Testing the Biopsychosociospiritual Model in primary care:
Development of the Biopsychosociospiritual Inventory

The late George Engel (1977) formulated the Biopsychosocial Model as a holistic alternative to the prevailing reductionistic biomedical model of his time. This model proposed that illness and health were the result of an interaction between biological, psychological and social factors. The track record of this model is so good that, although criticisms continue to be voiced against it, its validity cannot be questioned (Brody H, 1990). It is the cornerstone for the training of family physicians.

However, in view of the growing weight of evidence in support of the impact of religion and spirituality on health (Matthews, Larson, Barry, 1993; Larson, 1993; Matthews & Larson, 1995), it has been proposed that the Biopsychosocial Model needs to be revised to include spirituality as well (Onarecker & Sterling, 1995). It is consistent with the recent proposal that the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria include religious impairment as part of the “clinically significant impairment” criterion used in many psychiatric disorders. “Religious impairment” would mean a reduced ability to perform religious activities, achieve goals or experience religious states (Hathaway, 2003). In addition, the inclusion of the spiritual dimension is further supported based on its interactions with the other dimensions (Hannay, 1980; Highfield, 1992; Idler & Kasl, 1992; Ellis & Smith, 1999).

However, the research at this time has certain limitations. For example, most of the research has focused on a specific disease entity, using a mixture of measures to assess the dimensions. In addition, a cohesive instrument to measure each dimension in terms of its dimension-specific symptoms and functional status does not exist, serving as an obstacle to future research in this area.

This research seeks to develop and validate an instrument to measure each dimension in terms of its dimension-specific symptoms and functional status in an unselected group of primary care patients.

Methods

Sample: This study was conducted in the Family Health Center at the University Health Center-Downtown (at a low-income, inner city community health center) and at the Leonard G. Paul Family Health Center at the Diagnostic Pavilion (at a middle-class, medical center clinic). English-speaking adult patients (age > 18 years old) in the waiting rooms were approached and asked to participate in the study.

Instrument: The instrument assessed demographics, biopsycho­sociospiritual symptoms and function, and health outcomes. Potential items for the Biomedical Dimension were based on 12 somatic symptoms from the Symptom Checklist-90 (Derogatis et al, 1974) and four functional status items from the Medical Outcomes Study SF-36 (Ware & Sherbourne, 1992). Potential items for the Psychological Dimension were based on nine emotional symptoms and functional status items from the SF-36 (Ware & Sherbourne, 1992). Potential items for the Social Dimension were based on eight social items from the Duke Functional Social Support Questionnaire (Broadhead et al, 1988) and two social functioning items from the SF-36 (Ware & Sherbourne, 1992). Finally, potential items for the Spiritual Dimension were based on eight spirituality items from the FACIT-Sp (Cella, 1997) and two spiritual functioning items adapted from the Brief Multidimensional Measurement of Religiousness/Spirituality (Fetzer Institute, 1999).

Outcomes: Health care utilization was assessed using items from the Health Care Utilization questionnaire (Katerndahl, 1997), measuring two-month ambulatory (office visits to family physicians, general internists, medical specialists and mental health providers) and emergency (use of emergency department, minor emergency room and ambulance) utilization as well as non-medical services (visits to complementary and alternative medicine and spiritual practitioners) and annual hospitalization rate. Health status was measured using the general patient-perceived health status question (from “poor” to “excellent”). Quality of life was assessed using a modified version of the 16-item Quality of Life Inventory (Frisch, 1994).

Analysis: Responses to the 33 symptom and 12 functional status items were analyzed using factor analysis. Factor loadings that exceeded 0.500 were considered significant on the rotated matrix (See Table 1). All five scales underwent assessment of internal consistency using Cronbach’s alpha. Construct validity was assessed by seeking Pearson correlations of scale scores with dimension-specific measures of health services and satisfaction (from the QOLI).

Results

The majority of the 289 subjects (74 percent) were recruited from the Family Health Center at the University Health Center-Downtown. The sample consisted of 188 (65 percent) females with a mean age of 42.7 (± 13.5 SD) years. Race/ethnicity of the sample consisted of 108 (37 percent) Non-Hispanic whites, 143 (50 percent) Hispanics, and 22 (8 percent) African Americans.

Table 1 presents results from the rotated factor analysis. These factors accounted for over 60 percent of the variance. All 12 of the functional status items loaded on a single factor “Impaired Functional Status.” All eight social symptom items loaded on a single factor “Social Symptoms,” four of the five psychological symptoms loaded on a single factor “Psychological Symptoms,” and seven of the eight spiritual symptom items loaded on a single factor “Spiritual Symptoms.” Finally, 10 of the 12 physical symptoms loaded on two factors corresponding to musculoskeletal symptoms and non-musculoskeletal symptoms. When combined into a single 10-item factor “Physical Symptoms,” this scale had better internal consistency and construct validity than the two physical factors alone; thus, the single 10-item scale was used.

Table 2 presents the results of analyses of internal consistency and construct validity. All internal consistencies were excellent (alpha > 0.8). All five scales were highly correlated with measures suggesting construct validity. Hence, the Physical Symptom scale correlated with the number of medical diagnoses and medications as well as utilization of general health settings; it was inversely related to satisfaction with health. Similarly, the Psychological Symptom scale correlated with mental health diagnoses and medications as well as utilization of mental health settings. It was inversely related to satisfaction with self-esteem. The Social Symptom scale was inversely related to satisfaction with helping others, friends and relatives. The Spiritual Symptom scale correlated with utilization of spiritual practitioners and was inversely related to satisfaction with their faith. Finally, the Impaired Functional Status scale correlated with total number of health problems and medications as well as total ambulatory utilization and hospitalizations, but was inversely related to health status and total quality of life score.

Discussion

This study sought to develop and validate a cohesive instrument to measure each of the dimensions of the Biopsychosociospiritual Model in terms of its dimension-specific symptoms and functional status in an unselected group of primary care patients. The results demonstrated that BioPSSI scales of impaired functional status, social symptoms, psychological symptoms, spiritual symptoms and the 10-item physical symptoms all had excellent internal consistency and construct validity. Furthermore, the addition of spiritual functioning items to the functional status scale contributed to the validity of the functional status scale.

The development of this instrument has several potential implications. First, it is hoped this instrument will facilitate future research in this area. Second, this instrument will provide a holistic estimate of the impact of disease and its treatment, validating the primary care perspective and calling into question the relevance of a narrow, reductionist approach to patient care and research. Finally, if the validity of the Biopsychosociospiritual Model is demonstrated, it will call for new approaches to classification, going beyond the 5-axis approach of DSM.

In conclusion, almost 30 years ago Engel (1977) proposed the Biopsychosocial Model and there is mounting evidence justifying expansion to include the spiritual dimension—the Biopsychsociospiritual Model. This study has developed and validated a cohesive instrument to measure each of the dimensions in terms of its dimension-specific symptoms and functional status in the hope that this will facilitate research in this area.

References

Broadhead WE, Gehlbach SH, deGruy FV, Kaplan BH: Duke-UNC functional social support questionnaire. Med Care 1988; 26:709-23.
Brody H: Validation of the biopsychosocial model (ed). J Fam Pract 1990; 30:271-2.
Cella D: Functional Assessment of Chronic Illness Therapy Manual, version 4. Chicago: Center on Outcomes Research and Education, 1997.
Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L: The Hopkins symptom checklist (HSCL). Behav Sci 19:1-15, 1974.
Ellis JB, Smith PB: Spiritual well-being, social desirability, and reasons for living. Intl J Soc Psychiatry 1991; 37(1): 57-63.
Engel GL: Need for a new medical model. Science 1977; 196:129-36.
Fetzer Institute/National Institute on Aging Working Group: Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research. Kalamazoo, MI: Fetzer Institute, 1999.
Frisch MB: Quality of Life Inventory (QOLI). Minneapolis, MN: National Computer Systems, 1994.
Hannay DR: Religion and health. Soc Sci Med 1980; 14A: 683-5.
Hathaway WL: Clinically significant religious impairment. Ment Health Relig Cult 2003; 6(2): 113-29.
Highfield MF: Spiritual health of oncology patients. Cancer Nurs 1992; 15(1): 1-8.
Idler EL, Kasl SV: Religion, disability, depression, and the timing of death. Am J Sociol 1992; 97(4): 1052-79.
Katerndahl DA: Use of health care services by persons with panic symptoms. Psychiatr Serv 48: 1027-32, 1997.
Larson DB: The Faith Factor (vol 2). Washington, DC: National Institute for Healthcare Research, 1993.
Matthews DA, Larson DB, Barry CP: The Faith Factor (vol 1). Washington, DC: National Institute for Healthcare Research, 1993.
Matthews DA, Larson DB: The Faith Factor (vol 3). Washington, DC: National Institute for Healthcare Research, 1995.
Onarecker CD, Sterling BC: Addressing your patients’ spiritual needs. Fam Pract Mgmt 1995; May issue: 44-9.
Ware JE Jr, Sherbourne CD: The MOS 36-item short form health survey (SF-36), I. Conceptual framework and item selection. Med Care 30:473-483, 1992.

This study was funded in part by a research grant from the Texas Academy of Family Physicians Foundation.