health behaviours and the COM-B model Flashcards
what is health? (W.H.O, 1946)
A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity
why is the WHO definition out of date / not fit for purpose?
- ageing population
- ability to manage chronic health conditions
features of health
- people with chronic health conditions can still manage to have a good quality of life thanks to advancements in medicine
- health is not a binary state
- health on a spectrum
what did Huber et al. (2011) suggest?
proposed shifting the emphasis of health towards the ability to adapt and self-manage in the face of social, physical and emotional challenges
causes of death in the 1900s
- Tuberculosis (TB)
- Diarrhoea
- Heart disease
- Intracranial lesions (vasc.)
- Nephritis
- Accidents
- Cancer
- Senility
- Diphtheria
causes of death in the UK in 2006
men:
- all cardiovascular diseases = 35%
- all cancers = 29%
- respiratory disease = 13%
- accidents and injuries = 5%
- other causes = 18%
women
- all cardiovascular diseases = 34%
- all cancers = 26%
- respiratory disease = 14%
- accidents and injuries = 3%
- other causes = 23%
are diseases just in older age?
cardiovascular disease:
- higher death rates in older age due to cardiovascular disease
- but also a relatively high number of deaths in middle age
- is linear but also link to middle age
cancers:
- not linear
- increase with age, optimum in middle age, then decrease in older age
- peak is 55-64
what causes health outcomes?
- certain behaviours:
–> smoking
–> dietary choice
–> alcohol
–> physical activity - behavioural factors account for around 50% of premature deaths from the 10 leading causes
modern concept of ‘health behaviour’
- dated back to the Doll and Hill (1964)
- studied British doctors in the 1950s and found smoking was a major precursor of premature mortality
define health behaviour
any activity undertaken for the purpose of preventing or detecting disease or for improving health/well being
positive and negative health effects of health behaviour
- positive (aka protective)
–> health behaviour can be defined as “activities that may help to prevent disease, detect disease and disability at an early stage, promote and enhance health, or protect from risk of injury” - negative (aka risky)
–> health behaviour can be defined as “activities undertaken by people with a frequency of intensity that increases risk of disease or injury”
a different (broad) definition of health behaviour
behaviours individuals engage in that affect their health
protective behaviours examples
- wearing a seat belt
- wearing sun screen
- MMR vaccine
risky behahvior examples
- unprotected sex
- drug use
- smoking
- reckless driving
measuring health behaviour (typically)
- use behaviour
–> often the DV - but behaviour is hard to measure
- typically measured using categorical or continuous measurements using self-report questionnaires
- categorical
–> do you smoke? (yes/no) - continuous
–> how many cigarettes do you smoke a day?
limitations to health behaviour questionnaires (self-report)
- social desirability bias (under or over reporting)
- subject to recall bias
other ways to measure health behaviours
- observation:
–> CCTV cameras to observe mask wearing in supermarkets - proxy measures
–> blood tests
–> step counters
–> pill counters
limitations with proxy measures
- not always accurate
–> blood tests results can depend on metabolic rate
–> pill counters rely on pills being taken out of a bottle (are they always taken?)
–> step counters can have errors in measurement and can be falsified
Belloc (1973) - Alameda county study
- ~7000 adults
- baseline postal questionnaire in 1965 followed by regular surveys of death and illness
- 7 baseline negative health behaviors predicted mortality
7 baseline negative health behaviours (Belloc, 1973)
- lack of exercise
- snacking between meals
- smoking
- sleep (more than 8 hours, less than 7)
- skipping breakfast
- regularly drinking more than 5 units of alcohol
- over/underweight
7 features of a healthy lifestyle (Belloc, 1973)
- non-smoking
- moderate alcohol intake
- 7-8 hours of sleep per night
- exercise regularly
- maintain a healthy body weight
- avoid high-calorie snacks
- eat breakfast regularly
relationship between a healthy lifestyle and health (Belloc, 1973)
- relationship was so strong that they proposed that people aged over 75 years who carried out all 7 of the behaviours had health that was comparable to those aged 35-44 who did less than 3
Khaw et al (2008) - health behaviour
- analysed data from the EPIC Norfolk longitudinal study of 20,000 men and women
- baseline showed no known CVD/cancer (aged 45-79)
- followed up over 14 years
results of Khaw et al (2008)
- survival was associated with four health behaviours:
1. not smoking
2. being physically active
3. drinking moderately
4. eating 5 or more servings of fruit and veg a day - the fewer of these behaviours performed the greater the risk of death
Danaei et al (2009) - preventable causes of death
- investigation of deaths in the USA
- health behaviours can be linked to range of different causes of death
–> e.g. smoking attributable to CVD, cancer, diabetes and respiratory diseases
key features of health behaviour in the modern world
- the concept of health behaviour is fluid, and behaviours that are included can change as medical knowledge develops
- health behaviours are not uniformly important, but vary in their influence across time and across different populations
- the strength of the evidence relating behaviours with health outcomes is variable
- behaviours may be done for non-health purposes
–> e.g. limiting fat in the diet, going to the gym may be motivated by concern for appearance rather than health
what do psychologists need to remember about health behaviour?
need to view behaviour in a broad context and recognise that health motivations and cognitions are part of a wider set of influences on health behaviour
important health behaviours in he modern world
- diet
- physical activity
- smoking
- sexual behaviour
- alcohol
diet
In 2018 only 28% adults eating 5+ servings of fruit/veg a day
physical activity
More than 80% of adolescents and 27% of adults do not meet WHO’s recommended levels of physical activity
smoking
- rates declined over the last decade, but ~8 million adults in the UK smoke
- highest rates among 25-34 year old adults
sexual behaviour
47% of sexually active young people do not use a condom when sleeping with someone for the first time
alcohol
- 25-28% of adult drinkers in UK binge on alcohol on their heaviest drinking day
- 16-24 year old adults are less likely to drink than any other age group but most likely to binge drink when they do
different types of behaviour change
- initiate a new behaviour
–> e.g. wearing face masks - stopping an existing behaviour
–> e.g. stopping smoking
–> stop hugging friends/family - how a behaviour is performed
–> e.g. changing frequency
–> change intensity
–> changing duration of a behaviour (exercising more, eating less)
primary motivational concerns when changing behaviour
- primary motivational concerns in life are the same for humans as they are for most animals
–> food, water, air, reproduction etc… - challenging these behaviours that are motivated by these systems can be difficult
- for example:
–> sexual behaviour (condom use)
–> energy seeking behaviour (eating habits)
–> energy conservation behaviour (exercise levels)
determinants of health behaviour
biopsychosocial approach
- biology
- psychology
- social context
- all impact health
biological determinants of health behaviour
- evidence from twin studies suggest there is a heritable component to smoking initiation, nicotine addiction as well as body weight and obesity
- some health behaviours have a physiological response (smoking, drinking, eating, exercising) releasing dopamine, endorphins which can reinforce the behaviour
- the ability to carryout many health behaviours is affected by personal health
–> disabilities may impact ability to carry out physical activity
–> symptoms can act as cues to change or stop behaviour (e.g. smoking, adherence to medications etc…)
social determinants of health behaviour
- health behaviours are strongly affected by peer group influences, family habits and social networks
–> peer pressure in adolescence = origin of many risk behaviours
–> early socialization / observational learning leads to health habits
–> culturally valued or discouraged behaviour - socioeconomic status
–> financial barriers to health behaviours, lack of available resource, lower education - legislative laws
–> e.g. seat belt use, drink driving
psychological determinants of health behaviour
- emotion:
–> stress -> smoking, drinking, overeating and exercise
–> fear -> avoidance of healthcare
–> disgust -> fear avoidance - cognition:
–> attitudes/beliefs
–> social cognition models (e.g. Theory of Planned Behaviour) - interventions based on Theory of Planned Behaviour to improve health behaviour
what does the COM-B model stand for?
- compatibility
- opportunity
- motivation
- behaviour
the COM-B model
- compatibility, opportunity, motivation and behaviour ALL need to be present
- interactions between the components:
–> capability impacts motivation and behaviour
–> opportunity impacts motivation and behaviour
–> motivation impacts behaviour
–> behaviour impacts capability, opportunity and motivation
COM-B: capability
- ability to enact behaviour
- made up of physical and psychological capability
- physical capability
–> physical skill/strength to perform the behaviour
–> e.g. lift a 20kg weight - psychological capability
–> capacity to engage in necessary thought processes (knowledge, reasoning)
–> e.g. knowledge of COVID-19 transmission and how to avoid it
COM-B: opportunity
- environment that enables behaviour
- made up of physical and social opportunity
- physical opportunity
–< opportunity afforded by the environment
–> e.g. close proximity to a gym
–> availability of cycle lanes - social opportunity
–> opportunity afforded by social/cultural norms
–> e.g. people around you engaging in a behaviour
–> reminders to do something
–> having support from people around you
COM-B motivation
- mechanisms that activate or inhibit behaviour
- made up of reflective and automatic motivation
- reflective motivation
–> evaluations and plans
–> e.g. drinking responsibly is a good thing to do
–> e.g. planning to wake up early to go the gym - automatic motivation
–> emotional reactions
–> desires (wants and needs)
–> impulses
–> inhibitions
–> habits
–> e.g. anticipated pleasure at the prospect of eating a piece of cake
methods to collect data using COM-B
- questionnaires
–> specific questions about their capability/opportunity/motivation
–> reach larger groups of people - interview/focus groups
–> in depth qualitative data
–> ask open ended questions about capability/opportunity/motivation, barriers/facilitators of engaging in the desired behaviour
–> smaller samples - observation
–> self-report data from questionnaires/interviews may be far away from the truth, observations useful tool to see what actual happens
how well can the COM-B model explain behaviour? (Gibson-Miller, 2020)
- COM-B and behaviour during the COVID-19 Pandemic
- explore influences of COM-B components on hygienic practices
- first wave of a longitudinal survey of 2,025 adults representative of the UK population
- participants self‐reported motivation, capability, and opportunity to enact hygienic practices during the COVID‐19 outbreak
what were the hygienic practices in Gibson-Miller?
- handwashing frequently
- cleansing surfaces
- using tissues
- avoiding touching mouth and face
results of Gibson-Miller
- all COM-B components influenced behaviour
–> psychological capability, social opportunity and reflective motivation (biggest driver) positively influenced behaviour
–> automatic motivation and physical opportunity negatively influenced behaviour - interventions should focus on promoting and maintaining
–> reflective motivation to act (e.g. planning/goal setting)
–> social opportunity (social support)
–> psychological capability (knowledge of COVID-19 transmission)
Willmott et al (2021) COM-B and behaviour
- COM-B and physical activity
- cross-sectional survey
- used validated measures to capture COM (Capability, Opportunity, and Motivation) constructs
- measured physical activity behaviour
- administered online to a sample of young adults
–> aged 18–35 years
–> N = 582
–> mean age = 22.8
–> 80.3% female
results of Willmott et al (2021)
- COM-B model explained 31% of variance in physical activity
- capability and opportunity were found to be associated with behaviour through the mediating effect of motivation
- increased capability + opportunity led to increased motivation
- increased motivation led to increased physical activity
3 stages in interventions for behaviour change
- understanding the behaviour
–> using the COM-B model - identify intervention options
–> intervention functions and policy categories - identify content and implementation options –> behaviour change techniques and the delivery
the behaviour change wheel - interventions for behaviour change
- synthesis of 19 frameworks of behaviour change interventions
- it is comprehensive, coherent and linked to the COM-B model
- identified 9 intervention functions and 7 policy categories that could enable or support these interventions to occur
what are intervention functions?
- activities designed to change behaviour
- behavioural diagnosis allows aspects of COM-B that need addressing to be identified
- lead to intervention functions changing the behaviour
9 intervention functions in the behaviour change wheel
- education
–> increasing people’s knowledge - persuasion
–> using communication to induce positive or negative feelings - incentivisation
–> creating an expectation of reward - coercion
–> creating an expectation of cost or punishment - training
–> helping people to develop skills - modelling
–> providing an example for people to aspire to or emulate - environmental restructuring
–> changing the physical or social context - restrictions
–> using rules to reduce opportunity to engage in target behaviour - enablement
–> giving people means to engage in behaviour or reduce barriers
what are policy categories?
policies are decisions made by authorities concerning interventions
the 7 policy categories in the behaviour change wheel
- environmental/Social planning
–> designing and/or controlling the physical or social environment - communication & marketing
–> using print, electronic media, broadcasting - legislation
–> making or changing law - service provision
–> delivering a service - regulation
–> establishing rules or principles of behaviour or practice - fiscal measures
–> using the tax system to reduce or increase cost - guidelines
–> creating documents that recommend or mandate a certain practice
how do we deliver intervention functions?
via behavioural change techniques
behavioural change techniques (Michie et al., 2013)
- they are the “active ingredients” within the intervention designed to change behaviour
- they are:
1. observable
2. replicable
3. irreducible components of an intervention - created a Taxonomy of behaviour change techniques
–> to help specify interventions and their active ingredients in more detail - can be used alone or in combination
- smallest part of an intervention
examples of behaviour change techniques
- problem solving
- social comparison
- cue signaling reward
- 93 in total
- 19 groups
Munir et al (2018) - behaviour change model and COM-B model
- wanted to reduce sitting time at work
- used focus groups
–> identified barriers - used the behaviour change wheel, intervention functions and behaviour change techniques to address these barriers
- using the COM-B model and the behaviour change wheel led to greater standing
- people needed more role models, more practice/habit and more reinforcement
- prompts and cues helped
Martin-Payo (2021) - behavioural change wheel and COM-B model
- pilot behavioral intervention on diet and exercise for individuals with type 2 diabetes mellitus
- assessed the efficacy of an educational intervention based on the BCW framework for 111 patients with type 2 diabetes on diet and exercise behavior in Spain
- intervention and usual care group
- intervention group = significant improvement in diet, exercise, and a decrease in HbA1c levels
big message
- change policy
- think of new campaigns
- think of ways to motivate people, give them opportunity and make them feel capable
