theories of health behaviour health psychology. attribution theory according to the basic tenets of...

Theories of Health Behaviour

Health Psychology

Attribution theory

• According to the basic tenets of attribution theory people attempt to provide a causal explanation for events in their world particularly if those events are unexpected and have personal relevance (Heider, 1958). Thus it is not surprising that people will generally seek a causal explanation for an illness, particularly one that is serious.

Attribution theory

• Taylor et al. (1984) interviewed a sample of women who had been treated for breast cancer. They found that 95% of the women had a causal explanation for their cancer. These causes were classified as stress (41%), specific carcinogen (32%), heredity (26%), diet (17%), blow to breast (10%) and other (28%).

Women’s causal explanations for breast cancer

Attribution theory

• They also asked the women who or what they considered responsible for the disease and found that 41% of the women blamed themselves, 10% blamed another person, 28% blamed the environment and 49% blamed chance. The patients were also asked whether they felt any control over their cancer and they found 56% felt they had some control.

The women’s attribution of responsibility for their cancer

Attribution Theory

• Weiner et al. (1972) suggested that we can classify attributional dimensions along three dimensions:– 1 Locus: the extent to which the cause

is localized inside or outside the person.2 Controllability: the extent to which the person has control over the cause.3 Stability: the extent to which the cause is stable or changeable.

Health Locus of control

• Health locus of control, like attribution theory, also emphasises attributions for causality and control.


• Wallston and Wallston (1982) developed a measure of the health locus of control, which evaluates whether individuals regard their health as controllable by them or not controllable by them or they believe their health is under the control of powerful others.


• Health locus of control is related to whether individuals changed their behaviour and to the kind of communications style they require from health professionals.


• There are several problems with the concept of a health locus of control:

Is health locus of control a fixed traits or a transient state?

Is it possible to be both external and internal?

Going to the doctor could be seen as external (the doctor is a powerful other) or internal (I am looking after my health).

Unrealistic optimism

• Unrealistic optimism focuses on perceptions of susceptibility and risk.

• Weinstein (1984) suggested that one of the reasons why people continued to practice unhealthy behaviours is due to inaccurate perceptions of risk and susceptibility - their unrealistic optimism.


• He asked subjects to examine a list of health problems and displayed what "compared to other people of your age and sex, are your chances of getting the problem greater than, about the same, or less than theirs?" Most subjects believed they were less likely to get the health problem.


• Weinstein (1987) described four cognitive factors that contribute to unrealistic optimism:– 1. Lack of personal experience with

the problem

– 2. The belief that the problem is preventable by individual action


– 3. The belief that if the problem has not yet appeared, it will not appear in the future

– 4. The belief that the problem is infrequent.

The transtheoretical model of behaviour change (stages of change model)

• The transtheoretical model of change emphasises the dynamic nature of beliefs, time, and costs and benefits.


• 1. Precontemplation: not intending to make any changes

• 2. Contemplation: considering a change• 3. Preparation: making small changes• 4. Action: actively engaging in a new

behaviour• 5. Maintenance: sustaining change over

time


• Individuals would go through these stages in order but might also go back to earlier stages.

• People in the later stages, e.g. maintenance, would tend to focus on the benefits (I feel healthier after giving up smoking), whereas people in the earlier stages tend to focus on the costs (I will be at a social disadvantage if I give up smoking).


• A relationship has been found between level of education and the stage of change reached when contemplating taking regular exercise.


• Those people with lower levels of education tended to be at an earlier stage of change (Booth et al. 1993), and therefore it could be argued that the model could be improved by taking account educational attainment in order to help predict the length of time a person is likely to remain at the earlier stages.

Health belief model

• Support for individual components of the model.

• Norman and Fitter (1989) examined health behaviour screening (for example breast cervical cancer) and found that perceived barriers (the costs of attending) were the greatest predictors of whether a person attended the clinic.

Health belief model

• Several studies have examined breast self-examination (BSE) behaviour and report that barriers (Lashley 1987; Wyper 1990) and perceived susceptibility (the likelihood of having the illness) (Wyper 1990) are the best predictors of healthy behaviour.

Health belief model

• The role of giving information as a cue to action has been researched. Information in the form of fear-arousing warnings may change attitudes and health behaviour in such areas as dental health, safe driving and smoking (e.g. Sutton 1982; Sutton and Hallett 1989).

Health belief model

• Giving information about the bad effects of smoking is also effective in preventing smoking and in getting people to give up (e.g. Sutton 1982; Flay 1985). Several studies report a significant relationship between people knowing about an illness and their taking precautions.

Health belief model

• Rimer et al. (1991) report that knowledge about breast cancer is related to having regular mammograms. Several studies have also indicated a positive correlation between knowledge about BSE (Breast Self-examination) and breast cancer and performing BSE (Alagna and Reddy 1984; Lashley 1987; Champion 1990).

Health belief model

• Showing subjects a video about pap tests for cervical cancer was related to their actually having the pap test (O'Brien and Lee 1990'.)

Evidence Against the HBM

• Janz and Becker (1984) found that healthy behavioural intentions are related to low perceived seriousness - not high as predicted (e.g. healthy adult having a flu injection) - and several studies have suggested an association between low susceptibility (not high) and healthy behaviour (e.g. many students recently have agreed to be inoculated against meningitis) (Becker et al. 1975; Langlie 1977).


• Hill et al. (1985) applied the HBM to cervical cancer, to examine which factors predicted cervical screening behaviour. Their results suggested that benefits and perceived seriousness were not related.


• Janz and Becker (1984) carried out a study using the HBM and found the best predictors of health behaviour to be perceived barriers and perceived susceptibility to illness.


• However, Becker and Rosenstock (1984), in a review of 19 studies using a meta-analysis that included measures of the HBM to predict compliance, calculated that the best predictors of compliance are the costs and benefits and the perceived seriousness. So there is lack of agreement over what really does help to predict health behaviour.

Criticisms of the HBM

• Is health behaviour that rational? (Is tooth-brushing really determined by weighing up the pros and cons?).

Its emphasis on the individual (HBM ignores social and economic factors)

The measurement of each component The absence of a role for emotional

factors such as fear and denial.


It has been suggested that alternative factors may predict health behaviour, such as outcome expectancy (whether the person feels they will be healthier as a result of their behaviour) and self-efficacy (the person’s belief in their ability to carry out preventative behaviour) (Seydel et al. 1990; Schwarzer 1992).


Schwarzer (1992) has further criticized the HBM for saying nothing about how attitudes might change.


Leventhal et al. (1985) have argued that health-related behaviour is related more to the way in which people interpret their symptoms (e.g. if you feel unwell and you feel it is not going to cure itself then you would probably do something about it).

The revised HBM

• Becker and Rosenstock (1987) have revised the HBM and have described their new model as consisting of the following factors:

the existence of sufficient motivation; the belief that one is susceptible or vulnerable

to a serious problem; and the belief that change following a health

recommendation would be beneficial to the individual at a level of acceptable cost.

Protection motivation theory


• Rogers (1975, 1983, 1985) developed protection motivation theory (PMT) which expanded the HBM to include additional factors.

• Components of the PMT• Health-related behaviours are a

product of five components:


• Coping Appraisal• self-efficacy (e.g. 'I am confident that I can

change my diet'); • Response effectiveness (e.g. 'changing my diet

would improve my health'); • Threat Appraisal• Severity (e.g. 'bowel cancer is a serious

illness'); • Vulnerability (e.g. 'my chances of getting

bowel cancer are high'). • Fear


• According to the PMT, there are two sources of information:

• 1. environmental (e.g. verbal persuasion, observational learning) and

• 2. intrapersonal (e.g. prior experience). • This information elicits either an 'adaptive'

coping response (i.e. the intention to improve one's health) or a 'maladaptive' coping response (e.g. avoidance, denial).

Support for the PMT

• Rippetoe and Rogers (1987) gave women information about breast cancer and examined the effect of this information on the components of the PMT and their relationship to the women's intentions to practise breast self-examination (BSE).

Support for the PMT

• The results showed that the best predictors of intentions to practise BSE were response effectiveness (believing that BSE would detect the early signs of cancer), severity (believing that Breast cancer is dangerous and difficult to treat in it's advanced stages) and self-efficacy (belief in one's ability to carry out BSE effectively).

Support for the PMT

• In a further study, the effects of persuasive appeals for increasing exercise on intentions to exercise were evaluated using the components of the PMT. The results showed that vulnerability (ill health would result from lack of exercise) and self-efficacy (believing in one's ability to exercise effectively) predicted exercise intentions but that none of the variables were related to self-reports of actual behaviour.

Support for the PMT

• In a further study, Beck and Lund (1981) manipulated dental students' beliefs about tooth decay using persuasive communication. Their results showed that the information increased fear and that severity (tooth decay has disastrous consequences) and self-efficacy (I can do something about it) were related to behavioural intentions (flossing and brushing regularly especially after eating).

Criticisms of the PMT

• The PMT has been less widely criticized than the HBM; however, many of the criticisms of the HBM also relate to the PMT. For example, the PMT assumes that individuals are rational information processors (although it does include an element of irrationality in its fear component), it does not account for habitual behaviours, such as brushing teeth, nor does it include a role for social (what others do) and environmental factors (eg opportunities to exercise or eat properly at work).

Criticisms of the PMT

• Schwarzer (1992) has also criticized the PMT for not tackling how attitudes might change (a problem with the HBM as well).

Social cognition models

• Social cognition theory was developed by Bandura (1977, 1986) and suggests that expectancies, incentives and social cognitions govern behaviour. Expectancies include:

• Situation outcome expectancies: the expectancy that a behaviour may be dangerous (e.g. 'smoking can cause lung cancer').

• Outcome expectancies: the expectancy that behaviour can reduce the harm to health (e.g. 'stopping smoking can reduce the chances of lung cancer').


• Self-efficacy expectancies: the expectancy that the individual is capable of carrying out the desired behaviour (e.g. 'I can stop smoking if I want to').

• The concept of incentives suggests that behaviour is governed by its consequences. For example, smoking behaviour may be reinforced by the experience of reduced anxiety, whereas a feeling of reassurance may reinforce having a cervical smear after a negative result.


• Social cognitions involve normative beliefs (e.g. 'people who are important to me want me to stop smoking').

• Parents have a strong influence over the health behaviours of children of the same sex with regard to Exercise, Smoking, Drinking, Eating and Sleep (Wickrama, Conger, Wallace and Elder, Journal of Health and Social Behaviour, 1999).

Theory of planned behaviour


• The TPB emphasizes behavioural intentions as the outcome of a combination of several beliefs.

• Intentions - 'plans of action in pursuit of behavioural goals' (Ajzen and Madden 1986) and are a result of the following beliefs:

• • 1. Attitude towards a behaviour - positive

or negative -(e.g. 'exercising is fun and will improve my health').


• 2. Subjective norm - social pressure and motivation (e.g. 'people who are important to me will approve if I lose weight and I want their approval').

• 3. Perceived behavioural control - self-efficacy and possible barriers

Support for the TPB

• Povey et al (2000) studied the intentions of people to eat five portions of fruit and vegetables per day or to follow a low-fat diet. The TPB was good at predicting intentions but not behaviour. Self-efficacy was found to be a better predictor of behaviour.

Support for the TPB

• Rutter (2000) studied women and whether or not they attended two breast-screening sessions separated by three years. Intention and first-time attendance was successfully predicted by the TPB. Attendance at the first session, however, was the best predictor of whether the woman attended three years later.

Support for the TPB

• Brubaker and Wickersham (1990) examined the role of the theory's different components in predicting testicular self-examination and reported that attitude towards the behaviour, subjective norm and behavioural control (measured as self-efficacy) correlated with the intention to perform the behaviour.

Support for the TPB

• TPB in relation to weight loss (Schifter and Ajzen 1985). The results showed that weight loss was predicted by the components of the model; in particular, goal attainment (weight loss) was linked to perceived behavioural control.

Evaluation of the TPB

Good– Degree of irrationality – Considers Social and Environmental factors – Considers past behaviour within the

measure of perceived behavioural control.

Bad– Schwarzer (1992) Ajzen does not describe

either the order of the different beliefs or says what causes what (causality).

The health action process approach

The health action process approach

• The health action process approach (HAPA) was developed by Schwarzer in 1992.

• 1. it includes a temporal element in the understanding of beliefs and behaviour.

• 2. it emphasized the importance of self efficacy

• 3. distinction between a decision-making/motivational stage and an action maintenance stage.

Components of the HAPA

• According to the HAPA, the motivation stage is made up of the following components:– self-efficacy (e.g. 'I am confident that I can stop

smoking'); – outcome expectancies (e.g. 'stopping smoking

will improve my health'), and a subset of social outcome expectancies (e.g. 'other people want me to stop smoking and if I stop smoking I will gain their approval');

– threat appraisal, which is composed of beliefs about the severity of an illness and perceptions of individual vulnerability.

Components of the HAPA

• The action stage is composed of:– A cognitive factor made up of action plans

(e.g. 'if offered a cigarette when I am trying not to smoke I will imagine what the tar would do to my lungs') and action control (e.g. 'I can survive being offered a cigarette by reminding myself that I am a non-smoker').

– The situational factor consists of social support (e.g. the existence of friends who encourage non-smoking) and the absence of situational barriers (e.g. financial support to join an exercise club).

Support for the HAPA

• Schwarzer (1992) claimed that self-efficacy was consistently the best predictor of behavioural intentions and behaviour change for a variety of behaviours, including frequency of flossing, effective use of contraception self-examination, drug addicts' intentions to use clean needles, intentions to quit smoking, and intentions to adhere to weight loss programmes and exercise (e.g. Beck and Lund 1981; Seydal et al. 1990).

Criticisms of the HAPA

• Too rational - emotion is neglected • The social and environmental influences

are not considered as directly affecting behaviour, but rather as cognitions·

• Do these cognitive states exist or are they simply created cognitive theorists?

• The model attempts to combine components of the health belief model, the trans-theoretical model of change and the theory of planned behaviour.

Non-Rational processes

• The defence mechanism of Denial– Cigarette smokers etc

Lay theories about health

• Communication between health professional and patient would be redundant if the patient held beliefs about their health that were in conflict with those held by the professional.


• Pill and Stott (1982) reported that working-class mothers were more likely to see illness as uncontrollable.

• In a recent study, Graham (1987) reported that although women who smoke are aware of all the health risks of smoking, they report that smoking is necessary to their well-being and an essential means for coping with stress.


• Blaxter (1990) analysed the definitions of health provided by over 9000 British adults in the health and lifestyles survey. She classified the responses into nine categories:

Health as not-ill: the absence of physical symptoms.

Health despite disease. Health as reserve: the presence of

personal resources. Health as behaviour: the extent of

healthy behaviour


– Health as physical fitness.– Health as vitality.– Health as social relationships.– Health as function.

•


• It was found that there was considerable agreement in the emphasis on behavioural factors as causes of illness. There was however limited reference to structural or environmental factors, especially among those from working-class backgrounds. Gender differences were also found. The women were more likely to define health in terms of personal relationships. Murray and McMillan (1988) also found that working class women made repeated reference to their families when describing cancer.


• Chamberlain (1997) noted a series of social class differences in his review of several studies of lay people’s perceptions of health. Lower social economic status people emphasise the role of health in their ability to work whereas higher social economic status people referred more to their ability to participate in leisure activities. Four different lay views of health emerged:


• 1. Lower social economic status participants only reported a view that emphasised physical aspects.

• 2. Both lower and higher social economic status participants gave a dualistic view in which physical and mental aspects of health were combined.

• 3. Predominantly higher social economic status gave a complimentary view of health, which integrated both physical and mental dimensions.


• 4. Higher social economic status participants gave a multiple view of health, which included physical, mental, emotional, social and spiritual directions.


• Stainton-Rogers (1991) used Q-sort methodology to identify the concepts used by a sample of British adults to explain health. She identified eight different accounts of health and illness:

The ‘body as machine’ account which considered illness as naturally occurring and ‘real’ with biomedicine considered the main form of treatment.


The ‘body under siege’ account which considered illness as a result of external influences such as germs or stress.

The ‘inequality of access’ account which emphasized the unequal access to modern medicine.

The ‘cultural critique’ account which was based upon a sociological worldview of exploitation and oppression.


The ‘health promotion’ account which recognized both individual and collective responsibility for ill health.

The ‘robust individualism’ account which was concerned with every individual’s right to a satisfying life.

The ‘willpower account’ which defined health in terms of the individuals ability to exert control.

Assumptions in Health psychology

• 1. Humans are rational in their information processing. It is the role of perceived factors (e.g. risk, rewards, costs, etc) rather than actual risks.

• 2. Different cognitions are separate from and perform independently from each other. Could be because the researchers ask questions relating to each 'type' of cognition.

Assumptions in Health psychology

• 3. The types of cognition may not really exist nor play a part in the patient's thinking about their health; they could just be an artefact of the way the research was carried out.

• 4. Cognitions are not placed within a context. For example, actual social pressure and environment are not taken into account, only the individual's interpretation of social pressure and environmental influences.

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theories of health behaviour health psychology. attribution theory according to the basic tenets of...

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