How can health behavior be explained? - Chapter 5

What are the distal influences on health behavior?

If you look globally at influences on health behavior you can say that some influences are distal and others are proximal. This distribution makes it clear that some influences influence behavior indirectly. These variables are called mediators. Examples of distal influences are SES, age, ethnic origin, gender and personality. Proximal influences are someone's attitudes and beliefs towards health-risk and health-protective behavior. When something is distal, for example people with a low SES often smoke and drink more, this mainly reflects a fact or an observation and not so much an explanation. Further explanation can be offered from evidence showing that social class affects health beliefs. These health beliefs can be considered closer to the behavior of an individual (more proximal) and offer a more feasible target for intervention aimed at altering a person's social class. 

Demographic influences

Many health behaviors (alcohol, smoking, drugs) occur during childhood and adolescence. Teens change their beliefs when they become independent from their parents. Gender has an important influence on the performance of health protective or health threatening behavior.

Personality

A person's personality is in fact what makes him different from others. Although a personality is something that makes you unique, scientists have often tried to capture personality in models.

Eysenck's three-factor model is one of them. Eysenck distinguishes the following dimensions:

1. Extroversion (outgoing social nature) versus introversion.
2. Neuroticism (anxious, guilty or worrying) versus emotional stability (relaxed and satisfied). 
3. Psychoticism (self-centered, aggressive, antisocial) versus self-control (kind, predominant, obedient).

These three factors seem to give a good indication of a person's personality, because they are robust and cover most aspects of personality.

McCrae and Costa proposed a five-factor model with the following dimensions:

1. Neuroticism.
2. Extraversion.
3. Openness (to experience).
4. Compliance (agreeableness).
5. Conscientiousness.

This list is also called the Big Five and proves to be valid across different cultures and throughout life from age 14  to 50+. This theory has received the most support and attention. These five personality traits are each associated with specific health behaviors. For example, openness is associated with eating low-fat meat and high-fiber foods. Neuroticism is often associated with unhealthy behavior and neophobia. Neofobia is the fear of new things (new people, new food, unknown events). However, not all studies provide these results. Friedman says that healthy neurotics exist just as well as unhealthy neurotics.

Self-efficacy

In order to maintain and maintain healthy behavior, it is important to believe that you can and can sustain it. When you believe in yourself, you will also set higher goals and have a more positive expectation of the result, all of which help maintain the behavior. People with this setting have an internal locus of control. They take responsibility for their own actions and believe that they can determine their outcomes. Little trust in one's own ability and explaining outcomes by factors such as happiness is called an external locus of control. Researchers think that an internal locus of control is the most adaptive.

The perception that a person's health is under personal control is called a health locus of control. The MHLC ( multidimensional health locus of control ) distinguishes three independent dimensions:

1. Internal: strong internal beliefs consider the individual themselves as the prime determinant of their health state. Internal beliefs are theoretically associated with high levels of health protective behavior and with Bandura 's self-efficacy construct.
2. External / chance: strong external beliefs consider that external forces such as happiness or opportunity determine the health state of an individual rather than one's own behavior.
3. Powerful others: strong beliefs on this scale consider that a person's health status is determined by the actions of powerful others such as health and medical professionals.

Self-determination theory

The self-determination theory distinguishes between intrinsic and extrinsic motivation. With intrinsic motivation, a person is motivated to act in a certain way to gain personal satisfaction or rewards, such as a sense of competence. Extrinsically motivated behavior is due to external rewards, such as the appreciation of peers. There is a relationship between personality and behavioral motives.

Social influences

People are social beings and we learn through exposure to, and observation of, other people's expectations, behavior and experiences. With risk behavior this is reflected in the form of advertisements on television about the negative consequences of smoking, or a workshop in the classroom about how to say no to drugs.

Goals and self-regulation of behavior

Health protective and risk behaviors are performed for one reason: people have outcome expectations attached to them as described in Social Cognition Theory (SCT) and thus behavior tends to be goal-directed. Health behavior serves coping functions (short-term goals of behavior), for example smoking may serve the function to cope with stress. There are five coping functions for health behavior: problem solving, feeling better, avoidance, time out and prevention. Self-regulation is the process by which individuals monitor, control and adjust their behavior. thoughts and emotions in order to maintain a balance or a sense of normal function. Cognitive regulation is required as well emotion regulation if we are to successfully organise and execute goal-directed activity. Women use self-regulation more often than men.

What are models of health behavior?

People can be very inconsistent in exercising healthy behavior. There are many individuals who do a lot of exercise, but also smoke. Not only do individuals differ from each other in terms of motivation for certain behavior, these motivations can also change over time. Inconsistencies can be explained by the following things:

• Different health behaviors are controlled by different external factors.
• Attitudes towards health behavior vary within and between individuals.
• In the same individual, health behavior can be motivated by different expectations.
• Individual differences are in part explained by life stage.
• Individuals differ in their goals and motivations.
• Motivating factors may change over time.
• The social context can trigger or alternatively limit behavior.

Attitudes

Earlier theories were often formed according to the idea that new information changes someone's attitude and that a new attitude leads to a change in behavior. These days we know it is not that simple. Now attitudes are divided into three parts, namely:

1. Cognitive: beliefs about the object.
2. Emotional: feelings towards the object.
3. Behavioral: intended actions towards the object.

Many individuals have different, opposite beliefs to a particular object or event. These conflicting thoughts are also called dissonance. There are people who smoke despite having some negative beliefs about smoking. This is also called ambivalence.

Risk perception

There are a lot of people who display risky or unhealthy behaviors because they think they are not at risk or that it does no harm. This may be the cause of a lack of knowledge about the potential risks or may not accept the information. A lot of information is also stored in a way that it matches how the person sees the information. Many people have the idea that they are less likely to get an illness or accident compared to others, also known as unrealistic optimism. It is not yet clear whether these people display less risky behavior or underestimate the risks and show more risky behavior.

Self-efficacy

Self-efficacy is important in daily life and ensures that goals are achieved. Self-efficacy is the conviction of an individual that he has the capacity to achieve a goal and that this is under your control. This is connected with health, conduct and implementing changes. Self-efficacy is an important predictor of success, among other things, and will therefore be reflected in a number of models.

What are sociocognitive models of behavioral change?

According to Bandura, behavior is influenced by three types of expectations: situation-outcome expectations, outcome expectations and self-efficacy expectations. The Social Cognitive Theory (STC) proposes that these expectancies may or may not provide lasting incentives to change. 

The Health Belief Model (HBM)

The Health Belief Model is a cognitive model that proposes that the likelihood that a person will engage in particular health behavior depends on demographic factors, for example SES, gender, age and a number of four beliefs that may arise as a result of internal or external cue to action. These beliefs encompass perceptions of threat and evaluation of behavior in question, with cues to action and health motivation added at a later date. For example, someone could have ideas about how obesity affects heart and vascular diseases. In addition, someone may realize that he is overweight. This may again lead to the idea that health will improve if he fight obesity. A person becomes aware of the obstacles if he really wants to change his diet. For example, that the partner does not like vegetables at all. The cues that are of influence may be external, such as watching a cooking program, or internal, such as being out of breath after walking up a flight of stairs.

The HBM is widely used to predict whether women would examine their breasts themselves to discover any nodules that could indicate breast cancer. It turned out that when women were aware of the benefits of the study and had few barriers to its performance, the chances were that they would actually examine themselves regularly. For example, many specific behaviors include factors that best predict the final behavior. However, sometimes future behavior can best be predicted from behavior in the past and not at all by factors from the HBM.

Other points of criticism are the following.

• The HBM says nothing about how the various components work together, while many studies show that there is interaction between the components.
• Alleged benefits should be weighed against alleged obstacles, but nowhere does it explain how to make that calculation.
• The HBM is static, suggesting that beliefs occur simultaneously. 
• The HBM attaches great importance to the assumed threat (the severity of a disease), but many studies show that this does not necessarily have a major impact on actual behavior.
• Social influences receive limited attention in the model.
• Little attention is paid to mood or negative affect.
• The HBM may overestimate the role of threat.

The components of the HBM are therefore only responsible for a small proportion of variance in behavioral change. From this point of view, models have been developed that take more account of proximal influences.

The Theory of Planned Behavior (TPB)

Little research had been done on the Theory of Reasoned Action (TRA) when the Theory of Planned Behavior (TPB) was developed. The TRA focused primarily on conscious, controlled behavior, while the behavior of an addict for example is not at all voluntary.

To include uncontrolled behavior in the model, the TRA was provided with the variable perceived behavioral control (PBC). PBC has direct influence on intentions and therefore indirectly also on behavior. If someone thinks they cannot control their behavior, there is less chance that they will try to change their behavior at all.

The beliefs that someone has are formed by many factors, including behavior and possible success in the past. This makes the TPB better at predicting behavior than the TRA. The correlation between intention and TPB is greater than the correlation between intention and TRA. What also largely contributes to the variation in intention are the illness representations, beliefs about a particular illness and state of ill health. 

Behavior appears to be better predictable from intentions than from the TPB. The model claims that variables that are not included in the TPB are also not important in predicting behavior, but several studies indicate otherwise. Some behaviors are under the influence of moral norms and not (only) under the influence of social norms, as the TPB says. Regret for earlier behavior (for example regret for unsafe sexual contact) also has a lot of influence on future behavior. However, that does not apply to all behavior. Regretting an evening with too much alcohol has much less influence on future alcohol consumption.

Someone's (supposed) identity, for example that someone sees himself as environmentally aware, also has a lot of effect on behavior and intentions. If you think that you are environmentally aware, you will stick to eating organic products rather than when you do not find that identity important.

Believing in your own ability appears to be more strongly associated with behavior than PBC. Moreover, intentions are not always converted into behavior. There is another step in between, namely making more specific plans. Many people benefit from determining exactly how, when and where they will perform certain behaviors. These more specific goals are called implementation intentions (II).

Implementation intentions are different from Goal Intentions (GI) because a goal intention only describes that the behavior will take place, but says nothing about when, where, with whom and how. People often do not adhere to intended behavior because something comes up or because it is simply forgotten. If someone has made IIs, that chance is smaller.

Models such as the TRA and TPB are static models. A number of factors determine the course of behavior for a longer period. However, phase models describe different steps.

What are the stage models of behavioral change?

A stage theory requires four characteristics:

1. A classification system to define stages.
2. Ordering of stages.
3. Similar barriers to change facing people within the same stage.
4. Different barriers to change facing people at different stages.

The Transtheoretical model (TTM)

This model has two main assumptions, namely that people go through phases of change and that the processes and problems differ per phase and are independent. The phases that the TTM describes are the following:

• Pre-contemplation: the person does not think about changing behavior, does not think he has a problem and does not intend to change anything in the coming six months.
• Contemplation: there is a realization that something might have to change, but there is no rush. For example, people start looking for information about the problem or about healthier behavior.
• Preparation: the individual is ready for the change and makes plans, such as a start date (for example within two months). Motivation and believing in yourself are important in this phase.
• Action: someone starts with healthy behavior, for example by eating fruit instead of cake. Setting realistic goals is very important at this stage, as is social support.
• Maintenance: the individual continues with healthy behavior and can resist temptation.
• Termination: the behavior was good for a while, but now the individual has the idea of ​​falling back into unhealthy behavior.
• Relapse: falling back in the old behavior or going back one phase.

People do not necessarily gradually go from one phase to the other. Years or months may pass before someone actually carries out their plans and relapse to a previous phase is also common. The TTM makes a distinction between not wanting to change within the next six months and wanting to change in the coming three months. However, there is hardly any scientific reason to use these periods.

Because past behavior is a good predictor of future behavior, it seems strange to use current phases to predict behavior. According to Godin (2004) you could better combine the phases with earlier behavior. The model pays relatively little attention to the social aspects of much behavior.

The Health Action Process Approach (HAPA)

This model also consists of phases, but the people behind this have also thought of the transition between intention and behavior. The belief in one's own abilities and action plans play a major role in this model.

Awareness of the risk content and personal aspects that contribute to this are an important factor in the motivation phase.

The intentions that are being developed in this phase are goal-oriented, such as 'I intend to quit smoking in order to improve my health'. People have different ideas about their own abilities per phase. In this phase, for example, someone thinks "I think I can eat healthier even though I have to adjust my lifestyle a little".

When someone's intentions have been formed, it is time to make concrete plans. Just as with the implementation intentions, it is about where, when and how questions. It is important to adhere to the formed intentions. It is again important here to believe that behavior can be maintained, even though it may be difficult. For example, a person who started eating healthier would not have thought of a birthday where unhealthy food is abundant. When someone has given in to the temptation, the recovery phase comes, in which healthy behavior is resumed.

Although this model is relatively young, the research results are positive. Research into preventive breast examinations shows that phase-specific belief in one's own abilities is a good predictor of future behavior.