Health knowledge, attitudes and behaviour Synopsis: This lecture follows on from the lecture: “What kills us?”. In the preceding lectures, the argument has been developed that human behaviour and organization are the key determinants of health, illness and disease. This lecture begins to explore two major factors which are considered important in human behaviour - what people know (knowledge) and the views people take of things (attitudes). Both of these underpin much research into human health-related behaviour. For example, HIV/AIDS is a problem because of sexual practices, lung cancer because people smoke tobacco, diabetes because of the diet and activity patterns people have, GI cancers largely a result of the diet, smoking and drinking patterns people have, together with food preservation and bacteriological factors, while hypertension and coronary heart disease are both currently believed to involve diet and activity, amongst other things. Why and when people use health care resources are determined again by their actions. What people do when they feel ill and the factors that influence their choices are also strongly influenced by their attitudes. However, so far, models have not done a good job of explaining much of the variation in human health related behaviour by simply manipulating knowledge and attitudes. Despite this, considerable effort is being put into influencing both knowledge and attitudes in attempts to improve both community and individual health. R.Fielding

Learning objectives At the end of this lecture, you should be able to give a balanced account of the role of knowledge in behaviour change define “attitudes” and explain how they relate to both knowledge and behaviour The teaching objectives for this lecture are to introduce to you a series of basic perspectives regarding the roles of attitude and knowledge in health. To acheve this, you need to ensure you have met the learning objectives. First, you must be able to give a balanced account of the role of knowledge in behaviour change. You must be able to define the term “attitudes” and explain how these are believed to relate to both knowledge and behaviour. You must be able to define “self-efficacy”, and say why it is currently an important concept in behaviour change, and you should be able to think of and illustrate with good examples, barriers to health-related behaviour change. Finally, you could try to think of ways to overcome these different barriers

Continued define “self-efficacy” and explain why it is important in behaviour change give examples of barriers to behaviour change and examples of ways to overcome these.

Why is this topic important? CHD, HT, CVD and Cancers are commonest causes of death in HK and many other countries. Most can’t be cured, but a majority of cases could be prevented. Most of these diseases arise from people’s lifestyle (i.e. their behaviour), e.g. no exercise, diet, smoking. Why? As previous lectures have already shown, behaviour is a principal factor in the current epidemic of chronic diseases. Most of the major degenerative, chronic conditions that clog up health care services are incurable (which is why they’re chronic) without major transplantation technology, which is extremely expensive and replacement organs tends to develop the same problems as the original organs, unless recipients change their behaviour patterns significantly. For infectious conditions, such as TB, HIV/AIDS and hepatitis, behaviour is even more crucial. TB is the most important infectious disease on the planet and kills more people than any other, even though cheap and effective treatments exist, and growing antibiotic resistance is a result of human behaviour, including that of doctors.

Why is health knowledge important? To prevent disease people must change their hazardous behaviour. Why do people behave in ways hazardous to their health? Because most people don’t think of their health until it is threatened or they lose it, preferring instead to pursue their goals. Why is knowledge important? Health knowledge, or education, refers to the knowledge and understanding people have about health-related issues. It is important that people understand the causes of ill-health and recognise the extent to which they are vulnerable to, or at risk from, a health threat. In other words, knowledge is a necessary component of behaviour change, but on its own, it is not sufficient to bring about behaviour change. Why do people behave in ways that are hazardous to their health? For a number of reasons. Approximately how many times have you actively and deliberately thought about your health in the past six months? Very few, unless you have had some prompt, such as an active illness episode as a prompt. Most people don’t think about their health until it goes wrong, is threatened or is brought to their attention. Research has shown that, even when smokers are shown the cancerous lungs of other smokers removed post mortem, the decision to stop smoking lasts only about 24-48 hours, after which the impact is not noticeable in terms of their behaviour. Many of the things that are hazardous to health happen to be enjoyable or desired by most people. How many of you would stop eating seafood if you learned that each day 5 tons of toxic heavy metals are poured into Hong Kong’s waters , which end up in the food chain and eventually the fish you eat? Would you? For how long? See what I mean? Most adults who smoke, in Hong Kong anyway, are aware of most of the hazards of smoking, but chose to continue smoking anyway. In other words, peoples’ goals are usually not the same as those of health professionals

So why is knowledge important? Ignorance of health hazardous behaviour. Knowledge is a first step to changing behaviour. But knowledge alone insufficient to change behaviour. So knowledge is an important and necessary step - if people don’t know something is a hazard, they will continue to do it in ignorance of the risks it poses to them. To change behaviour, you first have to make people aware of the consequences of their behaviour. However, as has been said a number of times, knowledge alone is not sufficient to change behaviour. If it was, no one would smoke cigarettes, drive a car or eat most of the food available in HK. Two terms you might have heard but not be sure what they mean are risk and hazard. Risk is the quantification of a likely outcome occurring; a hazard is something that can cause harm.

Is knowledge alone sufficient? Not usually, although it helps. Knowing something can affect your health and perceiving a health threat are not the same. Once a threat is recognised, people may be more motivated to change their behaviour, except.... Knowing that something is a risk to your health and perceiving it as a threat (the anticipation of actual or imagined harm, which may be physical, psychological, social, financial or in any other form) are not the same. Knowledge will not motivate consideration of behaviour change unless it constitutes a threat to the person. Once a threat is recognized, then they may take some action, but the action may not be what is anticipated. Threat arises when there is the perception that some form of harm will occur. However, there is more than one way to avoid the threat. The person can stop the behaviour associated with the threat. This may be easy if it is not a valued or regular pattern of activity and is not constantly cued by a range of environmental factors, such as place, people, or time (examples of such cues are eating lunch at 1.00pm in a restaurant with your friends, smoking a cigarette with a cup of coffee when meeting friends, and so forth). However, if it is a regular pattern of behaviour valued by the person, there will be much less chance of it being changed. Instead, the person can escape the threat by moving away from it psychologically. These processes, such as cognitive dissonance and denial, are ways that people change their thinking to avoid confronting inconsistencies between what they do and what they believe. These processes are sometimes called psychological defense mechanisms.

Except what??? Unless the threat is imminent (with severe consequences), most people will ignore or forget it. Conversely, where a threat is perceived significant changes in behaviour may occur. e.g. belief that tap water in HK is unsafe to drink. Factors determining whether people change their behaviour in the face of a threat include imminence (how soon the threat will materialize). Threats that are likely to have an imminent impact will be more likely to motivate change in behaviour than will threats that will not manifest until 20 years later. As most health threats fall into the latter category of long-term threat, threat itself seldom generates the motivation to change. Events which trigger threat may be much more effective. For example, a heart attack in an otherwise well individual may promote a rapid change in behaviour because it represents a relatively unpredictable manifestation of an unanticipated threat. It could happen again at any time. But to many young adults, the hazard of lung cancer from smoking cigarettes may be 20-40 years away, plenty of time to change their behaviour, and so they may continue to smoke without any worries. The converse is also true. Where the perception of a threat exists, particularly when the manifestation of the hazard is uncertain, then behvaior changemay be maintained or reisted, despite the absence of any actual hazard inherent in the behaviour. Can you think of an example in HK? A good one is the belief that tap water in HK is not suitable for drinking, but must be boiled first. How many of you have been told by your family not to drink tap water unless it is boiled?

...and... e.g. UK, BSE in beef --> drop in beef consumption. Though beef is now safe, consumption remains low. e.g. most people who smoke know health risks, but continue to smoke (Li et al, 1996). In other words, there is often little correspondence between actual risk of a hazard and peoples’ perceptions of threat. It is largely the perception of threat that drives behaviour change, rather than objective knowledge of a hazard or clear estimations of risk. These perceptions are more like value judgements and can change depending on the salience (relevance and importance) that events and outcomes have for people. There is also the question of how much enjoyment, or other benefits a person perceives or believes they derive from the activity. Many enjoyable behaviours, as we have seen, can pose significant risks to health (sex, smoking, drugs, drink, driving, adventure sports, sunbathing are all risky behaviours). The perceived costs, in terms of loss of life quality, in giving up these activities may outweigh the perceived health benefits of doing so. In other words, people will try to maximize their gains while trying to minimize their losses when it comes to behaviours.

Why is attitude relevant? Attitudes are evaluative social judgements -orientations that locate objects of thought on dimensions of judgement Mixtures of components cognitive: beliefs emotional: feelings behavioural: predispositions to act Attitudes are value-ladened social judgements which possess a strong evaluative component. They are ways of viewing a particular set of values within a framework of different judgement criteria. We all have attitudes, lots of them, about almost everything, particularly socially-relevant things to do with behaviour of ourselves and others. Attitudes are constructs that psychologists have defined to help explain the values people hold - they have no “real”, objective existence as such, but can be shown to have different components. These include cognitive (belief), emotional (feeling) and behavioural (predispositional) elements. Recall something you feel strongly about. There, you have an attitude! Consider the different parts of this attitude: how you think about the subject affects how you feel, and it may generate a feeling of needing or wanting to do something about it. Attitudes even bias the kinds of things a person will remember about an event and even the kinds of information they will seek out on a subject. This usually reinforces the attitude. If you want to find out more about attitudes, you can look in Weiten: Psychology:Themes and variations (1992)

Do attitudes predict behaviour? Usually not very well. Giving information which changes attitudes doesn’t always change behaviour. Why? attitudes are generalisms, behaviours are more specific; attitudes are only predispositions to act. So, do attitudes do a better job of predicting behaviour? Well, a bit better. But it can be notoriously difficult to change peoples’ attitudes. When you give information which changes attitudes, it doesn’t always change behaviour. This is because attitudes are not motivations, but they are general perspectives or orientations that people hold. While they may predispose you to behave in a certain way, say to vote for rather than against something, in themselves they only give a predisposition, not activation. Behaviours are more specific acts. Numerous attempts to link behaviour change to attitude change have produced mixed results. Again, what we can say is that a change of attitude is often a precursor to behaviour change, but is not a guarantee of such change. Behaviour change itself will often lead to attitude change as much as will attitude change to behaviour change. In fact, much more research supports the notion that by changing behaviour it is easier to change attitude, than the other way around. However, because people cannot really be coerced into changing their behaviour to improve their health, this is seldom done. When it is, such as with laws demanding the use of seat belts in cars, attitude change often follows. But not always. Prohibition of alcohol use in the USA in 1919-1929 lead to underground drinking dens, while attempts to ban certain activities, such as religious practice in China have not been successful at changing many peoples’ attitudes towards religion.

Changing attitudes To effectively change attitudes you need: credibility (expertise/ trustworthy) likeability (physical attractiveness) persuasive arguments to consider listener’s original position. But sometimes there is a need to change peoples’ attitudes. In fact, attitude influencers are at work all around you, continuously. They have been called the “Hidden Persuaders”. Can you guess what I’m talking about? The advertising industry. Advertising exists to persuade you to change your behaviour, and instead of using product A, wants you to use product B. To do this, they use a wide range of psychological techniques. Think about adverts you have seen on TV recently. Most ads show attractive and high status people giving persuasive messages. By also considering the listener’s original position, an advert - or you - can present a persuasive means of changing attitude. Think about the people you have met who have had a major impact on our attitudes. What were their characteristics?

To effectively change behaviour, you need... Recognition that behaviour change is needed / desirable Motivation to make change Belief that change can occur and be maintained (perceived self-efficacy) Triggers/cues to initiate change Perceived benefits of that change. Changing attitude is one thing. The change behaviour requires a different set of factors, many of which we have already considered. The recognition and motivation to make a change may be present. However, if the person does not believe they will be successful in achieving the change, they will probably not be successful and may not even try. This is perceived self-efficacy. It refers to the belief that you can be effective when you attempt things and will be successful. Compared to people who perceive themselves as having low self-efficacy, those who perceive high self-efficacy will try harder, and keep trying longer in the face of repeated failure. As a result, they more often succeed than do those with low perceived self-efficacy. Other important components are some trigger or cue to initiate change and a clear sense of what benefits will occur as a result of making the change.

What is perceived self-efficacy? Modelling w. guided mastery --> new skills, but these not applied if no use. Acquiring vs. using skills effectively under different circumstances. “Success requires not only skills, but also a strong self-belief in one’s capabilities to master problems.” (Bandura, 1986) Perceived self-efficacy has been shown to be a powerful influence on behaviour. A tremendous amount of research has examined how to improve or change behaviour. A moment’s though would reveal that the potential applications of such a technique would be potentially limitless, in education, health care, correctional services, management and occupations. However, perhaps fortunately, we have not yet managed to find out how to do so very effectively. Most learning, like the kind you do when in the skills lab, involves what is called guided mastery. This is where an “expert” demonstrates the skill by modelling it, then you try to imitate that skill. The expert guides and gives feedback on your performance. While this is a good approach to acquire new skills, but if they do not work, or are not useful, the skills will not be applied, no matter how well they have been learned. There is a difference between acquiring and using skills under different circumstances. Reasearch has shown that, in addition to the skills, success also requires a strong belief in one’s capabilities to master problems - self -efficacy.

PSE affects every stage of change process: whether or not people consider changing how hard they try if they choose to do so their resiliance following setbacks how well they maintain the gains achieved (Bandura, 1986, p.162). This slide shows how and where self-efficacy influences behaviour change. As you can see, it impacts at every level.

...and Modelling?... Seeing effective practices in use is v. persuasive. greater demonstrable benefits, greater likelyhood example will persuade. exhortations to change are by themselves mostly useless. Confucian society relies on example for changing behaviour. Observing effective practices is a good way to prompt increases in effort to change. Through a series of simple steps which ensures success, people can learn to increase their perceptions of self-efficacy. Together with increasing perceived self-efficacy, modelling and guided practice are good ways to teach behaviour change skills. All that remains then is the need to demonstrate benefits from maintaining the new behaviour which outweigh the influences or benefits of returning to the previous behaviour. The greater are the demonstrable benefits of behaviour change, the greater will be the likelihood that change will be tried. Simply asking or telling people to change will not be very helpful, and are usually pretty useless. In traditional Confucian society, behaviour is taught by example by older and more experienced members of the community and emulated by younger members. Various incentives and disincentives traditionally helped people to adhere to strict protocols of behaviour.

Knowledge Attitude Behaviour This is not how it works. You will frequently see this kind of model being describe or proposed in the literature. Unfortunately, this is seldom the case. In a researcher’s dream things may work this neatly, but in reality, it is just a likely to be the other way around, or the case that none of the components have much influence on the other two. This is not how it works.

So..is health behaviour change hard to achieve...? Yes. Treatment non-adherence ranges from 30-60% Prophylactic treatment adherence only 30-35% Protective health behaviour 10-30% As you probably realise by now, much of your work as a doctor will revolve around getting your patients to change their behaviour. And you will also have realised that such change is quite hard to achieve, easier in some cases than others,. A moment’s glance at some health-related data will reveal the extent of the problem. Peoples’ adherence to treatment is usually not much better than 505; that is, one in two patients do not follow doctors’ instructions regarding treatment. For treatment regarding preventive measures, such as exercise or smoking cessation, the adherence rate drops to a low one in three, while for protective health behaviours, such as wearing a condom when having sexual intercourse, the adherence rate falls to as low as one in ten. This is not a very encouraging picture. And yet, behaviour change is probably the best way to deal with the problem of chronic disease.

Yet, people indulge in all kinds of health related activities - clearly it isn’t an aversion to these so much as an unwillingness or inability to adopt specific regimens prescibed by health professionals. And as the slide suggests, people’s behaviour indicates they are not averse to health-relevant behaviours so much as being unwilling or unable to follow specific regimens prescribed by health care practitioners (HCPs). From a psychological perspective, patterns of behaviour are often cued and thereby controlled, by environmental and social contingencies, or settings. One reason why behaviour change is so difficult is because the contingencies help elicit behaviour, This means that most behaviour you demonstrate is evoked by the context within which it occurs, rather than being a pure and independent act of free will. Consider this: why are you reading this? Wouldn’t you rather be doing something else? Eating? sleeping? talking or playing with friends? But you are reading this because the contingencies that exist around the context of studying elicit certain patterns of behaviour. Why do you study? Because you have certain goals you want to achieve. Why do you have these goals…? As you can see, you are inexorably tied into your own social contexts in such a way that makes changing the patterns of your behaviour rather difficult. Try stopping studying for six months and see what happens. You would find it very hazardous to your career to do so and I’m not advocating that you do this. But it serves to illustrate how behaviour is controlled by our contexts a lot more than we generally acknowledge.

Is it really that bad? Yes. Health behaviour change approaches usually ineffective. Few achieve more than the preoportions of people who successfully keep their New Year’s Resolutions. But if health workers adopted better methods, they would be more effective. Because of these contextual factors, its quite difficult to create halth behaviour change. The success rate is about the same as it is for people who successfully keep their New Year’s Resolutions. How many have you succeeded in keeping? Have you ever made one?

…Are health professionals better? Literature indicates HCPs do not follow clinical procedures they know should be implemented: Physician performance ranges between 48-72% of professional standard (Peterson etal, 1980) Because HCPs are people too and controlled by similar contingencies and contexts just like everyone els, they farelittle better when t comes to changing their own behaviour. Studies have shown that only between 48-72% of physician performance meets recommended professional standards of practice.

Nurses deviate from infection control rules (Raven & Harley, 1982) Dentists fail to adequately shield patients during x-rays (Green & Neistat, 1983), 20% error rate in care procedures in old people’s homes (Kayne & Cheung, 1973). etc... Nurses, also, often deviate from care practice guidelines, including rules for control of infection, often failing to wash their hands between touching patients, or not administering analgesic medication as required. These are a basic and simple practice, but work contingencies and a lack of appreciation for the seriousness of their actions can drive the behaviour to the most simple and least-effort route of care. Similarly, dentists unnecessarily expose patients to x-rays because they fail to correctly follow procedural guidelines closely enough. And so on. There are lots of different examples of this kind of problem. A further example is the high error rate in care procedures for older people in old people’s homes. You also cannot have failed to notice the recent spate of medical and nursing “errors” in Hong Kong’s hospitals, ranging from incorrect dialysis procedures through to medication errors.

Do HCPs modify their behaviour? Self-imposed protocols designed to improve care for UTI in primary care clinics were adhered to between100%-38% of the time. (Sullivan et al, 1980) We know that HCPs are just as likely to resist behaviour change for exactly the same kinds of reasons as are patients. Similarly, studies which have looked at the problem of trying to overcome care deficits among HCPs have failed to achieve very significant improveents. This is the case even when the practitioners themselves decided they wanted to change their own behaviour, so there isn’t likely to have been a problem of lack of motivation. In fact, studies that have looked at HCPs attempts to change their own behaviour have shown that new guidelines were not followed between 0-62% of the time, a very wide range of response, not that different from rates reported in studies of patient adherence.

Cont. US Residents in internal medicine given update reading materials on 13 common preventive care actions: adherence to recommendations <10% of time. (Cohen, 1985). When the equivalent of prophylactic practice was recommended for a sample of US Senior Medical Officers on preventive care actions, there was less than 10% adherence rate. This is among the lowest adherence figures in the literature. All these data indicate that HCPs as well as non-medical persons have considerable difficulties changing behaviour. It is important therefore, that careful adherence to principles of behaviour change be followed if behaviour change efforts are to be effective in medical practice. The problem is, as these studies suggest, most of you will not follow my recommendations for behaviour change practice yourselves, for exactly the same reasons!!!!

Why are things so poor among HCPs? The same factors that influence the public probably influence HCPs. These include: beliefs & attitudes of people about their actions the complexity of the procedures advocated the perceived costs (ie effort) versus benefits Those reasons include: the beliefs and attitudes we hold about people and why they behave the way they do - these implicit lay theories do not accurately reflect the reasons for people’s behaviour - for example, we assume that when other people act “incorrectly”, it is because they have some character deficit - because they are “bad people”, yet when we ourselves act badly, we explain it by blaming events and circumstances. Conversely, when other people succeed, we often explain it by reference to good luck or favorable circumstances, but when we ourselves succeed. We attribute the reasons to our abilities. In other words, the implicit theories we use to explain our won behaviour are the opposite of those we use to explain other people’s behaviour. This is called Fundamental Attribution Error by psychologists. A s second set of reasons is that, often, changes require the adoption of new skills or practices where the person has low perceived self-efficacy for change or which are perceived as being complex or requiring high levels of ability or skill to master. Finally, there is the problem of the perceived benefits from making the change being seen as not worth the costs of the giving up the old behaviours. In other words, its too much trouble to learn a new set of behaviours. You can find out more by following the links at the end of this lecture to other related topics that considersome of these points further.

Cont. low perceived self-efficacy faulty memory inadequate skills and resources previous failures. So, these factors, which include low perceived self-efficacy, attribution error, poor memory, inadequate skills and resources and previous failures all conspire to place considerable resistance in the path of people seeking change. While most health education programmes try to address the deficits in memory, skills and resources, few extend to addressing low perceived self-esttem and challenge both attribution errors and redressing previous failure. Finally, of course, there has to be sufficient motivation to change.

Implications “There is enough evidence of professional non-compliance for it to seem likely that even if clinicians were aware of these techniques, they would not necessarily use them.” Ley, (1986). The reality is that, even when they are made aware of the shortcomings in their practice, HCPs often do not make use of the techniques necessary for behaviour change because of the very reasons that their patients do not themselves achieve behaviour change.

Implications cont. If clinicians will not change their behaviour, are we being realistic in expecting patients to do so just because we exhaut them to? No, we need to change our behaviour if we expect patients to change theirs. This raises and interesting question: Is it realistic or even fair to expect behaviour change on the part of patients when HCPs themselves do not demonstrate the ability to change their own “behaviour change” behaviour? What do you think? And what does this suggest about the strategies we should use to tackle chronic disease? You can look at these associated lectures that address some related issues: see next slide for the links

The End. Attitudes 2: Interactions with patients. Addiction and behaviour. Who are you? Individuals and groups. These links are to associated lectures Attitudes 2 examines the social psychology of perception and attitudes in more theoretical detail and explores how we perceive and why we behave towards others n the ways we do. Addiction and behaviour gives a social psychological refutation of the neurochemical theory of drug addiction and proposes that alternative, social process better account for this phenomenon. This is related to how we see ourselves and how we explain our behaviour. Finally, Who are you? Looks at some of the influences of individual and group on defining who we are. This lecture addresses only the tip of the iceberg in this fantastically complex and intriguing area. Because these lectures are not scheduled in the Foundation course, they do not appear in the course handbook or lecture schedule for the MBBS foundation course on our home page. You can only get to them by following the above links.