Advantages of the Biopsychosocial Model ... - Meagher Lab

Advantages of the Biopsychosocial
Model: Comprehensiveness
Macrolevel and microlevel processes
Multiple factors
Mind and body are one, both influence
health
Emphasis on both health and illness

Systems Theory
All levels of organization in any entity are linked to
each other hierarchically
Changes in one level influence change at all other
levels
Microlevel processes are nested within macrolevel
processes
Changes on the microlevel can have macrolevel
effects and vice versa
-macrolevel: depression, social support, environment
-microlevel: chemical imbalance, inflammation, cytokines

Clinical Implications of the
Biopsychosocial Model
The process of diagnosis must consider the
interaction of (1) biological, (2) psychological,
and (3) social factors.
Recommendations for treatment must also
consider these three factors.
therapy is targeted to an individual
The relationship between the patient and the
health care practitioner is important in the
effectiveness of care. - improve adherence,
communication, & transmission of information.

Rise of Health Psychology
Changing patterns of illness
Acute Disorders - past pattern
Short-term medical illnesses
Examples: tuberculosis, pneumonia
Chronic Disorders - new pattern
Slow-developing diseases.
Often these cannot be cured, only managed
Psychological/Social factors are often causes

How are chronic diseases linked to
health psychology
Psychological/social factors contribute to the
development of chronic diseases,
Psychologists develop ways to change health-compromising
factors (diet, smoking) for patients and other family
members
Living with a chronic illness means years of
treatment regimens that may affect family
functioning
Psychologists help ease problems in relationships

The Rise of Health Psychology:
Expanded Services & Acceptance
Health care
Largest service industry in the United States
Health psychology’s main emphasis on prevention
has the potential of reducing health care costs
Health psychologists, in the past,
saw “problem patients”
administered/interpreted tests
Growing recognition
Psychological factors are ALWAYS important
The role of the health psychologist in
changing health habits and in contributing to
treatment is increasingly acknowledged

The Rise of Health Psychology:
Demonstrated Contributions
Short-term behavioral interventions
have been effective in helping
patients:
Manage pain
Modify bad health habits (such as smoking)
Manage side effects and treatment effects
when coping with chronic illness.

The Rise of Health Psychology:
Methodological Contributions
Psychologists have methodological and
statistical expertise that is required
for rigorous research investigations
Experiments
Randomized
clinical trials
Two or more conditions differ
from each other in exact and
predetermined ways; Random
assignment
Experiments to evaluate
treatments/interventions and
effectiveness over time

The Rise of Health Psychology:
Methodological Contributions
Correlational Studies
Comparing changes in
variables (cannot
determine causality
Prospective Designs
(longitudinal)
Retrospective Research
Looking forward
Looking backward

What is Health Psychology Training
for Careers in practice
health psychologists
physicians
physical therapists
social workers
occupational therapists
dietitians
nurses
public health workers

What is Health Psychology Training
for Careers in research
Public health researchers
May develop educational interventions to
promote the practice of better health behaviors.
May formally evaluate programs for improving
health-related practices.
May be administrators for health agencies.

What is Health Psychology Training
for Careers in research
Health Psychologists
Work settings include
Universities
Hospitals
Industrial/occupational health settings
HMOs and Pain Centers practices

Health Psychology 1/16/10
Chapter Two:
Background
material integrated in later lectures
Chapter Three:
Health Behaviors
Health Promotion
Modification of Health Attitudes and
Behavior
Project 1

Health Promotion: An Overview
Basic philosophy
Good health = individual and collective goal
Help people maintain healthy lifestyles
Cost effectiveness
Less costly than disease prevention
Individual efforts interact with the medical
system, mass media, and legislation
Environmental and community based strategies
are important factors, too much emphasis is
placed on individual level interventions
Public Health Strategies

Introduction to Health Behaviors: Role
of Behavioral Factors
Patterns of disease in the U.S. have
changed from acute infectious disorders
to “preventable” disorders of lifestyle.
Half the deaths in the U.S. are caused by
preventable behaviors
Obesity and lack of exercise
About to overtake tobacco as the most
preventable cause of death in the U.S.

CDC data
50% of deaths from leading causes of
death are due to modifiable lifestyle
and behavioral factors
25% of cancer deaths & heart attach
deaths reduced by modifying smoking
50% of cancer deaths reduced by not
smoking, eating fruits/veggies, exercise,
and screening
10% weight loss = 20% reduction in CHD,
OA, GI cancer, diabetes, stroke50% of

Introduction to Health Behaviors: What
are Health Behaviors
Behaviors that enhance or maintain
health
Health habits
Firmly established behaviors that are
often performed automatically
Examples: wearing a seatbelt,
brushing one’s teeth, healthy food
selections
Health habits begin in childhood and
stabilize at ages 11 or 12

Introduction to Health Behaviors: Role of
Behavioral Factors
Successful modification of health behaviors
can
Reduce deaths due to lifestyle related
illnesses.
Delay time of death, increasing longevity.
Expand years of life free from chronic disease
complications
Improve quality of life
Reduce health care costs

Impact of Epidemiology
The field of epidemiology is closely related to health
psychology and health promotion.
Epidemiology is the study of the
frequency
distribution
causes
of infectious and noninfectious disease in a population,
based on an investigation of the physical and social
environment.

Morbidity and Mortality Statistics
Morbidity
number of cases of a DISEASE that exist at some given
point in time
Incidence
number of NEW cases at a given time
Prevalence
TOTAL number of existing cases at a given time
Mortality
number of DEATHS due to a particular cause

Epidemiology
Risk factors- psychological, physiological,
social & environmental events related to
incidences and prevalence
Criteria for “causality”- strength of the
relationship, specificity, temporal
relationships, coherence, and impact of
preventive clinical trials.

Epidemiology
Relative risk - strength of relationship
between a risk factor and rates of morbidity or
mortality
Population attributable risk - societal
burden of the risk factor in terms of
unnecessary morbidity/mortality
Example: Does obesity have high relative
risk with specific diseases or high population
attributable risk

Winettʼs Framework
Framework - to design health promotion
programs that prevent morbidity and mortality
in large numbers of people.
National Goals - argues that health
psychologists should be guided by nation
goals set up by Healthy People 2010.
IDs priority areas, identifies health status, risk
reduction, service and protection goals.

Heathy People Goals:
increase span of healthy life
decrease disparities between different
populations
provide universal access to preventive
services
increased emphasis on HIV/AIDS
prevention

Leading Health
Indicators
Physical activity
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behavior
Mental health
Injury and violence
Environmental quality
Immunization
Access to health care

Exercise
In 1999, 65 percent of adolescents engaged in the recommended amount of
physical activity. In 1997, only 15 percent of adults performed the recommended
amount of physical activity, and 40 percent of adults engaged in no leisure-time
physical activity.

Exercise

Overweight & Obesity US 88-94

Obesity over time by age (BMI)

Smoking Cessation Progress

Adolescent vs. Adult Smoking

Smoking Cessation Progress

Adults with depression* who received
treatment,** United States, 1994-97
20 percent of the U.S. population is affected by mental illness during a given year.
Depression is the most common disorder. More than 19 million US adults suffer from depression.
Major depression is the leading cause of disability and is the cause of more than two-thirds
of suicides each year.
In 1997, only 23 percent of adults diagnosed with depression received treatment.

Responsible sexual behavior,
United States, 1995 and 1999

Motor vehicle deaths & homicides 1998

Environmental Quality:
Ozone and environmental tobacco
smoke exposure, 1988–94 and 1997

Immunization

Access to health care, United
States, 1997 and 1998

Three Types of Prevention
1) Primary Prevention - actions taken to avoid
disease or injury
2) Secondary Prevention - actions are taken to
identify and treat an illness or injury early with
the aim of stopping or reversing the problem
3) Tertiary Prevention -interventions to contain
or retard the damage caused by a serious
injury or a disease that has progressed
beyond the early stages and causes lasting
or irreversible damage

Primary Prevention
Taking measures to combat risk factors
for illness before an illness ever has a
chance to develop
Two general strategies
behavior-change to decrease poor health
habits
Prevent poor health habits from
developing

Introduction to Health Behaviors:
Practicing and Changing Health
Behaviors
Demographic Factors
Values
Social Influence
Perceived Symptoms
Age
Personal Control
Personal Goals
Cognitive Factors
Access to the Health Care Delivery System

Introduction to Health Behaviors:
Barriers to Modifying Poor Health
Behaviors
Stress and low social support
Poor health habits become ingrained
very difficult to change
Cumulative damage
isn’t evident for years
Unhealthy behaviors
can be pleasurable and addictive

Barriers to Modifying Poor Health
Behaviors
Health habits are only modestly related
to each other
Knowing that
a person wears a
seat belt
Knowing that
a person stopped
smoking
Doesn’t predict with great
confidence
dietary choices
Doesn’t
predict with great confidence
exercise program

Instability of Health Behaviors
What accounts for the lack of stability
Different health habits are controlled by
different factors
Different factors control the same behavior
for different people
Factors may change over the history of the
behavior
Factors change across a lifetime
Health behavior patterns vary substantially
across the lifetime for each person

Intervening with Children/Adolescents
Socialization influences early health habits
Socialization
The process by which people learn the norms, rules,
and beliefs associated with their family and society
Parents and social institutions are usually the
major agents of socialization.
Adolescents may ignore early training received
by parents, e.g., adolescent rebellion
Adolescents are vulnerable to problematic health
behaviors, e.g., smoking, poor diet, high risk
sexual behavior, substance abuse

Introduction to Health Behaviors:
Intervening with Children/Adolescents
Teachable Moment
Certain times are better than others for teaching
particular health practices
Examples
Drinking milk instead of soda at dinner
Emphasizing correct brushing at dental visit
Window of Vulnerability
At certain times, people are more vulnerable to
certain health problems
Smoking in junior high
Adolescent health behaviors predicts disease
after 45 better than adult health…
Sun exposure, calcium consumption, fat &
protein intake

Introduction to Health Behaviors:
Interventions with At-Risk People
Early identification may prevent poor health
habits that contribute to vulnerability
Knowledge helps individuals monitor their
situation
Problem
People don’t always perceive risk correctly
Most people are unrealistically optimistic about
their own vulnerability to risk
Ethical Issues – an area of controversy
At what point should people be alerted to their
risk Genetic risk for breast cancer..anxiety

Introduction to Health Behaviors:
Health Promotion and the Elderly
Maintaining a healthy, balanced
diet
Developing an exercise regimen
Taking steps to reduce accidents
Eliminating smoking
Reducing inappropriate use of
prescription drugs
Obtaining vaccinations against
influenza

Introduction to Health Behaviors:
Ethnic and Gender Differences
Exercise – Black and Hispanic women get
less exercise than Anglo women
Smoking – Anglo and Black women at greater
risk than Hispanic women.
Alcohol – Men at greater risk than women
Health promotion programs for ethnic
groups
Need to take account of co-occurring risk factors

Barriers to Health Promotion
A. Medical Barriers - Prevention is usually not taught in medical
school. Third party payers often do not reimburse for
prevention programs. Time consuming, iinterdisciplinary
coordination. Limited formal diagnostic measures of health
risk behaviors.
B. Individual Barriers -
1) Parental models - smokers beget smokers
2) Unrealisitic Optimism - overestimate the degree of control over
health. Underestimate genetics and environmental risks.
Overestimate frequency of poor behaviors in others.
C. Health Habit Barriers
1) Lack of Research
2) Independence. Health habits are relatively independent
3) Unstable over time. drinking, weight control, smoking relapse.
a) Different health habits controlled by diff factors
b) Individual differences in factors determining behavior
c) Factors controlling health behavior may change overtime in person

Determinants of good health
behavior
A. Demographic Variables -Younger, affluent, better-educated, low
levels of stress, social support (married, church). While low SES,
higher levels of stress & less social support are related to higher
levels of health compromising behaviors, smoking, ETOH abuse,
little exercise, poor sleep,
B. Early Socialization- modeling by parents
C. Values -of SES or subculture
D. Social Influence - family, friends colleagues
E. Emotional factors - overeating linked to stress for some obese
F. Personal Goals -
G. Perceived Symptoms - flabby --> exercise
H. Access to the Health Care System - medical preventive health
behaviors are moderately correlated, all influenced by access to
services.
I. Cognitive factors - beliefs that behaviors are beneficial, perceived
threat

Determinant of good health
behavior (continued)
J. Individual Diffs -
a) Age Differences -omnipotent when young adult,
structure of childhood promotes good habits then.
b) Locus of Control - internal or external factors
control reinforcement.
Internal = more likely to believe that their own behavior
determines reinforcement outcomes. Seems they seek out
more info, but weak unless person holds strong health
values.
External = reinforcement is controlled externally

Modification of Health
Behaviors
I. CHANGING HEALTH ATTITUDES: assumes that if
you can change a persons attitude about their
health behavior, they will be motivated to change
that behavior (Hovland et al., 1953).
Four factors:
1) the characteristics of the communicator
2) the characteristics of the message
3) channel of communication
4) characteristics of the audience
Importance of the content of the message and framing

Changing Health Habits:
Attitude Change and Health Behavior –
Fear Appeals John Huston
If people
are fearful,
then
they will
change
behavior to reduce fear
Research has found this doesn’t always hold
Too much fear may undermine change
Recommendations for action should be given

Is Fear Effective
1) FEAR -most people believe that fear is effective, yet can create
less attitude and behavior change than positive approaches.
a) Fear is not sufficient -may have the opposite effect
-- ignore or deny the problem if too anxious and given no
means of solving it. Effects are short-lived,habituate to fear
messages
-- fear can inhibit behavior
b) Fear effective when:
1) threat seems immediate and likely
2) people must be given recommendations for action and
information about the efficacy of these health behaviors. Without
an alternative course of action, the impact of fear declines or
boomerangs.
c) Fear may not be necessary - information alone or with a
positive appeal is better under certain circumstances

Informational/Educational Appeals
a) Communication - colorful, vivid examples, avoid stats
b) Source- expert, prestigious, honest
c) Discuss both sides if no consensus, but not if audience in
agreement
d) Strong points made at the beginning and end
e) message = short, clear, direct
f) explicit conclusions
g) extreme messages more effective, but limits
h) Avoid VERY extreme messages & eliciting too much fear
Limits of informational appeals are due to the complex multistage
process of attitude change: attention, comprehension, yielding,
retention, and action recommendations. Links between attitudes and
behavior are complex.

Changing Health Habits:
Attitude Change and Health Behavior –
Educational Appeals: Message Framing
Illness Detection: Emphasize problems that may
occur if it isn’t done
Focus on problems that may occur if testing not done
“Risk Frame” for changing attitudes
e.g.,mammography: late detection of BC at stage 2 and 3 =
poor prognosis
Health Promotion: Emphasize benefits to be gained
“Gain Frame”
e.g., sunscreen reduces risk of wrinkles and skin cancer
Non-receptive audiences need to hear both sides

Changing Health Habits:
Attitude Change and Health Behavior –
Message Framing
Messages that emphasize potential
problems
Work better for behaviors that have
uncertain outcomes
Messages that stress benefits
Work better for behaviors with certain
outcomes

Changing Health Habits: Attitude
Change and Health Behavior
Health Belief Model – Whether a person
practices a health behavior depends on
The degree to which the person perceives a
personal health threat
The perception that a particular behavior will
effectively reduce the threat
Self-Efficacy – The belief that one is able to
control one’s practice of a particular behavior
Criticisms: ignores social and environmental
factors

Health Belief Model

Changing Health Habits:
Theory of Reasoned Action and Planned
Behavior
Linking health attitudes directly to behavior
A health behavior is the direct result of a
behavioral intention
Behavioral intentions are made up of
Attitude toward the specific action
Subjective norms regarding the action (a social
factor)
Perceived behavioral control
The more favorable the attitude and the
subjective norm, and the greater the perceived
control the stronger should the person’s
intention to perform the behavior in question.

Theory of Planned Behavior
http://www.people.umass.edu/aizen/tpb.diag.html

Pros and Cons
Similar to the Health Beliefs Model, but allows more
precise measurement of concepts and specifies paths
of causation.
Focuses on intention to act as a key mediator between
attitude and behavior change and
External social factors, rather than simply internally
perceived threats are measured
CONCLUDE: Influential cognitive model, actions are
guided by our interpretation of events, not the
environmental events per se.
Useful in predicting when people will be motivated to
change health behaviors, but doesn't account for the
process involved in voluntarily acquiring and
maintaining health behaviors, especially complex
behaviors

Changing Health Habits:
Some Caveats
Attitudinal approaches don’t explain long-term
behavior change very well
Communications can provoke irrational,
defensive reactions
People may distort health-relevant messages
May falsely see themselves as less vulnerable than others
Thinking about disease may produce a negative
mood
Unrealistic optimism may be peculiarly
resistant to feedback according to some studies