MOTIVATION TO QUIT PROGRAM

INSIGHTS FROM HEALTH PSYCHOLOGY

Our health depends on a host of our everyday behaviours such as waking early for a
walk, brushing our teeth, using car seat belts for safety, avoiding air-pollution by
wearing masks. These are called healthy behaviours. On the other hand, most of our
health problems are engendered from our careless daily habits such as unhealthy eating
of excess fatty foods causes obesity which in effect results in Diabetes, hypertension,
arthritis etc. Another unhealthy behaviour, smoking, can be tied to a range of negative
health outcomes such as lung cancer and heart disease. Why do we engage in a
behaviour in spite of our knowledge that is detrimental to our health? How can we
change such unhealthy behaviours through a intervention program ? Say Health
education.

Health education attempts to close the gap between what is known about optimal
health practices and what is actually done (Griffiths, 1972). The goal of health education
is to teach people to limit behaviours detrimental to their health and increase
behaviours that are conducive to health. Health psychologists essentially follow the
same agenda but with more focus on individual factors such as attitudes, beliefs, and
personality traits.

What determines our healthy behaviours?

Our developmental history—comprising both our physiological and psychological
make-up—plays a major role in the health behaviours we practice. If you smoke, why?
Why don’t you get enough exercise? Do you eat well? No single factor or set of factors
adequately accounts for why we do what we do (Sallis & Owen, 2015). We need to
examine our developmental history and our social, cultural, and economic backgrounds
using the bio-psychosocial perspective, which can answer all these questions.

Figure 1. Key Factors Influencing Health Behaviours

Biological Factors
Biologically, we are born with many predispositions that can influence the types of
health behaviours that we practice. For example, if both your parents are very
overweight, there is a good chance that you will be overweight or have a propensity to
put on weight. From our parents we inherit metabolic rates, which determine how we
break down and process what we eat. The likelihood of becoming addicted to smoking
or drinking has been shown to have a biological basis. For example, the dopamine D2
receptor gene plays a role in alcoholism. Those who have more copies of this gene show
a higher likelihood of becoming addicted to alcohol. Dopamine is also associated with
addiction to gambling and to food addictions.

Psychological Factors
In examining the psychological predictors of health behaviours, personality traits and
characteristics play a large role in determining health behaviours (Husson, Denollet,
Ezendam, & Mols, 2017). The Big Five personality traits are good indicators of a
person’s likelihood to practice specific health behaviours. Extroverts are more likely to
participate in
risky behaviours such as smoking and drinking and to start drinking at an earlier age.
Conscientiousness and agreeableness are particularly noteworthy predictors of health
behaviours and cognitive
attitudes and tendencies.
In a demonstration of the long-term impact of personality, Hampson, Goldberg, Vogt,
and Dubanoski (2007)
studied 1,054 participants in the Hawaii Personality and Health study. This population-
based longitudinal
study of personality and health spanned 40 years from childhood to midlife. The study
found that childhood
agreeableness and conscientiousness influenced adult health status mediated by
healthy eating habits and
smoking. Therefore, in planning campaigns, perhaps health professionals need to design
programs that appeal to the unique psychological makeup of persons most at risk for
particular behaviours (Caspi et al., 1997).

Social Factors
The social part of the bio-psychosocial model is very important as well. The media
messages
we are exposed to have a strong impact on the types of health behaviours we perform.
The culture we live in
and what we are surrounded by give us a lot of information about what is acceptable
and what is not. As we
grow and look out at the communicators of culture (e.g., magazines, movies, or
television), what we see can
influence what we do.

To prove this association Meija et al. (2017) studied 2,502 Argentinian students in 33
secondary schools who
had never smoked; about 68% of the students completed a follow-up survey 17 months
later. Then, the
researchers watched a lot of movies. Focusing on the top 100 money makers, they
counted how much tobacco
use was featured. The students were asked which of the movies they had seen. It was
found that watching
movies with tobacco use had an effect. At follow-up, 24% of students who had never
smoked reported having
tried smoking and nearly 10% were regular smokers. In general, exposure to smoking
in films increased the
likelihood of future smoking.

Changing Health Behaviours

Health behaviours are a result of a constellation of factors. A person’s biology,

personality, and societal factors all play an important role. Identifying the critical factors
determining the
behaviour is a good starting point. A major part of
individual-level interventions, goal setting, and behaviour contracting involve setting
achievable incremental
goals, committing to achieving the goals through a behaviour contract, monitoring and
documenting progress,
and reinforcing goal achievements through rewards.
Key properties of health behavioural goal include
difficulty (e.g., running 10 miles vs. jogging for 1 mile), the time frame (e.g., lose 1 pound
in a week or 20
pounds in a year), and type of goal setting (e.g., self-set, doctor prescribed, or
collaborative).

Once target behaviour is identified, take a week or two and closely monitor the
behaviour that is to be
changed. Arrive at a baseline measure (including times,
places, and hunger level). If the goal is to stop smoking, similarly write down every time
a person engages in smoking behaviour (the urge,
the company, and so on). Self-observation or self-monitoring is the first and most
important step. Make sure
all relevant biopsychosocial factors are listed. For example, physical activity is
influenced by weight at the
biological level, self-efficacy at the psychological level, and support from family and
friends at the societal level.

Barriers of Change
Next, list the barriers that are preventing one from changing the unhealthy behaviour or
adding the healthy
behaviour. These may be practical issues (e.g., no time) or psychological ones (e.g., you
do not think you will
succeed). For each barrier you need a solution. Using this information, you can develop
a plan to change in an
organized manner. Use principles of operant conditioning (reinforcement and
punishment) to make sure one can
keep on track and set achievable goals. By paying close attention to the different bio-
psychosocial correlates of
health behaviours discussed here, one should be able to facilitate developing the
behavioural and cognitive skills to change any unhealthy behaviour.
What are the biggest barriers to behaviour change? An individual’s attitudes, beliefs,
knowledge, and skills are all important factors.

The Importance of Theory

Scientific theories guide our search to understand why behaviours are difficult to
change and to predict successful change. At the core, theory explains behaviour and
suggests ways to influence and change behaviour. If you want to successfully adopt
healthy behaviours, you can rely on explanatory or predictive theories to identify key
factors, and theories and models (analogous to theories) of behaviour change to help
focus on the process.

Key Theories of Health Behaviour Change

Health psychologists’ approaches to understanding and changing the extent to which
health behaviours are practiced nicely illustrate a full-cycle version of the scientific
method (Suls, Luger, & Martin, 2010). Observe a real-world problem, generate
hypotheses and a theory of why it occurs, design research to test it, and then apply
successful theory to help intervene and solve the problem. There have been and
continue to be a number of different theories to explain why we practice some
behaviours and fail to practice others (Michie, Marques, Norris, & Johnston, 2019).

Most theories draw on Social Cognitive Theory (SCT; Bandura, 1986, 1998), a
comprehensive theory of behaviour change that posits that characteristics of people
(i.e., their attitudes and beliefs), their environments, and their health behaviours all
interact and determine whether each person performs a health behaviour. SCT suggests
that the most central determinant of health behaviour change is self-efficacy, a concept
that is now included in numerous theories of health behaviour (Noar, 2005).
In addition to SCT, three theories dominate the literature: the Transtheoretical Model
and stages of change, the Health Belief Model, and the Theory of Planned Behaviour.
These theories all focus on some key predictors of behaviour, our attitudes, our
intentions, and our readiness to change.

Transtheoretical Model

TTM was developed to identify common themes across different intervention theories
(hence
Transtheoretical) and notes that we process through different stages as we think about,
attempt to, and finally
change any specific behaviour. Different psychological traditions had different
processes to account for why people changed their behaviours:
the behaviourists argued that people changed to manipulate the contingency of reward
and punishment, the
humanists believed that helping relationships spurred change, and the psychodynamic
theorists suggested that
change came about due to consciousness raising. DiClemente and Prochaska (1982)
assessed whether a group
of smokers who were trying to quit used any of these processes. The researchers found
that smokers used
different processes at different times in their quest to quit smoking and first identified
that behaviour change
unfolds in a series of stages. From smoking, the stage model was extended to study a
variety of behaviours with
health consequences including alcohol and substance abuse, delinquency, eating
disorders and obesity,
consumption of high-fat diets, unsafe sex with the risk of sexually transmitted diseases,
and sun exposure (Prochaska, Redding, & Evers, 2015).

The TTM sees change as a process occurring through a series of six stages. The main
stages are summarized
In Figure 2. If you know what stage a person is in, you will need to tailor your
intervention to fit the state of
mind that the stage describes. When people are not aware that they are practicing a
behaviour that is unhealthy
or do not intend to take any action to change a behaviour (especially not in the next 6
months), they are said to
be in the precontemplation stage. People could have tried to change before, failed, and
become demoralized
to change, or they may just be misinformed about the actual consequences of their
behaviour. Some teenage
smokers are so confident about their own health that they do not believe smoking is a
problem for them and
have no intention of quitting. People in this stage avoid reading, thinking, or talking
about their unhealthy
behaviours. Health promotion programs are often wasted on them because they either
do not know they have a
problem or do not really care.

When people recognize they may be doing something unhealthy and then intend to
change (within the next
month), they are said to be in the contemplation stage. Here they are more aware of the
benefits of changing
and are also very cognizant of the problems that changing may involve. For the dieter, it
may be avoiding the
foods that he or she has grown to love. For the smoker, it may mean not spending time
with the buddies he or
she always used to smoke with. The ambivalence associated with knowing the pros and
cons of the behaviour
change often keeps people in this stage for a long time and calls for unique
interventions.
Preparation is the stage in which the person is ready to take action to change the
behaviour. He or she
generates a plan and has specific ideas of how to change. Someone who wants to lose
weight may go out and
buy new workout clothes and a gym membership. Someone who wants to drink less
may give away all the
alcohol in the house or have a talk with a doctor to get help. In essence, these people
make a commitment to
spend time and money on changing their behaviours. As you can guess, this is the stage
people should be in if
an intervention is going to have any effect.
Once people are actually changing their behaviour, they are in the action stage. The
change has to have taken
place over the past 6 months and should involve active efforts to change the behaviour.
For example, frequent
trips to the gym characterize someone who is in the action stage of trying to get in
shape. Does any attempt to
change behaviour no matter how small count as being in the action stage? No, it does
not. People must reach a
criterion that health professionals can agree is sufficient to reduce the risk for disease
(Prochaska et al., 2015),
for example, losing enough weight to no longer be classified as obese or abstaining from
smoking for a
significant period of time. Can you slide back?
Maintenance is the stage in which people try to not fall back into unhealthy behaviours,
or to relapse. They
may still be changing their behaviours and performing new behaviours, but they are not
doing them as often as
someone in the action stage. In this stage, the temptation to relapse is reduced, and
there is often confidence
that the new behaviour changes can be continued for a period of time. For example,
maintenance of abstinence
from smoking can last from 6 months to 5 years.
Finally, people may reach a stage in which they are no longer tempted by the unhealthy
behaviour they have
changed. The ex-smoker no longer craves a cigarette, the ex-fast food addict now no
longer feels like eating a burger and fries, and the former couch potato is committed to
regular physical activity. If a person reaches this
point, he or she is in the termination stage. Can this stage be achieved? Snow, Prochaska,
and Rossi (1992)
found that fewer than 20% of former smokers and alcoholics reached this zero-
temptation stage. For the most
part, this part of the model has been loosely interpreted as representing a lifetime of
maintenance, and most
interventions aim to get participants to the maintenance stage.

The most helpful contribution of the TTM is that it clearly identifies how interventions
can be successful.
Interventions need to be tailored according to the stage of change that a person is in.
The most common
application involves the tailoring of communications to match the needs of the
individual. Individuals who are
in the precontemplation stage could be given information that would make changing
their behaviour more of a
pro and hence move themselves into the contemplation stage. For example, to get a
person in the
precontemplation stage to consider getting a flu shot researchers would use strategies
to capture attention
using narratives of compelling images (Rimer & Kreuter, 2006). Tailored interventions
using the TTM now
also use the Internet. Puff City was a Web-based program focused on asthma
management among urban
African American adolescents (Joseph et al., 2011).

Figure 2