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Theories and Models Commonly used for Health Promotion Interventions

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1 Theories and Models Commonly used for Health Promotion Interventions

2 Whenever there is a discussion about the theoretical bases for health education and health promotion, we often find the terms theory and model used. Some use the terms correctly, while others either use them synonymously or confuse their meaning.

3 We begin this chapter with a brief explanation of these terms, to establish a common understanding of their meaning: One of the most frequently quoted definitions of theory is "A theory is a set of interrelated concepts, definitions, and proposi­tions that presents a systematic view of events or situations by specifying relations among variables in order to explain and predict the events of the situations" .

4 Green and colleagues have stated, "The role of theory is to untangle and simplify for human comprehension the complexities of nature." In other words, a theory is a systematic arrangement of funda­mental principles that provide a basis for explaining certain happenings of life.

5 Hochbaum, Sorenson, and Lorig defined theories in relationship to health education as "tools to help health educators better understand what influences health-relevant individuals, group, and institutional behaviors and to thereupon plan effective interventions directed at health-beneficial results."

6 The primary elements of theories are known as concepts , When a concept has been developed, created, or adopted for use with a specific theory, it is referred to as a construct "In other words, constructs are synthesized thoughts of key concepts or specific theories“ The operational (practical use) form of a construct is known as a variable. Variables "specify how a construct is to be measured in a specific situation"

7 In comparison, a model is a subclass of a theory
In comparison, a model is a subclass of a theory. "Models draw on a number of theories to help people understand a specific problem in a particular setting or context“. Unlike theories, models do "not at­tempt to explain the processes underlying learning, but only to represent them"

8 Now consider how these terms are used in practical application
Now consider how these terms are used in practical application. A personal belief is a concept that has been shown to relate to various health behaviors. Using a theory that includes the concept of personal beliefs helps explain why people fear being trapped in a burning vehicle if they use their safety belts. This personal belief of fear acts as a perceived barrier to safety belt use. Perceived barrier is a part of a specific theory and is referred to here as a construct.

9 If a health educator develops a program around a theory to help people overcome this barrier and wear their safety belts, then safety belt use is the variable being studied. The health educator realizes that this theory, which emphasizes personal beliefs, will not explain all the reasons why people do not wear safety belts. Thus other theories, which emphasize other concepts (i.e., knowledge, environment, incentives, comfort, convenience, etc.) need to be considered.

10 Eventually, all of these theories may be combined into a model that will ex­plain, at least in cart. Why people wear safety belts. If a model were 3 perfect model, it would predict with 100% accuracy who would wear safely belts. Unfortunately, behavior is very complex and there are no perfect models in health education. It is therefore important for health educators to keep revising their models to improve their understanding of health behavior.

11 Based on these descriptions, it seems logical to think of theories as the back­bone of the processes used to plan, implement, and evaluate health promotion interventions. "A theory based approach provides direction and justification for program activities and serves as a basis for processes that are to be incorporated into the health promotion program "

12 ‘’Theories can provide answers to program developers' questions regarding why people aren't already engaging in a desirable behavior of interest, how to go about changing their behaviors, and what factors to look at when evaluating a program's focus’’ In addition, theoretical frameworks can alert planners to consider important influences outside the teaching-learning process", such as social support and environment, that have an impact on targeted program outcomes. Models provide the vehicle for applying the theories

13 All health promotion interventions should be planned and evaluated based on proven theories. "Theory is not a substitute for professional judgment, but it can assist health educators in professional decision making. Insofar as the application of theory to practice strengthens program justification, promotes the effective and efficient use of resources, and improves accountability, it also assists in establishing professional credibility"

14 However, this is not to say that a theory cannot be modified or expanded to include a logically valid idea or parts of other theories. "In fact, it is well understood that working with a theory has certain disadvantages; one of which is leaving out or ignoring factors that happen not to be theoretically relevant, even though they may be empirically significant’’

15 The importance of theory in planning health promotion interventions is best shown by the large number of health promotion programs that are designed to help facilitate health behavior change in the target population. Getting people to engage in health behavior change is a complicated process that is very difficult under the best of conditions. Without the direction that theories provide, planners can easily waste valuable resources in trying to achieve the desired behavior change. Therefore, program planners should ground their programming process in the theories that have been the foundation of other successful health promotion efforts.

16 Essentially, the principles and practices of health education are "derived from the egalitarian spirit and progressive theories of education and the fundamental theories of the behavioral sciences"

17 Behavior Change Theories:
Stimulus Response (SR) Theory Social Cognitive Theory (SCT) Theory of Reasoned Action (TRA) Theory of Planned Behavior (TPB) Theory of Freeing (TF) Problem-Behavior Theory (PBT)

18 Stimulus Response (SR) Theory
One of the theories used to explain and modify behavior today is the stimulus response, or SR ,theory. This theory reflects the combination of classical conditioning and instrumental conditioning theories. These early conditioning theories explain learning based on the associations among stimulus, response, and reinforcement. "In simplest terms, the SR theorists believe that learning results from events (termed ‘reinforcements’) which reduce physiological drives that activate behavior".

19 Stimulus Response (SR) Theory
The behaviorist B. F. Skinner believed that the frequency of a behavior was determined by the reinforcements that followed that behavior. In Skinner's view, the mere temporal association between a behavior and an immediately following reward is sufficient to Increase the probability that the behavior will be repeated. Such behaviors are called operants; they operate on the Environment to bring about changes resulting in reward or reinforcement. Stated another way, operant behaviors are behaviors that act on the environment to produce Consequences. These consequences, in turn, either reinforce or do not reinforce the behavior that preceded.

20 Stimulus Response (SR) Theory
The consequences of a behavior can come as either reinforcement or punishment. Individuals can learn from both. Reinforcement has been defined by Skinner as any event that follows a behavior, which in turn increases the probability that the same behavior will be repeated in the future.

21 Stimulus Response (SR) Theory
Behavior has a greater probability of occurring in the future : if reinforcement is frequent , if reinforcement is provided soon after the desired behavior. This immediacy clarifies the relationship between the reinforcement and appropriate behavior .

22 Stimulus Response (SR) Theory
While rein­forcement will increase the frequency of a behavior, punishment will decrease the frequency of a behavior. However, both reinforcement and punishment can be either positive or negative. The terms positive and negative in this context do not mean good and bad; rather, positive means adding something (effects of the stimulus) to a situation, whereas negative means taking something away (removal or reduction of the effects of the stimulus)

23 Stimulus Response (SR) Theory
If individuals act in a certain way to produce a consequence that makes them feel good or that is enjoyable, it is labeled positive reinforcement. While positive reinforcement helps individuals learn shaping behavior , behavior that avoids punishment is also learned because it reduces the tension that precedes the punishment.' when this happens, we are being conditioned by negative reinforcement : A response is strengthened by the removal of something of the situation, In such cases, the 'something' that is removed is referred to as negative reinforce or aversive stimulus.

24 Stimulus Response (SR) Theory
Some people think of negative reinforcement as a form of punishment, but it is not. While negative reinforcement increases the likelihood that a behavior will be repeated, punishment typically suppresses behavior.

25 Stimulus Response (SR) Theory
Skinner suggests two ways in which a response can be punished: by removing a positive reinforcer ,or by presenting a negative reinforcer (aversive stimulus) as a consequence of the response.

26 Stimulus Response (SR) Theory
Punishment is usually linked to some uncomfortable (physical, mental, or otherwise) experience and decreases the frequency of a behavior. Example of positive punishment: An aversive smoking cessation program that circulates cigarette smoke around those enrolled in the program as they smoke.(It decreases the frequency of smoking by presenting (adding) a negative reinforcer or aversive stimulus (smoke) as a consequence of the response)

27 Stimulus Response (SR) Theory
Examples of negative punishment (removing a positive reinforcer): not allowing teachers to use the teacher's lounge if they continue to smoke while using it Stimulus response theorists would note that taking away the privilege of using the teacher's lounge would cause a decrease in frequency of smoking among the teachers,

28 Stimulus Response (SR) Theory
Finally, if reinforcement is withheld-or stating it another way jf the behavior is ignored—the behavior will become less frequent and eventually will not be repeated. Skinner refers to this as extinction. Teachers frequently use this technique with disrupt with disruptive children in the classroom. If a child is acting up in class, the teacher may choose .to ignore the behavior in hopes that the no reinforced behavior will go away.

29 Social Cognitive Theory (SCT)
the social cognitive theory (SCT)-combine SR theory and cognitive theories. Those who espouse SCT believe that reinforcement contributes to learning, but reinforcement along with an individual's expectations of the consequences of behavior determine the behavior. . "Behavior, in this perspec­tive, is a function of the subjective value of an outcome and the subjective probabil­ity (or 'expectation)that a particular action will achieve that outcome. Such formulations are generally termed 'value- expectancy' theories" .

30 Social Cognitive Theory (SCT)
In brief, SCT describes learning as a reciprocal interaction between the individual's environment, cognitive processes, and behavior

31 Social Cognitive Theory (SCT)
Parcel and Baranowski (1981) have provided an explanation of several constructs of SCT and health education, starting with reinforcement. According to SCT, rein­forcement can. be accomplished in one of three ways: directly, vicariously, or through self-management.

32 Social Cognitive Theory (SCT)
examples of: direct reinforcement is a group facilitator who provides verbal feedback to participants for a job well done. Vicarious reinforcement is having the participants observe someone else being reinforced for behaving in an appropriate manner. This is often referred to as social modeling. In a system of reinforcement by self-management, the participants would keep records of their own behavior, and when the behavior was performed in an appropriate manner, they would reinforce or reward themselves.

33 Social Cognitive Theory (SCT)
In addition to the constructs dealing with reinforcement, SCT has other, constructs applicable to health promotion. Those constructs identified by Parcel and Baranowski (1981) include : behavioral capability, expectations, expectancies, self-control, self-efficacy, emotional-coping responses, and reciprocal determinism.

34 Social Cognitive Theory (SCT) The constructs identified by Parcel and Baranowski
If individuals are to perform specific behaviors, they must know first what the behaviors are and then how to perform them. This is referred to as behavioral capability. The construct of expectations refers to the ability of human beings to think and thus to expect certain things to happen in certain situations.

35 Social Cognitive Theory (SCT) The constructs identified by Parcel and Baranowski
III. expectancies, not to be confused with expectations, are the values that individuals place on an ex­pected outcome. If people value an expected outcome, they are more likely to per­form the necessary behavior to yield the outcome. IV. The construct of self-control or self- regulation states that individuals may gain control of their own behavior through monitoring and adjusting it .

36 Social Cognitive Theory (SCT) The constructs identified by Parcel and Baranowski
V. One construct of SCT that has received special attention in health promotion programs is self-efficacy ,which refers to the internal state that individuals experience as "competence" to perform certain desired tasks or behavior. This state is situation specific; that is, someone may be self-efficacious when it comes to aerobic exercise but not so when faced with reducing the amount of fat in her diet. People's competency feelings have been referred to as efficacy expectations.

37 Social Cognitive Theory (SCT) The constructs identified by Parcel and Baranowski
Efficacy expectations: Thus, someone who thinks he can exercise on a regular basis no matter what the circumstances has efficacy expectations. Even though people have efficacy expectations, they still may not want, to engage in a behavior because they may not think the outcomes of that behavior would be beneficial to them. These beliefs are called outcome expectations.

38 Social Cognitive Theory (SCT) The constructs identified by Parcel and Baranowski
An example of outcome expectations: in order for a person to quit smoking for health reasons (behavior), she must believe both that she is capable of quitting (efficacy expectation) and that cessation will benefit her health {outcome expectation)

39 Social Cognitive Theory (SCT) The constructs identified by Parcel and Baranowski
Person behavior outcome Efficacy expectations Outcome expectations

40 Social Cognitive Theory (SCT) The constructs identified by Parcel and Baranowski
Individuals become self-efficacious in four main ways: Through performance attainments (personal mastery of a task). Through vicarious experience (observing the performance of others). . As a result of verbal persuasion (receiving suggestions from others). Through emotional arousal (interpreting one's emotional state).

41 Social Cognitive Theory (SCT) The constructs identified by Parcel and Baranowski
VI. The construct of emotional-coping responses states that for a person to learn, he must be able to deal with the sources of anxiety that may surround a behavior. VII. The construct of reciprocal determinism states, unlike SR theory, that there is an interaction among the person, the behavior, and the environment, and that the person can shape the environment as well as the environment shaping the per­son. All these relationships are dynamic.

42 Social Cognitive Theory (SCT)
Finally, there is one other construct that grew out of the social learning theory of Rotter. that needs to be mentioned because of its association with health behavior. "Rotter posited that a person's history of positive or negative re­inforcement across a variety of situations shapes a belief as to whether or not a person's own actions lead to those reinforcements" . Rotter referred to this construct as locus of control.

43 Social Cognitive Theory (SCT)
Thus, he felt that people with internal locus of control perceived that reinforcement was under their control, whereas those with external locus of control perceived reinforcement to be under the con­trol of some external force. The internal locus of control belief about one's own health status is a necessary but not sufficient determinate of health-enhancing behavior.

44 Social Cognitive Theory (SCT)
Since the rise of the construct of self- efficacy, Wallston feels that self-efficacy is a better predictor of health-promoting behavior than locus of control. This not to say that locus of control is not a useful construct in developing health promotion programs.

45 Theory of Reasoned Action (TRA)
this theory was developed to explain not just health behavior but all volitional behaviors. The theories discussed earlier were directly concerned with behavior; however, this one provides a framework to study attitudes toward behaviors.

46 Theory of Reasoned Action (TRA)
Fishbein and Ajzen distinguish among attitude, belief, behavioral intention, and behavior, and they present a conceptual framework for the study of the relationship among these four constructs. According to the model, an individual's intention to perform a given behavior is a function of her attitude toward performing the behavior and normative beliefs about what relevant others think she should do, weighted by motivation to comply with those others.

47 Theory of Reasoned Action (TRA)
this theory has one element that distinguishes it from other theories that try to explain human behavior: This is the construct that deals with the normative beliefs about what relevant others think the person should do. This construct states that individuals' intent to perform a given behavior is dependent partly on their belief that others (individuals or groups) think they should do so, and partly on the fact that they care about what these others think. This construct is often referred to as the subjective norm.

48 Theory of Planned Behavior (TPB)
The theory of reasoned action has proved to be most successful when dealing with purely volitional behaviors, but complications are encountered when the theory is applied to behaviors that are not fully under volitional control. The theory of planned behavior (TPB) is an extension of the theory of reasoned action that addresses the problem of incomplete volitional control.

49 Theory of Planned Behavior (TPB)
The major difference between TPB and TRA is the addition of a third, conceptually independent determinant of intention. Like TRA, TPB includes attitude toward the behavior and subjective norm, but it has added the concept of perceived behavioral control. This refers to the perceived ease or difficulty of performing the behavior and is assumed to reflect past experience as well as anticipated impediments and obstacles.

50 Theory of Planned Behavior (TPB)
Attitude toward the behavior Intention Behavior Subjective norm Perceived behavioral control

51 Theory of Planned Behavior (TPB)
the figure illustrated two important features of this theory: First , perceived behavioral control has motivational implications for intentions. That is, without perceived control, intentions could be minimal even if attitudes toward the behavior and subjective norm were strong. Second , there may be a direct link between perceived behavioral control and behavior. Behavior depends not only on motiva­tion but also on adequate control. Thus, it stands to reason that perceived behavioral intention.

52 Theory of Planned Behavior (TPB)
For example: predicts that a person will give up smoking if she: Has a positive attitude toward quitting. Thinks others whom she values believe it would be good for her to quit . Perceives that she has; control over whether she quits.

53 Theory of Planned Behavior (TPB)
Because the TPB is comparatively new, evidence about its usefulness is just now becoming more common. Godin and Kok (1996) presented a review of 58 studies where the theory was applied to health-related behaviors. They found that the efficiency of the theory seemed "to be quite good for explaining intention, perceived behavioral control being as important as attitude across behavioral categories.

54 Theory of Planned Behavior (TPB)
The efficiency of the theory, however, varied between health-related behavior categories.

55 Theory of Freeing (TF) A theory that takes a much different approach from the other theories presented is the theory of freeing (TF) . It is a theory aimed" at empowering education. Wallerstein and Bernstein define empowerment as "a social action process that promotes participation of people, organizations, and communities in gaining control , over their lives in their community and larger society. With this perspective, empowerment is not characterized as achieving power to dominate others , but rather power to act with others to effect change."

56 Theory of Freeing (TF) The underlying concept of this theory is that critical consciousness is determined by the interaction with culture. Consciousness is influenced by and influences the culture. Education is the key to becoming critically conscious. However, the education that is meant here is not education in the traditional sense. Education occurs through dialogue, not through lecture. People who use dialogue are teachers, whereas those who just talk are lecturers. And in this type of education, participants replace pupils. All those involved in the educational process learn from one another.

57 Theory of Freeing (TF) they state that freire’s theory includes 3 stages:
Stage1: is the listening stage, in which those in the target population have the opportunity to share their thoughts; identify the problems, and set the priorities. Unlike in a more traditional planning process, the program planners do not collect data and determine the needs. In­stead, the target population is identifying the issues and prioritizing the needs.

58 Theory of Freeing (TF) they state that freire’s theory includes 3 stages:
Stage2: is a dialogue process. The dialogue revolves around a code."A 'code' is a concrete physical representation of an identified community issue in any form role plays, stories, slides, photographs songs, etc" . After experiencing a code, group facilitators lead the target population through a discussion that helps the people move from a personal to a social analysis and action level.

59 Theory of Freeing (TF) they state that freire’s theory includes 3 stages:
They do this by asking the target population to respond to these five statements: 1. Describe what you see and feel. 2. As a group, define the many levels of the problem. 3. Share similar experiences from your lives. 4. Question why this problem exists. 5. Develop action plans to address the problem.

60 Theory of Freeing (TF) Stage3: of this theory is the action stage, in which those in the target population try out the plans that came from the listening and dialogue stages. As the people put their plans into action, they reflect on their new experiences and create a thinking-acting cycle. "This recurrent spiral of action- reflection-action enables people to learn from their collective attempts at change and to become more deeply involved to surmount the cultural, social, or historic barriers.

61 Problem-Behavior Theory (PBT) :
This theory rests on the social-psychological relationships that occur within arid among the three major systems of " personality, perceived environment, and behavior. Each of these systems includes a variety of variables that are interrelated and organized in such a manner as to generate a greater or lesser likelihood of occurrence of problem behavior

62 Health Behavior Models
Health Belief Model (HBM) The Transtheoretical Model (TTM) Cognitive-Behavioral Model of the Relapse Process.

63 Health Belief Model (HBM)
The HBM hypothesizes that health-related action depends on the simulta­neous occurrence of three classes of factors: The existence of sufficient motivation (or health concern) to make health issues salient or relevant. The belief that one is susceptible (vulnerable) to a serious health problem or to the sequelae of that illness or condition. This is often termed perceived threat.

64 Health Belief Model (HBM)
3. The belief that following a particular health recommendation would be beneficial in reducing the perceived threat, and at a subjectively acceptable cost, Cost refers to the perceived barriers that must be overcome in order to follow the health recommendation; it includes/ but is not restricted to, financial outlays . In fact, the lack of self-efficacy is also seen as a perceived barrier to taking a recommended health action .

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