Health behaviour models criticisims

Specific models of health-

related behavior

Presentation and critiscisms

Aymery Constant, PhD

Health Psychology Lecturer

EHESP

Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)

The leading model since the 50s (“top down”)

Info

rmation

« There is a lion in front of me »

Expected Consequences

Subjective Probabilities



Info

rmation « The lion will attack me »

High



Cognitive Evaluation



Info

rmation

This is a bad

situation

I might die





Emotion


Info

rmation

I have a bad feeling about this™




Decision


Emotion


Info

rmation

Run away




Decision

Consequences


Emotion


Info

rmation

Safety

Models of health-related behaviors

The major models in health behavior research:

The Basic Risk Perception Model

The Health Belief Model (HBM)

The Protection Motivation Theory (PMT)

The Trans-theoritical Model (TTM)

The Theory of Plannified Behavior (TPB)

The Basic Risk Perception model

The basic risk perception model focus on only two

dimensions of health hazard:

the likelihood of harm if no action is taken

the severity of harm if no action is taken

The basic risk perception model

This model is an adaptation of the expected-utility

theory to decision in health behaviors.

Two characteristics:

Likelihood is one’s probability of being harmed by a hazard under

certain behavior conditions. Example: “What is the likelihood that

you will get the flu this year?”

Susceptibility (or vulnerability) emphasize an individual’s

constitutional vulnerability to a hazard. Example: “Are you more

likely to get the flu than other people?”

1) the likelihood of harm:


can be defined as the extent of harm a hazard would cause.

Examples of questions:

“How serious a disease is the flu?”

“Can Influenza cause death?”

“If you had influenza, would you be able to manage daily

activities?”

2) the severity of harm:


CONCLUSION


Higher levels of severity and likelihood are associated with

higher motivation

It included Thirty-four studies (N = 15,988). Risk likelihood,

susceptibility, and severity were significantly correlated:

Risk likelihood: pooled r = .26

Risk susceptibility : pooled r = .24

Risk severity: pooled r = .16

Risk perceptions are core concepts in predicting preventive

behavior.

But correlations are quite small

A meta-analysis of the relationship between risk perception and adult vaccination has been conducted (Brewer et al, 2007):


The Health Belief Model (HBM)

The health belief model was initially developed in the 1950s by a

group of social psychologists in the U.S. Public Health Service

Research was initiated to explain failure of large number of

eligible adults to participate in tuberculosis screening programs

provided at no charge in a mobile X-ray units conveniently located

in various neighborhoods.

Researchers were concerned with identifying factors that were

facilitating or inhibiting participation.

The health belief model (HBM)

ORIGINS OF THE HEALTH BELIEF MODEL


COMPONENTS OF THE HEALTH BELIEF MODEL

Perceived susceptibility

Perceived severity

Perceived threat Behavior change

Perceived benefits of change

Perceived barriers of change



Perceived susceptibility : one’s subjective perception of risk of

contracting an illness.

Perceived severity : beliefs concerning the seriousness of

consequence of contracting an illness (e.g., death, disability, and

pain). This includes the social consequences (e.g., work, family life,

leisure, etc.).

Perceived benefits : beliefs regarding the effectiveness and the

efficacy of various available actions in reducing the disease threat,

but also the non-health-related benefits (save money, relative

approval, etc.).



Perceived barriers : spontaneous cost analysis which occurs

when the individual evaluate preventive actions that may be

expensive, dangerous, unpleasant, inconvenient, time-consuming,

and so forth.

Self-efficacy : this concept introduced in 1977 by Bandura refers

to the conviction that “one can successfully execute the behavior

required to produced the outcomes”

People must not only feel threatened by their current behavioral

patterns and believe that change of a specific kind will be beneficial

at acceptable cost, but they must also feel themselves competent

to overcome perceived barriers to taking action.


Reviews of HBM studies (Janz & Becker, 1984)

Perceived barriers were found to be the powerful single

predictor of the HBM dimensions across all studies and health

threat.

Perceived susceptibility and perceived benefits were both

important, while PS seem to be a stronger predictor of preventive

behavior than PB.

Perceived severity was the least powerful predictor. However,

this dimension was sometime strongly related to certain risk

behavior.

The Protection Motivation Model

Mass media and prevention programs frequently provide

people with information about unpleasant, but

avoidable, health consequences.

It is assumed that the threat of pain and suffering

motivates people to take protective action.

PMT explain the effects of threatening health

information on public attitude and behavior change.

The amount of protection motivation is supposed to be a

function of the threat and coping appraisal processes.

Origins and purpose

The protection motivation theory (PMT)


OVERALL MODEL OF PMT

PMT describes adaptive and maladaptive coping

with a health threat as a result of two appraisal

processes:

A process of threat appraisal and a process of

coping appraisal, in which the behavioral options to

diminish the threat are evaluated (Boer, Seydel, 1996).


OVERALL MODEL OF PMT


COGNITIVE MEDIATING PROCESSES OF PMT

The components of threat appraisal :

Vulnerability of being exposed to the hazard: “probability that

the event will occur provided that no adaptative behavior is

performed” (Roger, 1975, p. 97).

Perceived severity: in PMT, severity refers to the degree of

physical, psychological, social and economic harm.

Intrinsic rewards: physical and psychological pleasure associated

with maladaptive responses (e.g. smoking, high calorie diet, etc.).

Extrinsic rewards: it refers mostly to peer approvals (relatives,

friends, parents, etc.).


The status of fear in PMT:


Fear is assumed to play only an indirect role in threat

appraisals.

Research reviewed by Rogers (1983) found that fear influences

attitude and behavior change, not directly but indirectly by affecting

the appraisal of the severity of the danger.

Some studies have nevertheless shown that too much fear can

have a detrimental effect on attitude change by inducing maladaptive

change such as defensive denial.

« Inverted U-curve »

The results of meta-analysis of PMT studies:

In a literature review that included 65 relevant studies (N = 30,000)

representing over 20 health issue, Floyd et al (2000) found the

following results:

Perceived threat vulnerability had a significant but weak effect

on health behavior or attitudes.

Perceived threat severity, rewards, response efficacy and self-

efficacy had a moderate effect on health behavior or attitudes.

Response cost related to adaptive coping had the strongest

impact on health behavior or attitudes.


Transtheoretical Model and Stages of

Change

Resolutions on News Years Eve?

Stop smoking

Eat more vegetable and fruits

Sport

Use byclicle, etc.

Mainly consist of:

- quitting unhealthy/inadequate behaviors

- adopting healthy behaviors

Behavior change

Transtheoretical Model:

The Transtheoretical Model uses stages of change to integrate

processes and principles of change from across major theories of

intervention.

It was called transtheoretical because concepts come from different

theories of human behavior and views of how to change people

Comparative analysis theories and behavioral change identified ten

processes of change among them, which unfold through a series

of stages

Core Constructs:

Stages of Change: Behavioral change can seen as a

progression through a series of stages.

Previous research has measured a number of cognitive and

behavioral markers that have been used to identify these

stages.

Stages of Change:

1) Precontemplation: subject has no intention to act in the near future (in the next six months at least), due to lack of information or demoralization from past attempts

2) Contemplation: subject intend to change in the near future; he is aware of pros and cons of changing

3) Preparation: he has intention to take action in the immediate future (within 1 month); have a plan of action

Stages of Change:

4) Action: the subject has taken observable action within the last 6 months

5) Maintenance: the subject actively work to prevent relapse; less temptation and more confidence

6) Termination: the subject has no temptation and is 100% efficient

Stages of Change

Precontemplation: no intention to change

Termination

Stages of Change

Precontemplation

Termination

Contemplation

Preparation

Action

Maintenance

Linear progression

through the stages

Circular

progression Enter here

Termination

Core Constructs:

Processes of Change: Stages of Change are useful in explaining when

changes in cognition, emotion, and behavior take place,

But the processes of change help to explain how these changes occur.

These ten observable and non-observable processes need to be

implemented to successfully progress through the stages of

change

They can be divided into two groups: cognitive/affective processes,

and behavioral processes.

Enter here

Termination

processes

processes

processes processes

processes

Stages of Change in Which Change Processes

Are Most Emphasized

Stages of Change

Precontemplation Contemplation Preparation Action Maintenance

Consciousness Raising

Dramatic relief

Environmental reevaluation Behavioral processes

Self-reevaluation

Self-liberation

Reinforcement Management

Helping relationships

Counterconditioning

Cognitive / emotional processes Stimulus Control

Cognitive/Emotional Processes

Consciousness Raising [Increasing Awareness]

I recall information people had given me on how to stop smoking.

Dramatic Relief [Emotional Arousal]

I react emotionally to warnings about smoking cigarettes.

Environmental Reevaluation [Social Reappraisal]

I consider the view that smoking can be harmful to the people around me.

Social Liberation [Environmental Opportunities]

I find society changing in ways that make it easier for the nonsmoker.

Self Reevaluation [Self Reappraisal]

My dependency on cigarettes makes me feel disappointed in myself.

Behavioral Processes

Stimulus Control [Re-Engineering] I remove things from my home that remind me of smoking.

Helping Relationships [Supporting] I have someone who listens to me when I need to talk about my

smoking.

Counter Conditioning [Substituting] I find that doing other things with my hands is a good substitute for

smoking.

Reinforcement Management [Rewarding] I reward myself when I don’t smoke.

Self liberation [Committing] I make commitments not to smoke.

Core Constructs:

Decisional Balance: weighing pros and cons of changing.

As individuals progress through the Stages of Change, decisional balance shifts in critical ways.

Relationship between Stage and the Decisional

Balance for quitting unhealthy Behavior :

Relationship between Stage and the Decisional

Balance for adopting healthy Behavior :

Self-Efficacy

Self-Efficacy: (Bandura, 1977, 1982). the degree of confidence the individual has in maintaining their desired behavioral change in situations that often trigger relapse.

It is also measured by the degree to which the individual feels tempted to return to their problem behavior in these high-risk situations.

Temptation: the intensity of urges to engage in a specific habit when in the midst of difficult situations, including:

Negative affect or emotional distress

Positive social occasions

Cravings

The Relationship between Stage and both Self-efficacy

and Temptation

Cochrane review

Authors from the Cochrane Collaboration tested the effectiveness of stage-based interventions in helping smokers to quit.

• They found 41 trials (>33,000 participants) which met inclusion criteria. Four trials, which directly compared the same intervention in stage-based and standard versions, found no clear advantage for the staging component.

• The TTM is of little interest for intervention purposes

The Theory of Planned Behaviour

Created by Azjen in 1991, from a previous 1985 model

Designed to predict any type of voluntary behavior

Not restricted to health behavior (economy; etc.)

One of the most popular models used to predict a wide

range of behavior, including health behaviors

Theory of planned behaviour

Model of the TPB

Extension: speed driving

Affective attitudes

Extension of social norms

Influence of TPB variables

High influence on intention low influence on actual

behaviour

Time to retire the TPB

Editorial by F. Sniehotta

10-15 mn reading

Try to identify main criticisms

Note: Remarks on TPB might be extrapolated to others models

Main criticisms

Study design: Cross-sectional vs. longitudinal; university

students; self-reported behaviors; correlations between

repeated measures

Structural flaws: Assumptions based on common sense

that cannot be refuted; Gap between intention and action not

taken into account; not a dynamic model

Poor predictive validity: Some pivotal variables are not

assessed in the model, not useful to predict behavior or

implementing behavior change

Changing human behavior to prevent

disease

Article by T. Marteau

10-15 minutes reading

Identify main criticisms of past health interventions

Suggested future directions

The underlying mechanism of decision-making

Source : Kahneman, D. (2002), Maps of Bounded Rationality : A Perspective on Intuitive

Judgments and Choices, Nobel Prize Lecture 2002.

Huge Influence on behaviours Psychological models

65

PRIME Theory: reflective and automatic processes

www.primetheory.com

Changing the future

= require new approaches

Determinants (beliefs; attitudes; norms..)

New

Behaviour Current

Behaviour

How the TPB (and most others models) work :

Explaining the past

= how behavior s occured

Changing human behavior to prevent

disease

Future directions according to Marteau

Altering environment to constrain behavior

Architecture of choice

Offer healthy alternatives

Nudging

Targeting automatic associative processes

Change automatic reactions to external cues

Change associations

Alter environment

Alter environment

The term “nudge” was first used in a book of the

same title to describe “any aspect of the choice

architecture that alters people’s behaviour in a

predictable way without forbidding any options or

significantly changing their economic incentives

Marteau (2011).Judging nudging. BMJ

Create new associations in mind (healthy=fun)

Provide alternative healthy choices

What about motivation ?

74

Understanding motivation

Brain processes that energise and direct behaviour

Not limited to choice and goal pursuit

Needs to include

drive

habit

desire

instinct

self-regulation

etc.

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COM-B system for analysing

behaviour in context 1. Capability, motivation and opportunity all

need to be present for a behaviour to occur

2. They all interact as part of a system

3. Motivation must be stronger for the target

behaviour than competing behaviours

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Common terms for methods for inducing behaviour

change

Capability

Educate

Train

Help

Motivation

Expose to

Inform

Discuss

Suggest

Encourage

Incentivise

Ask

Order

Plead

Coerce

Force

Opportunity

Provide

Prompt

Constrain

Most behavioral models are based on perceptions (attitudes,

norms, beliefs) that might be relevant

But they ignore some of the most pivotal variables shaping

behaviors (habits; contexts; environment; desires; needs…)

They correlate poorly with actual behavior and are not very

useful for designing behavior change interventions

Behavior change technique should include motivation

New approaches targeting environment, motivation and

habits are warranted to promote healthy behavior

Conclusions

Health behaviour models criticisims

Health & Medicine

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