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Population Health for Nurses

15.3 Theories and Models

Population Health for Nurses15.3 Theories and Models

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
  • Define the population(s) at risk and their levels of risk
  • Tailor risk information based on an individual’s characteristics or behaviors
  • Help the individual develop an accurate perception of their own risk
Perceived severity Beliefs about the seriousness of a condition and its consequences
  • Specify the consequences of a condition and recommend action
Perceived benefits Beliefs about the effectiveness of taking action to reduce risk or seriousness
  • Explain how, where, and when to take action and the potential positive results of doing so
Perceived barriers Beliefs about the material and psychological costs of taking action
  • Offer reassurance, incentives, and assistance
  • Correct any misinformation
Cues to action Factors that activate “readiness to change”
  • Provide “how to” information, promote awareness, and employ reminder systems
Self-efficacy Confidence in one’s ability to take action
  • Provide training and guidance in performing actions
  • Use progressive goal setting
  • Give verbal reinforcement
  • Demonstrate desired behaviors
Table 15.4 The Health Belief Model (HBM) (See National Cancer Institute, 2005.)

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.

  1. Which stage of the transtheoretical model is the focus of the podcast?
  2. 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
Table 15.5 Social Cognitive Theory (SCT) (See National Cancer Institute, 2005.)

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:

  1. What is the environment in which HoMBReS is delivered?
  2. 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
Table 15.6 Concepts in Diffusion of Innovations (See National Cancer Institute, 2005.)

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?
Table 15.7 Key Attributes Affecting an Innovation’s Diffusion (See National Cancer Institute, 2005.)

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
  • They want to be the first to try the innovation.
  • They are interested in new ideas and challenges and are willing to take risks.
Early Adopters
  • They tend to be opinion leaders in a social system and have influence over the decisions of others.
  • They are already aware of the need for change, so they are comfortable adopting new ideas.
Early Majority
  • They are rarely leaders, but they adopt new ideas before the average person.
  • They typically need to see evidence that the innovation works before they are willing to adopt it.
Late Majority
  • They are skeptical of change.
  • They will adopt an innovation only after the majority has tried it.
Laggards
  • They are very skeptical of change.
  • They are the hardest group to persuade to adopt an innovation.
Table 15.8 Adopter Categories in Diffusion of Innovations Theory (See Ohkubo et al., 2015.)

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.

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