By the end of this lecture the students should be able to: Define behavior and related terms Define and understand healthy behavior.

‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
Saudi Arabia
Ministry of higher education
Al-Baha University
******
Faculty of Applied Medical Sciences
Public Health Department
Health and Human behavior
Prepared and presented by :
Dr. Abdalla Hassaballa Elmanna
Assistant professor of health education

Lecture No 1
• Introduction to human behavior
Objectives:
By the end of this lecture the students
should be able to:
1. Define behavior and related terms
2. Define and understand healthy
behavior.

Introduction to health behavior :
The field of behavior as approach health psychology
developed relatively recently—the 1970s, to be exact—to
address the challenges presented by the changing field of
health and health care. A century ago, the average life
expectancy in the Saudi Arabia was approximately 50 years
of age, far shorter than it is now. When people in the Saudi
died, they died largely from infectious diseases such as
pneumonia, tuberculosis, diarrhea, and enteritis. These
conditions resulted from contact with impure drinking water,
contaminated foods, or sick people. People might seek
medical care only after they became ill, but medicine had
few cures to offer. The duration of most diseases—such as
typhoid fever, pneumonia, and diphtheria—was short; a
person either died or got well in a matter of weeks. People

Task 1
• Q1: define behavior
• Q 2 A person’s behavior may be the main
cause of their health problems, but it can also
be the main solution.
• Q3

Introduction to health behavior
Life—and death—are now dramatically different
than they were a century ago. Life expectancy
Saudi is nearly 80 years of age. Vaccines and
treatments exist for many infectious diseases.

improvements in the prevention and treatment of
infectious diseases allowed for a different class
of disease to emerge as the new century’s killers:
chronic diseases. Heart disease, cancer, and
stroke—all chronic diseases—are now the
leading causes of mortality in the Saudi and
account for a greater proportion of deaths than
infectious diseases ever did. These diseases
associated with individual behavior and lifestyle.

continuous
A person’s behavior may be the main cause of their
health problems, but it can also be the main
solution.
1. Human behavior is among the major
determinants of the health of individuals,
families or communities.
2. Healthy behaviors contribute to the overall
health of individuals and communities and
passive health behaviors adversely affect the
quality of life people at different levels.
3. Most health issues cannot be dealt with by
treatment alone.

Definition of health behavior and other related terms
Behavior:
Behavior : Is an action that has a specific
frequency, duration, timing and purpose whether
conscious or unconscious.
• It are what we “do” and how we “act”.
• People stay healthy or become ill, often as a
result of their own action or behavior.

Field theory
B =F(P,E)
• B: behavior
• F : behavior function
• P : person
• E : environment
Behavior is the function of person’s
characteristics and the characteristics of
surrounding environment

Eight parameters of behavior are:
B = Behavior
1. I= Identity of the individual who is behaving
2. W- Want
3. K= Knowledge (Cognition)
4. K-H= Know-How
5. P= Performance
6. A= Achievement
7. PC= Personal Characteristics
8. S= Significance.

PERCEPTION
Perception is a way of regarding, understanding, or
interpreting something; a mental impression.

Lecture 2
Human Behavior and
Health

Human Behavior and Health
Health Behavior:
• Health behavior includes all of those things we
do that influence our physical, mental,
emotional, psychological, and spiritual selves.
• These behaviors range from brushing our teeth
every day to having unprotected sex, from
practicing exercises to smoking for weight
management.

continuous
Health behavior :
It defined as “Any activity undertaken by
an individual, regardless of actual or
perceived health status, for the purpose of
promoting, protecting or maintaining
health, whether or not such behavior is
objectively effective towards that end”.
Reference: Health Promotion Glossary, 1986.

Healthy behavior:
Actions that healthy people undertake to
keep themselves or others healthy and
prevent disease.
Good nutrition, breast feeding, reduction
of health damaging behaviors like smoking
are examples of healthy behaviors.

Preventive health behavior or behaviors
promoting health
These are actions that healthy people
undertake to keep themselves or others
healthy and prevent disease or detect
illness when there are no symptoms.
Examples include Eating a balanced diet,
do exercises, hand washing with soap,
using insecticide treated mosquito nets and
exclusive breastfeeding to age six
months…etc.

Illness behaviors
Any activities undertaken by individuals
who perceive themselves to be ill for the
purpose of detecting his health status.
This would include recognition of early
symptoms and prompt self referral for
treatment.

Sick-role behaviors
Any activities undertaken by individuals
who consider themselves to be ill, for
the purpose of getting well.
It includes receiving treatment from
medical providers and generally involves a
whole range of potentially dependent
behaviors. It may lead to some degree of
exemption from one’s usual
responsibilities.

LECTURE 3
The concepts of
behavior

The concepts of behavior
The defining characteristics of behavior include:
1. Behavior is an individual phenomena
2. Behavior includes some movement, regardless
of scale
3. Behavior occurs in real time
4. Behavior is dynamic--it changes over time
5. A response is a specific instance of a particular
behavior
6. An individual emits an operant response

Three requirements of an appropriate
target behavior
1. Is the target behavior an observable,
measurable movement?
2. Is the behavior repeatable to assure adequate
opportunity to work with and change?
3. Is the definition of the behavior clearly and
objectively defined?

Operant behavior :
Operant behavior is any behavior whose
probability of occurrence is determined by its
history of consequences.
• The consequences of an operant behavior are
responsible for determining the behavior's
future rate of occurrence.
• An operant response should also be described
in terms of a given set of antecedent
conditions.

Respondent behavior is
Behaviors elicited by stimuli that precede
them (a built-in response to a specific
stimuli (e.g., pupil contraction).

A principle of behavior
Principle I - Behavior is controlled by its
consequences
• Behaviors are strengthened.
• Behaviors are weakened.
• Behaviors are maintained

Principle II - Behavior is strengthened or
maintained by reinforcement.
Positive reinforcement
• when a behavior is immediately followed by the
presentation of a stimulus and, as a result, occurs
more often in the future.
Negative reinforcement
• The contingent removal of an aversive stimulus
immediately following a response that increases
the future rate and/or probability of that response
occurring in the future.

Principle III - Behavior is weakened by removing
the consequences that have been maintaining it.
• This process is called extinction
Principle IV - Behavior is weakened by
punishment.
• Remember - Eliminating a negative behavior does
not necessarily mean it will be replaced with a
positive behavior.

Principle V - Consequences must consistently and
immediately follow the behaviors they are meant to
control.
• Some are naturally systematic and predictable, but
many are not. To modify most classroom behaviors we
must contrive contingencies.
Principle VI - Stimuli that immediately precede the
response or are present during reinforcement are
affected by the reinforcement and acquire some
control over the recurrence of the response.
• This is referred to as stimulus control

Principle VII - Behavior also is strengthened,
weakened, or maintained by modeling.
• Modeling
• Demonstrating a desired behavior in order to
prompt an imitative response.
Principle VIII - Shaping uses the
reinforcement of successive approximation to
a desired behavior to teach new behavior.

Lecture 4
Factors influence the
types of behaviors

Factors influence the types of
behaviors
These are general factors :
• socioeconomic status,
• Skills
• Culture
• Attitudes
• Beliefs
• Attitude
• Values
• Religion, and
• Gender.

The Complexity of Human
Behavior
Why do people do what they do, and why do the
bodies that do it have the structures they have? We
can trace a small part of human behavior, and a
much larger part of the behavior of other species, to
natural selection and the evolution of the species,
but the greater part of human behavior must be
traced to contingencies of reinforcement, especially
to the very complex social contingencies we call
cultures. Only when we take those histories into
account can we explain why people behave as they
do.

Some reasons for the complexity of
behavior
1. Complexity of the human repertoire
• Human beings are capable of an incredible
range of behaviors.
• In any given setting concurrent contingencies
are vying for control of different behaviors.
• Examples -
A single behavioral event often has multiple
effects.

Attitude
Attitude is a settled way of thinking or feeling
about someone or something, typically one that
is reflected in a person's behavior.
Attitude ( positive + negative)
Ex. Positive attitude = I like my job(attitude
toward work)

Socioeconomic Status
Socioeconomic status (SES) makes a significant
contribution to health since it encompasses education,
income, and occupation. Education, in particular,
affects health because of its relationship to income
and occupation. The more education, the better the
job, the greater the income. People with more
education and money tend to live in safer homes
(communities), have better health insurance, and
access to healthier foods. These factors are related to
less disease risk, especially from chronic illnesses like
heart disease, diabetes, and obesity, and more positive

Skills
• In the grand scheme of things, it’s relatively easy to
teach people new information, thereby increasing
their knowledge. But without the skill or ability to
use that knowledge, it’s almost useless.
• So, behavior is influenced by having both
knowledge and skill .
• Another example where knowledge alone is
insufficient is with child safety seats. Parents know
the importance of using child safety seats. What
they don’t know is how to use them correctly.

Culture
Culture is defined as everything that people
have, think, and do as members of society.
Sometimes, even armed with information and
skills, people still don’t use what they know and
do what
they know how to do. That’s because behavior is
significantly influenced by culture. In every
culture
there are norms, or expected, accepted practices,
values, and beliefs that are the foundation for

Beliefs
• Beliefs are intimately woven with culture.
• Beliefs are one’s own perception of what is true,
although they might not be viewed as being true by
others.
• Belief a state or habit of mind in which trust or
confidence is placed in some person or thing something
that is accepted, considered to be true, or held as an
opinion. conviction of the truth of some statement or
the reality of some being or phenomenon especially
when based on examination of evidence.
• Believes are usually derived from our parents, grand
parents and other respected people in addition to
religious, customs and traditions. .

Values
o Qualities, characteristics, or ideas about which
we feel strongly.
o Our values affect our decisions, goals and
behavior.
o A belief or feeling that someone or something
is worthwhile.
o Values define what is of worth, what is
beneficial, and what is harmful
o Values are standards to guide your action,
judgments, and attitudes.

Life style:
Refers to the collection of behaviors that make
up a person’s way of life-including diet, clothing,
family life, housing and Work.
Customs:
It represents the group behavior. It is the pattern
of action shared by some or all members of the
society.
Traditions:
Are behaviors that have been carried out for a
long time and handed down from parents to
children.

Factors affecting human behavior
Psychologists identify four reasons for human
behavior which include:
1. Thoughts and feelings.
2. People who are important to us.
3. resources:
4. Culture

1- Thought and feeling which include
•Knowledge
•Believes
•Attitudes and
•Values

1. Thought and feeling
1. Knowledge:
• Knows things, objects, events, persons, situations and
everything in the universe.
• Knowledge is a familiarity, awareness, or
understanding of someone or something, such
as facts , information's ,descriptions ,or skills
which is acquired through experiences or
education by perceiving ,discovering or
learning .

1. Thought and feeling
1. Knowledge:
• It is the collection and storage of information or
experience. It often comes from experience. We
also gain knowledge through information
provided by teachers, parents, friends, books,
newspapers, Etc…E.g. knowledge about methods
of prevention of Malaria
• Knowledge acquisition involves complex
cognitive process : perception ,communication
and reasoning , while knowledge is also said to be
related to the capacity of acknowledgement in
human beings.

The 6 Types Of Knowledge: From A
Priori To Procedural
1. A Priori
2. A Posteriori
3. Explicit Knowledge
4. Tacit Knowledge
5. Propositional Knowledge (also Descriptive or
Declarative Knowledge)
6. Non-Propositional Knowledge (also
Procedural Knowledge)

Thought and feeling
2. Belief
• Belief a state or habit of mind in which trust or confidence is
placed in some person or thing
• something that is accepted, considered to be true, or held as an
opinion .
• conviction of the truth of some statement or the reality of some
being or phenomenon especially when based on examination
of evidence
• Believes are usually derived from our parents, grand parents
and other respected people in addition to religious, customs
and traditions .

Thought and feeling
3. Attitude
Attitude is relatively constant feelings, predispositions or
set of beliefs directed towards an object, person or
situation.
• They are evaluative feelings and reflect our likes and
dislikes. They often come from our experiences or from
those of people close to us. They either attract us to
things, or make wary of them.
• A mental organized through experience influencing
dynamically or directly the individuals’ response to all
objects and situations with which it is related.
• Attitude is a learned predisposition to respond in a
consistently favorable or unfavorable manner with
respect to a given object

Thought and feeling
4. Value?
1. Qualities, characteristics, or ideas about which we feel
strongly.
2. Our values affect our decisions, goals and behavior.
3. A belief or feeling that someone or something is
worthwhile.
4. Values define what is of worth, what is beneficial, and
what is harmful
5. Values are standards to guide your action, judgments, and
attitudes.
6. Values give direction and consistency to behavior.
7. Values help you know what to and not to make time for.
8. Values establish a relationship between you and the world.
9. Values set the direction for one’s life.

Where do we get values?
• our homes,
• school,
• society,
• friends,
• TV,
• church,
• music,
• books,
• families,
• culture,
• employers,
• time-period in which
you were raised

Your age will greatly influence your values. Different
people and things influence you at different ages:
• Ages 1-7 --- parents
• Ages 8-13 --- teachers, heroes (sports, rocks,
TV)
• Ages 14-20 --- peers (values because of peers
or peers because of values?)
• Ages 21+ your values are established, but you
may test your values from time to time.

“If you stand for
nothing.
You fall for
anything.”

“It’s not doing things
right,
but doing the right things. “

2- People who are important to us
• The second reason for our behavior related to
the influence of people whom are important to
us.
• Family
• Peers, teachers
• Employers, health providers
• Community leaders
• Decision makers

3-Resources
• A third reason for people behavior is the
availability of resources like (money, facilities,
labor, services and skills).

4- Culture
• Culture is defined as everything that people have, think, and
do as members of society.
• The normal behaviors ,believes ,values and use of resources in
a community form pattern or way for life .these is known as
culture .
• Cultures has been developed from many thousands of years by
people living together and sharing experiences in certain
environment .cultures are continue to change some times
slowly and some times quickly, due to natural events or
contact with other people with different cultures ,while normal
behavior is one of the aspects of culture ,culture in its turn
has deep influence in behavior .
• In the practical you can see, hear, and understand culture
whenever you are in the community by observing dress,
common foods and organization of work or by listing to songs.

Definitions of theory
Theory: (DEFINITIONS)
A theory is “a set of statements or principles
devised to explain a group of facts or
phenomena, especially one that has been
repeatedly tested or is widely accepted and can
be used to make predictions about natural
phenomena “(American Heritage Dictionary of
the English Language).

• A theory is a set of interrelated concepts,
definitions, and propositions that explains
or predicts events or situations by
specifying relations among variables.
• A theory is a set of interrelated concepts,
definitions, and propositions that explains
or predicts events or situations by
specifying relations among variables.

From a health promotion and disease prevention
perspective,
“the term theory is used to represent an
interrelated set of propositions that serve to
explain health behavior or provide a systematic
method of guiding health promotion practice”
(DiClemente, Crosby, & Kegler, 2002, p. 8).

Important of theories
Theories can guide the search to:
• Understand why people do or do not practice
health promoting behaviors;
• Help identify what information is needed to
design an effective intervention strategy; and
• Provide insight into how to design a program so it
is successful.
• Theory is also the driving force behind research.
It guides the variables to be studied, how they
should be measured, and how they might be
combined

Important of theories
• Theories provides a framework for explaining
phenomena and may serve as the basis for
further research as well as practice application
• theories explain behavior and thus can suggest
ways to achieve behavior change
• By understanding why people engage in
unhealthy behaviors, we can better develop
interventions that will enable them to change
their behavior and adopt healthier lifestyles, if
they choose.

Theory and model
Models:
A model is a composite, a mixture of ideas or
concepts taken from any number of theories and
used together. Models help us understand a
specific problem in a particular setting ,which
perhaps one theory alone can to do. Theories and
models help us explain, predict, and understand
health behavior. Understanding the determinants
of health behavior and the process of health
behavior change provides the basis upon which
interventions can be developed to improve the
publics health and their effectiveness evaluated .

Types of Theories
Theories and models can be separated into three
different levels of influence:
1. Intrapersonal theories
2. Interpersonal theories
3. Community theories

Intrapersonal Theories :
At the intrapersonal or individual level, theories focus on
factors within the person that influence behavior, such as
knowledge, attitudes, beliefs, motivation, self-concept,
developmental history, past experience, and skills . These
theories and models include,
1. Health Belief Model, (HBM) ‫الصحية‬ ‫المعتقدات‬ ‫نموذج‬
2. Theory of Reasoned Action, (TRA)‫السلوكية‬ ‫الدواع‬ ‫نظرية‬
3. Theory of Planned Behavior (TPB) ‫السلوكي‬ ‫التخطيط‬ ‫نظرية‬
4. Self-Efficacy Theory, (SET) ‫بالنفس‬ ‫الثقة‬ ‫نظرية‬
5. Attribution Theory, and ATT)‫الشخصية‬ ‫السمات‬ ‫نظرية‬
6. the Trans-theoretical Model. (TTM) ‫السلوك‬ ‫نظرية‬
‫المتمرحل‬
‫او‬
‫االنتقالي‬

Interpersonal Theories
Theories addressing factors at the interpersonal
level operate on the assumption that other people
influence our behavior. Other people affect
behavior by sharing their thoughts, advice, and
feelings and by the emotional support and
assistance they provide. These other people may
be family, friends, peers, healthcare providers, or
coworkers Ex.
• Social Cognitive Theory (SCT)
• ‫االجتماعي‬ ‫االدراك‬ ‫نظرية‬

Community-Level Theories .
Community-level models and theories focus on factors
within social systems (communities, organizations,
institutions, and public policies), such as rules,
regulations, legislation, norms, and policies. These
theories and models suggest strategies and initiatives that
can be used to change these factors .These are change
theories more than explanatory theories. Changing a
social system from one that maintains and supports
unhealthy behaviors to one that supports healthy
behaviors ultimately supports individual behavior change.
A commonly used community-level theory is
• Diffusion of Innovation theory .

Health beliefs model
The Health Belief Model (HBM) was developed in the early 1950s by a
group of social psychologists at the U.S. Public Health Service , an attempt
to understand “the widespread failure of people to accept disease
preventives or screening tests for the early detection of asymptomatic
disease
The hypothesis is that behavior depends mainly upon two variables:
1) The value placed by an individual on a particular goal and
2) The individual’s estimate of the likelihood that a given action will
achieve that goal
When these variables were conceptualized in the context of health-related
behavior, the correspondences were:
1) The desire to avoid illness (or if ill, to get well) and
2) The belief that a specific health action will prevent (or ameliorate)
illness (i.e., the individual’s estimate of the threat of illness and of the
likelihood of being able, through personal action, to reduce that threat.

Health Belief Model
• The Health Belief Model (HBM) was developed
to help understand why people did or did not use
preventive services offered by public health
departments.
• In the 1950’s, and has evolved to address newer
concerns in prevention and detection (e.g.,
mammography screening, influenza vaccines) as
well as lifestyle behaviors such as sexual risk
behaviors and injury prevention.
• The HBM theorizes that people’s beliefs about
whether or not they are at risk for a disease or
health problem, and their perceptions of the

Core constructs of the HBM
• Perceived susceptibility and perceived severity
• Perceived benefits
• Perceived barriers
• Cues to action
• Self-efficacy (added more recently)

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.
Application:
1. Define population at risk (apply descriptive
epidemiology)
2. Personalize risk (discussion, role play, simulation, case
study)

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
Application :
• Specify consequences of the risk and the
condition (lecture, discussion, self-reflection,
case study, case narration, video presentation)

• 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)

Perceived barriers:
Belief of a person regarding actual and imagined costs
of performing the new behavior.
Application:
1. Reassurance (one-on-one counseling, case study,
discussion, active listening)
2. Correction of misinformation (lecture, video
presentation, role play)
3. Incentives (tangible and intangible aids, verbal
encouragement, case accounts)
4. Assistance (providing services, transportation)

Cues to action:
Precipitating force that makes the person feel
the need to take action
1. Provide how-to information (lecture,
demonstration, re-demonstration, role play)
2. Employ reminder system (buddy system, log,
diary, Post-it notes)

Self-efficacy:
Belief or confidence in performing a behavior
Application :
1. Provide training in small steps (demonstration,
re-demonstration)
2. Progressive goal setting (self-reflection, diary)
3. Verbal reinforcement (one-on-one counseling)
4. Reduce anxiety (stress management techniques)

Applications of HBM
1. Screening behaviors (TB, breast cancer,
colorectal cancer, influenza vaccinations, Toy-
Sachs disease, high blood pressure, etc.)
2. Preventive behaviors (seat belt use, smoking
cessation, physician visiting, etc.)
3. Health promotion behaviors (exercise, healthy
nutrition, etc.)
4. Treatment compliance behaviors (diabetes, end-
stage renal disease, bronchial asthma, weight loss,
etc.)

Lecture No 6
Theory of Reasoned Action
(TRA) Theory of Planned
Behavior (TPB)

Lecture learning outcomes
1. Students describe the historical development of the Theory
of Reasoned Action (TRA), Theory of Planned Behavior
(TPB) effectively
2. Students explain the main constructs in the TRA, TPB
3. Students recognize the similarity between these theories’ key
constructs and constructs from other behavioral theories.
4. Student describe measurement of the key constructs of TRA,
TPB
5. Students explain how and why elicitation should be
conducted to identify and select the content for the model
construct measures for the health behavior and population
studied.

Theory of Reasoned Action (TRA)
Theory of Planned Behavior (TPB)
A theory is 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.

Theory of Reasoned Action (TRA) Theory of
Planned Behavior (TPB)
The Theories
1. TRA, TPB & IBM are essentially one theory
that has evolved over time .
2. TRA developed first; after the addition of
perceived behavioral control to the model,
TPB was developed.
3. TPB was expanded to include components of
other theories of behavior.

Developed by Ajzen & Fishbein in 1980
Basic Assumptions:
1. People are rational and will make predictable
decisions in specific circumstances
2. An “intention to act” is the most important
determinant of behavior
3. We do not always act the way we intend to

Two Variables :
Theory of Reasoned Action:
Attitudes about
the behavior
Subjective norms
Behavioral Intention Behavioral
Theory of Reasoned Action:
Attitudes + Subjective Norms = Intention (leads to behavior)

Two Variables
1. Attitudes
Beliefs about the consequences of the behavior
Appraisal of positive and negative aspects of
adopting or changing a behavior.
2. Subjective Norms
What “significant others” do and expect
The degree to which someone wants to conform
to others’behaviors or expectations.

Predicts a person will adopt, maintain or change
a behavior if they believe:
1. The behavior will benefit them
2. The behavior is socially desirable
3. There is social pressure to conform to the
behavior
4. The opinion of others matters to them
In practice, two methods of impacting behavior
are to influence attitudes and exert social
pressure

Theory of Planned Behavior
A third factor influencing behavioral intention was
added to the : Theory of Reasoned Action =
Behavioral Control
Behavioral control = control beliefs + perceived power
Theory of Planned Behavior:
A third factor influencing behavioral intention was
added to the Theory of Reasoned Action =
Behavioral Control
Behavioral control = control beliefs + perceived
power .

• The theory of planned behavior (TPB) is one of
the most widely cited and applied behavior
theories. It is one of a closely inter-related family
of theories which adopt a cognitive approach to
explaining behavior which centers on individuals’
attitudes and beliefs. The TPB (Ajzen 1985, 1991;
Ajzen and Madden 1986) evolved from the theory
of reasoned action (Fishbein and Ajzen 1975)
which posited intention to act as the best
• predictor of behavior

Theory of Planned Behavior
Intention is itself an outcome of the combination of
attitudes towards a behavior. That is the positive or
negative evaluation of the behavior and its expected
outcomes, and subjective norms, which are the social
pressures exerted on an individual resulting from their
perceptions of what others think they should do and their
inclination to comply with these. The TPB added a third
set of factors as affecting intention (and behavior);
perceived behavioral control. This is the perceived ease or
difficulty with which the individual will be able to perform
or carry out the behavior, and is very similar to notions of
self-efficacy (see Bandura 1986, 1997; Terry et al. 1993).

Lecture 7
Trans-theoretical Model/Stages
of Change/ Key Constructs

Transtheoretical Model/Stages of Change/ Key
Constructs
1. Long-term changes in health behavior involve multiple actions
and adaptations over time.
2. Some people may not be ready to attempt changes, while others
may have already begun implementing changes in their
smoking, diet, activity levels, and so on.
3. The construct of “stage of change” is a key element of The
Transtheoretical Model (TTM) of behavior change, and
proposes that people are at different stages of readiness to adopt
healthful behaviors.
4. The notion of readiness to change, or stage of change, has been
examined in health behavior research and found useful in
explaining and predicting changes for a variety of behaviors
including smoking, physical activity, and eating habits. The

Important Theories and Their Key Constructs
Stages of change is a heuristic model that
describes a sequence of steps in successful
behavior change
1. Precontemplation;
2. Contemplation;
3. Preparation;
4. Action; and
5. Maintenance.

Behavior Change Stages and Their Characteristics
Precontemplation No recognition of need for or interest in
change (in the next six months)
Contemplation
Thinking about changing (in the next
six months)
Preparation Planning for change (generally within the
next month)
Action Adopting new habits (for at least six
months)
Maintenance Ongoing practice of new, healthier
behavior (over six months and chances to
return to old behavior are few)

Stage 1: Precontemplation or Unaware
Some people have not begun to move through
the stages of change.
• These individuals are in the unaware stage.
• They do not see that they have a problem.
• They may be in denial that any problem exists despite
evidence to the contrary.
• Individuals in this stage will actively resist change or
any discussion of the problem behavior at hand.

Stage 2: Contemplation
• In this stage, people begin to acknowledge that their
behavior and choices may be causing problems and
they begin to think about solving them.
• Coupled with the will to change, however, is the fear
and anxiety of change that pulls these individuals in
conflicting directions.
• Some people get stuck in this stage as they wait for a
“magic moment” for change.
• Others look for a way to maintain their current
behavior while simply lessening the severity of the
consequences.

Stage 3: Preparation
• Individuals in this stage begin to focus less on the
past and more on the future.
• Alternatives and solutions are the primary concern.
• Some anxiety may still persist, but the individual
possesses a growing confidence in the decision to
change.
• It is important to take time to prepare for change
before diving in.
• Individuals will want to consider a variety of options
and evaluate the benefits and consequences of each
before making a decision about what course of action
to pursue.

Stage 4: Action
• At this stage, people make a commitment to a
specific change plan and implement it.
• The focus of this stage is on effective
countering – finding healthy alternatives to old
ways, problem-solving tough situations, and
focusing on the benefits of change.

Stage 5: Maintenance or Stick With
It
• This stage allows individuals the opportunity
to reevaluate their plans and make
adjustments.
• Change rarely happens without some mistakes.
Mistakes do not equate with failure.
• This stage encourages individuals to continue
to work on their change plan despite
frustration or “slips.”
• The support of others and the benefits of
change will help sustain motivation.

The Transtheoretical Model of
Behavior Change (continued)
One of the most valuable components of the change
model is the use of the 10 processes that support change.
These processes can be implemented through hundreds of
techniques or methods. The key is to recognize that many
processes are available to support a person’s change
efforts.
There are 10 processes of change that can generally be
broken up into two categories.
1. “Pre-action” processes are best used to assist
individuals in the pre-contemplation, contemplation,
and preparation stages of change.
2. “Action” processes are best used in the action and
maintenance stages of change.

“Pre-action” processes
1. Consciousness Raising: Gathering information
To allow an individual to better assess and make
decisions about problem behavior. Example of
use: This may include going to a local library
and researching the behavior, watching a video
or program about it or asking a professional for
help in understanding it.

2. Social Liberation:
Taking advantage of social structures that
support the plan for change. Looking for people
and places in the community that support and
promote positive life change. Example of use:
Individuals may choose to join an organization,
attend self-help meetings, or become involved in
other community support activities for
individuals who are working on similar issues.

3. Emotional Arousal
Experiencing and expressing feelings about
problems and solutions. Increasing awareness
and depth of feelings about the changes an
individual wishes to make. Example of use:
This may include exploring feelings about past
mistakes and choices an individual has made due
to a problem behavior and exploring the positive
feelings an individual hopes to gain by making
changes.

4. Self-reevaluation
Examining one’s own attitudes and behaviors.
Example of use: This may include taking a
serious look at problem behaviors and how they
match or do not match up with an individual’s
values.

5. Environmental Reevaluation
Recognizing the effect one’s behavior can have
on others and acting as a positive role model for
others who wish to change. Example of use:
Individuals may look at how their behavior has
affected their relationships with family members
and friends.

2. “Action” processes are best used in
the action and maintenance stages of
change.
They include:

“Action” processes
6. Helping Relationships:
Asking for and receiving help from others.
Example of use: This can include forming
relationships with people who support their new
behaviors.
7. Commitment:
Choosing to take action and believing in one’s
ability to change. Example of use: Individuals
can explore their options for change and share
their goals for positive change with others.

8. Countering:
Identifying healthy alternatives to negative behavior. Example
of use: This may involve learning how to replace negative
thoughts, feelings, and behaviors with positive, responsible
ones and refocusing energy on what will help a person to
become happier and healthier (e.g., physical exercise, and
practicing relaxation techniques).
9. Environment Control:
Avoiding people, places, and things that may encourage the
behavior the individual wishes to change. Example of use:
Individuals may consider changing their routine and daily
patterns or developing the skill of being aware of cues that
lead to negative or irresponsible behaviors.

10. Reward:
Receiving rewards for making wise choices.
Example of use: This may include doing
something special when an individual achieves a
positive goal. Rewards can be positive self-
statements (for example, “Way to go,” “Good
job” or “Keep up the good work”) or material
treats.

TTM Usage
• The stages of change model can be used both to
help understand why people at high-risk for
diabetes might not be ready to attempt behavioral
change, and to improve the success of health
counseling.
• Another application of the stages of change
model in organizations and communities
involves conceptualizing organizations along
the stages-of-change continuum according to
their leaders’ and members’ (i.e., employees’)
readiness for change.

People do not always move through the
stages of change in a linear manner –
they often recycle and repeat certain
stages, for example individuals may
relapse and go back to an earlier stage
depending on their level of motivation
and self-efficacy.

Lecture 8
Self-Efficacy Theory

Self-Efficacy is the belief in one’s ability to succeed in achieving an outcome or
reaching a goal. Self-efficacy is informed by five influences (also known as
sources): performance experience, vicarious experience, social persuasion,
imagine experience, and physical and emotional states.

The concepts of self-efficacy
Concepts :
“I think I can. I think I can.” This is the concept of self-efficacy.
Self-efficacy is the belief in one’s own ability to successfully accomplish
something, achieve a goal.
Self-Efficacy Theory tells us that people generally will only attempt things
they believe they can accomplish and wont attempt things they believe they
will fail.
It makes sense—why would you try doing something you don’t think you can
do? However, people with a strong sense of efficacy believe they can
accomplish even difficult tasks. They see these as challenges to be mastered,
rather than threats to be avoided.
Efficacious people set challenging goals and maintain a strong commitment to
them. In the face of impending failure, they increase and sustain their efforts to
be successful. They approach difficult or threatening situations with
confidence that they have control over them. Having this type of outlook
reduces stress and lowers the risk of depression.

Theory constructs
Self-Efficacy Theory introduces the idea that the
perception of efficacy is influenced by four factors:
1. Mastery experience: Prior success at having
accomplished something that is similar to the
new behavior .
2. Vicarious experience: Learning by watching
someone similar to ourselves be successful
3. Verbal persuasion: Encouragement by others
4. Somatic and emotional states:

Somatic and emotional states:
The physical and emotional states caused by
thinking about undertaking the new behavior, The
physical and emotional states that occur when
someone contemplates doing something provide
clues as to the likelihood of success or failure.
Stress, anxiety, worry, and fear all negatively affect
self-efficacy and can lead to a self-fulfilling
prophecy of failure or inability to perform the feared
tasks . Stressful situations create emotional arousal,
which in turn affects a persons perceived self-
efficacy in coping with the situation.

Why Self-Efficacy Matters
Self-efficacy determines how one feels, thinks, motivates
themselves, behaves, and performs. Students with high self-
efficacy:
• Have better self-regulation
• Are more resilient in the face of obstacles
• Demonstrate stronger academic performance and achievement
• Are more motivated in school
• Set more challenging and higher academic goals
• Are better prepared to adapt to and succeed in their first year of
college
• Go on to have more successful careers and are open to a wider
range of career choices
• Are happier all around

Self efficacy theory constructs

Self-Efficacy in the Classroom

Questions to consider
How do your students…
• Think about setting goals?
• Think about the impact of their own abilities and
efforts on their performance?
• Approach challenges?
• Respond to setbacks?
• Define success?

Lecture 9
Social Cognitive Theory

Social cognitive theory (SCT), the cognitive formulation of social
learning theory that has been best articulated by Bandura
• Explains human behavior in terms of a three-way, dynamic,
reciprocal model in which personal factors, environmental
influences, and behavior continually interact.
• SCT synthesizes concepts and processes from cognitive,
behavioristic, and emotional models of behavior change, so it
can be readily applied to counseling interventions for disease
prevention and management.
• A basic premise of SCT is that people learn not only through
their own experiences, but also by observing the actions of
others and the results of those actions.

Assumptions Of Social Cognitive Theory
 Learning occurs by
observing others and
modeling.
 Internal processes and cognition
of observed behavior may or may
not lead to a learned behavior (
learning performance distinction).
 Behavior is goal directed- goals are
set and behavior is directed to
accomplishing the goal (motivation
driven) .
 Behavior is eventually self-
regulated.
 Punishment and reinforcement
have indirect effects on the
learning process.

Environmental factors:
Social models Instruction
Feedback
Personal factors:
(cognitive) Goals Sense of
efficacy Attributions
Behaviors: Process of
self-regulation Goal
progress Motivations
Learning (Zimmerman,
1989).

Types of Learning
• Enactive Learning-
learning by doing and
is reinforced by the
consequences of
actions/outcomes.
• Vicarious
Learning- learning
through observation
not performance .

The Learning Process Requires:
• Attention- Learning by being attentive. Anything that distracts the
attention will going to have a negative effect on learning. If the
situation is far likely to the interest, the more the learner dedicate
his full attention to learn.
• Retention- The ability to store information is also important part of
the learning process. This can be affected by a number of factors,
but he ability to pull up information later and act on its vital
observation.
• Reproduction-Once person pays attention and able to retain the
information, it is time to actually perform the behavior you
observed. Further practice of the learned behavior leads to
improvement and skill advancement.
• Motivation-In order to be successful, you have to be motivated to
learn being aware of it outcome. Reinforcement and punishment
play an important role in motivation.

• Models can be real
people (teachers,
coaches etc.)
• Models can also come
from media: books,
TV, Magazines
(symbolic)
• Models can influence
behavior: positively
or negatively

Characteristic of
Models
Both real and
symbolic, have:
• Have prestige and
power
• Models are
competent
• Perform tasks
well that others
would like to be
able to do (Hurst,
2014).

Evaluation of Learning and
Behavior
• Perceived self-efficacy
• Outcome expectations
• Goal Setting
• Self-evaluation
• Goal Progress
• Cognitive modeling
• Self-instruction
(Schunk,
2012).

•
Weaknesses of Theory
1. The theory is loosely structured.
2. Doesn’t take emotional responses into
account.
3. Ignores biological differences between
individuals –genetic factors
4. Assumes that all behavior is a result of
modeling, not genetics, illness, or other
influences .

Lecture 10
Social Ecological
Model (SEM)

Social Ecological Model (SEM)
The Social Ecological Model (SEM) is a theory-
based framework for understanding the multifaceted
and interactive effects of personal and
environmental factors that determine behaviors, and
for identifying behavioral and organizational
leverage points and intermediaries for health
promotion within organizations. There are five
nested, hierarchical levels of the SEM:
Individual, interpersonal, community,
organizational, and policy/enabling environment

Social Ecological Model
• The social ecological model helps to understand
factors affecting behavior and also provides guidance
for developing successful programs through social
environments.
• Social ecological models emphasize multiple levels
of influence (such as individual, interpersonal,
organizational, community and public policy) and the
idea that behaviors both shape and are shaped by the
social environment.

Social Ecological Model
Policy/Enabling
Environment
(national, state, local
laws)
Organizational
(organizations and social
institutions
Community
(relationships between
organizations)
Interpersonal
(families, friends,
social networks)
Individual
(knowledge,
attitudes,
behaviors)
Source : http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html
(

Five levels in The SEM of McLeroy
1988
1. Intrapersonal
2. Interpersonal
3. Organizational
4. Community
5. Public policy

A Description of Social Ecological Model
(SEM) Levels
SEM : individual Level :
Characteristics of an individual that influence
behavior change, including knowledge, attitudes,
behavior, self-efficacy, developmental history,
gender, age, religious identity, racial/ethnic/caste
identity, sexual orientation, socio-economic
status, financial resources, values, goals,
expectations, literacy, stigma, and others.

(SEM) Levels
SEM: Interpersonal Level
Formal (and informal) social networks and social
support systems that can influence individual
behaviors, including family, friends, peers, co-
workers, religious networks, customs or
traditions.

(SEM) Levels
SEM: Community Level
Relationships among organizations, institutions,
and informational networks within defined
boundaries, including the built environment
(e.g., parks), village associations, community
leaders, businesses, and transportation.

(SEM) Levels
SEM: Organizational Level
Organizations or social institutions with rules
and regulations for operations that affect how, or
how well, for example, MNCHN services are
provided to an individual or group; schools that
include MNCHN in the curriculum.

(SEM) Levels
SEM: Policy/Enabling Environment Level
Local, state, national and global laws and
policies, including policies regarding the
allocation of resources for maternal, newborn,
and child health and access to healthcare
services, restrictive policies (e.g., high fees or
taxes for health services), or lack of policies that
require childhood immunizations

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