Health Promotion Planning

Phase 4, Page 1

Educational & Ecological Assessment:

"What's the solution?"



As a behavioral objective, "Within two years of program implementation, district residents aged 20-35 will show a 20% reduction in the prevalence of cigarette smoking," what is lacking is how this objective will be met. You need to determine whether residents will reduce their behavior because they learn about the dangers of tobaccoˇXKnowledgeˇXbecause they change their Attitude, or because they learn new skillsˇXBehavior? This additional level of specificity results in learning and resource objectives. They actually allow us to develop the program.

There are hundreds of models to explain human behavior, and while each one adds something to our understanding, none succeed fully. We will present a summary of some of the primary health behavior models.

Figure 5-1Predisposing, Enabling, and Reinforcing factors do not, in and of themselves, constitute a human behavior theory but, rather, represent one, handy way of categorizing various behavioral causes Here's how this diagram might explain motor vehicle speeding behavior:

  1. Predisposing Factors: These are an individual's attitudes, values, or ethics toward a particular behavior. The person has an initial reason to speed. He or she may be late for an appointment, or may simply be sick of being passed by everyone else on the road. The reason may be enough for the person to begin the behaviorˇXpushing down on the gas pedalˇXbut unless the person is physically capable of holding the pedal at a speeding rate of speed, and unless the car is capable of going faster than the speed limit, the behavior will not be completed; speeding will not occur. This initial motivation toward speeding is a predisposing factor.

  2. Enabling Factors: These are skills or abilities, or environmental factors that make it possible or very unlikely that a person will perform a particular behavior. For instance, until a person becomes used to driving at excessive speed, he or she may feel very uncomfortable or scared, and may not speed for very long. As the person becomes more experienced, his or her level of fear may subside, and a feeling of driving skillfulness may occur. Similarly, a car capable of speeding, and a road good enough to accommodate high speed are also enabling factors.

    police chase

  3. Reinforcing Factors: Once a person perform a behavior, society, friends, family, and other important people will either reward the person or punish him or her. If the speeder's friends approve of and encourage the behavior, he or she is likely to continue the behavior. However, if stopped by the police or caught by parents, the speeder is may not continue speeding. This is how positive and negative reinforcement, respectively, work.

Health Behavior Theories

Here's a brief overview of the theories we discuss below. While we will concentrate on Predisposing, Reinforcing, and Enabling factors as a way of getting to educational objectives, you might perfer a different model. Use whatever you're comfortable with.

Health Belief Model

This model attempts to explain and predict a person's decision about whether to undertake a health behavior. A person's motivation to undertake a health behavior is determined by a two major issues: individual perceptions and modifying factors. The model emphasizes the importance of perceptions. As Simons-Morton et al. note, "It is less important how effective a therapy is than how effective the patient or consumer believes it to be. Individual perceptions are things affecting the individual's perception of the particular illness or disease. According to the model, these four issues, also shown in the diagram above, determine whether a person will follow a recommended course of action:

  1. Susceptibility: "How susceptible am I to this illness or disease?"

  2. Seriousness: "How serious is this illness or disease to my health?"


  3. Benefits: "What's in it for me?"

  4. Barriers: "What's it going to cost me?"

Demographic variables, perceived threat, and cues to action modify an individual's decision to act. One demographic characteristic is educational level. If the person knows something about the illness or disease, he or she is more likely to take action.

Cues bring a person's particular belief into consciousness, thereby impacting a particular health decision. Cues may be planned or unplanned. A billboard promoting cycling helmets is a planned cue. The sight of a cyclist smeared across the pavement is an unplanned cue.

Theory of Planned Behavior

According to this theory, the most important cause of a person's behavior is behavioral intent. A person's intention to perform a behavior is a combination of attitude toward performing the behavior, subjective norms, and perceived behavioral control.

cyclistAttitudes toward the behavior refer to the expected net outcome or result of the behavior. The motorcycle rider may have developed a negative attitude toward using a helmet from riding with others who spurned a helmet. However, if the rider begins riding with a girlfriend who wears a helmet he may want to wear one to please her. The summation of these attitudes toward wearing a helmet and toward the results of the helmet contributes to the rider's intention to wear a helmet.

cyclistSubjective norms: a person's behavioral intentions are partly dependent on what they believe people who are important to them will think about them if they actually perform the behavior. This is because most people want to comply with the norm. It doesn't matter what the important people actually think, but what the person thinks they will think. So, if our cyclist thinks his new girlfriend will approve, and he wants his girlfriend's approval, he is more likely to wear a helmet.

Perceived behavioral control refers to the how difficult the person thinks it will be to perform the behavior successfully. While anyone can actually wear a motorcycle helmet, not everyone who rides a cycle believes they can ride a cycle successfully while wearing a helmet. If our cyclist holds this belief, he will be less likely to wear his helmet.

Health Locus of Control

cyclistHealth Locus of Control, as measured by the Multidimensional Health Locus of Control Scale is intended to represent the degree to which a person believes their health is controlled by themselvesˇXunder internal control; by powerful other peopleˇXunder external control; or, is just a matter of luck or fateˇXunder the control of chance.

cyclist Those who believe their health is a matter of internal locus of control are more likely to perform a healthy behavior. This is because they believe they are in control of what happens to them. Conversely, a person who believes their health is a matter of external locus of control tends to point the finger of responsibility away from themself. So, if our motorcycle rider thinks, "When it is your time to go, you go," he is less likely to wear a helmet, since this would be an example of external not internal locus of control.

Stages of Change
It appears people may go through six stages before they change their behavior:
  1. cyclistPrecontemplation: Not considering changing behavior.

  2. Contemplation: Beginning to consider changing behavior.

  3. Preparation: Prepares for and experiments with new behavior.

  4. cyclistAction: Trying the new behavior.

  5. Maintenance: New behavior is sustained.

  6. Termination: New behavior becomes normal behavior.

A person may relapse at any point in the process. This can cause him or her to return to the beginning of the current state, or even revert to a previous state.

Diffusion of Innovation

Diffusion theory is concerned with how quickly members of a community will adopt an innovative health behavior. Diffusion is the process by which (1) something new to the target population, called an "innovation" (2) is communicated through certain channels (3) over time (4) among the members of a social system. Diffusion is a special type of communication concerned with the spread of new behaviors and ideas.

An innovation is an idea, practice, or object perceived as new by an individual. The characteristics of an innovation as perceived by the members of a social system determine its rate of adoption. Why do certain innovations spread more quickly than others? The characteristics which determine an innovation's rate of adoption are:

  1. relative advantage,
  2. compatibility,
  3. complexity,
  4. trialability, and,
  5. observability.

cyclistRelative advantage is the degree to which an innovation is perceived as better than the idea it supersedes. The degree of relative advantage may be measured in economic terms, but social prestige, convenience, and satisfaction are also important factors. It does not matter so much if an innovation has much objective advantage. What does matter is whether an individual perceives the innovation as advantageous. The greater the perceived relative advantage of an innovation, the more rapid its rate of adoption will be.

cyclistCompatibility is the degree to which an innovation is perceived as being consistent with the existing values, experiences, and needs of potential adopters. If an idea is incompatible with the values and norms of a social system, it will not be adopted as rapidly as a compatible innovation. The adoption of an incompatible innovation often requires the prior adoption of a new value system, which is a relatively slow process.

cyclistComplexity is the degree to which an innovation is perceived as difficult to understand and use. Some innovations are readily understood by most members of a social system; others are more complicated and will be adopted more slowly. Simpler new ideas are adopted more rapidly than innovations requiring the adopter to develop new skills and understandings.

cyclistTrialability is the degree to which an innovation may be experimented with on a limited basis. If a new ideas can be tried on an "installment plan," it will generally be adopted more quickly than permanent innovations. A reversible innovation represents less uncertainty to the individual who is considering it for adoption, since he or she can learn by doing.

Observability is the degree to which the results of an innovation is visible to others. The easier it is for individuals to see the results of an innovation, the more likely they are to adopt it. Such visibility stimulates peer discussion of a new idea, as friends and neighbors of an adopter often request innovation-evaluation information about it.

In summary, then, innovations perceived by individuals as having greater relative advantage, compatibility, trialability, observability, and less complexity will be adopted more rapidly than other innovations.

Social Cognitive Theory

Social Cognitive Theory views human behavior as a three-way, reciprocal interaction of environmental factors, personal factors, and behavioral factors.

Environmental factors include:

  1. The person's physical environment;
  2. Reinforcement; and,
  3. Observational learning.

cyclistReinforcement, is the consequences associated with any particular behavior. Condequences influence how likely we are to repeat the behavior, and how often we are likely to perform it.

However, the model emphasizes three additional aspects of reinforcement:

  1. Perceived consequences are more important than the actual consequences.

  2. Vicarious reinforcement prompts us to perform the behavior when we see someone else benefiting from it.

  3. Self-reinforcement is an internal process affecting what behavior a person performs based on self-imposed consequences of the behavior.

cyclistObservational learning is, as you might have guessed, learning to perform a behavior by watching someone else do it. The person we watch is called "the model," and the model can encourage us to or discourage us from performing the behavior.

Personal factors include:

  1. Outcome expectations,
  2. Outcome expectancies, and,
  3. Efficacy expectations.

cyclistOutcome expectations is the result the person expects from performing a particular behavior. A person who expects something positive to happen as a result of the behavior is more likely to perform the behavior, while someone who expects something bad to happen is less likely to perform the behavior.

An outcome expectancy is how desirable the outcome will be.

Efficacy expectations refer to a person's belief that he or she will be able to perform the behavior properly. People who believe they can actually perform the behavior are more likely to try than those who doubt their ability.

Behavioral factors include:

  1. Self-observation,
  2. Self-judgment, and,
  3. Self-reaction.

cyclistSelf-observation is a person's attempt to monitor their behavior to maximize positive outcomes and minimize negative ones. A behavior accompanied by a positive outcome is more likely to be repeated.

Self-judgment refers to a person's beliefs of whether a behavior is "good" or "bad." Perceived good behaviors are more likely to be repeated.

Self-reaction is how a person rewards or punishes himself or herself for performing a good or bad behavior. Rewards tend to increase self-esteem, and lead to behavioral repetition, while punishment decreases self-esteem and leads to behavioral avoidance.

Example of Educational & Ecological Assessment

Phase Description Outcome Process (how to) Example
1. Social Assessment Quality of life concerns: Community's perceptions of health needs or barriers to quality of life. Community members' perceptions: Quality of life concerns ranked in priority order. Surveys, interviews, focus or nominal group, or Delphi technique. Top-ranked concern: Low graduation rate.
2. Epidemiological Assessment Epidemiological analysis: Identify important health problems, contributing behavioral & environmental factors. Health objectives Gather mortality & morbidity data (school absence rates);disease rates Program goal and health objectives: Missed school days because of high rates of influenza.

Decrease incidence of influenza by increasing number of children immunized.

By December 31, 2002, there will be a 50% reduction in the reported incidence of influenza among children ages six and ten in Kuku County.

3. Behavioral & Environmental Assessment Link behavioral factors to health objective; link environmental factors to health objective. Behavioral factors and environmental factors. Identify most important and most changeable behavioral and environmental factors; review with community: Associate factors and health; determine prevalence of risk factors Behavioral and environmental objectives: By December 31, 2002, 60% of the children aged six to ten in Kuku County, will have received the influenza shot.
4. Educational & Ecological Assessment Determine causes of behavioral & environmental causes. Learning objectives: ranked list of predisposing, enabling, and reinforcing factors.

Resource objectives: non-behavioral factors influencing learning objectives.

Associate factors and behavior; determine prevalence of the factor, degree of urgency, level of necessity, or assessment of changeability: Review literature, develop checklists & questionnaires, use community resource directory. Educational and resource objectives: After the instructional programs, 90% of students will be able to list three benefits of the influenza shots.

Between October 31, 2002 and December 15, 2002, the Health Department will provide a nurse once a week every week for each school to deliver the influenza vaccine to the children in the schools.