Principles and Models of Health Psychology

Question 1

Part One
Introduction to Health Psychology: Theories and Methods

What does Health Psychology explore?

Answer 1

the role of psychological factors in physical health across the lifespan and along the continuum from health to illness. This book consists of discussing health beliefs, health behaviours, behaviour change, illness cognitions, stress, coping, social support, chronic illness, quality of life, and gender issues. it illustrates some of the reasons why people behave the way they do and think in terms of peer pressure, role models and social support. these factors make up the essence of what health psychology is.

THE BACKGROUND OF HEALTH PSYCHOLOGY

during the nineteenth century, modern medicine was established. Darwin’s thesis (1856) described the theory of evolution. this evolutionary theory identified a place for man within nature and suggested that we are part of nature, that we developed from nature and that we are biological beings. this was in accord with the biomedical model of medicine, which studies man in the same way that other members of the natural world had been studied in earlier years. this model described human beings as having a biological identity in common with all other biological beings.

the 20th century experienced challenges to some of the underlying assumptions of biomedicine which emphasised an increasing role for psychology in health and a changing model of the relationship between the mind and body. disciplines that challenged biomedical model of health;

• Psychosomatic medicine - freud described a condition ‘hysterical paralysis’, whereby patients presented paralysed limbs with no obvious physical cause. freud argued this condition reflected an individuals state of mind (repressed feelings), this indicates an interaction between mind and body. suggests that psychological factors are consequences of illness and cause. this lead to the development of psychosomatic medicine in response to freuds analysis.
• Behavioural Medicine - overall, behavioural medicine focuses on psychology in the study of health, treatment, prevention and intervention as well as challenging the traditional separation of the mind and body.

What is the Biomedical Model of Medicine?

according to this model, diseases either come from outside of the body, invade the body and cause physical changes within the body, or originate as internal involuntary physical changes. such diseases may be caused by several factors such as chemical imbalances, bacteria, viruses and genetic predisposition.
because illness is seen as arising from biological changes beyond their control, individuals are not seen as responsible for their illness. They are regarded as victims of external force causing internal changes.
the biomedical model regards treatment in terms of vaccination, surgery, chemotherapy, and radiotherapy, all of which aim to change the physical state of the body.
the responsibility for treatment rests with the medical professional. within this model, health and illness are seen as qualitatively different - you are either healthy or ill, there is no continuum between the two. According to the biomedical model, the mind and body function independently of each other. this is comparable to a traditional dualistic model of the mind-body split. from this perspective, the mind is capable of influencing physical matter and the mind and body is seen in terms of physical matter such as skin, muscles, bones, brain, and organs. changes in the physical matter are regarded as independent of changes in state of mind.
within traditional biomedicine, illness may have psychological consequences, but not psychological causes. for example, cancer may cause unhappiness but mood is not related to either the onset or progression of the cancer

Question 2

What is Health Psychology?

Answer 2

what causes illness?

Health Psychology suggests that humans should be seen as complex systems and that illness is caused by a multitude of factors and not by a single causal factor. Health psychology therefore attempts to move away from a simple linear model of health and claims that illness can be caused by a combination of biologcial (e.g. a virus), psychological (e.g. behaviours, beliefs) and social (e.g. employment) factors.

who is responsible for illness?

because illness is regarded as a result of a combination of factors, the individual is no longer simply seen as a passive victim. for example, recognition of a role of behaviour in the cause of illness means that the individual may be held responsible for their health and illness.

How should illness be treated?

according to health psychology, the whole person should be treated, not just the physical changes that have taken place. this can change, encouraging changes in beliefs and coping strategies, and compliance with medical recommendations.

who is responsible for treatment?

because the whole person is treated, not just their physical illness, the patient is therefore in part responsible for their treatment. this may take the form of responsibility to take medication and/or responsibility to change their beliefs and behaviour. they are not seen as a victim.

What is the relationship between health and illness?

from this perspective, health and illness are not qualititatively different, but exist on a continuum. rather than being either healthy or ill, individuals progress along this continuum from health to illness and back again.

what is the relationship between the mind and body?

they interact together as we now see people with a more holistic approach, looking at the whole person to health.

what is the role of psychology in health and illness?

What are the Aims of Health Psychology?

health psychology aims to:
1) understand, explain, develop and test theory by evaluating the role of behaviour in the aetogology of illness; predicting unhealthy behaviours; evaluating the interaction between psychology and physiology; understanding the role of psychology in the experience of illness; and evaluating the role of psychology in the treatment of illness.
2) put theory into practice. this can be implemented by promoting healthy behaviour and preventing illness.
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Clinical vs. Health Psychology

Clinical:
focuses on mental health for example anxiety, depression, psychosis, OCD, anorexia, bulimia, self-harm, addiction and personality disorder. uses approaches such as CBT, psychotherapy, psychoanalysis, family therapy, and counselling to help treat patients.

Health:
focuses on physical health for example health behaviours (diet, sleep, exercise, and medication adherence) and chronic conditions (obesity, diabetes, heart disease, cancer). focuses on beliefs, behaviours, behaviour change, sense making, and the quality of life.

both clinical and health psychology are concerned with the role of psychological factors in the development and experience of health. there are crossovers between them which can make it difficult to distinguish between them due to the increasing focus on a holistic approach and the interaction between mind and body. for example, those who have anxiety might as well health problems such as obesity or take part in unhealthy behaviours such as smoking or having a poor diet. therefore the differences are not discrete.

Question 3

The Focus of Health Psychology

Answer 3

four key frameworks in the analysis of health and illness:

• biopsychosocial model of health
• health as a continuum
• direct and indirect pathways between psychology and health
• focus on variability

Biopsychosocial Model of Health

this model was developed by Engel (1977) and represented an attempt to integrate the psychological and the environmental into the traditional biomedical model of health as follows;

• ‘bio’ contributing factors included genetics, viruses, bacteria and structural defects
• ‘psycho’ aspects of health and illness were described in terms of cognitions (e.g. expectations of health), emotions (e.g. fear of treatment) and behaviours (e.g. smoking, diet, exercise or alcohol consumption)
• ‘social’ aspects of health were described in terms of social norms of behaviour (e.g. smoking/not smoking), pressures to change behavior (e.g. peers and parental), social values on health (e.g. health regarded as good or bad), social class and ethnicity.

Health as a Continuum

health and illness on a continuum and explores ways in which psychological factors impact health at all levels. at the start of the continuum psychology is involved in illness onset (e.g. beliefs and behaviours such as smoking, diet, alcohol intake and stress). then once a person becomes ill, psychology is involved in illness adaptation (e.g. seeking help, coping, pain, social support, behaviour, illness beliefs, and adherence) and then as illness progresses towards illness outcomes psychology also plays a role (e.g. quality of life, longevity, behaviour, adherence).

The Relationship Between Psychology and Health

consider both direct and indirect pathways between psychology and health. the direct pathway reflects in the physiological literature and is illustrated by research exploring the impact of stress on illnesses such as coronary heart disease and cancer. from this perspective, the way a person experiences their life has a direct impact upon their body which can change their health status. the indirect pathway is reflected more in the behavioural literature and is illustrated by research exploring smoking, diet, exercise, and sexual behaviour.
from this a way a person thinks (e.g. feeling stressed) can influence their behaviour (e.g. will have a cigarette) which in turn can impact upon their health.

A Focus on Variability

health and illness vary along a number of domains including geographical location, time, social class and gender. health psychology explores this variability with a focus on the role of behaviour. However, there is also variability between people and this is also the focus of health psychology. for example, 2 people might both know that smoking is bad for them but one one stops smoking. this variability indicates that health and illness cannot only be explained by illness severity (i.e. type of cancer, severity of heart attack) or knowledge (i.e. smoking is harmful), but that other factors must have a key role to play. these factors are central to the discipline and include a wide range of psychological variables such as;

• cognitions
• emotions
• expectations
• learning
• peer pressure
• social norms
• coping
• social support

Question 4

Key Theories

Answer 4

healthy psychology ‘steals’ its theories from other psychological perspectives. for example;

• it uses learning theory with its emphasis on associations and modelling
• social cognition theories with their emphasis on beliefs and attitudes
• stage theories with their focus on change and progression
• decision-making theory highlighting a cost-benefit analysis and the role of hypothesis testing
• physiological theories with their interest in biological processes and their links with health

these theories have been used to explain health status and health-related behaviours.

theories relating to health beliefs, health behaviour and behaviour change:
- social cognition theory
- stage theory
- integrated theory
- health belief model
- the theory of planned behaviour
- COM-B model

theories relating to becoming ill:

• self-regulatory model
• diagnosis as decision making
• transactional model of stress

theories relating to being ill:

• psychosocial model of pain
• quality of life

Question 5

Thinking Critically about Health Psychology

Answer 5

being critical is about developing the confidence to question a paper to see whether it really makes sense and whether the conclusions are justified. this can involve exploring such things as the measures used, the statistical tests employed, or the chosen research paradigm. being critical can also highlight fundamental flaws in a discipline about the authors underlying assumptions or what a discipline chooses to focus on and chooses to ignore. being critical also involves learning to trust your instincts when something isnt’ quite right, doesn’t make sense, or is so obvious that it’s not interesting.

BEING CRITICAL OF THEORY

constructs:
health psychology uses a wide range of constructs such as coping, illness beliefs, perceived control, quality of life, depression and anxiety. we need to ask whether these constructs are meaningful and discrete. for example;
- is ‘i feel depressed’ an emotion or a cognition?
- can depression cause poor quality of life or is it part of quality of life?
- can poor health status lead to poor quality of life or is health status part of quality of life?
- is the illness belief ‘my illness won’t last a long time’ an illness belief or a coping mechanism?
- are different personality types mutually exclusive to each other (can i be an extrovert and introvert)?

Stage Models:
health psychology uses a number of stage models such as the SOC (stages of change model). we need to ask;
- are the different stages qualitatively separate from each other?
- are stages real or a product of statistics (i.e. if I ask if people across stages are different, will I then find that they are different because I am imposing a difference on the data)?
- are stages an artefact of labeling them as such?

Finding Associations in our theories:
many theorists argue that different constructs are associated with each other (e.g. self-efficacy predicts behaviours intentions; control-related illness cognitions predict coping) therefore we need to ask,
- are these associations by definition?
- are these associations true by observations?

Finding Differences in Our Theories:
many theorists also look for difference between populations (e.g. men vs. women, old vs. young, doctor vs. patient). we need to ask
- are these differences artefacts of the statistics we use?
- are the variables that we use to explore differences really dichotomous variables or artificially created as binary variables?

Can Theories Be Tested:
much research in health psychology aims to test a theory. we need to ask,
- can theory ever be rejected?
- can theory ever be accepted?

BEING CRITICAL OF METHOD

Quantitative Studies:
qualitative studies are the mainstay of more traditional forms of empirical research and involve collecting numerical data through questionnaires (or trials) or computer tasks. such quantitative data is often assumed to be more objective and controlled than qualitative data. but being critical involves asking questions such as,
- is quantitative data really objective and value-free? the researchers choose which questions to ask, how the data should be coded, what sample to select, what variables to analyse, what tests to use and what story to tell in the final paper. all these processes involve subjective judgements which are value-laden.

Qualitative Studies:
methods include focus groups and interviews and applies different data analysis approaches such as thematic analysis, interpretative phenomenological analysis (IPA) or narrative analysis. Qualitative researchers are clear about the subjective nature of their data and argue that their findings are neither generalisable nor representative. but we need to ask the following questions,
- if the data analysis is open to subjective interpretation by the researcher, how much of the analysis reflects only what the researcher wants to see and is any of the analysis reflective of what went on in the interview? is qualitative analysis purely a product of what is in the mind of the researcher?
- although qualitative findings are not supposed to be generaliseable, are we in fact interested to see if they can tell us about people other than those few (just ten perhaps?) who took part in the study?

The Sample:
Quantitative research requires larger samples that are representatives so that the results can be generalised. qualitative studies involve much smaller samples as generalisation is not the aim. But…
- can a sample ever be representative and if so of whom?
- can a small sample of participants really tell us much apart from about those individuals? and if not, then why study only 7 people?

Research Designs:
we have a number of research designs all of which have their strengths and weaknesses. we need to ask,
- how can the authors describe ‘cause’ or predict anything when a cross-sectional design was used?
- how can the results be generalised when the data were collected in an artificial laboratory setting?
- how can the results be trusted when they were collected in a natural setting with so many uncontrolled potentially confounding variables?

being critical of methodology involves understanding these problems and making sure that the conclusions from any study are justified.

BEING CRITICAL OF MEASUREMENT

Subjective Measures:
it is acknowledged that self-report measures such as questionnaires and interviews are subjective. this raises problems such as,
- are participants just saying what they believe the researcher wants them to say?
- does the participant have the language and insight to express what they really feel?
- can people really differentiate their feelings, beliefs or behaviours into the level of detail expected bu numerical scales with 5 or 7 or even 100 options?

Objective Measures:
some measures are more objective but these also have their problems,
- most measures still involve the possibility of human error or bias through coding, choosing what to measure and when and deciding how the data should be analysed
- an objective measure of a psychological construct may miss the important part of that construct

A Leap of Faith:
researchers develop tools to assess quality of life, pain, stress, beliefs and behaviours. these tools are then used by them to examine how the research participants feel/think/behave. however, this process involves an enormous leap of faith - that our measurement tool actually measures something ‘out there’.

BEING CRITICAL OF A DISCIPLINE

The Mind-Body Split:

Health Psychology challenges the traditional medical model of the mind-body split and provides theories and research to support the notion of a mind and body that are one. However, does this approach really represent an integrated individual? although all these perspectives and the research that has been carried out in their support indicate that the mind and the body interact, they are still defined as separate. the mind reflects the individuals psychological states, which influence but are separate from their bodies.

The Problem of Progression:
being critical involves developing the confidence to evaluate and assess any paper (or book) in terms of all of these dimensions and learning to question whether a conclusion is justified, whether a theory makes sense or whether the underlying assumptions which form the basis of any piece of work are clear and transparent.

Question 6

Working in Health Psychology

Answer 6

The Clinical Health Psychologist:

has been defined as someone who merges,
‘clinical psychology with its focus on the assessment and treatment of individuals in distress… and the content field of health psychology’
(Belar and Deardorff, 1995)

in order to practice as a this psychologist, it is generally accepted that someone would first gain training as a clinical psychologist and then later acquire expertise in health psychology, which would involve an understanding of the theories and methods of health psychology and their application to the health care setting. a trained clinical health psychologist tend to work within the field of physical health, including stress and pain management, rehabilitation for patients with chronic illnesses or the development of interventions for problems such as spinal cord injury and sifiguring surgery.

Health Psychology Practitioner:

trained to an acceptable standard in health psychology and works as a health psychologist. they should have competence in 5 areas; ethical practice, research, teaching, interventions and consultancy. in addition, they should be able to show a suitable knowledge base of academic health psychology, normally by completing a higher degree in health psychology. could work within the health promotion setting, within schools or industry, and/or within the health service.

Academic Health Psychologist:

usually has a first degree in psychology and then completes a masters in health psychology and a PhD in a health psychology-related area. involves teaching at all levels, project supervision for students, carrying out research, writing books and research articles in peer review journals and presenting work at conferences. they also have an administrative role such as managing the examination process or directing the teaching programmes for undergraduate or postgraduate students.

Question 7

Part Two
Staying well: health beliefs, behaviour and behaviour change

Health beliefs

Answer 7

WHAT ARE HEALTH BEHAVIOURS?

in health psychology health behaviours are generally regarded as any behaviour that is related to the health status of the individual (e.g. eating a healthy diet, going to the doctors, taking medication, smoking)

Why Study Health Behaviours?
McKeown (1979) examined health and illness and argued that contemporary illness is caused by ‘influences…which the individual determines by his own behaviour (smoking, eating, exercise, and the like)’ (p.188).
more recent data support the emphasis on chronic illnesses which are related to behaviour. for example, in 2008 Allender et al. published data on the most common causes of death across Europe and concluded that cardiovascular diseases and cancer account for 64% of male and 71% of female deaths.

Behaviour and Longevity
the role of behaviour has been highlighted in the work of Belloc and Breslow and their colleagues who examined the relationship between mortality rates and behaviour among 7000 people as part of the Alameda County study in the USA, which began in 1965. they concluded that seven behaviours were related to positive health status;
- sleeping 7-8hrs a day
- having breakfast everyday
- not smoking
- rarely eating between meals
- being near or at prescribed weight
- having moderate or no use of alcohol
- taking regular exercise
they did another study 10 years later and reported that these 7 behaviours were related to mortality. also they suggested for people aged 75 who carried out all these behaviours, health was comparable to those aged 35-44 who followed less than three.

Behaviour and Mortality
In 2016, data from the Global Burden of Disease protocol shows that behavioural risk factors account for more deaths than metabolic or environmental factors. specifically, dietary risk factors accounted for 20%, smoking accounted for about 14%, with behaviour in general accounting for about 50%.
it has been calculated that all lung cancer mortality is attributable to cigarette smoking, which is also linked with other illnesses. In 2004, Mokdad et al. identified a link between risk behaviours and the deaths of 2.4 million people who had died in the year of 2000 in the USA.
the studies done support the link between behaviour and mortality and supports the role of a healthy lifestyle. the relationship can be also illustrated by the longevity of people in different countries. the longevity of people tends to be due to a combination of biological, lifestyle and social factors. healthy behaviours may be related to longevity however cross-sectional studies are problematic in terms of the direction of causality.

THE ROLE OF HEALTH BELIEFS

Individual Beliefs:
- Attribution Theory - Heider (1958) argued that individuals are motivated to see their social world as predictable and controllable - there is a need to understand causality. Kelley (1971) provided a more clearly defined theory suggesting that attributions about causality were structured according to causal schemata made up by the following criteria; distinctiveness, consensus, consistency over time and consistency over modality. she believed that the type of attribute made determines the extent to which the cause of a behaviour is regarded as a product of a characteristic internal to the individual or external to them. Since the theories publishment, the dimensions of attribution have been redefined as follows; internal vs. external, stable vs. unstable, global vs. specific, controllable vs. uncontrollable.
the internal vs. external dimension of this theory has been specifically applied to health in terms of the concept of a health locus of control. individuals differ as to whether they tend to regard events as controllable by them (an internal locus of control) or uncontrollable by them (an external locus of control). Health locus of control has been shown to be related to whether an individual changes their behaviour or adheres to recommendations made by their doctor. it also shows what kind of communication style people require from health professionals.

Risk Perception:
one key health benefit that people hold relates to their perception of risk and their sense of whether or not they are susceptible to any given health problem. in contrast, other estimate their risk of illness, believing that obesity runs in the family and that there is little they can do to prevent themselves from becoming overweight. perceptions of risk have been studied within two frameworks: unrealistic optimism and risk comprehension,
- Unrealistic Optimism - Weinstein (1983) evaluate the reasons that people continue to practice unhealthy behaviours (which could be due to inaccurate perceptions of risk and susceptibility). the results from his study presented 4 cognitive factors contributing to unrealistic optimism. (1) lack of personal experience with the problem (2) belief that the problem is preventable by individual action (3) belief that if the problem has not yet appeared, it will not appear in the future (4) belief that the problem is infrequent. Weinstein argued that individuals show selective focus; ignore their own risk-increasing behaviour and focus on their risk-reducing behaviour. therefore an individual may be unrealistically optimistic if they focus on the time they use condoms when assessing their own risk and ignore the times they do not and, in addition, focus on the times that others around them do not practice safe sex and ignore the times they do.
- Risk Compensation - people are exposed to often competing desires and motivations. for example, they like eating cake but want to be thin. some individuals opt for an extremely healthy approach to life and ensure that all their behaviours are protective and that only desires they give in to are the healthy ones. many, however, show risk compensation and believe that ‘i can smoke because I go to the gym at the weekend’. from this perspective, people believe that one set of risky behaviours can be neutralised or compensated for by another.

Motivation and Self-Determination Theory (SDT)
the motivation to carry out a behaviour is a core construct in a lot of research exploring health behaviour and it is widely accepted that an individual needs to be motivated to either start a new behaviour or change an existing one. SDT focuses on the reasons and motives that regulate behaviour and distinguishes between two kinds of motivation. first it describes autonomous motivations which relate to engaging in behaviours that fulfill personally relevant goals such as eating nice food or talking to friends (referred to as intrinsic motivation) which makes them feel satisfied and rewarded. second it describes controlled motivations which are driven by external factors such as the need to please friends, and are also referred to as extrinsic motivations. these controlled motivations tend to make the person feel less personally satisfied and are linked with the avoidance of health behaviours.

Self Efficacy
first developed by Bandura (1977) which was then expanded into his social learning theory to explain a range of behaviours. self-efficacy is ‘the belief in one’s capabilities to organise and execute the sources of action required to manage prospective situations’ (Nadura 1986). it is very closely related to feeling confident in one’s ability to engage in any given behaviour. therefore stopping smoking would be related by the belief ‘i am confident i can stop smoking’.

Question 8

Using Stage Models

Answer 8

a stage model is deemed to have four basic principles (Weinstein et al. 1998):

• a classification system to define the different stages
• ordering of stages
• people within the same stage face similar barriers
• people from different stages face different barriers

THE STAGES OF CHANGE MODEL (SOC)

components/stages of SOC:

1) pre-contemplation - not intending to make any changes
2) contemplation - considering a change
3) Preparation - making small changes
4) action - actively engaging in a new behaviour
5) Maintenance - sustaining the change over time.

however, these stages do not always simple move from 1 to 5 (linear fashion), and the theory describes behaviours change as dynamic and not ‘all for nothing’. the model also examines how the individual weighs up the costs/benefits of a particular behaviour, which is referred to as decisional balance. the author suggests that people at different stages will focus on either the costs (pre-contemplation) or benefits (action and maintenance). decisional balance is experienced differently in every stage.

Using the SOC
for example, trying to stop smoking,
1) pre-contemplation - i am happy being a smoker and intend to continue smoking
2) contemplation - i have been coughing a lot recently, perhaps i should think about stopping smoking
3) Preparation - i will buy lower tar cigarettes
4) action - i have stopped smoking
5) Maintenance - i have stopped smoking for 4 months now

Evidence of the SOC
SOC has been used for several health-related behaviours such as smoking, alcohol use, exercise and screening behaviour. it is also increasingly used as a basis to develop interventions that are tailored to the particular stage of the specific person concerned. for example, a smoker identified being at the preparation stage would receive different interventions to one who was at a different stage.
From Gourlan et al. (2016) conducting a meta-analysis study on the effects of theory-based interventions promoting physical activity, he concluded that SOC had an overall significant effect. However, Marshall and Biddle (2001) and Rosen (2000) also concluded from their meta-analysis on the use of SOC that it can be used in research to explore changes in health behaviours and that some differences in decisional balance appear to exist between people classified as being at different stages. However, analyses also revealed inconsistencies in the data.

HEALTH ACTION PROCESS APPROACH

The Health Action Process Approach (HAPA)
This is another model of health beliefs and behaviours developed by Schwarzer (1992) which highlights the need to include a temporal element in the understanding of beliefs and behaviours. In addition, it emphasised the importance of self-efficacy as a determinant of both behavioural intentions and self-reports of behaviour. HAPA includes several individual beliefs and several elements from the social cognition models and attempts to predict both behavioural intentions and actual behaviour.

Components of HAPA:
the main novel component of the HAPA is the distinction between a decision-making/motivational stage and an action/maintainence stage. Therefore the model adds a temporal and process factor to understanding the relationship between beliefs and behaviour and suggests that individuals initially decide whether or not to carry out a behaviour (the motivations stage), and then make plans to initiate and maintain this behaviour (the action phase). according to the HAPA, the motivation stage is made up of the following components,
- self-efficiacy (e.g. i am confident I can stop smoking)
- outcome expectancies (e.g. stopping smoking will improve my health) which has a subset of social outcome expectancies (e.g. other people want me to stop smoking and i stop smoking i will gain their approval)
According to HAPA, the end result of the process is an intention to act.

The action stage is composed of cognitive (volitional), situational and behavioural factors. the integration of these factors determines the extent to which a behaviour is initiated and maintained via these self-regularity processes. the cognitive factor is made up of action plans and action control. these two cognitive factors determine the individuals determination of will. this situational factor consists of social support and the absence of situational barriers.

Schwarzer (1992) argued that the HAPA bridges the gap between intentions and behaviour and emphasises self-efficacy, both in terms of developing the intention to act and also implicitly in terms of the cognitive stage of the action stage, whereby self-efficacy promotes and maintains action plans and action control, therefore contributing to the maintenance of the action. he maintained that the HAPA enables specific predictions to be made about causality and also describes a process of beliefs whereby behaviour is the result of a series of processes.

Evidence for the HAPA
the individual components of the HAPA have been tested, providing some support for the model. Schwarzer (1992) claimed that self-efficacy was consistently the best predictor of behavioural intentions and behaviour change for a variety of behaviours such as the intention to use dental floss, frequency of flossing, effective use of contraception, BSE, drug addicts intentions to use clean needles, intentions to quit smoking and intentions to adhere to weight loss programmes and exercise. Research also indicates that the model, and in particular the element of self-efficacy, predicted BSE in a large sample of German women. Further, Reyes Fernandez et al. (2016) used the HAPA to predict handwashing and found that whilst outcome expectancies and self-efficacy were significant predictors of intention, action and planning control mediated between intentions and actual changes in hand washing frequency.

Question 9

Using Social Cognition Models

Answer 9

stage models focus on the movement between stages as an individual changes their behaviour whereas this model examines the predictors and precursors to health behaviours and take a continuum approach to behaviour and behaviour change. they draw upon subjective expected utility theory, which suggests that behaviour results from weighing up the costs and benefits of any given action and emphasises how individuals are rational information processors. social cognition models are also based upon social cognition theory which was developed by Bandura (1977, 1986) and suggests that behaviour is governed by expectancies, incentives and social cognitions. Expectancies include;

• situation outcome expectancies - the expectancy that a behaviour may be dangerous
• outcome expectancies - the expectancy that a behaviour can reduce the harm of health
• self-efficacy expectancies - the expectancy that the individual is capable of carrying out the desired behaviour.

The concept of incentives suggests that a behaviour is governed by its consequences. social cognitions are a central component of social cognition models and reflect the individual’s representations of their social world. Social cognition models attempt to place the individual within the context both of other people and the broader social world, although the extent to which this is achieved varies between models. the main models currently in use within health psychology are the health belief model (HBM), protection motivation theory (PMT) and the theory of planned behaviour (TPB).

THE HEALTH BELIEF MODEL
developed initially by Rosenstock (1966) and further by Becker and colleagues throughout the 1970’s and 1980’s in order to predict preventive health behaviours and also the behavioural response to treatment in acutely and chronically ill patients. However, over recent years the HBM has been used to predict a wide range of health-related behaviours.

Components of the HBM
HBM predicts that behaviour is a result of a set of core beliefs, which have been redefined over the years. the original core beliefs are the individuals perception of,
- susceptibility to illness
- the severity of the illness
- the costs involved in carrying out the behaviour
- the benefits involved in carrying out the behaviour
- cues to action, which may be internal (e.g. the symptom of breathlessness), or external (e.g. information in the form of health education leaflets)

HBM suggests that these core beliefs should be used to predict the likelihood that a behaviour will occur. after criticisms of the HBM, ‘health motivation’ was added to the construct to reflect an individuals readiness to be concerned about health matters. Becker and Rosenstock (1987) also suggested that perceived control (e.g. i am confident i can stop smoking) should be added to the model.

Using the HBM
if applied to a health-related behaviour such as screening for cervical cancer, the HBM predicts regular screening if an individual perceives that she is highly susceptible to cancer of the cervix, that cervical cancer is a severe health threat, that the benefits of regular screening are high, and the costs of such action are comparatively low. this will also be true id she is subjected to cues to action that are external (leaflet in doctors waiting room or internal (symptom perceived to be related to cervical cancer). when using the new amended HBM, the model would also predict that a woman would attend for screening if she is confident that she can do so and if she is motivated to maintain her health.

Evidence for the HBM
several studies support the predictions of the HBM. research indicates that dietary compliance, safe sex, having vaccinations, making regular dental visits and taking part in regular exercise programmes are related to the individuals perception of susceptibility to the related health problem, to their belief that the problem is severe and their perception that the benefits of preventive action outweigh the costs.

PROTECTION MOTIVATION THEORY (PMT)
Rogers (1975, 1985) developed the PMT, which expanded the HBM to include additional factors. the main contribution of PMT over the HBM was the addition of fear and an attempt to include an emotional component into the understanding of health behaviours.

Components of PMT:
PMT describes health behaviours as a product of 5 components,
1) severity (cancer is a serious illness)
2) susceptibility (chances of getting cancer might be high)
3) response effectiveness (changing diet would improve health)
4) self-efficacy (feel confident in changing diet)
5) fear (scared of getting cancer)

these components predict behavioural intentions, which are related to behaviour. PMT describes the first 3 components relating to threat appraisal and the last 3 components relating to coping appraisal. according to PMT there are two types of sources of information environmental (e.g. verbal persuasion, observational learning) and interpersonal (e.g. prior experience). this information influences the 5 components of PMT, which then elicit either an ‘adaptive’ coping response (i.e. behavioural intention) or a ‘maladaptive’ coping response (e.g. avoidance, denial).

Using the PMT
if applied to dietary change, PMT would make the following predictions; information about the role of a high fat diet in CHD would increase fear, increase the individuals perception of how serious CHD is (perceived severity) and increase their belief that they are likely to have a heart attack (perceived susceptibility/susceptibility). if the individual also felt confident that they could change their diet (self-efficacy) and that this change would have beneficial consequences (response effectiveness), they would report high intentions to change their behaviour (behaviour intentions). this would be seen as an adaptive coping response.

Evidence for the PMT
Norman et al. (2003) used the PMT to predict children’s adherence to wearing an eye patch. Parents of children diagnosed with eye problems completed a baseline questionnaire concerning their beliefs and a follow-up questionnaire after two months describing the child’s level of adherence. the results showed that perceived susceptibility and response costs were significant predictors of adherence.

THEORIES OF REASONED ACTION AND PLANNED BEHAVIOUR (TRO AND TPB)
the TRA has been extensively used to examine predictors of behaviours and was central to the debate within social psychology concerning the relationship between attitudes and behaviour. the TRA emphasised a central role for social cognitions in the form of subjective norms (the individuals beliefs about their social world) and included both beliefs and evaluations of these beliefs (both factors constituting the individuals attitudes). therefore it is an important model as it placed the individual within the social context and in addition suggested a role for value, which was in contrast to the traditional more rational approach to behaviour. TPB was developed by Ajzen and colleagues and represented a progression from the TRA. where the TRA has added subjective norms, the TPB added both subjective norms and a measure of behavioural control. both models also emphasise behavioural intentions as an important precursor to actual behaviour.

Components of the TPB
TPB emphasises behavioral intentions as the outcome of a combination of several beliefs. the theory proposed that intentions should be conceptualised as ‘plans of action in pursuit of behavioural goals’ and are a result of the following beliefs,
- attitude towards behaviour; composed of either positive or negative evaluation of a particular behaviour and beliefs about the outcome of the behaviour
- subjective norm; composed of the perception of social norms and pressure to perform a behaviour, and an evaluation of whether the individual is motivated to comply with this pressure
- perceived behavioural control; composed of a belief that the individual can carry out a particular behaviour based upon a consideration of internal and external control factors, both of which relate to past behaviour.

Using the TPB
if applied to alcohol consumption, the TPB would make the following predictions; if an individual believed that reducing their alcohol intake would make their life more productive and be beneficial to their health, and believed that the important people in their life wanted them to cut down, and in addition believed that they were capable of drinking less alcohol due to their past behaviour and evaluation of internal and external control factors, then this would predict high intentions to reduce alcohol intake.

Evidence for the TPB

Godin and colleagues applied the TPB to a wide range of health behaviours including condom use in both gay and heterosexual populations, blood donation for blood transfusion and organ donation (e.g. 2007, 2008a). it has also been used to predict smoking, exercise during pregnancy, walking and less obvious health behaviours such as speeding behaviour using a driving simulator and on-road speed camera and deliberate self-harm and suicidality.

Question 10

Using Integrated Models

Answer 10

there has been a call to integrate models to form one definitive model that consists of the most useful cognitions and can be used to predict (and change) most health behaviours. one integrated model has been called the ‘major theorists model’ as it emerged out of a workshop attended by many of the most prominent researchers within psychology. through discussion they identified 8 key variables which they believed should account for most of the variance in any given (deliberative) behaviour. these were divided into those that directly impact upon behaviour (e.g. environmental constraints, intention, skills) and those that relate to the intention (e.g. self-discrepancy, advantages/disadvantages, social pressure, self-efficacy, emotional reaction). research has also tested the effectiveness of integrating models in other ways.

THE COM-B
an integrated model which has probably been used the most over recent years is the COM-B developed by Michie and colleagues. the COM-B was derived from carrying out an analysis of 83 theories and 1659 constructs by a cross disciplinary team of researchers in terms of 3 dimensions; comprehensiveness, coherence and a clear link to an overarching model of behaviour. the core components of this new model are capability, opportunity and motivation which predict behaviour.

Using the COM-B
can predict behaviour such as cooking would indicate the following; people cook because they are capable of cooking (e.g. skills), because they are motivated to cook, and because they have the opportunity to cook.

Evidence for the COM-B
has been used in a multitude of studies to predict a wide range of behaviours such as physical activity, weight loss, hand hygiene, dental hygiene, diet, smoking, medication adherence, prescribing behaviours, condom use and female genital mutilation.
although the idea of integrating models makes common sense as there is substantial overlap between the different approaches, there are some problems,
- models which are small and focused can be tested in research and used to develop interventions but may miss important other variables
- larger models that are more inclusive may miss out less but are more unwieldy to use in both research and practice
- theories and models are often the work of individuals who have invested a large part of their career in their development. they may be reluctant to have their model subsumed within some one else’s model.
- there will always remain variance in any behaviour that cannot be explained by any model how ever refined, expanded or integrated, as any number of unexpected events may happen at any time to dislodge the individual from their path towards any given behaviour. this problem has been the focus of research on the intention-behaviour gap.

Question 11

The Intention-Behaviour Gap

Answer 11

the link between intentions and behaviour has not always that straightforward and research has highlighted the problem of the intention-behaviour gap with studies showing that many factors can stop even the best intentions from translating into behaviour. Psychologists have addressed this problem in two ways;

(1) past behaviour has been used as a direct predictor of behaviour
(2) variables that bridge the intention-behaviour gap have been studied

THE ROLE OF PAST BEHAVIOUR AND HABIT
It is possible that behaviour is not predicted by cognitions but by our behaviour. from this perspective individuals are more likely to eat healthy tomorrow if they ate healthily today. they are also more likely to go to the doctor for a cervical smear if they have done so in the past. research suggests that such past behaviour can account for about 13% of future behaviour and predicts behaviours such as cycle helmet use, bringing up condom use, wearing an eye patch, attendance at health checks and breakfast consumption. in addition, past behaviours may itself predict cognitions that then predict behaviour.

SO HOW DOES PAST BEHAVIOUR INFLUENCE FUTURE BEHAVIOUR?

Ouellette and Wood (1998) identified two possible routes for the link between past behaviour and future behaviour. first, that past behaviour may influence future behaviour indirectly through a conscious change in cognitions - for example, ‘i had breakfast yesterday and it made me realise that I had more energy so I will have breakfast again today’. Such a route is more common for behaviours which are infrequent as they offer a new experience. secondly, they argued for a role of habit with future behaviour occurring after past behaviour in a more automatic way, with very little effort or conscious processing.

this route is more likely to be taken for frequently occurring behaviours which offer no new experience. In line with this second route, Verplanken and colleagues (e.g. Verplanken et al. 1994; Verplanken and Aarts 1999) have explored ways to measure habit strength, and research indicates a role for habit in explaining a number of behaviours such as travel mode, condom use, and peoples use of information.

BRIDGING THE INTENTION-BEHAVIOUR GAP
the second approach to address the limited way in which research has predicted behaviour has been to suggest variables that may bridge the gap between intentions to behave and actual behaviour. in particular, some research has highlighted the role of plans for action, health goals commitment, action control and trying as a means to tap into the kinds of cognitions that may be responsible for the translation of intentions into behaviour. Most research, however, has focused on Gollwitzer’s (1993) notion of implementation intentions, which are a simple form of action plans.

According to Gollwitzer, carrying out an intention involves the development of specific plans as to what an individual will do given a specific set of environmental factors. therefore, implementation intentions describe the ‘what’ and the ‘when’ of a particular behaviour. for example, the intention ‘i intend to stop smoking’ will be more likely to be translated into ‘i have stopped smoking’ if the individual makes the implementation intention ‘i intend to stop smoking tomorrow at 12 when i have finished my last packet’.

some experimental research has shown that encouraging individuals to make implementation intentions can actually increase the correlation between intentions and behaviour for behaviors such as adolescent smoking, fruit consumption, exercise, taking a vitamin C pill, reducing dietary fat, and reducing binge drinking in university students.

Question 12

THINKING CRITICALLY ABOUT HEALTH BELIEFS

Answer 12

SOME CRITICAL QUESTIONS
- how important are our beliefs compared to our emotions?
- can we really measure what someone believes without changing it through our questions?
- to what extent are our beliefs captured by those described in our models?
- what factors might influence why people don’t always behave as they intend to?
- why are some of our models too simple?
- why are some of our models too complex?
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SOME PROBLEMS WITH….

Stage Models (SOC and HAPA)
- difficult to determine whether behaviour change occurs according to stages or along a continuum. researchers describe the difference between linear patterns between stages which are not consistent with a stage model and discontinuity patterns which are consistent
- the absence of qualitative differences between stages could either be due to the absence of stages or because the stages have not been correctly assessed and identified.
- most studies based on the SOC use cross-sectional designs to examine differences between different people at different stages of change. such designs do not allow conclusions to be drawn about the role of different causal factors at the different stages (i.e. people at the preparation stage are driven forward by different factors than those at the contemplation stage.) experimental and longitudinal studies are needed for any conclusions about causality to be valid.
- the concept of a 'stage' is not a simple one as it includes many variables; current behaviour, quit attempts, intention to change and time since quitting. perhaps the variables should be measured separately.
- the model focuses on conscious decision-making and planning process. further, it assumes that people make coherent and stable plans
- using the model may be no better than simply asking people, 'do you have any plans to try to...?' or 'do you want to...?'
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Problems with Social Cognition Models
these problems can be categorise as conceptual, methodological and predictive,

Conceptual Problems:

• some overlap between the variables, suggestion that key constructs are integrated across models instead.
• the causality between variables are ambiguous and cannot be concluded unless experimental methods are used. assumptions about association are flawed
• the models cannot be rejected as caeats can always be offered to perpetuate the belief that the model has been supported
• research should generate truth by observation rather than by definition. the models produces statements that are true by definition, therefore the findings are tautological (redundant)
• research should inform us about the world rather than create the world. you shouldn’t ask questions that may change the way in which people think rather than get them to just describe their thoughts.

Methodological Process:

• cross sectional research can only show associations rather than causality
• much research uses inappropriate analysis when using TRA and TPB
• think-aloud study revealed 16 problems with 52 questions of a questionnaire, indicating that research participants may not always interpret questions in the ways intended by the researchers.

Predictive Problems:
- it has been suggested that TRA, TPB, HBM and PMT models are not successful at predicting behaviours intentions. Sutton (1998a) argued that studies using social cognition models only manage to predict between 40 to 50% of the variance in behavioural intentions. that means up to 50% of the variance remains unexplained.
- such models are even less effective at predicting actual behaviour. Sutton (1998a) argued that these studies only predict 19-38% of the variance in behaviour. this may be due to the behaviour being beyond the control of the individual concerned.
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Problems with Integrated Models:
models such as the COM-B are a relatively new approach to understanding health related behaviours, these too have their problems and have been criticised in the following ways,

The Problem with Variability:
- COM-B is designed to reduced variability in research, in practice, and between patients. such a systematic approach can limit research and reduce creativity if everyone is encouraged to use the same approach in their research. It also rules out the ‘art’ of practitioner work and can reduce professionals to technicians who follow rules and guidelines leaving no space for responding to the needs of the client or the dynamic with the professional. there is also so many variables that predict what we do and when, it seems naive to believe that one model could possibly explain all behaviours carried out by all people for all the time.

The Tension Between Inclusivity and Specificity:
inclusive models (a multitude of different constructs and cover every idea from every angle) can never be criticized for missing anything out but are unwieldy and difficult to operationalise and test. in contrast, some models are very narrow and focused. these are much easier to test as they have fewer constructs and can be turned into measures. However, such specific models can also be criticized not complex enough and oversimplify the world we live in. Integrated models illustrate the tension between inclusivity and specificity as they are either too complex or simple.

The Tension Between Now and Then:

now would be the right time to consolidate what we know, build a sample and integrated model and synthesize the research we have, to come up with a solution. But, although health psychologists have been on the task for a while the evidence we have is very often weak, flawed and often absent. therefore, although the impatient response is to integrate and synthesize now, perhaps it is too early and we need to wait a while longer until our evidence base is stronger.

The Tension between Who We Are Speaking To:

models that are complex, inclusive and the conclusion are tentative can be appropriate for fellow academics who see the world through academic eyes. but for policy makers and practitioners this is pretty useless if they want to know what to say or do next. Simplified, integrated and common-sense models when talking to policy makers and practitioners. therefore there is tension which is reflected in the integrated models as some can be too complex or simple.

Problems with All Models:
Health Psychology emphasises the role fo health beliefs in predicting health behaviours. Underpinning this approach is the assumption that humans are rational information processors governed by cognitions. much of what we do, however, is also governed by less rational factors such as our social context and emotions.
In summary, thinking critically about health beliefs involves a consideration of a wide range of problems relating to the conceptualisation of models, the methodologies used in research and the assumptions behind this area of research. these problems are apparent in all the models we use in health psychology. this does not undermine the value of our discipline. it just means that it should be seen with a critical eye within an understanding of what is feasible in research when you are researching something as complicated as the human being.