Health Psychology & Human

Diversity

Health and illness

related behaviour

Offered by:

Dr. Mahdi Abdul Karim

MB.CH.B FICMS
Consultant Psychiatrist
Head of Psychiatric Department
Wasit Health Directorate

makmahdi3@gmail.com
What are health and illness related
behaviours?
• Anything that may promote good health or lead
to illness, e.g.
– Smoking
– Drinking
– Drug use
– Taking exercise
– Eating a healthy diet
– Taking up screening activities
– Adhering to treatment regimens etc.!

Theories/models to help understand

people’s health and illness related
behaviours
• Learning theories
– Classical Conditioning (Pavlov)
– Operant conditioning (Skinner)
– Social learning theory (Bandura)
• Cognition and social cognition models
– Health beliefs model (Becker)
– Theory of reasoned action/planned behaviour (Ajzen &
Fishbein)
• Stages of change model
– Transtheoretical model (Prochaska and DiClemente)
 Learning Theories

• Classical (Pavlovian) conditioning

Classical Conditioning (Pavlovian conditioning)

(food) UCS UCR (salivation)

(bell+ food) UCS+CS UCR (salivation)

(bell) CS CR (salivation)

Behaviour shaped through association of new stimulus to original one that

provokes a ‘natural’ or reflex response. Learn to give the same response to a
new stimulus.

U: un
C: conditioned
S: stimulus
R: response
 John Watson

• Conditioned fear response, generalisation

– E.g. ‘Little Albert’ learned fear of animals
http://www.dushkin.com/connectext/psy/ch06/watson.mhtml

Health related behaviours and association

Break from work (UCS) feel relaxed (UR)

Break & cigarette (UCS & CS) feel relaxed (UR)

Cigarette (CS) feel relaxed (CR)

• Associative learning can be barrier to changing health

behaviour e.g. smoking associated with taking a break
and relaxing / coffee / pleasant social environment
• Conditioned behaviours - habit
 Classical conditioning and changing health
behaviour

• Aversive techniques in smoking/alcohol

misuse = pair behaviour with unpleasant
response
– e.g. smoke holding
– e.g. alcohol + medication to induce nausea
(nausea is result of medication + alcohol but
comes to be associated with alcohol (CR))
• Break unconscious response
– elastic band on cigarette packet!

More Learning Theories

BF Skinner
Operant Conditioning
• People/animals act on the environment and behaviour is
shaped by the consequences
• behaviour reinforced (increases) if it is
– rewarded (+R) positive reinforcement
– a ‘punishment’ is removed (-P) negative reinforcement
• behaviour decreases if it is
– punished (+P) aversive
– a reward is taken away (-R)

positive punishment
negative punishment
Operant conditioning
• Key way that we learn all the time
Rewards and punishments to shape
behaviour
– Computer games
– Child behaviour

Operant conditioning and changing health

behaviour
• Shape behaviour through positive or
negative reinforcement (punishment or
reward)
– e.g. save up cigarette money for holiday

** Key concepts in operant conditioning are

positive reinforcement, negative reinforcement,
positive punishment and negative punishment.
 • Classical and operant conditioning based on
simple stimulus-response associations
• No account of cognitive processes, knowledge,
beliefs, memory, attitudes, expectations etc.
• No account of social context

"Stimulus response, stimulus

response! Can't you ever think?"

More Learning Theories Albert Bandura

Social Learning theory

• People can learn vicariously (observation/modelling)
• Bandura and the Bobo Doll experiments
Social learning theory (Albert Bandura)
posits that learning is a cognitive process that
takes place in a social context and can occur
purely through observation or direct
instruction, even in the absence of motor
reproduction or direct reinforcement

Social Learning theory

• People behave in certain ways to achieve

desired goals/outcomes
• People motivated to perform behaviours:
– that are valued (expectancy)
– that they believe they can enact (self-efficacy)

• Modelling more effective if models high

status or ‘like us’ (value/ability)
 Social Learning theory & health promotion
• Influence of media figures, role models
(e.g. smoking)

• Important for health promotion campaigns

(e.g. Robbie and self examination for
testicular cancer)
http://www.icr.ac.uk/everyman/events/robbie
.html

Self efficacy / health locus of control

• Self-efficacy important concept developed from
social learning theory

• belief that person can carry out/control desired

behaviour (“I can quit smoking if I want to”)
(Bandura, 1977)

• Health locus of control:

– Internal
– External
– Powerful others (Wallston et al 1978)
Cognition and social cognition
models
• Focus on cognitive factors in health-related
behaviour (knowledge, beliefs, attitudes,
expectations etc.)

• Early health promotion based on cognitive

dissonance theory (Festinger, 1957)
– providing health information (usually uncomfortable!) would
create mental discomfort (fear!) and prompt change in behaviour
– but information provision alone not enough / fear can be
counterproductive
– more complex models of cognition and behaviour required

Cognition Models:
Health Belief Model (Becker 1974)

Beliefs about health threat

- perceived susceptibility
- perceived severity Action

Beliefs about health-related

behaviour
- perceived benefits Cues to Action
- perceived barriers
Limitations of cognition models

• Rational and reasoned?

– function / substance
• Decisions?
– habit / conditioned behaviour / coercion
• Emotional factors (e.g. fear, see
protection-motivation theory)
• Social as well as individual factors

Social cognition models:

Theory of reasoned action/planned behaviour

• TRA developed by Ajzen and Fishbein (1980), later

developed & expanded into Theory of Planned
Behaviour (TPB)
• Similar to HBM (Health belief model) but attitudes rather
than beliefs
• Attitudes to health have two parts:
– Belief about the outcome of a behaviour e.g. eating
fruit will keep me healthy
– Evaluative component e.g. I value keeping healthy
(therefore I’ll eat fruit)
 Theory of reasoned action/planned
behaviour: 3 key elements
• Cognitive factors
– person’s own attitude towards the behaviour

• Social factors
– ‘social norms’ (e.g. brushing teeth a good idea since
bad teeth not seen as attractive to others)
– ‘salient others’ friends / peer group with views held as
important to person

• Perceived control (added in TPB)

– may have attitudes and norms that lead to an
intention to behave in a healthy way, but if you don’t
believe that you can implement the behaviour then
you are unlikely to try

Theory of reasoned action/planned

behaviour

belief about outcomes Attitude

evaluation of outcomes toward

normative beliefs
behaviour
!
Subjective Behavioural
motivation to comply Behaviour
norm intention

individual control
Perceived
barriers and facilitators
control
Stages of change (transtheoretical) model
(Prochaska and DiClemente 1984)

• Cognition models (HBM , TRA/TPB etc) all assume that

each cognitive component of decision making for health
occurs in same time frame / parallel.

• The way people think about health behaviours, &

willingness to change their behaviour, are not static

• Stages of change model - 5 stages which people may

pass through over time in decision making / change

• NOT predicting what influences health behaviour, BUT

describing process of changing health behaviour ,
identify what can help at different stages

Stages of change model

Preparation

Action

Contemplation

Precontemplation
Maintenance
Relapse
TTM with smoking
1 Pre-contemplation: I’m a smoker and not worried about it
2 Contemplation: Been coughing lot recently. Maybe it’s the
smoking?
3 Preparation: I’ll try to cut down gradually until I quit
4 Action: I am smoking 1 cig per day less than the day
before until I get down to zero
5 Maintenance: I’ve not smoked for 3 months
5 Relapse: Just the odd cigarette when I’m in the pub won’t
hurt - I’ll cut back again (? cycle back to 3 Preparation
stage)

• Intervention must be appropriate to the stage the person

is at

Summary
• Different models offer different ways of
understanding health-related behaviours
– Learning theories: behaviours learned and maintained
through association, positive consequences, and
observation of others
– Cognition and social cognition models: beliefs and
attitudes, social norms, and perceptions of control
play an important part in behaviour too
– Stages of change model: people pass through
different stages of willingness to change; efforts to
change health related behaviour need to be
appropriate to the stage a person is at
 Conclusions
• Theories and models each have their own strengths and
weaknesses, but perhaps each can add part of the
jigsaw?
– Most models designed to look at populations not individuals
– However, may identify useful questions to ask individuals (but
don’t pre-judge individuals based on group membership)
– Different models may be most helpful with different behaviours
and contexts
• Behaviour is complex and dynamic
– Influences interact and may change over time
– It is not helpful to ‘blame’ people for their behaviour, and against
GMC guidelines to allow patients’ ‘lifestyle’ choices influence
treatment
– Health education is only one part of the solution
– We need to understand barriers to change in order to help people
overcome them

QUIZ
• A: What is the difference between a neutral
stimulus and an unconditioned stimulus?
• B: What is an example of a conditioned
stimulus?
• C: What is conditioned and unconditioned
stimulus?
• D: What is an example of a conditioned
response?
• E: What is an example of a negative
reinforcement?