Chapter 6 and Lecture 5: From Habits to Health: Factors in Behaviour

The Role of Behaviour in Health

• People’s health-related behaviours (“health habits”) influence their likelihood of developing chronic and fatal diseases, such as heart disease, cancer, and HIV/AIDS

• Illness and early death could be substantially reduced if people would adopt lifestyles that promote wellness, such as eating healthy diets, exercising, not smoking, and being safe (whether in the sun or in sex).

• But the typical person’s lifestyle includes many behaviours that are risk factors for illness and injury

• Leading killers in developed nations: Cancer and cardiovascular disease

• Adults who have a healthy lifestyle (exercising, healthy diet, not smoking, not excessive drinking) can expect to live up to 12 years longer

Health behaviors

Activities that ppl perform to maintain or improve health, or prevent illness, regardless of health status or whether the activity actually improves health

People’s health status can affect the type of health behaviour they perform and their motivation to do it...

Well Behaviour

any activity people undertake to maintain or improve current good health and avoid illness.

• E.g., eating a healthy diet, exercising, getting vaccinated

Symptom-Based Behaviour

Any activity ill people do to determine the problem and find a remedy.

• E.g., complaining about symptoms, seeking advice.

• Fear and lack of money can prevent this behavior

Sick-Role Behaviour

any activity people undertake to treat or adjust to a health problem.

• E.g., adhering to medical advice, staying home from school/work.

• This special “role” let them take a break from normal responsibilities like going to school or work

Breast cancer screening

• Only mammograms are proven effective in detecting early breast cancer and reducing mortality

• Manual examinations are no longer widely recommended

Identified 7 risk factors (health habits) associated w poor physical health and increased mortality

1. Smoking cigs (cigs also enhance the effects of other substances like alcohol)

2. Drinking excessive amounts of alcohol

3. Being obese

4. Being physically inactive

5. Eating between meals (snacking)

6. Not eating breakfast

7. Sleeping fewer/more than standard hours (7-8)

10 predisposition factors that increase mortality (in order of significance)

1. current smoker

2. history of divorce

3. history of alcohol abuse

4. recent financial difficulties

5. history of unemployment

6. previous history as a smoker

7. lower life satisfaction

8. never married

9. history of food stamps

10. negative affectivity

Correlation between health habits

 Not strongly tied to each other; knowing someone practices one healthy habit does not accurately predict they will practice another.

Attitude and health habits

Not governed by a single set of attitudes (Someone may use seal bests for safety but diet for attractiveness)

Factors for change of health habits

• Differential Effects: Different factors in a person's life may affect different behaviours (e.g., social encouragement to overeat while also being encouraged to limit smoking).

• Learned from experience (เข็ด)

• Changing life circumstances (Ex. The absence of peer pressure)

The Prospective Urban Rural Epidemiology (PURE) Study

A study of the relationship between health outcomes and health habits/behaviours.

• Higher carbohydrate and lower total fat intake each associated with higher mortality

• Fruit, vegetables, & legumes associated with lower mortality

• Ultra-processed foods associated with inflammatory bowel disease

  • But high healthy fat does not correlate w mortality

  • Ultra-processed foods are those that are not recognizable in the natural form

3 types of prevention efforts

1. Behavioural Influence: Promoting health actions (e.g., demonstrating proper brushing/flossing techniques).

2. Environmental Measures: Public health actions (e.g., adding fluoride to water supplies).

3. Preventive Medical Efforts: Clinical actions (e.g., dental professional removing tartar).

Primary Prevention

• Actions taken to avoid disease or injury (or prevent onset of illness).

• E.g., exercise, wearing seatbelt, flossing, immunization/vaccination, handwashing, physical distancing, wearing mask (as in pandemic)

• Can technically be undertaken by either the individual or society. 

• Health promotion initiatives (e.g., providing information about how to stay healthy) are often aimed at primary prevention.

• Well behavior

Secondary prevention

Early detection and prompt intervention to halt or reverse a health problem's progression, like cancer screenings or blood pressure checks.

Overlap w symptom-based and sick role

Tertiary prevention

Managing an existing illness to slow its progression, prevent complications, and improve the patient's QoL and function

Ex. Rehab, medication management, support group

Also sick role

Problems in Promoting Wellness: Factors within the Individual

• Motivation: Healthy behaviours can be perceived as less convenient or appealing than unhealthy ones, leading to procrastination or a desire to maintain a balance.

• Self-Efficacy: Lack of belief in one's ability to successfully carry out a new behaviour.

• Habitual/Addictive Behaviours: Long-standing behaviours like smoking are very difficult to modify

Problems in Promoting Wellness: Interpersonal Factors

• Social Influence: One partner's unhealthy behaviour (e.g., eating unhealthfully) before marriage can be adopted by the other partner over time.

• Interpersonal Conflicts: A family member's healthy behaviour (e.g., exercising) may disrupt the daily routine of another, creating conflict that undermines the change effort.

Problems in Promoting Wellness: Factors in the Community

• Lack of Focus on Prevention: Health professionals have traditionally focused on treatment rather than prevention.

• Resource and Infrastructure Issues: Public health systems suffer from insufficient funds, and some communities lack safe/convenient places to exercise.

• Ethical Dilemmas: Communities face the challenge of balancing public health (e.g., reducing pollution) with economic priorities (e.g., not forcing a job-creating industry out of business)

Health-related behavior determinants: General Factors

• Heredity: Genetic factors, such as in the development of alcoholism, can influence health-related behaviours.

• Learning: Behaviours are learned through consequences, following the principles of: Reinforcement (consequences that increase a behaviour), Extinction (eliminating the reinforcer weakens the behaviour), and Punishment

• Modelling: Learning occurs by observing the behaviour of others and the consequences they receive

Health-related behavior determinants: Social, Personality, and Emotional Factors

• Conscientiousness: This personality trait (dutiful, organized) is strongly linked to practicing many healthy behaviours (e.g., high fitness, low tobacco use, following medical instructions).

• Stress: High stress is linked to less exercise, poorer diets, and more use of alcohol and cigarettes, as people often cope with stress by using these substances.

Health-related behavior determinants: Perception and Cognition

• Misconceptions: People's judgments about their health can be based on misconceptions, such as hypertensive patients incorrectly believing they can sense their high blood pressure.

• Unrealistic Optimism: People commonly believe they are less likely than others to develop a health problem. This belief can impair preventive action, but it often gives way to "unrealistic pessimism" when a clear threat of illness is present.

Health Belief Model

The likelihood that a person will perform some health behaviour depends on the outcome of two assessments the person makes:

1. Perceived threat associated with a health problem: a) perceived vulnerability, b) perceived seriousness, c) cues actions — ex. if alcoholics, then bar close to home

2. Perceived benefits and barriers of taking action

Widely supported across various health behaviors (e.g., dental visits, vaccinations, exercise programs).

Perceived threat (belief) (Health belief)

• Perceived seriousness

• Perceived vulnerability

• Cues to action/reminders 

  • Ex. feel out of breath again → train endurance, seek help, commit to a sport

  • Haven’t had a flu shot, I’m at higher risk of getting sick from the flu → get a shot

Perceived benefits and barriers (pros and cons) (health belief)

• Belief that benefits outweigh costs (sum = benefits - barriers)

• Ex. → Going to gym when you have time/motivated instead of staying in. benefits (healthy, fit) > costs (gym membership, less chill time)

Criticism of health belief model:

• Left out self-efficacy

• No standard way of measuring components (perceived threat?)

• Ppl don’t usually assess like this

Cognitive Adaptation Theory

A little denial of physiological risk may have better mental health and cope w risk better.

• E.g. HIV positive men who inaccurately, but optimistically, believed that they could halt the progression of AIDS → better health habits than those who were pessimistic.

• Only moderate degree of optimism is beneficial (too high or too low is harmful)

Theory of Planned Behavior (TPB)

Behavior result from intentions. There are 3 factors determine one’s intention to perform a behavior:

1. Attitude to Behaviour: Judge if the behavior is good or bad.

2. Subjective Norm: Appropriateness or acceptability of behavior (based on beliefs about others’ opinions, social norms).

3. Perceived Control: Expectation of success.

• Similar to self-efficacy – belief that one can execute a course of action, achieve a goal; correlated with performance/success

Criticism of TPB

• Doesn’t account for gap between intention and behavior (ppl don’t always do what they intend) 

• Leave out other factors

• Doesn’t account for the role of past habitual behavior

Theory of Planned Behaviour Applied to HPV Vaccine

Attitude: Believe that HPV is severe and vaccine is safe

Norm: Getting vaccine is common and normalized

Perceived control: Believe that vaccine is effective against cervical cancer

There’s notable increases in online searches abt STD/HIV testing and at-home HIV tests

Celebrity Influence on subjective norms

New York City poison control center received a higher-than-normal number of calls the day after Trump speculated that injecting household disinfectants could be a COVID treatment

The Transtheoretical Model

(Stages of Change Model) recognizes that it may not be possible to change all at once. Recognizes the steps ppl take to change behaviors

• Validated across various health behaviours (e.g., quitting smoking, cancer screening, vegetable consumption, safe sex practices).

• (Contrast to Health belied model and theory of behavior) Especially useful in clinical settings (therapist assess readiness and guide)

Stages of change in the Transtheoretical model

1. Precontemplation: Not considering changing, no intention (No plan to get vaccinated in next 3 months)

2. Contemplation: Aware of need to change, contemplating change (Considering getting vaccinated)

3. Preparation: Ready to change (ex., Planning to change diet tmr)(Try to schedule to get vaccinated)

4. Action: Start successfully making changes to behav

   1. Get 1 dose of vaccine and schedule for 2nd

5. Maintenance: (should be maintained >6) Work to maintain new behav, avoid relapse (esp imp for therapists so they can support ppl in avoiding relapses) (lapse is one time, normal, the imp thing is to avoid multiple relapses)

To help ppl change, it depends on

…which stage they are currently, in their readiness to change. Each stage need diff kinds of support

Ways to help ppl advance through the stages

• Describe in detail how a person would carry out the behavior change (e.g. give info)

• Match strategies to the person’s current needs to promote advancement to the next stage

  • Precontemplation stage is the BEST stage to give ppl w basic info abt health risks (ex. If person smokes daily and not thinking abt quitting, it’s the best time to give info abt harms)

  • Discuss perceived barriers work best in contemplation

• Plan for problems that may arise when trying to implement the change (imp to prevent relapses in maintenance stage)

Less rational processes

The flawed decisions that people make about their health often result from other motivational and emotional processes.

There’s: Motivated reasoning and conflict theory

Motivated reasoning

Emotionally-biased reasoning intended to produce justifications or make decisions that are most desired rather than those that reflect the evidence

• Ppl may search for reasons to accept supportive info and ignore disconfirming information (denial/confirmation bias)

• Explain why ppl still maintain unhealthy behaviors (like sugary food)

Conflict theory (emotional factors, and vigilance/hypervigilance)

• Ppl have stress due to conflict between perceived risk, hope, and adequate time

• In certain instances (e.g. hypervigilance, when risk is high, hope remains, but have little time) ppl will be desperate for a solution and may act irrationally (like alternative health practice in their search)

Vigilance vs Hypervigilance in Conflict Theory

• Vigilance (Adaptive): Perceiving serious risks and having adequate time/hope leads to moderate stress and a tendency to search carefully and make rational choices.

• Hypervigilance (Maladaptive): Perceiving serious risks but feeling time is running out leads to high stress → searching for a quick solution, often resulting in hasty, non-rational choices

The 2 other cognitive factors in less rational processes

• False Hope: Believing without a rational basis that one will succeed in a difficult change (like weight loss) after a previous failure, often by concluding they "didn't try hard enough" before.

• Willingness: For spontaneous risky behaviours (e.g., drinking), the factor predicting the behaviour is willingness rather than intention; this is heightened by having a favorable social image of the behaviour.

Development and health

• Gestation: The mother's behaviour (e.g., nutrition, avoidance of addictive drugs/alcohol) directly impacts fetal development and birth outcomes (e.g., preventing Fetal Alcohol Syndrome).

• Adolescence: A critical time where teens, despite having the cognitive ability for healthy choices, are highly susceptible to taking part in risky behaviours like substance use, which is a key driver of death by accident in this age group.

• Adulthood/Aging: Older adults are generally less likely to engage in high-risk behaviours and are more likely to practice healthy habits, in part because they perceive themselves as more vulnerable to illness

Gender and Health:

• Life Expectancy: Women live a few years longer than men due to biological factors (e.g., lower cardiovascular reactivity to stress, estrogen's protective effect on the heart) and behavioural factors.

• Men's Risk: Men are more likely to smoke, drink, use drugs, and engage in risky activities.

• Women's Advantage: Women are more likely to consult a physician when they feel ill

Effective promoting of health

Requires a biopsychosocial perspective and a grassroots, culturally relevant approach

SuperAmma Handwashing Campaign

Designed to increase handwashing of moms in rural villages in South India (Handwashing prevents diarrhea)

• Targeted emotional drivers found to be the most effective levers for behavior change

• 6 months later, increase 30% of handwashing behavior, and sustained for 12 months

Targeted emotional drivers found to be the most effective levers for behavior change in handwashing campaign (4)

1. Status (desire to have greater access to resources than others)

2. Affiliation (desire to fit in)

3. Nurture (desire for a happy, thriving child)

4. Disgust: Desired to avoid and remove contamination. (most likely to feel disgust to outward group, could be explained by evolutionary – disgust toward possible disease outsiders bring in)

Nurse/physician handwashing study

Monitored contents of hand soap/gel dispensers in a hospital and measure how much it’s used, before vs after putting new signs near them

• Few reasons why they don’t wash as often as they should: Constant, soap is irritating, don’t think they’re at risk, no one tracks it anyway

• 3 signs in this study at the handwashing station

  • Hand hygiene prevents you from catching diseases

  • This sign was most effective: Hand hygiene prevents patients from catching diseases

  • Gel in, wash out

• Patient-focused sign had 17% increase in soap/gel, cuz it triggered empathy. 1st and 3rd signs didn’t show increase in hand-washing behavior

Studies of epidemic/outbreaks and empathy

Studies of coping during the SARS epidemic, West Nile virus outbreaks in NA, H1N1 pandemic (india), and seasonal influence (2015) found the same relationship:

• Epidemic is diff from outbreaks in terms of availability of vaccines

• Behavioral responses to disease threat: Empathic responding is the most imp, the other one that’s MORE imp is perceived threat

• Healthier or younger ppl may not perceive as much threat, so empathy may help to supplement in giving more motivation

What are the effects of disease threat?

• Inequality → socioeconomic disparities in disease threat

• Pandemics can either worsen inequality (by leading ppl to defend and protect the status quo or reduce it (The rich got richer during the pandemic)

• Infectious diseases have been asso w “othering” (racism, xenophabia, bigotry)

  • Outbreaks create fear. (Fear is key to racism)

  • Historical pathogen prevalence asso w closed-mindedness, and authoritarianism

  • Higher conformity to traditional gender roles/support for gender stereotypes after COVID-19

Empathy during COVID-19

Increases empathic responding (as well as an imp role of trait empathy) → increases uptake of health health precautions during COVID (consistent w health belief model)

• Perceived threat is low, empathy matters in increasing preventative behaviors (In short, empathetic responding is especially imp when perceived threat is low)

• Perceived threat is high: There’s not much difference in preventative behaviors between high vs. low empathetic response

Empathy and perspective-taking have been shown to reduce…(3)

• Prejudice

• Stereotype expression

• Interpersonal aggression

In addition to increasing health precautions, empathic responding may also:

• Mitigate the negative social consequences of pandemics (racism, discrimination, “othering”)

• While improving support and care provision to the sick

Herd immunity

Some ppl are allergic to smth in vaccines (can’t get vaccinated themselves) so they rely on herd immunity for protection from many diseases

• The more people that are immunized for a virus, the more infections are disrrupted

• So everyone thinking of other ppl → encourage them to get vaccine to build immunity and protect other ppl who are more vulnerable (to allergies/diseases) than others

Study of Antisocial traits in COVID in Brazil

• Antisocial Traits: Lower levels of empathy, higher levels of callousness (negative views of society), deceitfulness, and risk-taking (like psychopathy)

  • Assoc w lower engagement in recommended health precautions (measures) (ex. Social distancing, mask-wearing, handwashing)

• These traits asso narcissism and more hoarding (prevention) during COVID-19 

• Antisocial = socially disruptive, violating the rights of others

Study on intention to wear mask during COVID in the US

• Where masks were not mandatory, men were less likely wear mask than women

• They said cuz wearing mask is shameful, not cool, a sign of weakness, and a stigma (Toxic masculinity! Other behaviors from this is like not washing hands, eat more red meat)

Study: messages focusing on “your community” were effective?

Effective in motivating mask-wearing behavior

Study: White Americans exposed to info abt COVID-19 racial disparities

• REDUCED support to engage in health precautions and perceived overall lower threat

• Explaination

  • Reduced fear (cuz White ppl were told that white ppl are at lower risk of COVID than other races → less fear)

  • Reduced empathy (To outgroup! They don’t care much aside from white ppl themselves)

Vaccine riot in Montreal in 1800s

Ppl have been protesting for anti-vaccine since the first vaccine

Measles party

• Ppl throw a party, expose their kids to kid who has the measles, and that’s their way to build immunity

• Getting measles → impairs (harmed) 7-8 years after infection

Anti-Vax Movement & Vaccine hesitancy

• Most ppl that didn’t get vaccine were more reluctant to get it than being anti-vaccine

• Easy to convince Vaccine hesitant ppl by a talk w physician, but it’s IMPOSSIBLE to convince anti-vax ppl

• It takes ONE social media post to make ppl reluctant abt vaccine

• Lead to declining immunization rates and an increasing frequency of outbreaks in viruses like measles and whooping cough in Western nations and other parts of the world → Now affecting other vaccines like the flu vaccine, and has had a sig impact on COVID-19 vaccine

Rise in negative attitudes abt vaccines (vaccine hesitancy - anti-vaccine)

•  Vaccine hesitancy is a bigger threat every year (listed as major threat by WHO, even before COVID, becoming more worldwide)

• Spillover effect within and between countries

Fraud study: MMR (measles, mumps, rubella) Vaccine & Autism – Wakefield

• Found that Wakefield falsified medical records to find the result, and he also didn’t follow ethic methods

• Wakefield was PAID a lot by a law firm that was looking to sue the vaccine manufacturer

• He even did invasive vaccination onto children in his studies (some kids were reported abused!)

• He has continued to be one of the leading voices in anti-vaccine (wtf)

• Led by celebrities like Jenny McCarthy → had even more attention on media

  • Books published by doctors/scientists (ex. Diet books) that are not peer-reviewed.

Measles outbreaks in NA (recent)

• More and more throughout few past decades, even spreaded to Europe

• In Canada, it was mostly in Alberta

• Measles death in the past was more common, but dropped prevalence sharply 1964-1970 cuz of vaccine

On Childhood Vaccinations...

A 2014 Review of 11 different childhood vaccines (including MMR, hepatitis B, and chickenpox).

• No link with childhood leukemia (blood cell cancer)

• No link between MMR vaccine and autism.

• No link between hepatitis B vaccine and multiple sclerosis

• A lot of money was wasted to combat w anti-vax attitude

Adverse reactions are extremely rare: (including seizure & fever), ranging in frequency, far less likely than complications due to the viruses being vaccinated.

Which factors from each model (Health belief and planned behav) help to explain vaccine hesitancy?

• Perceived threat asso w prevention of disease (likelihood to get vaccine), not w the disease itself (likelihood to get COVID)

  • A lot of burden to try to encourage

Factors in Vaccine hesitancy & resistance

• Fear/perceived dangers of vaccines, scared of blood/needle

• Lack of trust: Ppl who don’t trust other ppl in general also don’t trust medical community

• More vaccine resistancy in discriminated popul (Indigenous)

• Conspiracy theory: 

  • Associated w low agreeableness, low trust in others (suspicious)

  • high thinking that the world is a dangerous place

  • Rejected socially, isolated

• Reliance on religious beliefs, alternative medicine (think abt Na oai situation)

• These are all correlated: Narcissism (more likely to believe in conspiracy theory, low in inhulimity–less likely to take advice from other ppl), low empathy, low altruism, individualism (focus on how they’re “not like other ppl”)

• High reactance to the perceived their rights and freedoms “taken away”  (they just don’t get vaccinated just cuz they don’t wanna be told what to do)

Individualism and narcissism are correlated with anti-vaccine attitudes and defiance of COVID-19 precautions like mask-wearing

• More individualistic countries have higher COVID-19 cases and mortalities from it (like conservative states in US like kentucky, florida, texas)

• Messages that frame social challenges as issues of individual choice do not advance public support for policy systems, or environmental solution

The Dunning-Kruger Effect

a cognitive bias whereby people with limited knowledge or competence in a given intellectual or social domain greatly overestimate their own knowledge or competence in that domain

(Like people who never took a psych class and only know a few Freud’s theories, think they know a lot abt Psych, more than us psyc students)

Overconfidence (Dunning-Kruger effect) is also associated with

• Anti-vaccine attitudes (and opposition to vaccine mandates); and overconfidence in anti-vaccine ideas is highest among those w low levels of knowledge abt vaccine and diseases

• Also increased support of non-expert views in policy decisions

Backfire effect

cognitive bias that causes people who encounter evidence that challenges their beliefs to reject that evidence and strengthen their support of their original stance.

Ppl concerned abt side effects of flu shot were given info abt how it COULDN’T cause the flu, they actually became less willing to get it

So kinda like motivated reasoning

Solution to convince ppl to give vaccine

Info on disease threat, rather than info debunking vaccination myths, works best to change attitudes about vaccine