Theories of Health Behavior

Diadaptasi oleh
Hartiah Haroen
Program Magister keperawatan
Fakultas Keperawatan UNPAD
2010
 Behavior Change in Health

Some questions:
What factors predict health behaviors?
e.g., Why do you floss every night? or why not?
How do people change their health behaviors?
Why dont people change? What are some of the
barriers?
Theories, Models, and Practicalities
 Behavioral Immunogens and
Pathogens
Behavioral Pathogen
A health-compromising behavior or habit
smoking, excessive eating, substance abuse, dangerous
driving, risky sexual behavior
Behavioral Immunogen
A health-enhancing behavior or habit
exercising regularly, using sunscreen, healthy eating,
practicing safe sex, wearing seatbelts
What influences Health Behaviors?

Fig. 6.1, p.177

Health Promotion Means Changing Behavior
at Multiple Levels
A Individual: knowledge, attitudes, beliefs,
personality
B Interpersonal: family, friends, peers
C Community: social networks, standards,
norms
D Institutional: rules, policies, informal
structures
E Public Policy: local policies related to
healthy practices
 The Purpose of Theory

Predict
to anticipate events

Explain
to account for what has happened

Focus
to limit options and reduce waste of effort

Simplify
to manage complex systems, tolerate ambiguous contexts, and
prepare for unpredictable threats
 A: Individual-Oriented Models
Individual most basic unit of health promotion
Individual-level models components of
broader-level theories and approaches
Models
Stages of Change Model
Health Belief Model
The Planned behavior
 Stages of Change Model
Precontemplation

Maintenance Contemplation

Action Decision
 Stages of change

The transtheoretical model of

behavioural change
People are at different stages of
readiness to change
Four components:
stages
self-efficacy
decisional balance
processes of change
Prochaska 1994
 Stages

Pre-contemplation I wont
Contemplation I might
Preparation I will
Action I am
Maintenance I have been
Self-efficacy

Self-defined ability or confidence to

engage in the behaviour
Key determinant of efforts to change
Confidence increases as people move
through stages
 Decisional balance
Two-part analysis of pros and cons of
change
Initially cons outweigh pros
Pros gradually increase
Usually cross in preparation

Pros

Cons

Pre-c Cont Prep Act Main

Change processes

Derived from models or theories that

have been integrated into this
framework
Actions or interventions which assist
the person to make the change
 Processes
Consciousness Self-liberation
raising Social liberation
Dramatic relief Stimulus control
Supportive Counter-conditioning
relationships Reinforcement
Self re-evaluation management
Environmental re-
evaluation
Processes
Pre- Contemplation Preparation
contemplation Action
Increasing Higher
confidence confidence
Confident
Self- temptations
confidence
Cons >Pros Cons <Pros
Cons <Pros
Cons >Pros
Self-evaluation Self-
Environmental liberation Stimulus
evaluation Social control
Dramatic relief liberation
Consciousness raising Counter-
Supportive relationships conditioning
Relationships
 Stage identification
Question Stage if yes

Have you been _______ for Maintenance

more than the past six months?

Have you been _______ for less Action

than six months?
Are you planning to start Preparation
_______ in the next month?

Have you been thinking about Contemplation

starting _______ in the next six
months?
Do you intend to start Pre-contemplation
_______in the next six months?
Pre-contemplation
No change for at least six months
Lack of knowledge or conscious
decision
Low self-confidence
Cons > pros
Interventions
consciousness raising
dramatic relief
supportive relationship
Contemplation

Thinking about it
Self confidence increasing

Cons > pros

Interventions
self re-evaluation
environmental re-evaluation
list pros/cons
 Preparation

Preparing to make the

change
Self-confidence increased
Cons = pros

Interventions
self-liberation (contract)
social liberation
supportive relationships
 Action

Actively involved in making the

change
Confidence is high
Cons < pros

Interventions
stimulus control
counter-conditioning
supportive relationships
Maintenance

Continuation of change
Risk of relapse

Intervention
reinforcement management
Health belief model
Factors considered important in healthcare
decisions
Perceived severity
Perceived susceptibility
Value of the treatment
Barriers to treatment
Cost of treatment physical and
emotional

Richards 1997
 Premise of the HBM
Individuals will take action toward off, to screen for,
or to control an ill health condition if:
1) they regard themselves as susceptible to the
condition
2) they believe it to have potentially serious
consequences
3) they believe a course of action can reduce the
susceptibility and seriousness
4) they believe the costs of the action are outweighed by
its benefits
 Health Belief Model
Individual Perceptions Modifying Factors Likelihood of Action

Variables Perceived Benefits of

Preventive Action
Demographic
minus
Sociopsychological
Perceived Barriers to
Structural
Preventive Action

Perceived
Susceptibility to Perceived Threat of Likelihood of Taking
Disease X Disease X Recommended
Perceived Seriousness Preventive Health
of Disease X Action

Cues to Action
Health belief model
Health belief model can predict users of
healthcare services
Barriers and costs most significant reasons
for not making changes
People calculate return on investment
based on own perceptions
Perceived severity
Ask people what they know about the
condition
How serious do they think it is
What they know about complications

Interventions
give basic information on the
condition
do not threaten or scare
Perceived susceptibility

How likely is it that

The condition will get worse
That complications will develop

Interventions
discuss with patient
stay positive - good management will
reduce likelihood
Value of treatment

Perception of efficacy
Knowledge of treatment options

Interventions
discuss possible regimens
explore fears
give choices
Barriers to treatment

Time
Money
Side effects

Interventions
pros and cons of treatment
resources to confront barriers
long-term support
Theory of Planned Behavior (Reason action)
Finsbein & Ajzen

Attitude
Toward
Behavio
r

Ibehavioral
Subjective
ntention Behavior
Norm

Perceived
Behavioral
Control
Theory of Planned Behavior
 B: Interpersonal Level:
Social Learning Theory
Interaction of individual factors, social
environment, and experience
Reciprocal dynamic
Observational learning
Capability of performing desired behavior
Perception of self-efficacy
 Interpersonal Level:
Social Learning Theory (cont.)
Three strategies for increasing self-efficacy
Setting small, incremental goals
Behavioral contracting: specifying goals and
rewards
Self-monitoring: feedback can reinforce
determination to change (keep a diary)
Positive reinforcement: encouragement helps

Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).
 Social Cognitive Theory
Bandura
The Difference Between Efficacy and Outcome Expectations

Person Behavior Outcome

Efficacy Outcome
Expectations Expectations
 C: Community-Level Models
Analyze how social systems function
Mobilize communities, organizations, and
policymakers
Use sound conceptual frameworks
Community Mobilization
Organizational Change
Diffusion of Innovations Theory
 Community Mobilization
Encompasses wider social and political
contexts
Community members assess health risks, take
action
Encourages empowerment, building on
cultural strengths and involving
disenfranchised groups

Source: National Cancer Institute, Theory at a Glance: A Guide for Health Promotion: 18; Paolo Freire, Pedagogy of
the Oppressed (New York: Continuum, 1970.); Saul Alinsky, Rules for Radicals: A Pragmatic Primer for Realistic
Radicals (New York: Vintage Books, 1971; revised edition, 1989).
 Organizational Change
Organizational Stage Theory Organizational Development
Theory

Define problem

Organizational structures
Identify solutions

Initiate action

Allocate resources Worker behavior and motivation

Implement

Institutionalize
 Diffusion of Innovations Theory
How new ideas, products, and behaviors
become norms
All levels: individual, interpersonal,
community, and organizational
Success determined by: nature of
innovation, communication channels,
adoption time, social system

Source: Everett M. Rogers, Diffusion of Innovations, 4th ed. (New York: The Free Press, 1995).
 Diffusion of Innovations (cont.)
Nature of innovation
Relative advantage over what is being
replaced
Compatible with values of intended users
Easy to use
Opportunity to try innovation
Tangible benefits
 Diffusion of Innovation Theory
Rogers

40

20
Time
0
Laggards Late Late Majority Early Early Innovators
Adopters Majority Adopters
 Diffusion of Innovations (cont.)
Communication channels
Mass media (enhanced by listening groups,
call-in opportunities, and face-to-face
approaches)
Peers
Respected leaders
 Diffusion of Innovations (cont.)
Adoption time
Awareness Intention Adoption Change
Gradual
Movement through groups
Pioneers
Early adopters
Masses
 Diffusion of Innovations (cont.)
Social system:
Identify influential networks to diffuse
innovation: health systems, schools, religious
and political groups, social clubs, unions, and
informal associations
Identify opinion leaders, peers, and targeted
media channels to diffuse innovations
What influences the adopter categories?

Attributes of the Characteristics of

Innovation Adopter
Relative advantage Beliefs
Compatibility Values
Complexity Experience
Trialability
Observability
 Models that Influence H.E.
PRECEDE-PROCEDE
Generalized Model for Program
Development
Model for Health Education Planning and
Resource Development (MHEPRD)
Model for Health Education Planning
(MHEP)
 Precede Proceed
L. W. Green & M. W. Krueter

Predisposing
Factors

Health Promotion

Reinforcing Behavior
Health Education
Factors and Quality
Lifestyle Health of Life

Policy
Regulation Enabling Environment
Factors
Organization
Programmatic and Intrapersonal Determinants of
Sexually Abstinent
Behavior
Program Deliverer
Intrapersonal Factors
Preparation Positive Emotions
Competence Environmental
Self-Standards/Comfort Constraints/Barriers

Abstinent Behavior
Attitudes Positive Attitudes
Social Norms

Sexually
Self-Efficacy
Social Norms INTENTION
Time on Task
(program dose/exposure)
Self-Efficacy
Curriculum Used Ability/Skills
(school-based programs)
Self-Standards
Fidelity of
Implementation

Program Factors Participant Factors

Conceptual Model for Health Education
Planning and Resource Development
Bates & Winder Health Education
Plans

Evaluation
Process
Research Evaluation Information Evaluation Demonstration
Programs Process and Statistics
Evaluation
Process Programs
Process

Operational
Programs
 Generalized Model for Program
Development
J. F. McKenzie and J. L. Smeltzer

Assessing Identifying Setting

Need the Goals and
Problem(s) Objectives

Implementin
Evaluating Developing an
g the
the Results Intervention
Intervention
 Application Exercise

Please choose a health behavior and population

Assume you are an advertising specialist contracted to develop

a persuasive communication (poster, news advertisement etc.)
to improve the health behavior for the population

Create a message that includes severity, susceptibility,

response efficacy, and self-efficacy for the target population