The Health Belief Model and the Transtheoretical Model: Similarities and Differences Similarities

Both models aim to determine what it takes for people to protect themselves from illness (Clemow, 2004) and to understand, predict, and affect individual's health behaviors and the ability to change (Glanz, Rimer, Viswanath, 2008). The Health Belief Model (HBM) is a cognitively based model that focuses on mental processes as they pertain to changes in health behaviors. It does not concern itself with the emotional component of health behaviors. The Transtheoretical Model, however, is concerned with the behavioral aspect of health behavior change, specifically the attitudinal stages of awareness or readiness of the individual (Glanz et al., 2008; Rossi, 2004). Both models focus on awareness, although the HBM focuses on constructs that promote change and TTM focuses on attitude and belief stages that are antecedent in the ability to change. Both models take self-efficacy into account.

Differences

Whereas the HBM focuses on perceived risks and self-efficacy, the TTM concerns itself with readiness to perceive. Interventions based on HBM and TTM both focus on creating awareness, although HBM is cognitively based, and TTM is behavior-oriented (Clemow, 2004; Glanz et al., 2008; Rossi, 2004).

Whereas TTM uses stages and experiences of individuals placed into discrete categories, the HBM uses value-based constructs that are not discrete but are easily perceived on a continuum (Berg, 2004). The HBM focuses on generally applied interventions whereas the TTM is concerned with individually tailored interventions (Berg, 2004). The TTM, however, must take into account the individual's stage prior to educating them. The TTM is based on individual readiness and the HBM is concerned with individual attitudes and beliefs (Glanz et al., 2008). Brug (2004) believed that HBM is evidence-based whereas TTM is social or culturally-based.

TTM assumes interventions should be prescribed according to individual readiness, whereas HBM claims generally prescribed interventions will affect most individuals. HBM argues that behavior reflects perceived values whereas TTM claims that behavior reflects readiness to respond (Glanz et al., 2008).

Examples of Models in Practice
For example, the HBM theorizes that individuals will be prompted to take action according to value placed on illness, susceptibility, and their ability to avoid the illness. For example, in the case of women's cancer screening, a woman must perceive the actual threat of breast cancer, that the cancer can be avoided by breast cancer screening, and that she is capable of accessing the resource of screening at her local clinic, which may include remembering the appointment, having the financial resources to pay for the screening, driving herself to the clinic, and not being afraid of the procedure (Aşcı, & Şahin, 2011).

The TTM may be better utilized in a population that has limited to no understanding of a particular disease and its prevalence in the population. Using the same example, women in some populations may not be aware of the risk of breast cancer (the precontemplation stage), so women did not consider preventive screenings. In the second stage of contemplation, women have become aware that there is a risk they may have breast cancer at some point in their lives and began to think about being screened at their local clinic. In the Preparation stage, women are ready to take action because they understand the importance of making changes to their behavior. They may discuss their choice to change with close friends and family. During the maintenance stage, women are well aware of their susceptibility to breast cancer, but must be reminded to maintain their regular screening routine (Glanz et al., 2008).

Although many scientists believe there is a paucity of research on the use of TTM, others believe it is effective for changing some health behaviors (Velicer, Redding, Sun, & Prochaska, 2007) Other research, however, suggested TTM-based interventions were no more effective than HBM-based interventions (Riemsma et al., 2003). Eisen (1992) suggested gender differences and other variables may make one model more effective than the other in different circumstances.

References

Aşcı, Ö., & Şahin, N. (2011). Effect of the Breast Health Program Based on Health Belief Model on Breast Health Perception and Screening Behaviors. Breast Journal, 17(6), 680-682. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1111/j.1524-4741.2011.01143.x

Brug, J. (2004). The Transtheoretical Model and stages of change: A critique: Observations by five Commentators on the paper by Adams, J. and White, M. (2004) Why don't stage-based activity promotion interventions work? Health Education Research, 20(2), 244-258. doi: 10.1093/her/cyh005

Clemow, L. (2004). Health belief model. In N. Anderson (Ed.), Encyclopedia of health and behavior. (pp. 390-393). Thousand Oaks, CA: SAGE Publications, Inc. doi: 10.4135/9781412952576.n113

Eisen, M et.al. (1992). A Health Belief Model — Social Learning Theory Approach to Adolescents' Fertility Control: Findings from a Controlled Field Trial. Health Education Quarterly. Vol. 19.

Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health behavior and health education: Theory, research, and practice (4th ed.). San Francisco, CA: Jossey-Bass.

Velicer, W. F., Redding, C. A., Sun, X., & Prochaska, J. O. (2007). Demographic variables, smoking variables, and outcome across five studies. Health Psychology, 26, 278-287.

Riemsma, R. P., Pattenden, J., Bridle, C., Sowden, A.J., Mather, L., Watt, I. S., Walker, A. (2003). Systematic review of the effectiveness of stage based interventions to promote smoking cessation. British Medical Journal 326(7400), 1175–1177. doi: 10.1136/bmj.326.7400.1175

Rossi, J. (2004). Transtheoretical model of behavior change. In N. Anderson (Ed.), Encyclopedia of health and behavior. (pp. 719-722). Thousand Oaks, CA: SAGE Publications, Inc. doi: 10.4135/9781412952576.n211

The Pervasive Nature of Bias

The potential for bias from the above mentioned researcher certainly exists. Religious and spiritual beliefs are often deeply-rooted and writers may unknowingly use language that makes unfair assumptions about individuals, cultures, or contexts. The APA (2010) warns researchers and scholars that their beliefs, worldviews, and attitudes are tremendously influential, even when they are well aware of their bias, and they should be diligent in working toward fairness in their research and writing. According to Stewart and Bennett (2006), people tend to believe in the superiority of their personal beliefs, whether religious, cultural, or contextual. Further, they often unconsciously measure others by their own norms and expectations (Stewart & Bennett, 2006). It will be important for the researcher to be mindful of basing the review solely on empirically derived information and refrain from showing partiality or perpetuating any demeaning attitude. The APA (2010) advises writers against extraneous evaluation of any individual or group. The researcher will have to make a deliberate attempt to refrain from bias and personal opinion.

Creswell (2009) advises researchers to be aware of potential bias and other ethical issues in data analysis and interpretation. The potential to fail to include relevant information, misconstrue data, or fail to maintain objectivity because of intrinsic bias is a fraudulent use of one's influence as a researcher and is considered unethical and is regarded as scientific misconduct (Creswell, 2009).

References

American Psychological Association. (2010). Publication manual of the American Psychological Association (6th Edition). Washington, DC: Author.

Creswell, J. (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd ed.). Thousand Oaks, CA: Sage Publications.

Stewart, E. C., & Bennett, M. J. (2006). American cultural patterns: a cross-cultural perspective. Yarmouth, ME: Intercultural Press.

Theory and Behavior Change

Several factors exist that may increase or decrease an individual's chances of changing negative health behaviors. Additionally, a variety of motivations may initiate behavioral changes. The goal of this paper is to describe factors that instigate negative and positive health behaviors and the influences that motivate an individual to change. In addition, it will explain the role of theory in the development of health behavior interventions.

Altering the Chances for Change

Negative health behaviors are usually coping behaviors initiated because of an underlying inability to cope with stress (Glanz, Rimer, & Viswanath, 2008). Having adequate social support and a supportive and encouraging environment increase an individual's chances of maintaining long-term positive changes in health behavior (Glanz et al., 2008). Isolation and a sense of personal vulnerability decreases self-efficacy and the opportunity to instigate lasting behavior change. Further, individuals usually need constant reinforcement (from a support system) of strategies that help maintain self-efficacy, and the perceived ability to manage stress.

When individuals perceive their circumstances as beyond their control, they experience a decrease in self-control and self-efficacy. Negative perceptions of personal circumstances, or subjective psychological burden, initiates a cycle of negative health behavior and a lack of self-care. (Schwarzer & Luszczynska, 2008). If individuals initiate negative health behaviors because of stress, changing their perception of the stress (or their psychological burden) may contribute to an increase in self-control and self-efficacy (Gräßel & Adabbo, 2011).

Motivating Change

Descriptive Norm Information

Burger and Shelton (2011) found that presenting individuals with descriptive norm information changed their behavior. For example, Burger and Shelton installed a sign near the building elevators that explained more people used the stairs rather than the elevator. After reading the sign, a significant number of people began using the stairs (Burger & Shelton, 2011). Similar research by Cialdini, Reno, and Kallgren (1990) found individuals behave according to expected and established norms. Applying this concept to health behaviors may instigate systemic changes in large populations by establishing and utilizing readily available norms, in effect, manipulating the normal expectations for the individuals (Burger & Shelton, 2011). As individuals initiate behavioral change, they establish new norms for behavior, which will reinforce the change. Utilizing this concept, it may be possible to change health behaviors by establishing norms that suggest most people do not smoke, or participate in whichever health behavior needs change (Burger & Shelton, 2011).

Changing Self-Perceptions

Changes in self-perception have been shown to motivate change. Cognitive strategies that increase self-control and self-efficacy have been proven effective for managing emotions and decreasing negative behaviors and thought patterns that are often established in chronically stressful circumstances. Perceived self-efficacy and other cognitive strategies facilitate behavioral change when intentions alone fail to promote successful outcomes (Schwarzer & Luszczynska, 2008). Wood and Neal (2007) suggested changing one's environment and consequently the cues for negative behaviors may lead to creating positive behaviors. By removing the psychological triggers for negative behavior, behavior is changed (Wood & Neal, 2007). Schwarzer and Luszczynska (2008) found individually tailored interventions were more effective than generic solutions.

The Role of Theory in Interventions
Interventions designed for changing health behaviors are far more effective when they are
informed by theory (Glanz et al., 2008). The combination of research and theory and the information they provide in practice contribute to the effective implementation of strategies that create sustained behavior change (Glanz et al., 2008). Theory is the conceptual framework foundational in the practical implementation of interventions successful in changing health behavior, and is a critical component of explaining and predicting health behaviors (Lippke & Ziegelmann, 2008). For example, before psychologists can predict changes in behavior, they must first understand the primary drive of the behavior. Theory can elaborate on these motivating factors and explicate techniques that may be used to instigate change (Lippke & Ziegelmann, 2008).

Theory-based interventions are a critical component of promoting long-term change in health behavior. Its importance, however, exists in the translation of theory into practice. As a greater number of theories are introduced and implemented in practice, empirical evidence is needed to determine that theory-based interventions are, in fact, superior (Bhattacharyya, Reeves, Garfinkel, & Zwarenstein, 2006). For example, in the field of mental health counseling, various theories and approaches claim superior effectiveness, yet Wampold (2001) determined that most modalities were effective, but none were necessarily superior.

Conclusion

Cognitive strategies have proven effective in altering perception and habit. Additionally, providing positive self-perceptions promotes self-control and self-efficacy which are central to establishing positive health behaviors. Theory provides a foundational conceptual framework for research, which ultimately determines the effectiveness of theoretical applications in practice.

References

Bhattacharyya, O., Reeves, S., Garfinkel, S., & Zwarenstein, M. (2006). Designing theoretically- informed implementation interventions: Fine in theory, but evidence of effectiveness in practice is needed. Implementation Science, 15-3. doi:10.1186/1748-5908-1-5

Burger, J. M., & Shelton, M. (2011). Changing everyday health behaviors through descriptive norm manipulations. Social Influence, 6(2), 69-77. doi:10.1080/15534510.2010.542305

Cialdini, R. B., Reno, R. R., & Kallgren, C. A. (1990). A focus theory of normative conduct: Recyling the concept of norms to reduce littering in public places. Journal of Personality and Social Psychology, 58, 1015–1026.

Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health behavior and health education: Theory, research, and practice (4th ed.). San Francisco, CA: Jossey-Bass.

Gräßel, E., & Adabbo, R. (2011). Perceived burden of informal caregivers of a chronically ill older family member: Burden in the context of the transactional stress model of Lazarus and Folkman. Geropsych: The Journal Of Gerontopsychology And Geriatric Psychiatry, 24(3), 143-154. doi:10.1024/1662-9647/a000042

Lippke, S., & Ziegelmann, J. P. (2008). Theory-Based Health Behavior Change: Developing, Testing, and Applying Theories for Evidence-Based Interventions. Applied Psychology: An International Review, 57(4), 698-716. doi:10.1111/j.1464-0597.2008.00339.x

Schwarzer, R., & Luszczynska, A. (2008). How to overcome health-compromising behaviors: The health action process approach. European Psychologist, 13(2), 141-151. doi:10.1027/1016-9040.13.2.141

Wampold, B. E. ( 2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum.

Wood, W., & Neal, D. T. (2007). A new look at habits and the habit-goal interface. Psychological Review, 114(4), 843–863.

Aligning Philosophies

I agree with Creswell’s (2009) alignment of philosophies as long as the alignments are recognized, as Creswell discussed, as a guide for tendencies, not as binding rules. Various aspects of exploration, such as the research design, the issue of study, the researcher’s experiences and philosophy of science, all contribute to the choice of the research design.

Empiricism

I align empiricism with quantitative approaches, because empiricism deals with absolute truths, which can be better facilitated and explained by quantitative methods (Creswell, 2009), although empiricism may be applied to qualitative exploration as well. Quantitative approaches often deal with numerical data or quantities, as the name suggests. A long-standing belief held that empiricism was the only true science because it concerned itself with absolutes rather than subjective knowledge, meaning, or inference (Hammersley, 2004). I agree with Hammersley (2004) that although some empiricists argue that empirical or numerical data are irrefutable, no data exists that is not impervious to change or a shift in paradigm that more accurately identifies and explains traditionally accepted evidence. As paradigms shift, empirical findings can change or become obsolete (Creswell, 2009). Additionally, as science finds new ways of assessment, even the most exact data may be perceived differently. Hammersley notes that evidence that may not be observed or quantified can have value, although the narrow perspective of empiricism may not lean toward this belief.

Interpretism

Interpretism, which is closely aligned with constructivism seems to be most accurately aligned with qualtitative research design or may be used as part of a mixed methods approach (Blaikie, 2004; Creswell, 2009). Interpretism concerns itself with placing personal or subjective value into findings and creating meaning. It makes inferences and interpretations about data. It tends to examine personal or subjective meaning rather than numerical or absolute data (Creswell, 2009). Blaikie (2004) described interpretism as a social study rather than the empirical study of nature. As the study of people and human nature, it seems logical and appropriate that interpretism would be best expressed through qualitative research design.

Critical Theory

Critical theory aligns best with qualitative approaches, although may provide data for the quantitative approach (Creswell, 2009). Because critical theory concerns itself with disenfranchised or marginalized peoples and seeks to instigate change or transcendence of established challenges of these peoples (Creswell, 2009), a qualitative approach could determine the subjective experiences of the people and make inferences and suppositions that may contribute to change. May (2004) expanded critical theory's history to include Freud's identification and development of self-misunderstanding as a critical part of social theory. When exploring the intrinsic self beliefs of individuals, it makes sense that critical theory would ordinarily utilize qualitative approaches for its consideration of subjective and personal narrative (Creswell, 2009). It seems important to note, however, that the information gained through critical theory may provide data for a mixed methods or quantitative approach because it concerns itself with the interplay of theory and facts (May, 2004).

In Conclusion

In sum, although tendencies exist for specific types of exploration as it relates to methods and approaches, the lines should not be considered as binding limits for research design, only a loose guideline suggesting common tendencies. It seems important to understand that it is improbable that a scientist can begin research prior to committing to an ontology and an epistemology because these overarching perspectives contribute to the appropriate research approach (Scotland, 2012).


References

Blaikie, N. (2004). Interpretivism. In M. Lewis-Beck, A. Bryman, & T. Liao (Eds.), Encyclopedia of social science research methods. (pp. 509-511). Thousand Oaks, CA: SAGE Publications, Inc. doi: 10.4135/9781412950589.n442

Creswell, J. (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd ed.). Thousand Oaks, CA: Sage Publications.

Hammersley, M. (2004). Empiricism. In M. Lewis-Beck, A. Bryman, & T. Liao (Eds.), Encyclopedia of social science research methods. (pp. 307-308). Thousand Oaks, CA: SAGE Publications, Inc. doi: 10.4135/9781412950589.n277

May, T. (2004). Critical theory. In M. Lewis-Beck, A. Bryman, & T. Liao (Eds.), Encyclopedia of social science research methods. (pp. 224-225). Thousand Oaks, CA: SAGE Publications, Inc. doi: 10.4135/9781412950589.n198

Scotland, J. (2012). Exploring the Philosophical Underpinnings of Research: Relating Ontology and Epistemology to the Methodology and Methods of the Scientific, Interpretive, and Critical Research Paradigms. English Language Teaching, 5(9), 9-16. doi:10.5539/elt.v5n9p9

Older Adults as Caregivers to Spouses with Dementia

I have chosen the population of older adults who function as caregivers for spouses diagnosed with dementia. Typical negative health behaviors for this population include a decrease in exercise, inadequate sleep, unhealthy diets, excessive smoking, and alcohol consumption (Gallant & Connell, 1998). For the purposes of this discussion, I have chosen lack of exercise because evidence suggests caregivers are less active after a spouse's diagnosis of dementia (Gallant & Connell, 1998).

Caregiving to family members with dementia is emotionally and physically challenging, even in the best conditions (Rabinowitz, Mausbach, Atkinson & Gallagher-Thompson, 2009). Because of the tremendous personal burden of caregiving, it is not uncommon for caregivers to experience a decline in psychological and physiological health, usually because of a decrease in self-care. Lazarus and Folkman's coping paradigm determined that when individuals perceive their subjective burden as exceedingly challenging and beyond their control, they are prone to experiencing excessive stress, which affects psychological health (Gräßel & Adabbo, 2011). A decrease in psychological health and well-being provokes inadequate self-care, and this inadequacy has been associated with an increase in disabilities and mortality in older adults (Breslow & Breslow, 1993; Gallant & Connell, 1998).

Older adults are considered a vulnerable population because they have chronic conditions that demand a higher level of self-care, they are less mobile, have access to fewer resources, and suffer higher rates of depression (Remley & Herlihy, 2010). Maintaining a healthy exercise program while caregiving can be difficult for an older adult whose mobility may have already been compromised. Furthermore, the psychological burden of caregiving may decrease the ability to maintain normal routines (Gallant & Connell, 1998) and increase negative perceptions of the role of caregiving (Rabinowitz et al., 2008). Additionally, it can increase a sense of personal vulnerability and isolation, and decrease self-efficacy (Schwarzer & Luszczynska, 2008). All of these factors may increase the caregiver's subjective burden, which can contribute to a sense of self-inadequacy, which promotes inadequate self-care, in this case, failure to engage in physical exercise.

Lowering Subjective Burden

Changing negative health behaviors has significant implications for the continued care of the patient as well as for the caregiver (Rabinowitz et al., 2009). Failure to maintain caregivers' health undermines their ability to care for the ill family member and contributes to increased institutionalization (Rabinowitz et al., 2009). Health psychology can help this population by determining how to increase self-efficacy to lower the caregiver's subjective burden. Lowering the perception of subjective burden of caregiving may have a meaningful affect on caregivers by increasing psychological health and the impetus for self-care. For example, if caregivers receive adequate support, it may increase their coping skills and their ability to deal with their role as a caregiver, lowering their subjective burden, and changing their perspective that they can manage and perform their caregiver role effectively (Gallant & Connell, 1998; Rabinowitz et al., 2009; Schwarzer & Luszczynska, 2008). Support may be in the form of a support group, psychotherapy, or other assistance. As self-efficacy is increased, they will gain psychological well-being, which will, consequently incite their desire to care for themselves, in this case, develop and utilize an exercise routine.

Strategies

It has been shown that the use self-control strategies and increasing self-efficacy helps individuals contend with emotions, behavior and negative thought patterns typical in extremely challenging circumstances (Gallant & Connell, 1998; Schwarzer & Luszczynska, 2008). In sum, cognitive interventions that increase self-efficacy and self-control may help caregivers perceive their role differently. However, this may not be as simple as it sounds. Glanz, Rimer, and Viswanath (2008) claim changing and maintaining health behavior does not take place in a social vacuum. Older adult caregivers, like any other population may only instigate and maintain long-term change with adequate social support, an encouraging environment, and the continual reinforcement of effective strategies (Glanz, Rimer, & Viswanath, 2008).

References

Breslow, L. & Breslow, N., (1993). Health practices and disability: Some evidence from Alameda County. Preventive Medicine, 22, 86-95

Gallant, M. P., & Connell, C. M. (1998). The stress process among dementia spouse caregivers: are caregivers at risk for negative health behavior change? Research on Aging, 20(3), 267-297. doi: 10.1177/0164027598203001

Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health behavior and health education: Theory, research, and practice (4th ed.). San Francisco, CA: Jossey-Bass.

Gräßel, E., & Adabbo, R. (2011). Perceived burden of informal caregivers of a chronically ill older family member: Burden in the context of the transactional stress model of Lazarus and Folkman. Geropsych: The Journal Of Gerontopsychology And Geriatric Psychiatry, 24(3), 143-154. doi:10.1024/1662-9647/a000042

Rabinowitz, Y. G., Mausbach, B. T., Atkinson, P. J., & Gallagher-Thompson, D. (2009). The relationship between religiosity and health behaviors in female caregivers of older adults with dementia. Aging & Mental Health, 13(6), 788-798. doi:10.1080/13607860903046446

Remley, T. P., Jr., & Herlihy, B. (2010). Ethical, legal, and professional issues in counseling (3rd ed.). Upper Saddle River, NJ: Merrill/Pearson Education.

Schwarzer, R., & Luszczynska, A. (2008). How to overcome health-compromising behaviors: The health action process approach. European Psychologist, 13(2), 141-151. doi:10.1027/1016-9040.13.2.141