Behaviour change

CHAPTER 7 Behaviour change



Patricia Barkway, Dianna Kenny



Key points


♦ Health behaviours are influenced by a range of physical, psychological and social factors.

♦ Psychological theories and models can predict an individual’s health behaviours.

♦ Psychological theories and models identify strategies whereby individuals can change health behaviours.

♦ While psychological theories and models provide useful insights for understanding, predicting and changing health behaviours they, nevertheless, have limitations and are not necessarily universally applicable.


Learning objectives


The material in this chapter will help you to:


♦ describe and understand the dominant psychological approaches that attempt to explain health behaviours, namely:
• learning theory

• cognitive theory

• health belief model

• theory of planned behaviour

• transtheoretical model of behaviour change

• health action process approach

♦ utilise the above theories and models to explain the initiation of and the continuation of health enhancing and health ‘risk’ behaviours

♦ utilise the above theories and models to modify health behaviours

♦ identify the limitations of psychological theories and models as predictors and moderators of health behaviours.


Key terms


♦ Behaviourist/learning theories


♦ Cognitive theories


♦ Health belief model


♦ Theory of planned behaviour


♦ Transtheoretical model of behaviour change


♦ Health action process approach



Introduction


How healthy is your lifestyle? Do you regularly follow the health practices identified in Chapter 4 regarding nutrition, physical activity, cigarette smoking and alcohol consumption? Have you ever made a decision regarding one of these health behaviours but not continued with the activity as you intended, for example, to exercise regularly? Or perhaps you did follow through with your intention and maintained the activity. Why might there be different outcomes to these scenarios when your intention was the same in both? What other factors might influence the outcomes in these two scenarios?


Such questions underpin psychological health research and contribute to the development of theories and models that can explain and predict an individual’s health-related behaviours. Additionally, theories can identify opportunities for intervention for unhealthy behaviours and models of intervention. This chapter will examine a range of psychological approaches that propose explanations as to how internal (within the person) and external (within the environment) factors influence an individual’s health behaviours and lifestyle.



Health-enhancing behaviours: what are they?


Health behaviours are actions that enhance, maintain or threaten an individual’s health. They are activities that an individual practices or abstains from in order to maintain health or to reduce the risk of illness or accident. Health behaviours can be either positive or negative and include such practices as: following a healthy diet and eating in moderation; not driving a car while under the influence of alcohol or drugs; and keeping immunisation up to date and regular health screening such as for breast or prostate cancer. When practised regularly (such as daily teeth brushing) a health behaviour is called a health habit, while clusters of health behaviours are referred to as lifestyle



CRITICAL THINKING



image Make a list of behaviours and practices that are consistent with a healthy lifestyle.

image Make a list of behaviours and practices that contribute to an unhealthy lifestyle.

image What factors do you think influence an individual to engage in a healthy or unhealthy lifestyle?

image Does an individual choose his/her lifestyle? Explain your answer.

image Is willpower alone sufficient to ensure that an individual will cease a harmful behaviour or commence a positive one? Explain your answer.


Health-enhancing behaviours: why focus on them?


Up until the mid-20th century global public health threats were mainly from infectious and communicable diseases. However, in developed countries, a shift occurred over the past one hundred years whereby the major health threats are now posed by diseases in which lifestyle plays a role in the aetiology and/or management of illness. For example, the modifiable risk factors for coronary heart disease, a leading cause of disease burden, are: tobacco smoking; high blood pressure; high cholesterol level; insufficient physical inactivity; overweight and obesity; poor nutrition and diabetes (AIHW 2006 p 61), all of which are linked to health behaviours and lifestyle.


Disease burden is measured by disability adjusted life years (DALYs) which comprises years of life lost (YLLs) (mortality) and years lived with disability (YLD) (morbidity). In Australia, New Zealand and other Western nations the health conditions with the greatest disease burden (measured by DALYs and YLDs) are cancers, cardiovascular diseases, mental illness, injuries, chronic respiratory disease and diabetes (AIHW 2006). Each of these conditions, at least in part, can be attributed to lifestyle and the course of the conditions can be moderated by health behavioural practices. Hence, there is intuitive appeal in encouraging people to lead a healthy lifestyle to thereby reduce their disease risk and to improve quality of life for people with chronic health conditions.


From the individual’s perspective the reasons to change one’s health behaviours include prevention (to avoid the risk of a health problem), management (treatment of an identified health problem) and for general wellbeing. From the health professionals’ and health services’ perspectives additional motives include reducing the incidence and burden of the health issue in the community and the best utilisation of resources.



Health psychology: theories and models


Health psychology is interested in factors that influence the initiation, continuation, cessation and modification of behaviours that impact on health and health outcomes. To this end psychological theories propose hypotheses to explain and predict behaviour, while models (which are derived from theories) detail the processes and stages of how the behaviour under observation is enacted. In addition to observable behaviours the health beliefs held by individuals and the impact these beliefs have on their health-related behaviours are investigated. Finally, health psychology is interested in finding effective strategies to help people to overcome resistance to change their behaviour and prevent relapse.


Psychological theories and models of health behaviour attempt to explain or predict an individual’s engagement in behaviours that influence the risk for illness or injury and the maintenance of health. In the main, psychological theories of health behaviour fall into two broad categories: behaviourist/learning theories and cognitive theories. Behaviourist/learning approaches include operant conditioning, classical conditioning and modelling or imitation (see also Chapter 1). Cognitive approaches include the health belief model and the transtheoretical model of behavioural change. The theory of planned behaviours introduces social influences to a cognitive model as does the health action process approach. These behavioural and cognitive approaches to behaviour change will now be examined.



Learning theories


Learning (also called behaviourist) theories propose that personality is determined by prior learning, that human behaviour is changeable throughout the lifespan and that changes in behaviour are generally caused by changes in the environment. They are concerned only with behaviour that is observable and not mental or affective processes. Specifically, learning theories focus on the conditions that produce behaviour, factors that reinforce behaviour and vicarious learning through watching and imitating the behaviour of others. The three main learning approaches are:


• classical conditioning – learning by association

• operant conditioning – learning by reinforcement

• social learning theory – vicarious learning (modelling/observation and copying).


Classical conditioning


As outlined in Chapter 1, classical conditioning was first described by the Russian Ivan Pavlov who observed the relationship between stimulus and response through demonstrating that a dog could learn to salivate (respond) to a non-food stimulus (a bell) (Pavlov 1927).



Operant conditioning


B F Skinner formulated the notion of instrumental or operant conditioning in which reinforcers (rewards) contribute to the probability of a response being either repeated or extinguished. Skinner’s research demonstrated that the contingencies on which behaviour is based are external to the person, rather than internal. Consequently, changing contingencies could alter an individual’s behaviour (Skinner 1953).



Observational learning theory


Observational learning theory (also called modelling or social learning theory) was proposed by Bandura (1969, 2006) who asserts that observational learning has a more significant influence on how humans learn than intrapsychic (psychoanalytic) or environmental (behaviourist/learning) forces alone. Bandura proposed that human behaviour results from interaction between the environment and the person’s thinking and perceptions. He also asserted that humans learn from observing not only by doing. Observational learning differs from operant conditioning in that it is not the learner who is rewarded for the behaviour; rather, the learner observes the other person being rewarded and learns vicariously through this.


Observational learning is particularly important for children’s learning because it is easier to influence a behaviour while it is being acquired rather than changing an established behaviour (Niven 2000). Hence parents and family play a significant role in the health habits that children acquire. These habits can be both positive health behaviours, such as participating in sport, or negative, such as tobacco smoking.



Learning theory approaches


Have you ever received a parking fine, a speeding ticket, lost your driver’s licence, been locked out of a concert until interval because you arrived late or been refused borrowing rights at your library until you paid your fine for late returns? Do you feel motivated after your boss tells you that he is impressed with your work or smile back at someone who has just smiled at you? Most of us, without realising it and without being able to use the technical terminology of behavioural change programs, actually practise behaviour modification in our everyday lives and have it practised on us. In your various roles as citizens, partners, parents, friends and professionals, you will, by the end of this chapter, be surprised to discover how much of your own behaviour is governed by the fundamental principles of learning theory, on which behavioural change programs are based, and how much of the behaviour of those around you is at least partly determined by your own behavioural change strategies.



Behaviour change programs


Behaviour change programs aim to change behaviour, not attitudes, beliefs, motivation, personality or other unobserved characteristics of individuals. Behaviour may be defined as anything that a person does or says; that is, behaviour is any action or response to an environmental event that is observable and measurable. Behaviours can be overt (readily observed and counted) or covert (not readily observed but can still be counted and changed, such as thoughts and feelings using the principles described in this chapter). Regardless of the orientation of specific programs, all behavioural change programs operate on the following four tenets:


• behaviour can be explained by the principles of learning and conditioning

• the same laws of learning apply to all behaviour, both normal and abnormal

• abnormal behaviour is the normal, lawful response to abnormal learning conditions

• behaviour can be ‘unlearned’ and changed.

These four tenets underpin the four major theoretical models that have been derived from learning theory, namely, classical conditioning, operant conditioning observational (imitation) learning and cognitive behaviourism (Ellis 1984, Beck 1976, Meichenbaum 1974).


Historically, behaviour therapy referred to the techniques based on classical conditioning, devised by Wolpe (1958) and Eysenck (1960) to treat anxiety; behaviour modification was used to describe programs based on the principles of operant conditioning devised by Skinner (1953) to create new behaviours in children who had an intellectual disability and patients with psychotic symptoms.


In current practice, the terms behaviour therapy, behaviour change programs and behaviour modification are used interchangeably to denote therapeutic programs based on the principles of behaviourist/learning theory. The term ‘behavioural change program’ will be used in this chapter. The following outlines the principles a clinical psychologist would use when designing a behavioural program.



FUNCTIONAL ANALYSIS OF BEHAVIOUR


The principles of operant conditioning describe the relationship between behaviour and environmental events, both antecedents and consequences that influence behaviour. This relationship, referred to as a contingency, consists of three components:


• antecedents (i.e. stimulus events that precede or trigger the target behaviour)

• behaviours (i.e. responses, usually the identified problem behaviour)

• consequences (outcomes of the behaviour, i.e. what actually happened immediately after the problem behaviour occurred).

Specifying these contingencies forms the basis of a functional analysis of behaviour. The aim of a functional analysis is to identify factors that influence the occurrence and maintenance of a particular (problem) response. This process should not be confused with other explanatory models that may seek to explain behaviour in terms of a medical diagnosis or a personality trait. Behaviour change programs are more concerned with the nature of our interactions with the environment than with our nature per se.


Conducting a functional analysis of behaviour is the first step in designing a behavioural change program. It consists of the three components outlined below.



1. SELECTING THE TARGET BEHAVIOUR


The target behaviour must be specified in such a way that it can be readily observed and measured. The behaviour of interest may be a behavioural excess (e.g. tantrums, exceeding the speed limit, verbally abusing hospital staff) or a behavioural deficit (e.g. a child who omits consonant sounds in words, an eight-year-old who cannot tie his shoelaces, an adult who does not complete prescribed physiotherapy exercises, a well elderly person who does not perform self-care activities). From the examples given, it will be clear that behavioural deficits are of two types: behaviours that exist in the behavioural repertoire of the individual but which the individual does not perform and behaviours that are not in the behavioural repertoire of the individual and must be developed. It is important to distinguish among these different groups of target behaviours as each requires the application of different behavioural change strategies.


Behaviour must never been viewed in a vacuum. The behavioural change agent considers the setting in which the behaviour occurs, the nature of the task and the characteristics of the client in his/her formulations. Behaviour may be appropriately performed in one setting and not another. For example, a child with intellectual disability who has just learned to unzip and remove his trousers may perform this behaviour in a busy shopping centre. A behavioural change program in this instance would aim to teach the child the appropriate setting for performing this newly acquired behaviour. Behaviour may also be considered problematic due to its rate, duration or intensity rather than to topography. For example, taking a shower is a normal behaviour that may become problematic if the person spends one hour doing so or showers multiple times through the day. In this case, the behavioural change program would aim to reduce the amount of time spent in the shower or the frequency of showers.



2. IDENTIFYING CURRENT CONTINGENCIES


This process involves two steps. The first is identifying the stimulus event(s) (i.e. antecedents) that precede(s) an occurrence of the problem behaviour. This includes an assessment of the physical (where the behaviour occurs) and social (who is present) environment in which the behaviour occurred. Certain behaviours will frequently occur at a high rate in one setting and be absent or occur at a low rate in others. For example, parents may complain about their child’s tantruming and talking back behaviour at home to the child’s teacher, who reports that the child is compliant and polite in the classroom. Alternatively, the teacher may notice that the child stays on task in some subjects and not in others or during the morning session but not during the afternoon. In the rehabilitation setting, two nurses may discover that Mr Stone rings the buzzer for nursing assistance twice as often for one nurse compared with another, or that a child with cerebral palsy is more likely to persist with his physiotherapy exercises when his mother is not in the treatment room. These observations provide important information about the stimulus events that may be controlling the target behaviour.


The second step requires the identification of the consequences that follow the problem behaviour; that is, what happened after the behaviour was performed? To follow through with our examples above, did the parents respond to the child’s tantrum by giving the child what s/he wanted or did they ignore his/her tantruming behaviour? Did they engage in a verbal debate with the child when he talked back or did they calmly state their rule that talk backs would not be answered? Were there any differences in each of the two nurses’ responses to Mr Stone’s buzzer ringing? What was the mother doing in the treatment room to discourage her child’s physiotherapy exercise practice? Answers to these questions are essential for effective behavioural management to occur.



3. MEASURING AND RECORDING BEHAVIOUR


This includes:


• narrative recording

• counting or frequency data

• timing or duration recording (temporal data)

• checking or interval recording (categorical data)

• rating (magnitude data).

Once you have specified the target behaviour and identified the setting in which this behaviour occurs, it is necessary to obtain a baseline of the frequency or length of its occurrence. The way you measure frequency or length depends on the nature of the target behaviour and what you wish to find out about the behaviour. There are five basic methods of measuring behaviour in healthcare settings. These are: narrative recording, counting (frequency data); timing or duration recording (temporal data); checking, also known as interval recording (categorical data); and rating (magnitude data).



Narrative recording


Narrative recording involves the observation and recording of behaviour in progress. It is often used in the early stages of the functional analysis of behaviour as a way of identifying possible antecedents and consequences of a given problem behaviour. Figure 7.1 provides an example of a narrative recording chart.


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Figure 7.1 Narrative recording sheet for assessing a child’s problematic behaviour

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Jun 19, 2016 | Posted by in PSYCHOLOGY | Comments Off on Behaviour change

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