In health education and health promotion an ideal theory is one that is exclusive to health behaviors, predicts health behavior change, is based on empirical evidence with health behavior changes, provides enough predictive power, is parsimonious, has constructs that are malleable, caters to both one-time and long-term health behavior change, works at individual, group and community levels, and is applicable across cultures. This commentary discusses the limitations of commonly used theories such as health belief model, transtheoretical model, PRECEDE-PROCEED and ecological models and proposes a framework for a new theory exclusive for health behavior change. Such a new theory will address both initiation and sustenance of health behavior change, will incorporate cognitive, conative, and environmental empirically tested components from existing theories, will be parsimonious, applicable at individual, group and community levels, will be culturally robust and useful for resource-scarce settings.
In health education and health promotion we are interested in theories that are exclusive to health behaviors, can predict health behavior change, are based on empirical evidence with health behavior change, provide adequate predictive power, are parsimonious, have constructs that are malleable, induce immediate and long-term health behavior change, can be applied at individual, group, and community levels and are applicable across cultures.1 Of all the theories that have been applied in health education and health promotion since the 1950s, there is only one theory that is exclusive to health behaviors and that is the health belief model (HBM).2 The HBM is particularly useful for programs for disease and injury avoidance, but it does not lend itself very well to long-term behavior change.1 A classic meta-analysis of the relationships among four HBM dimensions (perceived susceptibility, perceived severity, perceived benefits, and perceived costs) and health behaviors across 16 studies found weak effect sizes and lack of homogeneity in a majority of the studies.3 A more recent meta-analysis of 18 studies also confirmed that perceived severity was a weak predictor of behavior, and perceived susceptibility was almost always unrelated to predicting health behaviors.4 Cultural factors, socioeconomic status, and previous experiences also shape health behaviors, and those factors are not accounted for in the model. Another problem has been that the constructs of the HBM do not all carry equal value.5 For example, perceived barriers are the most important predictors of behaviors and it is not possible to easily influence the barriers, and in the absence of addressing the barriers the model does not work. Further, Ogden has criticized the conceptual basis of HBM.6 On the whole, HBM does not have good consistent predictive power, is not culturally versatile, and is not about changing health behavior but only explaining it.
Of all the theories, in use in health promotion and health education there is only one theory that is about behavior change and that is the transtheoretical model.7 Many critics have argued that the stages in the model are purely arbitrary and after classifying a population into different stages it offers no benefit.8-15 They see change being a continuous process with no discrete categories. Further, there is little empirical evidence regarding sequential transition between the stages and that no single study has documented movement through the entire spectrum of stages.12 Another limitation of the TTM that has been pointed out in the literature is its lack of predictive potential.14 Application of the TTM to substance abuse behaviors16 and dietary and physical activity interventions17 has yielded weak results. Another limitation of the model is that TTM is not parsimonious.18 Having ten processes of change and several other constructs make this model rather cumbersome. On the whole, TTM uses arbitrary stages, is not parsimonious, some of its constructs are not malleable, and the terminology and context it uses is that of psychotherapy and not of health education.
A criticism of HBM, TTM and some other similar models is that they address only individual level change in behavior.6 However, there is a framework in health promotion for the past 30 some years that is called the PRECEDE-PROCEED model.19 I like to call it a health promotion planning model. It is among the most popular and most researched model in our field. Over 1,000 published and numerous unpublished studies have used this model and the model is still widely used. This model incorporates theories of sociology, anthropology, economics and psychology. A limitation of the PRECEDE-PROCEED model like other similar ecological models20 is that these models are very comprehensive making them somewhat impractical.1 No doubt so many studies have used the PRECEDE-PROCEED model but none have operationalized it adequately or fully.1 The model poses special problems in resource-scarce contexts as it requires heavy outlay of resources both human and financial.1 Furthermore, it does not allow the practitioners and researchers to decipher to what extent which construct is working.1 Clubbing different constructs into three categories is also not sound from a research perspective though it may have practical advantages.1 On the whole, ecological models are very comprehensive, do not identify distinct measurable constructs, and are impractical.
Similarly, we can discuss the merits and shortcomings of classic health education and promotion theories which is not what I intend to do in this commentary. In this commentary, I intend to present a model for empirical testing that is exclusive for health education; has empirically tested “constructs” for health behavior change; is parsimonious; affects cognitive, conative and environmental domains; has constructs that are malleable; caters to both one-time and long-term behavior change; works at individual, group and community levels; and is applicable across cultures. I call it the multi-theory model (MTM) for health behavior change. While the constructs that make up this model have been tested, this model altogether has not been tested.
I wish to dissect health behavior change into two components: initiation of the behavior change and sustenance or continuation of the health behavior change. Initiation of the behavior change is the same as adoption of one-time behavior such as receiving a one-time vaccination. It is the process of moving from one behavior to another. And sustenance or continuation of the health behavior change is the same as long-term performance of the health behavior change such as performing physical activity behavior over a course of life-time. Why this differentiation is needed is because the constructs that influence initiation of change are different than the constructs that sustain the behavior change. This differentiation has not been made by the existing theories that explain behavior and as a result when you operationalize them you get low predictive power.
There are three main constructs that influence the initiation of behavior change. The first one is the “participatory dialogue” derived from the Freire’s model of adult education.21 For behavior change this participatory dialogue can be initiated by the health educator. The important part is that the content of this dialogue must focus on advantages and disadvantages of the health behavior change. This is similar to the pros and cons of the transtheoretical model, 7 or perceived benefits and perceived barriers in the health belief model2 but is somewhat different in the process because this is participatory which means it has to be a two-way communication or mutual exploration which is emphasized by Freire but ignored by the transtheoretical model and health belief model. The construct of participatory dialogue is a very robust construct that has been tested across cultures in all six continents.22
The second construct is “behavioral confidence” derived from Bandura’s self-efficacy23 and Ajzen’s perceived behavioral control.24 There are three reasons for calling it behavioral confidence and not the latter two terms. First one is simplicity. I have conducted workshops in several parts of the world, and few are able to appreciate what these jargons mean if they heard it the first time. Most of my students get self-efficacy confused with program efficacy. The second reason is that this construct has perhaps greater predictive power in the United States because of cultural closeness of this construct but when it comes to my work in China,25 India,26 and Iran27 it has either shown very modest predictive power or no predictive power which may be due to obvious cultural differences. The construct of behavioral confidence is more culturally-specific than self-efficacy. The source of behavioral confidence is not confined to self or is not totally internal but it also can come from external sources such as influential people in life, health educator, God etc. The final reason is that behavioral confidence is slightly different from Bandura’s “self-efficacy” and Ajzen’s “perceived behavioral control” which are about learning a behavior and my conceptualization pertains to changing a health behavior so it is not about “here and now” but about “future.” This construct is a projection of your sureness to perform a health behavior change in the future not in the present. This line of reasoning is supported by work on prefactual and counterfactual conditionals.28
The third and final construct for initiation of a behavior is the “changes in physical environment” derived from Bandura’s construct of environment,23 Prochaska’s construct of environmental re-evaluation,7 environmental factors in Fishbein’s integrative model29 etc. This conceptualization pertains only to the “physical” and not the social environment and entails making changes to obtainability, availability, accessibility, convenience, and readiness of resources. This model is depicted in Figure 1.
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Let us now look at the sustenance or continuation of the health behavior change or modification for long term health behavior change. There are three main constructs that influence the sustenance of health behavior change. The first construct is derived from self-motivation construct of emotional intelligence theory30 which means “gathering up” one’s feelings and directing oneself toward a goal, despite self-doubt, inertia and impulsiveness. I call it “emotional transformation” because it is converting or transforming emotions toward the health behavior change. In simple terms, it means taking one’s emotions and directing them toward changing the behavior.
The second construct is derived from Freire’s adult education model’s19 praxis and is called “practice for change.” Praxis refers to active reflection and reflective action. Practice for change entails constantly thinking about the health behavior change and making mid-term rectifications to one’s strategy, overcoming barriers, and remaining focused on health behavior change. This can be done by keeping a diary or a journal that records progress toward behavior change or taking action during natural times that prepare for the health behavior action, such as putting your workout clothes out in the evening for a morning activity. This work is supported by research on mindfulness meditation.31
The third and final construct is derived from the construct of environment, 21 helping relationships, 7 social support32 and so on. It is called “change in social environment” and entails creating social support from the environment. This change in social environment can be natural or artificial. The health educator can provide help with change in the social environment. This model is depicted in Figure 2.
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I have presented this model based on my research and empirical experience in the field with the various behavioral theories since 1981 using the Knowledge-Attitudes-Practices (KAP) model,33 health belief model,34 social cognitive theory,35 transtheoretical model,36 theory of planned behavior,37 emotional intelligence theory,38 social support theory,39 PRECEDE-PROCEED model,40 capability theory,41 and Freire’s adult education model.42 I believe the constructs chosen in this model are independent, not related to each other, and hold a track record toward making behavior change thereby making it a useful theory. The multi-theory model (MTM) for health behavior change has not been empirically tested though I am in the process of doing so. I believe this model can be applied to behavior change at individual, group, and community levels and is particularly well suited for resource-scarce settings. I would request the readers of this commentary to also test this model and improve it further. I am not providing a critique of this model and leave it to the readers to do so.
Note. In the Figures, the arrows connecting the constructs to initiation and sustenace of behavior change are not showing up on pdf despite several attempts.
I am indebted to my former students, Dr. Adam Knowlden of University of Alabama and Dr. Paul Branscum of University of Oklahoma for their astute comments on this paper. I am also thankful to Dr. Lawrence Green of University of California at San Francisco, Dr. Stephen Gambescia of Drexel University and Dr. Larry Olsen of A.T. Still University for their kind feedback.
- Sharma M, Romas JA. Theoretical Foundations of Health Education and Health Promotion,2nd ed. Sudbury, MA: Jones and Bartlett; 2012.
- Rosenstock IM. Historical origins of the health belief model. In: Becker MH, ed. The Health Belief Model and Personal Health Behavior. Thorofare, NJ: Charles B. Slack; 1974: 1-8.
- Harrison JA, Mullen PD, Green LW. A meta-analysis of studies of the health belief model with adults. Health Educ Res. 1992;7(1): 107-116.
- Carpenter CJ. A meta-analysis of the effectiveness of health belief model variables in predicting behavior. Health Commun.2010; 25:661-9.
- Champion VL, Skinner CS. The health belief model. In: Glanz K, Rimer BK, Viswanath K, eds. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco: Jossey-Bass; 2008: 45-66.
- Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychol. 2003;22:424–428.
- Prochaska JO. Systems of Psychotherapy: A Transtheoretical Analysis. Homewood, IL: Dorsey Press; 1979.
- Bandura A. Self-efficacy: The Exercise of Control. New York: W. H. Freeman; 1997.
- Davidson R. Prochaska and DiClemente’s model of change: a case study? Br J Addict. 1992;87:821–822.
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- Herzog TA. When popularity outstrips the evidence: comments on West (2005). Addiction. 2005;100:1040–1041.
- Littell JH, Girvin H. Stages of change. A critique. Behav Modif. 2002 26, 223–273.
- Sutton S. Can stages of change provide guidance in the treatment of addictions? A critical examination of Prochaska and DiClemente’s model. In: Edwards G, Dare C. eds. Psychotherapy, Psychological Treatments and the Addictions. Cambridge, UK: Cambridge University Press; 1996:189-205.
- West R. Time for a change: putting the transtheoretical (stages of change) model to rest [Editorial]. Addiction. 2005;100:1036–1039.
- Whitelaw S, Baldwin S, Bunton R, et al. The status of evidence and outcomes in stages of change research. Health Educ Res. 2000;15:707–718.
- Migneault JP, Adams TB, Read JP. Application of the transtheoretical model to substance abuse: historical development and future directions. Drug Alcohol Rev. 2005;24:437–448.
- Mastellos N, Gunn LH, Felix LM, et al. Transtheoretical model stages of change for dietary and physical exercise modification in weight loss management for overweight and obese adults. Cochrane Database Syst Rev. 2014;2:CD008066.
- West R. The transtheoretical model of behavior change and the scientific method. Addiction. 2006;101:774–778.
- Green LW, Kreuter MW. Health Program Planning. An Educational and Ecological Approach. (4th ed.) Boston: McGraw Hill; 2005.
- Richard L, Potvin L, Kishchuk N, Prlic H, Green LW. Assessment of the integration of the ecological approach in health promotion programs. Am J Health Promot. 1996;10(4):318-28.
- Freire, P. Pedagogy of the Oppressed. New York: Continuum; 1970.
- Sharma M. Freire's adult education model: an underutilized model in alcohol and drug education? [Editorial]. J Alcohol Drug Educ. 2001;47:1-3.
- Bandura A. Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice-Hall; 1986.
- Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179–211.
- Murnan J, Sharma M, Lin D. Predicting childhood obesity behaviors using social cognitive theory: children in China. Int Q Community Health Educ.2006-07;26:73-84.
- Sharma M, Mehan M, Surabhi S. Using social cognitive theory to predict obesity prevention behaviors among preadolescents in India. Int Q Community Health Educ. 2008-09;29:351-361.
- Bagherniya M, Sharma M, Mostafavi F, et al. Application of social cognitive theory in predicting childhood obesity prevention behaviors in overweight and obese Iranian adolescents. Int Q Community Health Educ. 2014-15;35:133-147.
- Byrne RM, Egan SM. Counterfactual and prefactual conditionals. Can J Exp Psychol. 2004;58(2):113-20.
- Fishbein M. An integrative model for behavioral prediction and its application to health promotion. In Diclemente RJ, Crosby RA , Kegler MC, eds. Emerging Theories in Health Promotion Practice and Research. 2nd ed. San Francisco, CA: Jossey-Bass; 2009: 215-234.
- Goleman D. Emotional Intelligence. New York: Bantam; 1995.
- Khoury B, Sharma M, Rush SE, Fournier C. Mindfulness-based stress reduction for healthy individuals: a meta-analysis. J Psychosom Res. 2015;78(6):519-28. doi: 10.1016/j.jpsychores.2015.03.009.
- House JS. Work, Stress, and Social Support. Reading, MA: Addison-Wesley; 1981.
- Lakhan R, Sharma M. Knowledge, attitudes, and practices (KAP) survey of families toward their children with intellectual disability in Barwani, India. Asia Pacific Disability Rehabilitation Journal. 2010;21:101-117.
- Mehta P, Sharma M, Lee R. Designing and evaluating a health belief model based intervention to increase intent of HPV vaccination among college men. Int Q Community Health Educ.2013-14;34:101-117.
- Sharma M, Petosa R, Heaney CA. Evaluation of a brief intervention based on social cognitive theory to develop problem solving skills among sixth grade children. Health Educ Behav. 1999; 26:465-477.
- Fahrenwald NL, Belitz C, Keckler A, et al. Sharing the gift of life: an intervention to increase organ and tissue donation for American Indians. Prog Transplant. 2007;17:281-287.
- Ickes M, Sharma M. Does behavioral intention predict nutrition behaviors related to adolescent obesity? Infant Child Adolesc. Nutr. 2011;3:38-48.
- Branscum P, Bhochhibhoya A, Sharma M. The role of emotional intelligence in mental health and Type D Personality among young adults. Int Q Community Health Educ. 2013-14;34:351-365.
- Kanekar A, Sharma M, Atri A. Enhancing social support, hardiness, and acculturation to improve mental health among Asian Indian International students. Int Q Community Health Educ. 2009-10;30:55-68.
- Sharma M, Reese-Smith J. Suicide Prevention and Depression Awareness (SPAD) among African-American College Students, Unpublished grant proposal, 2015.
- Sharma M. Reifying capability theory in disability and rehabilitation research. APDRJ. 2005;16:110-116.
- Sharma M, Deepak S. A participatory evaluation of community-based rehabilitation program in North Central Vietnam. Disabil Rehabil. 2001;23:352-358.
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