Lecture 1 Introduction PDF

Medizinische Fakultät PBM-4.1. Social and Behavioral Medicine Lecture 1: Introduction Summer Term 2024 Viktoria Feit M.Sc. & Carolin Walter M.Sc. Outline PART I: Organization PART II: Introduction to social and behavioral me...

Medizinische Fakultät PBM-4.1. Social and Behavioral Medicine Lecture 1: Introduction Summer Term 2024 Viktoria Feit M.Sc. & Carolin Walter M.Sc. Outline PART I: Organization PART II: Introduction to social and behavioral medicine 1. Introduction 2. Behavioral medicine 3. Social medicine 4. The biopsychosocial model of health 5. References | 2 PART I: Organization | 3 Content and objectives of the module content fundamental concepts of social and behavioral sciences the biopsychosocial health model standards of living nutrition in social and behavioral medicine and application of this knowledge socio-economic determinants of health: income, labor, education, family determinants of behavior behavioral modification social settings and public health interventions | 4 Content and objectives of the module objectives understand the role of social and behavioral phenomena in population health describe the relationships between the social and demographic structure and population health apply the knowledge of social and behavioral medicine to develop tailored health program | 5 Requirements for obtaining credits (Studienleistung) coursework will be introduced in week 5, session 05 Behavioral modification brief outlook − group work: 2-3 students each − topic: “Develop and present a tailored behavioral health program targeting a specific health issue within a chosen community” − duration of presentations: 10-15 min − discussions | 6 Examination Credits (Prüfungsleistung) Module Biopsychosocial Medicine form of exam: written exam, multiple-choice questions duration: 90 min date of exam: 09.08.24 | 7 Semester overview PBM-4.1 Social and Behavioral Medicine Semester Date Topic week 1 17.04.24 Introduction to Biopsychosocial Medicine 2 24.04.24 Social and behavioral determinants of health 3 01.05.24 Tag der Arbeit (Labor Day) 4 08.05.24 Individual factors influencing behavior 5 15.05.24 Behavioral modification (+ introduction to the coursework) 6 22.05.24 Pfingstpause (Pentecost) 7 29.05.24 Implementation of a prevention program 8 05.06.24 Behavioral Medicine 9 12.06.24 Basics of nutrition in social and behavioral medicine 10 19.06.24 Assignment presentation and discussion 11 26.06.24 Nursing, what it is and what it isn’t 12 03.07.24 Complementary Medicine 13 10.07.24 Health care during the childbearing continuum 14 17.07.24 Applying nutritional knowledge in social and behavioral medicine 15 24.07.24 Revision 16 09.08.24 Exam Legend: gold, guest lectures; grey, public holidays | 8 ILIAS | 9 How should you contact us? Carolin Walter [email protected] Viktoria Feit [email protected] | 10 PART II: Introduction to social and behavioral medicine | 11 1. The biomedical perspective | 12 Biomedical model of disease dominant model in current medical (and healthcare) theory and practice based on the following assumptions: (1) Every disease has a specific cause. (2) Every disease is characterized by some basic damage. (3) Diseases have typical external signs (symptoms) and can therefore be recognized by scientifically trained personnel (doctors). (4) Diseases have a describable and predictable course; they get worse without medical intervention. Trabert and Waller, 2023. | 13 Biomedical model of disease (1) Every disease has a specific cause. chemical physical (e.g., asbestos, (e.g., radiation, benzene) heat) microorganisms biochemical effects (viruses, bacteria, etc.) (e.g., insulin deficiency) mechanical genetic changes disease effects (e.g., accidents) Trabert and Waller, 2023. | 14 Biomedical model of disease (2) Every disease is characterized by some basic damage (either localized in the cell, in the tissue, or consists of a malfunction in the control of mechanical or biochemical processes) Trabert and Waller, 2023; Karaca, Magnan, and Kargar, 2009. | 15 Biomedical model of disease (3) Diseases have typical external signs (symptoms) and can therefore be recognized by scientifically trained personnel (doctors) example: symptoms of type 2 diabetes mellitus: unexplained frequent irritability dry mouth weight loss fatigue pain, burning repeated decreased and numbness itching infections vision of feet acanthosis nigricans (dark, velvety patches in body folds) Trabert and Waller, 2023. | 16 Biomedical model of disease (4) Diseases have a describable and predictable course; they get worse without medical intervention. major microvascular and macrovascular complications associated with diabetes mellitus Trabert and Waller, 2023; Aramabašić et al., 2021. | 17 Biomedical model of disease dominant model in current medical (and healthcare) theory and practice based on the following assumptions: (1) Every disease has a specific cause. (2) Every disease is characterized by some basic damage (either localized in the cell, in the tissue, or consists of a malfunction in the control of mechanical or biochemical processes) (3) Diseases have typical external signs (symptoms) and can therefore be recognized by scientifically trained personnel (doctors). (4) Diseases have a describable and predictable course; they get worse without medical intervention. What are limitations of this model? Trabert and Waller, 2023. | 18 Limitations/criticism of the biomedical model of disease one-sided biological approach; can only capture a part of the causes of disease individualized approach and a curative orientation; preventive and rehabilitative measures are underdeveloped stabilizes the dominance of doctors in the health system and leads to the medicalization* of society (Ivan Illich) limited effectiveness in treating disease; example: tuberculosis (Thomas McKeown) *”process by which nonmedical problems become defined and treated as medical problems often requiring medical treatment.” Trabert and Waller, 2023.; Conrad and Bergey, 2015. | 19  Tuberculosis = infection caused by Mycobacterium tuberculosis Example: the decline of tuberculosis in industrialized countries medical etiology medical medical therapy prevention Decline in tuberculosis mortality - mean annual death rates for England and Wales, standardized to the population of 1901; BSG, Bacillus Calmette–Guérin Lettow and Whalen, 2008; Trabert and Waller, 2023. | 20 Example: the decline of tuberculosis in industrialized countries thesis of Thomas McKeown (1912– 1988): “[…] decline in tuberculosis mortality was largely the result of improvements in standards of living and nutrition rather than advances in medicine, such as antibiotics” Source: Lettow and Whalen, 2008; Trabert and Waller, 2023. | 21 Do we need social and behavioral medicine? goals: disease prevention effective rehabilitation key considerations: comprehensive broader determinants of management of chronic health conditions Medicine is more impact of societal than bio-medicine! structures importance of lifestyle choices influence of psychological factors Trabert and Waller, 2023. | 22 Significance of social and behavioral medicine 1st example life expectancy in the U.S. at age 25, by education and gender, 2006 → higher educational attainment is associated with higher life expectancy for both men and women Braveman and Gottlieb, 2014. | 23 Significance of social and behavioral medicine 2nd example aim: Categorize adult heart health risk by social/health factors; examine the relationship with undiagnosed diabetes/pre-diabetes across races/ethnicities method: − analyzed data from 38,476 US adults in NHANES 1999-2018 with no prior diabetes diagnosis − utilized clustering algorithms for subgroup identification based on social/health factors − employed logistic regression to determine associations Ding et al., 2023. | 24 Significance of social and behavioral medicine 2nd example results: − identified three subgroups with distinct characteristics: 1. cluster: middle-aged, unhealthy lifestyle habits 2. cluster: young, non-white, financially disadvantaged 3. cluster: older, inactive males with healthcare access − highest undiagnosed diabetes risk in Cluster 3, followed by Clusters 1 and 2 − pre-diabetes risk was higher in Cluster 1 and 3; race/ethnicity impacted pre-diabetes risk across clusters Ding et al., 2023. | 25 Significance of social and behavioral medicine 2nd example conclusion: − grouping based on self-reported behavior and metabolic factors reveals distinct risk profiles − tailored screening and prevention strategies can be informed by subgroup classifications Ding et al., 2023. | 26 Significance of social and behavioral medicine 3rd example aim: investigate potential mediators like health habits, obesity, medication, and comorbidity between psychiatric disorders and type 2 diabetes risk methods: − data combination from a large population-based survey with register-based data − follow-up of a sample of 250,013 Danes (≥16 years) for up to 8.9 years − mediation analyses of associations between psychiatric disorders and incident T2D Lindekilde et al., 2023. | 27  Significance of social and behavioral medicine 3rd example = variables that explain a part of the variability in the outcome = “intervening variables that lie along the causal pathway between the intervention and the results: outcome of interest” − substance use disorder, (13-32 %) − schizophrenia, − mood disorder, − neurotic disorder, − eating disorder, … significantly − personality associated with T2D disorder … Lindekilde et al., 2023; Field-Fote, 2019. | 28 Significance of social and behavioral medicine Some other studies … Pantell et al., 2019; Liu et al., 2023. | 29 2. Behavioral medicine | 30 What is behavioral medicine? Behavioral medicine is an interdisciplinary field that studies the interplay among psychosocial, biological, and behavior pathways on the natural progression of disease.“ Jiménez and Mills, 2012. | 31 Overlaps between psychological and other disciplines in behavioral medicine no clear lines between disciplines and sub-disciplines → merge into each other Example: behavioral medicine focuses on integrating multiple disciplines to improve health at the population level health psychology concentrates on individual psychological influences on health and disease Johnston and Johnston, 2017; Smith, 2020. | 32 Typical research questions in behavioral medicine What factors What What types of How can we influence behaviors interventions get people to adherence to increase the work to live healthier treatment risk of reduce the lives with protocols in developing risk of health- positive patients with certain damaging habits? chronic diseases? behaviors? diseases? | 33  Exposome = “totality of environmental drivers of disease that an individual experiences over the course of their life” Behavioral medicine Example: type 2 diabetes − environmental factors and their potential impact on the risk of type 2 diabetes Beulens et al., 2022. | 34 3. Social medicine | 35 What is social medicine? Origin often traced back to 19th century German physician Rudolf Virchow: He wanted physicians to not only focus on individual factors but look at the social contexts of health and disease Social medicine considers the practice of medicine to be inextricably linked to the social and cultural environment the patient lives in and wherein also the diagnosis and treatment take place Rudolf Carl Virchow, MD, as a young man Virchow RC, 1848 | 36  Social determinants of health WHO: “The social determinants of health (SDH) are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age and the wider set of forces and systems shaping the conditions of daily life” World Health Organization, 2024a | 37 Social determinants of health Can you think of some examples for SDH? − income and social protection − education − unemployment, job security, work life conditions − food insecurity − housing, basic amenities and the environment − early childhood development − social inclusion and non-discrimination − structural conflict − access to affordable health services of decent quality − access and connectivity to digital technologies − … | 38 Determinants of health Team of researchers and designers at GoInvo: looked at different organizations like WHO, Institute of medicine or Healthy People → categories of determinants of health: Individual behavior Social circumstances Genetics & Biology Medical Care Environment → Compared and averaged available data about the impact of these determinants on health outcomes (data from 1980-2010) For those interested: https://www.goinvo.com/vision/determinants-of-health/ Choi, Edwin, and Juhan Sonin, 2019 | 39 Determinants of health Choi, Edwin, and Juhan Sonin, 2019 | 40 Determinants of health z Choi, Edwin, and Juhan Sonin, 2019 | 41 Determinants of health ~89% of health outcomes are a results of factors other than medial care z Choi, Edwin, and Juhan Sonin, 2019 | 42 Determinants of health Choi, Edwin, and Juhan Sonin, 2019 | 43  Health inequalities WHO: „Health inequities or inequalities are avoidable inequalities in health between groups of people within countries and between countries. These inequities arise from inequalities within and between societies.” World Health Organization, 2024b | 44 Global inequity in diabetes The Lancet, 2023a; The Lancet, 2023b | 45 Global inequity in diabetes In 2021, type 2 diabetes accounted for 96% of all diabetes prevalence Due to rising prevalence of obesity & demographic shifts The Lancet, 2023a; The Lancet, 2023b | 46 Global inequity in diabetes The Lancet, 2023a; The Lancet, 2023b | 47  DALYs DALY disability affected life year infographic.png, 2024 | 48 Global inequity in diabetes Currently, only 10% of diabetics from LMIC receive guideline-based diabetes care In 2021, type typ 22diabetes diabetesaccounted accountedfor for 90% of all diabetes prevalence 96% Rising prevalence of obesity & demographic shifts → increase in type 2 diabetes The Lancet, 2023a; The Lancet, 2023b | 49 Global inequity in diabetes Proximate social determinants of health: High BMI Tobacco Use Alcohol Use Dietary risks Lack of physical activity Environmental and occupational risks The correlation between risk factors and diabetes outcomes varies depending on the global region! The Lancet, 2023a; The Lancet, 2023b | 50 Correlation between HDI and diabetes prevalence depending on country’s development status 45 national surveys (24 – developing, 21 – developed) from 32 countries r = −0.442 p = 0.045 r = 0.421 p = 0.041 HDI: Human Development Index (0-1) Xu, Yu, Yin Zheng & Li, 2017 | 51 Correlation between HDI and diabetes prevalence depending on country’s development status 45 national surveys (24 – developing, 21 – developed) from 32 countries Limitations: r = −0.442 p = 0.045 r = 0.421 p = 0.041 Unclear HDI sorting of developed & developing countries, was that decided before they looked at the data? No studies from South America, few from Africa No other measures of socio-economic status considered HDI: Human Development Index (0-1) Xu, Yu, Yin Zheng & Li, 2017 | 52 From Societal Inequality to Health Outcomes Interesting resources to investigate different kinds of inequalities: − WHO inequality monitor: https://www.who.int/data/inequality-monitor/publications − Global Health Observatory: https://www.who.int/data/gho − WHO HEAT Tool: https://whoequity.shinyapps.io/heat/ − Homework till next class: Use either of these tools to look up a specific case of health inequality within a country or between two countries that you find particularly interesting. Do a brief online research about it and take some notes. During the next class you‘ll give a brief presentation to your neighbor and discuss it. | 53 4. The biopsychosocial model | 54 The biopsychosocial model of health first developed by George Engel in 1977 following world war II “Illness and health are the result of an interaction between biological, psychological and social factors” Kusnanto, Agustian, and Hilmanto, 2018 | 55 Biopsychosocial model of health and disease What are biological factors affecting health? Naughton, 2018 | 56 Biopsychosocial model of health and disease What are biological factors affecting health? Naughton, 2018 | 57 Biopsychosocial model of health and disease What are psychological factors affecting health? Naughton, 2018 | 58 Biopsychosocial model of health and disease What are psychological factors affecting health? Naughton, 2018 | 59 Biopsychosocial model of health and disease What are social factors affecting health? Naughton, 2018 | 60 Biopsychosocial model of health and disease What are social factors affecting health? Naughton, 2018 | 61 Biopsychosocial model of health and disease Family Relationships Trauma divided intersections health as common intersection Naughton, 2018 | 62 Examples for application of the biopsychosocial model in public health and clinical settings (1) rehabilitation services and chronic pain management: “Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain” (2) disease prevention and health promotion (3) mental health disorders (4) geriatric care Kamper et al., 2015; Schüz, 2021 | 63 However … there seems to be a slow progress of the biopsychological model of health and disease “Biopsychosocial model is neglected or inadequately applied in clinical practice, especially the sociocultural factors.” → Why do you think it might be hard to implement such a model into clinical and public health practice? … Kusnanto, Agustian, and Hilmanto, 2018 | 64 Challenges of Implementing the biopsychosocial model into clinical practice complexity practicality for resource training and and time certain intensiveness education consumption conditions evaluation and systemic and measurement institutional challenges barriers requiring significant effort from physicians who are already burdened with clinical duties, administrative work, and possibly research activities. … Kusnanto, Agustian, and Hilmanto, 2018 | 65  Reminder ☺ From Societal Inequalitities to Health Outcomes Interesting resources to investigate different kinds of inequalities: WHO HEAT Tool: https://whoequity.shinyapps.io/heat/ WHO inequality monitor: https://www.who.int/data/inequality- monitor/publications Global Health Observatory: https://www.who.int/data/gho Homework till next class: Use either of these tools to look up a specific case of health inequality within a country or between two countries that you find particularly interesting. Do a brief online research about it and take some notes. During the next class you‘ll give a brief presentation to your neighbor and discuss it. | 66 5. References Aramabašić Jovanović J, Mihailović M, Uskoković A, Grdović N, Dinić S, Vidaković M. The Effects of Major Mushroom Bioactive Compounds on Mechanisms That Control Blood Glucose Level. J Fungi (Basel). 2021;7(1):58. Published 2021 Jan 16. doi:10.3390/jof7010058 Beulens JWJ, Pinho MGM, Abreu TC, et al. Environmental risk factors of type 2 diabetes-an exposome approach. Diabetologia. 2022;65(2):263-274. doi:10.1007/s00125-021-05618-w Braveman P, Gottlieb L. The social determinants of health: it's time to consider the causes of the causes. Public Health Rep. 2014;129 Suppl 2(Suppl 2):19-31. doi:10.1177/00333549141291S206 Choi, Edwin, and Juhan Sonin. 2019. “Determinants of Health.” GoInvo. https://www.goinvo.com/vision/determinants-of-health/. Conrad P, Bergey M. Medicalization: Sociological and Anthropological Perspectives. In: International Encyclopedia of the Social & Behavioral Sciences. [Online]. Elsevier Ltd. 2015; pp. 105–109. DALY disability affected life year infographic.png. (2024, March 5). Wikimedia Commons. Retrieved 08:12, April 16, 2024 from https://commons.wikimedia.org/w/index.php?title=File:DALY_disability_affected_life_year_infographic.png& oldid=858190790. Ding Q, Lu Y, Herrin J, Zhang T, Marrero DG. Uncovering heterogeneous cardiometabolic risk profiles in US adults: the role of social and behavioral determinants of health. BMJ Open Diabetes Res Care. 2023;11(5):e003558. doi:10.1136/bmjdrc-2023-003558 | 67 5. References Field-Fote EE. Mediators and Moderators, Confounders and Covariates: Exploring the Variables That Illuminate or Obscure the "Active Ingredients" in Neurorehabilitation. J Neurol Phys Ther. 2019;43(2):83-84. doi:10.1097/NPT.0000000000000275 Jiménez JA, Mills PJ. Behavioral Medicine. Encyclopedia of Human Behavior. 2nd edition. Academic Press; 2012: 311-318. https://doi.org/10.1016/B978-0-12-375000-6.00057-4. Johnston M, Johnston D. What Is Behavioural Medicine? Commentary on Definition Proposed by Dekker, Stauder and Penedo. Int J Behav Med. 2017;24(1):8-11. doi:10.1007/s12529-016-9611-6; Smith, 2020. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ. 2015;350:h444. Published 2015 Feb 18. doi:10.1136/bmj.h444 Karaca M, Magnan C, Kargar C. Functional pancreatic beta-cell mass: involvement in type 2 diabetes and therapeutic intervention. Diabetes Metab. 2009;35(2):77-84. doi:10.1016/j.diabet.2008.09.007 Kusnanto H, Agustian D, Hilmanto D. Biopsychosocial model of illnesses in primary care: A hermeneutic literature review. J Family Med Prim Care. 2018;7(3):497-500. doi:10.4103/jfmpc.jfmpc_145_17; Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129-136. doi:10.1126/science.847460 Lindekilde N, Diaz LJ, Lasgaard M, et al. Elevated risk of developing type 2 diabetes in people with a psychiatric disorder: What is the role of health behaviors and psychotropic medication?. J Diabetes Complications. 2023;37(11):108591. doi:10.1016/j.jdiacomp.2023.108591 | 68 5. References Naughton CA. Patient-Centered Communication. Pharmacy (Basel). 2018;6(1):18. Published 2018 Feb 13. doi:10.3390/pharmacy6010018 Pantell MS, Prather AA, Downing JM, Gordon NP, Adler NE. Association of Social and Behavioral Risk Factors With Earlier Onset of Adult Hypertension and Diabetes. JAMA Netw Open. 2019;2(5):e193933. Published 2019 May 3. doi:10.1001/jamanetworkopen.2019.3933 Schüz B. Psychologie und Public Health. In: Schmidt-Semisch H, Schorb F eds. Public Health. 2021; https://doi.org/10.1007/978-3-658-30377-8. Smith TW. Health psychology and behavioral medicine: Methodological issues in the study of psychosocial influences on disease. In A. G. C. Wright & M. N. Hallquist (Eds.), The Cambridge handbook of research methods in clinical psychology (pp. 287–298). Cambridge University Press. 2020. https://doi.org/10.1017/9781316995808.027 The Lancet. Global inequity in diabetes. 2023. Accessed April 5, 2024 from https://www.thelancet.com/infographics-do/global-inequity-diabetes-2023 The Lancet. Diabetes: a defining disease of the 21st century. Lancet. 2023;401(10394):2087. doi:10.1016/S0140-6736(23)01296-5 Trabert G, Waller H. Sozialmedizin. Grundlagen und Praxis. 8th ed. Kohlhammer; 2023. van Lettow M, Whalen C. Tuberculosis. In: Semba RD, Bloem MW, Piot P. (eds) Nutrition and Health in Developing Countries. Nutrition and Health Series. Humana Press. 2008. https://doi.org/10.1007/978-1- 59745-464-3_10 | 69 5. References Virchow RC. Report on the typhus epidemic in Upper Silesia. 1848. Am J Public Health. 2006;96(12):2102- 2105. doi:10.2105/ajph.96.12.2102 Walker AF, Graham S, Maple-Brown L, et al. Interventions to address global inequity in diabetes: international progress. Lancet. 2023;402(10397):250-264. doi:10.1016/S0140-6736(23)00914-5 World Health Organization. "Social determinants of health." Retrieved April 5, 2024, from https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 World Health Organization. "Social determinants of health: Key concepts." Retrieved April 5, 2024, from https://www.who.int/news-room/questions-and-answers/item/social-determinants-of-health-key-concepts Xu Z, Yu D, Yin X, Zheng F, Li H. Socioeconomic status is associated with global diabetes prevalence. Oncotarget. 2017;8(27):44434. | 70