Theories of Health Behaviour
Health Psychology
Attribution theory
• According to the basic tenets of
attribution theory people attempt to
provide a causal explanation for events
in their world particularly if those events
are unexpected and have personal
relevance (Heider, 1958). Thus it is not
surprising that people will generally
seek a causal explanation for an illness,
particularly one that is serious.
Attribution theory
• Taylor et al. (1984) interviewed a
sample of women who had been
treated for breast cancer. They found
that 95% of the women had a causal
explanation for their cancer. These
causes were classified as stress (41%),
specific carcinogen (32%), heredity
(26%), diet (17%), blow to breast
(10%) and other (28%).
Women’s causal explanations for breast cancer
Attribution theory
• They also asked the women who or
what they considered responsible for
the disease and found that 41% of the
women blamed themselves, 10%
blamed another person, 28% blamed
the environment and 49% blamed
chance. The patients were also asked
whether they felt any control over their
cancer and they found 56% felt they
had some control.
The women’s attribution of responsibility
for their cancer
Attribution Theory
• Weiner et al. (1972) suggested that we
can classify attributional dimensions
along three dimensions:
– 1 Locus: the extent to which the cause is
localized inside or outside the person.
2 Controllability: the extent to which the
person has control over the cause.
3 Stability: the extent to which the cause is
stable or changeable.
Health Locus of control
• Health locus of control, like
attribution theory, also emphasises
attributions for causality and
control.
Health Locus of control
• Wallston and Wallston (1982) developed
a measure of the health locus of
control, which evaluates whether
individuals regard their health as
controllable by them or not controllable
by them or they believe their health is
under the control of powerful others.
Health Locus of control
• Health locus of control is related to
whether individuals changed their
behaviour and to the kind of
communications style they require from
health professionals.
Health Locus of control
• There are several problems with the
concept of a health locus of control:
 Is health locus of control a fixed traits or a transient
state?
 Is it possible to be both external and internal?
 Going to the doctor could be seen as external (the
doctor is a powerful other) or internal (I am looking
after my health).
Unrealistic optimism
• Unrealistic optimism focuses on
perceptions of susceptibility and
risk.
• Weinstein (1984) suggested that one of
the reasons why people continued to
practice unhealthy behaviours is due to
inaccurate perceptions of risk and
susceptibility - their unrealistic
optimism.
Unrealistic optimism
• He asked subjects to examine a list of
health problems and displayed what
"compared to other people of your age
and sex, are your chances of getting
the problem greater than, about the
same, or less than theirs?" Most
subjects believed they were less likely
to get the health problem.
Unrealistic optimism
• Weinstein (1987) described four
cognitive factors that contribute to
unrealistic optimism:
– 1. Lack of personal experience with the
problem
– 2. The belief that the problem is
preventable by individual action
Unrealistic optimism
– 3. The belief that if the problem has not
yet appeared, it will not appear in the
future
– 4. The belief that the problem is
infrequent.
The transtheoretical model of
behaviour change (stages of
change model)
• The transtheoretical model of
change emphasises the dynamic
nature of beliefs, time, and costs
and benefits.
The transtheoretical model of
behaviour change (stages of
change model)
• 1. Precontemplation: not intending to
make any changes
• 2. Contemplation: considering a change
• 3. Preparation: making small changes
• 4. Action: actively engaging in a new
behaviour
• 5. Maintenance: sustaining change over
time
The transtheoretical model of
behaviour change (stages of
change model)
• Individuals would go through these stages in
order but might also go back to earlier
stages.
• People in the later stages, e.g. maintenance,
would tend to focus on the benefits (I feel
healthier after giving up smoking), whereas
people in the earlier stages tend to focus on
the costs (I will be at a social disadvantage if
I give up smoking).
The transtheoretical model of
behaviour change (stages of
change model)
• A relationship has been found between
level of education and the stage of
change reached when contemplating
taking regular exercise.
The transtheoretical model of
behaviour change (stages of
change model)
• Those people with lower levels of
education tended to be at an earlier
stage of change (Booth et al. 1993),
and therefore it could be argued that
the model could be improved by taking
account educational attainment in order
to help predict the length of time a
person is likely to remain at the earlier
stages.
Health belief model
• Support for individual components of
the model.
• Norman and Fitter (1989) examined
health behaviour screening (for
example breast cervical cancer) and
found that perceived barriers (the costs
of attending) were the greatest
predictors of whether a person attended
the clinic.
Health belief model
• Several studies have examined breast
self-examination (BSE) behaviour and
report that barriers (Lashley 1987;
Wyper 1990) and perceived
susceptibility (the likelihood of having
the illness) (Wyper 1990) are the best
predictors of healthy behaviour.
Health belief model
• The role of giving information as a cue
to action has been researched.
Information in the form of fear-arousing
warnings may change attitudes and
health behaviour in such areas as
dental health, safe driving and smoking
(e.g. Sutton 1982; Sutton and Hallett
1989).
Health belief model
• Giving information about the bad
effects of smoking is also effective in
preventing smoking and in getting
people to give up (e.g. Sutton 1982;
Flay 1985). Several studies report a
significant relationship between people
knowing about an illness and their
taking precautions.
Health belief model
• Rimer et al. (1991) report that
knowledge about breast cancer is
related to having regular mammograms.
Several studies have also indicated a
positive correlation between knowledge
about BSE (Breast Self-examination)
and breast cancer and performing BSE
(Alagna and Reddy 1984; Lashley 1987;
Champion 1990).
Health belief model
• Showing subjects a video about pap
tests for cervical cancer was related to
their actually having the pap test
(O'Brien and Lee 1990'.)
Evidence Against the HBM
• Janz and Becker (1984) found that healthy
behavioural intentions are related to low
perceived seriousness - not high as predicted
(e.g. healthy adult having a flu injection) and several studies have suggested an
association between low susceptibility (not
high) and healthy behaviour (e.g. many
students recently have agreed to be
inoculated against meningitis) (Becker et al.
1975; Langlie 1977).
Evidence Against the HBM
• Hill et al. (1985) applied the HBM to
cervical cancer, to examine which
factors predicted cervical screening
behaviour. Their results suggested that
benefits and perceived seriousness
were not related.
Evidence Against the HBM
• Janz and Becker (1984) carried out a
study using the HBM and found the
best predictors of health behaviour to
be perceived barriers and perceived
susceptibility to illness.
Evidence Against the HBM
• However, Becker and Rosenstock
(1984), in a review of 19 studies using
a meta-analysis that included measures
of the HBM to predict compliance,
calculated that the best predictors of
compliance are the costs and benefits
and the perceived seriousness. So there
is lack of agreement over what really
does help to predict health behaviour.
Criticisms of the HBM
• Is health behaviour that rational? (Is
tooth-brushing really determined by
weighing up the pros and cons?).
 Its emphasis on the individual (HBM
ignores social and economic factors)
 The measurement of each component
 The absence of a role for emotional
factors such as fear and denial.
Criticisms of the HBM
 It has been suggested that alternative
factors may predict health behaviour,
such as outcome expectancy (whether
the person feels they will be healthier
as a result of their behaviour) and selfefficacy (the person’s belief in their
ability to carry out preventative
behaviour) (Seydel et al. 1990;
Schwarzer 1992).
Criticisms of the HBM
 Schwarzer (1992) has further criticized
the HBM for saying nothing about how
attitudes might change.
Criticisms of the HBM
 Leventhal et al. (1985) have argued
that health-related behaviour is related
more to the way in which people
interpret their symptoms (e.g. if you
feel unwell and you feel it is not going
to cure itself then you would probably
do something about it).
The revised HBM
• Becker and Rosenstock (1987) have
revised the HBM and have described
their new model as consisting of the
following factors:
 the existence of sufficient motivation;
 the belief that one is susceptible or vulnerable
to a serious problem;
 and the belief that change following a health
recommendation would be beneficial to the
individual at a level of acceptable cost.
Protection motivation
theory
Protection motivation
theory
• Rogers (1975, 1983, 1985) developed
protection motivation theory (PMT)
which expanded the HBM to include
additional factors.
• Components of the PMT
• Health-related behaviours are a product
of five components:
Protection motivation
theory
• Coping Appraisal
• self-efficacy (e.g. 'I am confident that I can
change my diet');
• Response effectiveness (e.g. 'changing my
diet would improve my health');
• Threat Appraisal
• Severity (e.g. 'bowel cancer is a serious
illness');
• Vulnerability (e.g. 'my chances of getting
bowel cancer are high').
• Fear
Protection motivation
theory
• According to the PMT, there are two sources
of information:
• 1.
environmental (e.g. verbal persuasion,
observational learning) and
• 2.
intrapersonal (e.g. prior experience).
• This information elicits either an 'adaptive'
coping response (i.e. the intention to improve
one's health) or a 'maladaptive' coping
response (e.g. avoidance, denial).
Support for the PMT
• Rippetoe and Rogers (1987) gave
women information about breast cancer
and examined the effect of this
information on the components of the
PMT and their relationship to the
women's intentions to practise breast
self-examination (BSE).
Support for the PMT
• The results showed that the best
predictors of intentions to practise BSE
were response effectiveness (believing
that BSE would detect the early signs of
cancer), severity (believing that Breast
cancer is dangerous and difficult to
treat in it's advanced stages) and selfefficacy (belief in one's ability to carry
out BSE effectively).
Support for the PMT
• In a further study, the effects of persuasive
appeals for increasing exercise on intentions
to exercise were evaluated using the
components of the PMT. The results showed
that vulnerability (ill health would result from
lack of exercise) and self-efficacy (believing in
one's ability to exercise effectively) predicted
exercise intentions but that none of the
variables were related to self-reports of actual
behaviour.
Support for the PMT
• In a further study, Beck and Lund (1981)
manipulated dental students' beliefs about
tooth decay using persuasive communication.
Their results showed that the information
increased fear and that severity (tooth decay
has disastrous consequences) and selfefficacy (I can do something about it) were
related to behavioural intentions (flossing and
brushing regularly especially after eating).
Criticisms of the PMT
• The PMT has been less widely criticized than
the HBM; however, many of the criticisms of
the HBM also relate to the PMT. For example,
the PMT assumes that individuals are rational
information processors (although it does
include an element of irrationality in its fear
component), it does not account for habitual
behaviours, such as brushing teeth, nor does
it include a role for social (what others do)
and environmental factors (eg opportunities
to exercise or eat properly at work).
Criticisms of the PMT
• Schwarzer (1992) has also criticized the
PMT for not tackling how attitudes
might change (a problem with the HBM
as well).
Social cognition models
• Social cognition theory was developed by
Bandura (1977, 1986) and suggests that
expectancies, incentives and social cognitions
govern behaviour. Expectancies include:
• Situation outcome expectancies: the
expectancy that a behaviour may be
dangerous (e.g. 'smoking can cause lung
cancer').
• Outcome expectancies: the expectancy that
behaviour can reduce the harm to health
(e.g. 'stopping smoking can reduce the
chances of lung cancer').
Social cognition models
• Self-efficacy expectancies: the expectancy
that the individual is capable of carrying out
the desired behaviour (e.g. 'I can stop
smoking if I want to').
• The concept of incentives suggests that
behaviour is governed by its consequences.
For example, smoking behaviour may be
reinforced by the experience of reduced
anxiety, whereas a feeling of reassurance
may reinforce having a cervical smear after a
negative result.
Social cognition models
• Social cognitions involve normative beliefs
(e.g. 'people who are important to me want
me to stop smoking').
• Parents have a strong influence over the
health behaviours of children of the same sex
with regard to Exercise, Smoking, Drinking,
Eating and Sleep (Wickrama, Conger, Wallace
and Elder, Journal of Health and Social
Behaviour, 1999).
Social cognition models
Social cognition models
Theory of planned behaviour
Theory of planned behaviour
• The TPB emphasizes behavioural intentions
as the outcome of a combination of several
beliefs.
• Intentions - 'plans of action in pursuit of
behavioural goals' (Ajzen and Madden 1986)
and are a result of the following beliefs:
•
• 1.
Attitude towards a behaviour - positive
or negative -(e.g. 'exercising is fun and will
improve my health').
Theory of planned behaviour
• 2.
Subjective norm - social pressure
and motivation (e.g. 'people who are
important to me will approve if I lose
weight and I want their approval').
• 3.
Perceived behavioural control self-efficacy and possible barriers
Support for the TPB
• Povey et al (2000) studied the
intentions of people to eat five portions
of fruit and vegetables per day or to
follow a low-fat diet. The TPB was good
at predicting intentions but not
behaviour. Self-efficacy was found to be
a better predictor of behaviour.
Support for the TPB
• Rutter (2000) studied women and
whether or not they attended two
breast-screening sessions separated by
three years. Intention and first-time
attendance was successfully predicted
by the TPB. Attendance at the first
session, however, was the best
predictor of whether the woman
attended three years later.
Support for the TPB
• Brubaker and Wickersham (1990)
examined the role of the theory's
different components in predicting
testicular self-examination and reported
that attitude towards the behaviour,
subjective norm and behavioural control
(measured as self-efficacy) correlated
with the intention to perform the
behaviour.
Support for the TPB
• TPB in relation to weight loss (Schifter
and Ajzen 1985). The results showed
that weight loss was predicted by the
components of the model; in particular,
goal attainment (weight loss) was
linked to perceived behavioural control.
Evaluation of the TPB
Good
– Degree of irrationality
– Considers Social and Environmental factors
– Considers past behaviour within the
measure of perceived behavioural control.
Bad
– Schwarzer (1992) Ajzen does not describe
either the order of the different beliefs or
says what causes what (causality).
The health action process
approach
The health action process
approach
• The health action process approach (HAPA)
was developed by Schwarzer in 1992.
• 1. it includes a temporal element in the
understanding of beliefs and behaviour.
• 2. it emphasized the importance of self
efficacy
• 3.
distinction between a decisionmaking/motivational stage and an action
maintenance stage.
Components of the HAPA
• According to the HAPA, the motivation stage
is made up of the following components:
– self-efficacy (e.g. 'I am confident that I can stop
smoking');
– outcome expectancies (e.g. 'stopping smoking will
improve my health'), and a subset of social
outcome expectancies (e.g. 'other people want me
to stop smoking and if I stop smoking I will gain
their approval');
– threat appraisal, which is composed of beliefs
about the severity of an illness and perceptions of
individual vulnerability.
Components of the HAPA
• The action stage is composed of:
– A cognitive factor made up of action plans (e.g. 'if
offered a cigarette when I am trying not to smoke
I will imagine what the tar would do to my lungs')
and action control (e.g. 'I can survive being
offered a cigarette by reminding myself that I am
a non-smoker').
– The situational factor consists of social support
(e.g. the existence of friends who encourage nonsmoking) and the absence of situational barriers
(e.g. financial support to join an exercise club).
Support for the HAPA
• Schwarzer (1992) claimed that self-efficacy
was consistently the best predictor of
behavioural intentions and behaviour change
for a variety of behaviours, including
frequency of flossing, effective use of
contraception self-examination, drug addicts'
intentions to use clean needles, intentions to
quit smoking, and intentions to adhere to
weight loss programmes and exercise (e.g.
Beck and Lund 1981; Seydal et al. 1990).
Criticisms of the HAPA
• Too rational - emotion is neglected
• The social and environmental influences are
not considered as directly affecting behaviour,
but rather as cognitions·
• Do these cognitive states exist or are they
simply created cognitive theorists?
• The model attempts to combine components
of the health belief model, the transtheoretical model of change and the theory of
planned behaviour.
Non-Rational processes
• The defence mechanism of Denial
– Cigarette smokers etc
Lay theories about health
• Communication between health
professional and patient would be
redundant if the patient held beliefs
about their health that were in conflict
with those held by the professional.
Lay theories about health
• Pill and Stott (1982) reported that workingclass mothers were more likely to see illness
as uncontrollable.
• In a recent study, Graham (1987) reported
that although women who smoke are aware
of all the health risks of smoking, they report
that smoking is necessary to their well-being
and an essential means for coping with
stress.
Lay theories about health
• Blaxter (1990) analysed the definitions of
health provided by over 9000 British adults in
the health and lifestyles survey. She
classified the responses into nine categories:

Health as not-ill: the absence of
physical symptoms.

Health despite disease.

Health as reserve: the presence of
personal resources.

Health as behaviour: the extent of
healthy behaviour
Lay theories about health
– Health as physical fitness.
– Health as vitality.
– Health as social relationships.
– Health as function.
•
Lay theories about health
• It was found that there was considerable
agreement in the emphasis on behavioural
factors as causes of illness. There was
however limited reference to structural or
environmental factors, especially among
those from working-class backgrounds.
Gender differences were also found. The
women were more likely to define health in
terms of personal relationships. Murray and
McMillan (1988) also found that working class
women made repeated reference to their
families when describing cancer.
Lay theories about health
• Chamberlain (1997) noted a series of social
class differences in his review of several
studies of lay people’s perceptions of health.
Lower social economic status people
emphasise the role of health in their ability to
work whereas higher social economic status
people referred more to their ability to
participate in leisure activities. Four different
lay views of health emerged:
Lay theories about health
• 1.
Lower social economic status
participants only reported a view that
emphasised physical aspects.
• 2.
Both lower and higher social economic
status participants gave a dualistic view in
which physical and mental aspects of health
were combined.
• 3.
Predominantly higher social economic
status gave a complimentary view of health,
which integrated both physical and mental
dimensions.
Lay theories about health
• 4. Higher social economic status
participants gave a multiple view of
health, which included physical, mental,
emotional, social and spiritual
directions.
Lay theories about health
• Stainton-Rogers (1991) used Q-sort
methodology to identify the concepts used by
a sample of British adults to explain health.
She identified eight different accounts of
health and illness:

The ‘body as machine’ account which
considered illness as naturally occurring and
‘real’ with biomedicine considered the main
form of treatment.
Lay theories about health

The ‘body under siege’ account which
considered illness as a result of external
influences such as germs or stress.

The ‘inequality of access’ account which
emphasized the unequal access to modern
medicine.

The ‘cultural critique’ account which was
based upon a sociological worldview of
exploitation and oppression.
Lay theories about health

The ‘health promotion’ account which
recognized both individual and collective
responsibility for ill health.

The ‘robust individualism’ account which
was concerned with every individual’s right to
a satisfying life.

The ‘willpower account’ which defined
health in terms of the individuals ability to
exert control.
Assumptions in Health
psychology
• 1. Humans are rational in their information
processing. It is the role of perceived factors
(e.g. risk, rewards, costs, etc) rather than
actual risks.
• 2. Different cognitions are separate from
and perform independently from each other.
Could be because the researchers ask
questions relating to each 'type' of cognition.
Assumptions in Health
psychology
• 3. The types of cognition may not really
exist nor play a part in the patient's thinking
about their health; they could just be an
artefact of the way the research was carried
out.
• 4. Cognitions are not placed within a
context. For example, actual social pressure
and environment are not taken into account,
only the individual's interpretation of social
pressure and environmental influences.
The end