Theories Inform Behavior Change Communication
Theories about why and how people change their behavior guide communication strategies. Behavioral theories help programs to understand why people behave as they do. With this understanding, programs develop strategies that reinforce healthy behavior or change unhealthy behavior (63, 91, 129, 137).
Two types of behavioral theories are important for BCC programs—theories of behavioral prediction and theories of behavior change. Predictive theories address why people change behavior. They identify what prompts people to perform (or not perform) a health-related behavior. In contrast, behavior change theories explain how people change behavior. They describe the “stages” that individuals may go through as they change their behavior.
Prediction Theories Explain What Determines Behavior
Behavioral prediction theories focus on the internal and external factors that influence people’s behavior. These factors help explain why some members of a given population are performing a behavior while others are not (63). (These theories are called predictive because they focus on the factors that determine or “predict” people’s behavior.)
BCC programs make use of these theories to identify the factors that will most influence behavior (56, 91). BCC programs use several different theories of behavioral prediction, such as the Health Belief Model (15, 97, 126), Social Cognitive Theory (8-10), and the Theory of Reasoned Action (3, 4). There is growing consensus, however, that eight factors best explain and predict behavior (61-63, 91). Although different theories use different terms, these eight factors include: intention to perform the behavior; environmental (external) constraints or barriers; skills (the necessary abilities to perform the behavior); attitude (benefits of the behavior outweigh the risks); perceived social (normative) pressure (individuals’ perceptions that other important people think they should or should not perform the behavior); self-image (behavior suits how people see themselves); emotional reaction; and self-efficacy (feeling capable of performing the behavior) (61-63, 91).
Generally, the first three factors together—that is, strong positive intention, the necessary skills, and lack of external constraints—are considered necessary and sufficient to perform any behavior (61-63). Intention is defined as a person’s subjective judgment: “How likely am I to do that (or not do that)?” People do not always act on their intentions, however. They may intend to act, but they discover that they do not have the necessary skills to carry out the behavior. Alternatively or in addition, people may encounter external constraints. For example, people may intend to use condoms. They do not, however, because they do not have access to condoms or because their partners object to condoms.
Most scholars generally view the remaining five factors— attitude, perceived social (normative) pressure, self-image, emotional reaction, and self-efficacy—as influencers of the strength and direction of intention. Of course, once a person tries a behavior, the good or bad result strongly influences whether that person tries it again (63).
How to apply theories of behavioral prediction. Theories of behavioral prediction and the eight factors identified above help a BCC program to understand the intended audience’s perspective and to decide how to address that audience (62, 91). Which of the eight predictive factors are standing in the way of healthier behavior? Which factors provide crucial support for the behavior? Research with the intended audience identifies these factors and other important information (see Step 1 : Analysis). Then the program can focus messages and activities on eliminating the key negative factors and/or reinforcing the key positive factors. The program will either have to increase skills, remove or help people overcome external constraints, change intention, or some combination of these (63).
Behavior Change Theories Describe Process of Change
Behavior change theories focus on the stages that people pass through as they change their behavior. For example, one widely known theory, the Stages of Change Theory, identifies five phases: precontemplation, contemplation, preparation, action, and maintenance (see illustration) (136, 148). Another theory, the Diffusion of Innovation Theory, proposes that people adopt a new idea (an innovation) through a different five-stage process: knowledge, persuasion, decision, implementation, and confirmation. This theory stresses the importance of interpersonal communication through peer networks and of opinion leaders to influencing an individual’s adoption or rejection of a new idea (156, 210). The process of behavior change is not always linear, however. People may move from one stage to the next, or they may fall back to an earlier stage (63, 75, 108).
How to apply theories of behavior change. Identifying the intended audience’s current stage of behavior change helps tailor approaches and messages to their information needs (see Step 1 : Analysis). Tailored messages seek to move the intended audience from its current stage to the next stage. Knowing the audience’s current stage also helps the program to gauge how much change is possible and to set realistic objectives (56).
Philippines Program Applies Theories
In the Philippines a program found that key individual factors and environmental (external) constraints, as identified in theories of behavioral prediction, explained the lack of condom use among sex workers based at establishments such as bars, nightclubs, and massage parlors. Individual factors, including the sex workers’ low perceived susceptibility to HIV and low knowledge about AIDS, contributed to their negative attitudes towards condoms. One key environmental constraint was actual and perceived negative attitudes of managers of the establishments towards providing sex workers with AIDS prevention information. Also, these establishments lacked policies mandating condom use between sex workers and clients (127).
To reduce HIV risk behavior among sex workers, the program aimed to improve sex workers’ attitudes towards condoms and remove environmental constraints (change establishment norms and expectations for condom use). The program implemented different activities at four sites. All sites offered a “standard care” component including free, routine examination for sexually transmitted infections (STIs) and prescription for treatment if diagnosed. It also included health education sessions that addressed sex workers’ risk behaviors for STIs and HIV, negative consequences of STIs and HIV, and benefits of correct and consistent condom use.
One site added a peer counseling program based in part on the Diffusion of Innovation Theory. Program staff trained popular, respected sex workers (opinion leaders) to counsel other sex workers on high risk behaviors and condom use and to build self-efficacy for condom use with clients. Sex workers were at the earliest stages of adopting condom use. Such opinion leaders potentially were key to influencing their behavior.
Another site addressed environmental constraints by training managers of entertainment establishments on how to implement, support, and reinforce safe sexual practices within the workplace. The managers then created their own professional association. They set policies requiring condom use across all establishments in the city. Also, they required sex workers to visit health clinics that offered AIDS education and clinical services. One final site implemented all three program components (188).
The final evaluation showed that the site with the combined activities that addressed all the relevant behavioral factors identified in behavioral theories had a 60% decline in STI rates from the baseline survey to the end of the program—the greatest decline in STI rates among the four sites. This site also had the greatest reductions in negative condom-use attitudes among sex workers and the highest levels of establishment rules concerning condom use (188).
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