Models Of Health Behavior Change
There are a number of theoretical models in the literature that address effective ways to change health behaviors. The brief descriptions below outline basic theories and the recommended strategies to help clients reduce tobacco use.
Transtheoretical Model of Change
Theory
According to the Transtheoretical Model,1, 2 the process of quitting smoking can be conceptualized as progressing through a series of Stages of Change. Once individuals become dependent on nicotine, individuals move through five sequential stages in order to achieve long-term sustained health behavior change (i.e., quitting tobacco use). The stages are Precontemplation, Contemplation, Preparation, Action, and Maintenance. There are also cognitive/experiential and behavioral Processes of Change that have been identified as central to movement through the Stages. Cognitive/Experiential processes identify ways of thinking and feeling that create change. They include consciousness-raising, emotional arousal, self-reevaluation, environmental reevaluation, and social liberation. Behavioral processes are oriented toward making a commitment and taking action to quit tobacco use. Specific behavioral processes are self-liberation, stimulus generalization or control, conditioning or counterconditioning, reinforcement management, and helping relationships.
Strategies
- Determine which Stage of Change (link to stage of change tables in MD data) your client is in for tobacco use cessation (or for initiation if you plan to implement a prevention program).
- Motivational Interviewing is an effective tool for helping clients resolve ambivalence regarding quitting tobacco use.
- For individuals progressing through the Stages of Change for tobacco use cessation, certain techniques or strategies may be more useful at a particular stage of change. To identify which stage-specific tasks would be helpful for your client(s), read the Stage Tasks pdf.
Measures
Behavior Modification
Theory
Behavior modification is a widely used approach to change behavior. The basic principles focus on rewarding positive behaviors and denying rewards for undesirable behaviors. In order to develop a Behavior Modification program, triggers and consequences of the undesired behavior (in our case, tobacco use) must be identified. Once these components are determined and how tobacco use functions for the client is understood, the tobacco cessation professional can work with the client to develop an appropriate intervention. One popular approach to decrease negative behavior is to make changes in the client's immediate environment.
Strategies
- Teach client skills associated with quitting tobacco use.
- Reduce reinforcement for tobacco use.
- Identify positive reinforcers to reward successful changes in tobacco consumption.
- Identify negative reinforcers to implement when changes in use do not occur.
- Reinforce behavior by consistently highlighting the client's progress.
Measures
Fagerström Test for Nicotine Dependence (FTND).1 *Permission to use this scale for purposes other than research should be obtained from K. L. Fagerström.
Health Belief Model
Theory
The Health Belief Model emphasizes that tobacco use (and other health behavior) is determined by an individual's perceptions about 1) personal vulnerability to illness caused by tobacco use, 2) the perceived seriousness of tobacco as a problem, 3) treatment cost and effectiveness (i.e., the benefits of taking action), 4) barriers to quitting, and 5) cues to change tobacco use behavior.
Strategies
Frame the tobacco cessation message according to the assessment of the client's:
- Perceived susceptibility to tobacco dependency;
- Perceived severity of smoking outcomes;
- Barriers to quitting tobacco use; and
- Perceived benefits of quitting.
Implement cessation by:
- Clarifying the risks of continued use and the benefits of reducing use or quitting;
- Helping the client identify strategies for overcoming barriers;
- Providing "cues to action" that activate readiness to change; and
- Reinforcing change behavior by highlighting the benefits achieved by quitting.
Social Cognitive Theory
Theory
The interactions among an individual's cognitions, behavior, and environment are the key components of social cognitive theory and interventions. Outcome expectancies and self-efficacy are two processes that influence the interactions between the cognitive and behavioral. If positive outcome expectancies are endorsed and self-efficacy for quitting tobacco use is low, then the likelihood of a successful quit attempt is also low.
Strategies
- Increase the client's feelings of self-efficacy to quit using tobacco products.
- Help clients acquire the necessary skills for change.
- Model non-use of tobacco products
- Engage the client in role-plays about non-use.
- Ask the client to self-monitor tobacco use via a behavior diary.
- Discuss previous attempts to quit and the factors (individual & environmental) that contributed to relapse.
- Emphasize behavior changes that the client has made and discuss how past success can generalize to quitting tobacco use.
- Increase the positive outcome expectancies for quitting smoking.
- Introduce the client to others who have quit using tobacco and can endorse positive outcomes.
Cognitive (Information Processing) Models
Theory
When providing counseling for tobacco cessation, patient comprehension is central to making progress toward quitting. Therefore, the intervention specialist must continuously confirm that the client understands the importance of quitting tobacco use, the basic processes that underlie behavior interventions, and the specific approaches that are being used to help the individual quit.
Strategies
- Discuss the client's cognitions about quitting tobacco use and establish what information the client already knows.
- Share information that is consistent with the client's previous experience with quitting, stressing the most important information first.
- Provide sensory and procedural information.
- Provide written information consistent with the client's educational level.
- Establish that the client can comprehend the material and help integrate it into the client's schema about quitting tobacco use.
Theory of Reasoned Action/Theory of Planned Behavior
Theory
The theory of reasoned action emphasizes an individual's intention to change. Behavioral Intention can be determined by evaluating the client's expectancies regarding the outcomes of tobacco use, attitudes about use, and normative beliefs about the use of others.
Strategies
- Assess the degree to which the client intends to change their tobacco use behavior.
- Discuss the positive and negative expectancies the client has for tobacco use, and provide feedback about incorrect expectancies.
- Ask the client whether family members and friends support tobacco use.
- Draw attention to the social pressure to quit using tobacco.
- Provide contact with others who have quit using tobacco.
Self-management Theory
Theory
Self-management approaches to changing behavior stress the importance of perceived control over the behavior change process. If an individual is proficient in goal setting, self-evaluation, and self-reinforcement, maintaining abstinence from tobacco products is more likely. Setting behavioral goals is central to this approach because they provide a measure for which the client can compare his or her progress.
Strategies
- Teach client how to monitor smoking or other tobacco use.
- Help client identify which internal cues increase tobacco use.
- Identify competing behaviors that can take the place of tobacco use.
- Teach client how to use external cues to reinforce quitting.
Interpersonal (Social Support) Theories
Theory
Interpersonal approaches to intervention focus on the relationship between the client and the professional providing treatment. When addressing tobacco use, treatment providers are encouraged to discuss the quit plan and progress towards goals at every meeting. Regular discussion of treatment recommendations will also help clients maintain focus on the process of change. Providers are perceived as the main source of social support within the context of quitting tobacco use, demonstrating empathy and caring.
Strategies
- Be empathetic and understanding regarding how difficult it is to stop using tobacco.
- Provide a "safe environment" where clients can share, instructions can be clarified, and resistance to change can be evaluated.
- Maintain follow-up appointments to discuss progress and model support for change.
- Engage loved ones in supporting the client and becoming involved the process of quitting tobacco use.
References
1 DiClemente, C.C., & Prochaska, J.O. (1998). Toward a comprehensive, transtheoretical model of change: Stages of change and addictive behaviors. In: W.R. Miller & N. Heather, Treating Addictive Behaviors (2nd ed.). New York: Plenum Press, 3-24.
2 DiClemente, C.C. (2003). Addiction and change: How addictions develop and addicted people recover. New York: The Guilford Press.
Key Article: Elder, J.P., Ayala, G.X., & Harris, S. (1999). Theories and intervention approaches to health-behavior change in primary care. American Journal of Preventive Medicine, 17(4), 275-284.
