Health Psychology: Theory, Research and Practice - David F. Marks 2010
Theories, Models and Interventions
Theories, Models and Interventions for Health Behaviour Change
’A fresh approach is needed, yielding new theories and interventions that work.’
Fine and Feinman (2004)
We review the principal theories, models and interventions designed to explain, predict and control health behaviour. Most models and theories in health psychology are at the level of the individual and are based on constructs that are purported to be universally applicable. The models and theories have been widely applied for several decades to many health behaviours and scenarios. Self-reported intention to change, rather than actual behaviour, has often been the focus of attention. Unfortunately, the outcomes generally have been disappointing, including the as yet unsolved problem of the intention—behaviour gap. Our theoretical critique indicates the scope, and hope, for fresh lines of inquiry, including a new Homeostasis Theory of Well-being.
We explore here, in roughly chronological order, the most popular theoretical approaches to health psychology and evaluate their success with data from controlled studies and meta-analyses. The principal approach has been to construct individual-level theoretical concepts and models as a basis for studying people’s actions and choices. Many of the theories and models assume that humans are rational beings, i.e., that people use the information available to them in a rational manner. This assumption must always be viewed with suspicion as the importance of emotion and motivation can never be underestimated.
The goal of theories in psychology is to explain and predict behaviour which is anything a person says or does in response to internal or external events. In psychology, theorizing of the type described in this chapter is known as ’black box’ theorizing, because processes are represented as boxes with invisible, unknown workings inside. Interventions using this approach are based on preconceived, theoretical ideas. They may be described as ’top-down’ as they are constructed by the theorist, who decides what makes people behave in the way they do. The theorist makes use of internalized concepts and then tests the theory to see if it fits a controlled set of data.
We outline here eight theories that have informed the majority of interventions in health psychology: the health belief model, protection motivation theory, the theory of reasoned action, the theory of planned behaviour, the common sense model or self-regulation theory, the information—motivation—behavioural skills model, the transtheoretical or stages of change model, and social cognitive theory. For the aficionado, a more sanguine review is provided by Conner and Norman (2015).
The findings are a ’mixed bag’, and in-depth testing has not gone well for many of the models that can, respectfully, be viewed today as ’museum pieces’. Some are still actively admired, are being polished and worked on, and may yet yield results in the field of prevention. However, the flaws in many of the theories and models suggest a need for new approaches grounded in realistic assumptions about emotion, motivation, and the social and economic constraints of contemporary living that exist for the vast majority of people.
The Health Belief Model
The health belief model (HBM) was developed by Rosenstock (1966) more than 50 years ago. The HBM (see Figure 8.1) contained four central constructs:
1. Perceived susceptibility (an individual’s assessment of their risk of getting the condition).
2. Perceived severity (an individual’s assessment of the seriousness of the condition and its potential consequences).
3. Perceived barriers (an individual’s assessment of the influences that facilitate or discourage adoption of the promoted behaviour).
4. Perceived benefits (an individual’s assessment of the positive consequences of adopting the behaviour).
The likelihood of a behaviour is influenced by cues to action that are reminders or prompts to take action consistent with an intention. These cues to action can be internal (e.g., feeling fatigued) or external (e.g., seeing health promotion leaflets/posters or receiving personal communication from health professionals, family members, peers, etc.)
The aim of the HBM is to predict the likelihood of implementing health-related behaviour. Additional factors are included in the model: demographic factors (e.g., age, sex and socio-economic background), psychosocial factors (e.g., personality traits, peer influence, family, etc.) and structural factors (e.g., knowledge of the health condition or previous contact with the disease).
The HBM was tested in many studies and used as a theoretical framework for interventions. Jones et al. (2014) addressed the HBM as the theoretical basis for interventions to improve adherence. Of 18 eligible studies, only six used the HBM in its entirety and five measured health beliefs as outcomes, not behaviour. The authors’ conclusion stated: ’Intervention success appeared to be unrelated to [the] HBM construct addressed, challenging the utility of this model as the theoretical basis for adherence-enhancing interventions’ (Jones et al., 2014a: 253). This conclusion is an accurate reflection of the literature across the board. It can be truthfully stated that the HBM died a natural and fairly painless death. Other theories, to be discussed next, have been more resilient.
Figure 8.1 The health belief model
Protection Motivation Theory
Protection motivation theory (PMT) was developed by Rogers (1975) to describe coping with a health threat in light of two appraisal processes — threat appraisal and coping appraisal. It introduces a most basic human emotion into health protection: fear. Fear is widely used in campaigns and behavioural change interventions, yet empirical support for its use remains unconvincing. According to PMT, the appraisal of the health threat, basically one’s fear of the consequences of one’s actions, and the possible coping response result in an intention, or ’protection motivation’, to perform either an adaptive response or a maladaptive response. According to PMT, behaviour change is best achieved by appealing to an individual’s fears. The PMT proposes four constructs, which are said to influence the intention to protect oneself against a health threat:
1. The perceived severity of a threatened event (e.g., HIV infection).
2. The perceived probability of the occurrence, or vulnerability (e.g., the perceived vulnerability of the person to HIV).
3. The efficacy of the recommended preventive behaviour (i.e., how effective is the wearing of a condom?).
4. The perceived self-efficacy (e.g., the person’s confidence in putting a condom in place) (see Figure 8.2).
This theory takes account of both the costs and benefits of behaviour in predicting the likelihood of change. PMT assumes that protection motivation is maximized when:
· the threat to health is severe;
· the individual feels vulnerable;
· the adaptive response is believed to be an effective means for averting the threat;
· the person is confident in his or her abilities to complete successfully the adaptive response;
· the rewards associated with the maladaptive behaviour are small;
· the costs associated with the adaptive response are small.
Such factors produce protection motivation and subsequently an adaptive, or coping, response (Figure 8.2).
Figure 8.2 The four constructs and the two appraisal processes that result in protection motivation
Source: Adapted from Stroebe (2000)
Bui et al. (2013) carried out a systematic review on protection motivation theory and physical activity in the general population. The authors concluded that ’the PMT shows some promise, however, there are still substantial gaps in the evidence’ (Bui et al., 2013: 522).
A key component of this model is fear (perceived severity). Ruiter et al. (2014) reviewed six meta-analytic studies on the effectiveness of fear appeals. They concluded that coping information aimed at increasing perceptions of response effectiveness and especially self-efficacy is more important than presenting health information aimed at increasing risk perceptions and fear arousal. Attempts to change behaviour by appealing to fear receive only limited empirical support. The fear approach has fallen into disrepute and faded away. Alternative approaches seem more fruitful.
Theory of Reasoned Action and Theory of Planned Behaviour
The theory of reasoned action (TRA) includes three constructs: behavioural intention, attitude and subjective norm. The TRA is based on the assumption that a person is likely to do what he or she intends to do. The theory assumes that a person’s behavioural intention depends on the person’s attitude about the behaviour and subjective norms. The theory is illustrated in Figure 8.3.
Figure 8.3 The theory of reasoned action
Source: Fishbein and Ajzen (1975)
In spite of efforts to apply the TRA to health behaviour, it fails to capture the complexity of health experience. Like other models reviewed in this chapter, the TRA is based on the assumption of rationality, that human beings ordinarily make systematic and logical use of available information. It also assumes that human behaviour is determined by free choice in a manner that is unrestrained by political or economic factors, neglects the role of emotion and feelings, and does not incorporate self-efficacy and self-esteem. For these reasons, the theory failed to provide an explanatory account of health behaviour. Along came the theory of planned behaviour (TPB).
Behaviour is complex and rarely controlled with as much rationality as the TRA suggested. Sex, smoking, eating, and substance and alcohol use are all examples of behaviour that people have difficulty controlling in a completely rational and voluntary way. Ajzen (1985) added perceived behavioural control to produce the TPB (see Figure 8.4). In doing so, Ajzen produced the most cited theory in the history of psychology.
Perceived behavioural control refers to one’s perception of control over the behaviour, and reflects the obstacles and successes encountered in past experience with this behaviour. The TPB proposes that perceived behavioural control influences intentions and behaviour directly.
For the college student population, attitudes towards safe sex, condom use self-efficacy and beliefs about peer norms have all been shown to predict unsafe sexual activity (Lewis et al., 2009; Hittner and Kryzanowski, 2010). The success of the TPB in predicting safer sexual behaviour was reviewed in a meta-analysis published by Albarracín et al. (2001) (see below).
Figure 8.4 The theory of planned behaviour
Source: Ajzen (1991)
However, not all in the TPB garden has the sweet smell of roses. The important factors of moral norms (Godin et al., 2005), culture and religion also have a strong influence on behaviour but are are missing from the TPB. To give one of many examples, Sinha et al. (2007) studied sexual behaviour and relationships among black and minority ethnic (BME) teenagers in East London. They collected data from 126 young people, aged 15—18, mainly using focus groups in three inner London boroughs. Sexual behaviour was mediated by gender, religion and youth in ways not included in the TPB. A systematic review of 237 independent prospective tests found that the TPB accounted for only 19% of the variability in health behaviour (McEachan et al., 2011). This is typical of many systematic reviews.
Multiple studies concur that the TPB, and its many extensions and adaptations, fail to account for more than 20% of the variability in health behaviour. Thus, 80% of health behaviour variance is unexplained by the TPB. This is not an exciting amount of success. Sniehotta et al. (2014) suggested that it was ’time to retire’ the TPB. Unperturbed by the critics, Ajzen (2014) remained steadfastly convinced that the THP is ’alive and well’. Every holy cow needs its guru. Citations rain down like the monsoon, and the theory just will not be washed away.
The Common Sense Model
The ’common sense model’ (CSM), also known as the ’self-regulatory model’ (SRM) or ’Leventhal’s model’, was developed by Howard Leventhal and colleagues (Leventhal et al., 1980, 2003, 2016). In this approach, the patient is viewed as a problem solver, attempting to make sense of an illness. A key construct within the CSM is the idea of illness representations or ’lay’ beliefs about illness. These representations integrate with normative guidelines that people hold to make sense of their symptoms and guide any coping actions. Five components of illness representations in the CSM are: identity, cause, time-line, consequences and curability/controllability.
A systematic review determined whether people’s beliefs about their illness, expressed in CSM terms, prospectively predict adherence to self-management behaviours (e.g., attendance, medication, diet and exercise) in adults with physical illnesses (Aujla et al., 2016). Data from 52 studies were extracted, of which 21 were meta-analysed using correlation coefficients while the remainder were descriptively synthesized. The effect sizes for individual illness belief domains and adherence to self-management behaviours indicated very weak, predictive relationships. The authors concluded that ’Individual illness belief domains, outlined by the CSM, did not predict adherence to self-management behaviours in adults with physical illnesses’ (Aujla et al., 2016: 1).
Weinman et al. (1996) developed the Illness Perception Questionnaire (IPQ) to assess the cognitive representation of illness in the CSM. The predictive validity of a brief version of the IPQ was evaluated using correlations between illness perceptions and depression, anxiety, blood glucose levels and quality of life (Broadbent et al., 2015). Findings showed modest but reliable associations with outcome measures (0.25—0.49 for consequences, identity and emotional representations; −0.12 to −0.27 for personal control).
However, psychometric research used Rasch analysis to assess the validity of the IPQ—Revised to assess beliefs about diabetes in 470 participants with Type 2 diabetes and 71 participants with Type 1 diabetes (Rees et al., 2015). All IPQ—Revised scales were found to have psychometric issues, including poorly utilized response categories, poor scale precision and multidimensionality. Only four of the eight scales were found to be psychometrically adequate (Consequences, Illness coherence, Timeline cyclical and Emotional representations). Rees et al. (2015: 1340) concluded: ’the diabetes-specific version of the Illness Perception Questionnaire—Revised provides suboptimal assessment of beliefs held by patients with diabetes’.
Recent meta-analyses have found weak relationships between CSM mental representations and adherence (Brandes and Mullan, 2014; Law et al., 2014). One systematic review examined the use of the CSM to develop interventions for improving adherence to health care behaviours (medication and dietary/lifestyle) and assessed intervention effectiveness (Jones et al., 2016). Six of the nine studies (67%) obtained a statistically significant effect of the intervention on improving at least one aspect of adherence.
The CSM has been partially successful in predicting adherence, but the effects are modest. We return to the CSM in Chapter 15.
The Information—Motivation—Behavioural Skills Model
The information—motivation—behavioural skills model (IMBS; Fisher and Fisher, 1992, 2000) focuses on (yes, you guessed it) information, motivation and behavioural skills associated with wellness behaviours. According to the IMBS model, the learning of health-related information is a prerequisite to action in these areas. In the context of sexual health, HIV-related information is likely to include statements about HIV infection (e.g., ’Oral sex is safer than vaginal or anal sex’) designed to facilitate preventive behaviour. The IMBS model assumes that having the motivation to practise specific sex-related behaviours is necessary for the production of problem prevention or wellness promotion. Finally, sexuality-related behavioural skills are a third fundamental determinant of acting effectively to avoid sexual problems and achieving sexual well-being. The behavioural skills construct focuses on the person’s self-efficacy in performing sexual problem-prevention or well-being-related behaviours, including insisting on abstinence from intercourse, discussing and practising contraceptive use, and sexual behaviours that optimize a couple’s sexual pleasure. Barak and Fisher (2001) proposed an internet-driven approach to sex education using the internet based on the IMBS model. An illustration of the IMBS model applied to adherence in using HAART medication for HIV infection is shown in Figure 8.5.
Figure 8.5 The information—motivation—behavioural skills model
Source: Adapted from Fisher et al. (2006)
There have been many studies of the IMBS model in different settings. Eggers et al. (2014) tested the IMBS model with 1,066 students from Cape Town, South Africa to assess the hypothesized motivational pathways for the prediction of condom use during last sexual intercourse. Knowledge of how to use a condom and how STIs are transmitted directly predicted behaviour as hypothesized by the IMBS model. However, an alternative model had a higher proportion of significant pathways.
Mongkuo et al. (2012) applied the IMBS model to prevention education, prevention personal motivation and prevention knowledge on HIV infection prevention skills among black college students. Prevention HIV infection education motivation and HIV infection prevention knowledge had no significant effect on prevention behavioural skills, while HIV infection personal prevention knowledge emerged as having a significantly large effect in explaining HIV infection prevention behavioural skills among the students. The authors suggested that future studies should expand the exogenous variables in the IBMS model to include exposure to violent living conditions. The complexity of behaviour is quite difficult to capture in a model with only three process variables. However, the IBMS has enjoyed limited success.
The Transtheoretical or Stages of Change Model
The transtheoretical model (TTM), otherwise known as the ’Stages of Change Model’, was developed by Prochaska and DiClemente (1983). It is a general model that applies across all types of psychological change and which has been highly influential in the research literature. The TTM hypothesizes six discrete stages of change (see Figure 8.6), through which people are alleged to progress in making a change:
· Pre-contemplation — a person is not intending to take action in the foreseeable future, usually measured as the next six months.
· Contemplation — a person is intending to change in the next six months.
· Preparation — a person is intending to take action in the immediate future, usually measured as the next month.
· Action — a person has been making specific overt modifications in his/her lifestyle within the past six months.
· Maintenance — a person is working to prevent relapse, a stage that is estimated to last from six months to about five years.
· Either termination — an individual has zero temptation and 100% self-efficacy, or relapse — an individual reverts to the original behaviour.
The TTM has been tested in multiple studies with mixed results. For example, Velasquez et al. (2009) carried out a trial designed to reduce sexual risk behaviours and alcohol use among HIV - positive men who have sex with men. They used a stages of change-based intervention and also the technique of motivational interviewing (MI). Valasquez et al. found reductions in the number of drinks per 30-day period, the number of heavy drinking days per 30-day period, and the number of days on which both heavy drinking and unprotected sex occurred.
A meta-analysis by Noar et al. (2009) indicated that interventions using the Stages of Change Model were relatively effective. However, critics have suggested that the model contains arbitrary time periods and that the supportive evidence is meagre and inconsistent (e.g., Sutton, 2000a; West, 2005; Armitage, 2009). The TTM has been defended by its advocates (e.g., Diclemente, 2005; Prochaska, 2006), is resilient and remains popular as a model of change. Critics have offered nothing that is more valid in its place. If there is a better description than stages of change, what would that description be? For these reasons, it is likely that the TTM will continue to be an active focus for research and interventions.
Figure 8.6 The transtheoretical model or Stages of Change Model
Source: DiClementi and Prochaska (1983); Prochaska and Velicer (1997)
Box 8.1 The Stages of Change or Transtheoretical Model
According to the transtheoretical model (TTM), people making changes need:
· A growing awareness that the advantages (the ’pros’) of changing outweigh the disadvantages (the ’cons’) — decisional balance.
· Confidence that they can make and maintain changes in situations that tempt them to return to their old, unhealthy behaviour — self-efficacy.
· Strategies that can help them make and maintain change.
The ten processes of change are:
1. Consciousness-raising — increasing awareness via information, education and personal feedback about the healthy behaviour.
2. Dramatic relief — feeling fear, anxiety or worry because of the unhealthy behaviour, or feeling inspiration and hope when they hear about how people are able to change to healthy behaviours.
3. Self-reevaluation — realizing that the healthy behaviour is an important part of who they are and want to be.
4. Environmental reevaluation — realizing how their unhealthy behaviour affects others and how they could have more positive effects by changing.
5. Social liberation — realizing that society is more supportive of the healthy behaviour.
6. Self-liberation — believing in one’s ability to change, and making commitments and recommitments to act on that belief.
7. Helping relationships — finding people who are supportive of their change.
8. Counter-conditioning — substituting unhealthy ways of acting and thinking for healthy ways.
9. Reinforcement management — increasing the rewards that come from positive behaviour and reducing those that come from negative behaviour.
10. Stimulus control — using reminders and cues that encourage healthy behaviour as substitutes for those that encourage the unhealthy behaviour, such as masturbation.
One angle that stage models offer is that of the stage-matched intervention to change behaviour (Dijkstra et al., 2006). In this, the content of intervention is adapted to the different stages that people are in. This should make them more effective than standardized interventions. The study by Dijkstra et al. (2006) found, at two-month follow-up, that matched interventions were significantly more effective (44.7%) than were mismatched interventions (25.8%; odds ratio = 2.78; confidence interval = 1.85—4.35). For another review of the TTM, see Heather and Hönekopp (2013).
The Social Cognitive Theory of Bandura
Bandura’s (1986) social cognitive theory (SCT) examines the social origins of behaviour in addition to the cognitive thought processes that influence human behaviour. Bandura’s social-cognitive approach proposes that learning can occur through the observation of models in the absence of any overt reinforcement. The acquisition of skill and knowledge has an intrinsic reinforcement value independent of biological drives and needs. Two key planks in the social-cognitive platform are observational learning and self-efficacy.
Bandura observed that people learn by watching or observing others, reading about what people do, and making general observations of the world. This learning may or may not be demonstrated in the form of behaviour. Bandura proposed a four-step conceptual scheme for observational learning:
· Step 1: attentional processes, including certain model characteristics that may increase the likelihood of the behaviour being attended to and the observer characteristics, such as sensory capacities, motivation and arousal levels, perceptual set, and past reinforcement.
· Step 2: retention processes, including the observer’s ability to remember and to make sense of what has been observed.
· Step 3: motor reproduction processes, including the capabilities that the observer has to perform the behaviours being observed. Specific factors include physical capabilities and availability of responses.
· Step 4: motivational processes, including external reinforcement, vicarious reinforcement and self-reinforcement. If a behaviour is to be imitated, an observer must be motivated to perform that behaviour.
Bandura (1994: 71) defined the concept of ’perceived self-efficacy’ as:
People’s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives. Self-efficacy beliefs determine how people feel, think, motivate themselves and behave. Such beliefs produce these diverse effects through four major processes. They include cognitive, motivational, affective and selection processes.
Self-efficacy is a person’s belief that they have behavioural competence in a particular situation (’I can do it’). It is related to whether or not an individual will undertake particular goal-directed activities (’I will do it’), the amount of energy that he or she will put into their effort (’I want to do it’) and the length of time that the individual will persist in striving to achieve a particular goal (’I need to do it’). Among the sources of self-efficacy are:
· performance accomplishments: past experiences of success and failure (’I have already done it’);
· vicarious experience: witnessing others’ successes and failures (’I saw somebody do it’);
· verbal persuasion: being told by others that one can or cannot competently perform a particular behaviour (’You can do it’);
· emotional arousal: when engaging in a particular behaviour in a specific situation (’I would love to do it’).
The self-efficacy concept has been widely applied in studies and interventions. Models of human health behaviour — the PMT, the HBM, and TPB — include self-efficacy as an important component. Self-efficacy refers to one of the ’truths’: believing that we can accomplish what we want to accomplish is ’one of the most important ingredients — perhaps the most important ingredient — in the recipe for success’ (Maddux, 2002: 277). Self-efficacy can be viewed as one of the sources of the human meaning of life. Major human needs related to subjective fulfilment include purpose, value, self-efficacy and self-worth (Baumeister and Vohs, 2002). The concept mirrors the self-help literature of the kind Dale Carnegie founded on the principle that people can achieve great things by believing that they can do so, so-called ’positive thinking’. Carnegie (1913) was an erudite scholar of the art of rhetoric who believed that reading yielded priceless knowledge. Ideas about positive thinking and self-efficacy are very prevalent in popular culture. Carnegie’s ideas have appeared in the writings of other leading self-development ’gurus’, such as Norman Vincent Peale (The Power of Positive Thinking, 1952) and Wayne Dyer (Your Erroneous Zones, 1976).
Bandura has made some extremely important observations about human learning and thought. Observational learning and self-efficacy are invaluable concepts. However, critics argue that the relationship between the concepts is not clear. Others say it’s just common sense, written in abstract jargon.
Attempts at Theoretical Integration
The great range and variability in theories, models and concepts call for integration. One integrated model is the ’COM-B’ that focuses on capability, opportunity and motivation, and the ’Behaviour Change Wheel’ (Michie and Wood, 2015). An analysis of 83 theories and frameworks included 1,659 constructs in three dimensions: comprehensiveness, coherence and a clear link to an overarching model of behaviour. The Behaviour Change Wheel has been proposed for physical activity, weight loss, hand hygiene, dental hygiene, diet, smoking, medication adherence, prescribing behaviours, condom use and female genital mutilation.
One critic questioned whether the COM-B and the Behaviour Change Wheel ’can ever be tested’ and points out that it remains ’unclear how it can be ever falsified if its constructs remain broad and all encompassing. … And does it promote and facilitate creativity in those that do the thinking?’ (Ogden, 2016: 7). An excellent question.
The complex array of theories and models can be a little overwhelming. Theories are often poorly applied and interventions suffer because they lack empirical support. One way of making progress would be to determine a consensus among knowledgeable researchers about what works and what doesn’t. Michie et al. (2005) developed a consensus on theoretical constructs, a ’Theoretical Domains Framework’ (TDF), in six phases: (1) identifying theoretical constructs; (2) simplifying into domains; (3) evaluating the domains; (4) interdisciplinary evaluation; (5) validating; and (6) piloting interview questions. The contributors were a ’psychological theory’ group (n = 18), a ’health services research’ group (n = 13) and a ’health psychology’ group (n = 30). A total of 12 domains were initially identified, which were later refined to 14 domains: Knowledge, Skills, Social/professional role and identity, Beliefs about capabilities, Optimism, Beliefs about consequences, Reinforcement, Intentions, Goals, Memory, attention and decision processes, Environmental context and resources, Social influences, Emotions and Behavioral regulation (Cane et al., 2012).
A questionnaire was designed to facilitate the use of the TDF in practice change (Huijg et al., 2014). A systematic literature review comparing the original with the refined TDF found that the ’environmental context and resources’, ’beliefs about consequences’ and ’social influences’ were the three domains most frequently cited in the reviewed studies (84%, 74%, and 66%, respectively; Mosavianpour et al., 2016). This finding is consistent with the idea that self-control is constrained, as we stated in a previous chapter: ’what individuals can do to change their lives is not simply a matter of personal choice — choices are constrained biologically, culturally, economically and environmentally’. These constraints are one of the reasons that individual-level black-box models and theories are unable to explain more than 20% of health behaviour.
Intentions versus Behaviour and the ’Intention—Behaviour Gap’
The evidence from studies of the models and theories is that it is relatively easy to predict the self-reported intention to act, but more difficult to predict action itself. It is commonly the case that a person develops an intention to change their health behaviour (e.g., to stop smoking), but they might not take any action (e.g., actually to stop smoking). This discrepancy has been labelled the ’intention—behaviour gap’. What leads to the translation between an intention and an action is reduced in many models to an arrow between two black boxes. However, we need to breakdown intention into two phases: goal intention and implementation intention (Gollwitzer, 1993, 1999; Gollwitzer and Brandstätter, 1997). Goal intention is a commitment towards a goal (’I intend to achieve the goal X’), while implementation intention is about the necessary action (’I intend to initiate the behaviour Y in situation Z’). This second phase is not addressed in the models but is a key part of the process of performing a behaviour.
We know that unhealthy behaviour is more common among lower SES groups, which helps to create health inequalities. One possibility is that the intention—behaviour gap is wider among the lower SES groups. Vasiljevic et al. (2016) tested this hypothesis using objective and self-report measures of three behaviours, pooling data from five studies. The intention—behaviour gap did not vary with deprivation for diet, physical activity or medication adherence in smoking cessation. However, they did find a larger gap between perceived control over behaviour (self-efficacy) and behaviour in the more deprived. Choices are especially constrained economically and environmentally among lower SES groups, regardless of the good intentions to change towards healthier behaviours.
Interventions to plug the intention—behaviour gap have been employed, such as self affirmation tasks, planning or implementation intentions. These have met with some limited success (Steele, 1988; Gollwitzer, 1993; Gollwitzer and Sheeran, 2006; Epton et al., 2015; Synergy Expert Group, 2016: 1). Another approach has been to catelogue behaviour change techniques with the aim of making interventions repeatable and replicable. As we shall see, the hype has run ahead of the actual results.
Behaviour Change Techniques
A behaviour change technique (BCT) is a systematic procedure (or a category of procedures) included as an active component of an intervention designed to change behaviour. The defining characteristics of a BCT are that it is:
4. A component of an intervention designed to change behaviour.
8. A postulated active ingredient within the intervention (Michie et al., 2011).
A BCT taxonomy has been employed to code descriptions of intervention content into behaviour change techniques (Michie et al., 2011). The taxonomy aims to code protocols in order to describe transparently the techniques used to change behaviour. If the protocols can be made clearer, then studies can be replicated (Michie and Abraham, 2008; Michie et al., 2011). A taxonomy can also be used to identify which techniques are most effective so that intervention effectiveness can be raised and more people will be able to change their behaviour. Two reviewers independently coded BCTs and then discussed their presence/absence. Fidelity of treatment refers to confirmation that the manipulation of the independent variable occurred as planned. A 30-item Treatment Fidelity Checklist (Borrelli, 2011) was used to assess whether treatment fidelity strategies were in place with regard to study design, interventionist training, treatment delivery, treatment receipt and treatment enactment. Percentage scores for each area were awarded to reflect the proportion of items with evidence of at least one treatment fidelity strategy.
A total of 27 BCTs were identified across 5 interventions with a mean number of BCTs coded per intervention of 10 and a range of 4 to 15. Michie et al. (2011) found that the most frequently occurring BCT was ’problem solving’, which occurred in four of the five interventions. Three BCTs were coded in three out of five interventions: ’information about social and environmental consequences’, ’reduce negative emotions’ and ’pros and cons’. All studies measured outcomes using self-reports.
The production of a structured list of BCTs provides a ’compendium’ of behaviour change methods that helps to map the domain of behaviour change and inform practitioner decision-making. However, it also risks becoming a prescriptive list of ingredients for a ’cook-book’ of which therapeutic techniques must be applied to patients presenting with a specific behavioural problem.
Another problem with the compendium approach is that BCTs are not all optimally effective when combined in a ’pick-and-mix’ fashion. There needs to be a coherence to the package of BCTs, and the BCTs need to be combined in the right amounts and proportions. This optimum mix of ’ingredients’ can only be provided by a theory that offers power and meaning and connects the BCT components into an integrated and coherent combination. To use again the analogy of baking, if you have eggs, flour, baking powder, salt and pepper but no recipe and no chef, the ingredients are useless. If the ingedients fall into the wrong hands and are badly combined, the outcomes could well be disastrous (Figure 8.7). There is a need for a coherent theory and expertise to provide structure and meaning both for the change agent (chef) and the client (diner).
Figure 8.7 I have everything I need except I don’t know how to cook
Source: Ngkrit’s portfolio, Photo ID: 287581859, acquired via Shutterstock
By way of illustration, consider an intervention for smoking cessation, Stop Smoking Now (Marks, 2017b). This integrative therapy is an effective method for clearing the human body of nicotine. The desire to smoke and any satisfaction gained from smoking are abolished using a combination of BCTs consisting mainly of different forms of cognitive behavioural therapy (CBT) and mindfulness meditation. Stop Smoking Now includes 30 BCTs integrated within a coherent theory of change based on the concept of homeostasis (Chapter 2). In Stop Smoking Now, a structured sequence of BCTs is provided that takes into account the nesting of BCTs such that guided imagery works best in combination with relaxation and both of these work best following enhancement of self-efficacy, which is achieved using self-recording, positive affirmations and counter-conditioning. In a theory of change, the whole is always more than the sum of the parts.
Of equal importance to the necessary theory of change, which is required to integrate the BCTs, is the quality of the change agent.
Behaviour Change Agents
We find it helpful to use an analogy that there is more to baking a cake than the ingredients. Of course, one needs a good set of ingredients (the BCTs), but one also needs a good baker — the behaviour change agent (BCA). The BCA/therapist must be fit for purpose and so fully capable and competent to deliver the BCTs in a persuasive, stylish and professional manner. The qualities of effective therapists have been studied for at least 50 years. It is an oversight that people working on BCTs tend to neglect the importance of the ’baker’ — the all-important BCA.
In a recent critique of the cookbook approach, Hilton and Johnston (2017) point out that: ’In essence, the where, when, why, who and how of practice has been relatively ignored in favour of vague suggestions of what practice ingredients might include’ (Hilton and Johnston, 2017: 2).
The role of empathy, the ability to understand and share the feelings of another, in therapy, medicine and prosocial behaviour, has been accepted for centuries. Originally a part of ’sympathy’ (e.g., Smith, 1759/1948; Darwin, 1888), the English word empathy is derived from the Ancient Greek word ἐμπάθεια (empatheia, ’physical affection or passion’). The term had been adapted in German as Einfühlung (’feeling into’), which was translated by Titchener to become empathy (Titchener, 1909/2014).
In 1957 the therapist Carl Rogers listed the necessary and sufficient conditions for constructive change:
· Two persons are in psychological contact.
· The first, whom we shall term the client, is in a state of incongruence, being vulnerable or anxious.
· The second person, whom we shall term the therapist, is congruent or integrated in the relationship.
· The therapist experiences unconditional positive regard for the client.
· The therapist experiences an empathic understanding of the client’s internal frame of reference and endeavors to communicate this experience to the client.
· The communication to the client of the therapist’s empathic understanding and unconditional positive regard is to a minimal degree achieved.
· No other conditions are necessary. If these six conditions exist, and continue over a period of time, this is sufficient. (Rogers, 1957: 2)
Research over many decades has confirmed the positive role of empathy in medical and psychological practice, along with other characteristics such as warmth (Rollnick et al., 1992; Marshall, 2002; Skinner and Spurgeon, 2005; Avenell, 2006; Hassed et al., 2009). Therapists’ interpersonal style, empathy and communication skills are essential requirements for successful behaviour change (Hagger and Hardcastle, 2016). Hiding empathy within a BCT called ’social support (emotional)’, as suggested by Michie et al. (2008), is inaccurate. Empathy and the ability to strengthen the therapeutic alliance are necessary characteristics of a successful behaviour change agent. To quote Hilton and Johnston (2017): ’a key factor...to the success of treatment is the strength of the therapeutic alliance (Roth and Fonagy, 2005). More than 30 years of psychotherapy research has shown therapeutic alliance to be a consistent predictor of outcomes’ (Hilton and Johnston, 2017: 2).
In contrast with an almost obsessional effort to categorize BCTs, there has been hardly any research effort in health psychology on specifying the essential characteristics of the successful BCA: empathy, warmth and positivite regard. However, there are some interesting studies on the part played by these characteristics in motivational interviewing (e.g., Miller and Rose, 2009) and mindfulness training (e.g., Birnie et al., 2010). Empirical evidence suggests that empathy is teachable, for example to undergraduate medical students (Batt-Rawden, 2013) or physicians (Riess et al., 2012; Kelm et al., 2014). A related construct of ’charisma’ has been discussed in the context of leadership in organizational change (Bryman, 1992) and group therapy, for example with substance abusers (Woodward and McGrath, 1988) and diabetes patients (Tattersall et al., 1985). To neglect the key variables of the BCA ’ignores the need for flexibility, variability and change according not to the type of behaviour, or the type of intervention or even the type of patient but how that individual patient happens to feel, think, look, behave or respond at any particular time’ (Ogden, 2016). It is essential to explore not only the what, but the where, when, why, who and how of implementation science in putting theory into practice.
Critique of Individual-Level Theories and Models
In spite of widespread use in health psychology research, the evidence does not justify any confidence in the majority of theories and models reviewed in this chapter. The outcome of meta-analyses of theory testing paints a disappointing picture. The pattern of evidence suggests that current psychological theories and models do not provide a viable foundation for effective interventions. We analyse some of the reasons for this situation in the following paragraphs.
Choice and responsibility are internalized as processes within individuals in a similar way to the operating system of a computer. The human ’operating system’ is assumed to be universal and rational, following a fixed set of formulae that the models attempt to describe. Yet even within its own terms, the programme of model testing and confirmation is failing to meet the goals it has set.
Lack of Ecological Validity and Questionable Statistical Methods
Thousands of published studies have used null hypothesis testing with small samples of college students or patients. The power, ecological validity and generalizability of these studies is questionable. We do not really know their true merit because of uncertainties about representativeness, sampling and statistical assumptions. Rarely are alternative approaches to theory testing utilized (e.g., Bayesian statistics and power analyses) to assess the importance of the effects rather than their statistical significance (Cohen, 1994).
Most studies use self-reported measures of intention and behaviour rather than objective measures. This always presents a huge problem! It means that the academic studies have little contact with the universe of real-world, objective behaviour.
Neglect of Culture, Religion and Gender
Religion, culture and gender are neglected by most socio-cognitive models. The models aim at universal application, which is unachievable.
Some strident critics have suggested that the models are tautological and therefore unfalsifiable (Smedslund, 2000; Ogden, 2003). A tautology is a statement that is necessarily true, e.g., ’Jill will either stop or not stop smoking’ or ’the earth is a sphere’ (not ’The earth is round (p < .05)’, as one famous paper would have it! — Cohen, 1995). Whatever data we obtain about Jill’s smoking, the statement will always be true; it is a very safe prediction. Smedslund (2000) further deduced that, if tautological theories are disconfirmed or only partially supported by empirical studies, then the studies themselves must be flawed for not ’discovering’ what must be the case! Bad models can only be supported by bad research. Others have argued that behavioural beliefs (attitudes) and normative beliefs are basically the same thing. Ogden (2003) analysed empirical articles published between 1997 and 2001 from four health psychology journals that tested or applied at least one social cognition model (the theory of reasoned action, the theory of planned behaviour, the health belief model, and protection motivation theory). Ogden concluded that the models do not enable the generation and testing of hypotheses because their constructs are unspecific. Echoing Smedslund (2000), she suggested that the models focus on analytic truths that must be true by definition.
However, not all theorists agree that social cognition models (SCMs) are tautological and/or unfalsifiable. Trafimow (2009) claimed to have demonstrated that the TRA and TPB are falsifiable because these theories make risky predictions. Furthermore, he claimed to have falsified one of the assumptions of the TPB, namely, that perceived control is a worse predictor of behavioural intentions than perceived difficulty (Trafimow et al., 2002). Yet perceived behavioural control is usually measured by items evaluating control and items evaluating difficulty. If empirical falsification of the TPB has actually occurred then the theory must, ipso facto, be falsifiable, and one of the main criticisms has been eliminated.
The transtheoretical model has received particular criticism. Sutton (2000b) argued that the stage definitions are logically flawed, and that the time periods assigned to each stage are arbitrary. Herzog (2008) suggested that, when applied to smoking cessation, the TTM does not satisfy the criteria required of a valid stage model and that the proposed stages of change ’are not qualitatively distinct categories’.
French et al. (2007) investigated what people think about when they answer TPB questionnaires using the ’think aloud’ technique. They found problems relating to information retrieval and to participants answering different questions from those intended. They concluded that ’The standard procedure for developing TPB questionnaires may systematically produce problematic questions’ (French et al., 2007: 672).
Neglect of Motivation
Another common complaint about the SCMs is that they do not adequately address the motivational issues about risky behaviours. Surely it is their very riskiness that in part is responsible for their adoption. Willig (2008: 690) questioned the assumption that lies behind behind much of health and sex education ’that psychological health is commensurate with maintaining physical safety, and that risking one’s health and physical safety is necessarily a sign of psychopathology’. On the basis of current evidence, grand theories claiming universal application are lacking any empirical support.
Studies measuring social cognitions rely upon questionnaires that presuppose that cognitions are stable entities residing in people’s heads. They do not allow for contextual variables that may influence social cognitions. For example, an individual’s attitude towards condom use may well depend upon the sexual partner with whom they anticipate having sexual contact. It may depend upon the time, place, relationship and physiological state (e.g., intoxication) within which sex takes place.
Economics of health care
The ability of health care practitioners to provide face-to-face therapy to change behaviour is far outstripped by need. Attempts to provide distance cost-effective treatments include bibliotherapy (Glasgow and Rosen, 1978; Marrs, 1995) and internet-based self-help treatment with minimal therapist contact (e.g., Carlbring et al., 2006; Riper et al., 2014). Another option is mobile health or m-health, the practice of medicine, health psychology and public health supported by mobile devices. The internet, text messaging and social networking enable m-health tools for health promotion and risk reduction. This is an area that is rapidly changing. Current m-health interventions and programmes include: mobile phone text messaging to support patients with diabetes, hypertension, asthma, eating disorders and HIV treatment; mobile text messaging and personal digital assistants (PDAs) as aids to smoking cessation, body weight loss, reducing alcohol consumption, sexually transmitted infection prevention and testing; and PDAs for data collection and to support health education and clinical practice (Phillips et al., 2010). There is great potential for extending the range of application of m-health in low-income countries as access to mobile phones in these regions increases.
Apps are being increasingly used for the delivery of interventions designed to promote health behaviour change. Webb et al. (2010) found that interventions had a small but significant effect on health-related behaviour. Interventions that incorporated more BCTs also tended to have larger effects compared to interventions that incorporated fewer techniques. Effectiveness of internet-based interventions was enhanced by the use of SMS reminders.
As noted above, e- and m-health have become popular approaches for attempting to improve population health. The efficacy of behavioural nutrition interventions using e-health technologies to decrease fat intake and increase fruit and vegetable intake has been demonstrated, with approximately 75% of trials showing positive effects (Olson, 2016). However, objective measures are rarely available and almost total reliance is placed on self-reported measures of behaviour.
The Elephant in the Room: The Persistence of Error
There is an embarrassing, unanswered question about theories and models in psychology that is screaming to be answered. If the evidence in support of SCMs is so meagre and feeble, how have they survived for such a long time? The scientific method is intended to be a fail-safe procedure for abandoning disconfirmed hypotheses and progressing with improved hypotheses that have not been disconfirmed. The psychologists who dream up these theories and test them claim to be scientists, so what the heck is going on?
One reason why theories and models become semi-permanent features of textbooks and degree programmes is that simple rules at the very heart of science are persistently broken. If a theory is tested and found wanting, then one of two things happens: either (1) the theory is revised and retested or (2) the theory is abandoned. The history of science suggests that (1) is far more frequent than (2). Investigators become attached to the theories and models that they are working with, not to mention their careers, and they invest significant amounts of time, energy and funds in them, and are loath to give them up — a bit like a worn-out but comfortable armchair. Not for nothing, Max Planck, originater of quantum theory in Physics, stated that Science advances one funeral at a time. Nothing dishonest seems to be happening; it is simply an unwitting bias to confirm one’s theoretical predilections. This is the well-known confirmation bias studied by — yes, you guessed it — psychologists (e.g., Nickerson, 1988).
The process of theory or model testing is illustrated in Figure 8.8. The diagram shows how the research process insulates theories and models against negative results, leading to the persistence of error over many decades. Continuous cycles of revisions and extensions following meagre or negative results protect the model from its ultimate abandonment until every possible amendment and extension has been tested and tried and found to be wanting. Several methods of protection are available to investigators in light of ’bad’ results: (1) amend the model and test it again, a process that can be repeated indefinitely; (2) test and retest the model, ignoring the ’bad’ results until some positive results appear, which can happen purely by chance (a Type 2 error); (3) carry out some ’statistical wizardry’ to concoct a more favourable-looking outcome; (4) do nothing, i.e., do not publish the findings; and/or (5) look for another theory or model to test and start all over again! Beside all of these issues, there is increasing evidence of a lack of replication, the selective publication of positive findings and outright fraud in psychological research, all of which militate against the authentic separation of fact from fantasy (Yong, 2012).
Little attention has been paid to the cultural, socio-political and economic conditions that create the context for individual health experience and behaviour (Marks, 1996). Thousands of studies have accumulated to the evidence base that is showing that the socio-cognitive approach provides inadequate theories of behaviour change. Any theory that neglects the complex cognitive, emotional and behavioural conditions that influence human choices is unlikely to be fit for purpose. Furthermore, as discussed in previous editions, health psychology theories are disconnected from the known cultural, socio-political and community contexts of health behaviour (Marks, 2002a). Slowly but surely these issues are becoming more widely recognized across the discipline and, at some point in the future, could become mainstream.
Figure 8.8 Another thing most textbooks don’t tell you: the persistence of error — the manner in which a model or theory is ’insulated’ against negative results
As we have seen, critics of the socio-cognitive approach have suggested that SCMs are tautological and irrefutable (Smedslund, 2000; Ogden, 2003). If this is true, then no matter how many studies are carried out to investigate a social cognitive theory, there will be no genuine progress in understanding. Weinstein (1993: 324) summarized the state of health behaviour research as follows: ’despite a large empirical literature, there is still no consensus that certain models of health behaviour are more accurate than others, that certain variables are more influential than others, or that certain behaviours or situations are understood better than others’. Unfortunately, there has been little improvement since then. The individual-level approach to health interventions focuses on theoretical models, piloting, testing and running randomized controlled trials to demonstrate efficacy. It has been estimated that the time from conception to funding and completing the process of demonstrated effectiveness can take at least 17 years (Clark, 2008). The meta-analyses, reviewed above, suggest that the ’proof of the pudding’ in the form of truly effective individual-level interventions is yet to materialize. Alternative means of creating interventions for at-risk communities and population groups are needed.
Homeostasis Theory of Well-Being
A new theory proposes that behaviour and experience follow the principle of homeostasis (Marks, 2015, 2016, 2018). It is established across multiple fields of natural science that homeostasis is a singular unifying principle for all living beings. In the theory, which extends this well-known principle from Physiology to Psychology, all human behaviour and experience, including health protection and illness prevention, and the regulation of emotion, are under homeostatic control.
Homeostasis operates at all levels of living systems: in molecules, cells, tissues, organs, organisms, societies, ecosystems and the planet as a whole (Lovelock and Margulis, 1974). Tissue homeostasis regulates the birth (mitosis) and death (apoptosis) of cells; many diseases are directly attributable to defective homeostasis, leading to the overproduction or underproduction of new cells relative to cell deletion (Fadeel and Orrenius, 2005). Biochemical and physiological feedback loops regulate billions of cells and thousands of compounds and reactions in the human body to maintain body temperature, metabolism, blood pH, fluid levels, blood glucose and insulin concentrations inside the body (Matthews et al., 1985). A body in good physical health is in biochemical and physiological homeostasis. Severe disruptions of homeostasis cause illnesses or can even be fatal.
A person in good health is in a state of homeostatic balance that operates across systems of biochemical, physiological, psychological and social homeostasis. Outward and inward stability in a living being is only possible with constant accommodation and adaptation. All living beings strive to maintain equilibrium and stability with the surrounding environment through millions of micro-adjustments and adaptations to the continuously changing circumstances. Adjustments and adaptations can be both conscious and unconscious. The majority of fine adjustments are occurring at an unconscious level, hidden from both external observers and the individual actor. The Homeostasis Theory of Well-being utilizes the fact that human beings are natural agents of change who adapt, accommodate and ameliorate under continuously changing conditions, both external and internal, to maximize the stability of physical and mental well-being. The Homeostasis Theory of Well-being (HTW) is illustrated in Figure 8.9.
Well-being is the outcome of a multiplex of continuously changing feedback loops in a system of psychological homeostasis, which has four main component processes: well-being, cognitive appraisal, emotion and action. Homeostasis maintains both physical and psychological equilibrium with the ever-changing external and internal environments, courtesy of an infinitude of micro-feedback-systems that fall within the four main macrosystems defined above. Psychological homeostasis regulates through feedback loops that control thought, emotion and action. Continuously flexible micro-adjustments of activity within feedback loops maintain equilibrium from moment to moment. Psychological homeostasis occurs in response to the infinite variety of circumstances that can affect well-being, including both internal adjustments (e.g., emotional regulation) and external adjustments using deliberate behavioural regulation (e.g., communicating, working, eating and drinking). In synchrony and synergy with all of the body’s other homeostatic mechanisms, psychological homeostasis operates throughout life during both waking and sleeping.
Figure 8.9 The Homeostasis Theory of Well-being
In prevention and treatment of clinical conditions, individuals can help themselves and be helped by external techno aids to monitor and maintain physiological variables using behavioural forms of homeostasis, e.g., in diabetes, metabolic syndrome, hypertension, thyroid problems, skin disorders such as urticaria, or obesity. Biochemical, physiological and psychological homeostasis are of similar complexity. Behavioural forms of homeostasis occur in actions designed to support neural systems of regulation. Social homeostasis in supportive actions by other humans, requested or volunteered, provides another way to support and protect an individual’s well-being.
Inputs to homeostasis include technological systems such as: (1) scales for measuring body weight; (2) thermometers to measure body temperature; (3) pulse measurements; (4) electro-mechanical homeostasis, developed by engineers to enhance human control systems such as heating (thermostat), driving (cruise control), navigation (automatic pilot), and space exploration (computer navigation systems); (5) life support systems (e.g., artificial respirators, drip feeding, kidney dialysis, intensive care units); (6) medical and surgical interventions; (7) pharmaceutics; (8) alternative and complementary therapies; (9) yoga and meditation; and (10) all forms of behavioural and psychological therapy
1. People are social and emotional beings, and these features need to be restored into theories and models of behaviour and behaviour change.
2. Future research must look at the potential of m-health as a tool for engaging people of all ages in health promotion and risk reduction.
3. Changing the focus from individuals to communities and populations would also be a sensible decision in maximizing the impact of interventions.
4. The Homoestasis Theory of Well-being needs to be tested in randomized controlled trials and prospective studies to determine its scientific validity and applicability to health care.
1. Individual-level theories and models are based on universal constructs concerning behavioural adoption, maintenance and change.
2. Thousands of studies and meta-analyses have tested individual-level, social cognitive theories and models with mixed success. Only modest amounts of variation in intentions and behaviour are accounted for using a social cognitive approach.
3. Critics have suggested that individual-level theories and models of social cognition are flawed, unfalsifiable and tautological. On the other hand, others have attempted to integrate theory to produce improved prediction and intervention.
4. A major obstacle has been the ’intention—behaviour gap’. Attempts to bridge the gap, such as the implementation-of-intentions approach, are having some success.
5. Seemingly insulated from the disconfirming results, many theories and models continue to be the main focus for research and interventions. If health psychology is to show its full potential, it will be essential to develop a properly scientific method based on a valid theoretical approach, which to date has not been provided.
6. Another project has been to classify behaviour change techniques into a taxonomy. From this, it is hoped that different techniques can be combined to maximize the chance of successful outcomes. Critics have suggested that creativity, empathy and therapist delivery may be cramped by taxonomic treatments.
7. Another approach is the use of bibliotherapy, m-health and apps for mobile devices. Combined with social networking, apps are a popular approach for engaging people in health promotion and risk reduction, but their potential has yet to be proven.
8. Social support remains indispensable for the maintenance of well-being.
9. The Homeostasis Theory of Well-being applies the core concept of homeostasis from Physiology to behaviour, cognition, emotion and well-being.
10. The Homeostasis Theory of Well-being utilizes the fact that human beings are natural agents of change who adapt, accommodate and ameliorate under continuously changing conditions, both in the external and internal environment, to optimize the stability of physical and mental well-being.