Models of Behaviour Change

Matt Vreugde

M.Vreugde@Warwick.ac.uk

Key Questions

What psychological factors influence health behaviour?

Can we explain and predict health behaviour?

Can we use this understanding to change health behaviour?

Will interventions that change health behaviour actually benefit patients?

Behaviourism Behaviour is a conditioned response

occurring in the presence of a stimuli

If behaviour is learned, it can also be unlearned / modified through conditioned learning

Social Cognition Theories

Social cognition theories attempt to explain the relationship between social cognitions (e.g. beliefs, attitudes, goals, etc.) and behaviour

Health Belief Model (Rosenstock, 1966)

Theory of Planned Behaviour (Ajzen, 1988)

Transtheoretical Model (Prochaska and DiClemente, 1983)

Health-Belief Model (HBM)

HealthBehaviour

PerceivedThreat

PerceivedSeverity

PerceivedEfficacy

PerceivedSusceptibility

PerceivedBenefits

PerceivedBarriers

(Rosenstock, 1966)

Using the HBM in clinical practice

Example (Changing a risky health behaviour: Smoking)

Exploring perceived susceptibility and severity How do you think smoking is affecting your health? (current susceptibility) How might it affect your health in ten years time? (future susceptibility) What would it be like if that happened to you/you got the illness (Severity)

Perceived benefits and barriers What are the pros of smoking for you? (current benefits) What are the benefits of stopping smoking for you? (future benefits) Is there anything stopping you from giving up? (current barriers)

Theory of Planned Behaviour (TPB)

Behaviour

BehaviouralAttitude

SubjectiveNorm

PerceivedBehavioural

Control

Behavioural beliefs+

Outcome evaluation

Normative beliefs+

Motivation to comply

Control beliefs +

Self-efficacy

BehaviouralIntention

(Ajzen, 1988)

Using the TPB in clinical practiceChanging a risky health behaviour: Smoking

Behavioural Attitude (Behavioural beliefs + Outcome Evaluation): What do you think about smoking? Is smoking a good or bad for you? In what way? [Educate!]

Subjective Norms (Normative beliefs + Motivation to comply): What do your family/friends/partner think about you smoking? (normative beliefs) Whose opinion is most important to you? (motivation to comply) Would you like to give up smoking for (person)? (motivation to comply)

Perceived behavioural control (Control Beliefs + Self-Efficacy): Do you think you can give up smoking? If perceived control is low explore reasons why and challenge beliefs. If perceived control is high, the patient is ready to attempt behaviour change and you

should work with patients to plan next steps.

Behavioural Intentions Have you ever thought about giving up smoking? Do you intend to give up smoking in the next few months?

Precontemplation

Preparation

Contemplation

Maintenance

Action

Relapse

Transtheoretical Model (aka Stages of Change)

Definitions Behaviours that patients engage in once

they believe that they are ill. The belief can be objective or subjective; confirmed or suspected, self or other notified.

A patient’s implicit understanding of their health status based on common-sense beliefs about their illness, e.g. beliefs about the cause, course and consequences of the illness

Clustering of related beliefs which provide a framework for an understanding, or picture, of illness that serves to direct coping responses and illness behaviour

Illness behaviour:

Illness beliefs:

Illness representations:

Illness Representations Five belief dimensions:

Identity: what is it?

Cause: what caused it?

Time: how long will it last?

Consequence: how will it impact my life?

Control-Cure: can it be treated, controlled, managed, etc?

Illness representations direct illness behaviours

Identity Identity refers to the (diagnostic) label patients give to their

illness What you feel your disease is Illness beliefs may be incorrect and / or unhelpful

Labels bias the interpretation and assimilation of illness-related information Increased importance of label-relevant information, i.e.

attentional bias Interpret new information (e.g. symptoms) in light of dominant

illness representation Assimilate new information if consistent with current beliefs,

i.e. reject inconsistent / disconfirming information

Cause Patients develop ideas about the cause of their illness

Genetic; Lifestyle; Stress; Environmental; Chance; etc.

Causal beliefs influence treatment expectations: Type, e.g. homeopathic or medical, pharmacological or

psychological, intervention or watchful waiting, etc. Adherence to treatment and advice influenced by degree of

consistency with expectations

Causal beliefs influence emotional response to illness: Cancer self-blame; Genetic conditions guilt and

helplessness

Time

Three main timelines for illness Acute (e.g. flu); Chronic (e.g. heart disease);

Cyclical (e.g. hay fever)

Mismatch in perceived time and natural illness course is not uncommon Hypertension commonly believed to be

cyclical, e.g. high blood pressure only when stressed

Consequences Perceived effect of illness on the patient’s life

Personal identity, social relationships, finances, etc.

Perceived severity of consequences is prognostic(Petrie et al., 2003)

Control-Cure

Beliefs about how an illness can be treated and the effectiveness of treatment

Patients who believe its possible to control illness are more likely to Adapt to the consequences of the

illness Attend rehabilitation programmes Adhere to treatment

Self Regulatory Model

InterpretationSymptom perception, Social messages

AppraisalWas my coping effective?

CopingApproach or avoidance coping

Representation of illnessIdentity, cause, consequences, timeline, cure/control

Emotional response to illness

Fear, Anxiety, Depression

(Leventhal 1980)