Making decisions about benefits and harms of medicinesBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7456.47 (Published 01 July 2004) Cite this as: BMJ 2004;329:47
Box A: Some health and social psychology explanations of health-related decision-making
Health belief model. Any health-related decision is influenced by five key factors: (a) perceived susceptibility to an adverse health state; (b) perceived severity of that state, including physical and social consequences; (c) perceived efficacy of a particular intervention in reducing the threat of illness; (d) perceived barriers to taking action (physical, psychological, financial); and (e) a cue to action such as a relevant symptom or illness in a close family member.w12 A sixth factor was later added to this model: (f) self-efficacy – confidence in one’s ability to take action w13.
Theory of planned behaviour. A particular behaviour is determined most immediately by the intention to behave in that way. Intention is in turn determined by (a) subjective norms (beliefs about what behaviour is expected by significant others and motivation to comply with these expectations); (b) attitudes towards the behaviour (based on beliefs about, and evaluation of, the likely consequences of that behaviour); and (c) perceived (internal and external) behavioural control w14.
Stages of change (‘transtheoretical’) model. An individual faced with a behaviour change will be in one of five states: (a) pre-contemplative (in which they are not even considering the change); (b) contemplative (in which they are considering the change but not attempting to change); (c) preparation (in which they are getting ready to make the change); (d) action (in which they are actively making the change); and maintenance (in which they are attempting to maintain the change). Movement between states is due to decisional balance, i.e. the outcome of weighing costs and benefits. The model suggests different approaches to influencing and supporting the patient, depending on their state at the time w15.
Box B: Other explanations of health-related decision-making
Social modelling. In Bandura’s words: "Most human behavior is learned observationally through modeling: from observing others, one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action." w16 (p22). In many social situations, especially those involving complex choices, we do what we believe someone like us would do in such circumstances.
Psychoanalytic theory. Two key concepts are the existence of the unconscious (i.e. human feelings, behaviour and symptoms are determined partly by influences inaccessible to our everyday awareness) and the critical impact of early childhood experience on the development of personality and subsequent behaviour. This leads to repression, denial and other irrational forces that influence decision-making.15
Narrative theory. A narrative (story) has four key features: a teller and listener (or reader); characters (agents who do things and to whom things happen); an account of events over time; and surprise (something unexpected happens, which often needs to be put right). The focus of analysis in narrative is meaning (why people behaved and things unfolded as they did). Narrative is inherently creative (in particular, the teller can construct and reconstruct identities for the characters) and rhetorical (it is a powerful tool of persuasion). To these ends, the teller uses a range of literary devices such as suspense, humour, metaphor, satire, allegory, self-disclosure and so on. w17
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w8 Chapman LJ, Chapman JP. Genesis of popular but erroneous psychodiagnostic observations. Journal of Abnormal Psychology 74: 271-280, 1969.
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w12. Rosenstock IM, Stecher VJ, Becker MH. Social learning theory and the health belief model. Health Education Quarterly 1998;15:175-83.
w13. Bandura A. Social learning theory. Englewood Cliffs, New Jersey: Prentice-Hall, 1977.
w14. Azjen I. The theory of planned behaviour. Organizational Behaviour and Human Decision Processes 1991;50:179-211.
w15. Prochaska VO,.Velicer WF. The transtheoretical model of health behavior change. American Journal of Health Promotion 1997;12:38-48.
w16. Bandura A. Social foundations of thought and action: a social cognitive theory Englewood Cliffs, New Jersey: Prentice-Hall, 1986.
w17. Greenhalgh T. Narrative and the primary care consultation. The academic basis of primary health care, London: BMJ Publications (in press), 2004.
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