Learning Outcomes
By the end of this section, you should be able to:
- 15.3.1 Describe health promotion models at the systems level that can guide the identification, development, and implementation of interventions.
- 15.3.2 Describe health promotion models and theories at the intrapersonal level that can guide the identification, development, and implementation of interventions.
- 15.3.3 Describe health promotion models and theories at the interpersonal level that can guide the identification, development, and implementation of interventions.
- 15.3.4 Utilize a theory or model to guide the identification, development, and implementation of interventions.
Various theories and models support the practice of health promotion and disease prevention. These theoretical bases guide the identification, development, and implementation of interventions. In many cases, they explain how health behaviors are influenced or how to influence health behaviors (Rejeski & Fanning, 2019). As such, they are commonly called behavior change theories and are geared toward individual health behaviors. However, it is also necessary to look at health promotion from a systems level to encompass the holistic nature of health and all the factors that impact health, or the SDOH, as discussed previously.
Applying a Systems Perspective to Health Promotion
There are different levels of influence that can affect health behavior. Recall Deanna in the case scenario. After receiving the blood pressure reading at the community health screening, Deanna may delay going to her provider for an annual exam. At the intrapersonal (individual) level, Deanna may have been stressed about the blood pressure reading, which she knows may increase her blood pressure even more, so this inaction may be due to fears of what the exam will reveal. At the interpersonal level, Deanna’s friends like to engage in regular exercise. This would be a positive factor, encouraging Deanna to participate in healthy activities. At the institutional level, scheduling an appointment may be difficult due to limited office hours. At the public policy level, Deanna may lack insurance coverage and have difficulty affording the appointment’s cost. The outcome of the individual avoiding an annual exam and potentially negatively affecting their health may result from every level of influence.
Theories and Models at the Intrapersonal, Interpersonal, and Community Levels
This section examines theories and their applications at the individual (intrapersonal), interpersonal, and community levels of the socio-ecological perspective (see Socio-Ecological Perspectives and Health). At the intrapersonal and interpersonal levels, these theories can be broadly categorized as cognitive-behavioral theories, which have three common concepts (National Cancer Institute, 2005, p. 12):
- Behavior is mediated by cognition. In other words, what people know and think affects how they act.
- 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” (National Cancer Institute, 2005, p. 12) and complement education by providing efforts to change the social and physical environment in hopes of supporting positive behavior changes.
Individual or Intrapersonal Level
The individual level is the most basic level of health promotion and disease prevention. Individual behavior is the most fundamental unit of group behavior; therefore, individual-level (intrapersonal-level) influence is necessary to promote behavior change at the larger levels. Intrapersonal-level theories focus on intrapersonal factors, which exist or occur within the individual self or mind. These factors include knowledge, attitudes, beliefs, motivation, self-concept, developmental history, past experiences, and skills.
The health belief model (HBM) focuses on an individual’s perceptions of the threat that a health problem poses, the benefits of avoiding the threat, and the factors that influence the decision to act. The threat could relate to susceptibility or severity, and factors influencing the decision to act could involve barriers, cues to action, or self-efficacy. One of the first theories of health behavior, the HBM was developed in the 1950s through the U.S. Public Health Service to explain why so few people were participating in free, government-supported programs to prevent and detect disease. The HBM (National Cancer Institute, 2005, p. 13) indicates that an individual is ready to act regarding their health if six constructs are in place (see Table 15.4).
The six constructs provide a beneficial framework for designing short-term and long-term behavior change strategies in individuals. They can also be used to design or adapt health promotion or disease prevention programs for groups. The HBM may be used alone or in combination with other theories or models.
| Construct | Definition | Potential Change Strategies |
|---|---|---|
| Perceived susceptibility | Beliefs about the chances of getting a condition |
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| Perceived severity | Beliefs about the seriousness of a condition and its consequences |
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| Perceived benefits | Beliefs about the effectiveness of taking action to reduce risk or seriousness |
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| Perceived barriers | Beliefs about the material and psychological costs of taking action |
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| Cues to action | Factors that activate “readiness to change” |
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| Self-efficacy | Confidence in one’s ability to take action |
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Another theory that can be used at the intrapersonal level for health promotion and prevention is the stages of change, or transtheoretical, model. This model is based on the premise that behavior change is a process, not an event, and as a person attempts to change a behavior, they move through five stages: precontemplation, contemplation, preparation, action, and maintenance. For more on these stages, see Socio-Ecological Perspectives and Health. An example of how this model may be applied is the CDC (2017) fact sheet “Talking about Fall Prevention with Your Patients” that describes strategies for matching fall prevention advice to a client’s stage of readiness.
Theory in Action
The Transtheoretical Model
The podcast “Lifestyle and Behavior Change” provides a discussion of how to use the Transtheoretical Model when performing health coaching for lifestyle and behavior change.
Listen to the podcast or read the transcript, and then respond to the following questions.
- Which stage of the transtheoretical model is the focus of the podcast?
- What are some specific examples of health coaching in public health?
Interpersonal Level
At the interpersonal level, “theories of health behavior assume individuals exist within, and are influenced by, a social environment” (National Cancer Institute, 2005, p. 19). The social environment can include anyone with whom an individual interacts, such as family, friends, coworkers, health professionals, and others. The opinions, thoughts, behaviors, advice, and support of these people influence the individual’s feelings and behavior, and the individual has an equal effect on these people.
Social cognitive theory (SCT) is the most frequently used example of an interpersonal model. SCT describes the influence of experiences, actions of others, and environmental factors on an individual’s health behaviors. Three main factors that affect the likelihood that a person will change a health behavior, according to the SCT, are self-efficacy, goals, and outcome expectancies. SCT includes six constructs, described in Table 15.5.
| Construct | Definition | Potential Change Strategies |
|---|---|---|
| Reciprocal determinism | The dynamic interaction of the person, behavior, and environment in which the behavior is performed | Consider multiple ways to promote behavior change, including making adjustments to the environment or influencing personal attitudes |
| Behavioral capacity | Knowledge and skill to perform a given behavior | Promote mastery learning through skills training |
| Expectations | Anticipated outcomes of a behavior | Model positive outcomes of healthful behavior |
| Self-efficacy | Confidence in one’s ability to take action and overcome barriers | Approach behavior change in small steps to ensure success and be specific about the desired change |
| Observational learning (modeling) | Behavioral acquisition that occurs by watching the actions and outcomes of others’ behavior | Offer credible role models who perform the targeted behavior |
| Reinforcements | Responses to a person’s behavior that increase or decrease the likelihood of recurrence | Promote self-initiated rewards and incentives |
Conversations About Culture
HoMBReS
HoMBReS is a community-based intervention designed to reduce the risk of HIV and other sexually transmitted infections among Latino men living in rural areas of the United States. The program is based on the SCT and trains “navegantes” (navigators) who provide information and risk reduction materials to the target population.
Read about HoMBReS, and then respond to the following questions:
- What is the environment in which HoMBReS is delivered?
- Which construct of SCT does HoMBReS seem to primarily focus on?
Community Level
Communities are at the heart of public health promotion and disease prevention. Community-level models explore how social systems function and change and how to activate community members and organizations. Models using community-level strategies can be used in numerous settings, including health care institutions, schools, workplaces, community groups, and government agencies. These models use the ecological perspective, as described in Socio-Ecological Perspectives and Health, addressing individual, group, institutional, and community issues (National Cancer Institute, 2005).
One of the most frequently used community-level models is the diffusion of innovations theory. It addresses how new ideas, products, and social practices spread within an organization, community, or society or from one society to another (National Cancer Institute, 2005). Diffusion of innovations is “the process by which an innovation is communicated through certain channels over time among the members of a social system” (National Cancer Institute, 2005, p. 27). These four central concepts are defined in Table 15.6.
| Concept | Definition |
|---|---|
| Innovation | An idea, object, or practice that is thought to be new by an individual, organization, or community |
| Communication channels | The means of transmitting the new idea from one person to another |
| Social system | A group of individuals who together adopt the innovation |
| Time | How long it takes to adopt the innovation |
Diffusion of innovations as it relates to health promotion and disease prevention requires a multilevel change process. At the individual or intrapersonal level, adopting a health behavior innovation usually involves lifestyle change. At the organizational or interpersonal level, it may involve starting programs, changing regulations, or altering roles. At the community level, the media, policies, or beginning initiatives may be involved. Considering the attributes that determine how quickly and to what extent an innovation will be adopted and diffused (see Table 15.7) can help health care professionals position it most effectively.
| Attribute | Key Question |
|---|---|
| Relative advantage | Is the innovation better than what it will replace? |
| Compatibility | Does the innovation fit with the intended audience? |
| Complexity | Is the innovation easy to use? |
| Trialability | Can the innovation be tried before making a decision to adopt? |
| Observability | Are the results of the innovation observable and easily measurable? |
The diffusion of innovations theory also involves categories of adopters, seen in Table 15.8. By identifying the characteristics of people in each adopter category, health care professionals can more effectively plan and implement strategies customized to their needs (National Cancer Institute, 2005).
| Category of Adopter | Characteristics |
|---|---|
| Innovators |
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| Early Adopters |
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| Early Majority |
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| Late Majority |
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| Laggards |
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The diffusion of innovations theory combines all of these elements to guide the health care professional in providing health promotion and disease prevention efforts. For example, a local university designs a program for the county public school system to decrease obesity in elementary school students. In the classroom, students learn about healthy foods, nutrition, and reading nutrition labels. The school cafeteria provides sample lunch menus with nutrition information. In physical education classes, students learn how different physical activities contribute to healthy living. After a few years, the program is considered a success. Program participants continued to have healthier habits than children who graduated before the program began.
The program’s success, however, is not enough. To broaden its impact, diffusion is necessary. The program’s relative advantage could be demonstrated to other school district leaders. The program’s compatibility could be demonstrated by illustrating how it meets national and state standards for health and physical education. Complexity could be addressed with teaching toolkits that make content easily accessible to educators. Interested educators could access free sample teaching materials via a website for trialability. Finally, observability could be provided via a video on the same website for demonstration purposes. Once adopted by another school district, leadership at the district could use the categories of adopters to roll out the program to educators.