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Theory Application Paper

Student Name

Johns Hopkins University

AS.480.602.81.FA24: Changing Behavior Through Communication

Dr. Kristen Willett

October 29, 2024

Chronic sleep deprivation is a significant problem in the United States. The National Sleep Foundation (2021) recommends that adults sleep seven to nine hours each night, but 33.2% fail to do so, engaging in a problematic behavior that can have wide-reaching ramifications (Pankowska et al., 2023). Research has linked short sleep duration — getting less than seven hours of sleep in a 24-hour window — to a myriad of health issues, such as diabetes, hypertension, obesity, heart disease, cancer, and even death (Chattu et al., 2019; Knuston & Van Cauter, 2008; Liu et al., 2016). For example, in one study, Gottlieb et al. (2005) found that adults who slept five hours or less each night were nearly three times more likely to have diabetes than those who slept for the recommended minimum of seven hours. Additionally, while sleep deprivation affects many across the country, it is rife among Black people in low-income urban neighborhoods (Harvard Medical School, n.d.; Ramirez, 2024). According to the CDC, 43.5% of Black adults do not get enough rest, making short sleep duration more common for this group than Whites (30.7%), Hispanics (32.1%), Asians (30.5%), and American Indians/Alaska Natives (38.5%) (Pankowska et al., 2023). Furthermore, the frequency of short sleep duration increases as annual household income decreases (Gradner et al., 2010; Pankowska et al., 2023). Many of the health risks associated with sleep deprivation — obesity, diabetes, stroke, cancer, and heart disease — already disproportionately affect Black Americans (Heywood, 2023). Hence, mobilizing a sleep health campaign to change this behavior is imperative. The first step toward doing so is comparing the strengths and limitations of different behavioral theories and identifying the most appropriate one to guide campaign efforts, which is the goal of this analysis.

Theory Application

Theory 1: Theory of Planned Behavior

Developed by social psychologist Icek Ajzen (1991), the Theory of Planned Behavior (TPB) states that intention, an individual’s willingness to perform an observable action, determines behavior. Building on Ajzen and Martin Fishbein’s Theory of Reasoned Action, the TPB proposes that three factors influence intention — attitudes, subjective norms, and perceived behavioral control (PBC) (Ajzen & Schmidt, 2020). Beliefs concerning whether a behavior will result in a worthwhile outcome or experience dictate if someone will have positive or negative feelings regarding said behavior, shaping their attitude. Meanwhile, normative beliefs refer to a person’s impressions of what those they deem important expect them to do. These beliefs exert social pressure to participate in or avoid a behavior, forming subjective norms. Lastly, control beliefs reflect an individual’s confidence, or lack thereof, to adopt a behavior and contribute to their perceived behavioral control or self-efficacy. Relative to attitudes and subjective norms,

PBC can sometimes be a more influential component within the TPB model, as people with high self-efficacy may go straight to fulfilling the desired action (Manstead, 2001). In short, the TPB stipulates that “the more favorable the attitude and subjective norm with respect to a behavior, and the greater the perceived behavioral control, the stronger should be an individual’s intention to perform the behavior under consideration” (Ajzen, 1991, p. 188).

Applying the TPB to Sleep Health

Over the years, researchers have utilized the TPB to get better insight into people's sleeping habits and learn how to modify their behavior such that they get at least seven to nine hours each night. In one of the first studies to operationalize the TPB for this purpose, Knowlden et al. (2012) used Ajzen's behavioral theory to examine sleep intentions and behaviors among undergraduate college students at a Midwestern university. They found that attitudes, subjective norms, and PBC significantly predicted intentions to get sufficient nightly sleep and that intention was a strong predictor of performing the actual behavior.

Similarly, Tagler et al. (2016) distributed a questionnaire to 480 Midwest college students, assessing their attitudes, subjective norms, PBC, and intentions regarding following suggested sleep routines. Some of the recommendations were sleeping for at least eight hours, going to bed and waking up at consistent times each day, minimizing caffeine and alcohol intake before bed, and abstaining from eating large meals before bedtime. The results aligned with the TPB — attitudes, subjective norms, and PBC significantly predicted intentions to practice proper sleep hygiene. Tagler et al. also conducted another study exploring whether intention translated into actual behavior. After surveying 99 undergraduates about their behavioral, normative, and control beliefs about sleep hygiene and their intention to get eight hours of sleep the next week, Tagler and his associates gave them wrist actigraphs to measure their sleep duration. The study supported the previous finding that the three TPB variables are reliable indicators of intention and revealed intention to be a significant predictor of getting enough sleep.

Schmidt et al. (2023) corroborated this in a study involving 69 fatigued German teachers. They invited these educators first to complete a set of baseline questions evaluating TPB factors. Subsequently, they gave each of them a Fitbit to track their sleep duration and a diary to monitor their subjective sleep quality for three weeks. Teachers went into either the intervention or control group; those in the intervention group received worksheets explaining the benefits of adhering to healthy sleeping habits and offering tips on overcoming barriers that lie between intention and behavior. Attitudes, subjective norms, and PBC predicted intention to get plenty of rest, and increased intention resulted in teachers modifying their behavior. In addition, the study found that participants who received the implementation intention intervention — the worksheet — slept longer and experienced better quality sleep.

The TPB is a strong candidate for a sleep health campaign. While intention does not always translate into behavior, research indicates that increased intentions to sleep for seven to nine hours — moderated by attitudes, subjective norms, and PBC — do tend to lead to the act of doing so. However, one limitation of the TPB is that it does not consider environmental, socioeconomic, and other prominent factors that may affect an individual’s behavioral intentions (Boston University School of Public Health, n.d.-a). Since the target audience of this campaign suffers from short sleep duration due to environmental obstacles such as excess noise and light and key determinants like race and income, it is important not to dismiss these considerations when attempting to modify this audience’s sleep behavior (Ellison, 2021). A potential solution to this issue, if the campaign proceeds with the TPB, is to incorporate the Integrative Model of Behavioral Prediction, a slightly expanded version of the TPB that includes background variables like these and “recognizes that the beliefs that ultimately guide behavior are grounded in an audience’s demographic, socioeconomic, and cultural factors” (Yzer, 2012, p. 25).

Theory 2: Transtheoretical/Stages of Change Model

James Prochaska and Carlo DiClemente’s Transtheoretical Model (TTM) frames behavior change as an extensive process during which people progress through six stages:

precontemplation, contemplation, preparation, action, maintenance, and termination (Prochaska et al., 2015). During the precontemplation stage, a person is unaware of any problem and has no intention to change. At the contemplation stage, the individual acknowledges that a problem exists and begins thinking about changing their behavior, although nothing is set in stone. If an individual decides they have a problem and begins mapping out a plan to address it in the near future, they are in the preparation stage. They move to the action stage once they start executing the plan and taking the steps necessary to change their behavior. The next stage is maintenance — the person has successfully changed their behavior and tries their best to stay on track. Finally, there is the termination stage, where they have no concerns about returning to old habits and are confident in maintaining their new behavior. Termination is a distant stage that most audiences never reach, as the temptation to revert to past behavior rarely disappears completely. Ultimately, the primary benefit of the TTM is that it helps behavior change communicators identify what stage members of their audience are at and craft messages tailored to meet their unique needs, making them more receptive to the possibility of change.

Applying the TTM to Sleep Health

While not many studies have applied the TTM to sleep behavior, there are some worth mentioning. For instance, Hui and Grandner (2015) examined data from a health risk assessment survey administered to 13,222 Kansas state employees in 2008. The survey questioned employees about their quality of sleep and what changes, if any, they intend to make to their stress management, physical activity, alcohol use, smoking, and weight. Statistical analysis of the survey data showed that poor sleep quality led to an increased chance of contemplation, preparation, and action when it comes to adopting healthy behaviors but a lower possibility of maintenance. This suggests that raising awareness about the benefits of getting adequate amounts of sleep each night could cause people to contemplate altering their behavior and maybe even do it, but maintaining that change over time is unlikely without further intervention.

Employing the TTM in the Motivating Teens to Sleep program, a Montreal initiative designed to promote healthy sleeping habits among Montreal teens, Cassoff et al. (2014) demonstrated that stage-based interventions can generate long-term behavior change. Besides including one-on-one motivational interviews with teens, the program set out to provide them with tailored messaging specific to their needs and stage-based interventions based on the TTM. During the program's pilot phase, a group of high school students completed a screening questionnaire that ascertained their sleeping routine and current stage of behavior. They then received actiwatches to document their sleeping duration for one week before returning the devices and beginning the four-week program. Participants in the experimental group received interventions matching their current stage within the TTM, while those in the control group did not get personalized guidance. After the program and during three- and six-month follow-ups, participants wore actiwatches again to gauge their sleeping patterns. The researchers observed that the teens in the experimental group not only practiced better sleep hygiene by the end of the program but also maintained the behavior three and six months later (Cassoff et al., 2015).

Considering a person’s readiness to change their behavior affects how they respond to interventions, the main benefit of the TTM is its ability to help sleep behavior specialists develop targeted messaging that meets their audiences where they are. According to Cassoff et al. (2014), tailored TTM sleep interventions have been constructive: “Personalizing information or tailoring messages for each individual have been shown to be more effective than presenting generic information in engaging individuals, building their self-efficacy and improving health behaviors” (p. 2). Despite this, some limitations linger. For one, there are no standardized criteria for identifying what stage someone is at, with the lines between the stages blurring at times (Boston University School of Public Health, n.d.-b). This limitation could pose problems, as there is the risk of misidentifying a person’s stage of behavior and providing them with misguided campaign materials that fail in modifying their behavior. Secondly, the model does account for socioeconomic factors such as income and education, which are especially relevant in this case given who the campaign will be targeting (Boston University School of Public Health, n.d.-b)

Integration and Comparison

Although researchers have used both the TPB and TTM to study sleep behavior, findings suggest that the former may be more adept at modifying it. Take Lao et al. (2016), for example, and their use of the TPB to inspect the sleeping patterns of Chinese college students. Substantiating the studies previously outlined, they concluded that attitudes, subjective norms, and PBC significantly influenced intention, which was positively associated with gaining sufficient sleep. Likewise, a study involving American students found that the TPB components increased intentions to get a good night’s rest and that norms and PBC predicted intentions to maintain the behavior months later (Branscum et al., 2020). Moreover, they reported that PBC had the most considerable impact on intentions to perform and maintain the behavior, stating that those seeking to modify sleeping habits should prioritize increasing their audience’s self-efficacy.

Meanwhile, a study using the TTM to alter sleep disorders among the elderly declared self-efficacy to be positively associated with sleep quality and play a crucial role in stage progression (Nazari et al., 2014). Also, during a study on what makes people want to alter their sleep behavior, a survey assessed 1,007 respondents’ intentions to improve their sleep quality, what stage of change they were at, and if they believe short sleep duration leads to dire outcomes (Khader et al., 2021). The researchers determined that “the degree to which an individual believes insufficient sleep leads to adverse consequences may influence the likelihood of changing sleep habits” and that educating people about the benefits of getting ample rest “should be further supplemented with resources that address barriers to achieving healthy sleep” (Khader et al., 2021, p. 102). The conclusions of these studies imply that behavioral and control beliefs — elements emphasized in the TPB — are vital when it comes to changing sleep behavior.

Assessment of Fit

Given the critical role attitudes, subjective norms, and PBC play in persuading individuals to adopt and maintain healthy sleep behavior, it is evident that the TPB offers a more compelling intervention strategy than the TTM. In an article reviewing studies that have applied behavioral theories to sleep, Mead and Irish (2020) affirmed that the TPB has shown great promise in predicting and modifying behavior and that PBC has the most significant impact on intention. They also state, “To date, only a few studies have used health behavior theories to predict healthy sleep health intentions, with almost all studies utilizing iterations of the TPB” (Mead & Irish, 2020, p. 5.). One study they reference is Stanko (2013), which described using the TPB model to predict intentions to sleep seven to nine hours each evening among 57 undergraduates. Favorable subjective norms and increased PBC produced greater intentions to improve their sleep duration. In another, a survey evaluating the attitudes, subjective norms, and PBC of 1,822 Iranian teenagers and a six-month follow-up confirmed the TPB’s ability to predict intentions to participate in and continue recommended sleep behaviors (Strong et al., 2018).

Additionally, Tagler (2024) argued that sleep interventions should focus on highlighting PBC and developing an audience’s time management skills, as many insufficient sleepers have low confidence in this area. Considering multiple job holding is common among low-income Black people, they likely do not trust their ability to find the time to sleep seven to nine hours each night (Marte & Mutikani, 2021; U.S. Bureau of Labor Statistics, 2023). Consequently, a theoretical framework combating this barrier by increasing their PBC would be most appropriate, making the TPB the best fit for a sleep intervention targeting this audience.

Conclusion

Of the two theories discussed, the TPB emerged as the most fitting or a campaign designed to modify sleep behavior, as many studies point to PBC and other components of the model playing a major role in determining whether someone sleeps seven to nine hours each night. Ample research in this area has shown that behavioral, normative, and control beliefs ultimately influence intention, which is a significant predictor of following best sleeping practices. Additionally, the expanded version of the TPB — the integrative model of behavioral prediction — accounts for relevant demographic and socioeconomic variables influencing the target audience’s sleeping habits. With this theoretical framework forming the foundation, the campaign will concentrate on producing materials that emphasize the benefits of sufficient sleep and increase self-efficacy by offering tips on managing one’s time, especially as a multiple jobholder. Additional tactics include leveraging the social proof principle and sharing visuals depicting Black people getting their rest. Grounded in the TPB, the forthcoming campaign can help alleviate sleep deprivation within poor African American areas.

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