Application of health education

theories and models

in
behavior change

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 Course contents

• Human behavior and health

• Health education theories and models
o Health Belief Model(HBM)
o Social learning theory/Social Cognitive Theory
(SCT)
o Trans-theoretical Model (TTM)/Stages of Change
(SOC)
o Diffusion of Innovation Theory(DIT)
o Theory of Planned Behavior (TPB)

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 Health and Health Behavior

Behaviour

• Behaviour is an action that has a specific frequency,

duration and purpose whether conscious or
unconscious
• Behaviour is what we do and how we act
• People stay healthy or become ill often (not always)
as a result of their own action or behaviour .

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 Health behavior

Health behavior (Parkerson`s definition)

It refers to the actions of individuals, groups, and organizations,
as well as their determinants, correlates, and consequences,
including social change, policy development and
implementation, improved coping skills, and enhanced quality of
life

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 Health behavior

• Health behavior (Gochman`s definition )

• It is “those personal attributes such as beliefs,
expectations, motives, values, perceptions, and
other cognitive elements;
• personality characteristics, including affective
and emotional states and traits; and overt
behavior patterns, actions, and habits that
relate to health maintenance, to health
restoration, and to health improvement”
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As Gochman definition is compared with Parkerson definition
It-emphasizes on individuals.
-includes not only observable, overt actions but also the mental
events and feeling states that can be reported and measured.
Examples of health behaviours
• Using/not using- mosquito nets(ITN)
• breast milk feeding-Bottle feeding
• eating /not eating raw meat
• Medication/dietary adherence
• doing physical activity(exercise)
• Smoking/Alcohol consumption/Drug dependence
• practicing safe sex(using condom)
• utilizing Institutional delivery services

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 Health behavior
•Positive, informed and voluntary health behavior changes are typically
the ultimate aims/targets of health education programs.

•If behaviors change but health is not subsequently improved, the result
is a paradox that must be resolved by examining other issues, such as
the link(association) between behavior and health status or the ways in
which behavior and health (or both) are measured.

removing -ve
Health Positive Health
factor &
education Health Status
replacing
programs Behavior
with +ve improve-
change
factor ment

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 Factors affecting health behavior

1.Predisposing factors
• are antecedents to behavior that provide the rationale or
motivation for the behavior.
• these include individuals’ knowledge, attitudes, beliefs,
personal preferences, existing skills, and self-efficacy
beliefs.
• It is the absence of these positive factors that result in
• ‘’negative /unhealthy behaviors”.
• to bring positive behavior change, we need to convert the
negatively acting factors to act in positive direction to
predispose to’’ positive/healthy behavior. ‘’

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• e.g. “Lack of awareness about availability of
institutional delivery services(negative
factor )should be converted through health
education to being “aware of the availability of
institutional delivery services(positive factor).”
• So, such positive factors = “being aware of the
availability of institutional delivery services” are
called predisposing factors to “utilization of the
services.”
• i.e. When the negatively acting factor is changed
into positively acting factor, then it is considered as
the predisposing factor for the positive behavior.
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Factors affecting health behavior…

2. Reinforcing factors
• are those factors following a behavior that provide
continuing reward or incentive for the persistence or
repetition of the behavior”.
• Examples include social support, peer influence,
significant others, and vicarious reinforcement.
• e.g. Appreciation of the neatness after institutional
delivery services by a mother who delivered in a
health institution for the first time is a reinforcing
factor for sustained utilization of the service.
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Factors affecting health behavior…

• 3. Enabling factors
• are antecedents to behavioral or environmental
change that allow a motivation or environmental
policy to be realized”
• Enabling factors can affect behavior directly or
indirectly through an environmental factor.
• They include programs, services, and resources
necessary for behavioral and environmental
outcomes to be realized and, in some cases, the new
skills needed to enable behavior change.
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Enabling factors …

 They are factors without which the positive

behaviour change cannot be achieved even if the
predisposing factor is acting to its maximum.
 e.g. Utilization of institutional delivery services
cannot be realized unless the health institution is
made accessible.
 Therefore, making the health institution accessible is
the enabling factor for utilization of institutional
delivery services.

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 Models of Individual Health Behavior

I. Health Belief Model

•The HBM contains several primary concepts

that predict why people will take action to
prevent, to screen for, or to control illness
conditions.
• these include susceptibility, seriousness,
benefits and barriers to a behavior, cues to
action, and self-efficacy.

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Health Belief Model
If individuals
 Regard themselves as susceptible to a condition,
 Believe that condition would have potentially serious
consequences,
 Believe that a course of action available to them
would be beneficial in reducing either their
susceptibility to or severity of the condition, and
believe the anticipated benefits of taking action
outweigh the barriers to (or costs of) action,
they are likely to take action that they believe will
reduce their risks.
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Perceived susceptibility = Belief about the chances of experiencing
a risk or getting a condition or disease
Perceived Severity = Belief about how serious a condition and its
sequelae are.
perceived threat =the combination of perceived susceptibility and
perceived severity
Perceived Benefits = Belief in efficacy of the advised action to
reduce risk or seriousness of impact
Perceived Barriers = Belief about the tangible and psychological
costs of the advised action (The potential negative aspects of a
particular health action)
Cues to action = (Strategies to activate “readiness” /reminder
system/ factor that can trigger actions) e.g. bodily events,
environmental events such as media publicity
Self-efficacy =Confidence in one’s ability to take action 15
Health Belief Model:

Perceived
benefits l th
He a

Perceived Perceived
Behavior
susceptibility seriousness

cy Cues to
ca action
- effi Perceived
el f
S barriers

16
 Applications of HBM
To predict who will:
• make use of free health examinations
• yearly medical checkups
• Take vaccines
• disease specific screening programs

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II. Social learning theory/Social Cognitive Theory (SCT)
•SCT emphasizes reciprocal determinism in the
interaction between people and their
environments.
•SCT conceives that human behavior is the
product of the dynamic interplay of personal,
behavioral, and environmental influences.
•Although it recognizes how environments
shape behavior, this theory focuses on people’s
potential abilities (collective actions) to alter
and construct environments to suit purposes
they devise for themselves. 18
II. Social learning theory/Social Cognitive
Theory (SCT)

• Social cognitive theory that states an

individual's knowledge acquisition can be
directly related to observing others within the
context of social interactions, experiences,
and outside media influences.

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• SCT emphasizes reciprocal determinism in the
interaction between people and their environments.
• SCT conceives that human behavior is the product of
the dynamic interplay of personal, behavioral, and
environmental influences.
• Although it recognizes how environments shape
behavior, this theory focuses on people’s potential
abilities (collective actions) to alter and construct
environments to suit purposes they devise for
themselves.
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•Societies seek to control the environmental and social
factors that influence health behaviors and health
outcomes.
•This enables individuals to work together in organizations
and social systems to achieve environmental changes that
benefit the entire group.

SCT Environment

Behavior Health
Individual
actions
&
Collective
actions

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 Application of SLT
• Social learning theory examples in everyday
life are common
• one of the most evident being the behaviors
of children, as they imitate family members,
friends, famous figures and even television
characters.
• If a child perceives there is a meaningful
reward for such behavior, they will perform it
at some point.
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 III. Trans-theoretical Model (TTM)
/Stages of Change (SOC)/

• The transtheoretical model of behavior

change is an integrative theory of therapy that
assesses an individual's readiness to act on a
new healthier behavior, and provides
strategies, or processes of change to guide the
individual.

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• TTM uses stages of change to integrate processes and
principles of change across major theories of
intervention, hence the name
• Trans-theoretical.
• The core constructs/concepts of TTM are -5 stages of
change, 10 processes of change, pros and cons of
changing, self-efficacy, and temptation.
• TTM is also based on critical assumptions about the
nature of behavior change and interventions that can
best facilitate such change
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 critical assumptions of TTM

1. No single theory can account for all complexities of behavior change.

A more comprehensive model is most likely to emerge from integration
across major theories.
2. Behavior change is a process that unfolds over time through a
sequence of stages.
3. Stages are both stable and open to change, just as chronic
behavioral risk factors are stable and open to change.
4. The majority of at-risk populations are not prepared for action
and will not be served effectively by traditional action-oriented
behavior change programs that expect participants to take action
immediately.
5. Specific processes and principles of change should be emphasized at
specific stages to maximize efficacy.

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 the core constructs of TTM
Stages of Change-The TTM hypothesizes change as a process
that unfolds over time, with progress through a series of six stages,
although frequently not in a linear manner.
1. Pre-contemplation = no intention to take action within the
next 6 months.
2. Contemplation = Intends to take action within the next 6
months.
3. Preparation = Intends to take action within the next 30 days
and has taken some behavioral steps in this direction.
4. Action = Changed overt behavior for less than 6 months.
5. Maintenance = Changed overt behavior for more than 6
months.
6. Termination = No temptation to relapse and 100% confidence.
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termination

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28
• It is also used to provide strategies to guide
the individual to change the behavior through
stages of motivational readiness
• This model has been effectively applied to
various health behaviors such as smoking,
alcohol use, substance abuse, and physical
activity (exercise)

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IV. Diffusion of Innovations Model

• Is a model that describes how a new idea,

product or positive health behavior spreads
through a community or social structure.
• The model identifies several factors that
influence how quickly an idea or behavior is
adopted.

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 Diffusion of Innovations Model

an innovation is an idea, information, practice, product, object

or technology that is perceived as new by an individual or other
unit of adoption.
diffusion is the process by which an innovation is communicated
through certain channels over time among the members of a
social system
Dissemination- The planned, systematic efforts designed to
make a program or innovation more widely available.
Diffusion is the direct or indirect outcome of those efforts.

The Diffusion of Innovations model is used to understand the

steps and processes required to achieve widespread
dissemination and diffusion of public health innovations.
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 Diffusion of Innovations Model

•If effective public health programs, products, and practices are

not widely and effectively disseminated, they will not achieve
their potential impact to improve the public’s health.
•If you are successful in diffusing the innovation, then you will be
able to change the behavior.
•If you fail to diffuse an innovation to bring a behavior change Or,
if you are asked to evaluate a program that implemented diffusion
of innovation, then you would use your knowledge of this theory
to diagnose where the failure lies and try again by learning from
experience.

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How is innovation diffused(disseminated)?

Passive versus Active diffusion of innovation:

Although diffusion of most innovations involves both passive
and active features, the spread of an innovation can be
conceptualized on a continuum.
Passive diffusion –(in which the spread is unplanned, informal,
and largely mediated horizontally by peers and social
networks) lies at one end of the continuum.
active dissemination–(in which the spread is much more
planned, formal, centralized and likely to occur through vertical
hierarchies) is at the other end.

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 Stages in the multistep diffusion process

1st stage=innovation development

2nd stage= dissemination
3rd stage= adoption
4th stage =implementation
5th stage=maintenance
6th stage= sustainability
7thstage= institutionalization

the evaluation follows this order also in investigating the factors

that act negatively at each step.

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Innovation Development -All the decisions and activities (and
their impacts) that occur from the early stage of an idea to its
development and production.
Adoption- Uptake of the program or innovation by the target
audience.
Implementation -The active, planned efforts to implement an
innovation within a defined setting.
Maintenance- The ongoing use of an innovation over time.
Sustainability -The degree to which an innovation or program
of change is continued after initial resources are expended.
Institutionalization -Incorporation of the program into the
routines of an organization or broader policy and legislation.

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 Stages in the multistep diffusion process.

Innovation
development Dissemination

Maintenance &
sustainability
/ Institutionalization Adoption

Implementation by
the adopters
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 Stages in the multistep diffusion process.
1. During the innovation development phase, social marketing
often has been used to design, target, refine, and implement
health promotion innovations or “products”.

2. The dissemination process requires planning to persuade

target groups to adopt an innovation, but it is critical that the
intervention has been developed with the target population in
mind and is appropriate to the intended settings.

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3. In the adoption phase several issues require attention: the
needs of target adopters, their current attitudes and values,
how they will respond to the innovation, what factors will
increase likelihood of adoption, how potential adopters can be
influenced to change their behaviors, and barriers to adoption
of an innovation and how they can be overcome.

The decision to adopt is influenced by three types of

knowledge:
(1) awareness knowledge that the innovation exists,
(2) procedural knowledge about how to use the innovation,
(3) principles knowledge or understanding about how the
innovation works.
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4. The implementation phase:
The decision to adopt is not based solely on knowledge and
inevitably also requires attitude change.
Often a partial trial of the innovation leads to a choice to adopt
or reject the innovation.
As part of the process of implementation of an innovation,
prospective users are likely to think about what problems
might be encountered and to seek resources for and support in
putting the innovation into practice.
Research studies often have focused on improving the self-
efficacy and skills of adopters, and encouraging a trial of the
innovation.

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5. The stages of maintenance and sustainability involve
continued use of the program, and the final stage is
institutionalization into communities, organizations, or other
settings.
Sometimes sustainability and institutionalization are combined
into a single stage, although it is possible for an innovation to
be sustained for a period of time but not ultimately
institutionalized.

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Factors that affect Innovation diffusion process

1.Characteristics of Innovations

2.Characteristics of adopters (Individuals)

3.Features of the Setting

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Characteristics of Innovations that affect diffusion of
innovation

1. Relative advantage = Is the innovation better than what was there

before?
2. Compatibility = Does the innovation fit with the intended audience?
3. Complexity = Is the innovation easy to use?
4. Trialability = Can the innovation be tried before making a decision to
adopt?
5. Observability = Are the results of the innovation visible and easily
measurable?

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Characteristics of adopters (individuals)
There are five adopter categories depending on their
characteristics in the adoption process:
(1) innovators –(are technology enthusiasts)
(2) early adopters-(are visionaries)
(3) early majority adopters-(are pragmatists)
(4) late majority adopters-(are conservatives)
(5) laggards-(are skeptics)

•The pace of change of the proportion of each category matters

during the process.
• If a large proportion remains ‘laggards’ towards the end of
implementation period, definitely, the process is likely to fail.
Why so high laggards?
•Ongoing research answers and suggests corrective actions. 44
Technology(innovation) adoption curve

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Features of the Setting
Innovations may be disseminated successfully in some settings
but not in others.
The features of settings can be categorized as:
(1) geographical settings,
(2) Societal culture,
(3) political conditions,
(4) globalization and uniformity.

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Theory of Planned Behavior/TPB

•Perceived behavioral control was added to TRA to account

for factors outside individual control that may affect
intentions and behaviors.

•TPB aims to explain rationally motivated, intentional

health and non-health behaviors.

•TPB assumes a causal chain that links attitudes, subjective

norms, and perceived behavioral control to behavior
through behavioral intentions.
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TPB behavioral intentions are affected (determined) by
attitudes toward the behavior, subjective norms,
and perceived behavioral control .

Health

Attitude
towards the
behavior Behavioral Behavior
intention

Subjective
Relative weights of these three
norms factors in determining intentions
Perceived vary for different behaviors and
control populations.

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TPB

Behavioral
Attitude
beliefs
towards the
behavior
Evaluation of Behavioral
Subjective intention Behavior
behavioral
outcomes norms

Perceived
control

Attitude towards the behavior is affected by behavioral beliefs and

evaluation of behavioral outcomes. 49
 subjective norms are affected by
TPB normative beliefs and motivation to
comply.
Behavioral
beliefs
Attitude
Evaluation of towards the
behavioral behavior
outcomes Behavioral
Behavior
Subjective intention
norms
Normative
beliefs Perceived
control

Motivation
to comply

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 Perceived (behavioral) control is affected
TPB by control beliefs and perceived power.
.
Behavioral
beliefs
Attitude
Evaluation of towards the
behavioral behavior
outcomes Behavioral
Subjective intention Behavior
norms
Normative
beliefs Perceived control

Motivation
Control
to comply
beliefs
Perceived
power
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Attitudes are relatively constant feelings, predispositions or set of
beliefs directed towards an object, person or situation.
They are evaluative feelings and reflect our likes and dislikes.

Attitude toward the behavior

-a person’s overall favorableness or unfavorableness toward
performing the behavior.

Attitude towards a behavior is determined by behavioral beliefs (the

individual’s beliefs about outcomes or attributes of performing the
behavior) weighted by evaluations of those outcomes or attributes.

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behavioral beliefs- the likelihood that performance of the
behavior will result in certain outcomes and are measured on
bipolar “unlikely-likely” or “disagree-agree” scales.
e.g. using condom will unlikely reduce sexual feelings.
Evaluations of behavioral outcome are measured on bipolar
“good-bad” scales
e.g. the reduction of sexual feelings is good/bad

Attitudes can be:

1.experiential attitude(affective)
-emotional response to the idea of performing a behavior
-feelings about behavior
e.g. I like/dislike using condom
2. instrumental attitude(cognitive)=behavioral beliefs/ the
likelihood that performance of the behavior will result in certain
outcomes/
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behavioral belief-evaluation outcome product=attitude

A person’s behavioral belief

a. “my quitting smoking will unlikely cause me to gain weight’’. =negative
b.” my quitting smoking will likely cause me to gain weight.” =positive
The person’s evaluation of this outcome
c. “my gaining weight” is good=positive
d.“ my gaining weight” is bad=negative

axc=-ve x +ve=>negative attitude towards the behavior

axd =-ve x -ve=>positive attitude towards the behavior
bxc =+ve x +ve=>positive attitude towards the behavior
bxd =+ve x -ve=>negative attitude towards the behavior

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•a person who beliefs that quitting smoking will unlikely cause
weight gain and value that gaining weight” is good has a negative
attitude towards quitting smoking.

•a person who beliefs that quitting smoking will unlikely cause

weight gain and value that gaining weight” is bad has a positive
attitude towards quitting smoking.

•a person who beliefs that quitting smoking will likely cause weight
gain and value that gaining weight” is good  has a positive
attitude towards quitting smoking.

•a person who beliefs that quitting smoking will likely cause weight
gain and value that gaining weight” is bad  has a negative
attitude towards quitting smoking.

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In other words:

•a person who holds strong beliefs that positively valued

outcomes will result from performing the behavior will have a
positive attitude toward the behavior.

•Conversely, a person who holds strong beliefs that negatively

valued outcomes will result from the behavior will have a
negative attitude.

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 Subjective norm
•Is perception about the particular behavior, which is influenced by the
judgment of significant others (e.g., parents, spouse, friends, teachers).

•it involves the people around you, more specifically, what you think
they think about a given behavior.

subjective norm is determined by normative beliefs, weighted by

motivation to comply with those referents.

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Normative belief- Belief about whether important referent
individuals approves or disapproves of performing the behavior.

Examples of normative beliefs

1. A person might believe that his wife approves of him doing of
physical exercise.
2. A smoker might believe that his wife disapproves of him smoking.

Motivation to comply- Motivation to do what those important

referents think.
1. Hence he wants to do physical exercise.
2. Hence he wants to quit smoking

Subjective norm= normative belief x motivation to comply

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.
•A person who believes that certain referents think s/he should
perform a behavior and is motivated to meet expectations of
those referents will hold a positive subjective norm.

•Conversely, a person who believes these referents think s/he

should not perform the behavior and is motivated to meet
expectations of those referents will have a
negative subjective norm.

•a person who is not/less/ motivated to comply with those

referents will have a relatively neutral subjective norm.

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Example:
•A person who believes that his wife approves of his doing of
physical exercise and therefore he wants to do physical exercise
holds a positive subjective norm.

•A smoker who believes that his wife disapproves of his smoking

and therefore he wants to quit smoking holds a negative
subjective norm.

•A smoker might believe that his wife disapproves of his smoking

but who wants to smoke holds a neutral subjective norm.

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 Types of subjective norms
1.‘’ I want to do what my wife thinks I should do.”
=positive subjective norm
2. ‘’I don’t want to do what my wife thinks I shouldn’t do.”
=negative subjective norm
3. ’’I want to do despite my wife thinks I shouldn’t do.”
=neutral subjective norm
4. ’’I don’t want to do despite my wife thinks I should do.”
= neutral subjective norm

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Class exercise
What is the subjective norm of the following behaviors

1. ‘’my girl friend thinks that I should use condom and I want to
use condom.”=
2. ‘’my wife thinks that I should not smoke cigarettes and I don`t
want to smoke cigarettes’’=
3. ’’ I want to smoke cigarettes though my wife thinks that I should
not smoke cigarettes’’ =
4. ’’I don’t want to use condom though my girl friend thinks that I
should use condom.” =

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 Perceived behavioral control
•perceived ease or difficulty of performing a particular behavior.
•It accounts for external factors that may affect the person's intent
toward a behavior.

•Perceived control is determined by control beliefs concerning the

presence or absence of facilitators and barriers to behavioral
performance, weighted by their perceived power or the impact of
each control factor to facilitate or inhibit the behavior.

control beliefs- belief concerning the presence or absence of

facilitators and barriers to behavioral performance
= Perceived likelihood of occurrence of each facilitating or
constraining condition.( Measured bipolar scale=-3 to +3)

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 perceived power - the impact/effect of each control factor to
facilitate or inhibit the behavior.
= Perceived effect of each facilitator or barrier in making behavioral
performance difficult or easy .( Measured bipolar scale=-3 to +3)

i.e.
the impact/effect of a barrier in making quitting smoking difficult
•the impact/effect of a facilitator in making quitting smoking easy

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 e.g. a smoker control beliefs and perceived effects of barriers and
facilitators

1-control belief of a barrier(withdrawal symptoms)to quitting smoking

is the likelihood of withdrawal symptoms will occur with quitting
smoking might be +3)
2-control belief of a facilitator(daily walking regimen)to quitting
smoking is the likelihood of the person will have daily walking (daily
walking regimen will occur) with quitting smoking might be +3)
3-perceived power/effects of withdrawal symptoms to hinder quitting
smoking is +2)
4- perceived power/effect of daily walking regimen will help in quitting
smoking +3)
His Perceived control to quit smoking is strong (barrier=+2x+3=+6 is
less than facilitator=+3x+3=+9 he will likely intend quitting
smoking)
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In other words,
•quitting smoking is under the person`s control.
or
•It is easy for the person to quit smoking.
and
•therefore he intends/determines to quit smoking.

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Class exercise
If a person believes that using condom will likely result in reduction of
sexual pleasure(scale=+1) and perceives that the effect of this sexual
pleasure reduction with using condom will make using condom
difficult(scale=-2) moreover he believes that his girl friend will likely to
prefer to have sex with condom (scale=+1) and perceives that his girl
friend preference to have sex with condom will make using condom
difficult(scale=-1).

•What is the perceived (behavioral) control of using condom of the

person?

•What is the likelihood that this person will determine (intend) to use
condom? (likely/unlikely?)
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Topics for Community project activity, group
assignment and presentation

1. According to the 2011 EDHS report, the CPR

(proportion of married women age 15-49 yrs that
were using a modern method of family planning) in
Dire Dawa was 32%

•identify the causes/determining factors leading to the problem by

interviewing as many women of reproductive age group as possible who
came to the PHCU for any purpose and health staffs.
•What health education theories and models would you apply to
increase the utilization rate of modern family planning? Explain why.
•Design health behavior change interventions directed at increasing the
of use modern methods of family planning.

68
 2. According to the 2011 EDHS report, 28.3% of the
men age 15-49 yrs in Dire Dawa use some kind of
tobacco (cigarettes and/or other tobacco).

•Identify the causes/determining factors leading to the problem by

interviewing as many tobacco users as possible who came to the PHCU
for any purpose and health staffs.
•What health education theories and models would you apply to
decrease the number of tobacco users? Explain why.
Design health behavior change interventions directed at cessation of
using tobacco.

69
3. According to the 2011 EDHS report, the proportion
of institutional deliveries in Dire Dawa was 40%

•Identify the causes/determining factors leading to the problem by

interviewing as many women of reproductive age group as possible who
came to the PHCU for any purpose and health staffs.
•What health education theories and models would you apply to
increase the rate of institutional delivery that is attended by skilled
health personnel? Explain why.
•Design health behavior change interventions that enhance institutional
delivery service utilization.

70
4. According to the 2007 Ethiopia`s central statistics
agency report, the proportion of households which
have no toilet facility in Dire Dawa was 20%

•Identify the causes/determining factors leading to the problem by

interviewing as many people as possible who came to the PHCU for any
purpose and health staffs,
•What health education theories and models would you apply to
increase the proportion of households having toilet facility? Explain why.
•Design health behavior change interventions targeting head of the
households without any toilet facility to start constructing affordable
toilets?

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