Chapter Two

Health beliefs and illness cognition

HEALTH BEHAVIORS

 Kasl and Cobb (1966) defined three types of health-related behaviors.

A health behavior is a behavior aimed to prevent disease (e.g.

eating a healthy diet).

 An illness behavior is a behavior aimed to seek remedy (e.g.

going to the doctor).

A sick role behavior is any activity aimed to get well (e.g. taking

prescribed medication, resting).

 Cont…

Health behaviors were further defined by Matarazzo (1984)

in terms of either
health impairing habits, which he called ‘behavioral

pathogens’ (e.g. smoking, eating a high fat diet), or

 health protective behaviors, which he defined as

‘behavioral immunogens’ (e.g. attending a health check).

Generally health behaviors are regarded as behaviors that

are related to the health status of the individual.

 Predicting Health Behaviors
Researches described factors that they
believed predicted health behaviors:
 social factors, such as learning,
reinforcement, modeling and social norms
 emotional factors, such as anxiety, stress,
tension and fear
 perceived symptoms, such as pain and
tiredness
 the beliefs of the patient and the beliefs of
the health professionals.
 Cont’…
combination of these factors could be used to

predict and promote health-related behavior.

 Approaches to health beliefs include attribution theory, the

health locus of control, unrealistic optimism and the

stages of change model.
 Cont’…
1. Attribution theory
Attribution theory suggesting that attributions about

causality were structured according to causal

schemata made up of the following criteria:
 Distinctiveness: the attribution about the cause of

a behavior is specific to the individual carrying out

the behavior.
 Cont…

 Consensus: the attribution about the cause of a

behavior would be shared by others.
 Consistency over time: the same attribution about

causality would be made at any other time.

 Consistency over modality: the same attribution

would be made in a different situation.

 cont’…
In addition, the dimensions of attribution have
been redefined as follows:
 internal versus external : e.g. my failure to get a job is
due to my poor performance versus the interviewer’s
problem
 stable versus unstable : e.g. the cause of my failure to
get a job will always be around versus was specific to
that one event
 Cont’…
 global versus specific: e.g. the cause of my failure to

get the job influences other areas of my life versus only

influenced this specific job interview
 controllable versus uncontrollable: e.g. the cause of my

failure to get a job was controllable by me versus was

uncontrollable by me.
 2. Health locus of control

Individuals differ as to whether they tend to regard

events as controllable by them (an internal locus of

control) or uncontrollable by them (an external locus
of control).
 Cont’…
Wallston (1982) developed a measure of the health

locus of control which evaluates whether:

 an individual regards their health as controllable by

them (e.g. ‘I am directly responsible for my health’)

 they believe their health is not controllable by them

and in the hands of fate (e.g. ‘whether I am well or

not is a matter of luck’)
 Cont…
 They regard their health as under the control of
powerful others (e.g. ‘I can only do what my
doctor tells me to do’).
Health locus of control has been shown to be related

to whether an individual changes their behavior (e.g.

gives up smoking) and to the kind of communication
style they require from health professionals.
 3. Unrealistic optimism

Weinstein (1983) suggested that one of the reasons

why people continue to practice unhealthy behaviors

is due to inaccurate perceptions of risk and their
unrealistic optimism/confidence/.
 Cont’…
 Four cognitive factors that contribute to
unrealistic optimism:
1. lack of personal experience with the problem
2. the belief that the problem is preventable by
individual action
3. the belief that if the problem has not yet
appeared, it will not appear in the future
4. the belief that the problem is infrequent
/uncommon.
 4. The stages of change model

 Research suggests model of behavior change is

based on the following stages:
a) Pre-contemplation: not intending to make any

changes
b) Contemplation: considering a change
c) Preparation: making small changes
d) Action: actively engaging in a new behavior
e) Maintenance: sustaining the change over time.
 Cont’…
 These stages, however, do not always occur in a linear

fashion
 The model also examines how the individual weighs up

the costs and benefits of a particular behavior.

 The stages of change model has been applied to several

health-related behaviors, such as smoking, alcohol use,

exercise behavior.
 Cont…
If applied to smoking termination, the model would
suggest the:
a) Pre contemplation: ‘I am happy being a smoker
and intend to continue smoking
b) Contemplation: ‘I have been coughing a lot
recently, perhaps I should think about stopping
smoking
c) Preparation: ‘I will stop by starting using lower
tar cigarettes
d) Action: ‘I have stopped smoking
e) Maintenance: ‘I have stopped smoking for four
months now
 Integrating these different health beliefs

Attribution theory and the health locus of control

emphasize attributions for causality and control.

 Unrealistic optimism focuses on perceptions of

susceptibility or vulnerability and risk.

 Stages of change model emphasizes the dynamic

nature of beliefs, time, costs and benefits.

 Cont’…
 These different aspects of health beliefs have been

integrated into structured models of health beliefs and

behavior.
 These models will be divided into cognition models and

social cognition models.

 Cont…

1. COGNITION MODELS
 Cognition models examine the predictors and

predecessor to health behaviors .

This model describe behavior as a result of rational

information processing and emphasize individual

cognitions, not the social context .
 This section examines the health belief model and

the protection motivation theory.

 A. The health belief model

 The health belief model (HBM) was developed initially

by Rosenstock (1966).
 The health belief model has been used to predict a wide

variety of health-related behaviors.

 Components of the HBM

 The HBM predicts that behavior is a result of a set of

core beliefs.
 Cont’…
The original core beliefs are the individual’s
perception of:
 susceptibility to illness e.g. ‘my chances of getting lung
cancer are high
 the severity of the illness e.g. ‘lung cancer is a serious
illness
 the costs involved in carrying out the behavior e.g.
‘stopping smoking will make me irritable
 the benefits involved in carrying out the behavior e.g.
‘stopping smoking will save me money
 cues to action, which may be internal or external
 Cont…

 The HBM suggests that these core beliefs should be used

to predict the likelihood that behavior will occur.

susceptibility

severity

Core belief cost Likelihood of

variables behaviour
benefit

cues to action

Perceived Health
control motivation
 B. The protection motivation theory

 Protection motivation theory (PMT) expanded the HBM to

include additional factors.
 Components of the PMT
 The original protection motivation theory claimed that health-
related behaviours are a product of four components:
 Severity (e.g. ‘cancer is a serious illness’);
Susceptibility (e.g. ‘My chances of getting cancer are
high’);
Response effectiveness (e.g. ‘Changing my diet would
improve my health’);
 Self-efficacy (e.g. ‘I am confident that I can change my
diet’).
 These components predict behavioural intentions.
 Cont…

 Rogers (1985) has also suggested a role for a fifth

component, fear (e.g. an emotional response).
 The PMT describes severity, susceptibility and fear as

relating to threat appraisal (i.e. appraising to outside

threat) and response effectiveness and self-efficacy as
relating to coping appraisal (i.e. appraising the
individual themselves).
 2. SOCIAL COGNITION MODELS

 Social cognition models examine factors that predict

behaviour and/or behavioural intentions.
 In addition examine why individuals fail to maintain

a behaviour to which they are committed.

 Social cognition theory was developed by Bandura

(1977, 1986) and suggests that behaviour is governed

by expectancies, incentives and social cognitions.
 Cont…
 Expectancies include:
 Situation outcome expectancies: the expectancy

that a behaviour may be dangerous (e.g. ‘smoking

can cause lung cancer’)
 Outcome expectancies: the expectancy that a

behaviour can reduce the harm to health (e.g.

‘stopping smoking can reduce the chances of lung
cancer’)
 Cont’…

 Self-efficacy expectancies: the expectancy that the

individual is capable of carrying out the desired

behaviour (e.g. ‘I can stop smoking if I want to’).
 The concept of incentives suggests that a
behaviour is governed by its consequences.
 For example, smoking behaviour may be

reinforced by the experience of reduced anxiety.

 Cont…

Social cognitions are a central component of social

cognition models.
 social cognition models include measures of the

individual’s representations of their social world.

 This section examines the theory of planned

behaviour (derived from the theory of reasoned

action) and the health action process approach.

A. The theories of reasoned action and planned behaviour

 The theory of reasoned action (TRA) was extensively

used to examine predictors of behaviours.
 The theory of reasoned action emphasized a central

role for social cognitions in the form of subjective

norms (the individual’s beliefs about their social
world).
 Cont’…
 The theory of planned behaviour (TPB) represented a

progression from the TRA.

 Components of the TPB

 The TPB emphasizes behavioural intentions as the outcome

of a combination of several beliefs.

 The theory proposes that intentions should be conceptualized

as ‘plans of action in pursuit of behavioural goals.

 Cont…

This is the result of:

Attitude towards a behaviour, which is composed of both a

positive or negative evaluation (e.g. ‘exercising is fun and

will improve my health’).
 Subjective norm, which is composed of the perception of

social norms and pressures to perform a behaviour .

 Cont’…
Perceived behavioural control, which is composed of a

belief that the individual can carry out a particular

behaviour based upon a consideration of internal
control factors AND external control factors.
 B. The health action process approach

 The health action process approach (HAPA) was developed by

Schwarzer (1992).
 It emphasized the importance of self-efficacy as a determinant

of both behavioural intentions and self-reports of behaviour.

 Components of the HAPA

 The main addition made by the HAPA to the existing theories

is the distinction between a decision-making/motivational

stage and an action/maintenance stage.
 Cont’…
The main components are
 self-efficacy
 outcome expectancies which has a subset
of social outcome expectancies
 threat appraisal, which is composed of
beliefs about the severity of an illness and
perceptions of individual vulnerability
 According to the HAPA the end result of it
is an intention to act.
 Illness cognitions
 WHAT DOES IT MEAN TO BE HEALTHY?
 Lau (1995) found that when young healthy adults were asked
to describe in their own words ‘what being healthy means to
you’, their beliefs about health could be understood within the
following dimensions:
 Physiological/physical, e.g. good condition, have energy.
 Psychological, e.g. happy, energetic, feel good
 Behavioural, e.g. eat, sleep properly.
 Future consequences, e.g. live longer.
 The absence of, sick, disease, symptoms.
 Lau (1995) suggested that healthiness is most people’s normal
state and represents the backdrop to their beliefs about being
ill.
 Cont…

 WHAT DOES IT MEAN TO BE ILL?

 Lau (1995) also asked ‘what does it mean to be sick?’
the dimensions they use to conceptualize illness:
 Not feeling normal
 Specific symptoms, e.g physiological/
psychological
 Specific illnesses
 Consequences of illness
 Time line, e.g. how long the symptoms last
 The absence of health
 WHAT ARE ILLNESS COGNITIONS?
Leventhal and his colleagues defined illness
cognitions as ‘a patient’s own implicit common sense
beliefs about their illness’.
 They proposed that these cognitions provide patients
with a framework or a schema for
coping with and understanding their illness, and
telling them what to look out for if they are
becoming ill.
 Cont’…
 Researchers identified five cognitive dimensions of these

beliefs:

1. Identity: This refers to the label given to the illness (the

medical diagnosis) and the symptoms experienced (e.g. I
have a cold, ‘the diagnosis’, with a runny nose, ‘the
symptoms’).

2. The perceived cause of the illness: causes may be

biological or psychosocial.
 Cont…

3. Time line: refers to the patients’ beliefs about how

long the illness will last, whether it is acute or
chronic.

4. Consequences: This refers to the patient’s perceptions

of the possible effects of the illness on their life.
 may be physical (e.g. pain, lack of mobility),

emotional (e.g. loss of social contact, loneliness) or

a combination of factors
 Cont’…
5. Curability and controllability: Patients also
represent illnesses in terms of whether they believe
that the illness can be treated and cured and the
extent to which the outcome of their illness is
controllable either by themselves or by powerful
others
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