Even though there has been much research and a multitude of interventions, many people con-tinue to behave in unhealthy ways. For example, although smoking in the UK has declined from 45 per cent in 1970 to 26 per cent in 2004, a substantial minority of the population still con-tinue to smoke (National Statistics 2005). Similarly, the prevalence of diet- and exercise-related problems, particularly obesity and overweight, rising (Obesity in the United Kingdom 2005;
Ogden et al. 2006a). Further, even though many people show initial changes in their health-related behaviours, rates of sustained behaviour change are poor, with many people reverting to their old habits. For example, although obesity treatments in the last 20 years have improved rates of initial weight loss, there has been very little success in weight loss maintenance in the longer term with up to 95 per cent of people returning to baseline weights by five years (NHS Centre for Reviews and Dissemination 1997; Jeffery et al. 2000; see Chapter 15). Similarly, nearly half of those smokers who make a quit attempt return to smoking within the year (National Statistics 2005; see Chapter 5). If real changes are to be made to people’s health status then research needs to address the issue of behaviour change in the longer term. To date,
PROBLEMS WITH THE MODELS 41
however, most research has focused on the onset of new behaviours or changes in behaviour in the short term due to the use of quantitative methods, with prospective designs that have follow-ups varying from a few weeks only to a year, as longer-term follow-ups require greater investment of time and cost. Some research, however, has addressed the issue of longer-term behaviour change maintenance, particularly for weight loss, smoking cessation and exercise.
■ Weight loss maintenance – Research indicates that although the majority of the obese regain the weight they lose, a small minority show weight loss maintenance. The factors that predict this are described in detail in Chapter 15; they illustrate a role for profile character-istics such as baseline body mass index (BMI), gender and employment status, historical factors such as previous attempts at weight loss, the type and amount of help received and psychological factors including motivations and individuals’ beliefs about the causes of their weight problem. In particular, research suggests that longer-term weight loss mainte-nance is associated with a behavioural model of obesity whereby behaviour is seen as central to both its cause and solution (Ogden 2000). This is in line with much research on adherence and illness representations and is discussed in detail in Chapter 3.
■ Smoking cessation – In terms of smoking cessation, much research has drawn upon a stage model approach and suggests that smoking cessation relates to factors such as action plans, goal setting and the transition through stages (e.g. Prochaska and Velicer 1997, see Chapter 5). In contrast, however, West and Sohal (2006) asked almost 2000 smokers and ex-smokers about their quit attempts and reported that nearly half had made quit attempts that were unplanned and that unplanned attempts were more likely to succeed than planned ones. They argue that longer-term smoking cessation may not always be the result of plans and the transition through stages and is often the result of ‘catastrophies’ which suddenly motivate change.
■ Exercise – As with changes in diet and smoking, much research exploring exercise uptake has focused on short-term changes. From this perspective most research shows that exer-cise is related to social factors and enjoyment rather than any longer-term consideration of health goals (see Chapter 7). Armitage (2005) aimed to explore the problem of exercise maintenance and explored the predictors of stable exercise habits over a 12-week period.
This study used the standard TPB measures and indicated that perceived behavioural control predicted behaviour in terms of both initiation and maintenance.
In general it would seem that there is a role for a range of demographic, psychological and structural factors in understanding longer-term changes in behaviour and that, while some changes in behaviour may result from the ‘drip drip’ effect illustrated by stages and plans, other forms of change are the result of more sudden shifts in an individual’s motivation. To date, however, there remains very little research on longer-term changes in behaviour. Further, the existing research tends to focus on behaviour-specific changes rather than factors that may gen-eralize across behaviours.
FOR DISCUSSION 43
To conclude
The role of health beliefs in predicting health-related behaviours has become increasingly salient with the recent changes in causes of mortality. Some studies exploring health beliefs have emphasized lay theories, which present individuals as having complex views and theories about their health which influence their behaviour. This perspective regards individuals as less rational and examines lay theories in a relatively unstructured format using a qualitative approach. Other studies have taken a more quantitative approach and have explored constructs such as attributions, health locus of control, unrealistic optimism, self-affirmation and stages of change. Psychologists have also developed structured models to integrate these different beliefs and to predict health behaviours such as the health belief model, the protection motivation theory, the theory of planned behaviour and the health action process approach. These models consider individuals to be processors of information and vary in the extent to which they address the individual’s cognitions about their social world. The models can be used to predict health behaviours quantitatively and have implications for developing methods to promote change.
Questions
1 Recent changes in mortality rates can be explained in terms of behaviour-related illnesses.
Discuss.
2 Discuss the contribution of attribution theory to understanding health behaviours.
3 Health beliefs predict health behaviours. Discuss with reference to two models.
4 Discuss the role of the social world in understanding health behaviours.
5 Human beings are rational information processors. Discuss.
6 Discuss the argument that changing an individual’s beliefs would improve their health.
7 Discuss some of the problems with the structured models of health beliefs.
8 To what extent can social cognition models be used to change health behaviours?
9 Design a research project to promote non-smoking in a group of smokers using two models of health beliefs.
For discussion
Consider a recent change in your health-related behaviours (e.g. stopped/started smoking, changed diet, aimed to get more sleep, etc.). Discuss your health beliefs that relate to this change.
Further reading
Conner, M. and Norman, P. (eds) (1998) Special issue: social cognition models in health psychol-ogy, Psychology and Health, 13: 179–85.
This special issue presents research in the area of social cognition models. The editorial provides an overview of the field.
Conner, M. and Norman, P. (2005) Predicting Health Behaviour (2nd edn) Buckingham: Open Uni-versity Press.
This book provides an excellent overview of the different models, the studies that have been carried out using them and the new developments in this area.
Gollwitzer, P.M. and Sheeran, P. (2006). Implementation intentions and goal achievement: a meta-analysis of effects and processes, Advances in Experimental Social Psychology, 38: 69–119.
This paper provides a detailed account of the research using implementation intentions. It is also an excellent example of a meta-analysis and how this approach can be used effectively.
Assumptions in health psychology
Research into health beliefs highlights some of the assumptions in health psychology:
1 Human beings as rational information processors. Many models of health beliefs assume that behaviour is a consequence of a series of rational stages that can be measured. For example, it is assumed that the individual weighs up the pros and cons of a behaviour, assesses the seriousness of a potentially dangerous illness and then decides how to act. This may not be the case for all behaviours. Even though some of the social cognition models include past behaviour (as a measure of habit), they still assume some degree of rationality.
2 Cognitions as separate from each other. The different models compartmentalize dif-ferent cognitions (perceptions of severity, susceptibility, outcome expectancy, inten-tions) as if they are discrete and separate entities. However, this separation may only be an artefact of asking questions relating to these different cognitions. For example, an individual may not perceive susceptibility (e.g. ‘I am at risk from HIV’) as sepa-rate to self-efficacy (e.g. ‘I am confident that I can control my sexual behaviour and avoid HIV’) until they are asked specific questions about these factors.
3 Cognitions as separate from methodology. In the same way that models assume that cognitions are separate from each other, they also assume that they exist independent of methodology. However, interview and questionnaire questions may actually create these cognitions.
4 Cognitions without a context. Models of health beliefs and health behaviours tend to examine an individual’s cognitions out of context. This context could either be the context of another individual or the wider social context. Some of the models incor-porate measures of the individuals’ representations of their social context (e.g. social norms, peer group norms), but this context is always accessed via the individuals’
cognitions.
FURTHER READING 45
Rutter, D. and Quine, L. (eds) (2003) Changing Health Behaviour: Intervention and Research with Social Cognition Models. Buckingham: Open University Press.
This edited book provides an excellent review of the intervention literature including an analysis of the problems with designing interventions and with their evaluation.
Webb, T.L. and Sheeran, P. (2006) Does changing behavioural intentions engender behaviour change? A meta-analysis of the experimental evidence, Psychological Bulletin, 132: 249–68.
This paper presents a meta-analysis of the research exploring the links between intentions and behaviour. It is a useful paper in itself but also provides an excellent source of references.
Woodcock, A., Stenner, K. and Ingham, R. (1992) Young people talking about HIV and AIDS: inter-pretations of personal risk of infection, Health Education Research: Theory and Practice, 7: 229–47.
This paper illustrates a qualitative approach to health beliefs and is a good example of how to present qualitative data.
Chapter overview
Chapter 2 described health beliefs and the models that have been developed to evaluate these beliefs and their relationship to health behaviours. Individuals, however, also have beliefs about illness. This chapter examines what it means to be ‘healthy’ and what it means to be ‘sick’ and reviews these meanings in the context of how individuals cognitively represent illness (their illness cognitions/illness beliefs). The chapter then assesses how illness beliefs can be measured and places these beliefs within Leventhal’s self-regulatory model. It then discusses the relationship between illness cognitions, symptom perception and coping behaviour. Finally, the chapter exam-ines the relationship between illness cognitions and health outcomes and the role of coherence.
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This chapter covers
● What does it mean to be healthy?
● What does it mean to be ill?
● What are illness cognitions?
● Measuring illness cognitions
● Leventhal’s self-regulatory model of illness cognitions
● Symptom perception
● Coping