Behavior change theories and models

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					Behavior change theories and

     Geoffrey Setswe DrPH
        SBI Workshop
        29 March 2009
AIDS Behavioural theories/models

 1.    Health Belief Model (HBM)
 2.    AIDS Risk Reduction Model (ARRM)
 3.    Stages of Change of the Transtheoretical Model
 4.    Theory of Reasoned Action (TRA)
 5.    Diffusion of Innovation Theory
 6.    Ecological Systems Theory
 7.    Social Capital Theory
 8.    Social Cognitive Theory
 9.    Social Network Theory
 10.   Theory of Gender and Power
 11.   Edutainment Programming Model

   Source: Rachel King's "Sexual behavioral change for HIV: Where have theories taken us?" June 1999
      Creation of a theory-based HIV prevention

        Assessment of pre-intervention levels of factors theorized to
                 influence risk and preventive behavior

            Design and implementation of targeted interventions to
                change factors theorized to influence HIV risk and
                              preventive behaviour

            Evaluation of intervention impact on factors theorized to
            influence STD/HIV risk and preventive behavior and HIV
                              preventive behavior
Source: Fisher WA. A Theory-Based Framework for Intervention and Evaluation in STD/HIV Prevention
1. Health Belief Model

   HBM) is a psychological model that attempts to explain
   and predict health behaviors by focusing on the attitudes
   and beliefs of individuals.

   Developed in the 1950s to explain the lack of public
   participation in health screening and prevention

   Adapted to explore a variety of long- and short-term
   health behaviors, including sexual risk behaviors and the
   transmission of HIV/AIDS.

   Condom use

              Rosenstock, Strecher and Becker, (1994):
       Key variables of the HBM

Perceived Threat: Consists of two parts: perceived susceptibility
and perceived severity of a health condition.
   Perceived Susceptibility: One's subjective perception of the risk of
   contracting a health condition,
   Perceived Severity: Feelings concerning the seriousness of
   contracting an illness or of leaving it untreated (including evaluations
   of both medical and clinical consequences and possible social
Perceived Benefits: The believed effectiveness of strategies
designed to reduce the threat of illness.
Perceived Barriers: The potential negative consequences that may
result from taking particular health actions, including physical,
psychological, and financial demands.
Cues to Action: Events, either bodily (e.g., physical symptoms of a
health condition) or environmental (e.g., media publicity) that
motivate people to take action. Cues to actions is an aspect of the
HBM that has not been systematically studied.
Health Belief Model (HBM)
     2. AIDS Risk Reduction Model

The AIDS Risk Reduction Model (ARRM), introduced in 1990,
provides a framework for explaining and predicting the behaviour
change efforts of individuals specifically in relationship to the
sexual transmission of HIV/AIDS. A three-stage model

Stage 1: Recognition and labeling of one's behaviour as high
    risk. Hypothesised influences:
    knowledge of sexual activities associated with HIV
    believing that one is personally susceptible to contracting
    believing that having AIDS is undesirable;
    social norms and networking

           Catania, Kegeles and Coates, 1990
Stage 2: Making a commitment to reduce high-risk sexual
   contacts and to increase low-risk activities
Hypothesized influences include cost and benefits; enjoyment (e.g.,
   will the changes affect my enjoyment of sex?); response efficacy
   (e.g., will the changes successfully reduce my risk of HIV
   infection?); self-efficacy; knowledge of the health utility and
   enjoyability of a sexual practice, as well as social factors (group
   norms and social support), are believed to influence an individual's
   cost and benefit and self-efficacy beliefs.

Stage 3: Taking action. This stage is broken down into three phases:
   1) information seeking; 2) obtaining remedies; 3) enacting
   solutions. Depending on the individual, phases may occur
   concurrently or phases may be skipped.
Hypothesised influences include social networks and problem-solving
   choices (self-help, informal and formal help); prior experiences with
   problems and solutions; level of self-esteem; resource
   requirements of acquiring help; ability to communicate verbally with
   sexual partner; sexual partner's beliefs and behaviours.
   AIDS Risk Reduction Model (ARRM)

Catania, J.A., Kegeles, S.M., and Coates T.J. (1990). Towards an understanding of
risk behavior: An AIDS risk reduction model (ARRM). Hlth Ed Quarterly, 17(1), 53-72.
3. Stages of change model

 Posits six stages that individuals pass through when changing
 behaviour e.g. Smoking cessation
10 processes help predict and motivate individual
movement across stages.

           Prochaska, DiClemente and Norcross (1992)
4. Theory of Reasoned Action (TRA)

    TRA is based on the assumption that human beings are
    rational and make systematic use of the information to make
    choices about whether to enact a behavior or not.

    The theory provides a construct that links individual beliefs,
    attitudes, intentions, and behavior


       (Fishbein, Middlestadt and Hitchcock, 1994)
 Theory of Reasoned Action (TRA)

Ajen,I., Fishbein, M. (1980) Understanding attitudes and predicting social
behavior. New Jersey: Prentice-Hall, Inc.
  5. Diffusion of Innovations Theory

    There are four main elements to the diffusion of innovations:
(1) the innovation, (2) its communication, (3) in a social system, (4) over a
    period of time.
    Innovation – any item, thought, or process that is viewed to be new by
    the consumer e.g. Femidom
    Communication – the process of the new idea traveling from one
    person to another or from one channel to the individual.
    Social System – the group of individuals that together complete a
    specific goal (adoption)
    Time – how long it takes for the group to adopt an innovation as well as
    the rate of adoption for individual

1) Innovators, 2) Early adopters, 3) Early majority, 4) Late majority,
    and 5) Laggards

    Rogers, E.M. (1995). Diffusion of innovations (4th edition). The Free Press. New York.
 Different adopter categories are
           identified as:
  Innovators (venturesome);

  Early adopters (respectable);

  Early majority (deliberate);

  Late majority (sceptical);

  Laggards (traditional).

Project Accept: VCT
      6. Ecological Systems Theory

Specifies four types of nested environmental systems, with bi-
directional influences within and between the systems. The four systems:
    Microsystem: Immediate environments (family, school, peer group,
    neighborhood, and childcare environments)
    Mesosystem: A system comprising connections between immediate
    environments (i.e., a child’s home and school)
    Exosystem: External environmental settings which only indirectly affect
    development (such as parent's workplace)
    Macrosystem: The larger cultural context (Eastern vs. Western culture,
    national economy, political culture, subculture)
Recognizes that successful activities to promote health, including
HIV risk reduction, not only address changing individual behaviors,
but address multiple levels.

HIV disclosure
                      7. Social Capital Theory

         …Those resources inherent in social relations which facilitate
         collective action.

         Social capital resources include trust, norms, and networks of
         association representing any group which gathers consistently for a
         common purpose. A norm of a culture high in social capital is
         reciprocity, which encourages bargaining, compromise, and
         pluralistic politics. Another norm is belief in the equality of citizens,
         which encourages the formation of cross-cutting groups.

         The theory asserts that social life, networks, norms and trust enable
         participants to act together more effectively to pursue shared
         objectives, such as HIV risk reduction.

    Needle exchange programmes

Coleman, J.S. (1988) Social Capital in the Creation of Human Capital," American Journal of Sociology
(94:Supplement: Organizations and Institutions: Sociological and Economic Approaches to the Analysis of Social Structure) 1988
           Social capital theory

Source: Narayan and Cassidy (2001)
   8. Social Cognitive Theory (SCT)

   SCT explains how people acquire and maintain certain behavioral
   patterns, while also providing the basis for intervention strategies.
   Evaluating behavioral change depends on the factors Environment,
   People and Behaviour.
   SCT provides a framework for designing, implementing and
   evaluating programs.

The premise of the SCT (or SLT) is that new behaviours are learned
   either by modeling the behaviour of others or by direct experience.
   The confidence one feels towards enacting a behavior = Self-
   efficacy, is a key component of the theory.

Positive Prevention and Stepping Stones projects

                         (Bandura, 1997)
        Social Cognitive Theory (SCT)

SCT is relevant for designing health education and health behavior programs.
This theory can also be used for providing the basis for intervention strategies

 Source: Pajares (2002). Overview of social cognitive theory and of self-efficacy. 12-8-04.
              9. Social Network Theory

SNT views social relationships in terms of nodes and
  ties. Nodes are the individual actors within the
  networks, and ties are the relationships between the

Looks at social behavior not as an individual
  phenomenon but through relationships, and
  appreciates that HIV risk behavior, unlike many other
  health behaviors, usually directly involves two people.
  “It takes two to tango”.

M.S. Granovetter., "The strength of weak ties: A network theory revisited, " Social Structure and Network
Analysis (P.V. Marsden and N. Lin, Eds.). Sage, Beverly Hills CA, 1982, pp. 105-130.
Example of a social network map with
        nodes and linkages
10. Theory for Individual and Social Change
         or Empowerment Model:

   Asserts that social change happens through dialogue to build up a
     critical perception of the social, cultural, political, and economic
     forces that structure reality, and by taking action against forces
     that are oppressive.

   Empowerment should increase problem solving in a participatory
     fashion, and should enable participants to understand the
     personal, social, economic, and political forces in their lives in
     order to take action to improve their situations
   Men As Partners (MAP), Women’s dialogue

Karusa Kiragu and Julie Pulerwitz, "Application of behavior change theory to HIV programs: Lessons learned from
operations research at Horizons,"
unpublished manuscript,
   11. Theory of Gender and Power

  TGP is a social-structural theory addressing the wider social and
environmental issues surrounding women, such as distribution of
power and authority, and gender-specific norms.
  There are three major social structures that characterize the
gendered relationships between men and women:
      the sexual division of labor,
      the sexual division of power, and
      the structure of cathexis

Women’s Empowerment Project
12. Edutainment Programming Model

 IHDC/Soul City uses this model to inform
 understanding of how edutainment can be
 used for social change and communicating