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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: C.Bridle@warwick.ac.uk www.warwick.ac.uk/go/hpsych. - PowerPoint PPT Presentation
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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: C.Bridle@warwick.ac.uk www.warwick.ac.uk/go/hpsych
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
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
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
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)
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
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.
Are there potential negative consequencesassociated with screening?
Four screening phases
Invited to participate
Complete the screening test
Wait for results
Receiving results and recommendations
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
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
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?
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)
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)
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)
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
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
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
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
Once a decision to quit has been made, success is determined more by level of dependence
than level of motivation
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)
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
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
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
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
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
Recommended