Evaluating complex interventions: Perspectives and issues for health behaviour change interventions

Objective: Health behaviour change interventions (HBCIs), used in health education, health promotion, patient education and psychotherapy areas, are considered complex interventions. The objective of this article is to discuss the value and limitations of using randomised clinical trials (RCTs) to asses HBCIs.

Methods: A scoping review of the literature was conducted to identify the main challenges of using RCTs for evaluating HBCIs. The issues were illustrated by case studies selected from research conducted by our multidisciplinary team.

Results: In complex interventions, effects are produced not only by the intervention, but are strongly linked to context. Issues relating to transferability of results are therefore critical, and require adjustments to the RCT model. Sampling bias, biases related to the experimental conditions and biases due to the absence of double-blindness were examined and illustrated by case studies.

Conclusion: The results underline the importance of a multidisciplinary approach. They call for adapted or alternative evaluation models that overcome the limitations of RCTs.     

Teleonics of health and healthcare: Focus on health promotion

Teleonics is an approach to the study of living systems. The latter can be regarded as synergistic collections of processes through which the systems interact with their internal and external environments. Teleonics can serve as a framework for positioning issues of health into the wider context of the fabric of life. There are essentially three webs of processes that are of relevance for a discussion of healthcare, viz, the normal web of the living fabric (Biomatrix), the “web of disease” (Pathomatrix) and the web of Healthcare. The latter interacts with the first two through the processes of Health Promotion, Disease Prevention and Disease Management. The end result of these interactions is an entirely new web of great complexity that incorporates the processes of all three webs intertwined with each other. This complexity presents a considerable challenge to all those involved in healthcare and can only be untangled with the aid of a process‐based methodology, such as teleonics.     

Preventive behaviour and health status among the elderly

Abstract

The research describes the range of preventive health behaviours undertaken by the elderly, investigates the dimensionality of preventive health behaviour, and explores the relationship between preventive health behaviour, self-assessed and medically assessed health status. Previous research has relied mainly on self-reports of health status. Data from medical examinations and interviews with 115 elderly individuals (aged 65–75) indicated that most elderly persons performed some intentional preventive health practices, as well as a broad range of normative preventive health practices. Particular clusters of preventive health behaviour emerged when the data were subjected to cluster analysis. A short index consisting of five personal preventive health behaviours found in other studies to have a protective effect on long-term health was found to have a low to moderate correlation with the medical and self-assessments of health status employed in the study. These findings indicate particular types of preventive health behaviour of importance for health promotion programmes with the elderly.     

Health behavior, knowledge and attitudes among Swedish university students

A range of health behaviors was related to beliefs concerning health practices and health knowledge. A questionnaire dealing with health-related practices, health beliefs and knowledge of health risk factors was answered by 166 male and 179 female students aged 18–30 years at Stockholm University. Female students reported engaging in better health behavior than males. Beliefs about the importance of health behaviors were closely related to their frequency of occurrence. There was only a weak relationship between health behaviors and knowledge of specific health matters. It is concluded that health attitudes rather than health knowledge determine health behavior.     

Australian community responses to the use of genetic testing for personalised health promotion

Personalised genetic health promotion may soon be available and affordable. To explore its likely public acceptance in Australia, a community sample (N = 800) provided quantitative and qualitative responses to a vignette scenario about a hypothetical expert who could test their genes and, based on this genetic profile, provide personalised health promotion advice. Three theoretical models were tested to explicate the process by which cognitive–affective factors of risk beliefs, benefit beliefs, and trust judgements influenced behavioural intentions. Results supported an expert trust model, where general beliefs about the risks and benefits of medical advances and general medical trust had indirect influences, while trust in a specific medical expert had a direct influence, on health promotion intentions. Subjective reasons for intentions included moral concerns, fear, trust, mistrust and a desire to maintain health at any cost. The advent of personalised genetic health promotion may heighten the need for specialised health psychologists.     

The effects of message quality and congruency on perceptions of tailored health communications

Recent research has documented the effectiveness of tailoring health behavior change messages to characteristics of the recipients, but little is known about the processes underlying these effects. Drawing from the elaboration likelihood model (Petty & Cacioppo, 1986), we examined the role of message scrutiny in moderating the congruency effect (Mann, Sherman, & Updegraff, 2004). One hundred and thirty-six undergraduate participants read either a strong or weak message promoting regular dental flossing with a frame (gain vs. loss) that either matched or mismatched their motivational orientation (approach vs. avoidance). Results showed that participants were sensitive to argument quality in the matched but not mismatched conditions. Further, argument quality moderated the effect of congruency on participants’ attitudes and perceived norms regarding flossing, as well as their subsequent self-reported flossing behavior. Results suggest that increased message scrutiny underlies message tailoring effects.     

Mental health professionals' attitudes towards people who are deaf

Mental health professionals' attitudes towards deaf people were examined in relation to their previous contact with deaf people and their knowledge of deafness. Data were gathered regarding different aspects of contact, including the number and type of relationships participants had had with deaf people. A cognitive-processing theory of attitude change following contact (Rothbart & John, 1985) was explored. Knowledge of deafness did not correlate with attitudes towards deaf people but a relationship was found between the amount of contact that professionals had with deaf people of equal or higher status and more positive attitudes.     

Health promotion from the perspective of social cognitive theory

Abstract

This article examines health promotion and disease prevention from the perspective of social cognitive theory. The areas of overlap with some of the most widely applied psychosocial models of health are identified. The models of health promotion and disease prevention have undergone several generational changes. We have shifted from trying to scare people into health, to rewarding them into health, to equipping them with self-regulatory skills to manage their health habits, to shoring up their habit changes with dependable social supports. These transformations have evolved a multifaceted approach that addresses the reciprocal interplay between self-regulatory and environmental determinants of health behavior. Social cognitive theory addresses the socio structural determinants of health as well as the personal determinants. A comprehensive approach to health promotion requires changing the practices of social systems that have widespread detrimental effects on health rather than solely changing the habits of individuals. Further progress in this field requires building new structures for health promotion, new systems for risk reduction and greater emphasis on health policy initiatives. People's beliefs in their collective efficacy to accomplish social change, therefore, play a key role in the policy and public health approach to health promotion and disease prevention.     

From health beliefs to self-regulation: Theoretical advances in the psychology of action control

Abstract

The paper reviews the theoretical concepts included in a range of social cognitive models which have identified psychological antecedents of individual motivation and behaviour. Areas of correspondence are noted and core constructs (derived primarily from the theory of planned behaviour and social cognitive theory) are identified. The role of intention formation, self-efficacy beliefs, attitudes, normative beliefs and self-representations are highlighted and it is argued that these constructs provide a useful framework for modelling the psychological prerequisites of health behaviour. Acknowledging that intentions do not translate into action automatically, recent advances in our understanding of the ways in which prior planning and rehearsal can enhance individual control of action and facilitate the routinisation of behaviour are considered. The importance of engaging in preparatory behaviours for the achievement of many health goals is discussed and the processes by which goals are prioritised, including their links to self-representations, are explored. The implications of social cognitive and self-regulatory theories for the cognitive assessment of individual readiness for action and for intervention design in health-related settings are highlighted.     

Prediction of dietary adherence in cholesterol reduction: Relative contribution of personality variables and health attitudes

Abstract

The purpose of this study was to identify personality and health attitude variables that might predict adherence to a cholesterol-reducing diet.

After taking a battery of psychological inventories, 66 subjects entered a 26 week diet program. Adherence indices included attendance rate at scheduled appointments, changes in diet, and changes in serum cholesterol levels.

Of the 55 subjects with complete data, 7 dropped out, 7 attended inconsistently, and 41 completed the program. Drop-outs scored significantly lower on the Health Belief measures of seriousness, susceptibility, and benefits. Improvement in serum cholesterol was positively correlated with the Health Belief Benefits Scale and negatively correlated with the Health Locus of Control chance scale. Dietary reduction in saturated fat was positively associated with the Health Belief Seriousness and Benefits Scales.

Health attitudes and beliefs were better predictors of adherence than personality trait measures.     

Health professionals: A source of variance in health outcomes

Abstract

The behaviour of health professionals is rarely considered systematically by psychologists. This paper makes the following argument: first, that the behaviour of health professionals is influenced by other factors as well as medical knowledge; second, that various psychological models of human behaviour previously used only in considering the behaviour of patients may also be used to explain, predict and change the behaviour of health professionals; third, to implement effective care the behaviour of health professionals needs to be considered alongside that of patients.     

The prediction of safe sex behaviour: The role of intentions,attitudes, norms and control beliefs

Abstract

The present study was designed to examine the utility of the theory of reasoned action (Fishbein and Azjen, 1975) in relation to people's propensity to engage in a range of different safe sex strategies, including engaging in an exclusive sexual relationship, avoiding casual sex, and asking sexual partners about their previous sexual and IV drug use history. It was proposed that the intention to engage in a particular safe sex practice would be influenced by the person's attitude towards engaging in the practice, as well as his or her perception of the extent to which others thought they should do so (subjective norm), while behavioural intentions were proposed to predict actual behaviour. The study was also designed to examine whether, after control of the effects of the components of the theory of reasoned action, the person's generalised control beliefs would explain any additional variance in either behavioural intentions or actual behaviour. One hundred and two sexually active heterosexual students participated in the study. At the first wave of data collection, subjects completed measures of intentions, attitudes, and norms appropriate to each of the different behaviours. Measures of actual behaviour were obtained at follow-tip (three months after first period of data collection). The results of the study indicated that attitudes and norms predicted intentions for avoiding casual sex and asking sexual partners about their previous sexual and IV drug use history, while intentions predicted actual behaviour for all three safe sex strategies. Although there were no significant main effects of control beliefs on intentions or behaviour, subjects with internal control beliefs were more likely than their counterparts with external control beliefs to behave in accordance with their intentions to engage in an exclusive sexual relationship and ask sexual partners about their previous sexual and IV drug use history. Additional analyses revealed that the levels and determinants of intentions and actual behaviour were, in general, similar for males and females.     

The interpretation of change in verbal reports: Implications for health psychology

Abstract

This paper raises a number of issues for health psychology in relation to the interpretation of change in verbal reports. Drawing on a typology of change developed to evaluate organisational interventions, it is suggested that change may occur at an alpha level (e.g. changed health status), beta level (e.g. a recalibration of the respondent's scale for assessing health status) or gamma level (e.g. a reconceptualisation of the meaning attached to health). Given the likely presence of beta and/or gamma change in intervention data in health psychology, researchers may be analysing their change data at an inappropriate level. A number of existing methodologies which attempt to detect beta and gamma change are presented and discussed. The need to develop further methodologies which focus more explicitly on the nature of change is highlighted. Finally, the proposed typology has a number of practical implications for the design of health promotion interventions.     

Social cognition models and health behaviour: A structured review

Abstract

A number of social cognition models have been developed to account for socio-demographic variations in health behaviour. This paper distinguishes between: (a) motivational, (b) behavioural enaction, and (c) multi-stage models of health behaviour. The models are evaluated in terms of advancement of existing knowledge and - where appropriate - predictive utility. Common themes that appear within- and between- these categories are discussed, with consideration of ways in which theory may be advanced by future research. Each approach has associated strengths and weaknesses, suggesting that a “consensus” approach to the study of health behaviour may prove fruitful. Identification of the key constructs across different model types would allow coherent integration and promote further understanding of the psycho-social determinants of health behaviour.     

Health, happiness and health promotion

This article claims that health promotion is best practiced in the light of an Aristotelian conception of the good life for humans and of the place of health within it.     

Socio-economic health inequalities: Their origins and implications

Abstract

Evidence attests to substantial variations in health contingent on socioeconomic position. It is argued that these effects cannot be dismissed as artefact nor can they be explained, in the main, by either social selection or an unequal distribution of accepted behavioural risk factors among different social groups. The most likely explanation would seem to be social causation. However, it is continuing social and material inequality that appears most implicated; accounts which locate the effects in childhood social and material causes are far less compelling. The persistence of socioeconomic health differentials into the materially better-off social strata and the possible determining role of relative as well as absolute living standards suggest that psychological, in addition to material, variables are likely to be involved. Isolating the key psychological variables and identifying the nature of their influences will not be easy tasks, although social relations, psychological stress, uplifts, and control have emerged as possible candidates. However, psychological mediators of this sort most probably constitute surface rather than basic causes. Socio-economic inequality, it is contended, remains the basic cause, and, as such, the proper target for intervention. Psychological interventions are unlikely to yield much in the way of dividends in this context and indeed could inadvertently contribute to victim blaming.     

Mental health,self-esteem,and influences on sexual values and attitudes among black South African adolescent males

This study investigated the relationships between sexual values and attitudes, self-esteem, and mental health among black South African adolescents. Adolescent males (n = 522) aged between 13 and 21 years participated in the study. They completed the Mathteck Sexuality Questionnaire for Adolescents: Attitude and Value Inventory, the Rosenburg Self-esteem Scale, and the Mental Health Continuum. Structural Equation Modelling (Mplus 7.31) was computed to identify an explanatory model for sexual values and attitudes as correlated to self-esteem and mental health of black adolescent males. Results suggest the youth's self-esteem significantly mediate the relationship between mental health and sexual values and attitudes. Specifically, mental health had indirect effects on values about sexuality and on healthy attitudes towards aspects of intimacy, through the teenagers’ self-esteem.     

Work attitudes, employment barriers, and mental health symptoms in a sample of rural welfare recipients

Most of the extant research on welfare reform has neglected to consider the experiences of families in rural settings. Fifty women receiving welfare for their dependent children in a rural community were interviewed about their work experiences and aspirations, barriers to employment and service use, as well as mental health and social support. The findings indicate that the majority of participants were connected to the labor force and expressed positive attitudes about work. Barriers to employment (lack of available jobs, child care) and service use (transportation, inconvenient office hours) were endorsed. Perceived social support was negatively related to depression symptoms and positively related to self-efficacy and self-esteem. The importance of understanding the life experiences of welfare recipients in different contexts is discussed.     

Positive affective processes underlie positive health behaviour change

Positive health behaviours such as physical activity can prevent or reverse many chronic conditions, yet a majority of people fall short of leading a healthy lifestyle. Recent discoveries in affective science point to promising approaches to circumvent barriers to lifestyle change. Here, we present a new theoretical framework that integrates scientific knowledge about positive affect with that on implicit processes. The upward spiral theory of lifestyle change explains how positive affect can facilitate long-term adherence to positive health behaviours. The inner loop of this spiral model identifies nonconscious motives as a central mechanism of behavioural maintenance. Positive affect experienced during health behaviours increases incentive salience for cues associated with those behaviours, which in turn, implicitly guides attention and the everyday decisions to repeat those behaviours. The outer loop represents the evidence-backed claim, based on Fredrickson’s broaden-and-build theory, that positive affect builds a suite of endogenous resources, which may in turn amplify the positive affect experienced during positive health behaviours and strengthen the nonconscious motives. We offer published and preliminary evidence in favour of the theory, contrast it to other dominant theories of health behaviour change, and highlight attendant implications for interventions that merit testing.