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HealthNotes
Psychology
 SYLLABUS

Unit 1: Introduction:

● Introduction to Health Psychology: components of health: social, emotional, cognitive and

physical aspects,
● mind-body relationship,

● goals of health psychology,

● Bio-psychosocial model of health

Unit 2: Behavior and health:

● Characteristics of health behaviour;

● Barriers to health behaviour;

● Theories of health behaviour and their implications.

Unit 3: Health Enhancing Behaviours:

● Exercise,

● nutrition,

● safety,

● pain,

● stress management

Unit 4: Health and Well-being:

● Happiness;

● Life satisfaction;
 ● Resilience;

● Optimism and

● Hope

Unit- 1
Health psychology is an exciting and relatively new field devoted to understanding
psychological influences on how people stay healthy, why they become ill, and
how they respond when they do get ill. Health psychologists both study such
issues and develop interventions to help people stay well or recover from illness.

World Health Organization (1948) defined health as “a complete state of physical,

mental, and social well-being and not merely the absence of disease or infirmity.”
This definition is at the core of health psychologists’ conception of health. Rather
than defining health as the absence of illness, health is recognized to be an
achievement involving balance among physical, mental, and social well-being.

Health psychology is defined as the: educational, scientific, and professional

contributions of the discipline of psychology to the promotion and maintenance of
health, the prevention and treatment of illness, the identification of etiology and
diagnostic correlates of health, illness and related dysfunction, and the
improvement of the healthcare system and health policy formation. (Matarazzo,
1982, p.4)

The Six Components of Health are: • Physical • Social • Environmental •

Emotional • Cognitive •Intellectual/Mental Physical Health. Physical health refers
to the way that your body functions. This includes eating right, getting regular
exercise, and being at your recommended body weight. Physical health is also
avoiding drugs and alcohol and being free of disease and sickness Social Health
Social health is the quality of your relationships with friends, family, teachers, and
others you are in contact with. Environmental Health- Environmental health is
keeping your air and water clean, your food safe, and the land around you
enjoyable and safe. Emotional Health Emotional health is expressing your
emotions in a positive, nondestructive way. Cognitive health—the ability to clearly
think, learn, and remember—is an important component of brain health. Others
include: Motor function—how well you make and control movements, Emotional
function—how well you interpret and respond to emotions and Sensory function—
how well you feel and respond to sensations of touch, including pressure, pain, and
temperature. Intellectual/Mental Health Mental health is the ability to recognize
reality and cope with the demands of daily life.
Drinking plenty of water, getting enough sleep, meditating, exercising, having
nutritious diet etc., are some of the various characteristics of healthy behavior. The
barriers to good health behaviors for individuals include: enjoyment of competing
poor health behaviors, the immediate adverse effects of poor health behaviors, the
amount of effort involved in changing health behavior and fear leading to denial
that there is a problem with the behaviors. Other barriers include – false consensus,
unrealistic optimism and pessimism, belief in personal coping capacity, fatalism
and nature of health behaviors. Enjoyable risky behaviors can be hard with an
addictive component can be hard to stop (eg- cigarette smoking). Most smokers
know that it is harmful to their health and they may not stop (Friedan &Blakeman,
2005).

GOALS-Health psychologists focus on health promotion and maintenance, which

includes issues such as how to get children to develop good health habits, how to
promote regular exercise, and how to design a media campaign to get people to
improve their diets. Health psychologists study the psychological aspects of the
prevention and treatment of illness. A health psychologist might teach people in a
high-stress occupation how to manage stress effectively so that it will not
adversely affect their health. A health psychologist might work with people who
are already ill to help them follow their treatment regimen. Health psychologists
also focus on the etiology and correlates of health, illness, and dysfunction.
Etiology refers to the origins or causes of illness. Health psychologists especially
address the behavioral and social factors that contribute to health, illness, and
dysfunction, such as alcohol consumption, smoking, exercise, the wearing of seat
belts, and ways of coping with stress. Finally, health psychologists analyze and
attempt to improve the health care system and the formulation of health policy.
They study the impact of health institutions and health professionals on people’s
behavior to develop recommendations for improving health care.

In summary, health psychology examines the psychological and social factors that
lead to the enhancement of health, the prevention and treatment of illness, and the
evaluation and modification of health policies that influence health care.

THE MIND-BODY RELATIONSHIP

● During prehistoric times, most cultures regarded the mind and body as
intertwined. Disease was thought to arise when evil spirits entered the body,
and treatment consisted primarily of attempts to exorcise these spirits.
● The ancient Greeks were among the earliest civilizations to identify the role
of bodily factors in health and illness. Rather than ascribing illness to evil
spirits, they developed a humoral theory of illness. According to this
viewpoint, disease resulted when the four humors or circulating fluids of the
body—blood, black bile, yellow bile, and phlegm—were out of balance. The
goal of treatment was to restore balance among the humors.
● By the middle Ages, however, the pendulum had swung to supernatural
explanations for illness. Disease was regarded as God’s punishment for
evildoing, and cure often consisted of driving out the evil forces by torturing
the body. Later, this form of “therapy” was replaced by penance through
prayer and good works.
● Beginning in the Renaissance and continuing into the present day, great
strides were made in understanding the technical bases of medicine. As the
science of cellular pathology progressed, the humoral theory of illness was
put to rest. Medical practice drew increasingly on laboratory findings and
looked to bodily factors rather than to the mind as bases for health and
 illness. In an effort to break with the superstitions of the past, practitioners
resisted acknowledging any role for the mind in disease processes. Instead,
they focused primarily on organic and cellular pathology as a basis for their
diagnoses and treatment recommendations.

The resulting biomedical model, which has governed the thinking of most health
practitioners for the past 300 years, maintains that all illness can be explained on
the basis of aberrant somatic bodily processes, such as biochemical imbalances or
neurophysiological abnormalities.

BIOMEDICAL MODEL : The biomedical model assumes that psychological and

social processes are largely irrelevant to the disease process.

Health is usually associated with doing something physical to the patient, such as
cutting something out of the body, or administering some chemicals. This is at the
heart of the biomedical model of health.

The biomedical model asks us to look at people as if they are biological machines.
If something is going wrong then we need to fix the machine in the same way we
might fix a car. We make observations and diagnose the faulty bit, then we can
repair it if possible, or replace it if necessary. Sometimes we might benefit from a
general overhaul and sometimes from some minor adjustments. This biomedical
model has some appeal because we are clearly made up of biological bits, and also
because some biomedical treatments produce dramatic improvements in health.

The biomedical model has a number of key features:

1. Reductionism: The model tries to reduce explanations of illness to the simplest

possible process. For example, it will look for explanations in disordered cells
rather than psychological or social processes.

2. Single-factor causes: The biomedical model looks for the cause of a disorder
rather than looking for a range of contributory factors. For example, there are
numerous attempts to explain complex disorders in terms of a simple genetic
effect. Also, there is a tendency to describe smoking as the cause of coronary heart
disease, yet many smokers do not develop the disease and many non-smokers do.
The process would seem to have more than one cause and more than one
contributory factor. It is not easy to define health and illness. Among other things
they depend on our expectations of life, and when if these are raised, our
perception of good health changes.

3. Mind–body distinction: Dating back to the French philosopher Rene Descartes,

Western science has made a distinction between the mind and the body. In some
ways this is a religious distinction and encourages us to see people as split into two
parts – a ghost and a biological machine. (This is often referred to as the ‘Cartesian
dualism’ – Cartesian after Descartes, and dualism because it proposes a split into
two). In many ways this is a comforting idea, especially when someone we love
changes their personality and behaviour due to their poor health. For example,
when someone develops Alzheimer’s disease they become unrecognisable from the
person they were throughout much of their life. It is comforting to think that the
original person is still there but trapped in a decaying body.

4. Illness not health: ‘If it ain’t broke don’t fix it’ might well be the motto of the
biomedical model. It deals with illness and the development of illness rather than
the promotion of good health.

There are three main changes that have led to dissatisfaction with the bio- medical
model.

First, throughout the twentieth century there was a decline in the incidence of
infectious, single cause diseases. In this country at the beginning of the twentieth
century, the three most common causes of death were:

1. Influenza and pneumonia

2. Tuberculosis

3. Gastro-enteritis

Secondly, there has been a dramatic increase in specialist technology and an

equally dramatic increase in the cost of healthcare. The costs of treating someone
who is ill are now prohibitively high so there is a major incentive to prevent people
getting ill in the first place.
 The third change is a growing emphasis on quality of life. People are developing
an expectation that they should have a healthy, enjoyable and active life.

These three factors have changed the general view of health from one where we
deal with illness to one where we promote good health.

It is important to add that this description of the changing priorities of health only
applies to the technologically advanced countries. In other parts of the world,
infectious diseases still cause many deaths despite there being relatively easy and
cheap medication for them.

THE BIOPSYCHOSOCIAL MODEL: The biomedical viewpoint began to change

with the rise of modern psychology, particularly with Sigmund Freud’s (1856–
1939) early work on conversion hysteria. According to Freud, specific unconscious
conflicts can produce physical disturbances that symbolize repressed psychological
conflicts.

The idea that the mind and the body together determine health and illness logically
implies a model for studying these issues. This model is called the
biopsychosocial model. Its fundamental assumption is that health and illness are
consequences of the interplay of biological, psychological, and social factors
(Keefe, 2011). The biopsychosocial model maintains that biological,
psychological, and social factors are all important determinants of health and
illness. Both macrolevel processes (such as the existence of social support or the
presence of depression) and microlevel processes (such as cellular disorders or
chemical imbalances) continually interact to influence health and illness and their
course (Suls & Martin, 2011). The biopsychosocial model emphasizes both health
and illness. From this viewpoint, health becomes something that one achieves
through attention to biological, psychological, and social needs, rather than
something that is taken for granted.

The Role of Biological Factors: This term includes the genetic materials and
processes by which we inherit characteristics from our parents. It also includes the
function and structure of the person’s physiology. The body is made up of
enormously complex physical systems. For instance, it has organs, bones, and
nerves, and these are composed of tissues, which in turn consist of cells,
molecules, and atoms. The efficient, effective, and healthful functioning of these
systems depends on the way these components operate and interact with each
other.

The Role of Psychological Factors : When we discussed the role of lifestyle and
personality in health and illness earlier, we were describing behavior and mental
processes.

o Behavior and mental processes are the focus of psychology, and they
involve cognition, emotion, and motivation.
o Cognition is a mental activity that encompasses perceiving, learning,
remembering, thinking, interpreting, believing, and problem solving.
o Emotion is a subjective feeling that affects and is affected by our thoughts,
behavior, and physiology. Some emotions are positive or pleasant, such as
joy and affection, and others are negative, such as anger, fear, and sadness.
Motivation is the process within individuals that gets them to start some
activity, choose its direction, and persist in it. A person who is motivated to
feel and look better might begin an exercise program, choose the goals to be
reached, and stick with it. Many people are motivated to do what important
people in their lives want them to do.

The Role of Social Factors: People live in a social world. We have relationships
with individual people—a family member, a friend, or an acquaintance—and with
groups. As we interact with people, we affect them, and they affect us. On a fairly
broad level, our society affects the health of individuals by promoting certain
values of our culture, such as that being fit and healthy is good.

The biopsychosocial model is useful for clinical practice with patients as well.
First, the process of diagnosis can benefit from understanding the interacting role
of biological, psychological, and social factors in assessing a person’s health or
illness. Recommendations for treatment can focus on all three sets of factors. The
biopsychosocial model makes explicit the significance of the relationship
between patient and practitioner. An effective patient-practitioner relationship
can improve a patient’s use of services, the efficacy of treatment, and the rapidity
with which illness is resolved.

Using the biopsychosocial model as a guide, researchers have discovered new and
important findings and ways to promote people’s health and recovery from illness.

The comparison of the biomedical and biopsychosocial model can be done as

given below:

BIOMEDICAL MODEL BIOPSYCHOSOCIAL MODEL

Focus is on illness and not on health Biological, sociological and

psychological, all play a significant role
in disease and illness.

Focus on causes rather that contributory Assumes that health and illnesses have
factors many causes and can have c=various
effects

Considers the absence of disease as Assumes that continuum between the

physical wellness health and illnesses must be analyzed
and considered as a system

People not responsible for illnesses People’s behavior influences health and
people can change a behavior

Explains illness by simplest possible Integrative medicine relies on this

process. model because the focus is on whole
 body

Hence, we can infer from the information given above that an alternative approach
to the biomedical model is to look at all the biological, psychological and social
factors that are associated with health and illness. It is a real mouthful of a name,
but it does have the advantage of telling you exactly what it refers to. In contrast to
the biomedical model, the biopsychosocial model is not reductionist. Instead it
looks at all levels of explanation from the micro-level to the macro-level. The
biopsychosocial model does not look for single causes but starts from the
assumption that health and illness have many causes, and also produce many
effects. The model does not make the distinction between mind and body but
instead looks at the connections between mental events and biological changes.
Finally, the biopsychosocial model is concerned as much with health as it is with
illness.

UNIT 2
Introduction to Health behaviors

In the past century, patterns of disease in the United States have changed substantially. There
has been a decline in acute infectious disorders dueTo changes in public health standards, but
there has been An increase in the preventable disorders, including lung Cancer, cardiovascular
disease, alcohol and drug abuse, And vehicular accidents. Nearly half the deaths in the United
states are caused by Preventable factors, with smoking, obesity, and problem Drinking being
three of the main causes (Centers for Disease control and prevention, 2009a).
■ health promotion: Health promotion is a philosophy That has at its core the idea that good
health, or wellness, is A personal and collective achievement. For the individual, it involves
developing a program of good health habits. For the medical practitioner, health promotion
involves teaching people how to achieve a healthy lifestyle and helping people at risk for
particular health problems off-set or monitor those risks. For the health psychologist, health
promotion involves the development of interventions to help people practice healthy
behaviors. For community and national policy makers, health promotion involves emphasizing
good health and providing information and resources to help people change poor health habits.
Successful modification of health behaviors will have several beneficial effects. First, it will
reduce deaths due to lifestyle-related diseases. Second, it may delay time of death, thereby
increasing life expectancy. Third and most important, the practice of good health behaviors
may expand the number of years during which a person may enjoy life free from the
complications of chronic disease. Finally, modifi cation of health behaviors may begin to make a
dent in the more than $2.6 trillion that is spent yearly on health and illness (Centers for
Medicare and Medicaid Services, 2011).

Health Behaviors and Health Habits

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 (Cohen, Brownell, & Felix, 1990). Wearing a seat belt, brushing one’s teeth, and eating
a healthy diet are examples of these kinds of 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. As such, habits can be highly resistant to change.
Consequently, it is important to establish good health behaviors and to eliminate poor ones
early in life. An illustration of the importance of good health habits is provided by a classic study
of people living in Alameda County, California, conducted by Belloc and Breslow (1972). Th ese
scientists focused on several important health habits:

• 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 regular exercise

• Not eating between meals

• Being no more than 10 percent 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.

What factors lead one person to live a healthy life and another to compromise his or her
health?

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 (Hanson & Chen, 2007).

Age Health habits are typically good in childhood, deteriorate in adolescence and young
adulthood, but improve again among older people.

Values Values affect the practice of health habits. For example, exercise for women may be
considered desirable in one culture but undesirable in another(Guilamo-Ramos, Jaccard, Pena,
& Goldberg, 2005).

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. The health locus of control
scale (Table 3.2) (Wallston, Wallston, & DeVellis, 1978) measures the degree to which people
perceive their health to be under personal control, control by the health practitioner, or
chance.

Social Influence Family, friends, and workplace companions infl uence health-related behaviors,
sometimes in a benefi cial direction, other times in an adverse direction (Broman, 1993; Turbin
et al., 2006). For example, peer pressure often leads to smoking in adolescence but may infl
uence 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 raspythroat 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. For example, obtaining a regular Pap smear, getting mammograms, and
receiving immunizations for childhood diseases depend on access to health care.

Other behaviors, such as losing weight and stopping smoking, may be indirectly encouraged by
the health care system through lifestyle advice.

Knowledge and Intelligence The practice of health behaviors is tied to cognitive factors, such as
knowledge and intelligence (Jaccard, Dodge, & Guilamo-Ramos, 2005). More knowledgeable
and smarter people typically take better care of themselves. People who are identifi ed as
intelligent in childhood have better health-related biological profi les in adulthood, which may
be explained by their practice of better health behaviors in early life (Calvin, Batty, Lowe,
&Deary, 2011).

Q1. What are the barriers to health behavior? How can we work towards
overcoming these barriers? Explain through suitable case examples.
Engaging in healthy behaviors—such as regular physical activity and following a nutritious and
balanced diet—brings about numerous health, social, and self-evaluative benefits. However
many a times we are too used to our routine behaviors that we forget to analyze whether those
behaviors are appropriate for our healthy mind and body.

There are a lot of barriers which can stop us from changing our unhealthy lifestyle and move
towards a healthy living. Some of them include:

Lack of motivation: In many situations, we do not feel the need or there is lack of motivation to
change our way of living. We may feel free in our comfort zones where there is no pressure to
follow a healthy diet, go to gym, or practice yoga and meditation to our mind and body cool and
follow a proper sleep pattern.
Amount of effort: bringing any change in your lives requires conscious efforts. However, when
we do not want to take responsibilities for changing our health behaviors it acts as a barrier to
healthy living. For example: many people pay fees for gym but because of the lack of effort to
work-out and exercise they miss their gym on a regular basis.

Habits: this is one of the biggest barriers’ to healthy behavior, because we are too used to our
habits that it is difficult to change them. People are not ready to move out of their comfort zones
and practice healthy living. For example: despite knowing that smoking is injurious to health and
warning on the packet, people do smoke out of their habit.

People know that drink and drive can cause accidents, but still people do practice such things out
of their unhealthy lifestyles.

Other barriers include:

False consensus: The tendency to overestimate how much other people agree with us is known
among social psychologists as the false consensus effect. This kind of cognitive bias leads people
to believe that their own values and ideas are "normal" and that the majority of people share
these same opinions. For example, people who smoke and drink believe that there are large
number of students who engage themselves in smoking and drinking. They will generally over
estimate a behavior in which they themselves engage. Cunningham and Celeby (2007) believed
that normative feedback (stating facts to the person) is an effective intervention in reducing bad
habits.

Unrealistic optimism and pessimism: Optimism bias (or the optimistic bias) is a cognitive bias
that causes someone to believe that they themselves are less likely to experience a negative
event. It is also known as unrealistic optimism or comparative optimism. An over optimistic
person will fail to analyze the risk factors associated with unhealthy behaviors and might
continue to engage in continuing with it. Such people believe that nothing can happen to them
and thus they are not ready to change their unhealthy living. People who smoke and drink despite
of the warnings can be one of the cases of unrealistic optimism.

Fatalism: Fatalism refers to the general belief that events, such as the actions and occurrences
that form an individual life, are determined by fate, and, thus, beyond the capacity of human
beings to control. When applied to health, fatalism can be conceptualized as the belief that the
development and course of health problems is beyond an individual’s personal control
(Straughan & Seow, 1998). Research on the relationship between fatalism and health has
generally focused on fatalistic beliefs about specific diseases, the most commonly studied being
cancer. Powe and Johnson (1995) defined cancer fatalism as a situational manifestation of
fatalism where an individual feels powerless in the face of cancer and views its diagnosis as a
struggle against insurmountable odds.

Overcoming health barriers:

In order to overcome these barriers, at first place it is important to realize that you want a
positive change in your lifestyle. In this fast paced life we have left our health unnoticed for a
long time. So at first place it is important to set realistic goals for yourself and schedule your
time, so that you can take out time for our work as well as for workout, gyming, yoga or any
other positive health behavior. Write reminder notes to yourself or set your watch alarm when
it’s time to be active. Have a set time and place for activity so it becomes a routine and you don’t
have to think about it.

-Spend some time learning about the physical and psychological benefits of activity.

-Choose an activity you enjoy. Start at a comfortable level then gradually increase the length of
time, number of days per week and level of effort. Progressing gradually will help you avoid
injury. Don’t push yourself so hard that you can’t talk to a friend or sing a song while exercising.
Try a different activity once in a while. Variety keeps things interesting.

-Choose an activity that’s suited to your health status, abilities, limitations, personal goals and
activity preferences or interests.

-"I don't have time to make changes."

This is a very common reason not to change. It can take the form of "My life is too busy," or "I'm
always feeling rushed," or "I have more important things to do."

Possible solutions:

Learn ways to manage your time better. Find time-management techniques that work for you.

Ask others how they manage to fit good nutrition into their lives.

Don't try to make too many changes at once. Small changes take less time, but they add up.

Ask your family and friends for help as you change your eating behavior. This may involve
having them help you to free up your time.

-It’s OK to have a setback in your regular activity or routine. Setbacks can happen for lots of
reasons. For instance, you may have been sick or gone on vacation. To help avoid being
discouraged, think about how you can overcome difficulties or challenges ahead of time. Have a
support system to encourage you (friends, family, an exercise professional, group or club). Keep
changing and adding variety to your activity routine.

THEORIES OF HEALTH BEHAVIOUR

Why do we need theories of health behavior?

Because a theory provides a road map for studying problems, developing appropriate interventions, and
evaluating their successes

HEALTH BEHAVIOUR MODEL

Attitudinal approaches to health behavior change have been formalized in several specific theories that
have guided interventions to change health behaviors. An early influential attitude theory of why people
practice health behaviors is the health belief model (Hochbaum, 1958; Rosenstock, 1966). 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.

History of HBM

During 1950s researchers and health practitioners were worried because few people were getting screened
for tuberculosis (TB), even if mobile X-ray cars went to neighborhoods.

Free screening of TB through mobile X-ray units was offered, but uptake was low. Hochbaum
administered questionnaires to probability samples of over 1200 adults who were offered free TB
screening .

- If reported personal susceptibility and benefits from screening, 82% had X-ray
- If reported neither, 21% had X-ray

NOTE: Personal susceptibility refers to a person's subjective perception of the risk of acquiring an illness
or disease

Result of studies by Hochbaum and others in the US Public Health Service were summarized in the
Health Belief Model. Early model described in 1958. Rosenbaum published more detailed description in
1966 . Further elaboration by Becker and others in 1970s and 1980s

Significance of Health Belief Model

1. Indicated that we could analyze systematically why people do or do not accept public health
interventions.
2. Promoted the idea of planning of educational interventions
3. Indicated how we might intervene – e.g. if perceived susceptibility is low, need to explain to
people why they are susceptible
4. Other than understanding the perceived susceptibility vulnerability to a disease , HBM also tried
to understand ‘the perceived level of threat associated with a disease
5. And formed an analysis of the relative costs and benefits of acting preventively.
In a nutshell, there are six constructs of the HBM. The first four constructs were developed as the
original tenets of the HBM. The last two were added as research about the HBM evolved.
1. Perceived susceptibility - This refers to a person's subjective perception of the risk of acquiring an
illness or disease. Example: Young people who don't think they're at risk of lung cancer are unlikely
to stop smoking.
2. Perceived severity : The probability that a person will change his/her health behaviors to avoid a
consequence depends on how serious he or she considers the consequence to be. Example: if a person
believes that he can develop lung cancer soon if he keeps on smoking , he might leave smoking.
3. Perceived benefits: it's difficult to convince people to change a behavior if there isn't something in it
for them. People don't want to give up something they enjoy if they don't also get something in return.
Example: he probably won't stop smoking if he doesn't think that doing so will improve his life in
some way.
4. Perceived barriers: This refers to a person's feelings on the obstacles to performing a recommended
health action. One of the major reasons people don't change their health behaviors is that they think
that doing so is going to be hard. Sometimes it's not just a matter of physical difficulty, but social
difficulty as well. Changing your health behaviors can cost effort, money, and time. Example: If he
quits smoking, his friends wouldn’t hang out with him or he’ll feel less confident
5. Cues to action: This is the stimulus needed to trigger the decision-making process to accept a
recommended health action. These cues can be internal (e.g., chest pains, wheezing, etc.) or external
(e.g., advice from others, illness of family member, newspaper article, etc.). Eg : motivational posters
or a pep talk to stop smoking
6. Self-efficacy: This refers to the level of a person's confidence in his or her ability to successfully
perform a behavior. This construct was added to the model most recently in mid-1980. Self-efficacy
is a construct in many behavioral theories as it directly relates to whether a person performs the
desired behavior.
Demographic variables

The theory also proposes that characteristics of individuals can influence their perceptions of benefits,
barriers, and threat. These factors include the person’s age, sex, race, ethnic background, social class,
personality traits, and knowledge about or prior contact with the health problem. Thus, for example,
people who are poor are likely to see strong barriers to getting medical treatment. Women, but not men,
over 50 are likely to perceive a substantial risk of breast cancer. And elderly individuals whose close
friends have developed severe cases of cancer or heart disease are more likely to perceive a personal
threat of these illnesses than young adults whose friends are in good health.

Clinical application of HBM

A man advised to reduce his weight to control mild hypertension

1. Perceived susceptibility - like most hypertensive, he is unlikely to detect any symptoms of the
disease and most likely to enjoy his food
2. Perceived severity – if he sees that there is something wrong with his BP because of the food
habits and it could kill him then he might go on the prescribed route
3. Perceived Benefits – good health, health lifestyle
4. Perceived barriers - giving up the food he likes
Research support

Has research generally supported the health belief model’s explanation of health-related behavior? The
model has generated hundreds of studies, most of which have upheld its predictions for a variety of health
behaviors, including getting vaccinations, having regular dental visits, and taking part in exercise
programs (Becker & Rosenstock, 1984; Conner & McMillan, 2004a; Kirscht, 1983). For instance,
compared to people who do not take prescribed medication as directed or do not stick with dietary
programs, those who do are more likely to believe they would be susceptible to the associated illness
without the behavior and that the benefits of protective action exceed the barriers. Perceived risk
(susceptibility ) and perceived barriers appear to be critical elements for predicting health behavior, such
as getting vaccinations and performing BSEs (Brewer et al., 2007; Conner & McMillan, 2004a), but
strong barriers may have more influence than risk. Research has also supported the role of cues to action
—for instance, individuals are more likely to perform BSEs or engage in brisk walking if they receive
reminders (Craun & Deffenbacher, 1987; Prestwich, Perugini, & Hurling, 2010).

Limitations of the model

Despite the health belief model’s success, it has some shortcomings.

1. One shortcoming is that it does not account for health-related behaviors people perform habitually,
such as tooth brushing—behaviors that probably originated and have continued without the person’s
considering health threats, benefits, and costs.
2. Another problem is that there is no standard way of measuring its components, such as perceived
susceptibility and seriousness. Different studies have used different questionnaires to measure the
same factors, thereby making it difficult to compare the results across studies.
These problems do not mean the theory is wrong, but that it is incomplete. We now turn to another theory
that focuses on the role of people’s beliefs on their practice of health-related behavior.

PROTECTIVE MOTIVATION THEORY

In order to include additional explanatory factors in HBM, Rogers (1985) developed the PMT. The theory
attempts to explain and predict what motivates people to change their behavior. The protection motivation
theory was originally developed to explain how people respond to :

1. A fear-a rousing situation

2. And what motivates them to change

Components of PMT given by Rogers

This theory proposes that we protect ourselves through a number of ways:

1) Perceived vulnerability

2) Perceived severity

3) Response efficacy (the belief that the recommended action is effective in reducing the threat)

4) Perceived self-efficacy (the belief that one can successfully perform the recommended action).

Cognitive Process in Behaviour

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.

Threat Appraisal

It deals with how threatened one feels by the threat. For example, how threatened is an individual by
the possibility that she may have breast cancer. 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. For example, the individual may be asked to rate his chances using a Likert scale of ‘how
likely he is to get lung cancer based on his smoking habits.’

Feeling that the health threat will have severe consequences in one’s life is called as perceived severity.
This is measured in terms of choosing from responses like I agree, I strongly disagree, and I disagree
when given sentences like ‘AIDS is a very dangerous disease.’

Fear arousal is a means of assessing how much fear has been evoked as a result of perceived
vulnerability and severity. Individuals can be asked how they feel about the thought of having a
particular disease. Responses like not worried, very anxious are indicators of the level of fear regarding a
threat.

Coping Appraisal

Are seen as a function whether a certain medicine(remedy) is working or not and what is the cost of
compliance ?( I’m listening to doctor, not eating junk food, eating my medicines- but side effects? My
happiness?

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.’

The second, self-efficacy deals with the belief that one has the required capabilities to engage in a health
behavior. This is measured by responses to a statement like ‘It is easy to wake up early every day and
exercise’ with words like I agree, I disagree, etc.

The last set of beliefs, 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.
Feeling awkward may deter her from undergoing the exam.
Applications of PMT

An example of clinical application of this model would be the example of a pregnant woman who is told
that her heavy drinking might cause foetal alcohol syndrome in her baby. The information would increase
perception of severity and perceived susceptibility. If she felt confident that she could stop drinking
(response efficiency) and that this would be beneficial (low response cost), she would probably stop
drinking, at least for the duration of pregnancy

Research supporting PMT

The PMT has generated research over 2 decades. A meta analysis of its effectiveness found 65 relevant
studies of 20 different health issues. (Floyd, Prentice- Dunn, & Rogers, 2000). While the mean overall
threat size was only moderate, in general increases in threat- (severity or susceptibility) response
effectiveness and self-efficacy facilitated adaptive intentions or behaviours. The PMT model is intuitively
appealing, but Redfern’s et al’s (2000) study of British stroke patients showed that only a minority of
them changed risky behaviour such as smoking and drinking excessively, and over one-third that is, 36%
remained obese one year after the stroke. At the current level of knowledge about behaviour change, it is
difficult to predict which patients will improve their health behaviours even in the response to life
threatening illnesses.

Overlap b/w HBM and PMT

There is considerable conceptual overlap between the 2 models, with both making perceived
susceptibility and the perceived severity of the negative health consequences the basis of individual
actions to prevent the disease. While perceived susceptibility plays an important role in both models.
Neither explains how perceptions of susceptibility accrue. This is an important consideration, as
Weinstein (1987, 1989) has shown in his analysis of cognitive biases. Gerend et al. (2004) investigated
the relationship between perceived susceptibility and objective risk of breast cancer, osteoporosis and
heart disease, as well as psychological factors influencing perceived personal susceptibility in a
community sample of 312 American women. They found that perceived similarity to the typical woman
who develops the disease was the single strongest correlation with perceived susceptibility to it. Although
all 3 diseases investigated are common among older women, there was a strong negative correlation
 between women’s age and their perceptions of personal vulnerability for reasons which were unclear.
Gerend et al. suggested that older women might have been less knowledgeable about diseases other than
younger women, might have been using an emotional regulation strategy for maintaining wellbeing in the
face of increased disease threat as age increased or might have displayed absent/exempt beliefs. They
concluded that health interventions should stress important similarities between people who have the
disease and people who are the targets of such intervention.

Limitations of PMT

refer to the pdf of critiques of the model

THEORY OF REASONED ACTIONS (TRA)

In the 1960s and 1970s, the prevailing assumption was that attitude and behavior were strongly related in
that attitude determined behavior. Even though research repeatedly failed to show a strong relationship
between attitude and behavior, there was nonetheless, widespread acceptance of the assumption (Fishbein
& Ajzen, 1975). In 1975, Fishbein and Ajzen (1975) conducted a review of studies done on attitude and
behavior and, once again, found little evidence supporting a relationship between the two, further
confirming the assumption was false. They argued that although atti-tude should be related to behavior, it
is not necessarily so. Instead, they proposed it was the intention to perform rather than the attitude toward
a behavior that determined behavior; and with this came the conceptual basis for the Theory of Reasoned
Action. As it turned out, the Theory of Reasoned Action (TRA) was useful in explaining behaviors under
a person’s willful (volitional) control, but not so useful in explaining behaviors not under willful control.
To address this situation, in 1991 an additional construct was added to the original theory, with the
revised identified as the Theory of Planned Behavior (TPB) (Ajzen, 1991, 2002b).

The Theory of Reasoned Action (TRA) was developed in 1967. During the early 1970s the theory was
revised and expanded by Ajzen and Fishbein. By 1980 the theory was used to study human behavior and
develop appropriate interventions. TRA is a widely studied model from social psychology, which is
concerned with the determinants of consciously intended behaviors (Ajzen and Fishbein, 1980; Fishbein
and Ajzen, 1975).

The TRA and the TBP propose that behavior is based on the concept of intention. Intention is the extent to which
someone is ready to engage in a certain behavior or the likelihood that someone will engage in a particular behavior
(Ajzen & Fishbein, 1980; Fishbein, 1967). People are more likely to do something if they plan or aim to do it than if
they do not.

In TRA, effecting a change in behaviour is viewed as primarily a matter of changing the cognitive structures that
underlie the behaviour in question. If the beliefs about or attitudes towards, a behaviour can be changed, then the
likelihood of performing it will also change. The most immediate determinant of a behaviour in this model is believed
to be the respondent’s intention to perform it. Intentions are conceptualized as containing 2 major components

1. Attitude towards the action (personal)

2. Subjective norms towards the appropriateness of the action (reflecting social influences)
- Attitudes Attitudes are formed by a series of beliefs and result in a value being placed on the outcome
of the behavior (Ajzen, 2002a). If the outcome or result of a behavior is seen as being positive,
valuable, beneficial, desirable, advantageous, or a good thing, then a person’s attitude will be favorable
with a greater likelihood of the person engaging in the behavior. For example, if someone believes
eating soy is healthier than eat- ing animal protein, that it’s better for the environment, and carries less
of a chance of foodborne illness, the individual’s attitude toward eating soy products would be
favorable. Conversely, an unfavorable attitude toward soy consumption may result from the beliefs that
soy products have an unpleasant taste and texture and are too expensive (Rah, Hasler, Painter, &
Chapman, 2004). These attitudes would nega- tively influence the intention to eat soy
products. Another example of how intention to engage in a behavior is impacted by atti- tude is seen
with meditation. When people have a positive attitude toward medita- tion born from the beliefs that
meditating is good, enjoyable, pleasant, and a wise choice, their intention to meditate is greater
(Lederer & Middlestadt, 2014). In another example of how attitude impacts intention and ultimately
behavior, parental attitude affects whether they have their children vaccinated. Adolescents whose
parents have more positive attitudes toward vaccines are more likely to be vaccinated against the flu
than are those whose parents have less positive attitudes (Gargano et al., 2015).
- Subjective Norms In addition to attitude, intention is influenced by subjective norms. A subjective
norm is the perceived social pressure to engage or not to engage in a certain behav- ior. It is determined
by normative beliefs. These are the behaviors that we perceive important people in our lives expect
from us (Ajzen, 2002a). These important people are often family members, friends or peers, religious
figures, healthcare provid- ers, or others we hold in high esteem—people we like to please. Subjective
norms result from the behaviors we perceive these important people expect from us and our desire to
comply with their perceived expectations (given below in the figure). Note that these expectations may
or may not be based in reality, as they are our perceptions.
` Continuing with the soy consumption example used previously, if a healthcare provider and
family member suggest that an individual eat soy products and if the person wants to make these others
happy, there is a greater willingness to comply and a greater likelihood of soy consumption (Rah et al.,
2004). On the other hand, if the healthcare provider does not make the suggestion to consume soy and
there is limited family support to try this food source, then the likelihood of soy being eaten is greatly
diminished. Salient beliefs: The focus of subjective norms and behaviours is on salient beliefs. While
many people can list several beliefs about any health behaviour, they can only process a certain amount
of information in a given time, so the decision making is influenced by salient beliefs only. The
acquisition of beliefs has been portrayed as active by recent researchers; people do not passively soak
up beliefs about desirable behaviours but select, modify and transform the information they accept.

Components of TRA

1. Attitudes towards the proposed actions are believed to be based on beliefs about the likely
outcomes of the behaviours and evaluations of those outcomes
2. Subjective norms are derived from what a person thinks that other person think he/she should do
(normative beliefs) and from motivations to comply with these beliefs.
3. Intentions are determined by the favourability of attitudes towards the behaviour and the extent of
perceived normative pressures to perform it (subjective norm)
4. Attitude towards a behaviour are also a function of beliefs about the consequences of performing
it (behavioural beliefs) weighted by the values placed on each of the consequences (outcome
evaluations)
 5. The TRA proposes that attitudes and subjective norms can be multiplied to predict intentions,
which in turn determines those behaviours under the control of the person. Whether people
multiply numbers in their heads to decide their intentions has never been determined.

Applications of TRA
A clinical example of how TRA might work is a heroin(drug) user who believes that her addiction causes
serious health problems, who knows that significant others (such as her doctor) think that she should
give up her heroin use, and who becomes motivated to comply with those normative beliefs, possibly by
major health scare. If she believes that she can overcome her addiction and that doing so would
improve her health, she will have a positive attitude.

She would be viewed as more likely to intend to give up drugs than another user who lacks these beliefs
and attitudes.

Limitations OF TRA

- Theory of Reasoned Action (TRA) was useful in explaining behaviors under a person’s willful
(volitional) control, but not so useful in explaining behaviors not under willful control.

- The vision of human in this model proposes rational beings who act only when they have
evaluated their options, reflected on the consequences of their actions and considers what
others expect of them; it does not explain hasty-ill-considered decisions.

THEORY OF PLANNED BEHAVIOURS

Suppose you are having dinner at a restaurant with Dan, a friend who is overweight, and you wonder
whether he will order dessert. How could you predict his behavior? That’s simple—you could ask what
he intends to do. According to the theory of planned behavior (Ajzen, 1985), an expanded version of
the theory of reasoned action (Ajzen & Fishbein, 1980), people decide their intention in advance of most
voluntary behaviors, and intentions are the best predictors of what people will do.

What determines people’s intentions? The theory indicates that three judgments determine a person’s
intention to perform a behavior, which we’ll illustrate with a girl named Ellie who has decided to start
exercising:
1. Attitude regarding the behavior, which is basically a judgment of whether or not the behavior is a good
thing to do. Ellie has decided that exercising ‘‘would be a good thing for me to do.’’ This judgment is
based on two expectations: the likely outcome of the behavior (such as, ‘‘If I exercise, I will be healthier
and more attractive’’) and whether the outcome would be rewarding (for example, ‘‘Being healthy and
good looking will be satisfying and pleasant’’).

2. Subjective norm. This judgment reflects the impact of social pressure or influence on the behavior’s
acceptability or appropriateness. Ellie has decided that exercising ‘‘is a socially appropriate thing for me
to do.’’ This decision is based on her beliefs about others’ opinions of the behavior (such as, ‘‘My family
and friends think I should exercise’’) and her motivation to comply with those opinions (as in, ‘‘I want to
do what they want’’).

3. Perceived behavioral control, or the person’s expectation of success in performing the contemplated
behavior (which is very similar to the concept of self-efficacy). Ellie thinks she can do the exercises and
stick to the program.

The theory of planned behavior proposes that these judgments combine to produce an intention that leads
to performance of the behavior. If Ellie had the opposite beliefs, such as, ‘‘Exercising is a waste of time,’’
‘‘I don’t care about my family’s opinion,’’ and ‘‘I’ll never find time to exercise,’’ she probably wouldn’t
generate an intention to exercise, and thus would not do so. Self-efficacy is an important component.

When deciding whether to practice a health behavior, people appraise their efficacy on the basis of the
effort required, complexity of the task, and other aspects of the situation, such as whether they are likely
to receive help from other people (Schunk & Carbonari, 1984).

In another words, taking into ccount the criticisms of the TRA, Ajzen and Madden (1986) revised,
extended and renamed it a theory of planned behavior (TPB). The main alteration is that the perceived
amount of volitional control that a person has over the behvaiour has been added to the original model.
Perceived volitional control over behaviour now influences several of the components of the old TBA,
including subjective norms and intention as well as a direct line of influence or behaviours

Application of this theory requires that the degree of a person’s perceived volitional control over the
criterion behaviour be established before the behaviour can be predicted. Perceived volitional control is a
similar concept to self-efficacy. It addresses the question- to what degree does this person believe that
his/her actions can be controlled by willpower?

Perceived control influences both intentions and behaviours, as suggested by this model.

Within the constraints of the degree of perceived control, the model of human behaviour shown in the
TPB suggests that intentions are the primary guide

The major propositions of TPB and the relationship between different components is described below in
the diagram
Application of TPB

1. Schifter and Ajzen (1985) controlled for attitudes and norms and found that perceived
behavioural control predicted intentions to lose weight.
2. TPB has been used successfully to encourage safety helmet use among British school children
(Quine, Rutter &Arnold, 2001)
3. TPB has been used to promote cervical cancer screening (Sheeran and Orbell, 2000)
4. TPB has been used to also predict contraceptive intentions (Fekadu & Kraft, 2002).

Research on TPB

The theory of planned behavior has generated many dozens of studies, including a meta-analysis showing
that attitudes toward a behavior, subjective norms, and perceived behavioral control (self-efficacy)
influence intentions and behavior (Conner & McMillan, 2004b).

Table below gives a sample of studies on a variety of healthrelated behaviors that support the role of the
three factors. Also, a meta-analysis of dozens of experiments revealed that interventions can change the
factors, and these changes strongly influence intentions, which, to a much lesser extent, improve the
targeted health behaviors (Webb & Sheeran, 2006). In general meta-analysis has shown that intentions
can be predicted quite successfully with 40-50% of the variance explained by attitudes, social norms and
perceived volitional control
Limitations of TPB

What shortcomings does the theory of planned behavior have?

1. One problem is that intentions and behavior are only moderately related—people do not always
do what they plan (or claim they plan) to do. But the ‘‘gap’’ between intention and behavior can
be reduced. Research has found that people are more likely to carry out their intentions if they
make careful plans for doing so, keep track of their efforts, and recognize that they will need to
continue the behavior on a long-term basis and are confident they can (Sniehotta, Scholz, &
Schwarzer, 2005). Keep in mind that people’s intentions to perform a health behavior, such as
eating healthy food, can change from one day to the next. But if individuals perform preparatory
behaviors, such as buying only healthy food, after the intention is made, the chances of actually
following a healthy diet increases greatly.
2. Another problem is that the theory is incomplete; it does not include, for example, the important
role of people’s prior experience with the behavior. In a blood donation study the subjects asked
about their past behavior in donating or not donating blood (Bagozzi, 1981). Of those subjects
who said they intended to give blood, those who had given before were more likely actually to
give than those who had not donated in the past. Similarly, studies have found that people’s
history of performing a health related behavior, such as exercising or using alcohol or drugs,
strongly predicts their future practice of that behavior (Bentler & Speckart, 1979; Godin, Valois
et al., 1987). Thus, for example, compared to adults who have engaged in little exercise in the
past, those who have exercised are much more likely to carry out their romises to exercise in the
future.