• Health behavior is central to disease
prevention and management.
• Nurses play a pivotal role in health behavior
change due to their credibility as patient
• 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
• 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
• 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
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
• 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-
• Revealed that good mother-son relationships
yielded higher condom use intention and self-
• 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
• 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
The Transtheoretical Model and Stages
of Change(2 of 2)
Examples of Application of the
• A study of individuals with co-occurring conditions
sought to understand the way people undergo
• Revealed that one disorder can make it difficult to
recognize the need for assistance with the other
• 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
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
• 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
• Revealed that electronic diaries with built-in
feedback messages related to progress added
an extra reinforcement element that improved
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
The Representational Approach (RA)
• Posits that linking health psychology to
educational theory aids patient-centered
• Relies on seven elements:
– Representational assessment
– Misconception exploration
– Condition creation for conceptual change
– Introduction of new information
– Goal setting and maintenance
– 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
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
Applications in Nursing and Nursing
• Nurses should use theory to guide research and
• Theory framework shapes the research process
and data interpretation, and influences
• Theory functions as a thread consistently
interwoven with a study and is not merely a
• 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.