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Applying health behavior theory to multiple behavior change:Considerations and approaches

Seth M. Noar , Melissa Chabot, Rick S. Zimmerman Department of Communication, 248 Grehan Building, University of Kentucky, Lexington, KY 40506-0042, USA

Available online 11 August 2007

Abstract

Background. There has been a dearth of theorizing in the area of multiple behavior change. The purpose of the current article was to examinehow health behavior theory might be applied to the growing research terrain of multiple behavior change.

Methods. Three approaches to applying health behavior theory to multiple behavior change are advanced, including searching the literature for potential examples of such applications.

Results. These three approaches to multiple behavior change include (1) a behavior change principles approach; (2) a global health / behavioralcategory approach, and (3) a multiple behavioral approach. Each approach is discussed and explicated and examples from this emerging literatureare provided.

Conclusions. Further study in this area has the potential to broaden our understanding of multiple behaviors and multiple behavior change.Implications for additional theory-testing and application of theory to interventions are discussed. 2007 Elsevier Inc. All rights reserved.

Keywords: Theory; Multiple behavior change; Health behavior

Many of the leading causes of death in the United States are behavior-related and thus preventable ( Mokdad et al., 2004 ).While a number of health behaviors are a concern individually,increasingly the impact of multiple behavioral risks is beingappreciated (e.g., Fine et al., 2004;Reeves andRafferty, 2005 ).Asnewer initiatives funded by the National Institutes of Health andRobert Wood Johnson Foundation begin to stimulate research inthis important area ( Jordan et al., 2005; Orleans, 2004 ), a criticalquestion emerges: How can we understand multiple health behavior change from a theoretical standpoint? While multiple

behavior change interventions are beginning to be developed andevaluated (e.g., Goldstein et al., 2004; Prochaska et al., 2006 ), todate there have been few efforts to garner a theory-basedunderstanding of the process of multiple health behavior change.

The purpose of the current article is to discuss how theoriesof health behavior and behavior change might be applied to theunderstanding of engagement in multiple behaviors andmultiple health behavior change. In particular, we suggest three approaches, including (1) a behavior change principles

approach; (2) a global health/behavioral category approach; and(3) a multiple behavioral approach. Given that so littletheoretical work currently exists in this area, our main purposeis to advance the conversation on how health behavior theorycan help us to achieve a greater understanding of multiple behavior change. The approaches discussed have implicationsfor both theory-testing as well as intervention design.

Health behavior theory

Reviews of the literature ( Glanz et al., 1997; Noar, 2007; Noar and Zimmerman, 2005 ) have suggested that the most commonly used individual-level theories of health behavior and behavior change include the Health Belief Model (HBM;Becker, 1974 ), Theories of Reasoned Action (TRA; Ajzen andFishbein, 1980 ) and Planned Behavior (TPB; Ajzen, 1991 ),Social Cognitive Theory (SCT; Bandura, 1986 ), and theTranstheoretical Model (TTM; Prochaska and DiClemente,1983 ). Newer theories, such as the Information Motivation Behavioral Skills Model (IMB; Fisher and Fisher, 2002 ) and thePrecaution Adoption Process Model (PAPM; Weinstein andSandman, 2002 ), have also been receiving increasing attention.

Available online at www.sciencedirect.com

Preventive Medicine 46 (2008) 275 280www.elsevier.com/locate/ypmed

Corresponding author. Fax: +1 859 257 4103. E-mail address: snoar2@uky.edu (S.M. Noar).

0091-7435/$ - see front matter 2007 Elsevier Inc. All rights reserved.doi:10.1016/j.ypmed.2007.08.001

mailto:snoar2@uky.eduhttp://dx.doi.org/10.1016/j.ypmed.2007.08.001http://dx.doi.org/10.1016/j.ypmed.2007.08.001mailto:snoar2@uky.edu

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While these theories all have differences among them, the vast majority contain common factors widely believed to be impor-tant to behavior and behavior change ( Fishbein et al., 2001; Noar and Zimmerman, 2005; Weinstein, 1993 ). In particular,most of the theories suggest that the most proximal influenceson health behavior are attitudinal, social influence, self-efficacyand intention/stage of change variables ( Fishbein et al., 2001; Noar, 2006 ), although differing terms are sometimes used for similar or identical concepts ( Nigg et al., 2002; Noar andZimmerman, 2005 ). While there is consensus on the importanceof a number of these theoretical factors to health behavior change, there is much less consensus as to how these factorscombine to predict the enactment of health behavior or health behavior change ( Fishbein et al., 2001; Noar and Zimmerman,2005; Weinstein, 1993 ).

In addition, while most of these theories describe factors that predict ongoing behaviors and as such have been termedtheories of behavioral prediction (Fishbein et al., 2001 ), the

TTM and PAPM focus more explicitly on behavior change , in particular as a progression through a series of discrete stages(see Noar, 2007; Weinstein et al., 1998 ). While theories of behavioral prediction are concerned with factors that serve asdeterminants of ongoing behaviors (typically in an attempt tounderstand why some individuals engage in a behavior whileothers do not), behavior change theories are focused more onidentifying the processes that individuals engage in when theyactually change their behavior ( Fishbein et al., 2001; Weinsteinet al., 1998 ). In the current article, we are focused on bothgoals understanding ongoing health behaviors as well ashealth behavior change. However, since the ultimate goal of all of the theories is to identifyfactors thatcan influence health behavior change (either naturally or through formalized interventions), our primary focus is similarly on health behavior change.

Traditionally, these health behavior theories have beenapplied in studies to a single behavior at a time, advancingour understanding of that particular behavior but providing littleguidance on multiple behaviors and the process of multiple behavior change. Next, we discuss some specific ways in whichthese theories might be applied to multiple behavior change.

Behavior change principles approach

Health behavior theories are attempts to describe why

individuals do or do not engage in particular health behaviorsand how individuals go about changing their unhealthy tohealthy behaviors. Thus, each theory suggests behavioral prin-ciples that are proposed to be common across health behaviors.That is, none of the theories listed above suggests that their application should significantly differ depending on which behavior is under study. Thus, if these theories apply equallyacross health behaviors, then a common set of behavior change principles could be derived and applied across health behaviors. From this perspective, one set of principles would be capable of explaining most or all health behaviors and anintervention might teach individuals the key principles of behavior change as well as how to apply those principles acrosshealth behaviors.

A critical question that must be asked, however, is whether there are in fact a common set of principles of health behavior change that transcend individual health behaviors. This is anarea where much data already exists, as health behavior theorieshave been tested across numerous health behaviors (typically, asingle behavior at a time) and could potentially be synthesizedand compared. The integration of findings from studies acrossdiverse behavioral areas, however, is not what it could be. Infact, theoretical reviews and meta-analyses of the literature tendto use a single behavior paradigm and thus often review theapplication of theory to a single behavioral domain, precludingcomparisons from being made.

Some examples of such an integrative approach, however, doexist. For instance, Godin and Kok (1996) reviewed studies of the TPB applied to numerous health-related behaviors. Acrossseven categories of health behaviors, they found TPB compo-nents to offer similar prediction of intention but inconsistent prediction of behavior. They concluded that the nature of

differing health behaviors may require additional constructs to be added to the TPB, such as actual (versus perceived) be-havioral control.

Prochaska et al. (1994) examined decisional balance acrossstages of change for 12 health-related behaviors. Similar pat-terns were found across nearly all of these health behaviors,with the pros of changing generally increasing across thestages, the cons decreasing, and a pro/con crossover occurringin the contemplation or preparation stages of change. Prochaskaet al. (1994) concluded that clear commonalties exist acrossthese differing health behaviors which were examined in dif-fering samples.

Finally, Rosen (2000) examined change processes from theTTM across six behavioral categories, examining whether thetrajectory of change processes is similar or differentacross stages of change in those health areas. He found that for smoking cessation,cognitive change processes were used more in earlier stages of change than behavioral processes, while for physical activity anddietary change, both categories of change processes increasedtogether. Rosen (2000) concluded that while the use of change processes varies by stage, these patterns differ across different health areas.

Clearly, more work is needed to better integrate the existingliterature in this area and more clearly understand whether acommon set of behavioral principles does indeed exist. In

particular, additional meta-analytic projects across behaviors arenecessary to shed light on potential common and/or uniquemechanisms of health behavior and health behavior change.Such a focus brings the field back to basic but compellingquestions such as whether or not there are theoretical differencesin addictive versus non-addictive behaviors, one-time behaviorsversus those that are maintained, and adoption versus cessation behaviors (see Noar and Zimmerman, 2005 ).

Global health/behavioral category approach

A second approach is the following: Rather than applyingtheoretical concepts to specific behaviors, such concepts might be applied at the general or global level in order to understand

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broader attitudes or orientations that may underlie the adoptionof multiple health behaviors. As appealing as this idea is, suchan approach has typically had little success. For example, Ajzenand Timko (1986) examined beliefs and attitudes of 24 health-related behaviors, including a variety of general health attitudes.Results indicated that a variety of general health attitudes werelargely unrelated to a number of health behaviors, while behavior-specific attitudes predicted behavior more precisely.Studies of self-efficacy have resulted in similar findings (e.g.,Ajzen and Timko, 1986; Bandura, 1997; Strecher et al., 1986 ).

Are such studies conceptualizing global health attitudes andself-efficacy in the right manner, however? That is, a generalorientation toward health may not lead directly to specifichealth behaviors, but it may increase the chances of particular health-related attitudes, which may in turn lead to specifichealth behaviors. In fact, although Ajzen and Timko (1986)found general health attitudes to be poor predictors of behavior,such attitudes were significantly related to specific health

attitudes and perceived behavioral control over specific behaviors. In addition, although Bandura (1997) suggests that

there is not a global health self-efficacy factor or trait, he doessuggest that there is some commonality to self-efficacy, par-ticularly when there is similarity in functions and sub-skillswithin a class of behaviors (see Bandura, 1991 ). Might there bean underlying general health orientation that could contribute toour understanding of multiple health behaviors and multiple behavior change?

Moreover, it is likely that when we consider multiple behav-iors that we may discover an entire network of health attitudesand beliefs that are interrelated. In fact, studies of single behaviors essentially take those behaviors out of the multi-attitude and multi-behavioral context in which they areembedded. For instance, although attitudes toward walkingmay be a better predictor of walking behavior than attitudestoward physical activity ( Ajzen and Fishbein, 1980 ), walking behavior is part of a larger physical activity behavioral category . While predicting that particular behavior may be best served by the specific measure, the larger category is both

relevant and of interest ( Hornik, 2007 ). Thus, it may be that there are higher order constructs to be understood here, in that

Fig. 1. Hypothesized hierarchical structure of health behavior attitudes.

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(1) global health attitudes predict attitudes (or global self-efficacy predicts self-efficacy) toward behavioral categories;(2) attitudes toward behavioral categories predict attitudestoward specific behaviors; and (3) attitudes toward specific behaviors predict those actual behaviors (see Fig. 1). Moreover,in the case of individuals affected by chronic diseases such ascardiovascular disease and diabetes, rather than general healthas an organizing construct, the disease itself (managed through aset of health behaviors) would likely be more appropriate. Thereis again a network of attitudes to be understood with regard tothe multitude of behaviors associated with management or prevention of chronic disease. Such an approach may move usin the direction of recognizing the broader context in whichhealth behavior operates, and may help us to uncover moregeneral health dimensions to be understood (e.g., an activelifestyle, successful aging, etc.).

Multiple behavioral approach

A third approach is a multiple behavioral approach, or onewhich focuses on the linkages among health behaviors. It sharessome similarities to the approach just described. Here the focusis more strictly on how particular health behavior constructsrelate to one another, however, and this approach raisescompelling theoretical questions as to how individuals actuallychange multiple health behaviors (e.g., sequentially or simul-taneously). Although most studies to date have not taken suchan approach, a few studies do exist to exemplify it.

King et al. (1996) applied constructs from the TTM (stage of change, decisional balance and self-efficacy) in order to examineassociations between exercise and smoking cessation variables ina work site sample of N =332 smokers. They found significant positive associations between the cons of smoking and prosof exercise as well as between self-efficacy to refrain fromsmoking and exercise self-efficacy. In addition, those further along the stages of change for exercise were more likely to report higher self-efficacy to refrain from smoking, and the reverse of this was also true. King et al. (1996) concluded that multiple behavior change may be more likely to occur sequentially (versussimultaneously), as those who had successfully changed one behavior were more likely to be motivated to change another.

Grembowski et al. (1993) examined self-efficacy and out-come expectancies in five health behaviors including exercise,

dietary fat intake, weight control, alcohol intake, and smoking in asample of N =2524 older adults. They found that self-efficacy beliefs for all five behaviors were inter-correlated, with small tomoderate correlations among the five. Smoking and alcoholintake, and exercise, diet, and weight control, respectively, werefound to make up two separate factors. Results for outcomeexpectancies were similar although all five expectancies werefound to form a single factor. In addition, self-efficacy for one behavior was found to correlate withoutcome expectancies for theother behaviors . Grembowski et al. (1993) concluded that although self-efficacy varies by behavior, there appears to besome generalityto self-efficacy in behavioralareas that are similar.

Finally, studies taking this approach have examined inter-relationships among stages of change for various health be-

haviors. Such studies have found smokers to be in earlier stagesof change for physical activity and dietary fat intake whencompared to non-smokers ( Emmons et al., 1994 ); statisticallysignificant associations among stages of change for exercise andnutrition ( Clark et al., 2005 ); and various associations amongstages of change for 10 health behaviors ( Nigg et al., 1999 ).These studies have raised the additional question of which behavior or behavior(s) individuals should try and change first,and whether there are so-called gateway behaviors. For instance, should smokers in the Emmons et al. (1994) study betreated for smoking, diet, or exercise first, or should treatmentsoccur simultaneously? These are additional questions in need of further investigation. While some of the answers may comefrom basic theory-testing research, it should also be acknowl-edged that experiments and interventions may be necessary inshedding light on theoretical questions in this area ( Rothman,2004; Weinstein, 2007 ).

Implications for interventions

Each of the approaches discussed in the current article hasimplications for interventions to change multiple health be-haviors. For instance, a behavior change principles approachsuggests interventions teach individuals common principles of behavior change as well as how to apply those principles to avariety of health behaviors. In fact, interventions such as LifeSkills Training have for years taken the approach of focusing ongeneral skills and abilities as a route to multiple behavior change (Botvin and Griffin, 2004 ). The Life Skills programemphasizes personal self-management skills, including deci-sion-making/problem-solving skills, media literacy, and emo-tional coping skills; social skills, including initiating socialinteractions and relationship/dating skills; and drug-relatedinformation and skills. Such a program, by teaching general life skills, encourages adolescents not only to reject drug use but to learn skills they can apply to other behavioral areas. Infact, even though Life Skills does not directly address sexual behavior, a recent evaluation found protective of effects of the program on later HIV risk behavior ( Griffin et al., 2006 ).

In addition, some emerging multiple behavior change inter-ventions have used what amounts to a behavior change prin-ciples approach. Namely, such studies have applied the sametheoretical model to numerous single behaviors and intervened

on those behaviors concurrently (e.g., Prochaska et al., 2005 ).Although the behaviors themselves are as diverse as smoking,diet, physical activity, and mammography, the theoretical principles used to drive behavior change are the same for allof the behaviors. Namely, positive aspects of the healthy behavior are highlighted while negative aspects are decreased,self-efficacy for the behavior is enhanced, and use of change processes which drive movement through the stages of change isencouraged ( Prochaska et al., 2005 ). In this manner, participantsmay internalize common principles of behavior changecommunicated to them across a number of health behaviors,which may result in synergistic change effects.

A global health/behavioral category approach suggests promoting broader-based health categories as routes to

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promoting specific health behaviors, such as promoting ahealthy lifestyle as a route to multiple behavioral changes. Infact, while promising interventions consistent with thisapproach exist for individuals with disease states such ascardiovascular disease and diabetes ( Goldstein et al., 2004 ),many fewer interventions exist for individuals who are healthyor who may become at risk for suchdiseases. A recent adolescent obesity prevention intervention in a rural setting illustrates suchan approach ( Hawley et al., 2006 ). The overriding focus of thisintervention is to achieve and maintain a healthy weight (i.e.,obesity prevention). This is accomplished through particular changes in the behavioral categories of diet and physical activity,which can be achieved through changes in a variety of specific behaviors. The specific actions taken may vary greatly from person to person, and such an approachputs a focus on the issue of choice. For example, whereas one individual may choose to havea very strict diet and only limited physical activity, another individual may make fewer dietary changes but focus more on

adopting vigorous physical activities. Such an approach wouldfocus on the outcome of healthy weight as a conceptual categoryto organizeand ultimatelydrive a multitude of possible behavioralchanges. As such, the intervention is organized around the broader health category of weight which, incidentally, wouldlikely be more motivating to an audience of adolescents ascompared to other broader-based health categories (e.g., healthylifestyle, heart health).

Finally, a multiple behavioral approach suggests interveningon behaviors that hold similarities or have relationships with oneanother, such as drinking and smoking ( Goldstein et al., 2004 )diet and exercise ( Clark et al., 2002 ), or drinking and risky sex(Brown and Vanable, in press ). In addition, such an approachsuggests interventions focus on sequential rather than simulta-neous changes in health behaviors, as individuals who haverecently successfully changed one behavior may be moremotivated (e.g., have higher self-efficacy) to try and changeanother ( Emmons et al., 1994; King et al., 1996 ). For instance,Spring et al. (2004) conducted a multiple behavior changeintervention with female smokers, targeting smoking cessation,diet, and exercise, and using the rationale that quitting smokingwould create a teachable moment for other health behavior changes, particularly those related to weight gain. Resultsindicated that weight control treatment did not underminesmoking treatment and results most strongly supported a

sequential approach in which smoking was treated first followed by weight control.

The issue of sequential versus simultaneous multiple be-havior change has already stimulated a variety of interventionstudies, with at least two interventions finding support for sequential over simultaneous multiple behavior change ( Springet al., 2004; Vandelanotte et al., 2007 ). Other studies, however,have found simultaneous multiple behavior change interven-tions to have beneficial effects ( Prochaska et al., 2004;Prochaska et al., 2005; Smeets et al., 2007 ) or to in fact besuperior to sequential interventions ( Hyman et al., 2007 ). Moreresearch is clearly needed on the critical question of how best to implement and sequence multiple health behavior interventions.

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