The Theory of Reasoned Action

Its application to AIDS-Preventive Behaviour

Cynthia Gallois, Malcolm McCamish, Deborah J Terry

• Publisher: Routledge
• Year: 2015
• eBook ISBN: 9781134675647
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The Theory of reasoned action explores the theory and emphirical reserach in to the factors which influence whether people engage in high-risk practices , with specific reference to AIDS education.

1
The Theory of Reasoned Action and Health Care Behaviour

DEBORAH TERRY, CYNTHIA GALLOIS and MALCOLM MCCAMISH
The Univerisity of Queensland, Brisbane, Australia

It is now widely recognised that, by adopting a healthy lifestyle, people can actively contribute to their state of health (Taylor, 1991). In recent years, researchers have been concerned with identifying the factors that influence people's willingness to engage in health care behaviour (i.e., actions that promote well-being and help prevent disease). This research has been motivated by the realisation that knowledge of the determinants of health care behaviour has implications for the general understanding of health behaviour, as well as the development of intervention programs to encourage people to engage in health-promoting practices. In overall terms, research into the determinants of health care behaviour is significant both for the well-being of individuals and for the collective well-being of a community. The more willing and able people are to protect themselves from preventable illnesses, the more resources the community will have available to be channelled into other areas. Moreover, it can be assumed that, via the effects of modelling and normative influence, collective wellbeing will have a positive impact on future community health.

Researchers have focused on a range of different health care behaviours. They have, for instance, considered the determinants of behaviours that reflect a healthy lifestyle, including participation in a regular exercise program, adherence to a healthy diet and the avoidance of potentially harmful health habits (e.g., smoking, the consumption of large amounts of alcohol and the use of illicit drugs). Attention has also been focused on people's willingness to use contraceptives (mainly the contraceptive pill and condoms), to engage in dental health behaviours, to participate in screening programs (e.g., pap tests for cervical cancer) and to vaccinate against infectious diseases. As a consequence of the emerging threat of HIV infection, more recent research on health care behaviour has focused on safer sex behaviours (including condom use and having sex in a monogamous relationship).

One of the major goals of health research has been to identify the factors that distinguish people who choose to engage in health care behaviours from those who adopt less healthy lifestyles. In this respect, Fishbein and Ajzen's (1975; Ajzen & Fishbein, 1980) theory of reasoned action has been particularly influential. The theory has been demonstrated to be useful across the range of health care behaviours identified above. More recently, a number of researchers have suggested that it may be useful in the context of safer sex behaviour (see Fisher & Fisher, 1992). The application of the theory of reasoned action to the explanation of variation in people's willingness to engage in safer sex behaviour is the central theme of this book.

In the present chapter, a detailed description of the theoretical basis of the theory of reasoned action and its recent extension, the theory of planned behaviour, is provided. Methodological issues involved in testing the usefulness of the two models are also discussed in some detail. Prior to describing the theory of reasoned action, the past literature on the determinants of health care behaviour is reviewed, as is the health belief approach to the study of health care behaviour. In the next chapter, Lewis and Kashima discuss issues of relevance to HIV/AIDS. Specifically, the next chapter describes the epidemiological and social context of the epidemic, reviews previous research on AIDS-prevention, and discusses a number of issues that are relevant when applying the theory of reasoned action to the study of safer sex behaviour.

Determinants of Health Care Behaviour

In an attempt to identify the determinants of health care behaviours, researchers have considered the extent to which a large number of different variables can explain variation in people's willingness to engage in such behaviours. Much of this research has focused on demographic variables. Age, for instance, appears to have a curvilinear relationship with people's willingness to engage in health care behaviours. Adolescents and young adults engage in more risky health behaviours than either children or older adults (Taylor, 1991). Children, in general, have little choice in lifestyle issues, a factor which presumably accounts for their comparatively low level of health risk behaviours. For adolescents and young adults, feelings of invulnerability (see Elkind, 1967,1985) combined with the desire for a range of different life experiences may explain the heightened incidence of risky health behaviours at this stage of the lifespan, while older persons presumably adopt a more healthy lifestyle than their younger counterparts because feelings of invulnerability dissipate, they gain more responsibilities and they become more aware of their health problems (Taylor, 1991).

There is evidence of age differences in people's preferences for different sexual practices. In a comprehensive study of gay men, Kippax, Connell, Dowsett and Crawford (in press) found that older gay men preferred penetrative anal sex, while younger men preferred non-penetrative sex. In a similar vein, research with heterosexuals suggests that adolescents are more likely than young adults to prefer non-penetrative sex, a pattern of results that possibly reflects a developmental progression to full sexual maturity. To modify the safety of people's sexual practices, educational programmes need to acknowledge age-related preferences for different sexual practices.

Gender has also been linked to health care behaviour. In general, females are less likely to smoke than males (Taylor, 1991; Waldron, 1988). In comparison with males, they also consume less alcohol, pay more attention to their diet, take more vitamins and engage in more dental care behaviours (see Waldron, 1988). Males are, however, more likely than females to engage in regular exercise (Rodin & Salovey, 1989). Such gender differences have been interpreted as being consistent with traditional norms for sex-role appropriate behaviour (Rodin & Salovey, 1989; Waldron, 1988). It is considered appropriate for women to take care of their physical appearance, while a greater latitude of freedom is typically allowed to men in terms of such behaviours as alcohol consumption (Waldron, 1988). To date, there has been alack of compelling evidence of gender differences in people's willingness to adopt different safer sex strategies (Gallois, Statham & Smith, 1992). There may, however, be subtle gender differences in beliefs about safer sex (e.g., females may have different beliefs about the costs and benefits of condom use) and constraints to successful behavioural enactment (e.g., females may lack the necessary assertion skills to ensure that a condom is used) that need to be acknowledged by education programmes.

Researchers have also considered the role that socio-economic status plays as a determinant of preventive health behaviour. In this respect, there is evidence of a positive relationship between socio-economic status and the incidence of a range of different health care behaviours, including adherence to a regular exercise programme (Rodin & Salovey, 1989), willingness to make preventive visits to a dentist and participation in vaccination programs (Coburn & Pope, 1974; Kirscht, 1983). Such results presumably reflect the fact that, as a consequence of better education, people with higher socio-economic status are likely to be knowledgeable about health issues. They also may have greater access to health care facilities than people with lower socio-economic status (Coburn & Page, 1974). Other research has demonstrated that there are ethnic differences in people's willingness to engage in health-promoting behaviours (e.g., Gottlieb & Green, 1988). These differences should, however, be interpreted with caution, given that ethnicity is confounded with social class (Rodin & Salovey, 1989).

There is evidence of effects of social class on sexual behaviour. Men from a working class background, for instance, are more likely to have extra-marital affairs than middle-class men (Argyle, 1993). In research on safer sex, the possible effects of social class have typically been ignored. Researchers have tended to study accessible populations that, because of the socio-economic status of researchers, are characterised by a middleclass bias. Future research needs to broaden the focus of research activity on safer sex, given that the salient beliefs and norms about safer sex are likely to be divergent across different groups at risk for HIV (e.g., homeless youth, bisexual men).

In addition to demographic variables, there is evidence that a range of other variables influence health care behaviour. There is, for instance, strong evidence linking peer influence (Grube, Morgan, & McGree, 1986; Leventhal & Cleary, 1980) and family modelling (Sallis & Nader, 1988) to smoking behaviour among adolescents. Family factors have also been found to be influential in the context of safer sex. In a study of older adolescents, Peterson and Feeney (1993) reported that subjects' habitual style of conflict resolution with their parents influenced both their willingness to discuss AIDS and safer sex with a sexual partner and the extent to which they felt confident in their ability to perform safer sex strategies. Other researchers have considered the role that individual difference variables may play in health care behaviour. In particular, interest has centred on the proposal that people who believe that they have control over their health will engage in more health care behaviours than people who attribute their state of health to external factors. Research has provided some support for this supposition. Internal health beliefs have been linked to seat belt use (Williams, 1972), breast self-examination (Lau, 1988) and contraceptive use (Lundy, 1972). Such beliefs have also been found to relevant in the context of safer sex. Terry, Galligan and Conway (in press), for instance, found that people with internal control beliefs were more likely than people with external control beliefs to behave in accord with their intentions to have sex in an exclusive relationship and discuss their partner's sexual and i.v. drug use history.

Theoretical Models of Health Care Behaviour

Although research examining the correlates of health care behaviour has been informative, such research is limited because in general it has not been theory-based. Most of the studies have examined the effects of only one or two variables. It is, thus, difficult to integrate the findings into a coherent model of the determinants of health care behaviour. Moreover, the failure to consider the effects of a range of different predictors of health care behaviour may mean that some of the findings in earlier literature are spurious. To provide further insight into the basis of variation in people's willingness to engage in health care behaviours, it is necessary to develop models that specify sets of theoretically-derived predictors of health care behaviours. The health belief model (Rosenstock, 1974a,b) and Fishbein and Ajzen's (1975; Ajzen & Fishbein, 1980) theory of reasoned action have been particularly influential models in this context. Both of these models consider the underlying cognitive factors that may explain variation in health care behaviour. Such factors are likely to be important determinants of such behaviours, given that they reflect people's beliefs about the behaviour, rather than their more generalised background features and personality dispositions (Ajzen, 1988). Prior to discussing the theory of reasoned action (the focus of the present book) in detail, the health belief model is described.

The Health Belief Model

The health belief model (Rosenstock, 1974a,b) has been widely used to predict health behaviours from knowledge of a person's beliefs and attitudes. The model proposes that readiness to take preventive health action arises from an evaluation of the level of threat associated with a disease (assessed with measures of the perceived susceptibility to the disease and its severity), as well as an analysis of the costs and benefits of taking the action. Specifically, the model is made up of four components. The perceived susceptibility dimension reflects the individual's perception of vulnerability or risk of contracting the disease, while perceived severity refers to the individual's beliefs about the seriousness of consequences associated with that disease. The positive outcomes of performing the preventive health behaviour, including estimates of risk reduction and feelings of security, are seen as the perceived benefits of taking the action, and are typically weighted against the potential negative aspects, the perceived barriers of performing the preventive behaviour, including estimates of physical, psychological, financial and other costs incurred in performing the behaviour. Modifications to the original model have included the addition of self-efficacy (Rosenstock, Strecher & Becker, 1988), internal or external cues to action (Rosenstock, 1974b) and salience of health to the individual (Rosenthal, Hall, & Moore, 1992).

There is evidence that health belief variables successfully predict a range of different health behaviours, including dietary compliance (Becker, Haefner, Mainman, Kirscht & Drachman, 1977), calcium intake (Wurtel, 1988), breast self-examination (Kelly, 1979; Hallal, 1982) and vaccination (Cummings, Jette & Rosenstock, 1978). In their review of the health belief model, Janz and Becker (1984) observed that support for the model was evident in both retrospective and prospective designs. Moreover, they found some support for the role of each of the four dimensions of the health belief model (severity, susceptibility, benefits and barriers) in the prediction of health behaviour. Across a range of different behaviours, the dimension of perceived barriers emerged as the most important component of the health belief model. The evidence linking the susceptibility and benefits dimensions of the model to health behaviour was also strong, although the strength of support for each of the dimensions was dependent on the type of behaviour under consideration. Perceived susceptibility had a stronger effect on preventive health behaviours than on sick role behaviour (health behaviours engaged in after diagnosis of a particular medical condition), while the reverse was true for perceived benefits. Overall, the evidence in support of the proposed effect of perceived severity was weaker than for the other components of the model (particularly for preventive health behaviours).

In a more recent meta-analysis, Harrison, Mullen and Green (1992) found weaker support for the health belief model. Only 16 of 147 studies met their criteria of inclusion—that is, that they were based on original data collected from adults; included the four variables of susceptibility, severity, benefits and costs, related the variables to actual behaviour rather than to attitudes or intentions and reported reliability of the measures. The model's performance was generally poor. Harrison et al. found that, for any one dimension of the model, 10% was the largest proportion of variance explained in actual behaviour. They questioned whether the model's key variables were able to discriminate between, and therefore apply differentially to, ...

Table of contents

• Cover
• Title
• Copyright
• Contents
• PREFACE
• LIST OF CONTRIBUTORS
• INTRODUCTION BY MARTIN FISHBEIN
• 1. The Theory of Reasoned Action and Health Care Behaviour
• 2. Applying the Theory of Reasoned Action to the Prediction of AIDS-Preventive Behaviour
• 3. Influences on Condom Use among Undergraduates: Testing the Theories of Reasoned Action and Planned Behaviour
• 4. Predicting AIDS-Preventive Behaviour among Adolescents
• 5. Attitudes Towards Condoms and the Theory of Reasoned Action
• 6. The Theory of Reasoned Action as Applied to AIDS Prevention for Australian Ethnic Groups
• 7. Extending the Theory of Reasoned Action: The Role of Health Beliefs
• 8. Self-Efficacy Expectancies and the Theory of Reasoned Action
• 9. Theory of Reasoned Action and the Role of Perceived Risk in the Study of Safer Sex
• 10. Application of the Theory of Reasoned Action to the Measurement of Condom Use among Gay Men
• 11. A Theory Based Intervention: The Theory of Reasoned Action in Action
• 12. The Theory of Reasoned Action and Problem-Focused Research
• 13. On the Need to Mind the Gap: On-Line versus off-Line Cognitions Underlying Sexual Risk Taking
• 14. Flaws in the Theory of Reasoned Action
• EPILOGUE
• REFERENCES
• AUTHOR INDEX
• SUBJECT INDEX