Oana Ciocanel Directorate of Public Health NHS Tayside

Learning outcomes Understand what are health behaviours and how they relate to health Understand and evaluate the contribution of different social cognition models to predicting and changing health behaviour

Overview of Lecture Health behaviours: o What are health behaviours? o Why study health behaviours? o What factors predict health behaviours? Social cognition models o Types of SCMs o Three social cognition models: 1. Health Belief Model 2. Theory of Planned Behaviour 3. Transtheoretical Model of Change

What are Health Behaviours? Definition: “Overt behavioural patterns, actions and habits that relate to health maintenance, health restoration and health improvement” (Connor & Norman, 2005). Examples: o Health impairing habits (e.g., Excessive alcohol consumption, smoking, eating a high fat diet); o Health enhancing behaviours (e.g. exercise participation, healthy eating); o Health-protective behaviours (e.g. health screening, vaccination against disease). (Matarazzo, 1984)

Leading Causes of Death All Ages: Ages 15-24: 1. Heart disease 2. Cancer 3. Stroke 4. Chronic lung disease 5. Accidents 6. Pneumonia/influenza 7. Diabetes 8. AIDS 9. Suicide 1. Accidents 2. Homicide 3. Suicide 4. Cancer 5. Heart disease 6. AIDS 7. Congenital anomalies 8. Chronic lung disease 9. Pneumonia/influenza

Behaviour and Mortality  50% of deaths from the leading causes of death are due to modifiable lifestyle and behavioural factors: 1. Tobacco 2. Diet and activity patterns 3. Alcohol 4. Sexual behavior 5. Motor vehicles 6. Drug use 7. Screening

Alameda County Study (Belloc and Breslow, 1972) Seven healthy habits associated with physical health status and mortality:  Not smoking  Having breakfast each day  Having no more than one or two alcoholic drinks per day  Taking regular exercise  Sleeping seven to eight hours per night  Not eating between meals  Being no more than 10 per cent overweight

The role of health behaviours  Reduce mortality and morbidity: o Reduce the risks of developing serious illnesses (e.g. lung cancer, coronary heart disease, stroke, cirrhosis of the liver) o Expand years of life from chronic disease complications (e.g. Type 2 diabetes);  Reduce health care costs;  Possible impact on quality of life and well being;  Greater individual responsibility for health;  Potentially modifiable through interventions.

Factors extrinsic to the individual: Incentives structures (e.g. Taxing tobacco and alcohol); Legal restrictions (e.g. Fining individuals for not wearing seatbelts, banning dangerous substances).

Factors intrinsic to the individual: Demographic factors (e.g. age, gender, socioeconomic and ethnic status); Social factors (e.g. learning, reinforcement, modelling and social norms); Genetics (e.g. Possible genetic basis for alcohol use); Socio-economic/Environmental (e.g. Income, access); Emotional factors (e.g. anxiety, stress, tension and fear); Personality factors (e.g. Sensation seeking); Cognitive factors (e.g. knowledge, beliefs, attitudes- patient and health professionals).

Social Cognition Models (SCMs)  Basis for health behavioural interventions  Widely used to examine the predictors of health behaviours using individuals’ cognitions to: o Understand determinants of current intentions and behaviour o Predict future health intentions and behaviour o Predict which determinants should be targeted to change behaviour  Trying to answer the following question: o Why (and how?) would a person change (or not) his or her health behavior?

Types of Social Cognition Models Armitage and Conner (2000): 1. Motivational Models (e.g. The HBM, PMT, TPB).  Focus on the motivational factors that support individuals' decisions to perform (or not to perform) health behaviours.  They imply that motivation is sufficient for successful behavioural enaction. 2. Behavioural Enaction Models  Focus on post-intentional (motivation not sufficient for action)  Focus on bridging the "gap" between motivation and behaviour 3. Multi-Stage Models (e.g. HAPA, TTM)  Individuals at different stages behave in different ways  Interventions should be stage-matched

Health Belief Model (HBM) (Rosenstock, 1966; Becker et al, 1974) Background Perceptions Action Threat Analysis of the costs/benefits Demographic variables Psychosocial variables Structural variables Susceptibility Severity Perceived benefits Perceived barriers Likelihood of behaviour Cues to action Health Motivation Adapted from Janz & Becker (1984). Health Education Quarterly, 11, 1-47.

HBM-Example: Smoking cessation Perceptions Action Threat Analysis of the costs/ benefits Susceptibility: “If I don’t stop smoking there is a high possibility I will get lung cancer” Severity: “Lung cancer is a serious illness” Benefits: “If I stop smoking I will have whiter teeth and fresher breath” Barriers: “ Stopping smoking will make me put on weight” Likelihood of Stopping smoking Cues to action: the symptom of breathless; information in the form of leaflets.

HBM-Evidence The HBM has been applied to a wide range of health behaviours:  Uptake of flu vaccinations  Anti-hypertensive regimes  Breast self-examination  Risk factors behaviours (e.g. Attendance at health check- ups, dietary change, smoking cessation, seatbelt use, etc.) Overall, the HBM is marginally successful in predicting health behaviours.

HBM-Evidence cont’  Janz and Becker, 1984  Literature review of studied published between :  Perceived barriers most significant variable for predicting and explaining health related behaviours  Other significant HBM components were perceived benefits and perceived susceptibility  Perceived severity -the least significant variable  Mullen and Green,1992  Meta-analysis:  Small impact of constructs on health behaviour  Sutton, 1982 : Unclear impact of cues to action and health motivation

HBM-Limitations Ogden (2007):  Absence of emotional factors (i.e. Fear, anxiety, denial);  Relationships between components not well described;  Its focus on rational processing of information  Its emphasis on the individual-absence of social or economic factors;  Static approach to health beliefs: beliefs are described as taking place concurrently with no room for change, development or process.  Unclear impact of “cues to action”

Activity  Work in pairs. Discuss how HBM explains behaviour, using the following example: This is Scott He has type 2 diabetes. He is overweight, not very active and he is not taking his medication as prescribed. This is not good because we know failing to manage diabetes can lead to long-term complications, such as heart disease, eye problems, kidney problems, feet problems, etc. According to the HBM, what cognitions would help Scott to increase the likelihood of being more active, lose weight and take his medication as prescribed?

Beliefs about outcomes Evaluations of these outcomes Beliefs about important other’s attitude to behaviour Motivation to comply with others Internal control factors External control factors Attitude towards the behaviour Subjective norm Perceived behavioural control Behavioural intention Behaviour Theory of Planned Behaviour (TPB) (Ajzen, 1985)

Attitudes towards reducing alcohol intake: “I think reducing my alcohol intake would help me improve my relationships with my wife and children and will be beneficial to my health” Subjective norm “My family really wants me to cut down” Perceived behavioural control: “I am confident I can drink less alcohol” Intention: “I intend to drink less alcohol” Behaviour: “Reduce alcohol intake” TPB-Example: Reduce alcohol consumption

TPB-Evidence  TPB applied to a range of health behaviours (e.g. drug use, condom use, dietary behaviour, alcohol consumption, health screening attendance, exercise, etc.) Schifter and Ajzen (1985) examined TPB in relation to weight loss. TPB components predicted weight loss. Perceived behavioural control better predictor of weight loss than other components. Povey et al (2000) investigated the intentions of people to keep a low-fat diet and or to eat five portions of fruit and vegetables per day. The TPB components predicted intentions but not behaviour. Self-efficacy was found to be a better predictor of behaviour. Brubaker and Wickersham (1990) studied the role of TPB components in predicting testicular self-examination. Attitude towards the behaviour, subjective norm and behavioural control (measured as self-efficacy) were associated with the intention to perform the behaviour.

TPB-Evidence Cont’ Armitage &Conner (2001)  Meta-analysis of 185 observational studies  TPB accounted for 39% variance in intention and 27% in variance in behaviour Godin and Kok (1996)  Meta-analysis of 87 TPB studies applied to health behaviour.  TPB accounted for 41% of the variance in intentions and 34% of the variance in behaviours. Attitudes and perceived behavioural control better predictors of intentions than subjective norms Additional constructs including self-identity, moral norms, anticipated regret and past behaviour may help explain intentions and improve translation to behaviour (Conner and Armitage (1998); Conner et al (2000).

TPB-Strengths and Weaknesses  Strengths: Includes a degree of irrationality (in the form of evaluations) Takes into account some social and environmental factors (in the form of normative beliefs). Includes a role for past behaviour within the measure of perceived behavioural control.  Weaknesses Omission of factors such as demographics and personality No clear definition of “perceived behavioural control” (hard to measure) Failure to describe the order of the different beliefs or any direction of causality (See Schwarzer,1992)

Activity Groups of three or four Choose a health behaviour (e.g. Alcohol consumption) Conduct a short focus group to identify the most important beliefs that are relevant to attitudes, subjective norms and perceived behavioural control.  Make a list of the most mentioned beliefs or commonly agreed themes.

Precontemplation Increase awareness of need to change Contemplation Motivate and increase confidence in ability to change Action Reaffirm commitment and follow-up Termination Transtheoretical Model (Prochaska & DiClemente, 1992) Relapse Assist in Coping Maintenance Encourage active problem-solving Preparation Negotiate a plan

Stages of change Precontemplation Contemplation Preparation Action Maintenance Relapse

TTM-Example: Weight Loss StageCharacteristicPatient verbal cue Appropriate intervention Pre- contemplation Unaware of problem Can’t see the problem No interest /intention to change “I am not really interested in weight loss. Weight is not a concern for me”  Provide information about health risks and benefits of weight loss Contemplation Acknowledges the problem Beginning to think about change No specific plans in place “ I know I need to lose weight but I am too busy right now to start making any changes”  Help resolve ambivalence, discuss barriers

StageCharacteristicPatient verbal cue Appropriate intervention Preparation Focus on solution and future Realises the benefits of losing weight and starts making plans Full commitment “I am ready to start making some changes to lose weight”  Provide education, teach behaviour modification; Help setting an agenda, a coping plan etc. Action Actively taking steps towards behaviour change “ I am doing my best. I am eating healthier and exercising regularly”  Provide guidance and support and discuss long-term Maintenance Initial treatment goals reached Old behaviour is still a temptation “I have lost quite a few pounds”  Relapse control

TTM-Evidence Has previously been applied to a wide variety of problem behaviours:  Smoking cessation  Exercise  Low fat diet  Alcohol abuse  Weight control  Drug abuse  Medical compliance  Use of sunscreens to prevent skin cancer

TTM-Strengths and weakness Strengths Has been applied widely and it is linked to practice Offers some insight into the processes of change It also gives methods for moving people from one stage to the next Weaknesses: The model does not explain the role of social and cognitive factors in the change process The description of change is rather unsatisfying; no details are provided about how people change and why some individuals will be successful and others not.

Stages of change-Activity 1. Pre-Contemplation: the person does not identify the issue as a problem 2. Contemplation: the person begins to identify the issue as a problem 3. Preparation for Action: the person seeks information, support and alternatives for making a change 4. Action: the person begins to make a change in her/his life 5. Maintenance: the person sustains the change

Social Cognition Models Potential Advantages: 1.Provide a clear theoretical background to research 2. Identify targets for interventions Potential Disadvantages: 1.Neglect other (non-/cognitive) variables 2. How to change cognitions?

Criticisms of SCMs SCMs are only concerned with cognitively mediated behaviours They do not take into account the direct effects of influences of emotional factors and social factors. People do not always do what they intend (or claim they intend) to do (“the intention-behavior gap”) Attitudes predict some health-related behaviors, but not others They assume the same variables predict health behaviours for diverse groups of people. The predictive power of these theories is greater for some groups (high-SES, for example) than for others

Criticisms of SCMs Cont. The theories ignore past experience with a specific health-related behavior and past behaviour is often the best predictor They do not describe in much detail how intentions are translated into action They are unrealistically complex Health habits are often unstable over time

References Armitage,C.J. & Conner, M. (2000). Social cognition models and health behaviour: A structured review. Psychology and Health, 15: Conner, M. & Norman, P. (1996). Predicting Health Behavior. Search and Practice with Social Cognition Models. Open University Press: Ballmore: Buckingham. Ogden, J. (2007). Health Psychology: A textbook. (4 th ed). Buckingham: Open University Press. Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), Prochaska, J.O., Velicer, W.F., Rossi, J.S., Goldstein, M.G., Marcus, B.H., Rakowski, W., Fiore, C., Harlow, L.L., Redding, C.A., Rosenbloom, D., & Rossi, S.R. (1994). Stages of change and decisional balance for twelve problem behaviors. Health Psychology, 13(1),