behavior change models (2023)

behavior change models

Public health is a multidisciplinary field that aims to 1) prevent disease and death, 2) promote a better quality of life, and 3) create environments in which people can be healthy by intervening at the institutional, community, and societal levels. .

The ability of public health professionals to perform this task depends on their ability to accurately identify and define public health problems, assess the root causes of those problems, identify populations most at risk, design theory-based interventions and evidence and implement, evaluate and refine these interventions to ensure that they achieve the desired results without unintended negative consequences.

To be effective in these efforts, public health professionals must know how to apply fundamental principles, theories, research, and methodologies from the social and behavioral sciences to support their efforts. A deep understanding of the theories used in public health, derived mainly from the social and behavioral sciences, allows professionals to:

• Evaluate the root causes of a public health problem and
• Develop interventions to address these problems.

Note: This module was translated into Estonian by Marie Stefanova. The translation is available at

https://www.bildeleekspert.dk/blog/2018/08/06/sotsiaalsete-normide-teooria/

After successful completion of these modules, students can:

• Name and describe the most important buildings.health belief modeland the theory of planned behavior and explain how they can be applied to design effective public health interventions
• Name and describe the elements of "Perceived behavioral control"
• Describe the underlying theory and basic elements ofsocial norms theoryand marketing campaigns
• Name and describe the most important constructions ofsocial cognitive theoryand explain how they can be used to develop effective public health interventions
• Summarize the criticisms made against the most importantTraditional models of health behaviorchange and why these models do not seem adequate to explain observed health behaviors
• Describe the main steps oftranstheoretical model
• List the characteristics of each step.transtheoretical model
• To describeinnovationsdiffusiontheoryand how it can be used in health promotion
• Describe the basic structures.theory of gender and powerand its application to public health
• Explain the buildings.Sexual Health Modeland its application in health care

The Health Belief Model (HBM) was developed by social scientists in the US Public Health Service in the early 1950s with the goal of understanding people's failure to employ disease prevention strategies or evidence of early detection of diseases. Subsequent uses of HBM were for patient response to symptoms and adherence to medical treatments. The HBM suggests that a person's belief in a personal threat of illness, together with a person's belief in the effectiveness of the recommended health behavior or action, predicts the likelihood that the person will adopt the behavior.

HBM is derived from psychology and behavioral theory because the two components of health-related behavior are 1) a desire to avoid illness or, conversely, to improve when already ill; and 2) the belief that certain health measures will prevent or cure disease. Ultimately, a person's course of action often depends on their perception of the benefits and barriers associated with health behaviors. There are six builds from HBM. The first four constructs were developed from the original HBM principles. The last two were added as research on HBM evolved.

1. Perceived Vulnerability – Refers to the subjective perception that a person has of the risk of contracting a disease or illness. There is great variation in a person's feelings about personal susceptibility to illness or disease.
2. Perceived Severity: Refers to a person's feelings about the seriousness of contracting a disease or illness (or leaving the disease or illness untreated). A person's perception of heaviness varies widely, and often a person will consider both medical (eg, death, disability) and social (eg, family life, social relationships) consequences when assessing severity.
3. Perceived utility: refers to an individual's perception of the efficacy of various available interventions in reducing the threat of a disease or illness (or in curing a disease or illness). The course of action a person takes to prevent (or cure) a disease or condition depends on the consideration and evaluation of perceived vulnerability and perceived benefit, such that the person would accept recommended health actions if they were found to be beneficial. .
4. Perceived barriers: refers to a person's feelings about the barriers to completing a recommended health action. There are large differences in the perception of barriers or obstacles that lead to a cost-benefit analysis. The individual weighs the effectiveness of interventions against perceptions that they may be expensive, dangerous (eg, side effects), unpleasant (eg, painful), time-consuming, or inconvenient.
5. Recommendation for Action - It is the necessary stimulus to trigger the decision-making process to accept a recommended health action. These signs may be internal (eg, chest pain, wheezing, etc.)
6. Self-efficacy: refers to a person's confidence in their ability to successfully perform a behavior. This construct was not introduced into the model until the mid-1980s. Self-efficacy is a construct in many behavioral theories because it is directly related to whether a person performs the desired behavior.

Limitations of the health belief model

There are several limitations of HBM that limit its utility for public health. Model limitations include the following:

• It does not take into account a person's individual attitudes, beliefs, or other determinants that determine the acceptability of a health behavior by a person.
• It does not take habitual behaviors into account and can therefore influence the decision-making process to take a recommended action (for example, smoking).
• Does not account for behaviors carried out for reasons unrelated to health, such as: B. Social acceptance.
• It does not take into account environmental or economic factors that may prohibit or encourage the recommended action.
• It assumes that everyone has access to the same amount of information about the disease.
• It is assumed that incentives to act are widely used to encourage people to act and that "health" measures are the main objective in the decision-making process.

HBM is descriptive rather than explanatory and does not suggest a strategy for changing health related interventions. Regarding preventive health behaviors, early studies showed that perceived vulnerabilities, benefits, and barriers were consistently associated with desired health behaviors; Perceived severity was less frequently associated with desired health behaviors. The individual constructs are useful depending on the health outcome of interest, but for the most effective use of the model, it must be integrated with other models that consider the environmental context and suggest strategies for change.

The Theory of Planned Behavior (TPB) began in 1980 as a Theory of Reasoned Action to predict a person's intention to engage in behavior at a specific time and place. The theory purports to explain all behaviors over which people have the ability to exercise self-control. The main component of this model is behavioral intention; Behavioral intentions are influenced by attitudes about the likelihood that the behavior will have the expected outcome and subjective assessments of the risks and benefits of that outcome.

TPB has been used successfully to predict and explain a wide range of health behaviors and intentions, including smoking, drinking, using health services, breastfeeding, and substance use, among others. The TPB states that behavioral performance depends on both motivation (intention) and ability (behavioral control). He distinguishes between three types of beliefs: behavioral, normative, and control beliefs. The TPB consists of six constructs that together represent a person's actual control over their behavior.

1. Attitudes: refers to the extent to which a person views the behavior of interest positively or negatively. It involves looking at the results of performing the behavior.
2. Behavioral Intention: Refers to the motivating factors that influence a particular behavior, the stronger the intention to perform the behavior, the more likely the behavior.
3. Subjective norms: they are related to the belief that the majority of people approve or disapprove of the behavior. Refers to a person's beliefs about whether peers and significant others think they should engage in the behavior.
4. Social norms: they refer to the usual codes of behavior in a group or town or in a broader cultural context. Social norms are considered normative or standard in a group of people.
5. Perceived power: refers to the perceived presence of factors that may facilitate or hinder the performance of a behavior. Perceived power contributes to a person's perceived behavioral control over each of these factors.
6. Perceived Behavior Control – Refers to a person's perception of whether it is easy or difficult to perform the desired behavior. Perceived behavioral control varies by situation and action, resulting in a person having different perceptions of behavioral control depending on the situation. This theoretical construct was added later and created the transition from the theory of reasoned action to the theory of planned behavior.

Limits of the theory of planned behavior

There are several limitations of the TPB, including the following:

• It is assumed that the person has acquired the skills and resources to successfully perform the desired behavior, whatever the intent.
• Other variables that influence behavioral intention and motivation, such as fear, threat, mood, or past experiences, are not considered.
• Although it accounts for normative influences, it still does not account for environmental or economic factors that might affect an individual's intention to perform a behavior.
• It assumes that behavior is the result of a linear decision-making process and does not take into account that it can change over time.
• Although the additional construction of perceived behavioral control was an important addition to the theory, it says nothing about actual control over behavior.
• The theory does not address the period between "intention" and "behavioral action".

The TPB has been shown to be more useful for public health than the Health Belief Model, but it is still limited in its inability to account for environmental and economic impacts. In recent years, researchers have used some TPB constructs and added other components of behavior theory to make it a more integrated model. This was in response to some of the limitations of TPB in addressing public health issues.

The diffusion of innovation (DOI) theory developed by E.M. Rogers in 1962, is one of the oldest theories in the social sciences. It has its origin in communication to explain how an idea or product gains strength over time and spreads (or spreads) in a certain 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 different than before (ie, buys or uses a new product, acquires and performs a new behavior, etc.). The key to adoption is for the person to perceive the idea, behavior, or product as new or innovative. This allows diffusion.

The adoption of a new idea, behavior, or product (ie, "innovation") does not occur simultaneously in a social system; Rather, it is a process in which some people are more likely to adopt the innovation than others. The researchers 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 group, it is important to understand the characteristics of the target group that support or hinder the adoption of the innovation. They existfive established categories of adopters, and although most of the general population tends to fall into the intermediate categories, it is still necessary to understand the characteristics of the target population. When promoting an innovation, different strategies are used to attract different categories of adopters.

1. Innovators: These are people who want to be the first to experience innovation. You are adventurous and interested in new ideas. These people are very willing to take risks and are often the first to develop new ideas. Little, if anything, needs to be done to attract this population.
2. Early adopters: These are people who represent opinion formers. Enjoy leadership roles and seize opportunities for change. They are already aware of the need for change and are therefore very good at adopting new ideas. Strategies to address this demographic include instruction manuals and implementation fact sheets. You don't need any information to convince them to switch.
3. Early Majority: These people are rarely leaders, instead adopting new ideas earlier than average. However, they often need to see evidence that the innovation works before they are willing to adopt it. Strategies for targeting this audience include success stories and evidence of the effectiveness of the innovation.
4. Late Majority: These people are skeptical of change and will only adopt an innovation after the majority have experienced it. Strategies for targeting this demographic include information about how many other people have successfully experienced and adopted the innovation.
5. Laggards - These people are traditional and very conservative. They are very skeptical of change and are the most difficult group to recruit. Strategies for targeting this demographic include statistics, fear appeals, and pressure from people in other adopter groups.

Those: http://blog.leanmonitor.com/early-adopters-allies-launching-product/

The stages through which an individual adopts an innovation and by which diffusion is achieved include:knowledgethe need for innovation,decision to make(or reject) the innovation,initial useof innovation to test andreuseof innovations They existfive main factors that influence the adoption of an innovation, and each of these factors plays a different role in the five categories of adopters.

1. Relative Advantage: The degree to which an innovation is considered better than the idea, program, or product it replaces.
2. Compatibility: how consistent the innovation is with the values, experiences, and needs of potential users.
3. Complexity: how difficult it is to understand and/or use the innovation.
4. Triability: The extent to which the innovation can be tried or tested before committing to adoption.
5. Observability: The extent to which innovation produces tangible results.

Limits to the diffusion of innovation theory

There are several limitations of the diffusion of innovation theory, including the following:

• Much of the evidence for this theory, including the adoption categories, does not come from public health and was not developed to be explicitly applicable to the adoption of new health behaviors or innovations.
• It does not promote a participatory approach in the adoption of a public health program.
• It works better with adopting behaviors than with stopping or preventing behaviors.
• Individual resources or social support to adopt the new behavior (or innovation) are not considered.

This theory has been used successfully in many fields, including communications, agriculture, public health, criminal justice, social work, and marketing. In the field of public health, the Diffusion of Innovation Theory is used to accelerate the adoption of important public health programs, usually aimed at changing the behavior of a social system. For example, an intervention is designed to solve a public health problem and the intervention is promoted to people in a social system with the aim of adoption (based on the diffusion of innovation theory). The most successful implementation of a public health program comes from understanding the target audience and the factors that affect its acceptance rate.

To learn more about diffusion of innovation theory, read "On the Diffusion of Innovations: How New Ideas Spread" by Leif Singer.

Social Cognitive Theory (SCT) began as Albert Bandura's Social Learning Theory (SLT) in the 1960s. Developed at SCT in 1986, it posits that learning occurs in a social context with dynamic, reciprocal interaction between people. , environment and behavior. The unique feature of SCT is its emphasis on social influence and its emphasis on external and internal social reinforcement. SCT takes into account the unique ways in which individuals acquire and maintain a behavior while also considering the social environment in which individuals perform the behavior. The theory takes into account a person's past experiences that determine whether the behavioral action occurs. These past experiences influence the reinforcements, expectations, and expectations that determine whether a person will engage in a particular behavior and the reasons why a person engages in that behavior.

Many behavioral theories used in health promotion do not consider behavior maintenance, but instead focus on behavior initiation. This is unfortunate because maintaining the behavior, not just initiating the behavior, is the true goal of public health. The purpose of SCT is to explain how people regulate their behavior through control and reinforcement to achieve goal-directed behavior that can be sustained over time. The first five buildings were developed as part of the SLT; The self-efficacy construct was added as SCT theory evolved.

1. Reciprocal Determinism: This is the central concept of SCT. It refers to the dynamic and reciprocal interaction of the person (an individual having a set of learned experiences), the environment (external social context), and behavior (responses to stimuli to achieve goals).
2. Behavioral ability: refers to the actual ability of a person to perform a behavior through basic knowledge and skills. To successfully perform a behavior, a person must know what to do and how to do it. People learn from the consequences of their behavior, which also affects the environment in which they live.
3. Observational learning: states that people can observe and observe the behavior of others and then reproduce those actions. This is usually demonstrated by the "behavioral model". When people see a successful demonstration of a behavior, they may also successfully complete it.
4. Reinforcements: refers to internal or external responses to a person's behavior that affect the likelihood of continuing or stopping the behavior. Reinforcements can be self-initiated or environmental, and reinforcers can be positive or negative. It is this construct of the SCT that is most closely related to the interrelationship between behavior and the environment.
5. Expectations: refers to the expected consequences of a person's behavior. Results expectations may or may not be related to health. People anticipate the consequences of their actions before they engage in the behavior, and these anticipated consequences can affect the successful completion of the behavior. Expectations are largely derived from past experiences. While expectations are also derived from past experiences, expectations focus on the value placed on the outcome and are subjective to the individual.
6. Self-efficacy: refers to a person's confidence in their ability to successfully perform a behavior. Self-efficacy is unique to SCT, although other theories have added this construct at later times, such as the Theory of Planned Behavior. Self-efficacy is influenced by a person's specific abilities and other individual factors, as well as environmental factors (barriers and drivers).

Limitation of sociocognitive theory

There are several limitations of SCT that need to be considered when applying this theory to public health. Model limitations include the following:

• The theory is that changes in the environment automatically lead to changes in the person, although this is not always the case.
• The theory is loosely organized and based solely on the dynamic interaction between person, behavior, and environment. It is not clear to what extent each of these factors affects actual behavior and whether one has more influence than the other.
• The theory largely focuses on learning processes, ignoring biological and hormonal predispositions that can influence behavior independent of past experiences and expectations.
• The theory does not focus on emotions or motivation except by reference to past experiences. Attention to these factors is minimal.
• The theory can be broad, so it can be difficult to fully operationalize it.

Sociocognitive theory considers many levels of the socioecological model when addressing behavior change in individuals. SCT has been widely used in health promotion due to its emphasis on the individual and the environment, with the latter becoming an important focus for health promotion activities in recent years. As with other theories, the applicability of all SCT constructs to a public health problem can be difficult, especially when developing focused public health programs.

The transtheoretical model (also called the stages of change model) developed by Prochaska and DiClemente in the late 1970s evolved through studies that examined the experiences of smokers who quit on their own with those who need additional treatment to quit. smoking Understand why people were able to quit smoking on their own. It was found that people would quit smoking if they were willing to do so. Thus, the Transtheoretical Model (TTM) focuses on individual decision making and is a model of predicted change. TTM assumes that people do not change their behavior quickly and decisively. Rather, behavior change, particularly habitual behavior, occurs continuously through a cyclical process. TTM is not a theory but a model; Different behavioral theories and constructs can be applied at different stages of the model where they are most effective.

The TTM assumes that people go through six phases of change: preview, contemplation, preparation, action, maintenance, and completion. Termination was not part of the original model and is used less when stages of change apply to health-related behaviors. For each stage of change, different intervention strategies are most effective in moving the person to the next stage of change and then through the model to maintain the stage of ideal behavior.

1. Anticipation: In this phase, people do not intend to act in the foreseeable future (defined as within the next 6 months). People are often unaware that their behavior is problematic or has negative consequences. People at this stage often underestimate the benefits of behavior change and overemphasize the downsides of behavior change.
2. Contemplation: In this stage, people intend to initiate healthy behaviors in the foreseeable future (defined as within the next 6 months). People recognize that their behavior can be problematic, and there is a more thoughtful and practical consideration of the pros and cons of behavior change that takes both into account equally. Even with this admission, people can feel ambivalent about changing their behavior.
3. Preparation (Determination): At this stage, people are ready to take action over the next 30 days. People are beginning to take small steps toward behavior change, believing that changing their behavior can lead to a healthier life.
4. Action: At this stage, people have recently changed their behavior (defined as within the last 6 months) and intend to continue with that behavior change. People can show this by changing their problem behaviors or adopting new, healthy ones.
5. Maintenance: At this stage, people have maintained their behavior change for some time (defined as more than 6 months) and intend to maintain the behavior change in the future. People in this stage are working to prevent relapse in earlier stages.
6. Cessation: At this stage, people are unwilling to return to their harmful behaviors and trust that they will not relapse. Because this is rarely achieved and people are more likely to remain in the maintenance phase, this phase is often not considered in health promotion programs.

To go through the phases of change, people use cognitive, affective and evaluative processes. Ten change processes were identified, with some processes being more relevant to a particular change phase than other processes. These processes lead to strategies that help people create and sustain change.

1. Awareness: Raise awareness about healthy behavior.
2. Dramatic Relief: Emotional enthusiasm for the health behavior, whether positive or negative enthusiasm.
3. Self-assessment: self-assessment to realize that healthy behavior is part of who they want to be.
4. Environmental Reassessment: Social reassessment to see how your harmful behaviors affect others.
5. Social Liberation: Environmental opportunities that exist to demonstrate that society supports healthy behavior.
6. Self Liberation - Commitment to behavior change based on the belief that healthy behavior is possible.
7. Supportive Relationships: Find supportive relationships that foster the change you want.
8. Counterconditioning: Replacing healthy thoughts and behaviors with unhealthy thoughts and behaviors.
9. Reinforcement Management – ​​Reward positive behavior and reduce rewards for negative behavior.
10. Stimulus Control: The environment has been redesigned to have reminders and cues that support and encourage healthy behaviors and remove those that encourage unhealthy behaviors.

Limits of the transtheoretical model

There are several limitations of the TTM that must be taken into account when using this theory in the public health setting. Model limitations include the following:

• The theory ignores the social context in which the changes occur, such as SES and income.
• The boundaries between stages can be arbitrary, with no defined criteria for determining an individual's stage of change. Questionnaires designed to assign an individual to a phase of change are not always standardized or validated.
• There is no clear idea of ​​how long each stage takes or how long a person can stay in a stage.
• The model assumes that individuals make coherent and logical plans in their decision-making process, although this is not always the case.

The transtheoretical model offers proposed strategies for public health interventions directed at people at different stages of the decision-making process. This can result in interventions that are personalized (ie, a message or program component is tailored specifically to the level of awareness and motivation of the target audience) and effective. The TTM promotes an assessment of an individual's current stage of change and accounts for relapse in people's decision-making process.

Social norm theory was first used by Perkins and Berkowitz in 1986 to study patterns of high school alcohol use. As a result, social norms theory, and later the approach, is best known for its effectiveness in reducing alcohol use and alcohol-related injuries among college students. The approach has also been used to address a wide range of public health issues, including tobacco use, drinking and driving prevention, seat belt use, and most recently sexual assault prevention. . The target audience for social norms approaches are typically college students, but they have recently been used with younger student populations (ie, high school students).

This theory aims to understand the environment and interpersonal influences (eg, peers) in changing behavior, which may be more effective than focusing on the individual in changing behavior. Peer influence and the role it plays in individual decision-making related to behavior is the main focus of social norm theory. Peer influences and normative beliefs are particularly important when it comes to youth behavior. Peer influences are the most affected.perceived norms(waswe seeas typical or standard in a group) and notnormal real(the originalgroup beliefs and actions). The gap between the perceived and the real is awrong perception, and this forms the basis of the social norms approach.

Social norms theory posits that our behavior is influenced by misperceptions about how those around us think and act. Overestimating the problem behaviors of others will cause us to reinforce our own problem behaviors; Underestimating the problem behaviors of those around us will discourage us from engaging in the problem behaviors. Therefore, the theory states that correcting misperceptions ofunderstood standardswill likely result in a reduction in problem behavior or an increase in desired behavior.

Social norms interventions aim to present correct information about peer group norms to correct misperceptions of norms. In particular, many intrusions into social normsMedia campaigns on social normswhere misperceptions are addressed through community-wide electronic and print media that promote accurate and healthy norms of health behaviors. The phases of a media campaign for social norms include:

• Evaluation or data collection for message information.
• Selection of the normative message to distribute
• Test the message with the target audience to make sure it resonates
• Selecting how the message will be delivered
• Quantity or dose of message to deliver
• Evaluation of the effectiveness of the message

Social norms media campaigns are funded by many federal agencies, state agencies, foundation grants, and non-profit organizations. Media campaigns on social norms are sometimes financed by the industry. Various evaluations have been carried out on social norms campaigns.

There are several limitations of social norm theory that must be considered before using the theory. The limitations of the theory include the following:

• Participants in an intervention focused on social norms are likely to question the original message presented to them based on misperceptions. Information must be presented in a reliable way to correct these misperceptions.
• Inadequate data collection in the early stages can result in unreliable data and a poor choice of policy message. This can undermine the campaign and reinforce false perceptions.
• Sources that are not trustworthy or sources that are not credible to the target audience can result in an unflattering message that undermines the campaign, even if the message is chosen correctly.
• The dose or amount of message that the target audience receives should be enough to make an impact, but not so much that it becomes commonplace.

While these limitations exist, when applied correctly, social norm theory can be very effective in changing individual behavior by focusing on changing misperceptions at the group level. Social norms interventions can be used alone or in conjunction with other types of intervention strategies. The most effective social norms interventions are those that contain targeted and influential messages to at-risk groups. To place messages in a targeted manner, a significant amount of research and data collection must be invested to understand the existing norms in the interest group. Social norms interventions are also most effective when presented in interactive formats that actively engage the target audience.