Title: The sigificance of health psychology approach in transforming societies
1The sigificance of health psychology approach in
transforming societies
- Maria Kopp, MD, PhD.
- Keynote Address
- 20th Annual Conference of the European Health
Psychology Society - Warsaw, Aug.30-Sept 2, 2006
2CentralEastern European legacy
- In the twentieth century, Hungarian born
scientists, such as - Sándor Ferenczi,
- Franz Alexander,
- Hans Selye,
- Michael Bálint,
- significantly contributed to laying the
foundations of psycho-social attitude in medicine
- During the communist period psychology was
regarded ideologically incorrect
3Morbidity and mortality crisis in the
transforming societies
- The morbidity and mortality crisis of the
transforming Central and Eastern European
countries is an extraordinary natural experiment
to understand better the importance of
psychosocial factors in health, - Because the existing explanatory models are not
able to explain these rapid changes in the health
status of these populations.
4Characteristics of the Central-Eastern-European
(CEE) health paradox
- In the 60-ies the mortality rates were better for
example in Hungary than in some Western-European
countries - In the last decades while mortality rates
declined in Western Europe, in CEE countries this
tendency reversed, especially among middle-aged
men - Paradoxical features
- The health status worsened during economic
development - Why are middle aged men most vulnerable?
- Why is the life expectancy relatively better
after 65 years of age?
5Characteristics of health crisis in Hungary
- Since the late 1980s, the mortality rates among
45-64 year old men in Hungary has risen to higher
levels than they were in the 1930s, - Large gender difference in mortality rates.
- Large regional differences in the 20 Hungarian
counties and in the 150 subregions -
6Mortality rate in 1000 men in corresponding age
groups in the Hungarian population (Demographic
Yearbook, 2004)
7Trends in the other CEE countries
- Similar trends in Poland and in Czech Republic,
but the improvement had started much earlier and
it was more considerable, - Dramatic health crisis in Russia, Ukraine and in
the Baltic countries - Common features health crisis among middle aged
men
8Life expectancy of men in 1965 and 1992
Marmot M The social pattern of heath and
disease In.Health and Social Organization, Edited
by D Blane, E Brunner, R Wilkinson
Michael
9Life expectancy of women in 1965 and 1992
10Mortality rates of middle aged (45-64) Hungarian
men and women in 2001
11Special experimental model
- The paradoxical features of premature mortality
and morbidity in Central-Eastern-European
countries might be regarded as - a special experimental model to understand the
health consequences of sudden societal changes - that is those processes where psychology meets
physiology, which is the central question of
health psychology
12What can explain the opposite changes in
East-West life expectancy?
- In the 1970s no differences in Austrian and
Hungarian life expectancy - Life expectancy in Hungary today
- Male 68.2, female 76.5 years,
- Life expectancy in neighbouring Austria
- Male 75.9- they live 7.7 years longer,
- Female 81.7- they live 5.2 years longer
13Gender differences
- Although men and women share the same
socio-economic circumstances, there are
significant gender differences in worsening
mortality rates. - What is the explanation for the increased
vulnerability of middle aged men during this
period of rapid economic change?
14Possible explanations
- This deterioration cannot be ascribed to
defficiencies in health care,because - during these years there was a significant
decrease in infant and old age mortality and
improvements in other dimensions of health care. - Between 1960 and 1989 there was a constant
increase in the gross domestic product in
Hungary. Worsening material situation cannot be
the explanation
15Paradox of old age mortality
- Above 65 years the male life expectancy is
similar to the Western patterns - What could be the explanation?
- The influence of medical care is most important
for the ageing population and around birth - In middle aged population the health
psychological factors would be fundamental in
successful coping
16Growing polarization of the socio-economic
situation between 1960 and 2002
- Until 1960, practically no income inequality,
there were no mortality differences between
socio-economic strata. - Since that time increasing disparities in
socio-economic conditions have been accompanied
by a widening socio-economic gradient in
mortality, especially among men.
17Aggregate mortality according to low versus high
education(Mackenbach et al, 1999)
18Status syndrome
- M. Marmot Status syndrome, Times Books,2004
British civic servants - In 1992-96 10 years difference between
- the highest educational group- 78 years life
expectancy and - the lowest - 68 years life expectancy 1.5-times
higher myocardial infarct mortality after
controling for smoking and alcohol consumption
19Objectives of our epidemiological studies in
Hungary
- To reveal those social, psychological and
behavioural factors in their inter-relatedness
with biological processes that lead to health
deterioration and thus to the decline of quality
of life of the Hungarian middle-aged population - To introduce effective preventive health
psychology strategies that are based on research
findings
20Research Activities
- Mapping the demographic, social, economic,
behavioural and psychological factors determining
the quality of life and health deterioration of
the middle-aged Hungarian population. - Psychophysiological research to analyse the
effects of psychosocial factors on the central
nervous system- ie. sleep research - Organization of community-based prevention,
health promotion and rehabilitation programs with
evidence based, effective health psychology
methods.
21National representative surveys in the Hungarian
population
- The samples represent the Hungarian population
above age 18 according to gender, age and county - Hungarostudy 1983 more than 6000 persons
- Hungarostudy 1988 20.902 persons
- Hungarostudy 1995 12.463 persons
22Latest surveys Hungarostudy 2002 and follow up
in progress
- 12,643 persons were interviewed in their homes,
they represented the population above age 18
according to age and sex and 150 subregions - The refusal rate was 17,7 for the full sample,
although there were significant differences,
depending on settlements - About 6.500 persons agreed to participate in a
follow up study- now in progress
23Socio-economic factors
- Education,
- Income,
- Subjective socioeconomic status (Nancy Adler)
- Acces to car
- Employment
- Marital status
- Housing environment
- Family environment
- Childhood experiences
- Self-rated socioeconomic changes
24Hungarostudy indicators, health psychology
- Shortened Beck Depression Score
- WHO Wellbeing Questionnaire (Bech,1996)
- Hostility score (Cook-Medley, 1954)
- Self-efficacy score (Schwarzer, 1992)
- Vital exhaustion score (Appels, 1988)
- Type D Personality Questionnaire(Dennolet, 2000)
- Hospital Anxiety Score
- Hopelessness Score (Beck, 2000)
25Further psychological indicators
- Ways of coping (Folkman, Lazarus, 1980)
- Purposes in Life(Crumbaugh, Maholick,1964)
- Anomie score
- TCI shortened cooperativeness and sensation
seeking - Dysfunctional attitudes
- (Weissman,1979)
- Social support (Caldwell,1987)
- Marital stress questionnaire
- Stress and coping (Rahe,2002)
- Meaning in life (Rahe,2002)
- Life events
26Social capital measures
- Social capital defined as the assets and
resources available to individuals through civic
participation appears to be a potential
determinant of population health status - Social trust
- Reciprocity
- Participation in civic organizations
- Low anomie
- Low competitiveness- rivalry
- Chicago collective efficacy (Neighbourhood
cohesion) - Religious involvement
27Work stress variables
- Job security
- Control at work
- Social support at work
- Working hours per week days and weekend
- Troubles with work as life event
- Income as job related reward
- Satisfaction with work situation
- Satisfaction with boss
- Unemployment
28Health behaviour, lifestyle and other confounding
factors
- Religious involvement
- Suicidal behaviour
- Womens health- factors related to pregnancy and
birth - ethnical factors
- Smoking
- Alcohol (AUDIT)
- Drug consumption
- Physical activity
- Body weight and height- BMI
- Sleep complaints
29Significance of chronic stress-depressive
symptomatology
- Based on the data of our national representative
surveys, we found that the worse socioeconomic
situation is linked to higher morbidity and
mortality rates in Hungary as well, - however, higher morbidity rates are connected to
relatively poor socioeconomic situations mainly
through the mediation of depressive symptoms, - in broader sense through chronic stress
30Depressive symptomatology (BDI) severity
categories in the Hungarian population
31(No Transcript)
32Low income, depression and morbidity
- In 1988 depression mediated between low income
and self-rated morbidity among men, - while among women low income was not
significantly connected neither to depression,
nor with self reported morbidity. - In 1995 low income became directly connected to
morbidity both in men and women, - but the mediating effect of depression between
low income and morbidity remained more important
among men than among women.
33Why are men more susceptible to relative income
inequality?
- 1.Income inequality is much higher among men.
- 2. Men are more susceptible to loss of status
than women. Animal experiments have shown males
to be more sensitive than females to loss of
dominance position, that is loss of position in
hierarchy. In animal studies social rank is the
best predictor of quality of life and health
among males.
34Depression and chronic stress
- A self-destructive circle develops from the
enduring relatively disadvantageous socioeconomic
situation and depressive symptoms, - This circle resulting in chronic stress, might
play a significant role in the increase of
morbidity and mortality rates in the lower
socioeconomic groups of the population. - Kopp MS, Réthelyi J (2004) Where psychology meets
physiologychronic stress and premature
mortality- the Central-Eastern-European health
paradox, Brain Research Bulletin ,62,351-367. -
35Ecological level analysespositive psychology
determinants of mid-aged mortality
differencesbased onnational representative
survey data and national statistical mortality
data
- For 20 counties and 150 subregions
36Mortality rates of middle aged men and depression
scores in 2002
37Why ecological analyses?
- Mortality rates can be computed only on regional
(county or subregional) level - The determinants of mortality differences cannot
be computed with multi-level methods, because
there is only one mortality value for each
subregion - In analyses we worked with weighted values
according to numbers of persons in subregions
38Determinants of middle aged mortality in the
150 Hungarian subregions
- Socio-economic status (education and income),
social capital (social distrust) and collective
efficacy (neigborhood cohesion) explained a
considerable part of the sub-regional variance
in middle aged mortality rates, - Competitive attitude was a significant predictor
of mortality only among men, while religious
involvement was a significant protective factor
only among women. - Skrabski Á, Kopp MS, Kawachi I (2004) Social
capital and collective efficacy in
Hungarycross-sectional associations with middle
aged female and male mortality rates, J
Epidemiology and Community Health ,30, 65-70.
39Amos structural model for male mortality
(CFI0.99,CMIN/Df3.02)
40Interaction between male and female health
- It is an interesting finding that the most
important social capital variables of the
opposite sex seem to influence the mortality for
the other sex - Civic support perceived by men is a protective
factor for women, while the amount of reciprocity
perceived by women seems to be a significant
predictor of male health. - Skrabski ,Á, Kopp MS, Kawachi I.(2003) Social
capital in a changing societycross sectional
associations with middle aged female and male
mortality rates, J Epidemiology and Community
Health 57, 2, 114-119.
41Which are the protective factors for women?
- Relative economic deprivation, rival attitude and
social distrust are all less important risk
factors for women - The socio-economic differences are less important
regarding the middle aged female mortality
differences. - Neighborhood cohesion, religious involvement and
reciprocity were not so much influenced by sudden
socio-economic changes, therefore the protective
network of women remained relatively unchanged.
42Gender paradox of subjective social status
- Female subjective social status influenced highly
significantly the male mid-aged mortality - r for female SSS and male mid-aged mortality
was -.597 p.000 - That is, the subjective evaluation of the
relative social deprivation by women might be an
important risk factor for men as well - Kopp MS, Skrabski Á, Kawachi I, Adler NE (2005)
Low socioeconomic staus of the opposite gender is
a risk factor for middle aged mortality, J.
Epidemiology and Community Health 59,675-678.
43Correlations of male and female social status and
male mid aged mortality
Korrelációs együtthatók, középkoró férfiak
halálozása
44Effective health promotion
- In a suddenly transforming society the health
psychology approach might have central importance
in effective health promotion, - Cognitive behavioural methods of early correction
of vulnerability in high risk groups are in the
focus of our preventive programmes.
45Community based health promotion programs
- preventive group-intervention for the at-risk
persons (Williams Life skills Training), - Health promotion programs among the members of
the Dimension health funds, - Screening and prevention of depression among
roma youth.
46Social communication
- At national level via mass media
- interactive counselling service on the
Internet www.behsci.sote.hu - education by means of conferences, workshops
and courses with involvement of the media,
schools and churches.
47References
- Kopp MS, Réthelyi J (2004) Where psychology meets
physiologychronic stress and premature
mortality- the Central-Eastern-European health
paradox, Brain Research Bulletin ,62,351-367. - Kopp MS, Skrabski Á, Réthelyi J, Kawachi I, Adler
N (2004) Self Rated Health, Subjective Social
Status and Middle- Aged Mortality in a Changing
Society, Behavioral Medicine,30, 65-70. - Kopp MS (interview) (2000) Stress The invisible
Hand in Eastern Europe s Death Rates, Science,
288, 9.June 2000, 1732-1733. - Kopp MS, Skrabski Á, Szedmák S (2000)
Psychosocial risk factors, inequality and
self-rated morbidity in a changing society,
Social Sciences and Medicine 51, 1350-1361. - Skrabski,Á.Kopp MS, Rózsa S, Réthelyi J, Rahe RH
(2005)Life meaning an important correlate of
health int he Hungarian population, International
Journal of Behavioral Medicine, 12,2, 78-85. - Kopp MS, Skrabski Á, Kawachi I, Adler NE (2005)
Low socioeconomic staus of the opposite gender is
a risk factor for middle aged mortality, J.
Epidemiology and Community Health, 59,675-678. - Kopp,M., Skrabski, Á., Szántó, Zs., Siegrist,
J. Psychosocial determinants of premature
cardiovascular mortality differences within
Hungary, J ournal of Epidemiology Community
Health (in press)