HEALTH PSYCHOLOGY lectures.pdf

Building Blocks of Behavior 1- Learning Types of ASSOCIATIVE learning - Classical condi:oning o Link to s:muli to illicit a specific reac:on § Pavlovian dogs § LiCle albert (white rat and loud noise) o Apply to the clinical seIng – limit nega:ve experiences to be associated with the procedure/ the en...

Building Blocks of Behavior 1- Learning Types of ASSOCIATIVE learning - Classical condi:oning o Link to s:muli to illicit a specific reac:on § Pavlovian dogs § LiCle albert (white rat and loud noise) o Apply to the clinical seIng – limit nega:ve experiences to be associated with the procedure/ the environment - Operant condi:oning o Changing behaviour and voluntary choices in response to consequences o Posi:ve and nega:ve reinforcement à increase the behaviour § +VE= increase the reward § -ve= removes the punishment o (ac:on either results in award or removal of punishment) o Decrease behaviour Likelihood of the of the behaviour being o Punishment: nega:ve behaviour and nega:ve response to decrease the response o Spontaneous recovery: fear response triggered out of the blue - Cogni:ve learning o Acquiring new behaviours and informa:on through observa:on and informa:on rather than direct experience o Observa:onal learning § Alfred bandura § No direct experience necessary – see what happens to others Either through punishment or Absence of rewards § Observing models, social situa:ons and is based on human percep:on of the situa:on occurring in front of them § Therapies based on learning theory - Systema:c desensi:za:on - CBT - Behavior modifica:on 1 BUILDING BLOCKS OF BEHAVIOUR 2- MEMORY Hippocampus- responsible for memory. Transfers short term memory to long term memory Types of memory: - Episodic memory– an event happens, and it is remembered. - Procedural memories – taught through repe::on. Types of amnesia - Retrograde - Antero-retrograde Components of memory encoding: getting the info into "memory" storage: maintaining the info in "memory" retrieval: grabbing the info from memory for use Encoding What Is important for encoding to happen: - ACen:on to the event/ info is cri:cal “focusing awareness.” - Divided aCen:on reduces memory. Types: - Shallow: structural—physical appearance - Intermediate: phonemic – sound - Deep: seman:c – meaning Storage Mul:-store model of storage: like a computer analogy àby Atkinson and Shiffrin - Sensory memory – like the CD put in, and can be taken out, temporary o Dependent on s:muli o Info lasts millisecs or secs depending on s:muli 2 o Auditory, tac:le, visual - Short term memory – like a central process system o Rehearsal is necessary to maintain the info (verbally repea:ng it) o Limited capacity- only lasts 20-30 sec o Dependent on aCen:on o 7+/- 2 units of info (i.e phone numbers)à chunking numbers helps remember increased numbers o Hard to mul:task, distrac:ons make you forget it - Long term memory – like a hard drive o Unlimited capacity to remember. à “Working Memory Theory” Baddeley – short term memory theory o Memory can work despite distrac:ons § Eavesdropping on convos in a busy room § Proves that we pay aCen:on surroundings, and can divert aCen:on as necessary (name, gossip, smoke) Format of working memory theory: o a central execu;ve control system § enables us to focus on one or two things in our environment – it is essen:ally responsible for aCen:on; and it is supported by 3 subsystems: 1. the visuospa;al sketchpad à eaves dropping § monitors our visual environment all the :me, in case an important visual s:mulus arises that needs aCen:on diverted to it 2. The phonological loop § is used in everyday conversa:on –thinking or rehearsing what we are going to say conversa:on § taking a few seconds to work out what they are going to say. § “ac:ve listening” in clinical where you try to suppress the phonological loop to an extent, so that you listen to exactly what the pa:ent says. 3. The episodic buffer 3 § § § a temporary and limited capacity store that allows the various components of working memory and LTM to integrate informa:on and serves as an interface between working memory and LTM essen:ally integrates the informa:on in working memory, but also is responsible for retrieving informa:on from long-term memory (situa:onally) responsible for passing rehearsed informa:on into long-term memory. Retrieval - recovering info from memory - can be faulty/not perfect- misinforma:on/ false memories - affected by o :me o meaningfulness o connectedness o retrieval cues o retrieval methods: • recall • recogni:on • relearning • reconstruc:on ForgeIng - ineffec:ve encoding: o problems with encoding due to lack of aCen:on o “pseudo forgeIng” never a true memory to begin with because it didn’t reach storage step - decay of memory o memory fades over :me due to decay in physiological mechanisms - interference with other info o new informa:on impairs reten:on of old – retroac:ve interference o old informa:on interferes with reten:on of new – proac:ve interference - retrieval failure o on the :p of the tongue o difficulty retrieving o note that retrieval is best when the context is similar to the encoding context - mo:vated forgeIng o unpleasant/embarrassing/trauma:zing memories à repressed “Freudian theory” 4 Memory Disorders AMNESIA - retrograde amnesia o inability to remember events that happened prior to onset § retrieval failure - anterograde amnesia o inability to take in new info/ difficulty remembering day to day events § consolida:on failure - post trauma:c amnesia o combo anterograde and retrograde – cannot store new memory, cannot remember past events o onset due to a trauma:c head injury – classified as mild, moderate, severe causes - trauma:c brain injury - drugs - encephali:s - ECT - Alcohol – Korsakoff syndrome - Lack of s:mula:on of neurons – age amnesia - Emo:onal trauma - Alzheimer’s Clinical implica:ons - Understand factors that affect recall o Factors affec:ng encoding o Working memory capacity – chunk info together when presen:ng it o Be aware of how the info is presented § most important given early and summarized at the end à primacy and recency effect o facilitate encoding from working memory to long term memory § rehearsal of info § make info meaningful via examples, ra:onales, and the usage of visual aidesà deep encoding and elabora:on is promoted o facilitate recall § recall cues, diagrams, leaflets, instruc:ons wriCen down personal implica:ons - maximize encoding capacity by reducing distrac:ons - chunk the info – be aware of working memory capacity - don’t shallowly process- not just read/re-read, draw diagrams, make examples, paraphrase, build connec:ons with exis:ng knowledge - recall techniques 5 HUMAN DEVELPOMENT 1: INFANCY TO CHILDHOOD HUMAN DEVELOPMENT includes: - emo:onal - physical - cogni:ve - motor - language Motor development - - con:nuous development o gradual progressive discon:nuous development – by stages o progress in par:cular order because each stage builds on the last; progress through them is strongly related to age; development is marked by major disrup:ve changes o cephalocaudal: § head to foot motor development § upper body development before lower body o proximodistal development § center to outward motor development § control of trunk before control of extremi:es gross motor skills – large muscle groups o moving arms, grab toys fine motor skills – small muscle groups o holding a pencil, finger movements Cogni0ve development Erik Erickson’s Stages of cogni:ve development - landmark stages of cogni:ve development à healthy/ unhealthy growing Age 0-18 months 2-3 years Stage Trust v mistrust Achieved Trust is developed for the caregiver à op:mism later on basic needs are met by the caregiver. Op:mis:c personality Autonomy v shame & Autonomy doubt àself sufficiency Not achieved Mistrust is formed à insecure personality Shame & Guilt 6 3-6 years Ini:a:ve v guilt 6-12 Industry v inferiority à TOILET TRAINING. Encouragement for children to do tasks on their own promotes autonomy Ini:a:ve develops à increased self esteem and confidence through socializa:on àacts all grown up Industry à acquiring new skills, academically and socially à func:oning outside of family à disbelief in own abili:es. Doesn’t think they can do it Guilt à excess conflict because of responses from others when trying to achieve goals = feelings of guilt Inferiority à nega:ve experiences at this stage can develop inferiority Emo0onal development: ATTACHMENT - bonding bw infant and caregiver reflec:ve of paren:ng styles mirrored in how one acts in the future in other rela:onships different from culture to culture o Japan has very liCle avoidant aCachment instances whereas Germany has very many as they try to push independence early on à ATTACHMENT STYLES: - Ainsworth Strange situa:on procedure o Secure (75% of children) § Child is distressed when parent is gone § Not comfortable around strangers w/o parents § When mother is present is more open to strangers § Comforted by parent’s presence § Typically means that the child has trus:ng rela:onships and good self esteem o Anxious-Ambivalent § Child is distressed when parent is gone § Wary around strangers, even when parent is present § Not comforted when parent returns ”how could you do this to me” § Distrus:ng rela:onships, worry their partner doesn’t love them o Avoidant § Avoids parents 7 § § § - Doesn’t seek comfort or contact from parents No preference bw parent and stranger Problems with in:macy, invest very liCle emo:on, cannot share thoughts/feelings Main and Solomon o Adapted aCachment tyles: Emo0onal Development: Temperament Temperament: Innate aspect of personality - Natural way of ac:ng/ reac:ng to the world - Nature vs nurture 3 types: - Easy/ flexible - calm, happy, adaptable, regular in sleeping and ea:ng habits, posi:ve in mood and interested in new experiences - Difficult/feisty/ac;ve- fussy, irregular in feeding and sleeping habits, low in adaptability, fearful of new people or situa:ons, easily upset, highly strung and intense in their reac:ons - Slow/cau;ous – rela:vely inac:ve, reflec:ve, tend to withdraw or react more nega:vely to novelty, but their reac:ons gradually become more posi:ve with experience - COMBO 8 Piaget Theory of Cogni0ve Development Stage 1: sensorimotor period - Object permanence develops Stage 2: preopera:onal period - Lacking conserva:on – if an object’s appearance changes, to the child it is no longer the same object - Centra:on- focus on one thing only, not the other aspects - Irreversibility – can’t take back what has been done - Animism- all things are living creatures - Egocentrism Stage 3: concrete opera:onal - Develop conserva:on understanding – decentra:on - Reversibility - Declined egocentrism Implica0ons for HCPs Concept of illness in children - Can observe child’s behavior and understand needs of the child - What influences children behavior - Understand developmental milestones and educate parents on them to see if their children are mee:ng those milestones and support them in their development 0-2 yrs: Incomprehension as a result of sensorimotor period - Irrelevant answers and evades the ques:on 3-5 yrs: phenominism as a result of preopera:onal - Par:cular objects cause illness but no reasoning behind them o Monsters cause illness because they just do 5-7 yrs: contagion as a result of the preopera:onal period - Illness is caused by objects/people related/near the child, no understanding of the cause - You get measles waling near people 7-9 yrs: contamina;on as a result concrete opera:onal - Illness is understood to be through contact - Illness is viewed as a punishment for being bad - You’re outside without a hat when it is cold causes a cold because you start sneezing 9-11 yrs: internaliza;on as a result of the concrete opera:onal period - Illness is caused by many external factors – swallowed / inhaled = internalized - These children can differen:ate between body organs and func:on and can understand specific simple informa:on about their illness. - They can also see the role of treatment and/or personal ac:on as returning them to health 9 Post partum depression - 13% new mothers - S:gma in women voicing difficul:es auer birth à undetected cases Predictors/Risk factors: 1. Prenatal depression 2. Low self-esteem 3. Childcare stress 4. Prenatal anxiety 5. Life stress 6. Low social support 7. Poor marital rela:onship 8. History of depression 9. Difficult infant temperament 10. Maternity blues 11. Single marital status 12. Unplanned pregnancy 13. Low socioeconomic status Diagnos:c criteria - 2 weeks of dysphoric (low) mood à lacks pleasure in normal ac:vi:es - + 4 of the following: o Appe:te disturbance o Sleep disturbance o Psychomotor ac:va:on or retarda:on o Fa:gue or loss of energy o Feelings of worthlessness or excessive guilt o Impaired concentra:on o Suicidal Idea:on Effects on infants and children - Cogni:ve problems such as lower cogni:ve performance, less crea:ve play as a toddler - Emo:onal and behavioural problems such as anger, withdrawal, less mature expression of autonomy, passive noncompliance, lower levels of interac:on - Nega:ve impact on cogni:ve development - This is resultant of withdrawn/ lack of affec:on from mother 10 Human development: adolescence Adolescence key features: - Synapse forma:on in the prefrontal cortex - Increased control over impulse and decision making - Adap:ve life stage, prepared for change from home to outside world Erickson’s cogni0ve development: Iden0ty vs confusion - Who am I and where am I going Healthy resolu:on of earlier conflicts serve as founda:on for search for iden:ty Adolescents struggle to make decisions Healthy: experiment with iden:ty and roles in society Unhealthy: Lack of confidence: A lack of self-identity can make it difficult for people to have confidence in themselves and their abilities. PIAGET: FORMAL OPERATIONAL - Abstract thinking (not concrete) - Understand hypothe:cals - Capable of abstract logic and debate àUnderstanding of illness: 1. Physiological Good understanding of physiological causes and nature of illness (internal organs effected by different illnesses; cancer is when cells grow too fast); age 11+ 2. Psychophysiological Illness can result from and be aggravated by physiological and psychological causes Social development - Peers play a huge role in the social development of Nature of rela:onships – Early adolescence – non-roman:c friendships, ‘cliques’, groups, clubs – Late adolescence – establish sexual iden:ty. Paren;ng style o Parental responsiveness (acceptance) vs demandingness (control) o Need a balance of control and autonomy- give opportuni:es for growth meanwhile giving guidance, standards, limits o Important for developing independence, self-esteem à indulgent/neglecwulà substance abuse, conduct disorder “ac:ng out” 11 à authoritarian à associated with demonstrate insecurity, anxiety, depression and ea:ng disorders. Impact of chronic illness/ disability o Physical effects § Physical deformity, no:ceable, makes them seem different from their peers, results in lowered self-image/ self-esteem o Emo:onal effects § Aliena:on § Low levels of emo:onal well being o Social/educa:onal/ voca:onal effects § Social isola:on d/t frequent hospitaliza:on § Low educa:on § Difficulty geIng job/ Financial independence Implica:ons for HCPs - Adherence to treatment – conflic:ng priori:es: teenagers care about here and now while drs care about long term - Meet them half way o See adolescent alone / confiden:al seIng o Be non-judgmental o When asking about meds, indicate poor adherence is normal o Explore knowledge base of the teenager; correct misunderstandings o Educate about illness o Nego:ate short-term goals as opposed to long term ones Sexual behaviors in adolescence - Partners have a role in behavior in general Condoms can be s:gma:zing Social expecta:ons and behavior – societal penalty and reward (i.e. culturally) Percep:on of men vs women partaking in sexuality, and sexual behavior 12 Mental health in adolescence - Severe depression Difficul:es in mental health found to impact teens-young adults MWS (my world survey risk index for mental health) o Increased trend in depression and anxiety § protec:ve factors related to mental health such as self-esteem, op:mism and resilience have decreased – especially in females § sleep, physical ac:vity, social media use and pornography use were strongly associa:ons § Risk factors: • Experience of health, work and rela:onship stress • Family difficul:es • Experience of being in an abusive in:mate rela:onship • Having a bisexual or homosexual orienta:on Human development: Adulthood & Ageing Adulthood - No major changes in development – calm in comparison - PaCerns of behavior and psychological states à morbidity/mortality Erickson’s Stages of Development Age 20-40 Stage In:macy vs isola:on 40-65 Genera:vity vs isola:on Met Develops in:mate and healthy rela:onship with others Empathy Understanding of others, love and companionship Grandparent mentality Adult ability to care for another person, guide the next gen à Have children, nurtures them or guidance for the next gen Unmet If sense of iden:ty is undeveloped – fear of commitment and retract into isola:on if unable to form friendships à put current issues and their resolu:on at the forefront or it can lead to stagna:on in later life 13 65+ Integrity vs despair Look back on life posi:vely with sense of accomplishment Life has been wasted, many regrets Baltes theory of successful ageing – SOC model theoretical framework that explains how individuals can utilize their inner resources to transform negative situations into positive ones = increased sa:sfac:on in life à S= SELECTION : reconstructing goals to prioritize those that are most important or meaningful to the individual. The selection process is important because it allows individuals to allocate their limited resources, such as time and energy, to the goals that matter most to them. à O= OPTIMIZATION: engaging in goal-directed actions and means to achieve one's goals. This involves investing time and energy into the acquisition, refinement, and application of goal-relevant means. - acquisition of new skills/resources, and practice of skills, taking advantage of the right moment à C= maintaining a given level of functioning in the face of loss and decline in goal-relevant means. This involves investing in compensatory means to address the declines and losses that occur. Examples of compensation strategies include modifying behaviors, using external aids - acceptance altering and geIng help in order to meet those goals Implica0ons for HCPs Elder abuse - Financial and material Physical/ sexual Psychological Neglect MUST REPORT Care giver burnout - DEATH - Affects women more than men; more ouen the caregiver, although there is an increase in male caregivers of family >40 hrs/ week of care Decreased health, mental and physical o Depression, social isola:on, stress and anxiety à manifest into soma:c symptoms - Kubler-Ross 5 Stages of grief: DABDA DENIAL, ANGER, BARGAIN, DEPRESSION, ACCEPTANCE 14 Risk percep:on Risk percep;on is the subjec've assessment we make about the probability of an event/accident happening and how concerned we are with the consequences - Processing of risk informa:on influences risky behavior à influenced by heuris:cs= cogni:ve bias à adver:sing uses cogni:ve bias and emo:ons Availability heuris;c overes:ma:ng frequency of vivid or easily recalled events – e.g., fear of flying versus fear of travelling in car? Representa;veness heuris;c if something is similar to things in a certain category, it belongs to that category Omission bias – avoid taking ac:on because of too much informa:on à the thought that harm from inaction as less severe than harm from action. à implications in situations where both acting and not acting carry potential risks Unrealis;c op;mism/Op;mis;c bias – some behavior is more risky for others than for self (unrealis:c op:mism) - leads individuals to underestimate their personal risk of experiencing negative events compared to others Public health strategies to increase risk awareness: - Posters with acronyms à FAST for stroke assessment and ac:on = decrease in mortality rate for stroke because people know how to iden:fy and react \ 15 Communica0ng risk Accurately communica:ng risk to pa:ents: - Communica:ng numbers quan:fying risk à being consistent, clear and using precise numbers rather than “low risk/rare” - Use posi:ve and nega:ve stats - Use visual aids to represent data, and show risk in perspec:ve - Express encouragement and hope Rela:ve risk vs number needed to treat vs absolute risk RR - RR is the comparison of the ARs of two groups, such as the intervention group and the control group o “what are my chances of geIng infected rela:ve to a vaccinated person?” Rela:ve risk stats can be misleading – used by companies o e.g., 5/100 die if given no treatment, 4/100 die if given treatment = 20% reduc:on in mortality rate NNT - AR - NNT is the number of people who need to be treated with an intervention to prevent one harmful event Best way to communicate to people stats - AR is the probability of an event occurring in a population Provides context absolute risk reduc:on compares how much your risk reduces by geIng a vaccine. Social context Conformity: Yielding to real or imagined social pressure - fear of being disliked/ made fun of - assump:on that the group collec:vely is smarter - who were the whistle blowers - conformity/lack of repor:ng - criminal proceedings/ gov’t report - obedience à Defini;on: form of compliance that occurs when people follow direct commands, usually from someone in direct authority 16 Milgram’s Experiment - Shock each :me mistake made, increasing by 15v each :me - Agonised protests of “Learner” audible through par::on auer 150v - 300v - “Learner” yells and pounds par::on - 315v - “Learner” groans, swears and pounds par::on - 315v+ - no further sound from “Learner” Bystander effect - People less likely to provide help to those in need when in groups than when they are alone - Diffusion of responsibility: which the responsibility for an action is shared among a group of people, making it less likely that any one person will take action o Someone else will - Pluralis:c ignorance: majority of people privately believe something, but assume that most others believe the opposite. o This can lead to a situation where people are reluctant to act, even if they believe that something is wrong, because they think that no one else cares. o Nazi soldiers in Nazi Germany ALCOHOL USE DISORDER Quan:fying: 17 Criteria: Alcohol Use Disorder DSM-5: Single construct: dis4nguished on number of criteria Mild = 2-3 points Moderate= 4-5 Severe = 6+ Criteria includes: • • • • • • • • • • • Recurrent use à in failure to fulfil obliga:ons Recurrent use à in hazardous situa:ons (inebriated at work, drunk driving) Con:nued use despite alcohol-related social or interpersonal problems Tolerance to alcohol Withdrawal or substance use for relief/avoidance of withdrawal Alcohol craving Drinking in larger amounts or for longer than intended Persistent desire or unsuccessful aCempts to stop/reduce drinking Great deal of :me spent obtaining, using, or recovering from alcohol Important ac:vi:es given up/reduced because of drinking Con:nued drinking despite knowledge of physical or psychological problems caused by alcohol Embedded in learning theory à operant condi:oning: reward from drinking acts as a posi:ve reinforcement as opposed to the repercussions of the hangover later (delayed nega:ve effect) à social learning: self-confidence in social situa:ons; learn by imita:ng peers Dependence: - Gene:cs vs environmental theories o Biology vs social situa:ons o High gene:c “loading” = highly likely suscep:bility to alcohol dependence o Environment = peers, societal percep:on (media, drinking culture), adver:sing 18 Gene0cs - Variable alcohol metabolism based on gene:c background of the individual Nega0ve consequences: - Cirrhosis CVD, diabetes, HTN Cancer Low educa:on aCainment GeIng fired from missing work Financial problems Violent behavior/ involved in bad situa:ons as a vic:m Memory loss/ blacking out , insomnia Repeat accidents or trauma lack of personal care withdrawal symptoms Assessment - Physical condi:ons Psychiatric problems Frequent consulta:ons with different doctors UNIT consump:on, withdrawal symptoms, when the pt first starts drinking in the day Preven0on and treatment Consider support groups if: - Pa:ent fails to benefit from (extended) brief interven:on - pa:ents drink more than 30 units of alcohol daily, or show signs of moderate/severe dependence - have a history of epilepsy, withdrawal related seizures, or delirium tremens - or have comorbid physical or mental health condi:ons CAGE ASSESSMENT TOOL = ASSESS DEPENDENCE 1. Have you ever felt you should Cut down on your drinking? 2. Have people Annoyed you by cri:cising your drinking? 3. Have your ever felt bad or Guilty about your drinking? 19 4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)? +2 more = problem AUDIT-C TOOL= ASSESS FOR abuse, bingeing, frequency, amount If score is 5+, ask remaining AUDIT ques:ons below: Score 8-19: offer brief structured advice Based on readiness to change behavior 20-40 = specialist assessment RISKY SEXUAL BEHAVIOR 20 SEXUAL HEALTH and Health care - Contracep:ves - STI Preven:on and Tx - Fer:lity management: pregnancy, planning, abor:on - HCPs need to know how to address these concerns with pts, build rapport and develop a safe environment for self-disclosure - HCPs need to be educated in concerns, and understand where their role comes in (recommenda:ons for tx, referrals, etc.) RISKY SEXUAL BEHAVIOUR - Sex work - Sex with strangers - Unprotected sex with a partner: genital and oral - Early sexual ac:vity - Having a high risk partner (has mul:ple partners, is an IVDU) Implica:ons for Safe sex prac:ces - Contracep:on - Need to understand the cultural, societal beliefs that influence personal behaviors - Promote STI tes:ng, pap smears, OBESITY 21 Obesity: - Increased body fat as opposed to lean body mass Adverse health outcomes resultant o Physical and mental health implica:ons High heritability of BMI from bioparents o Epigene:cs is involved Obesogenic factors: Measured by BMI: Weight (kg) Height (m2) à normal= 18.5-24.99; overweight >25 à BMI DOESN’T ACCOUNT FOR EVERYTHING AND IS NOT FULLY ACCURATE o Age o Gender o Body frame o Sleep, stress, coping style, financial issues, pain, medica:on side effects o Waist circumference à more accurate in determining risk factor for CVD o Waist:hip ra:o o Adipose :ssue around abdomen TREATMENT 1. 2. 3. 4. Explain health risks Explore reasons for obesity Iden;fy barriers to weight loss Develop weight loss targets with the individual 22 5. Training – brief behaviour change interven;ons 6. Informa:on on suppor:ve services – wriCen informa:on, community based groups, online resources. 7. Monitor any weight changes (safe/unsafe/ineffec:ve) 8. Provide pharmacological support if necessary (~BMI>30) 9. Refer to bariatric surgery service if necessary (~BMI>40) Behavioral therapy Not specific to obesity- seen in smoking and alcohol cessa:on: 5As 1. Ask 2. Advise 3. Assess 4. Assist 5. Arrange follow up § Involves: Diet, physical ac:vity, lifestyle modifica:on Pharmacological therapy To be used when behavioral therapy has not worked - Orlistat – acts on GI and reduces fat absorp:on o Criteria: § a BMI of 28.0 kg/m2 or more with associated risk factors § a BMI of 30.0 kg/m2 or more o First line tx § therapy should be con:nued beyond 3 months only if the person has lost at least 5% of their ini:al body weight since star:ng drug treatment • otherwise d/c § the decision to use drug treatment for longer than 12 months (usually for weight maintenance) should be made auer discussing poten:al benefits and limita:ons with the pa:ent § the co-prescribing of orlistat with other drugs aimed at weight reduc:on is not recommended o Phentermine – reduces appe:te Surgery - to be used when behavioral therapy AND pharmacology has not worked o Gastric bypass surgery 23 o Complica:ons post- op: pneumonia, infec:on, leakage from re-shaped intes:ne o 15%+ of cases fail (e.g., pa:ent snacks con:nuously, fails to lose weight) o Helpful in tx of T2DM, hyperlipidemia , HTN, associated sleep apnea Gender Based Violence UN defini:on: "Gender-based violence is violence that is directed against a person on the basis of gender or sex. It includes acts that inflict physical, mental or sexual harm or suffering, threats of such acts, coercion and other depriva:ons of liberty…. While women, men, boys and girls can be vic:ms of gender-based violence, women and girls are the main vic:ms*.” - Violence against women (VAW) - In:mate partner violence (IPV) Several levels to GBV, encompassed and normalized by: - Family - Community - State/ Ins:tu:ons Sexual Health - Posi:ve, healthy experience - No coercion, discrimina:on, violence (WHO) Sexual rights, are engrained in human rights: Sexual rights protect all people’s rights to fulfil and express their sexuality and enjoy sexual health, with due regard for the rights of others and within a framework of protec:on against discrimina:on - the rights to life, liberty, autonomy and security of the person the rights to equality and non-discrimina:on the right to be free from torture or cruel, inhuman or degrading treatment or punishment the right to privacy the rights to the highest aCainable standard of health (including sexual health) and social security the right to marry and to found a family and enter into marriage with the free and full consent of the intending spouses, and to equality in and at the dissolu:on of marriage the right to decide the number and spacing of one’s children the rights to informa:on, as well as educa:on the rights to freedom of opinion and expression, and 24 - the right to an effec:ve remedy for viola:ons of fundamental rights. TYPES OF SEXUAL VIOLENCE - non-contact = sexual harassment, revenge porn - contact = nonconsensual touching - penetra:ve abuse = oral, anal, vaginal penetra:on - forced marriage - denial to use contracep:on - female genital mu:la:on, compromised sexual integrity of women - forced pros:tu:on/ trafficking, exploita:on key features of GBV - harassment – women more than men, and most ouen in public - violence- from family member - many woman worry about crimes – limi:ng where they go and who they go with - underrepor:ng- disbelief in the vic:m, vic:m retalia:on child sexual abuse = <17 yrs old, children and adolescents adult sexual abuse= >17 yrs old In:mate partner violence à abuse con:nuum - paCern of increasingly abusive behaviour leading to emo:onal/ psychological abuse - control of the partner IPV consequences- short term/long term - physical injuries - IBS – induced by stress - Gynecological disorders, infer:lity, PID - STIs - Unwanted pregnancy, unsafe abor:ons - Unhealthy coping mechanisms - Poor mental health 25 - Fatality Acute tx of vic:m of SA - SATU – treatment unit, works in collab with the police § Tx of the vic:m § Collec:on of forensic evidence - Emergency Dept § Emergency Contracep:on § HIV prophylaxis § Hep b § Evalua:on of safety at home (child) § STI follow up § Offer collab with SATU to collect forensic evidence – this has to have consent obtained by adult pts Implica:ons for HCPS - Advocacy of the pts - Comprehensive and holis:c treatment of the pt o Encourage HCPs sensi:vity training o So that they may effec:vely treat and provide support o Effec:ve assessment à make the environment safe for disclosure o Ac:ve listening, emo:onal support - Referral and support – stop the recurrence of violence; police, shelters etc. - Sex ed to young people – importance of understanding posi:ve sexuality - Look towards the popula:on to see what works (evidence based) - Work with the pa:ents. Consent consent consent - Do not stereotype - Educate on access to services, and culturally competent services Complementary and Alterna:ve Medicine What to ask as a HCP: • Have you ever been to a CAM prac::oner? • Did you wait long to be seen? • How long was the visit? • Did it work? • Have you ever spent money on self-care? 26 Complementary: used with western/modern medicine Alterna:ve: used as a replacement - Goal = treatment/cure/pain management Applies to biopsychosocial model à biomedicine model: what is the best treatment for everyone (overall) Examples: 1. 2. 3. 4. 5. Mind-body interven:ons (Ex: prayer, art therapy, yoga) Biologically-based therapies (Ex: Chinese and ayurvedic medicine) Manipula:ve/Body-based methods (Ex: massage, acupuncture, osteopathy) Biofield/Energy therapies (Ex: Reiki, craniosacral therapy) Alterna:ve medical systems (Ex: Homeopathy, Chinese medicine) à not conven:onal medicine à sought d/t the limita:ons of conven:onal medicine Principles: - Lacks evidence to support - Tailored to individual and their problem Rela0onship between medicine and CAM Integra;ve; A concept that describes the integra:on between western and alterna:ve forms of medicine to offer a more holis:c and individualized approach to healing à complementary + conven:onal Monopoly: only modern medicine is legally recognized Tolerance: state funding goes to medicine, where pts can seek out CAMs privately Parallelism: both are equally recognized and available for pts Implica0ons for HCPs - Evaluate if harmful or not Opportunity to enhance physician-pa;ent communica;on, create a safe space Recognize importance and legi;macy of pa;ent experiences Not be dismissive of what is outside conven:onal medicine Encouraged to look into CAMs o Not prescribe it unless formally trained o Understand the cultural context 27 Healthcare Ethics 4 principles: 1) Respect for Autonomy - Pa:ent ability to choose for themselves 2) Nonmaleficence - Do no harm - Opposite: negligence, professional malprac:ce o Imposing risks, inten:onally/uninten:onally 3) Beneficence: Principle of Beneficence refers to a statement of moral obliga:on to act for the benefit of others. - Non-maleficence - Paternalism = taking control, infringing on the pt § Manipula:on of informa:on § Nondisclosure of informa:on § Decep:on § Lying § Coercion à and jus;fying this ac;on by: § Reference to the pa:ent’s best interests; § Preven:ng harm to the pa:ent; § Mi:ga:ng harm to the pa:ent. 4) Jus;ce - Punishment for malprac:ce - Ra:oning necessi:es based on who deserves it more, and deciding who deserves it more Ethical decision making: 4 QUAD METHOD - Based on: 28 o type and severity of the illness o presence of comorbidi:es and frailty à impairment of the other organs and systems, can the impairment be alleviated with ICU treatment o how long the pt needs ICU care for, can they withstand the treatment o survival o does the pa:ent, informed of the treatment and what it entails, s:ll what to follow through with it Ethical decision making: Pandemic - - minimizing public harm o restrict individual liberty: self-isolate, access to services, limi:ng visitors to hospitals/residen:al facili:es, restric:ng public gatherings. propor:onality o measures to restrict individual liberty should not exceed more than what is necessary solidarity o collabora:ve approach that sets aside self-interest for the greater good. Applies to every level of society. fairness o healthcare resources are distributed fairly, and effec:vely, representa:ve of equality in terms of accessibility for all duty to provide care o code of ethics of all hcps o hcps need to weigh their jobs and obliga:ons with their own health and personal obliga:ons reciprocity privacy o depending on necessity, a person has a right to con:ngent privacy and confiden:ality Procedural Values to Guide Pandemic Time Decision Making - - reasonableness openness and transparency inclusiveness responsiveness o There should be an opportunity to revisit and revise decisions as new informa:on becomes available, as well as mechanisms to address disputes and complaints accountability 29 Placebo RCT- placebo: the pt, through random alloca4on, does not know whether they have the placebo or not Double-blind RCT- placebo: placebo is given to par4cipants through random alloca4on, both par4cipant and experimenter do not know the alloca4on Recent findings: - the blinding doesn’t maLer as much - simula4ng the therapeu4c environment> hiding the fact there is a sugar pill placebo effect: - placebo follows the same trajectory as actual medica4on not as strong as the medica4on placebo users may increase dosage to achieve the same affect= habitua4on o behavioral and physiological responses can be seen o can cause dependency, withdrawal symptoms as well Theories on why placebo works: Non-interac+ve theories Treatment characteris4cs - sham surgery - injec4on - pills: àquan4ty: more>less à size: bigger>smaller àcolor: green>red/yellow àbrand names: well known name over generic ànew> old. à more expensive Pa4ent characteris4cs Interac+ve theories Experimenter bias: - impact of experimenter’s expecta4ons have on the study Repor4ng error 30 - emo4onal dependency extraversion neurosis HCP characteris4cs: - beLer reputa4on of the HCP the more the placebo effect - more enthusiasm - interpersonal skills: warm, empathe4c Physiological theories - confabula+on: symptoms are the SAME, pt reports geWng beLer - biased percep+on of the pt and the doctor= spontaneous improvements Anxiety reduc4on theory: - any treatment reduces one’s anxiety - gate control theory: anxiety reduc-on may close the gate and reduce pain, whereas increased anxiety may open the gate and increase pain Learning theory: - classical condi4oning - treatment is associated with condi4oned s4mulus à elicit a response Pa4ent expecta4ons: - seeing administra4on over hidden - adherence Non-interac4ve theories: - only looks at the pt, tx, professional INDEPENDENTLY - does not look at interac4ons bw physiological theories - placebo ac4vates endogenous opiate release and decreases pain à can be countered by naloxone - placebo can cause habitua4on, withdrawal and dependency Nocebo: - the drug will harm, pt reports side effects of a treatment drowsiness, nausea, fa4gue, insomnia women>men Pain Defini:on: • An unpleasant sensory and emo:onal experience associated with actual or poten:al :ssue damage Note: - Subjec:ve - Sensa:on and emo:on - Pain without injury - Injury without pain 31 Cost: - - Personal cost: o Associated with extended hospital stay o lost working days o increased use of social welfare benefits o Debilita:ng and distressing Healthcare system cost o High popula:on incidence o Major reason people see a doctor Gate control theory of pain: PERIPHERY - Nociceptors: (receptors of pain)Injury/irrita:on ac:vate nerve endings at the site of damage. o A-delta fibres: – these react to sudden mechanical or heat damage § they are myelinated fibres, and therefore ac:va:on results in very quick transmission. § trigger reflex: These fibres rapidly transmit impulses and terminate in the cerebral cortex. They therefore result in very quick percep:on and ac:on – e.g., puIng hand on hot plate and hand is withdrawn very quickly, before we realise we’re burned o C polymodal fibres – these are slow ac:ng fibres. § They’re not myelinated, and transmit message slowly, dull, aching pain § They terminate below the cerebral cortex in the thalamus and hypothalamus § these are the centres in the brain associated with mood, and so prolonged ac:va:on of c-polymodal fibres results in altera:ons to mood and mo:va:on. o A-beta fibres- are also large myelinated fibres BUT they are essen:ally an:-pain fibres, that are ac:vated by touch or temp, such as rubbing, or a hot water boCle, and they counteract the pain message. o Gate Control Theory of Pain: Cogni:on And Mood : • Mood – Anxiety and depression – reduced pain tolerance and increased repor:ng of pain • Cogni:ons: – ACen:on: focusing on pain increases experience of pain = increased pain – Expecta:ons of increases or reduc:ons in pain can be self-fulfilling. Also: • ACribu:ons of the cause of pain • Beliefs about the ability to tolerate pain • Beliefs about the ability to control pain • Expecta'ons of relief from pain – the placebo effect. Summary: factors that influence pain percep:on 32 Increase pain (open gate) Decrease (closed gate) Physical : - injury - inac:vity - drug/alcoholism Behavioral: - Poor sleep - Busy life Physical : - medica:on - Massage - Heat/cold Behavioral: - Excersizing - Relaxing - Good sleep habits Emo:onal: - Humor - Op:mism - Enjoyable ac:vi:es Cogni:ve: - Distrac:on - Coping skills Emo:onal - Anxiety/depression - Stress - Helplessness/hopeless Cogni:ve: - Focus on pain - Worry about the pain - Expect the worst Dura:on of pain - Acute: limited dura:on, likely to get beCer à pain management: o Coping skills à distrac:on, relaxa:on, hypnosis o Pharmacological interven:onà PCA, - Chronic: long term disease, >6months Management: o Behavioral strategies, cogni:ve strategies (CBT)à address nega:ve thinking, reinforce adap:ve behaviours ASESSMENT - SOCRATES/OPQRSTUV, survey Stress and Health Affects of Stress - Chronic mental and chronic physical health problems Depression Anxiety Lowered immunity Causes physical and mental health problems Worsens pt outcomes Greater use of healthcare services 33 Defining stress: 3 modelsà s0mulus, transac0on, reac0on S:mulus: o Objec:ve and measurable o Types: § Major life events • Assessed by ra:ng scale in Life Change Unites • Frequency, :ming, dura:on of stressors • Can precede some disorders, mostly people do not develop psychological problems sugges:ng many variables are involved 34 § Catastrophes o Countered by enjoyment Transac:on o The external or internal event (stressor) environment o Individual’s characteris:cs and appraisals (percep:on of the stressor) o The internal or external resources a person has available\ - Stress will occur when demand or appraisal is greater than coping ability Subjec:ve Variable to pt coping mechanisms Social context of appraisal Dynamic à constant reappraisal (re-evaluate) Theories in Transac:on: 1. Posi;ve linear theory a. stress and anxiety present challenges to the individual, which, in turn, improve performance b. stress mo:vates you to study, so you perform beCer 2. The Nega;ve Linear Theory o stress at any level consumes an individual’s :me, energy, and aCen:on, taking away from the task at hand and consequently inhibi:ng performance 3. Inverted-U Theory of Stress / Yerkes-Dodson Law (YDL) This is the idea that a certain amount of stress is good for you and leads to beCer performance because it acts as a mo:vator. However, when stress gets beyond the point where we can cope with it, or goes on too long, it can become a nega:ve force Response: - Behavioural responses/ coping mechanism o Adap:ve (healthy)/maladap:ve (unhealthy) 35 à Maladap:ve: - Poor nutri:on - Lack of exercise - Alcohol and drug use - Risky sexual behaviour - Smoking - Learned helplessness à Adap:ve coping: - Construc:ve strategies o Problem-focused coping: o dealing directly with the stressor - Emo:on-focused coping: o changing our feelings about the stressor (e.g. cogni:ve reappraisal) - Factors that improve coping: o Social support: correlates with beCer physical and mental health o Op:mism: appraise events in a less threatening way; less suscep:ble to illness o Perceived control: percep:on of control over our circumstances Physiological response à Flight or fight response Stress management àIncrease Sleep, sleep hygiene: - Stress à fa4gue àDecrease caffeine intake - Caffeine à release of stress hormones, affects sleep; high doses can increase anxiety and risk of panic aLacks 36 - Low doses may have protec4ve effects on psychological stress and cogni4ve func4oning during stress àRegular exercise: - Redirect energy/high level of arousal; releases endorphins àTime-out/Pacing and maintaining a good work-life balance - Ven4ng/Support system - Expressive wri4ng (Seligman, Pennebaker àChanging triggers - Iden4fying situa4ons that contribute to stress and changing them àBehavioural techniques - Iden4fy triggers and prac4se behavioural responses - Plan responses to stressors rather than reac4ng àRelaxa4on techniques: - Skills to: lower BP, slower pulse, slower breathing - Medita4on – incorpora4ng set periods of relaxa4on or “4me-out” àCogni4ve techniques: - Restructuring/Reframing: Doesn’t change the external reality but changes perspec4ve àIden4fying and challenging stress-evoking cogni4ons e.g. CBT, posi4ve self-talk - Maintaining realis4c expecta4ons : more predictable à greater control “Third wave therapies” - Tolera4ng rather than challenging responses Predic:ng Measure Health Behaviors - Public health measures understand health behaviors Con;nuum models (i.e. A leads to B leads to C) The Health Belief Model (HBM) à do people believe they are at risk à do people believe in the benefits of taking ac:on to avoid it Pros: common sense Cons: assumes people will make logical decisions about health neglects social factors Stage models (can move between stages) The Transtheore:cal Model (TTM) - different people have different stages of readiness if health programmes match the stage that people are at, it will increase reten:on/recruitment 37 alterna:ve stage 6: relapse, if they cannot maintain - Pros: tailored to the stage of change, recognized the difficul:es in adherence and allows for failure Cons: assumes logical and ra:onal thinking; does not address context Dynamic models (integrated) Behaviour change wheel (I.E. COM-B) - Brings different models together - Capability, opportunity, mo:va:on - Accounts for context à Most behaviours influenced/dependent on, others Patients ask if they have cleaned their hands Senior doctors hand hygiene behaviour Domestic staff ensuring availability of dispensers Nurse hand hygiene behaviour EXAMPLE= COM-B model Capability - Physical capability: having skills/strength to do the behavior - Psychological capability: having the psych. Skills to perform à behavior regula:on Opportunity - Physical Opportunity: environment provides u the opportunity - Social Opportunity: social acceptance, cultural à supports self-regula:on à change rou:ne and environment 38 Mo:va:on - (Head) Reflec:ve mo:va:on: self-conscious planning, analysis, decision making. Internal belief and inten:on - (Heart) Automa:c mo:va:on: Emo:ons and impulses that arise from associa:ve learning or innate disposi:on (i.e. pleasure of ea:ng a cake) à supports engaging in the desired behavior Pros: comprehensive approach with many op:ons; takes context into considera:on (COM) Cons: evidence is s:ll emerging on efficacy of this model Personality and Illness Personality: internal factors that are rela:vely constant accoun:ng for individual behavior 4 theories: - Psychoanaly:cal - Behavioural - Humanis:c - Biological Psychoanaly0cal Freudian theory - Sigmund Freud Observa:onal theory, based on women subjects All behavior is d/t the subconscious mind ID: primi:ve, behavior according pleasure - Unconscious EGO: decision making, according to making it reality - Conscious SUPER EGO: moral component -> social standards of right and wrong - VERY unconscious à balance of all 3= dynamic equilibrium à imbalance= conflict à anxiety/neurosisà defensive behavior - Results in defense mechanisms Defense mechanisms: Repression Regression - Trauma:c experience, try to forget Retreat to early stage of development à Older child pees bed when sibling is born 39 Denial - Displacement Ra:onalisa:on - Reac:on forma:on - Sublima:on - Projec:on Intellectualiza:on - Refusing to acknowledge smthg unpleasant is happening Divert emo:ons from one thing to another Crea:ng a false but plausible excuse to jus:fy unacceptable behavior Behaving in an opposite way to how you actually feel Transforming a socially unacceptable impulse into an admired and socially valued goal ACribu:ng OWN nega:ve quali:es to others Avoiding the emo:ons associated with anxiety-provoking experiences by focusing on abstract/impersonal thoughts Pros to Freudian theory: - Includes child development - Considers nature and nurture in personality development Cons: - The sample group was emo:onally disturbed people that this theory was based on, very UNTESTABLE Biological Big 5 theory of personality Eysenck - Suggests that gene:cs and a person’s physiology translates to the type of personality they have o A highly aroused person à introvert because social unease 3 dimensions - Extraversion v introversion - Neuro:cism v emo:onal stability - Psycho:cism v self-control 5 big personali:es: - Openness: open to new experiences, eccentric - Conscien:ousness: organized, self-directed, controlling - Extraversion: outgoing, enthusias:c, ac:ve - Agreeableness: trus:ng, compliant, empathe:c - Neuro:cism: prone to stress, worry, nega:vity 40 à can be high or levels of any of these domains PERSONALITY TYPES - Idea that personality can influence illness vulnerability and progression Independent of hereditary/ family history of the disease Type A: - Associated with CORONARY HEART DISEASE - Very compe::ve and ambi:ous - Sense of urgency and :melyness - Strong achievement drive - Hos:le, angry, aggressive à linked to smoking and drinking Type B: laid back - Opposite to type A - Not compe::ve, no hos:lity/anger - No care for :me Type C: à CANCER - Coopera:ve, appeasing - Compliant, passive - Suppress nega:ve emo:on Type D: - Tendency to experience nega:ve emo:ons o Anxiety, depression - Socially inhibitedè crazy outgoing to avoid disapproval 41 - o Social aliena:on Does not cause CHD, prognos:c risk factor for CHD Other personali:es : - Op:mism - Depression: risk factor for death auer MI - Pessimism/ fatalism à low survival :me in AIDS/ cancer Implica:ons for HCPs: - Personality may predict disease onset - Personality may also change because of an illness (gained helplessness) - Personality may have indirect link to unhealthy behaviors - Personality may influence illness progression/outcome because it influences individual coping responses à understanding of individual differences , and that everyone requires a different approach - Can tailor treatment to the individual if you understand their personality Adherence Adherence: A BEHAVIOUR - Pa:ent and HCP engagement in a treatment regime Not en:rely on the pt NOT COMPLIANCE – compliance suggests that the pt has nothing to do with their treatment and is just passively following the doctor’s orders Professional non-adherence (to do beCer for the pa:ent): - Adherence doesn’t just apply to pts - HCPsà ethical implica:ons of what is necessary for the pt o Prescribing an:bio:cs for viruses o Not adhering to professional guidelines o Concentra:ng on procedures which pay most o Not recording pa:ent informa:on e.g. smoking status 3 elements: 1. Ini:a:on: when the first dose is taken 2. Implementa:on: does dose taken = prescribed dose? Un:l the last dose 3. Persistence: :me bw ini:a:on and discon:nua:on (end of therapy) 42 Measuring adherence Measurement should be (guidelines): - Reliable - Valid - Immediate results - Safe, prac:cal, non-invasive - Applicable to a variety of treatments Measuring tools - Subjec:ve o Pt repor:ng - Objec:ve methods: o Measuring drug concentra:on, tablet coun:ng, therapeu:c outcome achieved, electronic measuring systems Should they be categorical OR dichotomous? - Categorizing measurement of what is good or bad levels of adherence Dichotomous = good/bad Con:nuousà measuring adherence as a percentage (i.e. pt was adherent to % of the regimen) EMERGE guidelines to measure adherence - 4 domains for measuring adherence domains - 17 dedicated to adherence repor:ng Non-Adherence Types 1. Inten:onal = Choosing not to - Pt beliefs/ cogni:ons towards: o Cause of the disease o Dura:on/:meline o Consequences of the disease o Curability o Emo:ons towards it o Treatment § Addic:on to medica:on § Is the treatment worth it § Worried about side effects à balancing the pros and cons (necessity v concern) translates to increased adherence 2. Uninten:onal 43 - Forgewulness/ distrac:on Inability to adhere- i.e. being physically unable to maintain a fitness regime because of the difficulty CAUSES Consequences of non-adherence - Longer tx :me - Poor health outcomes - Rehospitaliza:on/ longer stay - Increased dosing dt tolerance/ drug resistance - Increase cost on the healthcare system Implica0ons - Ethically – should we stop trea:ng? --> need to find a solu:on, understand why it is happening Facilita:ng adherence o Understanding of the condi:on and its treatment § Establish concordance 44 § Encourage ques:ons, ask pts about their understanding of the treatment o Memory for the info given § Avoid jargon, provide opportunity to take notes and give wriCen instruc:ons § Simplify when possible § Develop systems, like reminders, for long term plans à phone reminder to take birth control pill o Sa:sfac:on with the process of the treatment à strategies to encourage adherence should be tailored to why there was non-adherence in the first place Access to Quality healthcare Resource alloca0on - Microalloca:on = bw pts Macroalloca:on= divide the healthcare budget Problem of resource alloca0on - Changes in demographic o i.e. ageing popula:on changes in the percep:on of health dynamic need for the healthcare system = sudden increase in need during COVID inves0ng in health vs healthcare health à think social determinants of health - environment - life-style - societal support - gene:cs research healthcare - medical care – weigh:ng in SDH is very LOW - ques:onable importance – would we need this as much if we had a healthy society? Ra0oning of resources and principle of Jus0ce and Equity - remember ra:oning falls under Jus:ce principle • Aristotle formal principle of Equality: equals should be treated equally, and unequals treated unequally in propor:on to the relevant inequali:es 45 • John Rawls “theory of jus:ce”: we should allocate resources to ensure that those in poorest health, or greatest need, are as well off, in terms of health, as they can be 2 compe:ng ethical theories: U:litarianism: alloca:on towards treatment s that provide the greatest benefit à i.e. $1mil going to flu vaccine distribu:on vs hereditary disease tx à looks at QALYs quan:fying benefit of interven:on compared to other interven:ons à pros: cost effec:veness> need for the healthcare interven:on à cons: Deontology: allocate resources to give pts the tx they want Supply and demand Who decides resource alloca:on? o Medicine profession/HCP bodies o Government o Individual doctors Influences on who gets treatment: - Market forces àAbility to pay - Desert: treatment according to merit - Contribu:on to society: social value - LoCery Needs principles: - Distribu:on in propor:on: o to degree of immediate threat to life o to degree of immediate ill health o to life:me of ill-health o to immediate capacity to benefit o to cost of exhaus:ng the capacity to benefit Maximizing principles: - maximize health - max well being Egalitarian principle - equalize life:me health expectancy 46 - equalize the opportunity for life:me health expectancy combina:on principles - combine maximize health w/ equalize life:me and health expectancy - combine needs w/ maximizing Medical neediness - criterion for selec:on: those in most urgent need are given priority, with the provision that there is a reasonable chance of success o if there were mul:ple people affected by the same thing: § random selec:on § Treat equally w/ resources available - Priori:za:on protocols may be put in place à i.e. during COVID 19 o Considering frailty, comorbidi:es for ICU treatment – benefit to them and survival :me post Access to quality health care- disability Classifying Intellectual disability - DSM 5: 3 domains of impairment BEFORE AGE 18 o Conceptual: limits in intellectual func:oning: language, math, problem solving o Social: limits in empathy, social judgement o Prac:cal: self-management, personal care, responsibili:es o + IQ test Examples: - Fragile X - Prader-willi - Down syndrome 47 - Lesch-nyhan CAUSES OF INTELLECTUAL DISABILITY Prenatal: - obstetric complica:ons - FASD - Drug/toxin - Pre-eclampsia - Birth complica:ons - Perinatal factors - Cerebral palsy - Hydrocephalus - Neural tube deficit - Spina bifida Postnatal: Infec:ons/ head injury/ hypoxia HEALTH RISKS FOR THOSE WITH AN INTELLECTUAL DISABILITY Primary secondary - Epilepsy - obesity - Mobility problems - fractures - Hearing - poor health - Visual -cons:pa:on - Mental health disorders - GERD - Psychosis - STIs - ALZHEIMERS à ouen rely on health management by proxy (cant make decisions by themselves) - Health promo:on and screening - Disease preven:on measures - Management for exis:ng problems - Con:nuous assessment necessary to iden:fy any other concerns Classifying Physical disability - Impairment, ac:vity limita:on and par:cipa:on restric:on Total/par:al loss of body/ body func:on Can be life-long Categorizing disability - - ICF (interna:onal classifica:on of func:oning) framework by WHO o Shared system for communica:on, common language, categorizing disability o Related health informa:on systems à FRAMEWORK : BODY FUNCTION ACTIVITY 48 - PARTICIPATION ENVIRONMENT PERSONAL FACTORS IMPLICATIONS FOR HCPS: - Understand there is aCen:on defecit - May be unable to communicate pain or distress - HCPs need to communicate directly to the pt, (where possible) they are not incompetent (someone with quadriplegia for example, s:ll can speak and make their own decisions) S0gma “less than” because of differences - Stereotyping - Prejudice - Discrimina:on o Discreditable s:gma – for those who you cant see their disability o Discredited- for those whose disability is more obvious \ Felt - Individual expects nega:vity Enacted - Actual behavioral discrimina:on Accessibility of quality healthcare: Pallia:ve Care 49 What is pallia;ve care: Focus of reducing pain and increasing comfort, (NOT CURE) usually in the context of chronic disease. Does not focus only on the pa:ent, but their family too. - Holis:c approach: spiritual, social, psychosocial needs are cared for - Interdisciplinary input - affirms life and regards dying as a normal process - neither hastens nor postpones death § Contrast with euthanasia and physician assisted suicide - provides relief from pain and other distressing symptoms - integrates the psychological and spiritual aspects of pa:ent care - offers a support system to help pa:ents live as ac:vely as possible un:l death - offers a support system to help the family cope during the pa:ent’s illness and in their own bereavement - Uses a team approach to address the needs of pa:ents and their families, including bereavement counselling, if indicated - Will enhance quality of life, and may also posi:vely influence the course of illness LEVELS OF PALIATIVE CARE: - LEVEL 1: PALLIATIVE CARE: mindset adopted and demonstrated by all hcps and all care facili:es LEVEL 2: GENERAL PALLIATIVE: special training LEVEL 3: SPECIALIST PALLIATIVE