Behavior Change Theories and Models

Because theories and models of human behavior can guide the development and refinement of health promotion and education efforts, this page reviews elements of behavioral and social science theories and models.

Learning Theories
Health Belief Model
Transtheoretical Model
Relapse Prevention Model
Reasoned Action and Planned Behavior
Social Learning/Social Cognitive Theory
Social Support
Ecological Approaches
Summary

Learning Theories

Learning theories emphasize that learning a new, complex pattern of behavior, like changing from a sedentary to an active lifestyle, normally requires modifying many of the small behaviors that compose an overall complex behavior . Principles of behavior modification suggest that a complex-pattern behavior, such as walking continuously for 30 minutes daily, can be learned by first breaking it (down into smaller segments (e.g., walking for 10) minutes daily). Behaviors that are steps toward a final goal need to be reinforced and established first, with rewards given for partial accomplishment if necessary. Incremental increases, such as adding 5 minutes to the daily walking each week, are then made as the complex pattern of behavior is "shaped" toward the targeted goal. A further complication to the change process is that new patterns of physical activity behavior must replace or compete with former patterns of inactive behaviors that are often satisfying (e.g., watching television), habitual behaviors e.g., parking close to the door),or behaviors cued by the environment (e.g., the presence of an elevator).

Reinforcement describes the consequences that motivates individuals either to continue or discontinue behavior. Most behaviors, including physical activity, are learned and maintained under fairly complex schedules of reinforcement and anticipated future rewards. Future rewards or incentives may include physical consequences (e.g., looking better), extrinsic rewards (e.g., receiving praise and encouragement from others, receiving a T-shirt), and intrinsic rewards (e.g., experiencing a feeling of accomplishment or gratification from attaining a personal mile stone). It is important to note that although providing praise, encouragement, and other extrinsic rewards may help people adopt positive lifestyle behaviors, such external reinforcement may not be reliable for sustained long-term change.

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Health Belief Model

The health belief model stipulates that a person's health-related behavior depends on the person's perception of four critical areas: the severity of a potential illness, the person's susceptibility to that illness, the benefits of taking a preventive action, and the barriers to taking that action. The model also incorporates cues to action (e.g., leaving a written reminder to oneself to walk) as important elements in eliciting or maintaining patterns of behavior. The construct of self-efficacy, or a person's confidence in his or her ability to successfully perform an action (discussed in more detail later in this chapter), has been added to the model, perhaps allowing it to better account for habitual behaviors, such as a physically active lifestyle.

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Transtheoretical Model

In this model, behavior change has been conceptualized as a five-stage process or continuum related to a person's readiness to change: precontemplation, contemplation, preparation, action, and maintenance. People are thought to progress through these stages at varying rates, often moving back and forth along the continuum a number of times before attaining the goal of maintenance. Therefore, the stages of change are better described as spiraling or cyclical rather than linear. In this model, people use different processes of change as they move from one stage of change to another. Efficient self-change thus depends on doing the right thing (processes) at the right time (stages). According to this theory, tailoring interventions to match a person's readiness or stage of change is essential. For example, for people who are not yet contemplating becoming more active, encouraging a step-by-step movement along the continuum of change may be more effective than encouraging them to move directly into action.

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Relapse Prevention Model

Some researchers have used concepts of relapse prevention to help new exercisers anticipate problems with adherence. Factors that contribute to relapse include negative emotional or physiologic states, limited coping skills, social pressure, interpersonal conflict, limited social support, low motivation, high-risk situations, and stress. Principles of relapse prevention include identifying high-risk situations for relapse (e.g., change in season) and developing appropriate solutions (e.g., finding a place to walk inside during the winter). Helping people distinguish between a lapse (e.g., a few days of not participating in their planned activity) and a relapse (e.g., an extended period of not participating) is thought to improve adherence.

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Theory of Reasoned Action and Theory of Planned Behavior

The theory of reasoned action states that individual performance of a given behavior is primarily determined by a person's intention to perform that behavior. This intention is determined by two major factors: the person's attitude toward the behavior (i.e., beliefs about the outcomes of the behavior and the value of these outcomes) and the influence of the person's social environment or subjective norm (i.e., beliefs about what other people think the person should do, as well as the person's motivation to comply with the opinions of others). The theory of planned behavior adds to the theory of reasoned action the concept of perceived control over the opportunities, resources, and skills necessary to perform a behavior. The concept of perceived behavioral control is similar to the concept of self-efficacy -- person's perception of his or her ability to perform the behavior. Perceived behavioral control over opportunities, resources, and skills necessary to perform a behavior is believed to be a critical aspect of behavior change processes.

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Social Learning/Social Cognitive Theory

Social learning theory, later renamed social cognitive theory, proposes that behavior change is affected by environmental influences, personal factors, and attributes of the behavior itself. Each may affect or be affected by either of the other two. A central tenet of social cognitive theory is the concept of self-efficacy. A person must believe in his or her capability to perform the behavior (i.e., the person must possess self-efficacy) and must perceive an incentive to do so (i.e., the person's positive expectations from performing the behavior must outweigh the negative expectations). Additionally,a person must value the outcomes or consequences that he or she believes will occur as a result of performing a specific behavior or action. Outcomes may be classified as having immediate benefits (e.g., feeling energized following physical activity) or long-term benefits (e.g., experiencing improvements in cardiovascular health as a result of physical activity). But because these expected out-comes are filtered through a person's expectations or perceptions of being able to perform the behavior in the first place, self-efficacy is believed to be the single most important characteristic that determines a person's behavior change. Self-efficacy can be increased in several ways, among them by providing clear instructions, providing the opportunity for skill development or training, and modeling the desired behavior. To be effective, models must evoke trust, admiration, and respect from the observer; models must not, however, appear to represent a level of behavior that the observer is unable to visualize attaining.

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Social Support

Often associated with health behaviors such as physical activity, social support is frequently used in behavioral and social research. There is, however, considerable variation in how social support is conceptualized and measured. Social support for physical activity can be instrumental, as in giving a nondriver giving a ride to an exercise class; informational, as in telling someone about a walking program in the neighborhood; emotional, as in calling to see how someone is faring with a new walking program; or appraising, as in providing feedback and reinforcement in learning a new skill. Sources of support for physical activity include family members, friends, neighbors, co-workers, and exercise program leaders and participants.

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Ecological Approaches

A criticism of most theories and models of behavior change is that they emphasize individual behavior change process and pay little attention to sociocultural and physical environmental influences on behavior. Recently, interest has developed in ecological approaches to increasing participation in physical activity. These approaches place the creation of supportive environments on a par with the development of personal skills and the reorientation of health services. The concept of a health-promoting environment has been demonstrated by describing how physical activity could be promoted by establishing environmental supports, such as bike paths, parks, and incentives to encourage walking or bicycling to work.

An underlying theme of ecological perspectives is that the most effective interventions occur on multiple levels. A model has been proposed that encompasses several levels of influences on health behaviors: intrapersonal factors, interpersonal and group factors, institutional factors, community factors, and public policy. Similarly, another model has three levels (individual, organizational, and governmental) in four settings (schools, worksites, health care institutions,and communities). Interventions that simultaneously influence these multiple levels and multiple settings may be expected to lead to greater and longer-lasting changes and maintenance of existing health-promoting habits. This is a promising area for the design of future intervention research to promote physical activity.

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Summary

Some similarities can be noted among the behavioral and social science theories and models used to understand and enhance health behaviors such as physical activity. Many of the theoretical approaches highlight the role of the perceived outcomes of behavior, although different terms are used for this construct, including perceived benefits and barriers (health belief model) and outcome expectations (social cognitive theory and theory of planned behavior). Several approaches also emphasize the influence of perceptions of control over behavior; this influence is given labels such as self-efficacy (health belief model, social cognitive theory) and perceived behavioral control (theory of planned behavior). Other theories and models feature the role of social influences, as in the concepts of observational learning (social cognitive theory), perceived norm (theory of reasoned action and theory of planned behavior), social support, and interpersonal influences (ecological perspective). Most of the theories and models, however, do not address the influence of the environment on health behavior.

These descriptions of behavior change models and theories are from the US Surgeon General's Report on Physical Activity and Health, Chapter 6 - Understanding and Promoting Physical Activity (available in Jim Grizzell's office or purchase by calling call 1-888-232-4674 (Toll Free).

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Please visit Jim Grizzell's Perspectives on Health Promotion used for health education and promotion of Cal Poly Pomona students, and Ease Health Management & Health-Pros web pages:

Health Education Partners for program evaluation and corporate health promotion (www.healthedpartners.org)

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Jim Grizzell, MBA, MA, Certified Health Education Specialist

Fellow - American College Health Association

(909) 856-3350 Cal Poly Pomona, jvgrizzell@csupomona.edu

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Updated: 9/30/2003, 1/27/2007