Health promotion is a burgeoning industry backed by governments, the World Health Organization, researchers, even entrepreneurs looking to make a buck. According to the World Health Organization’s website, “health promotion is the process of enabling people to increase control over, and to improve their health.” Governmental health promotion efforts extend to people of all ages and facilitate the formation of healthy habits or breaking bad habits.
A premise of health promotion is that people can be trained to adopt healthy behaviors and continue those behaviors for life. Efforts are also directed at changing unhealthy habits that have developed and may be resistant to change, such as smoking cigarettes or obesity.
Decades of research addressing the question, “what makes people change?” now fosters a narrower focus on change in health behavior. Through education and intervention, health promotion targets simple behavior, such as consistently taking prescribed medication, to much more complex and intractable behavior, such as overcoming addiction.
Various theories have proposed mechanisms of action whereby permanent behavior change occurs, and these can be broken down into smaller increments or steps in the process. Internal processes including cognitions and intentions are believed to lead to external actions or behaviors.
Since correlational data is limiting and can only establish if constructs are related to one another, Sheeran and colleagues chose to pull together existing experimental studies. Their meta-analysis of experimental studies provides proof of the causal pathway between cognitions, intentions, and behaviors. The specific research question of interest was: does eliciting changes in attitudes, norms, and self-efficacy (cognitions) lead to change in intentions and behavior?
Before outlining the specific plans and results of the study, let’s define key terms. According to the study: “attitude refers to people’s evaluation of the consequences of performing health behavior; social norms are perceptions of social pressure from other people and beliefs about how other people act; self-efficacy refers to how confident people are that they can perform a focal behavior; intentions are people’s decisions or self-instructions to act” (p. 3).
In selecting studies for inclusion in the meta-analysis, the researchers used specific inclusion criteria that would allow them to draw cause-effect conclusions. Only experimental studies with a control group and random assignment to groups were included. All studies employed a manipulation of the attitudes, norms, and/or beliefs of participants as a predictor of later intentions and behaviors. Studies of psychiatric patients were excluded.
A total of 155 studies met these inclusion criteria. The studies attempted to change behaviors in a variety of health domains including physical activity and exercise, smoking cessation, condom use, screening, blood donation, and alcohol use.
The interventions deployed in these studies were moderately successful at changing attitudes, norms, and self-efficacy. In turn, changes in these cognitions lead to changes in intentions and behavior, with a stronger effect on intentions. Thus, cognitive processes may motivate our intentions, but those intentions don’t always lead to actions.
In connecting their results to health promotion, the authors explained: “the present review supports the premise that attitudes, norms, and self-efficacy have a causal effect on intention and behavior, and indicates that interventions that successfully change these cognitions promote health behavior change” (p. 7). These cognitions changed both intentions and behavior, which should be seen as separate and important outcomes. “Changing attitudes or norms had small-to-medium effects on behavior, and changing self-efficacy had a medium-sized effect” (p. 7). Did the three cognitions have an additive effect on intentions and behavior? The authors were surprised to discover “that interventions that changed more than one cognition did not generate larger effects on intentions or behavior” (p. 7).
These results confirm that each of these cognitions (attitudes, norms, and self-efficacy) independently and causally lead to changes in behavior. Thus, they confirm prior correlational evidence but go a step further in proving the causal direction of influence. These findings lend support to self-efficacy theory that proposes that individuals can exert control over the events in their lives.
The fact that cognitions had a greater effect on intentions than on behavior is important. Research on intentions and behavior has found that intentions can, but do not always, lead to behavior. However, in this meta-analysis, removing intentions from the path from cognitions to behavior did not render this connection non-significant. So, cognitions also directly impact behavior.
For those designing future health promotion interventions, they can confidently employ strategies to alter cognitions with the expectation that modified cognitions will lead to changes in intentions and behavior.
Citation: Sheeran, P., Maki, A., Montanaro, E., Avishai-Yitshak, A., Bryan, A., Klein, W. M., … & Rothman, A. J. (2016). The impact of changing attitudes, norms, and self-efficacy on health-related intentions and behavior: A meta-analysis. Health Psychology, 35(11), 1178.
©Jennie Dilworth, Ph.D