What can health psychology
contribute to public health?
Dr Frank Doyle & Dr Catherine Darker
Division of Health Psychology
Overview
• What is Health psychology, and why are we here?
• 4 studies that use health psychology approaches
– Time-to-treatment for stroke
– Adherence to the oral contraceptive pill
– Adapting alcohol interventions
– Increasing walking in sedentary adults
• Where do we go from here?
What is Health Psychology
anyway?
Health Psychology
• Application of psychological theory, methods
and research to health, physical illness and
health care for the promotion and
maintenance of well-being
• Focus on:
– Individuals
– Communities
– Populations
Health Psychology Training – knowledge base
• Theory-based approaches in…
–
–
–
–
–
–
–
Lifespan perspectives and developmental processes
Health-related cognitions and behaviour
Psychoneuroimmunology
Professional-patient communication
Personality, health and disease
Stress, illness and coping
Primary, secondary and tertiary prevention in the context
of health-related behaviour
• Population approach is key difference to other
psychologists
Why are we here?
• We are keen to build links with public health
– As is happening in UK, especially Scotland
• Scotland:
– Novel training programme combining public health and health
psychology
– 10 Trainee Health Psychologists
• Project example:
– A behaviour change service for looked after young people
– Sexual health, smoking, healthy eating, physical activity
• Other examples include:
– pharmaceutical public health, alcohol use during pregnancy,
breastfeeding, child healthy weight etc
Gilinsky et al. BMC Public Health 2010, 10:692
How can Health Psychology
contribute to Public Health?
Case 1 – Reducing patient delay time
in stroke?
Acute stroke treatment: ‘time is brain’
• Stroke is the third leading cause of death and disability
worldwide
– Ireland: 10,000 strokes per year; 30,000 with significant disability
• Thrombolysis within 4.5 hours of symptom onset
– improves neurological outcome (ischaemic stroke)
– INASC (2008) – 1% of patients received thrombolysis
– Patient pre-hospital delay is biggest barrier
• Reducing hospital presentation time critical
– Mass media interventions useful?
Mellon et al, Emerg Med J 2013, doi: 10.1136/emermed-2012-202280
May 2010: The first national mass media stroke awareness campaign – Irish Heart
Foundation Act F.A.S.T. Campaign
• 5 waves of television advertising
– May, October, January – high intensity day & night
– June & July – occasional daytime only TV
Mellon et al, Emerg Med J 2013, doi: 10.1136/emermed-2012-202280
F.A.S.T. campaign: admissions
• Campaign did increase
knowledge (Hickey et al, 2011)
• Significant level trend for ED
attendances with reported
stroke symptoms
– (.84, 95% CI, .43-1.24; p < .001)
• Wave 1 only
• Significant slope change
following Wave 1
– (-.08, 95% CI, -14 to -.01)
• But no sustained campaign
effect
Mellon et al, Emerg Med J 2013, doi: 10.1136/emermed-2012-202280
So what could work?
• Systematic review of
interventions to
reduce delay in
hospital presentation
with stroke symptoms
• Found 11 studies for
review
Mellon et al, submitted for publication
Reference, country
Intervention type
Behavioural outcome
Addo et al. 92012) UK
Public education (media
campaign)
Public and professional
education
Time to presentation
Thrombolysis rate
Presentation under 24 hours
Barsan et al. (1994) USA
Public and professional
education
Time to presentation
Bray et al. (2011) Australia
Public education (media
campaign)
Public education (media
campaign)
Public and professional
education
Proportion of ambulance dispatches for stroke
Morgensten et al. (2002)
Public and professional
education
Thrombolysis rate; Time to presentation;
Müffelmann et al. (1995)
Public education
Time to presentation; Admission <4 hours; Thrombolysis rate
Alberts et al. (1992) USA
Hodgeson et al (2007)
Luiz et al. (2001)
Müller-Nordhorn et al. (2009) Public education
Total number of stroke ED visits; Presentation <5 hours;
Presentation <2.5 hours
Time to presentation; EMS activation time; EMS use
Time to presentation; Thrombolysis rate; Mortality
Schmidt et al. (2005)
Public education
Time to presentation; Admission <3 hours; Thrombolysis rate
Wojner-Alexandrov et al.
(2005)
Public and professional
education
Ambulance transports for stroke; Time to presentation <2
hours; Thrombolysis rate
Mellon et al, submitted for publication
Findings
• Only one intervention showed a sustained increase in
thrombolysis rates from 2.21% to 8.65% (Morgenstern et al. 2002)
• This was the only intervention designed using a structured
theoretical approach focussed on:
– changing perceived norms of stroke treatment
– Reinforcing behaviour change (quick response to stroke symptoms) by using
role-modelling techniques - advertisement of community stroke survivors
who received thrombolysis
– Standard health psychology techniques!
• Caveat: needs replication
Mellon et al, submitted for publication
How can Health Psychology
contribute to Public Health
Case 2 – Identifying psychosocial
predictors of non-adherence to the
oral contraceptive pill
Oral contraceptive pill
• Second most commonly used contraception in Ireland
• Excellent efficacy:
– <1% women taking it correctly will experience unintended
pregnancy within a year, but…
• Rosenberg et al., (1998)
– 47% do not fully adhere
– 22% miss two or more pills per cycle
– Therefore risk of OCP failure – and
unintended pregnancy – remains high
– Estimated 8% 1-year incidence of
unintended pregnancy in those who do
not adhere fully
Trussell J. Contraceptive efficacy. In Hatcher RA, et al, Contraceptive Technology: Nineteenth Revised Edition. NY: Ardent Media, 2007.
Better adherence associated with
modifiable determinants? Examples:
• Intention e.g. I want to
take my pill as prescribed
• Perceived behavioural
control e.g. To what
extent do you see
yourself as being capable
of taking your pill as
prescribed?
• Anticipated regret: e.g.
If I did not take my pill as
prescribed, I would feel
regret
• Action planning: I have
made a detailed plan
regarding….when, where,
how
• Coping planning: ….what
to do if something interferes
with my plans (Sniehotta et
al., 2005)
Molloy et al. BMC Public Health 2012, 12:838
Methods
Crosssectional study
of female
university
students
(N=130, mean
age 20.5
SD:3.01, range
17-36)
Outcome variable: Medication
adherence report scale for OCP
1. I forget….
2. I alter the dose….
3. I stop taking…
4. I decide to miss out a dose..
5. I take less than instructed
Rated as: 1 Never to 5 Always
Higher scores poorer adherence to
OCP
Molloy et al. BMC Public Health 2012, 12:838
Results
100
90
90
Participants
who miss
OCP either:
82
80
70
60
50
Never
44
40
Once
Twice or more
30
20
10
0
% who take pill at fixed time
Participants
who didn’t
have a fixed
time for
OCP use
much more
likely to
miss their
OCP once
or more
(OR 3.62,
95% CI
1.34-9.79)
Molloy et al. BMC Public Health 2012, 12:838
Variable
Intention
Perceived behavioural
control
Anticipated Regret
Necessity beliefs
Concerns beliefs
Action planning
Coping planning
Beta
95% CI
Lower
95% CI
Upper
0.05
-0.07
0.17
-0.35
-0.45
-0.26
0.04
-0.01
0.09
-0.05
-0.14
0.05
0.07
-0.04
0.17
0.03
-0.05
0.11
-0.10
-0.19
-0.01
Multiple
regression
analysis of
adherence to
OCP by
psychological
predictors:
Total R2 = 0.48
Molloy et al. BMC Public Health 2012, 12:838
Summary
1.
2.
3.
4.
5.
6.
7.
lower concerns about OCP
higher necessity beliefs
higher intentions
higher perceived behavioural control
lower anticipated regret about not using OCP
higher action planning in relation to OCP
higher coping planning in relation to OCP
• =>Interventions targetting such beliefs/strategies
could be effective in increasing adherence to OCP
– And potentially avoid unintended pregnancies
Molloy et al. BMC Public Health 2012, 12:838
How can Health Psychology
contribute to Public Health
Case 3 – Adapting brief interventions
for alcohol misuse in an opiate
dependent population
Background
• At present there is in excess of 9,500 patients receiving
methadone maintenance throughout the Irish Republic (Central
Treatment List, 2013).
• A small cohort also abuse alcohol and a proportion of these
eventually develop alcohol dependence.
• The intravenous drug using cohort also have high prevalence
rates for hepatitis C, variously estimated at between 60-75%
carrying the active virus at any one time (Smyth, O’Connor, Barry &
Keenan, 2003).
Alcohol & opiate dependence
• Increased risk of:
– Heroin overdoses (Gossop, 1996)
– Unsafe injecting behaviour (Stein, et al., 2000)
– Complications of methadone dosage (Kreek, 1990)
• Ryder et al., (2010) prevalence of problem alcohol use among
heroin users in GP. Screened 196 patients, 68 patients (35%)
AUDIT positive.
– Of those 68 patients, 33 (48%) patients ‘hazardous’ and 8 (12%)
patients ‘harmful’, 27 (40%) patients dependent
•
Effectiveness
of
BI
Primary care
– Recent Cochrane review (Kaner et al., 2007) of 22 RCTs (enrolling
7,619 Ss) showed that overall BI of up to four sessions, lowered
alcohol consumption.
• Opiate dependent groups
– Stein et al., (2002) needle exchange clients. Two 1 hour sessions
of MI reduced alcohol consumption
– Gerald, et al., (2002) MMT Ss nine sessions of MI reduced alcohol
consumption
• Can an effective BI be delivered in one session to an opiate
dependent MMT cohort?
Method
• Design
– a quasi- experimental design with before and after scores on the
AUDIT being compared from baseline to three months follow-up.
• Setting
– Three methadone maintenance clinics in Dublin
• Participants
– Participants were all opiate dependent and accessing methadone
maintenance treatment; All patients attending the clinics
– All clinical staff, were trained in BI protocols by an expert trainer in the
area using World Health Organisation guidelines of evidence-based
approaches (Babor & Higgins-Biddle, 2001).
Brief Intervention
(WHO; Babor & Higgins-Biddle, 2001)
•
•
•
•
•
•
Present screening results
Identify risks and discuss consequences
Provide medical advice
Solicit patient commitment
Identify goal
Give advice and encouragement
There was a statistically significant reduction in AUDIT C scores
from T1 (x=6.74, sd=2.35) to T2 (x=5.74, sd=2.66) for the BI group
[IQR1 5-8 IQR2 4-7; Wilcoxon rank test p<0.001].
Darker et al., 2011 Drug & Alcohol Review
Next BI trial
HRB funded RCT to test the effectiveness of a WHO Brief Intervention
for illicit drugs in an opiate dependent cohort
WHO recommend each team/country developing a BI that is culturally and
contextually
Appropriate
Intervention development = focus groups with clinicians & semi-structured
interviews
with patients. Address issues:
-Low literacy
-‘Americanism’ – more Dublin
Substance Risk Card
How can Health Psychology
contribute to Public Health
Case 4 – Increasing walking in
sedentary adults using a theorybased intervention
Background
• Approximately 41% Irish adults meet recommended minimum
physical activity (PA; SLAN, 2007)
– 30 minutes of moderate PA 5 days a week (i.e., brisk walking) (DoH,
2009)
• Regular physical activity = reduced risk of CHD, type 2
diabetes, overweight & obesity, stroke, cancer & depression
• Intention behaviour gap – people have difficulty in translating
recommendations into meaningful lifestyle changes
Method
• Walking list RCT
• N=130 sedentary adults
• Intervention = Theory of Planned Behaviour &
Social Cognitive Theory
• strategies to boost pts perceived control, and close the
intention behaviour gap (a single session with a
Psychologist)
• Measures = self-report & objective
(accelerometers)
Did intervention group increase
objectively measured walking?
Darker et al., 2010, Psychology & Health
Summary
• Health psychology is very broad, and can be
applied to public health problems
• Potential for impact on public health
– Health behaviours becoming more important
– Complex, theory-based interventions required to
promote well-being in individuals and populations
– Health psychologists are experts in theory-driven
behaviour change techniques
Further Information
• Division of Health Psychology website (PSI)
http://www.psihq.ie/psi-division-health-psychology
• Emails:
–
–
–
–
[email protected]
[email protected] (alcohol, walking)
[email protected] (stroke)
[email protected] (oral contraceptive pill)
– DHP Honorary Secretary: [email protected]