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Theories, models and interventions

Overview

This presentation will

Review the principal theories, models and interventions designed to explain, predict and control health behaviour

Explore the most popular theoretical approaches to health psychology and evaluate their success with data from controlled studies and meta-analyses

Outline eight theories that have informed the majority of interventions in health psychology and health promotion:

The health belief model

Protection motivation theory

The theory of reasoned action

Overview

The theory of planned behaviour

The information–motivation–behavioural skills model

The common sense model or self-regulation theory

The trans-theoretical or stages of change model

Social cognitive theory

The health belief model

HBM was developed by Rosenstock (1966), more than 50 years ago. The HBM contained four central constructs:

Perceived susceptibility (an individual’s assessment of their risk of getting the condition)

Perceived severity (an individual’s assessment of the seriousness of the condition, and its potential consequences)

Perceived barriers (an individual’s assessment of the influences that facilitate or discourage adoption of the promoted behaviour)

Perceived benefits (an individual’s assessment of the positive consequences of adopting the behaviour)

The health belief model

The aim of the HBM is to predict the likelihood of implementing health-related behaviour

Additional factors are included in the model: demographic factors (e.g. age, sex and socio-economic background), psychosocial factors (e.g. personality traits, peer influence, family, etc.) and structural factors (e.g. knowledge of the health condition

The health belief model

The HBM was tested in many studies and used as a theoretical framework for interventions. Jones et al. (2014) addressed the HBM as the theoretical basis for interventions to improve adherence. Of 18 eligible studies, only six studies used the HBM in its entirety and five studies measured health beliefs as outcomes, not behaviour

The authors’ conclusion stated: ‘Intervention success appeared to be unrelated to HBM construct addressed challenging the utility of this model as the theoretical basis for adherence-enhancing interventions’ (p. 253)

Protection motivation theory

PMT was developed by Rogers (1975) to describe coping with a health threat in light of two appraisal processes, threat appraisal and coping appraisal

It introduces a most basic human emotion into health protection: fear

According to PMT, behaviour change is best achieved by appealing to an individual’s fears. The PMT proposes four constructs, which are said to influence the intention to protect oneself against a health threat:

Radhika Mohan (M) - ED: The 4 constructs for PMT is not given below. Please provide.

Protection motivation theory

PMT assumes that protection motivation is maximized when: the threat to health is severe; the individual feels vulnerable; the adaptive response is believed to be an effective means for averting the threat; the person is confident in his or her abilities to complete successfully the adaptive response; the rewards associated with the maladaptive behaviour are small; the costs associated with the adaptive response are small

Protection motivation theory

Fear is widely used in campaigns and behavioural change interventions, yet empirical support for its use remains unconvincing

Bui et al. (2013) carried out a systematic review on protection motivation theory and physical activity in the general population. The authors concluded that: ‘the PMT shows some promise, however, there are still substantial gaps in the evidence’ (p. 522)

Protection motivation theory

A key component of this model is fear (perceived severity). Ruiter et al. (2014) reviewed six meta-analytic studies on the effectiveness of fear appeals. They concluded that coping information aimed at increasing perceptions of response effectiveness and especially self-efficacy is more important than presenting health information aimed at increasing risk perceptions and fear arousal. Attempts to change behaviour by appealing to fear receive only limited empirical support

The fear approach has fallen into disrepute and faded away

Theory of reasoned action: Fishbein and Ajzen (1975)

The theory of reasoned action (TRA) is based on the assumption that a person is likely to do what he or she intends to do. The theory assumed that a person’s behavioural intention depends on the person’s attitude about the behaviour and subjective norms

It fails to capture the complexity of health experience

The TRA is based on the assumption of rationality, that human beings ordinarily make systematic and logical use of available information

Theory of reasoned action: Fishbein and Ajzen (1975)

It also assumes that human behaviour is determined by free choice in a manner that is unrestrained by political or economic factors, neglects the role of emotion and feelings, and does not incorporate self-efficacy and self-esteem

For these reasons, the theory failed to provide an explanatory account of health behaviour. Along came the Theory of Planned Behaviour (TPB)

Theory of planned behaviour: Ajzen (1991)

Behaviour is complex and rarely controlled with as much rationality as the TRA suggested

Sex, smoking, eating, substance and alcohol use are all examples of behaviour that people have difficulty controlling in a completely rational and voluntary way

Ajzen (1985) added perceived behavioural control to produce the theory of planned behaviour. In doing so, Ajzen produced the most cited theory in the history of psychology

Theory of planned behaviour: Ajzen (1991)

A systematic review of 237 independent prospective tests found that the TPB accounted for only 19% of the variability in health behaviour (McEachan et al., 2011)

Indeed, multiple studies concur that the TPB, and its many extensions and adaptations, fail to account for more than 20 percent of the variability in health behaviour. Thus, 80% of health behaviour variance is unexplained by the TPB. This is not an exciting amount of success

Sniehotta et al. (2014) suggested that it was ‘time to retire’ the TPB

The common sense model

The ‘common sense model’ (CSM) was developed by Howard Leventhal and colleagues (Leventhal et al., 1980, 2003, 2016)

In this approach, the patient is viewed as a problem solver, attempting to make sense of an illness. A key construct within the CSM is the idea of illness representations or ‘lay’ beliefs about illness. These representations integrate with normative guidelines that people hold, to make sense of their symptoms and guide any coping actions

Five components of illness representations in the CSM are: identity, cause, time-line, consequences and curability/controllability

The common sense model

One systematic review examined the use of the CSM to develop interventions for improving adherence to health-care behaviours (medication and dietary/lifestyle), and assessed intervention effectiveness (Jones, Smith and Llewellyn, 2016). Six of the nine studies (67%) obtained a statistically significant effect of the intervention on improving at least one aspect of adherence

The CSM has been partially successful in predicting adherence, but the effects are modest

The information–motivation–behavioural skills model

This model (IMBS; Fisher and Fisher, 1992, 2000) focuses on information, motivation and behavioural skills associated with wellness behaviours

The information–motivation–behavioural skills model

Eggers et al. (2013) tested the IMBS model to assess the hypothesized motivational pathways for the prediction of condom use during last sexual intercourse with 1,066 students from Cape Town, South Africa

Knowledge of how to use a condom and how STIs are transmitted directly predicted behaviour as hypothesized by the IMBS model. However, an alternative model had a higher proportion of significant pathways

The information–motivation–behavioural skills model

Mongkuo et al. (2012) found that prevention HIV infection education motivation and HIV infection prevention knowledge had no significant effect on prevention behavioural skills, while HIV infection personal prevention knowledge emerged as having a significantly large effect in explaining HIV infection prevention behavioural skills among the students

The authors suggested that future studies should expand the exogenous variables in the IBMS model to include exposure to violent living conditions

The complexity of behaviour is quite difficult to capture in a model with only three process variables. However, the IBMS has enjoyed limited success

The transtheoretical model or stages of change model

The ‘Transtheoretical Model’ (TTM), otherwise known as the ‘Stages of Change Model’, was developed by Prochaska and DiClemente (1983)

It is a general model that applies across all types of psychological change and which has been highly influential in the research literature

The TTM hypothesizes six discrete stages of change, which people are alleged to progress through in making a change:

Pre-contemplation – a person is not intending to take action in the foreseeable future, usually measured as the next six months

The transtheoretical model or stages of change model

Contemplation – a person is intending to change in the next six months

Preparation – a person is intending to take action in the immediate future, usually measured as the next month

Action – a person is making specific overt modifications in his/her lifestyle within the past six months

Maintenance – a person is working to prevent relapse, a stage that is estimated to last from six months to about five years

Either termination – an individual has zero temptation and 100% self-efficacy, or relapse – an individual reverts to the original behaviour

The transtheoretical model: Prochaska and Diclementi (1982)

The transtheoretical model

TTM has been tested in multiple studies with mixed results.

A meta-analysis by Noar et al. (2009) indicated that interventions using the Stages of Change Model were relatively effective

However, critics have suggested that the model contains arbitrary time periods and that the supportive evidence is meagre and inconsistent (e.g. Sutton, 2000; West, 2005; Armitage, 2009)

The transtheoretical model

However, one angle that stage models offer is that of the stage-matched intervention to change behaviour (Dijkstra, Conijn and De Vries, 2006)

In this, the content of intervention is adapted to the different stages that people are in, which should make them more effective than standardized interventions

The study by Dijkstra et al. (2006) found, at 2-month follow-up, that matched interventions were significantly more effective (44.7%) than were mismatched interventions. For another review of the TTM, see Heather and Hönekopp (2013)

The social cognitive theory of bandura

Bandura’s (1986) ‘social cognitive theory’ (SCT) examines the social origins of behaviour in addition to the cognitive thought processes that influence human behaviour

Bandura’s social-cognitive approach proposes that learning can occur through observation of models in the absence of any overt reinforcement. The acquisition of skill and knowledge have an intrinsic reinforcement value independent of biological drives and needs. Two key planks in the social-cognitive platform are observational learning and self-efficacy

The social cognitive theory of bandura

Observational learning

Bandura observed that people learn by watching or observing others, reading about what people do, and making general observations of the world

This learning may or may not be demonstrated in the form of behaviour

Self-efficacy

Bandura (1994) defined the concept of ‘perceived self-efficacy’ as people’s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives

The social cognitive theory of bandura

Among the sources of self-efficacy are:

Performance accomplishments: past experiences of success and failure (‘I have already done it’)

Vicarious experience: witnessing others’ successes and failures (‘I saw somebody do it’)

Verbal persuasion: being told by others that one can or cannot competently perform a particular behaviour (‘You can do it’)

Emotional arousal: when engaging in a particular behaviour in a specific situation (‘I would love to do it’)

The social cognitive theory of bandura

The self-efficacy concept has been widely applied in studies and interventions

Models of human health behaviour – the PMT, the HBM, and TPB – include self-efficacy as an important component

Self-efficacy refers to one of the ‘truths’: believing that we can accomplish what we want to accomplish is ‘one of the most important ingredients – perhaps the most important ingredient – in the recipe for success’ (Maddux, 2002: 277)

The social cognitive theory of bandura

The concept mirrors the self-help literature of the kind Dale Carnegie founded on the principle that people can achieve great things by believing that they can do so, so-called ‘positive thinking’

Observational learning and self-efficacy are invaluable concepts. However, critics argue that the relationship between the concepts is not clear

Others say, it's just common sense, written in more abstract jargon

Theoretical integration

The great range and variability in theories, models and concepts calls for integration

One integrated model is the ‘COM-B’ that focuses on capability, opportunity and motivation and the ‘Behaviour Change Wheel’ (Michie and Wood, 2015)

The Behaviour Change Wheel has been proposed for physical activity, weight loss, hand hygiene, dental hygiene, diet, smoking, medication adherence, prescribing behaviours, condom use and female genital mutilation

Theoretical integration

One critic questioned whether the COM-B and the Behaviour Change Wheel ‘can ever be tested’ and points out that it remains ‘unclear how it can be ever falsified if its constructs remain broad and all encompassing ... And does it promote and facilitate creativity in those that do the thinking?’ (Ogden, 2016)

Theoretical domains framework

The complex array of theories and models can be a little overwhelming

Theories are often poorly applied and interventions suffer because they lack empirical support

One way of making progress would be to determine a consensus among knowledgeable researchers about what works and what doesn’t

Theoretical domains framework

Michie et al. (2005) developed a consensus on theoretical constructs, a ‘Theoretical Domains Framework’ (TDF), in six phases:

Identifying theoretical constructs

Simplifying into domains

Evaluating the domains

Interdisciplinary evaluation

Validating

Piloting interview questions

Theoretical domains framework

A questionnaire was designed to facilitate the use of the TDF in practice change (Huijg et al., 2014)

A systematic literature review comparing the original with the refined TDF found that the ‘environmental context and resources’, ‘beliefs about consequences’, and ‘social influences’ were the three domains most frequently cited in the reviewed studies (84%, 74%, and 66%, respectively; Mosavianpour et al., 2016)

Theoretical domains framework

This finding is consistent with the idea that self-control is constrained: what individuals can do to change their lives is not simply a matter of personal choice – choices are constrained biologically, culturally, economically and environmentally

These constraints are one of the reasons that individual-level black-box models and theories are unable to explain more than 20% of health behaviour

Intentions vs. behaviour and the ‘intention–behaviour gap’

The evidence from studies of the models and theories is that it is relatively easy to predict the intention to act, but more difficult to predict action itself

It is commonly the case that a person develops an intention to change their health behaviour (e.g. to stop smoking) but they might not take any action (e.g. actually to stop smoking). This discrepancy has been labelled the ‘intention–behaviour gap’

What leads to the translation between an intention and an action is reduced in many models to an arrow between two black boxes. However, we need to breakdown intention into two phases: goal intention and implementation intention (Gollwitzer 1993, 1999; Gollwitzer and Brandstatter, 1997)

Intentions vs. behaviour and the ‘intention–behaviour gap’

Goal intention is a commitment towards a goal (‘I intend to achieve the goal’)

Implementation intention is about the necessary action (‘I intend to initiate the behaviour X in situation Y’). This second phase is not addressed in the models but is a key part of the process of performing a behaviour

Intentions vs. behaviour and the ‘intention–behaviour gap’

We know that unhealthy behaviour is more common amongst lower SES groups, helping to create health inequalities. One possibility is that the intention–behaviour gap is wider amongst the lower SES groups

Vasiljevic et al. (2016) tested this hypothesis using objective and self-report measures of three behaviours, pooling data from five studies

The intention–behaviour gap did not vary with deprivation for diet, physical activity, or medication adherence in smoking cessation

Intentions vs. behaviour and the ‘intention–behaviour gap’

However, they did find a larger gap between perceived control over behaviour (self-efficacy) and behaviour in the more deprived

Choices are especially constrained economically and environmentally among lower SES groups, regardless of the good intentions to change towards healthier behaviours

Interventions to plug the intention–behaviour gap have been employed such as self-affirmation tasks, planning or implementation intentions which have met with some, limited success (Gollwitzer, 1993; Gollwitzer and Sheeran, 2006; Steele, 1988; Epton et al., 2015; Synergy Expert Group, 2016, p. 1)

Behaviour change techniques

A behaviour change technique (BCT) is a systematic procedure included as an active component of an intervention designed to change behaviour

The defining characteristics of a BCT are that it is:

Observable

Replicable

Irreducible

A component of an intervention designed to change behaviour

A postulated active ingredient within the intervention (Michie et al., 2011)

Behaviour change techniques

A BCT taxonomy has been employed to code descriptions of intervention content into BCTs (Michie et al., 2011, 2013)

The production of a structured list of BCTs provides a ‘compendium’ of behaviour change methods which helps to map the domain of behaviour change and inform practitioner decision-making. However it risks becoming a prescriptive ‘cook-book’ of what therapeutic techniques must be applied to patients presenting with a specific behavioural problem

Behaviour change techniques

Another problem with taxonomy approach is that BCTs are not all optimally effective when combined in ‘pick-and-mix’ fashion. There needs to be a coherence to the package that is provided by a theory that offers power and meaning and connects the components into a working set

Of equal importance to the nature of the BCTs is the quality of the change agent

Behaviour change agents

To use an analogy, there is more to baking a cake than the ingredients. Of course one needs a set of ingredients (the BCTs) but one also needs a baker – the behaviour change agent (BCA)

The BCA/therapist must be fit for purpose and so fully capable and competent to deliver the BCTs in a persuasive and stylish manner

The qualities of effective therapists have been studied for at least 50 years. It is an oversight that people working on BCTs tend to neglect the importance of the ‘baker’ – the BCA

Behaviour change agents

Therapists’ interpersonal style, empathy and communication skills are essential requirements for of successful behaviour change (Hagger and Hardcastle, 2016)

Empirical evidence suggests that empathy is teachable, e.g. to undergraduate medical students (Batt-Rawden, 2013) or physicians (Riess et al., 2014; Kelm et al., 2014)