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
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.
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
enga
gem
ent
Dis
enga
gem
ent
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
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
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