Behavioural Change and Health Promotion
The Social Cognitive Theory model and the Transtheoretical Model of Change by Indiana Rose Wellbeing
Background
Generally, good health is maintained through healthy lifestyle behaviours. Health Behaviour Models look at the sociological aspects involved in achieving good health and can guide research and change at an individual and societal level.
There is growing awareness and evidence of how good health behaviours such as nutrition, exercise, and relaxation can impact positively on quality of life, health and longevity. There is also evidence that poor health behaviours such as smoking, alcohol consumption, fast and processed foods, and stress can negatively affect quality of life and contribute to poor health and chronic disease (Hilliard et al., 2018. p xviii).
Engaging in preventative health activities, can reduce the risks of chronic diseases such as cancer, cardiovascular disease, diabetes, liver disease, and kidney disease. Achieving good health is an interplay between individual, personal, interpersonal, and social ecological factors which influence people’s health and wellness (Hilliard et al., 2018. p xviii).
Research from behavioural change theories and models, can be applied to decision making when it comes to decisions about health, education, action, outcomes, and also policy making relating to public health. Health professionals and individuals wishing to change their health behaviours can refer to strategies outlined in various health models to affect change (Hilliard et al., 2018. p xix).
Two health models will be discussed in this essay: The Social Cognitive Theory model (SCT) and the Transtheoretical Model (TTM) also known as the Stage of Change Theory model.
Description of Theories
“Health behaviour is a combination of knowledge, practices, and attitudes that together contribute to motivate the actions we take regarding health” (The Free Medical Dictionary, 2022)
The Social Cognitive Theory model (SCT)
The SCT model examines how people make decisions about their health and behaviour. It’s a continuum model that observes the interchangeable factors effecting health behaviour. Five main components of SCT are: observational learning, reciprocal determinism, self-efficacy, motivation, and outcome; these will be discussed here in further detail when evaluating SCT theory (Hilliard et al., 2018. p 111).
The Transtheoretical Model (TTM).
The TTM model is different to the continuum model that SCT encompasses. TTM is a process oriented model of action. It has 6 interchangeable stages that individuals and health professionals follow to assist in changing behaviour. These are Precontempation, Contemplation, Preparation, Action, Maintenance, and Success. A main component of this theory is progression of both forward and backward movement through the stages until a new habit is ingrained and a person has successfully achieved healthful behaviour change (Hilliard et al., 2018. p 11,12).
Evaluation of Theories
The Social Cognitive Theory model (SCT)
SCT is derived from Albert Bandura’s Social Learning Theory (SLT) in which he saw that the effects of one’s environment, influenced and impacted on behaviour through observational learning, motivation, practice of a skill, and self-efficacy (Edinyang, 2016). A simple example of this is parent child modelling, whereby a child who sees their parent brushing their teeth may want to do the same (observation & motivation). The child may ask for a step stool and a toothbrush to do the same alongside them (action & self-efficacy) (Shearer, et al., 2012). This example also highlights another central theme of SCT, Reciprocal Determinism, whereby three factors have influenced the child’s success: 1. Environment (support to brush teeth with toothbrush, toothpaste, and social support from parents) 2. Person (Self efficacy and cognitive initiative to get a step stool and ask parent for help) 3. Behaviour (successful social interaction, verbal responses, and motor responses to complete the task) (Cherry, K., 2021). Learning continues if the child feels they can continue to confidently do this task. They will develop ‘self-efficacy’ wherever they can successfully complete it again, perhaps next time they will self-initiate the behaviour without relying on the external cue of modelling from their parent (Hilliard et al., 2018. p 4; McLeod S., 2011; Ryan & Deci, 2000).
Another element of SCT is Self-Regulation. To the extent to which one is able to make conscious decisions in the context of their environment, they’re able to implement learning and change. Four components of self-regulation are: Attention, Retention, Reproduction, and Motivation (McLeod, 2011). Attention and Retention impact the individuals focus on behaviours and consequences that have the most meaning and purpose; It might be that a person values a behaviour – morally, ethically, and or from a standpoint of virtue (Ahrens & Cloutier, 2019) or alternately does not value certain behaviours because they go against what a person wants to achieve personally or perhaps socially or culturally as well (Seifert et al., 2012). Reproduction of a behaviour takes repetition and motivation to practice the skill. Whether or not one perceives they can learn a new behaviour is determined by many factors including Self Efficacy and Self-Regulation (Hilliard et al.2018, p 4; McLeod., 2011).
The Transtheoretical Model (TTM).
The Trans theoretical model is a stage model There are 6 stages that support the actions required for health behaviour change. Health professionals can adopt various techniques and health theories (including SCT) to support actions in TTM (Hilliard., 2018. p 11; Prochaska & Velicer.,1997). One technique is Motivational Interviewing, whereby discussion, counselling, and client and practitioner feedback supports both successes and failures in achieving change. Motivational interviewing holds the client in high regard and focuses on achievements, personal insights, education, adaptation and solutions (Hilliard et al., 2018. p 146). For example, if a client has changed their diet and not lost weight the client and practitioner work as a team to review what has happened and take the next step in achieving the weight loss goal. If we examine the SCT influences leant to TTM behavioural change, there are components of focus on: attention, retention, motivation, and reproduction of newly learned behaviours in each stage of the model until success is achieved. To reiterate, the TTM views both successes and failures as an expected part of the process and each stage of the model as people make adaptations and learn new behaviours and skills until they can permanently integrate these into their lifestyle (Hilliard et al., 2018. p 11).
TTM Pre-Contemplation Stage
In this stage a person may not perceive that a change is possible or worth the effort, or they may not see that improvements can be made to their health to reduce future risks of chronic illness. Education promoting the potential benefits of change to individuals is a key focus of Health Professionals in this stage. All those using TTM may promote educational theories related to areas such as physical activity, nutrition, and wellbeing, through various places including schools, workplaces, community centres, senior citizen’s clubs, and at dental, and doctor’s surgeries. Examples may be nutrition related programs at schools, physical activity incentives such as lunchtime walking in workplaces, physical exercise classes sponsored by the council at local parks, or group activities sessions for senior citizens advertised in community and senior’s newspapers (Bedoya, D (n.d.); Hilliard et al., 2018. p 11; Kelly et al; 2016).
TTM Contemplation Stage
In this stage people may be intending to change in the future. Here, a change in perception has led to contemplation and further research on pursuing behaviour change that is of interest to the individual. This stage involves self-efficacy and thinking about the possible outcomes of change and how to achieve them (Bedoya, D (n.d.); Hilliard et al., 2018. p 11).
TTM Preparation Stage
Here there is a focus on detail and weighing up the pros and cons of change. The individual and health professional may use the Yale Communication model to get to the nitty gritty of what needs to change: who, what, when, where and how – are some of the components of this model which seeks to look at the elements that persuaded the process of change. The individual is then conscious of the factors that motivated the change and begins to prepare a plan that is likely to succeed in taking action in the future based on what is perceived as necessary and also achievable (Oxford, 2022). Self-efficacy and motivation become important in valuing changes that increase their wellness and wellbeing, thus with supports in place the Action stage can be implemented (Bedoya, D (n.d.); Hilliard et al., 2018. p 11).
TTM Action Stage
Here a plan is being enacted. Components of a successful plan include individual motivation, interpersonal support, family support, community support, and health practitioner level support working to assist in achieving the desired change. As with every stage of TTM a person may experience successes and failures as they modify their behaviours. They may go back to precontempation, contemplation, or planning stages as they have new experiences and derive learning from them. Support can be an important factor as to whether a person achieves their goals. In this stage a person is working with intrinsic and extrinsic motivations to change until their goals are in maintenance stage and new behaviours are learned (Bedoya, D (n.d.); Hilliard et al., 2018. p 11; Ryan & Deci 2000).
TMM Maintenance Stage
Occurs when the behaviour change has been well established and a person is enjoying the benefits of their changed behaviour, here, the person is avoiding or countering situations and or behaviours that previously created problems for them. There may be stimuli that reverts a person to past behaviours, however if it is seen as a set back and not a permanent failure, then the newly learned skills will continue to be practiced and the person will see the benefits (Bedoya, D (n.d.); Hilliard et al., 2018. p 11).
TTM Success Stage
This stage is also called the termination stage because the plans and goals for behaviour change have been achieved and integrated successfully into a person’s life style. The person will have a holistic sense that they have learned from past behaviours and now prefer and can implement the newly integrated ones, along with a renewed outlook on life and decision making processes. The influential factors of the Action stage including social and healthcare supports are still vital to the prevention of relapses or setbacks to newly gained health and lifestyle outcomes at all stages of TTM (Bedoya, D (n.d.); Hilliard et al., 2018. p 11).
Supporting Evaluation with Evidence
The Social Cognitive Theory model (SCT)
(Hilliard et al., 2018. p 6) states that,
“SCT has been most often applied to explaining or promoting lifestyle behaviours” … “In a review of SCT based diet and physical activity interventions for adult cancer survivors, there is a significant pooled intervention effect on physical activity, and most studies were successful in changing at least one aspect of nutrition related behaviour (Hilliard et al., 2018; Stacey et al., 2015)”.
Many other studies were looked at for this essay including one relating to the adoption of moderate intensity physical activity in those with living with diabetes. This study showed that the components of SCT motivation and self-efficacy were key factors in whether participants met their weekly goals for participation in physical activity. Higher levels of motivation and self-efficacy transferred to successful participation (Lakerveld, et al., 2020).
A contributor to motivation and self-efficacy is self-regulation. Hilliard et al., 2018. p 6, states,
“Leventhal’s self-regulation model suggests a process with four steps: (a) extract information from the environment; (b) generate representation of the illness as dangerous to oneself; and (C) plan and act, which involves imagining response alternatives to deal with the problems and emotions it generates; and then taking selected actions to achieve specific effects. The Feedback loop is achieved by the last step: (d) monitor or appraise how one’s coping affects the problem and oneself (Leventhal et al., 1980; Hilliard et al., 2018. p. 6)”.
This extract is a further example of the interplays of observation, reciprocal determinism and self-efficacy in SCT.
The Transtheoretical Model (TMM)
Hilliard et al., 2018; p. 11, states that a number or reviews and meta analyses examined TTM based interventions in health related behaviours such as smoking, physical activity and dietary change for those with diabetes. The meta analysis did find support for Prochaska’s “strong and weak principles of change”, which state that:
“For an individual to move from precontemplation to action they need to experience 1 standard deviation increase of perceived pros of changing, and 1 ½ standard deviation decrease in perceived cons of changing”. Furthermore, “Across the reviews authors noted inconsistent and often incomplete application of the model, and methodological weaknesses made it difficult to draw conclusive results about the value of TTM for behaviour change interventions…” (Hilliard et al., 2018. p 12).
From the research in this essay it appears that the components of TTM are useful in considering how behaviour change in enacted. Though it hasn’t yet been possible to draw conclusive results about successes of TTM in behaviour change and healthcare it is still a widely used tool in health research, planning and in enacting change. Further to this, two studies were looked at for this essay including one measuring the effictiveness of digital health and SMS to raise conciousness and prevent or delay type 2 diabetes in impaired glucose tolerance patients embarking on behaviour change using the TTM. Results from this study showed that the majority of participants felt supported and encouraged to action for nutritional changes and physical activity through receiving sms reminders (Alzeidan, et al., 2019). This study brings questions as to the role of technology in assisting behaviour change in the future and its possible contributions to TTM health outcomes.
Comparison of Theories
The Social Cognitive Theory Model (SCT Model)
While the strengths and processes of SCT have been explored in this essay, the weakness of SCT are that it doesn’t go into depth regarding sociological determinants of health behaviours, for example what are the barriers to change where one has high motivation and self-efficacy, however may lack of knowledge about healthy eating behaviours? Can observation and reciprocal determination be affected negatively by persuasion, fast food advertising, stress, lowered social support and societal influences that compete with intended behaviour changes. There will be times where barriers to behaviour change are beyond a person’s control (Cherry, K 2021; Dixon et al., 2007; Hilliard et al., 2018. p 11,12; Moore et al., 2012).
The Transtheoretical Model (TTM Model)
To elaborate on the strengths of TTM it’s a flexible model that can accommodate the interplay of individual circumstances and social determinants of health. This might make TTM successful in managing multiple health issues and improving quality of life and health outcomes over time (Bedoya, D (n.d.); Hilliard et al., 2018. p 11, 12).
In summary more research into the applications and outcomes of Health Behaviour Models is needed to improve the body of evidence in this area. There are approximately eleven main models, SCT and TTM are just two of these. Further understanding can assist individuals and health professionals in improving health outcomes and reducing risks such as the development of chronic diseases (Hilliard., 2018 p. xviii, xix, 4,5,6,11,12).
References
Ahrens, A., & Cloutier, D. (2019, March 20). Acting for good reasons: Integrating virtue theory and social cognitive theory. Social and Personality Psychology Compass, 13(4). doi:https://doi.org/10.1111/spc3.12444
Alzeidan, R., Shata, Z., Hassounah, M., Rashad Baghdadi, L., Hersi, A., Fayed, A., . . . Elmorshedy , H. (2019, November). Effectiveness of digital health using the transtheoretical model to prevent or delay type 2 diabetes in impaired glucose tolerance patients: protocol for a randomized control trial. BMC Public Health. doi:https://doi.org/10.1186/s12889-019-7921-8
Bedoya, D. (n.d.). Transtheoretical Model of Change. You Tube. Retrieved from https://youtu.be/EneFU1xZ56A
Cherry, K. (2021, May). What Is Reciprocal Determinism? Retrieved from Very Well Mind: https://www.verywellmind.com/what-is-reciprocal-determinism-2795907
Cherry, K. (2022, December). Locus of Control and Your Life. Very Well Mind. Retrieved from https://www.verywellmind.com/what-is-locus-of-control-2795434
Dixon, H., Scully, M., Wakefield, M., White, V., & Crawford, D. (2007). The effects of television advertisements for junk food versus nutritious food on children’s food attitudes and preferences. Social Science and Medicine, 65(7), 1311-1323. doi:https://doi.org/10.1016/j.socscimed.2007.05.011
Edinyang, S. (2016). The significance of social learning theories in the teaching of social studies education. International Journal of Sociology and Anthropology Researc, 2(1), 40-45. Retrieved from file:///C:/Users/Admin/Downloads/5y1.org_0ea4a436d20a78c4176c4ee659bdf803.pdf
Engel, P., Santos, F., & Gathercole, S. (2008, December). Are Working Memory Measures Free of Socioeconomic Influence? Journal of Speech, Language, and Hearing Research. doi:https://doi.org/10.1044/1092-4388(2008/07-0210)
Heiss, V., & Petosa, R. (2015, November). Social cognitive theory correlates of moderate-intensity exercise among adults with type 2 diabetes. Biomedical; Europe; Peer Reviewed; UK & Ireland. doi:10.1080/13548506.2015.1017510
Hilliard, M., Riekert, K., Ockene, J., & Pbert, L. (2018). The Handbook of Health Behaviour Change (Fifth Edition ed.). New York: Springer Publishing Company.
Kelly, S., Martin, S., Kuhn, I., Cowan, A., Brayne, C., & Lafortune, L. (2016, January). Barriers and Facilitators to the Uptake and Maintenance of Healthy Behaviours by People at Mid-Life: A Rapid Systematic Review. Plos One. doi:https://doi.org/10.1371/journal.pone.0145074
Lakerveld, J., Palmeira, A., Duinkerken, E., Whitelock, V., Peyrot, M., & Nouwen, A. (2020). Motivation: key to a healthy lifestyle in people with diabetes? Current and emerging knowledge and applications. Diabetic Medicine, 37(3), 464-472. doi:https://doi.org/10.1111/dme.14228
McLeod, S. (2011). Albert Bandura’s Social Learning Theory. Simply Psychology. Retrieved from https://www.simplypsychology.org/bandura.html
McLeod, S. (2014, September). Bobo Doll Study. Retrieved from Simply Psychology: https://www.simplypsychology.org/bobo-doll.html
Moore, A., Grime, J., Campbell, P., & Richardson, J. (2012). Troubling stoicism: Sociocultural influences and applications to health and illness behaviour. Sage Journals, 17(2). doi:https://doi.org/10.1177/136345931245117
Oxford Reference. (2022). Yale Model. Retrieved from https://www.oxfordreference.com/display/10.1093/oi/authority.20110803125236559;jsessionid=3180E9E25B3C8E2820B98E889E472781
Plotnikoff , R., Nandini , K., & Brunet, S. (2005). A comparison of physical activity-related social-cognitive factors between those with type 1 diabetes, type 2 diabetes and diabetes free adults. Psychology, Health & Medicine, 14(5), 536-544 . doi:https://doi.org/10.1080/13548500903012863
Ryan, R., & Deci, E. (2000). Intrinsic and Extrinsic Motivations: Classic Definitions and New Directions. Contemporary Educational Psychology, 25(1), 54-67. doi:https://doi.org/10.1006/ceps.1999.1020
Seifert, C., Chapman, L., Hart, J., & Perez, P. (2012). Enhancing Intrinsic Motivation in Health Promotion and Wellness. American Journal of Health Promotion, 26(3). doi:https://doi.org/10.4278/ajhp.26.3.tahp
Shearer, D., Thompson, W., Caspi, A., Moffitt, T., Broadbent, J., & Poulton, R. (2012). Family history and oral health: findings from the Dunedin Study. Community Dentistry and Oral Epidemiology, 40(2), 105-115. doi:https://doi.org/10.1111/j.1600-0528.2011.00641.x
The Free Medical Dictionary. (2022). Health Behaviour. Retrieved from https://medical-dictionary.thefreedictionary.com/health+behavior