1. Models of Behaviour Change Matt Vreugde M.Vreugde@Warwick.ac.uk

2. Key Questions  What psychological factors influence health behaviour?  Can we explain and predict health behaviour?  Can we use this understanding to change health behaviour?  Will interventions that change health behaviour actually benefit patients?

3. Behaviourism  Behaviour is a conditioned response occurring in the presence of a stimuli  If behaviour is learned, it can also be unlearned / modified through conditioned learning

4. Social Cognition Theories  Social cognition theories attempt to explain the relationship between social cognitions (e.g. beliefs, attitudes, goals, etc.) and behaviour  Health Belief Model (Rosenstock, 1966)  Theory of Planned Behaviour (Ajzen, 1988)  Transtheoretical Model (Prochaska and DiClemente, 1983)

5. Health-Belief Model (HBM) Health Behaviour Perceived Threat Perceived Severity Perceived Efficacy Perceived Susceptibility Perceived Benefits Perceived Barriers (Rosenstock, 1966)

6. Using the HBM in clinical practice Example (Changing a risky health behaviour: Smoking) Exploring perceived susceptibility and severity How do you think smoking is affecting your health? (current susceptibility) How might it affect your health in ten years time? (future susceptibility) What would it be like if that happened to you/you got the illness (Severity) Perceived benefits and barriers What are the pros of smoking for you? (current benefits) What are the benefits of stopping smoking for you? (future benefits) Is there anything stopping you from giving up? (current barriers)

7. Theory of Planned Behaviour (TPB) Behaviour Behavioural Attitude Subjective Norm Perceived Behavioural Control Behavioural beliefs + Outcome evaluation Normative beliefs + Motivation to comply Control beliefs + Self-efficacy Behavioural Intention (Ajzen, 1988)

8. Using the TPB in clinical practice Changing a risky health behaviour: Smoking Behavioural Attitude (Behavioural beliefs + Outcome Evaluation): What do you think about smoking? Is smoking a good or bad for you? In what way? [Educate!] Subjective Norms (Normative beliefs + Motivation to comply): What do your family/friends/partner think about you smoking? (normative beliefs) Whose opinion is most important to you? (motivation to comply) Would you like to give up smoking for (person)? (motivation to comply) Perceived behavioural control (Control Beliefs + Self-Efficacy): Do you think you can give up smoking? If perceived control is low explore reasons why and challenge beliefs. If perceived control is high, the patient is ready to attempt behaviour change and you should work with patients to plan next steps. Behavioural Intentions Have you ever thought about giving up smoking? Do you intend to give up smoking in the next few months?

9. Precontemplation Preparation Contemplation Maintenance Action Relapse Transtheoretical Model (aka Stages of Change)

10. Definitions  Behaviours that patients engage in once they believe that they are ill. The belief can be objective or subjective; confirmed or suspected, self or other notified.  A patient’s implicit understanding of their health status based on common-sense beliefs about their illness, e.g. beliefs about the cause, course and consequences of the illness  Clustering of related beliefs which provide a framework for an understanding, or picture, of illness that serves to direct coping responses and illness behaviour  Illness behaviour:  Illness beliefs:  Illness representations:

11. Illness Representations  Five belief dimensions:  Identity: what is it?  Cause: what caused it?  Time: how long will it last?  Consequence: how will it impact my life?  Control-Cure: can it be treated, controlled, managed, etc?  Illness representations direct illness behaviours

12. Identity  Identity refers to the (diagnostic) label patients give to their illness  What you feel your disease is  Illness beliefs may be incorrect and / or unhelpful  Labels bias the interpretation and assimilation of illness-related information  Increased importance of label-relevant information, i.e. attentional bias  Interpret new information (e.g. symptoms) in light of dominant illness representation  Assimilate new information if consistent with current beliefs, i.e. reject inconsistent / disconfirming information

13. Cause  Patients develop ideas about the cause of their illness  Genetic; Lifestyle; Stress; Environmental; Chance; etc.  Causal beliefs influence treatment expectations:  Type, e.g. homeopathic or medical, pharmacological or psychological, intervention or watchful waiting, etc.  Adherence to treatment and advice influenced by degree of consistency with expectations  Causal beliefs influence emotional response to illness:  Cancer  self-blame; Genetic conditions  guilt and helplessness

14. Time  Three main timelines for illness  Acute (e.g. flu); Chronic (e.g. heart disease); Cyclical (e.g. hay fever)  Mismatch in perceived time and natural illness course is not uncommon  Hypertension commonly believed to be cyclical, e.g. high blood pressure only when stressed

15. Consequences  Perceived effect of illness on the patient’s life  Personal identity, social relationships, finances, etc.  Perceived severity of consequences is prognostic (Petrie et al., 2003)

16. Control-Cure  Beliefs about how an illness can be treated and the effectiveness of treatment  Patients who believe its possible to control illness are more likely to  Adapt to the consequences of the illness  Attend rehabilitation programmes  Adhere to treatment

17. Self Regulatory Model Interpretation Symptom perception, Social messages Appraisal Was my coping effective ? Coping Approach or avoidance coping Representation of illness Identity, cause, consequences, timeline, cure/control Emotional response to illness Fear, Anxiety, Depression (Leventhal 1980)