Psychology and Health, 1998, Vol. 13, pp. 735-739 © 1998 OPA (Overseas Publishers Association) N.Y. Reprints available directly from the Publisher Published by license under Photocopying permitted by license only the Harwood Academic Publishers imprint, part of The Gordon and Breach Publishing Group. Printed in India. MODELS OF HUMAN SOCIAL BEHAVIOR AND THEIR APPLICATION TO HEALTH PSYCHOLOGY ICEK AJZEN* Department of Psychology, Box 37710 — Tobin Hall, University of Massachusetts, Amherst, MA 01003-7710, USA (Received 3 March, 1997; in final form 7 July, 1997) Theoretical models popular in the health domain differ in level of generality. Some were developed to deal with any human social behavior and then applied to health psychology, others were specifically designed to deal with health-related issues. Content-specific theories, such as the health-belief model and the perceptual-cognitive approach, outline in detail factors relevant for our understanding of health-related beliefs and actions. In con- trast, it is only in the course of empirical research that content-free models, such as social cognitive theory and the theory of planned behavior, obtain the specific information required for understending. Their advantage lies in their applicability across behavioral domains. Whether content-specific or content-free, the major utility of rmediels developed to date has been to organize and communicate knowledge about health-related behavior. Few profound insights have as yet resulted from their application, with the possible exception of the recognition that self-regulation, and especially self-efficacy, plays a major role in all aspects of health illness, and recovery. KEY WORDS: Social cognitive theory, self-efficacy, perceptual cognitive approach, theory of planned behavior. Pethaps more than any other concern, questions of illness and well-being have preoccu- pied human beings for millennia. Efforts to explain disease and offer cures have produced an embarrassment of riches. Strategies that search for bodily causes and cures have been supplemented by behavioral approaches that emphasize the importance of diet, physical activity, and other lifestyle factors. Yet even within the more limited behavioral domain, the abundance of ideas calls for a systematization of knowledge, and “self-regulation” has emerged as the most promising theme. The papers published in this special issue are representative of the thinking that has guided recent research in health psychology. My comments, focusing on theories that address self-regulation and its application to health behavior, are relevant most directly to Bandura’s (1998) paper on social cognitive theory and to the paper by Leventhal, Leventhal and Contrada (1998) describing a perceptual— cognitive approach. MODELS AT DIFFERENT LEVELS OF GENERALITY The need to systematize knowledge and ideas about health-related behavior has, as noted by Bandura, resulted in a proliferation of partly overlapping conceptual models. This is hardly surprising in light of the fact that investigators in this domain come from a variety of * E-mail: aizen@psych.umass.edu. 73s736 1. AIZEN professional disciplines with divergent practical and theoretical concems. Nevertheless, lit- tle is gained by needlessly multiplying predictors, using different labels for basically the same construct, or otherwise duplicating our theoretical efforts. Bandura’s attempt to offer an overarching framework in the context of social cognitive theory makes an important contribution toward conceptual simplification and integration. However, although quite per- suasive, this approach also tends to gloss over some important differences between models. The major theoretical models in use in the health domain converge on the importance of self-regulatory processes. As noted by Leventhal, Leventhal and Contrada, perhaps the most fundamental assumption in these models is that individuals are motived by self-generated goals and act to achieve those goals. People take into account anticipated consequences of their actions, as well as factors that may help or interfere with goal attainment, and they evaluate progress in light of feedback from their behavior. This assumed pattern of “reasoned action” (Ajzen and Fishbein, 1980) contrasts with views of human behavior that attribute primary motivation to unconscious needs, fears and desires. Content-Free Models Within this general framework there is room for models formulated at different levels of generality. Of the models popular in the health domain, the theory of planned behavior (Ajzen, 1985; 1991) is arguably the most general. It contains a small number of con- structs, defined without regard to any specific content. Briefly, according to the theory, a central determinant of behavior is the individual’s intention to perform the behavior in question. Intentions capture the goal-oriented nature of human behavior; they are indica- tions of how hard people are willing to try, of how much of an effort they are planning to exert, in order to perform a goal-directed behavior. As they formulate their intentions, people are assumed to take into account three conceptually independent types of consid- erations. First, they form beliefs about the likely consequences of a contemplated course of action, beliefs which, in their aggregate, result in a favorable or unfavorable attitude toward the behavior. A second type of consideration has to do with the perceived norma- tive expectations of relevant referent groups or individuals. These considerations lead to the formation of a subjective norm — the perceived social pressure to perform or not to perform the behavior. Finally, people are assumed to take into account factors that may further or hinder their ability to perform the behavior, and these considerations lead to the formation of perceived behavioral control, which refers to the perceived ease or difficulty of performing the behavior. Perceived behavioral control is assumed to reflect personal expetience with the behavior, modeling, self-knowledge, and anticipated impediments and obstacles. As a general rule, the more favorable the attitude and subjective norm with respect to a behavior, and the greater the perceived behavioral control, the stronger should be an individual’s intention to perform the behavior under consideration. It can be seen that the constructs in the theory of planned behavior are content-free. ‘The content is provided in the process of applying the theory to explain or influence a given behavior or course of action. Thus, an investigator trying to understand the prevail- ing determinants of maintaining a certain medical regimen would elicit salient beliefs about the consequences of this behavior, about the expectations of salient referent indi- viduals or groups, and about facilitating or inhibiting factors that may affect control over performance of the behavior (see Ajzen, 1991). Examination of the most frequently listed considerations provides a picture of the behavior’s important determinants. This informa- tion can then be used to devise effective intervention strategies.MODELS OF HUMAN SOCIAL BEHAVIOR BI Bandura’s social cognitive theory is also formulated at a high level of generality, and is potentially applicable to all behaviors that involve an element of self-regulation. However, this theory is more differentiated than the theory of planned behavior. As can be seer in Figure 1 of Bandura’ s paper, social cognitive theory deals with the same cate- gories of variables, but subdivides them into a greater number. Thus, instead of a single intention, it distinguishes between proximal and distal goals; instead of beliefs about behavioral consequences and social norms, it refers to physical, social, and self-evaluative outcome expectations; and instead of a single factor referring to perceived behavioral control, it draws a distinction between beliefs about self-efficacy on one hand and about personal and situational versus health system impedirnents on the other. There is of course nothing wrong with formulating constructs at higher or lower levels of generality. One level is not superior to another, The utility of a proposed set of con- structs is an empirical question that must be evaluated anew in any given application. The distinctions between attitudes, subjective norms, perceived behavioral control, and inten- tions have been found useful in a great number of applications (see Ajzen, 1991; for a review of applications in the health domain, see Godin and Kok, 1996). In his paper, Bandura argues persuasively for the utility of the constructs included in his social cogni- tive theory, especially as applied to health-related behavior. It must be noted, however, that with respect to any theory, a case can been made for the inclusion of additional con- structs. With respect to the theory of planned behavior, for example, it has been proposed that personal norms as well as moral norms and anticipated affect be considered as addi- tional determinant of intentions and behavior. These variables are similar in many ways to Bandura’s concept of self-evaluative reactions. My own preference nas been for parsimony as an important criterion in theory build- ing. I added the construct of self-efficacy or perceived behavioral control to the original theory of reasoned action when the work of Bandura and his associates made it clear that this construct was needed to deal with determinants of human behavior that are not under complete volitional control (see Ajzen, 1985). The three major determinants in the theory of reasoned action — attitudes, subjective norms, and perceived behavioral control — seem 0 be important variables in most applications of the model and thus deserve @ permanent place in it. Other factors appear to make an important contribution only in selective con- texts, such as situations in which moral considerations become important, These factors can be added when the need arises, but for the sake of simplicity and parsimony, we may not want to make them a permanent part of the theory. Content-Specific Models In contrast to social cognitive theory and the theory of planned behavior, both of which are content-free and can be applied to deal with virtually any behavior of interest, most of the remaining models popular in the health domain are formulated specifically to deal with issues of health and illness. Thus, the health belief model (Rosenstock, 1966; Becker and Maiman, 1975) explains motivation to adhere to a medical regimen by reference to such factors as general health motivation; the perceived threat posed by an illness, depending in part on its perceived severity and on judgments of one’s own vulnerability; the anticipated effectiveness of the regimen, based among other things on faith in doctors and medicine; and a variety of moderating and enabling factors, such as cost of the regi- men and prior experience with the illness. The perceptual-cognitive approach described in the Leventhal, Leventhal and Contrada paper follows in this tradition, although it is78 1. AJZEN much more circumscribed, dealing primarily with illness representations, i.e., common- sense views of health threats and with coping procedures or actions taken to prevent or treat disease, Nevertheless, like the health-belief model, this approach is specifically tai- lored to the content domain of illness and health. Developing content-specific models of this kind has its advantages and disadvantages. On the positive side, these models outline in detail the kinds of factors that must be considered if we are to understand health-related beliefs and behavior. According to the perceptual~ cognitive approach, people’s representations identify symptoms, apply labels to the dis- ease, and outline its likely consequences as well as the degree to which the course of the disease can be controlled. In addition, the model assumes that behavioral procedures involve an “if-then” rule whereby people’s representations of illness (the “if”) determine the remedial course of action they take (the “then”). A model of this kind clearly carries more information directly relevant to an understanding of health-related behavior than does a content-free mode] which requires that the content be filled in as the model is being applied to the health domain The disadvantage of taking a content-specific approach is that it requires construction ofa different model for each domain of human social behavior. In fact, we have been wit- nessing a proliferation of models specifically designed to explain not only health behav- ior but also voting behavior, consumer behavior, interracial behavior, religious behavior, and so forth. Each model incorporates a different set of constructs appropriate for its domain of application, with the ramification that there are as many determinants of human behavior as there are behavioral domains. Content-free models are clearly more parsimonious in that they stipulate a small set of constructs that can be applied across behavioral domains. In contrast to the content-specific models, they suggest that the types of considerations that motivate behavior in one domain also motivate behavior in other domains. Thus, efficacy beliefs and outcome expectancies, two of the variables in social cognitive theory, can help explain behavior related to health, voting, work, scholastic per- formance, and any other behavior. This obviates the need to develop new models as our research leads us into new behavioral domains. INSIGHTS DERIVED FROM THEORETICAL MODELS In the final analysis, the major purpose of using any theoretical model is to help us better understand behavior in the health domain, and to help us design more effective interven- tions. We must thus compare the information gained by applying our models to the infor- mation we Could have obtained without them. If one had to point to one profound insight produced by work on self-regulation, it is probably the tremendous importance of self-efficacy beliefs or perceived behavioral control. Bandura’s paper makes a persuasive case for the impact of this variable on health-related behavior and on the effectiveness of behavioral interventions.’ Beyond demonstrating the importance of self-efficacy beliefs, however, our theoretical models ' The success of the self-efficacy construct contrasts sharply with the failure to establish an important role for general self-esteem (see Dawes, 1994). Unlike self-efficacy, overall self-esteem is found to have little if any effect on behavioral achievement. The difference is that self efficacy deals with control over the specific behav- ior of interest whereas self-esteem is a much more general personality variable. That behavior-specific predic tors fare better than generalized dispositions is consistent with the Principle of compatibility established in research on the attitude-behavior relation (see Ajzen, 1988).MODELS OF HUMAN SOCIAL BEHAVIOR 9 have failed to generate many insights that could not have emerged without them. To be sure, the propositions and generalizations derived from work with these models appear reasonable and they provide a good framework for the development of intervention strategies. Nevertheless, most of these generalizations could have been developed intu- itively or on the basis of open interviews with a sample of respondents. Consider, for example, the following statements: “People cannot influence their own motivation and actions very well if they do not pay adequate attention to their own performances, the conditions under which they occur and to the immediate and distal effects they produce” (Bandura, p. 633), And, “The representation of a health problem may change if symp- toms worsen or decline, if new symptoms appear and/or if early symptoms fail to respond to intervention” (Leventhal, Leventhal and Contrada, p. 721). Similar examples of intuitively reasonable conclusions can be found in research that has applied the theory of planned behavior in the health domain. The point is that these kinds of conclusions can be reached on the basis of almost any theoretical model and, in fact, without the benefit of any model at all. These comments are not meant to imply, however, that non-theoretical interventions based on common sense are likely to be as effective as interventions based on existing theoretical models. As mentioned earlier, these models serve the important function of systematizing our knowledge about health-related beliefs, attitudes, and behavior. Intuitive approaches developed ad hoc often rely on unproven methods, and they run the risk of omitting important considerations in the development of an intervention strategy. The advantage of having a systematic theoretical model is especially apparent in Bandura’s paper, which manages to summarize the conclusions of a great deal of research in a few short pages. It is also evident in the Leventhal, Leventhal and Contrada paper which orga- nizes our knowledge about the ways people interpret symptoms, their causes and conse- ‘quences, and how these interpretations lead to the adoption of a particular coping strategy. Author Note I would like to express my appreciation to James Averill for his comments on an earlier draft of this paper. References Aizen, 1 (1985), From intentions te actions: A theory of planned behavior. In J. Kuhl and J. Beckmann (Eds), Action-control: From cognition to behavior (pp. 1\-39). Heidelberg: Springer. Ajzen, 1 (1988). Attitudes, personality, and behavior. Chicago: Dorsey Press ‘Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 3D, 179-211 Ajzen, 1. and Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood-Cliffs, NJ: Prentice-Hall Bandura, A. (1998). Health promotion from the perspective of social cognitive theory. Psychology and Health, 13, 623-649. Becker, M.H. und Maiman, L.A. (1975), Sociobehavioral determinants of compliance with health and medical recommendations. Medical Care, ¥3, 10-24 Dawes, RLM. (1994). House of cards: Psychology and psychotherapy built on myth. New York: Free Press. Godin, G. and Kok, G. (1996). The theory of planned behavior: A review of its applications to health-related behaviors. American Journal of Health Promotion, M1, 87-98, Leventhal, H., Leventhal, E.A. and Contrada, RJ. (1998), Self regulation, health, and behavior: A perceptual- cognitive approach. Psychology and Health, 13, 717-733 Rosenstock, I. (1966). Why people use health services. Milbank Memorial Fund Quarterly, 44, 94-124