Session Twelve (Health Related Behaviour Models)

Question 1

What is a “Health Behaviour”?

Answer 1

Steptoe, 2010:
Activities that may help to prevent or detect disease and disability at an early stage promote and enhance health, or protect from risk of injury

Question 2

What is a “Health Risk Behaviour”?

Answer 2

Steptoe, 2010:

Any activity undertaken by people with a frequency or intensity that increases risk of disease or injury

Question 3

What is “Positive Health Behaviour”?

Answer 3

Any behaviour undertaken by a person who believes themselves to be healthy for the purpose of preventing disease or detecting it at an asymptomatic stage.

Ignores behaviours of those already ill undertaken behaviours to minimise their illness

Question 4

Give some examples of health related behaviours?

Answer 4

• Going to appointments
• Adhering to medications
• Using sun cream
• Eating well
• Drinking water
• Sleeping

Question 5

Why is health behaviour so important to healthcare in the UK?

Answer 5

Many of the most common causes of death in the UK are directly related to one or more health behaviours e.g:

• Heart disease
• Stroke
• COPD
• Resp cancers

Defra et al, 2008:
- 25% of deaths in young and Middle Aged adults are attributable to cardiovascular disease.

Furthermore, strong association between certain health behaviours and levels of all-cause morbidity and mortality (White et al, 2008)

Question 6

What is the link between SES and health outcomes?

Answer 6

Recognised link between the two, however SES can only predict, and not explain, health outcomes.

Link likely related to some underlying association e.g we know smoking becomes more prevalent as you drop in SES.

Part of the reason HRBs are studied is to try and understand this relationship

Question 7

Outline the findings of the Alameda County study, 1965?

Answer 7

Looked at 7 HRBs in 7000 adults:

• Lack of exercise
• Snacking between meals
• Smoking
• Sleeping (more than 8 vs less than 7)
• Skipping breakfast
• Regularly drinking 5 units of alcohol
• Weight (over vs under)

Found between these 7 factors you could reliably predict all-cause mortality.

Question 8

Outline the findings from the EPIC-Norfolk study, 2008?

Answer 8

Found death rates to be inversely associated with four health factors:

• Not smoking
• Physical activity
• Moderate alcohol consumption
• Consuming 5+ Fruit and veg

Question 9

Explain the difference between fixed and modifiable risk factors?

Answer 9

Fixed factors = things that can’t be changed in a consultation, don’t cause disease but predispose someone to disease e.g:

• Age
• SES
• Ethnicity
• Level of education
• Job status

Modifiable risk factors can be (theoretically) changed in consultations:

• Behaviours
• Emotions
• Cognitive factors such as beliefs and attitudes
• Social factors (modelling and observing, being around good habits)
• Environment (access, cultural, financial barriers)

Question 10

Outline Rosenstock’s 1974 Health Belief Model?

Answer 10

An early theoretical model used to understand individual differences in behaviour, multiple components:

• Baseline factors: demographic (e.g. age, SES) and psychological (e.g. personality, social group)
• These affect common sense conditions which determine commitment to a behaviour, and include: Threat perception, Health motivation and Behavioural evaluation
• These in turn influence action (as does cues to that action)

Question 11

What aspects if the Health Belief Model can be targeted by intervention

Answer 11

The middle 3 aspects, those that directly influence action.

• Threat perception: Both the perceived susceptibility and severity of the condition
• Behavioural evaluation: Perceived benefits and barriers around a HRB
• General health motivation

Question 12

How practically useful is the HBM?

Answer 12

Moderately.

• In patients who (e.g.) see high threat, high benefit, low costs and are cued to the behaviour we can reasonably expect to see the behaviour
• In the opposite case can reasonably expect the behaviour not to occur
• Model fails when it comes to mixed cases, unpredictable
• Appears to depend on a number of personal factors which the model doesn’t really include

Question 13

What evidence is there around the effectiveness of the HBM at predicting health behaviours?

Answer 13

Harrison et al, 1992:

• Meta-analysis of 16 studies into the impact of crucial HBM factors on health behaviour
• Measured Suceptibility, Severity, Benefits and barriers
• On the +ve side, found that all 4 were significantly correlated to behaviours (0.3 or greater)
• On the -ve side, total variance in behaviour explained by the model was only 10%
• Barriers best predictor, Severity weakest

Question 14

Give some pros and cons of the HBM?

Answer 14

Pros:

• Furthered understanding of public health behaviour for educational interventions
• Variables ARE significant, in spite of small effect sizes
• Training health care professionals to work from patients subjective perceptions of illness and treatment

Cons:

• Reliant on self-reported evidence
• Doesn’t tell us anything about cost-benefit threshold
• Cross-sectional research measuring health beliefs and health behaviours at the same time

Question 15

Give some examples of demographic and psych factors included in the HBM?

Answer 15

Demographic:

• Age
• Gender
• SES
• Education

Psychological:

• Personality
• Social group
• Temperament

Question 16

How has the HBM been used to help patients engage in HRBs?

Answer 16

• Model provides a blueprint for health interventions

- But essentially if model can predict behaviour, opportunity to change predictors, change health outcomes

Question 17

What did Hegel’s 1992 study into HBM intervention on dialysis patients show?

Answer 17

• Individual HBM-based educational interventions were compared to ‘reward for behaviour’ interventions vs combined group
• Weight gain between dialysis was marker of adherence (to fluid restrictions)
• No changes in core HBM factors; susceptibility, seriousness, benefits, concerns
• Reward for behaviour led to reduced reported barriers to behaviour
• Also lead to increased adherence in the long term
• HBM led to short term improvements, not maintained over time
• Combo condition no better or worse than just doing reward (suggests HBM is useless)

However this used a very small sample size and did not compare to treatment as usual

Question 18

What did Ludwick et al’s 2001 breast self-examination study find about the HBM?

Answer 18

• Looked into 93 14-18 year olds
• Risks of contracting cancer were explained (thereby increasing knowledge, susceptibility and severity)
• Cue cards in shower (created cues to action)
• Demonstrated how to perform BSE (low barrier)
• Evaluated through questionnaire 1 month later
• Rates of not performing BSE dropped from 64% to 32%

Pros of this study: worked on every facet of HBM, suggests if applied properly can be effective

Cons: no control group, only followed them up in the short term, did not measure change in HBM factors therefore change wasn’t necessarily to do with HBM

Question 19

What did Jones et al’s 2014 meta-analysis into the effectiveness of HBM methods show?

Answer 19

• 14/18 interventions based on HBM reported significant improvements in adherence
• However the success does not appear to depend on model constructs
• Overall evidence was limited in quality (lack of control groups, short follow-up, no randomisation)

Question 20

What is the Theory of Planned Behaviour?

Answer 20

• Model designed after the HBM
• Ajzen et al, 1988
• Widely used to study cognitive determinants of intentions for health behaviours and health outcomes
• Deliberate processing model, assumes people’s attitudes and beliefs are formed after careful consideration of information available
• Fundamentally based on intention to perform a behaviour, therefore ignores potential barriers
• Makes the assumption that human behaviour is based on rational and careful consideration (which it isn’t)

Question 21

Outline the ToPB?

Answer 21

Attitudes towards act or behaviour + Subjective norm + Perceived behavioural control –> Behavioural Intention –> Behaviour

• Perceived control also directly influences behaviour
• SNs = made up of what people think others want of them e.g. my doctor/family want me to do this AND social influence e.g. will I get made fun of for this
• There is a question marker over how BI leads to B, missing part of our understanding on how HRBs work.

Question 22

Much research evidence around the ToPB has been around breastfeeding, give some exampled of how the various factors from the ToPB could influence breast feeding behaviour?

Answer 22

Attitudes:

• More positive beliefs and attitudes around breastfeeding
• e.g. Its good for the baby

Social Norm:

• More previous experience
• Others around you having that experience

Perceived Behavioural Control:
- Greater belief in their ability to successfully breastfeed

All have been shown to influence intention to breastfeed (McMillan et al 2008, Bai et al 2010)

Question 23

What evidence is there around the link between ToBP factors and breastfeeding behaviour?

Answer 23

• Overall, effect sizes are small but significant.
• Evidence shows a gap between what they INTEND to do and what they actually do
• Ismail et al, 2016: ToPB accounts for 50% of intention but only 10% of behaviour
• McMillan et al, 2008: found the predictive utility of this model decreased over time (ToPB was able to effectively predict intention, sort of predict immediate behaviour, not really predict long-term behaviour)
• Wambach et al, 1997: Intention only accounted for 4% of variance of BF outcome at 4-6 weeks

Question 24

What did McEachan’s 2011 meta-analysis of of the ability of the TPB to plan behaviour reveal?§

Answer 24

Massive variation, in terms of:

• TPB’s ability to create intension
• How much that intension actually translates to behaviour

There was also significant variation in how effective it was at different interventions e.g. adhering to medication vs exercising

Question 25

What are some pros and cons of the ToPB?

Answer 25

Pros:

• Used to predict range of behaviours, varying success
• Guidelines for questionnaire items (so easy to use)

Cons:

• Hasn’t investigated how demographic or personality factors influence intentions or behaviours
• Intention and perceived behavioural control doesn’t account for all variation in behaviour
• Gap between what people intent to of and actually do has yet to be resolved

Question 26

Give an example of interventions designed around the ToPB?

Answer 26

Implementation Intention Formation Instructions:

• Get individual to generate plans in the form of If XXX then I will YYY
• Can add in times and locations e.g. If it is 8 and I’m in the bathroom I should take my pills
• Increases accountability between patient and doctor, harder for them to ignore
• SMART implementations

Question 27

What evidence is there surrounding the use of Implementation Intention Formation Instructions?

Answer 27

Milne, Orbell and Sheeran, 2002:

• Experiment attempted to increase student’s exercise levels using TPB methods and implementation intention
• 3 groups: read a leaflet about risks of CVD and benefits of exercise VS leaflet and also II intervention vs controls
• All groups reported similarly high levels of intentions to exercise
• But the leaflet + II group showed greatest carry over into actual exercise behaviour
• Suggests ToPB interventions are good at bridging the gap between intention and actual behaviour

Question 28

Outline the Common Sense Model of HRBs (Leventhal, Diefenbach, 1992)?

Answer 28

Official name = the self-regulation model of illness cognition and behaviour

• Outlines how illness representations guide responses to illness-related experiences
• Patients select and monitor behaviour in order to reach goals
• Lay illness representations guide behaviour and affect outcomes
• Dual process: cognitive processing and emotional response

Question 29

What are the 5 types of illness representations according to the CSM?

Answer 29

• Identity (illness label, symptoms)
• Cause (factors or conditions believed to cause the illness e.g. genetics stress and infections)
• Timeline (beliefs about the expected duration and nature of the disease e.g. chronic, fixed (e.g. a flu) or cyclical (e.g. migraines)
• Consequences (beliefs about expected effects of the illness on their lives)
• Control/Cure (beliefs about the extent to which the illness can be controlled or cured)

Analysing these 5 features can normally get to the core of why a patient is not adhering

Question 30

Outline how the CSM explains HRB when faced by an illness threat?

Answer 30

• Illness threat occurs, threatens the status quo
• 5 Illness perceptions + emotional state affect coping ability
• We then appraise our coping and re-evaluate
• Models works on the idea of dynamic self-regulation

Question 31

What studies have shown support for interventions based on the CSM?

Answer 31

Petrie et al, 2002:

• CSM for heart attack patients
• Aimed to increase control beliefs, decrease consequence beliefs, reduce timeline beliefs and create an action plan
• At 3 month follow up: less angina, returned to work sooner

Davies et al, 2009:

• DESMOND trial for self-management of T2DM
• Understand a person’s personal beliefs about their diabetes and use their own stories to develop a self-management plan
• Patients after 1 year follow up showed: higher consequence beliefs, chronic timeline beliefs, higher personal responsibility beliefs, greater weight loss and a non-significant decrease in HbA1c

Question 32

What was the aim of the COM-B model?

Answer 32

Michie et al, 2011:

• A framework that aims to bring together different models into something comprehensive and coherent
• Maps onto the behaviour change wheel
• Provides a framework to map intervention techniques onto theoretical components

Question 33

Outline the COM-B model?

Answer 33

• Capability (psych and physical)
• Opportunity (social environment that enables the behaviour)
• Motivation (reflective and automatic mechanisms that activate or inhibit behaviour)

…all combine to influence Behaviour

Question 34

What is the behaviour change wheel?

Answer 34

A diagram representing the 96 components to the COM-B model which can influence a person’s likelihood of performing a behaviour.

Can be used clinically as it relates specific issues to specific interventions.

Question 35

Give some general appraisal for the idea of “health behaviour”?

Answer 35

• HBs change over time, models need to reflect that
• HBs are not universal in their importance, different according to cultures
• Evidence is mixed and normally of poor quality, many methodological issues in the research
• HBs are not always performed out of desire for health, models could use this (e.g. people eat healthy or go to the gym because they like it, or out of habit)
• Models assume a degree of rationality when it comes to information HRBs

Nonetheless, these models represent the best thinking we currently have around how beliefs affect behaviour.