Psychosocial Behavioral Intervention
A psychosocial behavioral intervention has been defined as “any intervention that emphasizes psychological or social factors rather than biological factors” (Ruddy and House 2005). It refers to an intervention that addresses the psychological and social determinants of health behavior(s). Core to a psychosocial behavioral intervention is the fact that it incorporates psychosocial intervention strategies aimed at influencing a person’s behavior(s) in order to improve their health and well-being. Such interventions can be delivered in different ways, e.g., in groups or individually, as well as through organizations and/or via other settings in the community.
Health behavior refers to a person’s beliefs and actions regarding their health and well-being. They are shaped by individuals’ choices and external constraints and are influenced by social, cultural, and physical environments in which people live and work. Health behaviors are very important for maintaining a healthy lifestyle, and typically, they are early indicators of population health. Positive health behaviors help promote health and prevent disease.
Behavior change refers to efforts to change people’s personal habits to prevent disease and/or to improve the health and well-being of populations (WHO 2002). Behavior change programs typically focus on actions or strategies that address modifiable determinants of behaviors.
A psychosocial intervention for older adults can address both health-related behaviors and those determinants that can influence quality of life and social and mental health such as loneliness, social isolation, and social or family problems (Forsman et al. 2001).
Behavior is central to the development, prevention, treatment, and management of the preventable manifestations of diseases and health conditions (heart disease, cancer, stroke, chronic obstructive pulmonary diseases, unintentional injuries, pneumonia and influenza, diabetes, suicide, kidney diseases, chronic liver disease, and cirrhosis). Behavioral interventions can be effectively used to prevent disease, improve management of existing disease, and increase quality of life and even reduce healthcare costs (Fisher et al. 2011).
Recent research on psychosocial behavioral interventions for older adults have had two major focuses. The first is a focus on theory-based interventions for unhealthy behaviors, which are high-risk factors related to chronic diseases, such as smoking, unhealthy diet, physical inactivity, and alcohol consumption. For these, intervention programs typically apply health behavior theories or models to guide planning, implementation, and evaluation (Chase 2013). The second focus has emphasized cognitive behavioral strategies to address psychological factors, such as anxiety and depression. Intervention programs mostly utilize cognitive behavioral strategies to intervene older adults for improving mental conditions. Examples include motivational interviewing, patient health education, barrier identification and management, and decisional balance activities (Conn et al. 2002). However, chronic illnesses are frequently associated with mental conditions, especially for older adults. Thus, cost-effective interventions need to combine theory-based behavior change techniques with cognitive behavioral strategies to maximize positive outcomes.
The socio-ecological model is an important framework for understanding and guiding the development of multilevel strategies for addressing health behaviors and their determinants (Glanz and Rimer 2012). It aids understanding of the multiple determinants of health-related behaviors, which typically refer to intrapersonal- or individual-, interpersonal-, institutional-, community-, and policy-level factors.
Intrapersonal/individual factors , which influence behavior such as knowledge, attitudes, beliefs, self-efficacy, and personality.
Interpersonal factors , which influence behavior by interactions with other people such as families, friends, and peers that provide social identity, support, and role definition.
Institutional and organizational factors , which include the rules, regulations, policies, and informal structures that constrain or promote healthy behaviors.
Community factors , such as formal or informal social norms that exist among individuals, groups, or organizations, can limit or enhance healthy behaviors.
Public policy factors , including local, state, and federal policies and laws that regulate or support health actions and practices for disease prevention, early detection, control, and management.
Health behavior theories or models play a critical role during the design of intervention program and can be applied to target different factors. Healthcare professionals can use theories at an individual, interpersonal, or community level to design comprehensive intervention programs. Examples of theories that focus on individual, interpersonal, and community levels are listed below.
Health Belief Model (HBM): This psychological model provides an explanation and prediction of health behaviors through a focus on the attitudes and beliefs of individuals (Janz and Becker 2016). This model explains the relationships between people’s beliefs about whether or not they are susceptible to disease and their perceptions of the benefits of trying to avoid it, with their readiness to take some action to reduce their “risk.” Factors: perceived susceptibility/severity/benefits/barriers, readiness to act, cues to action, and self-efficacy.
Protection Motivation Theory (PMT): This theory focuses on understanding the fear appeal that mediates behavior change and describes how threat/coping appraisal is related to how adaptive or maladaptive when coping with a health threat (Rogers 1975). Factors: perceived severity, vulnerability, and response efficacy.
Trans-theoretical Model (TTM): This theory uses “stages of change” to describe individuals’ motivation and readiness to change a behavior. The model construes behavior change as an intentional process that unfolds over time and involves progress through a series of five stages of change. As a person attempts to change a behavior, they move through five stages: precontemplation, contemplation, preparation, action, and maintenance (Prochaska and Velicer 1997).
Theory of Planned Behavior (TPB): This theory aims to predict the specific plan of an individual to engage in a behavior; it examines the relationship between an individual’s beliefs, attitudes, intentions, and perceived control over that behavior (Ajzen 1991).
Social Cognitive Theory (SCT): This theory explains behavioral learning through observation and social contexts and is centered on the belief that behavior is influenced by the context of the environment through psychological processes (Bandura 2008). Factors: self-efficacy, knowledge, behavioral capability, goal setting, outcome expectations, observational learning, reciprocal determinism, reinforcement.
Social Support Theory (SST): Social support is the perception and actuality that one is cared for, has assistance available from other people, and, most popularly, is part of a supportive social network. These supportive resources can be emotional, informational, or companionship, tangible or intangible (Vaux 1988). Social support has been linked to many benefits for both physical and mental health.
Community Organization : This theory entails community-driven approaches to assessing and solving health and social problems. Factors: empowerment, community capacity, participation, relevance, issue selection, and critical consciousness.
Diffusion of Innovation (DOI): This theory seeks to explain how, why, and at what rate new ideas, behaviors, and products are communicated and spread throughout group and community. There are five established adopter categories: innovators, early adopters, early majority, later majority, Laggards (Rogers 2003). Factors: relative advantage, compatibility, complexity, trial-ability, and observability.
Key Research Findings
An increasing number of studies have examined the effectiveness of interventions addressing psychosocial factors, including studies addressing lifestyle, chronic disease self-management, and psychological conditions in the aging population.
Aging is accompanied by declines in physical health, mental well-being, and functional ability (National Institute on Aging 2007; Smith et al. 2002). Fortunately, age-related declines can be delayed by engagement in a healthier lifestyle (Low and Molzahn 2007; Rowe and Kahn 1997; Hendricks and Hatch 2009). Lifestyle interventions offer potential for reducing such negative outcomes. Studies show that preventive lifestyle-based intervention for older adults can sustain and improve mental and physical well-being and cognitive function (Clark et al. 2012). For example, the Well Elderly Study was a randomized trial intervention in older adults that found significant health, function, and quality of life benefits (Clark et al. 1997).
Over the past decades, many physical activity interventions for older adults have been developed (Conn et al. 2003; King et al. 1998; Van der Bij et al. 2002). Recent synthesis reports have examined the effectiveness of physical activity interventions in older adult populations and found that these types of interventions can improve depressive symptoms and chronic illness (Conn et al. 2002). There are multiple effective behavior change techniques including supervised exercise sessions, self-monitoring, group support, and prompting within older adults (Chase 2013).
Aging also poses nutritional risks due to deterioration in health, cognition, and physical functioning (Morley 2012). Healthy diet interventions for older adults with chronic conditions have a significant impact on the morbidity and mortality of cardiovascular diseases (Xiao et al. 2018). For example, utilizing multicomponent telemonitoring intervention on behavioral determinants of nutrition in older adults in the Netherlands led to improvements in self-monitoring, goal setting, perceived behavioral control, knowledge for healthy eating, and attitude towards changing eating habits. Self-monitoring mediated the effect of the intervention on total diet quality score and compliance with the guidelines for the intake of fruit and saturated fatty acids. Knowledge mediated the effect of the intervention on compliance with the guidelines for the intake of protein (Van Doorn-van Atten et al. 2018).
Chronic Disease Self-Management Intervention
Multimorbidity, the association of chronic diseases with advancing age, is a common problem in elderly populations (CDC 2003), and self-management for chronic conditions is an essential role for preventing complication. Chronic disease self-management includes diet management, physical activity, medication adherence, and self-monitoring (of blood pressure, glucose). Research demonstrates that interventions focusing on self-management behaviors among older adults with chronic disease can reduce diabetes complications (Glasgow et al. 1992) as well as myocardial infarction, stroke, or death from cardiovascular disease (Nathan et al. 2005). For example, a community-based peer-led support program (PLSP) for older adults (mean age 64 years) with type 2 diabetes implemented in China aimed to improve self-management behaviors by addressing physical activity, healthy diet, blood sugar monitoring, and medication adherence. This intervention significantly increased knowledge about diabetes, self-efficacy, and perceived social support. These mediating factors further led to an increase in physical activity and medication adherence, as well as improvement in BMI, systolic blood pressure, diastolic blood pressure, and both fasting and 2-h postprandial blood glucose (Zhong et al. 2015).
Mental Health Intervention
Loneliness, social isolation, and social exclusion are important social determinants and risk factors of ill health among older people. They affect all aspects of health and well-being, including mental health (WHO 2018). Cognitive behavioral strategies have been used broadly with older adults. A systematic review shows that clinical studies have examined the efficacy of cognitive behavioral interventions in treating older adults for anxiety, depression, insomnia, and other disorders (Satre et al. 2006). In addition, community-based social support and social network interventions, which increased meaningful social events (e.g., group activities and peer support), had significant effect on life satisfaction and reduced depressive symptoms (Fisher et al. 2011). Maintenance of strong social relationships, through social network and social support intervention, has been linked to positive mental health and increased longevity in older adults (Satre et al. 2006). For example, frequent volunteering in American adults over 70 years was associated with reduced risk of dying regardless of physical health status (Harris and Thoresen 2005). Volunteering retirees from Singapore had significantly better cognitive performance scores, fewer depressive symptoms, and better perceived mental well-being and life satisfaction (Schwingel et al. 2009).
Future Directions of Research
There is still a lack of well-designed theory-based comprehensive interventions focusing on health and well-being for older adults. Such interventions need to take into account characteristics unique to older adults. Those include aspects of the social context, cognitive changes with aging, personality, and emotional development. Future research should emphasize interdisciplinary studies and focus on (1) the interrelationships between different psychosocial factors and behaviors specifically for older adults; (2) the mechanisms of mental, behavioral, and biological interactions; (3) the effect of psychosocial intervention on both physical and mental health outcomes; and (4) the application of effective intervention strategies implementation by using behavior theories/models and cognitive strategies.
Finally, telehealth and mobile health programs will also play an increasingly important role in psychosocial behavioral interventions in the future. The impact of digital technology in older adults needs to be investigated and evaluated more comprehensively. Specifically, the effectiveness of telehealth for both lifestyle and mental health interventions may be advantageous over traditional methods in terms of personalization, scalability, accessibility, and reduced costs (Celis et al. 2015).
Psychosocial behavioral interventions have an important role to play in promoting healthy aging by changing unhealthy behaviors, reducing stress exposure in later life, enhancing social supports and coping resources, and promoting the use of both preventive and corrective proactive adaptations. Furthermore, the interventions can also directly enhance psychological well-being, meaningfulness, and quality of life in late life among older adults.
Effective psychosocial behavior interventions help the aging population maintain and improve health, reduce disease risks, and manage chronic illness. They can improve the well-being and self-sufficiency of individuals, families, organizations, and communities.
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