Chapter 9 Developing personal skills
People’s health behaviour or lifestyles have been regarded as the cause of many modern diseases. Therefore a main focus of health promotion has been on modifying those aspects of behaviour which are known to have an impact on health.
In previous chapters we have argued that such an approach is unlikely to be effective unless it acknowledges how people’s behaviour may be a response to, and maintained by, the environment in which they live. Many health promoters, however, see their role as helping people to live their lives to its best potential, which may involve some change in their health behaviour.
This chapter is concerned with those aspects of health behaviour that people can control. Understanding why people behave in certain ways and how they can be helped to maintain chosen behaviours is central to self-empowerment. This chapter explores the usefulness of social psychology which offers several theoretical models that identify the determinants of behaviour change. This can contribute to, if not the prediction, then at least an understanding of how people make decisions about their health. This can be a useful tool in planning health promotion interventions. The influence of specific factors such as individual self-esteem or people’s perceptions of control over their lives needs to be taken into account by the health promoter in order to offer practical support and positive experiences in making choices.
Enabling people to change is often assumed by health promoters simply to mean health education. Such programmes are described by Keleher (2007, p. 145) as typically delivered as brief interventions or in a series of sessions covering those things the clinician or health promoter regard as important with compliance as the goal.
Client-centred health education is concerned with a person’s agency in decision-making. Such an approach acknowledges that people can take some control over their lives through knowledge, skills and confidence and it may enable people to identify structural barriers and facilitators to their health. This kind of empowering education was described by Paolo Freire (see Chapter 10) in his description of radical adult literacy pedagogy. Frequently however developing personal skills is equated with helping people to change, drawing on psychological theories of behaviour change, motivation and self-efficacy.
This chapter explores the application of these models of behaviour change to health, and considers how an understanding of cognition and decision-making can be incorporated into empowerment and education strategies.
According to social psychology theories of behaviour change, people’s behaviour is partly determined by their attitude to that behaviour. An individual’s attitude to a specific action and the intention to adopt it are influenced by beliefs, motivation which comes from the person’s values, attitudes and drives or instincts, and the influences from social norms.
A belief is based on the information a person has about an object or action. It links the object to some attribute. For example, a person believes that potatoes (object) are fattening (an attribute). Theories of health-related behaviour change are based on the idea that an individual’s behaviour will be based on his or her beliefs. In this example, the person will cut down on potatoes if they wish to lose weight. If this person is encouraged to believe that potatoes are not fattening but a useful bulk food, then he or she may include them in the diet. In other words, that information can influence beliefs which will then, in turn, influence behaviour. This simple model is sometimes referred to as the knowledge–attitudes–behaviour (KAB) model. Of course, behaviour change is never quite as simple as that. Information alone is neither necessary nor sufficient for behaviour change. The health risks of smoking are well known and yet 30% of the population continue to smoke.
These are acquired through socialization and are those emotionally charged beliefs which make up what a person thinks is important. A person’s values will influence a whole range of feelings about family, friendships, career and so on. For example, values relating to sex and gender give rise to a number of attitudes towards motherhood, employment of women, body image, breast-feeding and sexuality.
These are more specific than values and describe relatively stable feelings towards particular issues. There is no clear association between people’s attitudes and their behaviour. Sometimes changing attitudes may stimulate a change in behaviour and sometimes behaviour change may influence attitudes. For example, many people continue to smoke despite a negative attitude to smoking. Yet once the behaviour is stopped, they may develop vehement antismoking views.
Attitudes are very hard to change. They may be changed by providing more or different information, or by increasing a person’s skills. For example, a person’s attitude towards the benefits of exercise might be influenced by providing information about different types of physical activity and their effects on the body. It might also be influenced by improved performance which motivates the person and encourages him or her to think of exercise as enjoyable.
Festinger (1957) used the term cognitive dissonance to describe a person’s mental state when new information is given which is counter to that already held. This prompts the person either to reject the new information (as unreliable or inappropriate) or to adopt attitudes and behaviour which would fit with it.
Some people may become concerned and change when presented with information about health risks. Others may make some change such as switching to a lower-risk substitute (e.g. low-fat spread). Others may deny their risk, perhaps by underestimating the frequency or amount of their current behaviour.
The term ‘drive’ is used in the Health Action model (Tones & Tilford 2001) to describe strong motivating factors such as hunger, thirst, sex and pain. It is also used to describe motivations which can become drives, such as addiction. Some studies suggest that addiction is the consequence of frequently repeated acts which become a habit and its base is a psychological fear of withdrawal (Davies 1997). Social learning theory (Bandura 1977) uses the term instinct to describe behaviours which are not learned but are present at birth. Instincts can override attitudes and beliefs. Hunger, for example, can easily override a person’s favourable attitude and intention to diet.
The practitioner needs to understand what contributes to people’s decision-making about health and what makes some people more amenable to change than others. The social cognition models which we shall now consider highlight the following as important:
How do you explain consistent findings in many studies that show a gap between knowledge and behaviour change, e.g. 70% of the population know about the importance of 5 a day but only 35% of the population act on it (Scottish Executive 2005)?
Such findings illustrate that knowledge of health benefits is only loosely associated with behaviour change. Although opportunities to change are greatest in most affluent areas, little action is taken. Self-reported motivation is unrelated to propensity to change. Understanding the wider cultural frameworks such as pleasure, comfort and convenience underpinning decision-making is essential to motivating individuals and groups.
The following theoretical models try to unpack the relative importance of these factors, recognizing that what people say is not necessarily a guide to what they will do, and that there are numerous antecedent and situational variables.
The health belief model
The Health Belief model is probably the best-known theoretical model highlighting the function of beliefs in decision-making (Figure 9.1). This model, originally proposed by Rosenstock (1966) and modified by Becker (1974), has been used to predict protective health behaviour, such as screening or vaccination uptake and compliance with medical advice (e.g. Gillam 1991). The model suggests that whether or not people change their behaviour will be influenced by an evaluation of its feasibility and its benefits weighed against its costs. In other words, people considering changing their behaviour engage in a cost–benefit or utility analysis. This may include their beliefs concerning the likelihood of the illness or injury happening to them (their susceptibility); the severity of the illness or injury; and the efficacy of the action and whether it will have some personal benefit, or how likely it is to protect the person from the illness or injury.
A mother of three children under 5 receives a card from her GP informing her that her youngest child should receive a Hib injection to protect him from meningitis. The woman works at a local factory as an hourly paid packer. Her mother cares for the children whilst she is at work, but has no transport.
If we are to use the Health Belief model as a model for predicting health behaviour, we would see the mother as a rational problem-solver who would not only be aware of the causes of Hib meningitis but also the risks of contracting it (the child’s susceptibility and severity). We would assume that the mother would have been made aware of the efficacy of the vaccine and be aware of its protection against one type of meningitis only (Haemophilus influenzae B). She would also be aware of any possible side-effects or contraindications. If the mother has had previous children vaccinated with no adverse effects or had this child or other children immunized against other diseases, she is more likely to view this vaccination favourably and have confidence in its effectiveness. In using this model as a predictor of behaviour, we need to take into account the perceived barriers and costs to taking this action. The mother would need to ask her own mother to take the child to the doctor. The child’s grandmother may be unwilling or unable to take three children on public transport. Or the mother would have to take time off work with consequent loss of earnings.
Most learning theories are based on the premise that people’s behaviour is guided by consequences. If these are positive or deemed to be positive, then the person is more likely to engage in that behaviour. These explanations, which see behaviour as a simple response to positive or negative rewards, do not seem to account for the persistence of health behaviours which have apparently negative consequences, such as smoking or drinking and driving. Short-term gratification is a greater incentive than possible long-term harm.
Becker suggests that individuals are influenced by how vulnerable they perceive themselves to be to an illness, injury or danger (their susceptibility) and how serious they consider it to be (severity). People’s perception and assessment of risk are central to the application of this model. Most people make a rough assessment about whether they are at risk. This seems to be influenced by four factors:
There are over 250 000 traffic accidents each year with 30 000 casualties, of which 3400 are fatalities. Excess speed is a contributory factor in a significant number of road accidents. In one survey (Scottish Office 1998) 88% of drivers admitted to driving at 40 mph in a 30 mph zone at least sometimes. The current response to speeding is:
Since beliefs may be affected by experience, direct contact with those who have a condition can powerfully affect attitudes exposing stereotypes and prejudice. For example, contact with a person who is human immunodeficiency virus (HIV)-positive or who is living with acquired immunodeficiency syndrome (AIDS) can change beliefs about the fatality of the disease, and about who is affected and how.
Those who work with young people find perceptions of risk are very different. Risk-taking is an important task of adolescence and part of separation from family. It is hard for young people to appreciate the long-term effects of, for example, smoking when 25 can seem old.
Many health education campaigns have attempted to motivate people to change their behaviour through fear or guilt. Drink–drive campaigns at Christmas show the devastating effects on families of road accident fatalities; smoking prevention posters urge parents not to ‘teach your children how to smoke’. Increasingly hard-hitting campaigns are used amongst others to raise awareness of the consequences of binge drinking, smoking and drug use. Whether such campaigns do succeed in shocking people to change their behaviour is the subject of ongoing debate (see, for example, Hill et al 1998). Although fear can encourage a negative attitude and even an intention to change, such feelings tend to disappear over time and when faced with a real decision-making situation. Being very frightened can also lead to denial and an avoidance of the message. Protection Motivation theory (Rogers 1975) suggests that fear only works if the threat is perceived as serious and likely to occur if the person does not follow the recommended advice.