Chapter 11Health Behavior

Theories

Introduction

• Health behavior is central to disease prevention and management.

• Nurses play a pivotal role in health behavior change due to their credibility as patient educators.

• Nurses may provide intensive patient counseling in a variety of settings, including clinics, work sites, and communities.

Evolution of Health Behavior Theory

• Theories reflect an amalgamation of approaches, methods, and strategies from social and health sciences.

• Many professionals contribute to and conduct health behavior and education research and programs.

• Nurses bring unique expertise for working with individuals and families to teaching about change and quality of life.

Trends in Use of Theories and Models• The most dominant theories of health behavior

therapy are the social cognitive theory, the transtheoretical model, and the health belief model.

• Importance of individual worldview, behavior change as a process, and motivation versus intention cut across many theories.

• In recent years, behavior change has focused on obstacle reduction and empowerment.

The Health Belief Model (HBM)• Posits that beliefs about susceptibility and

perceptions about the benefits of prevention influence patients’ readiness to act.

• Readiness based on six criteria:– Perceived susceptibility– Perceived severity– Perceived benefits– Perceived barriers– Cue to action– Self-efficacy

Examples of Application of the HBM

• An extensive HBM research project sought to develop a preconceptual counseling program for teens with type 1 diabetes.

• Focused on teen’s perceptions of reproductive problems due to diabetes and their adherence to safe sex practices.

• Led to development of a reproductive health program to aid decision making by diabetic teens.

The Theories of Reasoned Action (TRA) and Planned Behavior (TPB)

• TPB evolved from TRA.• Posits that health decisions are influenced by a

person’s view of actions and whether important others would approve.

• Useful for explaining why some people change behavior and others do not after completion of health education programs.

• Good fit for predicting behaviors like exercise, and health services utilization.

The Integrated Behavior Model (IBM)

• IBM is a combination of TPB, TR, and other behavioral theories.

• Developed in response to criticism that TPB ideas were too far removed from individuals to accurately predict behavior.

• Identifies specific belief targets for behavior change interventions based on attitudes, norms, control, and self-efficacy.

Examples of Application of TPB

• A study of condom use by male South Korean college students sought to establish a TPB link between condom self-efficacy and parent-adolescent relationships.

• Revealed that good mother-son relationships yielded higher condom use intention and self-efficacy.

• Illustrated how cultural practices in parenting can influence intention and behaviors.

The Transtheoretical Model and Stages of Change (1 of 2)

• Posits that people are at different stages of readiness to adopt healthful behaviors.

• Describes a sequence of steps in successful behavior change:– Pre-contemplation– Contemplation– Preparation– Action– Maintenance

• Ability to advance through stages and need to repeat stages is based on patient level of motivation and self-efficacy.

• Useful for explaining why patients are not ready to change and helps improve the success of patient education.

The Transtheoretical Model and Stages of Change (2 of 2)

Examples of Application of the Transtheoretical Model

• A study of individuals with co-occurring conditions sought to understand the way people undergo change.

• Revealed that one disorder can make it difficult to recognize the need for assistance with the other disorder.

• Suggested that individuals with co-occurring conditions need different interventions than individuals with only a single condition.

Social Cognitive Theory (SCT) (1 of 2)

• Developed from the social learning theory.• Explains behavior in terms of a three-way,

dynamic, reciprocal model in which personal factors, environmental influences, and behavior continually interact.

• Posits that people learn through their own experiences and by observing the actions of others.

Social Cognitive Theory (SCT) (2 of 2)

• Focuses on self-efficacy and deliberate efforts to increase self-efficacy in patients via three strategies:– Setting small, incremental goals– Using formalized behavior contracts– Monitoring and reinforcing behavior

• Environmental changes, role models, and reinforcement can be used to promote good behavior.

• Useful for nutritional interventions.

Examples of Application of SCT

• A study of self-monitoring via paper and electronic diaries sought to understand the ways in which feedback acts as a behavioral reinforcement.

• Revealed that electronic diaries with built-in feedback messages related to progress added an extra reinforcement element that improved patient success.

Social Ecological Models• Posits that behaviors both shape and are shaped

by the social environment.• Focuses on factors affecting behavior and provides

guidance for developing successful programs through social environments.

• Suggests that creating an environment conducive to change is important for making it easier to adopt healthy behaviors.

The Representational Approach (RA)• Posits that linking health psychology to

educational theory aids patient-centered interventions.

• Relies on seven elements:– Representational assessment– Misconception exploration– Condition creation for conceptual change– Introduction of new information– Goal setting and maintenance– Summary– Evaluation and revision

Examples of Application of RA

• A study of symptom management in ovarian cancer patients sought to understand the success of written interactions between patients and nurses.

• Revealed that written interactions were more effective than face-to-face interactions because of the greater time and flexibility allowed in communication.

Cross-Cutting Concepts: Patient’s View of the World

• Behavior change depends on sound understanding of the patient’s worldview.

• Poor adherence arises because patients lack behavioral skills to make lifestyle changes.

• Relationships between knowledge, awareness, intention, and actual change are complex.

• Attention to group patterns combined with individual understanding is key.

Cross-Cutting Concepts: Behavior Change as a Process

• Behavior change is a process, not an event.• Sustained health behavior change involves

multiple actions and adaptations over time.• Four concerns are important to this process:– Motivation vs. intention– Intention vs. action– Changing behavior vs. maintaining change– The role of biobehavioral factors

Control Over Behavior and Health: Control Beliefs and Self-Efficacy

• Control beliefs and self-efficacy are common deterrents to positive health behavior change.

• Found in both the SCT and TPB models.• Important to enhance perceived behavioral

control and increase self-efficacy to improve patient motivation and persistence in the face of obstacles.

Applications in Nursing and Nursing Research

• Nurses should use theory to guide research and theory application.

• Theory framework shapes the research process and data interpretation, and influences intervention design.

• Theory functions as a thread consistently interwoven with a study and is not merely a statement.

Summary• Health behavior theories are important for

understanding patient actions and the success or failure of nursing interventions.

• Many theories exist, and common themes cut across these theories and suggest that change is largely based on a patient’s worldview and treatment of change as a process.

• Research design and application are closely tied to theoretical frameworks.