Chapter 3 Understanding Health and Illness Behaviours © John Hubley & June Copeman 2013

PROBLEM, BEHAVIOUR or SITUATION Figure 3.1 What models do In this book we use the term ‘theory’ to refer to broad concepts and principles and use the term ‘models’ for specific frameworks that can be applied to understand health behaviours. A model will often draw upon one or more theories. In seeking to understand behaviour, researchers draw from a wide range of disciplines including psychology, sociology, economics and anthropology. Many different models have been proposed which fall into two groups. The first group are called explanatory models and the second change models (see Figure 3.1). This chapter will discuss some theories and introduce a range of models that we have found helpful in health promotion. Change theory Which strategies and messages will change it? How should the program work? Explanatory theory Why does it happen? What can be changed?

Smoking Not starting to smoke Stopping smoking Not starting up after quitting Family planning Not becoming pregnant before 18 Using contraception until one wants to have the first child Using contraception to stop having children Immunization Bringing a child to clinic for immunization Allowing a child to be immunized by a health worker Just by defining the behaviour precisely you can tell a great deal about the likely influences, feasibility of change and appropriateness as a target for a health education

Feeling something is ‘wrong’ – perception of symptoms Seeking advice from members of family or others in the community Self-medication Approaching informal or formal systems of health care Consultation with healer/ health-care provider Actions after consultation, use of medication, compliance with regimes Follow-up consultations Cure/death Illness behaviour Actions taken by individuals when they perceive themselves to be ill depends on perceptions of symptoms social networks beliefs on prevention, cure Figure 3.2 Illness behaviour

Health belief model For a person to take action he/she must: believe they are susceptible believe the health problem is serious believe that the advantages of taking action outweigh the disadvantages Figure 3.3 The Health Belief Model The Health Belief Model was first introduced by Becker to explain utilization of health services and has been widely applied to other health related behaviours. The model tries to explain health actions through the interaction of three sets of beliefs perceived susceptibility perceived seriousness perceived benefits and disadvantages. The model helps to explain why, even after receiving health education, people may not take action: They may accept a disease is serious but do not believe they are at risk. People may accept that they are at risk but not believe the problem is serious. People may believe that the effort of taking action is not worth the potential benefits. The Health Belief model provides a useful check list of issues that need to be addressed in a health education campaign. A major weakness is that it sees behaviour change in a highly individualistic way and does not take into account social influences. A trigger may be needed to encourage the person to act

Stages of change model Maintaining ‘safer’ lifestyle not interested Making changes Ready to change Maintaining changes Thinking about change not interested in changing ‘risky’ behaviour Relapsing Prochaska & DiClemente

Attitude Behavioural intention Subjective norm Behaviour change Beliefs about the consequences of taking action and judgement of those consequences Attitude Behavioural intention Behaviour change Beliefs whether others in their networks would approve or disapprove of them taking action Subjective norm Figure 3.5 Theory of Reasoned Action This theory (Fishbein and Ajzen, 1975) is the second model we present based on Value Expectancy Theory. While the Health Belief Model focuses on the individual and his or her beliefs, the Theory of Reasoned Action considers the individual and the influence of those around them. One of the strengths of the theory is that it fits very well with every-day experience. Sometimes we want to do something but do not because we feel that others would not approve of us doing it. On other occasions we may be pressurized by others to do things we may not want to. Applying the theory involves initial research/questioning to find out: What consequences does the person believe might follow if he or she adopts the behaviour and to what extent does that person rate those consequences positively or negatively? If the person believes that the overall consequences will be positive, then that person will have a favourable attitude to adopting that behaviour. What does the person believes that those around them would feel if they were to adopt that behaviour? If they believe that the people most important to them would be in favour of them adopting the behaviour, they would have a positive ‘subjective norm’. If they believed that people around them would object, then they would have a negative subjective norm

Significant others in family partners in relationships, Social networks Influence pressure to act in particular ways Information on health, disease and sources of help Significant others in family friends - peers partners in relationships, opinion leaders in community Support help and support in times of crisis, difficulty and solving problems

Social Networks influence health Social networks as sources of information Social networks as sources of pressure and influence Social networks as sources of support Social networks as sources of information We find out information about health and other topics through our networks and we tend to believe information from the people that we trust (have high source credibility). Social networks as source of pressure and influence Some people may have more influence than others and in health promotion we need to find out who are the influences at family, peer and community. Social networks as sources of support When we have financial problems, are sick or other problems we rely on our network of family and friends for emotional and practical support.

Investigating social networks Who makes the decisions in the family… in the community… about… care of children? use of health services? use of medicines?

Concept of culture Norms: the shared characteristics of a group Traditions: ideas, values and practices that have been held for a long time and passed on through to the next generation Systems of thought and ideas: reinforced by language, religion and systems of medicine

Is the health issue affected by culture? Life course Masculinity and femininity Patterns of living and consumption Patterns of communication Health and illness behaviours Religion and 'world view' Patterns of social influence, social networks and political organization Economic patterns Box 3.4 How to determine the role of culture on health? Is the health issue affected by any of the following– Life cycle: family structure, patterns of influence among family members, role of women, children, rituals and roles surrounding birth, growing up, relations with other people, sex and marriage; family formation, work, growing old, death; Masculinity and femininity: roles of men and women in the society, views of what makes a ‘man’ and ‘woman’, beauty and body image, gender stereotypes, divisions of roles and responsibilities between genders; Patterns of living and consumption: clothing; housing; child rearing, food production, storage and consumption; hygiene practices; sanitation; Health and illness behaviours: concepts of health and illness; ideas about mental illness and handicap; care of sick people; traditional medicine systems; patterns of help-seeking when ill; use of doctors and traditional healers; responses to pain, concepts about the biological workings of the body, growth, conception, pregnancy, birth etc.; Patterns of communication: language; verbal and non-verbal communication; taboos on public discussion of sensitive items; vocabulary of the language; oral traditions; Religion and 'world view': ideas about the meaning of life and death; rituals surrounding important life events; ideals about the possibility and desirability of change; Patterns of social influence, social networks and political organisation: influences in family and community; community leadership and authority; political structures; divisions and social inequalities; and Economic patterns, types of employment:

HEALTH BEHAVIOUR Intrapersonal (individual) factors Interpersonal Knowledge Attitudes Beliefs Interpersonal factors Family Friends Peers HEALTH BEHAVIOUR Community factors Norms Standards Institutional factors Rules Regulations Policies Public policy Local and national laws Regulations Figure 3.6 An ecological model for health promotion (McElroy, 1988)