lthy behaviour?Is it possible to help people to change to more healthy behaviour?
Theories about changes in health behaviour tend to look at:
Cognition: the way people define and think about what they do and how they change their minds in ways that can lead to changing the ways they act; and
Context: the cultural, social, physical, emotional and psychological environments that shape people and the factors that can facilitate change. No one theory can sum up all the factors in health behaviour, but theories can be used to focus on particular aspects of behaviour and to choose the most appropriate programmes for cancer control.
Behaviour: what people do
Behaviour’ is the general term covering all the physical acts performed by individuals. Examples of physical acts include walking, interacting with others, writing, reading and preparing to learn. Behaviour includes seeking or not seeking advice for health care and following or not following a prescribed medical regimen. It includes relationships with tobacco, food, alcohol and so on.
Cognition: what and how
Cognition’ is the term given to all the mental processes of an individual and includes not only aspects of thinking, such as knowledge, attitudes, motives, attributions and beliefs, but also perceptions, personal values, perceived cultural truths and memory. Cognition can be influenced by intelligence and past experience. Examples are religious convictions, wanting to be a good parent, distrusting modern medicine, knowing that smoking is dangerous for others but believing that it is not dangerous for one’s own health, and so on.
Context: the setting of
behaviour and cognition
Context’ is a general term that is more inclusive than the general perception of the environment. It includes not only the social, cultural and physical environment but also interpersonal influences on behaviour and the emotional and psychological
contexts of each act and cognition. These include laws, norms (socially defined and accepted cognition and behaviour) and social dynamics. Much healthy behaviour is not practised simply because, for instance, it is not defined as necessary by the community (e.g. skin protection), the appropriate choice is not available (e.g. healthy eating at work or school), other forces push society towards an unhealthy alternative
(E.g. the tobacco industry) or an unhealthy behaviour is reinforced by contingencies (e.g. pressures of time that reinforce driving rather than walking). These three dimensions may interact in various ways.
cognition and behaviour
The clearest evidence that cognition leads to new behaviour is the development of skills through formal and informal education. Cognition such as beliefs and attitudes can be translated into action if a change is perceived to be possible, if there is no opposition to or difficulty in performing the action or if the cognition is a central component of the person’s teleological system, such as religious beliefs. Cognition that is forged from past experience often influences behaviour. For example, a patient who has been successfully treated in the past is likely to return for care when a new illness appears. Cognitive theories of behaviour attempt to predict what people will do in certain circumstances. The challenge is in identifying which cognition is most salient and the degree to which it can predict change. Many people know that they should exercise and eat a healthy diet, and they form an intention: they decide that they will begin to exercise regularly and limit their intake of sweets and fats. If a large proportion of people with this intention do indeed perform these behavioural
changes, intention is a good predictor. In many cases, however, behaviour can change thought patterns. In the case of exercise and diet, a person can desire to be healthy but stop working in this direction when he or she finds it difficult to make time to exercise and makes little progress in changing eating patterns. Diet and exercise then become less important. If this is true for many people, intention is not a strong predictor, or the wrong intention has been measured. Indeed, observations of human behaviour indicate that it is easier for people to find reasons for what they do than to change
The research should allow for refinement or new theories. Theories and strategies related to health behaviour generally give predominance to the connection between cognition and behaviour or to that between the context and behaviour. The measurements made in each type of theory fall into two main categories. Quantitative measurement involves the assessment of observable, objective behaviour, defined health states and contextual events, or countable scales for subjective variables such as cognition, and the relationships between them. Qualitative measurement involves the assessment of subjective accounts of cultural or social perceptions, which can indicate contextual elements, and the environmental changes required to facilitate alternative behaviour that corresponds to belief structures.
of health behaviour
Most models of behavioural change are based on an assumption of volitional, that is cognitively determined, behavior. For example, the health belief mode land its offshoots are based on the premise that attitudes and beliefs are the major determinants of health behaviour, and that any behaviour in response to a health threat is based on two major types of cognition: the expectation that a specific action will lead to improved health, and the subjective value that is placed on improved health. Any divergence in behaviour is thus related to the adequacy of cognition and how readily cognition is adapted tone experience. Cognitive theories have been used to investigate the roles of motivation, fear and misperception. In all, the basic premise is the same: preventive behaviour is a function of the perception of threat and of the belief that the best course of action includes new
behaviour. With the recognition that context also plays a role, evolving theory includes cues to action and general orientation to health as subjective cultural values. Stage models of behaviour have been developed from Rogers’ concept that adoption of new behaviour is a process, and diffuses across society from individual sat various stages (diffusion of innovations) .Stage models of individual behaviour are based on the hypothesis of interactions between behaviour and cognition, so that different types of cognition operate at different stages. For example, the trans-theoretical model of stages of change proposes that an individual passes through a growing degree of readiness for change before initiating that change. Interventions based on stage models encourage identification of stage, and the cognitions associated with that stage are targeted. In stage theories, intention is considered to be the last step before a new behaviour is practiced. Cognitive models generally assume that self-efficacy(the confidence of having the means to enact change) is in operation, and the specific role of the context is added as an aspect of perception of social norms and barriers to action. Social marketing is a strategy that applies the theory of stages by adapting commercial marketing strategies for target audiences, particularly those in the early stages of readiness to change, to influence desire and intention to adopt healthy behaviour . Social marketing strategies are based on the assumption that persistence and long-term perspectives are needed to influence social behaviour and that communication must correspond to the needs and desires of specific target groups, which are ascertained by qualitative measures, such as in focus groups and in-depth interviews. While social marketing involves a stage model of behavioural change, health education is based on the assumption of a more direct line between knowledge and behaviour. Cognitive and motivational approaches reconsidered important for trendsetters who adopt new behaviou rand whose behaviour influences the choices of others. This is a necessary background for community commitment for policy and social change.
Theories of the context
A general theory related to context is the ‘ecological’ approach, in which multiple and reciprocal levels of influence are identified, including interpersonal or individual factors (biology, psychology and behaviour), interpersonal factors, institutional or organizational factors, community factors and public policy factors. In this perspective, cognitive elements play a relatively small role in health behaviour in relation to context, which is divided into several categories. In structural models, change in individual behaviour is considered to be a result of changes in the organizational conditions within which the individuals live and work. By changing the structure, change is allowed to occur. For example, the observed decrease in the incidence of stomach cancer has been attributed not to individuals deciding to change their eating patterns, but rather to the quality and variety of foods that have become available with modern refrigeration and food preservation techniques . Research into health-care systems is based on a structural model of behaviour. In grounded theory, a social and structural model often used in work on sex differences in health, subjective experiences are examined qualitatively to determine the dominant social and structural processes that account for the greatest variation in behaviour in particular situation, and these become the focus for change.
Participatory models are based on the premise that sustained change comes about through social change orchestrated byte community itself . Participatory studies address community programmes that involve the collaboration of various sectors of society for change designated and desired by the community. The North Karelia study in Finland was influential in demonstrating that a community could become involved in social change and that health professionals, political leaders and institutions could work together. Advocacy is a major strategy for social change. It is a systematic attempt to gain political and social support for changes related to health in the population. It does not involve promotion of individual solutions but garners support for changes in the social environment that legitimize or de-legitimize certain behaviour, creating the changes in social conditions that allow individuals to adopt healthy behaviour . Social mobilizations an extension of advocacy for changes in social conditions. It emphasizes coalition building to raise awareness and to mobilize the community to demand political action in response to a newly defined community need. More emphasis is being placed on finding precise indicators for measuring social change and the effectiveness of advocacy and social mobilization, in order to provide a better empirical basis for social measures.
Finding the right mix
Actions related to health behaviour are effective if they strengthen the capacity to exert control over the determinants of health. It is therefore important to identify and measure those determinants. The field of health promotion started with a purely cognitive approach to behaviour, proposing changes in personal behaviour that would result in a healthy population. It became clear, however, that this approach ignored the role of context, and the view was modified over time. Larger social and political processes were seen to facilitate or encourage unhealthy behaviour, and less emphasis was placed on the individual’s role in change. Health promotion today is seen as the process of modifying the environment to encourage healthy choices, by using a combination of programmes and interventions, focusing on maintaining health and preventing disease through education, policy and environmental support. Theories and strategies are of value only insofar as they help to produce results. In tobacco control, for example, some people work on changing the legislative change perceptions and motivations with regard to tobacco use, and others concentrate on the most effective treatment to help people fight addiction. These are all important, useful approaches, but they are based on different theories for promoting change. Theory is important to avoid wasting resources on ineffective activities to describe,
understand or influence the factors related to health behaviour and change. Thus, theories compete to best fit a health problem. Cognitive theories are now more inclusive of related elements beyond interpersonal relations, whereas environmental theories often give little importance to the role of cognition.
As a general rule, programmes or strategies based on stage theories or social cognitive learning which focus on the cognition-behaviour interaction would appear to be useful in situations in which individuals want to change; and programmes or
strategies based on structural theories or community strategies that focus on the context-behaviour interaction appear to be useful when individuals are nonspecifically motivated for change or do not have options for change. The challenge is to determine when each factor is of sufficient importance in relation to the other. When the context presents barriers to change, interventions on cognition will not suffice, and removing barriers to change will not result in change unless individuals have a reason to do so. Campaigns to encourage jogging in areas where it may be unsafe are unlikely to produce change; however, changing the environment is not usually successful unless the new activity is perceived to be beneficial. For example, provision of free nicotine replacement products to low income groups will not change their behaviour if there is no desire to quit smoking. Thus, the strategies available to influence health behaviour are based on diverse theories. A NGO’s goal is to channel its efforts in the most effective way, to predict the outcome of its actions in terms of change. Decisions must be based on the validity of the measures for assessing change. Various theoretical approaches are available for different target groups and settings. Well-designed research and informed practice rely on choosing the theory and conceptual background best adapted
to the situation .Nevertheless, focusing on only one aspect of health behaviour is no longer sufficient or viable, as shown by the evolution of health promotion from an individual- toad society-based approach. In conclusion, theories must look at the ways individuals perceive and determine action, or at the way the context shapes the behavioural choices of individuals. To cover a maximum number of possibilities, programmes should include multiple strategies, integrating the goals of changing the context and changing cognition.
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