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Specific models of health- related behavior
Presentation and critiscisms
Aymery Constant, PhD
Health Psychology Lecturer
EHESP

2.
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
The leading model since the 50s (“top down”)
Information
« There is a lion in front of me »

3.
Expected
Consequences
Subjective
Probabilities
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
The leading model since the 50s (“top down”)
Information
« The lion will attack me »
High

4.
Expected
Consequences
Subjective
Probabilities
Cognitive
Evaluation
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
The leading model since the 50s (“top down”)
Information
This is a bad situation
I might die

5.
Expected
Consequences
Subjective
Probabilities
Cognitive
Evaluation
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
Emotion
The leading model since the 50s (“top down”)
Information
I have a bad feeling about this™

6.
Expected
Consequences
Subjective
Probabilities
Cognitive
Evaluation
Decision
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
Emotion
The leading model since the 50s (“top down”)
Information
Run away

7.
Expected
Consequences
Subjective
Probabilities
Cognitive
Evaluation
Decision
Consequences
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
Emotion
The leading model since the 50s (“top down”)
Information
Safety

8.
Models of health-related behaviors
The major models in health behavior research:
The Basic Risk Perception Model
The Health Belief Model (HBM)
The Protection Motivation Theory (PMT)
The Trans-theoritical Model (TTM)
The Theory of Plannified Behavior (TPB)

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The Basic Risk Perception model

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The basic risk perception model focus on only two dimensions of health hazard:
 the likelihood of harm if no action is taken
 the severity of harm if no action is taken
The basic risk perception model
This model is an adaptation of the expected-utility theory to decision in health behaviors.

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Two characteristics:
Likelihood is one’s probability of being harmed by a hazard under certain behavior conditions. Example: “What is the likelihood that you will get the flu this year?”
Susceptibility (or vulnerability) emphasize an individual’s constitutional vulnerability to a hazard. Example: “Are you more likely to get the flu than other people?”
1) the likelihood of harm:
The basic risk perception model

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can be defined as the extent of harm a hazard would cause. Examples of questions:
 “How serious a disease is the flu?”
 “Can Influenza cause death?”
 “If you had influenza, would you be able to manage daily activities?”
2) the severity of harm:
The basic risk perception model

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CONCLUSION
The basic risk perception model
Higher levels of severity and likelihood are associated with
higher motivation

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It included Thirty-four studies (N = 15,988). Risk likelihood, susceptibility, and severity were significantly correlated:
 Risk likelihood: pooled r = .26
 Risk susceptibility : pooled r = .24
 Risk severity: pooled r = .16
Risk perceptions are core concepts in predicting preventive behavior.
But correlations are quite small
A meta-analysis of the relationship between risk perception and adult vaccination has been conducted (Brewer et al, 2007):
The basic risk perception model

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The Health Belief Model (HBM)

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 The health belief model was initially developed in the 1950s by a group of social psychologists in the U.S. Public Health Service
 Research was initiated to explain failure of large number of eligible adults to participate in tuberculosis screening programs provided at no charge in a mobile X-ray units conveniently located in various neighborhoods.
 Researchers were concerned with identifying factors that were facilitating or inhibiting participation.
The health belief model (HBM)
ORIGINS OF THE HEALTH BELIEF MODEL

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The health belief model (HBM)
COMPONENTS OF THE HEALTH BELIEF MODEL
Perceived susceptibility
Perceived severity
Perceived threat
Behavior change
Perceived benefits of change
Perceived barriers of change

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The health belief model (HBM)
COMPONENTS OF THE HEALTH BELIEF MODEL
 Perceived susceptibility : one’s subjective perception of risk of contracting an illness.
 Perceived severity : beliefs concerning the seriousness of consequence of contracting an illness (e.g., death, disability, and pain). This includes the social consequences (e.g., work, family life, leisure, etc.).
 Perceived benefits : beliefs regarding the effectiveness and the efficacy of various available actions in reducing the disease threat, but also the non-health-related benefits (save money, relative approval, etc.).

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The health belief model (HBM)
COMPONENTS OF THE HEALTH BELIEF MODEL
 Perceived barriers : spontaneous cost analysis which occurs when the individual evaluate preventive actions that may be expensive, dangerous, unpleasant, inconvenient, time-consuming, and so forth.
 Self-efficacy : this concept introduced in 1977 by Bandura refers to the conviction that “one can successfully execute the behavior required to produced the outcomes”
People must not only feel threatened by their current behavioral patterns and believe that change of a specific kind will be beneficial at acceptable cost, but they must also feel themselves competent to overcome perceived barriers to taking action.

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The health belief model (HBM)
Reviews of HBM studies (Janz & Becker, 1984)
 Perceived barriers were found to be the powerful single predictor of the HBM dimensions across all studies and health threat.
 Perceived susceptibility and perceived benefits were both important, while PS seem to be a stronger predictor of preventive behavior than PB.
 Perceived severity was the least powerful predictor. However, this dimension was sometime strongly related to certain risk behavior.

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The Protection Motivation Model

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Mass media and prevention programs frequently provide people with information about unpleasant, but avoidable, health consequences.
It is assumed that the threat of pain and suffering motivates people to take protective action.
PMT explain the effects of threatening health information on public attitude and behavior change.
The amount of protection motivation is supposed to be a function of the threat and coping appraisal processes.
Origins and purpose
The protection motivation theory (PMT)

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The protection motivation theory (PMT)
OVERALL MODEL OF PMT
PMT describes adaptive and maladaptive coping with a health threat as a result of two appraisal processes:
A process of threat appraisal and a process of coping appraisal, in which the behavioral options to diminish the threat are evaluated (Boer, Seydel, 1996).

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The protection motivation theory (PMT)
OVERALL MODEL OF PMT

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The protection motivation theory (PMT)
COGNITIVE MEDIATING PROCESSES OF PMT

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The components of threat appraisal :
 Vulnerability of being exposed to the hazard: “probability that the event will occur provided that no adaptative behavior is performed” (Roger, 1975, p. 97).
 Perceived severity: in PMT, severity refers to the degree of physical, psychological, social and economic harm.
 Intrinsic rewards: physical and psychological pleasure associated with maladaptive responses (e.g. smoking, high calorie diet, etc.).
 Extrinsic rewards: it refers mostly to peer approvals (relatives, friends, parents, etc.).
The protection motivation theory (PMT)

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The status of fear in PMT:
The protection motivation theory (PMT)
 Fear is assumed to play only an indirect role in threat appraisals.
 Research reviewed by Rogers (1983) found that fear influences attitude and behavior change, not directly but indirectly by affecting the appraisal of the severity of the danger.
 Some studies have nevertheless shown that too much fear can have a detrimental effect on attitude change by inducing maladaptive change such as defensive denial.

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« Inverted U-curve »

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The results of meta-analysis of PMT studies:
In a literature review that included 65 relevant studies (N = 30,000) representing over 20 health issue, Floyd et al (2000) found the following results:
 Perceived threat vulnerability had a significant but weak effect on health behavior or attitudes.
 Perceived threat severity, rewards, response efficacy and self- efficacy had a moderate effect on health behavior or attitudes.
 Response cost related to adaptive coping had the strongest impact on health behavior or attitudes.
The protection motivation theory (PMT)

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Transtheoretical Model and Stages of Change

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Resolutions on News Years Eve?
Stop smoking
Eat more vegetable and fruits
Sport
Use byclicle, etc.
Mainly consist of:
- quitting unhealthy/inadequate behaviors
- adopting healthy behaviors
Behavior change

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Transtheoretical Model:
The Transtheoretical Model uses stages of change to integrate processes and principles of change from across major theories of intervention.
It was called transtheoretical because concepts come from different theories of human behavior and views of how to change people
Comparative analysis theories and behavioral change identified ten processes of change among them, which unfold through a series of stages

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Core Constructs:
Stages of Change: Behavioral change can seen as a progression through a series of stages.
Previous research has measured a number of cognitive and behavioral markers that have been used to identify these stages.

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Stages of Change:
1) Precontemplation: subject has no intention to act in the near future (in the next six months at least), due to lack of information or demoralization from past attempts
2) Contemplation: subject intend to change in the near future; he is aware of pros and cons of changing
3) Preparation: he has intention to take action in the immediate future (within 1 month); have a plan of action

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Stages of Change:
4) Action: the subject has taken observable action within the last 6 months
5) Maintenance: the subject actively work to prevent relapse; less temptation and more confidence
6) Termination: the subject has no temptation and is 100% efficient

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Stages of Change
Precontemplation: no intention to change
Termination

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Stages of Change
Precontemplation
Termination
Contemplation
Preparation
Action
Maintenance
Linear progression through the stages

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Circular
progression
Enter here
Termination

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Core Constructs:
Processes of Change: Stages of Change are useful in explaining when changes in cognition, emotion, and behavior take place,
But the processes of change help to explain how these changes occur.
These ten observable and non-observable processes need to be implemented to successfully progress through the stages of change
They can be divided into two groups: cognitive/affective processes, and behavioral processes.

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Enter here
Termination
processes
processes
processes processes
processes

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Stages of Change in Which Change Processes Are Most Emphasized
Stages of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
Consciousness Raising
Dramatic relief
Environmental reevaluation
Behavioral processes
Self-reevaluation
Self-liberation
Reinforcement Management
Helping relationships
Counterconditioning
Cognitive / emotional processes
Stimulus Control

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Cognitive/Emotional Processes
Consciousness Raising [Increasing Awareness]
I recall information people had given me on how to stop smoking.
Dramatic Relief [Emotional Arousal]
I react emotionally to warnings about smoking cigarettes.
Environmental Reevaluation [Social Reappraisal]
I consider the view that smoking can be harmful to the people around me.
Social Liberation [Environmental Opportunities]
I find society changing in ways that make it easier for the nonsmoker.
Self Reevaluation [Self Reappraisal]
My dependency on cigarettes makes me feel disappointed in myself.

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Behavioral Processes
Stimulus Control [Re-Engineering]
I remove things from my home that remind me of smoking.
Helping Relationships [Supporting]
I have someone who listens to me when I need to talk about my smoking.
Counter Conditioning [Substituting]
I find that doing other things with my hands is a good substitute for
smoking.
Reinforcement Management [Rewarding]
I reward myself when I don’t smoke.
Self liberation [Committing]
I make commitments not to smoke.

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Core Constructs:
Decisional Balance: weighing pros and cons of changing.
As individuals progress through the Stages of Change, decisional balance shifts in critical ways.

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Relationship between Stage and the Decisional Balance for quitting unhealthy Behavior :

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Relationship between Stage and the Decisional Balance for adopting healthy Behavior :

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Self-Efficacy
Self-Efficacy: (Bandura, 1977, 1982). the degree of confidence the individual has in maintaining their desired behavioral change in situations that often trigger relapse.
It is also measured by the degree to which the individual feels tempted to return to their problem behavior in these high-risk situations.
Temptation: the intensity of urges to engage in a specific habit when in the midst of difficult situations, including:
Negative affect or emotional distress
Positive social occasions
Cravings

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The Relationship between Stage and both Self-efficacy and Temptation

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Cochrane review
Authors from the Cochrane Collaboration tested the effectiveness of stage-based interventions in helping smokers to quit.
•They found 41 trials (>33,000 participants) which met inclusion criteria. Four trials, which directly compared the same intervention in stage-based and standard versions, found no clear advantage for the staging component.
•The TTM is of little interest for intervention purposes

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The Theory of Planned Behaviour

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Created by Azjen in 1991, from a previous 1985 model
Designed to predict any type of voluntary behavior
Not restricted to health behavior (economy; etc.)
One of the most popular models used to predict a wide range of behavior, including health behaviors
Theory of planned behaviour

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Model of the TPB

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Extension: speed driving

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Affective attitudes

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Extension of social norms

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Influence of TPB variables
High influence on intention
low influence on actual
behaviour

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Time to retire the TPB
Editorial by F. Sniehotta
10-15 mn reading
Try to identify main criticisms Note: Remarks on TPB might be extrapolated to others models

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Main criticisms
Study design: Cross-sectional vs. longitudinal; university students; self-reported behaviors; correlations between repeated measures
Structural flaws: Assumptions based on common sense that cannot be refuted; Gap between intention and action not taken into account; not a dynamic model
Poor predictive validity: Some pivotal variables are not assessed in the model, not useful to predict behavior or implementing behavior change

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Changing human behavior to prevent disease
Article by T. Marteau
10-15 minutes reading
Identify main criticisms of past health interventions
 Suggested future directions

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The underlying mechanism of decision-making
Source : Kahneman, D. (2002), Maps of Bounded Rationality : A Perspective on Intuitive
Judgments and Choices, Nobel Prize Lecture 2002.
Huge Influence on behaviours Psychological models

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65
PRIME Theory: reflective and automatic processes
www.primetheory.com

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Changing the future
= require new approaches
Determinants (beliefs; attitudes; norms..)
New Behaviour
Current
Behaviour
How the TPB (and most others models) work :
Explaining the past
= how behavior s occured

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Changing human behavior to prevent disease
Future directions according to Marteau
Altering environment to constrain behavior
Architecture of choice
Offer healthy alternatives
Nudging
Targeting automatic associative processes
Change automatic reactions to external cues
Change associations

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Alter environment

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Alter environment
The term “nudge” was first used in a book of the
same title to describe “any aspect of the choice
architecture that alters people’s behaviour in a
predictable way without forbidding any options or
significantly changing their economic incentives
Marteau (2011).Judging nudging. BMJ

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Create new associations in mind (healthy=fun)

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Provide alternative healthy choices

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What about motivation ?

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Understanding motivation
Brain processes that energise and direct behaviour
Not limited to choice and goal pursuit
Needs to include
drive
habit
desire
instinct
self-regulation
etc.

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COM-B system for analysing behaviour in context
1.Capability, motivation and opportunity all need to be present for a behaviour to occur
2.They all interact as part of a system
3.Motivation must be stronger for the target behaviour than competing behaviours

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Common terms for methods for inducing behaviour change
Capability
Educate
Train
Help
Motivation
Expose to
Inform
Discuss
Suggest
Encourage
Incentivise
Ask
Order
Plead
Coerce
Force
Opportunity
Provide
Prompt
Constrain

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Most behavioral models are based on perceptions (attitudes, norms, beliefs) that might be relevant
But they ignore some of the most pivotal variables shaping behaviors (habits; contexts; environment; desires; needs…)
They correlate poorly with actual behavior and are not very useful for designing behavior change interventions
Behavior change technique should include motivation
New approaches targeting environment, motivation and habits are warranted to promote healthy behavior
Conclusions