Many models have been proposed to predict health behaviours. The Health Belief Model, proposed by Rosenstock (1966), suggested that the likelihood of the behaviour being performed was determined by several factors: perceived susceptibility to an illness, perceived severity of the illness, the assessment of the benefits and barriers to performing the behaviour, and cues to action (internal or external). The component of perceived control has recently been added. Many studies have shown that the HBM can predict a wide range of behaviours, from maintaining a healthy diet to engaging in safe sex. However, it has been criticised for its emphasis on rational thinking and also on the individual without considering the wider social environment.
Another model that has been proposed is the Protection Motivation Theory, which is an expansion of the HBM (Rogers, 1975). Rogers believed that there were four main factors which predicted behavioural intentions: severity and susceptibility (as in the HBM), self-efficacy, and response effectiveness (i.e. the effectiveness of the outcome of the behaviour). Feeding into these factors are environmental and interpersonal variables. Severity and susceptibility combine into appraisal of threat, and self-efficacy and response effectiveness feed into coping appraisal. In an attempt to incorporate an emotional component, Rogers has included fear in the appraisal of threat. Despite this, it has been criticised in many of the same ways as the HBM, for example, reliance on the individual without consideration of social pressures.
The most recent model to be proposed is that of Schwarzer (1992); the Health Action Process Approach. It has two main stages: the motivation stage (determined by self-efficacy, outcome expectancies and threat appraisal) and the action stage (cognitive/volitional processes of action plans and action control, and situational factors such as barriers/resources and social support).
Schwarzer believed that self-efficacy was the best predictor of intentions and behaviour, and this has been shown to be true in other studies for many behaviours, such as smoking cessation and weight loss (eg. Beck and Lund, 1981; Seydel et al, 1990). Again the model has been criticised for failure to account for emotional, social and environmental influences.
The model which best explains X’s smoking behaviour is the Theory of Planned Behaviour (Azjen, 1985, 1991). The model suggests that behavioural intention is the best predictor of actual behaviour, and that intention is determined by three factors: attitudes towards the behaviour, subjective norms and perceived behavioural control. Attitudes to the behaviour are made up of the person’s beliefs about whether the outcomes will be positive or negative, or indeed if they will have any effect at all, and also how the person evaluates these outcomes (something like assessing costs and benefits in the previous models). Subjective norms are what people perceive to be normal within their particular social environment. This consideration of social influences sets it apart from the other models, which have been criticised for focussing on the individual. In the TPB, subjective norms are made up of beliefs about the attitudes of others in your social group (such as friends or family) and how strongly you want to comply with these attitudes. The concept of perceived behavioural control has been said to be the most important factor in predicting not only behavioural intentions, but actual behaviour. Perceived behavioural control is similar to the concept of self-efficacy (i.e. the extent to which a person believes they are in control of the behaviour), and is determined by three factors: internal influences (e.g. possession of certain skills or abilities), external influences (e.g. barriers to performing the behaviour) and past experience of the behaviour.
In the case of X self-efficacy seems to be the biggest determinant of intentions and behaviour related to smoking. This has been found in several studies, for example, DeVries et al (1994) found that increased self-efficacy was related to preparation to quit smoking among pregnant women. The importance of self-efficacy levels in smoking behaviour in young adults has also been shown in several studies (e.g. DeVries et al, 1995; Lawrence, 1989). Bandura (1986) stated that “self-confidence of smokers to resist external or internal pressures to continue smoking…affect them to become and remain ex-smokers”. In terms of subjective norms and attitudes, X lives with other smokers who share her positive attitude to smoking. Also, when she goes out to a bar or nightclub, smoking is very much the norm in this environment. X’s family have negative attitudes towards smoking, but as X no longer lives with them, their opinions are not as important. Therefore, she has a strong motivation to comply with her housemates by continuing her smoking, and no motivation to comply with her family’s attitudes. As mentioned above, X has a positive attitude towards smoking, and believes that the outcomes of quitting would be negative (e.g. increased anxiety, irritability etc.). She also holds the belief that the costs of quitting outweigh the benefits, as she enjoys smoking and is not currently suffering any ill effects.
Combining these factors to predict intentions to quit smoking, X has negative attitudes about quitting, quitting is not the norm in her current social environment, and she has low perceived behavioural control due to previous failed attempts to quit. Therefore intentions to quit will be low. To aid X in altering her smoking behaviour, the most important intervention would have to tackle the problem of low self-efficacy, as this seems to be the main factor in the maintenance of the smoking behaviour. As her current living situation cannot be altered, perhaps an attempt to change attitudes might be useful. X rates her enjoyment of smoking as very high, so a technique to reduce this enjoyment may be useful, such as aversion therapy. Also, as X smokes a lot when drinking alcohol, cue exposure procedures may help X formulate strategies to cope with this high-risk situation.
The above case has been studied using the cognition and social cognition models of health beliefs. While these may apply to other health behaviours, such as exercise or diet, and are quite useful when considering psychological aspects of smoking, they fail to account for the physical dependence on nicotine. Therefore, a combination of these models with an addiction perspective may be more helpful when determining suitable interventions to help X quit smoking.
REFERENCES:
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Azjen, I. “From intentions to actions: A theory of planned behaviour” in Beckman, J. and Kuhl, J. (eds), Action-control: From cognition to behaviour (Heidelberg: Springer) 1985, pp.11-39 ctd in Ogden, J. Health Psychology: A Textbook 3rd Ed. (Berkshire: Open University Press/McGraw-Hill Education) 2004
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Azjen, I. “The Theory of Planned Behaviour”, Organisational Behaviour and Human Decision Processes Vol.50, pp.179-211 (1991).
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Bandura, A. Social foundations of thought and action (New Jersey: Prentice-Hall), 1986.
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Beck, K.H. and Lund, A.K. “The effects of health threat seriousness and personal efficacy upon intentions and behaviour”, Journal of Applied Social Psychology Vol.11, pp.401-415 (1981).
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DeVries, H. and Backbier, E. “Self-efficacy as an important determinant of quitting among pregnant women who smoke: The φ pattern”, Preventive Medicine Vol. 23, pp. 161-174 (1994) ctd in Rutger, C.M.E., Engels, M.A., Knibbe, Ronald A., Ph.D, DeVries, Hein, Ph.D and Drop, Maria J., Ph.D “Antecedents of smoking cessation among adolescents: Who is motivated to change?”, Preventive Medicine Vol. 27, pp.348-357 (1998)
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DeVries, H., Backbier, E., Kok, G. and Dijkstra, M. “The impact of social influences in the context of attitude, self-efficacy, intention and previous behaviour as predictors of smoking onset” Journal of Applied Social Psychology Vol. 25, pp.237-257 (1995).
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Lawerence, L. “Validation of a self-efficacy scale to predict adolescent smoking” Health Education Research Vol.4, pp.351-360 (1989) ctd in Rutger, C.M.E., Engels, M.A., Knibbe, Ronald A., Ph.D, DeVries, Hein, Ph.D and Drop, Maria J., Ph.D “Antecedents of smoking cessation among adolescents: Who is motivated to change?”, Preventive Medicine Vol. 27, pp.348-357 (1998)
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Rogers, R.W. “A protection motivation theory of fear appeals and attitude change”, Journal of Psychology Vol.91, pp.93-114 (1975), ctd in Ogden, J. Health Psychology: A Textbook 3rd Ed. (Berkshire: Open University Press/McGraw-Hill Education) 2004, pp.27-30
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Rippetoe, P.A. and Rogers, R.W., “Effects of components of protection-motivation theory on adaptive and maladaptive coping with a health threat”, Journal of Personality and Social Psychology Vol.52, pp.596-604 (1987), ctd in Ogden, J. Health Psychology: A Textbook 3rd Ed. (Berkshire: Open University Press/McGraw-Hill Education) 2004 p.30
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Rosenstock, I.M. “Why people use health services”, Millbank Memorial Fund Quarterly Vol.44, pp.94-124 (1966), ctd in Ogden, J. Health Psychology: A Textbook 3rd Ed. (Berkshire: Open University Press/McGraw-Hill Education) 2004 pp.24-26
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Seydel, E., Taal, E. and Wiegman, O. “Risk appraisal, outcome and self-efficacy expectancies: Cognitive factors in preventative behaviour related to cancer”, Psychology and Health Vol.4, pp.99-109 (1990).
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Schwarzer, R. Self-efficacy: Thought Control of Action (Washington D.C.: Hemisphere), 1992, pp.217-243 ctd in Ogden, J. Health Psychology: A Textbook 3rd Ed. (Berkshire: Open University Press/McGraw-Hill Education) 2004 pp.34-35
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Weinstein, N. “Unrealistic optimism about illness susceptibility: conclusions form a community-wide sample”, Journal of Behavioural Medicine Vol.10, pp.481-500 (1987) ctd in Ogden, J. Health Psychology: A Textbook 3rd Ed. (Berkshire: Open University Press/McGraw-Hill Education) 2004 p.21
