Health Psych Week 6

Language Barriers to Effective Communication

-19% of the US pop speaks language other than English at home, and more than 22 million people have liited English proficiency -Language barriers is a formidable problem. Not enough interpreters available who can address this problem, and physicians cultural competency (their ability and comfort with dealing with patients from other backgrounds) may be low -Patients who experience langauge problems are less adherent to treatment, less likely to have a regular source of care, and more likely to leave the hospital against medical advice -Language barriers contribute to communication problems

Employment

-45% of health psychologists go into academic settings or teach in medical schools -In academic positions, health psychologists are responsible for educating undergraduate and graduate studnets, physicians, nurses, and other health care workers. Most also conduct research to uncover the factors associated with the maintenance of health and the onset of illness -About 35% of health psychologists work with medical patients in a hospital or another treatment setting -About 28% are involved in private practice, in which they provide therapy and other mental health services to people with medically related problems -The short-term cognitive-behavioral interventions that work well in modifying health habits, controlling pain, managing side effects of treatments, and the like represent the kind of activities that health psychologists in these settings undertake -Health psychologists are increasingly employed in the workplace or as consultants to the workplace. They advise employers attempting to set up new health care systems about what kind of system will provide the best care for the least money. Ex. establish work-site interventions to teach employees how to manage stress, they set up exercise programs, or they establish work-site competittions to help overweight employees lose weight -Health Psychologists deliver a wide range of services to an ever-growing and diverse group of employers -Number of health psychologists in US and other places is growing rapidly. Since the beginning of the field (approx. 30 years ago), the number of health psychology training programs in the country has also grown exponentially. Health psychologists have provene vital to medical research and health services delivery in this country -What do health psychologists do? -57.1% research -58.6% education -71.5% health/mental health services -20.9% educational services -20.4% management/administration -36.6% other

Interactive Aspects of the Communication Problem

-A major problem is that the patient-provider interaction does not provide the opportunity for feedback to the provider. When patient does not return after diagnosis, a number of things might have happened: 1. the treatment may have cured the disorder 2. the patient may have gotten worse and decided to seek treatment elsewhere 3. the treatment may have failed, but the disorder may have cleared up anyway 4. patient may have died -Not knowing which occured, provider doesn't know the impact and success rate of the advice given . It is to the providers psychological advantage to believe that the diagnosis was correct and the patient followed advice and were cured -Provider may also find it hard to know whether a satisfactory personal relationship has been established with a patient. If patients are dissatisfied, they simply change providers instead of directly talk about it. -When providers do get feedback, it is more likely negative than positive: patients whose treatments have failed are more likely to go back than are patients whose treatments are successful -Important points: 1. learning is fostered more by positive than negative feedback; positive feedback tells someone what they're doing right, whereas negative feedback tells one what to stop doing but not necessarily what to do instead. Bc providers get more negative feedback than positive, this situation is not conductive to learning 2. learning occurs only with feedbacl, but in the provider's case, lack of feedback is the rule. It's hard for the provider to know whether communication is adequate and if not how to change it

Health Promotion as a Park of Medical Practice

-A true philosophy of health promotion cannot be adequately implemented until a focus on health promotion becomes an intrgral part of medical practice -There is no process for identifying and targeting preventive health behaviors on an individual basis. If the annual physical would include a simple review of the particular health issues and habits, it could alert us to the health goals we should consider and might prod us in the direction of taking necessary action -Physicians are high in status and are persuasive when other agents aren't -A 28 year old man in a high-stress occupation might be urged by his health care practitioner to practice stress management and be given a self-help programs for stopping smoking -In the future, we might see practicing physicians integrate prevention into their daily practice with their healthy patients as well as their ill ones

Nonadherence to Treatment Regimens

-Adherence to tratment regimens in the contect of health behaviors and noted how difficult it can be to modify and eliminate poor health habits, such as smoking, or to achieve a healthy lifestyle -Adherence: The degree to which an individual follows a recommended health-related or illness-related recommendation

Recent Promising Findings

-American Legacy Foundation's truth anti-smoking campaign for youth from 2000 to 2002 -Costs $100 Million per year with paid media ads based upon effective truth campaigns in FL, CA, & MA -Truth ads were hard hitting to reveal deceptive marketing by tobacco industry -E.g., promoted only glamour of use and ignored multiple causes of death, nicotine addiction, and targeting teens to replace dying adults e truth® campaign is now considered one of the most successful public health campaigns in U.S. history. One reason it appealed to adolescents so well is that it abandoned the old (and useless) approach of telling them what they should and should not do. Instead, it told viewers that the tobacco industry executives saw them as suckers and easy to manipulate through cigarette advertising. What kind of teenager do you know that enjoys being labeled as a sucker and unable to make decisions for themselves? This campaign tapped right into the developmental stage of mild rebellion in adolescents to activate behavior change in the other direction.

Systematic Documentation of Cost Effectiveness and Treatment Effectiveness

-An important professiona goal of health psychology is the continued documentation of the treatment effectiveness of our interventions -Debate rages over whether and to what degree behavioral and psychological interventions should be covered in managed health care systems -Cost Containment: the effort to reduce or hold down health care costs -Cost containment pressures have promoted the development of interventions that are time limited, symptom focused, and offered on an outpatient basis, a format that is not always conductive to change through behavioral intervention -This trend has been accompanied by a shift in treatment decision-making power from behavioral health care providers to policy makers -The pressures of cost containment push health psychology in the direction of research that is designed to keep people out of the health care system altogether -On the clinical practice side, interventions include self-help groups, peer counseling, self-managment programs, and other inexpensive ways to provide services to those who might otherwise not receive care. -Writing about intensely traumatic or stressful events is also a low-cost, easily iplemended intervention that has demonstrated beneficial effects -A lack of data regarding treatment outcomes and efficacy represents a striking gap in how behavioral scientists and practitioners present their interventions to policy makers. Gap occurs in part bc behavioral scientists fail to recognize or document the treatment implications of their work and bc practitioners may lack the interest or expertise to conduct the formal scientific investigations that would make the scientific care for their interventions -Evidence-based Medicine: the conscientious, explicit, judicious use of the best scienftific evidence for making decisions about the care of individual patients; the criterion for adopting medical standards -This trend means that, with the documentation fo he success of health psychology interventions, the potential for empirical evidence to contribute to practice is enhanced -Economic factors play a formidable role in the field of health psychology. On one hand, the field cannot afford to pursure its scientific and intervetion mission without regard to cost. On the other hand, cost containment issues can compromise scientific and intervention mssions of the field by prematurely choking off areas of inquiry that do not immediately appear to be cost-effective. The relative lack of attention to issues of rehabilitation, in contrast to to the heavy preponderance of reaserch in primary prevetnion activities, can be regarded as one casualty of these procedures -Ways to ensure that advances in health psychology can have an impact on patient caare and health care policy: --integration of health psychology into the medical curriculum --the development of departments of behavioral medicine within traditional medical schools --the integration of behavioral medicine into health care institutions, such as hospitals and clinics -Tying health psychology research more closely to clinical interventions and to health policy increases the likelihood that health psychology discoveries will have an impact

HMOs and Patient Care

-As efficiency and cost-cutting pressures have assumed increasing importance, and as physicians have been urged to avoid expensive tests and shorten hospital stays, evidence suggests that quality of care has eroded -The ill elderly and poor fares especially poorly in HMOs, compared with people in fee-for-service practices. -Bc fee-for-service practices allows patients a much broader choice of doctors and places fewer restrictions on services, their care is better -A study on HMOs saw that their care ranged from barely satisfactory to excellent, depending on the facility -Changes in the practice of medicine have led to a rise in negative attitudes toward physicians and medical practice. Clearly, managed care does not guarantee a higher standard of care -HMOs may undermine care in other ways: --being pressured to see as many patients as possible results in long waits and short visits --May be compounded if a patient is referred to several specialists, which may lead to another long wait and short care --Patients feel that they're being shunted from provider to provider with no continuity in their care and no opportunity to build up a personal relationship with one individual -Third-party mayment systemd adopt cost-saving strategies that may inadvertently restrict clients' choices of when and how they can receive medical services. Bc patients value choice, these restrictions contribute to dissatisfaction -Some HMOs have taken steps to reduce long waits, to allow for personal choice, and to make sure a patient sees the same provider at each visit. However, then chaning structure of medical practice generally may undermind emotional satisfaction and does not gaurantee a high standard of care

The Changing Nature of Medical Practice

-As the population has aged, the significance of diseases of aging has increased, such as the morbidity and mortality due to prostate cancer -The physical environment pses unprecendented challenges. Ex. current levels of air collution have chronic negative effects on lung development in children, leading to risks not only in childhood but adulthood as well -Climate change affects patterns of illness. Ex. tropical diseases such as malaria and diarrheal disorders are increasing in frequncey and spreading north -The face of health psychology may change as patterns of infectious disease change. Infectious diseases are responsible for 13 million US deaths each year. -Changes in society, technology, and microorganisms themselves are leading to the emergence of new diseases, the reemergence of disease that were once controlled, and problems with drug-resistant strains of once-controlled disorders -How can health psychologists help? -Getting ppl to use antibiotics correctly and not to overuse them may help deter the rise of drug-resistant strains -Another example concerns the increasing availability of risk factor testing for identifying genes implicated in such diseases as Huntington's disease, breast cancer, and colon cancer -A handful of prescient health psychologists have begun to explore why some people fail to minimize their risk on learning that they may be vulnerable, as opposed to becoming more vigilant by taking effective preventive action or monitoring themselves more closely -Much of this is conducted in the laboratory on hypothetical risk factors, and more understanding of how people manage their actual risks is essential

The Case of Fear Appeals

-Assumes that if people are fearful that a habit is hurtful, they will change behavior to reduce that fear --Ex. Anti-smoking campaign in Australia -Mixed support with research -Eliciting too much fear may undermind efforts -Need to include recommendations for action or information about making changes I want to speak briefly again on fear appeals as they are used often in trying to reduce negative health behaviors (e.g., drug use, unsafe sex, etc.). The logic assumes that if we scare people enough about their behavior, it will motivate them to change it. This works for some people some of the time for some things, but rarely to the degree or impact we hope for in our efforts. Research consistently finds mixed results with some studies showing benefits, others neutral, and still others that actually increase negative behaviors. When they elicit too much fear, people often distrust the validity of the message and tune it out. Or, they become so anxious about the behavior that they give up hope of ever overcoming it. Lastly, most focus so much on the fear that they fail to provide concrete guidance on what people can actually do to change their behavior. Remember the Stages of Change Model introduced early in this course. Fear appeals might be useful in moving someone from the Precontemplation to Contemplation stages, but probably less useful in the Action or Maintenance stages.

Setting

-Average visit lasts only 12-15 minutes, and a physician will interrupt you before you get 23 seconds into your comments -It is difficult to present your complaints effectively when you are in pain or have a fever, and your ability to be articulate may be reduced further by anxiety or embarassment about the symptoms or the examination -The provider has the task to extract significant information as quickly as possible from the patients -The difficultie spresented by the patient may have been made more complex by the use of various over-the-counter remedies, which can mask and distort the symptoms -The patients ideas about what symptoms are imporant may not correspond to the provider's knowledge, and so important signs may be overlooked

Quality-of-Life Assessment

-Chief goal for health psychologists in the coming years should be to develop cost-effective interventions to improve quality of life -Initial assessment during the acute period is an important first step. Supplementing initial assessment with regular needs assessment over the long term can help identify potential problems, such as anxiety or depression, before they fully disrupt the patient's life and bring additional costs to the health care system -Psychological interventions need to be directed to depression and hostility bc they're important cofactors in illness -No intervention that fails to improve psychological functioning is likely to profoundly affect health or survival

The Nature of Patient-Provider Communication

-Criticisms of providers usually center on volumes of jargon, lack of feedback, and depersonalized care. -Poor patient-provider communication has been tied to outcomes as problematic as nonadherence to treatment recommendations and the initiation of malpractice litigation

Media Literacy

-Definition: process of accessing, analyzing, evaluating,a nd creativn messages in a wide variety of media modes, genres, and forms -If there was one class I would require for all U.S. undergraduate students, it would be one on media literacy. In addition to being a lot of fun to learn (and teach), I think it is one of the most valuable life skills since we spend much of our lives bombarded by media. Acquiring media literacy makes you a much better informed consumer and more resistant to the messages designed to influence your attitudes, beliefs, and purchasing behaviors!

Nonperson Treatment

-Depersonalization -May be employed intentionally to try to keep the patient quiet while an examination, a procedure, or a test is being conducted, or it may be used unintentionally bc the patient has become the focus of the provider's attention -If a patient could drop off their bodies as they do cars and pick them up later after the treatment, it would save the provider and patient a lot of trouble -The provider is like an auto mechanic who has the misfortune of having the car's owner follow him or her around, creating trouble, while they are trying to fix the car -May be employed at particularly stressful moments to keep the patient quiet and to enable the practitioner to concentrate. In this way, it may serve as a valuable medical function -Can have adverse medical effects. Medical staff may use either highly technical or euphemistic terms when discussing cases with their colleagues, which may confuse or alarm the nonparticipating but physically present patient, an effort to which the provider may be oblivious -Patient depersonalization also provides emotional protection for the provider. It's hard for a doctor to work realizing that every disease they make could affect someones health, and they need to find a way to deal when a patient dies. Depersonalization provides a way to cope -The emotion and empathy communicated by a provider in interaction with a patient can affect patient's attitude toward the provider, the visit, and his or her condition -Study: women getting mammogram results from a seemingly worried physician recalled less information, perceived their situation to be more severe, showed higher levels of anxiety, and had significantly higher pulse rates than women receiving mammorgram results form a nonworried physician -When there is a mismatch between patient expectations regarding sharing of information, involvement in treatment, and socioemotional support, satisfaction with care is lower

Dr.McKelley's Shin Ramyun Soup for the Sick Soul

-Dry cleaning shirts, mr and mrs yung -Gave super hot ramen noodles and within 2 days her cold was gone

Postgraduate Work

-Either go to job market or get additional training inthe form of postdoctoral research -Many psychologists choose to acquire postdoctoral training bc health psychology training is not uniform across universities. Identifying gaps in your training reveals the type of postdoctoral training you should seek out -Postdoctoral training is undertaken at a laboratory different from the place at which you completed your Ph.D., and takes place under the guidance of a senior scientist whose worl you admire. May spend up to 3 years in this person's lab, after which you shoulf be ready to go on the job market

Malpractice Litigation

-Exploded in recent decades -Some of this malpractice litigation can be tied to increases in the technical complexity of medicine. The overuse of new and complex machinery can lead to patient harm, either because the treatment is not necessary or because the side effects of the technology are not known. -1999 report by the Institute of Medicine estimated that between 48000 and 98000 errors occur every year and that most of these are medication errors, such as prescribing the wrong drug or wrong dosage. -Malpractice litigation has also been tied to the administrative complexity of the health care system. Patients may be unwilling to sue an individual physician, but if they can sue an in institution and convince themselves that the settlement money will never be missed, they're more likely to sue -The most common grounds for malpractice suit are incompetence and negligence, but patients are increasingly citing factors related to poor communication as a basis for their suits, such as not being informed of the treatment. -More suits were initiated against physicians who were fearful of patients, insecure with them, or derogatory towards them -When patients felt that their medical complains had been ignored or rudely dismissed, they were more likely to file suit, perhaps as retaliations. According to a health care negotiator, patients are seeking three things when a medical mistake has occurred: 1. they want to find out what happened 2. they want an apology from the doctor or hospital 3. they want to know that the mistake will not happen again -Study: 958 members of an HMO were given a fictitious situation involving a doctor who made a a mistake with varying consequences and then disclosed it with varying degrees of candor. In soe cases, the doctor apologized unreservedly, whereas in other cases the doctor was more evasive. Patients were then asked what they thought they would do in response to such a circumstance- stay with the doctor, change doctors, or talk with an attorney. On the whole, the physician was viewed more favorably when they admitted to making the mistake -The longterm fallout from the escalating frequency and costs of malpractice suits is that many physicians have had to change the way they conduct their practices, and some have had to leave medicine altogether.

Promoting Resilience

-Future health promotions should place greater weight on positive factors that may reduce morbidity or helay mortality -W.J. McGuire: Health psychologists could make a giant leap forward by going after this health-related factor and opening a marriage bureau --This is bc eliminating cancer= lengthen lives but marriage would add several years to a man's life -Studying how some peoeple spontaneously reduce their levels of stress, for ex., and how they seek out opportunities for rest, renewal, and relaxation may provide knowledge for effective interventions -Personal resources, such as optimism or a sense of control, have proven to be protective againt chronic illness -Research has found that these can be taught

Good Communication

-Good communication fosters adherence -Much nonadherence occurs bc the patient does not understand what the treatment regimen is -Adherence is highest when the patient receives a clear, jargon-free explanation of the etiology, diagnosis, and treatment recommendations. Also enhanced by factors that promote good learning: adherence is higher is the patient has beena sked to repeat the instructions, if the instructions are written down, if unclear recommendations are pointed out and clarified, and if the instructions are repeated more than once -Satsifaction with the patient-provider relationship predicts adherence. When patients percieve the provider as warm and caring, they are more compliant. Providers who answer patients' questions have more adherent patients. Providers who show anger or impatience toward their patient, or who just seem busy, have more nonadherent patients -Final step of adherence involves the patient's decision to adhere to a prescribed medical regimen. Many providers simply assume that patients will follow their adivce, without realizing that the patients must decide to do so

Health Service

-Health care reform is one of the most urgent issues facing the US. -US healthcare system is marked by at least three basic problems: health care costs too much; the system is grossly inequitable; favoring the wealthy over the poor; and health care consumers use health care services inappropriately

Legal System

-High rate of malpractice suits --Mixed research on direct effects --Ex. in 2009, highest rates of insurance in Nevada for OB/GYNs ---Make pay between 85000 to 142000 per year although average annual salary for such doctors is around 180000 ---increased cost of healthcare of all parties -Deterrent to try CAM intervention -I won't spend too much time discussing how the legal system impacts provider-patient communication because it is a very complex topic beyond the scope of this course. However, I feel strongly about helping students understand the relationship between living in a litigious society like the U.S., and the sometimes unintended consequences it can have on our behavior. There is mixed research out there on the role of malpractice suits on the cost of healthcare. Some studies show that it adds significantly to our costs due to frivolous claims and high damages for pain/suffering; others suggest it lowers cost by keeping healthcare providers in check by limiting their scope of practice. Many of you (self included) fail to appreciate the cost of malpractice insurance on healthcare providers. It varies by state and by area of practice, but I want to use OB/GYNs as an example. I know some who have dropped or are thinking of dropping their obstetrics practices and focusing only on gynecology. Even though they would make less by doing only gynecology, they also pay much less for insurance and have significantly less stress. Parents go crazy with their babies, and as a parent I can understand. The malpractice rate with obstetrics is one of the highest. If/when something goes wrong during pregnancy or childbirth, heartbroken parent(s) want someone to blame. Pregnancy has ALWAYS been a high risk part of the human experience. Most procedures carry some degree of risk to a fetus or mother. But instead of acknowledging the statistical possibility of things going wrong, we sometimes sue providers for negligence as a way to help deal with the pain of injury or death to our children. The cost of legal proceedings (whether or not the patient's case is "won") add to the total cost of healthcare, and can influence the decisions that some providers make during treatment and intervention. Ironically, the threat of malpractice can sometimes result in patients getting less than ideal care because it can prevent providers from trying CAM treatments that might actually work. It's been heartening to see all of the research going in to CAM treatments over the years as they become an additional part of American healthcare. But progress can sometimes get slowed down since the risk and fear of malpractice can influence a decision to try something new (even if it has been widely used in other cultures' formal medical treatment).

African-American and African Immigrant Culture

-Historically largest US minority -22% live in pverty and life expectancy 5.9 years less --2x stroke death, 36% w/ hypertension vs <25% Whites -Caribbean and African *immigrants have better life expectancies than native* blacks -Mistrust of institutions sometimes historically justified --E.g., Tuskegee syphilis experiments On these next slides I am going to highlight some major themes in healthcare issues specific to some cultural subgroups in the U.S. They are not meant to apply to everyone in that culture, nor do they represent all of the potential issues to consider. There are significant health discrepancies between European-Americans and African-Americans in the U.S. Much of that can be explained by correlations with socio-economic disparities and systemic bias/discrimination; however, some cardiovascular differences have a biological explanation. Some of you have heard of sickle cell anemia, a red blood cell disorder that results from RBCs having an elongated (instead of circular) shape in some racial/ethnic groups. Interestingly, this shape is a protective factor against malaria, and is found in higher rates among equatorial cultures (Africa among them). Having that shape with the right diet and lifestyle doesn't significantly increase one's risk of CV problems. However, people of African decent living in the U.S. have access to diets high in fat/cholesterol, and a much more sedentary lifestyle than comparable groups in African countries. Sickle shaped RBCs do not flow smoothly through clogged arteries; therefore, people of African descent living in the U.S. are at a much higher risk for hypertension and other CV disease. In other words, the traditional American diet and lifestyle can be a high-risk environment. But this isn't the entire picture. Interestingly, Caribbean and African immigrants who move to the U.S. have better health outcomes and life expectancies than native blacks born in the U.S. even if exposed to the same diet. What's happening here? After controlling for those factors, some research suggests that blacks born in the U.S. experience significantly more stress related to racism, discrimination, etc. Chronic exposure to that kind of stress takes its toll on our body systems. In contrast, Caribbean and Africans are in the majority in their cultures of origin, and many of them haven't personally experienced some of the events that African-Americans have from an early age. Lastly, one barrier for more African-Americans accessing U.S. healthcare services stems from distrust of government institutions. Some of you might recall the Tuskegee syphilis experiments where the U.S. government deliberately withheld antibiotic treatment from a sample of African-American men to study the disease progression. They told the men that they were receiving free health care and did not tell them they were infected. This controversial study is one of the reasons they formed Institutional Review Boards (IRBs) to protect human participants in research studies. While there is some debate about the influence of this study on African-Americans' willingness to seek medical help, there are other similar historical events that add to mistrust.

The Holistic Heath Movement and Health Care

-Holistic health: the idea that health is a postivie state to be actively achieved, not merely the absense of disease -This viewpoint acknowledges psychological and spiritual influences on achieving health, and it gives patients responsiblity for both achieving health and curing illness through their behaviors, attitudes, and spiritual beliefs -It emphasizes health education, self-help, and self-healing. Natural, low-technology interventions and non-Western techniques of medical practice may be substituted for traditional care and include herbal medicine, acupuncture, acupressure, massage, psychic diagnosis, spiritual healing, the laying on of hands, and dance therapy -These changes alter the relationship between provider and patient, making it more open, equal, and reciprocal and potentially bringing emotional contact into the relationship

Giving Bad News

-In many cultures, customary to *first inform family* and let them decide if/when patient should be informed -Violated US HIPAA regulations -At least in US, *ask patient how s/he would like family involved* -Explain to family that informing patient first is standard US practice HIPAA regulations in the U.S. are in place to protect patients' health information and privacy. With the exception of minors, HIPAA regulations require that practitioners share medical news directly with patients. This is not the case in some cultures where it is customary to first share the news with family members. You can demonstrate cultural competence by educating ALL patients and their families about how HIPAA works, and to have a discussion about how best to communicate health results and procedures in a way that protects your liability and respects the wishes of the patient and family.

Refocusing Health Promotion Efforts

-In the past, we've stress mortality over morbility -There will always be 10 major causes of death, so refocusing effort toward morbidity is important for a number of reasons 1. Cost. Chronic diseases are expensive to treat. Rheumatoid arthritis and osteoarthritis have little impact on mortality but have a major impact on the functioning and well-being of the pop. Keeping people healthy for as long as possible will help reduce the burden of chronic illness costs 2. Maximizing the number of good years during which a person is free from the burdens of chronic illness produces a higher quality of life -Priorities for the future include developing interventions that can address more than one behaviroal risk factor at a time, addressing the difficult issue of continues maintenance, and integrating individual-level interventions into the broader environmental and health policies that support and sustain individual efforts

Provider Behaviors that Contribute to Faulty Communication

-Inattentiveness -Use of Jargon -Baby Talk -Nonperson Treatment -Stereotypes of Patients

Inattentiveness

-Inattentiveness= not listening. Patients typically dont have the opportunity to finish their explanation of concerns before the provider begins the process of diagnosis -Study: 69% of the visits, the physician interrupted, directing the patient toward a particular disorder. This pattern prevents patients form discussing their concerns and may also lead ro loss of important information. -And stat may be even higher bc the doctors in the study knew they were being recorded -Physicians are also interrupted a lot by other people, which frustrates the patient and can undermine communication further

SES and Health Disparities

-Individual health behavior changes alone may not substantially improve the heatlh of the general population. What is needed is individual change coupled with social change -US spends more on health care than any country in the world, and yet we're neither the longest life expectancy or the lowest infant mortality rate -US is 15 out of 19 (near the bottom). Many people live in intrinsically unhealthy environments -Efforts to postpone morbidity and disability into the last years of life will be unsuccessful without attention to our country's and the world's large socioeconomic disparities in health and health care -The US is the last industrialized nation to move toward universal health care -47 million people are without health insurance, and hundreds of millions more have difficulty paying their health care bills -US also only country where health care for most people is financed by for-profit, minimally regulared private insurance companies -Being born into low social class bring more stressors of all kind which takes a cumulative toll on health. Lower income and educational and occupational attainment lead to exposure to a borad array of stressors including inadequate housing, violence, danger, lack of vital good and services, inadequate medical facilities, poor sanitation, and exposure to environmental pollutants and numerous other hazards. -Ppl with higher income and educational attainment have many psychosocial resources and a lower risk of illnesses and disabilities across the life span. These disparities have barely declines -Effect of low socioeconomic status on health is true for both men and women, at all age levels and across most countries of the world --Risk factors tied to low ses: alcohol consumption, high levels of lipids, obesity, tobacco use, and fewer psychosocial resources such as a sense of mastery, self-esteem, and social support -Low SES is linked to a higher incidence of chronic illness, a heightened risk of low-birth-weight babies and infant mortality, and a heightened risk of accidents among numercous other causes of death and disability. Overwhelming majority of diseases and disorders show an SES gradient, with poor ppl experiencing greater risk -Even among diseases equally likely to low and high SES like breast cancer, mortality is earier among the more disadvantaged -Interventions targeted specifically to low-SES individuals to modify irsk factors aossciated with social class, such as smoking, drug use, alcohol consumption, and diet, as well as those targeted to more generalized risk factors such as poor education need to assume very high priority -African Americans have poorer health at all ages, as well as higher levels of depression, hostility, anxiety, and other emotional risk factors for chronic disease. The life expectancy gap between African Americans and Whites remina high, at a more than 5-year difference. AA also have a higher infant mortality rate than Whites and higher rates of most chronic diseases and disorders, with racial differences especially dramatic for hypertension, HIV, diabetes, and trauma -The differences are due in part bc AA are often in low SES, so they are disproportionately subject to the stressors that accompany low SES, but some stressors are due to racism -More than 18% of the pop has no health insurance, and this gap disproportionately affects the poor. -Medicade was designed to help the poor but now families at poverty-level incomes are not eligible for benefits -Costs of health care continues to increase. Between 2000 and 2006, health care expenditures per person increased by 46% -We currently have a two-tiered medical system: high-quality and high-technology care go to the well-to-do and not to the poor. -Unless the health care available to the poorer segments of society begins to match that available to the wealthier segments, morbidity may not be significantly reduced by intervention efforts

A Focus on Those At Risk

-Individuals who are identified early as at risk for particular disorders need to learn how to cope with their risk status and how to changetheir modifable risk-relevant behaviors. Health psych can aid in both -ppl who are at risk for particular disorders are very useful in identifying additional risk factors for various chronic disorders. By studying which ppl actually get the disease, researchers can identify the further precopitating or promoting factors of these illnesses

Making Messages More Effective

-Integrate different strategies -Use emotional/ psychological content for health issues -Make health issues more relevant to audience, social, and cultural setting Most benefit from integrating strategies to appeal to different types of audiences at different stages in their willingness to change behavior. In general, most people don't respond well to logic appeals and statistics. If you do, it might reflect that you belong to a population of adults currently taking higher education classes (or with a college degrees) that teach about statistics. Most American adults do NOT have college education, and might benefit from other appeals. Tapping into our emotions is often a good way to encourage (and discourage) some behaviors providing the emotions are reasonable given the product, problem, etc. And lastly, market segmentation should be as important in public health campaigns as it is in selling consumer goods. The old public service announcements that used to appear during Saturday morning cartoons is not going to cut it, nor are commercials that only show middle class, two-parent households of European American adults with 2.3 kids and a Golden Retriever. Health messaging should recognize the cultural diversity represented by our population, and understand how those messages are received by different groups of people.

The Problem with Nestle

-International Baby Food Action Network (IBFAN), and Save the Children claim that promotion of infant formula over breat-feeding led to health problems and deaths among infants in less economically developed countries -Three problems of switching to formula: 1. Formula must be mixed with water, often contaminated in poor countries -Ex. Non-breastfed child in unhygenic conditions 6-25 times more likely to die of diarrhea and 4 times more likely to die of pneumonia than breastfed child 2. Many poor mothers use less formula powder to make a container last-> infants receive inadequate nutiriton from weak solutions 3. Breast milk has many natural benefits lacking from formula (nutrients, antibodies, hormones, etc.) See above. No matter how hard science tries, it has failed to produce an artificial formula that is as healthy for babies as nature's breast milk. Although breastfeeding fell out of favor in the U.S. for an entire generation of mothers and their children (thanks to marketing and a frenzy for scientifically engineered foods), it is back to being the recommended nutritional choice for infants. There is nothing inherently wrong or unhealthy about giving an infant formula—much of the Baby Boomer generation was raised on it. But you can see from IBFAN's arguments that it wasn't a viable option for poor mothers in developing countries.

Use of Jargon

-Jargon-filled explanations may be used to keep the patients from asking too many questions or from discovering that the provider actually is not certain what the patient's problem is -Jargon has been used as far back as the 13th century. Arnold of Villanova urged colleagues to seek refuge behind impressive-sounding language when they could not explain a patient's ailment. -Adding "itis" to anything would forestall any additional questions from the patient -More commonly, jargon useage is a result of their techical training. They learn complex vocabularly for understandig illnesses and communicating about them to other professionals; they often find it hard to remember that patients do not share this expertise -Use of jargon may also stem from inability to gauge what the patient will understand

Latino (or Hispanic) Culture

-Largest, fastest growing US minority -Many nationalities and subcultures: Mexican, Puerto Rican, Cuban, Brazilian, Guatemalan, Colombian -Importance of balance in health --Cold/hot duality similar to the Yin/Yang of Asian medicine --Key distinction of natural (mal natural) vs. supernatural causation (mal puesto) That Latin@ population is now the fastest growing group in the U.S., and estimated to be the largest minority by 2050. Many Americans still fail to appreciate the diversity within Hispanic cultures, leading to false stereotypes or generalizations regarding healthcare. Historically, the idea of balance is an important concept in their ideas about health and wellbeing. For Hispanic subcultures that have religious or spiritual beliefs integrated into health, there are some disorders associated with biology (mal natural) and others with supernatural origina (mal puesto). Going into the specific disorders falling under each of these categories goes beyond the scope of the this lecture.

Trends in Healthcare

-Life expectancy in the us reached an all-time high of 77.9 years in 2007 -deaht rates dropped significantly for 8 of the 15 leading causes of death in the US between 2006 and 2007 -Fewer americans died in traffic fatalities in 2008 than in any year since 1961 -In 2007, 3 out of 10 children aged 5-17 did not miss a single day of school due to injury or illness within the preceding year -Amost 62% of adults say they are in excellent health -More on pg. 381

Health Promotion

-Many ppl have stopped smoking and reduced consumption of bad food -Coronary heart disease and others have shown dramatic decrease as result -Exercise has increased, alcohol consumption unchanged -Despite these changes, obesity and overweight are currently endemic and will shortly supplant smoking as the major avoidable contributor to mortality -Cearly everyone knows that thye need to practice good health behaviors but not everyone is successful. The potential for health psychology to make a contribution to health promotion remains -Expect to identify the most important part of behavior change programs in order to incorporate them into a cost-effective, efficient intervention that reach the largest number of people -In particular, expect to see the design interventions for mass consumption in the community, the workplace, the media (including internet), and the schools

Containing Costs of Health Care

-Medicine is high technology, and high technology is expensive. -Most surveys suggests that patients want less, not more, expensive, high-tech treatments, especially in the terminal phase of illness -The increasing use of technology may have more to do with physicians' desire to provide state-of-the-art care -Deficit financing of federal health care programs has added billions of dollars to the national debt, and the inability of the government to cover the uninsured, let alone fun Medicare and Medicaid, have contributed to the rapid rise in costs. These matters have prompted the scrutiny of health care by the government in recent years

Changes in the Philosophy of Health Care Delivery

-Most importantly, the physicians role is changing -The newer organizational systems for delivering services, such as HMOs,a dn the rising numbers of women in the medical profession have changed what was once a physician role characterized by dominance and authority. Responsibilityies that once fell exclusively to physicians are now shared with other authorities, including administrators and patients -Health illiteracy has some into the fore bc patients now expected to assume more responsibility for their care -Many ppl don't have the skills to adhere to medical prescriptions, comprehend the meaning of any risk factors they may have, or interpret the results of tests of physicians -The poorly education people, the elderly, and non-english speakers may have particular problems adopting the consumer role toward their care -Improving the nations basic education may help reduce this problem

Stereotypes of Patients

-Negative stereotypes of patients may contribute to poor communication and subsequent treatment. -Physicians give less information, are less supportive, and demonstrate less proficient clinical performance with Black and Hispanic patients and patients of lower socioeconomic class than is true for more advantaged patietns, even in the same health care settings -When a person is seen by a physician of the same race of ethnicity, satisfaction with treatment tends to be higher, underscoring the importance of increasing the number of minority physicians -Sexism. Medical intervention was perceived to be less important for the female patient for chest pain. Male and female patients do not always communicate well with each other -Female physicians generally conduct longer visits, ask more questions, make more positive comments during a visit, and show more nonverbal suport, such as smiling and nodding. The matching of gender between patient and practicioner appears to foster more rapport and disclosure. However, physicians of both genders still prefer male patients -Patients who are regarded as seeking treatment largely for depression, anxiety, or other forms of psychological disorder also provoke negative reactions from physisicnas. Physician attention may be especially cursory -Physicians also prefer healthier patients over sicker ones, and they actually prefer acutely ill to chronically ill patients; chronic illness poses uncertainties and raises questions about prognosis, which acute diseases do not. Chronic illness can also increase stress and distress over having to give bad news

Rates of Nonadherence

-Nonadherence: Noncompliance; when patients do not adopt the behaviors and treatments their providers recommend -Esimates of nonadgerence vary from low of 15% to a high of 93%. Averaging across all treatment regimens, nonadherence to treatment recommendations is about 26% -Adherence rates vary dramatically, depending on the treatment recommendations: --For short-term antibotic regimens, one of the most common presciptions, about 1/3 of patient sfial to comply adequately. Between 50 and 60% of patients do not keep appointments for modifying preventive health behaviors. More than 80% of patients who receive behavior-change recommendations from their doctors fail to follow through. Even heart patients who should be motivated to adhere show an adherence rate of only 66-75% -Overall, about 85% of patients fial to adhere completely to prescribed medications. Adherence is typically so poor that researchers believe that the benefits of many medications cannot be realized at the levels of adherence that most patients achieve. -Adherence is highest for treatments for HIV, arthritis, gastrointestinal disorders, and cancer, adn lower among patients with pumonary disease, diabetes, and sleep disorders

Judging Quality of Care

-Often judge quality of their care by criteria that are irrelevant to its technical quality. Most of us are insufficiently knowledgeable about medicine and standards of practice to know whether we have been treated well -Consequently, we often judge technical quality on the basis of the manner in which care is delivered. A warm, confident, friendly provider is judged to be both nice and competent, whereas a cool, aloof provider may be judged as both unfriendly and incompetent -The technical quality of care and the manner in which care is delieverd are unrelated

Measuring Adherence

-One classic study that assessed the use of the drug therophylline for patients sufering from chronic obstructive pulmonary disease found that physicians reported that 78% of their COPD patients were on the medication, chart audit revealed that 62% of the patients were on the mediction, videotaped observation of patient visits produced an estimate of 69%, and only 59% of the patients reported they were on the drug -The study didn't even assess whether theophylline was administered correctly, only if it was used at all -Asking patients of their adherence yields artifically high estimates. As a consequence, researchers draw on indirect measures of adherence, such as the number of follow-up or referral appointments kept, but even these measures can be biased -Overall, research statistics probably underestimate the amount of nonadherence that is actually going on

DRGs and Patient Care

-One cost-containment effort invovles the creation of diagnostic-related groups (DRGs), a patient classification scheme taht determines the typical nature and length of treatment for particular disorders. -Patients in a DRG category (x. a hernia surgery candidate) are assumed to be a homogeneous group that is clinically similar and that should require approximately the same types and amounts of treatments, length of hospitalization, and cost. -DRGs define what are called trim points: these are the boundaries that define unually long or short lengths of stay -If patient care falls within the classification scheme, reimbursement for care will be forthcoming from the third party, whether the federal or state government or an insurance company. In the care of an outlier (for ex, a patient who stays in the hospital longer than the DRG specifies), the case is typically subject to review, and the extra costs may not be paid. This puts pressure on medical facilities to limit patient stays and treatment costs -Proponent smaintain that DRGs can produce more efficient patient care, thereby reducing costs. The effects of DRGs on medical care are several. The DRG system implicitly rewards institutions for the detection and treatment of complication or co-occurring medically problematic conditions, so it provides an impetus for diagnostic vigilance. -However, DRGs implicitly adopt biomedical criteria for how and how long a disease should be treated, often ignoring psychosocial issues. As a result, DRGs are quite poor predictors of patients' need for services and length of hospitalization -DRGs can contribute to a tendency to discharge partients before the DRGs boundaries for length of stay are exceeded. THus, althought DRGs can have some positive effects on quality of care (such as attentiveness to the diagnostic process), they may also compromise care

Terminal Care

-Past 20 years= substantial changes in attitudes towards terminal care -Health psychology research has been both a cause and effect of these changing attitudes, as clinical health psychologists have turned their attention to the needs of the terminally ill and the gaps in psychological care that still exist -The face of aids is changing, and it has spread heavily into the poor urban populations of the country, involving many Black and Hispanic men and women. Women are of special risk, and as a reuslt, a growing population of infants is infected with HIV as well -These people are less likely to have expensive protease inhibitors available, so their prospects for long-term survival may be low -Aids is becoming a disease of the family, and attention needs to help single mothers and HIV infected children who will survive their mothers -Ethical issues surrounding death and dying including assisted suicide, living wills, the patient's right to die, family decisions making on death and dying, and euthansia, will increasingly assume importance -Solutions will be imposted externally by the courts if medical agencies and health psychs can't figure it out

Patient Attitudes Towards Symptoms

-Patients place considerable emphasis on pain and on symptoms taht interfere with their activities, but providers are more concerned with the underlying illness, its severity, and treatment -Patients may misunderstand the provider's emphasis on factors that they consider to be incidental, they may pay little attneiton, or they may believe that the provider has made an incorrect diagnosis -Patients sometimes give providers misleading information about their medical history or their current concerns. They may be embarassed about their health history or their health practices, and they may not report these important pieces of info to the physician

Patient Consumerism

-Patients' have increasingly have adopted consumerist attitudes toward their health care. This is due for several reasons: 1. to induce a patient to follow a treatment regmen, one must have the patients' full cooperation and participation in the treatment plan. Encouraging the patient to accept a role in the development and enactment of the plan can help ensure such commitment. 2. Lifestyle is a major cause of illness. Modifying lifestlye factors such as diet, smoking, and alcohol consumption must be done with the patient's full cooperation if change is to be achieved 3. A patient usually has expertise about their illness. A patient will do etter if this expertise is tapped and integrated into the treatment program -A study of pediatric asthma patients found that parents modification of a child's asthma regimen on the basis of severity of the disease, seasonal changes, symptoms, and side effects produced better asthma control than strick adherence to the prescribed medical regiment. Clearly the relationship between patients and provider is changing in ways that make good communication essential

Building Better Consumers

-People who are ill and who are treated for illness are frequently not the same individuals -About 1/2 to 2/3s of people who seek and receive treatment have complaints that are related to psychological distress -Creating responsible and informed health care consumers is thus a high priority -Patients need to be comanagers in theri own care, monitoring their symptoms and treatments in partnership and physicians and other health care practitioners. -Good health behaviors are critical to the achievement of good health and to secondary prevention with the chronically ill, the fact that 97% of patients fail to adhere to lifestyle recommendations takes on added significance -Trends within medical care suggest that the problem of patient-provider communication is likely to get worse, not better -Increasingly patients are receiving their medical care through prepaid, colleague-centered services rather than through private, free-for-service, client-centered practices. -These changes may improve the quality of medical care, but they may sacrifice the quality of communication -The probability that communication suffers in these settings is heightened by the fact that the clinetele sreved by prepaid plans is disproportionately poor, poorly educated, and non-English speaking. -Health settings that rob patients of feelings of control can breed anger or depression, motivate people not to return for care, and possibly even contribute to a physiological state conductive to illness or its exacerbation

Baby Talk

-Practitioners may underestimate what their patients will understand about an illness and its treatment so they'll use baby talk and simpilistic language -Overly simple explanations coupled with infantilized baby talk can make the patient feel like a helpless child. Also, such behavior can forestall questions. The patients may not know how to begin to ask for solid information from the useless explanation they received. -Typically, the providers underestimate the ability of patients to understand information about the origins, diagnosis, prognosis, and treatment of their disorders

Prevention

-Preventing poor habits from developing will continue to be a priority for health psychology -Adolescence is a window of vulnerability for most bad health habits, and so closing this window is important -Behavioral Immunization: programs designed to inoculate people against adverse health habits by exposing them to mild versions of persuasive sommunications that try to engage them in a poor health practice and giving them techniques that they can use to respond effectively to these efforts Behavioral Immunization programs are already in existance for smoking, drug abuse, and diet and eating disorders. Programs that expose 5th and 6th graders to antigrug material before they begin these habits are somewhat successful in keeping some adolescents from undertaking such habits -Behavioral immunicatization for other health habits like safe sex and diet also hold promise -For some health habit, we may need to start even earlier and initiate behavioral pediatric programs to teach parents how to reduce the risks of accidents in the home, how to practice good safety habits in automobiles, and how to instill in their children good health habit such as exericse, proper diet, regular immunications and medical checkups and regular dental care

Potease Inhibitors (HAART): An Adherence Nightmare?

-Protease is an HIV enzyme that is required fir HIV replication. Protease inhibitors, usually referred to as Highly Active Anti-Retroviral Therapy (HAART) prevent protease enzyme from cleaving the virus complex into pathogenic virions (the infective form of a virus). Taken regularly they stop the spread of HIV and sometimes get rid of the traces of AIDs all together -Rotease inhibitors have several qualities that make adherence problematic 1. many ptotease inhibitors must be taken four times a day. Ppl can barley remember to take one tablet a day. Missisng even one dose of a protease inhibitor may make the medication permanently unsuccessful 2. Many protease inhibitors require refrigeration, and consequently, the patient must reamin close to the refrigerated drug throughout the day so as to take the medication on time. This factor is impractical for some ppl with AIDS 3. For middle-class ppl with stable lives, regular employment, and socially supportive networks, adherence may be likely. But for the poor, the homeless, and the unemployed, who may lack even a refrigerator for keeping protease inhibitors cold, much less the stable life that promotes their regular use, adherence is a difficult task 4. Drug use, chronic anxiety, and other affectice or psychotic disorders interfere with the ability to use the drugs properly, and these states characterize some of the people who are eligible for protease inhibitors 5. May also have unpleasant side effects, including diarrhea and nausea, which can lead to nonadherence -Although protease inhibitors represent a life-saving discovery, they have mayn features that make their faithful use problematic. Integrating medication into busy, often chaotic and chaning lives is difficult. But adherence holds the key to survival

Treatment Regimen

-Qualities of treatment regimen also influecne the degree of adherence a patient will exhibit -Treatment regimens must be followed over a long time, that are highly complex, that require frequent dosage, and that interfere with other desirable behaviors in a person's life all show low levels of adherence -Keeping first appointments and obtaining medical tests are associated with high adherence rates -Adherence is high (about 90%) when the advic is perceived as "medical" ( like taking medication) but lower (76%) of the advice is vocational (ex. taking time off from work) and lower still (66%) if the advice is social or psychological (ex. avoiding stressful social situations) -Complex self-care regimens show the lowest level of overall adherence. Even with the best of intentions, it is difficult to engage in all the required behaviors, which take up several hours a day. Advoidant coping stategies are associated with poor adherence to treatment recommendations. The patients who cope with stressful events via avoidance are less attentive or responsive to information about threatening events, such as health problems -Nonadherent patients also cite lack of time, no money, or distracting problems at home, such as instability and conflict, as impediments to adherence. Ppl are increasingly cutting back on their prescriptions to save money -Ppl who enjoy the activities in their lives are more motivated to adhere to treatment. Asherence is substantially higher with patients who live in cohesive families but lower with patients whose families are in conflict. Ppl who are depressed show poor adherence to treatment medication

Stress and It's Management

-Recent attention to stress and inflammatory processes prepresent a significant breakthrough of the past few years. Advances have been made in research on environmental and occupational stress. Stressors such as noise or crowding do not show consistently adverse effects but do appear to adversely affect vulnerable populations. Thus, the health needs of children, the elderly, and the poor have taken special priority in the study of stress and its reduction -Job characteristics tied to stress: low control, high demands, and little opportunirty for social support. As a consequence, promising workplace interventions have been developed to redesign jobs or reduce on-the-job stressors -The demographics of strsss may be offsetting whatever concession can or might be made in the workplace. The majority of American families find that both parents must work in order to make ends meet, yet, the two-career family must absorb an extra month a year of housework, home activities, and child care -Typically, this extra month a year is taken on by women. Increasing numbeer of adult children have responsibility for their aging parents, and these responsibilities fall more frequently to women than men. -These trends put the adult American female pop under unprecedented stress, patterns that are increasing in toher countries as well. Solutions have yet to emerge

Where is Stress Research Headed?

-Research should focus on those populations at particular risk for stress-related disorders in an attempt to reduce or offset their stressful circumstances -Knowledgee of how people adjust to stressful events can be translated into interventions to help those coping unsuccessfully to cope more successfull -Many important advances in stress research will come from research on the neurophysiology of stress, particularly the links between stress and corticosteroid functioning, dispositional differences in sympathetic nervous system activity, factor influencing the release of endogenou opiod peptides, and links to the immune system, including inflammatory processes -One of the most significant advances in stress research is the discovery that social support can buffer stress. Fostering social support systems to offset social trends that isolate people, such as divorce and geographic mobility, should be a high priority for prevention. -Also should teach ppl how to provide support for others. Providing and recieiving social support has health benefits -Self-help groups are possible ways of providing social support for those who otherwise might lack it. People can discuss a common problem and try to help each other work it out. Once orientated around particular diseases like cancer or health problems like obesity, these groups are becoming increasingly available for those going through divorce, the loss of a child, and other specific stressful events

Doctor and Patient, Now at Odds

-Research suggests that many patients don't trust doctors -1 in 4 patients feel that their physicians sometimes expose them to unnecessary risk. Whether patients trust a doctor strongly influences whether they take their medication -People aren't talking to patients. Doctors are working in a broken system and are so rushed -The reason for all this frustration are complex. Doctors, facing declining reimbursements and higher costs, only have minutes to spend with each patients. News reports about medical errors and drug industry influence have increased patients' distrust. And the risk of direct-to-consumer drug advertising and medical websites have taught patients to research their own medical issues and made them more skeptical and inquisitive. -Problem also stems from a grueling training system that removes doctors from the world patients live in -"There is a diconnect between the way doctors and patients view medicine. Doctors are trained to diagnose disease and treat it, while patients are interested in being tended to and being listened to and being well" -Starting in 2003, some medical schools started requiring bedside manner courses and exams (estimated the 75% of med schools will adopt this) -Medical training has changed quite a bit since I was pre-med in college. At that time, the medical model was dominant, and managed care was in full swing. Many doctors I talked with at the time were dissatisfied with the direction the practice of medicine had gone since they were in med school. They complained that they could no longer spend enough time with patients, and were restricted with the treatment choices available due to insurance pressure. -During my senior year I had the unique experience to take a health communication course taught by two professors who also taught bedside manner courses at Northwestern's Feinberg School of Medicine. We helped them with research by watching hours and hours of the drama shows ER and Chicago Hope and coding the characters' speech by how they communicate health-related information. It was one of the best homework assignments I had in college. The two went on to develop provider-patient communication courses that are now a critical part of many medical schools. -Placebo effect studies says that faith in physicians can help healing -The situation is not hopeless. Patients who don't trust their doctor should look for a new one, but they may be able to improve existing relationships by being more open and communicative -Patients who are open with their doctors about their feelings and fears will often get the same level of openness in return

Patient Characteristics

-Several characteristic contribute to poor patient-provider communcations -Neurotic patients often present an exaggerated picture of their symptoms, compromising a physician's ability to effectively gauge the seriousness of a patient's condition -When patients are anxious, their learning can be impaired. Anxiety makes it difficult to focus attention and process incoming information and retain it 1. Incorrect (and sometimes ridiculous) expectations of medical providers' knowledge -I never failed to appreciate the kind of unrealistic expectations put on doctors until my friends became them, or until I started working with some as clients. I had one client who was an OB/GYN. She often complained about the questions that patients brought to her because they were so outside her professional duties. They would get frustrated with her and she had to explain to them that she had very deep expertise in things related to obstetrics and gynecology, but couldn't remember the names of every muscle group or answer questions about immunology. Most people have no idea of the type of training required for medical school, and we assume that all MDs are all-knowing about every field in medicine. 2. Non-adherence to recommendations -15-93% of people do not take doctors' advice --In surveys of patient follow-through on medical advice on medication, exercise, therapy, etc., anywhere from 15 to 93% fail to adhere to their providers' recommendations. 93 percent! Providers can justifiably be frustrated when patients fail to listen, and that can negatively impact their interpersonal frustration. Some patients come to professionals for their expertise and guidance only to pick and choose the advice that suits them. We sometimes fail to take responsibility for our role in health care. 3. Lack of education about the process, illness, etc. --Not everyone has full access to healthcare information, and lack of awareness about the process of medical care can get in the way of adaptive provider-patient communication 4. Effect of internet on info availability --The advent of the internet was probably one of the best and worst things to happen for provider-patient communication. On the positive side, it levels the playing field and gives patients access to health information that was never available before. We can educate ourselves and come to appointments with very educated questions about disease, injury, etc. This is a double-edged sword because it also increases the likelihood of self-diagnosis and exposure to incorrect information. My doctor friends' biggest frustration is when patients come in with stacks of information they printed from web searches. Patients can get belligerent if/when a doctor provides recommendations that conflict with what they "read on the internet." In my opinion, our education system doesn't do a good enough job teaching students how to discern between good and bad sources.

Pain Management

-Shift away from dependence on expensive pharmacologic and invasic surgical pain control techniques to ones that favor cognitive-behavioral methods, such as relaxation -This change has shifted responsibility for pain control from practitioner to comanagment between patient and practitioner -The development for pain management programs has been valuable for consolidating what is known about pain control technology -Health psychologissts may need to become involved in the ongoing controversies that surround alternative medicine. -Both the worried well and those with chronic illnesses are treating themselves in nontraditional ways, through herbal medicine, homeopathy, and other untested regimens -Health psychologists may need not only to evaluate these alternative medical practices but also to help develop interventions that will address the psychological needs currently met by these treatments

The Impact of Technology

-Technological advances in medicine have contributed greatly to the enormous costs of contemporary medicine -Explaining the purposes of these technologies and using control-enhancing interventions to enable people to feel like active participants in their treatment can help reduce fear -Growth of medical technology also raises complex questions about how it should be used. Ex. transplants readily available but only to ppl who can pay. Heath psychologists have a potential role to play in designing communications to encourage people to donate organs -As medical care has grown more technologically complex, it has also paradoxically begun to incorporate psychological and spiritual approaches to healing, especially those that draw on Eastern healing traditions. Relaxation and other nontraditional treatment methods are a boon to HMOs because thosee methods are typically low cost and yet can be remarkably effective for treating stress-related disorders, including such severely problematic conditions as hypertension. Continued evaluation of the health benefits of such interventions as yoga and mindfulness meditation is important

Patient Dissatisfaction in Managed Care

-The changing structure of the health care delivery system can undermine patient-provider communication. Prepaid plans often operate on a referral basis, so that the provider who first sees the patient determines what is wrong and then recommends specialists to follow up with treatment. Bc providers are often paid according to the number of cases they see, referrals ar desirable -Therefore, a colleague orientation, rather than a client or patient orientation, can develop. -A colleague orientation is a physician orientation toward gaining the esteem and regard of one's colleagues; fostered by any health care provider arrangement that does not involve direct reimbursement to physicians by patients -Bc the patient no longer pays directly for service, and bc the provider's income is not directly affected by whether the patient is pleased with the service, the provider may not be overly concerned with patient satisfaction. The provider is, however, concerned with what his or her colleagues think, bc it is on their recommendations that he or she received assitional cases. In theory, such a system can produce high technical quality of care bc providers who make errors recieve fewer refferals; however, there is less incentive to offer emotionally satisfying care -

The Aging of the Population

-The substantial aging of the population poses a challenge for health psychologists -As population ages we can expect to see a higher invidence of chronic but not life-threatening conditions, such as arthritis, osteoporosis, hearing losses, incontinence, and blindness. -Some efforts to control these disorders must necessarily focus on prevention. Ex. deafness is increasing bc of music so prevention of it is key

Structure of the Health Care Delivery System

-Until a few decades ago, most Americans received their health care from private physicians, whom they paid directly on a visit-by-visit basis, which was permed private, fee-for-service care. Each visit was followed by a bill and the patients paid out of their own pocket -More than 69 million Americans now receive their health care through a prepaid financing and delivery system, termed a health maintenance organization (HMO). In this, an employer or employee pays an agree-on monthly rate, and the employee is then entitled to use services at no additional (or a greatly reduced) cost, which is called managed care -In some cases, HMOS have their own staff, from which enrollees must seek treatment. In preferred-provider organizations (PPOs), a network of affiliated practictioners have agreed to charge preestablished rates for particular services, and enrolles in the PPO must choose from these practitioners when seeking treatment

Patient Knowledge

-With patients now expected to to assume more responsibility and increased decision making with respect to their care, lack of medical knowledge clearly interferes with their ability to play a consumer role effectively -Patients for whom the illness is new and who have little prior information about the disorder show the greatest distortion in their explanations -Cognitive deficits in memory and attention predict nonadherence and, as cognitive functioning can be quickly and easily assessed, measures of cognitive functioning may help to identify patients at particular risk for poor adherence -Disorganized families with no regular routines have poorer adherence -Low IQ is associated with a higher risk of early mortality, in part bc of low IQs association with poor adherence, and so consequently, treatment recommendations must be very simple and very clear to offset risks -Physicians are usually upper middle class and often while and male, whereas their patients may be of a lower social class, a different ethnicity, and a different sex. There may also be class-based, sociolinguistic factors that contribute to poor communication -As ppl age, their number of medical problems increase but their ability to present their complains effectively and to follow treatment guidelines can decrease -About 40% of patients over age 50 have difficulty understanding their prescription instructions

Patients' Contribution to Faulty Communication

-Within a few minutes of having discussed their illness with a provider, as many a 1/3 of patients cannot repeat their diagnosis, and up to 1/2 do not understand important details about the illness or treatment -Dissatisfied patients complain about the incomplete or overly technical explanations they receive from providers, dissatisfied providers complain that even when they give clear, careful explanations to patients, the explanation goes in one ear and out the other

A Focus on the Elderly

-Within the next 10 year swe will have the largest elderly cohort ever seen in this and other countries -This corhort can be an ill one, marked by disease, diabiliy, and depression or it can be a healthy, active one -Interventions should focus on helping the elderly through programs that emphasize diet, exericse, control of acohol consumption, and other health habits

Gender and Health

-Women are studied by what men don't have (breasts and genitals), therefore breast, ovarian, and other cancers of the sex or reproductive organs have received substantial attention, but many disorder have not -Weak justification for such discrimination has sometimes been based on the fact that women live, on average, 6.5 years longer than men. But women are sick more than men, and their advantage in mortality has been decreasing in recent years, a trend that appears to be due in part to women's use of cigarettes -Women are less likely than men to have health insurance, and even if they do, their policies may fail to cover basic medial care, such as pap smears for the detection of cervical cancer -More women are insured through their husbands' job than their own jobs, but bc of instability in marriage, coverage for women is irregular -Especially problematic for African American women -Women are not included as research subjects in studies of many major diseases. They're essential to include bc of many reasons: 1. women may have different risk factors for major diseases, or existing risk factors may be more or less virulent 2. Men and women differ in both their biochemistry and their physiological reactions to stress. Consequently, their symptoms, their age of onset for the same disease, and their reaction to treatment and needed dosage levels of medication may all differ (ex. women risk for coronary heart disease increases greatly following menopause) -Without a systematic investigation of women's health and their particular risk factors, as well as changes in both over the lifespan, women will siply be treated more poorly than men for the same diseases

International Health

-World's pop has increased from 2.5 billion in 1950 to nearly 7 billion today. Shifted away from Europe, North America, and Latin American towards Africa and Asia. Life expectancy increased everyone with particular improvements in developing countries -Disease prevalence differs greatly by country -Poverty, lack of education, and lack of health care resources contribute to a high incidence of acute infectious diseases -As smoking has declined in the US, its incidence is rising in many developing countries. Whereas Americans are beginning to exercise more, countries that are becoming modernized are losing the exercise benefits that accompanies an active lifestyle. Many developing nations like China and India are beginning to experience the burden of increases in chronic stress -Health psychologists and behavioral scientists are more likely than people in traditional medical disciplines to understand the significance of varying cultural norms and expectations, the way social institutions function, and the roles that culturally-specific attitudes and behaviors may play in health care practices and decisions

Results of Poor Patient-Provider Communication

-Wouldn't be a big deal if not for the toll it takes on health -Dissatisfied patients are less likely to comply with treatment recommendations or to use medical services in the future; they are more likely to turn to alternative services that satisfy emotional rather than medical needs; they are less likely to obtain medical checkups; and they are more likely to change doctors and to file formal complaints

Graduate Experience (phD)

1. Decide if intrests lies in research, clinical practice, or both Research? -your choice of programs are likely to be physiological psychology, which focuses heavily on the biology and neurological aspects of health psych; social psychology, which examines social and psychological processes in adipting preventive health behaviors, managing stress, and coping with chronic disease, among other issues; clinical psychology, which interventions with patietns will be one of your primary tasks; or developmental psychology, in which you will look especially at the health of children and the factors that affect it -Take courses in methodology and statistics and epidemiology. Most importantly is to get practical experience by working with a health psychologist on several research or clinical projects -Look for opportunities to get practical, hands-on experience Clinical Practice? -Take standard clinical curriculum, which includes courses and practical experience addressing major metal disorders and community intervention and therapy. -Expected to complete a year's internship in a field setting in a hospital, clinic, or health maintenance organization that gives you direct patient contact -Dissertation, major research project on your own. Will take a year or more to complete -On completion of dissertation and receipt of your Ph.D., you can find clinical setting and get more experience, then you have to take several hours of licensure exams, the exact form of which varies from state to state; on receipt of your license, you will be able to practice psychology

Cross Cultural Interview

1. Establising trust -May take much more time- often mistrust if inherent -Do not assume that you are trusted just because you are a medical provider. Be open to the possibility that it might take a few appointments for the relationship to develop. 2. Eye contact issues -May be avoided among less Westernized Asians (unless of equal status/gender) -Americans value direct eye contact and see it as a sign of respect and assertiveness. Many cultures do NOT value eye contact. When they do, it might only be under certain conditions (men to other men, people of higher to lower status, etc.). Do not assume that avoidance of eye contact represents rudeness or disinterest—it might reflect respect. 3. Personal Space -Be aware that people have different comfort with personal space. 4. Gender issues and casual touch -Touch between strangers can be a major taboo in some cultural groups. For example, it might be very offensive for a female practitioner to lay her hand on a male client's shoulder during an appointment during casual conversation. 5. Facial expressions/body language -Ex. smiling as embarrassment instead of happiness -Never assume that all facial expressions and nonverbal body language mean the same things to all cultural groups. Smiling is a classic example. In some Asian cultures, smiling can represent embarrassment in addition to happiness. I once had a therapy client born in Vietnam but who had lived in the U.S. for 20 years. She was very accustomed to U.S. culture and looked/acted like any other college student. However, she also came from a family that maintained strong cultural values of Vietnam at home. I was very confused during our first few counseling sessions because I perceived some of her smiles and laughter to be incongruent with some of the topics we were discussing. At some point I mentioned my observation and she explained to me that it showed her discomfort with what we were talking about—very different from what I thought was going on. We ended up learning a lot from each other and therapy ended up being a very positive experience. 6. Time and punctuality -Agrarian "rubber time" vs industrial time -We already discussed this different value in time. I'm not suggesting that U.S. healthcare professionals abandon schedules. But understanding this might help practitioners communicate the importance of making appointments on time ("If you show up 20 minutes late it means that there might be other families that won't be able to have appointments") or not assuming a patient is rude or resistant if they are a few minutes late.

Health Care Concerns for Asians

1. Loud tone of voice may be misinterpreted by some Asians as showing hostility -I failed to understand how loud we are as Americans until I started traveling abroad. It really is pretty easy to identify Americans by their volume of voice in public places. And once again, we don't do it for any purpose or intent—it is just part of our culture. However, this can be perceived as an expression of hostility by others, and put stress on a patient-provider relationship. 2. Left hand used for personal hygiene and considered unclean -Medical samples offered with left hand may be discarded -In some cultures, the left hand is used exclusively for wiping and other personal hygiene; therefore, it is not used to exchanging things socially. Patients that adhere to strict cultural beliefs and who may have very little exposure or assimilation to U.S. culture may be offended if offered things from the provider's left hand. Once again, this may be restricted to a small number of people, but some of you might end up working in communities where it could be helpful to at least be aware of the possibility. 3. US medical practices not always congruent -Ex. Chinese "sitting month" after delivery: --Belief that women undergo cold stage after delivery due to loss of blood --Need to consume "hot" food (i.e., soups, ginger, wine and food high in protein) and avoid exposure to cold air, cold water, or wind -I want to share one specific example of very different expectations in healthcare between U.S. and Chinese cultures. I first learned about it from an OB/GYN that had a lot of Chinese-American patients. Since then I've learned that some of my Chinese-American friends have practiced a modified version of the Chinese sitting month out of respect for their female relatives' cultural beliefs. This period is called 'sitting month' or 'doing the month'. Based on Chinese traditional medicine, postpartum women are in a 'weak' state because of 'Qi' deficiency and blood loss. Their body can be easily attacked by 'heat' or 'cold ', which may cause some health problems like dizziness, headache, or backache in the month or in later years. Therefore, Chinese women are advised to follow a specific set of food choices and health care practices. For example, the women should stay inside and not go outdoors; all windows in the room should be sealed well to avoid wind. Bathing and hair washing should be restricted to prevent possible headache and body pain in later years. Foods such as fruits, vegetables, soybean products and cold drinks which are considered 'cold' should be avoided. In contrast, foods such as brown sugar, fish, chicken and pig's trotter which are considered 'hot' should be encouraged. It is believed that if a woman does not observe these restrictions, she may suffer a poor health at her later life. These traditional postnatal believes and practices are often passed down from senior females in the family to the younger generations. You can see how these are in direct conflict with post-delivery healthcare in the U.S. Culturally competent healthcare providers have learned to respect some of the aspects of the sitting month while also explaining how some of their medical guidelines (or requirements) are necessary for patients.

Provider Characteristics

1. Motives for entering the profession (ex. his experience in pre-med) -People go into professions for all kinds of reasons. I noticed four major drivers for my pre-med peers' interest in medicine were (1) a sincere interest in helping others through the practice of medicine, (2) a love for biology, (3) the prestige and/or money associated with being an MD, and (4) "it's what my parents want me to do." You can imagine that each of these reasons may produce very different types of doctors. It was disheartening at times to learn that a fair number of them never mentioned the first reason. 2. Not listening 3. Use of Jargon 4. Impersonal Treatment -Patients' perception that medical treatment is impersonal isn't always the fault of care providers. Patients often fail to appreciate the pressure that providers are under to meet billable hours quotas from hospital administration. It sometimes results in spending too little time in the exam room, giving patients the feeling that they are simply a number. 5. Stereotypes of patients -Recall our early discussion of extreme somatizers—a very small group of patients responsible for a large share of medical time and energy. Unfortunately, it is sometimes trouble patients that stick out in providers' memories, and that frustration can influence how they perceive other patients. 6. Some lack of communication training in medical school

Language and Body Language

1. Patients may say they understand...instead have them repeat what you want them to do -One of the best ways to assure understanding is to ask a patient to repeat/summarize what it is that you want/expect them to do for follow up. This helps reduce a great deal of miscommunication. 2. Nodding vigorously may indicate respectful attnetion but not agreement or understanding -It is common for us to assume that people understand what we are saying as they nod their head in agreement during conversations. I see it all the time during classroom lectures. Make sure you seek clarification on what it really means. 3. Speak slowly and simply but not loudly -Some of you have seen the stereotype of the American speaking really loudly in English when trying to communicate with someone who speaks another language. My grandfather was especially embarrassing while traveling abroad as he seemed to shout at people. Native language speakers tend to speak their language faster than non-native speakers. There is nothing wrong with slowing down the pace of your speech to help English language learners with comprehension—but no need to raise your voice in a condescending tone. The only exception to this is if a patient is hearing impaired. ;) 4. Eye contact in non-western cultures may indivate disrespect of authority and/or sexual interest 5. Avoid idioms -E.g. "go under the knife", "draw blood", "under the weather" -All languages use their own idioms that are understood by most members of that cultural group. However, they range from meaning nothing to meaning very different things to non-native speakers. For example, we refer to surgery as "going under the knife." As a healthcare professional, try to avoid using idioms and instead communicate in terms with clear meaning.

Issues in Latino Health Care

1. Personalismo -Necessary trust established prior to medical part of interview -Personalismo is an important cultural value that encourages warm and friendly relationships as opposed to impersonal or formal interactions in everyday life; it is an expectation among Hispanics that they will be treated in a caring and respectful manner. Typical medical appointments in our modern medical practice doesn't always allow for that kind of relationship building, which can make it less likely that people follow through on medical recommendations. 2. Personal Space -Tolerate more closeness than Americans, sometimes resulting in a "dance" where practitioner retreats and perceived as being "cold" -One stark difference between Americans and many other cultures across the globe is our value (or apparent "need") for interpersonal distance and space. When I used to travel a lot in my consulting career and interacted with colleagues from other countries, it took some adjustment for me to get comfortable talking so close to someone that I could feel their breath on my face! Think about how much space there is between a doctor/nurse/etc. during an average appointment. Sometimes there is a desk between you. Some Latin@s perceive medical practitioners to be "cold and aloof" as they back away from social encounters. This can erode trust between providers and patients. 3. The Latino Paradox -being a little "gordito" is often perceived as healthy -While Mexican-Americans have up to 5x as much type 2 diabetes as whites- risk of coronary death is lower -There is something in epidemiological research called the "Latino Paradox" (AKA epidemiologic paradox), referring to the epidemiological finding that Hispanic and Latin@ Americans tend to have health outcomes that paradoxically are comparable to, or in some cases better than, those of their U.S. white counterparts, even though Hispanics have lower average income and education. There remains debate about what leads to these differences, but some suggest there are protective factors such as very strong social support (known as familisimo) that might serve as buffers. 4. More relaxed concept of time- people more important than schedules -Lastly, time orientation can influence perceptions between Latin@ patients and providers. Americans share a time orientation with Northern European cultures that expect punctuality and assume that people who fail to make appointments on time are disrespectful. In contrast, other cultures operate on what is called "rubber time" where people are more important than schedules. Although I might have a 1:30pm doctor's appointment, I might get held up visiting with a neighbor and show up 15 minutes later. This isn't a problem in cultures where it is the norm; however, that orientation runs in stark contrast to expectations of our medical settings where appointments are scheduled to the minute. This also puts great stress on provider-patient relationships.

Reality of Mass Media: "The Can Do"

1. Raise awareness, information, and knowledge about health issues and problems 2. Provide advocacy and support that facilitates placing health issues on the agenda 3. Assist in changing behavior when other enabling factors are present -But ONLY when other factors are in place (e.g., access to resources, information, etc.) We often are overly optimistic about what we can achieve through advertising and mass media. Above are some of the things that can be achieved through mass messaging. We can raise public awareness, encourage policy change, and possibly change behaviors as long as there aren't significant barriers in place.

Healthcare System

1. Switch to managed care --Doctors, facing declining reimbursement and higher costs, have only minutes to spend with each patient --There are some forces outside of our control as patients. Managed care has certainly helped healthcare in some ways, but can also hurt it in others. One of the major complaints of providers is the restrictions placed on them by insurance companies. For example, some psychiatrists are expected to see 4-5 patients PER HOUR to maintain profitable bill rates. This works sometimes when there is simple med adjustments necessary, but a total disaster when a psychiatric patient needs much more time exploring the complexity of their mental health concerns. 2. Changes in the philosophy of healthcare delivery --E.g., patients must assume more responsiblity --Greater expectations are being placed on patients to take control of their own healthcare. This concept is called "rolled back healthcare", and more services are being done outside of expensive medical facilities. The easiest example is self-screening tests for blood-glucose levels, blood pressure, etc. Some pacemakers can now upload information wirelessly to providers so cardiac rehab patients no longer have to go to a hospital to upload their pacemaker data. This is fine for people with access to telecommunications, but what about the 1 in 5 Americans with no access to the internet? 3. Holistic health movement and health care --Western medicine incorporating Eastern approaches -There is a major trend underway to explore non-traditional interventions in medicine. The technical term is complementary and alternative medical (CAM) treatments. Many patients are now coming in to appointments with information about CAM interventions that their providers may or may not have any experience or knowledge. This can create both opportunities and challenges for provider-patient communication. 4. Influence of pharmaceutrical industry, specifically advertising --There is no doubt that it has radically improved the health outcomes and extended life expectancy of many, many people. Pharmacological interventions can be a critical and integral part of treatment. However, its influence and reach in treatment should be questioned. The U.S., Australia, and New Zealand have some of the highest rates of prescription drug abuse in the world. Interestingly, they are also the ONLY countries in the world that allow direct-to-consumer advertising by pharmaceutical companies. Think about that. Every other culture recognizes that it is the responsibility of trained medical professionals to help decide the right drug treatments for their patients. Here in the U.S., people watch TV commercials for medications and then go to their appointments demanding that medication without any knowledge of whether or not it is an appropriate treatment for them. It can negatively impact provider-patient communication when patients feel they are being denied a treatment by their provider even if there are really good reasons why from a medical perspective

Undergraduate Experience

1. Take all the health psychology courses that you can 2. Develop knowledge about the biological bases of behavior by taking courses in physiological psychology and neuroscience 3. Use summers effectively. Research assistantship, volunteer, summer employment in medical school or hospital. 4. Ask questions

The Reality of Mass Media: "The Cannot Do"

1. Teach skills -E.g., negotiate safer/healthier sex -Mass media has failed miserably in teaching specific health-related skills. One of the least successful areas is in changing sexual behaviors (e.g., encouraging condom use). Think about how difficult it is to teach an adolescent how to (1) decide when it is "right" for them to become sexually active, (2) have an actual discussion with their sexual partner about what they want (and want to avoid) in their sexual experiences, and (3) how to use birth control methods effectively. 2. Change behaviors in absence of other enabling factors -E.g., healthy eating in low-income heighborhoods -By now I hope you appreciate the enormous impact on environment on our health behaviors. You can spend millions on TV and billboard advertising to encourage healthier food choices while shopping at the grocery store in poor, urban neighborhoods. But nothing will change if you don't provide those healthy choices at prices equivalent to less healthy food. 3. Cause attitudinal changes if new message challenges basic beliefs -E.g., Bike to Work campaigns -It is remarkably difficult to change a person's core beliefs. For example, the automobile is king in the U.S. Many Americans have a fundamental value that we should be able to drive wherever we want, whenever we want. City, suburban, and rural development reflect the value of the automobile as it is impossible to live without one in many places. While the Bike to Work campaigns are excellent in theory, they do very little to change individuals' behaviors to switch to cycling over driving to work. 4. Present complex information -E.g., relative risk of different types of fats in diet -Not surprisingly, mass media cannot communicate complex information. I'm willing to bet that if I polled or quizzed you on all of the different types of dietary fat out there (names, health benefits vs. risks, etc.), no one would have all of the information. Instead, campaigns and consumer product advertising went with the general "no fat" or "low fat" diets. We now know that they failed to achieve the desired health outcomes because it's not that simple.

Asian and Asian-American Culture

1. Third largest US winority; many nationalities/ ethnicities -Asian-American is also an overgeneralization term given that it represents tremendous diversity of backgrounds and cultures. 2. Hierarchical family structure -Many Asian cultures have more defined family structures than we are accustomed to in the U.S. where there are clear guidelines as to who makes decisions about health, and how information is shared between members in a family. For many, the head of the household is the father (and in some cases elders in the community). 3. Poverty still a problem despite stereotypical strong family commitment to work, education, and advancement -Some of you have heard the term "model minority" applied to Americans of Asian descent. There is the stereotype that they work harder than other non-dominant groups, value education and academic achievement, and rise to higher levels of the socioeconomic ranks. Unless you've had history courses that have focused on the different waves of Asian migration to the U.S., you (and most Americans) might not be aware of how this "model minority" stereotype came about. While it is a complex issue, one explanation is from selective immigration. There is one wave of Asian immigrants that come from the cream of the cream of the crop since it is very expensive to immigrate to the U.S. They come from families with significant economic resources that already valued achievement (similar to high SES European-American families), and therefore found it easier to perform well and get ahead. In contrast, there are other groups of Asian immigrants that have come to the U.S. as refugees (think post-Vietnam countries like Vietnam, Laos, and Cambodia) that arrived under very different circumstances. Many had few existing relatives in the U.S., little to no English, few transferrable skills, poor urban living conditions, etc. There are still problems with poverty and healthcare disparities in Asian-American subgroups despite the stereotypes that persist 4. Accommodation rather than assertiveness valued -Yes may really mean no in some instances (you may also be told what your patients thinks you want to hear) -One cultural value shared by many Asian subgroups is the concept of the collective over the individual. Out of that value comes a strong value to avoid causing shame or embarrassment to someone in a social setting, and this might result in avoiding disagreement or conflict. In healthcare that might come across as a patient shaking their head in agreement with instructions from the provider even though that individual has no plans to follow up on the recommendation. I encountered this both in international business as well as my clinical work at the hospital. It isn't out of malice or resistance, but it is important for healthcare providers to understand the possibility that this value is at play during medical appointments (although it also might not depending on the person).

Advertising and Marketing

Advertising -To express and promote ideas using individual contact and/or through mass media -Advertising is the actual expression of ideas through text, images, etc. It is the "creative" side of bringing a product or idea to market. Marketing/audience segmentation -Divison of a population into more homogenous groups based on similarities in attitudes, beliefs, and knowledge to allow greater impact of a message - Identifying the target group that you want to get your message across. The whole point of market segmentation is to learn as much as possible by a target group to help you develop the most successful strategy (and best advertising approach) to reach that group.

Cultural Dynamics and Clinical Encounters

American Culture -Health is the absence of disease -Seeks medical system to prevent and treat disease -Seeks practitioners (doctors, nurses, etc...) Non-Western Culture -Health is state of harmony between body, mind, and spirit -Seeks medical system in acute stage of illness -Seeks herbalists, priests, shamans, etc...Doctors may be sought out later in the "hierarchy of care" Above are some generalizations about the differences between mainstream American healthcare and non-Western delivery. I just want to highlight that although other cultural groups may have culturally specific practices, traditional healthcare is usually part of the care hierarchy. So even though a tribal group might first seek out a shaman, more formal doctors are used in the acute or severe stages of an illness. It is a false stereotype of developing countries that they don't use what we would call traditional medicine—it is just that they may have a broader view of other people involved in the hierarchy of care.

Nestle Boycott

As a result of the health marketing efforts of IBFAN and Save the Children, they launched one of the largest product boycotts in history. This just shows you the power of viral mass media used to remedy a major health (and ethics) problem

Common Advertising Techniques

Associaton -Connects/ associates the product with a POSITIVE IMAGE, like youth, beauty, success, happiness, etc. -E.g., Marlboro and beauty of the great outdoors Testimonial -Famous person endorses the product Bandwagon -Everybody is doing it; you are not with it if you don't -E.g., 4 out of 5 dentists recommend Crest Plainfolks -Product features country images, common people, and down-home appeal -E.g., "KFC tastes like its homemade!" Snob Appeal -Appeals to people who think they are "superior", high-class, rich, or very intellectual -E.g., many beauty/health products Sex Appeal -Uses a sexy person to catch your attention -E.g., every Axe Body Spray commercial EVER Logical Appeal -Uses statistics or facts (real or imagined) to appeal to your logic Play on Fears -Product offers protection, comfort, or security from fear Bonus tip: Most of you have heard the old "4 out of 5 dentists recommend Crest" line in commercials. At first glance that sounds pretty impressive. Then you might ask yourself, "Wait. Did they do a random sampling of American dentists and ask them which brand they recommend to patients? Did they conduct some sort of double-blind study?" Then you hear my voice reply, "No." You ask, "But how can they say that if it isn't true?" I would tell you that the Crest marketing team can quite easily report these results with some simple techniques. All you need to do is mail a bunch of dentists some free samples of Crest and ask them to mail back an answer to the following question: "Would you recommend Crest to your patients? Yes or no?" I'm willing to bet almost any dentist would say, "Sure. This toothpaste is just fine. Why not?" no matter what toothpaste they were considering. It really means that when dentists were asked if they would recommend Crest as an acceptable toothpaste for patients, 4 out of 5 of them said it was. The 5th dentist must have held stock in a competing consumer product company...

Culturally Appropriate Gestures

Beckoning -Should not be with index finger (S. America, Asia) since this si reserved for dogs or considered very rude Displaying (or touching other with) your feet -Insulting in Asia and Africa Patting a child on the head -Insult in SE Asia since the head is consideered the sacred seat of the soul "Thumbs up" Sign -Same as the US middle finger in some middle Eastern countries My favorite is the last one because U.S. media outlets still seem to get this wrong. I remember seeing a news clip a few years ago of a group of Iraqis giving the cameras the thumbs up sign shortly after American soldiers had traveled through their village. The reporter commented on how the soldiers were enthusiastically received by the villagers and grateful for the U.S. presence in Iraq!

Comprehensive Intervention

Comprehensive Intervention Models: models that pool and coordinate the medical and psychological expertise in a well-defined area of medical practice so as to make all available technology and expertise available to a patient; the pain management program is one example of a comprehensive intervention model -Ex. pain management programs, in which all available treatments for pain have been brought together so that individual regimens can be developed for each patients -Second model is the Hospice, in which palliative management technologies and psychotherapeutic technologies are available to the dying patient -Coordinated residential and outpatient rehabilitation programs for coronary heart disease pateitns, in which multiple health habits are dealt with simultaneously, constitute a third example -Most comprehensive intervention models thus far have been geared to specific diseases or disorders, but increasingly, researchers are urging that this model be employed for concerted attacks on risk factors as well -The mass media, youth prevention projects, educational interventions, and social engineering solutionas to such problems as smoking, ecessive alcohol consumption, and drug abuse, ex, can supplement programs that currently focus primarily on health risks that are already in place -Comphrehensive interventions for particular health problems may provide the best quality of care, but they can also be expensive -For comprehensive intervention models to continue to define the higher quality of care, attention must be paid to cost effectiveness (the formal evaluation of the effeectiveness of an intervention relative to its cost and the cost of alternative interventions) as well as to treatment effectiveness (formal documentation of the success of an intervention)

Creative Nonadherence

Creative Nonadherence, or intelligent nonadherence, involves modifying and supplementing a prescribed treatment regimen. Ex. poor patient may change the dosage level of required medication to make the medicine last as long as possible. One study of nonadherence among the elderly estimated that 73% of nonadherence was intentional rather than accidental -Creative nonadherence can also result from personal theories about a disorder and its treatment. Patient may alter the doage requirement -Nonadherence is widespread and complex behavior

Hypertension Control in Blacks

Differential effects of meds than Whites -More sodium sensitive -Beta-blockers may be less effective (thiazides and calcium channel blockers more helpful) -3-4x greater risk of angioedema from ACE inhibitors Controvery over race-specific marketing of pharmaceuticals I want to share one more challenge in health education and promotion that has roots in racial/ethnic differences. One of the major criticisms against the pharma industry is that most of early medication trials were on white men, so little was (and in some cases still is) known about how they work for women and people of color. However, we now have enough data showing that African-Americans respond differently to traditional beta blockers for hypertension, which is one of the go-to meds for this disorder. They are also at 3-4 times the risk of developing angioedema (swelling under the skin) while taking ACE inhibitors (induces dilatation of blood vessels to lower blood pressure). You might think knowing this makes healthcare better, but it can raise problems when we consider that our pharma industry can advertise and market directly to consumers. There have been attempts in the past to produce race-specific marketing of medication, but exposure to that kind of advertising can be controversial. Imagine you are a person of color watching TV. You see four different commercials for hypertension medication for whites, and then one for blacks. How might you respond? You might wonder, "Why is there a special one for me? Is it as effective?" We need to provide better health education to everyone to understand differential effects of specific treatments, including educating those who prescribe medications to make sure they know all of the information.

2010 US Census Data

Ethnic/racial breakdown of the 299.7 million US population --72.4% Caucasian (63.7% not of Hispanic/Latino origin) --16.3% Hispanic or Latino --12.6% African American --4.8% Asian --.9% American Indian or Alaska Islander --.2% Native Hawaiian or other Pacific Islander Language --79% speak English --21% speak a language other than English By 2050, US will have "minority majority" Census estimates from the past several census surveys are forecasting that non-dominant racial/ethic groups (Latin@, African-American, etc.) will make up the majority of the U.S. population by 2050. Healthcare MUST change to meet the needs of a rapidly shifting population to ensure we deliver culturally relevant services.

Truth Campaign

Hersey et al. (2005): Random sample of 16,000 youths 12-17 (before, 8 months and 15 months after launch) found that those in TV markets with higher campaign exposure by comparison had: -Significantly more negative beliefs and attitudes about tobacco industry -Lower intentions to use -Lower receptivity to pro-tobacco ads and marketing practices (E.g., branch merchandise, etc.) Farrelly et al., 2005 reported a *dose-response* relationship between exposure to truth ads and youth smoking prevalence -Smoking prevalence for youths in grades 8, 10, 12, declined on average from 25.3% (1999) to 18% (2002) with the largest decline occurring for 8th graders -Exposure to the truth campaign accounted for 22% of this decrease in smoking prevalence -Decline equivalent to having 30,000 fewer youth smokers as a result of the campaign Just to clarify what "accounted for 22% of this decrease" means in a study report. Given the margin of error always present in research and after controlling for the effects of other influences on smoking (e.g., higher taxes on packs, other forms of messages, tougher laws with carding buyers, etc.), this means that the campaign accounted for about 1/5 of the decrease. While this number might not seem large, compare it to the effect sizes you saw on previous slides. It was about 4-5 times more effective than previous efforts. And when put against actual numbers, 300,000 is a lot of impact.

Meta-Analysis of Media Health Campaigns on Behavior

Mediated health campaigns in the US have small effect sizes (ES) in the short term -Strength of effect of an intervention after accounting for any placebo effect ES=average correlations -ES= .15 seatbelts -ES= .13 oral health -ES= .09 alcohol -ES= .05 heart disease prevention -ES= .05 smoking -ES= .04 sexual behaviors Guidelines for effect sizes in social sciences suggest that correlations below .10 are weak, .30 medium, and .50 large. Mass media is just barely effective in increasing seatbelt use and brushing/flossing, and not effective for reducing negative health behaviors. Above is a summary of the research on health campaigns and behavior. One statistical measure of the strength of a study is its effect size, or the quantitative measure of the strength of a phenomenon. For example, some of you may have heard about that recent controversial Facebook study on emotion words (Kramer, Guillory, & Hancock, 2014). It showed that when emotionally positive posts were reduced in Facebook users' news feeds, users' status updates used fewer positive words (Cohen's d = 0.02) and more negative words (d = 0.001). Cohen's d is one measure of effect size. Because these effect sizes (d=0.02 and 0.001) are very close to zero, they indicate that this phenomenon is extremely weak; however, the reduction in positive words (d=0.02) was 20 times stronger than the increase in negative words (d=0.001).

Marketing Gone Bad: Nestle

Not all health product marketing is used for good. There is a famous case of Nestle from back in the late 1970s/early 80s. They went into new markets in developing countries with a massive marketing campaign for their infant formula. Here are some images from their efforts in parts of Asia. You can see from the imagery that it is selling the infant formula (replacement for breast milk) as a way to help make your baby strong and grow healthy.

What is a Health Care Provider?

Nurses as Providers -Advanced-practice nursing is an umbrella term given to registered nurses who have gone beyong the typical 2-4 years of basic nursing education and who have multiple responsiblities for patients -Nurse Practitioners are affilitated with physicians in private practice; they see their own patients, provide all routine medical care, prescribe treatment, monitor the progress of chronically ill patients, and see walk-in patients with a variety of disorders. They explain disorders and their origins, diagnoses, prognoses, and treatments. Nurses frequently give treatment instructions or screen patients before they are seen by a physician -Other advanced practice nurses include nurse widwives, who are responsible for some obsterical care and births; clinical nurse specialists, who are experts in a specialty, such as cardiac or cancer care; and certified registered nurse anesthetists, who administer anesthesia. -An expaning role for nurses in primary health care is likely Physicians' Assistants as Providers -Physicians' assistants perform many routine health care tasks, such as taking down medical information or explaining treatment regimens to patients. -Educated in 2-year programs in medical schools and teaching hospitals, as well as throughout the armed forces. -Programs typically require 2 years of college and previous experience in health care. -Physicians assistants take the same classes as medical students during the first year, and the second year is spent in clinical rotation, with direct patient contact -Other professionals such as biofeedback technicians and psychologists have also become involves in specialized care

Guidelines Generated by Research Findings that can Help Providers Improve Adherence

Pg. 221 -Nonadherence to treatment is a formidable medical problem -More than 85% of patients are at least occassionally nonadherent to treatment -Many of the reasons for nonadherence can be traced directly to poor communication between the provider and patient

Reducing Error in Adherence

Recommendations by the Center for the Advancement of Health to increase patient adherence: 1. make adult literacy a national priority 2. Require that all prescriptions by typed on a keyboard 3. Make commonplace a secure electronic medical record for each individual that document shis or her complete medication history and that is accessible to both patients and their physicians 4. Enfore requirements that pharmacists provide clear instructions and counseling along with prescription medication 5. Develop checklists for both patients and doctors, so they can ask and answer the right questions before a prescription is written -These can empower patients and can even help mitigate racial and ethnic disparities in treatment

Cross-Cultural Terms

Stereotyping -Mistaken asusmption that everyone in a given culture is alike- closed to exceptions (ending point) -It is a (universally human) cognitive bias that leaves us taking a perceived group characteristic and using it to make assumptions about an individual's personality, beliefs, behaviors, etc. If a healthcare provider acts on stereotypes about a person (e.g., denying a prescription for Vicodin cough syrup to a college student), it usually ends up becoming a barrier to more effective treatment by negatively impacting patient-provider communication, trust, etc. All of us act on stereotypes about groups; however, with practice, we can develop awareness of and sometimes prevent them from being part of our Ethnocentrism -Unconscious conviction that one's own culture should be the norm- this is almost a universal human trait -Rampant in Western Medicine -Ethnocentrism is a belief that your own culture should be the norm. This is also an almost universally human trait. We tend to think our group's way of doing things is the right/best/only way to do things. This is apparent in the way we practice Western medicine. For example, acupuncture has been practiced in Chinese medicine for thousands of years, and continues to be part of modern practice. A common use is to help provide anesthesia for mild surgical procedures. Despite the fact that modern Chinese medicine is quite advanced, Western hospitals still don't include acupuncture as a potential standard practice for similar procedures. It is important to remain open-minded about health practices, and consider how we might integrate them as part of individuals' preferred treatment options. Generalizing -Awareness of cultural norms- open to educational, generational differences (starting point) -Generalizing is the awareness that different cultures have different ways of viewing the world. It is not stereotyping as it doesn't make specific questions. It opens the possibility to ask additional questions (hence, starting point). Let me illustrate the difference between stereotyping and generalizing in healthcare. Assume you have a Spanish-speaking patient from Latin America, and you are aware that some Latin@ cultural groups use a curandero (more on that in later slides) as part of the healing process. Here's an example of stereotyping: "I'm happy to talk with your curandero as we work on treating your hypertension." You may think that you are being culturally sensitive. The patient might be impressed, or they might be offended that you assumed they believe in the use of curanderos just because they are Latin American. Here's an example of using that same knowledge but with generalizing: "I think it is important to make sure we treat your hypertension in the most effective ways. Is there anyone else in your life that you want to include as part of the treatment process?" This doesn't make any assumptions, but gives the patient an opportunity to include others if desired.

Stigma of Mental Illness

Stigma of mental illness is often devastating- viewed as disgrace to family and seldom discussed --Somatization more common-> depression should be considered and dealt with tractfully as an "imbalance" --*Mental illness often presents with physical complains Counseling viewed by many as suitable only for hopelessly mentally ill, so unlikely to follow through Since this is a health psychology course, I should point out that research has shown that some Asian cultures report higher than average stigma for mental illness. This makes sense when you consider that highly collectivist cultures could perceive mental illness as bringing shame to the family—where in the U.S. we often see it as an individual's responsibility. Collectivist cultures have higher rates of somatizing symptoms than individualist cultures. Depression is more likely to be experienced through physical symptoms (gastrointestinal distress, physical fatigue/pain) than emotional ones (sadness). Healthcare professionals should understand how somatization might be part of the picture. There is a large literature base suggesting that Asian-Americans have lower help-seeking attitudes and behaviors for therapy than their European-American peers. It's not that counseling isn't an option, but it is often seen as a last resort, and only then for the severely mentally ill. This is challenging for practitioners because about 85% of counseling clients are what we call the "worried well"—people who usually function just fine but have time in their lives where outside professional help is necessary. I learned from a Taiwanese clinician friend that there is no equivalent word in Mandarin Chinese for therapy/counseling, which might explain why research shows lower rates of professional help seeking due to translation issues with surveys. But there are words for helping, guidance, etc., and some clinicians are changing the ways they describe services to decrease the stigma associated with seeking counseling.

Improving Patient-Provider Communication and Reducing Adherence

Teaching Providers How to Communicate -It is now known that anyone, given the desire, has the potential to be an effective communicator -Course of medical treatment can be affected by communication Training Providers -Communication programs should teach skills that can be learned easily, that can be incorporated in medical routines easily -Many communication failures in medical settings stem fro violations of simple rules of courtesy: greeting patients, addressing them by name, telling them where they can ahng up their clothes if an examination is necessary, explaining the purpose of a procedure while it is going on, saying goodbye, and again, using the patient's name. Such behaviors are seen as warm and supportive -Communication needs to be practiced in situations in which the skills will be used. Training that uses direct superviced contact with patients and gives students immediate feedback after a patient interview works well for training both medical and nursing students -Videotaping the student's interactions with patients makes it possible for good and bad points in teh interview to be pointed out. Specially made tapes that illustrate common problems can be used so that students can see both the right and the wrong ways to handle issues -Cultural competence (the developing knowledge and skills for communicating with a multicultural patient) is emphasized -Nonverbal communication can create an atmosphere of warmth or coldness. A forward lean and direct eye contact can reinforce an atmosphere of supportiveness, whereas a backwards lean, little eye contact, and a postural orientation away from the patient can undercut verbal efforts at warmth by suggesting distance of discomfort. The ability to understand what patients' nonverbal behaviors may mean can also be associated with better communication and adherence -More complex material may be introduced into courses, such as how to draw out a reticent patient,how to deal with a patient's guily or shame over particular symptoms, how to learn what a symptoms means to the patient, and how to communicate bad news -Patient-centered communication is one way to improve the patient-provider dialogue. This type of communication enlists the patient directly in decisions about medical care: providers try to see the disorder and the treatment as the patient does, and in so doing enlist the patient's cooperation in the diagnostic and treatment process. This approach seems to be especially effective with "difficult" patients, such as those who are anxious. Evaluations indicat that communication training with physicians can improve pateitn satisfaction with care Training Patients -Teaching patients skills for eliciting information from physicians -Study: women who listed questions in advanced asked more questions during the visit and were less anxious -Study: third condition: some women received a message from their physician encouraging question asking. These women also asked more questions they wanted to, had greater feelings of personal control, and were more satisfied with the office visit Probing for Barriers to Adherence -Patients are really good at predicting how compliant they will be with treatment regimens. By making use of this knowledge, the provider may discover what some of the barriers to adherence will be -For the vocational and social advice for which nonadherence rates are known to be high, special measures are needed. The health care provider can begin by explaining why these seemingly nonmedical aspects of the treatment regimen are important to health -Bc of face-to-face nature of patient-provider interaction, the provider may be in a good position to extract a commitment from the patient- that is, a promise that the recommendations will be undertaken and followed through. Associated with increased adherence -Breaking advice down into manageable subgoals that can be monitored by the provider is another way to increase adherence -The importance of the physicians' recommendation should not be underestimated. When lifestyle change programs are "prescribed" for patients by physicians, patient show higher rates of adherence than if they are simply urged to make use of them -Best way to think about adherence is as an effective combination of information, motivation, and behavioral skills Health Care Institution Interventions --Postcards or phone calls to patients reminding them to return can reduce high rates of no-shows -Reducing the amount of time a patient must wait before receiving service also improves the rate of follow-through on appointments

Role of Mass Media in Health Promotion

There are generally three goals for the role of mass media in promoting positive health. 1. Raise public awareness about a problem or issue -E.g., Pink Ribbon campaign to raise awareness about breast cancer 2. Create climate of opinion and provide food for thought -E.g., recent advertising by consumer product companies trying to get peope to buy (more expensive) gluten-free versions of food 3. Stress ill effects of unhealthy behavior and benefits of preventative behavior

Application of Mass Media

Two major ways that health information is communicated, and both have their pros/cons: 1. Planned campaigns and advertising -Advantage of targeting wide audience and tailored to meet specific objectives -Ex. Truth campaign -The most commonly used approach is through planned campaigns. These are well-organized efforts to craft messages to apply to certain audiences. Teams of people conduct focus group interviews, conduct surveys, test messages on sample groups, etc. The national truth® campaign to prevent youth smoking is one of the classic examples. It cost 100s of millions to develop and launch, and continues to be researched on its effectiveness. The challenge with formal campaigns and advertising is that people can be skeptical of them based on who is actually funding the campaign. There has been backlash against some campaigns once people find out the companies behind them. 2. Unpaid publicity and media advocacy -May be low-cost campaigns that can sometimes seem to provide greater credibility to target audience -Ex. Canadian Public Health "The Crazy Race" based on answering health questons correctly --inital group of 215 were sent an invitation to participate --After 15 days, generated 110,200 Web user participatns who registered and sent a total of 439,275 invitations without any advertising -Viral marketing and unpaid publicity is another way to get messages across. Often they are low-cost, and for whatever reason, pick up considerable popularity by people sharing the info with each other through their social networks. In some cases they are seen as being more credible because they are shared among peer groups. I am more likely to trust the recommendation of a close friend than some stranger suggesting a product. It is notoriously difficult to purposefully develop a viral marketing campaign, but the Canadian Public Health service was able to develop and study a campaign designed to raise awareness of general health behaviors. It involved a short trivia game that sped people through a race based on how they answered the questions. The initial invitation group was encouraged to challenge their friends to beat their times, and two weeks later the 215 initial users grew to almost 440,000 participants.