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

1. Module: Health PsychologyLecture: Preventive MedicineDate: 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.ukwww.warwick.ac.uk/go/hpsych

2. 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

3. Definitions 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 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

4. 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

5. 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)

6. 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

7. 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.

8. Are there potential negative consequencesassociated with screening? • Four screening phases • Invited to participate • Complete the screening test • Wait for results • Receiving results and recommendations

9. Breast Cancer (50-64 Years) Sensitivity (a/a+c) = 83% probability a case will screen positive Specificity (d/b+d) = 95% probability a non-case will screen negative

10. 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 behaviours Initiate health-damaging behaviours Ignoring subsequent symptoms False – (10) Untreated progression of disease • Amended (510) Loss of trust in service, and provider Less and delayed use of health care

11. 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?

12. 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)

13. 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)

14. 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)

15. 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

16. 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

17. 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

18. 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

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

20. 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)

21. Your patient (Ask about smoking) Smoker Never smoked Ex-Smoker (>1 year) Advise: As your Doctor I must advise you that … Assess motivation: Do you want to quit for good? Assessment & BPI Algorithm Ready to quit Thinking about quitting Not thinking of quitting Assist: NRT, cessation support Assist: Enhance motivation to trigger quit attempt Assist: Enhance motivation - raise awareness - 5 Rs Arrange follow-up

22. 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

23. 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

24. 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

25. 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