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Intrapersonal Theoriesof Health Behavior

Ron D. Hays, Ph.D.David Geffen School of Medicine at UCLA

July 16, 2003, 8:30-10:15am

hays@rand.orghttp://www.gim.med.ucla.edu/FacultyPages/Hays/

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Today¶s QuestionW hy do people behave in health-compromising ways?

³Theory needs questioners more than loyalfollowers´ (Rimer, 2002, p. 156).

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W hy do people ...

do things that are bad for their health such as smokecigarettes or drink too muchalcohol?not do things that are health-enhancing like exercise or eating low fat foods?

not do things that maximizethe likelihood of better outcomes such as wearingseat belts?

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W hy do people«?

smoke cigarettes?drink too much alcohol?

overeat?fail to follow their doctor¶srecommendations?

-->Break into groups

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Transtheoretical Model

Stages of Change³Ordered categories along acontinuum of motivationalreadiness to change a problembehavior´

http://www.uri.edu/research/cprc/transtheoretical.htm

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F ive Stages of ChangePrecontemplationContemplationPreparation*

ActionMaintenance

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P recontemplationN o intention to change behavior in theforeseeable future (next 6 months ).

Includes people who are unaware of theproblem plus those who know about theproblem but are not considering change.³I am not thinking about changing myrisky sexual behavior within the next 6months to reduce the risk of getting HIV.´

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ContemplationPeople are aware that a problem existsand are seriously thinking aboutovercoming it but have not yet made afirm commitment to take action.Intending to change within 6 months;open to feedback and information abouthow to change. However, ambivalentabout the costs and benefits of their behavior.³I am thinking about changing my riskysexual behavior within the next 6 monthsto reduce the risk of getting HIV.´

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ActionStage in which individuals modify their behavior, experiences, or environment inorder to overcome their problems.Involves overt behavioral changes andrequires commitment of time and energy.e.g., cessation of smoking has occurredand last cigarette was less than 6months ago.³In the last few months I have changedmy risky sexual behavior to reduce therisk of getting HIV.´

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MaintenancePeople work to prevent relapse andconsolidate the gains attained during

action.Sustaining change and resistingtemptation to relapse.Stage extends from 6 months andbeyond the initial behavioral change.³For more than 6 months I have changedmy (former) risky sexual behavior toreduce the risk of getting HIV.´

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Decisional BalancePros and cons combine to form abalance sheet of comparative

potential gains and losses.Balance varies by stage of change.

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Self Efficacy Perceived ability to perform a task.Self efficacy predicts futurebehavior if there are adequateincentives and skills.

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P rocesses of ChangeHow shifts in behavior occur

Consciousness raisingCounter-conditioningDramatic relief Environmental reevaluationHelping relationships

Reinforcement management

Self-liberationSelf-reevaluationSocial liberationStimulus control

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P recaution AdoptionP rocess Model

Stage 1: Unaware of issueStage 2: Unengaged by issueStage 3: Deciding about actingStage 4 : Decided not to actStage 5: Decided to act

Stage 6: ActingStage 7 : Maintenance

http://www.psandman.com/

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P recaution AdoptionP rocess Model Do you know what it means to floss your teeth?

N o -> {stage 1}Yes -> {go to next q}

Do you floss your teeth now?Yes -> {Stage 6 or 7 }N o -> {go to next q}

W hich of the following best describes you?I¶ve never thought about flossing. {Stage 2}I¶m undecided about flossing. {Stage 3}I¶ve decided I don¶t want to floss. {Stage 4 }I¶ve decided I do want to floss. {Stage 5}

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Health Belief Model SusceptibilitySeverityCosts/BenefitsCues/MotivationBarriers

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Susceptibility

How likely onethinks a badoutcome (e.g.,get sick or adisease) is if behavior persists(doesn¶t change).

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Severity

The consequenceis perceived to besevere asopposed to mild.

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Benefits of Behavior

The alternative behavior willreduce the likelihood of the

negative consequence (e.g.,disease).

&Benefits are perceived to outweighcosts.

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Motivational cues

Cues (internal or external) thathelp convert intentions into

behavior

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Barriers

There are notsignificantpsychological,financial, or other costs or barriersto engaging in thebehavior.

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J ane is not likely tocontinue smokingbecause«

She thinks that she might get lungcancer if she continues to smoke

(susceptibility ).She believes that dying from lungcancer is terrible ( severity ).Jane does not find smoking to be

very pleasurable ( cost/benefits ).Her friends are supportive of her quitting (absence of barrier )

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J on is likely to continuesmoking because

He agrees with the tobacco industry--smoking doesn¶t cause lung cancer (susceptibility ).He believes that dying from lung cancer is not any worse than any other way of dying ( severity ).Jon feels that smoking relaxes him(cost/benefits ).His friends offer him cigarettes ( barrier to quitting)

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Theory of Reasoned Action

Intentions Attitudes

Beliefs (outcome expectancies)Values

Subjective N orms

Beliefs (about what others thinkyou should do)Motivation to comply

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Intentions

³Barring unforeseen events, aperson will usually act in

accordance with his or her intentions´ (Ajzen & Fishbein,19 80, p. 5).

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Attitudes

One¶s positive or negativeevaluation of performing a

behavior Beliefs: about the consequences of performing the behavior (outcomeexpectancies)

Values: appraisal (importance) of the consequences

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Subjective Norms

One¶s perception of the socialpressures to perform or not

perform a behavior.Beliefs: about whether specificindividuals or groups think oneshould perform the behavior.

Motivation to comply with thesepeople.

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Someone likely to drink and drive

ATTITUDE: Bob feels more at ease withothers when he drinks ( beliefs about theconsequences and values )SUBJ N ORM: Bob feels that hiscolleagues encourage him to drink after work ( belief ) and he wants them to likehim ( motivation to comply )IN TE N TION : Bob intends (expects) todrink with his colleagues after work andthen drive home 1 or more times in thenext 30 days ( intentions ).

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Theory of P lanned Behavior

Past Behavior Perceived BehavioralControl/Locus of Control/Self-Efficacy

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P ast Behavior

Always the bestpredictor of futurebehavior.

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Behavioral Control

Intention -> Behavior Link is problematic when behavior

is not fully under the individual¶scontrol.

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Differential Association-Reinforcement Theory

Differential association with peers,family, school, work, church groupsshape behavior Imitation of ModelsDifferential Reinforcement

Exposure and Adoption of EvaluativeDefinitionsBehavioral Consequences

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Imitation of Models

W e learnbehavior bywatching andimitating other people.

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Differential Reinforcement

Positive reinforcement (rewards)N egative reinforcement (avoidance of

something bad)Positive punishment (aversive stimuli)N egative punishment (loss of reward)

Positive (present something)N egative (take something away)Reinforcement (behavior increases)Punishment (behavior decreases)

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Exposure and Adoptionof Evaluative Definitions

The more an individual defines abehavior as good or at least

justified rather than bad, the morelikely they are to engage in it.

Evaluative definitions positive, neutral, negative norms, attitudes, orientations

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Behavioral Consequences

W hat happenedafter the behavior was performed?

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J erry is likely to overeat

Jerry¶s parents are big eaters ( imitationof models )

Jerry¶s family serves big meal portionsand encourages him to ³clean your plateor you won¶t get dessert´ ( negativereinforcement )Jerry feels that thin people are unhealthy(evaluative definitions ).Jerry¶s family praises him for finishing hismeals ( behavioral consequences ).

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Concluding Thoughts

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This class was supported in part by the UCLA/DREW

Project EXPORT, National Institutes of Health,National Center on Minority Health & HealthDisparities, (P20-MD00148-01) and the UCLACenter for Health Improvement in Minority Elders /Resource Centers for Minority Aging Research,National Institutes of Health, National Institute ofAging, (AG-02-004).