Health and Sport Psychology PDF

HEALTH AND SPORTS PSYCHOLOGY Dr.ssa USTA Chapter 1.1-1.2-1.3 “HEALTH PSYCHOLOGY AND BEHAVIOR CHANGE” WHAT IS HEALTH? The extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for everyday life, not t...

HEALTH AND SPORTS PSYCHOLOGY Dr.ssa USTA Chapter 1.1-1.2-1.3 “HEALTH PSYCHOLOGY AND BEHAVIOR CHANGE” WHAT IS HEALTH? The extent to which an individual or group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities. WHAT IS HEALTH PSYCHOLOGY? Health psychology is a specialized field within psychology that focuses on the interplay between psychological, behavioral, and physiological processes and how they impact health and illness. Historical context: Emerged in the 1970s as a response to the limitations of the biomedical model, emphasizing a more integrated view of health. Interdisciplinary nature: Draws on clinical psychology, behavioral medicine, and public health for a comprehensive approach. Health psychology and human behavior One of the significant contributions of health psychology is in the development of interventions aimed at changing health behaviors: 1. Health psychology recognizes that behaviors, such as smoking, alcohol consumption, diet, and physical activity, are major determinants of health outcomes; 2. Research has consistently shown that psychological wellbeing, including factors like optimism, life satisfaction, and social support, is associated with better physical health outcomes. Biopsychosocial Model of Health Historical context and development: The biopsychosocial model was developed by George Engel in the late 1970s as a response to the limitations of the traditional biomedical model. → The biomedical model focused primarily on biological factors, such as pathogens and genetic abnormalities, to explain illness, often neglecting the psychological and social dimensions of health. Engel proposed the biopsychosocial model to address this gap by emphasizing the interconnectedness of biological, psychological, and social factors in understanding health and illness. This model represents a paradigm shift in healthcare, promoting a more holistic view of patient care. Applications in health care: 1. Chronic disease management Chronic diseases, such as diabetes, cardiovascular disease, and chronic pain, are particularly well-suited to the biopsychosocial model because these conditions are influenced by a combination of biological, psychological, and social factors. - Effective management of these diseases often requires a multidisciplinary approach that includes medical treatment, psychological counseling, and social support. - The integration of medical treatment, psychological counseling, and social support through a multidisciplinary approach is essential for achieving optimal patient outcomes. ù 2. Mental health The biopsychosocial model is also highly relevant in the field of mental health, where disorders such as depression, anxiety, and schizophrenia are understood to result from a combination of genetic vulnerabilities, psychological stressors, and social influences. - Treatment approaches often combine medication (biological), therapy (psychological), and community support (social). 3. Public health initiatives On a broader scale, the biopsychosocial model informs public health initiatives that aim to address the social determinants of health. - For example, programs designed to reduce health disparities might focus on improving access to healthcare (social), promoting mental health awareness (psychological), and preventing disease through vaccination campaigns (biological). Salutogenic Model of Health Historical context and development: The salutogenic approach or salutogenesis is a term applied in health sciences, and more recently in other fields, to refer to an approach to wellness focusing on health and not on disease (pathogenesis). Salutogenesis translates to “the origins of health”, from the Latin 'Salus' meaning Health, and the Greek 'Genesis' meaning origin or beginning. → The term was first coined in 1979 by the medical sociologist Aaron Antonovsky in his book “Health, Stress and Coping”: that suggested the way people view their lives has a positive or negative influence on their health. The salutogenic model posits that health is not merely the absence of disease but a dynamic state of well-being influenced by the ability to cope with stressors. It centers on the concept of "sense of coherence" (SOC), which is a global orientation that expresses the extent to which one perceives the world as comprehensible, manageable, and meaningful. ➔ Comprehensibility: The belief that events and stressors are structured and predictable ➔ Manageability: The belief that one has the resources to cope with these events  ➔ Meaningfulness: The sense that challenges are worth facing and have personal significance. → On the other hand, “the General Resistance Resources” are the biological, material and psychosocial factors that make it easier for people to perceive life as understandable, structured and consistent. If a person has access to these kinds of resources, there is a better chance for them to deal with the challenges of life and to construct coherent life experiences; general resistance resources would therefore represent a type of health kit that could help individuals and their communities to improve or retain health. Examples: - Money - Knowledge and intelligence - Experience - Self-esteem - Healthy behaviour - Social support - Ego / identity DETERMINANTS OF HEALTH BEHAVIOR Determinants of health behaviors refer to individual, social, and environmental factors that influence how people engage with their health. Key determinants include attitudes, beliefs, motivation, self efficacy, stress, and emotional regulation. → Research consistently shows that these psychological components shape decisions around preventive behaviors (e.g., exercise, diet), health-compromising behaviors (e.g., smoking, substance abuse), and adherence to medical advice. Understanding the role of these determinants is crucial for designing effective health interventions that can change behaviors and improve health outcomes. I. Self-efficacy and health behaviors Initially, self-efficacy was introduced by Albert Bandura (1977) as «an individual’s belief (confidence) about his or her ability to perform a specific behavior or set of behaviors required to produce an outcome» (Bandura, 1977). Self-efficacy is not actually concerned with the specific skills of the person, but rather with the judgments of what a person can do with those specific skills. - Self-efficacy is related to a specific situation in a certain field and cannot be sensed globally. - Self -efficacy is central to behavior change interventions Research has shown that higher self -efficacy is positively correlated with a range of health behaviors, including smoking cessation, weight loss, and increased physical activity. For example, interventions that enhance self - efficacy through mastery experiences (e.g., skill training), verbal persuasion (e.g., encouragement), and vicarious learning (e.g., observing others) can promote sustained health behavior change. ➔ Performance/Mastery experience: it refers to an individual’s previous and related experience, which can influence their perception of whether or not one has the competence to perform the task.  This determinant tends to be what influences self efficacy the most. - Example: In people with intellectual disabilities who have type 2 diabetes, mastery experiences increase their self-efficacy to manage their disease (examples of these experiences include successfully learning about diet, medication administration, and blood sugar monitoring). ➔ Vicarious experience (observational learning, modeling, imitation): it influences self-efficacy expectancy when people observe others’ behaviors, see what they are able to do, note the consequences of their behavior, and then use this information to form experiences about their own behavior. Watching someone like yourself successfully accomplish something you would like to attempt increases self efficacy. - Example: When overweight people see others like themselves lose weight and keep it off by following a sensible diet and exercising, this strengthens their belief in their own ability to do the same. ➔ Verbal/Social persuasion: it refers to verbal encouragement or discouragement about a person’s ability to perform. Typically, the more credible the source, the more impact this source is likely to have on a person’s self efficacy; when people are verbally persuaded that they can achieve or master a task, it goes a long way in boosting their self-efficacy and making it more likely they will do the task. (Remember what coaches do). - Example: Verbal persuasion was used in a program aimed at increasing the self-efficacy of women with hypertension to reduce their salt intake. The program consisted of two in-person 60-90 mins sessions and two follow-up phone calls. During the phone calls, participants were encouraged (verbal persuasion) to resist the temptation to use more than the recommended daily amount of salt. ➔ Imaginal experience: it refers to a person’s use of their imagination to envision his or her success at a task. When models are unavailable or impractical, imagining oneself or others engaging in feared behaviors or overcoming difficulties can be used to enhance self-efficacy and motivation and facilitate effective coping. - Example: Cognitive therapy for anxiety and fear problems often involves modifying visual images of danger and anxiety, including images of oneself coping effectively with the feared situation. ➔ Physical and emotional states: it refers to how one experiences physical sensations and emotional states when facing a task or challenge. Stress, worry, anxiety, and fear negatively affect self efficacy and can lead to inability to perform the feared tasks. - Example: People new to exercising at the gym, especially if they perceive that others are watching them, can become anxious in anticipation of an exercise session. This negative emotional or physical response can be detrimental to their exercise self efficacy and in turn, threaten their continued exercising. II. Perceived susceptibility and risk perception  In health psychology, susceptibility refers to an individual's perception of how vulnerable they are to a particular illness or health condition. People who perceive themselves to be at higher risk of illness are more likely to engage in preventative behaviors. - Ex: Women who believed they were at high risk for breast cancer were significantly more likely to participate in mammography screenings. - Ex: Individuals with heightened perceptions of risk were more likely to seek vaccinations for infectious diseases like influenza. - Health campaigns often use risk communication strategies to increase perceived susceptibility in order to motivate behavior change. BIG FIVE: Personality traits, particularly as defined by the Five-Factor Model (openness, conscientiousness, extraversion, agreeableness, neuroticism), have been found to predict health behaviors. 1. Open to experience → intellectual curiosity, intelligence, creative, reflective 2. Conscientiousness → vigilant, careful, organized 3. Extraversion → outgoing, talkative, energetic 4. Agreeableness → kind, cooperative, trustworthy 5. Neuroticism → anxiety, anger, guilt, frustration Health behaviors = actions individuals take that affect their health, either positively or negatively: ➔ Those high in openness are more likely to experiment with new health behaviors, such as trying new diets, or alternative health practices like yoga, meditation, pilates, etc… ➔ Those high in neuroticism are more likely to turn into health-compromising behavior such as smoking, drinking, binge eating, etc… ➔ Those high in conscientiousness tend to plan and follow their routines, they’re more dedicated (ex: having and following a regular exercise schedule) ➔ Those high in extraversion often seek social activities that include groups sports or social fitness classes because usually these type of people enjoy the social interaction and group motivation ➔ Those high in agreeableness may engage in healthy behaviors that promote well-being for both themselves and the others (ex: quit smoking for themselves and to protect their loved ones from second-hand smoke. For instance, individuals with high levels of conscientiousness are more likely to engage in preventive health behaviors, while those high in neuroticism may experience heightened stress and poor health behaviors. - Conscientiousness was found to be a strong predictor of health promoting behaviors such as physical activity, healthy eating, and medication adherence. (Miller & McGowan, 2019) - Conversely, neuroticism has been associated with higher levels of stress and engagement in risky health behaviors, such as smoking and alcohol abuse. Emotional regulation and health behaviors Emotional regulation refers to how individuals manage and respond to their emotions. Poor emotional regulation can result in impulsive or unhealthy behaviors as a coping mechanism for their negative emotions, such as emotional eating, substance use, or sedentary behavior Emotional regulation difficulties are also linked to overeating and obesity, as individuals often turn to food for emotional comfort. Stress and health behaviors Chronic stress has been extensively studied for its detrimental effects on health behaviors, contributing to both physical and psychological illnesses; for instance, it has been demonstrated that chronic stress significantly increases serum corticosterone levels, indicating a sustained activation of the HPA axis. This chronic elevation of glucocorticoids has been linked to various health issues, including obesity, cardiovascular diseases, and metabolic syndrome, as it can lead to increased appetite and fat accumulation, particularly in the abdominal area. The psychological impact of chronic stress is equally significant, often manifesting as anxiety, depression (happens when chronic stress induces neuronal atrophy and dendritic changes in the hippocampus), and other mood disorders. Chronic stress can lead to maladaptive health behaviors, such as increased substance use, poor dietary choices and sedentary lifestyles. Cognitive processing and decision-making Decision-making is often affected by cognitive biases, which are systematic patterns of deviation from rational judgment; these biases can impair the ability to make sound health-related decisions, as individuals may misjudge the risks and benefits of certain behaviors. → Two important cognitive biases that affect health decision-making are optimism bias and present bias: Optimism bias: Individuals may delay getting vaccinated or attending health screenings because they assume they won’t contract the illness or experience severe symptoms, despite public health recommendations. Present bias: Someone may avoid exercise, focusing on the discomfort and effort involved in the present moment rather than the long-term benefits of improved fitness and reduced disease risk. Knowledge and health literacy Health literacy is critical for determining how individuals navigate healthcare systems, understand medical instructions, and make informed decisions about their health. It is more than just the ability to read health information; it encompasses a person’s ability to obtain, process, understand and use health-related information to make appropriate health decisions. Functional HL = ability of reading, writing and to understand the medical information Communicative HL = seeing if the patient can interact with the health care providers (ex: ask questions and communicate about the treatment) Critical HL = about criticizing the health care information. ➔ Individuals with high health literacy are better equipped to manage chronic conditions, adhere to treatment plans, and engage in preventive health behaviors, leading to better overall health. They are more likely to utilize preventive services, attend regular checkups, and seek care earlier, reducing emergency room visits and hospitalizations. - High health literacy fosters better understanding and communication with healthcare providers, leading to informed decision-making and greater patient satisfaction. - By making informed choices and using healthcare resources appropriately, individuals with high health literacy contribute to reduced healthcare expenditures for both themselves and the system. SOCIAL DETERMINANTS OF HEALTH BEHAVIORS 1. Family influence → Family plays a crucial role in shaping health behaviors, as early experiences and interactions within the family unit often set the foundation for lifelong habits, emotional well-being and coping strategies; research indicates that early experiences, including parental attitudes, modeling behaviors, and communication patterns, significantly impact children's health-related choices. - For instance, parents who prioritize healthy eating and physical activity are more likely to raise children who adopt similar behaviors. - Supportive family environments characterized by open communication, emotional support, and positive reinforcement contribute to better mental health outcomes. - Family also plays a crucial role in shaping health-related decision-making processes and their beliefs and attitudes toward health can significantly influence their children's choices. 2. Peer pressure and social networks → Social Cognitive Theory (Bandura) emphasizes that individuals learn behaviors through observing and interacting with others in their social environment. The influence of peers can both positively and negatively affect individual health behaviors. → Observational Learning: According to Bandura’s Social Cognitive Theory, individuals learn behaviors by observing others and imitating their actions; this process involves not only watching the behavior but also the perceived rewards or consequences associated with it. → Modeling: Peer groups often serve as models for behavior. For instance, adolescents may adopt smoking or drinking habits if they observe these behaviors being rewarded or normalized within their social circles. Negative influences of peer pressure: substance use, risky behaviors (e.g. unsafe sexual practices or reckless driving), normalization of harmful behaviors. Positive influences of peer pressure: health promotion, support networks, social reinforcement. 3. Cultural norms and social expectations → PPT (we’ll get back to it) 4. Social support and integration → Social support is a critical factor in health behavior, influencing both mental well-being and engagement in health-promoting behaviors. - Social networks can provide emotional support, practical help, and motivation for behavior change, such as quitting smoking or adhering to a diet plan. - Individuals with higher levels of social support had lower rates of cardiovascular disease and improved recovery from surgery. - Interventions involving peer support, such as smoking cessation groups, have been shown to increase long-term success rates. 5. Socioeconomic status (SES) → Socioeconomic status significantly impacts health behaviors and outcomes by shaping access to resources, exposure to risks, and opportunities for making health-conscious decisions (ex: advanced treatments, delayed care, access to nutritious food, higher or lower life expectancy, health insurance, comprehension of the medical advices, etc..) 6. Media and social media influence → Media plays a major role in shaping health behaviors through advertising, portrayal of lifestyle choices, and the dissemination of health information. While some media campaigns promote healthy behaviors (e.g., anti smoking ads), others may contribute to unhealthy norms (e.g., glamorization of alcohol consumption, body image..).  - The rise of social media platforms has created new avenues for both positive and negative health influences: social media can promote mental health awareness by providing access to supportive communities and educational resources. Many platforms host mental health campaigns, offering a space to share experiences and seek help, reducing stigma around mental health issues. - In contrast, social media can contribute to body image issues due to the prevalence of unrealistic beauty standards: exposure to edited or idealized images can lead to dissatisfaction with one's own appearance, potentially resulting in lower self-esteem and the development of eating disorders (ex: use use of medication only meant for diabetic people, only to get skinnier). ENVIRONMENTAL DETERMINANTS OF HEALTH BEHAVIORS 1. Built environment → The availability of parks, sidewalks, bike lanes, and recreational facilities has a direct impact on physical activity levels, it creates a synergistic effect that promotes physical activity. Parks provide essential spaces for exercise, social interaction, and relaxation, which can enhance overall well-being. - Also, urban environments that promote walkability and outdoor activities lead to higher rates of exercise. - Conversely, in areas with poor infrastructure (e.g., lack of sidewalks or parks), residents may be less likely to engage in physical activity, increasing the risk of obesity and related diseases. The absence of these critical features can create an obesogenic environment, where the built environment discourages physical activity and promotes sedentary behaviors. 2. Access to healthcare services → Proximity to healthcare facilities is a crucial determinant of health behaviors; individuals living closer to healthcare services are more likely to engage in preventive care and seek timely treatment. For instance, a lack of nearby hospitals or clinics can lead to increased travel times for patients, which may discourage them from seeking necessary medical attention. - Affordability is another critical factor influencing health behaviors. The financial strain of healthcare expenses can lead to postponement of necessary treatments, resulting in exacerbated health conditions. High out-of-pocket costs can serve as a barrier to accessing healthcare services, particularly for individuals in rural and underserved areas. - Health insurance coverage plays a significant role in determining healthcare affordability. - The availability of healthcare professionals is a crucial determinant of health behaviors and outcomes ( for example, rural areas often face significant shortages of healthcare providers, including primary care physicians, mental health specialists, and other essential healthcare workers). 3. Food environment → The types of food readily available in a community affect dietary choices. - "Food deserts," areas with limited access to affordable, nutritious food, force residents to rely on processed and fast foods, increasing the risk of diet-related diseases like obesity and diabetes. - The lack of supermarkets and grocery stores in these areas often results in a reliance on convenience stores and fast-food outlets, which typically offer processed foods high in sugars and unhealthy fats. - In communities with limited access to nutritious food, residents often face barriers such as higher prices for healthy options and lower availability of fresh produce. In contrast, areas with a variety of supermarkets and farmer's markets encourage healthier eating habits. When  communities have better access to nutritious foods, residents are more likely to adopt healthier dietary patterns, leading to improved health outcomes. 4. Public policy and regulations → Public health policies play a crucial role in shaping health behaviors by creating environments that facilitate healthier choices. - Smoking bans in public places were associated with a significant decrease in hospital admissions for respiratory and cardiovascular diseases. - Policies such as minimum unit pricing, restrictions on advertising, and limiting the hours of sale have been shown to decrease alcohol consumption and related health issues. For example, minimum unit pricing in Scotland led to a measurable decline in alcohol sales and associated health problems. - Clear labeling on food products is essential for enabling consumers to make informed dietary choices: consumers are more likely to choose healthier options when nutritional information is readily available and easy to understand. Cultural considerations and their impact on health behaviors Cultural beliefs and practices significantly influence health behaviors, shaping individuals' attitudes toward health and healthcare utilization. Understanding these cultural influences is crucial for developing effective public health strategies. Cultural competence and humility are essential for healthcare providers to engage effectively with diverse populations and address their unique health needs. → Dietary practices: Some cultures follow specific dietary restrictions, such as vegetarianism in Hinduism or kosher diets in Judaism, which can influence nutritional health and food choices. → Health-seeking behaviors: Certain cultures, such as in Japan, emphasize preventive care and regular checkups, while others may only seek medical attention when symptoms are severe. → Childbirth and reproductive health: In many cultures, childbirth practices, such as home births or traditional midwifery, are preferred over hospital deliveries, affecting maternal health outcomes. → Mental health treatment: In some Latin American and Asian cultures, mental health issues are often considered a family matter and may be hidden or treated within the family, rather than seeking professional help. UNDERSTANDING HEALTH BEHAVIORS Steps to provide healthier lifestyles: 1. Reviewing evidence-based strategies for promoting healthy behaviors at individual, community, and policy levels; 2. Evaluating the effectiveness of interventions such as health education campaigns, social marketing, and legislative policies; 3. Discussing challenges and opportunities in implementing comprehensive health promotion initiatives. health behavior = a behavior aimed to prevent disease (e.g., eating a healthy diet) illness behavior = a behavior aimed to seek remedy (e.g., going to the doctor) sick role behavior = any activity aimed to get well (e.g., taking prescribed medication, resting). ➔ behavioral pathogens = also called “health impairing habits”, they are factors that make you sick (e.g., smoking, eating a high fat diet)  ➔ behavioral immunogens = also called “health protective behaviors”, (e.g., attending a health check). Health behavior change involves the process by which individuals adopt or alter behaviors to improve or maintain their health. This field draws on several psychological theories, which offer insights into the factors that influence decision-making and behavior modification. Health promotion, on the other hand, refers to efforts aimed at empowering individuals and communities to make healthier choices through education, policy, and environmental interventions. Why and how do people adhere to healthy behaviors? We define adherence as a person’s ability and willingness to follow recommended health practices. → R. Brian Haynes (1979) suggested a broader definition of the term, defining adherence as: “the extent to which a person’s behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health advice. This definition expands the concept of adherence beyond merely taking medications to include maintaining healthy lifestyle practices, such as eating properly, getting sufficient exercise, avoiding undue stress, abstaining from smoking cigarettes, and not abusing alcohol. In addition, adherence includes making and keeping periodic medical and dental appointments, using seat belts, and engaging in other behaviors that are consistent with the best health advice available. Adherence is a complex concept, with people being adherent in one situation and nonadherent in anothers. There are at least six basic methods of measuring patient adherence are available: 1. Ask the practitioner, 2. Ask the patient, 3. Ask other people (hospital personnel, family members etc.) 4. Objectively monitor a person’s behavior 5. Examine biochemical evidence 6. Use a combination of these procedures. What are the BARRIERS to ADHERENCE? Examples: Many people fail to adhere because their intentions do not translate into behavior. For some people, this may occur because of behavioral willingness, which represents a person’s willingness to engage in risky behaviors at a given moment (this happens with strong social pressures). People may also not adhere because they do not plan adequately: implementational intentions represent specific plans that link a situation with the enactment of a behavior and can boost adherence to a variety of health behaviors. Strategies for behavior change ➔ Motivational interviewing (MI) is a person-centered counseling method developed to enhance an individual's motivation to change by helping them explore and resolve ambivalence. Rather than persuading or advising, MI involves guiding the individual toward their own reasons for change. - It is particularly effective in the areas of substance abuse, medication adherence, and chronic disease management. The core principles of MI—expressing empathy, developing discrepancy, rolling with resistance, and supporting self efficacy—make it a highly respected method in health behavior change. ➔ Goal setting and action planning: goal setting is a fundamental behavior change strategy, particularly when using the SMART framework: Specific, Measurable, Achievable, Relevant, and Time-bound. People who set clear goals are more likely to succeed in behavior change because it gives them a sense of direction and control. Action planning complements goal setting by breaking down goals into smaller, manageable steps and  creating contingency plans for overcoming obstacles. ➔ Nudge theory: Nudge theory suggests that subtle changes in the environment can promote healthier decisions without forcing individuals to choose a particular behavior. - Nudges don't restrict choice but rather make the healthier option more accessible or appealing. This concept, pioneered by Thaler and Sunstein, has been used in various health-related interventions (ex: reorganizing school cafeterias so that healthier foods are more prominent increases the likelihood of students selecting them). Barrier to behavior change a. psychological → stress, anxiety, and low self efficacy can impede behavior change b. socioeconomic and environmental → individuals from lower-income backgrounds often facing greater barriers to adopting healthier lifestyles c. cultural and social norms → in some cultures, certain foods are integral to social gatherings and traditions, making dietary changes difficult. Chapter 1.4 “PSYCHOLOGICAL PERSPECTIVE OF NUTRITION AND FOOD CONSUMPTION” NUTRITION AND FOOD CONSUMPTION Food is not just fuel for the body; it plays a crucial role in shaping our emotions, moods, and mental well-being. Food and mood are intricately connected in a bidirectional relationship: both biological and psychological processes. The foods we consume have a direct impact on our emotional states, while our emotions, in turn, influence the types of foods we crave and consume. → Nutrients, such as omega-3 fatty acids, vitamins, and minerals, have direct impacts on brain function, mood stabilization, and even the prevention of mental health disorders. Conversely, a diet lacking essential nutrients can lead to the deterioration of mental health, contributing to issues such as anxiety, depression, and cognitive decline. - Ex: foods rich in complex carbohydrates, such as whole grains and vegetables, promote steady levels of serotonin, which helps regulate mood, reduce anxiety, and improve emotional stability; - When individuals are stressed, anxious, or depressed, they are more likely to make impulsive food choices, often selecting highly palatable, calorie-dense foods that provide immediate gratification. Nutrients impact: 1. In recent years, the gut-brain axis has emerged as a significant focus in understanding how food affects mental health. The gut-brain axis refers to the bidirectional communication system between the gastrointestinal tract and the central nervous system. This communication is mediated by hormones, immune responses, and neural pathways, with the gut microbiome playing a central role in this interaction. Diet and gut-brain: A diet rich in fiber, fermented foods, and probiotics supports the growth of beneficial bacteria in the gut, which in turn positively affects brain health and mood regulation. → Foods like yogurt, kefir, cheese, and other fermented products introduce beneficial bacteria that help maintain the integrity of the gut lining, reduce inflammation, and produce mood stabilizing neurotransmitters. → Conversely, a diet high in processed foods, sugar, and unhealthy fats can disrupt the gut microbiome, leading to inflammation, which is associated with mental health disorders such as depression and anxiety. 2. The human gut contains trillions of microorganisms, including bacteria, fungi, and viruses, collectively known as the gut microbiome. These microorganisms influence a wide range of physiological processes, including digestion, immune function, and brain health. The gut microbiome produces neurotransmitters, such as serotonin and dopamine, and affects the production of molecules that influence brain function and emotional regulation. Approximately 90% of serotonin, a key neurotransmitter involved in mood regulation, is produced in the gut. Therefore, the health of the gut microbiome can significantly influence emotional states and behaviors. 3. Neurotransmitters: chemical messengers that facilitate communication between neurons which are directly influenced by the nutrients we consume. Different foods and nutrients affect the production and function of key neurotransmitters, which in turn influence mood, cognition, and behavior. - Serotonin: «Happiness hormone» regulates mood, appetite, and sleep; it is synthesized from tryptophan (amino acid), protein-rich foods such as turkey, eggs, and nuts. Low levels of serotonin are associated with mood disorders such as depression and anxiety. - Dopamine: involved in reward, motivation, and pleasure. Synthesized from tyrosine, rich in foods like chicken, almonds, and avocados. Dopamine dysfunction is linked to conditions such as depression, anxiety, and addiction. Psychological food involvement: The emotional connection to eating At the core of understanding how individuals manage their relationship with food is the concept of psychological food involvement. → Psychological food involvement refers to how much a person is mentally and emotionally invested in their food related behaviors, including planning, preparation and the enjoyment of meals. Some people view food as a practical necessity, while others are deeply engaged in every aspect of it (ex: thinking about food, preparing it, and savoring the experience of eating; this involvement is more than just an interest in food, it often reflects deeper psychological and emotional patterns. High food involvement: Often display a more thoughtful and intentional approach to their dietary habits. People may derive more pleasure from cooking or from the sensory experience of eating, and this engagement/high awareness often leads to better nutritional choices. - Studies suggest that high psychological food involvement correlates with more deliberate and conscious food choices. - Individuals who are highly involved with food may be more aware of their nutritional needs and the emotional satisfaction that food can bring. Low food involvement: May approach food in a more utilitarian manner, treating it as a necessary activity rather than a source of enjoyment or engagement. This detachment from the food experience can lead to impulsive eating behaviors, often driven by external factors such as stress or emotional distress, rather than internal hunger cues. - Individuals with lower involvement may be more susceptible to mindless eating or unhealthy food choices due to a lack of engagement in the eating process. However, the psychological attachment to food can also become problematic: people who rely on food for emotional fulfillment may develop maladaptive eating behaviors, such as overeating in response to stress or boredom. This duality highlights the complexity of food involvement, while it can promote healthy eating, it can also contribute to emotional eating patterns, particularly in times of stress. COMFORT FOOD While emotional and stress eating are often associated with negative outcomes, there is another concept that requires examination: the consumption of comfort foods. a. Comfort foods are typically indulgent and rich in fat, sugar, or carbohydrates. b. These foods provide immediate emotional relief, which is why they are often craved during periods of emotional distress. c. The consumption of comfort foods triggers the release of dopamine, the brain’s pleasure neurotransmitter, creating a sense of satisfaction and well-being. d. Comfort foods are often associated with positive memories, nostalgia, or emotional warmth; people tend to turn to these foods during times of emotional distress (stress and sadness) because they evoke feelings of safety, security, or pleasure by triggering the brain’s pleasure pathways. - Ex: foods like ice cream, chocolate, pizza, or macaroni and cheese are common comfort foods because they are rich, calorie dense and provide a sense of emotional satisfaction. → While comfort foods provide short-term emotional comfort, their long-term effects can be detrimental: Regular consumption of high-calorie comfort foods can lead to unhealthy weight gain, poor metabolic health, and increased risk of chronic diseases like diabetes and heart disease; Psychologically, reliance on comfort food as a coping mechanism can prevent individuals from developing healthier emotional regulation strategies, such as mindfulness or emotional resilience. → Interestingly, not all comfort food consumption is necessarily harmful; some research has suggested a "bright side" to stress induced eating. Certain individuals use food to manage stress in a controlled and temporary manner, and in these cases, comfort food can provide short-term psychological benefits without leading to overconsumption or weight gain. However, the line between occasional use of comfort foods and habitual reliance is thin, and individuals with lower food involvement or poor emotional regulation are more likely to fall into patterns of unhealthy eating. EMOTIONAL EATING Emotional eating: it refers to the tendency to eat in response to emotional cues rather than physical hunger. While stress eating is a response to external pressures, emotional eating is a direct response to internal emotional states. - Unlike comfort eating, which may be tied to specific foods or nostalgic experiences, emotional eating is more about using food as a tool for temporal emotional regulation in the face of stress or negative affect. Unfortunately, this relief is fleeting, and emotional eaters often find themselves in a cycle of eating to feel better, only to feel worse afterward. → Emotional eating is often triggered by negative emotional states such as sadness, loneliness, boredom, or anxiety and emotional eaters use food as a way to manage or suppress emotions, seeking out foods that provide immediate comfort or distraction. However, it is not always negative emotions that drive this behavior; some individuals may eat in response to positive emotions, using food as a reward or to celebrate. → Emotional eating is a learned behavior, often beginning in childhood, where food is used as a tool for soothing discomfort. STRESS EATING Stress is an important aspect of modern life, and for many, it significantly influences their eating behavior. → Stress eating, or eating in response to stress, is a common phenomenon where individuals either increase or decrease their food intake depending on how they cope with stress.  - For some, stress leads to overeating, particularly of high calorie, energy-dense foods, while for others, it may result in reduced appetite and food intake. This variability in stress responses is shaped by both biological and psychological factors (factors like sex, body mass index (BMI), and perceived stress levels influence these patterns). - From a biological standpoint, stress triggers the release of cortisol, a hormone associated with increased appetite and cravings for high-fat, sugary foods. This is part of the body's fight-or-flight response, which historically ensured that humans had enough energy reserves to deal with threats. However, in modern life, chronic stress without physical exertion leads to an accumulation of these energy-dense foods, which can result in weight gain over time. Chronic reliance on stress eating can lead to a vicious cycle; stress triggers unhealthy eating, which may result in weight gain, feelings of guilt, and ultimately, more stress. This cycle not only impacts physical health, but also mental well-being, contributing to anxiety, depression and reduced emotional resilience. The Salzburg Stress Eating Scale (SSES): developed to measure individual differences in stress eating, highlights this variability. The scale reveals that individuals with high stress reactivity tend to consume more food during stressful times, which can lead to negative health outcomes like increased BMI and obesity. - Some individuals eat more when stressed, while others eat less. Common psychological barriers that prevent individuals from maintaining healthy eating habits Despite growing awareness of the importance of healthy eating for both physical and mental well-being, many individuals struggle to maintain healthy eating habits. There are some psychological barriers that hinder people from making consistent healthy food choices, such as: 1. cognitive dissonance → the mental discomfort that arises when a person's actions are not aligned with their beliefs or knowledge. - Many individuals understand the importance of healthy eating and are aware of the benefits of consuming a balanced diet rich in fruits, vegetables, whole grains and lean proteins. - However, despite this knowledge, they often engage in behaviors that contradict their understanding of what is healthy, such as overeating, consuming processed foods, or skipping meals. 2. food availability and environment → the food environment, including the availability and affordability of healthy versus unhealthy foods, plays a critical role in shaping eating behaviors. - In many low-income or urban areas, access to fresh, nutritious foods is limited, while fast food and convenience stores offering processed and unhealthy options are abundant. - This "food desert" phenomenon creates a significant barrier to healthy eating, as individuals may not have access to affordable, nutritious foods even if they want to make healthier choices. 3. cultural influence → cultural traditions deeply influence what we eat and how we consume food. Food is more than nourishment: - Social life: Central to gatherings and rituals; - Identity: Reflects cultural values and traditions.  Example: The Mediterranean diet reflects the cultural practices of the Mediterranean region, where meals are often shared communally, and the emphasis is on fresh, seasonal, and locally sourced foods. Urbanization and Westernization have shifted global eating habits: Spread of highly processed, fast foods low in nutritional value; Rise in diet-related diseases and mental health issues. 4. the influence of food advertising and societal pressures → the two main influences that we experience are the: - family influence: households prioritizing healthy eating often raise individuals with similar habits + Unhealthy family habits may lead to struggles with changing eating patterns: - media and peer influence: advertising and social media exert a powerful influence on food choices (ex: marketing campaigns often promote highly processed, sugary, and fatty foods) + social media platforms can contribute to both positive and negative food-related behaviors + Instagram and Pinterest can promote healthy eating showcasing nutritious recipes and lifestyle habits. 5. addiction-like behaviors related to unhealthy foods 6. the complex relationship between body image, self-esteem, and food consumption → ➔ Body image: Poor body image is a significant risk factor for disordered eating behaviors, including restrictive diets, binge eating, and emotional eating. - Individuals who are dissatisfied with their body shape or size may turn to extreme dieting or unhealthy eating patterns in an attempt to control their weight and conform to societal standards of beauty. This can lead to cycles of restrictive eating followed by overeating, as the body responds to the deprivation by triggering cravings for high-calorie, high-fat foods. - Over time, these cycles can result in weight gain, further lowering self-esteem and reinforcing negative eating behaviors. ➔ Self-esteem: Low self-esteem often exacerbates emotional eating, as individuals may use food as a coping mechanism to deal with feelings of inadequacy, loneliness, or stress. - Emotional eating provides temporary relief from negative emotions but ultimately contributes to weight gain and poor body image, creating a feedback loop that is difficult to break. - Conversely, individuals with high self-esteem are more likely to engage in healthy eating behaviors and have a positive relationship with food, as they are less influenced by external pressures and more focused on nourishing their bodies for health and well-being. Health promotion STRATEGIES 1. Cognitive-behavioral strategies (CBT) They can be effective in addressing maladaptive eating patterns such as stress eating or emotional eating. These strategies help individuals identify the triggers that lead to unhealthy eating behaviors and develop healthier coping mechanisms.  2. Mindful eating It is an approach that encourages individuals to become more aware of their eating habits and the emotional triggers behind their food choices. It is rooted in mindfulness, a psychological practice that involves paying attention to the present moment in a non-judgmental way. By applying mindfulness to eating, individuals can develop a more balanced and healthy relationship with food, particularly when it comes to emotional eating. → One of the primary goals of mindful eating is to help individuals recognize the difference between physical hunger and emotional hunger: by becoming more aware of emotional triggers, such as stress, boredom, or sadness, individuals can learn to respond to these emotions in healthier ways, rather than turning to food for comfort. - Mindful eating teaches individuals to pay attention to hunger and satiety cues, encouraging them to eat when they are physically hungry and stop when they are full. - Mindful eating involves several key practices, such as slowing down during meals, savoring each bite, and paying attention to the sensory experience of eating (taste, texture, aroma). - By focusing on the present moment and the experience of eating, individuals are less likely to engage in mindless eating, where food is consumed quickly and without awareness. - This practice also encourages individuals to reflect on their emotional state before and during eating, allowing them to identify whether their desire to eat is driven by physical hunger or emotional needs. 3. Improving health literacy Health literacy, defined as the ability to understand and use health information to make informed decisions, plays a crucial role in shaping dietary behaviors; individuals with higher levels of health literacy are more likely to engage in healthy eating practices, recognize the importance of nutrition for mental health, and avoid the pitfalls of fad diets and misinformation. Education for Children: lessons on the importance of balanced diets, the role of nutrients in brain function, and the impact of food on mood and cognitive performance. Education for Adults: useful to increasing health literacy through public health initiatives, community programs, and healthcare providers. 4. Public health initiatives Examples: Encouraging health eating through education Access to nutritious food Culturally sensitive approaches Underserved communities based programs (ex: mental-health focused nutrition campaigns) Policy interventions. Chapter 1.5 “CULTURE, ETHICS AND HEALTH” CULTURE, ETHICS AND HEALTH Culture in health provides a lens through which people interpret symptoms, illness causation, and healthcare-seeking behavior. These interpretations extend to how individuals recognize symptoms, the seriousness they ascribe to those symptoms, and their subsequent health-seeking behaviors. - For example, in some cultures, certain symptoms may be seen as a natural part of aging or a result of spiritual imbalance, leading people to seek non-medical interventions such as prayer, herbal medicine, or community-based healing practices. → In addition to influencing symptom interpretation, cultural beliefs also play a crucial role in defining what constitutes "healthy" behaviors. For instance, in some cultures, thinness might be associated with illness and weakness, while in others, it might be considered an ideal of health and beauty. The perception of a healthy diet may vary significantly from one culture to another, depending on traditional foods and dietary practices; these interpretations of health are deeply rooted in cultural history and values, often passed down through generations. Cultural beliefs about illness causation These beliefs vary significantly across cultures and influence the types of treatments people seek. ➔ Environmental factors: Some cultures emphasize the role of environmental conditions in causing illness. For instance, in Traditional Chinese Medicine (TCM), illness is frequently attributed to an imbalance between the body's internal state and external environmental factors such as wind, cold, or humidity. ➔ Social relationships: In collectivist cultures, illness may be seen as a disruption in social harmony or as a consequence of negative relationships within the family or community. This can result in communal healing practices aimed at restoring relational balance rather than focusing solely on the individual. Impact of health behavior choices These cultural frameworks profoundly influence the health behaviors people adopt in response to illness. → For instance, someone in a society influenced by TCM might prioritize balancing their diet according to yin and yang principles or seek out acupuncture as a primary treatment. In contrast, a person raised in a Western biomedical context may immediately seek out pharmaceuticals or consult a physician when symptoms arise. This divergence in behavior illustrates how cultural beliefs about the body, illness, and treatment shape people's health-related decisions. The PEN-3 cultural model = a framework to integrate culture into health promotion and disease prevention. I. Cultural identity (PEN): Highlights the importance of identifying the cultural identity of the individual, family, or community. Person: Individual behaviors or characteristics; Extended family: The role of family in influencing behaviors; Neighborhood: The broader social and community context II. Relationships and expectations (PEN): Explores the influence of social relationships and expectations on health behaviors. Perceptions: How individuals perceive health risks and benefits Enablers: Factors that enable or hinder health-promoting behaviors, such as resources or infrastructure;  Nurturers: The influence of significant others, such as family or community leaders, on health choices. III. Cultural empowerment (PEN): Focuses on categorizing cultural practices and beliefs related to health. Positive: Practices that enhance health and should be encouraged; Existential: Culturally specific practices that may not affect health directly but are valuable to the culture; Negative: Practices that are harmful to health and need to be addressed in a culturally sensitive way. Example: CULTURAL INFLUENCE OF HEALTH PERCEPTIONS Health beliefs, which are shaped by cultural values can vary dramatically across cultures, influencing whether people focus more on preventive health measures or seek care only during times of acute illness. In this way, we can say that culture not only dictates how health is maintained, but also shapes the broader concepts of what constitutes “illness” and “well-being.” Examples: 1. African Americans position both their ethnic and mainstream culture as important influences on their health behaviors pertaining to food intake and physical activity. - Most participants reported taking advantage of “the best of both worlds” by engaging in picking and choosing healthy behaviors from both cultures to which they belong, and they perceived preparing healthy makeovers as a way to optimize their health. 2. In the Confucian culture of Korea, which values masculinity, depressed males are also less likely to seek help or to visit doctors than females because they may think that it is not masculine. Cultural health practices often fall into two broad categories: preventative and reactive. Preventive health → some cultures prioritize preventative health, believing that maintaining balance in daily life, whether through diet, physical activity, or spiritual practices, prevents illness.  These practices are often deeply rooted in cultural beliefs and traditions, which can significantly influence individuals' health behaviors. For instance, many cultures emphasize the importance of diet and nutrition as a means of preventing disease. - Another aspect of preventative practices is the use of traditional healing methods and rituals. In various African cultures, for instance, herbal medicine and spiritual practices are commonly employed to prevent illness and maintain health. Reactive health → other cultures may emphasize reactive health, where individuals only seek treatment when symptoms become severe or life-threatening. In many cases, the choice of reactive health practices is influenced by the perceived severity of the illness and the cultural stigma associated with certain conditions. For instance, mental health issues may be viewed as a source of shame in some cultures, leading individuals to avoid seeking help from healthcare professionals. Example: Mediterranean diet VS Acute care in the U.S - MEDITERRANEAN: In many Mediterranean cultures, the routine consumption of olive oil, fresh vegetables, and moderate amounts of wine is part of daily life, viewed as essential for maintaining heart health and preventing chronic diseases. These preventative measures are deeply embedded in the culture and contribute to long-term health benefits. - ACUTE: In the U.S., many individuals only visit a healthcare provider when symptoms escalate to a serious level, such as persistent chest pain or high fever. This approach can lead to delayed diagnosis and treatment of conditions. Impact of culture on dietary practices Food holds profound cultural significance and is often linked to spiritual, religious, and social practices; dietary guidelines prescribed by healthcare professionals may sometimes conflict with these culturally ingrained practices, creating challenges for both patients and providers in managing health conditions. → Example: Religious fasting, such as during Ramadan in Islam, is a prime example of how culture impacts dietary behaviors. During Ramadan, Muslims fast from sunrise to sunset, refraining from all food and drink. While this practice is spiritually significant, it poses challenges for individuals with chronic health conditions, such as diabetes, who must manage their blood glucose levels carefully. Cultural beliefs and medication adherence In cultures where traditional or holistic medicine is highly valued, patients may prefer herbal remedies or spiritual healing to pharmaceutical treatments, even when biomedical treatments are readily available; this can lead to challenges in managing chronic diseases that require consistent medication use, such as hypertension or asthma. → Example: In some African and Caribbean communities, traditional herbal remedies are often used in conjunction with or as an alternative to prescribed medications. A patient might take a prescription for high blood pressure medication but also rely on herbs passed down through generations, which are believed to lower blood pressure naturally. This dual adherence to both biomedical and traditional treatments may lead to inconsistent medication use, potentially compromising the effectiveness of the prescribed treatment. Exercise and physical activity In Western cultures, physical activity is often framed in terms of individual fitness and health goals, such as weight loss, cardiovascular fitness, or muscle strengthening. Gyms, exercise classes, and personal trainers are common in these cultures, and physical activity is often pursued as an individual endeavor. → Example: In many Indigenous cultures, physical activity is often integrated into daily life through communal or spiritual practices. Activities like dancing, hunting, and farming are viewed not only as physical exercise but as expressions of cultural identity and spiritual connection. COLLECTIVISM VS INDIVIDUALISM IN HEALTH CARE 1. Collectivism: In collectivist cultures, which are prevalent in many parts of Asia, Africa, Latin America, and the Middle East, individuals see themselves as part of a larger social group, such as family, community, or society. - The needs and expectations of the group are often prioritized over individual desires. - In this context, health behaviors and decisions are heavily influenced by family and community expectations, and individuals may defer to collective norms when making choices about seeking healthcare or adhering to treatment. 2. Individualism: Individualist cultures, which are more common in Western countries such as the United States, Canada, and Northern Europe, emphasize personal responsibility and individual autonomy in decision-making. - Health is viewed as a personal matter, and individuals are encouraged to make choices based on their own needs, desires, and medical advice, rather than prioritizing the needs of the group. - Individuals are expected to take proactive steps to maintain their health, whether through regular exercise, balanced diets, or routine medical check-up. Cultural competence in health interventions Cultural competence in healthcare refers to the ability of healthcare providers to recognize and understand the cultural factors that influence their patients' health behaviors, beliefs, and attitudes. → It developed largely in response to the recognition that cultural and linguistic barriers between healthcare providers and patients could affect the quality of healthcare delivery. → Culturally tailored care acknowledges that health behaviors are deeply embedded in cultural contexts and that one-size-fits-all approaches may not be effective across diverse populations. Tailoring interventions to meet the cultural needs of patients has been shown to increase engagement, improve adherence to treatment plans, and foster trust between patients and healthcare providers. THE ROLE OF ETHICS IN HEALTH Ethics is an academic activity and is defined as the scientific study of morality or the science of morality. → Ethics is an inherent and inseparable part of clinical medicine, as the healthcare professionals has an ethical obligation: - to benefit the patient, - to avoid or minimize harm, and - to respect the values and preferences of the patient. A number of deplorable abuses of human subjects in research, medical interventions without informed consent, experimentation in concentration camps in World War II along with salutary advances in medicine and medical technology and societal changes, led to the rapid evolution of bioethics from one concerned about professional conduct and codes to its present status with an extensive scope that includes research ethics, public health ethics, organizational ethics, and clinical ethics. Bioethics Bioethics is both a field of study and professional practice, interested in ethical issues related to health (primarily focused on the human, but also increasingly includes animal ethics), including those emerging from advances in biology, medicine, and technologies. It proposes the discussion about moral discernment in society (what decisions are "good" or "bad" and why) and it is often related to medical policy and practice, but also to broader questions as environment, well-being and public health. Health professionals face ethical decisions when promoting behaviors that affect individuals' health but may involve some level of persuasion or coercion. Reasons for the importance of bioethics in healthcare Information overload Technology-driven medicine Increased industry sponsored clinical research Changes in health care Changes in health policies Social change Patients are more conscious Factors affecting the development of bioethics The atomic bomb (misuse of science) Nazi experiments Biomedical innovations / technologies (organ transplantation, artificial nutrition, genetic engineering etc.) Civil / human and patient rights Environmental destruction Inequitable distribution of health resources Example: Genetic tests Ethical principles: 1. Beneficence → Acting in the best interest of the patient or population; 2. Non-maleficence → Avoiding harm to patients or populations; 3. Autonomy → The right of individuals to make decisions about their health and medical treatment; 4. Justice → Ensuring fairness in the distribution of healthcare resources and interventions; 5. Fidelity → Being loyal to commitments and accountable for responsibilities; 6. Veracity → Avoiding misleading patients; 7. Confidentiality → Pertains to the amount of information that can be disclosed about a patient without his/her consent; 8. Privacy → Limiting the amount of information to disclose about oneself. Informed consent: informed consent is a fundamental ethical principle that ensures individuals understand the risks and benefits of health interventions before agreeing to them. Ethical dilemma: an ethical dilemma occurs when a person faces two or more conflicting moral principles or values, and choosing one course of action may violate another. → Balancing individual autonomy and public health The autonomy vs. public good dilemma: One of the central ethical challenges in health behavior change is balancing respect for individual autonomy with the need to protect public health. Public health interventions, such as vaccination programs or quarantine measures, can sometimes infringe on personal freedoms for the greater good. - Example: During the COVID-19 pandemic, mandatory lockdowns and mask mandates raised ethical questions. While these measures were intended to protect public health (beneficence and non-maleficence), they also limited personal freedoms, leading to debates about their ethical justification. ETHICAL FRAMEWORKS There are two main ethical frameworks often applied in public health interventions: A. Utilitarian approach = Focuses on the greatest good for the greatest number of people. This approach often supports interventions like vaccination mandates or taxes on unhealthy behaviors, as they benefit the majority, even if they limit individual freedoms. B. Deontological approach = Emphasizes the rights of individuals, including autonomy, regardless of the collective outcome. In this framework, policies that infringe on individual rights for the greater good are often seen as unethical.  ➔ Ethical relativism: this perspective holds that ethical standards are culturally determined, and what is right or wrong depends on a society’s values and traditions. Healthcare professionals who practice in culturally diverse environments must navigate these different ethical frameworks. - Example: in some cultures, euthanasia or physician-assisted suicide is viewed as a compassionate choice, allowing individuals to die with dignity and avoid prolonged suffering. In contrast, other cultures or religious groups may view these practices as morally unacceptable, valuing the sanctity of life above individual suffering. ➔ Ethical universalism: universalism suggests that there are some ethical standards, such as the right to life or the prohibition of harm, that should apply across all cultures. Universalists argue that healthcare professionals have a duty to uphold these universal rights, even when cultural practices conflict with them. - Example: the health area is the global consensus on the prohibition of torture or inhumane treatment in medical settings, such as during medical experiments or treatment of prisoners. - The principles outlined in documents like the Declaration of Human Rights and the Geneva Convention assert that, regardless of cultural differences or local laws, it is universally unethical to harm individuals or violate their dignity in medical contexts. These standards are considered binding for all people, everywhere, irrespective of specific cultural norms or practices. Cultural – ethical conflicts in health care Cultural values and ethical principles can sometimes clash in health interventions when a patient’s deeply held beliefs or community practices oppose medical recommendations that are grounded in evidence based practice. Some common areas of conflict include: Refusal of medical treatment: In certain cultures or religious communities, practices such as prayer, fasting, or traditional healing are preferred over modern medical interventions. - Example: some Jehovah’s Witnesses refuse blood transfusions based on religious doctrine, even when it is medically necessary to save their lives. This creates a conflict between respecting the patient's cultural autonomy and the ethical principle of beneficence, which obliges healthcare professionals to provide lifesaving care. Vaccination resistance: In some cultures, mistrust of government or medical institutions leads to resistance against vaccines, as seen in communities that view vaccines as harmful or unnatural. The ethical dilemma lies in promoting vaccination (nonmaleficence and beneficence) to protect public health, while respecting cultural beliefs that reject this intervention. Traditional practices vs. modern medicine: Some Indigenous communities or rural populations rely heavily on traditional medicine, such as herbal remedies or spiritual healers, and may reject modern medical treatments like antibiotics or surgery. This can conflict with ethical duties like non-maleficence, as ignoring evidence-based interventions may cause harm or death. Chapter 2.1 “THE PSYCHOLOGICAL LANDSCAPE OF CHRONIC DISEASES” MANAGING CHRONIC CONDITIONS 1. Diabetes → a metabolic disorder characterized by hyperglycemia due to insulin resistance or insufficient insulin production. - As of 2021, the International Diabetes Federation estimates that approximately 537 million adults (20-79 years) are living with diabetes worldwide, with the number expected to rise to 643 million by 2030. - Epidemiological trends show a sharp increase in both type 1 and type 2 diabetes, with the rise in obesity and sedentary lifestyles playing key roles. - Geographical distribution: the highest prevalence is in low and middle-income countries, especially in South Asia, the Middle East, and parts of Africa. 2. Hypertension (high blood pressure) → is often called a “silent killer” because it frequently goes undiagnosed until it leads to complications like heart disease, stroke, and kidney failure. - The WHO reports that over 1.28 billion people globally have hypertension, with two-thirds of them living in low- and middle-income countries (WHO, 2021). - Diets high in salt, physical inactivity, tobacco use, alcohol consumption and stress are key contributors to hypertension and genetic predisposition also plays a significant role. - Age and gender distribution: prevalence increases with age and tends to be higher in men up to age 65, after which it becomes more common in women. 3. Cancer → refers to a group of diseases characterized by uncontrolled cell growth, with more than 100 types affecting different parts of the body. - According to the Global Cancer Observatory (2020), there were approximately 19.3 million new cancer cases and 10 million cancer deaths worldwide in 2020. - The most common cancer types include breast cancer, lung cancer, prostate cancer, and colorectal cancer. - Risk factors for cancer include smoking, alcohol use, poor diet, and exposure to environmental toxins like radiation. Main characteristics of chronic diseases: Long duration (typically for three months or more, they often last a lifetime and require ongoing management); Non-communicable (not contagious or infectious, not spread from person to person); Multifactorial causes (including genetic, environmental, behavioral, lifestyle factors); Gradual onset (develop slowly, often without noticeable symptoms at early stages-hard to diagnosis); Periods of stability and flare-ups (relatively stable when symptoms are manageable, however unpredictable flare-ups or exacerbations exist); Irreversible or manageable, not curable (cannot be cured, but can be managed effectively with medical care, lifestyle modifications, adherence to treatment plans); Impact on quality of life (limits a person’s physical abilities, causing pain, impacting mental health, social economic well-being); Risk of complications (lead to organ damage, disability, increased risk of other health issues when left unmanaged);  Need ongoing care (long-term medical care and monitoring including regular check-ups, medication management, and lifestyle modifications); Coexistence of multiple chronic conditions (having more than one condition simultaneously, increases the complexity); Public health challenges (due to their prevalence, impact on morbidity and mortality, and the strain they place on healthcare systems). → As we understood, the relationship between chronic diseases and physical health is multifaceted, encompassing both direct physiological effects and indirect consequences that stem from associated psychological and social factors. Example: Musculoskeletal disorders (MSKDs) have been shown to have a pronounced negative impact on physical health, with studies indicating that conditions like arthritis and chronic lung disease significantly lower physical health scores on assessments such as the SF-36. This deterioration in physical capabilities can lead to increased disease related disability, as individuals struggle with mobility and daily activities, which in turn can exacerbate health anxiety, particularly among the elderly. Social impact of chronic diseases Alteration of social relationships: Individuals often experience changes in their social dynamics, which can lead to feelings of isolation and loneliness. - Example: studies have shown that chronic pain conditions can interfere with social life, family interactions, and professional relationships, leading to a diminished quality of life. The inability to participate in social activities due to health limitations can create a sense of disconnection from peers and community, exacerbating feelings of isolation. - This social withdrawal can further contribute to mental health issues, creating a cycle of decline in both physical and emotional well-being. The need for social support: perceived social support positively influences psychosocial adjustment and coping strategies among patients with chronic conditions. - Support from family, friends, and healthcare providers can mitigate the adverse effects of chronic illnesses, enhancing individuals' ability to cope with their conditions and maintain social connections. - Additionally, the stigma associated with chronic illnesses can lead to social discrimination, impacting individuals' self-esteem and social identity. Socioeconomic burden of chronic diseases on healthcare systems and society The socioeconomic burden of chronic diseases on healthcare systems and society is substantial, affecting not only the direct costs associated with medical care but also broader economic implications, including lost productivity and increased social welfare needs. Chronic diseases, such as diabetes, cardiovascular diseases and obesity, impose significant financial strains on healthcare systems, families and caregivers who often face emotional and financial challenges associated with providing care and society as a whole. - This caregiving burden can lead to negative health outcomes for caregivers themselves, creating a ripple effect that impacts the overall well-being of families + it can also lead to potential conflicts within the household. → The socioeconomic burden also manifests in social inequalities, as chronic diseases disproportionately affect vulnerable populations. The costs associated with managing chronic conditions can lead to stress and reduced access to necessary healthcare services, which can exacerbate physical health issues. Importance of chronic care in healthcare ➔ Modern healthcare emphasizes patient-centered care, which involves tailoring healthcare services to individual patient needs and preferences. Chronic care models prioritize patient involvement in decision-making and self-management, aligning with this patient-centric approach ➔ Quality of Life is the feeling of overall life satisfaction, as determined by the mentally alert individual whose life is being evaluated. Chronic conditions can have a profound and long-lasting impact on individuals' quality of life; managing chronic conditions effectively can improve patients' well-being, reduce symptoms, and enhance their ability to engage in daily activities. ➔ Many complications and comorbidities associated with chronic conditions are preventable with proper management: this includes reducing the risk of heart attacks, strokes, kidney failure, and amputations through effective chronic care. ➔ As populations age, the prevalence of chronic conditions tends to increase: modern healthcare must adapt to meet the complex and evolving healthcare needs of an aging demographic. Chronic care is essential in addressing these challenges. ➔ Effective chronic care often includes strategies for prevention and health promotion. These efforts can empower individuals to make lifestyle changes that reduce their risk of developing chronic conditions in the first place. ➔ Chronic care models promote efficiency and sustainability in healthcare systems by shifting the focus from acute/crisis oriented care to proactive, preventive, and long-term management. This can help healthcare systems allocate resources more effectively. Medical check-ups alone are not sufficient to ensure effective self-management interventions in patients; modern chronic disease care needs well-planned interaction between the healthcare team and the patient to sustain care. For this reason, several organizational models for chronic care management have been proposed and implemented internationally. THE CHRONIC CARE MODEL The best-known and most influential model is the “Chronic Care Model”. → The Chronic Care Model was developed by Wagner et al. in the 1990s: CCM provides a paradigm shift from our current system and a multifaceted framework for redefining our current views on healthcare delivery. The CCM focuses on linking informed, activated patients with proactive and prepared healthcare teams It is used and developed mostly/aims to ensure: - to reduce the cost of care - to improve the quality of care by creating a new interaction policy between previously prepared and trained healthcare teams and better informed patients; - to reduce the economic and social burden of chronic diseases. - the development of existing resources - the addition of new resources Why is the chronic care model important? Improved outcomes in chronic conditions (death-disability rates, quality of life, satisfaction of healthcare services) Patients receive support and build self-confidence to become an active player in their care Caring for patients with CDs consumes too much time for providers: - Keeping records of appointments and follow-ups - Following test results - Patient’s visits to EDs and specialists - Any changes in the patient’s condition Providers must educate staff Stay abreast of the most recent studies Provide care for acute conditions along with existing chronic conditions → The Chronic Care Model addresses the needs of both the patient and the clinician. - Clinicians need a cost-effective program to help them manage the needs of patients with chronic conditions, and chronically ill patients need ongoing care and support. - The needs of both parties can be met when the guidelines of the Chronic Care Model are followed and adjusted to fit into a provider’s organization. - Patients receive management of their chronic condition, and clinicians receive administrative and clinical support to meet the needs of the patient cost-effectively. The Chronic Care Model (CCM): Key components A. Health system: Creating an organization that provides safe, high-quality care A health system’s business plan reflects its commitment to applying the CCM across the organization. - Clinician leaders are visible, dedicated members of the team. This component of the CCM includes: Establishing the necessary infrastructure for care; Cost-effective use and management of resources; Quality improvement; Coordination between agencies; Policy making and healthcare service planning; Supporting agencies to expand self-management programs; Identifying new effective strategies in line with changing healthcare needs. B. Self-management support: Empowering and preparing patients to manage their healthcare Patients who participate actively in their care achieve valuable and sustained improvement in physical and psychological well-being. - The support must include both ways of coping with the disease and the development of personal skills for health and wellness; - Effective self-management helps patients and families adhere to regimens to minimize complications, symptoms, and disabilities associated with chronic disease; - Self-management training (for example, to improve adherence to medications, consistent exercise, proper nutrition, regular sleep, and tobacco cessation) can reduce the frequency of follow-up visits and will prove cost-effective with time + they need to go beyond traditional health education. C. Delivery system design: Assuring the delivery of effective, efficient clinical care and self-management support The clear and explicit definition of the duties and responsibilities of the professionals in the healthcare team. - The key to successful integrated care is effective communication between all participants in the care delivery process and an approach that coordinates the delivery of care and support at the appropriate time; - On the contrary, problems in communication create barriers to successful and effective team management. So we should: planning the roles and responsibilities of the healthcare professionals determining the labor force clearly and precisely providing adequate training for the healthcare team to ensure an increase in the quality of care.  D. Decision support: Promoting clinical care that is consistent with scientific evidence and patient preferences Useful both in dealing with the impact of disease and making choices that support health and well-being. - Healthcare professionals require to have the necessary knowledge for optimal patient care; - Evidence-based clinical practice guidelines and protocols provide standards for optimal chronic care and should be integrated into daily practice to ensure that best practices are available to the clinician Effective technology programs ensure that providers have access to expertise facilitated through evidence-based decision support; - Integration, guidance, and consultation of specialists within the health care team is very important for the decision support component. E. Clinical information systems: Organizing patient and population data to facilitate efficient and effective care Provide and organize the clinical data about the patient population to provide effective and efficient services and facilitate disease management. - Clinical information systems consist of components such as electronic health records, clinical decision support systems, nurse information systems, image management and storage systems, clinical communication systems, telemedicine, case informatics, virtual reality applications, smart card applications, hospital information systems, clinical guidelines, and care maps; - Emerging technologies that add intelligence can be applied to provide busy practitioners the necessary support to ensure quality. For example: The embedding of biometric devices (digital scales, modem-enabled glucose meters, blood pressure monitoring, etc.) into these programs can further enhance patient–provider communication and time-saving opportunities. F. Community resources and policies: Mobilizing community resources to meet needs of patients Refers to cooperation between community resources and healthcare systems. - Development of partnerships with community organizations that meet and support the needs of patients; - Community resources: peer support groups, education programmes, exercise programmes, media, patient organizations etc. Health promotion programs on healthy eating and exercise, weight control, smoking cessation Effective use and support of community-based practices Establishing policies on issues such as reducing the price of healthy food products Ensuring cooperation between the health care team and community leaders and pharmaceutical companies. Facilitators to adapting the CCM Barriers to adapting the CCM Outcomes and impact on patient care Improved medication adherence when cost is a barrier in patients with different chronic diseases Supported the glycemic control and improved the HbA1c levels of type 1 and type 2 diabetes patients Lowered the cardiovascular disease risk factors of patients with diabetes Enhanced patient health status and health-related quality of life Predicted more positive experiences of patients throughout chronic care Improved mental and physical outcomes for individuals with mental disorders. Psychological responses to chronic illnesses Being diagnosed with a chronic illness such as diabetes, cancer or arthritis can come as a blow. It’s normal to experience a range of emotions in the wake of such a diagnosis: from shock and denial to anxiety and fear about the future. - Patients frequently grapple with the loss of their previous healthy identity, which can result in identity disruption. - It can cause the feeling of uncertainties due to recurrence, putting life on hold, depending on treatment. Example: individuals diagnosed with diseases like diabetes or cancer may initially feel  disconnected from their previous self-concept, as the illness forces new constraints on their daily life and future expectations. Once the reality of the diagnosis sets in, patients often face an: ➔ emotional rollercoaster: that includes feelings of helplessness, frustration, and anger. - These emotions are particularly prevalent in diseases that are unpredictable in nature, such as Multiple Sclerosis (MS) or Rheumatoid Arthritis, where flare-ups can disrupt everyday functioning. - Research shows that patients with MS often report higher levels of emotional distress due to the unpredictable progression of their disease. ➔ Chronic sorrow and grief: many individuals experience chronic sorrow, a form of grief that recurs as patients continuously face limitations imposed by their illness. - Chronic sorrow is not a one-time event but a persistent feeling of loss as patients confront the changes to their physical abilities, relationships, and independence. - This emotional burden can be especially profound in conditions like Parkinson’s disease, where progressive physical decline often exacerbates feelings of loss and hopelessness. ➔ Stress: chronic illness inherently imposes long-term stress on the individual, arising from factors such as physical discomfort, medical treatment regimens, financial burdens, and limitations on daily activities. - This type of stress is considered a chronic stressor, meaning it is persistent and lacks a clear resolution. - Chronic stress in the context of illness can lead to negative health outcomes, including heightened levels of inflammation, weakened immune function, and increased vulnerability to secondary conditions. Example: patients with heart disease who experience high levels of chronic stress are at greater risk of experiencing future cardiac events, suggesting that stress exacerbates the physiological progression of illness. ➔ Distress: psychological distress refers to the emotional suffering and discomfort that arises from difficult life circumstances, such as a chronic illness diagnosis. Distress is a broad term that encompasses anxiety, depression, sadness, frustration, and fear, all of which are common in chronic disease populations. - Anxiety: many patients experience health-related anxiety, often tied to concerns about disease progression, pain, and the potential for disability or death. For example, individuals with cancer may experience significant distress surrounding their treatment and fear of recurrence, known as fear of cancer recurrence. - Depression: depressive symptoms are prevalent in many chronic illness populations, with research indicating that approximately 20-30% of patients with chronic diseases like diabetes, heart disease, or cancer develop clinical depression. The emotional toll of living with a chronic condition, combined with physical fatigue and treatment side effects, can contribute to both situational and clinical depression. ➔ Adjustment: refers to the psychological and behavioral processes through which individuals adapt to the challenges posed by their health conditions.  Unlike acute illnesses, chronic conditions often require ongoing management, prompting individuals to make significant lifestyle changes. - Psychological adjustment is not a one-time event but a continuous process of adaptation influenced by personal, social, and environmental factors. - Furthermore, the process of adjustment is not static; it can evolve over time as individuals navigate the challenges of their chronic conditions. - Factors such as changes in health status, treatment responses, and life circumstances can all influence the adjustment process. - Therefore, ongoing support and interventions aimed at enhancing adjustment skills are essential for individuals living with chronic diseases. - Programs that focus on psychological flexibility and resilience can help patients develop the skills necessary to adapt to their changing health needs and maintain a positive outlook on their lives. ➔ Coping strategies: play a vital role in how individuals manage the psychological stress associated with chronic diseases. Coping refers to the cognitive and behavioral strategies that individuals employ to manage the stress and challenges associated with their health conditions. - Coping mechanisms can vary widely, encompassing both problem-focused strategies, which aim to address the source of stress, and emotion-focused strategies, which aim to regulate emotional responses to stressors. - Individuals who utilize problem-focused coping strategies, such as actively seeking solutions or engaging in self-care, tend to report higher quality of life and better emotional adjustment compared to those who rely on avoidance or denial. - Patients with chronic heart failure who adopted proactive self-care coping styles, such as monitoring symptoms and adhering to treatment plans, experienced better health outcomes. Coping also plays a significant role in the adjustment process following a chronic illness diagnosis. - Individuals who develop effective coping strategies are better equipped to navigate the emotional and practical challenges of their conditions, leading to a more positive adjustment overall. For example, coping strategies that involve acceptance and seeking information about the illness can help individuals feel more in control and less overwhelmed by their circumstances. - This adjustment is crucial for maintaining motivation and engagement in self-management behaviors, which are essential for managing chronic diseases effectively. ➔ Resilience: is a positive adaptation after stressful situations and it represents mechanisms of coping and rising above difficult experiences, (ex: the capacity of a person to successfully adapt to change, resist the negative impact of stressors and avoid occurrence of significant dysfunctions). It represents the ability to return to the previous, so-called "normal" or healthy condition after trauma, accident, tragedy, or illness. - The higher the resilience, the lower the vulnerability and risk of illness. - Resilient individuals tend to be optimistic, have a tendency to see everything as a useful experience, focus on personal strengths and qualities, use constructive criticism, develop close relationships with others, have developed social skills, and are emotionally conscious. The five stages of grief model (Kübler-Ross) The five stages of grief model (or the Kübler-Ross model) is popularly known as a model that describes a series of emotions experienced by people who are grieving: denial, anger, bargaining, depression and acceptance. 1. Denial The first stage is shock or denial, and an individual puts forward their defense mechanisms to deflect the actual occurrence of the change. 2. Anger When the reality of change sinks in, it’s manifested in the form of fear or anger. Any change initiative has the potential to spiral out of control in this stage, resulting in significant change failures. 3. Bargaining Once an individual crosses the anger stage of the change curve, they attempt to salvage the situation by exploring the path of least objection. They may try to negotiate and find a compromise. 4. Depression In the depression stage, a person loses hope entirely. There are signs of extreme sadness, regret, and demotivation. 5. Acceptance In the final stage of the change curve, individuals come to terms with the change. Their inhibitions are lowered, they accept the change and start to explore new favorable opportunities that are a result of the change. Leventhal’s common-sense model (CSM) Leventhal's Common-Sense Model (CSM) provides a comprehensive framework for understanding how individuals perceive, interpret and respond to their illness. This model suggests that patients develop cognitive and emotional representations of their illness, which guide their coping behaviors and management strategies. - Cognitive representations include identity, cause, time