Icek Ajzen

University of Massachusetts Amherst

Influencing Health-Related Behavior: A Reasoned Action Perspective

May, 2001 Chambry, France

Theory of Planned Behavior

(Ajzen, 1985; 1991)
Attitude Toward the Behavior

Behavioral Beliefs and Ou tcome Evaluations

Normative Beliefs and Motivation to Comply

Subjective Norm

Intention

Behavior

Control Beliefs and Perceived Power

Perceived Behavioral Control

Actual Behavioral Control

Theory of Planned Behavior: Sample Applications

Meta Analysis of TpB Research Based on ~150 Data Sets: Average Correlations (Armitage &
Conner, in press) R2 = .39
Attitude Toward the Behavior

R2 = .27

.49 .34 Intention .43 .47 Behavior

Subjective Norm Perceived Behavioral Control

.37

Physical Exercise Among Hospitalized Cancer Patients (Courneya, Keats, & Turner, 2000)
R2 = .69
Attitude Toward the Behavior

R2 = .36

.51 .06* Intention .39 .32 Behavior

Subjective Norm Perceived Behavioral Control

.33

*not significant

Cannabis Use Over 3 Months Period

(Conner & McMillan, 1999) R2 = .65
Attitude Toward the Behavior

R2 = .72

.42 .11 Intention .43 .78 Behavior

Subjective Norm Perceived Behavioral Control

.09*
*not significant

Meta Analysis of Research in the Health Domain (Godin & Kok, 1996)
.39 Overall .42 .41 .29 .37 .52 .35 --.56 .50 .46 .44 .43 .30 .16 .33 .48 .32 .49 .34 .51 .26 .53 HIV/AIDS Exercising Eating Screening Clinical (n=58) Car Addictive (n=6) P I PBC with S B BC AN safety (n=13) Health Behavior (n=8) Behavior behaviors (n=11) Intention (n=4) Category Mean r (n=8)

Factors Attenuating Observed Relations in the TpB

Faulty measurement operations Unreliable measures Artificial dichotomization of intentions or behavior Lack of compatibility in target, action, context, or time elements Lack of scale compatibility Restriction of range and lack of correspondence in marginal distributions

Behavioral Interventions in the TpB: Basic Principles

Intentions can be modified in two ways

By changing the major determinants of intentions: Attitudes, subjective norms, and/or perceptions of behavioral control By changing the relative weights of the three determinants

Changes in intentions will result in behavioral change to the extent that

the intention is directly compatible with the behavior the person has adequate control over the behavior

Getting Information About Accessible Behavioral, Normative, and Control Beliefs

Elicit accessible beliefs using open-ended questions

Outcome evaluations: Advantages & disadvantages; likes and dislikes associated with the behavior Normative referents: People or groups who approve or disapprove; perform or do not perform the behavior Control factors: Factors that make performance of the behavior easier or more difficult

Construct lists of accessible personal or modal behavioral, normative, and control beliefs

Constructing a Standard TpB Questionnaire

Direct measures

2 or 3 items, usually in semantic differential format, to assess attitude, subjective norm, perceived behavioral control, and intention Behavioral beliefs and outcome evaluations Normative beliefs and motivations to comply Control beliefs and perceived power

Beliefs strength and scale value

Assessment of behavior: Observation or self-report Regression or structural equation analyses are used to evaluate the predictive power of the model, and to establish the relative weights of attitudes, subjective norms, and perceptions of behavioral control

Targeting the Intervention: General Considerations

Mean levels of predictor variables

Consider possible floor or ceiling effects Generally, it is safer to target an intervention at the component(s) that account for more variance However, interventions directed at a component with a low regression weight can also be effective

Relative weights of predictor variables

Belief strength vs. scale value Existing accessible beliefs vs. new beliefs Success depends on change in the total set of beliefs

Designing and Pretesting the Intervention

The TpB provides general guidelines and suggests possible target beliefs. Designing the details of an effective intervention depends on the investigators experience and creativity. Possible approaches

Persuasive communication (ads, flyers, lectures) Face-to-face discussions Observational modeling Simulations

Pretesting to establish that the intervention influences the beliefs it was designed to change, and that it does not have unanticipated (and undesirable) impact effects on other beliefs

Taking the Bus to Campus (Bamberg, Ajzen, &

Schmidt, in press)

Population: College students at the University of Giessen, Germany Behavior: Self-reported bus use to get to the campus Intervention: Prepaid semester bus ticket, accompanied by an extensive informational campaign.

Taking the Bus to Campus: Intervention Outcomes (Bamberg, Ajzen, & Schmidt, in press)
1994 Attitude Subjective Norm Perceived Behavioral Control Intention Behavior (%) 2.31 2.24 2.14 1.65 .15 1995 2.60* 2.46* 3.00* 2.11 .36*

TpB Intervention: Job Search Behavior (van

Ryn & Vinokur, 1992)

Attitude Toward the Behavior

R2 = .64 .47 .31 .24

R2 = .52

Subjective Norm Intervention

Intention

Behavior

.06 .24 Perceived Behavioral Control .06

One-month Post-test

Joining an Alcohol Treatment Unit (Fishbein,

Ajzen, & McArdle, 1980)

Population: Veterans diagnosed as alcoholics

50% originally willing to join ATU

Behavior: Joining the ATU immediate post-test Intervention: 15-minute persuasive appeal by the director of the ATU

Two types of appeal (1) Traditional threat appeal (2) Theory-based appeal No message control group

Traditional Threat Appeal

(Fishbein, Ajzen, & McArdle, 1980)

Continued drinking of alcohol linked to 10 negative outcomes, e.g.,

Ruined physical and mental health Poorer relationship with family and employer Less help from hospital staff Less self-government while in the hospital

Recommendation: Joining the ATU will give you the opportunity to solve your drinking problem. Therefore, I urge you to sign up for the ATU now!

Percentage Signing Up for the ATU

(Fishbein, Ajzen, & McArdle, 1980)

55% 50% 45% 40% 35% 30% 25%

No message control

Traditional appeal

Pre-message

Post-message

Theory-Based Appeal
(Fishbein, Ajzen, & McArdle, 1980)

Not signing up for the ATU linked to 10 negative outcomes, e.g.,

Ruined physical and mental health Poorer relationship with family and employer Less help from hospital staff Less self-government while in the hospital

Recommendation: You will only be hurting yourself if you dont sign up for the ATU. Therefore, I urge you to sign up for the ATU now!

Change in Targeted Beliefs (Fishbein, Ajzen, &

McArdle, 1980)

7 6 5 4 3 2 1 0 Traditional Theory-Based

Appeal

Impact on Relevant Non-Targeted Beliefs

(Fishbein, Ajzen, & McArdle, 1980)

6 5 4 3 2 1 0 -1 -2 Traditional Theory-Based

Appeal

Percentage Signing Up for the ATU

(Fishbein, Ajzen, & McArdle, 1980)

65% 60% 55% 50% 45% 40% 35% 30% 25%

Theory-bas ed appeal

No message control

Traditional appeal

Pre-message

Post-message

Testicular Self-Examination
(Murphy & Brubaker, 1990)

Population: 10th grade students in health classes Behavior: Self-reported TSE 4 weeks following intervention Intervention: Persuasive communication 3 conditions

TpB-based: 12-minute videotaped message designed to strengthen AB , SN, and PBC toward performing TSE Cancer information: Audio-visual slide presentation providing general information about testicular and other cance rs Health information control: Pamphlet about health in general

Testicular Self-Examination: Intervention Outcomes (Murphy & Brubaker, 1990)

4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 -0.5 ATT INT BEH 45% 40% 35% 25% 20% 15% 10% 5% 0% Health Control Cancer Info TpB - TSE
Behavior

Attitude / Intention

30%

Testicular Self-Examination
(Brubaker & Fowler, 1990)

Population: College students Behavior: Self-reported TSE 1 week and 4 weeks following intervention Intervention

TpB-based: 10-minute audiotaped message providing information about TSE and focusing on outcomes of TSE No-message control

Testicular Self-Examination: Intervention Outcomes (Brubaker & Fowler, 1990)

TpB Message Attitude Subjective norm Perceived control Intention TSE 1 week (N = 97) TSE 4 weeks (N = 89) 20.05 1.85 6.05 1.73 23% 31% No Message 15.73* 0.30* 4.32* 0.85* 12%* 13%*

Testicular Self-Examination: Path Coefficients (Brubaker & Fowler, 1990)

Transtheoretical Stages of Change Model

(Prochaska & DiClemente, 1983)

Different intervention strategies may be required at

different stages of intention formation and action

Precontemplative stage Contemplative stage Preparation stage Action stage Maintenance stage

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}

Target: Goal intentions Target: Implementation intentions

TpB Constructs by Stage of Exercise Readiness (Courneya, 1995)

2.5 2 1.5 1 0.5 0 -0.5 Pre-cont. Cont. Prep. Action Maint. INT PBC ATT SN

Effects of Cardiovascular Risk Assessment and Discussion (Boudreau, Godin, Pineau, & Bradet, 1995)
12 11
Intention

Behavior at 2 months

4 9 8 7 6 No interventi on Interventi on 2
Immediate intention

P hysical Exercise

Median Percentage Acting and Not Acting in Accordance with Intentions (Sheeran, in press)

Behaviors: 6 studies on condom use, cancer screening, and exercise

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Inte ntion Be havi or + Be havi or -

Intention +

Behavior

10

Implementation Intention: Taking Daily Vitamin C Pills (Sheeran & Orbell, 1999)

Population: College students Behavior: No. vitamin C pills missed, 10 days and 3 weeks after intervention Intervention: Implementation intention (when and where to take the pills)

Effect of Implementation Intention on Taking Daily Vitamin C Pills (Sheeran & Orbell, 1999)
4 3.5
No. Pills Missed

3 2.5 2 1.5 1 0.5 0

Impl. Int. No Impl. Int.

Pill Count

Self-Report

Pill Count

Self-Report

After 10 Days

After 3 Weeks

Implementation Intention: Cervical Cancer Screening (Sheeran & Orbell, 2000)

Population: Women registered at a health center in rural England Behavior: Getting a cervical smear test in the next 3 months Intervention: Implementation intention (where, when, and how to make an appointment for the test)

Intentions and Actual Attendance of Cervical Cancer Screening (Sheeran & Orbell, 2000)
95% 90% 85% 80% 75% 70% 65% 60% 55% 50%

Behavior

No implementation intention

Implementation intention

Implementation Intention: Breast SelfExamination (Orbell, Hudgkins, & Sheeran, 1997)

Population: Female college students and administrators Behavior: Performing BSE; 1 month follow-up Intervention: Implementation intention (when and where to perform BSE)

Percent Women Performing BSE (Orbell, Hodgkins,

& Sheeran, 1997)

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All Participants Prior Intenders

No Impl. Int. Impl. Int.

Behavior

Prior NonIntenders

TpB: Hypothesized Effects of Implementation Intentions

Attitude Toward the Behavior

Subjective Norm

Intention

Behavior

Implementation Intention

Perceived Behavioral Control

Actual Behavioral Control

Conclusions

TpB can be used to identify possible targets for an intervention. Using a prospective design with a control group, the effects of the intervention can be traced through the determinants of intentions. Interventions that effect a change in intentions can have a sizable impact on behavior. The effect of the intervention can be strengthened by induction of implementation intentions.

The End