Health Action Process Approach
Encyclopedia
Health behavior change refers to a replacement of health-compromising behaviors (such as sedentary behavior) by health-enhancing behaviors (such as physical exercise). To describe, predict, and explain such processes, theories or models are being developed. Health behavioural change theories
are designed to examine a set of psychological constructs that jointly aim at explaining what motivates people to change and how they take preventive action. The Health Action Process Approach (HAPA) is a psychological theory of health behavior change. It has been developed by Ralf Schwarzer, Professor of Psychology at the Freie University
of Berlin, Germany. It is an open framework of various motivation
al and volitional
constructs that are assumed to explain and predict individual changes in health behaviors such as quitting smoking or drinking, and improving physical activity
levels, dental hygiene
, seat belt
use, breast self-examination
, or dietary behaviors. HAPA suggests that the adoption, initiation, and maintenance of health behaviors should be conceived of as a structured process including a motivation phase and a volition phase. The former describes the intention formation while the latter refers to planning, and action (initiative, maintenance, recovery). The model emphasizes the particular role of perceived self-efficacy at different stages of health behavior change.
and consists of several qualitative steps that reflect different mindsets of people. A two-layer framework that can be applied either as a continuum or as a stage model is HAPA. It includes self-efficacy, outcome expectancies, and risk perception
as distal predictors, intention
as a middle-level mediator, and volitional factors (such as action planning) as the most proximal predictors of behavior. See Self-efficacy
.
Good intentions are more likely to be translated into action when people plan when, where, and how to perform the desired behavior. Intentions foster planning, which in turn facilitates behavior change. Planning was found to mediate the intention-behavior relation. A distinction has been made between action planning and coping planning. Coping planning takes place when people imagine scenarios that hinder them to perform their intended behavior, and they develop one or more plans to cope with such a challenging situation.
HAPA is designed as a sequence of two continuous self-regulatory processes, a goal-setting phase (motivation) and a goal-pursuit phase (volition). The second phase is subdivided into a pre-action phase and an action phase. Thus, one can superimpose these three phases (stages) on the continuum (mediator) model as a second layer, and regard the stages as moderators. This two-layer architecture allows to switch between the continuum model and the stage model, depending on the given research question.
Principle 1: Motivation and volition. The first principle suggests that one should divide the health behavior change process into two phases. There is a switch of mindset
s when people move from deliberation to action. First comes the motivation phase in which people develop their intentions. Afterwards, they enter the volition phase.
Principle 2: Two volitional phases. In the volition phase there are two groups of individuals: those who have not yet translated their intentions into action, and those who have. There are inactive as well as active persons in this phase. In other words, in the volitional phase one finds intenders as well as actors who are characterized by different psychological states. Thus, in addition to health behavior change as a continuous process, one can also create three categories of people with different mindsets depending on their current point of residence within the course of health behavior change: preintenders, intenders, and actors. The assessment of stages is done by behavior-specific stage algorithms.
Principle 3: Postintentional planning. Intenders who are in the volitional preactional stage are motivated to change, but do not act because they might lack the right skills to translate their intention into action. Planning is a key strategy at this point. Planning serves as an operative mediator between intentions and behavior.
Principle 4: Two kinds of mental simulation. Planning can be divided into action planning and coping planning. Action planning pertains to the when, where, and how of intended action. Coping planning includes the anticipation of barriers and the design of alternative actions that help to attain one's goals in spite of the impediments. The separation of the planning construct into two constructs, action planning and coping planning, has been found useful as studies have confirmed the discriminant validity of such a distinction. Action planning seems to be more important for the initiation of health behaviors, whereas coping planning is required for the initiation and maintenance of actions as well.
Principle 5: Phase-specific self-efficacy. Perceived self-efficacy is required throughout the entire process. However, the nature of self-efficacy differs from phase to phase. This is because there are different challenges as people progress from one phase to the next one. Goal setting, planning, initiation, action, and maintenance pose challenges that are not of the same nature. Therefore, one should distinguish between preactional self-efficacy, coping self-efficacy, and recovery self-efficacy. Sometimes the terms task self-efficacy instead of preaction self-efficacy, and maintenance self-efficacy instead of coping and recovery self-efficacy are preferred.
, weight loss
, fun) as opposed to the negative outcomes that accompany the current (sedentary) behavior (such as developing an illness or being unattractive). In contrast, intenders should not benefit from such a treatment because, after setting a goal, they have already moved beyond this mindset. Rather, they should benefit from planning to translate their intentions into action. Finally, actors do not need any treatment at all unless one wants to improve their relapse
prevention skills. Then, they should be prepared for particular high-risk situations in which lapses are imminent. This can be done by teaching them to anticipate such situations and by acquiring the necessary levels of perceived recovery self-efficacy.
There are quite a few randomized controlled trials that have examined the notion of stage-matched interventions based on HAPA, for example in the context of dietary behaviors, physical activity,
and dental hygiene.
Lippke, S., Wiedemann, A. U., Ziegelmann, J. P., Reuter, T., & Schwarzer, R. (2009). Self-efficacy moderates the mediation of intentions into behavior via plans. American Journal of Health Behavior, 33(5), 521-529.
Renner, B., Kwon, S., Yang, B.-H., Paik, K-C., Kim, S. H., Roh, S., Song, J., Schwarzer, R. (2008). Social-cognitive predictors of dietary behaviors in South Korean men and women. International Journal of Behavioral Medicine, 15(1), 4-13.
Reuter, T., Ziegelmann, J. P., Wiedemann, A. U., & Lippke, S. (2008). Dietary planning as a mediator of the intention-behavior relation: An experimental-causal-chain design. Applied Psychology: An International Review. Special Issue: Health and Well-Being, 57, 194-297.
Scholz, U., Sniehotta, F. F., Schüz, B., & Oeberst, A. (2007). Dynamics in self-regulation: Plan-execution self-efficacy and mastery of action plans. Journal of Applied Social Psychology, 37, 2706-2725.
Scholz, U., Nagy, G., Schüz, B., & Ziegelmann, J. P. (2008). The role of motivational and volitional factors for self-regulated running training: Associations on the between- and within-person level. British Journal of Social Psychology, 47(3), 421-439.
Wiedemann, A. U., Lippke, S., Reuter, T., Ziegelmann, J. P., & Schüz, B. (2011). The more the better? The number of plans predicts health behaviour change. Applied Psychology: Health and Well-Being, 3, 87-106. DOI: 10.1111/j.1758-0854.2010.01042.x
Wiedemann, A. U., Lippke, S., Reuter, T., Ziegelmann, J. P., & Schwarzer, R. (2011). How planning facilitates behaviour change: Additive and interactive effects of a randomized controlled trial. European Journal of Social Psychology, 41, 42-51. doi: 10.1002/ejsp.724
Behavioural change theories
Behavioural change theories and models are attempts to explain the reasons behind alterations in individuals' behavioural patterns. These theories cite environmental, personal, and behavioural characteristics as the major factors in behavioural determination...
are designed to examine a set of psychological constructs that jointly aim at explaining what motivates people to change and how they take preventive action. The Health Action Process Approach (HAPA) is a psychological theory of health behavior change. It has been developed by Ralf Schwarzer, Professor of Psychology at the Freie University
Free University of Berlin
Freie Universität Berlin is one of the leading and most prestigious research universities in Germany and continental Europe. It distinguishes itself through its modern and international character. It is the largest of the four universities in Berlin. Research at the university is focused on the...
of Berlin, Germany. It is an open framework of various motivation
Motivation
Motivation is the driving force by which humans achieve their goals. Motivation is said to be intrinsic or extrinsic. The term is generally used for humans but it can also be used to describe the causes for animal behavior as well. This article refers to human motivation...
al and volitional
Volition (psychology)
Volition or will is the cognitive process by which an individual decides on and commits to a particular course of action. It is defined as purposive striving, and is one of the primary human psychological functions...
constructs that are assumed to explain and predict individual changes in health behaviors such as quitting smoking or drinking, and improving physical activity
Physical exercise
Physical exercise is any bodily activity that enhances or maintains physical fitness and overall health and wellness. It is performed for various reasons including strengthening muscles and the cardiovascular system, honing athletic skills, weight loss or maintenance, as well as for the purpose of...
levels, dental hygiene
Oral hygiene
Teeth cleaning is part of oral hygiene and involves the removal of dental plaque from teeth with the intention of preventing cavities , gingivitis, and periodontal disease. People routinely clean their own teeth by brushing and interdental cleaning, and dental hygienists can remove hardened...
, seat belt
Seat belt
A seat belt or seatbelt, sometimes called a safety belt, is a safety harness designed to secure the occupant of a vehicle against harmful movement that may result from a collision or a sudden stop...
use, breast self-examination
Breast self-examination
Breast self-examination is a screening method used in an attempt to detect early breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling....
, or dietary behaviors. HAPA suggests that the adoption, initiation, and maintenance of health behaviors should be conceived of as a structured process including a motivation phase and a volition phase. The former describes the intention formation while the latter refers to planning, and action (initiative, maintenance, recovery). The model emphasizes the particular role of perceived self-efficacy at different stages of health behavior change.
Background
Models that describe health behavior change can be distinguished in terms of the assumption whether they are continuum-based or stage-based. A continuum (mediator) model claims that change is a continuous process that leads from lack of motivation via action readiness either to successful change or final disengagement. Research on such mediator models are reflected by path diagrams that include distal and proximal predictors of the target behavior. On the other hand, the stage approach assumes that change is non-linearNonlinearity
In mathematics, a nonlinear system is one that does not satisfy the superposition principle, or one whose output is not directly proportional to its input; a linear system fulfills these conditions. In other words, a nonlinear system is any problem where the variable to be solved for cannot be...
and consists of several qualitative steps that reflect different mindsets of people. A two-layer framework that can be applied either as a continuum or as a stage model is HAPA. It includes self-efficacy, outcome expectancies, and risk perception
Risk perception
Risk perception is the subjective judgment that people make about the characteristics and severity of a risk. The phrase is most commonly used in reference to natural hazards and threats to the environment or health, such as nuclear power. Several theories have been proposed to explain why...
as distal predictors, intention
Intention
Intention is an agent's specific purpose in performing an action or series of actions, the end or goal that is aimed at. Outcomes that are unanticipated or unforeseen are known as unintended consequences....
as a middle-level mediator, and volitional factors (such as action planning) as the most proximal predictors of behavior. See Self-efficacy
Self-efficacy
Self-efficacy is a term used in psychology, roughly corresponding to a person's belief in their own competence.It has been defined as the belief that one is capable of performing in a certain manner to attain certain set of goals. It is believed that our personalized ideas of self-efficacy affect...
.
Good intentions are more likely to be translated into action when people plan when, where, and how to perform the desired behavior. Intentions foster planning, which in turn facilitates behavior change. Planning was found to mediate the intention-behavior relation. A distinction has been made between action planning and coping planning. Coping planning takes place when people imagine scenarios that hinder them to perform their intended behavior, and they develop one or more plans to cope with such a challenging situation.
HAPA is designed as a sequence of two continuous self-regulatory processes, a goal-setting phase (motivation) and a goal-pursuit phase (volition). The second phase is subdivided into a pre-action phase and an action phase. Thus, one can superimpose these three phases (stages) on the continuum (mediator) model as a second layer, and regard the stages as moderators. This two-layer architecture allows to switch between the continuum model and the stage model, depending on the given research question.
Five principles of the Health Action Process Approach
HAPA has five major principles that make it distinct from other models.Principle 1: Motivation and volition. The first principle suggests that one should divide the health behavior change process into two phases. There is a switch of mindset
Mindset
In decision theory and general systems theory, a mindset is a set of assumptions, methods or notations held by one or more people or groups of people which is so established that it creates a powerful incentive within these people or groups to continue to adopt or accept prior behaviors, choices,...
s when people move from deliberation to action. First comes the motivation phase in which people develop their intentions. Afterwards, they enter the volition phase.
Principle 2: Two volitional phases. In the volition phase there are two groups of individuals: those who have not yet translated their intentions into action, and those who have. There are inactive as well as active persons in this phase. In other words, in the volitional phase one finds intenders as well as actors who are characterized by different psychological states. Thus, in addition to health behavior change as a continuous process, one can also create three categories of people with different mindsets depending on their current point of residence within the course of health behavior change: preintenders, intenders, and actors. The assessment of stages is done by behavior-specific stage algorithms.
Principle 3: Postintentional planning. Intenders who are in the volitional preactional stage are motivated to change, but do not act because they might lack the right skills to translate their intention into action. Planning is a key strategy at this point. Planning serves as an operative mediator between intentions and behavior.
Principle 4: Two kinds of mental simulation. Planning can be divided into action planning and coping planning. Action planning pertains to the when, where, and how of intended action. Coping planning includes the anticipation of barriers and the design of alternative actions that help to attain one's goals in spite of the impediments. The separation of the planning construct into two constructs, action planning and coping planning, has been found useful as studies have confirmed the discriminant validity of such a distinction. Action planning seems to be more important for the initiation of health behaviors, whereas coping planning is required for the initiation and maintenance of actions as well.
Principle 5: Phase-specific self-efficacy. Perceived self-efficacy is required throughout the entire process. However, the nature of self-efficacy differs from phase to phase. This is because there are different challenges as people progress from one phase to the next one. Goal setting, planning, initiation, action, and maintenance pose challenges that are not of the same nature. Therefore, one should distinguish between preactional self-efficacy, coping self-efficacy, and recovery self-efficacy. Sometimes the terms task self-efficacy instead of preaction self-efficacy, and maintenance self-efficacy instead of coping and recovery self-efficacy are preferred.
Psychological interventions based on the Health Action Process Approach
When it comes to the design of interventions, one can consider identifying individuals who reside either at the motivational stage or the volitional stage. Then, each group becomes the target of a specific treatment that is tailored to this group. Moreover, it is theoretically meaningful and has been found useful to subdivide further the volitional group into those who perform and those who only intend to perform. In the postintentional preactional stage, individuals are labeled "intenders", whereas in the actional stage they are labeled "actors". Thus, a suitable subdivision within the health behavior change process yields three groups: nonintenders, intenders, and actors. The term "stage" in this context was chosen to allude to the stage theories, but not in the strict definition that includes irreversibility and invariance. The terms "phase" or "mindset" may be equally suitable for this distinction. The basic idea is that individuals pass through different mindsets on their way to behavior change. Thus, interventions may be most efficient when tailored to these particular mindsets. For example, nonintenders are supposed to benefit from confrontation with outcome expectancies and some level of risk communication. They need to learn that the new behavior (e.g., becoming physically active) has positive outcomes (e.g., well-beingQuality of life
The term quality of life is used to evaluate the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare, and politics. Quality of life should not be confused with the concept of standard of...
, weight loss
Weight loss
Weight loss, in the context of medicine, health or physical fitness, is a reduction of the total body mass, due to a mean loss of fluid, body fat or adipose tissue and/or lean mass, namely bone mineral deposits, muscle, tendon and other connective tissue...
, fun) as opposed to the negative outcomes that accompany the current (sedentary) behavior (such as developing an illness or being unattractive). In contrast, intenders should not benefit from such a treatment because, after setting a goal, they have already moved beyond this mindset. Rather, they should benefit from planning to translate their intentions into action. Finally, actors do not need any treatment at all unless one wants to improve their relapse
Relapse
Relapse, in relation to drug misuse, is resuming the use of a drug or a dependent substance after one or more periods of abstinence. The term is a landmark feature of both substance dependence and substance abuse, which are learned behaviors, and is maintained by neuronal adaptations that mediate...
prevention skills. Then, they should be prepared for particular high-risk situations in which lapses are imminent. This can be done by teaching them to anticipate such situations and by acquiring the necessary levels of perceived recovery self-efficacy.
There are quite a few randomized controlled trials that have examined the notion of stage-matched interventions based on HAPA, for example in the context of dietary behaviors, physical activity,
and dental hygiene.
Further reading
Gutiérrez-Doña, B., Lippke, S., Renner, B., Kwon, S., & Schwarzer, R. (2009). How self-efficacy and planning predict dietary behaviors in Costa RicaLippke, S., Wiedemann, A. U., Ziegelmann, J. P., Reuter, T., & Schwarzer, R. (2009). Self-efficacy moderates the mediation of intentions into behavior via plans. American Journal of Health Behavior, 33(5), 521-529.
Renner, B., Kwon, S., Yang, B.-H., Paik, K-C., Kim, S. H., Roh, S., Song, J., Schwarzer, R. (2008). Social-cognitive predictors of dietary behaviors in South Korean men and women. International Journal of Behavioral Medicine, 15(1), 4-13.
Reuter, T., Ziegelmann, J. P., Wiedemann, A. U., & Lippke, S. (2008). Dietary planning as a mediator of the intention-behavior relation: An experimental-causal-chain design. Applied Psychology: An International Review. Special Issue: Health and Well-Being, 57, 194-297.
Scholz, U., Sniehotta, F. F., Schüz, B., & Oeberst, A. (2007). Dynamics in self-regulation: Plan-execution self-efficacy and mastery of action plans. Journal of Applied Social Psychology, 37, 2706-2725.
Scholz, U., Nagy, G., Schüz, B., & Ziegelmann, J. P. (2008). The role of motivational and volitional factors for self-regulated running training: Associations on the between- and within-person level. British Journal of Social Psychology, 47(3), 421-439.
Wiedemann, A. U., Lippke, S., Reuter, T., Ziegelmann, J. P., & Schüz, B. (2011). The more the better? The number of plans predicts health behaviour change. Applied Psychology: Health and Well-Being, 3, 87-106. DOI: 10.1111/j.1758-0854.2010.01042.x
Wiedemann, A. U., Lippke, S., Reuter, T., Ziegelmann, J. P., & Schwarzer, R. (2011). How planning facilitates behaviour change: Additive and interactive effects of a randomized controlled trial. European Journal of Social Psychology, 41, 42-51. doi: 10.1002/ejsp.724