Continuing Education Activity

Human behavior in a social environment (HBSE) is a concept that describes a comprehensive view of people and is fundamental to the study of social sciences. Its concepts apply to all forms of clinical work, as it integrates concepts from the biological, psychological, and social sciences. This activity outlines a brief introduction to HBSE and reviews the interprofessional team's role in improving patient care through an understanding of HBSE.

Objectives:

• Summarize the typical description of HBSE.
• Identify the common functions of HBSE.
• Outline three common theories applicable to the concept of HBSE.
• Explain interprofessional applications of HBSE in clinical practice to improve patient care coordination and optimize clinical outcomes.

Introduction

Human Behavior in a Social Environment (HBSE, also referred to as Human Behavior and the Social Environment) is a broad topic that often comprises entire courses or academic degrees. It is a foundational aspect of social work, and its topics apply to multiple fields of medicine. As the term itself implies, HBSE seeks an understanding of human behavior and all of the contributors to and characteristics of human behavior; the social environment and different levels and systems of this environment; and the interface between them. 

Function

HBSE provides a framework to understand both individuals and the environment in which they live. This facilitates a more comprehensive understanding of the individual presenting for treatment. This can be particularly important in understanding barriers to adherence, personality structures, interactional styles, irregular follow-ups and no-shows, and other such clinically-pertinent behaviors. In this way, HBSE provides a method to broaden the clinician's view of the patient's life and the challenges and limitations that exist for the patient. Through this understanding, one can garner an appreciation for these barriers, which can subsequently facilitate an ability to address some of the barriers that exist. This is particularly relevant when understanding social determinants of health. Social determinants of health are considered vital contributors to adherence, response to treatment, and follow-up.[1][2]

This concept called "Person-in-Environment" is closely related to the HBSE framework and is often considered a foundational aspect of the practice of social work. "Person-in-Environment" considers both the individual and the multiple environments with which and within which the individual interacts. "Person-in-Environment" also considers that both the individual and environment share a reciprocal relationship.[3] Several theories can help clinicians identify contributors to this reciprocal relationship, as defined below. Each of these theories describes static and dynamic contributors to the person's presentation. They can be combined or used individually to capture a complete understanding of the patient or client.

Issues of Concern

Theories applicable to HBSE include Micro, Mezzo, Macro Approaches; Biopsychosocial-Spiritual Approach; Systems Theory; Social-Ecological Model; and Ecological Systems Model. These theories and models facilitate an understanding of "Person-in-Environment." Many of these theories overlap in how they organize an understanding of individuals and associated contributors to their presentation. There are also differences between each theory regarding how each identifies and analyzes specific information. Here, the "Micro, Mezzo and Macro Approach," the "Biopsychosocial-Spiritual Approach," and the "Ecological Systems Model" are described to highlight similarities and differences.

Micro, Mezzo, and Macro Approach[4]

"Micro, mezzo, and macro approach" refers to a three-level understanding of contributors to systems involving and surrounding the individual.

• Micro: Micro-level involves considerations for biological and psychological characteristics of the individual. These could include personality, mental and physical health or pathology, and education levels, as examples.
• Mezzo: Mezzo-level formulation takes into account the immediately surrounding networks and services of an individual. These can include the home and neighborhood environments, social networks (including friends, neighbors, and family), and available medical and social services.
• Macro: Macro-level contributors include the largest scale contributors that can impact an individual through the mezzo level, including economic and political changes and regulations as well as natural forces, such as earthquakes, tornados, and others.

Biopsychosocial-spiritual Model[5]

The biopsychosocial model was first introduced in 1977 by George Engel to understand the multitude of factors that contribute to a person. It has been argued that the biopsychosocial model itself does not include existential factors, including spirituality or death. As such, the biopsychosocial-spiritual model was proposed to provide a more comprehensive view in this regard.

• Biological factors can be understood as any medical or biological contributors to the person's presentation. These include medical illnesses, genetics, neurobiology, physical attributes, diet, substances, and medications.
• Psychological contributors include temperament, personality, memory, attitudes, coping mechanisms, and beliefs.
• Social contributors include social support networks, culture, workplace, education, socioeconomic status, and relationships.
• Spiritual contributors include any aspects of belief for or against a spiritual or religious entity.

Ecological Systems Model

The Ecological Systems Model was originally described by Bronfenbrenner and described 5 system levels from smallest to largest, as they pertain to the individual.[6]

• Microsystem is that which directly surrounds the individual and that the individual interacts with directly and most intimately. This can include home, work, school, and relationships within this system, including family, friends, and caregivers.
• Mesosystem describes the following level, where each specific microsystem interconnects with the other and indirectly impacts the individual. For example, the work system and associated demands may either positively or negatively influence the home system.
• Exosystem describes a system level in which the individual is affected but unable to effect change. These can include an individual's company going out of business and losing their job as a result.
• Macrosystem includes a higher level still, in which the cultural, political, and economic environment can be understood, all of which can affect the individual.
• Finally, the chronosystem describes dynamic and timing-dependent events, including how historical events might impact an individual's life.

Clinical Significance

HBSE in clinical practice and application can be best described using a case example. Consider a 40-year-old male with a history of hypertension, type 2 diabetes mellitus, hyperlipidemia, coronary artery disease status-post 2-vessel coronary artery bypass grafting (CABG) 3 months ago, major depressive disorder, and generalized anxiety disorder, who presents for an evaluation of brittle diabetes. He recently lost his job and is going through a divorce, and he is currently living on his own. Utilizing any of the above theories, we can identify quickly that the information we have thus far only constitutes a basic level of understanding of this presenting individual. 

As an example, we can use the Micro-Mezzo-Macro approach. We can identify that thus far, we understand some biological and psychological factors contributing to his presentation (the Micro factors). These include the medical and psychiatric disorders listed. On further analysis of each of these disorders alone, one can begin to formulate hypotheses about some initial contributors to the patient's labile blood sugars. Some hypotheses might include considering the patient's mood, anhedonia, and hopelessness and how this may impact his adherence to medical treatment, which we could further assess. Also, one might consider that the patient is experiencing ongoing psychological and/or physiological effects of his CABG, which is making it difficult to exercise, contributing to more difficult control of blood sugars. Other considerations might be whether treatment interactions are affecting his insulin resistance or response to medications. We may also consider that his cognition may be affected on some level and contribute to his inability to remember to take his medications.

One can also see that mezzo and macro-level contributors are less clear based on the initial information. We may need to explore these factors further to understand how they may contribute to this patient's presentation. We see that he has recently lost his job, and one can formulate a hypothesis that he may have some financial strain as a result, and he may also have lost his insurance coverage. Both of these could make affording medications or visits with providers unfeasible. We also understand that he is living on his own. He may have limited social support to take care of himself and his needs, which could be various and may also affect his perception of the importance of treatment adherence. The divorce process may also contribute to financial strain and interpersonal difficulties, making it more difficult for him to trust or interact with others, including his providers. It may also be worsening his depressive or anxiety-related symptoms as above as well as his diet. Another consideration could include that his job loss occurred in the setting of a worsening economy, or as a result of deteriorating interpersonal relations at his work, his decreasing perception of his self-importance and self-worth, among others. We may also consider that losing his job could mean that he has lost a significant portion of his social support network. 

Other contributors might include the availability of green spaces near him, neighborhood safety, nearby community organizations that could support him, legislation affecting the patient's housing or job security, or healthcare policies or changes. Additionally, concepts such as discrimination and prejudice and the impact of race on this individual can inform adherence, trust in healthcare providers, and an understanding of potential significant life stressors contributing to the patient's presentation. As we continue to consider aspects of this individual's presentation, we can see that there may be multiple other factors contributing to his presenting complaint. Psychosocial factors, as described above, have been reported in the literature to have a significant impact on healthcare outcomes in a variety of studies.[7][8][9][10]

Other Issues

HBSE also utilizes theories of development through the lifespan and other psychological theories, including psychoanalytic theory, as well as Erikson, Piaget, and Kohlberg's theories of development. Here we will focus primarily on Erikson, Piaget, and Kohlberg theories. These theories can be particularly useful in understanding an individual's overall development and any aspects of their presentation associated with an incomplete transition through stages of development.

The Erikson theory of development describes stages of development that range from infancy to old age, with a total of 8 stages.[11] Each stage describes a major developmental period, where adequate adaptation, support, and development can lead to more fulfilling lives. The stages of this theory are as follows:

• Stage 1 - "Trust vs. Mistrust"
  • Infancy - first 18 months
  • Development of stable, nurturing, and consistent relationships with caregivers
  • Disruptions in the stability or consistency of the relationship can lead to impairments in trust.
• Stage 2 - "Autonomy vs. Shame and Doubt"
  • Early childhood - 18 months to ~3 years
  • Development of independence, sense of control over abilities (including bodily functions), and assertiveness
  • Over-control or excess criticism during this period leads to shame, self-doubt, and increased dependence on others.
• Stage 3 - "Initiative vs. Guilt"
  • Preschool age - ~3 to 5 years
  • Development of interpersonal skills, assertiveness, and social interactions
  • Restriction from exploring these environments can lead to a sense of guilt as the child may view its way of interacting as a nuisance.
• Stage 4 - "Industry vs. Inferiority"
  • School-age - 5 to ~12 years
  • Development of self-esteem through social interactions and peer groups, and feelings of pride and accomplishment during a time of increasing demands from academic and social situations
  • Disruptions in this time can lead to feelings of failure and inferiority especially compared to peers.
• Stage 5 - "Identity vs Confusion"
  • Adolescence - 12 to 18 years
  • Development of a sense of identity and sense of self through in-depth self-exploration, including beliefs and values, and an increasing sense of independence
  • Erickson described this stage as the bridge between the morality learned as a child and the ethics developed by the adult.
  • Disruption in this stage leads to a sense of confusion and a lack of sense of self.
• Stage 6 - "Intimacy vs. Isolation"
  • Young adulthood - 18 to 40 years
  • Development of secure and enduring intimate relationships with others that are meaningful and lasting
  • Disruptions in this result in a sense of isolation and loneliness
• Stage 7 - "Generativity vs. Stagnation"
  • Adulthood - 40 to 65 years
  • Development of feeling of accomplishment, contributions to society, to children, and the world
  • Disruptions lead to feelings of disillusionment, distance, and stagnation.
• Stage 8 - "Integrity vs. Despair"
  • Old age - 65 years onward
  • Development of an understanding of one's life and a review of one's accomplishments, to feel integrity and coherence about one's self, which leads to wisdom
  • Disruption in this stage can lead to feelings of despair and regret

The Piaget model describes the development in 4 stages of childhood cognitive development.[12][13] The stages or periods are summarized as follows:

• The sensorimotor period from birth to 18 to 24 months
  • As the name implies, sensations, bodily functions, and movements ("sensorimotor") are developed in this stage
  • The concept of "object permanence" is also developed during this stage, in which the child recognizes the existence of an object (parent, toy, etc.) despite not being able to sense it immediately
• The pre-operational period between two and seven years
  • A semiotic function is developed during this stage, which is the development of the symbolic representation of thoughts, memories, and events, as well as imaginative thought
  • This represents the beginning of the assimilation of ideas and thoughts in addition to describing and identifying these ideas
• The concrete operational period from ages seven through 11 or 12 years
  • In this stage, the child can apply logic and rules to concrete objects in their environment to predict and understand the world in greater detail
  • The concept of conservation is developed in this stage, wherein the child understands that the amount of liquid does not change after being poured into a wider or thinner container (which affects the height or level of water)
• The formal operational period from 12 until adulthood
  • Application of rules and logic to more abstract concepts is developed during this stage
  • The types of thought developed during this stage include hypothetical-deductive thought, propositional thought, and isolating variables, and examining combinations

Piaget also commented on "moral development," in which he describes two stages: heteronomy and autonomy.

The concept of heteronomy or "heteronomous morality" is the child's understanding that there are rules and duties and authority figures who must be obeyed. This is related to the idea of "Moral Realism," in which the rule itself is more important than the purpose of the rule. In this regard, the intention of the person doing the act is less important than the outcomes of the actions to the child. The child expects that violations of these rules will be punished, referred to as "Immanent Justice." In this regard, heteronomous morality considers that power is handed down from above (heteronomously).

During play, children develop an understanding of "moral relativism," where morality can be considered more with regard to intentions rather than consequences. This results in the development of "autonomous morality" or autonomy. The concept of punishment also changes where the purpose of punishment is to correct wrongs rather than punish the guilty.

The Kohlberg theory expounded on the concept of morality development and described three stages (with six "substages") of the development of morals and considers that the development of morality takes longer.[14]

• Preconventional morality - up to age 9
  • Obedience and Punishment Orientation
    • The child is punished for doing something wrong
    • Punishment is avoided by doing good
  • Individualism Orientation
    • "What's in it for me?"
    • Individual needs are prioritized.
• Conventional - through adolescence and adulthood
  • Good Intentions and Social Norms Orientation
    • The child wishes to win the approval of others
    • Emphasis is placed on people being "nice" to others
  • Authority and Social-Order Orientation
    • The child accepts rules without question as a means of maintaining social order.
    • This goes beyond wishing to win the approval of others
• Postconventional - through adulthood
  • Social Contract and Individual Rights
    • Multiple world views are acknowledged, accepted, and respected
    • Laws are considered social contracts instead of a rigid set of rules
  • Universal Principles
    • Abstract reasoning around morals is applied
    • Rather than laws being followed, individuals choose the moral principles by which they live.

Each of these above theories describes the development of the child as it progresses through changing social environments. When assessing each patient, they will have varying degrees of development or disruption in development in each stage, which can affect their behavior and approaches to prescribed treatments, as well as interpersonally and in other settings.

The disease and medical models also provide useful ways to approach patient care and contribute significantly to the understanding of patients. This is the more traditional biomedical view, in which syndromes are identified, and through the process of identifying syndromes, diseases are thus identified. Pathophysiology, etiology, epidemiology, pathology, and other such concepts are applied to develop an understanding of each disease. Through this developed understanding, the ability to diagnose and then treat accurately is garnered. The success of this model is evident in the modern-day practice of healthcare, in which most healthcare workers are familiar with and apply this model. However, significant limitations of this model include that it tends to neglect psychosocial components, or as HBSE describes, many of the other factors that contribute to a person's development and situation. Many of these factors contribute to the precipitation and perpetuation of disease in an individual patient.[15]

Clinicians' understanding of mental health and disorders is evolving towards a more dimensional approach.[16] This is a currently evolving model of mental health and disorders. As such, there is not a widespread consensus regarding how this model can be accepted and applied to clinical practice. A significant advantage to a dimensional model is that it removes the arbitrary separation between health and disorder. By placing health and disorder on the same spectrum, stigma can be reduced by understanding the human condition and the spectrum of human behavior and mental health. Also, this model allows a more effective understanding of the evolution of disorders in mental health, as individuals who may be on one part of the spectrum during a single point in time and may transition to another part of the spectrum at another point in time. Such a dimensional approach may also prove useful in medical illness, especially in conditions where cutoffs or ranges of normality may have an arbitrary or uncertain origin.

Enhancing Healthcare Team Outcomes

HBSE can provide a framework for collaborative care and interprofessional teams to provide optimal patient care. In these situations, healthcare professionals of different disciplines may have different means of formulating an understanding of the patient. Interprofessional teams can thus use HBSE concepts to understand cross-discipline formulations and treatment plans. Given the limitations of the current healthcare system and system pressures on individual providers, each individual provider might consider focusing on addressing one aspect of the individual's care while maintaining an understanding of the greater contributors to the patient's presentation. Of primary importance is assessing and evaluating a trained social worker that can identify factors hindering patient care and outline in depth the patient's expectation from treatment. Communicating these factors to the trained specialty nurse can help in patient education and improve compliance with care. Identifying detrimental factors as well as adverse reactions and notifying the clinicians of these findings can help improve clinical outcomes and prevent complications. Electronic medical records could assist with this through a computer-assisted identification of major factors or deficits in the patient's life that may limit adherence, healthcare literacy, or communication. Through a greater understanding of HBSE, a more integrated healthcare team and a resulting healthcare system are achievable. The Canadian Institutes of Health Research identified ten principles for healthcare integration to occur successfully, and this included "Standardized Care Delivery through Interprofessional Teams."[17] 

One of the identified factors under this principle included "one standard-of-care." In this regard, a comprehensive view of each individual, using an understanding of HBSE, would allow for a universal standard-of-care to be developed across healthcare systems. Also, emphasis on well-being and health promotion was recognized, which again can be facilitated through an understanding of HBSE. [Level 3]

Nursing, Allied Health, and Interprofessional Team Interventions

The interprofessional team can provide support through various approaches, including making follow-up phone calls after hospital discharge or a clinic appointment to ensure adherence. These calls may also facilitate and address other factors contributing to the patient's presentation, which could not be captured during the appointment. Some examples include difficulty with transportation or identifying public transportation schedules, health literacy over the phone, and identifying complex family systems that may affect patients' adherence. Some such barriers can thus be identified and addressed through various public and health system programs.

Nursing, Allied Health, and Interprofessional Team Monitoring

Monitoring patient's adherence and barriers to adherence can be facilitated with an understanding of HBSE. Identifying factors outside of the biological realm can provide perspective for healthcare providers as to other contributors to adherence. For example, identifying cost considerations and financial strain as a contributor to non-adherence to prescriptions can allow the provider or healthcare team to recommend a prescription coupon site or assist the patient in applying for patient assistance programs. Interprofessional team monitoring can be particularly useful in identifying these varied factors. Each healthcare team member can work to identify different aspects of the patient's presentation using a biopsychosocial model. All interprofessional healthcare team members (clinicians, mid-level-practitioners, pharmacists, nurses, therapists, and ancillary staff) can thus provide support to the individual patient in a variety of more complicated ways that are more holistic and comprehensive compared to a traditional disease-oriented model.