JW L2 Fear appeal & HBM_24Sep9(1) PDF

Fear appeal and the Health Belief Model PHPC2016 Assistant Professor Johnson Wang BMed, MMed, PhD JC School of Public Health and Primary Care,...

Fear appeal and the Health Belief Model PHPC2016 Assistant Professor Johnson Wang BMed, MMed, PhD JC School of Public Health and Primary Care, Faculty of Medicine, CUHK The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Sep 9, 2024 1 Key points for lecture 1 1. Psychosocial construction of health and illness among individuals (1) Health, disease and illness (2) Medicalization (3) Illness representation 2. Social impact on health (1) Socio-ecological model of health (2) Social capital The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 2 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Health, diseases and illness Health is a state of complete physical, mental and social well-being, not merely absence of disease or infirmity (WHO definition, 1948) Social construction of health - People have their own understanding of health problems - Health being socially defined Disease = “the malfunctioning of biological and/or psychological processes” (Kleinman A, 1980, p.72); often has biomedical cause(s) Illness = “the psychosocial experience and meaning of perceived disease” (Kleinman A, 1980, p.72) Able to tell the differences between illness and diseases The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 3 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Medicalization A process by which nonmedical problems become defined and treated as medical problems, usually in terms of illnesses or disorders  Changing a process or a condition considered normal into one requiring medical intervention (Conrad, 1992) Pros  Medical treatment can sometimes bring about improvements  Stigma reduction: many people get mental illness, including you, so it is okay to accept others and to seek treatment Cons  Sometimes neglect the social dimensions of these problems, but only to reduce symptoms  Individualization of social problems (alcoholism)  Shift control to doctors (e.g., IGD?)  Encourage over self-assessment and search for medical labels which may be problematic The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 4 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Illness representations How people think about a disease or health condition Cognitive representations  Identity --- What are the symptoms that go with the illness/disease (e.g., COVID-19, hypertension, drug addiction, HIV, influenza)  Cause --- Attributing likely causes of the illness/disease (e.g., genetic, environmental, personal choice, others’ faults, fate)  Timeline --- the expected duration and course of the illness (e.g., acute or chronic)  Consequences --- severity of the illness/disease (e.g., mild or severe)  Treatment and personal control --- whether something can be done to control the illness (e.g., can be cured or kept under control)  Illness coherence --- overall comprehensibility of the illness Emotional representations  The extent to which individuals are emotionally affected by the illness (e.g., feeling anger, guilt or shame) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 5 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Self-regulation model of illness representations how people make sense/perceive and cope with/self-manage their illness Social and Cultural influences Cognitive representation (e.g., identity, cause, time-line, consequences, controllability) Coping Appraisal Stimuli (external and/or internal) Emotional representation (e.g., fear, anger) Coping Appraisal (Adapted and elaborated from Diefenbach & Leventhal, 1996) 6 Socio-ecological model of health Shift from biomedical model of health to social ecological model of health Individual level: knowledge, attitudes, genetic, physiology Interpersonal level: families, friends and social network Organizational level: workplace, formal and informal groupings Community level: physical environment, social capital National level: policies The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 7 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Structural and cognitive social capital Structural social capital refers to the extent and intensity of networks  Whether you are a member of any groups/community?  Whether you receive support from groups?  Whether you receive support from other individuals?  Whether you have participated in some citizenship activities? Cognitive social capital  Perceived levels of trust, social harmony, sense of belonging and fairness. In general, better social capital is associated with better health outcomes Able to comment on the status/changes in social capital under a given situation The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 8 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Outline for today’s lecture 1. Fear appeal approach (1) What is it (2) Application of fear appeal approach to change health behaviors 2. Health Belief Model (HBM) (1) Constructs of the HBM (2) Strategies for behavioral change based on the HBM (3) Application of the HBM to change health behaviors The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 9 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong 1. Fear appeal approach The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 10 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Types of health behaviors --- consider the relationship between health and behaviors Health enhancing behaviors: behaviors aimed to enhance or maintain health and prevent disease (e.g. healthy lifestyle, healthy diet, wearing seat belt, taking up vaccination) Health compromising behaviors: (e.g. smoking, substance use, unprotected sex) Sick role behaviors: behaviors aimed to get well (e.g. taking prescribed medication, self-care behaviors) Karl & Cobb (1966), Matarazzo (1984) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 11 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Danger, fear, and behavioral changes All of us would like to avoid danger --- part of human nature Danger is very often associated with fear, which “warns” us about potential danger. (e.g., fire is associated with fear; you would not walk into a room with a fire accident and the fear warns you..) Thus, the rationale is that it is believed that if a behaviour would result in fear, we would be less keen to do the behaviour, as we would like to reduce our fear. Thus, health promotion sometimes tries to induce fear in order to make people avoid doing a health compromising behaviour (e.g. smoking). It is called the fear appeal approach. Today, we are looking at the pros and cons and how to increase effectiveness of such an approach. >> Our memory: Have your parents used fear appeal to change your behaviours? The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 12 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong The fear appeal approach It is one of the most commonly used strategies in health promotion It is also a hot topic in health communication research It aims at creating emotions, not changes in attitudes or beliefs In the past, health promotion campaigns mainly used this approach Examples in the following slides. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 13 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong  Fear appeal against smoking “Smoking isn’t just suicide. It’s murder.” - Chilean Corporation Against Cancer 14 Fear appeal against smoking Fear appeal images become bigger and bigger on the packages of cigarettes The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 15 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Fear Appeal: Mothers Against Drunk Driving (US) “Don’t make it a grad to forget.” The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 16 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong The way to scare people is about the same Hong Kong COSH Australia Health Authority Philippines Department of Health Singapore Health Promotion Board 17  Hong Kong Road Safety PSA 1989 http://www.youtube.com/watch?v=XEdJtD_viCk The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 18 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong UK: Ad against drunk driving (2010) https://www.youtube.com/watch?v=kLpp17O9rHc The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 19 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Hong Kong: Keep Off the Tracks (1983) https://www.youtube.com/watch?v=WjuPMkLp5Zk The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 20 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Hong Kong: Household safety (1985) http://www.youtube.com/watch?v=pjEDfoCYpQI The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 21 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Hong Kong: Occupational Safety (1995) http://www.youtube.com/watch?v=pv4WkMNy-qo The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 22 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Fear appeal in local drug free campaign (10 years ago) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 23 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Fear appeal in local drug free campaign (Nowadays) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 24 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Please share your views When you see these posters How much fear has been induced after looking at these posters?  Not at all / little / moderate / much / too much Are you feeling frightened?  Yes / No / Uncertain What would be your likely responses to these posters?  Avoid looking at them / not to try drugs / no responses The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 25 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Is fear appeal an effective approach? Mass medias tend to use the fear-appeal approach frequently. Effectiveness is inconsistent (Soames Job 1988, Tay R 2001) :  21 studies showing a positive association between fear and persuasion. However, 16 of such studies were based on self-reported data.  Four meta-analyses showed that fear appeal resulted in changes in attitudes, intention, and behaviors (Green and Witte 2006) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 26 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Criticisms Many researchers criticize the governments for continuing to use this approach.  Only “creates an impression of effectiveness” but has not always been tested  Falsely assume that a higher level of fear would always drive people to change their behaviors  During the COVID-19, less than half of older adults in HK thought that health promotion materials produced by the government were able to address their concerns related to vaccination (41.6%), or help them make a decision on whether to receive the vaccine (48.2%). Other studies showed that a positive reinforcement approach may be more effective The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 27 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Potential harms of ineffective health messages Not only wasting resources, but making the target audience even more likely to continue the unhealthy behaviors Immunize their audience against the message (McGuire W T 1962) – the message is wrong/not true (e.g. My friends have been smoking for years and nothing happens) Pushing someone to change their behaviors when they are not ready would lead to resistance The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 28 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Why fear appeal is not always effective Besides the intended induction of fear, fear appeal may bring changes in some attitudes that can lead to its ineffectiveness  The “Third Person Effect” – Other people may have the bad consequences but NOT me [e.g. I am better than an average person! I am strong. I am young]  Optimistic Bias (unrealistic optimism, Scheier & Carver 1992) – The chance of developing severe consequences after Omicron infection is so low, even without vaccination.  Maladaptive coping responses – People showing fatalism, avoidance, denial to the problem (e.g. it is scary, let’s not think about it; let us not think about cancer caused by smoking until it happens, “When it is you, it is you” “If it is bad fortune, you cant not avoid it”) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 29 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Theories behind fear appeal approach --- The Parallel Response Model Fear may induce two different responses Danger control: One may remove the source of fear by performing adaptive behaviors, i.e., acceptance of messages and change their behaviors:  To kill the approaching tiger (an effective response)  To stop smoking to remove the fear for cancer Fear control: One may also avoid thinking about the fear. Thus resulting in maladaptive behaviors:  To run away from the tiger  To deny the problem  Other ineffective responses The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 30 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong The Extended Parallel Process Model Threat (what composes fear?) Severity of the threat (How bad is to get COVID-19?) Susceptibility to the threat (How likely I will get COVID-19?) - Both elements are needed to induce fear. - Examples: Ebola vs. COVID-19, which is a bigger threat? - You won’t feel the fear if it is too severe but to feel a lower chance that it would happen (e.g. fear toward flight clash when you travel) or vice versa (e.g. I am very likely to get a flu but consequence is not big). - Health promotion needs to increase both severity and susceptibility (Hong Kong governmental seasonal influenza vaccination promotion for older adults) - Older adults are more likely to have severe symptoms of seasonal influenza (emphasize severity) - Older adults have higher chance to have seasonal influenza (emphasize susceptibility) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 31 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong The Extended Parallel Process Model (Cont.) Efficacy associated with the behavior (Witte K, 1992) Response efficacy --- how effective is the behavior in reducing the threat Can I prevent seasonal influenza if I get vaccinated (how effective is the vaccine) Self-efficacy --- whether you are confident to perform the behavior Are you confident to receive a seasonal influenza vaccine if you wanted? Health promotion using fear appeal approach need to improve these two types of efficacies The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 32 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong A quiz What type of efficacy is the statement talking about: 1: Doing 30 minutes of physical activity per day can be easy for me  A: Self-efficacy B: Response efficacy C: None of above 2: Doing physical activity can prevent diabetes  A: Self-efficacy B: Response efficacy C: None of above The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 33 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Pitfall of fear appeal approaches Low self-efficacy  I am sacred about getting HIV, but I am not confident to use condoms because my partner does not like it Not clear about the threat  Internet addiction (not clear about severity), Mpox [dated: monkeypox] (low susceptibility) Questionable response efficacy The Extended Parallel Process Model provide insights on how to design our health promotion based on fear appeal. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 34 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong An appropriate level of fear is required Too low: no response if the level of fear inducted is too low Too much: may result in avoidance if too much fear is induced A threshold may exist (Henthorne TL 1993) 35 Suggestions for improving effectiveness of fear appeal approaches 1. The onset of fear should preferably precede the performance of behaviors (before onset of sex, smoking etc.) 2. The scary consequences are very likely to occur in the presence/absence of the behavior (versus use drugs but no death observed) 3. A specific behavior should be offered that could reduce the threat 4. The resulting behavior induces observable fear offset (removing the danger), confirming its response efficacy The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 36 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Case study 1 --- the AIDS pyramid http://www.youtube.com/watch?v=3mE12JWAfbA The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 37 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Case study 1 --- the AIDS pyramid At that time, there were only 400 reported HIV cases in Hong Kong (about 10,000 now). The advertisement was on TV targeting general public. 1. How is the level of fear induced on general public? (Too high, appropriate, too low) 2. Is it overemphasizing perceived susceptibility and severity? (Yes, no, hard to say) 3. Does it specify a health behavior to remove the fear? (Yes, no, hard to say) 4. Does it mention response efficacy and self-efficacy? (Yes, no, hard to say) 5. Would it be more likely to trigger off fear control or danger control? (Fear control, danger control, neither, hard to say) 6. Would you expect the health message to be effective? (Yes, no, hard to say) 7. Can you expect any harmful effects when people watch this advertisement? The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 38 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Case study 2 – Franco’s pain Aim: using fear appeal approach to promote consistent condom use among MSM First question need to be answered: what do they fear about? In the mind of some health workers HIV! However …… The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 39 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Case study 2 – Franco’s pain What do they fear about (obtained from focus group)?  What they fear most: Loss of relationship, difficulty to find partners due to STD statuses  Scary images of STD symptoms? Yes, but not too much It was shown to MSM when they are using HIV testing services. Could effectively reduce unprotected anal sex by about 16% compared to the control group after three months Let us take a look at the video. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 37 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Fear appeal components (in addition to visual image about STD symptoms) Break up with boyfriend Difficult to find new partner The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 38 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong 2. The Health Belief Model The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 42 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong What is a behavioral change theory? It presents a systematic way for understanding health-related behaviors and its determinants (factors): In general, a theory is made up by a set of concepts (usually called constructs in this context), and propositions that are inter-related to each other can be used to understand the events/situations by illustrating the relationships between these variables. It must be applicable to a broad variety of situations instead of a single incidence (it rains today and I am happy). (Glanz & Rimer, 2005) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 43 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong What makes up a good theory? It explains the behavior  Most constructs of a theory were determinants of a behavior It successfully predicts the behavior  Constructs of a theory measured at baseline were associated with the onset of a behavior in future It can be verifiable through research  Changes in some constructs of a theory via interventions would lead to change in a behavior The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 44 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Applications to behavioural health Research / need assessment: Theories help us to decide what factors should be included in a study, thus increase the study’s ability to explain the behaviour Health promotion / interventions Meta-analyses have shown that interventions based on behavioural health theories are more likely to be effective. Its significant risk/preventive factors suggest how to change behaviours by forming intervention strategies to modify such factors in a systematic manner (a later slide). The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 45 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Behavioral change theories at individual- level Health Belief Model (Rosenstock, 1966) Theory of Planned Behavior (Ajzen & Madden, 1996) Stages of Change (Prochaska & DiClemente, 1983) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 46 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong  The Health Belief Model (HBM) History of the HBM In the 1950s, a free TB screening was found unsuccessful. Researchers sought accounts for not joining the program, which are summarized as…: None of my family Even I really get tuberculosis, the What’re the members has tuberculosis. consequence is not serious, I won’t die. procedures? I’m not My risk of getting confident in taking tuberculosis is low. up the screening. I’m scared to find out What’s the usefulness that I get tuberculosis. I of screening? don’t want to know about the results I have no symptoms such To provide sputum specimen, as fever, night sweats, I have to visit the offices cough, losing weight, or multiple times. In addition, it having blood in my sputum is difficult to make an appointment with a doctor The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 47 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong The Health Belief Model (HBM) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 48 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Construct 1: Perceived susceptibility Definition: The subjective belief that a person may acquire a disease or enter a harmful state Key points Subjective belief: from very low to very high Can be “In general” or “results of a specific behavior”: “In general, what is your risk of having COVID-19?” “What is your risk of having COVID-19 if you are a close contact” Postulation: Higher perceived susceptibility increases the chances of performing/not performing the target behaviour. It has a strong cognitive component partly dependent on knowledge The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 49 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Examples: How to measure perceived susceptibility Strongly disagree to strongly agree: “Very few people get HIV in Hong Kong, my chances are very low even if I don’t use condoms” “Without vaccination, the chance of getting flu is quite high” Very low to very high “What are your chances of contracting HIV if you do not use condoms?” “What are your chances of getting H1N1 flu without vaccination?” The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 50 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Construct 2: Perceived severity The belief in the extent of harm that can result from the acquired disease or harmful state as a result of the particular behavior Different types of harm  Medical and clinical (e.g., death, disability, pain)  Social consequences (e.g., effects of the conditions on work, family life, and social relations)  Psychological consequences (e.g., making you worry) Has a strong cognitive component and is partly but not totally dependent on knowledge The combination of perceived susceptibility and severity is labeled as perceived threat. These two constructs are related to health problem but not directly on perceptions toward the behavior (the other four constructs focus on perceptions toward the target behavior). The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 51 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Examples: How to measure perceived severity The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 52 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Construct 3: Perceived benefits The beliefs in the efficacy of the target behavior in reducing the risk or seriousness of the health problem Benefits can be health/non-health-related  Example: taking up COVID-19 vaccination  Can effectively protect you from COVID-19 (health-related)  Can effectively protect your family from COVID-19 if you got vaccinated (health- related)  Can make your feel at ease (psychological, non-health-related)  Can bring your life back to the time before COVID-19 (non-health-related)  Can contribute to COVID-19 prevention and control in Hong Kong (non-health-related) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 53 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Construct 4: Perceived barriers The belief concerning the costs of performing the suggested behavior It includes tangible, physical or psychological costs Example: taking up COVID-19 vaccination Would have severe side-effects on me (physical) The protection of the vaccines only lasts for a short time (physical) The cost of COVID-19 vaccination is too expensive for me (tangible) It is inconvenient for me to visit organizations providing vaccination (tangible) Sometimes, people concern about being labelled or stigmatized for performing a behavior (e.g., being stigmatized by service providers when taking up HIV testing for a gay man). The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 54 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Construct 5: Cue to action Precipitating forces that make a person feel the need to take actions Include internal cues (e.g. symptoms) or external cues (e.g. media publicity) Taking up COVID-19 screening “I have been experiencing symptoms of fever, cough, chest pain, …” (Internal cues) “My neighbor has been diagnosed with COVID-19” (external cues) “People who are important to me (doctor, family member, friends) suggest you to take up COVID-19 screening” (external cues) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 55 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Construct 6: self-efficacy The confidence in one’s ability to acquire the new behavior or change the behavior It was added in the model later to increase its predictability It is especially important for behaviors that require long-term changes The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 56 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Applications of HBM to health behaviors Screening behaviors  Colorectal cancer screening (Sung et al., 2008)  Cervical cancer screening (Reiter et al., 2009)  Breast cancer screening (Wu et al., 2006) Health-promoting behaviors  Vaccination (Lau et al., 2006)  Eating behaviors (Kloeblen et al., 1999)  Exercise (Al-Ali & Haddad, 2004)  Condom use (Zhao et al., 2012) Health-compromising behaviors  Drinking behaviors (Von Ah et al., 2006)  Smoking (Morris, 2005) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 57 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Example 1 --- Application of HBM to understand determinants of pneumococcal vaccination uptake among older adults in HK Perceived susceptibility (from 1=very low to 5=very high)  How high is your chance of having pneumonia?  How high is your chance of having invasive pneumococcal diseases? Perceived benefit for oneself (1=disagree, 2=neutral, 3=agree)  PV (pneumococcal vaccine) is highly effective in preventing you from pneumonia  PV is highly effective in preventing you from severe invasive pneumococcal diseases  You will feel at ease after taking up PV Perceived benefit for others (1=disagree, 2=neutral, 3=agree)  Taking up PV is highly effective in preventing pneumonia transmission in Hong Kong  Taking up PV is highly effective in protecting your family The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 58 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Application of HBM Example 1 --- measurements based on the HBM (cont.) Perceived barriers of receiving PV (1=disagree, 2=neutral, 3=agree)  PV is expensive for you  You concern about side-effects of PV  The time and venue of PV is inconvenient for you Cue to action (1=disagree, 2=neutral, 3=agree)  Your significant others suggest you to take up PV Perceived self-efficacy (1=disagree, 2=neutral, 3=agree)  You are confident to take up PV if you want The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 59 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong HBM could explain uptake of PV among older adults in Hong Kong Perceived susceptibility Perceived benefits for oneself Perceived benefits for others Uptake of PV Perceived barriers of PV Cue to action Perceived self-efficacy 60 Comments on the HBM Strengths HBM continues to be a major organizing framework for explaining and predicting health behaviors Findings from prospective and retrospective research all provide favorable results A meta-analysis of 18 longitudinal studies showed that benefits and barriers were consistently the strongest predictors of health behaviors (Carpenter, 2010) Criticisms Interrelationships between components are unclear e.g. whether the effects are addictive or interactive? Health behaviors are not completely rational? e.g., decision to use condoms could be more than a rational choice Do not take into account social (e.g., gender power in sexual decision) and emotional factors (e.g. trust between sex partners) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 61 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong From behavioural change theories to intervention strategies Formation of strategies is the purpose of applying theories for behavioural changes: Theory > significant constructs > behavioural change (e.g. HBM) (e.g. safety) (e.g. vaccination) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 62 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong The HBM: Strategies for intervention Common strategies to increase perceived susceptibility  personalized risk based on a person’s characteristics or behavior  The level of risk need to be specific and relevant  Example 1: the chances of developing lung cancer for smokers are 22 times more than a nonsmoker  Example 2: studies showed that the risk of having anal cancers among men who have sex with men (MSM) was 80 times higher than non-MSM males Notes  One should not create unrealistic or exaggerated fears about the condition 63 The HBM: Strategies for intervention (cont.) Common strategies to increase perceived severity  Specific negative consequences of a disease and condition  Poorer control of diabetes can harm your heart, brain, legs, eyes, kidneys, nerves, and skin, resulting in heart failure, strokes, poor vision, and skin breakdown  Personalize the seriousness  Share a story about a person who has diabetic foot amputated  Make use of images and narratives  Images of the symptoms --- not too many  People are likely to trust opinions and experience of their peers 64 The HBM: Strategies for intervention (cont.) Common strategies to increase perceived benefits  Define action to take and direct and specific benefits  Use condoms consistently during sexual intercourse can reduce your risk of HIV infection by over 90%  Doing physical activity at least 30 minutes per day and 3 days a week can reduce your risk of having diabetes and improving your sleep quality  Emphasize both on physical and mental/social benefits  Ease of mind  Protect family members  Narratives are always powerful  Peers taking about positive experiences after behavioral changes 65 The HBM: Strategies for intervention HBM constructs Potential strategies Perceived barriers Reassure that the behavior has minimal cost (it will only take 15 minutes while taking a shower for breast self-examination) Identify and reduce perceived barriers through reassurance, correction of misinformation, giving incentives, assistance e.g. cost subsidy (HPV vaccination), online appointment for HIV testing, HIV self- testing at home Cues to action Employ reminder systems (e.g. post a note or call the person or advice from health professionals) Self-efficacy Provide training, guidance in performing action Practice in small steps Use progressive goal setting Give verbal reinforcement Have a role model demonstrate the behavior Reduce stress associated with implementing a new behavior The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 66 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Case study Promoting HPV vaccination among men who have sex with men in Hong Kong Why HPV vaccination for MSM is important  MSM are at high risk of contracting HPV and its related diseases (e.g., genital warts and penile/anal cancers)  HPV vaccination is highly effective in preventing vaccine-type genital warts and cancers among MSM  Those who have already infected with one or more HPV types can still get protection from other HPV types in the vaccines  Prevent developing/recurrence of subsequent HPV-related diseases  Strong need for health promotion: HPV vaccination uptake among male population is very low in Hong Kong The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 67 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Applying the HBM to understand facilitators/barriers to receive HPV vaccination among local MSM Significant constructs are (Wang Z, et al, 2013):  Perceived susceptibility (risk of HPV, genital warts and penile/anal cancer)  Perceived severity (chance of HPV infection causing genital warts and penile/anal cancers)  Perceived benefit of HPV vaccination (efficacy in preventing genital warts and penile/anal cancers, duration of protection)  Perceived barriers (high cost, potential side effects, and embarrassment)  Cue to action (recommended by doctor or peers to take up the vaccines) These constructs were considered to develop an online video promoting HPV vaccination The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 68 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Strategies based on the HBM Let us watch the video and see what strategies are used The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 69 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Increase perceived susceptibility Message:  Studies showed that the risk of having anal cancers among MSM was 80 times higher than non-MSM males  HPV infection doubled the risk of HIV infection among MSM  60% of Chinese MSM were infected with HPV The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 70 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Increase perceived severity Messages (personalize the severe consequences):  HPV causes genital warts, which is difficult to cure. The treatment is painful and the recurrence rate is high.  HPV causes anal cancers. Out of 100 HPV-infected MSM, 8 of them would develop precancerous lesions. Out of six MSM with precancerous lesions, one would develop anal cancers within 3-5 years. The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 71 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Increase perceived benefits Messages (Define action to take and direct and specific benefits to be experienced):  HPV vaccination is highly effective in preventing genital warts, penile and anal cancers among MSM  The duration of protection is at least 10 years  No need to worry about these diseases after vaccination (psychological benefits) The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 72 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Reduce perceived barriers Messages:  Reduced cost: participants received 10% discount to purchase the vaccine  Reassure that it is worthy: ~$1 per day for 10-year protection  Demonstrate the procedures of taking up HPV vaccination to emphasize clinics providing HPV vaccination are gay-friendly.  Making appointment is easy, and the environment is comfortable and can protect privacy. 73 Provide cue to action Peer provided suggestion to take up HPV vaccination Reminders were given to those who intended to take it up but not yet did so The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 74 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong Group discussion HBM and HPV vaccination among female university students Give examples of the six HBM constructs that are potential factors of HPV vaccination in this context: - Perceived susceptibility - Perceived severity - Perceived benefits - Perceived barriers - Cue to action - Self-efficacy How would you modify these theoretical constructs (intervention strategies and methods) in your health promotion? 75 Key points for today’s lecture 1. Fear appeal approach (1) Theories behind fear appeal (fear control, danger control, response efficacy, self-efficacy) (2) Able to use fear appeal approach to change health behaviors when you are given a real case 2. The Health Belief Model (1) Constructs of the HBM (definition and how to measure) (2) Strategies for behavioral change based on the HBM (3) Able to use the HBM to change health behaviors when you are given a real case The contents of this class are protected by copyright under international conventions and the reproduction, distribution, republication, and/or re-transmission of the contents of this lesson are prohibited without the prior written 76 consent of The Jockey Club School of Public Health and Primary Care of The Chinese University of Hong Kong The group project Aim: To apply the behavioural change theories learnt in class to design a health promotion intervention to change a health behavior Focus: In simplicity, design of a health promotion needs: 1. Needs assessment (e.g. why important, what has been done, what are the risk factors) 2. Define the behavioural objective(s) 3. Formulation of the intervention strategies 4. Design the program and evaluation The project focuses on 2 and 3; 1 and 4 can be brief. Grouping and tutorial Randomly assign students from a same major to one group (7-8 group members) Basic materials will be given to each group, further search are expected. Example of topics: reduce screen time, vaccination, breast feeding, physical activity Tutorials 1. Understanding the topic and requirements and knowing the tutor 2. Draft of the report form 3. Finalizing work and prepare for the presentation Evaluation 1. Filling out a report form (to be supplied) 2. Presentation Evaluation based on: Understanding the problem well Good application of theories Strategies are feasible and potentially effective Good process: rated by tutors Peer evaluation (5 marks)  Thank you [email protected]