Human Behavior in a Social Environment

Function

HBSE provides a framework to understand both individuals and the environment in which they live, which can help facilitate a more comprehensive understanding of the individual presenting for treatment. This approach can be particularly important in understanding barriers to adherence, personality structures, interactional styles, irregular follow-ups and no-shows, and other clinically pertinent behaviors.

Accordingly, 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, subsequently facilitating an ability to address some existing barriers. This insight is particularly relevant to understanding social determinants of health, which are considered vital contributors to adherence, response to treatment, and follow-up.[1][2]

The concept of "person-in-environment" is closely related to the HBSE framework and is often considered a foundational aspect of social work practice. Person-in-environment takes into account both the individual and the multiple environments within which the individual interacts, acknowledging that both share a reciprocal relationship.[3] Several theories can help clinicians identify contributors to this reciprocal relationship, as discussed below. These theories describe static and dynamic contributors to a person's presentation and can be combined or used individually to capture a complete understanding of the patient or client.

Issues of Concern

The theories and models applicable to HBSE include:

• Micro-mezzo-macro approach
• Biopsychosocial-spiritual approach
• Systems theory
• Social-ecological model
• Ecological systems model

Facilitating 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. 

Micro-Mezzo-Macro Approach

This approach refers to a 3-level understanding of contributors to systems involving and surrounding the individual.

• Micro: Involves considerations for the biological and psychological characteristics of the individual, including personality, mental and physical health or pathology, and education levels
• Mezzo: Takes into account the networks and services immediately surrounding an individual, including the home and neighborhood environments, social networks (friends, neighbors, family), and available medical and social services.
• Macro: Includes 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 (eg, earthquakes, tornados).[4]

Biopsychosocial-Spiritual Model

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 this 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 contributors: Any medical or biological contributors to the person's presentation, including medical illnesses, genetics, neurobiology, physical attributes, diet, substances, and medications.
• Psychological contributors: These include temperament, personality, memory, attitudes, coping mechanisms, and beliefs.
• Social contributors: These include social support networks, culture, workplace, education, socioeconomic status, and relationships.
• Spiritual contributors: These include any aspects of belief for or against a spiritual or religious entity.[5]

Ecological Systems Model

The ecological systems model was originally described by Bronfenbrenner, who posited 5 system levels (from smallest to largest) as they pertain to the individual.

• Microsystem: Refers to things that directly surround the individual and that the individual interacts with most intimately (eg, home, work, school, and relationships within this system, including family, friends, and caregivers)
• Mesosystem: Refers to interconnections between microsystems and their impact on the individual (eg, 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 (eg, an individual's company going out of business and losing their job as a result).
• Macrosystem: Describes a system level in which the cultural, political, and economic environment can be understood, all of which can affect the individual.
• Chronosystem: Describes dynamic and timing-dependent events, including how historical events might impact an individual's life.[6]

Clinical Significance

Case Example

The application of HBSE in clinical practice can best be understood using a case example. Consider a 40-year-old male who presents for an evaluation of brittle diabetes; he has: 

• A history of hypertension
• Type 2 diabetes
• Hyperlipidemia
• Coronary artery disease status post 2-vessel coronary artery bypass grafting (3 months ago)
• Major depressive disorder
• Generalized anxiety disorder

Additionally, he recently lost his job, is going through a divorce, and is currently living alone. Using any of the above theories, we can quickly identify that the information we have thus far only constitutes a basic level of understanding of this presenting individual. 

Micro-Mezzo-Macro Approach

Hypotheses: micro factors

Using the micro-mezzo-macro approach, for example, we can identify some biological and psychological factors contributing to his presentation (ie, the micro factors). These include the medical and psychiatric disorders listed above. 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. These hypotheses might take into consideration:

• Mood/emotional state: The patient's mood, anhedonia, and hopelessness may impact his adherence to medical treatment, which we could further assess.
• Psychological or physiological effects: The ongoing psychological or physiological effects of the patient's CABG may make it difficult for him to exercise (and therefore control his blood sugar).
• Treatment interactions: Treatment interactions might affect the patient's insulin resistance or response to medications.
• Cognition: The patient's cognition may be affected on some level, contributing to his inability to remember to take his medications.

Hypotheses: mezzo- and macro-level contributors

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.

• Job loss:
  • The patient may have some financial strain as a result of his recent job loss; he may also have lost his insurance coverage. Both these factors could make affording medications or visits with providers unfeasible.
  • Another consideration might be that his job loss occurred in the setting of a worsening economy.
  • We could also hypothesize that his job loss was the result of deteriorating interpersonal relations, which in turn damaged his perception of his self-importance and self-worth.
  • We may also consider that losing his job means that he has lost a significant portion of his social support network. 
• Living alone: 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: This factor 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 well as his diet.
• Other contributors: 
  • These 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 and theories of development proposed by Erikson, Piaget, and Kohlberg. These theories can be instrumental in understanding an individual's overall development and any aspects of their presentation associated with an incomplete transition through stages of development.

Erikson's Stages of Psychosocial Development

This theory describes stages of development that range from infancy to old age, with a total of 8 stages.[11] Each stage describes a significant developmental period, where adequate adaptation, support, and development can lead to more fulfilling lives. 

Stage 1: Trust versus 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 versus shame and doubt

• Early childhood: Ages 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 versus guilt

• Preschool age: Ages ~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 their way of interacting as a nuisance.

Stage 4: Industry versus inferiority

• School-age: Ages 5 to ~12 years
• Development of self-esteem through social interactions and peer groups; feelings of pride and accomplishment during a time of increasing demands from academic and social situations
• Disruptions during this time can lead to feelings of failure and inferiority, especially compared to peers.

Stage 5: Identity versus confusion

• Adolescence: Ages 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 versus isolation

• Young adulthood: Ages 18 to 40 years
• Development of secure and enduring intimate relationships with others that are meaningful and lasting
• Disruptions during this stage result in a sense of isolation and loneliness.

Stage 7: Generativity versus stagnation

• Adulthood: Ages 40 to 65 years
• Development of feeling of accomplishment, contributions to society, to children, and the world
• Disruptions during this stage lead to feelings of disillusionment, distance, and stagnation.

Stage 8: Integrity versus Despair

• Old age: Age 65 and older
• Development of an understanding of one's life and a review of one's accomplishments; feeling integrity and coherence about one's self, which leads to wisdom
• Disruptions during this stage can lead to feelings of despair and regret.

Piaget's Stages of Cognitive Development

This model describes 4 stages of childhood cognitive development.[12][13] 

Sensorimotor period

• Ages: 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 (eg, parent or toy) despite not being able to sense it immediately.

Preoperational period 

• Ages: 2 to 7 years
• A semiotic function is developed during this stage, which is the development of the symbolic representation of thoughts, memories, events, and imaginative thought.
• This period represents the beginning of the assimilation of ideas and thoughts, in addition to describing and identifying these ideas.

Concrete operational period

• Ages: 7 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).

Formal operational period

• Ages: 12 until adulthood
• The 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, isolating variables, and examining combinations.

Piaget also commented on "moral development," describing 2 stages: heteronomy and autonomy.

Heteronomy

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).

Autonomy

During play, children develop an understanding of "moral relativism," where morality can be considered more about 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.

Kohlberg's Stages of Moral Development

The Kohlberg theory expounded on the concept of morality development. It describes 3 stages (with 6 substages) of the development of morals and considers that the development of morality takes longer.[14]

Preconventional morality

• Ages: Birth to 9 years
• 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

• Ages: Adolescence 
• 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

• Ages: 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 theories describes the development of individuals as they progress through changing social environments. Patients presenting for assessment will have varying degrees of development or disruption in development at each stage, which can affect their behavior, interpersonal relationships, and approaches to prescribed treatments, among other things.

Traditional Disease and Medical Models

The disease and medical models also provide useful ways to approach patient care and contribute significantly to understanding patients. In this more traditional biomedical view, the process of identifying syndromes leads to the identification of diseases; pathophysiology, etiology, epidemiology, pathology, and other such concepts are then applied to develop an understanding of each disease. Through this developed understanding, the ability to diagnose and accurately treat patients is garnered.

The success of these models is evident in the modern-day practice of healthcare, in which most healthcare workers are familiar with and apply them. However, significant limitations of this approach include that it tends to neglect psychosocial components, or as HBSE describes, many other factors that contribute to a person's development and situation. Accordingly, these additional factors can contribute to the precipitation and perpetuation of disease in patients.[15]

A More Dimensional Approach

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 of 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. This model also allows a more effective understanding of the evolution of disorders in mental health, as individuals 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 diagnosing medical illness, especially in conditions where cutoffs or ranges of normality may have an arbitrary or uncertain origin.

The Transtheoretical Model

Another clinically relevant model is the transtheoretical model.[17][18] This model consists of 5 stages of change, along with termination.

Precontemplation

• The individual will not take action in the foreseeable future (ie, within the next 6 months).
  • This decision may be related to being misinformed, uninformed, or demoralized.

Contemplation

• The individual is planning to change in the foreseeable future.
• Awareness of the pros and cons of change.
• Some individuals can become stuck in this stage.

Preparation

• The individual acknowledges the behavior will need to change and commits to doing so.
  • Often, the individual plans to do so in the immediate future (ie, within the next month).
  • A plan of action accompanies the decision.

Action

• The individual has made specific changes in their lives within the past 6 months.
• Confidence is built during this stage.

Maintenance

• The individual continues the behavior and system changes for more than 6 months.
• Skills are developed to anticipate triggers and maintain awareness of thoughts to return to previous habits.

Termination

• Termination is defined as individuals with "zero temptation and 100% self-efficacy."
  • This is often omitted as a stage, as it is very difficult to achieve.
  • Maintenance may be a more realistic lifetime goal.

An individual may move through each stage in sequence or exit and re-enter at any stage. The transtheoretical model can be best understood using the person-in-environment concept, as the individual's progression through each stage often depends on their social and physical environments.[19] 

For example, a person with alcohol-use disorder in the precontemplation stage may feel reluctant to pursue behavior changes as they find familiarity in their surroundings, including the people they drink with or the places they may frequent for a drink. These aspects of their life may contribute to a lack of awareness of a particular issue. In this way, facilitating change can often require the clinician to understand the individual's social environment in addition to their stage of change. Understanding the social environment can help the clinician facilitate progress through stages of change. For example, the client may need to give up or replace various aspects of their lives with new ones, such as a sober living environment and a sober social group.

Operant and Classical Conditioning Models 

Finally, operant and classical conditioning models can be considered in the social environment context. B.F. Skinner defined operant behavior as behavior "controlled by its consequences."[20] Classical conditioning is a similar phenomenon characterized by an individual developing a response to a stimulus, wherein this stimulus previously did not elicit a response.[21][22][23]

Operant conditioning 

Operant conditioning can be organized as follows:

• Positive ("good") intervention: Refers to something given to the individual.
• Negative ("bad") intervention: Refers to something taken away.  
• Reinforcement: Refers to an increase in behavior as a result of the intervention.
• Punishment: Refers to a decrease in behavior.

Classical conditioning

Classical conditioning can be organized in the following way:

• Unconditioned stimulus: Stimulus that elicits a preexisting response from the individual
  • This response is not dependent on previous experience or learning and does not go away with time
• Unconditioned response: Response from the individual to the unconditioned stimulus
• Neutral stimulus: Stimulus that does not elicit a response before training

When the neutral stimulus is provided at the same time as the unconditioned stimulus, over time, the individual will begin to develop the same response to the neutral stimulus as they have to the unconditioned stimulus. In other words, the neutral stimulus begins to elicit a conditioned response, and the neutral stimulus is now referred to as a conditioned stimulus. The conditioned response is the same behavior as the unconditioned response, except that the conditioned response is susceptible to extinction. Extinction refers to a loss of the conditioned response without frequent reinforcement of the response.

Classical conditioning was described concurrently by Edwin Twitmyer in his doctoral thesis in 1902 and by Ivan Pavlov's publication in 1903. Ivan Pavlov described the phenomenon in dogs, where dogs were trained to salivate at the ring of a bell. In this case, the bell was the neutral stimulus and was associated with the introduction of food, which was the unconditioned stimulus. The unconditioned response of salivation at the sight of food was then developed into a conditioned response, wherein the dogs salivated (conditioned response) at the ring of the bell (now the conditioned stimulus instead of a neutral stimulus).[23] Twitmyer demonstrated that classical conditioning is also present in humans, where a bell could be associated with a reflex hammer and elicit the knee-jerk reflex in much the same way as the reflex hammer. In this case, the bell became the conditioned stimulus and elicited the conditioned response of the knee jerk.[21]

The Learning Process

Operant and classical conditioning provide a behavioral understanding of the learning process, which can be relevant when considering the above HBSE theories. Initially, learning primarily occurs within the microsystem, where the individual's learning is most immediately influenced by the most proximal relationships, experiences, and places. These may include close family members, such as siblings, parents, and grandparents; school, teachers, and classmates; and games, television, and social media.[24] For example, individuals can develop an understanding of interpersonal relationships through these proximal components of their microsystem, which can subsequently influence how the individual interacts with larger systems later in life.

From an operant perspective, individuals who experience positive, trusting relationships early on may be positively reinforced to continue interacting with others and develop additional relationships outside their immediate circles. Those who experience negative, hurtful relationships may experience positive punishment with interpersonal relationships, and therefore, these individuals may reduce how often they explore new relationships. Over time, as the individual's awareness of larger systems develops, these early experiences can influence their willingness and ability to interact with and understand these larger systems, influencing change when possible. For example, those positively reinforced by interpersonal relationships may develop relationships that later allow them to work together and influence change on a larger systems level. In addition to the concept of interpersonal relationships, operant and classical conditioning have been explored in pain modulation, fatigue, and placebo effects.[25][26][27][28]

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 the pressures it places on individual providers, each provider might consider focusing on addressing one aspect of the individual's care while maintaining an understanding of the more significant contributors to the patient's presentation. Of primary importance is assessing and evaluating a trained social worker who can identify factors hindering patient care and outline the patient's expectations from treatment in depth. Communicating these factors to the trained specialty nurse can help educate patients and improve compliance with care. Identifying detrimental factors and adverse reactions and notifying the clinicians of these findings can help improve clinical outcomes and prevent complications. Electronic medical records could assist with this by computer-assisted identification of significant 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 system are achievable. The Canadian Institutes of Health Research identified 10 principles for healthcare integration to occur successfully, including "Standardized Care Delivery through Interprofessional Teams."[29] One identified factor 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, an emphasis on well-being and health promotion was recognized, which can be facilitated by understanding HBSE. 

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 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 patients' 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, including physicians, advanced practice providers, social workers, case managers, pharmacists, nurses, therapists, and all other clinicians 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.