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Preventive Medicine 46 (2008) 275 280 www.elsevier.com/locate/ypmed

Applying health behavior theory to multiple behavior change: Considerations and approaches
Seth M. Noar , Melissa Chabot, Rick S. Zimmerman
Department of Communication, 248 Grehan Building, University of Kentucky, Lexington, KY 40506-0042, USA Available online 11 August 2007

Abstract Background. There has been a dearth of theorizing in the area of multiple behavior change. The purpose of the current article was to examine how health behavior theory might be applied to the growing research terrain of multiple behavior change. Methods. Three approaches to applying health behavior theory to multiple behavior change are advanced, including searching the literature for potential examples of such applications. Results. These three approaches to multiple behavior change include (1) a behavior change principles approach; (2) a global health / behavioral category approach, and (3) a multiple behavioral approach. Each approach is discussed and explicated and examples from this emerging literature are provided. Conclusions. Further study in this area has the potential to broaden our understanding of multiple behaviors and multiple behavior change. Implications for additional theory-testing and application of theory to interventions are discussed. 2007 Elsevier Inc. All rights reserved.
Keywords: Theory; Multiple behavior change; Health behavior

Many of the leading causes of death in the United States are behavior-related and thus preventable (Mokdad et al., 2004). While a number of health behaviors are a concern individually, increasingly the impact of multiple behavioral risks is being appreciated (e.g., Fine et al., 2004; Reeves and Rafferty, 2005). As newer initiatives funded by the National Institutes of Health and Robert Wood Johnson Foundation begin to stimulate research in this important area (Jordan et al., 2005; Orleans, 2004), a critical question emerges: How can we understand multiple health behavior change from a theoretical standpoint? While multiple behavior change interventions are beginning to be developed and evaluated (e.g., Goldstein et al., 2004; Prochaska et al., 2006), to date there have been few efforts to garner a theory-based understanding of the process of multiple health behavior change. The purpose of the current article is to discuss how theories of health behavior and behavior change might be applied to the understanding of engagement in multiple behaviors and multiple health behavior change. In particular, we suggest three approaches, including (1) a behavior change principles
Corresponding author. Fax: +1 859 257 4103. E-mail address: snoar2@uky.edu (S.M. Noar). 0091-7435/$ - see front matter 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2007.08.001

approach; (2) a global health/behavioral category approach; and (3) a multiple behavioral approach. Given that so little theoretical work currently exists in this area, our main purpose is to advance the conversation on how health behavior theory can help us to achieve a greater understanding of multiple behavior change. The approaches discussed have implications for both theory-testing as well as intervention design. Health behavior theory Reviews of the literature (Glanz et al., 1997; Noar, 2007; Noar and Zimmerman, 2005) have suggested that the most commonly used individual-level theories of health behavior and behavior change include the Health Belief Model (HBM; Becker, 1974), Theories of Reasoned Action (TRA; Ajzen and Fishbein, 1980) and Planned Behavior (TPB; Ajzen, 1991), Social Cognitive Theory (SCT; Bandura, 1986), and the Transtheoretical Model (TTM; Prochaska and DiClemente, 1983). Newer theories, such as the InformationMotivation Behavioral Skills Model (IMB; Fisher and Fisher, 2002) and the Precaution Adoption Process Model (PAPM; Weinstein and Sandman, 2002), have also been receiving increasing attention.

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While these theories all have differences among them, the vast majority contain common factors widely believed to be important to behavior and behavior change (Fishbein et al., 2001; Noar and Zimmerman, 2005; Weinstein, 1993). In particular, most of the theories suggest that the most proximal influences on health behavior are attitudinal, social influence, self-efficacy and intention/stage of change variables (Fishbein et al., 2001; Noar, 2006), although differing terms are sometimes used for similar or identical concepts (Nigg et al., 2002; Noar and Zimmerman, 2005). While there is consensus on the importance of a number of these theoretical factors to health behavior change, there is much less consensus as to how these factors combine to predict the enactment of health behavior or health behavior change (Fishbein et al., 2001; Noar and Zimmerman, 2005; Weinstein, 1993). In addition, while most of these theories describe factors that predict ongoing behaviors and as such have been termed theories of behavioral prediction (Fishbein et al., 2001), the TTM and PAPM focus more explicitly on behavior change, in particular as a progression through a series of discrete stages (see Noar, 2007; Weinstein et al., 1998). While theories of behavioral prediction are concerned with factors that serve as determinants of ongoing behaviors (typically in an attempt to understand why some individuals engage in a behavior while others do not), behavior change theories are focused more on identifying the processes that individuals engage in when they actually change their behavior (Fishbein et al., 2001; Weinstein et al., 1998). In the current article, we are focused on both goals understanding ongoing health behaviors as well as health behavior change. However, since the ultimate goal of all of the theories is to identify factors that can influence health behavior change (either naturally or through formalized interventions), our primary focus is similarly on health behavior change. Traditionally, these health behavior theories have been applied in studies to a single behavior at a time, advancing our understanding of that particular behavior but providing little guidance on multiple behaviors and the process of multiple behavior change. Next, we discuss some specific ways in which these theories might be applied to multiple behavior change. Behavior change principles approach Health behavior theories are attempts to describe why individuals do or do not engage in particular health behaviors and how individuals go about changing their unhealthy to healthy behaviors. Thus, each theory suggests behavioral principles that are proposed to be common across health behaviors. That is, none of the theories listed above suggests that their application should significantly differ depending on which behavior is under study. Thus, if these theories apply equally across health behaviors, then a common set of behavior change principles could be derived and applied across health behaviors. From this perspective, one set of principles would be capable of explaining most or all health behaviors and an intervention might teach individuals the key principles of behavior change as well as how to apply those principles across health behaviors.

A critical question that must be asked, however, is whether there are in fact a common set of principles of health behavior change that transcend individual health behaviors. This is an area where much data already exists, as health behavior theories have been tested across numerous health behaviors (typically, a single behavior at a time) and could potentially be synthesized and compared. The integration of findings from studies across diverse behavioral areas, however, is not what it could be. In fact, theoretical reviews and meta-analyses of the literature tend to use a single behavior paradigm and thus often review the application of theory to a single behavioral domain, precluding comparisons from being made. Some examples of such an integrative approach, however, do exist. For instance, Godin and Kok (1996) reviewed studies of the TPB applied to numerous health-related behaviors. Across seven categories of health behaviors, they found TPB components to offer similar prediction of intention but inconsistent prediction of behavior. They concluded that the nature of differing health behaviors may require additional constructs to be added to the TPB, such as actual (versus perceived) behavioral control. Prochaska et al. (1994) examined decisional balance across stages of change for 12 health-related behaviors. Similar patterns were found across nearly all of these health behaviors, with the pros of changing generally increasing across the stages, the cons decreasing, and a pro/con crossover occurring in the contemplation or preparation stages of change. Prochaska et al. (1994) concluded that clear commonalties exist across these differing health behaviors which were examined in differing samples. Finally, Rosen (2000) examined change processes from the TTM across six behavioral categories, examining whether the trajectory of change processes is similar or different across stages of change in those health areas. He found that for smoking cessation, cognitive change processes were used more in earlier stages of change than behavioral processes, while for physical activity and dietary change, both categories of change processes increased together. Rosen (2000) concluded that while the use of change processes varies by stage, these patterns differ across different health areas. Clearly, more work is needed to better integrate the existing literature in this area and more clearly understand whether a common set of behavioral principles does indeed exist. In particular, additional meta-analytic projects across behaviors are necessary to shed light on potential common and/or unique mechanisms of health behavior and health behavior change. Such a focus brings the field back to basic but compelling questions such as whether or not there are theoretical differences in addictive versus non-addictive behaviors, one-time behaviors versus those that are maintained, and adoption versus cessation behaviors (see Noar and Zimmerman, 2005). Global health/behavioral category approach A second approach is the following: Rather than applying theoretical concepts to specific behaviors, such concepts might be applied at the general or global level in order to understand

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broader attitudes or orientations that may underlie the adoption of multiple health behaviors. As appealing as this idea is, such an approach has typically had little success. For example, Ajzen and Timko (1986) examined beliefs and attitudes of 24 healthrelated behaviors, including a variety of general health attitudes. Results indicated that a variety of general health attitudes were largely unrelated to a number of health behaviors, while behavior-specific attitudes predicted behavior more precisely. Studies of self-efficacy have resulted in similar findings (e.g., Ajzen and Timko, 1986; Bandura, 1997; Strecher et al., 1986). Are such studies conceptualizing global health attitudes and self-efficacy in the right manner, however? That is, a general orientation toward health may not lead directly to specific health behaviors, but it may increase the chances of particular health-related attitudes, which may in turn lead to specific health behaviors. In fact, although Ajzen and Timko (1986) found general health attitudes to be poor predictors of behavior, such attitudes were significantly related to specific health attitudes and perceived behavioral control over specific behaviors. In addition, although Bandura (1997) suggests that

there is not a global health self-efficacy factor or trait, he does suggest that there is some commonality to self-efficacy, particularly when there is similarity in functions and sub-skills within a class of behaviors (see Bandura, 1991). Might there be an underlying general health orientation that could contribute to our understanding of multiple health behaviors and multiple behavior change? Moreover, it is likely that when we consider multiple behaviors that we may discover an entire network of health attitudes and beliefs that are interrelated. In fact, studies of single behaviors essentially take those behaviors out of the multiattitude and multi-behavioral context in which they are embedded. For instance, although attitudes toward walking may be a better predictor of walking behavior than attitudes toward physical activity (Ajzen and Fishbein, 1980), walking behavior is part of a larger physical activity behavioral category. While predicting that particular behavior may be best served by the specific measure, the larger category is both relevant and of interest (Hornik, 2007). Thus, it may be that there are higher order constructs to be understood here, in that

Fig. 1. Hypothesized hierarchical structure of health behavior attitudes.

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(1) global health attitudes predict attitudes (or global selfefficacy predicts self-efficacy) toward behavioral categories; (2) attitudes toward behavioral categories predict attitudes toward specific behaviors; and (3) attitudes toward specific behaviors predict those actual behaviors (see Fig. 1). Moreover, in the case of individuals affected by chronic diseases such as cardiovascular disease and diabetes, rather than general health as an organizing construct, the disease itself (managed through a set of health behaviors) would likely be more appropriate. There is again a network of attitudes to be understood with regard to the multitude of behaviors associated with management or prevention of chronic disease. Such an approach may move us in the direction of recognizing the broader context in which health behavior operates, and may help us to uncover more general health dimensions to be understood (e.g., an active lifestyle, successful aging, etc.). Multiple behavioral approach

haviors. Such studies have found smokers to be in earlier stages of change for physical activity and dietary fat intake when compared to non-smokers (Emmons et al., 1994); statistically significant associations among stages of change for exercise and nutrition (Clark et al., 2005); and various associations among stages of change for 10 health behaviors (Nigg et al., 1999). These studies have raised the additional question of which behavior or behavior(s) individuals should try and change first, and whether there are so-called gateway behaviors. For instance, should smokers in the Emmons et al. (1994) study be treated for smoking, diet, or exercise first, or should treatments occur simultaneously? These are additional questions in need of further investigation. While some of the answers may come from basic theory-testing research, it should also be acknowledged that experiments and interventions may be necessary in shedding light on theoretical questions in this area (Rothman, 2004; Weinstein, 2007). Implications for interventions

A third approach is a multiple behavioral approach, or one which focuses on the linkages among health behaviors. It shares some similarities to the approach just described. Here the focus is more strictly on how particular health behavior constructs relate to one another, however, and this approach raises compelling theoretical questions as to how individuals actually change multiple health behaviors (e.g., sequentially or simultaneously). Although most studies to date have not taken such an approach, a few studies do exist to exemplify it. King et al. (1996) applied constructs from the TTM (stage of change, decisional balance and self-efficacy) in order to examine associations between exercise and smoking cessation variables in a work site sample of N = 332 smokers. They found significant positive associations between the cons of smoking and pros of exercise as well as between self-efficacy to refrain from smoking and exercise self-efficacy. In addition, those further along the stages of change for exercise were more likely to report higher self-efficacy to refrain from smoking, and the reverse of this was also true. King et al. (1996) concluded that multiple behavior change may be more likely to occur sequentially (versus simultaneously), as those who had successfully changed one behavior were more likely to be motivated to change another. Grembowski et al. (1993) examined self-efficacy and outcome expectancies in five health behaviors including exercise, dietary fat intake, weight control, alcohol intake, and smoking in a sample of N = 2524 older adults. They found that self-efficacy beliefs for all five behaviors were inter-correlated, with small to moderate correlations among the five. Smoking and alcohol intake, and exercise, diet, and weight control, respectively, were found to make up two separate factors. Results for outcome expectancies were similar although all five expectancies were found to form a single factor. In addition, self-efficacy for one behavior was found to correlate with outcome expectancies for the other behaviors. Grembowski et al. (1993) concluded that although self-efficacy varies by behavior, there appears to be some generality to self-efficacy in behavioral areas that are similar. Finally, studies taking this approach have examined interrelationships among stages of change for various health be-

Each of the approaches discussed in the current article has implications for interventions to change multiple health behaviors. For instance, a behavior change principles approach suggests interventions teach individuals common principles of behavior change as well as how to apply those principles to a variety of health behaviors. In fact, interventions such as Life Skills Training have for years taken the approach of focusing on general skills and abilities as a route to multiple behavior change (Botvin and Griffin, 2004). The Life Skills program emphasizes personal self-management skills, including decision-making/problem-solving skills, media literacy, and emotional coping skills; social skills, including initiating social interactions and relationship/dating skills; and drug-related information and skills. Such a program, by teaching general life skills, encourages adolescents not only to reject drug use but to learn skills they can apply to other behavioral areas. In fact, even though Life Skills does not directly address sexual behavior, a recent evaluation found protective of effects of the program on later HIV risk behavior (Griffin et al., 2006). In addition, some emerging multiple behavior change interventions have used what amounts to a behavior change principles approach. Namely, such studies have applied the same theoretical model to numerous single behaviors and intervened on those behaviors concurrently (e.g., Prochaska et al., 2005). Although the behaviors themselves are as diverse as smoking, diet, physical activity, and mammography, the theoretical principles used to drive behavior change are the same for all of the behaviors. Namely, positive aspects of the healthy behavior are highlighted while negative aspects are decreased, self-efficacy for the behavior is enhanced, and use of change processes which drive movement through the stages of change is encouraged (Prochaska et al., 2005). In this manner, participants may internalize common principles of behavior change communicated to them across a number of health behaviors, which may result in synergistic change effects. A global health/behavioral category approach suggests promoting broader-based health categories as routes to

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promoting specific health behaviors, such as promoting a healthy lifestyle as a route to multiple behavioral changes. In fact, while promising interventions consistent with this approach exist for individuals with disease states such as cardiovascular disease and diabetes (Goldstein et al., 2004), many fewer interventions exist for individuals who are healthy or who may become at risk for such diseases. A recent adolescent obesity prevention intervention in a rural setting illustrates such an approach (Hawley et al., 2006). The overriding focus of this intervention is to achieve and maintain a healthy weight (i.e., obesity prevention). This is accomplished through particular changes in the behavioral categories of diet and physical activity, which can be achieved through changes in a variety of specific behaviors. The specific actions taken may vary greatly from person to person, and such an approach puts a focus on the issue of choice. For example, whereas one individual may choose to have a very strict diet and only limited physical activity, another individual may make fewer dietary changes but focus more on adopting vigorous physical activities. Such an approach would focus on the outcome of healthy weight as a conceptual category to organize and ultimately drive a multitude of possible behavioral changes. As such, the intervention is organized around the broader health category of weight which, incidentally, would likely be more motivating to an audience of adolescents as compared to other broader-based health categories (e.g., healthy lifestyle, heart health). Finally, a multiple behavioral approach suggests intervening on behaviors that hold similarities or have relationships with one another, such as drinking and smoking (Goldstein et al., 2004) diet and exercise (Clark et al., 2002), or drinking and risky sex (Brown and Vanable, in press). In addition, such an approach suggests interventions focus on sequential rather than simultaneous changes in health behaviors, as individuals who have recently successfully changed one behavior may be more motivated (e.g., have higher self-efficacy) to try and change another (Emmons et al., 1994; King et al., 1996). For instance, Spring et al. (2004) conducted a multiple behavior change intervention with female smokers, targeting smoking cessation, diet, and exercise, and using the rationale that quitting smoking would create a teachable moment for other health behavior changes, particularly those related to weight gain. Results indicated that weight control treatment did not undermine smoking treatment and results most strongly supported a sequential approach in which smoking was treated first followed by weight control. The issue of sequential versus simultaneous multiple behavior change has already stimulated a variety of intervention studies, with at least two interventions finding support for sequential over simultaneous multiple behavior change (Spring et al., 2004; Vandelanotte et al., 2007). Other studies, however, have found simultaneous multiple behavior change interventions to have beneficial effects (Prochaska et al., 2004; Prochaska et al., 2005; Smeets et al., 2007) or to in fact be superior to sequential interventions (Hyman et al., 2007). More research is clearly needed on the critical question of how best to implement and sequence multiple health behavior interventions.

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