Intro to Health Prof. Gentili (UNIPD) PDF

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Health Psychology (prof. Gentili, Padova) Psicologia Università degli Studi di Padova 10 pag.

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THE TOP 10 CAUSES OF MORTALITY IN THE WORLD • • • • • • • • • •

Ischemic heart disease (7 million) Stroke (6.2 million) Lower respiratory infec�on (3.2 million) Chronic Lung Diseases (3 million) Diarrheal diseases (1.9 million) AIDS (1.6 million) Lung diseases (including cancer) (1.5 million) Diabetes mellitus (1.4 million) Road injury (1.3 million) Prematurity (1.2 million)

DIMENSIONS OF HEALTH (Bauman 1961) • • •

a ‘general sense of well-being’; feeling iden�fied with ‘the absence of symptoms of disease’; 0 1 F 8 6Symptom orienta�on seen in ‘the things that a person who is physically fit is able to do’ 0 1 F 8 6performance

DIMENSIONS OF HEALTH (Benne� 2000) • • •

absence of illness (being) a posi�ve resource or reserve (having) physical (and psychological) fitness or func�on (doing)

DIMENSIONS OF HEALTH (The Health and Lifestyles Survey) • • • • • •

as lack of illness as reserve as behavior [especially in others] as physical fitness and vitality [fit for males, full of energy for females] as psychosocial well-being as having a (social) func�on

MODERN DEFINITIONS OF HEALTH World Health Organiza�on (1947): A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. 32 Bircher (2005): A dynamic state of well-being characterized by a physical and mental poten�al, which sa�sfies the demands of life commensurate with age, culture, and PERSONAL responsibility. CONSIDERATION OF HEALTH DURING THE LIFESPAN: Children under 7: magic explana�on (if any) are typical. • Incomprehension: child gives irrelevant answers or evades ques�on: e.g. sun causes heart a�acks. • Phenomenonism: illness is a sign that the child has associated with the illness, but with li�le grasp of cause and effect: e.g. a cold is when you sniff a lot. • Contagion: illness is usually from a person or object that is close by, but not necessarily touching the child; or it can be a�ributed to an ac�vity that occurred before the illness: e.g.: ‘You get measles from people’. If asked how? ‘Just by walking near them’ Children between 8 and 11 years: explana�ons of illness as being more concrete and based on a causal sequence. • Contamina�on: i.e. children understand that illness can have mul�ple symptoms, and they recognize that germs, or even their own behavior, can cause illness: e.g. ‘You get a cold if you get sneezed on, and it gets into your body’.

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Internaliza�on: i.e. illness is within the body, and the process by which symptoms occur can be par�ally understood. The cause of a cold may come from outside germs that are inhaled or swallowed and then enter the bloodstream. Can differen�ate between body organs and func�on and can understand specific, simple informa�on about their illness. They can also see the role of treatment and/or personal ac�on as returning them to health. In this concrete opera�onal stage, medical staff are s�ll seen as having absolute authority, but their ac�ons might be cri�cized/avoided: e.g. reluctance to give blood, accusa�ons of hur�ng unnecessarily, etc. may appear as children can now begin to weigh up the pros and cons of ac�ons.

During adolescence: illness concepts at this stage as being at an abstract level, based on interac�ons between the person and their environment. • Physiological: adolescents now reach a stage of physiological understanding where most can define illness in terms of specific bodily organs or func�ons (e.g. germs cause white blood cells to get / ac�ve to try and fight them), and begin to appreciate mul�ple physical causes, e.g. genes plus pollu�on plus behavior. • Psychophysiological: in later adolescence (from around 14 years) and in adulthood, many people grasp the idea that mind and body interact, and under- stand or accept the role of stress, worry, etc. in the exacerba�on and even the cause of illness. IN AVERAGE, AGEING IS RELATED TO: • • • • • •

Decrease of movement and, in general healthy behaviors Loss of strength, stamina, physical condi�on Loss of independence Loss of role (re�rement) Loss of significant others Chronic condi�ons (e.g. Hypertension, Diabetes etc.)

5 PROGRESSIVELY MORE INCLUSIVE “MODELS” OF SUCCESSFUL AGING: Bowling and Iliffe (2006) 1. Biomedical: physical and psychiatric func�oning – diagnoses and func�onal ability 2. Broader biomedical: as above but plus social engagement and ac�vity. 3. Social func�oning: nature and frequency of social func�oning and networks, social support accessed. 4. Psychological resources: personal characteris�cs of op�mism and self-efficacy and on sense of purpose, coping and problem solving, self- confidence and self-worth. 5. Lay: above variables plus socio- economic variables of income and ‘perceived social capital’, which included access to resources and facili�es, environmental quality and problems (e.g. crime, pollu�on, places to walk). ASPECTS THAT INFLUENCE PERCEPTION OF ILLNESS THROUGH SYMPTOMS • •

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Painful or disrup�ve: if a bodily sign has consequences for the person Novel: subjec�ve es�mates of prevalence significantly influence (1) the perceived severity of a symptom and (2) whether the person will seek medical a�en�on. Experiencing a ‘novel’ symptom (new to one- self or believed not to have been experienced by others) is likely to be considered indica�ve of something rare and serious, whereas experiencing a symptom thought to be common leads to assump�ons of lower severity and a reduced likelihood to seek out health informa�on or care. Persistent: a bodily sign is more likely to be perceived as a symptom if it persists for longer than is considered usual, or if it persists in spite of self-medica�on. Pre-exis�ng chronic disease: past or current illness experience has a strong influence upon soma�za�on (i.e. a�en�on to bodily states) and increases the number of other symptoms perceived and reported

DOMAINS OF MENTAL REPRESENTATIONS OF ILLNESS •

Iden�ty: variables that iden�fy the presence or absence of the illness. Illnesses are iden�fied by label, concrete signs and concrete symptoms. For example, ‘I feel shivery and my joints ache, I think I have flu’.

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Consequences: the perceived effect of illness on life: physical, emo�onal, social, economic impact or a combina�on of factors. May be short-term or long- term. For example, ‘Because of my illness I will have to take early re�rement’. Cause: the perceived cause(s) of illness. May be biological (e.g. germs), emo�onal (e.g. stress, depression), gene�c or environmental (e.g. pollu�on), or as a result of an individual’s own behavior. Timeline: the perceived �meframe for the development and dura�on of the illness. Can be acute (or short-term, with no long-term consequences), chronic (or long term) or episodic (or cyclical). For example, ‘I think my flu will last only three or four days’ or ‘My pain comes and goes’. Curability or controllability: the extent to which individuals perceive they, or others, can control, treat or limit progression of their illness. For example, ‘If I take this medicine it will help to reduce my symptoms’ This dimension may be par�cularly relevant for those facing chronic disease.

ILLNESS REPRESENTATIONS AND OUTCOMES: Illness representa�ons may also affect the outcomes trough several pathways: • • • • • •

seeking and using/adhering to medical treatment engagement in self-care behavior or behavior change a�tudes towards the use of brand-specific vs. generic medicines, and treatment choices illness-related disability and return to work caregiver anxiety and depression quality of life

CHARACTERISTIC THAT AFFECT TIMING OF SEEKING MEDICAL HELP (POSSIBLY AS EMOTIONS AND PERSONALITY TRAITS) • • • •

Neuro�cs and those with high Nega�ve Affect tend to report symptoms quicker Anxiety and fear are, on the other hand, o�en reported as a cause to delay Denial and unrealis�c op�mism are typical causes of delay (while op�mism per se is a posi�ve predictor) healthy hardiness (the extent to which a person is commi�ed to and involved in health-relevant ac�vi�es, perceives control over their health and responds to health stressors as challenges or opportuni�es for growth) is a predictor of small delay

PHASES OF CLINICAL CONSULTATION 1. The doctor establishes a rela�onship with the pa�ent. 2. The doctor a�empts to discover the reason for the pa�ent’s a�endance. 3. The doctor conducts a verbal or physical examina�on or both. 4. The doctor – the doctor and the pa�ent – the pa�ent (in that order of probability) considers the condi�on. 5. The doctor, and occasionally the pa�ent, considers further treatment or further inves�ga�on. SHARED DECISION-MAKING PROCESS VOCABULARY: CHOICE 0 1 F 8 6PROVIDE A KNOWLEDGE ABOUT REASONABLE TREATMENT OPTIONS TO THE PATIENTS – MAKE SURE THEY KNOW THEY CAN CHOOSE 0 1 F 8 6PROVIDING A MORE DETAILED INFORMATION ABOUT REASONABLE TREATMENT OPTIONS OPTION

DECISION 0 1 F 8 6SUPPORT A THE PATIENTS’ PROCESS OF DECISION BASED FIRST ON THEIR EXISTING KNOWLEDGE AND AFTER WITH INFORMED UNDERSTANDING CONSIDERING THEIR PRIORITIES

BREAKING A BAD NEWS – THE SPIKES MODEL Step 1: S – SETTING UP the interview: mentally rehearsing the likely plan of how the interview will proceed and se�ng up the physical se�ng in an appropriate way. -

Arrange for privacy

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Involve significant others (it is a pa�ent’s choice)

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Make connec�on with the pa�ent

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Manage �me constraints and interrup�ons

Step 2: P – Assessing the pa�ent's PERCEPTION (What do you know about your clinician so far?) Step 3: I – Obtaining the pa�ent's INVITATION (understanding how much the pa�ents want to know about his/her situa�on) Step 4: K – Giving KNOWLEDGE and informa�on to the pa�ent (when the bad news is given) Step 5: E – Addressing the pa�ent’s EMOTIONS with empathic responses: -

Observe for any emo�on on the part of the pa�ent.

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Try to follow and iden�fy the emo�ons experienced by the pa�ent. If they appear sad but silent, the clinician should use open ques�ons to find what they are thinking or feeling.

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The reason for the emo�on should be iden�fied. It is easy to assume this is due to the bad news, but it may not be clear which issue is of concern.

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A�er the pa�ent has been given a brief period of �me to express his or her feelings, the clinician should respond to their distress through empathic feedback:

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Any further medical dialogue needs to be suspended un�l the pa�ent is able to reengage with it. This may take some �me, during which the clinician may provide more empathic responses

Step 6: S – STRATEGY and SUMMARY: having – and knowing – a clear treatment plan will reduce anxiety and uncertainty but should be discussed only a�er pa�ents are ready to address these issues.

SOME FACTORS THAT DETERMINE A SUB-OPTIMAL CONCORDANCE TO TREATMENT •

social factors: low levels of educa�on, unemployment, concomitant drug use, low levels of social support;

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psychological factors: high levels of anxiety and depression, use of emo�on focused coping strategies such as denial, a belief that con�nued use of a drug will reduce its effec�veness, taking drug holidays to prevent ‘harm’ as a consequence of long-term drug use;

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treatment factors: misunderstandings regarding treatment, complexity of the treatment regimen, high numbers or fear of side effects, li�le obvious benefit from taking medica�on, poor rela�onship between pa�ent and health-care provider, poor health professional–pa�ent communica�on.

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Illness representa�on and health beliefs (especially in case of asymptoma�c condi�ons)

WAYS TO IMPROVE ADHERENCE TO TREATMENT: •

Self-control strategies: par�cipants are more likely to adhere to a program if they a�ribute any successful behavioral change to their own efforts rather than those of health professionals. This can be enhanced by teaching self-management skills such as self-monitoring, goal se�ng, planning

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Relapse preven�on: this involves iden�fying high-risk situa�ons that may result in ‘relapse’ back to previous behaviors and planning how to avoid or cope with them. It may also involve planning how to re-engage with any behavioral change following a ‘relapse’.

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Mo�va�onal strategies: these may include a stepwise progression in the degree of behavior change made se�ng achievable personal goals and measuring successes in reaching them, rewarding oneself for success – with concrete rewards

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Making change habitual: change should be con�nuous and sustained, not intermi�ent. Rewarding appropriate dietary choice with, for example, an occasional high- calorie ‘take way’ meal prevents the establishment of long-term habits, which are the key to long-term change.

STAGE APPROACH OF DEALING WITH HAVING A DISEASE: 1. Uncertainty: in this period the individual tries to understand the meaning and severity of the first symptoms. 2. Disrup�on: this occurs when it becomes evident to the individual that they have a significant illness. They experience a crisis characterized by intense stress and a high level of dependence on health professionals and other people emo�onally close to them. 3. Striving for recovery: this period is typified by the individual a�emp�ng to gain some form of control over their illness by means of ac�ve coping. 4. Restora�on of well-being: in this phase, the individual achieves a new emo�onal equilibrium based on an acceptance of the illness and its consequences.

TWO POSSIBLE PROCESSES/OUTCOMES AFTER “LOSS OF SELF” (ESTABLISHED BY AUJOULAT ET AL.) -

‘hold on’ to earlier ideas of ‘self’ (iden�ty and worth, different roles) and learning to control the illness as something separate to these

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‘le�ng go’ where pa�ents accept that they cannot control everything and that they have boundaries.

POST-TRAUMATIC GROWTH CAN BE CHARACTERIZED BY: • • •

Memory bias Subjec�ve Bias (the change is a�ributed to the disease) “Magnitude of change” bias (“exaggera�ng the difficulty of past experiences is another way people enhance their current status – Schacter 2001)

“MEASURING” POST-TRAUMATIC GROWTH 1. evaluate her/his current standing on the dimension described in the item, e.g., a sense of closeness to others; 2. recall her/his previous standing on the same dimension; 3. compare the current and previous standings; 4. assess the degree of change; 5. determine how much of that change can be a�ributed to the stressful encounter

PROCESSES THAT RESULTED FROM THE CRISIS OF ILLNESS (MOOS AND SCHAEFER – ILLNESS AS CRISIS): 1. Cogni�ve appraisal: the individual appraises the implica�ons of the illness for their lives. 2. Adap�ve tasks: the individual is required to perform illness-specific tasks such as dealing with symptoms, and general tasks such as preserving emo�onal balance, or rela�onships with others 3. Coping skills: the individual engages in coping strategies defined as either appraisal-focused (e.g. denial or minimizing, posi�ve reappraisal, mental prepara�on/ planning); problem-focused and emo�on- focused.

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COPING WITH AN ILLNESS IMPLIES: •

dealing with the symptoms of the disease and the possibility of pain;

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maintaining control over illness, including aspects of symptom management, treatment, or preven�on of progression;

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managing communica�ve rela�onships with health professionals;

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facing and preparing for an uncertain future;

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preserving self-image and possibly self-esteem when challenged (e.g. by altered appearance or func�on);

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maintaining control and emo�onal balance over health and life in general;

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dealing with changes in rela�onships with family and friends.

QUALITY OF LIFE (QOL) 0 1 F 8 6INDIVIDUAL’S A EVALUATION OF OVERALL LIFE EXPERIENCE (SITUATION, EXPERIENCES, STATES AND PERCEPTIONS) AT A GIVEN TIME A OF THIS LIFE EXPERIENCE AND HOW IT IS AFFECTED BY HEALTH-RELATED QOL (HRQOL)0 1 F 8 6EVALUATIONS SYMPTOMS, DISEASE, ACCIDENTS OR TREATMENTS, AND ALSO BY HEALTH POLICY A GAP BETWEEN OUR EXPECTATIONS OF HEALTH AND HEALTH-RELATED QUALITY OF LIFE (FOR CARR0)1 F 8 6THE OUR EXPERIENCE OF IT

QUALITY OF LIFE ACCORDING TO THE WHO CONSISTS IN: •

physical health: pain and discomfort; energy and fa�gue; sleep and rest;

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psychological: posi�ve feelings; self-esteem; thinking, memory, learning and concentra�on; bodily image and appearance; nega�ve feelings;

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level of independence: ac�vi�es of daily living (e.g. self-care); mobility; medica�on and treatment dependence; work capacity;

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social rela�onships: personal rela�onships; prac�cal social support; sexual ac�vity;

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rela�on to environment: physical safety and security; financial resources; home environment; availability and quality of health/social care; learning opportuni�es; leisure par�cipa�on and opportuni�es; transport; physical environment;

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spirituality, religion and personal beliefs

EXPECTATION OF HEALTH (AND THUS QOL AND HRQOL) MAY BE INFLUENCED BY: • • • •

demographics health condi�on: e.g. symptoms, presence or absence of pain, func�onal disability treatment: e.g. its availability, nature, extent, toxicity, side effects, etc.; psychosocial factors: e.g. emo�ons (anxiety, depression), coping, social context, goals and support.

WHAT INFLUENCES QoL: •

Psychological variables (especially anxiety and mood symptoms)

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Some findings suggest that several QoL measures are highly (nega�vely) correlated to depressive mood

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Coping strategies (some findings suggest that even avoidant coping may increase QoL in some situa�ons, other suggest that acceptance and posi�ve re-interpreta�ons are always be�er to increase QoL)

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Social support is posi�vely correlated with QoL

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If the disease produces goal disturbance, there is a nega�ve effect to the QoL

REASONS TO MEASURE QoL: •

to inform: increased understanding about the mul�dimensional impact of illness and factors that moderate impact to: -

evaluate interven�ons and best prac�ce

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inform pa�ents about treatment outcomes or possible side effects in order that they are ‘prepared’ for them, or so that suppor�ve resources can be put in place.

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to evaluate alterna�ves: QoL measures may be used as a form of clinical ‘audit’ to iden�fy which interven�ons have the ‘best’ outcomes – for the pa�ent, but also o�en in rela�on to costs (QALYs number of years achieved with a good QoL).

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to promote communica�on: enable health professionals to address areas (otherwise not considered) like treatment sa�sfac�on, treatment or illness impact on family interac�ons, social...