create2004day1

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CREATE Workshop 2004 Predicting and Changing Health Behaviour: Conducting and Publishing Theory-Based Research Paul Norman & Peter Harris Department of Psychology University of Sheffield

Overview of Workshop: 

Overview of Workshop 1: Predicting Health Behaviour 2: Theory-Based Interventions 3: Dissemination

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1. Predicting Health Behaviour Overview of Social Cognition Models of Health Behaviour Background, Model Description, Measurement, Example Studies Future Directions…

Health Behaviour: 

Health Behaviour Kasl & Cobb (1966) Health behaviour - aimed to prevent disease i.e. “any activity undertaken by a person believing himself to be healthy for the purpose of preventing disease or detecting it at an asymptomatic stage” Illness behaviour - aimed to seek remedy e.g. go to the doctor Sick role behaviour - aimed to get well e.g. take prescribed medication

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Matarazzo (1984) Health impairing habits - “behavioural pathogens” e.g. smoking, eating a high fat diet Health protective behaviours - “behavioural immunogens” e.g. attending a health check

Health Behaviour - Mortality and Morbidity: 

Health Behaviour - Mortality and Morbidity Belloc & Breslow (1972), Belloc (1973) 7 health behaviours - sleeping 7-8 hour a day - having breakfast every day - not smoking - avoiding snacking - ideal body weight - moderate or no use of alcohol - regular exercise

Health Behaviour - Exercise: 

Health Behaviour - Exercise Physical Health Benefits Reduced risk for CHD, stroke, and hypertension Increased metabolism of carbohydrates and fats Mental Health Benefits Reduced levels of anxiety and life stress Enhanced positive mood states Increased satisfaction with physical shape

Predicting Health Behaviour : 

Predicting Health Behaviour To understand why individuals do/do not perform a variety of health behaviours To design interventions to change behaviour

Cummings et al. (1980) : 

Cummings et al. (1980) Accessibility of health care services Attitudes to health care Perceptions of disease threat Knowledge about disease Social network characteristics Demographics factors

Focus on social cognitive factors : 

Focus on social cognitive factors Differentiate between individuals Mediate impact of other factors Are more amenable to change Parsimony

Social Cognition Models : 

Social Cognition Models Potential Advantages: 1. Provide a clear theoretical background to research Identify targets for interventions Potential Disadvantages: 1. Neglect other (non-/cognitive) variables How to change cognitions?

Social Cognition Models : 

Social Cognition Models Health Belief Model Protection Motivation Theory Theory of Planned Behaviour Social Cognitive Theory Health Locus of Control Self Regulation Theory

Protection Motivation Theory (Rogers, 1983) : 

Protection Motivation Theory (Rogers, 1983) Early work on fear appeals - fear-drive model Fear appeal + behavioural advice Hovland et al. (1967) - 3 main stimulus variables in a fear appeal: Magnitude of noxiousness or severity of an event Probability of event occurrence if no action is taken Efficacy of the recommended coping response

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Rogers (1975) - cognitive mediational effects 1. Magnitude of noxiousness or severity initiates perceptions of severity Probability of event occurrence if no action is taken initiates perceptions of vulnerability 3. Efficacy of the recommended coping response initiates perceptions of response efficacy Protection motivation (i.e. intention to follow advice) “arouses, sustains, and directs activity”.

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Rogers (1983) - Revised PMT Broader range of factors that may initiate cognitive processes (e.g. observational learning, past experience, personality) Additional cognitive mediating processes (i.e. perceptions of rewards of maladaptive responses, self-efficacy, response costs) Organised into two cognitive mediating processes focusing on threat appraisal and coping appraisal

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Leventhal (1970) - Parallel Response Model Fear control - attempts to reduce to emotional threat Danger control - attempts to reduce to threatened danger

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Intrinsic and Extrinsic Rewards Response Efficacy Protection Motivation Self- Efficacy Behaviour Severity Vulnerability = Response Costs Threat Appraisal Coping Appraisal _ _ = Maladaptive Response Adaptive Response Protection Motivation Theory (Rogers, 1983)

Hodgkins & Orbell (1998) - PMT and BSE: 

Hodgkins & Orbell (1998) - PMT and BSE Salient cognitions about BSE and breast cancer identified from an elicitation survey with 40 women

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Perceived Severity Developing breast cancer would force me to change my goals in my life Perceived Vulnerability My chances of developing breast cancer in the future are… … very low-very high Intrinsic/Extrinsic Rewards of Maladaptive Response

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Response Efficacy If I were to carry out BSE I would ensure early detection of any abnormalities Self-Efficacy I am discouraged from performing BSE as I feel I do not know how Response Costs I would feel awkward examining my breasts

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Operationalization of the Model Development of questionnaire items 1. Content of items - literature review, pilot interviews 2. Factor analyses and reliability analyses

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Norman, P., Searle, A., Harrad, R., & Vedhara, K. (2003) Predicting adherence to eye patching in children with amblyopia: An application of protection motivation theory. British Journal of Health Psychology, 8, 67-82.

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Pilot Interviews 20 parents of children with amblyopia Main Study - Respondents 151 parents attending follow-up appointment at orthoptic clinic 105 followed-up by postal questionnaire at two months PMT Questionnaire 42 items - factor analysed

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Protection Motivation I plan to patch my child as recommended by the orthopist Perceived Severity I believe that my child’s visual impairment is a serious condition Perceived Vulnerability If left untreated, what are the chances that your child’s visual impairment will affect his/her reading ability? Response Efficacy Eye patching is an effective treatment for my child’s condition

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Response Costs - Distress Patching causes distress for me Response Costs - Prohibits Wearing a patch prohibits my child from playing Response Costs - Stigma Negative comments from others about the patch upset me Self-Efficacy I feel confident in my ability to patch my child

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Table 1 Descriptive Statistics _____________________________________________ Items Alpha Mean SD _____________________________________________ Protection Motivation 3 0.91 4.50 0.85 Severity 6 0.78 3.57 0.82 Vulnerability 6 0.89 3.49 1.00 Response Efficacy 5 0.85 4.33 0.78 Response Costs - Distress 8 0.87 2.75 1.04 Response Costs - Prohibit 5 0.90 1.94 1.05 Response Costs - Stigma 5 0.72 2.85 0.95 Self-Efficacy 4 0.89 3.86 1.20 ______________________________________________

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Table 2 Correlations _____________________________________________ PM Adherence _____________________________________________ Protection Motivation - .09 Severity -.01 -.03 Vulnerability .27** .25* Response Efficacy .27** .28** Response Costs - Distress -.33*** -.23* Response Costs - Prohibit -.22** -.41*** Response Costs - Stigma -.21** -.16 Self-Efficacy .46*** .23 _____________________________________________ * p < .05, ** p < .01, *** p < .001

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Table 3 Regression Analysis Predicting Protection Motivation ____________________________________ Protection Motivation ____________________________________ Severity .01 Vulnerability .17* Response Efficacy .17* Response Costs - Distress -.04 Response Costs - Prohibit -.06 Response Costs - Stigma -.01 Self-Efficacy .37*** ____________________________________ R2 = .30***, * p < .05, *** p < .001

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Table 4 Regression Analysis Predicting Adherence _____________________________________ Step1 Step 2 _____________________________________ Protection Motivation .08 -.23* Severity -.01 Vulnerability .20* Response Efficacy .17 Response Costs - Distress -.10 Response Costs - Prohibit -.30** Response Costs - Stigma .03 Self-Efficacy .16 _____________________________________ R2 = .28***, * p < .05, *** p < .001

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PMT meta-analysis (Milne et al., 2000) ______________________________________________________ Behaviour __________________ PM Concurrent Future ______________________________________________________ Protection Motivation - .82*** .40*** Severity .10*** .13*** .07 Vulnerability .16*** .13*** .12** Response Efficacy .29*** .17*** .09 Self-Efficacy .33*** .36*** .22*** Response Costs -.34*** -.32*** -.25*** ______________________________________________________ r+ = sample weighted average correlations

Theory of Planned Behaviour (Ajzen, 1988): 

Theory of Planned Behaviour (Ajzen, 1988) Fishbein’s (1967) work on the psychological processes through which attitudes might cause behaviour and analysis of weak attitude-behaviour relations Fishbein and Ajzen (1975) - principle of correspondence Ajzen (1975) - principle of compatibility

Principle of Correspondence/Compatibility: 

Principle of Correspondence/Compatibility Each attitude and behaviour has four elements of: Action Target Context Time

Principle of Correspondence/Compatibility: 

Principle of Correspondence/Compatibility Each attitude and behaviour has four elements of: Action Flossing Target Teeth Context Bathroom Time Every morning Attitude-behaviour relations will be stronger when both are measured at the same level of specificity

Theory of Reasoned Action (Fishbein & Ajzen, 1975): 

Theory of Reasoned Action (Fishbein & Ajzen, 1975) 1. Social Norms Intention is the immediate determinant of behaviour - mediates the effects of attitudes and norms Attitude-behaviour relations will be stronger when both are measured at the same level of specificity

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Attitude Subjective Norm Intention Behaviour Theory of Reasoned Action (Fishbein & Ajzen, 1975) N.B. Relative importance of attitudes and norms - behaviours and populations

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Attitude Subjective Norm Theory of Reasoned Action (Fishbein &Ajzen, 1975) Beliefs about outcomes X Evaluation of outcomes Normative beliefs X Motivation to comply

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Attitude Subjective Norm Intention Perceived Behavioural Control Behaviour Theory of Planned Behaviour (Ajzen, 1988)

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Attitude Subjective Norm Perceived Behavioural Control Theory of Planned Behaviour (Ajzen, 1988) Beliefs about outcomes X Evaluation of outcomes Normative beliefs X Motivation to comply Likelihood of occurrence X Facilitating/inhibiting power

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Operationalization of the Model Belief-based (indirect) measures Pilot studies - semi-structured interviews or Qs

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Behavioural Beliefs What do you see as the advantages of engaging in regular exercise over the next six months? What are the likely positive outcomes of engaging in regular exercise over the next six months? What do you see as the disadvantages of engaging in regular exercise over the next six months? What are the likely negative outcomes of engaging in regular exercise over the next six months?

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Normative Beliefs Who (i.e. which individuals or groups) would approve of you engaging in regular exercise over the next six months? Who (i.e. which individuals or groups) would want you to engage in regular exercise over the next six months? Who (i.e. which individuals or groups) would disapprove of you engaging in regular exercise over the next six months Who (i.e. which individuals or groups) wouldn’t want you to to engage in regular exercise over the next six months?

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Control Beliefs What are the things that might make it easier for you to engage in regular exercise over the next six months? What are the things that might facilitate you engaging in regular exercise over the next six months? What are the things that might make it more difficult for you to engage in regular exercise over the next six months? What are the things that might hinder or prevent you from engaging in regular exercise over the next six months?

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Operationalization of the Model Belief-based (indirect) measures Pilot studies - semi-structured interviews or Qs Select the “modal salient beliefs” Ajzen & Fishbein (1980) suggest that “those beliefs that exceed a certain frequency” should be chosen

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Behavioural Beliefs and Outcome Evaluations 1. Engaging in regular exercise over the next six months would improve my fitness Unlikely 1 2 3 4 5 6 7 Likely 2. Improving my fitness would be… Bad 1 2 3 4 5 6 7 Good Bad -3 -2 -1 0 1 2 3 Good Bad        Good

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Normative Beliefs and Motivation to Comply 1. My friends think that I should/should not engage in regular exercise over the six months Think 1 2 3 4 5 6 7 Think I I should should not With regard to exercising, how much do you want to do what your friends think you should? Not 1 2 3 4 5 6 7 Very much at all

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Control Beliefs and Power The availability of cheap sports facilities would make engaging in regular exercise over the next six months… More 1 2 3 4 5 6 7 More easy difficult Cheap sports facilities are available… Never 1 2 3 4 5 6 7 Frequently

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Operationalization of the Model Direct measures Guidelines - Ajzen & Fishbein (1980), Ajzen (1988) - Conner & Sparks (1996, 2005)

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Attitude My engaging in regular exercise over the next six months would be… Bad 1 2 3 4 5 6 7 Good Pleasant 1 2 3 4 5 6 7 Unpleasant Enjoyable 1 2 3 4 5 6 7 Unenjoyable Wise 1 2 3 4 5 6 7 Foolish Harmful 1 2 3 4 5 6 7 Beneficial

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Subjective Norm People who are important to me would approve/ disapprove of me engaging in regular exercise over the next six months Would 1 2 3 4 5 6 7 Would approve disapprove 2. People who are important to me think I should/ should not engage in regular exercise over the next six months Think 1 2 3 4 5 6 7 Think I I should should not

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Perceived Behavioural Control How much control do you feel you have over engaging in regular exercise over the next six months? No 1 2 3 4 5 6 7 Complete control control 2. My engaging in regular exercise over the next six months would be… Easy 1 2 3 4 5 6 7 Difficult

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Intention I intend to engage in regular exercise over the next six months Definitely 1 2 3 4 5 6 7 Definitely do not do 2. How likely is it that you will engage in regular exercise over the next six months? Likely 1 2 3 4 5 6 7 Unlikely

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Norman, P., Conner, M., & Bell, R. (2000) The theory of planned behaviour and exercise. British Journal of Health Psychology, 5, 249-261.

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Respondents 110 patients attending a health promotion clinic at their general practice 87 followed-up by postal questionnaire at six months Time 1 - TPB Questionnaire Time 2 - Exercise Behaviour

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Attitude Taking regular physical activity over the next six months would be… bad-good, unpleasant-pleasant, etc Subjective Norm People who are important to me think that I should/should not take regular physical activity over the next six months Perceived Behavioural Control How much control do you feel you have over taking regular physical activity over the next six months? Intention I intend to take regular physical activity over the next six months

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Table 1 Descriptive Statistics _____________________________________________ Items Alpha Mean SD _____________________________________________ Intention 3 0.95 2.01 1.52 Attitude 5 0.85 2.21 0.97 Subjective Norm 1 - 1.40 1.77 Per Behav Control 4 0.87 1.71 1.33 ______________________________________________

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Table 2 Correlations _____________________________________________ Intention Behaviour _____________________________________________ Intention - .32** Attitude .33** .23* Subjective Norm .16 -.22 Per Behav Control .74*** .37** _____________________________________________ * p < .05, ** p < .01, *** p < .001

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Table 3 Regression Analysis Predicting Intention ____________________________________ Intention ____________________________________ Attitude .04 Subjective Norm .14 Per Behav Control .71*** ____________________________________ R2 = .53***, *** p < .001

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Table 4 Regression Analysis Predicting Behaviour _________________________________ Behaviour _________________________________ Intention -.01 Per Behav Control .39* _________________________________ R2 = .15**, * p < .05, ** p < .01

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BBs TPB meta-analysis (Conner & Armitage, 2001) CBs NBs ATT SN PBC BEH INT r=.50 r=.50 r=.52 r=.49 r=.34 r=.43 r=.47 r=.37

Social Cognition Models : 

Social Cognition Models Health Belief Model Protection Motivation Theory Theory of Planned Behaviour Social Cognitive Theory

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Action Cues to Action Perceived Severity Perceived Susceptibility Health Belief Model (Becker, 1974) Perceived Benefits Perceived Barriers Health Motivation

Social Cognitive Theory (Bandura, 1977): 

Situation-outcome expectancies Action-outcome expectancies Perceived self-efficacy Motivation/Intention Social Cognitive Theory (Bandura, 1977)

Future Directions: 

Future Directions Measurement of Perceived Risk - conditional measures Additional Variables - anticipated affect - moral norms - descriptive norms (Social Identity Theory) - behavioural willingness (prototypes) - self-identity Past behaviour / habit “Intention-Behaviour” Gap

Meta-analyses of intention-behaviour relations: 

Meta-analyses of intention-behaviour relations ________________________________ Meta-analysis R2 ________________________________ Sheppard et al. (1988) .28 Ajzen (1991) .20 Van den Putte (1993) .38 Randall & Wolff (1994) .20 Godin & Kok (1996) .21 Ouellette & Wood (1998) .29 Sheeran & Orbell (1998) .19 Conner & Armitage (2001) .22 ________________________________

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The “intention-behaviour gap” (Sheeran, 2002)

Stage Models of Health Behaviour: 

Stage Models of Health Behaviour Transtheoretical Model of Change (Prochaska & DiClemente, 1982) Health Action Process Approach (Schwarzer, 1992) Precaution-Adoption Process (Weinstein, 1988) Goal Setting Theory (Bagozzi,1993) Two themes: Temporal perspective Different cognitions at different stages Motivational versus volitional phases

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Transtheoretical Model of Behaviour Change (Prochaska & DiClemente, 1982) Precontemplation Contemplation Preparation Action Maintenance Pros and Cons - Decisional Balance Self-Efficacy Behavioural and Experiental Processes of Change

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Stage Definitions (from DiClemente et al., 1991) Precontemplation: Currently smoking and not seriously considering quitting within next 6 months Contemplation: Currently smoking and seriously considering quitting within next 6 months, not considering quitting within the next 30 days, not made a quit attempt of 24hr in past year, or both Preparation: Currently smoking, seriously considering quitting within next 6 months and planning to quit within the next 30 days, and made a quit 24hr attempt in past year Action: Currently not smoking; quit in last 6 months Maintenance: Currently not smoking; quit > 6 months

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Stages of Change Ladder (Marcus & Owen, 1992) 0 = Precontemplation: I currently do not exercise and I do not intend to start exercising regularly in the next 6 months 1-2 = Contemplation: I currently do not exercise regularly, but I am thinking about starting to exercise regularly in the next 6 months 3-5 = Preparation: I currently exercise some, but not regularly 6-8 = Action: I currently exercise regularly but I have only begun doing so within the last 6 months 9-10 Maintenance: I currently exercise regularly and have done so for longer than 6 months

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Decisional Balance (Pros and Cons) DBQ - Marcus et al. (1992) 16-items covering the positive (Pros, 10 items) and negative (Cons, 6 items) of exercise Self-Efficacy Gorley & Gordon (1995) - 5 items I am confident that I can participate in regular exercise when I am… tired, in a bad mood, etc.

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Processes of Change Questionnaire (Marcus et al., 1992) (39 items) Experiental: Consciousness Raising Dramatic Relief Environmental Reevaluation Self Reevaluation Social Liberation Behavioural: Self Liberation Helping Relationships Counter Conditioning Reinforcement Management Stimulus Control

Critique of TTM (Sutton, 2002): 

Critique of TTM (Sutton, 2002) Stage definitions - logically flawed? - past behaviour and intention Continuum vs. Stage Model - discontinuity patterns? Cross-sectional designs Processes of change Predicting stage transitions Stage-matched interventions

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Risk Perceptions Perceived Self-Efficacy Outcome Expectancies Goal Intentions Action Control Action Plans Health Action Barriers and Resources Schwarzer (1992) Health Action Process Approach

Implementation Intentions (Gollwitzer, 1993): 

Implementation Intentions (Gollwitzer, 1993) Goal intentions: “I intend to do x” Implementation intentions: “I intend to initiate goal-directed behaviour x when situation y is encountered”

Implementation Intentions and BSE (Orbell et al., 1997): 

Implementation Intentions and BSE (Orbell et al., 1997) Intention: “I intend to carry out BSE in the next month.” Implementation intention: “You are more likely to carry out your intention to perform BSE if you make a decision where and when you will do so. Decide now where and when you will perform BSE in the next month and make a commitment to do so.”

Performance of BSE at 1 month (All participants): 

Performance of BSE at 1 month (All participants)

Performance of BSE at 1 month (Intenders): 

Performance of BSE at 1 month (Intenders)

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Sheeran (2002) Meta-analysis of the effects of implementation intentions on behavioural performance 15 studies Effect size, d = 0.70