models of health behavior

7/28/2019 Models of Health Behavior

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Theories of Health Behaviour

Health Psychology


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Attribution theory

According to the basic tenets ofattribution theory people attempt to

provide a causal explanation for eventsin their world particularly if those eventsare unexpected and have personal

relevance (Heider, 1958). Thus it is notsurprising that people will generallyseek a causal explanation for an illness,particularly one that is serious.


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Attribution theory

Taylor et al. (1984) interviewed asample of women who had been

treated for breast cancer. They foundthat 95% of the women had a causalexplanation for their cancer. These

causes were classified as stress (41%),specific carcinogen (32%), heredity(26%), diet (17%), blow to breast(10%) and other (28%).


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Womens causal explanations for breast cancer


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Attribution theory

They also asked the women who orwhat they considered responsible for

the disease and found that 41% of thewomen blamed themselves, 10%blamed another person, 28% blamed

the environment and 49% blamedchance. The patients were also askedwhether they felt any control over theircancer and they found 56% felt theyhad some control.


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The womens attribution of responsibility

for their cancer


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Attribution Theory

Weiner et al. (1972) suggested that wecan classify attributional dimensions

along three dimensions: 1 Locus: the extent to which the cause is

localized inside or outside the person.

2 Controllability: the extent to which theperson has control over the cause.3 Stability: the extent to which the cause isstable or changeable.


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Health Locus of control

Health locus of control, likeattribution theory, also emphasises

attributions for causality andcontrol.


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Wallston and Wallston (1982)developed a measure of the health

locus of control, which evaluateswhether individuals regard their healthas controllable by them or not

controllable by them or they believetheir health is under the control ofpowerful others.


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Health locus of control is related towhether individuals changed their

behaviour and to the kind ofcommunications style they require fromhealth professionals.


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There are several problems with theconcept of a health locus of control:

Is health locus of control a fixed traits or a transientstate?

Is it possible to be both external and internal?

Going to the doctor could be seen as external (the

doctor is a powerful other) or internal (I am lookingafter my health).


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Unrealistic optimism

Unrealistic optimism focuses onperceptions of susceptibility and

risk. Weinstein (1984) suggested that one of

the reasons why people continued to

practice unhealthy behaviours is due toinaccurate perceptions of risk andsusceptibility - their unrealistic

optimism.


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He asked subjects to examine a list ofhealth problems and displayed what

"compared to other people of your ageand sex, are your chances of gettingthe problem greater than, about the

same, or less than theirs?" Mostsubjects believed they were less likelyto get the health problem.


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Weinstein (1987) described fourcognitive factors that contribute to

unrealistic optimism: 1. Lack of personal experience with the

problem

2. The belief that the problem ispreventable by individual action


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3. The belief that if the problem has notyet appeared, it will not appear in the

future 4. The belief that the problem is

infrequent.


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The transtheoretical model ofbehaviour change (stages of

change model) The transtheoretical model of

change emphasises the dynamic

nature of beliefs, time, and costsand benefits.


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change model) 1. Precontemplation: not intending to

make any changes

2. Contemplation: considering a change

3. Preparation: making small changes

4. Action: actively engaging in a newbehaviour

5. Maintenance: sustaining change overtime


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change model) Individuals would go through these stages in

order but might also go back to earlier

stages. People in the later stages, e.g. maintenance,

would tend to focus on the benefits (I feelhealthier after giving up smoking), whereas

people in the earlier stages tend to focus onthe costs (I will be at a social disadvantage ifI give up smoking).


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change model)A relationship has been found between

level of education and the stage of

change reached when contemplatingtaking regular exercise.


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change model) Those people with lower levels of

education tended to be at an earlier

stage of change (Booth et al. 1993),and therefore it could be argued thatthe model could be improved by taking

account educational attainment in orderto help predict the length of time aperson is likely to remain at the earlierstages.


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Health belief model

Support for individual components ofthe model.

Norman and Fitter (1989) examinedhealth behaviour screening (forexample breast cervical cancer) and

found that perceived barriers (the costsof attending) were the greatestpredictors of whether a person

attended the clinic.


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Health belief model

Several studies have examined breastself-examination (BSE) behaviour and

report that barriers (Lashley 1987;Wyper 1990) and perceivedsusceptibility (the likelihood of having

the illness) (Wyper 1990) are the bestpredictors of healthy behaviour.


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Health belief model

The role of giving information as a cueto action has been researched.

Information in the form of fear-arousingwarnings may change attitudes andhealth behaviour in such areas as

dental health, safe driving and smoking(e.g. Sutton 1982; Sutton and Hallett1989).


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Health belief model

Giving information about the badeffects of smoking is also effective in

preventing smoking and in gettingpeople to give up (e.g. Sutton 1982;Flay 1985). Several studies report a

significant relationship between peopleknowing about an illness and theirtaking precautions.


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Health belief model

Rimer et al. (1991) report thatknowledge about breast cancer is

related to having regularmammograms. Several studies havealso indicated a positive correlation

between knowledge about BSE (BreastSelf-examination) and breast cancerand performing BSE (Alagna and Reddy1984; Lashley 1987; Champion 1990).


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Health belief model

Showing subjects a video about paptests for cervical cancer was related to

their actually having the pap test(O'Brien and Lee 1990'.)


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Evidence Against the HBM

Janz and Becker (1984) found that healthybehavioural intentions are related to low

perceived seriousness - not high as predicted(e.g. healthy adult having a flu injection) -and several studies have suggested anassociation between low susceptibility (not

high) and healthy behaviour (e.g. manystudents recently have agreed to beinoculated against meningitis) (Becker et al.1975; Langlie 1977).


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Hill et al. (1985) applied the HBM tocervical cancer, to examine which

factors predicted cervical screeningbehaviour. Their results suggested thatbenefits and perceived seriousness

were not related.


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Janz and Becker (1984) carried out astudy using the HBM and found the

best predictors of health behaviour tobe perceived barriers and perceivedsusceptibility to illness.


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However, Becker and Rosenstock(1984), in a review of 19 studies using

a meta-analysis that included measuresof the HBM to predict compliance,calculated that the best predictors of

compliance are the costs and benefitsand the perceived seriousness. So thereis lack of agreement over what reallydoes help to predict health behaviour.


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CriticismsoftheHBM

Is health behaviour that rational? (Istooth-brushing really determined by

weighing up the pros and cons?). Its emphasis on the individual (HBM

ignores social and economic factors)

The measurement of each component

The absence of a role for emotionalfactors such as fear and denial.


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CriticismsoftheHBM

It has been suggested that alternativefactors may predict health behaviour,

such as outcome expectancy (whetherthe person feels they will be healthieras a result of their behaviour) and self-

efficacy (the persons belief in theirability to carry out preventativebehaviour) (Seydel et al. 1990;Schwarzer 1992).


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CriticismsoftheHBM

Schwarzer (1992) has further criticizedthe HBM for saying nothing about how

attitudes might change.


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CriticismsoftheHBM

Leventhal et al. (1985) have arguedthat health-related behaviour is related

more to the way in which peopleinterpret their symptoms (e.g. if youfeel unwell and you feel it is not going

to cure itself then you would probablydo something about it).


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Therevised HBM

Becker and Rosenstock (1987) haverevised the HBM and have described

their new model as consisting of thefollowing factors:

the existence of sufficient motivation;

the belief that one is susceptible or vulnerableto a serious problem;

and the belief that change following a healthrecommendation would be beneficial to the

individual at a level of acceptable cost.


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Protection motivationtheory


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Rogers (1975, 1983, 1985) developedprotection motivation theory (PMT)

which expanded the HBM to includeadditional factors.

Componentsof the PMT

Health-related behaviours are a productof five components:


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Coping Appraisal

self-efficacy (e.g. 'I am confident that I canchange my diet');

Response effectiveness (e.g. 'changing mydiet would improve my health');

Threat Appraisal

Severity (e.g. 'bowel cancer is a seriousillness');

Vulnerability (e.g. 'my chances of gettingbowel cancer are high').

Fear

i i i


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According to the PMT, there are two sourcesof information:

1. environmental (e.g. verbal persuasion,observational learning) and

2. intrapersonal (e.g. prior experience).

This information elicits either an 'adaptive'

coping response (i.e. the intention to improveone's health) or a 'maladaptive' copingresponse (e.g. avoidance, denial).

f h


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Support for the PMT

Rippetoe and Rogers (1987) gavewomen information about breast cancer

and examined the effect of thisinformation on the components of thePMT and their relationship to the

women's intentions to practise breastself-examination (BSE).

S f h


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Support for the PMT

The results showed that the bestpredictors of intentions to practise BSE

were response effectiveness (believingthat BSE would detect the early signs ofcancer), severity (believing that Breastcancer is dangerous and difficult to

treat in it's advanced stages) and self-efficacy (belief in one's ability to carryout BSE effectively).

S f h PMT


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Support for the PMT

In a further study, the effects of persuasiveappeals for increasing exercise on intentionsto exercise were evaluated using the

components of the PMT. The results showedthat vulnerability (ill health would result fromlack of exercise) and self-efficacy (believing inone's ability to exercise effectively) predicted

exercise intentions but that none of thevariables were related to self-reports ofactualbehaviour.

S t f th PMT


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Support for the PMT

In a further study, Beck and Lund (1981)manipulated dental students' beliefs about

tooth decay using persuasive communication.Their results showed that the informationincreased fear and that severity (tooth decayhas disastrous consequences) and self-

efficacy (I can do something about it) wererelated to behavioural intentions (flossing andbrushing regularly especially after eating).

C iti i f th PMT


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Criticisms of the PMT

The PMT has been less widely criticized thanthe HBM; however, many of the criticisms ofthe HBM also relate to the PMT. For example,

the PMT assumes that individuals are rationalinformation processors (although it doesinclude an element of irrationality in its fearcomponent), it does not account for habitual

behaviours, such as brushing teeth, nor doesit include a role for social (what others do)and environmental factors (eg opportunitiesto exercise or eat properly at work).

C iti i f th PMT


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Criticisms of the PMT

Schwarzer (1992) has also criticized thePMT for not tackling how attitudes

might change (a problem with the HBMas well).

S i l iti d l


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Social cognition models

Social cognition theory was developed byBandura (1977, 1986) and suggests thatexpectancies, incentives and social cognitions

govern behaviour. Expectancies include: Situation outcome expectancies:the

expectancy that a behaviour may bedangerous (e.g. 'smoking can cause lung

cancer'). Outcome expectancies:the expectancy that

behaviour can reduce the harm to health(e.g. 'stopping smoking can reduce the

chances of lung cancer').

S i l iti d l


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Self-efficacy expectancies:the expectancythat the individual is capable of carrying outthe desired behaviour (e.g. 'I can stop

smoking if I want to'). The concept ofincentivessuggests that

behaviour is governed by its consequences.For example, smoking behaviour may be

reinforced by the experience of reducedanxiety, whereas a feeling of reassurancemay reinforce having a cervical smear after anegative result.

S i l iti d l


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Social cognitions involvenormative beliefs(e.g. 'people who are important to me want

me to stop smoking'). Parents have a strong influence over thehealth behaviours of children of the same sexwith regard to Exercise, Smoking, Drinking,

Eating and Sleep (Wickrama, Conger, Wallaceand Elder, Journal of Health and SocialBehaviour, 1999).

S i l iti d l


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S i l iti d l


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Th f l d b h i


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Theory of planned behaviour

Theo of planned beha io


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The TPB emphasizes behavioural intentionsas the outcome of a combination of severalbeliefs.

Intentions - 'plans of action in pursuit ofbehavioural goals' (Ajzen and Madden 1986)and are a result of the following beliefs:

1. Attitude towards a behaviour - positiveor negative -(e.g. 'exercising is fun and willimprove my health').



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2. Subjective norm - social pressureand motivation (e.g. 'people who are

important to me will approve if I loseweight and I want their approval').

3. Perceived behavioural control -

self-efficacy and possible barriers

Support for the TPB


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Support for the TPB

Povey et al (2000) studied theintentions of people to eat five portions

of fruit and vegetables per day or tofollow a low-fat diet. The TPB was goodat predicting intentions but not

behaviour. Self-efficacy was found to bea better predictor of behaviour.

Support for the TPB


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Support for the TPB

Rutter (2000) studied women andwhether or not they attended two

breast-screening sessions separated bythree years. Intention and first-timeattendance was successfully predictedby the TPB. Attendance at the first

session, however, was the bestpredictor of whether the womanattended three years later.

Support for the TPB


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Support for the TPB

Brubaker and Wickersham (1990)examined the role of the theory's

different components in predictingtesticular self-examination and reportedthat attitude towards the behaviour,subjective norm and behavioural control

(measured as self-efficacy) correlatedwith the intention to perform thebehaviour.

Support for the TPB


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Support for the TPB

TPB in relation to weight loss (Schifterand Ajzen 1985). The results showed

that weight loss was predicted by thecomponents of the model; in particular,goal attainment (weight loss) was

linked to perceived behavioural control.

Evaluation of the TPB


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Evaluationofthe TPB

Good Degree of irrationality

Considers Social and Environmental factors Considers past behaviour within the

measure of perceived behavioural control.

Bad

Schwarzer (1992) Ajzen does not describeeither the order of the different beliefs orsays what causes what (causality).

The health action process


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The health action processapproach

The health action process


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The health action processapproach

The health action process approach (HAPA)was developed by Schwarzer in 1992.

1. it includes a temporal element in theunderstanding of beliefs and behaviour.

2. it emphasized the importance ofselfefficacy

3.

distinction between a decision-making/motivational stage and an actionmaintenance stage.

Components of the HAPA


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Componentsofthe HAPA

According to the HAPA, the motivationstageis made up of the following components: self-efficacy (e.g. 'I am confident that I can stop

smoking'); outcome expectancies (e.g. 'stopping smoking will

improve my health'), and a subset of socialoutcome expectancies (e.g. 'other people want meto stop smoking and if I stop smoking I will gaintheir approval');

threat appraisal, which is composed of beliefsabout the severity of an illness and perceptions ofindividual vulnerability.

Components of the HAPA


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Componentsofthe HAPA

The actionstage is composed of:A cognitive factor made up of action plans (e.g. 'if

offered a cigarette when I am trying not to smoke

I will imagine what the tar would do to my lungs')and action control (e.g. 'I can survive beingoffered a cigarette by reminding myself that I ama non-smoker').

The situational factor consists of social support

(e.g. the existence of friends who encourage non-smoking) and the absence of situational barriers(e.g. financial support to join an exercise club).

Support for the HAPA


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Support for the HAPA

Schwarzer (1992) claimed that self-efficacywas consistently the best predictor ofbehavioural intentions and behaviour change

for a variety of behaviours, includingfrequency of flossing, effective use ofcontraception self-examination, drug addicts'intentions to use clean needles, intentions to

quit smoking, and intentions to adhere toweight loss programmes and exercise (e.g.Beck and Lund 1981; Seydal et al. 1990).

Criticisms of the HAPA


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Criticismsofthe HAPA

Too rational - emotion is neglected

The social and environmental influences arenot considered as directly affectingbehaviour, but rather as cognitions

Do these cognitive states exist or are theysimply created cognitive theorists?

The model attempts to combine componentsof the health belief model, the trans-theoretical model of change and the theory ofplanned behaviour.

Non-Rational processes


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Non-Rational processes

The defence mechanism of Denial

Cigarette smokers etc

Lay theories about health


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Communication between healthprofessional and patient would be

redundant if the patient held beliefsabout their health that were in conflictwith those held by the professional.



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Pill and Stott (1982) reported that working-class mothers were more likely to see illnessas uncontrollable.

In a recent study, Graham (1987) reportedthat although women who smoke are awareof all the health risks of smoking, they report

that smoking is necessary to their well-beingand an essential means for coping withstress.



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Blaxter (1990) analysed the definitions ofhealth provided by over 9000 British adults inthe health and lifestyles survey. She

classified the responses into nine categories: Health as not-ill: the absence of

physical symptoms.

Health despite disease.

Health as reserve: the presence ofpersonal resources.

Health as behaviour: the extent of

healthy behaviour



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Health as physical fitness.

Health as vitality.

Health as social relationships.Health as function.



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It was found that there was considerableagreement in the emphasis on behaviouralfactors as causes of illness. There was

however limited reference to structural orenvironmental factors, especially amongthose from working-class backgrounds.Gender differences were also found. The

women were more likely to define health interms of personal relationships. Murray andMcMillan (1988) also found that working classwomen made repeated reference to their

families when describing cancer.



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Chamberlain (1997) noted a series of socialclass differences in his review of severalstudies of lay peoples perceptions of health.Lower social economic status peopleemphasise the role of health in their ability towork whereas higher social economic status

people referred more to their ability toparticipate in leisure activities. Four differentlay views of health emerged:



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1. Lower social economic statusparticipants only reported a view thatemphasised physical aspects.

2. Both lower and higher social economicstatus participants gave a dualistic view inwhich physical and mental aspects of healthwere combined.

3. Predominantly higher social economicstatus gave a complimentary view of health,which integrated both physical and mentaldimensions.



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4. Higher social economic statusparticipants gave a multiple view of

health, which included physical, mental,emotional, social and spiritualdirections.



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Stainton-Rogers (1991) used Q-sortmethodology to identify the concepts used bya sample of British adults to explain health.She identified eight different accounts ofhealth and illness:

The body as machine account which

considered illness as naturally occurring andreal with biomedicine considered the mainform of treatment.



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The body under siege account which

considered illness as a result of externalinfluences such as germs or stress.

The inequality of access account which

emphasized the unequal access to modernmedicine.

The cultural critique account which wasbased upon a sociological worldview ofexploitation and oppression.



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The health promotion account which

recognized both individual and collectiveresponsibility for ill health.

The robust individualism account which

was concerned with every individuals right toa satisfying life.

The willpower account which definedhealth in terms of the individuals ability toexert control.

Assumptions in Health


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psychology

1. Humans are rational in their information

processing. It is the role ofperceived factors(e.g. risk, rewards, costs, etc) rather thanactual risks.

2. Different cognitions are separate from

and perform independently from each other.

Could be because the researchers askquestions relating to each 'type' of cognition.



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psychology

3. The types of cognition may not reallyexist nor play a part in the patient's thinkingabout their health; they could just be an

artefact of the way the research was carriedout.

4. Cognitions are not placed within acontext. For example, actual social pressure

and environment are not taken into account,only the individual's interpretation of socialpressure and environmental influences.

The end


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The end

models of health behavior

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