Resisting Moralisation in Health Promotion

Health promotion efforts are commonly directed towards encouraging people to discard ‘unhealthy’ and adopt ‘healthy’ behaviours in order to tackle chronic disease. Typical targets for behaviour change interventions include diet, physical activity, smoking and alcohol consumption, sometimes described as ‘lifestyle behaviours.’ In this paper, I discuss how efforts to raise awareness of the impact of lifestyles on health, in seeking to communicate the (perceived) need for people to change their behaviour, can contribute to a climate of ‘healthism’ and promote the moralisation of people’s lifestyles. I begin by summarising recent trends in health promotion and introducing the notion of healthism, as described by Robert Crawford in the 1980s. One aspect of healthism is moralisation, which I outline (alongside the related term moralism) and suggest is facilitated by efforts to promote health via information provision and educational strategies. I propose that perceived responsibility plays a role in mediating the tendency to moralise about health and behaviour. Since I argue that states ought to avoid direct and indirect moralisation of people’s health-related behaviour, this suggests states must be cautious with regard to the use of responsibility-indicating interventions (including informational and educational campaigns) to promote health.     

Concordance between patients' information preferences and general practitioners' perceptions

Brief planning interventions, usually delivered within paper and pencil questionnaires, have been found to be effective in changing health behaviours. Using a double-blind randomised controlled trial, this study examined the efficacy of two types of planning interventions (action plans and coping plans) in increasing physical activity levels when they are delivered via the internet. Following the completion of self-reported physical activity (primary outcome) and theory of planned behaviour (TPB) measures at baseline, students (N = 1273) were randomised into one of four conditions on the basis of a 2 (received instructions to form action plans or not) × 2 (received instructions to form coping plans or not) factorial design. Physical activity (primary outcome) and TPB measures were completed again at two-month follow-up. An objective measure (attendance at the university's sports facilities) was employed 6 weeks after a follow-up for a duration of 13 weeks (secondary outcome). The interventions did not change self-reported physical activity, attendance at campus sports facilities or TPB measures. This might be due to low adherence to the intervention protocol (ranging from 58.8 to 76.7%). The results of this study suggest that the planning interventions under investigation are ineffective in changing behaviour when delivered online to a sample of participants unaware of the allocation to different conditions. Possible moderators of the effectiveness of planning interventions in changing health behaviours are discussed.     

Family characteristics and health behaviours of adolescents and families

Abstract

The relationship between general family characteristics, represented by family cohesion and adaptability, and health behaviours (smoking, alcohol use, food choice, sleeping, Body Mass Index, and physical activity) is studied in a first study of 429 adolescents and young adults, and in a second study of 522 family triads (adolescent-mother-father). Using cluster analysis, adolescent groups with four different profiles of health behaviour were identified. Very similar results were found in the two studies. The health behaviour patterns in the different subgroups show that forms of (un)desirable health behaviours are interrelated in some clusters. Adolescents in the most healthy clusters, consistently reported highest levels of family cohesion. The relationship between family adaptability and health behaviours showed only limited significance. In families characterised by a high level of emotional bonding between family members together with stability and regularity in roles rules and power structure, adolescents' behaviour is the most healthy. The findings suggest that parental involvement is desirable in health promotion intervention. Further, it seems possible that health behaviours originate from a relatively small set of family Characteristics and that modifying family interactions might be powerful, albeit very difficult to do so, in changing a variety of health behaviours in adolescents.     

Behaviour change among overweight and socially disadvantaged adults: A longitudinal study of the NHS Health Trainer Service

Social disadvantage is associated with being overweight, a poor diet and physical inactivity. The NHS Health Trainer Service (HTS) is a national initiative designed to promote behaviour change among socially disadvantaged people in England and Wales. This study reports pre–post changes in Body Mass Index (BMI), associated behaviours and cognitions among service users who set dietary or physical activity goals during a 12-month period (2008–2009; N?=?4418). Sixty-nine percent of clients were from the two most deprived population quintiles and 94.7% were overweight or obese. Mean BMI decreased from 34.03 to 32.26, with overweight/obesity prevalence decreasing by 3.7%. There were increases in fruit and vegetable consumption, reductions in fried snack consumption, increases in frequency of moderate or intensive activity and gains in self-efficacy and perceived health and wellbeing. Clients with higher BMI, poorer diet or less activity at baseline achieved greater change. Findings suggest that the NHS HTS has the potential to improve population health and reduce health inequalities through behaviour change.     

Behaviour change among overweight and socially disadvantaged adults: a longitudinal study of the NHS Health Trainer Service

Social disadvantage is associated with being overweight, a poor diet and physical inactivity. The NHS Health Trainer Service (HTS) is a national initiative designed to promote behaviour change among socially disadvantaged people in England and Wales. This study reports pre-post changes in body mass index (BMI), associated behaviours and cognitions among service users who set dietary or physical activity goals during a 12-month period (2008-2009; N?=?4418). Sixty-nine percent of clients were from the two most deprived population quintiles and 94.7% were overweight or obese. Mean BMI decreased from 34.03 to 32.26, with overweight/obesity prevalence decreasing by 3.7%. There were increases in fruit and vegetable consumption, reductions in fried snack consumption, increases in frequency of moderate or intensive activity and gains in self-efficacy and perceived health and wellbeing. Clients with higher BMI, poorer diet or less activity at baseline achieved greater change. Findings suggest that the NHS HTS has the potential to improve population health and reduce health inequalities through behaviour change.     

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.     

Are exercise social-cognitive factors and behaviours different for adults with diabetes? A randomized community sample

Exercise plays a key role in the prevention and delay of the onset of Type 2 diabetes and in the management of this disorder. To determine if there are differences in key social-cognitive determinants of exercise and self-reported physical activity levels between adults with diabetes and those without the condition, a random selected sample of adults was surveyed. A telephone interview assessed physical activity behaviour and key social-cognitive constructs from major health behaviour change theories/models. The mean energy expenditure was not significantly different between the diabetes (n?=?46) and the non-diabetes (n?=?1556) groups. The diabetes group reported significantly lower scores for self-efficacy and perceived behavioural control, but higher for fear of, and vulnerability to, general health and cardiovascular disease threat. The data suggest that it may not be necessary to promote health threat messages, as threat is already high for this diabetes population and studies have shown that excess threat does not promote recommended exercise and health behaviours. Instead, the low levels of self-efficacy and perceived behavioural control among those with diabetes emphasize the importance of designing specific strategies (e.g., skills, incremental success) to increase their self-confidence in undertaking physical activity.     

Investigating the predictive validity of implicit and explicit measures of motivation on condom use,physical activity and healthy eating

The literature on health-related behaviours and motivation is replete with research involving explicit processes and their relations with intentions and behaviour. Recently, interest has been focused on the impact of implicit processes and measures on health-related behaviours. Dual-systems models have been proposed to provide a framework for understanding the effects of explicit or deliberative and implicit or impulsive processes on health behaviours. Informed by a dual-systems approach and self-determination theory, the aim of this study was to test the effects of implicit and explicit motivation on three health-related behaviours in a sample of undergraduate students (N?=?162). Implicit motives were hypothesised to predict behaviour independent of intentions while explicit motives would be mediated by intentions. Regression analyses indicated that implicit motivation predicted physical activity behaviour only. Across all behaviours, intention mediated the effects of explicit motivational variables from self-determination theory. This study provides limited support for dual-systems models and the role of implicit motivation in the prediction of health-related behaviour. Suggestions for future research into the role of implicit processes in motivation are outlined.     

Investigating the predictive validity of implicit and explicit measures of motivation on condom use, physical activity and healthy eating

The literature on health-related behaviours and motivation is replete with research involving explicit processes and their relations with intentions and behaviour. Recently, interest has been focused on the impact of implicit processes and measures on health-related behaviours. Dual-systems models have been proposed to provide a framework for understanding the effects of explicit or deliberative and implicit or impulsive processes on health behaviours. Informed by a dual-systems approach and self-determination theory, the aim of this study was to test the effects of implicit and explicit motivation on three health-related behaviours in a sample of undergraduate students (N?=?162). Implicit motives were hypothesised to predict behaviour independent of intentions while explicit motives would be mediated by intentions. Regression analyses indicated that implicit motivation predicted physical activity behaviour only. Across all behaviours, intention mediated the effects of explicit motivational variables from self-determination theory. This study provides limited support for dual-systems models and the role of implicit motivation in the prediction of health-related behaviour. Suggestions for future research into the role of implicit processes in motivation are outlined.     

Stability and changes in health behaviours in young adults over a one year period

Abstract

Data concerning 19 health-related behaviours and associated beliefs were collected by questionnaire from 282 students in the Netherlands on two occasions over one year. While all behaviours showed moderate stability, there were variations in the degree of change. The highest stability was reported for sleep time, tooth brushing frequency, seat belt usage and health care service utilization. The least stable behaviours included regular exercise and various dietary measures. Predictors of changes in smoking, dietary fat intake, alcohol consumption and regular exercise were analysed in detail. Beliefs assessed at year 1 in the importance of these activities for health predicted changes in behaviour over the study year independently of prior behaviour levels. Awareness of the risks associated with behaviours, and explicit wishes to modify behaviour patterns (eg stop smoking, exercise more), did not predict change from year 1 to year 2. The results indicated that health behaviours vary in their stability, and that health beliefs may predict future health behaviour changes.     

Adoption of community-based cardiac rehabilitation programs and physical activity following phase III cardiac rehabilitation in Scotland: A prospective and predictive study

Little is known about levels of physical activity and attendance at phase IV community-based Cardiac Rehabilitation (CR) programs following completion of exercise-focussed, hospital-based phase III CR. This study aims to test, compare and combine the predictive utility of the Common-Sense Self-Regulation Model (CS-SRM) and the extended Theory of Planned Behaviour (TPB) with action planning for two rehabilitation behaviours: physical activity and phase IV CR attendance. Individuals diagnosed with coronary heart disease (n = 103) completed baseline measures of illness perceptions, intentions, perceived behavioural control (PBC), action planning and past physical activity in the last week of a phase III CR program, and 95 participants completed follow-up measures of physical activity and attended phase IV CR (objectively confirmed) 2 months later. Only one predictor (PBC/cyclical timeline) significantly predicted levels and change of physical activity. While illness perceptions were not predictive of phase IV CR attendance, the extended TPB model showed good predictive power with action planning and intention as the most powerful predictors. Amongst participants who planned when and where to attend phase IV CR at the end of phase III rehabilitation, 65.9% subsequently attended a phase IV CR program compared to only 18.5% of those who had not made a plan. This study adds to our understanding of cardiac rehabilitation behaviour after completion of health service delivered programs. Comparing theoretical models and rehabilitation behaviours contributes to the development of behaviour theory.     

Health performance of individuals within the Campbell paradigm

In this paper, we developed a comprehensive health performance measure that formally links individual health attitudes with the likelihood of engaging in a wide variety of health‐related behaviours from various domains such as sustenance, hygiene, and physical exercise. Within what Kaiser, Byrka, and Hartig (2010) call the Campbell paradigm, we equated general health attitude with what a person does to retain or promote his or her health. Thus, health behaviours, on one hand, were expected to form a homogeneous, transitively ordered class of behaviours. On the other hand, the very behavioural class was in turn thought to be the basis from which an individual's health attitude could be directly assessed. A sample of 391 adults provided us with survey data containing different sets of health behaviours as well as variables and personality measures that had been corroborated as health‐behaviour relevant in previous research. We found that self‐reports of 50 behaviours and expressions of appreciation for 20 of these behaviours from various domains formed a transitively ordered class of activities. In contrast to the conventional view in health psychology, in which attitudes are regarded as a psychological cause behind individual behaviour, and in contrast to conventional findings in health psychology, where behaviours appear to fall into numerous sets of more or less distinct domains of health‐enhancing activities (e.g., exercising or avoiding risks), our findings speak of the psychological and formal unity of health behaviour. Inevitably, attitude measures grounded in the Campbell paradigm gauge individual attitudes, and just as much, they measure the health performance of individuals.     

Exploring cues to sedentary behaviour as processes of physical activity action control

ObjectiveUnderstanding intention–behaviour relations is important in physical activity (PA) research given the large number of people who intend to be active but fail to translate these intentions into behaviour. The purpose of this study was to evaluate whether processes/cues for popular sedentary leisure-time behaviours and PA explain additional variance in PA behaviour after controlling for PA intention, and to evaluate whether these processes moderate PA intention–behaviour relations.DesignRandom population-based cross-sectional survey.MethodsParticipants were a random sample of 206 adults who completed measures of the processes of change pertaining to physical activity and four popular leisure-time behaviours (TV viewing, computer use, sedentary hobbies, and sedentary socializing) and an adapted Godin Leisure-Time Exercise Questionnaire.ResultsResults using hierarchical ordinary least-squares regression provided evidence that cognitive TV processes explain additional variance in PA behaviour and moderate PA intention–behaviour relations.ConclusionsThese results extend the prior literature on relationships between sedentary cognitions and physical activity and underscore the potential value of adding sedentary control interventions in concert with physical activity promotion.     

Predicting physical activity in adolescents: The role of compensatory health beliefs within the Health Action Process Approach

Objective: Compensatory health beliefs (CHBs), defined as beliefs that healthy behaviours can compensate for unhealthy behaviours, may be one possible factor hindering people in adopting a healthier lifestyle. This study examined the contribution of CHBs to the prediction of adolescents’ physical activity within the theoretical framework of the Health Action Process Approach (HAPA).

Design: The study followed a prospective survey design with assessments at baseline (T1) and two weeks later (T2).

Method: Questionnaire data on physical activity, HAPA variables and CHBs were obtained twice from 430 adolescents of four different Swiss schools. Multilevel modelling was applied.

Results: CHBs added significantly to the prediction of intentions and change in intentions, in that higher CHBs were associated with lower intentions to be physically active at T2 and a reduction in intentions from T1 to T2. No effect of CHBs emerged for the prediction of self-reported levels of physical activity at T2 and change in physical activity from T1 to T2.

Conclusion: Findings emphasise the relevance of examining CHBs in the context of an established health behaviour change model and suggest that CHBs are of particular importance in the process of intention formation.     

Health-related behaviour and personality trait development in adulthood

This investigation explored the contribution of a healthy lifestyle to personality trait stability and change during adulthood. A nationally representative sample of 11,133 Australian adults completed self-report measures of health-related behaviour and personality traits at baseline (2010) and again four years later (2014). Results showed that physical activity and alcohol intake, and to a lesser extent diet and cigarette smoking, were important for mean-level change and intra-individual stability of personality for all trait dimensions. Moreover, positive health behaviours were associated with less of a decrease in extraversion and more of an increase in openness, agreeableness and conscientiousness over four years.These findings suggest that healthy living might help to facilitate desirable personality trait stability and change during adulthood.     

‘I feel better when…’: An analysis of the memory-experience gap for peoples’ estimates of the relationship between health behaviours and experiences

Objective: People often overestimate how strongly behaviours and experiences are related. This memory-experience gap might have important implications for health care settings, which often require people to estimate associations, such as “my mood is better when I exercise”. This study examines how subjective correlation estimates between health behaviours and experiences relate to calculated correlations from online reports and whether subjective estimates are associated with engagement in actual health behaviour.

Design: Seven-month online study on physical activity, sleep, affect and stress, with 61 online assessments.

Main Outcome Measures: University students (N = 168) retrospectively estimated correlations between physical activity, sleep, positive affect and stress over the seven-month study period.

Results: Correlations between experiences and behaviours (online data) were small (r = ?.12–.14), estimated correlations moderate (r = ?.35–.24). Correspondence between calculated and estimated correlations was low. Importantly, estimated correlations of physical activity with stress, positive affect and sleep were associated with actual engagement in physical activity.

Conclusion: Estimation accuracy of relations between health behaviours and experiences is low. However, association estimates could be an important predictor of actual health behaviours. This study identifies and quantifies estimation inaccuracies in health behaviours and points towards potential systematic biases in health settings, which might seriously impair intervention efficacy.     

Beyond good intentions: The role of proactive coping in achieving sustained behavioural change in the context of diabetes management

This study examines the effectiveness of a brief self-management intervention to support patients recently diagnosed with type-2 diabetes to achieve sustained improvements in their self-care behaviours. Based on proactive coping, the intervention emphasizes the crucial role of anticipation and planning in maintaining self-care behaviours. In a randomised controlled trial among recent screen-detected patients, participants who received the intervention were compared with usual-care controls, examining changes in proximal outcomes (intentions, self-efficacy and proactive coping), self-care behaviour (diet, physical activity and medication) and weight over time (0, 3 and 12 months). Subsequently, the contribution of proactive coping in predicting maintenance of behavioural change was analysed using stepwise hierarchical regression analyses, controlling for baseline self-care behaviour, patient characteristics, and intentions and self-efficacy as measured after the course. The intervention was effective in improving proximal outcomes and behaviour with regard to diet and physical activity, resulting in significant weight loss at 12 months. Furthermore, proactive coping was a better predictor of long-term self-management than either intentions or self-efficacy. Proactive coping thus offers new insights into behavioural maintenance theory and can be used to develop effective self-management interventions.     

Post-traumatic stress disorder and health risk behaviour among persons 15 years and older in South Africa

The aim of this study was to investigate the association between post-traumatic stress disorder (PTSD) and health risk behaviours among persons 15 years and older in South Africa. We analysed data from the South African National Health and Nutrition Examination Survey (SANHANES-1, 2012) (N = 15 201; mean age = 36.9 years, SD = 16.5; 2.1% with PSTD, 4.0% with partial PTSD). The survey included questions from validated measures of the following health risk behaviours: problem drinking, current tobacco use, physical activity, sedentary behaviour, vegetable consumption, and fast food and frequent soft drinks consumption. In adjusted logistic regression analysis, only self-reporting with PTSD was associated with problem drinking. The data did not yield significant association between PTSD status and any of the other health risk behaviours (tobacco use, low physical activity, and fast food consumption).     

Predictors of physical activity,healthy eating and being smoke-free in teens: A theory of planned behaviour approach

This paper elicited context specific underlying beliefs for physical activity, fruit and vegetable consumption and smoke-free behaviour from the Theory of Planned Behaviour (TPB), and then determined whether the TPB explained significant variation in intentions and behaviour over a 1 month period in a sample of grade 7–9 (age 12–16 years) adolescents. Eighteen individual interviews and one focus group were used to elicit student beliefs. Analyses of this data produced behavioural, normative and control beliefs which were put into a TPB questionnaire completed by 183 students at time 1 and time 2. The Path analyses from the main study showed that the attitude/intention relationship was moderately large for fruit and vegetable consumption and small to moderate for being smoke free. Perceived behavioural control had a large effect on being smoke free and a moderately large effect for fruit and vegetable consumption and physical activity. Intention had a large direct effect on all three behaviours. Common (e.g. feel better, more energy) and behaviour-specific (e.g., prevent yellow fingers, control my weight) beliefs emerged across the three health behaviours. These novel findings, to the adolescent population, support the importance of specific attention being given to each of the behaviours in future multi-behavioural interventions.     

Is anxiety about health associated with desire to exercise, physical activity, and exercise dependence?

There are significant gaps in the literature regarding the behavioural consequences of health anxiety. Although past research indicates that health anxiety is associated with distinctive maladaptive behaviours, such as reassurance seeking, the relationship between health anxiety and wellness-related behaviours, such as physical activity, has not been adequately examined. Given that health anxiety is associated with excessive attempts to ensure health and avoid illness, health anxiety could be potentially related to extreme physical activity, known as exercise dependence. Using the cognitive behavioural model of health anxiety as a framework, this exploratory study investigated the relationships between health anxiety, exercise desire, physical activity, and exercise dependence.Undergraduate university students (n = 144) completed a battery of online measures. Results indicated that only the perceptual component of health anxiety, namely hypervigilance to somatic symptoms, was related to exercise desire and components of exercise dependence. Implications of the findings are discussed and future research avenues are explored.