Now that we’ve laid the foundation for the course in the first two modules, by

learning about what Health Psychology is, what Health Psychologists do, and the basic
functioning of some of the important systems of the body that influence our health,
now we’ll dive more into the realm where Health Psychologists can have one of their
greatest impacts – helping people develop and maintain healthy behaviours. This
chapter relates strongly to the first theme that Health Psychologists focus on that we
discussed back in module 1: Health promotion and maintenance. We’ve already
discussed that many of the diseases that tend to have a dramatic negative impact on
people’s lives in our modern world are chronic illnesses (instead of acute problems).

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Those chronic illnesses are often the result of lifestyle factors. You know what makes
up a good portion of our lifestyle? Our behaviours. The good thing about health
behaviours is that they are modifiable risk factors. We’re able to change them. Now,
that change isn’t always easy, as I’m sure many of you might know if you’ve ever tried
to change a behaviour or habit before, but they are changeable. And helping people
with health behaviour change is one of the important roles that a Health Psychologist
can take on.

Here I want to mention that many people think some factors related to health are not
changeable. Some people think this about behaviours. For example, when I used to
mention something about changing a health-related behaviour to my Dad, he would
say things like the classic ‘you can’t teach an old dog new tricks’ or ‘it’s too late for me,
save yourself’. But, when my Mom had a heart attack last year, that was the thing that
really struck him. It was like a lightbulb went off that if something like that could
happen to my Mom, then it could probably happen to him too. Also, when he saw my
Mom changing her behaviour, his arguments didn’t really hold any weight anymore
since my Mom is two years older than my Dad. So that was the motivation he finally
needed to change his behaviour to be healthier too.

The other factor about health that people tend to think is not changeable is our
genetics. We’re born with a certain set of genes and those are the genes we have for
life. However, so much has been learned about genetics, and particularly epigenetics,
in the last few decades that we now know that even if you are born with certain
genes, there are many factors outside of your genes that affect whether, or how
much, those genes will actually be expressed. And many of those factors are related
to our behaviours and our lifestyle. These include things like the foods we eat, the
places we live, the exercise we get, and the thoughts we think. Many of our genes are
called vulnerability genes – they increase or decrease our risk for certain things; but
for most cases, they don’t absolutely determine that risk. That risk is influenced by
many other things that we do have control over.

For example, my Mom has a genetic mutation that strongly increases her risk for
colon cancer. Many people in our family have died young from colon cancer. But just
because she has that gene, that doesn’t mean she will absolutely develop colon
cancer. There are things she can do, like improve her diet, and get early and regular
colonoscopies, that can help to lower her risk. So, I hope you’re already starting to get
the idea of just how important our behaviours and our lifestyle are to our overall
health. They impact everything touched on by the biopsychosocial model: Our
behaviours influence our biology (for example, what we choose to put in our bodies),
our psychology (for example, the thoughts we choose to pay attention to), and our
social aspects (for example, which friends we choose to hang around and how often).
Notice the word ‘choose’ in each of those examples. We generally have the power to
choose our health behaviours, for better or worse.

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In this video, we’re going to focus on some of the theories and models that are used
for understanding health behaviour change and how people’s attitudes and beliefs
about various things impact their motivation to engage in behaviour change. By
understanding the process of behaviour change, and the many psychological
components that go into motivating behaviour change, a Health Psychologist can
design the best programs for people to first help motivate them to want to change in
the first place, then help them to believe they can change, then help them actually
start to change, and then finally help people to maintain that behaviour change.
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 Attitude Change and
Health Behaviour

LO3: What Change attitude with information = change behaviour

theories and
models are
used for
Communicator:Expert, trustworthy, likeable,
similar tothe
understanding audience
health
behaviour Framing: HOW the message is presented.
change?
Loss-framedfor illness detection behaviours, avoidance
-oriented
people, and behaviours with uncertain outcomes.
Gain-framedfor health promotion behaviours, approach
-oriented
people, and behaviours with certain outcomes.

The first theory for health behaviour change we’ll focus on is the idea of first
changing people’s attitudes and beliefs about health behaviour. Just like I mentioned
on the last slide, some people believe that behaviours either aren’t a big factor
related to health, and health is more genetic, or they may believe that they can’t
change their behaviours, so why bother trying?

The idea behind attitudinal change for health behaviour is that if you give people
accurate information about their health (e.g., that behaviours can indeed influence
risk for health problems), that this information will motivate people to change those
habits in a healthy direction. This practice may induce a desire to change behaviour in
people, but may not be successful in actually explicitly teaching people how to
change their behaviours. It’s one thing to know you want to get healthier, but once
you decide that, how do you start? Where do you go from there? (We’ll cover some
of those topics in the next video.)

There are many aspects of how health information is delivered that are thought to
influence whether people will actually believe that information and be persuaded by
it. One thing research suggests is effective is a vivid case study example. I’ve done
this a couple times already in these videos, sharing both my own health challenge,
and then some health issues my Mom has faced. Both of these stories involved
behaviour change to improve our health. Stories like those tend to be more effective
at actually capturing people’s attention and motivating them to change than things

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like a list of facts or statistics. It might be that element of human connection. Hearing
that if one person could do it, especially if you relate to that person and think they’re
kind of like you, then maybe you can do it too. Just like what happened with my Dad
seeing my Mom change her behaviour. That vivid real-life story was way more
impactful to him to motivate behaviour change than any pamphlet full of facts about
high blood pressure or healthy eating.

It also helps if the person communicating the message is perceived as an expert, as

trustworthy, as likeable, and as similar to the audience. You obviously want to feel
like you can trust the information the person is telling you, otherwise why would you
be swayed to change your behaviour? It’s also less likely someone would change their
behaviour if they don’t perceive the person as likeable, like if they feel shamed or
judged by the person’s message, or that the person has some kind of ‘I’m better than
you because I do these healthy things’ vibe about them. And again, what I mentioned
about seeing some aspects of yourself reflected in the person communicating the
message about health can be persuasive. This idea of similarity between the
communicator and the audience can be particularly important when thinking about
different cultural groups. People are more likely to be persuaded by information that
comes from a member of their own cultural group that understands the nuances and
practices of their particular culture. So for example, research suggests that an
Indigenous person would be more persuaded by health messages coming from
another Indigenous person than from a person from a different culture that may not
understand the underlying beliefs and rituals of Indigenous peoples.

How the message is framed is also important. This is a concept you should have
learned back in Intro Psych. Framing is basically how you deliver the message – are
you delivering it in positive terms or negative terms? The classic example is
something like framing the risks of surgery. You could say: "This surgery has a 95%
success rate for curing the problem". Or, you could present the information in a
negative light and say: "This surgery has a 5% failure rate for curing the problem".
You’re presenting the exact same information, but in a very different way. People
tend to be more likely to choose to do the surgery if it is presented with positive
framing vs negative framing. You can also see an example of framing in the image on
this slide. Both ads are promoting healthy eating, but they’re focusing on different
outcomes; one is more of a ‘prevent disease’ outcome and the other is more of a
‘achieve vibrant health’ outcome (with the caveat that thin doesn't necessary equal
vibrant health!).

Health research also suggests that different types of framing are more effective for

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motivating different types of behaviour change. Here we’ll focus on illness detection
behaviours and health promotion behaviours. Illness detection behaviours are things
you do to try to prevent getting an illness or to detect it in its early stages. These
behaviours can include things like getting regular doctor’s check ups or screenings,
like my Mom getting early and regular colonoscopies to help prevent the
development of colon cancer. Health promotion behaviours are things people do to
try to promote good health and well-being (remember we said health was an active
achievement). These types of behaviours could include things like eating healthy and
exercising regularly. Sure, these behaviours might also help prevent you from
developing an illness, but really their main goal is to achieve that active state of
health, vitality, or wellness we talked about back in module 1.

For illness detection behaviours, loss-framed messages tend to be more effective for
motivating behaviour change. A loss-framed message focuses on what could happen
if someone doesn’t do the behaviour. So for example, if you don’t get your regular
colonoscopies, you could develop colon cancer and die. This type of framing works
well for motivating illness detection behaviours because the whole point of those
behaviours is to try to prevent something bad from happening to you. They don’t
necessarily function to improve your health in an active way. You could give this same
message by saying ‘get regular colonoscopies to ensure a healthy colon’ but that’s
not very motivating because people generally tend to think they have a healthy
enough colon already. But if you frame it as what could happen if they don’t do the
behaviour, that tends to be more motivating for illness detection behaviours.

Now on the flip side, for health promotion behaviours, emphasizing benefits gained
(rather than what someone might lose) is more effective at motivating behaviour
change. So in this case, the message to eat fruit and be slim would be more
motivating than don’t eat candy or you’ll get fat. [We won’t get into the can of
worms of how ‘slim’ isn’t a great health goal for now – we’ll talk about that topic
more in module 4.] Since health promotion behaviours are really targeting that
ACTIVE achievement of health, it makes sense to emphasize the gains that a person
would get by doing the behaviours instead of the potential things that might happen
if they don’t do the behaviour.

So, to sum up, loss-framed emphasizes the negative. Gain-framed emphasizes the
positive.

Now, in addition to different kinds of framing being more motivating for different
types of behaviour, research also suggests different kinds of framing can be more
effective for different types of people. For example, a message will be more effective
if it matches a person’s own motivational orientation. What I mean by that is that

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people tend to be either avoidance-oriented, so they are motivated to minimize
losses, or approach-oriented, so they are motivated to maximize rewards. You can
think of this like game show contestants. You know how some game shows will give a
person an option to keep the money they have or to risk that money for the chance
to win more money? An avoidance-oriented person seeks to minimize losses, so they
would be more likely to keep the money they already have. An approach-oriented
person seeks to maximize gains, so they’d be more likely to risk the money they have
to potentially get even more money.

Someone who is more avoidance-oriented tends to be more persuaded by

lossframed messages, because they want to minimize their losses, so focusing on
what they could lose by not doing a behaviour is more motivating to them to do the
behaviour to avoid the loss. Someone that is more approach-oriented tends to be
more persuaded by gain-framed messages, because they want to maximize rewards,
so focusing on what they could gain by doing the behaviour is more motivating to
them.

And lastly, messages that are loss-framed tend to work better for behaviours that
have uncertain outcomes. For example, you don’t know if your colonoscopy will
reveal colon cancer, but if it does, that’s really bad. Gain-framed messages tend to
work better for behaviours that have certain outcomes. If you exercise regularly, that
will definitely improve your health compared to if you don’t exercise at all. It’s less
motivating to focus on healthy gains if you don’t know that those gains will actually
happen if you do the behaviour. But, if there is any risk of losing something related to
your health if you don’t do a behaviour, that’s more motivating because we generally
at the very least like to preserve what we have in terms of health.

I hope you can see why it’s important for a Health Psychologist to know about
message framing if we believe that the first step to behaviour change is actually
motivating people to WANT to change in the first place. It helps to know how to best
motivate different people for different types of behaviours.

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 Social Cognition Models of Health Behaviour Change

LO3: What
theories and
Beliefsabout health behaviours impact
motivationto
models are change health behaviours
used for
understanding
Expectancy-Value Theory
health People choose to engage in behaviours expectto
they
behaviour succeedin and have outcomes they
value
change?
Efficacyexpectancies
: Confidence you can do the
behaviourto produce the desired outcome
Outcomeexpectancies : Belief the behaviour will
result
in the expected outcome

Ok, now that we’ve talked a bit about how to try to motivate people to want to
change their behaviours with information, now we’ll talk a bit about some of the
beliefs that people have that can make it more or less likely that they’ll be motivated
to engage in behaviour change. Social cognition models suggest that what people
believe about various health behaviours impacts their motivation to either want to
change those behaviours or not. These ideas are based on a theory called
Expectancy-Value Theory. This theory states that people will choose to engage in
behaviours that they expect to succeed in and that have outcomes that they value
(so, expectancy and value). This is similar to the idea of how you might choose your
courses. You likely choose courses you think you can succeed in and that are about
topics that you value.

Let’s look at an example related to health. You will be more likely to eat vegetables if
you believe that you can actually do that successfully (e.g., you can make vegetables
that you think taste good, you have access to quality produce, and you can afford to
buy vegetables) and if you believe that the outcome of eating vegetables will be an
improvement in your health and that an improvement in your health is something
you value. So you see there are a few steps here that could impact whether someone
eats vegetables. They could either not believe they can do it successfully, or the
outcome of doing the behaviour might not be something they value enough to do it.
So part of what a Health Psychologist could do is help someone believe that they

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could successfully engage in the behaviour in the first place, potentially by identifying
barriers to doing it and plans to address those barriers, or by trying to change the
way the person values the outcome of that behaviour (perhaps with some of the
messaging techniques we talked about on the previous slide).

So this model has two important components: Efficacy expectancies and outcome
expectancies.

Efficacy expectancies are basically your belief that you have control over the
behaviour. That you could do it successfully if you wanted to. This component is an
important determinant of the practice of health behaviours. You’ll be less likely to go
to the gym to exercise if you don’t believe you can successfully use all the machines
properly.

Outcome expectancies are basically your belief that the behaviour will lead to the
outcome that you want. This expectancy is needed to motivate behaviour change by
linking behaviours to outcomes. If you don’t think the behaviour will result in any
beneficial outcome, why would you bother doing it?

For example, a friend of mine recently decided to change her behaviour to improve
her health. She wanted to start exercising more but she wasn’t confident about going
to the gym. So, she got a week’s worth of personal training sessions to a gym that’s a
5min walk from her house. In the sessions, the trainer taught her how to properly
use all the equipment and set her up with a workout routine. That increased her self-
efficacy, or her belief that she could actually do the behaviour successfully. However,
after about a week of going to the gym consistently, she wasn’t seeing the changes
she wanted. The number on the scale hadn’t moved, she didn’t feel stronger, and
she didn’t feel healthier. So she started to doubt that the behaviour of going to the
gym would actually result in the changes that she wanted (the outcome). She talked
with her husband and committed to continuing for a couple more weeks. After
another week she started to see some of the results that she wanted – so her
behaviour started to produce the outcomes she valued. But that time period after
the first week where the outcomes weren’t being produced was a really vulnerable
period for the maintenance of her behaviour change.

Self-efficacy can play a role in providing motivation to initiate and maintain the
behaviour change and to persist in the face of difficulties, like my friend did. So her
belief that she could keep continuing to do the behaviour successfully helped her
push through that period where she became uncertain about the value of the
outcome.

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Another example using this theory is someone that believes that eating more
fermented foods will help to heal their gut (an outcome they value), and who
believes that they can ferment their own foods successfully at home and eat them
(so they have efficacy that they can do the behaviour) is more likely to actually do it.
If you don’t think fermented foods are good for your gut (which they are, they’re
good for adding beneficial bacteria to your gut flora), or you don’t believe you can
eat them because they’re expensive, or you don’t like the taste, or you don’t think
you can make them at home, you’re less likely to even try to adopt and maintain this
behaviour.

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 Health Belief Model

LO3: What 1. Perceived Health Threat: General health

theories and
models are values, perceived susceptibility, perceived
used for severity
understandi n g
health 2. Perceived Threat Reduction: Perceived
behaviour efficacy, perceived barriers
change?
3. Cues to Action: People, events, things that
stimulate behaviour
4. Self-Efficacy: Having confidence you can do
the behaviour

The last topic we’ll discuss in this video is the Health Belief Model. This model is an
example of a social cognition model, so it’s based on those ideas of self-efficacy
(believing you can do the behaviour) and valuing the outcome (doing the behaviour
will lead to an outcome that’s important to you). This model suggests that we can
understand why someone chooses to practice a health behaviour or not by knowing
4 important factors:
1) Whether the person perceives a personal health threat, so whether they think
that there is currently some kind of risk to their health
2) Whether the person believes that a particular health practice will be effective in
reducing that threat, so related to the outcome of the behaviour
3) Cues to action, which are things in the environment (they can be people, events,
or other things), that stimulate the action to do the health behaviour 4)
Self-efficacy, the confidence in yourself to actually be able to do the
behaviour.

Let’s now break these 4 factors down into some more specific elements. 1)
Someone’s perceived personal health threat is influenced by 3 elements:
a) General health values: This is their interest and concern about health. If they don’t
really care about being healthy (so they don’t value health), they’ll be less likely to
perceive something as a health threat.

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b) Perceived Susceptibility: This is a person’s belief about their own personal
vulnerability to a condition. If you believe you are more vulnerable to colon cancer
because of the risk genes that you have, you’re more likely to perceive colon
cancer as a health threat to you.
c) Perceived Severity: This is a person’s beliefs about the consequences of the
disorder and whether they are serious. If you believe you are susceptible to colon
cancer, but that if you get colon cancer it’s no big deal, you’ll be less likely to perceive
it as a health threat to you.

2) Perceived threat reduction is influenced by 2 elements:

a) Perceived Efficacy: Here we’re talking about efficacy of the health behaviour
itself, so your belief that doing the health behaviour will actually work to reduce
the health threat identified in factor 1. If you don’t think eating less sugar will
reduce your likelihood of getting diabetes, you’re not going to change that
behaviour.
b) Perceived Barriers: These are the obstacles you think are in your way to changing
your behaviour. Basically it comes down to, do the benefits of doing the
behaviour outweigh the costs. If you think that eating less sugar will make your
day to day life so unenjoyable that you’d rather have diabetes than give up sugar,
you’re not going to change your eating behaviour.
Perceived health threat and perceived threat reduction basically account for
someone’s readiness to act. They provide the motivation for wanting to change the
behaviour.

So to put these factors into an example, I’ll again use my Dad (that’s him in a minion
hat at my wedding). He generally does value his health, he perceives he is susceptible
to heart disease because he takes meds for high blood pressure, and he does believe
that the consequences of heart disease can be serious (especially after my Mom’s
heart attack). But, if his health behaviour is changing his diet, he didn’t really believe
that diet change alone was enough to reduce the risk of developing heart disease (so
he believed that health behaviour has low efficacy for reducing the risk of the health
threat) because he believed it was more genetic (both his parents have high blood
pressure). He also thought the daily pain of not eating all the bread and cheese and
fast food burgers that he wanted outweighed the costs of developing heart disease
since he was going to die of something some day anyway. So, he wasn’t motivated to
change his eating behaviour.

Ok, onto the next two factors of the Health Belief Model:
3) Cues to Action. These can be anything that basically stimulate us, or encourage us
to actually act on the motivation we have to change the behaviour. So things that get

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us to finally start DOING a behaviour we may have thought that we should do for
awhile. For example, my stomach pains were the cue in my body that finally got me
to do something and start looking into my digestive issues. Cues can be anything,
either an internal symptom like mine, or something external. For my Dad, it was
seeing my Mom have a heart attack, going with her to all her nutrition classes, and
seeing her health change from the lifestyle changes she made. Seeing all that right in
front of his face were cues for him to take action about his own eating habits. Seeing
those things also changed his perception about the efficacy of diet change for
reducing heart disease risk. Another example is something like reading a book or
watching a documentary about the dangers of eating too much sugar, or having a
relative be diagnosed with diabetes.

The last factor in the Health Belief Model comes back to Self-efficacy, which we
talked about earlier. This is your belief and confidence that you can actually do the
behaviour. On this slide is a picture of my friend Kendra at my wedding a few years
ago. She’s my friend that had the brain tumour. She continued to smoke all through
her chemo treatments, even though she believed it was bad for her health. She just
didn’t believe that she had the ability to quit and the barriers to doing it were too
high. To her, it was worth the pleasure she got from smoking because she didn’t
believe she had much time left anyway or that quitting would help her at that point.
So these ideas touch on both her lack of self-efficacy to do the behaviour of quitting
smoking but also her perceived barrier that the cost of quitting smoking (the
additional stress) outweighed the benefits (the pleasure it brought to her when most
other pleasures in her life had been stripped away by cancer and chemo).

The Health Belief Model, which ascertains whether a person perceives a threat to
health and whether a person believes that a particular health behaviour can
overcome that threat, influences a person’s use of health services. Based on the
Health Belief Model, research shows that highlighting perceived vulnerability to a
health threat and at the same time increasing the perception that a particular health
behaviour will reduce the health threat are somewhat successful in changing
behaviour. So you can see why it is important for a Health Psychologist to be familiar
with models of behaviour change like the Health Belief Model. They can use it to
figure out what beliefs a client might have that might be negatively impacting their
motivation to change a health behaviour and then target their messaging and their
behaviour change plan towards those particular beliefs to help motivate their client
to change.

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That’s it for this video. In our next video we’ll talk about some actual strategies for
helping people to change their behaviours once they have the motivation to do
so. See you there…!