MODELS OF
Behavior and Health Education helps the reader achieve greater understanding of theories that focus primarily on individual health behavior. Ultimately, researchers and practitioners may combine some of these theories with theories that focus on other levels of intervention. Indeed, as discussed throughout this book, combinations of theories are becoming the norm in health behavior change interventions.
Lewin’s seminal field theory (1935) was one of the early and most far-reaching theories of behavior, and most contemporary theories of health behavior owe a major intellectual debt to Lewin. Theories that focus on barriers and facilitators to behav- ior change and those that posit the existence of stages are rooted in the Lewinian tra- dition. During the 1940s and 1950s, researchers began to learn how individuals make decisions about health and what determines health behavior. In the 1950s, Rosen- stock, Hochbaum, and others, from their vantage point at the U.S. Public Health Ser- vice, began their pioneering work to understand why individuals did or did not participate in screening programs for tuberculosis. This and related work led to the Health Belief Model (HBM). In the last twenty years, considerable progress has been made in understanding determinants of individuals’ health-related behaviors and ways to stimulate positive behavior changes. Value expectancy theories, which include both the HBM and the Theory of Reasoned Action (TRA) and its companion, the Theory of Planned Behavior (TPB), matured during this time.
The Transtheoretical Model (TTM), also known as the Stages of Change (SOC) Model, which grew initially from the work of Prochaska, DiClemente, and colleagues, was developed in the late 1970s and 1980s and matured in the 1990s. Weinstein’s Pre- caution Adoption Process Model (PAPM) is the final chapter in the section.
In Chapter Three, Champion and Skinner review the evolution of the HBM and the constructs that are part of its current formulation. The authors explain that the HBM is used to understand why people accept preventive health services and why they do or do not adhere to other kinds of health care regimens. The HBM has spawned thousands of health education and health behavior research studies and provided the conceptual basis for many interventions in the years since it was formulated. It has been used across the health continuum, including disease prevention, early disease detection, and illness and sick-role behavior (Becker and Maiman, 1975; Janz and Becker, 1984). It is among the most widely applied theoretical foundations for the study of health behavior change. The HBM is appealing and useful to a wide range of professionals concerned with behavioral change. Physicians, dentists, nurses, psy- chologists, and health educators have all used the HBM to design and evaluate in- terventions to alter health behavior.
In Chapter Four, Montaño and Kasprzyk discuss two value expectancy theories—
the TRA and the TPB. This family of theories has had a major influence on both re- search and practice in health behavior and health education. The TRA, as developed by Fishbein and Ajzen (1975), and its extension by Ajzen to the TPB, propose that behavioral intentions and behaviors result from a rational process of decision mak- ing. Key constructs are subjective norms and intentions to perform specific actions.
TPB also includes another construct—perceived behavioral control. These theories
have been used to intervene in many health behaviors, including having mammo- grams, smoking, controlling weight, family planning, and using condoms to prevent AIDS (Jaccard and Davidson, 1972; Ajzen and Fishbein, 1980; McCarty, 1981; Lowe and Frey, 1983). The chapter also introduces and describes the Integrated Behavioral Model (IBM)—a further extension of the TRA and TPB, which grew out of increased interest in theory integration.
In Chapter Five, Prochaska, Redding, and Evers review TTM (or SOC), developed by Prochaska, DiClemente, and colleagues (Prochaska, DiClemente, Velicer, and Rossi, 1993). Over a relatively short time, this theory achieved widespread use and accept- ance by researchers and practitioners in health education and health behavior. The authors present the key components of the theory: concepts of stage, decisional bal- ance, pros and cons, and the processes of change that characterize people in different stages. They discuss the fact that to have a public health impact, increasingly it will be necessary for practitioners to use proactive strategies that reach out to people, rather than relying on reactive strategies that ultimately reach few individuals.
Chapter Six (the PAPM) is authored by Weinstein, who developed the PAPM, and his colleagues, Sandman and Blalock. Like the TTM (or SCM), PAPM is a stage model. As discussed in the Perspectives chapter (Chapter Seven), there are major dif- ferences between these two stage-based approaches. The building blocks of PAPM are the steps along a path from lack of awareness about a precaution (such as using condoms to protect against AIDS), to decision making, and then, in some cases, to adoption of the recommended precaution, initiation, and maintenance.
Taken together, these four chapters provide researchers and practitioners alike with an introduction to widely used theories of health education and health behavior.
The different theories are suitable to different problems and populations. Some are more well-developed and easier to use and apply than others. But each has made an important contribution to our understanding of health behavior. Each deserves to be read, studied, and used. Further refinement of the theories will result from their use in research and practice. The distinguished authors have provided chapters that should be accessible to a wide range of health professionals.
Chapter Seven provides a review of the individual chapters, highlights similarities and differences, and identifies some important future challenges and new directions.
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