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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
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
The leading model since the 50s (“top down”)
Info
rmation « The lion will attack me »
High
Expected Consequences
Subjective Probabilities
Cognitive Evaluation
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
The leading model since the 50s (“top down”)
Info
rmation
This is a bad
situation
I might die
Expected Consequences
Subjective Probabilities
Cognitive Evaluation
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
Emotion
The leading model since the 50s (“top down”)
Info
rmation
I have a bad feeling about this™
Expected Consequences
Subjective Probabilities
Cognitive Evaluation
Decision
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
Emotion
The leading model since the 50s (“top down”)
Info
rmation
Run away
Expected Consequences
Subjective Probabilities
Cognitive Evaluation
Decision
Consequences
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
Emotion
The leading model since the 50s (“top down”)
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:
The basic risk perception model
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:
The basic risk perception model
CONCLUSION
The basic risk perception model
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 basic risk perception model
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
The health belief model (HBM)
COMPONENTS OF THE HEALTH BELIEF MODEL
Perceived susceptibility
Perceived severity
Perceived threat Behavior change
Perceived benefits of change
Perceived barriers of change
The health belief model (HBM)
COMPONENTS OF THE HEALTH BELIEF MODEL
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.).
The health belief model (HBM)
COMPONENTS OF THE HEALTH BELIEF MODEL
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.
The health belief model (HBM)
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)
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).
The protection motivation theory (PMT)
OVERALL MODEL OF PMT
The protection motivation theory (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 protection motivation theory (PMT)
The status of fear in PMT:
The protection motivation theory (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.
The protection motivation theory (PMT)
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.
76
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
77
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