Tuesday, January 22, 2013

The Benefits and Problems with Online Health Information

For a discussion on online health care information, I used Mayoclinic.com (Mayo Clinic, 2011), which is a reputable online source for medical information for the lay person. I found 11 results that ranged from tonsillitis to cytomegalovirus infection. This site is user-friendly and designed for the general public, and the information was clear and concise. It contains pictures, discusses symptoms and causes, describes complications, tests, and treatments as well as lifestyle and home remedies. This website neither considers itself a replacement for face-to-face medical intervention nor does it offer much more than general information. More often than not, the site recommends seeking medical attention for ambiguous symptoms.

Perhaps the most remarkable benefit associated with researching health information online is that it connects individuals with expert knowledge from around the world (Hadley, 2005). It supports patient self-care and has the potential to improve overall health outcomes (Forkner-Dunn, 2003). Consumers can make informed decisions about their healthcare as long as they can distinguish between reputable sites and those that are otherwise (Hardey, 2005). A significant negative aspect of online information gathering is that users may retrieve and utilize poor quality information (Potts & Wyatt, 2005). Alternatively, some high quality information may be difficult for some individuals to understand and may lose its usefulness to complexity (Potts & Wyatt, 2005).

In many cases, though, consumers gain enough information to be able to negotiate their care (Hardey, 1999). For many people, playing an active role in their care has become an important issue. Some doctors may perceive this as an unwelcome change, but others welcome the idea of partnership in patient care (Hardey, 1999). Kock-Weser, Bradshaw, Gualtieri, & Gallagher (2010) suggested online health information is changing the way consumers communicate with their doctors about their care, and as a consequence, it is changing the way doctors must treat their patients.

In a survey of doctors' experiences with patients' internet use, doctors said the benefits outweighed the problems and they believed their patients received support and advice, although a few had concerns about misinformation (Potts & Wyatt, 2005). Another doctor-reported issue is that doctors may have to spend more time with patients who are better informed (Potts & Wyatt, 2005). Some doctors perceive this positively, others do not (Potts & Wyatt, 2005). Since the American Medical Association approved the use of social media by doctors, information seekers will likely begin to see a greater online presence by these professionals (Warnock, 2011).

Some doctors thought when patients believed too strongly in alternative therapies found online, it could undermine the doctor/patient relationship (Potts & Wyatt, 2005). An interesting series of events has taken place as patients become knowledgeable consumers about the health care product. This added knowledge has demystified medical care, and some consumers have become skeptical about the profession in general (Hardey, 1999). Alternatively, many online information seekers find the same recommendations they receive from their health care provider, which supports their doctors' medical opinion (Hardey, 1999).

For serious illnesses such as cancer, online disease-specific forums can provide patients with valuable information about their disease. Both caregivers and patients are able to learn more about their disease and take a significant role in their health care decisions (Dolce, 2011). For example, the Association of Cancer Online Resources (ACOR) moderates online, disease-specific communities wherein people share information. Patients under the care of nationally recognized specialists, share pertinent information that other patients share with their oncologists, in effect, educating their doctors and enabling them to provide better care.

If people can receive valuable and accurate information online, it supports their ability to take a partnership role in their healthcare. Further, it may influence their decision to take action and seek medical intervention rather than waiting on ambiguous symptoms (Harris, Sillence, & Briggs, 2011). The antiquated model of health care in the United States is in need of foundational change, and the internet can serve as a reliable education and provider of information for consumer/patients (Forkner-Dunn, 2003).


Dolce, M. C. (2011). The Internet as a Source of Health Information: Experiences of Cancer Survivors and Caregivers With Healthcare Providers. Oncology Nursing Forum, 38(3), 353-359. doi: 10.1188/11.ONF.353-359

Forkner-Dunn, J. (2003). Internet-based Patient Self-care: The Next Generation of Health Care Delivery. Journal of Medical Internet Research, 5(2), E8. doi: 10.2196/jmir.5.2.e8

Hardey, M. (1999). Doctor in the house: the Internet as a source of lay health knowledge and the challenge to expertise. Sociology Of Health & Illness, 21(6), 820.

Harris, P., Sillence, E., & Briggs, P. (2011). Perceived threat and corroboration: key factors that improve a predictive model of trust in internet-based health information and advice. Journal Of Medical Internet Research, 13(3), e51. doi:10.2196/jmir.1821

Koch-Weser, S., Bradshaw, Y., Gualtieri, L., & Gallagher, S. (2010). The Internet as a health information source: findings from the 2007 Health Information National Trends Survey and implications for health communication. Journal Of Health Communication, 15279-293. doi:10.1080/10810730.2010.522700

Mayo Clinic. (2011). Swollen lymph nodes. Health Information. Retrieved January 19, 2013, from http://www.mayoclinic.com/health/search/search

Potts, H. W., & Wyatt, J. C. (2002). Survey of Doctors' Experience of Patients Using the Internet. Journal of Medical Internet Research, 4(1), E5. doi: 10.2196/jmir.4.1.e5

Warnock, G. (2011). Challenges of online health information for surgeons. Canadian Journal Of Surgery. Journal Canadien De Chirurgie, 54(4), 221-222. doi:10.1503/cjs.020011

Stress and Disease

 Cancer and Stress
The relationship between cancer and stress is not well-defined. Price et al. (2001) found no independent relationship between women and their stressful life experiences, but those who lacked an adequate social support system showed a higher risk for breast cancer. Michael et al. (2009) did not find strong enough evidence to link stress with this type of cancer. One study found care giving roles for women were protective for breast cancer, likely because the stress decreased the women's amount of female hormones (Kroenke et al., 2004). These same hormones, when found in excess are thought to contribute to breast cancer (Kroenke et al., 2004). In a study that evaluated over 11,000 women over nine years, Surtees, Wainwright, Luben, Khaw, and Bingham (2010) found no association between stressful events and the development of breast cancer. This study is perhaps more significant than other studies because the authors considered the individual differences, such as coping skills, that can mediate the overall effects of the stressors.

Brown et al., (2010) found a relationship between adverse childhood experiences and the initiation of smoking behavior, which contributed to an increased risk of lung cancer. Brown et al. suggested the stress incurred in childhood encouraged self medicating (with nicotine) but also found the stress affected parts of the brain that mediate responses to stress. Simply stated, these same processes contribute to sustained inflammation, which has been shown to contribute to the risk of cancer development (Brown et al., 2010). Perhaps the most interesting finding in Brown et al. was that they believed there were other unidentified reasons for premature death from lung cancer that were not explained by smoking. I found this extremely interesting because many alternative practitioners such as naturopaths and acupuncturists, believe an association exists between diseases of the lung and grief and sadness. This concept is based is based on the ancient Chinese 5-element theory.

Although there exists a common lay belief in an association between stress and the risk of cancer, Bergelt, Prescott, Grønbæk, Koch, & Johansen (2006) found a definitive correlation between stress and the development of unhealthy lifestyles, but no significant association between stress and the development of cancer. Further, no link was found between cancer development and depression and other psychological issues, life stressors, or personality traits (Bergelt et al., 2006). Both stress and the development of cancer have become commonplace in contemporary life. Perhaps studies will develop other, more specific means of measuring this relationship that will eventually determine an association between the two.

Stress and Infectious Disease
Ample research suggests a relationship exists between the immune system and stress (Deckers, 2010; Murray, Marks, Evans, & Estacio, 2011). The field of psychoneuroimmunology has long held the belief that psychological insults to the nervous system directly affect the immune system. Cohen and Williamson (1991) found a positive relationship between stress and upper respiratory illness, a suggestive, but inconclusive relationship between stress and herpes viruses, and a generally consistent association between stress and bacterial infections. Additionally, stress increased susceptibility to colds and respiratory infections (Cohen, Tyrrell, & Smith, 199; Cohen & Williamson, 1991).

In a study that examined all Danish children born between 1977 and 2004, Nielson, Hansen, Simonsen, & Hviid, (2012) found increased stress during childhood contributed to a biological susceptibility to infectious disease. Decreased immunity seems to render individuals more susceptible to a host of diseases, although even under extreme conditions, not all individuals become susceptible (Herbert & Cohen, 1993). Although an abundance of evidence suggests stress affects immunity which can lead to disease, a missing component may be that individual differences are the significant determinates of risk factors. Understanding the specifics of individuals (such as coping styles, personality type, and genetics) may lead to effective treatment designs as well as personalized strategies for circumventing illness overall (Buckley, 2011; Schmidt, Sterlemann, & Müller, 2008; Zozulya, Gabaeva, Sokolov, Surkina, & Kost, 2008).


Bergelt, C. C., Prescott, E. E., Grønbæk, M. M., Koch, U. U., & Johansen, C. C. (2006). Stressful life events and cancer risk. British Journal Of Cancer, 95(11), 1579-1581. doi:10.1038/sj.bjc.6603471

Brown, D. W., Anda, R. F., Felitti, V. J., Edwards, V. J., Malarcher, A., Croft, J. B., & Giles, W. H. (2010). Adverse childhood experiences are associated with the risk of lung cancer: A prospective cohort study. BMC Public Health, 10(1), 20. doi: 10.1186/1471-2458-10-20

Buckley, R. (2011). Infectious Disease Genomics: Individual Variability, New Opportunities. MD Conference Express, 4-5.

Cohen, S., & Williamson, G. M. (1991). Stress and infectious disease in humans. Psychological Bulletin, 109(1), 5-24. doi:10.1037/0033-2909.109.1.5

Cohen. S,. Tyrrell, U. & Smith, A. (1991). Psychological stress and susceptibility to the common cold. New England journal of Medicine,325, 606-612.

Deckers, L. (2010). Motivation: Biological, Psychological, and Environmental, (Chapter 8), (3rd ed.). Boston: Pearson/Allyn & Bacon

Herbert, T. B., & Cohen, S. (1993). Depression and immunity: A meta-analytic review. Psychological Bulletin, 113(3), 472-486. doi:10.1037/0033-2909.113.3.472

Kroenke, C. H., Hankinson, S. E., Schernhammer, E. S., Coditz, G. A., Kawachi, I., & Holmes, M. D. (2004). Caregiving stress, endogenous sex steroid hormone levels, and breast cancer incidence. American Journal of Epidemiology, 159, 1019–1027.

Marks, D. F., Murray, M., Evans, B., & Estacio, E. V. (2011). Health Psychology: Theory, Research, and Practice (3rd ed.). London: Sage.

Michael, Y. L., Carlson, N. E., Chlebowski, R. T., Aickin, M., Weihs, K. L., Ockene, J. K., & ... Ritenbaugh, C. (2009). Influence of stressors on breast cancer incidence in the Women's Health Initiative. Health Psychology, 28(2), 137-146. doi:10.1037/a0012982

Nielsen, N., Hansen, A., Simonsen, J., & Hviid, A. (2012). Stressful life events in childhood and risk of infectious disease hospitalization. European Journal Of Pediatrics, 171(1), 173-179. doi:10.1007/s00431-011-1498-2

Price, M. A., Tennant, C. C., Butow, P. N., Smith, R. C., Kennedy, J. S., Kossoff, M. B., et al. (2001). The role of psychosocial factors in the development of breast carcinoma: Part II. Life event stressors, social support, defense style, and emotional control and their interactions [Abstract]. Cancer, 91, 686–697.

Schmidt, M. V., Sterlemann, V., & Müller, M. B. (2008). Chronic Stress and Individual Vulnerability. Annals Of The New York Academy Of Sciences, 1148174-183. doi:10.1196/annals.1410.017

Surtees, P., Wainwright, N., Luben, R., Khaw, K., & Bingham, S. (2010). No evidence that social stress is associated with breast cancer incidence. Breast Cancer Research And Treatment, 120(1), 169-174. doi:10.1007/s10549-009-0454-6

Zozulya, A., Gabaeva, M., Sokolov, O., Surkina, I., & Kost, N., (2008). Personality, coping style, and constitutional neuroimmunology. Journal Of Immunotoxicology, 5(2), 221-225.doi:10.1080/15476910802131444

Wednesday, January 16, 2013

Representations of Ilnesses

Individuals' perceptions of disease and illness contribute to their health behaviors, which, in turn predict health outcomes (Murray, Marks, Evans, & Estacio, 2011). These perceptions as well as the emotional processes associated with them directly contribute to how patients respond to illness. Illness representations are usually established prior to a diagnosis, and may evolve over time and with experience (Murray et al., 2011).

Implications for understanding illness representations

The implications of illness representations play a powerful role as predictors of patient outcomes (Murray, et al., 2011). Understanding patients' illness representations can help medical personnel as well as psychological professionals anticipate and intervene in altering patients' belief systems, to improve patient outcomes (Lee, Chaboyer, & Wallis, 2010). For example, understanding how health representations affect treatment compliance, can contribute to developing interventions to alter compliance, hence, improving health outcomes (Leventhal, Diefenbach, & Leventhal, 1992).

Common Example

As an example of representations of illness, the common cold presents similar experiences in most individuals. Using the common sense model, individuals identify the threat (stuffy head), recognize the timeline associated with a common cold (problematic for a few days to a week), perceive the consequences as minimal and know the cause was likely transmission of a virus from another person. Further, they know the cold is self-limiting and can be controlled easily by resting, drinking fluids, and taking a fever-reducing medication. The individuals' established beliefs about the common cold predict how they will behave. The emotional reaction to the cold is minimal, unless the individual has a known respiratory weakness, which may cause concern over the cold developing into bronchitis (illness coherence).

Alternatively, if individuals believe the common cold must run its course and nothing can be done to lessen it effects or its timeline, they may not make appropriate changes to their behavior, which may lengthen the course of the illness. In sum, individuals' established and evolving beliefs about their illness predicts their behavior, and may affect health outcomes Leventhal, et al., 1992).

Unlike the illness representations associated with the common cold, behaviors associated with serious illness may have more significant implications for outcomes. For example, if an individual believes he is having a heart attack, but does not realize earlier medical intervention produces more positive outcomes, he may delay seeking help, which may directly affect his recovery, or even his mortality (Farquharson, Johnston, & Bugge, 2012). Alternatively, Filipino women often delay seeking medical attention when they find a breast lump. A pervasive cultural belief in this population associates breast lumps with death, rather than the need to seek medical intervention (Wu & Bancroft, 2006). The implications for these beliefs are that breast cancer is the leading cause of death in Filipino women (Ho, Muraoka, Cuaresma, Guerrero, & Agbayani, 2010). If changes can be made in the perceptions of breast cancer in this population, patient outcomes can be improved, specifically, fewer women dying of breast cancer.

The implications of illness representations are far-reaching. Chaboyer, Lee, Wallis, Gillespie, and Jones, (2010) found illness representations predict quality of life more than does the patients' demographic contexts and clinical factors. Further, illness representations continued to decrease quality of life six months after the illness (Chaboyer, Lee, Wallis, Gillespie, & Jones, 2010). On the positive side, patients gained a sense of self control in regard to their illness when their perceptions allowed them to adapt to their illness (Karademas, Kynigopoulou, Aghathangelou, & Anestis, 2011). On the contrary, when patients could not adapt to the perceptions of their illness, or when they adapted in unhealthy ways, they were prone to creating a cyclical effect of helplessness contributing to worse health outcomes (Karademas, et al., 2011). Optimism, too, had an effect on mediating illness representations, which consequently affected overall outcomes (Karademas, et al., 2011).

As a final thought, people have a tendency to cling to beliefs even when evidence is contradictory (belief perseverance), so changing established illness representations may present a considerable challenge. Disseminating correct information may help resolve the detrimental health outcomes that begin with illness representations, although Castillo, Godoy-Iquierdo, Vazquez, and Godoy (2012) found some lay perceptions of illness (cancer) were generally medically accurate. From a cognitive perspective, understanding the power of illness representations may contribute to devising effective means of cognitive restructuring that may aid in healing and recovery.


Castillo, A., Godoy-Izquierdo, D., Vázquez, M., & Godoy, J. (2011). Illness Beliefs About Cancer Among Healthy Adults Who have and have not Lived with Cancer Patients. International Journal Of Behavioral Medicine, 18(4), 342-351. doi:10.1007/s12529-010-9141-6

Chaboyer, W., Lee, B., Wallis, M., Gillespie, B., & Jones, C. (2010). Illness representations predict health-related quality of life 6months after hospital discharge in individuals with injury: A predictive survey. Journal of Advanced Nursing, 66(12), 2743-2750. doi: 10.1111/j.1365-2648.2010.05431.x

Farquharson, B., Johnston, M., & Bugge, C. (2012). Appraisal and illness delay with symptoms of ACS: A questionnaire study of illness representations. British Journal Of Cardiac Nursing, 7(10), 493-499.

Ho, R., Muraoka, M., Cuaresma, C., Guerrero, R., & Agbayani, A. (2010). Addressing the excess breast cancer mortality in Filipino women in Hawai'i through AANCART, an NCI community network program. Hawaii Medical Journal, 69(7), 164-166.

Karademas, E. C., Kynigopoulou, E., Aghathangelou, E., & Anestis, D. (2011). The relation of illness representations to the 'end-stage' appraisal of outcomes through health status, and the moderating role of optimism. Psychology & Health, 26(5), 567-583. doi:10.1080/08870441003653488

Lee, B., Chaboyer, W., & Wallis, M. (2010). Illness representations in patients with traumatic injury: A longitudinal study. Journal of Clinical Nursing, 19(3-4), 556-563. doi: 10.1111/j.1365-2702.2009.02972.x

Leventhal, H., Diefenbach, M.A., & Leventhal, E. A. (1992). Illness Cognition: Using common sense to understand treatment adherence and affect cognition interactions. Cognitive Therapy and Research, 16, 143-163.

Marks, D. F., Murray, M., Evans, B., & Estacio, E. V. (2011). Health Psychology: Theory, Research, and Practice (3rd ed.). London: Sage.

Wu, T., & Bancroft, J. (2006). Filipino American Women's Perceptions and Experiences With Breast Cancer Screening. Oncology Nursing Forum, 33(4), 71-78. doi: 10.1188/06.ONF.E71-E78

More Thoughts on Samples

Regarding the Thompson and Morgan study (see previous posts), scientists (and scholars) must be mindful of their sample populations. White college educated women do not create a representative sample. They do not represent even one percent of the female population of the entire human race. So, although it may seem provocative to generalize a sex study, such as Thompson and Morgan (2008) to wider populations, until the cultural and contextual influences on sexual identity can be determined, the study is better used as a starting point for future research. Underestimating the effects of culture (or context) in any study can skew inferences made in different populations and marginalize and pathologize them (Sue & Sue, 2008; Whiston, 2009).

I believe the Thompson and Morgan (2008) study was more of a jumping off place, an introduction of sorts, to the idea that perhaps gradient descriptions are more inclusive than the traditional sexual identity labels.  College students have been a good starting point for many studies, and in this case, the sexual openness, exploration, and tendencies typical for this age group served the purposes of the exploration (Thompson & Morgan, 2008). 

To study any construct or tendency in a population, the researcher often designs a reasonable and easily constructed sample.  This provides the opportunity to conduct basic research, and although not generalizeable to wider populations, it provides information for the knowledge base and perhaps an inspiration for future research (Whiston, 2009).  This seems an important consideration, at least in my mind.  Research is hardly conclusive, but rather builds a platform for ongoing exploration. 

In any event, who research studies will determine what researchers learn (Shen et al., 2011), and although the results of samples are not always generalizeable, it is in these seminal studies that new research directions are born.

I think it's important to note that most all studies have limitations.  Although the sample of this study had limitations (mentioned by Thompson and Morgan) it is not necessarily flawed.  Seminal studies are often times not generalizeable to wider populations.  Valuable information comes from such studies as well as a basis for future exploration.

Shen, W., Kiger, T. B., Davies, S. E., Rasch, R. L., Simon, K. M., & Ones, D. S. (2011). Samples in applied psychology: Over a decade of research in review. Journal of Applied Psychology, 96(5), 1055-1064. doi: 10.1037/a0023322

Sue, D.W., Sue, D (2008). Counseling the Culturally Diverse Theory and Practice (5th ed.). John Wiley & Sons, Inc., Hoboken, New Jersey.

Thompson, E., & Morgan, E. M. (2008). 'Mostly straight' young women: Variations in sexual behavior and identity development. Developmental Psychology, 44(1), 15-21. doi:10.1037/0012-1649.44.1.15

Whiston, S. C. (2009). Principles and applications of assessment in counseling (3rd ed.). Belmont, CA: Brooks/Cole, Cengage Learning.

Acacemic Excellence and Ethical Behavior

Academic and professional excellence are ongoing goals that evolve as scholars gain knowledge and experience. Ethical behavior, too, may begin as simple rule following, but can evolve depending on the individual's deliberate attempt to become ethical. Scholars must practice ethical judgment and decision making continually, as well as develop a personal understanding of morality. I intend to do both.

Furthermore, for psychological professionals, it is important to strive to do no harm, provide a benefit to those with whom they cross paths, and protect the rights of others (American Psychological Association (APA), (2010). When facing challenges, it is wise to seek the counsel of peers as well as the advice of supervisors (APA, 2010). In the field of health psychology, scholars work toward understanding and integrating biological knowledge and science with psychological knowledge (APA, Division 38, 2013). These are personally meaningful and essential goals to which I strive.

It is important to include the importance of cultural and contextual awareness, especially that psychological professionals understand the implications of helping individuals or entire populations that are unlike their own (APA, 2010). Further that they must tolerate and respect foreign ideologies and norms, remembering the natural human tendency to overestimate positive traits in people who are familiar and emphasize negative traits in those who are unfamiliar or different (Heider, 1959). It seems essential, although challenging, to refrain from presuming the superiority of one's culture and norms (Stuart & Bennett, 2006) .

The APA (2010) has described, in detail, appropriate behavior for psychological professionals. These guidelines provide scholars and professionals with a fundamental parameter by which to establish and maintain ethical behavior. However, the APA contends with thousands of ethical infractions committed by psychological professionals each year (Plante, 2011). This may be a reminder that understanding ethical behavior by its rules, rather than its essence, is a process, and not one that all scholars of psychology attain. Although conducting oneself ethically is admirable, one must be ethical to consistently uphold the principles of the APA with integrity. The depth and reflection upon ethical behavior that is required to develop a truly ethical nature may be challenging, however, holding this ideal will serve as a guide for facing ethically ambiguous situations in practice.


American Psychological Association (APA). (2010). General principles. Ethical Principles of Psychologists and Code of Conduct. Retrieved January 14, 2013, from http://www.apa.org/ethics/code/index.aspx?item=3

American Psychological Association, Division 38. (2013). Mission Statement. APA Division 38: Our Mission. Retrieved January 14, 2013, from http://www.health-psych.org/AboutMission.cfm

Heider, F. (1959). The psychology of interpersonal relations. New York: Wiley.

Plante, T. G. (2011). Contemporary clinical psychology (3rd ed.). Hoboken, NJ: John Wiley & Sons.

Stewart, E. C., & Bennett, M. J. (2006). American cultural patterns: a cross-cultural perspective. Yarmouth, ME: Intercultural Press.