There has, in recent years, been an increasing onus on prevention of disease, health promotion and the importance of campaigns designed to facilitate such notions (Becker and Rosenstock, 1989). For instance, since 1999, the UK has spent around £13.73 million on anti-smoking campaigns alone, which equates to roughly £0.29 per capita , and a recent Government white paper, Choosing Health: Making Healthier Choices Easier (DoH, 2004) set out the Blair administration’s continuing commitment to the area of prevention rather than treatment. The document makes it clear that, not only is health behaviour a major facet of Governmental thinking but it also features prominently in the psychology of the general public:
“Millions of people are trying to lose weight. Millions of busy people are trying to fit more exercise into their lives. 70% of England’s 10 million smokers want to stop smoking. Millions of parents are looking for cheap and convenient ways to provide good food for their children. That strong desire by millions of individuals in England to change to a healthier way of life is an opportunity.” (DoH, 2004)
In their article Health Promotion, Disease Prevention and Program Retention, Becker and Rosenstock (1989) trace this resurgence in the concept of prevention to the “middle of the twentieth century” (Becker and Rosenstock, 1989: 285) and state that a major factor was the widespread decline in instances of serious infectious diseases and the realisation of the prevalence of chronic syndromes and deaths caused by accidents and acts of violence . All of these could, it was thought, be highly effectively prevented through suitable health promotion and the alteration of behaviour.
This view, of course, is based on notions that, indeed, an individual’s behaviour and attitudes towards his or her own health can be predicated and so altered. In this essay I would like to look at two of the main models of health behaviour and examine their aetiology, efficacy and influence on health and social policy in the last twenty years.
The two models I have chosen to look at are the Health Belief Model (HBM) and the Theory of Planned Behaviour (TPB) which, I think, represent not only the most straightforward and consistent theoretical frameworks of health psychology but also feature highly in any formation of policy and Governmental decision making .
Health Belief Model
The HBM, as Brannon and Feist (2004) detail, extends as far back as the early work of Geoffrey Hochbaum in the late 1950’s . However, it was through the work of Becker (1979, 1984, 1989) and Rosenstock (1984, 1989, 1990) that it was fully conceptualised and, from there, applied to not only health psychology but health practice.
The HBM is centred around five basic assumptions: that for a person to take preventative action against a disease they must, feel susceptible on a personal basis to the disease itself; feel that such a disease would have severe enough affects on them; feel that preventative benefits would be worth while in reducing the risk of acquiring the disease; think that external barriers such as pain, inconvenience, social embarrassment or financial difficulties would be less than contracting the disease and, lastly, that “cues to action” (Pitts and Phillips, 1998: 9) such as media advertising and health promotion would provide sufficient impetus to take measures.
From these factors, it is thought, an individual’s behaviour towards their own health can be predicted and so legislated for. As Brannon and Feist asserts this model equates, in some sense at least, to common sense:
“When people perceive that they are susceptible to a severe illness and can benefit from their ability to overcome barriers to good health, they should be guided by their own self-interest and actively seek health care” (Brannon and Feist, 2004: 47)
It is this aspect that has made the HBM a popular theory in recent times. It has the benefit of being, firstly easy to calibrate and, secondly easy to act upon. It is easy to see the attraction of a model that espouses a relatively simple relationship between the perceptions of risk and the role of cues to action. Graham Russell (1999) calls the HBM “uncomplicated” and “intuitive” (Russell, 1999: 114) and details that it has common applications in two major regimes of health care, where stress is placed upon:
“Encouraging people to seek early professional help for signs and symptoms of illness.”
And
“Improving uptake on preventative health programmes such as immunisation and screening for disease” (Russell, 1999: 115)
Within these notions, of course, we could cite breast cancer screening (mammography), flu immunization, dietary education and change to exercise routines as examples of the ways in which the HBM directly reflects Government policy and people’s own health behaviour.
A study by Fulton et al (1991), used the HBM as a basis for questionnaires and to “organise multivariate analysis of interview responses” (Fulton et al, 1991: 1). The study used a telephone canvassing methodology, looking at 852 women from Rhode Island USA, all above 40 in order to ascertain their behavioural patterns regarding their own health and attitudes towards disease prevention.
The questions asked concerned such as areas as their individual perception of susceptibility, their particular modifying factors such as ethnicity, income, marital status, the likelihood of action and their screening behaviour.
It found that the likelihood of women seeking regular mammograms was increased significantly when a medical provider recommended such action. However, almost one-fifth of the women had no such provider, 13 per cent had no source of gynaecological care, one-fourth felt susceptible to breast cancer and a third thought mammograms were too uncomfortable to undergo. (Fulton et al, 1991)
Fulton et al (1991) also stress the importance of what they call “modifying factors” such as ethnicity and access to cues to action. There was a direct relationship, they found, between exposure to cues to action and the willingness to undergo preventative screenings . This is also bourn out in such studies as Hyman, Baker, Ephraim, Moadel and Phillip’s 1994 study that showed that “being an African American women – rather than a European American woman – was a better predicator of mammography use than any of the four elements of the health model belief.” (Brannon and Feist, 2004: 47). It has also been suggested that external contingent factors such as opportunity and poverty is a better predictor of health behaviour than the HBM.
One of the most effective and useful applications of the HBM is in the predictive take up of screening for sexually transmitted diseases such as HIV and Hepatitis. A study in the US by Hergenrather and Rhodes (2003) of the MSM (men who have sex with men) community and their willingness to be vaccinated against Hepatitis A, found that men who reported “high levels of communication with their healthcare provider about their sexual orientation and risk behaviour were more likely to be vaccinated” (Hergenrather and Rhodes, 2003:1). Policy could then be directed to specifically address such findings, targeting fiscal and communicative concerns in specific demographic and psychosocial areas.
The Theory Of Planned Behaviour
The TPB is derivative of an earlier concept; the Theory of Reasoned Action and both appear in the works of Icek Ajzen. Ajzen stresses the importance of ‘perceived behavioural control’ (1991: 103) in affecting people’s attitudes and choices relating to their health. Ajzen postulates that it is possible to predict an individual’s behaviour through knowledge of, firstly, their attitude towards that behaviour, secondly, their ‘subjective norm’ and, lastly, their perceived behavioural control. All of these factors combine to produce an individual’s intentions.
Perceived behavioural control is the extent that one feels one can alter the outcome of a situation, it is based on a number of influencing factors including past experience, access to pertinent knowledge and a perception of one’s own ability to overcome obstacles (Brannon and Feist, 2004:50). Ajzen cites studies such as Alagna and Reddy (1984) that suggest there is particular pertinence to the area of health regarding this particular theory:
“When reduced to the level of specific response tendencies, perceived self-efficacy or perceived control over performance of a behaviour is found to correlate strongly with actual performance.(Ajzen, 1991: 107)
In this view, it is thought that those who feel as though they can easily complete a task or overcome an obstacle are more likely to have intensions to do so. Studies such as Orbell, Blair, Sherlock and Conner (2001) and Maher and Rickwood (1991) have suggested that the TPB can be especially effective in predicting behaviour concerning the purchase and consumption of illegal drugs by the young, for instance, or the up-take of smoking.
Knowledge of an individual’s attitudes on, for instance, cannabis (Armitage et al, 1999), their perception of their own level of control and the subjective norms of their peer group can all aid in the prediction of their behaviour. In Attitudes, Personality and Behaviour, Ajzen gives us a suitably succinct summation of his theorum:
“With varying implications, attitudes and personality traits can be reduced to the level of a particular behaviour, and such behaviour-specific dispositions are found to correlate well with compatible action tendencies.” (Ajzen, 1991: 109)
He stresses the notion that behaviour is a planned function of the individual and that any decision concerning health and disease prevention can be predicted with knowledge of such intentions.
Of course as many commentators have pointed out (Pitt and Phillips, 1998, Armitage, 1999) the main difficulty with this model is that it only identifies intentions of behaviour, intentions that, may or may not result in actual behavioural outcomes. There are many reasons why an intention may not be acted upon; it may be unsuitable at the time, for instance, or there maybe other contingent external factors (Pitt and Phillips, 1998:13).
In an Australian study carried out by Kashima and McCamish (1992), it was found that past experience played a considerable role in forming intentions regarding condom use in the prevention of AIDS and HIV:
“The role of past behaviour, in particular, appears to be central to understanding sexual practice in general, and the use of condoms in particular. Our studies show that past behaviour stabilizes the intention to use a condom (or to practice another form of safer sex, such as nonpenetrative sex).” (Kashima and McCamish, 1992: 40)
The importance of such notions of ‘temporal stability’ (Ajzen, 1991: 99) is also stressed by Ajzen who cites studies concerning smoking as indicators that specific response tendencies can be both a formative influence of future behaviour and a reliable predictive tool for the health authorities. Behaviour that can predicted, it is thought, can lead to better targeted and so cost effective health care prevention.
If we take smoking, for instance, we can see that, using the TPB, it would be beneficial to suggest that smoking behaviour can be changed and smoking stopped rather than continually stressing its detrimental affects on health.
A recent NHS initiative stresses the behavioural control a smoker has over the outcomes of their action and the degree to which they can expect to overcome the obstacle of giving up cigarettes. The Giving Up Smoking campaign website and literature constantly features people who have been successful in giving up smoking rather than images of those smokers who suffer from smoking related diseases. There are testimonials and plans dedicated to help the smoker give up, each of which reinforce their control and target their sense of autonomy over the addiction.
As detailed in Hardill, Kofman and Graham’s (2001) Human Geography of the UK, the Labour Government’s 1998 white paper Our Healthier Nation (DoH, 1998) not only pledged more money and resources to campaigns that promoted “strategies of lifestyle management” (Hardill, Kofman and Graham, 2001: 124) but obviously reflected such health behaviour predictors as the Health Belief Model and the Theory of Planned Behaviour:
“The government has announced a plan to save 148,000 deaths from stroke and coronary heart disease by 2010. Funding will go on training more cardiac surgeons, creating a number of ‘chest pain clinics’ and ‘stop smoking clinics’.” (Hardill, Kofman and Graham, 2001: 124)
The inference in this statement is clear: behaviour, according to the Government at least, can be predicted and health policy adjusted accordingly. Here, the onus on ‘stop smoking clinics’ and chest pain clinics stress the importance of early detection and prevention, an obvious outcome in a faith in behavioural models as they relate to the health service.
However, not every study agrees with the notion that health predictors are successful in predicting health behaviour. Heaven (1996) cites a study in Australia that looked at the responses of 18 year olds to the threat of AIDS , it predicted, using health belief models that the more severe the threat and the more at risk the participants thought themselves in the greater the chance that they would practice safe sex. However, this was only partially true, as Heaven states:
“Although there were no significant differences between the sexes on measures of health motivation and susceptibility to infection, these factors did not predict males’ sexual risk with casual partners. Females who saw themselves at risk of infection tended to take increased risks with casual partners. Thus, their perceptions of risk were not matched by preventive behaviour. ” (Heaven, 1996: 35)
Allied to this is a study conducted by Conner and Flesch (2001) that suggested there was strong external reasons, such as alcohol and peer grouping that contributed more to young people ignoring contraception advice than planned behaviour and Brannon and Feist (2004) suggesting outright that “Research has shown that the health belief model has only limited success in predicting health-related behaviour” (Brannon and Feist, 2004: 54).
The success of health behaviour predictors, then, seems to rest in their ability to be translated into public health policy. It is easy to see how relatively simple structures such as the health belief model form the basis of Government thinking on such areas as giving up smoking, screening for breast cancer and use of contraceptives. As many commentators have suggested (Brannon and Feist, 2004; Freeman and Levine, 1989; Pitt and Phillips, 1998) the actual picture is, perhaps, more complicated, with an-ever growing network of influencing factors constantly at play. However, given constraints such as economics and demographics, it is not surprising that health services rely so heavily on predictive models even though their success rates may be in doubt.
References
- Ajzen, Icek (1991), Attitudes, Personality and Behaviour, (Milton Keynes: Open University Press)
- Ajzen, Icek and Fishbein, Martin (1980), Understanding Attitudes and Predicating Behaviour, (New Jersey: Prentice Hall)
- Armitage, Simon, et al (1999), Different Perceptions of Control: Applying an Extended Theory of Planned Behaviour to Legal and Illegal Drug Use, published in Basic and Applied Social Psychology, Vol. 21.
- Becker, Marshall (1979), Understanding Patient Compliance: The Contributions of Attitudes and Other psychosocial Factors, published in Cohen, I.(ed), New Directions in Patient Compliance, (Lexington: Lexington Books)
- Becker, Marshall and Rosenstock, Irwin (1989), Health promotion: Disease Prevention and Program Retention, published in Freeman, Howard and Levine, Sol (eds), Handbook of Medical Sociology – Fourth Edition, (New Jersey: Prentice Hall)
- Becker, Marshall and Rosenstock, Irwin (1984), Compliance With medical Advice, published in Steptoe, A.and Mathews, A. (eds), Health Care and Human Behaviour, (London: Academic Press)
- Beisecker, Analee (1991), Interpersonal Communication Strategies to Prevent Drug Abuse by Health Professionals and the Elderly: Contributions of the Health Belief Model, published in Health Communication Vol. 3.
- Brannon, Linda and Feist, Jess (2004), Health Psychology: An Introduction to Behaviour and Health – Fifth Edition, (London: Thompson and Wadsworth)
- Choosing Health: Making Healthier Choices Easier, (DoH, 2004)
- Conner, M and Flesch, D. (2001), Having Casual Sex: Additive and Interactive Effects of Alcohol and Condom Availability on the Determinants of Intentions, published in The Journal of Applied Social Psychology, Vol.31
- Fulton, John et al, A Study Guided By the Health Belief Model of the Predictors of Breast Cancer Screening of Women Ages 40 and Older, published in Public Health Reports Vol. 106, 1991.
- Hardill, Irene, Kofman, Eleonore and Graham, David (2001), Human Geography of the UK, (London: Routledge)
- Heaven, Patrick, (1996), Adolescent Health: The Role of Individual Differences, (London: Routledge)
- Hergenrather, Kenneth and Rhodes, Scott (2003), Using An Integrated Approach to Understand Vaccination Behaviour Among Young Men Who Have Sex With Men: Stages of Change, the Health
- Belief Model and Self Efficacy, published in Journal of Community Health, Vol. 28.
- Hochbaum, Geoffrey (1958), Public Participation in Public Screening Programs, (Washington: DHEW)
- Kishima, Yoshihisa and McCamish, Synthia (1992), Predicting Use of Condoms: Past Behaviour, Norms and the Sexual Partner, published in Edgar, Timothy et al (eds), AIDS: A Communication Perspective, (London: Lawrence Erlbaum)
- Lewis, K., and Bradley, C (1994), Measures of Diabetes Specific Health Beliefs, published in Bradley C (ed), Handbook of Psychology and Diabetes, (London: Harwood)
- Maher, R and Rickwood, D., (1997), The Theory of Planned Behaviour, Domain Specific Self Efficacy and Adolescent Smoking, published in Journal of Child and Adolescent Substance Abuse, Vol. 6
- Orbell, S. et al (2001), The Theory of Planned Behaviour and Ecstasy Use: Roles for Habit and Perceived Control Over Taking Versus Obtaining Substances, published in Journal of Applied Psychology, Vol. 31.
- Our Healthier Nation (DoH, 1998)
- Pitts, Marian and Phillips, Keith (eds), The Psychology of Health: An Introduction – Second Edition, (London: Routledge)
- Rosenstock, I., (1990), The Health Belief Model: Explaining Health Behaviour Through Expectancies, published in Glanz, K., Lewis, F.M. and Rimer, B.K. (eds)., Health Behaviour and Health
- Education: Theory, Research and Practice, (San Franciso: Jossey-Bass)
- Russell, Graham (1999), Essential Psychology for Nurses and Other Health Professionals, (London: Routledge)