Lecture 6

who is most targeted by primary intervention programs and campaigns (2)

• teenagers and young adults to intervene and ask them to adopt healthy behaviours before they have unhealthy behaviours

• people who are at risk for any reason

CDC’s anti smoking campaign (8)

• costed 54 million dollars

• ran for 12 weeks and randomly called americans

• aimed to get 500,000 people to quit and 50,000 to quit long term

• ad showed clear negative outcomes, affecting other people in your life, immediate benefits, fear and disgust aspect of scar, person is real and relatable, no jargon, where to get more information

• found that 80% of smokers and 75% non smokers recalled at least one of the ads

• estimated 1.6 million smokers attempted to quit smoking - extrapolation

• estimated more than 200,000 americans quit smoking immediately, 100,000 likely to quite smoking permanently

• however its just correlation, no causation

what was found to be the most successful anti- smoking ads

those that are emotionally evocative and contain personalised stories

methods for promoting change (4)

• providing information

• education appeals

• message framing

• fear appeals

providing information (2)

• the way in which health related information is delivered can play an important role in whether or not it is effective

• for example, is it persuasive and/ or results in actual change

education appeals (7)

• providing general information

• assume that people will be motivated to improve a health behaviour if they have the correct information

• not always successful and many factors that must be considered

  • visual appearance of ads

  • avoidance of jargon and stats

  • placement of strong arguments - beginning or at the end

  • clarity of information

message framing (3)

• refers to whether the information emphasises the benefits (gains) or costs (losses) associated with a behaviour or decision

• gain framed messages vs loss framed messages

• most research but yet least conclusively understood phenomena in health communication due to inconsistency in literature

gain framed messages (3)

• focus on experiencing desirable consequences and/ or avoiding negative ones

• it works best for motivating behaviours that serve to prevent or recover from illness or injury (e.g physical therapy)

• e.g. “ if you exercise, you will become more fit and less likely to develop heart disease”

loss framed messages (5)

• focus on experiencing undesirable consequences and/ or avoiding positive ones

• it works best for behaviours that occur infrequently and serve to detect a health problem early (e.g. getting a mammogram)

• e.g. “if you do not get your blood pressure checked, you could increase your chances of having a heart attack or stroke and you won’t know that your blood pressure is good”

• despite sounding awkward, manipulating messages in subtle ways can still lead to differences in intention and motivations

• when the outcome of behaviour is uncertain, loss framed is more effective

message framing for covid-19 (3)

• meta analysis found no significant differences in messages for covid-19 vaccines

• another study found loss framed message to be more effective

• complex area of research as effectiveness of message depends on numerous factors (e.g. cultural factors, motivation, population etc)

fear appeals (3)

• message framing that assumes instilling fear will lead to change

• fear is a motivating emotion and it is the only thing that will motivate us to engage in health behaviours

• effects tends to be transient, they don’t stick

fear appeals are more persuasive if (4)

• consequences are emphasised

• inclusion of personal testimonial

• provided specific instructions

• boost self efficacy before urging them to change

but why can too much fear be problematic (2)

• can lead to stress and anxiety

• people might just be motivated to ignore it and don’t receive the information that you want them to

behavioural and cognitive methods to promote change (5)

• behavioural methods focus on helping people manage the antecedents and consequences of a behaviour

• cognitive methods of focus on changing people’s thought processes

• cognitive behaviour therapy

• motivational interviewing

• social engineering

cognitive behaviour therapy (3)

• evidence based psychotherapeutic intervention that promotes self observation and self monitoring to increase awareness and control of negative thoughts and harmful behaviours

• the goal is to regulate thoughts, attitudes, beliefs, emotions and behaviours through personal coping strategies

• also referred to self management - the idea that clients can eventually apply the methods themselves without supervision

CBT applied to alcohol misuse (3)

• first step is to identify unhelpful/ unrealistic thoughts and beliefs that contribute to the problem behaviour

• then identify triggers (internal/ external) that cause you to drink

• engage in more realistic and helpful thoughts

why can maintaining health behaviour changes be difficult

due to lapse and relapse

lapse (3)

• single instance of backsliding which does not indicate failure

• they are part of the experience when one is trying to quit a behaviour

• clients needs to have the right tools for coping strategies to not fall into a relapse

relapse (2)

• falling back to original pattern of undesirable and problematic behaviour

• very common when people try to change long term habits

abstinence violation effect (2)

• when someone experiences a lapse, it can ruin their confidence in remaining abstinent and lead to a full relapse

• they attribute a lapse to a relapse and think of it as a failure

motivational interviewing (5)

• a one on one counselling style designed to help individuals explore and resolve their ambivalence in changing a behaviour

• originally developed for counselling of alcoholics

• targets people who are not highly motivated to change and uncertain about changing behaviour at that time

• highly emphatic approach to counselling

• intention from clinician to not engage in judgement and accept person as they are

approach of motivational interviewing (2)

• semi directive - no strict protocol for clinicians to follow

• client centred - empathic approach, seeing things from their perspective

what does motivational interviewing adopt

adopts a transtheoretical model of behaviour change in combination with CBT methods

2 key features of motivational interviewing

• decisional balance - clients list reasons for and against changing behaviour and discuss

• personalised feedback- clients receive information on their pattern of problem behaviour, comparisons with norms and risks of behaviour

brief alcohol screening and intervention for college students (BASICS) (3)

• harm reduction approach

• designed to help students make better alcohol use decisions based on a clear understanding of the risks associated with problem drinking

• aimed at college students esp 1st and 2nd year where behaviour is just emerging

what does BASICS involve (4)

• 2 brief interview

• assessing risk of problem behaviours, obtaining commitment to monitor drinking between interviews

• providing personalised feedback, including comparisons to norms, risks and advice on how to drink safely

• strategies include - slowing down, drink for quality not quantity

BASICS: one year follow up study (2)

• randomly assigned college students to three conditions - one motivational interviewing, control group (waitlist) + talking to clinician but general discussion

• after one year, found that skill training group had fewer days being drunk and fewer number of days of continuous drinking

BASICS overall findings (5)

• found to be effective

• some studies show 4 year long effects even with just 2 interviews

• effects better seen in yr 1 and yr 2 than yr 3

  • behaviours are less habitual

  • intervention occurring at the right time

social engineering (2)

• changing the social environment in order to better support healthy behaviours

• e.g. nutritional guidelines, school vaccination programs, taxation of alcohol to increase cost

what is common with such initiatives

resistance is common

e.g. regulation/ prohibition of drugs

traditional approach to preventing substance use/ misuse is to regulate, prohibit and/ or criminalise addictive or harmful substances

legalisation vs decriminalisation (2)

• legalisation - removal of legal prohibitions against previously illegal actions

• decriminalisation - the removal of criminal status from a certain behaviour or action

decriminalisation and harm reduction (5)

• evidence indicates that decriminalisation does not typically increase the use of drugs

• but legislation in Canada has been correlated with increase in drug use - normalisation by public

• in contrast to criminalisation, a harm reduction approach aims to reduce the negative consequences of substance/ drug use and to treat people who use drugs with respect and dignity

  • in order to reduce/ remove the effects of social stigma

  • in order to better motivate them to be healthy and contributing members of society

insite supervised drug consumption (5)

• exposure to illegal toxic drug supply was the leading cause of death from ages 10-59

• insite supervised drug consumption is an attempt to reduce this

• reduction in public injecting and syringe sharing

• increases in the use of detox services and addiction treatment

• significant drop in overdose deaths and new cases of HIV infection

harm reduction today (4)

• numerous safe consumption sites opened around Canada

• in 2020, BC became the first jurisdiction globally to launch a large scale province-wide safer supply policy - allowing individuals with opioid use disorder at high risk of overdose to receive pharmaceutical grade opioids

• some provinces have tested decriminalisation of illicit drugs

• BC decriminalised possession of some illicit substances in 2023 but ended the program as unclear if there are benefits and not enough support to continue policy

addiction (2)

• state of psychological and/or physical dependence on the use of drugs or other substances, such as alcohol or behaviours like gambling

• common for them to co occur

psychological dependence

state in which individual feel compelled to use a substance or engage in a behaviour for the effect it produces

physical dependence

exists when the body has adjusted to a substance and incorporated it into the normal functioning of the body’s tissue

what are the 3 possible diagnoses when each substance disorder

• use disorder - addiction

• intoxication

• withdrawal

short effects of alcohol (5)

• reduced coordination

• diminished cognitive ability

• judgement, decision making

• aggression/ emotionality

• accidents

long term effects of alcohol (5)

• liver damage

• cardiovascular disease

• various types of cancer

• depression

• alcohol use disorder

why is alcohol use/ misuse a complicated behaviour (4)

• socially accepted and encouraged

• use to destress as well

• there is a pronounced psychological component

• when to drink can be associated with any emotions

alcohol use disorder (DSM-5-TR) (4)

• problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by 2 or more symptoms occuring within a 12 month period

• tolerance and withdrawal symptoms are seen in everyone with this disorder

• tolerance - diminished effect over time or need for greater amounts to achieve same effect

• withdrawal - severe symptoms when stop using, like nausea, sweating, tremors, insomnia etc

is alcohol use disorder a categorial or continuous approach (4)

• it is a scale that is an integration of categorical and continuous approach

• mild - 2-3 symptoms present

• moderate - 4-5 symptoms

• severe alcohol use disorder - 6 or more symptoms

alcohol intervention (3)

• 12 step program and AA

• CBT

• motivational interviewing

12 step programs and AA (3)

• may be comparable to other treatments

• inconsistent experimental evidence of effectiveness across studies

• challenge is that each support group is different where the traits and characteristics of people are different and there is normally one person leading the meetings

CBT (2)

• there is a small but statistically significant treatment effect across controlled studies

• focused on identifying and micromanaging behaviour

motivational interviewing (2)

• most effective approach

• consistent and significant effects in large majority of studies and outperforms traditional counselling

abstinence vs moderation - which one is better (5)

• the less severe the drinking problem, the more likely moderation, controlled drinking will work

  • best prospects for those who are young, socially stable and have short history of alcohol misuse and have not experience severe withdrawal

• for long term alcohol users to pursue a goal of controlled drinking is unrealistic and probably not in their best interests

• but it is dependent on a case by case basis

• controlled drinking is not recommended but abstinence is by health professionals due to health outcomes

is some alcohol healthy (5)

• previous research suggest that light to moderate alcohol intake is protective against coronary heart disease

• but raises the question of who are the abstainers

• many abstainers abstain because of illness and or medication

  • when we see poorer health it is not because they are abstaining from alcohol but because of their underlying condition - suggesting a third variable

• when this was controlled for, there was no significant difference between abstainers and moderate drinkers in CHD

moderate drinking may be good for heart conditions - possible mechanisms (4)

• good for cholesterol

• good for coping with stress

• social activity, more positive social benefits than negative outcomes

• but even if there is a small benefit, the overall risks still outweigh any benefits

the obesity epidemic

occurred from the mid to late 20th century and obesity has increased significantly around the world

obesity

having a very high amount of body fat in relation to lean body mass or BMI of 30 or higher

body mass index (BMI) (4)

• a measure of an adult’s weight in relation to their health

• specifically the adult’s weight in kilograms divided by the square of their height in metres

• not developed to be used on an individual basis but rather when looking at a population level

• many differences like sex and cultural differences are not taken into account so not accurate

obesity trend among US adults (2)

• increase in obesity from 1990- 2010

• today it is even worse with ¾ of population being overweight

obesity trends in Canada (2)

• in 2022, most Canadian adults were classified as overweight or obese

• 10% lower than what is seen in the US

prevalence of obesity around the world (2)

• global challenge

• continue to worsen over time

what contributes to this crisis (2)

• food environment

• fast food chains and food availability

who is responsible for this crisis (3)

• easy availability of fast food chains

• no access to healthy food, grocery stores

• attributed to a systems approach where multiple factors plays a role

a systems approach to obesity (4)

• obesity is an end result of the intricate interactions of biology, behaviour and environment

• obesity is heritable, but in most cases of genetic predisposition, risk of obesity is increased by 20-30%

• the obesity epidemic is driven largely by environmental and lifestyle factors rather than biological ones

• lifestyle factors does not mean blaming the individual as it is determined by the environment the person is

healthwashing

making products seem healthier when it isnt

the health halo effect (4)

• tendency to judge an entire food item as healthier based on one or more narrow attributes that are perceived as healthy

• food is considered healthier when

  • it is labeled as low calorie, organic or all natural

  • it comes from a restaurant seen as healthier

does the health halo effect apply to entire menus (5)

• examined how consumers food choices differed when healthy items were included on a menu

• individuals were more likely to make indulgent food choices when a healthy item is available compared to when it is not

• why?

  • vicarious nutritional goal fulfilment - they imagined fulfilling their healthy eating goals

  • status quo bias - when presented with more option, more motivated to choose what people would normally choose due to it being overwhelming

behaviours implicated in obesity across the lifespan (6)

• unhealthy diet

• physical inactivity

• poor sleep

• screen time

• stress (cortisol)

• interpersonal factors

which diets work (4)

• fad or “crash” diets are often problematic and can be unhealthy

• recent study revealed an increased risk of premature death for those on low carb diet

• research suggest that going low carb may lower levels of serotonin and be problematic for those with pre existing depression

• added/ processed sugar appears to be more predictive of both poor health and obesity than most dietary fat

which diet is the best

sustainable, balanced diets that provide optimal amounts of all essential nutrients for the body’s metabolic needs are best

gluten free diet

talking about gluten intolerance but not celiac disease

research on if non celiac gluten sensitivity exist (4)

• 2011 - published results of a study suggesting that non celiac gluten sensitivity may exist but not confirmed as a real thing

• 2013 - published results suggesting that there is no such thing, suggested that it is more likely that something else is involved

• 2018 - showed fructans a short chain of carbohydrates induce symptoms of gluten sensitivity, not gluten

  • people who think that they have gluten intolerance may just have a sensitivity to fructans

long term gluten consumption and health (3)

• long term intake of gluten is not associated with risk of CHD

• but rather cutting out healthy carbohydrates and avoiding health benefits of fibre by going GF may affect cardiovascular risk

• so promotion of GF diets among people without celiac disease should not be encouraged

canada’s current food guide (2)

• more balanced diet

• how to integrate food into social lifestyle- in line with biopsychosocial model

what is an alternative to dieting and weight control

the health at every size approach

the health at every size approach (4)

• shift in philosophical approach, focusing on weight neutral outcomes, not focusing on losing weight or BMI but noting that health can be had in a variety of different conditions and body types

• focuses on if a person is engaging in healthy behaviours, daily habits etc

• goal is to promote size acceptance, end weight discrimination and reduce the cultural obsession with weight loss and thinness

• some evidence of effectiveness but found to be more effective when integrated with different approaches

weight stigma (5)

• is a factor in both weight gain and poor health

• stigma predicts mortality

• numerous mechanisms including increased stress and poor coping which affects ability to stay on diet and be healthy

• weight stigma and anti- fat bias in health care also lead to poorer treatment and inadequate care for patients with obesity due to assumption made by doctors that anything that is wrong is due to their weight

• internalisation of weight biases has been shown to interfere with weight management interventions

what must we do to overcome stigma

we need to change the attitudes and behaviours of those who stigmatise

sedentary behaviour

anything activity involving sitting, reclining or lying down that has a low energy expenditure

risk of sedentary lifestyle (2)

• meta analysis found that it may be a distinct risk factor for premature death and adverse health, independent of low physical activity

• it is a significant risk factor on its own

watching tv vs smoking

study found that watching tv for an hour reduces lifespan by 22 minutes whereas smokers shorten their lives by 11 minutes on avg per cigarette

but what is important about sedentary lifestyle and health

we can reverse the effects as it is not long lasting such that we can see benefits when people make changes to their health habits