SOC AD. (CASTROSANTO) Some type of change model will also be needed.

All of
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.

Commonly used strategies at the interpersonal level

include lay health advisors and social support programs.
Underlying theoretical constructs include social support,
social norms and social networks. Intervention strategies
at the organizational level include provider reminders
and feedback, and other systems changes. The process
of creating organizational change is often informed by
organizational development theory. At the community
level, coalition-building is a particularly common
Interventions to Change Health Behavior intervention strategy.
Health behaviors are shaped through a complex
interplay of determinants at different levels. For example, Theory Use in Intervention Research
physical activity is influenced by self-efficacy at the Recently, several reviews have examined which theories
individual level, social support from family and friends at were used in health behavior intervention research and
whether theory-based strategies are positively applied; 3.6 percent were tested, and only 9.4 percent
associated with desirable outcomes. Table 2 summarizes involved building/creating theory (84). These findings
11 systematic reviews published since 2000 – most underscore the importance of more thorough application
within the past three years – that reported on theory use and testing of health behavior theories to advance
and, in several cases, the effects of using theories for science and move the field forward.
intervention design. They cover a range of behavioral
topics: dietary fat and fruit and vegetable intake; cancer Choosing the Right Theory
screening; injury prevention; HIV-related sexual risk Effective interventions and sound research both depend
behaviors; and contraception. These reviews also on marshaling the most appropriate theory and practice
examined tailored print and computer-based strategies for a given situation. Different theories are
interventions. best suited to different units of practice, such as
individuals, groups, and organizations. For example,
As shown in Table 2, the most-often used theories in when one is attempting to overcome women's personal
these reviews are Social Cognitive Theory (SCT), The barriers to obtaining mammograms, the Health Belief
Transtheoretical Model/stages of change (TTM), the Model may be useful. The Transtheoretical Model may
Health Belief Model (HBM), Theory of Planned Behavior be especially useful in developing smoking cessation
(TPB), and the PRECEDE/PROCEED planning model. interventions. When trying to change physicians'
mammography practices by instituting reminder systems,
Few of these reviews compared the relative effects of organizational change theories are more suitable. At the
using different theories as the basis for interventions, but same time, physicians might use The Transtheoretical
several explored whether using a theoretical foundation Model to inform their discussions with individual patients
led to larger effects. Several reviews concluded that about getting a first mammogram or annual screening.
interventions based on theory or explicitly described
theoretical constructs were more effective than those not ; Public health experts at once benefit from and are challenged
using theory. The mechanisms that explain these larger by the multitude of theoretical frameworks and models from the
effects are not clear. The use of theories that fit well with social sciences available for their use, because the best
the problems and context in the studies might explain the choices and direct translations may not be immediately
evident.
success of theory-based interventions. It is equally ; The choice of a suitable theory or theories should begin with
plausible that theory-based strategies are developed identifying the problem, goal, and units of practice, not with
with greater care, fidelity and structure. There may be selecting a theoretical framework because it is intriguing,
other explanations as well. familiar, or in vogue. One should start with a logic model of the
problem and work backwards to identify potential solutions.
How Theory is Used
The social and behavioral science theories used as a Choosing the Right Theory
basis for health interventions reflect the field, which is The adequacy of a theory most often is assessed in
both eclectic and in a relatively early stage of terms of three criteria:
development. The question of how theories are used (or 1. Its logic, or internal consistency in not yielding
not used) in research and practice is as important as mutually contradictory derivations,
researchers try to ascertain the role of theory in 2. The extent to which it is parsimonious, or
intervention development and evaluation. In a recent broadly relevant while using a manageable
review of theory use from 2000 to 2005, we classified number of concepts, and
articles that employed health behavior theory along a 3. Its plausibility in fitting with prevailing theories in
continuum: the field.
1. Informed by theory: a theoretical framework was
identified, but no or limited application of the theory Theories also are judged in the context of activities of
was used in specific study components and practitioners and researchers. Practitioners may apply
measures; the pragmatic criterion of usefulness to a theory and
2. Applied theory: a theoretical framework was thus would be concerned with its consistency with
specified, and several of the constructs were everyday observations. Researchers make scientific
applied in components of the study; judgments of a theory's ecological validity, or the extent
3. Tested theory: a theoretical framework was to which it conforms to observable reality when
specified, and more than half the theoretical empirically tested.
4. constructs were measured and explicitly tested, or
two or more theories were compared to one Challenges Moving Forward
another in a study; or Science is by definition cumulative, with periods of
5. Building/creating theory: new or paradigm shifts that come more rarely as a result of
revised/expanded theory was developed using crises when current theories fail to explain some
constructs specified, measured, and analyzed in a phenomena. The same applies to the science base that
study. supports long-standing as well as innovative health
behavior interventions. More research is needed at all
More than two-thirds of the studies in the review used points along the research continuum. We need more
theory to inform a study; 17.9 percent of theories were basic research to develop and test theories, more
intervention research to develop and test evidence- policy and organizational change that complement
based interventions, and more concerted, focused individually-oriented theories, but are underutilized. They
attention to dissemination of evidence-based should be further operationalized, tested and
interventions. Moreover, both the research and practice disseminated.
communities in health education and health behavior are
sorely in need of more rigor and precision in theory The audience for health behavior change programs is
development and testing—in measures, assessment of truly global, and the professional community represents
mediating variables, and in specification of theoretical many different settings and countries. Theory developers
elements. We encourage more care and attention to how and theory users must consider more than ever how
theories are tested, and especially to the way variables culture, context, and health problems can and should
are measured and analyzed. Building a solid, cumulative affect their choices and applications of theory and
base of theory development is very difficult when one interventions. Professionals designing interventions have
researcher’s findings cannot be compared to another’s. more options than ever before, yet our theories have
improved only incrementally while our technologies have
Successful behavior changes strategies take many changed exponentially. This should be a wake-up call to
forms. Theory and research suggest that the most public health practitioners to think more concretely,
effective behavior change interventions are those that expansively and deeply about how they and their co-
use multiple strategies and aim to achieve multiple goals workers use theory.
of awareness, information transmission, skill
development, and supportive environments and policies. ---- SUMMARY ----
Goal-setting and monitoring are important elements of Theory, research, and practice are part of a continuum
many successful interventions. The emergence of for understanding the determinants of behaviors, testing
information technology tools such as the internet, strategies for change, and disseminating effective
wireless technology, and personal digital assistants have interventions. Rigorous tests of theory-based
expanded the range of theory-based strategies available interventions, including measurement and analyses of
for effective behavior change in health care and mediator and moderators, are the building blocks of the
community settings. Behavioral interventions should be evidence base in health behavior change.
sensitive to audience and contextual factors, and
recognize that most behavior change is incremental and Recent reviews of research on health behavior change
that maintenance of change usually requires continued have shown that interventions based on theory or
and focused efforts. theoretical constructs are more effective than those not
using theory. However, the mechanisms that explain the
When is a new theory needed? larger effects have not been studied.
As noted previously in the description of theory use in
published articles, there is a proliferation of theories but The most-often used theories of health behavior are
few are being widely used. Often, developers state that Social Cognitive Theory, The Transtheoretical
existing theories do not meet their needs and so a new Model/Stages of Change, the Health Belief Model, and
theory or model is necessary. However, careful thought the Theory of Planned Behavior. The most-often
about the generalizability, testability, and support for a mentioned theoretical model that has not been fully
“new” theory might instead lead to the choice of a applied in research and practice is the Social Ecological
suitable theory, to minor adaptations for unique cultural Model. This promising model needs to better articulated,
groups, and modified measures and evaluation applied and evaluated.
procedures. Work with culturally diverse groups provides
a case in point. Fundamental views of matters such as Other widely used theoretical models and planning
causes of health and disease among some ethnic frameworks:
groups may seem to point to a need for “new” theories. a. Theory of Reasoned Action/Theory of Planned
However, familiarity with a range of theories and Behavior
thoughtful selection of the best-suited theories might b. PRECEDE/PROCEED Model
solve this problem. c. Social support and social networks
d. Stress and coping theories
Population-focused programs and individual- e. Diffusion of innovations
focused f. Social marketing
strategies
In population-focused programs, it is of limited value to The strongest interventions may be built from multiple
adopt a program oriented solely toward modifying theories. When combining theories, it is important to
individuals’ behaviors (e.g., teaching patient low-fat food clearly think through the unique contribution of each
cooking methods). A more productive strategy would theory. The question of when a “new” theory is needed
also include environmental change, for example requires careful thought and more attention. There is
expanding the availability and affordability of more already a proliferation of theories though only a few are
nutritious food choices. When this is done along with widely used. When applying theory, there is no substitute
individual skill training, longer-lasting and meaningful for knowing the audience. Participatory program design,
changes can be achieved. There are many theories of evaluation and research improve the odds of success.
Also, health behavior change programs that address
significant public health problems should strive to
complement individually-oriented intervention models
with strategies and models to develop healthier policies,
systems and environments.