HUMAN BEHAVIOURHUMAN BEHAVIOUR AND HEALTH AND HEALTH

PROMOTION LINKAGEPROMOTION LINKAGE

PHASES BETWEEN PHASES BETWEEN KNOWLEDGE & BEHAVIOURKNOWLEDGE & BEHAVIOUR

Source: Adapted from Fishbein & Ajzen 1975.)

Knowledgeof correcthealth action

Perception Interpretation SaliencePutting theknowledgeinto action

BEHAVIOUR: DEFINITIONBEHAVIOUR: DEFINITION

Behaviour is …...

BEHAVIOURBEHAVIOUR

1. HEALTH-DIRECTED

2. HEALTH-RELATED

TYPES OF TYPES OF HEALTH-RELATED BAHAVIOURHEALTH-RELATED BAHAVIOUR

1. PREVENTIVE HEALTH BEHAVIOUR

2. ILLNESS BEHAVIOUR

3. SICK-ROLE BEHAVIOUR

BEHAVIOURAL THEORIES BEHAVIOURAL THEORIES AND MODELSAND MODELS

HEALTH BELIEF MODELHEALTH BELIEF MODEL“Two major factors influence the likelihood that a person will adopt a recommended preventive health action

First they must feel personally threatened by disease I.e. they must feel personally susceptible to a disease with serious or severe consequences

Second they must believe that the benefits of taking the preventive action outweigh the perceived barriers to (and/or cost of) preventive action”

HEALTH BELIEF MODEL (Visual)HEALTH BELIEF MODEL (Visual)

Demographic variable[age, sex, raceethnicity, etc.]

Socio-psychologicalvariables

Perceived Threat ofDisease “X”

PerceivedSusceptibility to

Disease “X”

Perceived Severityof Disease “X”

Perceived benefitsof preventive

action

minus

Perceived barriersto preventive

action

Likelihood of TakingRecommended

Preventive HealthActionCues To Action

Mass Media CampaignsAdvice from others

Reminder postcard from physicilan or dentistIllness of familiy member or friend

Newspaper or magazine article

INDIVIDUALPERCEPTIONS

MODIFYINGFACTORS

LIKELIHOODOF ACTION

HEALTH BELIEF MODEL (Detailed)HEALTH BELIEF MODEL (Detailed)Concept Definition Application

PerceivedSusceptibility

One’s opinion of chances ofgetting a condition

Define population(s) at risk basedon a person’s features or behaviour.Heighten perceived susceptibilityif too low

PerceivedSeverity

One’s opinion of how serious acondition and its sequelae are

Specify consequences of risk andcondition

PerceivedBenefits

One’s opinion of the efficacy ofthe advised action to reduce risk orseriousness of impact

Define action to talk: how, where,when; clarity the positive effects tobe expected

PerceivedBarriers

One’s opinion of the tangible andpsychological costs of the advisedaction

Identify and reduce barriersthrough reassurance, incentives,assistance

Cues to Action Strategies to activate “readiness” Provide how-to information,promote awareness, reminders

Self-Efficacy Confidence on one’s ability to takeaction

Provide training, guidance inperforming action

Modified Health Belief Model as Applied to Modified Health Belief Model as Applied to HIV/AIDS ProgrammeHIV/AIDS Programme

PerceivedsusceptibilityYoung man hasbeen engaging insex with multiplepartners.

PerceivedSeverityYoung manbelieves thatAIDS is a deathsentence sincethere is no cure.

PerceivedThreatYoung manbelieves that heis at risk becausefriend is ill.

Cues to ActionRadio messagesexplaining theneed for safe sex.Peer education onsafe sex and HIV.

Benefits/ barriers Condoms are

easy to use, onecan feel safe

Condoms notreadily available,costly

DesiredBehaviourYoung man buysand uses condomsregularly.

Self-efficacyYoung man hashad practice usingcondoms and feelsconfident to usethem.

THEORY OF REASONED ACTIONTHEORY OF REASONED ACTION

“…there is one primary determinant of behaviour, namely the person’s intention to perform it. This intention is itself viewed as a function of two determinants.

- person’s attitude toward performing the behaviour (based on his/her beliefs about the consequences of performing the behaviour, i.e. his or her beliefs about the costs and benefits of performing the behaviour) and

- the person’s perception of social (or normative) pressure exerted upon him or her to perform the behaviour.”

Source : Fishbein and Ajzen [1975], Ajzen and Fishbein [1980] Fishbein, Middlestadt and Hitchcock [1991], page 4 in Developinh Effective Behaviour Change Interventions, Fishbein M, Univ. of Illinois.

THEORY OF REASONED ACTIONTHEORY OF REASONED ACTIONExternal variables

DemographicvariablesAge, sex, occupationsocio-economicstatus, religion,education.

Attitudes towardstargetsAttitude towardspeopleAttitudes towardsinstitutions

Personality traitsIntroversion-extraversionNeuroticismAuthoritarianismDominance

Beliefs that thebhaviour leads tocertain outcomes

Evaluation of theoutcomes

Beliefs that specificreferents think Ishould not performthe behaviour

Motivation tocomply with thespecific referents.

Attitudes towardsthe behaviour

Relativeimportance ofattitudinal andnormativecomponents

Subjective norm

Intention Behaviour

Possible explanations for observed relations between external variables and behaviour.

Stable theoretical relations linking beliefs to behaviour.

Theory of Reasoned Action and Personal Theory of Reasoned Action and Personal Behaviour applied to HIV/AIDS programme Behaviour applied to HIV/AIDS programme action (Adapted to key focus areas)action (Adapted to key focus areas)

Subjective norm(perceived socialpressure)Young man believesthat his friends thinkscondoms are not cool.

Perceivedbehavioural controlYoung man feelsconfident that he canuse condoms andhandle his sexual drive.

Personal attitudeYoung man is afraid ofgetting AIDS andbelieves that wearingcondoms is goodprotection. Behavioural

intentionYoung manindicates awillingness touse condomsregularly andask forinformation onwhere he canobtain themcheaply.

Desired behaviourtakenYoung man buyscondoms and begins touse them regularly.

SOCIAL COGNITIVE THEORYSOCIAL COGNITIVE THEORY“Two major factors influencing the likelihood that one will take preventive action:

First, like the Health Belief Model, a person believe that the benefits of performing the behaviour outweigh the costs (i.e. a person should have more positive than negative outcome expectancies)

Second, and perhaps most important, the person must have a sense of personal agency, or self-efficacy with respect to performing the preventive behaviour … must believe that he or she has the skills and abilities necessary for performing the behaviour under a variety of circumstances”.

Source: Fishbein summarising Bandura [1986, 1989, 1991, page 3 in Developing Effective Behaviour Change Interventions, Fishbein M, Univ of Illinois.

SOCIAL LEARING THEORYSOCIAL LEARING THEORYOROR

SOCIAL COGNITIVE THEORYSOCIAL COGNITIVE THEORYConcept Definition Application

Reciprocal Determinism Behaviour changes result from interactionbetween person and environment; changeis bi-directional.

Involve the individual and relevantothers; work to change theenvironment, if warranted.

Behavioural Capability Knowledge and skills to influencebehaviour.

Provide information and training aboutaction.

Expectations Beliefs about likely results of action. Incorporate information about likelyresults of action in advice.

Self-Efficacy Confidence in ability to take action andpersist in action.

Point out strengths; use persuasion andencouragement; approach behaviourchange in small steps.

Observational Learning Beliefs based on observing others likeself and/or visible physical results.

Point out others’ experience. Physicalchanges’ identity role models toemulate.

Reinforcement Responses to a person’s behaviour thatincrease or decrease the chances ofrecurrence.

Provide incentives, rewards, praise;encourage self-reward; decreasepossibility of negative responses thatdeter positive changes.

Stages of changing health behaviour (Adapted Stages of changing health behaviour (Adapted from Neesham C, 1993 and Prochaska J & from Neesham C, 1993 and Prochaska J & DiClemente C, 1984)DiClemente C, 1984)

Pre-contemplationNot interested in changing ‘risky’ lifestyle

Exit:Maintaining ‘safer’ lifestyleAction:

Making changes

Maintenance:Maintainingchange

Relapse:Relapsingback

Contemplating:Thinking about change

Commitment:Ready to change

Stages of Change as applied to Stages of Change as applied to HIV/AIDS ProgrammeHIV/AIDS Programme

PrecontemplationYoung man has heard about AIDS but doesn’t think it is relevant to his life.

ContemplationYoung man believes that he and his friends are at risk and thinks that he should do something.

Decision/DeterminationYoung man is ready & plans to use condoms so goes to a shop to buy them.

MaintenanceWearing condoms has become a habit and young man regularly buys them.

ActionYoung man buys

and uses condoms.

STAGES OF CHANGE MODELSTAGES OF CHANGE MODELConcept Definition Application

Pre-contemplation Unaware of the problem hasn’tthough about change.

Increase awareness of need forchange, personalizeinformation on risks andbenefits.

Contemplation Thinking about change, in thenear future.

Motivate, encourage to makespecific plans.

Decision/Determination

Making plan to change. Assist in developing concreteaction plans, setting gradualgoals.

Action Implementation of specificaction plans.

Assist with feedback, problemsolving, social support,reinforcement.

Maintenance Continuation of desirableactions, or repeating periodicrecommended step(s).

Assist in coping, reminders,finding alternatives, avoidingslips/relapses (as applies).

THE BEHAVIOUR CHANGE SPIRALTHE BEHAVIOUR CHANGE SPIRALMaintenance: practice required for the new behaviour to be consistentlymaintained, incorporated into the repertoire of behaviours available to aperson at any one time.

Action: people make changes, acting on previous decisions, experience,information, new skills, and motivations for making the change.

Contemplation: something happens to prompt the person to startthinking about change – perhaps that someone has made changes – orsomething else has changed – resulting in the need for further change.

Pre-contemplation: changing a behaviour has not been considered;person might not realise that change is possible or that it might be ofinterest to them.

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Preparation: person prepares to undertake the desired change – requiresgathering information, finding out how to achieve the change,ascertaining skills necessary, deciding when change should take place –may include talking with others to see how they feel about the likelychange, considering impact change will have and how will be affected.

The Behaviour Change Spiral in the The Behaviour Change Spiral in the context of the Enabling Environmentcontext of the Enabling Environment

Social featurese.g. nature of personalrelationships; expectations ofclass, position, age, gender;access to knowledge,information

Cultural features- the behaviours and attitudesconsidered acceptable in givencontext – e.g. relating to sex,gender, drugs, leisure,participation

Ethical and spiritual features- influence of personal andshared values and discussionabout moral systems fromwhich those are derived – caninclude rituals, religion andrights of passage

Resource features- affect what is required tomake things happen –covers human, financialand material resources;community knowledge andskills; and items forchange.

Political features- systems of governance inwhich change will have totake place – can, forexample, limit access toinformation andinvolvement in socialaction.

Legal features- laws determining whatpeople can do and activitiesto encourage observance ofthose laws

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DIFFUSION MODELDIFFUSION MODEL

KNOWLEDGE PERSUASION DECISION IMPLEMENTATION CONFIRMATION

PRIOR CONDITIONS1. Previous practice2. Felt needs/problems3. Innovativeness4. Norms of social systems

COMMUNICATION CHANNELS

Characteristics ofthe DecisionMaking Unit:1. Socio-

economiccharacteristics

2. Personalityvariables

3. Communicationbehaviour

Perceived Characteristicsof the Innovation1. Relative Advantage2. Compatibility3. Complexity4. Trialability5. Observability

1. Adoption Continued AdoptionLater Adoption

2. Rejection DiscontinuanceContinued Rejection

DIFFUSION OF INNOVATION PROCESSDIFFUSION OF INNOVATION PROCESS

Cummulative number or % of adopters

Time

Innovators

Early adopters

Early majority

Late majority

Late adopters

Source: Green & MCAlister 1984.

DIFFUSION OF INNOVATIONDIFFUSION OF INNOVATIONTime Relapse between awareness, interest, Time Relapse between awareness, interest, trial and adoptiontrial and adoption

Time

Percentage of

population

25

50

75

100

A B C

E F G

STAGES

Awareness

Interest

Trial

Adoption

Late adopters

Early adopters

Source: Green & MCAlister 1984.

STEPS TO BEHAVIOUR CHANGESTEPS TO BEHAVIOUR CHANGE

Knowledge

1. Recalls family planning messages.

2. Understands what family planning means.

3. Can name family planning method(s) and/or source of supply.

Approval

4. Responds favorable to family planning messages.

5. Discusses family planning with personal networks (family, friends).

6. Thinks family, friends, and community approve of family planning.

7. Approves of family planning.

As developed by Population Communication Services for communication programmes appropriate for family planning and reproductive health.

Intention

8. Recognise that family planning can meet a personal need.

9. Intends to consult a provider.

10. Intends to practice family planning at some time.

Practice

11. Goes to a provider of information/supplies/services.

12. Chooses a method and begins family planning use.

13. Continues family planning use.

Advocacy

14. Experiences and acknowledges personal benefits of family planning.

15. Advocates practice to others.

16. Supports programmes in the community.

VARIABLES UNDERLYING VARIABLES UNDERLYING BEHAVIOURAL PERFORMANCEBEHAVIOURAL PERFORMANCE

Generally speaking it appears that in order for a person to perform a given behaviour one or more of the following must be true:

1. The person must have formed a strong positive intention (or made a commitment) to perform the behaviour;

2. There are no environment constraints that make it impossible to perform the bahviour;

3. The person has the skills necessary to perform that behaviour;

4. The person believes that the advantages (benefits, anticipated positive outcomes);

5. The person perceives more social (normative) pressure to perform the behaviour than to not perform the behviour;

6. The person perceives that performance of the behaviour is more consistent than inconsistent with his or her self image, or that it’s performance does not violate personal standards that activate negative self-actions;

7. The persons emotional reaction to performing the behaviour is more positive than negative; and

8. The person perceives that he or she has the capabilities to perform the behaviour under a number of different circumstances…”

Audiences along a Behaviour Continuum: Audiences along a Behaviour Continuum: Possible Communication StrategiesPossible Communication Strategies

Unaware

Aware, concerned,knowledgeable

Motivated toChange

Tries NewBehaviour

Sustains NewBehaviour

Raise awareness. Recommend a solution.

Identify perceived barriers and benefits tobehaviour change.

Provide logistical information.Use community groups to counsel and motivate.

Provide information on correct use.Encourage continued use by emphasisingbenefits.Reduce barriers through problem solving.Build skills through behavioural trials.Social support.

Remind them of benefits of new behaviour.Assure them of their ability to sustain newbehaviour.Social support.

Health-related behaviour change: the Health-related behaviour change: the examples of exercise for womenexamples of exercise for women

Cognitive information:

Different types(stamina, strength,suppleness)

Effect on the body.

Benefits:Exercise is enjoyableSociableHelps to lose weight,get fitFeel exhilarated

Susceptibility:UnfitOverweight

Barriers:TimeMoneyEmbarassment

Self-esteem increasedby:Observation ofsuccess in someonesimilar persuasion bysports leaderimprovedperformance.Values:Attraction = beingslim, tone, activeAttitudes:Exercise is easyExercise is for all

Return from holiday:Desire to stay fitKeep up withchildrenSet an example topartnerNewspaper series ongetting fit

Beliefs about efficacy in sportscompetence; physical fitness;physical appearance andattractiveness

Local leisure centre Open early and late; free crecheSeveral health clubs women only groups

Good social support networks, stable,prediction and comfortable circumstances, e.g.regular income, good housing

SOCIAL NORMS

INFORMATION BELIEFS MOTIVATION CUE TO ACTION

SOCIAL CIRCUMSTANCES

SELF-CONCEPT

EXPERIENCE

PRECEDE-PROCEED PHASESPRECEDE-PROCEED PHASESPRECEDE

PROCEED

Phase 5Administration &policy Diagnosis

Phase 4Educational &OrganisationalDiagnosis

Phase 3Behavioural &EnvironmentalDiagnosis

Phase 2EpidemiologicalDiagnosis

Phase 1Social Diagnosis

HEALTHPROMOTION

HealthEducation

Policyregulationorganisation

Phase 6Implementation

Phase 7Process Evaluation

Phase 8Impact Evaluation

Phase 9Outcome Evaluation

Predisposingfactors

Reinforcingfactors

Enablingfactors

Behaviourlifestyle

Environment

Health Quality oflife

PRECEDE/PROCEED MODEL PRECEDE/PROCEED MODEL (Behavioural Domains)(Behavioural Domains)

Desiredbehaviour

Predisposing factors (motivating)Opinions, Attitudes, ValuesBeliefsNeedsAwareness, Interest, KnowledgePerceived skills

Enabling factors (facilitating)Organisational barriers/supportsInter-organisational barriers/supportsInterpersonal barriers/supportsPersonal skills, +/-Models/examples from real life

Reinforcing factors (maintaining)Intrinsic rewards/barriers/supportsExternal rewards/barriers/supportsPunishment/barriersPositive supports

CONCEPTUAL MODEL OF CONCEPTUAL MODEL OF COMMUNITY EMPOWERMENT COMMUNITY EMPOWERMENT (Perceived Control)(Perceived Control)

Multiple levels of perceived control

IndividualOrganistaional

Community

Demographic characteristic: Race, gender, income, education

Attitudes about effectiveness

Participation in action

Event to which local group attempts to influence public policy

Participatory events in organisation (activity level and leadership)

MASLOW’S HIERARCHY OF NEEDSMASLOW’S HIERARCHY OF NEEDS

Basic physiological needs - hunger, thirst and related needs

Safety needs - to feel secure and safe, out of danger

Belongingness and love needs - to affiliate with others, be accepted and being

Esteem needs - to achieve, be competent, and gain approval and recognition

Self-actualization needs - to find self-fulfilment and realise one’s own potential