Health psychology: Critical to understanding health and illness

With the Federal Government's health reform agenda focused on reducing hospital stays and better management of chronic health conditions to prevent hospital admissions, the specialisation of health psychology has much to offer. Health psychology encompasses the biological, psychological and social determinants of health and illness within the context of healthcare systems and the wider community. Its practitioners have expertise in understanding the psychology of health risk factors, beliefs and attitudes, as well as models of behaviour change in health promotion and acute and chronic illness. Health psychologists are employed in a variety of settings including government health departments and health promotion organisations, hospital medical units, pain management and rehabilitation facilities, community health centres and primary health care practices. Three prominent applications of health psychology are profiled below.

• Health psychologists in the acute medical setting
• Prevention and management of chronic disease
• Strategies for pain management

Health psychologists in the acute medical setting

The number of hospitalisations per annum is a measure of the burden of severe illness in the population. It is influenced by the age profile of the population, the incidence of acute disease and injury, the availability of health services and treatment options. Hospitalisation is costly to the individual and health care system (Allen, 2010). The recent reports of the Federal Government's National Health and Hospitals Reform Commission and the National Preventative Health Taskforce recommend a model of health care that emphasises prevention and effective management of disease through efficacious primary and secondary health care services. This model of health care is absolutely necessary in light of the ageing population in Australia, where preventative and cost-effective management of disease is a desired outcome. Health psychology interventions can assist with minimising hospital stay and associated healthcare costs, reducing the secondary trauma of hospitalisation, and preventing relapse requiring costly re-admissions.

A randomised controlled study on the effects of preparation for surgery reported that patients demonstrated positive effects from relaxation training and cognitive coping strategies (Shelly et al., 2009). Specifically, positive surgery-specific post-operative attitudes and behaviours were reported. Additionally, health psychology research has indicated less surgical pain during the recovery process and a higher level of activity, such as return to normal daily activities at follow-up, compared to controls (Mirö et al., 1999). Psychological intervention with women undergoing mastectomy indicated that all women believed psychological consultation aided decision-making and preparation for surgery (Patenaude et al., 2008). Strong support was also demonstrated for the role of the health psychologist in deciding and adapting to the surgery.

Pre-surgery psychological interventions

• Review and development of patient expectations following procedures, such as anticipated pain levels, mobility, requirements for medical support equipment and cognitive awareness
• Identification and development of coping mechanisms to improve surgical and personal outcomes of surgery
• Support and training in health assertive processes to empower patients to seek appropriate medical, social and functional support
• Identification of intrinsic patient motivators that support positive health outcomes

Support for patients undergoing dialysis treatment

• Support to identify and improve the negative perceptions of the impact of dialysis on day-to-day activities
• Exploration of a cognitive framework that supports adaptation to change, such as deciding on, and living with, an organ transplant
• Development of skills in non-drug pain management techniques, such as distraction, dissociation and self-hypnosis
• Development of adaptive thinking styles, such as wilingness to consider new techniques and advances in medical interventions
• Management of negative emotions such as anxiety, depression and anger, particularly with an awareness of the procedures, drug side-effects and the sequalae and prognosis of the medical condition

Prevention and management of chronic disease

The World Health Organisation (WHO) describes chronic medical conditions as a hidden epidemic, with chronic diseases such as heart disease, stroke, cancer and diabetes being the leading causes of mortality and disability in the world. Chronic diseases are estimated to be the largest contributor to the burden of disease for individuals and the healthcare system in Australia and their predicted prevalence is expected to continue to rise. The National Preventative Health Taskforce (2008) has identified obesity and smoking as two of the main health priority targets in Australia. It states: "Put together, smoking, obesity, harmful use of alcohol, physical inactivity, poor diet and the associated risk factors of high blood pressure and high blood cholesterol cause approximately 32% of Australia's illness burden... In total the overall costs to the healthcare system associated with [the three risk factors of smoking, obesity and alcohol misuse] is in the order of almost $6 billion per year, whilst lost productivity is estimated to be almost $13 billion."

Health psychology interventions

The evidence base for psychological treatment intervention and prevention in chronic disease self-management is well documented. A Cochrane review identified that psychological and behavioural interventions played an important role in reducing risk factors for cardiovascular disease (Hackett et al., 2008). Shaw et al. (2005) demonstrated that behaviour therapy and cognitive behavioural interventions show significant benefits in reducing weight.

Health psychology has played an important role in Australia's efforts to successfully develop and implement prevention strategies, for example related to heart health (Oldenberg & Owen, 1990). It has been clearly identified that chronic health conditions require people to adopt numerous treatment requirements, and that health behaviour change is a crucial component of adherence to these requirements. The WHO (2003) reported that awareness of health and illness knowledge alone is no guarantee that individuals will change their health behaviours. Many people cannot achieve the required behaviour change without professional guidance. Health psychologists play a vital role in identifying the behaviours, beliefs and attitudes that negatively impact on the prevention and management of chronic disease and assist in increasing adherence to prescribed medicines, medical testing and lifestyle changes. This is achieved through motivational interviewing techniques, assessing readiness to change, goal setting, managing positive illness perception changes, identifying interactions between medications and psychological functioning, and determining psychosocial factors and influences.

Additionally, recent literature has supported the value of inter-professional care for positive patient outcomes in the management of chronic diseases. Interdisciplinary chronic disease and lifestyle risk management networks, facilitated by health psychologists, are currently being established across Australia to ensure more effective collaboration in consumer health care.

Interventions for obesity

• Development of behaviour programs aimed at increasing physical activity and changing diet, including self-monitoring strategies
• Goal setting using specific and measurable goals to break habits of overeating or eating inappropriate foods
• Addressing maladaptive thought patterns, health beliefs and negative mood states that may be acting as a barrier to weight loss
• Motivational interviewing to resolve ambivalence to change by increasing intrinsic motivation and supporting self-efficacy in belief about change

Interventions for Type 2 diabetes

• Formulation of a health psychology treatment plan, including awareness of symptoms and treatment requirements
• Facilitating adherence to treatment interventions including schedules for blood testing, vascular care, eye care, wound care and healthy circulation
• Promoting self-monitoring techniques for blood sugar level testing with adjustments to dietary intake, medication and physical activity levels as indicated
• Promotion of behavioural weight loss and weight control interventions
• Addressing lifestyle and social impacts of the disease including levels of distress, coping mechanisms at work, and personal and sexual functioning

Interventions for chronic obstructive airways disease

• Ensuring adherence to treatment interventions for care of related symptomatology such as asthma, emphysema and congestive cardiac failure
• Assessing attitudes and belief systems about preventative medicine
• Assessing intrinsic motivators for changing maladaptive behaviours
• Developing a treatment plan around lifestyle changes such as quitting smoking, avoiding toxic environments

Strategies for pain management

The National Pain summit in Canberra in March this year was the first comprehensive initiative in Australia to establish a national strategy to improve the assessment and treatment of all forms of pain. One in five Australians, including children and adolescents, will suffer chronic pain in their lifetime and up to 80 per cent of people living with chronic pain are missing out on treatment that could improve their health and quality of life (Walsh et al., 2008). It has been estimated that chronic pain costs the Australian economy $34 billion per annum and is the nation's third most costly health problem. It is anticipated that the application of evidence-based psychological treatments could save half of these annual costs and improve the lives of many patients, families and communities.

In the psychological and environmental/social domains, there is ample evidence that important factors play a significant, and sometimes dominant, role in the ongoing experience of chronic pain and in the impact that the pain has on the individual's quality of life. For example, changes in neurotransmitters associated with mood changes such as anxiety and depression are similar to those seen in chronic pain. Fear-avoidance behaviour is frequently associated with chronic pain and leads to a downward spiral of reduced activity, de-conditioning, postural changes and loss of muscle support of various joints and also the spine (Leeuw et al., 2007). Cochrane database reviews demonstrate the outcome efficacy and effectiveness of treatment intervention and prevention of chronic pain by health psychologists for both children and adults (Toumbourou, 2010). In addition, evidence that children and adolescents can develop psychological techniques to manage pain provides a theoretical basis for further exploration of preventative interventions.

Psychological care for chronic pain involves cognitive and behavioural interventions covering three areas: non-drug treatment; reduction of emotional stress (for example depression, anxiety, fear, guilt and grief); and improved adherence to medical, physical and other strategies to achieve good quality of life. Group cognitive behavioural therapy focusing on beliefs and behaviours has been demonstrated to have effective therapeutic applications in pain management (Lamb et al., 2010). In particular it has been noted to be more cost-effective and associated with longer term outcomes than other interventions for pain relief such as acupuncture, spinal manipulation and hypnosis. A randomised controlled trial with patients with subacute chronic lower back pain found that, compared to advice alone, the cognitive behavioural group intervention was associated with significant benefits in nearly all outcomes at 3, 6 and 12 months. Psychological interventions embed strategies that ensure positive management of chronic pain is maintained over a long period of time. No one treatment is necessarily successful in eliminating pain. Most people have to adapt to the presence of chronic pain and learn self-management in the face of persistent pain and accompanying symptoms.

Health psychology interventions

Interventions for acute gynaecological pain

• Psychoeducation, including understanding the physiological mechanisms that result in pain and the interplay of changes in hormonal levels on psychological functioning
• Enhancing the individual's sense of control through self efficacy
• Promoting the predictive ability of pain levels and developing strategies at times of reduced pain, for example stress inoculation techniques
• Ensuring awareness of medical and surgical interventions, for example during child birth, and developing health assertiveness skills for these situations
• Exploring non-drug psychological interventions, for example breathing techniques during child birth

Interventions for chronic pain

• Psychoeducation about the experience of pain and the gate control theory of chronic pain
• Adherence to primary treatment interventions, including medication regimes, mobility and functionality programs
• Assistance with decision making processes regarding options for surgery, return to work and lifestyle activities
• Exploration of beliefs and attitudes about chronic pain using illness perception paradigms
• Development of new coping strategies, techniques and reinforcement of strategies in pain management
• Implementation of cognitive behaviour therapy techniques that have specific evidence-based efficacy for pain management, for example self-distraction
• Addressing potential changes in cognition and emotional states that may have a significant social impact, for example with intimate relationships