2.2.2 SOCIAL: Health Behaviour and the COM-B. Model

1-40: Define what we mean by ‘health’ and ‘health behaviour 41-62 Demonstrate examples of behaviour in determining health status 63-77: Explain some of the determinants of health behaviour 78-88: Discuss how the COM-B model can explain behaviour (real world issues) 89- Discuss how the Behaviour Change Wheel can be used to develop behaviour change interventions

WHO (1964): health definition

a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity

criticism of WHO (1964) health definition

out of date and not fit for purpose due to ageing population and ability to manage chronic health conditions (CHCs)

what is health? (how do you quantify it)

not a binary state, but on a spectrum

Huber et al., (2011): what do they propose?

shift the emphasis of health towards the ability to adapt and self-manage in the face of social, physical, and emotional challenges

causes of death in 1900s

• Pneumonia/flu

• TB

• Diarrhoea

• Heart disease

• Intracranial lesions (vasc.)

• Nephritis

• Accidents

• Cancer

• Senility

• Diphtheria

Allender et al. (2008): categories of major causes of death in 2006 (COD)

• all cardiovascular diseases (CVDs)

• all cancers

• respiratory disease

• accidents and injuries

• other causes

% of deaths from all CVDs in UK in 2006 (Allender et al., 2008)

m - 35%

w - 34%

% of deaths from all cancers in UK in 2006 (Allender et al., 2008)

m - 29%

w - 26%

% of deaths from respiratory disease in UK in 2006 (Allender et al., 2008)

m - 13%

w -14%

% of deaths from accidents and injuries in UK in 2006 (Allender et al., 2008)

m - 5%

w - 3%

% of deaths from “other causes” in UK in 2006 (Allender et al., 2008)

m - 18%

w - 23%

Defra (2008)

study examining % of deaths due to major causes like CVDs and cancer across lifespan, against age and sex

Defra (2008): % of deaths due to CVD across lifespan- findings

• increase overlifespan

• 25-34: m and f around the same, higher for f

• 35-64 - see drastic increase in men dying from CVDs, from 44yo almost double men compared to women

• women gradually increase across lifepspan, biggest jumps between 55-64 and 65-74, and then 64-74 and 75-84.

• elderly population (75+), similar between men and women (slightly more women 85+ slightly more men 75-84)

• risk for women appears more associated w old age , for men, anything above 45 seems high

Defra (2008): % of deaths due to cancer across lifespan- findings

• not associated w old age, peaks middle age for both sexes

• women much higher, over double in young adults - 25-34

• mild increase for men linearly under 55-64 and same at 65-74 and then gradual decrease

• women, increase to 55-64

• well over double men for 35-44

• gap between men and women closes 65-74

• in elderly population, men higher than women

• men double women 75-84

• smaller gap but men slightly more 85+

what does Defra (2008) findings highlight?

significant sex differences in causes of deaths and differing dispersion of and relationship between

middle age women at highest risk for death by cancer

biggest gap between deaths by cvd in men vs women in the 35-64 age group (men more)
biggest gap between deaths by cancer in women vs men in 25-34, 35-44 and 45-54 (women more), and then large/double 75-84 (men more)

Adler et al. 1999: explaining health outcomes

• behaviours like smoking, dietary choice, alcohol consumption, regular physical activity

• play important role in HOs

Gruman + Follick, 1998: health outcomes

behavioural factors account for around 50% of premature deatths from the 10 leading causes

what % of premature deaths from the 10 leading causes can be accounted to behavioural factors

50

what marks the start of the modern concept of health behaviour

Doll and Hill (1964): studied british docs in 1950s and found smoking was a major precursor of premature mortality

health behaviour (Conner & Norman, 1996) definition

any activity undertaken for the purpose of preventing or detecting disease or disease or for improving health/wellbeing

Steptoe, Gardner, & Wardle, 2010: health behaviours

can have positive and negative health effects

what effects do health behaviours have?

positive and negative (Steptoe.. 2010)

types of health behaviour (HB)

• protective

• risky

term for negative health behaviour

risky health behaviour

term for positive health behaviour

protective health behaviour

protective health behaviour (PHB): definition

activities that may help to:

(and/or)

• prevent disease

• detect disease and disability at an early stage

• promote and enhance health

• project from risk of injury

risky health behaviour (RHB): definition

activities undertaken by people with a frequency of intensity that increases risk of injury or disease

health behaviours (broadest/ Steptoe, Gardner, & Wardle, 2010) definition:

behaviours individuals engage in that affect their health

difference in Conner & Norman 1996 and Steptoe, Gardner, & Wardle, 2010

CN1996- define HB as any activity undertaken for purpose of preventing or detecting disease or for improving health and wellbeing

their definition of HB is what SGC2010 define as the definition of protective HB

SGC2010 highlight two types of HBs- protective vs risky, and so define HB broadly as behaviours individuals engage w that affect (non directional bc can be good or bad) their health

measuring health behaviours: what is often the dv + why

behaviour

bc the currency of research into health behaviours

challenge with measuring HBs

• dv behaviour

• behaviour notoriously hard to measure

how are health behaviours typically measured?

• self report questionnaires using categorical or continuous measures

smoking: two main types of self report qs, format example

categorical: do you smoke- yes/no

continuous: how many cigarrettes do you smoke a day?

issues with measuring health behaviours via self report questionnaires

• social desirability bias → over/under repporting

• subject to recall bias

measures of health behaviours

• self report questionnaire (typically categorical or continuous)

• observation

• proxy measures

what is CCTV cameras to observe mask wearing in supermarkets an example of

an observational measure of health behaviours

what are some examples of proxy measures of HBs

• blood tests

• step counters

• pill counters

what are blood tests, step counters, pill counters, etc examples of?

proxy measures of HBs

issue w proxy measures of HBs

not always accurate

accuracy issues w proxy measures of HBs (examples)

• blood test results can depend on metabolic rate

• pill counters rely on pills actually being taken out of a bottle

• step counters- errors in measurement, can be falsified

also: (my thghts): positive health behaviours do not always equal positive health outcomes, underlying conditions can perservere regardless of behaviour, blood tests cld be perfect in someone who eats poorly, doesnt diet, and cld show nutrient deficiencies in someone who eats well, takes supplements etc. plus possibly issues w measures being geared towards male levels/ white ppl/ miscalculated or wrongly balanced for Black ppl and other poc. so may not acc indicate health behaviours always.

Alameda country study (Belloc, 1973): procedure/participants

around 7000 adults

baseline postal questionnaire in 1965 followed by regular surveys of death and illness

Alameda country study (Belloc, 1973): findings

7 negative health behaviours predicted mortality:

• lack of exercise

• snacking between meals

• smoking

• sleep (more than 8 hrs, less than 7), 

• skipping breakfast

• regularly drinking more than 5 units of alcohol

• over/underweight

negative health behaviours predicting mortality in Belloc, 1973 study + study name

Alameda country study

• lack of exercise

• snacking between meals

• smoking

• sleep (more than 8 hrs, less than 7), 

• skipping breakfast

• regularly drinking more than 5 units of alcohol

• over/underweight

Belloc (1973): features of a healthy lifestyle

• 7 negative health behaviours predicted mortality

• highlighted then 7 features of a healthy lifestyle

1. non smoking

2. moderate alcohol intake

3. 7-8hrs sleep nightly

4. exercise regularly

5. maintain a healthy body weight

6. avoid high cal snacks

7. eat breakfast regularly

7 features of a healthy lifestyle (Belloc 1973): relationship strength

very strong

relationship between the 7 health behaviours + death/illness lead Belloc (1973) to propose that…

people aged 75+yo who carried out all 7 of the positive behaviours had health comparable to those aged 35-44 who did less than 3

Belloc (1973) proposed

people aged 75+yo who carried out all 7 of the positive health behaviours (‘features of a healthy lifestyle’) had health comparable to those aged 35-44 who did less than 3

Khaw et al., (2008): procedure

• analysed data from the EPIC Norfolk longitudinal study of 20,000 men and women

• baseline - no known cvd/cancer, aged 45-79

• followed up over 14 years

• looked at association between cumulative survival and health behaviours

Khaw et al., (2008): findings

• survival was associated with 4 health behaviours:

1. not smoking

2. being physically active

3. drinking moderately

4. eating 5 or more servings of fruit and veg per day

• the fewer of these behaviours performed → the greater the risk of death

number of health behaviours- studies

• Belloc (1973): Alameda country study

• Khaw et al., (2008): analysed data from EPIC Norfolk longitudinal study

preventable causes of death by health behaviour- study

• Danaei et al., (2009)- investigation of deaths in USA

Danaei et al., 2009

• investigation of deaths in USA

• health behaviours can be linked to range of different causes of deaths - CV, cancer, diabetes, respiratory, other NCD, injury

• e.g. smoking attributable to CVD, cancer, diabetes, and resp diseases

health behaviours in the modern world: points emerging from definitons of HB and its study

• concept of health behaviour is fluid and behaviours included can change as medical knowledge develops

• health behaviours not uniformly important, but vary in their influence across time and different populations

• strength of evidence relating behaviours w health outcomes is variable

• behaviours may be done for non health purposes- e.g. motivated for appearance over health

key point:

health psychologists need to view behaviour in a broad context and recognise that health motivations and cognitions are a part of a wider set of influences on health behaviour

what perspective shld health psychologists take

view behaviour in a broad context and recognise that health motivations and cognitions are a part of a wider set of influences on health behaviour

strength of evidence relating behaviours with health outcomes

• variable

• case control, prospective, experiemtnal, cross sectional (but association =/= causation)

• consistent results w diff samples and study desgins, and a clear biological mechanism → stronger evidence

case- control study

• type of observational study commonly used to look at factors associated w disease or outcomes

• two existing groups differing in outcome/condition are identified and compared on the basis of supposed causal attribute/s

important health behaviours in the modern world

• diet

• physical activity

• smoking

• sexual behaviour

• alcohol

diet (NHS, 2020)

in 2018 only 28% adults eating 5+ servings fruit/veg per day

physical activity (WHO, 2022)

more than 80% adolescents and 27% adults do not meet their recommended levels

smoking (ONS, 2021)

• rates declined over last decade but still 8ish million adults in uk who do

• highest rates 25-34yos

sexual behaviour (YouGov poll, 2017)

47% of sexually active young ppl do not use a condom when sleeping with sm1 for the first time

alchohol (ONS, 2017)

25-28% adult drinkers in UK binge on alc on their heaviest drinking day

types of behaviour change

• initating a new behaviour

• stopping an existing behaviour

• how a behaviour is performed (changing frequency, intensity, duration)

changing behaviour: what do we need to consider?

• biopsychosocial approach to health

• primary motivational concerns in life same for humans as are for most animals- food,water,air,reproduction,etc

• challenging behaviours motivated by these systems can be difficult (e.g.: sexual behaviour-condom usage; energy seeking behaviour- eating habits; energy conservation behaviour- exercise levels)

• appreciation of evolutionary/biological, psychological, social contexts in which behaviour takes place to understand and then attempt to change

determinants of health behaviour: biopsychosocial approach

biology x psychology x social context

overlap of all = health

biological determinants of health behaviour

• gender

• physical illness

• disability

• genetic vulnerability

• immune function

• neurochemistry

• stress reactivity

• medication effects

psychological determinants of health behaviour

• learning/memory

• attitudes/beliefs

• personality

• behaviours

• emotions

• coping skills

• past trauma

social context determinants of health behaviour

• social supports

• family background

• cultural traditions

• social/economic status

• education

Plomin et al., 2000: biological determinants

twin studies evidence suggesting heritable component to smoking initiation, nicotine addiction, as well as body weight and obesity

biological determinants of health behaviours- physiology

some HBs have physiological response (smoking, drinking, ating, exercising) → releasing dopamine, endorphins which can reinforce the behaviour

biological determinants of health behaviours- ability

• ability to carry out many HBs is affected by personal health

• disabilities may impact ability to carry out physical activity

• symptoms can act as cues to change or stop behaviour (e.g. smoking, adherence to meds, etc)

social determinants of health behaviours (Baranowski, 1997)

• HBs strongly affected by peer group influences, family habits, and social networks

• early socialisation- observational learning → health habits e.g. brushing teeth, smoking

• culturally valued or discouraged behaviour → e.g. alc consumption in some religions

• peer pressure in adolescence → contributor/origin of many risk behaviours

social determinants of health behaviour (Pampel, Kreuger, Denney, 2010)

• socioeconomic status (SES)

• financial barriers to health behaviours, lack of available resource, lower education

social determinants of health behaviour (DeJong & Hingson, 1998)

legislative laws

• e.g seat belt use, drink driving

psychological determinants of health behaviour: two core components

• emotion

• cognition

psychological determinants of health behaviour (Ferrer and Mendes, 2018)

emotion

• stress - smoking, overeating, drinking, and exercise

• fear - avoidance of healthcare (e.g. dental- delay in response to symptoms, screening etc)

• disgust → fear avoidance - blood test, cervical screening

psychological determinants of health behaviour (Armitage and Conner, 2000)

cognition

• attitudes/beliefs

• social cognition models (e.g. ToPB, Azjen, 1991)

• interventions based on ToPB to improve HB

COM-B Model (Michie et al., 2011)

C = capability

O = opportunity

M = motivation

B = behaviour

COM-B: C

• capability

• the ability to enact behaviour

• capability = physical + psychology capability

COM-B: O

• opportunity

• environment that enables behaviour

• opportunity = physical + social opportunity

• physical- afforded by environment

• social- afforded by social/cultural norms

COM-B: M

• motivation

• mechanisms that activate or inhibit behaviour

• motivation = reflective + automatic motivation

• reflective- evaluations (beliefs about what is good/bad), plans (intentions)

• automatic- emotional reactions, desires (wants and needs), impulses, inhibitions. e.g. anticipated pleasure

methods to collect data using COM-B

• questionnaires

• interviews/ focus groups

• observation

questionnaire method to collect data using COM-B

• specific Qs about their C/O/M

• reach larger groups of ppl

interview/ focus group method to collect data using COM-B

• in depth qualitative data

• ask open ended Qs about C/O/M/ barriers/ facilitators of engaging in desired behaviour

• smaller samples

observation method to collect data using COM-B

• self report data from questionnaires/interviews may be far from the truth

• observations useful tool to see what acc happens

how well can the COM-B explain behaviour? study

Willmott et al., (2021) COM-B and physical activity

Willmott et al., (2021): design

• COM-B and physical activity

• cross sectional survey

• used validated measures to capture COM constructs and physical activity behaviour

• administered online to sample of young adults 18-35yo

• N = 582, mean age 22.8, 80.3% female

Willmott et al., (2021): findings

the COM-B model explained 31% of variance in physical activity

• C and O found to be associated with B through mediating effect of M

• increased C + increased O → increased M → increase physical activity (B)