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Behavioral Change Models
Behavioral Change Models
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Behavioral Change Models
Public health is a multi-disciplinary field that aims to 1) prevent disease and death, 2)
promote a better quality of life, and 3) create environmental conditions in which
people can be healthy by intervening at the institutional, community, and societal level.
Whether public health practitioners can achieve this mission depends upon their
ability to accurately identify and define public health problems, assess the fundamental
causes of these problems, determine populations most at-risk, develop and implement
theory- and evidence-based interventions, and evaluate and refine those interventions
to ensure that they are achieving their desired outcomes without unwanted negative
To be effective in these endeavors, public health practitioners must know how to apply
the basic principles, theories, research findings, and methods of the social and
behavioral sciences to inform their efforts. A thorough understanding of theories
used in public health, which are mainly derived from the social and behavioral sciences,
allow practitioners to:
- Assess the fundamental causes of a public health problem, and
- Develop interventions to address those problems.
The Health BeliefModel
The Health BeliefModel (HBM)was developed in the early 1950s by social scientists
at the U.S. Public Health Service in order to understand the failure of people to adopt
disease prevention strategies or screening tests for the early detection of disease.
Later uses of HBM were for patients’ responses to symptoms and compliance with
medical treatments. The HBM suggests that a person’s belief in a personal threat of an
illness or disease together with a person’s belief in the effectiveness of the
recommended health behavior or action will predict the likelihood the person will
adopt the behavior.
The HBM derives from psychological and behavioral theory with the foundation that
the two components of health-related behavior are 1) the desire to avoid illness, or
conversely get well if already ill; and, 2) the belief that a specific health action will
prevent, or cure, illness. Ultimately, an individual’s course of action often depends on
the person’s perceptions of the benefits and barriers related to health behavior. There
are six constructs of the HBM. The first four constructs were developed as the original
tenets of the HBM. The last two were added as research about the HBM evolved.
- Perceived susceptibility – This refers to a person’s subjective perception of
the risk of acquiring an illness or disease. There is wide variation in a
person’s feelings of personal vulnerability to an illness or disease.
- Perceived severity – This refers to a person’s feelings on the seriousness of
contracting an illness or disease (or leaving the illness or disease untreated).
There is wide variation in a person’s feelings of severity, and often a person
considers the medical consequences (e.g., death, disability) and social
consequences (e.g., family life, social relationships) when evaluating the
- Perceived benefits – This refers to a person’s perception of the effectiveness
of various actions available to reduce the threat of illness or disease (or to
cure illness or disease). The course of action a person takes in preventing (or
curing) illness or disease relies on consideration and evaluation of both
perceived susceptibility and perceived benefit, such that the person would
accept the recommended health action if it was perceived as beneficial.
- Perceived barriers – This refers to a person’s feelings on the obstacles to
performing a recommended health action. There is wide variation in a
person’s feelings of barriers, or impediments, which lead to a cost/benefit
analysis. The person weighs the effectiveness of the actions against the
perceptions that it may be expensive, dangerous (e.g., side effects),
unpleasant (e.g., painful), time-consuming, or inconvenient.
- Cue to action – This is the stimulus needed to trigger the decision-making
process to accept a recommended health action. These cues can be internal
(e.g., chest pains, wheezing, etc.) or external (e.g., advice from others, illness
of family member, newspaper article, etc.).
- Self-efficacy – This refers to the level of a person’s confidence in his or her
ability to successfully perform a behavior. This construct was added to the
model most recently in mid-1980. Self-efficacy is a construct in many
behavioral theories as it directly relates to whether a person performs the
Limitations of Health BeliefModel
There are several limitations of the HBMwhich limit its utility in public health.
Limitations of the model include the following:
- It does not account for a person’s attitudes, beliefs, or other individual
determinants that dictate a person’s acceptance of a health behavior.
- It does not take into account behaviors that are habitual and thus may
inform the decision-making process to accept a recommended action (e.g.,
- It does not take into account behaviors that are performed for non-health
related reasons such as social acceptability.
- It does not account for environmental or economic factors that may prohibit
or promote the recommended action.
- It assumes that everyone has access to equal amounts of information on the
illness or disease.
- It assumes that cues to action are widely prevalent in encouraging people to
act and that “health” actions are the main goal in the decision-making
The HBM is more descriptive than explanatory and does not suggest a strategy for
changing health-related actions. In preventive health behaviors, early studies showed
that perceived susceptibility, benefits, and barriers were consistently associated with
the desired health behavior; perceived severity was less often associated with the
desired health behavior. The individual constructs are useful, depending on the health
outcome of interest, but for the most effective use of the model it should be integrated
with other models that account for the environmental context and suggest strategies
The Theory of Planned Behavior
The Theory of Planned Behavior (TPB) started as the Theory of Reasoned Action in
1980 to predict an individual’s intention to engage in a behavior at a specific time and
place. The theory was intended to explain all behaviors over which people have the
ability to exert self-control. The key component to this model is behavioral intent;
behavioral intentions are influenced by the attitude about the likelihood that the
behavior will have the expected outcome and the subjective evaluation of the risks and
benefits of that outcome.
The TPB has been used successfully to predict and explain a wide range of health
behaviors and intentions including smoking, drinking, health services utilization,
breastfeeding, and substance use, among others. The TPB states that behavioral
achievement depends on both motivation (intention) and ability (behavioral control). It
distinguishes between three types of beliefs – behavioral, normative, and control. The
TPB is comprised of six constructs that collectively represent a person’s actual control
over the behavior.
- Attitudes – This refers to the degree to which a person has a favorable or
unfavorable evaluation of the behavior of interest. It entails a consideration
of the outcomes of performing the behavior.
- Behavioral intention – This refers to the motivational factors that influence a
given behavior where the stronger the intention to perform the behavior,
the more likely the behavior will be performed.
- Subjective norms – This refers to the belief about whether most people
approve or disapprove of the behavior. It relates to a person’s beliefs about
whether peers and people of importance to the person think he or she
should engage in the behavior.
- Social norms – This refers to the customary codes of behavior in a group or
people or larger cultural context. Social norms are considered normative, or
standard, in a group of people.
- Perceived power – This refers to the perceived presence of factors that may
facilitate or impede performance of a behavior. Perceived power
contributes to a person’s perceived behavioral control over each of those
- Perceived behavioral control – This refers to a person’s perception of the
ease or difficulty of performing the behavior of interest. Perceived
behavioral control varies across situations and actions, which results in a
person having varying perceptions of behavioral control depending on the
situation. This construct of the theory was added later and created the shift
from the Theory of Reasoned Action to the Theory of Planned Behavior.
Limitations of the Theory of Planned Behavior
There are several limitations of the TPB, which include the following:
- It assumes the person has acquired the opportunities and resources to be
successful in performing the desired behavior, regardless of the intention.
- It does not account for other variables that factor into behavioral intention
And motivation, such as fear, threat, mood, or past experience.
- While it does consider normative influences, it still does not take into
account environmental or economic factors that may influence a person’s
intention to perform a behavior.
- It assumes that behavior is the result of a linear decision-making process,
and does not consider that it can change over time.
- While the added construct of perceived behavioral control was an important
addition to the theory, it doesn’t say anything about actual control over
- The time frame between “intent” and “behavioral action” is not addressed by
The TPB has shown more utility in public health than the Health BeliefModel, but it is
still limiting in its inability to consider environmental and economic influences. Over
the past several years, researchers have used some constructs of the TPB and added other components from behavioral theory to make it a more integrated model. This has
been in response to some of the limitations of the TPB in addressing public health
Diffusion of Innovation Theory
Diffusion of Innovation (DOI) Theory, developed by E.M. Rogers in 1962, is one of the
oldest social science theories. It originated in communication to explain how, over time,
an idea or product gains momentum and diffuses (or spreads) through a specific
population or social system. The end result of this diffusion is that people, as part of a
social system, adopt a new idea, behavior, or product. Adoption means that a person
does something differently than what they had previously (i.e., purchase or use a new
product, acquire and perform a new behavior, etc.). The key to adoption is that the
person must perceive the idea, behavior, or product as new or innovative. It is through
this that diffusion is possible.
Adoption of a new idea, behavior, or product (i.e., “innovation”) does not happen
simultaneously in a social system; rather it is a process whereby some people are more
apt to adopt the innovation than others. Researchers have found that people who
adopt an innovation early have different characteristics than people who adopt an
innovation later. When promoting an innovation to a target population, it is important
to understand the characteristics of the target population that will help or hinder
adoption of the innovation. There are five established adopter categories, and while the majority of the general population tends to fall in the middle categories, it is still
necessary to understand the characteristics of the target population. When promoting
an innovation, there are different strategies used to appeal to the different adopter
- Innovators – These are people who want to be the first to try the innovation.
They are venturesome and interested in new ideas. These people are very
willing to take risks, and are often the first to develop new ideas. Very little,
if anything, needs to be done to appeal to this population.
- Early Adopters – These are people who represent opinion leaders. They
enjoy leadership roles, and embrace change opportunities. They are already
aware of the need to change and so are very comfortable adopting new
ideas. Strategies to appeal to this population include how-to manuals and
information sheets on implementation. They do not need information to
convince them to change.
- Early Majority – These people are rarely leaders, but they do adopt new
ideas before the average person. That said, they typically need to see
evidence that the innovation works before they are willing to adopt it.
Strategies to appeal to this population include success stories and evidence
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