Health and ill-health Attitudes and Behaviours
Reading
Banyard, P., Applying Psychology to Health, Hodder & Stoughton, 1996, Chapter 6.
Curtis, A.J., Health Psychology, Routledge, 2000, Chapter 1.
Ogden, J., Health Psychology, Open University press, 1996, Chapter 2.
Sarafino, E.P., Health Psychology, Wiley, 1994, Chapter 6
What are health behaviours?
Kasl and Cobb (1966) defined three types of health related behaviours. They suggested that;
Health behaviours have also being defined by Matarazzo (1984) in terms of either:
Health impairing habits, which he called "behavioural pathogens" (for example smoking, eating a high fat diet), or
Health protective behaviours, which he defined as "behavioural immunogens" (e.g. attending a health check).
Behaviour and mortality
50% of mortality from the 10
leading causes of death is due to behaviour
Doll and Peto (1981) estimated that 75%
of cancer deaths were related to behaviour (see pie chart). 90%
of all lung cancer mortality is attributable to cigarette smoking,
which is also linked to other illnesses such as cancers of the
bladder, pancreas, mouth, and oesophagus and coronary heart
disease. Bowel cancer is linked to behaviours such as a diet high
in total fat, high in meat and low in fibre.
Longevity: cross cultural differences
In the USA and the UK only three people out of every 100,000 live to be over 100. In Georgia, among the Abkarsians, 400 out of every 100,000 people live to be over 100, and the oldest recorded Abkarsian was 170. Weg (1983) suggests that their longevity is due to the following factors:
Belloc and Breslow (1972) examined the relationship between mortality rates and behaviour among seven thousand people. From their correlational analysis seven behaviours were found to relate to health status:
People aged over 75 who carried out all of these health behaviours had health that was compatible to those aged 35-44 who followed less than 3 of the health behaviours.
Kristiansen (1985) found that health behaviours were correlated with
Leventhal et al (1985) described factors that they believed predicted health behaviours:
Taking a combination of these factors might enable us to predict and promotes health-related behaviour.
Summaries of some theories - Click here
Attribution theory
Attribution theory emphasises attributions for causality and control.
Kelley (1972) developed the notion of causal schema to account for attributions made on the basis of information about a single behaviour or event. Taking an example, we could ask why David was angry with his client. The perceiver will process the available information in terms of three dimensions:
Kelley argued that attributions are made according to these criteria and that the type of attribution made determines the extent to which the cause of behaviour is regarded as a product of a characteristic internal or external to the individual.
Attribution theory has been developed so as to distinguish between self-attributions and attributions made about the behaviour of others. The dimensions of attribution have been redefined as follows:
Brickman et al. (1982) points out that attributions are not just made about the causes of a problem but are also made about the possible solutions. For example an alcoholic may believe that his lack of will power is the cause of his drinking problem but he may also believe that the medical profession is responsible for making him well again.
Herzlich (1973) interviewed 80 people about the general causes of health and illness and found that health is regarded as internal to the individual and illness is seen as something that comes into the body from the external world.
Bradley (1985) perceived control over illness was related to diabetic's choice of treatment. Those patients choosing an insulin pump showed decreased control over their diabetes and increased control attributed to powerful doctors.
King (1982) found that individuals who believed that hypertension was external but controllable by the individual were more likely to attend a screening clinic.
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:
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:
It can be seen that the perception of own risk is not a rational process.
Weinstein (1983) individuals ignore their own risk increasing behaviour (I drink lots of alcohol but that's irrelevant) and focus on a risk reducing behaviour (but at least I don't smoke). In addition to this people are egocentric and therefore tend to ignore others risk decreasing behaviour (my friends drink in moderation but that's irrelevant).
Hoppe and Ogden (1996) heterosexual subjects were asked to complete a questionnaire concerning their beliefs about HIV and their sexual behaviour. Subjects were allocated to one of two conditions, risk increasing condition and risk decreasing condition. In the risk-increasing condition they were asked, "since being sexually active, how often have you asked about your partners HIV status?" It was found that few subjects would be able to answer that they had done this frequently and therefore would feel more risk. In the risk decreasing condition subjects were asked, "since being sexually active, how often have you tried to select your partners carefully?" It was thought that most people would answer this by saying that they did thus, making them feel less at risk. It was then found that those who focused on risk decreasing tended to increase their optimism because they thought others were more at risk.
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.
Prochaska and DiClemente (1982) proposed a model of behaviour change based on the following stages:
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).
Evaluation of stages of change model
Successful for smoking cessation, reduction in alcohol intake, exercise and cancer screening behaviour.
Takes account of the passage of time. Difficult to know what stage an individual is in. Prochaska et al (1992) Only ten to 15% of addicted smokers were prepared for action. Most in the pre-contemplative and contemplative stages.
Cognitive or rational models
The health belief model and protection motivation theory are cognitive models that emphasise individual cognitions, not the social context of these cognitions. It is assumed that behaviours result from a rational weighing up of the potential costs and benefits of the behaviour.
The Health Belief Model (Rosenstock 1966, revised by Becker et al)
The health-belief model considers three levels in predicting people's behaviour. The first thing that must be taken into account is the patient's readiness to act, or perception of the need for action. Such readiness is determined by the perceived severity of the disease state that exists or is likely to exist and the perceived susceptibility of the illness or its consequences. Thus, if patients don't believe that an illness is severe or that they themselves will become ill, readiness to act is low. Readiness to act is high if the obverse is true. For example, people are far more likely to get flu shots if they see the strain of flu that is expected as severe and highly contagious than if they think of it as mild and relatively rare.
The second set of considerations in this model involves estimation of costs and benefits of compliance. In order to comply, patients must believe that the regimen will be effective. They must also feel that the benefits of following it outweigh the costs. Consistent with reinforcement theories, compliance occurs only when the incentives for accepting doctors' orders are greater than those for not doing so.
Finally, the health-belief model includes a cue to action, something that makes the subject aware of potential consequences. Internal signals that something is wrong (pain, discomfort) or external stimuli such as health campaigns or screening programs are necessary to set in motion the analyses listed above. Demographic variables are also included, though they have not shown any systematic relation to compliance.
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. 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.
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). 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. 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). 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
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. In other words women do not get the smear test because they feel that cervical cancer is particularly life-threatening. Obviously this study involved women only, one wonders whether men would share the same philosophy! 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
The revised HBM
Becker and Rosenstock (1987) have revised the HBM and have described their new model as consisting of the following factors:
Comparing the HBM with stages of change model
We know more about the cause of illness, disease and "health risking" behaviours than about preventive health behaviours.
Case study:-testicular self examination. (T. S. E)
Far more women know about and carry out breast cancer screening (BS E) compared with men knowing about and carrying out T. S. E.
T. S. E is carried out during a warm bath or shower. Testicles are rotated between the thumb and forefinger to check that they are free of lumps.
Frimen et al (1986) Young men given a checklist of T. S. E skills had increased confidence in reporting symptoms of T. S. E. Telephone follow-up showed that the skill continued long after the intervention. The men believed they were reducing their risks of cancer and that others would approve of this screening behaviour (subjective norms).
Focus on Research on the Health Belief Model
Factors Which Influence Cervical Cancer Screening Among Lesbians
Lynn E, Kunkel and Laurie A. Skokan
Objective: Screening and early detection are essential for the management and control of most diseases. It is important for women to practice routine health care that includes both clinical and self-evaluations. Today, many lesbians go without health care due to barriers which prevent them from obtaining adequate care. The present study was designed to investigate, using the Health Belief Model, the factors that influence compliance with cervical screening guidelines. Method: A questionnaire measuring each component of the Health Belief Model was mailed to 619 women in a south-western city. Using the current guidelines for cervical cancer screening, comparisons were made between compliant and noncompliant women. Results: Responses from 171 women who self-identified as lesbian or bisexual indicated that the Health Belief Model was a significant predictor of whether women complied with recommended guidelines for Pap smears. Further analyses indicated that the most predictive components of the model were self-efficacy and perceived barriers. The more self-efficacy women reported, the more likely they were to comply with screening guidelines, whereas the more barriers the women reported, the less likely they were to comply. Conclusions: The results are consistent with past research indicating that the Health Belief Model is a good predictor of health behavior for some groups.