Theories to Health Behavior Change

LEARNING OBJECTIVES
• By the end of this lecture, students should be able to:
– Understand what is theory.
– Define key concepts and terms of health behaviour theories.
– Outline theories commonly used in HEP practice.
– Outline the importance of health behaviour theories in HEP practice.
 What is a theory?

• “ A set of interrelated concepts, definitions, and

propositions that present a systematic view of events or situations
by specifying relations among variables, in order to explain and predict the events
or situations.”
– A theory presents a systematic way of understanding events or situations
– Theories are general, theories must be applicable to a broad variety of
situations.
– They are abstract, don’t have a specified content or topic area
 Why is theory important?
• Why is theory important?
– Directs our research strategy
– Shapes and guide our interventions
– Explains our outcomes
– Theory, Research and Practice are integrally related
• The theories in the field of health promotion have been
derived from education, sociology, psychology, anthropology,
and public health
 Important terms & Concepts in theory

• Concepts are the building blocks—the primary elements—of a theory

• Constructs are concepts developed or adopted for use in a particular
theory. The key concepts of a given theory are its constructs.
• Variables are the operational forms of constructs. They define the
way a construct is to be measured in a specific situation.
• Models may draw on a number of theories to help understand a
particular problem in a certain setting or context. They are not always
as specified as theory.
 Common Behavior change theories
• The Health Belief Model (HBM)
• The Trans-theoretical Model (TTM)
• Theory of Reasoned Action & Theory of Planned Behavior (TPB)
• Social Learning Theory
• Diffusion of Innovation
• Other Theories:
– Elaboration Likelihood Model of Persausion
– Information – Motivation – Behavioral Skills Model
– Health Action Process Approach
HEALTH BELIEF MODEL (HBM)
 Historical Perspectives
• Early 1952: U.S. Public Health Service hired G. Hochbaum to
study the reasons for low participation in TB screening programs
• Geoffrey Hochbaum, along with Stephen Kegels and Irwin
Rosenstock, proposed the basic health belief model (HBM) in the
late 1950s
• Expanded in the 1980s by Becker
• Based on general principles of value expectancy—desire to
avoid sickness (value), belief in availability of preventive tools
(expectancy)
Constructs of the HBM
 Constructs of the HBM
• Perceived susceptibility: Belief of a person regarding the
possibility of acquiring a disease or harmful state as a result
of a particular behavior
• Define population at risk (apply descriptive epidemiology)
• Personalize risk (discussion, role play, simulation, case
study)
• Consistent with actual risk (apply analytical epidemiology)
 Constructs of the HBM (cont’d)
• Perceived severity: Belief of a person
regarding the extent of harm that can result
from the acquired disease or harmful state as a
result of a particular behavior
– Specify consequences of the risk and the
condition (lecture, discussion, self-reflection,
case study, case narration, video
presentation)
 Constructs of the HBM (cont’d)
• Perceived benefits: Belief of a person regarding the
usefulness of the methods suggested for reducing risk or
seriousness of the disease or harmful state resulting from a
particular behavior
– Define action to take (clear steps, specific demonstration, re-
demonstration)
– Clarify the positive effects to be expected (discussion, lecture,
self-reading, video presentation, computer-aided presentation)
 Constructs of the HBM (cont’d)

• Perceived barriers: Belief of a person regarding actual and

imagined costs of performing the new behavior
• Reassurance (one-on-one counseling, case study, discussion,
active listening)
• Correction of misinformation (lecture, video presentation, role
play)
• Incentives (tangible and intangible aids, verbal encouragement,
case accounts)
• Assistance (providing services, transportation)
 Constructs of the HBM (cont’d)
• Cues to action: Precipitating force that makes the
person feel the need to take action
– Provide how-to information (lecture, demonstration, re-
demonstration, role play)
– Employ reminder system (buddy system, log, diary, Post-it
notes)
 Constructs of the HBM (cont’d)
• Self-efficacy: Belief or confidence in performing a
behavior
– Provide training in small steps (demonstration, re-
demonstration)
– Progressive goal setting (self-reflection, diary)
– Verbal reinforcement (one-on-one counseling)
– Reduce anxiety (stress management techniques)
 Applications of HBM
• Screening behaviors (TB, breast cancer, colorectal cancer, influenza
vaccinations, Tay-Sachs disease, high blood pressure, etc.)
• Preventive behaviors (seat belt use, smoking cessation, physician
visiting, etc.)
• Health promotion behaviors (exercise, healthy nutrition, etc.)
• Treatment compliance behaviors (diabetes, end-stage renal disease,
bronchial asthma, weight loss, etc.)
 Application of HBM
to Safer Sex

How the health belief model can be used to modify sexual behavior in youth to
promote safer sex.
Strengths of HBM
• Only model from health field
• Tested extensively
• Simple and easy to understand
• Can be applied to both one-time and long-term behaviors
 Limitations of HBM

• Model lacks consistent predictive power mainly because it

focuses on a limited number of factors; factors other than health
beliefs (such as cultural factors, socioeconomic status, previous
experiences, etc.) also shape health behaviors but are not
accounted for in the model
• Measurement error in operationalization
• Cross-sectional data’s failure to provide evidence of temporality
 Limitations of HBM (cont’d)
• Comparative studies are few and lacking
• Need to understand relative importance of constructs
• Need to use behavioral anchors in articulating questions, for
example, “If you do not practice safer sex, how likely are you to
become infected with HIV/AIDS?” as opposed to “How likely are
you to become infected with HIV/AIDS?”
Theory of Reasoned Action and
Theory of Planned Behavior
TRA/TPB constructs
Theory of Reasoned Action and
Theory of Planned Behavior

How important the

situation is to
What people them, or how
think the much control they
situation is have over it
 Theory of Reasoned Action and
Theory of Planned Behavior
Constructs:
1.  Behavioral intentions
2.  Attitude toward the behavior
3.  Subjective norm
4.  Perceived behavioral control
 TRA/TPB:
#1. Behavioral
intentions
  Best measured by linking the behavior
The best predictor of actual to
specifically defined:
behavior
–  Action
–  Target
–  Context
–  Time
TRA/TPB: Behavioral intentions
  Be specific re: intentions and behaviors:
–  Action Target Context Time
– 
– 
– 
  “Reducing risk of HIV transmission (action) by
formula feeding (target) when the mother is
HIV infected (context) every time (time)”
  “Reducing risk of head injuries (action) by
wearing a helmet (target) when skateboarding
(context) at night (time)”
 Norms

  Norms are everywhere

–  What should I wear?
–  What should I eat?
–  Should I smoke?
–  How many children should a couple
have?
 Norms and group identity
  “Group identity-based codes of conduct that are
understood and disseminated through social interaction” (Rimal &

Real, 2003, p. 185)

  Norms reinforce group identity, and group identify reinforces

norms
 
“A rule that is socially enforced”
 
Violators of norms are considered eccentric or even deviant,
  not good members of the group
Violation of a critical norm, or persistent violation of norms,
can result in stigmatization
 Subjective norms
  Adding on normative/social dimension to HBM
  Two parts:
  Normative beliefs: What do I think people I
know think I should do?
–  My sexual partner thinks I should use a condom
My family thinks I should breastfeed
– 
  Motivation to comply: How important is it me to do to
what others think I should do?
–  It is very important to me to do what my
partner/family thinks I should do
TRA applied to wearing helmet

Specific to Action, Target,

Wearing a helmet
protects your head in a Context, Time.
I think wearing a
fall. helmet is good.
Crashing without a helmet can
kill you.
Wearing
Helmet
My friends think wearing a
helmet is not cool.
If I wear a helmet my
friends will think I am not
cool.
I care a lot about what my
friends think of me.
TRA applied to sleeping under
mosquito net
Specific to Action, Target,
Using a bednet protects me Context, Time.
from malaria. I think using a bednet is
good.
Malaria can kill you.
Using
Bednet
My family thinks using a bednet
is for people who are weak.
If I use a bednet my
family will think I am
I care a lot about what my weak.
family thinks of me.
 Theory of Planned Behavior:
Perceived Behavioral Control
  Some similarity to self-efficacy
  Control Belief
–  Perceived likelihood of each facilitating (or
constraining) condition
•  Example – It is likely that be the elevator will
crowded
  Perceived Power
–  Perceived effect of each condition in making
behavioral performance difficult or easy
•  Example – If the elevator is crowded I will
probably take the stairs
Social Learning &Social Cognitive Theories
 Social Learning Theory
• Developed by Albert Bandura’s- 1963, 1977
• Social Learning Theory posits that people learn from one
another, via observation, imitation, and modeling
• integrated behavioral and cognitive theories of learning
in order to provide a comprehensive model that could
account for the wide range of learning experiences that
occur in the real world
 Key Concepts
•Learning is not purely behavioral; rather, it is a cognitive process that takes
place in a social context.
•Learning can occur by observing a behavior and by observing the
consequences of the behavior (vicarious reinforcement).
•Learning involves observation, extraction of information from those
observations, and making decisions about the performance of the behavior
(observational learning or modeling). Thus, learning can occur without an
observable change in behavior.
•Reinforcement plays a role in learning but is not entirely responsible for
learning.
•The learner is not a passive recipient of information. Cognition, environment,
and behavior all mutually influence each other (reciprocal determinism).
 NECESSARY CONDITIONS FOR EFFECTIVE
MODELING
• Attention — various factors increase or decrease the amount of attention
paid. Includes distinctiveness, affective valence, prevalence, complexity,
functional value. One’s characteristics (e.g. sensory capacities, arousal level,
perceptual set, past reinforcement) affect attention.
• Retention — remembering what you paid attention to. Includes symbolic
coding, mental images, cognitive organization, symbolic rehearsal, motor
rehearsal
• Reproduction — reproducing the image. Including physical capabilities, and
self-observation of reproduction.
• Motivation — having a good reason to imitate. Includes motives such as
past (i.e. traditional behaviorism), promised (imagined incentives) and
vicarious (seeing and recalling the reinforced model)
 Reciprocal Determinism

•  This notion states that just as an individual's behavior

is influenced by the environment, the environment is
also influenced by the individual's behavior.
• A person's behavior, environment, and personal
qualities all reciprocally influence each other
 Role Modelling
Bandura outlined three types of modeling stimuli:

•Live models, where a person is demonstrating the desired behavior

•Verbal instruction, in which an individual describes the desired
behavior in detail and instructs the participant in how to engage in the
behavior
•Symbolic, in which modeling occurs by means of the media, including
movies, television, Internet, literature, and radio. Stimuli can be either
real or fictional characters.
 Application of the SLT
• Criminology-criminal behavior is learned in both social
and nonsocial situations through combinations of direct
reinforcement, vicarious reinforcement, explicit
instruction, and observation.
• Developmental psychology -social factors, involving
all the interactions the individual encounters
• Management- proposes that rewards aren't the sole
force behind creating motivation. Thoughts, beliefs,
morals, and feedback all help to motivate us
 Application Cont’
• Media Violence-studies have discovered significant
correlations between viewing violent television and
aggression later in life and many have not, as well as
playing violent video games and aggressive behaviors
( basis of TV ratings)
• Edutainment-soap opera can help viewers learn socially desired
behaviors in a positive way from models portrayed in these
programs
• Health Education in schools-For example, using the technique
of guided participation, a teacher says a phrase and asks the
class to repeat the phrase. Thus, students both imitate and
reproduce the teacher's action, aiding retention
Social Cognitive Theory

Behavior

Personal Factors Environmental

Factors
(Cognitive,
affective, &
Biological events)
 Social Cognitive Theory

  The triangle that is always shown to summarize SCT

is not analogous to the models for HBM and TRA/TPB,
refers to broader processes
  The key difference is agency: People’s capacity to
make choices and impose those choices on the world
Social Cognitive Theory
“Reciprocal
Determinism”

Behavior

Personal Factors Environmental

Factors
(Cognitive,
affective, & Includes
Biological events) both social
& physical
environment
 Self-efficacy
  A cornerstone of Social Cognitive Theory
  Belief/conviction (may or may not be true)
that one has the power to act in a certain
manner to achieve specific goals/outcomes
  Distinct from self-esteem, one’s feelings of self-
worth
  A person with low self-efficacy in relation to
behavior X may have high or low self- esteem
 Measurement of self-efficacy
  Measured through a series of statements:
–  “I feel confident I can refuse a cigarette when
my peers offer one to me”
–  “I feel confident that I can ask my
partner whether she agrees to us using
a condom”
  Examples of response categories:
–  Strongly disagree, disagree, neutral, agree,
strongly agree
–  Not at all confident, a little confident,
confident, very confident
 Factors increasing self-efficacy
  Experience carrying out the behavior,
“mastery experience” e.g. previous refusal of
cigarettes offered by peers
  Modeling of behavior by others / vicarious
experience
  Encouragement/mentoring by others to carry out
the behavior
  Experience with overcoming constraints to
practicing the behavior
 Self-efficacy
  Popular concept, has been incorporated
into many different models and frameworks
  Bandura and others feel self-efficacy doesn’t make as
much sense when it isn’t “at home” in Social Cognitive
Theory
SCT especially applicable where
self-control is needed
  Self control required in refusal to:
–  Smoke cigarette when offered by peer
–  Have sexual intercourse/have sexual
intercourse without a condom
–  Have multiple sexual partners
–  Have large family
–  Eat everything on the dinner plate
– 
Eat snacks when offered
TRANS THEORETICAL MODEL (TTM)/ STAGES OF
CHANGE
 Historical Perspectives
• Late 1970s: James Prochaska from the University of Rhode Island
undertook a task to review various theories behind psychotherapy
• 1980s: The University of Rhode Island Change Assessment
(URICA) scale was developed
• 1990s: Two scales were developed on TTM
– Readiness to Change Questionnaire (RCQ)
– Stages of Change Readiness and Treatment Eagerness Scale
(SOCRATES)
• 2000s: Variety of health applications
• 2010s: Health coaching & online applications
• At present enjoys the status of being the most popular model
 Stages of Behavior Change
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Termination
 Stages of Behavior Change

Stages of change in the transtheoretical model. The progression through the

stages is not linear but cyclical or spiral; one might progress from
precontemplation to action and then regress to contemplation and then again
progress to action and so on.
 Stages & Processes of TTM

Relationship of the constructs and processes of the transtheoretical model to

stages of change.
 Decisional Balance
• Relative weighing of the pros and cons of changing
• Pros: The benefits of changing
– Janis and Mann (1977) identified the following components
(recent work has found not much gain in predictive value):
• Instrumental gains for self
• Instrumental gains for others
• Approval for self
• Approval for others
 Decisional Balance (cont’d)

• Cons: The costs of changing

– Janis and Mann (1977) identified the following components:
• Instrumental costs to self
• Instrumental costs to others
• Disapproval from self
• Disapproval from others
 Self-Efficacy

• Confidence
– Behavior specific
– Situation specific
– “Here and now”
– Build small steps
© Olivier Le Moal/Shutterstock
 Self-Efficacy (cont’d)
• Temptation
• Counteract stress
• Avoid negative social occasions
• Control cravings
• Important in preparation and action stages

© Creativa Images/Shutterstock
 Consciousness Raising

• Increased awareness of behavior

• Experiential process
– Methods
• Feedback
• Confrontations
• Interpretations
• Important in contemplation, preparation, and action
stages
 Dramatic Relief

• Transition to emotional awareness

• Experiential process
– Psychodrama
– Role playing
– Personal testimony
– Grieving
© Andy Dean Photography/Shutterstock

• Important in contemplation and preparation stages

 Self-Reevaluation

• Cognitive and affective assessment of one’s self-image

• Experiential process
– Value clarification
– Healthy role modeling
– Mental imagery
• Important in preparation and action stages
 Environmental Reevaluation

• Affective and cognitive assessment of how one’s behavior

affects the social environment
• Experiential process
– Empathy training
– Documentary reflection
• Important in contemplation, preparation, and action
stages
 Self-Liberation

• Belief that one can change

• Behavioral process
• Commitment and recommitment
– “Skill power”
– Resolutions
– Public testimony
© Tashatuvango/Shutterstock

• Important in contemplation and preparation stages

 Helping Relationships

• Caring, trust, openness,

acceptance for behavior change
• Behavioral process
– Rapport building
– Therapeutic alliance
– Professional calls
– Buddy systems
• Important in action and
maintenance stages
 Counterconditioning
• Learning of healthy coping
• Behavioral process
– Relaxation
– Assertion
– Desensitization
– Nicotine replacement
– Positive self statements
• Important in preparation, action, and maintenance stages
 Contingency Management
• Consequences for taking steps in a particular direction
• Behavioral process
– Contingency contracts
– Overt and covert reinforcements
– Group recognition
• Important in action and maintenance stages
 Stimulus Control
• Removes cues for unhealthy habits
• Behavioral process
– Avoidance
– Environmental reengineering
– Self-help groups © Kheng Guan Toh/Shutterstock

• Important in action and maintenance stages

 Social Liberation
• Increase in social opportunities or alternatives
• Experiential process
– Smoke-free environment
– Access to healthy alternatives
• Important in action and maintenance stages
 Stages & Processes of TTM

Relationship of the constructs and processes of the transtheoretical model to

stages of change.
 Application of TTM
to Smoking Cessation

Application of the transtheoretical model for a smoking cessation program.

Strengths of TTM
• Only theory to talk about behavior change
• Tested extensively
• Presents five stages of change
• Rooted in several theories of psychotherapy
• Very elaborate

© Sergey Nivens/Shutterstock
 Some Limitations of TTM
• Stages in the model are arbitrary, and to classify a population in
different stages serves little utility
– People can move through the stages of the model in minutes
– The validity of self-reported behavior with regard to stage is
questionable
– A significant number of people cannot be assigned to
recognized stages
• Need to strive for parsimony of stage-matched behavior-specific
processes
 Some Limitations of TTM (cont’d)

• Comparative studies of stage-matched

versus non-stage-matched interventions
are lacking
• Applications to vulnerable subgroups of
populations are lacking
Diffusion of Innovation Theory
Background Information
• The originator of the Diffusion of Innovation Theory is Everett M.
Rogers.
• His upbringing on a farm in Iowa gave him the opportunity to
analyze the decision making process farmers used when
contemplating the adoption of an innovation for their farms.
• The theory addresses the process of adopting innovative ideas &
can be used to track the uptake of innovations by a target group or
audience.
• Rogers’ focus was on interpersonal networks, and social systems
that influenced farmer’s decisions and attitudes towards a new
product or idea.
• The theory can provide a conceptual paradigm for understanding
the process of diffusion and social change.
What is the Diffusion of Innovation Theory

“The process by which an innovation is

communicated through certain channels over
time among members of a social system”
 Innovation

• Innovation = An idea, practice, or object perceived as new by

an individual or other unit of adoption
• The Diffusion of Innovations Theory attempts to predict
adoption of innovations. . . Typically, the adoption follows a
standard pattern: (i.e. it explains how the new idea/ practice or
product spread and how it is adopted in a community)
 Adoption Decision Process
• Diffusion occurs through a five–step decision-making process.
• It occurs through a series of communication channels over a
period of time among the members of a similar social system.
• An individual might reject an innovation at any time during or
after the adoption process.
 Adoption Decision Process
Stages of adoption:

Awareness - the individual is exposed to the innovation but lacks

complete information about it

Interest - the individual becomes interested in the new idea and

seeks additional information about it

Evaluation - individual mentally applies the innovation to his

present and anticipated future situation, and then decides whether
or not to try it

Trial - the individual makes full use of the innovation

Adoption - the individual decides to continue the full use of the

innovation
 Adopter Categories
• The rate of adoption the relative speed at which
participants adopt an innovation.
• Measured by the length of time required for a certain
percentage of the members of a social system to adopt an
innovation
• Determined by an individual’s adopter category.
Adoption Curve
 Adopter Categories
Category Characteristics
• Innovators are willing to take risks, have the highest social status, have
financial liquidity, are social and have closest contact to scientific sources
and interaction with other innovators.
Innovators
• Their risk tolerance allows them to adopt technologies that may ultimately
fail.
• Financial resources help absorb these failures.
• These individuals have the highest degree of opinion leadership among the adopter
categories.
Early adopters
• have a higher social status, financial liquidity, advanced education and are more socially
forward than late adopters.

• They adopt an innovation after a varying degree of time that is significantly longer than the
innovators and early adopters.
Early Majority
• Early Majority have above average social status, contact with early adopters and seldom
hold positions of opinion leadership in a system
 Adopter Categories
Category Characteristics

• They adopt an innovation after the average participant.

• These individuals approach an innovation with a high degree of skepticism
Late Majority and after the majority of society has adopted the innovation.
• Have below average social status, little financial liquidity, in contact with
others in late majority and early majority and little opinion leadership.

• They are the last to adopt an innovation

• Show little to no opinion leadership.
Laggards • Typically tend to be focused on "traditions", lowest social status, lowest
financial liquidity, oldest among adopters, and in contact with only family and
close friends.
 Factors affecting diffusion
• Innovation characteristics

• Individual characteristics

• Social network characteristics

• Others…
 Innovation characteristics
• Observability
– The degree to which the results of an innovation are visible to potential adopters
• Relative Advantage
– The degree to which the innovation is perceived to be superior to current practice
• Compatibility
– The degree to which the innovation is perceived to be consistent with socio-cultural
values, previous ideas, and/or perceived needs
• Trialability
– The degree to which the innovation can be experienced on a limited basis
• Complexity
– The degree to which an innovation is difficult to use or understand.
 Individual characteristics
• Reliance on others as source of information

• Adopter threshold

• Need-for-change / Need-for-cognition
 Conclusions
Summary of health behaviour theories
 Why focus on the indirect behaviours

Leading Causes of Disease

Biology

20%

Behaviour
50% 20%
Environment
10%

Access
Behavioural contribution to management of
chronic illness estimated at >90% (Wanless,
2004)
(Healthy People 2000)
 Determinants of Health Behaviour
• Background factors: Characteristics that define the context in which
people live their lives; shared understanding and ways of knowing the
world
• Stable factors: Individual differences (personality) in psychological
activity that are stable over time and context
• Social factors: Social connections in the immediate environment; mostly
stable, but can be fragile, e.g. when in conflict with background factors
• Situational factors: Appraisal of personal relevance that shape responses
in a specific situation
 Common Health Behaviour Theories
• Theories attempt to explain the relationship between social cognitions and other
factors (e.g. beliefs, attitudes, goals, etc.) and behaviour
• Some examples:
– Health Belief Model (Rosenstock, 1966)
– Protection Motivation Theory (Rogers, 1975)
– Theory of Reasoned Action (Fishbein & Ajzen, 1975)
– Theory of Planned Behaviour (Ajzen, 1988)
– Transtheoretical Model (Prochaska and DiClemente, 1983)
Key Concepts of Common theories
 Proposition – Behaviours Theory of Planned Transtheoretcial
Concept Health Belief Model
more likely when Behaviour Model

Belief that significant others

Normative PoC: Helping
desire one to adopt the X Subjective norm
beliefs relationships
behaviour

Outcome Perceived benefits outweigh Behavioural Decisional

Benefits and Barriers
Evaluation perceived costs of behaviour Beliefs Balance

Belief in one’s ability to Perceived Perceived Behavioural Self-efficacy and

Self-efficacy
perform behaviour efficacy Control Situational Temptations

One feels at risk of an

Perceived Decisional
Risk beliefs outcome with negative X
Susceptibility Balance
consequences

Emotional response to
Perceived
Risk affect perceived risk within normal X PoC: Dramatic relief
Threat
limits

One has formed / holds an

Intention / Behavioural Stages if Change (Cont,
intention to perform the X
Motivation intentions Preparation and Action)
behaviour
Application of health behaviour theories
TRA/TPB constructs
TRA applied to sleeping under
mosquito net
Specific to Action, Target,
Using a bednet protects me Context, Time.
from malaria. I think using a bednet is
good.
Malaria can kill you.
Using
Bednet
My family thinks using a bednet
is for people who are weak.
If I use a bednet my
family will think I am
I care a lot about what my weak.
family thinks of me.
Concept Definition
Pre-contemplation Unaware of problem;
Has not thought about change
Contemplation Thinking about change in the
near future
Decision/Determination Making a plan to change
Action Implementation of specific
action plans
Maintenance Continuation of desirable
Actions, or repeating periodic
recommended step(s)
Application
Increase awareness of need
for change, personalise
information on risk and
benefits
Motivate, encourage to make
specific plans
Assist in developing concrete
action plans, setting gradual
goals
Assist with feedback,problem
solving, social support,
reinforcement
Assist in coping, reminders,
finding alternatives, avoiding
slips/relapses (as applies).
 Conclusions
• There are many determinants of health-related behaviours
• Determinants can be usefully grouped to form a conceptual framework
• Background, stable and social factors shape beliefs and situational appraisals
• Behaviour (typically) is most strongly influenced by situational beliefs /
appraisals
• Psychological models attempt to explain the relationship between beliefs and
behaviour
• Changing beliefs promotes long-term behaviour change