http://hpq.sagepub.com/Journal of Health Psychology

http://hpq.sagepub.com/content/early/2014/07/28/1359105314544072The online version of this article can be found at:

 DOI: 10.1177/1359105314544072

published online 7 August 2014J Health PsycholEvangelos C Karademas, Antonia Paschali, Michael Hadjulis and Angela Papadimitriou

information provided by physiciansMaladaptive health beliefs, illness-related self-regulation and the role of the

  

Published by:

http://www.sagepublications.com

can be found at:Journal of Health PsychologyAdditional services and information for    

  http://hpq.sagepub.com/cgi/alertsEmail Alerts:

 

http://hpq.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

What is This? 

- Aug 7, 2014OnlineFirst Version of Record >>

by guest on August 21, 2014hpq.sagepub.comDownloaded from by guest on August 21, 2014hpq.sagepub.comDownloaded from

Journal of Health Psychology 1 –10© The Author(s) 2014Reprints and permissions: sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1359105314544072hpq.sagepub.com

Introduction

Health-related cognitive processing and deci-sion making are not always based on reason. Consider, for example, the tendency of most people to evaluate themselves as more invul-nerable to health risks in comparison to others or the tendency to attribute ambiguous physical symptoms to stress (Cameron et al., 1995; Weinstein, 1984). In fact, these reactions reflect maladaptive beliefs, that is, biases and errors in health information processing. They are a quite common aspect of everyday life which may negatively affect health and well-being (e.g. Sjöberg, 2003; Weinstein, 1984). Therefore, the examination of the ways that these reactions

impact adaptation to illness as well as of the factors that can possibly reduce their detrimen-tal impact is important in order to expand our understanding of the mechanisms underlying adaptation to illness and improve patients’ well-being.

Maladaptive health beliefs, illness-related self-regulation and the role of the information provided by physicians

Evangelos C Karademas1, Antonia Paschali2, Michael Hadjulis2 and Angela Papadimitriou2

AbstractThis prospective study in 119 patients with cardiovascular diseases aimed to examine whether (a) illness representations mediate the relation of general maladaptive health beliefs to patients’ coping behaviours and (b) these relations are moderated by the patients’ perception of the amount of information provided by their physicians. Personal control and illness coherence mediated the relation of maladaptive health beliefs to coping behaviour. The amount of the provided information buffered the negative relation of maladaptive health beliefs to illness representations and coping. Thus, the detrimental effect of general maladaptive health beliefs may be counterbalanced by the amount of information provided by physicians.

Keywordscoping with illness, illness representations, maladaptive health beliefs, patient–physician communication, self-regulation

1University of Crete, Greece2University of Athens, Greece

Corresponding author:Evangelos C Karademas, Department of Psychology, University of Crete, Gallos Campus, Rethymnon 74100, Greece. Email: karademas@uoc.gr

544072 HPQ0010.1177/1359105314544072Journal of Health PsychologyKarademas et al.research-article2014

Article

by guest on August 21, 2014hpq.sagepub.comDownloaded from

2 Journal of Health Psychology

Maladaptive health beliefs and health

The term ‘maladaptive beliefs’ is used here to refer to erroneous or ‘irrational’, deeply held beliefs or attitudes, which include biases in information processing and inconsistencies with the more typical ways of understanding reality, and thus lead to unrealistic appraisals and maladaptive behaviour (Beck, 1995; Koopermans et al., 1994). Although maladap-tive thinking was initially associated only with mental health problems (Beck, 1995), it was soon realized that it may also affect the appraisal of health-related information and lead to poor health (Janis, 1984; Weinstein, 1984). Potential maladaptive health beliefs refer, for example, to the inclination of most people to believe that negative things (such as illness) are rather unlikely to happen to them, to seek for pleasure and disregard the potential negative effects of personal behaviours, and to avoid complex situ-ations (e.g. health-related decision making; Sjöberg, 2003).

The impact of maladaptive beliefs on phys-ical health has been examined in several stud-ies. Maladaptive beliefs have been associated with more physical symptoms (Howlett, 1994), and have been found to mediate the impact of stress and hostility on physical health (Lichtenberg et al., 1992; VanderVoort, 2006) as well as to affect caregivers’ well-being in a negative way (Stebbins and Pakenham, 2001). Furthermore, maladaptive health beliefs have been related to worse regi-men adherence in adults with diabetes (Christensen et al., 1999), poor decision mak-ing in HIV+ individuals (Benotsch et al., 2004), higher levels of health anxiety (Fulton et al., 2011) and weaker internal health locus of control (Christensen et al., 1999).

Maladaptive beliefs about specific health problems or behaviours (such as dietary habits) have also been associated with well-being in a negative way (e.g. Osberg et al., 2008; Wang et al., 2009). Yet, the specific ways through which maladaptive health beliefs affect well-being are not clear.

Maladaptive health beliefs and self-regulation

A possible pathway for the impact of maladap-tive health beliefs on adaptation to illness may be through the ways that patients perceive their health condition. According to the Common Sense Self-Regulation Model (CS-SRM), adaptation to illness depends on a self-regula-tion mechanism that incorporates at least three interrelated belief systems (Leventhal et al., 1999): representations about illness, represen-tations about treatment/recovery, and percep-tions about self. Self-regulation also integrates self-evaluations, motives, memories of previ-ous personal experiences and information from the broader environment (e.g. health profes-sionals) (Leventhal et al., 1980, 1992, 1998).

This complex mechanism is likely to include existing (or result to new) errors in health infor-mation processing (i.e. maladaptive health beliefs). For example, in a previous study, patients with asthma have reported that the regular use of an inhaler made them feel less ‘able’ and healthy (St Claire et al., 1996). Therefore, and in order to preserve their self-esteem, they did not consider regular use as a critical issue. In other words, a maladaptive belief related to their self-concept seemed to affect these patients’ illness-related self-regulation mechanism and, particularly, their ways of representing and coping with illness.

The present study

The aim of this study is twofold. The first aim was to examine whether patients’ illness repre-sentations (as a set of specific beliefs regarding their illness) mediate the relation of general mal-adaptive health beliefs (as a set of cognitive biases in how patients generally understand health-related issues) to their illness-related coping behaviour. The CS-SRM posits that patients develop specific cognitive and emo-tional representations of their condition in order to make sense of and manage the disease (Leventhal et al., 1980). In turn, and always according to the model, illness representations

by guest on August 21, 2014hpq.sagepub.comDownloaded from

Karademas et al. 3

are causally associated with coping behaviours (Leventhal et al., 1980, 1992). The development of illness representations is based on several fac-tors, including patients’ characteristics, knowl-edge and experience. Hence, it is possible that general maladaptive health beliefs, which reflect deep personal attitudes and experience regard-ing health (Koopermans et al., 1994), affect patients’ behaviour and well-being through their illness representations. Although general mala-daptive health beliefs and illness representations are probably two factors closely related, and despite that illness representations refer to both accurate and inaccurate perceptions of illness (Leventhal et al., 1980), the two constructs are not the same. The first refers to cognitive biases in the ways people generally appraise health-related situations, whereas the second refers to specific perceptions of a particular illness.

In general, the representation of a controllable, less burdensome condition has been related to more adaptive coping behaviours (e.g. problem solving), whereas a representation of a severe, uncontrollable illness has been related to less adaptive coping (e.g. avoidance) (Hagger and Orbell, 2003). Thus, provided that maladaptive beliefs lead to unrealistic or pessimistic apprais-als and emotions (Beck, 1995; Koopermans et al., 1994), our hypothesis was that general maladap-tive health beliefs are associated with a represen-tation of illness as a burdensome and less controllable condition, which in turn is related to less adaptive coping behaviours.

The second aim of the study was to examine whether the relation of general maladaptive beliefs to patients’ illness representations and behaviour is moderated by the extent to which physicians provide patients with an adaptive understanding of their condition. Health profes-sionals represent a crucial source of informa-tion which affects illness representations and the entire self-regulation process (Diefenbach and Leventhal, 1996; Leventhal et al., 2005). In this context, there is already evidence that when health professionals administer educational programmes or just communicate in a way that is based on the CS-SRM, patients develop a

more accurate/adaptive understanding of their condition, while their adaptation to illness is more effective (De Ridder et al., 2007; McAndrew et al., 2008; Petrie et al., 2002; Phillips et al., 2012). Thus, to the extent that maladaptive health beliefs reflect errors in information processing (Beck, 1995), it is pos-sible that their impact is affected by the amount of illness and treatment-related information provided by physicians.

Specifically, our second hypothesis was that physicians’ communication of the CS-SRM moderates (buffers) the indirect relation of gen-eral maladaptive health beliefs to coping behav-iours through illness representations. We expected that the relation of general maladap-tive health beliefs to illness representations and coping behaviours is interrupted when physi-cians provide more information based on the CS-SRM.

Method

Participants and procedure

The study was conducted in two phases: general maladaptive beliefs, illness representations and physicians’ communication of the CS-SRM were assessed in the first phase, and coping behav-iours were assessed in the second phase, about 2 months later. Consecutive patients visiting the outpatient cardiology department of a public hospital for a regular consultation with their phy-sician, as well as an Open Community Centre for the Elderly (a social welfare facility offering some primary healthcare services) were invited to participate in the study. Inclusion criteria were a chronic cardiovascular disease, age over 18 years, ability to understand the study protocol and provide informed consent. The study was approved by the Department of Psychology University of Crete Ethics Committee.

A total of 119 patients finally participated in the study (149 were originally approached; 24 refused participation and 6 refused or failed to attend the second phase). The final sample con-sisted of 82 males (69.9%) and 37 females

by guest on August 21, 2014hpq.sagepub.comDownloaded from

4 Journal of Health Psychology

(31.1%). Their mean age was 62.39 years (standard deviation (SD) = 12.94; range = 28–82). Most (49) had suffered a myocardial infarc-tion in the past; 32 were dealing with coronary artery disease, 21 were suffering from arrhyth-mias and 17 were suffering from other heart problems. The mean time elapsed since first diagnosis was 10.76 years (SD = 9.25). The majority (70.6%) were married and living with their families.

Measures

Maladaptive health beliefs. General maladaptive health beliefs were assessed with the Irrational Health Belief Scale (IHBS) (Christensen et al., 1999), which is an instrument designed to assess differences in the tendency to engage in health-related cognitive distortions or illogical interpretation of a situation. The scale consists of 20 items, each of which includes a brief vignette describing a health-related situation (e.g. ‘You have been taking a medication for 6 months and your medical problem has not improved’; ‘Your doctor has suggested a new drug’; ‘You think to yourself’, ‘If the last medi-cation didn’t help, a new one won’t do any good’). Respondents were asked to rate how similar would their own cognition be to the one described in the vignette, using a 5-point scale (1 = not at all – 5 = almost exactly, like I would think). Although the scale includes maladaptive beliefs that refer to personal experiences, treat-ment side-effects and the behaviour of others (Fulton et al., 2011), it reflects a single, overall factor of maladaptive thinking (Christensen et al., 1999). The scale was translated into Greek for the purposes of this study. The proce-dure followed was translation into Greek, back-translation by an English speaking expert and final corrections. The internal consistency coef-ficients of all measures are presented in Table 1.

Illness representations. Illness representations were assessed with the Revised Illness Percep-tion Questionnaire (IPQ-R) (Moss-Morris et al., 2002). Participants were asked to respond in relation to their cardiac problem. The illness

representations assessed were as follows: time-line acute/chronic (6 items; e.g. ‘My cardiac problem will last for a long time’); illness con-sequences (6 items; e.g. ‘My cardiac problem has major consequences on my life’); personal control over illness (6 items; e.g. ‘The course of my cardiac problem depends on me’); treatment control, that is, evaluations about the treatment efficiency (5 items; e.g. My treatment can con-trol my cardiac problem); illness coherence, that is, the patient’s ability to make sense of the illness (5 items; e.g. ‘I have a clear picture or understanding of my cardiac problem’); time-line-cyclical which refers to beliefs regarding illness predictability and variability (4 items; e.g. ‘My cardiac problem is very unpredicta-ble’); and emotional representations (6 items; e.g. ‘My cardiac problem makes me feel afraid’).

Moreover, 13 items were used to assess rep-resentations about the potential causes of illness which correspond to three factors (Karademas and Tsaousis, 2014): emotional causes (5 items, e.g. stress); biological causes (5 items, e.g. pol-lution) and personal behaviour (3 items, e.g. smoking). To answer, respondents used a five-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree).

Coping behaviours. In order to assess what par-ticipants did the last time they felt a new or intense cardiac symptom, we simply asked them whether they had employed each of nine specific behaviours, which were derived from the Coping with Health Injuries and Problems Scale (Endler et al., 1998; for the Greek adapta-tion, see Karademas et al., 2010). A principal component factor analysis revealed the pres-ence of two factors that explained 63.45 per cent of the total variance: active coping which includes behaviours related to seeking for med-ical help and adherence to medical advice (6 items, e.g. visited my doctor or the hospital; complied with advice; eigenvalue = 4.04) and palliative coping (3 items, e.g. stayed in bed; eigenvalue = 1.04). Participants were asked to indicate the extent to which they reacted in each specific way by using a five-point frequency

by guest on August 21, 2014hpq.sagepub.comDownloaded from

Karademas et al. 5

Tab

le 1

. D

escr

iptiv

e st

atis

tics

and

inte

rcor

rela

tions

of g

ener

al m

alad

aptiv

e he

alth

bel

iefs

, illn

ess

repr

esen

tatio

ns, c

opin

g be

havi

ours

and

phy

sici

ans’

co

mm

unic

atio

n of

the

CS-

SRM

(N

= 1

19).

12

34

56

78

910

1112

1314

1. M

alad

aptiv

e be

liefs

1.00

2.

Tim

elin

e.0

41.

00

3. T

imel

ine-

cycl

ical

.14

.14

1.00

4.

Con

sequ

ence

s.1

2.3

8.3

91.

00

5. P

erso

nal c

ontr

ol–.

25–.

20–.

09–.

071.

00

6. T

reat

men

t co

ntro

l–.

25–.

31–.

15–.

14.5

11.

00

7. Il

lnes

s co

here

nce

–.22

–.19

–.49

–.38

.32

.35

1.00

8.

Em

otio

nal r

epre

sent

..0

2.3

5.5

3.5

9.0

1–.

14–.

451.

00

9. B

iolo

gica

l cau

ses

.31

.09

.08

.11

–.15

–.10

–.14

–.03

1.00

10

. Em

otio

nal c

ause

s.1

2.3

2.3

5.4

5.0

7.0

5–.

23–.

37.1

31.

00

11. P

erso

nal b

ehav

iour

–.02

.14

.33

.23

.18

.15

–.18

.29

.13

.49

1.00

12

. Phy

sici

ans’

com

.–.

24.1

9–.

01.1

3.2

1.1

2.1

9.1

9–.

05.2

1.1

51.

00

13. A

ctiv

e co

ping

–.21

.27

.14

.33

.31

.16

.03

.37

.01

.24

.11

.43

1.00

14

. Pal

liativ

e co

ping

.04

.20

.17

.35

–.01

.08

–.20

.35

.04

.29

.12

.14

.57

1.00

Mea

n41

.40

22.3

511

.68

18.5

322

.10

18.9

718

.34

19.2

112

.37

16.8

710

.20

5.47

23.2

310

.15

SD14

.17

4.90

3.69

4.82

3.89

2.92

4.13

6.19

3.79

3.95

3.52

1.82

5.99

3.19

Cro

nbac

h’s α

.86

.81

.81

.78

.76

.70

.84

.92

.69

.70

.83

.76

.85

.72

CS-

SRM

: Com

mon

Sen

se S

elf-R

egul

atio

n m

odel

; SD

: sta

ndar

d de

viat

ion;

Phys

icia

ns’ c

om. =

Phy

sici

ans’

com

mun

icat

ion

of t

he C

S-SR

M.

Cor

rela

tions

gre

ater

tha

n or

equ

al t

o .1

8 ar

e si

gnifi

cant

at

p <

.05.

Cor

rela

tions

gre

ater

tha

n or

equ

al t

o .2

5 ar

e si

gnifi

cant

at

p <

.01.

by guest on August 21, 2014hpq.sagepub.comDownloaded from

6 Journal of Health Psychology

Likert-type scale ranging from 1 (not at all) to 5 (very much).

Physicians’ communication of the CS-SRM. To assess whether physicians provided patients with an understanding of illness and treatment according to the CS-SRM, we used the scale developed by Phillips et al. (2012). The scale consists of seven items, each referring to a spe-cific domain of illness representations: causes, identity, timeline, control and consequences (e.g. ‘The doctor told me how long I could expect to have this problem’). Participants were asked whether their physicians performed the behaviour described in each item in the past with a Yes/No/Not Applicable answer choice. Answers were summed up to a total score rang-ing from 0 to 7 (for the applicable items). The scale was translated into Greek for the purposes of this study. The procedure followed was simi-lar to the one performed for the IHBS.

Statistical analysis

To examine whether illness representations mediate the relation of general maladaptive health beliefs to patients’ behaviour, we used PROCESS, a freely available computational tool for SPSS and SAS (Hayes, 2012). With PROCESS, we examined to what extent each illness representation mediates the relationship after controlling for the other representations and certain covariates (i.e. specific indirect effects were examined). The method determines specific indirect effects by employing a multi-ple regression analyses framework. It also cal-culates the bootstrapped confidence intervals (CIs) for each specific indirect effect.

Furthermore, through PROCESS, we exam-ined whether physicians’ communication mod-erates the indirect impact of maladaptive beliefs. Specifically, we examined whether physicians’ communication moderates the rela-tion of the independent variable (i.e. maladap-tive health beliefs) to the mediator (i.e. illness representations). Specifically, in the analyses conducted, the moderator was assumed to affect the path from the independent variable to the

mediator. Also, this approach determines whether indirect effects vary at different levels of the moderator (by default, indirect effects are reported at M and ±1 SD of the moderator). Both normal-theory tests and bias-corrected and accelerated bootstrapping are employed to test these effects. A post hoc examination revealed a statistical power greater than .95 at an alpha level equal to 5 per cent and a medium effect size.

Results

As a preliminary analysis, a multivariate analy-sis of variance (MANOVA) of all measures included in the study across gender, type of car-diac disease, education level and family status was performed. No statistically significant dif-ferences were observed, Wilks λs < .80; Fs < 1.45, ps > .10. Almost all illness represen-tations were associated with age (7 statistically significant correlations out of 10; Pearson’s rs > .20, ps < .05). Furthermore, representations about personal control and personal behaviour (as the cause of illness) were associated with the duration of illness (rs > −.20, ps < .05). Finally, active and palliative coping behaviours were related to age (rs > .23, ps < .05). Thus, all subsequent analyses were performed after con-trolling for age and the duration of the cardiac problem.

As presented in Table 1, maladaptive beliefs were negatively associated with personal and treatment control, illness coherence, active cop-ing, and physicians’ communication of the CS-SRM (Pearson rs > −.20, ps < .05); and posi-tively with biological causes (r = .31, p < .01). Coping behaviours were related to several ill-ness representations. Physicians’ communica-tion was weakly associated with certain illness representations, but it was strongly associated with active coping (r = .43, p < .01).

Regarding the indirect relation of maladaptive health beliefs to coping behaviours, we focused on those illness representations that were signifi-cantly correlated to maladaptive beliefs, namely, personal control, treatment control, illness coher-ence and biological causes. Results indicated that

by guest on August 21, 2014hpq.sagepub.comDownloaded from

Karademas et al. 7

personal control mediated the relation of mala-daptive beliefs to active coping (see Table 2, upper half). Higher levels of maladaptive health beliefs were related to less use of active coping through a diminished perception of personal con-trol over illness. Also, illness coherence mediated the relation of maladaptive beliefs to palliative coping (see Table 2, lower half). Higher levels of maladaptive beliefs were related to more use of palliative coping behaviours through reduced lev-els of illness coherence.

The moderating effect of physicians’ com-munication of the CS-SRM was examined only in the two statistically significant indirect effects. In both cases (see Table 3), physicians’ communication affected the impact of maladap-tive beliefs. The relations were statistically sig-nificant at the lower and medium levels of physicians’ communication, but they were no longer significant at the higher levels of physi-cians’ communication. In other words, when physicians provided patients with more infor-mation, the relation between patients’ maladap-tive health beliefs and illness representations was interrupted and, consequently, the negative impact of maladaptive beliefs on adaptive cop-ing behaviours was prevented.

Discussion

In order to examine the ways that general mala-daptive health beliefs impact patients’ adaptation to chronic illness, we conducted a study, the results of which seem to have both theoretical and clinical implications. First, in accordance with our hypotheses, the findings indicated that illness representations (as a set of beliefs about a specific illness) mediate the relation of general maladap-tive health beliefs (as a set of biased beliefs in understanding general health issues) to patients’ health-related behaviour. In other words, it seems that illness representations, which have a key role in adaptation to illness (Leventhal et al., 1980), act as a link between general maladaptive beliefs and health-related behaviour and outcomes. In addition, maladaptive health beliefs that are deeply rooted in the ways that patients process health-related information appear to be one of the factors that conduce to a more ‘negative’ percep-tion of illness, certainly in interaction with cur-rent experience and several other factors. After all, illness representations are the complex prod-uct of the ongoing interaction between past and present experience and knowledge (Leventhal et al., 2005).

Table 2. Specific indirect effects of illness representations on the relation of general maladaptive health beliefs to illness-related coping behaviours.

Mediator Mean indirect effect (SE) 95% Confidence intervalsa

Upper Lower

Dependent variable: active copingPersonal control –.034 (.019) –.086 –.005*Treatment control .003 (.013) –.020 .033Illness coherence .003 (.010) –.011 .031Biological causes .012 (.011) –.008 .037Dependent variable: palliative copingPersonal control –.002 (.008) –.022 .011Treatment control –.009 (.010) –.038 .002Illness coherence .010 (.008) .002 .033*Biological causes .001 (.007) –.016 .013

SE: standard error.aBootstrapping bias corrected and accelerated (5000 bootstrap samples); after controlling for age and years since initial diagnosis. Indirect effects are significant at p < .05 for the 95% bootstrap confidence intervals, when the derived intervals do not include values of zero (indicated with an (*)).

by guest on August 21, 2014hpq.sagepub.comDownloaded from

8 Journal of Health Psychology

Tab

le 3

. M

ean

indi

rect

effe

cts

(SE

in p

aren

thes

es)

of g

ener

al m

alad

aptiv

e he

alth

bel

iefs

on

copi

ng b

ehav

iour

s th

roug

h ill

ness

rep

rese

ntat

ions

at

spec

ific

valu

es o

f phy

sici

ans’

com

mun

icat

ion

of t

he C

S-SR

M, a

nd C

I.

Leve

ls o

f phy

sici

ans’

com

mun

icat

ion

−

1 SD

(C

I (95

%)a

)M

ean

(CI (

95%

)a)

+1

SD (

CI (

95%

)a)

Med

iato

r: p

erso

nal c

ontr

ol; d

epen

dent

var

iabl

e:

activ

e co

ping

–.05

2 (.0

29)

(–0.

122

to –

0.00

6)*

–.02

0 (.0

14)

(–0.

056

to –

0.00

1)*

–.00

3 (.0

09)

(–0.

036

to 0

.006

)

Med

iato

r: il

lnes

s co

here

nce;

dep

ende

nt v

aria

ble:

pa

lliat

ive

copi

ng.0

35 (

.019

) (0

.004

to

0.08

4)*

.010

(.0

07)

(0.0

01 t

o 0.

029)

*–.

001

(.004

) (–

0.01

3 to

0.0

07)

CS-

SRM

: Com

mon

Sen

se S

elf-R

egul

atio

n m

odel

; SE:

sta

ndar

d er

ror;

SD

: sta

ndar

d de

viat

ion;

CI:

conf

iden

ce in

terv

als.

a Boo

tstr

appi

ng b

ias

corr

ecte

d an

d ac

cele

rate

d (5

000

boot

stra

p sa

mpl

es);

afte

r co

ntro

lling

for

age

and

year

s si

nce

initi

al d

iagn

osis

. Ind

irec

t ef

fect

s ar

e si

gnifi

cant

at

p <

.05

for

the

95%

boo

tstr

ap c

onfid

ence

inte

rval

s, w

hen

the

deri

ved

inte

rval

s do

not

incl

ude

valu

es o

f zer

o (in

dica

ted

with

an

(*))

.

A notable finding was that the illness repre-sentations which mediated, after controlling for all other representations included in the analy-ses, the impact of maladaptive beliefs (i.e. per-sonal control and illness coherence) were mostly referring to a sense of control over ill-ness. It seems that general maladaptive health beliefs impact adaptation to illness not through the perception of illness per se (e.g. its chronic-ity), but rather through patients’ perception of the role of self within illness. However, it is possible that this finding is just a reflection of the type of maladaptive beliefs included in the IHBS (Christensen et al., 1999), which typi-cally refer to self.

Moreover, the amount of information pro-vided by physicians seems to moderate the rela-tion of general maladaptive health beliefs to illness representations and, consequently, to behaviour. According to the results, the relation of maladaptive beliefs to illness representations was interrupted when patients reported that they were well informed by their physician. This finding indicates that, although earlier per-sonal experience (even when biased) is strongly associated with the self-regulation process (Leventhal et al., 2005), this relationship can still be modified by the information gained from the health professionals. This is in accord-ance with previous studies regarding the impor-tance of the patient–physician relationship (De Ridder et al., 2007; McAndrew et al., 2008; Petrie et al., 2002; Phillips et al., 2012). It is also in accordance with the CS-SRM sugges-tion that patients’ reaction to illness is a dynamic process that evolves through the integration of information coming from the person and the broader environment (Leventhal et al., 1998). In this regard, it would be interesting for a future study to examine the extent to which the information provided by physicians facilitates the modification of biased health beliefs through a feedback loop, that is, through illness repre-sentations or health-related behaviour.

The above-mentioned finding also has a sig-nificant clinical implication as it points out a helpful way of counterbalancing the negative effects of maladaptive health beliefs, that is, the

by guest on August 21, 2014hpq.sagepub.comDownloaded from

Karademas et al. 9

use by health professionals of a self-regulation-related framework (like the one described by the CS-SRM) during their interaction with patients. Within such a context, the ‘communi-cation’ between patients’ and health profession-als’ different knowledge and experience bases may help patients develop a more accurate understanding of their condition (Leventhal et al., 2011), which in turn can help them chal-lenge possible maladaptive beliefs.

The findings of our study should be consid-ered in relation to certain limitations. First, it was based on self-reported data with all the shortcomings this implies. Second, the study was prospective only in a ‘technical’ sense, as the time elapsed between the two assessment points was rather short. Also, general maladap-tive health beliefs were assessed together with illness representations at the same time point. Thus, we could not control for the possibility that maladaptive health beliefs are influenced by the patients’ current perception of their health condition. Finally, physicians’ communi-cation of the CS-SRM may not be accurate, as it was reported by the patients and not the physi-cians as well. Also, there is a possibility that patients’ reports on physicians’ communication of the CS-SRM are biased by their current health condition or their beliefs about the healthcare system, or just a reflection of their illness representations.

Despite these limitations, our study was the first to show that general maladaptive health beliefs may be involved in the illness-related self-regulation mechanism. It was also the first to show that this relation is conditional on the amount of information about illness provided by physicians. Of course, much further study is needed to examine the role of maladaptive health beliefs (general and specific) across dif-ferent chronic illnesses. The understanding of how maladaptive health beliefs are formed, the ways that they are involved in health, health decision making and adherence to medical advice, as well as of the possible ways that their detrimental effect can be reduced is important for facilitating patients’ adaptation to illness and improving their health.

Funding

This research was partly supported by the Grant 3786 from the Special Account for Research, University of Crete.

References

Beck AT (1995) Cognitive Therapy: Basics and Beyond. New York: Guilford Press.

Benotsch EG, Kalichman S and Weinhardt LS (2004) HIV-AIDS patients’ evaluation of health informa-tion on the internet: The digital divide and vulner-ability to fraudulent claims. Journal of Consulting and Clinical Psychology 72(6): 1004–1011.

Cameron L, Leventhal EA and Leventhal H (1995) Seeking medical care in response to symptoms and life stress. Psychosomatic Medicine 57(1): 37–47.

Christensen AJ, Moran PJ and Wiebe JS (1999) Assessment of irrational health beliefs: Relation to health practices and medical regimen adher-ence. Health Psychology 18(3): 169–176.

De Ridder DTD, Theunissen NCM and van Dulmen SM (2007) Does training general practitioners to elicit patients’ illness representations and action plans influence their communication as a whole? Patient Education and Counseling 66(3): 327–336.

Diefenbach MA and Leventhal H (1996) The common-sense model of illness representa-tion: Theoretical and practical considerations. Journal of Social Distress and the Homeless 5(1): 11–38.

Endler NS, Parker JDA and Summerfeldt LJ (1998) Coping with health problems: Developing a reliable and valid multidimensional measure. Psychological Assessment 10(3): 195–205.

Fulton JJ, Marcus DK and Merkey T (2011) Irrational health beliefs and health anxiety. Journal of Clinical Psychology 67(6): 527–538.

Hagger MS and Orbell S (2003) A meta-analytic review of the common-sense model of illness representations. Psychology & Health 18(2): 141–184.

Hayes AF (2012) PROCESS: A versatile compu-tational tool for observed variable mediation, moderation, and conditional process mod-eling. White paper. Available at http://www.afhayes.com/public/process2012.pdf (accessed 2 December 2012).

Howlett B (1994) An investigation of the relationship between general belief patterns and well-being.

by guest on August 21, 2014hpq.sagepub.comDownloaded from

10 Journal of Health Psychology

Journal of Rational-Emotive and Cognitive-Behavior Therapy 12(4): 205–218.

Janis IL (1984) Improving adherence to medical rec-ommendations: Prescriptive hypothesis derived from recent research in health psychology. In: Baum A, Taylor S and Singer J (eds) Handbook of Psychology and Health: Social Psychological Aspects of Health. Hillsdale, NJ: Erlbaum, vol. 4, pp. 113–147.

Karademas EC and Tsaousis I (2014) The rela-tionship of patient and spouse personality to cardiac patients’ health: Two observational studies of mediation and moderation. Annals of Behavioral Medicine 47(1): 79–91.

Karademas EC, Zarogiannos A, Stravodimos K, et al. (2010) The adaptation of the coping with health injuries and problems scale to a sample of Greek patients: Validity issues. Hellenic Journal of Psychology 7(2): 159–179.

Koopermans P, Sanderman R, Timmerman I, et al. (1994) The Irrational Beliefs Inventory (IBI): Development and psychometric evaluation. European Journal of Psychological Assessment 10(1): 15–27.

Leventhal H, Diefenbach M and Leventhal EA (1992) Illness cognition: Using common sense to understand treatment adherence and affect cognition treatment. Cognitive Therapy and Research 16(2): 223–230.

Leventhal H, Halm E, Horowitz C, et al. (2005) Living with chronic illness: A contextualized, self–regulation approach. In: Sutton S, Baum A and Johnston M (eds) The SAGE Handbook of Health Psychology. London: SAGE, pp. 197–240.

Leventhal H, Kelly K and Leventhal EA (1999) Population risk, actual risk, perceived risk, and cancer control: A discussion. Journal of the National Cancer Institute Monographs 25: 81–85.

Leventhal H, Leventhal EA and Breland JY (2011) Cognitive science speaks to the ‘Common-Sense’ of chronic illness management. Annals of Behavioral Medicine 41(2): 152–163.

Leventhal H, Leventhal EA and Contrada RJ (1998) Self-regulation, health, and behavior: A percep-tual-cognitive approach. Psychology & Health 13(4): 717–733.

Leventhal H, Meyer D and Nerenz D (1980) The common-sense representations of illness danger.

In: Rachman S (ed.) Medical Psychology. New York: Pergamon Press, vol. 2, pp. 7–30.

Lichtenberg J, Johnson D and Arachtingi B (1992) Physical illness and subscription to Ellis’s irrational beliefs. Journal of Counseling and Development 71(2): 157–163.

McAndrew LM, Musumeci-Szabo TJ, Mora PA, et al. (2008) Using the common sense model to design interventions for the prevention and management of chronic illness threats: From description to process. British Journal of Health Psychology 13(2): 195–204.

Moss-Morris R, Weinman J, Petrie KJ, et al. (2002) The Revised Illness Perception Questionnaire (IPQ-R). Psychology & Health 17(1): 1–16.

Osberg TM, Poland D, Aguayo G, et al. (2008) The Irrational Food Beliefs Scale: Development and validation. Eating Behaviors 9(1): 25–40.

Petrie KJ, Cameron L, Ellis CJ, et al. (2002) Changing illness perceptions after myocardial infarction: An early intervention randomized controlled trial. Psychosomatic Medicine 64(4): 580–586.

Phillips LA, Leventhal H and Leventhal EA (2012) Physicians’ communication of the common-sense self-regulation model results in greater reported adherence than physicians’ use of interpersonal skills. British Journal of Health Psychology 17(2): 244–257.

Sjöberg L (2003) Neglecting the risks: The irrational-ity of health behavior and the quest for La Dolce Vita. European Psychologist 8(4): 266–278.

St Claire L, Watkins CJ and Billinghurst B (1996) Differences in meanings of health: An explora-tory study of general practitioners and their patients. Family Practice 13(6): 511–516.

Stebbins P and Pakenham KI (2001) Irrational sche-matic beliefs and psychological distress in car-egivers of people with traumatic brain injury. Rehabilitation Psychology 46(2): 178–194.

VanderVoort DJ (2006) Hostility and health: Mediating effects of belief systems and coping styles. Current Psychology 25(1): 50–66.

Wang WC, Worsley A and Cunningham EG (2009) Social ideological influences on food consump-tion, physical activity, and BMI. Appetite 53(3): 288–296.

Weinstein ND (1984) Why it won’t happen to me: Perceptions of risk factors and susceptibility. Health Psychology 3(5): 431–457.

by guest on August 21, 2014hpq.sagepub.comDownloaded from