Theories of Health Behaviour

1. Theories of Health Behaviour Health Psychology

2. Attribution theory • According to the basic tenets of attribution theory people attempt to provide a causal explanation for events in their world particularly if those events are unexpected and have personal relevance (Heider, 1958). Thus it is not surprising that people will generally seek a causal explanation for an illness, particularly one that is serious.

3. Attribution theory • Taylor et al. (1984) interviewed a sample of women who had been treated for breast cancer. They found that 95% of the women had a causal explanation for their cancer. These causes were classified as stress (41%), specific carcinogen (32%), heredity (26%), diet (17%), blow to breast (10%) and other (28%).

4. Women’s causal explanations for breast cancer

5. Attribution theory • They also asked the women who or what they considered responsible for the disease and found that 41% of the women blamed themselves, 10% blamed another person, 28% blamed the environment and 49% blamed chance. The patients were also asked whether they felt any control over their cancer and they found 56% felt they had some control.

6. The women’s attribution of responsibility for their cancer

7. Attribution Theory • Weiner et al. (1972) suggested that we can classify attributional dimensions along three dimensions: • 1 Locus: the extent to which the cause is localized inside or outside the person.2 Controllability: the extent to which the person has control over the cause.3 Stability: the extent to which the cause is stable or changeable.

8. Health Locus of control • Health locus of control, like attribution theory, also emphasises attributions for causality and control.

9. Health Locus of control • Wallston and Wallston (1982) developed a measure of the health locus of control, which evaluates whether individuals regard their health as controllable by them or not controllable by them or they believe their health is under the control of powerful others.

10. Health Locus of control • Health locus of control is related to whether individuals changed their behaviour and to the kind of communications style they require from health professionals.

11. Health Locus of control • There are several problems with the concept of a health locus of control: • Is health locus of control a fixed traits or a transient state? • Is it possible to be both external and internal? • Going to the doctor could be seen as external (the doctor is a powerful other) or internal (I am looking after my health).

12. Unrealistic optimism • Unrealistic optimism focuses on perceptions of susceptibility and risk. • Weinstein (1984) suggested that one of the reasons why people continued to practice unhealthy behaviours is due to inaccurate perceptions of risk and susceptibility - their unrealistic optimism.

13. Unrealistic optimism • He asked subjects to examine a list of health problems and displayed what "compared to other people of your age and sex, are your chances of getting the problem greater than, about the same, or less than theirs?" Most subjects believed they were less likely to get the health problem.

14. Unrealistic optimism • Weinstein (1987) described four cognitive factors that contribute to unrealistic optimism: • 1. Lack of personal experience with the problem • 2. The belief that the problem is preventable by individual action

15. Unrealistic optimism • 3. The belief that if the problem has not yet appeared, it will not appear in the future • 4. The belief that the problem is infrequent.

16. The transtheoretical model of behaviour change (stages of change model) • The transtheoretical model of change emphasises the dynamic nature of beliefs, time, and costs and benefits.

18. The transtheoretical model of behaviour change (stages of change model) • 1. Precontemplation: not intending to make any changes • 2. Contemplation: considering a change • 3. Preparation: making small changes • 4. Action: actively engaging in a new behaviour • 5. Maintenance: sustaining change over time

19. The transtheoretical model of behaviour change (stages of change model) • Individuals would go through these stages in order but might also go back to earlier stages. • People in the later stages, e.g. maintenance, would tend to focus on the benefits (I feel healthier after giving up smoking), whereas people in the earlier stages tend to focus on the costs (I will be at a social disadvantage if I give up smoking).

20. The transtheoretical model of behaviour change (stages of change model) • A relationship has been found between level of education and the stage of change reached when contemplating taking regular exercise.

21. The transtheoretical model of behaviour change (stages of change model) • Those people with lower levels of education tended to be at an earlier stage of change (Booth et al. 1993), and therefore it could be argued that the model could be improved by taking account educational attainment in order to help predict the length of time a person is likely to remain at the earlier stages.

23. Health belief model • Support for individual components of the model. • Norman and Fitter (1989) examined health behaviour screening (for example breast cervical cancer) and found that perceived barriers (the costs of attending) were the greatest predictors of whether a person attended the clinic.

24. Health belief model • Several studies have examined breast self-examination (BSE) behaviour and report that barriers (Lashley 1987; Wyper 1990) and perceived susceptibility (the likelihood of having the illness) (Wyper 1990) are the best predictors of healthy behaviour.

25. Health belief model • The role of giving information as a cue to action has been researched. Information in the form of fear-arousing warnings may change attitudes and health behaviour in such areas as dental health, safe driving and smoking (e.g. Sutton 1982; Sutton and Hallett 1989).

26. Health belief model • Giving information about the bad effects of smoking is also effective in preventing smoking and in getting people to give up (e.g. Sutton 1982; Flay 1985). Several studies report a significant relationship between people knowing about an illness and their taking precautions.

27. Health belief model • Rimer et al. (1991) report that knowledge about breast cancer is related to having regular mammograms. Several studies have also indicated a positive correlation between knowledge about BSE (Breast Self-examination) and breast cancer and performing BSE (Alagna and Reddy 1984; Lashley 1987; Champion 1990).

28. Health belief model • Showing subjects a video about pap tests for cervical cancer was related to their actually having the pap test (O'Brien and Lee 1990'.)

29. Evidence Against the HBM • Janz and Becker (1984) found that healthy behavioural intentions are related to low perceived seriousness - not high as predicted (e.g. healthy adult having a flu injection) - and several studies have suggested an association between low susceptibility (not high) and healthy behaviour (e.g. many students recently have agreed to be inoculated against meningitis) (Becker et al. 1975; Langlie 1977).

30. Evidence Against the HBM • Hill et al. (1985) applied the HBM to cervical cancer, to examine which factors predicted cervical screening behaviour. Their results suggested that benefits and perceived seriousness were not related.

31. Evidence Against the HBM • Janz and Becker (1984) carried out a study using the HBM and found the best predictors of health behaviour to be perceived barriers and perceived susceptibility to illness.

32. Evidence Against the HBM • However, Becker and Rosenstock (1984), in a review of 19 studies using a meta-analysis that included measures of the HBM to predict compliance, calculated that the best predictors of compliance are the costs and benefits and the perceived seriousness. So there is lack of agreement over what really does help to predict health behaviour.

33. Criticisms of the HBM • Is health behaviour that rational? (Is tooth-brushing really determined by weighing up the pros and cons?). • Its emphasis on the individual (HBM ignores social and economic factors) • The measurement of each component • The absence of a role for emotional factors such as fear and denial.

34. Criticisms of the HBM • It has been suggested that alternative factors may predict health behaviour, such as outcome expectancy (whether the person feels they will be healthier as a result of their behaviour) and self-efficacy (the person’s belief in their ability to carry out preventative behaviour) (Seydel et al. 1990; Schwarzer 1992).

35. Criticisms of the HBM • Schwarzer (1992) has further criticized the HBM for saying nothing about how attitudes might change.

36. Criticisms of the HBM • Leventhal et al. (1985) have argued that health-related behaviour is related more to the way in which people interpret their symptoms (e.g. if you feel unwell and you feel it is not going to cure itself then you would probably do something about it).

37. The revised HBM • Becker and Rosenstock (1987) have revised the HBM and have described their new model as consisting of the following factors: • the existence of sufficient motivation; • the belief that one is susceptible or vulnerable to a serious problem; • and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost.

38. Protection motivation theory

39. Protection motivation theory • Rogers (1975, 1983, 1985) developed protection motivation theory (PMT) which expanded the HBM to include additional factors. • Components of the PMT • Health-related behaviours are a product of five components:

40. Protection motivation theory • Coping Appraisal • self-efficacy (e.g. 'I am confident that I can change my diet'); • Response effectiveness (e.g. 'changing my diet would improve my health'); • Threat Appraisal • Severity (e.g. 'bowel cancer is a serious illness'); • Vulnerability (e.g. 'my chances of getting bowel cancer are high'). • Fear

41. Protection motivation theory • According to the PMT, there are two sources of information: • 1.environmental (e.g. verbal persuasion, observational learning) and • 2.intrapersonal (e.g. prior experience). • This information elicits either an 'adaptive' coping response (i.e. the intention to improve one's health) or a 'maladaptive' coping response (e.g. avoidance, denial).

42. Support for the PMT • Rippetoe and Rogers (1987) gave women information about breast cancer and examined the effect of this information on the components of the PMT and their relationship to the women's intentions to practise breast self-examination (BSE).

43. Support for the PMT • The results showed that the best predictors of intentions to practise BSE were response effectiveness (believing that BSE would detect the early signs of cancer), severity (believing that Breast cancer is dangerous and difficult to treat in it's advanced stages) and self-efficacy (belief in one's ability to carry out BSE effectively).

44. Support for the PMT • In a further study, the effects of persuasive appeals for increasing exercise on intentions to exercise were evaluated using the components of the PMT. The results showed that vulnerability (ill health would result from lack of exercise) and self-efficacy (believing in one's ability to exercise effectively) predicted exercise intentions but that none of the variables were related to self-reports of actual behaviour.

45. Support for the PMT • In a further study, Beck and Lund (1981) manipulated dental students' beliefs about tooth decay using persuasive communication. Their results showed that the information increased fear and that severity (tooth decay has disastrous consequences) and self-efficacy (I can do something about it) were related to behavioural intentions (flossing and brushing regularly especially after eating).

46. Criticisms of the PMT • The PMT has been less widely criticized than the HBM; however, many of the criticisms of the HBM also relate to the PMT. For example, the PMT assumes that individuals are rational information processors (although it does include an element of irrationality in its fear component), it does not account for habitual behaviours, such as brushing teeth, nor does it include a role for social (what others do) and environmental factors (eg opportunities to exercise or eat properly at work).

47. Criticisms of the PMT • Schwarzer (1992) has also criticized the PMT for not tackling how attitudes might change (a problem with the HBM as well).

48. Social cognition models • Social cognition theory was developed by Bandura (1977, 1986) and suggests that expectancies, incentives and social cognitions govern behaviour. Expectancies include: • Situation outcome expectancies: the expectancy that a behaviour may be dangerous (e.g. 'smoking can cause lung cancer'). • Outcome expectancies: the expectancy that behaviour can reduce the harm to health (e.g. 'stopping smoking can reduce the chances of lung cancer').

49. Social cognition models • Self-efficacy expectancies: the expectancy that the individual is capable of carrying out the desired behaviour (e.g. 'I can stop smoking if I want to'). • The concept of incentives suggests that behaviour is governed by its consequences. For example, smoking behaviour may be reinforced by the experience of reduced anxiety, whereas a feeling of reassurance may reinforce having a cervical smear after a negative result.

50. Social cognition models • Social cognitions involve normative beliefs (e.g. 'people who are important to me want me to stop smoking'). • Parents have a strong influence over the health behaviours of children of the same sex with regard to Exercise, Smoking, Drinking, Eating and Sleep (Wickrama, Conger, Wallace and Elder, Journal of Health and Social Behaviour, 1999).