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Behavior Change -
a summary of four major theories:
Health Belief Model
AlDS Risk Reduction Model
Stages of Change
Theory of Reasoned Action
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The AlDS Control and Prevention (AIDSCAP) Project, implemented by Family Health International, is funded by the United States Agency for International Development.
Project 936-5972.314692046 Contract HRN-5972-C-00-4001-
Forfirther information, contact:
BEHAVIORAL RESEARCH UNIT
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Health Belief Model
AlDJ(AP (HBM)
The Health Belief Model (HEM) is a psychological model that attempts to explain and predict health behaviors by focusing on the attitudes and beliefs of individuals. The HEM was developed in the 1950s as part of an effort by social psychologists in the United States Public Health Service to explain the lack of public participation in health screening and pre- vention programs (e.g., a free and conveniently located tuberculosis screening project). Since then, the HBM has been adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIVJAIDS. The key variables of the HBM are as follows (Rosenstock, Strecher & Becker, 1994):
I PerceivedThreat: Consists of two parts: perceived susceptibil- ity and perceived severity of a health condition.
Perceived Susceptibility: One's subjective perception of the risk of contracting a health condition;
Perceived Severity: Feelings concerning the seriousness of contracting an illness or of leaving it untreated (includ- ing evaluations of both medical and clinical consequences and possible social consequences).
I Perceived Benefits: The believed effectivenessof strategies de- signed to reduce the threat of illness.
I Perceived Barriers: The potential negative consequences that may result from taking particular health actions, including physi- cal, psychological, and financial demands.
I Cues to Action: Events, either bodily (e.g., physical symptoms of a health condition) or environmental (e.g., media publicity) that motivate people to take action. Cues to actions is an aspect of the HBM that has not been systematically studied.
I OtherVariables: Diverse demographic,sociopsychological,and structural variables that afTect an individual's perceptions and thus indirectly influence health-related behavior.
I Self-Efficacy: The belief in being able to successfully execute the behavior required to produce the desired outcomes. (This con- cept was introduced by Bandura in 1977.)
Implications for Health Behaviors HEM research has been used to explore a variety of health behaviors in diverse populations. For instance, researchers have applied the HBM to studies that attempt to explain and predict individual participation in programs for influenza inoculations, Tay-Sachs carrier status screening, high blood pressure screening, smoking cessation, seatbelt usage, exer- cise, nutrition, and breast self-examination.With the advent of HIVJAIDS, the model also has been used to gain a better understanding of sexual risk behaviors (Rosenstock et al., 1994). Participantsin these studies, most of which were conducted in the United States, include people from the general population, homosexual men, adolescents,and pregnant women. Research designs also vary from longitudinal to cross-sectional and from retrospective to prospective studies.
1 References
1 I and
i Suggested
Reading
Banduta, A (1 989). Perceived selfsfficacy in the exercise of c o n d over AIDS infecrion. InVM.Map, G.W Abee & SESchneider (Eds.), Primary Prrvention of AlDS:Psyhdo@coIAppmoches (pp. 128-14t). London:Sage Publications.
B m L K , DiClement;e,RJ,& Reynolds, L.A.(i39 I). HIV prevenrionfor adoles- ens: U t i l i i of the Health Belief Model.NDS Edomtion and ~ ~ i? , 3 ( ~ ) , ~ & ~ 9.
J ~ N. % & W C MW[1984). The Health M e f ModekA decade tater.Heohh Educa- tion Quarter& i 1 [I),1-47.
i(itscht,j.?,&Joseph,j.G @989), The Health BefiefModel: Some implicationsfor behav- ior change,with reference to hornosexuaf males.InVM. G.W Albee & S.E Schneider (Eds.), Primory Pip ve&n ofAfDPPsychdogkoI Appm%es@p. 11 1-127). LondmSage Publicatiom.
Rorenstock I,Strecher, V,& Becker,M.(1994). The Health I3eJiefModeJand HIV risk Mavior change. In Kj.DiClernente,& f.L P e n o n (Eds.), hw&g AID5:Theories and Method. of ~ o fntwverrtionsd @p5- 24). NervYork:Pienurn Press
VanLandingham,Mj., Sup- !L,Gandjean,
N.,& SiW.(J995).
Tm views of risky sexual practices among Northern
Thai mates :The H& Be-
lief Model and theTheory of R ~ A c t i o n. J ~ ~ m o i ~ &xdthandsociorsehoviw, 195-
In a literature review of all HBM studies published from 1974-1984, the authors iden-
tified, across study designs and populations, perceived barriers as the most influen-
tial variable for predicting and explaining health-related behaviors (Janz & Becker, 1984).Other significant HBM dimensions were perceived benefits and perceived sus- ceptibility, with perceived severity identified as the least significant variable. More recently, though, researchers are suggesting that an individual's perceived ability to successfully carry out a "health" strategy,such as using a condom consistently, greatly influences hislher decision and ability to enact and sustain a changed behavior (Bandura, 1989).
Limitations General limitations of the HBM include: a) most HBM-based research to date has incorporated only selected components of the HBM, thereby not testing the useful- ness of the model as a whole; b) as a psychological model it does not take into con- sideration other factors, such as environmental or economic factors, that may influ- ence health behaviors; and c) the model does not incorporate the influence of social norms and peer influences on people's decisions regarding their health behaviors (a point to consider especially when working with adolescents on HIVIAIDS issues).
Sociodemographic Factors
(e.g., education, age, sex, race, ethnicity) I
,, , 1 - j, , , , - , , ,, I , , , ~wce~ffdffa : , < , , I , ' , , ' I , , , ,^ :,^ ,^ ,^ ,,^ ,, ,
Expectations Threat Perceived benefits of action (minus) Perceived susceptibility (or acceptance of the Perceived barriers diagnosis) t o action Perceived severity of Perceived self-efficacy ill-health condition t o perform action
Cues to Action
Media
Behavior to reduce threat Personal based on influence expectations
Reminders
Source: Rosennock I.,Strecher,V"& Becker,M. ( 1 994).
The H& Belief Model and HN risk behavior change. In It]. DiClemente& J.LPetenon (Eds.),
PreventingAIDS:The4ries and methods of behavioral nitervenoiins (pp.5-24). NewYork:Plenum Press. (^) I
I N level of self-esteem; I
resource requirements of acquiring help;
N ability to communicate verbally with sexual partner;
sexual partner's beliefs and behaviors.
In addition to the stages and influences listed above, the authors of the ARRM (Catania et al., 1990) identified other internal and external factors that may motivate indi- vidual movement across stages. For instance, aversive emotional states (e.g., high lev- els of distress over HIVIAIDS or alcohol and drug use that blunt emotional states) may facilitate or hinder the labeling of one's behaviors. External motivators, such as public education campaigns, an image of a person dying from AIDS, or informal support groups, may also cause people to examine and potentially change their sexual activities.
To date, ARRM studies in the United States have examined a variety of populations, includingpeople attending HIV testing clinics, gay and bisexual men, unmarried white, black and hispanic heterosexuals, and adolescent females attending family planning centers. (These are unpublished studies conducted by the Center for AIDS Preven- tion as described in Catania et al., 1990.) Results from a published study revealed how difficult it was for urban and rural women in Zaire to label their behavior as problematic: only one-third of the study participants felt personally at risk for con- tracting HIVIAIDS (Bertrand, Brown, Kinzonzi, Mansilu & Djunghu, 1992). Other research has expanded the ARRM to examine the behaviors of injecting drug users, as well as the protective behaviors of women who are already infected with H N (Malow, Corrigan, Cunningham,West & Pena, 1993;Kline &Vanlandingham, 1994).
Limitations: A general limitation of the ARRM model is its focus on the individual. For instance, many women in an ARRM-based study in Kampala, Uganda, felt at risk for HIV, not due to their own behavior but because of the behaviors of their sexual partners - an issue the women reported was outside of their control (McGrath et al., 1993).As a result, the researchers suggested that the ARRM take into greater consideration the sociocultural issues that influence, and may limit, an individual's behavior choices and ability to take action.
Resignation
Source:Catania, JA,Kegeles,S.M.,& CoatesTJ. (1990). Towards an understanding of risk behavior: An AIDS risk reductionmodel (ARRM). Heoh E d u h n @or&& 17(1),53-
Mabw,RM,Eommgan,
SA,Cundngham,S.C+, p-%J.M. 4[993), ~ ~ c i IdaMs a t ymi-
ated widr condom we
amongAfrican.dme- drvgabusersinaeaaent AfDSEdumtiOn mdP ~ ' o n , 5 ( 3 ), 244 - 253.
Mffitatlt,J.W., Rwabukwali,C.B.,
Sehumann,DJL,Person-
Mj.,NWmS., Namande, B. N a W b* I..,& Mukasa, R(1993). AnthmpofogyandAlDS: The w h a l Eontext of semd risk behavior among urban Ebgandawomen in Gunpals, Uganda Sod01 SB
efm and Mne.36.429-
439.
Rothenam-&rm,M.J., IClipman&& Rosariq M. (1992). o-talk ailorirg p m t i o n piwgmsrtaactr- ing-ies to adolwens' semmustn R]. D E l e m e r r e e ( E ~ A d ~ andAIDS -A Genemlion in feopordu@pziz*~q. Nwvbury FrtrlSWmia: W E Publications.
AIDSCAP Stages of Change
1 t
Psychologists developed the Stages of Change Theory in 1982 to com- i (^) pare smokers in therapy and self-changers along a behavior change con- ! (^) tinuum. The rationale behind "staging" people, as such, was to tailor
ii
therapy to a person's needs at hidher particular point in the change pro- i cess.^ As^ a result, the four original components of the Stages of Change
1 Theory (precontemplation, contemplation, action, and maintenance) f were identified and presented as a linear process of change. Since then, a ! (^) fifth stage (preparation for action) has been incorporated into the theory,
/ as well as ten processes that help predict and motivate individual move-
ment across stages. In addition, the stages are no longer considered to be linear; rather, they are components of a cyclical process that varies for
I each individual. The stages and processes, as described by Prochaska, i DiClemente and Norcross (1992), are listed below. I
1 .Precontemplation: Individual has the problem (whether he/
she recognizes it or not) and has no intention of changing. j 1 Processes:^ Consciousness raising (information and
I
knowledge)
I
Dramatic relief (role playing)
Environmental reevaluation (how problem af- fects physical environment)
Contemplation: Individual recognizes the problem and is seri- ously thinking about changing.
Processes: Self-reevaluation (assessing one's feelings re- garding behavior)
Preparation for Action: Individual recognizes the problem and intends to change the behavior within the next month. Some behavior change efforts may be reported, such as inconsistent con- i dom usage. However, the defined behavior change criterion has (^1) not been reached (i.e., consistent condom usage).
Processes: Self-liberation (commitment or belief in abil- ity to change)
Action: Individual has enacted consistent behavior change (i.e., consistent condom usage) for less than six months.
Processes: Reinforcement management (overt and covert rewards)
Helping relationships (social support, self-help
groups)
Counterconditioning (alternatives for behavior)
i Stimulus^ control (avoid high-risk cues) !
I .Maintenance: Individual maintains new behavior for six months
i or more. I
References
and
Suggested
Reading
Centers tor Disease Contml and Preven- tion. (1 993). Distribution of STD dinic patiena along a stages of behavioral change con-
tinuum - selected sites,
1993.MMWR, 42880883.
Galavoai,C.,Cabtal,R, Grimtey,D,Riley,G.E, & PmcbaskqJ.0. (t993). Measurement ofwndom and other arftraceptivebe hawr change among m n rrc high risk ofHN i@&n a n d t m e Paper presented at the IX Internarionai Conference on AIDS (Abm PO-D 441 6),Beriin,Gemrany.
Higgins,D./Schnell, D.J,Beeker,C., Guenttre&rey,C.,
Fishbein, M,O'Reilty,
KR, & Sheridan,j.
(1 993). The AiDS mmuniqy d m onmotion pmPmjeb* m. e w and dteoreticd _fbundTheA/DS_* coin- m u n i t y d e r n ~ ~ w t pmjeas mead team. Paper ptesentedatthe JX InternationalConfe- on AIDS [AbaF PO-D f3- 3745). BerIin, Germany.
Pbsner,J&& Higuems, G.(1995). Wages ofchange in condom use udc@rnThe W m Cam&.Paper presemed byproyea0 C o r n SiDA M D , La ?Z%WM%at theTemfi tathAmerican Congress on STDstFourth PanAmerican Conference onAIDS,SantiwChile
Prod,~j.0.(1994). Smng and weak principles for progressing from prwontemplationto ac- tion on the basis of problem W o d - f e d t h P s y c h o b ~ f 3 ( 1 ), 47 - 51.
Theory of Reasoned
A1DSCAP
Action (TRA)
: (^) Research using the Theory of Reasoned Action (TRA) has explained and
i predicted a variety^ of human behaviors since 1967.Based on the premise i (^) that humans are rational and that the behaviors being explored are un-
/ der volitional control, the theory provides a construct that links indi- i vidual beliefs, attitudes, intentions, and behavior (Fishbein, Middlestadt j & Hitchcock, 1994). The theory variables and their definitions, as de-
] scribed by Fishbein et al. (1994), are:
i i Behavior:^ A specificbehavior defined by a combination of four components: action, target, context, and time (e.g., implement-
[ ing a sexual^ HIV^ risk reduction strategy^ (action)^ by using condoms i (^) with commercial sex workers (target) in brothels (context) every
time (time).
Intention: The intent to perform a behavior is the best predic- tor that a desired behavior will actually occur. In order to mea- sure it accurately and effectively, intent should be defined using the same components used to define behavior: action, target, con- text, and time. Both attitude and norms, described below, influ- ence one's intention to perform a behavior.
Attitude: A person's positive or negative feelings toward per- forming the defined behavior.
Behavioral Beliefs: Behavioral beliefs are a combination of a person's beliefs regarding the outcomes of a defined be- havior and the person's evaluation of potential outcomes. These beliefs will differ from population to population. For instance, married heterosexuals may consider introducing condoms into their relationship an admission of infidelity, while for homosexual males in high prevalence areas it may be viewed as a sign of trust and caring.
W Norms: A person's perception of other people's opinions regard- ing the defined behavior.
Normative Beliefs: Normative beliefs are a combination of a person's beliefs regarding other people's views of a be- havior and the person's willingness to conform to those views. As with behavioral beliefs, normative beliefs regard- ing other people's opinions and the evaluation of those opin- ions will vary from population to population.
The TRA provides a framework for linking each of the above variables together (see diagram). Essentially,the behavioral and normative beliefs
- referred to as cognitive structures - influence individual attitudes and subjective norms, respectively. In turn, attitudes and norms shape a person's intention to perform a behavior. Finally, as the authors of the TRA argue, a person's intention remains the best indicator that the de- sired behavior will occur. Overall, the TRA model supports a linear pro- cess in which changes in an individual's behavioral and normative be- liefs will ultimately affect the individual's actual behavior.
The attitude and norm variables, and their underlying cognitive struc-
I
tures, often exert different degrees of influence over a person's intention.
t
1 References
Suggested
Reading
Ajzen, I,& Fishbein, M.
Understonding ond prddngsoobl behiar. New JeqP~ntice-Hall,Inc. I Fishbein, M.,& Middlestadt,S.E.(1989). Usingthe theory of rea- soned action as a framework for undemandingand chang- ing AlDSrelated behavion. In m. rlays,G.WSJbee.& 5.E
Schneider (Eds.), Ptirnary pre-
vention o f / v D S : ~ d ~ c u I appmoche5 @p.93- 1 19). Lon- don:- Publications.
(1994). Using information w dmge sexually aansmiDed disease- relatedW m l n fy. ~ i ~ l e m e m e& j. t ~ & n o n (Eds.], PrevenringAlDS:Xhe ries and methods ofbehclvioml ( ~ 1 ~ I p p 6 1 - 7 8 ). N e w I YorkPlenum Press. I Gallois, C., Kashima,Y Hills, R,&Mctamish, M. _CI9_* Pnedstmtegier fir sex** Refotionto past and aduaf b e hoviorc~1~ng~exuLdlyodive men and women.Paper pre- sented attheVl International Conference onAIDS (Abnr Th.D.H),San b c i s w , W i - fomi
IemrnoG jemrn- J.B.(199 1). Applyingthe theory of ma- soned actionto AIDS risk behavior: Condom use amongblack women, Nursing Reseurh.40[4),22834.
KasprzykD.,Montano, D.
(1 993)
Theory basediden@caban of
p m m tocondm use. Pa- per presented at rhe iV In- ternational Conferenceon AIDS (AhWP0-D 13-3Tn), Wm,Germany.
For example, results from a study of northern Thai males revealed that men's percep- tions of peer norms were the best predictor of condom use (VanLandingham, Suprasert, Grandjean & Sittitrai, 1995).Yet in a study of college females in the United States, attitudinal beliefs exerted greater influence on the intent to use condoms by sexually inexperienced females (Middlestadt & Fishbein, 1990). In order to develop appropriate interventions for a specific population and behavior, therefore, it is im- portant to determine which variable and its corresponding cognitive structures ex- erts the greatest influence on the study population (Fishbein et al., 1994).
To date, behaviors explored using the TRA include smoking, drinking, signing up for treatment programs, using contraceptives, dieting, wearing seatbelts or safety hel- mets, exercising regularly, voting, and breast-feeding (Fishbein et d., 1994). Studies conducted in Zimbabwe applied the theory to research on condom usage by females and males (Montano,Kasprzyk&Wilson, 1990;Wilson, Zenda & Lavelle, 1993). Other study populations for TRA HIVIAIDS research include women, STD clinic patients, female commercial sex workers, men who have sex with men, college students, and injecting drug users (please see references and suggested reading list).
Limitations Some limitations of the TRA include the inability of the theory, due to its individual- istic approach, to consider the role of environmental and structural issues and the linearity of the theory components (Kippax & Crawford, 1993).Individualsmay first change their behavior and then their beliefslattitudes about it. For example, studies on the impact of seatbelt laws in the United States revealed that people often changed their negative attitudes about the use of seatbelts as they grew accustomed to the new behavior.
THEORY OF R~ASOIWED~CTIOIAJ,..
The person's beliefs
that the behavior leads
to certain outcomes Attitude toward
and hislher evaluations
of these outcomes
Relative importance
of attidudinal and
normative
Behavior
considerations -
The person's beliefs
that specific individuals
I
or groups think helshe
should or should not
perform the behavior
Subjective norm
and hislher motivation -
to comply with the
specific referents
Middledark, %E.,&
Fishbein, M. (1990). Fuca~s irqkndngqwienced and - i co@e 4 Wmen'simerrtionsmtelttfiek. pormenmusemndms. Pa- per presentedat thew in- termtianal Conlwenceon ADS (Absrr SC1706f,Sw FmciscgCafifDmik
M-%&KarIm% D.,&Wlwn,D. (19931. 7fieorybmebarRef~ofmrr dbm use inZiinhbwePaper
pmsemdatthe IV tmema-
h a 1 Confeme onADS [AbscrW-D12378Ef,BeF 1hGerrnany.
po&bcbon ~ a p e r ~ m e ~ b e d atthe IV InternationalCon- ferpnce WADS (Atstr PO- Dt43844),Eerlin,aw.
Vwianrlimgbm,M.J., S u p q s. , G r a n d i q M&siittiaa3W.(l99q. Tivigrvscfdslqcsexwl pacoices among N m Thai rnafesThe health bdief madelandthetheoyef reasonedaction.Joumal0f
~ a o d ~ ~ ~ s g
195-
Wilron,l&Zenda,A,% W l ~ S ( 1 9 9 2 }. i%ctcXsinpm-rtgiifieRded mndmnusernnongaba- --b@pnt Matthewit 1 - a- tionaf Confe-an-
I-bDsW,
AmmrwThe N d w kind%
I Source:^ AjenJ,^ Fishbein,^ M. (1980)^ Understanding^ mitudes^ and^ predicting^ swbl^ befmfo~: New^ JeneyPrenric~Hdl,Inc.^ I
