Behavioural models

Mitike Molla
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Health behaviour
 Definition:
 Health behaviour is any activity undertaken by a person believing

him/herself to be healthy for the purpose of preventing disease or

detecting it at an early stage (Kasl and cobb 1966)

 But this definition has its own limitation it lacks:

 The activities of people with recognized illnesses to delay disease
progression or improve the general well-being

 Omission of lay/self defined definition of health behaviour

 Any activity undertaken by an individual, regardless of actual or

perceived health status, for the purpose of promoting,
protecting or maintaining health, whether or not such behaviour is
objectively effective towards that end (web definition).

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Why do we study health behaviour?
 The study of health behaviour is based upon two
assumptions:

 a substantial proportion of mortality and morbidity is caused

due to a particular pattern of behaviour

 and that these behaviour patterns are modifiable

 It is recognized that individuals are the major

producers/contributors of their health

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Why do we study health behaviour?
 Research on health behaviour is based on
two main aims:

 To design interventions to improve such health

compromising behaviours

 To gain more general understanding of the reason

why individuals perform a variety of behaviours

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What do we focus on health behaviour
studies?
 The focus is in various health behaviours
running from health enhancing behaviours
like:
 regular exercise, screening, healthy eating etc.

 To health harming behaviours like:

 smoking, alcohol and drug abuse, and sick role
behaviours such as non-compliance with medical
regimens

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Focus cont…

 A unifying theme across these behaviours has been

that they have long–term effects upon the
individuals health and at least particularly with in the
individuals control

 Epidemiological studies have revealed considerable

variations in who perform these behaviours

 Broadly these factors are divided in to two

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Focus cont..

 Intrinsic factors:
 Socio-demographic factors, personality, social
support, cognition
 Extrinsic factors which can be divided into
two again as;
 Incentive structures such as: taxing tobacco, and
alcohol and subsidizing sporting facilities
 Legal restrictions such as: banning dangerous
substances, fining individuals for not wearing seat
belts

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Focus cont..

 The intrinsic factors have received attention

in psychological studies and among these the
cognitive factors have been focused upon as
the most important proximal determinants.

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 The role of health behaviours in
health outcomes
 A number of studies have looked at the relationship b/n the
performance of a range of health behaviours and a variety of
health outcomes

 For example:
 A study conducted in Alameda (California) on seven life styles i.e.,
avoid smoking, moderate alcohol intake, sleeping seven to eight hrs
at night, regular exercising, avoiding snacks and eating breakfast
regularly, maintaining a desirable body weight
 Were together associated with lower morbidity and higher
subsequent long-term survival (Bellock and Bereslow 1972; Belolock
1973; Berslow and Enstrom 1980).

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Predicting the performance of health
behaviours
 Can we predict and understand who performs health behaviour?

 This would enable us to contribute to the understanding of the

variation in the distribution of health across society

 It might also indicate for intervention designing to change health

behaviours

 demographic factors: age ( shows a curvilinear relationship in

smoking, where young children and the elderly not smoking)
 social factor: parental models and peer influence, and community
values.
 cognitive factors: knowledge, (the reduction of smoking in the past
20 yrs) is the result of health promotion

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Why behavioural models
 In the 1950s US public health researchers began
developing models which would identify appropriate
targets for health education programs. (Hochbaum 1958
and Rosenstock 1966))

 There were clear evidence that demographic variables

such as socioeconomic status, gender, ethnicity and age
affected the extent to which people would adopt
preventive health behaviour or use health services

 but this could not be modified through health education

and even when services are publicly financed the effects
of socioeconomic status were not eliminated.

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Why behavioural models
 It become clear that, effective health education
depended upon identifying how the different socialization
histories indexed by demographic variables led to
individual differences in intention to undertake
preventive action and follow medical advice.

 This requires measures of modifiable psychological

characteristics which were correlated with health
behaviour.

 Individual beliefs offered the ideal link between

socialization and behaviour.

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Why behavioural models
 Beliefs are enduring individual characteristics which shape
behaviour and can be acquired through primary
socialization.

 They are not, however, fixed and can differ between

individuals from the same background. In fact they are the
archetypal social cognitive construct.

 Models of how such cognitive factors produce various “social”

behaviours are commonly referred to as social cognitive models
(SCM)

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Why we focus on cognitive factors

 Social cognition is concerned with how individuals

make sense of social situations
 The justification for focusing in SCMs is two fold:

 First, these determinants are assumed to be important

causes of behaviour which mediate the effects of other
many determinants (eg. social class)

 Second, these SCFs are assumed to be more open to

change than other factors (eg. personality)

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Overview of commonly used SCMs

1. Health Belief Model

2. Health locus of control
3. Protection motivation theory
4. Theory of Reasoned Action
5. Theory of Planned Behaviour
6. Self-efficacy models

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The Health Belief Model
 The health belief model is one of the oldest models
Rosenstock 1966, Becker 1974.

 The model focuses on two aspects of individual

representation of health and health behaviour:

 threat perception
 behavioural evaluation.

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HBM

Perceived susceptibly
Demographic
factors Perceived severity

Health motivation Action

Psychological
factors
(Personality, Perceived benefits
peer influence
etc) Perceived barriers
Cues to action

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HBM cont..
 Threat perceptions are seen to depend upon two beliefs:
 perceived susceptibility to the illness and

 perceived severity of the consequence of such illness.

 together these two variables are believed to determine the

likelihood that the individual is following a health related action,

 although their effect is modified by individual differences in

demographic variables and psychological variables,
the particular action is believed to be determined by the
evaluation of available alternatives.

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Benefits, barriers, cues to action and
health motivation
 The benefits component comprise both medical and
psychosocial benefits of engaging in health promoting
behaviours

 The barrier component comprised of practical barriers such as

 Time, expense, availability, transport, waiting time

 As well as psychological costs associated with
performing the behaviour like (pain, embarrassment,
threat to well-being or life style and livelihood)

 More recent HBM formulations also include

psychological barriers to performing the behaviour like
perceived self efficacy and learning ability

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Benefits, barriers, cues to action and
health motivation
 The cue to action: include diverse range triggers
including:

 individual perceptions of symptoms

 Social influence (descriptive and injunctive social norms)
form medical professionals and significant others
 Health education campaigns

 Some individuals predisposed to such cues may

respond positively because of the value they place
to their health.

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HBM cont..

 The HBM asserts that :

 Individuals are likely to follow a particular health
action;
 if they believe to be susceptible to a particular
condition, which they also consider to be serious,
and believe that the benefits of action taken to
counteract the health threat outweigh the costs.

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Pitfalls in operationalization of HBM
 The general failure to operationalize the HBM in its
entirety is the combination of the two threat
components and trying to measure as a single
construct ‘threat’ (Becker and Maiman 1975)
 And also the benefit and barriers; rather than
subtracting one from the other treating as separate
components mixing them together (Becker and Maiman
1975)
 Some researchers have used the ‘threat index’ to measure the
two constructs of threat (Kirscht et al. 1976)
 And combine barriers and benefits in a single index of barriers
(Oliver and Berger 1979; Gianetti et al. 1985)

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Strength of the HBM

 Has provided a useful Theoretical frame work

for researchers of cognitive determinants of a
wide range of behaviours for over 30 years
 Its common sense constructs are easy to
non-psychologists to assimilate and apply
and can be cheaply operationalized
 It has focused health care professionals and
researchers attentions on behaviours which
are easily modifiable
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 Using a single index of ‘threat’ would seem to violate
the expectancy value structure of HBM therefore
incorrect operationalization of the model
 Combining benefits and barriers would seem to be
both a theoretical and an empirical issue.
 Eg salt restriction: Barriers (time, effort and loss of
pleasure)
 While avoiding hypertension is more hypothetical
 Generally:
 benefits like response efficacy and social approval
 and barriers like psychological costs and expenses can not
be measured together

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Limitation of HBM
 Compared to other social cognitive models of health
behaviours, the HBM suffers from number of
weaknesses:

 Its common sense, expectancy-value framework

simplifies health related representational processes.
Qualitative distinctions between beliefs encompassed
by each construct may be important to understanding
why an individual does or does not undertake a certain
behaviour. Such broadly defined theoretical
components mean that different operationalization
may not be strictly comparable

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Limitation of HBM cont..

 Several social cognitive variables

found to be highly predictive of
behaviours in other models are not
incorporated in the HBM.

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Limitation of HBM
 Perception of control over the performance of
behaviour (self efficacy beliefs), which have been
found to be such powerful predictors of behaviour
in models based upon self-efficacy (Bandura
1977), are not explicitly included in the HBM.
 In addition, lack of specification of casual
ordering among the variables in the HBM as is
done in other models;
 lack of more powerful analysis of data;
 clear indications of how interventions may have
their effects are precluded.

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Limitation of HBM

 The model indicate no clear

operationalization instructions in linking
perceived susceptibility and severity to threat
and action
 No formula was developed for an overall
behavioural evaluation measure was
developed. ( though it was mentioned that
perceived benefit is weighted against
perceived barriers)

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Limitation of HBM

 Therefore the model has usually been

operationalized as a series of up to six
separate independent variables which
potential account for variance in observed or
reported behaviour

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Theory of Reasoned Action
 Introduced in 1967 the theory has over the years
been refined, developed and tested (Fishbein &
Ajzen) 1975.
 TRA is based on the following assumptions:

 human beings are usually quite rational and make systematic

use the information available to them

 the theory further argues that, people consider the implications of

their actions before they decide to engage in a given behaviour

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TRA cont..
 The goal of this theory to predict and understand behaviour

 The first step towards this goal is to identify and measure the
behaviour of interest
 Once the behaviour is determined it is easy to know what
determines the behaviour
 The assumption in this model is
 most actions of social relevant are under volitional control
 consistent with this assumption, the theory views a
person’s intention to perform or not a behaviour as
immediate determinant of the action
 Intention represents a persons motivation in the sense of
her/his conscious plan or decision to exert effort or perform
the behaviour

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TRA cont….

 According to TRA a person’s intention is a function of

two basic determinants

 Attitude,
 is personal to the individual which is the positive or
negative evaluation of the individual towards the
behaviour
 It is the individuals judgement that, performing the
behaviour is good or bad, harmful or beneficial etc..
 Subjective norm, which is the person’s perception of
social pressure put on him whether to perform or not
perform the behaviour in question. (since it deals with
perceived prescriptions it is called subjective norm)

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TRA

Behavioural
beliefs

Attitude

Intention Behaviour

Subjective Norm

Normative
belief

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Why people hold certain attitudes and
subjective norm
 Attitudes are functions of beliefs i.e., a person who
believes that performing a certain behaviour will lead to
mostly positive outcomes will hold favourable attitudes
towards performing the behaviour these beliefs are
called behavioural beliefs

 Attitudes towards a specific behaviour exert their impact

upon performance of that behaviour via their impact
upon intention
 Thus, in TRA, the unobservable cognitive factor of an attitude
transformed into observable action is clarified by interpreting
another psychological event the formation of intention b/n
behaviour and attitude.

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Why people hold certain attitudes and
subjective norm
 Subjective norms are also functions of beliefs
but different type of beliefs called normative
beliefs. A persons belief that important others or
referents think he should or should not perform
the behaviour

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Weakness of the TRA
 In suggesting that behaviour is under the control of
intention the TRA restricts itself to volitional
behaviours.

 Those behaviours which requires skills, resources or

opportunities that are not freely available are not
considered to be within the domain of applicability of
TRA or will be poorly predicted.

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The theory of Planned Behaviour
 TPB (Ajzen 1985, 1988, 1991) is an extension of the earlier TRA and had
proved itself in predicting behaviours that are not under volitional control

 TPB was developed as a deliberate attempt to broaden the applicability of TRA to

include non–volitional behaviours by incorporating perceived control over
performance to the behaviour as an additional predictor of behaviours

 TPB takes the performance of TRA beyond easy performed volitional behaviours to
those complex goals which are dependent upon performance of complex other
behaviours which are often considered important in health outcomes

 Hence the TPB depicts a linear regression function of behavioural intention and
perceived behavioural control

 B=w1BI+w2PBC where B= Behaviour, BI =Behavioural intention

PBC= Perceived behavioural control
w1 and w2 are regression weights

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TPB cont..
 Therefore intention is a linear regression function of Att.
SN. PBC

 BI= w3AB+w4SN+w5PBC where

 BI= behavioural intention,

 AB = attitude towards the behaviour

 SNB = subjective norm towards the behaviour

 PBC= Perceived behavioural control

 W -w are empirical weights in the regression showing

3 5
the relative importance of the determinants of intention


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TPB (Ajzen, 1991)

Attitude

Intention
Behaviour
Subjective
norm

Perceived
behavioural
control

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Determinants of attitude
 The attitude component is a function of a person’s
salient beliefs, which will represent perceived
consequence of the behaviour.
 The model quantifies consequences as being composed
of the multiplicative combination of the perceived
likelihood that performance of the behaviour will lead to a
particular outcome and evaluation of that outcome
i=j
AB= ∑ bi ei
j=1
 Where bi is the belief that performing the behaviour leads to some
consequence I
 ei, is the evaluation of consequence I
 And j is the number of salient beliefs

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Determinants of subjective norm
This is quantified in the model as the subjective
likelihood that specific salient referents think the
person should or shouldn’t perform the
behaviour, multiplied by the person’s motivation
to comply with that referents expectation.
 j=m
SN= ∑ nbjmc j
j=1
Where
 SN is the subjective norm,

 nb is the normative belief that some referent j thinks one should

or shouldn’t perform the behaviour,
 mc, is the motivation to comply with referent j and m is the

number of salient referents

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Determinants of PBC
 Judgements of perceived behavioural control are
influenced beliefs concerning whether one has access
to the necessary resources and opportunities to
perform the behaviour successfully weighted by the
perceived power of each factor .
k=n
PBC= ∑ cb.pk
K=1
 The model quantifies control beliefs by multiplying the frequency of
likelihood of occurrence of the factor by the subjective perception of the
factor to facilitate or inhibit the performance of the behaviour
 Where:
 PBC is perceived behavioural control,
 Ck, is the perceived frequency ot likelihood of occurrence of factor k
 Pk is the perceived facilitating or inhibiting power of the factor k
 And n is the number of control factors

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TPB cont..
 Intention to perform certain behaviour is the central
point in the theory of planned behaviour as in the
theory of reasoned action.

 Intention is an indication of how hard people are willing

to try and how much effort they are putting in order to
perform a certain behaviour.

 In other words intentions possess the motivational

factor to affect or influence a certain behaviour.

 Generally, if the intention towards the behaviour is

strong, it would be easier to perform the behaviour, if it
is under the volitional control of the individual .

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TPB cont..
 Though it is possible to express a
behavioural intention into a behaviour that is
under the individual’s control, it is difficult to
do so for most behaviour that does not
depend only in motivational factors.

 The performance of these behaviours may

demand resources, skill and cooperation of
others or in other words the persons control
over these factors

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TPB cont..
 Therefore the theory of planned behaviour asserts
that a persons achievement of a certain behaviour
depends on the joint function of intention and ability
or behavioural control .

 Perceived behavioural control is comparable to

perceived self-efficacy of Bandura

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TPB cont..

 He defines perceived self-efficacy as “people’s

judgments of their capabilities to organize and
execute a course of action required to attain
designated types of performances”.

 It is concerned not with the skills one has, but

with judgments of what one can do with what
ever skills one possesses.

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 Bandura discussed further the importance of self-efficacy by
explaining why knowledge is not expressed in action in the
following manner:
 Knowledge is very important to accomplish a certain action
but it is not sufficient for accomplishment of performances.

 Though people possess appropriate knowledge that makes

them able to perform a certain task or action, they do not
tend to act optimally.

 This is because of self-referent beliefs that mediate

between knowledge and action. Self referent beliefs are
expressed on how other people believe their ability and self
perception of carrying out a certain task .


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How to measure behaviour
 In both TRA &TPB the authors developed the principles
of compatibility, Fishbien & Ajezen (1975) and Ajezen
and Fishbien (1988)

 This principle asserts that both behaviour and attitude

have the four elements of

 1) action (or behaviour),

 2) performed on or toward a target
 3) in context and
 4) at a time or occasion

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How to measure behaviour
 For example, a person concerned about oral hygiene

 a) brushes (action)
 B) Her teeth (target)
 C) in the bathroom (context)
 D) every morning after breakfast (time)

 This example illustrates how a behaviour can be

aggregated over a range of occasions

 Of course in health behaviour we are interested to predict

the repetition of a specific (tooth brushing) or a general
(healthy eating) behaviour
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Measurement cont…

 The principle of compatibility further asserts

that correspondence b/n the two will be the
greatest when both are measured at the
same level with respect to each of these
elements

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Measurement cont..
 The major attractiveness of the TRA/TPB has been the
clarity of measurement techniques described (Ajzen and
Fishbein 1980; Ajzen 1988: Fig 5.2)

 individual researcher will be left with a number of

decisions as to how best to construct and measure in a
study

 Data are typically reported in correlations b/n

components and multiple regressions

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Limitation and strength of TPB

 Strength:
 It offers an improvement to our understanding of
many health related behaviours

 Limitation:
 It deals with perception of control not actual
control

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