We tend to say first of all we need to change their attitudes to change their behaviors. How far is it true?
This post delves into the researchers’ quest finding answers to this question.
In the 1960s, Fishbein and Ajzen reviewed published research and concluded the relationship between attitudes and behavior is not straightforward. They suggested the intention to perform the behavior determines whether to engage or not in a particular behavior.
Theory of Reasoned Action
That was the basis for their first theory: The Theory of Reasoned Action (TRA). They published it in 1967.
What it says is this;
- Our action depends on the intent of either doing it or not doing it.
- Having an intent depends upon two determinants; not only the presence of a positive attitude towards the behavior but the presence of subjective norms (social pressure) matters too.
- A positive attitude includes two aspects: whether it is believed to be enjoyable or not enjoyable and beneficial or harmful.
- The social pressure needs to be perceived; it may experience in two ways: telling by your significant other and seeing that they themselves are doing that.
- Stronger the perceptions, the more likely stronger the intentions are.
Let us see how it applies in real life.
Think that someone wants to carry out self-examination of the breast. She might do that if she has any intention of doing that. It is a fairly simple straightforward explanation.
What is challenging is to find out an explanation of how that intent is developed. According to the Theory of Reasoned Action, the intent depends on the presence of a favorable attitude towards that behavior and whether they feel any sort of social pressure (perceived social pressure) to engage in this behavior. Below, you can see its application in a nutshell.
Theory of Planned Behavior
With time, Ajzen found the theory’s inadequacy in explaining some behaviors that are not under our control. As a result, he added another variable to the equation: perceived ability to perform the behavior as a determinant of the intent and re-named it as the “Theory of Planned Behavior”.
This theory is an extension of the theory of reasoned action. Both these are not exactly considered as behavior change theories but theories that help us to understand and predict the desired behavior. However, these two assist us in framing messages and developing health education materials too.
What it says:
- The third variable – perceived control over the performance of the behavior– was added to the previous theory. That is the only difference. In the example below, if someone believes she has the ability to perform the task, she is more likely to engage in breast self-examination. It also includes the perceived ability to overcome barriers: economic, social, geographic, or even cultural.
- The stronger the beliefs the stronger the intention of engaging in the behaviors are.
- However, Ajzen in his seminal paper published in 1991cautions about the possible feedback effects of the behavior on the antecedent variables. (This is not shown in the diagram).
- The perceived behavior control may have a direct influence on the behavior bypassing the intent of doing the behavior.
- Although it is not shown in the diagram, attitudes towards the behavior, perceived social pressure, and perceived ability to engage in the behavior can influence each other according to the Ajzen’s 1991 paper.
The following video clip explains the theory with an example.
Now, the most important question is this?
How can we use these theories for our benefit?
A review published in 1995 has concluded the efficiency of the theory varies depending on the type of behavior it was applied. They have found that two-third of the explained variation could be attributed to the intention of engaging in the desired behavior. This is a very important finding for us; in other words, most of our probability of engaging in a particular behavior depends on the degree of motivation. However, for addictive and screening behaviors, perceived behavioral control carried to have more control than the intention of doing the behavior.
Is it possible to quantify alcohol-related problems?
During the past half a century, researchers have been grappling with this problem. They have developed a plethora of tools to quantify alcohol-related problems depending on how they define it. One such famous tool to date is the A.U.D.I.T.: (Alcohol Use Disorders Identification Test). This 10-item instrument came to us as a result of a multi-center study executed by the World Health Organization (WHO).
I do not discuss how it was developed. Rather, I describe the test.
AUDIT (Alcohol Use Disorders Identification Test)
The AUDIT – the 10-item questionnaire – screens for alcohol-related problems within 10 minutes fairly accurately.
In 2001, the WHO published the tool as a freely available booklet. You can access it through this link: AUDIT test. Thomas Babor, John Higgins-Biddle, John Sanders, and Maristela Monteiro authored the booklet (Figure 1).
What is this instrument?
The instrument consists of 10 questions and each question owns 5 responses with scores ranging from 0 – 4. The respondent should choose one response out of 5 responses. This means after responding to all ten questions, the respondent’s score may be any value between 0 – 40.
All the questions inquire about the respondent’s alcohol consumption and related problems during the past 12 months from the date of the interview.
The interview version of the AUDIT tool
The instrument consists of 3 domains: hazardous alcohol use, dependence symptoms, and harmful alcohol use. The first three questions deal with the first domain – hazardous alcohol use while the second three questions probe about dependence symptoms. The last four questions seek information about harmful alcohol use. The box 2 summarises these three domains and its related question items succinctly.
Challenges in using the AUDIT instrument
Among several challenges in using this instrument, the most crucial one is assessing the hazardous consumption in terms of the amount of pure ethanol consumed in the 12 months prior to the interview. This is because the percentages of pure ethanol in alcohol beverages vary significantly by the product. For example, beer products contain about 5 percent of pure ethanol while spirits having about 40 percent of pure ethanol. The instrument adopts the standard drink size concept to overcome the challenge.
While I was validating the AUDIT – a tool widely used to quantify alcohol consumption and related problems – to the Sri Lankan context, although researchers and practitioners all over the world have been using it for decades, I faced many difficulties in translating its first three questions: the quantity-frequency questions.
However, I overcame the challenge. Before explaining the method which could be adapted by anyone in any cultural setting, I again will describe the first three AUDIT questions and the challenges of using it.
Keep in mind that these questions refer to the past 12 months from the date of the interview.
How often do you have a drink containing alcohol?
(1) less than monthly
(2) 2-4 times a month
(3) 2-3 times a week
(4) 4 or more times a week
Any respondent might answer the above question relatively easily if they can recall their past 12 months prior to the interview date. Both interviewers and respondents will face a big problem when dealing with the following two questions since both should know what a “drink” is.
How many “drinks” do you have on a typical day when you are drinking?
(0) 1-2 drinks
(1) 2-3 drinks
(2) 4-6 drinks
(3) 7-9 drinks
(4) 10 or more drinks
How often do you have 6 or more drinks on one occasion?
(1) less than monthly
(4) daily or almost daily
According to the original manual, a “drink” refers to an amount of an alcoholic beverage containing 10 grams of pure ethanol (see page 15 of the manual). This definition varies from country to country: It is 13.6 grams in USA and Canada.
The manual (see page 15 in the link) recommends explaining what a “drink” means to respondents. We first need to prepare visuals of drinks of different alcoholic products since drink sizes vary with its alcohol content: For example, a beer bottle equates a “10-grams drink” since its ethanol content is 5%; in contrast, a whisky shot glass equates a “10-grams of drink” whisky since its ethanol content is 40%. It is more challenging in cultures where informal, home-grown, sometimes illicit products, are commoner.