Professional Documents
Culture Documents
3 2005
Theory & Practice Pages 275–290
Advance Access publication 4 January 2005
Health Education Research Vol.20 no.3, Ó Oxford University Press 2004; All rights reserved doi:10.1093/her/cyg113
S. M. Noar and R. S. Zimmerman
1994; Murray-Johnson et al., 2001; Nigg et al., HBT should explain differences across situations,
2002a; Noar et al., 2003)]. contexts, populations and with regard to different
However, it is not clear whether anything has behaviors.
changed since Weinstein’s (Weinstein, 1993) arti- Within the study of health behavior, theories
cle. This leads us to ask the question: what is the have been proposed at a variety of levels, including
best way for the field to move forward? The the individual, interpersonal, group, organizational
overriding purpose of the current article is to offer and community levels. Further, theories vary in
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HBT and cumulative knowledge
The problem: numerous theories, little ious reasons were offered, although empirical
consensus studies showing the superiority of the chosen theory
over other theories was rarely among the reasons.
Numerous individual-level HBTs exist in the liter-
ature. These include the Health Belief Model [HBM Problems resulting from a lack of
(Becker, 1974)], Theory of Reasoned Action [TRA consensus
(Ajzen and Fishbein, 1980)] and Theory of Planned In addition, each of these theories can be viewed as
277
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Attitudinal beliefs
Appraisal of the the positive benefits, barriers/ behavioral beliefs behavioral beliefs outcome pros, cons
positive and aspects outweigh health motive and evaluation of and evaluation of expectations/ (decisional
negative aspects of the negative those beliefs those beliefs expectancies balance)
the behavior and aspects (attitudes) (attitudes)
expected outcome
of the behavior
Self-efficacy beliefs/beliefs about control over the behavior
Belief in one’s one believes in self-efficacy – perceived self-efficacy self-efficacy/
ability to perform their ability to behavioral control temptation
the behavior; perform the
confidence behavior
Normative and norm-related beliefs and activities
Belief that others one believes that cues from media, normative beliefs normative beliefs social support helping
want you to people important friends (cues to and motivation to and motivation to relationships
engage in the to them want them action) comply comply (process of
behavior (and to engage in the (subjective norms) (subjective norms) change)
one’s motivation behavior; person
to comply); may has others’ support
include actual
support of others
Belief that others one believes that – – – social social liberation
(e.g. peers) are other people are environment/ (process of
engaging in the engaging in the norms; modeling change)
behavior behavior
Responses to one receives cues from media, –a –a reinforcement reinforcement
one’s behavior positive friends (cues to management/
that increase or reinforcement action) stimulus control
decrease the from others or (processes of
likelihood one will creates positive change)
engage in the reinforcements for
behavior; may themselves
include reminders
Table I. Continued
Variable names in parentheses indicate that the variable(s) above it are part of that larger category, according to the theory.
a
Both the TRA and TPB contain normative components that are conceptualized as beliefs in reinforcement (normative beliefs), rather than the actual reinforcement itself.
It is not clear which conceptualization of these ideas is best for a theoretical framework.
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S. M. Noar and R. S. Zimmerman
carefully considered when such constructs are theories [e.g. (Madden et al., 1992; Prochaska
compared. et al., 1994)], but has rarely been addressed across
In addition, we as a field should never be blind theories. This is a question that may be better
advocates interested only in finding support for facilitated by answers to the more basic questions.
particular theories. Rather, we should put theories Finally, we should note that an issue that has
to the strongest possible tests and when such been discussed in the literature is whether or not
theories do not stand up to rigorous evaluation, a single theory is appropriate across multiple
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HBT and cumulative knowledge
existing theory or create a new theory altogether. testing across behaviors and situations, and refined
When Ajzen and Madden (Ajzen and Madden, as necessary. An integrated theory would first
1986) observed that the TRA could be improved, require that theorists agree on common conceptu-
they proposed the TPB. Their research demon- alizations and names for similar constructs.
strated that the addition of perceived behavioral There have been various attempts to create in-
control added variance in the prediction of health tegrated theories of health behavior, and a recent
behaviors (Madden et al., 1992) and subsequent example is Fishbein’s (Fishbein, 2000) integrated
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S. M. Noar and R. S. Zimmerman
such as Consumer Reports. How else can one know unique citations contained two or more theories in
what product is best, if we do not compare one to the search record. Further, when we more closely
the other? Theories are, in fact, academic products examined these 178 citations, we found the follow-
that are fashioned from well thought out conceptual ing. First, nine articles were excluded for various
work. Do they not justify comparison if they reasons (e.g. they were improperly coded in Psy-
all claim to explain the same phenomena, yet have cInfo and had no relevance here). This left 169
fundamental differences among them? articles, which were broken down into various cate-
Number of citations
those constructs is, and (2) compare theories to
600 509 (18%)
discover how these constructs combine and result in
the enactment of health behavior. Further, since 500
articles mentioned more than one theory and only Fig. 1. Number of unique citations (total N = 2901) for individual
four of these 10 were empirical comparisons. In versus multiple theories found in PsycInfo through June 2003.
order to examine an updated state of empirical
comparisons in the literature, we conducted a com-
prehensive search of the PsycInfo database through 90
80 (47%)
June of 2003. We searched for articles that were 80
classified in PsycInfo as health-related articles 67 (40%)
(using the keyword health which includes health 70
Number of citations
282
HBT and cumulative knowledge
empirical studies, but rather were descriptive theo- behavior, then some changes to the way we conduct
retical articles [e.g. (Sutton, 1987; Bandura, 1998)]. such research are necessary.
Next, N = 18 of the studies were intervention
projects [e.g. (Pinto et al., 2002)], while N = 4 were
categorized as ‘other,’ which contained studies such How should researchers empirically
as qualitative focus group investigations [e.g. (Levy compare theories?
and Bavendam, 1995)]. Finally, N = 80 were
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S. M. Noar and R. S. Zimmerman
search captured a number of important comparisons test theories in a number of ways within a single
in the literature. study, including testing multiple DVs [e.g. (Bish
Nineteen studies met the criteria and are de- et al., 2001)] as well as testing theories with and
scribed in Table II. All of the studies were corre- without past behavior [e.g. (Quine et al. 2000)] and
lational in nature and used survey data; none were demographics controlled for [e.g. (Vanlandingham
lab-based or experimental studies. In terms of et al., 1995)]. We also note that studies examining
analytic techniques, by far the most common multiple health behaviors allow us to examine the
284
Table II. Empirical comparisons of HBTs (N = 19)
Bish et al. cervical cancer longitudinal N = 133 females, HBM, TPB intention, correlations for theoretical components.
(2000) screening (baseline, mean age: 38.1 (UK) behavior multiple regression for complete theories;
3 months) R2. and b weights compared
Boyd and safer sex longitudinal N = 190 undergraduates, TRA, TABM intention, multiple regression for complete theories;
Wandersman (baseline, mean age: 18.9 (US) behavior R2. and significance of b weights compared
(1991) 3 months)
Conner and safer sex cross-sectional N = 218 undergraduates, HBM, TPB intention, correlations for theoretical components.
Graham (1993) age not reported (UK) behavior multiple regression for complete theories;
R2. and b weights compared
Conner and health screening longitudinal N = 407 individuals, HBM, TPB intention, correlations for theoretical components.
Norman (1994) (baseline, age not reported (UK) behavior multiple regression for complete theories (path
6 months) analysis); R2. and b weights compared
Garcia and resisting dieting cross-sectional study 1: N = 159 female HBM, HBM intention multiple regression for complete theories;
Mann (2003) and breast undergraduates; study 2: plus self-efficacy, R2. and b weights compared
self-exam N = 120 female TRA, TPB,
undergraduates; ages not HAPA
reported (US)
Hennig and cervical cancer cross-sectional N = 144 females, HBM, TRA intention correlations for theoretical components.
Knowles (1990) screening mean age: 54 (US) multiple regression for complete theories;
R2. and b weights compared
Hill et al. breast cross-sectional N = 123 females, HBM, TRA, intention multiple regression for complete theories;
(1985) self-examination, median age: 34 (US) SPM R2. and b weights compared
cervical cancer
screening
Kloeblen et al. breast-feeding cross-sectional N = 1001 females, TRA, TTM intention, correlations for theoretical components.
behavior
286
DV = dependent variable; TABM = Triandis attitude behavior model; HAPA = health action process approach; SPM = subjective probability model; PRECEDE =
Predisposing, reinforcing, enabling factors model; EPPM = extended parallel process model; PMT = Protection motivation theory; SEM = structural equation modeling.
HBT and cumulative knowledge
Table IV. Suggested important theory comparison questions for the field
1. What is the extent of similarity or difference regarding Is there any difference among behavioral beliefs (TRA), benefits
constructs from differing theories that appear to be similar or the and barriers (HMB), outcome expectancies (SCT), and
same in nature? decisional balance (TTM)? Are there substantive conceptual
differences between perceived behavioral control (TPB) and
self-efficacy (SCT) or are they essentially the same?
2. Are certain theories or elements of theories more useful in terms Does the stage-based TTM or continuum-based TRA provide
of predicting behavior or behavior change as compared to others? better prediction of behavior?
3. Are the combinatorial rules for one theory better supported Are health behaviors mediated by intention formation (as TRA/
empirically than for other theories? TPB suggest) or not (as the HBM suggests)?
4. Are certain theories or elements of theories better predictors Are SCT constructs better at predicting addictive behaviors, while
of addictive behaviors (as opposed to non-addictive behaviors)? TPB constructs are better at predicting non-addictive behaviors?
5. Are certain theories or elements of theories better predictors Are HBM constructs better at predicting one-time behaviors,
of one-time behaviors (e.g. vaccinations) as opposed to while constructs from the TTM better at predicting behaviors
behaviors that must be maintained over time (e.g. exercise)? that must be maintained?
6. Are certain theories or elements of theories better predictors Do theories such as the TRA/TPB predict adoption behaviors
of cessation behaviors (e.g. smoking cessation) as opposed to better than cessation behaviors, or vice versa?
behaviors that must be adopted (e.g. exercise)?
7. Are certain theories or elements of theories better predictors Is self-efficacy a better predictor in cultures with more of a focus
in different cultures? on individualism, and beliefs and norms better predictors in
cultures with more of a focus on collectivism?
8. Is there one set of behavior change principles that can account Questions 4–7 address this
for all health behaviors, or are they different according to
different behaviors, cultures and contexts?
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S. M. Noar and R. S. Zimmerman
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(Fishbein, 2000) integrative model and Prochaska Burkholder, G.J. and Evers, K.E. (2002) Application of the
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