Behavior Change in Health

Some questions: What factors predict health behaviors?

e.g., Why do you floss every night? or why not?

How do people change their health behaviors?

Why don’t people change? What are some of the barriers?

Theories, Models, and Practicalities…

Behavioral Immunogens and Pathogens

Behavioral Pathogen A health-compromising behavior or habit

smoking, excessive eating, substance abuse, dangerous driving, risky sexual behavior

Behavioral Immunogen A health-enhancing behavior or habit

exercising regularly, using sunscreen, healthy eating, practicing safe sex, wearing seatbelts

Behavioral Immunogens and Death Rate

Preventing Injury and Disease

Primary Prevention (Efforts to prevent disease or injury from occurring – e.g., practicing good nutrition, exercising, avoiding smoking, obtaining regular health screening – these are the behavioral immunogens)

Secondary Prevention (Actions taken to identify and treat an illness or disability early in its occurrence – e.g., monitoring symptoms, taking medication, following treatment regimens)

Tertiary Prevention (Actions taken to contain damage once a disease or disability has progressed beyond its early stages – e.g., radiation therapy, chemotherapy)

less cost-effective and less beneficial than primary or secondary prevention

the most common form of health care in the U.S.

Fig. 6.1, p.177

What influences Health Behaviors?

Barriers to Healthy Behaviors

Individual Barriers Inertia Operant conditioning issue – immediate rewards

and punishments are much more effective than delayed ones

Finances Optimistic Bias -- The tendency of most people to

believe that they are less likely to become ill than others

• People who feel vulnerable to specific health problems are more likely to practice preventive health behaviors

• Invincibility fable (especially in adolescents)• Within limits, optimism conveys health advantages

Family Barriers

Health habits are often acquired from parents and others who model health-compromising behaviors obese parents are more likely to have obese

childrenchildren of problem drinkers are themselves

at increased risk of abusing alcohol

Health System Barriers

Medicine tends to focus on treatment rather than prevention

A significant percentage of Americans do not have health insurance

Unrealistic or confusing recommendations

Community Barriers

Access to _____ (health care, exercise facilities, grocery stores)

Absence of community health promotion (e.g., no incentives to walk)

Some environments promote health-compromising behaviorse.g., alcohol use and binge drinking in

college

Models for Health Behavior Change

Given all these barriers, why (and how?) would a person change his or her health behavior? Theories and Models (give handout

“Changing Health Behavior Theories” for homework)

Stage Theories

Transtheoretical Model (see Table 6.2) People pass through 5 stages in altering health

behaviorStage 1: PrecontemplationStage 2: ContemplationStage 3: PreparationStage 4: ActionStage 5: MaintenanceStage 6: Termination

Examples -- http://www.psychologymatters.org/diclemente.html

Stage Theories

Stage theories provide a “recipe” for ideal behavior change, but… hard to put everyone in a discrete

“stage”; probably a more continuous and non-linear process

Enable interventions to be matched to the specific needs of a person who is “stuck” at a particular stage

OutcomeOutcome ExpectanciesExpectancies IntentionIntention

RiskRisk PerceptionPerception

Task Task Self-EfficacySelf-Efficacy

InitiativeInitiative MaintenanceMaintenance

RecoveryRecovery

ActionAction

Barriers and ResourcesBarriers and Resources

Dis

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Dis

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ActionActionPlanningPlanning

CopingCopingPlanningPlanning

Health Action Process Approach -- A continuum model http://userpage.fu-berlin.de/~health/hapa.htm

Coping Coping Self-EfficacySelf-Efficacy

RecoveryRecovery Self-EfficacySelf-Efficacy

The Health Belief Model(Cognitive model)

Example from text, p. 183

Theory of Planned Behavior (Social cognition model)

Support for these theories

People’s self-reported attitudes and intentions predict a variety of health-promoting actions (weight loss, condom use, smoking behavior, health screening)

People are more likely to engage in health-protective behaviors if they feel susceptible to the hazards of not doing so

Shortcomings of these theories

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

The predictive power of these theories is greater for some groups (high-SES, for example) than for others

The theories ignore past experience with a specific health-related behavior AND PAST BEHAVIOR IS OFTEN THE BEST PREDICTOR

Why Aren’t Health Behavior Theories More Precise?

They say little about how intentions are translated into action

They are unrealistically complexHealth habits are often unstable over

timeFor the very young, old, and ill,

health care decisions are often made by other people

Changing Behaviors

How can we influence people to change health behaviors? What needs to be done? What strategies might be effective?

Changing Behaviors: Interventions

I. Changing Health BeliefsII. Social EngineeringIII. Cognitive-Behavioral Methods

Changing beliefs: Health Education Campaigns

Health Education ideally… identifies specific health problems in a

community analyzes background factors that

predispose, enable, and reinforce lifestyle and environment elements

implements health education program

How Effective are Health Education Campaigns?

Mass media appear to be most effective in alerting people to health risks that they otherwise wouldn’t know about, but are less effective in long-term behavior change (unless the message is presented consistently over time, e.g., health risks of smoking)

What about fear-based messages (scare-tactics)? e.g., Framing the message to stress the risk of not performing a health behavior

Social Engineering

Changing the environment to change our behaviors

Automatic seat belts and air bags; lowering speed limit

Design change for baby walkersElimination of “Joe Camel” adsRequiring immunizations for school entryWorksite wellness programs

• on-the-job health promotion programs• structuring the environment (on-site gym, banning

smoking, etc.)

Cognitive-Behavioral Interventions

Methods are usually used in combination (a multimodal approach)

Should be tailored to each person

Too many interventions can overwhelm a person

Cognitive-Behavioral Interventions

Three stages: Self-observation / monitoring Implementing change Maintenance / Relapse prevention

Self-monitoring

Define target behavior Record and chart Continual process with revision

Implementing Change (overview)

Conditioning methodsModelingCognitive change strategiesEtc…

Conditioning methods

Classical (Pavlovian) Conditioning Interventions

• Antabuse• Counterconditioning (cancer nausea)

Operant Conditioning Interventions• Modify consequences of a behavior (e.g.,

seat belt buzzer)• Shaping • Using rewards (individually or in a group

setting, e.g., token economy)

Modeling

Observational learning• Preparing a child for an operation• Taking a yoga class• Watching a video on breast self-

examination• Going to A.A.• Most successful when it shows the

realistic difficulties that people encounter in making changes

Stimulus control

Modifying antecedents of a behavior Poor health habits often tied to events,

people, places, or things in the environment (called discriminative stimuli -- DS)

Examples (golden arches, …) These DS need to be identified and then

reduced

Contingency Contracting

Creating contract with another regarding consequences of one’s behavior “Every time I do _____, I instruct my

friend to _____”

Covert Self-control

Cognitive techniques (e.g., cognitive restructuring) Train people to recognize and modify

internal dialogue “I’m weak, I can’t control my smoking

urges…”This statement would be targeted for

modification

Skills Training and Behavioral Assignments

Learn skills to change behavior progressive muscle relaxation assertiveness training stress management nutrition education systematic homework assignments

Relapse

Why do people relapse? BioPsychoSocial factors (e.g., with smoking)

Bio: Withdrawal, Genetics, Wt. GainPsych: Boredom, stress, angerSocial: Conflicts, lack of social support, social cues (e.g.,

going to a bar) Relapse Prevention

Need to control the biopsychosocial factors, especially developing coping techniques for managing high-risk situations

Coping with a “slip”Integrate behavior change into a generally healthy lifestyle