Applying the Theory of Reasoned Action in Nursing as Health

Educators
M.A. Alatan, P.A. Candia, S.A. Flores, A.A. Igcalinos, J.V.F. Lim, R.J. Mangaliman, G. Paalan, R.J.
Romano, C.C.M. Tagra, W.A. Tubog, & A.J. Yu
Level I - A3, College of Nursing, Silliman University, Dumaguete City, 6200 Negros Oriental

OBJECTIVES
By the end of the [creative] presentation, the learners shall...
1. Understand the elements of the Theory of Reasoned Action (TRA) (knowledge-based),
2. Apply the TRA in health education to facilitate behavior modification (skills-based), and
3. Appreciate the intricate psychology of human behavior through the theory (attitude-based).

BACKGROUND
The Theory of Reasoned Action (TRA), often in tandem with the Theory of Planned Behavior,
is a cognitive theoretical model proposed by psychologists Icek Ajzen and Martin Fishbein (1975) that
seeks to understand how human behavior is influenced by behavioral intention. In fact, this theory
depicts the nature of human behavior as a mathematical model. Fishbein and Ajzen initially developed the
TRA to improve the Information Integration Theory, where the TRA introduced the idea of behavioral
attention and differentiated the differences between attitude and behavior. Remarkably, the theory has
been profoundly influential in facilitating discussions on health behaviors (LaCaille, 2020). The TRA
attempts to understand the psychological process behind performing—or not performing—a health
behavior. At the same time, health educators can develop strategies modeled after the theory to influence
a positive outcome in health behavior change with one's lifestyle. Its ideas and principles have influenced
the creation of campaigns and interventions that try to modify behavior by focusing on the following
terms or concepts: belief, attitude, subjective norms, and intention.

FRAMEWORK DIAGRAM
CONCEPTS
A belief is the probability that an object has some attribute or something has a certain quality. In a
health behavior context, the idea is that a behavior or action will lead to a consequence. One might ask,
"What effect will this behavior have on me?" For example, "I think exercising regularly can keep me fit."
An attitude is an evaluation of an object. Ajzen and Fishbein define attitude as “a disposition to
respond favorably or unfavorably towards some psychological object.” Hence, it is an individual's
positive or negative perception of a behavior upon evaluating its consequence. Furthermore, an attitude is
whether or not someone thinks a behavior is good or bad or if it will lead to an outcome they value or
otherwise (Nickerson, 2023). A person might ask, "Is this behavior a good or bad idea?" There are two
factors in processing an attitude toward a behavior:
a. Assessment ("What effect will this behavior have on me?") and
b. Evaluation of the consequences ("Is this effect/consequence/outcome good or bad for me?").
The TRA emphasizes that attitudes are a function of beliefs, meaning that an attitude equals the sum of all
belief strength of a behavior multiplied by one's evaluation of its consequences [attitude = belief strength
x evaluation of the consequences]. For example, a person's attitude toward exercising regularly would
depend on his/her beliefs about what the action would lead to and whether or not the outcomes are
desirable for him/her. A person would view exercising regularly as a positive thing if he/she personally
believes it would yield desirable/beneficial outcomes. This increases the person's likelihood to perform
the behavior. Otherwise, a negative evaluation of the consequences will lead to a negative attitude toward
the behavior, decreasing the person's likelihood of doing it.
Meanwhile, a subjective norm describes all the social pressures to engage in certain behaviors
that a person may face from their family, friends, and any important or relevant individual in a person's
life. Discussions of the TRA mention two forms of subjective norms: injunctive norms and descriptive
norms.
An injunctive norm is someone's thought of whether or not other people think such behavior is
right or wrong and should or should not be acted out: "My doctor told me exercising regularly is
beneficial for my body because it lessens the risk of acquiring cardiovascular disorders. He and my wife
encouraged me to do it." A person might ask this question: "What do others think is the right thing I
should do?"
A descriptive norm is someone's perception of what they think other people are actually doing: a
question one might ask is, "What are others actually doing?" For example, "I think many people are
exercising because I have seen many of my Facebook friends posting about their exercising journey. It
might be a good thing to try out."
Subjective norms are a function of the normative beliefs of a society and the motivation for
someone to comply. Normative beliefs are whether or not a person believes others want them to do that
behavior: "Do they want me to do this?" In the recurring scenario, the person may have the following
normative belief: "My family wants me to exercise regularly." Motivation to comply refers to the extent
to which someone wants to do what others want him/her to do: "How much do I want what they want me
to do?" For example, "I definitely want to exercise regularly, as suggested by my doctor!"
The preparedness to do something is the intention. This expresses an individual's subjective
probability (perceived likelihood) of engaging in a particular behavior: "Now, do I want to do this?" All
concepts mentioned above affect a person's intention or readiness to engage in healthy behavior.

KEY STRENGTHS
1. The Theory of Reasoned Action (TRA) provides a clear and structured framework for
understanding the psychological process of adopting human behavior.
2. It can predict human behavior based on attitudes and subjective norms.
3. Empirical studies have proven the significance of attitudes and subjective norms as determinants
of an individual's intention and subsequent behavior.
4. The TRA applies to diverse fields focusing on behavior (e.g., health-promoting behaviors,
consumer behaviors, etc.).
 5. This theory allows practicing professionals to develop effective strategies that foster behavioral
change.

LIMITATIONS
1. There are more predictors other than attitudes and subjective norms that influence behavioral
intention, which the TRA does not explicitly include.
2. It assumes that humans are purely rational decision-makers who carefully weigh out
consequences. However, emotions, habits, circumstances (past experiences), personal values, and
traits also impact their inclination to do an action.
3. Furthermore, it assumes behavior as a linear decision-making outcome, not a dynamic one that
can change over time.
4. Primarily, the TRA focuses on the individual level and can overlook contextual factors
surrounding the individual or external factors, such as cultural norms and societal pressures,
which can lead to oversimplifications when trying to understand behavior in a larger context.
5. This theory can be subjected to the social desirability bias since it relies on self-perceived
attitudes, beliefs, and subjective norms.
6. The theory does not consistently guarantee that intentions to do a human behavior translate to
actual actions because of an individual's circumstance, context, and self-regulatory processes.
7. The timeframe between the behavioral intention and performing the behavior is not explicit.

IMPROVEMENTS IN THE THEORY

In an attempt to address some limitations of the Theory of Reasoned Action, Icek Ajzen
developed the Theory of Planned Behavior (1985) as an extension to the TRA when discussing human
behavior. He added the concept of perceived behavioral control as a direct influence on intention and
behavior. Furthermore, online models include external factors as catalysts of behavioral intentions Ajzen
& Fishbein, 2005). These include personal factors (traits, values, emotions, etc.), social demographics
(age, gender, race, religion, education, and income), and information (experience, knowledge, and media
exposure).
APPLICATION TO HEALTH EDUCATION
As health educators, nurses can facilitate health-promoting behavior using Fishbein and Ajzen's
Theory of Reasoned Action by developing effective strategies that address the intention, attitude, and
subjective norms to achieve a positive outcome: behavior change. These strategies in health promotion
become explicit with TRA as a theoretical framework in practice. Hence, nurses can manipulate the
determinants that predict behavioral intention and subsequent behavioral performance, primarily through
establishing reinforcements in individual perceptions of health-promoting behavior. Health education
focuses on promoting healthy habits, so the learning strategies should prompt the clients/learners to
realize the importance and benefits of practicing such behavior. That said, health educators can tailor their
approach through the following strategies:
1. Identifying Perceptions. Assess individuals' attitudes and beliefs that influence their decisions
regarding the target health behavior.
2. Breaking Barriers. Address any negative attitudes or misconceptions that may hinder behavior
change by providing accurate information, debunking myths, and highlighting the benefits of
adopting the desired behavior.
3. Clarifying Subjective Norms. Discuss the perceived social pressures and expectations of
influential people around the individual regarding the behavior. These include social influences of
family and friends, cultural norms, and media portrayals.
4. Introducing Role Models. Highlight stories from individuals who have successfully adopted
healthy behavior, which can serve as powerful motivators and sources of social influence.
5. Offering Social Support. Create a supportive environment by reinforcing positive attitudes and
providing encouragement and assistance to individuals as they work toward adopting the desired
behavior.
6. Promoting Behavioral Intentions. Emphasize the personal relevance, importance, and benefits of
the behavior to strengthen individuals' intentions to perform and adhere to the target behavior.
7. Monitoring Progress and Providing Feedback. Help individuals track their behavioral change
efforts by providing feedback on the progress, celebrating successes, and offering guidance to
overcome obstacles in the behavior change process.

CASE STUDY
Scenario 1: Cessation of Smoking
Michael’s father was a heavy smoker and would finish a pack of cigarettes in a day. Micheal
followed in his father’s footsteps, now at age 30 he has become a heavy smoker for 15 years. For
Michael, smoking helps him relax, and it is quite enjoyable. His doctor kept on advising him to stop
smoking due to the risks of smoking, however, he finds it difficult to quit smoking. He thinks he could not
live life if he quits smoking. Michael believes that quitting smoking would increase his anxiety, as
smoking helps him relax. Over time, Michael began to experience serious health problems, he was
diagnosed with early-stage emphysema which made it harder for him to breathe. Michael’s family
encouraged him to quit smoking. They express their concern for him and regularly remind him of the
negative effects of smoking. Michael feels conflicted to comply because he feels that smoking is a
personal choice.

Questions:
1. What could be the targeted behavior?
- Quitting smoking.
2. What is the behavioral belief in the statement?
- Michael believes that quitting smoking would increase his anxiety, as smoking helps him
relax.
3. What is Michael’s attitude toward the targeted behavior?
- He thinks he could not live life if he quits smoking.
4. What subjective norms can you observe?
 -His doctor kept on advising him to stop smoking due to the risks of smoking...
-Michael’s family encouraged him to quit smoking. They express their concern for him
and regularly remind him of the negative effects of smoking.
5. Does Michael have the motivation to comply with the target behavior?
- No, Michael feels conflicted to comply because he feels that smoking is a personal
choice.
6. Does Michael have the intention to quit smoking?
- No!
7. How can a health educator help Michael?
- Assess Michael’s attitude and beliefs toward smoking.
- Inform him of the benefits, relevance, and importance of quitting smoking to his life.
- Teach Michael that using cigarettes as a coping mechanism will deteriorate his health.
- Create a supportive environment for him.

LEARNING ASSESSMENT ACTIVITY (10 items)

1. What term refers to an evaluation of an object, specifically an individual’s positive or negative
perception of a behavior upon evaluating its consequences?
A. Attitude
B. Belief
C. Intention
D. Perceived Belief Controls

2. An injunctive norm is someone’s thought of whether or not other people think such behavior is right or
wrong and should or should not be acted out.
A. True
B. Maybe
C. False

3. What concept best describes whether or not a person believes others want them to do that behavior?
A. Subjective norm
B. Intention
C. Normative belief
D. Motivation to Comply

4. What does the Theory of Reasoned Action (TRA) primarily seek to understand?
A. Human behavior in isolation from external influences
B. The cognitive process behind human behavior
C. Cultural norms and societal pressures
D. Emotional responses to stimuli

5. Which strategy involves assessing individuals' attitudes and beliefs that influence their decisions
regarding the target health behavior?
A. Breaking barriers
B. Identifying perceptions
C. Introducing role models
D. Offering social support

6. Which type of norm reflects someone's perception of what others are actually doing?
A. Injunctive norm
B. Descriptive norm
C. Personal norm
 D. Cultural norm

7. Which factor does the TRA not explicitly include as a predictor of behavioral intention?
A. Emotions
B. Subjective norms
C. Consequences
D. Reinforcements

8. What concept refers to how likely an individual will engage in a specific behavior?
A. Subjective Norm
B. Belief
C. Attitude
D. Behavioral Intention

9. According to the theory, behavioral intention is affected by all other concepts, such as an individual's
beliefs, attitudes, and subjective norms.
A. True
B. False

10. When did Fishbein and Ajzen formulate the TRA?

A. 1985
B. 1976
C. 1975
D. 1977
 REFERENCES
Ajzen, I., & Albarracín, D. (2007). Predicting and changing behavior: A reasoned action approach. In I.
Ajzen, D. Albaracin, & R. Hornik (Eds.), Prediction and change of health behavior: Applying
the reasoned action approach (pp. 1–22). Mahwah, NJ: Lawrence Erlbaum Associates.
Ajzen, I. & Fishbein, M. (2005). The Influence of Attitudes on Behavior.
eBusiness@Newcastle. (n.d.). Theory of Reasoned Action - TheoryHub - Academic theories reviews for
research and T&L. https://open.ncl.ac.uk/academic-theories/18/theory-of-reasoned-action/
The theory of planned behavior. (n.d.).
https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/BehavioralChangeTh
eories3.html
Lambert, B. (2021, May 9). Theory of Reasoned Action and Planned Behavior: Ultimate Guide — How
Communication works. How Communication Works.
https://www.howcommunicationworks.com/blog/2021/1/5/2t2nwgf1wtehyutw4z1k5ozesvmr4w
Nickerson, C. (2023, October 16). Theory of Reasoned Action (Fishbein and Ajzen, 1975). Simply
Psychology. https://www.simplypsychology.org/theory-of-reasoned-action.html
Theory of Reasoned Action: Definition & Example. (n.d.). StudySmarter UK.
https://www.studysmarter.co.uk/explanations/psychology/addiction/theory-of-reasoned-action/

APPENDIX

PRESENTATION FLOW POINT PERSON

I. Prayer class
II. Greetings Anne and Mark
III. Just Dance! Battle (Ice Breaker) Jvin, Wayne, and Sarah
IV. Introduction to Behavior Chino
V. Objectives Chino
VI. Four-Pics-One-Word (Pre-Assessment) Mark, Grace, and Raven
VII. Background Pearl
VIII. Framework Diagram Roxanne
IX. Concepts Roxanne
X. Key Strengths Pearl
XI. Limitations Alexia
XII. Improvements in the Theory Alexia
XIII. Application to Health Education Alexia
XIV. Short Recap Chino
XV. Case Study Workshop Anne, Mark, and Grace
XVI. Learning Assessment Activity Jvin, Wayne, and Sarah
XVII. Closing Mark and Grace
XVIII. Open Forum everyone
XIX. Photo Opportunity everyone
Tech. Team Raven, Anne, and Sarah