Outlook: Newsletter of the Society of Behavorial Medicine

Summer 2019

New Articles from Annals of Behavioral Medicine and Translational Behavioral Medicine

SBM's two journals, Annals of Behavioral Medicine and Translational Behavioral Medicine: Practice, Policy, Research (TBM), continuously publish online articles, many of which become available before issues are printed. Three recently published Annals and TBM online articles are listed below.

SBM members who have paid their 2019 membership dues are able to access the full text of all Annals and TBM online articles via the SBM website by following the steps below.

  1. Go to the Members Only section of the SBM website.
  2. Log in with your username and password.
  3. Click on the Journals link.
  4. Click on the title of the journal which you would like to electronically access.

To check if you are a current SBM member, or if you are having trouble accessing the journals online, please contact the SBM national office at info@sbm.org or (414) 918-3156.

Annals of Behavioral Medicine

Americans’ Health Mindsets: Content, Cultural Patterning, and Associations With Physical and Mental Health

Alana L Conner, Danielle Z Boles, Hazel Rose Markus, Jennifer L Eberhardt, Alia J Crum

Health mindsets are mental frameworks that help people recognize, organize, interpret, and respond to health-relevant information. Although mindsets shape health behaviors and outcomes, no study has examined the health mindsets of ethnically and socioeconomically diverse Americans.
We explored the content, cultural patterning, and health correlates of diverse Americans’ health mindsets.
Two studies surveyed approximately equal numbers of African American, Asian American, European American, and Latinx American men and women of lower and higher socioeconomic status (SES). Study 1 (N = 334) used open-ended questions to elicit participants’ mindsets about the definitions, causes, and benefits of health. Study 2 (N = 320) used Study 1’s results to develop a closed-ended instrument.
In Study 1, open-ended questioning revealed six overarching mindset themes: behavioral, medical, physical, psychological, social, and spiritual. The most prevalent mindsets were psychological definitions, behavioral causes, and psychological benefits. Participants mentioned more cause themes than definition or benefit themes, and mindset theme mentions correlated with worse health. Older participants mentioned more themes than younger, women mentioned more definition themes than men, and low-SES participants mentioned more cause themes than high-SES participants. In Study 2, closed-ended scales uncovered more complex and positive health mindsets. Psychological and spiritual benefit mindsets correlated with good mental health. African Americans and women endorsed the widest array of mindsets, and the spiritual benefit mindset partially explained the superior mental health of African Americans.
Many Americans hold simplistic, illness-focused health mindsets. Cultivating more complex, benefit-focused, and culturally appropriate health mindsets could support health.

Loneliness and Telomere Length: Immune and Parasympathetic Function in Associations With Accelerated Aging

Stephanie J Wilson, Alex Woody, Avelina C Padin, Jue Lin, William B Malarkey, Janice K Kiecolt-Glaser

Lonely people’s heightened risks for chronic health conditions and early mortality may emerge in part through cellular aging. Lonelier people have more severe sympathetic responses to acute stress, increasing their risk for herpesvirus reactivation, a possible path to shorter telomeres. Parasympathetic function may modulate this risk.
The current study aimed to examine the associations among loneliness, herpesvirus reactivation, and telomere length, with parasympathetic activity as a moderator, in healthy middle-aged and older adults.
A sample of 113 healthy men and women of ages 40–85 provided blood samples that were assayed for telomere length, as well as the latent herpesviruses cytomegalovirus (CMV) and Epstein-Barr virus (EBV). They also provided heart rate variability (HRV), a measure of parasympathetic activity, and reported on their feelings of loneliness.
Lonelier people with lower HRV (i.e., lower parasympathetic activity) had greater CMV reactivation and shorter telomeres compared with their less lonely counterparts, above and beyond demographics, health behaviors, resting heart rate, and social network size. However, loneliness was not associated with viral reactivation or telomere length among those with higher HRV. In turn, greater CMV and EBV reactivation was associated with shorter telomeres.
Taken together, these data implicate parasympathetic function in novel links between loneliness and accelerated cellular aging.

Why does work cause fatigue? A real-time investigation of fatigue, and determinants of fatigue in nurses working 12-hour shifts

Derek W Johnston, Julia L Allan, Daniel J H Powell, Martyn C Jones, Barbara Farquharson, Cheryl Bell, Marie Johnston

One of the striking regularities of human behavior is that a prolonged physical, cognitive, or emotional activity leads to feelings of fatigue. Fatigue could be due to (1) depletion of a finite resource of physical and/or psychological energy or (2) changes in motivation, attention, and goal-directed effort (e.g. motivational control theory).
To contrast predictions from these two views in a real-time study of subjective fatigue in nurses while working.
One hundred nurses provided 1,453 assessments over two 12-hr shifts. Nurses rated fatigue, demand, control, and reward every 90 min. Physical energy expenditure was measured objectively using Actiheart. Hypotheses were tested using multilevel models to predict fatigue from (a) the accumulated values of physical energy expended, demand, control, and reward over the shift and (b) from distributed lag models of the same variables over the previous 90 min.
Virtually all participants showed increasing fatigue over the work period. This increase was slightly greater when working overnight. Fatigue was not dependent on physical energy expended nor perceived work demands. However, it was related to perceived control over work and perceived reward associated with work.
Findings provide little support for a resource depletion model; however, the finding that control and reward both predicted fatigue is consistent with a motivational account of fatigue.


Translational Behavioral Medicine

Cost savings associated with an alternative payment model for integrating behavioral health in primary care

Kaile M Ross, Emma C Gilchrist, Stephen P Melek, Patrick D Gordon, Sandra L Ruland, Benjamin F Miller

Financially supporting and sustaining behavioral health services integrated into primary care settings remains a major barrier to widespread implementation. Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) was a demonstration project designed to prospectively examine the cost savings associated with utilizing an alternative payment methodology to support behavioral health services in primary care practices with integrated behavioral health services. Six primary care practices in Colorado participated in this project. Each practice had at least one on-site behavioral health clinician providing integrated behavioral health services. Three practices received non-fee-for-service payments (i.e., SHAPE payment) to support provision of behavioral health services for 18 months. Three practices did not receive the SHAPE payment and served as control practices for comparison purposes. Assignment to condition was nonrandom. Patient claims data were collected for 9 months before the start of the SHAPE demonstration project (pre-period) and for 18 months during the SHAPE project (post-period) to evaluate cost savings. During the 18-month post-period, analysis of the practices’ claims data demonstrated that practices receiving the SHAPE payment generated approximately $1.08 million in net cost savings for their public payer population (i.e., Medicare, Medicaid, and Dual Eligible; N = 9,042). The cost savings were primarily achieved through reduction in downstream utilization (e.g., hospitalizations). The SHAPE demonstration project found that non-fee-for-service payments for behavioral health integrated into primary care may be associated with significant cost savings for public payers, which could have implications on future delivery and payment work in public programs (e.g., Medicaid).

Consider the root of the problem: increasing trainee skills at assessing and addressing social determinants of health

Shawna M Sisler, Naomi A Schapiro, Linda Stephan, Jayme Mejia, Andrea S Wallace

National pediatrics guidelines recommend screening all patients for unmet social needs to improve self-management of chronic conditions and health outcomes and to reduce costs. Practitioners involved in training pediatric clinicians need to understand how to prepare pediatric clinicians to effectively conduct social needs screening and where current training methods fall short. Our qualitative study investigated whether using “standardized” patients during trainee education improved trainees’ ability to assess and address adolescent patients’ social needs. Vulnerable adolescents should be prioritized in social determinants of health translational research because increased risk taking and emotionality may predispose this population to lower self-esteem and self-efficacy. We trained 23 adolescents (aged 16–18) recruited from an urban health-career education program to act as standardized patients (SPs). Two cohorts of nurse practitioner trainees (n = 36) enrolled in a simulation where the patient-actor presented with a minor chief complaint and related a fabricated complex social history. Pre-encounter, Cohort 1 (n = 18) reviewed psychosocial screeners; Cohort 2 (n = 18) were given in-depth information about social needs before meeting patients. SPs gave individualized feedback to trainees, and self-reflections were analyzed using thematic analysis.
In Cohort 1, trainees identified some social needs, yet few intervened. Trainees expressed discomfort in: (a) asking socially sensitive questions and (b) triaging patient versus clinician priorities. Cohort 2 demonstrated improvements compared to Cohort 1 in identifying needs yet had similar difficulty with organization and questioning.
Trainees were able to utilize a lower-stakes interaction with patient-actors to raise awareness regarding a patient’s sensitive needs and to organize care surrounding these patient-centered concerns.

Can mindfulness in health care professionals improve patient care? An integrative review and proposed model

Sarah Ellen Braun, Patricia Anne Kinser, Bruce Rybarczyk

Mindfulness in health care professionals (HCPs) is often discussed as a tool for improving patient care outcomes, yet there has not been a critical evaluation of the evidence, despite a growing body of research on mindfulness-based interventions (MBIs). Numerous mechanisms exist by which mindfulness in HCPs may have an effect on patient care, and the field lacks an integrated model to guide future investigations into how MBIs may exert effects. The primary goals of this integrative review are to evaluate the evidence for the impact of MBIs in HCPs on patient care outcomes and to propose a causal model to guide future research. Databases were systematically searched for eligible studies investigating either an MBI or a measure of dispositional mindfulness in HCPs on patient care outcomes. Studies were critically evaluated using a previously developed tool. Twenty-six studies were identified (N = 1,277), which provide strong support for effects of mindfulness on HCP-reported patient care. Moderate support was found for patient safety, patient treatment outcomes, and patient-centered care. There was overall weak evidence to support a relationship between HCP-mindfulness on patient satisfaction. Mindfulness in HCPs may be related to several aspects of patient care.