Social and Behavioural Pharmacy

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What are the two broad psychological responses to illness?
Some cope well and continue to function well (find positive benefits). Others are significantly affected and cope in ways which often worsen illness outcome
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What are the two types of negative influence on illness outcome?
Via behaviour (e.g. non-adherence) and via mood/neuro-endocrine changes (e.g. post MI depression - higher MI reoccurrence)
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Outline the model of psychological response to illness
Patient, illness, social context. Perception of illness. Tasks to be coped with. Coping. Response to illness
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What are the two ways to measure response to illness?
Quality of life (assess effects of illness on range of physical and psychosocial functions). Mood/distress (anxiety in early stages or major changes, depression)
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Give examples of ways to measure quality of life (3)
General measures (e.g. SF-36). Illness specific measures (e.g. AIMS, EORTC). Individualised (e.g. PGI, SEQuOL)
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What are the two main types of strategies to cope with illness?
Problem focused (dealing directly with demands by active involvement e.g. learning new skills, taking treatment, seeking info). Emotion focused (dealing with anxiety, uncertainty and other negative emotions e.g. distraction, avoidance, emotions)
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What are illness related demands to be coped with (5)?
Pain/incapacity, dealing with a range of healthcare staff, hospital environment, treatment, making lifestyle changes
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What are the emotional/social demands to be coped with (4)?
Preserving emotional balance, self-imaging/sense of mastery/control, sustaining existing relationships, preparing for uncertain future
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Outline the maladaptive and adaptive coping model
Illness stressors, changeable/unchangeable, coping (problem or emotion focused), outcome (increase/decrease psychological distress/psychological well-being)
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What are the five main components of the patient illness perception model?
Identity (symptoms/labels), timeline (acute/chronic), cause (stress, genetic, lifestyle), consequences (effects of illness), cure/control (ability)
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What are the factors influencing illness perceptions and task demands (3)?
Patient variables, illness/treatment variables, social context
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Describe features of patient variables
Personality, age, past experience, psychological state at time of onset
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Describe features of illness/treatment variables
Life-threatening conditions, disfiguring or place limits on mobility, complex/multiple treatments
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Describe features of social context
Social support. Types (emotional, material). Matching to patient needs
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What are the aspects of patient education/self-management (psychological interventions to improve coping)?
Provision of information and new skills. Address many issues (e.g. recognise and respond to symptoms, adherence, emergencies, lifestyle). Involve motivation/behaviour change
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What are the aspects of emotion focused interventions (psychological interventions to improve coping)?
Help patients deal with illness emotions (support, exploration/expression of feelings, stress management). Individual and group approaches
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Describe the overall aspects of coping with illness
Framework for understanding responses to illness, treatment and health threats in patients. Further research to investigate all components of framework. Develop hospital/community pharmacy interventions to improve patient coping/self-management
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What are the aspects of health psychology and links with pharmacy practice?
Understand patients' illness behaviour (why they want help, impact, coping). Understand patients' treatment behaviour (adherence). Changing patient's behaviour (improve adherence/lifestyle). Communication
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What are the two basic components of symptom perception?
Awareness of changes in body sensation and perceiving the change as a symptom - equivalent to other perceptual mechanisms, critical role of attention and top-down processes
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What are the basic mechanisms of symptom perception?
Receptors (nocireceptors, thermal/mechanical), afferent pathways (L/S fibres) cortical/sub-cortical mechanisms (location/nature of signal and links to motor responses). Awareness - not inevitable (selective attention, top down processing)
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Describe aspects of selective attention
Multiple sensory inputs, limited capacity of awareness (working memory), automatic switching (context, novelty) - stroop test
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Describe aspects of top down effects
False BP feedback study, TAA enzyme study, medical students 'disease', nocebo effects
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What makes people notice/not notice bodily changes/symptoms?
Attentional focus (e.g. runner studies), external stimuli (e.g. cinema study), top down influences (e.g. labelling), health anxiety (monitoring, misattribution)
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Describe aspects of symptom perception and help-seeking
Evidence from symptom diary studies, symptom iceberg, delay studies (e.g. MI, cancer). Stages (appraisal delay, illness delay, utilisation delay). Frequent attenders
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Describe aspects of older theories for pain perception
Specificity (pain indicates receptor activity). Lack of 1:1 between sensory input and pain experience (Beecher study, phantom limb pain, placebo analgesia)
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What is the gate theory?
Spinal gating mechanisms which depend on interplay of L and S afferent fibres and top down influences (descending inhibition)
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Describe aspects of pain perception
Pain threshold, tolerance and behaviour. Measurement (sensory, affective, cognitive). Pain management (acute/pre-op preparation, chronic/self-management, coping, ACT/mindfulness)
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Describe aspects of adherence in healthcare
Entering and continuing a treatment programme. Keeping referral and follow-up appointments (DNA rates). Correct consumption of prescribed medicines. Following appropriate lifestyle changes. Avoidance of health risks
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Describe the problems with non-adherence based on the WHO report
Medicines prescribed for long term illnesses are not taken as directed. If prescription was appropriate then this would represent a loss for patients, NHS and pharma industries
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Describe aspects of the extent of the problem with adherence in healthcare
High levels of non-adherence for serious conditions and low levels for preventative treatments and/or lifestyle changes
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Describe aspects of treatment adherence in IMIDS
Low adherence. Non-adherence to therapy in most cases were intentional. Leads to worsening of disease (increased disease activity/reduced treatment efficacy, lower quality of life, hospitalisation, health care costs), irreversible damage to organs
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Describe ways of measuring rate of adherence (e.g. anti-arthritis medications in patients with RA, growth hormone treatment)
Questionnaire, prescription claims, pill count, MEMS, interview, drug level
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State the ways of measuring adherence
Self-report questionnaire, self-monitoring (diary), pill counts, behavioural measures, mechanical measures (microchips in bottle tops), marked sign technique (inactive markers), biochem indicators (blood/urine levels of drug), clinical (symptoms)
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What are the different types of non-adherence?
Unintentional (e.g. lack of info, understanding, skill) and intentional (decision no to adhere based on beliefs, motivation)
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What are the different drivers of non-adherence?
Capability (psychological and physical), opportunity (external social/physical factors) and motivation (beliefs, attitudes, mood)
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Outline the model for the role of beliefs when deciding to take medication
Illness perceptions, symptoms, negative views about medicines in general, concerns about potential adverse effects, beliefs about necessity of prescribed medicines, compliance
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What is the purpose of interventions?
Use consultation to anticipate and plan. Interventions to improve understanding of illness and treatment, enable patients to schedule medicine taking, deal with barriers etc.
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Describe the main aspects of using the consultation to facilitate informed adherence
Check patient's understanding of treatment and if necessary: provide clear rationale for necessity of treatment, elicit/address concerns, agree practical plan for how/where/when to take treatment, identify any possible barriers (HCP)
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Give examples of media being used as interventions to improve adherence
Text messaging, web-based interactive programmes and phone-based support
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Describe features of asthma
Common, chronic condition, caused by inflammation of airways. Symptoms - tightness in chest, shortness of breath, wheezing, cough. Patient prescribed reliever medication and preventer medication
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Why is the non-adherence to asthma preventer medication costly?
Increase in symptoms, increase in healthcare utilisation, reduction in quality of life
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What are the reasons for non-adherence?
Patient beliefs about: illness, medication
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What are the factors involved in the relationships between illness, medication beliefs and self-reported violence?
Age, timeline (chronic), inhaler symptoms, illness coherence, emotional representation, control, FH of asthma, asthma severity, consequences, self-efficacy, smoking status, timeline (cyclical), preventer adherence
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Which factors are involved in profiling patients based on risk of non-adherence?
Timeline, personal control, treatment control, identity, consequences, medication necessity and medication concerns (adherent/non-adherent)
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Which method was used to modify patients' illness/treatment beliefs to improve self-reported adherence to asthma preventer medication?
Text message programme
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Outline the method for the text message programme
Large sample, aged 16-45 (recruited from medicine packaging inserted/health websites (dx asthma), not taking preventer meds as prescribed, baseline assessment, compare normal care to text messages at 6/12/18 weeks and 6 months
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What were main conclusions from the text message programme?
Patients given text messages had higher preventer adherence levels (interventions improves adherence over time)
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Outline features of treatment adherence and risk of death post MI (study)
Sample of MI patients given propanolol or placebo
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State the outcomes of the placebo study
Patients with the placebo experienced similar effects in terms of b.p. and heart rate to that of propanolol
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Describe the adherence related effects in the placebo study
Odd ratios for adherent (>75%), less adherent patients. As the severity and risk factors increase, the adherence decreases for propanolol but increases for placebo (possibly due to placebo patients thinking the medicine works/more likely to adhere)
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Describe features of placebo effects
A therapeutic response (not due to active component of treatment). Wide range of disorders, treatments, responses
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What are the factors influencing placebo effect? (1)
Treatment characteristics (e.g. colour/size/shape of drug). Health care setting (home/hospital). Patient characteristics (expectations, treatment/illness beliefs, anxiety, adherence)
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What are the factors influencing placebo effect? (2)
Practitioner characteristics (empathy, status, treatment/illness beliefs). Patient-practitioner relationship (therapeutic alliance, length of consultation)
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What are the mechanisms of the placebo effect?
Expectancy, conditioning, cognitive dissonance, anxiety reduction, endorphin release etc. (multiple effects/mechanisms may be involved)
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State the aspects given in the Pharmaceutical Journal about the role of pharmacists
Sub-optimal medicines use is unacceptable and pharmacists have a duty to address that (core value of professionalism needs to be inherent). Pharmacists should reflect how much they are engaging with patients and the public
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Describe features of the consultation
The quality of clinical care depends in the last analysis on the interaction of HCP
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What is the main issue with consultation?
The interaction is too disappointing to both parties. One of the most important factors is the poor communication between HCP and patient
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Describe aspects of research on the consultation
Carried out for over 40 years. Very large number of studies use audio/video- tape recordings of clinical consultation. Now widely used routinely for teaching and assessment (e.g. MPharm). Very different levels of analysis
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Describe some of the issues in a consultation in terms of the message and the relationship
Lack of skill in terms of the HCP educating the patient. Lack of relationship between HCP and patient. Lack of communication
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What are the key components of the clinical consultation?
Input (HCP and Pt - what they bring to the consultation). Process (HCP and Pt - how they interact). Outcome (Pt - subsequent effects on patient)
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Which patient inputs are important?
Patient's expectations (why have they come?). Patient's knowledge/beliefs about symptoms/illness (identity, timeline, cause). Style of coping (info/involvement). Role perceptions. Preferences of involvement
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Describe features of HCP-Patient interaction
Range of methods for measuring/classifying HCP-Pt interaction. Code HCP's communication style/pattern e.g. HCP-centered vs Pt-centered (ROTER's interaction analysis system, categories of verbal communication, 5 styles from biomedical to psychosocial
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State the aspects of the outcome for the patient in the clinical consultation
Understanding/recall, satisfaction, adherence (compliance), health (recovery, symptomatic relief etc.)
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Describe some of the issues with consultation outcome
Many aspects of consultation not understood or misunderstood (insufficient info, complexity/jargon). Patient dissatisfaction with lack of interest/empathy. Forget information
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Describe features of patient satisfaction
Medical Interview Satisfaction Scale (MISS). Assess 3 components: affective (empathy/interest), behavioural (competence/skills) and cognitive (amount/quality of information)
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What are the two broad categories involved in the problems in clinical communication?
Quality of the message and the quality of the relationship
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What are the problems and effects of the quality of the message?
Insufficient information. Complexity (jargon), discrepancies in understanding (gap), lack of organisation. Poor recall, poor understanding, low satisfaction, reduced adherence to treatment/advice
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Describe features of insufficient information
Large number of patients found to be unclear on nature of problem/course of illness. Similar patterns in hospital patients and those with terminal illness, effects on uncertainty/helplessness (increases anxiety), important to use monitoring
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Describe features of complexity of medical information
Verbal (consultation) and written (patient booklets) information were too complex for patients
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Describe features of discrepancies in understanding (gap)
Differential HCP and Pt understanding (e.g. GP advice which patients do not follow: avoid aspirin containing substances, avoid foods containing starch/sugar) - Boyle study
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Describe feature of lack of organisation
Information in the consultation is often not organised in ways which make sense to the patient. Early (primacy) and late (recency) information tends to be recalled best. Other information is recalled better if clustered in a meaningful way
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Describe features of effects on outcome
Understanding (misunderstand consultation information). Recall (forget information within 5 minutes due to understanding/anxiety). Satisfaction (low with communication, complaints). Adherence (high rates of non-adherence for most treatments)
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Describe the overall features of the consultation
An interaction which can take place in many different ways. Many problems reported. Consultation process (and problems) have direct effects on many important patient outcomes
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Other cards in this set

Card 2

Front

What are the two types of negative influence on illness outcome?

Back

Via behaviour (e.g. non-adherence) and via mood/neuro-endocrine changes (e.g. post MI depression - higher MI reoccurrence)

Card 3

Front

Outline the model of psychological response to illness

Back

Preview of the front of card 3

Card 4

Front

What are the two ways to measure response to illness?

Back

Preview of the front of card 4

Card 5

Front

Give examples of ways to measure quality of life (3)

Back

Preview of the front of card 5
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