Rehabilitation Psychology 2011 American Psychological Association

2011, Vol. 56, No. 3, 161170 0090-5550/11/$12.00 DOI: 10.1037/a0024509

Mechanisms of Health Behavior Change in Persons With Chronic Illness

or Disability: The Health Action Process Approach (HAPA)
Ralf Schwarzer Sonia Lippke
Freie Universitat Berlin Jacobs University Bremen

Aleksandra Luszczynska
University of Colorado and Warsaw School of Social Sciences & Humanities

Objective: The present article presents an overview of theoretical constructs and mechanisms of health
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

behavior change that have been found useful in research on people with chronic illness and disability. A
This document is copyrighted by the American Psychological Association or one of its allied publishers.

self-regulation framework (Health Action Process Approach) serves as a backdrop, making a distinction
between goal setting and goal pursuit. Risk perception, outcome expectancies, and task self-efficacy are seen
as predisposing factors in the goal-setting (motivational) phase, whereas planning, action control, and
maintenance/recovery self-efficacy are regarded as being influential in the subsequent goal-pursuit (volitional)
phase. The first phase leads to forming an intention, and the second to actual behavior change. Such a mediator
model serves to explain social cognitive processes in health behavior change. By adding a second layer, a
moderator model is provided in which three stages are distinguished to segment the audience for tailored
interventions. Identifying persons as preintenders, intenders, or actors offers an opportunity to match theory-
based treatments to specific target groups. Numerous research and assessment examples, especially within the
physical activity domain, serve to illustrate the application of the model to rehabilitation settings and health
promotion for people with chronic illness or disability. Conclusions/Implications: The theoretical develop-
ments and research evidence for the self-regulation framework explain the cognitive mechanisms of behavior
change and adherence to treatment in the rehabilitation setting.

Keywords: rehabilitation, motivation, volition, self-efficacy, intention, risk perception

This article describes a health promotion model for persons with
chronic illness or disability. The Health Action Process Approach
(HAPA) has been found useful to describe, explain, and predict
changes in health behaviors in a variety of settings, in particular in
rehabilitation settings. Interventions need to be theory-guided to
allow for meaningful interpretations of empirical findings and to
draw valid conclusions. Recommendations for successful practice
need a theory base. It is therefore important for rehabilitation
psychologists to understand different theories and judge their
potential for diverse research questions. In the following section,
we will provide a brief introduction on lifestyle change in reha-
bilitation. Then we will describe various theoretical advances in
health behavior change.
This article was published Online First July 18, 2011.
Ralf Schwarzer, Department of Psychology, Freie Universitat Berlin,
Berlin, Germany; Sonia Lippke, Jacobs Center on Lifelong Learning and
Institutional Development, Jacobs University Bremen, Bremen, Germany;
Aleksandra Luszczynska, Trauma, Health, & Hazards Center, University
of Colorado and Warsaw School of Social Sciences & Humanities, War-
saw, Poland.
Correspondence concerning this article should be addressed to Ralf
Schwarzer, PhD, Department of Psychology, Freie Universitat Berlin,
Habelschwerdter Allee 45, 14195 Berlin, Germany. E-mail: ralf.schwarzer@
fu-berlin.de
Health Behavior Change in Rehabilitation
For people with chronic illness or disability, behavior change
can be an effective strategy to prevent further morbidity and
mortality. When people are enrolled in medical rehabilitation,
there is a good chance to help them learn how to improve their
health behaviors and maintain them after discharge. For example,
persons with Coronary Artery Disease (CAD) received the follow-
ing recommendations regarding their health behaviors to improve
their prognosis: (1) No smoking; (2) moderate to intensive phys-
ical activity, (3) moderate or no alcohol consumption; (4) healthy
body weight control; (5) limited intake of saturated fats and trans
fatty acids; (6) regular fish consumption; (7) sufficient amounts of
fruit and vegetables; (8) Sufficient fiber intake, for example from
grains, legumes, or nuts; (9) reduced salt intake (Iestra et al.,
2005). In a systematic review, Iestra et al. (2005) found for
all-cause mortality, that positive changes in all behaviors de-
creased the mortality risk. For example, physical activity in CAD
patients reduced the mortality risk by 25%. The authors also
compared their findings with the general population and found
comparable effects for four health behaviors.
The main challenge is to increase the patients motivation to
adhere to health behavior changes. Whether they adhere to an
intervention program has a substantial effect on health outcomes.
However, some programs fail to show evidence that they increase
the level of adherence (Cutrona et al., 2010; Dean, Walters, &
Hall, 2010; McLean, Burton, Bradley, & Littlewood, 2010). What

161
 162 SCHWARZER, LIPPKE, AND LUSZCZYNSKA
makes it more difficult to improve adherence are comorbidities
(e.g., depression, anxiety) and increased pain levels during exer-
cise, as well as health care-related factors, such as characteristics
of the health care providers and organizations. Moreover, patients
often face lower preexisting levels of physical activity, helpless-
ness, poor social support, and more perceived barriers to exercise
than the general population (McLean et al., 2010). Consequently,
more effective interventions to increase adherence are needed.
Theory- and evidence-based interventions that are tailored to psy-
chological constructs are more effective (Noar, Benac, & Harris,
2007).
Health self-regulation is mandatory, but it is very demanding for
someone with chronic illness and disability. Research on health
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self-regulation examines how change takes place, and why some
This document is copyrighted by the American Psychological Association or one of its allied publishers.
individuals change, whereas others do not. It identifies relevant
causal factors and their interplay in the change process. This leads
to theories that may be generalized to several health behaviors and
to several types of illness. For example, a theory could present
particular mechanisms that are valid for motivating orthopedic
patients to adopt and maintain physical exercise.
This article presents an overview of theoretical constructs and
frameworks that have been found useful in the context of behavior
change, in particular for individuals with chronic illness and dis-
ability. We will focus on empirical evidence in the context of
rehabilitation settings, confining the discussion to physical activity
as one of the main health behaviors, although the principles se-
lected also apply to other health behaviors.
Health Behavior Change: The Need for Theory
To explain, predict, and effectively improve the self-regulation
of individuals and to optimize treatment, theories of health behav-
ior change are needed (Dunn & Elliot, 2008). In general, such
theories are divided into continuum models and stage models. In
continuum models, people are positioned along a range that re-
flects the likelihood of action. Influential predictor variables are
identified and combined in one prediction equation. The goal of an
intervention is to move the person along this route toward action.
Health promotion, then, focuses on increasing all model-inherent
variables in all persons, without matching treatments to particular
audiences. The Theory of Planned Behavior (TPB; Ajzen, 1991) is
such a continuum model that is applied to rehabilitation settings
(Dixon, Johnston, Rowley, & Pollard, 2008; Eng & Martin Ginis,
2007; Galea & Bray, 2006; Latimer, Martin Ginis, & Arbour,
2006; Yardley & Donovan-Hall, 2007). Other continuum models
are the Social-Cognitive Theory (SCT; Bandura, 1986, 2004) and
the Protection Motivation Theory (PMT; Rogers, 1975).
To overcome the practical limitations of continuum models, the
change process has been subdivided by a number of qualitative
stages. According to stage theories, health behavior change con-
sists of an ordered set of categories (or stages) into which people
can be classified. These categories reflect cognitive or behavioral
characteristics, such as the intention to perform a behavior. Fol-
lowing Weinstein, Rothman, and Sutton (1998), the common de-
fining properties of stage models are: (1) Individuals can be
classified into different stages by a valid assessment procedure; (2)
The stages are ordered, that is, Stage 3 is closer to the criterion
behavior than Stages 1 and 2, and Stage 1 is farthest from the
criterion behavior. A person in Stage 1 has to move first to Stage
2 before proceeding to Stage 3 and finally adopting the criterion
behavior. Finally, (3) individuals in the same stage are more
similar than those in different stages; that is, they face the same
barriers, but these barriers are different from those in other stages.
The main purpose of applying stage models lies in the identifica-
tion of relatively homogeneous target groups for interventions and
the design of stage-matched treatments. The most popular stage
theory of health behavior change is the Transtheoretical Model
(TTM; J. O. Prochaska & DiClemente, 1983) that proposes five
stages of change. It has also been applied to rehabilitation settings
(e.g., Gorczynski, Faulkner, Greening, & Cohn, 2010).
Both continuum models and stage models have their advantages
and disadvantages. Continuum models have been found useful for
explanation and prediction, whereas stage models are often pre-
ferred to guide interventions. For health promotion, the continuum
models are often too general because all variables involved in such
a model need to be addressed in interventions, without considering
the special needs of particular subgroups of participants. However,
it is possible to integrate both approaches when researchers use a
continuum model as a theoretical template and, when it comes to
interventions, subdivide the audience into stage groups to allow for
stage-matched treatments.
Mechanisms of Change: Mediation and Prediction
The HAPA (Schwarzer, 2008) has two layers: a continuum layer
and a stage layer. We now describe this model in more detail. The
traditional continuum models have been criticized mainly because
of the so-called intention-behavior gap (referring to the frequent
failure of intention to predict behavior). A model that explicitly
includes postintentional factors to overcome this gap is the HAPA.
The model suggests a distinction between (1) preintentional mo-
tivation processes that lead to a behavioral intention, and (2)
postintentional volition processes that lead to the actual health
behavior. Within the two phases, different patterns of social
cognitive predictors may emerge (see Figure 1). In the initial
motivation phase (1), a person develops an intention to act. In this
phase, risk perception is seen as a distal antecedent (e.g., I am at
risk for cardiovascular disease). Risk perception in itself is insuf-
ficient to enable a person to form an intention. Rather, it sets the
Figure 1. The HAPA (Schwarzer, 2008).
 SPECIAL SECTION: HEALTH BEHAVIOR CHANGE
stage for a contemplation process and further elaboration of
thoughts about consequences and competencies. Similarly, posi-
tive outcome expectancies (e.g., If I exercise five times per week,
I will reduce my cardiovascular risk) are chiefly seen as being
important in the motivation phase, when a person balances the pros
and cons of certain behavioral outcomes. Further, one needs to
believe in ones capability to perform a desired action (perceived
self-efficacy; e.g., I am capable of adhering to my exercise sched-
ule in spite of the temptation to watch TV). Perceived self-
efficacy operates in concert with positive outcome expectancies,
both of which contribute substantially to forming an intention.
Both beliefs are needed for forming intentions to adopt difficult
behaviors, such as regular physical exercise. After forming an
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intention, the volitional phase (2) is entered.
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When a person is inclined to adopt a particular health behavior,
the good intention has to be transformed into detailed instruc-
tions on how to perform the desired action. Once an action has
been initiated, it has to be maintained. This is not achieved through
a single act of will, but involves self-regulatory skills and strate-
gies. Thus, the postintentional phase should be further broken
down into more proximal factors, such as planning, action control,
social support, and recovery self-efficacy. Most other social cog-
nition models do not explicitly address postintentional factors.
Social support is one factor reflecting the barriers and resources
part of the HAPA model: Support represents a resource, and the
lack of it can be a barrier to adopt or maintain health behaviors.
Instrumental, emotional, and informational social support can en-
able the adoption and continuation of behaviors. This was found in
studies with chronically ill people, for instance diabetics (Plot-
nikoff, Lippke, Courneya, Birkett, & Sigal, 2008). It has also been
found in a sample of multimorbid older adults that exercising
together with a partner has a beneficial effect on adherence (Gel-
lert, Ziegelmann, Warner, & Schwarzer, in press).
Including planning and self-efficacy as volitional mediators
renders the HAPA into an implicit stage model because it implies
the existence of at least a motivational and a volitional phase. The
purpose of such a model is twofold: It allows a better prediction of
behavior, and it reflects the assumed causal mechanism of behavior
change. Research that is based on this continuum layer of the
model, therefore, uses path-analytic methods (e.g., Lippke, Ziegel-
mann, & Schwarzer, 2005; Luszczynska & Schwarzer, 2003;
Renner et al., 2008; Schwarzer et al., 2007; Ziegelmann, Luszc-
zynska, Lippke, & Schwarzer, 2007).
Designing Stage-Matched Interventions:
Preintenders, Intenders, Actors
When it comes to the design of interventions, one can consider
turning the implicit stage model into an explicit one. This is done
by identifying individuals who are located either in the motiva-
tional stage or in the volitional stage. Then, each group receives a
specific treatment that is tailored to this group. Moreover, it is
useful and theoretically meaningful to subdivide the volitional
group further into those persons who perform and those who only
intend to perform. In the postintentional-preactional stage, indi-
viduals are labeled intenders, and in the actional stage actors. Coping planning includes the anticipation of barriers and the
Thus, a suitable subdivision within the health behavior change
process yields three groups: preintenders, intenders, and actors.
163
The term stage in this context was chosen to allude to the
stage theories, but not in the strict definition that includes irrevers-
ibility and invariance. The terms phase or mindset may be
equally suitable for this distinction. The basic idea is that individ-
uals pass through different mindsets on their way to behavior
change. Thus, interventions may be most efficient when tailored to
these particular mindsets. For example, preintenders are supposed
to benefit from confrontation with outcome expectancies and some
level of risk communication. They need to learn that the new
behavior (e.g., becoming physically active) has positive outcomes
(e.g., well-being, weight loss, fun) as opposed to the negative
outcomes that accompany the current (sedentary) behavior (such
as developing an illness or being unattractive).
In contrast, intenders should not benefit much from health
messages in the form of outcome expectancies because, after
setting a goal, they have already moved beyond this mindset.
Rather, they should benefit from planning to translate their inten-
tions into action. Finally, actors should be prepared for particular
high-risk situations in which lapses are imminent. Interventions
should help them if they desire to change something in their
routine (e.g., adopting or altering a behavior).
A Set of Principles
The HAPA is designed as an open architecture that is based on
principles rather than on specific testable assumptions. It was
developed in 1988 (Schwarzer, 1992) as an attempt to integrate the
model of action phases (Heckhausen & Gollwitzer, 1987) with
social cognitive theory (Bandura, 1986). It has five major princi-
ples that make it distinct from other models and that help to apply
the HAPA to research and interventions.
Principle 1: Motivation and volition. The first principle
suggests that one should divide the health behavior change process
into two phases. There is a switch of mindsets when people move
from deliberation to action. First is the motivation phase in which
people develop their intentions. Afterward, they enter the volition
phase.
Principle 2: Two volitional phases. In the volition phase,
there are two groups of people: those who have not yet translated
their intentions into action, and those who have. There are inactive
as well as active persons in this phase. In other words, in the
volitional phase one finds intenders as well as actors who are
characterized by different psychological states. Thus, in addition to
health behavior change as a continuous process, one can also
create three categories of people with different mindsets, depend-
ing on their current location within the course of health behavior
change: preintenders, intenders, and actors.
Principle 3: Postintentional planning. Intenders who are in
the volitional preactional stage are motivated to change, but do not
act because they might lack the right skills to translate their
intention into action. Planning is a key strategy at this point. It
serves as an operative mediator between intentions and behavior.
Principle 4: Two kinds of mental simulation. Planning can
be divided into action planning and coping planning. Action plan-
ning pertains to the when, where, and how of intended action.
design of alternative actions that help to attain ones goal despite
the impediments.
 164 SCHWARZER, LIPPKE, AND LUSZCZYNSKA

Principle 5: Phase-specific self-efficacy. Perceived self-ef-
ficacy is required throughout the entire process. However, the
nature of self-efficacy differs from phase to phase. This is because
there are different challenges as people progress from one phase to
the next. Goal setting, planning, initiative, action, and maintenance
all pose challenges that are not of the same nature. Therefore, one
should distinguish between preactional self-efficacy, coping self-
efficacy, and recovery self-efficacy. Sometimes the terms task
self-efficacy instead of preaction self-efficacy, and maintenance
self-efficacy instead of coping and recovery self-efficacy are pre-
ferred.
In summary, the HAPA has two layers: a continuum layer and a
phase (or stage) layer. Depending on the research question, one might
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eter or accelerometer (tracking steps or movements), a pill-coun-
ter, or direct observation of behaviors (attendance rates, observing
which products are bought or used for cooking, etc.). Although
objective measures are less likely to be biased, they are more
demanding to gather. As all social cognitive variables are mea-
sured subjectively, the scale correspondence is higher when be-
havior is also measured subjectively by self-report (Courneya,
1994). Most often, data are collected with questionnaires or in
personal interviews. Other subjective measures, such as diary logs,
might be more valid and reliable in comparison to typical ques-
tionnaires or interviews. However, data are often missing because
of noncompliance. A questionnaire regarding physical activity that
has been validated with physiological and anthropometric mea-

choose one or the other. HAPA is designed as a sequence of two sures (i.e., VO2 max and body fat) is the Godin Leisure-Time
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continuous self-regulatory processes, a goal-setting phase (motiva- Exercise Questionnaire (GLTEQ; Godin & Shephard, 1985), or its
tion) and a goal-pursuit phase (volition). The second phase is subdi- modified and adapted versions (Lippke, Fleig, Pomp, & Schwar-
vided into a preaction phase and an action phase. One can superim- zer, 2010; Plotnikoff et al., 2007).
pose these three phases on the continuum model as a second layer and
regard phase as a moderator.
Intention
This two-layer architecture allows to switch between the contin-
uum model and the stage model, depending on the given research
Intention to perform a behavior should be assessed the same way as
question. The stage layer is useful for designing stage-matched inter-
assessing behavior itself. For physical activity, one could pose the
ventions. For preintenders, one needs risk and resource communica-
following three items: I intend to perform the following activities at
tion, for example by addressing the pros and cons of a critical
least three [2] days per week for 40 [20] min . . . (1) . . . strenuous
behavior. For intenders, planning treatments are helpful to support
(heartbeats rapidly, sweating) physical activities; (2) . . . moderate
those who lack the necessary skills to translate their intentions into
(not exhausting, light perspiration) physical activities; and (3) . . .
behavior. Furthermore, for actors, one needs to stabilize their newly
mild (minimal effort, no perspiration) physical activity. Answers can
adopted health behaviors by relapse prevention strategies.
be entered on a six-point scale ranging from not at all true (1) to
The HAPA allows both the researcher and the practitioner to make
absolutely true (6). Two different scales may be aggregated corre-
a number of choices. Although it was initially inspired by distinguish-
sponding to the activity measurement: (1) Intention to Perform Stren-
ing between a motivational and a volitional stage, and later expanded
uous and Moderate Activities (the correlation of the two items is
to the distinction between preintenders, intenders, and actors, one
typically rather low, as the two items have desirable discriminant
need not necessarily group individuals according to such stages. If the
validity), and (2) Intention to Engage in Strenuous, Moderate, and
purpose is to predict behavior change, one would specify a mediator
Mild Activities.
model that includes postintentional constructs (such as planning and
Alternatively, intention can also be assessed with an ordinal rating
volitional self-efficacy) as proximal predictors of performance
scale in the same way that four domains of behavior are measured: (1)
(Scholz, Nagy, Ghner, Luszczynska, & Kliegel, 2009).
physiotherapeutic exercises (e.g., back training), (2) fitness activities
For stage-tailored interventions, however, usually three stage
(e.g., using an exercise bike), (3) resistance training (training muscle
groups would be established. This does not exclude the possibility
strength, e.g., on machines), (4) physical activity while commuting
of generating more than three stages. For example, for some
(e.g., going by bicycle or walking for longer distances). Intentions
research questions, one might subdivide the preintenders into
should also refer to exhausting activity and physical activity outside of
precontemplators and contemplators, according to the TTM (J. O.
work. Study participants can indicate the intended frequency and
Prochaska & DiClemente, 1993). Or one might opt for a distinc-
duration by ticking one of the following options: not at all (1), less
tion between preintenders, who are either (1) unaware of an issue,
than once per week for 40 [20] min (2), at least once per week for 40
(2) aware but unengaged, or (3) still deciding (Weinstein, Lyon,
[20] min (3), at least three [1] times per week for 40 [20] min (4), and
Sandman, & Cuite, 1998). Thus, HAPA is not a puristic stage
five times per week for 40 [20] min or more (5). Answers can be
model, but a versatile theoretical framework that allows for a
categorized in such a way that a dichotomous variable results, namely
variety of approaches.
whether cardiac [orthopedic] patients perform at least the recom-
mended activity three [2] times per week for 40 [20] min (1) or not
Measurement of Theory-Implied Constructs
(0).
The following section provides general assessment rules, citing
examples from the physical activity domain that can easily be Planning
adapted to other behaviors.
Action Planning can be assessed with items addressing the when,
Behavior where, and how of the activity. The items in the rehabilitation study
by Lippke, Fleig et al. (2010) were worded: For the month after the
Behavior can be assessed either subjectively or objectively: rehabilitation, I have already planned . . . (1) . . . which physical
Objective measures could be based on a device, such as a pedom- activity I will perform (e.g., walking), (2) . . . where I will be
 SPECIAL SECTION: HEALTH BEHAVIOR CHANGE
physically active (e.g., in the park), (3) . . . on which days of the
week I will be physically active, and (4) . . . for how long I will be
physically active. Coping planning, on the other hand, can be mea-
sured with the item stem I have made a detailed plan regarding . . .
and the items (1) . . . what to do if something interferes with my
plans, (2) . . . how to cope with possible setbacks, (3) . . . what to
do in difficult situations in order to act according to my intentions,
(4) . . . which good opportunities for action to take, and (5) . . .
when I have to pay extra attention to prevent lapses. In a study with
cardiac patients, the items proved high measurement qualities
(Sniehotta, Schwarzer, Scholz, & Schuz, 2005).
Action Control
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While planning is a prospective strategy, that is, behavioral
plans are made before the situation is encountered, action control
is a concurrent self-regulatory strategy, where the ongoing behav-
ior is continuously evaluated with regard to a behavioral standard.
Action control can be assessed with a 6-item scale comprising
three facets of the action control process (Sniehotta et al., 2005):
self-monitoring (Items a and b), awareness of standards (Items c
and d), and self-regulatory effort (Items e and f): (1) I consistently
monitored myself whether I exercised frequently enough, (2) I
consistently monitored when, where, and how long I exercise, (3)
I have always been aware of my prescribed training program, (4)
I often had my exercise intention on my mind, (5) I really tried
hard to exercise regularly, and (6) I took care to train as much as
I indented to.
Self-Efficacy
Perceived motivational and volitional self-efficacy can be
composed of items such as the following. Motivational self-
efficacy refers to the goal-setting phase and can be measured
with the stem I am certain . . . followed by the two items . . .
that I can be physically active on a regular basis, even if I have
to mobilize myself, and . . . that I can be physically active on
a regular basis, even if it is difficult (correlation of the two
items r .79; Lippke, Fleig et al., 2010). Volitional self-
efficacy refers to the goal-pursuit phase. It can be subdivided
into maintenance self-efficacy and recovery self-efficacy. Main-
tenance self-efficacy has been measured with the stem I am
capable of continuous physical exercise on a regular basis . . .
followed by the two items . . . even if it takes some time until
it becomes routine, and . . . even if I need several tries until
I am successful (correlation of the two items r .82; Lippke,
Fleig et al., 2010). Items on recovery self-efficacy can be
worded I am confident that I can resume a physically active
lifestyle, even if I have relapsed several times, I am confident
that I am able to resume my regular exercises after failures to
pull myself together, or I am confident that I can resume my
physical activity, even when feeling weak after an illness. In
three rehabilitation studies, the scales consisting of three to six
items exhibited high reliability and validity in orthopedic and
cardiac rehabilitation samples (Schwarzer, Luszczynska,
Ziegelmann, Scholz, & Lippke, 2008).
165
Risk Perception
Risk perception can be measured by items such as: How high
do you rate the likelihood that you will ever get one of the
following diseases, or that you will relapse to them? (a) cardio-
vascular disease (e.g., heart attack, stroke), (b) diseases of the
musculoskeletal system (e.g., osteoarthritis, herniated vertebral
disk)?Any other health risk can be added, especially if relevant to
the individual sample included in the study (Fleig, Lippke, Pomp,
& Schwarzer, 2011; Schwarzer et al., 2007).
Outcome Expectancies
Positive outcome expectancies (pros) and negative outcome
expectancies (cons) can be assessed with the stem If I engage in
physical activity at least three [two] times per week for 40 [20] min
. . . plus the following items. Pros are measured with five items,
for example, . . . then I feel better afterward, . . . then I meet
friendly people, or . . . then my elasticity would increase. Cons
were assessed by five items such as . . . then every time would
cost me a lot of money, . . . then I would be financially burned,
or . . . then I would have to invest a lot (e.g., into the organiza-
tion).
Social Support
Received social support can be from different sources, such as
family and friends. In a rehabilitation sample, social support re-
garding physical activity was assessed with 10 items: My family/
friends . . . (1) . . . have encouraged me to perform my planned
activities, (2) . . . have reminded me to engage in physical activity,
(3) . . . have helped me to organize my physical activity, (4) . . .
have managed the household for me so that I could engage in
physical activity, (5) . . . have engaged in physical activity with
me (Jackson, Lippke, & Ziegelmann, 2010).
Stage Algorithms
The assessment of stages should be measured without using a
specific time frame, in accordance with Sutton (2000). Study
participants are asked Please think about the month before the
rehabilitation started: Did you engage in physical activity at least
3 [2] days per week for 40 [20] min or more? Additionally, the
study participants read the instruction If you have had an accident
or some health conditions restraining you from performing your
typical activities, please think about the month before that inci-
dent. Possible answers were yes or no. Another question was:
For the month after the rehabilitation: Do you intend to perform
physical activities 3 [2] times per week for 40 [20] min or more?
with the answers yes or no. Again, for the stage items, the follow-
ing information was explicitly provided: When thinking about
physical activities, please consider: (1) You are performing the
activities during your recreational time or while commuting. (2)
You are not achieving them during your working time. (3) You are
doing them because you intend to do physical activities. (4) The
activities have to be at least somewhat exhausting. Participants
are asked to answer with either yes or no. Those individuals who
indicate that they were active before the rehabilitation are then
 166 SCHWARZER, LIPPKE, AND LUSZCZYNSKA
categorized as Actors. Those who answer that they were not active,
but intended to perform the recommended goal activity, are called
Intenders. And those answering that they were not active and did
not intend to perform the recommended goal activities are assumed
to be Preintenders. An alternative stage algorithm can be similar to
the one presented in Table 1, which was used in the study by
Lippke et al. (in press).
Persons indicating 1 and 2 on the list above would be catego-
rized as Preintenders, those answering 3 as Intenders, and 4 and 5
as Actors. The algorithm was designed as a rating scale, with
(precontemplating) preintenders on the very left and (maintaining)
actors on the very right, for two reasons: (1) This format is more
similar to the assessment of other social cognitive variables, such
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
as intention and planning, and, by this, measurement correspon-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
dence is achieved. (2) The format is less space consuming (Lippke,
Ziegelmann, Schwarzer, & Velicer, 2009). The algorithm has been
successfully adapted to other behaviors that are relevant for indi-
viduals with chronic illness: In a study by Lippke et al. (in press),
the adapted algorithm was successfully used to assess the stages
regarding foot care, nutrition, smoking, alcohol, and healthy drink-
ing in two samples of persons who had diabetes. The measurement
qualities of a stage algorithm cannot be evaluated in terms of
Cronbachs alpha, but in regard to Sensitivity (agreement between
classification as being active by the stage algorithm, and perform-
ing the goal activity according to a different measure) and Speci-
ficity (agreement between classification as being nonactive, and the
nonperformance of the goal activity). The algorithm presented in
Table 1 (Lippke, Ziegelmann et al., 2009) had high sensitivity
(70%) and specificity (80%) in comparison to previous studies
(Nigg, 2005; Plotnikoff et al., 2007). The algorithm described
above, specifically designed for rehabilitation patients, has dem-
onstrated very high sensitivity, but comparably lower specificity.
So far, it remains open whether this depends on the stage algorithm
or the rehabilitation contexts.
Empirical Evidence
How Does the Model Work? Mediating Effects
Empirical evidence on HAPA assumptions range from single
case studies in therapy and counseling (Fiore, 2007) to large-scale
investigations in rehabilitation settings (e.g., Schwarzer et al.,
2008). Experimental manipulation (Lippke, Ziegelmann, &
Schwarzer, 2004; Luszczynska, Gregajtys, & Abraham, 2007;
Sniehotta, Scholz, & Schwarzer, 2006; Scholz, Knoll, Sniehotta, &
Schwarzer, 2006; Ziegelmann, Lippke, & Schwarzer, 2006) and
Table 1
Stage Assessment
Please think about the month before the rehabilitation started. Did you engage in physical activity at least 3 days per week for 40 min or more?
Please choose the statement that describes you best.
No, but I am
No, and I do not considering No, but I seriously
intend to start it intend to start
Note. This stage assessment can be adapted to any other goal behavior.
experimental causal-chain-studies (Reuter, Ziegelmann, Lippke, &
Schwarzer, 2009) provide further evidence. In addition, meta-
analyses included aspects of the HAPA (e.g., planning: Gollwitzer
& Sheeran, 2006; self-efficacy, outcome expectancies and risk
perception: Milne, Sheeran, & Orbell, 2000; behavior change
techniques: Michie, Abraham, Whittington, McAteer, & Gupta,
2009; stages, self-efficacy, social support, intention, risk percep-
tion: Noar et al., 2007). In the following, findings are presented on
the five HAPA principles that may have implications for further
research and theory.
Principle 1: Motivation and volition. The two phases of
behavior change were found to be empirically different, for in-
stance in studies by Lippke et al. (2004, 2005) and Lippke,
Schwarzer et al. (2010). In an orthopedic sample, the three HAPA
stages were assessed, and it was investigated whether qualitatively
different stages of health behavior change and stage-specific mind-
sets would be evident. Significant differences between motiva-
tional and volitional individuals were supported by paired com-
parisons and nonlinear trends (Lippke et al., 2005). In particular,
preintenders reported significantly less self-efficacy, intention, and
planning than intenders. In addition, in longitudinal stage-specific
prediction patterns, it was important to consider stages: Preintend-
ers with high risk perception were much more likely to develop
higher intentions over time than preintenders with low risk per-
ception. However, this effect of risk perception was not found in
intenders (Lippke et al., 2005).
In an experimental trial with orthopedic patients, a volitional
intervention proved to be matched only to volitional study partic-
ipants. Accordingly, planning was not beneficial for persons in the
motivational stages (Lippke et al., 2004). This was replicated in an
Internet study that also demonstrated the specific mechanisms: The
planning intervention facilitated behavior change by means of
intention and planning, but only in the case of intenders, not in
preintenders (Lippke, Schwarzer et al., 2010). Thus, preintenders
first need to develop an intention. Accomplishing this depends
mainly on a motivational intervention that targets goal setting.
Principle 2: Two volitional phases, three stages. The study
outlined above with orthopedic participants (Lippke et al., 2005)
investigated the third HAPA stage in addition. This action stage
was found to be significantly different from the other ones. When
exploring the effects of a planning intervention on actors, they
seemed to benefit, but not as much as those volitional participants
who had not been active before (i.e., intenders). Thus, it is imper-
ative to distinguish the intention stage from the action stage.
Intenders benefit mainly from planning when adopting a new
behavior. On the contrary, actors rather need relapse prevention
Yes, but only for a brief Yes, and for a long
period of time period of time
 SPECIAL SECTION: HEALTH BEHAVIOR CHANGE
that helps them to recover from setbacks, and, in case of a relapse,
they need strategies for coping with them effectively.
Principle 3: Postintentional processes. As described above,
planning was mainly beneficial in the postintentional phase, that is,
for the volitional individuals (Lippke, Schwarzer et al., 2010). As
such, planning serves as an operative mediator between intentions
and behavior. This was also shown in structural equation analyses
(e.g., Schwarzer et al., 2008, 2007). Empirical tests on whether
planning mediates the relation between intention and behavior
have confirmed this assumption in the general population (Scholz,
Schuz, Ziegelmann, Lippke, & Schwarzer, 2008) as well as in
rehabilitation (Reuter et al., 2009). That planning mediates be-
tween intention and behavior was also demonstrated in orthopedic
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
outpatients (Lippke et al., 2005).
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Principle 4: Action planning and coping planning. Com-
plex planning interventions promote sustained behavior change
after rehabilitation. Planning can be subdivided into action plan-
ning and coping planning, as has been evaluated in different
samples of persons with chronic illness and disability. Sniehotta,
Schwarzer et al. (2005) examined the factorial structure of the two
planning aspects. When addressing action planning and coping
planning separately in interventions, different effects were found:
Those persons in cardiac rehabilitation became more active when
both kinds of planning were addressed in the intervention, as
opposed to a mere action planning intervention. In another re-
search sample, at 6 months after cardiac rehabilitation, participants
involved in a planning intervention consumed 13% less saturated
fat than controls (Luszczynska, Scholz, & Sutton, 2007). In ortho-
pedic rehabilitation, a delayed effect of coping planning on behav-
ior demonstrated that coping planning seems to be of higher
importance for long-term maintenance: Whereas behavior adop-
tion 2 weeks after rehabilitation was only correlated with action
planning, coping planning came into play only 4 and 26 weeks
later (Ziegelmann et al., 2006). In another study, action planning
transpired to be the mediator between intention and coping plan-
ning, and coping planning mediated between action planning and
behavior. This was true for different age groups in rehabilitation
participants with orthopedic diagnoses (Ziegelmann & Lippke,
2007). The discriminant validity between action and coping plan-
ning has been confirmed in an experiment by Wiedemann, Lippke,
Reuter, and Schuz (2011).
Principle 5: Phase-specific self-efficacy. Various studies
proved that self-efficacy is required throughout the entire process
of behavior adoption (Luszczynska, Gregajtys, & Abraham, 2007)
and maintenance (e.g., Lippke et al., 2005). There is also evidence
from rehabilitation samples on the changing nature of self-efficacy
as people pass through different stages of change (Schwarzer et al.,
2008; Ziegelmann & Lippke, 2007).
In cardiac rehabilitation, three phase-specific kinds of self-
efficacy were distinguished. They demonstrated discriminant va-
lidity and were analyzed regarding their predictions of intentions
and behavior. Those individuals in the maintenance phase (actors
who remained actors) were more likely to perform physical activ-
ities if they reported more maintenance self-efficacy than all oth-
ers. Study participants resuming their physical exercise after a
health-related break were more successful if they had higher
recovery self-efficacy in comparison to those who were active
without a break (Scholz, Sniehotta, & Schwarzer, 2005). Individ-
uals in cardiac rehabilitation who have strong coping self-efficacy
167
are likely to maintain the recommended rehabilitation exercise at
follow-up, whereas this type of self-efficacy does not help people
who have relapsed. Those who had a setback in adhering to
recommended exercise, but harbor strong recovery self-efficacy
beliefs, were more likely to regain control after a relapse (Luszc-
zynska & Sutton, 2006).
For Whom Does the Model Work? Moderator Effects
The previous discussion about mediation addressed the ques-
tion: How does it work? To further understand the mechanisms of
health behavior change, we also have to ask: For whom does it
work? Thus, we need to identify mediator effects as well as
moderator effects. The HAPA, for example, as a parsimonious
mediator model, includes stage as a moderator. That indicates that
a prediction model within one stage group operates in a different
way than a prediction model within an adjacent stage group. This
is similar to the assumption that one set of social cognitive vari-
ables can move people from Stage a to b, whereas a different set
of variables can move people from Stage b to c.
Although action planning has been found to mediate the inten-
tion-behavior relation (Gollwitzer & Sheeran, 2006), some studies
have failed to find such mediation effects (Norman & Conner,
2005). This suggests that the relationships between intentions,
planning, and behavior might also depend on other factors. For
example, the degree to which planning mediates between inten-
tions and behavior has been found to be higher in older than in
younger people (Renner, Spivak, Kwon, & Schwarzer, 2007;
Scholz, Sniehotta, Burkert, & Schwarzer, 2007). This represents a
case of moderated mediation. Perceived self-efficacy is one poten-
tial moderator for the degree to which planning has an effect on
subsequent behaviors. It is expected to moderate the planning-
behavior relation because people harboring self-doubts might fail
to act upon their plans. For persons with a high level of self-
efficacy, planning might be more likely to facilitate goal achieve-
ment. Self-efficacious people feel more confident about translating
their plans into actual behavior. In other words, whether planning
interventions (independent variable) actually affect behavior (de-
pendent variable) might depend on the individuals level of self-
efficacy (moderator). In a study on physical activity, longitudinal
data from an online survey were used to examine similar interre-
lationships (Lippke, Wiedemann, Ziegelmann, Reuter, & Schwar-
zer, 2009). Only those persons who had a sufficiently high level of
exercise self-efficacy acted upon their plans. Conversely, partici-
pants who were harboring self-doubts failed to act upon their plans
(see also Gutierrez-Dona, Lippke, Renner, Kwon, & Schwarzer,
2009; Richert et al., 2010).
Mediator models work well in some groups, but not in others.
By comparing men and women, younger and older people, and
those from different cultures, we identify relevant moderators
(Renner et al., 2007; Ziegelmann et al., 2006). When a mediator
model has strong interrelations within one category of participants,
but weak associations within a different category, then this is a
case of moderated mediation. The amount to which the mediator
translates the effect of the independent variable on the dependent
variable depends on the levels of a moderator variable.
Such moderators can be age, chronic illness, disability, and so
forth, but also psychological variables that are closely related to
the constructs used in health behavior models. Temporal stability
 168 SCHWARZER, LIPPKE, AND LUSZCZYNSKA

of intention, for example, may be a moderator (Conner, 2008). Table 2

Older age and stronger baseline self-efficacy levels may moderate Intervention Matrix for HAPA-Based Stage-Specific Treatments
the effects of self-efficacy interventions among individuals with Stage group
degenerative spine diseases enrolled in a rehabilitation program
Preintender Intender Actor
(Luszczynska, Gregajtys, & Abraham, 2007). Moderated media-
tion is also possible, with psychosocial variables, such as intention Motivational constructs
or planning. For example, the intention behavior link is mediated Self-efficacy (motivational) x
by planning, and this mediator effect can be moderated by level of Risk perception x
Outcome expectancies x
intention (Wiedemann, Schuz, Sniehotta, Scholz, & Schwarzer, Goal setting x
2009). Here we have a special case in which the independent Volitional constructs
variable (intention) of a mediator model serves the function of a Action planning x x
moderator in addition. In other words, only in highly motivated Coping planning x x
persons does the intention operate via planning on the improve- Social support x x
Self-efficacy (maintenance) x
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

ment of adherence, whereas in poorly motivated persons no such Self-efficacy (recovery) x

This document is copyrighted by the American Psychological Association or one of its allied publishers.

mediator effect is visible. Action control x

The best way to demonstrate the mechanisms of health behavior
change is the experimental manipulation of those variables that are
supposed to produce behaviors or to move people from one stage
ventions specifically targeting intenders or maintainers are prom-
to another (Michie, Rothman, & Sheeran, 2007; Reuter, Ziegel-
ising (Reuter et al., 2008). Such programs need to be further
mann, Wiedemann, & Lippke, 2008). Various experimental stud-
developed and tested in people with different chronic illnesses and
ies have shown that self-efficacy interventions do make a differ-
disabilities.
ence, which attests to the fact that self-efficacy is indeed an
The key characteristic of theory-based interventions such as one
operative construct that facilitates volitional processes, such as
based on HAPA is to first assess the needs of the recipients, for
effort and persistence (Luszczynska, Tryburcy, & Schwarzer,
example, their stage of change. Then, the stage-specific variables
2007). Self-efficacy beliefs, in turn, are mobilized by family sup-
are to be addressed. In an intervention with cardiac and orthopedic
port during rehabilitation (Luszczynska & Cieslak, 2009).
participants, the following contents were included (see Table 2).
The stage-specific evaluation of effects is imperative: If differ-
Outlook: Better Tailoring of Interventions for Persons ent stage-specific interventions are applied to different stages, it is
With Chronic Illness or Disability essential not only to search for changes in behavior or progression
from inactive to active stages, but also to look for stage transitions
between all stages. Alternatively, increases in the stage-specific
Based on their systematic review, McLean et al. (2010) con-
variables (such as goal setting or motivational self-efficacy in
clude that interventions may be most effective when they (1) have
preintenders) are relevant outcomes as well.
motivational-cognitive behavioral approaches (as theorized by the
People with chronic illness and disability have a higher likeli-
HAPA, improving motivational factors), (2) help patients to man-
hood of exhibiting multiple behavior risk factors, and they are at
age barriers (as theorized by the HAPA, improving volitional
risk for premature death compared to those with only one behav-
factors as coping planning and maintenance self-efficacy), and (3)
ioral risk factor or none. Furthermore, they also account for a
tackle issues related to health care providers and organizations.
disproportionate percentage of health care costs (J. J. Prochaska,
So far, the principles of the HAPA have proven to be convincing
Spring, & Nigg, 2008). Thus, it is important to understand not only
for the general population as well as for persons participating in
single behaviors (such as physical activity or smoking), but also
orthopedic or cardiac rehabilitation. However, we know much less
multiple health behavior mechanisms. Only if more is known
about the main differences between persons with various chronic
about multiple behavior mechanisms can we help people to adopt
illnesses and disabilities or their special needs compared to the
and maintain as many recommended health behaviors as possible
regular population. In studies investigating theories other than the
and, eventually, to stay healthy (Flay & Petraitis, 1994; Morabia &
SCT, TPB, PMT, and TTM, only few differences between various
Costanza, 2010). Furthermore, we need a more elaborated model-
chronic conditions and between individuals with and without di-
ing of multiple health behaviors to design effective treatments for
abetes were found (e.g., Plotnikoff et al., 2008, 2007). However, is
people with chronic illness or disability.
this also true for the HAPA? This warrants further study, as only
more empirical findings on such similarities and differences can
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Received September 10, 2010
Revision received January 27, 2011
Accepted May 28, 2011