Understanding behavioural change for health education design - decisions from a psychology point of view

By Christina (Chang) He, Psychology undergraduate at Oxford University:

How should health information be delivered? How can we educate people in a way that motivates healthy behaviours and behavioural change? As a student of Psychology at the University of Oxford, I am fascinated by whether an understanding of how people process health information and transform it into action might provide insight into this.

People do not always follow medical advice, especially when it is hard to understand. Health advice such as “stop smoking” or “cut down on drinking” is probably heard so many times that it goes in one ear and comes out the other. Simply providing patients with guidelines on how they could and should live healthily does not guarantee changes in people’s attitudes, habits and behaviours.

Unlike the way a computer processes information, there are far more components that determine how a human inputs and outputs information. All of these need to be considered when designing health information.

Information Processing and Decision Making

To understand how and why people make changes to their behaviours, it is crucial to understand how humans process information, internalise it and use it to make decisions. In this article, I consider how various aspects of information processing can guide us on how to best design health educational resources.

1 – People integrate new information into their existing knowledge

A person’s understanding of their illness is the result of active perceiving, encoding, and integrating new information into their existing beliefs and attitudes of the illness. This is explained by the ‘cognitive social health information-processing (C-SHIP) model’ which emphasises the integration of new information into existing knowledge

2 – Individual processing pathways and subconscious bias can create misguided expectations

Once patients have internalised information and formed a knowledge system, they have an initial basis for making medical decisions. We need to take into consideration individuals’ differences in how they process information, including the effect of subconscious bias, meaning that people’s understanding could be biased and not medically accurate, creating potentially misguided patient expectations.

We also should consider the emotional factors that can influence decision making. People can feel more informed when they have accurate information, while too much information may lead to unnecessary anxiety. Equally, life events can colour people’s understanding of health information, and confound their ability to objectively judge the information being presented, opening them up to misinformation online.

3 – ‘High monitoring patients’ tend to have greater concerns and anxiety

High monitoring patients keep themselves highly informed about their condition. They may amplify the threats and consequence by paying too much attention to minor or even unrelated details that creates concerns.

4 – ‘Low monitoring individuals’ can show avoidance behaviour, seeking to avoid cues and possible diagnosis

Low monitoring individuals tend to distract themselves and attenuate the threats, reducing anxious emotions. This avoidance behaviour risks misdiagnosis or late diagnosis.

5 – Patients’ existing health goals and values [3] can influence information processing and behaviour

Someone who puts health as a main priority will be more convinced by messages that tell them that living a positive, healthy lifestyle leads to good health, therefore more likely to adopt such a lifestyle. This belief and value system is dynamic; people tend to value health more as they age [4].

6 – Affects and Behaviour – incomplete understanding of a condition can lead to patient anxiety and avoidance behaviour

A patient’s anxiety partly stems from an incomplete, inaccurate and biased representation of their illness, which leads to avoidance behaviour to either health check-ups, appointments, or even surgery. Without an improvement in their health or receiving a clear diagnosis, anxiety levels can surge as uncertainty increases.

For instance, Durry et al. (2002) found a positive relationship between BMI (Body Mass Index) increase and delay/avoidance of healthcare in a sample of 216 women[5]. Reasons for this delay included “not wanting to be weighed on the scale” or “knowing they would be told to lose weight”. Societal and medical stigma towards obesity makes it even more difficult for patients to return to medical checks routinely. Individuals with stigmatised medical conditions could benefit from accurate information presented in a non-judgmental way, thoughtfully phrased advertisements, online forums and support groups, all of which should be supported by the healthcare industry.

Avoidance behaviours are also observed in surgery, where operation cancellations not only delays treatment for patients but also puts a burden on the healthcare system. Macarthur et al. (1995) reports that 10%-18% of paediatric same-day surgeries are cancelled, half of them for non-medical reasons[6]. To better prepare patients to go for surgery with the lowest anxiety level, the most important thing is to provide accessible and easily understood information which can fully inform the patient (or carer)  of what to expect during and after surgery. Furthermore, improving the patient’s knowledge and confidence in managing their condition post procedure can improve outcomes as they have a positive outlook and increased resilience after the procedure.

7 – External social opportunities can influence behaviours

As important as the internal, psychological factors that influence decision making and health behaviours, external social opportunities influence behaviour as well. Accessibility to healthcare services, financial ability, level of education, and awareness are all barriers to those who are disadvantaged. It is crucial for the healthcare industry to make healthy living more accessible by engaging in patient education programs and subsidising the cost for those who are economically disadvantaged. It has been reported that 43% of people lack the literacy skills, whilst 61% lack the numeracy skills to understand typical health information in England[8].

8 – The COM-B Model – Behavioural change in lifestyle is driven by capability, opportunity and motivation

The Capability, Opportunity, and Motivation Model of Behaviour (COM-B model) is one theory that explains behavioural change.

Capability includes both psychological and physical capability, including having the necessary knowledge, skill, or mental preparation to carry out an action.

Opportunity refers to social and environmental influences or resources.

Motivation is more of a neuropsychological process, which can be prompted by emotional responses, past beliefs, or conscious direction of behaviour. The COM-B model emphasises the interaction between the three factors [9].

Not only do capability, motivation, and opportunity influence behaviour, the change in behaviour in turn also influences each of the three factors. The COM-B model forms the essence of the behavioural change wheel (BCW), where every factor from COM points to an underlying intervention.

For example, patient education and training are common methods to increase capability, while public education towards stigmatised medical conditions and lowering healthcare costs provides more opportunity and a friendlier environment.

Providing accurate, engaging and memorable information at the right time in that patient’s health journey could correct beliefs regarding perceived risks and lower patient anxiety, which then increases motivation and reduces avoidance behaviour.

Applying our understanding of behavioural change for health education design  – case studies

An understanding of the barriers and facilitators of behavioural change is important to understand how best to motivate patients towards healthy living and active cooperation with clinicians.

To give an example of applying this understanding to the industry, the Blazed and Wasted campaign sought to reduce driving after drinking in young males. A programme to increase knowledge and education about safe alcohol consumption limits for driving was put in place with an aim to allow people to make informed decisions. To further increase motivation to choose alternate transport methods or to drive safely, consequences of drink driving were demonstrated. Free breathalyser packs were provided for people to self-check before driving. To provide more opportunities, bars and pubs were encouraged to provide more mocktail options. Use of bus services increased by 30% during the campaign period [10].

In the case of chlamydia testing for young people, the barriers of seeking care and treatment are examined through the COM-B model [11]. Factors that decrease motivation to have a test include existing perceptions of risk, plus embarrassment to seek sexual health support.

Young people who perceive themselves as less likely to be at risk of chlamydia (possibly due to lack of awareness) were less likely to test. Young women sometimes would experience shame and embarrassment, with the fear of being judged by healthcare professionals for having unprotected sex. From a provider perspective, testing related to sexual health needs to be standardised and normalised to increase capability and opportunity of healthcare. Good communication between practitioners and patients’ also needs to be appropriately framed and approached with caution.

Empowering patients with information – Cognitant’s role in promoting patient education

For patients to have the most accurate and objective understanding of their condition or treatment, reliable information must be provided. Cognitant Group is a healthcare technology company, with a mission to improve health outcomes by empowering people with clear, reliable health information and support tools. Instead of searching symptoms on Google and conducting “self-diagnosis”, patients can learn about their conditions and view trusted health information that is accurate and approved.

When referring to the COM-B model, Cognitant helps to address a person’s ‘capability’ to make behavioural changes to their health, supporting them with the necessary knowledge, skill, or mental preparation to help them to better manage their health. To maximise the effectiveness of this, Cognitant focuses on ensuring that the educational resources are co-created with patients and easy to understand for all ages and all abilities. This addresses the need for accessible healthcare services, ensuring that there is no barrier to those who are disadvantaged. Cognitant also addresses the ‘opportunity’ aspect of the COM-B model by maximising the opportunity for people to gain access to the right health information at the right time. The digital platform for health information prescriptions, Healthinote – www.healthinote.com, allows clinicians to prescribe trusted, validated information to patients, who can access this information at home through various digital methods, hence maximising accessibility.

Cognitant’s digital support centre “My Stroke Companion” launched in 2022 allows clinicians to send personalised information regarding symptoms, medication, treatments, and lifestyle tips to patients on the Healthinote platform. The easy-to-understand content omits medical jargon and includes various formats such as illustrative images and interactive videos, provided in different languages. Similar resources for other diseases, such as chronic kidney disease or asthma, have also been developed by Cognitant.

Cognitant recognises this issue and therefore offers information in visual formats such as videos, easy to understand language instead of medical jargons, and various languages that supports non-English speakers.

Empowering patients with the right information at the right time not only builds a good basis of existing knowledge for patients who are not yet diagnosed, but also ensures an accurate input of information for newly diagnosed patients to integrate into their existing knowledge system in order to make informed decisions. On average, Cognitant’s health education resources deliver a 70% increase in patient knowledge and 35% intention to change patient behaviour. Orienting patients to validated and accessible information is the basis to empower patients to make informed decisions and healthy behavioural changes.

 Conclusion

In order for health education to be delivered in an effective way that drives improved health outcomes, it is essential to consider how people are motivated to change their behaviours. This requires an understanding of how humans process information, internalise it and use it to make decisions, remembering that humans can differ in how they process information and process their decision making. In order to facilitate behavioural change relating to health management, reliable and accessible information must be provided so that people have the most accurate and objective understanding of their condition or treatment. This requires design of education that carefully responds to a clear understanding of the barriers and facilitators of behavioural change is, thus guiding people towards healthy living and active cooperation with treatment advice.

About the author

Christina (Chang) He is a Psychology undergraduate the University of Oxford. Christina completed a business internship at Cognitant as part of the Liber Programme supported by the University of Oxford and Saïd business school. During this internship, Christina applied her experience as a Psychology student to a broad range of Cognitant’s activities around the delivery of personalised, accessible health information and support tools.

References

[1] Miller, S. M., Shoda, Y., & Hurley, K. (1996). Applying cognitive-social theory to health-protective behavior: breast self-examination in cancer screening. Psychological bulletin, 119(1), 70.

[2] Miller, S. M. (1987). Monitoring and blunting: validation of a questionnaire to assess styles of information seeking under threat. Journal of personality and social psychology, 52(2), 345.

[3] Lau, R. R., Hartman, K. A., & Ware, J. E. (1986). Health as a value: methodological and theoretical considerations. Health psychology, 5(1), 25.

[4] Miller, S. M., & Diefenbach, M. A. (1998). The Cognitive-Social Health Information-Processing (C-SHIP) model: A theoretical framework for research in behavioral oncology. Technology and methods in behavioral medicine, 219-244.

[5] Alegria Drury, C. A., & Louis, M. (2002). Exploring the association between body weight, stigma of obesity, and health care avoidance. Journal of the American Academy of Nurse Practitioners, 14(12), 554-561.

[6] Macarthur, A. J., Macarthur, C., & Bevan, J. C. (1995). Determinants of pediatric day surgery cancellation. Journal of clinical epidemiology, 48(4), 485-489.

[7] Miller, S. M., & Diefenbach, M. A. (1998). The Cognitive-Social Health Information-Processing (C-SHIP) model: A theoretical framework for research in behavioral oncology. Technology and methods in behavioral medicine, 219-244.

[8] Rowlands G, Protheroe J, Winkley J, Richardson M, Rudd R. 2014. Defining and describing the mismatch between population health literacy and numeracy and health system complexity, an observational study. (Submitted to the BMC Public Health for peer review).

[9] Michie, S., van Stralen, M.M. & West, R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Sci 6, 42 (2011). https://doi.org/10.1186/1748-5908-6-42

[10] Blazed and Wasted Campaign Evaluation, August 2014, Road Safety Analysis Report, https://www.roadsafetyknowledgecentre.org.uk/rskc-1336/

[11] McDonagh, L.K., Saunders, J.M., Cassell, J. et al. Application of the COM-B model to barriers and facilitators to chlamydia testing in general practice for young people and primary care practitioners: a systematic review. Implementation Sci 13, 130 (2018). https://doi.org/10.1186/s13012-018-0821-y