Study Chapters: IHPSYCH EXAM PDF

k PART III LIFESTYLES TO ENHANCE HEALTH AND PREVENT ILLNESS 6 HEALTH-RELATED BEHAVIOR AND HEALTH PROMOTION Healt...

k PART III LIFESTYLES TO ENHANCE HEALTH AND PREVENT ILLNESS 6 HEALTH-RELATED BEHAVIOR AND HEALTH PROMOTION Health and Behavior PROLOGUE Lifestyles, Risk Factors, and Health k Interdisciplinary Perspectives “It’s getting worse—those health nuts are all over the k on Preventing Illness place these days, telling me how to live my life,” said Problems in Promoting Wellness Joshua between puffs on his cigarette. Things were not necessarily “worse,” but they had changed. People were What Determines People’s Health-Related now much more health conscious. They were exercising Behavior? more, eating more healthful diets, and using better General Factors in Health-Related Behavior hygiene. Does this story describe the contemporary scene The Role of Beliefs and Intentions in a technologically advanced country? It could, but it The Role of Less Rational Processes could also describe the mid-1800s in America. People of today are not the first to be interested in health and Developmental, Gender, and Sociocultural fitness. Factors in Health In the 1800s, disease was widespread, epidemics Development and Health were common, and physicians had few effective methods Gender and Health for preventing or treating illness. As a result, health Sociocultural Factors and Health reformers advocated that people change their lifestyles to Programs for Health protect their health (Collins, 1987; Leventhal, Prohaska, & Hirschman, 1985). These reformers were often imbued Promotion with patriotic or religious zeal. Some of them advocated Methods for Promoting Health vegetarian diets. Others proposed that people chew their Promoting Health in Schools and Religious food to a watery consistency, or stop smoking cigarettes Organizations and drinking, or get more exercise if they led sedentary Worksite and Community-Based lives. Often people who exercised wore loose-fitting gym Wellness Programs suits and used a variety of apparatuses, such as rowing Electronic Interventions machines. It was a lot like today, wasn’t it? for Health Promotion This part of the book contains three chapters con- Prevention with Specific Targets: cerned with behaviors that can enhance or compromise Focusing on AIDS health. In the present chapter, we’ll start with the health 135 k  k 136 Part III / Lifestyles to Enhance Health and Prevent Illness habits people practice and how their lifestyles affect their stroke), resulted mainly from modifications people health. Then we turn to factors that influence the health- made in behavioral risk factors and improved medical related behaviors individuals adopt and programs to treatment (Ford & Capewell, 2011). In virtually all help people lead more healthful lives. As we study these developed nations, the first and second leading killers topics, you will find answers to questions you may have are cardiovascular diseases and cancer (WHO, 2014). about health-related behavior and health promotion. Of course, we can’t live forever, but we can extend our Are people leading more healthful lives today than they lives and be healthier in old age by making several did in the past? Why is it that some people take bet- lifestyle changes (Manton, 2008; Yates et al., 2008). If we ter care of themselves than others do? How effective are made all these changes and researchers found cures for health-promotion programs that try to motivate healthful most major diseases, people’s average life expectancy behavior through fear? in technologically advanced countries would rise several years to about 85 years, its likely upper limit (Olshansky, Carnes, & Cassel, 1990). HEALTH AND BEHAVIOR The role of behavior in health has been receiving LIFESTYLES, RISK FACTORS, AND HEALTH increased attention in countries around the world The typical person’s lifestyle includes many behaviors because people’s health habits—that is, their usual health- that are risk factors for illness and injury. For instance, related behaviors—influence their likelihood of devel- millions of Americans smoke cigarettes, drink exces- oping chronic and fatal diseases, such as heart disease, sively, use drugs, eat high-fat and high-cholesterol diets, cancer, and AIDS (WHO, 2014). Illness and early death eat too much and become overweight, have too little could be substantially reduced if people would adopt physical activity, and behave in unsafe ways, such as by lifestyles that promote wellness, such as eating healthful not using seat belts in automobiles. Many people realize foods and not smoking. these dangers and adjust their behavior to protect their The percentage of deaths resulting from any specific health. Adults with healthful lifestyles that include k cause changes over time. Figure 6-1 depicts the pattern exercising, eating diets with fruits and vegetables, not k of changes in the United States that have occurred smoking, and not drinking too much, can expect to since the late 1960s. These changes, such as in live 12 years longer than they would otherwise (Kvaavik deaths from cardiovascular disease (heart disease and et al., 2010). Each of these four behaviors raises the Late 1960s Today 38.59 Heart disease 23.53 Heart disease 16.50 Malignancies (cancer) 22.52 Malignancies (cancer) 10.95 Stroke 5.75 Chronic lower respiratory disease (e.g., emphysema) Major causes of death 5.95 Accidents 5.03 Accidents 3.81 Pneumonia and influenza 4.97 Stroke 2.27 Early infancy diseases 3.26 Alzheimer's disease 1.99 Diabetes 2.91 Diabetes 1.74 Arteriosclerosis 2.19 Influenza and pneumonia 1.72 COPD (lung diseases, e.g., emphysema) 1.81 Kidney disease 1.51 Liver disease (e.g., cirrhosis) 1.58 Suicide 0 10 20 30 40 0 10 20 30 40 Percentage of all deaths Figure 6-1 Percentage of all deaths caused by each of the ten leading causes of death in the United States in the late 1960s (1968) and today. Notice that the percentage of deaths from cancer and COPD (now called chronic lower respiratory disease) increased greatly since 1968 (partly due to cigarette smoking); at the same time, heart disease and stroke deaths declined, and deaths from some diseases declined markedly and are no longer in the top ten. (Data from USBC, 1971, Table 77; NCHS, 2015, Table 20.) k  k Chapter 6 / Health-Related Behavior and Health Promotion 137 Table 6.1 Likelihood of 70-Year-Old Men with Certain Risk checkups, and getting vaccinations against diseases. But Factors Living to Age 90 when people are well, they may not feel inclined to Risk Factors Present at Age 70 Percent Living to 90 devote the effort and sacrifice that healthful behavior None of the five risk factors examined 54 entails. Thus, engaging in healthful behavior depends Having a sedentary lifestyle 44 on motivational factors, particularly with regard to Having high blood pressure 42 the individual’s perception of a threat of disease, the Being obese 32 value in the behavior in reducing this threat, and Having diabetes 28 the attractiveness of the opposite behavior. Some Smoking 25 unhealthful behaviors, such as drinking or smoking, are Three of the five risk factors 14 All five of the risk factors 4 often seen as pleasurable or the “in” thing to do. As a result, many individuals do not resist beginning an Source: Data from Yates et al., 2008. unhealthful behavior and may reject efforts or advice to get them to quit. likelihood of a longer life. Table 6.1 shows that the Symptom-based behavior is any activity people who chances of individuals in their 70s surviving to 90 years are ill undertake to determine the problem and find of age decrease substantially with each additional risk a remedy. These activities usually include complaining factor they have. about symptoms, such as stomach pains, and seeking help or advice from relatives, friends, and medical practitioners. Some people are more likely than others Health Behavior to engage in symptom-based behavior when symptoms Health behavior is any activity people perform to appear, and there are many reasons for these differences. maintain or improve their health, regardless of their For instance, some individuals may be more afraid than perceived health status or whether the behavior actually others of physicians, hospitals, or the serious illness achieves that goal. Researchers have noted that people’s a diagnosis may reveal. Some people are stoic or health status influences the type of health behavior they unconcerned about the aches and pains they experience, perform and their motivation to do it (Kasl & Cobb, 1966a, and others do not seek medical care because they simply k k 1966b; Parsons 1951). To illustrate these differences, we do not have the money to pay for it. Chapter 9 will will consider examples of behaviors people perform when examine these and other reasons why people do and do they are well, experience symptoms, and are clearly sick. not use health care services. Well behavior is any activity people undertake to Sick-role behavior refers to any activity people under- maintain or improve current good health and avoid take to treat or adjust to a health problem after deciding illness. These activities can include healthy people’s that they are ill and what the illness is. This behav- exercising, eating healthful diets, having regular dental ior is based on the idea that sick people take on a Hero Images/Getty Images People engage in health behaviors, such as using exercise bikes, to main- tain or improve their health and avoid illness. k  k 138 Part III / Lifestyles to Enhance Health and Prevent Illness special “role,” making them exempt from their normal Practicing Health Behaviors obligations and life tasks, such as going to work or school. You’d be showing sick-role behaviors if you got What health behaviors do people actually perform? In a prescription filled, used it as the physician directed, the United States, national surveys of men and women stayed home from work to recover, and had someone for a limited set of health-related behaviors revealed else do your household chores. Although this status the results given in Table 6.2. Although these data ordinarily obligates patients to try to get well, many do show important shortcomings in the health practices of not follow their recommended treatment, particularly if American adults, some of these levels of health-related it is inconvenient or uncomfortable to do. Sometimes behaviors are improvements over the levels assessed in sick-role behaviors seem to serve emotional functions, earlier surveys (McGinnis & Lee, 1995). as when patients moan or sigh and receive sympathy Who practices healthful behavior and why? We are as a result. far from a complete answer to this question, but there are How people behave when they are sick depends gender, sociocultural, and age differences in practicing in large measure on what they have learned. As an health behaviors (Schoenborn, 1993; NCHS, 2015). For example, a study found that children with the painful instance, an international survey of adults in European condition of irritable bowel syndrome are more likely countries found that women perform more healthful than other children with the same illness to stay home behaviors than men (Steptoe et al., 1994). One reason for from school if their parents also have that illness; display such differences is that people seem to perform behaviors sick-role behavior, such as staying home from work, when that are salient to them. For example, a study compared they are sick; and provide high amounts of attention the health behaviors of medical and nonmedical students and privileges when the children complain of symptoms and found that the medical students exercised more and (Levy, 2011). Learning processes like these probably play were much less likely to smoke cigarettes, drink alcohol a role in two research findings on cultural differences in excessively, and use drugs (Golding & Cornish, 1987). illness behavior. First, people in different cultures differ You probably know some individuals who are highly in the way they respond to symptoms and go about trying health-conscious and others who display little concern to get well (Korol & Craig, 2001). Second, immigrants in about their health. To some extent individuals who k the United States who come from different cultures differ practice certain behaviors that benefit their health k in their willingness to tolerate pain, but these differences also practice other healthful behaviors and continue diminish in succeeding generations (Chapman & Brena, to perform these behaviors over time (Schoenborn, 1985). (Go to.) 1993). But other people show little consistency in HIGHLIGHT Which Health Behaviors Are Beneficial against Breast Cancer? Breast cancer is a leading cause of against the breast tissue and moves them in a systematic women’s deaths around the world and is the second pattern until she examines the entire breast. The same most frequent type of cancer diagnosed among women basic method is used in professional breast examination. in the United States (ACS, 2015). Until the early 2000s, Are all three of these health behaviors effective in many experts thought three health behaviors were effec- detecting breast cancer early and reducing mortality? No. tive in detecting early breast cancer, which has a very high Reviews of many large-scale trials have found that only cure rate, and reducing mortality. One of these behaviors mammograms are effective in detecting cancer early and involves getting a mammogram, a radiological examina- reducing mortality; little or no support was found for the tion of the breasts. The two other behaviors apply manual effectiveness of breast self-examination and professional examinations, using the fingers to search for abnormal breast examination (Gregory & Sawaya, 2010; Nelson lumps; this approach can be done by the woman herself et al., 2009). As a result, the American Cancer Society no or by a professional. For breast self-examination, the longer recommends the manual examination methods woman lies on her back and uses the middle three and encourages “all women 40 and older to receive fingertips of her opposite-side hand to press flatly regular mammograms” (ACS, 2015, p. 10). k  k Chapter 6 / Health-Related Behavior and Health Promotion 139 Table 6.2 Percentages of American Adults with Selected Health-Related Behaviors or Characteristics Behavior/Characteristics Men (%) Women (%) Eat breakfast almost every daya 54.6 58.0 Rarely snacka 25.6 25.4 Smoke at least some daysb 20.8 16.1 Drink alcohol at least infrequentlyc 68.2 58.3 Had 5 or more drinks on at least 12 days past yearb 14.7 4.1 Met leisure-time aerobic exercise guidelinesb,d 54.3 46.2 Overweight or obese (measured directly)b 72.9 64.6 Sources: Data from a USBC (1995, Table 215), b NCHS (2015, Tables 54, 58, 63, and 64), c NCHS (2014, Table 24). d Aerobic exercise guidelines: “at least 150 minutes (2 hours and 30 minutes) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity” (NCHS, 2015, Table 63). their health habits (Kaczynski et al., 2008; Mechanic, treatment. Efforts to prevent illness can be of three types, 1979). Research results suggest three conclusions. First, which we’ll illustrate with tooth decay as an example: although people’s health habits are fairly stable, they Behavioral influence. In this approach, we might promote often change over time. Second, particular health tooth brushing and flossing by providing information behaviors are not strongly tied to each other—that is, and demonstrating the techniques. if we know a person practices one specific health habit, Environmental measures. Public health officials might such as using seat belts, we cannot accurately predict support fluoridating water supplies. that he or she practices another specific habit, such as Preventive medical efforts. Dental professionals can remove exercising. Third, health behaviors do not seem to be calculus from teeth and repair cavities. governed in each person by a single set of attitudes k or response tendencies. Thus, a girl who uses seat Behavioral influence approaches have a great impact k belts to protect herself from injury may watch her on health promotion for a variety of diseases, such as weight to be attractive and not smoke because she is cardiovascular disease and cancer, and behaviors, such allergic to it. as in reducing cigarette smoking and unhealthful dietary Why are health behaviors not more stable and practices (Fisher et al., 2011). strongly linked to each other? Here are a few reasons We usually think of prevention as occurring before (Leventhal, Prohaska, & Hirschman, 1985). First, various an illness takes hold. Actually, there are three levels of factors at any given time in people’s lives may differen- prevention, only one of which applies before a disease tially affect different behaviors. For instance, a person or injury occurs (Bowen & Boehmer, 2010; Patterson, may have lots of social encouragement to eat too much Scherger, & Smith, 2010). These levels are called primary, (“You don’t like my cooking?”), and, at the same time, secondary, and tertiary prevention. Each level of prevention to limit drinking and smoking. Second, people change can include the efforts of: oneself (in our well, symptom- as a result of experience. For example, many people did based, and sick-role behaviors), one’s social network, not avoid smoking until they learned that it is harmful. and health professionals. Third, people’s life circumstances change. Thus, factors, such as peer pressure, that may have been important in Primary Prevention initiating and maintaining exercising or smoking at one Primary prevention consists of actions taken to avoid time may no longer be present, thereby increasing the disease or injury. In avoiding automobile injuries, for likelihood that the habit will change. example, primary prevention activities might include our well behavior of using seat belts, a friend reminding us to use them, and public health reminders on TV to buckle INTERDISCIPLINARY PERSPECTIVES up. Primary prevention can be directed at almost any health behavior, including dietary practices, exercise, ON PREVENTING ILLNESS tooth brushing and flossing, and immunity against a The advances in health that have occurred over the years contagious disease. have come about through two avenues: efforts to prevent Primary prevention for an individual can begin before illness and improvements in medical diagnosis and he or she is born, or even conceived. For example, genetic k 140 Part III / Lifestyles to Enhance Health and Prevent Illness counselors can estimate the risk of a child’s inheriting a specific tests, each with recommended schedules rang- genetic disorder and, in some cases, to diagnose genetic ing from 1 to 10 years, depending on the person’s age abnormalities in the unborn fetus (AMA, 2003). These (CU, 1998). For instance, the American Cancer Society estimates are based on the parents’ family histories, recommends regular schedules after specific ages for all biological tests for carriers of specific genes, and women to have mammograms (breast X-ray) and for all biological tests on the fetus. Prospective and expectant adults to have colon inspections, such as a colonoscopy parents may use this information to help them make (ACS, 2015). The schedules depend on risk. Individuals important family planning decisions. Another primary who are not healthy or are considered to be at high risk— prevention act parents can exercise is having their for example, because of age, past illnesses, family his- children immunized against several diseases, including tory, or hazardous work conditions—should be examined diphtheria, tetanus, whooping cough, measles, rubella, more often than other people. mumps, and polio. Although worldwide immunization These medical examinations are recommended rates have increased in recent decades, they remain because they detect the disease earlier and save lives. lower in poorer than richer societies (WHO, 2014). In In the case of mammograms, women who follow the the United States, the percentage of preschool children recommended schedules after age 50 reduce their breast with full immunization from controllable diseases is cancer mortality by 26% in follow-ups of 10 years or about 70% overall, but is somewhat lower among African so after diagnosis (Kerlikowske et al., 1995). A national Americans (NCHS, 2015). survey found that two-thirds of American women over How else can medical professionals promote pri- 40 years of age had had a mammogram in the prior mary prevention? One way is to have patients complete 2 years, but the rate was much lower for poor and less a survey of health risks and receive advice for changing educated women (NCHS, 2015). Explicitly describing to behaviors they are ready to change (Phillips et al., 2014). a woman her relatively high risk of breast cancer due to If physicians have difficulty incorporating prevention her family history of the disease increases the likelihood advice in their practices, nurses or other medical staff that she will increase her frequency of mammograms might be able to do it (Glasgow et al., 2001; Radecki & (Curry et al., 1993). Fear, embarrassment, and fatalistic Brunton, 1992). A system of reminders to provide such thinking (such as, “It’s in God’s hands anyway”) are advice with individual patients can improve these activi- common reasons middle-age and elderly women give for ties (Anderson, Janes, & Jenkins, 1998). Another approach not having mammograms (Flynn, Betancourt, & Ormseth, involves constructing websites that give health promo- 2011; Fullerton et al., 1996). tion information (for example, http://www.hc-sc.gc.ca.). Tertiary Prevention Secondary Prevention When a serious injury occurs or a disease progresses In secondary prevention, actions are taken to identify beyond the early stages, the condition often leads and treat an illness or injury early with the aim of to lasting or irreversible damage. Tertiary prevention stopping or reversing the problem. In the case of involves actions to contain or retard this damage, someone who has developed an ulcer, for example, prevent disability or recurrence, and rehabilitate the secondary prevention activities include the person’s patient. For people with severe arthritis, for instance, symptom-based behavior of seeking medical care for tertiary prevention includes doing exercises for physical abdominal pain, the physician’s prescribing medication therapy and taking medication to control inflammation and dietary changes, and the patient’s sick-role behavior and pain. In the treatment of incurable forms of cancer, of following the doctor’s prescriptions. For other health the goal may be simply to keep the patient reasonably problems, instances of secondary prevention might comfortable and the disease in remission as long as include examination of the mouth and jaw regions possible. And people who suffer disabling injuries may for early cancer detection during dental visits, free undergo intensive long-term physical therapy to regain blood pressure measurements at shopping malls, and the use of their limbs or develop other means for assessments of children’s vision and hearing at school. independent functioning. A common secondary prevention practice is the com- plete physical examination, often done each year. These PROBLEMS IN PROMOTING WELLNESS checkups are costly in time and money because they include several imaging (such as X-ray) and laboratory The process of preventing illness and injury can be tests. Because not all of these tests have proven useful thought of as operating as a system, in which the indi- in prevention, medical experts now recommend getting vidual, his or her family, health professionals, and the  k Chapter 6 / Health-Related Behavior and Health Promotion 141 community play a role. According to health psycholo- gist Craig Ewart (1991), many interrelated factors and problems can impair the influence of each component in the system, and each component affects each other. Let’s look at some of these factors, beginning with those Courtesy of Randy Glasbergen within the individual. Factors within the Individual People who consider ways to promote their own health often face an uphill battle with themselves. One problem is that many people perceive some healthful behaviors as less appealing or convenient than their unhealthful alternatives. Some people deal with this situation by maintaining a balance in their lives, setting reasonable limits on the unhealthful behaviors they perform. But Suppose, for instance, that a member of a family other people do not, opting too frequently in favor of wants to consume less cholesterol, but no one else pleasure, sometimes vowing to change in the future: “I’ll is willing to stop eating high-cholesterol foods, such as go on a diet next week,” for example. They see little butter, eggs, and red meats. Or suppose the person incentive to change immediately, especially if they think has begun exercising three times a week, but this they are healthy. Even when individuals know they have disrupts the daily routine of another family member. The health problems, many drop out of treatment or fail to interpersonal conflicts that circumstances like these can follow some of the recommendations of their physician. create in the family may undermine preventive efforts Four other factors within the individual are also that the majority of family members support. Similar important. First, adopting wellness lifestyles may require interpersonal conflicts can undermine prevention efforts individuals to change longstanding behaviors that have among friends, classmates at school or college, and k become habitual and may involve addictions, as in fellow employees at work. k cigarette smoking. Habitual and addictive behaviors are very difficult to modify. Second, people need to Factors in the Community have certain cognitive resources, such as the knowledge and skills, to know what health behaviors to adopt, People are more likely to adopt healthful behaviors to make plans for changing existing behavior, and to if these behaviors are promoted or encouraged by overcome obstacles to change, such as having little time community organizations, such as governmental agen- or no place to exercise. Third, individuals need sufficient cies and the health care system. Health professionals self-efficacy regarding their ability to carry out the change. don’t usually have accurate information regarding their Without self-efficacy, their motivation to change will be patients’ health-related behavior, and they have tradi- impaired. Last, being sick or taking certain drugs can tionally focused their attention on treating, rather than affect people’s moods and energy levels, which may preventing, illness and injury. But this focus began to affect their cognitive resources and motivation. change some years ago, and physicians became more interested in prevention (Radecki & Brunton, 1992). The larger community faces an enormous array of Interpersonal Factors problems in trying to prevent illness and injury. These Many social factors influence people’s likelihood to problems include having insufficient funds for public adopt health-related behaviors. For instance, one part- health projects and research, needing to adjust to and ner’s exercising or eating unhealthfully before marriage communicate with individuals of very different ages and can lead his or her partner to adopt the same behavior sociocultural backgrounds, and providing health care over time (Homish & Leonard, 2008). The social influence for those who need it most. In some communities, probably involves individuals giving social support and a lack of safe and convenient places to exercise and encouragement for the other person to change his or her a high number of fast food restaurants can impair lifestyle. health promotion. Also, people’s health insurance may People living in a family system may encounter not cover preventive medical services. Among the most problems in their efforts to promote wellness. Some difficult problems communities face is trying to balance problems come about because the family is composed public health and economic priorities. For example, of individuals with their own motivations and habits. suppose the surrounding community of an industry is k  k 142 Part III / Lifestyles to Enhance Health and Prevent Illness subjected to potentially unhealthful conditions, such as headache, you take aspirin, and the headache goes away. toxic substances. But the community depends heavily on In this case, your headache was unpleasant and your that industry for jobs and tax revenue, and the cost of behavior of taking aspirin removed it from the situation. reducing the potential for harm would force the company The headache is called a “negative” reinforcer because it out of business. What should the community do? was taken away (subtracted) from the situation. In both Many such dilemmas exist in most societies throughout cases of reinforcement, the end result is a desirable state the world. of affairs from the person’s point of view. 2. Extinction. If the consequences that maintain a behavior are eliminated, the response tendency gradually WHAT DETERMINES PEOPLE’S weakens. The process or procedure of extinction exists HEALTH-RELATED BEHAVIOR? only if no alternative maintaining stimuli (reinforcers) for the behavior have supplemented or taken the place If people were all like Mr. Spock of the Star Trek TV of the original consequences. In the above example of show and movies, the answer to the question of what toothbrushing behavior, if the money is no longer given, determines people’s health-related behavior would be the child may continue brushing if another reinforcer simple: facts and logic, for the most part. These people exists, such as praise from her parents or her own would have no conflicting motivations in adopting satisfaction with the appearance of her teeth. wellness lifestyles to become as healthy as they can 3. Punishment. When we do something that brings be. In this section we examine the complex factors that an unwanted consequence, the behavior tends to be affect health-related behavior. suppressed. A child who gets a scolding from his parents for playing with matches is less likely to repeat that behavior, especially if his parents might see him. The GENERAL FACTORS IN HEALTH-RELATED influence of punishment on future behavior depends on BEHAVIOR whether the person expects the behavior will lead to The “average” person can describe healthful behaviors punishment again. Take, for example, people who injure k and generate a fairly complete list: “Don’t smoke,” “Don’t themselves (punishment) jogging—those who think they k drink too much, and don’t drive if you do,” “Eat balanced could be injured again are less likely to resume jogging meals, and don’t overeat,” “Get regular exercise,” and than those who do not. so on. But practicing these acts is another matter. People can also learn by observing the behavior Several processes affect people’s health habits, and one of others—a process called modeling (Bandura, 1969, factor is heredity. Genetic factors influence some health- 1986). In this kind of learning, the consequences the related behaviors—excessive alcohol use provides a model receives affect the behavior of the observer. If good example. As we’ll see in Chapter 7, twin studies a teenager sees people enjoying and receiving social and adoption studies have confirmed that heredity plays attention for smoking cigarettes, these people serve as a role in the development of alcoholism. models and increase the likelihood that the teenager will begin smoking, too. But if models receive punishment Learning for smoking, such as being criticized by classmates at People also learn health-related behavior, particularly school, the teenager may be less likely to smoke. In by way of operant conditioning, whereby behavior changes general, people are more likely to perform the behavior because of its consequences (Sarafino, 2012). Three types they observe if the model is similar to themselves—that of consequences are important. is, of the same sex, age, or race—and is a high-status person, such as a physically attractive individual, movie 1. Reinforcement. When we do something that star, or well-known athlete. Advertisers of products such brings a pleasant, wanted, or satisfying consequence, as alcoholic beverages know these facts and use them in the tendency to repeat that behavior is increased or their commercials. reinforced. A child who receives something she wants, If a behavior becomes firmly established, it tends such as a nickel, for brushing her teeth at bedtime to be habitual, that is, the person often performs it is more likely to brush again the following night. The automatically and without awareness, such as when a nickel in this example is a positive reinforcer because smoker catches a glimpse of a pack of cigarettes and it was added to the situation (the word “positive” refers absentmindedly reaches, takes a cigarette from the pack, to the arithmetic term for addition). But reinforcement and lights up (Orbell & Verplanken, 2010). Even though can also occur in another way. Suppose you have a the behavior may have been learned because it was k  k Chapter 6 / Health-Related Behavior and Health Promotion 143 reinforced by positive consequences, it is now less those who are very distressed about cancer are especially dependent on consequences and more dependent on unlikely to have a mammogram (Schwartz et al., 1999). antecedent cues (seeing a pack of cigarettes) with which A brief cognitive intervention to enhance coping skills it has been linked in the past (Sarafino, 2012). Antecedents can reduce cancer distress among women who have a are internal or external stimuli that precede and set the close relative with cancer and substantially improve their occasion for a behavior. A smoker who says, “I must have preventive behavior (Audrain et al., 1999). Second, we a cigarette with my coffee after breakfast,” is pointing out saw in Chapter 4 that people who experience high levels an antecedent. Behaviors that become habitual can be of stress engage in less exercise and consume poorer very difficult to change. diets and more alcohol and cigarettes than those who Because habitual behaviors are hard to change, experience less stress. If you ask people why they smoke, people need to develop well behaviors as early as for example, they often will say, “To relieve tension.” possible and eliminate unhealthful activities as soon Many people cite coping with stress as an important as they appear. Families play a major role in children’s reason for continuing to smoke (Gottlieb, 1983). learning of health-related behaviors (Wilson, St. George, & Zarrett, 2010). Children observe, for example, the Perception and Cognition dietary, exercise, and smoking habits of other family members and may be encouraged to behave in similar The symptoms people experience can influence their ways. Children who observe and receive encouragement health-related behaviors. The way they react varies from for healthful behavior at home are more likely than others ignoring the problem to seeking immediate professional to develop good health habits. care. Surely when the perceived symptoms are severe—as with excruciating pain, obvious bone fractures, profuse bleeding, or very high fever—almost everyone who has Social, Personality, and Emotional Factors access to a health care system will try to use it. When Many health-related behaviors are affected by social symptoms are not so severe, people often adjust their factors (Wilson, St. George, & Zarrett, 2010; Thirlaway & health habits, such as by limiting certain foods and drink, Upton, 2009). Friends and family can encourage or to meet the needs of the health problem as they see it k discourage children’s practice of health-related behav- (Harris & Guten, 1979). k iors, such as smoking and exercising, by providing Cognitive factors play an important role in the health consequences, such as praise or complaints, for a behaviors people perform. As we saw earlier, people behavior; modeling it; and conveying a value for good must have correct knowledge about the health issue health. These social processes may also lead to gender and the ability to solve problems that arise when trying differences in health behavior, such as the greater to implement healthful behavior, such as how to fit physical activity of American boys than girls. Very an exercise routine into their schedules. People also different patterns of encouragement may lead boys more make many judgments that have an impact on their than girls toward healthful physical activity. health. They assess the general condition of their health, Two other factors that are linked to health-related such as whether it is good or bad, and make decisions behavior are the person’s personality and emotional about changing a health-related behavior: If I begin an state, particularly stress. Conscientiousness—the tendency exercise program, will I stick to it? But the judgments of a person to be dutiful, planful, organized, and they make can be based on misconceptions, as when industrious—is a personality characteristic that is hypertensive patients overestimate their ability to sense associated with practicing many health behaviors, as when their blood pressure is high (Brondolo et al., 1999; Table 6.3 describes. And the role of emotions can be seen Pennebaker & Watson, 1988). Hypertensive patients often in two ways. First, among women who have a close rela- report that they can tell when their blood pressure tive with breast cancer and are low in conscientiousness, is up, citing symptoms—headache, warmth or flushing Table 6.3 Associations of Conscientiousness with Health-Related Behaviors or Characteristics Higher Conscientiousness Is Linked to Higher Higher Conscientiousness Is Linked to Lower Fitness levela Alcohol usea Healthy food selectiona Drug usea Mammogram testingb Risky drivinga Medication taking, as prescribedc Risky sexa Self-reported healthd Tobacco usea, d Sources: Based on a Bogg & Roberts, 2004, 2013; b Siegler, Feaganes, & Rimer, 1995; c Christensen & Smith, 1995; d Hampson et al., 2006. k  k 144 Part III / Lifestyles to Enhance Health and Prevent Illness face, dizziness, and nervousness—that are actually poor Studies of optimistic and pessimistic beliefs are estimators of blood pressure. People’s assessments of important for three reasons. First, they have revealed their blood pressure often correlate with their symptoms that feelings of invulnerability occur at all ages, not just and moods, but not with their actual blood pressure. adolescence (Renner & Schupp, 2011). Second, people The potential harm in their erroneous beliefs is that who practice health behaviors tend to feel they would patients often alter their medication-taking behavior or otherwise be at risk for associated health problems drop out of treatment on the basis of their subjective (Becker & Rosenstock, 1984). This means that people assessments of their blood pressure. Clearly, beliefs are with unrealistically optimistic beliefs about their health important determinants of health behavior. are unlikely to take preventive action. Third, health Another important belief that can impair health professionals may be able to implement programs to behavior is called unrealistic optimism. Neil Weinstein address these beliefs in helping people see their risks (1982) studied how optimistically people view their future more realistically. The next section examines the role of health by asking them, “Compared to other people your people’s health beliefs in more detail. age and sex, are your chances of getting lung cancer greater than, less than, or about the same as theirs?” He then had students fill out a questionnaire with a THE ROLE OF BELIEFS AND INTENTIONS long list of health problems, rating each problem for Suppose your friend believes in reflexology, a “healing” their own likelihood of developing it, relative to other method that involves massaging specific areas of the students of the same sex at the university. The results feet to treat illnesses. The belief underlying this method revealed that the students believed they were less likely is that each area of the foot connects to a specific area of than others to develop three-quarters of the health the body—the toes connect to the head, for instance, and problems listed, including alcoholism, diabetes, heart the middle of the arch links to certain endocrine glands attack, lung cancer, and venereal disease. They believed (Wikipedia, 2015). For a patient with recurrent headaches, they were more susceptible than other students to only a reflexologist’s treatment might include massaging the one of the health problems—ulcers. In a later study, toes. Your friend would probably try ways to prevent k Weinstein (1987) used similar questions in a mailed and treat illness that are different from those most k survey with 18- to 65-year-old adults in the general other people would try. Psychologists are interested in population. He found that these people were just as the role of health beliefs in people’s practice of health unrealistically optimistic as the students and that this behaviors. An early and extensively researched theory of optimism is based on illogical ideas—for instance, that why people do and do not practice these behaviors is they are at lower risk than other people if the health called the health belief model (Becker, 1979; Becker & problem occurs rarely and has not happened to them Rosenstock, 1984; Rosenstock, 1966). Let’s see what this yet. These factors do not affect one’s risk relative to that theory proposes. of others. Do people remain optimistic about their health The Health Belief Model when they are sick or when a threat of illness is clear? Evidently not. Using a procedure similar to According to the health belief model, the likelihood that Weinstein’s, a study found that university students who a person will take preventive action—that is, perform some were waiting for treatment at the student health center health behavior—depends directly on the outcome of were less optimistic about their future health than were two assessments he or she makes. Figure 6-2 shows that healthy students in a psychology course (Kulik & Mahler, one assessment pertains to the threat the person feels 1987b). Another study was conducted with students in regarding a health problem, and the other weighs the Poland, just after the radioactive cloud reached their pros and cons of taking the action. community from the explosion of the atomic power plant Three factors influence people’s perceived threat—that at Chernobyl in the Soviet Union (Dolinski, Gromski, & is, the degree to which they feel threatened or worried by Zawisza, 1987). Although these people believed they were the prospect of a particular health problem: less likely than others to have a heart attack or be injured 1. Perceived seriousness of the health problem. People con- in an accident, they believed they were equally likely sider how severe the organic and social consequences to develop cancer and more likely than others to suffer are likely to be if they develop the problem or leave it illness effects of the radiation over the next several years. untreated. The more serious they believe its effects will Thus, in the face of a real threat, they showed “unrealistic be, the more likely they are to perceive it as a threat and pessimism” regarding their health. take preventive action. k  k Chapter 6 / Health-Related Behavior and Health Promotion 145 Perceived threat of an illness or injury without the associated health behavior, based on: Perceived seriousness of the health problem Perceived susceptibility of the health problem Cues to action (reminders of the problem) Figure 6-2 The health belief model. People’s like- lihood of taking preventive action is determined by Likelihood of performing two assessments they make: their perceived threat the health behavior of the health problem and the sum of pros and cons they perceive in taking action. Many factors con- Perceived benefits and barriers (pros and cons) of a health behavior (sum = benefits – barriers) tribute to these assessments. (Based on material in Becker & Rosenstock, 1984.) 2. Perceived susceptibility to the health problem. People barriers, and threat. These factors include the person’s evaluate the likelihood of their developing the problem. age, sex, race, ethnic background, social class, person- The more risk they perceive for themselves, the more ality traits, and knowledge about or prior contact with likely they are to perceive it as a threat and take action. the health problem. Thus, for example, people who are 3. Cues to action. Being reminded or alerted about a poor are likely to see strong barriers to getting medical potential health problem increases the likelihood of treatment. Women, but not men, over 50 are likely to perceiving a threat and taking action. Cues to action can perceive a substantial risk of breast cancer. And elderly take many forms, such as a billboard about the dangers individuals whose close friends have developed severe of unprotected sex, a friend or relative developing an cases of cancer or heart disease are more likely to per- illness, an episode about a specific illness and its ceive a personal threat of these illnesses than young symptoms on a TV medical drama, or a reminder phone adults whose friends are in good health. call for an upcoming medical appointment. Has research generally supported the health belief k model’s explanation of health-related behavior? The k Figure 6-2 shows that in weighing the pros and cons model has generated hundreds of studies, most of of performing a health behavior, people assess the which have upheld its predictions for a variety of benefits—such as being healthier or reducing health health behaviors, including getting vaccinations, having risks—and the barriers or costs they perceive in taking regular dental visits, and taking part in exercise programs action. (Becker & Rosenstock, 1984; Conner & McMillan, 2004a; What barriers might people see in preventive action? Kirscht, 1983). For instance, compared to people who For the health behavior of getting a physical checkup, do not take prescribed medication as directed or do the barriers might include financial considerations (“Can not stick with dietary programs, those who do are I afford the bills?”), psychosocial consequences (“People more likely to believe they would be susceptible to will think I’m getting old if I start having checkups”), and the associated illness without the behavior and that physical considerations (“My doctor’s office is across the benefits of protective action exceed the barriers. town, and I don’t have a car”). The outcome of weighing Perceived risk (susceptibility) and perceived barriers the benefits against the barriers is an assessed sum: appear to be critical elements for predicting health the extent to which taking the action is more beneficial behavior, such as getting vaccinations (Brewer et al., for them than not taking the action. This assessed sum 2007; Conner & McMillan, 2004a), but strong barriers combines with the perceived threat of illness or injury to may have more influence than risk. Research has also determine the likelihood of preventive action. Thus, for supported the role of cues to action—for instance, the health behavior of having a medical checkup, people individuals are more likely to engage in brisk walking who feel threatened by an illness and believe the benefits if they receive reminders (Prestwich, Perugini, & Hurling, of having a checkup outweigh the barriers are likely to 2010). go ahead with it. But people who do not feel threatened Despite the health belief model’s success, it has or assess that the barriers are too strong are unlikely to some shortcomings. One shortcoming is that there is have the checkup. According to the health belief model, no standard way of measuring its components, such these processes apply to primary, secondary, and tertiary as perceived susceptibility and seriousness. Different prevention activities. studies have used different questionnaires to measure The theory also proposes that characteristics of the same factors, thereby making it difficult to compare individuals can influence their perceptions of benefits, the results across studies. These problems do not mean k  k 146 Part III / Lifestyles to Enhance Health and Prevent Illness the theory is wrong, but that it is incomplete. We now This decision is based on her beliefs about others’ opinions turn to another theory that focuses on the role of people’s of the behavior (such as, “My family and friends think beliefs on their practice of health-related behavior. I should exercise”) and her motivation to comply with those opinions (as in, “I want to do what they want”). The Theory of Planned Behavior 3. Perceived behavioral control, or the person’s expectation of success in performing the contemplated behavior Suppose you are having dinner at a restaurant with Dan, a (which is very similar to the concept of self-efficacy). Ellie friend who is overweight, and you wonder whether he will thinks she can do the exercises and stick to the program. order dessert. How could you predict his behavior? That’s simple—you could ask what he intends to do. According The theory of planned behavior proposes that these to the theory of planned behavior (Ajzen, 1985), an judgments combine to produce an intention that leads expanded version of the theory of reasoned action (Ajzen & to performance of the behavior. If Ellie had the opposite Fishbein, 1980), people decide their intention in advance beliefs, such as, “Exercising is a waste of time,” “I don’t of most voluntary behaviors, and intentions are the best care about my family’s opinion,” and “I’ll never find time predictors of what people will do. to exercise,” she probably wouldn’t generate an intention What determines people’s intentions? The theory to exercise, and thus would not do so. Self-efficacy is indicates that three judgments determine a person’s an important component. When deciding whether to intention to perform a behavior, which we’ll illustrate practice a health behavior, people appraise their likely with a girl named Ellie who has decided to start success on the basis of beliefs about their personal exercising: competence and the effort, complexity, and potential 1. Attitude regarding the behavior, which is basically a barriers in performing the behavior (Schwarzer, 2011). judgment of whether or not the behavior is a good The theory of planned behavior has generated many thing to do. Ellie has decided that exercising “would dozens of studies, including a meta-analysis showing be a good thing for me to do.” This judgment is based that the three factors—attitudes toward a behavior, on two expectations: the likely outcome of the behavior subjective norms, and perceived behavioral control (self- (such as, “If I exercise, I will be healthier and more efficacy)—influence intentions and behavior (Conner & k attractive”) and whether the outcome would be rewarding McMillan, 2004b). Table 6.4 gives a sample of studies k (for example, “Being healthy and good looking will be on a variety of health-related behaviors that support the satisfying and pleasant”). role of these factors. Also, a meta-analysis of dozens 2. Subjective norm. This judgment reflects the impact of experiments revealed that interventions can change of social pressure or influence on the behavior’s the three factors, and these changes strongly influence acceptability or appropriateness. Ellie has decided that intentions, which, to a much lesser extent, improve the exercising “is a socially appropriate thing for me to do.” targeted health behaviors (Webb & Sheeran, 2006). Table 6.4 A Sample of Research Supporting the Theory of Planned Behavior The theory proposes that for each of three factors, the higher its level the more likely the intention will be made and the behavior will be performed. Each study referenced below found this relationship between the factor and the intention or behavior. Factor Intention/Behavior Reference Attitude regarding the behavior Donating blood Bagozzi, 1981 Starting smoking Van De Ven et al., 2007 Quitting smoking Norman, Conner, & Bell, 1999 Exercising Wurtele & Maddux, 1987 Eating healthful diet Conner, Norman, & Bell, 2002 Condom use Montanaro & Bryan, 2014 Subjective norm Starting smoking Van De Ven et al., 2007 Cancer screening Sieverding, Matterne, & Ciccarello, 2010 Exercising Latimer & Ginis, 2005 Perceived behavioral control (self-efficacy) Starting smoking Van De Ven et al., 2007 Quitting smoking DiClemente, Prochaska, & Gilbertini, 1985 Exercising Armitage, 2005 Losing weight Schifter & Ajzen, 1985 Rehabilitation exercises Jenkins & Gortner, 1998; Kaplan, Atkins, & Reinsch, 1984 Condom use Montanaro & Bryan, 2014 k  k Chapter 6 / Health-Related Behavior and Health Promotion 147 What shortcomings does the theory of planned very vague reasons, such as, “My doctor says coffee is behavior have? One problem is that intentions and bad for you.” People appear to be especially inaccurate behavior are not strongly related—people do not always in estimating the degree of increased risk when the risks do what they decide (or claim they decide) to do (Rhodes of illness, such as cancer, increase beyond moderate & Dickau, 2012). But the “gap” between intention and levels—for example, for individuals who smoke more behavior can be reduced: people are more likely to carry than 15 cigarettes a day (Sastre, Mullet, & Sorum, out their intentions if they make careful plans for doing 1999; Weinstein, 2000). Also, neither theory accounts for so, keep track of their efforts, and recognize that they health-related behaviors people perform habitually, such will need to continue the behavior on a long-term basis as tooth brushing—behaviors that probably originated and are confident they can (Allan, Sniehotta, & Johnston, and have continued without the person’s considering 2013; Schwarzer, 2011; Sniehotta, Scholz, & Schwarzer, health threats, attitudes, and costs. Habit plays a strong 2005). Keep in mind that people’s intentions to perform a role in health-related behaviors, such as alcohol use health behavior, such as using condoms for safer sex, can (Albery et al., 2015). change from one day to the next (Kiene, Tennen, & Armeli, 2008). But if individuals perform preparatory or regulatory The Stages of Change Model behaviors, such as buying condoms and making sure to carry them, after the intention is made, the chances of A wife’s letter in a newspaper advice column described actually performing the behavior (using condoms in sex) her worry about her husband, who had suffered a heart increases greatly (Bryan, Fisher, & Fisher, 2002; de Bruin attack but hadn’t tried to lose weight or exercise as his et al., 2012). doctor recommended. This situation is not uncommon. Another problem is that the theory is incomplete; Although there are probably many reasons why this it does not include, for example, the important role man hadn’t changed his behavior, one may be that he of people’s prior experience with the behavior. In the wasn’t “ready.” Readiness to change is the main focus blood donation study listed in Table 6.4, the subjects of a theory called the stages of change model (also were asked about their past behavior in donating or called the transtheoretical model because it includes factors not donating blood (Bagozzi, 1981). Of those subjects described in other theories) (DiClemente et al., 1991; k Prochaska & DiClemente, 1984; Prochaska, DiClemente, k who said they intended to give blood, those who had given before were more likely actually to give than & Norcross, 1992). Figure 6-3 defines the model’s five those who had not donated in the past. Similarly, stages of intentional behavior change and shows how they studies have found that people’s history of performing spiral toward successful change. a health-related behavior, such as exercising or using alcohol or drugs, strongly predicts their future practice Maintenance. People in this stage work to maintain the successful of that behavior (Bentler & Speckart, 1979; Godin, Valois behavioral changes they achieved. Although this stage can last et al., 1987). Thus, for example, compared to adults who indefinitely, researchers often define its length as, say, 6 months, for follow-up assessment. have engaged in little exercise in the past, those who have exercised are much more likely to carry out their Action. This stage spans a period of time, usually 6 months, from the start of people’s successful and active efforts to change a promises to exercise in the future. The more habitual behavior. the past behavior, the more likely the person is to carry Preparation. At this stage, individuals are ready to try to change out the intention to perform it (Gardner, de Bruijn, & and plan to pursue a behavioral goal, such as stopping smoking, Lally, 2011). in the next month. They may have tried to reach that goal in the past year without being fully successful. For instance, these The health belief model and the theory of planned people might have reduced their smoking by half, but did not behavior provide valid explanations for parts of the yet quit completely. process that determine people’s practice of health- Contemplation. During this stage people are aware a problem related behavior. At their core, both theories assume exists and are seriously considering changing to a healthier people weigh factors and behave according to the behavior within the next several months. But they are not yet ready to make a commitment to take action. outcome of their analysis. But neither approach is Precontemplation. People in this stage are not considering sufficient and both have limitations (Janis, 1984; Kirscht, changing, at least during the next several months or so. These 1983; Weinstein, 1988). One weakness in these theories people may have decided against changing or just never thought about it. is that they assume people think about risks in a detailed fashion, knowing what diseases are associated Figure 6-3 Five stages of change in the transtheoretical with different behaviors and estimating the likelihood model advancing as a spiral from precontemplation (bottom), of becoming seriously ill. In reality, people may modify when the person is not considering change, to maintenance, their lifestyles, such as reducing coffee consumption, for when change is complete and stable. k  k 148 Part III / Lifestyles to Enhance Health and Prevent Illness According to the stages of change model, people who help her decide to change soon. Discussing the benefits are currently in one stage show different psychosocial and barriers she perceives in exercising, finding ways to characteristics from people in other stages. For instance, overcome barriers, and showing her that she can do the people in the precontemplation stage regarding an physical activities would help. unhealthy behavior, such as eating a high-cholesterol The stages of change model is a very useful diet, are likely to have less self-efficacy and see more theory. Table 6.5 lists a sample of studies which have barriers than benefits for changing that behavior than confirmed that people at higher stages are more likely people in the more advanced stages. Efforts to change the than others to succeed at adopting healthful behaviors. behavior are not likely to succeed until these individuals Research has also confirmed three expectations. First, advance through the stages. But people’s stages may the processes the model describes, such as self-efficacy, regress, too: someone who reached the action stage and do lead to advancement or regression within the began to change may fail, drop back to a less advanced stages (Schumann et al., 2005). Second, matching an stage, and repeat the process of advancing toward intervention to people’s stage of readiness improves change. People who justify continuing an unhealthy its success in changing unhealthful behaviors, such as behavior, such as when smokers say, “I know heavy smoking (Spencer et al., 2002). Third, when people in smokers who have lived long, healthy lives,” tend to an intervention want to change two related behaviors, progress through the stages slowly (Kleinjan et al., 2006). such as exercise and healthy eating, their progress Is it possible to help people advance through the to the action stage on one behavior increases the stages? Two ways that help are having them: likelihood of progress on the other (Johnson et al., 2014). However, interventions based on the theory have been Describe in detail how they would carry out the behavior less successful with certain behaviors, such as weight change, such as the exact foods they would eat to achieve loss (Tuah et al., 2012). And some evidence suggests a low-fat diet (Armitage, 2006). that four stages with somewhat different focuses may be Plan for problems that may arise when trying to better for describing the mindsets behind and accounting implement the behavior change, such as if they crave a for people’s behavior changes (Armitage, 2009; Richert, cigarette after quitting smoking (Armitage, 2008). Schüz, & Schüz, 2013). k In the preceding sections, we have examined many k Another way uses a unique feature of the stages of change aspects of people’s beliefs and intentions that appear to model: it describes important characteristics of people at influence their health-related behavior. These aspects each stage, enabling an intervention to match strategies include people’s perceived susceptibility to illness, to the person’s current needs to promote advancement perceived barriers and benefits to changing unhealthy to the next stage (Perz, DiClemente, & Carbonari, 1996; behavior, ideas about what behaviors are socially Prochaska, DiClemente, & Norcross, 1992). Let’s consider acceptable and encouraged by family and friends, self- an example of matching. Suppose you are a nurse efficacy beliefs, and readiness to change. These factors providing care to an elderly woman with heart disease seem sensible for individuals to consider, but the who doesn’t exercise, even though her physician advised decisions they make are often irrational or unwise. The her to do so. If she is at the precontemplation stage, flawed decisions that people make about their health you might talk with her about why exercise would help often result from motivational and emotional processes her and not exercising would harm her physically, for that are not addressed in the theories—for instance, instance, and have her generate ways this would improve people’s tendency to delay getting medical care when her general functioning. The goal at this point is just they have clear symptoms, such as chest pain. As they to get the person to consider changing the behavior. If consider that they may be having a heart attack, they she is at the contemplation stage, the goal might be to think something like Table 6.5 Sample of Research Supporting the Stages of Change Model Health Behaviors Reference Quit cigarette smoking Spencer et al., 2002 Breast cancer screening Spencer, Pagell, & Adams, 2005 Vegetable and fruit consumption Lippke et al., 2009 Using safer-sex practices Bowen & Trotter, 1995 Exercising Dishman et al., 2010; Hellsten et al., 2008; Lippke et al., 2009; Marshall & Biddle, 2001 k  k Chapter 6 / Health-Related Behavior and Health Promotion 149 “it couldn’t be happening to me.” The patients’ delay risk than nonsmokers do when asked to rate their own of treatment is not attributable to unavailability of risk of developing smoking-related diseases, such as lung medical aid or transportation delays; approximately cancer (Lee, 1989; McCoy et al., 1992). Beliefs like these 75% of the delay time elapses before a patient decides appear very resistant to change (Kreuter & Strecher, 1995; to contact a physician. (Janis, 1984, pp. 331–332) Weinstein & Klein, 1995). Thus, theories that focus on rational thinking do not adequately consider the processes we’re about to see False Hope and Willingness that can override logical decision making. Here are two features of health-related behaviors the theories we’ve considered don’t account for well. First, THE ROLE OF LESS RATIONAL PROCESSES most people who lose weight gain it back within a year or so, yet they try again at a later time. Similar patterns Although body builders generally know that using occur for quitting smoking or starting to exercise. Second, anabolic steroids can harm their health, some may many risky behaviors occur spontaneously, without the try to justify using these substances to build muscles individuals having thought it through. with statements like, “Experts have been wrong before.” It’s encouraging to know that people who don’t Why do people make decisions regarding health-related maintain a healthier behavior try again, but why do they behavior that are not more rational? We’ll look first at decide to retry if they’ve failed previously and are likely motivational factors that influence people’s decisions. to fail again? The reason may be that they develop false hopes, believing without rational basis that they will Motivational Factors succeed (Polivy & Herman, 2002). They form false hopes because they did succeed for a while, which provides What do people do when they expect that new informa- reinforcement for the efforts they made to that point, and tion they can receive will obligate them to experience they misinterpret their failures. Probably most changed something they don’t like, such as performing an behaviors are not maintained because people expect too unpleasant act? Many of these people will avoid that large a change in their behavior, too great an effect it k information, perhaps saying, “I don’t want to know” would have for them, and too quick and easy a process k (Howell & Shepperd, 2013). And if they receive the of change. But they often decide instead that they just information, they can try to discount its validity or utility didn’t try hard enough for enough time—after all, they through a process called motivated reasoning (Kunda, succeeded initially. 1990). For instance, individuals who prefer to reach a What risky behaviors occur without careful thought? particular conclusion, such as to continue to eat fatty Lots, maybe most. People often find themselves in foods or smoke cigarettes, might use biased cognitive situations they didn’t expect to happen in which they processes: they search for reasons to accept supportive have the opportunity to perform an attractive behavior, information and discount disconfirming information. such as drinking a bit too much or having sex, but In these approaches, people’s desires or preferences there’s some risk. In this type of situation, the critical motivate their behavior or judgments. issue may not be whether they “intend” to engage in a Studies have demonstrated nonrational thought risky behavior, but whether they are willing to do it. High processes in several types of health-related decisions. willingness to engage in a risky behavior depends on four First, of people with a chronic illness, such as diabetes, factors (Gibbons et al., 1998). Two factors are positive those who tend to use illogical thought patterns in subjective norms and attitudes toward the behavior, health-related situations tend not to follow medical which we considered as part of the theory of planned advice for managing their illness (Christensen, Moran, behavior. The other two factors that heighten willingness & Weibe, 1999). Second, people who use defense are having engaged in the behavior previously and having mechanisms a lot to cope with stressful information are a favorable social image of the type of person who would more likely than other individuals to deny that they are perform the behavior. at risk for AIDS, especially if their risk of infection is high (Gladis et al., 1992). Perhaps their high feeling of threat motivates their use of denial. Similarly, individuals seem Emotional Factors to use irrelevant information, such as a sexual partner’s Stress also affects the cognitive processes people use attractiveness, to judge the risks in having sex with that in making decisions (Lerner et al., 2015). For example, person (Blanton & Gerrard, 1997; Gold & Skinner, 1996). when given health promotion information, people under Third, people who smoke cigarettes give lower ratings of high stress pay less attention to it and remember less of k  k 150 Part III / Lifestyles to Enhance Health and Prevent Illness it than people under low stress (Millar, 2005). Conflict DEVELOPMENTAL, GENDER, AND theory presents a model to account for both rational and SOCIOCULTURAL FACTORS IN HEALTH irrational decision-making, and stress is an important factor in this model (Janis, 1984; Janis & Mann, 1977). It comes as no surprise that people’s health changes According to conflict theory, the cognitive sequence across the life span, that women and men have some people use in making important decisions starts when differences in health risks and needs, and that variations an event challenges their current course of action or in preventive behavior occur between individuals of lifestyle. The challenge can be either a threat, such as a different social classes and ethnic backgrounds. symptom of illness or a news story on the dangers of What are some of these changes and differences, smoking, or an opportunity, such as the chance to join a and why do they exist? Let’s examine these health issues, free program at work to quit smoking. This produces an starting with the role of development. appraisal of risk: if the person sees no risk in the status quo, the behavior stays the same and the decision- making process ends; but if a risk is seen, the process DEVELOPMENT AND HEALTH continues—for instance, with a survey of alternatives for dealing with the challenge. The biological, psychological, and social factors that Conflict theory proposes that people experience affect people’s health change throughout the life span, stress with all major decisions, particularly those relating causing individuals to face different health risks and to health, because of the importance of and conflicts problems as they develop. For instance, adolescents and about what to do. People’s coping with decisional young adults are at relatively high risk for injury from conflict depends on their perceptions of the presence automobile accidents, but older adults are at relatively or absence of three factors: risk, hope, and adequate time. high risk for hypertension and heart disease. As a result, These three factors produce different coping patterns, people’s preventive needs and goals change with age. two of which are: Table 6.6 presents main preventive goals for each period in the life span. Other individuals, such as relatives, may Hypervigilance. People sometimes see serious risks in assume responsibility for prevention, especially early k their current behavior and those alternatives they have and very late in the life span. k considered. If they believe they may still find a better solution but think they are fast running out of time, they experience high stress. These people tend to search During Gestation and Infancy frantically for a solution—and may choose an alternative Each year millions of babies around the world are hastily, especially if it promises immediate relief. born with birth defects—in the United States alone, Vigilance. When people perceive serious risks in all there are over 120,000 cases, or 3 out of every 100 possibilities they have considered but believe they may births annually (MD, 2012). These defects range from find a better alternative and have time to search, they relatively minor physical or mental abnormalities to experience only moderate levels of stress. Under these gross deformities; some are not apparent until months conditions, people tend to search carefully and make or years later, and some are fatal. Birth defects result rational choices. from genetic abnormalities and harmful factors in the When the challenge is very serious, such as a physician’s fetal environment. warning or obvious symptoms of illness, vigilance is the A mother can control much of the fetal environment most adaptive coping pattern. Although the conflict the- through her behavior. Early in gestation, a placenta and ory has not been tested sufficiently to know its strengths umbilical cord develo