Health Promotion and Ecological Perspective

The Ecological Perspective: A Multilevel, Interactive Approach

• Health promotion involves more than just educating individuals about healthy practices, it also involves changing organizational behavior, physical and social environment, and developing policies that support health.
• The ecological perspective emphasizes the interaction between and interdependence of factors within and across all levels of a health problem.
• Two key concepts of the ecological perspective:
  • Behavior is affected by and affects multiple levels of influence.
  • Individual behavior shapes and is shaped by the social environment (reciprocal causation).

Multiple Levels of Influence

• Five levels of influence identified by McLeroy and colleagues (1988):
  • Intrapersonal or individual factors
  • Interpersonal factors
  • Institutional or organizational factors
  • Community factors
  • Public policy factors
• Each level of influence can affect health behavior, and addressing the community level requires considering institutional and public policy factors, as well as social networks and norms.

Theories and Applications

• The ecological perspective shows the advantages of multilevel interventions that combine behavioral and environmental components.
• Effective tobacco control programs often use multiple strategies to discourage smoking, including employee smoking cessation clinics, workplace no-smoking policies, and city clean indoor air ordinances.

Theoretical Explanations of Three Levels of Influence

• Three key concepts that cut across individual-level theories:
  • Behavior is mediated by cognitions.
  • Knowledge is necessary for, but not sufficient to produce, most behavior changes.
  • Perceptions, motivations, skills, and the social environment are key influences on behavior.
• Community-level models offer frameworks for implementing multi-dimensional approaches to promote healthy behaviors.

Individual or Intrapersonal Level

• The individual level is the most basic level in health promotion practice.
• Individual-level theories focus on intrapersonal factors, such as knowledge, attitudes, beliefs, motivation, self-concept, developmental history, past experience, and skills.
• Theories at the individual level include:
  • The Health Belief Model (HBM)
  • The Stages of Change (Transtheoretical) Model
  • The Theory of Planned Behavior (TPB)
  • The Precaution Adoption Process Model (PAPM)

The Health Belief Model (HBM)

• Developed in the 1950s to explain why people were not participating in disease prevention and detection programs.
• Six main constructs influence people's decisions about whether to take action to prevent, screen for, and control illness:
  • Perceived susceptibility
  • Perceived severity
  • Perceived benefits
  • Perceived barriers
  • Cue to action
  • Self-efficacy

The Stages of Change (Transtheoretical) Model

• Developed by Prochaska and DiClemente to explain the process of behavior change.
• Five stages of change:
  • Precontemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance
• People at different stages have different informational needs, and benefit from interventions designed for their stage.

The Theory of Planned Behavior (TPB)

• Explores the relationship between behavior and beliefs, attitudes, and intentions.
• Assumes behavioral intention is the most important determinant of behavior.
• Influenced by a person's attitude toward performing a behavior, and by beliefs about whether individuals who are important to the person approve or disapprove of the behavior (subjective norm).### Community Organizing Approaches
• Empowerment is a social action process that enables individuals, organizations, or communities to gain confidence and skills to improve their quality of life.
• Community capacity refers to characteristics of a community that allow it to identify social problems and address them.
• Participation in the organizing process helps community members to gain leadership and problem-solving skills.
• Relevance involves activating participants to address issues that are important to them.
• Issue selection entails pulling apart a web of interrelated problems into distinct, immediate, solvable pieces.
• Critical consciousness emphasizes helping community members to identify the root causes of social problems.

Social Action Model

• The social action model differs from other forms of community intervention in that it is grassroots-based, conflict-oriented, and geared to mobilizing disadvantaged people to act on their own behalf.
• Goals vary, but typically include policy and other significant changes that participants have identified as important.
• This approach employs direct-action strategies as the primary means of fostering change.
• It focuses on building power and encouraging community members to develop their capacities as active citizens.

Media Advocacy

• Media Advocacy is an essential tactic in community organizing, involving the strategic use of the mass media to advance public policies.
• The media set the agenda for the public and policymakers by bringing attention to specific issues.
• Media advocacy assumes that the root of most health problems is not a lack of information, but a lack of power to change social and economic conditions.
• It seeks to balance news coverage by framing issues to emphasize social, economic, and political influences on health.

Participatory Action Research

• Participatory action research involves people being studied taking an active role in some or all phases of the research.
• It builds an alliance between professional researchers and lay participants, enabling a dialogue between them.
• Participants engage in a learning process, checking and complementing expert knowledge.

Diffusion of Innovations

• The Diffusion of Innovations theory addresses how ideas, products, and social practices that are perceived as "new" spread throughout a society or from one society to another.
• The theory explains how innovations are communicated through certain channels over time among the members of a social system.
• Factors that determine how quickly and to what extent an innovation will be adopted and diffused include:
  • Relative advantage
  • Compatibility
  • Complexity
  • Trialability
  • Observability

Media Effects

• Media effects research investigates how the media influence the knowledge, opinions, attitudes, and behaviors of audience members.
• Two central questions are:
  1. What factors affect the likelihood that a person will be exposed to a given message?
  2. How do media effects vary with the amount of exposure to that message?

Agenda Setting

• The mass media can illuminate and focus attention on issues, helping to generate public awareness and momentum for change.### Theories of Health Behavior
• The Theory of Planned Behavior (TPB) includes three constructs: attitude toward behavior, subjective norm, and perceived behavioral control
• Perceived behavioral control is the individual's belief that they can control their behavior
• TPB explains how behavioral intention determines behavior, and how attitudes, subjective norms, and perceived behavioral control influence behavioral intention

Precaution Adoption Process Model (PAPM)

• PAPM specifies seven distinct stages in the journey from lack of awareness to adoption and/or maintenance of a behavior
• The stages are: unawareness, awareness, unengaged, deciding about acting, deciding not to act, acting, and maintaining
• People pass through each stage of precaution adoption without skipping any of them
• PAPM recognizes that people who are unaware of an issue, or are unengaged by it, face different barriers from those who have decided not to act

Interpersonal Level

• Social Cognitive Theory (SCT) explores the reciprocal interactions between people and their environments
• SCT states that personal factors, environmental factors, and human behavior exert influence upon each other
• Three main factors affect the likelihood that a person will change a health behavior: self-efficacy, goals, and outcome expectancies

Social Cognitive Theory (SCT)

• SCT describes a dynamic, ongoing process in which personal factors, environmental factors, and human behavior exert influence upon each other
• Self-efficacy is the most important personal factor in behavior change
• Strategies for increasing self-efficacy include setting incremental goals, behavioral contracting, and monitoring and reinforcement
• Observational learning, or modeling, refers to the process whereby people learn through the experiences of credible others
• Reinforcements can be internal or external, and can be used to increase the likelihood of repeating a behavior

Community Level

• Community-level models explore how social systems function and change, and how to mobilize community members and organizations
• Community-level models address individual, group, institutional, and community issues
• Community organizing is a process through which community groups are helped to identify common problems, mobilize resources, and develop and implement strategies to reach collective goals
• Community organizing projects that start with the community's priorities are more likely to succeed

Community Organization and Other Participatory Models

• Community organization is a process-oriented approach that focuses on building consensus and capacity
• Social planning is a task-oriented approach that stresses problem-solving and usually relies heavily on expert practitioners
• Social action is a process- and task-oriented approach that aims to increase the community's capacity to solve problems and achieve concrete changes that redress social injustices

New Communication Technologies

• New communication technologies have opened up avenues for influencing health behavior
• E-health strategies include health information on the Internet, online support groups, and online collaborative communities
• E-health interventions can address issues at the individual, group, or community/societal level, and different theories may be appropriate, depending on the project's goals
• Innovative e-health projects are expanding the range of tools that planners can use to develop cancer control and other interventions