Health-related behaviours are a product of five components:

• self-efficacy (e.g. 'I am confident that I can change my diet');
• Response effectiveness (e.g. 'changing my diet would improve my health');

• 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).

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

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).

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

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.

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.

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.

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.

• Degree of irrationality
• Considers Social and Environmental factors
• Considers past behaviour within the measure of perceived behavioural control.

Schwarzer (1992) Ajzen does not describe either the order of the different beliefs or says what causes what (causality).

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.

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.

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).

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).

• 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?

Denial

Cigarette smokers etc

1. Biopsychosocial contexts (environment, Biophysical, Mood/Arousal)
2. Self-Change Process (Social Support, Cognitive Resources, Motivation, Problem Solving)
3. Action States (Health Routines, Social Interdependence, Outcomes)

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.

Helman (1978), in his paper 'Feed a cold starve a fever', explored how individuals make sense of the common cold and other associated problems and reported that such illnesses were analysed in terms of the dimensions hot-cold, wet-dry with respect to their aetiology (cause) and possible treatment.

In a further study, 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.

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.
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.

Franks, P. Campbell, T.L. Shields, C.G. (1992)

Social relationships and health: the relative roles of family functioning and social support

Assessment of the outcomes of health intervention

Rosmarie Erben, Peter Franzkowiak & Eberhard Wenzel
Manila, Wiesbaden, Cologne

Paper presented to the Twelfth International Conference on the Social Sciences and Medicine, Peebles, Scotland, 14-18 September, 1992

Behavior Change Models For Reducing HIV/STD Risk

Good review of models.

Can Theory Help In HIV Prevention?

Good review of models and application to HIV prevention.

•  
•   Motivational Readiness for Change: Diet, Exercise, and Smoking    
• Beth C. Bock, PhD;  
  Bess H. Marcus, PhD; 
  Joseph S. Rossi, PhD;  
  Colleen A. Redding, PhD 
• Objective: To examine the relationship between level of motivational readiness for changing exercise behaviour and motivation to change dietary behaviour and smoking status. Methods: Sedentary men and women (n=194) were recruited via newspaper advertisements to participate in a self-help physical activity promotion intervention. Self-report of motivational readiness for changing exercise and dietary behaviours, smoking status, and demographic variables was assessed at baseline via mailed questionnaires. Results: Readiness to adopt physical activity was positively associated with readiness to reduce dietary fat and with other healthy dietary behaviours, but was not differentially associated with readiness to quit smoking. Conclusion: Motivational readiness to change health behaviours appears to share correspondence across some, but not all health behaviours. Am J Health Behav 1998;22(4):248-258  

• Relationship of Changes in Adolescents' Leisure Activities to Alcohol Use    
• Judith R. Vicary, PhD; 
  Edward Smith, DrPH; 
  Linda Caldwell, PhD;  
  John D. Swisher, PhD 
• Objective: To determine if a decrease in involvement in positive leisure activities preceded the transition to monthly-or-more often use of alcohol. Methods: 460 rural students were surveyed annually for 5 years regarding their participation in health and leisure behaviours. Results: Although gender and grade differences were found, increases in social activities (parties, dating, being with a crowd) most often occurred prior to increased alcohol use; decreases in sports, hobbies and crafts, and church involvement also preceded females' increased alcohol use. Conclusion: Leisure activities should be carefully selected and monitored in efforts to limit adolescent involvement with problem behaviors including alcohol abuse. Am J Health Behav 1998;22(4):276-282  

Return to Gary Sturt's Home page