Chapter 3 Health Behavior and Health Behavior Theory
Clear understandings of health behavior and health behavior theory are requisites
to the design of effective health promotion and disease prevention programs in the
worksite. All too often in worksites, and other program implementation venues,
simplistic programs are implemented because corporate decision makers do not
understand the complexity of human health behavior and all the factors that influence
health behavior. As a result, “Just Say No” campaigns are thought to be effective
substance abuse prevention efforts, a blood pressure screening is seen as a resolution to
hypertension concerns, and health risk assessments, featuring individualized computer
printouts, will reduce medical care costs. Approaches like this deny the complexity of
health behavior, the human condition and the environmental, social and policy factors
that influence health and health behavior.
The purpose of Chapter II is to provide a basic background on determinants of
health and health behavior and contemporary health behavior theories applicable adult
and worksite populations. This discussion is not meant to be exhaustive. Rather, an
overview will be provided with an eye toward helping the program planners appreciate
the complexity of health behavior and the nature of the task when developing programs to
shape behavior, change behavior, and maintain behavior. Examples related to adults and
worksite health promotion application will support this discussion.
Health has been defined in many ways. Health has been thought to be the absence
of disease, ability to cope and adapt one’s environment or the quality of life one
experiences. For the purpose of this discussion, William Zimmerli’s definition of health
as a “personal, positive quality of life” will be used. Dr. Zimmerli believed that each
individual determined what a positive quality of life meant to them. This allows for both
intra-individual differences within the person across the lifespan and inter-individual
differences at any point in time. Intra-individual differences support the notion that
people can change their perception of what constitutes a positive quality of life for them.
We all reset our goals, expectations, and beliefs across our life course on a host of
factors, and health is no exception. Behaviors we embraced as college students are “no
longer” cherished once we enter the workforce, and what constitutes a positive quality of
life changes once we marry and have children.
Inter-individual differences reflect diversity of human thoughts and preferences.
One person’s quality of life is enhanced by preparing to run a marathon while another’s is
enhanced by maintaining a fruitful garden. Although we may place values on the same
behaviors that may enhance one’s quality of life (ie. smoking, overeating, sky diving,
cycling without head protection), we all can observe the diversity of ways in which
people seek to develop and maintain a personal, positive quality of life. Keep in mind
that social norms often play a role in these intra and inter individual differences. In the
1950s, seldom would you observe adults out jogging or cycling. This type of behavior
was not the norm. Today outdoor physical activity is common, socially supported, and
encouraged in communities.
In essence, health defined as a personal, positive quality of life is a consistent
construct. Those factors that may be considered quality of life indicators often change
Clear definitions of behavior and health behavior also help us to design health
promotion and disease prevention interventions. Green and Kreuter define behavior as
“an action that has a specific frequency, duration and purpose whether conscious or
unconscious.” This definition implies that a behavior is observable and measurable.
Although we may not be able to observe all behaviors of individuals all the time, a
behavior is purposeful and does occur. LaLonde defines a health behavior as “an
aggregation of decisions by individuals which affect their health and over which they
have more or less control.” This definition implies that health behavior is not one
decision but a series of decisions that yield a lifestyle or worldview for the individual.
This definition also implies that health behaviors tend to be interrelated. The marathon
runner is not likely to be a smoker, and diet and weight conscious people tend not to
abstain from exercise. This notion supports the notion that a health behavior change for
one’s behavior is often linked to other behaviors. So, as a person develops and maintains
an enhanced regimen of physical activity, they are often more likely to modify their diets
and sleep habits to support and augment their new physically active lifestyle.
Interestingly, a study conducted by Eddy and colleagues to examine the impact of a
corporate sponsored exercise programs for employees found, among other findings, that
employees who initiated and maintained participation in the program started to use their
car safety belts more than non-participants (keep in mind, this study was conducted
before safety belt laws had been enacted and enforced in most states). When a focus
group of employee participants in the exercise program were asked why safety belt use
had increased, the employees commented that the act of changing their level of physical
activity caused them to become more health conscious in general, and using their safety
belts was simply one more thing they could do to support a healthy lifestyle.
The definitions of behavior and health behavior also imply a level of volitional
control over the behavior. In other words, the person is in control of their behaviors and
can make conscious decisions. Although there are a variety of social, environmental,
economic, and political factors that influence health behavior, a behavior is not a
behavior unless we have control over the action. For example, most automobile
“accidents” are not accidents that are out of our control, but rather “unintentional
injuries” over which we have control. We can say we were in an accident when, in
actuality, driving at excessive speeds, driving under the influence, cell phone use, other
distractions, and failure to properly maintain the vehicle were antecedent behaviors which
led to the collision that yield the unintentional injures. Then, failure to wear a safety belt,
another volitional behavior, may exacerbate the unintentional injury.
Determinants of Health and Health Behavior
We often look for the one best answer or the single factor that causes a problem.
Perhaps the lack for a singular explanation for what influences health and health behavior
is what frustrates many worksite decision makers as they try to solve the health and
medical care problems of employees and their dependents. As a backdrop to approach
many of the health problems of employees, it is important to understand the inter-
relationship of the many factors that determine health and help to shape healthy
For the purpose of this discussion, these factors have been divided into
environmental and personal factors (Figure 2.1), although, as you can see, these factors
are clearly interrelated. This interrelatedness of factors that influence health and health
behavior often impacts our ability to arrive at a clear causation for many health
conditions and behaviors. Figure 2.2 provides an example of the possible factors that
influence smoking and physical activity behavior and increase risk of cancer and cardio
respiratory disease that are linked to smoking. These examples are noted as “quick facts”
about smoking, physical activity and health. Figure 2.2 highlights the interrelatedness of
the determinants of health and health behavior, and examples of this nature can be easily
created for numerous health and health promotion problems and concerns (e.g. cancer
and cancer control, stress and stress management, hypertension, CVD rise factors,
nutrition, weight management, unintentional injury control, etc).
Figure 2.1 Determinants of Health and Health Behavior
Environmental Determinants Personal
Social Physical Health
Work Mental Health
Figure 2.2 Quick Facts Related to Determinant of Health and Health Behavior For
Smoking and Physical Activity
Environmental Factors Quick Facts/Smoking Quick Facts/Physical Activity
Smokers living in areas with Safe, well lighted recreation areas
Physical high levels of air pollution with good parking support
increase their risk of smoking physical activities.
Social groups and peers have Some physical activities can only
Social been shown to support the be done with teams, and co-
initiating of smoking behavior workers support physical activity.
and continued smoking.
Worksites with properly Providing access and supportive
designed and enforced policies at the worksite will
Work environmental tobacco smoke increase physical activity.
policies have lover levels of
smoking among employees.
If parents smoke, there is an Family support for physical
Family increased likelihood that their activity increases prevalence.
children will smoke.
Appropriate and enforced state
and community ordinances
Community (e.g. sales to minors, smoking See Physical factors above.
in restaurants, etc.) influence
Personal Factors Quick Facts/Smoking Quick Facts/Physical Activity
The respiratory and immune From a genetic perspective, some
systems for some individuals people do not benefit from
Heredity are better able to handle smoke physical activity and/or should not
and all its components (e.g. engage in certain types of
Tar, Nicotine, CO, etc.) activities.
People who engage in regular Physical health and well-being
Physical Health physical activity tend not to impacts the ability to perform
smoke. some activities.
Smoking may help boost People who have a regular
Mental Health energy for some smokers and physical activity regimen can
relax others. Smokers often better handle stressful situations.
Almost all smokers know the Skills needed to safely engage in
Knowledge health consequences of physical activity can be learned.
“It’s difficult to stop smoking” Attitudes such as “exercise is
and “I’ll quit before I get ill” work” and “physical activity
Attitudes are attitudes that support relaxes me” influence behavior.
Environments and social Worksites where physical activity
Practices/Norms groups support smoking is the norm have more employees
behavior. practicing physical activity.
Most people quit smoking cold
Skills turkey, but for other smoking See Knowledge above.
cessation and behavior change
skills are helpful.
Corporate culture and other worksite related environmental concerns have been
discussed in Chapter I. For the purpose of this discussion, basic definitions of
environmental and personal factors that influence health and health behavior will be
briefly discussed below.
Physical Environment- Air, water, climate, land, noise, lighting, and
heating/cooling factors that impact health and health behaviors.
Social Environment- Coworkers, friends, social structures and
organizations that influence health and health behavior.
Work Environment- The culture, norms, policies, values and
supported factors of worksites either encourage or discourage heath
behaviors and influence health status in numerous ways.
Family Support- Health and other behaviors are learned and
supported in families.
Community Environment- Community policies, enforcement of
regulation, parks and regulation facilities, cultural events, etc can
influence health behaviors and, in some cases, health.
A variety of personal factors can influence health and health behaviors. As can be
noted from a quick review of Figure 2.2, these factors are often interrelated.
Heredity- Genetic predisposition determines potential life span, body
type, resistance to certain disease, and other physical body functions.
Physical Health- Our physical health, at any point in time, will
influence our overall quality of life.
Mental Health- Levels of mental health and well-being impacts our
attitudes and physical health in many ways.
Knowledge- Awareness of health problems and concerns is often the
first stop to changing lifestyles to improve health and well being.
Attitudes- Our beliefs and feelings, whether right or wrong, influence
our health behaviors and ultimately our health. Attitudes are often
more difficult to change than knowledge or behavior.
Practice/Norms- The prevailing behaviors and norms in companies
and communities influence the behaviors of employees and
Skills- Many successful approaches to help people adopt or maintain
healthful behaviors require skill development. These skills are often
Obviously, a thorough discussion of the environmental and personal factors that
influence health and health behavior is not possible in this text. Suffice to say that a basic
understanding of all the factors that influence health and health behavior will help the
program planner develop a more realistic perspective of all the factors that need to be
considered when developing health promotion and disease prevention programs for adult
and community populations. You’ll see many of these determinants of health and health
behavior in the discussion of health behavior theory that follows.
Health Behavior Theory
Glanz defines a theory as “a systematic way of understanding events or situations.
It is a set of concepts, definitions and propositions that explains or predicts these events
or situations by illustrating the relationships between variables” (p 4). In the design of
worksite health promotion programs, the use of theory will help the program planning to
better focus on those factors that have been shown to influence the desired behaviors.
Glanz also states that health behavior theories have both explanatory and change
functions. Explanatory theory helps to determine why the problems exists or what factors
facilitate or inhibit the behavior. For example, poor dietary behavior could be related to a
lack of knowledge of nutrition, lack of healthy food choices, insufficient resources to
purchase health foods, influences from family members and peers, or a combination of all
of these factors. Change theories help program planners to be more specific about the
assumptions and theoretical underpinnings upon which their program is based.
Figure 2.3 is taken from the National Cancer Institute publication titled “Theories
at a Glance: A Guide for Health Promotion Practice” written by Karen Glanz. This
schematic highlights the reciprocal and circular nature of the relationship between
explanatory theory and exchange theory. This dynamic relationship supports the fact that
many health behaviors are both explanatory and change in nature. This notion will be
highlighted in greater detail as selected theories are discussed.
Figure 3.3 Using Explanatory Theory and Change Theory to Plan and Evaluate
y Problem Theory
Why? Situation strategies?
What can Which
about how a
As the selected theories are discussed, terms such as concepts, constructs,
variables and models will be used. Glanz provides the operational definitions of these
Concepts are the building blocks—the primary elements—of a theory.
Constructs are concepts developed or adopted for use in a particular
theory. The key concepts of a given theory are its constructs.
Variables are the operational forms of constructs. They define the way
a construct is to be measured in a specific situation. Match variables
to constructs when identifying what needs to be assessed during
evaluation of a theory-driven program.
Models may draw on a number of theories to help understand a
particular problem in a certain setting or context. They are not always
as specified as theory (p. 4).
Before providing more specific information on the selected health behavior
theories that have relevance for worksite health promotion programs, it is important to
discuss why the program planner should use theories to design and organize their health
promotion and disease prevention program activities. First, health behavior theory helps
to focus on the target behavior and the environmental context within which that behavior
occurs. You’ll note that many of the health behavior theories discussed in this chapter
require an assessment of the environmental context of the behavior and a determination
of what environmental changes may foster the targeted behavior. Second, health
behavior theory helps the program planner to answer the why? what? and how?
questions. Explanatory aspects of theory will help us to determine why a behavior exists
(such as, lack of readiness to change, ignorance, or a social environment that supports
that behavior). While the change theory component will provide direction on what
variables should be targeted and the potentially most effective methods to foster the
appropriate behavior change. In essence, the use of a health behavior theory helps us to
both understand the nature and scope of the behavior of interest and to identify the most
suitable participants to include in the program and methods to foster the desired behavior.
The use of theory help us focus on “the big picture.” Health behavior theory help the
program planner to stay grounded and focused on the objectives and goals of the
programming effort. And finally, the use of theory will help others replicate successful
programs. An important caveat here is that the process used to design a program, in this
case, the health behavior theory, is more important to the program planner than the actual
program that was implemented by another company. The nature of work, work life, and
employees varies between organizations, so program replication of another company’s
program may not work even if that program was successful. It would be more important
to replicate the process used by the successful program to design their program. In other
words, the process that health behavior theories force us to use will better equip us to
design, implement, and evaluate programs that meet the needs and interests of employees
in the context and environment where the employee works.
Theories of Health Behavior and Health Behavior Change
Health behavior change is complex. Clearly, there is no unified theory of health
behavior, nor one that is universally accepted by all or most health promotion
professionals. This chapter presents a brief discussion of models and theories of health
behavior. In addition, a discussion of how incentives for health behavior can be
integrated into health promotion programs is included.
It should be noted that the discussion of health behavior change theory that
follows is designed to provide the health promotion manager with a basic understanding
of these concepts. This discussion is designed to introduce the health promotion manger
to related terms and concepts.
Social Ecology of Health Promotion
The Social Ecology of Health Promotion Model presents a global perspective on
factors that influence health behavior and factors to include in worksite health promotion
interventions to more effectively help employees change health behaviors and help the
company implement policies, procedures, and environmental support activities to
influence and support healthy behaviors. The Social Ecology of Health Promotion
approach goes beyond “victim blaming” to establish interventions that focus on the
social, environmental, and economic factors, as well as individual health behaviors that
may influence health status. For example, it is easy to say that employees need to
manage their stress to be more productive and healthier employees. The Social Ecology
of Health Promotion approach encourages health promotion program planners to also
address the interpersonal, institutional, community, and policy factors that influence
From the perspective of worksite health promotion, the ecological approach
should encourage the health promotion manager to examine all possible factors that
Intrapersonal Factors – knowledge, attitudes, skills, and self-concept of the
Interpersonal Processes – Impact of family, friends, co-workers, and other
social support groups on health behavior.
Institutional Factors – Formal and informal rules and regulations that affect
Community Factors – Relationships between the organization and other
institutions and networks in the community.
Public Policy – Local, state, and national laws and policies that affect health
Table 2.4 provides an operational example of how to apply the Social Ecology of
Health Promotion Model to worksite health promotion. These examples are just the “tip
of the iceberg” of possible ways to infuse this model into the worksite health promotion
program. Suffice to say, the more factors that you address in your health promotion
program, the greater are your chances of success. The program will also be a Healthy
Company approach rather than an individual, victim blaming approach.
Table 2.4: Social Ecology of Health Promotion – Background and Worksite Examples
Concept Definition Worksite Examples
Intrapersonal Level Individual characteristics that influence Health risk appraisals
behavior, such as knowledge, attitudes, Health communication campaigns
beliefs, and personality traits. Smoking cessation programs
Health education classes (i.e. stress, physical
activity, eating well, safety belts, etc.)
Interpersonal Level Interpersonal processes and primary groups Walking clubs
that provide social identity, support, and role Including family in programs
definition. Support groups
Community Level Rules, regulations, policies, and informal Corporate policies
Institutional factors structures, which may constrain or promote Medical care provision
recommended behaviors. Preventive screening offers
Corporate culture norms and values
Community Factors Social networks and norms, or standards, Community recreation facilities
which exist as formal or informal among Public health initiatives
individuals, groups, and organizations. Support of community organizations, including
faith based groups
Public Policy Local, state, and federal policies and laws that Safety belts, DUI laws, etc.
regulate or support healthy actions and Community health policies
practices for disease prevention, early Environmental tobacco smoke regulation
detection, control, and management. OSHA Guidelines
Adapted from: National Cancer Institute, Theories at a Glance, NIH publication NO. 05-3869, September 2005.
Health Belief Model
The Health Belief Model is based on the notion that the perceived threat of
disease serves as a motivator to action. In other words, informing employees of the
likelihood that high stress levels, lack of exercise, and poor diet will lead to
cardiovascular disease in an effort to motivate employees to modify such behaviors, so
that their health risks can be reduced, provides an example of how the HBM works.
Numerous other factors have an impact on this simple paradigm, thus influencing health
Three factors from a worksite perspective would be the employees’ belief related
to the following:
Perceived susceptibility – Does the employee believe he or she is “at risk” for
the targeted health problem?
Perceived seriousness – Is the health problem thought to be serious enough to
take the required action?
Perceived efficacy – Does the employee believe that the required action will
improve health or prevent disease?
Let’s examine the use of this model to help explain one health behavior, safety
belt use, and how the HBM could be used to structure a program intervention.
History – employee’s family and social support group influences safety belt
Characteristics of the individuals – age, sex, race, and personality will
influence safety belt use.
Health communications – all types of media messages can change employees’
perceived threat of injury or death from not wearing safety belts.
Advice/action of others – In some cases, advice from others (friends, family,
and health professionals) can influence perceptions and behaviors for safety
Critical life events – A critical life event (marriage, the birth of a child, the
death of a family member) can influence safety belt use.
Public policy/social support – For some employees, initiation of a company
policy or state law mandating safety belt use will influence behavior.
The National Cancer Institute publication titled “Theories at a Glance,” (2005)
provides an excellent description of the concepts included in a contemporary depiction of
the Health Belief Model (Table 2.5). In addition, this publication also provides the
following example of how the Health Belief Model (HBM) applies to hypertension.
High blood pressure screening campaigns often identify people who are at high
risk for heart disease and stroke, but who say they have not experienced any symptoms.
Because they don’t feel sick , they may not follow instructions to take prescription
medicine or lose weight. The HBM can be useful for developing strategies to deal with
noncompliance in such situations.
Table 2.5 Health Belief Model – Background and Worksite Physical Activity Examples
Concept Definition Potential Strategies Worksite Physical Activity Examples
Perceived Beliefs about the Define what populations are at risk and Link lack of physical activity to CVD,
susceptibility chances of getting a their levels of risk obesity, high blood pressure, etc.
condition Tailor risk information based on an Link physical activity to reduced stress and
individual’s characteristics or behaviors quality life
Help the individual develop an accurate Link lack of physical activity to back pain,
perception of his or her own risk mobility, etc.
Perceived severity Beliefs about the Specify the consequences of a condition Through health risk assessment, show lost
seriousness of a and recommended action years of life
condition and its Reveal the impact of regular physical activity
consequences on delaying the onset of chronic disease
(diabetes, CVD, cancer)
Perceived benefits Beliefs about the Explain how, where, and when to take Physical benefits
effectiveness of taking action and what the potential positive Mental and emotional benefits
action to reduce risk or results will be Health benefits
Perceived barriers Beliefs about the Offer reassurance, incentives, and Lack of facilities / environment to engage in
material and assistance; correct misinformation physical activity
psychological costs of Child care, family, work constraints
taking action Cost of equipment, membership, etc.
Cues to action Factors that activate Provide “how to” information, promote Health communications
“readiness to change” awareness, and employ reminder systems Incentives
Encouragement from managers and co-
Encouragement from physicians
Self efficacy Confidence in one’s Provide training and guidance in Start with simple, do-able activities and build
ability to take action performing action from there
Use progressive goal setting Encourage goal setting activities
Give verbal reinforcement Reward the attainment of physical activity
Demonstrate desired behaviors goals
Adapted from: National Cancer Institute, Theories at a Glance, NIH publication NO. 05-3869, September 2005.
According to the HBM, asymptomatic people may not follow a prescribed
treatment regimen unless they accept that, though they have no symptoms, they do in fact
have hypertension (perceived susceptibility). They must understand that hypertension
can lead to heart attacks and strokes (perceived severity). Taking prescribed medication
or following a recommended weight loss program will reduce the risks (perceived
benefits) without negative side effects or excessive difficulty (perceived barriers). Print
materials, reminders letters, or pill calendars might encourage people to consistently
follow their doctors’ recommendations (cues to action). For those who have, in the past,
had a hard time losing weight or maintaining weight loss, a behavioral contract might
help establish achievable, short-term goals to build confidence (self-efficacy).
Stages of Change Theory
The Stage Theory as outlined by Prochaska and DiClemente (1986), provides a
simple yet comprehensive paradigm to examine how the health promotion manager may
design an implementation. The Stage Theory says that employees fall into four levels or
stages related to a health behavior or health promotion activity, and the purpose is to
move employees along the continuum from stage to stage. A wide range of information
sharing and skill activities is required for employees at each stage.
1. Pre-contemplation. Employees in this stage are not thinking about modifying
the target health behavior.
2. Contemplation. Employees in this stage are thinking about changing a health
3. Preparation. Employees tend to act on a behavior within the next 30 days and
have to take some actions to prepare for the change.
4 Action. Employees in the maintenance stage try to maintain behavior change
5. Maintenance. Employees in the maintenance stage try to maintain behavior
change across time.
The stage approach to health promotion forces the health promotion manager to
view employees and employee interests in health promotion activities realistically.
Health promotion managers need to implement many different activities to meet the
health promotion needs of employees at various levels.
Table 2.6 provides a description of the Stages of Change Model process provided
by the National Cancer Institute Publication “Theories at a Glance.” As you can note,
many of the activities to move employees from the pre-contemplation to contemplation
stages relates to health communication and personal health assessment activities.
Guidelines to design, implement, and evaluate such activities are discussed in other
chapters of the Healthy Company Handbook. In addition, Theories at a Glance (2005)
also provides an excellent example of how to apply the stages of change model to plan a
smoking cessation program for employees.
Table 2.6: Stages of Change Model – Key concepts and Worksite Examples
Stage Definition Potential Change Strategies Worksite Examples
Pre-contemplation Has no intention of taking Increase awareness of need for Health communication activities
action within the next six change; personalize information Health risk appraisals (HRAs)
months about risks and benefits Health screening / secondary
Increase perceived susceptibly and
Contemplation Intends to take action in the Motivate; encourage making Incentives
next six months specific plans Encouragement from management
Preparation Intends to take action with Assists with developing and Guidelines to change behavior
the next thirty days and has implementing concrete action Environment support approach to
taken some behavioral steps plans; help set gradual goals behavior change
in this direction Encouragement and support from
management and co-workers
Action Has changed behavior for Assist with feedback, problem Continued management and co-
less than six months solving, social support, and worker support
reinforcement Incentives for reaching behavioral
Self efficacy awareness
Environmental support for behavior
Maintenance Has changed behavior for Assist with coping, reminders, Relapse prevention techniques
more than six months finding alternatives, avoiding Continue social and environmental
slips / relapses (as applicable) support
Supportive company policies
Adapted from: National Cancer Institute, Theories at a Glance, NIH publication NO. 05-3869, September 2005
Suppose a large company hires a health educator to plan a smoking
cessation program for its employees who smoke (200 people). The
health educator decides to offer group smoking cessation clinics to
employees at various times and locations. Several months pass,
however, and only 50 of the smokers sign up for the clinics. At this
point, the health educator faces a dilemma: how can the 150 smokers
who are not participating in the clinics be reached?
The Stages of Change Model offers perspective on ways to approach
this problem. First, the model can be employed to help understand
and explain why they are not attending the clinics. Second, it can be
used to develop a comprehensive smoking program to help more
current and former smokers change their smoking behavior, and
maintain that change. By asking a few simple questions, the health
educator can assess what stages of contemplation potential program
participants are in. For example:
* Are you interested in trying to quit smoking? (Pre-contemplation)
* Are you thinking about quitting smoking soon? (Contemplation)
* Are you ready to plan how you will quit smoking? (Preparation)
* Are you in the process of trying to quit smoking? (Action)
* Are you trying to stay smoke-free? (Maintenance)
The employees’ responses will help to pinpoint where the
participants are on the continuum of change, and to tailor messages,
strategies, and programs appropriate to their needs. For example,
individuals who enjoy smoking are not interested in trying to quit,
and therefore will not attend a smoking cessation clinic; for them, a
more appropriate intervention might include educational
interventions designed to move them out of the “pre-contemplation”
stage and into “contemplation” (e.g., using carbon monoxide testing
to demonstrate the effect of smoking on health). On the other hand,
individuals who are ready to plan how to quit smoking (the
“preparation” stage) can be encouraged to do so, and moved to the
next stage, “action.”
Social Cognitive Theory
The basic premise of the Social Learning Theory (SLT), also known as Social
Cognitive Theory (SCT) is that the potential for a behavior to occur in any given situation
is a function of the employee’s belief that the behavior will be rewarded or reinforced in
some manner. Glanz (2005) states about the Social Cognitive Theory that it describes a
dynamic, ongoing process in which personal factors, environmental factors, and human
behavior exerts influence upon each other.
According to SCT, three main factors affect the likelihood that a
person will change a health behavior: (1) self-efficacy, (2) goals, and
(3) outcome expectancies. If individuals have a sense of personal
agency or self-efficacy, they can change behaviors even when faced
with obstacles. If they do not feel that they can exercise control over
their health behavior, they are not motivated to act, or to persist
through challenges. As a person adopts new behaviors, this causes
changes in both the environment and in the person. Behavior is not
simply a product of the environment and the person, and
environment is not simply a product of the person and behavior.
SCT evolved from research on Social Learning Theory (SLT), which
asserts that people learn not only from their own experiences, but by
observing the actions of others and the benefits of those actions.
Table 2.7 provides a description of the key concepts of the Social Cognitive
Theory. Please note that this theory provides a menu of possible ways to intervene to
address a health problem, and it is not likely that a health promotion manager would
develop interventions using all these strategies (concepts) for a particular heath problem.
The strategies chosen should be based on the nature of the problem and the available
Table 2.7: Social Cognitive Theory – Key concepts and Worksite Examples
Concept Definition Potential Change Strategies Worksite Examples
Reciprocal determinism The dynamic interaction of the Consider multiple ways to Assess environment
person, behavior, and the promote behavior change, Identify existing behaviors
environment in which the including making adjustments to Assess knowledge and skills
behavior is performed the environment or influencing Identify barriers
Behavioral capacity Knowledge and skill to perform a Promote mastery learning through Conduct knowledge and skill
given behavior skills training analysis
Provide skill training
Evaluate/recycle skill training
Expectations Anticipated outcomes of a Model positive outcomes of Identify all possible outcomes
behavior healthful behavior. Model skills Provide successful models of
to perform behavior. outcomes and health behavior
from the workforce
Self-efficacy Confidence in one’s ability to Approach behavior change in Recognize success
take action and overcome barriers small steps to ensure success; be Allow all to succeed in some
specific about the desired change way
Build on success
View failure as one relapse
Observational learning Behavioral acquisition that occurs Offer credible role models who Recognize success
(modeling) by watching the actions and perform the targeted behavior Show process used to be
outcomes of others’ behavior successful
Use coworkers when possible
Reinforcements Response to a person’s behavior Promote self-initiates, rewards, Provde a variety of incentives
that increase or decrease the and incentives Reward behavior change
likelihood of reoccurrence Reward goal attainment
Adapted from: National Cancer Institute, Theories at a Glance, NIH publication NO. 05-3869, September 2005
To operatunalize the Social Cognitive Theory, Parcel and Baronowsky have
outlined four phases of a process to foster behavior change using Social Cognitive
Theory. These phases are:
1. Pre-training phase. The pre-training phase involves gathering information
on employees to structure a behavior change process. The employee needs
assessment section in Chapter 1 provides information useful in this phase.
2. Training phase. This phase involves providing employee programs and
opportunities to change behavior.
3. Initial testing phase. This phase starts when a member of the target audience
attempts to change the behavior learned in the training phase.
4. Continual performance phase. This phase provides reinforcement and
support of employee behavior change.
Table 2.8 provides an example of activities that could be implemented in each
stage of this training process.
The models of health behavior discussed previously in this chapter include a
significant relapse prevention or maintenance component. In general, health promotion
professionals have focused on leading employees to a behavior change, but have placed
little emphasis on maintenance of positive health behaviors.
In relapse prevention, the health promotion manager focuses some attention on
helping employees to maintain a behavior change. Relapse prevention in worksite health
promotion can be defined as educational programs, environmental/organizational
modifications, and policy changes designed to provide employees with the knowledge,
skills, and support to cope with problems of relapse.
Table 2.8: Social Cognitive Theory – Four Phases of Behavior Change with Cancer
Assessment of current lifestyles related to cancer risk
Assessment of beliefs and anxieties related to cancer
Examination of factors influencing behavior change related to cancer risk
Identification of how the target audience might seek help to reduce cancer risk
Initiation of awareness activities to shape attitudes and beliefs, related to
cancer risk reduction (such as posters, pay envelope stuffers, awareness,
articles in company newsletters, etc.)
Educational seminars and awareness activities on selected protective and risk
factors (adding vitamins C and A, the relationship of the sun and skin cancer,
the effects of cured meats, etc.)
Skill training sessions for selected protective and risk factors (how to add fiber
to your diet, how to trim fat from the diet, techniques to protect yourself from
the sun, etc.)
Selected behavior change programs (smoking cessation programs, weight
control sessions, and responsible drinking techniques)
Initial Testing Phase
Assess the environmental support capabilities of the corporation
Suggest activities to enhance the testing of cancer risk reduction behaviors
(develop an effective smoking policy, add healthy snacks to vending
machines, include appropriate foods in cafeterias, etc.)
Continuing Performance Phase
Implement relapse prevention techniques
Provide reinforcers and incentives for members of the target audience who
participate and complete activities (novelties, recognition, other rewards, etc.)
Create social support groups as appropriate
Develop long term self-control manuals for selected cancer risk behaviors
(smoking, weight control, fiber, etc.)
Educational programs provide behavior skills and cognitive techniques to train
employees to cope with problems of relapse. These include:
1. Behavioral self-management skills. Strategies to help employees manage
their behavior over an extended time frame. For a program dealing with
dietary habits, this would include detailed guidelines on how to monitor
dietary intake and make wise food choices.
2. Analysis of situational factors that influence relapse. In this aspect of
relapse prevention, employees discuss how they would cope with a situation
that may cause a relapse. For dietary habits, the employees may discuss how
they would handle controlling eating during a special event, such as an office
party or Thanksgiving dinner.
3. Dealing with psychological factors that impact relapse. Employees need to
address specific emotions and attitudes which affect the relapse process.
These include (1) self-efficacy – an employee’s belief about how capable he
or she is of maintaining a behavior change; and (2) abstinence violation
effect (AVE) – an employee convinces himself or herself that he or she is not
capable of maintaining the behavior change.