Social cognition models and health behaviour Oana Ciocanel Directorate of Public Health NHS Tayside
Transcript
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Oana Ciocanel Directorate of Public Health NHS Tayside
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Learning outcomes Understand what are health behaviours and how
they relate to health Understand and evaluate the contribution of
different social cognition models to predicting and changing health
behaviour
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Overview of Lecture Health behaviours: o What are health
behaviours? o Why study health behaviours? o What factors predict
health behaviours? Social cognition models o Types of SCMs o Three
social cognition models: 1. Health Belief Model 2. Theory of
Planned Behaviour 3. Transtheoretical Model of Change
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What are Health Behaviours? Definition: Overt behavioural
patterns, actions and habits that relate to health maintenance,
health restoration and health improvement (Connor & Norman,
2005). Examples: o Health impairing habits (e.g., Excessive alcohol
consumption, smoking, eating a high fat diet); o Health enhancing
behaviours (e.g. exercise participation, healthy eating); o
Health-protective behaviours (e.g. health screening, vaccination
against disease). (Matarazzo, 1984)
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Leading Causes of Death All Ages: Ages 15-24: 1. Heart disease
2. Cancer 3. Stroke 4. Chronic lung disease 5. Accidents 6.
Pneumonia/influenza 7. Diabetes 8. AIDS 9. Suicide 1. Accidents 2.
Homicide 3. Suicide 4. Cancer 5. Heart disease 6. AIDS 7.
Congenital anomalies 8. Chronic lung disease 9.
Pneumonia/influenza
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Behaviour and Mortality 50% of deaths from the leading causes
of death are due to modifiable lifestyle and behavioural factors:
1. Tobacco 2. Diet and activity patterns 3. Alcohol 4. Sexual
behavior 5. Motor vehicles 6. Drug use 7. Screening
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Alameda County Study (Belloc and Breslow, 1972) Seven healthy
habits associated with physical health status and mortality: Not
smoking Having breakfast each day Having no more than one or two
alcoholic drinks per day Taking regular exercise Sleeping seven to
eight hours per night Not eating between meals Being no more than
10 per cent overweight
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The role of health behaviours Reduce mortality and morbidity: o
Reduce the risks of developing serious illnesses (e.g. lung cancer,
coronary heart disease, stroke, cirrhosis of the liver) o Expand
years of life from chronic disease complications (e.g. Type 2
diabetes); Reduce health care costs; Possible impact on quality of
life and well being; Greater individual responsibility for health;
Potentially modifiable through interventions.
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Factors extrinsic to the individual: Incentives structures
(e.g. Taxing tobacco and alcohol); Legal restrictions (e.g. Fining
individuals for not wearing seatbelts, banning dangerous
substances).
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Factors intrinsic to the individual: Demographic factors (e.g.
age, gender, socioeconomic and ethnic status); Social factors (e.g.
learning, reinforcement, modelling and social norms); Genetics
(e.g. Possible genetic basis for alcohol use);
Socio-economic/Environmental (e.g. Income, access); Emotional
factors (e.g. anxiety, stress, tension and fear); Personality
factors (e.g. Sensation seeking); Cognitive factors (e.g.
knowledge, beliefs, attitudes- patient and health
professionals).
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Social Cognition Models (SCMs) Basis for health behavioural
interventions Widely used to examine the predictors of health
behaviours using individuals cognitions to: o Understand
determinants of current intentions and behaviour o Predict future
health intentions and behaviour o Predict which determinants should
be targeted to change behaviour Trying to answer the following
question: o Why (and how?) would a person change (or not) his or
her health behavior?
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Types of Social Cognition Models Armitage and Conner (2000): 1.
Motivational Models (e.g. The HBM, PMT, TPB). Focus on the
motivational factors that support individuals' decisions to perform
(or not to perform) health behaviours. They imply that motivation
is sufficient for successful behavioural enaction. 2. Behavioural
Enaction Models Focus on post-intentional (motivation not
sufficient for action) Focus on bridging the "gap" between
motivation and behaviour 3. Multi-Stage Models (e.g. HAPA, TTM)
Individuals at different stages behave in different ways
Interventions should be stage-matched
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Health Belief Model (HBM) (Rosenstock, 1966; Becker et al,
1974) Background Perceptions Action Threat Analysis of the
costs/benefits Demographic variables Psychosocial variables
Structural variables Susceptibility Severity Perceived benefits
Perceived barriers Likelihood of behaviour Cues to action Health
Motivation Adapted from Janz & Becker (1984). Health Education
Quarterly, 11, 1-47.
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HBM-Example: Smoking cessation Perceptions Action Threat
Analysis of the costs/ benefits Susceptibility: If I dont stop
smoking there is a high possibility I will get lung cancer
Severity: Lung cancer is a serious illness Benefits: If I stop
smoking I will have whiter teeth and fresher breath Barriers:
Stopping smoking will make me put on weight Likelihood of Stopping
smoking Cues to action: the symptom of breathless; information in
the form of leaflets.
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HBM-Evidence The HBM has been applied to a wide range of health
behaviours: Uptake of flu vaccinations Anti-hypertensive regimes
Breast self-examination Risk factors behaviours (e.g. Attendance at
health check- ups, dietary change, smoking cessation, seatbelt use,
etc.) Overall, the HBM is marginally successful in predicting
health behaviours.
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HBM-Evidence cont Janz and Becker, 1984 Literature review of
studied published between 1974-1984: Perceived barriers most
significant variable for predicting and explaining health related
behaviours Other significant HBM components were perceived benefits
and perceived susceptibility Perceived severity -the least
significant variable Mullen and Green,1992 Meta-analysis: Small
impact of constructs on health behaviour Sutton, 1982 : Unclear
impact of cues to action and health motivation
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HBM-Limitations Ogden (2007): Absence of emotional factors
(i.e. Fear, anxiety, denial); Relationships between components not
well described; Its focus on rational processing of information Its
emphasis on the individual-absence of social or economic factors;
Static approach to health beliefs: beliefs are described as taking
place concurrently with no room for change, development or process.
Unclear impact of cues to action
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Activity Work in pairs. Discuss how HBM explains behaviour,
using the following example: This is Scott He has type 2 diabetes.
He is overweight, not very active and he is not taking his
medication as prescribed. This is not good because we know failing
to manage diabetes can lead to long-term complications, such as
heart disease, eye problems, kidney problems, feet problems, etc.
According to the HBM, what cognitions would help Scott to increase
the likelihood of being more active, lose weight and take his
medication as prescribed?
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Beliefs about outcomes Evaluations of these outcomes Beliefs
about important others attitude to behaviour Motivation to comply
with others Internal control factors External control factors
Attitude towards the behaviour Subjective norm Perceived
behavioural control Behavioural intention Behaviour Theory of
Planned Behaviour (TPB) (Ajzen, 1985)
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Attitudes towards reducing alcohol intake: I think reducing my
alcohol intake would help me improve my relationships with my wife
and children and will be beneficial to my health Subjective norm My
family really wants me to cut down Perceived behavioural control: I
am confident I can drink less alcohol Intention: I intend to drink
less alcohol Behaviour: Reduce alcohol intake TPB-Example: Reduce
alcohol consumption
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TPB-Evidence TPB applied to a range of health behaviours (e.g.
drug use, condom use, dietary behaviour, alcohol consumption,
health screening attendance, exercise, etc.) Schifter and Ajzen
(1985) examined TPB in relation to weight loss. TPB components
predicted weight loss. Perceived behavioural control better
predictor of weight loss than other components. Povey et al (2000)
investigated the intentions of people to keep a low-fat diet and or
to eat five portions of fruit and vegetables per day. The TPB
components predicted intentions but not behaviour. Self-efficacy
was found to be a better predictor of behaviour. Brubaker and
Wickersham (1990) studied the role of TPB components in predicting
testicular self-examination. Attitude towards the behaviour,
subjective norm and behavioural control (measured as self-efficacy)
were associated with the intention to perform the behaviour.
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TPB-Evidence Cont Armitage &Conner (2001) Meta-analysis of
185 observational studies TPB accounted for 39% variance in
intention and 27% in variance in behaviour Godin and Kok (1996)
Meta-analysis of 87 TPB studies applied to health behaviour. TPB
accounted for 41% of the variance in intentions and 34% of the
variance in behaviours. Attitudes and perceived behavioural control
better predictors of intentions than subjective norms Additional
constructs including self-identity, moral norms, anticipated regret
and past behaviour may help explain intentions and improve
translation to behaviour (Conner and Armitage (1998); Conner et al
(2000).
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TPB-Strengths and Weaknesses Strengths: Includes a degree of
irrationality (in the form of evaluations) Takes into account some
social and environmental factors (in the form of normative
beliefs). Includes a role for past behaviour within the measure of
perceived behavioural control. Weaknesses Omission of factors such
as demographics and personality No clear definition of perceived
behavioural control (hard to measure) Failure to describe the order
of the different beliefs or any direction of causality (See
Schwarzer,1992)
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Activity Groups of three or four Choose a health behaviour
(e.g. Alcohol consumption) Conduct a short focus group to identify
the most important beliefs that are relevant to attitudes,
subjective norms and perceived behavioural control. Make a list of
the most mentioned beliefs or commonly agreed themes.
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Precontemplation Increase awareness of need to change
Contemplation Motivate and increase confidence in ability to change
Action Reaffirm commitment and follow-up Termination
Transtheoretical Model (Prochaska & DiClemente, 1992) Relapse
Assist in Coping Maintenance Encourage active problem-solving
Preparation Negotiate a plan
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Stages of change Precontemplation Contemplation Preparation
Action Maintenance Relapse
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TTM-Example: Weight Loss StageCharacteristicPatient verbal cue
Appropriate intervention Pre- contemplation Unaware of problem Cant
see the problem No interest /intention to change I am not really
interested in weight loss. Weight is not a concern for me Provide
information about health risks and benefits of weight loss
Contemplation Acknowledges the problem Beginning to think about
change No specific plans in place I know I need to lose weight but
I am too busy right now to start making any changes Help resolve
ambivalence, discuss barriers
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StageCharacteristicPatient verbal cue Appropriate intervention
Preparation Focus on solution and future Realises the benefits of
losing weight and starts making plans Full commitment I am ready to
start making some changes to lose weight Provide education, teach
behaviour modification; Help setting an agenda, a coping plan etc.
Action Actively taking steps towards behaviour change I am doing my
best. I am eating healthier and exercising regularly Provide
guidance and support and discuss long-term Maintenance Initial
treatment goals reached Old behaviour is still a temptation I have
lost quite a few pounds Relapse control
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TTM-Evidence Has previously been applied to a wide variety of
problem behaviours: Smoking cessation Exercise Low fat diet Alcohol
abuse Weight control Drug abuse Medical compliance Use of
sunscreens to prevent skin cancer
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TTM-Strengths and weakness Strengths Has been applied widely
and it is linked to practice Offers some insight into the processes
of change It also gives methods for moving people from one stage to
the next Weaknesses: The model does not explain the role of social
and cognitive factors in the change process The description of
change is rather unsatisfying; no details are provided about how
people change and why some individuals will be successful and
others not.
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Stages of change-Activity 1. Pre-Contemplation: the person does
not identify the issue as a problem 2. Contemplation: the person
begins to identify the issue as a problem 3. Preparation for
Action: the person seeks information, support and alternatives for
making a change 4. Action: the person begins to make a change in
her/his life 5. Maintenance: the person sustains the change
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Social Cognition Models Potential Advantages: 1.Provide a clear
theoretical background to research 2. Identify targets for
interventions Potential Disadvantages: 1.Neglect other
(non-/cognitive) variables 2. How to change cognitions?
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Criticisms of SCMs SCMs are only concerned with cognitively
mediated behaviours They do not take into account the direct
effects of influences of emotional factors and social factors.
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 They assume the same
variables predict health behaviours for diverse groups of people.
The predictive power of these theories is greater for some groups
(high-SES, for example) than for others
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Criticisms of SCMs Cont. The theories ignore past experience
with a specific health-related behavior and past behaviour is often
the best predictor They do not describe in much detail how
intentions are translated into action They are unrealistically
complex Health habits are often unstable over time
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References Armitage,C.J. & Conner, M. (2000). Social
cognition models and health behaviour: A structured review.
Psychology and Health, 15:173-189. Conner, M. & Norman, P.
(1996). Predicting Health Behavior. Search and Practice with Social
Cognition Models. Open University Press: Ballmore: Buckingham.
Ogden, J. (2007). Health Psychology: A textbook. (4 th ed).
Buckingham: Open University Press. Prochaska, J.O., DiClemente,
C.C. & Norcross, J.C. (1992). In search of how people change:
Applications to addictive behaviors. American Psychologist, 47(9),
1102-1114. Prochaska, J.O., Velicer, W.F., Rossi, J.S., Goldstein,
M.G., Marcus, B.H., Rakowski, W., Fiore, C., Harlow, L.L., Redding,
C.A., Rosenbloom, D., & Rossi, S.R. (1994). Stages of change
and decisional balance for twelve problem behaviors. Health
Psychology, 13(1), 39-46.