JW L1 Course Introduction_24Sep2024 PDF

Theories and concepts of health behaviours PHPC2016 Assistant Professor Johnson Wang BMed, MMed, PhD JC School of Public Health and Primary Care,...

Theories and concepts of health behaviours PHPC2016 Assistant Professor Johnson Wang BMed, MMed, PhD JC School of Public Health and Primary Care, Faculty of Medicine, CUHK The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong September 2, 2024 1 Outline for today’s lecture 1. Overview of this course 2. Psychosocial construction of health and illness (1) Health, illnesses, and diseases (2) Medicalization (3) Illness representation 3. Social determinants of health (1) WHO social determinants of health (2) Multi-level determinants of health (3) Social capital The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 2 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong 1. Overview of the course The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 3 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong You may have the following questions when you are choosing this course/program: Why health behaviours are important? What are behavioural change theories? How can they help us? How to change health behaviour? Is it hard? Let us find out the answers! The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 4 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Importance of health behaviours Increasing prevalence of non-communicable diseases due to unhealthy behaviours (over half and increasing). Behavioural diseases (e.g., addictions, internet gaming disorder) Behaviours and infectious diseases HIV: majority were caused by risk behaviours (condomless sex, injection drug use) Emerging infectious diseases (e.g., COVID-19): behaviours play important roles in prevention and control (e.g., vaccine hesitancy, facemask wearing, physical distancing) New technologies, theories, and methods for behavioural changes Example: ChatGPT, Chatbots, artificial intelligence (AI) Ø Human behaviours are complicated Ø We need interdisciplinary approaches (psychology, sociology, anthropology, economics, IT) Ø You may need to work with vulnerable groups (equity) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 5 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Behavioural health An umbrella term that describes the connection between behaviors and the health and well- being of people. Emphasizes on: Interactions among bio-medical, behavioural, psychosocial/cultural factors, and health outcomes Example: Factors affecting outcomes/progression of diabetes mellitus Behaviours: testing, self-care, diet, adherence to treatment, physical activity Culture/Psychology: mental health status (depression), perceptions Biomedical: medication, comorbidity (presence of one or more additional conditions co-occurring with a primary condition, often involve chronic diseases) Requires interdisciplinary input Complementary with various disciplines Lau JT. Commentary: Proposal for an update of the definition and scope of behavioral medicine. Int J Behav Med, 2017; 24(1): 12-15 6 Social and behavioural science is required for public health training The Association of Schools of Public Health emphasize five key competencies for public health training Biostatistics Social and behavioural science Environmental health Epidemiology Health policy and management Social and behavioural science will broaden your vision as a public health worker and differentiate you from clinicians Associations of Schools of Public Health: http://www.asph.org/document.cfm?page=851 7 Learning objectives of the course Understand the definitions and social constructions of health Understand major behavioural change theories and their application in formulating strategies to change health behaviors Understand key concepts in planning and evaluating health promotion The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 8 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Contents of this course 1. Concepts of the social construction of health 2. Major behavioural change theories (at individual, interpersonal and community levels) 3. Essential concepts in health promotion (e.g., need assessment, appropriate communication channels/methods, evaluation) 4. A group project (including tutorials) — to apply what you have learned from this course to design a health promotion program The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 9 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Assessments Mid-term: 30% — covering first 5 lectures — Lecture 1: Social construction of health — Lecture 2: Fear appeal approach and the Health Belief Model — Lecture 3: Theory of Planned Behaviours and Stages of Change — Lecture 4: Social Cognitive Theory, social support and social network — Lecture 5: Communication Theory, Diffusion of Innovations Group project with peer evaluation: 25% (group mark) + 5% (peer evaluation) — About 8 students per group. — Each group will be led by a tutor (Prof. Johnson Wang, Prof. Phoenix Mo, or Prof. Sherry Yang) Final exam: 40% — covering the following lectures, no overlap with the mid- term exam — Lecture 7: Social marketing and health promotion — Lecture 8: Implementation science — Lecture 9-10: Health promotion program planning and evaluation The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 10 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Teaching assistants and their roles Mr. Siyu Chen, Mr. Doug Cheung, and Mrs. Shuyi Wang will work as TAs to support this course Roles of TAs — Facilitate class discussions — Answer questions related to lecture content — Evaluate group project presentations — Handle course administration issues The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 11 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong 2. Psychosocial construction of health and illnesses The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 12 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Psychosocial construction of health and illnesses Health and illnesses do not naturally exist — they are ‘discovered’ (defined) by people. Their definitions change over time. Creating an illness and how people think about (perceive) their illness have important implications on their behaviours and health outcomes. We will first look at: Ø Health, illnesses and diseases Ø Medicalization Ø Illness representation The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 13 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong (1) Health, illnesses, and diseases WHO definition of health Health is a state of complete physical, mental and social well-being, not merely absence of disease or infirmity (WHO, 1948) However, the concept of health may change over time! Health and illness may be relative terms! http://www.who.int/about/definition/en/print.html 14 Definition of illness and disease Is illness the same as disease? — The two terms are often used interchangeably — They capture different aspects of health problems (Jennings, 1986; Wikman et al., 2005) Disease = “the malfunctioning of biological and/or psychological processes” (Kleinman A, 1980, p.72); often has biomedical cause(s) Illness = “the psychosocial experience and meaning of perceived disease” (Kleinman A, 1980, p.72) — A person with hypertension is diseased but may not feel ill — A person with anxiety feels ill but not necessarily diseased — A person with HIV is diseased, may or may not feel ill The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 15 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Changes in the Definitions of Illness and Diseases in the Post-Modern Era Post-modern era — The period commencing about 1950, after the end of World War 2 Before the post-modern era — Located the truth of illness from the doctor’s narratives — Embraces the biomedical model of illness — Views bodies as machines and separate bodies from minds — Illness = a malfunction of biophysical mechanisms In the post-modern era — The control of representation of illness is shifting from doctors to patients — Internet provides an unregulated and previous unimagined space where patients converse with patients in the absence of doctors — Embraces the biocultural / biopsychosocial models of illness — Illness = unique experience of a meaning-making, embodied cultural being + malfunction of biophysical mechanism 16 Post-modern illness Some features of modern illnesses (David Morris). Ambiguity of existence Reflective of lifestyle and politics Fragmentary and interdisciplinary Bio-cultural manifestations of post-modern illness Mysterious diagnoses The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 17 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Chronic pain Before the post-modern era — Biomedical model --- results of nerves and tissue damages However …… — Your pain and my pain, even with identical forms and degree of nerves/tissues damage, may differ significantly due to differences in personal histories, memories, and social network. — People who “hardly ever” enjoyed their jobs were 2.5 times more likely to report back pain in the workplace than people who said they “almost always” enjoyed their jobs ---- anatomy and physiology could not provide an explanation Definition of chronic pain in the post-modern era — Pain is not the transmission of noxious impulses, it is “always psychological” and always a “subjective state” --- The International Association for the Study of Pain 18 Depression --- an example of post-modern illness Symptoms and patterns can be very different from person to person (ambiguity of existence) — Feeling a loss of pleasure or interest in activities (last most of the day for at least two weeks) — Poor concentration — Disrupted sleep — Changes in appetite or weight (eat much more/less) — Feelings of excessive guilt or low self-worth — …… It can be: 1) single episode depressive disorder, 2) recurrent depressive disorder, 3) bipolar disorder 19 Depression --- an example of post-modern illness (cont.) Factors contributing to depression (bio-cultural manifestation) — Complex interaction of social, psychological, and biological factors. — Adverse life events (e.g., traumatic event) — Behaviors (e.g., physical inactivity, harmful use of alcohol) — Biological (e.g., biological parents had depression, caused by physical diseases) Diagnosis of depression (mysterious diagnosis) — Psychiatric evaluation (e.g., fill out a questionnaire), DSM-5 (by mental health professionals) Treatment of depression — Psychological treatment (e.g., cognitive behavioral therapy) — Anti-depressant medications 20 Other examples of post-modern illnesses Internet gambling disorder Drinking: cultural differences 21 Social construction theories “Truth” is created through a process of communication (R L Scott) It is formed in the context of: Ø A set of social norms, Ø Experience or matters that serve as reference points in working out human contingencies Ø Results of a process of interaction at a given moment Some examples Ø COVID-19 (from “zero-COVID” to “live with COVID”) Ø Can internet gaming be a disease? (social norms: too much gaming may not be good; we have problems with people gaming all the time) — experts meet to decide whether it is a disease 22 Social construction of health and illness Biological perspective (which dominated before the post-modern era) - Defined by laboratory tests, imaging, normal range, DSM (psychiatric diseases) - Being organic, verifiable, measureable signs of disease - Conveyed in the authoritative voice of physicians Social construction approach - People have their own understanding of health problems (Internet research) - Health being socially defined (social media) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 23 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Example: Mental illness is socially constructed “What is viewed as normal in one culture may be seen as quite aberrant in another…Notions of normality and abnormality may not be as accurate as people believe” (Rosenheim, 1973) In Cambodia and minorities in China (these symptoms are god’s punishments) One study published by Rosenhan (1973) — Faked symptoms of “madness” to be admitted to mental asylum — Once admitted, the person acted normally — Normal behaviours were labelled as abnormal — Kept in.. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 24 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Example: Mental illness is socially constructed (cont.) People appraise early signs of mental disorders and decide what should be done before seeking help from professionals (Hollingshead & Redlick, 1958; Link et al., 1999) Few people seek medical consultations to take care of mental health symptoms (Plaut, 2003) People diagnose themselves and others (a study in HK) — 9.2% believe they have mental illnesses without being diagnosed — 2.8% had been suggested by family members to have mental illnesses, in the absence of any medical suggestions — People consult their family members, and/or doctors and people like to play doctors The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 25 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Quiz 1. Presence of illnesses are determined by scientific methods? 2. Does health = absence of disease? 3. People who is diseased may not feel ill. 4. People who feel ill may not have diseases. Answer: True / False / Don’t Know The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 26 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong (2) Medicalization A process by which nonmedical problems become defined and treated as medical problems, usually in terms of illnesses or disorders — Changing a process or a condition considered normal into one requiring medical intervention (Conrad, 1992) Embraces the biomedical model of health Expansion of health problems and lowering threshold for treatment Creation of new diseases The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 27 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Example of medicalization #1 Social Anxiety Disorder – the Story of Paxil Ø “A cure that went out to look for a disease and found it” Ø FDA approved Paxil for treatment of depression in 1996 (in an already saturated market for treatment of depression after Prozac). Manufacturer of Paxil requested FDA’s approval for use of Paxil to treat panic disorder, obsessive compulsive disorder at first and then social anxiety disorder and generalized anxiety disorder, which was approved in 1999 and in 2001. It becomes one of the three most widely recognized drugs, after Viagra and Claritin (Marino, 2002) Ø Medicalization of emotion (e.g., worry, shyness) (Conrad, 2005) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 28 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Example of medicalization #1 Social Anxiety Disorder – the Story of Paxil DSM-IV DSM-5 A marked and persistent fear of one or more Marked fear or anxiety about one or more social or performance situations in which the social situations in which the individual is person is exposed to unfamiliar people or to exposed to possible scrutiny by others. possible scrutiny by others. Exposure to the feared social situation almost The fear or anxiety is out of proportion to the invariably provokes anxiety, which may take actual threat posed by the social situation and the form of a situationally bound or to the sociocultural context. situationally predisposed panic attack. ØThe manufacturer (GlaxoSmithKline) redefined social anxiety disorder as both common (reducing stigma associated with having a mental illness) and abnormal (subject to medical intervention) (Conrad, 2005) ØSophisticated marketing campaigns, creating a perception that social anxiety disorder could happen to anyone (Koerner, 2002). For instance, online self-tests to assess people’s likelihood of having social anxiety disorder The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 29 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Online self-test of social anxiety disorder 30 Can you recognize this small blue pill? 31 Example of medicalization #2 Erectile dysfunction --- more people need treatment The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 32 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Erectile dysfunction and Viagra In the 20th century, erectile dysfunction was seen as psychogenic In 1990s, the problem was redefined as sexual dysfunction, with a strong biogenic nature rather than being psychogenic (NIH Consensus Development Panel on Impotence, 1993) In 1998, FDA approved Viagra as a treatment for erectile dysfunction (primarily intended for the use of older men with erectile dysfunction associated with chronic medical problems) Created a huge market The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 33 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Erectile dysfunction (Cont.) — Active promotion of sexual difficulties as a common problem by its manufacturer (Pfizer): giving a boost in prevalence rate from 10-20 million men to up to 50% of American men having any sort of sexual dysfunction (Conrad & Leiter, 2004) — Build up norms about masculinity and sexual performance: erectile dysfunction is central to masculine self-esteem (Teifer, 1994) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 34 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Example of medicalization #3 Internet gaming Internet addiction — Low self-efficacy and self-esteem — High academic problems, social isolation, family problems — High mental distress and mental health problems (e.g., depression, anxiety, suicidal ideation, insomnia, ADHD, and drug addiction) — Internet addiction has more harmful effects on adolescents as their personality are actively developing Internet gaming disorder — Leads to significant impairment of personal and social functioning — Insufficient physical activity, unhealthy diet, problems with eyesight or hearing, musculoskeletal problems, sleep deprivation, aggressive behaviors, depression, anxiety, ADHD, seizures, and deaths — The clinical presentation is similar to substance use disorder (DSM-5) — High relapse risk The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 35 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Discussion about internet addiction/gaming addiction as disorder(s) In preparation for the DSM-5, the American Psychiatric Association (APA) convened workgroups to recommend improvements for diagnosing psychiatric disorders and specifically asked the Substance Use Disorder Workgroup to consider “behavioral addictions” (including gambling, internet gaming, internet use generally, work, shopping, and exercise) This is a highly controversial topic: Some argued that excessive behavioral patterns do not align well with substance use disorders, or they object to the construct of “addiction” as a medical condition. Others contended that excessive behavioral patterns can result in substantial impairments and deserve equal footing with other psychiatric disorders. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 36 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong The process of medicalization The DSM-5 Workgroup reviewed the literature on non-substance addictive behaviors. They voted to move gambling disorder to the substance-related and addictive disorders section in DSM-5 because of its overlap with substance use disorders in terms of etiology, biology, comorbidity and treatment. In terms of the other putative non-substance addictions, the DSM-5 Workgroup voted to include only one new condition: internet gaming disorder. The DSM-5 Workgroup concluded that research on other behavioral addictions was relatively limited, the adverse consequences were less well documented or less reflective of clinically significant impairment or the behavior pattern was not well aligned with substance use disorders. Therefore, no other non-substance addictions are included in DSM-5 IA (internet addiction) was widely discussed but not included (not specific enough what is Internet use in general) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 37 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Decisions about Internet gaming disorder May 18, 2013 : In the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders; APA, 2013), a new disorder called “Internet gaming disorder” was added in the section on Conditions Needing Further Research. July, 2018: The World Health Organization (WHO, 2018) announced that gaming disorder would be added as a new condition in the forthcoming 11th edition of the International Classification of Disease. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 38 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Treatments of internet gaming disorders According to King’s review (2017), the majority of studies (n =24) utilized diverse psychological or counseling [cognitive-behavioral therapy (CBT), motivational interviewing (MI), reality training, or a combination of psychological and/or counseling therapies interventions], with three studies also including a pharmacological or electro-acupuncture treatment. Pharmacological interventions predominantly employed antidepressants (i.e., bupropion and escitalopram), with one study using a psychostimulant for a sample with comorbid attention deficit problems. 39 Community responses: Yahoo News 「打機成癮」首列精神病 世衞籲納入醫療體系 The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 40 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Do we have internet gaming disorder? In the last 12 months (IGD DSM-5, APA 2013) Yes No 1. Preoccupation with Internet games (the individuals thinks about previous gaming activities or anticipates playing the next game; Internet gaming becomes the dominant activity in daily life) 2. Withdrawal symptoms when Internet gaming is taken away (the symptoms are typically described as irritability, anxiety, or sadness) 3. Tolerance --- the need to spend increasing amounts of time engaging in Internet games 4. Unsuccessful attempts to control the participation in Internet games 5. Loss of interests in previous hobbies and entertainments as a result of Internet games 6. Continued excessive use of Internet games despite knowledge of psychosocial problems 7. Has deceived family members, therapists, or others regarding the amount of internet gaming 8. Use of Internet games to escape or relieve a negative mood (e.g., feeling of helplessness, guilt, anxiety) 9.Has jeopardized or lost a significant relationship, job, or educational career opportunity because of participation in Internet games Yes=1, No=0. If you scored 5 or more, you have internet gaming disorder The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 41 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong What are the impacts of the medicalization of internet gaming disorder? People Ø Parents --- worry, relationship with children Ø Adolescents --- shift control to doctors? Ø Physicians --- potential issues of overtreatment Ø You Treatment Government Policy More studies are needed to find out…… The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 42 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Medicalization and de-medicalization of Homosexuality In 1952, when the American Psychiatric Association published its first Diagnostic and Statistical Manual of Mental Disorders, homosexuality was included as a disorder. In 1973, no longer define (i.e. include in DSM-III) homosexuality as an illness, stating that “homosexuality per se implies no impairment in judgment, stability, reliability, or general social or vocational capabilities.” (Conrad, 1992; Conger, 1975). China follows in 2001. A symbolic de-medicalization (Conrad & Schneider 1980a, Bayer 1981). Homosexuality is at least as often considered a lifestyle as an illness (Conrad, 1992). Scholars (e.g. Murray & Payne 1985) noted the onset of the AIDS epidemic has led to a partial re-medicalization of homosexuality, albeit in a different form. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 43 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Other examples of medicalization Menopause — Used to be a part of life — a deficiency condition on the health and well-being of midlife and older women (estrogen deficiency) — Relates lower estrogen levels to heart disease, osteoporosis and Alzheimer’s disease — Hormonal therapy — benefits and risks (stroke, breast cancer) Colon polyp — Common, especially among elderly — Relates colon polyp to cancers — With the advance in technology, even very small polyp can be found and removed — Polyp removal — benefits and risks (people are followed up regularly and treated as patients after polyp removal) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 44 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong More examples Attention-deficit hyperactivity disorder (ADHD) (Searight & McLaren, 1998) – definition becomes broader and broader Alcoholism (Appleton, 1995) Substance use (Levine, 1992) Shyness (Scott, 2006) Insomnia and snoring (Williams et al 2008) Sterility or pregnancy (in-vitro fertilization, Conrad & Leiter, 2004) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 45 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Pros and cons for medicalization Pros — Medical treatment can sometimes bring improvements — Stigma reduction: many people get mental illness, including you, so it is okay to accept others and to seek treatment Cons — Sometimes neglect the social dimensions of these problems, but only to reduce symptoms — Individualization of social problems (alcoholism) — Shift control to doctors — Encourage over self-assessment and search for medical labels which may be problematic The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 46 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Players contributing to medicalization Medical professionals Pharmaceutical companies (market and interest) Media (self-tests, stories) Professors Celebrities Followers The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 47 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong (3) Illness representations How people think about a disease or health condition Growing evidence suggests that illness representation is important in explaining health behaviors and health outcomes Leventhal’s Common-Sense Model of Self-Regulation — Individuals construct schematic representations of illness based on available information — A health threat (e.g., COVID-19) activates two types of illness representations at the same time — Cognitive representations — regulating the objective threat — Emotional representations — regulating emotions (e.g., anxiety/fear) arising as a result of the threat The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 48 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Dimensions of illness representations Cognitive representations — Identity — What are the symptoms that go with the illness/disease (e.g., COVID-19, hypertension, drug addiction, HIV, influenza) — Cause — Attributing likely causes of the illness/disease (e.g., genetic, environmental, personal choice, others’ faults, fate) — Timeline — the expected duration and course of the illness (e.g., acute or chronic) — Consequences — severity of the illness/disease (e.g., mild or severe) — Treatment and personal control — whether something can be done to control the illness (e.g., can be cured or kept under control) — Illness coherence — overall comprehensibility of the illness Emotional representations — The extent to which individuals are emotionally affected by the illness (e.g., feeling anger, guilt or shame) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 49 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Self-regulation model of illness representations how people make sense/perceive and cope with/self-manage their illness Social and Cultural influences Cognitive representation (e.g., identity, cause, time-line, consequences, controllability) Coping Appraisal Stimuli (external and/or internal) Emotional representation (e.g., fear, anger) Coping Appraisal (Adapted and elaborated from Diefenbach & Leventhal, 1996) 50 Applying illness representations to explain health behaviors Not limited to people with such illness/disease The concept has been expanding to explain health behaviors among healthy individuals, such as COVID-19/influenza/pneumococcal vaccination uptake, hepatitis C virus testing, cancer screening, and self-care practice for chronic diseases. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 51 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Example 1: Illness representations on pneumonia and pneumococcal vaccination uptake among HK elderly Streptococcus pneumoniae is a bacteria causing community-acquired pneumonia, and invasive pneumococcal diseases (sepsis, meningitis) Elderly with some chronic conditions are at high risk of invasive pneumococcal diseases. Four dimensions of illness representations on pneumonia were investigated — Timeline (e.g., pneumonia will last for a long time, 7.5%) — Consequences (e.g., pneumonia is a serious condition, 15.9%) — Treatment control (e.g., treatment can control pneumonia, 24.2%) — Emotional representation (e.g., pneumonia makes me feel afraid, 39.3%) Those who perceived more severe consequences of pneumonia, and belief that treatment can control pneumonia reported higher uptake of pneumococcal vaccination. Taking up pneumococcal vaccination is a potential coping strategy to deal with the health threat (pneumonia) Wang et al. Human Vaccines & Immunotherapeutic, 2020 52 Example 2: Illness representations on hepatitis C (HCV) predicted HCV testing uptake among HK MSM Untreated HCV infection can lead to life-threatening conditions such as cirrhosis and hepatocellular carcinoma Men who have sex with men (MSM) are at high risk of HCV infection Eight dimensions of illness representation on HCV were measured — Cognitive representations: Identity, timeline, consequence, personal control, treatment control, coherence — Emotional representations: concerns, negative emotions Perceived more severe consequences of HCV, belief that treatment can control HCV, and having negative emotions related to HCV were associated with higher HCV testing uptake during a 6-month follow-up period Taking up HCV testing is a coping strategy to deal with the threat caused by HCV Wang et al. Sexually Transmitted Infections, 2020 53 A brief measurement for illness representation (Brief-IPQ) Let us see how COVID-19 sounds to you Please choose from 0-10 If infected, how much will COVID-19 affect your life 0=no affect at all, 10=severely affect If infected, how long do you think COVID-19 will continue 0=a very short time, 10=forever If infected, how much control do you feel you have over COVID-19 0=absolutely no control, 10=extreme amount of control If infected, how much do you think treatment can help COVID-19 0=not at all, 10=extremely If infected, how much will you experience symptoms from COVID-19 0=no symptoms at all, 10=many severe symptoms If infected, how concerned are you about COVID-19 0=not at all concerned, 10=extremely concerned How well do you feel you understand COVID-19 0=do not understand at all, 10=understand very clearly If infected, how much will COVID-19 affect you emotionally (e.g., does 0=not at all affected emotionally, 10=extremely it make you angry, scared, upset or depressed?) affected emotionally Illness representation on COVID-19 may affect use of preventive measures (facemask wearing, hand hygiene), intention to use COVID-19 vaccines, and mental health 54 3. Social determinants of Health The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 55 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong (1) WHO social determinants of health Ten important determinants — Social gradient — Stress — Early life — Social exclusion — Work — Unemployment — Social support — Addiction — Food — Transport WHO. Social Determinants of Health, the solid facts. 2nd Ed. 56 (1) WHO social determinants of health (cont.) 1) The social gradient Life expectancy is shorter and most diseases are more common further down the social ladder in each society. People further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top. Social gradient in health runs right across society. Even among office workers, lower ranking staff suffer much more diseases and earlier death (Fig 1) 57 (1) WHO social determinants of health (cont.) 2) Stress Stressful circumstances, making people feel worried, anxious and unable to cope, are damaging to health and may lead to premature death. 3) Early life The health impact of early development and education lasts a lifetime (e.g., slow growth and poor emotional support raise the lifetime risk of poor physical health and reduce physical, cognitive and emotional functioning in adulthood). A good start in life means supporting mothers and young children. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 58 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong (1) WHO social determinants of health (cont.) 4) Social exclusion Social exclusion results from poverty, racism, discrimination, stigmatization, hostility and unemployment. These prevent people from participating in education/training, and gaining access to services/citizenship activities. 5) Work Stress in the workplace increases the risk of disease. People who have more control over their work have better health. 6) Unemployment Job insecurity increases risk of mental health problem (anxiety and depression), self-reported ill health, and heart disease. Very unsatisfactory or insecure jobs can be as harmful as unemployment --- job quality is important. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 59 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong (1) WHO social determinants of health (cont.) 7) Social support Friendship, good social relations and strong supportive network improves health at home/work/community 8) Addiction People turn to alcohol/substance to numb the pain of harsh conditions, and addiction leads to downward social mobility 9) Food A good diet and adequate food supply are central for promoting health and well- being 10) Transport Cycling, walking and the use of public transportation promote health in different ways (provide exercise, reduce fatal accidents, increase social contacts, and reduce air pollution). The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 60 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong (2) Multi-level determinants of health The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 61 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Socio-ecological model of health Shift from biomedical model of health to social-ecological model of health Ø Individual level: knowledge, attitudes, physiology Ø Interpersonal level: families, friends and social network Ø Organizational level: workplace, formal and informal groupings Ø Community level: physical environment, social capital Ø National level: policies Behavioral change theories are developed at different levels (which will be covered by this course — lecture 2-5) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 62 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Example: Applying socio-ecological model to understand health-related behaviors Self-reported compliance to personal preventive measures (facemask wearing, hand hygiene, physical distancing) among workers at the beginning of work resumption following COVID-19 outbreak in China Pan et al, JMIR, 2020 63 Determinants at different levels Individual level — Knowledge about COVID-19 (e.g., transmission routes) — Perceptions related to COVID-19 (e.g., perceived risk of contracting COVID-19, perceived severity of COVID-19, perceived effectiveness of some preventive behaviors) — Mental health (e.g., depression) Interpersonal level — Information exposure through different media channel (official, unofficial, face-to- face) Organizational level — Preventive measures implemented by factories (e.g., prohibiting non-employee entering workplaces, taking body temperature/sanitizing hands for employee, workplace disinfection, etc.) National level — Policy/guideline about facemask wearing and physical distancing in workplaces The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 64 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong (3) Social capital Overall, social capital is described as what people “do” and “feel” (Harpham et al., 2002) to improve society as a whole (Putnam, 1993). It is the glue that build up connections among individuals for betterment. An aspect of the social structure that actors can use as a resource to achieve their interest Bonds of community that in many ways enrich our lives (Putnam 2001) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 65 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Definition of social capital The most influential original ideas of social capital came from Coleman (1988) and Putnam (1993) — trust, norms and networks. Lochner et al. 1999, takes a more ecological perspective and views social capital as a factor of the social structure not the individual, therefore unlike Coleman and Putnam, social network and support are not included in his model. They included psychological sense of community and other constructs (collective efficacy, neighborhood cohesion and community competence). Harpham et al. 2002 developed two new constructs of social capital, structural and cognitive. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 66 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Structural and cognitive social capital Structural social capital refers to the extent and intensity of networks (e.g. collective action, cohesion, strength of community) Cognitive social capital represents support, trust, sharing and reciprocity (Harpham et al. 2002). Social capital within and across communities are both important Many studies now use one or more of the aforementioned constructs to define social capital based on their specific population (Onyx and Bullen, 2000; Agampodi et al, 2015; Yip et al, 2007) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 67 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong How to measure social capital Structural social capital will include group membership, support from groups, support from individuals and citizenship activities. 68 How to measure social capital (cont.) Cognitive social capital will include 4-items measuring trust, social harmony, sense of belonging and sense of fairness How about Hong Kong in terms of structural and cognitive social capital? Good or bad, getting worse or better? The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 69 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong How social capital works Influence health and risk behaviors: rapid flow of information and social control of deviance Facilitate access to services: draw providers to community Affect psychosocial processes by facilitating provision of social support Caring social relationships and meaningful community connections Maintain social cohesions at times of rapid changes Facilitate community self-help, allow communities to work together to solve collective health problems The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 70 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Social capital and population mental health Three systematic reviews report very strong negative associations between individual cognitive social capital and mental health/disorders (De Silva, McKenzie, Harpham & Huttly, 2005; Ehsan & De Silva, 2015; Agampodi et al., 2015), with social trust and sense of belonging being the strongest factors. (Agampodi et al., 2015) Structural social capital showed no association, conflicting associations and even positive associations with mental health. (Ehsan & De Silva, 2015) The effects of social capital on health and life satisfaction were stronger among females and older people. (Elgar et al, 2011) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 71 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Social capital and adolescent mental health Among Australian youth (n=991), trust in authorities and organizations (19-20) were negatively associated with early adulthood depression. (O’Connor et al, 2011). Among U.S. adults (25-74) (n=724), high social trust and high sense of belonging at baseline was negatively predictive of depression at follow-up; depression at baseline was controlled for (Fujiwara & Kawachi, 2008) In a combined study of both U.K. youth and adults (16+; n=7994), generalized trust was positively predictive of better self-rated psychological health; not trusting others, no social participation and less communication with neighbors (social network) was positively predictive of worse psychological health. (Giordano & Lindström, 2011). A longitudinal study conducted in China (n=5,164) found family social capital (β=- 0.091) and community social capital (β=-0.097) to be negatively associated with mental health (depressive symptoms) among adolescents. (Wu, 2010) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 72 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Parental social capital affect mental health of children Parental social capital affects child well-being (Cheung, 2011; Harpham, De Silva, Jones & Garlick, 2006). Globally, maternal structural social capital has shown positive associations with increased stunting in 8 year olds (Vietnam) and decreased child school enrollment (Ethiopia). (Harpham, et al, 2006) In Vietnam, high cognitive social capital was associated with better nutritional and physical health in 1-year olds and better psychosocial health in 8-year olds. In Peru and Ethiopia, caregiver cognitive social capital was positively associated with being in the correct grade level according to age and school enrolment in 8-year olds, respectively. (Harpham et al, 2006). The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 73 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Other benefits associated with social capital Child development at family, school and community level Public spaces are cleaner Lower crime rates Economic prosperity Better health and well being – 50% reduction in risk of mortality over the next year The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 74 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Neighborhood characteristics & cardiorespiratory resuscitation (CPR) non-provision CPR non-provision --- the failure of bystanders to provide CPR Neighborhood characteristics affect the likelihood of CPR provision — Race (racially integrated > predominately white > predominately black neighborhoods) (Iwashyna, Christakis, & Becker, 1999) 75 The Moving to Opportunity Experiment Between 1994 and 1997, 4,600 families in 5 large cities in the US (Baltimore, Boston, Chicago, Los Angeles, and New York City) were randomly assigned to three groups: — Housing vouchers that can be used to move to low-poverty neighborhoods — Housing vouchers with no geographical restrictions — No assistance In 2002, one adult from each family was interviewed regarding five domains: economic self-sufficiency, mental health, physical health, risky behavior and education. The evaluation found 17% reduction in depression rate and 11% reduction in obesity among the 1st group (moving to low-poverty neighborhoods). The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 76 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong  Social capital in Hong Kong According to the Legatum Prosperity Index, Hong Kong’s social capital is ranked twenty-six out of 142 countries: charitable donations (63.0% in 2012), helping a stranger (55% in 2012), weekly attendance at a place of worship (e.g. social networking) (18.6% in 2010), relying on family and friends for help (82.8% in 2012), being married (social support) (53.5% in 2012), volunteering (15% in 2012) and trusting people (30.3% in 2009). (Legatum, 2014). Overall trust in government, business, media and NGOs has been steadily decreasing in Hong Kong; 67% to 47% from 2013 to 2015. According to the 2015 Edelman Trust Barometer, trust in the government has decreased from 63% (2013) to 42% (2015) and only 43% report trusting elected officials. Overall, majority of Hong Kong people trust family, friends and academic experts the most (2015 Edelman Trust Barometer PPT) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 77 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Neighborhood and health Family Project (HKU) – district differentials in health outcomes: Shamshuipo 2nd best in happiness, top worst in physical health, 2nd best in neighborhood relationship; Central and West: 3rd worst in happiness, neighbor relationship, 3rd best in psychological health and family relationship School of Public Health, HKU http://forum.tvb.com/viewtopic.php?f=92&t=79504 78 Social unrest and population mental health Ni et al, Lancet, 2020 The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 79 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong In-class exercise Please apply socio-ecological model to discuss factors influencing your decision whether to take up a seasonal influenza vaccine. Individual level? Interpersonal level? Organizational level? Community level? Policy level? 80 Keypoints 1. Overview of this course 2. Psychosocial construction of health and illness (1) Health, illnesses, and diseases (2) Medicalization (3) Illness representation 3. Social determinants of health (1) WHO social determinants of health (2) Multi-level determinants of health (3) Social capital The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 81 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong  Thank you [email protected] Major references — Associations of Schools of Public Health: http://www.asph.org/document.cfm?page=851 — Rosenhan (1973). On being sane in insane places. Science, 179, 250-258. — Plaut, S. M. (2003). 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