Theory at a Glance: Application to Health Promotion and Health Behavior (Second Edition)

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2 Theory at a Glance A Guide For Health Promotion Practice (Second Edition) U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

3 Foreword Theory at a Glance was published. The guide was decade ago, the first edition of a welcome resource for public health practitioners seeking a single, concise summary of health behavior theories that was neither overwhelming nor superficial. A 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, Theory at a Glance , both as members of the public health research community also utilized 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. I am pleased to introduce this second edition of Theory at a Glance . I am especially impressed that the lead authors, Dr. Barbara K. Rimer and Dr. Karen Glanz, have enhanced and updated it throughout without diminishing the clarity and efficiency of the original. We hope that this new edition will empower another generation of public health practitioners to apply the same conceptual rigor to program planning and design that these authors exemplify in their own research and practice. Robert T. Croyle, Ph.D. Director Division of Cancer Control and Population Sciences National Cancer Institute Spring 2005

4 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. Thanks to the staffs of the Office of Communications, particularly Margaret Farrell, and the Division of Cancer Control and Population Sciences and Kelly Blake, who guided this monograph to completion. We appreciate in particular the work of Karen Harris, whose attention to detail and commitment to excellence enhanced the monograph’s content and quality.

5 Tables and Figures Table of Contents Tables Introduction viii Audience and Purpose 1 Table 1 Contents An Ecological Perspective: Levels of Influence 1 11 Table 2 Health Belief Model 14 Table 3 Stages of Change Model Part 1: Foundations of Theory in Health Promotion and Health Behavior 3 15 Table 4 Why Is Theory Important to Health Promotion and Health Behavior Practice? Theory of Planned Behavior 4 17 Table 5 What Is Theory? Social Cognitive Theory 4 20 Table 6 How Can Theory Help Plan Effective Programs? Community Organization 4 24 Table 7 Explanatory Theory and Change Theory Concepts in Diffusion of Innovations 5 27 Table 8 Fitting Theory to the Field of Practice Key Attributes Affecting the Speed and Extent of an Innovation’s Diffusion 5 28 Table 9 Using Theory to Address Health Issues in Diverse Populations Agenda Setting, Concepts, Definitions, and Applications 7 31 Table 10 Diagnostic Elements of PRECEDE-PROCEED 42 Table 11 Summary of Theories: Focus and Key Concepts Part 2: Theories and Applications 9 45 The Ecological Perspective: A Multilevel, Interactive Approach 10 Theoretical Explanations of Three Levels of Influence 12 Individual or Intrapersonal Level Figures 12 Health Belief Model 13 Figure 1 Stages of Change Model Using Explanatory Theory and Change Theory to Plan and Evaluate Programs 15 6 Figure 2 Theory of Planned Behavior A Multilevel Approach to Epidemiology 16 10 Figure 3 Precaution Adoption Process Model Theory of Reasoned Action and Theory of Planned Behavior 18 18 Figure 4 Interpersonal Level Stages of the Precaution Adoption Process Model 19 19 Figure 5 Social Cognitive Theory An Integrative Model 19 21 Figure 6 Community Level Sociocultural Environment Logic Framework 22 26 Figure 7 Community Organization and Other Participatory Models An Asthma Self-Management Video Game for Children 23 33 Figure 8 Diffusion of Innovations Social Marketing Wheel 27 38 Figure 9 Communication Theory The PRECEDE-PROCEED Model 29 40 Figure 10 Media Effects Using Theory to Plan Multilevel Interventions 30 46 Agenda Setting 30 New Communication Technologies 31 Part 3: Putting Theory and Practice Together 35 Planning Models 36 Social Marketing 36 PRECEDE-PROCEED 39 Where to Begin: Choosing the Right Theories 43 A Few Final Words 44 Sources 48 References 49

6 Introduction INTRO Theory at a Glance: Application to Health Promotion and Health his monograph, 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 T 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 Making Health Communication Programs Work: and model programs for practice, such as voluntary health agencies, community organizations, health care settings, schools, and the i A Planner’s Guide , and the Web portal, Cancer Control PLANET (Plan, Link, Act, Network private sector. ii with Evidence-based Tools). Theory at a Glance makes health behavior theory accessible 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 viii 1 is broadly defined as the health promotion programs. (For the purposes of this monograph, is designed to help users Theory at a Glance much more likely to produce desired outcomes. T H E O R Y AT A G L A N C E 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 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 for guidance on using theories about human behavior to inform Theory at a Glance Prevention (CDC) at . www.thecommunityguide.org program planning, implementation, and evaluation. We have received many testimonials T H E O R Y AT A G L A N C E 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. can be Theory at a Glance 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 describes ways that Foundations of Theory in Health Promotion and Health Behavior Part 1. 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. 1 Behavior and Health Education: Theory, Research, and Practice , 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. explains how theory can be used in health Part 3. Putting Theory and Practice Together 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. ii Cancer Control PLANET (http://cancercontrolplanet.cancer.gov) provides access to data and resources that can help planners, program staff, and researchers to design, implement, and evaluate evidence-based cancer control programs.

7 PART 1 Foundations of Theory in Health Promotion and Health Behavior Part 1 3 T H E O R Y AT A G L A N C E

8 to succeed than those developed without are the building blocks—the • Concepts interventions in theory creates innovative Why Is Theory Important to the benefit of a theoretical perspective. primary elements—of a theory. ways to address specific circumstances. Health Promotion and Health He or she does not depend on a “paint-by­ Behavior Practice? • Constructs are concepts developed or numbers” approach, re-hashing stale ideas, Explanatory Theory and adopted for use in a particular theory. but uses a palette of behavior theories, Change Theory Effective public health, health promotion, The key concepts of a given theory are skillfully applying them to develop unique, and chronic disease management programs its constructs. PART 1 tailored solutions to problems. Explanatory theory describes the reasons help people maintain and improve health, • 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 developing appropriate interventions, and Adoption Process Model. may draw on a number of theories • Models evaluating their successes. It can inform the F O U N D A to help understand a particular problem in Not all health programs and initiatives are planner’s thinking during all of these stages, Change theory guides the development of a certain setting or context. They are not equally successful, however. Those most offering insights that translate into stronger health interventions. It spells out concepts always as specified as theory. likely to achieve desired outcomes are T 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 programs. Theory can also help to explain that can be translated into program based on a clear understanding of targeted the dynamics of health behaviors, including messages and strategies, and offers a basis Most health behavior and health promotion health behaviors, and the environmental processes for changing them, and the for program evaluation. Change theory theories were adapted from the social and context in which they occur. Practitioners influences of the many forces that affect T H E O R Y AT A G L A N C E helps program planners to be explicit about behavioral sciences, but applying them to use strategic planning models to develop health behaviors, including social and their assumptions for why a program will health issues often requires that one be and manage these programs, and physical environments. Theory can also help work. Examples of change theories include familiar with epidemiology and the biological continually improve them through planners identify the most suitable target Community Organization and Diffusion of sciences. Health behavior and health meaningful evaluation. Health behavior audiences, methods for fostering change, Innovations. Figure 1. illustrates how promotion theories draw upon various theory can play a critical role throughout and outcomes for evaluation. explanatory theory and change theory can disciplines, such as psychology, sociology, the program planning process. be used to plan and evaluate programs. anthropology, consumer behavior, and Researchers and practitioners use theory marketing. Many are not highly developed What Is Theory? to investigate answers to the questions of Fitting Theory to the Field of Practice or have not been rigorously tested. Because “why,” “what,” and “how” health problems of this, they often are called conceptual A theory presents a systematic way of should be addressed. By seeking answers This monograph includes descriptions and frameworks ; here theoretical frameworks or understanding events or situations. It is a to these questions, they clarify the nature applications of some theories that are the terms are used interchangeably. set of concepts, definitions, and propositions of targeted health behaviors. That is, theory central to health behavior and health that explain or predict these events or guides the search for reasons why people promotion practice today. No single theory situations by illustrating the relationships How Can Theory Help Plan do or do not engage in certain health dominates health education and promotion, between variables. Theories must be Effective Programs? behaviors; it helps pinpoint what planners nor should it; the problems, behaviors, applicable to a broad variety of situations. need to know before they develop public populations, cultures, and contexts of public They are, by nature, abstract, and don’t Theory gives planners tools for moving health programs; and it suggests how to health practice are broad and varied. Some have a specified content or topic area. beyond intuition to design and evaluate devise program strategies that reach target theories focus on individuals as the unit of Like empty coffee cups, theories have health behavior and health promotion audiences and have an impact. Theory also change. Others examine change within shapes and boundaries, but nothing inside. interventions based on understanding of helps to identify which indicators should be families, institutions, communities, or They become useful when filled with behavior. It helps them to step back and monitored and measured during program cultures. Adequately addressing an issue practical topics, goals, and problems. consider the larger picture. Like an artist, 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

9 There are several reasons why culture and A Good Fit: Fig ure 1. Using Explanatory Theory and Change Theory to Plan and Evaluate Programs ethnicity are critical to consider when Characteristics of a Useful Theory applying theory to a health problem. First, morbidity and mortality rates for different A useful theory makes assumptions about diseases vary by race and ethnicity; second, a behavior, health problem, target there are differences in the prevalence of population, or environment that are: PART 1 risk behaviors among these groups; and Evaluation • Logical; third, the determinants of health behaviors • Consistent with everyday observations; vary across racial and ethnic groups. • Similar to those used in previous ChangeTheory Explanatory successful programs; and Problem Theory What People in the Field Say About Theory • Supported by past research in the same h strategies? Whic Behavior area or related ideas. Which messages? Why? or “Theory is different from most of the tools Assumptions about s more abstract, but I use in my work. It’ What can Situation 6 7 how a program that can be a plus too. A solid grounding be changed? should work Using Theor y to Address Health in a handful of theories goes a long way F O U N D A Issues in Diverse Populations toward helping me think through why I approach a health problem the way I do.” Planning T 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 The U.S. population is growing more — County Health Educator culturally and ethnically diverse. An increasing body of research shows health “I used to think theory was just for disparities exist among various ethnic and students and researchers. But now I have T H E O R Y AT A G L A N C E a better grasp of it; I appreciate how socio-economic groups. These findings practical it can be.” highlight the importance of understanding they have been applied in the past, the cultural backgrounds and life Because the social context in which — State Chronic Disease Administrator improves skills in this area. Selecting an experiences of community members, though behavior occurs is always evolving, theories appropriate theory or combination of research has not yet established when and that were important in public health “By translating concepts from theory theories helps take into account the multiple into real-world terms, I can get my staff under what circumstances targeted or education a generation ago may be of and community volunteers to take a closer factors that influence health behaviors. tailored health communications are more limited use today . At the same time, new we’re conducting programs look at why The practitioner who uses theory develops a effective than generic ones. (Targeting social science research allows theorists to they can succeed the way we do, and how nuanced understanding of realistic program involves using information about shared refine and adapt existing theories. A recent or fail.” 2 outcomes that drives the planning process. characteristics of a population subgroup to Institute of Medicine report observed that — City Tobacco Control Coordinator create a single intervention approach for several theorists have converged in their Choosing a theory that will bring a useful that group. In contrast, tailoring is a process views, identifying several variables as “A good grasp of theory is essential for perspective to the problem at hand does not that uses an assessment to derive central to behavior change. As a result, leadership. It gives you a broader way begin with a theory (e.g., the most familiar information about one specific person, and some constructs, such as self-efficacy, are of viewing your work. And it helps create , the theory mentioned in a recent theory then offers change or information strategies central to multiple theories. a vision for the future. But, of course, it’s journal article, etc.). Instead, this process for an outcome of interest based on that only worthwhile if I can translate it clearly 3 and simply to my co-workers.” starts with a thorough assessment of the person’s unique characteristics.) Effective practice depends on using situation: the units of analysis or change, theories and strategies that are appropriate — Regional Health Promotion Chief the topic, and the type of behavior to be Most health behavior theories can be to a situation. addressed. Because different theoretical applied to diverse cultural and ethnic “It’s not as hard as I thought it would be frameworks are appropriate and practical for groups, but health practitioners must to keep up with current theories. More One of the greatest challenges for those e are tools and than ever these days, ther different situations, selecting a theory that understand the characteristics of target concerned with behavior change is learning workshops to update us often.” “fits” should be a careful, deliberate process. populations (e.g., ethnicity, socioeconomic to analyze how well a theory or model “fits” Start with the steps in the box at the top of , age, and geographical status, gender a particular issue. A working knowledge of — Patient Education Coordinator the next page. location) to use these theories correctly. specific theories, and familiarity with how

10 PART 2 Part 2 Theories and Applications 9 T H E O R Y AT A G L A N C E

11 interactions with their physical and socio­ The Ecological Perspective: A An Ecological Perspective: Levels of Influence Table 1. cultural environments. Two key concepts Multilevel, Interactive Approach of the ecological perspective help to identify intervention points for promoting health: Concept Definition Contemporary health promotion involves first, behavior both affects, and is affected more than simply educating individuals Individual characteristics that influence behavior, such as Intrapersonal Level ; second, multiple levels of influence by, about healthy practices. It includes efforts PART 2 knowledge, attitudes, beliefs, and personality traits individual behavior both shapes, and is to change organizational behavior, as well shaped by, the social environment as the physical and social environment of Interpersonal Level Interpersonal processes and primary groups, including reciprocal causation ( ). 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 To explain the first key concept of the such as economic incentives. Health Community Level ecological perspective, multiple levels of promotion programs that seek to address 4 Institutional Factors influence, McLeroy and colleagues (1988) Rules, regulations, policies, and informal structures, which health problems across this spectrum may constrain or promote recommended behaviors identified five levels of influence for health- 10 employ a range of strategies, and operate 11 related behaviors and conditions. Defined on multiple levels. Social networks and norms, or standards, which exist as Community Factors in Table 1., these levels include: (1) T H E O R I E S A N D A P P L I C AT I O N S formal or informal among individuals, groups, and intrapersonal individual factors; (2) or emphasizes the ecological perspective The organizations institutional factors; (3) or interpersonal interaction between, and interdependence community organizational factors; (4) of, factors within and across all levels of a Local, state, and federal policies and laws that regulate Public Policy factors; and (5) factors. public policy or support healthy actions and practices for disease health problem. It highlights people’s prevention, early detection, control, and management T H E O R Y AT A G L A N C E A Multilevel Approach to Epidemiology Figure 2. unable to afford the fee. Thus, the outcome, In practice, addressing the community level the woman’s failure to get a mammogram, requires taking into consideration may result from multiple factors. institutional and public policy factors, as well Social and Economic Policies as social networks and norms. Figure 2. The second key concept of an ecological illustrates how different levels of influence Institutions perspective, reciprocal causation, suggests combine to affect population health. that people both influence, and are Neighborhoods and Communities influenced by, those around them. For Each level of influence can affect health e s r example, a man with high cholesterol may behavior. For example, suppose a woman Living Conditions u o find it hard to follow the diet his doctor has delays getting a recommended c e Social Relationships f prescribed because his company cafeteria mammogram (screening for breast cancer). i L To doesn’t offer healthy food choices. At the individual level, her inaction may be Individual Risk Factors comply with his doctor’s instructions, he can due to fears of finding out she has cancer. 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 neglect to tell her that she should get the the menu, or he can dine elsewhere. If he Pathophysiological test, or she may have friends who say they Pathways and enough of his fellow employees decide do not believe it is important to get a to find someplace else to eat, the cafeteria mammogram. At the organizational level, may change its menu to maintain lunch Individual/Population Health it may be hard to schedule an appointment, business. Thus, the cafeteria environment t n e because there is only a part-time radiologist may compel this man to change his dining m n o r i at the clinic. At the policy level, she may v habits, but his new habits may ultimately n E 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.

12 • The Stages of Change (Transtheoretical) In ensuing years, researchers expanded Community-level models offer frameworks An ecological perspective shows the Model describes individuals’ motivation upon this theory, eventually concluding that for implementing multi-dimensional advantages of multilevel interventions that and readiness to change a behavior. six main constructs influence people’s approaches to promote healthy behaviors. combine behavioral and environmental decisions about whether to take action to They supplement educational approaches components. For instance, effective • The Theory of Planned Behavior (TPB) prevent, screen for, and control illness. They with efforts to change the social and tobacco control programs often use 5 examines the relations between an argued that people are ready to act if they: physical environment to support positive multiple strategies to discourage smoking. PART 2 individual’s beliefs, attitudes, intentions, behavior change. Employee smoking cessation clinics have behavior, and perceived control over • Believe they are susceptible to the a stronger impact if the workplace has a that behavior. perceived susceptibility condition ( ) no-smoking policy and the city has a clean Individual or Intrapersonal Level indoor air ordinance. Adolescents are • Believe the condition has serious • The Precaution Adoption Process Model less likely to begin smoking if their The individual level is the most basic one ) consequences ( perceived severity (PAPM) names seven stages in an peers disapprove of the habit and laws in health promotion practice, so planners • Believe taking action would reduce their individual’s journey from awareness to prohibiting tobacco sales to minors must be able to explain and influence the susceptibility to the condition or its severity action. It begins with lack of awareness are strictly enforced. Health promotion behavior of individuals. Many health 12 13 ) ( perceived benefits and advances through subsequent stages programs are more effective when practitioners spend most of their work time of becoming aware, deciding whether planners consider multiple levels of in one-on-one activities such as counseling T H E O R I E S A N D A P P L I C AT I O N S perceived • Believe costs of taking action ( or not to act, acting, and maintaining influence on health problems. or patient education, and individuals are ) are outweighed by the benefits barriers the behavior. often the primary target audience for health • Are exposed to factors that prompt action education materials. Because individual Theoretical Explanations of Three (e.g., a television ad or a reminder from behavior is the fundamental unit of group Health Belief Model (HBM) Levels of Influence one’s physician to get a mammogram) behavior, individual-level behavior change The Health Belief Model (HBM) was one cue to action ) ( theories often comprise broader-level of the first theories of health behavior, and T H E O R Y AT A G L A N C E The next three sections examine models of group, organizational, community, remains one of the most widely recognized • Are confident in their ability to successfully theories and their applications at the and national behavior. Individuals participate in the field. It was developed in the 1950s perform an action ( ) self-efficacy individual (intrapersonal), interpersonal, in groups, manage organizations, elect and by a group of U.S. Public Health Service and community levels of the ecological appoint leaders, and legislate policy. Thus, social psychologists who wanted to explain perspective. At the individual and Since health motivation is its central focus, achieving policy and institutional change why so few people were participating in interpersonal levels, contemporary theories the HBM is a good fit for addressing requires influencing individuals. programs to prevent and detect disease. of health behavior can be broadly problem behaviors that evoke health For example, the Public Health Service was categorized as “Cognitive-Behavioral.” concerns (e.g., high-risk sexual behavior In addition to exploring behavior, individual- sending mobile X-ray units out to Three key concepts cut across and the possibility of contracting HIV). level theories focus on intrapersonal factors neighborhoods to offer free chest X-rays these theories: Together, the six constructs of the HBM (those existing or occurring within the (screening for tuberculosis). Despite the fact provide a useful framework for designing individual self or mind). Intrapersonal that this service was offered without charge 1. Behavior is mediated by cognitions; that both short-term and long-term behavior factors include knowledge, attitudes, in a variety of convenient locations, the is, what people know and think affects change strategies. (See Table 2.) When beliefs, motivation, self-concept, program was of limited success. The how they act. applying the HBM to planning health developmental history, past experience, question was, “Why?” programs, practitioners should ground their and skills. Individual-level theories are 2. Knowledge is necessary for, but not efforts in an understanding of how presented below. To find an answer, social psychologists sufficient to produce, most behavior susceptible the target population feels to the examined what was encouraging or changes. health problem, whether they believe it is • The Health Belief Model (HBM) addresses discouraging people from participating in serious, and whether they believe action the individual’s perceptions of the threat the programs. They theorized that people’s 3. Perceptions, motivations, skills, and can reduce the threat at an acceptable cost. posed by a health problem (susceptibility, beliefs about whether or not they were the social environment are key influences Attempting to effect changes in these factors severity), the benefits of avoiding the susceptible to disease, and their on behavior. is rarely as simple as it may appear. threat, and factors influencing the perceptions of the benefits of trying to decision to act (barriers, cues to action, avoid it, influenced their readiness to act. and self-efficacy).

13 of change. Nonetheless, the manner in Stages of Change (Transtheoretical) Model Health Belief Model Table 2. 6 which they pass through these stages may Developed by Prochaska and DiClemente, vary, depending on the type of behavior the Stages of Change Model evolved out change. For example, a person who is trying Potential Change Strategies of studies comparing the experiences of Concept Definition to give up smoking may experience the smokers who quit on their own with those • Define what populations(s) are at risk and Beliefs about the chances Perceived stages differently than someone who is of smokers receiving professional treatment. PART 2 their levels of risk of getting a condition susceptibility seeking to improve their dietary habits by The model’s basic premise is that behavior • Tailor risk information based on an eating more fruits and vegetables. change is a process, not an event. As a individual’s characteristics or behaviors person attempts to change a behavior, he • Help the individual develop an accurate perception of his or her own risk The Stages of Change Model has been or she moves through five stages: applied to a variety of individual behaviors, contemplation , precontemplation , • Specify the consequences of a condition Beliefs about the Perceived severity as well as to organizational change. The maintenance preparation , and action (see , and recommended action seriousness of a condition Model is circular, not linear. In other words, Table 3.). Definitions of the stages vary and its consequences people do not systematically progress from slightly, depending on the behavior at issue. 14 15 one stage to the next, ultimately • Explain how, where, and when to take People at different points along this Beliefs about the Perceived benefits action and what the potential positive effectiveness of taking “graduating” from the behavior change continuum have different informational T H E O R I E S A N D A P P L I C AT I O N S results will be action to reduce risk or process. Instead, they may enter the needs, and benefit from interventions seriousness change process at any stage, relapse to designed for their stage. an earlier stage, and begin the process • Offer reassurance, incentives, and Beliefs about the material Perceived barriers once more. They may cycle through this Whether individuals use self-management assistance; correct misinformation and psychological costs of taking action process repeatedly, and the process can methods or take part in professional truncate at any point. programs, they go through the same stages T H E O R Y AT A G L A N C E • Provide ”how to” information, promote Factors that activate Cues to action awareness, and employ reminder systems ”readiness to change” Stages of Change Model Table 3. • Provide training and guidance in Confidence in one’s ability Self-efficacy performing action to take action • Use progressive goal setting Potential Change Strategies Stage Definition • Give verbal reinforcement • Demonstrate desired behaviors Increase awareness of need for change; Precontemplation Has no intention of taking personalize information about risks action within the next and benefits six months High blood pressure screening campaigns often identify people who are at high risk for heart Motivate; encourage making specific plans Contemplation Intends to take action in 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 Assist with developing and implementing HBM can be useful for developing strategies to deal with noncompliance in such situations. Preparation Intends to take action concrete action plans; help set within the next thirty gradual goals days and has taken some According to the HBM, asymptomatic people may not follow a prescribed treatment regimen behavioral steps in unless they accept that, though they have no symptoms, they do in fact have hypertension this direction (perceived susceptibility). They must understand that hypertension can lead to heart attacks and strokes (perceived severity). Taking prescribed medication or following a recommended Assist with feedback, problem solving, Action Has changed behavior for weight loss program will reduce the risks (perceived benefits) without negative side effects social support, and reinforcement less than six months or excessive difficulty (perceived barriers). Print materials, reminder letters, or pill calendars might encourage people to consistently follow their doctors’ recommendations (cues to Assist with coping, reminders, finding Maintenance Has changed behavior for action). For those who have, in the past, had a hard time losing weight or maintaining alternatives, avoiding slips/relapses more than six months weight loss, a behavioral contract might help establish achievable, short-term goals to build (as applicable) confidence (self-efficacy).

14 7 situations, however. People’s perceptions a particular behavior. Azjen and Driver 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 PART 2 behavior if they feel they have a high 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 17 of contemplation potential program participants are in. For example: • Are you interested in trying to quit smoking? (Pre-contemplation) Measurement Approach T H E O R I E S A N D A P P L I C AT I O N S Definition Concept Are you thinking about quitting smoking soon? (Contemplation) • Are you likely or unlikely to Perceived likelihood of performing Behavioral intention Are you ready to plan how you will quit smoking? (Preparation) • (perform the behavior)? behavior Are you in the process of trying to quit smoking? (Action) • Do you see (the behavior) as Attitude Personal evaluation of the behavior • Are you trying to stay smoke-free? (Maintenance) good, neutral, or bad? T H E O R Y AT A G L A N C E The employees’ responses will help to pinpoint where the participants are on the Do you agree or disagree that Subjective norm Beliefs about whether key people continuum of change, and to tailor messages, strategies, and programs appropriate to most people approve approve or disapprove of the their needs. For example, individuals who enjoy smoking are not interested in trying to of/disapprove of (the behavior)? behavior; motivation to behave in a way that gains their approval quit, and therefore will not attend a smoking cessation clinic; for them, a more appropriate intervention might include educational interventions designed to move Do you believe (performing the Perceived behavioral Belief that one has, and can exercise, them out of the “precontemplation” stage and into “contemplation” (e.g., using carbon behavior) is up to you, or not control over performing the behavior control 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.” Surveillance data show that young, acculturated Hispanic women are more likely to get to the person approve or disapprove of the Theory of Planned Behavior (TPB) 8 A health department decides to Pap tests than those who are older and less acculturated. behavior ( ). The TPB and subjective norm The Theory of Planned Behavior (TPB) and implement a cervical cancer screening program targeting older Hispanic women. In TRA assume all other factors (e.g., culture, the associated Theory of Reasoned Action planning the campaign, practitioners want to conduct a survey to learn what beliefs, the environment) operate through the (TRA) explore the relationship between attitudes, and intentions in this population are associated with seeking a Pap test. They models’ constructs, and do not behavior and beliefs, attitudes, and design the survey to gauge: when the women received their last Pap test (behavior); how independently explain the likelihood that intentions. Both the TPB and the TRA likely they are to seek a Pap test (intention); attitudes about getting a Pap test (attitude); a person will behave a certain way. assume behavioral intention is the most whether or not “most people who are important to me” would want them to get a Pap important determinant of behavior. test (subjective norm); and whether or not getting a Pap test is something that is “under The TPB differs from the TRA in that it According to these models, behavioral my control” (perceived behavioral control). The department will compare survey results perceived includes one additional construct, intention is influenced by a person’s attitude with data about who has or has not received a Pap test to identify beliefs, attitudes, and ; this construct has to behavioral control toward performing a behavior, and by beliefs intentions that predict seeking one. do with people’s beliefs that they can control about whether individuals who are important

15 Theory of Reasoned Action and Theory of Planned Behavior Figure 4. Stages of the Precaution Adoption Process Model Figure 3. Behavioral : Stage 3 Stage 2 Stage 1 : : : Stage 5 beliefs Stage 7 : Stage 6 : Deciding Unengaged Unaware Decided Attitude toward PART 2 Acting Maintenance About of Issue by Issue to Act behavior Acting Evaluation of behavioral outcomes Stage 4 : Decided Normative Not to Act beliefs Behavioral Subjective Behavior intention norm 18 19 Motivation to comply T H E O R I E S A N D A P P L I C AT I O N S E C N A T A G L or may decide to act (Stage 5). The stages Interpersonal Level Control beliefs of action (Stage 6) and maintenance (Stage Perceived 7) follow. (See Figure 4.) According to the At the interpersonal level, theories of health behavioral control Y AR O E H PAPM, people pass through each stage of behavior assume individuals exist within, Perceived power precaution adoption without skipping any of and are influenced by, a social environment. Note: Upper blue section shows the Theory T them. It is possible for people to move of Reasoned Action; the entire figure The opinions, thoughts, behavior, advice, shows the Theory of Planned Behavior. backwards from some later stages to earlier and support of the people surrounding an ones, but once they have completed the first individual influence his or her feelings and two stages of the model they do not return behavior, and the individual has a reciprocal Figure 3. shows the TPB’s explanation for Precaution Adoption Process Model to them. For example, a person does not effect on those people. The social behavioral intention how determines The Precaution Adoption Process Model move from unawareness to awareness and environment includes family members, , behavior , and how attitude toward behavior (PAPM) specifies seven distinct stages in then back to unawareness. coworkers, friends, health professionals, subjective norm , and perceived behavioral the journey from lack of awareness to and others. Because it affects behavior, control influence behavioral intention . adoption and/or maintenance of a behavior. The PAPM bears similarities to the Stages the social environment also impacts health. According to the model, attitudes toward It is a relatively new model that has been of Change model, but differs in important Many theories focus at the interpersonal behavior are shaped by beliefs about what applied to an increasing number of health ways. Stages of Change offers insights for level, but this monograph highlights Social is entailed in performing the behavior and behaviors, including: osteoporosis addressing hard-to-change behaviors such Cognitive Theory (SCT). SCT is one of the outcomes of the behavior. Beliefs about prevention, colorectal cancer screening, as smoking or overeating; it is less helpful most frequently used and robust health social standards and motivation to comply mammography, hepatitis B vaccination, when dealing with hazards that have behavior theories. It explores the reciprocal . with those norms affect subjective norms and home testing for radon gas. recently been recognized or precautions interactions of people and their The presence or lack of things that will that are newly available. The PAPM environments, and the psychosocial make it easier or harder to perform the In the first stage of the PAPM, an individual recognizes that people who are unaware of determinants of health behavior. behavior affect perceived behavioral control . may be completely unaware of a hazard an issue, or are unengaged by it, face Thus, a causal chain of beliefs, attitudes, (e.g., radon exposure, the link between different barriers from those who have Social Cognitive Theory (SCT) and intentions drives . behavior unprotected sex and HIV). The person may decided not to act. The PAPM prompts Social Cognitive Theory (SCT) describes a subsequently become aware of the issue practitioners to develop intervention dynamic, ongoing process in which personal but remain unengaged by it (Stage 2). Next, strategies that take into account the stages factors, environmental factors, and human the person faces a decision about acting that precede active decision-making. behavior exert influence upon each other. (Stage 3); may decide not to act (Stage 4),

16 rather than through their own experience. describes According to SCT, three main factors affect Reciprocal determinism SCT evolved from research on Social Reinforcements are responses to behavior interactions between behavior, personal the likelihood that a person will change a Learning Theory (SLT), which asserts that affect whether or not one will repeat it. factors, and environment, where each that people learn not only from their own health behavior: (1) self-efficacy, (2) goals, Positive reinforcements (rewards) increase Behavioral capability and (3) outcome expectancies. If individuals influences the others. experiences, but by observing the actions a person’s likelihood of repeating the have a sense of personal agency or self- of others and the benefits of those actions. states that, to perform a behavior, a person behavior. Negative reinforcements may efficacy, they can change behaviors even must know what to do and how to do it. Bandura updated SLT, adding the construct PART 2 make repeated behavior more likely by Expectations when faced with obstacles. If they do not of self-efficacy and renaming it SCT. are the results an individual motivating the person to eliminate a anticipates from taking action. Bandura (Though SCT is the dominant version in feel that they can exercise control over their negative stimulus (e.g., when drivers put the self-efficacy the most important health behavior, they are not motivated to considers current practice, it is still sometimes called 9 key in the car’s ignition, the beeping alarm act, or to persist through challenges. personal factor in behavior change, and it SLT.) SCT integrates concepts and As a reminds them to fasten their seatbelt). processes from cognitive, behaviorist, is a nearly ubiquitous construct in health person adopts new behaviors, this causes or . external Reinforcements can be internal behavior theories. Strategies for increasing and emotional models of behavior change, changes in both the environment and in the Internal rewards are things people do to self-efficacy include: setting incremental so it includes many constructs. (See Table person. Behavior is not simply a product of reward themselves. External rewards (e.g., goals (e.g., exercising for 10 minutes each 5.) It has been used successfully as the the environment and the person, and 20 21 token incentives) encourage continued underlying theory for behavior change day); behavioral contracting (a formal environment is not simply a product of the 10 participation in multiple-session programs, in areas ranging from dietary change contract, with specified goals and rewards); person and behavior. T H E O R I E S A N D A P P L I C AT I O N S 11 but generally are not effective for sustaining and monitoring and reinforcement (feedback to pain control. long-term change because they do not from self-monitoring or record keeping). bolster a person’s own desire or commitment Observational learning , or modeling , refers to change. Figure 5. illustrates how self- Social Cognitive Theory Table 5. efficacy, environmental, and individual to the process whereby people learn through the experiences of credible others, factors impact behavior. T H E O R Y AT A G L A N C E Potential Change Strategies Definition Concept Consider multiple ways to promote Reciprocal The dynamic interaction of the An Intergrative Model Figure 5. behavior change, including making person, behavior, and the determinism adjustments to the environment or environment in which the influencing personal attitudes behavior is performed Promote mastery learning through Behavioral Knowledge and skill to perform skills training a given behavior capability Behavioral beliefs External variable and their Attitude Skills Model positive outcomes of Expectations Anticipated outcomes of evaluative aspects Demographic healthful behavior a behavior variables Approach behavior change in small Self-efficacy Confidence in one’s ability to steps to ensure success; be specific take action and overcome Attitudes toward Normative beliefs about the desired change barriers targets and motivation Behavior Norm Intention to comply Offer credible role models who Observational Behavioral acquisition that Personality traits perform the targeted behavior occurs by watching the actions learning (modeling) and outcomes of others’ behavior Other individual Environmental difference variables Self-efficacy Efficacy beliefs Promote self-initiated rewards Reinforcements Responses to a person’s constraints and incentives behavior that increase or decrease the likelihood of reoccurrence

17 networks social support and (exploring the The conceptual frameworks in this section influence of social relationships on health offer strategies for intervening at the A university in a rural area develops a church-based intervention to help congregation decision making and behavior) can be community level: members change their habits to meet cancer risk reduction guidelines (behavior). Many used to adapt community organizing members of the church have low incomes, are overweight, rarely exercise, eat foods that strategies to health education goals. • Community Organization and Other are high in sugar and fat, and are uninsured (personal factors). Because of their rural Social systems theory (exploring how emphasize Participatory Models location, they often must drive long distances to attend church, visit health clinics, or PART 2 organizations in a community interact with community-driven approaches to buy groceries (environment). each other and the outside world) is also assessing and solving health and useful for this purpose. social problems. 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 addresses • Diffusion of Innovations Theory 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 14 Rothman produced the best-known 22 23 to reward themselves by making time to relax (reinforcement). As church members learn to another. 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 T H E O R I E S A N D A P P L I C AT I O N S habits (reciprocal determinism). different types of communication affect to three general types: locality development, health behavior. social planning, and social action. These models sometimes overlap and can be combined. the community’s unique characteristics. Community Level Community Organization and Other This is particularly true when addressing Participatory Models (or community • Locality development health issues in ethnically or culturally T H E O R Y AT A G L A N C E Initiatives serving communities and Community organizing is a process through development) is process oriented. With the diverse communities. populations, not just individuals, are at which community groups are helped to aim of developing group identity and the heart of public health approaches to identify common problems, mobilize cohesion, it focuses on building consensus Comprehensive health promotion programs preventing and controlling disease. resources, and develop and implement and capacity. often use advocacy techniques to help Community-level models explore how strategies to reach collective goals. Strict support individual behavior change with social systems function and change and definitions of community organizing assume is task oriented. It stresses • Social planning organizational and regulatory change. In how to mobilize community members and that the community itself identifies the problem solving and usually relies heavily recent years, innovative tools and methods organizations. They offer strategies that problems to address (not an outside change on expert practitioners. for evaluation and measurement have been work in a variety of settings, such as health agent). Public health professionals often • Social action is both process and task developed to capture the successes of care institutions, schools, worksites, adapt the methods of community organizing 12 13 oriented. Its goals are to increase the community-level health promotion efforts. community groups, and government to launch programs that reflect the priorities community’s capacity to solve problems Tobacco control/smoking prevention is one agencies. Embodying an ecological of community members, but may not be and to achieve concrete changes that area where programs have been extensively perspective, community-level models initiated by them. Community organizing redress social injustices. evaluated. Local tobacco control initiatives address individual, group, institutional, projects that start with the community’s typically pursue four concurrent goals: (1) and community issues. priorities, rather than an externally imposed The different approaches broadly classified raising the priority of smoking as a health agenda, are more likely to succeed. as community organizing share in common concern, (2) helping community members to Communities are often understood in several concepts that are key to achieving change smoking behavior, (3) strengthening geographical terms, but they can be defined Community organizing is consistent with an and measuring change. (See Table 6.) legal and economic deterrents to smoking, by other criteria too. For instance, there are ecological perspective in that it recognizes describes a social action Empowerment and (4) reinforcing social norms that communities of shared interests (e.g., the multiple levels of a health problem. It can be process through which individuals, discourage smoking. This multi-level artists’ community) or collective identity integrated with SCT-based strategies that organizations, or communities gain approach has been proven very effective. (e.g., the African American community). take into account the dynamic between confidence and skills to improve their quality When planning community-level personal factors, environmental factors, 15 of life. Community capacity refers to interventions, it is critical to learn about social and human behavior. Theories of

18 In a social action approach to community is an essential tactic in Media Advocacy Community Organization Table 6. self-interest organizing, is seen as the community organizing. It involves using the mass media strategically to advance public motivation for action: community members 20 policies. become involved when they see that it will Because the media bring attention Potential Change Strategies Definition Term benefit them to take action, and targeted to specific issues, they set the agenda for the Community members assume Empowerment A social action process through institutions are willing to make changes public and policy makers. The media often PART 2 greater power, or expand their which people gain mastery over present health information in medical terms, when they believe it is in their self-interest power from within, to create their lives and their communities to do so. Community organizing seeks to focusing on technological breakthroughs and desired changes expand participants’ sense of self-interest personal health habits. Media advocacy Community members participate Community Characteristics of a community that to an ever-wider sphere, from the assumes the root of most health problems is actively in community life, gaining capacity affect its ability to identify, mobilize not that people lack information, but that they individual or family level to their block, leadership skills, social networks, around, and address problems 19 neighborhood, city, state, and so on. lack the power to change social and economic and access to power Participants grow through this process, conditions. It seeks to balance news coverage by framing issues to emphasize social, learning to take an active role in shaping Community members develop Participation Engagement of community 24 25 the future of their communities. economic, and political—rather than personal leadership skills, knowledge, and members as equal partners; reflects 21 resources through their the principle, “Never do for others and behavioral—influences on health. T H E O R I E S A N D A P P L I C AT I O N S involvement what they can do for themselves” Community members create Relevance Community organizing that ”starts their own agenda based on felt where the people are” Responding to high rates of cancer among African Americans, a health department needs, shared power, and wishes to increase consumption of fresh fruits and vegetables in a low-income, urban awareness of resources neighborhood. The department surveys community members to find out why they do T H E O R Y AT A G L A N C E Community members participate Issue selection Identifying immediate, specific, and not eat more fruits and vegetables. They learn there are few supermarkets within easy in identifying issues; targets are realizable targets for change that walking distance, and residents shop at local stores that do not offer fresh, affordable chosen as part of a larger strategy unify and build community strength produce. Many do not own cars; they must take the bus, spend money on taxis, or carry shopping bags for blocks to shop at the supermarket. Community members discuss the Critical Awareness of social, political, and root causes of problems and plan consciousness economic forces that contribute to actions to address them social problems The health department contacts a community-based organization that has been working to improve neighborhood conditions, and shares the findings with them (participation). The organization’s leaders invite department staff to attend a community meeting, where residents discuss why there are fewer supermarkets in low-income neighborhoods The social action model differs from other characteristics of a community that allow (critical consciousness). Residents say they would buy healthier, less expensive foods at forms of community intervention in that it it to identify social problems and address the supermarket if they could get a ride home (relevance). The community organization is grassroots based, conflict oriented, and them (e.g., trusting relationships between decides to organize a campaign to convince the local supermarket to start a shuttle geared to mobilizing disadvantaged people neighbors, civic engagement). Participation service (issue selection). 16 to act on their own behalf. Goals vary, but in the organizing process helps community typically include policy and other significant members to gain leadership and problem- The health department trains residents to assess the potential cost and ridership of the changes that participants have identified as Relevance involves activating solving skills. shuttle service (community capacity). Residents plan an event and invite the media. important. Largely based on the organizing participants to address issues that are They line up in front of the supermarket with shopping carts and signs, and explain work of Saul Alinsky and the Industrial Areas Issue selection entails important to them. both the problem and the potential solution to reporters (media advocacy). Stories 17 Foundation, this approach employs direct- pulling apart a web of interrelated problems appear in the local newspapers. The supermarket’s management meets with community action strategies as the primary means of into distinct, immediate, solvable pieces. residents and tells them the market loses thousands of dollars each year due to stolen fostering change. It focuses on building emphasizes helping Critical consciousness shopping carts. Residents explain that the store will have fewer shopping cart losses if power and encouraging community community members to identify the root they start a shuttle (self-interest). The supermarket agrees to give free rides to inner-city members to develop their capacities causes of social problems. shoppers. Through their success, residents gain skills and confidence, and are inspired 18 as active citizens. to think about other ways to strengthen their community (empowerment).

19 population health until effective programs the costs and benefits of each choice. They In participatory action research, the people Guide to The CDC Task Force on the are broadly diffused and disseminated. engage in a learning process, both checking Community and Preventive Services created who are being studied take an active role Multiple critiques, including one by the and complementing expert knowledge. One an organizing logic framework to illustrate in some or all phases of the research. National Cancer Policy Board, suggest that example of participatory action research is how community-level factors influence health Participatory research builds an alliance failing to implement proven methods of the NCI’s COMMIT program, which explored status. (See Figure 6.) They noted that between professional researchers and cancer prevention and early detection whether implementing an intervention disparities in access to health care; behaviors lay participants, and enables a dialogue PART 2 22 results in tens of thousands of premature through community organizations would between them. in response to illness; exposure to When planning and 26 deaths each year. result in a higher “quit rate” among heavy environmental and occupational hazards; implementing health programs, the Diffusion expands the smokers than in the comparison health promotion and disease prevention program’s beneficiaries help to direct the number of people who are exposed to and 2324 communities. behaviors; and experience of stress, societal type of inquiry, collect and analyze data, reached by successful interventions, support, and social cohesion all contribute imagine possible solutions, and evaluate 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 how ideas, products, and social practices neighborhood conditions, employment 26 27 that are perceived as “new” spread opportunities, behavioral norms, opportunities 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, IMMEDIATE OUTCOMES HEALTH OUTCOME DETERMINANTS 25 key to addressing health disparities. The diffusion of innovations is “the process by model shows elements and associations is communicated which an innovation * 1 EQUITY and Neighborhood Living at play in translating theory into research among time over through certain channels SOCIAL JUSTICE Conditions 27 and action. the members of a social system .” Diffusion Theory has been used to study the adoption T H E O R Y AT A G L A N C E of a wide range of health behaviors and Diffusion of Innovations SOCIETAL 2 Community Development and RESOURCES programs, including condom use, smoking In public health and health promotion, Employment Opportunities cessation, and use of new tests and practitioners who want to make efficient use Standard of living technologies by health practitioners. of resources must attend to the reach, Culture and history Table 7. defines concepts that are central adoption, implementation, and maintenance Social institutions Civic Engagement and 3 Built environments to this theory. of programs. It is not enough to develop Participation in Political structures Decision-Making innovative programs; to reduce the burden of Economic systems HEALTHIER cancer, these programs must be disseminated Diffusion of innovations that prevent disease Technology COMMUNITIES widely. Cancer control measures will not and promote health requires a multilevel 4 Prevaling Community Norms, change process that usually takes place in realize their full potential for improving Customs, and Processes PHYSICAL ENVIROMNMENT Concepts in Diffusion of Innovations Table 7. Natural Resources 5 Opportunities for Education and Developing Capacity Definition Concept SOCIETAL RESOURCES concerns the presence HEALTHY Innovation An idea, object, or practice that is thought to be new by an 6 of essential resources POPULATION Health Promotion, Prevention, while EQUITY and individual, organization, or community and Care Opportunities SOCIAL JUSTICE concerns the distribution Communication channels The means of transmitting the new idea from one person to another *Links 1-6 indicate strategic of those resources points for intervention within the population Social system A group of individuals who together adopt the innovation A pathway that will not be examined Time How long it takes to adopt the innovation Source: Institute of Medicine. Speaking of Health: Assessing Health Communications Strategies for Diverse Populations. Washington, D.C.: National Academies Press, 2002.

20 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 institutionalized . that it will be adopted and education curriculum, and it encourages physical activity through a physical education PART 2 level, diffusion can include using the media, Communication usually should include both 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 adolescence than those who did not go through the program. According to Rogers, a number of factors , two-step flow of communication Through the determine how quickly, and to what extent, information from the media moves in two The fact that the program is successful is not enough to ensure it will change elementary an innovation will be adopted and diffused. stages. First, opinion leaders, who pay school practices. To achieve a broader impact, the program must diffuse to other sites. By considering the benefits of an innovation close attention to the media, receive the relative advantage Program planners may seek to demonstrate the of the program by (see Table 8.), practitioners can position it information. Second, they convey their own by emphasizing its positive outcomes. They may try to show its compatibility effectively, thereby maximizing its appeal. interpretations, as well as the media content, 28 29 demonstrating that state policy-makers (e.g., the state Board of Education) have to others. This process highlights the can be limited by creating user-friendly approved its materials. The program’s complexity Specifically: value of social networks for influencing T H E O R I E S A N D A P P L I C AT I O N S materials for teachers and cafeteria workers. By making the materials available on a adoption decisions. Web site, they can enhance its . Professional demonstrations of the program trialability of an innovation relative advantage • The . 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 innovators , early adopters , early adopters: • Compatibility is an appropriate fit with the majority adopters , and , late majority adopters Public health communications should characteristics of people in each adopter T H E O R Y AT A G L A N C E intended audience. laggards . When an innovation is introduced, represent an ecological perspective and category, practitioners can more effectively has to do with how easy it is • Complexity the majority of people will either be early foster multilevel strategies, such as tailored plan and implement strategies that are to implement the innovation. majority adopters or late majority adopters; messages at the individual level, targeted customized to their needs. fewer will be early adopters or laggards; and messages at the group level, social marking • Trialability pertains to whether it can be very few will be innovators (the first people to at the community level, media advocacy at Communication Theory tried on an experimental basis. use the innovation). By identifying the the policy level, and mass media campaigns Communication theory explores “who says • Observability reflects whether the 29 at the population level. Public health what, in which channels, to whom, and with innovation will produce tangible results. communications can increase knowledge what effects.” It investigates how messages and awareness of a health issue; influence are created, transmitted, received, and perceptions, beliefs, and attitudes that assimilated. When applied to public health Table 8. Key Attributes Affecting the Speed and Extent of an Innovation’s Diffusion factor into social norms; prompt action; problems, the central question theories of demonstrate or illustrate healthy skills; communication seek to answer is, “How do increase support for services; debunk communication processes contribute to, or Attribute Key Question misconceptions; and strengthen discourage, behavior change?” Focused on 30 organizational relations. On the other improving the health of communities rather Is the innovation better than what it will replace? Relative advantage hand, without supports in the social and than examining the underlying processes of Does the innovation fit with the intended audience? Compatibility physical environment, health communications communication, public health communications alone may not be enough to sustain is the scientific development, strategic Is the innovation easy to use? Complexity individual-level behavior changes, may dissemination, and evaluation of relevant, not be effective for relaying complex accurate, accessible, and understandable Can the innovation be tried before making a decision to adopt? Trialability health messages, and cannot compensate health information, communicated to and for lack of access to health care or from intended audiences to advance the Are the results of the innovation observable and easily measurable? Observability 31 28 healthy environments. public’s health.

21 important. In other words, they tell the social networks can also generate excitement has been on how the mass media influence Since other communication strategies are to think about, but what audience not only about some messages, depending on discussed elsewhere in this monograph, this public opinion, especially about politics and 33 how to think about it. The way facts are their content. Agenda setting policymaking. section examines the role of mass media in involves setting packaged to tell a story creates the frame. public health interventions. The media are the media agenda (what is covered), the By framing stories to emphasize social and interconnected, large-scale organizations public agenda (what people think about), and How often do people need to hear a message environmental factors that affect health, that gather, process, and disseminate news, the policy agenda (regulatory or legislative before it influences their beliefs or behaviors? PART 2 36 public health advocates can use the media information, entertainment, and advertising actions on issues). This depends on several factors. (See Table 9.) Research to pressure decision makers to develop worldwide. Whether they are small Characteristics of target audiences (e.g., on agenda setting has shown that the amount and support healthy policies. operations, such as a neighborhood their readiness for change, the ways they of media coverage an issue receives 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 exposure to a health message and an mass media may not tell us what to think, but opened an extraordinary range of avenues 30 31 outcome effect. Repeated exposure to a they are surprisingly effective in telling us for influencing health behavior. “E-health” Media Effects message, especially when it is delivered what to think about . A critical construct of (one element of new communication The outcomes of media dissemination of T H E O R I E S A N D A P P L I C AT I O N S through multiple channels, may intensify agenda setting, however, reinterprets this technologies) is the use of emerging ideas, images, themes, and stories are 34 its impact on audience members. idea. is a process in which someone Framing information and communication technology, . Media effects research media effects termed tells the audience what aspect of the story is especially the Internet, to improve or enable investigates not only how the media influence 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 T H E O R Y AT A G L A N C E 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 Potential Change Strategies Definition Concept transmitted through the media reflects their possible paths through which a health needs, interests, and preferences. Two communications message can influence Understand media professionals’ Institutional factors and Media agenda setting needs and routines for gathering processes influencing how questions are central to understanding the someone’s beliefs and/or behaviors. These and reporting news the media define, select, and effects of media on audience members: 1) (people learn immediate learning include 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 Use media advocacy or The link between issues Public agenda setting 2) How do media effects vary with the until some time after it has been conveyed), partnerships to raise public covered in the media and the 32 awareness of key health issues public’s priorities amount of exposure to that message? (in addition to the generalized learning message itself, people are persuaded about social concepts related to the message), Funding is a primary factor that determines Advocate for media coverage to The link between issues Policy agenda setting (messages stimulate discussion diffusion whether or not audience members will be educate and pressure policy covered in the media and among social groups, thereby affecting exposed to a message through the mass makers about changes to the the legislative priorities of institutional diffusion (messages beliefs), and media, since money is needed to buy media physical and social environment policy makers needed to promote health instigate a response from public institutions time and space. Many public health programs that reinforces the message’s impact on the do not have large budgets, so they often must Community leaders, advocacy Factors and process leading to Problem definition 35 target audience.) rely on strategies for free distribution. Options groups, and organizations define the identification of an issue may include public service announcements, an issue for the media and as a “problem” by social embedding health messages in entertainment Agenda Setting offer solutions institutions programs (e.g., soap operas), or promoting The mass media can illuminate and focus Advocacy groups “package” an Selecting and emphasizing Framing news coverage of public health topics in print attention on issues, helping to generate important health issue for the certain aspects of a story and and electronic media. Community institutions public awareness and momentum for change. media and the public excluding others can adopt and disseminate messages, and A major focus of communications research

22 43 Not all e-health interventions are Web-based. (see Figure 7.). Community organizing approaches have health and health care. The term refers to an The games were based Computer applications have also allowed new been used to coordinate Internet-based emerging field in the intersection of medical on well-established theories of learning and 37 uses of traditional health communications www.Meetup.com campaigns through behavior change, such as Social Cognitive informatics, public health, and business. media, such as print and telephone. Tailored (a technology platform that helps people Theory. They reduced players’ urgent care It bridges clinical and non-clinical sectors, print communications (TPCs) and telephone- self-organize local gatherings). and emergency medical visits by as much and includes both individual and population 44 38 delivered interventions (TDIs) are two as 77 percent. health-oriented tools. Though research has E-health PART 2 examples that have the potential for reaching Innovative e-health projects are expanding communication strategies include, but are demonstrated the effectiveness of some linguistically and culturally diverse audiences. the range of tools that planners can use to new communications technologies, further not limited to: health information on the TPCs are printed materials created especially develop cancer control and other Internet, online support groups, online inquiry is needed into the mechanisms’ 45 for an individual, based on relevant interventions. For instance, NCI’s Cancer collaborative communities, information underlying success. information about that person. Over 40 studies Control Planet http://cancercontrolplanet. tailored by computer technologies, of TPCs have been conducted on a wide cancer.gov/ links public health professionals to educational computer games, computer- Opportunities are increasing for people to range of health topics, including diet, exercise, comprehensive cancer control resources. NCI controlled in-home telephone counseling, gain free access to the Internet via libraries 39 46 smoking cessation, mammography, and also has published data from its Health and patient-provider e-mail contact. and kiosks. Unequal access remains 32 33 prostate cancer; most have found positive Information National Trends Survey (HINTS) problematic, however. Significant gaps in outcomes evidence. TDIs include a range on the Web at http://cancercontrol.cancer.gov/ Internet usage between Caucasians, African Major benefits of e-health strategies are T H E O R I E S A N D A P P L I C AT I O N S 47 of human-delivered counseling and reminder . The HINTS program helps survey hints/ Americans, and Hispanics persist, increased reach (the ability to communicate and interventions delivered using the telephone researchers, program planners, and social to broad, geographically dispersed people with lower levels of educational and computer-generated voice response scientists understand how adults 18 years audiences), asynchronous communication attainment are also less likely to have systems. Studies indicate that TDIs are and older are using different communication (interaction not bounded by having to Internet access. Because the Internet is effective across different populations and channels, including the Internet. For example, communicate at the same time) the ability a text-based medium, literacy issues that health topics, but do not have a broad-based according to recent HINTS data, when asked to integrate multiple communication modes make it difficult for people to read print T H E O R Y AT A G L A N C E reach. They have not been widely used by where they would go first if they had a strong and formats (e.g., audio, video, text, materials are also barriers to accessing 42 diverse populations. need to get information about cancer, 34 graphics), the ability to track, preserve, and Web-based information. There is danger percent of respondents said they would go analyze communication (computer records that new computer technologies could to the Internet. of interaction, analysis of interaction trends), worsen existing inequities in health status Interactive games offer another vehicle for user control of the communication system for diverse populations. It is therefore intervention. Lieberman et al. designed a The HINTS data illustrate consumers’ (the ability to customize programs to user important to involve community members in series of Nintendo video games to improve increasing reliance on the Internet as an specifications), and interactivity (e.g., planning e-health interventions and to offer children’s and adolescents’ prevention and 40 easily accessible source of health information. increased capacity for feedback). them ongoing training and support for using self care behaviors for asthma, diabetes, 48 The Internet has been characterized as a these emerging communications tools. smoking prevention, and other health topics “hybrid technology” because it has the Educational and behavioral interventions potential to reach millions of people with employing new communication technologies Figure 7. information that can be tailored to individual are forging new ground and therefore benefit 41 needs and preferences. from the perspective provided by theories E-health An Asthma Self-Management of health behavior. Like communications in interventions frequently offer information, Video Game for Children other media, e-health interventions can education, and support directly to consumers. (Bronkie the Bronchiasaurus) address issues at the individual, group, or For example, the Association of Online 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. http://www.acor.org/ week ( ). 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.

23 PART 3 Putting Theory And Practice Together Part 3 35 T H E O R Y AT A G L A N C E

24 planning, implementation, and evaluation members and develops strategies and Alan Andreason defines it as “the Planning Models phases. During program planning, they methods accordingly. The four Ps of the application of commercial marketing explore the needs and resources of the marketing mix are: technologies to the analysis, planning, When practitioners begin the process of population and learn how to design effective execution, and evaluation of programs planning an intervention to promote health materials and strategies. During • Product (the right kind of behavioral designed to influence the voluntary behavior or change health behavior, theory helps implementation, they seek to build and change) includes not only the behavior of target audiences in order to improve their them interpret the situation and guides their PART 3 49 continually improve the program. After it that is being promoted, but also the personal welfare and that of society.” decisions about what design, procedures, ends, they assess what short-term and long- benefits that go along with it. voluntary exchange This process creates a and measurement indicators to select. term effects the program has had on the between a marketing organization and Depending on the unit of practice (e.g., • Price (an exchange of benefits and costs) health problem and its contributing factors. members of a target audience based on individuals, groups, organizations, refers to barriers or costs involved in mutual fulfillment of self-interest. In other community) and the nature of the health adopting the behavior (e.g., money, Both social marketing and the PRECEDE­ words, the marketing organization exists problem, different theoretical approaches time, effort). PROCEED model instruct the practitioner to fulfill its mission (as defined by the may be appropriate. Practitioners can find (making new behaviors easy to do) • Place to begin the planning process by assessing organization’s leadership), and the target that using more than one theory to address 36 37 is about making the “product” accessible the target audience’s needs at multiple audience members act in their own interests. a problem produces a stronger impact. and convenient. It means delivering levels of a health problem. In social This is particularly true when planning P U T T I N G T H E O R Y A N D P R A C T I C E T O G E T H E R benefits in the right place at the right time. marketing, this preliminary investigation Social marketing programs are generally comprehensive health promotion involves conducting consumer research and “consumer-driven,” not expert-driven. They programs that address multiple levels (delivering the message to the • Promotion market analysis. In PRECEDE-PROCEED, are targeted to serve a defined group of (e.g., individual, organizational, community) audience) is how the practitioner notifies it includes carrying out epidemiological people. To avoid delineating the target of a health problem. the target market of the product, as well assessment; behavioral, educational, market in an overly broad manner, social as its benefits, reasonable cost, environmental, and organizational marketing practitioners segment a larger, Planning models, such as PRECEDE­ T H E O R Y AT A G L A N C E and convenience. diagnosis; and administrative and policy heterogeneous target market into smaller PROCEED and social marketing, help Ideally, social marketing interventions begin assessment. Both planning models combine is the Market segmentation subgroups. practitioners develop programs step by step, (also called formative research with behavior change theories for greater impact process of dividing a target audience into integrating multiple theories to explain and audience or consumer research) to and use them as a basis for evaluation. these more homogenous subgroups with address health problems. Practitioners understand the target market’s perceptions, These planning models are described in distinct, unifying characteristics and needs. begin by using theory to develop a set of needs, and wants concerning the health greater detail in the sections that follow. For example, factors such as regional assumptions about factors contributing to a behavior. Formative research includes location, ethnicity, gender, exercise habits, health problem. They then use research to learning about consumers’ current behavior, readiness for change, or media habits could Social Marketing test, adjust, and add to these assumptions. what enables it, and what reinforces it. be used to segment the larger audience uses marketing techniques Social marketing Armed with a theoretical framework and Practitioners also conduct a second type of of “smokers.” Social marketing seeks to to influence the voluntary behavior of target situation-specific research findings, (also called competitive analysis research, identify patterns that distinguish one target audience members for health benefit. It practitioners design a targeted intervention environmental analysis), to learn about the group from another to effectively target is distinct from health education in that it strategy. This includes designing an environment in which members of the target marketing strategies. goes beyond informing or persuading evaluation to gauge whether or not the market are making behavior decisions. people to reinforcing behavior with approach is effective, and choosing realistic, This analysis examines competing The social marketing process involves incentives and other benefits. It also differs actionable goals that define in advance behaviors that are being promoted to the identifying an effective “marketing mix” from commercial marketing because the what programmatic success will look like. target market. (For example, messages (“The four Ps”) of product, price, place, people who gain from it are members of the encouraging people to eat convenient, and promotion. The optimal marketing mix target audience. Another difference is that Research (into the needs of the population, inexpensive fast foods compete with produces a timely exchange that heightens the marketing organization defines success resources available, and the situation in messages about eating 5 fruits and benefits, reduces barriers, and offers a in terms of positive effects on society. which the health problem occurs) is a vegetables a day.) It also investigates how better choice than the competition. The central feature of comprehensive planning consumers’ decisions are shaped by social marketer explores what benefits Social marketing is not a theory, but an models. Theory helps planners think about factors such as their social and physical are of most interest to target market approach to promoting health behavior. what questions to ask throughout program surroundings or their economic situation.

25 As an approach that promotes behavior compares the program’s program objectives Evaluation is a critical and ongoing preparing them, psychological cost of change through voluntary exchange and with its immediate and long-term outcomes component of social marketing programs. “worrying” about getting the recommended positive reinforcement, social marketing to determine what worked, what didn’t, and Formative research helps practitioners to number of servings) borrows substantively from behavior change whether the program was cost-effective. develop and refine concepts, messages, theory. Behavioral theory offers insights products, services, pricing, and distribution Grocery stores and other points • Place: into the current behavior of target market Social marketing programs are most channels before they are fully implemented. of purchase (the 5 A Day message and PART 3 members and what might influence or successful when they are implemented Marketers often use qualitative methods, healthy foods compete against unhealthy change that behavior. For example, a social using a research-driven process; then such as focus groups or key informant products for space and attention) marketer who references Social Cognitive consumer research can help to adjust interviews, to pre-test marketing concepts, Theory might examine how self-efficacy program messages and outputs. The social messages, and materials in a cost-effective • Promotion: Branding the 5 A Day and expectations about the outcome of a marketing process includes four stages: manner. They may also pilot-test materials campaign to increase awareness (e.g., behavior factor into certain health practices planning and strategy development; with individuals who share characteristics using a slogan and compelling images within a target market. development of pretesting concepts, of the target market in order to verify their that are easy to recall) messages, and materials; implementation; effectiveness, identify diverse channels 38 39 The California 5 A Day Campaign, which assessment of in-market effectiveness; for delivering the message, and measure Distribution channels include mass media was the model for the national 5 A Day and feedback to the first stage. (See outcomes. Process evaluation methods are P U T T I N G T H E O R Y A N D P R A C T I C E T O G E T H E R advertising, public service announcements, 50 program, Figure 8.) Within each stage, there is a used to track program outputs and processes employs social marketing to newsletters, the Internet, magazines, press constant feedback loop between research during implementation. Social marketers also increase Californians’ consumption of conferences, outreach activities, special and planning. conduct summative research, often in the fruit and vegetables through strategies events, and community-based groups, such form of outcomes monitoring. This analysis such as supermarket point-of-purchase as churches. Regular monitoring and interventions, industry promotional support, evaluation help to assess the reach and 51 media outreach, and community programs. T H E O R Y AT A G L A N C E impact of messages; efficient use of time, Social Marketing Wheel Figure 8. Several features of this program have been labor, and capital resources; and program 52 well-received. First, it has a focused goal: costs/benefits. to increase fruit and vegetable consumption by raising awareness of the health benefits. PRECEDE-PROCEED Second, its approach is built on an PRECEDE-PROCEED is a planning model, established theoretical framework—the Planning and not a theory. It does not predict or explain Stages of Change model. Third, messages Strategy factors linked to the outcomes of interest, 1 Development were designed and disseminated using but offers a framework for identifying consumer-driven communications Developing intervention strategies to address these strategies. Fourth, formative research (mall and Pretesting factors. Developed by Green, Kreuter, intercept interviews, focus groups, and Concepts, 53 and associates, PRECEDE-PROCEED Messages, baseline survey data) helped the planners provides a road map for designing health 4 and Materials to understand their audiences and improve education and health promotion programs. Assesing messages. Lastly, the program uses the It guides planners through a process that Effectiveness four Ps of social marketing: and Making starts with desired outcomes and works 2 Refinements 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 of cancer and improve health status Implementing the Program 3 Because the model views health behavior The costs of eating a healthier diet • Price: as influenced by both individual and (e.g., financial cost of buying fruits and environmental forces, it has two distinct vegetables, time cost of shopping for and parts: an “educational diagnosis”

26 , which enable persons to • Enabling factors During the diagnostic steps of the model, components of the model help practitioners (PRECEDE) and an “ecological diagnosis” act on their predispositions; these factors practitioners employ various methods to plan programs that exemplify an (PROCEED). The PRECEDE acronym include available resources, supportive learn about the community’s perceived and ecological perspective. stands for Predisposing, Reinforcing, policies, assistance, and services. actual needs, as well as the regulatory Enabling Constructs in Educational/ context in which the intervention will PRECEDE-PROCEED has nine steps. The Environmental Diagnosis and Evaluation. • Reinforcing factors , which come into play operate. To conduct social assessment , the first five steps are diagnostic, addressing Developed in the 1970s, this component PART 3 after a behavior has been initiated; they practitioner may use multiple data collection both educational and environmental issues. of the model posits that an educational encourage repetition or persistence of activities (e.g., key informant interviews, These include: (1) social assessment, (2) diagnosis is needed to design a health behaviors by providing continuing rewards focus groups, participant observation, epidemiological assessment, (3) behavioral promotion intervention, just as a medical or incentives. Social support, praise, surveys) to understand the community’s and environmental assessment, (4) diagnosis is needed to design a treatment reassurance, and symptom relief might all perceived needs. Epidemiological educational and ecological assessment, and plan. PROCEDE stands for Policy, be considered reinforcing factors. may include secondary data assessment (5) administrative and policy assessment. Regulatory, and Organizational Constructs analysis or original data collection to The last four comprise implementation and in Educational and Environmental prioritize the community’s health needs and evaluation of health promotion intervention. Development. This element was added 40 41 In the final diagnostic step of PRECEDE­ establish program goals and objectives. These include: (6) implementation, (7) to the framework later, in 1991, to take PROCEED, Administrative and Policy Behavioral and Environmental Assessment process evaluation, (8) impact evaluation, into account the impact of environmental P U T T I N G T H E O R Y A N D P R A C T I C E T O G E T H E R , intervention strategies reflect Assessment identifies factors, both internal and external and (9) outcome evaluation. (See Figure 9.) factors on health. Together, these two information gathered in previous steps; to the individual, that affect the health the availability of needed resources; and problem. Reviewing the literature and organizational policies and regulations applying theory are two ways to map out that could affect program implementation. The PRECEDE-PROCEED Model Figure 9. these factors. (See Table 10.) T H E O R Y AT A G L A N C E , Educational and Ecological Assessment In PRECEDE The four remaining steps of PRECEDE­ the practitioner identifies antecedent and PROCEED comprise program reinforcing factors that must be in place to STEP 1 STEP 4 STEP 3 STEP 2 STEP 5 implementation and evaluation. Before Educational and Administration Behavioral and Social Epidemiological initiate and sustain change. Behavior—such (Step 6) begins, Implementation Ecological Assessment and Policy Assessment Environmental as reducing intake of dietary fat, engaging Diagnosis Assessment Assessment practitioners should prepare plans for in routine physical activity, and obtaining evaluating the process (Step 7), impact annual mammograms—is shaped by (Step 8), and outcome (Step 9) of the Predisposing predisposing, reinforcing, and enabling Health factors gauges the intervention. Process Evaluation factors. Practitioners can use individual, Promotion extent to which a program is being carried interpersonal, or community-level change Impact Evaluation out according to plan. theories to classify determinants of behavior looks at changes in factors (i.e., Behavior and Health Reinforcing into one of these three categories and rank lifestyle education factors predisposing, enabling, and reinforcing their importance. Because each type of Quality factors) that influence the likelihood that Health factor requires different intervention of life behavioral and environmental change will Policy strategies, classifying them helps occur. Lastly, looks at outcome evaluation Enabling regulation Environment practitioners consider how to address organization factors whether the intervention has affected health community needs. The three types of and quality-of-life indicators. influencing factors include: STEP 9 STEP 8 STEP 7 STEP 6 As Table 11 shows, the individual, Process Implementation Impact Outcome • Predisposing factors , which motivate or Evaluation Evaluation Evaluation interpersonal, and community-level theories provide a reason for behavior; they include discussed in this monograph are most knowledge, attitudes, cultural beliefs, and useful when applied to PRECEDE- readiness to change. PROCEED PROCEED’s diagnostic steps. Community Source: Green LW, Kreuter MW, 1999.

27 To make appropriate use of theory in a reassurance that they do not have cancer Theory should guide practitioners’ exam­ organization relates to Step 1, which may given situation, practitioners must consider (perceived benefit) might be a reinforcing ination of predisposing, enabling, and entail working with communities to identify both the social or health problem at hand factor. Lack of insurance coverage for reinforcing factors. For example, the Health their own needs, strengths, resources, and and the context in which the intervention screening mammography (perceived Belief Model suggests that certain beliefs capacities. Descriptive epidemiology is most will take place. Once they have identified barrier) could be a negative enabling factor. might influence women’s decisions about pertinent to Step 2, but community-level a problem, they can use a planning system whether or not to get a mammogram, such theories may be relevant if the community PART 3 such as social marketing or PRECEDE­ By exploring the degree to which each of as perceived chances of developing cancer helps to choose the health problem that will PROCEED to identify social science these factors affects women’s behaviors, (perceived susceptibility), or how serious be addressed, or to set priorities among theories that contribute to their program planners can decide how to focus they believe cancer would be (perceived health problems. Theory is most directly understanding. These theories can guide program messages for a communications severity). Both beliefs constitute useful when applied to steps 3, 4, and 5, them to potential points of intervention. campaign or strategies for an administrative predisposing factors. Other HBM constructs since these steps call upon the practitioner Consulting the research literature helps intervention (such as providing low- or no- may identify possible perceived benefits of to make strategic decisions. By using theory, practitioners to learn about the past cost screening or changing insurance and barriers to screening. Receiving the practitioner can make sound choices successes or failures of intervention coverage). The best way to verify and rank that are based upon more than just intuition 42 43 strategies that they consider, and reflect explanations offered by theory is to gather and personal judgment. on whether those strategies are likely to information directly from women in the P U T T I N G T H E O R Y A N D P R A C T I C E T O G E T H E R work for the current situation. Pre-testing target population. Another, less ideal approach is to learn by reading research and actively discussing proposed Table 10. Diagnostic Elements of PRECEDE-PROCEED literature on women who share strategies with the target audience can also help to determine whether or not they characteristics with the target population. Examples of Relevant Theory Planning Step Function will be well received. Where to Begin: Choosing the T H E O R Y AT A G L A N C E Community organization 1. Social Assessment Assesses people’s views of Table 11. summarizes the focus and key Right Theories their own needs and quality concepts of each of the eight theories Community building of life described in this guide. Refer to this table Interventions that evolve from a Community-level theories Documents which health 2. Epidemiological to identify theories that help explain and comprehensive planning process, build (If the community helps to problems are most important Assessment address a health problem. For example, on prior research, and use health behavior choose the health problem that for which groups in a several theories could be used to inform the theories are more likely to be effective. will be addressed) community design of a program to reduce tobacco use By investigating what factors influence Interpersonal theories Identifies factors that among adolescents. By scanning the 3. Behavioral/ the target population’s behavior, including - Social Cognitive Theory contribute to the health Environmental “Focus” column, one can quickly gauge their social and physical environments, problem of interest Assessment which theories might apply to a particular practitioners gain the raw materials they Theories of organizational change situation. For example, The Stages of need to meet the needs of that population. Change model might be very useful, since it Community organization Theory helps practitioners to interpret the centers on individuals’ readiness to change. findings of their research, making the leap Diffusion of innovations On the other hand, the Health Belief Model from facts on a page to understanding the seems less promising, since young people dynamic interactions between behavior All three levels of change theories: Identifies preceding and 4. Educational/ may be less concerned about long-term and environmental context. Systematic - Individual reinforcing factors that must Ecological health problems. (In fact, they may not feel approaches to tailoring, targeting, - Interpersonal be in place to initiate and Assessment vulnerable to disease at all!) Social - Community sustain change implementing, and evaluating programs Cognitive Theory could be helpful because it provide practitioners with a framework for Community-level theories: Identifies policies, resources, Administrative/ 5. emphasizes the interplay between personal, translating this insight into actions that - Community organization and circumstances in the Policy environmental, and behavior factors. improve health outcomes. - Organizational change program’s context that may Assessment Likewise, Community Organization could help or hinder implementation offer perspective on activating young people

28 around tobacco control issues. Applying step-by-step process of examining health Table 11. Summary of Theories: Focus and Key Concepts each of these theories might look like this: and behavior at multiple levels. At the most basic level, an ecological Learn more about • Stages of Change: Focus Theory Key Concepts perspective points to two approaches to readiness to change among adolescents Health Belief Model Perceived susceptibility Individuals’ perceptions of Individual addressing health problems: change who smoke in order to plan appropriate Perceived severity the threat posed by a health Level PART 3 Perceived benefits problem, the benefits of people’s behavior or change the and effective cessation messages Perceived barriers avoiding the threat, and environment. The most powerful health and strategies. Cues to action factors influencing the promotion and behavior change decision to act Self-efficacy interventions integrate these approaches • Social Cognitive Theory: Examine how Stages of Change Individuals’ motivation and Precontemplation and treat them both as essential. Figure 10. social environment, including peer Model readiness to change a Contemplation illustrates that strategies intended attitudes, influences adolescents’ tobacco problem behavior Decision Action to change can often be people’s behavior use. What are the expectations of teens Maintenance derived from individual-level theories; those who experiment with tobacco, or who use 44 45 draw on aimed at changing the environment it regularly? How do observational learning Theory of Planned Individuals’ attitudes toward Behavioral intention Behavior a behavior, perceptions of Attitude community-level theories. Theories at the and reinforcement contribute to the P U T T I N G T H E O R Y A N D P R A C T I C E T O G E T H E R norms, and beliefs about the Subjective norm interpersonal level (such as Social Cognitive reasons why they smoke? Might these ease or difficulty of changing Perceived behavioral control Theory) lie in-between, exploring the constructs help identify someone who Precaution Unaware of issue Individuals’ journey from reciprocal exchanges between individuals can successfully help them to quit? Adoption Process Unengaged by issue lack of awareness to action and their environments. Model Deciding about acting and maintenance Deciding not to act • Community Organization: Consider how Deciding to act Practitioners who are aware of reciprocal to involve teen smokers in developing and T H E O R Y AT A G L A N C E Acting causation (i.e., that individual behavior carrying out the program. One idea might Maintenance both influences, and is influenced by, the be to organize a coalition of concerned environment) are more likely to design parents, teachers, and teens to help Social Cognitive Reciprocal determinism Personal factors, Interpersonal Theory Behavioral capability environmental factors, and multidimensional, effective health promotion explore why teens smoke, and identify Level Expectations human behavior exert programs. A change strategy based on potential solutions. Self-efficacy influence on each other individual-level theory may indirectly lead Observational learning Reinforcements to changes in the environment (e.g., when The examples above offer a basic individuals’ improved eating habits drive illustration of how multiple theories might the cafeteria to offer healthier choices). be combined to address a single problem. Community Community-driven Empowerment Community Organization approaches to assessing and Community capacity By the same token, a strategy based on The resulting program would be a multi­ Level solving health and social Participation community-level theory may yield improved faceted, multilevel effort. problems Relevance individual health behaviors (e.g., when Issue selection Critical consciousness an individual’s involvement in a community A Few Final Words organizing project to improve access to Diffusion of How new ideas, products, Relative advantage Innovations and practices spread within a Compatibility fruits and vegetables in the community Once one is familiar with some society or from one society Complexity inspires her to cook healthier foods for contemporary theories of health behavior, to another Trialability her family). the challenge is to use them appropriately Observability within a comprehensive planning process. Communication How different types of Example: Agenda Setting Theoretical frameworks offer flexible Planning systems, such as social marketing Theory communication affect health Media agenda setting guidance for applying the abstract and PRECEDE-PROCEED, facilitate the behavior Public agenda setting Policy agenda setting concepts of theory to a vast array of real process of developing successful programs Problem identification, circumstances. By becoming familiar with because they lead practitioners through a definition Framing

29 Figure 10. Using Theory to Plan Multilevel Interventions Useful Theories Examples Ecological Change Strategies of Strategies Level PART 3 Stages of Change • Educational sessions Individual Precaution Adoption Process • Interactive kiosks Change Health Belief Model • Print brochures People’s Behavior Theory of Planned Behavior Social marketing • campaigns 46 47 P U T T I N G T H E O R Y A N D P R A C T I C E T O G E T H E R Social Cognitive Theory • Mentoring programs Interpersonal • Lay health advising T H E O R Y AT A G L A N C E Communication Theory • Media advocacy Community Diffusion of Innovations campaigns Change Community Organizing Advocating changes to • the Environment company policy Becoming comfortable with behavior change behavior change theories and planning theory as an instrument of practice may take systems, practitioners gain access to tools some work, but the results are well worth that allow them to generate creative it. Behavior change theory is not simply a solutions to unique situations. They are able tool for academics and researchers; it to go beyond acting on instinct or repeating can be applied to the problems health earlier interventions to adopt a systematic, promotion practitioners face every day. scientific approach to their work. Theory The abstractions of theory help practitioners helps practitioners to ask the right questions to understand the dynamics underlying real and effective planning helps them zero in on situations and to think about solutions factors that contribute to a problem. Other in a new way key elements of effective programs include . 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.

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31 29 14 Ibid. Rothman J. Approaches to Community Intervention. In Rothman J, Erlich JL, Tropman JE (eds.), Strategies of Community Intervention. Itasca, Ill.: Peacock Publishers, 2001. 30 Office of Cancer Communications, National Cancer Institute. Making Health Communication 15 Programs Work: A Planner’s Guide (revised December 2001). NIH Pub. No. 02-5145, 2002. Wallerstein N. Powerlessness, empowerment, and health: implications for health promotion programs. American Journal of Health Promotion 6:197–205, 1992. 31 Freimuth V, Quinn SC. The Contributions of Health Communication to Eliminating Health 16 Disparities. American Journal of Public Health 94(12):2053–2054, December 2004. Fisher R. Social Action Community Organization: Proliferation, Persistence, Roots, and Prospects. In Minkler M (ed.), Community Organizing and Community Building for Health. Rutgers, 32 Institute of Medicine, op. cit. N.J.: Rutgers University Press, 1997. 33 17 Alinsky SD. Rules for Radicals. New York, N.Y.: Vintage Books, 1989. Freimuth V, Quinn SC, op. cit. 18 34 Parachini L, Covington S. Community Organizing Toolbox: A Funder’s Guide to Community Ibid. Organizing Neighborhood Funders Group. Washington, D.C.: April 2001. 50 51 35 Ibid. URL: http://www.aecf.org/tarc/publications/pubs_toolbox.php T H E O R Y AT A G L A N C E 19 36 Alinsky, op. cit. Dorfman L, Wallack L, Themba M, op cit. 37 20 Dorfman L, Wallack L, Themba M. Media Advocacy and Public Health: Power for Prevention. Eysenbach G. What is e-health? Journal of Medical Internet Research 3(2):e20, 2001. Newbury Park, Calif.: Sage Publications, 1993. URL: http://www.jmir.org/20012/e20 38 21 Eng TR. The eHealth Landscape: A Terrain Map of Emerging Information and Communication Wallack L., Dorfman L. Issue 1. Berkeley Media Studies Group, Berkeley, CA. January, 1997. T H E O R Y AT A G L A N C E Technologies in Health and Health Care. The Robert Woods Johnson Foundation, 2001. 22 URL: Nichter M. Project community diagnosis: Participatory research as a first step toward community http://www.informatics-review.com/thoughts/rwjf.html involvement in primary health care in Hahn RA (ed.), Anthropology in public health: Bridging the 39 differences in culture and society. New York, N.Y.: Oxford University Press, 1999. Neuhauser L, Kreps G. Rethinking Communication in the E-health Era. Journal of Health Psychology 8(1): 7–22, 2003. 23 Thompson B, Nettekoven L, Ferster D, Stanley LC, Thompson J, Corbett KK. Chapter 5: 40 Mobilizing the COMMIT Communities for Smoking Control. Smoking and Tobacco Control Science Panel on Interactive Communication and Health. Wired for Health and Well-Being: The Emergence of Interactive Health Communications. U.S. Department of Health and Human Monograph 6: Community-Based Interventions for Smokers: The COMMIT Field Experience. Tobacco Control Research Branch, Division of Cancer Control and Population Sciences, National Services, U.S. Government Printing Office. Washington, D.C.: April 1999. Cancer Institute, National Institutes of Health. 1993. URL: http://www.health.gov/scipich/pubs/finalreport.htm 24 41 Cassell MM, Jackson C, Cheuvront B. Health communication on the Internet: an effective Community-based interventions for smokers: The COMMIT Field Experience, Smoking and Tobacco Control Monograph No. 6. Burns D, Garfinkel L, Samet J, editors. USDHHS NIH NCI. NIH channel for health behavior change? J Health Commun 3(1):71-9, Jan-Mar 1998. Publication No. 95-4028, 1995. 42 Institute of Medicine, op. cit. 25 Institute of Medicine, op. cit. 43 Lieberman, D.A. Interactive video games for health promotion: Effects on knowledge, self- 26 efficacy, social support, and health. R.L. Street, W.R. Gold, & T. Manning (Eds.), Health promotion National Cancer Policy Board, Institute of Medicine. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, D.C.: The National Academies Press, 2003. and interactive technology: Theoretical applications and future directions. Mahwah, NJ: Lawrence Erlbaum Associates, pp. 103–120, 1997. 27 Rogers EM. Diffusion of Innovations (4th Edition). New York, N.Y.: Free Press, 1995. 44 Lieberman DA. Management of chronic pediatric diseases with interactive health games: 28 Theory and research findings. Journal of Ambulatory Care Management 24(1):26–38, 2001. Bernhardt JM. Communication at the Core of Public Health. American Journal of Public Health 94(12): 2051–2052, December 2004.

32 45 Kreps GL. Evaluating new health information technologies: expanding the frontiers of health care delivery and health promotion. Stud Health Technol Inform 80:205–12, 2002. 46 U.S. Department of Commerce. A Nation On-line: How Americans are Expanding their Use of the Internet. Economics and Statistics Administration, National Telecommunications and Information Administration. February 2002. URL: http://www.ntia.doc.gov/ntiahome/dn/anationonline2.pdf 47 Leslie Harris & Associates. Bringing a Nation On-line: The Importance of Federal Leadership. The Leadership Conference on Civil Rights Education Fund and the Benton Foundation. July 2002. URL: http://www.benton.org/publibrary/nationonline/bringing_a_nation.pdf 48 Institute of Medicine, op cit. 49 Andreasen A. Marketing Social Change: Changing Behavior to Promote Health, Social 52 Development, and the Environment. San Francisco, Calif.: Jossey-Bass, 1995. 50 National Cancer Institute. 5 A Day for Better Health Program, Chapter 1. National Institutes of Health. NIH Pub. No. 01-5019. Washington, DC: September 2001. 51 California Department of Health Services. Cancer Prevention and Nutrition Section. Eat 5 A Day for Better Health. 2005. URL: http://www.dhs.ca.gov/ps/cdic/cpns/ca5aday/ T H E O R Y AT A G L A N C E 52 Alcalay R, Bell R. Promoting Nutrition and Physical Activity Through Social Marketing. Department of Communication and the Center for Advanced Studies in Nutrition and Social Marketing. University of California, Davis, June, 2000. http://socialmarketing-nutrition.ucdavis.edu/publications.htm 53 Green LW, Kreuter MW. Health Promotion Planning: An Educational and Ecological Approach (3rd edition). McGraw-Hill, 1999.

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