2Objectives: You students will Understand the parameters required for health promotion modelBe able to apply those parameters on models they may suggest for your own society
3MODEL OF HEALTH PROMOTION 1: FOUR PARADIGMS OF HEALTH PROMOTION (CAPLAN AND HOLLAND - 1990) Radical changeNature of societyRADICAL HUMANISTHolistic view of healthDe-professionalizationSelf-help networksRADICAL STRUCTURLISTHealth reflects structural inequalitiesNeed to challenge inequity and radically transform society.SubjectiveObjectiveNature of knowledgeHUMANISTHolistic view of healthAims to improve understanding and development of selfClient-ledTRADITIONALHealth = absence of diseaseAim is to change behaviourExpert-ledSocial regulation
4MODEL OF HEALTH PROMOTION 2: HEALTH PROMOTION METHODS USING BEATTIE’S TYPOLOGY (BEATTIE – 1991) MODE OF INTERVENTIONLegislationPolicy making and implementationHealth surveillanceAdviceEducationBehaviour changeMass media campaignAuthoritarianIndividualCollectiveFocus of interventionCounsellingEducationGroup workLobbyingAction researchSkills sharing and trainingGroup workCommunity developmentNegotiated
5MODEL OF HEALTH PROMOTION 3: A TYPOLOGY OF HEALTH PROMOTION (FRENCH – 1990) DISEASE MANAGEMENTCurative servicesManagement servicesCaring servicesHEALTH EDUCATIONAgenda settingEmpowerment and supportInformationDISEASE PREVENTIONPreventive servicesMedical servicesBehaviour changePOLITICS OF HEALTHSocial actionPolicy developmentEconomic and fiscal policy
6MODEL OF HEALTH PROMOTION 4: TANNAHILL’S MODEL OF HEALTH PROMOTION (DOWNIE et al – 1990) 56. Positive health protection, e.g. workplace smoking policy.7. Health education aimed at positive health protection, e.g. lobbying for a ban on tobacco advertising.1. Preventive services, e.g. immunization, cervical screening, hypertension case finding, developmental surveillance, use of nicotine chewing gum to aid smoking cessation.2. Preventive health education, e.g. smoking cessation advice and information.Health education72461HealthprotectionPrevention33. Preventive health protection, e.g. fluoridation of water.4. Health education for preventive health protection, e.g. lobbying for seat belt legislation.5. Positive health education, e.g lifeskills with young people.
7MODEL OF HEALTH PROMOTION 5: THE CONTRIBUTION OF EDUCATION TO HEALTH PROMOTION (TONES et al – 1990) Public pressureHealthy public policyLobbyingAdvocacyMediationHealthy social and physical environmentEmpowered participating communityHealthy promoting organisationHEALTHHealthy servicesCritical consciousness raisingAgenda settingHealthy choicesProfessional educationEducation for health
9Approaches in Health Promotion: the example of healthy eating AimsMethodsWorker/clientrelationshipMedicalTo identify those at risk from disease.Primary health care consultation.e.g. measurement of body mass.Expert-led.Passive, conforming client.
10Approaches in Health Promotion: the example of healthy eating AimsMethodsWorker/clientrelationshipPersuasion through one-to-one advice, information, mass campaigns, e.g. ‘Look After Your Heart’ dietary messages.Expert-led.Dependent client.Victim blaming ideology.Behavior changeTo encourage individuals to take responsibility for their own health and choose healthier lifestyles.
11Approaches in Health Promotion: the example of healthy eating AimsMethodsWorker/clientrelationshipEducationalTo increase knowledge and skills about healthy lifestyles.Information.Exploration of attitudes through small group work.Development of skills, e.g. women’s health group.May be expert led.May also involve client negotiation of issues for discussion.
12Approaches in Health Promotion: the example of healthy eating AimsMethodsWorker/clientrelationshipEmpowermentTo work with client or communities to meet their perceived needs.AdvocacyNegotiationNetworkingFacilitation e.g. food co-op, fat women’s group.Health promoter is facilitator, client becomes empowered.
13Approaches in Health Promotion: the example of healthy eating AimsMethodsWorker/clientrelationshipSocial changeTo address inequalities in health based on class, race, gender, geography.Development of organizational policy, e.g. hospital catering policyPublic health legislation, e.g. food labelling.Fiscal controls, e.g. subsidy to farmers to produce lean meat.Entails social regulation and is top-down.
14Religion and Health - 3 Quran & Ahadith Five Pillars of Islam Elements of FaithIslamicJurisprudenceSalutogenicMechanismSense ofcoherencePredisposing &Enabling factorsAn in-depth review of literature shows that not much has been written in English language on the relationship between health behavior and Islam. Still a search on the Internet has shown several attempts by Muslims and non-Muslims to document various relationships between Islam and contemporary health. Ruck (2002), a health and development consultant from the UK has written an Internet based lecture on child health and Islam. In it she describes Islamic ideas in relation to Community Health Promotion, which include.Zat al Bain: essential bonds within a communityFard –El Kifaya: Collective duty to care about othersDe Leeuw and Hussein (1999) looked at the five action areas of the Ottawa charter and demonstrated their link to Islamic concepts of ‘Da’wah’, ‘Shari’ah’,’ Shuura’, ‘Hisba’ and ‘Waqf’. These notions, which show how Islam tries to establish a mechanism to care for each other in a community, are part of three major concepts in Islam, namely the five pillars of Islam, Elements of ‘Imaan’-Faith and Islamic Jurisprudence. These three concepts can be said to be the basis for an “Islamic Health Theory” (See figure 1 on slide). The figure shows how the Islamic concepts built upon the Quran and Ahadith could influence behavior through various determinants and ultimately leading to a healthy lifestyle which contributes to health as proven by various empirical studies. Obedience to the various concepts of Islam, based on Milgram’s experiment as described by Sabini (1992), is the assumption one has to take in applying this theory for health promotion interventions.References:De Leeuw, E. & Hussein, A. (1999). Islamic health promotion and interculturalization. Health Promotion International, Volume 14 No 4,Ruck, N. (2002). Child Care in Islam:Lessons for health promotion. Islamic supercourse lectures.BehaviorFigure 1: Pathways of ‘Islamic Health Theory’Healthy Lifestyle
15Putting Islamic Concepts Into Practice for Health Promotion 1 PlanDoCheckThere is a general consensus that genetics, environment and lifestyle form the basic factors that determine the health of an individual (Kemm & Close, 1995; Naidoo and Wills, 2000). Health promotion strategies try to influence these determinants as much as possible to enhance health. As these determinants are part of various fields of sciences, the health promotion concept can be said to have gathered several fields of studies under one umbrella (Bunton & Macdonald, 1992; Kemm & Close, 1995; Green & Kreuter, 1999; Naidoo and Wills, 2000). In 1986 WHO, in the first conference held on health promotion, declared one of the most comprehensive definitions of health promotion “the process of enabling people to increase control over, and to improve, their health”. Since then much has been written on health promotion and the various ways of designing, planning and implementing health promotion strategies.Reference:Bunton, R. & Macdonald, G. (1992). Health Promotion: Disciplines and diversity. London. Routledge.Green W. L. & Kreuter W. M. (1999). Health Promotion Planning: An Educational and Ecological Approach. 3rd ed. Mountain View. Mayfield Publishing Company.Kemm, J. & Close, A. (1995). Health Promotion: Theory and Practice. London. Macmillan Press LTD.Naidoo, J. & Wills, J. (2000). Health Promotion Foundations for Practice. 2nd ed. Bailliere Tindal. Harcourt Publishers Limited.World Health Organization. (1986). Ottawa Charter for health promotion. Geneva. WHO.
16Putting Islamic Concepts Into Practice for Health Promotion 2 Precede-proceed model.Intervention mapping.A five-stage model.There are so many ways that health promotion programs are started or implemented. The most successful ones are mainly those based on theoretical frameworks. There is enough material in health promotion that shows evidence that suggest the use of theories will enhance the chances of success in achieving pre-determined program objectives Most health promotion strategies use more than one single theory in the development of an intervention plan (Nutbeam and Harris, 1998).Reference:Nutbeam, D. & Harris, E. (1998). Theory in a Nutshell: a practitioner's guide to commonly used theories and models in health promotion. Sydney : University of Sydney, Department of Public Health and Community Medicine, National Centre fot Health Promotion
17Putting Islamic Concepts Into Practice for Health Promotion 2.1 The PRECEDE-PROCEED Model by Green & Kreuter, 1999Visit the website below for a figure of this model.In one of the most comprehensive theoretical model for health promotion intervention planning by Green and Kreuter (1999), the PRECEDE-PROCEED theoretical model, some of the determinants of behavior outlined include Predisposing factors, Enabling factors and Reinforcing factors. By moving progressively through nine phases this model offers comprehensive framework for planning a health promotion intervention. As mentioned earlier the PRECEDE-PROCEED model has nine phases, the first five 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 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.The four remaining phases in PRECEDE-PROCEED are implementation and evaluation (process, impact, and outcome), with emphasis on using the latter to improve the former. Evaluation of the process begins as soon as implementation does, in order to detect problems early so they can be corrected. As implementation 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.Reference:Green W. L. & Kreuter W. M. (1999). Health Promotion Planning: An Educational and Ecological Approach. 3rd ed. Mountain View. Mayfield Publishing Company.National Institute of health.
18Putting Islamic Concepts Into Practice for Health Promotion 2.2 Intervention mapping.STEP 1: Proximal program objective matricesSTEP 2: Theory –based methods and practical strategiesSTEP 3: Program planSTEP 4: Adoption and implementation planSTEP 5: Evaluation planIntervention Mapping, a model based as well on theories, provides health promotion planners also with a framework for decision making at all the stages of intervention planning, implementation, and evaluation. There are five main steps in intervention mapping. Each steps involves several tasks. Completion of a task from each step creates a product which becomes a guide to the next step. Moving from one step to the next is not necessary a linear process. In practice the steps are intertwined and one moves from within the steps as many times as necessary depending on their context.STEP 1: Proximal program objective matrices· State expected changes in behavior and environment· Specify performance objectives· Specify determinants· Create matrices of proximal program objectives, and write learning and change objectives.STEP 2: Theory –based methods and practical strategies· Brainstorm methods· Transfer methods into practical strategies· Organize methods and strategies at each ecological levelSTEP 3: Program plan· Operationalize the strategies into plans, considering implementers and sites· Develop design documents· Produce and pretest program materials with target groups and implementersSTEP 4: Adoption and implementation plan· Develop a linkage system· Specify adoption and implementation performance objectives· Create matrix or planning table· Write an implementation planSTEP 5: Evaluation plan· Develop an evaluation model· Develop effect and process evaluation questions· Develop indicators and measures· Specify evaluation designs· Write an evaluation planReference:Bartholomew, K.L., Parcel, S.G., Kok, G. &Gottlieb, H.N. (2001). Intervention Mapping: Designing Theory and Evidence-Based Health Promotion Programs. Mayfield Publishing Company.
19Putting Islamic Concepts Into Practice for Health Promotion 2.3 A five-stage model (Bracht et al. 1999)1. CommunityanalysisCOMMUNITYORGANIZATIONSTAGES5. Dissemination- reassessment2. Design- initiationThis model which is based on community organization work done by the authors, elements of organizational development and strategic planning, and community empowerment theory shows in practical ways how health promotion interventions could be initiated in a given community. Through out the five stages involvement of individuals is recommended and considered to be of high importance for successful health promotion interventions (Bracht et al., 1999).So far the lecture has shown the link between religion and health, Described various Islamic concepts derived from the three major concepts of Islam with bearings towards health, which have also been proven theoretically (See preceding slides for more details) and also three theoretical based models for implementing health promotion. However, what is missing is an elaboration on practical application of Islamic notions making use of these practical theoretical models of health promotion.Due to time and space I will use only one model to show how Islamic notions fit within contemporary health promotion notions. For the purpose of illustrating this, the model of Bracht et al (1999) will be used in the next five slides.Reference:Bracht, N., Kingsbury, L. & Rissel L. (1999). A Five stage Community Organization Model for Health Promotion. In Bracht, N (Ed.). Health Promotion at the community Level. (pp ). International Educational and Professional Publisher, Thousand Oaks, California SAGE Publications4. Maintenance- consolidation3. Implementation
20Putting Islamic Concepts Into Practice for Health Promotion 3.1 An illustration using the five-stage model (Bracht et al. 1999)1. Community analysis.The first stage requires a comprehensive accurate analysis and understanding of a community’s needs, resources, social structure, and values. To encourage and ensure that programs designed reflect these, this stage requires as well the involvement of community leaders. Islamic concepts based on the Quran and Ahadith are the starting point in understanding the social structure and values of an Islamic community. Imams and Quranic teachers are the main sources through which Muslims learn the teachings of the Quran and Ahadith and so could be construed as primary Islamic leaders in an Islamic community. The understanding of various Islamic concepts such as the three major concepts of Islam (‘Five pillars of Islam’, Elements of Imaan-Faith’ and Islamic Jurisprudence) can facilitate an in-depth community analysis of an Islamic community. These three major concepts of Islam have given birth to various other concepts, which are applied in various forms in different Islamic communities worldwide. These concepts include Da’wah’, ‘Shariah’,’ Shuura’, ‘Hisba’ and ‘Waqf’ among many other concepts. Da’wah for instance means invitation. Islam encourages everyone to invite each other to understand or to know what is good and to forbid what is bad. This is clearly stated in the Quran (9:71) as “The Believers, men and women, are protectors, one of another: they enjoin what is just, and forbid what is evil: they observe regular prayers, practice regular charity, and obey Allah and His Messenger. On them will Allah pour His Mercy: Allah is Exalted in power, Wise.” This however does not mean coercion in fact the Quran (16:125) states “Invite (all) to the way of thy lord with wisdom and beautiful Preaching; and argue with them in ways that are best and most gracious: for thy lord knoweth best, who have strayed from his path and who received guidance.” In understanding this simple but very important Islamic concept health promoters can initiate dialogues with Muslims directly at individual level or indirectly through their leaders. This dialogue in turn will offer the possibility for a comprehensive analysis and understanding of an Islamic community to conclude this first stage of Bracht et al. (1999) five-stage model.Reference:Bracht, N., Kingsbury, L. & Rissel L. (1999). A Five stage Community Organization Model for Health Promotion. In Bracht, N (Ed.). Health Promotion at the community Level. (pp ). International Educational and Professional Publisher, Thousand Oaks, California SAGE Publications
21Putting Islamic Concepts Into Practice for Health Promotion 3.2 An illustration using the five-stage model (Bracht et al. 1999)2. Design - initiation.The second stage of Bracht et al. (1999) model is the design and initiation stage, which calls upon the establishment of a core planning group and selecting a local organizer or coordinator. Concurrently to this, this stage also calls upon choosing of an organizational structure and examples of these are given as advisory board, council, coalition, lead agency, informal network, and grassroots or advocacy movements. In Islam the concept of Shuura is an example of organizational structure within Islamic community. This concept is comparable to the description of coalition described by Bracht et al. (1999) as being an “alliance of several community groups and/ or health organizations”. The concept of Shuura is not merely an advisory board or a coalition, rather in an Islamic community Muslims, through Shuura are obliged to work together in mutual consultation and decisions reached are binding (Hussein, 1998). Therefore this concept offers a possible entry point into the 2nd stage of Bracht et al. (1999) five-stage model.Reference:Bracht, N., Kingsbury, L. & Rissel L. (1999). A Five stage Community Organization Model for Health Promotion. In Bracht, N (Ed.). Health Promotion at the community Level. (pp ). International Educational and Professional Publisher, Thousand Oaks, California SAGE PublicationsHussein, A. A. (1998). The art of health promotion in Islam and the contemporary public health challenges, MPH Thesis. Maastricht. University of Maastricht.
22Putting Islamic Concepts Into Practice for Health Promotion 3.3 An illustration using the five-stage model (Bracht et al. 1999)3. Implementation.Implementation of a health promotion program is the 3rd stage in the Bracht et al. (1999) model. In this stage, theories and ideas are turn into action making use of professionals and other resource people in the community through out the planning of the intervention. Through out the process, available community resources are maximized and adapted to local constraints. The Islamic concept of Shariah, which falls under the Islamic jurisprudence concept, offers clear guidelines in dealing with various issues in Islam. For health promoters, to understand this would be crucial to ensure the success of their program. In knowing the point in the scale, of the area of intervention within the Shariah law (‘prescribed’, ‘recommended’, ‘permissible’, ‘disliked’ and ‘unlawful’) health promoters would be better equipped to tailor their interventions according to the perspective of the Islamic community intended for and so ensure better chances of success. The principles of Ijtihad within the Islamic Jurisprudence which include the fact that:1. Laws change with changes in time and place;2. Choosing the lesser of two harms; and3. Preserving public interestAlso offers channels of communications for health promoters to bring in new ideas in an Islamic community.Reference:Bracht, N., Kingsbury, L. & Rissel L. (1999). A Five stage Community Organization Model for Health Promotion. In Bracht, N (Ed.). Health Promotion at the community Level. (pp ). International Educational and Professional Publisher, Thousand Oaks, California SAGE Publications
23Putting Islamic Concepts Into Practice for Health Promotion 3.4 An illustration using the five-stage model (Bracht et al. 1999)4. Maintenance - consolidation.The theme of the fourth stage in the Bracht et al. (1999) model is program maintenance and consolidation. Zakat, Waqf and Saddaqa, Islamic concepts found in all the three major concepts (‘five pillars of Islam’, Elements of Imaan-Faith’ and ‘Islamic jurisprudence’), provides possible grounds by which health promoters can expound on in an Islamic community to ensure sustainable health promotion interventions. In these three Islamic concepts, both financial and other community structures in support of Islamic interests within the Islamic society are dealt with and can be exploited to benefit health interventions. For instance the concept of ‘Waqf’, an Islamic concept whereby able Muslims put aside material endowments to benefit the Islamic community can be an important means for ensuring and granting revenues for vital health promotion interventions (Hussein, 1998)Reference:Bracht, N., Kingsbury, L. & Rissel L. (1999). A Five stage Community Organization Model for Health Promotion. In Bracht, N (Ed.). Health Promotion at the community Level. (pp ). International Educational and Professional Publisher, Thousand Oaks, California SAGE PublicationsHussein, A. A. (1998). The art of health promotion in Islam and the contemporary public health challenges, MPH Thesis. Maastricht. University of Maastricht.
24Putting Islamic Concepts Into Practice for Health Promotion 3.5 An illustration using the five-stage model (Bracht et al. 1999)5. Dissemination - reassessment.Finally, the fifth stage of Bracht et al. (1999) model is dissemination and reassessment. In this stage key elements include updating the community analysis and profiles, “which involves looking for changes that might have occurred in leadership, resources, and organizational relationship in the community”. To carry out the activities of this stage the health promoter can make use of the concept of Shuura as described in the second stage. In addition several other channels of communication can be identified within an Islamic community, which include the Mosque and Quranic schools. The mosque is an important area in an Islamic community and offer possible means as way for disseminating health promotion ideals. For instance all Muslim men are obliged to attend Friday prayers in a mosque (Quran 62:9-10). This prayer is performed in a congregation and there are two sermons prior to the prayer. The first sermon is dedicated to issues on religion while the second sermon to issues on current affairs affecting the Muslim community. Prior to the sermons, the Khatib (the person saying the sermons) mingles with the congregation to discuss on any issues that might be of relevance for presentation during the sermons. By taking advantage of these channels of communication in Islamic society, the health promoter would be able to complete successfully health promotion interventions based on peoples’ own perspective on life, health and healthy behavior.Reference:Bracht, N., Kingsbury, L. & Rissel L. (1999). A Five stage Community Organization Model for Health Promotion. In Bracht, N (Ed.). Health Promotion at the community Level. (pp ). International Educational and Professional Publisher, Thousand Oaks, California SAGE Publications
26Behavior and Global Health “Health is a state of complete physical, psychological, and social well-being and not simply the absence of disease or infirmity.” (World Health Organization, 1948)Physical good health eludes billions of peopleDeath and disease from preventable causes remain highBehavior is a key factor in determining healthThe World Health Organization defines health as a “state of complete physical, psychological, and social well-being and not simply the absence of disease or infirmity.”Today, death and disease from preventable causes remain high. In spite of overall progress, good health eludes billions of people. Although viruses, bacteria, other pathogens, congenital factors, and genetics are obviously implicated in many of the world’s most pressing health problems, we cannot solve these problems solely through technical fixes such as vaccines, a new generation of antibiotics, or gene therapy. Human behavior is a key factor in determining health.
27Ten Leading Risk Factors for Preventable Disease Maternal and child underweightUnsafe sexHigh blood pressureTobaccoAlcoholUnsafe water, poor sanitation, & hygieneHigh cholesterolIndoor smoke from solid fuelsIron deficiencyHigh body mass index or overweightThe behavior-health link becomes clear when examining the 10 leading risk factors identified by the World Health Organization for preventable death and disease worldwide: maternal and child underweight; unsafe sex; high blood pressure; tobacco; alcohol; unsafe water, poor sanitation, and hygiene; high cholesterol; indoor smoke from solid fuels; iron deficiency; and high body mass index, or overweight. According to WHO, forty percent of deaths worldwide are due to these 10 risk factors alone.Source: WHO, World Health Report 2002: Reducing Risk, Promoting Healthy Life (Geneva: WHO, 2002), accessed online at on Nov. 15, 2004.
28Whose Behavior is Responsible For… Maternal and child underweightSmoking and alcohol abuse Unsafe sex Unsafe water and lack of adequate sanitation
29Maternal and Child Underweight Individuals (may resist nutrition education)Communities (male preference norms)Policymakers (fail to address poverty)Health planners and health workers (do not include nutrition programs for the poor)
30Smoking and Alcohol Abuse Individuals (choice)Communities (norms regarding smoking)Health policymakersLegislators & tax assessorsTobacco company executivesDecision-makers in marketing companies
31Unsafe Sex Individuals (abstinence, fidelity, condoms) Communities (norms regarding male dominance and multiple partners)Poverty (transactional sex for poor women)Health policymakers and health workers (effective AIDS prevention programs)
32Unsafe Water and Lack of Adequate Sanitation Individuals (where they fetch water, boiling water, washing hands)Communities (fatalism regarding diarrheal diseases, community latrines)Governments (ignore or underfund safe water and sanitation needs)
33Risky behaviors translate to diseases Risk factors translate into disease, disability, and death—collectively referred to as the “burden of disease.” Addressing risky behaviors rather than specific diseases is cost-effective because one risk factor can result in or worsen several diseases. For example, tobacco causes or contributes to lung cancer, ischemic heart disease, diabetes, and cerebrovascular disease. Undernutrition is an underlying cause of disease resulting in an estimated 60 percent of child deaths. Unsafe sex, the second-highest risk factor in poor countries, translates into HIV/AIDS; other sexually transmitted infections; fistulas; cervical cancer; and unsafe pregnancies, abortions, and births. Alcohol abuse contributes to brain impairment, including fetal alcohol syndrome, cirrhosis and cancer of the liver, and death and injuries from violence and accidents.
34Noncommunicable diseases Global Causes of DeathInjuriesCommunicable diseases, maternal and perinatal conditions, and nutritional deficienciesNoncommunicable diseasesBehavior plays a key role when looking at the direct causes of death. The World Health Report 2000 ranked the causes of global deaths into three categories. The highest, at almost 60 percent, is noncommunicable diseases; the greatest proportion of which is due to cardiovascular disease. More than 30 percent of global deaths are due to communicable diseases, maternal and perinatal conditions, and nutritional deficiencies. The remaining 10 percent are deaths by injuries.In poor countries, however, the order is quite different: Communicable diseases, maternal and perinatal conditions, and nutritional deficiencies cause the majority of deaths, followed by injuries and noncommunicable diseases.However, no matter where one lives, behavior change would significantly reduce exposure to these killers, or, once exposed, would mitigate their consequences through early treatment.Source: WHO, World Health Report 2000—Health Systems: Improving Performance (Geneva: WHO, 2000).
36Health Promotion Means Changing Behavior at Multiple Levels A Individual: knowledge, attitudes, beliefs, personality B Interpersonal: family, friends, peers C Community: social networks, standards, norms D Institutional: rules, policies, informal structuresE Public Policy: local policies related to healthy practicesHealth-related behaviors are affected by, and affect, multiple levels of influence: intrapersonal or individual factors, interpersonal factors, institutional or organizational factors, community factors, and public policy factors.Individual factors are individual characteristics such as knowledge, attitudes, beliefs, and personality traits that influence behavior.Interpersonal factors are interpersonal processes, and primary groups including family, friends, and peers that provide social identity, support, and role definition.Institutional factors are rules, regulations, policies, and informal structures that may constrain or promote recommended behaviors.Community factors are social networks and norms or standards that exist formally or informally among individuals, groups, and organizations.Public policy factors are local, state, and federal policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control, and management.Source: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion (2003), available online at
37A: Individual-Oriented Models Individual most basic unit of health promotionIndividual-level models components of broader-level theories and approachesModelsStages of Change ModelHealth Belief ModelThe individual is the most basic unit of health promotion. All levels such as groups, organizations, communities, and nations are composed of individuals.An individual can be influenced to make decisions in his or her personal life. But influencing some people—those who lead nations, manage organizations, sway their peers, raise children, and develop health-related policies— means influencing others as well.At the practical level, a large percentage of health professionals spend their time dealing with individuals in face-to-face encounters such as counseling or giving clients instructions. Educational materials such as booklets and posters in health clinics are intended for individual consumption while mass media reaches large numbers at the same time.Thus, although concentrating on individuals alone is still the default mode in many places, it is inadequate for widespread and sustained behavior change. Individual-level models such as the Stages of Change and Health Belief models should be components of, or at the least consistent with, broader-level theories and approaches.
38Stages of Change ModelChanging one’s behavior is a process, not an eventIndividuals at different levels of changeGear interventions to level of changeThe basic premise behind the Stages of Change Model is that behavior change is a process and not an event, and that individuals are found at varying levels of motivation, or readiness, to change. People at different points in the process can benefit from different interventions, matched to their stage.Source: James O. Prochaska et al., “In Search of How People Change: Application to Addictive Behaviors,” American Psychologist 47, no. 9 (1992):
39Stages of Change Model (cont.) PrecontemplationMaintenanceContemplationFive stages are identified in the Stages of Change Model: precontemplation, contemplation, decision/determination, action, and maintenance. This is a circular model, not a linear one. People do not have to go through every stage, and they can enter and exit at any point, and people often return to earlier stages.The Stages of Change Model can help explain why employees who smoke might not take part in free smoking-cessation clinics offered by employers. Individuals in the first stage—unaware of the risk or its application to themselves—need information and ways to personalize risk. Others need help in moving their contemplation of change to intentions to stop smoking; those who have made the decision to stop will be best helped by developing a step-by-step plan that includes breaking habits such as smoking after a meal. Those who have made the change need positive feedback and social support. To maintain their nonsmoking behavior, individuals need reinforcement and continued avoidance of factors associated with relapses. A person who relapses returns to an earlier stage and will need appropriate assistance.ActionDecision
40Health Belief ModelPerceived susceptibility and severity of ill healthPerceived benefits and barriers to actionCues to actionSelf-efficacyThe Health Belief Model is one of the most widely recognized conceptual frameworks of health behavior. According to the model individuals conduct an internal assessment of the net benefits of changing their behavior, and then decide whether to act.The Health Belief Model identifies several aspects of this internal assessment: perceived susceptibility to ill health, perceived severity of ill health, perceived benefits of behavior change, and perceived barriers to taking action. The right combination of perceptions adds up to an individual’s readiness to act. Health promotion messages—through mass media, peer education, and other interventions—act as cues to action, translating that readiness into overt behavior. These cues are often necessary to overcome habitual unhealthy behaviors such as not wearing seat belts, eating primarily high-fat foods, or smoking. The model also factors in an individual’s sense of self-efficacy or confidence in one’s ability to make the desired change.Source: Irwin M. Rosenstock et al., “Social Learning Theory and the Health Belief Model,” Health Education Quarterly 15, no. 2 (1988):
41B: Interpersonal Level: Social Learning Theory Interaction of individual factors, social environment, and experienceReciprocal dynamicObservational learningCapability of performing desired behaviorPerception of self-efficacySocial Learning Theory analyzes psychosocial influences arising from the interaction of individual factors, the social environment, and experience. The circle of influence includes those closest to an individual, such as family members, friends, and other peers, but can also include others such as co-workers and health professionals.While the physical and social environment shapes behavior, people are not passive in the process, since they in turn can change their environments, creating a reciprocal dynamic. For example, people can be put at risk by the high prevalence of malaria where they live, but they can reduce their personal risk by using insecticide treated bednets, or they can contribute to widespread risk reduction if they mobilize a community group pressuring the government to drain mosquito-breeding sites.Social learning theory also considers observational learning. People learn not only through their own experiences but also by observing the actions of others and the results of those actions.The theory emphasizes behavioral capability: A person needs to know what to do and how to do it. Thus, clear instructions and sometimes training are needed.Social Learning Theory considers self-efficacy as being one of the most important aspects in bringing about healthy behaviors.Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).
42Interpersonal Level: Social Learning Theory (cont.) Three strategies for increasing self-efficacySetting small, incremental goalsBehavioral contracting: specifying goals and rewardsSelf-monitoring: feedback can reinforce determination to change (keep a diary)Positive reinforcement: encouragement helpsSocial Learning Theory recommends three strategies for increasing self-efficacy:Setting small, incremental goals: When someone achieves a small goal, his or her sense of self-efficacy increases. Taking the next step—and another—makes the goal seem attainable.Behavioral contracting: Agreeing to a formal process that specifies goals and rewards so that individuals and groups will receive feedback, guidance, and praise for progress.Self-monitoring: Feedback from self-monitoring, such as keeping a journal, can reinforce determination to change and increase confidence in one’s ability to achieve the desired action.Finally, applying intermittent positive reinforcement over an extended period helps to maintain the desired behavior once it is adopted.Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).
43C: Community-Level Models Analyze how social systems functionMobilize communities, organizations, and policymakersUse sound conceptual frameworksCommunity MobilizationOrganizational ChangeDiffusion of Innovations TheoryDesigning health promotion interventions to reach entire communities or specific groups—rather than influencing one individual at a time—is a basic goal of public health. The health of communities can be improved through policies such as universal health insurance, programs such as prenatal care visits to poor pregnant women, and a community’s own actions such as organizing to demand better health services.Community-level models analyze how social systems function and therefore how communities, organizations that serve them, and policymakers can be mobilized for change.Three conceptual frameworks for community-level health promotion are: Community Mobilization, theories of Organizational Change, and Diffusion of Innovations Theory.
44Community Mobilization Encompasses wider social and political contextsCommunity members assess health risks, take actionEncourages empowerment, building on cultural strengths and involving disenfranchised groupsBecause communities are embedded in wider social and political contexts, community mobilization is also called “social mobilization” to acknowledge all levels of influence, including public policy.Community mobilization requires the active participation of community members to assess health risks and take action to reduce them. Empowerment of community members is a key component of this model, as part of the process of creating an environment for change. This means building on cultural strengths and tapping the often- unrecognized spirit and talents of the poor and other disenfranchised groups.It is important to note that community mobilization implies the involvement of many types of communities. The larger community contains social networks of the wealthy and other elites, the poor, the middle class, workers of various sorts, religious groups, mainstream and minority populations, and others. These subgroups have differing interests, power, and access to resources. One of the challenges in mobilizing communities is building group consensus around the most pressing problems common to all, such as poor sanitation, and then deciding what to do. Actions could include petitioning the government to dig latrines or harnessing local money and labor to dig the latrines as a community project. Whether involving local people or a national interest group, community or social mobilization creates the environment for healthy change.Source: National Cancer Institute, Theory at a Glance: A Guide for Health Promotion: 18; Paolo Freire, Pedagogy of the Oppressed (New York: Continuum, 1970.); Saul Alinsky, Rules for Radicals: A Pragmatic Primer for Realistic Radicals (New York: Vintage Books, 1971; revised edition, 1989).
45Organizational Change Organizational Stage TheoryOrganizational Development TheoryDefine problemIdentify solutionsInitiate actionAllocate resourcesImplementInstitutionalizeOrganizational structuresOrganizational Stage Theory is based on the observation that organizations, similar to individuals, pass through a series of stages as they change. Thus, interventions can be focused on moving the organization from one stage to the next. Groups can be resistant to change and need encouragement, new skills, and confidence to make a successful transition.An organization begins the process by first defining a problem and identifying solutions; management or workers might be the first to identify a problem and propose solutions. The next step is to initiate an action to address the problem and allocate resources to implement the change. The implementation stage follows and initial changes occur, then more change until the problem is solved. The last step— institutionalization—is critically important.Complementing the stage theory, the Organizational Development Theory focuses on how organizational structures and processes influence worker behavior and motivation. This theory encourages analysis of problems that interfere with an organization’s optimal performance, such as problems between the management and staff of a health clinic. Consultants are often brought in to help employees collectively identify problems and to generate solutions and action plans.Worker behavior and motivation
46Diffusion of Innovations Theory How new ideas, products, and behaviors become normsAll levels: individual, interpersonal, community, and organizationalSuccess determined by: nature of innovation, communication channels, adoption time, social systemDiffusion of Innovations Theory examines how new ideas, products and behaviors become norms. This theory deals with behavior change on all levels—individual, interpersonal, community, and organization—and integrates related theories.The theory focuses on widespread behavior change. Health interventions have yielded thousands of small-scale successes in behavior change, but how can this be done on a grand scale? How, for example, did vaccines and mass immunization of children become routine?Diffusion of Innovations Theory provides a description of how such innovations spread naturally through social networks and analyzes how to use diffusion networks to plan large-scale behavior change.Four main elements determine whether or not an innovation will succeed: the nature of the innovation itself, the kinds of communication channels available, the time taken for adoption, and the characteristics of the social system through which the innovation spreads.Source: Everett M. Rogers, Diffusion of Innovations, 4th ed. (New York: The Free Press, 1995).
47Diffusion of Innovations (cont.) Nature of innovationRelative advantage over what is being replacedCompatible with values of intended usersEasy to useOpportunity to try innovationTangible benefitsThe innovation must be seen as having a relative advantage over what it is replacing.The innovation must also be compatible with the values and life context of intended users.The degree of complexity matters too. If the innovation is difficult to adopt (for example, a hard-to remember medication regime), there is little chance that it will be adopted.People and groups appreciate trying out a proposed innovation on a limited basis before committing to it; if such a trial period is possible and successful, an innovation is more likely to be adopted.Once adopted, the innovation is likely to be adopted for the longterm, and others will be influenced to adopt it if the individual or group can observe tangible benefits of the change.
48Diffusion of Innovations (cont.) Communication channelsMass media (enhanced by listening groups, call-in opportunities, and face-to-face approaches)PeersRespected leadersCommunications channels—the means by which messages get from one individual to another—are also important.Mass media channels are effective in disseminating information about innovations to many people, but peers are highly influential in a person’s decision to adopt an innovation. Thus, using social networks to reinforce mass media messages is more effective than mass media alone. In addition, when respected leaders initiate or reiterate information provided through mass media channels, the chances increase that individuals and groups will decide to act.A combination of popular leaders’ recommendations, peer group approval, and mass media messages—especially if enhanced by coordinated listening groups, call-in opportunities, and face-to-face approaches—is a powerful impetus to adopt an innovation.
49Diffusion of Innovations (cont.) Adoption timeAwareness Intention Adoption ChangeGradualMovement through groupsPioneersEarly adoptersMassesDiffusion takes time. The process of going through the various stages of change—from initial awareness to intention to adoption to sustained change— may be gradual for both individuals and organizations.The funding for many promising programs ends or programs are prematurely evaluated and found wanting before desired change has had a chance to occur.An innovation is spread first by pioneering individuals who initiate or “import” it. Then comes a slightly larger group of early adopters, a category of local “missionaries” for speeding the diffusion process. Early adopters are key players in getting an innovation to the point at which enough individuals have adopted it that the innovation’s further rate of adoption becomes self-sustaining.
50Diffusion of Innovations (cont.) Social system:Identify influential networks to diffuse innovation: health systems, schools, religious and political groups, social clubs, unions, and informal associationsIdentify opinion leaders, peers, and targeted media channels to diffuse innovationsThe fourth element is the social system, which constitutes the boundary in which an innovation diffuses.A large social system, such as a city, has many subunits, such as health systems and facilities, religious and political groups, social clubs, unions, and informal associations of people. The structure and norms of each unit will affect diffusion within the unit, and whether an innovation will be adopted by a critical mass within the larger social system.Health promoters must try to understand the social systems into which a health innovation is being introduced. Qualitative research—in-depth interviews, focus groups, and social network mapping—can help identify opinion leaders who can diffuse the desirable innovations.
52Health Promotion Tools Mass mediaSocial marketingCommunity mobilizationHealth educationClient-provider interactionsPolicy communicationMost health planners use a combination of theory-based approaches and tools to promote positive behavior change. No single approach is likely to produce significant or sustainable change. For example, in the case of developing countries’ fertility transition to smaller families, mass media played a contributory role but only as part of a complex social process rather than as an independent effect. Multiple channels over time provide reinforcing messages that produce interpersonal discussion among more and more people and eventually result in a change in social values and behavior.Health promotion tools include: mass media, social marketing, nationwide and intensive community mobilization, health education, client-provider interactions in health facilities, and policy communication.Source: Robert Hornik and Emile McAnany, “Mass Media and Fertility Change,” in Diffusion Processes and Fertility Transition: Selected Perspectives, ed. John Casterline (Washington, DC: National Academies Press, 2001):
53Behavior Change Successes Reducing malnutrition (micronutrient initiatives)Preventing malaria (insecticide-treated bednets)Helping children survive (breastfeeding)Improving maternal health (safe motherhood movement, emergency obstetric care)Making family planning a norm (worldwide efforts)Combating HIV/AIDS (Uganda program)Behavior can be changed. A combination of behavior-change theories and tools have been successful in reducing malnutrition, reducing the toll of malaria, helping children survive, improving maternal health, making family planning a norm, and combating HIV/AIDS.Although aiming primarily to change behaviors of individuals and communities, these programs also focused on the behavior of health system officials and policymakers, and addressed important contextual factors.We are going to look more closely at one case study in particular: combating HIV/AIDS.
54Combating HIV/AIDS in Uganda Political support, multisectoral responseDecentralized behavior change campaignsFocus on women and youth, stigma and discriminationMobilization of religious leadersConfidential voluntary counseling and testingSocial marketing of condomsControl and prevention of STIsUganda is one of the earliest AIDS success stories. Although deaths from AIDS must be factored in, Uganda’s falling HIV prevalence is most likely attributable to the nationwide diffusion of an innovation: sexual behavior change. A 2002 analysis identified the following key elements:High-level political support led to a multisectoral response. Ugandan President Yoweri Museveni emphasized that openness, communication, and strong leadership were needed at every level. Approximately 700 government agencies and NGOs were involved across all districts.Decentralized behavior-change campaigns reached general populations and key at-risk groups. Campaigns included print materials, radio, and billboards, but mostly relied on grass-roots community mobilization.From the highest governmental to the grassroots levels, behavior change efforts emphasized empowerment of women and girls and the need to fight stigma and discrimination.Mainstream faith-based organizations—Christian, Islamic, and traditional—used their influence to fight AIDS and encourage acceptance of those infected.Uganda initiated Africa’s first confidential voluntary counseling and testing services, which were implemented in four major, urban areas.Social marketing of condoms played an important role although not a major one.Control and prevention programs for STIs received increased emphasis.Source: Edward C. Green, Rethinking AIDS Prevention: Learning from Successes in Developing Countries (Westport, CT: Praeger Publishers, 2003).
55Health Promotion: Lessons Learned Research underlying causesAddress contextual factorsIdentify and reach key actors at every levelInvolve stakeholders throughout processUse sound behavioral theoriesMonitor and evaluateResearchers have distilled a number of keys to success:Identify the specific health problem to be addressed and the corresponding behaviors that will ameliorate the problem. Identify relevant key actors at every level, from the individual to the policymaker.Use sound behavioral theories in designing health promotion programs.Understand underlying behavioral reasons for the health problem, including biologic, environmental, cultural and other contextual factors, and the likely motivations and constraints to change. Pay particular attention to barriers to change and vulnerabilities due to social and structural inequities.Include the participation of relevant stakeholders as true partners in the design, implementation, and evaluation of the intervention, using participatory assessment and learning tools.Organize a multifaceted intervention that addresses both behaviors and contextual factors to reach policymakers, gatekeepers, and beneficiaries. To reach key audiences, use communication channels identified through research such as mass media, face-to-face community activities, training of health workers, and policy-influencing conferences, with coordinated, mutually reinforcing messages and opportunities for community discussion.
56ConclusionImproving global health requires behavior change at every level—individuals, families, communities, organizations, and policymaking bodiesEvidence-based behavioral theories and successful behavior-change case histories point the wayNext step: political will and sufficient resourcesAddressing the world’s most serious health problems will depend on behavior change at every level—individuals, families, communities, organizations, and policymaking bodies. Fortunately, evidence-based behavioral theories and successful behavior-change case histories point the way. Bolstered by political will and adequate resources, adaptations of successful programs and new approaches will go a long way toward ensuring health for all.
57For More InformationElaine M. Murphy, “Promoting Healthy Behavior,” Health Bulletin 2 (Washington, DC: Population Reference Bureau, 2005).Available online atFor more information, please refer to the full report, “Improving the Health of the World’s Poorest People,” accessible on the PRB website:
58Objectives: You Students will Understand the parameters required for health promotion model.Be able to apply those parameters on models they may suggest for their own society.