Professional Documents
Culture Documents
at a
Glance
A
decade ago, the first edition of Theory at a Glance was published. The guide was
a welcome resource for public health practitioners seeking a single, concise
summary of health behavior theories that was neither overwhelming nor superficial.
As a government publication in the public domain, it also provided cash-strapped
health departments with access to a seminal integration of scholarly work that was useful to
program staff, interns, and directors alike. Although they were not the primary target audience,
members of the public health research community also utilized Theory at a Glance, both as
a quick desk reference and as a primer for their students.
The National Cancer Institute is pleased to sponsor the publication of this guide, but its
relevance is by no means limited to cancer prevention and control. The principles described
herein can serve as frameworks for many domains of public health intervention,
complementing focused evidence reviews such as Centers for Disease Control and
Prevention’s Guide to Community Preventive Services. This report also complements a
number of other efforts by NCI and our federal partners to facilitate more rigorous testing
and application of health behavior theories through training workshops and the development
of new Web-based resources.
One reason theory is so useful is that it helps us articulate assumptions and hypotheses
concerning our strategies and targets of intervention. Debates among policymakers
concerning public health programs are often complicated by unspoken assumptions or
confusion about which data are relevant. Theory can inform these debates by clarifying key
constructs and their presumed relationships. Especially when the evidence base is small,
advocates of one approach or another can be challenged to address the mechanisms by
which a program is expected to have an impact. By specifying these alternative pathways to
change, program evaluations can be designed to ensure that regardless of the outcome,
improvements in knowledge, program design, and implementation will occur.
Director
Spring 2005
Acknowledgements
The National Cancer Institute would like to thank Barbara Rimer Dr.P.H. and
Karen Glanz Ph.D., M.P.H., authors of the original monograph, whose knowledge of
healthcommunications theory and practice have molded a generation of health promotion
practitioners. Both have provided hours of review and consultation, and we are grateful to
them for their contributions.
Introduction viii
Tables
Audience and Purpose 1
Contents 1
Table 1
An Ecological Perspective: Levels of Influence 11
Table 2
Health Belief Model 14
What Is Theory? 4
Table 5
Social Cognitive Theory 20
Table 10
Diagnostic Elements of PRECEDE-PROCEED 42
Interpersonal Level 19
Figure 4
Stages of the Precaution Adoption Process Model 19
Community Level 22
Figure 6
Sociocultural Environment Logic Framework 26
Diffusion of Innovations 27
Figure 8
Social Marketing Wheel 38
Communication Theory 29
Figure 9
The PRECEDE-PROCEED Model 40
Media Effects 30
Figure 10
Using Theory to Plan Multilevel Interventions 46
Agenda Setting 30
Planning Models 36
Social Marketing 36
PRECEDE-PROCEED 39
Sources 48
References 49
Introduction
INTRO
T
his monograph, Theory at a Glance: Application to Health Promotion and Health Audience and Purpose
Behavior (Second Edition), describes influential theories of health-related behaviors,
processes of shaping behavior, and the effects of community and environmental This monograph is written primarily for public health workers in state and local health
factors on behavior. It complements existing resources that offer tools, techniques, agencies; it is also valuable for health promotion practitioners and volunteers who work in
and model programs for practice, such as Making Health Communication Programs Work: voluntary health agencies, community organizations, health care settings, schools, and the
A Planner’s Guide,i and the Web portal, Cancer Control PLANET (Plan, Link, Act, Network private sector.
with Evidence-based Tools).ii Theory at a Glance makes health behavior theory accessible
viii and provides tools to solve problems and assess the effectiveness of health promotion Interventions based on health behavior theory are not guaranteed to succeed, but they are 1
programs. (For the purposes of this monograph, health promotion is broadly defined as the much more likely to produce desired outcomes. Theory at a Glance is designed to help users
process of enabling people to increase control over, and to improve, their health. Thus, the understand how individuals, groups, and organizations behave and change—knowledge they
T H E O R Y AT A G L A N C E
T H E O R Y AT A G L A N C E
focus goes beyond traditional primary and secondary prevention programs.) can use to design effective programs. For information about specific, evidence-based
interventions to promote health and prevent disease, readers may also wish to consult the
For nearly a decade, public health and health care practitioners have consulted the original Guide to Community Preventive Services, published by the Centers for Disease Control and
version of Theory at a Glance for guidance on using theories about human behavior to inform Prevention (CDC) at www.thecommunityguide.org.
program planning, implementation, and evaluation. We have received many testimonials
about the First Edition’s usefulness, and requests for additional copies. This updated edition Contents
includes information from recent health behavior research and suggests theoretical
approaches to developing programs for diverse populations. Theory at a Glance can be This monograph consists of three parts. For each theory, the text highlights key concepts
used as a stand-alone handbook, as part of in-house staff development programs, or in and their applications. These summaries may be used as “checklists” of important issues to
conjunction with theory texts and continuing education workshops. consider when planning or evaluating programs or to prompt project teams to think about the
range of factors that influence health behavior.
For easy reference, the monograph includes only a small number of current and applicable
health behavior theories. The theories reviewed here are widely used for the purposes of Part 1. Foundations of Theory in Health Promotion and Health Behavior describes ways that
cancer control, defining risk, and segmenting populations. Much of the content for this theories and models can be useful in health behavior/health promotion practice and
publication has been adapted from the third edition of Glanz, Rimer, and Lewis’ Health provides basic definitions.
Behavior and Health Education: Theory, Research, and Practice,1 published by Jossey-Bass
in San Francisco. Readers who want to learn more about useful theories for health behavior Part 2. Theories and Applications presents an ecological perspective on health
change and health education practice can consult this and other sources that are behavior/health promotion programs. It describes eight theories and models that
recommended in the References section at the end of the monograph. explain individual, interpersonal, and community behavior and offers approaches to
solving problems. A brief description of each theory is followed by definitions of key
concepts and examples or case studies. The section also explores the use of new
communication technologies.
Part 3. Putting Theory and Practice Together explains how theory can be used in health
behavior/health promotion program planning, implementation, and evaluation.
Two comprehensive planning models, PRECEDE-PROCEED and social marketing,
are reviewed.
i Making Health Communication Programs Work (http://www.nci.nih.gov/pinkbook/) describes a practical
approach for planning and implementing health communication efforts.
PART 1
Foundations of Theory
in Health Promotion
and Health Behavior
3
T H E O R Y AT A G L A N C E
Why Is Theory Important to • Concepts are the building blocks—the interventions in theory creates innovative to succeed than those developed without
Health Promotion and Health primary elements—of a theory. ways to address specific circumstances. the benefit of a theoretical perspective.
Behavior Practice? He or she does not depend on a “paint-by
• Constructs are concepts developed or
numbers” approach, re-hashing stale ideas, Explanatory Theory and
adopted for use in a particular theory.
Effective public health, health promotion, but uses a palette of behavior theories, Change Theory
The key concepts of a given theory are
and chronic disease management programs skillfully applying them to develop unique,
its constructs.
tailored solutions to problems.
PART 1
help people maintain and improve health, Explanatory theory describes the reasons
• Variables are the operational forms of why a problem exists. It guides the search
reduce disease risks, and manage chronic
constructs. They define the way a Using theory as a foundation for program for factors that contribute to a problem (e.g.,
illness. They can improve the well-being
construct is to be measured in a specific planning and development is consistent with a lack of knowledge, self-efficacy, social
and self-sufficiency of individuals, families,
situation. Match variables to constructs the current emphasis on using evidence- support, or resources), and can be changed.
organizations, and communities. Usually,
when identifying what needs to be based interventions in public health, Examples of explanatory theories include
such successes require behavior change at
assessed during evaluation of a theory- behavioral medicine, and medicine. Theory the Health Belief Model, the Theory of
many levels, (e.g., individual, organizational,
driven program. provides a road map for studying problems, Planned Behavior, and the Precaution
4 and community). 5
• Models may draw on a number of theories developing appropriate interventions, and Adoption Process Model.
Not all health programs and initiatives are to help understand a particular problem in evaluating their successes. It can inform the
F O U N D AT I O N S O F A P P LY I N G T H E O R Y I N H E A LT H P R O M O T I O N P R A C T I C E
planner’s thinking during all of these stages,
T H E O R Y AT A G L A N C E
equally successful, however. Those most a certain setting or context. They are not Change theory guides the development of
likely to achieve desired outcomes are always as specified as theory. offering insights that translate into stronger health interventions. It spells out concepts
based on a clear understanding of targeted programs. Theory can also help to explain that can be translated into program
health behaviors, and the environmental Most health behavior and health promotion the dynamics of health behaviors, including messages and strategies, and offers a basis
context in which they occur. Practitioners theories were adapted from the social and processes for changing them, and the for program evaluation. Change theory
use strategic planning models to develop behavioral sciences, but applying them to influences of the many forces that affect helps program planners to be explicit about
and manage these programs, and health issues often requires that one be health behaviors, including social and their assumptions for why a program will
continually improve them through familiar with epidemiology and the biological physical environments. Theory can also help work. Examples of change theories include
meaningful evaluation. Health behavior sciences. Health behavior and health planners identify the most suitable target Community Organization and Diffusion of
theory can play a critical role throughout promotion theories draw upon various audiences, methods for fostering change, Innovations. Figure 1. illustrates how
the program planning process. disciplines, such as psychology, sociology, and outcomes for evaluation. explanatory theory and change theory can
anthropology, consumer behavior, and be used to plan and evaluate programs.
What Is Theory? marketing. Many are not highly developed Researchers and practitioners use theory
or have not been rigorously tested. Because to investigate answers to the questions of Fitting Theory to the Field of Practice
A theory presents a systematic way of of this, they often are called conceptual “why,” “what,” and “how” health problems
understanding events or situations. It is a frameworks or theoretical frameworks; here should be addressed. By seeking answers This monograph includes descriptions and
set of concepts, definitions, and propositions the terms are used interchangeably. to these questions, they clarify the nature applications of some theories that are
that explain or predict these events or of targeted health behaviors. That is, theory central to health behavior and health
situations by illustrating the relationships guides the search for reasons why people promotion practice today. No single theory
How Can Theory Help Plan do or do not engage in certain health
between variables. Theories must be Effective Programs? dominates health education and promotion,
applicable to a broad variety of situations. behaviors; it helps pinpoint what planners nor should it; the problems, behaviors,
They are, by nature, abstract, and don’t need to know before they develop public populations, cultures, and contexts of public
Theory gives planners tools for moving health programs; and it suggests how to
have a specified content or topic area. beyond intuition to design and evaluate health practice are broad and varied. Some
Like empty coffee cups, theories have devise program strategies that reach target theories focus on individuals as the unit of
health behavior and health promotion audiences and have an impact. Theory also
shapes and boundaries, but nothing inside. interventions based on understanding of change. Others examine change within
They become useful when filled with helps to identify which indicators should be families, institutions, communities, or
behavior. It helps them to step back and monitored and measured during program
practical topics, goals, and problems. consider the larger picture. Like an artist, cultures. Adequately addressing an issue
evaluation. For these reasons, program may require more than one theory, and no
a program planner who grounds health planning, implementation, and monitoring one theory is suitable for all cases.
processes based in theory are more likely
There are several reasons why culture and
Figure 1. Using Explanatory Theory and Change Theory to Plan and Evaluate Programs A Good Fit:
ethnicity are critical to consider when
Characteristics of a Useful Theory
applying theory to a health problem. First,
A useful theory makes assumptions about morbidity and mortality rates for different
a behavior, health problem, target diseases vary by race and ethnicity; second,
population, or environment that are: there are differences in the prevalence of
Evaluation risk behaviors among these groups; and
PART 1
• Logical;
third, the determinants of health behaviors
• Consistent with everyday observations;
vary across racial and ethnic groups.
• Similar to those used in previous
Explanatory ChangeTheory
successful programs; and
Theory Problem What People in the Field Say About Theory
Which strategies? • Supported by past research in the same
Behavior
Which messages? area or related ideas.
Why? or “Theory is different from most of the tools
Assumptions about
6 What can Situation how a program I use in my work. It’s more abstract, but 7
be changed? that can be a plus too. A solid grounding
should work Using Theory to Address Health in a handful of theories goes a long way
Issues in Diverse Populations toward helping me think through why I
F O U N D AT I O N S O F A P P LY I N G T H E O R Y I N H E A LT H P R O M O T I O N P R A C T I C E
T H E O R Y AT A G L A N C E
PART 2 T H E O R Y AT A G L A N C E
Theories and Applications
Part 2
PART 2
to change organizational behavior, as well
as the physical and social environment of shaped by, the social environment
(reciprocal causation). Interpersonal Level Interpersonal processes and primary groups, including
communities. It is also about developing and family, friends, and peers that provide social identity,
advocating for policies that support health, support, and role definition
such as economic incentives. Health To explain the first key concept of the
promotion programs that seek to address ecological perspective, multiple levels of Community Level
health problems across this spectrum influence, McLeroy and colleagues (1988)4 Institutional Factors
Rules, regulations, policies, and informal structures, which
10 employ a range of strategies, and operate identified five levels of influence for health- may constrain or promote recommended behaviors
11
on multiple levels. related behaviors and conditions. Defined
in Table 1., these levels include: (1) Community Factors
Social networks and norms, or standards, which exist as
formal or informal among individuals, groups, and
T H E O R I E S A N D A P P L I C AT I O N S
intrapersonal or individual factors; (2)
T H E O R Y AT A G L A N C E
Figure 2. A Multilevel Approach to Epidemiology In practice, addressing the community level unable to afford the fee. Thus, the outcome,
requires taking into consideration the woman’s failure to get a mammogram,
institutional and public policy factors, as well may result from multiple factors.
Social and Economic Policies as social networks and norms. Figure 2. The second key concept of an ecological
Institutions illustrates how different levels of influence perspective, reciprocal causation, suggests
combine to affect population health. that people both influence, and are
Neighborhoods and Communities
Each level of influence can affect health influenced by, those around them. For
e
rs
Living Conditions behavior. For example, suppose a woman example, a man with high cholesterol may
u
co
delays getting a recommended find it hard to follow the diet his doctor has
Life
Social Relationships mammogram (screening for breast cancer). prescribed because his company cafeteria
At the individual level, her inaction may be doesn’t offer healthy food choices. To
Individual Risk Factors
due to fears of finding out she has cancer. comply with his doctor’s instructions, he can
Genetic/Constitutional try to change the environment by asking the
Factors At the interpersonal level, her doctor may cafeteria manager to add healthy items to
Pathophysiological neglect to tell her that she should get the the menu, or he can dine elsewhere. If he
Pathways test, or she may have friends who say they and enough of his fellow employees decide
do not believe it is important to get a to find someplace else to eat, the cafeteria
Individual/Population mammogram. At the organizational level, may change its menu to maintain lunch
Health t it may be hard to schedule an appointment, business. Thus, the cafeteria environment
men because there is only a part-time radiologist may compel this man to change his dining
r on
E n vi at the clinic. At the policy level, she may habits, but his new habits may ultimately
lack insurance coverage, and thus be bring about change in the cafeteria as well.
Source: Smedley BD, Syme SL (eds.), Institute of Medicine. Promoting Health: Strategies from Social and Behavioral
Research. Washington, D.C.:, National Academies Press, 2000.
An ecological perspective shows the Community-level models offer frameworks • The Stages of Change (Transtheoretical) In ensuing years, researchers expanded
advantages of multilevel interventions that for implementing multi-dimensional Model describes individuals’ motivation upon this theory, eventually concluding that
combine behavioral and environmental approaches to promote healthy behaviors. and readiness to change a behavior. six main constructs influence people’s
components. For instance, effective They supplement educational approaches decisions about whether to take action to
tobacco control programs often use with efforts to change the social and • The Theory of Planned Behavior (TPB) prevent, screen for, and control illness. They
multiple strategies to discourage smoking.5 physical environment to support positive examines the relations between an argued that people are ready to act if they:
Employee smoking cessation clinics have behavior change. individual’s beliefs, attitudes, intentions,
PART 2
a stronger impact if the workplace has a behavior, and perceived control over • Believe they are susceptible to the
no-smoking policy and the city has a clean Individual or Intrapersonal Level that behavior. condition (perceived susceptibility)
indoor air ordinance. Adolescents are
• Believe the condition has serious
less likely to begin smoking if their The individual level is the most basic one • The Precaution Adoption Process Model
consequences (perceived severity)
peers disapprove of the habit and laws in health promotion practice, so planners (PAPM) names seven stages in an
prohibiting tobacco sales to minors must be able to explain and influence the individual’s journey from awareness to • Believe taking action would reduce their
are strictly enforced. Health promotion behavior of individuals. Many health action. It begins with lack of awareness susceptibility to the condition or its severity
12 13
programs are more effective when practitioners spend most of their work time and advances through subsequent stages (perceived benefits)
planners consider multiple levels of in one-on-one activities such as counseling of becoming aware, deciding whether • Believe costs of taking action (perceived
T H E O R I E S A N D A P P L I C AT I O N S
influence on health problems. or patient education, and individuals are or not to act, acting, and maintaining
T H E O R Y AT A G L A N C E
PART 2
• Tailor risk information based on an
individual’s characteristics or behaviors change is a process, not an event. As a eating more fruits and vegetables.
• Help the individual develop an accurate person attempts to change a behavior, he
perception of his or her own risk or she moves through five stages: The Stages of Change Model has been
precontemplation, contemplation, applied to a variety of individual behaviors,
Perceived severity Beliefs about the • Specify the consequences of a condition
preparation, action, and maintenance (see as well as to organizational change. The
seriousness of a condition and recommended action
and its consequences
Table 3.). Definitions of the stages vary Model is circular, not linear. In other words,
14 slightly, depending on the behavior at issue. people do not systematically progress from
15
Perceived benefits Beliefs about the • Explain how, where, and when to take People at different points along this one stage to the next, ultimately
effectiveness of taking action and what the potential positive continuum have different informational “graduating” from the behavior change
results will be
T H E O R I E S A N D A P P L I C AT I O N S
action to reduce risk or process. Instead, they may enter the
T H E O R Y AT A G L A N C E
Self-efficacy Confidence in one’s ability • Provide training and guidance in Table 3. Stages of Change Model
to take action performing action
• Use progressive goal setting
• Give verbal reinforcement
Stage Definition Potential Change Strategies
• Demonstrate desired behaviors
Precontemplation Has no intention of taking Increase awareness of need for change;
action within the next personalize information about risks
six months and benefits
High blood pressure screening campaigns often identify people who are at high risk for heart Contemplation Intends to take action in Motivate; encourage making specific plans
disease and stroke, but who say they have not experienced any symptoms. Because they don’t the next six months
feel sick, they may not follow instructions to take prescribed medicine or lose weight. The
HBM can be useful for developing strategies to deal with noncompliance in such situations. Preparation Intends to take action Assist with developing and implementing
within the next thirty concrete action plans; help set
According to the HBM, asymptomatic people may not follow a prescribed treatment regimen days and has taken some gradual goals
unless they accept that, though they have no symptoms, they do in fact have hypertension behavioral steps in
(perceived susceptibility). They must understand that hypertension can lead to heart attacks this direction
and strokes (perceived severity). Taking prescribed medication or following a recommended
Action Has changed behavior for Assist with feedback, problem solving,
weight loss program will reduce the risks (perceived benefits) without negative side effects
less than six months social support, and reinforcement
or excessive difficulty (perceived barriers). Print materials, reminder letters, or pill calendars
might encourage people to consistently follow their doctors’ recommendations (cues to Maintenance Has changed behavior for Assist with coping, reminders, finding
action). For those who have, in the past, had a hard time losing weight or maintaining more than six months alternatives, avoiding slips/relapses
weight loss, a behavioral contract might help establish achievable, short-term goals to build (as applicable)
confidence (self-efficacy).
a particular behavior. Azjen and Driver7 situations, however. People’s perceptions
added this construct to account for about controllability may have an important
Suppose a large company hires a health educator to plan a smoking cessation program
situations in which people’s behavior, or influence on behavior.
for its employees who smoke (200 people). The health educator decides to offer group
behavioral intention, is influenced by factors
smoking cessation clinics to employees at various times and locations. Several months
beyond their control. They argued that
pass, however, and only 50 of the smokers sign up for the clinics. At this point, the
people might try harder to perform a
health educator faces a dilemma: how can the 150 smokers who are not participating
behavior if they feel they have a high
PART 2
in the clinics be reached?
degree of control over it. (See Table 4.)
It has application beyond these limited
The Stages of Change Model offers perspective on ways to approach this problem. First,
the model can be employed to help understand and explain why they are not attending
the clinics. Second, it can be used to develop a comprehensive smoking program to help
more current and former smokers change their smoking behavior, and maintain that
change. By asking a few simple questions, the health educator can assess what stages
Table 4. Theory of Planned Behavior
16 of contemplation potential program participants are in. For example: 17
• Are you interested in trying to quit smoking? (Pre-contemplation)
Concept Definition Measurement Approach
T H E O R I E S A N D A P P L I C AT I O N S
• Are you thinking about quitting smoking soon? (Contemplation)
T H E O R Y AT A G L A N C E
• Are you ready to plan how you will quit smoking? (Preparation) Behavioral intention Perceived likelihood of performing Are you likely or unlikely to
behavior (perform the behavior)?
• Are you in the process of trying to quit smoking? (Action)
• Are you trying to stay smoke-free? (Maintenance) Attitude Personal evaluation of the behavior Do you see (the behavior) as
good, neutral, or bad?
The employees’ responses will help to pinpoint where the participants are on the
Subjective norm Beliefs about whether key people Do you agree or disagree that
continuum of change, and to tailor messages, strategies, and programs appropriate to approve or disapprove of the most people approve
their needs. For example, individuals who enjoy smoking are not interested in trying to behavior; motivation to behave in a of/disapprove of (the behavior)?
quit, and therefore will not attend a smoking cessation clinic; for them, a more way that gains their approval
appropriate intervention might include educational interventions designed to move
them out of the “precontemplation” stage and into “contemplation” (e.g., using carbon Perceived behavioral Belief that one has, and can exercise, Do you believe (performing the
control control over performing the behavior behavior) is up to you, or not
monoxide testing to demonstrate the effect of smoking on health). On the other hand, up to you?
individuals who are ready to plan how to quit smoking (the “preparation” stage) can be
encouraged to do so, and moved to the next stage, “action.”
Theory of Planned Behavior (TPB) to the person approve or disapprove of the Surveillance data show that young, acculturated Hispanic women are more likely to get
The Theory of Planned Behavior (TPB) and behavior (subjective norm). The TPB and Pap tests than those who are older and less acculturated.8 A health department decides to
the associated Theory of Reasoned Action TRA assume all other factors (e.g., culture, implement a cervical cancer screening program targeting older Hispanic women. In
(TRA) explore the relationship between the environment) operate through the planning the campaign, practitioners want to conduct a survey to learn what beliefs,
behavior and beliefs, attitudes, and models’ constructs, and do not attitudes, and intentions in this population are associated with seeking a Pap test. They
intentions. Both the TPB and the TRA independently explain the likelihood that design the survey to gauge: when the women received their last Pap test (behavior); how
assume behavioral intention is the most a person will behave a certain way. likely they are to seek a Pap test (intention); attitudes about getting a Pap test (attitude);
important determinant of behavior. whether or not “most people who are important to me” would want them to get a Pap
According to these models, behavioral The TPB differs from the TRA in that it test (subjective norm); and whether or not getting a Pap test is something that is “under
intention is influenced by a person’s attitude includes one additional construct, perceived my control” (perceived behavioral control). The department will compare survey results
toward performing a behavior, and by beliefs behavioral control; this construct has to with data about who has or has not received a Pap test to identify beliefs, attitudes, and
about whether individuals who are important do with people’s beliefs that they can control intentions that predict seeking one.
Figure 3. Theory of Reasoned Action and Theory of Planned Behavior Figure 4. Stages of the Precaution Adoption Process Model
Behavioral Stage 3:
beliefs Stage 1: Stage 2: Stage 5:
Deciding Stage 6: Stage 7:
Attitude toward Unaware Unengaged Decided
About Acting Maintenance
of Issue by Issue to Act
PART 2
behavior Acting
Evaluation of
behavioral outcomes
Stage 4:
Normative Decided
beliefs Not to Act
Subjective Behavioral
Behavior
norm intention
18 Motivation 19
to comply
T H E O R I E S A N D A P P L I C AT I O N S
T H E O R Y AT A G L A N C E
PART 2
feel that they can exercise control over their (Though SCT is the dominant version in anticipates from taking action. Bandura motivating the person to eliminate a
health behavior, they are not motivated to current practice, it is still sometimes called considers self-efficacy the most important negative stimulus (e.g., when drivers put the
act, or to persist through challenges.9 As a SLT.) SCT integrates concepts and personal factor in behavior change, and it key in the car’s ignition, the beeping alarm
person adopts new behaviors, this causes processes from cognitive, behaviorist, is a nearly ubiquitous construct in health reminds them to fasten their seatbelt).
changes in both the environment and in the and emotional models of behavior change, behavior theories. Strategies for increasing Reinforcements can be internal or external.
person. Behavior is not simply a product of so it includes many constructs. (See Table self-efficacy include: setting incremental Internal rewards are things people do to
20
the environment and the person, and 5.) It has been used successfully as the goals (e.g., exercising for 10 minutes each reward themselves. External rewards (e.g.,
21
environment is not simply a product of the underlying theory for behavior change day); behavioral contracting (a formal token incentives) encourage continued
person and behavior. in areas ranging from dietary change10 contract, with specified goals and rewards); participation in multiple-session programs,
T H E O R I E S A N D A P P L I C AT I O N S
to pain control.11 and monitoring and reinforcement (feedback but generally are not effective for sustaining
T H E O R Y AT A G L A N C E
PART 2
buy groceries (environment).
assessing and solving health and each other and the outside world) is also
social problems. useful for this purpose.
The program offers classes that teach healthy cooking and exercise skills (behavioral
capability). Participants learn how eating a healthy diet and exercising will benefit them • Diffusion of Innovations Theory addresses
Community organizing is not a single
(expectations). Health advisors create contracts with participants, setting incremental how new ideas, products, and social
mode of practice; it can involve different
goals (self-efficacy). Respected congregation members serve as role models (observational practices spread within an organization,
approaches to effecting change. Jack
learning). Participants receive T-shirts, recipe books, and other incentives, and are taught community, or society, or from one society
22
Rothman14 produced the best-known
to reward themselves by making time to relax (reinforcement). As church members learn to another. 23
classification of these change models,
about healthy lifestyles, they bring healthier foods to church, reinforcing their healthy
• Communication Theory describes how describing community organizing according
habits (reciprocal determinism).
T H E O R I E S A N D A P P L I C AT I O N S
different types of communication affect to three general types: locality development,
T H E O R Y AT A G L A N C E
PART 2
their lives and their communities power from within, to create
desired changes to do so. Community organizing seeks to focusing on technological breakthroughs and
expand participants’ sense of self-interest personal health habits. Media advocacy
Community Characteristics of a community that Community members participate to an ever-wider sphere, from the assumes the root of most health problems is
capacity affect its ability to identify, mobilize actively in community life, gaining individual or family level to their block, not that people lack information, but that they
around, and address problems leadership skills, social networks,
neighborhood, city, state, and so on.19 lack the power to change social and economic
and access to power
Participants grow through this process, conditions. It seeks to balance news coverage
24 Participation Engagement of community Community members develop learning to take an active role in shaping by framing issues to emphasize social,
25
members as equal partners; reflects leadership skills, knowledge, and the future of their communities. economic, and political—rather than personal
the principle, “Never do for others resources through their and behavioral—influences on health.21
involvement
T H E O R I E S A N D A P P L I C AT I O N S
what they can do for themselves”
T H E O R Y AT A G L A N C E
PART 2
implementing health programs, the result in a higher “quit rate” among heavy environmental and occupational hazards; deaths each year.26 Diffusion expands the
program’s beneficiaries help to direct the smokers than in the comparison health promotion and disease prevention number of people who are exposed to and
type of inquiry, collect and analyze data, communities.23 24 behaviors; and experience of stress, societal reached by successful interventions,
imagine possible solutions, and evaluate support, and social cohesion all contribute strengthening their public health impact.
to disparities in health status. Therefore,
community-level interventions that address Diffusion of Innovations Theory addresses
Figure 6. Sociocultural Environment Logic Framework neighborhood conditions, employment how ideas, products, and social practices
26 27
opportunities, behavioral norms, opportunities that are perceived as “new” spread
Guide to Community Preventive Services: Sociocultural Environment Logic Framework for education and training, and access to throughout a society or from one society to
T H E O R I E S A N D A P P L I C AT I O N S
health promotion, prevention, and care are another. According to the late E.M. Rogers,
T H E O R Y AT A G L A N C E
SOCIETAL RESOURCES
Concept Definition
concerns the presence
HEALTHY
of essential resources
6 Health Promotion, Prevention, POPULATION Innovation An idea, object, or practice that is thought to be new by an
while EQUITY and and Care Opportunities individual, organization, or community
SOCIAL JUSTICE
concerns the distribution Communication channels The means of transmitting the new idea from one person to another
of those resources *Links 1-6 indicate strategic
Source: Institute of Medicine. Speaking of Health: Assessing Health Communications Strategies for Diverse
Populations. Washington, D.C.: National Academies Press, 2002.
diverse settings, through different strategies. Effective diffusion requires practitioners to use
At the individual level, adopting a health both informal and formal communications
A university designs a program to help elementary school children cultivate healthy
behavior innovation usually involves lifestyle channels and a spectrum of strategies for
lifestyle habits and avoid chronic disease. The program has many components: it
change. At the organizational level, it may different settings. Disseminating an innovation addresses the foods that children eat by modifying the fat and sugar content of school
entail starting programs, changing regulations, in a variety of ways increases the likelihood lunches, it teaches important health information through a classroom-based health
or altering personnel roles. At a community that it will be adopted and institutionalized. education curriculum, and it encourages physical activity through a physical education
level, diffusion can include using the media, Communication usually should include both
PART 2
component. It is highly successful; follow-up studies show that children who went
advancing policies, or starting initiatives. mass media and interpersonal interactions. through the program in elementary school continue to have healthier habits in their
According to Rogers, a number of factors Through the two-step flow of communication, adolescence than those who did not go through the program.
determine how quickly, and to what extent, information from the media moves in two
an innovation will be adopted and diffused. stages. First, opinion leaders, who pay The fact that the program is successful is not enough to ensure it will change elementary
By considering the benefits of an innovation close attention to the media, receive the school practices. To achieve a broader impact, the program must diffuse to other sites.
(see Table 8.), practitioners can position it information. Second, they convey their own Program planners may seek to demonstrate the relative advantage of the program by
emphasizing its positive outcomes. They may try to show its compatibility by
28
effectively, thereby maximizing its appeal. interpretations, as well as the media content,
demonstrating that state policy-makers (e.g., the state Board of Education) have 29
to others. This process highlights the
approved its materials. The program’s complexity can be limited by creating user-friendly
Specifically: value of social networks for influencing materials for teachers and cafeteria workers. By making the materials available on a
T H E O R I E S A N D A P P L I C AT I O N S
adoption decisions.
T H E O R Y AT A G L A N C E
Web site, they can enhance its trialability. Professional demonstrations of the program
• The relative advantage of an innovation components can create an element of observability.
shows its superiority over whatever Rogers described the process of adoption as
it replaces. a classic “bell curve,” with five categories of
• Compatibility is an appropriate fit with the adopters: innovators, early adopters, early
intended audience. majority adopters, late majority adopters, and characteristics of people in each adopter Public health communications should
laggards. When an innovation is introduced, category, practitioners can more effectively represent an ecological perspective and
• Complexity has to do with how easy it is the majority of people will either be early plan and implement strategies that are foster multilevel strategies, such as tailored
to implement the innovation. majority adopters or late majority adopters; customized to their needs. messages at the individual level, targeted
• Trialability pertains to whether it can be fewer will be early adopters or laggards; and messages at the group level, social marking
tried on an experimental basis. very few will be innovators (the first people to Communication Theory at the community level, media advocacy at
use the innovation). By identifying the Communication theory explores “who says the policy level, and mass media campaigns
• Observability reflects whether the what, in which channels, to whom, and with at the population level.29 Public health
innovation will produce tangible results. what effects.” It investigates how messages communications can increase knowledge
are created, transmitted, received, and and awareness of a health issue; influence
assimilated. When applied to public health perceptions, beliefs, and attitudes that
Table 8. Key Attributes Affecting the Speed and Extent of an Innovation’s Diffusion problems, the central question theories of factor into social norms; prompt action;
communication seek to answer is, “How do demonstrate or illustrate healthy skills;
Attribute Key Question communication processes contribute to, or increase support for services; debunk
discourage, behavior change?” Focused on misconceptions; and strengthen
Relative advantage Is the innovation better than what it will replace?
improving the health of communities rather organizational relations.30 On the other
than examining the underlying processes of hand, without supports in the social and
Compatibility Does the innovation fit with the intended audience?
communication, public health communications physical environment, health communications
is the scientific development, strategic alone may not be enough to sustain
Complexity Is the innovation easy to use?
dissemination, and evaluation of relevant, individual-level behavior changes, may
accurate, accessible, and understandable not be effective for relaying complex
Trialability Can the innovation be tried before making a decision to adopt?
PART 2
worldwide. Whether they are small Characteristics of target audiences (e.g., on agenda setting has shown that the amount to pressure decision makers to develop
operations, such as a neighborhood their readiness for change, the ways they of media coverage an issue receives and support healthy policies.
newspaper, or large corporations employing process information), the complexity of the correlates strongly with the public’s opinion
tens of thousands of people, the media health issue, the presence of competing of how important that issue is. New Communication Technologies
influence almost every aspect of human life: messages, and the nature of the health
economic, political, social, and behavioral. message influence the relationship between An axiom underlying this area of study is that New communication technologies have
30
exposure to a health message and an mass media may not tell us what to think, but opened an extraordinary range of avenues
31
Media Effects outcome effect. Repeated exposure to a they are surprisingly effective in telling us for influencing health behavior. “E-health”
The outcomes of media dissemination of message, especially when it is delivered what to think about. A critical construct of (one element of new communication
T H E O R I E S A N D A P P L I C AT I O N S
ideas, images, themes, and stories are through multiple channels, may intensify agenda setting, however, reinterprets this technologies) is the use of emerging
T H E O R Y AT A G L A N C E
termed media effects. Media effects research its impact on audience members.34 idea. Framing is a process in which someone information and communication technology,
investigates not only how the media influence tells the audience what aspect of the story is especially the Internet, to improve or enable
the knowledge, opinions, attitudes, and Planners often assume that a certain
behaviors of audience members, but also how percentage of the target audience will be
audience members affect the media. Because exposed to a message and that another Table 9. Agenda Setting, Concepts, Definitions, and Applications
audience members are active seekers and fraction of those who receive the message
users of health information, the content will be engaged by it. Yet there are several Concept Definition Potential Change Strategies
transmitted through the media reflects their possible paths through which a health
needs, interests, and preferences. Two communications message can influence Media agenda setting Institutional factors and Understand media professionals’
questions are central to understanding the someone’s beliefs and/or behaviors. These processes influencing how needs and routines for gathering
effects of media on audience members: 1) include immediate learning (people learn the media define, select, and and reporting news
emphasize issues
What factors affect the likelihood that a directly from the message), delayed learning
person will be exposed to a given message? (the impact of the message is not processed Public agenda setting The link between issues Use media advocacy or
2) How do media effects vary with the until some time after it has been conveyed), covered in the media and the partnerships to raise public
amount of exposure to that message?32 generalized learning (in addition to the public’s priorities awareness of key health issues
message itself, people are persuaded about
Funding is a primary factor that determines concepts related to the message), social
Policy agenda setting The link between issues Advocate for media coverage to
whether or not audience members will be diffusion (messages stimulate discussion covered in the media and educate and pressure policy
exposed to a message through the mass among social groups, thereby affecting the legislative priorities of makers about changes to the
media, since money is needed to buy media beliefs), and institutional diffusion (messages policy makers physical and social environment
time and space. Many public health programs instigate a response from public institutions needed to promote health
do not have large budgets, so they often must that reinforces the message’s impact on the
rely on strategies for free distribution. Options target audience.)35 Problem definition Factors and process leading to Community leaders, advocacy
the identification of an issue groups, and organizations define
may include public service announcements, as a “problem” by social an issue for the media and
embedding health messages in entertainment Agenda Setting institutions offer solutions
programs (e.g., soap operas), or promoting The mass media can illuminate and focus
news coverage of public health topics in print attention on issues, helping to generate Framing Selecting and emphasizing Advocacy groups “package” an
certain aspects of a story and important health issue for the
and electronic media. Community institutions public awareness and momentum for change.
excluding others media and the public
can adopt and disseminate messages, and A major focus of communications research
health and health care. The term refers to an Community organizing approaches have Not all e-health interventions are Web-based. (see Figure 7.).43 The games were based
emerging field in the intersection of medical been used to coordinate Internet-based Computer applications have also allowed new on well-established theories of learning and
informatics, public health, and business.37 campaigns through www.Meetup.com uses of traditional health communications behavior change, such as Social Cognitive
It bridges clinical and non-clinical sectors, (a technology platform that helps people media, such as print and telephone. Tailored Theory. They reduced players’ urgent care
and includes both individual and population self-organize local gatherings). print communications (TPCs) and telephone- and emergency medical visits by as much
health-oriented tools.38 E-health delivered interventions (TDIs) are two as 77 percent.44 Though research has
communication strategies include, but are Innovative e-health projects are expanding examples that have the potential for reaching demonstrated the effectiveness of some
PART 2
not limited to: health information on the the range of tools that planners can use to linguistically and culturally diverse audiences. new communications technologies, further
Internet, online support groups, online develop cancer control and other TPCs are printed materials created especially inquiry is needed into the mechanisms’
collaborative communities, information interventions. For instance, NCI’s Cancer for an individual, based on relevant underlying success.45
tailored by computer technologies, Control Planet http://cancercontrolplanet. information about that person. Over 40 studies
educational computer games, computer- cancer.gov/ links public health professionals to of TPCs have been conducted on a wide Opportunities are increasing for people to
controlled in-home telephone counseling, comprehensive cancer control resources. NCI range of health topics, including diet, exercise, gain free access to the Internet via libraries
32
and patient-provider e-mail contact.39 also has published data from its Health smoking cessation, mammography, and and kiosks.46 Unequal access remains
33
Information National Trends Survey (HINTS) prostate cancer; most have found positive problematic, however. Significant gaps in
Major benefits of e-health strategies are on the Web at http://cancercontrol.cancer.gov/ outcomes evidence. TDIs include a range Internet usage between Caucasians, African
T H E O R I E S A N D A P P L I C AT I O N S
increased reach (the ability to communicate hints/. The HINTS program helps survey of human-delivered counseling and reminder Americans, and Hispanics persist,47 and
T H E O R Y AT A G L A N C E
to broad, geographically dispersed researchers, program planners, and social interventions delivered using the telephone people with lower levels of educational
audiences), asynchronous communication scientists understand how adults 18 years and computer-generated voice response attainment are also less likely to have
(interaction not bounded by having to and older are using different communication systems. Studies indicate that TDIs are Internet access. Because the Internet is
communicate at the same time) the ability channels, including the Internet. For example, effective across different populations and a text-based medium, literacy issues that
to integrate multiple communication modes according to recent HINTS data, when asked health topics, but do not have a broad-based make it difficult for people to read print
and formats (e.g., audio, video, text, where they would go first if they had a strong reach. They have not been widely used by materials are also barriers to accessing
graphics), the ability to track, preserve, and need to get information about cancer, 34 diverse populations.42 Web-based information. There is danger
analyze communication (computer records percent of respondents said they would go that new computer technologies could
of interaction, analysis of interaction trends), to the Internet. Interactive games offer another vehicle for worsen existing inequities in health status
user control of the communication system intervention. Lieberman et al. designed a for diverse populations. It is therefore
(the ability to customize programs to user The HINTS data illustrate consumers’ series of Nintendo video games to improve important to involve community members in
specifications), and interactivity (e.g., increasing reliance on the Internet as an children’s and adolescents’ prevention and planning e-health interventions and to offer
increased capacity for feedback).40 easily accessible source of health information. self care behaviors for asthma, diabetes, them ongoing training and support for using
The Internet has been characterized as a smoking prevention, and other health topics these emerging communications tools.48
Educational and behavioral interventions “hybrid technology” because it has the
employing new communication technologies potential to reach millions of people with
are forging new ground and therefore benefit information that can be tailored to individual Figure 7.
from the perspective provided by theories needs and preferences.41 E-health
of health behavior. Like communications in interventions frequently offer information, An Asthma Self-Management
other media, e-health interventions can education, and support directly to consumers. Video Game for Children
address issues at the individual, group, or For example, the Association of Online (Bronkie the Bronchiasaurus)
community/societal level; different theories Cancer Resources (ACOR), a collection of
may be appropriate, depending on the online communities designed to provide timely
project’s goals. For example, computer- and accurate information in a supportive
tailored print materials encouraging individuals environment, is one case in point. ACOR
to eat more fruits and vegetables could be delivers 1.8 million cancer messages each
designed using the Stages of Change Model. week (http://www.acor.org/).
Online support groups may apply theories of
social support and social networks.
Box art reproduction used by permission of Health Hero Network. Copyright © 1994 by Health Hero Network. All rights reserved.
Part 3
PART 3
Putting Theory And
Practice Together
35
T H E O R Y AT A G L A N C E
Planning Models planning, implementation, and evaluation Alan Andreason defines it as “the members and develops strategies and
phases. During program planning, they application of commercial marketing methods accordingly. The four Ps of the
When practitioners begin the process of explore the needs and resources of the technologies to the analysis, planning, marketing mix are:
planning an intervention to promote health population and learn how to design effective execution, and evaluation of programs
or change health behavior, theory helps materials and strategies. During designed to influence the voluntary behavior • Product (the right kind of behavioral
them interpret the situation and guides their implementation, they seek to build and of target audiences in order to improve their change) includes not only the behavior
decisions about what design, procedures, continually improve the program. After it personal welfare and that of society.”49 that is being promoted, but also the
PART 3
and measurement indicators to select. ends, they assess what short-term and long- This process creates a voluntary exchange benefits that go along with it.
Depending on the unit of practice (e.g., term effects the program has had on the between a marketing organization and
• Price (an exchange of benefits and costs)
individuals, groups, organizations, health problem and its contributing factors. members of a target audience based on
refers to barriers or costs involved in
community) and the nature of the health mutual fulfillment of self-interest. In other
adopting the behavior (e.g., money,
problem, different theoretical approaches Both social marketing and the PRECEDE words, the marketing organization exists
time, effort).
may be appropriate. Practitioners can find PROCEED model instruct the practitioner to fulfill its mission (as defined by the
that using more than one theory to address to begin the planning process by assessing organization’s leadership), and the target • Place (making new behaviors easy to do)
36 37
a problem produces a stronger impact. the target audience’s needs at multiple audience members act in their own interests. is about making the “product” accessible
This is particularly true when planning levels of a health problem. In social and convenient. It means delivering
PART 3
such as focus groups or key informant using a research-driven process; then change that behavior. For example, a social products for space and attention)
interviews, to pre-test marketing concepts, consumer research can help to adjust marketer who references Social Cognitive
messages, and materials in a cost-effective program messages and outputs. The social Theory might examine how self-efficacy • Promotion: Branding the 5 A Day
manner. They may also pilot-test materials marketing process includes four stages: and expectations about the outcome of a campaign to increase awareness (e.g.,
with individuals who share characteristics planning and strategy development; behavior factor into certain health practices using a slogan and compelling images
of the target market in order to verify their development of pretesting concepts, within a target market. that are easy to recall)
38
effectiveness, identify diverse channels messages, and materials; implementation;
39
for delivering the message, and measure assessment of in-market effectiveness; The California 5 A Day Campaign, which
Distribution channels include mass media
outcomes. Process evaluation methods are and feedback to the first stage. (See was the model for the national 5 A Day
advertising, public service announcements,
4
Assesing
Messages,
and Materials
baseline survey data) helped the planners
to understand their audiences and improve
messages. Lastly, the program uses the
and associates,53 PRECEDE-PROCEED
provides a road map for designing health
education and health promotion programs.
Effectiveness
and Making
Refinements
2 four Ps of social marketing:
It guides planners through a process that
starts with desired outcomes and works
backwards to identify a mix of strategies
• Product: Consuming more fruits and
for achieving objectives. (See
vegetables each day to minimize the risk
http://lgreen.net/index.html.)
3 Implementing
the Program
of cancer and improve health status
PART 3
diagnosis is needed to design a health These include: (1) social assessment, (2) activities (e.g., key informant interviews, encourage repetition or persistence of
promotion intervention, just as a medical epidemiological assessment, (3) behavioral focus groups, participant observation, behaviors by providing continuing rewards
diagnosis is needed to design a treatment and environmental assessment, (4) surveys) to understand the community’s or incentives. Social support, praise,
plan. PROCEDE stands for Policy, educational and ecological assessment, and perceived needs. Epidemiological reassurance, and symptom relief might all
Regulatory, and Organizational Constructs (5) administrative and policy assessment. assessment may include secondary data be considered reinforcing factors.
in Educational and Environmental The last four comprise implementation and analysis or original data collection to
40
Development. This element was added evaluation of health promotion intervention. prioritize the community’s health needs and
In the final diagnostic step of PRECEDE 41
to the framework later, in 1991, to take These include: (6) implementation, (7) establish program goals and objectives.
PROCEED, Administrative and Policy
into account the impact of environmental process evaluation, (8) impact evaluation, Behavioral and Environmental Assessment
Assessment, intervention strategies reflect
PART 3
be addressed, or to set priorities among (perceived susceptibility), or how serious these factors affects women’s behaviors, PROCEED to identify social science
health problems. Theory is most directly they believe cancer would be (perceived program planners can decide how to focus theories that contribute to their
useful when applied to steps 3, 4, and 5, severity). Both beliefs constitute program messages for a communications understanding. These theories can guide
since these steps call upon the practitioner predisposing factors. Other HBM constructs campaign or strategies for an administrative them to potential points of intervention.
to make strategic decisions. By using theory, may identify possible perceived benefits of intervention (such as providing low- or no- Consulting the research literature helps
the practitioner can make sound choices and barriers to screening. Receiving cost screening or changing insurance practitioners to learn about the past
42
that are based upon more than just intuition coverage). The best way to verify and rank successes or failures of intervention
43
and personal judgment. explanations offered by theory is to gather strategies that they consider, and reflect
information directly from women in the on whether those strategies are likely to
Table 10. Diagnostic Elements of PRECEDE-PROCEED approach is to learn by reading research and actively discussing proposed
literature on women who share strategies with the target audience can
characteristics with the target population. also help to determine whether or not they
Planning Step Function Examples of Relevant Theory will be well received.
1. Social Assessment Assesses people’s views of Community organization Where to Begin: Choosing the
their own needs and quality Right Theories Table 11. summarizes the focus and key
of life Community building concepts of each of the eight theories
Interventions that evolve from a described in this guide. Refer to this table
2. Epidemiological Documents which health Community-level theories to identify theories that help explain and
Assessment problems are most important (If the community helps to comprehensive planning process, build
on prior research, and use health behavior address a health problem. For example,
for which groups in a choose the health problem that
community will be addressed) theories are more likely to be effective. several theories could be used to inform the
By investigating what factors influence design of a program to reduce tobacco use
3. Behavioral/ Identifies factors that Interpersonal theories the target population’s behavior, including among adolescents. By scanning the
Environmental contribute to the health - Social Cognitive Theory
their social and physical environments, “Focus” column, one can quickly gauge
Assessment problem of interest which theories might apply to a particular
Theories of organizational change practitioners gain the raw materials they
need to meet the needs of that population. situation. For example, The Stages of
Community organization Theory helps practitioners to interpret the Change model might be very useful, since it
findings of their research, making the leap centers on individuals’ readiness to change.
Diffusion of innovations On the other hand, the Health Belief Model
from facts on a page to understanding the
dynamic interactions between behavior seems less promising, since young people
4. Educational/ Identifies preceding and All three levels of change theories:
may be less concerned about long-term
Ecological reinforcing factors that must - Individual and environmental context. Systematic
Assessment be in place to initiate and - Interpersonal approaches to tailoring, targeting, health problems. (In fact, they may not feel
sustain change - Community implementing, and evaluating programs vulnerable to disease at all!) Social
provide practitioners with a framework for Cognitive Theory could be helpful because it
5. Administrative/ Identifies policies, resources, Community-level theories:
translating this insight into actions that emphasizes the interplay between personal,
Policy and circumstances in the - Community organization
environmental, and behavior factors.
Assessment program’s context that may - Organizational change improve health outcomes.
help or hinder implementation
Likewise, Community Organization could
offer perspective on activating young people
around tobacco control issues. Applying step-by-step process of examining health
each of these theories might look like this: and behavior at multiple levels. Table 11. Summary of Theories: Focus and Key Concepts
• Stages of Change: Learn more about At the most basic level, an ecological Theory Focus Key Concepts
readiness to change among adolescents perspective points to two approaches to
who smoke in order to plan appropriate addressing health problems: change
Individual Health Belief Model Individuals’ perceptions of Perceived susceptibility
Level the threat posed by a health Perceived severity
and effective cessation messages people’s behavior or change the problem, the benefits of Perceived benefits
PART 3
and strategies. environment. The most powerful health avoiding the threat, and Perceived barriers
factors influencing the Cues to action
promotion and behavior change decision to act Self-efficacy
• Social Cognitive Theory: Examine how interventions integrate these approaches
Stages of Change Individuals’ motivation and Precontemplation
social environment, including peer and treat them both as essential. Figure 10. Model readiness to change a Contemplation
attitudes, influences adolescents’ tobacco illustrates that strategies intended problem behavior Decision
use. What are the expectations of teens to change people’s behavior can often be Action
Maintenance
44
who experiment with tobacco, or who use derived from individual-level theories; those
45
it regularly? How do observational learning aimed at changing the environment draw on Theory of Planned Individuals’ attitudes toward Behavioral intention
and reinforcement contribute to the community-level theories. Theories at the Behavior a behavior, perceptions of Attitude
norms, and beliefs about the Subjective norm
PART 3
• Educational sessions Individual Stages of Change
Change • Interactive kiosks Precaution Adoption Process
People’s Behavior • Print brochures Health Belief Model
• Social marketing Theory of Planned Behavior
campaigns
46 47
behavior change theories and planning Becoming comfortable with behavior change
systems, practitioners gain access to tools theory as an instrument of practice may take
that allow them to generate creative some work, but the results are well worth
solutions to unique situations. They are able it. Behavior change theory is not simply a
to go beyond acting on instinct or repeating tool for academics and researchers; it
earlier interventions to adopt a systematic, can be applied to the problems health
scientific approach to their work. Theory promotion practitioners face every day.
helps practitioners to ask the right questions The abstractions of theory help practitioners
and effective planning helps them zero in on to understand the dynamics underlying real
factors that contribute to a problem. Other situations and to think about solutions
key elements of effective programs include in a new way. Armed with this resource,
matching programs to the audience, making you may find yourself saying, as did
information accessible and practical, Winston Churchill in 1898, “I pass with relief
involving participants in active learning, from the tossing sea of Cause and Theory
and including elements that build skills to the firm ground of Result and Fact.”
and reinforce behavior change.
Sources
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