There are a wide range of theories, encountered often in the field of health, behavior change and persuasion. For each of these theories, we first summarize the most important information, alongside the most important constructs and models. Next, we link the theories to the features for mHealth apps. At the end of each theory, we also point the interested reader to more information.
The Theory of Reasoned Action (TRA) aims to understand the likelihood that a person will behave in certain way. It is often used in health education and health promotion to understand why people show certain (un)healthy behaviors. TRA states that a person’s intention to perform a behavior (BI) is driven by the person’s Attitude towards the behavior (A) and the person’s normative beliefs, also termed Subjective norm (SN).
Attitude towards the behavior is defined as “The sum of beliefs about a particular behavior, weighted by the evaluations of these beliefs”. In plain words, it refers to how people think or feel about the target behavior.
To understand people’s attitudes, you can ask yourself the following questions:
Do they find it useful? Easy? Comfortable? Cost-efficient? Desirable? Healthy? Time-consuming? Expensive? Good for the environment? And so on… Note that attitudes are beliefs, they are no objective truths. Hence, people may have beliefs that are perhaps superstitious or unscientific. That doesn’t make these attitudes less important to form a behavioral intention.
Subjective norm is defined as “The beliefs of other people, weighted by the importance one attributes to each of their opinions”. In plain words, it refers to what others think of the target behavior, and additionally, to how much a person cares about what these others think? To understand what the subjective norm is for a person, you can ask the following questions: What do friends think of it and how much does the person care about what friends think? What does the partner think of it and how much does the person care? What does the family think of the target behavior, and how much does the person care?
Predicting behavioral intention to perform the target behavior
Depending on the person and situation, these two drivers (A, SN) might have different impacts on behavioral intention (BI). Sometimes a person has very strong opinions and doesn’t care much about what others think. Sometimes a person does not have strong opinions towards the target behavior but is influenced by parents and friends. In this case, attitudes and subjective norms are unlikely to be weighted equally when influencing the intention to perform a targeted behavior. Therefore, a weight can be associated with each of these factors to represent the different importance and to predict behavioral intention to perform the target behavior.
Note: A more extended version of the Theory of Reasoned Action is the Theory of Planned Behavior.
The Theory of Planned Behavior (TPB) aims to predict the likelihood that a person will behave in a certain way. It is often used in health education and health promotion to understand why people show certain (un)healthy behaviors. More specifically, TPB states that a person’s intention to perform a behavior (BI) is driven by a person’s Attitude towards the behavior (A), the person’s normative beliefs, also termed Subjective norm (SN) and the person’s perceived control over the behavior (Perceived behavioral control).
Attitude towards the behavior refers to how people think or feel about the target behavior. It is defined as “The sum of beliefs about a particular behavior, weighted by the evaluations of these beliefs”. In plain words, it refers to how people think or feel about the target behavior.
To understand people’s attitudes toward the behavior are, you can ask the following questions: Do they find it useful? Easy? Comfortable? Cost-efficient? Desirable? Healthy? Time-consuming? Expensive? Good for the environment? And so on… Note that attitudes are beliefs, they are not objective truths. Hence, people may have beliefs that are perhaps superstitious or unscientific. That doesn’t make them less important.
Subjective norm refers to what others think of the target behavior, and to how much a person cares about what these others think. It is defined as “The beliefs of other people, weighted by the importance one attributes to each of their opinions”.
To understand what the subjective norm is, you can ask the following questions: What do friends think of it and how much does the person care about what friends think? What does the partner think of it and how much does the person care? What does the family think of the target behavior, and how much does the person care?
Perceived behavioral control refers to whether the person is in control on whether or not to perform the behavior. Sometimes external circumstances limit persons in what they can do. They may not have the money, place or time to perform the target behavior. It is defined as “A person's beliefs about the presence of factors that may facilitate or impede performance of the behavior”.
To understand a person’s perceived behavioral control you can ask the following questions: Does the person have the financial means to perform the target behavior? Does the person have the time and place to perform the target behavior? Does the person have access to the necessary infrastructure to perform the target behavior?
Predicting behavioral intentions to perform the target behavior
Depending on the person and situation, these three drivers (A, SN, PBC) might have different impacts on behavioral intention (BI). Sometimes a person has very strong opinions and doesn’t care much about what others think. Sometimes a person does not have strong opinions towards the target behavior but is influenced by parents and friends. In this case, attitudes and subjective norms are unlikely to be weighted equally when influencing the intention to perform a targeted behavior. Therefore, a weight can be associated with each of these factors to represent the different importance.
Note: The Theory of Planned Behavior (TPB) is an extension of the Theory of Reasoned Action (TRA). Ajzen concluded that Attitudes towards the behavior and Subjective norm alone did not account for all actions. Behavior is not always under voluntary control. Therefore, he extended TRA with this driver of perceived behavioral control and named this extended model the Theory of Planned Behavior.
Self-determination theory (SDT) is a theory of (intrinsic) human motivation. It is often used to better understand why people are (not) motivated to perform a certain health related behavior. SDT states that all humans have three basic needs that need to be met: the need for Competence (the effectiveness to deal with the situation), the need for Autonomy (the need to feel in control of our lives) and the need Relatedness (the need to feel connected to others). When these needs are satisfied, optimal growth can occur.
The need for Competence is defined as “The need to feel effective in one’s ongoing interactions with the social environment and experiencing opportunities to exercise and express one’s capacities.”
In plain words, the need for competence reflects the need to perceive that we are good at something. Competence involves feeling efficient, effective, and mastery. The need for Competence is not the same as skill or capability. In fact, people might, from an outsider perspective, perform a task sub optimally. What is important is that people still feel have feelings of mastery. They should feel confident to perform the task at a certain level and notice some form of success or improvement.
To understand whether the need for Competence is met, you can ask the following questions:
• Does the person feel good at performing a target behavior?
• Can people improve their skills?
• Can a person get a sense of mastering a behavior?
• Does a person feel confident that there will be some sense of success when performing the behavior?
The need for Autonomy is defined as “the need to be the perceived origin or choice of one’s own behavior, acting from one’s own interests and values”.
In plain words, Autonomy expresses that we all need to perceive that we have choices and that we have control over our actions. We need to experience a behavior as volitional, rather than feeling controlled or pressured into a behavior. However, Autonomy does not imply that you need to be feel independent of others. Rather, it implies that you choose voluntarily to perform a certain behavior.
To understand whether the need for Autonomy is met, you can ask the following questions:
• Does the person have different meaningful choices or different options?
• Do people have the freedom to choose?
• Is a person’s behavior voluntary?
• Can people feel that they themselves are responsible for the behavior?
The need foris defined as “the need to feel connected to others, to care for and be cared for by those others, to have a sense of belongingness both with other persons and with one’s community.”
In plain words, we all have a need to feel connected to others, via positive relationships. We need to feel cared for, and we need to feel we ware about others. Relatedness is about belonging, feeling part of a group and having a worthwhile place in that social group (e.g. in family, circle of friends, etc.) Hence, relatedness is ultimately also about having a meaningful role in society and about status.
To understand whether the need for Relatedness is met, you can ask the following questions:
• Does a person feel part of a social group?
• Is a person positively connected to others
• Do others care for the person?
• Does the person care for others?
• Is the person meaningful in someone else’s life?
Understanding intrinsic motivation via Self-Determination Theory
Self-Determination is ultimately a theory of (intrinsic) human motivation, it investigates how people self-determine to carry out a behavior. SDT claims that all people, across all cultures, have an innate tendency to grow and develop, and to master their potential. However, in order to do so, these three basic psychological needs of Competence, Autonomy and Relatedness need to be met. These needs should be met in order to feel mentally and physically healthy and being able to develop most optimally. So when a target behavior can satisfy the these needs, humans are intrinsically motivated to perform it.
With intrinsic motivation, the motivation comes from inside a person rather than from any external reward or punishment. In this case people are doing of an activity for the inherent satisfaction. When people that are extrinsically motivated will stop performing the behavior as soon as the (external) reward or punishment is removed. When people are intrinsically motivated, they will keep on performing the behavior.
The Information-Motivation-Behavioral Skills Model of Health Behavior (IMB model) is a model to better understand and promote health behavior. IMB asserts that health-related information, motivation, and behavioral skills are fundamental determinants of performance of health behaviors. When people are well informed, motivated to act, and possess the requisite behavioral skills for effective action, they will be likely to initiate and maintain health-promoting behaviors.
Information is defined as “the knowledge directly relevant to the performance health behavior and that can be easily enacted by the person in his or her social ecology”. So information is about having the knowledge about specific facts on health promotion as well as having guidelines about when and why to perform the health behavior.
In plain words, does the person know why the health behavior is important, for example, “Condom use prevents HIV transmission” or “Smoking increases the risk of developing lung-cancer”.
Motivation is composed of the combination of personal motivation (personal attitudes towards the health behavior) and social motivation (having social support for performing the health behavior).
In plain words, personal motivation is about how the person thinks and feels about performing the health behavior, for example, “using condoms takes away sexual pleasure”, or “smoking helps me relax in times of stress”. Social motivation refers to how family and circle of friends think and feel about the health-related behavior, for example, “my boyfriend does not want to use condoms”, or “my children want me to quit smoking”.
Behavioral skills is composed of people’s objective abilities as well as their sense of self-efficacy in performing the health-related behavior.
In plain words, it is about whether people actually know how to perform the behavior, and/or are physically capable, and even more so about people themselves have the believe that they know how to perform the behavior. For example, a person needs to have confidence in knowing how to ‘technically’ use a condom.
The Health Belief Model (HBM) is a model that tries to understand and predict why a patient will (or will not) take a health-related action. HBM provides important concepts to determine whether a person will take action or not. In particular, if a person perceives the severity or threat of a disease (Perceived threat) as high and also thinks his susceptibility to the disease (Perceived susceptibility) is high, than he is more likely to perceive the disease as a threat (Perceived threat) and more likely take action (Likelihood of behavior).
It also helps if a person is triggered to perform the behavior (Cue to Action).
And there are also personal variables that may influence the Perceived benefits and Perceived barriers, influencing the likelihood of action.
Perceived susceptibility is a measure of the person’s subjective assessment of how likely he is to be at risk for the disease or health problem. In plain words, how much does the person think that he or she is at risk.
Perceived severity is a measure of the person’s subjective assessment of how serious the disease is the consequences of the health problem for him or her. Sometimes, this is also called perceived seriousness.In plain words, how bad will the consequences be, when being ill or having the disease.
Perceived threat is the result of a person’s perceived susceptibility and perceived severity. If the person perceives the threat as high, he is more likely to act.
Cues to action should be understood as triggers to take action. These cues can be external, a reminder to visit the dentist, a warning label on a smoking package or a family member who asks to take medication. Cues to action can also be ‘internal’, such as experiencing pain, feeling a high heart rate, or experiencing shortness of breath.
Perceived benefits minus perceived barriers: it is also important to understand how the person evaluates the action. If this actions is perceived as beneficial towards the health problem, this will be more likely to be carried out. If a person evaluates the action as difficult, discomforting or inaccessible, it will be less likely be carried out.
Finally, it is also important to take into account personal characteristics as modifying variables. These include demographic variables such as age, gender, ethnicity, but also psychosocial variables such as personality or the peer groups. Finally, structural variables such as prior exposure to the disease, or knowledge about the disease matter too.
Our behavior is shaped by the consequences of that behavior. Operant conditioning (OC), sometimes also called instrumental learning, is a model of how people change their behavior because of the consequences directly following this behavior. It can also be used to understand why (or not) people perform health related behaviors. OC states that behaviors followed by positive consequences (Reinforcement) tend to be repeated. Behaviors that produce negative consequences (Punishment) are less likely to be repeated.
Reinforcement is defined as “strengthening a behavior through positive consequences following a behavior”. Reinforcement can be positive (the addition of an appetitive stimulus or reward) or negative (the removal of an aversive stimulus). In plain words, a behavior is more likely to be repeated when it is followed by something people like, or when it is helps stopping something that is people dislike.
To look for ways to strengthen a desired behavior, you can ask yourself:
• What do people experience as pleasant?
• What are consequences of a behavior do people like?
• What do people consider a reward?
• What do people dislike and how can we stop it?
Punishment is defined as “weakening a behavior through negative consequences, following a behavior”. Punishment can be positive (the addition of an aversive stimulus) or negative (the removal of a rewarding stimuli). In plain words, a behavior is less likely to be repeated when it is followed by something that people dislike, or when you are taking a way something people like.
To look for ways to weaken an undesired behavior, you can ask yourself:
• What do people experience as unpleasant?
• What are consequences of a behavior do people dislike?
• What do people consider to be a punishment?
• What do people value that can be removed?
Goal-Setting theory upholds that people are more motivated and perform better on (health-related) tasks when they are linked to a specific goal. However, there are several conditions that need to be fulfilled to increase motivation through goal setting. A person should feel Acceptance/commitment to the goal. Goals should be Specific and sufficiently Difficult. And a person should receive Feedback about the performance.
The goal should be accepted by the person completing the goal. The person should feel a sense of importance about the goal. Information about the goal may increase goal acceptance.
The goal should be specific. The more a goal is specified, the more motivated a person will become to attain the goal. Goals must be concrete, if possible quantified. A person should also feel that she is able to determine the absolute end-point of a goal. Moreover, goals should be achievable and believable (the person as well as the one setting the goal should be able to believe that the goal can be reached) and conceivable (understanding the goal).
The goal’s difficulty should be set as highly as possible without affecting performance. A goal should be challenging. However, it should not be too difficult. Demanding a person to achieve too difficult goals will not only undermine commitment and self-efficacy but also cause a feeling of dishonesty and corruption and will possibly lead to cutting corners.
Finally, a person should receive feedback. She should be able to monitor her progress towards the goal. If this is not possible, she will not be able to determine the amount of effort needed to complete the goal.
Generally, people perform better when in the presence of others, than when being alone. This effect of social presence is the main contribution of Social facilitation theory. However, social facilitation only works up to a certain point in task difficulty. When people attempt to perform tasks, which are more complex or with which they are not familiar, they may actually complete it with less accuracy when in the presence of others than when they alone. Thus, social inhibition also exists where the presence of others inhibits a person to do well.
Social Facilitation can be explained through the relationship between social presence, arousal and performance.
is the awareness of others being present, (imaginary or real) , and this serves as a source of arousal. Social presence increases physiological or mental arousal. Heightened arousal increases attention to the task, it releases stress hormones and reinforces dominant pathways in our brains.
. Hence, heightened arousal through social presence improves simple or habitual routine like responses. This heightened arousal increases the likelihood of people to do better on well-learned or habitual responses. For this reason, the presence of others improves performance on simple, or well-learned tasks.
. Heightened arousal through social presence decreases performance on complex, or not well-learned tasks. When levels of arousal become too high, or when tasks are too difficult performance decreases. This is caused by the negative effects of arousal (or stress) on cognitive processes like attention (e.g., "tunnel vision") and the fact that habitual responses tend to take over.
Social-Cognitive theory (SCT) is a theory of learning, that can be broadened to learning new health related behaviors. Central to SCT is the idea that people (also) learn from observing others. Hence, people do not need to go through a trial and error cycle themselves; watching someone else can also change a person's way of thinking and doing.
When people observe others performing a (health-related) behavior and they can see the consequences of that behavior through others, people will retain the sequence of actions (Modeling). Moreover, they will form expectations about themselves performing the behavior. The consequences of the behavior (whether others are rewarded or punished for their behavior), will influence their own expectations about the outcome (Outcome expectancies). This information will guide their subsequent behaviors. However, crucial are high self-efficacy beliefs. People must also belief they are capable of performing the behavior. The more people can identify with their model, the more likely they will be influenced by their behaviors.
The following concepts are important when talking about Social-Cognitive theory.
Modeling is the term for learning from observing others. Observing a model perform the behavior, and seeing the consequences of these behaviors allows a person to distill a plan of actions and remember how to tackle the plan.
Outcome expectancies. People must understand what the potential outcomes are if they repeat that behavior, positive (rewards) or negative (punishment). Hence, people form expectations on the basis of the consequences for the model. However, people will not only base their outcome expectancies on the model, they also take into account their own socio-structural factors. Hence, people do not expect the exact same outcomes as the model, outcomes are shaped by their own context too.
Self-Efficacy is a core central to Social-Cognitive theory. Self-efficacy should be understood as the belief of the person in her own capabilities to master the skills necessary to perform the behavior. If self-efficacy is low, a person is not likely to engage in a certain behavior, even when having observed a model and having positive outcome expectancies. Earlier experiences of mastery, encouragements, having a model to identify with and finally techniques to improve physical and mental state (e.g. mindfulness, yoga,…) can help increase self-efficacy beliefs.
Identification is the perception of that the model is similar to the person observing the behavior. The more a person has the impression that a one-on-one relationship exists between the person and the model, the more the likelihood that the person will perform the behavior.
Attitudes are very important to guide and shape behaviors. These attitudes can be attempted to be changed via messages. According to the Elaboration Likelihood Model, there are two paths towards processing the messages: the Central route and the Peripheral route. When people use the central route, behavior change will result after careful and thoughtful consideration of all information in the message related to the (health) behavior. When people use the peripheral route, their attitude towards a behavior is affected by their general feelings regarding the message, or build on certain (superficial) associations with.
The central route involves a high level of message elaboration (hence the name of this theory). The central route is used when a person has the motivation and the ability to think about the message and its topic. With the central route, the message is carefully processed, hence much cognitive effort is given to assess the nature and merits of the arguments the message provides. When effective in persuading, the results of attitude change will be relatively stable and, resistant, and predictive of behavior.
The peripheral route involves a lower level of message elaboration. The peripheral route is used when a person has a lesser interest in the topic or a lesser ability to process the message. In this case, people are looking for ways to reduce cognitive effort. So, they rely on heuristics (rules of thumb), general impressions or even cues associated with the message, that are unrelated to the actual arguments, such as their own mood or the attractiveness of the sources of the message.
As mentioned before, the likelihood of elaboration (in other words, whether a message will be processed via the central or peripheral route) will be determined by the motivation of the person and his ability to evaluate the argument being presented. As a researchers trying to get a message across, it is important to think about what amount of elaboration is likely to happen, and to ensure that both routes are ‘served’.
When aiming for health-related behavior change, it is important to understand such a transformation from unhealthy to healthy behavior is characterized by different stages and different processes of change. The Transtheoretical model (TTM) describes the different stages underlying health behavior change that a person goes through: 1) Precontemplation, people are not yet ready to take action. 2) Contemplation, people are considering whether they should take action, . 3) Preparation , people have decided they want to take action and are preparing for it, 4) Action people are taking the actual action, 5) Maintenance In this stage actions are limited to avoiding relapse, and 7) Termination people can stop the behavior as there is no longer a risk of relapse. TTM also distinguishes 6) Relapse people revert to one of the prior stages.
Additionally, TTM also describes different processes or strategies of changes that accompany the different stages.
People in this state are “not ready”. They do not plan to take action in the near foreseeable future (6 months). Being un- or misinformed about a behavior can keep people in this state. Appropriate strategies in this stage involve informing people about the importance of behavior change. Such a process of change to get the facts about the healthy/unhealthy behavior and raising awareness is termed Consciousness-raising.
People in this stage are “getting ready”. They are thinking about the behavior change. However, they are still ambivalent towards the behavior change, considering both the positive effects but are also aware of the negative consequences. They outweigh the pros and cons which can keep them in this state for some time before action really occurs.
Appropriate strategies in this stage involve helping people to reduce the cons and emphasizing the positive consequences. Paying attention to negative feelings related to the unhealthy behavior, and the positive feeling that may come from healthy behavior is termed Dramatic relief. Realizing that the healthy behavior is an important part of who they are and want to be, is termed as Self-reevaluation. Helping people notice the effect of their unhealthy behavior on others, and how this could be changed is termed Environmental reevaluation.
People in this stage are “ready” to take action in the next days or weeks. People form a plan of action and are preparing for the behavior change, by for example letting friends and family know, or by setting up the right infrastructure.
Appropriate strategies in this stage involve providing support and helping them be prepared. Paying attention to this support from friends for their healthy behavior is termed as social liberation. Also important is to help people believe in their abilities and to make a commitment, termed as Self-liberation.
People in this stage have taken action. They have changed their behavior. In this state, people have made significant changes in their lifestyle and are working hard to keep moving ahead.
Appropriate strategies in this stage involve techniques for keeping up commitments and rewarding them for the steps they have taking toward changing, termed Reinforcement management. Strategies also involve avoiding people and situations that may tempt them to relapse and to behave again in unhealthy ways. Finding people supportive of change is termed Helping relationships. Substituting unhealthy ways of acting and thinking by healthy ones is termed Counter-conditioning.
People in this stage have kept up their behavior change for over half a year. In this state, people have made significant changes in their lifes to maintain behavior change. They have established actions that allow the behavior change to be permanent. Therefore, the number of actions can be reduced as the actions are only meant to reinforce the behavior.
Appropriate strategies in this stage involve remembering them about the possible techniques to cope with stress and reminding them to engage in healthy activities and spending time with people that support them. Managing your environment and setting up reminders and cues to encourage healthy behavior as substitutes for those that encourage the unhealthy behavior is termed Stimulus control.
People in this stage can stop to take action, as there is no longer a chance for relapsing into prior stages.
This is not a stage in itself but points to the moment where a person reverts to one of the earlier stages.
In addition, TTM also distinguishes the decisional balance, pointing to the growing awareness that the advantages (the "pros") of changing outweigh the disadvantages (the "cons"), and self-efficacy, to be understood as the confidence a person can make and maintain changes in situations that tempt them to return to their old, unhealthy behavior.
Perceptual Control Theory is a theory of personal motivation that stems from engineering sciences, more particularly cybernetics. In origin, it is a theory applied to physical systems. But it can be applied to humans too. The important assumption underlying control theory is that all systems (humans too) are self-regulating, they seek a state of equilibrium.
Different versions, adaptations and extensions of Control Theory exist. One example is Perceptual Control Theory (PCT), comes with the GAP-ACT model. When aiming for a health-related change a person has a GAP, also termed discrepancy (d) between the goal (G), or desired standard and the perception (P) of the current standard. To reduce this gap, actions (A) need to be taken. Specific actions (ACT) to reduce or eliminate discrepancies are termed interventions (i). These actions are taken to control target variables (T). However, the target is rarely under complete control. There are always conditions (C) that disturb, hinder, impede, or offset our best efforts to influence the target. Through mechanisms of Feedback (f), we can update our perceptions of the target, and decide on additional action to satisfy any remaining discrepancies.
GAP: A discrepancy (d) or gap between the desired goal (G) and the perceived standard (P) inviting actions (A). For example a person may desire to have a healthy weight of 70 kg, but perceives he is currently weighing over 100 kg, which is a gap of 30 kg.
ACT: An intervention (i) or action to close the gap by controlling a target variable (T), of course this target is also influenced by conditions (C) outside your control as well, that disturb, hinder, impede, or offset efforts to influence the target. The person will decide to go on a diet as intervention, limiting the number of calories to 1200 per day (target variable). Unfortunately, at work, due to many new year receptions, he has not been able to reduce this intake.
Feedback (f): Perceptions of the target in which influences additional action to satisfy any remaining discrepancies. The person realizes that he has actually not been able to reduce caloric intake, which he can witness from his food diary.