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© 2005 POPULATION REFERENCE BUREAU Promoting Healthy Behavior
© 2005 POPULATION REFERENCE BUREAU Behavior and Global Health Physical good health eludes billions of people Death and disease from preventable causes remain high Behavior is a key factor in determining 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)
© 2005 POPULATION REFERENCE BUREAU Ten Leading Risk Factors for Preventable Disease 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 High body mass index or overweight Source: WHO, World Health Report 2002: Reducing Risk, Promoting Healthy Life (Geneva: WHO, 2002), accessed online at on Nov. 15, 2004.
© 2005 POPULATION REFERENCE BUREAU Whose Behavior is Responsible For… Maternal and child underweight Smoking and alcohol abuse Unsafe sex Unsafe water and lack of adequate sanitation
© 2005 POPULATION REFERENCE BUREAU Maternal 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)
© 2005 POPULATION REFERENCE BUREAU Smoking and Alcohol Abuse Individuals (choice) Communities (norms regarding smoking) Health policymakers Legislators & tax assessors Tobacco company executives Decision-makers in marketing companies
© 2005 POPULATION REFERENCE BUREAU Unsafe 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)
© 2005 POPULATION REFERENCE BUREAU Unsafe 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)
© 2005 POPULATION REFERENCE BUREAU Risky behaviors translate to diseases
© 2005 POPULATION REFERENCE BUREAU Global Causes of Death Noncommunicable diseases Communicable diseases, maternal and perinatal conditions, and nutritional deficiencies Injuries Source: WHO, World Health Report 2000Health Systems: Improving Performance (Geneva: WHO, 2000).
© 2005 POPULATION REFERENCE BUREAU Behavior change reduces risky behaviors
© 2005 POPULATION REFERENCE BUREAU Health Promotion Means Changing Behavior at Multiple Levels AIndividual: knowledge, attitudes, beliefs, personality BInterpersonal: family, friends, peers CCommunity: social networks, standards, norms DInstitutional: rules, policies, informal structures EPublic Policy: local policies related to healthy practices Source: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion (2003), available online at
© 2005 POPULATION REFERENCE BUREAU A: Individual-Oriented Models Individual most basic unit of health promotion Individual-level models components of broader-level theories and approaches Models Stages of Change Model Health Belief Model
© 2005 POPULATION REFERENCE BUREAU Stages of Change Model Changing ones behavior is a process, not an event Individuals at different levels of change Gear interventions to level of change Source: James O. Prochaska et al., In Search of How People Change: Application to Addictive Behaviors, American Psychologist 47, no. 9 (1992):
© 2005 POPULATION REFERENCE BUREAU Stages of Change Model (cont.) Precontemplation ActionDecision MaintenanceContemplation
© 2005 POPULATION REFERENCE BUREAU Health Belief Model Perceived susceptibility and severity of ill health Perceived benefits and barriers to action Cues to action Self-efficacy Source: Irwin M. Rosenstock et al., Social Learning Theory and the Health Belief Model, Health Education Quarterly 15, no. 2 (1988):
© 2005 POPULATION REFERENCE BUREAU B: Interpersonal Level: Social Learning Theory Interaction of individual factors, social environment, and experience Reciprocal dynamic Observational learning Capability of performing desired behavior Perception of self-efficacy Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).
© 2005 POPULATION REFERENCE BUREAU Interpersonal Level: Social Learning Theory (cont.) Three strategies for increasing self-efficacy Setting small, incremental goals Behavioral contracting: specifying goals and rewards Self-monitoring: feedback can reinforce determination to change (keep a diary) Positive reinforcement: encouragement helps Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall, 1986).
© 2005 POPULATION REFERENCE BUREAU C: Community-Level Models Analyze how social systems function Mobilize communities, organizations, and policymakers Use sound conceptual frameworks Community Mobilization Organizational Change Diffusion of Innovations Theory
© 2005 POPULATION REFERENCE BUREAU Community Mobilization Encompasses wider social and political contexts Community members assess health risks, take action Encourages empowerment, building on cultural strengths and involving disenfranchised groups 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).
© 2005 POPULATION REFERENCE BUREAU Organizational Change Organizational Stage Theory Define problem Identify solutions Initiate action Allocate resources Implement Institutionalize Organizational Development Theory Worker behavior and motivation Organizational structures
© 2005 POPULATION REFERENCE BUREAU Diffusion of Innovations Theory How new ideas, products, and behaviors become norms All levels: individual, interpersonal, community, and organizational Success determined by: nature of innovation, communication channels, adoption time, social system Source: Everett M. Rogers, Diffusion of Innovations, 4th ed. (New York: The Free Press, 1995).
© 2005 POPULATION REFERENCE BUREAU Diffusion of Innovations (cont.) Nature of innovation Relative advantage over what is being replaced Compatible with values of intended users Easy to use Opportunity to try innovation Tangible benefits
© 2005 POPULATION REFERENCE BUREAU Diffusion of Innovations (cont.) Communication channels Mass media (enhanced by listening groups, call-in opportunities, and face-to-face approaches) Peers Respected leaders
© 2005 POPULATION REFERENCE BUREAU Diffusion of Innovations (cont.) Adoption time Awareness Intention Adoption Change Gradual Movement through groups Pioneers Early adopters Masses
© 2005 POPULATION REFERENCE BUREAU Diffusion of Innovations (cont.) Social system: Identify influential networks to diffuse innovation: health systems, schools, religious and political groups, social clubs, unions, and informal associations Identify opinion leaders, peers, and targeted media channels to diffuse innovations
© 2005 POPULATION REFERENCE BUREAU Health Promotion
© 2005 POPULATION REFERENCE BUREAU Health Promotion Tools Mass media Social marketing Community mobilization Health education Client-provider interactions 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):
© 2005 POPULATION REFERENCE BUREAU Behavior 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)
© 2005 POPULATION REFERENCE BUREAU Combating HIV/AIDS in Uganda Political support, multisectoral response Decentralized behavior change campaigns Focus on women and youth, stigma and discrimination Mobilization of religious leaders Confidential voluntary counseling and testing Social marketing of condoms Control and prevention of STIs Source: Edward C. Green, Rethinking AIDS Prevention: Learning from Successes in Developing Countries (Westport, CT: Praeger Publishers, 2003).
© 2005 POPULATION REFERENCE BUREAU Health Promotion: Lessons Learned Research underlying causes Address contextual factors Identify and reach key actors at every level Involve stakeholders throughout process Use sound behavioral theories Monitor and evaluate
© 2005 POPULATION REFERENCE BUREAU Conclusion Improving global health requires behavior change at every levelindividuals, families, communities, organizations, and policymaking bodies Evidence-based behavioral theories and successful behavior-change case histories point the way Next step: political will and sufficient resources
© 2005 POPULATION REFERENCE BUREAU For More Information Elaine M. Murphy, Promoting Healthy Behavior, Health Bulletin 2 (Washington, DC: Population Reference Bureau, 2005). Available online at
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