1.

Theories Related to Health Promotion

Definition of terms:
 Theory – a plausible or scientifically acceptable general principle offered to
explain observed facts.
 A hypothesis assumed for the sake of argument or investigation.
 Model – visual representation of the concept that work together to become a
theory.
 A pattern of something to be made
Theories related to health promotion:
1. Pender’s Health Promotion Theory/Model
2. Bandura’s Self Efficacy Theory/Model
3. Health Belief Models
 Rosenstock’s Health Belief Model
 Becker’s Health Belief Model
4. Green’s Precede-Proceed Model

Pender’s Health Promotion Model

 Is a competence or approach-oriented model that depicts the multi -dimensional
nature of persons interacting with their interpersonal and physical environments
as they pursue health.
 Focused on health promoting behaviors rather than health protection or illness
prevention behaviors.
 
Variables of Health Promotion Model
1. Individual characteristics and experience
 An individual’s unique factors or characteristics and experiences will
depend on the target behavior for health promotion.
 Includes the following:
A. Personal factor
o Biological
o Psychological
o Socio-cultural
B. Prior related behavior
o Previous experience
o Knowledge
o Skills in health promoting actions

 - Notes from the actual lecture

2. Behavioral–specific cognitions and affect
 Constitute critical core for intervention because this can be modified
through nursing interventions.
 Includes the following:
A. Perceived benefits of action
o anticipated benefits or outcome affect the persons plan to
participate in health-promoting behaviors and may facilitate
continued practice (can be affected by experienselfce/vicarious
experience).
B. Perceived barriers to action
o person’s perceptions about available time, inconvenience expense
and difficulty performing the activity may act as a barrier (decrease
commitment to a plan of action).
C. Perceived self-efficacy
o the conviction that the person can successfully carryout the
behavior necessary to achieve a desired outcome (serious doubt
about capabilities decrease effort and give-up)
D. Activity related affect
o the subjective feelings that occur before, during, and following an
activity influence a person to repeat again or maintain behavior.
E. Interpersonal influence
o perception of the person concerning the behavior, beliefs or
attitudes of others.
o includes expectations of significant others, social support and
learning through observing others.
 Sources of interpersonal Influences:
1. Family
2. Peers
3. health professionals
(Sources of interpersonal influence can affect the person’s health-
promoting behaviors)
F. Situational Influence
o Direct and indirect influence on health-promoting behaviors.
o A person is apt to perform health-related behaviors if the
environment is comfortable versus feeling of alienations
 Includes the following:
1. Perception of available options
2. Demand characteristic
3. Aesthetic features of the environment

 - Notes from the actual lecture

 3. Commitment to a plan of action
 The interest of a person in carrying-out and reinforce health-promoting
behaviors.
 Involves 2 processes:
1. Commitment – good intention
2. Identifying specific strategy – actual performance of the behavior
4. Immediate competing demands and preferences
 Situations that the person is experiencing in everyday life that could affect
the control of health-promoting behaviors.
 Involves 2 types of control:
1. Low control
2. High control
5. Behavioral outcome
 Directed towards attaining positive health outcome for the client
 Should result in improved health and better quality of life at all stages of
development.

Bandura’s Self-Efficacy Theory

 Self-efficacy theory of Albert Bandura
o Self-efficacy – perception/belief of a person about his own capabilities to
produce effect.
o Self-regulation – exercise of influence over one’s own motivation, thought
process emotional state and patterns of behavior.
Sources of self-efficacy
o Self-efficacy is influenced by several factors: These are the 4 main source
of influences
1. Enactive mastery/Mastery of Experience/performance accomplishment
2. Vicarious Experience provided by social models
3. Verbal (Social) persuasion (Support/Motivation from significant others)
4. Physiological states (Arousal) - reduction of stress reactions and alter
negative emotional proclivities and interpretation of physical and emotional
traits.
“Strong sense of efficacy enhances human accomplishment and personal well-
being in many ways.”

Efficacy- Activated processes

 - Notes from the actual lecture

 There are 4 major psychological processes through which self-belief of
efficacy affect human functioning.
 
4  Major Psychological Processes:
1. Cognitive Process
o Thinking process, involve acquisition, organization and use of
information.
o Most course of actions are initially organized in thought.
2. Motivational Process
o Cognitive generated
o Activation to action
o Levels of motivation:
 Choice of course of action
 Intensity
 Persistence of effort
o Motivation processes is covered by 4 types of Self-Influence:
 Self-satisfying
 Self- dissatisfying reactions to one’s performance
 Perceived self-efficacy
 Readjustment of personal goal based on one’s progress
3. Affective Process
o Process regulating emotional state and elicitation of emotional
reactions.
o The stronger the sense of self-efficacy the bolder people are in taking
on taxing and threatening activities.
4. Selection Process
o The choices the person make that cultivate different competencies,
interest and social network that determines life courses.

“Self- Efficacy is concerned with people’s beliefs in their capabilities to exercise control
over their own functioning and over events that affect their lives.”

Health Belief Model

The Health Belief Model (HBM) was developed in the 1950's by social
psychologists Irwin M, Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegeles, and
Howard Leventhal, who were working in the U.S. Public Health Service to explain the
failure of people participating in programs to prevent and detect disease. Later, the

 - Notes from the actual lecture

model was extended by others to study people's behavioral responses to health-related
conditions.
Since this time, the Health Belief Model has evolved to address public health
concerns and has been applied to a broad range of populations and health behaviors.

CONSTRUCT DEFINITION
Belief about getting a disease or
Perceived Susceptibility
condition
Belief about the seriousness of the
Perceive Severity condition, or leaving it untreated and its
consequences
Belief about the potential positive aspects
Perceived Benefits
of a health action
Belief about the potential negative
Perceived Barriers
aspects of a particular health action
Cues to Action Factors which trigger action
Belief that one can achieve the behavior
Self-efficiancy
required to execute the outcome

 The HBM contains several constructs that are hypothesized to predict why
people engage in prevention, screening, and/or controlling health
conditions.
o Personal characteristics, such as age, gender, and ethnicity modify
individual perceptions, such as perceived susceptibility, severity, self-
efficacy, and benefits & barriers.
o Perceived susceptibility and severity of a health condition together, have
been labeled as "perceived threat."
o Perceived benefits help reduce perceived threat about a health behavior.
Perceived barriers impede health behaviors. Benefits minus barriers
support health behavior change.
o Self-Efficacy influences perceived threat (perceived susceptibility and
severity) and perceived benefits minus perceived barriers, which support
initiation of health behavior change.
o Cues in the environment trigger action and act on individual perceptions,
such as perceived benefits, and perceived susceptibility.

Green’s Precede-Proceed Model

 - Notes from the actual lecture

  Developed by Lawrence Green, Kreuter, and associates.
 The PRECEDE-PROCEED model provides a comprehensive structure for
assessing health and quality-of-life needs and for designing, implementing, and
evaluating health promotion and other public health programs to meet those
needs.
 PRECEDE (P redisposing, R einforcing, and E nabling C onstructs in E
ducational D iagnosis and E valuation) outlines a diagnostic planning process to
assist in the development of targeted and focused public health programs.
 Five steps or phases:
1. Phase one/Social Assessment – involves determining the quality of life
or social problems and needs of a given population.
2. Phase two/Epidemiological Assessment– consists of identifying the
health determinants of these problems and needs.
3. Phase three/Behavioral and Environmental Assessment – involves
analyzing the behavioral and environmental determinants of the health
problems.
4. In phase four/Educational and Ecological Assessment – the factors that
predispose to, reinforce, and enable the behaviors and lifestyles are
identified.
The three types of influencing factors include:
a. Predisposing factors – which motivate or provide a reason for
behavior; they include knowledge, attitudes, cultural beliefs, and
readiness to change.
b. Enabling factors – which enable persons to act on their
predispositions; these factors include available resources,
supportive policies, assistance, and services.
c. Reinforcing factors – which come into play after a behavior has
been initiated; they encourage repetition or persistence of
behaviors by providing continuing rewards or incentives. Social
support, praise, reassurance, and symptom relief might all be
considered reinforcing factors.
5. Phase five/Administrative and Policy Assessment – involves
ascertaining which health promotion, health education and/or policy-
related interventions would best be suited to encouraging the desired
changes in the behaviors or environments and in the factors that
support those behaviors and environments.
PROCEED (P olicy, R egulatory, and O rganizational C onstructs in E ducational and E
nvironmental D evelopment) guides the implementation and evaluation of the programs
designed using PRECEDE.

 - Notes from the actual lecture

  Four additional phases.
1. Phase six/Implementation – the interventions identified in phase five are
implemented.
2. Phase seven/Process Evaluation – entails process evaluation of those
interventions.
3. Phase eight/Impact Evaluation – involves evaluating the impact of the
interventions on the factors supporting behavior, and on behavior itself.
4. The ninth and last phase/Outcome Evaluation – comprises outcome
evaluation—that is, determining the ultimate effects of the interventions
on the health and quality of life of the population.

In actual practice, PRECEDE and PROCEED function in a continuous cycle.

Information gathered in PRECEDE guides the development of program goals and
objectives in the implementation phase of PROCEED.

This same information also provides the criteria against which the success of the
program is measured in the evaluation phase of PROCEED. In turn, the data gathered
in the implementation and evaluation phases of PROCEED clarify the relationships
examined in PRECEDE between the health or quality-of-life outcomes, the behaviors
and environments that influence them, and the factors that lead to the desired
behavioral and environmental changes. These data also suggest how programs may be
modified to more closely reach their goals and targets.

 - Notes from the actual lecture

2. Health and Human Behavior
Behavior is an action that has a specific frequency, duration and purpose whether
conscious or unconscious. It is what we “do” and how we “act”. 
People stay healthy or become ill, often as a result of their own action or behavior. 
The following are examples of how people’s actions can affect their health:
 Using mosquito nets and insect sprays helps to keep mosquito away.
 Feeding children with bottle put them at risk of diarrhea.
 Defecating in an open field will lead to parasitic infection.
 Unsafe sex predisposes people to unwanted pregnancy, HIV/AIDS and other
STDs
In health education it is very important to be able to identify the practices that cause,
cure, or prevent a problem.
The words actions, practices and behaviors are different words of  the same thing.
Life style: refers to the collection of behaviors that make up a person’s way of
life-including diet, clothing, family life, housing and work.
Customs: It represents the group behavior. It is the pattern of action shared by
some or all members of the society.
Traditions: are behaviors that have been carried out for a long time and handed
down from parents to children.
Culture: is the whole complex of knowledge, attitude, norms, beliefs, values,
habits, customs, traditions and any other capabilities and skills acquired by man
as a member of society.
Distinguishing characteristics of culture
 Culture is symbolic. It is an abstract way of referring to, and understanding
ideas, objects, feelings or behavior –the ability to communicate with symbols
using language.
To convey new ideas people may invent single words to represent many different ideas,
feelings or values.
 Culture is shared. People in the same society share common behavior patterns
and ways of thinking through culture.
   For example people living in a society share the same language, dress in similar
styles, eat much of the same food and celebrate many of the same holidays.
 Culture is learned. A person must learn culture from other people in a society. 

 - Notes from the actual lecture

For instance, people must learn to speak and understand a language and to abide by
the rules of a society.
 Culture is adaptive. People use culture to adjust flexibly and quickly to changes
in the world around them. 
For instance a person can adjust his diet when he changes an area of residence
Examples of behaviors promoting health and preventing  diseases
Healthy behaviours: - actions that healthy people undertake to keep themselves
or others healthy and prevent disease. Good nutrition, breast feeding, reduction
of health damaging behaviors like smoking are examples of healthy behaviors
Utilization behavior: - utilization of health services such as antenatal care, child
health, immunization, family planning…etc
Illness behavior: - recognition of early symptoms and prompt self referral for
treatment.
Compliance behaviors: - following a course of prescribed drugs such as for
tuberculosis.
Rehabilitation behaviors: - what people need to do after a serious illness to
prevent further disability.
Community action: - actions by individuals and groups to change and improve
their surroundings to meet special needs.
Factors affecting human behavior
1. Predisposing factors: provide the rationale or motivation for the behavior to occur.
Some of these are:
 Knowledge
 Belief
 Attitudes
 Values
E.g. For an individual to use contraception, she has to have knowledge about  it and
develop positive attitude towards utilization of it.
 Knowledge is knowing things, objects, events, persons, situations and
everything in the universe. It is the collection and storage of information or
experience. It often comes from experience. We also gain knowledge through
information provided by teachers, parents, friends, books, newspapers, etc
 E.g. knowledge about methods of prevention of HIV

 - Notes from the actual lecture

  Belief is a conviction that a phenomenon or object is true or real. Beliefs deal
with people’s understanding of themselves and their environment. People usually
do not know whether what they believe is true or false. They are usually
derived from our parents, grandparents, and other people we respect.
Beliefs may be helpful, harmful or neutral. If it is not certain that a belief is harmful, it is
better to leave it alone.
 For example, a certain society may have the following beliefs:
o Holding materials made of iron by mothers during postpartum (Neutral)
o Diarrhea may end up with death (helpful)
o Measles can not be prevented by immunization (harmful) 

 Attitudes are relatively constant feelings, predispositions or set of beliefs

directed towards an object, person or situation.
They are evaluative feelings and reflect our likes and dislikes.
They often come from our experiences or from those of people close to us. They either
attract us to things, or make wary of them.
 E.g. A woman had fever and visited the nearby health center. The staff on duty that day
was very busy and shouted at her,
“Do you want us to waste our time for a mild fever? Come back when we are less busy.”
She did not like being shouted at. This experience gave her bad attitude toward the
health staff. This bad attitude could discourage her from attending the health center next
time she is sick.
 Values are broad ideas and widely held assumptions regarding what are
desirable, correct and good that most members of a society share. Values are so
general and abstract that they do not explicitly specify which behaviors
are acceptable and which are not. Instead, values provide us with criteria and
conceptions by which we evaluate people, objects and events as their relative
worth, merit, beauty or morality.
 E.g. being married and having many children are highly valued in other countries.
 Norms are social rules that specify appropriate and inappropriate behavior in
given situations. They tell us what we should and must do as well as what we
should not and must not do.
 For Example,
• We often regard greeting as a social norm to be conformed among members who
know each other.

 - Notes from the actual lecture

• Murder, theft and rape often bring strong disapproval.

2. Enabling factors: these are characteristics of the environment that facilitates healthy

behavior and any skill or resource required to attain the behavior. Enabling factors are
required for a motivation to be realized.
Examples of enabling factors include:
 Availability and or accessibility of health resources
 Government laws, priority and commitment to health
 Presence of health related skills
E.g. Enabling factors for a mother to give oral rehydration solution to her child with
diarrhea would be:
 Time, container, salt, sugar
 Knowledge on how to prepare and administer it
In general, it is believed that enabling factors should be available for an individual or
community to perform intended behavior.
Behavioral intention----------------I--------------------- Behavioral change
Enabling factors
(Time, money and materials, skills, accessibility to health services)
Behavioral intention is willingness/ readiness to perform a certain behavior provided that
enabling factors are readily available.
3. Reinforcing factors: these factors come subsequent to the behavior.
They are important for persistence or repetition of the behavior. The most important
reinforcing factors for a behavior to occur or avoid include:
 Family
 Peers, teachers
 Employers, health providers
 Community leaders
 Decision makers
We are all influenced by the various persons in social network. 
Pressure from others can be a positive influence to adopt health promoting practices as
well as an obstacle. 
Influential people is significant influence to change others. In the case of a young child,
it is usually the parents who have the most influence. As a child grows older, friends

 - Notes from the actual lecture

become important and a young person can feel a powerful pressure to conform to the
peer group.
 E.g. a young man starts smoking because his friends encouraged him to do so.

2.1. The Role of Human Behavior in Prevention of Disease

and Promotion of Health
What is prevention? 
Prevention is defined as the planning for and the measures taken to forestall the onset
of a disease or other health problem before the occurrence of undesirable health
events. There are three distinct levels of prevention: primary, secondary, tertiary
prevention. 
Healthy person ----I---Early signs----I--- Disease----I-- Death
Primary                 Secondary          Tertiary
Primary prevention-  is comprised of those activities carried out to keep people healthy
and prevent them from getting disease.
 Examples of important behaviors for primary prevention includes using rubber gloves
when there is a potential for the spread of disease, immunizing against specific
diseases, exercise, and brushing teeth. And any health education or promotion program
aimed specifically at prevention of the onset of illness or health problems is also
an example of primary prevention.
Secondary prevention - includes preventive measures that lead to an early diagnosis
and prompt treatment of a problem before it becomes serious. It is important to ensure
that the community can recognize early signs of disease and go for treatment before the
disease become serious.
 Health problems like tuberculosis can be cured if the diseases is detected at an early
stage. 
The actions people take before consulting a health worker, including recognition of
symptoms, taking home remedies (‘self-medication’), consulting family and healers are
called illness behaviors. Illness behaviors are important examples of behaviors for
secondary prevention.
Tertiary prevention -seeks to limit disability or complication arising from an irreversible
condition. Even at this stage actions and behaviors of the patient are essential. 
The use of disability aids and rehabilitation services help people from further
deterioration and loss of function. For example, a diabetic patient should take strictly
his/her daily insulin injection to prevent complications. 

 - Notes from the actual lecture