Theoretical Models in

Health Psychology
 Defining Health
Behaviors
 Health Behavior – behavior aimed at preventing
disease (e.g. eat a healthy diet, go for a run)
 Illness Behavior – behavior aimed a seeking a remedy
(e.g. go to the doctor)
 Sick Role Behavior- activity aimed at getting well (e.g.
taking prescribed meds)
 Health-Impairing Habits – behavioral pathogens,
things that can lead to poor health (e.g. smoking,
remaining sedentary etc.)
 Health-Protective Behaviors – behavioral immunogens,
things that lead to better health (e.g. attending
regular check-ups)
 Knowledge is power…
But not the only factor
 Promoting understanding and awareness of health
behaviors can be helpful for increasing them:
 Correlation between knowledge of breast cancer and
regular mammograms/self-exams/early detection
 Cervical cancer information video linked to knowledge
of disease and future pap screenings.

 Unfortunately, just giving people information is not

usually sufficient to change health behaviors in the
long term.
 Attribution Theory
 Origins
 Heider (1958) – individuals motivated to see
their social world as predictable and
controllable

 Kelley (1971) – Built on Heider’s work

 Attributions about causality were structured
according to causal schemata

“Attribution theory deals with how the social

perceiver uses information to arrive at causal
explanations for events. It examines what
information is gathered and how it is combined to
form a causal judgment” (Fiske, & Taylor, 1991)
 Attribution Theory
 Causal Schemata:
 Distinctiveness –extent to which person behaves in the same way in a similar
situation
 High: Max only smokes marijuana when he goes home for Thanksgiving and sees his HS
friends.
 Low: Max smokes marijuana whenever he hangs out with any friends (old and new).
 Consensus – extent to which other people behave in the same way in similar
situations
 High: All of Max’s friends smoke when they meet up for Thanksgiving break
 Low: Max is the only one smoking at the reunion

 Consistency Over Time – extent to which person shows a behavior every time
a situation occurs
 High: Max smokes every year when his friends meet over Thanksgiving
 Low: Max only smoked at one of the reunions in the last 5 years

 Consistency Over Modality – extent to which person engages in same behavior

for particular outcome
 High: Max always uses marijuana to get high/become intoxicated
 Low: Sometimes Max uses marijuana, other times he takes pills or drinks alcohol to get
high
 Attribution Theory
 Dimensions of Attribution
 Internal vs. External

 Stable vs. Unstable

 Global vs. Specific

 Controllable vs. Uncontrollable

 Attribution Theory

 Bradley (1985)
 Studied attributions related to diabetes
 Perceived control over illness
 External attributions associated with selection
of insulin pump
 Attribution Theory

 Health Locus of Control

 Associated with changes in health behavior
and adherence to recommendations
 Health communication success
 How would you make a recommendation to
someone with external vs. internal locus of
control?
 Weakness of
Attribution Theory
 Is health locus of control state or trait?
 Can you be both internal and external?
 Do all behaviors fit into one or the other?
 For example, going to the doctor.
 What are the chances that you will be
diagnosed with cancer within the next year?
 Actual rate for developing cancer before age
20 (1 in every 285 individuals) 1/285 = .004
 Risk Perception
 Unrealistic Optimism
 Lack of personal experience with problem
 Belief problem is preventable by individual
action
 Belief that if problem has not appeared yet, it
won’t in the future
 Belief that problem is infrequent

 Selective Focus
 Risk Compensation
 Risk Perception

 Self Affirmation Theory

 General response is to become defensive
about unhealthy behaviors when asked to
change
 Not so much the case… When?
 Stage Models

 Classification system to define stages

 Ordering of stages
 Same stage = Similar barriers
 Different stage = Different barriers
 Health Psych Stage Models
 Stages of Change Model (SOC)
 Health Action Process Approach (HAPA)
 SOC/Transtheoretical
Model
 Pre-contemplation
 Contemplation
 Preparation
 Action
 Maintenance
 Problems with SOC?
 Stage (linear) vs. Continuum
 Lack of evidence for qualitative differences
between stages
 Shift between stages may be very quick
 SOC interventions may be effective due to person
feeling special
 Hard to determine stage
 May not be more helpful than just asking people
 Health Action Process
Approach (HAPA)
 Motivation Stage
 Self-Efficacy
 Outcome Expectancies
 Threat Appraisal

 Action Stage
 Cognitive (volitional)
 Action Plans
 Coping Planning
 Situational
 Social Support
 Absence of Barriers
 Problems with HAPA?

 Are individuals consciously processing this

info?
 Role of social and environmental factors?
Social Cognition Models
 Subjective Expected Utility (SEU)
 Behavior results from weighing benefits and
barriers

 Situation Outcome Expectancies

 Expectation that behavior may be dangerous

 Outcome Expectancies
 Expectation that a behavior can reduce harm to
health

 Self-Efficacy
 Belief that individual is capable of carrying out
desired behavior
 Health Belief Model
 Factors influencing health behavior:
 Susceptibility to illness
 Severity of illness
 Cost to carry out health behavior
 Benefits to carrying out behavior
 Cues to action
 Recent additions: Health motivation, Perceived
control
 Problems with HBM?

 Requires conscious processing of info

 Too much emphasis on individual
 Interrelationship between core beliefs
 Ignore emotional factors/barriers
 Protection Motivation
Theory
 Severity
 Susceptibility
 Response Effectiveness
 Self-Efficacy
 Fear

 Threat vs. Coping Appraisals

 Theory of Reasoned
Action (TRA)
 Emphasizes social cognition
 Subjective norms

 Places individual in social context

 Suggested role for value
 Theory of Planned
Behavior (TPB)
 Derived to reconcile intention/behavior gap in
TRA
 Attitudes towards a behavior
 Subjective norms
 Perceived behavioral control
 Problems with social
cognitive models
 How to change beliefs?
 Does behavior change?
 Changes in belief can be attenuated by other
variables thereby reducing impact on behavior

 Are other important factors missed?

 Assumption that all behavioral changes occur
as a function of changing intentions. Doesn’t
take into account effortless behavioral change
 Other Considerations
 Affective Beliefs
 Anticipated Regret
 Self-Identity
 Ambivalence
 Personality
 Role of Past Behavior and Habit
Intervention and
Adherence
 How to Change Health
Behaviors
 Effortful vs. Effortless
 1) Individual makes choices about how and whether to change
behavior

 2) Behavior changes occurs with no conscious processing

 Examples of each?

 Psychological approaches – encourage effortful change through

intervention targeted at individuals
 Public health – focus on structural and environmental changes that
lead to behavior change without individuals necessarily knowing
they are involved in intervention or even that behavior has changed
 Importance of Theory-
Based Interventions
 More recent movement toward using psychological
theories to inform behavioral health interventions

 Many interventions designed to promote health

behavior were not very effective (e.g. efforts to
promote changes in sexual behavior in early 1990’s;
lack of long-term success for weight loss programs)

 Most interventions at this time not based on any

theoretical framework
Learning and Cognitive
Theories
Relapse
Reinforcemen Modeling
Prevention
t

Learning (and Associativ

CBT cognitive) Theory e Learning

Exposure Incentives
Reinforcement
 Reinforcement
Continued
 Can influence behavior by positively reinforcing desired
behavior and ignoring or punishing less desired behavior
 Shown in preference for/consumption of foods
 Reinforcement based on reaction of others to food
 Token economy for increasing fruit and veggie consumption
 Orelistat (Alli)

 Substance Use
 Antabuse
 Behavioral Couples Therapy

 Helpful for initiating behavior change but evidence

suggest contingency must be continued to maintain
behavior
 More successful in long-term when old unhealthy behavior
is no longer functional
 Incentives
 Altering the monetary cost balance of a behavior
(e.g. Making cigarettes more expensive, paying
people to lose weight, stop smoking etc.)

 Some evidence that this does work

 Increased taxes on alcohol and cigarettes reduce
the behavior
 Providing pregnant women with food vouchers for
successful smoking abstinence
 Paying men and women in Tanzania to undergo
regular STD tests
 Factors that Influence Incentive
Intervention Success

 Greater incentive = greater likelihood of behavior

change
 Better at short-term rather than long-term change
 Depends upon the financial state of the individual
 More effective if money paid in close time
proximity to behavior
 Work better for discrete and infrequent behaviors
(e.g. getting a vaccination) rather than repeated,
habitual behaviors (e.g. dieting, smoking)
 Problems with
Incentive Interventions
 May undermine intrinsic motivation for
carrying out behavior
 Form of bribery undermining informed
consent and autonomy
 Alterations to doctor-patient relationship
 Modeling
 Providing direct examples of the health
behavior within a person’s environment
 Can be particularly useful with
children/adolescents
 Safe sex study
 Parental modeling has influence on:
 Smoking
 Exercise
 Emotional Eating
 Associative Learning
 Pairing two variables so that one acquires the value or
meaning of the other
 Evaluative Conditioning – form of associative learning where
an attitude object is paired repeatedly with an object that is
either viewed positively or negatively as a means to make the
attitude object either more positive or negative
 Examples: Attractive celebrity spokesperson, green fields,
catchy music

 Applied successfully to unhealthy snacks

 One condition saw unhealthy snack images interspersed with
aversive health images (artery disease, heart surgery)
 Other condition saw unhealthy snack images interspersed with
blank screen
 Intervention changed implicit associations to snack foods and
increased likelihood of choosing fruit versus high calorie snack
at end
 Exposure
 Capitalizes on the idea that past behavior
predicts future behavior
 Can be applied through increasing
availability of means to engage in health
behavior or rehearsal of specific skill
 Multiple studies showing increased
preference for vegetables in children after
repeated exposure
 Increased safe sex practices after skills
training

 Possible mechanism involves changes in

cognitions surrounding the behavior
 Cognitive Behavioral
Therapy
 Incorporates previous behavioral strategies but also
places greater emphasis on cognitions
 Key facets include:
 The link between thoughts and feelings
 Therapy as a collaboration between patient and
therapist
 Patient as scientist and role of experimentation
 Importance of self-monitoring
 Importance of regular measurement
 Collaborative session agendas set by patient and
therapist
 Treatment is about learning a set of skills
 Therapist is not the expert
 Regular feedback by both patient and therapist
 CBT Strategies
 Diary Card/Monitoring
 Gradually increasing new behaviors
(including exposure)
 Cue Exposure
 Relaxation Techniques
 Distraction Techniques
 Cognitive Restructuring
 CBT and Chronic Illness
 ABCDE System (Antoni et al., 2001; 2002)
 Awareness: Overcoming automaticity of thoughts to
become attuned to specific cognitions. Accomplished
with reflection, monitoring, interaction with therapist

 Beliefs: Rate belief about each thought in terms of

strength

 Challenge: Look for evidence, think of alternatives, how

might another person react

 Delete: Get rid of negative self-statements replace with

constructive cognitions

 Evaluate: Examine feelings after challenge and deletion

 Relapse Prevention
 Model to explore the process that occur when a
change in behavior fails to last
 Based on the following concept of addictive
behaviors:
 Addictive behaviors are learned and therefore
can be unlearned, they are reversible
 Addictions are not “all or nothing” but exist on a
continuum
 Lapses from abstinence are likely and acceptable
 Believing that “one drink = a drunk” is a self-
fulfilling prophesy

 First distinction between lapse and relapse

 Process from lapse to
relapse
 Baseline
 Abstinence: represents target behavior and indicates state of
behavioral control

 Pre-Lapse State
 High-risk situation – any situation that may motivate the
individual to carry out the behavior. Can be external
(availability of substance, seeing another smoke etc. ) or
internal (anxiety, boredom). Tops are negative emotions,
interpersonal conflict, and social pressure.
 Coping behavior – after exposed to high-risk situation. Can
be behavioral or cognitive.
 Positive outcome expectancies - based on previous
experience. Can be positive (‘smoking will make me less
anxious’) or negative (‘getting drunk will make me sick’).
 Lapse to relapse
continued
 No lapse: good coping strategies and negative
outcome expectancies raise self-efficacy, causing
abstinence to be maintained
 Lapse: poor or no coping strategies and positive
outcome expectancies lower self-efficacy causing an
initial use of the substance. Can either remain and
isolated incident or turn to full relapse.
 Abstinence Violation Effect (AVE)
 Determined by dissonance conflict and self-attribution
 If lapse attributed to self, may create guilt and self-
blame, lowering self-efficacy, and increasing chances of
a full-blown relapse
 If lapse attributed to the external world, guilt and self-
blame reduced and better change of lapse remaining
isolated
 Relapse Prevention
Program
 Self-monitoring (What do you do in high-risk
situations?)
 Relapse fantasies (What would it be like to
relapse?)
 Relaxation training/stress management
 Skills training
 Contingency contracts
 Cognitive restructuring (focused on not
making internal attributions for lapses)
Social Cognition Theory

TPB Implementatio
Interventions Plans n Intentions

Social
Cognition
Theory

Information
Giving
 Social Cognition: Theory
into Practice (Steps for
TPB)
 Step 1: Identify target behavior and target population
 Step 2: Identify the most salient beliefs about the target
behavior in the target population using open-ended
questions (look for modal beliefs)
 Step 3: Conduct a study involving closed questions to
determine which beliefs are the best predictors of
behavioral intention. Choose best belief as target belief
 Step 4: Analyze the data to determine the beliefs that
best discriminate between intenders and non-intenders
 Step 5: Develop an intervention to change these target
beliefs
 Planning and
Implementing
Intentions
 Intention-behavior gap – individual might
intent to do something but not carry through
on behavior
 Research indicates gap most likely to be
closed when intentions can be behaviorally
specified (e.g. SMART goals!)
 Problems with
Implementation

Interventions
Do people make plans when asked?
 20-40% of people don’t

 Impact of existing plans.

 Need to differentiate spontaneous plans and those made for the
intervention

 Do people own their plans?

 People may feel more ownership of their own spontaneous plans

 Is all behavior change volitional?

 Much behavior may be habitual or response to environment
which is not addressed in this framework

 Are all plans the same?

 Action plans – choosing the behavior that will achieve the goal
 Coping plans – prepare an individual to manage high risk
situations
 Information Giving
 Clear research evidence to suggest that
behavioral change much more likely when
person understands their susceptibility to
risk
 Smoking
 Cervical Cancer Risk

 Information giving not sufficient to change

behavior but is a useful and necessary
adjunct to any other form of behavior
change strategy (e.g. CBT, Relapse
Prevention)
 Stage Models
 Brought about the idea of stage-matched intervention
AND the development of motivational interviewing
 Motivational Interviewing – intervention for bringing
individuals from pre-contemplation to contemplation
stage
 Focuses more on the ‘should’ rather than the ‘how’
 Aims to increase cognitive dissonance
 Conflicts are highlighted then individual is asked to
discuss feelings related to this conflict
 Consider how things would be if they did change
behavior
 Approach is non-confrontational. Purpose is not to
convince/persuade individual to change their behavior
but to get them to start considering it
 Changing Affect
Affective
Attitude
Visualizatio s
n

Changing Affect Fear

Appeals

Self-Affirmation
 Visualization
 Assumes that visual images more powerful
at conveying message than language-based
messages
 Supported in:
 Anti-smoking campaigns (showing carotid
artery)
 Treatment compliance for CVD (image vs.
text)
 Dialysis compliance for kidney disease

 May be due to fact images are processed

more rapidly than text information, be more
memorable, and have greater impact on
 Affective
Attitudes/Cognitions
 Affect- the feeling we have before it can be
put into language and description
 Must use affective cognitions to change
behavior
 Exercise study with image of people smiling,
pictures of the heart, both types of image, or
no images. Affective images led to greatest
increases in exercise
 Similar findings in text message study aiming
to increase physical activity in adolescents
 Fear Appeals
 Based on evidence that fear can be a
particularly motivating emotion
 Generally interventions/campaigns involve 2
levels:
 1) Fear arousal
 There is a threat
 You are at risk
 The threat is serious
 2) Safety conditions
 Recommended protective action
 Action is effective
 Action is easy
 Self-Affirmation
 People often resist health behavior change by avoiding,
finding fault in the arguments used, criticizing the mode
of presentation
 Resistance especially salient if message evokes strong
emotional response
 Self-affirmation grounded in the idea of ‘self-integrity’
and posits people are motivated to maintain their sense
of self as being adaptively and morally adequate
 Information suggesting their behavior is damaging is
threat to self-integrity leading to greater resistance
 Resistance can be overcome if person encourage to
enhance their self-integrity by affirming their self-worth
and focus on other factors core to their self-view that are
unrelated to threat
 Self-affirmation
example
 Context: Person sees fear appeal that being
overweight can cause heart disease
 Emotional Response: Anxiety
 Resistance: Ignore message, “Research is always
wrong,” “That commercial was so low budget and
stupid”
 Self-Affirmation Intervention: Think of times when
you have been kind to others
 Emotional Response: “ I am reassured” “ I am a
good person”
 Reaction to Fear Appeal: “Maybe I should exercise a
bit more”
 Self-affirmation

interventions
Make a central and positive aspect of a person’s sense of
self more salient
 Provide a reminder of ‘who you are’
 Offer reassurance that there are other aspects to the
individual’s sense of self other than that which is
challenged by the fear appeal
 Meta-analysis showing interventions most effective with
 Caffeine consumption
 Smoking
 Sun safety
 Alcohol intake
 Safe sex

 Evidence for affect changes and short-term behavior

change. Less conclusive in long-term
 Modern Technologies
Ecological Web-based
Momentary Intervention
Intervention s
s

Modern
Technology

Mass Media Individualize

d Biological
Risk Data
 Ecological Momentary
Intervention (EMI)
 Previously homework/calling therapist was the only way to extend therapy
into natural environment
 EMI refers to any treatment provided to people during their everyday lives
and in natural settings
 Shown effective in studies of:
 Smoking cessation
 Weight Loss
 Anxiety
 Alcohol Use
 Dietary Change
 Exercise Promotion
 Diabetes Management
 CVD
 Eating Disorders and Obesity
 Review of EMI Studies
to Date
 Major findings after review of 27 studies:
 EMI’s can be easily and successfully delivered
to the target group
 Approach is acceptable to patients
 Effective at changing a wide range of health
behaviors
 Cost effective

-Downside: most studies only examine short-term

results. Still need focus on follow-up and effects
over time or when EMI removed.
 Web-Based
Interventions
 Allows access to treatment for patients who
may be opposed to face-to-face therapeutic
appointments or those unable to attend
 Allows flexibility of when treatment occurs
 Applied to range of both physical and
psychiatric illnesses
 Review of Web-Based
Interventions
 2009 Review:
 Sample sizes very large so acceptability of
trying WBI high
 Extremely high rate of dropout (up to 84%)
 Although delivered remotely, 73% of
interventions studied still involved some
interaction with a therapist
 Greater therapist involvement was associated
with less dropout
 Biological Risk Data
 Aim to increase an individual’s perception of risk as
a means to change their behavior
 Example: DNA test kits to get individual’s specific
risk for diseases
 Uses idea that personally salient info more effective
than general info
 Review of studies examining individual risks for
CVD, lung, breast, and colon cancer, inflammatory
bowel disease, and Alzheimer’s
 No effects on smoking cessation, physical activity,
medication or vitamin use
 Small effect on dietary change
 Overall not as promising as initially anticipated…
 Mass Media (Negative
Influence)
 Cigarette and alcohol advertisements banned due
to success at promoting these unhealthy behaviors.
 Food ads aimed at children under 5
 Unhealthy given almost twice as much air time and
shown to be significantly more valued than healthy
foods

 Food ads aimed at adolescents of different weight

categories
 Obese children show greater recognition of food ads
and recognition linked to increased snacking
 All children ate more after snack advertisements
than non-food ads.
 Memory for less healthy foods also better
 Mass Media (Positive
Change)
 Hard to distinguish if media campaigns actually
change behavior or simply raise awareness
 Effect of raised awareness may accumulate through
multiple add campaigns over several generations to
cause change (e.g. lower drunk driving rates)
 Elaboration Likelihood Model (ELM) – Need several
factors for media to change behavior:
 Motivation to receive argument
 Centrally process argument
Occurs if:
Message is congruent with existing beliefs
Message is personally relevant to them
Individual can understand the argument