Lecture 3 Health Psychology and Physical Illnesses I (Part 1)

1. Lecture 3Health Psychology and Physical Illnesses I (Part 1) Dr. Antoinette Lee The University of Hong Kong

2. Lecture Outline Part 1: • Psychological factors in Help-Seeking • Illness Cognitions and Representations • Coping with Chronic Illnesses Part 2: • Adherence to treatment Master in Behavioral Health Health Psychology Module Spring 2005

3. Lecture Outline Part 3: • Coronary Heart Disease • Psychological factors and CHD • Psychological responses to CHD • Psychological contributions to prevention and management of CHD Master in Behavioral Health Health Psychology Module Spring 2005

4. Health-Adjusted Life Expectancy • WHO’s concept of Health-Adjusted Life Expectancy (HALE) • Disability-adjusted life expectancy • Years of life in good health • Versus the concept of Life Expectancy which focuses on years of life in both good and ill health • HALE (at birth), 2000 & 2002: • USA: 65.7 / 67.2 (male) 68.8 / 71.3 (female) • China: 60.9 / 63.1 (male) 63.3/ 65.2 (female) • HK: 70.3 (male) 75.7 (female) (for 2000 only, Law & Yip, 2003) • Life Expectancy (at birth), 2000 & 2002: • USA: 74.3 / 74.6 (male) 79.7 / 79.8 (female) • China: 69.6 / 69.6 (male) 73.3 / 72.7 (female) • HK: 77 / 77.2 (male) 82.2 / 82.7 (female) Master in Behavioral Health Health Psychology Module Spring 2005

5. Help-Seeking • Prior experience • Expectations • Seriousness of Sx Lay referral network Individual factors Recognition of Symptom Interpretation of Symptom Help-seeking Health Behaviors Illness representations Situational factors Master in Behavioral Health Health Psychology Module Spring 2005

6. Factors Affecting Help-Seeking Behaviour • AGE- young children and the elderly population tend to seek help most often • GENDER- women seek help more often than men; physiological differences and social norms influence help-seeking behaviour • SOCIAL CLASS- in USA, those of lower SES use health services less. Is the situation the same in Hong Kong??? • EMERGENCE of irregular symptoms, disability, or serious illness • SOCIAL PSYCHOLOGICAL FACTORS- a person’s beliefs and attitudes on symptoms → The role of illness cognitions Master in Behavioral Health Health Psychology Module Spring 2005

7. Somatization • “the substitution of somatic preoccupation for dysphoric affect in the form of complaints of physical symptoms and even illness” (Kleinman, 1980, p.1) • Cultural influences • Are Chinese really somatizers? • The role of doctor-patent relationship, interviewing skills, and situational factors Master in Behavioral Health Health Psychology Module Spring 2005

8. Illness Cognitions and Representations • Illness cognition: • “a patient’s own implicit common sense beliefs about their illness” (Leventhal et al. 1980, 1997) • Knowledge about disease, meaning of illness, beliefs about illness…….. • Illness representations / schemas: organized conceptions of illness • Acquired through personal experience, family and friends, contacts with health care system, mass media • Provide patients with a framework or schema for • Understanding their illness • Coping with their illness • Telling them what to look out for if they are becoming ill Master in Behavioral Health Health Psychology Module Spring 2005

9. Illness Representations Five dimensions of illness representations: • IDENTITY • Label given to the illness and the symptoms experienced • Beliefs about associated symptoms • Disease prototype • PERCEIVED CAUSE OF ILLNESS • Biological, psychological, behavioral • Cultural influences • Internal versus external locus of control Master in Behavioral Health Health Psychology Module Spring 2005

10. Illness Representations • TIME LINE • Beliefs about the duration of illness • Acute • Chronic • Cyclic • CONSEQUENCES • beliefs about the impact of illness on their life (physical, emotional, social consequences) • beliefs about treatments that result • CURABILTY & CONTROLLABILITY • Can the illness be treated? How? • Extent to which the outcome is controllable by self or external factors Who can control the outcome of the illness (patients themselves, doctors, fate….) ? Master in Behavioral Health Health Psychology Module Spring 2005

11. Self-Regulatory Model of Illness Cognitions • Developed by Leventhal et al. (1980, 1997) to explain how illness cognitions affect coping strategies • Basis for model: • Humans develop problem solving techniques when normal state is altered (i.e. when health turns for the worse) • Motivated to re-establish state of normality and equilibrium • Three processes (interpretation, coping, appraisal) that interrelate in an on-going and dynamic manner Master in Behavioral Health Health Psychology Module Spring 2005

12. Self-Regulatory Model Representation of health threat - identity - cause - consequences - time line - cure/control Stage 1: Interpretation - symptom perception - social message -> deviation from norm Stage 2:Coping - approach coping - avoidance coping Stage3:Appraisal - Was my coping strategy effective? Emotional response to health threat - fear - anxiety - depression Master in Behavioral Health Health Psychology Module Spring 2005

13. Stage 1: Interpretation • Initial confrontation with the illness • An individual may be aware of illness either from symptom perception or social messages • Symptom perception , e.g. I have a pain in my chest • Social messages may take the form of doctor’s diagnosis, lab test result, or messages from lay referral system Master in Behavioral Health Health Psychology Module Spring 2005

14. Stage 1: Interpretation • Individual differences in symptom perception e.g. attentional differences, neuroticism, mood, expectations, situational factors • Interpretation activates illness representation in attempt to give meaning to the problem Master in Behavioral Health Health Psychology Module Spring 2005

15. Stage 2: Coping • Consideration and application of different coping strategies • Coping with illness as well as emotional reactions to illness • Can be broadly categorized into: • Approach coping • E.g. Consulting a doctor, adhering to treatment, rest, lifestyle change, seeking information, seeking support from others • Avoidance coping • E.g. Denial, wishful thinking Master in Behavioral Health Health Psychology Module Spring 2005

16. Stage 3: Appraisal • Evaluating if the coping efforts are effective • If not effective, reconsider coping strategies Master in Behavioral Health Health Psychology Module Spring 2005

17. Chronic Illness and The Self-Regulatory Model of Illness Cognitions • The model is useful in understanding and/or predicting: • Emotional reactions to illness • Coping with illness • Adherence with treatment and lifestyle changes • Outcomes of illness Master in Behavioral Health Health Psychology Module Spring 2005

18. Chronic Illness • Characteristics: • Long in duration • Long-term consequences • Usually involves multiple causes, including health habits • Cannot be fully cured; can only be managed • As many as 50% of population has some chronic condition • Cancer, heart diseases, diabetes, hypertension, arthritis, stroke……… Master in Behavioral Health Health Psychology Module Spring 2005

19. Challenges • Change in perception of self • Worries concerning the illness and one’s life • Treatment • Disruption in life and need for lifestyle change • Life plans • Health habits • Physical management • Monitoring of bodily changes (e.g. early signs of problems) • Vocational • Social • Financial Master in Behavioral Health Health Psychology Module Spring 2005

20. Chronic Illness • Emotional reactions to chronic illness • Shock and Denial • Anxiety • Depression • 1/3 of medical inpatients with chronic illness report moderate symptoms of depression • 1/4 report severe depression • Usually (but not necessarily) occur in later phases • Adverse impact on outcome • May lead to suicide • Difficulty in assessment Master in Behavioral Health Health Psychology Module Spring 2005

21. Chronic Illness • Factors affecting chance of depression among chronically ill patients: • Severity of illness • Pain and disability • Other negative life events • Social support • Age (Schnittker, 2004) Master in Behavioral Health Health Psychology Module Spring 2005

22. Chronic Illness • Schnittker, 2004’s study: • Impact of seven illnesses (high blood pressure, diabetes, cancer, chronic obstructed pulmonary disease, heart conditions, stroke, and arthritis) and three forms of disability (mobility, strength, activities of daily living) on depressive symptoms • The role of age in moderating the illness, disability, depression relationship • Main findings: • Age is associated with accelerated increase in depressive symptoms • However: • (1) Impact of illness on depressive symptoms decrease with age • 90% decrease in size of illness effect from 51 to 100 years of age for diabetes and high blood pressure; 59% decrease for arthritis Master in Behavioral Health Health Psychology Module Spring 2005

23. Chronic Illness • (2) Impact of disability on depressive symptoms decrease with age • Effect of ADL on depressive symptoms decrease by 46% from 51 to 100 years of age; effect of mobility disability and strength disability decrease by 28% and 43% respectively from 51 to 100 years of age Master in Behavioral Health Health Psychology Module Spring 2005

24. Chronic Illness • Illness as crisis • Unexpected appearance of illness • Unclear and ambiguous information about illness and the course of illness • Need to make quick decisions (on treatment, telling others, taking time off work) • Little experience with illness (limited past history) Master in Behavioral Health Health Psychology Module Spring 2005

25. Chronic Illness • What about positive reactions? • Escaped death, second chance • Healthy lifestyle change • Improved close relationship • Change in life priorities • Greater appreciation of health and life • Renewed meaning in life • Greater knowledge about health • Improved empathy • Stronger faith, spirituality Master in Behavioral Health Health Psychology Module Spring 2005

26. Chronic Illness and The Self-Regulatory Model of Illness Cognitions • The model is useful in understanding and/or predicting: • Emotional reactions to illness • Coping with illness • Adherence with treatment and lifestyle changes • Outcomes of illness Master in Behavioral Health Health Psychology Module Spring 2005

27. Coping Strategies for Chronic Illness • Similar to coping strategies for other stressful events in life except that chronically ill patients use less active coping methods: • Social support and direct problem-solving • “I talked to someone to find our more about the situation” • Distancing • I didn’t let it get to me” • Positive focus • “I came out of the experience better than I went in” • Cognitive escape / avoidance • “I wished that the situation would go away” • Behavioral escape / avoidance • “Avoiding the situation by eating, drinking, sleeping etc” Master in Behavioral Health Health Psychology Module Spring 2005

28. Chronic Illness and The Self-Regulatory Model of Illness Cognitions • The Self-Regulatory Model has been found to be useful in understanding and/or predicting: • Adherence with treatment and lifestyle changes • Brewer et al. (2002): belief that illness has serious consequences was related to medication adherence, and belief that illness is stable, asymptomatic, and with serious consequences was related to actual cholesterol control among patients with hypercholesterolaemia • Horne and Weinman (2002): Among patients with asthma, those who doubt the necessity of medication, have greater concerns about the negative consequences of medication had poorer adherence Master in Behavioral Health Health Psychology Module Spring 2005

29. Chronic Illness and The Self-Regulatory Model of Illness Cognitions • Outcomes of illness • Johnston et al. (1999): perceived control predicted recovery among stroke patients at one and six months after discharge from hospital • Petrie et al. (1996): Longitudinal study of 143 first-time MI patients aged 65 or below for 12 months following admission to hospital • Belief that the illness had less serious consequences and would last a shorter time (at baseline) predicted return to work at six weeks • Belief that the illness could be controlled or cured predicted attendance at rehabilitation classes Master in Behavioral Health Health Psychology Module Spring 2005

30. Part 2: Non-Adherence • Notes on non-adherence will be provided during class after the group presentation Master in Behavioral Health Health Psychology Module Spring 2005