Unplanned behaviour

This year’s British Psychological Society Division of Health Psychology annual conference was held at the Gateshead Hilton, and Ella Rhodes was there.

Health psychologists – practitioners and researchers – work in a fascinating variety of fields. They do, however, share many of the same values. At this year’s conference there was much talk in the air of moving beyond ‘one size fits all’ approaches to behaviour change and toward ways of working which take into account the true complexity of individual human experience.  

So much of the work of health psychologists involves attempting to predict and change health behaviours, and Professor Paul Norman (University of Sheffield) has spent many years exploring theories of behaviour change – particularly the Theory of Planned Behaviour. This theory suggests a person’s intentions toward a certain behaviour and subsequent behaviours are shaped by attitudes, subjective norms and their perceived behavioural control. While this is a well-established theory, and explains around 40 per cent of the variance in people’s intentions, it only explains around 20 per cent of the variance in an actual behaviour. In his keynote presentation Norman pointed to work on the intention-behaviour gap – why can someone have the best of intentions, but never actually act on them?

One of Norman’s own studies looked into this in relation to exercise. He found that the link between someone intending to do exercise and actually doing it is planning. Another important factor which the Theory of Planned Behaviour misses is the role of habits in behaviour. There are models which account for habit, but there is disagreement over whether or not intentions still play a role once a behaviour has become habitual. 

Where does this leave the Theory of Planned Behaviour in terms of actually changing behaviours? Beliefs are placed at the beginning of the theory – driving people toward engaging, or not, in a particular behaviour. Norman said in developing a behaviour change intervention based on the Theory of Planned Behaviour it may be necessary to find out some of the key beliefs associated with a given behaviour or intention, and develop messages to target these. 

Loneliness

Loneliness in the age of mass connectedness might just be the paradox of our time. While loneliness has always existed, research is increasingly revealing its damaging effects and exploring whether social networks such as Facebook or Instagram might be amplifying feelings of isolation for some people. 

Dr Bridget Dibb (University of Surrey) described research looking at two mechanisms which may explain loneliness in Facebook users – social comparison and rumination. She reported on the results of an online survey of 179 people who used the site between one and 300 minutes per day and had from five to more than one thousand friends. 

While the number of Facebook friends someone had didn’t impact on their feelings of loneliness, depression, levels of rumination and upward social comparison did. As this study was cross-sectional Dibb suggested longitudinal studies would be useful in the future, with some examination of the type of content which may lead a person to ruminate or compare themselves with people they assume are better in some way.   

The role

Trials of integrated primary care teams – where patients at GP surgeries also have access to nurses, healthcare assistants and behavioural health consultants – have shown promising results in the USA. Health Psychologist Dr Hannah Dale has been looking into the implementation and evaluation of a health psychology role at two GP practices in NHS Tayside in Scotland.

Dale hoped to develop and evaluate a behavioural health role within two surgeries. She explained some challenges this presented – while the two GP surgeries were initially intending to merge this didn’t go ahead, and as a result one surgery used the integrated care model while the other continued to function as a traditional GP practice. However, Dale and a colleague were on hand for referrals from both practices for patients with long-term conditions, those who needed help in managing symptoms and other wellbeing matters. 

They received the most referrals from the integrated practice, and patients had shorter waiting times in this practice (being seen within four days and sometimes on the same day as an initial appointment). Most of the cases they dealt with involved problems with stress, sleep, social difficulties including isolation and, while not their main function, they also saw patients with mental health problems and referred them on to more appropriate services.  

Following their intervention Dale and her colleague found improvement on a clinical global improvement measure, the scores on a question which asked patients to rate their general health improved from poor to average. Post-intervention patients also showed improvement on life satisfaction measures.

Dale said this integrated approach to primary care helped relationships among staff and encouraged working collaboratively with patients. However, there are challenges working within a traditional GP model in getting the right patients referred to them and helping staff understand what health psychology has to offer. 

Helpful or harmful?

While at the conference I asked delegates to tell me of some of the most helpful or harmful ideas, theories or behaviour change techniques within the field of Health Psychology. The overriding theme was an insistence that we should not underestimate the role of the environment on health behaviours. Tess Langfield, a PhD student at the University of Cambridge who also won an award for her conference abstract, said health psychologists shouldn’t assume that humans are rational actors when it comes to health-related behaviour. ‘It is harmful to believe that we act rationally at all times with regard to our health goals and motivations. Often, despite our best interests, we’ll act in ways that don’t benefit our health.’

William Day, a graduate teaching assistant and PhD student (Aston University) presented another award-winning abstract and said that one of the problems with behaviour change techniques and theories is that they are assumed to be universal. ‘Quite often these things downplay contextual concepts that really need to be taken on board. A lot of the data we’re using to design models in health psychology is quite often from very specific populations. I think these models are very driven towards identifying specific traits or psychological concepts that can explain behaviours and they aren’t taking into account any socioeconomic factors, ethnicities or cultural backgrounds.’ Day said qualitative work which explores the experiences and perceptions of under-represented groups can help us better fill these gaps in theory and models.  

Body image

Director of the Centre for Appearance Research Professor Diana Harcourt (University of the West of England) brought the conference to an end with her keynote address on body image in those with cancer. The centre (also known as CAR) works to understand the impacts of living with an altered appearance or visible difference as well as broader body image issues. 

The journey through cancer, from screening through to treatment and recovery or subsequent palliative care, is fraught with body-changing experiences for many. Treatments for cancer, in particular, can have drastic impacts on an individual’s body image – they may experience any combination of surgery, chemotherapy, radiotherapy and hormone treatment all of which have effects on their appearance including scarring, hair loss and limb amputation. The psychosocial impact of these changes, including anxiety, depression, a loss of function in some head and neck cancers, can be extensive and enduring. 

Harcourt has spent much of her academic career exploring the experiences of breast cancer patients and decision-making around treatment – particularly breast reconstruction after mastectomy. Around 15,000 women per year have a mastectomy and 30 per cent choose to have breast reconstruction, it is a complex decision to make for most women – they must decide whether to have it, whether to have it done at the same time as the mastectomy, and there is huge uncertainty around the results of the procedure. 

Harcourt worked with women who were attempting to make this decision. Some opted for no reconstruction, some for immediate reconstruction, some for delayed reconstruction and some of the women simply couldn’t decide. After a year Harcourt examined their levels of satisfaction with their decision and there was no difference between the groups. 

Some of the women who decided to have breast reconstruction were not happy with the results – they told Harcourt about scarring, regrets and wishing they had known what to expect – but many were still pleased they had had the procedure. She wondered whether patients’ expectations were realistic and if this had an impact on satisfaction. 

Harcourt began working with Alex Clarke in 2011 and they developed the PEGASUS intervention as a way to delve deeper into patient expectations to help inform their decisions about reconstruction. In this intervention patients meet with a coach who helps them decide what is most important to them, what’s normal for them and what they want to gain from any potential procedure – they can then take this information to their surgeon and discuss options. 

In some initial work using this approach 18 women were given coaching prior to making a decision on breast reconstruction. Between them the women came up with 70 goals they would hope for – these included functional concerns, psychosocial and intimacy issues, some spoke about wanting to be able to wear summer dresses while on holiday. Patients thought the PEGASUS approach helped them deeply consider their decisions and helped them to build up trust with their surgical teams – the health professionals were also positive about the information it helped glean. Harcourt and her colleagues are soon set to reach the end of a trial which will assess whether PEGASUS had an impact on patient outcomes. 

Harcourt is currently working on potential acceptance and commitment therapy and self-compassion interventions as well as training health professionals to be more aware of body image and appearance concerns. The CAR has also taken on a PhD student to research the effects of appearance concerns for men diagnosed with prostate cancer and body image issues faced by men with breast cancer. 

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