What Health communication is, from a psychologist's point of view

1. COMMUNICATION IN PUBLIC HEALTH:
FACTORS INFLUENCING HOW PUBLIC
HEALTH MESSAGES ARE ACTED ON
Aymery Constant, PhD
Health Psychology Lecturer
EHESP

2. WHY IS CURRENT HEALTH
COMMUNICATION A HUGE PILE OF CRAP ?
(…from a psychologist’s point of view)
PART 1

3. So, why?
Please, answer a few questions…
1. Do YOU consider drinking, smoking or unhealthy dietary habits
in a similar way to a wild beast running in your direction?
2. Are YOU identical to your siblings, your parents, your friends… ?
3. Do YOU know ANY smoker who thinks smoking is healthy ?
4. Motivation, habits, desires, imitation, etc… Rings a bell ?
If you answered 1) NO, 2) NO, 3) NO and 4)YES, then you
should easily understand why psychologists consider
current health communication as a pile of crap

4. Decision makers
Scientists, health providers
Communication specialists
Health practioners
Emitters
General population
Or
Specific groups
Receivers
Classical model of health
information/education/promotion/whatever
Message
Mass media
Flyers
Internet
Face to face
Etc.
SMOKING
= CANCER

5. Classical model of health
information/education/promotion/whatever
SMOKING
= CANCER
Providing information
« OMG! Smoking is dangerous ! » Increasing
Knowledge/Awarness
«I quit smoking» Behaviour change
ULTIMATE
GOAL

6. Comparative psychology: fishes

7. Fishes
• They behave exactly the same way when they
shares common characteristics
• Faced with a danger in a group, they react
similarly
• When knowing the danger, they do not take
risk and go away

8. For instance…

9. Comparative psychology: humans

10. Humans
• They do not behave exactly the same way,
even when they share common characteristics
• Faced with a danger, they react differently
• Some can take risk, even knowing the danger

11. For instance…

12. Why such differences ?
BECAUSE HUMANS ARE NOT FISHES

13. Why is this gentleman still in the water ?
• Not enough signs, we need more warning signs on the beaches
• Sign is not visible, we need bigger warning signs
• Message not clear enough, we need better wording/picture
• He cannot read, so we need reading education programs for
surfers
• He does not know sharks well, so we need more information
mass media campaigns about sharks attacks injuries and
fatalities

14. • Yes, these explanations are silly
• They would produce expensive preventive
interventions… deterring only those who are already
afraid of sharks
• They rely entirely on the “fight or flight” paradigm
• Make the treat visible (obvious) to trigger avoidance
Captain Obvious returns

15. “Fight or Flight” Still underlies most health education campaigns !

16. Research suggest that human behaviour is still influenced by
the primal “fight or flight” reaction, when we face immediate
danger (e.g. shark, lion, jealous husband..)
…but others psychological/social factors are now involved,
making human decision-making somewhat more complex
than 300,000 years ago (go figure !).

17. Another drawback
“Most of these (health) programs have been based on the premise
that the transfer of knowledge alone could change health
behaviour. Fortunately for Human nature, this proposal is
erroneous, and the decision to act is in fact based on various
personal dimensions”.
Gaston Godin (translation from La psychologie sociale au service de la santé publique et de
l'environnement) In : Environnement et santé publique - Fondements et pratiques, pp. 277-288. Gérin
M, Gosselin P, Cordier S, Viau C, Quénel P, Dewailly É, rédacteurs. Edisem / Tec & Doc, Acton Vale
/ Paris

18. So, why is current health communication such a huge pile of
crap ? (….according to psychologists)
• Because it relies upon the « fight or flight » paradigm
Do YOU consider drinking or smoking as a predator running in
your direction?
• Because it considers human population or even specific
populations as homogenous ensembles
Are YOU identical to your siblings, your parents, your friends… ?
• Because it considers people stupid
Do YOU know ANY smoker who thinks smoking is healthy ?
• Because it ignores a set of pivotal variables driving behaviour
change
• Motivation, habits, desires, imitation, etc… Rings a bell ?

19. THE PSYHOLOGICAL APPROACH :
MODELS OF HEALTH BEHAVIORS
PRESENTATION AND CRITISCISMS
PART 2

20. Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
The leading model from the 50s (“top down”)
Information
« There is a lion in front of me »

21. Expected
Consequences
Subjective
Probabilities
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
The leading model from the 50s (“top down”)
Information
« The lion will attack me »
High

22. Expected
Consequences
Subjective
Probabilities
Cognitive
Evaluation
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
The leading model from the 50s (“top down”)
Information
This is a bad
situation
I might die

23. Expected
Consequences
Subjective
Probabilities
Cognitive
Evaluation
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
Emotion
The leading model from the 50s (“top down”)
Information
I have a bad feeling about this™

24. Expected
Consequences
Subjective
Probabilities
Cognitive
Evaluation
Decision
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
Emotion
The leading model from the 50s (“top down”)
Information
Run away or
use the force
(Jedi only)

25. Expected
Consequences
Subjective
Probabilities
Cognitive
Evaluation
Decision
Consequences
Source: Loewenstein et al, 2001, Psychological Bulletin 127(2)
Emotion
The leading model from the 50s (“top down”)
Information
Safety

26. Models of health-related behaviors
Some major models in health behavior research:
 The Basic Risk Perception Model
 The Health Belief Model (HBM)
 The Theory of Planned Behavior (TPB)

27. The Basic Risk Perception model

28. The basic risk perception model focus on only two
dimensions of health hazard:
 the likelihood of harm if no action is taken
 the severity of harm if no action is taken
The basic risk perception model
This model is an adaptation of the expected-utility
theory to decision in health behaviors.

29. Two characteristics:
 Likelihood is one’s probability of being harmed by a hazard under
certain behavior conditions. Example: “What is the likelihood that
you will get the flu this year?”
 Susceptibility (or vulnerability) emphasize an individual’s
vulnerability to a hazard. Example: “Are you more likely to get the
flu than other people?”
1) the likelihood of harm:
The basic risk perception model

30. can be defined as the extent of harm a hazard would cause.
Examples of questions:
 “How serious a disease is the flu?”
 “Can Influenza cause death?”
 “If you had influenza, would you be able to manage daily
activities?”
2) the severity of harm:
The basic risk perception model

31. CONCLUSION
The basic risk perception model
Higher levels of severity and likelihood are associated with
higher motivation

32. It included thirty-four studies (N = 15,988). Risk likelihood,
susceptibility, and severity were significantly correlated:
 Risk likelihood: pooled r = .26
 Risk susceptibility : pooled r = .24
 Risk severity: pooled r = .16
Risk perceptions are involved in predicting preventive
behavior, but correlations are quite small
A meta-analysis of the relationship between risk perception and
adult vaccination has been conducted (Brewer et al, 2007):
The basic risk perception model

33. • Since first appeared in the South East of
France in 2004, Asian tiger mosquitos have
spread from there and caused serious
infections such as Dengue and Chikungunya
fever, notably during the summer of 2010
Mosquito-borne diseases

35. Knowledge about tiger mosquito-borne diseases in South
East France between 2012 and 2014
0
10
20
30
40
50
60
70
80
90
100
Diseases (unspecified) Chikungunya Dengue fever Malaria
2012
2013
2014
Year
percentages
Question: What are the potential consequences of tiger mosquito bites ?

36. Reports by the same respondents
0
10
20
30
40
50
60
70
80
90
100
Have seen tiger mosquitos in immediate
environement
Bitten by mosquitos Avoidance measures
2012
2013
2014
Year
percentages

37. • Preventive behaviour was not related to knowledge about mosquito-
borne diseases, or even tiger mosquito presence…
• …. because infections were perceived as severe, but rare events (high
severity; moderate vulnerability; low likelihood )
• Avoidance measures were mostly related to mosquito nuisance,
including from European Mosquito
• Not a « big deal » in terms of public health, but huge when it
comes to personal comfort and quality of life
Mosquito-borne diseases

38. The Health Belief Model (HBM)

39.  The health belief model was initially developed in the 1950s by a
group of social psychologists in the U.S. Public Health Service
 Research was initiated to explain failure of large number of
eligible adults to participate in tuberculosis screening programs
provided at no charge in a mobile X-ray units conveniently located
in various neighborhoods.
 Researchers were concerned with identifying factors that were
facilitating or inhibiting participation.
The health belief model (HBM)
ORIGINS OF THE HEALTH BELIEF MODEL

40. The health belief model (HBM)
COMPONENTS OF THE HEALTH BELIEF MODEL
Perceived susceptibility
Perceived severity
Perceived threat Behavior change
Perceived benefits of change
Perceived barriers of change

41. The health belief model (HBM)
COMPONENTS OF THE HEALTH BELIEF MODEL
 Perceived susceptibility : one’s subjective perception of risk of
contracting an illness.
 Perceived severity : beliefs concerning the seriousness of
consequence of contracting an illness (e.g., death, disability, and
pain). This includes the social consequences (e.g., work, family life,
leisure, etc.).
 Perceived benefits : beliefs regarding the effectiveness and the
efficacy of various available actions in reducing the disease threat,
but also the non-health-related benefits (save money, relative
approval, etc.).

42. The health belief model (HBM)
COMPONENTS OF THE HEALTH BELIEF MODEL
 Perceived barriers : spontaneous cost analysis which occurs
when the individual evaluate preventive actions that may be
expensive, dangerous, unpleasant, inconvenient, time-consuming,
and so forth.
 Self-efficacy : this concept introduced in 1977 by Bandura refers
to the conviction that “one can successfully execute the behavior
required to produced the outcomes”
 Cues to action: events, people, or things that move people to
change their behavior (e.g. illness of a family member, media
reports, advice from others, reminder postcards from a health
care provider, or health warning labels on a product.
.

43. Flu shot

44. Action is taken if perceived benefits outweight the perceived costs/barriers
HIV test

45. Lose weight

46. The health belief model (HBM)
Reviews of HBM studies (Janz & Becker, 1984)
 Perceived barriers were found to be the powerful single
predictor of the HBM dimensions across all studies and health
threat
 Perceived susceptibility and perceived benefits were both
important, while PS seem to be a stronger predictor of preventive
behavior than PB.
 Perceived severity was the least powerful predictor.

47. So much for the “Fight or Flight” Approach !

48. The Theory of Planned Behaviour

49.  Created by Azjen in 1991, from a previous 1985 model
 Designed to predict any type of voluntary behavior, not only
health behavior (economy; etc.)
 One of the most popular models used to predict a wide
range of behavior
 There is no health behaviour, there are social behaviours. And some of
them influence health (Gaston Godin)
Theory of planned behaviour

50. Model of the TPB

51. Affective attitudes

52. Extension of social norms

53. Extension: speed driving

54. Influence of TPB variables
High influence on intention
low influence on actua
behaviour

56. Main criticisms
 Study design: Cross-sectional vs. longitudinal; university
students; self-reported behaviors; correlations between
repeated measures
 Structural flaws: Assumptions based on common sense
that cannot be refuted; Gap between intention and action not
taken into account; not a dynamic model
 Poor predictive validity: Some pivotal variables are not
assessed in the model, not useful to predict behavior or
implementing behavior change

58. The underlying mechanism of decision-making
Source : Kahneman, D. (2002), Maps of Bounded Rationality : A Perspective on Intuitive
Judgments and Choices, Nobel Prize Lecture 2002.
Huge Influence on behaviours Psychological models

59. IMPROVING HEALTH BEHAVIOURS AND
LIFESTYE
TIME FOR GAME CHANGERS
PART 3

60. Changing the future
= requires new approaches
Determinants (beliefs; attitudes; norms..)
New
Behaviour
Current
Behaviour
How the TPB (and most others models) work :
Explaining the past
= how behavior occured

61. Models: One way relationship…
Attitudes in favor of smoking
• Enjoyable
• Looks cool
• Nice with a coffee
• Help to get relaxed
• Help to focus
• Etc..
Peer pressure
Controlability
…suggesting that we should target attitudes,
information, norms, control etc..

62. Emerging evidence : a bi-directional
relationship …
Attitudes in favor of smoking
• Enjoyable
• Looks cool
• Nice with a coffee
• Help to get relaxed
• Help to focus
• Etc..
• Peer pressure
• Controlability
…suggesting that we could also target behaviour
directly

63. Game Changers
 Future directions according to Marteau
 Altering environment to constrain behavior
 Architecture of choice
 Offer healthy alternatives
 Nudging
 Targeting automatic associative processes
 Change automatic reactions to external cues
 Change associations

64. Best behavioral intervention ever !

65. Promoting hygiene and safety

66. Alter environment

69. Alter environment
The term “nudge” was first used in a book of the
same title to describe “any aspect of the choice
architecture that alters people’s behaviour in a
predictable way without forbidding any options or
significantly changing their economic incentives
Marteau (2011).Judging nudging. BMJ

70. Create new associations in mind (healthy=fun)

71. Provide alternative healthy choices

72. Change the default choice

73. Change the default choice
plat du jour: a grilled steack
in restaurant 1 in restaurant 2
In restaurant 1: most people will eat vegetables
In restaurant 2: most people will eat french fries

74. What about motivation ?

75. 75
Understanding motivation
Brain processes that energise and direct
behaviour
Not limited to choice and goal pursuit
Needs to include
drive
habit
desire
instinct
self-regulation
etc.

77. 77
COM-B system for analysing
behaviour in context
1. Capability, motivation and opportunity all
need to be present for a behaviour to occur
2. They all interact as part of a system
3. Motivation must be stronger for the target
behaviour than competing behaviours

78. 78
Common terms for methods for inducing behaviour
change
Capability
Train
Help
Motivation
Expose to
Inform
Discuss
Suggest
Encourage
Incentivise
Ask
Order
Plead
Coerce
Force
Opportunity
Provide
Prompt
Constrain

80.  Most behavioral models are based on perceptions (attitudes,
norms, beliefs) that might be relevant
 But they ignore some of the most pivotal variables shaping
behaviors (habits; contexts; environment; desires; needs…)
 They correlate poorly with actual behavior and are not very
useful for designing behavior change interventions
 Behavior change technique should include motivation
 New approaches targeting environment, motivation and
habits are warranted to promote healthy behavior
Time for Game Changers !!!!
Conclusions