Monday, April 8, 2013
Models and theories are foundational in the development of any discipline. This paper will explicate the theorists, sources, and basic tenets of the Health Belief Model (HBM) and Engel's (1977) Biopsychosocial Model (BM) of health and illness, assess the relationship between the two models, and explain their importance to health psychology and medical science. Further, it will evaluate the role of these models in my intended research.
Key Theories in Health Psychology
The BM and the HBM are fundamental models that examine the complex association between physical and psychological health, and how individuals are motivated to change. The former was a seminal discussion on the need for a transition from a solely medical model of health to one that incorporated the effects of thought processes on health and illness (Engel, 1977). The latter, a model of behavior change, focuses on the likelihood that an individual will change. Both models guide understanding in health psychology and provide parameters for research in this field as well as in many other disciplines (Redding, Rossi, Rossi, Velicer & Prochaska, 2000).
Theorists, Sources, and Basic Tenets
The Biopsychosocial Model of Health
Theorist and Source. The classic work of George Engel (1977) contended that the linear concept of the medical model of health was in crisis because of an antiquated system that was "no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry" (p. 317). He further postulated that defining disease within strictly biological parameters did not adequately serve those who relied on the medical profession. Engel (1977) believed medical science needed a model that fairly and accurately accounted for the personal human experiences of disease (Engel, 1977). In a later classic work, Engel (1980) developed the concept of the model's usability in clinical applications.
Basic Tenets. The Biopsychosocial Model of Health was first suggested as a way to evolve from the linear science of medicine to a holistic perspective that includes multiple contributing factors to illness, including biological, psychological, and social influences (Engel, 1977; 1980). Further, this model introduced people to the new idea that they could perceive themselves as participants rather than as victims of disease (Marks, Murry, Evans, & Estacio, 2011). The model changed individual accountability for healthy behaviors, and it demanded a new, comprehensive design for healthcare.
The Health Belief Model
Theorist and Source. The Health Belief Model (HBM) was first introduced in the 1950s by employees of the Public Health Service to predict which individuals would utilize public programs designed to prevent and diagnose disease, as well as to determine why many individuals failed to use those resources (Rosenstock, 1960). Rosenstock's (1960) seminal research into this topic inspired ongoing research into health behavior. Rosenstock and others sought to understand why individuals did or did not take advantage of tuberculosis screening (Glanz et al., 2008). Later, classic articles by Becker (1974) and Kirscht (1974) described how the HBM could be utilized to study how people responded to diagnoses of disease and their symptoms, and how they complied with medical recommendations for treatment.
Basic Tenets. The HBM focuses on the likelihood that individuals will be motivated to act to prevent an illness according to how they perceive their personal vulnerability, the seriousness of the disease, the benefits and costs of taking action, and their sense of self-efficacy to effectively change their behavior (Glanz et al., 2008; Redding et al., 2000). These four factors influence the chance that an individual will act in a way that will mitigate the perceived threat and seriousness of the illness. This model of behavior change is a behavior expectancy theory that assumes individuals value the avoidance of illness and they expect that certain behaviors will help them avoid it (Glanz et al., 2008).
The Relationship Between the Theories
The HBM and the BM both stem from the understanding that the psychological and sociological aspects of individuals play a significant role in health. Because the HBM implicates individuals in the process of health and illness, the BM aimed to fill the gap in medical science and move toward a holistic system of health care, rather than the well-established linear model. Both models stem from an increase in understanding the social and psychological aspects of human health, and the role of the individual as a contributor in health and illness. The models perceive the individual as participatory, that they can affect their health outcomes. The BM was perhaps borne from a need created by the increased understanding that individuals do, in fact, have the power to change their health outcomes through behavior. This understanding became a provocation to medical science, that it must broaden its perception of the role of the individual in health care. The BM sought to fill a gap in medical science, a gap that had been widened by the conceptualization of individuals' role in health and illness.
Importance of the Theories
The Biopsychosocial Model
Engel's (1977) BM and the HBM are fundamental in the field of health psychology. In essence, health psychology was borne from Engel's general contention about illness and healing, and that medicine must evolve into a science that embraced the biological, psychological, and social aspects of disease (Redding et al., 2000). Engel's (1977) model continues to be utilized in a variety of other fields including social work, family therapies, mental health counseling, and clinical psychology. Various models of changing health behavior are aligned with Engel's original idea, that biological, psychological, and social factors contribute to health as well as illness. Further, modern medicine continues to evolve from a reductionist biomedical model to one that embraces the human aspects of illness and disease. Although McLaren (2002) trenchantly claims Engel's model was only a plea, not a fully designed or defined model or theory, it continues to influence the health fields as a seminal work upon which other models and theories on illness and disease are based.
My intended research stems, albeit indirectly, from Engel's idea that biological medicine must evolve, and to effectively heal disease and promote health, it is essential to grasp all of its contributing factors. My research is partly based on the theory that psychological support, in time of challenge, crisis, or illness, palliates some level of pain and suffering, and perhaps supports and even promotes biological healing. The Social Cognitive Theory partly informs this concept, although Engel's BM directly inspired investigation into other modes of healing. Social support has been empirically found to be integral in healing, along with pharmacological treatment and surgical interventions.
The Health Belief Model
Understanding an individual's role in health behavior is an essential component in health psychology. This understanding informs successful interventions, public health programs, and research in many fields (Glanz et al., 2008). Further, the HBM has inspired thousands of studies on health education and health behavior and is foundational in many effective interventions (Glanz et al., 2008). Equally important, the HBM has contributed to understanding how and why people change health behaviors and further, this model has been utilized to change health behaviors, which is an important element in people's lives. Considering that the twelve leading causes of death are preventable by a change in health behavior (Marks et al., 2009), this model of understanding how to facilitate this change becomes even more significant.
The HBM is important to my research, although the relationship may be considered indirect. The participants in my research have already been diagnosed with a disease, and are implementing resources practical to their situation, with the hope of facilitating the most positive outcome. They cannot avoid the disease, but they can work toward gaining self-efficacy. According to the HBM, an individual perceives self-efficacy when they are convinced that they can and will act successfully in a way that will produce the most favorable outcome for themselves (Bandura, 1997). The HBM implies that individuals have the capacity to make the ultimate contribution to positive health outcomes in the form of behavior change. With adequate information, this may include seeking psychological support as one component of behavioral change that may facilitate a positive outcome. My research interests are in creating a more accurate understanding of the role of online support and its effects on health and well-being.
The HBM and the BM are integral in the field of health psychology. Health behavior and its changeable nature is perhaps humankind's hope for preventing diseases that are, in fact, preventable. The BM embraces models and theories that contribute to the changing role of the individual in health care and the prevention of illness, and continues to hold medical science accountable to including the full range of contributing factors to health and illness. As an aspiring health psychologist, these models will guide my research as well as provide a parameter by which to explore the dimensional characteristics of human health and well-being.
Bandura, A. (1997). Insights. Self-efficacy. Harvard Mental Health Letter, 13(9), 4-6.
Becker, M. H. (1974). The health belief model and personal health behavior. Health Education Monographs, 2, 324-473.
Engel, G. (1977/2012). The need for a new medical model: a challenge for biomedicine. Psychodynamic Psychiatry, 40(3), 377-396. doi:10.1126/science.847460
Engel G. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137, 535–44.
Kirscht, J. P. (1974). The health belief model and illness behavior. Health Education Monographs, 2, 2387-2408.
McLaren N (2002). The myth of the biopsychosocial model. The Australian and New Zealand Journal of Psychiatry, 36(5): 701–703.
Marks, D. F., Murray, M., Evans, B., & Estacio, E. V. (2011). Health psychology: Theory, research, and practice (3rd ed.). Los Angeles, CA: SAGE.
Redding, C. A., Rossi, J. S., Rossi, S. R., Velicer, W. F., & Prochaska, J. O. (2000). The International Electronic Journal of Health Education, 3, 180-193.
Rosenstock, I., M. (1990) The health belief model: explaining health behavior through expectancies. In: Glanz, K., Lewis, F. M., Rimer, B. K., eds. Health Behavior and Health Education: Theory, Research, and Practice. San Francisco, CA: Jossey-Bass; 39-62.
Rosenstock, I. M. (1960). What research suggests about public health. American Journal of Public Health, 50, 295-302.
I have chosen to develop a teenage pregnancy prevention program. In the case of preventing teenage pregnancy, social marketing can address the perceived benefit of being sexually active (it may be perceived as sexy, cool, or mature). It could also address peer pressure, and the effects of media on adolescent sexuality (Evans, Silber-Ashley, & Gard, 2007).
I would call the program "No Love, No Glove, and Waiting" and I would try to establish a different perspective of norms in adolescent sexual behavior. For example, if the current adolescent perspective is that being sexually active is desirable or "cool", then the program would counter that idea by presenting an alternative that sexual responsibility and waiting to have sex is more socially desirable than being sexually active. Effective programs must present information in a way that is consequential to teens, and the presentation must be effective at their level (Card, 1999). Adolescents are keenly aware of the normative behavior of their teen culture, so it seems appropriate to inspire a change in their perception of what is normal behavior, with a goal that it could become a pervasive, culture-wide perception.
In developing a strategic marketing plan, it is important to identify the product (sexual responsibility) as a beneficial package (Storey, Saffitz, & Rimon, 2008). To do this, I would present sexual responsibility as more desirable than sexual promiscuity. Presenting abstinence and safe sex as a socially and culturally (meaning teen culture) through re-defining norms will provoke a change in their perceptions of sexual activity, similar to how media have established the current norm. This could be accomplished by engaging teens to help convey the messages about the new teen perspective. It will be important to have teens talking to teens. A program like this cannot be presented wholly by an adult to whom teens cannot relate.
By pairing the idea of desirability with sexual responsibility, the barriers to change would be decreased. This is especially true for adolescents who tend to want to belong to the majority teen culture. Peer pressure is more powerful in adolescents than during any other developmental period in life (Jaccard, Blanton, & Dodge, 2005). This program will use the strength of peer pressure to develop the new norm for sexual responsibility. By complying with the new norm, there is an additional benefit, which is the acceptance of peers.
This program will take place within the school, where adolescents should be able to find information and support, and possibly condoms, and where large and smaller group meetings can take place. Storey et al. (2008) gave the example of condom vending machines in night clubs. Although this may not be appropriate in a middle school, there is a need for the easy acquisition of information, peer support, and contraceptives. The program would establish peer groups that would continue to meet as agreed upon. This fills the need for social support that is so important during adolescence (Gardner & Steinberg, 2005). The students would be encouraged to plan events that keep students in larger groups that may decrease sexual activity. If the adolescents are similar to the sensation-seeking teens that Storey et al. (2008) suggests, it may be beneficial and effective to have adolescent parents speak about the challenges and frustrations that accompany teen parenting.
The theory of reasoned action and planned behavior (TRA) best relates to the program and my social marketing strategies. TRA states that an individuals' intention to behave a certain way is strongly related to actually behaving that way, and that people make conscious decisions based on rational thinking (Glanz, Rimer,& Viswanath, 2008; Redding, Rossi, Rossi, Velicer & Prochaska, 2000). Further, because the program is establishing a normative belief, the adolescents will be highly motivated to comply. The program to reduce teenage pregnancy has identified the motives for action, which is the increased desirability of sexual responsibility with little to no psychological cost. It's goal was to change adolescent beliefs about the consequences of unplanned sex, and create a new norm for the adolescent population. They will begin to see sexual responsibility as normal for their culture and will fulfill the adolescent need to belong (Gardner & Steinberg, 2005). The greatest recipient of the attitude change is adolescents, although parents and society in general are stakeholders in supporting this change in attitude.
Card, J. (1999). Teen pregnancy prevention: do any programs work?. Annual Review Of Public Health, 20257-285.
Evans, W. D., Silber-Ashley, O., & Gard, J. (2007). Social marketing as a strategy to reduce unintended adolescent pregnancy. The Open Communication Journal, 1(1), 1-8. doi: 10.2174/1874916X00701010001
Gardner, M., & Steinberg, L. (2005). Peer influence on risk-taking, risk preference, and risky decision making in adolescence and adulthood: An experimental study. Developmental Psychology, 41(4), 625–635.
Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health behavior and health education: Theory, research, and practice (4th ed.). San Francisco, CA: Jossey-Bass.
Jaccard, J., Blanton, H. & Dodge, T. (2005). Peer influences on risk behavior: An analysis of the effects of a close friend. Developmental Psychology, 41(1), 135–147.
Storey, J. D., Saffitz, G. B., & Romon, J. G. (2008). Chapter 19, Social Marketing. In Health behavior and health education: Theory, research, and practice (4th ed., pp. 435-464). San Francisco, CA: Jossey-Bass.
Redding, C. A., Rossi, J. S., Rossi, S. R., Velicer, W. F., & Prochaska, J. O. (2000). The International Electronic Journal of Health Education, 3, 180-193.
One of the primary characteristics of research is that it is substantiated by its foundation in the research of others (Creswell, 2009; Laureate Education, Inc., 2009). Empirical study is founded on the works of previous thinkers and discoverers. Researchers make progress because they begin where others have left off. The literature review in research is pivotal in the progress of empirical study. According to Creswell (2009), this component gives the researcher an understanding of ongoing dialogue, and general knowledge about a specific area of inquiry. Central to the topic of study, the literature review unearths what others have found, and whether shortcomings, inconsistencies, or gaps exist in the current knowledge (American Psychological Association, 2010; Laureate Education, Inc., 2009). Further, it can summarize or synthesize and offer a new interpretation of older literature, and provide a reference point for augmenting, adjusting, or contradicting contemporary insight (Creswell, 2008).
In a qualitative study literature may be used as an introduction and to review contemporary knowledge about the topic. The authors may use the literature review to frame the study and present background information. In the qualitative study of McGrath and Pistrang (2007), the authors use a review of the literature to describe what is known, what remains unknown, the limitations of current research, and their goal within the study to increase what is known about the circumstance and the population studied. As addressed in the Use of Literature Checklist (Laureate Education,Inc., n.d.), the literature review was used to introduce the issue central to the research. The authors identified and discussed the problem they sought to address and the central purpose of the study is stated. Further, the authors describe the participants in the study, and they summarized their findings. The journal article is clearly a qualitative research study that formulates a new idea about the relationship between homeless youth and the individuals who care for them. In the final discussion, the authors used literature to draw similarities between their findings and other studies that found a perceived dichotomy in the relationships between clients and counselors/workers.
The authors do not present the literature in a separate section, although definitively state the use of literature in presenting their study. They made the point that literature about similar circumstances in other populations was used to frame their study because of a paucity of research on their specific population and topic. The authors not only present research directly applicable to their central topic, but present the literature on similar topics and populations.
The literature review provides a perspective of the overall climate within a specific area of inquiry. Within that climate, researchers determine what is known as well as what is not known, and what they determine to make known. Prior to engaging in research on a topic, it is prudent to understand how and where one's research will fit in to the knowledge base (Laureate Education, Inc., 2009). Scholars and researchers have an obligation to the established knowledge base as well as other scholars and researchers to understand the foundations upon which they build their research (Laureate Education, Inc., 2009). The goal of researchers is to add to the knowledge base and foster future research (Creswell, 2009). In the qualitative study of McGrath and Pistrang (2007), the authors utilize the literature review to describe current knowledge, the gaps in similar research, and their goal to increase the level of knowledge about the quality of relationship between homeless youth and their key workers.
American Psychological Association. (2010). Publication manual of the American Psychological Association. Washington, DC: Author.
Creswell, J. (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd ed.). Thousand Oaks, CA: Sage Publications.
Laureate Education, Inc. (Executive Producer). (2009). Theory. Baltimore: Author.
McGrath, L., & Pistrang, N. (2007). Policeman or friend? Dilemmas in working with homeless young people in the United Kingdom. Journal of Social Issues, 63(3), 589-606. doi 10.1111/j.1540-4560.2007.00525.x
Laureate Education, Inc. (n.d.) Use of literature checklist. [Handout] Baltimore: Author
I have chosen to describe a program aimed to help older adults comply with medical recommendations for taking prescription medications. Research suggests many patients do not understand the information written on their prescription bottle label or the instruction communicated by their doctor (Carmona, 2007; Liechty, 2011). Older adults are prone to a number of chronic conditions that require medical and medicine adherence. Health literacy in older adults may vary; whereas some may have a good understanding of how to take their medication and why they take it, others do not have a full grasp on medical instructions. Older adults are particularly ambivalent about change and approximately 50% of older adults with chronic conditions are medically non-compliant. Failure to take medications properly contributes to one in ten hospitalizations for this age group (Kier et al., 2012).
Important factors to consider for this population are age, health literacy, and culture. It would be important to understand that older adults are an especially vulnerable population, although equally important to communicate and guide them without perpetuating ageist views (Nolan, 2011).
One factor to consider is the client's level of health literacy. Health literacy can affect an individual's adherence to medical treatment and it may prevent them from fully understanding the implications of not taking their medications or taking them incorrectly (Kier et al., 2012). Health literacy strongly influences health outcomes (Weekes, 2012). It is important that the individuals participating in the program understand the scope of the intervention and how it will affect their health. A lack of health literacy is implicated in poorer health outcomes for the elderly and those with chronic illness (Von Wagner et al., 2007).
Another consideration is the age of the participants in this program. Older adults may find it more difficult to understand the information conveyed to them, and they may be more forgetful than other age groups (Prabhavalkar & Chintamaneni, 2010). They may have fewer resources available to them, or they may not be aware of the resources that are available. To effect change in this population, information must be communicated in a way that it can be realistically implemented into their lives (Bryant, 2011). Age contributes to a decline in cognitive abilities (Santrock, 2008). Many older adult patients may experience a range of issues with even low levels of dementia including challenges to memory and attention span, and language skills (Prabhavalkar & Chintamaneni, 2010). All of these have implications for effective communication.
The individual's culture must be a consideration as well because culture affects an individual's perceptions and fundamental belief systems that may help or hinder medical compliance (Sue & Sue, 2008; Wagner et al., 2007). Individuals not fully integrated into the majority culture, especially those who are not fluent in the primary language spoken, are more likely to not understand health recommendations, dosing instructions, or other aspects of medical compliance (Bryant, 2011). These individuals are more likely to lack health literacy and they tend to have poorer health outcomes (Bryant, 2011).
Utilizing Motivational Interviewing
I would utilize motivational interviewing (MI) to strengthen self-efficacy for this program for older adults. As expressed by Rollnick, Miller, & Butler (2008), it is not only necessary to initiate motivation but to engage individuals in commitment to change. It facilitates intrinsic motivation by resolving issues of ambivalence that may include self-efficacy (Irby, Kaplan, Garner-Edwards, Kolbash & Skelton, 2010). MI emphasizes being empathetic rather than confrontational, and supports clients' confidence in their ability to undertake medical compliance effectively. Based on the theory that inducing durable change must incorporate intrinsic motivation, it can also reduce older adult's ambivalence to change (Kier et al., 2012). MI has been effective in many applications with older adults, although some research determined that the brevity with which MI is often implemented may not be sufficient to induce long-term change in older adults (Cummings, Cooper, & Cassie, 2008). Although there is a paucity of research on the exact amount needed to effect durable change in older adults, more than usual may be necessary (Cummings et al., 2008).
Bryant, A. (2011). Low health literacy affecting client's ability to receive adequate health care education. JOCEPS: The Journal Of Chi Eta Phi Sorority, 55(1), 7-11.
Carmona, R. H. (2007). Improving Americans’ health literacy. Journal of the American Dietetic Association, 20, 422-425.
Cummings, S. M., Cooper, R. L., & Cassie, K. M. (2008). Motivational Interviewing to Affect Behavioral Change in Older Adults. Research on Social Work Practice, 19(2), 195-204. doi: 10.1177/1049731508320216
Irby, M., Kaplan, S., Garner-Edwards, D., Kolbash, S., & Skelton, J. A. (2010). Motivational interviewing in a family-based pediatric obesity program: A case study. Families, Systems, & Health, 28(3), 236-246. doi:10.1037/a0020101
Kier, F. J., Byrne, A. J., Snider-meyer, J. M., Levine, D. A., Gresser, S. K., & Smith, H. M. (2012). Effectiveness of motivational interviewing on medication compliance in a geriatric home care service. Washington, District of Columbia, US: American Psychological Association (APA).
Liechty, J. M. (2011). Health Literacy: Critical Opportunities for Social Work Leadership in Health Care and Research. Health & Social Work, 36(2), 99-107.
Marks, D. F., Murray, M., Evans, B., & Estacio, E. V. (2011). Health Psychology: Theory, Research, and Practice (3rd ed.). London: Sage.
Nolan, L. C. (2011). Dimensions of Aging and Belonging for the Older Person and the Effects of Ageism. BYU Journal of Public Law, 25, 317-339.
Prabhavalkar, K. S., & Chintamaneni, M. (2010). Diagnosis and treatment of mild cognitive impairment: A review. Journal of Pharmacy Research, 3(2), 388– 392.
Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care. New York, NY: Guilford Press.
Santrock, J. W. (2011). A topical approach to life-span development (3rd ed.). New York, NY: McGraw-Hill.
Von Wagner, C., Knight, C., Steptoe, A., & Wardle, J. (2007). Functional health literacy and health promoting behavior in a national sample of British adults. Journal of Epidemiology and Community Health. 61(6), 1086-1091.
Weekes, C. V. (2012). African Americans and Health Literacy: A Systematic Review. ABNF Journal, 23(4), 76-80.