Understanding Health Related Behaviours

Question 1

What did Sigmund Freud find (1856-1939)?

Answer 1

Sigmund Freud (1856-1939) and his work on conversion hysteria:

• Specific unconscious conflicts can produce particular physical disturbances that symbolize repressed psychological conflicts
• Pt converts conflict into a symptom via voluntary nervous system, thus becoming free of the anxiety that would be produced by the conflict
• perhaps physical symptoms could manifest as a result of physical, psychosocial trauma
• moved away from medical model

Question 2

Describe the differences between the biomedical and the biopsychosocial model of health.

Answer 2

BIOMEDICAL MODEL:

• Illness and injury are biological problems with biomedical solutions
• Ignores psychological and sociocultural factors that are important in diagnosis, treatment, and recovery
• Limiting model

BIOPSYCHOSOCIAL MODEL:

• Illness and injury have biological, psychological, and sociocultural components
• Diagnosis and treatment should take into account all of the above components
• Mind and body cannot be distinguished in illness and health

Question 3

Describe the changing patterns of illnesses.

Answer 3

=> 1900’s and before - infectious diseases or war were the main cause of death (acute conditions such as TB and pneumonia)
=> 1960s - degenerative diseases main cause of death (chronic conditions)

=> Today :

    - most deaths are caused by heart disease, cancer and strokes, diseases which studies suggest are a by-product of lifestyle   - WHO (2004) - 65% of the world's population live in countries where overweight and obesity kills more people than underweight

Question 4

What is the social cognition model?

Answer 4

The social cognition approach to behaviours assumes that individuals’ behaviours are best understood by examining their perception of their environment.

They use cognitive variables (attitudes, beliefs, knowledge, etc) to understand individual social behaviours (Conner & Norman, 2005)

Many other determinants of behaviour like gender, socioeconomic status, etc are assumed to act through these social cognitive determinants

These factors are believed to be modifiable

Question 5

Why do we need models of health behaviour?

Answer 5

Provide a systematic way of organising determinants of health behaviours

Provide a way of testing relationships between constructs and how these relate to outcomes (behaviour)

Help identify constructs that are most relevant to a behaviour which could then be targeted in interventions

Question 6

What is the health belief model?

Answer 6

• One of the earliest models of health behaviour
• Example of a motivational model, i.e. the model focusses entirely on reasons for performing behaviour. The outcome of interest is often intention to perform behaviour
• Common-sense constructs, easily understood
  Used extensively in health promotion and communication

ref to diagram on ppt

Question 7

What is perceived susceptibility and perceived severity?

Answer 7

Perceived susceptibility refers to an individual’s perceptions about how vulnerable s/he feels to the disease or condition

Perceived severity relates to how serious the consequences of developing this condition are. Consequences may be physical, social, emotional, etc.

Question 8

What are perceived benefits and barriers?

Answer 8

Perceived benefits consider the advantage/effectiveness of carrying out a particular behaviour in relation to reducing/eliminating risk

Perceived barriers refer to difficulties or obstacles to carrying out this behaviour

Question 9

What is health motivation?

Answer 9

• Refers to an individual’s ‘readiness to be concerned regarding health matters’
• Is a later addition to the model (Becker et al., 1977)
• Is quite poorly defined, and so often excluded in tests of the model

Question 10

What are cues to action?

Answer 10

• As with health motivation, this too has been poorly defined and so relatively neglected in tests of HBM
• Generally refer to triggers such as health education campaigns, own perception of symptoms, diagnosis of a close friend or family member, etc

Question 11

What are the criticisms of the health belief model?

Answer 11

• The relationship between constructs is not clearly specified
• Although the model states that people “weigh up” benefits against barriers, no specific formula for this is provided
• Measurement issues
  a) Some constructs (cues to action, health motivation) are very poorly defined and have been operationalised in a range of different ways by different researchers.
  b) A meta-analysis carried out in 1992 identified 234 studies using the HBM, of which only 16 (~7%) had measured all constructs and included reliability checks (Harrison et al., 1992)
  Correlation of the constructs with behaviour is low (barriers at 0.21 was the highest, while severity at 0.08 was the lowest)

Question 12

What is the theory of reasoned action?

Answer 12

It was developed by Fishbein and Ajzen (1980)

• Is a deliberative-processing model, i.e. assumes that individuals make decisions regarding behaviours after carefully considering all available information
• Separates proximal & distal predictors of behaviour
  (see ppt for diagram)

Question 13

What is intention?

Answer 13

It is the main determinant of behaviour

It represents motivation or conscious, volitional plans to carry out the behaviour

Question 14

What are attitudes?

Answer 14

Ajzen 1975 - ‘A learned disposition to respond in a consistently favourable or unfavourable manner with respect to a given object’

• refers to positive or negative evaluations of the behaviour
• determined by individuals’ beliefs regarding outcomes associated with the behaviour and evaluations of these outcomes

Question 15

What is subjective norm?

Answer 15

• Refers to one’s perceptions about significant others’ beliefs regarding behaviours (injunctive norms)
• Later extensions to the model also take into consideration descriptive norms, i.e. what significant others actually do
• Subject norms are based on individuals’ normative beliefs and motivation to comply

Question 16

Describe the extension of the theory of reasoned action.

Answer 16

• The TRA assumes that behaviours under consideration are fully under volitional control
• This may often not be the case
• Ajzen (1985) proposed an extension to the TRA, including this construct. This extended theory is termed the ‘Theory of Planned Behaviour’

(see ppt for diagram)

Question 17

What is perceived behavioural control?

Answer 17

Considers the individual’s perceptions regarding resources, opportunities and abilities to perform the behaviour under consideration

Has a direct effect on behaviour

And also an indirect effect through intention, as believing that one doesn’t have required resources or opportunities to perform a particular behaviour is likely to affect intentions (motivational effect)

PBC is based on individuals’ control beliefs (beliefs re: facilitators & inhibitors) and perceived power of each factor to facilitate/inhibit the behaviour

Question 18

What are the criticisms of the ‘The Theory of Planned Behaviour’?

Answer 18

• Assumes all behaviour is rational, fails to take account of irrational determinants
• Emotional factors are usually ignored
• Better at predicting some kinds of behaviours (drug use, risky behaviours) over others (screening)
• It has been suggested that the model may not be sufficient and researchers have suggested additional variables that could be added to the model
  e. g. anticipated regret, moral norms, self-identity, past behaviour

Question 19

What is the Transtheoretical Model of Change (TTM)?

Answer 19

• Developed by Prochaska & colleagues (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992)
• Extensively used in smoking cessation
• Stage model of behaviour change, i.e. individuals progress through different stages as they attempt to change their behaviour.
• Emerges from the idea that there are different determinants of initiation vs maintenance of behaviour, so cognitions that matter at one stage may not matter (or matter less) in another stage

Question 20

What are the stages of behavioural change and describe each one?

Answer 20

PRE-CONTEMPLATION:

• No plans to make any changes to behaviour over the next 6 months
• Possibly due to lack of knowledge/awareness, or may have previously attempted to change, failed and become demoralized
• May be resistant to change behaviour

CONTEMPLATION:

• Thinking of making of changes in the next 6 months
• Still continues with risky behaviour, but is now aware of the problems with this
• Weighing pros and cons of changing behaviour
• Will change if pros outweigh cons
• Ambivalence can keep individuals in this stage for long periods (“chronic contemplation” or “behavioural procrastination”)

PREPARATION:

• Planning to make changes to behaviour over the next month
• May have made unsuccessful attempts to change behaviour
• Makes plans to change behaviours
• Most appropriate stage to invite people onto action-oriented programmes (e.g. weight loss clinics, smoking cessation programmes)

ACTION:

• The individual now has made efforts to change behaviours over the past 6 months
• Most ‘visible’ stage
• Must attain a criterion that is agreed on to reduce risk of poor outcomes (e.g. stopped smoking)
• Movement to next stage once a satisfactory criterion is reached, has positive affective state, receives positive feedback

MAINTENANCE:

• Greater confidence, less tempted to relapse
• Has kept up with new behaviour over past 6 months
• ‘Continuation of change’
• Limited use of change processes (i.e. overt & covert activities used to progress through stages)

RELAPSE:

• The individual reverts to the previous unhealthy behaviour
• Relapse to an earlier stage may also be possible from action or maintenance

Question 21

What are some additional constructs of the TTM?

Answer 21

Decisional balance: Weighing up pros & cons

Change processes - see ppt

Self-efficacy: Feelings of confidence about ability to deal situations that make reverting to the risky behaviour more likely

Temptation: Intensity of urge to indulge in the habit/risky behaviour. Usually brought about by emotional distress, positive environment or craving

Question 22

What are the criticisms of TTM?

Answer 22

• Constructs that determine the move between stages are not clearly specified
• Causal relationships between pros & cons, processes of change, self-efficacy, temptation are not specified
• Most studies are cross-sectional; limited longitudinal data
• No precise predictions re: use of different constructs across the stage & little consistent evidence re: the use of processes of change

Question 23

What are the criticisms of models of health behaviour?

Answer 23

• Considerable overlap in determinants from different models; very little work comparing models or developing integrated models
• Often explain little variance in behaviours
• Use in developing interventions is still limited
  - In 190 interventions on physical activity & healthy eating, 56% reported the use of a theory. 90% did not report a link between behaviour change techniques & their constructs (Prestwich et al., 2013)
  - Many interventions do not use theories extensively, or use multiple theories (Prestwich et al., 2015)

Question 24

Describe the newer models of health behaviour (e.g. COM-B).

Answer 24

Developed as the former models were inadequate to explain the data seen in practice

Developed to facilitate better links between models and interventions – i.e. to improve the evidence base of behavioural medicine

Question 25

Describe COM-B (Michie, van Stralen & West 2011).

Answer 25

Model considered the minimum number of factors needed to account for whether change in the behavioural would occur, given sufficient motivation.

Two sources used -

US consensus meeting of behavioural theorists in 1991
Principle of US criminal law dating back many centuries

The US consensus meeting identified three factors that were necessary and sufficient prerequisites for the performance of a specified volitional behaviour: 1.) the skills necessary to perform the behaviour, 2.) a strong intention to perform the behaviour, and 3.) no environmental constraints making it impossible to perform the behaviour.

Under US criminal law, in order to prove that someone is guilty of a crime one has to show three things: means or capability, opportunity, and motive.

Capability = the individual’s psychological and physical capacity to engage in the activity. includes having the necessary knowledge and skills.

Motivation = all those brain processes that energize and direct behaviour, not just goals and conscious decision-making. includes habitual processes, emotional responding, as well as analytical decision-making.

Opportunity = all the factors that lie outside the individual that make the behaviour possible or prompt it.

Interventions may change one or more components in the behaviour system. The causal links within the system then work to reduce or amplify the effect of particular interventions by causing changes elsewhere.
This model also provides a basis for designing interventions aimed at behaviour change. The task would be to consider what the behavioural target would be, and what components of the behaviour system would need to be changed to achieve that.

Question 26

What are the criticisms of newer models like COM-B

Answer 26

All are heavily biased towards us being rational beings making volitional decisions freely – this is contentious

None have been instrumental in explaining a majority of statistical variance in behavior