Behaviour Change

Behaviour change

Individual health behavior is an important predictor for a person's susceptibility of chronic diseases [1].

Some risky habits are for example tobacco use, diet or activity patterns [2].

Kasl and Cobb (3) defined health behavior threefold.

  1. Apparently healthy people become active in order to prevent or detect illness in an asymptomatic state. This is preventive health behavior.
  2. Person who perceive themselves as ill become active to get a diagnosis and treatment. This is illness behavior.
  3. person affected becomes active in order to manage treatments from medical providers. It is associated with a passive attitude and dependent behavior. The usual responsibility for one's live is partly released. This is sick-role behavior.

An informed agreement on behavioral changes are the desired goal of health education programs.Health education aims to reduce risky health behavior and to promote preventive health behavior as well as cooperation between all parties in the treatment of existing health problems [3].

Health behavior theories and models aim to understand health behavior of individuals, groups or communities. They help scientists to ask the right questions and to draw the right conclusions of their results. Models and theories are used to find out which factors health behavior of individuals determines. The audience for health education can be categorized to sociodemographic classes, ethnic or racial backgrounds, age-group or health-status. Each group may have its own behavioral determinants. This must be taken into account when implementing research results in clinical practice [4].

Davis et al. [5] found 59 theories related to health or health behavior in 276 Articles and 23 additional theories in an extended search area, formed through an advisory group.

Here will be six models mentioned:

  1. The Health Belief Model (HBM)
  2. Theory of Planned Action (TRA)
  3. Theory of Planned Behavior (TPB)
  4. Integrated Behavioral Model (IBM)
  5. Transtheoretical Model/Stages of Change Model
  6. Precaution Adoption Process Model (PAPM)

The theory of Planned Behavior/Reasoned Action was mentioned in 36 articles. The Transtheoretical Model/Stages of Change Model was mentioned in 91 articles. The Integrative Model of BehavioralPrediction was mentioned in 2 articles and the Health Belief Model was mentioned in 9 articles. The Precaution Adoption Process Model was mentioned 1 time [5].

Taylor et al. [6] notice that the TRA and TPB are mathematically refined and defined compared to HBM or TTM. This promotes consistency of use. HBM was most used in medical prevention issues, like vaccination. TRA and TPB were often used in exercise intentions and behavior studies, among other areas. TTM was often used in smoking cessation intervention studies, but in exercise and activity promotion, too.

Health Belief Model (HBM)

The HBM is a value-expectancy model. It is based on the assumption that an expected benefit of an action acts as a guide. This can be that an expected avoidance of a threat triggers a behavioral change, for example. A cue to action may be a physiotherapist's advice or illness symptoms. Self-efficacy is a subjective value. It means that someone beliefs that a taken action will have the desired result. In HBM self-efficacy is more related to regular activities as physical activity than to unique activities like a consultation, for example [6].

HBM Constructs

  • Perceived Susceptibility: Deals with the question if a person expects to get a chronic disease, maybe Hypertonus as a consequence of his or her lifestyle.
  • Perceived Severity: Deals with the perception of possible negative medical, clinical, social or other consequences of a possible illness.
  • Perceived susceptibility + perceived severity forms the label perceived threat.
  • Perceived Benefits: The person weighs off whether an action is worthwhile to achieve the desired condition. This includes financial or social considerations, e.g. if family members support new physical activity plans.
  • Perceived Barriers: Possible negative consequences of the new behavior are weighed, e.g. the possibility of musculoskeletal injuries, lack of time, not the right season…
  • Cues to Action: Events that trigger action, e.g. bodily events or the advice to get active through a physiotherapist.
  • Self-Efficacy: The confidence of a person that one can execute the necessary behavior that leads to the desired outcome.

“For behavior change to succeed, people must (as the original HBM theorizes) feel threatened by their current behavioral patterns (perceived susceptibility and severity) and believe that change of a specific kind will result in a valued outcome at an acceptable cost (perceived benefit). They also must feel themselves competent (self-efficacious) to overcome perceived barriers to take action.” (S.50)

Critical appraisal: Lack of precisely defined components [6]


Theory of Planned Action (TRA), Theory of Planned Behavior (TPB) and Integrated Behavioral Model (IBM)

Theory of Planned Action (TPA) takes intention as an action-guiding moment to an activity. The intention is determined by the attitude to an action [7]. Intentions leads the mind towards an aim.

Theory of Planned Behavior (TPB) adds the perceived control over a situation. Perceived control is determined by the ability to perform an action. It is to have control over a behavioral performance. Perceived control is assumed as an independent influencing factor for behavior performance [8].

Integrated Behavioral Model (IBM) unites TRA/TPB concepts with concepts from other relevant behavior theories [8].

Constructs of IBM:

Intention is fundamental as in TRA and TPB.

Knowledge and skills insure that the practical skills and theoretical knowledge for carrying out the action exist. In health care systems a basic knowledge about institutions and contact points are necessary to get access to the system.

Environmental constraints may be barriers, e.g. wide transport routes to contact points.

Saliency means that a planned action must be cued, e.g. an appointment in a physiotherapist's praxis must be written in a termination calendar, otherwise it will be forgotten. Or it is cued, or salient due to its importance for a person, because the physiotherapist will take the pain away. Here the cue is determined by the attitude “He/She will help me”.

Experience may make a performance habitually. Therefor the intention becomes less important in the behavioral performance.

Attitude: Persons with an emotional negative response to a behavior are unlikely to perform it. Instrumental attitude is cognitive based and refers to expected outcomes of a task. Experiential attitude affects perceptions of behavioral outcomes and influences intention indirectly. Perceived norms are determined by the perceived social pressure in relation to a behavior performance. Injunctive norm: What do the others think? Descriptive norm: What is usually done in my culture, age-group, etc.? Personal agencies are the two constructs self-efficacy and perceived control as explained above.

The three categories of IBM attitude, perceived norm and personal agency as determinants of behavior through forming intention, may differ in their specific importance from population to population.

  • Critical appraisal TRA: It is not clear if TRA may predict behavior if volitional control over behavior is

limited, when the intention to behave is limited.

  • Critical appraisal TPB: Few studies investigated the influence of control beliefs and perceived ability

to overcome barriers or to use specific facilitators. Most studies measured perceived control directly,

they didn't study the underlying concepts of an individual.

  • Critical appraisal IBM: IBM is investigated in developed and not so well developed countries and in

many cultures.

Transtheoretical Model/Stages of Change Model

Prochaska et al. identified six stages of change and ten processes of change, a decisional balancing process and a self –efficacy construct. They defined Behavioral change as a nonlinear process over time with possible backward loops. The stations do not have to be traversed in series, a relapse into earlier phases is possible [9].

The Stages of change and their definition:

  • Pre-contemplation: No intention to take action within the next 6 months
  • Contemplation: Intends to take action within the next 6 months
  • Preparation: Intends to take action within the next 30 days and has taken some behavioral steps in this direction
  • Action: Changed overt behavior for less than 6 months
  • Maintenance: Changed overt behavior for more than 6 months
  • Termination: No temptation to relapse and 100% confidence

The processes of change and their definition:

  • Consciousness raising: Finding and learning new facts, ideas, and tips that support the healthy behavior change
  • Dramatic relief: Experiencing the negative emotions (fear, anxiety, worry) that go along with unhealthy behavioral risks
  • Self-reevaluation: Realizing that the behavior change is an important part of one’s identity as a person
  • Environmental reevaluation: Realizing the negative impact of the unhealthy behavior or the positive impact of the healthy behavior on one’s proximal social and/or physical environment
  • Self-liberation: Making a firm commitment to change
  • Helping relationships: Seeking and using social support for the healthy behavior change
  • Counterconditioning: Substitution of healthier alternative behaviors and cognitions for the unhealthy behavior
  • Reinforcement management: Increasing the rewards for the positive behavior change and decreasing the rewards of the unhealthy behavior
  • Stimulus control: Removing reminders or cues to engage in the unhealthy behavior and adding cues or reminders to engage in the healthy  behavior
  • Social liberation: Realizing that the social norms are changing in the direction of supporting the healthy behavior change

Decisional Balance

Pros: Benefits of changing

Cons: Costs of changing


Confidence: Confidence that one can engage in the healthy behavior across different challenging


Temptation: Temptation to engage in the unhealthy behavior across different challenging situations

Critical appraisal TTM: In a systematic review about tailored print health behavior change interventions, Noar et al.  [10]found significantly greater effect sizes [11] in correlation to the quantity of the used TTM constructs. Highest effect sizes were correlated with the use of stages of change, pros and cons of changing, self-efficacy, and processes of change. If only stages of change were used, three of seven studies produced a significant effect size. Were stages of change and pros and cons used, three of five studies produced significant effect sizes. Four of five studies which used every TTM construct produced significant effects.

The Precaution Adoption Process Model (PAPM)

The PAPM (Weinstein and Sandman, 1988) is a stage theory of change. It assumes that there exist measurable qualitative differences between people in the different stages of change. It aims to describe how a person makes a decision about change and how this decision will be translated into action.

The PAPM defines seven stages of change [12].

  1. Stage 1: Unawareness. People are not aware about a specific health issue.
  2. Stage 2: Unengaged by issue. People do have some information about the issue but they are not engaged by it.
  3. Stage 3: Undecided About Acting. People are in the decision-making stage. The may act in three ways. They may stay in stage three. Or people decide to act and enter stage five or people decide not to act and enter stage four.
  4. Stage 4: Is a turn-off without breaking into one action. A move to stage five is every time possible or people leave in stage four.
  5. Stage 5: Is the transition phase to stage six.
  6. Stage 6: Is the initial phase, people start to act.
  7. Stage 7: Is busy with the maintenance of action.

Critical appraisal of PAPM: One of the strengths of the PAPM is that it looks at the people who have decided not to act and people who are unaware of a health topic, where the TTM presumes everybody as being in pre-contemplation. The model is not so often used in research like the other ones. PAPM is not a very specified theory [12].



  1. Swann, C., Carmona, C., Ryan, M., Raynor, M., Baris,  E., Dunsdon, S., Huntley, J.,Kelly, M. P 2010. Health systems and health-related behaviour change: a review of primary and secondary evidence. Copenhagen, National Institute for Clinical Excellence.   [Accessed 2/24/2017]
  2. Glanz,K., Rimer,B.K., Viswanath,K. Health Education and Health Behavior. Foundations. In: Health Education and Health Education. Theory, Research and Practice. 4th ed. San Fransico: Jossey-Bass; 2008
  3. Kasl, S. V., and Cobb, S. Health Behavior, Illness Behavior, and Sick-Role Behavior: II. Sick-Role Behavior. Archives of Environmental Health. 1966; 12, 531–541.
  4. Glanz, K., Rimer, B.K., Viwanath, K. Theory, Research, and Practice in Health Behavior and Health Education. . In: Health Education and Health Education. Theory, Research and Practice. 4th ed. San Fransico: Jossey-Bass; 2008.
  5. 5.0 5.1 Davis,R., Campbell,R., Hildon, Z., Hobbs, L., Michie,S. Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. Health Psychology Review. 2015; 9 (3): 323-344, DOI: 10.1080/17437199.2014.941722.
  6. 6.0 6.1 6.2 Taylor,D., Burgy,M., Campling,N., Carter, S., Garfied,S., Newbould,J., Rennie,T. A Review of the use of the Health Belief Model (HBM), the Theory of Reasoned Action (TRA), the Theory of Planned Behaviour (TPB) and the Trans-Theoretical Model (TTM) to study and predict health related behaviour change.
  7. Montaño,D.E., Kasprzyk,D. Theory of reasoned Action, theory of planned behavior, and the integrated behavioral model. In: Health Education and Health Education. Theory, Research and Practice. 4th ed. San Fransico: Jossey-Bass; 2008.
  8. 8.0 8.1 Oxford Dictionaries. 2017. [Accessed 2/24/2017].
  9. Prochaska, J. O., Redding, C., A. Evers, K., E. The Transtheoretical Model and stages of Change. In: Health Education and Health Education. Theory, Research and Practice. 4th ed. San Fransico: Jossey-Bass; 2008.
  10. Noar, S. M. Benac, C. N. Harris, M. S. Does Tailoring Matter? Meta-Analytic Review of Tailored Print Health Behavior Change Interventions. Psychological Bulletin. 2007; 133 (4): 673-693.
  11. Sullivan, G.M., Feinn, R. Using Effect Size- or why the p Value is not enough. Journal of Graduate Medical Education. 2012. [ Accessed 2/24/2017].
  12. 12.0 12.1 Weinstein, N. D., sandman, P., M., Blalock, S., J. The Precaution Adoption Process Model. . In: Health Education and Health Education. Theory, Research and Practice. 4th ed. San Fransico: Jossey-Bass; 2008.