HIM_hastalık_sağlık (DERS 1-2) 2023-2024 PDF

Sağlık gibi dost hastalık gibi düşman yoktur Basic Concepts Sinem YILDIZ İNANICI Marmara University School of Medicine Fall, 2023-2024 Sağlık varlıktan yeğdir. “When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence ca...

Sağlık gibi dost hastalık gibi düşman yoktur Basic Concepts Sinem YILDIZ İNANICI Marmara University School of Medicine Fall, 2023-2024 Sağlık varlıktan yeğdir. “When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.” – Herophilus The Greeks understood living well as eudaimonia, which translates to well-being or happiness. At its core is a Notion of flourishing, in mind, body, and spirit. 2 What is health? Not easy to define Is very individual For individuals, health and illness are subjective states of well-being Does the person feel or think they are healthy of ill? Do they have physical symptoms that they believe mean there is a problem with their health? 3 The meaning of «health» is important the word health appeared approximately in the year 1000 A. D. the state and the condition of being sound or whole. health was associated not only with the physiological functioning, but with mental and moral soundness, and spiritual salvation, as well. 4 WHO (The World Health Organisation) « a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity» Pros & cons ? Inclusive Wellbeing BUT criticised for being too broad to be useful referring to a Utopian perfect state 6 What could be the implications of this Utopian & broad definition ? Unrealistic pressure on countries to provide social circumstances and medical systems (for everyone in complete wellbeing) Complete wellbeing confuses happiness with health Limitless treatments if people view the pursuit of happiness as a legitimate medical goal. Ex: cosmetic surgery 7 The way you perceive (define) has impact on responsibilities and treatments For ex: «individuals are responsible for their health.» Providing fruit for young children Banning smoking in public spaces 8 Case 1.2 9 Obese children to institutes Assumptions: Obesity is an illness Obesity is controllable through diet Parental behavior is the major cause of childhood obesity A child’s physical health takes priority over the psychological impact of removing that child from their family 10 Case study-practice Inspect each case and Discuss whether a person is ill or healty? Which aspects attracted you while deciding the health status of the person? What are the conflict points in your discussion? 11 What is health? 12 What is health? 13 What is health? 14 Health definitions Description Characteristics Healthy or not? Emily Fiziksel (Physical) David Karen Absence of disease Healthy Ill Healthy Not vulnerable to disease Ill Ill Healthy Strong physical reserves Healthy Ill Healthy Physically fit, has vitality Healthy Healthy Ill Subjective (öznel) No symptoms of physical illness Healthy Ill Healthy Behavioural (davranışsal) Living a health life style Healthy Healthy Ill Functional (işlevsel) Able to function in day-to day life Healthy Healthy Ill Psychosocial (Psikososyal) Psycho-social well-being Healthy Healthy Ill Social (Sosyal) Able to contribute to society Healthy Healthy Ill Cultural (kültürel) Matches cultural norm for health Healthy Healthy Ill 15 The meaning of health (a) the traditional medical concept (b) the World Health Organization concept (c) the ecological concept (Balog, 1978) 16 The traditional health concept Disease-free state 1st half of the 20th century Assumption that health and disease were objective and observable phenomena Anatomy, bacteriology and physiology Lack of disease, symptoms, signs or problems. WHO’s concept of health “a well-being and wellness state of complete physical, mental have not been clearly defined yet. and social well-being and not merely as the absence of disease lacks specificity enough to or infirmity” be operationally and to be (p.defined 1-2, 1947, WHO, 1940). applied to practicalmore situations conceptualized in terms of the presence of absolute and apositive complete perfect state which is qualities. and unreachable unrealistic extends the traditional medical view by conceiving health as a positive state of well-being in which physical health is only one of the aspects involved conceptualized health social, psychological, physical, emphasising illness, economic and political aspects were neglected the individual as a incorporated whole by overemphasising specific health and illness are diseases and parts of the body. essentially multicausal, but also shifted the focus The ecological concept of health Conceiving health as a more relative sort of concept a greater emphasis on the interrelationships between the environment and the individual’s quality of life. heavily based on an evaluation of the person’s level of functioning and adaptation to the environment. conceptualized as individuals’ capacity to adjust adequately to their environment no clear distinctions between what constitutes a healthy and an unhealthy adaptation. 17 Criticism WHO definition of health-1948 “a state of complete physical, mental and social well-being and not merely as the absence of disease or infirmity” It unintentionally contributes to the medicalisation of society. The requirement for complete health “would leave most of us unhealthy most of the time.” 18 Criticism Medicalization is the process by which human conditions and problems come to be defined and treated as medical conditions, and thus become the subject of medical study, diagnosis, prevention, or treatment. Ex: menstruation, obesity, infertility… New screening technologies detect abnormalities at levels that might never cause illness and pharmaceutical companies produce drugs for “conditions” not previously defined as health problems. 19 Criticism Thresholds for intervention tend to be lowered—for example, with blood pressure, lipids, and sugar. Since 1948 the demography of populations and the nature of disease have changed considerably. Disease patterns have changed, with public health measures such as improved nutrition, hygiene, and sanitation and more powerful healthcare interventions. The number of people living with chronic diseases for decades is increasing worldwide; 20 Criticism Ageing with chronic illnesses has become the norm, and chronic diseases account for most of the expenditures of the healthcare system, putting pressure on its sustainability. WHO definition becomes counterproductive as it declares people with chronic diseases and disabilities definitively ill. For example: Huber et al.(8) noted that WHO’s emphasis on “complete” well-being fails to capture the longevity and high functioning of many individuals living with chronic conditions and disabilities. It minimises the role of the human capacity to cope autonomously with life’s ever changing physical, emotional, and social challenges and to function with fulfilment and a feeling of wellbeing with a chronic disease or disability. 21 Criticism The other problem is the operationalisation of the definition. "An operation is the performance which we execute in order to make known a concept." For example, an operational definition of "fear" (the construct) often includes measurable physiologic responses that occur in response to a perceived threat. WHO has developed several systems to classify diseases and describe aspects of health, disability, functioning, and quality of life. Yet because of the reference to a complete state, the definition remains “impracticable, because ‘complete’ is neither operational nor measurable.” (3, 4) 22 Criticism-Need for reformulation The Ottawa Charter (8) emphasises social and personal resources as well as physical capacity. However, WHO has taken up none of these proposals. Redefining health is an ambitious and complex goal; many aspects need to be considered, many stakeholders consulted, and many cultures reflected, and it must also take into account future scientific and technological advances. 23 Criticism-Need for reformulation The discussion of experts at the Dutch conference, however, led to broad support for moving from the present static formulation towards a more dynamic one based on the resilience or capacity to cope and maintain and restore one’s integrity, equilibrium, and sense of wellbeing (6). “the ability to adapt and to self manage.” physical, mental, and social 24 Physical health A healthy organism is capable of “allostasis”—the maintenance of physiological homoeostasis through changing circumstances (10). Mental health In the mental domain Antonovsky describes the “sense of coherence” as a factor that contributes to a successful capacity to cope, recover from strong psychological stress, and prevent post-traumatic stress disorders (12, 13). The sense of coherence includes the subjective faculties enhancing the comprehensibility, manageability, and meaningfulness of a difficult situation. 25 For example, patients with chronic fatigue syndrome treated with cognitive behavioural therapy reported positive effects on symptoms and wellbeing. Social health People’s capacity to fulfil their potential and obligations The ability to manage their life with some degree of independence despite a medical condition The ability to participate in social activities including work. Health in this domain can be regarded as a dynamic balance between opportunities and limitations, shifting through life and affected by external conditions such as social and environmental challenges. 26 Measuring health The general concept of health is useful for management and policies It can also support doctors in their daily communication with patients because it focuses on empowerment of the patient (for example, by changing a lifestyle), which the doctor can explain instead of just removing symptoms by a drug. However, operational definitions are needed for measurement purposes, research, and evaluating interventions. WHO has developed several classification systems measuring gradations of health (18). 28 Measuring health These assess aspects like disability, functioning, and perceived quality of life and wellbeing. The COOP/Wonca Charts Functional Health Assessment Charts present six different dimensions of health, each supported by cartoon-like drawings (19, 20) Each measures the ability to perform daily life activities on a 1 to 5 scale. 29 30 31 32 Measuring health-sample references Van Weel C, König-Zahn C, Touw-Otten FWMM, van Duijn NP, Meyboom-de Jong B. Measuring functional health status with the COOP/Wonca charts. Northern Centre for Health Care Research, University of Groningen, 1995. www.globalfamilydoctor.com/research/research.asp?refurl=r#R4. Nelson E, Wasson J, Kirk J, Keller A, Clark D, Dittrich A, et al. Assessment of function in routine clinical practice: description of the COOP Chart method and preliminary findings. J Chron Dis 1987;40(suppl 1):55S-63S. 33 Shroeder S: We can do better – improving the health of the American people. N Engl J Med 2007; 357: 1221–8. 39 40 Admiral Michael Mullin, observed that “regardless of one’s beliefs in a mind–body duality, a growing body of scientific evidence, as I read it, certainly links the general health of the body with the state of one’s perceptions of well-being. Scientists have also gathered ample evidence that one’s attitudes toward wellness influence how one maintains one’s physical health.” (5). 41 Illness perceptions of cancer patients 18 years old and higher Mental adjustment to cancer scale A diagnosis of cancer 4-point likert scale Fighting spirit 325 participants Helplessness/hopelessness No other specific disease Anxious preoccupation Illness perception questionnaire Fatalism Avoidance A-timeline acut-chronic B- timeline-cyclical C-consequences D-personal control E-treatment control F-Ilness coherence G- emotional representations & casual attributions 42 Ilness perceptions of cancer patients 161 men 21-89 years old %25 breast, %22 digestive system… 43 Ilness perceptions of cancer patients This indicates that many participants perceive their illness to continue for a long time but that there were also participants with another opinion in this respect. indicate that participants have a strong belief in the effectiveness of the cancer treatment and believe that they understand the illness rather well. It should be noticed that, in general, these patients perceive their personal control over the illness to be muc than its controllability by medical treatment. Regarding causal attributions, relatively low scores on the ‘Psychological’ scale indicate that participants do not perceive psychological factors to be a major cause of their illness. In contrast, they attribute their illness more to chance or bad luck, although there is some variety among the scores in this respect. 44 The meaning of illness While no one would reject the Notion that improper functioning and deviation from normality are essential components of illness, it might be not so easy to establish agreement concerning what constitutes proper functioning and what characterizes a deviation from normality. An individual may be functioning improperly, though not regarded as ill. Lack of observable or felt symptoms are also not good delimiters of a non sick state Medical professionals differ in their judgements and interpretations of symptoms and signs. Value judgements and social norms have played a strong role 45 In addition to individuals’ health concepts, psychological variables and emotions have an impact on their engagement in healthy related behaviours, as well (Lafreey, 1983, 1986; Segall & Wynd, 1990; Seligman & Cskiszentmihalyi, 2000). Prevention strategies Self-actualization, self-fulfilment and quality of life (Boruchovitch & Mednick, 1997). 46 Culture & Health Culture frames our worldview and helps us make sense of what we know. Culture is a dynamic yet stable set of goals, beliefs, and attitudes shared by a group of people (Matsumoto 2001). 47 Culture & Health Culture offers us a view of the world, that is, the perception of how the world is organized and how to act accordingly in a world that receives its meaning and value through culture. For obtaining food, and classifies, organizes and assigns values to various types of food, such as “good”, “weak”, “strong”, “light”(13). The concept of cleanliness and hygiene are fundamental categories present in all cultures. 48 Culture & Health The system of health care is both a cultural system and a social system of health. The social system of health is composed of its institutions, organization of the health specialists’ roles, rules of interaction, as well as power relationships inherent to it. Commonly, this dimension of the system of health care also includes specialists not recognized by biomedicine, such as folk healers (massage therapists, benzedeiras, curandeiros) or religious and faith healers (pastors, priests, benzedeiras, shamans, spiritists, and others), shaman). 49 Culture & Health Some societies conceptualize health in broader ways (Gurung 2006). Ayurveda, or ‘‘Knowledge of Life,’’ the ancient yet still widely practiced Indian system of medicine : health as a harmony between the body, sense organs, mind, and soul (Dash et al. 1997). Traditional Chinese Medicine views health as a balance between yin and yang, the two complementary forces of the universe (Kaptchuk, 2000). 50 Culture & Health In Porto Rico, the society blame mothers if they give birth to a child with a severe disability, because the child is viewed as a consequence of the mother’s sins (Rogers-Adkinson et al.2003). In India, the family and society may believe that the child’s disability comes about as a punishment for sins committed by the child or parent in a past life (Groce and Zola 1993). 51 Disability is seen as the result of a woman or a family being cursed by an enemy or someone giving them the ‘‘evil eye’’ (Groce and Zola 1993; Rogers-Adkinson et al. 2003). Kleinman found that among Chinese participants, chronic illness and disability were viewed as very negative, taking away an individual’s legitimacy. (1986) When a child’s disability is believed to be caused by such negative forces, the family and community may be less willing to expend scarce resources on the child (Groce and Zola 1993). 52 The Navajo tribe views a person with a disability as a teacher for the clan, one who brings special lessons to the tribe and who offers a sixth sense or a unique gift (Medina et al. 1998). 53 54 Culturally based health conceptions and beliefs are then organized into what Kleinman (1978) referred to as “explanatory models” of health and illness Which include beliefs about possible causes of illness onset and evolution of symptoms pathophysiology of illness, severity of illness, and possible treatments (Huff, 1999). 55 Helman (2001) described four categories of beliefs related to possible causes of illness: The individual Natural Social Supernatural worlds 56 Culture and Health Conceptions: Significant cultural differences were found on physical health, developmental health, spiritual health, and interdependent health. Post hoc Scheffé tests revealed that First Nations participants adhered to a developmental definition of health to a greater extent than Anglophones, but Francophones did not differ from either group. Francophones and Anglophones both placed more importance on physical health compared with First Nations participants, while the opposite trend was observed on spiritual health and interdependent health. 57 Culture and Health Practices: Significant cultural differences in health practices: having a healthy lifestyle managing stress Engaging in spiritual or religious practices, maintaining traditions and culture, and interdependent health practices Maintaining traditions and culture was rated as more important by First Nations participants compared with Francophones and Anglophones. More First Nations participants reported engaging in practices aiming at promoting the health of others and the environment compared with Francophones and Anglophones. 58 Bronfenbrenner’s ecological model: 59 Bronfenbrenner’s ecological model: Proximal (close) and distal (distant) processes affect human development at multiple levels. Influences at the microsystem level have the most direct impact on development: the relationships a child has with people (e.g., mother, father, teacher, friends) the settings in which the child lives and grows (e.g., home, classroom, playground) the material elements available (e.g., nutritious food, adaptive equipment, toys). 60 Bronfenbrenner’s ecological model: The mesosystem constitutes relationships between the proximal elements in a child’s life: the parents’ relationship with one other parent-professional relationships in a health care setting work-home problems in arranging schedules. 61 Bronfenbrenner’s ecological model: The exosystem, a more distal level, involves: the resources or infrastructure of a city or region, including the availability of clinics, hospitals, and specialists the capacity of a school system to meet the specialized needs of a child with a disability. The macrosystem level, the most distal influence: culture, with all its beliefs and assumptions and practices concerning health, government, spirituality, values, and the economy. The chronosystem encompasses the notion of historic time, the reality that things change over the decades and the centuries. 62 Bronfenbrenner’s ecological model: Proximal processes work in conjunction with the more distal influences in the macrosystem and exosystem. For ex., over time (chronosystem), if a culture becomes more accepting of children with disabilities, a nation might pass laws mandating enhanced disability policies for early intervention, schooling, and employment (macrosystem). At the exosystem level, cities would respond by requiring ramps and elevators in public buildings, and school systems would enact policies for individualized educational plans. At the mesosystem level, husband-wife tensions, as well as the relations between parents and professionals, might lessen as they developed mutual respect and trust. 63 Bronfenbrenner’s ecological model: Beliefs exist both at a cultural level and in the minds of individuals. Family members, at the microsystem level, greatly influence a child’s life through their: beliefs regarding the cause of a disability ideas about the worth of a person with a disability their acceptance of a person with a disability (Groce and Zola 1993). 64 Bronfenbrenner’s ecological model: Families’ beliefs affect the child’s participation in social activities, the resources they spend on the child, and their expectations for what their child might achieve in adulthood. Families’ beliefs about disability are not just peculiar to those parents but rather arise from the overarching beliefs and values of the society, including macro elements that are economic, political, social, and spiritual. 65 Bronfenbrenner’s ecological model: Parents’ beliefs about causes of their child’s disability play a role in the treatments they seek for their child. For ex., families in Pakistan who believed that their child’s intellectual disability was due to ‘‘Allah’s will’’ were more likely to consider their child’s condition as unchangeable and believed that they ought to only take care of their child in the most basic sense, for which Allah would reward them (Mirza et al. 2009). ‘‘We don’t have to make him get better. We only have to feed him, wash his clothes and clean him overnight etc. this awareness is very important’’ (Mirza et al. 2009, p 564). 66 Bronfenbrenner’s ecological model: Mexican Americans believe that there are both biological and spiritual causes for illness. While they believe that a medical doctor can cure the biological problems, only curanderos or healers can be trusted to cure spiritual problems (Gurung 2006). A family that believes that their child’s condition is caused by specific biological variables may seek medical treatments specific to that biological problem, while those who believe the cause was environmental may seek behaviorally-based interventions. Parents who believe that autism is caused by vaccines often seek to alter their children’s physiology through chelation or restricted diets, while those who believe that sensory issues are at the core of their children’s problem may use non-biological CAM (complementary and alternative medical) treatments such as auditory integration training or craniosacral therapy (Levy and Hyman 2003). 67 Bronfenbrenner’s ecological model: Parents’ beliefs about causes also inform the kinds of expectations they hold from the treatments they use with their children. For example, some parents of children with autism are convinced that if they find the right interventions and use them faithfully, their child will be cured of the condition (Christon et al. 2010; Mandell and Novak 2005). 68 Bronfenbrenner’s ecological model: Cultural factors influence the resources available to children with disabilities. In some cultures, education is available to all children, regardless of disability. In other cultures, that right is challenged by those who believe it is a waste of money to spend resources on those with disabilities, especially when nondisabled children might go without education. 69 Bronfenbrenner’s ecological model: In some societies a child with a severe disability is not expected to survive, and so it seems reasonable in these cultures to allocate scarce resources of medical care and parental attention to their healthier children; this cultural expectation often becomes a selffulfilling prophecy (Groce and Zola 1993). 70 Bronfenbrenner’s ecological model: Cultural factors influence the relationship between parents and the professionals who provide interventions for their children. An important aspect of this relationship is professionals’ and families’ beliefs about the degree of authority each should hold. These views range from a paternalistic view that ‘‘doctor knows best’’ to a collaborative understanding between the professional and the family. In many cases getting a diagnosis, as well as gaining desired treatment, depends in part upon the quality of their communication (Goi n-Kochel et al. 2006; Ka ba a nd Sooriakumaran 2007). 71 Culture & Health Health care providers and patients frequently disagree in terms of perceptions of reason for medical visits, symptom severity, and overall health status, or physical function. 1,2 3–9 10–22 Discordant perceptions between providers and patients associated with: 23–26 are inadequate and unnecessary treatment poor adherence to treatment advice, poor retention in care, dissatisfaction with care, diminished symptom resolution, mismatching of services to needs. 2 3 8,28,29 7,23,30–32 2,22 72 Culture & Health-sample research Differing evaluations of a patient’s health status are especially important, constituting ‘‘a key point in communication difficulties’’12 The Cherokee Nation, 50 years Self-reported cultural affiliations, patients were distributed across the range of scores on both the American-Indian and white-American identity indices All providers strongly affiliated with white-American cultural identity and only 1 strongly affiliated with American-Indian identity. 73 The diagonal indicates complete concordance in ratings The circles above and below indicate the number of visits with specific, discordant combinations of providerpatient scores. Overall, providers and patients differed in their evaluations in 40% of visits. The majority of discordant ratings (68%) were below the diagonal, indicating that providers rated patients healthier than patients rated themselves. For example, no visit occurred in which the provider rated the patient’s health as poor, although 7% of patients rated their own health in this category. Only 19% of scores lay above the diagonal, reflecting the smaller percentage of cases in which patients rated their health as better than their provider did. 74 Culture & Health-sample research The strength of white-American cultural identity was significantly associated with discordant health status ratings after adjusting for patients’ age, sex, education, marital status, previous visits, waiting time, and American-Indian identity index scores (p=.01). The mean difference score for patients who weakly affiliated with white-American cultural identity was larger than that for those who strongly affiliated with it (0.70 vs 0.12). 75 76 Patient-centered care Definition: care provision that is consistent with the values, needs, and desires of patients and is achieved when clinicians involve patients in healthcare discussions and decisions. The Patient Centered Clinical Method identifies that patient centeredness is achieved in part by understanding patients experiences with illness and disease as well as understanding patients holistically. 77 Patient-centered care The three essential components of patient-centered care: Effective communication Partnership Health promotion. 78 Patient-centered care Communication Three components of communication were commonly discussed: a) sharing information, b) compassionate and empowering care provision c) sensitivity to patient needs. a) Sharing information Many articles discussed effective communication of healthcare information from the clinician to the patient, but also included approaches to effective patient information uptake by the clinician. Effective information uptake is an essential step in tailoring information to suit patient needs, vulnerabilities, and capacities. Active listening, asking open ended questions, and developing functional goals were strategies to achieve effective information uptake 79 Patient-centered care Communication b) Compassionate and empowering care provision Such care is described as being attentive and altruistic, Compassionate and empowering care as contributing to the development of a strong clinician-patient relationship based upon patient feelings of autonomy and trust. c) Sensitivity to patient needs Acknowledging and adapting to unique patient identifiers Clinicians are urged to observe and reflect on fluctuating levels of patient alertness, patient comfort levels in the presence or absence of family members, and different communication barriers such as hearing loss, in order to facilitate clinical interactions 80 Patient-centered care Partnership Two components of partnership: a) relationship building b) inter-professional collaboration. a) Relationship building Contributes to understanding what problems the patient is most concerned with and how their illness or injury has affected their life The involvement of patients and families in their care builds trust and encourages mutual problem solving b) Inter-professional collaboration Decentralization as a team-based approach to care provision that contributed to efficient and focused care provision 81 Patient-centered care Health promotion requires reflection on how to best support optimal health and care provision through reflection on the patient’s history. a) effective case management b) efficient use of resources. Effective case management involves the evaluation of past successes and failures of care in order to best tailor future health initiatives and reduce risk of adverse health outcomes Efficient use of resources Using resources that best suit patient needs and values, clinicians can tailor treatment plans to best represent how patients are likely to respond to certain interventions This process is facilitated by discussions with patients about previous healthcare experiences in order to develop an understanding of how patients respond to certain types of care, such as care requiring follow-up appointments or self-directed home exercises 82 Relationship Between Health Definitions and Health Practices The health definitions taken together could significantly predict the following health practices: Understanding health needs Lifestyle Maintaining good relationships, Maintaining traditions Interdependent practices 83 Healthcare systems generally are disease-focused and concentrate resources on treatment modalities that often work well for acute or life-threatening illnesses such as physical trauma or infectious disease, but sometimes are poorly suited to the management of chronic illness.1–3 Modifying the healthcare system to recognize the importance of social, behavioral, economic, and environmental determinants of health might better address current population needs.4–6 Creating a more inclusive definition could support strategic planning of initiatives promoting health across multiple sectors of daily life, not just the clinic. 85 With the contemporary shifts in health care that focus increasingly on wellness, health management across the lifespan, patientcenteredness, evidence-based medicine, and the integration of complementary medicine, “integrative medicine” is a term that is increasingly used to describe healthcare interventions.9 86 Academic Consortium for Integrative Medicine and Health (previously named the Consortium of Academic Health Centers for Integrative Medicine) as, “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing.”10 87 This definition covered eight domains: 1. inter-relationships among all health-related domains; 2. the role of health determinants outside of health care (e.g., personal behaviors, genetics); 3. the role of upstream determinants (e.g., physical and social environment); 4. empowerment of individuals, groups, and communities; 5. the value of person-centered, evidence-based care; 6. receipt of appropriate services; 7. community-based strategies; and 8. population-based strategies. 88 Thank you for listening ☺ 89