The Health Action Model (HAM) was devised by Tones (1987 and Tones & Tilford 2001) and emphasises the important influence of self-esteem on behaviour. It assumes that someone with high self-esteem and a positive self-concept is likely to be more motivated towards ways of healthier living and that people with low self-esteem may feel that they have limited control over their behaviour and that they are victims of bad luck or fate. Many health promoters, particularly those working in the field of drugs, have used this model, through concentrating on boosting people’s self-esteem and their skills in resisting peer group pressure. According to this model, learning life skills such as how to be assertive may be essential before someone is ready to change their lifestyle.

The HAM identifies a variety of psychological, social and environmental influences which research and practice have shown to be important determinants of a number of health choices. The model offers an explanation about how these influences work. It suggests that health decisions and actions are influenced by our beliefs, our values, our motivation, our expectations of how other people will react to our actions and our self-concept and self-esteem (see Fig. 14.1).

The HAM is concerned with empowerment, with increasing the control people have over their lives. It suggests that health promotion should not just focus on the provision of information and the pros and cons of particular behaviours. More important than this are interventions that enable people to value themselves, and to acquire the skills to assert themselves. Equally important is the provision of environmental circumstances that facilitate healthy choices, rather than acting as barriers. And at a broader level, national and local policy needs to address the broader determinants of health, such as poverty and deprivation.

One way of supporting people in making health-related decisions and changing their behaviour is to consider all the stages in the process, and how people move from one stage to another. The Transtheoretical Model (TTM) developed by Prochaska & DiClemente (1982) is rooted in extensive research and integrates a range of psychological theories. The TTM has evolved over time and now contains five core constructs: stages of change, processes of change, decisional balance, self-efficacy and temptation (Prochaska & Velicer 1997) which provides a valuable conceptual framework for how people naturally change their behaviour. However, there is controversy and debate about whether this can consistently be translated into an intervention programme (see, for example, Aveyard et al 2009 and Prochaska 2009). Studies based on this model, such as Aveyard et al (2006) found no evidence that the smoking cessation intervention based on the model was more effective than a control intervention that was not tailored for stages of change. Armatage (2009) offers a useful critique of the model and an assessment of three studies that deemed to have successfully utilised the processes of change to reduce alcohol consumption, encourage smoking cessation and increase physical activity. It is important before using the approach to be abreast of the controversy and the systematic reviews on it’s effectiveness. A useful summary with a full set of up-to-date references is presented on Wikepedia (http://en.wikipedia.org).

The stages of change component of the TTM identifies a number of stages that a person can go through during the process of behaviour change. It takes a holistic approach, integrating factors such as the role of personal responsibility and choices, and the impact of social and environmental forces that set very real limits on the individual potential for change. It provides a framework for a wide range of potential interventions by health promoters, as well as describing the process individuals go through when acting as their own agents of change; for example, when someone stops smoking without any professional support. The main stages identified in the model are set out in Fig. 14.2 (see also Prochaska 2005).

The key to the model is to regard the cycle in the centre as a series of stages that people go through in the process of changing health behaviour, such as stopping smoking, taking more exercise regularly or adopting healthier eating. A crucial point is that the cycle can be thought of as a revolving door, because people usually go round more than once before emerging to a permanently changed state. It is also important to recognise that some people may never get as far as entering the revolving door.