Health behavior change theories

• Predicting and measuring health behavior is a theme of the principles of behavioral medicine.
• This lecture is for the Year 2 Medical Bahrain ENDO & Breast course.

Learning Outcomes

• Describe the role of behavior in health.
• Describe theoretical models that explain and predict health behavior.
• Explain each model's strengths and limitations.
• Outline an intervention based on each model.
• The models include:
  • Health Belief Model
  • Transtheoretical model
  • The behaviour change wheel and the COM-B

Role of Behavior in Health

• Health behavior is behavior performed by an individual, regardless of their perceived health status, to protect, promote, or maintain their health.
• Chronic disease is largely preventable.
• 85% of people in Ireland have at least one unhealthy behavior.
• 46% of people in Ireland have two or more unhealthy behaviors.
• The most successful public health programs understand health behaviors and their context.
• Interventions to improve health behavior need an understanding of relevant theories of behavior change and the ability to use them in practice.

Health Behavior Theory

• Health behavior theory explains or predicts events by specifying relations among variables.
• These theories help explain behavior and suggest how to develop more effective ways to influence and change behavior.
• Models of health behavior include cognitive and social cognitive models.
• Continuum models posit that A leads to B leads to C.
  • E.g. The Health Belief Model (HBM)
• Stage models allow individuals to move between stages.
  • E.g. The Transtheoretical Model (TTM)
• Dynamic models are integrated.
  • E.g. The Behavior Change Wheel (COM-B)

Health Belief Model (HBM)

• The Health Belief Model (HBM) theorizes that people's beliefs about their risk for a disease or health problem, and their perceptions of the benefits of taking action to avoid it, influence their readiness to take action.
• Preventive action depends on two critical factors: perceived threat of a specific illness and outcome expectations.
• The HBM states health behavior is a result of a set of beliefs:
  • Susceptibility to illness
  • Severity of illness
  • Benefits of health behaviors
  • Costs of health behaviors
  • Cues to action
  • Health motivation
• When using the HBM to assist in doctor-patient communication about smoking cessation:
  • Ask "has anything made you think about giving up smoking?" as cues to action.
  • Motivation can be addressed by asking "How concerned are you about your health?"
  • Assess susceptibility and severity by inquiring, "How do you think smoking is affecting your health?"
  • Understand perceived benefits and barriers by asking, "What are the pros and cons of smoking for you?"
• Strengths of HBM:
  • Common-sense constructs are easy for non-psychologists to assimilate and apply.
  • Focused research attention on modifiable predictors of behavior.
  • Makes testable predictions; large threats might be offset by large benefits, etc.
• Limitations of HBM:
  • Assumes people are logical/rational about health
  • Neglects social factors

Transtheoretical Model (TTM)

• The Transtheoretical Model (TTM) proposes that people are at different stages of readiness to adopt healthful behaviors.
• Assumptions of TTM:
  • Based on the concept that beliefs change over time
  • Identifies 5 stages of change that an individual goes through when moving toward a change in behavior
    • Precontemplation, Contemplation, Preparation, Action, Maintenance
  • Behavior change is dynamic; individuals may move back or forward between stages
  • Applicable to a wide range of health-related behaviors.
• Health programs are more successful when they are "stage matched" to suit the individuals.
• Using the TTM as a tool to assist in doctor-patient communication in the clinical situation:
  • Pre-contemplation:
    • Validate lack of readiness, clarify decision is theirs, encourage self-exploration, and explain/personalize the risk.
  • Contemplation:
    • Validate lack of readiness, clarify decision is theirs, encourage evaluation of pros & cons, and identify/promote new, positive outcome expectations.
  • Preparation:
    • Identify & assist in problem-solving re obstacles, help identify social support, verify underlying skills for behavior change, encourage small initial steps, and set a date.
  • Action:
    • Focus on restructuring cues & social support, bolster self-efficacy for dealing with obstacles, and combat feelings of loss & reiterate long-term benefits.
  • Maintenance:
    • Plan for follow-up support, reinforce internal rewards, and discuss coping with relapse.
  • Relapse:
    • Evaluate trigger for relapse, focus on the successful part of their plan, and encourage re-engaging their efforts.
• Strengths of TTM:
  • Facilitates design/tailoring of interventions to match an individual's stage of change.
  • Recognizes the difficulties inherent in behavior change and allows a person to fail.
• Limitations of TTM:
  • Assumes rational thinking
  • Does not address social context of behavior
• Currently used in the Irish healthcare setting via:
  • Training in smoking cessation for all hospital staff
  • Training based on TTM and motivational interviewing techniques.

Behavior Change Wheel (BCW)

• The Behavior Change Wheel addresses the limitations of previous behavior change models.
• It synthesizes the common features of previous frameworks and links them to a model of behavior.
• Identifies behavior as an interacting system involving the components of Capability, Opportunity, and Motivation.
• Behaviors do not occur in a vacuum but within the context of other behaviors.
• Most behaviors are influenced/dependent on, other behaviors from various networks.
• Capability:
  • Physical capability: Having physical skills, strength, or stamina to perform the behavior.
  • Psychological capability: Having the psychological skills to perform the behavior.
• Opportunity:
  • Physical opportunity: Opportunity afforded by the environment.
  • Social opportunity: Social acceptance, cultural milieu.
• Motivation:
  • Reflective motivation (The head): Self-conscious planning, analysis, and decision making, including beliefs and intentions.
  • Automatic motivation (The heart): Emotions and impulses arising from associative learning or innate disposition, including impulse and habit.
• COM-B components for cleaning hands using alcohol gel:
  • Physical capability: No evidence for role of this component.
  • Psychological capability: Knowing the correct technique to clean hands.
  • Reflective motivation: Being aware of the reduction in infection transmission by using alcohol gel.
  • Automatic motivation: Lack of routine or habit.
  • Physical opportunity: Availability of gel dispensers.
  • Social opportunity: Seeing senior health professionals clean their hands using alcohol.
• Identifying suitable behavior change approaches:
  • Map intervention to COM-B to maximize capability, opportunity, and motivation.
  • Maximize capability to regulate own behavior.
  • Maximize opportunity to support self-regulation.
  • Change routine and environment.
  • Increase motivation to engage in desired behavior.
• According to the COM-B model, one or more of its components must be changed in order to facilitate effective and long-standing behavior change.
• Strengths of BCW:
  • A comprehensive approach.
  • Prompts consideration of the full range of options.
  • Provides a basis for analyzing behavior in context to select an appropriate mix of options.
  • Takes account of environmental and intra-individual changes that may be needed.
• Limitations of BCW:
  • A newer model; longitudinal research evidence is still emerging.

Explore the key concepts, significance, and application of various health behavior change theories. Understand how these theories predict health behaviors and inform intervention strategies. Learn about the COM-B model and the Behaviour Change Wheel.