Cognitive dissonance and positive health behaviours: a systematic review shows dissonance-based interventions can be successful

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Most of us have heard of cognitive dissonance although the term is often used incorrectly. I’m sure when you find out you thought you were using it correctly but weren’t, you’ll feel bad. Cognitive dissonance refers to a state of psychological discomfort that arises from conflicting attitudes or beliefs. For example you may have a strong belief that you eat healthily, and then feel ashamed, embarrassed or uncomfortable when someone points out the cake the size of a Labrador’s head that you ate yesterday. Producing cognitive dissonance in people has been identified as a possible technique for producing positive changes in health behaviours. As such, interventions based on cognitive dissonance often involve creating a difference between an individual’s beliefs and their behaviour, following one of the following paradigms:

  • Hypocrisy dissonance is produced when people make a positive statement about a particular behaviour and are then reminded of the past instances when they have failed regarding that behaviour

    Hypocrisy dissonance is produced when people make a positive statement about a particular behaviour and are then reminded of the past instances when they have failed regarding that behaviour

    Belief disconfirmation – dissonance is produced when people are presented with information that contradicts their existing beliefs

  • Free choice – dissonance is produced when people think about the positive aspects of a choice that they have already rejected
  • Effort justification – dissonance is produced when people take part in a task that requires a lot of effort for apparently little or no purpose
  • Induced compliance – dissonance is produced when people act in opposition to their existing attitudes for apparently no purpose
  • Hypocrisy – dissonance is produced when people make a positive statement about a particular behaviour and are then reminded of the past instances when they have failed regarding that behaviour

However, it is not currently known whether dissonance-based interventions attempting to change non-clinical health behaviours such as smoking and alcohol use are useful. There is increasing evidence that various health behaviours might be amenable to dissonance-based interventions and therefore this systematic review aimed to draw together research in order to determine if dissonance-based interventions are effective at changing health behaviours, attitudes or intentions.

Methods

The studies analysed were identified through searches of relevant electronic databases e.g. PsychINFO, MEDLINE. Additional papers were sought via dissertation, theses databases and Google scholar.

Studies included had to satisfy a number of eligibility criteria:

  • All studies that tested people before and after a dissonance intervention using a numerical scoring system testing an intervention related to a health behaviour were considered
  • The participants in the studies had to be older than 2 years and less than 65 years old
  • Studies investigating interventions for health behaviours described as “dissonance-based” were considered
  • The measures of health behaviours that were of interest were self-reported or observed changes in health behaviour, attitude and intention. If a study did not include at least one of these measures it was not included
  • Studies that looked at behaviours that might be described as clinical e.g. eating disorder symptoms were not included

Any potentially relevant studies were selected by screening of article titles and abstracts. These studies were then read in full and it was decided if they were to be included for analysis based on the eligibility criteria.

Information about the studies was obtained by completing a form which was developed during a previous pilot study. Any research included in the systematic review was also reviewed for risk of bias.

Results

Studies included:

Twenty articles were identified for inclusion in the systematic review.

The majority of studies reported a positive effect on one or more of participant’s health behaviour, attitudes or intention following dissonance-based intervention.

The majority of studies reported a positive effect on one or more of participant’s health behaviour, attitudes or intention following dissonance-based intervention

Health related behaviours that were targeted by the studies included were:

  • Sexual health behaviours
  • Smoking
  • Sun protection
  • Drug use, weight loss
  • Exercise
  • Driving behaviour
  • Alcohol use
  • Playground risk behaviour
  • Healthy lifestyle behaviours

Three of the studies involved children and adolescents while the rest investigated interventions in adults. Seventeen of the studies investigated mainly females with five of the seventeen studies involving entirely female population samples.

Out of the 20 studies included, the paradigms of cognitive dissonance interventions used were:

  • 1 effort justification
  • 1 belief disconfirmation
  • 4 induced compliance
  • 14 hypocrisy

Effectiveness

The majority of studies reported a positive effect on one or more of participant’s health behaviour, attitudes or intention following dissonance-based intervention. Within the studies, changes in peoples’ attitudes and intentions were usually consistent with changes in their health-related behaviour.

Bias

The studies that this systematic review looked at had varying degrees of bias, but bias within each study was usually not addressed. For example, bias in terms of the selection, randomisation and allocation of people in the studies to interventions could not be assessed as too little information on the processes used was provided.

Many of the studies mainly recruited college students and as already noted many only really looked at the effect of intervention on women. This means it may be difficult to generalise any results to the larger population. A lot of the studies required the people taking part to report changes in attitude etc. themselves. This might mean that people were reporting changes not because of the intervention, but because they judged a change as being socially desirable.

Conclusions

Using objective measures of change in behaviour, attitude and intention will help to reduce bias in future research

Using objective measures of change in behaviour, attitude and intention will help to reduce bias in future research

The authors concluded that evidence regarding effectiveness of dissonance-based studies was largely positive and that within studies changes in behaviour were generally consistent with changes in attitude and intention. These findings are consistent with previous research. The hypocrisy paradigm was the most commonly used paradigm to induce cognitive dissonance and appeared to be the most effective in producing positive changes in health behaviours, attitudes and intentions.

However, future studies in this area need to address their risk of bias e.g. need to use an objective measure of change in behaviour, attitude and intention. Studies with some degree of follow-up, determining if positive changes in health behaviours were upheld in the long term would also be useful.

Summary

This systematic review shows that dissonance-based interventions may be useful for inducing positive health-related behaviours, for example, reducing alcohol use, safer sexual behaviours and so on. However it is not clear who would deliver these interventions. Would you need access to a psychologist, could dietitians deliver them or would your GP have to sort it all out?

Future studies may also need to focus on more objective measures than those generally used as well as determining if these interventions produce effective change in the long-term.

In terms of the actual intervention the hypocrisy method was the most studied and was the most effective in producing positive health behaviour changes. If this isn’t what I have argued in the past then I’m very sorry.

Links

Freijy. T, & Kothe. E.J. Dissonance-based interventions for health behaviour change: a systematic review. Br J Health Psychol. 2013 May;18(2):310-37. [Pubmed Abstract]

Festinger. L, & Carlmsith. J.M. Cognitive consequences of forced compliance. J Abnorm Psychol. 1959 Mar;58(2):203-10. [Pubmed]

Abraham, C., Kok, G., Schaalma, H. & Luszczynska, A. (2010). Health Promotion. In, P.R., Martin, F., Cheung, M., Kyrios, L., Littlefield, L., Knowles, M., Overmier, & J., M., Prieto (Eds.). The International Association of Applied Psychology Handbook of Applied Psychology. Oxford: Wiley-Blackwell. [PDF]

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David Steele

Dave Steele has degrees in Medicine and Applied Psychology. He has previously worked as an assistant for adults with learning disabilities, in psychology research (primarily schizophrenia and Alzheimers disease) and as a nursing assistant in an adolescent psychiatric unit. He has a particular interest in mental health stigma having written blogs previously on the subject (among myriad others) and has provided psychiatry teaching material on the stigma of mental illness and the diagnosis and management of delirium. He is also interested in schizophrenia, old age psychiatry, liaison psychiatry and the organisation of mental health care. He can be found on twitter, albeit talking about more varied (and most often nonsense) topics as @hullodave.

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