Health Behavior, Psychosocial Theories of

Stephen Sutton, Institute of Public Health, University of Cambridge, Cambridge, UK

2015 Elsevier Ltd. All rights reserved.

Abstract
A number of psychosocial theories have been developed to predict, explain, and change health behaviors. In this article, six
widely used theories are discussed in turn and then compared. They include four continuum theories (the health belief
model; protection motivation theory; the theory of planned behavior; and social cognitive theory), one stage theory
(the transtheoretical model), and one theory that has both stage and continuum versions (the health action process
approach). Common criticisms of these theories are briey addressed.

The term health behavior is used very broadly in this article to

refer to any behavior that inuences, or is believed to inuence,
physical health outcomes, either by increasing or decreasing
their risk or severity. A number of psychosocial theories (or
models the two terms are used interchangeably in this article)
have been developed to predict, explain, and change such
health behaviors. There are two main types: continuum theories and stage theories (Sutton, 2005; Weinstein et al., 1998).
Stage theories assume that behavior change involves movement through a sequence of discrete, qualitatively distinct,
stages, and that different factors are important at different
stages. Continuum theories have a simpler structure. They
specify a single prediction equation for behavior; for example,
the health belief model (HBM) species that behavior is
inuenced by perceived susceptibility, severity, benets, and
barriers. The difference in structure of these two types of
theories has implications for how they are tested and used as
the basis for health behavior interventions. An intervention
based on a continuum theory should target the determinants of
behavior that are specied by the theory, whereas, for a stage
theory, different interventions are required for people in
different stages to encourage or help them to move to the next
stage.
In this article, six theories are discussed in turn and then
compared. They include four continuum theories (the HBM;
protection motivation theory (PMT); the theory of planned
behavior (TPB); and social cognitive theory (SCT)), one stage
theory (the transtheoretical model (TTM)), and one theory that
has both stage and continuum versions (the health action
process approach (HAPA)). Common criticisms of these
theories are briey addressed.

the disease if he or she were to continue with the current course

of action. Perceived severity refers to the seriousness of the
disease and its consequences as perceived by the individual.
Perceived benets refers to the perceived advantages of the
alternative course of action including the extent to which it
reduces the risk of the disease or the severity of its consequences. Perceived barriers (or perceived costs) refers to the
perceived disadvantages of adopting the recommended action
as well as perceived obstacles that may prevent or hinder its
successful performance. These factors are commonly assumed
to combine additively to inuence the likelihood of performing the behavior. Thus, high susceptibility, high severity, high
benets, and low barriers are assumed to lead to a high probability of adopting the recommended action. Another factor
that is frequently mentioned in connection with the HBM is
cues to action (events that trigger behavior), but little empirical
work has been conducted on this construct.
There have been several meta-analyses (quantitative
reviews) of research using the HBM. The most recent of these
(Carpenter, 2010) was the most rigorous and focused on 18
studies that used a longitudinal design in which the HBM
variables were measured at time 1 and behavior at time 2.
Benets and barriers were consistently the strongest predictors
of behavior, with mean correlations of 0.27 and 0.30,
compared with 0.15 for severity and only 0.05 for susceptibility. Several moderators were identied, including the length
of time between the measurement of beliefs and behavior (the
longer the time, the lower the correlation) and prevention
versus treatment behaviors (higher correlations for prevention). Carpenter recommends that researchers should abandon
the simple four-variable additive model and instead examine
possible mediation and moderation among the variables.

The Health Belief Model

Protection Motivation Theory
The HBM (Becker, 1974) was developed in the 1950s by
a group of social psychologists working in the eld of public
health who were seeking to explain why some people do not
use health services such as immunization and screening. The
model is still in common use. There are four core constructs:
the rst two refer to a particular disease whereas the second two
refer to a possible course of action that may reduce the risk or
severity of that disease. Perceived susceptibility (or perceived
vulnerability) is the individuals perceived risk of contracting

International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 10

PMT (Rogers, 1983; Rogers and Prentice-Dunn, 1997) was

originally developed to explain how people respond to feararousing health threat communications or fear appeals. It can
be regarded as an adaptation of the HBM. Protection motivation
refers to the motivation to protect oneself against a health
threat; it is usually dened operationally as the intention to
adopt the recommended action. Of the determinants of intention specied by the model, the four that have received the most

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Health Behavior, Psychosocial Theories of

empirical attention are vulnerability and severity (equivalent to

perceived susceptibility and severity in the HBM), response
efcacy (the belief that the recommended action is effective in
reducing the threat), and perceived self-efcacy (the belief that
one can successfully perform the recommended action;
Bandura, 1997). Thus, a person will be more motivated to
protect himself or herself (i.e., have a stronger intention to
adopt the recommended action) to the extent that he or she
believes that the threat is likely if the current course of action is
continued, that the consequences will be serious if the threat
occurs, that the recommended action is effective in reducing the
likelihood or the severity of the threat, and that he or she is able
to carry out the recommended action.
In many studies using this model (e.g., Wurtele and
Maddux, 1987), specic PMT variables are experimentally
manipulated in a factorial design and their effects on intention
(and sometimes behavior) are measured. In fact, PMT is unique
among health behavior theories with respect to the relatively
large number of experimental tests that have been conducted.
To date, two meta-analyses of PMT studies have been conducted (Floyd et al., 2000; Milne et al., 2000). The analyses
used different study inclusion criteria and different effect size
measures. Floyd et al. analyzed 65 studies with about 30 000
research participants, whereas Milne and colleagues included
27 studies with about 8000 participants. There were only 12
studies in common. Both analyses found support for each of
the main PMT variables as predictors of intentions and/or
behavior. Self-efcacy had the strongest, most consistent, and
most robust effect.

The Theory of Planned Behavior

The TPB (Ajzen, 1991, 2006b), an extension of the theory of
reasoned action (TRA), developed out of socialpsychological
research on attitudes and the attitudebehavior relationship.
According to the theory, behavior is determined by the strength
of the persons intention to perform that behavior and the
amount of actual control that the person has over performing
the behavior. Perceived behavioral control, similar to Banduras
construct of self-efcacy, refers to the persons perceptions of
their ability to perform the behavior and is assumed to reect
actual behavioral control more or less accurately. To the extent
that perceived behavioral control is an accurate reection of
actual behavioral control, it can, together with intention, be
used to predict behavior.
The strength of a persons intention is determined by three
factors: their attitude toward the behavior (their overall evaluation of performing the behavior); their subjective norm (the
extent to which they think that important others would want
them to perform it); and their perceived behavioral control.
Attitude, subjective norm, and perceived behavioral control are
each held to be determined by sets of salient (readily accessible) beliefs about the behavior. Attitude toward the behavior
is determined by behavioral beliefs about the personal consequences of performing the behavior; subjective norm by
normative beliefs about the views of important others; and
perceived behavioral control by control beliefs about the
presence of factors that may facilitate or impede performance
of the behavior.

The TPB has been widely used in observational studies to

predict and explain intentions and behavior. Meta-analyses of
these studies show that, on average, the TPB explains between
35 and 50% of the variance in intentions and between 26 and
35% of the variance in behavior (Sutton, 2004). To date, the
theory has not been widely used to develop behavior change
interventions (Sutton, 2010).

Social Cognitive Theory

According to SCT (Bandura, 1986, 1997), behavior is inuenced directly by goals and self-efcacy expectations and
indirectly by self-efcacy, outcome expectations, and
sociostructural factors. Goals are similar to intentions in
other theories of health behavior; they determine the amount
of effort that the individual invests in changing their behavior
and serve as guides to action. Self-efcacy refers to a persons
belief in their ability to perform a specic action in
a particular situation. Outcome expectations are beliefs
regarding the consequences (positive and negative) of
performing the behavior. The theory distinguishes between
different kinds of outcome expectation. For example, social
outcome expectations might include anticipated approval or
disapproval from ones partner, whereas self-evaluative
outcome expectations refer to anticipated feelings arising
from internal standards such as pride in having achieved
a change in ones behavior. Finally, the theory incorporates
perceived opportunities and barriers, which are assumed to
inuence goals.
Although SCT includes a number of constructs, the majority
of empirical applications of the theory focus on self-efcacy.
There is a large body of evidence from observational studies
showing that self-efcacy expectations consistently predict
behavior (Luszczynska and Schwarzer, 2005). The theory has
also been used as the basis for behavior change interventions,
again focusing almost exclusively on self-efcacy. According
to Bandura (1997), there are several ways of enhancing selfefcacy. These include mastery experiences, in which the
person gains condence by achieving a modest goal;
observation of someone similar to themselves successfully
performing a behavior, known as modeling or vicarious
learning; and verbal persuasion.

The Health Action Process Approach

The HAPA (Schwarzer, 2008) exists in both continuum and
stage versions and is sometimes described as a hybrid model.
The model incorporates several constructs from other theories
of health behavior, including risk perception, outcome expectancies, self-efcacy, and intention. Unlike other theories, it
species different types of self-efcacy. For example,
maintenance (or coping) self-efcacy refers to optimistic
beliefs about ones ability to deal with barriers that arise
during the maintenance period, and recovery self-efcacy
refers to self-efcacy to get back on track after experiencing
a failure, lapse, or setback. Another HAPA construct that does
not occur in the other theories discussed in this article is
action planning (or action plans), which refers to having

Health Behavior, Psychosocial Theories of

made a detailed plan regarding when, where, and how to carry

out the target behavior.
Different versions of the model have been tested in longitudinal observational studies. In a typical application of the
HAPA model, the constructs are measured on two or three
occasions and structural equation modeling is used to test
a prespecied causal model. For example, Schwarzer and
Luszczynska (2008; Study 2) measured risk perception, positive outcome expectancies, pre-action self-efcacy and
intention at time 1, and maintenance self-efcacy, planning,
recovery self-efcacy, and behavior (high-fat diet) at time 2,
2 months later. Among other links, the model specied that
risk perception, positive outcome expectancies, and preaction self-efcacy directly inuenced intention to reduce
fatty foods; planning mediated the intentionbehavior
relationship; and planning and recovery self-efcacy directly
inuenced behavior.
These models, and the ndings from such model tests, are
often interpreted in terms of phases. For example, the part of
the model that deals with determinants of intention is referred
to as the motivational phase and the mediation of the intentionbehavior link is referred to as the postintentional or
volitional phase. However, the HAPA as specied and tested
in such studies is a continuum theory, similar in structure to
the TPB, for example (Sutton, 2005, 2008).
Several recent studies have specied the HAPA as an explicit
stage theory. For example, in a study of fruit and vegetable
intake, Wiedemann et al. (2009) used a staging algorithm to
categorize participants into three stages (pre-intenders,
intenders, and actors) and examined predictors of stage transitions between two time points.

The Transtheoretical Model

The TTM (Prochaska et al., 1992) is the dominant stage theory
in the health behavior eld. It developed from studies of the
processes of change in psychotherapy and smoking cessation.
Smoking still accounts for the majority of applications of the
model but it has been applied to a wide range of other health
behaviors, including condom use, exercise, sunscreen use, and
healthy eating (Prochaska and Velicer, 1997). Although it is
often referred to simply as the stages of change model, the TTM
includes 15 different theoretical constructs drawn from
different theories of behavior change. These include the stages
of change (which provide the basic organizing principle), the
10 processes of change, the perceived pros and cons of
changing, and self-efcacy and temptation. The TTM was an
attempt to integrate these different constructs in a single
comprehensive framework hence the name transtheoretical.
The version of the TTM used most widely in recent years
species ve stages: pre-contemplation, contemplation,
preparation, action, and maintenance (DiClemente et al.,
1991). Using a staging algorithm, participants are classied
into stages on the basis of their responses to a small number
of questionnaire items. Prochaska et al. (1992) represented
the stages of change as a spiral. People start at the bottom in
pre-contemplation. They then move through the stages in
order (contemplation, preparation, action, maintenance) but
may relapse to an earlier stage. They may cycle and recycle

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through the stages several times before achieving successful

long-term behavior change.
Of the other constructs in the TTM, the 10 processes of
change refer to the things that people think and do to help
them move through the stages, the pros and cons are the
perceived advantages and disadvantages of changing, selfefcacy is borrowed from Banduras SCT, and temptation is
a related concept that refers to the degree to which a person
expects to feel tempted to lapse in different situations.
Although the TTM is still enormously popular, it has
attracted a lot of criticism in recent years, culminating in a call
for the model to be abandoned (West, 2005). The problems
include lack of standardization of measures, particularly of the
central construct of stages of change; logical aws in current
staging algorithms; inadequate specication of the causal
relationships among the different constructs; misinterpretation
of cross-sectional data on stages of change; and confusion
concerning the nature of stage models and how they should
be tested. (Herzog, 2008; Sutton, 2005). However, although
the TTM cannot be recommended in its present form, the
notion that behavior change involves movement through
a sequence of qualitative stages is an important idea that
deserves further consideration.

Comparison of Theories
Aside from the distinction between stage and continuum
theories, the theories outlined earlier show a number of
important similarities and differences. Some constructs are
common to more than one theory. For example, perceived
susceptibility or perceived vulnerability occurs in the HBM,
PMT, and the HAPA. Other constructs appear to be very similar,
for example, perceived behavioral control and self-efcacy.
Resolution of current controversies concerning the extent
of overlap between such constructs requires the development
of clear denitions, so that similar constructs can be
distinguished on conceptual grounds, and more frequent
tests of discriminant validity to investigate whether sets of
apparently similar measures are tapping the same or different
constructs.
The theories also differ in the extent to which the constructs
and the causal relationships among them are clearly specied.
Of the four, the TPB is the most highly specied (though there
are still some ambiguities; Sutton, 2004). Another advantage of
the TPB is that there exist clear recommendations for how the
constructs should be operationalized (Ajzen, 2006a). In addition, Ajzen emphasizes the principle of compatibility. Put
simply, this states that for maximum prediction the measures
of all the constructs in the model should use the same wording
to dene the target behavior. This principle is not widely
applied in research using the other theories. The other theories
lack clarity in important respects. The TTM, for example, lacks
a clear specication of the variables that inuence each stage
transition.
The theories also differ with regard to their scope of application. Key constructs in the HBM and PMT include perceived
susceptibility and perceived severity with respect to a given
health threat. Although these components can be extended to
non-health-related events, for example, the risk of nancial

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Health Behavior, Psychosocial Theories of

loss, the scope of these theories is necessarily limited by the

nature of these two constructs. By contrast, SCT, the TPB, and
the TMM are general theories that can be applied to any
domain or behavior, for example, voting, career, and
purchasing decisions. Stated differently, these theories regard
health behaviors (or stage transitions in the case of the TTM)
as having the same proximal determinants as other kinds of
behavior. Thus, they offer the potential benet of parsimony.
The theories differ in the degree to which they specify the
content of the cognitions they identify. With the TPB, for
example, once the behavior of interest has been dened, it is
possible to generate questionnaire items for intention and for
the direct measures of attitude, subjective norm, and perceived
behavioral control. However, in order to generate items for the
underlying beliefs, it is recommended that researchers gather
information on salient beliefs from members of the target
population. These constructs remain content-free until such
information is obtained.
Theories of health behavior are often criticized for offering
an unrealistically rational account of how people form intentions and make decisions. However, the theories do not imply
that individuals always deliberate carefully and always make
optimal decisions. People may not be aware of all the options
available to them and of all the consequences that may follow
from their actions. They may hold incorrect beliefs about the
outcomes. They may make rapid decisions based on a few
salient considerations. Having made a considered decision
(e.g., to go jogging every Sunday morning), they do not
necessarily have to weigh up the pros and cons again unless
circumstances change; they may simply retrieve their previously
formed intention from long-term memory and act on it. Thus,
theories of health behavior imply a more limited rationality
than is sometimes suggested by their critics.
Theories of health behavior, particularly continuum theories, are also sometimes criticized for being static. This criticism
is unfounded: the theories summarize dynamic causal
processes. In SCT, for example, changes in self-efcacy and
outcome expectations are assumed to produce changes in
goals which in turn lead to changes in behavior. Theories of
health behavior should specify the time lags involved in
these causal processes but most of them do not. However, it
is often assumed implicitly that effects on intention are
almost instantaneous whereas effects on behavior may be
delayed.

Concluding Comments
There is a plethora of theories of health behavior and new
theories are continually being developed. Although this can
be interpreted as a sign of a eld rich in conceptual and
theoretical development, it makes it increasingly difcult
to accumulate research ndings into a coherent body of
knowledge. The eld would benet from clearer denition
of concepts, greater standardization of measures, more tests of
convergent and discriminant validity, greater concentration
on a small number of theories, and more empirical comparisons of theories. The vast majority of empirical studies use
nonexperimental between-individuals designs. Obtaining
repeated measures on the same individuals would allow

models to be tested at the individual level. Experimental

manipulation of constructs, as has been done in many
studies of PMT, would provide stronger evidence of causal
effects (Sutton, 2002).

See also: Control Beliefs: Health Perspectives; Health

Behaviors, Assessment of; Health Behaviors; Health
Psychology; Health Risk Appraisal and Optimistic Bias; Health
Risk Perception; Illness Behavior and Care-Seeking; Patient
Adherence to Health Care Regimens; Self-Efcacy and Health.

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