Learning and Conditioning

Among the oldest, most widely researched, and yet most often misunderstood models of individual behavior applied to
behavior change are those that deal with fundamental associative or classical conditioning and the related models of operant
conditioning. Classical conditioning, pioneered by Pavlov, modifies behavior by repeatedly pairing a neutral stimulus with
an unconditioned stimulus that elicits the desired response. Operant-conditioning builds on classical conditioning and
focuses on the hypothesis that the frequency of a behavior is determined by its consequences (or reinforcements; Skinner,
1938). Although learning theory has been criticized for treating behavior in simplistic and mechanistic stimulus response
terms, modern learning theory addresses complex components, including environmental cues and contexts, memory,
expectancies, and underlying neurological processes related to learning (Rescorla, 1988). As Kehoe and Macrae
(1998) note, today classical conditioning integrates cognition, brain science, associative learning, and adaptive behavior.

Classical conditioning introduced concepts that have been particularly important in the design of health-related
interventions, such as reinforcement, stimulusresponse relationships, modeling, cues to action, and expectancies.
However, given the particular difficulty in maintaining behavior changes, the relapse of behaviors that have been eliminated
(or extinguished) by an intervention is of particular interest. Relapse of extinguished behaviors is a major problem in
health-related behavior change interventions, especially those that target alcohol use, smoking, and diet (Dimeff and
Marlatt, 1998; Marlatt and George, 1998; Perri et al., 1992; Wadden et al., 1998). Extinction initially was conceptualized as
a process in which original learning, and therefore behavior, was unlearned or destroyed. That is, it was assumed that
extinguished behavior would no longer be elicited by the environmental cues that originally evoked it. However, extensive
research shows that extinction does not involve unlearning, but rather new learning that does not overwrite the original
learning. Furthermore, the physical environment and social context in which extinction takes place, as well as such internal
states as emotions, drug-related states, and time, will influence the process of extinction (Bouton, 1998, 2000).

Those findings have important implications for health-related behavior change. Specifically, the effectiveness of an
intervention to reduce or eliminate a health risk, such as cigarette-smoking, will be limited to the extent that it is bound to
the context in which it is delivered. As noted by Bouton (2000, p. 58), the reformed smoker who once habitually smoked in
a particular setting at work, or under the influence of a particular drug or alcohol, or in the presence of negative affect will
be ready to lapse when cigarettes are made available in one of those contexts again. We now think of extinction as
inherently context-specific, with the term context' being broadly defined.

One important implication of those findings is the importance of eliciting extinction in different contexts, including various
physical environments, times, and emotional states. For example, extinction trials that are more widely spaced and in
separate locations are more likely to be effective than core sessions that occur within short periods or in similar physical
circumstances. Behavior change efforts should recognize the possible influence of contextual cues, identify the cues that
might be involved, and help people avoid (or cope with) the contexts connected with the original health-compromising
behavior, whether physical environments, interpersonal relationships, or negative emotional states. The learning of the new
behavior (or extinction of the old) should take place in the contexts in which the person will need it the most.
There is another important difference between original learning and extinction, namely, that original learning of a behavior
readily generalizes across contexts, whereas extinction does not (Bouton, 2000, p. 61):

[F]irst-learned things seem much more likely to generalize over place and time. One implication of this is that if we really
want to reduce cardiovascular risk, we should arrange a world in which healthy behaviors are the first things, not the second
things, learned. One way of thinking about research on behavior change is that the organism seems to treat the second thing
learned about a stimulus as a kind of exception to a rule. It is as if the learning and memory system is organized with a
default assumption that the first-learned thing is correct, and everything else is conditional on the current context, place, or
time.

That perspective provides support for the importance of preventive interventions that promote health-enhancing behaviors,
as opposed to interventions designed to treat or change health-compromising behaviors.

The evidence that extinction depends on context is but one of several important results from basic research on learning and
conditioning with important implications for explaining health-related behavior change. Closer ties between intervention
research and basic learning theory and research could contribute to what O'Donohue (1998) called third-generation
behavior therapy, behavioral interventions that are informed by recent developments in learning theory and other fields of
basic behavioral science.

Cognitive Social Learning

Cognitive social-learning theory (e.g., Bandura, 1977, 1986, 1997) proposes that reinforcements are not the sole
determinants of behavior, but that behavior changes with observations of others. According to cognitive social-learning
theory, the most important prerequisite for behavior change is a person's sense of self-efficacy or the conviction that one is
able successfully to execute the behavior required to produce the desired outcome. People can feel susceptible to an illness,
expect to benefit if they change their behavior, and perceive their social environment as encouraging the change, but if they
lack a belief that they can indeed change, their efforts are not likely to succeed. Substantial empirical evidence suggests that
self-efficacy beliefs (and the related concept of optimism) are reliable predictors of behavior, and that they mediate the
effects of intervention on behavior change, including a number of health-related behaviors (e.g., Bandura et al.,
1987; Ewart, 1995; Kaplan et al., 1994; Scheier et al., 1989; Wiedenfeld et al., 1990). A growing body of literature supports
the importance of self-efficacy in initiation and maintenance of behavioral change (Bandura, 1977, 1986;Marlatt and
Gordon, 1985; Strecher et al., 1986).

Self-regulation is a concept that derives from cognitive social learning theory (see Bandura, 1986; Baumeister et al.,
1998; Carver and Scheier, 1998; Compas et al., 1999; Eisenberg et al., 1997), and it includes what many people call will
power. Self-regulation includes cognitive and behavioral processes that involve the initiation, termination, delay,
modulation, modification, or redirection of a person's emotions, thoughts, behaviors, physiological responses, or
environment (Compas et al., 1999). Self-regulation can be critical in such health-protective and health-maintaining
behaviors as eating a healthy diet, engaging in regular exercise, and managing stress. Conversely, the failure or breakdown
of self-regulatory efforts can be crucial in some risky behaviors, such as smoking, poor dietary management, and a
sedentary lifestyle.

Although much research supports the utility of Social Learning Theory, limitations have been noted. It is difficult to
evaluate the efficacy of theory-based interventions because the studies have involved only small numbers of subjects and
the intervention designs have been very complex. In addition it is difficult to quantify and measure the conceptual elements
of Social Learning Theory: self-efficacy, influence of observational learning, and emotional arousal.

Health Belief Model

One of the earliest theoretical models developed for understanding health behaviors was the health belief model
(HBM;Hochbaum, 1958). The model was developed in the 1950s to explain why people did not engage in behaviors to
prevent or detect disease early. It integrates elements of operant-conditioning and Cognitive Theory. Operant-conditioning
theory focused on the hypothesis that the frequency of a behavior is determined by its consequences while Cognitive Theory
gave more emphasis to expectations to explain behavior. For example, the desire to avoid becoming ill is a value, and belief
that a specific health behavior can prevent an illness is an expectancy. Perceived susceptibility is the perception of personal
risk of developing a particular condition, and it involves a subjective evaluation of risk rather than a rigorously derived level
of risk. Perceived severity is the degree to which the person attributes negative medical, clinical, or social consequences to
being diagnosed with an illness. Together, perceived susceptibility and perceived severity provide motivation for reducing
or eliminating such threats. The type of action taken depends on perceived benefits (beliefs about the effectiveness of
different actions) and perceived barriers (potential negative aspects of particular actions). People are thought to weigh an
action's effectiveness in reducing a health threat against possible negative outcomes associated with that action.

The HBM has been applied, among other things, to influenza inoculation, screening for Tay-Sachs disease, exercise
programs, nutrition programs, and smoking cessation (Strecher and Rosenstock, 1997). An important contribution of the
model is the recognition that prevention requires people to take action in the absence of illness. This continues to be useful,
for example, in explaining women's reluctance to perform breast self-examination or obtain mammograms (Rimer, 1990).
The limitations of the HBM are reviewed by Janz and Becker (1984). Perhaps the most critical of these is the lack of
predictive value for some of its central tenets. For example, the perceived severity of a risk does not reliably predict
protective health behaviors (Rimer, 1990). Moreover, the HBM is more descriptive than explanatory and does not
presuppose or imply a strategy for change (Rosenstock and Kirscht, 1974). The predictive utility of the HBM and its
applicability to behavior change can be improved by adding variables, such as self-efficacy, or by integrating it with other
models.

Theory of Reasoned Action

The Theory of Reasoned Action was first proposed by Ajzen and Fishbein (1980) to predict an individual's intention to
engage in a behavior at a specific time and place. The theory was intended to explain virtually all behaviors over which
people have the ability to exert self-control. Factors that influence behavioral choices are mediated through the variable of
behavioral intent. In order to maximize the predictive ability of an intention to perform a specific behavior, it is critical that
measures of the intent closely reflect the measures of the behavior, corresponding in terms of action, target, context, and
time.

Behavioral intentions are influenced by the attitude about the likelihood that the behavior will have the expected outcome
and the subjective evaluation of the risks and benefits of that outcome. The predictive power of the model depends
significantly on the identification of most or all of the salient outcomes associated with a given behavior for any particular
target population.

Stages-of-Change Model/Transtheoretical Model

Beginning with the first formulation of the HBM, Hochbaum (1958) assessed the readiness of adults to participate in
screening. The inclusion of beliefs about susceptibility to illness and the personal benefits of screening was seen as an
essential element in readiness. The concept was expanded into more elaborate models, such as the Transtheoretical Model
(also known as the Stages-of-Change Model) first proposed by Prochaska and DiClemente (1983). This model characterizes
the continuum of steps that people take toward change and includes the activities or processes to move people from one
stage to another. The earliest stage of behavior change starts with moving from being uninterested, unaware, or unwilling to
change (precontemplation) to considering a change (contemplation). This is followed by the decision to take action
(preparation) and the first steps toward the behavioral change (action). With determined action, the requirement for
maintenance and relapses are recognized as part of the process. In addition to these temporal stages, the Transtheoretical
Model encompassed the concepts of decision criteria, self-efficacy, and change processes (consciousness-raising, relief
from negative emotions associated with unhealthy behavior, self-reevaluation, environmental reevaluation, committing to
change, seeking support, substituting healthier alternative behaviors, contingency management, stimulus control, and
recognizing supportive social norms; Prochaska et al., 1997). The Transtheoretical Model has been influential in research on
smoking and was recently extended to other health risk behaviors (Prochaska et al., 1994).

The theoretical validity of the Stages-of-Change Model for behavior change is a matter of controversy (Budd and Rollnick,
1997; Sutton, 1996). Although early cross-sectional studies provided support for the theory (DiClemente et al., 1991; Fava
et al., 1995), recent longitudinal studies did not support the Transtheoretical Model (Herzog et al., 1999;Sutton, 1996).
Furthermore, multivariate analyses of several behavioral predictors demonstrate that the stages are weak predictors of
cessation (Farkas et al., 1996; Pierce et al., 1998). Variables from cognitive social learningsuch as outcome expectancy,
self-efficacy, and behavioral self-controlappear to be better predictors of change than are the stages and associated
processes (Bandura, 1997; Herzog et al., 1999).

Despite questions about its theoretical validity, the model has contributed to the recognition that most potential recipients of
health-related behavior change efforts are not motivated to change. Population surveys show 80% of the target group in the
precontemplation or contemplation stages. That result draws attention to the potential of approaches that increase
motivation for health promotion and illness prevention. The development of innovative motivational programs to encourage
less interested people to consider healthier lifestyles represents a new direction in health and behavior change (e.g., Miller
and Rollnick, 1995).
Social Action Theory

One important example of a model that attempts to integrate individual psychological processes with social contextual
factors is Social-Action Theory (Ewart, 1991), which builds on Social Cognitive-Learning Theory, models of self-
regulation, processes of social interdependence and social interaction, and underlying biological processes to predict health-
protective behaviors and outcomes (Ewart, 1991). It views the person as influenced by environmental contexts or settings to
which he or she brings a particular temperament and biological context. Thus, a person's capacity to practice healthy eating
habits and to exercise is influenced by access to health-enhancing foods and safe places to exercise and by internal goal
structures, self-efficacy beliefs, and problem-solving skills.

In Social-Action Theory, biology and social and environmental contexts determine the success of interventions to promote
individual behavior change (Ewart, 1991). Most behavioral research, however, has focused on individual strategies to
facilitate desired changes, and less is known about how social and other contextual factors can be mobilized to promote
behavior change. Social-Action Theory specifies mediating mechanisms that link organizational structures to personal
health and incorporates key concepts from the earlier theoretical models, including self-efficacy and outcome expectancies.
Some applications of social-action theory focus on the mechanisms and maintenance of behavior change (Ewart, 1990),
again placing the focus on the influence of context on individual behavior.

Social-Action Theory provides a framework for multilevel approaches to health promotion and illness prevention. It offers a
theoretical rationale for intervening in health policy and for creating environments that are conducive to self-protective
choices. It provides an approach for defining public health goals and modifiable social and personal influences that can be
used to encourage individual health-related behavior change. Social-Action Theory fosters interdisciplinary collaborations
by incorporating and coordinating the perspectives of the biological, epidemiologic, social, and behavioral sciences.