Copyright © 1998 Elsevier Science Ltd. All rights reserved.

8.01
Health Behavior
MARK CONNER
University of Leeds, UK
and
PAUL NORMAN
University of Sheffield, UK

8.01.1 INTRODUCTION 2
8.01.2 KEY BEHAVIORS INFLUENCING HEALTH, MORBIDITY, AND MORTALITY 2
8.01.2.1 Introduction 2
8.01.2.2 Smoking 3
8.01.2.3 Diet 3
8.01.2.4 Exercise 3
8.01.2.5 Other Behaviors 4
8.01.3 UNDERSTANDING THE BASIS OF HEALTH BEHAVIOR 5
8.01.3.1 Introduction 5
8.01.3.2 Health Belief Model 6
8.01.3.2.1 Model description 6
8.01.3.2.2 Review of research 7
8.01.3.2.3 Commentary 8
8.01.3.3 Theory of Planned Behavior 8
8.01.3.3.1 Model description 8
8.01.3.3.2 Review of research 10
8.01.3.3.3 Commentary 11
8.01.3.4 Health Locus of Control 12
8.01.3.4.1 Model description 12
8.01.3.4.2 Review of research 12
8.01.3.4.3 Commentary 13
8.01.3.5 Protection Motivation Theory 14
8.01.3.5.1 Model description 14
8.01.3.5.2 Review of research 15
8.01.3.5.3 Commentary 17
8.01.3.6 Self-efficacy 17
8.01.3.6.1 Model description 17
8.01.3.6.2 Review of research 18
8.01.3.6.3 Commentary 18
8.01.4 ENCOURAGING THE ADOPTION OF HEALTH BEHAVIORS 19
8.01.4.1 Intervention Studies 19
8.01.5 LIMITATIONS AND EXTENSIONS OF EXISTING MODELS 21
8.01.5.1 Limitations of Current Models 21
8.01.5.2 Additional Theoretical Constructs 22
8.01.5.3 Processes by which Cognitions Influence Behavior 24
8.01.5.4 Stage Models of Health Behavior 24
8.01.5.5 Theoretical Integrations and Future Directions 27

1
2 Health Behavior
8.01.6 CONCLUSIONS
8.01.7 REFERENCES
8.01.1 INTRODUCTION
Interest in health behaviors is derived from
two assumptions; that a substantial proportion
of the mortality from the leading causes of death
is attributable to the behavior of individuals,
and that the behavior is modifiable (Stroebe &
Stroebe, 1995). It is now widely recognized that
individuals can influence their own health and
well-being through the adoption of health-
enhancing behaviors (e.g., exercise) and the
avoidance of health-compromising behaviors
(e.g., smoking). The identification of the factors
which predict who engages in health behaviors
has become a focus of research in health
psychology and other health-related disciplines
in recent years (e.g., Adler & Matthews, 1994;
Conner & Norman, 1996a; Glanz, Lewis &
Rimmer, 1990; Hockbaum & Lorig, 1992;
Rodin & Salovey, 1989; Winett, 1985).
The health behaviors examined have been
many and varied; from health enhancing
behaviors such as exercise and healthy eating,
on the one hand, to avoidance of health harming
behaviors such as smoking and excessive
alcohol consumption, on the other. Each of
these behaviors have immediate or long-term
effects upon the individual's health and are to
varying extents within the individual's control.
Epidemiological studies reveal great variability
in who performs these behaviors. The ap-
proaches taken to understanding such indivi-
dual differences have been equally varied. One
can classify these approaches into those which
examine factors intrinsic to the individual (e.g.,
sociodemographic factors, personality, social
support, cognitions) and those which examine
factors extrinsic to the individual. This second
group of approaches can be further divided into
those based on incentive structures (e.g., taxing
tobacco and alcohol, subsidizing sports facil-
ities) and those based on legal restrictions (e.g.,
banning dangerous substances, financial penal-
ties for not wearing seat-belts). The first
approach (factors intrinsic to the individual)
has received most attention from psychologists,
with a particular focus on cognitive factors as
the most important proximal determinants of
behavior. A variety of models of how such
cognitive factors produce various ªsocialº
behaviors have been developed and are com-
monly referred to as social cognition models
(SCMs). SCMs are recognized to have made a
valuable contribution to the understanding of
both who performs health behaviors (Conner &
28
28
Norman, 1996b; Marteau, 1989) and how
extrinsic factors produce behavior change
(e.g., Rutter & Quine, 1996).
This chapter examines the key health beha-
viors and ways in which their adoption might
be encouraged. The chapter then considers the
contribution psychology has made to under-
standing and changing health behaviors
through the development of SCMs. The most
widely applied SCMs are described and re-
viewed along with recent developments and
future prospects for this field of research.
8.01.2 KEY BEHAVIORS INFLUENCING
HEALTH, MORBIDITY, AND
MORTALITY
8.01.2.1 Introduction
We might define health behavior as any
activity taken for the purpose of preventing or
detecting disease or for improving general well-
being (Conner & Norman, 1996b). The beha-
viors within this definition include medical
service usage (e.g., physician visits, vaccination,
screening), compliance with medical regimens
(e.g., dietary, diabetic, antihypertensive regi-
mens), and self-directed health behaviors (e.g.,
diet, exercise, smoking, alcohol consumption).
Numerous studies have examined the rela-
tionship between health behaviors and health
outcomes (e.g., Black Report, 1988; Blane,
Smith, & Bartley, 1990; Blaxter, 1990; Cox,
Huppert, & Whichelow, 1993; Doll, Peto,
Wheatley, Gray, & Sutherland, 1994; Gottlieb
& Green, 1984). Such studies demonstrate the
role of a variety of behaviors for both morbidity
and mortality. One of the first such studies in
Alameda County identified seven features of
lifestyle: not smoking, moderate alcohol intake,
sleeping 7±8 hours per night, exercising reg-
ularly, maintaining a desirable body weight,
avoiding snacks, and eating breakfast regularly
which together were associated with lower
morbidity and higher subsequent long-term
survival (Belloc, 1973; Belloc & Breslow, 1972;
Breslow & Enstrom, 1980). Such results have
been replicated in a variety of different popula-
tions (e.g., Brock, Haefner, & Noble, 1988;
Metzner, Carman, & House, 1983). The impact
of health behaviors upon individuals' quality of
life, via delaying the onset of chronic disease and
extending active life span, should also be noted
(Fries, Green, & Levine, 1989; Stroebe &
Stroebe, 1995). Smoking, alcohol consumption,
 Key Behaviors Influencing Health, Morbidity, and Mortality
diet, gaps in primary care services and low
screening uptake are all significant determi-
nants of poor health (Amler & Dull, 1987). Such
findings have led to a focus by those interested
in health promotion on changing such beha-
viors in order to improve health. For example,
in the USA, Healthy People 2000 (USDHHS,
1990) lists increased physical activity, changes in
nutrition and reductions in tobacco, alcohol,
and drug use as important for health promotion
and disease prevention.
Below we examine several health behaviors in
more detail, focusing on their prevalence and
relationship to health outcomes.
8.01.2.2 Smoking
Smoking is the behavior most closely linked
with long-term negative health outcomes. Both
morbidity and mortality from coronary heart
disease (CHD) are increased among smokers
(Doll et al., 1994; Friedman, Dales, & Ury,
1979). Moreover, there is a strong positive
relationship between the number of cigarettes
smoked per day and the incidence of CHD
(Friedman et al., 1979). In addition, smoking
has been linked to a number of cancers in-
cluding cancer of the lung, throat, stomach, and
bowel as well as a number of more immediate
negative health effects such as reduced lung
capacity and bronchitis (Royal College of
Physicians, 1983). Despite the array of negative
health outcomes, smokers often report positive
mood effects from smoking and the use of
smoking as a coping strategy (Graham, 1987).
The number of people smoking in the USA
and UK has shown a steady decline over the
past 20 years. Data from the General House-
hold Survey (1992) showed that 28% of people
over the age of 16 smoke in the UK. Smoking is
more common among men and among un-
skilled manual workers (General Household
Survey, 1994). A similar pattern is evident in the
USA, with smoking more common among less
educated, lower income, and minority groups
(Rigotti, 1989). Those who quit smoking reduce
the risk to their health, particularly if they quit
before 35 years of age (Doll et al., 1994).
8.01.2.3 Diet
The impact of various aspects of diet upon
health, morbidity, and mortality are well
established (USDHHS, 1988). Whilst in the
Third World the problems related to diet and
health are ones of undernutrition, in the First
World, the problems are predominantly linked
to overconsumption of food. In Western
industrialized countries the major problems
3
are linked to excessive fat consumption and
insufficient fiber, fruit, and vegetable consump-
tion. In addition, excess consumption of cal-
ories combined with insufficient exercise has
made obesity a major health problem. Diet has
been implicated in cardiovascular diseases
(CVDs), strokes and high blood pressure,
cancer, diabetes, obesity, osteoporosis, and
dental disease.
It is generally agreed that elevated blood
cholesterol level is a major risk factor for the
development of CVD (Consensus Development
Conference on Lowering Blood Cholesterol to
Prevent Heart Disease, 1985). Nutbeam and
Catford (1990) estimate that 26% of men and
25% of women in the UK have cholesterol levels
greater than 6.5 mmol l71 (a level considered to
be excessive). While in the USA, it is estimated
that 50% of the adult population is at risk of
CHD by virtue of elevated blood cholesterol
levels (Sampos, Fulwood, Haines et al., 1989).
International studies have clearly demonstrated
an association between saturated fat consump-
tion (one source of cholesterol) and blood
cholesterol levels. For example, Keys (1970)
reported a correlation of 0.89 across the seven
countries studied. The reduction of blood
cholesterol via dietary change is now widely
accepted as an important way of tackling CHD
(Expert Panel, 1993). Drug treatment to reduce
blood cholesterol levels is generally seen as only
advisable if dietary change is ineffective (War-
dle, 1995). Dietary recommendations include
reducing fat in the diet and increasing soluble
fiber intake (Committee on Medical Aspects of
Food Policy, 1991; Expert Panel, 1993). How-
ever, their impact upon cholesterol levels may be
limited.
8.01.2.4 Exercise
Engaging in regular exercise is seen to be
another key component of a healthy lifestyle.
The potential health benefits of engaging in
regular exercise are many and include reduced
cardiovascular morbidity and mortality (Ober-
man, 1985), lowered blood pressure (Blair,
Goodyear, Gibbons, & Cooper, 1984) and the
increased metabolism of carbohydrates (Len-
non et al., 1983) and fats (Rosenthal, Haskell,
Solomon, Widstrom, & Reavan, 1983), as well
as a range of psychological benefits such as
improved self-esteem (Sachs, 1984), positive
mood states (Folkins & Sime, 1981), reduced life
stress (Brown, 1991), and reduced levels of
anxiety (Singer, 1992).
However, despite the various health benefits
of exercise, a significant proportion of the
population lead a sedentary lifestyle. For
4 Health Behavior
example, the General Household Survey (1989)
indicated that only one in three men and one in
five women in the UK participate in any sport or
recreational physical activity. Moreover, the
Allied Dunbar Fitness Survey (1992) of 6000
English adults reported that one in six adults
had done no exercise (i.e., for 20 minutes or
more at a moderate or vigorous level) in the
previous four weeks. Participation in regular
exercise is strongly related to a number of socio-
demographic variables. In particular, young
people and males are more likely to engage in
regular exercise. For example, the 1988 Welsh
Heart Health Survey (Health Promotion
Authority for Wales, 1990) reported that among
18±34 year olds, 61% of men engaged in
moderately vigorous exercise at least two times
a week compared with only 35% of women. For
35±64 year olds, the percentages drop to 37%
for men and 17% for women. Overall, the
typical exerciser is likely to be young, well-
educated, affluent, and male (King et al., 1992).
8.01.2.5 Other Behaviors
A number of other behaviors show clear links
to health. Below we briefly consider recreational
drug use, safe sex, alcohol use, and health
screening as behaviors with important health
consequences.
The use of recreational drugs has long been
recognized as a potential health problem which
needs to be tackled (Aguirre-Molina & Gor-
man, 1996). The most commonly used drugs are
alcohol and tobacco, however, here we consider
what are usually referred to as psychoactive
drugs (i.e., a drug that alters mood or behavior).
There are a large number of such drugs
including hypnotic drugs such as barbiturates
which reduce anxiety and produce sedation;
stimulants such as amphetamines which elevate
mood, increase wakefulness, and give an
enhanced sense of mental and physical energy;
opiates such as opium and heroin which
produce pleasant mood states; antipsychotic
agents such as chlorpromazine which diminish
the symptoms of psychoses; and psychedelics/
hallucinogens such as LSD, cannabis, and
MDMA (3,4-methylenedioxymethampheta-
mine) which cause visual and auditory halluci-
nations. Most of these drugs have medical uses
as well as being used recreationally.
Data from various drug use surveys in the UK
(e.g., Leitner, Shapland, & Wiles, 1993) suggest
that opiate use has remained stable (at around
1%), but the use of cannabis and other
nonopiates has been on the increase over the
last 25 years. The 1968 OPCS survey reported
that 2% of the 16 years and over age group had
used cannabis at some stage, while the Leitner
et al. (1993) study reported that 10% of the same
age group had used it. In general, drug use in the
UK does not differ substantially from the rest of
the Western world. Reported lifetime usage in
the USA is slightly higher than in the UK,
although estimates for injecting use (1±2% of
the general population), alcohol use (around
85%), and lifetime tobacco use (around 75%)
are roughly similar.
Sexual behaviors have also long been con-
sidered health behaviors because of their impact
upon the spread of sexually transmitted diseases
(STDs) such as gonorrhoea and syphilis. More
recently, the role of sexual behaviors in the
spread of the human immunodeficiency virus
(HIV) has been a focus of attention (O'Leary &
Raffaelli, 1996). Whilst early health education
campaigns emphasized the need to reduce the
number of sexual partners or avoid particular
sexual practices (e.g., anal sex, penetrative sex),
more recently the focus has been upon the use of
condoms during penetrative sex to reduce the
risk of HIV transmission (Reiss & Leik, 1989).
Condom use is particularly recommended for
those with multiple partners or those who do not
know their partners' sexual history. For these
reasons, much of the health advice concerning
condom use has been focused on young people.
There seems to be considerable variation in
the use of condoms in response to the threat of
HIV/AIDS. For example, among heterosexuals,
Richard and van der Pligt (1991) reported that
50% of their sample of Dutch teenagers with
multiple partners consistently used condoms.
While other studies in the UK and USA report
rates of between 24% and 58% (Fife-Schaw &
Breakwell, 1992; Gerrard, Gibbons, & Bush-
man, 1996). Among homosexuals, Weather-
burn, Hunt, Davies, Coxon, and McManus
(1991) reported that 39% of their sample always
used a condom during anal sex. Whilst among
bisexuals, Boulton, Schram Evans, Fitzpatrick,
and Hart (1991) report that 25% of their male
sample used condoms with their current male
partner and only 12% with their current female
partner. The General Household Survey (1993)
in the UK reported changes by age group in the
use of condoms for the period 1983±1991.
Among 16±24-year-olds, condom use increase
from around 6% to around 12% during this
period, whilst among 40±49-year-olds it
dropped from around 18% to around 12%
over the same period. Thus, health messages
aimed at increasing condom use may be having
some impact among younger people, although
the overall rates of use are still worrying low.
High alcohol consumption has been linked to
a range of negative health outcomes including
high blood pressure (Shaper et al. 1981), heart
 Understanding the Basis of Health Behavior
disease (Sherlock, 1982), and cirrhosis of the
liver (Colliver & Malin, 1986), although there is
some evidence to suggest that low levels of
alcohol consumption may have slightly bene-
ficial effects on health (Hennekens, 1983). High
levels of alcohol consumption have also been
associated with accidents, injuries, suicides,
crime, domestic violence, rape, murder, and
unsafe sex (British Medical Journal, 1982).
While many of the adverse effects of high
alcohol consumption are due to continued
heavy drinking (e.g., cirrhosis of the liver, heart
disease), others are more specifically related to
excessive alcohol consumption in a single
drinking session (e.g., accidents, violence)
(Honkanen et al., 1983).
The General Household Survey (1992) re-
ported that the average weekly consumption of
alcohol in the UK was 15.9 units (approxi-
mately 8 pints of beer) for men and 5.4
(approximately 2.5 pints of beer) for women.
Of more interest was the finding that about 27%
of men and 11% of women were drinking more
than the recommended weekly sensible limits
(21 units for men, 14 units for women). Heavy
drinking is also more likely among younger age
groups. In a survey of 12 000 Welsh adults,
Moore, Smith, and Catford (1994) reported that
31.1% of drinkers aged 18±24 engaged in binge
drinking (i.e., drinking half the recommended
weekly consumption of alcohol in a single
session) at least once a week.
Finally, individuals may seek to protect their
health by participating in various screening
programs which attempt to detect disease at an
early, or asymptomatic, stage. In the UK,
screening programs have been set up for various
diseases including anemia (Ashworth, 1963),
diabetes (Redhead, 1960), bronchitis (Gregg,
1966), cervical cancer (Freeling, 1965), and
breast cancer (Forrest, 1986). Considering
breast cancer, it has been estimated that breast
screening programs which include mammo-
grams can reduce breast cancer mortality by up
to 40% among women aged 50 and over (Strax,
1984). However, participation rates in breast
screening programs show great variability
across different countries, ranging from 25%
to 89% (Vernon, Laville, & Jackson, 1990).
Participation tends to be negatively related to
age and positively related to education level and
socioeconomic status (Vernon et al., 1990).
8.01.3 UNDERSTANDING THE BASIS OF
HEALTH BEHAVIOR
8.01.3.1 Introduction
A clearer understanding of why individuals
perform health behaviors might assist in the
5
development of interventions to help indivi-
duals gain the benefits of improved health and
well-being. A variety of factors have been found
to account for individual differences in the
performance of various health behaviors,
including demographic factors, social factors,
emotional factors, perceived symptoms, factors
relating to access to medical care, personality
factors, and cognitive factors (Adler & Mat-
thews, 1994; Rosenstock, 1974; Taylor, 1991).
Demographic variables show reliable asso-
ciations with the performance of health beha-
viors. For example, there is a curvilinear
relationship between many health behaviors
and age, with high incidences of many health-
risking behaviors such as smoking in young
adults and much lower incidences in children
and older adults (Blaxter, 1990). Such behaviors
also vary by gender, with females being
generally less likely to smoke, consume large
amounts of alcohol, engage in regular exercise
but more likely to monitor their diet, take
vitamins, and engage in in dental care (Wal-
dron, 1988). Differences by socioeconomic
status and ethnic group are also apparent for
behaviors such as diet, exercise, alcohol con-
sumption, and smoking (e.g., Blaxter, 1990).
Generally speaking, younger, wealthier, better
educated individuals, under low levels of stress,
with high levels of social support, are more
likely to practice health enhancing behaviors.
Higher levels of stress and/or fewer resources
are associated with health-compromising beha-
viors such as smoking and alcohol abuse (Adler
& Matthews, 1994).
Social factors seem to be important in
instilling health behaviors in childhood. Parent,
sibling, and peer influences are important, for
example, in the initiation of smoking (e.g.,
McNeil et al., 1988). Cultural values also have a
major impact, for instance in determining the
number of women exercising in a particular
culture (e.g., Steptoe & Wardle, 1996). For
example, Steptoe and Wardle (1992) report that
between 34% and 95% of women in their
European student sample had exercised in the
past 14 days. Perceived symptoms control
health habits when, for example, smokers
regulate their smoking on the basis of sensations
in the throat. Access to medical care has been
found to influence the use of such health services
(e.g., Black Report, 1988). Personality factors
have also been associated with health behaviors
(Adler & Matthews, 1994; Steptoe et al., 1994).
Cognitive factors also determine whether or
not an individual practices health behaviors.
Knowledge about behavior±health links is an
important factor in an informed choice con-
cerning a healthy lifestyle. Various other
cognitive variables have been studied including
6 Health Behavior
perceptions of health risk, efficacy of behaviors
in influencing this risk, social pressures to
perform the behavior, and control over perfor-
mance of the behavior. The relative importance
of various cognitive factors in determining who
performs various health behaviors constitutes
the basis of different models. Such models have
been labeled SCMs because of their focus on
cognitive variables as the primary determinant
of individual social behaviors.
Two types of SCMs have been applied in
health psychology, predominantly to explain
health-related behaviors and response to treat-
ment (Conner, 1993). The first type focus on
individuals' understanding of the causes of
health-related events and are best typified by
attribution models (e.g., King, 1982). The
second type are more diverse in nature and
attempt to predict future health-related beha-
viors and outcomes. These include the health
belief model (HBM; e.g., Becker, 1974; Janz &
Becker, 1984; Sheeran & Abraham, 1996),
health locus of control (HLOC; Norman &
Bennett, 1996; Seeman & Seeman, 1983; Wall-
ston, Wallston, & De Vellis, 1978), protection
motivation theory (PMT; e.g., Boer & Seydel,
1996; Rogers, 1983; van der Velde & van der
Pligt, 1991), theory of reasoned action/theory of
planned behavior (TRA/TPB; e.g., Ajzen, 1988;
1991; Ajzen & Fishbein, 1980; Conner & Sparks,
1996), and self-efficacy (SE; e.g., Bandura, 1982,
1991; Schwarzer, 1992; Schwarzer & Fuchs,
1996). Other models include self-regulation
theory (Leventhal, Nerenz, & Steele, 1984),
the transtheoretical model of change (Prochas-
ka & DiClemente, 1984), the precaution-adop-
tion process (Weinstein, 1988), and the model of
goal achievement (Bagozzi, 1992). However,
none of these latter models have been widely
applied to the prediction of health behaviors at
present.
These social cognition models provide a basis
for understanding the determinants of behavior
and behavior change. Each of these models
emphasize the rationality of human behavior,
although they do not assume that all behavior is
based upon careful thought (Ajzen, 1996). Most
assume that behavior and decisions are based
upon elaborate, but subjective, cost/benefit
analysis of the likely outcomes of differing
courses of action. As such they have roots going
back to expectancy-value theory (Peak, 1955)
and subjective expected utility theory (SEU;
Edwards, 1954). It is assumed that individuals
generally aim to maximize utility and so prefer
behaviors which are associated with the highest
expected utility (Van der Pligt & de Vries, 1998).
Whilst such considerations may well provide
good predictions of which behaviors are
selected, it has been noted by several authors
that they do not necessarily provide an adequate
description of the way in which individuals
make decisions (e.g., Edwards, 1992; Feather,
1982; Frisch & Clemen, 1994; Jonas, 1993).
In the section which follows, the most widely
used of these models (HBM, TPB, HLOC,
PMT, SE) are outlined, the research using them
described, and their use reviewed.
8.01.3.2 Health Belief Model
8.01.3.2.1 Model description
The HBM is probably the most widely used
social cognition model in health psychology
(Becker, 1974; Rosenstock, 1966; Sheeran &
Abraham, 1996). It was originally developed by
US public health researchers attempting to
develop models upon which to base health
education programs (Hochbaum, 1958; Rosen-
stock, 1966). The model attempts to conceptua-
lize the health beliefs which make a behavior
more or less attractive. In particular, the key
health beliefs were seen to be the likelihood of
experiencing a health problem, the severity of
the consequences of the health problem, and the
perceived costs and benefits of the health
behavior. Thus, the HBM employs two aspects
of individuals' representations of health beha-
vior in response to threat of illness: perceptions
of the threat of illness and evaluation of the
effectiveness of behaviors to counteract this
threat (see Figure 1). Threat perceptions depend
upon two beliefs: the perceived susceptibility to
the illness and the perceived severity of the
consequences of the illness. Together these two
variables determine the likelihood of the
individual following a health-related action,
although their effect is modified by individual
differences in demographic variables, social
pressure, and personality. The particular action
taken is determined by evaluation of the
possible alternatives. This behavioral evalua-
tion depends upon beliefs concerning the
benefits or efficacy of the health behavior and
the perceived costs or barriers to performing the
behavior. Hence, individuals are likely to follow
a particular health action if they believe
themselves to be susceptible to a particular
condition or illness which they consider to be
serious, and believe the benefits of the action
taken to counteract the condition or illness
outweigh the costs. Cues to action and health
motivation are two other variables commonly
included in the model. Cues to action include a
diverse range of triggers to the individual taking
action and are commonly divided into factors
which are internal (e.g., physical symptom) or
external (e.g., mass media campaign, advice
from others such as physicians) to the individual
(Janz & Becker, 1984).
 Understanding the Basis of Health Behavior 7

EXTERNAL
VARIABLES Threat (motivation)
Demographic
variables Perceived susceptibility
Age, sex,
occupation,
socioeconomic status, Perceived severity
religion, education

Personality traits

Extraversion
Health motivation Behavior
Agreeableness

Conscientiousness

Neuroticism Response effectiveness

Openness
Perceived benefits
Other psychological
factors Cues to action

Peer pressure Perceived barriers

Self-efficacy

Figure 1 Health belief model.

Becker (1974) has argued that the HBM
should also contain a measure of health
motivation (readiness to be concerned about
health matters) because certain individuals may
be predisposed to respond to cues to action
because of the value they place on their health.
Other influences upon the performance of
health behaviors, such as demographic factors
or psychological characteristics (e.g., person-
ality, peer pressure, perceived control over
behavior), are assumed to exert their effect
via changes in the six components of the HBM.
This is a potentially important issue if the HBM
is to claim to be a complete model of health
behavior. However, this has not been widely
addressed in empirical studies and where it has
the evidence has been equivocal. Orbell,
Crombie, and Johnson (1995), for example,
reported that HBM components did mediate
the effects of social class upon uptake of cervical
screening, but did not mediate the effects of
marital status or sexual experience.
8.01.3.2.2 Review of research
The HBM has been applied to a very broad
range of health behaviors and populations.
Sheeran and Abraham (1996) distinguish three
broad areas of research. First, the HBM has
been applied to various preventive health
behaviors. These include health-risk behaviors
such as smoking (Gianetti, Reynolds, & Rihen,
1985; Stacey & Lloyd, 1990) and alcohol use (K.
H. Beck, 1981; Gottlieb & Baker, 1986), as well
as health-promoting behaviors such as diet
(Aho, 1979), exercise (Langlie, 1977), genetic
(Becker, Kaback, Rosenstock, & Ruth, 1975)
and health screening (Conner & Norman, 1994;
King, 1982), vaccination (Oliver & Berger,
1979), breast self-examination (Champion,
1984; Ronis & Harel, 1989), contraceptive use
(Hester & Macrina, 1985), and dental behaviors
(Chen & Land, 1986). A second area the HBM
has been applied to is various sick role behaviors
which refer to compliance with professionally
recommended medical regimens in response to
illness. These include compliance with antihy-
pertensive regimens (Taylor, 1979), diabetic
regimens (Harris & Lynn, 1985), and renal
disease regimens (Hartman & Becker, 1978),
and regimens adhered to by parents for a child's
condition (Becker, Radius, & Eveland, 1978).
Third, the HBM has been applied to clinic use,
which includes physician visits for a variety of
8 Health Behavior
reasons including preventative (Aiken, West,
Woodward, Reno, & Reynolds, 1994), psychia-
tric (Connelly, 1984), and parent and child
conditions (Kirscht, Becker, & Eveland, 1976).
There is no strong evidence that the HBM has
been more predictive of behavior in any one of
these behaviors compared with any other
(Sheeran & Abraham, 1996).
There have been two quantitative reviews of
research with the HBM (Harrison, Mullen, &
Green, 1992; Janz & Becker, 1984). The first,
conducted by Janz and Becker (1984), examined
the proportion of times each of the HBM's
components showed a significant relationship
with health behavior through the use of a
ªsignificance ratio.º Across the 46 studies
reviewed, the barriers component was found
to have the most consistent relationship with
health behavior (89%), followed by the suscept-
ibility (81%), benefits (78%), and severity
(65%) components. However, while Janz and
Becker (1984) suggest that the HBM compo-
nents are consistent predictors of health
behavior, they fail to estimate the strength of
the relationships. This question was addressed
in the second quantitative review, conducted by
Harrison et al. (1992). Over 200 published
studies on the HBM were identified although
only 16 of these were found to measure each of
the components adequately. Harrison et al's
(1992) meta-analysis on these 16 studies pro-
duced a similar pattern of results to Janz and
Becker's (1984) earlier review with the barriers
components having the highest average correla-
tion with health behavior (r = 70.21), followed
by the susceptibility (r = 0.15), benefits (r =
0.13), and severity (r = 0.08) components. The
predictive power of individual components is
therefore relatively modest, accounting for only
0.5±4% of variance in behavior. However, it
should be noted that it is the combined effects of
the six health beliefs which is generally of
interest and this is commonly in excess of the
sum of the effects of the individual components.
8.01.3.2.3 Commentary
The HBM has provided a useful framework
for investigating health behaviors and identify-
ing key health beliefs, has been widely used, and
has met with moderate success in predicting a
range of health behaviors (for reviews see
Harrison et al., 1992; Janz & Becker, 1984;
Sheeran & Abraham, 1996). The strength of the
HBM lies in the fact that it was developed by
researchers working directly with health beha-
viors and so many of the concepts possess face-
validity to those working in this area. This
commonsense operationalization of a number
of cognitive variables relevant to the perfor-
mance of health behavior partly account for the
model's popularity.
However, compared to other similar social
cognitive models of health behaviors, the HBM
suffers from a number of weaknesses. The way
in which the variables in the HBM combine to
produce behavior has not been precisely
specified (but see Becker & Rosenstock, 1987)
and so the HBM is thus frequently tested as six
independent predictors of behavior. In addition,
various researchers have used somewhat differ-
ent operationalizations of the six constructs (see
Becker & Maiman, 1983; Rosenstock, 1974).
Together these factors have weakened the status
of the HBM as a coherent SCM of health
behavior (Conner, 1993; Sheeran & Abraham,
1996). Moreover, key social cognitive variables,
found to be highly predictive of behavior in
other models, are not incorporated in the HBM.
For example, intentions to perform a behavior
and social pressure are key components of the
TRA/TPB which do not appear in the HBM.
Also, perceptions of personal control over the
performance of the behavior (self-efficacy
beliefs) which have been found to be such
powerful predictors of behavior in models based
upon social cognitive theory (Bandura, 1982;
Schwarzer & Fuchs, 1996) are not explicitly
included in the HBM. In addition, in not
specifying a causal ordering among the vari-
ables, as is done in other models, more powerful
analysis of data and clearer indications of how
interventions may have their effects are pre-
cluded in the HBM. Several authors have noted,
for example, that threat is perhaps best seen as a
more distal predictor of behavior acting via
influences upon outcome expectancies. Finally,
the model is static; there is no distinction
between a motivational stage dominated by
cognitive variables and a volitional phase where
action is planned, performed, and maintained
(Schwarzer, 1992). Such distinctions are
thought to be important in understanding
various health behaviors. Hence, while an
extremely popular SCM for use in under-
standing health behavior, it is also in a number
of ways limited and may receive relatively less
attention in the future.
8.01.3.3 Theory of Planned Behavior
8.01.3.3.1 Model description
The TPB was developed by social psycholo-
gists and has been widely applied to the
understanding of a variety of behaviors includ-
ing health behaviors (Ajzen, 1988, 1991; Conner
& Sparks, 1996) (see Figure 2). The TPB details
how the influences upon an individual deter-
mine that individual's decision to follow a
 Understanding the Basis of Health Behavior
particular behavior. This theory is an extension
of the widely applied TRA (Ajzen & Fishbein,
1980; Fishbein & Ajzen, 1975). The TPB
suggests that the proximal determinants of
behavior are intentions to engage in that
behavior and perceived behavioral control over
that behavior. Intentions represent a person's
motivation in the sense of his or her conscious
plan or decision to exert effort to perform the
behavior. Perceived behavioral control is a
person's expectancy that performance of the
behavior is within his/her control. The concept
is similar to Bandura's (1982) concept of self-
efficacy (see Schwarzer & Fuchs, 1996). Control
is seen as a continuum with easily-executed
behaviors at one end and behavioral goals
demanding resources, opportunities, and spe-
cialized skills at the other.
Intentions are determined by three variables.
The first is attitudes, which are the overall
evaluations of the behavior by the individual.
The second is subjective norms, which consist of
a person's beliefs about whether significant
others think he/she should engage in the
behavior. The third is perceived behavioral
control (PBC), which is the individual's percep-
tion of the extent to which performance of the
behavior is within his/her control. In addition,
to the extent that PBC reflects actual control, it
is predicted to directly influence behavior.
Just as intentions are held to have determi-
nants, so the attitude, subjective norm, and
EXTERNAL
VARIABLES
Demographic
variables
Age, sex,
occupation, Belief Evaluation
socioeconomic about x of
status, outcomes outcomes
religion, education
Personality traits
Extraversion Normative Motivation
x Behavior
beliefs to comply
Agreeableness
Conscientiousness
Perceived Perceived
Neuroticism
likelihood facilitating/
x behavioral
Openness of inhibiting
occurrence power
Figure 2 Theory of planned behavior.
9
perceived behavioral control components are
also held to have determinants. The attitude
component is a function of a person's salient
behavioral beliefs, which represent perceived
likely consequences of the behavior. Following
expectancy-value conceptualizations (Peak,
1955), the model quantifies consequences as
being composed of the multiplicative combina-
tion of the judged likelihood that performance
of the behavior will lead to a particular outcome
and the evaluation of that outcome. These
expectancy-value products are then summed
over the salient consequences. It is not claimed
that individuals perform such calculations each
time they are faced with a decision about
whether to perform a behavior or not, but rather
the results of such considerations are main-
tained in memory and retrieved and used when
necessary (Eagly & Chaiken, 1993). However, it
is also possible for the individual to retrieve the
relevant beliefs and evaluations when necessary.
Subjective norm is a function of normative
beliefs, which represent perceptions of specific
salient others' preferences about whether one
should or should not engage in a behavior. In
the model, this is quantified as the subjective
likelihood that specific salient groups or
individuals (referents) think the person should
or should not perform the behavior, multiplied
by the person's motivation to comply with that
referent's expectation. Motivation to comply is
the extent to which the person wishes to comply
Attitude
towards
behavior
Subjective Behavioral
norm intention
Perceived
control
10 Health Behavior
with the specific wishes of the referent on this
issue. These products are then summed across
salient referents. Judgments of perceived beha-
vioral control are influenced by beliefs concern-
ing access to the necessary resources and
opportunities to perform the behavior success-
fully, weighted by the perceived power of each
factor (Ajzen, 1988, 1991). The perception of
factors likely to facilitate or inhibit the
performance of the behavior are referred to as
control beliefs. These factors include both
internal control factors (information, personal
deficiencies, skills, abilities, emotions) and
external control factors (opportunities, depen-
dence on others, barriers). People who perceive
they have access to the necessary resources and
perceive that there are the opportunities (or lack
of obstacles) to perform the behavior are likely
to perceive a high degree of behavioral control
(Ajzen, 1991). Ajzen (1991) has suggested that
each control factor is weighted by its perceived
power to facilitate or inhibit performance of the
behavior. The model quantifies these beliefs by
multiplying the frequency or likelihood of
occurrence of the factor by the subjective
perception of the power of the factor to facilitate
or inhibit the performance of the behavior.
So, according to the TPB, individuals are
likely to follow a particular health action if they
believe that the behavior will lead to particular
outcomes which they value, if they believe that
people whose views they value think they should
carry out the behavior, and if they feel that they
have the necessary resources and opportunities
to perform the behavior.
8.01.3.3.2 Review of research
The TPB has been applied to the prediction of
a number of different behaviors including
health-relevant behaviors with varying degrees
of success (Ajzen, 1991; see Conner & Sparks,
1996 for a review of the application of the TPB
to health behaviors). For example, smoking has
been a focus of several studies (Babrow, Black,
& Tiffany, 1990; Godin, Valois, Lepage, &
Desharnais, 1992). Godin et al. (1992) looked at
the prediction of the frequency of smoking in the
general public over a six-month period. The
prediction of intentions was significantly im-
proved by the addition of the PBC component,
and actual smoking behavior appeared to be
primarily related to PBC. One study has
examined drinking alcohol (Schlegel, D'Aver-
nas, Zanna, & DeCourville, 1992) and found
that PBC contributed to the predictions of
intentions but not the frequency of getting
drunk in nonproblem drinkers, while in pro-
blem drinkers, the PBC also contributed to
predictions of frequency of getting drunk.
Several studies examined condom use (Bol-
dero, Moore, & Rosenthal, 1992; Wilson,
Zenda, McMaster, & Lavelle, 1992). Nucifora,
Gallois, and Kashima (1993), for example,
examined undergraduates' use of condoms
using the TPB. PBC was found to make a small
but significant contribution to the predictions of
intentions to use condoms and actual condom
use. However, intentions appeared to be
principally determined by attitudes and sub-
jective norms, while behavior was mainly
influenced by intentions. Exercise has also been
examined in several studies (Dzewaltowski,
Noble, & Shaw, 1990; Godin & Shepherd,
1987; Norman & Smith, 1995). Dzewaltowski
et al. (1990) reported the application of the TPB
to exercise participation. Intentions were based
both upon attitudes and PBC, but not subjective
norms, whilst actual behavior seemed to be
principally determined by intentions. Breast or
testicle self-examination has been the focus of a
couple of studies (McCaul, Sandgren, O'Neill,
& Hinsz, 1993; Young, Lierman, Powell-Cope,
& Kasprzyk, 1991). McCaul et al. (1993)
showed the TRA components to predict
breast/testicle self-examination intentions and
behaviors, with PBC adding significantly to
predictions of intentions but not behavior.
A range of other behaviors have been exam-
ined using the TPB, including health screening
attendance (DeVellis, Blalock, & Sandler, 1990;
Norman & Conner, 1993), food choices (Beale
& Manstead, 1991; Sparks & Shepherd, 1992),
kidney donation (Borgida, Conner, & Manteu-
fel, 1992), drug compliance (Hounsa, Godin,
Alihonou, & Valois, 1993), patient education
(Kinket, Paans, & Verplanken, 1992), and weight
control (Netemeyer, Burton, & Johnston, 1991;
Schifter & Ajzen, 1985).
The published studies applying the TRA have
been reviewed by Sheppard, Hartwick, and
Warshaw (1988) and van den Putte (1993), with
Ajzen (1991) reviewing 16 studies using the
TPB. The findings are generally supportive of
the TRA/TPB. Ajzen (1991) reports the multiple
correlation between intentions and attitude,
subjective norm and PBC to be 0.71 across the
16 studies he reviewed. Van den Putte (1993)
computes a value of r = 0.64, but notes the large
variation in results between behaviors. Ajzen
reports the mean correlation between inten-
tions, PBC and behavior to be 0.51, while van
den Putte computes a value of 0.46. Ajzen (1991)
and Madden, Ellen, and Ajzen (1992) report
empirical evidence that PBC significantly im-
proves predictions of both intentions and
behavior. Hence, in summary, the evidence is
broadly supportive of the TPB in helping to
understand and predict health behaviors. The
relative importance of the different predictors is
 Understanding the Basis of Health Behavior
largely an empirical matter. However, in terms
of predictors of intentions, it has been argued
that attitude may be more important than
subjective norms for health behaviors per-
formed in private (e.g., breast self-examina-
tion), while subjective norm may be more
important than attitudes where the behavior
is performed in public (e.g., safety helmet use)
(Quine, Rutter, & Arnold, 1998).
8.01.3.3.3 Commentary
The TPB has been widely tested and success-
fully applied to the understanding of a variety of
behaviors (for reviews see Ajzen, 1991; Conner
& Sparks, 1996; Sheppard et al., 1988). The
theory incorporates a number of important
cognitive variables which appear to determine
health behaviors (intentions, expectancy values,
perceived behavioral control). Also the role of
social pressure from others is incorporated in
the model in the form of subjective norms.
However, perhaps because the model was
developed outside the health arena, the model
does not make an assessment of health threat as
is included in models such as the HBM. Finally,
the theory states a clear causal ordering among
variables in how they relate to behavior,
allowing sophisticated analysis techniques to
be applied to assessing the model.
Sheppard et al. (1988), in a review of the
TRA, have argued for the need to consider both
behavioral intentions and self-predictions when
predicting behavior. Warshaw and Davis (1985)
noted a number of different ways in which
intentions had been measured, and distin-
guished measures of behavioral intentions
(e.g., ªI intend to perform behavior xº) and
from measures of self-predictions (e.g., ªHow
likely is it that you will perform behavior x?º).
This distinction is important when considering
the prediction of health behavior because while,
for example, David might intend to quit
smoking, he might also think that it is unlikely
that he will do so. Sheppard et al. went on to
argue that self-predictions should provide better
predictions of behavior as they are likely to
include a consideration of those factors which
may facilitate or inhibit performance of a
behavior as well as a consideration of the likely
choice of other competing behaviors. Sheppard
et al.'s meta-analysis supports this view;
measures of self-predictions were found to have
stronger relationships with behavior than
behavioral intentions. However, Norman and
Smith (1995) found no difference in the extent to
which the two measures correlated with exercise
behavior. Furthermore, the measures of beha-
vioral intentions and self-predictions are
strongly correlated, suggesting that the discri-
11
minant validity for the two concepts may be
weak. Bagozzi (1992) notes that the causal path
may begin with the formation of desires which
then develop into intentions, which in turn
inform self-predictions. However, Conner and
Sparks (1996) note that while theoretically these
concepts may be distinguishable, empirically
there is little to distinguish the three concepts.
Clearly, more work is needed to further
disentangle these and other related constructs
that have appeared in the literature such as
planning and commitment (Bagozzi, 1992,
1993), need to change (Paisley & Sparks,
1998), and behavioral willingness (Gibbons,
Gerrard, Ouelette, & Burzette, 1998).
Self-efficacy is a powerful predictor of the
performance of a range of health behaviors
(Schwarzer & Fuchs, 1996). Ajzen (1991) argues
that the PBC and self-efficacy constructs are
interchangeable. However, several authors (e.g.,
Terry & O'Leary, 1995) have suggested that self-
efficacy and PBC are not entirely synonymous.
Bandura (1986), for example, argues that
control and self-efficacy are quite different
concepts. Although Bandura (1986) accepts
that some external factors (e.g., task difficulty)
will have an influence on self-efficacy, it may
still be argued that self-efficacy is more
concerned with perceptions of control based
on internal control factors. In contrast, PBC is
likely to reflect more external factors, and may
be more usefully described as ªperceptions of
control over the behaviorº (Armitage & Con-
ner, in press). For example, Terry and O'Leary
(1995) measure self-efficacy over exercising by
items such as ªFor me to exercise would be . . .
easy±difficultº and perceived control over the
behavior by ªHow much control do you have
over exercising? no control±complete control.º
De Vries, Dijkstra, and Kuhlman (1988) have
advocated the use of measures of self-efficacy as
opposed to PBC in the prediction of intentions
and behavior. Further, Dzewaltowski et al.
(1990), in a comparison of the TRA, TPB, and
Bandura's (1986) Social Cognitive Theory,
found that self-efficacy rather than PBC had
a direct impact on behavior. Terry and O'Leary
(1995) examined exercise behavior and found
that self-efficacy only predicted intentions,
while PBC had main and interactive effects
on exercise behavior. Crucially, a combined
measure of PBC and self-efficacy failed to
moderate the effect of intention on behavior,
suggesting that the two constructs are not
synonymous. This issue warrants further em-
pirical study. It seems plausible, however, that
perceptions of control and self-efficacy are two
separable constructs which not only have
differential effects on intentions and behavior
but may act differently for different behaviors.
12 Health Behavior
The TPB is correctly regarded as a theory of
the proximal determinants of behavior. Indeed,
Ajzen (1991) describes the model as open to
further elaboration if further important prox-
imal determinants are identified. A number of
potential candidate variables for addition to the
TRA/TPB have been suggested. In each case
both theoretical and empirical justifications are
necessary (Fishbein, 1993). Some of the most
promising of these ªadditional variablesº are
considered in Section 8.01.5.2.
8.01.3.4 Health Locus of Control
8.01.3.4.1 Model description
The HLOC construct is one of the most
widely researched constructs in relation to the
prediction of health behavior (K. A. Wallston,
1992). Its origins can be traced back to Rotter's
(1954) social learning theory which states that
the likelihood of a behavior occurring in a given
situation is a function of the individual's
expectancy that the behavior will lead to a
particular reinforcement and the extent to which
the reinforcement is valued. As well as being
applied on a specific level, Rotter argued that
social learning theory could be applied on a
general level such that individuals may have
generalized expectancy beliefs which cut across
situations. It was at this generalized level that
Rotter introduced the distinction between
internal and external locus of control orienta-
tions, with ªinternalsº believing that events are a
consequence of their own actions and thereby
under personal control and ªexternalsº believ-
ing that events are unrelated to their actions and
thereby beyond their personal control.
Early work examining the relationship be-
tween locus of control and health behavior with
Rotter's (1966) Internal±External (I±E) scale
produced mixed results. However, the I±E scale
was criticized for being too generalized to
predict health behavior and for conceptualizing
locus of control as a unidimensional construct.
In particular, Levenson (1974) argued that
internal locus of control beliefs are orthogonal
to external locus of control beliefs, and that
within external locus of control a distinction can
be made between external control exerted by
powerful others and the influence of chance or
fate. The development of the multidimensional
health locus of control (MHLC) Scale (K. A.
Wallston et al., 1978) addressed both these
criticisms, and has since become the most
popular locus of control measure in research
on health behavior (Wallston & Wallston, 1981,
1982).
The MHLC scale measures generalized ex-
pectancy beliefs with respect to health along
three dimensions. These measure the extent to
which individuals believe their health is a
function of their own actions (i.e., internal
HLOC), the actions of powerful others such as
health professionals (i.e., powerful others
HLOC), and the influence of chance or fate
(i.e., chance HLOC). According to HLOC
theory, individuals who have strong internal
HLOC beliefs should be more likely to engage in
health-promoting behaviors. Conversely, those
who believe that their health is due to chance or
fate should be less likely to engage in health-
promoting behaviors. The prediction for power-
ful others HLOC is less clear cut. Strong
powerful others HLOC beliefs may reflect a
receptivity to health messages endorsed by
health professionals. Alternatively, strong
powerful others HLOC beliefs may indicate a
strong belief in the ability of health profes-
sionals to cure subsequent illnesses and may be
unrelated or negatively related to the perfor-
mance of health-promoting behaviors.
According to social learning theory, the above
relationships should only hold for individuals
who place a high value on their health as
behavior is a function of both expectancy beliefs
(e.g., HLOC) and the value attached to certain
outcomes (e.g., health value). As K. A. Wallston
(1991) argues, individuals are unlikely to engage
in health-promoting behaviors if they place a
low value on their health, whatever their HLOC
beliefs. Thus, health value should act as a
moderator of the relationship between HLOC
and health behavior.
8.01.3.4.2 Review of research
The majority of the research using the HLOC
construct has correlated HLOC beliefs with the
performance of health behavior, without paying
attention to the potential moderating role of
health value. This may be due to a lack of
appreciation of the complexity of social learning
theory (Wallston, 1991) and/or an unchallenged
assumption that all people value their health
(Lau, Hartman, & Ware, 1986).
Several studies have examined the relation-
ship between HLOC beliefs and general indices
of health behavior. Most of these have reported
a positive correlation between internal HLOC
beliefs and the performance of health-promot-
ing behaviours (Duffy, 1988; Mechanic &
Cleary, 1980; Seeman & Seeman, 1983; Waller
& Bates, 1992; Weiss & Larsen, 1990), although
other studies have failed to find such a
relationship (Brown, Muhlenkamp, Fox, &
Osborn, 1983; Muhlenkamp, Brown, & Sands,
1985; Norman, 1995; Steptoe et al., 1994;
Wurtele, Britcher, & Saslawsky, 1985). Some
studies have found a negative relationship
 Understanding the Basis of Health Behavior
between chance HLOC beliefs and health
behavior indices (Brown et al., 1983; Duffy,
1988; Muhlenkamp et al., 1985; Steptoe et al.,
1994). Finally, powerful others HLOC beliefs
have rarely been found to predict the perfor-
mance of health-promoting behaviors (Brown
et al., 1983; Duffy, 1988; Muhlenkamp et al.,
1985; Steptoe et al., 1994; Waller & Bates, 1992;
Weiss & Larsen, 1990). The above results are
generally in line with predictions, although the
relationship between HLOC and health beha-
vior is typically a weak one.
A similar pattern of results is obtained for the
relationship between HLOC beliefs and specific
health behaviors. For example, studies have
reported a link between internal HLOC beliefs
and exercise (Carlson & Petti, 1989; O'Connell
& Price, 1982; Slenker, Price, & O'Connell,
1985), while other studies have found only a
weak link or no link (Burk & Kimiecik, 1994;
Calnan, 1989; Liao, Hunter & Weinman, 1995;
Norman, 1990, 1995; Speake, Cowart, &
Stephens, 1991). In a large-scale representative
sample, Calnan (1989) found significant nega-
tive correlations between the powerful others
and chance HLOC dimensions and exercise.
In relation to alcohol consumption, a number
of early studies used the locus of control
construct to compare alcoholics with nonalco-
holics producing mixed results (Butts & Cho-
tlas, 1973; Costello & Manders, 1974). More
recent work with the HLOC construct has
produced similar mixed results with a number of
studies finding no relationship between HLOC
beliefs and drinking behavior (Dean, 1991; Liao
et al., 1995; Norman, 1990, 1995) and Calnan
(1989) only finding weak negative correlations
between powerful others and chance HLOC
beliefs and alcohol consumption.
A number of studies have applied the HLOC
construct to the prediction of smoking cessa-
tion. A few of these studies have found internal
HLOC beliefs to be related to smoking cessation
(Horwitz, Hindi-Alexander, & Wagner, 1985;
Rosen & Shipley, 1983). Other studies have
failed to find a relationship between internal
HLOC beliefs and smoking cessation (Kaplan
& Cowles, 1978; Segall & Wynd, 1990; Wojcik,
1988). Smokers who believe that their health is
under the control of powerful others might be
expected to be more successful in giving up
smoking after attending a formal smoking
cessation program. However, a couple of
studies suggest that strong powerful others
HLOC beliefs are related to a greater likelihood
of relapse following attendance at a smoking
cessation program (Segall & Wynd, 1990;
Wojcik, 1988).
Studies examining the relationship between
HLOC beliefs and the performance of breast
13
self-examination among women have found a
positive relationship with internal HLOC beliefs
(Redeker, 1989) and a negative relationship
with powerful others HLOC beliefs (Hallal,
1982; Nemeck, 1990). The negative relationship
with powerful others HLOC beliefs may reflect
a belief that breast examination is the respon-
sibility of health professionals. In support of
this view, Bundek, Marks, and Richardson
(1993) found a positive relationship between
gynecological screening including physician
breast examination and powerful others HLOC
beliefs, and a positive relationship between self
breast examination and internal HLOC beliefs.
However, other studies have failed to find any
relationship between HLOC beliefs and breast
self-examination (Lau et al., 1986; Liao et al.,
1995; Seeman & Seeman, 1983).
Those studies that have tested the moderating
role of health value have generally produced
positive results. Considering the prediction of
indices of health behavior first, Weiss and
Larsen (1990) found a significant correlation
between internal HLOC beliefs and a health
behavior index among individuals placing a
high value on their health, but a nonsignificant
correlation among individuals placing a low
value on their health. Similar results have been
reported by a number of researchers (Lau, 1982;
Lau et al., 1986; Seeman & Seeman, 1983; K. A.
Wallston & Wallston, 1980), although other
studies have failed to find evidence for the
moderating role of health value (Norman, 1995;
Wurtele et al., 1985). Studies looking at the
interaction between health value and the
powerful others and chance dimensions have
generally produced nonsignificant results (Lau
et al., 1986; Wurtele et al., 1985 ).
A similar pattern of results emerges when the
performance of specific health behaviors is
considered. Evidence for an interaction between
internal HLOC beliefs and health value has
been found for a range of behaviors including
dietary behavior (Hayes & Ross, 1987), smok-
ing cessation (Kaplan & Cowles, 1978), breast
self-examination (Lau et al., 1986), and in-
formation seeking (K. A. Wallston, Maiders, &
Wallston, 1976). However, other studies have
failed to find evidence for such an interaction
when considering cancer-preventive behavior
(McCusker & Morrow, 1979), exercise (Burk &
Kimiecik, 1994), attendance at health checks
(Norman, 1991), and information seeking (De
Vito, Bogdanowicz, & Reznikoff, 1982).
8.01.3.4.3 Commentary
Reviews of research with the HLOC con-
struct have concluded that HLOC is a weak
predictor of health behavior, even when
14 Health Behavior
considered in conjunction with health value
(Norman & Bennett, 1996; K. A. Wallston,
1991, 1992). There are a number of reasons for
this poor performance which are outlined
below.
K. A. Wallston and Wallston (1981, 1982)
have argued that certain combinations of
HLOC beliefs may be important in predicting
health behavior. For example, when being
advised to quit smoking by a health profes-
sional, it may be advantageous to have a
combination of strong powerful others and
internal HLOC beliefs. K. A. Wallston and
Wallston (1981) have therefore proposed a 2 6
2 6 2 typology based on median splits on the
three HLOC dimensions (see also Waller and
Bates, 1992). Using this typology, ªbelievers in
controlº (i.e., high internal high powerful
others, low chance HLOC beliefs) have been
found to show better adjustment in relation to
rheumatoid arthritis (Roskam, 1986) and
diabetes (Bradley, Lewis, Jennings, & Ward,
1990). To date, this approach has not been
applied to the prediction of health behavior.
However, despite the promise of this approach,
its utility may be limited given that large sample
sizes are required in order to compare all eight
types. In addition, this approach may lead to
results which are difficult to interpret, given the
large number of comparisons.
A number of researchers have questioned the
way in which health value is measured.
Typically, health value has been measured as
an absolute value using Lau et al.'s (1986) four-
item scale. However, when deciding whether or
not to perform a specific health behavior,
individuals are often faced with more appealing
alternatives. As a result, values other than
health may be important in determining
behavior. In such cases it may be more
appropriate to use relative measures of health
value. Kristiansen (1986) followed this ap-
proach and found that a measure of the value
placed on health relative to value of an exciting
life was more predictive of health behavior
among young people than an absolute measure
of health value. However, Wurtele et al. (1985)
reported the opposite pattern of results in a
sample of female undergraduates. Clearly, more
work is needed comparing different approaches
to the measurement of health value.
The need to consider behavior-specific con-
trol beliefs has been highlighted by a number of
researchers. In particular it is possible to argue
that one reason for the relatively poor perfor-
mance of the HLOC construct is that it
measures generalized expectancy beliefs with
respect to health. In other words, while HLOC is
specific to a given goal (i.e., health), it cuts
across many situations (e.g., smoking, exercise,
diet, etc.). As a result, the development of
behavior-specific HLOC scales has been advo-
cated. Georgiou and Bradley's (1992) smoking-
specific locus of control scale is a good example
of such a scale. This scale was found to have
stronger correlations with smokers' behaviors
and intentions than the more generalized
MHLC scale. Other scales have been developed
in relation to exercise (Burk & Kimiecik, 1994),
AIDS risk behavior (Kelley et al., 1990), weight
loss (Saltzer, 1982), alcohol use (Donovan &
O'Leary, 1978) and a range of specific condi-
tions including diabetes (Bradley et al., 1990),
arthritis (Nicassio, Wallston, Callahan, Her-
bert, & Pincus, 1985), cancer (Prwun et al.,
1988), hypertension (Stanton, 1987) and heart
and lung disease (Allison, 1987). Generally,
these scales have been found to be more
predictive of health behavior than more general-
ized measures (Lefcourt, 1991).
In conclusion, the amount of variance in
health behavior explained by the HLOC
construct is low, even when considered in
conjunction with health value (Norman &
Bennett, 1996; K. A. Wallston, 1991, 1992).
Nevertheless, the pattern of results obtained are
generally in line with predictions suggesting that
HLOC beliefs may have a distal influence on
health behavior. In line with this position, K. A.
Wallston (1992) has proposed a ªmodified
social learning theoryº in which health behavior
is a function of HLOC beliefs, health value, and
self-efficacy. Importantly, internal HLOC be-
liefs are seen to be a necessary, but not sufficient,
condition for performing a health behavior. To
date, there have been no formal tests of this
modified theory, although the attempt to embed
HLOC beliefs into a broader theoretical
perspective is an encouraging development.
8.01.3.5 Protection Motivation Theory
8.01.3.5.1 Model description
Protection motivation theory (Rogers, 1983)
was originally developed as a framework for
understanding the effectiveness of health-re-
lated persuasive communications, although
more recently it has also been used to predict
health protective behavior. It has its origins in
early work on the persuasive impact of fear
appeals, which was concerned with the condi-
tions under which fear appeals may influence
attitudes and behavior. In an extension of the
fear-drive model, Janis (1967) proposed that if a
persuasive communication successfully arouses
fear, usually through emphasizing the severity
of a threat and the likelihood of its occurrence,
individuals will be motivated to reduce this
unpleasant emotional state. If the message also
 Understanding the Basis of Health Behavior
contains recommendations for action, then one
way in which individuals can reduce this state of
arousal is to follow the communicator's advice.
If the message does not contain effective
behavioral advice, then maladaptive coping
reactions may follow such as denial or avoid-
ance. Janis proposed that fear appeals may be
most effective when a medium level of fear is
evoked. Under such conditions the cognitive
responses that promote adaptive reactions (e.g.,
following behavioral advice) outweigh those
that promote maladaptive reactions (e.g.,
denial). However, later work has failed to
confirm this hypothesis (Sutton, 1982).
Leventhal (1970) made a similar distinction
between adaptive and maladaptive reactions in
the parallel response model which differentiates
between two independent control processes that
are initiated by a fear appeal. The first, fear
control, focuses on attempts to reduce the
emotional threat (e.g., avoidance) while the
second, danger control, focuses on attempts to
reduce the threatened danger (e.g., following
behavioral advice). The parallel response model
is important in proposing that protection
motivation results from danger control pro-
cesses (i.e., cognitive responses) rather than
from fear control processes (i.e., emotional
responses).
Roger's (1983) (PMT) outlines the cognitive
responses resulting from fear appeals in more
detail (see Figure 3). It is argued that various
environmental (e.g., fear appeals) and intraper-
sonal (e.g., personality variables) sources of
information can initiate two appraisal pro-
cesses: threat appraisal and coping appraisal.
Threat appraisal, which is similar to Lazarus
and Launier's (1978) primary appraisal, focuses
on the source of the threat and the factors that
may increase or decrease the probability of the
maladaptive response. Both the perceived
severity of the threat and the individual's
perceived vulnerability to the threat are seen
to inhibit maladaptive responses. However,
there may be a number of intrinsic (e.g.,
pleasure) and extrinsic (e.g., social approval)
rewards which may serve to increase the
likelihood of maladaptive responses. Coping
appraisal, which is similar to Lazarus and
Launier's (1978) secondary appraisal, focuses
on one's ability to cope with the threat and the
factors that may increase or decrease the
probability of an adaptive response. Both the
belief that the recommended action will be
effective in reducing the danger (i.e., response
efficacy) and the belief that one is capable of
performing the recommended action (i.e., self-
efficacy) are likely to increase the probability of
an adaptive response, although various re-
sponse costs (e.g., financial cost) associated with
15
performing an adaptive response will serve to
inhibit such a response.
Protection motivation results from the two
appraisal processes and is a positive function of
beliefs about severity, vulnerability, response
efficacy, and self-efficacy, and a negative
function of beliefs about the rewards associated
with the maladaptive response and the response
costs of the protective behavior. Moreover, for
protection motivation to be elicited, it is
necessary for the rewards associated with the
maladaptive response to be outweighed by
perceptions of severity and vulnerability, and
the response costs of the protective behavior to
be outweighed by perceptions of response
efficacy and self-efficacy. Protection motiva-
tion, which is usually measured by behavioral
intentions, is seen to arouse, direct, and sustain
protective behavior.
8.01.3.5.2 Review of research
Protection motivation theory provides a
framework for understanding both the effects
of fear appeals and the social cognitive variables
underlying health behavior. As a result, tests of
PMT have taken two forms. In the first, the key
components of PMT are manipulated in
persuasive communications and their effects
on protection motivation tested (see Section
8.01.4.1). In the second, PMT is considered as a
general attitude±behavior model and its com-
ponents used as predictors of health behavior.
This work is reviewed below.
One area in which PMT has been used as a
general attitude±behavior model is in relation to
cancer-related preventive behavior. In one of
the few longitudinal tests of PMT, Hodgkins
and Orbell (1998) examined the social cognitive
predictors of breast self-examination (BSE) in a
sample of young women (17±40 year olds) over
a one-month period. Each of the main compo-
nents of PMT was measured (i.e., severity,
vulnerability, response efficacy, self-efficacy) as
well as the response costs of performing BSE
(e.g., I would feel awkward examining my
breasts). In a path analysis, only self-efficacy
was related to intentions to perform BSE. Time
one behavioral intention was in turn found to be
the most important predictor of performance of
BSE at one month follow-up. Similar results
have been reported by Seydel, Taal, and
Wiegman (1990) who found response efficacy
and self-efficacy to be predictive of intentions to
engage in, and concurrent performance of, a
number of cancer-related preventive behaviors.
Boer and Seydel (1996) also found response
efficacy and self-efficacy to be predictive of
intentions to participate in mammography
screening.
16 Health Behavior

SOURCES OF Threat appraisal

INFORMATION
Perceived vulnerability
Environmental

Fear appeals Perceived severity

Observation
Intrinsic rewards
Intrapersonal

Personality Extrinsic rewards

Protection
Behavior
Prior experience Motivation

Coping appraisal

Response costs
Other external
variables

Response efficacy
Age, sex, occupation,
socioeconomic status,
religion, education
Self-efficacy

Figure 3 Protection motivation theory.

A second area of application of PMT has
been in relation to AIDS risk-reducing beha-
viors such as condom use. Aspinwall, Kemeny,
Taylor, Schneider, and Dudley (1991) examined
the ability of the PMT components to predict
reductions in a number of AIDS risk-reducing
behaviors in a sample of gay men over a six-
month period. The results showed that strong
levels of self-efficacy and a high level of
perceived vulnerability at time one were pre-
dictive of a reduction in the number of sexual
partners over the six-month follow-up period.
In addition, self-efficacy also emerged as the
most important predictor of reductions in the
number of anonymous sexual partners.
Van der Velde and van der Pligt (1991) used
PMT as a framework for assessing the coping
responses of heterosexual men and women and
homosexual men with multiple partners. Con-
sidering the heterosexual sample first, it was
found that vulnerability, response efficacy, and
self-efficacy all had a direct positive effect on
behavioral intentions to use condoms. In
addition, severity had an indirect effect on
behavioral intentions through a measure of fear.
Similar results were found with the homosexual
sample with response efficacy, self-efficacy, and
severity having a positive effect on behavioral
intentions to engage in safe sex. However,
contrary to expectations, a negative relationship
was found between vulnerability and behavioral
intentions.
In a sample of male and female adolescents,
Abraham, Sheeran, Abrams, and Spears (1994)
found that self-efficacy had a positive influence
and response costs (i.e., concern about reputa-
tion) had a negative influence on behavioral
intentions to use a condom. In addition,
vulnerability had a negative effect on behavioral
intentions to limit the number of sexual
partners. In a cross-sectional study of male
and female heterosexuals, Bengel, Beltz-Merk,
and Farin (1996) found that self-efficacy was
related to a greater use of condoms and fewer
sexual partners. However, perceptions of vul-
nerability were related to greater use of
condoms, but also higher number of sexual
partners.
 Understanding the Basis of Health Behavior
Taken together, the above results suggest that
PMT is a useful framework for understanding
HIV-related protective behavior. Self-efficacy
emerges as the most important predictor of such
behavior, with response efficacy and severity
also emerging as significant predictors in some
studies. A conflicting pattern of results has been
found with the vulnerability component. Simi-
lar conclusions have been reached by Farin
(1994) in a meta-analysis of PMT and HIV-
protective behavior, in which self-efficacy and
response efficacy emerged as the best predictors
of protective behavior. However, these two
components were only able to explain 2.2% and
1.8% of the variance in such behavior. Severity
was seen to be less important, and vulnerability
had a conflicting pattern of results.
8.01.3.5.3 Commentary
Despite relatively few studies in the area, the
above review highlights the potential utility of
PMT as a framework for considering the social
cognitive predictors of health protective beha-
vior. However, there are a number of issues
which future work needs to address.
First, some studies have reported a positive
relationship between perceptions of vulnerabil-
ity and protection motivation, while others have
reported a negative relationship. Seydel et al.
(1990) suggest that the negative relationship
between vulnerability and intentions to engage
in cancer-related preventive behavior in their
study may be due to a ªdefensive avoidanceº
style of coping, in which perceptions of vulner-
ability to cancer may lead to feelings of anxiety
which may inhibit adaptive responses and
promote avoidance. However, it is more likely
that the mixed pattern of results is due to
measurement issues. As Weinstein and Nicolich
(1993) argue, a negative correlation may be
expected between perceptions of vulnerability
and concurrent protective behavior given that
one's current behavior may be used to make
vulnerability judgments. In contrast, a positive
correlation may be expected between percep-
tions of vulnerability and future protective
behavior to the extent that perceptions of
vulnerability motivates protective behavior.
Considering behavioral intentions, individuals
may feel vulnerable and therefore intend to
engage in a protective behavior (i.e., positive
correlation), or may feel vulnerable because they
do not intend to engage in a protective behavior
(i.e., negative correlation). Clearly, more con-
sideration needs to be given to the measurement
of perceptions of vulnerability and the potential
use of conditional measures of risk.
Second, while PMT provides a framework for
considering the social cognitive predictors of
17
protective behavior, a number of researchers
have commented on its lack of specification in
terms of the nature of its components and the
relationships between them (Bengel et al., 1996).
For example, Rogers (1983) states that the
response costs of the protective behavior need to
be outweighed by perceptions of response
efficacy and self-efficacy for protection motiva-
tion to be elicited. However, no guidance is
given as to how these variables are to be
measured and combined in order to predict
protection motivation.
Overall, PMT identifies many of the social
cognitive variables which are important pre-
dictors of health behavior. It shares a number of
similarities with the HBM (i.e., measures of
perceived susceptibility, severity, benefits, and
barriers) although it also includes self-efficacy,
which has been found to be one of the most
powerful explanatory constructs in relation to
health behavior (Schwarzer & Fuchs, 1996), and
a measure of behavioral intention, which is seen
to mediate the influence of threat appraisal and
coping appraisal. It is also important for
providing a synthesis between social cognitive
approaches and coping models as outlined by
Lazarus and Launier (1978). However, to date
there have been relatively few longitudinal tests
of PMT in relation to health behavior. Such
studies should help clarify some of the issues
raised above.
8.01.3.6 Self-efficacy
8.01.3.6.1 Model description
Self-efficacy is one of the most powerful
predictors of health behavior (K. A. Wallston,
1992). It has its origins in Bandura's (1977)
social cognitive theory which states that
behavior is a function of both incentives (i.e.,
reinforcements) and expectancies. Three kinds
of expectancies can be identified, these being
situation-outcome expectancies which refer to
beliefs about how events are connected, out-
come expectancies which refer to beliefs about
the consequences of performing a behavior, and
self-efficacy expectancies which refer to beliefs
about one's ability to perform the behavior.
Thus in order to perform a health behavior,
individuals must value their health (i.e., in-
centive), believe that their current lifestyle poses
a threat to their health (i.e., situation-outcome
expectancy), believe that adopting the new
behavior will reduce the threat to their health
(i.e., outcome expectancy) and believe that they
are capable of performing the behavior (i.e.,
self-efficacy expectancy). While all these beliefs
are seen to be important in the initiation and
maintenance of health behavior, self-efficacy
18 Health Behavior
expectancies are seen to be the most important.
Individuals with strong self-efficacy beliefs are
believed to develop stronger intentions to act, to
expend more effort to achieve their goals, and to
persist longer in the face of barriers and
impediments (Bandura, 1991).
Self-efficacy beliefs are therefore believed to
play a crucial role in the determination of health
behavior. According to Bandura (1977, 1982),
such beliefs can be conceptualized and measured
in terms of three parameters; magnitude,
strength, and generality. The first parameter
refers to the level of difficulty of the behavior.
Individuals with low-level expectations feel
capable of performing only very simple beha-
viors, whereas individuals with high-level ex-
pectations feel capable of performing even the
most difficult of behaviors. In this way it is
possible to assess individuals' expectations
about their level, or magnitude, of performance.
The second parameter refers to individuals'
confidence that they could perform a specific
behavior, while the third parameter refers to the
generality of expectations across situations or
domains. The measurement of self-efficacy
usually focuses on the strength of the self-
efficacy expectation (e.g., ªI am confident that I
can refrain from smokingº), although it will
often incorporate the magnitude of expectation
(e.g., ªI am confident that I can refrain from
smoking, even if someone offers me a cigaretteº).
8.01.3.6.2 Review of research
The self-efficacy construct has been success-
fully applied to the prediction of a range of
health behaviors (see Bandura, 1991; O'Leary,
1985; Schwarzer & Fuchs, 1996). One of the
main areas of application has been in relation to
smoking cessation (Condiotte & Lichtenstein,
1981; Colletti, Supnick, & Payne, 1985; Kava-
nagh, Piere, Lo, & Shelley, 1993). These studies
have found self-efficacy to be a consistent
predictor of smoking cessation. For example,
Condiotte and Lichtenstein (1981) found that
post-treatment self-efficacy beliefs were predic-
tive of both the probability of relapse and the
amount of time before relapse. In addition, a
close correspondence was noted between self-
efficacy beliefs for a range of specific tempting
situations (e.g., after a meal, when drinking
coffee) and the actual situation in which the
relapse occurred. The results therefore indicate
that self-efficacy is important not only in
predicting the likely success of smokers who
are trying to quit, but also the situations in
which they are most likely to relapse.
Self-efficacy has also been related to AIDS
risk-reducing behaviors, such as condom use
(Basen-Engquist & Parcel, 1992; Boyd &
Wandersman, 1991; Kok, de Vries, Mudde, &
Strecher, 1991; Morrison, Gillmore, & Baker,
1995). While the majority of studies examining
the relationship between self-efficacy and AIDS
risk-reducing behaviors have reported signifi-
cant results, a few studies have failed to do so
(Boyd & Wandersman, 1991; Morrison et al.,
1995). Considering exercise behavior, self-
efficacy has been found to be an important
predictor of both intentions to engage in regular
exercise and actual exercise behavior (Deshar-
nais, Bouillon, & Godin, 1986; McAuley, 1993;
Sallis, Howell, Hofsteffer, & Barrington, 1992).
Finally, self-efficacy has also been related to
dieting and weight control (Bernier & Avard,
1986; Hofstetter, Sallis, & Howell, 1990; Jeffrey
et al., 1984). For example, Jeffrey et al.
examined the relationship between self-efficacy
and weight loss following participation in a
behavioral treatment program over a two-year
period. Making a distinction between ªemo-
tionalº self-efficacy (i.e., confidence in one's
ability to refrain from eating during various
emotional states) and ªsituationalº self-efficacy
(i.e., confidence in one's ability to refrain from
eating in various situations), they found pre-
treatment measures of both types of self-efficacy
to be predictive of weight loss at one and two
years. However, post-treatment measures of
self-efficacy were not so powerful with only
ªsituationalº self-efficacy predictive of weight
loss at one year.
8.01.3.6.3 Commentary
The self-efficacy construct has been found to
be one of the most important predictors of
health behavior (K. A. Wallston, 1992). How-
ever, there are a number of issues which future
work needs to address. First, the relationship
between outcome and self-efficacy expectancies
has been a source of some debate (Corcorcan,
1991; Kirsch, 1986, Maddux, 1993). As Schwar-
zer (1992) argues, there may be a temporal and
causal order among the two types of expectancy
beliefs inasmuch as individuals are unlikely to
consider their ability to perform a behavior
before first considering the efficacy of the
behavior. Bandura (1991) argues that the effect
of outcome expectancies on intentions and
behavior are partly governed by self-efficacy
expectancies; even if outcome expectancy is
high, performance of a behavior is unlikely if
self-efficacy is low. As a result, when self-
efficacy is partialed out, any relationship
between outcome expectancy and behavior
should disappear. However, some research
has indicated that outcome and self-efficacy
expectancies can be independent predictors of
intentions and behavior (Maddux, 1993).
 Encouraging the Adoption of Health Behaviors
Second, the role of incentives, or outcome
values, has tended to be overlooked in research
with the self-efficacy construct. This is despite
the fact that a large body of research in
expectancy value theory has found outcome
value to be an important predictor (Kirsch,
1986; McCelland, 1985). Unfortunately, those
studies which have considered the role of
outcome and self-efficacy expectancies in con-
junction with incentives or outcome values have
produced mixed results (Maddux, Norton, &
Stoltenberg, 1986; Manning & Wright; 1983).
Third, there is some disagreement over
whether it is appropriate to consider generalized
self-efficacy expectancies. According to Ban-
dura's (1977) original conceptualization, self-
efficacy beliefs should focus on specific beha-
viors in specific situations. Self-efficacy is not
seen to be a personality trait as self-efficacy
beliefs can be seen to vary across behaviors and
situations, although self-efficacy beliefs may
generalize to other behaviors and situations to
the extent that the new behaviors require similar
skills and the new situations have similar
features (Bandura, 1986). Nevertheless,
Schwarzer and Fuchs (1996) have argued that
self-efficacy can be viewed as a generalized trait
reflecting a personal resource factor, pointing to
studies which have successfully employed gen-
eralized measures of self-efficacy to predict
behavior (Mittag & Schwarzer, 1993; Snyder
et al., 1991; K. A. Wallston, 1992). Generalized
self-efficacy may be closely related to disposi-
tional optimism (Scheier & Carver, 1992),
although on an empirical level Schwarzer
(1994) found a correlation of only 0.60 between
dispositional optimism and generalized self-
efficacy.
In conclusion, self-efficacy has been found to
be one of the most powerful and consistent
predictors of health behavior. For this reason
alone, it is not surprising that it has been
incorporated into a number of the main social
cognition models of health behavior; for
example, Rogers' (1983) PMT and Ajzen's
(1991) TPB. In addition, Rosenstock, Strecher,
and Becker (1988) have called for the inclusion
of self-efficacy in the HBM. It is likely that self-
efficacy will continue to attract considerable
interest and continue to be a key predictor of
health behavior.
8.01.4 ENCOURAGING THE ADOPTION
OF HEALTH BEHAVIORS
8.01.4.1 Intervention Studies
The models presented earlier in this chapter
outline some of the key social cognitive
determinants of health behavior. In this section
19
we consider the use of these models in the design
of interventions to encourage new health
behaviors. As Fishbein (1993) has argued, the
ultimate test of the utility of these models lies in
their ability to inform the design of effective
interventions. To the extent that these models
outline the key social cognitive determinants of
health behavior, interventions which target
these variables should lead to associated
changes in behavior. However, to date there
have been relatively few theoretically driven
interventions. As a result there is still a need for
more tests of these models ªin actionº (Fish-
bein, 1993).
Brawley (1993) argues that we need to take
account of the practicality of employing SCMs
when designing interventions. In short, a model
which offers a high level of practicality must be
shown to have predictive utility, to describe the
relationships between key constructs, to offer
guidelines for the assessment of these con-
structs, to allow the translation of these
constructs into operational manipulations,
and to provide the basis for detecting the
reasons why an intervention succeeds or fails.
The SCMs considered here can be been seen to
have a high level of practicality and therefore
should provide a good framework for the design
of effective interventions.
One model which has been used widely to
design interventions is the PMT. A good
example of the use of PMT in this respect is
provided by Wurtele and Maddux (1987) in
their study on exercise intentions and behavior.
In this study essays recommending beginning a
regular exercise program were presented to a
sample of nonexercising female undergradu-
ates. The essays were designed so that each of
the PMT's main components (i.e., severity,
vulnerability, response-efficacy, and self-effi-
cacy) were independently manipulated, result-
ing in a 2626262 between-subjects factorial
design with two levels (present vs. absent) of
each factor. For example, the severity message
emphasized the seriousness of the threat of a
sedentary lifestyle by vividly describing the
negative effects of a heart attack (e.g., ªNau-
seated, the victim vomits; pink foam comes out
of the mouth. The face turns ashen grey, sweat
rolls down the face . . .º). After reading an essay,
subjects completed a questionnaire containing
measures of the main components of PMT and
were followed up two weeks later to chart any
changes in exercise behavior.
Manipulation checks revealed that each of
the messages successfully manipulated their
corresponding component from PMT, as is
the case in most PMT intervention studies.
Of more interest was the effect of the messages
on protection motivation as measured by
20 Health Behavior
behavioral intentions to start a regular exercise
program. The results showed that only the
vulnerability and self-efficacy messages had a
significant effect on behavioral intentions,
although a three-way interaction between
vulnerability, response efficacy, and self-effi-
cacy was also found. In relation to changes in
exercise behavior over the two-week follow-up
period, a significant interaction was found
between severity and self-efficacy, such that
the self-efficacy message only had a significant
effect when the severity message was absent.
Overall, studies which have used PMT to
design interventions have shown that self-
efficacy is the most powerful component that
can be manipulated in persuasive messages
(Boer & Seydel, 1996). In addition, manipulat-
ing response efficacy has been found to have a
significant effect on intentions in a majority of
studies. These two variables have been shown to
influence intentions to engage in a range of
health behaviors including exercise (Stanley &
Maddux, 1986), quit smoking (Maddux &
Rogers, 1983), dietary intake (Wurtele, 1988),
and breast self-examination (Rippetoe & Ro-
gers, 1987). Manipulating perceptions of vul-
nerability has been found to influence intentions
in other studies (Maddux & Rogers, 1983;
Wurtele & Maddux, 1987), while manipulating
perceptions of severity has not been found to
have an influence on behavioral intentions.
However, many PMT intervention studies have
combined the vulnerability and severity com-
ponents so that the potential threat of a
maladaptive behavior is emphasized. This has
been found to have a significant effect on
intentions in relation to alcohol use (Stainback
& Roger, 1983), dental flossing (K. H. Beck &
Lund, 1981), dietary behavior (Wurtele, 1988),
information seeking (Brouwers & Sorrentino,
1993), and breast self-examination (Rippetoe &
Rogers, 1987).
Some studies have focused more specifically
on enhancing feelings of self-efficacy as a means
for encouraging health behavior change. As
Bandura (1986) outlines, there are four main
sources of self-efficacy, each of which could be
addressed in interventions. First, individuals
can develop feelings of self-efficacy from
personal mastery experience. For example, it
may be possible to split a behavior into various
subgoals, such that the easiest subgoals are
achieved before more difficult tasks are at-
tempted. Second, individuals may develop
feelings of self-efficacy through observing other
people succeed on a task (i.e., vicarious
experience). Third, it is possible to use standard
persuasive techniques to try to instil feelings of
self-efficacy. Finally, one's physiological state
may be used as a source of information, such
that high levels of arousal or anxiety may
indicate to the individual that he or she is not
capable of performing a given action. As a
result, relaxation techniques may be employed
to help maintain feelings of self-efficacy.
Each of these techniques have been used in
intervention studies to try to enhance feelings of
self-efficacy. Maibach, Flora, and Nass (1991)
report the results of a year-long community
health campaign to encourage the adoption of
health behaviors. The campaign materials were
all designed to reflect the main principles of
Bandura's (1986) social cognitive theory and
used a number of strategies for enhancing
feelings of self-efficacy and encouraging beha-
vior change attempts. These included encoura-
ging participants to set behavior change goals,
using community members who had success-
fully changed their behavior as role models,
using health experts to give advice about
behavior change and focusing on the skills
needed to support behavior change. The
campaign was found to successfully increase
feelings of self-efficacy which, in turn, were
related to the adoption of new health behaviors.
A number of interventions have focused on
more situation-specific feelings of self-efficacy.
Stevens and Hollis (1989) designed an interven-
tion to help smokers quit smoking which built
on the results of earlier research which had
shown that situation-specific ratings of self-
efficacy were predictive of the circumstances in
which relapses occurred (Condiotte & Lichten-
stein, 1981). Abstinent smokers have identified
potential relapse situations in which they
perceived low levels of self-efficacy and then
developed and rehearsed appropriate coping
strategies over three weekly meetings. This
intervention led to a greater abstinence rate at
one year than both a discussion-only interven-
tion and a no-treatment control. Other studies
which have attempted to improve behavioral
skills to enhance feelings of self-efficacy have
produced positive results in relation to alcohol
use (Baer et al., 1992) and dental hygiene
(McCaul, Glasgow, & O'Neil, 1992).
Few studies have attempted to use the TRA/
TPB as a framework for developing interven-
tions, despite quite clear guidelines outlined by
Ajzen and Fishbein (1980). In fact, van den Putte
(1993) reports a mere five studies which have
followed such an approach, with only limited
evidence for success compared to approaches
not based upon the model. For example,
Brubaker and Fowler (1990) examined the effect
of persuasive messages upon men's intentions to
perform testicular self-examination. A persua-
sive message based on the theory of reasoned
action was found to increase intentions to
perform testicular self-examination compared
 Limitations and Extensions of Existing Models
to a no-message control, but was no more
effective than a knowledge-only message. More
recently, Parker, Manstead, and Stradling
(1996) have developed intervention videos
based on the TPB to discourage speeding in
residential areas by car drivers. The results
showed that the normative belief video had a
significant effect on a postintervention measure
of normative beliefs, while the behavioral belief
video had no effect on behavioral beliefs, and
the perceived behavioral control video had a
negative effect on perceptions of control.
Overall, the videos had no effect on subjects'
expectations of speeding in residential areas
over the next year.
Finally, there is some evidence that tailoring
interventions to fit in with individuals' existing
belief orientations may lead to more effective
interventions. Chambliss and Murray (1979a)
devised a weight control program in which
participants were given placebo medication to
help control their metabolism. After two weeks
participants in one group were debriefed about
the placebo medication and encouraged to
attribute any weight loss to their own efforts
over the previous two weeks. Participants in a
second group were given further information
about the efficacy of the medication and
encouraged to attribute any weight loss to the
medication. At two-week follow-up, a signifi-
cant interaction was found between the giving of
information and participants' preprogram locus
of control orientation, such that ªinternalsº lost
more weight than ªexternalsº in the self-efficacy
information group, while the opposite pattern
of results was found for the drug information
group. Similar results have been reported by
Chambliss and Murray (1979b) in relation to
smoking cessation. These results led to further
work exploring the match between the control
orientation of the intervention and participants'
existing health locus of control beliefs. For
example, Quadrel and Lau (1989) found an
interaction between health locus of control
beliefs and the control orientation of a message
to encourage breast self-examination among
female students. In particular, those females
with strong internal health locus of control
beliefs who received a message in a ªcontrolº
frame were more likely to perform breast self-
examination at follow-up, although this effect
was reversed if a neutral reminder was sent.
Further evidence for a ªmatching hypothesisº
has been provided in relation to weight
reduction (B. S. Wallston, Wallston, Kaplan,
& Maides, 1976) and smoking cessation (Best,
1975).
Despite offering a high level of practicality,
there have been relatively few studies testing
SCMs ªin action.º As the above review shows,
21
practical applications of these models have met
with some success and suggest that health
behavior change interventions may have a lot to
gain from using these models as a guiding
framework. As Lewin (1951) concludes, ªthere
is nothing so practical as a good theoryº (p. 169).
8.01.5 LIMITATIONS AND EXTENSIONS
OF EXISTING MODELS
8.01.5.1 Limitations of Current Models
The SCMs described above represent one
widely used approach to understanding health
behaviors. Here we provide a critique of this
approach to understanding health behavior and
outline ways in which research might develop
through consideration of additional theoretical
constructs, the processes by which cognitions
influence behavior, stage models of behavior
change, potential integrations, and future
directions for work in this area.
There are several advantages of using social
cognition models in health psychology (Conner,
1993; Conner & Norman, 1996b). First, they
provide a clear theoretical background to
research, guiding the selection of variables to
measure, the procedure for developing reliable
and valid measures, and how these variables are
combined in order to predict health behaviors
and outcomes. Second, to the extent that the
models identify the important variables in
predicting health outcomes and behaviors, they
enable us to develop effective behavioral
interventions. Third, the models provide us
with a description of the cognitive processes
determining individuals' motivation to perform
different behaviors.
There are parallel disadvantages in too
exclusive a focus upon social cognition models
as the way to understand health behaviors.
First, in providing such an explicit general
theoretical framework, these models may lead
us to neglect variables (cognitive and noncog-
nitive) potentially important in understanding a
particular health behavior or outcome. For
example, the decision to use a condom may be a
function of cognitions, emotional reactions, and
also a complex interaction between the indivi-
duals involved. Social cognition models on their
own are unlikely to provide considerable
predictive power in these situations. In addition,
SCMs are open to extension when empirically
and theoretically justified (Fishbein, 1993).
Second, while such models provide us with
targets for interventions to produce behavior
change, they do not specify how such cognitions
are best changed. Effective interventions need to
consider both the targets (e.g., cognitions) and
the persuasion process itself. This process of
22 Health Behavior
persuasion is described by other models of social
cognitive processes (e.g., the elaboration like-
lihood model: Petty & Cacioppo, 1986; the
systematic-heuristic model: Chaiken, Lieber-
man, & Eagly, 1989). In addition, applications
of SCMs should not lead to neglect of
alternatives to persuasion in producing beha-
vior change such as extrinsic changes to the
rewards and costs of a given behavior. For
example, increased taxation and legal restric-
tions can be effective in producing change in
health behaviors either in isolation or in tandem
with persuasion.
Third, although SCMs have furthered our
understanding of motivational processes and
their influence upon behavior, they have
neglected other aspects of behavior change.
For example, few of the models consider
volitional processes beyond attempting to
explain intentions (Bagozzi, 1993; Gollwitzer,
1990). However, many individuals who intend
to change fail to do so. Hence, we need to
consider the other important volitional pro-
cesses associated with attempts to change and
maintain behavior change (see Norman &
Conner, 1996a; Schwarzer & Fuchs, 1996).
8.01.5.2 Additional Theoretical Constructs
While the social cognition models outlined
here provide an important framework for
considering the social psychological determi-
nants of health behavior, it is clear that in some
instances they only account for a modest
amount of the variance in health behavior.
For example, Sheppard et al. (1988) noted that
about 10% of studies they reviewed reported
correlations between behavioral intentions and
behavior below 0.2. This suggests that key
variables have failed to be included in these
models. We review here the most promising of
such variables appearing in the literature:
measures of norms, anticipated affective reac-
tions, self-identity, and past behavior.
A number of researchers have argued that
further attention needs to be paid to the concept
of normative influences (e.g., Cialdini, Reno &
Kallgren, 1990; Conner, Martin, Silverdale, &
Grogan, 1996). Of the major SCMs, only the
TPB incorporates perceived social pressures to
perform a behavior as a predictor of intentions.
Based upon social identification theory, Terry
and Hogg (1996) suggest that such (injunctive)
normative measures might be more predictive of
behavior if they employed a measure of group
identification rather than motivation to comply
(e.g., I identify with my friends with regard to
smoking). Similarly, Gibbons and Gerrard
(1995, 1997) have noted the need to consider
social comparison processes and how the social
image or prototype of the person who performs
a particular behavior influences the perfor-
mance of various health behaviors (particularly
among young people). Other researchers have
suggested other forms of normative influence we
might consider. These include descriptive norms
and personal or moral norms. Descriptive
norms are perceptions of the behavior of salient
others. For example, Jane's eating behavior may
be influenced not only by her perceptions of
what others think she should eat, but also
perceptions of what they actually do eat. Several
studies have reported that perceptions of others'
behavior contributed to the prediction of
intentions independently of perceived injunctive
norms (e.g., Conner et al., 1996; De Vries,
Backbier, Kok, & Dijkstra, 1995; Grube,
Morgan, & McGee, 1986). Personal, or moral,
norms are the individual's perception of the
moral correctness or incorrectness of perform-
ing a behavior (Ajzen, 1991; Sparks, 1994) and
take account of, ª. . . personal feelings of . . . re-
sponsibility to perform, or refuse to perform, a
certain behaviorº (Ajzen, 1991, p. 199). Moral
norms should have an important influence on
the performance of those behaviors with a moral
or ethical dimension (L. Beck & Ajzen, 1991;
Gorsuch & Ortberg, 1983; Kurland, 1995). A
number of studies have found measures of
moral norms to be predictive of blood donating
behavior (Pomazal & Jaccard, 1976; Zuckerman
& Reiss, 1978) as well as intentions to donate
organs (Schwartz & Tessler, 1972), eat geneti-
cally produced food (Sparks, Shepherd, &
Frewer, 1995), buy milk (Raats, 1992), use
condoms (Nucifora et al., 1993), and commit
driving violations (Parker, Manstead, & Strad-
ling, 1995).
Anticipated affective reactions to the perfor-
mance or nonperformance of a behavior may
also be an important determinant of behavior
(Triandis, 1977; Van der Pligt & de Vries, 1998),
especially in situations where the consequences
of the behavior are unpleasant or negatively
affectively laden. In the 1990s research has
focused on the influence of anticipated regret
(Parker et al., 1995; R. Richard & van der Pligt,
1991; Richard, Van der Pligt, & de Vries, 1995,
1996a, 1996b). It is argued that if individuals
anticipate feeling regret after performing a
behavior then they will be unlikely to perform
the behavior. Richard et al. (1995, 1996a)
investigated the role of anticipated regret in
relation to condom use among adolescents and
found such feelings to be an important predictor
of intentions. Richard et al. (1996b) examined
the influence of anticipated regret on subse-
quent behavior. Participants in their study were
asked to either focus on their anticipated
 Limitations and Extensions of Existing Models
feelings following safe and unsafe sexual
behavior or on their present feelings about
these behaviors. At follow-up, participants in
the anticipated feelings condition were more
likely to have used condoms in casual sexual
encounters in the intervening five months. The
effects of anticipated affective reactions have
been confirmed in studies of driving (Parker,
Manstead, Stradling, Reason, & Baxter, 1992)
and consumer behavior (Simonson, 1992).
However, in terms of developing social cogni-
tion models of health behavior, it is possible to
argue that anticipated affective reactions may
be incorporated into constructs that focus on
the consequences of behavior (e.g., behavioral
beliefs in the TPB; see Van der Pligt & de Vries,
1998).
The concept of self-identity has also been
suggested as a predictor of behavior (Biddle,
Bank, & Slavings, 1987; Charng, Piliavin, &
Callero, 1988). For example, the extent to which
individuals think of themselves as ªhealthy
eatersº should predict their dietary intentions
and behavior. In support, Sparks and Shepherd
(1992) found that respondents who thought of
themselves as ªgreen consumersº had stronger
intentions to consume organic vegetables.
Sparks (1994) noted that self-identity may
simply be a proxy for past behavior, although
Sparks and Shepherd (1992) found that the
relationship between self-identity and future
intentions remained when past consumption of
organic vegetables was controlled for. Self-
identity as someone who is concerned about the
health consequences of one's diet has also been
related to intentions to reduce fat consumption
(Sparks, Shepherd, Wieringa, & Zimmermanns,
1995), although in an earlier study Sparks,
Shepherd, Wieringa, and Zimmermanns (1994)
failed to find an independent effect for self-
identity. Role identity (regarded as synonymous
with self-identity) was measured by Theodor-
akis (1994) and found to be a significant
predictor of exercise behavior. Future work
needs to assess the influence of self-identity
across of range of behaviors as it may be the case
that self-identity is only important in a restricted
range of situations.
The influence of past on current behavior in
SCMs has attracted much attention. It is argued
that many health behaviors are determined by
one's previous behavior rather than cognitions.
The argument is based on the results of a
number of studies showing past behavior to be
the best predictor of future behavior. For
example, Mullen, Hersey, and Iverson (1987)
found initial behavior to be the strongest
predictor of the consumption of sweet and
fried foods, smoking, and exercise over an eight-
month period. Similar results have been
23
reported in relation to drug use (Bentler &
Speckart, 1979; Huba, Wingard, & Bentler,
1981), exercise (Godin, Valois, & Lepage, 1993;
Norman & Smith, 1995; Valois, Desharnais, &
Godin, 1988), breast self-examination (Hodg-
kins & Orbell, 1998), attendance at health
checks (Norman & Conner, 1993, 1996b) and
seat belt use (Sutton & Hallett, 1989). Such
results have led to calls for past behavior to be
considered as an independent predictor of
future behavior (Bentler & Speckart, 1979;
Fredricks & Dossett, 1983). However, there are
problems with this view. Ajzen (1988) argues
that the effects of past behavior on future
behavior should be mediated by the variables
included in social cognition models; past
behavior shapes individuals' beliefs about the
behavior in question, and it is these cognitions
that determine subsequent behavior. When past
behavior is found to have a direct effect on
future behavior it is because key social cognitive
variables have not been considered (Ajzen,
1991).
There has also been focus on the concept of
habit (i.e., behaving in a way you have acted
before without thinking about it). Eagly and
Chaiken (1993) review numerous studies where
the addition of habit has added to the prediction
of future behavior over and above the influence
of variables such as intention, attitude, and
subjective norm. Despite this evidence, few
SCMs incorporate a measure of habit. A
notable exception is Triandis (1977) who argues
that it is possible to make a distinction between
habitual and intentional behaviors. He argues
that novel behaviors will be primarily deter-
mined by intention, while repeated behaviors
will be primarily determined by habit. Ronis,
Yates, and Kirscht (1989) make a similar
distinction between habits and decisions, ar-
guing that the performance of repeated beha-
vior is determined by habit rather than social
cognitive variables. For example, Dishman
(1982) distinguished between the initiation
and maintenance of behavior in relation to
clinical exercise programs and found that only
the initiation of exercise behavior was predicted
by social cognitive variables. Sutton (1994) has
proposed a further distinction between habits
and routines. He argues that many health
behaviors commonly considered habitual may
be more appropriately considered routines.
Sutton (1994) describes a routine as a sequence
of behaviors which is repeated on a regular
basis. However, what distinguishes them from
habits is their need to be supported by self-
reminders. It may be possible therefore to make
the distinction between occasions when the
influence of past behavior is mediated by social
cognitive variables and those occasions when it
24 Health Behavior
is seen to have a direct influence via habitual
responses. In particular, future work should
develop measures of habit and routine that are
discriminable from frequency of past behavior
and outline the processes through which habit
and routine determine behavior.
8.01.5.3 Processes by which Cognitions
Influence Behavior
One important implication of Ronis et al.'s
(1989) distinction between habits and decisions
is the suggestion that social cognition models
may only predict health behavior under certain
conditions. This issue has been addressed by
Fazio (1990) in the development of the MODE
model of attitude±behavior relationships. He
suggests that attitudes (and presumably other
cognitions) influence behavior via two distinct
processes: a deliberative (or controlled) process
and a spontaneous process. Most social cogni-
tion models can be labeled as deliberative
processing models as they assume that behavior
results from a controlled process of conscious
deliberation. However, Fazio (1990) argues that
individuals may only make a behavioral
decision in such a manner when they have the
opportunity and motivation to do so. Under
other conditions, attitudes which are highly
accessible in memory may determine behavior
in a spontaneous fashion (Fazio, Powell, &
Williams, 1989). When the spontaneous process
is operating, an attitude may be automatically
activated from memory following the presenta-
tion of relevant cues, with the likelihood of
activation determined by the accessibility of the
attitude. Once activated, the attitude shapes the
perception of the attitude object in an auto-
matic, attitude-congruent, fashion. For exam-
ple, if a positive attitude is activated then this
will lead the individual to attend to and notice
the positive qualities of the attitude object. This
automatic process of selective perception will
therefore shape the individual's definition of the
event, and thus determine behavior. If the event
is defined on the basis of positive perceptions of
the attitude object, for example, then approach
behaviors will follow. In addition, it is argued
that normative guidelines (e.g., social norms or
rules) may also influence the definition of the
event and thus may help to determine behavior
in some situations.
One important feature of the spontaneous
processing model is that it outlines one way in
which social cognitive variables (i.e., highly
accessible attitudes) may determine behavior
without systematic deliberation. To date, there
has been little research on Fazio's model,
although it has been successfully shown that
the accessibility of relevant attitudes influences
the strength of the relationship between atti-
tudes and behavior (Fazio & Williams, 1986)
and that highly accessible attitudes can lead to
selective perception (Houston & Fazio, 1989;
Fazio & Williams, 1986). Both findings are
consistent with the spontaneous processing
model. This above work has important implica-
tions for SCMs and health behaviors. The
SCMs outlined here are deliberative processing
models inasmuch as they focus on the conscious
processing of information and fail to consider
spontaneous or automatic influences on beha-
vior. Hence, current SCMs may provide only a
partial account of the social cognitive determi-
nants of behavior, that is, they may only be
applicable in situations where the individual has
the ability and motivation to engage in
deliberative processing of information (Conner,
1993). For many behavioral decisions, simpli-
fied or spontaneous decision-making rules may
be employed instead (Norman & Conner, 1993).
Fazio's (1990) spontaneous model has consider-
able potential in helping to provide a full
account of the cognitive influences on behavior.
However, it is clear that most of the empirical
work to date has focused on issues surrounding
the activation of attitudes and their influence on
perception; later components of the model have
received less attention.
8.01.5.4 Stage Models of Health Behavior
A number of researchers have suggested that
there may be qualitatively different stages in the
initiation and maintenance of health behavior,
and that to obtain a full understanding of the
determinants of health behavior it is necessary
to conduct a detailed analysis of the nature of
these stages. From a social cognitive perspec-
tive, an important implication of this position is
that different cognitions may be important at
different stages in promoting health behavior.
One of the first stage models was put forward
by Prochaska and DiClemente (1984) in their
transtheoretical model of change (TTM). Their
model has been widely applied to analyze the
process of change in alcoholism treatment
(DiClemente & Hughes, 1990), smoking cessa-
tion (DiClemente et al., 1991), head injury
rehabilitation (Lam, McMahon, Priddy, &
Gehred-Schutlz, 1988), and psychotherapy
(McConnaughly, DiClemente, Prochaska, &
Velicer, 1989). In its most recent form, DiCle-
mente et al. (1991) identify five stages of change:
precontemplation, contemplation, preparation,
action, and maintenance. Individuals are seen to
progress through each stage to achieve success-
ful maintenance of a new behavior. Taking the
 Limitations and Extensions of Existing Models
example of smoking cessation, it is argued that
in the precontemplation stage smokers are
unaware that their behavior constitutes a
problem and have no intention to quit. In the
contemplation stage, smokers start to think
about changing their behavior, but are not
committed to try to quit. In the preparation
stage, the smoker has an intention to quit and
starts to make plans about how to quit. The
action stage is characterized by active attempts
to quit, and after six months of successful
abstinence the individual moves into the
maintenance stage characterized by attempts
to prevent relapse and to consolidate the newly
acquired nonsmoking status. Whilst relative
widely applied, the evidence in support of the
model and the different stages is at present
relatively weak (see Weinstein, Rothman, &
Sutton, in press).
Heckhausen (1991) has similarly identified
phases in the initiation and maintenance of
behavior change; these being the predecisional,
postdecisional, actional, and evaluative phases,
which follow a similar progressive sequence as
that outlined by Prochaska and DiClemente
(1984). It is further suggested that different
types of cognitions are important in each of
these phases. So in the predecisional phase,
cognitions about the desirability and feasibility
of the behavior are believed to be important
determinants of a desire to perform the behavior
in question. This phase ends with the formation
of an intention to change. In contrast, the
decisional phase focuses on the development
of plans and ends with the successful initiation
of the behavior. In the actional phase the
individual focuses on effectively achieving
performance of the behavior and ends with
the conlusion of the behavior. In the final,
evaluative phase the individual compares
achieved outcomes with initial goals in order
to regulate and maintain behavior. While this
four phase model of behavior was not developed
for the prediction of health behavior, the
potential for its application is clear (see
Gollwitzer, 1993). Other stage models have
been developed including the health action
process approach (Schwarzer, 1992; Schwarzer
& Fuchs, 1996), the precaution-adoption pro-
cess (Weinstein, 1988, Weinstein & Sandman,
1992), and goal setting theory (Bagozzi, 1992,
1993; Bagozzi & Edwards, 1998).
There are two important themes in each of the
stage models outlined above. First, they
emphasize a temporal perspective with different
stages of behavior change. While the models
postulate different numbers of stages, they all
follow the same pattern from a precontempla-
tion stage through a motivation stage to the
initiation and maintenance of behavior. The
25
important point is that these models are
dynamic in nature; people move from one stage
to another over time. Second, these stage
models imply that different cognitions are
important at different stages (Sandman &
Weinstein, 1993). For example, in the earlier
stages information may be processed about the
costs and benefits of performing a behavior,
while in the later stages cognitions become more
focused on the development of plans of action to
initiate and support the maintenance of a
behavior. This earlier motivational phase is
assumed to end with the formation of an
intention and only when the level of motivation
or intention reaches a particular level is the
individual assumed to be likely to move on to
later stages.
The main SCMs of health behavior are
primarily concerned with people's motivations
to perform a health behavior and, as such,
provide strong predictions of behavioral inten-
tions (i.e., the end of a motivational stage).
Ajzen (1991), for example, reports an average
multiple correlation of 0.71 between variables in
the TPB and behavioral intention. However,
intentions do not always lead to corresponding
actions. Studies examining the intention±
behavior relationship have reported a wide
range of correlations. For example, Sheppard
et al. (1988) reported intention±behavior corre-
lations ranging from 0.10 to 0.94. Clearly, many
people who intend to perform a behavior fail to
do so. However, the SCMs considered do not
address the issue of translating intentions into
action. They can be conceptualized as static
models that stop at the formation of an
intention without distinguishing between in-
tenders who become actors and those who do
not. As Bagozzi (1993) argues, the variables
outlined in the main social cognition models are
necessary but not sufficient determinants of
behavior. Clearly, a detailed analysis of the
social cognitive variables important in translat-
ing intentions into action is required to provide
a full account of the determinants of health
behavior.
Relatively little detailed attention has focused
on the cognitive processes underlying the
successful implementation of intentions. The
main social cognition models contain few
measures that account for the intention±
behavior gap (Abraham & Sheeran, 1993).
The TPB attempts to do this by proposing a
direct link between perceived behavioral control
and behavior. Thus, people's perceptions about
the amount of control they have over a behavior
influence the likely performance of behavior
independently of their intentions, although an
analysis of the volitional processes underlying
performance of a health behavior is required,
26 Health Behavior
and a number of researchers have focused
attention on this issue (e.g., Kuhl, 1985;
Schwarzer, 1992; Weinstein, 1988). Here we
focus on Gollwitzer's (1993) work on imple-
mentation intentions and Bagozzi's (1992)
model of goal achievement to highlight the
social cognitive variables important in the
initiation and maintenance of behavior.
Gollwitzer (1993) made the distinction be-
tween goal intentions and implementation
intentions. While the former are concerned
with intentions to perform a behavior or achieve
a goal (i.e., ªI intend to achieve xº), the latter are
concerned with plans as to when, where, and
how the goal intention is to be translated into
behavior (i.e., ªI intend to initiate the goal-
directed behavior x when situation y is
encounteredº). Goal intentions are most like
the intention construct in the TPB, although in
the TPB such intentions usually refer to actions
or behaviors rather than goals. The important
point about implementation intentions is that
they commit the individual to a specific course
of action when certain environmental condi-
tions are met; in so doing they help translate
goal intentions into action. Gollwitzer (1993)
argues that by making implementation inten-
tions individuals pass over control to the
environment. The environment acts as a cue
to action, such that when certain conditions are
met, the performance of the intended behavior
follows. These ideas have similarities with
Weinstein's (1988) ªmessy deskº analogy,
whereby people may have intentions to achieve
a number of goals (i.e., ªprojectsº) which get
ªlostº on the ªmessy desk.º Which project is
actually worked upon is determined by envir-
onmental factors in a similar way as outlined by
Gollwitzer (1993).
Gollwitzer (1993, 1996) has compiled a range
of experimental evidence to support the view
that the making of implementation intentions
can aid the performance of intended behavior.
To date, the only application of implementation
intentions to the prediction of health behavior is
a study by Orbell, Hodgkins, and Sheeran
(1997) on breast self-examination. At the end of
a questionnaire about breast self-examination,
half the women were asked to indicate when and
where in the next month they intended to
perform breast self-examination. A one month
follow-up found that 64% of these women had
performed breast self-examination that month
compared with only 16% of women who had
not made an implementation intention, despite
no difference in goal intentions. In addition,
everyone in the implementation condition who
actually performed the behavior reported doing
so in response to the environmental cue in the
implementation intention and not in response to
any other environmental cue. This suggests that
the making of an implementation intention can
significantly increase the performance of a
behavior. In a study on exercise behavior,
Kendzierski (1990) found that respondents were
more likely to implement their intentions to
exercise when they had engaged in some prior
planning. Further work needs to establish the
utility of implementation intentions in predict-
ing health behavior. However, initial findings
are encouraging and suggest that those who
make such plans of action are more likely to
initiate and maintain behavior.
The work of Gollwitzer (1993) is important in
that it identifies one way in which goal
intentions may be translated into behavior. A
similar but more comprehensive approach has
been put forward by Bagozzi (Bagozzi, 1992,
1993; Bagozzi & Edwards, 1998; Bagozzi &
Warshaw, 1990) in his model of goal achieve-
ment. He focuses on goal-directed behavior and
argues that to initiate behavior individuals need
to form an ªintention to tryº to achieve their
desired goal. Once an intention to try has been
formed, the individual focuses on the means, or
instrumental acts, by which to attempt to
achieve the desired goal. Considering the
example of weight loss, a number of instru-
mental acts can be identified, including restrict-
ing between-meal foods, reducing overall
calorie consumption, avoidance of high calorie
foods, exercise, and so on. Bagozzi (1993)
argues that for each of these instrumental acts,
three appraisal tasks are performed. First, the
individual considers the extent to which they are
confident that they could perform the instru-
mental act (i.e., specific self-efficacies). Second,
the likelihood that the instrumental act will help
in achieving the desired goal is assessed (i.e.,
instrumental beliefs). Third, the individual
considers an affective response towards the
instrumental act (i.e., affect towards means).
Once an individual initiates efforts to achieve a
goal, there are a number of cognitive activities
that support the successful initiation and
maintenance of goal-directed behavior. First,
the individual can develop plans in order to
ensure that instrumental acts are performed.
This involves identifying the situation or
triggering conditions under which the instru-
mental act is performed (Bagozzi & Warshaw,
1990). This idea that certain environmental
conditions may trigger behavior has a clear
overlap with Gollwitzer's (1993) work on
implementation intentions and Weinstein's
(1988) ªmessy deskº analogy. One way in which
plans are more likely to be acted upon is through
the development of scripts or cognitive rehear-
sal, whereby the individuals imagine themselves
performing the instrumental act (Anderson,
 Limitations and Extensions of Existing Models
1983). Another is through the use of precom-
mitting devices whereby the behavior is made
more likely by precommitting oneself to it (e.g.,
avoiding eating butter at home by not having
butter in the house). Bagozzi (1993) also
proposes that ongoing behavior has to be
monitored to ensure, for example, that the
instrumental acts achieve their objectives. If any
unforeseen impediments are encountered then
these need to be taken into consideration and
any future plans modified accordingly. These
ideas overlap with Kuhl's (1985) theory of
action control which identifies a number of
processes by which individuals attempt to
control their actions and achieve their goals.
These processes may be particularly important
in allowing individuals to overcome tempta-
tions to break their new behavior (see Loewen-
stein, 1996). Finally, goal-directed behavior is
likely to be stronger and more persistent if the
individual has a strong sense of commitment to
the decision to try to achieve the goal and the
means to achieve it.
8.01.5.5 Theoretical Integrations and Future
Directions
The above research demonstrates some of the
ways in which research into health behaviors
based upon social cognitive approaches is
developing. Here we outline possible directions
for the future development of an integrative
social cognition model of health behavior,
outline some of the basic requirements for such
a model, and indicate some fruitful avenues for
future research.
It is clear that to fully explain health behavior
it is necessary to develop a more dynamic model
that examines different stages or phases in the
contemplation, initiation, and maintenance of
behavior. What is being proposed is an
integration of current SCMs (such as the
TPB) with stage models of health behavior
(such as the TTM). Several authors have
recommended such an integration (e.g., Cour-
neya, Nigg, & Estabrooks, 1998; Godin,
Desharnais, Valois, & Bradet, 1995; Marcus,
Eaton, Rossi, & Harlow, 1994). Though the
stage models considered in this chapter have
suggested differing number of stages, it is likely
that an integrative model should address at least
four or five main stages: precontemplation,
contemplation, planning, action, and mainte-
nance (Norman & Conner, 1996a).
One implication of the identification of
different stages is that different cognitive
variables may be important in ensuring move-
ment from one stage to the next. In the first
stage, the individuals are not thinking about
27
making a change to their behavior. However,
this stage may be brought to an end by a range
of cues to action, as outlined in the HBM, which
may motivate the individual to start thinking
about performing a health-related behavior.
One such cue to action may be perceived threat
(i.e., perceived susceptibility and perceived
severity). While perceived susceptibility and
perceived severity are seen to be important
determinants of behavior in the HBM, research
with these dimensions has tended to show that
they are relatively weak predictors of behavior.
However, as Schwarzer (1992) has argued, it
may be more appropriate to consider these
variables to have an indirect or more distal
influence on behavior. Thus they may act as a
cue to action, motivating the individual to start
deliberating over performing a health-related
behavior, and thus ensuring movement from the
first to the second stage.
In the second stage, a decision-making or
motivation stage, the individual is thinking
about adopting a new behavior, and the stage
ends when the individual forms an intention to
perform the behavior. To date, most social
cognition models have been primarily con-
cerned with this stage. These models distinguish
between three distinct determinants of indivi-
duals' intentions to perform a health behavior.
First, are outcome expectancies, which focus on
the perceived consequences of performing a
behavior. These expectancies may also cover the
notion of behavioral beliefs as considered in the
TPB and include anticipated affective reactions.
Second, are normative influences which are
primarily tapped by the subjective norm and
normative belief components of the TPB. This
group of variables could also include descriptive
norms, moral norms, and perceived social
support. The third influence on individuals'
intentions to perform a behavior is control
beliefs (or self-efficacy expectancies) and may be
based on a consideration of perceived barriers
(HBM) and control beliefs (TPB). In the
motivation stage, it is likely that other variables
may have a more distal influence on behavioral
intention via the variables outlined above. For
example, health locus of control beliefs may
help shape self-efficacy expectancies, self-iden-
tity and health values may influence the
interpretation of the potential consequences
of a behavior, and past behavior or experience
may provide information which is used to
determine the ease or difficulty of performing a
behavior (i.e., self-efficacy).
Once a behavioral intention has been formed,
it has to be translated into behavior. In the third
stage, the individual is therefore concerned with
planning; focusing on the specific actions or
instrumental acts that need to be performed and
28 Health Behavior
the resources required to support them. Thus, a
number of authors have highlighted the im-
portance of action plans in this stage (Bagozzi &
Warshaw, 1990; Schwarzer, 1992). Similarly,
Gollwitzer (1993) focuses on implementation
intentions which help ensure performance of the
target behavior. Despite slight differences
between definitions of these two concepts, both
emphasize the need to construct fairly detailed
plans of action in order to bridge the intention±
behavior gap. As Schwarzer (1992) argues, self-
efficacy may have an important role to play in
the development and implementation of such
plans, as might self-identity (Sparks & Shep-
herd, 1992) and a sense of commitment
(Bagozzi, 1993). The planning stage is brought
to an end when the individual initiates behavior.
In the fourth stage, the individual has to
ensure that the behavior is successfully enacted.
Various cognitive processes which are con-
cerned with the monitoring and controlling of
behavior may be important in this stage.
Schwarzer (1992), for example, highlights the
need for action control in which the behavior is
re-evaluated against initial goals in order to
regulate and maintain behavior (see also
Bagozzi & Warshaw, 1990; Heckhausen,
1991). As with the development of action plans,
self-efficacy, self-identity, and commitment may
all be important variables in ensuring that
behavior is maintained. In addition, Kuhl
(1985) has argued that there may be individual
differences in people's propensity to engage in
monitoring activities that may account for why
behavior is not always maintained. These
monitoring activities help to ensure that the
behavior is successfully completed. The same
activities will be important in the fifth, main-
tenance stage for ongoing behaviors, where the
individual is concerned with ensuring that the
behavior is successfully repeated.
8.01.6 CONCLUSIONS
Health behaviors have been demonstrated to
have important consequences for both the
quality and length of life through influencing
various disease outcomes. We have attempted to
justify the interest in understanding health
behaviors as a basis for attempting to change
their occurrence in order to increase both length
and quality of life. SCMs provide one approach
to understanding health behavior in describing
the important social cognitive variables under-
lying such behaviors. We believe that these
models provide an important way of achieving
these aims by providing a means for identifying
useful targets for persuasion. It would seem that
there is already sufficient literature to support
the contention that important determinants of
health behaviors are identified in these models.
Further refinement and development of these
models along the lines we have suggested and
reviewed may lead to even better predictions of
behavior and greater understanding of health
behavior and how individuals may be encour-
aged to change.
However, persuasive messages targeted at
relevant cognitions identified by SCMs may not
be sufficient to produce the major behavior
change necessary for health benefits to accrue. It
may be that strategies which employ multiple
level interventions which take account not only
of the psychosocial factors influencing perfor-
mance of the behavior (derived from SCMs) but
also models of the process of persuasion of how
people change and the context in which changes
are made will be important (Glanz et al., 1990;
Hockbaum & Lorig, 1992; Winett, 1985).
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