Health and Human

Behavior

By:- Beimnet DK(MPH/HPHB)

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 Outline

➢ Behaviors
✓Definitions and concepts
✓Types of behaviors
➢ Factors affecting human behaviors
✓Predisposing factors
✓Enabling factors
✓Reinforcing factors
➢ The role of human behaviors in disease
prevention
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 Leaning outcome

At the end of this session, you will be able to;

➢ Define correctly what behavior mean
➢ Describe determinants of human behaviors
➢ Discuss the role of human behaviors in
disease prevention

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 Introduction

❖ An important justification for health education and

health promotion comes from the fact that health is
determined, not by medical services and drugs, but
by ordinary human actions and behaviors.
❖ Many health education programs have failed because
they put too much emphasis on individual behavior
and neglected to understand the cultural, social,
economic and political factors that influence his/her
behavior or action.

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 Intr …

❖ However, a proper understanding of the influences

outside the individual’s control will avoid the pitfall
of victim-blaming.

Victim-blaming is the name given to the process

when poorly- planned health education program
directs itself in changing the individual behavior
and ignores the factors outside the individual’s
control that influence behavior.

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 Behavior definition

✓Behavior- is an action that has specific

frequency, duration, and purpose,
whether conscious or unconscious.

E.g. Drinking/chat chewing

behavior
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 Behavior components

Basically, our behavior has 3 domains

I. Cognitive domain (Knowledge, Perception)
✓Encodes, stores, retrieves, processes information;
✓purpose is manipulation of information
-thinking & learning
II. Affective domain
✓purpose is to create arousal
-attitude, belief and value
III. Psychomotor domain
-practice/action/behavior
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 Healthy Versus Unhealthy
Behavior
I) Well/healthy behavior can promote health
• Healthy behavior is an overt behavioral patterns,
actions, and habits that relate to health
maintenance, to health restoration, and to health
improvement
E.g.. Physical exercise, breast feeding, seeking
treatment, ………..
Il) Unhealthy behavior harms health
E.g., Smoking, chat chewing, excessive alcohol
consumption, unsafe sex, sedentary lifestyle etc.
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 Types of health behaviors
❖ Simply put, health
behaviors- are actions that
healthy people undertake
to keep themselves or
others healthy and
prevent disease.
❖ Broadly health behaviors
can be divided into 6
categories:
I) Promotive and preventive
behaviors
II) Utilization behaviors
III) Illness behaviors
IV) Compliance behaviors
V) Rehabilitation behaviors
VI) Community action
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Types of healthy behaviors …

I. Promotive and preventive behaviors

Physical exercise , use of latrine, child spacing,
proper disposal of dirty water, good nutrition,
clean storage of food, breast-feeding, tooth
cleaning, reduction/cessation of unhealthy
practices such as cigarette smoking, and
excessive alcohol consumption.

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Types of healthy behaviors …

II) Utilization behaviours – utilization of health

services.
E.g., ANC service, immunization services, child-
health service screening programs, FP service

III) Illness behaviours - recognition of

symptoms and prompt self-referral.
✓It is what people do when they feel ill.
✓Aimed to seek remedy.
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Stages of illness behaviors

Becoming aware of symptoms/ Illness

Reporting the symptoms to others in family

Medication
Self-medication Home remedies
Decision to go for treatment
Modern health care Traditional healers

Doctor –patient consultation

Following advice and taking prescribed drugs

Compliance
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Returning for follow up
Types of healthy behaviors …

IV) Compliance (adherence) – following course

of prescribed medicines.
V) Rehabilitation behaviours – what people need
to do after an illness/surgery to recover.
 A type of behavior that prevent further
disabilities after a serious illness.
VI) Community action - actions by communities
to change their surroundings include
community participation in health decision-
making.
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 Burden: mortality, morbidity
and modifiable risk factors
The world is experiencing a shift in
➢ Cause of ill- health: Bacteria to Behavior
➢ Risk factors: Traditional risk to Modern risk
➢ Disease burden: Communicable disease to Non-
communicable –double burden (for developing
countries)

▪ Human behavior plays significant role as a cause as well as

a solutions for existing and emerging problems.

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15
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• According to WHO,
40% of deaths
worldwide are due to
these 10 risk factors
alone (behaviors).

• Global life expectancy

could be increased by
5-10 years if we reduce
these risks.

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 Factors influencing behavior

❖ Lawrence Green identified three

categories of factors affecting individual
or collective behavior, each of which has
a different type of influence on behavior:
I) Predisposing factors
II) Enabling factors
III) Reinforcing factors
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Determinants of human behaviors …
Knowledge, attitude,
Predisposing
factors perception, beliefs, values,
self-efficacy etc.

Cultures/nor Behaviors Enabling

ms/traditions factors

Availability,
affordability,
accessibility,
Peer pressure, influential people,
perceived social
resources to
pressures/significant others/ Reinforcing accomplish the
discouragement/encouragement factors behaviors

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 Determinants...

I) Predisposing factors
❖ Are antecedents to behavior that provide the
rationale or motivation for the behavior to occur.
-Perception, confidence/ self-efficacy, knowledge,
behavioral intention, belief, existing skills, attitude,
values
• They are generally referred to cognitive variables
because they are inside the mind –inside head
factors and have to do with knowing or believing
• They are also called psychosocial because they are
socially influenced.

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 Determinants...

II) Enabling factors

❖ Are those antecedents to behavior that facilitate a
motivation to be realized.
➢ The health-care environment (availability, accessibility
and affordability)
➢ Other environmental influences (community,
governmental laws and priority & commitment to health)
➢ New skills
➢ Resources (time, money, transportation—living conditions)

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 Determinants...

III) Reinforcing factors

❖ Are those factors subsequent to a behavior that
provide the continuing reward or incentives for the
behavior to be persistent and repeated.
• Social benefits( appreciation or depreciation )
• Physical benefits ( comfort or discomfort/pain)
• Tangible rewards ( economic benefits or avoidance
of cost)
• Imagined or vicarious benefit (improved
appearance, self-respect, association with an
admired person who demonstrated the behavior).

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 Factors elaborated as follows:

A) Knowledge or awareness
❖ knowledge of something include some
combination of
1. Simple awareness of facts and
2. understanding of how these facts relate
to one another.

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 Knowledge ….

• Knowledge is,
therefore, knowing
things, objects, events,
persons, situations and
everything in the
universe
• It is the storage of
information or
experience in the
brain.

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✓ knowledge can be viewed as an accurate impression of some
phenomenon.
What one knows

ENCODING STORAGE RETRIEVAL

Getting Retaining Taking

information information information
Perception into memory over time out of storage

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 Knowledge ….

 Knowledge is necessary but not sufficient in behavior

change.
 It is necessary, because, without adequate knowledge ,
people may be unaware of and concerned about health
problem and unable to manage their behavior.
• Simple logic for the specific knowledge is that before act
voluntarily people need to know,
-Why should they act?
-What actions are needed?
-When or under what circumstances?
-How to act and where?

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  Knowledge
about/awareness:
Knowledge about a topic
Knowledge
may be important in
developing interest in the
about/awareness topic and may even
Vs How-to/ motivate the behavior.
essential  How-to/ essential
knowledge knowledge: Intentional
behavior change depends on
it. It is practical/applicable
E.g. Knowing about condom, its
importance and benefits is less
important for behavior change than
knowing proper use or how-to use
condom.
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 Knowledge …

• In general, knowledge about a problem is not

as critical to behavior change as knowledge how
to perform about the target behaviors.
• How-to or essential knowledge is the major
components of skill.
• Therefore, one of the main task in health
education is helping the learner to become
knowledgeable about some health topic and how
to do the behavior .

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 Perception

✓ Perception: a process by which individuals

organize and interpret their sensory information in
order to give meaning it.
Perception is a means of acquiring knowledge. And it
is highly subjective.
➢ Knowledge, can therefore, be expressed by a
formula:
Perception + Storage of information in the
brain=Knowledge

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Perception is subjective

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Perception
is subjective
…. And it
influences
knowledge

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Knowledge/acquisition/formation

❖Knowledge often comes from personal or

other’s experience.
❖We also gain knowledge through
information collected from written
materials, mass media, teachers, parents,
friends, etc..

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 Attitude

❖ One of the vaguest yet most frequently used and

misused words in the behavioral sciences lexicon is
attitude.

❖ While there is no total consensus among

behavioral scientists, to keep matters short and
simple I offer two definitions that, in combination,
cover the principal elements of attitude.

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 Attitude …

❖ Mucchielli (1970) describes attitude as “a

tendency of mind or of a relatively constant feeling
towards a certain category of objects, people, or
situation.”
❖ Luis Thurston(1928) views attitude as “a sum total
of man’s inclination and feelings, prejudice or bias,
preconceived notions, ideas, fears, threats and
conviction about any specific topic.”

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 Characteristics of attitude

In order to develop inclination

1) Predisposition- exposure related to an attitudinal
object. No exposure, no attitude
2) Has directions- polar, +ve or -ve, good or bad.
Negative ……………… positive
3) Evaluation-can be evaluated by intensity or
judgment
e.g. Favorable or unfavorable

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 Characteristics …

4) Changeability-can be changed, not static.

5) Stability or consistency
✓Stability=related to time , constant over
time
✓Consistency= sameness of attitude
e.g. “Mood” changed quite often.

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 Formation of attitude

❖Formation of attitudes are not merely self-

generating they involve interpersonal
relations.
➢Attitudes can be formed from one’s
experience.
➢Attitudes can also come from other
people’s experience.

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 Relationship between attitude
and knowledge

❖ Often closely following knowledge is attitude.

With the knowledge or information that we have
on things the mind is able to develop different
feelings which make the person evaluate the
attitudinal object favorably or unfavorably.
❖ Attitude can, therefore, be expressed by the
formula:
Knowledge +Feeling=Attitude

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 Practice

❖ The words behavior, action, and practice are

different words of the same thing.
❖ All living things from the tiniest microbe display
different types of activities to support their life.
These activities can be:
1. Voluntary (purposeful)
2. Involuntary (not purposeful)
❖ In health education we refer only to those voluntary
movements and purposive acts arising out of
decisions taken by the motor center of the brain.

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 Skills

• Skill is the capability of accomplishing something with

precision and certainty.
• Skills require practical knowledge and ability
• On many occasions inappropriate or ineffective health
behavior may result from the lack of mastery of
specific skills.
• Knowledge and skills are interrelated in that skills are
the practical application of essential knowledge.
➢ Thus, main task of HE : Improve/enhance skill

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 Sequential relationship among
KAP

❖ The general trend is that knowledge (K) is followed

by attitude (A) and is followed by practice (P).
❖ But this rule is not universally applicable to every
behavior i.e. different possibilities and
combinations can come across with regard to KAP.
✓ When P or A precedes K, it is due either to an
imitation (modeling) or compulsion.

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 Sequential Relationship/Link among
Knowledge(K) and Attitude (A) and Practice (P)

Knowledge Attitude Practice

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In HE, we try to
close these gaps by
helping people to
practice what they
know.

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Cognitive consistency theory

• Apply cognitive consistency theory to close gaps.

• States people prefer to be consistent in their
knowledge, attitude and practice.
• New information creates dissonance between
knowledge, attitude and behavior and this
stimulates alternation in their behaviors consistent
with knowledge and attitude.

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 Cognitive consistency …

HE

Knowledge Attitude Behavior

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 Belief

❖ Faith, trust, and truth are words used to express

belief.
❖ The dictionary meaning of belief is ‘trust’ or
‘confidence’ or something regarded by a person as
truth.
❖ Is also refers to a conviction that a phenomenon or
object is true or real.
❖ It is different from knowledge in that it is
perceived whereas knowledge is accepted
objective truth.

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 Belief...

• They are derived from parents,

grandparents, and other people we
respect to listen and are accepted as true.
• But we accept beliefs without trying to
prove that they are true or false.

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 Belief formation

Beliefs can be formed at :

I) Individual, group, or community experiences
II) As a wider belief system
III) Primary socialization-parents
IV) Peers
V) Mass media, teachers, written materials, etc.

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 Difficulty index of changing
beliefs

It is usually easier to influence those beliefs

that
✓are held by individuals
✓have been acquired recently
✓come from not highly respected sources
✓are not part of religion or traditional
✓medical system

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 Difficulty index …

And it is usually difficult to change those

beliefs that
✓are held by the whole community
✓have been deep rooted in the culture
✓come from highly respected sources
✓are part of a religion or traditional
✓medical system

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 Types of beliefs

❖As beliefs can be held very strongly, they

are often difficult to change.
❖And one big wrong is that the health
workers themselves believe that any
traditional belief is bad and must be
changed.

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 Types of beliefs …

To overcome this, health workers must categorize

beliefs in advance as:
1. Useful (Helpful) beliefs= are beliefs which
preserve health.
2. Neutral beliefs= are beliefs which neither
damage nor preserve health. and
3. Harmful beliefs= are beliefs which damage
health.
Then, they can concentrate on trying to change only
the harmful and encourage the helpful ones.

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 Types of beliefs …

Mind now!
✓If you are unsure that a belief is harmful, it
is better to leave as it is because if too
many of their beliefs are challenged
people may anger at you and not
cooperate with you.

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Relationship between beliefs and attitudes

Attitude

Beliefs
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 Beliefs Vs attitude ….

• Our beliefs about things affect our attitude

towards it.
• Our beliefs, in turn, are influenced by our
attitudes.
• The judgment as good or bad and worth
carrying out a behavior will depend on the
beliefs about the consequences of
performing the behavior.

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 Beliefs Vs attitude ….

• If an individual beliefs the behaviors have

good outcomes (positive beliefs) - Positive
attitude.
• If an individual beliefs the behaviors have
bad outcomes (negative beliefs) - Negative
attitude.

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 Value

Every individual places or gives a relative

worth to everything around. This worth or
preference or judgment or weightage is
known as value.

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 Value...

❖ Usually, values are qualities at an abstract level

such as bravery and intelligence. A person values
might be reflected in the way he or she completes
the following statement: ‘the things that are
important to me are...’.
Examples of characteristics that can be valued by the
communities include being a good mother, having
many children/cattle, academic success, being a man
of God, being ‘modern’ , being healthy, etc.

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 Value...

❖ In short, values are beliefs and standards upon

which a man acts by preference.

So, ultimately they are contextual basis for justifying

one’s action in moral or ethical terms. i.e. they
underpin the right and wrong the good and bad
dimensions of people’s outlook on specific behaviors.
E.g. married vs unmarried woman

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 Criteria of value

❖To call something value there should be:

1-Free choice 4-Proud of selection
2-Alternatives 5-Accept
openly/frankly
3-Selection by 6-Act upon it
-reason 7-Act consistently
-consideration

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 Value conflict versus value
clarification

Consider this brief exchange between two people;

He: Did I hear you say that you are going to try skydiving?
She: Absolutely not!
He: Why not?
She: Because I value my life that’s why not!
He: Do you also value your health?
She: Of course, I do.
He: Then why do you smoke cigarettes?
She: Because I enjoy smoking and it helps me relax
He: If that is the case, can you honestly say you really value your life?
She: Sure, I can. It is not that I don’t value my life and health but
I value other things too, among these the pleasure of smoking.
What is wrong with that?

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 Value conflict versus value
clarification …

❖In the preceding scenario, the person who values

life, health and cigarettes, too, reveals conflict of
values=inconsistencies between two or more
values.
❖In short-term health education/promotion
programs one shouldn’t seek to change values
rather should help people recognize
inconsistencies between and among their values.

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 Value conflict versus value
clarification …

❖ But we can sometimes bring about changes by

emphasizing values which don’t involve health.
❖ As one aim of health education (from WHO expert
committee in 1954) is to promote health as a
valued asset in the community, we, health
educators, are often trying to encourage people to
think about their values. This process is called
value-clarification.

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 Difficult index;
in terms of difficulty of changing:

Values are thus more permanent and resistant

to change than attitudes and beliefs. So, in
terms of difficulty of changing:
Knowledge<beliefs < attitudes < values
Mind you,
• Beliefs, attitudes and values are independent
constructs, yet the differences between them
are often fine and complex.

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 Self-efficacy or self-confidence

❖It implies a mental or cognitive state of

taking control.
❖It is your belief in your ability or
competency to perform a behavior.
E.g., can you remember to take the
medication?

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 Behavioral intention

❖Is the willingness to perform a certain

behavior provided that the enabling factors
are readily available.
❖Sometimes a person may intend to perform
but still not do so. This is because of the
influence of enabling factors such as time,
money, equipment, skills and health services.

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 Behavioral intention …

E.g. (1): enabling factors to prepare ORS could be:

time, containers, salt and sugar and knowledge of
how to prepare and administer it.
Mind now!
❖ When the public make the effort to follow your
health education you should ensure that the
required services (enabling factors) such as
screening facilities, medicines, vaccines, building
materials, etc. are actually available.

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 Resources

❖ Facilities, money, time, labor services, skills,

materials and the distribution and their location
also affect people’s behavior.
Mind now!
❖ Behaviors which involve spending much time,
money, requiring new skills or conflict with existing
practices will be more difficult to promote than
those which are simple to carry out or fit with the
existing practices.

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 Significant others

❖Can also be called relevant others or

influential others or social pressure or
subjective norm or normative beliefs.
❖These people are significant (determinants)
for the behavior of others to encourage to or
prohibit from doing something.
❖We often listen to what he or she says and try
to do what he or she does.

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 Significant others ..

❖Among these important people are elders,

friends, peers, parents, grandparents,
village leaders, religious leaders and
people with a lot of experience and skills
(teachers, health workers, etc,)

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 Significant others …

❖ One reason for most health education programs to fail is that

they are directed at individual and ignore the influences of
other people-victim-blaming.

Think about your own family and friends. Whom do

you consult when you have to make an important
decision?
✓ The influential people change during a person’s life.
✓ Which people are significant may also vary according to
the setting.
 Friends Traditional
healers

Grand Religious
parents leaders

Husband

I want to use FP, but…

The influence of social pressure (circle of influence)

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 Summary of factors affect human behaviors

Predisposing factors
create intention to act

Realizes the
Enabling factors
intentions

Encourage behaviors to
Reinforcing factors persist

Sustainable behavior

Remember: Any given behavior can be explained as a function of the

collective influence of these three factors. 73
 Theoretical sequence to address determinants of behaviors

• Knowledge, Enabling
Behaviors
attitude,
factors • Peer
beliefs, • Availability, influence &
values affordability, social
accessibility pressure
& others Reinforcing
Predisposing
resources factors
factors

In practice simultaneously
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Educational approaches to behavior change

Determinants
of behaviors • Approaches to change
Direct communication with target individuals-
Predisposing factors educational approaches.

• Organization change, avail services,

Enabling factors accessibility, advocacy , resource mobilization.

• Indirect communication with the social

Reinforcing factors environments , influential peoples.

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 Changes of behavior

❖ Our behavior changes all the time some are

natural while others are planned changes.
I. Natural changes/Unintentional
❑ When changes occur because of natural events in
the community around us, we often change
without thinking much about it.
II. Planned changes/Intentional
❑ When changes occur deliberately and/or planned.

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Behavior change approaches

I. The persuasion approach-the deliberate

attempt to influence the other person to do
what we want them to do. (Often called the
‘directive’ approach or, when done forcefully,
coercion).
❖Such approach is used in situations where
there is serious treat such as epidemics and
natural disasters, and the actions needed are
clear-cut.

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Behavior change approaches …

II. The informed decision-making approach- giving

people information, problem-solving and decision-
making skills to make decision but leaving the
actual choice to the person (‘open’ or ‘non-
judgmental’ approach).
❖ Such approach is used with disadvantaged or
oppressed groups by promoting ‘conscious-raising’
and ‘building confidence’ that they have the power
to make their appropriate decisions for their own
lives called empowerment.

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 Further reading materials
1. Lawrence W. Green et al. 1980. Health education
planning a diagnostic approach

2. Randall R. Cottrell, James T. Girvan, James F. McKenzie

2006. Principles& foundations of health promotion
and education. Third ed. USA.

3. BruceG, Wlter H, Nell H. Introduction to Health

education and Health promotion; 2nd edition, 1984
4. Ramachandran L. and Dharmalingam. T. 1995. Health
education’s new approach.

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