Behavior Change-- A Summary of Four Major Theories
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Behavior Change -- A Summary of Four
This document presents and explains four of the most commonly cited theories used in HIV/AIDS
prevention on how behavior change is believed to occur.
Table of Contents
Health Belief Model
AIDS Risk Reduction Model
Stages of Change
Theory of Reasoned Action
How does behavior change occur? This question probably has as many answers as there are
diverse populations and cultures. Every HIV prevention program, however, is based on those
answers -- theories about why people change their behaviors. These underlying principles may
not be formally recognized as theories, but they focus HIV prevention efforts on the elements
believed to be essential for individuals to enact and sustain behavior change.
Four of the most commonly cited theories in HIV prevention literature are outlined in this
booklet: The Health Belief Model, the AIDS Risk Reduction Model, the Stages of Change, and
the Theory of Reasoned Action. These theories have yet to be extensively applied in research
outside of the United States, and they may not capture the elements necessary for behavior
change in every culture or population. They do provide, however, four examples of how the
behavior change process is believed to occur. By presenting a brief explanation of each theory,
the AIDS Control and Prevention (AIDSCAP) Project hopes to encourage people working with
HIV/AIDS to examine the theories, both formal and informal, that guide their prevention efforts.
Health Belief Model (HBM)
The 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. The HBM was developed in the 1950s as part of an
effort by social psychologists in the United States Public Health Service to
explain the lack of public participation in health screening and prevention
programs (e.g., a free and conveniently located tuberculosis screening
project). Since then, the HBM has been adapted to explore a variety of
long- and short-term health behaviors, including sexual risk behaviors and
the transmission of HIV/AIDS. The key variables of the HBM are as
lPerceived Threat: Consists of two parts: perceived susceptibility
and perceived severity of a health condition.
mPerceived Susceptibility: One's subjective perception of
the risk of contracting a health condition,
mPerceived 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 consequences).
lPerceived Benefits: The believed effectiveness of strategies
designed to reduce the threat of illness.
lPerceived Barriers: The potential negative consequences that may
result from taking particular health actions, including physical,
psychological, and financial demands.
lCues 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.
lOther Variables: Diverse demographic, sociopsychological, and
structural variables that affect an individual's perceptions and thus
indirectly influence health-related behavior.
lSelf-Efficacy: The belief in being able to successfully execute the
behavior required to produce the desired outcomes. (This concept
was introduced in 1977.)
Implications for Health Behaviors
HBM research has been used to explore a variety of health behaviors in
diverse populations. For instance, researchers have applied the HBM to
studies that attempt to explain and predict individual participation in
programs for influenza inoculations, Tay-Sachs carrier status screening,
high blood pressure screening, smoking cessation, seatbelt usage,
exercise, nutrition, and breast self-examination. With the advent of HIV/
AIDS, the model also has been used to gain a better understanding of
sexual risk behaviors (1994). Participants in these
studies, most of which were conducted in the United States, include
people from the general population, homosexual men, adolescents, and
pregnant women. Research designs also vary from longitudinal to crosssectional
and from retrospective to prospective studies.
In a literature review of all HBM studies published from 1974-1984, the
authors identified, across study designs and populations, perceived
barriers as the most influential variable for predicting and explaining
health-related behaviors ( 1984). Other significant HBM
dimensions were perceived benefits and perceived susceptibility, with
perceived severity identified as the least significant variable. More
recently, though, researchers are suggesting that an individual's perceived
ability to successfully carry out a "health" strategy, such as using a
condom consistently, greatly influences his/her decision and ability to
enact and sustain a changed behavior ( 1989).
General limitations of the HBM include: a) most HBM-based research to
date has incorporated only selected components of the HBM, thereby not
testing the usefulness of the model as a whole; b) as a psychological
model it does not take into consideration other factors, such as
environmental or economic factors, that may influence health behaviors;
and c) the model does not incorporate the influence of social norms and
peer influences on people's decisions regarding their health behaviors (a
point to consider especially when working with adolescents on HIV/AIDS
AIDS Risk Reduction Model (ARRM)
The AIDS Risk Reduction Model (ARRM), introduced in 1990, provides a
framework for explaining and predicting the behavior change efforts of
individuals specifically in relationship to the sexual transmission of HIV/
AIDS. A three-stage model, the ARRM incorporates several variables from
other behavior change theories, including the Health Belief Model,
"efficacy" theory, emotional influences, and interpersonal processes. The
stages, as well as the hypothesized factors that influence the successful
completion of each stage (please see attached diagram), are as follows
STAGE 1: Recognition and labeling of one's behavior as high risk
lknowledge of sexual activities associated with HIV transmission;
lbelieving that one is personally susceptible to contracting HIV;
lbelieving that having AIDS is undesirable;
lsocial norms and networking.
STAGE 2: Making a commitment to reduce high-risk sexual contacts
and to increase low-risk activities
lcost and benefits;
lenjoyment (e.g., will the changes affect my enjoyment of sex?);
lresponse efficacy (e.g., will the changes successfully reduce my risk
of HIV infection?);
lknowledge 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 selfefficacy
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.
lsocial networks and problem-solving choices (self-help, informal
and formal help);
lprior experiences with problems and solutions;
llevel of self-esteem;
lresource requirements of acquiring help;
lability to communicate verbally with sexual partner;
lsexual partner's beliefs and behaviors.
In addition to the stages and influences listed above, the authors of the
ARRM (1990) identified other internal and external factors
that may motivate individual movement across stages. For instance,
aversive emotional states (e.g., high levels of distress over HIV/AIDS or
alcohol and drug use that blunt emotional states) may facilitate or hinder
the labeling of one's behaviors. External motivators, such as public
education campaigns, an image of a person dying from AIDS, or informal
support groups, may also cause people to examine and potentially change
their sexual activities.
To date, ARRM studies in the United States have examined a variety of
populations, including people attending HIV testing clinics, gay and
bisexual men, unmarried white, black and hispanic heterosexuals, and
adolescent females attending family planning centers. (These are
unpublished studies conducted by the Center for AIDS Prevention as
described in 1990.) Results from a published study revealed
how difficult it was for urban and rural women in Zaire to label their
behavior as problematic: only one-third of the study participants felt
personally at risk for contracting HIV/AIDS (1992)
Other research has expanded the ARRM to
examine the behaviors of injecting drug users, as well as the protective
behaviors of women who are already infected with HIV (1993 ;1994)
A general limitation of the ARRM model is its focus on the individual. For
instance, many women in an ARRM-based study in Kampala, Uganda, felt
at risk for HIV, not due to their own behavior but because of the behaviors
of their sexual partners -- an issue the women reported was outside of their
control (1993). As a result, the researchers suggested that
the ARRM take into greater consideration the sociocultural issues that
influence, and may limit, an individual's behavior choices and ability to
Stages of Change
Psychologists developed the Stages of Change Theory in 1982 to compare
smokers in therapy and self-changers along a behavior change continuum.
The rationale behind "staging" people, as such, was to tailor therapy to a
person's needs at his/her particular point in the change process. As a result,
the four original components of the Stages of Change Theory
(precontemplation, contemplation, action, and maintenance) were
identified and presented as a linear process of change. Since then, a fifth
stage (preparation for action) has been incorporated into the theory, as
well as ten processes that help predict and motivate individual movement
across stages. In addition, the stages are no longer considered to be linear;
rather, they are components of a cyclical process that varies for each
individual. The stages and processes, as described by
(1992), are listed below.
lPrecontemplation: Individual has the problem (whether he/she
recognizes it or not) and has no intention of changing.
Processes: Consciousness raising
(information and knowledge)
Dramatic relief (role playing)
Environmental reevaluation (how problem
affects physical environment)
lContemplation: Individual recognizes the problem and is
seriously thinking about changing.
Processes: Self-reevaluation (assessing one's
feelings regarding behavior)
lPreparation for Action: Individual recognizes the problem and
intends to change the behavior within the next month. Some
behavior change efforts may be reported, such as inconsistent
condom usage. However, the defined behavior change criterion has
not been reached (i.e., consistent condom usage).
Processes: Self-liberation (commitment or
belief in ability to change)
lAction: Individual has enacted consistent behavior change (i.e.,
consistent condom usage) for less than six months.
Processes: Reinforcement management
(overt and covert rewards)
Helping relationships (social support, selfhelp
Counterconditioning (alternatives for
Stimulus control (avoid high-risk cues)
lMaintenance: Individual maintains new behavior for six months
A variety of behaviors, such as smoking cessation, weight control efforts
and mammography screening, have been explored in U.S. populations
using the Stages of Change Theory (1994). More recently, this
theory has been applied in research on sexual behaviors and HIV/AIDS.
For example, the Centers for Disease Control and Prevention (CDC) is
using the Stages of Change Theory in an HIV/AIDS Counseling and
Testing Study at sexually transmitted disease (STD) clinics. Consequently,
the counseling provided will be based on the client's particular stage
( 1993). Populations for other stages of change research conducted
in the U.S. consist of women, men who have sex with men but do not
identify themselves as homosexual, intravenous drug users, prostitutes,
couples, and youth. Preliminary results from these studies support the
Stages of Change Theory as a method for characterizing individuals along
a change continuum with the intent of enhancing the effectiveness of HIV/
AIDS interventions. In addition, the theory offers a method for evaluating
programs by measuring individual change.
Studies have also examined the usefulness of merging aspects of other
theories into the Stages of Change. These additional components are often
applied in an effort to clarify how individuals move across stages. For
instance, a U.S. study examined a variety of behavior problems using the
Stages of Change Theory and two constructs from the Decisional Balance
Model (1994). The incorporation of aspects from the
Decisional Balance Model into the study strengthened the Stages of
Change Theory by clarifying what motivates movement from one stage to
the next. Overall, the merging of components from various theories is
common, as researchers and programmers seek to gain a better
understanding of how behavior change occurs.
As a psychological theory, the stages of change focuses on the individual
without assessing the role that structural and environmental issues may
have on a person's ability to enact behavior change. In addition, since the
stages of change presents a descriptive rather than a causative explanation
of behavior, the relationship between stages is not always clear. Finally,
each of the stages may not be suitable for characterizing every population.
For instance, a study of sex workers in Bolivia discovered that few study
participants were in the precontemplative, contemplative stages in regard
to using condoms with their clients (1995).
Theory of Reasoned Action (TRA)
Research using the Theory of Reasoned Action (TRA) has explained and
predicted a variety of human behaviors since 1967. Based on the premise
that humans are rational and that the behaviors being explored are under
volitional control, the theory provides a construct that links individual
beliefs, attitudes, intentions, and behavior (1994)
The theory variables and their definitions, as described
by (1994), are:
lBehavior: A specific behavior defined by a combination of four
components: action, target, context, and time (e.g., implementing a
sexual HIV risk reduction strategy (action) by using condoms with
commercial sex workers (target) in brothels (context) every time
lIntention: The intent to perform a behavior is the best predictor
that a desired behavior will actually occur. In order to measure it
accurately and effectively, intent should be defined using the same
components used to define behavior: action, target, context, and
time. Both attitude and norms, described below, influence one's
intention to perform a behavior.
lAttitude: A person's positive or negative feelings toward
performing the defined behavior.
mBehavioral Beliefs: Behavioral beliefs are a combination of
a person's beliefs regarding the outcomes of a defined
behavior and the person's evaluation of potential outcomes.
These beliefs will differ from population to population. For
instance, married heterosexuals may consider introducing
condoms into their relationship an admission of infidelity,
while for homosexual males in high prevalence areas it may
be viewed as a sign of trust and caring.
lNorms: A person's perception of other people's opinions regarding
the defined behavior.
mNormative Beliefs: Normative beliefs are a combination of
a person's beliefs regarding other people's views of a
behavior and the person's willingness to conform to those
views. As with behavioral beliefs, normative beliefs
regarding other people's opinions and the evaluation of
those opinions will vary from population to population.
The TRA provides a framework for linking each of the above variables
together (see diagram). Essentially, the behavioral and normative beliefs
-- referred to as cognitive structures -- influence individual attitudes and
subjective norms, respectively. In turn, attitudes and norms shape a
person's intention to perform a behavior. Finally, as the authors of the
TRA argue, a person's intention remains the best indicator that the desired
behavior will occur. Overall, the TRA model supports a linear process in
which changes in an individual's behavioral and normative beliefs will
ultimately affect the individual's actual behavior.
The attitude and norm variables, and their underlying cognitive structures,
often exert different degrees of influence over a person's intention. For
example, results from a study of northern Thai males revealed that men's
perceptions of peer norms were the best predictor of condom use
(1995). Yet in a study
of college females in the United States, attitudinal beliefs exerted greater
influence on the intent to use condoms by sexually inexperienced females
(1990). In order to develop appropriate
interventions for a specific population and behavior, therefore, it is
important to determine which variable and its corresponding cognitive
structures exerts the greatest influence on the study population (1994)
To date, behaviors explored using the TRA include smoking, drinking,
signing up for treatment programs, using contraceptives, dieting, wearing
seatbelts or safety helmets, exercising regularly, voting, and breastfeeding
( 1994). Studies conducted in Zimbabwe applied
the theory to research on condom usage by females and males (1990 ; 1993)
Other study populations for TRA HIV/AIDS research include women, STD
clinic patients, female commercial sex workers, men who have sex with
men, college students, and injecting drug users
Some limitations of the TRA include the inability of the theory, due to its
individualistic approach, to consider the role of environmental and
structural issues and the linearity of the theory components (1993)
Individuals may first change their behavior and then
their beliefs/attitudes about it. For example, studies on the impact of
seatbelt laws in the United States revealed that people often changed their
negative attitudes about the use of seatbelts as they grew accustomed to
the new behavior.
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