Transcript Theory

Health Behaviors and Health
Promotion Theories and
Models
Professor Jin-Ding Lin, Ph.D.
SPH, NDMC, Taipei
1
Source:
1. National Cancer
Institutes (2005) Theory
at a Glance: Application
to Health Promotion and
Health Behavior (Second
Edition). U.S. Department
of Health and Human
Services.
http://www.cancer.gov/PDF/4
81f5d53-63df-41bc-bfaf5aa48ee1da4d/TAAG3.pdf
2. Other articles.
2
Section A
Foundations of Theory in
Health Promotion and Health
Behavior
3
Disease, Ecology, and Behavior
• Diseases occur within ecological settings and
are thus context dependent
• Cultural practices can directly alter ecological
relationships between hosts and agents of
disease
• Biological and cultural traits with adaptive value
against disease will generally be selected
• Human behavior plays a significant role in the
etiology of every major category of disease
• The understanding of the influence of human
behavior on disease requires a sociological
perspective
4
Theory
• A theory presents a systematic way of
understanding events or situations. It is a
set of concepts, definitions, and
propositions that explain or predict these
events or situations by illustrating the
relationships between variables.
5
Characteristics of a Useful
Theory
A useful theory makes assumptions about a behavior,
health problem, target population, or environment that
are:
• Logical;
• Consistent with everyday observations;
• Similar to those used in previous successful
programs; and
• Supported by past research in the same area
or related ideas.
6
What People in the Field Say
About Theory (1)
“Theory is different from most of the tools I
use in my work. It’s more abstract, but that
can be a plus too. A solid grounding in a
handful of theories goes a long way
toward helping me think through why I
approach a health problem the way I do.”
— County Health Educator
7
What People in the Field Say
About Theory (2)
“I used to think theory was just for
students and researchers. But now I have
a better grasp of it; I appreciate how
practical it can be.”
— State Chronic Disease Administrator
8
What People in the Field Say
About Theory (3)
“By translating concepts from theory into
real-world terms, I can get my staff and
community volunteers to take a closer look
at why we’re conducting programs the way
we do, and how they can succeed or fail.”
— City Tobacco Control Coordinator
9
What People in the Field Say
About Theory (4)
“A good grasp of theory is essential for
leadership. It gives you a broader way of
viewing your work. And it helps create a
vision for the future. But, of course, it’s
only worthwhile if I can translate it clearly
and simply to my co-workers.”
— Regional Health Promotion Chief
10
What People in the Field Say
About Theory (5)
“It’s not as hard as I thought it would be to
keep up with current theories. More than
ever these days, there are tools and
workshops to update us often.”
— Patient Education Coordinator
11
Concepts, Constructs, Variables
and Models
• Concepts are the building blocks—the primary
elements—of a theory.
• Constructs are concepts developed or adopted for use in
a particular theory. The key concepts of a given theory
are its constructs.
• Variables are the operational forms of constructs. They
define the way a construct is to be measured in a
specific situation. Match variables to constructs when
identifying what needs to be assessed during evaluation
of a theory-driven program.
• Models may draw on a number of theories to help
understand a particular problem in a certain setting or
context. They are not always as specified as theory.
12
Dimensions of Behavior
• Frequency
– Every time drinking water is collected from
the pond, which could range from daily to
a few times a week
13
Dimensions of Behavior (cont.)
• Duration
– Each individual filtering session may take
10–15 minutes; filtering as a health habit
needs to be practiced for several years
until guinea worm is eliminated from the
village
14
Dimensions of Behavior (cont.)
• Timing
– Filtering must be done immediately after
one reaches home
– with a bucket of pond water
– in order not to give anyone the opportunity
to drink unsafe water
15
Theory-Based Models
•
•
•
•
Force field analysis
Health belief model
Social (cognitive) learning theory
Theory of reasoned action/planned
behavior
• PRECEDE framework
16
What Is a Model?
• An ideal or exemplary program or method
• A simulation of reality in other dimensions (time,
scale)
• A conceptual structure successfully developed in
one field and applied to some other field to guide
research and practice (for example, an analogy)
• When used interchangeably with the term theory,
the visual representation of the elements of a
theory
17
Characteristics of a Good Theory
• A theory should logically explain existing
empirical generalizations and yield precise
and accurate predictions of new
generalizations
• It should explain and predict better than
other theories
• It should explain empirical findings in
substantive terms, not as artifacts of the
methods employed to obtain them
18
Characteristics of a Good Theory
• It should apply to complex real-life settings
as well as to highly simplified and tightly
controlled research contexts
• It should be generalizable to well-defined
and relevant universes and populations
beyond the boundaries of the particular
studies in which it was built and tested
19
Characteristics of a Good Theory
• It should infer casual relationships
between phenomena being investigated
• It should define those phenomena in
validly measurable terms appropriate to
the explanations and predictions made
20
Relationships Among
Variables in a Model
• Independent→Intermediate→Dependent
• Independent
– Age, gender, ethnic group, occupation
• Intermediate
– Knowledge, attitudes, perceptions
• Dependent
– Behavior, health status
21
Building Blocks of Theories
Variables and Concepts
• Value expectancies
– This may also be termed “attitude toward a
behavior” or “outcome expectancies” and is a
type of cost benefit analysis
– People first need to have some concept of the
potential or likely consequences of an action
22
Building Blocks of Theories
Variables and Concepts
• Value expectancies
– Judgment is made about whether that
consequence or outcome is desirable or not
– Weigh the advantages / disadvantages
– Perceived efficacy of the proposed action is
another way of looking at this concept
– Will the action produce a specified result, and
is that result good?
23
Attitudes
• An attitude is a disposition toward an
object, person, or situation
• This disposition may be favorable or
unfavorable
• An attitude may develop from personal
experience or through interaction with and
learning from other important people in a
person’s life
24
Attitudes
• An attitudinal disposition is stimulated by the
presence of or reference to the object, person,
or situation of interest
• Behavior of accepting or avoiding an object is
not automatically influenced by an attitude
• It is often the case that more than attitude is
present in a given circumstance, and, thus,
behavior may be influenced by the stronger or
more pressing attitude
25
Norms and Their Perception
• Norms are socially accepted behaviors or
social expectations of desirable behavior
• People belong to reference groups—
people to whom they look to get cues of
what behaviors are acceptable in a given
social situation
• Reference groups include, but go beyond,
peer groups
26
Norms and Their Perception
• Perception of norms concerns what people
believe their reference group expects them to do
• People put a value on those expectations and
consider whether or not they care what other
people think they should do
• People belong to more than one reference group
and may experience conflicting perceptions of
what is “correct” behavior in a situation
27
Skills vs. Self-Efficacy
• Skills
– The actual ability to perform a task is the
basis of skill
– Skill is mastery of a task both physically and
cognitively
28
Skills vs. Self-Efficacy
• Self-efficacy
– It is one thing for people to possess the
cognitive and motor skills to perform a task,
and quite another to have the confidence to
carry out the action
– Self-confidence is also termed self efficacy
– People gain self-efficacy by observing others,
listening to encouragement from others, and
by practicing the behavior themselves
29
Locus of Control
• A person’s perception that he/she is the
entity primarily responsible for life
outcomes
• In the case of illness, the belief that one
can personally prevent or make a
difference in recovery from sickness
• These are issues of control
30
Locus of Control
• External control means that the person
believes that chance, fate, or powerful
people are responsible for life outcomes
• While beliefs about internal control imply
that the person him/herself can make a
difference
31
Perceived Threat
• Does a person perceive that there are
specific circumstances that may arise that
could threaten or harm him/her?
• This may be broken down into two
components:
– Threat of susceptibility—could it happen to
me?
– Threat of severity—if it happens, will the
consequences be serious?
32
Knowledge and Beliefs
• Knowledge
– Recollection of factual information
– But knowledge is culture-bound
– It is possible for people to memorize facts
given at a clinic based health talk but not
believe them
• Beliefs
– Accepted truths or certainties
33
Enabling Factors
• The physical and material resources needed to
perform a behavior are known as enabling
factors
• These may include physical access to a service,
possession of the funds needed to purchase a
product, availability of transportation, and the
time needed to carry out a task
• The lack of resources is also termed barriers
34
Intention
• Intention is an intermediate variable
between such factors as attitude or
perceived norms and the actual behavior
• Intention reflects a decision or willingness
to undertake a behavior and is considered
a good predictor of future performance of
that behavior should the opportunity
present itself
35
(NCI, 2005: p.6)
Effective practice depends on using theories and
strategies that are appropriate to a situation.
36
Section B
Theories and Applications
37
(NCI, 2005: p.10)
Health promotion programs that seek to address health problems across
this spectrum employ a range of strategies, and operate on multiple levels.
38
Ecological Perspective
• It emphasizes the interaction between, and
interdependence of, factors within and across all
levels of a health problem. It highlights people’s
interactions with their physical and sociocultural
environments.
• Two key concepts of the ecological perspective
help to identify intervention points for promoting
health:
– first, behavior both affects, and is affected by, multiple
levels of influence;
– second, individual behavior both shapes, and is
shaped by, the social environment (reciprocal
causation, suggests that people both influence, and
are influenced by, those around them. ).
39
Addressing the Challenges:
Ecological Model of Health
• An Ecological Model includes:
– multiple determinants of health
– linkages and relationships among
determinants are emphasized
– multiple strategies by multiple sectors
(IOM, 2002)
40
Approach and rationale
A guide to thinking about the determinants of population health
Living and working conditions
may include:
Over the life span
• Psychosocial factors
• Employment status and
occupational factors
• Socioeconomic status (income,
education, occupation)
• The natural and builtc
environments
• Public health services
• Health care services
NOTES: Adapted from Dahlgren and Whitehead,
1991. The dotted lines denote interaction effects
between and among the various levels of health
determinants (Worthman, 1999).
(IOM, 2002)
41
Ecological Perspective, Multiple Levels of Influence
(NCI, 2005: p.11)
McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health
promotion programs. Health Education Quarterly 15:351–377, 1988.
42
Individual & Interpersonal Levels
At the individual and interpersonal levels, contemporary
theories of health behavior can be broadly categorized as
“Cognitive-Behavioral.” Three key concepts cut across these
theories:
1. Behavior is mediated by cognitions; that is, what
people know and think affects how they act.
2. Knowledge is necessary for, but not sufficient to
produce, most behavior changes.
3. Perceptions, motivations, skills, and the social
environment are key influences on behavior.
43
Individual & Interpersonal Levels
1. The Health Belief Model (HBM)
2. The Stages of Change (Transtheoretical)
Model
3. The Theory of Planned Behavior (TPB)
4. The Precaution Adoption Process Model
(PAPM)
5. The Social Cognitive theory
44
Community-level Models
• Community-level models offer frameworks
for implementing multi-dimensional
approaches to promote healthy behaviors.
They supplement educational approaches
with efforts to change the social and
physical environment to support positive
behavior change.
• Community organization, diffusion of
innovations, communication theory
45
Health Belief Model
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History and Orientation
• "The Health Belief Model (HBM) was one of the first
models that adapted theory from the behavioral sciences
to health problems, and it remains one of the most
widely recognized conceptual frameworks of health
behavior.
• It was originally introduced in the 1950s by psychologists
working in the U.S. Public Health Service (Hochbaum,
Rosenstock, Leventhal, and Kegeles).
• Their focus was on increasing the use of then-available
preventive services, such as chest x-rays for
tuberculosis screening and immunizations such as flu
vaccines. They assumed that people feared diseases,
and that health actions were motivated in relation to the
degree of fear (perceived threat) and expected fearreduction potential of actions, as long as that potential
outweighed practical and psychological obstacles to
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taking action (net benefits)."
History and Orientation
• The Health Belief Model (HBM) is a psychological model
that attempts to explain and predict health behaviors.
This is done by focusing on the attitudes and beliefs of
individuals.
• The HBM was first developed in the 1950s by social
psychologists Hochbaum, Rosenstock and Kegels
working in the U.S. Public Health Services.
• The model was developed in response to the failure of a
free tuberculosis (TB) health screening program. Since
then, the HBM has been adapted to explore a variety of
long- and short-term health behaviors, including sexual
risk behaviors and the transmission of HIV/AIDS.
48
Core Assumptions and
Statements
The HBM is based on the understanding that a
person will take a health-related action (i.e., use
condoms) if that person:
1.feels that a negative health condition (i.e., HIV)
can be avoided,
2.has a positive expectation that by taking a
recommended action, he/she will avoid a
negative health condition (i.e., using condoms
will be effective at preventing HIV), and
3.believes that he/she can successfully take a
recommended health action (i.e., he/she can
use condoms comfortably and with confidence).
49
(NCI, 2005: p.14)
The Health Belief Model (HBM)
The Health Belief Model (HBM) addresses the individual’s perceptions of the threat posed by a health problem
50
(susceptibility, severity), the benefits of avoiding the threat, and factors influencing the decision to act (barriers, cues to
action, and self-efficacy).
Conceptual HBM
Source: Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education:
Theory, Research and Practice. San Francisco: Wiley & Sons.
51
Scope and Application
The Health Belief Model has been applied to a broad range
of health behaviors and subject populations. Three
broad areas can be identified (Conner & Norman, 1996):
1) Preventive health behaviors, which include healthpromoting (e.g. diet, exercise) and health-risk (e.g.
smoking) behaviors as well as vaccination and
contraceptive practices.
2) Sick role behaviors, which refer to compliance with
recommended medical regimens, usually following
professional diagnosis of illness.
3) Clinic use, which includes physician visits for a variety
of reasons.
52
Limitations of HBM
General limitations of the HBM include:
a) most HBM-based research to date has incorporated only
selected components of the HBM, thereby not testing
the usefulness of the model as a whole;
b) as a psychological model it does not take into
consideration other factors, such as environmental or
economic factors, that may influence health behaviors;
and
c) the model does not incorporate the influence of social
norms and peer influences on people's decisions
regarding their health behaviors (a point to consider
especially when working with adolescents on HIV/AIDS
issues).
53
Example –
Condom Use Education
1. Perceived Susceptibility: Youth believe they
can get STDs or HIV or create a pregnancy.
2. Perceived Severity: Youth believe that the
consequences of getting STDs or HIV or
creating a pregnancy are significant enough to
try to avoid.
3. Perceived Benefits: Youth believe that the
recommended action of using condoms would
protect them from getting STDs or HIV or
creating a pregnancy.
54
Example –
Condom Use Education
1.
2.
3.
Perceived Barriers: Youth identify their personal
barriers to using condoms (i.e., condoms limit the
feeling or they are too embarrassed to talk to their
partner about it) and explore ways to eliminate or
reduce these barriers (i.e., teach them to put lubricant
inside the condom to increase sensation for the male
and have them practice condom communication skills
to decrease their embarrassment level).
Cues to Action: Youth receive reminder cues for
action in the form of incentives (such as pencils with
the printed message "no glove, no love") or reminder
messages (such as messages in the school
newsletter).
Self-Efficacy: Youth confident in using a condom
correctly in all circumstances.
55
Reading
• Eisen, M., PhD, Zellman, G.L., PhD, McAlister, A.L., PhD.
(1992) A Health Belief Model-Social Learning Theory
Approach to Adolescents' Fertility Control: Findings from
a Controlled Field Trial. Health Education Quarterly,
19(2), 249-262.
56
(NCI, 2005: p.15)
Stages of Change Model
The Stages of Change (Transtheoretical) Model describes
individuals’ motivation and readiness to change a behavior.
57
Theory of Planned Behavior
(NCI, 2005: p.17)
The Theory of Planned Behavior (TPB) examines
the relations between an individual’s beliefs, attitudes,
intentions, behavior, and perceived control over that
behavior.
58
Theory of Planned Behavior
(NCI, 2005: p.18)
The Theory of Planned Behavior (TPB) examines the relations between an individual’s
beliefs, attitudes, intentions, behavior, and perceived control over that behavior. Figure 3.
shows the TPB’s explanation for how behavioral intention determines behavior, and how
59
attitude toward behavior, subjective norm, and perceived behavioral control influence
behavioral intention.
PAPM
(NCI, 2005: p.19)
•The Precaution Adoption Process Model (PAPM) names seven stages
in an individual’s journey from awareness to action. It begins with lack of
awareness and advances through subsequent stages of becoming aware,
deciding whether or not to act, acting, and maintaining the behavior.
•The PAPM recognizes that people who are unaware of an issue, or are
unengaged by it, face different barriers from those who have decided not to
act. The PAPM prompts practitioners to develop intervention strategies that
take into account the stages that precede active decision-making.
60
Social Cognitive Theory
(NCI, 2005: p.20)
Social Cognitive Theory (SCT) describes a dynamic, ongoing process in which personal
factors, environmental factors, and human behavior exert influence upon each other.
According to SCT, three main factors affect the likelihood that a person will change a 61
health behavior: (1) self-efficacy, (2) goals, and (3) outcome expectancies.
An Integrative Model
(NCI, 2005: p.21)
An Integrative model illustrates how self-efficacy, environmental, and
individual factors impact behavior.
62
A General Model of the Determinants of
Behavioral Changes
63
(NCI, 2005: p.24)
64
(NCI, 2005: p.26)
65
(NCI, 2005: p.27)
Diffusion of Innovations Theory addresses how ideas, products, and
social practices that are perceived as “new” spread throughout a society or
from one society to another. According to the late E.M. Rogers (1995),
diffusion of innovations is “the process by which an innovation is
communicated through certain channels over time among the members of a
social system.
66
According to Rogers (1995), the following of factors
determine how quickly, and to what extent, an innovation
will be adopted and diffused:
(NCI, 2005: p.14)
Rogers EM. Diffusion of Innovations (4th Edition). New York, N.Y.: Free Press, 1995.
67
Communication Theory
• Communication theory explores “who says what,
in which channels, to whom, and with what
effects.” It investigates how messages are
created, transmitted, received, and assimilated.
• Public health communications is the scientific
development, strategic dissemination, and
evaluation of relevant, accurate, accessible, and
understandable health information,
communicated to and from intended audiences
to advance the public’s health.
-Bernhardt JM. Communication at the Core of Public Health. American Journal of
Public Health 94(12): 2051–2052, December 2004.
68
Public Health Communications
• can increase knowledge and awareness of a health
issue;
• influence perceptions, beliefs, and attitudes that factor
into social norms; prompt action;
• demonstrate or illustrate healthy skills;
• increase support for services;
• debunk misconceptions; and
• strengthen organizational relations
• Office of Cancer Communications, National Cancer
- Office of Cancer Communications, National Cancer Institute. Making Health
Communication Programs Work: A Planner’s Guide (revised December 2001).
NIH Pub. No. 02-5145, 2002.
69
(NCI, 2005: p.31)
Dorfman L, Wallack L, Themba M. Media Advocacy and Public Health: Power for Prevention.
Newbury Park, Calif.: Sage Publications, 1993.
70
New Communication
Technologies
• “E-health” is the use of emerging information
and communication technology, especially the
Internet, to improve or enable health and health
care. The term refers to an emerging field in the
intersection of medical informatics, public health,
and business
• Tailored print communications (TPCs) and
telephone-delivered interventions (TDIs)
• Interactive games…..
71
Interactive games
(NCI, 2005: p.33)
Lieberman et al. designed a series of Nintendo video games to improve
children’s and adolescents’ prevention and self care behaviors for
asthma, diabetes, smoking prevention, and other health topics.
Lieberman, D.A. Interactive video games for health promotion: Effects on knowledge, self-efficacy, social support, and
health. R.L. Street, W.R. Gold, & T. Manning (Eds.), Health promotion and interactive technology: Theoretical
applications and future directions. Mahwah, NJ: Lawrence Erlbaum Associates, pp. 103–120, 1997.
72
Section C
Putting Theory And Practice
Together
73
Planning Models
• Address multiple levels (e.g., individual,
organizational, community) of a health problem.
• Planning models, such as PRECEDEPROCEED and social marketing, help
practitioners develop programs step by step,
integrating multiple theories to explain and
address health problems.
• Instruct the practitioner to begin the planning
process by assessing the target audience’s
needs at multiple levels of a health problem.
74
Social Marketing
• Andreason (1995) defines it as “the application
of commercial marketing technologies to the
analysis, planning, execution, and evaluation
of programs designed to influence the voluntary
behavior of target audiences in order to improve
their personal welfare and that of society.”
- Andreasen A. Marketing Social Change: Changing Behavior to Promote Health, Social
Development, and the Environment. San Francisco, Calif.: Jossey-Bass, 1995.
• Social marketing uses marketing techniques to
influence the voluntary behavior of target
audience members for health benefit.
75
Social Marketing Process
• It involves identifying an effective
“marketing mix” (“The four Ps”) of product,
price, place, and promotion.
• The optimal marketing mix produces a
timely exchange that heightens benefits,
reduces barriers, and offers a better
choice than the competition.
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The four Ps
• Product (the right kind of behavioral change) includes
not only the behavior that is being promoted, but also the
benefits that go along with it.
• Price (an exchange of benefits and costs) refers to
barriers or costs involved in adopting the behavior (e.g.,
money, time, effort).
• Place (making new behaviors easy to do) is about
making the “product” accessible and convenient. It
means delivering benefits in the right place at the right
time.
• Promotion (delivering the message to the audience) is
how the practitioner notifies the target market of the
product, as well as its benefits, reasonable cost, and
convenience.
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Social Marketing Interventions
1. formative research (also called
audience or consumer research) to
understand the target market’s
perceptions, needs, and wants
concerning the health behavior.
Formative research includes learning
about consumers’ current behavior, what
enables it, and what reinforces it.
78
Social Marketing Interventions
2. competitive analysis (also called
environmental analysis), to learn about the
environment in which members of the target
market are making behavior decisions. This
analysis examines competing behaviors that
are being promoted to the target market. (For
example, messages encouraging people to eat
convenient, inexpensive fast foods compete
with messages about eating 5 fruits and
vegetables a day.)
79
(NCI, 2005: p.38)
The social marketing process includes four stages: planning and strategy development; development of pretesting
concepts, messages, and materials; implementation; assessment of in-market effectiveness; and feedback to the first
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stage. Within each stage, there is a constant feedback loop between research and planning.
81
82
Example –
The California 5 A Day Campaign
• The California 5 A Day Campaign, which
was the model for the national 5 A Day
program,50 employs social marketing to
increase Californians’ consumption of fruit
and vegetables through strategies such as
supermarket point-of-purchase
interventions, industry promotional support,
media outreach, and community programs.
83
Example –
The California 5 A Day Campaign
1. it has a focused goal: to increase fruit and vegetable
consumption by raising awareness of the health
benefits.
2. its approach is built on an established theoretical
framework—the Stages of Change model.
3. messages were designed and disseminated using
consumer-driven communications strategies.
4. formative research (mall intercept interviews, focus
groups, and baseline survey data) helped the planners
to understand their audiences and improve messages.
5. the program uses the four Ps of social marketing.
84
Example –
The California 5 A Day Campaign
•
•
•
•
Product: Consuming more fruits and vegetables each
day to minimize the risk of cancer and improve health
status
Price: The costs of eating a healthier diet (e.g., financial
cost of buying fruits and vegetables, time cost of
shopping for and preparing them, psychological cost of
“worrying” about getting the recommended number of
servings)
Place: Grocery stores and other points of purchase (the
5 A Day message and healthy foods compete against
unhealthy products for space and attention)
Promotion: Branding the 5 A Day campaign to increase
awareness (e.g., using a slogan and compelling images
that are easy to recall)
85
Example –
The California 5 A Day Campaign
• Distribution channels include mass media
advertising, public service announcements,
newsletters, the Internet, magazines, press
conferences, outreach activities, special events,
and community-based groups, such as
churches.
• Regular monitoring and evaluation help to
assess the reach and impact of messages;
efficient use of time, labor, and capital
resources; and program costs/benefits.
86
PRECEDE-PROCEED Model
• PRECEDE-PROCEED is a planning model, not a theory.
• Developed by Green, Kreuter, and associates,
PRECEDE-PROCEED provides a road map for
designing health education and health promotion
programs.
• It does not predict or explain factors linked to the
outcomes of interest, but offers a framework for
identifying intervention strategies to address these
factors.
- Green LW, Kreuter MW. Health Promotion Planning: An Educational and Ecological Approach
(3rd edition). McGraw-Hill, 1999.
87
PRECEDE-PROCEED Model
• an “educational diagnosis” (PRECEDE)
and an “ecological diagnosis” (PROCEED).
• PRECEDE-PROCEED has nine steps.
• 1-5 steps are diagnostic, addressing both
educational and environmental issues.
• 6-9 steps comprise implementation and
evaluation of health promotion intervention.
88
Nine Steps
(1) social assessment,
(2) epidemiological assessment,
(3) behavioral and environmental assessment,
(4) educational and ecological assessment, and
(5) administrative and policy assessment.
(6) implementation,
(7) process evaluation,
(8) impact evaluation, and
(9) outcome evaluation.
89
(NCI, 2005: p.40)
90
(Green & Kreuter, 1999)
91
(NCI, 2005: p.42)
92
(1) Social Assessment
• the practitioner may use multiple data
collection activities (e.g., key informant
interviews, focus groups, participant
observation, surveys) to understand the
community’s perceived needs.
93
(2) Epidemiological assessment
• Epidemiological assessment may include
secondary data analysis or original data
collection to prioritize the community’s
health needs and establish program goals
and objectives.
94
(3) Behavioral and
Environmental Assessment
• Behavioral and Environmental
Assessment identifies factors, both
internal and external to the individual, that
affect the health problem. Reviewing the
literature and applying theory are two
ways to map out these factors.
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(4) Educational and Ecological
Assessment
• Educational and Ecological Assessment, the
practitioner identifies antecedent and reinforcing
factors that must be in place to initiate and
sustain change.
• Behavior—such as reducing intake of dietary fat,
engaging in routine physical activity, and
obtaining annual mammograms—is shaped by
predisposing, reinforcing, and enabling factors.
• Practitioners can use individual, interpersonal, or
community-level change theories to classify
determinants of behavior into one of these three
categories and rank their importance.
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Three Types of Influencing
Factors
1.
2.
3.
Predisposing factors, which motivate or provide a
reason for behavior; they include knowledge, attitudes,
cultural beliefs, and readiness to change.
Enabling factors, which enable persons to act on
their predispositions; these factors include available
resources, supportive policies, assistance, and
services.
Reinforcing factors, which come into play after a
behavior has been initiated; they encourage repetition
or persistence of behaviors by providing continuing
rewards or incentives. Social support, praise,
reassurance, and symptom relief might all be
considered reinforcing factors.
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(5) Administrative and Policy
Assessment
• Administrative and Policy Assessment,
intervention strategies reflect information
gathered in previous steps; the availability
of needed resources; and organizational
policies and regulations that could affect
program implementation.
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(6)-(9) Implementation &
Evaluation
• Before Implementation (Step 6) begins, practitioners
should prepare plans for evaluating the process (Step 7),
impact (Step 8), and outcome (Step 9) of the intervention.
• Process Evaluation gauges the extent to which a program
is being carried out according to plan.
• Impact Evaluation looks at changes in factors (i.e.,
predisposing, enabling, and reinforcing factors) that
influence the likelihood that behavioral and environmental
change will occur.
• Lastly, outcome evaluation looks at whether the
intervention has affected health and quality-of-life
indicators.
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(NCI, 2005: p.45)
100
(NCI, 2005: p.45)
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(NCI, 2005: p.45)
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(NCI, 2005: p.46)
Figure 10. illustrates that strategies intended to change people’s behavior can often be derived from
individual-level theories; those aimed at changing the environment draw on community-level theories.
Theories at the interpersonal level (such as Social Cognitive Theory) lie in-between, exploring the
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reciprocal exchanges between individuals and their environments.