Health Psychology Flashcards
1: Predicting Health Behaviour
Learning Objectives
- Describe the key features and benefits of social cognitive approaches to predicting health behaviour
- Describe in detail social cognition models of predicting health behaviour and their application to health behaviour, with examples
- Be able to critically evaluate, and compare and contrast, different social cognition models of health behaviour (e.g., strengths and weaknesses)
For the exam: Understand the models and use examples from the reading
1: Predicting Health Behaviour
What are cognitions in the context of health behaviour?
Cognition represent our beliefs, attitudes and knowledge towards a health behaviour. They are:
- intrinsic to us
- vary between individuals
- modifiable determinants of behaviour
- give rise to social behaviour i.e. activities that promote health and prevent disease (exercise, diet, screening) or promote health and well-being (going to doctors, taking medication). These behaviours impact morbidity and mortality
1: Predicting Health Behaviour
What are Social Cognition Models?
Describe key cognitions and their interrelationships in the regulation of health behaviour
SCM…
- explain how key cognitions give rise to social (health) behaviours - how they CAUSE behaviour.
- predict WHO performs health behaviours (understanding of individual differences)
- indicate cognitive targets to intervention (help to CHANGE health behaviours)
1: Predicting Health Behaviour
Continuum vs Stage Theories
Continuum - suggests people are more likely to perform behaviour based on their position on a continuum e.g. HBM and TPB
Stage - suggests people move through different ‘stages’ toward behaviour e.g. TTM, HAPA
1: Predicting Health Behaviour
Health Belief Model
Continuum theory - people are likely to perform a behaviour based on their position on a continuum
- Lists variables that have been found to predict behaviour rather than being set out as a formal model
- Individual representation of health behaviour in relation to an illness threat can be divided into:
1) Perceptions of illness threat (perceived susceptibility & severity of illness consequences) and
2) Evaluations of behaviour to counteract the threat (benefits and costs of alternative actions) - Cues to action and motivational factors added later
- Demographic variables and psychological characteristics feed in
e.g. in order for someone to act they must perceive that they are ill, evaluate that illness as serious, and think it is better to act than to not act
1: Predicting Health Behaviour
Health Belief Model: Summary
- Widely used, common sense model
- Useful framework for investigating health behaviours
- Core beliefs are predictive of behaviour (See reviews by Janz & Becker, 1984; Harrison et al., 1992)
- Small effect sizes
- Cross-sectional studies
- Other cognitions found that are stronger predictors of behaviour (e.g., intentions, self-efficacy) suggesting that this is an incomplete model that would benefit from extensions to include other cognitions to increase the predictive power of the model
1: Predicting Health Behaviour
Theory of Planned Behaviour
Continuum theory - people are likely to perform behaviour based on their position on a continuum
- Sets out a decision-making process that determines an individual’s decision to carry out a particular behaviour
- Extension to Theory of Reasoned Action (TRA; Fishbein & Ajzen, 1975)
- TPB proposes that behaviour is determined by intentions to engage in that behaviour, and perceptions of control over that behaviour
- Intentions are determined by attitudes, subjective norms and perceived behavioural control
1: Predicting Health Behaviour
Theory of Planned Behaviour: Key Defintions
Attitude - the individual’s overall positive or negative evaluation of the behaviour
Subjective norm: the individual’s perception of the views of important others
Perceived behavioural control: the individual’s perception of the extent to which performance of the behaviour is easy or difficult i.e. under their control
1: Predicting Health Behaviour
Theory of Planned Behaviour and Intentions
The theory of planned behaviour would state that n individual is more likely to perform a behaviour if they form an intention to do so…
an intention forms because the individual has a positive attitude towards the behaviour, they think that important people (to them) would want them to and that the behaviour is under their control
1: Predicting Health Behaviour
The predictive value of the Theory of Planned Behaviour
Armitage & Conner (2001) report that:
- Intentions are the strongest predictor of behaviour
- Attitudes are the strongest predictor of intention
- Attitude + Subjective Norm + PBC predicts 39% of the variance in intentions
- Intention + PCB accounts for 27% of the variance in behaviour
1: Predicting Health Behaviour
Strengths and Limitations of the Theory of Planned Behaviour
Strengths:
- proposes how cognitions affect behaviour indirectly & how beliefs combine to influence motivation and action.
- social influences on action are considered
- has been successfully applied to a range of health behaviours
- widely used in designing interventions to change behaviour
Limitations:
- significant variation across behaviours & components differ in their predictive value (SN in particular)
- more successful in predicting behaviours that are largely under volitional control. TPB is less successful with predicting complex ‘risk’ behaviours (e.g., condom use), and also less successful with younger people
- Much variance remains unexplained! Possibly due to the intention-behaviour gap
- Addition of other predictive variables increase the predictive power – e.g., past behaviour/habit is a strong predictor of future behaviour
- The volitional phase of action is not addressed – i.e., how are intentions translated into action?
- Emphasis on rational and conscious reflection of decision making process – may not apply to all decisions
1: Predicting Health Behaviour
Overview of Stage Theories
• Stage models imply that there are qualitatively different stages in the initiation and maintenance of behaviour
- Individual progresses through stages to successfully change their behaviour
- Different factors (cognitions) are important at different stages for promoting health behaviour
• Four principles of stage models (Weinstein et al., 1998):
- Mutually exclusive stages
- Sequential stages
- Individuals should experience common barriers to change within a stage
- Individuals should experience different barriers to change across different stage.
- Longitudinal data examines stage sequences & comparison of relevant stage variables
1: Predicting Health Behaviour
Stage of Change Model / Transtheoretical Model
Stage model - people move through different “stages” towards behaviour
Emerged from work on addictive behaviours…
Progress through 5 discrete stages of change: 1. Pre-contemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance > Relapse
1: Predicting Health Behaviour
Transtheoretical Model - Worked example
Alcohol behaviour change
Precontemplation - individual is drinking, no intention to change in the next 6 months
Contemplation - individual is drinking but they intend to stop in the next 6 months
Preparation - indivudual is drinking less, intend to stop in the next 6 months
Action - individual has stopped drinking to excess within the past 6 months, percieved benefits are greater than percieved costs (Least stable stage)
Maintenance - individual has been a non-drinker for over 6 months - risk of relapse is small
1: Predicting Health Behaviour
Predicting TTM stage transitions in relation to condom-carrying behaviour
(Arden and Armitage 2008)
Longitudinal experimental design
- 525 adolescents aged 16-22 - questionnaire (intervention vs control, 2 month follow up).
Cross sectional – between stages
Prospective – predictors of stage transitions
Implementation intentions – progression from preparation to action stages
1: Predicting Health Behaviour
Strengths and Limitations of the TTM
Strengths:
- Popular, appealing model
- Allows for relapse as well as forward progression through the stages to positive behavioural change
- Emphasises importance of maintenance
- Behaviour change is a dynamic (non-linear) process
Limitations:
> Evidence to support ‘stages’ is weak:
- There is little support for clear cut stages with different cognitive processes (Rosen 2000)
- Difficult to define and measure the different stages, distinctions are “logically flawed” and based on “arbitrary time periods” (Sutton, 2005)
- “Pseudo stages” – Bandura 1998
> Stages as categorisation of a continuum
1: Predicting Health Behaviour
Summary of Lecture 1
o Individual differences account for differences in behaviour and health
o Social cognition models outline key cognitions that predict health behaviour
o The HBM and TPB are continuum models
o Both models are widely used and successfully predict behaviour to some extent, however, there is significant variation in their predictive value and extensions have been suggested
o Stage models describe a staged process of behaviour change
o The Transtheoretical Model (TTM) is an example of a stage model that describes individuals’ progress through 5 discrete stages of change
o The TTM is a popular model but has problems in upholding the notion of ‘stages’
2: Changing Health Behaviour
Learning Outcomes
- Describe the difference between motivational and volitional phases of behaviour change and identify interventions that target each phase
- Describe key features of social cognitive approaches to changing behaviour
- Describe how to develop and test theory-based interventions to change health behaviour
- Be able to critically evaluate theory-based interventions to change health behaviour
2: Changing Health Behaviour
Recap of lecture 1
Remember: Cognitions are modifiable determinants of behaviour and are therefore the targets of interventions to change behaviour
Difference SCMs (social cognition models) indicate different cognitive targets for interventions to change health behaviours
Changing cognitions = changing behaviour
2: Changing Health Behaviour
Volitional vs Motivational Phases of Behaviour Change
Motivational phase – decision making phase, process involved in decided whether/ how to change our behaviour
Volitional phase – action phase, intentions are realised, and behaviour is changed
Different models split up the motivational and volitional phases differently
Rubicon Model of Action Phases:
Motivational - Volitional - Volitional - Motivational
Health Action Processes Approach:
Motivation - Volitional (This model includes barriers and resources to behav change)
2: Changing Health Behaviour
Theory of Planned Behaviour + Intention Behaviour Gap
TPB used a lot when designing interventions to change behaviour…
*** Study 1: Quinn et al., 2001 “Persuading school-age cyclists to use safety helmets: Effectiveness of an intervention based on the Theory of Planned Behaviour”
- 97 school kids
- Intervention – booklet with persuasive messages influencing salient beliefs to predict intention
- Intentions were more positive in the intervention group
- 25% of intervention group taken up helmet wearing at 5-month follow up
*** Study 2: Hardeman et al., 2002 “Review of TPB health behaviour interventions”
- 24 intervention studies identified
- TPB typically used to evaluate interventions
- Only 12 TPB-based interventions
- Small to medium effects on intention and behaviour
3 main problems:
- Lack of initial TPB studies to identify appropriate targets
- How to change TPB cognitions?
- Lack of assessment of effects on TPB cognitions (mediation)
The Intention Behaviour Gap
Does changing intention produce a change in behaviour?
- Meta-analysis of 47experimental tests found that a medium-to-large change in intention (d=.66) leads to a small-to-medium change in behaviour (d=.36). Lots of variance is unexplained… the I-B gap
- Image in notes*
Most interested in inclined abstainers, those who intend to act but don’t, they fall in the gap. Why do 47% of people who intended to act, in this study, not actually act?
2: Changing Health Behaviour
Overcoming the intention behaviour gap
Implementation intentions
Goal intentions:
“I intend to do _”
- Goal intentions specify what one will do
Implementation intentions:
“I intend to initiate goal-directed behaviour _ when situation _ is encountered”
- Implementation intentions specify the when, where and how of what one will do
Implementation Intention and Breast Self-Examination
Intention:
“I intend to carry out BSE in the next month”
Implementation intention:
“You are more likely to carry out your intention to perform BSE if you make a decision where and when you will do so. Decide now where and when you will perform BSE in the next month and make a commitment to do so.”
Some people who intended did/did not make imp. intent., 53% with just intentions carried out the behaviour compared to 100% of the intervention group who both intended and made imp. intentions carried out the behaviour as planned.
Implimentation intentions, as opposed to just forming intentions, make engagement in a behaviour/ behav change more likely
2: Changing Health Behaviour
Transtheoretical Model
Stage Matched Interventions:
Transtheoretical model is a stage theory. Stage models show that behaviour change goes through stages, a more dynamic process where people can go back through the stages, not quite so linear as the health belief model and the TPB predict.
The main theory about the transtheoretical model is that you should match interventions to the stage of change that a particular person is at – if someone is in the precontemplation stage (no plans or intentions to change at all) there would be no point in making action plans with them because they are nowhere near the action and planning stage redundant intervention method. No one intervention would suit every person.
Tailoring:
- Programs that tailor on stage do better than those that do not, but this effect size is small
Study: Systematic review/ meta-analysis of the effectiveness of health behaviour interventions based on the TTM
Aim: To evaluate the effectiveness of the TTM interventions in facilitating health-related behaviour change
- 37 randomised control trials targeting 7 behaviours
Findings:
- Trial quality was variable
- Limited evidence for the effectiveness of stage-based interventions as a basis for behaviour change, or for facilitating stage progression
2: Changing Health Behaviour
Social Cogntition Models: A Critique
Main Criticisms of SCM generally
Main Criticisms:
1. Strength of predictive success (generally explains less than half the variance in behaviour) – i.e. unexplained variance in prediction (Sutton 1998)
2. Alternative predictors of behaviour are important – extension of models, neglects of important cognitions?
3. BIO? (psychosocial) – missing biological influences on behaviour, addictions for example – what is the impact of physiological motivation systems?
4. Identify cognitive targets to change but don’t specify how to change them (HBM/TPB)
5. Emphasis on rational and conscious reflection of decision-making process (reasoned action) – behaviour isn’t always rational
> Wider social context influences risk behaviour e.g. intending not to binge drink but when at a party will do so (see prototype willingness model, gibbons and gerrard 1998)
> Consider impulsive/ reactive route to behavioural decision making e.g. condom use, drinking alcohol – behaviours where social environment influences behaviour (strack and deutsch 2004; dual process models)
6. Survival function of “risky” behaviours? (some people use risky behaviours like smoking as coping behaviours e.g. smoking single mothers)
7. SCMs too simple to explain all health behaviours (trying to change some of these functional risky behaviours may have different implications)
2: Changing Health Behaviour
Social Cogntition Models: A Critique
Main Limitations of the TPB
1> There is significant variation across behaviours and components differ in their predictive value (subjective norms in particular)
2> The TPB is generally more successful in predicting behaviours which are largely under volitional control. TPB is less successful with predicting complex “risk” behaviours (e.g. condom use) and also less successful with younger people
3> Much variance remains unexplained! Possibly due to the intention-behaviour gap
4> Addition of other predictive variables would increase the predictive power – e.g. past behaviour/ habit is stronger predictor of future behaviour
5> The volitional phase of action is not addressed – i.e. how are intentions translated into action?
6> Emphasis on rational and conscious reflection of decision-making process – may not apply to all behaviour
2: Changing Health Behaviour
Criticisms of SCM, the debate goes on…
Ogden (2003) – Bad Theories
Ogden said that SCMs are bad theories as they try and explain everything.
a) Constructs are not falsifiable and cannot be tested
b) Compare analytic truths rather than synthetic
c) Create & change rather than describe cognitions and behaviour (as soon as we measure a cognition, we change it – mere measurement effect)
Ajzen and Fishbein (2004) disagree. Original authors of the TPB. They argue that these challenges are consistent with SCMs:
- Said the TPB was a valid measure of all the constructs – had evidence
- Questionnaire measurement is an empirical question – the idea of the measurement effect is a scientific issue, rather than a specific issue with this model
Some papers have suggested it’s time to retire the theory of planned behaviour – overused and not useful anymore to as a representation of the decision making process governing health behaviour
2: Changing Health Behaviour
Lecture Summary
- Social cognition models give insight into the cognitive targets for interventions to change health behaviour
- It is important to distinguish between volitional vs motivations phases of behaviour change
- SCMs have been influential in the field but have a wide range of critiques levelled at them
- Combining motivational and volitional approaches may represent a promising avenue of future research into behaviour change
3: Applied Health
Learning Objectives:
- Explain what Health Psychology is
- Adopt a wide perspective of the definition of ‘health’
- Describe the biopsychosocial model of health
- Importance of psychosocial factors in determining individual and population health status
- Demonstrate understanding of the role of wider influences on behaviour and health (UK health policy, social status, the brain)
- Understand the importance of behaviour in determining health status and how changing behaviour & lifestyle can impact upon health and illness
3: Applied Health
What is Health?
WHO definition: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity
3: Applied Health
What is Health Psychology?
“..the aggregate of the specific educational, scientific and professional contributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, the identification of etiologic and diagnostic correlates of health and illness and related dysfunctions, and the analysis and improvement of the health care system and health policy”
Matarazzo, 1980, p.815
Definition: “The scientific study of psychological processes of health, illness and health care”
3: Applied Health
The Role of a Health Psychologist
Health psychologists help people cope and manage illness and health behaviour
The main goals of health psychology are:
- The promotion and maintenance of health
- Improving health-care systems and health policy
- The prevention and treatment of illness
- Understand the causes of illness
Health psychologists must hold:
- BPS accredited BSc in Psychology and MSc in Health Psychology
- Stage 2 training (DHealthPsy) to become chartered with BPS
- Registered with the HCPC (Health Care Professions Council)
Roles can be situated in an applied health setting, larger heath organisations and academic settings.
Areas of work include:
- Health promotion services – smoking cessation, well being
- Pain management
- Public health
- Government agencies
3: Applied Health
Health Behaviour
Two kinds: risky/ preventative
Risky:
- smoking
- unprotected sex
- unhealthy diet
- sedentary lifestyle
- binge drinking
Preventative:
- regular exercise
- healthy eating
- help-seeking
- screening
7 features of a healthy lifestyle:
- 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
the 7 features lower morbidity and mortality
The relationship is so strong that they propose that people aged over 75 years who carry out all 7 of the behaviours likely have health comparable to those aged 35-44 who do less than 3.
3: Applied Health
Biopsychosocial model of health and illness
The view that:
“…health (or illness) results from the interaction of biological characteristics and processes (including genetic predispositions and physiological mechanisms), psychological processes (including perceptions, beliefs and behaviours) and social processes and contexts (including social structure, cultural influences and interpersonal relationships)…”
Abraham et al. 2008, p6
suggests that immunity could be improved by social support, would healing slowed by stress
Health psychologists look at the whole model and take the context of the whole person and the factors acting on their health to help them improve their health.
3: Applied Health
Biomedical model vs Biopsychosocial model
Biomedical model:
* Explains illness in simple terms
* Individual factors are identified as the single cause of illness
* Focus on illness rather than good health
* Does not consider the individual as
responsible for their ill health
Biopsycosocial model:
- Considers all levels of explanation from micro to macro level
- Multi-factor model which assumes that health and illness have many causes with various impacts on the individual
- Illness is not the primary focus, instead there is a health/illness continuum
- Health and illness as a result of individual behaviour, this behaviour can be changed
3: Applied Health
Behavioural determinants of disease and a case for behaviour change
- CVD
- Stroke
- Cancer
- Obesity
- Diabetes
- Hypertension
- COPD (chronic obstructive pulmonary disease)
These are the main killers of people nowadays, instead of infectious diseases most people die of CVD, strokes etc.
Leading causes of premature death & morbidity in the UK are influenced by behaviour (e.g., CVD, Cancer).
1 in 2 (50%) cancers are preventable (that’s 135,000 cases each year in the UK)
43% of tumours are due to unhealthy lifestyles –preventable! (Cancer research UK, British Journal of Cancer, 2011)
Poor diet & physical inactivity account for nearly 17% of premature deaths in the USA
Never too late! Change at 70 years old can increase life expectancy (Yates et al., 2008)
3: Applied Health
Wider determinants of Health
The individual is surrounded by both internal and external influences, for example: - Employment - Social support/Social class - Perceived control - Self-efficacy -Beliefs and attitudes • Illness – physical or psychological • Behaviour • Health policy
See image in notes
3: Applied Health
Health Inequalities
Younger, wealthier, better educated people with low stress levels and high social support are more likely to engage in health-enhancing behaviours (exercise, good nutrition, non-smoking, low alcohol intake)
If a person experiences high stress, fewer social, emotional and economic resources, they are more likely to engage in health compromising behaviours (smoking, high alcohol intake, sedentary lifestyle, poor nutrition)
Why are wealthier people healthier people?
Access to better health services e.g. gym membership
Area lived in and available resources e.g. supermarkets and food stocked
Skilled occupations and access to occupational health etc
Higher level of education and better understanding of nutrition and health
If from a wealthier family then growth and development will be supported by better nutrition and education
Health deprivation is self-perpetuating – people who are born into low SES and have poor health, tend to continue to have poor health across generations
3: Applied Health
UK Health Policy
In order to combat health inequalities and public health concerns there have been times when a government has legislated or launched nationwide public health campaigns to improve health, for example:
- Making seat belts a legal necessity – 1983/1989
road accident deaths decreased - Drink driving ban – 1966 drink driving related deaths decreased
- Smoking ban – 2007
lung cancer deaths decreased - 5-a-day campaign – 2003
bowel cancer and overall health improvements - Change 4 life – 2009
less people leading sedentary lifestyles
There have been several damning reports regarding public policy and health
3: Applied Health
The Brain and Behaviour
Our bodies and brains have evolved to function in an environment that most of us, in economically advanced countries, would actually find quite alien.
We have, as animals, motivations to eat, avoid threat and to procreate. Despite our motivations remaining much the same, our behaviour in modern day life is very different from hundreds of years ago – less need to exercise to find food, sedentary lifestyles are much more common, there are no longer common threats to life in terms of immediate mortality, but more in terms of threats to lifestyle (social hierarchies, privacy etc).
3: Applied Health
Changing behaviour
Our 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 e.g. condom use
- Energy seeking behaviour e.g. eating habits
- Energy conservation behaviour e.g. exercise levels
Health psychologists must first understand behaviour in order to change it, this requires adopting a biopsychosocial approach to health.
3: Applied Health
Summary
- Health psychology is the scientific study of psychological processes of health, illness and health care
- Health can be understood in terms of biological, social and psychological processes
- Health-promoting & health-risk behaviours contribute, in large part, to health status
- Disease can be prevented through changing health-related behaviour
- There are wider influences that also play an important on behaviour and health
