Unit 2 - Health Behaviours

Behavior and health: Characteristics of health behaviour; Barriers to health behaviour;

Theories of health behaviour and their implications.
Introduction: Health behaviour, health habit, well behaviour, symptom-based behaviour,
sick-role behaviour
Characteristics of Health Behaviour
Factors affecting Health Behaviours/ Practicing and Changing Health Behaviors
Barriers to Health Behaviour (from Allen)
Determinants of Health Behaviour: Learning; Social, Personality, and Emotional Factors;
Perception and Cognition
Theories of Health Behaviour
​ Health Belief Model
​ Stages of Change Model/Transtheoretical Model of Behaviour Change
​ Theory of Planned Behaviour
Health behavior is any activity people perform to maintain or improve their health, regardless
of their perceived health status or whether the behavior actually achieves that goal. Researchers
have noted that people’s health status influences the type of health behavior they perform and
their motivation to do it (Kasl & Cobb, 1966a, b; Parsons 1951). A health habit is a health
behavior that is firmly established and often performed automatically, without awareness. These
habits usually develop in childhood and begin to stabilize around age 11 or 12 (Cohen, Brownell,
& Felix, 1990). Wearing a seat belt, brushing one’s teeth, and eating a healthy diet are examples
of these kinds of behaviors. Although a health habit may develop initially because it is reinforced
by positive outcomes, it eventually becomes independent of the reinforcement process. As such,
habits can be highly resistant to change. Consequently, it is important to establish good health
behaviors and to eliminate poor ones early in life.

The role of behavior in health has been receiving increased attention because people’s health
habits influence their likelihood of developing chronic and fatal diseases (WHO, 2009). Illness
and early death could be substantially reduced if people would adopt lifestyles that promote
wellness.

To some extent individuals who practice certain behaviors that benefit their health also practice
other healthful behaviors and continue to perform these behaviors over time (Schoenborn, 1993).
But other people show little consistency in their health habits (Kaczynski et al., 2008; Mechanic,
1979). Research results suggest three conclusions. First, although people’s health habits are fairly
stable, they often change over time. Second, particular health behaviors are not strongly tied to
each other—that is, if we know a person practices one specific health habit, such as using seat
belts, we cannot accurately predict that he or she practices another specific habit, such as
exercising. Third, health behaviors do not seem to be governed in each person by a single set of
attitudes or response tendencies.

Hence, Matarazzo distinguished between those behaviours that have a negative effect (the
behavioural pathogens, such as smoking, eating foods high in fat, drinking large amounts of
alcohol) and those behaviours that may have a positive effect (the behavioural immunogens, such
as tooth brushing, wearing seat belts, seeking health information, having regular check-ups,
sleeping an adequate number of hours per night).

Well behavior is any activity people undertake to maintain or improve current good health and
avoid illness. These activities can include healthy people’s exercising, eating healthful diets,
having regular dental checkups, and getting vaccinations against diseases. But when people are
well, they may not feel inclined to devote the effort and sacrifice that healthful behavior entails.
Thus, engaging in healthful behavior depends on motivational factors.

Symptom-based behavior is any activity people who are ill undertake to determine the problem
and find a remedy. These activities usually include complaining about symptoms, such as
stomach pains, and seeking help or advice from relatives, friends, and medical practitioners.
Some people are more likely than others to engage in symptom-based behavior when symptoms
appear.

Sick-role behavior refers to any activity people undertake to get well after deciding that they are
ill and what the illness is. This behavior is based on the idea that sick people take on a special
‘‘role,’’ making them exempt from their normal obligations and life tasks. Although this status
ordinarily obligates patients to try to get well, many do not follow their recommended treatment,
particularly if it is inconvenient or uncomfortable to do. How people behave when they are sick
depends in large measure on what they have learned.

Characteristics of Health Behaviour

1.​ There are gender, sociocultural, and age differences in practicing health behaviors
(Schoenborn, 1993, 2009a). An international survey of adults in European countries found
that women perform more healthful behaviors than men (Steptoe et al., 1994). One reason for
such differences is that people seem to perform behaviors that are salient to them. Other
research has found that there are cultural differences in the way people respond to their
symptoms and go about trying to get well (Korol & Craig, 2001).

2.​ It is largely learned (via media, peer groups, society etc.). Some unhealthful behaviors,
such as drinking or smoking, are often seen as pleasurable. As a result, many individuals do
 not resist beginning unhealthful behaviors and may reject efforts or advice to get them to
quit. How people behave when they are sick depends in large measure on what they have
learned.

3.​ There are individual differences in health behavior. Some people are more likely than
others to engage in symptom-based behavior when symptoms appear, and there are many
reasons for these differences. For instance, some individuals may be more afraid than others
of physicians, hospitals, or the serious illness a diagnosis may reveal. Some people are stoic
or unconcerned about the aches and pains they experience, and others do not seek medical
care because they simply do not have the money to pay for it.

4.​ It depends on motivational factors. Researchers have noted that people’s health status
influences the type of health behavior they perform and their motivation to do it (Kasl &
Cobb, 1966a, b;Parsons 1951). When people are well, they may not feel inclined to devote
the effort and sacrifice that healthful behavior entails. Thus, engaging in healthful behavior
depends on motivational factors, particularly with regard to the individual’s perception of a
threat of disease, the value in the behavior in reducing this threat, and the attractiveness of
the opposite behavior. It can be changed through awareness, attitudinal changes and
reinforcement.

5.​ Health behaviors are not necessarily tied together (i.e., performing one health behavior
does not necessarily predict the likelihood of engaging in other healthful behaviors)—that is,
little consistency, why?
if we know a person practices one specific health habit, we cannot accurately predict that
they practice another specific habit. First, various factors at any given time in people’s lives
may differentially affect different behaviors. For instance, a person may have lots of social
encouragement to eat too much, and, at the same time to limit drinking and smoking. Second,
people change as a result of experience. For example, many people did not avoid smoking
until they learned that it is harmful. Third, people’s life circumstances change. Thus, factors,
such as peer pressure, that may have been important in initiating and maintaining exercising
or smoking at one time may no longer be present, thereby increasing the likelihood that the
habit will change.
 6.​ Some people may practice health behaviors without being health conscious (eating
third reason why
healthy to look attractive/wearing a seat belt to avoid being penalized). Health behaviors do
not seem to be governed in each person by a single set of attitudes or response tendencies.

Factors affecting Health Behaviours/ Practicing and Changing Health Behaviors

What factors lead one person to live a healthy life and another to compromise their health?
●​ Demographic factors: Younger, more affluent, better-educated people with low levels of
stress and high levels of social support typically practice better health habits than people
under higher levels of stress with fewer resources.
●​ Age and gender: Health habits are typically good in childhood, deteriorate in adolescence and
young adulthood, but improve again among older people.
●​ Values: Values affect the practice of health habits. For example, exercise for women may be
considered desirable in one culture but undesirable in another (Guilamo-Ramos, Jaccard,
Pena, & Goldberg, 2005).
●​ Personal Control: People who regard their health as under their personal control practice
better health habits than people who regard their health as due to chance.
●​ Social Influence: Family, friends, and workplace companions influence health-related
behaviors, sometimes in a beneficial direction, other times in an adverse direction (Broman,
1993; Turbin et al., 2006).
●​ Personal Goals and Values: Health habits are tied to personal goals. If personal fitness is an
important goal, a person is more likely to exercise.
●​ Perceived Symptoms: Some health habits are controlled by perceived symptoms. For
example, a smoker who wakes up with a smoker’s cough and raspy throat may cut back in
the belief that he or she is vulnerable to health problems at that time;
●​ Access to the Health Care Delivery System: Access to the health care delivery system affects
health behaviors. For example, obtaining a regular Pap smear, getting mammograms, and
receiving immunizations for childhood diseases depend on access to health care. Other
behaviors, such as losing weight and stopping smoking, may be indirectly encouraged by the
health care system through lifestyle advice.
●​ Knowledge and Intelligence: The practice of health behaviors is tied to cognitive factors,
such as knowledge and intelligence (Jaccard, Dodge, & Guilamo-Ramos, 2005). More
knowledgeable and smarter people typically take better care of themselves. People who are
 identified as intelligent in childhood have better health-related biological profiles in
adulthood, which may be explained by their practice of better health behaviors in early life
(Calvin, Batty, Lowe, & Deary, 2011).

Leventhal et al. suggested that a combination of these factors could be used to predict and
promote health-related behaviour.

Barriers to Health Behaviour – from extra reading

Determinants of Health Behaviour ​

Several processes affect people’s health habits, and one factor is heredity. Genetic factors
influence some health-related behaviors,

Learning
People also learn health-related behavior, particularly by way of operant conditioning, whereby
behavior changes because of its consequences (Sarafino, 2001). Three types of consequences are
important.

1.​ Reinforcement. When we do something that brings a pleasant, wanted, or satisfying

consequence, the tendency to repeat that behavior is increased or reinforced. A child who
receives something she wants, such as a nickel, for brushing her teeth at bedtime is more
likely to brush again the following night. The nickel in this example is a positive reinforcer
because it was added to the situation. But reinforcement can also occur in another way.
Suppose you have a headache, you take aspirin, and the headache goes away. In this case,
your headache was unpleasant, and your behavior of taking aspirin removed it from the
situation. The headache is called a ‘‘negative’’ reinforcer because it was taken away
(subtracted) from the situation. In both cases of reinforcement, the end result is a desirable
state of affairs from the person’s point of view.

2.​ Extinction. If the consequences that maintain a behavior are eliminated, the response
tendency gradually weakens. The process or procedure of extinction exists only if no
 alternative maintaining stimuli (reinforcers) for the behavior have supplemented or taken the
place of the original consequences. In the above example of toothbrushing behavior, if the
money is no longer given, the child may continue brushing if another reinforcer exists, such
as praise from her parents or her own satisfaction with the appearance of her teeth.

3.​ Punishment. When we do something that brings an unwanted consequence, the behavior
tends to be suppressed. A child who gets a scolding from his parents for playing with
matches is less likely to repeat that behavior, especially if his parents might see him. The
influence of punishment on future behavior depends on whether the person expects the
behavior will lead to punishment again. Take, for example, people who injure themselves
(punishment) jogging—those who think they could be injured again are less likely to resume
jogging than those who do not.

People can also learn by observing the behavior of others—a process called modeling (Bandura,
1969, 1986). In this kind of learning, the consequences the model receives affect the behavior of
the observer. If a teenager sees people enjoying and receiving social attention for smoking
cigarettes, these people serve as powerful models and increase the likelihood that the teenager
will begin smoking, too. But if models receive punishment for smoking, such as being avoided
by classmates at school, the teenager may be less likely to smoke.

If a behavior becomes firmly established, it tends to be habitual; that is, the person often
performs it automatically and without awareness, such as when a smoker catches a glimpse of a
pack of cigarettes and absentmindedly reaches, takes a cigarette from the pack, and lights up.
Even though the behavior may have been learned because it was reinforced by positive
consequences, it is now less dependent on consequences and more dependent on antecedent cues
(seeing a pack of cigarettes) with which it has been linked in the past (Sarafino, 2001).
Antecedents are internal or external stimuli that precede and set the occasion for a behavior.

Because habitual behaviors are hard to change, people need to develop well behaviors as early as
possible and eliminate unhealthful activities as soon as they appear. Families play a major role in
children’s learning of health-related behaviors (Baranowski & Nader, 1985). Children observe,
for example, the dietary, exercise, and smoking habits of other family members and may be
encouraged to behave in similar ways. Children who observe and receive encouragement for
healthful behavior at home are more likely than others to develop good health habits.

Social, Personality, and Emotional Factors

Many health-related behaviors are affected by social factors (Baranowski & Nader, 1985;
Thirlaway & Upton, 2009). Friends and family can encourage or discourage children’s practice
of health-related behaviors, such as smoking and exercising, by providing consequences, such as
praise or complaints, for a behavior; modeling it; and conveying a value for good health. These
social processes may also lead to gender differences in health behavior. Very different patterns of
encouragement may lead boys more than girls toward healthful physical activity. Two other
factors that are linked to health-related behavior are the person’s personality and emotional state,
particularly stress. Conscientiousness— the tendency of a person to be dutiful, planful,
organized, and industrious—is a personality characteristic that is associated with practicing​
many health behaviors.

Perception and Cognition

The symptoms people experience can influence their health-related behaviors. The way they
react varies from ignoring the problem to seeking immediate professional care. Certainly, when
the perceived symptoms are severe almost everyone who has access to a health care system will
try to use it (Rosenstock & Kirscht, 1979). When symptoms are not so severe, people often
adjust their health habits, such as by limiting certain foods and drinks, to meet the needs of the
health problem as they see it (Harris & Guten, 1979).

Cognitive factors play an important role in the health behaviors people perform. People must
have correct knowledge about the health issue and the ability to solve problems that arise when
trying to implement healthful behavior, such as how to fit an exercise routine into their
schedules. People also make many judgments that have an impact on their health. They assess
the general condition of their health, such as whether it is good or bad, and make decisions about
changing a health-related behavior: But the judgments they make can be based on
misconceptions, as when hypertensive patients overestimate their ability to sense when their
blood pressure is high (Baumann & Leventhal, 1985; Brondolo et al., 1999; Pennebaker &
Watson, 1988). The potential harm in their erroneous beliefs is that patients often alter their
medication-taking behavior or drop out of treatment on the basis of their subjective assessments
of their blood pressure. Clearly, beliefs are important determinants of health behavior.

Another important belief that can impair health behavior is called unrealistic optimism. Neil
Weinstein (1982) studied how optimistically people view their future health by asking them,
‘‘Compared to other people your age and sex, are your chances of getting lung cancer greater
than, less than, or about the same as theirs?’’ He then had students fill out a questionnaire with a
long list of health problems, rating each problem for their own likelihood of developing it,
relative to other students of the same sex at the university. The results revealed that the students
believed they were less likely than others to develop three-quarters of the health problems listed,
including alcoholism, diabetes, heart attack, lung cancer, and venereal disease. They believed
they were more susceptible than other students to only one of the health problems—ulcers. In a
later study, Weinstein (1987) used similar questions in a mailed survey with 18- to 65-year-old
adults in the general population. He found that these people were just as unrealistically
optimistic as the students and that this optimism is based on illogical ideas—for instance, that
they are at lower risk than other people if the health problem occurs rarely and has not
happened to them yet. These factors do not affect one’s risk relative to that of others.

Studies of optimistic and pessimistic beliefs are important for three reasons. First, they have
revealed that feelings of invulnerability are not a unique feature of adolescence (Cohn et al.,
1995). Second, people who practice health behaviors tend to feel they would otherwise be at risk
for associated health problems (Becker & Rosenstock, 1984). This means that people with
unrealistically optimistic beliefs about their health are unlikely to take preventive action. Third,
health professionals may be able to implement programs to address these beliefs in helping
people see their risks more realistically.

Theories of Health Behaviour

There are various frameworks, which highlight the lifestyle behaviours that impact health and
elucidate on the various aspects of behaviour change
Health Belief Model
Among the initial attitude theories that focus on why people practice health behaviours is the
health belief model (Hochbaum, 1958; Rosenstock, 1966). A fundamental principle is that
people have choices – and are proficient in evaluating situations and making competent
decisions about their health, when presented with appropriate information (Glanz, Rimer &
Lewis, 2002). This model argues that the probability of a person participating in a health
behaviour is dependent upon two factors: a person’s perception of a personal health threat, and
their consideration of a particular health practice as being effective in terms of threat-reduction.

Taking the example of tobacco use, the identified health behaviour is smoking cessation, where
an individual is likely to move towards action and stop this unhealthy behaviour if they perceive
a significant health threat and are aware of health practices that can reduce this threat.

The figure shows that one assessment pertains to the threat the person feels regarding a health
problem, and the other weighs the pros and cons of taking the action.

The factors that influence the aspect of perceived threat are as follows:

1. Perceived seriousness or severity of the health problem. Herein, individuals carry out a
subjective evaluation of the seriousness of the organic and social consequences related to the
 state or condition. The more serious they believe its effects will be, the more likely they are to
preventiveundertake preventive action for risk mitigation.
action

The factor of perceived seriousness can relate to the fact that smoking causes fatal diseases such
as cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary
disease (COPD). It also increases the risk of tuberculosis, certain eye diseases, and problems of
the immune system (CDC, 2014). In order to adopt a health behaviour, the smoker needs to have
appropriate and accurate information surrounding the various threats of this behaviour.
Additionally, the individual’s level of perceiving smoking as a health hazard will determine the
degree of preventive action undertaken. In other words, a smoker’s belief patterns regarding
seriousness of various smoking-related conditions and their possible consequences can stimulate
precautionary action.

E.g., How people are perceiving the seriousness of COVID, many people are considering it
serious and many aren’t those who perceive it to be serious they are taking desired precautions
and the rest aren't. Some people are perceiving it to be serious only when a someone in their
close relationship or surrounding have contracted the disease. Also, people are considering it to
be serious because of the attached mental stigma associated to it, the isolation they may face.

2. Perceived susceptibility to the health problem, wherein people assess the possibility of them
developing a certain problem. Here also, a higher amount of risk makes them perceive it as a
threat and they are more likely to take action.

The perceived seriousness guides the individual during the perceived susceptibility stage, during
which they recognise a personal vulnerability of developing a health condition, as a result of
smoking. Furthermore, witnessing a known individual suffer from a smoking-related ailment like
lung cancer can increase the perceived threat, subsequently increasing the likelihood of them
engaging in the health behaviour of smoking cessation.

E.g., High comorbidity, diabetes, pregnant women, old age people, children are more vulnerable,
low immunity, front line workers, smoking, asthmatic people, lung issues, bronchitis.
3. Cues to action serve as important reminders to take actions that are consistent with an
intention. They can take various forms, such as advertising and interactions with health
professionals, family members and/or other social network groups.

The availability of important prompts inevitably aids the process of decision-making. Cues to
action can be external, for example, an assessment by a health care professional and their
suggestions towards adoption of a healthier lifestyle to improve immunity. This initial
assessment from a professional is further highlighted by family members, wherein they
pressurise the smoker to engage in smoking cessation behaviour. These cues to action can also be
internal, such as the presence of an underlying illness that is caused or aggravated by smoking.
Overall, cues to action serve as strategies to activate the readiness to quit smoking.

E.g., Ringtone, caller tune, ads, billboards, news, govt. sanitization, free covid testing

An additional component of this model is self-efficacy, which focuses on an individual’s belief in

their ability to make a health-related change. A stronger level of efficacy translates into an
increased amount of effort and persistence, which in this case would mean that the smoker
believes that they can quit smoking.

In relation to weighing the pros and cons of performing a health behaviour, people assess the
benefits and the barriers they perceive in taking action. This assessment is influenced by
specific proximal factors and an individual’s overall health motivation. The end-result of
weighing the benefits against the barriers is an assessed sum: the degree to which taking the
action is more beneficial than not taking the action. Furthermore, the assessed sum takes
cognizance of the perceived threat of illness or injury to determine the likelihood of preventive
action.

Even though the behaviour of continuing smoking provides an increased sense of immediate
gratification and stress reduction, due to the perceived threat of illness, the benefits are likely to
outweigh the situational barriers. These barriers may include the side effects associated with
quitting smoking, such as irritability, headaches and intense nicotine cravings. Even though
cessation can be a challenge, there are a number of benefits related to physical and mental
health. Furthermore, the smoker is acquainted with the health problems related to smoking and
also has the first-hand experience of witnessing a known individual suffer from a
smoking-related ailment. This individual’s perception of benefits, barriers and threat is therefore
likely to promote the adoption of smoking cessation, wherein they will develop realistic
strategies to overcome any barriers to health-promotion.

For the health behavior of getting a physical checkup, the barriers might include financial
considerations (‘‘Can I afford the bills?’’), psychosocial consequences (‘‘People will think I’m
getting old if I start having checkups’’), and physical considerations (‘‘My doctor’s office is
across town, and I don’t have a car’’). This assessed sum combines with the perceived threat of
illness or injury to determine the likelihood of preventive action. E.g., perceived benefits and
costs of wearing masks.

According to the health belief model, these processes apply to primary, secondary, and tertiary
prevention activities. The theory also proposes that characteristics of individuals can influence
their perceptions of benefits, barriers, and threat. These factors include the person’s age, sex,
race, ethnic background, social class, personality traits, and knowledge about or prior contact
with the health problem. Thus, for example, people who are poor are likely to see strong barriers
to getting medical treatment to COVID-19. Working people are likely to perceive a substantial
risk of contracting COVID. And elderly individuals who have diabetes or a heart disease are
more likely to perceive a personal threat of COVID than young adults who are relatively well.

Implications: A number of studies have made use of the health belief model to increase
perceived risk and perceived effectiveness, in order to modify a broad range of health habits
ranging from health screening programs to smoking (e.g., Goldberg, Halpern-Felsher, &
Millstein, 2002). For instance, compared to people who do not take prescribed medication as
directed or do not stick with dietary programs, those who do are more likely to believe they
would be susceptible to the associated illness without the behavior and that the benefits of
protective action exceed the barriers. Perceived risk (susceptibility) and perceived barriers appear
to be critical elements for predicting health behavior, such as wearing masks, using sanitizers,
etc. but strong barriers may have more influence than risk. Research has also supported the role
of cues to action—for instance, individuals are more likely to maintain social distancing if they
see a billboard about it.

Limitations: However, despite the model’s success, it has does have some limitations.
One shortcoming is that since it rests on the fact that people consciously process information
around them, it does not account for health-related behaviors people perform habitually, such as
tooth brushing—behaviors that probably originated and have continued without the person’s
considering health threats, benefits, and costs. It places a lot of emphasis on the individual, but
does not consider other factors such as environmental and social disadvantages.

Another problem is that there is no standard way of measuring its components, such as perceived
susceptibility and seriousness. Different studies have used different questionnaires to measure
the same factors, thereby making it difficult to compare the results across studies. The 3
components of the model are also not conceptually explained - if they have a multifactorial or
linear relationship, etc. There is also an absence of a role for emotional factors such as fear and
denial that may play a role in determining health behaviours. Additionally, it has been suggested
that alternative factors may predict health behaviour, such as outcome expectancy and
self-efficacy which were not accounted for in the theory.

Yet another weakness is that the model assumes people think about risks in a detailed fashion,
knowing what diseases are associated with different behaviors and estimating the likelihood of
becoming seriously ill. In reality, people may modify their lifestyles, such as reducing coffee
consumption, for very vague reasons, such as, ‘‘My doctor says coffee is bad for you.’’ People
appear to be especially inaccurate in estimating the degree of increased risk when the risks of
illness, such as cancer, increase beyond moderate levels.
Schwarzer (1992) has further criticized the model for its static approach to health beliefs and
suggests that within the Health Belief Model, beliefs are described as occurring simultaneously
with no room for change, development or process. Leventhal et al. (1985) have argued that
static approach to HBM
perception of symptoms rather than individual factors

health-related behaviour is due to the perception of symptoms rather than to the individual
factors as suggested by the Health Belief Model.

Although there is much contradiction in the literature surrounding the Health Belief Model,
research has used aspects of this model to predict screening for hypertension, screening for
cervical cancer, genetic screening, exercise behaviour, decreased alcohol use, changes in diet and
smoking cessation.

Stages of Change Model/Transtheoretical Model of Behaviour Change

A health habit is changed gradually, where people go through a number of stages while they are
trying to change their health behaviours (Prochaska, 1994; Rothman, 2000). Based on this
framework, J. O. Prochaska and colleagues (Prochaska, 1994; Prochaska, DiClemente, &
Norcross, 1992) developed the transtheoretical model of behaviour change. This model assesses
the stages and processes of behaviour change and propose treatments, goals and interventions for
each stage. Three important elements of behaviour change encompass: the readiness to change
(availability of resources and knowledge that contribute to a lasting change); barriers to change
(factors that prevent or inhibit the process of change) and likelihood of relapse (triggers that
cause one to return to a former behaviour).

According to the stages of change model, people in one stage show different psychosocial
characteristics from people in other stages. As this model describes these important stage-wise
components, it enables the formulation of an intervention to match strategies to the person’s
current needs, while also promoting advancement to the next stage (Perz, DiClemente, &
Carbonari, 1996; Prochaska, DiClemente, & Norcross, 1992).

The following figure shows the model’s five stages of intentional behavior change and how they
spiral toward successful change.
The stages of change are as follows:
Precontemplation: At this stage, a person has no intention of changing their behaviour. In some
instances, they may be unaware of their problems, may not understand that their behaviour is
self-harming, or they can be under-informed about the consequences of their actions. Sometimes
people in the precontemplation phase seek treatment if they have been pressured by others to do
so. Not surprisingly, these people often revert to their old behaviors and so make poor targets for
intervention.

During the precontemplation phase, individuals who smoke would have no intention to quit or
reduce the frequency of smoking in the foreseeable future. Nicotine stimulates the pleasure
centre of the brain and creates an increasing dependence as the body gets used to the substance,
therefore making it difficult to give up the addiction. The positive connection between smoking
tobacco and stress alleviation (Parrott, 2002) reiterates the cycle of dependence. There may be a
lower amount of awareness in relation to the risks associated with smoking or in some cases,
previously failed attempts to quit smoking, which further affects the probability of engaging in
smoking cessation.
Contemplation: This is when people are aware that a problem exists, however, they are not
committed to take action. Interventions that are particularly aimed at increasing receptivity to
behaviour change can be beneficial at this stage (Albarracín, Durantini, Earl, Gunnoe, & Leeper,
2008).

At this stage, smokers become aware of the various risks of smoking but consciously choose to
not immediately perform the health behaviour of smoking cessation. The individual considers
changing their behaviour within the next 6 months. They try to gather appropriate and accurate
information, and carry out a cost-benefit analysis (also known as decisional balance) of
behaviour change. Contemplators may also be aware of the benefits of quitting, yet their reason
for continuing with the addiction outweighs such benefits.

Preparation: After contemplation, an individual intends to change their behaviour but have not
yet done it successfully. They may have modified the target behaviour but are not committed to
eliminate the behaviour altogether.

After coming to terms with the realities of implementing change, an individual will make the
commitment to quit smoking. This individual may make some lifestyle changes as they begin to
prepare for action. Social support and incentives can be considered as an important factor at this
stage, as it will lead to increased encouragement and reaffirmation of the health benefits of
smoking cessation. To begin with, an individual might choose to modify the habit of smoking
rather than eliminating the habit altogether. This may include reduction in smoking frequency or
switching to less harmful brands.

Action: The action stage occurs when people modify their behaviour, lifestyle and environment
to overcome the problem. Action necessitates the commitment of time and energy in order to
make real and lasting behaviour change.

Moving from preparation to action, the individual overcomes the barriers of behaviour change
and successfully adopts smoking cessation. An individual may use short-term rewards to sustain
their motivation, and analyse their behaviour change efforts in a way that enhances their
short-term rewards to sustain motivation, modify...helps them gain self -and restructure cues, imperative to overcome sudden
challenges.

self-confidence. They may also restructure cues with the intention of continuing the behaviour.
Furthermore, it is imperative to overcome sudden challenges to smoking cessation, while
keeping in mind the long-term benefits of the health behaviour.

Maintenance: In this stage, people make an effort to prevent relapse and consolidate the gains
they have made. Since relapses are a common occurrence in any behaviour change (LaMorte,
2009), this stage model is conceptualized as a spiral. effort to prevent relapse

Within the maintenance stage, as motivation and confidence increase, individuals would ideally
maintain the health habit for more than 6 months and incorporate it into their overall lifestyle.
The aspect of continued cessation focuses on the individual’s satisfaction with cessation. If there
is an increased temptation to smoke or if the pros of smoking begin to outweigh its costs, the
individual is likely to relapse from the maintenance state. The incidence of relapse is often
expected, because of the addictive nature of nicotine and the difficulty of adequately completing
all the tasks in an attempt to quit (Diclemente, 2005).

These prescribed stages do not always occur in a linear fashion but the theory describes
behaviour change as dynamic and not ‘all or nothing’. People’s stages may regress, too:
someone who reached the action stage and began to change may fail, drop back to a less
advanced stage, and repeat the process of advancing toward change. People who justify
continuing an unhealthy behavior tend to progress through the stages slowly.

Implications. At each stage, particular types of interventions may be most appropriate.

Specifically, providing people in the precontemplation stage with information about their
problem may move them to the contemplation phase. To move people from the contemplation
phase into preparation, an appropriate intervention may induce them to assess how they feel and
think about the problem and how stopping it will change them. Interventions designed to get
people to make explicit commitments as to when and how they will change their behaviour may
bridge the gap between preparation and action. Interventions that emphasize providing self-
reinforcement, social support, stimulus control, and coping skills should be most successful
with individuals already moving through the action phase into long-term maintenance.
People can be helped to advance through the stages. Two ways that help are having them:
●​ Describe in detail how they would carry out the behavior change (Armitage, 2006).
●​ Plan for problems that may arise when trying to implement the behavior change (Armitage,
2008).

Another way uses a unique feature of the stages of change model: it describes important
characteristics of people at each stage, enabling an intervention to match strategies to the
person’s current needs in order to promote advancement to the next stage (Perz, DiClemente,
& Carbonari, 1996; Prochaska, DiClemente, & Norcross, 1992). Thus, a potential implication of
this model is that healthcare providers can use it to tailor behavior change interventions, as well
as prioritize which behaviors to target for change. For example, a nurse provides care to an
elderly woman with heart disease who doesn’t exercise, even though her physician advised her to
do so. If she is at the precontemplation stage, the nurse might talk with her about why exercise
would help her and not exercising would harm her physically, for instance, and have her generate
ways that would improve her general functioning. The goal at this point is just to get the person
to consider changing the behavior. If she is at the contemplation stage, the goal might be to help
her decide to change soon. Discussing the benefits and barriers she perceives in exercising,
finding ways to overcome barriers, and showing her that she can do the physical activities would
help.

The stages of change model is a very useful theory and a lot of studies have confirmed that
people at higher stages are more likely than others to succeed at adopting healthful behaviors.
Research has also confirmed the processes the model describes as leading to advancement or
regression within the stages (Schumann et al., 2005) and the value of matching an intervention to
people’s stage of readiness to improve its success in changing unhealthful behaviors, such as
smoking (Spencer et al., 2002).

Limitations. There are also certain limitations of the Transtheoretical Model of Behaviour
Change.
Human behaviour is “too multifaceted to fit into separate, discrete stages” and “stage thinking
could constrain the scope of change-promoting interventions” (Bandura, 1997). The concept of a
‘stage’ is not a simple one as it includes many variables: current behaviour, quit attempts,
intention to change and time since quitting. The time period for each stage is arbitrary; the
definitive time span or variable time frame is likely to differ with relation to personality,
behaviour and treatments.

Literature also suggests that stages represent a linear measurement for readiness to change.
Precontemplation, contemplation and preparation could be a continuum to arrive from intention
formation to action. (Bandura, 1997; Kraft et al., 1999; Sutton, 2000; Sutton, 2001). The absence
of qualitative differences between stages could either be due to the absence of stages or because
the stages have not been correctly assessed and identified. Changes between stages may happen
so quickly as to make the stages unimportant.

Interventions that have been based on the stages of change model may work because the
individual believes that they are receiving special attention, rather than because of the
effectiveness of the model per se. Most studies based on the stages of change model use
cross-sectional designs to examine differences between different people at different stages of
change. Such designs do not allow conclusions to be drawn about the role of different causal
factors at the different stages (i.e., people at the preparation stage are driven forward by different
factors than those at the contemplation stage). Lastly, this model does not account for emotional
factors that may also be relevant to effect change.

Theory of Planned Behaviour

The theory of planned behaviour is a social cognition-based model of health. Social cognition
models examine factors that predict behaviour and/or behavioural intentions and in addition
examine why individuals fail to maintain a behaviour to which they are committed. Social
cognition theory was developed by Bandura (1977, 1986) and suggests that behaviour is
governed by expectancies, incentives and social cognitions. Expectancies include:
●​ Situation outcome expectancies: the expectancy that a behaviour may be dangerous
●​ Outcome expectancies: the expectancy that a behaviour can reduce the harm to health
●​ Self-efficacy expectancies: the expectancy that the individual is capable of carrying out the
desired behaviour

Although social cognition models regard individuals as information processors, there is an

important difference between cognition models and social cognition models – social cognition
models include measures of the individual’s representations of their social world. Accordingly,
social cognition models attempt to place the individual within the context both of other people
and the broader social world. This is measured in terms of their normative beliefs.

Theory of Planned Behaviour given by Azjen helps form a direct link between health beliefs
and behavior (1985). At the core of this theory lies the belief that intentions are the best
predictor of the behaviour people will engage in. According to this theory, a health behavior
is the direct result of a behavioral intention. Behavioral intentions are themselves made up of
three components: attitudes toward the specific action, subjective norms regarding the action,
and perceived behavioral control.

a. Attitudes toward the action center on the likely outcomes of the action and evaluations of
those outcomes. It is a judgement of whether a behaviour is good or not. It is based on two
expectations - the likely outcome of the behaviours and the evaluation of it, that is, if it will be
rewarding.

b. Subjective norms are what a person believes others think that person should do (normative
beliefs) and the motivation to comply with those normative beliefs.

c. The third component of behavioural intention is perceived behavioral control. It is the

perception that one can perform the action and that the action will have the intended effect; this
component of the model is similar to self-efficacy.

Self-efficacy has been defined by Albert Bandura as a person’s particular set of beliefs in their
own capabilities that determine how well a person can execute a plan of action in prospective
situations (Bandura, 1977). Simply speaking, self-efficacy is a person’s belief in their ability to
succeed in a particular situation. Self-efficacy is an important component within this model of
behavioural change. When a person is trying to decide if they should practice a particular health
behaviour, they appraise their efficacy on the basis of the effort it requires, complexity of the
behaviour and other aspects of the situation, such as if they will receive support from people
around them. These factors combine to produce a behavioral intention and, ultimately, lead to
behavior change.

Example
X is a final year university student who lives in a hostel surrounded by friends. X has recently
been feeling extremely stressed and anxious about his future education plans as well as career.
He finds himself spending a lot of time worrying about it, and has realized that smoking
marijuana helps him feel relaxed and relieve the stress. As a result of this, X has started
consuming marijuana in excessive amounts, such that he finds himself under its influence most
of the time. He continues consuming it still, and this behaviour can be understood under the
purview of the theory of planned behaviour in the following way.
A. Attitude:
- Belief about the Outcome - X believes that he requires marijuana in order to reduce the stress
and anxiety that he experiences due to questions about his future education and career, and it
allows him to feel relaxed. He feels good upon doing it.

- Evaluation of the Outcome - X believes that marijuana is good for him because his anxiety and
stress gets reduced, and he feels happier which is good for him. He believes it will not impact his
health negatively, but rather eventually help him feel better.

B. Subjective Norm: X sees that many people in his hostel also consume marijuana regularly,
hence he believes that what he is doing is common and nothing out of ordinary. He also believes
that everyone does what they need to do in order to feel good, and this is why he does marijuana
and it’s acceptable.

C. Perceived Behavioural Control: X believes that he has control over his body and his actions.
He is doing marijuana only for himself and because he likes it, and he can put a stop to it
whenever he wants to. He believes doing it will reduce his stress, which will eventually help him
focus on his career.

In this case, the behavioural intention is using marijuana as a way to relieve stress and anxiety,
which leads to the health behaviour of excessive marijuana consumption.

Eventually, X begins to realize that his excessive consumption of marijuana may not be as
good for him as he initially thought. He begins to notice it is impacting his physical and
mental health in several ways. He notices that even though his stress suddenly disappears
when he smokes marijuana, it returns intensely when he has not been under its influence for
some time. X also finds himself sleeping way more than usual, not being able to focus on
academics and everyday tasks and not eating properly. X finally decides to try and make a
change, and eliminate this behaviour over time, and also find more adaptive ways of dealing
with his stress and relaxing.
A. Attitude Towards the Specific Action:
- Behaviour about Outcome: X realizes the health implications of consuming marijuana. He
realizes he is constantly craving it, and that this is deteriorating his physical and mental health.
He decides to stop the consumption of marijuana to become healthier and more productive, and
find better ways of relieving stress.

- Evaluation of the Outcome: X believes that by eliminating marijuana from his lifestyle, he will
be able to focus more on his tasks and be productive. It will also help him become healthy
mentally and physically, which is more desirable in the long run than the short-term relief
provided by marijuana. He also realizes he will find more adaptive ways of relieving stress.

B. Subjective Norms: X sees how his family is concerned for him, and how his close friends
also believe that he should stop consuming marijuana. His family and friends both believe that if
he stopped his marijuana consumption and found healthier ways of dealing with stress, it would
help him achieve his true potential. He realizes how his excessive consumption of marijuana is
also seen as not acceptable in the society.

C. Perceived Behavioural Control: X realizes that even though it will be difficult and may take
some time and effort, his determination and perseverance will help him eliminate marijuana
consumption, while also finding healthier ways of dealing with stress, thus improving his overall
health and well-being.

In this case, the behavioural intention is to eliminate X’s dependence on marijuana as a way of
relieving stress and to replace it with healthier ways of dealing with it. The health behaviour here
is X finally being able to eliminate marijuana consumption from his lifestyle, while also
replacing it with healthier ways of dealing with stress, such as taking up exercise and different
hobbies that he enjoys.
Implication. The theory of planned behavior predicts a broad array of health behaviors
(McEachan,Conner, Taylor, & Lawton, 2011). Its components predict such behaviors as
condom use among students (Sutton, McVey, & Glanz, 1999), consumption of soft drinks
(Kassem &Lee, 2004) and food safety practices (Milton & Mullan, 2012). Moreover,
communications targeted to particular parts of the model, such as social norms, have been found
to change behaviors (Hennessy, 2012; Taylor, Conner, & Lawton, 2011).

The theory of planned behavior proposes that these judgments combine to produce an intention
that leads to performance of the behavior. If a person has the opposite beliefs, such as,
‘‘Exercising is a waste of time,’’ ‘‘I don’t care about my family’s opinion,’’ and ‘‘I’ll never find
time to exercise,’’ they probably wouldn’t generate an intention to exercise, and thus would
not do so. Thus, when deciding whether to practice a health behavior, people appraise their
efficacy on the basis of the effort required, complexity of the task, and other aspects of the
situation, such as whether they are likely to receive help from other people. The model also states
that perceived behavioural control can have a direct effect on behaviour without the mediating
effect of behavioural intentions.

The theory of planned behavior has generated many studies, including a meta-analysis showing
that attitudes toward a behavior, subjective norms, and perceived behavioral control
(self-efficacy) influence intentions and behavior (Conner & McMillan, 2004b). Also, a
meta-analysis of these experiments revealed that interventions can change the factors, and these
changes strongly influence intentions, which, to a much lesser extent, improve the targeted health
behaviors.

Relating it to the current context. Based on the results of many studies it was proved that
understanding of COVID-19 had significant direct effects on subjective norms and perceived
behavioral control. It could be interpreted that people can understand the virus if they are
surrounded by people who are following the preventive protocols given by the government, such
as wearing face masks outside, staying and working from home, using a hand sanitizer
frequently, and practicing social distancing during the outbreak. Moreover, if people have more
information about COVID-19 and know the right preventive measures, they are more confident
about their ability to stay away from it.

Limitations
The theory also has some limitations.
One problem is that intentions and behavior are only moderately related—people do not always
do what they plan (or claim they plan) to do. Hence this intention-behaviour gap reduces the
predictive value of the theory. However, by proper planning and effort, this gap between
intentions and behaviour can be reduced. The time frame between "intent" and "behavioral
action" is not addressed by the theory. It also does not account for other variables that factor into
behavioral intention and motivation, such as fear, threat, mood, or past experience.

This theory has also received criticism for assuming that behaviour is the consequence of a linear
decision-making process, and does not take into account the fact that it can change over time. It
assumes the person has acquired the opportunities and resources to be successful in performing
the desired behavior, regardless of the intention. While it does consider normative influences, it
still does not take into account environmental or economic factors that may influence a person's
intention to perform a behavior.

While the added construct of perceived behavioral control was an important addition to the
theory, it doesn't say anything about actual control over behavior. Schwarzer (1992) has
criticized this model for its omission of a temporal element and argues that the it does not
describe either the order of the different beliefs or any direction of causality.