KU Leuven Psychology of Prevention and Health Promotion: Comprehensive Study Notes

H1 – INTRODUCTION TO PREVENTION SCIENCE

• Aims of the Course

  • Learn about prevention as a scientific discipline, including background, theories, implementation, and dissemination.

  • Understand healthy and unhealthy behaviors and methodologies for changing them.

  • Learn how to implement behavioral changes and measure behavior and behavioral shifts.

  • Learn to conceive, implement, and judge the quality of a sound prevention campaign.

• Defining Prevention Science

  • Interdisciplinary Nature: It is an interdisciplinary specialty integrating psychology, counseling, social work, education, health sciences, economics, and public affairs.

  • Psychological Prevention Science: Focuses on preventing psychological and physical illness and promoting overall health and well-being using evidence-based practice at individual and systemic levels.

  • Specific Aims:

    • Reduce preventable deaths (deaths potentially prevented by promoting healthy habits or medical intervention).

    • Reduce premature deaths (defined as deaths occurring before the age of $75$).

    • Increase healthy life years and general quality of life.

    • Reduce the economic impact of diseases.

• Global Health Context and Epidemiology

  • Causes of Death (WHO):

    • Communicable, maternal, neonatal, and nutritional: Transmissible from others (more prevalent in low-income countries).

    • Noncommunicable: Not transmissible (dominant in high-income countries).

    • Injury.

  • Relevance: Prevention must target the specific problems of the setting. For example, diarrhea prevention is vital in low-income countries but may not be cost-effective as a large-scale campaign in high-income countries.

• Nomenclature and Key Definitions

  • Years of Life Lost (YLL): Number of years lost due to death or illness that impairs everyday life (e.g., chronic back pain preventing work or social activities).

  • Years Lost to Disability (YLD): Number of years a person lives with a limitation (does not automatically implicate a loss of Quality of Life).

  • Healthy Life Expectancy: Life expectancy spent in good health.

  • Disability-Adjusted Life Years (DALY): Sum of years lost to being sick and premature death.

  • Quality-Adjusted Life Years (QALY): The improvement in quality of living following an intervention.

  • Disability: An umbrella term covering impairments (body function/structure problem, e.g., blindness), activity limitations (executing tasks like washing), and participation restrictions (involvement in life situations).

  • Quality of Life (QoL): An individual’s perception of their position in life influenced by culture, value systems, and personal goals.

• Risk Factors and Modifiable Behaviors

  • Risk Groups in Europe: Metabolic risks (BMI, plasma glucose, LDL, kidney dysfunction), Environmental/Occupational (air pollution), and Behavioral (dietary, alcohol, tobacco).

  • Cancer Prevention: An estimated $40\%$ of all cancers in Europe are preventable through primary prevention, screening, and early detection.

  • Economic Impact: Prevention programs (like breast cancer screening for women aged $50-70$) have upfront costs but are cheaper for healthcare systems than treating late-stage disease.

  • Specific European Trends:

    • Tobacco: Price increases effectively reduce consumption; price decreases increase it.

    • Alcohol: Overuse peaks in the $55-64$ age category. Belgium uses campaigns like "Dry January" or "Tournée Minérale."

    • Eating: Continuous discussion on sugar-sweetened vs. artificially sweetened drinks. Snack intake peaks in children; sugary drinks peak in ages $15-34$.

    • Sedentary Behavior: High in age groups $15-24$ and $75+$. Recommended minimum movement is $150\,\text{min/week}$.

• Classification of Prevention (Caplan/Gordon)

  • Caplan’s Types:

    • Primary Prevention: Prevent problems from occurring across healthy populations (e.g., vaccinations).

    • Secondary Prevention: Target groups at risk for development (e.g., mammograms for those with family history).

    • Tertiary Prevention: Limit the impact of an existing problem (e.g., Alcoholics Anonymous).

  • Gordon’s Target Groups:

    • Universal Prevention: Offers value to an entire population (e.g., seat belts).

    • Selective Prevention: Targets subgroups with above-average risk (e.g., Head Start programs).

    • Indicated Prevention: Targets individuals at high risk or exhibiting early symptoms (e.g., support groups for widowers with depression).

• Strategy of Prevention: Lessons from Rose (1981)

  • Absolute vs. Relative Risk: Identifying risk in relative units can be misleading. Decisions must be made measuring risks and benefits in absolute terms (e.g., lives saved per $100,000$ people).

  • Population Attributable Risk: A large number of people exposed to a low risk (e.g., slightly elevated blood pressure) produces more cases than a small number of people exposed to a high risk.

  • High-Risk Strategy: Identifies the top of the distribution. Good for individuals but offers only a limited answer to community problems.

  • Mass Strategy: Aims to shift the entire population distribution (e.g., reducing salt intake for everyone).

  • The Prevention Paradox: A measure that brings large benefits to the community but offers little to each participating individual (e.g., seat belts, immunization).

  • Safety: Mass interventions must be paramountly safe. Removal of unnatural factors (reducing saturated fats) is generally safer than adding unnatural factors (long-term mass medication).

H2 – DETERMINANTS OF BEHAVIOR AND BEHAVIOR CHANGE

• Defining Health Behaviors

  • Health Behavior: Behavior aimed at preventing disease (e.g., gym, healthy diet).

  • Illness Behavior: Behavior aimed at seeking a remedy (e.g., visiting a doctor).

  • Sick Role Behavior: Activity aimed at getting well (e.g., taking medication).

  • Health Impairing Habits: Automatic, non-addictive behaviors that are difficult to target (starting the day with coffee).

• Levels of Determinants

  • Biological: Genetics, metabolic traits (nicotine metabolism, hunger/satiety, reward sensitivity).

  • Personal: Personality (impulsivity), learning history, attitudes, knowledge, and expectations.

  • Environmental: Availability (price), socio-cultural norms, and financial/economic conditions.

  • Protective Factors: Resilience, skills, and environmental advantages.

• Historical Evolution of Interventions

  • Pre-70s: Focus on environmental determinants (e.g., screening, food safety).

  • 70s: Focus on personal determinants (Health education, cognitive theories).

  • 90s: Emphasis on Health Promotion (prevention role of doctors).

  • Modern: Choice Architecture (Nudging); organizing context to orient decisions without forbidding options.

• Theoretical Models of Behavior Change

  • Fear Drive Model: Based on informing, fear appeals, disgust, and shame. It is often ineffective because fear habituates, is short-lasting, and focuses on negative feelings rather than long-term skills.

  • Subjective Expected Utility Theory: Humans as economic creatures weighing costs and benefits. It overemphasizes rationality and ignores social context.

  • Unrealistic Optimism: Four biases (belief that if a problem hasn't appeared yet, it won't; Infrequent estimation; Egocentric prevention belief; Lack of personal experience).

  • Self-Efficacy Theory (Bandura): Belief in one's capability to perform tasks to reach a goal. Distinct from self-esteem (overall worth). Determined by internal locus of control.

  • Health Belief Model (HBM): Predicts behavior based on Perceived Susceptibility, Perceived Severity, Perceived Benefits, and Perceived Barriers. Updated with "Cues to Action" and self-efficacy.

  • Protection Motivation Theory (PMT): Triggered by information leading to Threat Appraisal (severity/rewards) and Coping Appraisal (efficacy/costs). Protection motivation is the intention to perform the behavior.

  • Theory of Planned Behavior (TPB): Extension of TRA (Theory of Reasoned Action). Behavior is determined by Intention, which is influenced by Attitudes, Subjective Norms, and Perceived Behavioral Control. Criticized for the "Intention-Behavior Gap."

  • Transtheoretical Model of Change (TTM):

    1. Precontemplation: Unaware of the need to change.

    2. Contemplation: Planning change in the next $6$ months; weighing pros/cons.

    3. Preparation: Decision-making and preparing for action.

    4. Action: Commitment stage (0-6 months); non-stable.

    5. Maintenance: Avoiding relapse ($6$ months to $5$ years).

    6. Termination: Belief in no revert to old behavior.

  • Self-Determination Theory (SDT): Focuses on motivation types. Autonomous motivation (volition) is superior to Controlled motivation (extrinsic/punishment). Key needs: Competence, Autonomy, and Relatedness.

  • Social Ecological Models: Features multiple levels (interpersonal, organizational, community, public policy). Interventions must be behavior-specific and address influences across all levels.

H3 – PLANNING, IMPLEMENTATION, DISSEMINATION

• Pitfalls in Practice-Based Approaches

  1. Preventing unimportant/non-widespread problems (e.g., helium balloon use among teens).

  2. Changing the wrong behavior (targeting electric stoves for burns instead of general safety).

  3. Targeting the wrong determinants (focusing on seatbelt knowledge when the real issue is child behavior).

  4. Methods not fitting determinants (giving lectures where regulation is needed).

  5. Implementation failures (using highly motivated but non-representative executors).

  6. Uninformative evaluation.

• Evidence-Based Practice (EBP)

  • Three Pillars: Best scientific evidence, Clinical expertise, and Patient values/characteristics.

  • PICO Strategy: Patient, Intervention, Comparison, Outcome.

  • GRADE System: Grading of Recommendations, Assessment, Development, and Evaluations. Quality is rated High, Moderate, Low, or Very Low.

• Theoretical Frameworks for Implementation

  • Theoretical Domains Framework (TDF): Integration of theories into domains like Knowledge, Social Role, and Identity to identify behavior determinants.

  • Behavioral Change Techniques (BCT) Taxonomy: A list of $93$ observable, replicable components (e.g., feedback, reinforcement) clustered into $16$ groups.

• Developing Interventions: Intervention Mapping (Steps)

  1. Logic Model of the Problem: Assess health problems, behaviors, and environmental conditions with stakeholders.

  2. Program Outcomes and Objectives: Specify who and what will change. Create matrices of change outcomes.

  3. Program Design: Choose theory-based methods and practical applications (moving from theory to techniques).

  4. Program Production: Refine structure, create materials/protocols, and perform pilot testing.

  5. Implementation Plan: Identify potential users (implementers) and state objectives for program use.

  6. Evaluation Plan: Create effect and process evaluation questions.

• Standards for Prevention Evidence

  • Efficacy: Works in a controlled environment.

  • Effectiveness: Works in real-world conditions (population subgroups, fidelity).

  • Scale-up: Broad dissemination with cost-tracking tools and training support.

H4 – GUEST LECTURE: CLINICAL PHARMACOLOGY

• Evidence-Based Practice in Medication

  • Belgium uses a "Bible for pharmacists" summarizing studies for rational medication use.

  • The Knowledge-Implementation Gap: It often takes $17$ years for research to impact practice.

• The Problem in Nursing Homes (NH)

  • Complex Factors: Polypharmacy (often > 5 medications), multimorbidity, and altered pharmacokinetics in elderly (reduced renal function, higher risk of cognitive side effects).

  • Antibiotic Use (COMINANDO study):

    • Antibiotic use is $10\times$ higher in ambulatory/NH settings than in hospitals.

    • $75\%$ of NH antibiotic use is estimated to be inappropriate.

    • Common error: Assuming strong-smelling urine equals a Urinary Tract Infection (UTI).

• Intervention and Evaluation

  • COME ON Study: Cluster randomized trial in NHs. Used interdisciplinary case conferences. Found small positive effects on "potentially inappropriate prescriptions" (PIPs).

  • Core Outcome Sets: Use standardized outcomes like antibiotic consumption (initiated treatments per $1000$ resident days) and duration to allow comparison across studies.

  • Determinants of GP prescribing: Identified via TDF. Includes habits, lack of knowledge, and social role/identity.

H5 – PRIMARY PREVENTION & HEALTH PROMOTION

• Strategies in Primary Prevention

  • Risk Avoidance: Prevent risk behaviors among low-risk persons (preventing obesity).

  • Risk Reduction: Reduce factors among at-risk persons (Free drug tests at festivals, reducing alcohol in heavy drinkers).

• The Health Promotion Discipline

  • Ottawa Charter (1986): Aims to empower individuals to take control of their health determinants. Principles: Supportive environments, healthy public policies, and reorienting health services.

  • River Metaphor for Strategies:

    • Downstream: Educating/empowering individuals (reaching them where the river meets the sea).

    • Midstream: Creating environments (schools, workplaces) to facilitate health (building a dam to control flow).

    • Upstream: Mediating societal interests/policies (acting at the source/macro-level).

• Educational vs. Environmental Strategy

  • Education (Downstream): Significant for knowledge but often has no significant effect on behavior (The Intention-Behavior Gap).

  • Environmental (Midstream):

    • Antecedents: Remove stimuli provoking bad behavior (ash trays).

    • Consequences: Reward good behavior, increase costs of bad behavior (taxes on sugar/tobacco).

  • Nudging (Tversky & Kahneman): Dual-system theory focusing on automatic (Type 1) and reflective (Type 2) thinking. Example: placing vegetables at the front of a cafeteria. Nudging fails if the behavior is too unfamiliar.

• Social Marketing (Upstream)

  • Uses marketing principles to "sell" collective benefits rather than immediate product gratification. Requires segmentation (targeting high-risk groups) and competitive insight.

H6 – SECONDARY & TERTIARY PREVENTION

• Secondary Prevention and Screening

  • Objective: Early identification of pathological processes in asymptomatic individuals.

  • Screening Math:

    • $\text{Sensitivity (True Positive Rate)} = \frac{TP}{TP + FN}$

    • $\text{Specificity} = \frac{TN}{FP + TN}$

    • $\text{Positive Predictive Value (PPV)} = \frac{TP}{TP + FP}$

    • $\text{Negative Predictive Value (NPV)} = \frac{TN}{TN + FN}$

• Biases in Screening

  • Lead Time Bias: Earlier diagnosis gives the false impression of improved survival without actually delaying death.

  • Length Bias: Less aggressive malignancies are more likely to be detected in asymptomatic screening.

  • Example: Minnesota Colon Cancer Study found fewer colon cancer deaths but similar all-cause mortality due to the harms of aggressive treatment/psychological distress.

• Tertiary Prevention

  • Goal: Manage established chronic disease to prevent complications. Focus on (self-)management.

  • Chronic Care Models: Evolution from a paternalistic paradigm (physician knows best) to Collaborative Care (Shared Decision Making).

  • Shared Decision Making (SDM) Archetypes:

    • Active Engagement (SDM present, positive experience).

    • Simulated Engagement (SDM present, negative experience).

    • Assumed Engagement (SDM absent, positive experience).

    • Non-engagement (SDM absent, negative experience).

H7 – HEALTH LITERACY

• Defining Health Literacy (HL)

  • UNESCO Definition: Ability to identify, understand, and use materials in context.

  • HL Dimensions: Access, Understand, Appraise (Evaluate), and Apply health information.

  • Levels: Functional HL (basic words/numbers), Interactive HL, and Critical HL (problem-solving/critical thinking).

• Measuring Health Literacy

  • Clinical Screening Tools: REALM, TOFHLA, Newest Vital Sign (NVS).

  • European Health Literacy Survey (HLS-EU): Findings show $12\%$ inadequate HL and $35\%$ problematic HL in Europe.

  • Comparative Status: Bulgaria had $60\%$ insufficient HL; the Netherlands had the best HL due to political agenda and investment.

• Relevance and Mediation

  • Outcome Indicator: HL is the proximal outcome of health education.

  • Quality Determinant: Low HL corresponds to less optimal healthcare use, higher psychiatric consults, longer hospital stays, and lower therapeutic adherence.

  • Socioeconomic Link: HL partially mediates the relationship between low SES and poor health. It reduces stress and increases self-efficacy when individuals can navigate systems.

• Intervention Levels for HL

  1. Individual Skills: Education and training.

  2. Clinical Practice: Professionals checking comprehension (e.g., "Teach-back" method: "Can you repeat this in your own words?") and using visual aids.

  3. Organizational HL: Creating "HL-friendly" settings with leadership committed to simplifying navigation and avoiding stigmatization.