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Copy of Health Psychology
Transcript of Copy of Health Psychology
Sample: 475 patients from 5 practices in Lothian
Procedure: Survey using photos of different styles in male and female doctor and questions about attitude to doctor's dress in general
Overall, favored more formal approach
male doctor in formal suit and tie
female in white coat
Particularly true of older people of upper social classes
Male wearing tweed jacket, informal shirt and tie was least disliked.
Marked variation between preferences.
28% said they would be unhappy about consulting one of docs show, usually ones informally dressed
But some said they would dislike white coat
64% felt dress quite or very important
41% said they would have more confidence in ability of one of the docs based on appearance
Evaluation: Doctors should dress in a way that inspires more confidence. But more important factors exist: Argyle 1975 emphasized that all types of nonverbal communication interact with each other so dress alone not enough to create good communication. Study used static photos of doctors, so low ecological validity and reductionist. Non-verbal Communications
Mckinstry and Wang 1991 Verbal Communications Mckinlay 1975 Ley 1988 Aim: To assess lower-class women's understanding of terms doctors use
Sample: lower class women in maternity ward
Procedure: Recorded terms used in conversation with the women and then asked them what they understood by 13 of these terms (e.g. breech, purgative, mucus, glucose, antibiotic, protein, navel, umbilicus). Had doctors indicate for each word whether they thought "average lower working-class women" would understand term.
Results: On avg, each term understood by only 39% of women. 2/3 understood "breech" and "navel," but almost none understood "protein" and "umbilicus." Doctors expected even less comprehension, but still used these terms often.
Discussion: Doctors use complex medical terms out of habit, sometimes forgetting patient is less medically sophisticated. May feel patient doesn't need to know. Perception that this would benefit patient or medical staff. Sometimes person's knowing exactly what disease or its treatment is may produce too much stress or interference with treatment. Elevates status of practitioners. Summary of studies analyzing patient's understanding of diagnosis of condition and medical regimen prescribed.
5-53% fail to understand their medication
Especially patchy knowledge of dosage and timing of medication
Even if patients understand, recall is very poor
Patients interiewed after they visited the doctor
Asked to say what the doc had told them to do
Compared with a record of what had actually been said to them
In general, remembered around 55% of information
Amount forgotten increases with amount of information given
Good recall of first thing said--primacy effect
Recall didn't improve with repetition--didn't matter how often the doc repeated the information
Remembered categorized information (e.g. which tablets they should be taking) better than more general information
Remembered more if already had some medical knowledge
Follow up study: prepared a small booklet giving advice to doctors on how to communicate more clearly with patients. Patients whose docs read booklet recalled 70% of what they had been told: sig. increase on 55%. Diagnosis and Style Doctor & Patient centered Styles Byrne and Long 1976 Savage and Armstrong 1990 Aim: To identify different styles of patient practitioner interaction
Procedure: Analysis of 2500 tape-recorded medical consultations with docs in several countries, including England, Ireland, Australia and the Netherlands
Results: Each doc used consistent styles. Most of the styles classified as doctor-centered or patient centered.
Doctor centered style--emphasises imbalanced power relationship between doc and patient, with doc leading discussion by asking for medical facts and giving advice. Doc asks direct questions that require only brief answers and focuses mainly on first problem mentioned. Tend to ignore attempts by patients to discuss other problems. Intent on establishing link between initial problem and some organic disorder without being sidetracked. Patient just provides information about their complaint in response to the questions. Patient expected to be passive and not influence consultation. Doc makes decision and instructs patient.
Patient-centered--more emphasis on patient and unique individual needs. Doc tries to discover patient's concerns and needs, and adjust response to match. Less controlling role, with open-ended questions that allow patients to relate more info and introduce new facts that may be pertinent. Avoid medical jargon and allow patients to participate in decision making.
Patient-centered style is generally considered to be more favorable as it allows docs to gain fuller understanding of cause and prognosis of illness important for diagnosis. First complaint patient mentions is often not the most important or significant one. Patients appreciate warmth, sensitivity and concern. Greater satisfaction with practitioner translates into greater adherence. Aim: to examine effects of GP's consulting style on patient satisfaction
Design: Random control design in naturalistic setting (design controls for individual differences and has good ecological validity)
Sample: Took place in group practice in inner city London. Four patients from each surgery for one doctor, over 4 months, randomly selected. 16-75 yrs, no life-threatening condition, not attending for administrative or preventive reasons, GP said they wouldn't be upset by project. 200 patients in total
Procedure: two conditions, sharing consulting style vs directive consulting style. Patients randomly allocated by a set of cards to one of two conditions and received consultation from GP involving appropriate style. When patient entered consulting room, greeted and asked to describe problem, then GP turned over card to determine appropriate consulting style. Advice and treatment given by GP in that style.
E.g.: "This is a serious problem/I don't think this is a serious problem" vs "Why do you think this has happened?"
"You are suffering from..." vs "What do you think is wrong?"
"it is essential that you take this medicine" vs "What were you hoping I would be able to do?"
Consultations recorded and assessed by independent observer to make sure in appropriate style.
Patients asked to complete questionnaire just after consultation and one week later, satisfaction with consultation based on doc's understanding of prob: "I perceived the GP to have a complete understanding"
Adequacy of explanation of problem: "I received an excellent explanation."
Feeling helped: "I felt greatly helped." "I felt much better"
Results: More patient satisfaction in directive consulting style, especially in those who rarely attended surgery, had a physical problem, did not receive tests and received prescription.
Conclusion: Study provides support for educational model of patient-practitioner interaction, with doc acting as expert and authority figure. Misuse of Health Services Aleem and Ajarim 1995
Munchausen Syndrome Spitzer et al 1994 Hypochondriasis Safer 1979 Delay in Seeking Treatment Aim: To examine factors affecting delay in seeking health care at different times
Theory: Total delay broken down into three sequential stages:
Appraisal delay: Time taken for patient to recognize symptom as sign of illness
Illness delay: Time taken from deciding one is ill to deciding to seek health care
Utilization delay: Time taken from deciding to seek health care to actually getting it
Sample: Carried out in waiting rooms of four clinics in large inner city hospital in US. Interviewers approached patients who were there to report a new symptom or complaint and asked series of questions (45 min). 93 patients interviewed, avg 44 years, 60% black. Interviewers--black, female nurse and white male undergrad student
Procedure: Pps asked when they noticed first symptom, "What was your very first symptom or sign that you might be sick and when did it occur?"
When they decided they were really sick: "Was there some point in time when began to feel you were really sick?"
When they decided to seek medical help: "At what time did you decide to see a doctor?"
Also asked range of other qs, some open, some closed, to help discover factors contributing to decisions in getting help.
Results: No statistically significant correlation between Appraisal, illness and utilization delay, suggesting that these stages operate independently
Total mean delay 14.2 days
Appraisal delay: presence of severe pain, whether pp had read of symptoms, presence of bleeding--pain and bleeding imply illness, reading has opposite effect as it is passive monitoring which leads to further info searching rather than decision making, increasing delay
Illness delay: symptom new or experienced before, imagined -ve consequences of being ill and gender. Longer delay if old symptom, imagined consequences (-ve) and female
Utilisation: pps concerned about cost delayed longer, painful symptom or belief illness could be cured less delay
Patients with personal problems had longer delay overall
Conclusion: different factors mediate delay at each of the three stages. however, generalisability low because just one area studied. Hypochondriasis: preoccupation with fear of having serious disease resulting from unrealistic interpretation of physical signs and sensations for more than 6 months despite medical reassurance.
Case study: 38 yr radiologist, underwent extensive physical and lab exams, xray exams of entire gastrointestinal tract, esophagoscopy and colonoscopy at a diagnostic center. Results -ve for sig physical diseases, but appeared resentful and disappointed at findings.
Describes occasional twinges of mild abdominal pain, sensations of fullness, bowel rumblings and firm abdominal mass. Over the last few months, convinced these are signs of colon cancer. Tests stool for blood weakly and spends 15-20 min secretly massaging abdomen every 2-3 days at home, secretly performs xrays on self in office after hours
Successful at work, excellent attendance record and engages in community life, but spends much of his leisure time at home in bed. Wife is angry and bitter about behaviour, creates strain in marriage.
Fears began at 13 when heart murmur detected on school physical exam, removed from PE classes because younger brother had died in early childhood from congenital heart disease. Evaluations showed murmur was benign, but was convinced they missed something and considered occasional sensations of hear skipping a beat as evidence. Fears subsided over 2 yrs but never really left.
since 2nd year med student, repeatedly experienced series of concerns, preoccupation and negative physical examinations. At times returns to 'old' concern, but too embarrassed to pursue it with physicians he knows. Munchausen syndrome: physical symptoms intentionally feigned or produced in order to fulfill psychological need to assume sick role
Case study: 22yr Female uni student referred with possible case of immune deficiency. Painful swelling over right breast with history of similar recurrent swellings over past few months which needed repeated surgical draining in other hospitals on about 20 occasions.
Problems started at 17, with amenorrhea, treatment and subsequent swellings in groin area.
Father a teacher and supportive, friendly man. Mother died of breast cancer. Third of Six sisters. Intelligent but appeared to have only modest knowledge of medicine.
Swelling drained, but new swelling appeared.
Suspicions raised as to factitious nature of problem because no explanation for causes of abcesses and growth of multiple organisms from lesions.
Psychiatric consultation, very defensive and extremely rationalizing in her answers. Superficial affect regarding problems and experiencing great amount of stress due to conflicts.
One day when patient not in bed, nurse found syringe full of fecal material along with needles. When another patient told her of this, became very hostile and immediately left hospital against medical advice. Adherence to Medical Advice Types of Non-Adherence and Why Patients don't Adhere Bulpitt 1988 Rational
Non-Adherence Johnson & Bytheway 2000
Customizing Treatment Study on the use of treatments for hypertension
Aim: To compare the effects of two anti-hypertensive drugs on measures of quality of life over 3 months
Sample: 157 patients of eight hospital outpatient clinics in UK,
men and women over 21 yrs old
Quality of life assessed by self-report questionnaires
13 patients withdrew from study due to adverse effects
Found that the medication improved the condition by reducing symptoms of depression and headache
But also had side-effects of increased sexual problems such as difficulty with ejaculation and impotence, sleepiness and dizziness
For some price not worth paying
Review of studies showed 8% non-adherence due to sexual side-effects, 15% due to other side effects.
Declining to take medicine=rational decision
Patients only likely to adhere to treatment if they judge the changes have an overall benefit.
Other reasons for rational non-adherence:
believe treatment is not helping
side-effects unpleasant, worrying or reduce quality of life
confusion about dosage and timing of medication
practical barriers to treatment, such as cost
may want to check illness is still there when treatment is discontinued Aim: To study the experiences of older patients and their management of long-term medicine
Sample: 77 patients from eight diverse general practices in England and Wales. Pps over 75 yrs, living in own homes and on long-term medication for at least a year.
Procedure: interviews, semi-structured diaries, log of medicines and information from medical record held by practices
Findings: Older patients make a lot of use of over the counter medication, for four reasons:
prevention and maintenance, mainly nutrition supplements like vitamins or products that are good for the blood
alternatives to going to the doctor, for conditions such as indigestion, skin irritations or headaches
Supplements or replacements for prescription medicines, such as painkillers, or other medicines recommended by the doctor
Items to counteract side-effects of prescription medicines, e.g. laxatives to counter constipation caused by many painkillers
In the strictest sense, patients not adhering to medical regime, but may be following program that is right for them and makes best use of available info Measuring non-adherence Riekert and Drotar 1999 Self Reports Subjective Measures Aim: to examine the implications of nonparticipation in studies of treatment adherence among adolescents with chronic health conditions
Procedure: Empirical data from adherence study on adolescents with diabetes used to demonstrate influence of family participation on demographic and health outcome variables.
94 families classified into three groups: families that declined to participate in study at recruitment (non-consenters), families that failed to turn in self-reports (non-returners) and families that had at least one member turn in study questionnaire (participants)
Results: Despite being demographically similar, nonreturners had significantly lower treatment adherence scores and adolescents tested blood sugar less frequently than participants.
Hence self-report studies of adherence have low generalizability of findings because participants have higher adherence rates--estimates of adherence from self-report studies likely to be too high. Objective Measures Chung and Naya 2000
Pill Counting Sherman 2000
Repeat Prescriptions Braam 2008
Biochemical Tests Aim: To measure adherence rates in oral asthma medication using TrackCap
Procedure: Electronic device (TrackCap) on medicine bottle recorded date and time of each use of the bottle.
London patients told adherence rates being measured but not about details of TrackCap. Medicine supposed to be taken twice a day, adherence=TrackCap showing usage 2x day, 8 hours apart.
Compliance measured over 12 week period.
Results: Compliance relatively high (median=71%), and even higher (89%) if measure was comparison of TrackCap usage with number of tablets, regardless of timing. Aim: To determine whether a prescription refill history obtained by telephoning patients' pharmacies identifies poor adherence with asthma medication more frequently than physician assessment.
Sample: 116 medicaid recipient kids with persistent asthma
Method: During clinic visit, pulmonologists interviewed patients and caretakers and estimated adherence on a checklist
Nurse asked caretakers where they obtained medicines from and telephoned 66 pharmacies for refill history
Max possible adherence=no. of doses refilled/number of doses prescribed for mean of 163 days.
Accuracy of refill history verified by medicaid reimbursement records
Results: Info provided by pharmacies 92% accurate.
Mean max adherence ranged from 38-72% for three drugs
Physicians were only able to identify 49% of patients who refilled </=50% of their prescriptions and only 27% of those who used a certain drug excessively
Conclusion: Physicians unable to identify patients with very poor adherence. Checking prescription refills is a good way to verify adherence. Aim: To investigate different methods of measuring adherence in hypertensive patients
Methods: 30 hypertensive patients participated in the study, treated with anti-hypertensive drugs with potassium bromide added to each capsule as a marker.
Adherence measured by capsule counting (>80% drug intake=good), electronic registration of pill box openings (no. of times box opened/no. of days capsules should have been taken, >80%=good) and by measuring serum bromide concentrations in the blood (>80% increase in serum bromide as per results of healthy volunteers).
Results: Serum bromide and electronic monitoring gave comparable results of identifying non-adherent patients. Capsule counting not as good. Capsule counting and electronic monitoring do not ensure pills were ingested, serum bromide measures actual drug ingestion.
But multiple blood samplings required, so time, cost and work consuming. Increase in bromide is influenced by body weight and it can only monitor intake of one drug at a time. Interindividual variations can be large.
Electronic monitoring more appropriate for short-term, bromide for long term.
Bromide good measure of adherence, but though electronic monitoring may be slightly less direct predictor of actual injection, but is less complex and more cost-friendly. Ley 1988 Improving Practitioner Style Lewin 1992 Providing Information Burke 1997 Behavioural Techniques Cognitive hypothesis model of adherence: compliance can be predicted by a combination of patient satisfaction, understanding of information given and recall of this information.
One way of improving compliance is to improve communication in terms of content of oral communication:
Give advice early in interview
stress importance of instructions and advice
use short words and short sentences
arrange information into clear categories
give specific, concrete and detailed advice rather than general recommendations
written information increases compliance by 60% and outcome by 57%
Satisfaction stems particularly from affective aspects, e.g. emotional support and understanding,
Behavioural aspects, e.g. prescribing, adequate explanation
competence, e.g. appropriateness of referral, diagnosis
Content of consultation--patients want to know as much info as possible, even if it is bad news--cancer patients more satisfied if given diagnosis than if protected from info Home based exercise program found to be as useful as a hospital based one in improving cardiovascular fitness after an acute myocardial infarction.
Aim: To find out whether a comprehensive home-based program would reduce psychological distress
Sample: 176 patients with acute myocardial infarction
Method: pps randomly allocated to self-help rehab program based on the heart manual or to receive standard care plus placebo package of information and informal counselling.
The heart manual: home-based, cognitive behavioural, CHD self management program based around work book and phone calls. Includes interactive CD of education, relaxation program on tape, specially trained 'facilitator' who calls three times over 6-12 weeks post discharge
Results: psychological adjustment, as assessed by Hospital Anxiety and Depression Scale better in rehab group at one year.
Significantly less contact with GPs during following year and significantly (30%) fewer readmissions in first 6 months. Reviewed 46 studies of cardiovascular risk-reduction programs, findings:
Tailoring the regime: activities in treatment are designed to be compatible with patient's habits and rituals, e.g. taking a pill at home at breakfast or while preparing for bed is easier to do and remember for most people than taking it in the middle of the day
Providing prompts and reminders: serve as cues to perform recommended activities. These cues can include reminder phone calls for appointmenets or notes posted at home that remind the client to exercise. Innovative drug packaging can also help, e.g. some drugs today come in dispensers with dated compartments or built in reminder alarms.
Self-monitoring: patient keeps a written record of regimen activities such as the foods eaten each day
Behavioural contracting: the practitioner, client and family member negotiate a series of treatment activities and goals in writing and specify rewards the patients will receive for succeeding.
Advantage of active client involvement in design and execution of treatment, carried out alone or with the aid of practitioner, family or friends.
May be time consuming. Improving Adherence Pain Types and Theories of
Pain Gate Control Theory Melzack 1965 Neural 'gate' that can be opened or closed in varying degrees
Modulates incoming pain signals before they reach the brain
Gating mechanism is located in grey matter of spinal cord (substantia gelatinosa of dorsal horns)
Signals of noxious stimulation enter gating mechanism of spinal cord from pain fibers (a-delta and C fibers)
Signals activate transmission cells which send impulses to the brain
When output of signals from transmission cells reaches critical level, person perceives pain
Greater output beyond critical level=more pain
When gate is open, transmission cells send impulses freely
Gate closed, output of transmission cells inhibited
Activity in pain fibers opens gate, stronger noxious stimuluation=more active pain fibers
A-beta fibers (peripheral fibers) carry information about mild irritation or harmless stimuli, e.g. rubbing or light scratching. Activity of A-beta fibers closes gate (explains why massage or heat to sore muscles helps)
Neurons in the brainstem and cortex send impulses that can open or close gate. Effects of some brain processes (e.g. anxiety or excitement) have general inhibitory effect, others may have very specific impact applying only to some inputs from certain body parts (explains hypnotization and distraction in pain relief)
Biopsychosocial perspective, hence not reductionist, but nomothetic. Measuring Pain Psychometric Measures Stress Health and Safety Health Promotion Causes of Stress Lack of control Geer and Maisel 1972 Aim: To see if perceived control or actual control can reduce stress reactions to aversive stimuli
Sample: 60 psychology undergrads from New York University
Design: Independent measures lab experiment
Method: Each pp seated in sound-shielded room and wired up to galvanic skin response and heart-rate monitors
Group 1 given actual control over how long they saw pictures of car crash victims (+control +predictable)
Group 2 joined to group 1, warned how long pictures (60s) would be shown for and what noise would precede them (-control +predictability)
Group 3 Also joined to group 1 but told that from time to time they would see pictures and hear tones.
Psychophysiological responses collected by polygraph
Data converted from a voltmeter to printout
Each recording carried out in sound and electrically shielded room to make sure no audio or visual input from projector would interfere with data collection.
Heart monitors attached in standard positions, GSR electrodes placed between palm and forearm of pp's nonpreferred hand.
Results: Group 2 most stressed by tone. Group 1 least stressed by photographs. HR monitors provided inaccurate data, so discarded.
Likely that control decreases stress. Being able to terminate stressful stimuli reduces impact. GSR reliable measure of stress response. Work Johansson 1978 Aim: To measure psychological and physiological stress responses in two categories of employees
Sample: 24 workers at a Swedish sawmill, 14 high risk group (complex job, knowledge of raw materials, responsible for rate of finished objects completed, for own and team wages) 10 control group (cleaners or maintenance workers)
Method: Daily urine samples, upon arrival at work and three other times throughout day to measure adrenalin levels, body temp measured at same time and self-report of mood (sleepiness, well-being, irritation, efficiency), alertness and consumption of nicotine and caffeine on minimum to maximum millimeter scale. Baseline measurements taken at same time on a day when workers were at home
Results: First urine sample of day, high risk group had twice as high adrenalin levels as baseline, continued to increase throughout the day. Control group 1.5 times baseline, decreased throughout day. Self-report showed high risk group felt more irritated and rushed, and lower sense of well-being than control group.
Conclusion: repetitive, machine paced work, demanding attention and detail and highly mechanized contributed to higher stress in risk group. Personality Friedman and Rosenman 1974 Aim: To research links between personality factors, stress and CHD
Sample: 3000 healthy men 39-59
Method: Longitudinal study (9 years) men assessed to determine personality type then followed through. Two roughly equal groups:
Type A: time urgency, competitive-achievement orientation, anger/hostility, vigorous vocal style
Non-Type A (Type B): Low levels of competitiveness, time urgency, hostility--easy going and philosophical about life, give and take in conversation
Findings: 70% of the men who died during study were Type A, Type A twice as likely to develop and die of CHD
Conclusion: Type A more susceptible to stress because of personality and behavioural traits so more likely to suffer stress-related illness like CHD
Criticism: personality is not a fixed factor, individual differences cannot be grouped into two such general groups, may behave differently in different situations, reductionist view, correlation is not the same as cause. Holmes and Rahe 1967 Life events Lazarus 1981 Daily Hassles Aim: To create a method that investigates the extent to which life events are stressors
Sample: opportunity, 179m, 215f, range of occupations, education, ethnic groups, religion
Method: asked to rate 43 life events empirically derived from clinical experience on average degree of re-adjustment each necessitates
Social re-adjustment includes amount of change in one's accustomed pattern of life resulting from various life events. It measures intensity and length of time necessary to accomodate life event regardless of its desirability. First event (marriage) given arbitrary value of 500, asked to judge if events require more or less re-adjustment and more or less time to re-adjust and thus score events.
Results: responses of diff groups of people in startling agreement, correlation>0.9 except for correlation between white and black (0.82)
Evaluation: A number of studies by Holmes and Rahe in particular show correlation between high ratings and subsequent illness, but Sarafino claims correlation is only 0.3 so not much. Problems with scale--not all people experience all events, no. of events experienced increase with education and decrease with age from early adulthood to old age. Items are vague/ambiguous, some have greater value for some groups than others. Individual differences in coping if not in stress appraisal. No difference between positive and negative events. No account of degree of certain event (how big a change in responsibilities, how much trouble with boss, etc) Aim: To compare hassles and uplift scale and Berkman Life Events Scale as predictors of psychological symptoms of stress
Sample: 100 people who had previously completed a survey on health in 1965, Californians, mostly white, protestant, middle class, education up to ninth grade
method: all tests sent out by post one month before study began, pps asked to do hassles scale every month for nine months, then life events scale after 10 months, the hopkins symptoms checklist and bradburn moral scale every month for nine months
Results: hassles consistent from month to month. For men, hassles positively correlated with life events and uplifts negatively with life events. Women, hassles and uplifts both correlated positively with life events. Hassle frequency correlates to psychological symptoms on HSCL
Conclusion: Hassles more powerful predictor of psychological symptoms than life events. Hassles contribute to psychological symptoms of stress no matter what life events happen. Stress Management Budzinsky 1973 Biofeedback Bridge 1988 Imagery Meichenbaum 1985 Preventing Stress Aim: To investigate the efficacy of biofeedback in reducing tension headaches
Sample: Self-select pps via advertisement
Procedure: Three experimental groups, A: biofeedback+relaxation, B: relaxation techniques only, C: waiting list control
Biofeedback is a technique in which an electromechanical device monitors the status of a person's physiological processes and immediately reports that information back to the individual. The information enables the person to gain voluntary control over these processes through operant conidtioning.
Group A given biofeedback on muscle tension in thier foreheads using EMG
All patients completed psychometric test of depression and questionnaire on their headaches.
Results: Group A showed much less muscle tension and fewer headaches than B by end of training. Psychometric test showed reduction in depression for all groups, but A showed decrease in hypochondriasis as well
Conclusion: biofeedback effective training technique for stress management. relaxation techniques work better than just monitoring
Overcame ethical concerns of not giving all patients best possible treatment by offering therapy later to all. Aim: To investigate the efficacy of imagery in reducing the unpleasant emotional consequences of radiotherapy for women with breast cancer
Method: women allocated to one of three groups. 1: physical relaxation training, particularly control of muscle tension and breathing, 2: physical relaxation training as well as mental imagery (asking each person to concentrate on a peaceful scene of her own choice), 3: control group, encouraged to meet and simply talk about selves for same amount of time as treatment groups
Assessed women's moods using standard psychometric tests
Result: Women in treatment groups significantly less disturbed than control group, but group 2 more relaxed than 1. Aim: to compare Stress Inoculation Training with behavioural systematic desensitization
Participants: 42 students in experimental groups, wait list control group in addition
Method: 21 students allocated to each therapy group, SIT and systematic desensitization. Blind assessed via self-report anxiety adjective checklist and grade averages.
SIT: designed to help prepare people for stress and develop skills to cope with that stress
Conceptualization: trainer talks with patient about their stress responses and patient learns to identify and express feelings and fears. Patient is also educated in lay terms about stress and the effect it can have
Skill acquisition and rehearsal: patient learns basic behavioural and cognitive skills that will be useful for coping with stressful situations, e.g. relax and use self-regulatory skills. Practice under supervision
Application and follow through: trainer guides patient through a series of progressively more threatening situations. Patient given a wide range of possible stressors to prepare for real life
Results: Both therapy groups showed improvement but SIT group performed better on tests. Methods of Health Promotion Janis and Feshbach 1953
Fear Appeals Lewin 1992 Providing Information (secondary prevention) Aim: to study the motivational effects of fear arousal in health promotion
Sample: entire freshman year of large Connecticut high school, avg 15 years
Method: Prepared 3 15-min illustrated lectures on dangers of tooth decay and need for good oral hygiene, with recorded talks
Fear appeal: persuasive message that emphasises the harmful physical/social consequences of failing to comply with the recommendations of the message
Strong fear appeal: emphasised painful consequences of tooth decay, diseased gums and other dangers such as cancer and blindness that can result from poor oral hygiene. Used pictures of diseased mouths
Moderate fear appeal: described same dangers but in less dramatic way with less disturbing pictures
Minimal: talked about decayed teeth and cavities but did not refer to the serious consequences mentioned in other groups, used diagrams and x-rays instead of photos
Results: strong fear appeal created most anxiety and rated as more interesting, pictures for this talk received higher rating than pictures in other 2, but also received high negative ratings with 1/3 students saying pictures were too unpleasant. Interviews with students to discover oral hygiene habits and conformity scores to show how much they had changed their behaviour to follow the advice of the talk found that minimal fear appeal created greatest increase in conformity (36%) and Strong least (8%). See adherence study above
Patients empowered to understand their condition and take ownership of their health goals, in turn increasing their likelihood of individual achievement through active self-management
Addresses patient misconceptions and provides information on secondary prevention activity, exercise, goal setting and stress management. Uses written information, audio CDs and phone calls. Schools, Workplaces and Community Three Community Study Farquhar 1977 Worksite Gomel 1983 School Tapper 2003 Aim: To promote health behaviours to reduce heart disease
Sample: Residents from 3 cities in USA
Procedure: City 1-promotion of behaviours to reduce heart disease including bilingual (Eng&Spanish) mass media campaign, school based health education and screening programs in the workplace to provide early warning
City 2-1+group counselling for (100+) high risk ppl identified and their spouses on dietary change, exercise, smoking, weight loss employing behav modification techniques from health counselor and dietitian--nine sessions, 1.5-3.5h each
City 3-No intervention control
Media campaign via TV, radio, newspapers, posters and mailshots
Focus on reduced cholestrol and saturated fat consumption, increased polyunsaturated fat consumption--cookbooks, information booklets, newspaper columns by doc and dietitian
Several hundreds of people 35-60 yrs screened
Residents interviewed before, during and after 2yr project
Researchers assessed health knowledge and risk of heart disease
Findings: for 3, risk factors increased. 1&2 risk factors decreased. 1&2 increase in health knowledge. 2 increase in health behaviour. Intervention particularly helpful for minority groups.
Mass media campaign produces only small changes in behav but can act as cue for positive action if further encouragement offered Aim: To evaluate efficacy of four worksite health promotion programs, the efficacy of behavioural counseling vs screening and education in reducing cardiovascular risk factors
Factors: smoking, serum cholestrol, high b.p., physical inactivity and overweight
Sample: 28 ambulance service stations from different regions of Sydney metropolitan area. 431 pps
Method: Each station assigned to one program:
1-health risk assessment (screening and feedback 30min)
2-1+risk factor education (standardized advice on life-style changes required to reduce risk factors to those screened positive, general educational resource manual and videotapes provided. 30+50m)
3-2+behaioural counseling (6 lifestyle counselling sessions over 10 weeks, self-instructional life-style change manual w/programs for modifying risk factors, counseling and modeling based on stages of change model of behav (preparation, action, maintenance and relaps prevention)--reasons for and barriers to change, identifying behav contributing to risk factors, high-risk situations and coping strategies, short and long-term goals determined, positive effects of behav change. Ongoing assessment and feedback on risk factor status. 2h50)
4-3+incentives (lifestyle changes, meeting 3 and 6 month goals and station w/largest % meeting 6 month goals--lottery tickets and cash 2h30min)
Biochemical and physical measures to validate self-report behav changes
workplace steering committee with representatives drawn from management, unions and research team oversaw implementation
Results: BMI increased for all, but lowest increase for 3&4
%body fat over 12 months same, but 3&4 showed decrease then increase back to baseline
No sig change for cholestrol
Sig avg decrease for BP overall for 3, short-term decrease then return to baseline in 4
Sig increase then return to baseline for aerobic capacity
Sig higher % in 3&4 stopped smoking at 3 months, but not after--7% stopped at 12 mo (3&4), 0% from 1&2
Behaviour counseling produced larger changes but largely short term Aim: To increase fruit and vegetable consumption in school children by school health promotion campaign
Sample: 3 schools in England
Method: largely implemented by school staff
Food Dude videos with 6 6min adventure episodes
videomodelling component used animated characters "Jess and Jarvis
Set of Food Dude rewards
Set of letters from Food Dudes providing praise, encouragement and reminders of reward contingencies
Food Dude home package to encourage continued healthy eating at home
Staff manual and briefing video
set of educational support material to help teachers meet curriculum targets using Food Dude theme
Main intervention 15 days--watch videos, listen to teachers read out letters and receive rewards (sticker for tasting food, small prize for whole portion)
Maintenance phase--no videos, letters and rewards become more intermittent
Intervention introduced at snacktime first for fruit, then veggies
Levels of fruit and veg consumption recorded at lunchtime--never any rewards or videos at lunch
Results: statistically sig increases in consumption at snack and lunch for girls and boys 4-11 yrs old
Parents from one school reported sig increase in portions consumed on weekdays
4 month follow up showed continued effects
Positive feedback from teachers and parents
Worked because of discovery of intrinsically rewarding properties of fruits and veggies and develop liking for them--taste repeatedly, then eat for taste even when no rewards; culture within school changes to supportive of fruit and veg consumption--social reinforcement from peer group--guided by self-concept of 'i always eat my fruit' Definitions, Causes and Examples of Accidents Accident Proneness and Personality Reducing Accidents and Promoting Safety Behaviours Individual and System errors Three Mile Island 1979 Nuclear meltdown, USA
Maintenance crew introduces water into instrument air system
had happened twice but operating company took no prevention steps
Turbine tripped. Feedwater pumps shut down. Emergency pumps turn on automatically but flow blocked by 2 valves mistakenly left closed during maintenance 2 days ago
Maintenance tag obscured warning light showing valves closed
Rapid rise in core temp and pressure, causing reactor to rip. Relief valve opens automatically but sticks in open position. Loss of coolant accident imminent
Analyses of similar incidents not collated and information obtained regarding appropriate operator action not communicated to industry
Operators fail to realize relief valve stuck open. Primary cooling system has hole in it through which radioactive water under high pressure pours into containment area & into basement
Operators misled by control panel indicators--showed whether valve had been commanded shut, not actual valve status
Design and Management failure
Operators wrongly assumed high temp at drain pipe was due to chronically leaky valve
pipe normally registered high temp
Operators failed to daignose open relief valve for >2h. Resultant water loss caused significant damage to reactor.
Control panel poorly designed with hundreds of alarms not organized in logical fasion--many key indicators on back wall of control room. More than 100 alarms were activated with no means of suppressing unimportant ones
Several instruments went off scale
printer ran more than 2h behind events
Design and management failure
Operator training consisted mainly of lectures and work in reactor simulator with little training for coping with real emergencies--not much feedback given, insufficient evaluation
Training and management failure
Crew cut back high pressure injection (HPI) of water into reactor coolant system, reducing flow rate. Throttling caused serious core damage.
Training emphasized dangers of flooding core but didn't consider possible concurrent loss of coolant accident
Training and management failure
Nuclear regulatory commission issued a publication after a previous incident making no mention of operators interrupting HPI--incident had appeared under valve malfunction not operator error
Regulatory failure Riggio 1990
Human Error Barber 1988 Cognitive Overload Titanic
Illusion of Invulnerability By 1900 ships no longer getting lost at sea; big ships=illusion of invulnerability from natural hazards
Titanic huge ship--size of 11-story building, over 45,000 tons
Captain so confident that he ignored several iceberg warnings from other ships, though warnings increased in frequency
Outdated shipping regulations meant lifeboats for only half passangers
More lifeboats vetoed in cost-cutting measure
White Star publicity flacks labeled ship virtually unsinkable because of several safety features, e.g. watertight compartments
In the end, watertight compartments useless because too many were damaged--water simply flowed in from one to the other
Warnings of icebergs ignored till crow's nest reported large iceberg 500yards in front of ship when ship was steaming at fastest speed yet of voyage
when passengers ordered into lifeboats, many ignored orders--didn't know what the fuss was about
many lifeboats went away half empty
ship close by ignored distress signals--radio operator and captain had gone to bed an deck officers didn't realize something amiss
From that time onward:
commercial liners had to have enough lifeboats
class distinctions not to be factor in evacuation
shipboard wireless rooms operational 24x7
Atlantic sea lanes moved farther south
international ice patrol Selective attention highlights limitations in our ability to process information
Aircraft accident in area of then Yugoslavia
British airways Trident collided with a DC-9 of Inex Adria airways
Air traffic controller responsible for sector planes where flying in experienced cog overload
At time of accident, assistant missing
11 aircraft in sector, in simultaneous communication with four other aircraft
And taking part in phone conversation with Belgrade regarding 2 further aircraft
Controller had very short notice of arrival of DC-9 into sector
Overload of too much information+short notice=oversight
Prosecuted and jailed. Errors of omission--failure to carry out a task
Errors of commission--making an incorrect action
Timing--too quickly or too slowly
Sequence--doing things in the wrong order Fox 1987
Token Economy Cowpe 1989
Media Campaign 2 open cast pits in USA studied for 12 years
Workers divided into hazard groups based on number of lost time injuries reported during baseline period for people holding specific jobs.
Employees earned stamps for working without time lost for injuries, for being in work groups in which no one lost time due to injury, for not being involved in equipment damage, for making safety suggestions and for behaviour that prevented injury or accident.
Lost stamps for equipment damage, injuries to work group, failure to report accidents and injuries.
Tokens could be exchanged for a selection of thousands of items at redemption stores.
Produced dramatic reduction in days lost through injury and reduced costs of accidents and injuries. Improvement maintained over a number of years.
Reduction in costs far exceeded costs of operating the token economy. Possible to estimate changes in behaviour by comparing accident rates before and after ad campaigns
Discrepancy between attitudes and behaviours
Aim: to investigate effectiveness of series of ads about dangers of chip pan fires
Before ads, people knew about hazards, most claimed they always adopt safe practices
Statistics from fire brigades about frequency of chip pan fires and descriptions by people of what they should do suggested behav not as safe as they thought
TV ad campaign developed and broadcast showing dramatic images of how fires develop and how to deal with them
ads ended with simple statement, e.g. "Of course, if you don't overfill your chip pan in the first place, you won't have to do any of this"
Compared fire brigade statistics for areas with ads to other areas.
Ads produced up to 25% reduction in some areas, overall 12% reduction in chip pan fires
Surveys before and after showed increase in knowledge of how to deal with fire.
Public info films/health promo ads most effective if they contain information about what to do rather than what to think or be scared of (self-efficacy vs learned helplessness) Aim: