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Institute of Medicine (US) Committee on Comprehensive School Health Programs in Grades K-12; Allensworth D, Lawson E, Nicholson L, et al., editors. Schools & Health: Our Nation's Investment. Washington (DC): National Academies Press (US); 1997.

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Schools & Health: Our Nation's Investment.

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Appendix CModels of Health Behavior Change Used in Health Education Programs

Ken Resnicow, Ph.D.

Health education programs have been informed by several theoretical models of health behavior change including the Health Belief Model, the Theory of Reasoned Action, and the Operant Learning Theory (Skinner, 1974). Over the past 10 years, however, one model, the Social Cognitive Theory (SCT) (Bandura, 1986; Bandura, 1995; Perry et al., 1990) has become perhaps the dominant theoretical framework for health education. The emergence of SCT as the preeminent model within health education can be attributed to several factors. First, whereas the Health Belief Model (Rosenstock, 1988; Rosenstock, 1990) and the Theory of Reasoned Action/Planned Behavior (Ajzen and Fishbein, 1972; Ajzen and Madden, 1986) focus primarily on cognitive factors, SCT extends beyond knowledge and attitude domains to include behavioral elements, such as social skills, and environmental influences. Second, whereas the Health Belief Model, the Theory of Reasoned Action, and the Operant Learning theory focus essentially on individual-level behavior (Rosenstock, 1988; Skinner, 1974), SCT addresses the behavior of social groups and the dynamic interaction of the individual within the larger social context. Consequently, SCT may be a more appropriate model for designing comprehensive school health programs (CSHPs), which include both individual and environmental interventions. Given the predominance of SCT in the current health education paradigm, a brief overview, including a discussion of how this model can guide the development of health education programs, is provided.

Social Cognitive Theory: An Overview

At the core of Social Cognitive Theory is the triadic model comprising person, behavior, and environment. This model addresses the behavior of individuals and social groups, and their dynamic interaction, referred to as reciprocal determinism, is an essential element of SCT (Bandura, 1986; Bandura, 1995). To illustrate, individual person-level factors, such as outcome expectations and self-efficacy, may increase the likelihood of an individual's executing a behavior; conversely, the behavior of an individual within a defined social group (e.g., school) can shift norms among others within that shared social environment, which in turn may influence personal motivation (e.g., outcome expectations) and subsequent behavior. Environmental factors can also influence behavior (e.g., availability of healthful foods in the school cafeteria), serving either to enhance or to suppress individual motivation. Comprehensive school health education programs similarly include both individual and environmental intervention. Specifically, health education curricula tend to focus on person-level factors, whereas other elements of the CSHP program, such as healthy environment or school policy, foodservices, and community involvement, largely address environmental factors.


Self-efficacy (SE) plays a central role in SCT. SE is defined broadly as the confidence in one's ability to execute a specific behavior or set of behaviors. In other words, if a student does not feel confident in his or her ability to resist peer appeals to use drugs, the likelihood of employing appropriate communication skills is diminished; similarly, low efficacy regarding athletic performance may inhibit involvement in physical activity. Two fundamental assumptions regarding SE are critical to understanding its importance in SCT. First, Bandura (1986) posits SE as a cause of behavior, not simply as the result of reinforcement, as operant learning theorists may contend. Second, SE is task specific, as distinguished from more global, largely immutable personality attributes such as self-esteem, self-concept, and locus of control. Individuals are not self-efficacious in general, but instead, their sense of efficacy is tied to specific behaviors and tasks, which are amenable to change. For example, an adolescent may have high SE regarding his or her ability to perform well on standardized tests, but little efficacy regarding ability to dance or play sports. Although SE is conceptualized as task specific, when tasks are similar in their cognitive and behavioral demands, as well as in the context in which they occur, crossover or generalizability of SE can occur. For example, a high school student, because of positive experiences in high school mathematics, may have high efficacy regarding his or her ability to perform well in college math courses, despite having low efficacy regarding his or her ability to perform well in college language courses. Additionally, within tasks, the degree of SE that an individual may possess is not absolute. Instead, a gradient of SE can be plotted, with levels of SE generally decreasing as the complexity or difficulty of the task increases. Thus, an adolescent may report high SE that he or she can resist an appeal to try marijuana from a casual acquaintance but may report low SE if the appeal is from a popular peer opinion leader. Similarly, an adolescent may be highly self-efficacious with regard to asking a long-time partner to use a condom, but less efficacious with a new partner (Maibach and Murphy, 1995).

Efficacy can develop through four sources: performance mastery experience, vicarious observation, verbal persuasion, and physiologic or psychologic states. Performance mastery experiences are considered the most influential source, producing the strongest and most enduring efficacy effects. Performance success raises efficacy beliefs, whereas failure lowers them. Of considerable theoretical and clinical import is the fact that the perception of successful performance, rather than performance per se or subsequent external reinforcement, predicts future behavior. Thus, independent of actual performance, individuals who are convinced (through either their own appraisal or the assessment of others) that they performed well on a task develop stronger efficacy beliefs and are more likely to continue efforts than do individuals who perform well but perceive their performance as unsuccessful. This points to the need for health teachers to reinforce successful performance—for example, to praise even small positive changes in dietary, exercise, or safety habits.

Vicarious observation involves seeing (or visualizing) individuals under comparable demand parameters successfully perform the target behavior. This can include vicarious observation of simulated performance in clinical settings or instructional media or in vivo observation of peers and family members. Observing adult or peer role models successfully perform positive behaviors represents an important potential source of efficacy that is often lacking in disadvantaged populations. The absence of positive role models can then be recast as an absence of positive observational learning situations and, therefore, as a problem of low personal efficacy rather than low self-esteem. In addition to affecting efficacy directly, positive role models can also influence behavior by altering outcome expectations and normative beliefs.

Verbal persuasion, encouraging an individual to attempt a behavior change and providing assurance he or she has the skills necessary to do so, can be an effective motivational strategy, although encouragement must be titrated to the behavioral and cognitive capacity of the individual. Determining ''how high to aim" requires considerable understanding of an individual's talents, interests, motivation, and baseline efficacy. Finally, physiologic and affective states, such as excessive arousal, anxiety, and depression, can diminish efficacy and discourage continued efforts, whereas positive states, such as stimulation, euphoria, and physical enjoyment, can encourage future effort. Pressuring an adolescent to attempt a new behavior or modify an existing one when that person is not prepared or sufficiently motivated to do so can create dysphoric levels of anxiety, arousal, anger, or resentment that, even with successful performance, can result in diminished motivation to continue efforts. Efficacy operates through four processes: choice behavior, effort expenditure and persistence, thought patterns, and emotional reactions. The first two are reflected in the behavioral domain; the last two are largely cognitive in nature. Individuals with high SE are more likely to attempt to perform a behavior (i.e., choice) and more likely to continue their efforts in the face of initial setbacks or frustration (i.e., expenditure and persistence). On the cognitive level, highly self-efficacious individuals tend to visualize and dwell on their successes more than their failures (i.e., thought patterns) and to process positive affective aspects of their performance more than the negative (i.e., emotional reactions).

Outcome Expectations

Outcome expectations include the perceived positive and negative results of a behavior (i.e., pros and cons). Initial and continued behavioral efforts are more likely when perceived positive outcomes (i.e., benefits) outweight the perceived negatives (i.e., costs). This dimension of SCT includes much of what operant learning theorists classify as reinforcement, although SCT differs in its emphasis on the cognitive, conscious expectations of environmental contingencies rather than on the conditioned (and largely unconscious) responses resulting from reward or punishment. SCT delineates three categories of outcome effects: physical, social, and self-evaluative. Physical effects include anticipated positive and negative sensory experiences (pleasure or pain), as well as assumed short- and long-term health consequences resulting from a behavior. This may include achieving of positive physical effects (e.g., by losing weight) or avoiding negative effects (e.g., by reducing the risk of heart disease). It is within this domain that health knowledge operates. Knowledge regarding what behaviors improve or impair health, as well as the resources and options at one's disposal, are necessary though insufficient precursors of outcome expectations. As first described by Rosenstock (1988) in his delineation of the Health Belief Model, awareness of the connection between behavior and health generally does not spur action unless the individual feels personally susceptible to the potential risks (or rewards)—that is, the person believes the potential outcomes of a behavior are likely on a personal not only an abstract (i.e., to "others") level. Social effects include approval from friends and family, recognition, monetary reward, and improved status, as well as inhibiting factors such as disapproval, rejection, censure, or ostracization. Social effects are particularly influential among school-age youth, since their identity is determined largely through peer relationships and normative comparison. Studies on substance use, diet, and sexual habits have demonstrated that perceptions regarding peer behaviors and group norms are strong predictors of behavior (Botvin et al., 1992; Botvin and Dusenbury et al., 1993; Wulfert and Wan, 1993). The third class of outcome expectations, self-evaluation, includes the positive and negative internal reactions resulting from behavior. Although related to perceived social effects, insofar as personal values are largely derived from peer standards and social mores, self-evaluative expectations refer more to the perceived intra-personal or intrapsychic consequences of behavior—that is, how one will feel about him-or herself morally and emotionally as a result of engaging in a behavior, beyond its external, social contingencies. During adolescence, moral development is largely under construction and contingent more on external than on internal reference (Kohlberg, 1977; Kohlberg et al., 1983). As a result, self-evaluative effects are seen as less influential than social effects in this age group.

Modifying outcome expectations is an important component of many health education programs. For example, substance use programs often include information regarding the positive and negative physical health effects of tobacco, marijuana, and alcohol use, while nutrition education programs address the consequences of consuming foods high or low in fat. Given the "present" orientation of most adolescents, saliency of health information for this population is enhanced by focusing on immediate rather than delayed consequences of behavior. For example, substance use prevention programs that place greater emphasis on concurrent or short-term physical effects, such as impaired stamina and athletic performance, appear more effective than those emphasizing long-term health effects such as cancer, cirrhosis, or heart disease (Glynn et al., 1990).

Modifying perceived social effects may have an even greater impact on health behavior than does improving knowledge of physical consequences. Social effects include perceptions of how engaging in a behavior will alter social status. For example, decisions regarding substance use are influenced by how the individual perceives these behaviors will alter his or her social image. Based on the observation that many adolescents over-estimate the prevalence and therefore the normalcy of substance use, researchers have developed programs aimed at correcting erroneous perceptions regarding prevalence and acceptability, and initial results of these interventions appear promising (Hansen and Graham, 1991; Sussman et al., 1993). Although most "normative influences" programs have focused on substance use behaviors, this approach may be applicable to other health habits, such as sexual behavior and diet (Baranowski, 1989–1990; Jemmot and Jemmot, 1992; Maibach and Murphy, 1995).


Setting discrete, realistically ambitious goals and then attaining them can significantly increase performance motivation. Setting goals can establish a hierarchy of behavioral tasks that is sequential and reinforcing. Attainment of goals that are too easily achieved produces little motivation, while setting unrealistic goals, though initially motivating, can eventually take its toll, resulting in low efficacy states if not helplessness and depression. The relation between "attainability" and motivation may differ for short- and long-term goals. Ambitious long-term goals can be useful if the short-term goals needed to achieve them are divided into realistic, hierarchical steps and sequentially attained. Individuals, rather than hinging all sense of their success on glamorous future goals, can be taught to gain satisfaction from progressive mastery of "minigoals" and can then learn to use these short-term successes as stepping stones toward their ultimate ambition. Specifically, it may be appropriate to encourage youth to set their sights on high achievement, wealth, or fame, as long as appropriate, progressive proximal goals, such as completing high school, doing well on the SATs, and applying to college, are established and attained. SCT-based health education programs help youth establish positive goals, such as eating five servings of fruit and vegetables per day, regularly wearing a seat belt or safety helmet, or exercising three times per week. Similar to shaping techniques used in operant conditioning, goals are hierarchical and sequential—for example, starting with an increase of one serving of fruits, then adding one serving of vegetables, and gradually building toward the final goal of five servings a day.

According to SCT, personal goals mediate motivation in three ways. First, anticipated self-satisfaction from achieving performance standards can stimulate initial efforts and continued persistence (i.e., expectations of accomplishment can stir one to action). Second, successful performance and goal attainment can enhance personal efficacy, motivating heightened efforts and progression to more complex tasks and hierarchical goal achievement. The third type of influence involves adjustment of standards in response to performance attainment. Individuals who readjust their goals upward after successful performance are more likely to continue efforts, whereas those who are satisfied with simply attaining the same standard again invest little subsequent effort. In other words, individuals who continue setting their sights on new heights are often those who achieve greatness. The relationship among expectations, goals, and motivation can be somewhat complex. In the face of initial failure, some individuals become demoralized while others persist. Motivation is best maintained by a strong sense of efficacy not only to succeed but to withstand failure. In applying this principle to youth, it may be important to provide them with motivation not only to attempt new behaviors but also to prepare them to regroup and try again if initial efforts are not entirely successful. This strategy—encouraging realistic expectations for success and preempting defeatist interpretations of failure—is an essential element of relapse prevention (Brownell et al., 1986; Marlatt and Gordon, 1985). The challenge again lies in providing realistic expectations without injecting a self-fulfilling prophecy of failure.


For some behaviors, high SE and motivation (i.e., strong positive outcome expectations) are insufficient to produce successful behavior change. Task-specific social and motor skills are often needed. For example, to resist appeals from peers to use alcohol, tobacco, and other drugs, specific skills, decisionmaking, stress management, and communications may be needed. Younger children may require skills to request that parents purchase and serve healthier foods. Motor skills include athletic skills and condom use skills or, for youth with chronic illnesses, proper use of an asthma inhaler or insulin injection.

The Interaction of Self-Efficacy, Outcome Expectations, Skills, and Goals

As discussed earlier, SCT delineates multiple determinants of behavior change. Self efficacy is, however, seen as occupying a central role in this model. As such, it is important to understand how SE interacts with other personal and environmental determinants, as well as how a comprehensive school health program can employ SCT. Individuals with high SE are more likely to attempt a behavior if they have strong positive outcome expectancies and possess the skills necessary to accomplish the task. Possessing requisite skills is also likely to increase opportunities to attain mastery experiences, which will instill increased efficacy and promote continued behavioral effort. Additionally, if realistic goals are set, performance is more likely to be perceived as successful and efficacy beliefs will be strengthened. If unattainable goals are set, performance may be perceived as failure, which will decrease efficacy and thereby discourage persistence. On the environmental level, excessive levels of family stress, chaotic living conditions, lack of positive peer and adult models, and insufficient access to preventive services can suppress positive outcome expectations and initial effort, as well as reduce the likelihood of experiencing positive mastery experiences, which in turn can decrease efficacy and persistence.


  • Ajzen, I, and Fishbein, M. 1972. Attitudes and normative believes as factors in influencing behavioral intentions. Journal of Personality and Social Psychology 21(1):1-9.
  • Ajzen, I., and Madden, T.J. 1986. Understanding attitude and predicting social behavior. Englewood Cliffs, N.J.: Prentice-Hall.
  • Bandura, A. 1986. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, N.J.: Prentice-Hall.
  • Bandura, A. 1995. Self-Efficacy: The Exercise of Control. New York: Freeman.
  • Baranowski, T. 1989–1990. Reciprocal determinism at the stages of behavior change: An integration of community, personal and behavioral perspectives. International Quarterly of Community Health Education 10(4):297–327. [PubMed: 20840937]
  • Botvin, G.J., Baker, E., Botvin, E.M., Dusenbury, L., Cardwell, J., and Diaz, T. 1993. Factors promoting cigarette smoking among black youth: A causal modeling approach. Addiction and Behavior 18(4):397–405. [PubMed: 8213293]
  • Botvin, G.J., and Dusenbury, L. 1992. Smoking prevention among urban minority youth: assessing effects on outcome and mediating variables. Health Psychology 11:290–299. [PubMed: 1425546]
  • Brownell, K.D., Marlatt, G.A., Lichtenstein, E., and Wilson, G.T. 1986. Understanding and preventing relapse. American Psychologist 7:765–782. [PubMed: 3527003]
  • Glynn, T.J., Boyd, G.M., and Gruman, J.C. 1990. Essential elements of self-help/minimal intervention strategies for smoking cessation. Health Education Quarterly 17:329–345. [PubMed: 2228634]
  • Hansen, W.B., and Graham, J.W. 1991. Preventing alcohol, marijuana, and cigarette use among adolescents: Peer pressure resistance training versus establishing conservative norms. Preventive Medicine 20:414–430. [PubMed: 1862062]
  • Jemmott, L.S., Spears, H., Hewitt, N., and Cruz-Collins, M. 1992. Self-efficacy, hedonistic expectancies, and condom-use intentions among inner-city black adolescent women: A social cognitive approach to AIDS risk behavior. Journal of Adolescent Health 13:512–519. [PubMed: 1390819]
  • Kohlberg, L. 1977. Moral development: A review of the theory. Theory into Practice 16(2): 53–59.
  • Kohlberg, L., Levine, C. and Hewer, A. 1983. Moral stages: A current formulation and a response to critics. Contributions to Human Development 10:174.
  • Maibach E., and Murphy, D.A. 1995. Self-efficacy in health promotion research and practice: Conceptualization and measurement. Health Education Research 10(1):37-50.
  • Marlatt, G.A., and Gordon, J.R. 1985. Relapse Prevention Maintenance Strategies in Addictive Behavior Change. New York: Guilford.
  • Perry, C.L., Baranowski, T and Parcel, G. 1990. How Individuals, Environments, and Health Behavior Interact: Social Learning Theory in Health Behavior and Health Education: Theory, Research, and Practice. Glanz, K., editor; , Lewis, F.M., editor; and Rimer, B., editor. , eds., San Francisco, CA, Jossey-Bass.
  • Rosenstock, I. 1988. Social learning theory and the Health Belief Model. Health Education Quarterly 15:175–183. [PubMed: 3378902]
  • Rosenstock, I. 1990. The Health Belief Model: Explaining Health Behavior Through Expectancies in Health Behavior and Health Education: Theory, Research, and Practice, Glanz, K., editor; , Lewis, F.M., editor; and Rimer, B., editor. , eds., San Francisco, CA, Jossey-Bass.
  • Skinner, B.F. 1974. About Behaviorism. New York: Knopf.
  • Sussman, S., Dent, C.W., Stacy, A.W., Sun, P., Craig, S., Simon, T.R., Burton, D., and Flay, B.R. 1993. Project towards no tobacco use, 1-year behavior outcomes. American Journal of Public Health 83(9):1245–1250. [PMC free article: PMC1694992] [PubMed: 8362999]
  • Walter, H.J., Vaughan, R.D., Gladis, M.M., Ragin, D.F., Kasen, S. and Cohall, A.T. 1993. Factors associated with AIDS-related behavioral intentions among high school students in an AIDS epicenter. Health Education Quarterly 20(3):409–420. [PubMed: 8307763]
  • Wulfert, E., and Wan, C.K. 1993. Condom use: A self-efficacy model. Health Psychology 12:346–353. [PubMed: 8223358]
Copyright 1997 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK232688


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