Theories and Models in Health Education and

promotion

BY: Wubet Taklual ( MPH, Assistant Professor)

Jan/2024
By: Wubet T 04/27/2024 1
 Learning objectives
After this session students will be able to
• Explain Theory and Model

• Describe theories of different levels of influence on human

health related & directed behaviors.

• Recognize Some theories in Public Health intervention and

research
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 Brainstorming

• How do you define Theory?

• What is Model?

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 Theory

“Theory: - is a set of inter-related concepts,

definitions and prepositions that describe,
explain, predict, or control behavior. Theories
explain why, what, how, and when a particular
behavior occurs.
Is “A systematic explanation for the
observations that relate to a particular aspect of
life. E.g screening serv. use
By: Wubet T 04/27/2024 4
 Model

• Model: model is a subclass of a theory.

• It is a representations of theory and provide the vehicle for

applying the theories to understand a specific problem in a
particular setting or context.

• Semantic/ diagrammatic representation of a phenomenon.

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 Purpose of theory/Model
1. Describe-the behavior (what) : e.g. As event, as process

2. Explain- the causes of behavior (why)------factors

3. Predict- we predict the behavior (when) --- hierarchy

4. Control/change-then we change the behavior (how) --steps

5. Focus -to limit options and reduce waste of effort

6. Simplify- untangle and simplify the complexity of nature

• to manage complex systems, tolerate ambiguous contexts, and

prepare for unpredictable threats
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 Importance of theories and
Models in Health education
1. Guide the practice of Health Education and promotion at various Stages

2. Provides a platform for understanding why people engage in Health

compromising behaviors and how People adopt health protective
behaviors

3. Help to organize our thinking about a given Health problem & Human
behaviors related to it.

4. Help to set priorities for Health education interventions.

5. Prevent the planner from overlooking important factors.

By: Wubet T 04/27/2024 7
 Cont …

• A growing body of evidence suggests that

interventions developed with an explicit
theoretical foundation or foundations are more
effective than those lacking a theoretical base and
that some strategies that combine multiple
theories and concepts have larger effects.

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 Theories that Guides H.E. Practice
Three categories

1. Intrapersonal (Individual) Theories- “inside the head constructs”

a. Health Belief Model

b. Theory of Reasoned action/ Theory Planned Behavior

2. Interpersonal Theories – “inside the head constructs” + external

environmental

c. Social Cognitive Theory

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d. Tans theoretical Model
 Cont …

3. Community Theories- “inside the

head constructs” +community factors

a. Diffusion of Innovation Theory

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 Health Belief Model(HBM)

 HBM was developed in the 1950s, holds that healthy

behavior is a function of individual’s socio-
demographic characteristics, and Health belief.

 Developed to explain the widespread failure of people

to participate in programs to prevent and detect disease

(Hochbaum 1958, Rosenstock & Becker, 1960/74).

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 Cont …

 According to this model, a person must hold the

following beliefs in order to be able to change
behavior:

1. Perceived susceptibility: the extent to which an individuals

believes she or he is vulnerable to the health problem. (“ am I at
risk for HIV infection?”)
2. Perceived seriousness : the perceived relative severity of the
problem/ condition (“ how serious is AIDS; how hard would my
life be if I got it?”)
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04/27/2024
 Cont …

Susceptibility and severity combine to form the overall perceived threat

of the disease

If one feels susceptible to a serious disease like

HIV/AIDS then he should be motivated to take
action because the level of the treat is high, if he/she
does not feel he/she is at risk from a less sever
disease such as flu he is unlikely to take action
because he/she perceives the treat as minimal.
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 Cont …

3. Perceived benefits : subjective perception about the

benefits of taking health action and its effectiveness.

 Individuals must believe that recommended course of

action will actually do some good and effective.
(“ if I start using condoms, I can avoid HIV
infection”).
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 Cont …

4. Perceived barriers to taking action : includes the

barriers such as cost, side effects, culture, and convenience
which also influence the likely hood of taking action.

For example , the possible barriers for using condom could

be: are condoms available? Is the cost reasonable? Is
morally and socially acceptable to buy condoms from
shop? Is it comfortable to use it?
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 Cont …

5. Cues to action : it is remainders or motivators for action (“

witnessing the death or illness of a close friend or relative due to
AIDS”).

 Mass media campaigns

 advice from others
 Reminder postcard
 Illness of family member or friend
 Newspaper or magazine article
6. self-efficacy : Confidence in one’s ability to take action
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 Key Concepts and Definitions of the HBM
Constructs Definitions Application
Perceived Belief about the chances of Define population(s) at risk, risk levels
susceptibility experiencing a risk or
getting a condition Personalize risk based on a person’s characteristics
or behavior

Make perceived susceptibility more consistent with

individual’s actual risk

Perceived severity Belief about how serious a Specify consequences of risks

condition and its sequelae and conditions
are

Perceived benefits Belief in efficacy of the Define action to take: how,

advised action to reduce where, when; clarify the
risk or seriousness of positive effects to be expected
impact

17

By: Wubet T 04/27/2024

 …Constructs and Definitions of the HBM
Constructs Definitions Application
Perceived Belief about the tangible Identify and reduce perceived barriers
barriers and through reassurance, correction of
psychological costs of the misinformation, incentives, assistance
advised action

Cues to action Strategies to activate Provide how-to information,

“readiness” promote awareness,
use appropriate reminder systems

Self efficacy Confidence in one’s ability •Provide training and guidance in performing
to take action recommended action
•Use progressive goal setting
•Give verbal reinforcement
•Demonstrate desired behaviors
•Reduce anxiety
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 Other variables

Modifying factors
These variables modify any of the major HBM
constructs.
Socio demography, socio-psychological,
personality, knowledge, etc
Context in which behavior happens may modify
the model
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 The Health Belief Model
INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION

Demographic Variables Perceived benefits of

(age, sex, race, ethnicity, etc) preventative action
Minus
Socio psychological variables
Perceived barriers to
preventative action

Perceived susceptibility to Perceived Threat of Disease

Disease “X” Likelihood of Taking
“X” Recommended
Perceived Seriousness Preventative Health
(Severity) of Disease “X” Action
Cues to Action
Mass Media Campaigns
Advice from others
Reminder postcards from physician or
dentist
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Illness of family member or friend
Newspaper or magazine article
Health Education Quarterly (Spring 1984)
 Summary

Perceived susceptibility +Perceived severity = perceived

threat to the disease
When the benefits of Health action out weight the barriers in
the minds of a given person the likely hood of taking
action increases vice versa.
In short, the likely hood of taking action is high when
• the perceived treat of the disease is high and
• the benefits of the behavior out weight the barriers
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 Example : Hypertension

• High blood pressure screening campaigns often identify people

who are at high risk for heart disease and stroke, but who say
they have not experienced any symptoms.

• Because they don’t feel sick, they may not follow instructions to
take prescribed medicine or lose weight.

• Here, HBM can be useful for developing strategies to deal with

non-compliance in such situations.
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 Cont …

• According to the HBM, asymptomatic people may not

follow a prescribed treatment regimen unless they accept
that, though they have no symptoms, they do in fact have
hypertension (perceived susceptibility).
• They must understand that hypertension can lead to heart
attacks and strokes (perceived severity).
• Taking prescribed medication or following a recommended
weight loss program will reduce the risks (perceived
benefits) without negative side effects or excessive
difficulty (perceived barriers).
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 Cont …

 Print materials, reminder letters, or pill calendars

might encourage people to consistently follow
recommendations (cues to action).
 For those who have, in the past, had a hard time
losing weight or maintaining weight loss, a
behavioral contract might help establish achievable,
short-term goals to build confidence (self-efficacy).
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 2. Theory Of Reasoned Action/TRA/

( Fishbein & Ajzen, 1970’s)

… currently there is a Theory of Planned Behaviour

/TPB/ which is an extension of TRA…
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 Cont …
 The theory of reasoned action was developed in the mid-1960s by
Fishbein and Ajzen

 It is based on the assumptions that human beings are usually quite

rational and make systematic use of the information available to them.

 TRA/TPB is concerned with individual motivational factors as

determinants of the likelihood of performing a specific behavior.

 People consider the implications of their actions in a given context at a

given time before they decide to engage or not engage in a given
behavior
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 Cont …

• people behave the way that they do for a reason,

and thus behavior is logical.

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 Cont …

• The theory states that intentions are the

basis and the most immediate influences
for the behavior to be adapted.

Intention is itself viewed as a function of two

determinants.
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 Cont …

Intention is a measure of
motivation or readiness to
act and is excellent
predictors of behaviors

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 Cont …

1.Person’s attitude toward performing the behavior.

Attitude: are determined by the perceived
consequences of performing the behaviors/
evaluation of the outcome and beliefs

 If the person has positive beliefs about the outcome

of his /her behavior then he/she said to have
positive attitudes about the behavior and vise versa.
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 Cont …

2. Subjective norm: the person’s perceived social pressure

exerted upon him or her to perform the behavior.

Subjective norm: is influenced by significant others

(significant people such family, friends, peers, teachers etc.)

 It is the influence of one’s social environment on his /her

behavioral intention

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 •External variables :demographic variables

Perceived
consequence of
Attitudes
behaviors Intention Behavior

Significant Subjective
others norm

Figure: the theory of reasoned action

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 Cont …

Prediction : a person most likely to perform a behavior when

he/she feels good about the behavior (positive attitude) and
feels the social pressure favorable to perform the behavior (if
perceive significant people will like the behaviors if it occurs).

Note : attitude towards to the behaviors and subjective norm

towards to that behaviors, has been found to be predict the
actual behaviors.
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 Learning objective

• The Trans-theoretical Model (TTM)

• Constructs and application areas

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 …TTM

• Developed in 1979 by Prochaska and Diclemente.

• It emerged from comparative analysis of 18

psychotherapy systems & review of 300 therapy
outcomes (prochaska,1984).
• It evolved out of studies comparing the experiences
of smokers who quit on their own with those of
smokers receiving professional treatment.
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 …TTM

The model’s basic premise is that behavior

change is a process, not an event.
• It is one among stage theories.

• It uses stages of change to integrate processes and

principles of change from across major theories
of intervention.
• Concerned, convinced, plan of action & actions
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 1. Stages of change in TTM

1. Stages of change construct

• Pre-contemplation
• contemplation
• preparation
• action
• maintenance
• termination
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 Stages of Change Model
Precontemplation
Awareness of need to change

Contemplation
Increasing the Pros for Change
and decreasing the Cons

Preparation
Commitment & Planning
Relapse and
Recycling
Maintenance
Action
Integrating Change into
Implementing and
Lifestyle
Revising the Plan
38

04/27/2024
Termination By: Wubet T
 …stages of change model
Stage Definition Potential change strategies
Precontemplation Has no intention of taking action Increase awareness of need
within the next six months for change; personalize
information about risks and
benefits.
Contemplation Intends to take action in the next six Motivate; encourage making
months specific plans

Préparation Intends to take action within the next Assist with developing and
30 days and has taken some behavioral implementing concrete
steps in this direction action plans; help set
gradual goals

Action Has changed behavior for less than six Assist with feedback,
months problem solving, social
support, and reinforcement
Maintenance Has changed behavior for more than Assist with coping,
six months reminders, finding
alternatives, avoiding
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slips/relapses
04/27/2024
(as 39
applicable)
 …Stages of change

• PRECONTEMPLATION - The state in which there is little or

no consideration of change of the current pattern of behavior in
the foreseeable future.
• TASKS: Increase awareness of need for change and
concern about the current pattern of behavior; envision
possibility of change
• GOAL: Serious consideration of change for this
behavior

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 …Stage change

• CONTEMPLATION – The stage where the individual

examines the current pattern of behavior and the potential for
change in a risk – reward analysis.
• TASKS: Analysis of the pros and cons of the current
behavior pattern and of the costs and benefits of change.
Decision-making.
• GOAL: A considered evaluation that leads to a
decision to change.

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 …Stages of Change

• PREPARATION – The stage in which the individual makes a

commitment to take action to change the behavior pattern
and develops a plan and strategy for change.
TASKS: Increasing commitment and creating a
viable, realistic, change plan.
• GOAL: An action plan to be implemented in the near
term.

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 …Stages of Change

• ACTION – The stage in which the individual

implements the plan and takes steps to change the
current behavior pattern and to begin creating a new
behavior pattern.
• TASKS: Implementing strategies for change;
revising plan as needed; sustaining commitment in
face of difficulties
• GOAL: Successful action to change current
pattern. New pattern established for a significant
period of time (3 to 6 months).
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 …Stages of change

• MAINTENANCE – The stage where the new behavior

pattern is sustained for an extended period of time and
is consolidated into the lifestyle of the individual.
• TASKS: Sustaining change over time and
across a wide range of different situations. Avoiding
slips and relapse back to the old pattern of behavior.
• GOAL: Long-term sustained change of the old
pattern and establishment of a new pattern of behavior.

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 Stage of Change & summary of Tasks
45

 Precontemplation  Awareness, Concern,

Confidence
 Contemplation  Risk-Reward Analysis &
Decision making
 Preparation  Commitment & Creating
an Effective/Acceptable
Plan
 Adequate
 Action Implementation of Plan
and Revising as Needed
 Integration into Lifestyle
 Maintenance
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 How change occurs/process of change

• Processes of change are the covert and overt

activities that people use to progress through
each stages
• Ten processes have received the most
empirical support in research to date
Cont….
 Cont….
I. Processes of Change
1. Consciousness raising [increasing awareness]
• Increased awareness about the causes,
consequences and cures for a particular
problematic behavior
• Interventions that can increase awareness
include media, education…
• E.g. I recall information people had given me
on how to stop smoking
 Cont….
2. Dramatic relief [emotional arousal]
• Increased emotional experiences or reaction
• Role playing, personal testimonies and media
are examples of techniques that can move
people emotionally
• E.g. I react emotionally to warnings about
smoking cigarettes
 Cont….
3. Environmental reevaluation [Social
reappraisal]
• How the presence or absence of a personal
habit affects one's social environment
• E.g. I consider the effect of smoking on others
and the environment
• Documentaries can lead to such re-
assessments
 Cont….
4. Self-reevaluation [Self reappraisal]
• Assessments of one's self-image with and
without a particular unhealthy habit
• Healthy role models are techniques that can
move people evaluative
• E.g. My dependency on cigarettes makes me
feel disappointed in myself
 Cont….
5. Self Liberation [Committing]
• Is both the belief that one can change and the
commitment to act on that belief
• E.g. I make commitments not to smoke
• New Year's declarations and public
testimonies can enhance self-liberation
 Cont….
6. Counter Conditioning [Substituting]
• Requires the learning of healthier behaviors
that can substitute for problem behaviors
• E.g. I find that doing other things with my
hands is a good substitute for smoking
 Cont….
7.Social-Liberation[Environmental
opportunities]
• Increase in social opportunities or alternatives
• Appropriate policies, advocacy and
empowerment produce increased
opportunities for impoverished people health
promotion
• E.g. Such as create smoke-free zones and easy
access to condoms and other contraceptives
 Cont….
8. Stimulus Control [Re-engineering]
• Removes cues for unhealthy habits and add
healthier alternatives
• E.g. I remove things from my home that
remind me of smoking
 Cont….
9. Helping Relationships [Supporting]
• Support for the healthy behavior change
• E.g. I have someone who listens when I need
to talk about my smoking
• Therapeutic alliance and buddy systems can
be sources of social support
 Cont….
10. Reinforcement Management [Rewarding]
• Provides consequences for taking steps in a
particular direction
• E.g. I reward myself when I don’t smoke
• Positive self-statements and group recognition
increasing the probability that healthier
responses will be repeated
 Social cognitive Theory
(SCT)
(

( Rotter & Bandura, 1954/86)

… How individuals, behavior & environment interact:

By: Wubet T 04/27/2024 58
 Cont …

 Developed by Albert Bandura

 It is interpersonal theories

 Unlike intrapersonal theories, social cognitive theory gives due

attention to the external environment which can punish or
reward the behaviors.

 In addition, it gives due attention to human qualities such as

expectation, values, confidence and self-control.
By: Wubet T 04/27/2024 59
 Cont …
 Bandura stated that there are three factors that interact dynamically to
determine human behavior. These factors are;
1. Environmental influence
According to SCT, there are three major process by which the environment exert
its influences on behaviors, namely

a. The reinforcement or inhibition of behavior provided by its consequences

for particular action
b. The opportunity it provides for observational learning/modeling the
behaviors after that of the other person
c. The vicarious reinforcement it provides- reinforcement occurs for the
behaviors that an individuals has observed but not yet expressed.
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 Cont …

2. Personal factors: mainly related to prior

history in the form of knowledge and attitude
pertaining to the issue at hand.
3. Behavioral factors: mainly related to
individuals ability to exert self control as they
determine their response to the situation. It
includes factors such as self efficacy,
anxiety/emotions, coping, goal setting etc
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 Cont …

• According to SCT, behaviors is explained in

terms of a triadic, dynamic, and reciprocal
model in which behavior, personal factors,
and environmental influences Each others.

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 Bandura’s Triadic Determinism

B
Behavior factors

P/C E
Person and Environment
cognitive factors

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 Stage of communication…

Diffusion of Innovation
(DOI)

( Everett. M. Rogers, 1962/2005)

….How to deal with social systems in communicating a new product to target audiences.
By: Wubet T 04/27/2024 64
 Cont …

 It is one of the community models

 Developed by Everett M. Rogers (1962,1983,1995, 2003, 2005)

• Diffusion of innovation theory is a theoretical approach

which provides an explanation how innovation, or ideas
perceived as new are communicated (diffused ) through
channels among the members of the social system, how
people create & share information
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 Cont …

 Diffusion is the process by which an innovation is

communicated through certain channels over time
among the members of a social system (Rogers,
2003).
 A key premise of the Diffusion of Innovations model
is;
o some innovations diffuse quickly and widely, whereas others are weakly
or never adopted, and others are adopted but subsequently abandoned.
o innovations are adopted by different individuals and spread at different
rates in subgroups of individuals.

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 Cont …

 There are four main elements in the diffusion of new

ideas:

1. The innovation
2. Communication channels
3. The social system
4. Time
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 Cont …

1. Innovation -means an idea, practices or objects perceived as new by

the people.

2. Communication channels -the means by which the new idea is

communicated or message get from one individual to the other. E.g.
‘iqub’, ‘idir’ (social system)

3. Time- duration it takes to accept the innovation

4. Social system- a set of interrelated units that are engaged in joint

problem solving to accomplish a common goal.
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 Diffusion process
Diffusion process : The process by which an innovation is
communicated through certain channels over time
among the members of a social system
There are five segments (adopter categories) in the
diffusion process based on the amount of time it took to
adapt an innovation. These are;
I. Innovators
II. Early Adopters
III. Early Majority
IV. Late Majority
V. Laggards

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 Cont …

1. Innovators
 Are first to adapt an innovation (they want to be first to do
something)

 Risk takers even if the innovation is unprofitable.

 They are venturesome, rush

 They have higher socioeconomic status than any other group

 They require a shorter adoption period than any other category

04/27/2024 70

By: Wubet T
2. Early adopters
 Are very interested in innovation, but they do not
want to be first to be involved.
 Possess greatest degree of opinion leadership in
most social systems ( are respected by peers)
 Serve as role model for other members or society
By: Wubet T 04/27/2024 71
3. Early majority
 May be interested in innovation, but will need some
external motivation to get involved.
 Interact frequently with peers (sociable and jockey)
 Seldom held the position of opinion leadership.
 Deliberate (check and discuss) before adopting a new
idea.
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4. Late majority
• Are skeptical and cautious and will not
adopt an innovation until most people
adopt.
• Pressure from peers and adapt because of
economical necessity.
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5. Laggards
• Will be the last to get involved in an innovation, if
they get involved in an innovation at all.
• Posses no opinion leadership.
• Isolated in the social systems
• Point of reference is in the past. “Diro kere”, “diro
eko”, “Doro 25/50 santim neber”,etc
• Suspicious of innovation
By: Wubet T 04/27/2024 74
By: Wubet T 04/27/2024 75
 100

80
Cumulative Percent

Know ledge
60
Attitude
40
Practice
20

0
1 3 5 7 9 11 13 15 17 19
Time

By: Wubet T 04/27/2024 76

Figure : KAP curve in diffusion of innovation

 Adoption process

• Adoption process: is the mental process through

which an individual passes from first hearing
about an innovation to final adoption"- it pertains
to an individuals

• Rogers breaks the adoption process down into five

main stages. The five stages are:
By: Wubet T 04/27/2024 77
 Stages of adoption

Awareness - the individual is exposed to the

innovation but lacks complete information about
it

Interest - the individual becomes interested in the

new idea and seeks additional information about it

Evaluation - individual mentally applies the

innovation to his present and anticipated future
situation, and then decides whether or not to try it

Trial - the individual makes full use of the

innovation

Adoption - the individual decides to continue the

By: Wubet T 04/27/2024 78
full use of the innovation
 Rejection and Discontinuance

Rogers’s points out, an innovation may be rejected during

any stage of the adoption process. Rogers defines

Rejection: is a decision not to adopt an innovation.

Discontinuance: is a rejection that occurs after adoption

of the innovation.
By: Wubet T 04/27/2024 79
 The End

THANK YOU !!

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