Introduction to theories and

models of behavior change

Mulugeta Tamire (PhD)

SPH, AAU
Feb 2024
Outline

• Objectives
• Definitions
• Factors affecting human behavior
• Rationale of applyingTheories and Models in
Health Promotion
• Types of theiories and models

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Objectives

• At the end of this session, students

will be able to:
• Define theory and model
• Describe factors affecting human
behaviour
• Explain the importances of theory
and model
• List the types of theory and model

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• A theory is a set of interrelated
concepts, definitions, and propositions
that present a systematic view of
events or situations by specifying
relations among variables, in order to
explain and predict the events or
situations.
• A theory helps health education and
health promotion programs identify
program objectives, specify methods
for facilitating behavior change,
provide guidance about timing of
methods, and select method of
intervention.

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• CONCEPTS are the building blocks of theory, the
primary elements of theory
• A CONSTRUCT is the term used for a concept
developed or adopted for use in a particular theory
• Thus, a CONSTRUCT has a very specific and
technical meaning. "Key concepts" of a given theory
are its constructs
• VARIABLES are the operational forms of constructs-
how a construct is to be measured in a specific
situation
• It is important to keep in mind that VARIABLES
should be matched to CONSTRUCTS when you are
identifying what needs to be assessed in the
evaluation of a theory-driven program

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Model
• MODELS are generalized,
hypothetical descriptions, often
based on an analogy, used to
analyze or explain something
• A model can be characterized
as a theory in its early stages
• Models are eclectic, creative,
simplified miniaturized
applications of concepts for
addressing problems
 No single theory dominates health education and
Theories and models... promotion

Some theories focus on individuals as the unit of

change, while others focus on change in
organizations or cultures

Still, no one theory will be right in all cases

Depending on the unit of analysis or change

(individuals, groups, organizations,
communities) and the topic and type of behavior
you are concerned with
 Comparison between a model and a theory

Theory Model
• Explains or predicts a o Simplified application
phenomena of concepts for
• Micro-level guidance addressing problems
• Empirically tested o Macro level guidance
• Based in previous o Not enough empirical
literature evidence
• Usually parsimonious o Creative
• Does not contain any o Usually tries to cover
model a lot
• E.g. Social cognitive T o May embody one or
more theory 8
Types
• First, behavior is viewed as being
affected by, and affecting, multiple
levels of influence
• Five levels of influence for health-
related behaviors and conditions
have been identified.
 Intrapersonal, or individual
factors
 Interpersonal factors
 Institutional, or organizational
factors
 Community factors
 Public policy factors
Example

• For example, a woman might delay getting a recommended cancer

screening test (a mammogram) because she is afraid of finding out she
has cancer. This is an individual-level, or intrapersonal factor.
However, her inaction might also be influenced by her doctor's not
recommending mammography, the difficulty of scheduling an
appointment because there is only a part-time radiologist at the clinic,
and her inability to pay the high fee. These interpersonal,
organizational, and policy factors also influence behavior.
Why theories and models ?

• Theory can help us during the various

stages of planning, implementing, and
evaluating an intervention
• In guiding a search to answer
 WHY people are or are not following public
health and medical advice, or not caring for
themselves in healthy ways
 WHAT you need to know before developing or
organizing an intervention program
 HOW you shape program strategies to reach
people and organizations and make an impact on
them
 WHAT should be monitored, measured, and/or
compared in the program evaluation
Why theories and models ?

Theories can explain the

dynamics of the behavior, the
Theories can help us understand
processes for changing the
the nature of targeted health
behavior, and the effects of
behaviors
external influences on the
behavior

Theories can help us identify the

most suitable targets for Theories and models EXPLAIN
programs, the methods for behavior and suggest ways to
accomplishing change, and the achieve behavior CHANGE
outcomes for evaluation
General classification theories and models in health
education and promotion
Factors affecting human
behaviour
• Factors affecting behaviour are broadly classified in to
predisposing, enabling and reinforcing factors.
1. Predisposing factors: Provide the rationale or
motivation for the behavior to occur. Some of these
are:
• Knowledge
• Belief
• Attitudes
• Values

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Factors affecting human
behaviour(cont…)
2. Enabling factors: these are characteristics of the environment
that facilitates healthy behavior and any skill or resource
required to attain the behavior.
• Enabling factors are required for a motivation to be
realized.
Examples of enabling factors include:
• Availability and or accessibility of health resources
• Government laws, priority and commitment to health
• Presence of health related skills

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Factors affecting human
behaviour(cont…)
E.g. Enabling factors for a mother to give oral
rehydration solution to her child with diarrhea
would be:
• Time, container
• Knowledge of how to prepare and administer it.

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Factors affecting human
behaviour(cont…)
• In general, it is believed that enabling factors should be
available for an individual or community to perform
intended behavior.
• Behavioral intention Behavioral change

Enabling factors
(Time, money and materials, skills, accessibility to health
services)
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Factors affecting human
behaviour(cont…)

3. Reinforcing factors: these factors

come after the behavior.
• They are important for
persistence or repetition of the
behavior.
• The most important reinforcing
factors for a behavior to occur
or avoid include:
• Family
• Peers, teachers
• Employers, health providers
• Community leaders
• Decision makers

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The ABCs of Behavior
Modification
• When we look at behavior modification it is helpful to break
it down into the ABCs where;
A = Antecedent, B = Behavior, and C =Consequence

• According to behaviorists such as B. F. Skinner, almost all

behavior can be broken down into the ABC components.
Ante means before. The antecedent occurs before the
behavior while the consequence occurs after the behavior
Common theories and
models

THE HEALTH BELIEF THEORY OF THE TRANS-

MODEL (HBM) REASONED THEORETICAL
ACTION(TRA) & MODEL(TTM)
THEORY OF
PLANNED BEHAVIOR
(TPB)

SOCIAL COGNITIVE PRECEDE – DIFFUSION OF

THEORY (SCT) PROCEED MODEL INNOVATION
THEORY (DOI)

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A. The Health belief Model(HBM)
(Hochbaum, Rosenstock &Becker,1950-1974)

 Has been one of the most widely used conceptual

frameworks in health behavior.
 Has been used to explain change and maintenance of
health related behaviors and as guiding framework for
health behavior interventions.
• The model focuses on two aspects of individual
representation of health and health behaviour:
1. Threat perception
2. Behavioural evaluation

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HBM cont..
Threat perceptions are seen to depend upon
two beliefs:
Perceived susceptibility to the illness and
perceived severity of the consequence of such illness.
together these two variables are believed to determine the
likelihood that the individual is following a health related
action
Although their effect is modified by
individual differences in demographic
variables and psychological variables,
the particular action is believed to be determined by the
evaluation of available alternatives
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HBM…

• HBM hypothesizes that health related action

depends on simultaneous occurrence of three
classes of factors
• Health concern that makes health issues salient
(health motivation)
• Perceived threat from health issue
• Belief that a particular health recommendation
would be beneficial in reducing the threat at
subjectively acceptable cost

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 Components of the HBM

Concept/ Definition Application

Constructs

Perceived One’s belief regarding the chance Define population(s) at risk, risk levels.
susceptibility of getting a condition Personalize risk based on a person’s
characteristics or behavior.
Make perceived susceptibility more consistent
with an individuals actual risk.

Perceived severity one’s belief of how serious a Specify consequence of the risk and the
condition and its sequela are condition

Perceived benefits One’s belief in the efficacy of the Define action to take: how, where, when; clarify
advised action to reduce risk or the positive effects to be expected
seriousness of impact

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 Components of the HBM

Concept/ Definition Applications

Constructs

Perceived barriers One’s belief about the tangible and Identify and reduce perceived barriers through
psychological costs of the advised reassurance, correction of misinformation,
action incentives, assistance

Cues to action Strategies to activate one’s Provide how-to information, promote awareness,
“readiness” employ reminder systems

Self-efficacy One’s confidence in one’s ability to Provide training, guidance in performing action.
take action Use progressive goal setting.
Give verbal reinforcement.
Demonstrate desired behaviors.
Reduce anxiety.

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Example:
Hypertension
• High blood pressure screening campaigns
often identify people who are at high risk
for heart disease and stroke, but who say
they have not experienced any symptoms

• Because they don’t feel sick, they may not

follow instructions to take prescribed
medicine or lose weight.

• Here, HBM can be useful for developing

strategies to deal with non-compliance in
such situations

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Example…
• According to the HBM, asymptomatic people may not
follow a prescribed treatment regimen unless they accept
that, though they have no symptoms, they do in fact have
hypertension (perceived susceptibility).
• They must understand that hypertension can lead to heart
attacks and strokes (perceived severity).
• Taking prescribed medication or following a
recommended weight loss program will reduce the risks
(perceived benefits)without negative side effects or
excessive difficulty (perceived barriers).

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Example…
• Print materials, reminder letters, or
pill calendars might encourage
people to consistently follow
recommendations (cues to action).

• For those who have, in the past, had

a hard time losing weight or
maintaining weight loss, a behavioral
contract might help establish
achievable, short-term goals to build
confidence (self-efficacy).

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2.Theory of Reasoned Action(TRA) &
Theory of Planned Behavior (TPB)

• (Fishbein & Ajzen, 1970’s)

• TPB is newer and more evolved version of TRA.

• Both emphasize the role of thought in decision making

about engaging in behavior

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Cont..

• Basically, rooted in cognitive theory in which

 Human beings are usually very rational &
make systematic decisions based on available
information.
 most behavior are under volitional control.

 TRA/TPB is concerned with individual motivational

factors as determinants of the likelihood of
performing a specific behavior.

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• TRA and TPB both assume the best
predictor of a behavior is behavioral
intention.
• Behavioral intention (BI): is
subjective perception & report of the
probability that one will perform the
behavior .
• NB: Different levels of
intention for different actions
in different Context & time.
• TRA asserts, Direct determinants of
individuals’ behavioral intention are
their
• Attitude toward performing the
behavior and
• subjective norm (normative
perceptions) associated with the
behavior
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 Constructs of TRA and TPB

Distal Proximal
constructs constructs

Behavioral
beliefs
Attitude toward
behavior
Outcome
evaluations

Normative
beliefs Subjective Behavioral Health
norm intention behavior
Motivation to
comply

Control beliefs
Perceived behavioral
control
Perceived power
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Constructs of Theory of
Reasoned action

1) Behavior: a single action performed by an

individual that is observed. Condom use.
2) Behavioral intention: the thought to perform
the behavior, which is an immediate
determinant of a given behavior.
3) Attitude toward the behavior: the overall
feeling of like or dislike toward any given
behavior. The more favorable attitude, more
likely to perform.
4) Behavioral beliefs: beliefs that performing a
given behavior will lead to certain outcome.
5) Outcome evaluation: the value a person
places on each outcome resulting from
performance of the behavior.
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Constructs cont…

6) Subjective norm: person’s belief that most of the

significant others in his or her life think the person
should or should not perform the behavior.
7) Normative beliefs: how a person thinks others who
are significant in his/her life would like him/her to
behave.
8) Motivation to comply: the degree to which a person
wants to act in accordance with the perceived wishes
of those significant in his/her life.
• In subsequent research, Ajzen added the following
three constructs to create the TPB.

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 Perceived behavioral control: How much a person feels
he/she is in command of enacting the given behavior.

Additional Control beliefs: beliefs about the internal and external

factors that may inhabit or facilitate the performance of the
Constructs of the behavior.
Theory of Planned
Behavior Perceived power: perception about how easy or difficult it
is to perform the behavior in each condition identified in
the control beliefs.

TRA/TPB can be applied in condom use, exercise, , healthy eating behavior, school-based
intervention for HIV/AIDS prevention etc.
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3. The Trans-theoretical Model(TTM)

• By Prochaska & Diclemente, 1979

• Assumes that change is a process with stages not just
an event…so first look the concern of stage theories.

• View behavior as habitual pattern that requires

gradual development rather than event happening
without process (e.g: addictive b/rs
• As an event requiring deliberate steps under
individual conscious awareness.

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TTM…

The model’s basic premise is that behavior change is a

process that unfolds over time, not an event.
• It is one among stage theories.

• It uses stages of change to integrate processes and

principles of change from across major theories of
intervention.

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Principles of change

• People change voluntarily only when they

• Become concerned about the need for
change
• Become convinced that the change is in their
best interests or will benefit them more than
cost them
• Intend to take action in some context &
time.
• Organize a plan of action that they are
committed to implementing
• Take the actions that are necessary to make
the change and sustain the change

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Constructs of
TTM
• Stages of Change: temporal dimension

• Processes of Change: covert/experiential and

overt/ behavioral activities people use to
progress through the stages.

• Decisional Balance: weighing pros and cons of

changing.

• Self-Efficacy: temptation & confidence

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Stages of Behavior change

SUSTAINED
SUSTAINEDBEHAVIOUR
BEHAVIOUR
TRIAL
TRIAL
READINESS
READINESS
MOTIVATION
MOTIVATION
Acq.
Acq.Know.&
Know.&Skill
Skill
CONCERN
CONCERN
AWARENESS
AWARENESS
UNAWARENESS
UNAWARENESS
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1st: Stages of change:
integrative

1. Stages of change construct:

spiral than linear
• Pre-contemplation
• contemplation
• preparation
• action
• maintenance
• termination

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 Stages of Change Model
Pre-contemplation
Awareness of need to change

Contemplation
Increasing the Pros for
Change and decreasing the
Cons

Preparation
Commitment &
Planning
Relapse and
Recycling
Maintenance
Integrating Action
Change into Implementing and
Lifestyle Revising the Plan

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Termination
 Stages of change
Stage Definition Potential change
Strategies
Pre-contemplation Has no intention of acting within the next six Increase awareness of need for change;
months personalize information about risks and
benefits.

Contemplation Intends to act in the next six months
Preparation Intends to act within the next 30 days and has
taken some behavioral steps in this direction
Motivate; encourage making specific
plans
Assist with developing and implementing
concrete action plans; help set gradual
goals

Action Has changed behavior for less than six months Assist with feedback, problem solving,
social support, and reinforcement

Maintenance Has changed behavior for more than six Assist with coping reminders, finding
months alternatives, avoiding slips/relapses (as
applicable)
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4. Social Cognitive Theory (SCT)

• By Rotter & Bandura, 1954/86

• It is how individuals, behavior &
environment interact
 Social cognitive theory gives due attention
to the external environment which can
directly punish or reward the behaviors .
 In addition, it gives due attention to human
minds & qualities such as expectation,
values, confidence and self-control.

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 SCT…
• Bandura stated that there are three factors that
interact dynamically to determine human
behavior. These factors are;
1. Environmental influence: there are three major
processes by which the environment exert its
influences on behaviors.
 Observational learning: role model compulsion
 Indirect reinforcement : observed but not
expressed
 Direct reinforcement: resulting from the
consequences for particular action

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SCT…

2. Personal factors: mainly related to prior history in the form of skills,

knowledge and attitude pertaining to the issue at hand, plus demographic,
economic status etc. (cognitive+ physical person)

3. Behavioral factors: mainly related to individuals ability to exert self

control as they determine their response to the situation. It includes factors
such as self efficacy, anxiety/emotions coping, goal setting etc

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Main constructs Behavioral capability: Knowledge and skill to
perform a given behavior; (promote mastery
of SCT learning through skills training)

Expectations: Anticipatory outcomes of a behavior;

(Model positive outcomes of healthful behavior)

Expectancies: The values that the person places on

a given outcome, incentives; (Present outcomes of
change that have functional meaning)

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SCT constructs…
• Reciprocal determinism: The dynamic interaction of the person, the behavior, and the
environment in which the behavior is performed; (consider multiple avenues to
behavioral change, including environmental, skill, and personal change)

A b/r=a sustained
behavior

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SCT constructs…

• Observational learning: Behavioral acquisition that

occurs by watching the actions -late majority in DOI)
and outcomes of others’ behavior (early majority in
DOI); (Include credible role models of the targeted
behavior)
• attention, retention, production & motivation

• Reinforcements: Responses to a person’s behavior that

increase the likelihood of reoccurrence; (Promote self-
initiated rewards, vicarious and incentives)
• Vicarious, Self, &Direct

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…SCT constructs

• Self-control: Personal regulation of goal-

directed behavior or performance; (Provide
opportunities for self-monitoring, goal
setting, problem solving, and self-reward)

Emotional coping responses: Strategies or

tactics that are used by a person to deal with
emotional stimuli; provide training in
problem solving and stress management

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 SCT…
 Self-efficacy: The person’s confidence in performing a
particular behavior;
 Approach behavioral change in small steps to ensure
success (Goal setting)
 self-efficacy increases through:
 through performance (personal mastery of
task)
 through vicarious experience (observing
others performance e.g use ordinary person
performance)
 verbal persuasion (receiving suggestions
from others)

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6. DIFFUSION OF INNOVATION
THEORY (DOI)

 It is about how to deal with social systems in

communicating a new product to target
audiences.
 It is one of the community models
 Developed by Everett M. Rogers
(1962,2003)
 Diffusion of innovation theory is a
theoretical approach which provides an
explanation of how innovation, or ideas
perceived as new are communicated
(diffused) through channels among the
members of the social system.

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Theory of Diffusion of Innovation (DOI)

 It is one of the community models

 Developed by Everett M. Rogers (1962, 2003)
 Diffusion of innovation theory is a theoretical
approach which provides an explanation of how
innovation, or ideas perceived as new are
communicated (diffused) through channels among
the members of the social system.

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 Cont…
 Diffusion is the process by which an
innovation is communicated through certain
channels over time among the members of a
social system (Rogers, 2003).
 A key premise of the Diffusion of Innovations
model is;
 some innovations diffuse quickly
and widely, whereas others are
weakly or never adopted, and
others are adopted but
subsequently abandoned.
 innovations are adopted by
different individuals and spread at
different rates in subgroups of
individuals.

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Elements in the
diffusion of innovation

There are four main

elements in the diffusion of
new ideas:
1. The innovation
2. Communication channels
3. The social system
4. Time

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Elements

1. Innovation: An idea, practice, or object that

is perceived as new by an individual or other
unit of adoption.(packed bundle of benefits for
consumers)
• Innovation could be ideas and practices-
based;
• ideas based innovation-most difficult to
implement
• Practice-based innovation-best chance
of success
2. Communication Channels: Means by which
messages about innovation spread; including
mass media, interpersonal channels, electronic
communications and installment places.

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Elements…

3. Social System: Set of interrelated units that are

engaged in joint problem solving to accomplish a
common goal.
 Social systems have structure, including norms and
leadership.
 The social system constitutes a boundary within which
an innovation diffuses.
4. Time: time dimension is involved in diffusion in three
ways.
 The innovation-diffusion process, adopter
categorization/ innovativeness, and rate of adoptions-
all include a time dimension.
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Characteristics of Individuals

 There are five segments (adopter categories) in the

diffusion process based on the amount of time it takes
to adopt an innovation. These are;
1. Innovators
2. early adopters
3. early majority
4. late majority and
5. laggards
 Rogers (2003) defined the adopter categories as “the
classifications of members of a social system on the
basis of innovativeness”

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 …CONT

• Rogers (1995, 2003) described the process of

innovation adoption by individuals as a normal,
bell-shaped distribution

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61
Cont…

In each adopter category, individuals are similar in terms

of their innovativeness:
Incomplete adoption and non-adoption do not form this
adopter classification.
Only adopters of successful innovations generate this
curve over time.
Identifying adopter categories could provide a strong
basis from which to design and implement intervention
strategies aimed at particular groups of individuals.

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1. Innovators
• Are first to adapt an innovation (they want
to be first to do something)
• Risk takers even if the innovation is
unprofitable.
• While an innovators may not be respected
by the other members of a social system,
they play an important role in the diffusion
process
• They launch the new idea in the system by
importing the innovation from outside of
the system's boundaries.

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2. Early adopters

• Are very interested in innovation, but they do

not want to be first to be involved.
• Opinion leaders/respected by peers
• Serve as role model for other members or
society
• More limited with the boundaries of the social
system

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3. Early majority
 May be interested in innovation, but will
need some external motivation to get
involved.
 Interact frequently with peers (sociable and
jockey)
 Deliberate (check and discuss) before
adopting a new idea.
4. Late majority
 Are skeptical and cautious and will not
adopt an innovation until most people
adopt.
 Pressure from peers
 interpersonal networks of close peers
should persuade the late majority to adopt
it.

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5. Laggards
 Will be the last to get involved in an innovation
 tend to decide after looking at whether the innovation is
successfully adopted by other members of the social
system in the past.
 Possess no opinion leadership.
 Isolated in the social systems
 Point of reference is in the past.
 Suspicious of innovation

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Planning models

PRECEDE-
PROCEED PEN-3 Others
Framework

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PRECEDE – PROCEED Model
…

• PRECEDE stand for predisposing,

reinforcing, and enabling constructs in
educational diagnosis and evaluation

• PROCEED stands for policy, regulatory,

and organizational constructs in
educational and environmental
development.
2022 edition

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PEN-3 Model ...

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Cultural empowerment and relationship & expectations

Domains Positive Existential Negative

Perception PP EP NP

Enabler PE EE NE

Nurturer PN EN NN

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Thank you!