theory.pdf

Theory at a Glance A Guide For Health Promotion Practice (Second Edition) U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health Foreword A decade ago, the first edition of Theory at a Glance was published. The guide was a welcome resource for pu...

Theory at a Glance A Guide For Health Promotion Practice (Second Edition) U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health Foreword A decade ago, the first edition of Theory at a Glance was published. The guide was a welcome resource for public health practitioners seeking a single, concise summary of health behavior theories that was neither overwhelming nor superficial. As a government publication in the public domain, it also provided cash-strapped health departments with access to a seminal integration of scholarly work that was useful to program staff, interns, and directors alike. Although they were not the primary target audience, members of the public health research community also utilized Theory at a Glance, both as a quick desk reference and as a primer for their students. The National Cancer Institute is pleased to sponsor the publication of this guide, but its relevance is by no means limited to cancer prevention and control. The principles described herein can serve as frameworks for many domains of public health intervention, complementing focused evidence reviews such as Centers for Disease Control and Prevention’s Guide to Community Preventive Services. This report also complements a number of other efforts by NCI and our federal partners to facilitate more rigorous testing and application of health behavior theories through training workshops and the development of new Web-based resources. One reason theory is so useful is that it helps us articulate assumptions and hypotheses concerning our strategies and targets of intervention. Debates among policymakers concerning public health programs are often complicated by unspoken assumptions or confusion about which data are relevant. Theory can inform these debates by clarifying key constructs and their presumed relationships. Especially when the evidence base is small, advocates of one approach or another can be challenged to address the mechanisms by which a program is expected to have an impact. By specifying these alternative pathways to change, program evaluations can be designed to ensure that regardless of the outcome, improvements in knowledge, program design, and implementation will occur. I am pleased to introduce this second edition of Theory at a Glance. I am especially impressed that the lead authors, Dr. Barbara K. Rimer and Dr. Karen Glanz, have enhanced and updated it throughout without diminishing the clarity and efficiency of the original. We hope that this new edition will empower another generation of public health practitioners to apply the same conceptual rigor to program planning and design that these authors exemplify in their own research and practice. Robert T. Croyle, Ph.D. Director Division of Cancer Control and Population Sciences National Cancer Institute Spring 2005 Acknowledgements The National Cancer Institute would like to thank Barbara Rimer Dr.P.H. and Karen Glanz Ph.D., M.P.H., authors of the original monograph, whose knowledge of healthcommunications theory and practice have molded a generation of health promotion practitioners. Both have provided hours of review and consultation, and we are grateful to them for their contributions. Thanks to the staffs of the Office of Communications, particularly Margaret Farrell, and the Division of Cancer Control and Population Sciences and Kelly Blake, who guided this monograph to completion. We appreciate in particular the work of Karen Harris, whose attention to detail and commitment to excellence enhanced the monograph’s content and quality. Table of Contents Tables and Figures Introduction viii Tables Audience and Purpose 1 Contents 1 Table 1 An Ecological Perspective: Levels of Influence 11 Table 2 Health Belief Model 14 Part 1: Foundations of Theory in Health Promotion and Health Behavior 3 Table 3 Stages of Change Model 15 Why Is Theory Important to Health Promotion and Health Behavior Practice? 4 Table 4 Theory of Planned Behavior 17 What Is Theory? 4 Table 5 Social Cognitive Theory 20 How Can Theory Help Plan Effective Programs? 4 Table 6 Community Organization 24 Explanatory Theory and Change Theory 5 Table 7 Concepts in Diffusion of Innovations 27 Fitting Theory to the Field of Practice 5 Table 8 Key Attributes Affecting the Speed and Extent of an Innovation’s Diffusion 28 Using Theory to Address Health Issues in Diverse Populations 7 Table 9 Agenda Setting, Concepts, Definitions, and Applications 31 Table 10 Diagnostic Elements of PRECEDE-PROCEED 42 Part 2: Theories and Applications 9 Table 11 Summary of Theories: Focus and Key Concepts 45 The Ecological Perspective: A Multilevel, Interactive Approach 10 Theoretical Explanations of Three Levels of Influence 12 Individual or Intrapersonal Level 12 Figures Health Belief Model 13 Stages of Change Model 15 Figure 1 Using Explanatory Theory and Change Theory to Plan and Evaluate Programs 6 Theory of Planned Behavior 16 Figure 2 A Multilevel Approach to Epidemiology 10 Precaution Adoption Process Model 18 Figure 3 Theory of Reasoned Action and Theory of Planned Behavior 18 Interpersonal Level 19 Figure 4 Stages of the Precaution Adoption Process Model 19 Social Cognitive Theory 19 Figure 5 An Integrative Model 21 Community Level 22 Figure 6 Sociocultural Environment Logic Framework 26 Community Organization and Other Participatory Models 23 Figure 7 An Asthma Self-Management Video Game for Children 33 Diffusion of Innovations 27 Figure 8 Social Marketing Wheel 38 Communication Theory 29 Figure 9 The PRECEDE-PROCEED Model 40 Media Effects 30 Figure 10 Using Theory to Plan Multilevel Interventions 46 Agenda Setting 30 New Communication Technologies 31 Part 3: Putting Theory and Practice Together 35 Planning Models 36 Social Marketing 36 PRECEDE-PROCEED 39 Where to Begin: Choosing the Right Theories 43 A Few Final Words 44 Sources 48 References 49  Introduction INTRO T his monograph, Theory at a Glance: Application to Health Promotion and Health Audience and Purpose Behavior (Second Edition), describes influential theories of health-related behaviors, processes of shaping behavior, and the effects of community and environmental This monograph is written primarily for public health workers in state and local health factors on behavior. It complements existing resources that offer tools, techniques, agencies; it is also valuable for health promotion practitioners and volunteers who work in and model programs for practice, such as Making Health Communication Programs Work: voluntary health agencies, community organizations, health care settings, schools, and the A Planner’s Guide,i and the Web portal, Cancer Control PLANET (Plan, Link, Act, Network private sector. with Evidence-based Tools).ii Theory at a Glance makes health behavior theory accessible viii and provides tools to solve problems and assess the effectiveness of health promotion Interventions based on health behavior theory are not guaranteed to succeed, but they are 1 programs. (For the purposes of this monograph, health promotion is broadly defined as the much more likely to produce desired outcomes. Theory at a Glance is designed to help users process of enabling people to increase control over, and to improve, their health. Thus, the understand how individuals, groups, and organizations behave and change—knowledge they T H E O R Y AT A G L A N C E T H E O R Y AT A G L A N C E focus goes beyond traditional primary and secondary prevention programs.) can use to design effective programs. For information about specific, evidence-based interventions to promote health and prevent disease, readers may also wish to consult the For nearly a decade, public health and health care practitioners have consulted the original Guide to Community Preventive Services, published by the Centers for Disease Control and version of Theory at a Glance for guidance on using theories about human behavior to inform Prevention (CDC) at www.thecommunityguide.org. program planning, implementation, and evaluation. We have received many testimonials about the First Edition’s usefulness, and requests for additional copies. This updated edition Contents includes information from recent health behavior research and suggests theoretical approaches to developing programs for diverse populations. Theory at a Glance can be This monograph consists of three parts. For each theory, the text highlights key concepts used as a stand-alone handbook, as part of in-house staff development programs, or in and their applications. These summaries may be used as “checklists” of important issues to conjunction with theory texts and continuing education workshops. consider when planning or evaluating programs or to prompt project teams to think about the range of factors that influence health behavior. For easy reference, the monograph includes only a small number of current and applicable health behavior theories. The theories reviewed here are widely used for the purposes of Part 1. Foundations of Theory in Health Promotion and Health Behavior describes ways that cancer control, defining risk, and segmenting populations. Much of the content for this theories and models can be useful in health behavior/health promotion practice and publication has been adapted from the third edition of Glanz, Rimer, and Lewis’ Health provides basic definitions. Behavior and Health Education: Theory, Research, and Practice,1 published by Jossey-Bass in San Francisco. Readers who want to learn more about useful theories for health behavior Part 2. Theories and Applications presents an ecological perspective on health change and health education practice can consult this and other sources that are behavior/health promotion programs. It describes eight theories and models that recommended in the References section at the end of the monograph. explain individual, interpersonal, and community behavior and offers approaches to solving problems. A brief description of each theory is followed by definitions of key concepts and examples or case studies. The section also explores the use of new communication technologies. Part 3. Putting Theory and Practice Together explains how theory can be used in health behavior/health promotion program planning, implementation, and evaluation. Two comprehensive planning models, PRECEDE-PROCEED and social marketing, are reviewed. i Making Health Communication Programs Work (http://www.nci.nih.gov/pinkbook/) describes a practical approach for planning and implementing health communication efforts. ii Cancer Control PLANET (http://cancercontrolplanet.cancer.gov) provides access to data and resources that can help planners, program staff, and researchers to design, implement, and evaluate evidence-based cancer control programs. Part 1 PART 1 Foundations of Theory in Health Promotion and Health Behavior 3 T H E O R Y AT A G L A N C E  Why Is Theory Important to Concepts are the building blocks—the interventions in theory creates innovative to succeed than those developed without Health Promotion and Health primary elements—of a theory. ways to address specific circumstances. the benefit of a theoretical perspective. Behavior Practice? He or she does not depend on a “paint-by­ Constructs are concepts developed or numbers” approach, re-hashing stale ideas, Explanatory Theory and adopted for use in a particular theory. Effective public health, health promotion, but uses a palette of behavior theories, Change Theory The key concepts of a given theory are and chronic disease management programs skillfully applying them to develop unique, its constructs. tailored solutions to problems. PART 1 help people maintain and improve health, Explanatory theory describes the reasons Variables are the operational forms of why a problem exists. It guides the search reduce disease risks, and manage chronic constructs. They define the way a Using theory as a foundation for program for factors that contribute to a problem (e.g., illness. They can improve the well-being construct is to be measured in a specific planning and development is consistent with a lack of knowledge, self-efficacy, social and self-sufficiency of individuals, families, situation. Match variables to constructs the current emphasis on using evidence- support, or resources), and can be changed. organizations, and communities. Usually, when identifying what needs to be based interventions in public health, Examples of explanatory theories include such successes require behavior change at assessed during evaluation of a theory- behavioral medicine, and medicine. Theory the Health Belief Model, the Theory of many levels, (e.g., individual, organizational, driven program. provides a road map for studying problems, Planned Behavior, and the Precaution 4 and community). 5 Models may draw on a number of theories developing appropriate interventions, and Adoption Process Model. Not all health programs and initiatives are to help understand a particular problem in evaluating their successes. It can inform the F O U N D AT I O N S O F A P P LY I N G T H E O R Y I N H E A LT H P R O M O T I O N P R A C T I C E planner’s thinking during all of these stages, T H E O R Y AT A G L A N C E equally successful, however. Those most a certain setting or context. They are not Change theory guides the development of likely to achieve desired outcomes are always as specified as theory. offering insights that translate into stronger health interventions. It spells out concepts based on a clear understanding of targeted programs. Theory can also help to explain that can be translated into program health behaviors, and the environmental Most health behavior and health promotion the dynamics of health behaviors, including messages and strategies, and offers a basis context in which they occur. Practitioners theories were adapted from the social and processes for changing them, and the for program evaluation. Change theory use strategic planning models to develop behavioral sciences, but applying them to influences of the many forces that affect helps program planners to be explicit about and manage these programs, and health issues often requires that one be health behaviors, including social and their assumptions for why a program will continually improve them through familiar with epidemiology and the biological physical environments. Theory can also help work. Examples of change theories include meaningful evaluation. Health behavior sciences. Health behavior and health planners identify the most suitable target Community Organization and Diffusion of theory can play a critical role throughout promotion theories draw upon various audiences, methods for fostering change, Innovations. Figure 1. illustrates how the program planning process. disciplines, such as psychology, sociology, and outcomes for evaluation. explanatory theory and change theory can anthropology, consumer behavior, and be used to plan and evaluate programs. What Is Theory? marketing. Many are not highly developed Researchers and practitioners use theory or have not been rigorously tested. Because to investigate answers to the questions of Fitting Theory to the Field of Practice A theory presents a systematic way of of this, they often are called conceptual “why,” “what,” and “how” health problems understanding events or situations. It is a frameworks or theoretical frameworks; here should be addressed. By seeking answers This monograph includes descriptions and set of concepts, definitions, and propositions the terms are used interchangeably. to these questions, they clarify the nature applications of some theories that are that explain or predict these events or of targeted health behaviors. That is, theory central to health behavior and health situations by illustrating the relationships guides the search for reasons why people promotion practice today. No single theory How Can Theory Help Plan do or do not engage in certain health between variables. Theories must be Effective Programs? dominates health education and promotion, applicable to a broad variety of situations. behaviors; it helps pinpoint what planners nor should it; the problems, behaviors, They are, by nature, abstract, and don’t need to know before they develop public populations, cultures, and contexts of public Theory gives planners tools for moving health programs; and it suggests how to have a specified content or topic area. beyond intuition to design and evaluate health practice are broad and varied. Some Like empty coffee cups, theories have devise program strategies that reach target theories focus on individuals as the unit of health behavior and health promotion audiences and have an impact. Theory also shapes and boundaries, but nothing inside. interventions based on understanding of change. Others examine change within They become useful when filled with helps to identify which indicators should be families, institutions, communities, or behavior. It helps them to step back and monitored and measured during program practical topics, goals, and problems. consider the larger picture. Like an artist, cultures. Adequately addressing an issue evaluation. For these reasons, program may require more than one theory, and no a program planner who grounds health planning, implementation, and monitoring one theory is suitable for all cases. processes based in theory are more likely  There are several reasons why culture and Figure 1. Using Explanatory Theory and Change Theory to Plan and Evaluate Programs A Good Fit: ethnicity are critical to consider when Characteristics of a Useful Theory applying theory to a health problem. First, A useful theory makes assumptions about morbidity and mortality rates for different a behavior, health problem, target diseases vary by race and ethnicity; second, population, or environment that are: there are differences in the prevalence of Evaluation risk behaviors among these groups; and PART 1 Logical; third, the determinants of health behaviors Consistent with everyday observations; vary across racial and ethnic groups. Similar to those used in previous Explanatory ChangeTheory successful programs; and Theory Problem What People in the Field Say About Theory Which strategies? Supported by past research in the same Behavior Which messages? area or related ideas. Why? or “Theory is different from most of the tools Assumptions about 6 What can Situation how a program I use in my work. It’s more abstract, but 7 be changed? that can be a plus too. A solid grounding should work Using Theory to Address Health in a handful of theories goes a long way Issues in Diverse Populations toward helping me think through why I F O U N D AT I O N S O F A P P LY I N G T H E O R Y I N H E A LT H P R O M O T I O N P R A C T I C E T H E O R Y AT A G L A N C E approach a health problem the way I do.” Planning The U.S. population is growing more — County Health Educator culturally and ethnically diverse. An increasing body of research shows health “I used to think theory was just for disparities exist among various ethnic and students and researchers. But now I have socio-economic groups. These findings a better grasp of it; I appreciate how highlight the importance of understanding practical it can be.” Because the social context in which they have been applied in the past, the cultural backgrounds and life — State Chronic Disease Administrator behavior occurs is always evolving, theories improves skills in this area. Selecting an experiences of community members, though that were important in public health appropriate theory or combination of research has not yet established when and “By translating concepts from theory education a generation ago may be of theories helps take into account the multiple under what circumstances targeted or into real-world terms, I can get my staff limited use today. At the same time, new factors that influence health behaviors. tailored health communications are more and community volunteers to take a closer The practitioner who uses theory develops a effective than generic ones. (Targeting look at why we’re conducting programs social science research allows theorists to the way we do, and how they can succeed refine and adapt existing theories. A recent nuanced understanding of realistic program involves using information about shared or fail.” Institute of Medicine report2 observed that outcomes that drives the planning process. characteristics of a population subgroup to several theorists have converged in their create a single intervention approach for — City Tobacco Control Coordinator views, identifying several variables as Choosing a theory that will bring a useful that group. In contrast, tailoring is a process perspective to the problem at hand does not that uses an assessment to derive “A good grasp of theory is essential for central to behavior change. As a result, leadership. It gives you a broader way some constructs, such as self-efficacy, are begin with a theory (e.g., the most familiar information about one specific person, and of viewing your work. And it helps create central to multiple theories. theory, the theory mentioned in a recent then offers change or information strategies a vision for the future. But, of course, it’s journal article, etc.). Instead, this process for an outcome of interest based on that only worthwhile if I can translate it clearly Effective practice depends on using starts with a thorough assessment of the person’s unique characteristics.)3 and simply to my co-workers.” theories and strategies that are appropriate situation: the units of analysis or change, — Regional Health Promotion Chief to a situation. the topic, and the type of behavior to be Most health behavior theories can be addressed. Because different theoretical applied to diverse cultural and ethnic “It’s not as hard as I thought it would be One of the greatest challenges for those frameworks are appropriate and practical for groups, but health practitioners must to keep up with current theories. More concerned with behavior change is learning different situations, selecting a theory that understand the characteristics of target than ever these days, there are tools and to analyze how well a theory or model “fits” “fits” should be a careful, deliberate process. populations (e.g., ethnicity, socioeconomic workshops to update us often.” a particular issue. A working knowledge of Start with the steps in the box at the top of status, gender, age, and geographical — Patient Education Coordinator specific theories, and familiarity with how the next page. location) to use these theories correctly.  9 PART 2 T H E O R Y AT A G L A N C E Theories and Applications Part 2  The Ecological Perspective: A interactions with their physical and socio­ cultural environments. Two key concepts Table 1. An Ecological Perspective: Levels of Influence Multilevel, Interactive Approach of the ecological perspective help to identify Contemporary health promotion involves intervention points for promoting health: Concept Definition more than simply educating individuals first, behavior both affects, and is affected by, multiple levels of influence; second, Intrapersonal Level Individual characteristics that influence behavior, such as about healthy practices. It includes efforts individual behavior both shapes, and is knowledge, attitudes, beliefs, and personality traits PART 2 to change organizational behavior, as well as the physical and social environment of shaped by, the social environment (reciprocal causation). Interpersonal Level Interpersonal processes and primary groups, including communities. It is also about developing and family, friends, and peers that provide social identity, advocating for policies that support health, support, and role definition such as economic incentives. Health To explain the first key concept of the promotion programs that seek to address ecological perspective, multiple levels of Community Level health problems across this spectrum influence, McLeroy and colleagues (1988)4 Institutional Factors Rules, regulations, policies, and informal structures, which 10 employ a range of strategies, and operate identified five levels of influence for health- may constrain or promote recommended behaviors 11 on multiple levels. related behaviors and conditions. Defined in Table 1., these levels include: (1) Community Factors Social networks and norms, or standards, which exist as formal or informal among individuals, groups, and T H E O R I E S A N D A P P L I C AT I O N S intrapersonal or individual factors; (2) T H E O R Y AT A G L A N C E The ecological perspective emphasizes the organizations interaction between, and interdependence interpersonal factors; (3) institutional or of, factors within and across all levels of a organizational factors; (4) community Public Policy Local, state, and federal policies and laws that regulate health problem. It highlights people’s factors; and (5) public policy factors. or support healthy actions and practices for disease prevention, early detection, control, and management Figure 2. A Multilevel Approach to Epidemiology In practice, addressing the community level unable to afford the fee. Thus, the outcome, requires taking into consideration the woman’s failure to get a mammogram, institutional and public policy factors, as well may result from multiple factors. Social and Economic Policies as social networks and norms. Figure 2. The second key concept of an ecological Institutions illustrates how different levels of influence perspective, reciprocal causation, suggests combine to affect population health. that people both influence, and are Neighborhoods and Communities Each level of influence can affect health influenced by, those around them. For e rs Living Conditions behavior. For example, suppose a woman example, a man with high cholesterol may u co delays getting a recommended find it hard to follow the diet his doctor has Life Social Relationships mammogram (screening for breast cancer). prescribed because his company cafeteria At the individual level, her inaction may be doesn’t offer healthy food choices. To Individual Risk Factors due to fears of finding out she has cancer. comply with his doctor’s instructions, he can Genetic/Constitutional try to change the environment by asking the Factors At the interpersonal level, her doctor may cafeteria manager to add healthy items to Pathophysiological neglect to tell her that she should get the the menu, or he can dine elsewhere. If he Pathways test, or she may have friends who say they and enough of his fellow employees decide do not believe it is important to get a to find someplace else to eat, the cafeteria Individual/Population mammogram. At the organizational level, may change its menu to maintain lunch Health t it may be hard to schedule an appointment, business. Thus, the cafeteria environment men because there is only a part-time radiologist may compel this man to change his dining r on E n vi at the clinic. At the policy level, she may habits, but his new habits may ultimately lack insurance coverage, and thus be bring about change in the cafeteria as well. Source: Smedley BD, Syme SL (eds.), Institute of Medicine. Promoting Health: Strategies from Social and Behavioral Research. Washington, D.C.:, National Academies Press, 2000.  An ecological perspective shows the Community-level models offer frameworks The Stages of Change (Transtheoretical) In ensuing years, researchers expanded advantages of multilevel interventions that for implementing multi-dimensional Model describes individuals’ motivation upon this theory, eventually concluding that combine behavioral and environmental approaches to promote healthy behaviors. and readiness to change a behavior. six main constructs influence people’s components. For instance, effective They supplement educational approaches decisions about whether to take action to tobacco control programs often use with efforts to change the social and The Theory of Planned Behavior (TPB) prevent, screen for, and control illness. They multiple strategies to discourage smoking.5 physical environment to support positive examines the relations between an argued that people are ready to act if they: Employee smoking cessation clinics have behavior change. individual’s beliefs, attitudes, intentions, PART 2 a stronger impact if the workplace has a behavior, and perceived control over Believe they are susceptible to the no-smoking policy and the city has a clean Individual or Intrapersonal Level that behavior. condition (perceived susceptibility) indoor air ordinance. Adolescents are Believe the condition has serious less likely to begin smoking if their The individual level is the most basic one The Precaution Adoption Process Model consequences (perceived severity) peers disapprove of the habit and laws in health promotion practice, so planners (PAPM) names seven stages in an prohibiting tobacco sales to minors must be able to explain and influence the individual’s journey from awareness to Believe taking action would reduce their are strictly enforced. Health promotion behavior of individuals. Many health action. It begins with lack of awareness susceptibility to the condition or its severity 12 13 programs are more effective when practitioners spend most of their work time and advances through subsequent stages (perceived benefits) planners consider multiple levels of in one-on-one activities such as counseling of becoming aware, deciding whether Believe costs of taking action (perceived T H E O R I E S A N D A P P L I C AT I O N S influence on health problems. or patient education, and individuals are or not to act, acting, and maintaining T H E O R Y AT A G L A N C E barriers) are outweighed by the benefits often the primary target audience for health the behavior. Theoretical Explanations of Three education materials. Because individual Are exposed to factors that prompt action behavior is the fundamental unit of group Health Belief Model (HBM) (e.g., a television ad or a reminder from Levels of Influence behavior, individual-level behavior change The Health Belief Model (HBM) was one one’s physician to get a mammogram) theories often comprise broader-level of the first theories of health behavior, and (cue to action) The next three sections examine theories and their applications at the models of group, organizational, community, remains one of the most widely recognized Are confident in their ability to successfully individual (intrapersonal), interpersonal, and national behavior. Individuals participate in the field. It was developed in the 1950s perform an action (self-efficacy) and community levels of the ecological in groups, manage organizations, elect and by a group of U.S. Public Health Service perspective. At the individual and appoint leaders, and legislate policy. Thus, social psychologists who wanted to explain achieving policy and institutional change why so few people were participating in Since health motivation is its central focus, interpersonal levels, contemporary theories the HBM is a good fit for addressing of health behavior can be broadly requires influencing individuals. programs to prevent and detect disease. For example, the Public Health Service was problem behaviors that evoke health categorized as “Cognitive-Behavioral.” concerns (e.g., high-risk sexual behavior Three key concepts cut across In addition to exploring behavior, individual- sending mobile X-ray units out to level theories focus on intrapersonal factors neighborhoods to offer free chest X-rays and the possibility of contracting HIV). these theories: Together, the six constructs of the HBM (those existing or occurring within the (screening for tuberculosis). Despite the fact individual self or mind). Intrapersonal that this service was offered without charge provide a useful framework for designing 1. Behavior is mediated by cognitions; that both short-term and long-term behavior is, what people know and think affects factors include knowledge, attitudes, in a variety of convenient locations, the beliefs, motivation, self-concept, program was of limited success. The change strategies. (See Table 2.) When how they act. applying the HBM to planning health developmental history, past experience, question was, “Why?” and skills. Individual-level theories are programs, practitioners should ground their 2. Knowledge is necessary for, but not efforts in an understanding of how sufficient to produce, most behavior presented below. To find an answer, social psychologists examined what was encouraging or susceptible the target population feels to the changes. health problem, whether they believe it is The Health Belief Model (HBM) addresses discouraging people from participating in the individual’s perceptions of the threat the programs. They theorized that people’s serious, and whether they believe action 3. Perceptions, motivations, skills, and can reduce the threat at an acceptable cost. the social environment are key influences posed by a health problem (susceptibility, beliefs about whether or not they were severity), the benefits of avoiding the susceptible to disease, and their Attempting to effect changes in these factors on behavior. is rarely as simple as it may appear. threat, and factors influencing the perceptions of the benefits of trying to decision to act (barriers, cues to action, avoid it, influenced their readiness to act. and self-efficacy).  Stages of Change (Transtheoretical) Model of change. Nonetheless, the manner in Table 2. Health Belief Model Developed by Prochaska and DiClemente,6 which they pass through these stages may the Stages of Change Model evolved out vary, depending on the type of behavior Concept Definition Potential Change Strategies of studies comparing the experiences of change. For example, a person who is trying smokers who quit on their own with those to give up smoking may experience the Perceived Beliefs about the chances Define what populations(s) are at risk and of smokers receiving professional treatment. stages differently than someone who is susceptibility of getting a condition their levels of risk The model’s basic premise is that behavior seeking to improve their dietary habits by PART 2 Tailor risk information based on an individual’s characteristics or behaviors change is a process, not an event. As a eating more fruits and vegetables. Help the individual develop an accurate person attempts to change a behavior, he perception of his or her own risk or she moves through five stages: The Stages of Change Model has been precontemplation, contemplation, applied to a variety of individual behaviors, Perceived severity Beliefs about the Specify the consequences of a condition preparation, action, and maintenance (see as well as to organizational change. The seriousness of a condition and recommended action and its consequences Table 3.). Definitions of the stages vary Model is circular, not linear. In other words, 14 slightly, depending on the behavior at issue. people do not systematically progress from 15 Perceived benefits Beliefs about the Explain how, where, and when to take People at different points along this one stage to the next, ultimately effectiveness of taking action and what the potential positive continuum have different informational “graduating” from the behavior change results will be T H E O R I E S A N D A P P L I C AT I O N S action to reduce risk or process. Instead, they may enter the T H E O R Y AT A G L A N C E needs, and benefit from interventions seriousness designed for their stage. change process at any stage, relapse to Perceived barriers Beliefs about the material Offer reassurance, incentives, and an earlier stage, and begin the process and psychological costs assistance; correct misinformation Whether individuals use self-management once more. They may cycle through this of taking action methods or take part in professional process repeatedly, and the process can programs, they go through the same stages truncate at any point. Cues to action Factors that activate Provide ”how to” information, promote ”readiness to change” awareness, and employ reminder systems Self-efficacy Confidence in one’s ability Provide training and guidance in Table 3. Stages of Change Model to take action performing action Use progressive goal setting Give verbal reinforcement Stage Definition Potential Change Strategies Demonstrate desired behaviors Precontemplation Has no intention of taking Increase awareness of need for change; action within the next personalize information about risks six months and benefits High blood pressure screening campaigns often identify people who are at high risk for heart Contemplation Intends to take action in Motivate; encourage making specific plans disease and stroke, but who say they have not experienced any symptoms. Because they don’t the next six months feel sick, they may not follow instructions to take prescribed medicine or lose weight. The HBM can be useful for developing strategies to deal with noncompliance in such situations. Preparation Intends to take action Assist with developing and implementing within the next thirty concrete action plans; help set According to the HBM, asymptomatic people may not follow a prescribed treatment regimen days and has taken some gradual goals unless they accept that, though they have no symptoms, they do in fact have hypertension behavioral steps in (perceived susceptibility). They must understand that hypertension can lead to heart attacks this direction and strokes (perceived severity). Taking prescribed medication or following a recommended Action Has changed behavior for Assist with feedback, problem solving, weight loss program will reduce the risks (perceived benefits) without negative side effects less than six months social support, and reinforcement or excessive difficulty (perceived barriers). Print materials, reminder letters, or pill calendars might encourage people to consistently follow their doctors’ recommendations (cues to Maintenance Has changed behavior for Assist with coping, reminders, finding action). For those who have, in the past, had a hard time losing weight or maintaining more than six months alternatives, avoiding slips/relapses weight loss, a behavioral contract might help establish achievable, short-term goals to build (as applicable) confidence (self-efficacy).  a particular behavior. Azjen and Driver7 situations, however. People’s perceptions added this construct to account for about controllability may have an important Suppose a large company hires a health educator to plan a smoking cessation program situations in which people’s behavior, or influence on behavior. for its employees who smoke (200 people). The health educator decides to offer group behavioral intention, is influenced by factors smoking cessation clinics to employees at various times and locations. Several months beyond their control. They argued that pass, however, and only 50 of the smokers sign up for the clinics. At this point, the people might try harder to perform a health educator faces a dilemma: how can the 150 smokers who are not participating behavior if they feel they have a high PART 2 in the clinics be reached? degree of control over it. (See Table 4.) It has application beyond these limited The Stages of Change Model offers perspective on ways to approach this problem. First, the model can be employed to help understand and explain why they are not attending the clinics. Second, it can be used to develop a comprehensive smoking program to help more current and former smokers change their smoking behavior, and maintain that change. By asking a few simple questions, the health educator can assess what stages Table 4. Theory of Planned Behavior 16 of contemplation potential program participants are in. For example: 17 Are you interested in trying to quit smoking? (Pre-contemplation) Concept Definition Measurement Approach T H E O R I E S A N D A P P L I C AT I O N S Are you thinking about quitting smoking soon? (Contemplation) T H E O R Y AT A G L A N C E Are you ready to plan how you will quit smoking? (Preparation) Behavioral intention Perceived likelihood of performing Are you likely or unlikely to behavior (perform the behavior)? Are you in the process of trying to quit smoking? (Action) Are you trying to stay smoke-free? (Maintenance) Attitude Personal evaluation of the behavior Do you see (the behavior) as good, neutral, or bad? The employees’ responses will help to pinpoint where the participants are on the Subjective norm Beliefs about whether key people Do you agree or disagree that continuum of change, and to tailor messages, strategies, and programs appropriate to approve or disapprove of the most people approve their needs. For example, individuals who enjoy smoking are not interested in trying to behavior; motivation to behave in a of/disapprove of (the behavior)? quit, and therefore will not attend a smoking cessation clinic; for them, a more way that gains their approval appropriate intervention might include educational interventions designed to move them out of the “precontemplation” stage and into “contemplation” (e.g., using carbon Perceived behavioral Belief that one has, and can exercise, Do you believe (performing the control control over performing the behavior behavior) is up to you, or not monoxide testing to demonstrate the effect of smoking on health). On the other hand, up to you? individuals who are ready to plan how to quit smoking (the “preparation” stage) can be encouraged to do so, and moved to the next stage, “action.” Theory of Planned Behavior (TPB) to the person approve or disapprove of the Surveillance data show that young, acculturated Hispanic women are more likely to get The Theory of Planned Behavior (TPB) and behavior (subjective norm). The TPB and Pap tests than those who are older and less acculturated.8 A health department decides to the associated Theory of Reasoned Action TRA assume all other factors (e.g., culture, implement a cervical cancer screening program targeting older Hispanic women. In (TRA) explore the relationship between the environment) operate through the planning the campaign, practitioners want to conduct a survey to learn what beliefs, behavior and beliefs, attitudes, and models’ constructs, and do not attitudes, and intentions in this population are associated with seeking a Pap test. They intentions. Both the TPB and the TRA independently explain the likelihood that design the survey to gauge: when the women received their last Pap test (behavior); how assume behavioral intention is the most a person will behave a certain way. likely they are to seek a Pap test (intention); attitudes about getting a Pap test (attitude); important determinant of behavior. whether or not “most people who are important to me” would want them to get a Pap According to these models, behavioral The TPB differs from the TRA in that it test (subjective norm); and whether or not getting a Pap test is something that is “under intention is influenced by a person’s attitude includes one additional construct, perceived my control” (perceived behavioral control). The department will compare survey results toward performing a behavior, and by beliefs behavioral control; this construct has to with data about who has or has not received a Pap test to identify beliefs, attitudes, and about whether individuals who are important do with people’s beliefs that they can control intentions that predict seeking one.  Figure 3. Theory of Reasoned Action and Theory of Planned Behavior Figure 4. Stages of the Precaution Adoption Process Model Behavioral Stage 3: beliefs Stage 1: Stage 2: Stage 5: Deciding Stage 6: Stage 7: Attitude toward Unaware Unengaged Decided About Acting Maintenance of Issue by Issue to Act PART 2 behavior Acting Evaluation of behavioral outcomes Stage 4: Normative Decided beliefs Not to Act Subjective Behavioral Behavior norm intention 18 Motivation 19 to comply T H E O R I E S A N D A P P L I C AT I O N S T H E O R Y AT A G L A N C E or may decide to act (Stage 5). The stages Interpersonal Level Control beliefs of action (Stage 6) and maintenance (Stage Perceived 7) follow. (See Figure 4.) According to the At the interpersonal level, theories of health behavioral control PAPM, people pass through each stage of behavior assume individuals exist within, Perceived power Note: Upper blue section shows the Theory precaution adoption without skipping any of and are influenced by, a social environment. of Reasoned Action; the entire figure them. It is possible for people to move The opinions, thoughts, behavior, advice, shows the Theory of Planned Behavior. backwards from some later stages to earlier and support of the people surrounding an ones, but once they have completed the first individual influence his or her feelings and two stages of the model they do not return behavior, and the individual has a reciprocal Figure 3. shows the TPB’s explanation for Precaution Adoption Process Model to them. For example, a person does not effect on those people. The social how behavioral intention determines The Precaution Adoption Process Model move from unawareness to awareness and environment includes family members, behavior, and how attitude toward behavior, (PAPM) specifies seven distinct stages in then back to unawareness. coworkers, friends, health professionals, subjective norm, and perceived behavioral the journey from lack of awareness to and others. Because it affects behavior, control influence behavioral intention. adoption and/or maintenance of a behavior. The PAPM bears similarities to the Stages the social environment also impacts health. According to the model, attitudes toward It is a relatively new model that has been of Change model, but differs in important Many theories focus at the interpersonal behavior are shaped by beliefs about what applied to an increasing number of health ways. Stages of Change offers insights for level, but this monograph highlights Social is entailed in performing the behavior and behaviors, including: osteoporosis addressing hard-to-change behaviors such Cognitive Theory (SCT). SCT is one of the outcomes of the behavior. Beliefs about prevention, colorectal cancer screening, as smoking or overeating; it is less helpful most frequently used and robust health social standards and motivation to comply mammography, hepatitis B vaccination, when dealing with hazards that have behavior theories. It explores the reciprocal with those norms affect subjective norms. and home testing for radon gas. recently been recognized or precautions interactions of people and their The presence or lack of things that will that are newly available. The PAPM environments, and the psychosocial make it easier or harder to perform the In the first stage of the PAPM, an individual recognizes that people who are unaware of determinants of health behavior. behavior affect perceived behavioral control. may be completely unaware of a hazard an issue, or are unengaged by it, face Thus, a causal chain of beliefs, attitudes, (e.g., radon exposure, the link between different barriers from those who have Social Cognitive Theory (SCT) and intentions drives behavior. unprotected sex and HIV). The person may decided not to act. The PAPM prompts Social Cognitive Theory (SCT) describes a subsequently become aware of the issue practitioners to develop intervention dynamic, ongoing process in which personal but remain unengaged by it (Stage 2). Next, strategies that take into account the stages factors, environmental factors, and human the person faces a decision about acting that precede active decision-making. behavior exert influence upon each other. (Stage 3); may decide not to act (Stage 4),  According to SCT, three main factors affect SCT evolved from research on Social Reciprocal determinism describes rather than through their own experience. the likelihood that a person will change a Learning Theory (SLT), which asserts interactions between behavior, personal Reinforcements are responses to behavior health behavior: (1) self-efficacy, (2) goals, that people learn not only from their own factors, and environment, where each that affect whether or not one will repeat