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SOCIAL AND BEHAVIORAL THEORIES the theories and models described here have some
potential as both explanatory and change models,
INTRODUCTION though they might be better for one or the other purpose.
- The most successful public health programs and For example, the Health Belief Model was originally
initiatives are based on an understanding of health developed as an explanatory model, whereas in contrast
behaviors and the context in which they occur. the Stages of Change construct of The Transtheoretical
Therefore, interventions to improve health behavior Model was conceived to help guide planned change
can be best designed with an understanding of efforts
relevant theories of behavior change and the ability
to use them skillfully. Both explanatory theories and change theories are
- The science and art of using health behavior rooted in an understanding of the social determinants of
theories reflect an amalgamation of approaches, health and health behavior. Many social, cultural, and
methods, and strategies from social and health economic factors contribute to the development,
sciences. This broad range of perspectives from maintenance, and change of health behavior patterns. It
social and behavioral sciences are referred to “social is now generally recognized that public health and health
and behavioral science theory” throughout this promotion interventions are most likely to be effective if
chapter. Influential work draws on the theoretical they embrace an ecological perspective and include
perspectives, research, and practice tools of such upstream approaches, as discussed in McKinlay’s
diverse disciplines as psychology, sociology, social chapter on Appropriate Research Methods. That is,
psychology, anthropology, communications, nursing, interventions should not only be targeted at individuals
economics, and marketing. but should also affect interpersonal, organizational, and
environmental factors influencing health behavior.
Theory and Why It is Important
A theory presents a systematic way of understanding Important Theories and Their Key Constructs
events, behaviors and/or situations. Theories that gain recognition in a discipline shape the
- A theory is a set of interrelated concepts, definitions, field, help define the scope of practice, and influence the
and propositions that explains or predicts events or training and socialization of its professionals. Today, no
situations by specifying relations among variables. single theory or conceptual framework dominates
research or practice in health promotion and education.
The notion of generality, or broad application, is However, reviews of journal articles published in the past
important. Thus, theories are by their nature abstract and two decades have revealed the most often-used theories
not content- or topic-specific. Even though various in health behavior research and trends in theory use.
theoretical models of health behavior may reflect the Dozens of theories and models have been used, but only
same general ideas, each theory employs a unique a few of them were used in multiple publications and by
vocabulary to articulate the specific factors considered to several authors. What follows is a description of the
be important. Theories vary in the extent to which they central elements of four of the most widely-used
have been conceptually developed and empirically theoretical models of health behavior:
tested; however, “testability” is an important feature of a 1. The Health Belief Model (HBM)
theory. As Stephen Turner has noted in his chapter on 2. The Transtheoretical Model/Stages of Change
“Theory Development,” social science theories are better (TTM)
understood as models that work in a limited range of 3. Social Cognitive Theory (SCT)
settings, rather than laws of science which hold and 4. The Social Ecological Model.
apply universally.
; Other often-used theories and models (not described here)
Theories can guide the search to: include the Theory of Reasoned Action/Theory of Planned
1. Understand why people do or do not practice health Behavior (TRA/TPB), social support and social networks,
social marketing, diffusion of innovations, and several
promoting behaviors;
communication theories
2. Help identify what information is needed to design
an effective intervention strategy; and
Health Belief Model (HBM)
3. Provide insight into how to design a program so it is
The Health Belief Model (HBM) was developed to help
successful.
understand why people did or did not use preventive
services offered by public health departments in the
These two broad types of theory
1950’s, and has evolved to address newer concerns in
(1) explanatory theory
prevention and detection (e.g., mammography
(2) change theory
screening, influenza vaccines) as well as lifestyle
behaviors such as sexual risk behaviors and injury
may have different emphases but are complementary.
prevention. The HBM theorizes that people’s beliefs
For example, understanding why an employee smokes
about whether or not they are at risk for a disease or
are one step toward a successful cessation effort, but
health problem, and their perceptions of the benefits of
even the best explanations won’t be enough by
taking action to avoid it, influence their readiness to take
themselves to fully guide change to improve health.
action.
Stages of change is a heuristic model that describes a
Core constructs of the HBM: sequence of steps (see Table 1) in successful behavior
- Perceived susceptibility and perceived severity change:
- Perceived benefits and perceived barriers 1. Precontemplation;
- Cues to action 2. Contemplation
- Self-efficacy (added more recently) 3. Preparation;
4. Action; and
The HBM has been most-often applied for health 5. Maintenance.
concerns that are prevention-related and asymptomatic,
such as early cancer detection and hypertension The stages of change model can be used both to help
screening – where beliefs are as important or more understand why people at high-risk for diabetes might
important than overt symptoms. The HBM is also clearly not be ready to attempt behavioral change, and to
relevant to interventions to reduce risk factors for improve the success of health counseling.
cardiovascular disease.
; Another application of the stages of change model in
organizations and communities involves conceptualizing
organizations along the stagesof-change continuum according
to their leaders’ and members’ (i.e., employees’) readiness for
change.
Transtheoretical Model/Stages of Change (TTM) People do not always move through the stages of change in a
Long-term changes in health behavior involve multiple linear manner – they often recycle and repeat certain stages,
actions and adaptations over time. Some people may not for example individuals may relapse and go back to an earlier
stage depending on their level of motivation and self-efficacy.
be ready to attempt changes, while others may have
already begun implementing changes in their smoking,
Social Cognitive Theory (SCT)
diet, activity levels, and so on. The construct of “stage of
Social cognitive theory (SCT), the cognitive formulation
change” is a key element of The Transtheoretical Model
of social learning theory that has been best articulated
(TTM) of behavior change, and proposes that people are
by Bandura, explains human behavior in terms of a
at different stages of readiness to adopt healthful
three-way, dynamic, reciprocal model in which personal
behaviors. The notion of readiness to change, or stage
factors, environmental influences, and behavior
of change, has been examined in health behavior
continually interact (See Figure 3). SCT synthesizes
research and found useful in explaining and predicting
concepts and processes from cognitive, behavioristic,
changes for a variety of behaviors including smoking,
and emotional models of behavior change, so it can be
physical activity, and eating habits. The TTM has also
readily applied to counseling interventions for disease
been applied in many settings
prevention and management. A basic premise of SCT is
that people learn not only through their own experiences,
but also by observing the actions of others and the
results of those actions.
Key constructs of social cognitive theory that are the interpersonal level, and perceptions of crime and
relevant to health behavior change interventions include: safety at the community level. Ecological models
- Observational learning suggest that these multiple levels of influence interact
- Reinforcement across levels. For example, social support for exercise
- Self-control from co-workers may interact with the availability of
- Self-efficacy exercise equipment at the worksite to lead to increased
physical activity.
Some elements of behavior modification based on SCT
constructs of self-control, reinforcement, and self- Traditionally, and especially in clinical settings, strategies
efficacy include goal-setting, self-monitoring and to change health behaviors have focused on individual-
behavioral contracting. Goal-setting and self-monitoring level factors such as knowledge, beliefs, and skills. As
seem to be particularly useful components of effective ecological thinking has gained currency, intervention
interventions. strategies have broadened to target factors at other
levels of influence such as organizational policies and
Self-efficacy, or a person’s confidence in his or her ability the built environment. This recognition of the complex
to take action and to persist in that action despite range of factors that shape health behaviors can make
obstacles or challenges, is especially important for the selection of intervention strategies daunting.
influencing health behavior change efforts.
Researchers and program planners can select from
Reciprocal Determinism individual-level theories such as the Health Belief Model,
The key Social Cognitive Theory construct of reciprocal which emphasizes beliefs of susceptibility and severity of
determinism means that a person can be both an agent a health problem, and perceived benefits and barriers of
for change and a responder to change. Thus, changes in taking action. Alternatively, an intervention planner might
the environment, the examples of role models, and use organizational development theories to create policy
reinforcements can be used to promote healthier or environmental change within an organization such as
behavior. a clinic or school.
; This core construct is also central to social ecological Intervention strategies targeting the individual level
models and is more important today than ever before include goal setting, behavioral contracting, and tailored
health communication. These strategies most typically
Social Ecological Model (SEM) draw on Social Cognitive Theory (SCT) and the stages
The social ecological model helps to understand factors of change construct from the Transtheoretical Model.
affecting behavior and also provides guidance for Social Cognitive Theory (SCT) explains human behavior
developing successful programs through social in terms of a three-way, dynamic, reciprocal model in
environments. Social ecological models emphasize which personal factors, environmental influences, and
multiple levels of influence (such as individual, behavior continually interact. Key constructs of social
interpersonal, organizational, community and public cognitive theory that are relevant to behavior change
policy) and the idea that behaviors both shape and are interventions include observational learning,
shaped by the social environment. The principles of reinforcement, self-control, and self-efficacy. Health
social ecological models are consistent with social professionals or public health educators can make
cognitive theory concepts which suggest that creating an deliberate efforts to increase clients’ self-efficacy using
environment conducive to change is important to making three types of strategies:
it easier to adopt healthy behaviors. A. setting small, incremental and achievable goals;
B. using formalized behavioral contracting to
establish goals and specify rewards;
C. monitoring and reinforcement, including client
self-monitoring by keeping records.