behavioural models in health promotion

25 Apr 2016

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behavioural models in health promotion

  1. Seminar-9 Dr. M.S.Bala Vidyadhar Date:01-01-2016 BehaviorModels In HealthPromotion
  2. Contents  Introduction  Definitions  History & Background  Importance of Behavior models  Behavior Theories/Models Of Health Promotion  Oral Health Applications Of Theories in Research  Conclusion  References  Previous Year Questions
  3. Introduction  Health education is a profession of educating people about health.  Areas within this profession encompass environmental health, physical health, social health, emotional health, intellectual health, and spiritual health.  It can be defined as the principle by which individuals and groups of people learn to behave in a manner conducive to the promotion, maintenance, or restoration of health.
  4. Definitions  WHO definition of Health  Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.  Health promotion  Health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions.
  5. Definitions  Theory: A supposition or a system of ideas intended to explain something, especially one based on general principles independent of the thing to be explained.  Model: A thing used as an example to follow or imitate.  Patient Autonomy: The capability and right of patients to control the course of their own medical treatment and participate in the treatment decision making process.
  6. Definitions  The Joint Committee on Health Education and Promotion Terminology of 2001 defined Health Education as “Any combination of planned learning experiences based on sound theories that provide individuals, groups, and communities the opportunity to acquire information and the skills needed to make quality health decisions.”
  7. Definitions  The World Health Organization defined Health Education as “Comprising of consciously constructed opportunities for learning involving some form of communication designed to improve health literacy, including improving knowledge, and developing life skills which are conducive to individual and community health.”
  8. History & Background  The fundamental needs of shelter, food, water, and safety are health related, and the writings of the Babylonians, Egyptians, and Old Testament Israelites indicate that various health promotion techniques were utilized.  There were community systems to collect rain water or otherwise provide safe drinking water.
  9.  There were various sewage disposal methods, including the use of earth closets. Personal cleanliness was advocated.  Intoxication was recognized as troublesome.  Disease, though not understood, was known to be contagious and various forms of quarantine were used, as were herbal medicines
  10.  Business and industry have also been major players in health education and health promotion programming since the Industrial Revolution, admittedly prodded into action by labour unions.  Early efforts to improve safety and eliminate inhumane working conditions have evolved into comprehensive employee wellness programs.
  11.  President Eisenhower officially established the Department of Health, Education and Welfare on April 11, 1953 in the USA.  The Department of Education and the Department of Health and Human Services were later separated.
  12. Theories Of Health Behaviors
  13. Health Promotion Theories and Models  Behavior change theories provide structures that educators may use to systematically design educational programs, and to explain how and why a program is expected to be effective.  No one theory can address all variables that contribute to a person’s behavior, and not all theories are applicable to all situations.  But elements of different theories may be combined to create a program tailored for a specific issue and target population.
  14. A health behaviour theory offers a number of benefits and can be seen:  As a Toolbox for moving beyond intuition to designing and evaluating health education interventions that are based on an understanding of why people engage in certain health behaviour;  As a Foundation for programme planning and development that is consistent with the current emphasis on using evidence-based interventions;  As a Road map for studying problems, developing appropriate interventions, identifying indicators and evaluating impacts;
  15. A health behaviour theory offers a number of benefits and can be seen:  As a Guide to help explain the processes for changing health behaviour and the influences of the many forces that affect it, including social and physical environments;  As a Compass to help planners identify the most suitable target audiences, methods for fostering change and outcomes for evaluation.
  16. The Health Belief Model by Hockbaum
  17. Health Belief Model (HBM)  The Health Belief Model (HBM) is an intrapersonal (within the individual, knowledge and beliefs) theory used in health promotion to design intervention and prevention programs.  It was designed in the 1950’s by Hockbaum and continues to be one of the most popular and widely used theories in intervention science.  The model was created in reaction to a failed, free tuberculosis screening program.
  18. Health Belief Model (HBM)  The HBM assumes that behavior change occurs with the existence of three ideas at the same time: 1. An individual recognizes that there is enough reason to make a health concern relevant (perceived susceptibility and severity) 2. That person understands he or she may be vulnerable to a disease or negative health outcome. (perceived threat) 3. Lastly the individual must realize that behavior change can be beneficial and the benefits of that change will outweigh any costs of doing so. (perceived benefits and barriers).
  19. Limitations  Research has not supported HBM to be a model that will produce predictable changes.  This model might help in changing beliefs but may not be sufficient for behavior change.  Behavior changes rarely follow a logical stepwise pattern.
  20. The Trans-theoretical Model And Stages Of Change by Prochaska, Norcross & DiClemente
  21. The Trans-theoretical Model And Stages Of Change  Model inspired by smoking cessation studies  Draws on fields of psychotherapy and behaviour change  Seeks to help us understand behaviour change  Model has been applied to a wide range of health behaviours: Addiction, bullying, eating disorders, HIV/AIDS prevention, etc.
  22. Trans-theoretical Model Constructs  Model consists of four core constructs: 1. Stages of Change (6 stages) 2. Processes of Change (10 processes) 3. Decisional Balance (Pros/Cons) 4. Self-Efficacy (Confidence/Temptation)
  23. Question: Do you have any plans to begin exercising more in the future?
  24. Step 2
  25. Decisional Balance  Weighing of the pros (benefits) and cons (costs) of changing a behaviour  Pros should be higher than cons in order to move into the action stage and beyond
  26. Self-Efficacy (Confidence/Temptation)  Confidence that one can engage in healthy behaviours across different challenging situations.  Temptation to engage in unhealthy behaviours across different challenging situations
  27. Limitations  TTM considers Individual health behaviour change in isolation from social and environmental factors  TTM aims to produce individual change and not structural change, so interventions are usually limited to the individual level  Increased responsibility is placed on the individual-Potential for victim-blaming.  TTM interventions usually target people with change potential  Model does not acknowledge that people with lower change potential are often socially or economically disadvantaged  Can further increase inequities.
  28. Theory of Reasoned Action and Theory of Planned Behavior By Fishbein and Ajzen
  29. History of the model  Originated in the field of social psychology.  The concept of “attitude” as a trigger and predictor of human behavior.  Value-Expectancy theory
  30. Assumptions of the Model  Human behavior is under the voluntary control of the individual  People think about the consequences and implications of their actions, then decide whether or not to do something.  Therefore, intention must be highly correlated with behavior.  Whether or not a person intends to perform a health behavior should correlate with whether or not they actually DO the behavior
  31. Components of the Model  Behavior is a function of 2 things:  Attitudes toward a specific action  What will happen if I engage in this behavior?  Is this outcome desirable or undesirable?  Subjective norms regarding that action  Normative beliefs: others expectations  Motivation to comply: do I want to do what they tell me? How much? Why?
  32. What ISN’T in the Model  Other factors such as the modifying factors in the HBM (demographics, etc.) are not directly addressed.  They can have an indirect effect on the other components, but are not specifically incorporated into the model.
  33. Beliefs and Evaluations of Behavioral Outcomes Attitude Toward The Behavior Behavioral Intention Behavior Normative Beliefs Subjective Norms
  34. Limitations of TRA  People who have little power over their behaviors (or believe they have little power).  As a result, Ajzen added a third element to the original theory:  Perceived Behavioral Control
  35. Theory of Planned Behavior
  36. Uses for TRA/TPB  TRA works best when applied to behaviors that are under the person’s control (or they think they are)  TPB works best when the behavior is NOT perceived to be under the person’s control.
  37. Limitations  Factors such as demographics and personality still not in model  No clear definition of perceived behavioral control (hard to measure)  Assumption that perceived behavioral control predicts actual behavioral control.  The more time between behavioral intent and actually doing the behavior, the less likely the behavior will happen.  Theory assumes people are rational and make systematic decisions based on available information. Ignores unconscious motives
  38. Social Cognitive Theory Of Learning by Bandura, 1986.
  39. Social Cognitive Theory Of Learning  Social cognitive learning theory highlights the idea that much of human learning occurs in a social environment.  By observing others, people acquire knowledge of rules, skills, strategies, beliefs, and attitudes.  Individuals also learn about the usefulness and appropriateness of behaviors by observing models and the consequences of modelled behaviors and they act in accordance with their beliefs concerning the expected outcomes of actions.
  40.  Social cognitive theory defines learning as “An internal mental process that may or may not be reflected in immediate behavioral change” (Bandura, 1986).  Assumptions / Basic Principles: 1. People learn by observing others: Modeling 2. Learning is internal. 3. Learning is goal-directed behavior. 4. There are ways to reinforce behaviors:
  41. Behavioral Reinforcers  There are 3 types of reinforcers of behaviors: A. Direct reinforcement -- direct reinforcement would be directly experienced by the learner. B. Vicarious reinforcement -- vicarious reinforcement would be observed to be consequences of the behavior of the model. C. Self reinforcement -- self reinforcement would be feelings of satisfaction or displeasure for behavior gauged by personal performance standards.
  42. Limitations  No big picture of the person  Too much focus on situations  Ignore biological factors  Mechanical -- No free will
  43. Locus Of Control By Wallston & Kaplan in 1970s
  44. Locus of Control Generalized Expectancies to perceive reinforcing events One’s own behavior Beyond control
  45. Internal Locus of Control  A belief that reinforcement is brought about by one’s own behavior.
  46. External Locus of control  A belief that reinforcement is under the control of other people, fate or Luck.
  47. Scales to measure Locus of Control  I-E Scale(1966).  Interpersonal trust Scale(1967).  Situation Specific scales.  Rotter Incomplete Sentence Blank (1950).  Intellectual Ascription of responsibilty scale.(1965).  Standford preschool I-E Index.
  48. Sense of Coherence By Antonovsky
  49. Health, Stress & Coping  Morbidity hypothesis: at least 1/3 & possibly majority of population is characterized by some morbidity at any point in time  Views health as a continuum ease → dis-ease
  50. Salutogenesis  Saluto (health) + genesis (origins)  How do we stay healthy?  Why?  “What are the stressors in the lives of poor people that underlie the brute fact that with regard to everything related to health, illness & patienthood, the poor are affected?”
  51. Stressors  Stressor: characteristic that introduces entropy into the system; life experience characterized by inconsistency, under- or overload, & exclusion from decision making  Chronic: Enduring, permanent, generalized phenomenon; primary determinant of SOC  Major life events: Specifiable in time & space; Strength of SOC → outcome is noxious, neutral or salutary  Daily hassles: No automatic adaptive response, but no impact on SOC or health status
  52. Sense of coherence (SOC)  Global orientation that expresses the extent to which one has a pervasive, enduring & dynamic feeling of confidence that one’s internal & external environment are predictable.  High probability that things will work out as reasonably as can be expected.  Generalized, long-lasting way of seeing the world & one’s position in it.
  53. Sense Of Coherence Contd..  Shaped & tested, reinforced & modified  Constant tendency towards consistency & generalization, stability & continuity  Weak SOC: Anticipate things will go wrong, difficulty expecting needs to be fulfilled, lack hope  Strong SOC: Life is complicated, but understood & in the end things will work out
  54. Development of SOC  Certain individuals & social groups likely to have stronger SOC than others.  Social-structural & cultural-historical situations provide developmental & reinforcing experiences → strong SOC.  Different from internal locus of control – “I am in control” vs. “Things are under control”.
  55. Operationalizing SOC  Strong SOC is salutogenic.  Operationalize:  Don’t commit to one methodology  Requires exploration before it’s a systematic tool  SOC is not dichotomous  All problems have an answer, challenge/doubt intolerable, no flexibility to adapt to change, claim ultimate control/understanding, denial of sadness, incapacity to admit uncontrollable → Fake SOC
  56. 3 components of SOC  Comprehensibility: Extent to which one perceives stimuli as ordered, consistent, etc.  Manageability: Extent to which one perceives resources available as adequate to meet demands.  Meaningfulness: Extent to which one feels life makes sense, some demands worth investing in, challenges welcome.
  57. Measuring the SOC concept  29-item questionnaire 13 item short form  7-point Likert type scale  Questionnaire which measures Orientation to Life.  Should not measure scores on subscales, inconsistent with theoretical formulation
  58. Oral Health Applications & Recent Research
  59. The Application of the Health Belief Model in Oral Health Education  By M Solhi  The Goal of this study was to determine the application of health belief model in oral health education for 12-year-old children and its effect on oral health behaviors and indexes.  A quasi- experimental study was carried out on twelve-year-old girl students (n-291) in the first grade of secondary school, in the central district of Tehran, Iran. Ref: Iranian J Publ Health, Vol. 39, No.4, 2010, pp. 114-119
  60.  Methodology:  First, a descriptive study was applied to individual perceptions, oral behaviors, Oral Hygiene Index (OHI) and Decayed, Missing and Filled Teeth Index (DMFTI).  Then an educational planning based on the results and Health Belief Model (HBM) was applied.  The procedure was repeated after six months. Ref: Iranian J Publ Health, Vol. 39, No.4, 2010, pp. 114-119
  61.  Results:  After education, based on HBM, all the oral health perceptions increased (P<.05). Correct brushing and flossing are influenced by increased perceptions.  A low correlation between the reduction of DMFTI and increased perceived severity and increased perceived barriers are found.  In addition, there was a limited correlation between OHI and increased perceived benefits .  Conclusion:  Using health belief model in oral health education for increasing the likelihood of taking preventive oral health behaviors is applicable. Ref: Iranian J Publ Health, Vol. 39, No.4, 2010, pp. 114-119
  62. Oral hygiene behaviours and readiness to change using the TransTheoretical Model  By Wade KJ The aim of this study was to investigate the Transtheoretical Model (TTM) in relation to measures of readiness to change oral hygiene behaviours.  A self-administered questionnaire was designed; it included four measures related to inter-dental cleaning used for TTM staging, confidence and frequency measures of future interdental cleaning and tooth brushing, together with items seeking demographic details.  Data collection occurred before a dental hygiene appointment where oral health advice was offered, and then at three and six months afterwards, in order to measure readiness to change post-intervention. Ref: N Z Dent J. 2013 Jun;109(2):64-8.
  63.  Results:  The confidence measures for maintaining toothbrushing twice per day and for interdental cleaning were associated with TTM staging at baseline.  Participants were likely to be in a higher TTM stage at 3 months after attendance at the dental hygiene clinic and then decline to a lower TTM stage by 6.  Of the 31 participants who improved their TTM staging between baseline and 3 months, 11 fell back to a lower category between 3 months and 6 months, 14 maintained their improvement, and 6 improved further. Ref: N Z Dent J. 2013 Jun;109(2):64-8.
  64.  Conclusions: Understanding a person's readiness to change could improve the way in which oral hygiene interventions and advice are given in the clinical setting.  The TTM staging measurement tool used here provides insight into people's readiness to change their oral hygiene behaviours, and its use would aid practitioners in the delivery of oral health messages.  The initial improvement in TTM stage and subsequent regression was consistent with the TTM's relapse phenomenon and reinforces the concept that on-going support is crucial to maintaining behaviour change. Ref: N Z Dent J. 2013 Jun;109(2):64-8.
  65. The Theory Of Reasoned Action In Describing Tooth Brushing, Dental Caries And Diabetes Adherence Among Diabetic Patients.  By Syrjälä AM  The aim here was to analyze the variables of Ajzen and Fishbein's theory of reasoned action to explain the reported frequency of tooth brushing, dental caries, HbA1c level and diabetes adherence.  Cross-sectional data were gathered from 149 IDDM patients by means of a quantitative questionnaire, clinical examination and patient records. Ref: J Clin Periodontol. 2002 May;29(5):427-32.
  66.  Results: The results showed that a firmer intention to brush the teeth was related to a higher reported frequency of tooth brushing.  The attitude to and the subjective norm of tooth brushing were related to the intention to brush and to the reported frequency of tooth brushing.  A better dental attitude was related to better diabetes adherence and fewer decayed surfaces, and a firmer intention to brush the teeth was related to a lower HbA1c level.  Conclusion: Results suggest that in oral health promotion among diabetic patients, both subjective norm and attitude are important and that diabetes adherence may be influenced by promoting dental attitude. Ref: J Clin Periodontol. 2002 May;29(5):427-32.
  67. Applying Social Learning Theory To Children With Dental Anxiety.  By Catherine  Through a review of the literature dental anxiety has been found to be prevalent and problematic within the child population.  This article seeks to apply Albert Bandura's social learning theory to reduce dental anxiety in children, in a preventative nature.  The social learning theory offers not only a preventative approach but also easy and effective interventions that can be used with children, in particular ranging from 4-9 years of age. Ref: J Contemp Dent Pract. 2004 Feb 15;5(1):126-35.
  68.  A dentist can act on his own free will to reduce disruptions in his office by incorporating either films or live observations within his or her practice.  This article concluded that the collaboration between psychology and dentistry offers both fields a better understanding of dental anxiety and further improves the resources available to those children that suffer with dental anxiety. Ref: J Contemp Dent Pract. 2004 Feb 15;5(1):126-35.
  69. Dental Fear And Locus Of Control: A Pilot Study  By Per Otto Neverlien et. Al.  In a pilot study among 25 Norwegian elementary schoolchildren age 13 the external part of a Health Locus of Control (HLC) inventory, when scored in internal direction, showed remarkably high positive correlations with clinical anxiety (r = 0.81) and scores on Corah's Dental Anxiety Scale (CDAS) (r = 0.77).  The high correlation between the E-part of the HLC scale and CDAS was upheld when HLC was given to 19 children 20 months later. Ref: Community Dentistry and Oral Epidemiology Volume 16, Issue 2, page 127,April 1988
  70. A Salutogenic Perspective To Oral Health  By Jarno Savolainen et al  The study verified Sense of coherence as a determinant of oral and general health behaviours, and oral health-related quality of life.  The present study uses data from the nationally representative Health 2000 survey carried out in 2000–2001 by the National Public Health Institute of Finland.  The cross-sectional data was collected via home interviews, self- administered questionnaires, or clinical examinations. Ref: A Salutogenic Perspective To Oral Health By Jarno Savolainen
  71.  Results:  Sense of coherence was positively associated with oral health behaviours, such as dental attendance and tooth-brushing frequency. In addition to tooth-brushing frequency, sense of coherence was also positively associated with the level of oral hygiene.  A strong sense of coherence was strongly associated with a positive oral health-related quality of life (OHIP).  Sense of coherence was also associated with all of the OHIP sub- scales, and the association was most evident in the psychological discomfort, psychological disability and handicap sub-scales.  A strong sense of coherence was a common determinant of healthy behaviours in general, as well as of a good subjective health status. Ref: A Salutogenic Perspective To Oral Health By Jarno Savolainen
  72.  Conclusions:  This study recognizes the sense of coherence as a common health-promoting determinant of oral and general health behaviours, good oral health, and a good Oral Health-related Quality Of Life.  The results thus suggest that the role of psycho-social factors should not be underestimated in health promotion. Ref: A Salutogenic Perspective To Oral Health By Jarno Savolainen
  73. Conclusion
  74. Conclusion  Improving the health of individuals and communities was a concern of the earliest civilizations and it remains a concern today.  Indeed, health education and promotion has evolved into a profession, and certification indicating adequacy of training and competence is now available.  Health promotion programming is pervasive in the private and public sectors of most industrialized societies, and it has even been suggested that we are in a “golden age” of health education and promotion.
  75. Conclusion  Health promotion programming is pervasive in the private and public sectors of most industrialized societies, and it has even been suggested that we are in a “golden age” of health education and promotion.  Yet the question remains whether the profession will continue to flourish (because its practice has improved) or whether it will begin to decline (because it has not lived up to its potential).  The answer to this question is largely in the hands of today’s practitioners.
  76. References  Primary Preventive Dentistry: Norman O. Harris, 7th Edition.  Community Oral Health: Cynthia Pine Et Al.  Parks Textbook Of Public Health Medicine 23rd edition.  Health Promotion Theories and Models for Program Planning and Implementation Rowan Frost, Mel & Enid Zuckerman College of Public Health University of Arizona.  Health Education: Theoretical Concepts, Effective Strategies And Core Competencies: WHO Library Cataloguing in Publication Data
  77. References  Health education:  Evolution of Health Education, Health Promotion, and Wellness Programs: 42376_BOOK_johnson.indb  html  The Transtheoretical Model And Stages Of Change Laura Kadowaki Gero 820  Social Cognitive Theory Albert Bandura Stanford University
  78. References  Iranian J Publ Health, Vol. 39, No.4, 2010, pp. 114-119  N Z Dent J. 2013 Jun;109(2):64-8.  J Clin Periodontol. 2002 May;29(5):427-32.  J Contemp Dent Pract. 2004 Feb 15;5(1):126-35.  Community Dentistry and Oral Epidemiology Volume 16, Issue 2, page 127,April 1988  A Salutogenic Perspective To Oral Health By Jarno Savolainen
  79. Previous Year Questions  Health education Models: RGUHS May 2009 (20mks).  Behavior Modification Theories: RGUHS 2004 (20mks).  Health Promotion Models: RGUHS 2013 (20mks).  Motivational Models: NTRUHS May 2012 (AP)-(5mks).