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Behavior Change Theories and Frameworks in Pulmonary Rehabilitation

Behavior Change Theories and Frameworks in Pulmonary Rehabilitation
Author: Rachel S. Tappan, PT, DPT
Department of Physical Therapy and Human Movement Sciences
Department of Medicine (Pulmonary and Critical Care)
Feinberg School of Medicine, Northwestern University
Chicago, IL


Long-term behavior change related to physical activity and exercise is an important goal for pulmonary rehabilitation.1-3 Therefore, interventions that help to achieve this goal are critical. Health behavior change theories and frameworks can help guide intervention development, implementation, and the investigation of effectiveness.4,5 In this Quarterly Bite, we describe commonly used health behavior change theories and frameworks underlying interventions that aim to increase physical activity and exercise in people with chronic respiratory disease, including: Social Cognitive Theory (SCT),6-11 the COM-B model,12 and the Transtheoretical Model (TTM).6,7,13,14


Social Cognitive Theory (SCT)

SCT aims to explain the interaction between a person, their environment, and behavior. A person’s self-efficacy and outcome expectancies influence their engagement in a given behavior.15 For instance, if a person believes that they can successfully perform exercise, and they believe that exercise will help improve their quality of life, then they are more likely to invest time and effort in an exercise plan. Other key components of SCT are goal setting and consideration of other factors that influence a person’s behavior (i.e., facilitators and barriers that may be related to personal circumstances or political, economic, or environmental systems).


COM-B Model

The COM-B model is a framework for understanding behavior in context.16 For behavior to occur, the person must have the capability to perform the behavior. There must also be opportunity for the behavior to occur in the physical and social environment. Last, there must be motivation to engage in the behavior. Therefore, the COM-B model posits that influencing behavior change involves changing the capability, opportunity, and/or motivation relating to either the target behavior or behaviors that support or compete with the target behavior. It is also important to note that capability, opportunity, motivation, and behavior are inter-related and interdependent. For instance, increasing a person’s capability to exercise without increasing motivation to exercise may not be sufficient to increase exercise behavior. And yet, increasing a person’s capability to exercise may, in itself, lead to increased motivation to exercise.


Transtheoretical Model (TTM)

TTM focuses on intentional behavior change and includes two key elements: stages of change and processes of change.17 The stages of change describe the person’s level of motivation and readiness to change at a given time. The five stages of change are: precontemplation, contemplation, preparation, action, and maintenance. The processes of change are activities that help a person move toward a change in behavior as they move through the stages of change. Different processes of change may be more important than others for successful behavior change at any given time, depending on the stage of change that the person is in. For instance, increasing awareness of the potential benefits of exercise will likely be more critical in facilitating exercise behavior in someone in the precontemplation stage than someone in the maintenance phase.


Other Theories and Frameworks

While these three health behavior change theories have been used more frequently in research investigating physical activity and exercise interventions for people with chronic respiratory disease, there are other theories and frameworks to consider as well. Self-efficacy theory,18 Habit Formation Model,19 Self-Determination Theory,13,14 Goal Setting Theory,13,14 and Self-Regulation Theory11 have all been incorporated into physical activity interventions for people with chronic respiratory disease. There are also additional health behavior change theories and frameworks that merit consideration. For instance, the Health Action Process Approach is a behavior change framework that incorporates intention to change, risk perception, outcome expectancies, self-efficacy, planning, and behavior maintenance.20 The Social Identity Approach is a framework that incorporates social identity theory and self-categorization theory to explore the impact of social factors on physical activity and exercise.21 Behavior change theories that consider the role of individuals’ affective associations with physical activity, such as the Affective-Reflective Theory of physical activity and exercise, should be considered as well.22,23


In conclusion, health behavior change theories and frameworks can help pulmonary rehabilitation clinicians and researchers to better understand and influence the complex process of helping people with chronic respiratory disease increase their physical activity and exercise. Here, we have described some commonly used theories and frameworks and highlighted others that may be of interest in the future.




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