PSYC-314 Health Psychology Lecture Notes PDF

PSYC-314 Health Psychology UBC Distance Education David King, PhD Module 2/Lecture 2 Fight or Flight—or Frenzy? Understanding Stress Today Defining Stress; The Impact of Stress on Health; Posttraumatic Stress Disorder (PTSD); Sources of Stress; Benefi...

PSYC-314 Health Psychology UBC Distance Education David King, PhD Module 2/Lecture 2 Fight or Flight—or Frenzy? Understanding Stress Today Defining Stress; The Impact of Stress on Health; Posttraumatic Stress Disorder (PTSD); Sources of Stress; Benefits of Stress? L-2 Health Tips: 1. Stress is in your head (mostly). 2. Avoid traffic jams—they could kill you. 3. Do NOT freeze in emergencies! 4. Find your ‘zone’—and stay in it. What isisstress? Where the stress? Oh !$@#%! 1. Stress as a Stimulus Stress is defined as a stimulus or change in the environment. “stressor” Types of Stressors Acute Stressors (limited), e.g., running late, fight, accident Chronic Stressors (prolonged, repeated), e.g., job strain, poverty Also: major life events, daily hassles Major Life Events (Holmes & Rahe, 1967) Major Life Events Scale (AKA Social Readjustment Rating Scale) Change (+ or -) is assumed to be stressful. Items are assigned a life change unit score based on severity. correlations have been shown with incidence of heart attacks, broken bones, diabetes, multiple sclerosis, tuberculosis, complications of pregnancy, decline in academic performance, etc. Major Life Events Scale (Holmes & Rahe, 1967) Death of Spouse = 100 Jail term = 63 Marriage = 50 Death of a Friend = 37 Vacation = 13  Life Event Stress & Colds More stressful life events = increased likelihood of contracting cold virus (Cohen, Tyrell, & Smith, 1991; N = 394) viral infection infection + symptoms Following exposure to cold virus. X axis = number of stressful life events in preceding year. Daily Hassles Day-to-day unpleasant or potentially harmful events. Ideally measured as they unfold using daily process methods (DeLongis, 2014; DeLongis et al., 1988). Hassles (and also uplifts) may be more strongly associated with health than life events. 2. Stress as a Response Stress can be defined as a person’s physiological response (fight-or-flight; also reactivity)… 2. Stress as a Response Oh !$@#%! and/or a person’s psychological response (i.e., thoughts and emotions; e.g., nervousness). “strain” Fight-or-Flight Response (Cannon, 1932) Mobilization, increased energy, and increased focus… Breathing increases Heart rate increases Blood pressure rises Muscles tense Blood glucose rises Pupils dilate, tunnel vision Sweating increases Digestion slows Mouth gets dry Bladder relaxes Hands & feet get cold etc. Epinephrine / Norepinephrine (Catecholamines) Sympathetic Nervous System (SNS) Epinephrine (adrenaline) & Hypothalamus norepinephrine (noradrenaline) are released by the adrenal glands (part of SNS). Hormones/neurotransmitters (catecholamines) that regulate heart rate, metabolism, respiration, oxygen to the brain and muscles, etc. Adrenal Glands Cortisol (“The Stress Hormone”) (Corticosteroid / Glucocorticoid) Hypothalamic-Pituitary- Adrenal (HPA) Axis Cortisol complements the SNS… Hypothalamus Increases blood pressure / blood glucose; Pituitary Gland enhances brain’s use of glucose. Suppresses nonessential systems (e.g., digestive, reproductive, immune). Reduces inflammation. Adrenal Glands …and assists return to homeostasis. Cortisol output automatically decreases over time (negative feedback loop). Measuring Cortisol Cortisol is difficult to study! Influenced by exercise, diet, mood, and many other factors. Individual differences in diurnal cycles, average output, etc. Inconsistent results across types of stressors, except... (Dickerson et al., 2004; Stone et al., 2001) 3. Stress as a Transaction Oh !$@#%! Stress can be defined as a process involving continuous interactions and adjustments between a person and the environment, each affecting and affected by the other. “stressor” “strain” Transactional Model of Stress (Lazarus, 1984) It is how an event or situation is appraised or evaluated by a person that matters (cognitive appraisal). Primary Appraisal – Is this a threat to my physical or mental well-being? Is it stressful? Or perhaps it is good or irrelevant instead? → If appraised as stressful: Harm-loss? Threat or challenge? Secondary Appraisal – Do I have the resources to meet the demands? I can’t do it—I know I’ll fail. I’ll try, but my chances are slim. I can do it if a friend will help. Behavioural Control If this method fails, I can try a few others. CONTROL Cognitive Control* I can do it if I work hard. No problem—I can do it. Stages of the Stress Transaction Stress is a transaction leading a person to perceive a discrepancy between demands of a situation and the resources of their biological, psychological, or social systems. Oh !$@#%! Cognitive Stimulus Appraisal Not a threat Factors affecting Appraisal Personal Factors Personality, self-esteem, motivation, perfectionism, etc. Situational Factors Degree of demand; imminence; timing; ambiguity. Desirability – some situations are undesirable to most people. Controllability – some situations are outside of behavioural or cognitive influences. Chronic Stress What happens when stress is prolonged or repeated over time? How does stress affect health? Chronic stress can cause or contribute to illness in two ways… Directly via physiological effects on various bodily systems. Indirectly via health behaviours. substance use, unhealthy eating, lack of exercise, poor sleep, etc. General Adaptation Syndrome (Selye, 1956) Stages of the stress response… 1. Alarm – physiological mobilization for action. → Fight or flight response. If the stressor continues… 2. Resistance – body tries to adapt to stimulus. 3. Exhaustion – breakdown of organs, disease, death; burnout. Chronic Stress & Cortisol Cortisol High Normal Low Normal Stage 1 Stage 2 Stage 3 Failure Could last days or years / intermittent or trauma Progression (time of each stage highly variable) Phys. Effects of Chronic Stress Cortisol stops working over time as the HPA axis becomes dysregulated. Immune system impaired (susceptible to infection); inflammation ensues. Elevated blood glucose; maturation of fat cells; increased visceral fat. Hippocampal atrophy (shrinking of hippocampus, cellular degeneration). Persistent surges of epinephrine also affect health, esp. cardiovascular health, blood pressure, anxiety. Pain, weight gain, fatigue, memory impairment, depression, anxiety, sleep problems, aging, & higher risk of heart disease, stroke, diabetes, cancer, etc. Immune Functioning Stress is associated with impaired immune functioning. Release of catecholamines and corticosteroids alter functioning of the immune system in a number of ways… Brief stressors activate some components of the immune system (typically nonspecific immunity), while suppressing specific immunity. Chronic stress suppresses/disrupts both nonspecific & specific functions. (Kemeny, 2007; Segerstrom & Miller, 2004) Cancer WHO (2017) estimates 30–50% of cancer cases are preventable (i.e., lifestyle-related or environmental); this varies by site. Though up to 2/3 may be due to random errors during DNA replication (Tomasetti et al., 2017, Science). Can stress cause cancer? Chronic stress weakens the immune system (via cortisol), which may accelerate cancer or tumour growth. Or, via health-compromising behaviours in response to stress. Insights from Animal Research Example of research: Thaker (2006, Nature Medicine) Experimental design – mouse model with control group. Injected human ovarian carcinoma cells into mice. Mice were exposed to chronic stress (2 hours of physical restraint per day for 21 consecutive days). Insights from Animal Research Number Total of Tumour Tumour Weight Nodules in Mice in Mice (Thaker, (Thaker, 2006) 2006) Cardiovascular Disorders Chronic stress (including perceived stress) is associated with increased risk of coronary heart disease (CHD). Greater cardiovascular reactivity and poorer recovery associated with… heightened blood pressure diagnosed hypertension atherosclerosis – plaque builds up in arteries, restricting blood flow Stress increases levels of cholesterol (via cortisol) and inflammatory substances circulating in the blood, contributing to atherosclerosis. (Carroll et al., 2012; Richardson et al., 2012, meta-analysis) Psychophysiological Disorders Physical symptoms or illnesses that result from the interplay of psychosocial and physiological processes. Previously referred to as “psychosomatic” → may be caused by or aggravated by stress. Digestive system diseases (e.g., ulcers) Asthma Recurrent headache (inc. migraines) Rheumatoid arthritis Allostatic Load (McEwan & Stellar, 1993) Accumulating effects (wear and tear) that result from the body adapting repeatedly to stressors over time. e.g., fluctuations in levels of hormones like epinephrine and cortisol, blood pressure, and immune function. Allostatic load impairs the body’s ability to adapt to future stressors. Even daily hassles may cause serious health problems (Aldwin et al., 2014; Piazza et al., 2013). Fight-or-Flight then… “Life was hard. Perhaps in that environment, where stressors were more often physical, the stress response was more useful.” (Nesse & Young, 2000) Fight-or-Flight today… “Today, we mainly face social and mental threats, so the actions of the HPA system may yield net costs.” (Nesse & Young, 2000) Trauma & Stressor-Related Disorders Trauma: An emotional response to a distressing event (e.g., accident, assault). Trauma & Stressor-Related Disorders Diagnostic & Statistical Manual of Mental Disorders (DSM-5-TR, APA, 2022) Acute Stress Disorder Severe anxiety, dissociation, and other symptoms within 1 month after exposure to an extreme traumatic stressor (e.g., witnessing a death, serious accident). Posttraumatic Stress Disorder (PTSD) Severe anxiety disorder resulting from exposure to a traumatic event/experience (either acute or chronic); symptoms lasting for more than 1 month. DSM-5-TR Criteria for PTSD A. The Stressor: Direct exposure; Witnessing, in person; Indirectly, by learning that relative/friend exposed to trauma; Repeated or extreme indirect exposure to aversive details of event (e.g., on job). B. Intrusion: Recurrent, involuntary, & intrusive memories; Traumatic nightmares; Flashbacks; Intense distress to traumatic reminders; etc. C. Avoidance: Avoidance of trauma-related thoughts/feelings, trauma- related external reminders (people, places, activities, objects, situations, etc.). D. Negative Alterations in Cognitions/Mood: Persistent negative thoughts, emotions (fear, horror, anger, guilt); Lack of positive; Distorted blame of self or others for causing event; Diminished interest in activities; Alienation. E. Alterations in Arousal: Irritable or aggressive behaviour; Reckless behaviour; Hypervigilance; Exaggerated startle response; Sleep disturbance, etc. F. > 1 month | G. Functional Significance | H. Exclusion (APA, 2022) PTSD & Cortisol Output Research tends to show blunted cortisol output in PTSD… For example: No PTSD Thomas et al. (2013) Cortisol (nmol/l) Female caregivers with symptoms of PTSD. PTSD (symptomatic) Diathesis-Stress Why ModelPTSD? do some develop resilient individual (without predisposition) positive health outcome Support for diathesis-stress model in PTSD (plus other disorders) has been well documented (McKeever negative et al., 2003). negative positive environment / life event Posttraumatic Growth (PTG) Positive psychological changes following a highly challenging event or experience: Appreciation of life. Renewed commitment to goals, new goals/priorities. Greater sense of personal strength. Greater intimacy in relationships. Warmer, more loving personality. Higher life satisfaction. Wu et al. (2018, meta-analysis) – Nearly 50% experience PTG after trauma. What determines PTSD vs. PTG? What might lead a person to suffer rather than grow from a traumatic experience? We’re not entirely certain, but research on PTSD suggests… Family history; prior/childhood trauma. Low openness to experience, low extraversion (personality). Peri-traumatic dissociation, perceived threat to life. Maladaptive coping responses (e.g., denial). Low post-trauma social support. Also: being a woman, low income/status, and low education. (Chen et al., 2017; Soler-Ferrería et al., 2014; Ozer et al., 2003; Tang et al., 2017) Fight-Flight-or-Freeze ? When neither fight nor flight seem like enough… And the fear is intense…. You may feel paralyzed and unable to respond. A parasympathetic brake on the motor system (Roelofs, 2017). May be a way to dissociate from highly dangerous and potentially traumatic events. Sometimes it’s adaptive, sometimes it’s not. Fight-Flight-or-Freeze Primary predictors of the freeze response are feelings of anxiety and panic during highly stressful events (Schmidt et al., 2007). AND…dissociation during high-stress events increases likelihood of PTSD (van der Kolk & van der Hart, 1989). Panic! Freeze Trauma Adaptive Responses to Adversity? Syme & Hagen (2020), biological anthropologists, suggest that PTSD, anxiety disorder, and major depressive disorder (MDD) may be functional/adaptive responses to adversity (despite aversive qualities). Depression may help prevent future adversity by shifting attention/focus; anxiety is a response to threat; and PTSD involves avoidance of trauma-related stimuli and hypervigilance. These disorders are relatively low in heritability, indicating that environmental factors play a large role (PTSD requires an event). They are also quite common in the population, can occur at any age, and are more common in conflict-affected countries. Sources of Stress Sources of Stress Within the Individual Illness and disease Conflicting motivations (approach, avoidance) Health Frustrated goals Within one’s family / social network New addition to family Family Relationship strain, separation, divorce Family illness, disability, death Within the community / society Work Occupational stress Environmental stress Occupational Stress What is the most stressful job? It’s not easy to say… Police Officers: routine stressors associated with PTSD symptomology and problem behaviours (e.g., gambling). Nurses, ER Doctors: lower self-reported health and well-being, high burnout, higher PTSD symptomology, etc. Truck Drivers: unhealthy lifestyle, being away from home, long hours lead to greater work strain. Also studied: Air traffic controllers, IT consultants, factory workers, teachers… Example: Paramedics & EMTs Among Cdn paramedics… 29% had PTSD symptoms (significantly higher than sample of Navy personnel) 44% had clinical symptoms of depression 74% also had 1+ symptoms of high burnout Why? (King, 2013; King & DeLongis, 2014) Demand-Control-Support Model of Occupational Stress (Johnson & Hall, 1988) Three factors proposed to predict stress & wellbeing on the job… Perceived Demand Lowest Highest Stress + Stress Highest Perceived Control Lowest Well-Being + Well-Being Perceived Social Support Also: The work environment, responsibility for other people’s lives, etc. Stress Contagion Stress Spillover Occurs within the individual; Stress experienced at work can be brought home, or stress experienced at home can be brought to work. Stress Crossover Occurs between people; Stress experienced at work can be brought home and transmitted to the spouse, child(ren), etc. Stress Contagion in Paramedics Evidence of both spillover and crossover effects in our sample of medics and their spouses… Medics’ same day (evening) and next day stress were predicted by earlier work stress (controlling for AM stress). Earlier on-the-job support from work partner associated with later satisfaction with spouse at home and greater support to the spouse. Spouses reported higher relationship satisfaction on days when medics had less tension with their work partners. (King, 2013) Environmental Stressors Aversive and primarily uncontrollable environmental stimuli; sometimes unpredictable, variable in duration and frequency. Typically require low to moderate adjustments. Common examples: noise, crowding, air pollution Or cataclysmic events e.g., natural or human- caused disasters Can Stress Be Good? Can stress be good for you? Selye (1974, 1985) differentiated between distress and eustress (from the Greek eu, which means “good”), which refers to stress that is beneficial or constructive. Some degree of arousal is optimal (Hebb, 1955) → Flow An optimal state of complete absorption in work, play, or creativity; arises spontaneously while engrossed. Intense concentration, loss of self-awareness, loss of time awareness (or time ‘flying’), loss of environmental awareness, and feeling perfectly challenged (neither bored nor overwhelmed). The activity becomes an end in itself. An indicator of mental health and optimal functioning. (Csikszentmihalyi, 1990; Nakamura & Csikszentmihalyi, 2009) Flow as Optimal Arousal A match Stress / Anxiety between the demands of a Demand / Challenge situation and the skills or abilities of the individual… “the optimal Boredom experience” Skill / Ability What do you believe about stress? The effects of stress on health appear worse for those who believe it is harmful to their health (Keller et al., 2012; Nabi et al., 2013). But despite the risks, stress still functions to prepare us to respond to threats and meet the demands of life. The Solution? Rethink/appraise your stress response as helpful, and your physical response as more similar to excitement and joy. “This is my body helping me rise to the challenge.” See also: TED Talk by Kelly McGonigal: How to Make Stress Your Friend Are there other benefits? Acute/moderate stress can… Stimulate cell growth in brain’s learning centres (Kirby et al., 2013). Stimulate immune activity (Dhabhar et al., 2012). Improve accuracy in cognitive tasks (Kohn et al., 2017). Reinforce good (and bad) habits (Neal et al., 2013). Learning Objectives Describe the leading perspectives on stress and provide examples where applicable. Summarize the stress response, physiological and psychological considerations; define the transactional model of stress. Summarize primary health effects of chronic stress and cortisol. Define the general adaptation syndrome and allostatic load. Define PTSD and factors associated with posttraumatic growth; describe the freeze response. Consider sources of stress; discuss occupational and environmental stress and relevant factors. Discuss the ways in which stress can be beneficial; define flow. Copyright Notice © David King This lecture presentation and accompanying PowerPoint slides are the exclusive copyright of David King, PhD. They may only be used by students enrolled in the respective course at the University of British Columbia. Unauthorized or commercial use of these lectures, including uploading to sites off of the University of British Columbia servers, is expressly prohibited. PSYC-314 Health Psychology UBC Distance Education David King, PhD Module 3/Lecture 3 The Means to Success: Coping & Stress Management Coping with and Reducing Stress; Social Support; Human-Animal Interaction (HAI); Nature & Health; Meditation & Mindfulness L-3 Health Tips: 1. Accept the things you cannot change. 2. Change the things you can. 3. Put your relationships to good use. 4. Talk to animals, hug trees, live near water—and meditate. Coping with Stress Responding to Stress, Coping Behaviour, and Stress Management What is Coping? Coping refers to the things that people do to reduce their stress. The process by which people try to manage the perceived discrepancy between the demands and resources they appraise in a stressful situation. Includes efforts to manage internal and external demands, whether successful or not (do not confound the behaviour with the outcome!). Not a single event; involves continuous transactions with the environment and continuous appraisals/reappraisals. → A dynamic process. Transactional Model of Stress and Coping (Richard Lazarus and colleagues, 1980, 1984) Transactional/Dynamic Primary & Secondary Coping Stimulus Appraisal Response(s) Oh !$@#%! Functions of Coping (Lazarus & Folkman, 1984) Problem-Focused Coping – Direct efforts to solve the problem. Emotion-Focused Coping – Efforts to manage emotions generated by the stressful situation. Relationship-Focused Coping – Efforts to maintain and manage social relationships during stressful periods (DeLongis & O’Brien, 1990). Problem-Focused Coping Changing the situation Thinking of options / Weighing pros & cons Making a plan of action / Formulating a list Increasing efforts to make things work Changing ourselves Seeking information from other sources Learning new skills / Practicing / Rehearsing Taking a course / Reading a book Emotion-Focused Coping Denial (I told myself it didn’t happen.) Escape-Avoidance (I avoided thinking about the problem.) Distancing (I tried to forget it and put it out of my mind.) Wishful Thinking (I wished it would go away.) Emotional suppression (I tried not to cry.) Emotional expression (I told others.) Positive reappraisal (I focused on the bright side.) Self-Care (I took a break.) Social comparison (I reminded myself that I’m still better off.) Prayer (I prayed for things to get better.) Substance use (I had a drink.) Other Defence Mechanisms (e.g., intellectualizing), etc. Relationship-Focused Coping Empathic responding (I tried to understand how other person felt.) Perspective taking (I tried to see things from person’s perspective.) Support seeking (I called a friend for help.) Support provision (I tried to help the other person involved). Compromise (I tried to find a solution that was fair to all involved.) Interpersonal withdrawal (I spent time alone.) Confrontation (I expressed anger to the other person.) Mixed functions, interactive effects. Meaning-Focused Coping (Pearlin& Schooler, 1978) Meaning-Focused Coping – Efforts to manage the meaning of an event or situation. According to Folkman (2008): Drawing on beliefs (e.g., religious, spiritual, or beliefs about justice), values, and existential goals (e.g., purpose in life) to motivate and sustain coping and well-being in difficult times. Approach vs. Avoidance (Billings & Moos, 1981; others) Approach Coping – Attempts to actively deal with the problem or manage the tension. cognitive (e.g., trying to see the positive) or behavioural (e.g., talking to a friend) Avoidance Coping – Attempts to distance oneself from the problem and not think about it. cognitive (e.g., trying not to think about it) or behavioural (e.g., drinking to reduce tension) Approach vs. Avoidance What are the possible benefits and costs of each? Possible benefits? Possible costs? Approach Coping ??? Appropriate action; ??? Increased distress; Release of emotions; Non-productive worry Assimilation of trauma; and rumination Stress reduction Avoidance Coping Short-term??? stress ??? Increased distress; reduction; Allows for Interference with action; dosing; Increased hope Emotional numbness; and courage Disruptive behaviours What is the best way to cope? No one way of coping is good for all situations all of the time… Depends on personal attributes, abilities, contextual factors, social factors, controllability of stressor, etc. For example, avoidance is better than approach if the situation is uncontrollable; yet approach is better if one can take advantage of opportunities for control (Roth & Cohen, 1986). Successful Coping The best indicator of effective coping is THE OUTCOME. Was the goal accomplished? Was the problem solved? Was the challenge overcome? Was there an impact on mood or health? Was there an impact on the relationship? Research methods? Daily process / daily diary studies Resilience Psychological Resilience: Positive adaptation or successful coping after a stressful or adverse situation (Hopf, 2010). → Recovery from stress / adversity without a lasting impact. According to Major et al. (1998), resilience involves high levels of 3 positive aspects of personality: self‐esteem, personal control, and optimism. → Similar to hardiness (control, commitment, challenge) Resilience Health outcomes of resilience in old age (MacLeod et al., 2016)… Improved quality of life Independence in ADL Faster cardiovascular recovery Increased longevity Lower mortality risk Better mental health Greater happiness, well-being Lower rates of depression Higher life satisfaction Successful aging (despite adversities) Other Helpful Traits What other traits and characteristics are associated with more successful coping? In addition to resilience and hardiness… Sense of coherence (seeing life as manageable, meaningful). Optimism (expectation that good things will happen). Low neuroticism / high emotional stability. High extraversion, agreeableness, and conscientiousness. High openness to experience. Type B personality (low competitiveness, low hostility). Some recommendations from the research… Deal with things, problem-solve. (problem-solving / denial/avoidance) Process and express your feelings. (disclosure / rumination) Engage positive emotions; find benefits/meaning. (positive reappraisal) Accommodate to the stressor as needed. (acceptance) Find support and collaborate. (support-seeking / empathy / withdrawal) Also: Interact with friendly animals. Spend time in nature. Meditate and be mindful. A Closer Look at Positive Reappraisal A highly adaptive strategy focused on gaining meaning from a stressful event. Involves deriving personally relevant positive meaning from an experience in the face of its negative qualities. Much more than simply looking on the bright side of things… A Closer Look at Positive Reappraisal Nowlan et al. (2016): Examined positive reappraisal in response to adverse life events among older adults (62-88). Positive reappraisal was associated with higher current and future positive emotion, as well as lower anxiety and depression. PR coping intervention programs show success in reducing anxiety and improving clinical outcomes (e.g., Ockhuijsen et al., 2014). A Closer Look at Disclosure An adaptive strategy in which a person describes their feelings about a stressful or traumatic experience. Similar to emotional expression; an important aspect of emotion regulation. Disclosure can be verbal or written. Ideally should be engaged in with the intent of resolving or working through things… A Closer Look at Disclosure Cepeda et al. (2008): Asked cancer patients to write a story about how cancer affected their lives for 20 minutes/week for 3 weeks. Patients whose narratives contained more emotional disclosure had significantly less pain and reported higher well-being compared to less emotional. Also benefits of disclosure in narrative therapy for PTSD (Sloan et al., 2015), eating disorders (Weber et al., 2006), etc. The Social Context of Stress Social Networks & Social Support: Their roles in stress and health Tend-and-Befriend (Shelley Taylor et al., 2000) People also respond to stress with social behaviours. Tend-and-Befriend (Shelley Taylor et al., 2000) Oxytocin People also respond to stress with social behaviours. The Stress Buffering Hypothesis Social support is a protective factor; it buffers the impact of stress and environmental demands on the individual. Stress Health Social Support Social vs. direct effects: Support Health The Stress Buffering Hypothesis e.g., in couples coping with early-stage dementia Gellert et al. (2018) Examined whether the negative relationship between perceived stress and quality of life can be buffered by perceived social support in patients with dementia and in their caregivers. Types of Social Support Emotional/Esteem– feeling loved and cared for by others; valued and respected by others; empathy, concern, positive regard. Tangible/Instrumental – receiving material aid, assistance from others. Informational Support – getting advice & information from others. Companionship Support – availability of others to spend time with. Which type of support is best? Also: Invisible Support (Bolger et al., 2000) Not all support is good… Protective Buffering – keeping information from someone in order to protect them; avoiding potential for negative interaction. Solicitousness – expressing concern; helping without request. These forms of interaction are maladaptive for both parties involved (e.g., Kool et al., 2009; Zniva et al., 2017). Why are these types of support problematic? Benefits of Support Provision Does providing support also have benefits for health? Research has found health-related benefits associated with helping and prosocial behaviour (e.g., volunteerism)… Stress-buffering effects via increased oxytocin (Poulin & Holman, 2013). Reduced hypertension (Sneed & Cohen, 2013). Reduced depression (Creaven et al., 2017). Quality vs. Quantity Social Support – Functional content and quality of social relationships. Social Networks – Number of social relationships; degree of social integration. Most research has found that quality matters more to health, but quantity DOES still matter (Ozbay et al., 2007). Social Networks & the Common Cold Cohen et al. (1997) examined the role of social network diversity (# of different types of relationships) in contracting a cold. Measured network diversity and then exposed subjects to cold virus. People with fewer than 4 types of social roles were over 4 times more likely to catch cold than those with 6 or more roles. Social Network Diversity LeRoy et al. (2017) – Subjective loneliness also worsens cold symptoms. The Power of Social Networks Fowler & Christakis (2008) followed a large social network of 4739 individuals from 1983 to 2003. Identified clusters of happiness; people surrounded by happy people are more likely to become happy themselves. The relationship between people’s happiness extends up to three degrees of separation (for example, to the friends of one’s friends’ friends. In other studies, similar results for tastes, health, wealth, beliefs, weight, etc. See TED Talk: https://www.youtube.com/watch?v=2U-tOghblfE  What about social media and online social networks? In research, social media use has been associated with… Loneliness, frustration, anger (after using FB; Krasnova et al., 2012). Lower well-being and life satisfaction (after using FB; Kross et al., 2013). Increasing depression (Lin et al., 2016). Negative body image (Hogue & Mills, 2019). Narcissism (w/increased visual use of social media; Reed et al., 2019). Depression, anxiety, psych. distress (Keles et al., 2020; systematic review). Support via Technology? Can social support be effectively provided through technology (e.g., text messages, social media)? It appears that it can, but likely to a lesser degree than in-person support. Here are some select findings… Holtzman et al. (2017) found that supportive text messages led to increased positive affect, but in-person support was better. Hooker et al. (2018) found that supportive partner text messages can reduce cardiovascular responses to stress. Cole et al. (2017) found that social media support was associated with lower depression in young people (esp. for those lacking in-person support). The Risk of Loneliness Meta-analysis by Holt-Lunstad et al. (2015) examined loneliness and social isolation as risk factors for mortality. Increased likelihood of early mortality for… Loneliness…………… 29% Social Isolation……. 26% Living Alone………… 32% The Importance of Healthy Relationships The health benefits of marriage (Waite & Gallagher, 2000), relationship satisfaction (Kiecolt-Glaser & Newton, 2001), and social connectedness (Dias et al., 2018; Ozbay et al., 2007) have been well documented in research. Harvard Study on Adult Development (1938 --) “The surprising finding is that our relationships and how happy we are in our relationships has a powerful influence on our health. Taking care of your body is important, but tending to your relationships is a form of self-care too. That, I think, is the revelation.” - Robert Waldinger, Study Director Recommended TED Talk: https://www.youtube.com/ watch?v=8KkKuTCFvzI Human-Animal Interaction (HAI) Exploring the Benefits of Nonhuman ‘Support’ Benefits of HAI Meta-Analysis by Beetz et al. (2012): review of 69 HAI studies Physiological: reduced blood pressure; improved cardiovascular health; enhanced immune system functioning; reduced susceptibility to infection; improved pain management; lower cortisol output. Psychosocial: improved mood; lower anxiety and reduced impact of stress; lower fear; reduced aggression; increased trustworthiness and trust of others. Stress Buffering: HAI reduces the impact of stress on health. Benefits of HAI Meta-Analysis by Beetz et al. (2012) Select findings… Increased survival time after heart attack for dog owners. Decreased heart rate from petting a dog. Reduction of cardiovascular stress in the presence of a dog. Reduced cortisol in healthcare workers after 5 minutes w/ therapy dog. Sign. reduction in minor health issues for 10 mos. after getting a dog. Fewer doctor visits per year for elderly dog owners than non-owners. Benefits of HAI “Most of these studies show that the presence of friendly animals, both familiar or unfamiliar, can effectively reduce heart rate and blood pressure or buffer increases in these parameters in anticipation of a stressor. These effects may even be stronger with one’s own pet.” (Beetz et al., 2012) Animal vs. Human Interaction Allen et al. (2002) Pet owners showed lower reaction to stressors (mental arithmetic task and putting hand in ice water) and faster recovery compared to non- pet-owning participants who had a friend present. In married couples, the presence of a pet attenuated the stress response more than the presence of the spouse (based on 2 stress tasks). Mechanisms of HAI Are animals actually providing support? What types of support are they providing? Emotional? Tangible? Esteem? Are there underlying factors/ mechanisms that are the same in HAI and ‘HHI’? What are they? Mechanisms of HAI Beetz et al. (2012) propose that activation of the oxytocin system plays a key role in the majority of benefits of HAI. Studies have found that HAI leads to higher output of oxytocin. And the effects of HAI & oxytocin largely overlap, supporting its role. Oxytocin is released in both humans and animals in response to touch/ petting and mutual gaze (Beetz et al., 2012; Fiset & Plourde, 2015). Current State of HAI Research Recent meta-analyses have suggested that HAI boosts learning and engagement in schools (Gee et al., 2017a) and improves health outcomes in older adults (Gee et al., 2017b). Current research is testing the effects of HAI in veterans with PTSD. Gee et al. (2017b) note some limitations to be overcome… Lack of standardized measures of variables (e.g., pet bonding). Reliance on small sample sizes, short-term outcomes. Degree of pet involvement & previous ownership not controlled. Animals not typically well described. Lower blood pressure/heart rate from viewing an aquarium (e.g., DeSchriver & Riddick, 1990). Connection to Nature? e.g., Dijkstra et al. (2008) UBC STUDY: The visual presence of wood in a room lowers sympathetic nervous system (SNS) activation in occupants (Fell, 2010). Health Benefits of Nature Health Benefits of Greenspace Meta-analysis of 143 studies by Twohig-Bennett & Jones (2018)… Greenspace exposure was associated with wide ranging health benefits across 143 included studies. Significant reductions in… Decreases in incidence of… heart rate Type 2 diabetes diastolic blood pressure all-cause mortality salivary cortisol cardiovascular mortality Health Benefits of Greenspace How can we explain these positive effects on physical health? What mechanisms may be at play? According to Twohig-Bennett & Jones (2018)… Opportunities for physical activity & exercise. Increased social interaction. Exposure to sunlight & associated benefits. Mitigation of harmful environmental exposure (noise, pollution). The “old friends” hypothesis → Increased exposure to a range of micro- organisms which may be important for the development of the immune system and the regulation of inflammatory responses. Mental Health Benefits? Lower risk of mental illness (De Vries et al. 2003; Grahn and Stigsdotter 2003). Lower rumination and reduced depression (e.g., Bratman et al., 2015; Shanahan et al., 2016). Recent meta-analyses have suggested a more significant impact on positive affect (happiness) and a small but significant impact on negative affect (Capaldi et al., 2014; McMahan & Estes, 2015). Tree Cover & Stress Jiang et al. (2016) examined self-reported recovery from stress in a stress induction experiment as a function of tree exposure. Following stress induction, participants watched 1 of 10 3-D videos of street scenes that varied in tree cover. Found a positive, linear association (dose-response) between density of urban street trees and self-reported stress recovery, controlling for gender, age, and baseline stress. Get Out of the City… Bratman et al. (2015): Compared to those who walked in a high-traffic urban area, participants who walked for 90 minutes in a natural area showed lower rumination & decreased activity in brain regions associated with depression. Nature Deprivation Louv (author, Last Child in the Woods) – “nature-deficit disorder” Argues that elements of our urbanized lifestyle (lack of natural space, cars, screen time, increased pressures at work and school), combine to decrease or eliminate contact with nature for adults and children, resulting in negative outcomes for mental health and well-being. Tillmann et al. (2018 Review): There is consistent evidence of mental health benefits of nature contact for children, but more rigorous research is needed. Meditation and Mindfulness Meditation Meditation refers broadly to various practices and behaviours that induce a calm, peaceful, or relaxed state. Suggested to increase a person’s ability to create a “relaxation response” as an alternative to the stress response (Benson, 1984). Practicing meditation appears to alleviate stress, reduce blood pressure, and enhance immune function (Barnes et al., 2004; Davidson et al., 2003; Jain et al., 2007). Mindfulness Mindfulness is the intentionally focused awareness of one’s immediate inner and outer experiences; commonly integrated into meditation (“mindfulness-based meditation”). Moment-by-moment attention to thoughts, emotions, sensations, and surroundings. Lack of judgment; simple observation. Combined successfully with CBT. Mindfulness & Health Khoury et al. (2013): Meta-analysis of mindfulness-based therapy; 209 studies enrolling 12,145 participants with a variety of disorders (esp. depression, anxiety, stress-related). MBT is moderately effective in pre-post comparisons and in comparisons to wait-list control groups. Also effective when compared to other treatments; but not significantly different from CBT or behavioural techniques. Mindfulness & Health Khoury et al. (2015): Meta-analysis of mindfulness-based stress reduction for *healthy* individuals; 29 studies enrolling 2,668 participants. MBSR is moderately effective in reducing stress, depression, anxiety and distress and in improving quality of life. More research needed to identify the most effective elements. Practicing Mindfulness 1. Set aside some time to observe the moment as it is; let your judgements roll by. 2. Body Scan – Observe the sensations throughout your body. 3. Mindfulness-Based Meditation – Pay attention to breathing, relaxation; observe your thoughts and feelings. Shinrin-Yoku (Forest Bathing) A traditional Japanese practice of immersing oneself in nature. Hansen et al. (2017, meta-analysis) note numerous potential health benefits of forest bathing and other forms of nature therapy… E.g., Qing (2009) reported improved immune function in adults (increased natural killer cell activity) following a 3- day/2-night shinrin-yoku. Learning Objectives Define coping and its primary functions (with examples). Discuss effective coping and stress management strategies. Distinguish between social support and social networks; compare direct effects model & stress buffering hypothesis. Name and distinguish among types of social support, with considerations of less healthy forms. Consider the role of online social media/technology in health. Describe and think critically about the general research findings on human-animal interaction, including underlying mechanisms. Discuss the role of nature in physical and mental health. Discuss meditation and mindfulness as a means of stress management. Copyright Notice © David King This lecture presentation and accompanying PowerPoint slides are the exclusive copyright of David King, PhD. They may only be used by students enrolled in the respective course at the University of British Columbia. Unauthorized or commercial use of these lectures, including uploading to sites off of the University of British Columbia servers, is expressly prohibited. PSYC-314 Health Psychology UBC Distance Education David King, PhD Module 4/Lecture 4 Widening Our Lens: The Social Determinants of Health Health Disparities; Factors in Indigenous Health; The Socioeconomic Gradient in Health; Minority Stress & Stigma L-4 Health Tips: 1. Differences matter in matters of health. 2. You are affected by your situation (whether you like it or not). 3. We may find ourselves in the same storm (e.g., the pandemic), but we are not all in the same boat... The Social Context of Health Health Canada (2020) Main determinants of health: 1. Income and social status 2. Employment/working conditions 3. Education and literacy 4. Childhood experiences 5. Physical environments 6. Social supports and coping skills 7. Healthy behaviours 8. Access to health services 9. Biology and genetic endowment 10. Gender 11. Culture 12. Race / Racism Widening Our Lens… Health Canada (2020) Main determinants of health: 1. Income and social status 2. Employment/working conditions 3. Education and literacy 4. Childhood experiences 5. Physical environments 6. Social supports and coping skills 7. Healthy behaviours 8. Access to health services 9. Biology and genetic endowment 10. Gender 11. Culture 12. Race / Racism Health Disparities Inequalities in Morbidity & Mortality Health Disparities Inequalities or gaps in health or health care between groups (gender, ethnicity, culture, region, social status, etc.). Can affect… how frequently a disease affects a group. how many people in a group get sick. how often the disease causes death for a group. i.e., differences in morbidity and mortality rates between groups. Health Disparities in Canada 2018 Report from the Public Health Agency of Canada “Health inequalities in Canada exist, are persistent, and in some cases, are growing. Many of these inequalities are the result of individuals' and groups' relative social, political, and economic disadvantages.” Examples include (but are not limited to): Shorter life expectancies among those living in lower-income areas. High suicide mortality rates in First Nations, Métis, and Inuit communities. Lower self-reported mental health / higher mental illness among LGBTQ+ people, Indigenous people, and lower-income Canadians. Higher rates of asthma, diabetes, and obesity among First Nations people, Métis, and those living in Northern regions.  Indigenous Peoples in Canada The Canadian Constitution defined 3 groups of Aboriginal peoples in Canada, now referred to as Indigenous: First Nations, Inuit, & Métis. Lower life expectancies; higher infant mortality rates. Lower self-reported health; higher rates of obesity, cancer, heart disease, hypertension, diabetes, asthma, etc. Higher rates of depression, substance abuse, and other mental illnesses. Up to 4 X more likely to experience stress and trauma of all varieties. Youth are over 5 X more likely to die by suicide (11 X for Inuit youth). Sources: Health Canada; Public Health Agency of Canada; Statistics Canada; see text for references.  Life expectancy at birth by Indigenous identity, compared to non-Indigenous people, Canadian households (2011) 100 90 87.3 82.3 81.4 80 77.7 76.9 76.1 72.5 70 70 60 Years 50 40 30 20 10 0 First Nations Métis Inuit Non-Indigenous Female Male Source: Tjepkema et al. (2019) / Statistics Canada (2011) https://www150.statcan.gc.ca/n1/pub/82-003-x/2019012/article/00001-eng.htm  Prevalence of self-reported “very good” or “excellent” health by Indigenous identity, aged 12+ (2007-2010) 80 75 70 66 67 65 63 Percent of Population 60 54 55 50 50 40 30 20 10 0 First Nations Métis Inuit Non-Indigenous Health Mental Health Source: Statistics Canada (2015), Canadian Community Health Survey (2007-2010)  Prevalence of select health conditions among First Nations on-reserve and general Canadian population (2002-2003) 25 20.4 19.7 20 Percent of Population 16.4 15 10.6 10 7.8 7.6 5.2 5 5 3.7 2.6 2.4 1.9 1 1.4 0 First Nations On-Reserve General Canadian Population Source: Health Canada (2009)  Percentage of population who are overweight or obese, Indigenous and non-Indigenous, 18+, Canada (2009-2010) 45 40 Percentage of Population 35 30 25 20 15 10 5 0 First Nations First Nations Métis Inuit Non-Indigenous (On-Reserve) (Off-Reserve) Overweight Obese Source: Public Health Agency of Canada (2011), Canadian Community Health Survey (2009-2010)  Prevalence of diabetes (self-reported) by Indigenous identity, compared to non-Indigenous people, 12+ (2009-2010) 18 16 15.3 14 Percent of Population 12 10 8.7 8 5.8 6 6 4 4 2 0 First Nations First Nations Métis Inuit Other (On-Reserve) (Off-Reserve) Source: Public Health Agency of Canada (2011), Canadian Community Health Survey (2009-2010) Diabetes among First Nations Genetic & Environmental Factors The "thrifty gene effect” – may be predisposed to conserve calories. Also possibility of glucose intolerance in Indigenous females. Environmental & lifestyle factors are largely to blame. Less access to healthy food and health care services. Lower consumption of traditional foods, less physical activity due to historical changes to way of life. (Public Health Agency of Canada, 2011) Diabetes among First Nations Is poverty also a factor? 60% live in poverty (CCPA, 2016) Low income and education are believed to play a role in the increased stress and poorer health experienced by Indigenous people (Bombay et al., 2009; Mikkonen & Raphael, 2010). There is a link between poverty and higher blood glucose levels. What are the possible mechanisms? 1. Diet → Fewer healthy dietary options High blood 2. Stress → Elevated cortisol levels glucose Spiralling Suicide Rates… Case in point: The Ontario First Nation of Attawapiskat… Population of 2000; Over 100 suicide attempts (ages 9-71) in 7 months (2016). 30 suicide attempts in month of March, 2016. 11 suicide attempts (ages 9-14 years old) on the night of April 9, 2016.  Comparison of suicide rates of First Nations and general population in Canada (1979–2000) 40 35 Rate per 100,000 Population 30 25 20 2019: Rate of suicide was 3 x 15 higher among First Nations 10 people compared to the general 5 population (Statistics Canada). 0 79-81 82-84 85-87 88-90 91-93 1999 2000 Year(s) First Nations General Population Source: Government of Canada (2006); Health Canada (2003) The Trauma of Colonization For Indigenous peoples, European colonization involved a series of highly traumatic stressors, including new disease, loss of land, criminalization/loss of culture, genocide, and forced assimilation. Despite little research, there is evidence of higher prevalence of PTSD among Indigenous people in Canada (Bellamy et al., 2015). Indigenous peoples around the world report higher psychological distress (Tindle et al., 2022). 150,000 1996 First Nation, Inuit and Métis children E.g., Among 127 former residential school students in BC, 64% met criteria for PTSD (Corrado & Cohen, 2003). Intergenerational Trauma Such historical traumas have had lasting effects on Indigenous peoples that are still felt today, including increased distress and compromised health (see review by Gone et al., 2019). Intergenerational trauma refers to trauma passed down to subsequent generations. What direct & indirect mechanisms may be involved in the experience of intergenerational trauma? Direct experiences of trauma. Vicarious trauma (via stories, etc.). Lack of culture & cultural identity. Marginalization & discrimination. Compromised parental functioning. Modelling of poor coping. Genetic/biological vulnerabilities. Epigenetic Effects of Trauma Epigenetics: The study of changes in organisms caused by changes in gene expression due to environmental influences. Barha et al. (2007) – Cortisol receptor gene promotors of pups are affected by licking behaviour of mother rats in 1st week, resulting in individual differences in stress responsiveness and reactivity in adulthood. Gapp et al. (2014) – PTSD-like symptoms of isolation and jumpiness observed in male mice exposed to early stress/trauma; also alterations in genes associated with stress-related hormones and behaviours. These mice fathered young, but played no role in rearing. Pups showed same symptoms of trauma: anxious behaviour, same signature gene changes. IG Effects in Humans At this time, it is not possible to attribute intergenerational effects in humans to a single set of biological determinants, epigenetic or otherwise (Yehuda & Lehrner, 2018). But studies have suggested a role of epigenetics… E.g., One study found that children of Holocaust survivors had epigenetic changes to a gene linked to cortisol (Yehuda et al., 2016). Prospective, multi‐generational studies are needed (Yehuda & Lehrner, 2018). IG Effects of Res. Schools? In a study of 90 adult children of residential school survivors… Maternal res. school attendance Childhood adversity in adult Paternal res. school attendance children Also… Allostatic load in Maternal res. school attendance adult children But childhood adversity did NOT Childhood mediate theadversity rel’p, suggesting in adult maternal And tested if… trauma may have become ? biologically children embedded and passed on to children. Possibly through epigenetic mechanisms (but unknown). (Moon-Riley et al., 2019) Cultural Identity Cultural identity is a key factor in health. Historical and ongoing attacks on Indigenous culture have compromised cultural identity clarity (Chandler et al., 2000; Lalonde, 2006). Cultivating a stronger cultural identity may be an important way to reduce the impact of stress and trauma on the health of Indigenous communities (Iwasaki & Bartlett, 2006; Taylor & Usborne, 2010). Factors in Resilience Indigenous communities have demonstrated resilience in the face of profound trauma, and despite ongoing threats to cultural identity, e.g., discrimination (Taylor & La Sablonnière, 2014). Indigenous communities that engage in more efforts to reclaim culture experience: decreases in youth suicide, improved education, and fewer children placed in care (Lalonde, 2006). Among Indigenous youth (urban and rural), a sense of connection to the land and nature and engagement with nature have been associated with better health and resilience in qualitative research (Hatala et al., 2020; Lines et al., 2019). Socioeconomic Status (SES) NOTE: Income quintiles explained… Income quintiles reflect efforts to divide Canadians according to 5 evenly distributed groups based on personal income, family income, or average neighbourhood income. In Canada, the lowest quintile (Q1) had an average personal income (after tax) of $16,000 in 2010. The highest quintile (Q5) had an average personal income of $85,500 in 2010. Income, Education, Neighbourhood  Life expectancy at birth, Canadian females and males, by neighbourhood income quintile (2005-2007) 86 84.0 84 83.0 83.3 83.3 81.7 82 80.3 80 78.7 79.1 77.8 78 Years 75.6 76 74 72 70 Q1 Lowest Q2 Q3 Middle Q4 Q5 Highest Neighbourhood Income Quintile Males Females Source: Statistics Canada (2005)  Mortality rates per 100,000 for select causes of death, by income quintile, males & females 25+, Canada (1991-2006) 600 500 Mortality Rate per 100,000 400 300 200 100 0 Cancer (M) Cancer (F) Heart Disease (M) Heart Disease (F) Q1 Lowest Q2 Q3 Q4 Q5 Highest Source: Statistics Canada (2015)  Five-year net survival by patient income quintile for four cancers, age-standardized (2004–2009 diagnosis years) 100 90 80 70 Percent Surviving 60 50 40 30 20 10 0 Breast Colorectal Lung Prostate Q1 Lowest Q2 Q3 Q4 Q5 Highest Source: Canadian Partnership Against Cancer (2017). Adapted from data published by provincial cancer agencies and programs.  Mortality rates per 100,000 for HIV/AIDS, by income quintile, males and females 25+, Canada (1991-2006) 14 12 Mortality Rate per 100,000 10 8 6 4 2 0 Q1 Lowest Q2 Q3 Q4 Q5 Highest Male Female Source: Statistics Canada (2015)  Percent of Canadians reporting diabetes (Type 1, Type 2, & gestational) by income quintile (2013) 10 Percent with Diabetes 8 6 4 2 0 Q1 Lowest Q2 Q3 Middle Q4 Q5 Highest Income Quintile Source: Canadian Institute for Health Information (2016). Trends in Income-Related Health Inequalities in Canada, Revised July 2016. Ottawa, ON: CIHI.  The Socioeconomic Gradient in Health “At each rung up the income ladder, Canadians Health have less sickness, longer life expectancies and improved health.” (Health Canada, 1999) $$ $$ Income Adapted from Evans et al. (2012) The Socioeconomic Gradient in Health “Thousands of studies across a variety of disciplines have documented that people with larger incomes and better education tend to have better health and Health live longer. This pattern holds across all ages and in all countries that have been studied, and for virtually all measures of health...” (Wolfe et al., 2012, The Biological Consequences of Socioeconomic Inequalities) Income Recommended documentary: SES & Health Stress: Portrait of a Killer National Geographic Documentary on Stress (2008) What’s really going on? http://topdocumentaryfilms.com/stres s-portrait-of-a-killer/ The Whitehall Studies (1967-1988) Series of longitudinal studies investigating the social determinants of health in thousands of British civil servants (government employees), all of whom are ranked yet have equal access to health care. In studies of over 28,000 men and women, higher employment grade (ranking) was associated with higher life expectancy (in a gradient-like relationship; e.g., Marmot, 1978). Gradients were also found for many diseases and risk factors: hypertension, heart disease, some cancers, chronic lung disease, gastrointestinal disease, back pain, depression, suicide, obesity, smoking, physical activity, general feelings of ill-health, STRESS, sickness absence, etc. were all higher among lower-ranking employees. The Whitehall Studies (1967-1988) Series of longitudinal studies investigating the social determinants of health in thousands of British civil servants (government employees), all of whom are ranked yet have equal access to health care. STRESS and cortisol specifically were proposed as mechanisms to explain these gradients (Marmot & Davey, 1991). But what factors/mechanisms specifically cause greater stress for those at the bottom? Suggestions: Lower control (Kuper, 2003), reduced predictability (Vaananen et al., 2008), and/or fewer resources due to smaller paycheque (Yarnell, 2008). Baboons & Stress (Robert Sopolsky) Lower-ranking males experience ongoing, uncontrollable social stress which affects health. Among baboons, displacement aggression is common: top baboon kicks the one below him, and so on. This leads to chronically elevated stress hormones in low-ranking members of the pack. The Status-Health Relationship It has been found that… Low is associated with Increased Morbidity & Mortality, Lower S.E.S. Quality of Life, etc. But stress appears to be one key mechanism, such that… Low Increased Morbidity Chronic & Mortality, Lower S.E.S. Stress Quality of Life, etc. Low SES, Stress, and Appraisal Low-SES individuals report more frequent stressful life events and more chronic stressors (Chandola & Marmot, 2011; Lantz et al., 2005). Low-SES individuals also have a tendency to interpret stressors as more threatening (Chen & Miller, 2007). Suggested to develop as a result of living and working in unpredictable settings. Low SES and Coping Disadvantaged people (including those with lower income/status) also cope less effectively with stress (Marco, 2004). Low-SES people also tend to have smaller and less diverse social networks compared to people with higher income and education (Finney et al., 2015; Pilisuk, 1982). Why? People with larger and more diverse networks are less likely to become poor (Finney et al., 2015). There is also evidence that social support less consistently buffers the impact of stress in people living in poverty (Moskowitz et al., 2013). Low SES and Allostatic Load McEwan & Seeman (1999) The burden of coping with limited resources and negative life events results in increased allostatic load on individuals at lower ends of the socioeconomic gradient.* * Social ordering and dominance hierarchies are among the most potent stressors. Biological Embedding Model (Miller et al., 2011) Childhood adversity gets programmed into the immune system through multiple mechanisms, including epigenetics. E.g., Immune cells develop pro-inflammatory tendencies that manifest throughout life and contribute to increased chronic disease. Chen et al. (2007) have found increased asthma symptoms among youth living in poorer neighbourhoods. Factors in Resilience ‘Shift-and-Persist’ (Chen & Miller, 2012) Some individuals are able to overcome low-SES adversities… Over a lifetime, some low-SES children develop an approach to life that prioritizes: 1. Shifting Oneself → Accepting stress for what it is and adapting through reappraisals. 2. Persisting → Enduring life with strength by maintaining meaning and optimism.  Key Factors to Consider in the Link between Income & Health (WHO, 2010) Social status – Social hierarchies result in chronic stress and poor health for people at the bottom. Individual income – Less money to invest in health. Reverse association – Poor health interferes with an individual’s ability to secure and maintain employment. Social cohesion – Income inequality leads to a decrease in the social bonds that exist in society, aggravating problems (e.g., crime). Social disinvestment – In lower-income neighbourhoods, fewer health- promoting resources are invested in the social and physical environment. Source: World Health Organization (2010). A Conceptual Framework for Action on the Social Determinants of Health. Geneva, Switzerland: WHO. What’s the Impact on the Group? Is social inequality bad for everyone’s health? What is the impact on the group? Watch TED Talk by Richard Wilkinson, British researcher and expert on the social determinants of health. http://www.youtube.com/watch?v=cZ7LzE3u7Bw (16:55) Among rich countries, higher income inequality (i.e., larger gap between rich and poor) is associated with lower life expectancy, higher rates of mental illness, higher crime, poorer childhood outcomes, lower well-being, etc. (on average for a given society). Even the rich in more unequal countries are worse off (on average) than the rich in more equal countries. Consider: How might inequality affect everyone, regardless of status? Could inequality even impact the rich? Primary Mechanism(s)? How exactly is social inequality having a negative impact? We’re not entirely sure, but Wilkinson suggests these factors… heightened levels of competition in a society. social evaluation anxiety – increased stress due to greater threats to self-esteem, social status, and fear of judgment. Inequality is a detriment at all levels… EXAMPLE: Status Anxiety: “Some people look down on me because of my job situation or income.” (Analysis based on independent study of 35 ,634 adults in 31 countries.) (Wilkinson & Pickett, 2017) What is the extent of the impact? Narcissism: Excessive attention-seeking, derogation of others, grandiose superiority, bragging. (Analysis based on 2 independent studies.) (Wilkinson & Pickett, 2017) Moving Forward… “The evidence that large income differences have damaging health and social consequences is strong and in most countries inequality is increasing. Narrowing the gap will improve the health and wellbeing of populations.” (Pickett & Wilkinson, 2015, Income inequality and health: a causal review, Social Science & Medicine) Consider: Outside the context of a single person or family, what does it mean to maintain good social health? What does a ‘healthy society’ look like?  Minority Stress & Stigma Stigma = negative attitudes & behaviours based on group membership or affiliation. Marginalization = treatment of person or group as less important. Minority Stress Model (Meyer, 2003) Stigma, prejudice, and discrimination create a hostile social environment → leads to increased stress for minorities and increased incidence of disease & illness. Minority Stress Examined primarily in regards to racial and sexual minorities. African Americans have higher rates of stroke, diabetes, perinatal disease, some cancers, depression, & substance abuse. LGBTQ+ individuals have higher rates of immune dysfunction, some cancers, substance abuse, depression, anxiety, & attempted suicide. Found or suggested to explain health disparities in many other groups, including Indigenous peoples (e.g., Shepherd et al., 2017). Minority Stress Specific sources of stress vary, but include… direct experiences of discrimination, prejudice, harassment. social stigma; internalized bias and stigma rejection and expectations of rejection hiding or concealing identity (esp. LGBTQ+ people) Minorities are also more likely to live in poverty… Discrimination and marginalization are common barriers for minorities seeking to escape poverty (Corcoran & Nichols-Casebolt, 2004).  Culture Race Sexual Ability Orientation Ethnicity Religion Sexual Identity Intersectionality Nationality refers to the ways in which different Gender forms of discrimination and oppression (e.g., sexism, racism, classism, Region Gender homophobia, and transphobia) interact Expression to shape experiences. Status Gender (SES) Sex Class Identity Age Racism and Health Racism places a substantial strain on the mental and physical health of targeted individuals. Research suggests a consistent relationship between racism and a variety of mental health outcomes (Paradies, 2006; Pascoe & Smart Richman, 2009; Priest et al., 2013)… in addition to physical health outcomes (e.g., cardiovascular disease; Wyatt et al., 2003). Mechanisms? Institutional racism can limit resources and opportunities (which then impacts health, leads to stress), while personal experiences of racism increase stress over time. (For a review, see Brondolo et al., 2011; Brondolo et al., 2016) Trans Stigma and Stress Trans (transgender) people represent one of the most stigmatized and marginalized groups in Canada/internationally. Canadian Trans Youth Health Survey (Veale et al., 2013): 2/3 of participants reported discrimination because of gender identity. 1/3 of younger participants had been physically threatened or injured. Poverty, hunger, mental health, accessing health care issues for many. Trans Stigma and Mental Health Suicidality is highly prevalent among trans people (similar to or greater than other members of the LGBTQ+ community). 2010 US study of 7000 trans people: 41% had attempted suicide. 2011 Ontario study of 433 trans people: 77% had seriously considered suicide; 43% had attempted suicide. …compared to 1.5% of the general population who have ever attempted suicide. Sources: National Center for Transgender Equality and the National Gay and Lesbian Task Force (2010); Trans Pulse Project (2011); Grant et al. (2011) Factors in Resilience Grossman et al. (2011) examined resilience in trans youth… Personal mastery, social support, and emotional coping were significant predictors of reduced depression, trauma symptoms, and psychological problems. Trans adults who engaged in more support-seeking and positive reappraisal, while avoiding denial and substance use, had lowest risk of suicidality (Freese et al., 2017). Lower suicidal ideation has also been associated with greater gender identity clarity (Wolford-Clevenger et al., 2019). Let’s summarize… Low S.E.S., Low Social Rank, Increased Morbidity Subordination, & Mortality, Lower Minority Status Quality of Life, etc. Social Evaluation, Chronic Stigma, Discrimination, Stress Marginalization The Status-Health Relationship Expanded Low S.E.S., Low Social Rank, Increased Morbidity Subordination, & Mortality, Lower Minority Status Quality of Life, etc. Social Evaluation, Increased Chronic Stigma, Discrimination, Marginalization, Lower Stress Control What are the effects of disease threat? Consider: How might disease threat (as in a pandemic) affect inequality, stigma, discrimination, and/or racism? Regarding inequality, it may be exacerbated by socioeconomic disparities in disease threat (see Furceri et al., 2020). According to Stanford historian Walter Scheidel… Pandemics can either worsen inequality (by leading people to defend and protect the status quo) or reduce it (by upending the status quo). Scheidel suggests that a pandemic has to get “bad enough” so that it leads people to question existing hierarchies and social systems and eventually construct new ones. Read more here (for your interest): https://news.stanford.edu/2020/04/30/pandemics-catalyze-social-economic-change/ What are the effects of disease threat? Consider: How might disease threat (as in a pandemic) affect inequality, stigma, discrimination, and/or racism? Throughout history, infectious diseases have been associated with “othering” (racism, xenophobia, bigotry; White, 2020, The Lancet). “Outbreaks create fear, and fear is a key ingredient for racism and xenophobia to thrive.” (Devakumar et al., 2020, The Lancet) Historical pathogen prevalence around the world has been associated with authoritarianism (the trait), authoritarian governance, and more conservative political ideologies (Murray et al., 2013). Research has also found that being vaccinated and using hand sanitizer can reduce anti-immigrant attitudes (Huang et al., 2011). Learning Objectives Define health disparities and discuss research findings related to Indigenous peoples and socioeconomic status (including the socioeconomic gradient in health). Define intergenerational trauma and discuss the potential role of epigenetics (from a basic perspective). Discuss possible explanations for health disparities, including subordination, lower perceived control, stigma, discrimination, etc. Explain how inequality may impact population health (noting the role of social evaluation anxiety/increased stress). Describe/summarize the relationships that exist among social inequality/social status, stress, & health. Discuss and provide examples of the minority stress model and the role of stigma in health, noting examples provided. Copyright Notice © David King This lecture presentation and accompanying PowerPoint slides are the exclusive copyright of David King, PhD. They may only be used by students enrolled in the respective course at the University of British Columbia. Unauthorized or commercial use of these lectures, including uploading to sites off of the University of British Columbia servers, is expressly prohibited. PSYC-314 Health Psychology UBC Distance Education David King, PhD Module 5/Lecture 5 From Habits to Health: Understanding Behaviour Health Behaviours; Psychosocial Factors in Health Behaviour; A Closer Look at Disease Threat and Vaccine Hesitancy/Resistance L-5 Health Tips: 1. What you do on a daily basis matters! 2. But WHY you do it is complicated… 3. In any crisis of public health, consider how your choices affect others. 4. Vaccines are complicated, too, but they don’t need to be.  Reminder: The Leading Causes of Death in Canada… Consider: (malignant neoplasms) What are some things they share in common? (cardiovascular disease) Source: Statistics Canada (2019) The Role of Behaviour in Health… We know that people’s usual health-related behaviours (their “health habits”) influence their likelihood of developing chronic and fatal diseases, such as heart disease, cancer, and HIV/AIDS (WHO, 2019). Illness and early death could be substantially reduced if people would adopt lifestyles that promote wellness, such as eating healthy diets, exercising, not smoking, and being “safe” (whether in sun or in sex!). But the typical person’s lifestyle includes many behaviours that are risk factors for illness and injury. Health Behaviours Health Behaviours Activities that people perform to maintain or improve health (or prevent disease and illness), regardless of health status or whether the activity actually improves health. Health Behaviour & Health Status People’s health status can affect the type of health behaviour they perform and their motivation to do it… Well Behaviour = any activity people undertake to maintain or improve current good health and avoid illness. E.g., eating a healthy diet, exercising, getting vaccinated. Symptom-Based Behaviour = any activity ill people undertake to determine the problem and find a remedy. E.g., complaining about symptoms, seeking advice. Sick-Role Behaviour = any activity people undertake to treat or adjust to a health problem. E.g., adhering to medical advice, staying home from school/work. Many Health-Compromising Behaviours… Physical Inactivity Poor Diet & Nutrition Cigarette Smoking Alcohol Consumption Unprotected Sex Excessive Sun Exposure Poor Sleep Habits Infrequent Handwashing Poor Oral Hygiene Not Seeking Medical Care Poor Road Safety etc. The Alameda County Study (1965–1999) Investigated the link between lifestyle & health. Identified 7 risk factors (health habits) associated with poor physical health and increased mortality: N = 6,928, followed 1. smoking cigarettes for 20 yrs 2. drinking excessive amounts of alcohol 3. being obese 4. being physically inactive 5. eating between meals 6. not eating breakfast 7. sleeping fewer or more than 7-8 hours /night The Prospective Urban Rural Epidemiology (PURE) Study (2002—) Examined health outcomes and risks associated with a wide variety of key health behaviours. N = 135,000+ adults Dehghan et al. (2017) from 25 countries, Higher total mortality was associated with including Canada higher carbohydrate intake and lower total fat intake; Stroke was associated with lower intake of saturated fat. Miller et al. (2017) Higher fruit, vegetable, and legume consumption was associated with a lower risk of total mortality. U.S. Health & Retirement Study (1992–2014) Puterman et al. (2020) Analyzed data from 13,611 1. Current smoker American adults between 2. History of divorce 1992 and 2008. 3. History of alcohol abuse 4. Recent financial difficulties Among 57 factors (social, behavioural, economic), the 5. History of unemployment 10 most closely associated 6. Previous history as a smoker with death between 2008 and 2014 were → 7. Lower life satisfaction 8. Never married (in order of significance) 9. History of food stamps 10. Negative affectivity Primary Prevention Primary prevention involves actions taken to avoid disease or injury (or prevent onset of illness). E.g., exercise, wearing seatbelt, flossing, immunization/vaccination, handwashing, physical distancing, wearing mask (as in pandemic) Can technically be undertaken by either the individual or society. Health promotion initiatives (e.g., providing information about how to stay healthy) are often aimed at primary prevention. Secondary & Tertiary Prevention Secondary prevention involves actions taken to identify and treat an illness or injury early with the aim of stopping or reversing the problem. E.g., medical exams, cancer screening, symptom-based behaviour of seeking medical care for pain, sick-role behaviour of taking medication, treating the flu or pneumonia Tertiary prevention involves actions to contain or slow damage of injury/disease, prevent disability or recurrence, and rehabilitate the patient. E.g., physical therapy for people with arthritis, taking medication to control pain, providing comfort for people with terminal cancer Problems in Promoting Wellness Successfully promoting wellness depends on a variety of factors. Problems can include… Factors within the individual – attitudes, perceptions, difficulty changing habits, lack of resources, low self-efficacy, etc. Interpersonal Factors – lack of social support, conflicts among behaviours in family systems, disruptions to behaviour, etc. Factors in the Community – lack of public health funding, lack of safe/clean space, economic resources, etc. What really matters? What actually determines people’s health behaviours? In this lecture, we’ll explore factors primarily occurring within the individual and the individual’s social context. In the next lecture, we’ll take a closer look at factors in the community, including public service announcements (PSAs) and psychosocial interventions. Focus on Disease Threat We will be taking a closer look at behaviours related to disease threat in our examination of factors in health-related behaviour. mask- wearing physical distancing handwashing & disinfectant use condom use vaccination Factors in Health Behaviour What determines people’s health-related behaviour? Learning Although health behaviours have a degree of heritability, learning also plays a significant role. Operant Conditioning – behaviour changes due to consequences. Reinforcement: When we do something that brings a pleasant consequence, the tendency to repeat that behaviour is increased. Extinction: If the consequences that maintain a behaviour are eliminated, the response tendency gradually weakens. Punishment: When we do something that brings an unwanted consequence, the behaviour tends to be suppressed. Learning Although health behaviours have a degree of heritability, learning also plays a significant role. Modelling – learning occurs through observing others (e.g., parents). Classical Conditioning – over time, a stimulus (e.g., cigarette pack) can come to elicit a response through association with an unconditioned stimulus (e.g., feeling relaxed after a cigarette). These stimuli can serve as “cues” or “triggers” for behaviour (e.g., smoking a cigarette). Contribute to a behaviour becoming established and habitual. Other Psych./Social Factors Social influences, stress, emotional factors, personality, etc. E.g., The ‘Big 5’ personality trait Conscientiousness is associated with increased healthy behaviours and decreased problematic behaviours (e.g., Bogg & Roberts, 2004; Hampson et al., 2006). Including following rules and recommendations during the COVID- 19 pandemic (Clark et al., 2020). Perception (e.g., of health, of symptoms) and cognition (health- related knowledge, judgments about symptoms, optimistic and pessimistic beliefs, etc.). The likelihood that a person will perform some health behaviour Health depends on the outcome of two assessments the person makes: Belief (1) the threat associated with a health Model problem and (2) pros and cons of taking action Widely supported across various health behaviours (e.g., dental visits vaccinations, exercise programs). Health Belief Model (Hochbaum, 1958; Rosenstock, 1966) Perceived Perceived Seriousness Threat Perceived Vulnerability (Belief in Health Cues to Action/Reminders Threat) Likelihood of Performing the Health Behaviour Perceived Perceived “Pros & Cons” Benefits and Belief that Benefits Barriers outweigh Costs (sum = benefits – barriers) (Pros & Cons) Health Belief Model Applied to Flu Vaccination (Hochbaum, 1958; Rosenstock, 1966) Perceived “I haven’t had a Perceived severity of / flu shot, which Threat vulnerability to the flu puts me at risk Cues to action from (Belief in Health of getting sick physicians about flu shot Threat) from the flu.” Likelihood of Getting Flu Vaccine “I believe the flu Perceived shot works. I Perceived “Pros & Cons” Benefits and don’t believe Belief that the flu shot is the Barriers flu shot can effective, belief that it is give you not harmful (risks low). (Pros & the flu.” Cons) (Abraham & Sheeran, 2005; Cheney & John, 2013) Perceived Risk & Optimism Can perceiving physiological risk be harmful psychologically? According to Cognitive Adaptation Theory (Taylor, 1983), those who do not fully accept their physiological risk may have better mental health → and be better able to cope with risk. E.g., Taylor et al. (1992) found that HIV positive men who inaccurately, but optimistically, believed that they could halt the progression of AIDS practiced better health habits than those who were pessimistic. How can we reconcile these findings with research on unrealistic optimism (i.e., the finding that people who are unrealistically optimistic take less preventive action)? Health behaviour is the direct result of behavioural intentions, which are Theory of influenced by 3 key factors. Planned Behaviour Widely supported across various health behaviours (e.g., exercising, smoking, cancer screening, losing weight, donating blood). Theory of Planned Behaviour (Ajzen& Madden; Fishbein & Ajzen) 3 factors determine one’s intention to perform a behaviour: 1. Attitude Regarding the Behaviour: Judgment of whether the behaviour is good or bad. 2. Subjective Norm: Appropriateness or acceptability of behaviour (based on beliefs about others’ opinions, social norms). 3. Perceived Behavioural Control: Expectation of success. Similar to self-efficacy – belief that one can execute a course of action, achieve a goal; correlated with performance/success. Theory of Planned Behaviour Applied to HPV Vaccine Uptake Among adolescent girls, baseline intention to get the HPV vaccine was a strong predictor of getting at least one dose of the vaccine at follow-up → approx. 2/3 But, other factors were also at play, including ethnicity and cultural values. (Bowyer et al., 2014) Theory of Planned Behaviour Applied to HPV Vaccine Uptake Attitudes → Belief that HPV is severe, vaccine is safe. Subjective Norm Intention Getting to get HPV → Parents & friends vaccine. vaccine. thought they should. Perceived Control → Belief that vaccine is effective against cervical cancer; belief that parents would let them get vaccine. (Bowyer et al., 2014) Importance of Subjective Norm Celebrity influence? Charlie Sheen’s 2015 disclosure about his HIV status coincided with notable increases in online searches about STD/HIV testing and at- home HIV tests. Importance of Subjective Norm Celebrity influence? New York City poison control center received a higher-than-normal number of calls the day after Trump speculated that injecting household disinfectants could be a coronavirus treatment. The Transtheoretical Model (Stages of Change Model) recognizes that it may Stages of not be possible to change all at once… Change Validated across various health Mode