Part 7- Social Science Behavior Theories and Models

Part 7- Social and Behavioral Theories

Theory and Why It is Important

We’ve stated that theories and hypotheses are ideas, but what sort of ideas are they, exactly? A theory is a well-developed set of ideas that propose an explanation for observed phenomena. Theories are repeatedly checked against the world, but they tend to be too complex to be tested all at once; instead, researchers create hypotheses to test specific aspects of a theory.

Figure.

The scientific method of research includes proposing hypotheses, conducting research, and creating or modifying theories based on results.

ISKME OpenStax CC BY SA

Theories can guide the search to:

• Understand why people do or do not practice health promoting behaviors;

• Help identify what information is needed to design an effective intervention strategy; and

• Provide insight into how to design a program so it is successful.

Theories and models help explain behavior, as well as suggest how to develop more effective ways to influence and change behavior.

Two broad types of theory – explanatory theory and change theory – may have different emphases but are complementary. For example, understanding why an employee smokes is one step toward a successful cessation effort, but even the best explanations won’t be enough by themselves to fully guide change to improve health. Some type of change model will also be needed. Both explanatory theories and change theories are rooted in an understanding of the social determinants of health and health behavior. Many social, cultural, and economic factors contribute to the development, maintenance, and change of health behavior patterns.

All of the theories and models described here have some potential as both explanatory and change models, though they might be better for one or the other purpose. For example, the Health Belief Model was originally developed as an explanatory model, whereas in contrast the Stages of Change construct of The Transtheoretical Model was conceived to help guide planned change efforts. Interventions should not only be targeted at individuals but should also affect interpersonal, organizational, and environmental factors influencing health behavior.

A theory presents a systematic way of understanding events, behaviors and/or situations.

The notion of generality, or broad application, is important. Thus, theories are by their nature abstract and not content- or topic-specific. Even though various theoretical models of health behavior may reflect the same general ideas, each theory employs a unique vocabulary to articulate the specific factors considered to be important. Theories vary in the extent to which they have been conceptually developed and empirically tested; however, “testability” is an important feature of a theory. As Stephen Turner has noted in his chapter on “Theory Development,” social science theories are better understood as models that work in a limited range of settings, rather than laws of science which hold and apply universally.

We continue to see growing evidence that health interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base (Glanz, et al). There is a vast array of theories and models, however, an overview of the most common theories and models will be given, followed by theories and models related to more specific health topics.

Important Theories and Their Key Constructs

Theories that gain recognition in a discipline shape the field, help define the scope of practice, and influence the training and socialization of its professionals. Today, no single theory or conceptual framework dominates research or practice in health promotion and education. However, reviews of journal articles published in the past two decades have revealed the most often-used theories in health behavior research and trends in theory use. Dozens of theories and models have been used, but only a few of them were used in multiple publications and by several authors. What follows is a description of the central elements of four of the most widely-used theoretical models of health behavior:

• The Health Belief Model (HBM)

• The Transtheoretical Model/Stages of Change (TTM)

• Social Cognitive Theory (SCT)

• The Social Ecological Model.

Other often-used theories and models (not described here) include the Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB), social support and social networks, social marketing, diffusion of innovations, and several communication theories.

Health Belief Model

The Health Belief Model (HBM) was developed to help understand why people did or did not use preventive services offered by public health departments in the 1950’s, and has evolved to address newer concerns in prevention and detection (e.g., mammography screening, influenza vaccines) as well as lifestyle behaviors such as sexual risk behaviors and injury prevention. The HBM theorizes that people’s beliefs about whether or not they are at risk for a disease or health problem, and their perceptions of the benefits of taking action to avoid it, influence their readiness to take action.

Core constructs of the HBM:

• Perceived susceptibility and perceived severity

• Perceived benefits and perceived barriers

• Cues to action

• Self-efficacy (added more recently)

The HBM has been most-often applied for health concerns that are prevention-related and asymptomatic, such as early cancer detection and hypertension screening – where beliefs are as important or more important than overt symptoms. The HBM is also clearly relevant to interventions to reduce risk factors for cardiovascular disease.

The Health Belief Model Graphic:

Source: Becker, M. H. & Maiman, L. A., (1975). Sociobehavioral determinants of compliance with health and medical care recommendations. Medical Care, 134(1), 10-24. Figure 1, p. 12. (Permissions pending).

Transtheoretical Model/Stages of Change

Long-term changes in health behavior involve multiple actions and adaptations over time. Some people may not be ready to attempt changes, while others may have already begun implementing changes in their smoking, diet, activity levels, and so on. The construct of “stage of change” is a key element of The Transtheoretical Model (TTM) of behavior change, and proposes that people are at different stages of readiness to adopt healthful behaviors. The notion of readiness to change, or stage of change, has been examined in health behavior research and found useful in explaining and predicting changes for a variety of behaviors including smoking, physical activity, and eating habits. The TTM has also been applied in many settings.

Transtheoretical/Stages of Change Model Graphic:

Stages of change is a heuristic model that describes a sequence of steps (see Table 1) in successful behavior change:

1. Precontemplation;

2. Contemplation;

3. Preparation;

4. Action; and

5. Maintenance.

The stages of change model can be used both to help understand why people at high-risk for diabetes might not be ready to attempt behavioral change, and to improve the success of health counseling.

People do not always move through the stages of change in a linear manner – they often recycle and repeat certain stages, for example individuals may relapse and go back to an earlier stage depending on their level of motivation and self-efficacy.

Transtheoretical Model Activity:

Social Cognitive Theory

Social cognitive theory (SCT), the cognitive formulation of social learning theory that has been best articulated by Bandura, explains human behavior in terms of a three-way, dynamic, reciprocal model in which personal factors, environmental influences, and behavior continually interact (See Figure 3). SCT synthesizes concepts and processes from cognitive, behavioristic, and emotional models of behavior change, so it can be readily applied to counseling interventions for disease prevention and management.

SCT was found to be the most common theory utilized as a basis for research on self-care.

Jaarsma T, Westland H, Vellone E, Freedland KE, Schröder C, Trappenburg JCA, Strömberg A, Riegel B. Status of Theory Use in Self-Care Research. Int J Environ Res Public Health. 2020 Dec 17;17(24):9480. doi: 10.3390/ijerph17249480. PMID: 33348884; PMCID: PMC7765830.

A basic premise of SCT is that people learn not only through their own experiences, but also by observing the actions of others and the results of those actions.

Key constructs of social cognitive theory that are relevant to health behavior change interventions include:

• Observational learning

• Reinforcement

• Self-control

• Self-efficacy

Some elements of behavior modification based on SCT constructs of self-control, reinforcement, and self-efficacy include goal-setting, self-monitoring and behavioral contracting. Goal-setting and self-monitoring seem to be particularly useful components of effective interventions.

Self-efficacy, or a person’s confidence in his or her ability to take action and to persist in that action despite obstacles or challenges, is especially important for influencing health behavior change efforts.

Reciprocal Determinism

The key Social Cognitive Theory construct of reciprocal determinism means that a person can be both an agent for change and a responder to change. Thus, changes in the environment, the examples of role models, and reinforcements can be used to promote healthier behavior.

This core construct is also central to social ecological models and is more important today than ever before.

Social Ecological Model

The social ecological model helps to understand factors affecting behavior and also provides guidance for developing successful programs through social environments. Social ecological models emphasize multiple levels of influence (such as individual, interpersonal, organizational, community and public policy) and the idea that behaviors both shape and are shaped by the social environment. The principles of social ecological models are consistent with social cognitive theory concepts which suggest that creating an environment conducive to change is important to making it easier to adopt healthy behaviors.

Interventions to Change Health Behavior

Health behaviors are shaped through a complex interplay of determinants at different levels. For example, physical activity is influenced by self-efficacy at the individual level, social support from family and friends at the interpersonal level, and perceptions of crime and safety at the community level. Ecological models suggest that these multiple levels of influence interact across levels. For example, social support for exercise from co-workers may interact with the availability of exercise equipment at the worksite to lead to increased physical activity.

Traditionally, and especially in clinical settings, strategies to change health behaviors have focused on individual-level factors such as knowledge, beliefs, and skills. As ecological thinking has gained currency, intervention strategies have broadened to target factors at other levels of influence such as organizational policies and the built environment. This recognition of the complex range of factors that shape health behaviors can make the selection of intervention strategies daunting.

Fortunately, there are several broadly applicable and widely used theories and models for targeting behavioral determinants at various levels, so a firm grasp of available options makes it unnecessary to “reinvent the wheel”. Researchers and program planners can select from individual-level theories such as the Health Belief Model, which emphasizes beliefs of susceptibility and severity of a health problem, and perceived benefits and barriers of taking action. Alternatively, an intervention planner might use organizational development theories to create policy or environmental change within an organization such as a clinic or school.

Intervention strategies targeting the individual level include goal setting, behavioral contracting, and tailored health communication. These strategies most typically draw on Social Cognitive Theory (SCT) and the stages of change construct from the Transtheoretical Model. Social Cognitive Theory (SCT) explains human behavior in terms of a three-way, dynamic, reciprocal model in which personal factors, environmental influences, and behavior continually interact. Key constructs of social cognitive theory that are relevant to behavior change interventions include observational learning, reinforcement, self-control, and self-efficacy.

Health professionals or public health educators can make deliberate efforts to increase clients’ self-efficacy using three types of strategies:

1. setting small, incremental and achievable goals;

2. using formalized behavioral contracting to establish goals and specify rewards; and

3. monitoring and reinforcement, including client self-monitoring by keeping records.

Several reviews have examined which theories were used in health behavior intervention research and whether theory-based strategies are positively associated with desirable outcomes.

The choice of a suitable theory or theories should begin with identifying the problem, goal, and units of practice, not with selecting a theoretical framework because it is intriguing, familiar, or in vogue. One should start with a logic model of the problem and work backwards to identify potential solutions.

Successful behavior change strategies take many forms. Theory and research suggest that the most effective behavior change interventions are those that use multiple strategies and aim to achieve multiple goals of awareness, information transmission, skill development, and supportive environments and policies. Goal-setting and monitoring are important elements of many successful interventions. The emergence of information technology tools such as the internet, wireless technology, and personal digital assistants have expanded the range of theory-based strategies available for effective behavior change in health care and community settings. Behavioral interventions should be sensitive to audience and contextual factors, and recognize that most behavior change is incremental and that maintenance of change usually requires continued and focused efforts.

Glanz K, Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health. 2010;31:399-418. doi: 10.1146/annurev.publhealth.012809.103604. PMID: 20070207.