Changing Health Behaviour PDF

CHANGING HEALTH BEHAVIOUR
INTERVENTION AND RESEARCH

WITH SOCIAL COGNITION MODELS
Edited by
Derek Rutter and Lyn Quine
Open University Press

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First Published 2002
Copyright Derek Rutter, Lyn Quine and the contributors, 2002
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ISBN
0 335 20432 5 (pb) 0 335 20433 3 (hb)
Library of Congress Cataloging-in-Publication Data

Changing health behaviour: intervention and research with social cognition
models/edited by Derek Rutter and Lyn Quine.
p. cm.
Includes bibliographical references and index.
ISBN 0-335-20433-3 ISBN 0-335-20432-5 (pbk.)
1. Health behavior. 2. Health attitudes. 3. Social perception.
4. Behavior modication. I. Rutter, D.R. (Derek R.) II. Quine, Lyn.
RA776.9 .C437 2002
613dc21
2001036115
Typeset by Graphicraft Limited, Hong Kong

Printed in Great Britain by Biddles Limited, Guildford and Kings Lynn
CONTENTS
List of contributors
Acknowledgement
List of abbreviations
1 Social cognition models and changing health behaviours
vii
ix
x
1
2 Encouraging safer-sex behaviours: development of the SHARE

sex education programme
Charles Abraham, Daniel Wight and Sue Scott
28
3 Smoking and smoking cessation: modifying perceptions

of risk
Lynn B. Myers and Susie Frost
49
4 Reducing the risks of exposure to radon gas: an application

of the Precaution Adoption Process Model
Neil D. Weinstein and Peter M. Sandman
66
5 Reducing fat intake: interventions based on the Theory of

Planned Behaviour
Christopher J. Armitage and Mark Conner
87
6 Increasing participation with colorectal cancer screening:

the development of a psycho-educational intervention
Sara Williamson and Jane Wardle
105
vi
Contents
7 Changing health behaviours: the role of implementation

intentions
Sheina Orbell and Paschal Sheeran
123
8 Changing drivers attitudes to speeding: using the

Theory of Planned Behaviour
Dianne Parker
138
9 Improving pedestrian road safety among adolescents: an

application of the Theory of Planned Behaviour
Daphne Evans and Paul Norman
153
10 Increasing cycle helmet use in school-age cyclists: an

intervention based on the Theory of Planned Behaviour
Lyn Quine, Derek Rutter and Laurence Arnold
172
11 Using social cognition models to develop health behaviour

interventions: problems and assumptions
Stephen Sutton
193
Index
209
LIST OF CONTRIBUTORS
Professor Charles Abraham is Professor of Psychology at the Centre for

Research in Health and Medicine (CRHaM), University of Sussex.
Dr Christopher Armitage is Lecturer in Social and Health Psychology at the
Department of Psychology, University of Shefeld.
Dr Laurence Arnold recently completed his PhD at the Department of
Psychology, University of Kent at Canterbury.
Dr Mark Conner is Reader in Applied Social Psychology at the School of
Psychology, University of Leeds.
Dr Daphne Evans recently completed her PhD at the Department of Psychology, University of Wales, Swansea.
Susie Frost is a clinical research worker at the Eating Disorders Research
Unit, Institute of Psychiatry, Kings College London.
Dr Lynn B. Myers is Lecturer in Health Psychology at the Department
of Psychiatry and Behavioural Sciences, University College London.
Dr Paul Norman is Senior Lecturer in Psychology at the Department of
Psychology, University of Shefeld.
Professor Sheina Orbell is Professor of Psychology at the Department of
Psychology, University of Essex.
Dr Dianne Parker is Senior Lecturer in Social Psychology at the Department
of Psychology, University of Manchester.
viii
List of contributors
Dr Lyn Quine is Reader in Health Psychology at the Department of

Psychology, University of Kent at Canterbury.
Professor Derek Rutter is Professor of Health Psychology at the Department
of Psychology, University of Kent at Canterbury.
Dr Peter M. Sandman, formerly Director of the Environmental Communication Research Program at Rutgers University, now runs a risk communication consultancy based in Princeton, New Jersey, USA.
Professor Sue Scott is Professor of Sociology at the Department of Sociology
and Social Policy at the University of Durham.
Dr Paschal Sheeran is Reader in Psychology at the Department of Psychology, University of Shefeld.
Professor Stephen Sutton is Professor of Behavioural Science at the Institute
of Public Health, University of Cambridge.
Professor Jane Wardle is Professor of Clinical Psychology at the Department
of Epidemiology and Public Health, University College London, and Director
of the Imperial Cancer Research Funds Health Behaviour Unit.
Dr Neil D. Weinstein is Professor of Human Ecology at the Department of
Human Ecology, Rutgers University, New Brunswick, New Jersey.
Dr Daniel Wight is a senior researcher at the Medical Research Councils
Social and Public Health Sciences Unit, University of Glasgow.
Sara Williamson is a research psychologist at the Imperial Cancer Research
Funds Health Behaviour Unit in the Department of Epidemiology and
Public Health, University College London.
DEREK RUTTER AND

LYN QUINE
SOCIAL COGNITION MODELS AND

CHANGING HEALTH BEHAVIOURS
1 Social cognition models

For many years, social psychological models have been at the forefront
of research into predicting and explaining health behaviours. The most
frequently used have been social cognition models. Until recently, however,
there were few attempts to go beyond prediction and understanding to
intervention the systematic attempt to change peoples health behaviours
but since the mid-1990s the position has changed, and there are now a
number of very good, theory-driven, interventions in progress. As yet, so
far as we know, there has been no attempt to bring the research together,
and it is for that reason that we have produced this edited book. We
have tried to include a representative cross-section of research, in that each
chapter takes a particular health behaviour (sometimes more than one) and
uses a particular theoretical model or framework to design and carry out
the intervention. We hope that the book will appeal to academics, health
professionals, and advanced students in psychology and health-related
disciplines.
The starting point for the book is social cognition theory. Denitions
of social cognition may vary, but the central tenet is that peoples social
behaviour is best understood by examining their beliefs about their behaviour in a social context, and their social perceptions and representations.
Recognition of the term probably stems from the reconceptualization of
social psychology that took place in the late 1960s and early 1970s. Social
psychologists had struggled to demonstrate the links between attitudes and
behaviour that tradition had accepted must exist, and they turned to new
concepts and models for solutions, among them the young Theory of
Reasoned Action (Fishbein and Ajzen 1975). Social cognition quickly
became a distinctive and accepted term, and research developed apace to
make the area one of the fastest growing in the discipline. By the mid1990s, the role of social cognition models in helping to understand and
predict health behaviours was well established in the literature, and the
principal models and health-related research that each had inspired were
brought together for the rst time in Predicting Health Behaviour, edited
by Mark Conner and Paul Norman, which was published by Open University Press in 1996.
The purpose of Conner and Norman (1996) was to provide an integrated
and critical review of the main social cognition models and the research in
health behaviour that had been published within each of the frameworks.
The chapters were contributed by specialists and covered ve widely used
approaches: the Health Belief Model, Health Locus of Control, Protection
Motivation Theory, the Theory of Planned Behaviour and Self-Efcacy. Each
chapter ended with speculations about future directions. Since then, a number
of developments have taken place in the literature, and they are discussed in
this chapter and elsewhere in the book. First, there have been new critical
reviews, some organized by model and some by behaviour. Second, there
have been meta-analyses, which allow results from all the available studies
that reach the authors methodological criteria to be combined statistically.
Third, several writers have explored ways of modifying the existing models,
or adding variables to them, in an effort to strengthen and clarify the prediction and understanding of health behaviours. And, fourth, the rst interventions designed to modify health behaviours through the application of
social cognition models have been designed and preliminary ndings have
begun to appear.
It is the purpose of this book to report some of the most important
interventions that have been recently completed or are in progress. We have
chosen to organize the material by behaviour, but each empirical chapter is
intended to stand alone. Like Conner and Norman, we have asked contributors to follow a common format. Each chapter begins with a statement
of the epidemiological facts about the health problem it addresses, and
describes the links between the behaviour in question and outcome. It then
outlines the theoretical stance the chapter takes, generally by describing
the particular form of the model it employs. The authors then report their
intervention or interventions, and the chapter ends with a discussion of the
implications of the ndings for theory, policy and practice. The one exception to the common format is the concluding chapter, by Stephen Sutton
a nal reection on the problems that authors face and the assumptions
they make in using social cognition models to develop health behaviour
interventions.
Social cognition models and changing health behaviours 3

2 The empirical chapters
The body of the book consists of nine empirical chapters, each concerned
with a particular behaviour or set of behaviours. Chapters 2 to 4 examine
risk-related behaviours (safer sex; smoking; exposure to radon gas); Chapters 5 to 7 turn to health-enhancing behaviours and screening (reducing fat
intake; uptake of vitamin C; breast self-examination; participation in cervical and colorectal cancer screening); and Chapters 8 to 10 explore road
safety (speeding by drivers; pedestrian behaviour; cycle helmet use). In this
section of the introductory chapter, we outline the aims and objectives of
the studies, and in the following section we introduce the models on which
the interventions are based.
Chapter 2 is by Charles Abraham, Daniel Wight and Sue Scott. It describes
a large-scale, schools-based intervention designed to encourage safer-sex
behaviours. The median age for rst sexual encounters continues to fall,
and substantial numbers of young people are putting themselves at risk of
sexually transmitted infections. The case for interventions to improve sex
education and encourage safer-sex behaviours is strong and clear, but there
has been little investment in setting up and testing theory-driven programmes.
The SHARE project (Sexual Health and Relationships: Safe Happy and
Responsible), the subject of the chapter, is a notable exception. It is currently being tested and developed in secondary schools in eastern Scotland,
and it is based in the classroom. It includes a ve-day training course for
the teachers who deliver it, together with a teachers resource pack of
twenty sessions, and it takes place over two school years. Its theoretical
base is symbolic interactionism and script theory not encountered elsewhere in the book and among the themes of the intervention are discussion, negotiation, sexual identity and agency. Outcome data are not yet
available the effects of the programme on young peoples behaviour but
the chapter reports preliminary ndings from rst experiences of delivering
the programme, and discusses implications for testing and developing it
further.
Chapter 3 is by Lynn B. Myers and Susie Frost, and reports an intervention designed to encourage smokers to quit. Smoking is one of the worlds
most pressing health problems, and it is estimated that, across the globe,
450 million people alive today will die of smoking-related illnesses over
the next 50 years. The benets to the individual of quitting, however late,
are considerable the risk of lung cancer falls by 50 per cent over 10 years,
for example yet the success rates of interventions are seldom high. Two
strategies have predominated: motivational (to strengthen smokers attempts
to give up) and treatment (to support abstinence by helping to overcome
the effects of nicotine withdrawal, through nicotine patches and the like).
The authors intervention is motivational, and seeks to modify what smokers
believe about the risks of contracting smoking-related diseases by attacking
their unrealistic optimism and helping them to see the risks as they really
are. The work is based on asking participants to imagine scenarios in which
they develop the disease and have to think about the consequences for their
lives personal, social and work alike. The results so far have differed
markedly according to how optimistically biased respondents were before
the intervention started. The dependent measure was how much peoples
beliefs changed, and the ndings showed an unexpected pattern: those who
were optimistically biased at the outset became less optimistic, but those
who were not became more optimistic. The implication is that interventions must be carefully tailored to peoples initial positions.
Chapter 4 is by Neil D. Weinstein and Peter M. Sandman, and takes
the argument about individual tailoring one step further. It reports a eld
experiment designed to encourage people to test their homes for radon gas.
The basis of the intervention is Weinsteins own Precaution Adoption Process Model (PAPM), and the chapter is an instructive example of the cyclical way in which theory leads to experimental intervention, which leads
back in turn to modications to theory. Radon is a radioactive gas produced by the decaying uranium found naturally in the soil. In the USA, it is
the leading cause of lung cancer after smoking. The PAPM, a stage theory,
has been used to analyse a variety of health behaviours, and argues that
people will be persuaded to change only if the message is matched to the
stage they have reached in their thinking: unaware of the issue, unengaged,
deciding about acting, decided not to act, decided to act, acting, and maintenance. The chapter focuses on two transitions: unengaged to deciding,
and deciding to acting (in this case ordering a radon testing kit). The intervention was based on videos, and strong support for the model and the
approach to interventions was found: there was good evidence for distinct
stages; and stage-matched attacks, though expensive to produce, succeeded
where others did not.
Chapter 5 is by Christopher J. Armitage and Mark Conner. It is the
rst of the chapters on health-enhancing behaviours, and it reports an
intervention to encourage people to reduce their intake of fat. Excessive fat
is known to be associated with many disorders, including heart disease
and cancer, and guidelines have been produced in several countries. In the
UK, for example, the recommendation is that no more than 35 per cent of
food energy should come from fat, and no more than 11 per cent from
saturated fat, but the average has remained above these gures for 20 years
or more and shows little sign of falling. The authors intervention was
based on their newly extended version of Ajzens Theory of Planned
Behaviour (TPB), and used a randomized control design. Fat intake was
measured at Time 1; three months later participants underwent one of
three interventions (TPB, self-efcacy, or plain information), and ve months
later still their fat intake was measured again. All three interventions
used leaets. Both the TPB and self-efcacy conditions had a small effect

on total fat intake across the whole group, but all three led to a reduction among people whose normal intake was high. Thus, against prediction, all conditions produced measurable effects on behaviour; but the two
theory-driven conditions were more successful than the information-only
control.
Chapter 6 is by Sara Williamson and Jane Wardle, and reports an
intervention to increase uptake of a new bowel cancer screening test, exible
sigmoidoscopy. Bowel cancer is one of the most common causes of cancer
death in the UK and most of Europe, and in the USA. Survival rates are
low but, if the disease is detected early and the pre-cancerous polyps are
removed, the chance of survival is much enhanced. Flexible sigmoidoscopy
(FS) allows both detection and removal, and is the current approach of
choice, but uptake is low. The authors purpose was to try to increase
uptake by means of an intervention based on the Health Belief Model.
The study was conducted as part of a UK national trial of FS, and used a
booklet designed to reduce perceptions of barriers and increase positive
beliefs among people who had declared themselves probably interested in
attending if offered the chance. The booklet acknowledged potential barriers,
suggested possible coping strategies, allowed participants to rehearse the
benets of screening, and directed their attention to the positive emotional
impact of screening. It also provided normative information and modelled
ways of seeking social support. Participants were assigned at random to
booklet and no booklet conditions, and it was found that screening
intention was inuenced markedly 42.5 per cent said they were very
likely to attend after the intervention, against 29.4 per cent in the control
condition. Whether intention has translated into action will be known
shortly.
Chapter 7 is by Sheina Orbell and Paschal Sheeran. It takes a different
approach from other chapters in that it reports three interventions, but all
are based on the one concept, implementation intentions. The health issues
addressed are practising breast self-examination (BSE), using vitamin C
supplements, and attending for cervical screening. Social cognition models
are generally about the motivational phase of planning behaviour, the processes up to intention, and stop short of trying to bridge the gap to behaviour, the post-decisional volitional phase. What Orbell and Sheeran do is
try to increase the probability that the behaviour will occur by intervening
to make people plan when and where they will execute the behaviour itself
the process of forming implementation intentions. Their technique is
simple ask participants to write down their plan and commit themselves
to it and the ndings were striking. In the BSE study, 100 per cent of
intenders who underwent the intervention subsequently examined themselves,
against 53 per cent of intenders in the control condition; in the cervical
screening study, attendance rates were 92 per cent and 69 per cent; and
in the vitamin C study, signicantly fewer experimental participants than
controls missed pills. Interventions using implementation intentions are both

cheap and easy to conduct, and these rst applications to health behaviours
indicate that they produce strong and reliable results.
Chapter 8 is by Dianne Parker and is the rst of the nal group of three,
on road safety. One of the most important contributors to road trafc
accidents and to serious injuries is driving too fast. Speeding has been
estimated to be second only to drink-driving as a cause and is known to be
directly associated with accident death rates. Many governments impose
speed limits, of course, but failure to respect them is widespread, is seldom
punished severely, and is socially acceptable to many people. The intervention reported in this chapter followed a long programme of research to
identify the beliefs and values that distinguish drivers who report committing violations on the road, including speeding, from those who do not. It
was based on the TPB, and its purpose was to persuade drivers to slow
down. Four short videos were made, each designed to change beliefs,
attitudes and intentions associated with driving at 40 m.p.h. in a 30 m.p.h.
area. One concentrated on behavioural beliefs, another normative beliefs,
another perceived behavioural control, and another anticipated regret. All
showed the same central character driving too fast along a quiet residential
road and being assailed by triggers in the normative condition, for example,
members of his family and salient others disapproving of his speeding.
The main outcome measure was responses to the Driver Attitude Questionnaire, a standardized index of general attitude to driving violations, and the
strongest response was found for anticipated regret. This is a variable that
has recently been used by the author and others to extend the TPB, and the
chapter thus provides a good example of something we pointed out earlier
the way in which experimental interventions can make not only a practical contribution but a theoretical one too, testing theory and exploring
ways of extending and improving it.
Chapter 9 is by Daphne Evans and Paul Norman, and turns to adolescent
pedestrians. One child in fteen is injured on the roads of Britain before the
age of 16, and children aged 10 to 15 have the highest road casualty rate
of the whole population. The intervention was based again on the TPB, but
this time made use of theatre and drama. In the drama condition, 1112year-olds worked with their teacher to produce a 15-minute play about
crossing the road safely, using information provided by the authors and
their own observations of how they and their peers behaved as pedestrians.
In the theatre condition, children of the same age watched the play as
the drama class performed it. Both groups completed TPB questionnaires
before and after the intervention, including items on additional variables
that the authors used to supplement the model moral norm, anticipated
regret and self-identity. The theatre intervention produced changes in both
behavioural and normative beliefs, while the drama condition inuenced
both perceived behavioural control and intention. The implications are that

school-based interventions have considerable potential, and that active
engagement is the key.
Chapter 10 is by Lyn Quine, Derek Rutter and Laurence Arnold, and
completes the empirical chapters with an examination of cycle helmet use
among children riding to and from school. Deaths and injuries among schoolage cyclists between 8 and 19 account for almost 40 per cent of all injuries
to cyclists in Britain and are probably under-reported. Accidents are most
likely to occur during school journeys on weekdays, and the injuries are
often to the head and brain. Helmets are known to reduce the risk of head,
face and brain injury by up to 90 per cent, yet few school-age cyclists wear
them. The chapter reports an intervention based once more on the Theory
of Planned Behaviour, but using techniques from the Elaboration Likelihood Model of Persuasion to encourage systematic thinking about the
message. The purpose of the intervention was to persuade non-wearers to
become wearers. The participants were adolescents who rode to school
regularly but did not wear a helmet. Participants were randomly assigned to
intervention or control conditions. Initial beliefs were measured just before
the intervention at Time 1. In the intervention condition, participants carried out two paper and pencil tasks, both of them designed to encourage
recall and elaboration of salient beliefs about wearing a helmet: completing
word and picture ow charts; and thought listing. In the control condition,
participants were given similar materials and tasks, but this time concerned
with a hypothetical cycling prociency and maintenance course. The immediate effects of the intervention on attitude, subjective norm, control beliefs
and intention were measured after the intervention at Time 2. Five months
later, at Time 3, the long-term effects of the intervention on beliefs, intentions and behaviours were measured. It was found that 25 per cent of the
intervention group were now wearing their helmets against none of the
control group. There was good evidence that the difference was associated
with belief change. While the intervention was time-consuming to conduct,
incorporating it routinely into cycling prociency training would be both
easy and cost-effective.
3 The theoretical models

In this section of the chapter, we turn to the models or theoretical approaches on which the empirical chapters are based. A number of the authors
have used extended or variant forms of the models, and they explain their
choices and amendments in their own chapters. Our purpose in this chapter
is to outline the original forms of the models and to indicate some of the
ways in which they have been used in the literature. There are ve approaches
to discuss: risk perception and optimistic bias; the Health Belief Model; the
Theory of Planned Behaviour; implementation intentions; and stage models.
3.1 Risk perception and optimistic bias

The literature on risk perception and optimistic bias owes most, perhaps,
to Neil Weinstein. Weinstein (1980) drew attention to what he called the
popular belief that people tend to think they are invulnerable. We generally
expect misfortunes to happen to others, he argued, not ourselves, and most
members of a group will say they are less likely than the average to suffer
the bad things in life and more likely than the average to experience the
good things. The bias holds for a wide range of health and other outcomes,
from the trivial (being ill in bed for a day or two, or having a tooth extracted)
to the life threatening (having a heart attack, or being involved in a road
accident). The name he coined for the bias was unrealistic optimism.
Since Weinsteins rst papers (Weinstein 1980, 1982, 1983, 1984, 1987),
a considerable literature on unrealistic optimism has developed, and many
useful reviews have been published (see for example Perloff and Fetzer 1986;
Hoorens 1994; Schwarzer 1994; Van der Pligt 1994; Taylor and Armor
1996; Weinstein and Klein 1996; Van der Pligt 1998). Once descriptive
research had made clear the extent of the bias, attention turned to a variety
of theoretical issues, of which two in particular have recurred in the literature. The rst is where the bias comes from, its origins in peoples motives
and cognitions, and the ways in which it may be mediated by experience.
For Weinstein, the most likely motivational candidates were defensiveness
and wishful thinking, but overall he gave more weight to cognitive factors.
Thus, the more probable I believe an event to be, he argued, the more likely
I am to believe that its probability for me is greater than average; the more
I believe I can control a negative event, the more I will perceive my own
probability as less than average; and if I have personal experience of the
negative event, I am more likely to perceive its future probability for me as
greater than average. Controllability (Van der Velde et al. 1992; McKenna
1993; Harris and Middleton 1994; Harris 1996; Hoorens 1996; Myers and
Reynolds 2000), the debiasing effects of experience (Dolinski et al. 1987;
Van der Pligt 1991; Van der Velde and Van der Pligt 1991; Burger and Palmer
1992; McKenna and Albery 2001) and experimental interventions to produce debiasing (Kreuter and Strecher 1995; Weinstein and Klein 1995;
Stapel and Velthuijsen 1996; McKenna and Myers 1997) have all generated
extensive literatures.
The second issue has been whether unrealistic optimism predicts behaviour. Weinstein (1989) argued that it probably does, or at least that it ought
to, but that the literature has been bedevilled by conceptual and methodological problems. Chief among them is that most of the analyses have been
cross-sectional or retrospective, so that respondents report their risk perceptions on the same occasion as their concurrent or even past behaviour (see,
for example, Svenson et al. 1985; Dolinski et al. 1987; Weinstein et al.
1990; Weinstein and Nicolich 1993; Hoorens 1994; Gerrard et al. 1996).

As Van der Pligt (1994) argued, prospective studies are essential if causal
ordering is to be disentangled, but relatively few have been reported and
the results have been inconsistent (see the review by Hoorens 1994). Moreover, Otten and Van der Pligt (1992) have suggested that unrealistic optimism is in any case a much less powerful predictor than prior behaviour.
There are two reasons, they argue: rst, prior behaviour affects subsequent
behaviour directly (Bentler and Speckart 1979); and second, perceptions of
risk are themselves a product of prior behaviour, and their role is at most to
mediate its effects. Thus, prior behaviour will absorb most of the variance,
and any apparent effect of risk perception is likely to be less a pure effect
of perceived risk than an indirect effect of prior behaviour. Once again, if
an experimental approach is not feasible, the most useful alternative is a
prospective longitudinal design.
3.2 The Health Belief Model

The Health Belief Model (HBM: Rosenstock 1966, 1974a, 1974b) proposes
that people will be motivated to carry out preventive health behaviours in
response to a perceived threat to their health (see Figure 1.1). Two classes
of variables are important: (1) the psychological state of readiness to take
specic action, and (2) the extent to which a particular course of action is
believed to be benecial in reducing the threat (Rosenstock 1966: 98).
Both variables, Rosenstock argued, are two-dimensional. The individuals
Perceived susceptibility
Perceived severity
Demographic
variables
Perceived benets
Perceived barriers
Cues to action
Figure 1.1 The Health Belief Model
Behaviour
10
state of readiness to act is determined by perceptions of personal susceptibility or vulnerability to a particular health threat, and perceptions of the
severity with which that threat might affect their life. The extent to which a
course of action is believed to be benecial is the result of beliefs about the
benets to be gained by a particular action weighed against the costs of or
barriers to action. Rosenstock (1966: 101) believed that the level of readiness provided the energy or force to act and the perceptions of benets less
barriers provided a preferred path of action. However, the combination of
these could reach considerable levels of intensity without resulting in overt
action unless some instigating event occurred to set the process in motion
or trigger action in an individual psychologically ready to act (Rosenstock
1966:102). Thus, in addition to the variables already described, a factor
that serves as a cue or a trigger to appropriate action is necessary such
as having an accident oneself (in the case of road safety, for example), or
recent media attention to the issue. This Rosenstock named the cue to
action. Some years later, Rosenstock and his colleagues also suggested that
behavioural intention might be a mediating variable between the components of the HBM and behaviour (Becker et al. 1977). Other researchers have
taken up this suggestion (King 1982; Calnan 1984; Norman and Fitter 1989;
Quine et al. 1998).
Despite its intuitive appeal, the HBM has conceptual difculties. Rosenstock did not specify how different beliefs inuence one another, or how
the explanatory variables combine to inuence behaviour. As a result, different studies have used different combinations of variables, and researchers
have treated variables differently in the analysis. Some, for example, have
used additive models in which the combined weight of the variables is
used to predict outcome, while others have combined variables by adding
vulnerability and severity (Wyper 1990; Witte et al. 1993), multiplying them
(Haefner and Kirscht 1970; Hill et al. 1985; Conner and Norman 1994) or
subtracting barriers from benets (Oliver and Berger 1979; Rutledge 1987;
Wyper 1990). A close inspection of Rosenstocks discussion of the model,
however, seems to indicate that the dimensions are to be treated as separate inuences on health behaviour and that an additive combination is consistent with the underlying theoretical principles (see Weinstein 1988 for
a discussion).
A second problem is that Rosenstock offered no operational denitions
of the variables and therefore researchers use different methods (Champion
1984). Perceived vulnerability is used to measure either personal vulnerability to a specic health threat or a general vulnerability to disease relative
to other people. Barriers, which Rosenstock viewed as primarily psychological, are often used to assess structural impediments instead (Hill et al.
1985; Melnyk 1988; Simon et al. 1993). Several revisions to the model
have therefore been suggested (Becker et al. 1972; Becker and Maiman
1975; Becker et al. 1977). Becker (1974) has argued that the value placed

upon their health by some individuals may predispose them to respond to
the cues to action. Some researchers have suggested that health locus of
control beliefs should be included (Wallston and Wallston 1981; Lau et al.
1986; Arnold and Quine 1994). Others have produced new conceptual
frameworks using some of the HBMs constructs: see Schwarzer (1992),
Schwarzer and Fuchs (1996), Schwarzer (1999) (the Health Action Process
Approach); Rogers (1975, 1985), Prentice-Dunn and Rogers (1986), Boer
and Seydel (1996) (Protection Motivation Theory).
Despite these theoretical and conceptual problems, the HBM has received
sustained empirical support and is still widely used to predict health
behaviours. Since the early 1990s, for example, it has been applied to
mammography and cervical screening (Aiken et al. 1994; Fischera and Frank
1994; Champion and Miller 1996; Orbell et al. 1996; Brenes and Skinner
1999); breast self-examination (Champion 1990; Friedman et al. 1994;
Savage and Clarke 1996; Millar 1997); adherence to medication (Budd
et al. 1996; Hughes et al. 1997; Nageotte et al. 1997) (antipsychotic medication), (Brown and Segal 1996) (antihypertensive medication), (Bond et al.
1992) (insulin), (Abraham et al. 1999) (malaria medication); exercise behaviour (Corwyn and Benda 1999); safe-sex behaviours (Petosa and Jackson
1991; Abraham et al. 1992; Walter et al. 1993; Lux and Petosa 1994; Steers
et al. 1996; Bakker et al. 1997); attendance at health checks (Norman and
Conner 1993); delay in seeking medical care (Leenaars et al. 1993) (sexually transmitted infections: STIs), (Dracup et al. 1995) (heart attack); and
many other health behaviours. Two reviews using rather different methods
have examined the utility of the Health Belief Model constructs (see Janz
and Becker 1984; Harrison et al. 1992). These are evaluated in Sheeran
and Abraham (1996), who concluded that though the HBM constructs are
frequently signicant predictors of behaviour, their effects are usually small.
3.3 The Theory of Planned Behaviour
The TPB is an expectancy-value model that was expanded from the Theory
of Reasoned Action (TRA: Fishbein and Ajzen 1975; Ajzen and Fishbein
1980) (see Figure 1.2). It provides a theoretical account of the way in which
attitude, subjective norm and behavioural intentions combine to predict
behaviour. According to the TRA, the best predictor of behaviour is the
persons intention to perform the behaviour (for example I intend to do
X). Intention summarizes the individuals motivation to behave in a particular way and indicates how hard the person is willing to try and how
much time and effort they are prepared to expend in order to perform
the behaviour (Ajzen 1991: 199). In turn, intention is determined by two factors: attitude towards the behaviour and subjective norm or perceived
social pressure to perform (or not perform) the behaviour. Attitude is the
product of a set of salient beliefs about the consequences of performing the
12
Beliefs about
outcomes
Outcome evaluation
Attitude
Normative beliefs
Motivation
to comply
Subjective
norm
Perceived likelihood
of occurrence
Perceived power to
facilitate/inhibit
Perceived
behavioural
control
Intention
Behaviour
Figure 1.2 The Theories of Reasoned Action and Planned Behaviour

(TPB components shown shaded in grey)
behaviour (for example Wearing a safety helmet would protect my head if

I had an accident), each weighted by an evaluation of the importance of
each of the consequences (for example Protecting my head if I had an accident is good/bad). Subjective norm is determined by the persons normative
beliefs about perceived social pressure from signicant others (for example
My parents think I should wear a safety helmet) weighted by the persons
motivation to comply with those others (Generally I want to do what my
parents think that I should do).
The TRA was intended to be applied to the prediction of purely volitional behaviours but, as Ajzen (1988) later argued, many behaviours are
not under complete volitional control. He therefore expanded the TRA by
adding the concept of perceived behavioural control, which refers to peoples
appraisals of their ability to perform the behaviour. According to Ajzen
(1988), perceived behavioural control should predict behavioural intention
and, when peoples perceptions of control accurately reect their control
over behaviour, it should predict actual performance of the behaviour too.
Perceived behavioural control is underpinned by control beliefs about perceptions of obstacles, impediments, skills, resources, and opportunities that
may inhibit or facilitate performance of the behaviour. These may be external
(for example availability of time or money) or internal (for example ability,
skills).
There has been some controversy about how the construct of perceived
behavioural control should be operationalized (Terry 1993; Armitage and

Conner 1999b). Ajzen and Madden (1986) rst assessed it by summing the
frequency of occurrence of various factors facilitating or inhibiting behavioural performance. More recently, Ajzen and his colleagues have suggested
that evaluations of the power of factors likely to facilitate or inhibit performance of the behaviour should be weighted by their frequency of occurrence (Ajzen 1991; Ajzen and Driver 1991). Other authors have suggested
that perceived control over behaviour (a variant of perceived behavioural
control) should be distinguished from perceived condence in ones own
ability to perform the behaviour (self-efcacy) and that both constructs
should be measured (Terry 1993; Terry and OLeary 1995; Conner and
Armitage 1998; Armitage and Conner 1999a; Povey et al. 2000; Abraham,
Wight and Scott, Chapter 2 in this volume).
Both the TRA and the TPB have attracted enormous attention from
social psychologists interested in identifying beliefs underpinning health
behaviours that may be amenable to change, and the models have received
extensive support: see Sheppard et al. (1988) and Van den Putte (1993) for
reviews of the TRA; Ajzen (1991), Conner and Sparks (1996), Godin and
Kok (1996), Conner and Armitage (1998), Ajzen and Fishbein (2000),
Armitage and Conner (2000) and Armitage and Conner (in press) for reviews
of the TPB; and Sheeran and Taylor (1999) and Albarracn et al. (2001) for
meta-analyses and comparisons of the TRA and TPB. Godin and Kok (1996),
in a review of the TPBs application to health behaviours, found that
components of the TPB explain on average 41 per cent of the variance in
intention; in a review of a wider range of behaviours, Armitage and Conner
(in press) found that the TPB accounted for 39 per cent of the variance.
The prediction of behaviour from TRA and TPB variables is less impressive. Godin and Koks (1996) review found that TPB constructs accounted
for only 31 per cent of the variance in behaviour in prospective studies,
while Armitage and Conner (in press) found a gure of 27 per cent. The work
of other researchers has generally conrmed these ndings (Sheppard et al.
1988; Randall and Wolff 1994; Sheeran and Orbell 1998; Sutton 1998).
Since the large amount of unexplained variance is unlikely to be due to
measurement error, this suggests a role for other variables.
One of the central tenets of the TRA and TPB has been that the models
are sufcient that is, that variables external to the models fail to account
for additional variance in intentions or behavioural performance once the
effects of the models components have been taken into account. A number
of researchers have attempted to challenge this assumption and to increase
the predictive power of the model by including additional variables. Many
of these have been described by Eagly and Chaiken (1993: 17793) and
Manstead and Parker (1995). A number of the constructs are hypothesized
to account for variance in behavioural intention over and above what is
accounted for by the TPB or TRA. They include personal/moral norm or
perceived moral obligation (Beck and Ajzen 1991; Boyd and Wandersman
14
1991; Sparks 1994; Parker et al. 1995; Conner and McMillan 1999; Evans
and Norman, Chapter 9 in this volume); anticipated regret (Parker et al.
1995 and Parker, Chapter 8 in this volume; Evans and Norman, Chapter
9); anticipated affect (Van der Pligt and de Vries 1998; Bish et al. 2000);
and affective evaluations of behaviour (Manstead and Parker 1995). A
further construct, self-identity (see Evans and Norman, Chapter 9), has
been proposed as an extension to the TPB to improve the prediction of
intention after criticisms concerning the narrow conceptualization of subjective norm and its consistently weak prediction of intention (see Van den
Putte 1993; Godin and Kok 1996; Armitage et al. 1999; Terry et al. 1999).
Self-identity refers to the idea that intentions are linked to identiable societal
roles and that these roles drive intention (Armitage and Conner in press).
A number of studies using a version of the TPB extended to include selfidentity have found support for this suggestion (Sparks and Shepherd 1992;
Sparks and Guthrie 1998; Evans and Norman, Chapter 9). Yet further
research has been concerned with factors that might moderate the relationship between intentions and behaviour. These include self-schemas (Sheeran
and Orbell 2000a), attention control (Orbell and Sheeran 1998) and implementation intentions (Gollwitzer and Brandsttter 1997; Orbell et al.
1997; Sheeran and Orbell 1999; Orbell and Sheeran, Chapter 7 in this
volume).
3.4 Implementation intentions
The concept of implementation intentions comes from the work of Peter
Gollwitzer. Gollwitzer (1990) and Heckhausen (1991) contend that progress
towards a particular goal begins with a deliberative phase in which the
costs and benets of pursuing the goal are evaluated. The deliberative phase
results in the development of goal intentions or decisions whether or not to
perform the behaviour. Forming a goal intention (for example I intend
to perform X) involves committing oneself to reaching a desired outcome.
Fishbein and Ajzens (1975) Theory of Reasoned Action is similar, in that
behavioural intention is seen as the immediate determinant of behaviour.
However, people frequently have difculty in translating their goals into
action. Gollwitzer (1993) also proposed an implemental phase, in which
planning when, where and how to carry out the goal-directed behaviour (I
intend to perform X whenever Y conditions are encountered) increases
the likelihood that the goal will be attained. The name Gollwitzer used for
these plans was implementation intentions.
Gollwitzer and colleagues (Gollwitzer 1993; Gollwitzer and Brandsttter
1997; Gollwitzer and Oettingen 1998; Gollwitzer and Schaal 1998;
Gollwitzer 1999) have gone on to build a considerable body of empirical
evidence that formulating implementation intentions furthers goal attainment. Gollwitzer and Brandsttter (1997), for example, found that students

whose goal intention to write an assignment during the winter vacation
was augmented by an implementation intention were more than twice as
likely to submit their work on time as students who were not asked to form
a plan. The implementation intention was concerned with precisely where
and when the assignment would be written. Implementation intentions
thus overcome the potential conict between routes to goal realization and
potential problems in translating goals into action (failing to get started,
becoming distracted) by committing the individual to a specic course of
action when the environmental conditions specied in their implementation
intentions are encountered.
A number of studies have reported good evidence that implementation
intentions can signicantly increase the performance of health behaviours
including breast self-examination (Orbell et al. 1997), healthy eating
(Verplanken and Faes 1999), attendance for cervical cancer screening (Orbell
and Sheeran 1998), consumption of vitamin C pills (Sheeran and Orbell
1999) and mobility after joint replacement surgery (Orbell and Sheeran
2000). Orbell et al. (1997), for example, showed that women who were
asked to form implementation intentions were more than twice as likely to
perform breast self-examination as those who were not asked to do so. In
a later intervention, Sheeran and Orbell (2000b) found that women in an
experimental group who formed implementation intentions were much more
likely to attend for cervical screening than women in a control group (92
per cent compared with 69 per cent), despite equal motivation. Further
information about the studies is included in Chapter 7.
A question that remains for theory is how implementation intentions
have their effect, and perhaps the most likely explanation is that they operate
through memory. That is, they increase memory for behavioural action
through the formation of plans involving anticipated environmental and
contextual cues, which act as an unconscious reminder for the behaviour
when they are encountered. The mechanism is probably similar to the
cognitive mechanisms involved in habitual behaviour. Consistent with these
suggestions, Sheeran and Orbell (2000b) found that implementation intentions mediate the relationship between intention and behaviour suggesting that a strong memory trace is indeed formed when implementation
intentions are made. A detailed account of the role of memory, and of the
other possible mechanisms, is to be found in Gollwitzer (1999).
3.5 Stage models
The approaches we have discussed so far risk perception, the Health Belief
Model and the Theory of Planned Behaviour can all be seen as continuum
accounts of behaviour. Each takes one or more perceptions or beliefs, or
perhaps sets of perceptions or beliefs, and tries to predict from their combined effect where the individual will lie on an outcome continuum such as
16
intention or behaviour. For example, one might use behavioural beliefs,

normative beliefs and control beliefs in the TPB to predict how much fat
people will eat, how safely they will drive, and how likely they will be to
attend for health screening. The purpose of an intervention would be to
change those perceptions or beliefs in an attempt to move the person up
or down the outcome continuum. Stage models, by contrast, as their name
suggests, see individuals as located not on continua but at discrete, ordered
stages, each one denoting a greater inclination to change outcome, typically
behaviour, than the previous one. There are currently two main stage models
in health psychology, the Transtheoretical Model (TTM) of Prochaska
and DiClemente, and the Precaution Adoption Process Model (PAPM) of
Weinstein (see Figure 1.3).
Transtheoretical Model
Stage 1
Precontemplation
Stage 2
Contemplation
Precaution Adoption Process Model

Stage 1
Unaware of issue
Stage 2
Unengaged by issue
Stage 3
Deciding about acting
Stage 3
Preparation
Stage 5
Decided to act
Stage 4
Action
Stage 5
Maintenance
Stage 4
Decided not to act
Stage 6
Acting
Stage 7
Maintenance
Figure 1.3 Stages of change models

The TTM proposes ve stages: precontemplation (no intention of changing behaviour); contemplation (beginning to consider change, at some probably ill-dened time in the future); preparation (getting ready to change
in the near future); action (engaged in change now); and maintenance
(steady state of change reached). The possibility of relapse to an earlier
stage is acknowledged, right back to precontemplation but not necessarily
so, and the model allows that people may start the climb anew. Where an

individual is to be located is dened by previous behaviour and current
intentions, and the stages are seen as mutually exclusive and cannot be
straddled. The model was rst applied to smoking and has been adapted
by Raw (1994) as an accessible decision chart for general practitioners
but it has since been applied to a wide variety of other health behaviours
too. Reviews are to be found in Prochaska et al. (1994), Herzog et al. (1999),
Sutton (1999, 2000) and Velicer et al. (1999), and particularly accessible
accounts of the model have been published in Prochaska et al. (1992) and
Prochaska and Prochaska (1999). Evaluations of the models constructs,
methodology and ndings have been published by Sutton (1996, 1997, 2001)
and by Weinstein et al. (1998), Kraft et al. (1999) and Rosen (2000a, 2000b).
The PAPM is described by its author, Neil Weinstein, in Chapter 4. As
its name suggests, the model is concerned with preventive or precautionary
behaviour against threat. This time, there are seven stages: unaware (not
aware that there is an issue or threat); unengaged (aware but not engaged);
deciding about acting (considering the possibility of taking action); decided
not to act; decided to act (to adopt the precaution); acting; and maintenance. Unlike the TTM, the PAPM thus distinguishes people who are unaware from those who are aware but are not considering action; and it
allocates those who have decided not to act to a stage of their own, separate from those who are failing to act because they have not yet thought
about the issue. Further detailed comparisons between the two models are
to be found in Weinstein and Sandman (1992), Weinstein (1993) and
Weinstein et al. (1998). The model has been applied to a variety of precautionary behaviours in health including protection against osteoporosis
(Blalock et al. 1996), hepatitis B (Hammer 1997) and radon gas (Weinstein
and Sandman 1992, and Chapter 4 in this volume); and uptake of
mammography (Clemow et al. 2000). A review is to be found in Weinstein
et al. (1998).
The most important debate about stage models is the one suggested at
the beginning of this section whether we really do pass through stages as
we move from the beginnings of awareness to behaviour, or whether stages
are rather points on a continuum. There are other issues too, however.
Does every stage have to be visited, in a xed order, or can a stage sometimes be missed out? Do individuals located at a given stage all have to
overcome the same barriers if they are to move on? What is it that triggers
movement, and are particular triggers conned to one stage only or are
they the same at all stages? Do the barriers and triggers cross behaviours,
or do they differ by domain (taking precautions against radon or against
pregnancy, for instance)? How are stage models to be tested empirically,
and how are they to be used for designing and mounting interventions?
Detailed accounts are to be found in Sutton (1996, 1997, 2001), Weinstein
et al. (1998), Kraft et al. (1999) and Rosen (2000a, 2000b) and in Chapter 4 of this volume.
18
4 Conclusions and future directions

To conclude the chapter, we should like to pose two questions. The rst is what
makes for a good intervention, and we believe the book provides a number of
answers. First, and most important of all, interventions must be theory driven.
Theories provide constructs, processes and hypotheses, and they point to procedures and methodologies for setting up interventions and testing their
effectiveness. Without theory there is no framework or underpinning, and
no progress or development. Second, interventions must tackle important
health issues with identiable associated behaviours whether risk related,
health enhancing, or any other that has serious consequences and implications.
Third, processes and outcomes must be clearly dened and carefully measured,
and the links between processes and procedures must be properly spelt out.
Both requirements are part of having a theoretical base, and an important
effect will be that the intervention can be tailored successfully to the target
group or individuals. Finally, a good intervention will have implications for
theory, policy, and practice, and they will be testable implications.
Our second question is what are the likely future directions in intervention research, and again there are strong indications in the chapters
that follow. First, there will be a move towards large-scale randomized controlled trials (RCTs). Many of the interventions in the book adopt the
classic experimental group control group design that is the core of the
RCT, and the value of the approach for teasing out causal processes will
be apparent chapter by chapter. The longer-term added value of full-scale
RCTs will be to establish sizes of effect and reliability. Second, interventions will more frequently than now incorporate measures of behavioural
outcome that is, not just how much people change their perceptions, or
beliefs, or intentions, but also how much they change their behaviour. Third,
we must acknowledge our responsibilities to policy-makers and practitioners,
and make our approaches accessible. Interventions must have an understandable theoretical base, must be easy to design, run and evaluate, and
must be cost-effective. Finally, to return to our rst criterion for a good
intervention, interventions must continue to be rmly theory driven, and
we must resist the temptation to devise one off attacks on behaviour based
on common sense. Theory provides the foundation for successful interventions, and through interventions we are able to test, and so develop, theory.
From theory comes intervention and from intervention comes further theory.
That, we believe, is the key theme of the book.
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CHANGING HEALTH BEHAVIOUR

INTERVENTION AND RESEARCH

Open University Press

Open University Press

0 335 20432 5 (pb) 0 335 20433 3 (hb)

Library of Congress Cataloging-in-Publication Data

Typeset by Graphicraft Limited, Hong Kong

2 Encouraging safer-sex behaviours: development of the SHARE

3 Smoking and smoking cessation: modifying perceptions

4 Reducing the risks of exposure to radon gas: an application

5 Reducing fat intake: interventions based on the Theory of

6 Increasing participation with colorectal cancer screening:

7 Changing health behaviours: the role of implementation

8 Changing drivers attitudes to speeding: using the

9 Improving pedestrian road safety among adolescents: an

10 Increasing cycle helmet use in school-age cyclists: an

11 Using social cognition models to develop health behaviour

Professor Charles Abraham is Professor of Psychology at the Centre for

Dr Lyn Quine is Reader in Health Psychology at the Department of

DEREK RUTTER AND

SOCIAL COGNITION MODELS AND

1 Social cognition models

Derek Rutter and Lyn Quine

Social cognition models and changing health behaviours 3

Derek Rutter and Lyn Quine

Social cognition models and changing health behaviours 5

Derek Rutter and Lyn Quine

controls missed pills. Interventions using implementation intentions are both

Social cognition models and changing health behaviours 7

3 The theoretical models

Derek Rutter and Lyn Quine

3.1 Risk perception and optimistic bias

Social cognition models and changing health behaviours 9

3.2 The Health Belief Model

Figure 1.1 The Health Belief Model

Derek Rutter and Lyn Quine

Social cognition models and changing health behaviours 11

Derek Rutter and Lyn Quine

Figure 1.2 The Theories of Reasoned Action and Planned Behaviour

behaviour (for example Wearing a safety helmet would protect my head if

Social cognition models and changing health behaviours 13

Derek Rutter and Lyn Quine

Social cognition models and changing health behaviours 15

Derek Rutter and Lyn Quine

intention or behaviour. For example, one might use behavioural beliefs,

Precaution Adoption Process Model

Figure 1.3 Stages of change models

Social cognition models and changing health behaviours 17

Derek Rutter and Lyn Quine

4 Conclusions and future directions

Social cognition models and changing health behaviours 19

Derek Rutter and Lyn Quine

Social cognition models and changing health behaviours 21

Derek Rutter and Lyn Quine

Gollwitzer, P.M. and Brandsttter, V. (1997) Implementation intentions and

Social cognition models and changing health behaviours 23

Derek Rutter and Lyn Quine

Social cognition models and changing health behaviours 25

Derek Rutter and Lyn Quine