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Theory of Planned Behaviour

7 Jan

The theory of planned behaviour (TPB) is possibly the most popular health behavioural model out there apparently. An individual’s intention to carry out a health behaviour is shaped by 3 things: attitude, social norms, and perceived behavioural control. Depending on these three factors, once enough intention is built up this is translated into actual behaviour.

Theory of Planned behaviour

Theory of Planned behaviour

ADV: It has been used extensively throughout social psychology as well as public health. It includes the all important consideration of social pressures et al on an individual’s behaviour. It gives an accurate prediction of behaviour in comparison to the other models

DISADV: it is a motivation model like the HBM and the PMT, meaning that intention is the key focus. In actual fact, there is such a thing called the Intention behaviour gap which signifies the difficulties in getting individuals to convert their intentions (I want to quit smoking) to the action (I will quit smoking, NOW!).

 

Protection Motivation Theory

7 Jan

The Protection Motivation Theory (PMT) is a follow on from the HBM, with the addition of self-efficacy. Protection motivation arises from a combination of two types of appraisal:

Threat appraisal

This is made up of perceived susceptibility and severity of the consequences of not following the proposed health behaviour, and is no different from the HBM in this respect.

Coping appraisal

This involves a combination of response appraisal and self appraisal. Response appraisal describes an individual’s belief of how effectively the proposed health behaviour will prevent bad health consequences. Self appraisal describes an individual’s belief in their ability to carry out the health behaviour successfully.

Protection motivation then leads to a coping response. This response may be adaptive (leads to desired health behaviour) or maladaptive (refusal to believe in proposed behaviour leads to inaction).

A bit confusing maybe, so here is a diagram:

Protection Motivation Theory

Protection Motivation Theory

ADV: It is an improvement on the HBM as it includes self-efficacy. It also describes the relationships between health beliefs and intentions. Additionally, it offers a good prediction of motivation

DISADV: It is very individualistic in approach and does not address social pressures that may influence behaviour

 

Health Belief Model

7 Jan

The Health Belief Model (HBM) is probably the most commonly heard of, it was the first attempt to categorise the determinants of health behaviour. It states that the willingness of an individual to take up a health intervention relies on five different things:

Perceived susceptibility to the outcome if intervention isn’t followed

Perceived severity of outcome if intervention isn’t followed

Perceived benefits of the intervention

Perceived barriers of the intervention

Cues to action (a final push to encourage action)

ADV: It is a useful framework to investigate what’s going on in terms of health behaviour.

DISADV: it doesn’t specify relationships between variables and ignores the crucial role ofbehavioural skills and control in performing behaviour.

E.g. Encouraging individuals to stop smoking

Perceived susceptibility to what might happen if  you don’t stop smoking (what is the probability of developing lung cancer etc)

Perceived severity of outcome if you don’t stop smoking (how bad is lung cancer?)

Perceived benefits of stopping smoking (better health and general well-being, sense of achievement)

Perceived barriers of stopping smoking (hard to quit when stressed, difficulty in not smoking in social situations where other people smoke

Cue to action (knowing someone who has quit or alternatively, who has gotten lung cancer, stopping quitting before having children etc)

Public Health Promotion: various approaches

7 Jan

Public Health Promotion is all about health (unsurprisingly). It aims to improve health by health education, the provision of preventive services, and the improvement of a population’s social, physical and economic environment. So already you are looking at three “approaches” to health. It is important to emphasise the distinction between health promotion and health prevention. Health protection serves to protect the population from diseases and exposures to hazards such as chemicals, physical dangers etc. Health promotion however promotes a healthy lifestyle such as increasing physical activity or improving diet. In a nutshell, the difference lies in whether you are preventing bad health, OR promoting good health. Subtle but distinct.

There are various approaches to public health promotion, as follows:

Broad vs Narrow

A broad approach to public health is often difficult to achieve as it involves the coordination of multiple sectors and the smooth cooperation and communication between them also. It can be time-consuming and complex, and at the end of the day, this complexity makes such approaches very difficult to evaluate, which is a key aspect of public health promotion. Examples could be tackling salt reduction in the UK: as well as increasing awareness and hopefully triggering some sort of action amongst the public, the food industry and the hospitality industry need to be taken on board to make a significant difference to the average salt intake of the population (currently at 8-10g). The government’s voluntary opt-in scheme is testament to how difficult it may be to garner the cooperation of such massive industries that include powerful international brands and corporations. Companies such as Starbucks, KFC and Pizza Hut have yet to sign the list, representing a clear problem of such voluntary schemes. Additionally, the scheme does not target independent fast food outlets, which are clearly a significant source of diet for many (students in particular, I hear).

A narrow approach is more specialised, focusing on a health problem with a simple solution. This means evaluating the ensuing effects and benefits is relatively easier, but this approach is also insufficient in tackling many real life health problems that are often affected by multiple determinants. You only have to look at Dahlgren and Whitehead’s model of the wider determinants of health to know what I mean.

High risk or Population

Geoffrey Rose’s work was seminal in demonstrating the clear differences between high risk approaches and population approaches. His book (here) is definitely a MUST-READ for people in public health.

High risk approaches make a lot of sense at first sight: they target the people who are at highest risk of suffering from poor health, and will therefore benefit the most, relative to others in the population. Hypertension is a great example (I think Rose used this, off the top of my head): those classed as high risk individuals are often more motivated to do something about their health, which means targeted health promotion can be effective – Rose describes it as “appropriate”. There is a hidden disadvantage however, in that the high risk population need to be identified before they can be targeted, via expensive screening programmes.

Additionally there is the all important Prevention Paradox (again Rose’s work. Just read it.) to consider. This brings the attention to the fact that the high risk population is actually a small proportion of the entire population. The majority of cases of a disease will be caused by individuals at low risk, purely because there are more of them than the high risk individuals. This means that at a population level, preventing disease in the high risk population only makes very little difference to overall disease levels. This isn’t so good for the public health practitioner, because by definition public health is about the health of the population, right? Rose suggests that instead of the high risk approach, the population approach may be better.

Targeting public health promotion via the population approach is, on paper, a very promising method to make a significant difference to health at a population level. It targets everyone’s health and allows improvements to be made at population level, not just in a minority of cases. As it is targeting everyone, individuals have more social pressure and/or incentive to follow public health advice and change their lifestyles for the better. The population approach however is not without its disadvantages. As alluded to by the Prevention Paradox, a population approach leads to benefits across the population. But as the majority are not at high risk, the benefits most individuals see are very little. The use of helmets in cyclists or seatbelts in motorists is commonly used as an example here. Most individuals would not have been at risk of an accident even without the helmet or seatbelt. The knowledge of this can demotivate individuals and their physicians. It’s not easy convincing someone to change their diet when they are of a healthy weight already in order to improve their health that little bit more.

Target Audience

The target audience of health promotion can be considered in three different ways:

Patients: This involves taking quite a paternalistic view of the target population. It is commonly seen with clinical issues, and is more likely to be used for infectious disease than chronic diseases.

Consumers: This approach considers the needs and interests of the target population, and takes a lot of social marketing into account.

Participants: In some cases, it may be necessary to consider the target audience as participants, rather than passive recipients of information and public health goodness. Individuals are considered to have an active interest in the intervention and are often crucial in determining the success of the intervention.

Case study

The National Child Measurement Programme (NCMP) measures the weight and height of children in reception (4-5 years old) and Year 6 (9-10 years old). It is a population approach in the sense that it is not targeted towards obese children only. The target audience (the children and their parents) are considered as participants: the parents are given feedback on the results of their child’s assessment and advice on diet, physical activity etc. Considering obesity is a mountain of issues to be tackled, I guess this would be described as a narrow approach.

Conclusion

Considering the different approaches to public health promotion is important in the context of designing an intervention. The final approach that is taken will depend on a multitude of factors such as resource availability (financial and otherwise), what the intervention is targeting, the scope and general rationale behind the intervention etc.