Health Psychology Chapters 3, 4, 5, 8, 9 PDF

HEALTH PSYCH CHAPTERS 3,4,5,8,9, + LECTURES CHAPTER 3: Health Behaviours What is health promotion? - Health promotion is a general philosophy that has at its core the idea that good health, or wellness, is a personal and collective achievement - For the medical practitioner, health promoti...

HEALTH PSYCH CHAPTERS 3,4,5,8,9, + LECTURES CHAPTER 3: Health Behaviours What is health promotion? - Health promotion is a general philosophy that has at its core the idea that good health, or wellness, is a personal and collective achievement - For the medical practitioner, health promotion involves teaching people how best to achieve this healthy lifestyle and helping people at risk for particular health problems learn behaviours to offset or monitor those risks - For the psychologist, health promotion involves the development of interventions to help people practice healthy behaviours and change poor ones - For community and national policymakers, health promotion involves a general emphasis on good health, the availability of information to help people develop and maintain healthy lifestyles, and the availability of resources, conditions, and facilities that can help people change poor health habits - The mass media can contribute to health promotion by educating people about health risks posed by certain behaviours, such as smoking or excessive alcohol consumption - Legislation can contribute to health promotion by mandating certain activities that may reduce risks, such as the use of child-restraining seats and seat belts, and banning smoking within indoor public places - Health promotion differs from disease prevention in several ways. Most notable is that health promotion is a positive conception of health that takes a more holistic approach, and in this respect is reflective of a biopsychosocial model of health - Disease prevention takes a negative view of health as being the absence of disease, and concentrated efforts on early detection and prevention that is more aligned with the biomedical model - Disease prevention occurs in stages along a continuum from disease risks to development: - Primary prevention includes behaviours that reduce the risks of disease (healthy diet, exercise) - Secondary prevention includes behaviours that help slow the progression of disease in its early stages (cancer screenings) - Tertiary prevention includes behaviours that help reduce the impact of a disease once it has developed (blood tests, follow-up examination) What are health behaviours? - Behaviours to enhance or maintain health - Positive health behaviours promote good health and prevent the onset of illness - Negative health behaviours create risk for illness  - Treatment-related behaviours optimize health and prevent further illness-related complications - A health habit is a health-related behaviour that is firmly established and often performed automatically, without awareness - These habits usually develop in childhood and begin to stabilize around age 11 or 12 - Although health habits may have developed initially because it was reinforced by specific positive outcomes, such as parental approval, it eventually becomes independent of the reinforcement process and is maintained by the environmental factors with which it is customarily associated→ can be highly resistant to change - 7 importance good health habits: sleeping 7-8 hours a night, not smoking, eating breakfast, no more than 1 or 2 alcoholic drinks each day, regular exercise, not eating between meals, and being no more than 10% overweight Primary Prevention - Instilling good health habits and changing poor ones is the task of primary prevention - There are 2 general strategies of primary prevention: - 1. To employ behaviour-change methods to get people to alter their problematic health behaviours, such as programs to lose weight - 2. To keep people from developing poor health habits in the first place such as smoking prevention programs with young adolescents Role of behavioural factor in disease and disorder - The prevalence of acute infectious disorders, such as tuberculosis, influenza, measles, and poliomyelitis, has declined because of treatment innovations and changes in public health standards, such as improvements in waste control and sewage - There has been an increase in “preventative” disorders, including lung cancer, cardiovascular disease, alcohol and other drug abuse, and vehicular accidents - It’s estimated that nearly half the deaths in canada are caused by modifiable behaviour, with smoking, poor diet, and physical inactivity as the leading social behaviour risk factors - Cancer deaths alone could be reduced by 30-50% simply by getting peopled to avoid smoking, eat more fruits and vegetables, boost physical activity, protect themselves from the sun, tell their doctor when their health changes, handle hazardous materials carefully, and obtain early screening for breast and cervical cancer - Successful modification of health behaviour will have several beneficial affects: - 1. It will reduce deaths due to lifestyle-related diseases - 2. It may delay time of death, thereby increasing individual longevity and general life expectancy of the population  - 3. The practice of good health behaviours may expand the number of years during which a person may enjoy life free from complications of chronic disease - 4. Successful modification of health behaviours may begin to make a dent in the more than 308 billion that was spent in canada in 2021 on health services What factors influence the practice of health behaviours? - Socioeconomic factors: health behaviours differ according to demographic factors. Younger, more affluent, better educated people under low levels of stress with high levels of social support typically practice better health habits than people under higher levels of stress with fewer resources, such as individuals low in social class - Age: typically, health habits are good in childhood, deteriorate in adolescence and young adulthood, improve again among retired adults under 73, but then may deteriorate among adults 73 and older - Gender: there are significant gender differences in the practice of health-related behaviours, which may vary by age or developmental stage. For example– among school-aged children, girls tend to eat healthier foods than boys, but girls tend to engage in more unhealthy dieting and meal skipping. Girls are also less likely to be physically active than boys - Values: values heavily influence the practice of health habits. For example– exercise for women may be considered desirable in one culture but undesirable in another, exercise patterns among women will differ greatly between cultures - Personal control: research on the “health locus of control” scale measures the degree to which people perceive themselves to be in control of their health, perceive powerful others to be in control of their health, or regard chance as the major determinant of their health - Social influence: family, friends, and workplace companions can all influence health-related behaviours–sometimes in a beneficial direction, other times in an adverse direction. For example–peer pressure often leads to smoking in adolescence but may influence people to stop smoking in adulthood. Social influence from indirect sources such as the media may also influence health behaviours, for better or worse. - Personal goals: if personal fitness or athletic achievement is an important goal that doesn’t interfere with the achievement of other goals, such as family goals, the person will be more likely to exercise on a regular basis than if fitness is not a prioritized personal goal - Perceived symptoms: for example, smokers may control their smoking on the basis of sensations in their throat. A smoker who wakes up with a cough and raspy throat may cut back in the belief that they are vulnerable to health problems at that time. - Access to health care services: using screening programs, obtaining a regular pap smear, obtaining mammograms, and receiving vaccinations for communicable diseases are examples of behaviours that are directly tied to  the health care delivery system. Other behaviours, such as losing weight and stopping smoking, may be indirectly encouraged by the healthcare system because many people now recieve lifestyle advice from their healthcare providers - Place: living in a rural area where there is less access to healthcare services may make it difficult to follow through with intentions to practice preventative health behaviours, such as cancer screenings. There’s also some evidence that those living in rural areas have higher rates of smoking - Supportive environments: for example, creating communities and cities that inclue green space and walking and biking pathways, and that provide availability and access to healthy and nutritious food options may help curb childhood obesity and promote health across all age groups. - Cognitive factors: the belief that certain health behaviours are beneficial or the sense that one may be at risk for illnees or disease is one doesn’t practice a particular health behaviour. Similarly, being less health conscious and thinking less about the future can also lead to unhealthy behavioural choices Barriers to modifying poor health behaviours - People often have little immediate incentive for practicing good health behaviour. - Health habits develop during childhood and adolescence, when most people are healthy - Smoking, drinking, poor nutrition, and lack of exercise initially have no apparent effect on health and physical functioning - The cumulative damage that these behaviours cause may not become apparent for years, and few children and adolescents are sufficiently concerned about what their health will be like wheh they are 40 or 50 years old - As a result, bad habits have a chance to make inroads - Once bad habits are ingrained, people are not always highly motivated to change them. - Unhealthy behaviours can be pleasurable, automatic, addictive and resistant to change - Many people find it too difficult to change their health habits because their bad habits are enjoyable - Health habits are only modestly related to eachother–knowing one health habit does not enable one to predict another with great confidence. The person who exercises faithfully doesn’t necessarily wear a seat belt Instability of health behaviours - Why are health habits relatively independet of eachother and unstable? - 1. Different health habits are controlled by different factors. For example, smoking may be related to stress, whereas exercise may depend on ease of access to sports facilities - 2. Different factors may control the same health behaviour for different people. Thus, one person’s overeating may be “social”, and they may  overeat primarily in the pesence of other people. In contrast, another individual’s overeating may depend on levels of tension, and they may overeat only when under stress - 3. Factors controlling a health behaviour may change of the history of the behaviour. The initial instigating factors may no longer be significant, and new maintaining factors may develop to replace them. Although peer pressure (social factors) is important in initiating the smoking habit, over time, smoking may be maintained because it reduces craving and feelings of stress. One’s peer group in adulthood may actually oppose smoking - 4. Factors controlling the health behaviour may change across a person’s lifetime. Regular exercise occurs in childhood because it is built into the school curriculum. But in adulthood, this automatic habit must be practiced consciously, and there is at risk for declining. - 5. Health behaviour patterns, their developmental course, and the factors that change them across a lifetime will vary substantially between individuals. Thus, one individual may have started smoking for social reasons but continue smoking to control stress; the reverse pattern may characterize the smoking of another individual Intervening with children and adolescents Socialization - Health habits are strongly affected by early socialization, especially the influence of parents as role models. - Parents may instill certain habits that become automatic. However, in many families even basic health habits may not be taught - As children move into adolescence, they sometimes backslide or ignore the early training they received from their parents, because they often see little apparent effect on their health or physical functioning - Adolescence are vulnerable to an array of problematic health behaviours, including excessive alcohol consumption, smoking, drug use, and sexual risk taking, particularly if their parents aren’t monitoring them very well and their peers closely - Adolescents appear to have an incomplete appreciation of the risks that encounter through faulty habits - interventions with children and adolescents are high priority Using the teachable moment - The concept of a teachable moment refers to the fact that certain times are better than others for teaching particular health practices - Many teachable moments arise in early children - Parents can have a limited understanding of the importance of their role in promoting healthy heaviour in their children and may fail to follow up after intially communicating about health-related rules - Other teachable moments arise because they’re built into the healthcare delivery system, family physicians often make usre of some visits to teach parents the basics  - But what can children themselves really learn about health habits? - Very young children have cognitive limitations that keep them from fully comprehending the concept of health promotion but they can develop personal responsibility for aspects of their health - Certain health behaviours are clearly within the comprehension of children as young as 3 or 4, as long as the behaviours are explained in concrete terms and the implication for actions are clear - Teachable moments are not confined to children and adolescence, adults with newly diagnosed coronary artery disease may also be especially motivated to change their health habits - Identifying teachable moments is a high priority for primary prevention Closing the window of vulnerability - Middle school appears to be a particularly important time for the development of several health-related habits. Food choices, snacking, and dieting all being to crystallize around this time - There is also a window of vulnerability for smoking and drug abuse that occurs in middle school when students are first expoesed to these habits among their peers and older siblings - Psychosocial vulnerability (low well-being, poor social relationships, low self-esteem, low self-perceived socioeconomic status, and being female) is associated with heightened risk for engagement in smoking, drinking, irregular meal frequency, and low levels of physical activity among adolescents Adolescent health behaviours influence adult health - Precautions taken in adolescence may be better predictors of disease after age 45 than are adult health behaviours - Excessive sun exposure, sun burns, and poor sun safety behaviours in childhood heighten the risk for the development of cancers in adulthood - 80% of all lifetime sun exposure takes place before the age of 18 - Adolescence may actually be a highly vulnerable time for a variety of poor health behaviours that lay the groundwork for future problems in adulthood - Invulnerability may continue into emerging adulthood and contribute to the increase in weight gain commonly seen from adolescence to young adulthood Interventions with at-risk people - Children and adolescence are 2 vulnerable populations toward which health promotion efforts have been heavily directed - Another vulnerable group consists of people who are at risk for particular health problems → obesity, breast cancer Benefits of focusing on at-risk people - Early identification of these people may prevent or eliminate poor health habits that can exacerbate vulnerability. For example, helping men at risk for heart disease avoid smoking or getting them to stop at a young age may prevent a debiliating chronic illness. Even if no intervention is available to  reduce risk, knowledge of risk can provide people with information they need to monitor their situation - Efficient and effective use of health promotion dollars. When a risk factor has implications for only some people, there is little reason to implement a general health intervention for everyone. Instead, it makes sense to target those people for whom the risk factor is relevant - Focusing on at-risk populations makes it easier to identify other risk factors that may interact with the targeted factor in producing an undesirable outcome→ not everyone who has a family history of hypertension with develop hypertension, but by focusing on those at-risk, other factors that contribute to its development may be identified Problems of focusing on risk - Most people are unrealistically optimistic about their vulnerability to health risks - Sometimes, testing positive for a risk factor leads people into needlessly hypervigilant and restrictive behaviour - People may also become defensive and minimized the significance of their risk factor and avoid using appropriate services or monitoring their condition Ethical issues - Given that high levels of cancer-related worry do not match actual genetic contribution to risk, unnecessarily creating distress may not justify instilling risk-reducing behaviours - We may not know what an effective intervention will be for other disorders - Emphasizing risks that are inherited can raise complicated issues of family dynamics, potentially pitting parents and children against eachother and raising issues of who is to blame for the risk→ daughters of breast cancer patients may suffer considerable stress and behaviour problems due in part to the enhanced recognition of their risk Health promotion with older adults - The emphasis on health habits among older adults is well placed - Health habits are a major determinant of whether an individual will have a vigorous or an infirmed old age - Current evidence suggests that health habit changes are working - Reports indicated that most canadian seniors rate their health as excellent, very good, or good. Ethnic and gender differences in health risks and habits - Alcohol consumption is a greater problem for men than women - Smoking is a greater problem for men who are not visible minorities than for other groups - Smoking rates among indigenous youth are triple the rate for canadians in general - Indigenous peoples are less likely to exercise regularly and be likely to be overweight. Diabetes is an epidemic 3X the national rate  - People who are south asian or chinese may have more dangerous abdominal fat that people who are european with the same totaly amount of body fat, thus putting them at greater risk for cardiovascular disease, hypertension, diabetes, etc - The combined effects of low SES and biological predisposition put certain groups at greater risk Attitude change and health behaviour Educational appeals - Best ways to persuade people through educational appeals: - 1. Communications should be colorful and vivid rather than steeped in statistics and jargon - 2. The communicators should be expert, prestigious, trustworthy, likeable, and similar to the audience. Similarity may be especially important when the appeal is directed toward a particular cultural group and for people whose identity is strongly tied to their cultural group identity - 3. Strong arguments should be presented at the beginning and end of a message, not buried in the middle - 4. Messages should be short, clear, and direct - 5. Messages should state conclusions explicitly. For example, a communication extolling the virtues of a low-cholesterol diet should explicitly conclude that the reader should alter their diet to lower cholesterol - 6. Extreme messages produce more attitude change but only up to a point. Very extreme messages are discounted - 7. For illness detection behaviours (such as HIV testing or obtaining a mammogram), emphasizing the problems that may occur if they are not undertaken (i.e. loss framed messages) will be most effective. For health promotion behaviours (sunscreen use) emphasizing the benefits to be gained may be more effective. For preventative health behaviours (reducing spread of virus), emphasizing the risk of infection and trusting health authorities may be most effective - 8. If the audience is receptive to changing a health habit, then the communication should include only favourable points, but if the audience is not inclined to accept the message, the communication should discuss both sides of the issue - Providing information does not ensure that people will perceive that information accurately. Smokers know they’re at greater risks for lung cancer than non-smokers, they see lung cancer as less likely or problematic and smoking as more common than non-smokers Fear appraisals - Fear appraisals: this approach assumes that if people are fearful that a particular habit is hurting their health, they will change their behaviour to reduce their fear  - Common sense suggests that the relationship between fear and behaviour change should be direct: the more fearful an individual is, the more likely they will be to change the relevant behaviour - However, persuasive messages that elicit too much fear may actually undermine health behaviour change and trigger avoidance of change - Fear alone may not be sufficient to change behaviour→ strong fear appraisals coupled with recommendations for actions or information about the efficiency of the health behaviour may be needed to produce the greatest behaviour changes Message framing - According to prospect theory, different presentations of risk information will change people’s perspectives and actions - Messages that emphasize potential problems (loss framed) should work better for behaviours that have uncertain outcomes (high risk) - Messages that stress benefits (gain framed) may be more persuasive for behaviours with certain outcomes (low risk) - However, when risk is more salient, messages that highlight risk, such as the undesirable outcomes of inadequate diabetes self care, may be more effective than those that focus on the positive outcomes of effective self care - The effectiveness of the type of message framing may also depend on how congruent the message is with the individual’s own motivation - People who are approach oriented or seek to maximize rewards are more influenced by gain-framed messages, whereas people who are avoidance-oriented or seek to minimize losses are influenced by messages that are loss-framed - Congruency framed messages increase feelings of self-efficacy for engaging in the behaviour and also depend on matching the message to current the emotional state of the message recipient Social cognition models of health behaviour change - Social cognition models suggest that the beliefs that people hold out particular health behaviour motivated their decision to change that behaviour - These models are based on the core assumptions of the expectancy-value theory, which suggests that people will choose to engage in behaviours that they expect to succeed in and that have outcomes that they value Self-efficacy and health behaviours - Self-efficacy: the belief that one is able to control one’s practice of a particular behaviour - A core concept in Bandura’s social cognitive theory, which states that behaviour results from efficacy expectancies (the confidence that one can successfully engage in a behaviour to produce desired outcomes) and outcome expectancies (the belief that a given behaviour will result in a particular outcome)  - Outcome expectancies can motivate behaviour by linking behaviours to outcomes and are, therefore, most important for the development of intentions to engage in behaviours - Efficacy expectancies play a critical role once intentions are formed by providing motivation to initiate and maintain behaviour change. For example, smokers who believe that using the patch will help them quit and believe that they will be able to break their habit are more likely to try to quit - Research finds a strong relationship between perceptions of self-efficacy and both initial health behaviour change and long-term maintenance of that behaviour change The health belief model - The health belief model states that whether a persons practice a particular health behaviour can be understood by knowing 2 factors: - Whether the person perceives a personal health threat - Whether the person believes that a particular health practice will be effective in reducing that threat - Later the health belief model was updated to include 2 new factors –cues to action and self-efficacy– to help address the challenges of changing unhealthy behaviours such as smoking and unhealthy eating Perceived health threat - The perception of a personal health threat is influenced by at least 3 factors: - General health values, which include interst and concern about healtj - Perceived susceptibility, which refers to specific beliefs about personal vulnerability to a particular disorder - Perceived severity, which involves beliefs about the consequecnes of the disorder, such as whether they are serious Perceived threat reduction - Whether a person believes a health measure will reduce a threat has 2 subcomponents: percieved efficacy (whether the individual thinks a health practice will be effective) and perceived barriers (whether the cost of undertaking the measure exceeds the benefit of the measure) Cues to action - The health belief model also posits that the perception of the health threat and the perceived threat reduction account for an individual’s readiness to act. The cues to action then are people, events, or things that activate this readiness and stimulate behaviour. Self-efficacy - Self-efficacy is a powerful determinant of health behaviour change and maintenance. - It is also an important factor for understanding why some individuals may not perform a health behaviour that they feel will effectively reduce a health threat.  - Not having confidence that you can successfully quit smoking may interfere with successful attempts, even when other cues to action may activate your readiness to change your smoking behaviour Support for the health belief model - The health belief model explains people’s practice of health habits quite well. - It predicts preventative dental care, breast self-examination, sexual risk-taking behaviours among college and university students, and drinking and smoking intentions among adolescents. - Typically, health beliefs are a modest determinant of intentions to take these health measures Changing health behaviour using the health belief model - Interventions that draw on the health belief model have generally supported its predictions. Highlighting perceived vulnerability and simultaneously increasing the perception that a particular health behaviour will reduce the threat are somewhat successful in changing behaviour - However, the health belief model focuses mainly on beliefs regarding risk rather than the emotional responses to perceived risk, which are known to predict behaviour - The health belief model leaves out an important component of health behaviour change: the perception that one will be able to engage in the health behaviour. Protection Motivation Theory - Protection motivation theory is a framework that was developed to understand the cognitive processes underlying the persuasiveness of fear appeals, and specifically how perceptions of threat might motivate health behaviours to protect oneself from that threat - As an expectancy-value theory, PMT shares many of the same factors as the health belief model - According to PMT, the motivation to protect oneself results from 2 appraisal processes: a threat appraisal, followed by a coping appraisal - These processes are independent and are initiated by information sources in the environment (fear appeal) and within the individual (personality) Threat appraisals - Threat appraisals involve the source of the threat as well as the factors that might lead to a maladaptive response to threat, such as avoiding it or engaging in wishful thinking or denial of the threat. - Similar to the health belief model, if the individual perceieves the threat to be severe (e.g. developing lung cancer), and that they are personally vulnerable to the threat (being a heavy smoker), if they do not engage in a protective response (quitting smoking), then they will be less likely to engage in maladaptive responses.  - Fear resulting from perceptions of vulnerability to and severity of the threat is what increases motivation to engage in protective behaviour Coping appraisals - The coping appraisal includes assessing the efficacy of the recommended health behaviour to deal with the threat (response efficacy), as well as the individual’s belief that they are capable of engaging in the protective behaviour (self-efficacy) - The physical and psychological costs of responding to the threat are also taken into consideration - These response costs can weak motivation, such as when a smaker is concerned about increased craving when they quit or not fitting in with their peers to smoke Using protection motivation theory to change health behaviour - PMT has been used both to develop persuasive communications designed to change behaviour, and as a framework for predicting health behaviour change. - For the most part, evidence indicates that PMT can be effective for predicting whether people engage in behaviours that can reduce risk for a variety of health threats - PMT may be particularly useful for predicting people’s responses to health threats that potentially pose an immediate rather than long-term risk The Theory of Planned Behaviour - According to this theory, health behaviour is the direct result of a behavioural intention. - Behavioural intentions are themselves made up of 3 components: attitudes towards the specific action, subjective norms regarding the action, and perceived behavioural control - Attitudes toward the action are based on beliefs about the likely outcomes of the action and evaluations of those outcomes - Subjective norms are what a person believes others think that person should do (normative beliefs) and the motivation to comply with those normative references - Perceived behavioural control is when an individual needs to feel that they are capable of performing the action contemplated and that the action undertaken will have the intended effect; this component of the model is very similar to self-efficacy - These factors combine to produce a behavioural intention, and ultimately, behaviour change - Example: smokers who believe that smoking causes serious health outcomes, who believe that other people think they should stop smoking, who are motivated to comply with those normative beliefs, and who believe that they are capable of stopping smoking will be more likely to intend to stop smoking than individuals who do not hold these beliefs Benefits of the Theory of Planned Behaviour  - The theory of planned behaviour is a useful addition to understanding health behaviour-change processes for 2 reasons: - First, it provides a model that links beliefs directly to behaviour - Second, it provides a fine-grained picture of people’s intentions with respect to a particular health habit - Criticisms: - Some researchers have called into question the validity of the theory as there are few experimental tests of its predictions or its utility, suggesting that the field of health behaviour change has evolved past the theory of planned behaviour and that it should now be retired Evidence for the Theory of Planned Behaviour - The theory of planned behaviour predicts a broad array of health behaviours, including condom use among injection drug users, sunbathing and sunscreen use, use of oral contraceptives, consumption of soft drinks by adolescents, mammography participation, participation in cancer screening programs,etc. Implementation Intentions and Health Behaviour Change - One approach that can help bridge the intention-behaviour gap is forming implementation intentions. - An implementation intention is a specific behavioural intention that highlights the “how, when, and where” of behaviour, and also includes “if-then” contingency plans to deal with anticipated barriers to the behaviour. - More specific type of intention provides a clear plan of how the intention can be carried out even in less-than-ideal circumstances, and accordingly has a stronger influence on behaviour than more general intentions for behaviour - Implementation intentions have been found to be an effective way to shield ongoing dieting and exercise goals from interfering states, such as cravings and disruptive thoughts, and are effective for promoting physical activity - When used as an intervention strategy, implementation intentions are an effective way to increase fruit consumption, especially when paired with mental imagery - Implementation intentions can be especially effective for those with strong unhealthy snacking habits when the implementation intentions are framed in a manner that is congruent with personal approach or avoidance tendencies - Implementation intentions are also effective for health protective behaviours. The Transtheoretical Model of Behaviour Change - The transtheoretical model of behaviour change acknowledges that changing a bad health habit may not take place all at once by addressing the process or stages of behaviour change - This model accounts for and analyses the stages of change that people go through as they attempt to change health behaviour, and suggests treatment goals and interventions for each stage - Originally developed to treat addictive disorders, such as smoking, drug use, and alcohol addiction, the transtheoretical model of behaviour change (or stages of change model, as it is often referred to) has also been applied to other health habits, such as diet change and exercising Precontemplation - The precontemplation stage occurs when a person has no intention of changing their behaviour - Many individuals in this stage are not even aware that they have a problem although others around them do - Sometimes people in the precontemplation phase seek treatment, but typically they do so only if they have been pressured by others and feel themselves coerced into changing their behaviour Contemplation - Contemplation is the stage in which people are aware that a problem exists and are thinking about it but have not yet made a commitment to take action - Many individuals remain in the contemplation stage for years - Individuals in the contemplation stage are typically still weighing the pros and cons of changing their behaviour, continuing to find the positive aspects of the behaviour enjoyable - Those who do decide to change their behaviour have typically formed favourable expectations about their ability to do so and the rewards that will result Preparation - In the preparation stage, individuals intend to change their behaviour but may not yet have begun to do so - In some cases, it is because they have been unsuccessful in the past, or they may simply be delaying action until they can get through a certain event or stressful period of time - In some cases, individuals in the preparation stage have already modified the targe behaviour somewhat, such as smoking fewer cigarettes than usual, but have not yet made the commitment to eliminate the behaviour altogether Action - The action stage is the one in which individuals modify their behaviour to overcome the problem. - Action requires the commitment of time and energy to making real behaviour change.  - It includes stopping the behaviour and modifying one’s lifestyle and environment so as to rid one’s life of cues associated with the behaviour Maintenance - Maintenance is the stage in which people work to prevent relapse and to consolidate the gains they have made - Typically if a person is able to remain free of the addictive behaviour for more than 6 months, they are assumed to be in the maintenance stage - Self-efficacy can help individuals deal with the temptations they encounter while making a health behaviour change, and therefore help prevent relapse Importance of the stages of change model - It captures the processes that people actually go through while they are attempting to change their behaviours - It illustrates that successful change may not occur on the first try or all at once - It also explicates why many people are unsuccessful in changing their behaviour - Specifically, people who are in the pre-contemplation stage or the contemplation stage are not ready to be thrust into action - A study of smokers revealed that 10-15% were prepared for action, 30-40% were in the contemplation stage and 50-60% were in the precontemplation stage Using the stages of change model - Applications of the stages of change model of health behaviour have shown mixed success - The model has been used with many different health behaviours How are Cognitive-Behavioural approaches used to change health behaviours? - Cognitive behaviour therapy (CBT) approaches to health habit modification change the focus to the target behaviour itself–the conditions that elicit and maintain it and the factors that reinforce it - CBT also focuses heavily on the beliefs that people hold about their health habits and therfore it may be an effective way to support health behaviour change - Recognition that people’s cognition about their health habits are important in producing behaviour change has led to insight: the importance of involving the patient as a co-therapist in the behaviour-change intervention. - Most behaviour-change programs begin with the client as the object of behaviour-change efforts, but in the therapeutic process, control over behavioural change shifts gradually from the therapist to the client - By the end of the formal intervention stage, clients are monitoring their own behaviour, and rewarding themselves, or not, appropriately Cognitive-behavioural interventions draw on a variety of behaviour-change techniques, including some of the following strategies: Self-observation and Self-monitoring - Self-observation and self-monitoring assess the frequency of a target behaviour and the antecedents and consequences of that behaviour - First step: learn to discriminate the target behaviour. Although for some behaviours (such as smoking) this step is easy, for others (such as the urge to smoke) discrimination may be more difficult - Second step: recording and charting the behaviour. Techniques range from very simple counters for recording the behaviour each time it occurs, to complex records documenting the circumstances under which the behaviour was enacted as well as the feelings it aroused. - Although self-observation is usually only a beginning step in the behaviour stage, it may itself produce behaviour change. - Often people are resistant to tracking their health behaviours because the desire to self-protect or self-enhance when behaviour change is slow can conflict with the desire to reach one’s health behaviour goal. - This tendency, referred to as the “ostrich problem”, can interfere with successful health behaviour change Classical Conditioning - One of the earliest principles of behaviour change identified - The essence of classical conditioning is the pairing of an unconditioned reflex with a new stimulus, producing a conditioned reflex - Example: consider its use in the treatment of alcoholism–antabuse (unconditioned stimulus) is a drug that produces extreme nausea, gagging and vomiting (unconditioned response) when it is taken it conjunction with alcohol. Over time, alcohol will become associated with the nausea and vomiting caused by the drug and elicit the nausa, gagging and vomiting response (conditioned response) - Clients know they this method work: if they do not take the drug, they will not vomit when consuming alcohol - Thus, even is classical conditioning has successfully produced a conditioned response, it is heavily dependent on the client’s willing participation. - Procedures like this produce health risks as well so they are no longer widely used Operant Conditioning - The key is operant conditioning is reinforcement - When an individual performs a behaviour and its followed by positive reinforcement, the behaviour is likely to occur again - If an individual performs a behaviour and reinforcement is withdrawn or the behaviour is punished, the behaviour is less likely to be repeated - For example: drinking may be maintained because mood is improved by alcohol, reinforcement maintains the poor health behaviour - Using this principle to change behaviour requires altering the reinforcement or its schedule Operant Conditioning to Change Health Behaviours - At the beginning of an effort to change a faulty health habit, people typically will be positively reinforced for any action that moves them closer to their goal. - As progress is made toward reducing or modifying the health babit, greater behaviour change may be required for the same reinforcement Modelling - Modelling is learning that occurs by virtue of witnessing another person perform a behaviour - Modelling can also occur by observing someone in a video successfully engaging in health behaviour - The principle of modelling is implicit is some self-help programs that treat destructive health habits, such as alcoholism or drug addiction - In these programs, a person who is newly committed to changing joins an individual who had the same problem and has had some success in solving it - In meetings, people often share the methods that helped them overcome their problem–by listening to these account, people can learn how to do likewise and model effective techniques in their own rehabilitation - Modelling can be used as a technique for reducing the anxiety that can give rise to some bad habits or fear when going through some preventative health behaviours - When used for anxiety or fear, it is better to observe model that are also fearful but are able to control their distress rather than models demonstrating no fear in a situation - Modelling may be the most successful when it shows the realistics difficulties that people encounter in making these changes Stimulus control - Discriminitive stimulus: an environmental stimulus that is capable of eliciting a particular behaviour, for example; the sight of food may act as a discrimintive stimulus for eating - Stimulus control interventions take 2 approaches: - 1. Ridding the environment of discriminative stimuli that evoke the problem behaviour - Creating new discriminative stimuli signalling that a new response will be reinforced - For example: to reduce overeating, a person could remove rewarding but unhealthy foods, not eat while engaging in other activities (watching TV) and introduce other reinforcers such as the reward that will come from not overeating The Self-Control of Behaviour - CBT, including that used to modify health habits has moved toward a therapeutic model that emphasizes self-control  - The individual who is the target of the intervention acts, at least in part, as their own therapist and, together with outside guidance, learns to control the antecedents and consequences of the target behaviour to be modified Self-Reinforcement - Self-reinforcement involves systematically rewarding the self to increase or decrease the occurrence of a target behaviour - Positive self-reward involves reinforcing oneself with something desirable after successful modification of a target behaviour - Negative self-reward involves removing an aversive factor in the environment after successful modification of the target behaviour - Self-punishment has 2 types: - Positive self-punishment involves an unpleasant stimulus to punish and undesirable behaviour - Negative self-punishment consists of withdrawing a positive reinforcer in the environment each time an undesirable behaviour is performed - The success of self-punishment suggests 2 conclusions: - Positive self-punishment works somewhat better than negative self-punishment - Self-punishment works better if it is also coupled with self-rewarding techniques Contigency Contracting - An individual forms a contract with another person, such as a therapist, detailing what rewards or punishments are contingent on the performance or non-performance of a behaviour - Such contracts can be effective for increasing physical activity when exercise goals aren’t met, especially when combined with incentives Covert Self-Control - Trains individuals to recognize and modify these internal monologues to promote health behaviour change - Cognitions themselves may be the targets for modification→ cognitive restructuring is a method for modifying internal monlogues that has been widely used use in the treatment of stress disorders - In a typical intevention, clients are first trained to monirtor their monologues in stress-producing situations so that they learn to recognize what they say to to themselves during times of stress - They are then taught to modify their self-instructions to include more constructive cognitions Skills training - A number of programs designed to alter health habits include either social skills training or assertiveness training, or both, as part of the intervention  - The goals of social skills programs as a technique in health behaviour change are: - 1. To reduce anxiety that occurs in social situations - 2. To produce new skills for dealing with situations that previously aroused anxiety - 3. To provide an alternative behaviour for the poor health habit that arose in response to social anxity Motivational interviewing - It is a client-centred counselling style designed to get people to work through whatever ambivalence they may be experiencing about changing their health behaviours - It appears to be moderately effective for helping people reduce binge drinking and alcohol consumption, and increasing physical activity - There is no effort to dismantle the denial often associated with the practice of bad health behaviours or to confront irrational beliefs or even to persuafe a client to stop drinking, stop smoking and improve health - The goal is to get the client to think through and express some of their own reasons for and against change and for the interviewer to listen and provide encouragement rather than give advice - An appropriate approach for helping to motivate those unmotivated to make health behaviour changes Relaxation training - The procedure involves training clients to subsitute relaxation in the presence of circumstances that usually produce anxiety - Deep breathing and progressive muscle relaxation - In deep breathing: a person takes deep and controlled breaths which decrease heart rate and blood pressure and increase oxygenation of the blood→ people engage in this kind of breathing spontaneously when they are relaxed - In progressive muscle relaxation: learn to relax all the muscles in the body to discharge tensions or stress, a technique that can be effectively used for stress reduction Broad-Spectrum Cognitive-Behaviour Therapy - Sometimes known as the multimodal cognitive-behaviour therapy - Several advantages: - 1. Carefully selected set of techniques can deal with all aspects of a probem: self-observation and self-monitoring define the dimensions of a problem; stimulus control enables a person to modify antecedents of behaviour; self-reinforcement controls the consequences of a behaviour; and social skills training may be added to replace the maladaptive behaviour one it has been brought under some degree of control  - 2. The Therapeutic plan can be tailored to each individual’s problem. Each person’s faulty health hbait and personality is different. - 3. Multimodal interventions impart a broad range of skills that can be used to modify several health habits at the same time Relapse - One of the biggest problems faced in health-habit modification is the tendency for people to relapse to their previous behavour following initial successful behaviour change. - This problem occurs both for people who make health-habit changes on their own and for those who join formal programs to alter their behaviour Why do people relapse? - Genetic factors may be implicated in alcoholism, smoking, and obesity - Withdrawal effects occur in response to abstinence from alcohol and cigarettes and may prompt a relapse, especially shortly after efforts to change behaviour - Conditioned associations between cues and physiological responses may lead to urges or cravings to engage in the habit - Relapse is more likely when people are depressed, anxious, or under stress - Relapse is more likely to occur within 6-12 months of quitting smoking, for example, when there are a number of friends who also smoke - Relapse is less likely if a person has social support from family and friends to maintain the behaviour change, but it is more likely to occur if the persons lack social support or is in a conflictual interpersonal situation - The abstinence violation effect–a feeling of loss of control that results when a person has violated self-imposed rules– can result when someone dieting who is trying to avoid sweets has a bad day and eats a whole pint of icecream - The result is that a more serious relapse is then likely to occur as the individual sees their resolve falter Consequences of relapse - Relapse produces negative emotions. - Even a single lapse can lead a person to experience profound disappointment, a reduced sense of self-efficacy, and a shift in attributions for controlling the health behaviour from the self to uncontrollable external forces - A relapse could also lead people to feel that the can never control the habit–that is is simply beyond heir efforts - The person who relapses may nonetheless have acquired useful information about the habit and have learned ways to prevent relapse in the future Reducing relapse - Booster sessions following the termination of the initial treatment phase→several weeks or months after the end of formal intervention, follow-up sessions  - Booster sessions may be successful at reducing relapse but their effects may not emerge immediately following the session - Consider abstinence as a lifelong treatment process, as is done in programs such as Alcoholics Anonymous and other treatment programs - Although this approach can be successsful it has certain disadvantages→ can leave people with the perception that they are constantly vulnerable to relapse, potentially creating the expectation of relapse when vigilance wanes - The approach implies that people are not in control of their habit, self-efficacy is an important component in initiating and maintaining behaviour change Relapse prevention - Must be integrated into treatment programs from the ouset - Consistent with the transtheoretical model, it is a process that may occur in stages and relapse prevention efforts can be built in at all stages - People who are initially highly commited to the programs and motivated to engage in behaviour change are less likely to relapse - One strategy is having people identify the situations that are likely to promote a relapse and then develop coping skills that will enable them to manage that stressful event successfully - Successful adherence promotes feelings of self-control and that having available coping techniques can enhance feelings of control further - Cue elimination, or restructuring the environments to avoid situations that evoke the target behaviour, can be used - Some relapse-prevention programs deliberately expose people to the situations likely to evoke the old behaviour to give them practice in using their coping skills - Such exposure can increase feelings of self-efficacy and decreased the positive expectations associated with the addictive behaviour Health legislation - Requiring vaccinations for school entry in some provinces has led to moe than 98% of children receiving most of the vaccinations they need - There are limits on the use of legislation to change health habits more generally - Even though smoking has been banned in public areas, it is still not illegal to smoke; if this were to occur most smokers and non-smokers would find such measures unacceptable interference with civil liberties - Even when the health advantages of legislating health behaviour change can be dramatically illustrated, the sacrifice in personal liberty may be considered too great  - Many health habits will remain at the discretion of the individual The health practitioner’s office - Among the advantages of intervening in the physician’s office is that physicians are highly credible sources for instituting health-habit change, and their recommendations have the force of their expertise behind them The family - First: children learn their health habits from their parents, so making sure the entire family is committed to a healthy lifestyle gives children the best chance at a healthy start in life - Second: families, especially those in which there are children and one or more adults who work, typically have more organized, routinized lifestyles than single people do, so family life often builds in healthy behaviours - Married and co-habitating men have better health habits than single men, single and married women have equally healthy lifestyles, single women with children are disadvantaged with respect to health - Third: multiple family members are affected by any one member’s health habits. A clear example is second-hand smoke, which harms not only the smoker but those around them - Fourth: if behaviour change is introduced at the family level all family members are on board, ensuring great commitment to the behaviour-change program and providing social support for the person whose behaviour is the target - The involvement of family members can increase the effectiveness of an intervention substantially Self-help groups - Bring together individuals with the same health-habit program, either in person or online, and often with the help of a counsellor, they attempt to solve their problem collectively - Some prominent self-help groups include overeaters anonymous for obesity, alcoholics anonymous for alcoholism, and smokenders for smoking - Many of the leaders of these groups employ cognitive-behavioural principles in their programs - The social support of mutual suffers are an important factor in producing successful outcomes Schools - First: most children go to school; therefore, virtually the entire population can be reached, at least in their early years - Second: the school population is young. When young people are taught good health behaviours early, these behaviours may become habitual and stay with them their whole lives - Third: schools have health classes of approximately 1 hour - Fourth: certain sanctions can be used in the school environment to promote health behaviours. For example: school systems in most provinces now  require that children receive a series of inoculations before they attend school Work-site Interventions - On-the-job health promotion programs that help employees practice better health behaviours - In canada, most employers offer some form of wellness initiative to help promote the health of their employees - These programs involve smoking cessation, stress management, weight control, physical fitness, nutrition awareness, CPR, first aid training, etc. - Often such programs begin with a health risk assessment (HRA) to identify employees’ specific risks based on age, family history, and lifestyle factors - HRAs provide employers with a general view of their employees’ health - Work-site interventions are moderately successful Community-Based Interventions - Could be a door-to-door campaign informing people to the risks of smoking, a diet-modification program that recruits through community institutions, or a mixed intervention involving both media and interventions directed to high-risk community members - Structure the environmen to help people engage in healthy activities - Some industries provide special incentives, such as reduced insurance premiums for individuals who successfully modify their health habits - Several advantages: - 1. Reach more people than individually based interventions or interventions in limited environments such as workplaces and classrooms - 2. Community-based interventions can build on social support for reinforcing compliance with recommended health changes - 3. Community-based interventions can potentially address the problem of behaviour-change maintenance by restructuring the community environment to reduce or eliminate cues and reinforcers of risky behaviour and replace them with cues and reinforcements for health behaviours - These interventions show good success rates The Mass Media - Mass media campaigns bring out modest attitude change but less long-term behaviour change - Most effective in alerting people to health risks that they would not otherwise know about - By presenting a consistent media message over time, the mass media can also have a cumulative effect in changing the values associated with health practices - In conjunction with other techniques for behaviour change, such as community interventions, the mass media can also reinforce and underscore elements in existing behaviour-change programs The Internet - Provides low-cost access to health messages for millions of people who can potentially benefit from the information, suggestions, and techniques offered on websites - Websites designed to convey important health-promotion methods can be effective venues for health behaviour change by providing information about certain health risks and how they can be avoided CHAPTER 4: preventative and health-promoting behaviours Home and workplace unintentional injuries - Interventions to reduce preventable injuries at home are typically conducted with parents because they have control over the child’s environment - Parents are most likely to undertake injury prevention activities if they believe that the recommended steps really will avoid injuries, if they feel knowledgeable and competent to teach safety skills to their children, and if they have a realistic sense of how much time will actually be involved in doing so - Providing education and resources about how to keep the home safe is key to preventing accidents in the home Motorcycle and Automobile Unintentional Injuries - Almost 2000 canadians are killed each year in motorcycle and automobile accidents - Efforts have concentrated on factors such as the maintenance of roadways, the volume of travel, and safety standards in automobiles - It is clear that safety measures such as reducing highway driving speeds, requiring seat belts, and placing young children in safety restraint seats have reduced the number of severe injuries and vehicular fatalities - Making themselves visible through reflective or fluorescent clothing anf the use of helmets among bicycle and motorcycle riders has reduced the severity of accidents and preventing head injury - The rate of seat belt use in canada is generally high but young drivers tend to wear seat belts less - To promote the use of seat belts, a combination of social engineering, health education and psychological intervention may be most appropriate - Enforcement of penalties is also essential, as decreases in seat belt use are known to correspond with decreases in enforcement of fines for non-use Preventable Injuries among Indigenous Peoples - Injury is a leading cause of death in Canada, but indigenous and non-indigenous populations experience differences in the rates of injury-related death - An estimated 6% of non-indigenous Canadians die from injuries, 26% of deaths among indigenous peoples are caused by injury, the majority of these deaths are caused by motor vehicle accidents, followed by suicide  - Compared to non-indigenous peoples, first nations, inuit, and metis people are 3.5, 3.2, and 2.7 times higher risk for mortality from unintentional injuries - Indigenous peoples tend to have fewer years of education, experience higher levels of unemployment, and have lower average incomes than other Canadians - Living conditions are often less safe, poorer social conditions, and lack of access to adequate resources and support - 6 “E’s”: education, engineering, enforcement, empowerment, enabling, and employment What are cancer-related health behaviours? - It is estimated that approximately 2 in 5 canadians will be diagnosed with cancer and 1 in 4 will die from cancer - Screening and other preventative behaviours, is therefore essential to help reduce the future incidence of cancer and loss of life to this disease Breast cancer screening - Although most people with breast cancer are women, men can also have it, as well as people who do not self-identify as women. - The death rate from breast cancer in Canada has dropped significantly since breast screening programs were initiated across canada in 1986 - Breast cancer remains one of the leading causes of cancer deaths among canadian women and the most common cause of cancer death in women under 50, affecting 1 out of every 9 women at some point during her life - Different screening activities recommended for women in different age and risk groups - Clinical breast exams were formerly recommended, the current recommendations are to not routinely perform this exam as a screen for breast cancer - Women aged 50-69 should have a mammogram every 2 years - Although breast self-exams (BSE) were once commonly used for screening, current evidence suggesting that the BSE is not an effective method of screening Mammograms - Mammography rates among women 50-74 have reached 91%, up from only 40% in 1990 - Why is screening through mammography so important for older and high-risk women? There are several reasons: - 1. The prevalence of breast cancer in this country remains high, with over 26,000 canadian women being diagnosed each year - 2. The majority of breast cancers continue to be detected in women over age 40, so screening this age group is cost-effective. However, mammography is usually warranted for women under 50 only if recommended by a nurse or doctor, as the benefits of mammography for this age group remain unclear  - 3. Most important, early detection, as through mammograms, can improve survival rates Getting individuals to obtain mammograms - Women who are immigrants, who smoke, and who do not have a regular family doctor are less likely to get screened - Fear of radiation, embarassment over the procedure, anticipated pain, anxiety, fear of cancer, and no perception of need act as detterents to get regular mammograms - Lack of awareness, time, incentive, and availability are also important - Among women who do have a mammogram, 70% did so because it was part of a routine follow-up, highlighting the need for health professionals to remind women of the need for this important screening behaviour - Educational programs designed to raise awareness of the need for mammography also need to be culturally sensitive, and consider the cultural beliefs, attitudes, and practices of certain minority groups, such as indigenous women and south asian immigrants, who are less likely to have regular cancer screening - Theory of planned behaviour to predict the likelihood of obtaining regular mammograms: although perceived behaviour control may be most important for predicting mammography use, the addition of optimism and risk perception may enhance the effectiveness of this model - Instead of receiving all necessary diagnostic tests and check ups from one physician, as adult men do, many older women must make multiple appointments with a general practitioner and a mammography centre - Minority and older women and those living in rural areas often do not have a regular source of health care - Socioeconomic status plays a role Prostate cancer screening - In canada, prostate cancer is the most common cancer among men, and the third leading cause of death from cancer in canada - Risk for prostate cancer increases with age, screening is recommeneded over 50 - There are 2 screening tests for early detection: - The digital rectal exam (DRE) is most common - The prostate specific antigen test (PSA) involves a blood test to screen for prostate problems - Both tests are susceptibles to false positives and false negatives Colorectial cancer screening - In western countries, colorectal cancer is the second-highest cause of cancerous deaths - In canada it is among the 5 most common cancers for men and women - Colorectal cancer is increasing at higher rates among indigenous people  - Screening recommended at least once every 2 years for men and women between aged 50-74 for those with normal risk, and more frequently for those at high risk Sun safety practices - Each year in canada more than 7200 new cases of skin cancer are diagnosed - Malignant melanoma takes over 1200 lives each year in canada - Most common and most preventable cancer - Risk factor: excessive exposure to ultraviolet radiation - Women are more likely than men to practice sun-protective behaviours - Sun safety behaviours increase with age, sun exposure and lack of sun protective practices are highest among those 18-29 - Tanning beds, living in southern latitudes, outdoor activities increase ultraviolet radiation - Many people use inadequate SPF (sun protection factor) in sunscreens How does exercise enhance health? - Aerobic exercise is sustained exercise that stimulates and strengthens the heart and lungs, improving the body’s utilization of oxygen - Aerobic exercise is high intensity, long duration and high endurance - Examples: jogging, bicycling, rope jumping, running, swimming - Less effect on overall fitness: Other forms of exercise such as isokinetic exercises (weightlifting) and high intensity, short duration, low endurance exercises (sprinting) Benefits of exercise - Aerobic exercise increases cardiovascular fitness and endurance and reduced risk for heart attack - Most important health habit for the elderly - Strenuous exercise in adolescents and moderae exercise in post-menopausal women may reduce the risk of breast cancer - Effects of exercise translate directly into increased longevity - Regular exercise can have cognitive benefits, which may be especially important for older adults How much exercise? - 150 minutes per week of moderate to vigorous physical activity - 30 minutes 5 times a week - Youth aged 12-19 have highest rates of being moderately physically active - Adults over 65 have lowest rates of physical activity - Regional variations in activity levels: BC, yukon and albera largest portion of moderately active individuals Effects of psychological health - Regular exercise improves mood and feelings of well-being immediately after a workout  - Among patients with ongoing mental health issues, whose with higher subjective and objective reports of physical activity were found to use inpatient mental health services less frequently - Mood improves 10-20 minutes during exercise - 30 minutes of moderate-intensity exercise had beneficial effects on the mood of people with major depressive disorder - Even acute exercise may provide beneficial psychological effects - Group cohesion and social support arising from shared exercise classes can increase both positive mood and self-efficacy to exercise - Sense of self-efficacy can underlie some of the mood effects of exercise - Exercise has been used as a treatment for depression, stress, anxiety, and menopausal depression - An increase in symptoms of depression is one of the risks of stopping exercise Determinants of regular exercise - Many children get regular exercise through require gym classes in school - How much parents exercise plays a role in their children’s exercise - Accelerometer-measured→ Every 20 minute increase in parents’ physical activity was associated with 5-10 minutes increase in their child’s physical activity - Smoking, being overweight, and teen pregnancy also account for some of the decline in physical activity - People may begin an exercise program but find it difficult to make exercise a regular activity Individual characteristics - Who is most likely to exercise? - People who perceive themselves as athletic or as the type of person who exercises - People who enjoy their form of exercise - People who have positive attitures toward physical activity - People who have a strong sense of self-efficacy for exercising - People who have social support from friends to exercise - Important sex-related differences: - Boys get more exercise than girls from an early age - Women report significant barriers to getting exercise, including caregiving responsibilities and concomitant lack of energy - Race also predicts who is more likely to exercise: - Compared to non-indigenous canadians, first nations and metis people are more likely to have physically active lifestyles - Social support predicts exercise: - A sense of support and group cohesion contributes to participation - Engaging in exercise with others serves to reinforce social norms, which, according to the theory of planned behaviour, contribute to the performance of health behaviours  - Self-efficiacy: - People who are high in self-efficacy with respect to exercise are more likely to practice it and more likely to perceive that they are benefiting from it - Middle-aged adults with high self-efficacy beliefs with respect to exercise perceive themselves to expend less effort and report more positive mood during exercise than those low in self-efficacy - The positive emotions experienced during exercise predicted subsequent self-efficacy beliefs, positive affect may help maintain the practice of exercise - Individuals low with self-efficac beliefs with respect to exercise are less likely to engage in it Characteristics of the setting - What characteristics of exercise programs promote its practice? - Convenient and easily accessible exercise settings lead to higher rates of adherence - Less access to schools, gyms, and the effects of social restrictions on organized sports and social interactions likely contribute to decrease - Interventions that target an individual’s time perspective, such as goal setting and focus on the long-term benefits of exercise before an exercise program is started, may be one way to help encourage long-term exercise participation Characteristics of interventions Strategies - Initial perceived behaviour control and stable exercise habits developed during exercise participation further increased perceptions of behavourial control over the ability to exercise which contributed to successful maintenance of exercise behaviour - Cognitive-behavioural strategies–including contingency contracting, self-reinforcement, self-monitoring, and goal setting– have been employed in exercise interventions and appear to promote adherence - According to the transtheoretical model, different interventions should be targeted to people at different stages of readiness to exercise - Interventions designed to increase physical activity that are matched to the stage of readiness of the sample are more successful thant interventions that do not have this focus - Even minimal interventions to promote exercise show success they’re low cost and ease of implementation - Incorporating exercise into a more general program of healthy lifestyle change can be successful as well by linking healthy habits to each other Individualized exercise programs - If people participate in activities that they like, for which they can develop goals, and that they are motivated to pursue for the pleasure of exercising  rather than for achieving a specific outcome, exercise adherence will be greater - Ensuring that people have realistic expectations for their exercise programs may also impove long-term adherence - Increasingly, people are turning to apps to monitor their physical activity and weight management efforts - More than 50% if the population owns a smartphone so this would appear to be the ideal way to effect health behaviour change on a larger sclae - Because behaviour change theory suggests that individual techniques tend to be most effective when used together, individuals may have to use multiple apps to help them initiate and maintain their health behaviour change The importance of having a healthy diet - Dietary chanfe is often critical for people at risk for or already diagnosed with chronic diseases, such as coronary artery disease, hypertension, diabetes and cancer - People with low SES are more at risk and explains some of the relation between low SES and theses disorders - Supermarkets is high SES neighbourhoods carry more health-oriented food products than markets in low SES neighbourhodds - The best known relation to diseases and dietary factors is the total serum cholesterol level and low-density lipid proteins - Elevated total serum cholesterol and low-density lipid proteins are risk factors for the development of coronary heart disease and hypertension - Switching from trans fats (fried food) and saturated fats (meat and dairy) to polyunsaturated and monounsaturated fats is one of the most widely recommended courses of action - Diet high in fibre protects against obesity and cardiovascular disease, lower insulin levels, diversify gut bacteria which can protect against diseases - The psychological characteristics of people who adopt vegan and vegetarian diets reflect healthier eating motives, and higher self esteem and self-efficacy than those who pursue a weight-loss diet Resistance to modifying diet - Health behaviours and eating habits become established by age 11 or 12 which is why dietary changes may be resistant to change, especially if the change isn’t self-motivated - The typical reason people switch to a healthier diet is to improve appearance, not to improve health - The problem of maintaining change: - Insufficient attention to the needs for long-term monitoring and relapse prevention techniques - A strong sense of self-efficacy, motivation, and the perception that dietary change has important health benefits are critical to successfuly making dietary changes  - Some dietary recommendations are restrictive, monotonous, expensive, and hard to find and prepare - Comfort foods high in fat and sugar may help to turn off stress hormones, such as cortisol - People who are high in conscientiousness and intelligence tend to do a better job of adhering to a low-cholesterol diet, and people high in depression or anxiety are less likely to do so - Stress has a direct effect on eating, especially in adolescence - Greater stress is tied to consuming more fatty and fast foods - Stress may contribute to long-term risk for disease by steering adolescents’ and young adults diet in an unhealthy direction - Mood can also have significant impact on eating behaviours–negative mood can lead to eating more food, positive mood is linked to eating high-calorie foods Interventions to modify diet - Much dietary change has been implemented through cognitive-behavioural interventions=self-monitoring, stimulus control, and contingency contracting, coupled with relapse-prevention techniques - Motivational interviewing can also be successful to get people to increase fruit and vegetable intake - Another method is transtheoretical stages of change= different interventions are required for people at different stages Family interventions - Family members typically meet with a dietary counsellor to discuss the need to change the family diet and ways of doing so - They are effective,despite the fact that obesity rates have increased and the environment has become more obesogenic Community interventions - Specifically in the school system - Students from schools with an intensive program showed lower rates of obesity, healthier diets, and higher levels of physical activity than those from schools with or without a healthy menu - Simply offering a healthy menu at school may not be sufficient to reduce childhood obesity The importance of weight control The regulation of eating - Leptin and insulin: - circulate in the blood in concentrations that are proportionate to body fat mass - They decrease appetite by inhibiting neurons that produce the molecules neuropeptide Y (NPY) and agouti-related peptide (AgRP), peptides that wold otherwise stimulate eating - Stimulate melacortin-producing neurons in the hypothalamus, which inhibit eating  - An important player in weight control is leptin which is secreted by fat cells - Leptins signals the neurons of the hypothalamus as to whether the body has sufficient energy stores of fat or whether it needs additional energy - The brain’s eating control centre reacts to the signals sent from the hypothalamus to increase or decrease appetite - Leptin inhibits the neurons that stimulate appetite and activates those that suppress appetite - Ghrelin: - stimulates the appetite by activating the NPY-AgRP expressing neurons - Its secreted by specialized cells in the stomach, spiking before meals and dropping afterward - When people are given ghrelin injections, they feel extremely hungry - Blocking ghrelin levels or the action of ghrelin may help people lose weight and keep it off - Rats who have a damaged ventromedial hypothalamus behave like humans who are obese do: they eat excessive amounts of food, show little sensitivity to internal cues related to hunger, and respond to food-related external cues - This evidence implies that at least some humans who are obese have a malfunctioning ventromedial hypothalamus, which interferes with normal eating habits Obesity as a health risk - Obesity is an excessive accumulation of body fat - Fat should constitute 20-27% of body tissue in women and about 15-22% in men - Worldwide obesity has more than doubled since 1980 - 600 million people are obese - More than 1 in 5 canadian adults are obese, more men than women - 5 in 10 women and 7 in 10 men consume more calories than they need - Why are people becoming obese? - Food industry spends 600 million per year for promotion of food - Portion sizes have increased - Healthy food are often not available - Canadian adults are getting almost half of their daily calories from ultra processed foods - 60% of children’s diets are comprised of unhealthy ultra processed foods - Ultra processed foods: sweetened cereals, frozen meals, packaged breads - Processed foods are hyperglycemic and less satiating wich can lead to the dysregulation of blood sugar and eating more than needed Where the fat is - Abdominally localized fat is an especially potent risk factor for cardiovascular disease, diabetes, hypertension, and cancer  - Assessing obesity by measuring the waist-hip-ratio (WHR) or waist circumference (WC) may therefore be better indicators of risk for obesity-related illnesses - WHR is best predictor of cardiovascular disease morality, BMI weakest indicator - Stress weight–abdominal fat increases especially in response to stress - People with excessive central weight “apples” are more psychologically reactive to stress and show greater cardiovascular reactivity and neuroendoccrine reactivity to stress - Reactivity to stress may be the link between centrally deposited fat and increased risk for diseases - Uncontrollable stress may contribute to mortality risk from diseases, abdominally localized fat may represent a sign that health is eroding in response to stress Risk of obesity - 2.8 million deaths each year worldwide can be attributed to being overweight and obesity - Obesity is associated with atherosclerosis, hypertension, diabetes, gallbladder disease, and arthrtis - Obesity increases risk in surgery, anesthesia administration and child-bearing, as well as increased risk of stroke during and after pregnancy - Obesity is often stigmatized and seen as something that is under the individual’s control - Use of diet pills, fad diets, fasting, and anorexia nervosa or bulimia, create substantial risks of their own - People who are obese are worse off in terms of psychological functioning, especially in depression and anxiety - Depression may be maintained by increasing recognition that the world is not designed for overweight people–buying 2 airplane seats, rude comments, etc - The stigmas and stereotypes that obese people are subject to may furthr reduce their psychological health - People who are obese are one of very few disabled groups to endure public criticism for their disability - Obesity stigma is greater among ethnic women with low SES - Obesity increases the risk for a number of diseases, yet individuals who are obese often avoid trips to the physicians who can help them - Some people who are obese might not fit in standard wheelchairs, x-rays may not penetrate far enough for accurate readings, BP cuffs aren’t big enough and hospital gowns do not cover them Obesity in childhood - The prevalence of obestity has inccreased over the past 20 years among children and adolescents 5-17 years of age  - Particularly concerning are the rates of obesity among boys aged 6-17 which are higher than they are for girls - Indigenous children and adolescents have obesity rates that are 2 and a half times higher that of the national average - In canada, 23% of children are overweight and almost 14% are obese - Obesity can have significant negative psychological consequences for children’s self esteem - 60% of overweight children and adolescents are already showing risk factors for cardiovascular disease, such as elevated BP, elevated lipid levels and hyperinsulinemia - What is leading to childhood obesity? - Sedentary lifestyle involving TV and video games - Children are less likely to be obese when they participate in organized sports or physical activity - The link between inactivity and obesity is stronger for boys than girls - Parental behaviours are also related to their children’s obesity. Simply have a parent who is obese greatly increases the odd that a child will be obese Factors associated with obesity - Obesity depends on both the number and the size of an individual’s fat cells - Amongst people who are moderately obese, fat cells are typically large but there isn’t an unsual numbers of them - For severely obese people there is a large number of fat cells and the cells are large - What determines the number and size of fat cells and the propensity to be obese? - Childhood has a window of vulnerability - The number of fat cells an individual has is typically determined in the first few years of like, by genetic factors, or by early eating habits - A high numbers of fat cells leads to a propensity for fat storage, promoting obesity in adulthood - Poor eating habits in adolescence and adulthood are more likely to affect the size of fat cells but not their number - Calorie consumption - Many canadians get more calories from snacks consumed between meals than meals - The time involved in preparing food because of microwave ovens and advances in food processing and packaging has led to greater convenience for preparing food Family history and obesity - Parents who are overweight are more likely to have children who are overweight - Genetic and lifestyle factors - Genetics explained atleast 50% of variance in individual differences in BMI  - Twins reared apart showed a tendency toward obesity when both parents were obese, even when the twins’ environments were different - Genetically based tendencies to store energy as fat or lean tissue - Whether or not one diets is influenced by family environment - Efforts to lose weight among daughters are influenced heavily by perceived criticism of parents, sons’ weight loss efforts seem to be more related to fathers’ attitudes toward eating SES, culture, and obesity - Women of low SES tend to be heavier than women of high SES and indigenous women particularly appear to be vulnerable to obesity - Obesity rises with SES and and increasing wealth - Poor neighbourhoods→ high obesity rates - Rich neighbourhoos→ low obesity rates - Lack of access to high energy sports, which are expensive to participate in, as well as restricted access to healthy food choices are possible explanations - Thinness is valued in women from high SES and developed countries, which leads to a cultural emphasis on dieting and physical activity - Women who are intrinsically motivated are less vulnerable to thin ideals Stress and eating - About half of people eat more when they are under stress and half eat less - For people who are not obese and dont diet, the experience of stress or anxiety may suppress physiological cues suggesting hunger, leading to lower consumption of food - Stress and anxiety can disinhibit the dieter, removing self-control, leading to an increase in dieters and people who are obese - People who eat in response to stres are usually dieters who change their food choices from low calorie, low fat foods to higher calorie and high fat foods when they are stressed - Anxiety and depression contribute to stress eating as well which can contribute to weight gain - Susceptibility to overeating in response to emotional distres was significantly associated with weight gain in women over a 20 year period - Those who eat in response to negative emotions show a preference for sweet and high fat foods Weight loss strategies and treatment - Most people are motivated by the fact that being overweight is considered to be unattractive and that it carries a social stigma, and thus they internalize these weight biases Dieting - People are trained to restrict their caloric and or carbohydrate intake - Generally, weight losses produced through dietary methods are small and rarely maintained for long - Weight losses achieved through dieting rarely match the expectations of clients, whose disappointment may contribute to the regain the lost weight  - Very low carb or low fat diets do the best job in helping people lose weight initially, but these diets are the hardest to maintain and people commonly revert to their old habits - Repeated dieting may increasingly redispose the dieter to put on weight - Weight gain following reduced caloric intake or even fasting does not result from overeating following the food restriction; weight gain following restrictive eating likely results from changes in metabolic rate induced by restrictive eating - Reducing caloric intake to recommended levels, increasing exercise, and sticking with an eating plan over the long term are the only factors reliably related to staying slim Surgery - Surgical procedures, especially gastric surgeries, represent a radical way of controlling extreme obesity - In the most common procedure, the stomach is stapled to reduce its capacity to hold food so that the individual who is obese must restrict their intake - There are some risks and side effects such as gastric and intestinal distress - This procedure is usually reserved for people who are atleast 100% overweight who have failed to lose weight through other methods and have complicating health problems The multimodal approach Screening - Some programs begin with screening applicants for their readiness and their motivation to lose weight - Unsuccessful dieting, weight regained, body dissatisfaction and low self esteem are all criteria that can be used to screen individuals before treatment and used to provide a better match between a treatment program and client Self-monitoring - This kind of monitoring is always important for weight loss, but it becomes especially so at high-risk times, such as during the holidays when the weight gain reliably occurs - Clients are trained to modify the stimuli in their environment that have previously elicited and maintained overeating - Such steps include purchasing low calorie foods, making access to them easy, and limited the high calorie foods kept in the house - Clients are taught to confine eating to one place at particular times of day - Also trained to develop new discriminative stimuli that will be associated with eating, such as using a particular place setting and to eat only when those stimuli are present - When environmental cues are used to prime dieting goals, they may be particularly effective for promoting self-regulating of eating, especially in the presence of tempting eating situations Control over eating - Train clients to gain control over the eating process itself - Clients may be to urge count each mouthful of food, each chew, or each swallow - They may be told to put down eating utensils after every few mouthfuls until the food is swallowed - Longer and longer delays are introduced to introduce slow eating, which tends to reduce intake - Delays are introduced at the end of the meal and progressively moved closer to the beginning of the meal - Clients are uged to enjoy and savour their food and to make a conscious effort to appreciate it while eating - Clients are trained to gain control over the consequences of the target behaviour and to reward themselves for activities they carry out successfully - Developing a sense of self-control over eating is an important part of behavioural treatments of obesity - Training in self-control can help people override the impact of urges or temptations Adding exercise - As people age, increasing exercise is essential just to maintain weight and avoid gaining it - High levels of physical activity are associated with initial successful weight loss, better eting self-regulation and the maintenance of weight loss Controlling self-talk - Poor health habits can be maintained through dysfunctional monologues - Participants in many weight loss programs are urged to identify the maladaptive thoughts they have regarding weight loss and its maintenance and to substitute positive self-instruction - Having a strong sense of self-efficacy–believing in oneself–predicts weight loss Social support - Clients with high degrees of social support are more successful than those with little social support - Programs that include training in eliciting effective support from family, friends, an co-workers are more successful at promoting weight loss and maintenance of weigh loss compared to programs without social support strategies - Even supportive messages from a behavioural therapist over the internet seem to help people lose weight more successfully Relapse prevention - Relapse prevention is important not only for diet control but also for the self-crimination that occurs when people are unsuccessful - Such negative consequences may fall more heavily on women than men  - Women are more likely to blame their own lack of self-discipline, whereas men are more likely to blame external factors, such as work - Often, weight loss efforts fail simply because the process of maintaining behaviours needed for weight loss is so arduous and there are few long term rewards for doing so - Some people may undo their dieting efforts by justifying their relapse, and focusing on the future healthy behaviours that will balance out an occasional slip - These compensatory health beliefs are aimed at neutralizing the negative feelings that come from giving in to a desire or craving that interferes with one’s health goals - Although such beliefs may help minimize any guilt from giving into this craving, they can interfere with successful adherence to health behaviour change such as dieting - Interventions that target and minimize these beliefs may be useful for preventing relapse and promoting dietary adherence Evaluation of cognitive-behavioural weight loss techniques - Cognitive behavioural interventions can be successful for helping people lose weight and maintain weight loss up to 3 years later, whether they are administered on an individual or group basis - Dieting remains on of the most popular options for weight management outside a formal treatment environment Taking a public health approach to weight management - If parents can be trained early to adopt sensible meal planning and eating habits that they can convey to their children, the incidence of obesity may ultimately decline - Using nutritional labels to help motivate consumers to make healthy food choices is another strategy that can help families prevent the development of obesity - Sch