DOSSIER
THE CONTRIBUTION OF
PSYCHOLOGICAL THEORY TO THE
UNDERSTANDING OF HEALTH
BEHAVIOUR CHANGE AND
MAINTENANCE.
APPLICATIONS TO EXERCISE
Ma i Sø ensen
ABSTRACT: Human beha iou is s ill mys e ious. Why do we do wha we do? Why do we some imes no
do wha we wan o do? Why is i so di icul o change habi s? The pu pose o his pape is o examine how
gene al psychological heo y o heal h beha iou change and main enance con ibu e o he unde s anding
o ini ia ing and main aining exe cise beha iou . Some popula models o iden i y wha psychological ac o s
in luence ou heal h beha iou and some models ha y o desc ibe he p ocesses o heal h beha iou
Co espondence: Ma i Sø ensen. The No wegian Uni e si y o Spo and Physical Educa ion. Box
4014, Ulle aal hageby, 0806 Oslo, No way. Fax. + 47 22185718.
REVISTA DE PSICOLOGÍA DEL DEPORTE
So ensen, M. (1997)
The con ibu ion o pysichological heo y...
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change and main ainance a e examined and discussed in ela ion o exe cise beha iou .
RESUMEN: La conduc a humana sigue siendo mis e iosa. ¿Po qué hacemos lo que hacemos?. ¿Po qué a
eces no hacemos lo que end íamos que hace ?. ¿Po qué es an di ícil cambia de hábi os?. El p opósi o
de es e a ículo es examina cómo la eo ía gene al psicológica del cambio y man enimien io de conduc as
saludables puede con ibui al en endimien o de la iniciación y el man enimien o de la conduc a de eje cicio
ísico. Se discu en y examinan algunos modelos que iden i ican cuáles son los ac o es psicológicos que
DOSSIER: THE CONTRIBUTION OF PSYCHOLOGICAL THEORY... / M. SØRENSEN
Heal h and heal h beha iou
The way we hink abou heal h has changed in ou pa o he wo ld, wi h he
changing pa e ns o illness. Disease and mo ali y a e now o a much g ea e ex en
han be o e caused by li es yle and en i onmen al ac o s. Psychological heo y is he
heo y abou beha iou and men al p ocesses,and i could be a gued ha psychology
has con ibu ed o new ways o hinking abou heal h. Ques ions abou beha iou al
causes o illness and heal h a e now a cen al ocus in mode n medicine. Howe e ,
he e i is consciously a oided o p esen one de ini ion o heal h, because in his
con ex i is mo e impo an o de e mine wha heal h concep is held by he indi idual.
This will a y wi h cul u al backg ound, age, gende and social class, o men ion some
a iables (Co nwell,1984; Naidoo and Wills, 1994; Sek, Scigala, Pasikowski, Beise
and Bleja, 1993). As an example: Some moun ain climbe s asse ed ecen ly in a
newspape ha isk beha iou con ibu es o hei heal h by gi ing li e mo e meaning
and joy (Dagblade , May, 1997). Ob iously, o he s would no sha e hei heal h
de ini ion.
E en i a heal h de ini ion may be a pe sonal p e e ence, some ypes o beha iou
a e gene ally ag eed upon as impo an o heal h. Taking isks may be conside ed
heal hy by some, bu inju y is gene ally conside ed de imen al o hela h, as is alcohol
o d ug abuse, smoking, nega i e s ess o e long pe iods, e c. O he beha iou s a e
gene ally accep ed as posi i e o heal h, such as main aining a balanced die , ge ing
a easonable amoun o exe cise, enough sleep, engaging in posi i e ela ionships
wi h o he s, e c. When conce ned wi h heal h beha iou change, I choose o ocus on
a change in beha iou owa d mo e posi i e heal h p omo ion o p o ec ion. I may be
o adop a new posi i e beha iou , like mode a e exe cise, o educe o change a
de imen al ype o beha iou , like physical inac i i y. Psychological heo ies y o
explain why and how some ac o s in luence heal h beha iou , and y o iden i y
ac o s ou side he indi idual ha a e in ol ed in he p ocesses o changing beha iou
main enenance o such beha iou .
Di e en app oaches o heal h beha iou change
Because heal h beha iou is so di e se and complex, he e a e many ideas abou
how o in luence i , and i is ha dly ealis ic o ind one uni e sal way. A emp s o ind
in e ela ionships be ween di e en heal h beha iou s ha e mos ly no suppo ed he
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idea ha people simply can be classi ied in o hose who li e heal hy li es and hose
who do no (K onen eld, Goodyea , Pa e, Blai , Howe, Pa ke and Blai , 1988;
S ephens, 1986).
Di e en ypes o psychologic heo ies y o explain beha iou change in di e en
ways. Psychodynamic heo y has mos ly been applied in clinical app oaches o
indi iduals wi h men al dis u bances. The means o ini ia e change a e a emp s o
b ing o consciousness he unconscious p ocesses ha go e n unwan ed beha iou
and dis u b men al heal h, in o de o gain con ol. Humanis ic heo y ocus on
empowe men (which is he indi idual’s abili y o di ec his o he own li e), sel
esponsibili y and human g ow h.
In he a ea o gene al heal h p omo ion and heal h beha iou change, he ocus
has been on lea ning heo y and cogni i e heo y. Lea ning heo y de eloped basic
p inciples o how en i onmen al ac o s a ec lea ning by esponden condi ioning,
ope an lea ning and s imulus con ol. A mul i ude o app oaches ha e been
de eloped. Classical condi ioning is used o changing unwan ed beha iou , and was
he basis o a e sion he apy, whe e in ake o alchohol was linked wi h an a e si e
s imulus, eal (as gi ing omi ing inducing d ugs wi h alchohol, Leme s and Voeg lin,
1950) o imagina y (Elkins, 1975). Ope an condi ioning ocus on he ela ionship
be ween a beha iou and i s consequences, such as c ea ing sys ems o p esen ing -
o wi hd awal- o ewa ds o speci ic ypes o beha iou . Con olling s imuli ha
occu s be o e a beha iou , is ano he way o using lea ning heo y.
These a e among he basic echniques in beha iou modi ica ion, and may exe
s ong in luences o e heal h beha iou . Howe e , in o de o wo k e icien ly, a g ea
deal o sys ema ic con ol is o en necessa y. Besides, we lea n in o he ways, oo
(Bandu a, 1986), o ins ance by wa ching o he s. Cogni i e p ocesses and a pe son’s
abili y o in luence his o he en i onmen a e no aken in o conside a ion in
app oaches based on classic lea ning heo y.
Wi hin cogni i e heo y, se e al models ha e been de eloped o desc ibe he
ela ionship be ween beha iou and cogni i e ac o s like pe cep ions, belie s,
a i udes, and no ms. Cogni i e heo y is used o iden i ying and co ec maladap i e
hough s ha causes p oblem beha iou and is called cogni i e es uc u ing
(Meichenbaum, 1977). Many beha iou modi ica ion p og ams d aw on se e al
heo ies in b oad spec ed app oach, such as Sel di ec ed beha iou change
p og am which is used o each people skills o ake con ol o e own beha iou . Bo h
goal speci ica ion, decicion making, sel moni o ing,, s imulus con ol, sel
ein o cemen , social suppo and beha iou ehea sal a e usual me hods in such
p og ams.
Cogni i e and social cogni i e models
A ocus on he ole o cogni ions in heal h beha iou esul ed in he de elopmen o
The Heal h Belie Model (HBM) ( Maiman and Becke , 1974). The HBM was
de eloped in o de o unde s and a lack o compliance wi h p e en i e heal h ca e
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beha iou (Maiman and Becke ,1974). Fou ypes o belie s we e pos ula ed o
in luence he likelyhood o engaging in heal h beha iou ele an o a speci ic heal h
p oblem. The hypo hesis is ha i he e exis s a pe cep ion o a h ea o pe sonal
heal h, i he condi ion in ques ion is pe cei ed as se e e, and he e is a con ic ion
ha a speci ic beha iou will success ully diminish his h ea , he pe son will be mo e
likely o engage in ha beha iou . Added o his is a cos /bene i analysis, whe e
pe cei ed ba ie s o he ac ion is weigh ed owa ds he bene i s. The model has la e
been ex ended o include some kind o cue o a igge o be p esen o people o ac ,
o ins ance illness o somebody close.
The Heal h Belie Model has been widely used as a basis o heal h p omo ion
campaigns and educa ional p og ams, and has gene a ed a lo o esea ch on a
a ie y o heal h beha iou s. The esea ch has, howe e yielded mixed esul s, and
he model seems o wo k he bes o he kind o beha iou i was de eloped o
(Cummings, Je e, B ock and Hae ne ,1979). In a eas as smoking (Flay, 1985), d ug
use (Do n, 1986) and exe cise (Biddle and Mu ie, 1991) i does no appea o be so
success ul.
The c i icism o he model ela e o he ac ha i conside s complex beha iou only
as a sum o pa s, and he assump ion ha hese pa s a e equally impo an . Ano he
p oblem is ha in many si ua ions people ha e been ound o demons a e un ealis ic
op imism abou hei si ua ion. Especially younge indi iduals seem o ha e “an illusion
o in ulne abili y”in ela ion o isk beha iou such as sexual beha iou and AIDS (Cli e
al, 1989) and physical isky ac i i ies, bu also wi h o he heal h beha iou s. On he
o he hand, i is known ha pe cep ion o h ea and se e i y may e oke ea induced
de ense mechanisms (Le en hal, 1980), making people esis change.
Ano he basically cogni i e model ocus on he in luence o in en ions on beha iou
in gene al. The model was i s called Theo y o Reasoned Ac ion (Ajzen & Fishbein,
1980), and s a es ha a pe son’s beha iou can be p edic ed by in en ions. In en ion
is a unc ion o a i ude owa ds he beha iou , which again is in luenced by pe cei ed
consequences o he beha iou and hough s abou wha o he s expec . The heo y
di e s om The Heal h Belie Model mainly in how social no ms and he in luence o
signi ican o he s a e included as de e mining ac o s.
One p oblem wi h his model has been ha o olun a y con ol. As he assump ion
was ha in en ion would p edic beha iou , i would only be applicable o beha iou s
unde olun a y con ol (S oebe & S oebe, 1995). As mos o us know, he old
saying abou “ he spi i being willing, bu he lesh weak” holds conside able u h; a
lo o heal h beha iou , a e no always unde con ol o he will, many ac o s can
weaken good, e en s ong and ela i ely s able in en ions.
In line wi h his kind o c i ique, he model was modi ied and enamed Theo y o
Planned Beha iou ( TPA) (Ajzen, 1991). Pe cei ed beha iou al con ol was included
bo h as an indi ec in luence h ough in en ions, bu also unde ce ain ci cums ances
as a di ec in luence on beha iou . This imp o ed p edic ion o bo h in en ions and
beha iou in empi ical esea ch (Ajzen, 1991).
The pe cep ion o con ol as used in TPA, has a lo in common wi h sel e icacy in
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social cogni i e heo y de eloped by Bandu a (1977, 1986). Building on ea lie o ms
o social lea ning heo y (e. g. locus o con ol), his model assumes he mo i a ional
ac o o be he pe cep ion o being able o do wha is necessa y o ob ain an
expec ed ou come. Two cogni i e p ocesses a e hough o be in luen ial o e
beha iou ; ou come e icacy, which is he belie ha an ac ion will p oduce a speci ied
e ec (do you expec ha a pa icula exe cise p og am will make mo e physically i ),
and sel e icacy expec a ions which is he belie in one’s capaci y o pe o m ha
beha iou (do you hink you can show he neccessa y discipline o keep i ).
Acco ding o he heo y, sel e icacy is de eloped by mas e y expe ience o
pe o mance accomplishmen s, by model lea ning o ica iuos lea ning, by e bal
pe suasion om o he s, and om coping wi h o posi i e in e p e a ion o
physiological a ousal in he si ua ion (Bandu a, 1986). Sel e icacy has been
documen ed o apply o heal h ela ed beha iou (Ewa , Taylo , Reese and DeBusk,
1984), and has been ound o be a easonably good p edic o o he ex en o which
people comply wi h medical egimens (O’Lea y, 1992; Dzewal owski,1989), and o
eliably a ec pe sis ence in exe cise (McAuley and Jacobson,1991; McAuley, 1992).
Ha ing p o en a ela i ely powe ul p edic o o beha iou and pe sis ence, he sel
e icacy heo y has in luenced u he de elopmen o heo e ical models in his ield,
as well as p ac ical beha iou modi ica ion s a egies. Se e al o he models ha e
been de eloped, mos o hem ying in di e en ways o combine he mos use ul
cons uc s om hese basic models, and using hem in di e en ways. Examples a e:
P o ec ion Mo i a ion model (Roge s and Mewbo ne, 1976), Heal h Ac ion model
(Tones, 1987)
The p ocess o change
So a we ha e looked a wha ac o s a e in ol ed in heal h beha iou change,
ano he ma e is ha change in beha iou is a p ocess, i may occu g adually.
James P ochaska and Ca lo Di Clemen e (1984) obse ed in hei wo k as
psycho he apis s ha people seemed o go h ough simila s ages o beha iou al
change, ega dless o wha psycho he ape ic app oach was used. They desc ibed
hese changes in a ans heo e ical model wi h wo basic elemen s: s ages o change,
and p ocesses o change. The s ages a e p econ empla ion, whe e no change is
hough abou o in ended, con empla ion, whe e a hough abou making a change is
p esen , bu people a e no ye eady. In he p epa a o y s age he indi idual is ge ing
con inced abou making he change and p epa e o i . The ac ion s age is ying ou
he new beha iou , and he main enance s age is when he beha iou is con inued.
The model also conside s elapse as a s age and no necessa ily a ailu e o he
p ocess. The model sugges s ha di e en s a egies a e needed o enhance he
p ocess a he di e en s ages, o ins ance ha whe eas in o ma ion is impo an in
he p econ empla ion and con empla ion s age, goal se ing and ein o cemen a e
mo e impo an in he ac ion phase, and social suppo in he main enance s age. The
model has been s udied and demons a ed o be use ul in ela ion o se e al heal h
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DOSSIER: THE CONTRIBUTION OF PSYCHOLOGICAL THEORY... / M. SØRENSEN
beha iou s; mos ex ensi ely wi h smoking cessa ion (Di Clemen e, P ochaska,
Fai hu s , Velice , Velasquez and Rossi, 1991), bu also wi h alchohol ea men , (Di
Clemen e and Hughes, 1990), weigh con ol (O’Connell and Velice , 1988), and
exe cise (Ma cus and Simkin, 1993), among o he s. The e exis o he s age models
(e. g. Schwa ze ,1992,), bu he basic no ion as we ind i in he ans heo e ical
model, is simila .
Compa isons o models. A emp s on syn hesis
I ha e chosen o ocus on some models and heo ies ha ha e gene a ed
ex ensi e esea ch o he cons uc s included. The models ha e also been compa ed
as o e ec i eness in changing heal h beha iou (e. g. Dzewal owski, 1989), and in
gene al; i seems as i me hods based on social cogni i e and lea ning heo y ha e
p o ed o be he mos e ec i e. A emp s ha e also been made o blend impo an
heo e ical ideas in o a syn hesis. Ba anowski (1992) e alua ed and compa ed i e
heo ies, applied he s ages o change model, and p esen ed a syn heo e ical model
o belie s as mo i a o s in he beha iou change p ocess. In addi ion o he heo ies
al eady desc ibed, he also d ew on Di usion o Inno a ion, a sociological desc ip ion
o how new knowlegde o new beha iou sp ead in a communi y. New elemen s a e
hough o di use in o he popula ion s a ing wi h he inno a o s, hen ea ly adop e s
ollowed by he ea ly majo i y. La e he la e majo i y will adop he new, and las ly he
lagga ds, he inal 15-16% who a e es is an o change.
Di e en componen s o he model a e hough o be impo an o he di e en
ypes o eadiness o change (e.g. inno a o s e sus lagga ds) and a di e en
s ages o change. The model so a is specula i e and in need o empi ical es ing, as
is he case wi h o he comp ehensi e models (Schwa ze , 1992). This ype o models
a e e y complex, a e di icul o es ou empi ically, bu may se e as use ul ools as
amewo ks o p ac ical applica ions.
Di e en heal h beha iou s
As men ioned ea lie , he e is no a consis en ela ionship be ween di e en heal h
beha iou s, and i has become appa en ha di e en heal h beha iou s demand
di e en heo e ical app oaches. In ui i ely i seems easonable ha di e en
mechanisms ope a e o mo i a e ac ion ha demands ime, e o and e en swea ,
compa ed o less demanding ac ions as ha ing a heal h check up, o o con ol o
ex inc ion o unwan ed beha iou such as alchohol o d ug abuse. As an example, le
us ake a b ie look a exe cise beha iou .
Se e al esea che s ha e ied o de elop exe cise and i ness speci ic measu es
o gene al heal h psychological heo ies in o de o explain exe cise beha iou ,
especially wi hin amewo ks o locus o con ol heo y, and sel concep heo y
amewo k ( o a de ailed o e iew, see Biddle & Mu ie, 1991). The esul s ha e
been a ied, and i seems ha social-cogni i e models a bes accoun o less han
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40 % o he a iance in exe cise beha iou . Dealing p ima ily wi h p edisposing
ac o s o beha iou , his may no be su p ising (Godin, 1994). Howe e , in he
exe cise a ea, he cogni i e models such as heal h belie s and heo y o planned
beha iou ha e p o en o be less powe ul in explaining exe cise beha iou han sel
e icacy heo y (Biddle & Mu ie, 1991; Dishman, 1994;. Schwa ze , 1993; Sø ensen,
1997 b). I has been a gued ha he a i udes and belie s seem o be e explain
seden a y beha iou han physical ac i i y (Biddle & Mu ie, 1991). I has also been
sugges ed ha sel p esen a ional conce ns, e.g. o look in a be e shape, may be as
impo an o adop ing physical ac i i y as heal h conce ns (Lea y, 1992), and sel
pe cep ions ela ed o exe cise has been demons a ed o play a ole in de elopmen
o exe cise beha iou (Kendzie ski, 1990, Sø ensen, Ande ssen, Hje man, Holme &
U sin, 1997). The e is also e idence ha men and women s a exe cising o di e en
easons; men esponding mo e o s imuli in he physical en i onmen , and women
esponding mo e o social in luences (Sallis, Ho ell & Ho s e e , 1992).
Se e al beha iou change in e en ions based on lea ning heo y and social
lea ning heo y ha e been used wi h success o inc easing main enance o exe cise
beha iou , o e iews, see Dishman, (1994) and King, (1994). Bu e en so, o
main enance o exe cise beha iou , he expe ience wi h he ac i i y, he a ec i e
s a es and he physiological eedback gene a ed by he ac i i y a e likely o be
impo an . I has been di cul o ind suppo o a di ec ela ionship be ween he
physiological and he psychological a iables (Moses, 1994). Howe e , in ou
esea ch, we ound ha engaging in physical exe cise esul ed in a posi i e eedback
loop whe e enhanced sel pe cep ions and physiological changes accoun ed o 43 %
o he a iance in exe cise compliance in a one-yea s udy (Sø ensen, 1997 a).
Ob iously, he e a e some o e laps in heo e ical conside a ions o impo ance o
di e en heal h beha iou s, bu he e seems o be a need o de elop heo ies ha a e
speci ic o di e en ypes o heal h beha iou s, and in exe cise, i seems impo an o
apply a biopsychological app oach
C i ique o he heal h beha iou models
The mos widely used models om gene al psychology o heal h beha iou hus
seem o be o a somewha limi ed alue o explain exe cise beha iou . The e seems
o be se e al me hodological p oblems in ope a ionalisa ions and measu emen o
some o he cons uc s sugges ed in he di e en heo e ical models, and he e is a
need o u he de elopmen o models ela ed o di e en heal h beha iou s, as
exe cise. Gene al heal h psychology as a ield has also gene a ed some c i icism
which should be conside ed. Some poin s will e y b ie ly be summa ized:
I has been poin ed ou ha in heal h psychology a basic assump ion in his way o
looking a heal h p oblems is ha people a e a ional and wan o li e a heal hy,
egula ed li e. Fu he , ha by ollowing ad ice om expe s in he ield, people can
lea n wha is good o hem, and how o li e hei li es (Kimiecik & Lawson, 1996).
Heal h psychology p o essionals ha e been accused o exe ing o much ex e nal
con ol (S ain on Roge s, 1991), and ha e oo li le espec o indi iduals’ pe sonal
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heal h de ini ions.
Feminis ic heo y poin ou ha gende di e ences in cogni ions and pe cep ions
a e no gi en enough a en ion (Bem, 1993). Mos o he heal h beha iou models do
no ake in o conside a ion ha males and emales expe ience he wo ld di e en ly
and hold di e en alues, which will ha e implica ions o heal h beha iou change
and main enance.
Basing in e en ions and educa ion on cons uc s like pe cei ed ulne abili y and
se e i y has been seen as a emp s o con ol people by playing oo much on ea ,
and he eby educe eedom o li e (Lup on. 1993).
A majo issue in he c i ique has been ha heal h psychology is ocusing oo much
on he beha iou al aspec and iews heal h as a pe sonal ouble, and lack o heal as
a de ici (Ingham, 1985) ega dless o li e si ua ions and ac ual possibili ies. Aa ø
(1986) concluded ha heal h “pa ly depends on social class and social en i onmen ,
and o ocus excusi ely on he li es yle explanan ion would be o u n a social p oblem
in o an indi idual one”(p.144).
Some o hese issues a e impo an o conside , also in ela ion o heal h ela ed
exe cise and hey should inspi e new app oaches. As an example o a di e en end,
Williams, Deci & Ryan (1996) a gue ha de elopmen and suppo o sel
de e mina ion and au onomous mo i a ion lead o mo e posi i e heal h s a us, be e
men al heal h and main ained beha iou change.
Conclusion
Gene al heal h psychological heo ies p o ide se e al concep ual amewo ks ha
help ou unde s anding o heal h beha iou change and main enance. Heal h
psychology and exe cise psychology esea ch has been domina ed by lea ning heo y
and cogni i e/ social - cogni i e models. These models ha e in gene al been only
mode a ely success ul in p edic ing exe cise beha iou , and he e seems o be a
need bo h o de elop mo e exe cise speci ic models as well as applying o he ypes o
amewo ks. The need o include bo h physiological and en i onmen al ac o s has
been add essed conside able ime ago. An o he in e es ing a enue may be o
in es iga e models like empowe men , au onomy and sel de e mina ion as basis o
ini ia ion and main enance o exe cise.
Re e ences
Aa ø. L.E. (1986). Heal h beha iou and socioeconomic s a us. A s a us among he
adul popula ion in No way. Doc o al hesis, Be gen: Uni e si y o Be gen.
Ajzen, I. (1991). The heo y o planned beha iou . O ganiza ional Beha io and
Human Decicion P ocesses, 50, 179-211.
Ajzen, I. and Fishbein, M. ( 1980). Unde s anding A i udes and p edic ing Social
beha iou . Englewood Cli s, NJ.: P en ice Hall.
Bandu a, A. (1986). Social Founda ions o Though and Ac ion: A Social Cogni i e
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