Why do theories change

Explanation and change models I: Changes in attitude and behavior

Annette C. Seibt

Introduction and background

In retrospect, the development of health education and prevention towards health promotion and its evaluation research (quality assurance) has taken a clearly understandable path. The first models from the 1950s with the aim of Behavior changes generally too understand and to influence through interventions, related to a contextless individual (health belief model; attribution theory). The chronologically following models or theories also related to the influence of other people or specific information (theory of planned behavior; theory of protective motivation), and then the Way of life and its determinants, i.e. the social and socio-cultural environment and their interactive dynamics (Social-cognitive theory). These later models increasingly focused on predictions of health and disease behavior.

The terms theory and model used interchangeably, although they mean different things in epistemological terms and in common parlance. In the present context, a stricter distinction does not make sense, since the individual structures of thought were called either model or theory by their authors themselves - without differentiating definitions. This vagueness also applies to the use of the terms Constructs and Concepts to what the individual, more or less distinguishable elements of the thought structures are meant.

All the theories and models of health psychology presented here address the question of why people with their habits that are hazardous to health do not simply change their behavior on the basis of "correct, scientifically proven and proven information"? Which cognitive, emotional, behavior-hindering or motivating factors - possibly in combination with one another - play the decisive roles so that behavioral changes take place or not? The illumination of this "black box" is the original question of the presented here and many other theories. To this day there is no definitive explanation for this question, but many attempts to explain it.

Health Belief Model

The Health Belief Model was developed in the United States in the 1950s. The research question was whether regular conditions and repeatable "patterns" could be found to induce people to change their behavior. The reason was the low participation of the population in free tuberculosis vaccinations. The model is based on the assumption that people think rationally and want to avoid negative consequences of their behavior.

Constructs of the model are still used in health programs today, mostly in combination with other theoretical constructs (theory of protective motivation, social-cognitive process model of health behavior).

The original model consisted of four independent constructs or subjective perception concepts, the interaction of which results in the probability of health action (Fig. 1):

  1. Subjectively perceived susceptibility to illness, vulnerability or vulnerability: Only those who feel vulnerable to illness take preventive action or follow health advice.
  2. Severity of the disease or its consequences (perceived severity): Even if the vulnerability is high, the consequence can be acceptable (“I can then take medication”). Long-term and short-term consequences are weighed up (e.g. premature death in 30 years versus renunciation of pleasure today).
  3. Benefits or benefits: After a kind of cost-benefit analysis, people decide which approach they consider to be the most effective and effective.
  4. Barriers: Typical negative aspects are e.g. social or financial costs, side effects or inconveniences.

The subjective vulnerability (1) and the subjective severity (2) make up the energy and the motive for action and are called subjective threat designated. A positive balance of the advantages (3) against the barriers (4) shows the direction of action (Fig. 1).

Over the years, the model has been expanded to include three concepts:

  • caused by internal or external triggers Trigger for action (cue to action), such as a family illness, a conversation or a casual media spot;
  • the demographic, socio-psychological differentiation according to age, gender, ethnicity, socio-economic status etc .;
  • that as Self-efficacy belief defined concept borrowed from social-cognitive theory.

The model is used worldwide both to explain behavior and to develop intervention strategies.
In the following, the first researched application example from the USA is presented: Older people at risk had received a postcard from their family doctor with the request for a free flu vaccination in three different text versions:

  • Neutral ("Vaccination is possible with your family doctor"), or
  • In person ("As your general practitioner, I would like to ask you to come over for a vaccination") or
  • operationalized according to the health belief model ("People your age are particularly at risk this year ..

The risk of illness is greatly reduced by vaccination and the side effects are negligible ”). Compared to people in the first two groups, significantly more people took part in the flu vaccinations who had received a postcard operationalized according to the Health Belief model.

The limitations of the model became increasingly clear in the light of the development of health promotion: it can only be used for limited problems of prevention, because it focuses primarily on health behavior as an individual decision-making process and only takes into account social, economic and institutional environmental conditions on the margins (namely via the demographic construct and psycho-social). For example, for prostitutes, the pressure from clients to work without condoms, despite the perceived subjective STI threat, will result in no effective protective behavior if the customers and thus their income are lost as a result.

The model was the first scientific attempt to develop theory-guided strategies for population-related behavior change, and thus to give health authorities a general instrument to address their particularly vulnerable population groups.

Protection motivation theory

The Protection Motivation Theory was developed to understand the importance of fear appeals for health-related behavioral changes. This type of information content is based on creating fear in people in order to motivate them to behave differently. The original theory, by R.W. Rogers formulated in 1975, encompassed the three constructs perceived own vulnerability, the perceived severityborrowed from the Health Belief Model and the Expectation of effectiveness of action from (social-cognitive theory), which - in this context - means an effective protective motivation. The model later became the construct of the intention added from planned behavior theory; According to theory, intentions precede behavior and are considered to be the strongest predictor of behavior change. The concept of Protection motivation can be considered identical to that of the Intention to perform a new behavior, be considered.

Fear is understood to be a negative emotional reaction to which those affected have the opportunity to react through specific behavior. At best, the fear should be reduced by this behavior with the aim of repeating the new behavior independently.

The perception of health-related information in the form of fear appeals will influence the Threat assessment and on the Coping Assessment taken. The Threat assessment according to the model intrinsic and the extrinsic rewards out that can be modified by the assessment of the vulnerability and their Severity. The Coping Assessment is defined as an assessment of the possibilities for averting the threat and is made up of the constructs of Self-efficacyexpectation of opportunity (self efficacy) and the Expectation of effectiveness of action (also: consequence / result expectation, outcome expectations, defined as the anticipated consequences of behavior minus the so-called costs of action, such as overcoming and exertion (Fig. 2).

Studies on the effect of fear appeals, however, show that in addition to reactions desired from a public health perspective, "inappropriate" behavior such as dissuasion, hiding, refusal or aggression can result. It is also known that fear usually only has a short-term influence, and threats are perceived very differently by people or that people react differently to them.

In the public health sector, it is generally viewed as critical or unethical to deliberately cause uncertainty and threats. Research shows, however, that deliberate fear appeals for the purpose of health promotion are quite effective (and possibly acceptable?), if Immediately and at the same time coping options and alternatives are "included": e.g. if condoms are included as part of an information brochure on the subject of HIV infections. A current subject of investigation in protective motivation theory are warning signs on cigarette packets as examples of fear appeals. From May 2016, large images of attacked yellow teeth, cancer lungs and smoker's legs can also be seen on cigarette packets in Germany. Research results show that this deterrent strategy reduces the number of smokers, as the images trigger negative feelings about smoking. In Australia, atrocities of this kind can be seen all over the front and back of the packs, and the phone number for the anti-smoking support hotline is also printed in large letters.

Other topics were cancer prevention, sport and nutrition, smoking, HIV prevention, alcohol abuse, but also more extensive public health problems such as the use of pesticides, accident prevention by wearing bicycle helmets, protection of endangered animal species, prevention of child abuse, etc.

Planned Behavior Theory

The Planned Behavior Theory - too Induction theory or Theory of Rational Action called (Theory of Planned Behavior / Reasoned Action) - describes the relationship between beliefs, attitudes, intentions and behavior. The links between these constructs are used to derive predictions as to whether or not people will change their behavior. The starting point of the theory are the assumptions that a) behavior is subject to free human will and, b) people, weighing rational-psychological reasons, an intention or Behavioral intention form. According to theory, intentions are the most direct predictions of behavior change.

The theory was introduced by the Americans Fishbein and Ajzen in the mid-1960s. In the early 1990s she got the construct perceived behavior control (perceived behavioral control) added, which is defined as the degree of controllability and personal competence and is identical to the construct of Self-efficacy belief (self-efficacy) from social-cognitive theory.

Parallel to perceived behavior control - determined by the Belief in control and their estimated Strength - the behavioral intentions are influenced by two further factors (Fig. 3):

  • By your own attitude towards the behavior, which in turn is determined by the convictionthat this behavior can achieve the desired result and that this behavior is beneficial to health; as
  • By subjective norms than the belief that "other important people" expectations have, and the degree of importance of approval or disapproval from those caregivers.

The theory also takes social normative factors into account. The intention to act is therefore determined both by subjective attitudes and assessments as well as by social norms and the perception of external influences: People are very likely to carry out a desired behavior if they a) believe that this is good for their health (attitude), and if they b) experience pressure from the social environment to behave accordingly (social influence) and if they, c) have the power to make decisions and see themselves in a position to carry out the behavior.

The key to program success is therefore the identification of the factors that are most likely to be changed for the respective target group. For example, adolescents are often of the opinion that most classmates (already) have multiple sexual experiences. If they have not yet experienced a "first time", they feel they are in the minority and do not conform to the social norm. They do not feel "normal", think that they cannot have a say and have peer pressure to comply with the supposed norms. This can lead to rash and unwanted sexual encounters.

Theory-guided measures of the model target the three factors attitude, standard and Behavior control. They have been operationalized in a variety of ways for health programs - for example for behavior such as smoking, drinking alcohol, receiving medical treatment, using contraceptives and condoms, buckling up or wearing safety helmets, regularly exercising, breastfeeding, voting, buying goods or services, donating money, etc.

In addition to or in combination with social learning theory, the theory of planned behavior is now often used for prevention and health promotion programs. It is the basis of the social-cognitive process model of health behavior. The theory is useful in identifying all those factors that influence health-related behavior and helps to select intervention goals. Health promotion experts can be advised when planning the program both to record the target group's perception of a specific health topic and to identify and include the important people who influence them (mostly from the immediate social environment). It should be noted that this is also an individual-related, psychological theory. Structural or cultural elements are not explicitly taken into account or it is assumed that these have already been implicitly incorporated into the beliefs and their evaluation.

Attribution theory

Attributions are ascriptions, i.e. subjective explanations for the success or failure of one's own behavior, which lead to different expectations of success in the future. The theory postulates that people rationally explain a positive or negative result of their past behavior to themselves: they look for "reasons" which then influence what result they expect as a result of their future behavior. Various thought models with attributions that have been formulated since the middle of the 20th century were summarized by the American psychologist Bernard Weiner in the 1970s as a separate attribution theory. According to theory, explanations given by smokers who have relapsed, for example, about their "failure" are decisive for whether they will make further attempts to quit. Self-made explanations run within three dimensions:

  1. Location of causality: Lies the explanation for the result within or outside of your own person? A relapse to smoking can either be considered an internal weakness of its own or can be explained by external circumstances. A positive result is more likely to be attributed to the person, a negative result to the “situation”. "I am a self-determined person and can do it if I want" is an attribution that is ascribed to myself. On the other hand, a causality that is located as external peer pressure is: "My friends seduced me into smoking".
  2. Stability: Stable reasons for the result cannot be changed and are expected again the next time. Unstable reasons, on the other hand, could no longer exist or be different in a new attempt. For example, if a person writesattributes her success to her own abilities and emphasizes that “I stand by my resolutions” (stable), expectations of renewed success are greater than if she ascribes success to the unstable reason “happiness”. If the failure of one's own inability is attributed to “I always get weak in these situations”, this is a more stable attribution than “I had a bad day”. People with stable attributions for their own failure have lower expectations of success and consequently invest less energy in upcoming tasks.
  3. Controllability: The third dimension describes the degree of controllability of future results: "With more effort and preparation, I can do it next time" predicts behavioral success better than "I am overwhelmed with that, it is very difficult for me".

The theory is used to give people a Um-interpretation of counterproductive ascriptions, where their relevance for health promotion lies. The theory also suggests that when designing projects, the persons affected should be asked about their “layperson” statements (subjective health / everyday health concepts).

The theory is particularly important for relapse prevention. For people who smoke again, for example, the reasons given are reinterpreted in order to motivate them to try again. For this purpose, a stable and uncontrollable attribution for failure (“own character weakness”) is reinterpreted into an unstable and controllable attribution (“most people need several attempts before they succeed and learn in the process”). If more knowledge and new skills are acquired in the meantime, the expectation of success also increases, which increases the effort and makes the next success more likely (self-efficacy belief from social-cognitive theory).

Early attribution therapy interventions in Germany related, among other things, to changes in the attribution of causes in cardiac neurotics, people with anxiety about speech, type 1 and type 2 diabetics, obese people and smokers, e.g. Sometimes with preventive and health-promoting intentions. In the course of individual and group interventions, attempts were made to create a health-promoting attribution of personal controllability. For years, consideration has also been given to influencing health-impairing attributions and a lack of personal responsibility for health across the population through appropriate health communications.

Attribution theory has served as a guide to changing health attitudes and behavior,

  • for attempts to quit smoking
  • for weight control in overweight people,
  • to influence discriminatory attitudes and behavior towards HIV-infected or AIDS-sick people.

Social-cognitive theory

The social-cognitive theory (SKT), formerly known as social learning theory, is the result of decades of efforts in psychology to explain principles of human behavior in a generally applicable manner. The theory describes how people learn, especially like them learn to behave. The SKT deals with the determinants of behavior and suggests programmatic methods of change.

The SKT emphasizes the interaction between the individual and the environment. Learning and doing is called the triad of the three determinants person, behavior and environment viewed that mutually condition and influence each other:

  1. Cognitive, affective and biological determinants of the individual person,
  2. Behavioral determinants: that Act that person, and
  3. Influences arising from the social or physical environment affect the person and / or emanate from this person on the environment.

This principle is called reciprocal determinism (Fig. 4).

Healthy eating habits, for example, are influenced on the one hand by individual preferences, attitudes and habits (person). On the other hand, it requires the ability to distinguish between healthier and less healthy foods when shopping and to be able to prepare them (behavior). Thirdly, it is important whether and how certain goods are accepted, e.g. horse meat, algae, maggots or raw fish, as well as the distribution and accessibility of these goods (environment). Here it becomes clear that the interplay between person, environment and behavior is subtle and complex, especially since in many situations "only" informal social and cultural norms are effective (environment), which can be individually interpreted in very different ways.

The SKT was developed by Albert Bandura in the mid-1980s as an extension of the classical learning theories; those had explained human behavior as a consequence of a stimulus-response mechanism. By the social-cognitive theories are cognitive expectations "Interposed" that "mediate" between environmental stimulus and behavior: the Expectation of consequences act as a mediator on behavior. People can learn both through their own experiences (e.g. shortness of breath as a result of smoking), but also through observing others: they draw conclusions about the expected result of their own behavior from the consequences and results of their behavior. So the theory speaks to the people too Ability of observational or vicarious learning to.

In health programs, this ability can be used to specifically set role models for desired health behavior, whereby people can learn:
that they too can (probably) expect a certain result; this construct is called “expected result” in the SKT;
that and how the behavior can be carried out, which increases the “self-efficacy assessment”.

The construct Self-efficacy assessment (self-efficacy) is also called action or personal competence, self-efficacy or competence expectation. It is defined as an assessment of one's own ability and possibility to achieve a behavior result or as a conviction that a behavior can be carried out successfully. This SKT construct has been adopted in other theories (model of health beliefs, theory of planned behavior, social-cognitive process model of health behavior, theory of protective motivation).

The SKT has recognized for health promotion practice for health psychological interventions that measures cannot only be focused on the individual in isolation, i.e. on their behavior or attitudes. In addition, the theory shows the dynamic and mutual influence between the individual, their behavior and the social and / or physical environment, which can mean for practice to promote the individual's ability to act and knowledge through training and reflected learning opportunities, and also the environment and Include the social environment for support: for this purpose, role models should be used as role models in order to change the perception of the environment and one's own assessment of competencies.

In addition to the theory of planned behavior and the transtheoretical model, the SKT is probably the most frequently used for theory-based prevention and health promotion programs. The reasons are that
it has constructs that have proven to be particularly relevant for changing problem behavior;
their constructs can be relatively easily operationalized for practice and evaluation;
From many years of practical experience, the opportunity arose to use a theoretical model of psychology for ever new problem areas (e.g. violence prevention) in applied health sciences / public health.
Historically, it is to the merit of this theory that it has drawn attention to the enormous importance of the environment / the surrounding area on human behavior. Today it is widely used in public health campaigns around the world (particularly in Australia and the US).


 Literature Health Belief Model:
Skinner CS / Tiro J / Champion VL, The Health Belief Model, in: Glanz K / Rimer BK / Viswanath K, eds. Health Behavior: Theory, Research, and Practice. Jossey-Bass, 2015, 75-94
National Institutes of Health (NIH), Theory at a Glance: A Guide for Health Promotion Practice, National Cancer Institute, USA 2005
Schwarzer R, Psychology of Health Behavior. 3rd, revised. Edition, Berlin 2004
Nutbeam D / Harris E / Wise M, Theory in a Nutshell - A practical guide to health promotion theories. 3rd ed, Sydney 2010

Literature Theory of Protection Motivation:
Rogers RW, Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation, in Cacioppo JR / Petty RE (eds.), Social psychology: A sourcebook, New York: Guilford Press, 1983, 153-176
BZgA (ed.), Prevention through Fear? - Status of fear appeal research. Research and Practice in Health Promotion, Volume 4; Cologne 1998
Drambyan Y, The Theory of Protection Motivation Today - A Study on the Effectiveness and Graphic Warnings on Cigarette Shafts, Hamburg; 2011
Lippke S / Renneberg B, theories and models of health behavior, in: Renneberg Hammelstein P (ed.), Gesundheitspsychologie, Heidelberg, Springer Medizin Verlag, 2006, chap. 5, 35-60.
en.wikipedia.org/wiki/Protection_Motivation_Theory. Seen on 3.1. 2016

Literature Theory of Planned Behavior:
Ajzen I, The Theory of Planned Behavior, in: Organizational Behavior and Human Decision Processes, 1991, 50, 179-211
Schwarzer R, Psychology of Health Behavior. 3rd, revised. Edition, Berlin 2004, 53
Montano DE / Kasprzyk, Theory of Reasoned Action, Theory of Planned Behavior, and the Integrated Behavioral Model, in: Glanz K / Rimer BK / Viswanath K, eds. Health Behavior: Theory, Research, and Practice, San Francisco, Jossey-Bass, 2015, 95-124

Literature attribution theory:
Weiner B, An attributional theory of motivation and emotion, New York 1996
Haisch J, Attribution-changing measures in psychotherapy and medicine: Theoretical justification, starting points and success, in: Journal for Clinical Psychology, Psychopathology and Psychotherapy 43, 1995, 234-248
Haisch J, How personal responsibility and participation of the population in prevention can be strengthened. Public Health Forum 12, 2004, 16
Lewis F / Daltroy LH, How Causal Explanations Influence Health Behavior: Attribution Theory, in: Glanz K / Lewis FM / Rimer BK, eds, Health Behavior and Health Education - Theory, Research and Practice, 2nd ed, San Francisco 1990, 92- 114
Schwarzer R, Psychology of Health Behavior. 3rd, revised. Edition, Berlin 2004, 51-56

Literature social-cognitive theory:
Bandura A, Social Foundations of Thought and Action - A Social Cognitive Theory, Englewood Cliffs 1986
McAlister AL / Perry CL / Parcel GS, Social Cognitive Theory, in: Glanz K / Rimer BK / Viswanath K, Health Behavior and Health Education: Theory, Research, and Practice, 4th edition, San Francisco 2008, 169-188
Kelder SH / Hoelscher D / Perry CL, How Individuals, Environments, and Health Behaviors Interact, in: Glanz K / Rimer BK / Viswanath K, eds. Health Behavior: Theory, Research, and Practice. Jossey-Bass, 2015, 159-182
Schwarzer R, Psychology of Health Behavior. 3rd, revised. Edition, Berlin 2004, 61-73
Nutbeam D / Harris E, Theory in a Nutshell - A practical guide to health promotion theories, 2nd ed, Sydney 2009.


Prevention and disease prevention, subjective health: everyday health concepts, target groups, multipliers