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3 Attitudes, beliefs and behaviour

Models of health behaviour change

Contents

Introduction
Introduction to social cognition models
Social Cognitive Theory
We do what we see: the historical development of the Social Cognitive Theory
Overview of the Social Cognitive Theory
Core process 1: outcome expectancies
Self-efficacy ‘the belief that we are capable’
Core process 2: socio-structural factors
Core process 3: goal setting
Health Belief Model
Summary and future directions
Protection Motivation Theory
Summary and future directions
Theory of Reasoned Action and Theory of Planned Behaviour
The development of the theory of planned Behaviour
Summary and future directions
Stage models of change
Stages of change ‘When you change’
1. Processes of change
2. Self-efficacy
3. Decisional balance
Summary and future directions
Final overview and summary
References

Introduction
The ultimate question health psychologists ask is ‘How can we get an individual to change their health
behaviour?’ Yet, before we can change a health behaviour we must first understand the reasons why
an individual may choose to engage or not engage in the health behaviour in question. For example,
why do some people choose to smoke even though we have known for over 50 years that it is linked
to cancer and premature death?
Health psychologists draw on a wide range of evidence-based theoretical models to help us
understand psychological predictors that influence a decision to engage or not engage with a health
behaviour. These theories enable us to understand individual health beliefs and motivation in relation
to a given behaviour and, consequently, enable us to intervene and support individuals to make

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positive behaviour change. In short, theoretical frameworks outline factors which should be
considered when trying to change behaviour. A theory may explain:

• factors influencing a phenomenon (e.g. why some people smoke);

• the relationship between these factors (e.g. whether this decision is related to levels of knowledge
and risk perceptions, attitudes, beliefs about smoking, influence of other people (social norms) and
so on;
• the conditions in which these relationships occur (e.g. do smoking rates fall when there is high
media attention highlighting risk?).

This chapter aims to describe the components of key theoretical models that have been used and
developed to explain why people engage in health-risk, health-protective or health-enhancing
behaviours. There are two main groups of models which will be considered, commonly referred to as
(1) ‘social cognition models’ and (2) ‘stage models’. Social cognition models, refer to a group of
similar models which argue that cognitive and affective factors (beliefs and attitudes) are the proximal
determinants of behaviour. We will look at some of these theories in detail; Social Cognitive Theory
(SCT), Health Belief Model (HBM), Protection Motivation Theory (PMT), Theory of Reasoned
Action (TRA) /Planned Behaviour (TPB). Stage models, such as the Transtheoretical Model (TTM)
use similar concepts, although these are organised in a different way, namely arguing that behaviour
change involves movement through a sequence of stages. Each model will be described, and then
applied to a range of health behaviours and then finally, evaluated in light of the evidence of its
effectiveness.
This chapter will end with a case study of a health psychologist, who works in a real life setting
within smoking cessation, looking at how these theories help guide her practice.

Introduction to social cognition models

Historically, we were viewed as passive agents to illness with treatment solely in the hands of the
healthcare professionals. However, health psychology operates under the assumption that the leading
causes of mortality and morbidity are attributable to our individual lifestyle behaviour, which is
modifiable. So, instead of being passive to illness there is a belief that we as individuals can actively
change our own health behaviour through the uptake of health enhancing behaviours (e.g. eating
healthily, keeping physically active) and avoiding risky health behaviours (e.g. smoking). If we can
accept these assumptions then we are saying that we can change an individual’s health behaviour i.e.
someone who smokes can quit smoking and in turn we can intervene to help someone quit smoking.
Health behaviour is extremely complex. How we view our health is not a shared concept,
influenced by our cultural background, our age, gender and the communities in which we reside [1].
As such there is not one universal way to determine why someone is healthy and someone is not. We
therefore need to identify factors that are outside the individual’s control which could help us
understand the mechanisms of health behaviour change and maintenance. In health psychology, and
more specifically the area of health behaviour change, we use a group of theories called Social
Cognition Models (SCM) to achieve this. Traditionally it was assumed that the largest predictors of
our health behaviour remain dependent on our individual differences (age, gender) and social factors
(where someone lives and others around them). However, social cognitive theorists argue that it is the
cognitive (attitudes and beliefs) factors which have been shown to act as the most direct influence of
behaviour. Thus, SCM incorporate all of these factors and in turn suggest that personal (e.g. age,
gender, personality), cognitive (e.g. attitudes, beliefs) and environmental factors act as mutual causes
of each other.
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Social Cognitive Theory

We do what we see: the historical development of the Social Cognitive Theory
The influence of the social environment on our behaviour can be traced back to the 1930s through the
work of Holt and Brown, who argued that animals imitate by watching others within their
environment [2]. This work paved the way for theorists to understand the role of the social
environment and imitation on human behaviour, a term later coined as ‘social learning’ [3].
Bandura, well regarded for his work on social learning, advanced this through the completion of a
series of ground breaking studies, labelled the Bobo Doll Experiment [4, 5]. In these studies children
were exposed to aggressive and non-aggressive role models acting differently towards a ‘bobo doll’
toy. The aggressive models hit the bobo doll shouting ‘Hit him’, ‘Kick him’ whilst children watched
as they were waiting in a room purposefully full of toys that they were told they could not play with.
The aggressive was ignored (punished) by the experimenter, with the non-aggressive model allowed
to play with toys after (rewarded). The children who observed an adult role model acting aggressively
to the ‘bobo doll’ imitated this behaviour (modelling). The findings also revealed that not only does
learning take place when we are rewarded and punished, but we also learn from watching others being
rewarded and punished, a concept Bandura defined as ‘observational learning’. Thus, in Bandura’s
development of the Social Learning Theory, he argued that we do not learn new behaviours by just
failing or succeeding (behavioural), but instead our behavioural action is dependent on observational
learning and, consequently, our choice of whether we want to replicate the behaviour modelled [6]. In
the 1980s Bandura relabeled Social Learning Theory as Social Cognitive Theory (SCT) [7].

Overview of the Social Cognitive Theory

At the core of SCT are three components: (1) ‘Person’, their personality, their genetics and other
personal factors that influence how the individual views the behaviour; (2) ‘Behaviour’, what the
person does and how this behaviour influences the person and environment, and finally; (3) ‘
Environment’, the social world around us and how this influences our behaviour and the person, for
example, our friends and what they do, the places around us, social norms i.e. how we think other
people and society would expect us to behave. These three components all interact and influence each
other and together are referred to as ‘reciprocal determinism’ (Figure 3.1).
The SCT assumes that our behaviour (what we do) and what motivates us is governed by
forethought, in other words we carefully consider what will be necessary or may happen in the future.
With this in mind there are three core processes that influence our specific actions, which include (1)
self-efficacy, (2) outcome expectancies and finally, (3) goals and socio-structural factors [7, 8] (see
Figure 3.2). We will discuss these in full below.

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Figure 3.1 Reciprocal determinism in the SCT

Core process 1: outcome expectancies

An integral component of the SCT is outcome expectancies. These expectations relate to our estimate
that our behaviour will lead to a perceived desirable or undesirable outcome. We are in effect
weighing up the pros and cons of a behaviour and then deciding if the outcome is worth it. If, for
example, going for a jog several times a week, is expected to cause an improvement in health and
wellbeing, the person will be more likely to go for a jog. If they expect to be too tired or embarrassed
they will be less likely to do it.

Self-efficacy ‘the belief that we are capable’

Self-efficacy beliefs are self-regulatory beliefs which determine a) whether actions will be initiated; b)
how much effort will be expended; and finally, c) how long it will be sustained in the face of obstacles
and failures. These beliefs collectively influence our ability to prepare for behavioural action and can
enhance (or impede) our levels of motivation. These beliefs are shown to not only influence the
challenges that people decide to meet, but also how high they set their goals, for example ‘I intend to
reduce my smoking’, Vs. ‘I intend to quit smoking altogether’. These are ultimately beliefs focused on
success not failure.
Bandura [7] argues that self-efficacy beliefs are derived from four information sources, these
include: performance attainments; vicarious experience; verbal persuasion; and our physiological state.

• Performance accomplishments
• Our previous performance accomplishments are shown to be the most influential source of self-
efficacy information ‘I have done it before and can do it again’.

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• Vicarious experience
• We are what we see. According to Bandura [9], watching others (either succeeding or not)
shapes our beliefs of our own ability.
• Verbal persuasion
• We draw on others’ encouragement and conviction to perform a task.
• Physiology
• Physiological feedback is shown to impact on an individual’s level of self-efficacy. For
example, if an individual becomes anxious during a task this could negatively hinder a person’
s belief that they can perform or maintain a given behaviour.

According to the SCT the likelihood of behaviour is dependent on both outcome and efficacy
expectations. For example, if the behaviour is to give up smoking, the outcome is to have improved
health, then we must believe that (1) we are capable of quitting smoking (efficacy expectations) and
that (2) quitting smoking will benefit our health (outcome expectancies) (Figure 3.3).

Figure 3.2 Social Cognitive Theory [8]

Core process 2: socio-structural factors

These are the environmental factors which can influence our behaviour that may facilitate or impede
our behaviour. If we were interested in children’s nutrition as an example we might be interested in
access to healthy food at schools and at home.

Core process 3: goal setting

Goal setting is also an important factor in performance and behavioural attainment. Those who set
goals have been shown to exert more effort when compared to those who do not. The goals that we set

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are a direct influence of our capability (self-efficacy), socio-structural factors and outcome
expectancies (Figure 3.2). Another important aspect is self-regulation, self-generated thoughts,
feelings and actions which influence our goal attainment and motivation.
There are three psychological sub functions which are:

• Self-monitoring
• When we deliberately pay attention to our performance, what we are doing and then evaluate
the effects they produce on our health we use this information to set realistic goals and then
evaluate our progress in achieving them. The more closely we look at our performance the
more likely we are to set ourselves more progressive and realistic goals, which enables us to
focus all of our efforts on achieving what we set out to do.
• Self-reactive influences
• These are the incentives which influence our motivation to change our own behaviour. We are
more likely to pursue an action if it produces positive self-reactions than those that do not. Put
simply, ‘why should I bother?’
• The incentive could be health status, physical appearance, approval of others, economic gain,
or other consequences [10]. What is more important is that the individual is incentivised. Let’s
take a final year university student as an example, the student may do lots of revision for their
final exam because of their desire to get a high grade. We can see that the student is therefore
motivated by their aspiration to achieve a high grade.
• Judgemental sub function
• We observe and evaluate ourselves based on our own personal standards. These standards are
not something we are born with, instead they are developed within our social environment,
surrounded by those who are important to us, for example our family, friends, neighbours and
wider community networks.
• These standards, gained through a mechanism called ‘social modelling’, are formed from how
important people around us teach us, how they respond to our behaviour and how we, in turn,
judge ourselves based on their reaction and standards [11].
• However, we must remember that others’ standards are not always consistent, in other words,
whilst some people might be good at telling us how to eat healthily we might know through
our observations that they themselves do not eat healthily. Therefore, we try to develop our
standards upon our reflections of multiple social influences.

Box 3.1 Case study: applying the SCT to understand exercise behaviour
Jon, is inactive and has high blood pressure. He has recently been told by his healthcare provider
that increasing his levels of physical activity (e.g. attending a gym) would benefit his health.
According to the SCT before Jon could attend the gym he would need to:

• Believe that he could attend the gym despite the challenges, failures and obstacles that he
may face (self-efficacy);
• Believe that going to the gym would benefit him (outcome expectancies);
• Have access to a gym, and be able to afford the membership to attend the gym (social-
structural);
• Be incentivised to go to the gym (improve appearance, improve health and wellbeing), value
others around him who attend a gym and pay attention to his behaviour (self-regulation);
• Have realistic goals to enable him to achieve his target behaviour (goals).

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If we wanted to intervene using the SCT we might typically teach Jon skills that help start and
maintain his level of physical activity (e.g. instruct how to use equipment, teach Jon how to
monitor performance and set new goals), whilst also improving Jon’s social and physical
environment to facilitate rather than hinder the target behaviour (e.g. improving access to gyms,
cost effective memberships, more suitable opening and closing times) [12].

Summary and future directions

The SCT has been applied to understand a wide range of health behaviours including: sexual risk
behaviour [13], physical exercise [14], nutrition and weight control [15], addictive behaviour [16] and
medication adherence [17]. Several reviews have suggested that interventions based on Social
Cognitive Theory (SCT [38] can lead to small to moderate effects with strongest effects seen in
physical activity [18; 19]. Consequently the SCT has been viewed as a useful framework for
understanding and intervening in health behaviour [20]. Self-efficacy, or an individual’s self-belief
that they are capable of performing a behaviour, has been consistently shown to directly influence
behaviour with self-efficacy viewed as the most important predictor of the SCT in explaining
behaviour [21]. It is therefore not surprising that the development of self-efficacy has since gone on to
be a core and integral component in many theories developed later.
Despite this, there have been some noteworthy limitations that should be considered. A common
problem in evaluating the success of the SCT (although not unique to just the SCT) is assessing if this
theory has been measured correctly. A common pitfall is that the questionnaires developed to measure
the theory have not been able to measure the theory accurately. This is further complicated by
misinterpretations of how the mechanisms of the SCT operate and link. Therefore, we need more
clarity on how the variables operate and more consistent and concrete approaches to measurement.
Another issue, again not unique to the SCT is that a large number of studies are based on self-
report data. There is a large variation between what people self-report when compared to more
objective measures. For example, an individual who asked to self-report how many minutes exercise
they have performed in the last week is more likely to overestimate their actual level of activity and
this consequently overestimates the effect of the intervention. In fact, evidence suggests that studies
that have been based on more objective data did not provide any support for the SCT [8]. Therefore, it
could be argued that basing our evidence on self-report data alone is not a valid approach and instead
we need to utilise more objective measures, so in the example of physical activity we could compare
self-report data (e.g. ‘how many times did you do 30 minutes of moderate to vigorous activity in the
past week’) to data received from accelerometers. There are of course some behaviours which are
more difficult to objectively measure, for example, condom use, self-examination behaviours,
therefore we need to consider these limitations when interpreting the results.

Health Belief Model

The Health Belief Model (HBM), developed in the 1950s is the oldest and most commonly used
social cognition model used in public health and health promotion [22]. The HBM, similarly to the
SCT, is a value-expectancy theory, based on the idea that our behaviour is the subjective value of the
outcome ‘Why should I do this?’ and subjective expectation of achieving the outcome ‘Am I able to
do this’. However, unlike the SCT, HBM focuses on individual representations of health and
determines that these are key influences in health behaviour.
The HBM suggests that the likelihood of taking behavioural action is dependent on three core
beliefs: 1) perceived threat, 2) expectations and 3) cue to action.
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Sophie has been invited to attend a cervical smear test, a routine screening test offered to all
women aged 25 years and older as a method to detect abnormal cells on the cervix. Let’s imagine we
wanted to determine the likelihood of Sophie attending a cervical screening test. Presented in Figure
3.4, according to the HBM we would need to determine:

1. Perceived threat: Is the individual ready to act?

• She would need to feel that she is at perceived threat (of getting cervical cancer). This threat
is based on the belief that she is susceptible (perceived susceptibility) to getting cervical
cancer, for example. ‘It is possible that I could get cervical cancer in the future’, and that this
threat is severe (perceived severity), for example ‘Getting cervical cancer would be very
serious’.
2. Expectations: What is the estimation of the costs and benefits of the behaviour?
• She would also need to believe that following a health recommendation (attending a cervical
smear test) would be beneficial (benefits) in reducing the perceived threat, and that these
benefits would outweigh any obstacles (barriers). For example, ‘Having a smear test would
reduce my risk of getting cervical cancer and give me reassurance, for me this would be more
important that any embarrassment or inconvenience that I may feel’.
3. Cue to action: Is the individual aware of the potential consequences?
• Internal signals that something is wrong (pain, discomfort) or external stimuli such as health
campaigns or screening programmes are necessary to set in motion the cognitions above.

Modifying factors are also said to influence the way we think. These include demographics (age,
gender and ethnicity), socio-psychological (personality, social economic status, peer and group
pressure) and structural influences (knowledge about disease, prior contact with disease) to influence
her expectations and perceived threat.
The HBM was later revised in the 1980s [23] with the addition of self-efficacy, which was defined
as the likelihood of behavioural action being dependent on her belief that she could successfully take a
recommended health action (i.e., attend a cervical smear comfortably and with confidence).
If we go back to Sophie, according to the Health Belief Model interventions to encourage her to
make and attend a cervical smear test would include:

• Inform Sophie of the benefits of attending a cervical smear test and try to reassure her of the
barriers.
• Support Sophie to feel confident in her ability to attend a cervical smear test (self-efficacy).
• Make Sophie aware of her risk of cervical cancer and the severity of having cervical cancer, and
inform her that the perceived threat would be reduced through attending a cervical smear test.

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Figure 3.3 Illustration of relationship between expectancies, behaviour and outcome [6]

Summary and future directions

The HBM was first developed to understand the reasons why people attend or don’t attend
tuberculosis screening [22]. Since then, this model has been used to understand a wide range of health
behaviours [22], which have included:

• uptake of healthcare services [24];

• screening attendance and behaviour [25–27];
• safe sex and condom use [28];
• smoking [29];
• patient adherence and self-care behaviours [30].

The HBM, viewed as pioneering in its time, has generated more research than any other theoretical
model. However, the use of this model has been variable and frequently has failed to explain a large
proportion of health related behaviour [31]. This may be due to the fact that the constructs within the
model have not been adequately defined. Consequently, various methods of measurement have been
used, which has subsequently led to diverse results. Therefore, it remains unclear if the poor
predictive value is an artefact of poor measurement or definition or if this is because the HBM cannot
adequately explain health behaviour [31].
In understanding the effectiveness of the HBM there remains a greater argument. That being said,
can our behaviour be purely explained by our personal characteristics such as how old we are, and
where we live? Can our behaviour be explained simply by the perceived barriers we see? If so, this
would suggest that we always do what we should do, we are fully in control and consequently this is
governed by our conscious perceptions of the world. However, academics have argued that behaviour
cannot be this simply explained. Instead, could our behaviour be more effectively determined by our
habits (regular activities in which we take part), emotions (how we feel e.g. fear, denial) and other
unconscious and/or otherwise non-rational reactions to the external world. For example many smokers
are in denial that smoking is risky for their health, this is an emotional response to external factors that
dictate that smoking is unhealthy [31].

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Protection Motivation Theory

Fear based appeals such as commercial advertisements that warn us of the effects of smoking, have
been a common approach used in health promotion to change public attitudes and behaviour.
According to the Drive-fear Model (the oldest theory of fear appeals) we are motivated to achieve
homeostasis, which is a physiological state of equilibrium [32]. These persuasive fear-based messages
aim to induce an unpleasant emotional state. We then adopt a ‘new’ behaviour (e.g. stop smoking) to
reduce this fear (e.g. getting lung cancer), this in turn restores homeostasis, which ultimately
reinforces our modified behaviour (i.e. smoking cessation).
The Protection Motivation Theory (PMT) [33] was used to understand the impact of these appeals
and examine the processes involved to determine the mechanisms of behaviour change. The PMT
contains elements from the SCT and HBM. However, unlike the HBM, this model articulates links
and relations between the variables.
According to the PMT information that we acquire from environmental sources (i.e. fear appeals)
and intrapersonal sources (i.e. our personalities and prior experiences) two important cognitive
factors that influence us:

1) threat appraisal, a function of perceived susceptibility to illness and severity;

2) coping appraisal, a function of response efficacy and self-efficacy beliefs.

The outcome of these appraisals is suggested to influence an intention to change behaviour (protection
motivation). The strength that reflects our motivation to protect our health is also thought to directly
predict behaviour (Figure 3.5). Therefore, an individual is most likely to change behaviour i.e. give up
smoking in response to a fear-arousing health message if they believe:

(a) they are susceptible to disease (vulnerability) ‘My chances of getting lung cancer are high’;
(b) that the disease will have a severe consequence (severity) ‘Lung cancer is a serious illness’;
(c) There is a link between the protective behaviour and reduced risk of disease (response
effectiveness) ‘If I give up smoking I will reduce my chance of getting lung cancer’;
(d) They are capable of engaging in protective behaviour (self-efficacy) ‘I am confident I can give up
smoking’.

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Figure 3.4 Belief Model applied to the likelihood to attend cervical screening [22]

Summary and future directions

The PMT has been applied to a range of health promoting and compromising behaviours which have
included: physical activity [34]; dietary behaviour [35]; screening behaviour [36]; alcohol
consumption [37]; smoking [38] and treatment adherence [39].

• Meta-analyses have found that both threat and coping appraisal components of PMT were useful
in predicting health related intentions [40];
• Coping appraisal (i.e. perceived response efficacy, self-efficacy and response costs) has been
identified as the most important cognition [41] compared to threat appraisal [40].
• Therefore, the most successful approach to motivating people to change using this theory has been
through changing an individual’s perception of self-efficacy, for example setting achievable goals,
providing feedback on performance, reflecting on past achievements [41].

However, there are some limitations that should be considered.

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• The PMT assumes that we are rational thinkers, however, as we mentioned previously this is not
always the case. Whilst we may know all the risks linked to a behaviour that we do or do not do,
this may not influence our performance of it.
• Some argue that ‘emotion’ is not effectively explained, for example how do the cognitive
processes influence our emotions, and in turn how does this influence our behaviour.
• There is also the risk that scaring somebody does not always lead to positive change, in fact it
could lead to a negative outcome. Imagine a smoker who watched an advertisement campaign of a
person dying from a smoking related disease (fear arousing stimuli), the fear of this happening to
the individual and leaving their family makes them really scared. However, as a coping
mechanism this negative arousal may inadvertently make them smoke more, or perhaps adopt
another maladaptive behaviour. As such it has been suggested that ‘emotional response’ should be
included within the PMT as a mediating factor for an individual’s coping response.

Theory of Reasoned Action and Theory of Planned Behaviour

The Theory of Reasoned Action (TRA) developed by Fishbein [42], is a deliberative processing
model which implies that an individual’s attitudes are formed after careful consideration of the
available information, a sum of the likelihood and evaluation of the potential outcome. The likelihood
that an action might promote a given outcome, for example ‘If I eat more healthily I will improve my
health’ and evaluation of outcomes achieved/avoided and desirable and negative consequences ‘being
healthy will improve my health’.
This model was developed in response to criticisms of previous models and attempted to address
the gap between our attitudes and our behaviour i.e. whilst an individual may have positive attitudes
to eating more healthily (attitude) this does not necessarily mean they will eat more healthily
(behaviour). The TRA suggested that the gap between our attitudes and behaviour is bridged by our ‘
intentions’ to perform a given behaviour i.e. our motivation to exert effort into the performance of a
behaviour.
The TRA is also centred on the idea that an individual’s beliefs about their social world plays a
central role in decision making, referred to as ‘subjective norms’. The concept of putting the
individual in their social context and acknowledging social influences on an individual contrasted with
previous cognitive influences, for example SCT, HBM. Subjective norms, similarly to attitudes are
the sum of two beliefs:

(1) ‘normative beliefs’, the behaviours that others may expect of me, for example ‘my family and
friends think that I should eat healthily’.
(2) the degree to which an individual wants to comply with others, for example ‘I want to eat healthily
as my family and friends want me to’.

The development of the theory of planned behaviour

The TRA, whilst well received in its time began to suffer from mounting criticism that it lacked
explanatory power to adequately predict health behaviour. This model was subsequently succeeded by
the theory of planned behaviour, which expanded the TRA model with its design and adaption to take
into account Bandura’s pioneering work of self-efficacy [43]. This was considerably important as
research clearly identified during this period that including a self-efficacy element to the TRA could
strengthen the theoretical model through its application to complex health behaviours. The succession
of this newer model revolved around the inclusion of ‘perceived behavioural control’, the degree to
which the behaviour is perceived to be under the control of the individual.
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The TPB, like the TRA suggests an individual’s intention is the central factor to perform a given
behaviour. Motivational factors are central to our intention to perform a behaviour and are key
indicators to how hard an individual is willing to try and how much effort they will exert to perform
the behaviour [44]. The stronger the intention the stronger the performance. The TPB has three
conceptually independent determinants, which in turn predict intentions, these are: attitudes,
subjective norms and perceived behavioural control (see Figure 3.6). The TPB stipulates that our
behavioural intentions, for example ‘I am going to start eating healthily’, are the main antecedent to
behavioural action ‘Individual starts eating more healthily’. These intentions are based on a
combination of three factors: a) attitude to the behaviour ‘eating more healthily would be a good
thing for me to do’, b) subjective norms ‘eating healthy is an appropriate thing to do’ and c)
perceived behavioural control ‘I can resist all temptation to not eat healthily’.

Figure 3.5 Protection Motivation Theory

Summary and future directions

The TPB has been used to predict several health behaviours including: healthy eating [45], alcohol
consumption [46], drug use [47], physical activity [48], smoking [49], blood donation [50], HIV
prevention and condom use [51] amongst many others.
To understand how successful this model has been Armitage and Conner [52] conducted a meta-
analytic review, a study which uses statistical methods to pool the results from multiple studies to
create a single more precise estimate of the outcome. This study specifically analysed 185
independent studies which applied the TPB to a wide range of health behaviours in a variety of
contexts. The findings confirmed that the TPB was more superior in explaining behaviour to that of
the TRA and HBM [31].
Research has also shown that:

• intention and perceived behavioural control remain consistent psychological predictors of

behaviour [53];
• interventions that have resulted in large changes in intention are likely to also change behaviour
[54].

However, the TPB has not withstood criticism. Some limitations have included:

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• The role of subjective norms has been challenged as they are consistently found to be the weakest
predictor of intentions [52]. However, this may be a consequence of not being measured correctly,
or not having considered descriptive norms i.e. what those around actually do rather than what
they approve of.
• When behaviour measures have been self-reported (i.e. reported by the individual) there has been
an exaggerated increase in reported behaviour [52].
• There is also a large discrepancy between the predictability of intention and behaviour. This is
mostly related to ‘included abstainers’, individuals who form an intention and subsequently fail to
act [55].

Stage models of change

The Transtheoretical Model [56] was developed from a study which compared the experience of
smokers who quit on their own, against smokers who received professional treatment. Prochaska and
DiClemente argued that ‘change’ is an intentional process that occurs in stages rather than a one-time
event. Thus the stages of change were born.

Stages of change ‘When you change’

The TTM suggests that there are six sequential stages of change. These stages are:

1. Precontemplation
• The individual is not interested in changing their behaviour in the next six months ‘I am not
planning to quit smoking in the next 6 months’.
2. Contemplation
• The individual is deciding to change their behaviour in the next six months ‘I will decide to
quit smoking in the next 6 months’.
3. Preparation
• Individual is preparing to change and take action in the next month, they are developing
strategies for change and have a plan of action ‘I am ready to quit smoking’.
4. Action
• The individual has changed their behaviour within the last six months ‘I have quit smoking’.
5. Maintenance
• The individual has changed their behaviour for more than six months ‘I have quit smoking for
more than six months’.
6. Termination
• Behaviour change has been permanently adopted and the individual has no temptation to
relapse ‘I have not smoked for more than 5 years and have no desire to smoke in the future’.

These stages are viewed as a revolving door, where an individual can enter, exit and re-enter at any
stage (Figure 3.7). An individual may, for example be sparked into going from stage 1
(precontemplation) to taking action (stage 4) following a recent health scare and consequently go onto
successfully quit and terminate the behaviour (stage 6). Relapse is an expected part of this model and
is most common in the action stage (Figure 3.7).

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Figure 3.6 Theory of Planned Behaviour applied to healthy eating

The TTM also features (1) processes of change ‘How you change, (2) self-efficacy ‘Confidence to
change’ and (3) decisional balance ‘Why you change’.

1. Processes of change
There are 10 processes of change (experiential and behavioural), which enable individuals to move
and progress between the stages.
Experiential processes are the cognitive and affective processes where we gain relevant
information based on our own actions and experiences.

I. Consciousness Raising [Increasing Awareness]

• Enhancing knowledge and tips to support the behaviour change ‘I recall information people
had given me on how to stop smoking’.
II. Dramatic Relief [Emotional Arousal]
• This relates to the experience of emotions of the health risks of the behaviour ‘I react
emotionally to warnings about smoking cigarettes’.
III. Environmental Re-evaluation [Social Reappraisal]
• Where an individual considers the negative impact of the old behaviour or the positive
impact of the behaviour change on the individual’s social and physical environment ‘I
consider the view that smoking can be harmful to the people around me’.
IV. Social Liberation [Environmental Opportunities]
• This is where we notice public support, ‘I find society changing in ways that make it easier
for the nonsmoker’.
V. Self-Re-evaluation [Self Re-appraisal]
• Where we create a new self-image, ‘My dependency on cigarettes makes me feel
disappointed in myself’.

Behavioural processes are generated through environment events and behaviours including:

VI. Stimulus Control [Re-Engineering]

• How we manage our environment ‘I remove things from my home that remind me of
smoking’.
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VII. Helping Relationships [Supporting]

• Where we obtain support to help us ‘I have someone who listens to me when I need to talk
about my smoking’.
VIII. Counter Conditioning [Substituting]
• We substitute the unwanted behaviour by replacing it with something more positive ‘I find
doing other things with my hands is a good substitute for smoking’.
IX. Reinforcement Management [Rewarding]
• We reward positive behaviour change ‘I reward myself when I don’t smoke’.
X. Self-liberation [Committing]
• Where we make a commitment to change ‘I make a commitment not to smoke’.

These processes, whilst all important, are influential for progression during different stages of change (
Figure 3.8). This is useful to know because it helps us to develop stage based interventions tailored to
the individual. For example Joan, 56, who smokes 20–30 cigarettes per day is referred by her GP to
see a health psychologist. Following an assessment Joan is found to be in the pre-contemplation stage
i.e. she is not planning to quit smoking in the near future. According to the processes of change
suitable interventions to encourage her to move to the contemplation stage would be:

• increase Joan’s knowledge about the dangers of smoking and provide her tips and advice on how
she could quit smoking (consciousness raising);
• invoke an emotional reaction to her health behavior, for example receive pictures of the dangers of
smoking, see others who have been negatively impacted by smoking (emotional arousal);
• support Joan to consider the impact of her smoking to others around her (environmental re-
evaluation).

You may notice that the process ‘social liberation’ is not included, this is because it is unclear of its
relationship to particular stages.

Figure 3.7 The Stages of Change: The revolving-door based on Figure 2, p. 283 [56]
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2. Self-efficacy
An individual’s level of self-efficacy and their ability to resist temptation is an important factor in
achieving movement across the stages. This refers to individuals’ confidence that they can manage
high risk situations without relapsing and resist the desire to perform the unhealthy behaviour in
challenging situations.

3. Decisional balance
This is the process of weighing up the pros and cons of changing the target behaviour. The relative
weight people assign to the pros and cons of a behaviour which influences an individual’s decision to
change their behaviour.

Summary and future directions

Over the past three decades the TTM has been the most popular stage model applied to a wide range
of health behaviours, which have included:

• smoking cessation [57];

• physical activity and exercise [58];
• fruit and vegetable intake [59];
• weight management [60];
• condom use [61]);
• sun protection [62].

The appeal of the TTM is that it acknowledges that people are at various stages of behaviour change;
which can then be targeted by using stage-matched intervention strategies. However, the extent to
which the TTM is a model of behaviour change has been hotly debated. Whilst this model has been
popular among clinicians and healthcare professionals, this optimism has not been shared by
academics.
Despite some research, which has shown that decisional balance and stages of change are
important factors in understanding health behaviour [63], overall effectiveness of the TTM has been
weak. A systematic review of 37 RCTs across multiple health interventions including dietary change,
physical activity, multiple lifestyle changes and the uptake of unhealthy behaviours such as alcohol
use. Findings concluded that there was little evidence to support the effectiveness of transtheoretical
interventions [64].
A main criticism has been centred on the ‘stages of change’. Stage matching interventions have
proven problematic; it is often difficult to clearly identify the stage that the individual is in [65].
Further, the model is not predictive and the stages are not discrete. Researchers have therefore argued
that we should focus less on the stage but instead focus on the behaviour change itself. For example
just because an individual moves from being in the ‘precontemplation stage’ to the ‘contemplation’
state does not mean that they will achieve behaviour change success. In fact the concept of stage
based models has been criticised more generally. As Bandura, the founder of the SCT states, ‘human
functioning is simply too multifaceted and multidetermined to be categorized into a few discrete
stages’ [6]. Many scholars have argued that the model should be disregarded [66]. However, it is
argued that this model has been taken out of the context it was meant for. As Povey et al. [67] explain,

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stage models such as the TTM were originally designed as descriptive devices to enable clinicians to
create appropriate interventions for people with addictive behaviours rather than models or tools to
predict and explain behaviour with a certain level of academic rigour.

Box 3.2 Case study: A health psychologist (Jo Meola, Smoking Cessation Advisor)
A trainee health psychologist, smoking cessation lead discusses their role of applying the
Transtheoretical Model of Change to an individual in practice.
Richard was in his mid-thirties, a regular smoker of around 20–30 cigarettes per day. He
started smoking from around the age of 15 years. Richard had a steady reliable job, was married
and a dad to three children (aged 2, 6, 8). His wife and friends all smoked around him). Not once
did Richard ever worry about his smoking behaviour or the impact it might have at the time or in
the future on his health. Richard had no medical conditions and rarely visited his GP, yet always
had ‘a cough’; this was linked to his grandmother who also had a lifelong cough but had never
smoked in her life, so was put down to a hereditary trait.
This was until one day when Richard’s marriage fell apart and his circumstances and lifestyle
changed. He became aware of all the unhealthy behaviours in which he was engaging and
decided that stopping smoking would protect his future health for him and his children. This can
be viewed as a ‘social reappraisal’ where an individual considers the negative impact of their
behaviour. Richard initially began to think about all the pros and cons (decisional balance)
linked to smoking and decided that trying to stop would be a good idea (contemplation). From
this Richard tried to stop smoking alone (action). However, he continued to socialise with
friends who smoked and soon returned to his initial behaviour (relapse).
However, he soon realised the benefits of stopping smoking outweighed the benefit of
continuing to smoke (decisional balance) so he went to his GP who gave him some brief
information about the benefits of stopping together with some medication to help with the
nicotine withdrawal (increasing awareness) and advised him to go back in a couple of weeks.
This enabled Richard to try to quit smoking again (action), but unfortunately only for a short
time as one week later he starting smoking again (relapse).
Finally, and fairly soon afterwards, following one defining moment Richard made the
decision that he was going to stop smoking. He announced that he ‘did not want to become ill’ or
‘die early from smoking’ (self-liberation). A real-life video was released on social media of a
similar aged smoker who was dying of cancer who explained he was leaving behind his young
children all because of his smoking behaviour (emotional arousal). This video impacted on
Richard so much that it led to his final and, importantly, successful attempt to stop smoking. His
final attempt (action) was after a lot of thought and planning during a time where his triggers
were reduced (re-engineering). He built upon his previous quit attempts which gave him the
confidence to succeed (self-efficacy). Richard has now given up smoking for over 6 months (
maintenance).
Additional learning: Think of a situation where you may know someone who has experienced
a healthy lifestyle choice and apply the Transtheoretical Model to consider what their journey
may have been.

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Final overview and summary

• We know that health behaviour is complex, health psychology has however offered us a plethora
of models and theories which have enabled us to explain, predict and facilitate health behaviour.
• The discussed theories and models contain a wide variety of components. Whilst some are unique
to particular models, many share identical or overlapping characteristics.
• Behaviour change theories have demonstrated varying success. Each have their own advantages
and disadvantages, which should be considered in relation to the behaviour in question and the
empirical evidence to hand.

Figure 3.9 Processes which influence progression across the stages of change

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Cook, Erica, and Lynne Wood. Health Psychology : The Basics, Taylor & Francis Group, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bibliounisanitas/detail.action?docID=6407017.
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