THEORY AT A GLANCE A GUIDE FOR HEALTH PROMOTION PRATICE
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- THEORY AT A GLANCE A GUIDE FOR HEALTH PROMOTION PRATICE
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Karen Glanz, f
University^
Barbara K. R1
Duke University
TABLE OF CONTENTS
INTRODUCTION
5
PART 1. FOUNDATIONS OF APPLYING THEORY IN
HEALTH PROMOTION PRACTICE................................
9
Why Are Theories and Models Important in Health Promotion?
.9
Explanatory Theory and Change Theory (Figure 1) . . .
10
What People in the Field Are Saying............................
11
What Is Theory?...........................................................................
11
Fitting a Theory or Theories to the Field of Practice.................
12
A Good Fit: The Theory Will Do the Following...........
PART 2. THEORIES AND APPLICATIONS
12
15
The Importance of a Multi-Level, Interactive Approach......................
15
An Ecological Perspective: Levels of Influence (Table 1) ....
16
Cognitive-Behavioral Models: Leading the Way in Individual and
Interpersonal Theories.............................................................................
16
Individual- (or Intrapersonal-) Level Model..................................
17
Stages of Change .............................................................................
17
Stages of Change (Table 2) ......................................................
18
Health Belief Model.........................................................................
18
Health Belief Model (Table 3).................................................
19
Consumer Information Processing .................................................
20
Consumer Information Processing Model of Choice (Figure 2)
20
21
Consumer Information Processing (Table 4) ..........................
THEORY AT A GLANCE
J
HM
:-
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Theories of Interpersonal Health Behavior
Social Learning Theory or Social Cognitive Theory
Social Learning Theory or Social Cognitive Theory (Table 5)
Community-Level Models
Community Organization . .
Community Organization (Table 6)
Diffusion of Innovations .
Diffusion of Innovations (Table 7)
Organizational Change
Organizational Change: Stage Theory (Table 8)
■
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<-- W.
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. . . . .23
25
26
27
28
28
29
... .30
PART 3. PUTTING IT TOGETHER . . . .
. . .33
Social Marketing ...
Social Marketing Wheel (Figure 3)
PRECEDE-PROCEED. .
PRECEDE-PROCEED (Figure 4)
PRECEDE-PROCEED as an Organizing Framework for
Application of Theory (Table 9)
Where to Begin: The Range of Theories..................................
Summary of Theories: Focus and Key Concepts (Table 10)
A Few Final Words
... .33
z.. .34
. . . .35
...36
37
39
40
41
BIBLIOGRAPHY . . .
43
ANNOTATED BIBLIOGRAPHY
45
NOTES . . . .
47
4
Table of Contents
si ■
*
INTRODUCTION
his monograph describes theories of health-
schools, and the private sector. It is intended for use
MhH related behaviors, the processes of changing
as a stand-alone handbook, as part of in-house staff
behaviors, and community and environmental factors
development programs, or in conjunction with
that influence behavior in a practical, easily applied
continuing education workshops.
style. Public health workers will he able to use this
guide to improve the impact of their efforts, and to
This monograph consists of three main sections.
analyze the reasons for success, or the lack thereof, in
completed programs.
Part 1. Foundations of Applying Theory in Health
Promotion Practice discusses the ways that
This monograph presents ideas that can be used as
tools for problem solving in the field of health promo
tion. It complements existing resources that provide
theories and models can be useful in health
promotion practice and provides basic
definitions and context for the monograph.
tools and techniques for practice. It aims to increase
the accessibility of different theoretical and conceptual
frameworks to health promotion practitioners who
Part 2. Theories and Applications begins by present
ing an ecological perspective on health
design and implement programs that seek to change
promotion programs, then describes seven
health behaviors.
theories or models of behavior at the individ
ual, interpersonal, and community levels.
The primary audience for this monograph is public
health workers in state and local health agencies;
approach to solving a practical problem.
secondary audiences include health promotion profes
Next, a brief description is followed by defini
sionals and volunteers working in voluntary health
tions of key concepts and additional examples
agencies, community organizations, health care settings,
THEORY AT A GLANCE
■
Each theory is introduced as a possible
or case studies.
5
Part 3. Putting It Together explains how theories
Throughout the text, you will find boxed sections that
can be used in health promotion program
highlight, clarify, and illustrate important concepts and
planning, implementation, and evaluation.
their applications. Many of these are based on com
This includes an overview of two comprehen
ments, examples, and questions of public health profes
sive planning models, PRECEDE-PROCEED
sionals whose work forms both the rationale and the
and Social Marketing. Within these two
basis for this monograph.
planning models, theories can be combined
for greater impact and also used as a basis for
The boxed sections and figures can be used in various
evaluations that create feedback loops for
ways. For example, the boxed information can be used
more successful efforts in the future.
as a checklist to consider some key concepts as part of
a planning process. Another use might be when a pro
For this monograph, it was necessary to choose a small
gram is being reviewed: The points in the boxes can
number of theories for easy reference. Those which
help a project team think about the broad range of
are included were selected because they have the
influences the program should be considering. We
widest applicability for public health workers. Even
hope you will experiment with the most practical
some well known and familiar theories and models had
and relevant uses for your situation.
co be left out. For readers who want to learn about
other useful theories for health promotion, the bibliog
raphy at the end of the monograph lists some recom
mended sources.
6
Introduction
$
5
□
FOUNDATIONS OF APPLYING THEORY I N
HEALTH PROMOTION PRACTICE
Why Are Theories and Models Important
in Health Promotion?
Public health and health promotion programs can
help to improve health, reduce disease risks, manage
chronic illnesses, and improve the well-being and self-
sufficiency of individuals, families, organizations, and
communities. But not all health promotion programs
and initiatives are equally successful. The programs
1
that are most likely to succeed are based on a clear
un^erstanding of the targeted health behaviors and
their environmental context^ Thevjir^developed and
managed using strategic ptaimingmodels, and are con
tinually improved through meaningful evaluation.
3
Theories of health behavior can play a critical role in
all of these areas.
Theory can help us during rhe various stages of plan
ning, implementing, and evaluating an intervention.
Program planners use theories to shape rhe pursuit of
answers to WHY? WHAT? and HOW? That is, theo
ries can be used to guide the search for reasons WHY
people are or are not following public health and med
ical advice, or not caring for themselves in healthy
ways. They can help pinpoint WHAT you need to
know before developing or organizing an intervention
and the outcomes for evaluation. Theories and models
EXPLAIN behavior and suggest ways to achieve
behavior CHANGE.
Models that support program planning processes
include Green and Kreuter’s PRECEDE-PROCEED
model and Social Marketing. Processes such as these
are what get the job done. These processes involve
research, thought, and action at all stages. Theory
directs our research strategy (what to look for), inter
vention goals (what to achieve), and what might
explain outcomes ot interventions. Theory also helps
us think of ideas we might never have considered.
And, when we look at multiple theories, it helps us to
keep our minds open and disciplined at once, resulting
in more effective programs. While theory alone does
not produce effective programs, theory-based planning,
implementation, and monitoring does.
Explanatory
Theory
=
Helps describe factors influencing behavior or a
situation and identify WHY a problem exists. These
theories guide the search for modifiable factors like
knowledge, attitudes, self'efficacy, social support,
program. They can provide insight into HOW you
shape program strategies to reach people anti organiza
lack of resources, and so on.
tions and make an impact on them. They also help you
identify WHAT should be monitored, measured, and/or
compared in the program evaluation.
Change Theory
Theories can help us understand the nature of targeted
health behaviors. They can explain the dynamics of
the behavior, the processes for changing the behavior,
and rhe effects of external influences on the behavior.
Theories can help us identify the most suitable targets
for programs, the methods for accomplishing change,
THEORY AT A GLANCE
Theory of
the Problem
Theory of Action
Guides the development of health promotion inter
ventions. These theories spell out concepts that can
be translated into program messages and strategies.
They are the jumping-off point for using theory as a
basis for evaluation, and they push you to make
explicit your assumptions about how a program
should work (i.e., how your “theory of action”
will affect your “theory of the problem”).
9
FIGURE 1
Explanatory Theory and Change Theory in the Process of Program Planning and Evaluation
EVALUATION
EXPLANATORY
THEORY
PROBLEM
BEHAVIOR
Why?
What can be changed?
OR
SITUATION
CHANGE THEORY
Which strategies?
Which messages?
Assumptions about how a
program should work
PLANNING
Two planning approaches. Social Marketing and
PRECEDE-PROCEED are discussed in Putting It
Together (Part 3).
Theory can take you beyond being a technician or a
Health promotion has adapted ideas from rhe behav
ioral and social sciences to fit the concerns of public
health workers. These adaptations are based on what
we have learned over many years. Currently, theory
is more accessible than ever. Concrete examples and
brief explanations, comparisons across theories and
mechanic. It can help you to step back and think
about the larger picture. An awareness of different
behavior theories and the ability to apply them skillful-
models, and theories and models ar multiple levels
can be found here and in the sources listed in the
in practice is what distinguishes a professional and
.der from someone simply carrying out a set of activi
bibliography. People in the field recognize the value
of theory, as you can see from the next page.
ties. A public health professional with theory can solve
problems. Like an expert chef, a theoretically grounded
health education professional does not blindly follow a
cookbook recipe, but constantly creates it anew,
depending on the circumstances. Without theory, sh<ie
or he has only the skills of a cafeteria line worker.
10
Foundations of Applying Theory
What People in the Field Are Saying
“Theory is different from most of the tools I use in my work. It’s more abstract, but that can be a plus too.
A solid grounding in a handful of theories goes a long way toward helping me think through why I
approach a health problem the way I do.”
— County Health Educator
“I used to think theory was just for students and researchers. But now I have a better grasp of it,
I appreciate how practical it can be.”
— State Chronic Disease Administrator
“By translating concepts from theory into real-world terms, I can get my staff and community volunteers
to take a closer look at WHY we’re conducting programs the way we do, and HOW they can succeed or fail."
— City Tobacco Control Coordinator
“A good grasp of theory is essential for leadership. It gives you a broader way of viewing your work.
And it helps create a vision for the future. But, of course, it's only worthwhile if I can translate it clearly
and simply to my co-workers."
— Regional Health Promotion Chief
"It’s not as hard as I thought it would be to keep up with current theories. More than ever these days,
there are tools and workshops to update us often."
*
— Patient Education Coordinator
What Is Theory?
events or situations by specifying relations among vari
■ VARIABLES are the operational forms of
constructs. They state how a construct is to be
measured in a specific situation. It is important
to keep in mind that VARIABLES should be
ables, in order to explain and predict rhe events or situa
matched to CONSTRUCTS when you are
tions. The notion ot generality, or broad application, is
identifying what needs to be assessed in the
evaluation of a theory-driven program.
A theory is a set of interrelated concepts, definitions,
and propositions that present a systematic view of
important. Also, theories are by their nature abstract:
that is, they don’t have a specified content or topic
area. Like an empty coffee cup, they have a shape and
boundaries but nothing concrete inside. They only
come alive when they’re filled with practical topics,
goals, and problems.
■ MODELS are generalized, hypothetical descrip
tions, often based on an analogy, used to analyze
or explain something.
Most health promotion theories come from the social
■ CONCEPTS are the building blocks of theory,
rhe primary elements of theory.
■ A CONSTRUCT is the term used for a concept
developed or adopted for use in a particular theory.
Thus, a CONSTRUCT has a very specific and
technical meaning. “Key concepts” of a given
theory are its constructs.
THEORY AT A GLANCE
and behavioral sciences, but their application often
requires familiarity with epidemiology and physical sci
ences, too. They borrow from various disciplines such
as psychology, sociology, anthropology, consumer
behavior, and marketing. Many theories are not high
ly developed or have not been rigorously tested.
Because of this, we often label them as conceptual
frameworks or theoretical frameworks; here the terms
are used interchangeably.
11
in
Fitting a Theory or Theories to the
Field of Practice
You may notice that theories often overlap, and that
some seem as if they can fit “within” broader models.
Also, you might recognize that more than one theory
is needed to adequately address an issue. For compre
hensive health promotion programs, this is almost
always true. It is also evident in the use and descrip
No single theory dominates health education and pro
motion. Nor should it: the health problems, behav
iors, populations, cultures, and contexts of public
health are broad and varied. In addition, the impor
tion of applied theories in the professional literature.
The last section of this monograph will give specific
tance of some types of problems—for example, small
pox and certain strains of influenza—change over time
because of new technology and successful public health
examples of combining theories for greater impact.
activities. Other kinds of problems—like AIDS and
environmental hazards—are emerging because of a
combination of biological and social factors. Some
theories focus on individuals as the unit of change,
while others focus on change in organizations or cul
One of the greatest challenges, to public health profes
tures. Because of these different frames of reference,
aeories that were very important to public health edu
been applied will go a long way to improve one’s skill
in this area. However, the first rule, and best advice
keep in mind, is this:
sionals is to learn to analyze the “fit” of a theory or
model for issues one is working with. A working
knowledge of a handful of theories and how they hi
cation a generation ago may be of limited use today.
Think before you leap.
Effective practice depends on marshaling
the most appropriate theory or theories
and practice strategies for a given situation.
A good place ro start is with the tijSs in the box below.
This monograph includes descriptions and applications
Theories, or conceptual frameworks, can be and are
of some theories that are dominant in health promo
useful for health promotion practice. They enrich,
tion today. Still, no one theory will be right in all
inform, and complement practical skills and technolo
gies and enable you to solve problems. They are an
cases! Depending on the unit of analysis or change
(individuals, groups, organizations, communities) and
the topic and type of behavior you are concerned with
excellent basis for critical appraisal of what is (or
not) being accomplished in your work.
(one-shot or repetitive behaviors, addictive or habitual
behaviors, or those involving choice of “brands”), difent theoretical frameworks will have a good fit and
be practical and useful.
A Good Fit: the Theory Will Do the Following...
Make assumptions about a behavior, health problem, or condition of people
or the environment that are:
■ Logical
■ Consistent with everyday observations
■ Similar to those used in previous successful program examples you have read or heard about
■ Supported by past research in the same area or related ideas
It WON’T work to try to fit a square peg into a round hole!
12
Foundations of Applying Theory
7
r
2
THEORIES AND APPLICATIONS
The Importance of a Multi-Level,
Interactive Approach
The second key idea relates to the possibility of
reciprocal causation between individuals and their envi
Contemporary health promotion includes not only
educational activities but also advocacy, organizational
change efforts, policy development, economic supports,
ronments; that is, behavior both influences and is
influenced by the social environment.
environmental change, and multi-method programs.
This highlights the importance of approaching public
health problems at multiple levels, and stressing the
A man with high cholesterol might have a hard time
following his prescribed low-fat diet because his com
interaction and integration of factors within and across
levels. This approach has been referred to as an
Ecological Perspective.
Two key ideas ficuuoan ecological perspective help
direct the identification of personal and environmental
leverage points for health promotion interventions.
pany cafeteria doesn’t offer low-fat food choices that
he likes. He can try to change the environment by
talking with the cafeteria manager or the company
medical or health department staff, and asking that
healthy food choices be added to the menu. Or, if
employees start to dine elsewhere in order to eat lowfat lunches, the cafeteria may change its menu to
maintain its lunch business.
First, behavior is viewed as being affected by, and
affecting, multiple levels of influence. Five levels of influ
ence for health-related behaviors and conditions have
This multi-level, interactive perspective clearly shows
been identified. They are: (1) intrapersonal, or indi
vidual factors; (2) interpersonal factors; (3) institution
al, or organizational factors; (4) community factors; and
(5) public policy factors (McLeroy et al., 1988).
components. For example, employee smoking cessa
tion clinics are more successful if there is also a
For example, a woman might delay getting a recom
mended cancer screening test (a mammogram) because
she is afraid of finding our she has cancer. This is an
individual-level, or intrapersonal factor. However, her
inaction might also be influenced by her doctor’s not
recommending mammography, the difficulty of sched
uling an appointment because there is only a part-time
radiologist at the clinic, and her inability to pay the
high fee. These interpersonal, organizational, and
policy factors also influence her behavior. These
factors are defined in Table 1.
THEORY AT A GLANCE
the advantages of multi-level interventions, such as
those that combine behavioral and environmental
no-smoking policy at the workplace and a city clean
indoor air ordinance. Adolescents are less likely to
take up smoking if their peer groups disapprove of the
habit and if laws that prohibit tobacco sales to minors
are strictly enforced.
Health promotion will succeed most when problems
are analyzed and programs are planned, keeping in
mind the various levels of influence the ecological
perspective comprises. Thus, the comprehensive
planning systems, PRECEDE-PROCEED and Social
Marketing, which are discussed in Part 3, both start
with extensive research to assess needs at multiple
levels. This often involves consumer and market
15
TABLE 1
An Ecological Perspective: Levels of Influence
Concept
Intrapersonal Factors
Interpersonal Factors
Definition
Individual characteristics that influence behavior, such as knowledge, attitudes,
beliefs, and personality traits
Interpersonal processes, and primary groups including family, friends, peers, that
provide social identity, support, and role definition
Institutional Factors
Rules, regulations, policies, and informal structures, which may constrain or
promote recommended behaviors
Community Factors
Social networks and norms, or standards, which exist as formal or informal
among individuals, groups, and organizations
Public Policy
Individual- (or Intrapersonal') Level Model
Stages of Change
Individual is the most basic level of health promotion
Suppose you were working with a large company with
practice. All other levels of health promotion, includ
about 200 smokers to plan a smoking cessation pro
ing groups, organizations, communities, and nations,
gram. You might provide group cessation clinics and
are composed of individuals. They are rhe entities that
offer them at various times and locations. However,
comprise groups, manage organizations, elect or
if several months passed and only 50 of the smokers
appoint leaders, and legislate policies. Thus, individual
had signed up for the clinics, you might face a problem
level models can be pieces of broader-level theories;
regarding what to do next: How to reach the many
even policy and institutional changes require, at some
smokers who did not take part in the clinics? The
point, influencing individuals.
Stages of Change Model, introduced by Prochaska and
DiClemente, suggests one perspective for approaching
In addition, many health professionals spend most of
this problem.
their time and effort working at the individual level in
Local, state, federal policies and laws that regulate or support healthy actions
and practices for disease prevention, early detection, control, and management
one-on-one encounters such as counseling and patient
The Stages of Change Model evolved from work with
education. Individuals are often the prime audiences
smoking cessation and the treatment of drug and alco-
for health educational materials, too. For many differ
hol addiction and has recently been applied to a vari
ent reasons, therefore, health practitioners must be able _
ety of other health behaviors. The basic premise is
to explain and influence the behavior of individuals.
that behavior change is a process and not an event, and
.
that individuals are at varying levels of motivation, or Q
Theories at the individual level also focus on intra
readiness, to change. People at different points in the
personal ("within individuals") factors. These are
process of change can benefit from different interveji-
characteristics of individuals such as their knowledge,
tions, matched to their stage at th-at time.
attitudes, beliefs, motivation, self-concept, develop-
Cognitive-Behavioral Models: Leading the
Way in Individual and Interpersonal Theories
mental history, past experience, skills, and behavior.
Five distinct stages are identified in the Stages of
cational, environmental, and organizational diagnosis;
We will discuss three theories at this level: Stages of
Change Model: pre-contemplation, contemplation,
and administrative and policy assessment. It is in the
Contemporary models of health behavior at the indi
Change, the Health Belief Model, and Consumer
decision/ determination, action, and maintenance.
research and diagnostic phases of program develop
vidual and interpersonal levels usually fall within the
Information Processing. Each has a distinct focus:
analysis; epidemiological assessment; behavioral, edu
ment, in particular, that social and behavioral theories
are most valuable.
At this point, it is useful to examine theories and
theories. Two key concepts cut across these theories:
Behavior is considered to be mediated through .
their applications in three levels consistent with the
cognitions; that is, what we know and think affects
ecological perspective: individual (intrapersonal),
Tow we act.
institutional factors, community factors, anil publii
policy. The third level of influence represents a com
posite of factors related to larger social structures,
■ The Stages of Change Model concerns indiv-
not a linear model. People don’t go through the stages
idtials’ rcddmcss to change or attempt to change
and “graduate”; they can enter and exit at any point,
toward healthy behaviors.
and often recycle. Studies have shown that individuals
go through the same changes when using self-help or
■ The I leaith Belief Model addresses a person’s
self-management methods, or when they seek profes
perceptions of the threat of a health problem
sional help or go to organized programs. Also, there
2. Kmju ledge isuweessary but not sutiiaaii to nroducu-
and the accompanying appraisal of a recom
appear to be differences in. how the stages fit the skuar-
Ivhavior ih.ingc. I'cii epi i.'O', m- -I n al h-n. 'kill',
and factors in the social environment also play
mended behavior lor preventing or managing
thin for different problem areas. For example, with a
the problem.
problem that involves overt, easily recognized behavior
interpersonal, and community. The third level
community—represents rhe combined elements of
(See Table 2 for definitions and applications for inter
vention.) It is important to note that this is a ciTCitkir,
broad category of COGNITIVE-BEHAVIORAL
I
\
and includes a physical addiction component (e.g.,
important roles.
which share common aspects under the general head
■ Consumer Information Processing Theory
ing of “community.”
addresses the processes by which consumers
alcoholism), the stages might have a different meaning
than with a problem where target goals are not easily-
lake in and use information in their decision
identified and where undesirable habits may have been
making.
formed without physiological addiction (e.g., following
a diet with no more than 30 percent calories from far).
16
Theories and Applications
....... •
THEORY AT A GLANCE
3
The Stages of Change Model can be used both to help
Health Belief Model
understand (explain) why employees who smoke might
not take part in the group clinics and to develop a
smoking control program that reaches more smokers
(change). First, to explain the situation: Current or
former smokers can be classified according to the stage
that they are in by asking a few simple questions—
are they interested in trying to quit, thinking about
High blood pressure screening campaigns often identify
people who are at high risk for heart disease and
stroke, but who do not experience any symptoms.
Thus, they may not think it is necessary to discuss the
condition with a physician, or might not follow
instructions to take prescribed medicine or lose weight.
The Health Belief Model (HBM) can be useful in
quitting soon, ready to plan a quit attempt, in the
process of cessation, or trying to stay smokc-fice? By
knowing their current stage, you can help set realistic,
analyzing these people’s inaction or noncompliance.
program goals—perhaps movement to the next stage,
The HBM was one of the first models that adapted
theory from the behavioral sciences to health problems,
or joining a clinic and actually quitting or staying
smoke-free. When it comes to change efforts, you can
tailor messages, strategies, and programs to the appro
priate stage. This might mean developing materials
and activities focusing mainly on motivation, such as
:arbon monoxide testing, or holding a one-session
free sample smoking cessation seminar for people
considering quitting. These stage-based strategies
would probably appeal to smoking employees who are
not yet ready to join a quitting group. (See Table 2 for
details.)
and it remains one of the most widely recognized con
ceptual frameworks of health behavior. It was originally
introduced in the 1950s by psychologists working in the
U.S. Public Health Service (Hochbaum, Rosenstock,
Leventhal, and Kegeles). Their focus was on increasing
the use of then-available preventive sendees, such as
chest x-rays tor tuberculosis screening and immuniza
tions such as flu vaccines. They assumed that people
feared diseases, and that health actions were motivated
TABLE 2
Stages of Change Model
Concept
Definition
Application
Unaware of problem,
hasn’t thought about change
Increase awareness of need for change,
personalize information_on risks and
benefits
Contemplation
Thinking about change,
in the near future
Motivate, encourage to make specific
plans
Decision/Determination
Making a plan to change
Assist in developing concrete action
plans, setting gradual goals
Action
Implementation of specific
action plans
Assist with feedback, problem solving,
social support, reinforcement
Continuation of desirable
actions, or repeating periodic
recommended step(s)
Assist in coping, reminders, finding
alternatives, avoiding sIips/reIapses
(as applies)
Pre*contemplation
Maintenance
18
Theories and Applications
in relation to the tlcgrcc ol fear (pcrccix'cd threat) and
expected fear-reduction potential of actions, as long as
that potential outweighed practical and psychological
obstacles to taking action (net benefits).
The HBM was spelled out in terms of four constructs
representing the perceived threat and netbenefits:
_ perceived susceptibility, perceived severity, perceived
^nd perceived barriers. These concepts were
proposed as accounting for people’s “readiness to act.”
An added concept, cues to action, would activate that
readiness and stimulate overt behavior. A recent
addition to the HBM is the concept of self-efficacy,
Rosenstock and others in 1988 to help the HBM
better fit the challenges of changing habitual
unhealthy behaviors, such as being sedentary,
smoking, or overeating. (See Table 3.)
Originally, the HBM was developed to help explain
health-related behaviors. It could guide the search for
“why” and help identify leverage points for change. It
can be a useful framework for designing change strate
gies, too. The most promising application of the HBM
is for helping to develop messages that are likely to
persuade individuals to make healthy decisions. The
or one’s confidence in the ability to successfully
messages can he delivered in print educational materi
als, through electronic mass media, or in one-to-one
perform an action. This concept was added by
counseling.
TABLE 3
Health Belief Model
Concept Definition
............ <..........
Perceived Susceptibility One’s opinion of chances of
getting a condition
Application
Define population(s) at risk, risk levels
Personalize risk based on a person’s
features or behavior
Heighten perceived susceptibility if
too low
Perceived Severity
One’s opinion of how serious a
condition and its sequelae are
Specify consequences of the risk
and the condition
Perceived Benefits
One’s opinion of the efficacy of
the advised action to reduce
risk or seriousness of impact
Define action to take:
how, where, when; clarify the positive
effects to be expected
Perceived Barriers
One’s opinion of the tangible 9
and psyabolpgiccil costs of
the advised action
Identify and reduce barriers through ; ■,
reassurance, incentives, assistance L
Cues to Action
Strategies to activate "readiness"
Provide how-to information, promote
awareness, reminders
Confidence in one’s ability
to take action
Provide training, guidance in
performing action
Self-Efficacy
THEORY AT A GLANCE
'
19
Messages that are suited to health education for hyper-
The HBM has a “good fit” when the problem behavior
or condition evokesJiealth motivation, since that is its
central focus. While HBM concepts also can be
tension control illustrate the components of the HBM.
Before one will accept a diagnosis of hypertension and
follow a prescribed treatment regimen, one must
stretched to relate to social or economic motivations (for
example, greater attractiveness after weight loss, saving
believe that one can have the condition without symp
toms (issusceptible), that hypertension can lead to
heart attacks and strokes (the severity is great), and
that taking prescribed medication or following a rec
ommended weight loss program will reduce the risk
(benefits) without negative side effects or excessive dif
ficulty (barriers). Print materials, reminder letters, or
pill calendars might promote consistent adherence
(cues to action). And if the individual has had a hard
time losing weight and keeping it off in the past, a
behavioral contracting strategy might be used to estab
lish achievable short-term goals so that his or her con-
" fence can increase (self-efficacy). (See Table 3 for
application of concepts.)
money by quitting smoking), these matters might be bet
ter addressed by other theories and models.
Consumer Information Processing
The Consumer Information Processing Model (CIP)
grew out of the study of human problem solving and
information processing. It was not developed specifi
cally to study health-related behavior nor to be applied
in health promotion programs, but it has many useful
applications in the health arena. Information is a
common tool for health education, and is often an
essential foundation for health decisions. However,
FIGURE 2
Motivation
Goal Hierarchy
Processing
Capacity
Attention
Perceptual
Encoding
Information
Acquisition and
Evaluation
Internal
Search
Decision
Processes
External
Search
Consumption and
Learning Processes
* Excerpted from Bettman, 1979.
20
Theories and Applications
TABLE 4
Consumer Information Processing Model
Concept
Definition
Application
Information Processing
Capacity
Individuals’limitations in the
amount of information they
can acquire, use, and remember
Choose the most important and useful
points to communicate, whether orally or
in print materials
Information Search
Processing of acquiring and
evaluating information;
affected by motivation, attention,
and perception
Provide information so it takes little effort
to obtain, draws consumer’s attention,
and is clear
Decision Rules/
Heuristics
Rules of thumb, developed and
used to help consumers select
among alternatives
Learn key ways to synthesize information
in ways that have meaning and appeal for
your audience
Consumption and
Learning
Internal feedback based on
outcome of choices, and use in
future decisions
Keep in mind that people have probably
made related choices in the past, and
are not “empty vessels"
Amount, location, format,
readability, and processability
of relevant information
Design information tailored to the
audience; place it conveniently for use
Information
Environment
as we noted earlier, information is necessary but not sufficient for encouraging healthful behaviors. Still, misj
conceptions can lead even motivated consumers to
behave in risky ways.
People require information about medical self-care reg
imens, guidance in choosing among alternative treat
ment modalities, and specific information to choose
foods for therapeutic diets. Information can increase
or decrease people’s anxiety, depending on their infor
mation preferences, and how much and what kind of
information they are given. Also, ijlness and its treatmcnts can interfere with informarion^processing. By
people pay to it. Central assumptions of CIP are that:
(1) Individuals are limited in how much information
they can process, and (2) in order to increase the
usability of information, they combine bits of informa
tion into “chunks” and create decision rides, known
as heuristics, to make choices faster and more easily.
(See Table 4 for a summary of key concepts and
applications.)
One of the best known models of CIP was developed
by James Bettman (see Figure 2). It depicts a cyclical
process of information search, choice, use and learning,
and feedback for future decisions. It is important to
understanding the key concepts and processes of CIP,
health educators can examine why people use or fail to
use health information, and design informational
strategies with better chances for success.
note the feedback loops throughout the model.
Bettman’s model has been extended to consider that
the information environment affects how easily people
obtain, process, and use information. This leads to
some basic CIP concepts for application in health pro
CIP theory reflects a combination of rational and
motion: Before people will use health information, it
must be (1) available, (2) seen as useful and new, and
(3) processable, or format-friendly.
motivational ideas. The use of information is an
intellectual process; however, motivation drives the
search for information and how much attention
THEORY AT A GLANCE
21
Table 4 illustrates generic applications of key CIP
concepts. An example that applies CIP is point-ofpurchase (P-O-P) nutrition information in grocery
cation, social networks, and social support, are also
useful, but they are not discussed in depth in this
monograph because of length constraints.
stores. In P-O-P programs, information is presented
in summary form and only selected, useful points are
communicated (information processing capacity, decision
ndes). Stickers or labels bearing symbols or phrases
such as “low-fat” or “low-calorie” are conveniently
provided on food items or as shelf tags so that they are
Social Learning Theory assumes that people and their
environments interact continuously. It is important to
recognize that SET clearly addresses both the psychoso
cial factors that determine JiealtK-behavior and strategies to promote behavior change.
easy to locate (information search). The most successful
programs provide information that is likely to be new
and helpful in choosing foods that vary in nutritional
value, such as dairy products, and not by telling con
Social Learning Theory or Social
Cognitive Theory
sumers something they probably already know—for
instance, by labeling all fresh vegetables as “healthy”
[am^urnption_and learning). During the design of
As the prevalence of sexually transmitted diseases in
adolescents rises, the importance of consistent use of
condoms by sexually active teens has come to the
)-P programs, health educators should conduct
formative evaluations to be sure the audience finds
attention of health educators. It appears that there are
several reasons why these youth do not routinely use
the materials convenient, attractive, and easy to use
protection: some do not know what kind of condoms
are best and how to use them properly; others fear that
(information environment).
Theories of Interpersonal Health Behavior
potential partners will reject them if they insist on con
doms; and some who believe condoms are important
find it hard to be assertive in intimate situations.
The SET can be used to turn these explanations into
Theories of health behavior at the interpersonal level
assume that individuals exist within environments
where other people’s thoughts, advice, examples, assis
successful health education strategies.
tance, and emotional support affect their own feelings,
behaviors, and health. The significant individuals and
Another example involves a new mother who wants to
breastfeed but has just returned to work, where lack of
groups include family members, co-workers, peers,
health professionals, and other social entities who
privacy, a busy schedule, and lack of refrigeration keep
her away from her infant for long hours and preclude
are similar to or influential for them. People are
pumping breast milk for later use. Social Learning
Theory suggests possible responses to this problem, also.
both influenced by, and influential in, their social
environments.
Theories of interpersonal health behavior are not lim
ited to developing an understanding of interactions,
though the dynamics of relationships are often at the
core of these theoretical frameworks. The theories at
this level include factors related to individuals’ experi-
ence and perceptions of their environments in combi
nation with their personal characteristics.
Social Learning Theory (SET) is complex and includes
many concepts that are useful in health promotion.
For this reason, we concentrate here on describing and
applying SET Other theories of interpersonal influ
ence, including social power, interpersonal communi-
22
In Social Learning Theory, human behavior is
explained in terms of a three-way, dynamic, reciprocal
theory in which personal factors, environmental influ
ences, and behavior continually interact. A basic
premise of SET is that people learn not.only through
their own experiences, but also by observing the
1
actions of others and the results of those actions.
In the 1970s, Albert Bandura published a comprehen
sive framework for understanding human behavior,
based on a cognitive formulation which he named rhe
Social Cognitive Theory. That framework is currently
the dominant version used in health behavior and
health promotion; however, it is still often referred
to as SET, the term we will use in this section.
Theories and Applications
i-
Social Learning Theory synthesizes concepts and
processes from cognitive, behavioristic, and emotional
models of behavior change. As a result, it is very com
begins a support group or advocacy effort to persuade
management to provide mothers’ rooms and refrigera
plex and includes many key constructs. Selected key
concepts are defined and their applications presented
in Table 5. The first concept, reciprocal determinism,
tors, her personal views and behavior may change.
Her opportunities for breastfeeding and/or for storing
pumped breast milk will increase, as will her confidence
that motherhood can be compatible with her job.
means that behavior and the environment are recipro
cal systems and that the influence is in both directions.
The concept of behavioral capability maintains that a
(This idea is also central to the ecological perspective.)
That is, the environment shapes, maintains, and
constrains behavior; but people are not passive in
the process, as they can create and change their
environments.
Consider the dilemma of the new mother described
above. If she becomes an advocate for flextime and
3
person needs to know what to do and how to do it;
thus, clear instructions and/or training may be needed.
Expectations are the results that a person thinks will
occur as a result of action. Self-efficacy? which Bandura
considers the single most important aspect of the sense
of self that determines one’s effort to change behavior,
is selTconfidence in one’s ability to successfully per
form a specific type of action.
TABLE 5
Social Learning Theory or Social Cognitive Theory
4
Definition
Application
Behavior changes result from
interaction between person
and environment; change is
bidirectional
Involve the individual and relevant others;
work to change the environment, if
warranted
Knowledge and skills to
-influence behavior
Provide information and training about
action
Expectations
Beliefs about likely results
of action
Incorporate information about likely results
of action in advice
Self-Efficacy
Confidence in ability to take
action and persist in action
Point out strengths; use persuasion and
encouragement; approach behavior
change in small steps
Observational Learning
Beliefs based on observing
others like self and/or visible
physical results
Point out others' experience, physical
changes; identify role models to emulate
Responses to a person’s
behavior that increase or
decrease the chances of
recurrence
Provide incentives, rewards, praise;
encourage self-reward; decrease
possibility of negative responses that
deter positive changes
Concept
Reciprocal Determinism
Behavioral Capability
Reinforcement
THEORY AT A GLANCE
23
/?
In order for sexually active teens to consistently use
condoms to protect them from sexually transmitted
diseases, they need to know what type of condoms
work best and how to use them properly (behavioral
capability), to believe that potential sex partners won’t
reject them because they want to use condoms (expec^
tationsjj and to have the strength of confidence in
themselves to state their wishes clearly before or during
an intimate encounter (self-efficacy).
Observational learning is often referred to as “modeling,”
that is, that people learn about what to expect through
the experience of others. This means that people can
gain a concrete understanding of the consequences of
their actions by observing others and noting whether
the modeled behaviors are desirable or not.
Observational Jeaming is most powerful when the
person being observed is powerful, respected, or
considered to be like the observer.
■ Children may observe their parents not using
seatbelts, driving above the speed limit, and
consuming too much alcohol. If they do not see
any negative effects, they are more likely to
adopt these behaviors themselves.
■ A woman who has tried numerous weight-loss
diets may feel discouraged until she sees an old
friend who has much the same problem, but who
has slimmed down. There is a good chance that
woman will be motivated to try the approach
(or diet) that worked so well for her friend.
24
Reinforcement is a response to a person’s behavior that
affects whether or not the behavior will be repeated.
Positive reinforcements, often called “rewards,”
increase the chances that behaviors will be repeated.
Negative reinforcements include punishment and lack
of any response. Health promotion programs that
provide tangible rewards or praise and encourage self
reward, encourage people to establish positive habits.
LllLIOiV'
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cnanop
should be used with caution to avoid developing
dependence on external reinforcements. They are
often useful as motivators for continued participation
but not for sustaining long-term change.
Token reward systems and refundable deposits have
been used successfully to increase participation rates
and reduce attrition in a variety of health promotion
programs that involve multiple sessions, such as smok
ing cessation, physical activity, and weight manage
ment programs.
Because sclf-efficacx is considered so important in SLT,
it is worth looking at ways to increase self-efficacy.
The advantages of greater self-efficacy include higher
motivation in the face of obstacles and better chances
of persisting over time outside a situation of formal
supervision. Three strategies for increasing self-efficacy
are consistent with other aspects of SLT, too:
1. Setting small, incremental goals: When some
one achieves a small goal, like exercising for 10
minutes each day, her self-efficacy increases.
Thus, the next goal (longer periods each day,
5 days in a row) seems achievable, and her
persistence is greater.
Theories and Applications
; ■■■■
-
2. Behaiwrafcontracting: By using a formalized
process to establish goals and specify rewards
(reinforcement), a patient trying to adhere to
a self-care regimen can receive feedback about
performance, praise, and a tangible, motivating
reward.
3. Monitoring and reinforcement: Feedback from
self-monitoring or recordkeeping can reduce
anxiety about one’s ability to achieve a behavior
change, thus increasing self-efficacy.
Coni muni ty-Le vc I Mode Is
Designing health promotion initiatives to serve com
munities and targeted populations, and not just single
individuals, is at the heart of a public health orienta
tion. The collective well-being of communities can be
fostered by creating structures and policies that support
healthy lifestyles, and by reducing or eliminating hazar^s in social an^ PhY^l^nvironments. Community
level models are frameworks for understanding howsocial systems function and change, and how commu
nities and organizations can be activated.
I
I
Community-level models are essential for comprehen
sive health promotion efforts. These models embody
an ecological perspective and are the foundations for
pursuing goals of better health for individuals, groups,
institutions, and communities. They complement
individually oriented behavior change goals with broad
aims that include advocacy and policy development.
Community-level models suggest strategies and initia
tives that are planned and led by organizations and
institutions whose missions are to protect and improve
health: schools, worksites, health care settings, com
munity groups, and government agencies.
Ideally; comprehensive health promotion efforts build
on strategies that have been tried and found effective
for reaching health and health behavior goals.
However, while strategies have been shown to be effec-
tive in many behavioral arenas (e.g., marketing, politi
cal), there are currently few health issues for which a
variety of demonstrably effective strategies are known.
■ Smoking prevention and control is one area
for which effective interventions have been
developed and evaluated. Thus, community
level tobacco control efforts are well defined.
They involve simultaneous pursuit of four main
goals within a defined locale: (1) raising the
priority of smoking as a health concern,
(2) improving communities’ abilities to change
smoking behavior, (3) increasing the influence
of existing legal and economic factors that
discourage smoking, and (4) strengthening social
norms and values supporting nonsmoking.
Achieving these goals means creating an environment
for change. Similar goals can be applied to other
important community health issues, also. Each of the
conceptual frameworks in this section applies to one or
more strategies aimed at these goals.
This section describes three conceptual frameworks for
community-level change in health promotion:
■ Community Organization has its roots in theories
of social networks and support. It emphasizes
active participation and the development of
communities that can better evaluate and solve
health and social problems.
■ Diffusion of Innovations Theory addresses how
new ideas, products, and social practices spread
within a society or from one society to another.
■ Theories of Organizational Change concern the
processes and strategies for increasing the
chances that healthy policies and programs will
be adopted and institutionalized within formal
organizations.
THEORY AT A GLANCE
25
Community Organization
The challenge of activating and involving specific, and
often underserved, population groups faces many pub
lic health organizations. For instance, high rates of
hypertension among African-Americans may combine
with low socioeconomic status and a sense of alien
ation from mainstream medical care to inhibit success
ful cardiovascular risk reduction programs. Other
groups, such as people who share common health prob
lems like AIDS, may feel disenfranchised from the
powerful medical establishment. Community organiza
tion models are useful for designing programs to
improve health in both of these situations.
Community organization is the process by which com
munity groups are helped to identify common prob
lems or goals, mobilize resources, and develop and
implement strategies for reaching their goals. It has
roots in several theoretical perspectives: the ecological
perspective, social systems perspective, social networks,
and social support. It is also consistent with Social
Learning Theory and can be successfully used along
with SLT-based strategies. Community organization is
composed of several alternative change models, often
identified using Rothman’s typology that consists of
three models: locality development, social planning,
J and social action. These models sometimes overlap
and can be combined.
■ Locality development (also called community
development) uses a broad cross-section of
people in the community to identify and solve
their own problems. It stresses consensus devel
opment, capacity building, and a strong task
orientation; outside practitioners help to
coordinate and enable the community to
successfully address its concerns.
■ Social planning uses task goals and addresses
substantive problem solving, with expert
practitioners providing technical assistance to
benefit community consumers.
26
■
•
■ Social action aims to increase the problem
solving ability of the community and to
achieve concrete changes to redress social
injustice that is identified by a disadvantaged
or oppressed group.
Although community organization does not use a sin
gle unified model, several key concepts are central to
the various approaches. (See Table 6). The process of
empowerment is intended to stimulate problem solving
and activate community members. Community compe
tence is an approximate community-level equivalent of
self-efficacy plus behavioral capability, that is, the con
fidence and skills to solve problems effectively.
Participation and relevance go together: They involve
citizen activation and a collective sense of readiness for
change. Issue selection concerns identifying “winnable
battles" as a focus for action, and critical conscimtsness
stresses the active search for root causes of problems.
An important step in changing public policy is creat
ing the environment in which change can take place.
In public health, this often means examining social
and political environments and inequities that need
attention along with overt health concerns.
Cardiovascular disease risk reduction programs based
in African-American churches have used community
organization strategies to set up risk factor reduction
programs for congregation members. Using a combina
tion of locality development and social planning mod
els, they have established task forces and trained lay
educators to conduct blood pressure screenings, orga
nize healthy potluck meals, and begin physical activity
programs like walking clubs. In these programs,
empowerment and community competence are
increased by the use of task forces that identify ways to
improve the health of congregants and learn skills to
put those techniques into practice. Participation is
achieved by inviting a broad spectrum of individuals to
play active roles, and issue selection is reflected in the
decision to focus on risk factors that can be measured
and affected in a fairly short time period.
Theories and Applications
TABLE 6
Community Organization
Concept
Definition
Application
Process of gaining mastery
and power over oneself/
one’s community, to
produce change
Give individuals and communities tools
and responsibility for making decisions
that affect them
Community Competence
Community’s ability to engage
in effective problem solving
Work with community to identify problems,
create consensus, and reach goals
Participation
and Relevance
Learners should be active
participants, and work should
“start where the people are"
Help community set goals within the
context of pre-existing goals, and
encourage active participation
Issue Selection
Identifying winnable, simple,
specific concerns as focus
of action
Assist community in examining how they
can communicate the concerns, and
whether success is likely
Critical Consciousness
Developing understanding of
root causes of problems
Guide consideration of health concerns
in broad perspective of social problems
Empowerment
Social action approaches to community organizing go
beyond the traditional notion of geographical and
political boundaries. Communities of people who
share common health problems ha\ e coalesced to
attract attention for and obtain power to address their
needs—including health services, antidiscrimination
policies, and more research funding. Foremost among
these groups presently are AIDS activists. Women’s
health advocates have also used social action to pres
sure powerful institutions to address their problems;
breast cancer is now a focus for action and advocacy
among breast cancer survivors and their relatives.
They have used media advocacy as a powerful tool in
their efforts. Participation and relevance are inherent
in these health action coalitions. The act of joining
forces plants the seeds for empowerment, and the
experiences of group members and precedents set by
other groups enhance community competence.
Critical thinking about the causes of their problems
THEORY AT A GLANCE
may lead these groups to address issues of discrimina'
tion and oppression of women or homosexuals.
However, they tend to choose issues that are clear and
specific as the goals for their action.
Media advocacy is the strategic use of mass media as a
resource for advancing a social or public policy initia
tive. It is an important, and often essential, part of
social action and advocacy campaigns because the
media focus public concern and spur public action.
The core components of media advocacy are developing
an understanding of how an issue relates to prevailing
public opinions and values, and designing messages that
frame the issues” so as to maximize their impact and
attract powerful and broad public support. Groups like
Action AIDS and tobacco control coalitions have been
creative and strategic in their use of mass media. As a
result, they have made major advances in public sup
port, funding, and policies in a remarkably short time.
27
Wil
Diffusion of Innovations
The availability of new screening technologies and med
ical self-care products for home use provides exciting
opportunities to detect disease in earlier, more treatable
stages and to reduce the cost and inconvenience of fre
quent medical visits. But it may be inconvenient to
obtain cancer screening, and home blood pressure and
diabetes testing kits can be difficult to understand and
use. Diffusion of Innovations Theory is helpful for
understanding these concerns and the dissemination of
new health promotion tools and strategies, including
prevention and health education curricula.
Diffusion of Innovations Theory addresses how new
ideas, products, and social practices spread^withinj.
:iety or from one society to another. In public
nealth and health promotion, it is a major challenge to
disseminate new prevention, early detection, and treat
ment methods and to increase the use of programs and
curricula that have been found to be successful.
Sometimes, purchase decisions, or “adoption” decisions,
are made on behalf of large organizations or communi
ties. This happens when a school system adopts a cur
riculum, a teacher adopts a course textbook, a worksite
health manager contracts for screening services, and a
city council decides to acquire recycling bins. The
challenge of diffusion requires approaches that differ
from those focused solely on individuals or small
groyp§. It involves paying attention to the innovation
(a new idea, product, practice, or technology) as well
as to communication channels and social systems (net
works with members, norms, and social structures).
A focus on characteristics of imiovations can improve the
chances that they will be adopted, and hence diffused.
It also has implications for how the innovation is posi
tioned to maximize its_appeal. (See Table 7.) Some of
the most important characteristics of innovations are
their relatiYe_adpant<ige (is it better than what was there
before?), compatibility (fit with the intended audience),
complexity (ease of use), trialability (can it be tried out
first?), and observability (visibility of results).
TABLE 7
Diffusion of Innovations Theory
Definition
Application
Relative Advantage
The degree to which an innovation
is seen as better than the idea
practice, program, or product
it replaces
Point out unique benefits: monetary value
convenience, time saving, prestige, etc.
Compatibility
How consistent the innovation
is with values, habits, experience,
and needs of potential adopters
Tailor innovation for the intended
audience’s values, norms, or situation
Complexity
How difficult the innovation is
to understand and/or use
Create program/idea/product to be
uncomplicated, easy to use and
understand
Trialability
Extent to which the innovation
can be experimented with before
a commitment to adopt is required
Provide opportunities to try on a limited
basis, e.g., free samples, introductory
sessions, money-back guarantee
Observability
Extent to which the innovation
provides tangible or visible results
Assure visibility of results: feedback or
publicity
Concept
28
Theories and Applications
WfcW-'■ • .’*■ hiu vjc'W'WWraraBs
■ A mobile mammography unit that offers the
same service as a hospital or doctor’s office, but
saves travel time and money, has advantages over
a stationary facility (relative advantage).
■ Culturally sensitive AIDS education videotapes
are more acceptable in Hispanic communities
than the same materials produced for white or
African'American audiences (compatibility).
■ A diabetes home testing kit might seem like a
good idea, but if it is too difficult to use most
people with diabetes will not use it regularly or
effectively. But a digital blood pressure monitor
may be appealing for home monitoring because
it is easier to use and to understand than a
traditional stethoscope model (complexity).
■ An open introductory session can help attract
more employees to register for a multiple-session
nutrition course than a course that permits only
preregistered participants (trialability).
■ By providing feedback in the form of case
examples or cumulative statistics, clinic users
can get a concrete sense of the value of a cancer
screening program (observability).
Communication channels are another important compo
nent of Diffusion of Innovations theory. Diffusion the
ories view communication as a two-way process, rather
than one of merely “persuading” an audience to take
action. The two-step flow of communication, in
which opinion leaders mediate the impact of mass
media, emphasizesthe value of social networks, or
interpersonal .channels, over and above mass media,
for adoption decisions.
Physicians and community leaders are important allies
in communicating about new practices or ideas to
improve health. When they reiterate information
that is provided through mass media channels, the
chances that consumers will decide to act increase.
If a nurse demonstrates a diabetes home testing kit
in the health care setting, and supervises a patient’s
practice in using it, he or she will be more likely to
use it properly at home.
THEORY AT A GLANCE
Organizational Change
Smoke-free work environments can reduce the costs of
building maintenance, prevent health problems due to
environmental tobacco smoke, and encourage smokers
to quit and quitters to remain tobacco-free. But smok
ing policies challenge the status quo and are viewed by
some as threats to individual privacy. They can evoke
conflict among workers and management and raise
questions of authority versus sejf-determination.
Tobacco policies are organizational changes that are
best attempted with an understanding of organizational
change theories.
Organizations are complex and layered social systems,
composed of resources, members, roles, exchanges, and
unique cultures. Thus, organizational change can best
be promoted by working at multiple levels within the
organization. Understanding organizational change is
important in promoting health to help establish pollcies and environments that support healthy practices
and the capacity to solve new problems. While there
are many theories of organizational behavior, two are
especially promising in public health interventions:
Stage theory and Organizational Development
(ODhtheory.
Stage theory is based on the idea that organizations
pass through a series of steps or stages as they change.
By recognizing those stages, strategies to promote
change can bejna.tdLe.d.to_various points in the process
of change. An abbreviated version of Stage theory
involves four stages: problem definition (awareness),
imtiauon^iLaciion (adoption), implemerrtation, and
institutionaHiation. (See Table 8.) When problems
are first being recognized, awareness_of various^options
is important. Practical information is needed when
leaders are ready to decide on a course of action, and
training and technical assistance are most suitable
during the implementation stage. For organizational
change to be complete, the new policy or program
should be institutionalized, that is, become entrenched
in the organization.
29
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•
-
’
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■
TABLE 8
Organizational Change: Stage Theory
Definition
Application
Problem Definition
(Awareness Stage)
Problems recognized and
analyzed; solutions sought
and evaluated
Involve management and other personnel
in awareness-raising activities
Initiation of Action
(Adoption Stage)
Policy or directive formulated;
resources for beginning
change allocated
Provide process consultation to inform
decision makers and implementers
of what adoption involves
Implementation of
Change
Innovation is implemented,
reactions occur, and role
changes occur
Provide training, technical assistance,
and problem-solving aid
Policy or program becomes
entrenched in the organization;
new goals and values are
internalized
Identify high-level champion, work to
overcome obstacles to institutionalization,
and create structures for integration
Concept
Institutionalization of
Change
Organizational Development theory grew out of the
recognition that organizational structures and processes
influence worker behavior and motivation. Both tech
nologies and workplace norms can be foci for OD
theory. OD theory concerns identifying problems that
impgdxL-an organization’s functioning, rather than the
introduction of a specific type of change. Human relations and so-called quality of work life factors are often
rhe targets of OD problem diagnosis, action planning,
iterventions, and evaluation. A typical OD strategy
involves process consultation, in which an outside spe
cialist helps identify problems and facilitates the plan
ning of change strategies.
Stage theory and OD theory have the greatest poten
tial to produce health-enhancing change in organiza
tions when they are combined. That is, OD strategies
can be used at various stages as they are warranted.
Simultaneously, the stages signal the need to involve
organization members and decision makers at various
points in the process.
30
Organizational change theories can guide the develop
ment of a smoke-free work environment. A represent
tative committee (including smokers and nonsmokers)
would first analyze the situation, needs, and advantages
and disadvantages of various approaches (problem
definition). Senior management might decide to offer
smoking cessation programs, but also to implement a
restrictive smoking policy in the company (initiation of
action). At this stage it is important to continue
involving the representative committee to avoid major
obstacles. Training of managers, communicatign
regarding new policies and their enforcement, and hir
ing leaders for cessation programs would then follow
(implementation). After a period of fine-tuning and
adjustment, management might decide to make the
policy permanent and offer ongoing smoking cessation
opportunities (institutionalization). A standing advisory
committee could be established at that time, also.
Theories and Applications
••’Lt
s
PUTTING
Many health workers find that they can achieve the
greatest impact by combining more than one theory to
address a problem. The theories in this monograph are
most effective if they are integrated within a compre
hensive planning system. Such a system assigns a central
IT TOGETHER
intervention strategies, it helps pinpoint intermediate
steps that should be assessed in evaluation. These
“mediating factors” help to clarify the reasons why pro
grams achieve or fail to achieve our goals for
success in changing behaviors or environments.
role to research as input to determine the situation and
needs of the population to be served, the resources
While theory alone does not produce effective pro*
available, and the progress and effectiveness of the
grams, research, planning, implementing, and monitor
ing do. Two well-developed planning models that can
be used to integrate diverse theoretical frameworks,
program at various stages. Planning is a continuous
process, in which new information is gathered to build
or improve rhe program.
Theories can be combined within one level, or across
levels of practice. For example, the Health Belief
Model might provide the basis for a message encourag
ing women to obtain cervical cancer screening (Pap
smears), and Consumer Information Processing might
guide the design and format for providing information.
When it comes to combining theories across levels of
Social Marketing and PRECEDE-PROCEED, are dis
cussed below.
Social Marketing
Social Marketing is a process to develop, implement,
evaluate, and control behavior change programs by
creating and maintaining exchanges, such as volunteer
time for community recognition or individual effort for
the health of future generations. Kotler and
practice, you need only remember that the broader or
larger levels (interpersonal, community) are composed
of units at the more narrow levels (individual, intra
Andreasen define it as the adaptation of commercial
marketing technologies to the analysis, planning, exe
personal). Thus, a cancer control program using
the locality development model of Community
cution, and evaluation of programs designed to influ
ence the behavior of target audiences in order to
Organization theory could employ skill development
improve their physical and mental well-being and/or
that of the society of which they are a part.
strategies suggested by Social Learning theory. Further,
those skill development strategies could be phased in,
thus designed to help move a wide variety of commu
Marketing takes a consumer orientation: Success will
nity dwellers through the Stages of Change.
come to the organization that best determines the per
Although health behavior theories are critical tools,
the health educator cannot substitute theory for
planning or research. However, theories help us inter
pret problem situations and plan feasible interventions.
Theory also plays an important role in program evalua
tion. Because it identifies the assumptions behind
THEORY AT A GLANCE
ceptions, needs, and wants of target markets and satis
fies them through the design, communication, pricing,
and delivery of appropriate, competitive, and visible
offerings. The process is consumer-driven, not expertdriven. Social Marketing uses the principle of volun
tary exchange: Individuals, groups, and organizations
have resources (such as money, effort, or time) which
33
they are willing to exchange for perceived benefits
(such as looking and feeling better, social prestige, and
being independent). Marketing facilitates the
Social Marketing is most successful when it is imple
mented as a systematic, continuous process which is
driven at every step by decision-based research used as
exchange by providing the audience with benefits they
value as being worth the cost—does so in a way that
feedback to adjust the program. A clear, workable mar
keting process includes six stages: analysis, planning,
allows the marketer to continue to provide and
development of plan elements, implementation, assess
ment of in-market effectiveness, and feedback to the
first stage. (See Figure 3.) There is constant research
based feedback and planning within each stage as well.
improve that offering, and does so efficiently. The
exchange satisfies the customer and the marketer.
Social Marketing concentrates on tailoring programs
to serve a defined target group. That group can be
health professionals, community leaders, legislators,
corporate executives, retail store managers, media decision makers, public health officials, and various public
audiences. It is not just “the individual.” A tight,
continuous focus on the particular consumers one is
trying to affect (the “target”) will assure the planner’s
ability to identify and meet consumer needs.
To change the consumer's behavior one must first
understand both what drives and maintains current
behavior and what “levers” in the consumer's life and
environment might drive and maintain rhe new
behavior. To create and run an effective program, one
must also understand what drives, facilitates, and
maintains the behavior of potential intermediaries,
channels of distribution and communication, and actu-
FIGURE 3
Social Marketing Wheel
2
1
Selecting
Channels and
Materials
Planning and
Strategy
3
'
Developing
Materials and
Pretesting
Research
6
z
4
Implementation
Feedback
to Refine
Program
5
Assessing
Effectiveness
34
Putting It Together
al and potential competitors (including internal and
“friendly” competitors such as employees and other
health organizations, respectively).
Analysis involves learning about the behaviors and
environment to be changed. It includes learning about
consumers’ current behavior, what enables it, and what
reinforces it, as well as the various factors in their
environment that might be benefits or barriers to the
desired behavior; consumers’ current attitudes, opin
ions, interests, activities, and concerns; and consumers’
product usage and media habits. Part of consumer
analysis is to divide the market into subgroups that are
relatively homogeneous in their needs and their likely
response to different programs and messages (i.e., to
“segment” it). For example, smokers may be divided by
geography, demography, social setting, lifestyle, level
of readiness for change, and media habits, among other
factors. The more specific the target, the more cus
tomized the program offering can be to satisfy them—by
reaching them with the right message about the right
product at the right price in the right place and time.
Planning invokes identification of clear, realistic, mea
surable behavior objectives that fit the organization’s
mission, the behavior and environment to be changed,
and the organization’s resources. It includes selecting ’
the target segment(s) for the program. For each seg
ment chosen, one must plan a distinctive marketing mix
of “4 Ps”: product, price, place (distribution), and pro
motion (communication). The product is the program
and/or action you are encouraging. Price includes both
tangible and intangible costs to engage in action or
take part in a program; it includes money, time, oppor
tunity costs, and even pain and fear of the action’s
consequences. Distribution involves the location or
system for getting the program, product, or action to
consumers, and communication involves all strategies
to promote the program/action and to inform con
sumers about it and its advantages.
Much of the research conducted in marketing is formalive and process research to know the consumer and to
develop and refine concepts, messages, products, ser
vices, pricing, and distribution channels before they
are implemented fully. Marketers view techniques
such as focus groups, intercept interviews, and pilot
studies as cost-efficient necessities to optimize program
content and delivery and to avoid exposing expensive
and irreversible disasters to the target audience. It is
better (and cheaper) to avoid disasters than to measure
them. Summative research is also conducted in social
marketing, often in the form of outcome monitoring.
It is conducted to compare the impact and outcomes
against planned program objectives so that one can tell
(1) what worked and what needs improvement, and
(2) whether the program has been worth its cost.
PRECEDE-PROCEED
PRECEDE-PROCEED is a planning model designed by
Lawrence Green and Marshall Kreuter for health edu
cation and health promotion programs. Its overriding
principle is that most enduring health behavior change
is voluntary in nature. This principle is reflected in a
systematic planning process which seeks to empower
individuals with understanding, motivation, and skills
and active engagement in community affairs to
improve their quality of life. This is also practical:
Much research shows that behavior change is most
likely and lasting when people have actively partici
pated in decisions about it. In the process, they make
healthy choices easier by changing their behavior and
by changing the policies and regulations which influ
ence their behavior.
THEORY AT A GLANCE
35
FIGURE 4
PRECEDE-PROCEED*
PRECEDE
Phase 5
Administration
and Policy
Diagnosis
r
i
Phase 4
Educational and
Organizational
Diagnosis
i
I
r
HEALTH
PROMOTION
Phase 3
Behavioral and
Environmental
Diagnosis
I
r
i
Phase 2
Epidemiological
Diagnosis
1
i
Phase 1
Social
Diagnosis
1
i
Predisposing
factors
I
Health
education
Reinforcing
factors
I Policyf
I
Behavior and
lifestyle
I
Enabling
factors
regulation
organization
I
T
I
■>
Environment
j
f
I
Phase 6
Implementation
Phase 7
Process
Evaluation
Quality
of life
Health
Phase 8
Impact
Evaluation
J
J
L
Phase 9
Outcome
Evaluation
PROCEED
*Source: Green and Kreuter, 1991.
PRECEDE-PROCEED has nine phases, the first five of
which are diagnostic: (1) social diagnosis of the self'
determined needs, wants, resources, and barriers to them
in the target community; (2) epidemiological diagnosis
of the health problems; (3) behavioral and environmental
diagnosis of the specific behaviors and environmental
factors for the program to address; (4) educational and
36
organizational diagnosis of the predisposing, enabling,
and reinforcing conditions which immediately affect
behavior; and (5) administrative and policy diagnosis of
the resources needed and available in the organization,
as well as the barriers and supports available in the
organization and community.
Putting It Together
. . •.■J.
TABLE 9
PRECEDE-PROCEED as an Organizing Framework for Application of Theory
Diagnostic Phase
PHASE 1
Social Diagnosis
PHASE 2
Epidemiological
Diagnosis
PHASE 3
Behavioral &
Environmental
Diagnosis
PHASE 4
Educational &
Organizational
Diagnosis
X
X
PHASE 5
Administrative &
Policy Diagnosis
THEORY
Stages of Change
Health Belief Model
X
Consumer Information
Processing
X
Social Learning
Theory
Community
Organization
X
X
Organizational
Change
Diffusion of Innovations
X
X
X
X
X
X
These diagnoses involve research in target communi
The four remaining phases in PRECEDETROCEED
ties and the change-initiating organization to identify
goals and specific objectives and set priorities among
the objectives to be addressed in the program. Each
diagnosis identifies objectives and sets priorities among
are implementation and evaluation (process, impact,
and outcome), with emphasis on using the latter to
them based on their importance, immediacy, and
changeability. The result of all of these diagnoses is a
plan with specific objectives and strategies. The
assumptions behind the strategies are based on what
was learned in the diagnostic phases about key causes
and factors contributing to problems or needs; the
application of theory, then, is useful in pinpointing
which factors to examine within each diagnostic cate
gory. The plan leads right back to the end-goal: meet
ing the community’s self-determined needs and wants.
improve the former. Evaluation of the process begins
as soon as implementation does, in order to detect
problems early so they can he corrected. As imple
mentation proceeds, the planner starts evaluating in
the order in which program effects are expected. First,
its immediate effects (impacts) are evaluated, in order
to determine the extent to which the program needs
modification. Finally, when enough time has passed—
as specified in the objectives—the ultimate intended
effects on morbidity, mortality, and quality of life are
assessed. This kind of phased evaluation allows you to
see what works and what does not.
THEORY AT A GLANCE
37
■■■
To use PRECEDE-PROCEED as an organizing frame
rewards or incentives; they contribute to repeti
work for application of theory, it is first important to
reflect on which phases have the closest parallels to
theories at the individual, interpersonal, and commu
tion or persistence of behaviors. Social support,
praise, reassurance, and symptom relief might all
be reinforcing factors.
nity levels. As Table 1 shows, the application of theo
ries discussed in this guide is clustered around Phases 3,
4, and 5: behavioral and environmental diagnosis;
educational and organizational diagnosis; and adminis
trative and policy diagnosis. Community organization
also relates to Phase 1, social diagnosis. None of the
theories is especially informative for epidemiological
diagnosis, where straightforward descriptive epidemiol
ogy is most pertinent. Still, community organization
might come into play when it comes to setting priorities
among existing health problems.
•^^Theory is most likely to be informative during Phase 4
of the planning process suggested by PRECEDE-PRO
CEED, or the educational and organizational diagnosis.
This phase focuses on examining factors that shape
behavioral actions, and environmental factors.
Behavioral actions—such as reducing intake of dietary
fat, engaging in routine physical activity, and obtaining
annual mammograms—are shaped by predisposing, rein
forcing, and enabling factors, many of which are
amenable to change. Environmental factors—such as
availability of prevention services, hazardous workplace
conditions, and reimbursement for cancer screening—
are influenced primarily by enabling factors.
Suppose you were planning chronic disease interven
tion programs to reduce cancer risk. Those programs
can only be effective if they influence the precursors to
ehaviors (or environments); and to influence those
precursors, you must first be able to identify them.
■ Predisposing factors provide the motivation
or reason behind a behavior; they include
knowledge, attitude, cultural beliefs, readiness
to change, and so on.
■ Enabling factors make it possible for a motivation to be realized; that is, they “enable” persons
to act on their predispositions; they include
available resources, supportive policies, assis
tance, and services.
■ Reinforcing factors come into play after a
behavior has begun, and provide continuing
38
Theories help guide the examination of predisposing,
enabling, and reinforcing factors. For example, the
Health Belief Model targets certain kinds of beliefs
that might lead a woman to get a mammogram, or to
avoid one—her perception of her chances of develop
ing cancer (susceptibility), and how serious she thinks
cancer would be (severity)-, both are predisposing
factors. Other HBM constructs relate to benefits of
and barriers to screening. A potential benefit would
be reassurance that she does not have cancer (a rein
forcingfactor)-, and the,lack of insurance coverage for
screening mammography might be a barrier (negative
enabling factor). By finding out how important each of
these factors is to her behavior, program planners might
prioritize rhe importance of a message (for example,
about personal susceptibility) or an administrative inter
vention (such as providing low- or no-cost screening, or
changing insurance coverage). The best way to do this
is by gathering information directly from women in that
group (market segment); a next-best approach is to
leam through reading the research literature on women
with similar characteristics.
PRECEDE-PROCEED and Social Marketing are both
comprehensive planning systems based on the needs of
the people or community to be served. Both start with
extensive research and analysis to assess those needs,
planning backwards from the needs to steps which will
meet them. Both deal with the individuals to be
served—(health) consumers—and with others who
have resources or influence on them, such as channels
of distribution or “intermediaries” and “partners,”
including community leaders, media decision makers,
parents, peers, teachers, and health professionals. Both
use this analysis to focus on specific levers which might
best influence the desired behavior. Levers are sought
among predisposing factors such as motives, reinforcing
factors such as rewards, and enabling factors or barriers.
Both use this analysis to focus on specific, realistic
behavioral objectives which can be measured for eval
uation. And both use research to help create and
refine the program elements continually. Finally, both
provide ample opportunities for the use of multiple
theories and methods.
Putting It Together
:
J,' . . tSa..'-. >
Where to Begin: The Range of Theories
In order to make good use of theory in a given practice
situation, it is necessary to consider both the social
or health problem at hand and the community or
organizational context for which the intervention is
intended. Remember, theories are abstractions, so it’s
best not to merely begin with a “favorite theory.” Once
a problem is identified, one or the other of the plan
ning systems outlined here—Social Marketing or PRECEDE-PROCEED—can be used to identify the social
science theories that are most appropriate for under
standing the problem behavior or situation. As
Burdine and McLeroy point out, the theories can then
be used to identify potential points of intervention.
Methods of intervention can then be examined for
their “fit” to the working model, and the past successes
of those intervention strategies can be explored.
Finally, thoughtful reflection on whether those inter
vention strategies are likely to work in a given situa
tion is invaluable before proceeding. That process of
reflection can be extended to pretesting or actively dis
cussing proposed strategies with the person, group, or
community that is involved.
Table 10 summarizes the focus and key concepts of
each of the seven theories described in this guide.
This table can be used as a reference point for identify
ing multiple theories that help understand and address
a problem. For example, a program to reduce adoles
cents’ tobacco use might be approached using several
theories. Looking at the “focus”.column first: The
Stages of Change model might be very useful, whereas
the Health Belief Model seems less promising—
because youth don’t think of tobacco in terms of its
long-term health impact; in fact, they don’t feel vul
nerable to disease at all! Likewise, Consumer
Information Processing would not seem suitable to this
problem, because the “information” that tobacco use is
dangerous, and liiegal for minors, is widely available
and probably not causally linked with tobacco use.
Social Learning Theory is also promising, because it
emphasizes the interchange among personal, environ
mental, and behavioral factors. Likewise, community
organization and organizational change have a bearing
on tobacco use in relation to community activation,
and school and retail outlet policies regarding smoking
and access.
These theories could be used as focal points for needs
assessment, or problem diagnosis, and later serve as
reference points for shaping intervention strategies.
The application of each of the theories above might
include these points:
■ Stages of Change: By learning more about the
stages of readiness among smoking adolescents,
appropriate and effective cessation messages and
strategies can be planned.
■ Social Learning Theory: In the assessment
process, it is helpful to examine how the social
environment, including peer attitudes, influences
tobacco use. The expectations of teens who
experiment with tobacco or use it regularly would
be particularly revealing, and observational
learning and reinforcement might provide keys
to both understanding why teens smoke and how
to help them succeed at quitting.
■ Community Organization: A coalition of
concerned parents, teachers, and teens might
be organized to help explore the nature of the
tobacco use problem and potential solutions.
The participation of smokers would be
important. The coalition might later serve
as a vehicle for program development and
evaluation.
■ Organizational Change: Issues relating to
organizational change include school-based
tobacco policies and access to tobacco through
retail outlets. The development and enforcement
of school-based policies directly parallel the
phases of Stage Theory: problem definition,
initiating action, implementation, and institu
tionalization of change. For reinforcement of
laws regarding sales of tobacco products to
minors, there may need to be a much longer
period of problem definition, and establishment
of cooperative relationships, before new
approaches will be adopted.
THEORY AT A GLANCE
39
TABLE 10
Summary of Theories: Focus and Key Concepts
THEORY
FOCUS
KEY CONCEPTS
Stages of Change
Model
Individuals’ readiness to
change or attempt to change
toward healthy behaviors
Precontemplation
Contemplation
Decision/determination
Action
Maintenance
Health Belief
Model
Persons’ perception of the
threat of a health problem
and the appraisal of
recommended behavior(s)
for preventing or managing
the problem
Perceived susceptibility
Perceived severity
Perceived benefits of action
Perceived barriers to action
Cues to action
Self-efficacy
Consumer
Information
Processing
Model
Processing by which
consumers acquire and use
information in their decision
making
Information processing
Information search
Decision rules/heuristics
Consumption and learning
Information ^environment
Social Learning
Theory
Behavior is explained via
a 3-way, dynamic
reciprocal theory in which
personal factors, environmental
influences, and behavior
continually interact
Reciprocal determinism
Behavioral capability
Expectations
Self-efficacy
Observational learning
Reinforcement
Community
Organization
Theories
Emphasizes active participation
and development of com
munities that can better
evaluate and solve health
and social problems
Empowerment
Community competence
Participation and relevance
Issue selection
Critical consciousness
Organizational
Change Theory
Concerns processes and
strategies for increasing the
chances that healthy policies
and programs will be
adopted and maintained in
formal organizations
Problem definition
(awareness stage)
Initiation of action
(adoption stage)
Implementation of change
Institutionalization of change
Diffusion of
Innovations
Theory
Addresses how new ideas,
products, and social practices
spread within a society
or from one society to another
Relative advantage
Compatibility
Complexity
Trialability
Observability
Individual Level
Interpersonal Level
Community Level
40
Putting It Together
■
w;
TYPE OF ACTIVITY
I
PROMISING THEORIES
Change People
■ Educational Materials
■ Behavioral Programs
( I
Individual
Level
Health Belief Model
Consumer Information Processing
Stages of Change
I »
Social Learning Theory
< '
<
Change the Environment
■ Policy Changes
■ Regulatory Changes
■ Organizational Changes
Community
Level
The example above illustrates how multiple theories
can he combined to address a single problem. Clearly,
the resulting program will be a multi-component,
multi-level effort. Given the limits of a written
description, the application above must be considered
as only a first §tep toward applying theory in the devel
Community Organization (and Media
Advocacy for Social Action)
Diffusion of Innovations
Organizational Change
Learning Theory, which has at its core a focus on the
reciprocal causation between individuals and their
environments.
If you regard theoretical frameworks as guides in your
opment of a public health program.
pursuit of successful efforts, you will maximize your
flexibility and develop an ability to apply the abstract
A Few Final Words
concepts of theory in a way that is most useful in your
work settings and situations.
Once you are familiar with some contemporary theo
ries of health behavior, the challenge is to use these
critical tools within a comprehensive planning process.
Planning systems like Social Marketing and PRECEDE-PROCEED increase the odds of success by
examining health and behavior at multiple levels.
This ecological perspective emphasizes our two main
options:
A knowledge of theory and comprehensive planning
systems offers much. Other key elements of effective
programs to remember are: a good program-to-people
match (goals, needs, culture, educational and reading
levels); accessible how-to information; active learning
and getting involved; and skill building, practice, and
reinforcement. Theory helps you ask the right ques
tions, and effective planning lets you zero in on these
elements in relation to a specific problem.
■ Change people
■ Change the environment
The most powerful approaches will use both of these
options together. Both are essential for truly compre
hensive programs. Note, in the box above, how the
activities most directly tied to changing people arc
derived from individual-level theories. In contrast,
activities aimed at changing the environment draw
on community-level theories. In between is Social
Effective use of theory for practice cakes practice, but
its an effort that can pay off handsomely. Abstractions
become concrete thoughts as you
“...pass with relief from the tossing sea of cause
and theory to the firm ground of result and fact.”
(Winston Churchill, 1898)
THEORY AT A GLANCE
41
..
SB
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I
ANNOTATED BIBLIOGRAPHY:
SELECTED KEY REFERENCES
Bracht N (Ed.). Health Promotion at rhe Community Level.
Newbury Park, Cal.: Sage Publications, 1990.
(Paperback, ^20 pages)
I
Discusses theoretical foundations, practical strategies,
examples for community demonstration projects, and pro
gram evaluation methods for comprehensive community
health approaches. Includes how community approaches
effect social and behavioral change, community organiza
tion, community analysis and activation, and multi-method
intervention strategies.
TO ORDER: 805/499-9774 (phone)
805/499-0871 (fax)
I
Glanz K, Lewis FM, Rimer BK. Health Behavior and Health
Education: Theory, Research, and Practice. San Francisco:
Jossey-Bass, Inc., 1990. (Hardcover, 460 pages)
'i
I
This book analyzes a broad range of theories of health
behavior and shows how they can be applied to the
practice and study of health education. Explains how
health behavior can be influenced through various health
education strategies, at rhe levels of individuals, groups,
and the community.
TO ORDER: 415/433-1767 (phone)
415/433-0499 (fax)
Green LW, Kreuter MW. Health Promotion Planning:
An Educational and Environmental Approach
(Second Ed.). Mountain View, Cal.: Mayfield, 1991.
(Hardcover, §06 pages)
This book describes the PRECEDE planning framework for
health educati^Mnd the PROCEED framework for planni
pol‘
re^fetir tnd
»an' dor ' int
ent' s. I
Hochbaum GM, Lorig K (I
Theory in Health Educ
Quarterly, Volume 19, ’
(Paperback, 12^ pages)
This special issue of He
articles about the role <
tice, how practitioners 1
of theory in self-regulat
and empowerment of pi
TO ORDER: 212/85*
Custom
U.S. Department of Hcaltl
Health Service, Nation
to Control Tobacco Us<
for Public Health Acti<
Tobacco Control Mom
This monograph provid
learned over nearly 40
smoking. It includes ex
theory to public health
various populations an<
tinuum of use, e.g., inii
TO ORDER: NIHP
Call th.
1-800A
I
Marlatt GA, Gordon JR. Relapse Prevention.
New York: Guilford Press, 1985.
Rimer BK, Glanz K, Lcrman C. Contributions of public
health to patient compliance. Journal of Community
Health 16:225-240, 1991.
McLeroy KR, Biheau D, Steckler A, Gian: K. An ecological
perspective on health promotion programs. Health
Education Quarterly 15:351-377, 1988.
Rogers EM. Diffusion of Innovations (3rd Edition).
New York: The Free Press, 1983.
Mohrman AM, Mohrman SA., Ledford GE, Cummings TG,
Lawler EE. Large-Scale Organizational Change.
San Francisco: Jossey-Bass, Inc., 1989.
Rosenstock IM, Strecher VJ, Becker MH. Social learning
theory and the health belief model. Health Education
Quarterly 15:175-183, 1988.
Office of Cancer Communications, National Cancer Institute.
Making I lealth Communication Programs Work: A
Planner's Guide. N1H Publ. No. 89-1493, 1989.
Rothman J, Tropman JE. Models of community organization
and macro practice: Their mixing and phasing.
In: FM Cox, JL Ehrlich, J Rothman, «Si JE Tropman (Eds.)
Strategies of Community Organization, 4th Edition
Itasca, III.: Peacock, 1987.
Parcel GS, Simons-Morton BG, Kolbe LJ. Health promotion:
Integrating organizational change and student learning
strategies. I lealrh Education Research 15:435-450, 1988.
Prochaska JO, DiClemente CC, Norcross JC. In search of how
people change: Applications to addictive behaviors.
American Psychologist 47:1102-1114, 1992.
Rimer BK. Audiences and messages for breast and cervical
screening. Health Education Quarterly (in press), 1995.
ANNOTATED BIBLIOGRAPHY:
SELECTED KEY REFERENCES
Bracht N (Ed.). Health Promotion at the Community Level.
Newbury Park, Cal.: Sage Publications, 1990.
I Pal>erhack, J20 [wges)
Discusses theoretical foundations, practical strategies,
examples tor community demonstration projects, and pro
gram evaluation methods for comprehensive community
health approaches. Includes how community approaches
effect social and behavioral change, community organiza
tion, community analysis and activation, and multi-method
intervention strategies.
TO ORDER: 805/499-9774 (phone)
805/499-0871 (fax)
Stokols D. Establishing and maintaining healthy environ
ments: Toward a social ecology of health promotion.
American Psychologist 47:6-22, 1992.
Winetr RA, King AC, Altman D. Health Psychology and
Public Health: An Integrative Approach. Elmsford,
N.Y.: Pergamon Press, 1989.
Glanz K, Lewis FM, Rimer BK. Health Behavior and Health
Educat ion: Theory, Research, and Practice. San Francisco:
Josscv-Bass, Inc.. 1990. (Hardcover. 460 pages)
I
i
Tins book analyzes a broad range of theories of health
behavior and shows how they can he applied to the
practice and study of health education. Explains how
health behavior can be influenced through various health
education strategies, at the levels of individuals, groups,
ami the communitv.
TO ORDER: 415/4 3 3-1767 (phone)
415/43 3-0499 (fax)
Hochbaum GM, Lorig K (Eds.). Roles and Uses of
Theory in Health Education Practice. Health Education
Quarterly, Volume 19, Number 3, 1992.
(Palterhack, raj pages)
This special issue of Health Education Quarterly contains
articles about the role of theory in health education prac
tice, how practitioners regard theory, and applied examples
of theory in self-regulation of behavior, health advocacy,
and empowerment of professionals.
TO ORDER: 212/850-6645 (phone)
Customer Service at John Wiley & Sons
U.S. Department of Health and Human Services, PublicHealth Service, National Cancer Institute, 1991. Strategies
to Control Tobacco Use in the United States: A Blueprint
for Public Health Action in the 1990s. Smoking and
Tobacco Control Monographs®!. (Pa|H.’rhack, 307 pages)
This monograph provides a summary of what has been
learned over nearly 40 years of public health effort against
smoking. It includes examples of practical applications of
theory to public health programs relating to tobacco use in
various populations and at-different points along the con
tinuum of use, e.g., initiation, cessation, and maintenance.
TO ORDER: NIH Publication No. 92-3316
Call the Cancer Information Service at
1-800/4-CANCER.
Green LW. Kreuier MW. I Icahh Promotion Planning:
An I-J11cai10n.1l ami Environmental Approach
(Second Ed.). Mountain View, Cal.: Mayfield. 1991.
(I lardcovci. 506 (xiges)
This hook ilescribes the PRECEDE planning framework for
health education ami the PROCEED framework for plan
ning policy, regulatory, ami organizational interventions. It
uses examples from many area- of health promotion and
illusiratc-s how theories can he used at various points in
planning and evaluation processes.
TO ORDER: 800/433-1279 (phone)
415/960-0328 (fax)
I
Bibliography
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