Health Belief Model
The health belief model stipulates that a person’s health-related behavior depends on the person’s perception of four critical areas: the severity of a potential illness, the person’s susceptibility to that illness, the benefits of taking a preventive action, and the barriers to taking that action. The model also incorporates cues to action (e.g., leaving a written reminder to oneself to walk) as important elements in eliciting or maintaining patterns of behavior. The construct of self-efficacy, or a person’s confidence in his or her ability to successfully perform an action (discussed in more detail later in this chapter), has been added to the model, perhaps allowing it to better account for habitual behaviors, such as a physically active lifestyle.
In this model, behavior change has been conceptualized as a five-stage process or continuum related to a person’s readiness to change: precontemplation, contemplation, preparation, action, and maintenance. People are thought to progress through these stages at varying rates, often moving back and forth along the continuum a number of times before attaining the goal of maintenance. Therefore, the stages of change are better described as spiraling or cyclical rather than linear. In this model, people use different processes of change as they move from one stage of change to another. Efficient self-change thus depends on doing the right thing (processes) at the right time (stages). According to this theory, tailoring interventions to match a person’s readiness or stage of change is essential. For example, for people who are not yet contemplating becoming more active, encouraging a step-by-step movement along the continuum of change may be more effective than encouraging them to move directly into action.
Relapse Prevention Model
Some researchers have used concepts of relapse prevention to help new exercisers anticipate problems with adherence. Factors that contribute to relapse include negative emotional or physiologic states, limited coping skills, social pressure, interpersonal conflict, limited social support, low motivation, high-risk situations, and stress. Principles of relapse prevention include identifying high-risk situations for relapse (e.g., change in season) and developing appropriate solutions (e.g., finding a place to walk inside during the winter). Helping people distinguish between a lapse (e.g., a few days of not participating in their planned activity) and a relapse (e.g., an extended period of not participating) is thought to improve adherence.
Theory of Reasoned Action and Theory of Planned Behavior
The theory of reasoned action states that individual performance of a given behavior is primarily determined by a person’s intention to perform that behavior. This intention is determined by two major factors: the person’s attitude toward the behavior (i.e., beliefs about the outcomes of the behavior and the value of these outcomes) and the influence of the person’s social environment or subjective norm (i.e., beliefs about what other people think the person should do, as well as the person’s motivation to comply with the opinions of others). The theory of planned behavior adds to the theory of reasoned action the concept of perceived control over the opportunities, resources, and skills necessary to perform a behavior. The concept of perceived behavioral control is similar to the concept of self-efficacy — person’s perception of his or her ability to perform the behavior. Perceived behavioral control over opportunities, resources, and skills necessary to perform a behavior is believed to be a critical aspect of behavior change processes.
Social Learning/Social Cognitive Theory
Social learning theory, later renamed social cognitive theory, proposes that behavior change is affected by environmental influences, personal factors, and attributes of the behavior itself. Each may affect or be affected by either of the other two. A central tenet of social cognitive theory is the concept of self-efficacy. A person must believe in his or her capability to perform the behavior (i.e., the person must possess self-efficacy) and must perceive an incentive to do so (i.e., the person’s positive expectations from performing the behavior must outweigh the negative expectations). Additionally,a person must value the outcomes or consequences that he or she believes will occur as a result of performing a specific behavior or action. Outcomes may be classified as having immediate benefits (e.g., feeling energized following physical activity) or long-term benefits (e.g., experiencing improvements in cardiovascular health as a result of physical activity). But because these expected out-comes are filtered through a person’s expectations or perceptions of being able to perform the behavior in the first place, self-efficacy is believed to be the single most important characteristic that determines a person’s behavior change. Self-efficacy can be increased in several ways, among them by providing clear instructions, providing the opportunity for skill development or training, and modeling the desired behavior. To be effective, models must evoke trust, admiration, and respect from the observer; models must not, however, appear to represent a level of behavior that the observer is unable to visualize attaining.
Often associated with health behaviors such as physical activity, social support is frequently used in behavioral and social research. There is, however, considerable variation in how social support is conceptualized and measured. Social support for physical activity can be instrumental, as in giving a nondriver giving a ride to an exercise class; informational, as in telling someone about a walking program in the neighborhood; emotional, as in calling to see how someone is faring with a new walking program; or appraising, as in providing feedback and reinforcement in learning a new skill. Sources of support for physical activity include family members, friends, neighbors, co-workers, and exercise program leaders and participants.
A criticism of most theories and models of behavior change is that they emphasize individual behavior change process and pay little attention to sociocultural and physical environmental influences on behavior. Recently, interest has developed in ecological approaches to increasing participation in physical activity. These approaches place the creation of supportive environments on a par with the development of personal skills and the reorientation of health services. The concept of a health-promoting environment has been demonstrated by describing how physical activity could be promoted by establishing environmental supports, such as bike paths, parks, and incentives to encourage walking or bicycling to work.
An underlying theme of ecological perspectives is that the most effective interventions occur on multiple levels. A model has been proposed that encompasses several levels of influences on health behaviors: intrapersonal factors, interpersonal and group factors, institutional factors, community factors, and public policy. Similarly, another model has three levels (individual, organizational, and governmental) in four settings (schools, worksites, health care institutions,and communities). Interventions that simultaneously influence these multiple levels and multiple settings may be expected to lead to greater and longer-lasting changes and maintenance of existing health-promoting habits. This is a promising area for the design of future intervention research to promote physical activity.