Health promotion

There are several strategies to try to change the health behaviours of either an individual or a whole population. As you can probably guess, these models do not work for everyone, but in order to be effective, they should be able to produce a noticeable and enduring change in a significant percentage of the population.

The IB exam asks students to be able to examine models and theories of health promotion. The command term is asking that students are able to explain the basic assumptions upon which these models and theories are based. I would study one example as a class and then have students investigate a second model on their own with the goal of comparing their own model to the model that we studied together as a class.

Areas of inquiry

Behavioural change theories are theories that are based on the idea that people can change their own health behaviours based on their level of self-efficacy - that is, the belief that they can actually change their behaviour.

There are several different behavioural change theories that could be studied. For example:

  • The Health Belief Model (Rosenstock, 1966)
  • Theory of Reasoned Action (Fishbein & Ajzen, 1975)
  • Theory of Planned Behaviour (Ajzen, 1985)
  • Social Learning Theory (Bandura, 1989)
  • Self-Determination Theory (1991)
  • Stages of Change Model (DiClemente & Prochaska, 1997)

All of these strategies, however, are for individual change. When looking at models for changing health behaviours within a community or larger population, other ecological models/theories are employed:

  • Social planning: This is a plan by the community to directly target health problems. For example, an immunization program, providing better social housing, free lunch programs at schools.
  • Community mobilization: systematically involve community leaders, social networks, mass communication campaigns, and direct education of the general population. Has been highly effective in HIV prevention.
  • Diffusion of innovations (Rogers, 1962): When promoting an innovation to a target population, it is important to understand the characteristics of the target population that will help or hinder adoption of the innovation.

For the purpose of this lesson, we are going to look at the Health Belief Model and Social Learning Theory.

Task 1. Thinking about health choices

In the world of non-stop information it is difficult to believe that the average person does not know that some behaviours are bad for their health. In most countries, for example, cigarettes are clearly labeled with a warning that says that Cigarette Smoking Causes Cancer. In spite of this, people continue to smoke. Why?

Such examples show that we human beings are very good at discounting the threats that their behaviours cause to their health.

Watch the following video. What do you think? Will this change a smoker's behaviour? Why or why not?

Task 2. Collecting data on health beliefs

When discussing health choices, it is not just about smoking. It is about sex safe, drug and alcohol use, diet choices, exercise routines and stress management. For this task, you are going to be asked to find out what the disconnect is between health beliefs (or knowledge) and actual behaviour.

Read the following article on knowledge of the health benefits of exercise and actual behaviour.

Then let's do some research in our community. To do this, we are going to create a short survey and then quantify and represent our data.

Step 1. Write out your survey. In your survey think of questions that would ask both about how much someone exercises and then how much he or she know about the health benefits of exercise.

Step 2. Carry out the surveys. If a participants reads your whole survey before answering, there may be strong expectancy effects. Therefore, it would be best for you to carry out the survey orally. Try to find five people to interview. If possible, avoid interviewing fellow students.

Step 3. Come back together as a class. Time to graph your data as a class. There are many ways that you can do this based on how you wrote your survey. For example, in the survey I designed, I asked how many times that exercised per week on a regular basis and then asked them to name as many health benefits of exercise that they knew. So, for may graph, I am going to make my x axis be the number of times that they exercise per week and the y axis be the number of correct health benefits that were identified.

To make my graph, I can use a simple online tool like "scatter plot generator." When I enter my data and choose linear regression, it may look like this:

As you can see from the graph and the line of best fit, there is a very minimal link between the two variables. In order to actually see the level of correlational, click on "correlational coefficient." This is a calculation of the Pearson's r test. When I do my calucation, I find that the correlational coefficient for my data is r = -0.23. This means two things. A value of 1.0 would mean a very strong correlation - that is, that those that know more about exercise do more exercise. In this case, it is only .23. So there is only a very weak correlation. Secondly, you can see the negative sign. This indicates the direction of the correlation. In this case, it appears that there is a very slight correlation in the direction that those that exercise more know less about the health benefits.

How does your class's data compare to mine?

The Health Belief Model

This model is one of the oldest attempts to explain health behaviour. It is based on the assumption that for a behavioural change to succeed, individuals must have the incentive to change, feel threatened by their current behaviour, and feel that a change will be beneficial and be at acceptable cost. They must also feel competent to implement that change. Most importantly, the Health Belief Model believes that we are rational beings that will evaluate a threat and then examine the cost and benefits of taking different actions to address that threat.

The Health Belief Model argues that a person's "readiness to change" is based on five factors:

  • Perceived susceptibility
  • Perceived severity
  • Perceived benefits
  • Perceived barriers
  • Cues to action

An example of this can be seen in campaigns to promote the use of condoms to avoid HIV infection.

Perceived susceptibility: People believe that they can get HIV and know how one contracts the disease.

Perceived severity: People believe that the consequences of getting HIV are significant enough that they want to avoid contracting it.  This is often accomplished through fear arousal.

Perceived benefits: People understand the benefit of using condoms to avoid HIV infection.

Perceived barriers: Embarrassed to ask partner to use condom, embarrassed or don't want to pay to buy condoms. When identifying barriers to carrying out the healthy behaviour, it is necessary to identify how to overcome them. So, for example, practicing condom communication skills or informing them about where they can get free condoms.

Cues to action: People are reminded of safe sex practice in newsletters, a conversation with a friend or receiving a pin that say "no glove, no love" or "respect wears a condom."

A final aspect of the Health Belief Model is the concept of self-efficacy, or one's confidence in the ability to successfully perform an action.

Evaluating the Health Belief Model

The Health Belief Model has been successfully applied in many cases to change behaviours from as varied as smoking to safe sex to dietary change to prevent type II diabetes.

Strengths

  • Becker (1974) found that there was a positive correlation between a mother's belief about their child's susceptibility to asthma attacks and the likelihood that they would comply with a medical regime.
  • Carpenter (2010) carried out a meta-analysis of 18 studies (2,702 subjects)  to determine whether the Health Belief Model could longitudinally predict behavior. Identification of benefits and barriers were consistently the strongest predictors of behavioural change.  Perceived susceptibility and severity demonstrated only weak predictive validity.  This was confirmed in a study by Gerrad et al (1996) that found there was no association between a person's perceived vulnerability to HIV and their practice of safe sex.

Limitations

It assumes that we are rational beings. Weinstein (1987) found that we often show an optimism bias with regard to our own health behaviours and level of risk - that is, we tend to believe that our behaviours are healthier than they actually are and that we are at lower risk than others to have health problems. In the task about where we ask people how often they exercise on a weekly basis, we have to account for optimism bias.

The model assumes that health behaviour change can happen simply by conscious choice. This may not always be the case. People suffering from nicotine addiction often want to quit, but simply cannot.

The HBM also ignores the role of social and environmental factors on health, such as peer pressure.

And finally, since health behaviour is seen solely as a choice, there is the temptation to "blame the victim" rather than recognizing the complexities of changing behaviour.

Social Cognitive Theory

Social Cognitive Theory is the more modern term for "Social Learning Theory." Social Learning Theory suggests that health promoters act as ‘change agents’, facilitating change through modification of the social environment and the development of skills and capacities that enable individuals to make healthy changes. If you remember from the core, there are several important components of Social Learning Theory.

Observational learning is the ability to learn by observing the behaviour of others. For example, people may be more likely to follow the example of people they see as role models. Seeing someone you respect refuse to eat unhealthy foods may therefore change your attitude about what you eat.

Expectations are the value an individual places on the outcomes resulting from different behaviours. For example, if you believe that smoking will help you to lose weight and place great value on weight loss, then you may be more likely to take up smoking.

Reciprocal determinism describes the way in which behaviour and the environment continuously interact and influence one another. This is a key difference between this theory and the Health Belief Model.  Social Cognitive Theory stresses the need for addressing environmental influences in order to promote change. For example, modifying social norms about smoking is considered to be one of the most powerful ways of promoting cessation among adults.

Self-efficacy is an individual’s belief and level of confidence in her/his own ability to successfully make a change or perform a behaviour. Social learning theory identifies self-efficacy as the most important factor for successful change.

Health promotion campaigns that are based on Social Cognitive Theory include an informational component to increase perceptions of the risks and benefits associated with a particular behavior, teaching social and cognitive skills that can be used to initiate behavior change, building self-efficacy to promote behavior maintenance, and building social support to sustain change.

Remember that the Sabido method has been used effectively to change health related behaviour.

Take a look at this video.  In what ways does this campaign use Social Cognitive Theory to change behaviour?

Evaluating Social Cognitive Theory

Strengths

Unlike the Health Belief Model, the SCT includes environmental factors and seeks to change social norms.

Programs such as the Sabido Method have been effective in changing behaviour.

Limitations

The theory not explain why people choose to change.

It is difficult to measure levels of "self-efficacy" - and it is based on self-reported data.

In many studies on the effectiveness of SCT, self-efficacy has not shown to be a valid predictor of behavioural change.

Checking for understanding

1. According to the Health Belief Model, what would be a perceived barrier to a healthy exercise regime?

A perceived barrier could be that there is not enough time to get to the gym, that gym memberships are expensive or that there are health problems that may prevent all types of exercise.  The Health Belief Model gets people to identify the barriers that are preventing healthy behaviour and find a way to address them.

2. To what extent can the Health Belief Model predict behavioural change?

Research seems to support the idea that perceived benefits and barriers can be used successfully to promote healthy behaviour.  Simply knowing about the risk or about severity of a problem does not appear to be as successful in predicting change.  Often individuals display an "optimism bias" that their behaviour is healthier than it actually is, and that the risk to them is lower than the general population.

3. What is one ethical concern about the Health Belief Model?

One ethical concern is that the model makes it appear that all negative health behaviours can be changed simply by choice.  This is not true and thus may result in feelings of helplessness by individuals or blaming them for their failure. Another concern is the use of fear arousal in order to increase the perception of severity.  This may cause undue stress and harm, especially if the individual lacks the resources to change his/her own behaviour.

4. What is Bandura's concept of Reciprocal Determinism?

This is the idea that behaviour affects the environment and the environment affects behaviour in a bidirectional relationship. This is an important part of Social Cognitive Theory as it acknowledges the role that environmental and social factors may play on changing one's behaviour.

5. What are the key differences between the Health Belief Model and the Social Cognitive Theory approach to health promotion?

Social Cognitive Theory addresses environmental factors.  It also takes out the role of conscious decision making in changing behaviour.  Social Cognitive Theory also emphasizes the need for role models - or "change agents." The theory also encourages the teaching of social and cognitive skills that can be used to initiate behavior change, build self-efficacy to promote behavior maintenance, and build social support to sustain change.

6. What is one example of a successful SCT-based campaign?

The Sabido method was successfully applied from 1993 to 1997  in Tanzania to promote AIDS prevention behavior. In order to test the effectiveness of the program, a nationwide program was set up. The experiment used an independent samples design. In the area near the capital city of Dodoma, a music program was played. This was the control. The rest of the country heard the serial broadcast by Radio Tanzania.

Two years later, Tanzanians were more likely to believe that unprotected sex could result in HIV infection, talked more about AIDS, reduced their number of sexual partners and increased condom use.

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