Health Promotion

Behaviour change theories

Rob Moodie
Melbourne School of Population Health
 What this talk is about

Introduction
Key conceptual models
Big 5 principles of behaviour change*

* From Hill and Dixon The Big Five principles of behaviour change
 Introduction
➢Purpose: translation of theory and research into
successful behavioural change programs

➢Application: to individuals, family, community,

national

➢Role of evidence: built on rigorous

epidemiological analysis

➢Ultimate aim: reduce risk (improve health and well

being) by adoption of recommended preventive behaviours
 What behaviours are we talking about?
➢ Eating, physical exercise, sexual activity,
sunbathing, smoking, alcohol consumption, driving,
level of social connection, discrimination against
others, gun ownership

➢ Health seeking behaviours such as having a

screening test (e.g. mammogram, Pap smear), having
an immunisation, treatment

➢ Work-related behaviours – physical and emotional

risks

➢ Political decision making

➢ Profit making behaviours

 Key conceptual models
1. Social Cognitive Theory
2. Health Belief Model
3. Theory of Planned Behaviour
4. Precede Proceed Model
5. Stages of Change Theory
6. Social Ecological Approach
7. Behavioural Economics
 Why have conceptual or
theoretical models?
➢“Nothing more practical than a good theory” (Kurt Lewin,
1952)

➢Test assumptions and logic

➢Theory points to where to intervene

➢Articulate what leads to what…..and why!

➢Theory builds the structure for implementation and

evaluation

➢Helps develop common understandings

➢May help you to remember

 1. Social Cognitive Theory
Originates from social learning
theory proposed by Miller and
Dollard in 1941.

It is a learning theory based on the

ideas that people learn by watching
what others do.

Thus the observer solidifies that

learned action and would be
rewarded with positive reinforcement

The learned behaviour displayed in the environment in which one

grows up is important, as is the individual person (the way people
think) in determining development.

The proposition of social learning was expanded upon by Canadian

psychologist Albert Bandura from 1962
 2. Health Belief Model

The Health Belief Model (HBM) is a psychological model that

attempts to explain and predict health behaviors by focusing on the
attitudes and beliefs of individuals.

Developed in the 1950s by social psychologists in the US Public

Health Service to explain the lack of public participation in health
screening and prevention programs (e.g. a free and conveniently
located tuberculosis screening project).

The Health Belief Model has been adapted to explore a variety of

long- and short-term health behaviours, including sexual risk
behaviours and the transmission of HIV.
 2. Health Belief Model
Key Variables (Rosenstock, Strecher and Becker, 1994):

➢Perceived Threat: Consists of two parts

➢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

➢Perceived Benefits: The believed effectiveness of strategies

designed to reduce the threat of illness.

➢Perceived Barriers: The potential negative consequences that may

result from taking particular health actions, including physical,
psychological, and financial demands.
 2. Health Belief Model

Key Variables (continued):

➢Cues to Action: Events, either physical symptoms or

environmental influences (e.g. media publicity) that motivate
people to take action.

➢Other Variables: Diverse demographic, socio-psychological, and

structural variables that affect an individual's perceptions

➢Self-Efficacy: The belief in being able to successfully execute the

behaviour required to produce the desired outcomes. (This
concept was introduced by Bandura in 1977)
 3. Theory of Planned Behaviour
From intentions to actions

➢ Human behaviours are governed not only by personal attitudes,

but also by social pressures and a sense of control.

➢ It assumes that rational considerations govern the choices and

behaviors of individuals (Ajzen, 1985; Ajzen, 1991; Ajzen
& Fishbein, 2005).

➢ Specifically, according to a precursor of this theory, called the

theory of reasoned action, behaviour is determined by the
intentions of individuals - their explicit plans or motivations to
commit a specific act.
 3. Theory of Planned Behaviour

➢ In addition, the degree to which significant individuals, such as

relatives, friend, or colleagues, condone actions, called
subjective norms, also affects intentions (Ajzen & Fishbein).

➢ Finally, according to the theory of planned behaviour, the extent

to which individuals feel they can engage in these behaviors,
called perceived behavioral control, also impinges on their
intentions and behaviors (Ajzen, 1991).
 4. Precede Proceed Model

This is a structure for assessing health needs and for designing,

implementing, and evaluating health programs to meet those needs.
(Larry Green and Marshal Kreuter)

PRECEDE (Predisposing, Reinforcing, and

Enabling Constructs in Educational
Diagnosis and Evaluation) is a
diagnostic planning process to
assist in the development of public health
programs.

PROCEED (Policy, Regulatory, and Organizational Constructs in

Educational and Environmental Development) guides the implementation
and evaluation of the programs designed using PRECEDE.
4. Precede Proceed Model
 4. Precede Proceed Model

PRECEDE consists of five steps or phases

1. Determining the problems and needs of a given population.

2. Identifying the health determinants of these problems and

needs.

3. Analyzing the behavioural and environmental determinants of

the health problems.

4. Identifying the factors that predispose to, reinforce, and enable

the behaviours and lifestyles

5. Ascertaining the best interventions to encourage the desired

changes in the behaviours or environments and in the factors
that support those behaviours and environments.
 4. Precede Proceed Model

PROCEED is composed of four additional phases.

6. The interventions identified in phase five are implemented.

7. Process evaluation of those interventions.

8. Evaluation of the impact of the interventions on the factors

supporting the behaviour, and on behaviour itself.

9. The ninth and last phase comprises outcome evaluation—that is,

determining the ultimate effects of the interventions on the health
and quality of life of the population.
 Stages of Change Theory

Another widely known theory, the Stages of Change Theory (or

Transtheoretical Model) identifies five phases: (Prochaska 1977)

1. Precontemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance
Stages of Change Theory
 5. Social Ecological Approach

➢ This theory highlights the relationship between environmental

and behavioural determinants of health.

➢ This relationship is reciprocal; the environment affects health-

related behaviours, and people can, through their actions,
affect the environment.

Bronfenbrenner’s (1977, 1979)

➢ It is based on Urie
Ecological Systems Theory which describe influences as
intercultural, community, organizational, and interpersonal or
individual. This is an extension from Kurt Lewin’s (1935)
classic equation showing that behaviour is a function of the
person and the environment.
5. Social Ecological Approach
 5. Social Ecological Approach

➢ Our health is shaped by many environmental subsystems,

including our family, community, workplace, cultural beliefs and
traditions, economics, the physical world, and our web of social
relationships.

➢ Health promotion efforts must thus be comprehensive,

addressing those systems that positively or adversely affect the
person's capacity for living healthily.
 5. Social Ecological Approach

➢ People should be expected to behave differently in different

environments. An individual's behaviours may vary with
situation because the situation is partially responsible

➢ People have different capacities for action in varying

environments because environments differ in the resources
they provide to individuals.

➢ Reinforcements we receive for a particular action may be

different across contexts – e.g. positive in one environment and
negative in another.
 6. Behavioural economics

Standard neoclassical economists assume that humans are

rational and behave in a way to maximise their individual self-
interest.

While this assumption is widely accepted , it has many shortfalls

that can lead to unrealistic analysis and policy-making.
 6. Behavioural economics

The main shortfalls in the neoclassical model of human behaviour.

1. Other people’s behaviour matters: people do many things by

observing others and copying; people are encouraged to continue to
do things when they feel other people approve of their behaviour.

2. Habits are important: people do many things without consciously

thinking about them. These habits are hard to change – even though
people might want to change their behaviour, it is not easy for them.
 6. Behavioural economics

People are motivated to ‘do the right thing’: there are cases where
money doesn’t always motivate as it undermines people’s intrinsic
motivation, e.g. You’d stop inviting friends to dinner if they insisted
on paying you.

People’s self-expectations influence how they behave: they want

their actions to be in line with their values and their commitments.

People are loss-averse and hang on to what they consider ‘theirs’.

 6. Behavioural economics

People are bad at computation when making decisions: they put undue
weight on recent events and too little on far-off ones; they cannot
calculate probabilities well and worry too much about unlikely events;
they are strongly influenced by how the problem/information is
presented to them.

People need to feel involved and effective to make a change: just giving
people the incentives and information is not necessarily enough.
 Big Five Principles of Behaviour Change
Hill and Dixon

Repeated and habitual voluntary behaviours are determined

by
➢Motivation (wants to do it)

➢Modelling (sees others doing it)

➢Resources (has the required capacity –

understanding, training, self efficacy to do it)

➢Memory (remembers to do it)

➢Reinforcement (is ‘rewarded’ for doing it, ‘punished’

for not doing it)
 Big Five Principles of Behaviour Change
Hill and Dixon

Motivation (wants to do it)

➢Tricky concept
➢Reasons for doing something aren’t necessarily
logical
➢Physiology
➢Learning
➢Genetics
➢It’s a force, a drive
➢Necessary but insufficient cause of behaviour
change
➢“Knowing” the risks/benefits is simply not
enough!
 Big Five Principles of Behaviour Change
Hill and Dixon

Motivation (wants to do it)

➢Trying to determine “real”
motives
➢Get inside the way people
see the world

➢Aversion to skin wrinkles

(e.g. exposure to sun or
tobacco) rather than fear of
cancer as key motivating
factor
 Big Five Principles of Behaviour Change
Hill and Dixon

➢Modeling (sees others doing it)

➢Central to social cognitive theory
➢Role modeling
➢Patients
➢Friends
➢Footballers

➢Using role models and using mass

media – pros and cons
 Big Five Principles of Behaviour Change
Hill and Dixon

➢Resources (has the required capacity –

understanding, training, self efficacy to do it)
➢“Objective” capacity
➢The physical resources e.g. availability of
condoms, fruit and vegetables
➢Footpaths and overweight
➢Ecological models (use of legislation,
policy change)
 Big Five Principles of Behaviour Change
Hill and Dixon

➢Resources (has the required capacity –

understanding, training, self efficacy to do it)
➢“Objective” capacity – example
 Big Five Principles of Behaviour Change
Hill and Dixon

➢Resources (has the required capacity –

understanding, training, self efficacy to do it)

➢“Subjective” capacity
➢Self efficacy (social cognitive theory and theory of
planned behaviour)
➢Belief of ability to carry out the planned behaviour
➢Based on out own successes and failures
➢Promotion of self efficacy by education and
training

➢ e.g. peer education

➢raising self efficacy in sex workers
in India - mobile phones
 Big Five Principles of Behaviour Change
Hill and Dixon

➢Memory (remembers to do it)

➢Storing and retention of
information
➢Need for reminders (prompts)
➢Health belief model “cues for
action”
➢Mass media campaign
➢Card from GP
➢Advice from friends
➢Illness of a friend
➢Newspaper article

➢SMS for quitting in NZ – affordable, personalised,

age appropriate and not location dependent
 Big Five Principles of Behaviour Change
Hill and Dixon

➢Reinforcement (is ‘rewarded’ for doing it, ‘punished’

for not doing it)
➢Direct, vicarious or self directed
➢Jogger – endorphins, praise from friends (direct),
high profile athletes (vicarious),
➢reward for completing a marathon
(self directed) - or for getting a
good mark in your MPH)
 Big Five Principles of Behaviour Change
Hill and Dixon

➢Tax on cigarettes (reinforcement en masse)

➢Positive reinforcement (save money by giving up)

➢Negative reinforcement (by increased costs of
smoking)

➢Coughing up more than $16 a pack

 Big Five Principles of Behaviour Change

Translating the Big Five principles into the design of interventions

➢Identify behavioural and environmental risk factors linked to the

problem

➢Consider the attitudes, knowledge, social norms and patterns of

social and community organisation that contribute to the
behavioural risk factors

➢What are the “levers for change”

➢Learn from previous research, authoritative reviews, what has

worked elsewhere
 Big Five Principles of Behaviour Change
Hill and Dixon

➢You may have to collect data on missing

elements

➢What motivates people to behave in

a certain way

➢Who would the target audience

perceive to be a credible role model?

➢Do they have the resources and self

efficacy to adopt the desired
alternative behaviour?

➢How best to prompt and remind

(messages and channels)

➢What factors reinforce the

behaviours?
 Big Five Principles of Behaviour Change

Behaviour change is often about a reversal of behaviour

And it’s about a chain of behaviours not just a single behaviour

(so can this be broken down into its component parts – so you
can work out where best to intervene?
 Big Five Principles of Behaviour Change

Creating a problem specific conceptual model

“Nothing more practical than a good theory” ( Kurt Lewin,

1952)

Test assumptions and logic

Theory points to where to intervene

Articulate what leads to what…..and why!

Theory builds the structure for implementation and evaluation