Vous êtes sur la page 1sur 222

Health Behavior Theories

1. Understand the importance of theories in health promotion planning

2. Know the importance of theories in making the change

in behaviors, policies, organizations and communities. 3. Identify the most prominent types of theories used in HP

4. Know the characteristics and limitations of these


How are theories used in health promotion?

Theories explaining behavior change in individuals Theories explaining change in communities Theories explaining change in organizations Models of developing healthy public policies

systematically organized knowledge applicable in a relatively wide variety of circumstances ..

devised to analyze, predict or otherwise explain

the nature or behaviour of a specified set of phenomena .. that could be used as the basis for action

Understand the individuals` behaviour,

organizations and communities they work with; Development of health promotion strategies

and plans
Explain the factors promoting and inhibiting change at the individual, community and societal levels

Used in designing and implementing health promotion programmes Drawn from other disciplines: psychology, sociology , management sciences, marketing, consumer behaviour, political science Improves the effectiveness of interventions



Health Belief Model Theory of Reasoned Action / Planned Behaviour Transtheoretical (Stages of Change) Model Social Learning Theory Community mobilization Social planning Social action Community development Diffusion of Innovations Communication for behaviour change Social marketing Theories of organisational change Models of intersectoral action

Explain health behaviour and health behaviour change in the INDIVIDUALS

Explain change in COMMUNITIES and community action for health

Guide the use of COMMUNICATION strategies for change to promote health

Models that explain changes in ORGANIZATION and the creation of health-supportive organisational practices

Models that explain the development and implementation of healthy public POLICY

Ecological framework for policy development Determinants of policy making Indicators of health promotion policy

Areas of health promotion action and related theories and models (Nutbeam & Harris, 2004)

Picture: G Dahlgren and M Whitehead Policies and Strategies to Promote Social Equity in Health (Institute of Futures Studies Stockholm 1991)

What is Health Behavior Theory

Theres nothing quite so useful as a good theory- K. Lewin

Health behavior theories provide a basis for: Understanding and explaining human behavior Planning, implementing, and evaluating individual and community health interventions

What is Theory
A theory is a set of interrelated concepts, definitions, and propositions that present a systematic view of events or situations by specifying relations among variables in order to explain or predict the events or situations .

A health promotion programme or intervention is most likely to benefit participants and the community when it is guided by a

theory of health behaviour.

Why Theory?
Theory is the mother of practice. Without theory, practice is just routine born of habit.


Why Theory?
In the context of professional practice theories are essentially statements identifying factors that are likely to produce particular results under specified conditions

Why Theory?

Theories of health behaviour identify targets for change and the methods for accomplishing these changes.

Why Theory?
Theories also inform the evaluation of change efforts by helping to identify the outcomes to be measured and the methods of study to be used.

Other terms often used

Concepts building blocks, primary
elements of a theory

Constructs key concepts developed

or adopted for a particular theory

Variables operational forms of

constructs, way construct is measured

Models number of theories to help

understand a particular problem in a certain setting or context

Helps design interventions based on understanding of behavior Moves beyond intuition Consistent with using evidence-based interventions Explains dynamics of health behaviors and processes to change them Helps identify suitable target populations Helps define what should be evaluated

How Theory Can Help Programs

A good theory makes assumptions about a behavior, health problem, target population or environment that are: Logical Consistent with everyday observations Similar to those used in previous successful programs Supported by past research in the same or related areas

Characteristics of a Useful Theory

3-in-1 approach with theory

Individual/intrapersonal approaches
Individual characteristics that influence behavior KAB, personality

Interpersonal processes and primary groups family, friends, social identity, social support

Community Level

3-in-1 approach with theory

Institutional Factors (rules, regulations,
policies that may constrain/promote

behavior) Community Factors (informal and formal

social networks, norms and standards among individuals., groups and organizations.)

Public Policy (policies & laws that

regulate or support healthy actions and practices)

Intrapersonal/Individual Theories

The Health Belief Model

The Health Belief Model

* Oldest model of health behaviour. * Model most widely used to explain behaviour. * Developed by the US Public health service in 195 * Originally to explain uptake of: screening immunisation * Now also applied to : sick-role behaviour illness behaviour clinic utilisation risk factor behaviours * Explains and predicts behaviour.

The Health Belief Model ...

* is a value expectancy theory * views behaviour of an individual as a function of the: a) subjective VALUE he/she gives to an outcome b) EXPECTATION that he/she has that a particular action will achieve that outcome.

In the context of health behaviour

a) the desire to avoid illness or to get well (VALUE) b) the belief that a specific available health action would prevent or ameliorate illness (EXPECTANCY)

Specifically, the HBM consists of the following dimensions: * Perceived susceptibility * Perceived severity
* Perceived benefits
* Perceived barriers

* Cues to Action
* Demographic and Sociopsychological Variables

* Perceived Susceptibility An individuals subjective perception of his or her risk of contracting a condition. (personal vulnerability).

* Perceived Severity
An individuals subjective perception of how serious it would be to them to contract an illness or to leave it untreated.
* Perceived Susceptibility + Perceived Severity

Perceived Threat

* Perceived Benefits
How effective does the individual believe taking the available actions to be in reducing the threat? Includes non-health-related benefits.

* Perceived Barriers What potential barriers does the individual perceive which may impede undertaking the behaviour?

(A nonconscious cost - benefit analysis)

* Cues to Action
The readiness to take action has to be potentiated by internal ( ie symptoms) or external (eg media, interactions with others etc)

* Demographic and Sociopsychological Variables. These

thus indirectly influence health-related behaviour. Eg, educational attainment influences perceived susceptibility, severity, benefits and barriers.

The Health Belief Model

Self Efficacy
* Introduced in 1977 in Banduras Social learning theory. * Defined as ones confidence in ones ability to take action. * Added to the HBM in 1988.

Confidence in ability to change Approach change in small steps Performance accomplishments Modeling observing the successful performance of others Verbal persuasion, encouragement




Demographic Variables (age, sex, race, ethnicity, etc.) Sociopsychological Variables (personality, social class, peer and reference group pressure, etc.
Perceived Susceptibility to Disease X plus Perceived Seriousness (severity) of Disease X

Perceived Benefits of Preventive Action minus Perceived Barriers to Preventive Action

Perceived Threat of Disease X

Likelihood of Taking Recommended Preventive Health Action

CUES TO ACTION Mass Media Campaigns Advice from Others Reminder Postcard from Physician or Dentist Illness of Family Member or Friend Newspaper or Magazine Article
The Health Belief Model Used as a Predictor of Preventive Health Behavior

Health Belief Model

Perceived Susceptibility
PERCEIVED THREAT Perceived Benefits Perceived Barriers

Perceived Severity

Health Belief Model

Perceived Susceptibility PERCEIVED THREAT Perceived Barriers

Perceived Benefits

Perceived Severity

Behavior Change

Health Belief Model

Perceived Susceptibility

Ones opinion of chances of getting a condition

Define population(s) at risk, risk levels Personalize risk based on a persons features or behavior Heighten perceived susceptibility if too low Specify consequences of the risk and the condition Define action to take: how, where, when; clarify the positive effects to be expected

Perceived Severity

Ones opinion of how serious a condition and its sequelae are Ones opinion of the efficacy of the advised action to reduce risk or seriousness of impact

Perceived Benefits

Health Belief Model

Concept Definition Application
Perceived Barriers Ones opinion of the tangible and psychological costs of the advised action Strategies to activate readiness Confidence in ones ability to take action Identify and reduce barriers through reassurance, incentives, assistance

Cues to Action

Provide how-to information, promote awareness, reminders Provide training, guidance in performing action


Perceived susceptibility
1. What are the chances that you might contract AIDS?
2. To what extent are you afraid that you might contract AIDS?

Amount: Very low

Very high

Perceived severity
1. AIDS causes death. 2. AIDS reduces the bodys natural protection against diseases. 3. There is no cure for AIDS at present. 1 2 3 4 5
Very high

Level of Agreement: Very low

Perceived benefits
1. The chances of contracting AIDS can be significantly reduced by using a condom.

2. Using a condom reduces the risk of contracting most sexually transmitted diseases.

Level of Strongly Agreement: disagree

Strongly Agree

Perceived barriers
1. Using a condom seems like an insult to my partner. 2. Using a condom, or suggesting using it, ruins the moment. 3. It is embarrassing to me to carry condoms regularly. 4. It is embarrassing to me to buy condoms. 5. Using a condom is, or would be, embarrassing. 6. I do not enjoy, or think I might not enjoy, sex when using a condom. 7. Most of my friends believe that condoms are too much of a hassle to use. 8. Many of my friends believe that using a condom interferes with spontaneity. 9. Most of my friends believe that using a condom inhibits sexual pleasure. Strongly Strongly Disagree Agree Level of Agreement: 1 2 3 4 5

Cues to Action
1. Did you get any information referring to condom use and its relationship to the prevention of AIDS, from radio, TV, medical staff, family or friends? 2. Did you get any practical suggestions referring to condom use?

Amount: Not at all

To a great extent

Self Efficacy
1. It is difficult for me to discuss sexual habits or preferences with my sex partner. 2. I have problems (or would have) talking about the use of a condom with sexual partners. 3. I have no problem in the use of a condom on a regular basis. 4. I can always tell a sex partner that I wont have sex with him/her unless we use a condom.

How can we affect...

Perceived Severity

Perceived Susceptibility

How can we affect...

Perceived Benefits

Perceived Barriers

Cues to Action
* provide how to information

* promote awareness * employ reminder systems

Health Belief Model Example: HIV/AIDS

Belief in reality of the health threat general health values

I am concerned about my health

specific beliefs about vulnerability

As a person who has unprotected sex, I could get AIDS

beliefs about severity of the disorder

I would die if I developed AIDS

Belief that a behavior can reduce threat belief that it can protect against a threat

Health Behavior:

I will always use condoms.

If I always use a condom, I will not develop AIDS.

belief that benefits of health measure exceed costs

Even though it will be hard to always use a condom, it will be worth it.

Self Efficacy

* Provide training and guidance in performing action

* Use progressive goal setting.

* Give verbal reinforcement.

* Demonstrate desired behaviours.

* Reduce anxiety.

Research with the Health Belief Model

Predicts some behaviors, such as sexual risk, screenings. However, the research is inconsistent. Perceived barriers and susceptibility to the disease are most powerful predictors. May be most predictive in highly educated, more affluent (i.e., high SES) populations.

Theory of Reasoned Action and Planned Behavior

Behavioral intentions:
Attitudes Subjective Norms

Perceived Behavior Control

similar to self-efficacy

Theory of Reasoned Action

there is one primary determinant of behavior, namely the persons intention to perform it. This intention is itself viewed as a function of two determinants - the persons attitude toward performing the behavior ( based on his/her beliefs about the consequences of performing the behavior, i.e. his or her beliefs about the costs and benefits of performing the behavior) and - the persons perception of the social (or normative) pressure exerted upon him or her to perform the behavior.

the likelihood of performing a given behavior is determined by intentions, habits and facilitating factors.
Intentions are, in turn, viewed as a function of : - perceived consequences of performing the behavior (outcome expectancies) - social influences (including norms, roles and the self concept) and emotions

Theory of Reasoned Action (1975) and Theory of Planned Behaviour (1986)

Beliefs that the behavior leads to certain outcomes and ones evaluation of these outcomes Attitudes toward the behavior

Beliefs that others think one should or should not perform the behavior and ones motivation to comply Control beliefs

Relative importance of attitudinal and normative considerations



Subjective norm

Perceived power

Perceived behavioural control

Theory of Reasoned Action

Works moderately well when behavior is very specifically defined
Not well when we are trying to understand global behavior

Reasoned Action/Planned Behavior: Example

Smoking Cessation
Attitude toward the Behavior: "You know what? I think, smoking is dangerous for my health." Subjective Norms: "I wonder if my wife would like me to quit smoking." Perceived Behavioral Control: "I can quit smoking, even if Im hooked on cigarettes!" Intention: I want to quit smoking right now!" Behavior: "I am not smoking anymore. Instead of taking a cigarette, when I get the cravings, I chew gum."

Example Theory of Reasoned Action

Target Population: Clients of Seniors Centre that serves 2000 Senior citizens

Quality of Life/Health Issue: Prevention of Osteoporosis Behavioural Issue: low rates of physical activity in aging population

Interviews revealed several clear patterns:

*Many older adults believed that at their age, there was little benefit from physical activity *Many older adults reported that their friends and neighbours were not physically active. *Many older adults and some family members thought of physical activity as jogging or bicycling, as they saw the young people in the park doing. *Many family members of older adults thought that physical activity would be dangerous for their relatives.

According to the Theory of Reasoned Action, the best predictor of a person taking some health-related action is whether the person intends to take action. Intention is determined by 2 factors:
1. The persons attitude towards the behaviour 2. What the person thinks other people want him/her to do : the behaviour.

A persons attitudes are made up of:

a. Beliefs about the outcomes of doing the behaviour b. Beliefs about how desirable or undesirable those outcomes are. A persons perceptions of others beliefs are determined by: i) What the person thinks others would like him to do ii) how much or how little the person wants to comply with what others think he should do.

In summary:
When a person believes a behaviour will lead to some valuable outcome, and believes that others whom that person respects and wants to please think he or she should engage in the behaviour, then the person is more likely to intend to take

action, and therefore is more likely to act

To change older adults attitudes about physical activity: Add a new, positive belief
physical activity like walking is safe and beneficial, can be a social activity with friends and can reduce your risk of injury by making your body stronger

Reinforce an existing positive belief

Remember how much you used to enjoy a more active lifestyle? Regular physical activity can help you become that way again

Challenge an existing negative belief

You think you are too old, but doctors say its one of the best things you can do for yourself no matter what your age

Enhance the perceived desirability of a new or existing belief

The stronger you are the less youll have to rely on others, the longer youll be able to live independently and the more you can play with your grandchildren.

To change older adults beliefs about what others want them to do: Change the attitudes of important others Help family member and friends recognise the value of physical activity for older adults and ask them to support and encourage their efforts to be more active. Add new others to their lives Introduce new social contacts, such as members of a walking club, a doctor, a pharmacist who support physical activity. Challenge their beliefs about what others think they should do Actually, your friends, your family and your doctor all think it would be a good idea for you to become more active why dont you ask them? Change the motivation to comply with others. You shouldnt be concerned with what Mr Jones thinks; your doctor and your family think its a good idea for you to be physically active

The Transtheoretical Model

Common principles of behavior change

Integrates variables from other health behavior theories

The Transtheoretical Model

INTENTIONAL Behavior Change
Stages of Change Processes of Change Decisional Balance (Pros/Cons) Situational Self Efficacy (Temptations)

Different variables predict stage movement for each stage

The Stages of Change:

Maintenance Action Preparation Contemplation, Pre contemplation

Not Ready To Act


no intention to start taking action in next 6 months

Characteristics of a Precontemplator:

Avoid reading, talking, and thinking about the behavior that needs to be changed. The least confident about ability to take action. Most resistant to public policy changes. Feel pressured by others to take action, but have developed defenses to cope with such pressures. Typically less than 1% of those at risk participate in traditional programs. About 40% of people at risk are in Precontemplation.

Thinking About Taking Action

to start in next 6 months

Characteristics of Contemplators:

Substitute thinking for acting Often waiting for the magic moment Not confident enough about their abilities to change, feel unprepared

Ambivalent about changing

Typically less than 1% of those at risk participate in traditional programs About 40% of people at risk are Contemplators

Getting Ready to Take Action

the behavior


to start in next 30 days

Characteristics of Preparation:

More confident & less tempted Assess the Benefits (Pros) as higher than the Costs (Cons) Most likely to participate in programs and most likely to benefit Participants that health promotion programs love Less than 20% of people at risk are in Preparation

Recently Started to Change Behavior

for less than 6 months

Has Changed Behavior


6 months or more

The Stages of Change

Precontemplation Contemplation Preparation Action Maintenance Not thinking about changing Seriously thinking about changing Intending to change in the near future

Having made a change attempt

Having sustained a change attempt

* the ultimate goal for all changers * the persons former addiction or problem will no longer be a threat or a temptation * the person will have complete confidence that he/she can cope without fear of relapse

* regressing to an earlier stage * relapse and recycling through the stages is the rule rather than the exception

* the vast majority of relapsers recycle back to the contemplation or preparation stages.

Do you really intend to quit smoking in the next six months?

Do you smoke now?

Were you ever a smoker?






Do you intend to quit in the next month?


Have you smoked in the past six months?


In the past year did you quit for at least 24 hours?






Do you really intend to begin exercising regularly in the next six months?

Do you exercise regularly now?

Have you Exercised regularly For more than 6 months?




Do you intend to start in the next month?


In the past year did you exercise regularly 3 times a week for at least a week?






The Transtheoretical Model of Change Processes of Change

Consciousness Raising
Increasing information about self and problem

Dramatic Relief
Experiencing and expressing feelings

Environmental Reevaluation
Assessing how smoking affects physical environment

How one feels about oneself with regard to smoking

Choosing and committing to quit

The Transtheoretical Model of Change

Processes of Change
Reinforcement Management Rewarding ones self, or being rewarded by others for not smoking Counterconditioning Substituting alternative behaviors for smoking Stimulus Control Avoiding or countering smoking cues Helping Relationship Being open and trusting about smoking with someone who cares

The Transtheoretical Model of Change The Integration of Stages and Processes

Stage of Change in Which Particular Processes of Change Are Emphasized

Precontemplation Contemplation Preparation Action Maintenance

Consciousness Raising Dramatic Relief Environmental Reevaluation Self-reevaluation


Stimulus Control Counterconditioning Reinforcement Management Helping Relationship

Processes of Change

people change


affective, evaluative, interpersonal , and behavioral strategies and techniques used to change behavior transitions between stages of intervention design



Processes of Change
Experiential Processes Behavioral Processes

Thinking, Feeling or Experiencing


Consciousness Raising Dramatic Relief Self-Reevaluation Self-Liberation Environmental Reevaluation Social Liberation

Helping Relationships Reinforcement Management Counter Conditioning Stimulus Control

Transtheoretical Model Core Constructs

Decisional Balance
Pros and Cons

Decisional Balance
* A measure of the weight a person gives to the pros of the unhealthy behaviour (benefits) and the cons of the unhealthy behaviour (disadvantages) * The relative strength of each persons pros and cons for a given behaviour can be predictive of their readiness to change. * The pros of changing increase from precontemplation to contemplation. * The cons of changing decrease from contemplation to action

Decisional Balance
Pros of Change
perceived positive consequences the benefits of changing

Cons of Change
perceived negative

consequences costs of changing

Transtheoretical Model Core Constructs

Social Learning Theory Construct (Bandura)

Confidence across high-risk situations

Consciousness Raising
Consciousness Raising
Increase information about oneself and the problem that support the behavior change.
For best results, relevance is critical .

Specific strategies:
information, relevant statistics observations, confrontations testimony of significant peers local/relevant examples

Environmental Reevaluation
Environmental Reevaluation
Assessing how ones problem affects physical and social living environment. Home School Work Recreation

Specific strategies:
documentaries, photo evidence tours or videos featuring physical and/or social impact testimony of significant peers observation of actual evidence

Dramatic Relief
Dramatic Relief
Experience and express negative feelings associated with behavior problem.


Specific strategies:
videos, movies role plays, puppet shows actually observing others plight small group sharing listening to problems of others (even talk shows)

Self- Reevaluation
Self- Reevaluation
Assessing & realizing that the behavior change is an important part of ones identity.

Specific strategies:
value clarification reflection and imagery counseling diaries, letters, art work

Self- Liberation
Self- Liberation
Choose & commit to act; and increase efficacy.

I can, and I will

!. . .

Specific strategies:
private & public resolutions contracting personal testimony attempting strategies decision-making therapy group support activity learning coping skills

. . . And this is how.

Social Liberation
Social Liberation
Realizing norms are changing to favor behavior change; Increasing healthy alternatives in society.

Specific strategies:
noticing positive/healthy choices overt support for positive change noticing healthy policy changes creating positive choices & policies empowering people to change



Counter- Conditioning
Counter- Conditioning
Substituting healthy alternatives and cognitions for problem behaviors.

Specific strategies:
learning to recognize triggers learning to change reactions relaxation techniques of all sorts group exploration/support positive self-statements & assertions

Stimulus Control
Stimulus Control
Avoiding (-) or countering (+) problem-promoting stimuli.

Specific strategies:
restructuring environment (+) avoiding high risk triggers changing relationships (+) changing daily patterns (+) developing reminders & cues asking for support

Reinforcement Management
Reinforcement Management
Increasingly rewarding ones self or accepting rewards from others.

Specific strategies:
contingency contracts overt reinforcement, rewards recognition, celebrations awards, bets (?) internal reinforcement, pride increasing self-reward

Helping Relationships
Helping Relationships
Seeking and using social support. Being open and trusting about problems with a caring person. Learning to accept & give support.

Specific strategies:
talking and listening self-help groups family & social support pets (?)

Caveat 1: Relapse is the Rule

Relapse is normal. Be prepared to provide ongoing maintenance support. The normal path of health behavior change is not a straight line forward It is a spiral that goes forward and ? also backward.

Caveat 2: Not a Silver Bullet

Stage of change is associated [ex.] with only 10-15% of variance in dietary intake. That means that 85-90% of a persons eating behavior is associated with something OTHER THAN their stage of change. In other words, creating readiness is not the whole answer.

Using Transtheoretical Model

Change to stage paradigm, rather than action paradigm. . . . to proactive recruitment rather than reactive recruitment. . . . to expecting program to match participants, rather than reverse.

Self Efficacy

. Confidence - how far do people feel confident in specific situations that they can cope without relapsing to their unhealthy or high-risk habits.

. Temptation - how intense is the urge to engage in a specific habit when in the midst of the most difficult situations. Eg caused by emotional distress, social occasions and cravings.

Interpersonal Level Theories

Social Learning/Social Cognitive Theory

Social Learning Theory

Learning would be exceedingly laborious, not to mention hazardous, if people had to rely solely on the effects of their own actions to inform them what to do.

Fortunately most human behaviour is learned observationally through modelling: from observing others one forms an idea of how new behaviours are performed, and on later occasions this coded information serves as a guide for action. (Bandura 1977)

Social Learning Theory

Individuals are proactively engaged in their own development and can make things happen by their actions.

What people think, believe and feel affects how they behave (Bandura 1986). Individuals are viewed both as products and as producers of their own environments and social systems.

Social Learning Theory

Explains human behaviour in terms of continuous reciprocal interaction between cognitive, behavioural and environmental influences

Social Learning/Social Cognitive Theory

Behavior is explained via a 3-way, dynamic reciprocal theory in which personal factors, environmental influences and behavior continually interact

Social Learning (Cognitive) Theory

Two major factors influencing the likelihood that one will take preventive action:
First, like the Health Belief Model, a person believes that the benefits of performing the behavior outweigh the costs (i.e. a person should have more positive than negative outcome expectancies) Second, and perhaps most important, the person must have a sense of self-efficacy with respect to performing the preventive behavior.must believe that he or she has the skills and abilities necessary for performing the behavior under a variety of circumstances

Social Cognitive Theory

Change results from learning via interactions among: Person (e.g., cognitive, affective, biological) Behavior (e.g., self-regulation) Environment (e.g., economics, SES, social networks) Person shapes environment and environment shapes person.

Reciprocal Determinism



Key Concepts of SCT: Person

Decision-making rarely conducted in vacuum People make decisions based on: Outcome expectations Outcome expectancies Efficacy expectations

Key Concepts of SCT: Person

Outcome expectations: Perceptions about
consequences of behaviors based on past experiences, observational learning, knowledge Outcome expectancies: Values attached to beliefs about consequences of behaviors Efficacy expectations: Beliefs about persons behavioral capabilities (e.g., knowledge, skills) of changing behavior; enhanced through Performance accomplishments Vicarious experience Verbal persuasion Physiological state

Key Concepts of SCT: Behavior

Humans behaviors are:
Relatively consistent Self-regulated (from internalized performance standards and moral codes)

Three major activities play role in behavioral consistency:

Self-observation Self-judgment Self-reaction

Key Concepts of SCT: Behavior

Self-observation: Observation and
evaluation of your own actions People vary widely in accuracy of their observations Knowledge can increase accuracy Emotions can distort accuracy

Self-judgment: Monitoring, judging, or

evaluating your actions in terms of effectiveness or ethical standards, direct tuition, social norms

Self-reaction: Internal reward or punishment for


Key Concepts of SCT: Environment Behavior is influenced by external events and perceptions of those events

Three environmental processes

influence behaviors:

Reinforcement Vicarious reinforcement Observational learning

Key Concepts of SCT: Environment Reinforcement: Consequences of current

actions influence future actions; influenced by locus of control; types:
Perceived consequences Vicarious reinforcement Self-reinforcement

Observational learning: Learning by

watching others, modeling; sequences:
Attention Retention Motor reproduction Acquisition

Social Cognitive Theory

Past Experiences

Efficacy Expectations

Modeling Verbal Persuasion Outcome Expectations

Physiological States

Social Learning Theory Social Cognitive Theory

Concept Definition Application



Confidence in ability to take action and persist in action

Point out strengths; use persuasion and encouragement; approach behavior change in small steps

Observational Learning

Beliefs based on observing Point out others experience, physical others like self and/or visible changes; identify role models to emulate physical results
Responses to a persons behavior that increase or decrease the chances of recurrence Provide incentives, rewards, praise; encourage self-reward; decrease possibility of negative responses that deter positive changes


Social Learning Theory Social Cognitive Theory

Concept Definition Application


Reciprocal Determinism

Behavior changes result from Involve the individual and relevant others; interaction between person work to change the environment, if and environment; change is warranted bi-directional

Behavioral Capability Expectations

Knowledge and skills to influence behavior Beliefs about likely results of action

Provide information and training about action Incorporate information about likely results of action in advice

Social Cognitive Theory

Bottom line: Change comes from reciprocal determinism or the interaction of person, behavior, and environment Has been used to explain behaviors unusually resistant to change (e.g., smoking cessation, weight reduction, increased exercise, contraceptive use, and AIDS prevention)

Applications of SCT
Principles can guide refinement of techniques for improving knowledge, development, attitudes, and behavior Techniques stemming from SCT: Modeling Skill training Contracting Self-monitoring

Limitations of Social Cognitive Theory

Pro: Broad and well-integrated theory of human
behavior, includes both internal and external factors in decision-making process

Con: Too comprehensive, tries to explain everything

Limited in ability to predict behavior Does not capture the non-linear aspects of life, including addressing alternative behaviors Testing of components and interactions among them increasing in recent years

Theory Concepts
implications for intervention

Concept 1: Environment
Definition: Factors physically external
to the person

Implications: Provide opportunities and social


Example : alcohol use prevention project in schools

Concept: Environment
* Alcohol-free alternative activities offered for teens at school and in the community * Parents involvement in the home programme

Theory Concepts
implications for intervention

Concept 2:

Definition: Persons perception of the

Implications: Correct misperception and

promote healthful norms

Example : alcohol use prevention project in schools

Concept: Situation
* Audiocassettes are played of teen role models, part of curriculum to create negative perceptions of alcohol use.

Theory Concepts
implications for intervention

Concept 3: Behavioural Capability

Definition: Knowledge and skill to perform a
particular behaviour

Implications: Promote mastery learning

through skills training

Example : alcohol use prevention project in schools

Concept: Behavioural

* Students develop skills during the curriculum to resist influences to alcohol use * Students develop skills to create alcohol-free social events

Theory Concepts
implications for intervention

Concept 4: Expectations
Definition: Anticipatory outcomes
of a behaviour

Implications: Model positive outcomes of

healthful behaviour

Theory Concepts
implications for intervention

Concept 4: Expectations
Expectations are learned in 4 ways: 1) previous experience 2) observing others 3) hearing about similar situations 4) emotional or physical responses to behaviours

Example : alcohol use prevention project in schools

Concept: Expectations
* Peer leaders direct discussion on negative consequences of drinking

Theory Concepts
implications for intervention

Concept 5: Expectancies
Definition: The values that the person
places on a given outcome, incentives

Implications: Present outcomes of change

that have functional meaning

Example : alcohol use prevention project in schools

Concept: Expectancies
* Curriculum activities portray alcohol use as not cool, attractive or functional.

Positive Outcome Expectation

If I conduct more exercise, then my blood pressure will be lowered.

Negative Outcome Expectation

If I conduct more exercise, then I have to invest more time and money.

Theory Concepts
implications for intervention

Concept 6: Self Control

Definition: Personal regulation of goal-directed
behaviour of performance

Implications: Provide opportunities for

self-monitoring, goal-setting, problem solving and self reward

Example : alcohol use prevention project in schools

Concept: Self-Control
* Students write about remaining alcohol free

Theory Concepts
implications for intervention

Concept 7: Observational Learning

Definition: Behavioural acquisition that occurs
by watching the actions and outcomes of others behaviour

Implications: Include credible role models of the

targeted behaviour

Example : alcohol use prevention project in schools

Concept: Observational Learning

* Elected and trained peers conduct the curriculum. * Audiotaped teens tell their alcohol related stories * Students create parties for their peers

Theory Concepts
implications for intervention

Concept 8: Reinforcements
Definition: Responses to a persons behaviour
that increase or decrease the likelihood of reoccurrence

Implications: Promote self-initiated rewards

and incentives

Example : alcohol use prevention project in schools

Concept: Reinforcement
* Students design and distribute T-shirts

Theory Concepts
implications for intervention

Concept 9: Self Efficacy

Definition: The persons confidence in
performing a particular behaviour

Implications: Approach behavioural change

in small steps to ensure success; seek specificity about the change sought

Example : alcohol use prevention project in schools

Concept: Self-Efficacy
* Curriculum activities include role-plays and groups activities on resisting influences to use alcohol

Smoking Cessation Self-Efficacy

If someone offers me a cigarette, I can decline it without hesitating.

Condom Use Self-Efficacy Scale

I feel confident in my ability to suggest using condoms with a new partner. I feel confident in my ability to put a condom on my partner. I feel confident that I could purchase condoms without feeling embarrassed.

Nutrition Self-Efficacy
I am certain that I can stick to a healthy diet, even if my partner continues to consume junk food.

Physical Exercise Self-Efficacy

I am certain that I can exercise....
- even if I feel exhausted. - even if I have a high workload. - even if there is something exciting on TV.

The Physical Exercise Self-Efficacy Scale How certain are you that you could overcome the following barriers? I can manage to carry out my exercise intentions,
1 2 3 4 5 ...even when I have worries and problems. ...even if I feel depressed. ...even when I feel tense. ...even when I am tired. ...even when I am busy.

The Alcohol Resistance Self-Efficacy Scale

I am certain that I can control myself to... 1 2 3 ...reduce my alcohol consumption. ...not to drink any alcohol at all. ...drink only at special occasions.

Perceived Self-Efficacy
facilitates - goal-setting, - effort investment, - persistance in face of barriers - recovery from setbacks.

Theory Concepts
implications for intervention

Concept 10:

Emotional Coping Responses

Definition: Strategies or tactics that are used
by a person to deal with emotional stimuli

Implications: Provide training in problem

solving and stress management; include opportunities to practice skills in emotionally arousing situations

Theory Concepts
implications for intervention

Concept 11:

Reciprocal Determinism
Definition: The dynamic interaction of the
person, the behaviour and the environment in which the behaviour is performed

Implications: Consider multiple avenues to

behavioural change including environmental, skill and personal change

Example : alcohol use prevention project in schools

Concept: Reciprocal Determinism

* Students learn skills to deal with social influences to drink * The social environment changes so there are fewer opportunities to drink * Fewer students drink so there are fewer influences to drink

Self Efficacy
Anna is the head of the student health service at a large University. In addition to providing primary-care services for students, the Service provides a variety of educational Programmes, peer counselling and an orientation for all new students.

In the past Anna and her team have developed programmes to reduce stress and to discourage drug use. Now they had a new challenge.
For the third year in a row, the rate of sexually transmitted diseases among students reporting symptoms at the student health service has increased.

With the help of a faculty member from the school of public health Anna developed a survey to assess students beliefs and practices about sexual activity. Either out programmes arent addressing The real problem they arent reaching the students, or both. We need to know where to direct our energy.

The anonymous survey was mailed to a random sample of 800 undergraduates of whom 468 responded. The survey showed the following results among sexually active students:

The Results
-Only 16% said they use a condom every time they have sex -only 26% have ever initiated a discussion about condom use with a sex partner. -79%, including 92% of females said that they could not easily discuss condom use with a sex partner. -66%, including 75% of females said that talking about condom use with a partner probably would not make condom use any more acceptable. -43% of females said that it was likely that asking a sex partner to use a condom would make a partner angry.

The Solution - 1
There are 4 main factors that affect Self-Efficacy: 1. Personal experience 2. Observational experience 3. Verbal persuasion 4. Physiological state Therefore: *Teach and Model specific behavioural and communciation skills for negotiating condom use *Provide opportunities for students to rehearse these behavioural and comunication skills

The Solution - 2
*Make the initial objectives of the programme relatively simple for students to achieve. for example, an objective might be to ask your partner any one question about condoms the next time you are together. Successes no matter how small, can help build efficacy for future actions. *Focus on positive aspects of an incomplete performance. Even in an unsuccessful attempt to initiate discussion about condom use, the student should be able to focus on something positive. Finding and emphasising something that can offset damage to self-efficacy.

The Solution - 3
*Provide reinforcement and encouragement. Hearing that others believe in you, or think you can do it, builds self efficacy. *Teach relaxation skills. Students who feel very nervous, become short of breath, or perspire when thinking about talking to a partner about condom use, may interpret these signs as meaning they wont be able to do it. Knowing how to calm yourself down can help prevent losing self-efficacy.

Health Locus of Control (HLOC)

developed out of Social Learning Theory

Locus of Control is a measure of:

perceived control over outcomes

of a particular behaviour (rather than actual control of behaviour)



Internal Health Locus of Control



Chance (destiny/fate/Gods will) Health Locus of Control


Low Powerful Others Health Locus of Control

Internal HLOC:
Your beliefs about the impact of your own actions on a desired outcome. Examples: A person with a high internal HLOC believes that her own actions have a lot to do with his/her health, and that if he/she takes care of his/ her teeth and eats properly, he/she will have better oral health than if he/she didnt. A person with low internal HLOC does not believe that his/her actions have much or any effect on his/ her health.

Chance HLOC:
Your beliefs about the effect of chance or fate or Gods will on outcome.

Examples: dental clinic attenders who score high on this dimension may be heard to say some people just get more cavities than others.

People who score low on this dimension do not believe that fate or chance play a role in their oral health.

Powerful Others HLOC:

Your beliefs about the influence of important people other than yourself on outcome.

Examples: dental clinic attenders with high powerful others HLOC believe that their dental health is to a large extent dependent on what their dentist does.

People with low powerful others HLOC are less likely to see the value in regular attendance, especially for preventive care.

1. Successful people in Western Societies often have a high internal HLOC. 2. Less privileged members of the community such as ethnic minorities, lower classes and women are often more external in their LOC, and with good reason their beliefs that they have less control over outcomes such as jobs, housing, education and health are realistic and based on experience.

Crucial concepts - HLOC

1. HLOC is not a personality trait. For each person it will vary between situations and over time, because it is a dynamic expression of ones current beliefs. 2. HLOC is a way of describing personal beliefs about control and power. It is not meant to describe reality. 3. HLOC is only one determinant of behaviour. You may believe you can predict the outcome of your behaviour, but if you dont value the outcome, you are unlikely to act to gain it. 4. It is incorrect to assume that high internal HLOC is always better than chance or powerful others HLOC.

Social Network/Social Support Theory

Structure size and density Interaction reciprocity (mutual

sharing), intensity & frequency of interactions,

Social Networks

Function social support,

provide social identity, connections to social contacts, resources

Social Support
Emotional Support listening,
showing trust and concern

Instrumental Support offering real

aid in the form of labor, money, time

Informational Support providing

advice, suggestions, directives, referrals

Appraisal Support affirming one

another and giving feedback

Social Support Strategies

Strengthening existing network and support Develop new linkages (mentoring, support groups) Enhancing networks through natural or lay helpers Enhance networks at the community level through community building

Community Level

Communications Persuasion Model

Input Variables
Source (number, demographics, appeal,

Message (appeal, info, whats

included/excluded, organization, repetition)

Channel (modality audio/video,

direct/indirect, context)

Receiver (demographics, knowledge,

skills, motivation, lifestyle)

Behavior (long/short term,)

Output Variables
Exposure to communication Attention Developing interest and attraction Understanding/learning from the communication Skill acquisition Attitude change

Output Variables
Remembering the message and attitude toward it Retrieval of information Deciding what to do Acting in accordance with decision Being reinforced for behavior Behavioral consolidation

Persuasive Health Message Framework

Concepts & Constructs

TRA/TPB + HBM + Communications Persuasion Message Goals (overall message + behavior + population) Salient Beliefs (susceptibility, severity, self-efficacy, response efficacy) Salient Referrents (susceptibility, severity, self-efficacy, response efficacy)

Message Goals Overall to reduce negative consequences related to highrisk behavior Behavior protective behaviors Population first year students in a medical college

Example Salient Beliefs

Susceptibility little susceptibility to negative consequences of alcohol Severity little severity if negative consequences occur Barriers to self efficacy associate protective factors as non-fun/boring, lack of education on how to drink responsibly Barriers to response efficacy will protective factors really reduce my risk?

Social Marketing

price--what the consumer must give up in

order to receive the program's benefits. These "costs" may be intangible (e.g., changes in beliefs or habits) or tangible (e.g., money, time, or travel)

The 4 Ps

product--what the program is trying to

change within the target audience

promotion-- how the exchange is

communicated (e.g., appeals used)

place--what channels the program uses to

reach the target audience (e.g., mass media, community, interpersonal)


The adoption of ideas in a community diffuses among individuals in that community at varying rates Early in the introduction of a new idea, it is picked up by innovators (between 2 and 3% of the target population) who are venturesome, independent, risky and daring. They want to be the first to do things and they may not be respected by others in the social system.

The second group of people, the early adopters (about 14% of the target population) are very interested in the innovation but they are not the first to sign up. They wait until the innovators are already involved to make sure the innovation is useful. They are respected by others in the social system and looked at as opinion leaders.

The next group early majority (about 34% of the target population) may be interested in the innovation but will need external motivation to become involved, They will deliberate for some time before making a decision. The late majority (also about 34% of the target population) are next and it will take more time to get them involved for they are skeptical and will not adopt an innovation until most people in the social system have done so.


The last group the laggards (about 16% of the target population are not very interested in innovation and would be the last to become involved. They are very traditional and are suspicious of innovations. Laggards tend to have limited communication networks, so they really do not know much about new things. This situation calls for different strategies for different categories of people and at different stages of the adoption process.


Late adopters Cumulative number or % of adopters Late majority Early majority Early adopters Innovators Time

PRIOR CONDITIONS 1. Previous practice 2. Felt needs/problems 3. Innovativeness 4. Norms of social systems COMMUNICATION CHANNELS






Characteristics of the Decision Making Unit: 1. Socioeconomic characteristics 2. Personality variables 3. Communication behaviour

Perceived Characteristics of the Innovation 1. Relative Advantage 2. Compatibility 3. Complexity 4. Trialability 5. Observability

1. Adoption

Continued Adoption Later Adoption Discontinuance Continued Rejection

2. Rejection

Perceived characterstics of the innovation

Definition Relative How far is it seen as better Advantage than the idea, practice or product it replaces Compatibility How consistent with values, habits, experience and needs of potential adopters Complexity How difficult is it to understand and/or use Trialability The extent to which it can be experimented with before committing Observability The extent to which it provides tangible results Concept Why not adopt? Benefits not evident, eg doesnt save time
Not consistent with my values or needs

Too complicated You wont let me see if I like it, so no thanks How do I know it will work, I dont see anyone else doing it

Ecological/Environmental Model of Health Behavior

Assumes an interaction among both physical and social contingencies to explain and ultimately control health behavior.

Interrelations between organisms and their environments Behaviors are influenced by Intrapersonal, sociocultural, policy, and physicalenvironmental factors Purpose is To focus attention on the environmental causes of behavior and to identify environmental interventions

Extension of SCT Reciprocal Determinism

Multiple levels can influence behavior Those levels may interact Environment can have a direct influence on behavior

An Ecological Approach to Addressing Smoking

Emphasizes multiple factors related to smoking Emphasizes the role of society, community, and institutions Emphasizes interrelations between contributory factors Decreases victim-blaming

Social Norms/ National polices

Community factors

Intrapersonal factors

Institutional factors

Interpersonal factors

Social Norms & National Policies

Increased technology Cigarette availability Types of available tobacco products o Decrease in academic rigor/requirements? Cigarette advertising Pricing strategies Social norms about smoking

Social Norms/ National polices

Community factors

Intrapersonal factors

Institutional factors

Interpersonal factors

Community Factors
Safety concerns Lack of monitored/supervised off campus housing options Many cigarette distributors/bars

Lack of smoke free options Inconsistent enforcement

Social Norms/ National polices

Community factors

Intrapersonal factors

Institutional factors

Interpersonal factors

Institutional Factors
Lack of smoking -free choices Lack of connectivity between curricular and co/extra-curricular activities Lack of interaction between faculty and students outside of academic context Inconsistent enforcement on-campus, or inconsistent with off-campus enforcement

Social Norms/ National polices

Community factors Intrapersonal factors

Institutional factors

Interpersonal factors

Learned behaviors Family smoking patterns Low levels of family engagement Parental attitudes about childs tobacco use Lack of peer norms that encourage non-smoking. Norms that emphasize smoking as socially acceptable

Interpersonal Factors

Social Norms/ National polices

Community factors

Intrapersonal factors

Institutional factors

Interpersonal factors

Intrapersonal Factors
Genetic predisposition Poor self image Dislike or lack of skill re: protective factors Low academic/co-curricular activity activity Perceived norms Perceptions about referents views on norms

In conclusion
Use appropriate theories to guide programming Use constructs to help define intervention activities, as well as evaluate/measure Use multiple theories together Continue to look at new theories

Lay theories about health

Communication between health professional and patient would be redundant if the patient held beliefs about their health that were in conflict with those held by the professional.

Pill and Stott reported that working-class mothers were more likely to see illness as uncontrollable. In a recent study, Graham reported that although women who smoke are aware of all the health risks of smoking, they report that smoking is necessary to their well-being and an essential means for coping with stress.

Lay theories about health

Blaxter analysed the definitions of health provided by over 9000 British adults in the health and lifestyles survey. She classified the responses into nine categories: Health as not-ill: the absence of physical symptoms. Health despite disease. Health as reserve: the presence of personal resources. Health as behaviour: the extent of healthy behaviour

Lay theories about health

Lay theories about health Health as physical fitness. Health as vitality. Health as social relationships. - Health as function.

Lay theories about health

It was found that there was considerable agreement in the emphasis on behavioural factors as causes of illness. There was however limited reference to structural or environmental factors, especially among those from working-class backgrounds. Gender differences were also found. The women were more likely to define health in terms of personal relationships. Murray and McMillan also found that working class women made repeated reference to their families when describing cancer.

Lay theories about health

Chamberlain noted a series of social class differences in his review of several studies of lay peoples perceptions of health. Lower social economic status people emphasise the role of health in their ability to work whereas higher social economic status people referred more to their ability to participate in leisure activities. Four different lay views of health emerged:

Lay theories about health

1. Lower social economic status participants only reported a view that emphasised physical aspects. 2. Both lower and higher social economic status participants gave a dualistic view in which physical and mental aspects of health were combined. 3. Predominantly higher social economic status gave a complimentary view of health, which integrated both physical and mental dimensions.

Lay theories about health

4. Higher social economic status participants gave a multiple view of health, which included physical, mental, emotional, social and spiritual directions.

Lay theories about health

Stainton-Rogers used Q-sort methodology to identify the concepts used by a sample of British adults to explain health. She identified eight different accounts of health and illness: The body as machine account which considered illness as naturally occurring and real with biomedicine considered the main form of treatment.

Lay theories about health

The body under siege account which considered illness as a result of external influences such as germs or stress. The inequality of access account which emphasized the unequal access to modern medicine. The cultural critique account which was based upon a sociological worldview of exploitation and oppression.

The health promotion account which recognized both individual and collective responsibility for ill health. The robust individualism account which was concerned with every individuals right to a satisfying life. The willpower account which defined health in terms of the individuals ability to exert control.

Lay theories about health

1. information processing. It is the role of perceived factors (e.g. risk, rewards, costs, etc) rather than actual risks. 2. Different cognitions are separate from and perform independently from each other. Could be because the researchers ask questions relating to each 'type' of cognition.

Assumptions in Health psychology Humans are rational in their

3. really exist nor play a part in the patient's thinking about their health; they could just be an artefact of the way the research was carried out. 4. Cognitions are not placed within a context. For example, actual social pressure and environment are not taken into account, only the individual's interpretation of social pressure and environmental influences.

Assumptions in Health The types of cognition may not psychology