Health & Nutrition:

Human Health
HEALTH EDUCATION BEHAVIOR MODELS AND
THEORIES-- A REVIEW OF THE LITERATURE - PART
I
As a part of any planning model, it is necessary to attempt to classify and explain the multitude of factors
which can, and do, influence human behavior. Current models/theories that help to explain human
behavior, particularly as it relates to health education, can be classified on the basis of being directed at
the level of: a) Individual (Intrapersonal); b) Interpersonal; or c) Community. Within these three categories,
those models/theories that have tended to dominate in the health education field in the past 20-30 years
will be briefly outlined.

Individual (Intrapersonal) Health Behavior Models/Theories

1. Health Belief Model (Rosenstock, Becker, Kirscht, et al.)

The Health Belief Model (HBM) was one of the first models which adapted theories from the
behavioral sciences to examine health problems. It is still one of the most widely recognized and
used models in health behavior applications. This model was originally introduced by a group of
psychologists in the 1950's to help explain why people would or would not use available
preventive services, such as chest x-rays for tuberculosis screening and immunizations for
influenza. These researchers assumed that people feared diseases and that the health actions of
people were motivated by the degree of fear (perceived threat) and the expected fear reduction of
actions, as long as that possible reduction outweighed practical and psychological barriers to
taking action (net benefits).

The HBM can be outlined using four constructs which represent the perceived threat and net
benefits: 1) perceived susceptibility, a person's opinion of the chances of getting a certain
condition; 2) perceived severity, a person's opinion of how serious this condition is; 3)
perceived benefits, a person's opinion of the effectiveness of some advised action to reduce the
risk or seriousness of the impact; and 4) perceived barriers, a person's opinion of the concrete
and psychological costs of this advised action. (See Figure 1) Another concept is known as cues
to action. These are events (internal or external) which can activate a person's "readiness to act"
and stimulate an observable behavior. Some examples of external strategies to activate
"readiness" can be delivered in print with educational materials, through any electronic mass
media or in one-to-one counseling. Another concept that has been added to HBM since 1988 in
order to better meet the challenges of changing unhealthy habitual behaviors (such as being
sedentary, smoking or overeating) is self-efficacy. Self-efficacy, a concept originally developed
 by Albert Bandura in social cognitive theory (social learning theory), is simply a person's
confidence in her/his ability to successfully perform an action.

Even though the HBM was originally developed to help explain certain health related behaviors, it
has also helped to guide the search for "why" these behaviors occur and to identify points for
possible change. Using this framework, change strategies can be designed as referred to earlier.
The HBM has been used to help in developing messages that are likely to persuade an individual
to make a healthy decision. Using the HBM, messages that are suitable to health education for
such topics as hypertension, eating disorders, contraceptive use, or breast self-examination have
been developed.

However, there are two main weaknesses which have been noted about the HBM. First, health
beliefs compete with an individual's other beliefs and attitudes (outside of those described in
modifying factors in Figure 1) which can also influence behavior. Secondly, in decades of
research in the social psychology of behavioral change, it has not been shown that belief
formation always precedes behavioral change. In fact, the formation of a belief may actually
follow a behavior change.

2. Stages of Change Model or Transtheoretical Model (Prochaska and DiClemente)

The Stages of Change or Transtheoretical Model was initially published in 1979 by Prochaska. In
the 1980's Prochaska and DiClemente worked further on this model in outlining the stages of an
individual's readiness to change, or attempt to change, toward healthy behaviors. The Stages of
Change Model evolved from research in smoking cessation and also the treatment of drug and
alcohol addiction. More recently it has been applied to other health behaviors, such as dietary
changes. Behavior change is viewed as a process, not an event, with individuals at various levels
of motivation or "readiness" to change. Since people are at different points in this process,
planned interventions should match their stage.

There are six stages that have been identified in the model: 1) Precontemplation - the person is
unaware of the problem or has not thought seriously about change; 2) Contemplation - the
person is seriously thinking about a change (in the near future); 3) Preparation - the person is
planning to take action and is making final adjustments before changing behavior; 4) Action - the
person implements some specific action plan to overtly modify behavior and surroundings; 5)
Maintenance - the person continues with desirable actions (repeating the periodic recommended
steps while struggling to prevent lapses and relapse; and 6) Termination - the person has zero
temptation and the ability to resist relapse.

In relapse, the person reverts back to old behavior which can occur during either action or
maintenance. This model is a circular, rather than a linear model. In fact, as seen in Figure 2, it is
more of a spiral as the person may go through several cycles of contemplation, action, relapse (or
recycle) before either reaching termination or exiting the system without becoming free of the
addictive behavior. Prochaska has used a "revolving-door schema" to explain the sequence that
people pass through in their efforts to become free from addictions. People do not go through the
stages and graduate; they can enter and exit at any point and often recycle several times. Other
studies indicate that individuals often go through these same changes whether they use self-help
or self-management techniques, seek professional counseling or attend organized programs.

3. Consumer Information Processing Model (Bettman, McGuire, et al.)

The Consumer Information Processing (CIP) Model developed out of the study of human problem
solving and information processing. Information processing has been one of the dominant
paradigms in social psychology for quite a while, even though CIP is still relatively new. This
model was not developed specifically for health related behavior, but it has many useful
 applications in the area of health education. Information is a necessary tool in health education.
However, just as knowledge is necessary but not sufficient for behavior change, information is
necessary but not sufficient for knowledge. There are limits to any person's information
processing capacity. This is defined as the limitations upon individuals in the amount of
information they can acquire, use and remember.

By understanding the key concepts and processes of CIP, health educators can examine why
people use or fail to use health information, and then design informational strategies that have
better chances for success. The search for information is the process of acquiring and
evaluating information. This process is affected by the person's motivation, attention and
perception at that point in time. In general, consumers tend not to engage in extended information
searches.

There are two central assumptions of CIP. First, individuals are limited to how much information
they can process (the information processing capacity referred to earlier). Secondly, in order to
increase the usability of information, individuals combine little pieces or bits of information into
"chunks" and make decision rules or heuristics to make choices faster and more easily. These
are the rules of thumb which are developed and used to help consumers select more easily
among alternatives.

James Bettman created one of the best known models of CIP which is shown in Figure 3. It
shows a cyclical process of information search, choice, use and learning, and feedback for future
decision-making. There are several feedback loops throughout the model. The consumption and
learning processes involve internal feedback based on the outcome of choices and their use in
future decisions. Bettman's version of this model has now been extended to consider that the
information environment affects how easily people obtain, process and use information. This
includes the amount, location, format, readability, and ability to process relevant information.

There are some basic CIP concepts that can be applied to health education. Before people will
use health information, it must be: 1) available, 2) seen as useful and new, and 3) processable or
in a friendly format. It is necessary to choose the most important and useful points to
communicate (either verbally or in print) and place this information first and/or last in the
presentation in order to be remembered best. The information should take little effort to obtain,
draw the consumer's attention, and be clear. Key ways to synthesize information ("rules of
thumb") that have meaning and appeal for the target population should be formulated. In the
learning process, keep in mind that participants have probably made related choices before and
are not necessarily starting from scratch. The information designed specifically for the target
population must be placed conveniently for their use.

4. Theory of Reasoned Action (Fishbein and Ajzen)

The Theory of Reasoned Action was designed to explain not just health behavior but all volitional
behaviors. This theory is based on the assumption that most behaviors of social relevance are
under volitional (willful) control. In addition, a person's intention to perform (or not perform) the
behavior is the immediate determinant of that behavior. The goal is to not only predict human
behavior but also to understand it.

According to this theory, a person's intention to perform a specific behavior is a function of two
factors: 1) attitude (positive or negative) toward the behavior and 2) the influence of the social
environment (general subjective norms) on the behavior. The attitude toward the behavior is
determined by the person's belief that a given outcome will occur if s(he) performs the behavior
and by an evaluation of the outcome. The social or subjective norm is determined by a person's
normative belief about what important or "significant" others think s(he) should do and by the
individual's motivation to comply with those other people's wishes or desires.
 Attitudes are a function of beliefs in this theory. If a person believes that performing a given
behavior will lead to on the whole positive outcomes, then s(he) will hold a favorable attitude
toward performing that behavior. On the other hand, a person who believes that performing the
behavior will lead to mostly negative outcomes will hold an unfavorable attitude. These beliefs
that form the foundation of a person's attitude toward the behavior are referred to as behavioral
beliefs.

Subjective norms are also a function of beliefs. However, these are beliefs of a different kind.
These are the person's beliefs that certain individuals or groups think (s)he should or should not
perform the behavior. If the person believes that most of these significant others think s(he)
should perform the behavior, the social pressure to perform it will increase the more s(he) is
motivated to comply with these others. If s(he) believes that most of this reference group is
opposed to performing the behavior, her/his perception of the social pressure not to perform the
behavior will increase along with her/his motivation to comply with these referents. The beliefs
which underlie a person's subjective norms are termed normative beliefs. The interactions
among the pieces of this model are illustrated in Figure 4.

5. Social Learning Theory or Social Cognitive Theory (Rotter and Bandura)

In Social Learning Theory, human behavior is explained using a three-way reciprocal theory in
which personal factors (one's cognitive processes), behavior, and environmental influences
continually interact in a process of reciprocal determinism or reciprocal causality. These are
very dynamic relationships where the person can shape the environment as well as environment
shaping the person. Change is bi-directional. Social Learning Theory is the result of separate
research by Rotter (1954) and Bandura (1977). Bandura retitled the theory Social Cognitive
Theory to emphasize the cognitive aspect. According to this theory, reinforcement contributes to
learning, but reinforcement along with an individual's expectations of the consequences of
behavior determine the behavior. Behavior is seen as a function of the subjective value of an
outcome and the subjective probability (or expectation) that a particular action will achieve that
outcome. This type of approach has been referred to as "value-expectancy theory."

There are several constructs in Social Learning Theory (SLT) which help to explain learning.
According to SLT, reinforcement can be accomplished in one of three ways: 1) direct, 2)
vicarious, or 3) through self-management. Direct reinforcement is supplied directly to the
person. In vicarious reinforcement the participant observes someone else being reinforced for
behaving in an appropriate or inappropriate manner. This has also been called social modeling
or observational learning. Reinforcement by self-management involves record-keeping by the
participant of her/his own behavior. When the behavior is performed correctly, the person would
reinforce or reward her/himself. The construct of self-control goes along with this type of
reinforcement since it reflects the idea that individuals may gain control of their own behavior by
monitoring it.

There are several other constructs which may be applicable to learning situations in health
education. Behavioral capability refers to the knowledge and skills necessary to do a behavior
which influence actions. If individuals are to be able to perform specific behaviors, they must first
know what the behaviors are and how to perform them. Therefore, clear instructions and/or
training may be needed. Another construct mentioned earlier, expectations, refers to the ability
of humans to think and, therefore, to expect certain results in certain situations. Expectancies
are the values that people place on an expected outcome. The more highly valued the expected
outcome, the more likely the person will perform the needed behavior to yield that outcome.

One construct of SLT has received extra attention in health education programs. Bandura
considered self-efficacy the single most important aspect of the sense of self that determines
one's effort to change behavior. This self-confidence in one's ability to successfully perform a
 specific type of action has been so well accepted that it was also added to the Health Belief
Model in 1988 as mentioned earlier in this review. This internal state is very situation specific. For
example, a person may experience a high level of self-efficacy in aerobic exercise but very little
when attempting to reduce the amount of fat in her/his diet. These feelings of competency have
been called an individual's efficacy expectations. Even though people may have efficacy
expectations, they still may not attempt the behavior because they believe the outcome of that
behavior (reinforcement) is not great enough for them. These beliefs are called outcome
expectations. (See Figure 5 for a diagram of the difference between efficacy and outcome
expectations.) A person can increase self-efficacy through: 1) personal mastery of a task; 2)
observing the performance of others (vicarious experience); 3) verbal persuasion, such as
receiving suggestions from others; and 4) arousal of her/his emotional state. In the construct of
emotional coping responses, a person must be able to deal with any sources of anxiety
surrounding that behavior in order to learn.

Interpersonal Health Behavior Theories

1. Social Networks/Social Support Theories (Eng, Israel, et al.)

Most health educators today recognize the critical importance of the social environment and
advocate changes in the social ecology which is supportive of individual change leading to better
health and a higher quality of life. However, within the community, long-term behavior change
depends on the level of participation and ownership felt by those being served. In order to see
how Social Networks and Social Support Theories might impact on health needs, it is first
necessary to define what is meant by certain concepts.

Social networks can be kin (extended family) or non-kin (church or work groups, friends or
neighbors who regularly socialize, clubs and sporting teams). Social networks have certain types
of characteristics: 1) Structural, such as size (number of people) and density (extent to which
members really know one another); 2) Interactional, which include reciprocity (mutual sharing),
durability (length of time in relationship), intensity (frequency of interactions between members),
and dispersion (ease with which members can contact each other); and 3) Functional, such as
providing social support, connections to social contacts and resources, and maintenance of social
identity.

Social support refers to the varying types of aid that are given to members of a social network.
Research indicates that there are four kinds of supportive behaviors or acts: 1) Emotional
support - listening, showing trust and concern; 2) Instrumental support - offering real aid in the
form of labor, money, time; 3) Informational support - providing advice, suggestions, directives,
referrals; and 4) Appraisal support -affirming each other and giving feedback. This social
support is given and received through the individual's social network. However, it is important to
remember that "some or all network ties may or may not be supportive."

Social trends in the United States offer support for health education intervention strategies that
promote lay helping. Some of these trends include: 1) the increase in chronic illnesses requiring
long-term care which have tended to dominate U.S. disease patterns in the last half of this
century; 2) a rapid expansion of health materials available for the lay public; 3) a wide range of
medical technology now available to the public (e.g. blood pressure cuffs, glucose meters,
pregnancy tests); 4) over-the-counter medications that have increased in number and potency; 5)
a public that is better able to see both the beneficial and harmful effects of medical care and 6) a
recognition that human behavior is an important aspect of medicine. Along with the recognition of
this need for lay volunteers, a host of programs to train a core of "lay health advisors" (LHAs) has
mushroomed. These LHAs are lay people to whom others in the social environment turn for
advice, emotional support and/or aid. There are many terms which can be used instead of LHAs.
Some of these are listed in below:
 Alternate Terms for Lay Health Advisors

Canvasser Home visitor

Community health advisor Indigenous paraprofessional
Community health advocate Informal helper
Community health aide Lay community health worker
Community health opinion leader Lay volunteer
Community health representative Natural caregiver
Community health worker Natural helper
Community helper Natural neighbor
Family health promoter Nonprofessional
Health education aide Nonprofessional neighborhood
support care worker
Health facilitator  
Health guide outreach worker Paraprofessional
Health promoter Resource mother
Health visitor Voluntary health educator
Health liaison  

LHAs should serve foremost as a source of help that is available within a community. Both LHAs
and professionals can provide the four basic types of social support mentioned earlier--emotional,
instrumental, informational and appraisal. However, the lay helping role should complement the
specialized roles of the professionals as shown by some examples in Figure 7. Overall, there are
three general roles in which LHA's may serve. They may: 1) link and/or negotiate agency services
for their people in need, 2) counsel as a part of the natural exchange of feedback and advice to
people who know and trust them; and 3) educate people and help them organize their resources
to advocate for improvements in their own health care on a community-wide basis.

There are several examples of LHA programs across the country. The Resource Mother's Project
in South Carolina, the Camp Health Aid Program in Michigan, the Community Health Advocacy
Program and the Save Our Sisters Project, both in North Carolina, and the Community Health
Advisor Network in Mississippi are just a few. The main characteristics which are sought in these
lay helpers are their willingness to help, their ties to others in their own social networks, and their
ability to access resources in the local health care system.

Eng and Young (1992) have offered a planning process model for LHA interventions that asks
four major questions on needs to be considered:

1. At what level or levels is the program outcome desired? This could include individual
changes in behavior, social network changes in working with agencies, service delivery
changes in the structure of agencies, or community changes in problem-solving abilities.
2. What network intervention strategies will be used? Possibilities would be strengthening
existing networks, enhancing the total network, or organizing community efforts.
3. What existing structures (such as family and friends, religious and social organizations,
civic organizations, service organizations, neighborhoods, or businesses) will be targeted
to initiate any change?
4. Which social support functions--emotional, instrumental, informational, or appraisal--will
the LHAs be expected to carry out?
 This model does encourage an approach to establishing LHA programs which are adaptable to
different settings and purposes within the realm of public health.

Community Level Models/Theories

1. Community Organization The phrase Community Organization has emerged from a specific
field of activity within social work in the late 1800's into a much broader process which involves
working with people as they attempt to "define their own goals, mobilize resources, and develop
action plans" for meeting the needs they have identified collectively. Community organization has
been formally defined as "the method of intervention whereby individuals, groups, and
organizations engage in planned action to influence social problems." It has been viewed as an
art in consensus building concerned with the enrichment, development and change of social
institutions. Community organization has roots in several theoretical frameworks: ecological
theory, social systems theory, and theories of social networks and social support.
a. Three Models of Community Organization

Rothman and Tropman (1987) considered that community organization could be

categorized into three distinct models of practice: 1) locality development; 2) social
planning; and 3) social action. Locality development is a very process-oriented model.
Community change is sought through participation of a broad cross-section of members
in the community who attempts to identify and solve their own problems. It stresses
consensus, cooperation, building group identity and a sense of community. Outside
practitioners (coordinators or enablers) help to coordinate this effort and enable the
community to successfully address its own concerns. In the literature, a segment of this
field is referred to as "community development." Some examples of an application of this
model include neighborhood work programs conducted by settlement houses, Volunteers
in Service to America (VISTA), and the Peace Corps. Social planning stresses a
technical aspect of problem solving with community participation varying from much to
little depending on the problem and the organization variables present. It is more task
oriented. Expert planners are to use their technical abilities to guide complex change
processes. The design and implementation of social plans and policies is the central
focus of this model. Building community capacity for a community to solve its own
problems or encouraging either radical or fundamental social change is not a central part
of this model. The United Way, urban affairs, city planning and social planning divisions
of housing authorities typify this approach to community organization. Social action is
both task and process oriented. This model is used to increase the problem-solving ability
of the community and also to achieve some concrete changes in order to correct social
injustice that has been identified by a disadvantaged or oppressed group. Basic changes
are sought in major institutions or community practices. An attempt is made to
redistribute power, resources or decision-making in the community and/or to change
basic policies of formal organizations. Application of this approach in the past has
included the civil rights movement, some of the early black-power groups, labor unions,
women's liberation and the welfare rights movement. Even though these three models
have been isolated or set apart in their descriptions, in actual practice these approaches
overlap.

b. Key Concepts in Community Organization

Even though community organization does not use a single unified model, there are
several key concepts that are central to its practice to bring about change on the
community level. The first of these, empowerment, has been described as a process by
which individuals and communities gain mastery over their lives by becoming enabled to
take power and and then to act effectively to transform or change their environments.
Within community organization, this concept of empowerment operates on two levels at
 the same time. First, the individual who is involved in the community organizing effort
may experience increased social support, a concept considered earlier in this review.
This support may result in a more generalized sense of control. An increased sense of
control (empowerment) could have positive benefits on one's health. Researchers have
indicated that social participation can decrease the individual's susceptibility to illness. On
the second and broader level, community organization can contribute to community-level
empowerment which leads to increased community competence. Community
competence may be thought of as the equivalent of self-efficacy and behavioral capability
on a community level; both the confidence and skills to solve problems effectively are
present within the community. The health practitioner or community organizer could play
a crucial role in helping communities increase their problem-solving ability.

Two principles which are important in community organization practice are the principle
of participation and the principle of relevance. Dewey (1946) and Lindeman (1926)
paid close attention to the principle of participation or "learn by doing" in their work within
the field of adult education. Adult education was (and still is) considered a process of
increasing people's understanding, activating them, and helping them make decisions for
themselves. This idea fits nicely with the community organization principle of gaining true
involvement and participation by community members at each stage within the process.
The principle of relevance was identified by Dorothy Nyswander (1966) as one of
"starting where the people are." The change agent who begins with the individual or
community's felt needs rather than a personal or agency plan will experience far more
success than imposing an agenda from outside. It is widely accepted that communities
should identify their own needs and issues to be addressed. When an issue is chosen by
the community, a sense of ownership emerges which leads to empowerment and the
development of a competent community.

However, in the concept of issue selection one must differentiate between problems,
which are troublesome, and issues, which are problems the community feels strongly
about. In addition, the selected issue should also be: 1) specific, 2) simple, and 3)
winnable. A good issue should be able to be clearly explained in a sentence or two by
any member in the group. As people begin to work on it, they should be able to remain
upbeat and optimistic if the issue is "doable."

One of the most important concepts by Brazilian educator Paulo Freire (1973) was
recently added to the model of community organization. In the concept of critical
consciousness, Freire spoke of entering a dialogue with illiterate peasants so that they
could teach themselves how to read and write as well as how to understand the root
causes of their problems.

According to Friere, the educator's main role is to converse with the students about
concrete situations and offer them the tools in order for the students to teach themselves
to read and write. It is a collaborative effort. From this understanding, a person could
really learn to think critically about real-life problems and and take action to change
his/her world for the better. Applied to health education, communities should consider
their health concerns in the broader context of their political and social situation in order
to develop their own plan of action to deal with any problems collectively identified.

c. Studies Using Models of Community Organization

Two studies which demonstrate the application of concepts and principles in the models
of community organization are the Tenderloin Senior Organizing Project (TSOP) in San
Francisco's Tenderloin hotels in 1979 and the Minnesota Heart Health Program (MHHP)
started in the 1980's. The TSOP was directed at the low-income elderly in Tenderloin
 (single room occupancy) hotels within San Francisco. In an effort to combat poor health,
social isolation and helplessness, health educators attempted to encourage social
support and social action among these residents. In identifying problems, a modified
approach to Freire's method was used to help residents share their problems along with
their causes and to create possible action plans. Next, specific and winnable issues were
selected. Group members were encouraged to meet their social needs along with the
political concerns of some members of the hotel group. Indicators, such a reduced crime
rate in the area and qualitative changes in the health and the life satisfaction of residents,
suggest that a more competent community resulted. The MHHP is a scientific project
while at the same time being a community-based program. This study involves about
250,000 people in three communities with the stated goal of reducing mortality and
morbidity rates due to cardiovascular disease. There have been three educational
approaches used in this project: community organization, media and face-to-face
education. Since the beginning of this program, a high priority has been assigned to
developing community partnerships for health where community members work with the
research team in making decisions and implementing programs. A community advisory
board was formed early in each community to also ensure a high level of community
involvement. All three of these advisory boards have now become private nonprofit
organizations. The program has also moved increasingly from a social planning model
toward a community development approach.

2. Diffusion of Innovations Theory (Rogers and Shoemaker)

Diffusion of Innovations Theory provides an explanation for how new ideas, products and social
practices diffuse or spread within a society or from one society to another. Diffusion can be
thought of as a special type of communication in which messages are concerned about a new
idea. If a health education program is viewed as an innovation, this theory could describe the
pattern the target population would follow in adopting the program.

The pattern of adoption has been represented as a bell-shaped curve. As can be seen in Figure
8, time is an important element in this diffusion process. Five adopter categories are used to
classify members of a social system on the basis of their innovativeness: 1) innovators (active
information seekers of new ideas); 2) early adopters (very interested in the innovation but not
the first to sign up); 3) early majority (need external motivation to get involved); 4) late majority
(are skeptics and will not adopt an innovation until most people in the social system have done
so); and 5) laggards (last to become involved by a mentoring program or through constant
exposure and have limited communication networks).

Another aspect of time considers the rate of adoption, which is the speed in which an innovation
is adopted by members of a social system. When the number of individuals adopting a new idea
is plotted on cumulative number or percentage of adopters over time, the result is an s-shaped
curve as illustrated in Figure 9. Most innovations have this s-shaped rate of adoption. However,
the slope can be very steep, as when a new idea diffuses rapidly, or more gradual in a slower
rate of adoption.

There are certain characteristics which are associated with successful diffusion efforts. These
attributes of innovations can help to explain the different rates of adoption of innovations by
individuals. Some of these include: 1) Relative advantage - the level at which an innovation is
perceived as better than the idea it attempts to replace; 2) Compatibility - the level at which an
innovation is viewed as being consistent with the existing values, past experiences and needs of
the potential adopters; 3) Complexity - the level at which an innovation is viewed as difficult to
use and understand; 4) Trialability or Flexibility - the level at which an innovation can be
experimented with on a limited or "trial" basis; 5) Observability - the level at which the results of
an innovation can be seen by others.
 This process of diffusion of an innovation involves an innovation, someone who has knowledge or
experience with using the innovation, someone else who does not yet have knowledge of the
innovation, and a communication channel between the two people. The communication
channel is the means by which messages get from one individual to another. Mass media
channels are the most rapid and effective ways to create an awareness/knowledge about an
innovation. These channels are mass media, such as radio, television, newspapers, and
magazines, where one source can potentially reach an audience of many. In regards to improving
health, when physicians and community leaders act to reinforce information that is also provided
through mass media channels, there is a much better chance that consumers will decide to act.
This goes along with the research that interpersonal channels, which involve a face-to-face
exchange between two or more people, are more effective in persuading an individual to adopt a
new idea.

The innovation-decision process is a five-step procedure through which an individual passes.

These steps include: 1) knowledge, 2) persuasion, 3) decision, 4) implementation, and 5)
confirmation. The person has an awareness/knowledge of an innovation, forms an attitude about
it, decides to accept or reject, implements the new idea, and confirms the decision. Re-invention
is a concept that was added to diffusion in the 1970's and refers to the degree to which an
innovation is changed or modified by a user in the process of its adoption. It is most likely to occur
during the implementation stage. In the decision stage, the innovation may be adopted or
rejected. However, decisions can be reversed later. Discontinuance is the decision to reject an
innovation after it was adopted earlier. This may be due to dissatisfaction or to an improvement in
the innovation.

Individuals also often adopt innovations as members of organizations. Such people seldom adopt
an innovation until it is first adopted by the organization. These adoptions have been referred to
as contingent innovation-decisions because the adoption and implementation of an innovation
by these individuals is contingent upon organizational adoption. One example of this would be a
health educator using a new curriculum after it has been formally adopted by the school district.

3. Organizational Change Theories

Organizations are complex and layered social systems. Change may be influenced at each of
these levels. Health education strategies that are directed at several layers at once may be the
most durable over time in producing the desired results. In terms of sociology, ecology refers to
the study of human populations in terms of physical environment, spatial organization distribution,
and cultural characteristics. Since organizations can be influenced at many levels in their ecology,
no single theory can completely explain how and why organizations change. Among the many
theories of organizational behavior, two have shown special promise in the area of public health:
a) Stage Theory and b) Organizational Development.

a. Stage Theory of Organizational Change (Lewin (1951), Zaltman, Duncan and Holbek
(1973) and Beyer & Trice (1978))

This theory helps to explain how organizations plan and implement new goals, programs,
technologies and ideas. Organizations are believed to pass through a series of "stages"
with each stage requiring a unique set of strategies if the innovation is to progress. A
strategy that may be effective at one stage may be wrongly applied at the next. An
innovation's current stage of development must be correctly assessed and the proper
strategies selected in order to be successful in the application of Stage Theory.

One shortened version of Stage Theory consists of four stages: 1) Awareness (Problems
are recognized and analyzed, and solutions are suggested and evaluated); 2) Adoption
(Policies are formulated, and resources for beginning change(s) are allocated); 3)
 Implementation (The innovation is implemented, reactions take place, and changes in
roles occur); 4) Institutionalization (The policy or program becomes an integral part of
the organization, and new goals and values are a part of its structure). These stages are
"in sequence." However, movement can be forward, backward, or abandoned at any
point in the process.

It is also known that different actors may play leading roles at different stages of the
organizational change. Senior-level administrators tend to be important at the awareness
and early adoption stages. Mid-level administrators become important at the adoption
and early implementation stages. Workers (e.g. teachers) are instrumental at the
implementation stage. Finally, senior-level administrators again play a key role during the
institutionalization stage.

There are some criticisms of Stage Theory. First, the stages need to be better defined.
Second, the stage model is not yet complete since beyond institutionalization there
should be renewal, when a well-established program evolves to meet changing demands.
Lastly, the factors known to contribute to the program's development at each stage need
to be expanded.

b. Organizational Development Theory (Lewin (1951) and Porras & Robertson (1987))

Human relations and the quality of life at work are often the targets of Organizational
Development Theory. It has been divided into two main sections: 1) Change Process
Theories and 2) Implementation Theories. Change Process Theories deal with the
underlying dynamics of change. There are only a few of these theories according to
Porras and Robertson, and these have not yet been integrated into an adequate
explanation of the change process. On the other hand, Implementation Theories are
much better defined. These are the activities that health educators would use to make
sure the change is successful. Under Implementation, there are Procedure Theories
which identify the sequence of actions needed for producing change in the organization.
These four steps include: 1) Diagnosis - a specially trained person, usually an outside
consultant, helps the organization identify its most striking problems which interfere with
its functions; 2) Action Planning - strategies are developed for addressing these
diagnosed problems; 3) Intervention - the consultant usually does not offer specific
solutions but will aid in problem solving among the organization's members in group
interactions; 4) Evaluation - the effort of the planned changes is assessed, and these
changes in the organization are allowed to settle.

Generally speaking, Stage Theory and Organizational Development Theories have the
greatest potential for creating positive health changes in organizations when used
together. One example would be using consultation (Organizational Development) as the
intervention in both the adoption and institutional stages (Stage Theory) in an
organizational change.

4. Ecological Models

Ecological models for health education focus attention on the individual and the social
environmental factors as the targets for any interventions. Some health education professionals
maintain that using such terms as "lifestyle" and "health behavior" may direct attention toward
changing individuals, rather than changing the social and physical environment, which can serve
to reinforce unhealthy behaviors. This emphasis on individuals and their choices can lead to the
support of victim-blaming. An ecological outlook suggests a "reciprocal causation" between the
individual and the environment.
Ecological models are systems models; however, certain patterned behaviors (whether for one or
many persons) are the outcomes of interest. Human behavior is viewed as being determined by
the following:

a. Intrapersonal Factors - The theory of change is one of changing characteristics of the

individual, such as knowledge, attitudes, skills or intention to comply with certain
behavioral norms.
b. Interpersonal Relationships - Relationships with family, friends, neighbors, coworkers
and acquaintances are important influences on the health behavior of individuals. An
individual can belong to one or more social networks. Through these ties in social
networks, people acquire norms.
c. Organizational Factors - Within the ecological framework, organizational characteristics
can be used to support behavioral change. Organizations, such as school, work, church,
professional or neighborhood groups, may have positive or negative effects on the health
of their members. Since they are important sources and transmitters of social norms and
values, organizations can provide the opportunity to build social support for a desirable
behavior change. Organizational changes are needed to support long-term behavioral
changes among individuals.
d. Community Factors - Community can refer to the face-to-face primary groups to which
an individual can belong. These "mediating structures," such as family, church, informal
social networks, and neighborhoods, may provide social identity and resources.
Community can also be concerned with the relationships among organizations within a
political or geographic area. Many organizations competing for scarce resources usually
results in the inefficient use of these resources, unless there is coordination and coalition
building among community agencies in planning health education interventions. A
community can also be defined as a population which is political and has one or more
power structures. These power structures play a crucial role in defining this community's
health problems as well as allocating its resources. Often those with the most serious
health problems in a community are also those with the least access to its power
structures (e.g. poor, rural, uneducated, homeless, unemployed, minorities,
handicapped).
e. Public Policy - Within public health, the health of the population has been emphasized.
Regulatory policies, procedures and laws have been passed (national, state or local) to
help protect the health of communities. These policies have been traditionally focused on
reducing death and disease from infectious agents. This success has now led to the
development of public policy in the area of chronic diseases. As a part of the policy
development process, increasing the public's awareness of health and policy issues must
be included.

An ecological model should focus attention on the environmental causes of behavior (rather than
be individually focused) and should also identify environmental interventions for enhancing
health. In the literature, three formal ecological models are outlined: 1) The Mandala of Health, 2)
Human Development and 3) Health and the Community Ecosystem.

The Mandala of Health is a model of the human ecosystem and presents those factors that
affect health as shells or levels that extend out from the individual as seen in Figure 10. The
systems which expand out from the holistic individual (mind, body, spirit) are family, community
and its environment, and culture and the biosphere in the outer shell. The model also provides for
the inclusion of the social sciences in the upper half of the figure and the natural sciences in the
lower half. Sick care service (i.e. health care system) is only one factor of health, besides work
and lifestyle, which integrate the social and physical sciences. This is described as a very
dynamic and three-dimensional model in which the pieces can change in shape and size
depending on the need over time and in different communities. The essence of the mandala
 model is the notion that for any health intervention to be successful the approaches must be
"multi-level, multi-faceted, and multi-disciplinary."

Human Development, a second model, focuses on sustainable health for all. There is a strong
interrelationship between health, environment and economy as diagrammed by three interlocking
circles shown in Figure 11. The economy has to be environmentally sustainable by conserving
resources and controlling pollution. In addition, the economy must also be socially sustainable.
This involves the concept of equity. Resources (including wealth) should be distributed so that
everyone's "basic human needs" are met. In a fair and just society, humans will have an "equal"
opportunity to meet their health needs. The concept of viability, at the top of Figure 11,
emphasizes the environmental conditions that support human life and well-being. Environment
includes both the natural environment as well as the created environment that humans build for
themselves. This health-environment-economy model considers the economy as an important
support to the environment and human health. Described as a "central model for healthy public
policy," this model has, as its overall goal, "maximizing human rather than economic
development."

In the third model, Health and the Community Ecosystem, the central focus is health or human
development (See Figure 12). There are three qualities for each of the areas of community, the
environment and the economy that must be present for the highest level of human health and
development to be achieved. A community needs to be: 1) convivial (have social support
networks), 2) livable (provide a viable human environment), and 3) equitable (treat all with
fairness and justice). The economy must be adequate; it must generate enough wealth so that its
members can achieve an acceptable level of health. This implies an equitable distribution within
the community. In addition, the economy must also be socially and environmentally sustainable.
The environment, like economy, must be sustainable so that its diversity can be maintained. It
must also be viable for humans. As discussed earlier in the Human Development model,
environment includes both the natural environment and the created environment, which must be
livable for the community and its individuals. All three of these models suggest a holistic approach
to meeting the environmental, social, economic, land use, and health or human development
needs of its members.

Students, in fact all individuals, are most effective when they are taught in their personal learning style.
In fact, there are three major types of learners: visual, auditory, and tactile/kinesthetic. While most
individuals without disabilities can learn using any one of these styles, most people have one for which
they show a stronger affinity.

A Look at the Three Learning Styles

Visual Learners - Visual learners are those who generally think in terms of pictures. They often prefer to
see things written down in a handout, text or on the overhead. They find maps, graphs, charts, and
other visual learning tools to be extremely effective. They remember things best by seeing something
written.

Auditory Learners - Auditory learners are those who generally learn best by listening. They
typically like to learn through lectures, discussions, and reading aloud. They remember best
through hearing or saying items aloud.

Kinesthetic Learners- Kinesthetic, also called tactile, learners are those who learn best through
touching, feeling, and experiencing that which they are trying to learn. They remember best by
writing or physically manipulating the information.
Learning Style Assessments

There are many tests available to help you and your students discover your best learning style.
Generally speaking, however, if you are someone who is more likely to think in pictures, prefer
to meet with someone in person, and are more likely to want visual diagrams when completing a
project you have tendencies towards visual learning. Similarly, if you are more likely to think in
terms of sounds, prefer to speak on the phone with someone, and want verbal instructions then
you tend towards auditory learning. Finally, if you are more likely to think in terms of moving
images like mini-movies in your mind, prefer to participate in an activity when you meet to
speak with someone, and tend to jump right into a project without reading directions you tend
towards tactile/kinesthetic learning.

How to Effectively Use Learning Styles in Class

In the best of all possible worlds, you would incorporate all three learning styles into each of your
lessons. However, this is just not possible in the real world of teaching. In truth, it is often not hard to
include both auditory and visual learning styles in your lessons. For example, you can have instructions
written on the board and say them out loud. However, it is not always as easy to include the
tactile/kinesthetic learning style into your lessons. The sad truth is that many students have this as their
strongest learning style. It is best to not force the issue but instead find natural places to include
kinesthetic learning. If your class warrants it, you could include simulations, role-playing, debates, or the
use of manipulatives.

Concerns When Incorporating Learning Styles

Though rarer today then in the past, some teachers discount the importance of learning styles. They
continue to teach in their one major method without trying to vary instructional methods. This is a
mistake that will lead to less learning in the classroom.

On the other hand, many students and to a lesser degree some teachers make the mistake of
thinking that they cannot learn using methods that are not focused on their learning style. This is
also a huge mistake that in the end will result in less learning. If teachers do not help their
students find ways to be successful learning information presented in any style, they are not
helping them succeed in the future. The fact is that students will be faced with many different
styles of teaching during the educational career. Only by finding ways to adapt and learn using
other styles, will students end up succeeding.

Examples of ways that students can adapt:

 Kinesthetic learners would include writing down information that they are to learn.
 Visual learners could create word webs, venn diagrams, or other visual presentations of
information.
 Auditory learners could read a passage out loud from their textbook or from handouts.

Three Learning Styles

 Visual Learners
  Auditory Learners
 Kinesthetic Learners

More About Learning Styles

 Learning Styles Menu

 Learning Styles Strategies
 Learning Styles Assessments