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MODULE 2: HEALTH BEHAVIOUR & PRIMARY PREVENTION HEALTH BEHAVIOURS Health behaviors are behaviors undertaken by people to enhance or maintain their health. A health habit is a health behavior that is firmly established and often performed automatically, without awareness. These habits usually develop in childhood and begin to stabilize around age 11 or 12. Wearing a seat belt, brushing one’s teeth, and eating a healthy diet are examples of these behaviors. Although a health habit may develop initially because it is reinforced by positive outcomes, such as parental approval, it eventually becomes independent of the reinforcement process. For example, you may brush your teeth automatically before going to bed. It is important to establish good health behaviors and to eliminate poor ones early in life. Important healthy habits include: • Sleeping 7 to 8 hours a night • Not smoking • Eating breakfast each day • Having no more than one or two alcoholic drinks each day • Getting egular exercise • Not eating between meals • Being no more than 10% overweight PRIMARY PREVENTION Instilling good health habits and changing poor ones is the task of primary prevention. This means taking measures to combat risk factors for illness before an illness has a chance to develop. There are two general strategies of primary prevention. ✓ The first and most common strategy is to get people to alter their problematic health behaviors, such as helping people lose weight through an intervention. ✓ The second, more recent approach is to keep people from developing poor health habits in the first place. Smoking prevention programs with young adolescents are an example. FACTORS INFLUENCING HEALTH BEHAVIOUR • Demographic Factors Younger, more affluent, better-educated people with low levels of stress and high levels of social support typically practice better health habits than people under higher levels of stress with fewer resources. • Age Health habits are typically good in childhood, deteriorate in adolescence and young adulthood, but improve again among older people. • Values affect the practice of health habits. For example, exercise for women may be considered desirable in one culture but undesirable in another • Personal Control People who regard their health as under their personal control practice better health habits than people who regard their health as due to chance. • Social Influence Family, friends, and workplace companions influence health-related behaviors, sometimes in a beneficial direction, other times in an adverse direction. For example, peer pressure often leads to smoking in adolescence but may influence people to stop smoking in adulthood. • Personal Goals and Values Health habits are tied to personal goals. If personal fitness is an important goal, a person is more likely to exercise. • Perceived Symptoms Some health habits are controlled by perceived symptoms. For example, a smoker who wakes up with a smoker’s cough and raspy throat may cut back in the belief that he or she is vulnerable to health problems at that time. • Access to the Health Care Delivery System Access to the health care delivery system affects health behaviors. • Knowledge and Intelligence The practice of health behaviors is tied to cognitive factors, such as knowledge and intelligence. More knowledgeable and smarter people typically take better care of themselves. People who are identified as intelligent in childhood have better health-related biological profiles in adulthood. The health locus of control scale measures the degree to which people perceive their health to be under personal control, control by the health practitioner, or chance. CHANGING HEALTH HABITS ATTITUDE CHANGE AND HEALTH BEHAVIOR • Educational Appeals Educational appeals make the assumption that people will change their health habits if they have good information about their habits. More recently, though, a fact that attitude change may not lead to behavior. • Fear Appeals Attitudinal approaches to changing health habits often make use of fear appeals. This approach assumes that if people are afraid that a particular habit is hurting their health, they will change their behavior to reduce their fear. However, this relationship does not always hold. Persuasive messages that elicit too much fear may actually undermine health behavior change. Moreover, fear alone may not be sufficient to change behavior. • Message Framing A health message can be phrased in positive or negative terms. For example, a reminder card to get a flu immunization can stress the benefits of being immunized or stress the discomfort of the flu itself. Messages that emphasize problems seem to work better for behaviors that have uncertain outcomes, for health behaviors that need to be practiced only once, such as vaccinations, and for issues about which people are fearful. Which kind of message framing will most affect behavior also depends on people’s personal characteristics. SOCIAL ENGINEERING Much health behavior change occurs not through programs such as CBT interventions, but through social engineering. Social engineering modifies the environment in ways that affect people’s abilities to practice a particular health behavior. Often, social engineering solutions are legally mandated. Some examples include requiring vaccinations for school entry. COGNITIVE BEHVAIOURAL APPROACH COGNITIVE-BEHAVIOR THERAPY (CBT) Cognitive-behavior approaches to health habit modification focus on the target behavior itself, the conditions that elicit and maintain it, and the factors that reinforce it. The most effective approach to health habit modification often comes from cognitive-behavior therapy (CBT). CLASSICAL CONDITIONING First described by Ivan Pavlov, a Russian physiologist. It is a process that involves pairing of an unconditioned reflex with a new stimulus, producing a conditioned reflex. OPERANT CONDITIONING First described by B. F. Skinner, an American psychologist. It focusses on using either reinforcement or punishment in order to increase or decrease a behaviour. SELF MONITORING Many programs of cognitive-behavioural modification use self-monitoring as the first step toward behavior change. The rationale is that a person must understand the dimensions a target behaviour before change can be inflicted. Two steps are involved: 1. Learn to discriminate the target behaviour. e.g. A smoker should be able to tell whether he/she is smoking. 2. Charting the behaviour. e.g. A smoker may be trained to keep a detailed behaviour record of all the smoking events. SELF REINFORCEMENT Self-reinforcement involves systematically rewarding oneself to increase or decrease the occurrence of a target behaviour. • Positive self-reward involves rewarding oneself with something desirable after successful modification of a target behaviour. e.g. going to a movie following successful weight loss • Negative self-reward involves removing an aversive factor in the environment after successful modification of target behaviour. e.g. taking the Miss Piggy poster off the refrigerator once regular controlled eating has been achieved • Positive self-punishment involves the administration of an unpleasant stimulus to punish an undesirable behaviour. e.g. electric shock each time he or she experiences a desire • Negative self-punishment involves withdrawing a positive reinforce in the environment each time an undesirable behaviour is performed. e.g. rip up money each time he or she has a cigarette that exceeds a quota. These reinforcements and punishments are effective only if they perform the activities. One form of self-punishment that is effective in behavior modification is contingency contracting. Contingency Contracting is when an individual forms a contract with another person such as a therapist, detailing what rewards/punishments are contingent on the performance or non performance of a behaviour. HEALTH BELIEF MODEL An early influential attitude theory of why people practice health behaviors is the health belief model. According to this model, whether a person practices a health behavior depends on two factors: whether the person perceives a personal health threat, and whether the person believes that a particular health practice will be effective in reducing that threat. 1. PERCEIEVED HEALTH THREAT The perception of a personal health threat is influenced by at least three factors: • General health values, which include interest in and concern about health • Specific beliefs about personal vulnerability to a particular disorder • Beliefs about the consequences of the disorder, such as whether they are serious. Thus, for example, people may change their diet to include low cholesterol foods if they value health, feel threatened by the possibility of heart disease, and perceive that the personal threat of heart disease is severe. 2. PERCEIVED THREAT REDUCTION Whether a person believes a health measure will reduce threat has two subcomponents: • Whether the person thinks the health practice will be effective • Whether the cost of undertaking that measure exceeds its benefits. For example, the man who is considering changing his diet to avoid a heart attack may believe that dietary change alone would not reduce his risk of a heart attack and that changing his diet would interfere with his enjoyment of life too much to justify taking the action. So, even if his perceived vulnerability to heart disease is great, he would probably not make any changes. Many studies have used the health belief model to modify a large variety of health habits. The health belief model does, however, leave out an important component of health behavior change, and that is a sense of self efficacy: the belief that one can control one’s practice of a particular behavior. For example, smokers who believe they cannot stop smoking are unlikely to make the effort.

THEORY OF PLANNED BEHAVIOUR A theory that attempts to link health beliefs directly to behavior is Ajzen’s theory of planned behavior. According to this theory, a health behavior is the direct result of a behavioural intention. Behavioral intentions are themselves made up of three components:

• Attitudes toward the specific action: Attitudes toward the action center on the likely outcomes of the action and evaluations of those outcomes.

• Subjective norms regarding the action: what a person believes others think that person should do (normative beliefs) and the motivation to comply with those normative beliefs.

• Perceived behavioural control: It is the perception that one can perform the action and that the action will have the intended effect; this component of the model is similar to self efficacy. These factors combine to produce a behavioural intention and, ultimately, behavior change. For example, smokers who believe that smoking causes serious health outcomes, who believe that other people think they should stop smoking, who are motivated to comply with those normative beliefs, who believe that they are capable of stopping smoking, and who form a specific intention to do so will be more likely to stop smoking than people who do not hold these beliefs.

TRANS THEORETICAL MODEL Changing a bad health habit does not take place all at once. People go through stages while they are trying to change their health behaviors. The trans theoretical model of behavior change is a model that analyses the stages and processes people go through in bringing about a change in behavior and suggested treatment goals and interventions for each stage.

Originally developed to treat addictive disorders, such as substance abuse, the stage model has now been applied to a broad range of health habits, including exercising and sun protection behaviors.

STAGES 1. Precontemplation: The precontemplation stage occurs when a person has no intention of changing his or her behavior.

2. Contemplation: It is the stage in which people are aware that they have a problem and are thinking about it but have not yet made a commitment to take action. Many people remain in the contemplation stage for years. Interventions aimed at increasing receptivity to behavior change can be helpful at this stage.

3. Preparation: In this stage, people intend to change their behavior but have not yet done so successfully. In some cases, they have modified the target behavior somewhat, such as smoking fewer cigarettes than usual, but have not yet made the commitment to eliminate the behavior altogether.

4. Action: This stage occurs when people modify their behavior to overcome the problem. Action requires the commitment of time and energy to making real behavior change. It includes stopping the behavior and modifying one’s lifestyle and environment to rid one’s life of cues associated with the behavior.

5. Maintenance: In the stage of maintenance, people work to prevent relapse and to consolidate the gains they have made. For example, if a person is able to remain free of an addictive behavior for more than 6 months, he or she is assumed to be in the maintenance stage.

A person may take action, attempt maintenance, relapse, return to the precontemplation phase, cycle through the subsequent stages to action, repeat the cycle again, and do so several times until they have eliminated the behavior

PROTECTION MOTIVATION THEORY The decision on whether or not to engage in health related behaviors is governed by two distinct cognitive processes – threat appraisal and coping appraisal. Both these processes deal with the consequences that can be expected as a result of engaging or not engaging in specific health behavior. Perceptions of what others will expect or react are aspects of both types of appraisal.

THREAT APPRAISAL It deals with how threatened one feels by the threat. In threat appraisal, the mind evaluates the various factors that are likely to influence one to get involved in a potentially unhealthy behavior like smoking or using drugs. Perceived vulnerability and perceived severity are the two sets of beliefs from which threat appraisals are derived. • Perceived vulnerability is the individual’s belief that he is susceptible to an illness that is a potential health threat. • Perceived Severity-Feeling that the health threat will have severe consequences in one’s life is called as perceived severity.

COPING APPRAISAL Here one evaluates the various factors that are likely to ensure that one engages in a recommended response that is preventive in nature. For example, taking a daily walk or using a condom. There are three sets of beliefs involved here. • Response efficacy is the belief that engaging in a certain behavior will result in the health threat getting reduced. For example, here there is a feeling that ‘If I exercise more, I will lose weight and lessen the threat of heart disease.’ • self-efficacy deals with the belief that one has the required capabilities to engage in a health behavior. • The perceived response-cost deals with the costs that one attaches to the performance of a health behavior. For example, a lady should feel comfortable getting a mammogram.