Theories of Health Behavior

Abstract

There are many models, theories, and interventions developed in the field of health behavior. These contribute to the design, development, and implementation of effective interventions aimed at promoting public well-being and healthy behaviors, as well as long-term adherence to beneficial change. These interventions—which can be health programs, public policies, better lifestyle choices, and other such actions—take place in a wide variety of social settings and are meant to address different health issues. Therefore, they must be tailored, as much as possible, to the individuals, populations, and communities they aim to support.

Overview

Theories the field of health behavior seek to understand why individuals act against the interests of their own health and well-being and how to motivate healthy behaviors. Researchers hope to develop effective interventions that promote public health and healthy behaviors, as well as encourage long-term adherence to beneficial change. These interventions may take the form of health programs and public policies, or find application to individual lifestyle choices such as smoking cessation and nutritional eating. Health issues occur in a wide variety of social settings, among and across regions and demographics, and therefore cannot be addressed without particular attention to the condition and requirements of individuals, populations, and communities.

Modern health professionals have long sought to understand what motivates individuals and groups of people to adopt healthy attitudes and behaviors. Theories of human behavior and research on healthy lifestyles and preferences started to come together and coalesce into the professional field around the 1950s and 1960s. Although theories of human behavior have evolved into a vast and very diverse field and all strive to explain human behaviors and propose ways to change these, these tend to fall into two main branches of behavioral theory: the field of persuasion and that of behaviorist theories. Moreover, most theories work from the premise that behaviors have two fundamental elements: First, that people can be persuaded at multiple levels—for instance, by personal and interpersonal experiences, by collective and organizational factors, by government policies, and so on; and second, behaviors have a dialectical causality with their environment, that is, they are a direct result or consequence of external stimuli from their environment.

In the arena of health behavior, theorists and practitioners are also concerned with the distinction between individual and public health behaviors. These differences are important for the development of strategies and interventions. For example, at the individual level, healthful behaviors are often promoted by handing educational material or disseminating it via mass media. To be effective at the community level, on the other hand, it is necessary to enact changes by way impacting social norms, organizational behavior, and public policies, among others. Although both levels—individual and collective—combine behavioral and environmental factors, the strategies for impact are different. Take, for instance, the goal of deterring young people from smoking. A community-based strategy could organize or sponsor sports and music events in communities, promote youth leadership programs in schools, and lobby for or implement laws that prohibit the sale of tobacco to minors. An individualized approach, however, could include handing out print material in schools or youth groups, or a campaign of addressing young people individually through other channels of communication.

The first group of theories to be adopted into the field of health behavior are known as behaviorism. Theories of behavior, or behaviorism, are greatly influenced by the ideas of the proponents of classical conditioning. The best known member of this school is B.F. Skinner, and his theory known as “operant conditioning” is of particular importance to the field of health behavior. Operant conditioning stems from Edward Thorndike’s Law of Effect, which states that behavior that is reinforced tends to be strengthened and repeated. According to Skinner’s theory, behavioral changes are responses to environmental stimuli. The theory developed the idea of “pairings,” that is, the desired behavior is paired with a specific reinforcement. As the behavior keeps repeating and being positively reinforced, it strengthens and becomes ingrained. Reinforcement can be negative or positive and will have a definitive effect on a behavior increasing or decreasing.

In time, behaviorist theories were considered too limited or narrow to comprehend the full complexity of the human experience, giving way to a wider spectrum of theories, such as cognitive theories, the health belief model, consumer and interpersonal theories, reasoned action theories and many others.

Cognitive social theories posit that human behavior is much more complex than a set of stimuli and response; rather, human behavior is influenced by personal factors, such as beliefs, perceptions, and experiences, and environmental or social factors. For instance, an individual can be incentivized to perform some tasks or change a behavior, as long as the person believes he or she is capable of doing so. In health behavior theories, this is known as self-efficacy and is often explained as “believing in yourself.” The success of this behavior is a better predictor of it becoming repeated, rather than any specific reinforcement.

The health beliefs model, developed in the 1950s more or less at the same time as cognitive social theories, and is based on four key concepts of the level of risk or susceptibility to illness that an individual believes himself or herself to be subject to, and whether this person believes that a healthier behavior will be successful. In this sense, then, it is much more based on subjectivity, that is, deeply reliant on an individual’s mind, rather than on external factors. Social cognitive theory and cognitive belief models are sometimes applied together, as they can be complementary.

A few other theories come into play in the field of health behavior; one of the most prominent is the theory of reasoned action, developed by Martin Fishbein and Icek Ajzen in the 1980s. The main focus of this theory is intention, such as the intention of an individual to engage in or change a specific behavior. This is a wide step away from classic behaviorism, which posits that human behavior is basically a set of responses to an external stimulus. All these theories and models are also known as “continuum theories,” because they aim at identifying the variables or factors that influence people’s behaviors and how likely it is for a person—or a group of people—to change or engage in a given behavior. Many other theories exist, including the transtheoretical model, the planned behavior theory, and social ecological model.

Applications

Theories and models of human behavior may help understand an unhealthy behavior and identify ways to help effect change. The theories that have endured and become adopted successfully across various societies and cultures can be grouped as follows:

• Individual models
• Interpersonal theories
• Community level models

The individual and interpersonal levels share two key concepts: (1) the idea that behaviors are mediated by knowledge; that is, what we know or believe affects how we act, and (2) although knowledge is a necessary element in change, it is also insufficient to cause a change in behavior. Individual-level models look at behavior at its most basic level: the person. It also looks at what it takes for a person to develop the intention to change a harmful behavior to a healthier behavior. One of the individual angles, the stages of change model, argues that behavioral change has five key phases, in which health professionals may intervene to help enact change:

• Precontemplation—At this stage, an individual may not be conscious of a problem nor contemplate change. A health professional may build consciousness of a need for change by giving personal information on risks and benefits.
• Contemplation or consideration—Here, the individual has considered a change for the near future. A health professional may encourage specific plans.
• Decision or determination—Informal plans are made to enact change. A health professional can help develop concrete action plans and goals.
• Action—Implementation of specific actions. A health professional can provide feedback and support.
• Maintenance—The individual has adopted and continues his or her healthy behavior.

This model explains that change is gradual and involves actions that take an individual to the next stage. It also emphasizes the importance of receiving pertinent information and support at each step of the way.

The health beliefs model is one of the most commonly employed in the health professions. Health behavior researchers developed this model to help understand and predict the behavior of individuals in relation to the use of health services for prevention. It is based upon four key concepts: (1) The individual’s perception of susceptibility or risk to suffering an illness or lesion. For instance, upon becoming aware of his or her medical history, an individual may believe that his or her susceptibility of acquiring cancer has increased; this leads to a higher probability of the individual paying more attention to health advice. (2) An individual’s perception about the grade of severity of an illness or lesion; if it is not perceived as severe, there is little probability that he or she will seek attention and care. (3) The perception an individual has about preventive care and action. If he or she doubts the effectiveness of a recommendation for a specific condition, there is little probability that he or she will follow it. (4) The perception of a barrier to action. Perceived barriers vary and may include financial, cultural or educational aspects. For instance, if a person believes that eating healthier is costlier, it is less probable that he or she will alter eating habits. In short, according to the health beliefs model, if individuals have access to information about the severity of an illness or condition they have or are susceptible to, they will adopt healthier behaviors—as long as they believe the recommended behavior will be effective.

This theory evolved from a case study in which U.S. public health experts tried to understand why people did not take the free X-rays offered in units that visited various neighborhoods. They found, for instance, that 82 percent of those who believed they were susceptible to tuberculosis and believed they would benefit from an X-ray, agreed to be checked. On the other hand, only 21 percent of those who did not believe they were susceptible nor that they would benefit from early detection, agreed to get checked. This led experts to realize that it is important that health professionals understand the beliefs and perceptions of the people in the communities they serve.

A model that was adopted from another discipline into the field of health behavior is that of consumer information processing. This theoretical model adopted cognitive and behavioral elements to identify how consumers of a good or service uses information in their decision-making. The information was incorporated into the health professions in order to understand the decisions that individuals make relating to behaviors that affect their health. They discovered that for people to be able to use information, it must be accessible and available, new, user-friendly and easy to understand. Abundant research in this field suggest that:

• People use and process only a limited amount of information. Moreover, there are limitations as to the amount of information that people can remember. Therefore, the best strategy is to provide information in small segments, based on the most important points.
• Individuals combine different segments of information. Therefore, it is best if communicators provide information in ways that are easy to access and is clear and concise. To date, for instance, experts suggest that the most effective and popular medium to transmit health information is social media.
• People are not empty receptacles. They are bound in a specific society and share experiences and cultures with many. Information, then, should be molded, as much as possible, to the users’ experiences, culture, and environment.

Issues

As the field of health behavior has evolved through the decades, theorists have been moving further away from the individual model into more community and interpersonal theoretical models. This is not to say that other theories have been abandoned. In fact, important factors from individual-level theories are still used and adapted into more current models.

Interpersonal theories of health, for instance, are based upon theories of interpersonal communication developed by Albert Bandura and his colleagues in the 1960s. It posits that individuals are embedded into a social network and that their identity and standing in said networks are of great importance to their decisions. It is also used to identify attitudes toward health care in communities so that implemented programs are more effective. For instance, interpersonal health strategies frequently aim to develop programs that promote healthy lifestyles for individuals and their environment. These will be more sustainable and feasible if they incorporate the culture and beliefs of the community. There are a few main concepts in this theory meant to help professionals ensure their health and well-being programs are successfully implemented:

• The information provided must emphasize the positive and the benefits of a concrete healthy behavior.
• People learn better by observation and practice—this is known as heuristics. Health communication or intervention must provide believable behavioral models and show credible benefits.
• Interventions should aim at improving self-efficacy, increasing the trust of the individual and the possibilities in a specific social context.

Community-level models are more “macro”; that is, they seek large-scale behavioral change and aim to illuminate and explain how whole social systems function and evolve, particularly in relation to attitudes toward health and well-being. Community-level models incorporate an ecological perspective, which means a perspective that takes into account physical surroundings and the community’s relation to other living organisms. Goals and interventions seek to improve health and well-being not only for individuals, but also for groups and organizations, such as schools, workplaces, neighborhoods, villages, and so on. The demographic targets vary, since it can be a school program or a citywide program.

Therefore, strategies and initiatives are planned differently than at the individual level. Various levels of intervention may be employed, including individual, familial, interpersonal, and community. They are almost always structured and directed by organizations or agencies whose mission is to prevent, protect, and improve health. These include schools, clinics, worksites, health centers, non-profit organizations, churches, government agencies, and many others.

Community-based models include a variety of actors as well. While an institution or organization is usually in charge of developing it, a community-level intervention often includes advisory committees that involve community coalitions, parents’ groups, activists and organizers, and other community groups and members. Examples of types of community-based health interventions are HIV prevention, violence prevention, vaccination promotion, access to health care, and many other programs that promote healthier life choices and the common good.

Terms & Concepts

Behavioral Model: Also known as behaviorism, posits that human behavior is learned. It emphasizes the objective and measurable aspects of human behavior and focuses on observable stimulus-and-response behaviors.

Community-Based Model: A participative and community-wide approach; that is, it includes all key partners in a community who are affected by a situation, or their representatives.

Health Intervention: Any action or policy aimed at improving the health on a demographic or community level.

Heuristics: Refers to “hands-on” learning or learning through observation and practice.

Self-efficacy: An individual’s belief in his or her capacity to achieve or execute something.

Susceptibility: Being at risk or vulnerable of being harmed, influenced, or otherwise affected by something.

Bibliography

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Suggested Reading

Bøttcher Berthelsen, C., Lindhardt, T., & Frederiksen, K. (2014). Inhibiting interference—a grounded theory of health professionals’ pattern of behaviour related to the relatives of older patients in fast-track treatment programmes. Scandinavian Journal of Caring Sciences, 28(3), 609–617.

Dennis, C. B., Davis, T. D., Bernardo, K. R., & Kelleher, S. R. (2017). Enhancing health-conscious behaviors among clients in substance abuse treatment programs. Journal of Social Work Practice in the Addictions, 17(3), 291–306. Retrieved January 1, 2019 from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=124062508&site=ehost-live

Gillen, E. M., Hassmiller Lich, K., Yeatts, K. B., Hernandez, M. L., Smith, T. W., & Lewis, M. A. (2014). Social ecology of asthma: Engaging stakeholders in integrating health behavior theories and practice-based evidence through systems mapping. Health Education & Behavior, 41(1), 63–77.

Hays, K. (2018). Reconceptualizing church-based mental health promotion with African Americans: A social action theory approach. Journal of Religion & Spirituality in Social Work, 37(4), 351–372. Retrieved January 1, 2019 from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=133159956&site=ehost-live

Meier, P. S., Warde, A., & Holmes, J. (2018). All drinking is not equal: How a social practice theory lens could enhance public health research on alcohol and other health behaviours. Addiction, 113(2), 206–213. Retrieved January 1, 2019 from EBSCO Online Database Sociology Source Ultimate. http://search.ebscohost.com/login.aspx?direct=true&db=sxi&AN=127216737&site=ehost-live

Worawong, C., Borden, M. J., Cooper, K. M., Pérez, O. A., & Lauver, D. (2018). Evaluation of a person-centered, theory-based intervention to promote health behaviors. Nursing Research, 67(1), 6–15.