Annals of Behavioral Medicine

, Volume 33, Issue 1, pp 1–10 | Cite as

Misleading tests of health behavior theories

Original Articles


Most tests of cognitively oriented theories of health behavior are based on correlational data. Unfortunately, such tests are often biased, overestimating the accuracy of the theories they seek to evaluate. These biases are especially strong when studies examine health behaviors that need to be performed repeatedly, such as medication adherence, diet, exercise, and condom use. Several misleading data analysis procedures further exaggerate the theories’ predictive accuracy. Because correlational designs are not adequate for deciding whether a particular construct affects behavior or for testing one theory against another, most of the literature aiming to test these theories tells us little about their validity or completeness. Neither does the existing empirical literature support decisions to use these theories to design interventions. In addition to discussing problems with correlational data, this article offers ideas for alternative testing strategies.


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  1. (1).
    Noar SM, Zimmerman RS: Health behavior theory and cumulative knowledge regarding health behavior: Are we moving in the right direction?Health Education Research. 2005,20:275–290.PubMedCrossRefGoogle Scholar
  2. (2).
    Becker MH: The health belief model and personal health behavior [Special issue].Health Education Monograph. 1974,2(4).Google Scholar
  3. (3).
    Rogers RW: A protection motivation theory of fear appeals and attitude change.Journal of Psychology. 1975,91:93–114.Google Scholar
  4. (4).
    Rogers RW, Prentice-Dunn S: Protection motivation theory. In Gochman D (ed.),Handbook of Health Behavior Research: Vol. 1. Determinants of Health Behavior: Personal and Social. New York: Plenum, 1997, 113–132.Google Scholar
  5. (5).
    Edwards W: The theory of decision making.Psychological Bulletin. 1954,51:380–417.PubMedCrossRefGoogle Scholar
  6. (6).
    Ronis DL: Conditional health threats: Health beliefs, decisions, and behaviors among adults.Health Psychology. 1992,11:127–134.PubMedCrossRefGoogle Scholar
  7. (7).
    Ajzen I, Fishbein M: Attitude-behavior relations: A theoretical analysis and review of empirical research.Psychological Bulletin. 1977,84:888–918.CrossRefGoogle Scholar
  8. (8).
    Fishbein M: A theory of reasoned action: Some applications and implications. In Howe HE Jr, Page MM (eds),Nebraska Symposium on Motivation (1979). Lincoln: University of Nebraska Press. 1980, 65–116.Google Scholar
  9. (9).
    Ajzen I: From intentions to action: A theory of planned behavior. In Kuhl J, Beckman J (eds),Action Control: From Cognition to Behavior. New York: Springer-Verlag, 1985, 11–39.Google Scholar
  10. (10).
    Ajzen I, Madden TJ: Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control.Journal of Experimental Social Psychology. 1986,42:426–435.Google Scholar
  11. (11).
    Weinstein ND: Testing four competing theories of health-protective behavior.Health Psychology. 1993,12:324–333.PubMedCrossRefGoogle Scholar
  12. (12).
    Fisher JD, Fisher WA: The information-motivation skills model. In Diclemente RJ, Crosby RA, Kegler MC (eds),Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. San Francisco: Jossey-Bass, 2002, 40–70.Google Scholar
  13. (13).
    Schwarzer R, Fuchs R: Self-efficacy in the adoption and maintenance of health behavior: Theoretical approaches and a new model. In Schwarzer R (ed),Self-Efficacy: Thought Control of Action. Washington, DC: Hemisphere, 1992, 217–243.Google Scholar
  14. (14).
    Witte K: Putting the fear back into fear appeals: The extended parallel process model.Communication Monographs. 1992,59:329–349.CrossRefGoogle Scholar
  15. (15).
    Weinstein ND, Rothman AJ: Commentary: Revitalizing research on health behavior theory.Health Education Research. 2005,20:294–297.PubMedCrossRefGoogle Scholar
  16. (16).
    Albarracin D, Johnson BT, Fishbein M, Muellerleile PA: Theories of reasoned action and planned behavior as models of condom use: A meta-analysis.Psychological Bulletin, 2001,127:142–161.PubMedCrossRefGoogle Scholar
  17. (17).
    Armitrage CJ, Conner M: Efficacy of the theory of planned behaviour: A meta-analytic review.British Journal of Social Psychology. 2001,40:471–499.CrossRefGoogle Scholar
  18. (18).
    Floyd DL, Prentice-Dunn S, Rogers RW: A meta-analysis of research on protection motivation theory.Journal of Applied Social Psychology. 2000,30:407–429.CrossRefGoogle Scholar
  19. (19).
    Harrison JA, Mullen PD, Green LW: A meta-analysis of studies of the health belief model with adults.Health Education Research. 1992,7:107–116.PubMedCrossRefGoogle Scholar
  20. (20).
    Hausenblas HA, Carron AV, Mack DE: Application of the theories of reasoned action and planned behavior to exercise behavior: A meta-analysis.Journal of Sport & Exercise Psychology. 1997,19:36–51.Google Scholar
  21. (21).
    Marshall SJ, Biddle SJH: The transtheoretical model of behavior change: A meta-analysis of applications to physical activity and exercise.Annals of Behavioral Medicine. 2001,23:229–246.PubMedCrossRefGoogle Scholar
  22. (22).
    Milne S, Sheeran P, Orbell S: Prediction and intervention in health-related behavior: A meta-analytic review of protection motivation theory.Journal of Applied Social Psychology. 2000,30:106–143.CrossRefGoogle Scholar
  23. (23).
    Notani AS: Moderators of perceived behavioral control’s predictiveness in the theory of planned behavior: A meta-analysis.Journal of Consumer Psychology. 1998,7: 247–271.CrossRefGoogle Scholar
  24. (24).
    Rosen CS: Is the sequencing of change processes by stage consistent across health problems?Health Psychology. 2000,19:593–604.PubMedCrossRefGoogle Scholar
  25. (25).
    Schulze R, Wittmann WW: A meta-analysis of the theory of reasoned action and the theory of planned behavior: The principle of compatibility and multidimensionality of beliefs as moderators. In Schulze R (ed),Meta-Analysis: New Developments and Applications in Medical and Social Sciences. Ashland, OH: Hogrefe & Huber, 2003, 219–250.Google Scholar
  26. (26).
    Sheeran P, Taylor S: Predicting intentions to use condoms: A meta-analysis and comparison of the theories of reasoned action and planned behavior.Journal of Applied Social Psychology. 1999,29:1624–1675.CrossRefGoogle Scholar
  27. (27).
    Witte K, Allen M: A meta-analysis of fear appeals: Implications for effective public health campaigns.Health Education and Behavior. 2000,27:591–615.PubMedCrossRefGoogle Scholar
  28. (28).
    Brewer NT, Chapman GB, Gibbons FX, et al.: A meta-analysis of the relationship between perception and health behavior: The example of vaccination. Unpublished manuscript, Department of Health Behavior and Health Education, University of North Carolina, Chapel Hill, 2005.Google Scholar
  29. (29).
    Bickman L (ed):Research Design: Donald Campbell’s Legacy. Thousand Oaks, CA: Sage, 2000.Google Scholar
  30. (30).
    Bickman L (ed):Validity and Social Experimentation: Donald Campbell’s Legacy. Thousand Oaks, CA: Sage, 2000.Google Scholar
  31. (31).
    Holland PW: Statistics and causal inference.Journal of the American Statistical Association. 1986,81:945–970.CrossRefGoogle Scholar
  32. (32).
    Pearl J:Causality: Models, Reasoning, and Inference. Cambridge, UK: Cambridge University Press, 2000.Google Scholar
  33. (33).
    Shadish WR, Cook TD, Campbell DT:Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston: Houghton Mifflin, 2002.Google Scholar
  34. (34).
    Sutton SR: Testing attitude-behaviour theories using non-experimental data: An examinations of some hidden assumptions.European Review of Social Psychology. 2002,13:293–323.CrossRefGoogle Scholar
  35. (35).
    Sutton SR: Determinants of health-related behaviours: Theoretical and methodological issues. In Sutton S, Baum A, Johnston M (eds),The Sage Handbook of Health Psychology. London: Sage, 2004.Google Scholar
  36. (36).
    Bandura A: Health promotion from the perspective of social cognitive theory.Psychology and Health. 1998,13:623–649.CrossRefGoogle Scholar
  37. (37).
    Kok G, DeVries H, Muddle AN, Strecher VJ: Planned health education and the role of self-efficacy: Dutch research.Health Education Research. 1991,6:231–238.CrossRefGoogle Scholar
  38. (38).
    Bem DJ: Self-perception: An alternative interpretation of cognitive dissonance phenomena.Psychological Review. 1967,74:183–200.PubMedCrossRefGoogle Scholar
  39. (39).
    Cialdini RB:Influence: Science and Practice (4th Ed.), Needham Heights, MA: Allyn & Bacon, 2001.Google Scholar
  40. (40).
    Harmon-Jones E, Mills J (eds):An Introduction to Cognitive Dissonance Theory and an Overview of Current Perspectives on the Theory. Washington, DC: American Psychological Association, 1999.Google Scholar
  41. (41).
    Boney-McCoy S, Gibbons FX, Reis TJ, et al.: Perceptions of smoking risk as a function of smoking status.Journal of Behavioral Medicine. 1992,15:469–488.CrossRefGoogle Scholar
  42. (42).
    Gerrard M, Gibbons FX, Benthin AC, Hessling RM: A longitudinal study of the reciprocal nature of risk behaviors and cognitions in adolescents: What you do shapes what you think, and vice versa.Health Psychology. 1996,15:344–354.PubMedCrossRefGoogle Scholar
  43. (43).
    Braithwaite D, Sutton S, Steggles N: Intention to participate in predictive genetic testing for hereditary cancer: The role of attitude toward uncertainty.Psychology & Health. 2002,17:761–772.CrossRefGoogle Scholar
  44. (44).
    Helmes AW: Application of the protection motivation theory to genetic testing for breast cancer risk.Preventive Medicine. 2002,35:453–462.PubMedCrossRefGoogle Scholar
  45. (45).
    Poss JE: Factors associated with participation by Mexican migrant farm workers in a tuberculosis screening program.Nursing Research. 2000,49:20–28.PubMedCrossRefGoogle Scholar
  46. (46).
    Brewer NT, Weinstein ND, Cuite CL, Herrington J, Hayes N: Measuring risk perception and its relation to risk behavior.Annals of Behavioral Medicine, 2004,27:125–130.PubMedCrossRefGoogle Scholar
  47. (47).
    Ouellette JA, Wood JS: Habit and intention in everyday life: The multiple processes by which past behavior predicts future behavior.Psychological Bulletin. 1998,124:54–74.CrossRefGoogle Scholar
  48. (48).
    Fazio RH, Zanna MP: Direct experience and attitude-behavior consistency. In Berkowitz L (ed.),Advances in Experimental Social Psychology (Vol. 14). New York: Academic Press, 1981, 161–202.Google Scholar
  49. (49).
    Loehlin JC:Latent Variable Models. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc., 1987.Google Scholar
  50. (50).
    Chapman G: Personal communication. September 22, 2004.Google Scholar
  51. (51).
    Pedhazur EJ:Multiple Regression in Behavioral Research (3rd Ed.). New York: Harcourt Brace, 1997.Google Scholar
  52. (52).
    Cohen J, Cohen P:Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc., 1983.Google Scholar
  53. (53).
    Bish A, Sutton S, Golombek S: Predicting uptake of a routine cervical smear test: A comparison of the health belief model and the theory of planned behaviour.Psychology and Health. 2000,15:35–50.CrossRefGoogle Scholar
  54. (54).
    Ried LD, Christensen DB: A psychosocial perspective in the explanation of patients’ drug-taking behavior.Social Science & Medicine. 1988,27:277–285.CrossRefGoogle Scholar
  55. (55).
    Conner M, Norman P: Comparing the health belief model and the theory of planned behaviour in health screening. In Rutter DR, Quine L (eds),Social Psychology and Health: European Perspectives. Brookfield, VT: Avebury/Ashgate Publishing, 1994, 1–24.Google Scholar
  56. (56).
    Warwick P, Terry D, Gallois C: Extending the theory of reasoned action: The role of health beliefs. In Terry DJ, Gallois C, McCamish M (eds),The Theory of Reasoned Action: Its Application to AIDS-Preventive Behaviour. Elmsford, NY: Pergamon, 1993, 117–133.Google Scholar
  57. (57).
    Wulfert E, Chan CK: Safer sex intentions and condom use viewed from a health belief, reasoned action, and social cognitive perspective.Journal of Sex Research. 1995,32:299–311.CrossRefGoogle Scholar
  58. (58).
    Sutton SR: Using social cognition models to develop health behaviour interventions: Problems and assumptions. In Rutter D, Quine L (eds.):Changing Health Behaviour: Intervention and Research with Social Cognition Models. Buckingham, UK: Open University Press, 2003, 193–208.Google Scholar
  59. (59).
    Cook TC, Campbell DT:Quasi-Experimentation: Design and Analysis for Field Settings. Boston: Houghton Mifflin, 1979.Google Scholar
  60. (60).
    Baron RM, Kenny DA: The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations.Journal of Personality and Social Psychology. 1986,51:1173–1182.PubMedCrossRefGoogle Scholar
  61. (61).
    MacKinnon DP, Lockwood CM, Hoffman JM, West SG, Sheets C: A comparison of methods to test mediation and other intervening variables.Psychological Methods. 2002,7:83–104.PubMedCrossRefGoogle Scholar
  62. (62).
    Shrout PE, Bolger N: Mediation in experimental and nonexperimental studies: New procedures and recommendations.Psychological Methods. 2002,7:422–425.PubMedCrossRefGoogle Scholar
  63. (63).
    Klein D: Flawed meta-analyses comparing psychotherapy with pharmacotherapy.American Journal of Psychiatry. 2000,157:1204–1211.PubMedCrossRefGoogle Scholar
  64. (64).
    Collins LM, Sayer AG:New Methods for the Analysis of Change. Washington, DC: American Psychological Association, 2001.CrossRefGoogle Scholar
  65. (65).
    Singer JD, Willett JB:Applied Longitudinal Data Analysis: Modeling Change and Event Occurrence. New York: Oxford University Press, 2003.Google Scholar
  66. (66).
    Weinstein ND, Nicolich M: Correct and incorrect interpretations of correlations between risk perceptions and risk behaviors.Health Psychology. 1993,12:235–245.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Behavioral Medicine 2003

Authors and Affiliations

  1. 1.Department of Human EcologyRutgers, The State University of New JerseyUSA

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