Health Behaviour Change

Question 1

How have the causes of death changed form 1990-2012

Answer 1

1990:
Infectious disease - 24%
All other causes- 34%

2012:
Infectious diseases - 1%
Cancer- 30%
Circulatory diseases - 29%

Question 2

What were the top 3 causes of death in males in 2015

Answer 2

1. Heart Disease
2. Dementia and A.D
3. Lung cancer

Question 3

What were the top 3 causes of deaths in females in 2015

Answer 3

1. Dementia and A.D
2. Heart Disease
3. Stroke

Question 4

What did the peto study show regarding the fate of smokers aged 20

Answer 4

Half of them died due to smoking

With half of this cohort dying before the age of 70.

Question 5

Describe the impact of smoking on mortality

Answer 5

 About half of all persistent cigarette smokers are killed by their habit—a quarter while still in middle age (35-69 years).
 Smoking is the number one cause of preventable illness and death.
 On average, cigarette smokers die about 10 years younger than non-smokers.
 Current prevalence of 19% in UK adults (45% in mid 70s)

Question 6

Describe the epidemiology of overweight and obese adults in England (2012-2014)

Answer 6

Almost 7 out of 10 men are overweight or obese (66.4%)
Almost 6 out of 10 women are overweight or obese (57.5%)
Adult (aged 16+) overweight and obesity: BMI ≥ 25kg/m2

Question 7

how do we calculate high risk categories

Answer 7

Adults aged 16+ years. Using combined waist circumference and BMI classification, as recommended by NICE
proportion of people in high risks groups has increased in recent years.

Question 8

Why are we getting fatter

Answer 8

Individual food consumption- our food supply determines what we buy and eat
Individual psychology- societal influences: media, peer influences, and culutre
Individual activity- depends on our activity environment
Biology: Influence of our genetics and ill health.

We live in an obesogenic environment- more sugary, fatty foods and more escalators (less physical activity).

Question 9

What did the Guyunet study show regarding obesity

Answer 9

As our calorie intake increased- so did the proportion of obese and very obese people in the population.

Question 10

Describe how auto-dependency can make us fat

Answer 10

Study showed that increased uses of walking, cycling and transit use were associated with lower levels of obesity.

Question 11

Which factors are considered to be the 5 modern daily killers

Answer 11

Dietary excess 
Alcohol consumption 
Lack of exercise 
Smoking 
Unsafe sexual behaviour

Question 12

Describe the importance of health behaviour in medicine

Answer 12

TACKLING DISEASE = CHANGING BEHAVIOUR

We can change people’s behaviours regarding these 5 biggest killers to prevent disease and morbidity.

Question 13

Define health behaviour

Answer 13

“Any activity undertaken by an individual believing himself to be healthy, for the purpose of preventing disease or detecting it at an asymptomatic stage”

Question 14

What did the Alameda study show regarding health behaviour

Answer 14

• 6,928 residents of Alameda county, CA, completed a list of 7 health behaviours they practised regularly- not smoking, eating breakfast, not snacking, regular exercise, getting 7-8 hrs sleep, moderate alcohol, moderate weight.
• At 10 year follow-up the mortality rate in individuals who practised all seven behaviours was less than 1/4 of that in individuals who practised three or less.

Question 15

Summarise the behaviourally inspired causes of death

Answer 15

§ Causes of death (behaviourally inspired causes):

o Circulatory diseases have gone from 14% of deaths in 1900 to 29% of deaths in 2012.

o Causes of death in smokers in 50% of cases is due to the smoking.

§ Smoking is the number 1 cause of preventable illness and death (on average, smokers die 10 years younger than non-smokers).

o 7/10 men and 6/10 women in the UK are overweight.

§ Due to – complex reasons, increased calorie intake, auto-dependency (cars, etc.).

Question 16

Describe the different levels of behaviour change interventions

Answer 16

Population: everyone targeted regardless of status e.g. Social media
Community: specific group targeted based on status e.g. Cardiac rehabilitation
Individual: targeted intervention for one person - motivational interviewing to help patient give up smoking

Question 17

Describe the nutbeam study showing the impact of smoking education in schools

Answer 17

• A programme of education about the effects of smoking was conducted in 39 comprehensive schools in England & Wales
• The programme involved specially trained teachers providing teaching sessions spread over a 3 month period
• Outcomes: a self report questionnaire combined with a saliva test before teaching, immediately afterwards and at 1 year follow-up

Knowledge change in intervention group significantly increased compared to control
However the % never smokes was the same in both groups- highlighting that education is not enough to change complex behaviours such as smoking.

Question 18

Describe the potential role for education in changing health behaviours

Answer 18

• Information does have an important role and is most effective for discrete behaviours (eg getting a child vaccinated)
• Messagestailoredtoaparticularaudiencearemore effective (eg complete abstinence Vs condom use to reduce teenage pregnancy)
• But often people need more than knowledge to change habitual lifestyle behaviours, particularly addictive behaviours (eg social & psychological support, skills to change)

Question 19

What are the cues for unhealthy eating

Answer 19

 Visual (eg. fast food signs, sweets at checkout)  Auditory (eg. ice cream bell)
 Olfactory (eg. smell of baking bread)
 Location (eg. the couch or car)
 Time (eg. evening)/ Events (eg. end of TV programme )  Emotional (eg. bored, stressed, sad, happy).

Question 20

Describe some reinforcement contingencies in changing unhealthy eating behaviours

Answer 20

 Positive reinforcement:
 Dopamine (feel good), filling an empty void/boredom.

 Praise for preparing a high-fat meal for the family.

 Negative Reinforcement:
 Avoid painful emotions by comfort eating.

 Punishment:
 Preparing a low fat meal is criticised.

Question 21

What is the issue with positive reinforcement in encouraging healthy eating

Answer 21

 Limited/delayed positive reinforcement for healthy eating:

 Efforts at dietary change/weight loss go unnoticed by others; Avoiding future health problems is too remote.

Question 22

Describe some stimulus control techniques to help modify behaviour

Answer 22

• Keep ‘danger’ foods out of the house
• Avoid keeping biscuits in the same cupboard as tea & coffee •Eat only at the dining table
• Use small plates
• Do not watch TV at the same time as eating.

Question 23

Describe counter conditioning as a behaviour modification technique

Answer 23

•Identify ‘high-risk’ situations/cues (eg stress) and ‘healthier’ responses:
–Eg Can you think of something other than eating that makes you feel better? Maybe something relaxing or exercise?

Question 24

Describe some examples of contingency management to help modify behaviour

Answer 24

Involve significant others to praise healthy eating choices Plan specific rewards for successful weight loss (not food!)
Vouchers for adherence to healthy eating & weight loss.

Question 25

Describe some naturally occurring reinforces that can be exploited to help modify behaviours

Answer 25

Improved self-esteem (positive reinforcement).

Reduction in symptoms of breathlessness (negative reinforcement).

Question 26

Describe the study on positive reinforcement intervention for behaviour change

Answer 26

Children given a talk on dental hygiene and then received one of three types of follow up:
1. 2. 3.
No further input
Discussion session
Reward for compliance with mouthwash programme
Outcome: Compliance with the mouthwash programme assessed over 20 weeks.

Reward group showed highest levels of compliance- but this compliance reduced over time

Question 27

Describe the study on the use of incentives to change behaviour

Answer 27

 Five year review – incentives used in smoking cessation schemes were most effective those aimed at weight loss were the least effective.
 E.g. Successful scheme in Dundee offered cash to expectant mothers for giving up smoking - over 90% of the 52 participants quit throughout pregnancy and for 3 months after.

However, a financial incentive did not work for changing unhealthy eating behaviours.

Question 28

Describe the limitations of reinforcement strategies used to try and modify behaviours

Answer 28

• Lack of generalization (only affects behaviour regarding the specific trait that is being rewarded).
• Poor maintenance (rapid extinction of the desired behaviour once the reinforcer disappears)
• Impracticalandexpensive.

Question 29

Describe the study on the use of fear arousal to modify behaviour

Answer 29

• 50 high school students given one of three different lectures on dental health.
• Lectures designed to induce low, moderate or high fear.
• Effect on subsequent dental hygiene behaviour was measured with self-report questionnaires one week later.

Low level of feat was more effective in behaviour change
High levels of fear- negative reinforcer -so lead to avoidance and thus we don’t learn the new behaviour

Question 30

What happens to an individual if they live with smokers in their house

Answer 30

Their likelihood of smoking increases with the number of smokers in that household.

Question 31

Describe the peer influences on adult smoking

Answer 31

 Adolescents are particularly susceptible to social influences given their developmental stage and the importance of school and peer groups.
 Substantial peer group homogeneity with respect to adolescent smoking.
 Best friends have the greatest influence on adolescent smoking, followed by peer groups.

Question 32

Describe the Waterloo smoking prevention project

Answer 32

• High school students allocated to a smoking prevention or control condition.
• The programme consisted of 6 sessions including rehearsing skills to build confidence in ability to resist peer pressure to smoke.
• Significant effect in reducing number of children starting smoking, especially amongst those with family members who smoked.

Question 33

Define what is meant by the expectancy-value principle

Answer 33

The potential for a behaviour to occur in any specific situation is a function of the expectancy that the behaviour will lead to a particular outcome and the value of that outcome”

e.g a patient in cardiac rehabilitation is told that exercising will give him extra years of life

Exercising = behaviour
Expectancy= how likely that behaviour will improve their lives
value= how much they treasure the outcome.

Question 34

Outline the health belief model

Answer 34

Likelihood of behaviour change depends on:
perceived threat- this depends on demographic variables (age, race, ethnicity), structural variables (knowledge of disease and prior contact with disease), and also the perceived susceptibility and seriousness of the disease. Also depends on cue to action, reminder from a doctor/friend and advice from others.

Also depends on the perception of the behaviour:
Perceived benefits of the behaviour
Perceived cost and barriers to the behaviour
This is also influenced by modifying factors, both demographic and structural.

modifying factors also influence perceived susceptibility and seriousness.

Question 35

Apply the health beliefs model to deciding wether to get a flu vaccine or not

Answer 35

• Susceptibility – “A lot of people I know have got flu symptoms”
• Seriousness – “It’s not something to really worry about”
• Benefits – “The vaccination will stop me getting sick”
• Costs/barriers - “The injection will be painful and it might make me ill for a while”
• Cues – Doctor strongly advises to have it.

Question 36

Apply the health beliefs model to smoking cessation

Answer 36

• Explore Cues to Action:
Has anything made you think about giving up smoking? • Explore perceived susceptibility and severity:
How do you think smoking is affecting your health? What would it be like if you got it (eg lung cancer)?
• Explore perceived benefits and barriers:
What are the pros and cons of smoking for you?
Is there anything stopping you from quitting?

Question 37

Describe the different efficacy beliefs

Answer 37

• Outcome efficacy - Individuals expectation that the behaviour will lead to a particular outcome
• Self Efficacy - Belief that one can execute the behaviour required to produce the outcome

Question 38

What are the influential factors on self efficacy

Answer 38

o Influencing factors include:

§ Mastery experience – goal-related success.

§ Social learning – observational (modelling) learning.

§ Verbal persuasion/encouragement.

§ Physiological arousal – breathlessness is worrying- but realise it’s normal when embarking on new behaviours

Question 39

Summarise the theory of planned behaviour

Answer 39

The Theory of Planned Behaviour is based on the idea that a person’s intention is the key determinant in predicting behaviour. The intention is influenced by the individual’s pros and cons towards the behaviour which form the attitude, and what the person believes others important to them think about the behaviour and their motivation to adhere to those beliefs. It also acknowledges the importance of self-efficacy or perceived behavioural control.

Pros and cons- beliefs about outcome and evaluation of outcome. This is related to the expectancy- value principle

Internal control factors- related to self-efficacy
External control factors - related to perceived costs/barriers

Question 40

Apply the theory of planned behaviour to smoking cessation

Answer 40

 Explore attitudes towards smoking:
What do you think about smoking?
Is smoking a good or bad thing for you?
 Explore the norms of important people around her:
What do your friends/family think about you smoking? Would you like to quit for [person]?
 Explore whether she intends to quit smoking:
Have you ever thought about quitting? Do you intend to quit in
the next few months?
 Explore how much control she thinks she has:
 Do you think you can quit? What makes you think that you can’t?

Question 41

Outline the transtheoretical (stages of change) model

Answer 41

Pre-contemplation -does not recognise the need for change or is not actively considering change
Contemplation- recognises problem and is considering change
Preparation- is getting ready to change
Action - is initiating change
Maintennance- is practicing change and is practicing new skills and behaviour to sustain change
The patient may then permanently lead to cycle or relapse
Relapse may occur- start cycle again at contemplation.

Question 42

Summarise the stages of change model

Answer 42

§ The model begins with pre-contemplation to enter the cycle.

§ The behaviour may often go around the cycle a few times before the individual permanently exists the cycle and thus the unwanted behaviour.

Question 43

Outline some approaches to modify health behaviour in a patient

Answer 43

§ Approaches to modify health behaviour in a patient:

o Listen/validate experiences.

o Remedy gaps in knowledge.

o Identify cues and reinforcers.

o Modify unhelpful beliefs.

o Enhance self-efficacy.

o Identify barriers to change.

o Identify good role-models.

o Encourage social support.

o Tailor intervention.

o Motivational interviewing.

Question 44

Summarise the COM-B model

Answer 44

Middle of wheel- sources of behaviour (capability, opportunity and motivation)
Outside this- intervention functions- which influence sources of behaviour
Outside this- policies- which influence intervention functions and thus sources of behaviour.