Core Theory 1: The Health Belief Model

The Health Belief Model (Hochbean, Rosenstock, Kegeles & Leventhal, 1950-1980s)

The Health Belief Model was one of the first theories developed to exclusively address health related
behaviours in the 1950s by a group of American social psychologists who were struggling to get individuals
to participate in preventive and disease detection programs. It has been updated on several occasions
through to the 1980s and therefore representations of it vary a little depending on which version is cited.

The HBM is based on value expectancy theories, which propose that behaviour is dependent on two
factors: (1) value placed on the outcome and (2) estimate of the likelihood that the action will result in an
outcome.

HBM consists of six constructs:

1. Perceived susceptibility: individual subjective beliefs about the risk of acquiring a disease or
experiencing a health outcome. This construct has a strong cognitive element and is
dependent on knowledge and experiences.
2. Perceived severity: subjective beliefs about the level of harm the disease or negative health
outcome or behaviour will cause. Some of the things that may be important in assigning value
to this construct include: concern of signs and symptoms, limitations due to the disease,
temporary or permanent nature of the condition, and socio-economic consequences. Note:
sometimes perceived susceptibility and perceived severity are grouped into perceived threat.
3. Perceived benefits: this refers to the advantages of mitigating risk.
4. Perceived barriers to action: as we know, barriers (real or perceived) can drastically affect
the ways in which individuals behave. In HBM, this construct is about cost of action or inaction.
5. Cues to action: this is the culmination of the forces that push a person to take action.
 6. Self-efficacy: this was a late addition to the HBM in the 1980s, which arose out of further
thinking from the social cognitive theory. Self-efficacy is about the confidence to pursue the
behaviour.

Limitations of the Health Belief Model

The HBM is useful for planning programmes for disease and injury avoidance, but less useful for health
behaviour promotion or longer-term behaviour change. A number of studies have been conducted that
suggest the overall predictive power is limited, likely because of the limited number of factors that are
included within the model.

Yet, it’s one of the most widely used theories of behaviour and is perhaps the ‘classic’ public health
approach to behaviour change.
Core Theory 2: Social Cognitive Theory

Social Cognitive Theory (Bandura, 1963)

Social Cognitive Theory emerged in 1963 and brought a new perspective to explaining and influencing
human behaviour. It was previously termed social learning theory – and you may still see references to this
in the literature.

The SCT posits that human behaviour can be explained as a triad of reciprocal causation. The three sides
to the triangle include behaviour, environmental factors, and personal factors. Immediately you can see that
the environment is something that wasn’t even referenced in the Health Belief Model.

The theory states that the unique interaction between these three things is what drives behaviour change
and thus interventions must target all three. This is reciprocal determinism. Bandura and Waters postulated
that there were three important influences on learning:

1. Imitation
2. Reinforcement patterns, and
3. Self-control

The theory places importance on the potential of human beings by exploring or postulating that there are
five basic human capacities:
 1. Symbolizing capacity: the use of symbols to attribute meaning to experiences, which is an
important factor in understanding and interacting with one’s environment.
2. Vicarious capacity: the ability to learn from observation. Some complex skills can only be
learned through modelling, particularly complex social interactions.
3. Forethought capacity: this refers to the fact that most behaviour is purposive and regulated by
prior thought.
4. Self-reflective capability: which is an internal analysis of experiences.
5. Self-regulation capability: this refers to setting an internal standard and self-evaluation
reactions for one’s behaviour. Goal setting and self-satisfaction are important components of
this capacity.

In addition to these, there are nine constructs that make up SCT:

1. Knowledge: Learning facts and gaining insights related to an action, idea, object, person, or
situation.
2. Outcome expectations: anticipation of the probable outcomes that would result from the
behaviour. There are three types of outcomes: (1) physical, both positive and negative, (2)
social approval or disapproval, and (3) positive or negative self-evaluations.
3. Outcome expectancies: These go hand-in-hand with outcome expectations, which refer to
the value a person places on the outcome of a behaviour.
4. Situational perception: This refers to how one perceives and interprets the environment.
5. Environment: The physical or social circumstances or conditions.
6. Self-efficacy: The confidence that one has to pursue a behaviour. There are four strategies to
accomplishing this: (1) breaking down the behaviour into practical and doable steps, (2) using
demonstration from credible role models, (3) using persuasion and reassurance, and (4)
reducing stress.
7. Self-efficacy in overcoming impediments: This refers to an individual’s confidence that they
will be able to overcome barriers to performing a specific behaviour.
8. Goal setting or self-control: which refers to developing plans and goals to accomplish a
behaviour.
9. Emotional coping: refers to the techniques used to control emotional and physiological states
associated with a new behaviour.

Limitations of Social Cognitive Theory

SCT can be applied easily; however, it Is not designed to change a behaviour. Other criticisms include the
fact that there are too many constructs and that they lack an arrangement which intuitively makes sense.

Despite this, Social Cognitive Theory is employed commonly throughout public health today.
Core Theory 3: Theory of Planned Behaviour

Theory of Planned Behaviour (Ajzen, 1991) previously the Theory of Reasoned Action

The Theory of Reasoned Action (TRA) and its more developed successor, the Theory of Planned
Behaviour (TPB), originated from the idea that there is a relationship between beliefs and attitudes. At its
core the TRA states that a person’s behaviour is determined by their intention to carry out that behaviour.
Initially the likelihood that someone would perform a behaviour comprised two factors:

1. Attitude towards the behaviour: this is defined as a person’s like or dislike towards a
behaviour. The more positive a person feels about the behaviour the more likely they are to
intend to perform it, and vice versa. Attitude is determined by two additional factors (a)
behavioural beliefs, or that behaving a certain way will lead to as specific outcome, and (b)
outcome evaluations, or the value
2. Subjective norms: this is defined by a person’s belief about whether you should behave in a
certain way. For instance, a person might think that it will make their family proud if the study
hard and get good grades. These norms are defined by two additional factors: (a) normative
beliefs, or how a person would like them to behave; and (b) motivation to comply, or the
degree with which a person wants to confirm to the normative standards.

Later Ajzen and Fishbein re-evaluated their theory, deciding that the theory did not adequately account for
people who did not feel they had control over their behaviours. To create the Theory of Planned Behaviour,
they added a third factor to the original TRA :

3. Perceived behavioural control: this is defined as how much a person feels in command of their
behaviours. It is dependent upon their (a) beliefs about the internal and external factors that inhibit or
facilitate behaviours, or control beliefs and (b) perception of how easy or difficult it is to perform the
behaviour, or perceived power.
Limitations of the Theory of Planned Behaviour

The TPB is useful understanding how both individual pressures and social norms affect behaviour;
however, there is still limited ability to consider the environmental and economic influences over behaviour,
and the timeframe between intent and action is not addressed.
Quick recap and even more theories of
behaviour!

So many different theories

Each of these theories provides a different perspective on behaviour. While some focus more on baseline
knowledge beliefs and attitudes, others focus on the enabling factors, such as skills, resources, or
reinforcing factors that predispose towards one choice over another. These theories consider motivation,
from both an individual and community level, and how individual and interpersonal interaction might affect
intention to change.

The table below shows some of the most commonly cited theories and indicate at what level they typically
support intervention development. The table is purely for you to recognise some of the names that you may
or may not come across if you want to work in this area. The three theories that have been highlighted in
the previous reading are some of the most commonly used and cited. The list shows the great number of
other theories that you may wish to draw on as a public health professional. You may also wish to use this
as a reference if you want to find out more. Remember it is by no means exhaustive!

How to use the Behaviour Change Wheel

methodology
You've just had a brief introduction to the Behaviour Change Wheel (BCW) as a methodology. As a
reminder, there are three stages to the overall BCW methodology:

1. Understanding the behaviour using the COM-B model

2. Identifying the intervention options using the Behaviour Change Wheel (BCW)
3. Identifying content and implementation options using the Behaviour Change Taxonomy (BCT)

There are two points that are critical for you in understanding the next two lessons:

 The Behaviour Change Wheel methodology (as we're calling this) describes all three steps of this
process. Confusingly, the Behaviour Change Wheel is a component part of this. We'll use the term
'methodology' when referring to the overall approach approach.
 The initialism BCT for the purposes of this course refers to the Behaviour Change Taxonomy. Again,
confusingly, BCT is sometimes used in other literature for Behaviour Change Technique. So do watch
out for the differences!

Now please take some time to read through the original BCW methodology paper.

Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and
designing behaviour change interventions. Implementation science. 2011 Dec;6(1):42.

https://d3c33hcgiwev3.cloudfront.net/
4bzolbQ5EemfOA4lDN_klA_ddd5ea027c994c60a6b2c2bacab76038_Michie-_2011_.-Behavior-change-
wheel.pdf?
Expires=1618272000&Signature=SqEKcMYCCBNvbUTbDijYem8X~nIS2VyMKdrz5SXw5kRObtteAk1oNG
Y20RMIbfSMiFbReNrcL7zF5nhJ-
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lmo6vfsUlFr4Ku4w_&Key-Pair-Id=APKAJLTNE6QMUY6HBC5A
Using the COM-B approach in medicines adherence

Summary of COM-B

As you learnt in the first video of this module, the COM-B model identifies three inter-related contributors to
overall behaviour, each of which can be sub-divided into two sub-domains:

1. Capability: physical & psychological

2. Opportunity: physical & social
3. Motivation: reflective & automatic

COM-B and medicines adherence

While many of our modern medicines are very efficacious, the principle limitation in much of today's health
system lies not in technology, but in implementation. In the case of medicines - while a drug might work (it's
efficacious) - effectiveness is limited by whether or not a patient takes the medicine as directed by their
physician.

Many patients don't take their medicines as directed - some do this intentionally, and others do this
unintentionally. Perhaps the side-effects are too severe in the case of the former. Perhaps the regimen is
too complicated to remember if the latter.

Have a look at this study by Jackson et al., which has taken a systematic approach using COM-B to
identifying the factors required to enable adherence (in this case, the target behaviour). You will want to
read pages 10-14.

For the purposes of this reading, we've summarised a key factor for each of the six sub-domains (Table 1).
Table 1. Key factors required for medicines adherence using the COM-B framework (adapted from
Jackson et al. 2014).

Capability Opportunity Motivation

Physical: dexterity to open Physical: access to prescriptions and Reflective: belief that the
packages or bottles medication dispensing through a local treatment will be beneficial
pharmacy

Psychological: cognitive function Social: absence of stigmatisation of Automatic: cues /

to comprehend the benefits of disease reminders to take the
treatment medicines

Stage 1: Mapping the target behaviour against the COM-B

domains
The inner circle of the behavior change will consist of the COM-B model. It serves the grounding from
which you can begin to think about analyzing behavior with a view to changing it. This is the first stage
of the behavior change approach. Thinking back to the e-tivity that you've just completed, there are a
multitude of factors that might mean that a population doesn't achieve sufficient levels of physical
activity of which some might be more important for different populations or subgroups. I'm going to
draw your attention to a few examples of these potential drivers using the COM-B model to identify
barriers in the uptake of physical activity. The target behavior is increasing physical activity for adults.
In the real-world, there would be a target behavior that was more specific, but for the purposes of
this example I want to keep things a bit more flexible. But start with capability, you'll recall capability
is defined as an individual's psychological and physical capacity to carry out a specific activity, focusing
on knowledge and skills. It's useful to separate physical from psychological. Taking like physical
capability first, let's say that you were seeking to promote cycling as a means to improving overall
activity. The physical capability domain but highlight that people need to have the physical skills to
ride a bicycle and they need to own or access a bicycle. Barriers therefore, would be bicycle access
and cycling skills. Along these lines, you might want to ask a population to find out if bicycle skills
lessons or subsidy initiative would be appropriate. Moving on to the psychological capability, this is
akin to knowledge. For example, do you know that cycling is healthy and that the activity is being
encouraged. In this way, the barriers to behavior might be around the world of cycling and physical
health. Here is how we get behavior instead was that people should buy a bike or attend a lesson, but
they know how to do this. Psychological capability overlaps with the more generic idea of knowledge
in the COM-B model. So if it was that you needed more people skilling up on cycling, advertisements
and public information campaigns might be a means to address deficits in the psychological capability
domain. The next domain is opportunity. Again, there are two types; physical opportunity and social
opportunity. Physical opportunity is about identifying what are the barriers to undertaking the action.
In the case of physical activity, what are the environmental and restructuring barriers that prevent
people from doing so? Could it be that the pavement or the sidewalk is too narrow or too deploreded
to encourage people to walk? Is there a lack of green space or nearby shops so walking around a
residential environment is not encouraged? Could it be that the stairwells in buildings are hidden and
the elevators are too obvious, and this prevents people from walking up the stairs? Social opportunity
is about social norms. Are these right? If society prizes car ownership and builds a town out of
shopping malls, and it's not surprising that people drive everywhere. Social barriers are difficult to
address at least in the short-term. In the UK, a relatively recent innovation has been the introduction
of female swimming classes. Not only does this alleviate social anxiety or the requirements of
religious custom, but it'll also suggests there's a new social norm, women are swimming. The final
domain is motivation, and this falls within two categories; automatic and reflexive. coercion

There was little positive feedback for the individual by undertaking the targeted behavior. So what can
be done about it? Well, perhaps some of the way of closing the loop that may be helpful. Fitness
trackers do this by counting the number of steps taken each day, the feedback is accelerated so people
perceive a greater and faster return on invested time. Going further by tracking weight and other
metrics, incremental change may also be observed. Automatic motivation is a bit more fun. In the
COM-B model, you want to think about shortcuts that prevent people from undertaking physical
activity. This one could be quite simple. Without making physical inactivity more difficult, it might be
possible to offer incentives for people who undertake physical activity. They may be financial or they
may be more nuanced. Automatic motivation is Automatic motivation is more about utilizing emotion
to override the reflective pathway. So this has been an example of using the COM-B part of the
behavior change wheel to identify some of the barriers to achieving the desired behavioral target.
Jumped around a bit with the example, the reason being that depending on the circumstances, there
will be some situations where you might conclude that only three or four of the six sub-domains are
relevant. You'll also discover that some of the potential barriers will arise from a review of the
evidence while others may arise from your own thinking and reasoning. There is no hard or fast rule
about precisely how you use the framework, but I find COM-B to be a very helpful way of breaking
down a problem. In this example, I've tried to focus on barriers to the target behavior. This is only the
first step. The implementation of a behavior change program will require you to select particular
barriers to overcome, and in doing so, drive change.
Stage 2a: Identifying intervention functions
So far, you've been looking at behavior, either in terms of a positive behavior that has barriers or
negative behavior that has enablers. I have also suggested that these barriers or enablers are means
to understanding how to affect change. Now that you understand broadly why poor health behaviors
are common, I want to turn to the idea of overcoming barriers and using behavior change theory to its
fullest extent to improve health. I'm now going to connect the behavioral framework to possible
interventions to improve the levels of physical activity. You will recall that the behavior change wheel
identifies nine categories which map onto the sources of behavior. These categories termed
intervention functions are as follows; education, increasing knowledge or understanding. Persuasion,
using communication to prompt positive or negative feelings or actions. Incentivization, creating an
expectation of reward. Coercion, creating expectation of punishment or cost. Training, building skills.
Restriction, using rules to reduce the opportunity or ability to engage in the behavior. Environmental
restructuring, changing the physical or social context. Modeling, providing an example to follow, and
then enablement, reducing the barriers to increased opportunity. Each of these approaches has been
connected with one of the six subdomains you can see in the coverage here. You take the example of
the physical opportunity being a barrier, then the table shows that restriction, environmental
restructuring, and enablement, are some of the approaches that might be useful in developing an
intervention.
As you've seen so far, the reasons for engaging in less healthy behaviors are multi-factorial, and
therefore, multi-faceted interventions are far more likely to work than a single poster or leaflet in a
doctor's office. Looking at the table, you can see that education alone relates only to psychological

capability and reflective motivation.

So now, let's consider a more tangible situation. If you found out that safety is a big concern in the
community, high levels of crime and lack of public safe spaces mean that people are less willing to
build in physical activity as part of their travel plans or engage in any exercise outside. You're
essentially suggesting the main barrier is to physical and to a lesser extent, social opportunity. So what
could be more effective in these circumstances? Well, using the table, we can see that restriction,
environmental restructuring, enablement, are three suggested intervention functions for the
opportunity domain. Let's think function by function about what we might do. Restriction. In this case,
you'd be thinking about restricting the possibility of undertaking physical inactivity, and that doesn't
really make sense, so I think we can rule that out. Environmental restructuring. Well, this offers some
opportunities. We can look at providing safer spaces, whether by designing out crime or creating
infrastructure that's less susceptible to fear and impact of criminality. You're less likely to get mugged
on a bicycle than you would be walking home late from a night shift. Schools and youth clubs are safer,
less public spaces, so you might want to focus on improvements there. Enablement. This is looking to
reduce the barriers. It's here that the public health is important to remember. Often, the fear of crime
is more harmful than the crime itself. You might want to work with law enforcement on how they
message and communicate violent crime. In most parts of the world, you're nowhere near as likely to
be a victim of crime as the tabloids or media might suggest, but you may also want to identify barriers
to taking part in activity in safe spaces, like providing subsidized or even free tickets for swimming
classes or dance classes. Likewise, creating a healthy schools charter to enable physical education
classes in public schools, may be another opportunity. I hope that you're now beginning to see how
the behavior change wheel can be used to analyze a problem using the COMBI model, and then to use
the lookup table to identify potential intervention functions.
Stage 2b: Selecting policy options
The next stage of this behavior change approach is mapping intervention functions to the potential
policy options, and as you might expect, there's another lookup table. There are seven policy
categories. These are effectively options for us public health professionals to effect change. They are;
communication, guidelines, fiscal measures, regulation, legislation, environmental and social planning,
and service provision. Now these are relatively self-explanatory but you can find more information in
the behavior change wheel reading. One of the most promising intervention functions when thinking
about the example of low levels of physical activity I discussed earlier is environmental restructuring.
So let's use this one going forward. You will need to identify what policy options you have to achieve
environmental restructuring. Let's select creating safer spaces to be active as our target. You will see
that environmental restructuring is associated with guidelines, fiscal measures, regulation,
legislation, and planning.

So what might the options be; guidelines. Guidelines in this context apply more to urban planning and
development rather than anything clinical or public facing, but guidelines can be introduced to
developers and urban planners that ask the question of how any change will impact on public safety
and the ability to undertake or achieve active travel. You have to be slightly careful about this though.
The requirement to design out crime can be quite a blunt instrument. For example designing out
crime in the UK has meant intentionally providing very uncomfortable park benches so that people
don't loiter. This is meant the loss of comfortable spaces for everyone. Many public toilets have also
been removed with the unintended consequence that public spaces are now not often very friendly to
the very young or the very old. So options that would promote and enable physical activity need to be
considered and balanced, but there is sometimes competing needs to provide public safety. Fiscal
measures; this is another big box of options. On the one hand you might want to incentivize positive
behavior in the form of exercise or indeed penalize negative behavior by a taxation or otherwise.
There are several options that I might consider here. How about providing subsidies for the materials
that you need to be physically active such as comfortable footwear or providing taxes to offset local
businesses who make their toilet facilities available to the members of the public. On the other hand,
you might want to think about wider ring-fence local taxes that could contribute to improving safety
by supporting community engagement groups that could become responsible for the parks, providing
cameras or even paying law enforcement officers. Environmental and social planning; this is very much
about the public realm in urban planning. You may want to implement policies that prohibits certain
businesses such as loan sharks, gambling shops or bars from operating in certain areas, at least
businesses that may attract and perpetuate anti-social behavior or criminality in the vicinity of public
spaces that are designated for promoting physical activity. You've may have noticed that I've not
covered regulation or legislation which is included in the behavior change wheel. In the examples that
I've given you, regulation and legislation have probably failed to some extent so far, in that crime by
definition is in fact illegal, but what I want you to take from this is that you're free to use the
framework however you wish. It's a tool and there will be some instances as you've seen where some
of the elements work better than others depending on the circumstances. For the purposes of the
behavior change process, I'll stop at this point. I've taken you through a step-by-step process that can
be used to guide the development of policies and interventions.
Stage 3: The Behaviour Change Taxonomy
(BCT)

Going back to the start of this module, you'll remember that there were three stages of the BCW
methodology, and it's the third of the stages that we'll cover in this activity:

1. Understanding the behaviour using the COM-B model

2. Identifying the intervention options using the Behaviour Change Wheel (BCW)
3. Identifying content and implementation options using the Behaviour Change Taxonomy
(BCT)

Now the Behaviour Change Taxonomy is an evolving piece of work that is seeking to codify the evidence
around different types of behavioural insight-driven intervention. As you might have observed on this
course so far, terminology in behaviour change work is quite confusing. The BCT project was developed so
that the language can be harmonised and evidence can then be assessed like-for-like. Yet this remains a
bit of a work in progress.

The BCT project identifies 93 different behaviour change techniques and their database seeks to provide a
single-point of engagement through which you can appraise and select behaviour change techniques that
have proven effective in a given area.

You can look at the website here. There is a search function that allows you to filter by one of the 93
behaviour change techniques, or indeed by the topic against which the technique is applied.

We're not covering the BCT in any further depth on this course: and that's for two reasons. The BCT
remains an evolving project. And secondly we simply don't have enough time to look at this in further detail.
But if you are interested, then do take some time to look around the website (linked above) and see how
they've mapped the techniques against the various papers.
Reflections on the BCW methodology

So you're now familiar with the BCW methodology. But if you're still finding it a bit confusing, we'll go
through a worked example in the next lesson.

The key learning that you need to take from this last lesson is:

1. The COM-B model is an agile and evidence-based framework through which to analyse
problems, and is the first stage in generating solutions.
2. The BCW methodology overall is an evidence-based approach to developing interventions.

Now the second of these two points might seem rather obvious. Yet historically in public health practice,
we've followed the principle of ISLAGIATT - "it seemed like a good idea at the time". And that's too often
been the basis for us spending large amounts of resource on interventions that ultimately haven't returned
on their investment.

The advantage of an evidence-based and systematic approach to analysing a problem and generating a
solution is profound!
Introduction to the worked example

You're now familiar with the BCW methodology. We're going to use this lesson to take the BCW
methodology forward using a worked example.

In the previous lesson you learnt about physical activity through the lens of the BCW methodology. You
learnt about the general issues. So now we're going to narrow the scope. Our target population is going to
be young people in Boston MA. This is a much more realistic target population - but this makes the task:

 Easier: because we can be more focused in the analysis and synthesis of our ideas - we know
the place we're working in and we can surmise some of the cultural and sociological barriers
that we're likely to come across.
 Harder: because there's comparatively less specific health intelligence about this more-
narrowly defined group. Accordingly you will have to draw inference from other comparable
sources of information. You may need to justify such as sources as being valid in these
circumstances - or at a minimum recognise the limitations or risks of bias.

We've designed this lesson so that you can develop your approach based on evidence that we're
sign-posting. You should jot down notes throughout this activity and then compare your ideas with
our ideas that we'll tell you about in the video.

Why do some adolescents in Boston undertake low

levels of physical activity?
Overview

In this activity you will be presented with some information about adolescent physical activity, starting with
more basic predictors, or determinants, and moving to some data about Massachusetts and Boston.

Reading

Read: Park, H. and N. Kim (2008). Predicting Factors of Physical Activity in Adolescents: A
Systematic Review. Asian Nursing Research 2(2): 113-128.
BCW Methodology in Boston: Stage 1 - analysing the
problem using COM-B
In the data presented for the E-tivity, you will have observed high rates of physical inactivity among young
people in Boston Massachusetts. Across the board, these indicators were typically worse for girls, and for
those from minority backgrounds. Let's think about the factors that might play a role in the low rates of
physical activity. As you now know, there are a huge number of influences that might affect this behavior. In
this lesson, we won't be able to cover them all, but we'll look into a few including those that were explained
in the reading, and fit them into the COM-B framework for our behavior. Low levels of physical activity
among adolescents in Boston Massachusetts in the United States. In order to analyze the behavior, we
need to contextualize the problem. Boston is a large city on the East Coast of the United States with a
population of about three-quarters of a million people. It's a population with a mixed background, and a
sizable portion of the reticence not told in American citizenship. The city is home to a number of universities
who provides significant employment, along with tech, financial, health, and real estate sectors. Boston has
a relatively high poverty rate in comparison to other major cities with a wide range in salaries, but is slightly
more equitable than the national average using the Gini coefficient. Poverty is more pronounced and
women particularly young adults, but is relatively equal amongst racial groups. Massachusetts the state in
which Boston sits has high levels of health insurance coverage with better access to affordable coverage
and care, the most conservative parts of the countries. Disability levels are about the national average.
Home ownership is significantly lower than both the national and state averages and commute times are
about the same, roughly a half an hour. Public transport and driving are the most common methods of
travel. The average age of just over 30 is a bit younger than the national and state averages with just under
20 percent of the population under 18 years of age, which is less than the proportion of youth in both the
state and nationally. The city has high high-school graduation rates. For this exercise, we will be defining
adolescents using the WHO definition of 10-19 years of age. Looking into physical activity, the data that
you've explored suggests that high school aged youth about 14-19 in Massachusetts are less active than
the national average across all of the indicators. They are also more likely to skip physical education, PE,
and play video games or watch television. When broken down by ethnicity, white adolescents are more
active than their minority counterparts with results closer to and sometimes better than the national
average. Girls are less physically active than boys, but trends closely aligned with the national averages.
The Commonwealth of Massachusetts requires all students to attend PE class, however, there have been
reports in the past few years that many schools do not provide these classes. Often this is a result of
budget cuts and pushes to prepare students for state exams, which help secure funding for the schools.

Now that you have a clear picture about some of the statistics from the city of Boston and physical activity,
let's go back to our behavior change wheel and think about our behavior. Low levels of physical activity
among adolescents in Boston Massachusetts in the United States.

Let's look at Physical opportunity first, specifically focusing on the environment. Research suggests that the
majority of young people in Boston lived within five minutes of a park. However, when looking at the safety
scores of these parks, we see that socioeconomic status and the racial or ethnic makeup of the community
was predictive of how physically safe the features of the park world. This is an important factor in physical
activity, but likely for younger children rather than adolescents who are no longer interested in playing on a
jungle gym. The social environment too has an impact on adolescents level of physical activity, not just
within parks. The data suggests that high levels of social fragmentation are associated with lower levels of
physical activity. Social fragmentation is linked to the breakdown of communities. It's an indication of
population turnover and rented tenancy. While the exact link is not known, it suggests that the both
adolescents and their parents might feel unsafe, and thus may influence levels of physical activity including
active travel such as walking or cycling. The data from adults in Boston links the opportunity with capability
further bolstering the argument that the physical environment is a factor in physical activity. Looking at both
measures of confidence and the ability to exercise, and perceptions of neighborhood safety, data from low-
income housing projects suggest that many people feel safe during the day, but they don't at night,
especially women. In the neighborhoods where people did not feel safe at night, they were less likely to feel
confident in their ability to be physically active and be physically active as measured by pedometers.
Thinking about the time zone and climate of Boston, which mean that for most of the year, it is quite dark
early, the fact that many high school students either work or have extra curricular activities that are not
sports-related, it's possible that the same findings would hold true for adolescents. Motivation to exercise
has been linked to self-esteem, body image, and perceived peer attitudes. This is particularly true for
adolescent girls. Given the low levels of physical activity among adolescent girls in Boston and higher rates
of PE non-attendance, it would stand to reason that at least some of these documented factors might be
adversely influencing physical activity in girls in Boston. I've now gone through some of the evidence that
you might use to analyze the situation and try to better understand the sources of behavior, in this case,
lack of physical activity among adolescents in Boston Massachusetts.