Chapter 7 Lecture

Chapter 7:
Theories and
Models Commonly
Used for Health
Promotion
Interventions

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 Definitions – 1

• Theory
• “A set of interrelated concepts, definitions, and
propositions that presents a systematic view of
events or situations by specifying relations among
variables in order to explain and predict the events of
the situations” (Glanz, Lewis, & Viswanath, 2008, p. 26).
• For health education specialists, theories “provide a
framework for generating testable hypotheses and
integrating empirical evidence and, over time, a road
map for the design and implementation of
intervention strategies” (Rothman, 2009, p. 150S).

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 Definitions – 2

• Model
• “A composite, a mixture of ideas or concepts taken from any
number of theories and used together” (Hayden, 2009, p. 1)
• Do not have to explain, only represent process
• Can have several theories within a model
• Concept
• Primary elements of theories or building blocks of theory (Glanz et al.,
2008b)
• Construct
• A concept developed, created, or adopted for use with a specific theory
(Kerlinger, 1986)
• Variable
• The operational (practical use) form of a construct (Rimer & Glanz,
2005); how a construct will be measured (Glanz et al., 2008b)
• Can be measured

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 Examples of the Definitions

• Concept – Personal belief

• Construct – Perceived barrier
• Variable – On a scale of 1 to 10, with 1 being
least important and 10 being most important,
how important is wearing a safety belt to you?
• Model – Health Belief Model
• Theory – Social Cognitive Theory

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 Theories – 1

• Theories serve as the backbone of processes

used to plan, implement, and evaluate health
promotion interventions.
• There is no perfect theory, and no one theory
dominates research or practice.
• Approximately 10 theories and models are used
regularly to plan programs.

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 Theories – 2

• Theories can help by:

1. Identifying why people are not behaving in healthy ways
2. Identifying information needed before developing an
intervention
3. Providing a framework for selecting constructs to
develop the intervention
4. Providing direction and justification for program activities
5. Providing insights into how best to deliver the
intervention
6. Identifying what needs to be measured to evaluate the
impact of the intervention
7. Helping to guide research identifying the determinants of
health behavior

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 Types of Theories & Models

• Planning models (or theories/models of

implementation): theories and models used for
planning, implementing, and evaluating health
promotion programs
• Behavior change theories (or change process
theory)
• “Specify the relationships among casual
processes operating both within and across
levels of analysis” (McLeroy et al., 1992, p. 3)
• Help explain how change takes place

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 Behavior Change Theories – 1

• The underlying concept of the socio-ecological

approach (sometimes referred to as the ecological
perspective) is that behavior has multiple levels of
influences.
• Social context
• “Defined as the sociocultural forces that shape people’s
day-to-day experiences and that directly and indirectly
affect health and behavior” (Burke, Joseph, Pasick, &
Barker, 2009, p. 56S).
• Because of the underlying concepts that are captured in
the constructs of individual theories, certain theories are
more useful in developing programs aimed at specific
levels of influence.

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 An Ecological Perspective: Levels of
Prevention

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 Behavior Change Theories – 2

• Theories can be categorized by approach:

• Continuum Theories
• Use an approach that identifies variables that
influence action and combines them into a
prediction equation (e.g., HBM, TPB)
• Stage Theories
• Are composed of an ordered set of categories
into which people can be classified and that
identify factors that could induce movement
from one category to the next (e.g., TTM,
PAPM, HAPA)
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 Behavior Change Theories – Intrapersonal
Level
• This group of theories focuses on factors within the
individual such as knowledge, attitudes, beliefs, self-
concept, feelings, past experiences, motivation, skills,
and behaviors (Rimer & Glanz, 2005).
• Examples
• Stimulus Response (SR)
• Theory of Planned Behavior (TPB)
• Health Belief Model (HBM)
• Protection Motivation Theory (PMT)
• The Elaboration Likelihood Model of Persuasion
• Information-Motivation-Behavioral (IBM) Skills Model
• Transtheoretical Model (TTM)
• Precaution Adoption Process Model

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 Stimulus Response (SR) Theory

Stimulus Response Consequence

• The mere temporal association between a behavior and an

immediately following reward is sufficient to increase the
probability that the behavior will be repeated.
• If the consequence is reinforcement then there is an
increase in behavior.
• If the consequence is punishment then there is a decrease in
behavior.
• Reinforcement should be frequent and occur soon after the
desired behavior.
• Complex behavior should be shaped in small steps.
• Reinforcement and punishment can be either positive or
negative.
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 2 × 2 Table of the Stimulus Response
Theory

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 Theory of Planned Behavior (TPB) – 1

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 Theory of Planned Behavior (TPB) – 2

• An extension of the theory of reasoned action (TRA); it

addresses the problem of incomplete volitional control
• Adds the concept of perceived behavioral control
• Perceived behavioral control – perceptions of a
person's ability to perform a given behavior
• The more favorable the attitude and subjective norm
with respect to a behavior, and the greater the
perceived behavioral control, the stronger should be
the individual's intentions to perform the behavior
under consideration (Ajzen, 1988).
• Successful performance of the behavior depends not
only on a favorable intention but also on a sufficient level
of behavioral control.
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 Health Belief Model (HBM) – 1

• History
• Developed in 1950s by
Hockbaum/Kegeles/Leventhal/Rosenstock to help
explain the use of health services
• Based on K. Lewin’s decision-making model (goal
oriented/directed)
• Hypothesizes that health-related action depends on the
simultaneous occurrence of three classes of factors:
1. The existence of sufficient motivation to make issues
salient or relevant
2. The belief one is susceptible (or perceived threat)
3. The belief that the benefits are worth the cost (or
perceived barriers)
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 Health Belief Model

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 Health Belief Model (HBM) – 2

• People must also feel themselves competent

(self-efficacious) to overcome perceived barriers
to taking action (Champion & Skinner, 2008, p. 50).
• Constructs:
• Cues to action
• Perceived susceptibility
• Perceived seriousness/severity
• Perceived barriers
• Perceived benefits
• Likelihood of taking recommended preventive health
action

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 Protection Motivation Theory (PMT) – 1

• A value-expectancy theory
• Theory of persuasive communication that
includes reward and self-efficacy components
• The PMT has some similarities to the HBM.

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 Protection Motivation Theory (PMT) – 2

• Inputs come from environmental sources of

information and from intrapersonal sources.
• Based on these inputs, people make a
cognitive assessment of whether there is a
threat to their health.
• Arouses two cognitive mediating processes:
threat appraisal and coping appraisal
• Examples of program interventions that use
PMT include breast self-examination, living wills,
sun protection behavior, and weight loss.

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 The Elaboration Likelihood Model of
Persuasion (ELM) – 1
• Designed to help explain how persuasion
messages (aimed at changing attitudes) were
received and processed by people
• Has been used to help interpret and predict
the impact of health messages
• Useful in message tailoring

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 The Elaboration Likelihood Model of
Persuasion (ELM) – 2
• The ELM does four things:
• Proposes that modifying attitudes or other judgments can
be formed as a result of a high degree of thought (i.e.,
central process route) or a low degree of thought (i.e.,
peripheral and processing route); postulates that there are
numerous specific processes of change that operate along
the elaboration continuum
• When comparing the consequences of the two routes,
there are times when the results are similar. However, the
two routes usually lead to attitudes with different
consequences (Petty et al., 2009, p. 197).
• “Organizes the many specific processes by which
variables can affect attitudes into a finite set that operate
at different points along the elaboration continuum” (Petty
& Briñol, 2012, p. 226)
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 The Elaboration Likelihood Model of
Persuasion (ELM) – 3

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 Information-Motivation-Behavioral (IMB)
Skills Model
• Initially developed for HIV/AIDS prevention
efforts (Fisher & Fisher, 1992)
• The constructs of information, motivation, and
behavioral skills are the fundamental
determinants of preventive behavior.
• The information provided needs to be
relevant, easily enacted based on the specific
circumstances, and serve as a guide to
personal preventive behavior.
• Prevention motivation includes both personal
motivation and social motivation to act.
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 The Information-Motivation-Behavioral
Skills Model of HIV Prevention

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 Transtheoretical Model (TTM) – 1

• “An integrative framework for understanding how

individuals and populations progress toward adopting
and maintaining health behavior change for optimal
health” (Prochaska, Johnson, & Lee, 1998, p. 59)
• Has five major constructs:
1. Stages of change (this is why some call it the
“Stages of Change Model”)
2. Decisional balance
3. Self-efficacy
4. Processes of change
5. Temptation

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 Transtheoretical Model (TTM) – 2

• Based on five critical assumptions:

1. No single theory can account for all the complexities
of behavior change.
2. Behavior change is a process that unfolds over time
through a sequence of stages.
3. Stages are both stable and open to change.
4. The majority of at-risk populations are not prepared
for action and will not be served by traditional action-
oriented behavior change programs.
5. Specific processes and principles of change should
be emphasized at specific stages to maximize
efficacy.

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 The Stages of Change

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 How to Stage a Person Using the TTM
Do you exercise regularly?

No Yes
Do you intend to in the Have you been doing so
next 30 days? for more than six months?

No Yes No Yes

Do you intend to in Preparation Action Maintenance

the next six months?

No Yes

Precontemplation

Contemplation

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 Processes of Change that Mediate
Progression Between Stages of Change

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 Precaution Adoption Process Model (PAPM)

• Is more recent than the Transtheoretical Model

• PAPM explains how people come to the decision
to take action and how they translate that
decision to action.
• Most applicable for use with the adoption of a
new precaution, or the abandonment of a risky
behavior that requires a deliberate action
• It can also be used to explain why and how
people make deliberate changes in habitual
patterns.
• Includes seven stages
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 Application of the Precaution Adoption
Process Model

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 Progress Between Stages of the Precaution
Adoption Process Model

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 Staging a Person Using Precaution
Adoption Process Model
• What are your intentions for receiving the new vaccine
for shingles?
• I have already gotten it. (Stage 6)
• I have decided to get it. (Stage 5)
• I have thought about it and decided not to get it.
(Stage 4)
• I am not sure. I am still trying to decide whether to get
it or not. (Stage 3)
• I heard there was a vaccine, but I really haven't
thought much about it. (Stage 2)
• I was not aware there was a vaccine for shingles.
(Stage 1)

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 Change Process Theories – Interpersonal
Level
• This group of theories “assume individuals exist within, and
are influenced by, a social environment. The opinions,
thoughts, behavior, advice, and support of people surrounding
an individual influence his or her feelings and behavior, and
the individual has a reciprocal effect on those people” (Rimer
& Glanz, 2005, p. 19).
• Research has shown that social relationships can be a
powerful influence on health and health behaviors.
• Examples:
• Social learning
• Social power
• Interpersonal communication
• Social networks
• Social capital theory
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 Social Cognitive Theory (SCT)

• Combines the SR theory and cognitive theories

• Reinforcement contributes to learning, but reinforcement
along with an individual's expectations of the
consequences of behavior determine
the behavior.
• Reinforcement is an important
component of SCT.
• Three types of reinforcement:
• Direct reinforcement
• Vicarious reinforcement (observational learning or
social modeling)
• Self-reinforcement

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 Often-Used Constructs of the SCT

• Behavior capability
• Expectations
• Expectancies
• Self-control/self-regulation
• Self-efficacy
• Through performance attainment (mastery of task)
• Through vicarious experience (observing others)
• As a result of verbal persuasion (suggestions from others)
• Through emotional arousal (interpreting one's emotional
state)
• Collective efficacy
• Emotional-control responses
• Reciprocal determinism
• Locus of control

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 Social Network Theory (SNT) – 1

• Developed in the 1950s by sociologists who

studied Norwegian villages
• The social network, and the closely related
concept of social support, “do not connote
theories per se. Rather, they are concepts
that describe the structure, processes, and
functions of social relationships” (Heaney &
Israel, 2008, p. 193).
• Social networks can impact health, but the
specifics of who is most impacted and how best
to set up and use social networks are unknown.

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 Social Network Theory (SNT) – 2

• When assessing a social network, consider the

following:
• Centrality versus marginality of individuals in
the network
• Reciprocity of relationships
• Complexity or intensity of relationships in the
network
• Homogeneity or diversity of people in the
network
• Subgroups, cliques, and linkages
• Communication patterns in the network
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 Social Capital Theory

• Social capital is “the relationships and structures

within a community, such as civic participation,
networks, norms of reciprocity, and trust, that
promote cooperation of mutual benefit” (Putnam,
1995, p. 66).
• Studies show that greater social capital is
linked to several different positive outcomes,
whereas lack of social capital is related to
poorer health outcomes.
• It is not an intervention in itself, but it is a
concept that needs to be considered and
monitored.
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 Social Capital

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 Behavior Change Theories – Community
Level
• This group of theories applies the last three levels of the
ecological perspective: institutional (e.g., rules and
regulations), community (e.g., social networks and
norms), and public policy (e.g., legislation).
• “… They explore how social systems function and
change and how to mobilize community members and
organizations” (Rimer & Glanz, 2005, p. 22).
• Examples:
• Theories associated with these factors include
theories of community organizing and community
developing.

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 Diffusion Theory

• Provides an explanation for the pattern of adoption of the

innovations
• Like other processes, adoption is situation specific, and it
results from people going through a series of stages:
• Knowledge (acquisition of about the innovation)
• Persuasion (i.e., attitude concerning the innovation)
• Decision (about adopting or not adopting)
• Implementation (beginning to use the innovation)
• Confirmation (commitment to use, continue to use, or
discontinue use of the innovation)
• One of the more useful application of the diffusion theory
is when marketing a health promotion program.

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 Diffusion Theory – Pattern of Adoption

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 Community Readiness Model (CRM)

• A stage theory for communities

• Like individuals, communities are at various
stages of readiness for change.
• Nine stages:
1. No awareness 5. Preparation
2. Denial 6. Initiation
3. Vague awareness 7. Stabilization
4. Pre-planning 8. Confirmation/Expans
ion
9. Professionalism

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 Cognitive-Behavioral Model of the Relapse
Process – 1
• For most, relapse is a part of change.
• Relapse – breakdown or failure in a person's
attempt to change or modify a particular
(health) behavior
• Lapse – a single slip or mistake
• Planners need to make sure that program
interventions include the skills necessary for
dealing with difficult times during behavior
change.

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 Cognitive-Behavioral Model of the Relapse
Process – 2
• Relapse prevention – a self-control program
designed to help individuals to anticipate and
cope with the problem of relapse when changing
(health) behavior
• Relapse is triggered by high-risk situations.
• People who have the coping skills to deal
with a high-risk situation have a much greater
chance of preventing relapse than those who
do not.

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 Limitations of Theory

• Although all the theories presented have been

found to be useful in certain situations and
settings, no one theory has been shown to be
useful in all situations and settings. In fact, each
of the theories presented has its limitations.
• Three sources (Angus et al., 2013; Boston
University School of Public Health, 2013; Munro,
Lewin, Swart, & Volmink, 2007) present
limitations of many of the theories presented in
this chapter.

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