MODELS OF HEALTH PROMOTION

MODELS OF HEALTH PROMOTION

Objectives: You students will
Understand the parameters required for health promotion model Be able to apply those parameters on models they may suggest for your own society

MODEL OF HEALTH PROMOTION 1: FOUR PARADIGMS OF HEALTH PROMOTION (CAPLAN AND HOLLAND - 1990)
Radical change Nature of society RADICAL HUMANIST Holistic view of health De-professionalization Self-help networks RADICAL STRUCTURLIST Health reflects structural inequalities Need to challenge inequity and radically transform society. Subjective Objective Nature of knowledge HUMANIST Holistic view of health Aims to improve understanding and development of self Client-led TRADITIONAL Health = absence of disease Aim is to change behaviour Expert-led Social regulation

MODEL OF HEALTH PROMOTION 2: HEALTH PROMOTION METHODS USING BEATTIE’S TYPOLOGY (BEATTIE – 1991)
MODE OF INTERVENTION Legislation Policy making and implementation Health surveillance Advice Education Behaviour change Mass media campaign Authoritarian Individual Collective Focus of intervention Counselling Education Group work Lobbying Action research Skills sharing and training Group work Community development Negotiated

MODEL OF HEALTH PROMOTION 3: A TYPOLOGY OF HEALTH PROMOTION (FRENCH – 1990)
DISEASE MANAGEMENT Curative services Management services Caring services HEALTH EDUCATION Agenda setting Empowerment and support Information DISEASE PREVENTION Preventive services Medical services Behaviour change POLITICS OF HEALTH Social action Policy development Economic and fiscal policy

MODEL OF HEALTH PROMOTION 4: TANNAHILL’S MODEL OF HEALTH PROMOTION (DOWNIE et al – 1990)
5 6. 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 education 7 2 4 6 1 Health protection Prevention 3 3. 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.

MODEL OF HEALTH PROMOTION 5: THE CONTRIBUTION OF EDUCATION TO HEALTH PROMOTION (TONES et al – 1990)
Public pressure Healthy public policy Lobbying Advocacy Mediation Healthy social and physical environment Empowered participating community Healthy promoting organisation HEALTH Healthy services Critical consciousness raising Agenda setting Healthy choices Professional education Education for health

APPROACHES TO HEALTH PROMOTION

Approaches in Health Promotion: the example of healthy eating
Aims Methods Worker/client relationship Medical To identify those at risk from disease. Primary health care consultation. e.g. measurement of body mass. Expert-led. Passive, conforming client.

Aims Methods Worker/client relationship Persuasion through one-to-one advice, information, mass campaigns, e.g. ‘Look After Your Heart’ dietary messages. Expert-led. Dependent client. Victim blaming ideology. Behavior change To encourage individuals to take responsibility for their own health and choose healthier lifestyles.

Aims Methods Worker/client relationship Educational To 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.

Aims Methods Worker/client relationship Empowerment To work with client or communities to meet their perceived needs. Advocacy Negotiation Networking Facilitation e.g. food co-op, fat women’s group. Health promoter is facilitator, client becomes empowered.

Aims Methods Worker/client relationship Social change To address inequalities in health based on class, race, gender, geography. Development of organizational policy, e.g. hospital catering policy Public health legislation, e.g. food labelling. Fiscal controls, e.g. subsidy to farmers to produce lean meat. Entails social regulation and is top-down.

Religion and Health - 3 Quran & Ahadith Five Pillars of Islam Elements
of Faith Islamic Jurisprudence Salutogenic Mechanism Sense of coherence Predisposing & Enabling factors An 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 community Fard –El Kifaya: Collective duty to care about others De 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. Behavior Figure 1: Pathways of ‘Islamic Health Theory’ Healthy Lifestyle

Putting Islamic Concepts Into Practice for Health Promotion 1
Plan Do Check There 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.

Putting 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

Putting Islamic Concepts Into Practice for Health Promotion 2.1
The PRECEDE-PROCEED Model by Green & Kreuter, 1999 Visit 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.

Intervention mapping. STEP 1: Proximal program objective matrices STEP 2: Theory –based methods and practical strategies STEP 3: Program plan STEP 4: Adoption and implementation plan STEP 5: Evaluation plan Intervention 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 level STEP 3: Program plan · Operationalize the strategies into plans, considering implementers and sites · Develop design documents · Produce and pretest program materials with target groups and implementers STEP 4: Adoption and implementation plan · Develop a linkage system · Specify adoption and implementation performance objectives · Create matrix or planning table · Write an implementation plan STEP 5: Evaluation plan · Develop an evaluation model · Develop effect and process evaluation questions · Develop indicators and measures · Specify evaluation designs · Write an evaluation plan Reference: 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.

A five-stage model (Bracht et al. 1999) 1. Community analysis COMMUNITY ORGANIZATION STAGES 5. Dissemination - reassessment 2. Design - initiation This 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 Publications 4. Maintenance - consolidation 3. Implementation

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

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 Publications Hussein, A. A. (1998). The art of health promotion in Islam and the contemporary public health challenges, MPH Thesis. Maastricht. University of Maastricht.

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; and 3. Preserving public interest Also 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

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 Publications Hussein, A. A. (1998). The art of health promotion in Islam and the contemporary public health challenges, MPH Thesis. Maastricht. University of Maastricht.

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

Promoting Healthy Behavior

Behavior 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 people Death and disease from preventable causes remain high Behavior is a key factor in determining health The 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.

Ten Leading Risk Factors for Preventable Disease
Maternal and child underweight Unsafe sex High blood pressure Tobacco Alcohol Unsafe water, poor sanitation, & hygiene High cholesterol Indoor smoke from solid fuels Iron deficiency High body mass index or overweight The 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.

Whose Behavior is Responsible For…
Maternal and child underweight Smoking and alcohol abuse  Unsafe sex  Unsafe water and lack of adequate sanitation 

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) 

Smoking and Alcohol Abuse
Individuals (choice) Communities (norms regarding smoking) Health policymakers Legislators & tax assessors Tobacco company executives Decision-makers in marketing companies 

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) 

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)

Risky 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.

Noncommunicable diseases
Global Causes of Death Injuries Communicable diseases, maternal and perinatal conditions, and nutritional deficiencies Noncommunicable diseases Behavior 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).

Behavior change reduces risky behaviors

Health 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 structures E Public Policy: local policies related to healthy practices Health-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

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 The 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.

Stages of Change Model Changing one’s behavior is a process, not an event Individuals at different levels of change Gear interventions to level of change The 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):

Stages of Change Model (cont.)
Precontemplation Maintenance Contemplation Five 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. Action Decision

Health Belief Model Perceived susceptibility and severity of ill health Perceived benefits and barriers to action Cues to action Self-efficacy  The 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):

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 Social 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).

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 Social 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).

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 Designing 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.

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 Because 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).

Organizational Change
Organizational Stage Theory Organizational Development Theory Define problem Identify solutions Initiate action Allocate resources Implement Institutionalize Organizational structures Organizational 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

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 Diffusion 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).

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 The 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.

Communication channels Mass media (enhanced by listening groups, call-in opportunities, and face-to-face approaches) Peers Respected leaders Communications 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.

Adoption time Awareness Intention Adoption Change Gradual Movement through groups Pioneers Early adopters Masses Diffusion 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.

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 The 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.

Health Promotion

Health Promotion Tools
Mass media Social marketing Community mobilization Health education Client-provider interactions Policy communication Most 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):

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) 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.

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 Uganda 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).

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 Researchers 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.

Conclusion Improving global health requires behavior change at every level—individuals, 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 Addressing 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.

For More Information Elaine M. Murphy, “Promoting Healthy Behavior,” Health Bulletin 2 (Washington, DC: Population Reference Bureau, 2005). Available online at For more information, please refer to the full report, “Improving the Health of the World’s Poorest People,” accessible on the PRB website:

Objectives: 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.

MODELS OF HEALTH PROMOTION

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