module: health psychology lecture:preventive medicine date:16 february 2009

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Module: Health Psychology Lecture: Preventive Medicine Date: 16 February 2009 Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick Tel: +44(24) 761 50222 Email: [email protected] www.warwick.ac.uk/go/hpsych

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Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009. Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick Tel: +44(24) 761 50222 Email: [email protected] www.warwick.ac.uk/go/hpsych. - PowerPoint PPT Presentation

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Page 1: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Module: Health Psychology

Lecture: Preventive Medicine

Date: 16 February 2009

Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick

Tel: +44(24) 761 50222 Email: [email protected] www.warwick.ac.uk/go/hpsych

Page 2: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Aims and Objectives

Aim: To provide an overview of psychological issues relevant to screening and preventive intervention

Objectives: By the end of this session you should be able to describe … the different types (levels) of screening

the psychological factors that contribute to variation in screening uptake

the ethics of screening in terms of the psychological and behavioural effects of screening

brief screening methods for two common presentations, i.e. depression and alcohol misuse

brief screening and preventive intervention for smoking

Page 3: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Definitions

Preventive Medicine Health care initiatives

aiming to maintain and/or improve health among people who are currently free of symptoms

Preventing disease onset - delayed mortality, reduced morbidity and lowered incidence, e.g. heath promotion

Preventing disease progression, e.g. screening

Screening Presumptive identification

of unrecognised disease or defect by tests, examinations or other procedures

Early detection increases treatment effectiveness, with potential to delay mortality and reduce morbidity

Can not reduce, but may increase, incidence rate

Page 4: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Types of Screening

Population Screening

Services aimed at identifying health problems, e.g. mammography and PAP smear

Self-Screening

Behaviours aimed at identifying health problems, e.g. breast and testicular self-examination

Opportunistic Screening

Adjunctive identification of (other) health problems, e.g. hepB in pregnancy and depression in primary care

Page 5: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Screening Uptake

Much variation in the uptake of screening services Disease

Mammography, 75% - HIV testing, 6%

Country Mammography, 78% (England), 68% (Wales), 38% (Eire)

Geographical region Mammography, 81% (South-East), 62% (North-East)

Sub-groups Mammography, <50% in low S-E-S and minority groups

Jepson et al (2000)

Page 6: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

What factors influence the uptakeof screening services?

Patient factors Background demographic factors, stable individual

differences, social network, and situational factors Variation between people and within people

Provider factors Provider beliefs and behaviour

Organisational factors Invitation delivery, invitation response type, and

screening location

Page 7: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Why is there ethical controversy over screening?

A large number of people are tested in order to detect a small proportion of individuals who have preclinical disease.

Many people screened unnecessarily, and screening may have negative effects

Thus, a much larger number of people may experience harm from screening than those who experience the potential benefits from screening.

Page 8: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Are there potential negative consequencesassociated with screening?

Four screening phases

Invited to participate

Complete the screening test

Wait for results

Receiving results and recommendations

Page 9: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Breast Cancer (50-64 Years)

Mam

mogra

ph

y R

esu

lt

Breast Cancer

Present Absent Total

Positive 50 500 550

Negative 10 9440 9450

Total 60 9940 10,000

Sensitivity (a/a+c) = 83% probability a case will screen positive

Specificity (d/b+d) = 95% probability a non-case will screen negative

Page 10: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Negative Effects of Test Result

Result(per1000) Response / Effect True + (50) Anxiety, fear, stress, guilt, etc.

Patient, patient’s family, and provider Lower use of services by social group

False + (500) Unnecessary treatment

True – (9450) Maintain health-damaging behavioursInitiate health-damaging behaviours Ignoring subsequent symptoms

False – (10) Untreated progression of disease

Amended (510) Loss of trust in service, and providerLess and delayed use of health care

Page 11: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Ethical Considerations

Informed uptake Conflict between research/practice goals and ethical

considerations – biased framing

Consent Invitation to participate presupposes consent, and can

not be withdrawn

Effect of screening on others Relatives in the context of genetic screening

Confidentiality of medical information How confidential are test results and patient data, not

just now but also in the future?

Page 12: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Depression

Depression is the largest source of morbidity in the world (WHO)

Easy and quick to screen patients - questions based on affect and motivation within a specified time period

Two questions:

During the past month have you often been bothered by feeling down, depressed or hopeless?

During the past month have you been bothered by having less interest or pleasure in doing things?

(Arroll et al., 2005)

Page 13: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Alcohol

Hazadous alcohol use V Alcohol misuse

Easy and quick to screen patients with many different mnemonics, e.g. CAGE

Have you ever felt the need to Cut down your drinking?

Have you ever felt Annoyed by criticism of your drinking?

Have you had Guilty feelings about your drinking?

Did you ever need a morning Eye-opener?

(Ewing, 1984)

Page 14: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Smoking

Proportion of smokers abstaining from smoking long term, by cessation intervention

6-Month Intervention Abstinence (%)

No intervention (self-help/willpower) 2 (30% try)

Brief, opportunistic screening 5 and BPI from doctor to stop + NRT 10

Intensive support from specialist 10 + NRT 18

(West et al, 2000)

Page 15: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

The 5 A’s

For every patient at every consultation

ASK the patient if he or she uses tobacco

ADVISE him or her to quit

ASSESS willingness to make a quit attempt

ASSIST him or her in making a quit attempt

ARRANGE for follow-up to prevent relapse

Page 16: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

The 5 R’s

For smokers unwilling to make a quit attempt

RELEVANCE: Tailor advice & discussion to each patient

RISKS: Outline the risks of continuing smoking

REWARDS: Outline the benefits of quitting

ROADBLOCKS: Identify barriers to quitting

REPETITION: Repeat message at every visit

Page 17: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

The 5 Stages

Stage of change Precontemplation

Contemplation

Preparation

Action

Maintenance

Motivation Not thinking about stopping

Thinking about stopping

Planning to stop

Trying to stop

Stopped for some time

Page 18: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Assessing Motivation

Simple test of motivation to stop smoking Do you want to stop smoking for good? Are you interested in making a serious attempt to stop in

the near future? Are you interested in receiving help with your quit

attempt?

A “yes” response to all questions suggests high motivation to quit

Used to allocate resources High: behavioural support and/or medication Low: BPI to increase motivation, i.e. stage progression

Page 19: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Once a decision to quit has been made, success is determined more by level of dependence

than level of motivation

Page 20: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Assessing Nicotine Dependence

Important to assess dependence Guide choice of nicotine-based pharmacotherapy, i.e.

nicotine dose should reflect dependence level

Two question screen: How many cigarettes do you smoke a day? (15+ =

high)

How soon after you wake up do you smoke your first cigarette? (within 30 minutes reflects high dependence)

Page 21: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Ex-Smoker(>1 year)

Neversmoked

Smoker

Your patient(Ask about smoking)

Advise: As your Doctor I must advise you that … Assess motivation: Do you want to quit for good?

Not thinking ofquitting

Thinking aboutquitting

Ready to quit

Assist: NRT,cessation support Assist: Enhance

motivation totrigger quit

attempt

Assist: Enhancemotivation -

raise awareness- 5 RsArrange

follow-up

Ass

essm

ent

& B

PI

Alg

orith

m

Page 22: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Smoking Summary

Smoking cessation integrated into routine clinical practice - the 5A’s

Don’t give up on smokers not yet ready to quit – the 5R’s

Motivational messages are effective if tailored / personalised – the 5 stages

Choice of NRT should be guided by level of nicotine dependence

Page 23: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Conclusions

Preventive medicine is a integral part of clinical practice

Screening has many important health benefits

Screening uptake is variable

Individual screening behaviours are disease-specific

Screening has potentially negative consequences

Ethical considerations must be acknowledged

Page 24: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Summary

This session would have helped you to understand …

the different types (levels) of screening

the psychological factors that contribute to variation in screening uptake

the ethics of screening in terms of the psychological and behavioural effects of screening

brief screening methods for two common presentations, i.e. depression and alcohol misuse

brief screening and preventive intervention for smoking

Page 25: Module: Health Psychology Lecture:Preventive Medicine Date:16 February 2009

Any questions?

What now?

Obtain / download one of the recommended readings

In your small groups consider today’s lecture in relation to next week’s tutorial tasks:

a) integrated template

b) ESA question