Identifying similar health-related behaviour and attitudes in school children – the Hungarian experience

In recent years, the improvements in the health of Hungarians has not matched the socioeconomic development of the country.  Several unhealthy behaviours are widespread in the Hungarian population, so changes are needed to improve population health. In order to plan effective interventions for children, a study took place covering of children in the 5th and 9th school years, aiming to identify homogeneous groups with similar health-related behaviour and attitudes, and their specific characteristics. In order to do this, a new methodology and segmentation procedure based was applied. This was based on the COM-B model, which explains behaviour as being determined by capability, opportunity, and motivation.

By Péter Csizmadia

This study covered several research fields, such as survey methodology, statistics, psychology, and health promotion. The Methodology was published in the International Journal of Public Health [1], and a paper on results has been submitted to Journal of Applied Behaviour Analysis by Birkás Béla, a psychologist.

The COM-B model

The COM-B model. From the Inherit Baseline review available at Based on Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci.2011;6:42

The advantage of the COM-B model is that is encompasses all possible determinants of behaviour, and therefore allows to identify ways in which interventions might stimulate  behavioural changes. It has been successfully used to explain and modify various health behaviours, such as tobacco use and for health practitioners’ risk-assessment strategies to improve prevention guidelines, promote perinatal behavioural change, or maintain positive health behaviour.

The components of the COM-B model and the suggested relationship between them allows for a precise description of the groups identified by the model. These details may provide professionals with opportunities to gain additional information about particular groups. More specifically, information about the main communication channels used by individuals and the characteristics of particular behaviour is essential to creating targeted and effective behavioural interventions.

The study

In the first phase of the study, questionnaires were developed for students in school years five and 9. These covered all components of the COM-B model, namely capacity, opportunity, motivation, and behaviour. The collected data was analysed using a type of latent class analysis (LCA) method for segmentation. The analyses identified eight different groups with similar health-related behaviours and attitudes (three groups in the 5rd year and five in the 9th year). This clustering of different characteristics may help analyse unhealthy behaviour and plan interventions for behavioural change. For example, in the 5th grade children we identified a group who we considered to be unhealthy. Children in this group often consumed fast food, energy drinks and chips, and lived a sedentary lifestyle. Moreover, this group had limited time or opportunity to access a computer at home, lacked self-confidence, and was not motivated to attend school. These children often lived in large families where family members do not spend adequate amounts of time with each other. In the next phase, we used the COM-B model and Behaviour Change Wheel (BCW) framework to define possible interventions for improving health-related behaviour in the Hungarian population. Since each group possesses a specific set of characteristics, it is essential that prevention strategies and behavioural interventions are customised to their target groups. Although groups may share common attributes, they differ from each other in respect to other characteristics, and need to be targeted very specifically.

The Behavioural Change Wheel with COM-B in the centre. From the Inherit Baseline review available at Based on Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci.2011;6:42

We identified barriers and enablers that affected these groups’ behaviour. In the example, the factors contributing to the bad health of these children included an unhealthy lifestyle and diet. Their low self-confidence and motivation to attend school may correlate with a lack of trust in their competences. Therefore, if we can enhance success in school and improve these children’s sense of confidence and competence, we can positively influence motivation and attitudes towards school and learning.

In line with these assumptions, we proposed using a behavioural change strategy that considered the children’s key competences, such as good computer proficiency. School activities that target well-developed skills of students and provide experiences of success and competence are probably suitable to increase motivation and commitment towards learning. More positive attitudes towards school and learning might impact children’s interest in information and activities regarding healthy diet and healthy lifestyles. Moreover, health-related interventions in schools might increase children’s understanding of the impact of their actions and ways to adopt healthy behaviour.

There is an increasing demand for effective and integrated health policies, strategies and interventions that act on the causal link between health determinants and health outcomes. The BCW framework is useful, as it enables the practical assessment of integrated health policies. By using this framework to analyse behavioural systems, our study provided relevant information about health-related attitudes and behaviour in school children. This information can now be used to develop interventions in which all three aspects of behaviour (motivation, capability and opportunity) are addressed to establish more integrated health policies.

[1] Balku E, Tóth G, Nárai E, Zsiros E, Varsányi P, Vitrai J. Methodology for identification of healthstyles for developing effective behavior change interventions. J Public Health. 2017;25: 387-400.

Péter Csizmadia
Hungarian Public Health Center | + posts

Péter works for the Hungarian Public Health Center, and has been active in the field of health promotion for many years.

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