the contemplation stage several times before progressing to the action stage. Even when anindividual has reached the maintenance stage, they may slip backto the contemplation stage over time.The model also examines how we weigh up the costs andbenefits of a particular behaviour. In particular, individuals at different stages of change will differentially focus on either the costsof a behaviour (‘Giving up smoking will make me anxious incompany’) or the benefits (‘Giving up smoking will improve myhealth’).INTEGRATEDMODELSAttribution theory and the health locus of control modelemphasize attributions for causality and control, unrealisticoptimism focuses on perceptions of susceptibility and risk, andthe stages of change model stresses the dynamic nature of beliefs,time, and costs and benefits. These different perspectives onhealth beliefs have been integrated into structured models.The health belief modelThe health belief model (figure 19.2) was developed initiallyby Rosenstock in 1966 and further by Becker and colleaguesthroughout the 1970s and 1980s (e.g. Becker et al., 1977). Theiraim was to predict preventative health behaviours and thebehavioural response to treatment in acutely and chronically illpatients. Over recent years, the model has been used to predictmany other health-related behaviours.According to the health belief model, behaviour is a product ofa set of core beliefs that have been redefined over the years. Theoriginal core beliefs are the individual’s perception of:nnnnnsusceptibility to illness – ‘My chances of getting lung cancerare high’;the severity of the illness – ‘Lung cancer is a serious illness’;the costs involved in carrying out the behaviour – ‘Stoppingsmoking will make me irritable’;the benefits involved in carrying out the behaviour –‘Stopping smoking will save me money’; andcues to action, which may be internal (e.g. the symptom ofbreathlessness) or external (e.g. information in the form ofhealth education leaflets).The health belief model suggests that these core beliefs are usedto predict the likelihood that a behaviour will occur.In response to criticisms, the model was revised to add the construct health motivation to reflect readiness to be concernedabout health matters (‘I am concerned that smoking might damage my health’). More recently, Becker and Rosenstock lesBenefitsLikelihoodof behaviourCues to actionHealth motivationPerceived controlFigure 19.2The health belief model. Source: Ogden (2000), after Beckeret al. (1977).
PSY C19.qxd 1/2/05 3:52 pm Page 414414Health Psychologysuggested that perceived control (‘I am confident that I can stopsmoking’) should also be added to the model (see chapter 17).When applied to a health-related behaviour such as screeningfor cervical cancer, the health belief model predicts that someoneis likely to have regular screening if she perceives that:nnnnshe is highly susceptible to cancer of the cervix;cervical cancer is a severe health threat;the benefits of regular screening are high; andthe costs of such action are comparatively low.There will also most likely be relevant cues to action – eitherexternal (such as a leaflet in the doctor’s waiting room) or internal (such as pain or irritation, which she perceives to be related tocervical cancer).The new, amended model would also predict that a woman ismore likely to attend for screening if she is confident that she cando so, and she is motivated to maintain her health.The protection motivation theoryRogers (1975, 1983, 1985) developed the protection motivationtheory (figure 19.3), which expanded the health belief model toinclude additional factors.The original protection motivation theory claimed that healthrelated behaviours are a product of, and therefore predicted by,five components:severity – ‘Bowel cancer is a serious illness’;susceptibility – ‘My chances of getting bowel cancer are high’;response effectiveness – ‘Changing my diet would improve myhealth’;self efficacy – ‘I am confident that I can change my diet’; andfear – ‘Information about the links between smoking and lungcancer makes me feel quite frightened’.The protection motivation theory describes severity, susceptibility and fear as relating to ‘threat appraisal’ (i.e. appraisingan outside threat), and response effectiveness and self gure 19.3The protection motivation theory. Source: Ogden (2000), afterRogers (1985).as relating to ‘coping appraisal’ (i.e. appraising the individualthemselves). According to the theory, there are two types ofinformation source: environmental (e.g. verbal persuasion, observational learning) and intrapersonal (e.g. prior experience). Thisinformation influences the five components listed above, whichthen elicit either an adaptive coping response (a behaviouralintention) or a maladaptive coping response (such as avoidanceor denial).If applied to dietary change, the protection motivation theorywould make the following predictions. Information about therole of a high fat diet in coronary heart disease would increasefear, increase the individual’s perception of how serious coronaryheart disease was (perceived severity) and increase their beliefthat they were likely to have a heart attack (perceived susceptibility). If the individual also felt confident that they could changetheir diet (self efficacy) and that this change would have beneficialconsequences (response effectiveness), they would report highintentions to change their behaviour (behavioural intentions).This would be regarded as an adaptive coping response to thepresented information.The theory of planned behaviourThe theory of planned behaviour (figure 19.4) was developed byAjzen and colleagues (Ajzen, 1985; 1988; Ajzen & Madden, 1986).It emphasizes behavioural intentions as the outcome of a combination of several beliefs (see chapter 17).The theory proposes that intentions should be conceptualizedas ‘plans of action in pursuit of behavioural goals’ (Ajzen &Madden, 1986), and that these are a result of the following composite beliefs:Attitude towards a behaviour – composed of a positive or negative evaluation of a particular behaviour, and beliefs aboutthe outcome of the behaviour (‘Exercising is fun and willimprove my health’).Subjective norm – this represents the beliefs of importantothers about the behaviour, and the individual’s motivation to comply with such beliefs (‘People who are important to me will approve if I lose weight, and I want theirapproval’).Perceived behavioural control – comprising a belief that the individual can carry out a particular behaviour based on a consideration of internal control factors (e.g. skills, abilities,information) and external control factors (e.g. obstacles,opportunities) – both of which are related to pastbehaviour.These three factors predict behavioural intentions, which arethen linked to behaviour. (The theory of planned behaviouralso states that perceived behavioural control can have a directeffect on behaviour without the mediating effect of behaviouralintentions.)Applied to alcohol consumption, the theory would predictthat someone will have high intentions to reduce alcohol intake(behaviour intentions) if he believes that:
PSY C19.qxd 1/2/05 3:52 pm Page 415415Illness BeliefsBeliefs aboutthe outcome ofthe behaviour(‘If I exercisemore, I will loseweight, feel fitterand improvemy health’)Evaluationsspecific tothe expectedoutcomes ofthe behaviour(‘Being healthy,slim and fitis desirable’)Normativebeliefs(‘My familyand friendsthink Ishould getmore exercise’)PioneerHoward Leventhal (1931– ) is Professor of Psychology atthe State University of New Jersey at Rutgers. He hascarried out extensive research into the experience of beingill, which has informed much work on illness perceptions,and he developed the self-regulatory model of illnessbehaviour. He places emphasis on the role of symptomperception in triggering illness behaviour and the linksbetween emotion and health.Attitudetowards thespecificactionBehaviouralintention(intentionto get otivationto comply(‘I want todo what theywant meto do’)Control beliefs(‘How likely isit that I willmanageto get moreexercise if I try?’)PerceivedbehaviouralcontrolFigure 19.4The theory of planned behaviour applied to the intention toengage in physical exercise. Source: Ogden (2000), after Ajzen(1985) and Stroebe (2000).nnnreducing his alcohol intake will make his life more productive and be beneficial to his health (attitude to thebehaviour);the important people in his life want him to cut down (subjective norm); andhe is capable of drinking less alcohol due to his pastbehaviour and evaluation of internal and external controlfactors (high behavioural control).The model also predicts that perceived behavioural controlcan predict behaviour without the influence of intentions. Forexample, a belief that the individual would not be able to exercisebecause they are physically incapable of doing so might well be abetter predictor of their exercising behaviour than their highintentions.ILLNESS BELIEFSLeventhal and colleaguesillness beliefs examples are how long(Leventhal, Meyer & Nerenz,the illness will last and what impact it1980; Leventhal & Nerenz,will have on the patient’s life1985) defined illness beliefsas a patient’s own implicit,commonsense beliefs about his or her illness. They proposed thatthese beliefs provide a framework, or schema, for coping withand understanding an illness, and for telling us what to look outfor if we believe that we are becoming ill.THEDIMENSIONS OF ILLNESS BELIEFSUsing interviews with patients suffering from a variety of illnesses, Leventhal et al. identified five dimensions of illness beliefs:1. Identity refers to the label given to the illness (the medicaldiagnosis) and the symptoms experienced; for example, ‘Ihave a cold . . .’ (the diagnosis) ‘. . . with a runny nose’ (thesymptoms).2. The perceived cause of the illness – this may be biological (e.g.a virus, in the case of a cold, or an injury or lesion, in thecase of another type of illness) or psychosocial (e.g. stressor health-related behaviour). Patients may also hold representations of illness that reflect a variety of different causalmodels; for example, ‘My cold was caused by a virus’versus ‘My cold was caused by being run-down’.3. Time line refers to beliefs about how long an illness will last,whether it is acute (i.e. short term) or chronic (i.e. longterm); for example ‘My cold will be over in a few days’.4. Consequences refers to the patient’s perceptions of the possible effects of the illness on his or her life. These may bephysical (e.g. pain, lack of mobility), emotional (e.g. loss ofsocial contact, loneliness) or a combination of factors; forexample, ‘My cold will prevent me from playing football,which will prevent me from seeing my friends’.5. Curability and controllability refers to the patient’s beliefsabout whether their illness can be treated and cured, andthe extent to which its outcome is controllable (either by
PSY C19.qxd 1/2/05 3:52 pm Page 416416Health Psychologythemselves or by others): for example, ‘If I rest, my coldwill go away’, ‘If I get medicine from my doctor, my coldwill go away’.Evidence for the dimensionsThe extent to which beliefsabout illness comprise thesedifferent dimensions has beenstudied using both qualitativeand quantitative research.Leventhal and colleaguescarried out interviews withindividuals who were chronicquantitative research uses methodsally ill (having been recentlysuch as questionnaires, experimentsdiagnosed with cancer) andand structured interviews, where thehealthy adults. Participants’data are analysed using numbersdescriptions of their illnessindeed suggested underlyingbeliefs made up of the above dimensions. Other studies haveprovided support for these dimensions using more artificial andcontrolled methodologies. Lau, Bernard and Hartman (1989)a
Learning Objectives By the end of this chapter you should appreciate that: n health psychologists study the role of psychology in health and wellbeing; n they examine health beliefs as possible predictors of health-related behaviours; n health psychology also examines beliefs about illness and how people conceptualize their illness; n a health professional’s beliefs about the
International Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006 129 Blackwell Publishing IncMalden, USAIJNTInternational Journal of Nursing Terminologies and Classifications1541-5147 2005 Blackwell Publishing Ltd.73Original ArticleUsing NANDA, NIC, and NOC (NNN) Language for Clinical
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