PSYC3500 Handbook PDF

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Summaries of all lectures in the 2018 Health Psychology Course. ...

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The University of Newcastle Health Psychology PSYC3500

Chelsea Scott

What is health psychology?... and some of its important underpinnings ‘Health psychology’ is interested in understanding the socio-environmental, behavioural, cognitive and emotional factors that influence: maintenance of optimal health, development and course of illness and disease, and response to illness and disease – by patient, family, community, health care providers. What is health? ‘A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’ World Health Organisation (WHO) 1948. Takes healthcare away from medical approach and broadens the approach. Illness/ Wellness Continuum: Everyone is on this continuum. We aim to not just be in the neutral point but in the high-level wellness. Bio Psycho Social model The biopsychosocial model: the interaction between biological, psychological and social factors is a prime determinant of an individual’s current health status. The biopsychosocial models involves complex interactions, holistic, interactive, emphasises health, and multidisciplinary – people feel mentally and socially unwell… not just physical health. The model posits that the mind and body cannot be distinguished and that social and psychological factors also influence disease. Macro and micro level processes influence health. Encourages active participation by ‘the patient’. A sharing of responsibility and decision-making: collaborative, patient-centred and multi-disciplinary approach to care. Sees ‘healthiness’ as a continuum. For the chronically ill person, coping is the best possible outcome, if they cannot hope to be cured. Biological factors may consist of: genetic predisposition and physiological functioning. Psychological factors may include: cognition, personality, emotion, and motivation. Social factors may include: culture, community, legislation, family, and access to education. Australian health stats; epidemiology; useful measures Epidemiology is the study of the frequency, distribution and causes (aetiology) of disease in a population… Morbidity: the cases of a disease that exist at some point in time ‘incidence’ – new cases and ‘prevalence’ – total number of existing cases. Mortality: numbers of deaths due to particular causes. Incidence: new health events or new cases of disease that occur within a defined population over a specified period of time: Cumulative incidence and Incidence density (incidence rate). Prevalence: the total number of cases of a disease (new and old) present within a specified population at a designated point in time: Point prevalence and Period prevalence. Health of Australians – Statistics We are living 30 years longer than in 1800, Males 47.2 years to 80.3 and for females 50.8 years to 84.4 years. Despite an increase in the absolute number of deaths, death rates have been continuing to fall. From 1907 to 2013, the age-standardised death rate for males and females fell by 71% and 76% respectively. Lung cancer, alziemhers & dementia, cardiovascular disease, and chronic obstructive pulmonary disease are the leading causes of death. All types of cancer deaths surpass the rate of all CVD. Premature death rates have fallen: Just iver 1 in 3 deaths in Australia were ‘premature’ (before age 75). The three leading causes were lung cancer, CHD, and suicide. Overall burden of disease has fallen: It measures both the burden of living with ill health as well the burden of dying prematurely, using disability-adjusted life years (DALY) as the unit of measurement. 1 DALY = 1 year of ‘healthy life’ lost due to a disease or injury. Lost healthy life can be from premature death, prolonged illness or disability, or a combination. More DALYs = Greater burden. YLD = years of life lost due to disability. YLL= years of life lost due to death.

Prevalence depends upon incidence rate and duration. Health inequities Health outcomes for Aboriginal and Torres Strait Islander people continue to experience greater health disadvantage—they are more likely to die at younger ages and to have a higher prevalence of many chronic health conditions. Indigenous males born in 2010–12 could expect to live to 69.1 years—10.6 years less than non-Indigenous males. For females, the gap was 9.5 years (a life expectancy of 73.7 and 83.2 years, respectively). The rate of premature deaths among Indigenous Australians is higher than among non-Indigenous Australians for both males and females across every age group. Between 2009 and 2013, 81% of all Indigenous deaths were of people aged under 75, compared with 34% for non-Indigenous Australians. ‘Potentially avoidable deaths’ refer to deaths from conditions that could have been avoided, given timely and effective health care. Rates of potentially avoidable deaths in a population represent the underlying population health, as well as health-service utilisation and the accessibility and effectiveness of the health system. After adjusting for differences in age structure, in the 2009–2013 period the mortality rate for Indigenous Australians who died from all potentially avoidable causes was more than 3 times the rate for non-Indigenous Australians (351 and 110 deaths per 100,000 population, respectively)

Inequities in preventable risks: Smoking in minority populations:

Primary, Secondary and Tertiary Prevention. Primary: Preventing the occurrence of the disease or health problem. Secondary: Preventing or slowing the progress of a disease or health problem and Reducing eliminating the health problem before it causes insignificant negative health consequences. Tertiary: Treating or managing an existing disease or health problem so as to lessen its impact on the individual. Chronic disease... and potential for prevention. Half of Australians are affected by at least one of the following eight chronic diseases: arthritis, asthma, back pain and problems, cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, and mental health conditions. The eight selected chronic diseases are associated with more than three-fifths (61%) of the total burden of disease in Australia, with cancer (19%) and cardiovascular disease (15%) accounting for the greatest burden. Around 1 in 3 (30%) problems managed in general practice in 2014 and 2015. More than 1 in 3 (39%) potentially preventable hospitalisations in 2013-14. More than three-fifths (61%) of the total burden of disease in 2011. Over 7 in 10 (73%) deaths in 2013. A large proportion of the burden is preventable: 31% of the burden experienced by the

population could be prevented by reducing the exposure to modifiable risk factors. The five risk factors included in the ABDS that caused the most burden were tobacco use, high body mass, high alcohol use, physical inactivity and high blood pressure. Health Psychology in Practice: ‘Clinical Health Psychology’: Applying psychology to illness assessment, treatment and rehabilitation and Mostly secondary and tertiary prevention. ‘Public or Population Health Psychology’: Health promotion / illness prevention and mostly primary prevention. Why a public or population approach? Focus on causes not symptoms. Focus on populations/communities not individuals directly. Opportunity to change environment, social determinants. Specific groups have similar health risks (eg Aboriginal and Torres Straight Islanders). Interventions targeting groups more cost effective than those targeting individuals. What is health promotion? ‘Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. To reach a state of complete physical, mental and social well-being an individual or group must be able to identify and realise aspirations, to satisfy needs and to change or cope with the environment.’ For example, Motor vehicle crash deaths and daily smokers have gone down due to health promotion.

Theory In Practice Role of theory, and types of theories that inform health psychology (& examples) Theory – a systematic way of understanding events or situations: a set of concepts, definitions and propositions that explain or predict these events or situations by illustrating the relationships between variables, applicable to a broad variety of situations, and abstract –until filled with practical topics, goals and problems. 9 criteria by which to access the quality of a theory. (i) clarity of constructs – ‘Has the case been made for the independence of constructs from each other?’ (ii) clarity of relationships between constructs – ‘Are the relationships between constructs clearly specified?’ (iii) measurability – ‘Is an explicit methodology for measuring the constructs given?’ (iv) testability – ‘Has the theory been specified in such a way that it can be tested?’ (v) being explanatory – ‘Has the theory been used to explain/ account for a set of observations? (statistically or logically)’. (vi) describing causality – ‘Has the theory been used to describe mechanisms of change?’ (vii) achieving parsimony – ‘Has the case for parsimony been made?’ (viii) generalisability – ‘Have generalisations been investigated across’: (a) behaviours? (b) populations? (c) contexts?’(ix) having an evidence base. Two types/ applications for theory? Explanatory theory – describes the reasons a problem exists – guides the search for factors which contribute and which can be changed, Eg Health Belief Model, Theory of Planned Behaviour. Change theory – guides the development of health interventions – spells out concepts that can be translated into program messages and strategies, and offers a basis for program evaluation – helps us be explicit about assumptions for why a program will work, Eg Diffusion of Innovations, Implementation theory *The two types of theory are not mutually exclusive. An ecological approach – what does that mean? An Ecological Perspective: a multilevel, interactive approach: Emphasises the interaction between, and interdependence of, factors within and across all levels of a health problem. Behaviour both affects, and is affected by, multiple levels of influence. Individual behaviour both shapes, and is shaped by, the social environment: reciprocal causation. Advantages of multi-level interventions that combine behavioural and environmental components.

Taking the example of encouraging parents to reduce the exposure of infants to environmental (second hand) tobacco smoke… what might be some of the influences on behaviour at each of the 3 levels of the (socio) ecological model? 

Individual/intrapersonal: attitudes/ beliefs that it’s unsafe for infants to be exposed or lack of knowledge about potential harms.

Interpersonal: reminder if a non-smoking friend is present, determining the social acceptability of smoking around infants based on what you see others do.  Community: Pre-schools/ day care/ baby health clinics providing pamphlets about smoking around children. Media targeting populations, smoking cessation campaigns sponsoring community events. All states and territories have smoking bans in vehicles with children policies prohibiting smoking within a certain distance of public building entries. (1) Individual or Intrapersonal (cognitive-behavioural) level: 3 concepts (1) behaviours is mediated by cognitions – what we know and think affect our actions, (2) knowledge is necessary for, but not sufficient to produce, most behaviour changes. (3) Perceptions, motivations, kills, and the social environment for key influence on behaviours. Theories for the Intrapersonal level are: 

(2) Intrapersonal level: assumes individuals exist within, and are influences by, a social environment. Opinions, thoughts, behaviour, advice, and support of people around us influence our feeling and behaviours, and that effect is reciprocal. Theories include: Social Cog Theory: One of the most frequently used and robust health behaviour theories explores the reciprocal interactions of people and their environments, and the psychosocial determinants of health behaviour. 3 main factors affect the likelihood a person will change a health behaviour: self-efficacy; goals; outcome expectancies. Concepts include: reciprocal determinism, behavioural capacity, expectations, self-efficacy, observational learning, and reinforcements. (3) Community: Explore how social systems function and change, and how to mobilise community members and organisations. Application across a wide variety of settings, such as: health care institutions, schools, worksites, community groups, and government agencies. Embody an ecological perspective – address individual, group, institutional and community issues. It is important to understand the ‘community’s’ unique characteristics. Diffusions of Innovations Theory (Rogers): Important to consider program reach, adoption, implementation and maintenance – innovative programs are worthless unless disseminated widely. Addresses how ideas, products, and social practices that are perceived as ‘new’ spread throughout a society or community (or from one to another). The process by which an innovation is communicated through certain channels over time among the members of a social system. By considering the benefits of an innovation, it can be positioned effectively, thereby maximising its appeal and affecting the speed and extent of its diffusion. Key Concepts are: (a) innovation, communication channels, social systems, and time. Key

attributes affecting the speed and extent of an innovation’s diffusion: (a) relative advantage, (b) compatibility, (c) complexity, (d) trialability, and (e ) observability. Self-report, and it’s accuracy Self-report is a widely used method of data collection in Health Psychology. It is easy and cheap, and sometime the only ethical option. Self-report is necessary to systematically collect peoples’ related attitudes, opinions, and beliefs. We’re aware about the accuracy of self-report measures and can consider the levels and significance of measurement error. 

What factors impact on accuracy… what are some of the reasons for inaccuracy? - Recall difficulty: e.g., telescoping error – recalling an event as occurring more recently than it did (i.e., last pap-smear). - Lack of knowledge/ inability to answer: weight & height; alcohol (what is a standard drink)?; pap tests undertaken as part of other gynaecological examinations. - Poorly designed survey instruments – inadequate or confusing response options. - Poor interviewer manner – e.g., failure to adequately probe; failure to ask all questions or to asl in a non-judgemental manner (e.g., clarification of alcohol consumption). - Lack of motivation to answer – ‘satisfying’ more likely to occur with greater task difficulty, the lower the respondent’s ability, and the lower the respondent’s motivation to optimise. Demand characteristics: e.g., desirability response bias – over-reporting of admirable behaviours and under-reporting those that are not socially respected or desirable. - Differences between instruments/ measures. E.g., measurement of alcohol consumption by diary vs QF. - Differences according to the modes of data collection: e.g. telephone vs faceto-face interviews; p&p vs. computer. - Imperfect ‘gold standard’ – there is no truly gold ‘gold’ standard. - Dishonesty: ‘evaluation apprehension’; fear of negative consequence e.g., drug use.

What are the consequence of inaccuracy: (a) Under- or over-estimation of the prevalence of risk factors or health behaviours leads to inappropriate targeting of interventions and resource allocation (Self report consistently underestimates the proportion of individuals ‘at risk’ for a health behaviour). (b) Mis-classification of risk status at the individual level leads to inappropriate decisions … (c) Obscuring (possibly causal) relationships between risk factors and subsequent disease. (d) Erroneous conclusions drawn about the effectiveness of intervention strategies. 

How we can optimise accuracy? -

• Reduce response costs (time, effort, negative consequence / risk)

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• Maximise rewards for responding optimally (tangible and/or intangible)

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• Ensuring respondent’s understanding of the Qs (piloting)

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• Minimising response biases through Q phrasing, structure

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• Using recall-aiding strategies e.g. bounded recall, diaries

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• Ensuring that Qs have clear, exhaustive, mutually exclusive response categories

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• Bogus pipeline techniques

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• Validation sub-studies - allowing for estimation of and adjustment for extent of inaccuracy

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• Careful and justified choice of measures / instruments and modes of data collection

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• Triangulation

Evidence Based Practice What constitutes (high quality) evidence Levels of evidence Levels of evidence: the research designs we use to evaluate programs can be categorised into ‘levels of evidence’. Levels of evidence reflect how confident we can be about the findings of program evaluations.

Level 4: No Planned data collection. e.g., exert opinion, non-empirical information such as case reports etc. Limitations: typically, reliant on theory, animal models or parallel research which are often poor predictors of outcomes. Particularly vulnerable to bias or vested interest, experiences based on small numbers, and often not considered ‘evidence’. Example of an intervention implemented based on expert opinion. Sexual abstinence strategies – virginity pledges (BMJ 2008; 337: a3168) - $200 million dollar investment. No difference in sexual activity for pledge students’ vs non-pledge students, Pledgers less likely to use contraception or protect themselves against STIs. Level 3: ‘Other empirical studies (not RCTs). Non-randomised trials/ trials without comparison groups. E.g., pseudo-randomised controlled trails, comparative studies with historical controls, interrupted time series etc. Limitations very depending on study design. Uncontrolled study designs: (1 experimental group) various, the most important of which are secular trends (changes that are happening overtime anyway). Example of an uncontrolled trial designs. Pre-post trial: measures are taken at a single point in time preand post the intervention. An individual’s/ groups/ organisation receives the intervention. A frequently used evaluation design in health promotion. E.g., quit smoking media campaigns. A pre-post trails design for a quit smoking media campaign intervention: Secular trends. However, other things could have impacted this trend…. The trends could have been due to variability in estimates…. Interrupted time series. Repeated measures are taken pre-and post-intervention. An intervention is introduced to all individuals/ groups/ organisations at one point in time. A change in the slope or level of series following the introduction of the intervention is evidence of an intervention effect. Cn be done retrospectively, e.g., medical record audit. Or… trends could have just been decreasing… (and we cannot account for these existing variations in data with just single measurement points). Controlled study designs: various, the most important of which is that the groups may differ in way other than the variable under study. An example of a controlled design: Multiple baseline. Repeated measures are taken pre- and post – intervention. An intervention is introduced sequential to all groups. Each site acts as a control. A change in the slope or level of the series following the introduction of the intervention (while remaining stable in other sites) is evidence of an intervention effect. Can be done retrospectively. Prevention care project. Advantages: requires fewer population groups, communities act as their own controls, all communities receive intervention, appropriate and accepted statistical analyses exist, and design consistent with planned roll-out/

decision making process. Another example of a controlled trail design: Quasi experimental design/ non-randomised trial. Measures are taken pre-and and ...