Wk 6: Disease Risk

• In the context of health behaviours, outcome expectancies refer to expectations/beleifs about the consequences of specific actions or behaviours.
• Sometimes also called behavioural beliefs or the 'pros and cons'.
• Outcome may be cognitive "if i don't use sunscreen, I will get burn"
• May be emotional "If i don't use sunscreen, I will feel guilty and worried"

Outcome expectancies can also be divided as oriented towards positive or negative outcomes

• Severity: how bad is it if it happens? 'It' may be developing a disease, getting into an accident etc
• Likelihood: how likely (probability) that 'it' will occur?
• Risk: combination of severity and likelihood.
• Low risk can occur through either low severity or low likelihood.
• Eg. Plane crashes are often fatal (high severity) but they are extremely rare. Thus an individual's risk of dying from a plane crash is very low.

• Studies show that sensitivity to risk does not always follow the actual risk, but differs depending the combination of severity and likelihood.
• Found that little variation in perceived risk beyond a 50% likelihood (eg. 50% vs 75% chance did not change individual's perceived risk compared to 0 vs 25%)
• With high severity events, individuals tend to overweight risk, even when likelihood of occurrence is very low.

• Many health behaviours risk is often low at particular timepoints, with large risks often due to cumulative effects.
• Eg. supposed contraceptive has 1% failure every year, someone using it from age 20-35 has total risk of 15%.
• Cumulative effects can be misinterpreted at either end. One study showed:
• Overestimated the probability that HIV will be transmitted from male to female in 1 case of protected condom intercourse.
• Underestimated the probability that HIV will be transmitted from male to female in 100 cases of protected intercourse. 

• Another challenge with many health behaviours is that risk may be synergistic.
• People may believe that both smoking and consuming alcohol confers the same risk as either smoking OR consuming alcohol.
• Conversely, people may believe that the benefits of one behaviour (eg. lots of exercise) balances out risk of another (eg. unhealthy diet)

• Relative: exercise halves your risk of developing heart diseases in a year (50% in relative risk)
• Absolute: regular exercise changes your risk of developing heart disease in a year from 2% to 1%

• Defensive optimism
• Rating your own risk as lower than average (most people's risk)
• Perhaps driven by comparing to high risk people.
• Eg. A non-smoker may perceive low risk if compared to smokers. 
• A smoker may perceive lower than average risk if compared to heavy smokers.

• In general, people accept less negative feedback (eg. rate as less accurate).
• Also discount severity.
• People relatively more positive feedback.

For example, people told they screen positive for a disease would be likely to discount the severity of the disease and believe the test was less accurate whereas those told they screened at low risk may say it is a moresevere disease and believe the test (that they are low risk) is quite accurate

• Study showed screening alone resulted in lower cholesterol, blood pressure, BMI than those not screened. Although smoking was unchanged. 
• In most cases, communication of risk alone is inadequate to motivate and achieve sustained behavioural change.

Risk communication alone only targets one aspect of behaviour change models.

• At individual level, behaviour change is unlikely if individuals are not motivated to change. 
• MI is most common approach to increasing motivation for change.
• MI is a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence.
• MI elicits attitudes and beliefs about the pros and cons of a behaviour.
• Individuals' perceived benefits may not always map onto what the interventionist perceives as a benefit. However these are still important to consider as they matter to the individual in weighing whether to attempt change.
• MI is designed to be non confrontational and avoid triggering a defensive response.
• MI has people consider both the perceived benefits of a particular behaviour and the perceived costs.

• Have been shown to be effective for a variety of situations:
• Adherence and overall outcomes (eg. weight loss, blood pressure) in primary care settings.
• Promotes engagement in the treatment of mental health problems.
• Adolescent health behaviour such as physical activity and diet.

• MI often combined with other interventions.
• Behaviour change interventions often have the first session of first module as MI to ensure that people are motivated before moving onto other module that help enact change.
• MI can also elicit helpful information for use throughout the intervention.

• (or modules in more complex interventions) seek to identify barriers or challenges and develop practical steps to deal with these.
• May involve breaking down 'big' changes into manageable steps.
• Identifying triggers (eg. I've tried to quit smoking before, but when I have a bad day I start smoking again) and a plan to deal with these (eg. can bad days be identified in advance? Emergency 'help' such as a friend who can be called for support on tough days etc)

• Problem solving interventions are collaborative as actions like identifying triggers requires interaction and input from participants.
• Solutions also need to be explored with participants to ensure they are feasible.

• Depending on the driver, triggers and perpetuating factors, participants may need help with coping or regulating emotions.
• If someone drinks to help cope with overwhelming emotional distress, asking them to give up without addressing the underlying distress and without providing an alternative coping strategy will be likely ineffective.

Emotional awareness, build distress tolerance ('sitting with' feelings), and reduce emotional avoidance.

• Modelling often is accomplished through videos, often featuring the target audience. 
• Eg. if the goal is to get adolescents to practice safe sex, the modelling video often features adolescents.
• Modelling can provide concrete examples about how to do something and also help destigmatise behaviour.

• Practice or role play in interventions can be helpful as difficult or uncomfortable aspects (eg. saying no to friends, asking a partner to use a condom) can first be tried in a safe and supportive environment. 
• It also allows the interventionist to troubleshoot issues.

• Cognitive interventions focus on addressing cognitions that inhibit behaviour change.
• Common cognitive interventions address irrational beliefs.
• "I made a mistake and everyone must have thought I looked so stupid"
• Might question the assumptions (eg. is it really likely that everyone was just paying attention to you?) or help provide alternatives to fixed or rigid thoughts and beliefs.

• Cognitive interventions can utilise "experiments".
• "If i don't drink, I won't be relaxed or fun at a party and people won't like me"
• Define a target, such as how the person feels or how many people they talk with at a party.
• Then ask them to record results once with drinking and then just one, experiment with not drinking and record how many people they talk with. 
• Such experiments can be easier to try as not asking them to change permanent;y and the empirical results can help to confront and change irrational beliefs.

• Commonly used in the treatment of substances, eating disorders and mental health (eg. depression, anxiety).
• They are relatively complicated, in that they require discussion and often multiple sessions with an experienced health professional, so that they often are not the first line interventions for changing health behaviours, but they are powerful and effective at dealing with difficult to change behaviours and psychopathology.

• Diabetes prevention program
• Found that behavioural intervention outperformed mefornin (drug).