Description

Health Promotion Theories and Models

An Overview
• This section of the course provides an
overview of contemporary social and
behavioral science theory use for
development, implementation and
evaluation of public health and health
promotion interventions.
• The following slides defines theory
and key types of theory in the context
of the multiple determinants and
multiple levels of determinants of
health and health behavior.

2

Lecture Objectives
• Define and explain the difference among
theory, concept, construct, variable, and
model
• Explain the importance of theory to
health education/promotion
• Explain what is meant by behavior
change theories and planning models

Lecture Objectives
• Identify and briefly explain the behavior change theories, and
their components, used in health education/promotion:

– Health Belief Model
– Theory of Planned Behavior
– Theory of Reason Action
– Social Cognitive Theory
– Social Learning Theory
– Transtheoretical Model of
Change
– Elaboration Likelihood Model
of Persuasion

– Precaution Adoption Process
Model
– Diffusion Theory
– Information-MotivationBehavioral Skills Model
– Social Network Theory
– Social Capital Theory
– Community Readiness
Model

Introduction
• Health promotion is a multifaceted effort aimed at
empowering individuals and communities to improve their
health and well-being.
• To effectively achieve this goal, it is essential to understand
the underlying theories that guide health promotion efforts.
• This lecture will explore several key theories that have been
influential in the field of health promotion.

5

Today’s Question
• Why do people behave in healthcompromising ways?

6

Determinants of Health

• Health is multidimensional and multifactorial. Thus, many factors
influence health.
• The factors which influence health lie both within the individual
and externally in the society in which he or she lives.
• These factors interact and these interactions may be healthpromoting or deleterious. Thus, the health of individuals and
communities may be considered to be the result of many
interactions.
• Also; Health behaviors are influenced by many factors. (think
about health determinants)

What are Behaviors?
• Behavior refers to the actions, reactions, or responses
of an individual or organism to internal or external
stimuli.
• It encompasses a wide range of activities, including:
• Observable Actions: Physical activities such as
walking, talking, and eating.
• Social Interactions: How individuals engage with
others, including communication and relationships.
• Emotional Responses: Reactions to feelings, such as
crying when sad or laughing when happy.
• Cognitive Processes: Thoughts and decision-making
processes that influence actions.
9

• Health behaviour is defined as:
“any activity undertaken by an individual for the purpose of
preventing disease or detecting it at an asymptomatic stage’’.
“an action to maintain, attain, or regain good health and to
prevent illness”.
Health behaviour is determined by:
▪ biological factors
▪ psychological factors
▪ Individual factors
▪ family and social environment
▪ culture
▪ laws
▪ economic factors
▪ environment and resources

Health risk behaviours: describe behaviors with
potentially negative effects on health.
Such as:
▪ Smoking
▪ Alcohol consumption
▪ High fat food
▪ Low fruit and vegetables diet
▪ Using drugs
▪ Unsafe out of marriage sexual behaviours
11

GLOBAL HEALTH RISKS
• The leading global risks for mortality in the world
are high blood pressure, tobacco use, high blood
glucose, physical inactivity, and overweight and
obesity.
• These risks are responsible for raising the risk of
chronic diseases such as heart disease, diabetes
and cancers. They affect countries across all
income groups: high, middle and low.
•

12

Top Risk Factors Leading to Disease,
Disability, or Death
Poorest Countries
1. Underweight
2. Unsafe sex
3. Unsafe water, sanitation
hygiene
4. Indoor smoke
5. Zinc deficiency
6. Iron deficiency
7. Vitamin A deficiency
8. High blood pressure
9. Tobacco
10. High cholesterol

13

Developed Countries
1. Tobacco
2. High blood pressure
3. Alcohol
4. High cholesterol
5. High BMI
6. Low fruit & vegetable intake
7. Physical inactivity
8. Illicit drugs
9. Unsafe sex
10. Iron deficiency

According to WHO :
“life expectancy could be increased by 5 to 10 years if
health-promoting decisions by individuals, communities,
health systems, and governments reduced these risks”.

Source: WHO, World Health Report 2002: Reducing Risk, Promoting Healthy Life (Geneva: WHO, 2002),

14

Fact:
Risky behaviours
translate to diseases or disability or
even death

So:
Risky Behaviours = Poor Health

Why do people …
▪ do things that are bad for
their health such as smoke
cigarettes or drink alcohol?
▪ not do things that are healthenhancing like exercise or
eating low fat foods?
▪ not do things that maximize
the likelihood of better
outcomes such as wearing
seat belts?
16

Why do people…?
• drive unsafely?
• overeat?
• smoke cigarettes?
• drink alcohol?
• use drugs?
• fail to follow health
recommendations advises?

Why and Why is it important to
have theories?
• A theory presents a systematic way of
understanding events, behaviors and/or
situations.
• By understanding the factors that influence
our choices, we can make informed decisions
that promote our well-being.

Importance of Using Theory in Health
Education/Promotion
▪ Understand why people do or do not practice health promoting
behaviors;
▪ Theories provide direction and organizes knowledge
– Indicates reasons why people are not behaving in healthy ways
– Identifies information needed for intervention development
– Provides a conceptual framework
– Gives insight for delivery
– Identifies measurements needed for evaluation

▪ Provide insight into how to design a program so it is successful
▪ Programs based upon sound theory more likely to succeed

Evidence from research
• A growing body of evidence suggests that interventions
developed with an explicit theoretical foundation are more
effective than those lacking a theoretical base and that some
strategies that combine multiple theories and concepts have
larger effects.

• The most successful public health programs and initiatives are
based on an understanding of health behaviors of individuals
and the context in which they occur.
• Therefore, interventions to improve health behavior can be
best designed with an understanding of relevant theories of
behavior change and the ability to use them skillfully.

Definitions
• theory – “a set of interrelated concepts, definitions, and repositions
that present a systematic view of events or situations by specifying
relations among variables in order to explain and predict the events
of the situations” (Glanz et al., 2008, p. 26)

• 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, p. 4); how a construct will be measured (Glanz et al., 2008)

Health Promotion Means Changing Behavior at Multiple
Levels
Health-related behaviors are affected by, and affect,
multiple levels of influence: intrapersonal or individual
factors,
interpersonal
factors,
institutional
or
organizational factors, community factors, and public
policy factors.
▪ Individual: knowledge, attitudes, beliefs, personality traits
▪ Interpersonal: family, friends, peers
▪ Community: social networks, standards, norms
▪ Institutional: rules, policies
▪ Public Policy: laws, policies related to healthy practices

Source: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion (2003), available online at

• There are several theories and models that support
the practice of health promotion and disease
prevention.
• Theories and models are used in program planning
to understand and explain health behavior and to
guide the identification, development, and
implementation of interventions.

23

Health Belief
Model

24

Health Belief Model
• The HBM was first developed in the 1950s by social
psychologists Hochbaum, Rosenstock and Kegels working in the
U.S. Public Health Services.
• 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 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 shortterm health behaviors.

Health Belief Model
• The Health Belief Model is one of the most widely
recognized conceptual frameworks of health behavior.
• According to the model individuals conduct an internal
assessment of the net benefits of changing their behavior,
and then decide whether to act.
• Key concepts: Perceived susceptibility, perceived severity,
perceived benefits, perceived barriers, cues to action, and
self-efficacy.

Health Belief Model
– Explains the likelihood of an individual to take action to prevent a
disease or injury based upon:
▪Perceived Susceptibility: Belief about the likelihood of getting a disease.
▪Perceived Severity: Belief about the seriousness of the disease.
▪Perceived Benefits: Belief in the efficacy of the advised action to reduce
risk.
▪Perceived Barriers: Belief about the costs or obstacles to taking action.
▪Cues to actions: Triggers that prompt engagement in health-promoting
behaviors. There are two types of ‘cue to action’; internal, which in the
health context includes symptoms of ill health, and external, which
includes media campaigns or the receipt of other information. These cues
affect the perception of threat and can trigger or maintain behaviour.
▪Self-efficacy: The individual’s perceived capacity to adopt the
behaviour. Confidence in one’s ability to take action.

HEALTH BELIEF MODEL (Detailed)
Concept

Definition

Application

Perceived
Susceptibility

One’s opinion of chances of
getting a condition

Define population(s) at risk based
on a person’s features or behaviour.
Heighten perceived susceptibility
if too low

Perceived
Severity

One’s opinion of how serious a
condition and its sequelae are

Specify consequences of risk and
condition

Perceived
Benefits

One’s opinion of the efficacy of
Define action to talk: how, where,
the advised action to reduce risk or when; clarity the positive effects to
seriousness of impact
be expected

Perceived
Barriers

One’s opinion of the tangible and
psychological costs of the advised
action

Cues to Action Strategies to activate “readiness”

Self-Efficacy

Identify and reduce barriers
through reassurance, incentives,
assistance
Provide how-to information,
promote awareness, reminders

Confidence on one’s ability to take Provide training, guidance in
action
performing action

29

Health Belief Model as a predictor of preventive health behavior

Example
• Sultan is not likely to continue smoking because:
• He thinks that he will get lung cancer if he continues to
smoke (susceptibility).
• He believes that lung cancer is deadly disease and dying
from lung cancer is terrible (not worth it) (severity).
• Sultan does not find smoking to be very pleasurable
(cost/benefits).
• His family/friends are supportive of he quitting (absence of
barrier)
• He belief that people can give up smoking, as well as he has
strong belief that he can do so (self-efficacy)
31

Example
• MAJED is likely to continue smoking because:
• He agrees with the tobacco industry–smoking might cause
lung cancer (Susceptibility-not quit strong).
• He believes that lung cancer is curable, and dying from lung
cancer is not any worse than any other way of dying
(Severity-not harsh).
• Majed feels that smoking is cool and relaxes him
(cost/benefits- cost over benefit).
• His best friends are smokers and offer him cigarettes
(barrier)
• He belief that it is hard to quit smoking, and most people
32
fail (low self-efficacy)

“in order for behaviour to change, people must feel

personally vulnerable to a health threat, view the
possible consequences as severe, and see that taking
action is likely to either prevent or reduce the risk at
an acceptable cost with few barriers. In addition, a
person must feel competent (have self-efficacy) to
execute and maintain the new behaviour. Some
trigger, either internal … or external …, is required to
ensure actual behaviour ensues”.
Nisbet and Gick (2008)

33

Summary

• The HBM suggests that individuals’ health
behaviors are influenced by their beliefs about
their susceptibility to a disease, the severity of
the disease, the benefits of preventive actions, the
barriers to taking action, cues to action, and their
self-efficacy.
▪First they must feel personally threatened by
disease i.e. they must feel personally susceptible
to a disease with serious or severe consequences
▪Second they must believe that the benefits of
taking the preventive action outweigh the
perceived barriers to (and/or cost of) preventive
action

• Implications for health promotion: Health
promotion interventions can be designed to
increase individuals’ perceived susceptibility and
severity, highlight the benefits of preventive
actions, address perceived barriers, and provide
cues to action.
34

Barriers, most be minimized
• So, there are no significant
psychological, financial, or
other costs or barriers to
engaging in
the healthy
behavior.

35

Theory of Reasoned
Action and Theory
of Planned Behavior
(Fishbein and Ajzen – 1975)

THE THEORY OF REASONED
ACTION
• The Theory of Reasoned Action (TRA) and the Theory of Planned Behavior
(TPB) are psychological theories that aim to predict and understand human
behavior. They are frequently used in fields like marketing, health
psychology, and social sciences.
• Unlike the Health Belief Model, this model is based on rationality and does
not provide explicitly for emotional ‘fear-arousal’ elements such as the
perceived susceptibility to illness
• Basically more emphasis is put on intention rather than attitudes. (Note:
attitudes and intention are strongly related).

TRA and TPB
• Two closely associated theories (The Theory of Reasoned Action and the Theory
of Planned Behavior) suggest that a person’s health behavior is determined by
their intention to perform a behavior.

• A person’s intention to perform a behavior (behavioral intention) is predicted
by:
• 1) a person’s attitude toward the behavior
• 2) subjective norms regarding the behavior.
• Generally, positive attitude and positive subjective norms result in greater
perceived control and increase the likelihood of intentions governing changes in
behavior.
38

THE THEORY OF REASONED
ACTION
• Developed by Martin Fishbein and Icek Ajzen in the late 1960s.
• Suggests that a person’s behavior is determined by their intention to
perform the behavior.
• Intention is influenced by two factors: Attitude and Subjective
Norms.
• Proposes that voluntary behavior is predicted by one’s intention to
perform the behavior (e.g. how likely is it that you will take up a
quit smoking programme?)
• Intention, in turn, is a function of :
– attitude towards the impending behaviour (do you feel good or
bad about quitting smoking?), and
– subjective norms (do most people who are important to you
think you should quit?)

THE THEORY OF REASONED
ACTION
▪ Attitude is a function of beliefs about the consequences of the behaviour
(how important do you think it is to quit?) weighted by an evaluation of
the importance of that outcome (how important is it to you to quit?)
▪ Subjective norms are a function of expectations of significant others (does
your friend/family member/spouse think you should quit?) weighted by
the motivation to conform (how important is it to do what your
friend/family member/spouse wants?)
❑ Behavioral Intention=Attitude+Subjective Norms

41

TRA Formula
• In its simplest form, the TRA can be expressed as the following
equation:
• BI= (AB)W + (SN)W

• where:
• BI = behavioral intention
• AB= one’s attitude toward performing the behavior
• SN = one’s subjective norm related to performing the behavior
• W = empirically derived weights

42

43

Strategies to Use with Tobacco Users
1. Assess the degree to which the client intends to change their

tobacco use behavior
2. Discuss the positive and negative expectancies the client has
for tobacco use, and provide feedback about incorrect
expectancies
3. Ask the client whether family members and friends support
tobacco use
4. Draw attention to the social pressure to quit using tobacco
5. Provide contact with others who have quit using tobacco
6. Work to build self-efficacy for quitting smoking and staying quit
in challenging situations

44

Theory of Planned Behavior
•

The Theory of Planned Behavior (TPB) started as the Theory of Reasoned
Action (TRA) to predict an individual’s intention to engage in a behavior at
a specific time and place.

•
•

An extension of TRA, introduced by Ajzen in 1985.
Adds a third element: Perceived Behavioral Control.

• People act after they’ve developed an intention, which requires
adopting a positive attitude toward the behavior, seeing it as a norm,
and believing they have the ability to act.

Theory of Planned Behavior
▪ Individuals’ intention to perform a given behavior is a function of their
attitude toward the behavior, their belief of what others think they
should do, and their perception of level of ease or difficulty of the
behavior in which they are considering action
▪ Attitude toward the behavior
▪ Subjective norm
▪ Perceived behavioral control
▪ Actual behavioral control

The TPB is comprised of six constructs that collectively represent
a person’s actual control over the behavior:
• Attitudes – This refers to the degree to which a person has a favorable or
unfavorable evaluation of the behavior of interest
• Behavioral intention – This refers to the motivational factors that influence a given
behavior where the stronger the intention to perform the behavior, the more
likely the behavior will be performed.
• Subjective norms – This refers to the belief about whether most people approve
or disapprove of the behavior. It relates to a person’s beliefs about whether peers
and people of importance to the person think he or she should engage in the
behavior.
• Social norms – This refers to the customary codes of behavior in a group or people
or larger cultural context. Social norms are considered normative, or standard, in
a group of people.
• Perceived behavioral control – This refers to a person’s perception of the ease or
difficulty of performing the behavior of interest. This construct of the theory was
added later, and created the shift from the Theory of Reasoned Action to the
Theory of Planned Behavior.
47

Theory of Planned Behavior (TPB)

Theory of Planned behaviors

49

Theory of Planned Behavior (TPB)

50

Theory of Planned behaviors

51

Theory of Planned behaviors Formula

Behavioral Intention=Attitude+Subjective Norms+Perceived Behavioral Control

52

TPB and TRA
Practical
Implications

• Policy Making: Developing
policies that consider the social
and psychological factors
influencing behavior
• Health Promotion: Designing
interventions that target attitudes,
social norms, and perceived
control to change health
behaviors.
• Marketing: Understanding how
attitudes and social norms
influence consumer behavior.

53

Transtheoretical Model/Stages of
Change (Prochaska, 1979)
•

The model identifies a number of stages which a person can go through
during the process of behavior change

•

It takes a holistic approach, integrating a range of factors such as the role
of personal responsibility and choices, and the impact of social and
environmental forces that set very real limits on the individual potential for
behavior change

•

It provides a framework for a wide range of potential interventions by
health promoters

Transtheoretical Model/Stages of Change
• Long-term changes in health behavior involve
multiple actions and adaptations over time.
• Some people may not be ready to attempt
changes, while others may have already begun
implementing changes in their smoking, diet,
activity levels, and so on.

Transtheoretical Model/Stages of Change
• The construct of “stage of change” is a key element of
The Transtheoretical Model (TTM) of behavior change,
and proposes that people are at different stages of
readiness to adopt healthful behaviors.

• The notion of readiness to change, or stage of change,
has been examined in health behavior research and
found useful in explaining and predicting changes for a
variety of behaviors including smoking, physical activity,
and eating habits.
• The TTM has also been applied in many settings.

Transtheoretical Model of Change (TMC)
– People make behavior change through a series of
different stages related to the behavior
– Stages of change:
• Precontemplation: stage people are in before they are
ready to change and are not intending to change
• Contemplation: stage when individuals are considering
making a behavior change within the next 6 months
• Preparation: stage where the individual is actively
planning change
• Action: the effort to make the change in behavior
• Maintenance: sustaining the change and resisting
relapse
• Termination: quitting , stopping change

STAGES OF CHANGE MODEL
▪ Pre-contemplation stage: The stage which precedes
entry into the change cycle. At this stage the person has not
considered changing their lifestyle or become aware of any
potential risks in their health behaviour.

▪ Contemplation stage: Although the individual is aware of
the benefits of change, they are not yet ready and may be
seeking information or help to make the decision. This stage
may last a short while or several years.

STAGES OF CHANGE MODEL

▪ Preparation stage: When the perceived benefits seem to
outweigh the costs and when the change seems possible as
well as worthwhile, the individual may be ready to change,
perhaps seeking some extra support.

▪ Action stage: The early days of change require positive
decisions by the individual to do things differently. A clear
goal, a realistic plan, support and rewards are features of this
stage.

STAGES OF CHANGE MODEL
▪ Maintenance stage: The new behaviour is sustained and
the person moves into a healthier lifestyle

▪ Relapse stage: Although individuals experience the
satisfaction of a changed lifestyle for varying amounts of time,
most of them cannot exit from the revolving door first time
around. Typically, they relapse back. Of great importance,
however, is that they do not stop there, but move back into
the contemplation stage.

STAGES OF CHANGE MODEL
(Prochaska J & DiClemente C, 1984)

62

STAGES OF CHANGE MODEL
Concept

Definition

Application

Pre-contemplation

Unaware of the problem hasn’t
though about change.

Increase awareness of need for
change, personalize
information on risks and
benefits.

Contemplation

Thinking about change, in the
near future.

Motivate, encourage to make
specific plans.

Commitment

Making a plan to change.

Assist in developing concrete
action plans, setting gradual
goals.

Action

Implementation of specific
action plans.

Assist with feedback, problem
solving, social support,
reinforcement.

Maintenance

Continuation of desirable
actions, or repeating periodic
recommended step(s).

Assist in coping, reminders,
finding alternatives, avoiding
slips/relapses (as applies).

Stages Of Change Model As Applied To Smoking

64

Stages Of Change Model As Applied To
Smoking cessation Programme
Precontemplation
Smoker young man
has heard
about lung cancer but
doesn’t think it is
relevant to his life.

Contemplation
Young man
believes that he
and his friends
are at risk and
thinks that he should
do something.

Maintenance
He successfully maintain
quitting smoking.

Decision/
Determination
Young man is
ready & plans to
Quit smoking.

Action
Young man seeks advice and
Start stopping smoking.

Summary

• The TTM suggests that individuals go
through a series of stages as they
change their behaviors.
• Health promotion interventions can be
tailored to individuals’ stage of change
to maximize their effectiveness.
• Implications for health promotion:
Health promotion interventions can
provide different types of support for
individuals at different stages of
change.

66

SLT and SCT:
• Social learning theory and social cognitive theory are theories
that try to explain learning in the social context, with the main
position being that people acquire new behaviors by observation.
• The Social Cognitive Theory (SCT) started as the Social
Learning Theory (SLT) in the 1960s by Albert Bandura.
• Is a theory of learning process and social behavior which
proposes that new behaviors can be acquired by observing and
imitating others.
• It suggests that learning occurs in a social context with a dynamic
and reciprocal interaction of the person, environment, and
behavior.

67

68

SLT and SCT:
• The word ‘social’ refers to the influence of social interactions on
how we acquire new behaviors which may not necessarily be
social in nature, and how we preserve them.
• The two are very similar in content, so similar that both are
sometimes attributed to just one man, Albert Bandura.
• Although not by much, social learning theory is a fairly older
body of knowledge while social cognitive theory has a broader
scope. And while social cognitive theory can be attributed solely
to Bandura, social learning theory is a collection of ideas from
various thinkers.
69

SLT and SCT
▪ It considers observational learning. People learn from:
1.
their own experiences
2. learn by observing the actions of others and the results of those
actions.
▪ It emphasizes behavioral capability: A person needs to know what to do
and how to do it. Thus, clear instructions and sometimes training are
needed.
▪ It considers self-efficacy as being one of the most important aspects in
bringing about healthy behaviors.

The Bobo Doll experiments
(Bandura, 1961)
• Bandura developed what famously became known as the Bobo
Doll experiments. In these studies, children watched adults model
either violent or passive behavior towards a toy called Bobo Doll;
what they saw influenced how they themselves subsequently
interacted with the doll. Specifically, children who observed
violent behavior imitated this behavior and were verbally and
physically aggressive toward the doll. Children who witnessed
nonviolent behavior behaved less aggressively toward the doll.
• Bandura concluded that children learn aggression, violence, and
other social behaviors through observation learning, or watching
the behaviors of others.
71

SCT and SLT
The first five constructs were developed as part of the SLT; the
construct of self-efficacy was added when the theory evolved
into SCT:
1.

Reciprocal Determinism – It refers to the dynamic and reciprocal
interaction of person (individual with a set of learned experiences),
environment (physical and external social context), and behavior
(responses to stimuli to achieve goals).

2.

Behavioral Capability – This refers to a person’s actual ability to
perform a behavior through essential knowledge and skills. In order to
successfully perform a behavior, a person must know what to do and
how to do it. People learn from the consequences of their behavior,
which also affects the environment in which they live.

SLT and SCT
3. Observational Learning – This asserts that people can
observe a behavior conducted by others, and then reproduce
those actions. This is often presented through “modeling” of
behaviors. If individuals see successful demonstration of a
behavior, they can also complete the behavior successfully.
4. Reinforcements – This refers to the internal or external
responses to a person’s behavior that affect the likelihood of
continuing or discontinuing the behavior. Reinforcements can
be self-initiated or in the environment, and reinforcements can
be positive or negative.

SLT and SCT
5. Expectations – This refers to the anticipated consequences of
a person’s behavior. People anticipate the consequences of
their actions before engaging in the behavior, and these
anticipated consequences can influence successful completion
of the behavior. Expectations derive largely from previous
experience.
6. Self-efficacy – This refers to the level of a person’s
confidence in his or her ability to successfully perform a
behavior. Self-efficacy is influenced by a person’s capabilities,
individual factors, and environmental factors (barriers and
facilitators).
74

Social Cognitive Theory (Bandura,
1986)
– With social cognitive theory, Bandura broadens his social learning theory
by starting with a conceptualization of humanity as having agency and
capability, that is, humans are not just shaped by their environments and
inner forces but also shape their environment and can regulate those inner
forces.
– Is a reciprocal interaction between the individual’s environment, cognitive
process, and behavior.
– Reciprocal determinism means that a person can be both an agent for
change and a responder to change.
– Thus, changes in the environment, the examples of role models, and
reinforcements can be used to promote healthier behavior.
– Media provides models for a vast array of people in many different
environmental settings.

76

Social Cognitive Theory (SCT)
• A basic idea of SCT is that people learn not only through
their own experiences, but also by observing the actions of
others and the results of those actions.
• The theory states that when people observe a model
performing a behavior and the consequences of that
behavior, they remember the sequence of events and use
this information to guide subsequent behaviors.
• Observing a model can also prompt the viewer to engage in
behavior they already learned.
• Four conditions are necessary in any form of observing
behavior: attention, retention, reproduction, and motivation.

Necessary conditions for effective
modeling
•

•

•
•

Attention — various factors increase or decrease the amount of attention
paid. Includes distinctiveness, affective valence, prevalence, complexity,
functional value. One’s characteristics (e.g. sensory capacities, arousal
level, past reinforcement) affect attention.
Retention — remembering what you paid attention to. Includes symbolic
coding, mental images, cognitive organization, symbolic rehearsal, motor
rehearsal.
Reproduction — reproducing the image. Including physical capabilities,
and self-observation of reproduction.
Motivation — having a good reason to imitate. Includes motives such as
past (i.e. traditional behaviorism), promised (imagined incentives) and
vicarious (seeing and recalling the reinforced model)

78

Implications for health promotion
•

Health promotion interventions can be designed to enhance
individuals’ self-efficacy, provide positive role models, and
help individuals develop self-regulation skills.

79

Summary
• Health education/promotion is a multidisciplinary profession.
• Many of the theories & models used in health
education/promotion have evolved from other disciplines.
• Theories in health promotion and health education provide
crucial frameworks for understanding in influencing behavior.
• By applying these theories, practitioners can develop more
effective interventions that improve public health outcomes.
• There is no absolute perfect model.

Questions

Discussion Questions
• Which health behavior theories do you find
most applicable in your field, and why?
• How can we ensure that health interventions
are culturally sensitive and effective?
• What are some strategies for sustaining longterm behavior change in individuals?

82

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83

Health Promotion Theories and Models

An Overview
• This section of the course provides an
overview of contemporary social and
behavioral science theory use for
development, implementation and
evaluation of public health and health
promotion interventions.
• The following slides defines theory
and key types of theory in the context
of the multiple determinants and
multiple levels of determinants of
health and health behavior.

2

Lecture Objectives
• Define and explain the difference among
theory, concept, construct, variable, and
model
• Explain the importance of theory to
health education/promotion
• Explain what is meant by behavior
change theories and planning models

Lecture Objectives
• Identify and briefly explain the behavior change theories, and
their components, used in health education/promotion:

– Health Belief Model
– Theory of Planned Behavior
– Theory of Reason Action
– Social Cognitive Theory
– Social Learning Theory
– Transtheoretical Model of
Change
– Elaboration Likelihood Model
of Persuasion

– Precaution Adoption Process
Model
– Diffusion Theory
– Information-MotivationBehavioral Skills Model
– Social Network Theory
– Social Capital Theory
– Community Readiness
Model

Introduction
• Health promotion is a multifaceted effort aimed at
empowering individuals and communities to improve their
health and well-being.
• To effectively achieve this goal, it is essential to understand
the underlying theories that guide health promotion efforts.
• This lecture will explore several key theories that have been
influential in the field of health promotion.

5

Today’s Question
• Why do people behave in healthcompromising ways?

6

Determinants of Health

• Health is multidimensional and multifactorial. Thus, many factors
influence health.
• The factors which influence health lie both within the individual
and externally in the society in which he or she lives.
• These factors interact and these interactions may be healthpromoting or deleterious. Thus, the health of individuals and
communities may be considered to be the result of many
interactions.
• Also; Health behaviors are influenced by many factors. (think
about health determinants)

What are Behaviors?
• Behavior refers to the actions, reactions, or responses
of an individual or organism to internal or external
stimuli.
• It encompasses a wide range of activities, including:
• Observable Actions: Physical activities such as
walking, talking, and eating.
• Social Interactions: How individuals engage with
others, including communication and relationships.
• Emotional Responses: Reactions to feelings, such as
crying when sad or laughing when happy.
• Cognitive Processes: Thoughts and decision-making
processes that influence actions.
9

• Health behaviour is defined as:
“any activity undertaken by an individual for the purpose of
preventing disease or detecting it at an asymptomatic stage’’.
“an action to maintain, attain, or regain good health and to
prevent illness”.
Health behaviour is determined by:
▪ biological factors
▪ psychological factors
▪ Individual factors
▪ family and social environment
▪ culture
▪ laws
▪ economic factors
▪ environment and resources

Health risk behaviours: describe behaviors with
potentially negative effects on health.
Such as:
▪ Smoking
▪ Alcohol consumption
▪ High fat food
▪ Low fruit and vegetables diet
▪ Using drugs
▪ Unsafe out of marriage sexual behaviours
11

GLOBAL HEALTH RISKS
• The leading global risks for mortality in the world
are high blood pressure, tobacco use, high blood
glucose, physical inactivity, and overweight and
obesity.
• These risks are responsible for raising the risk of
chronic diseases such as heart disease, diabetes
and cancers. They affect countries across all
income groups: high, middle and low.
•

12

Top Risk Factors Leading to Disease,
Disability, or Death
Poorest Countries
1. Underweight
2. Unsafe sex
3. Unsafe water, sanitation
hygiene
4. Indoor smoke
5. Zinc deficiency
6. Iron deficiency
7. Vitamin A deficiency
8. High blood pressure
9. Tobacco
10. High cholesterol

13

Developed Countries
1. Tobacco
2. High blood pressure
3. Alcohol
4. High cholesterol
5. High BMI
6. Low fruit & vegetable intake
7. Physical inactivity
8. Illicit drugs
9. Unsafe sex
10. Iron deficiency

According to WHO :
“life expectancy could be increased by 5 to 10 years if
health-promoting decisions by individuals, communities,
health systems, and governments reduced these risks”.

Source: WHO, World Health Report 2002: Reducing Risk, Promoting Healthy Life (Geneva: WHO, 2002),

14

Fact:
Risky behaviours
translate to diseases or disability or
even death

So:
Risky Behaviours = Poor Health

Why do people …
▪ do things that are bad for
their health such as smoke
cigarettes or drink alcohol?
▪ not do things that are healthenhancing like exercise or
eating low fat foods?
▪ not do things that maximize
the likelihood of better
outcomes such as wearing
seat belts?
16

Why do people…?
• drive unsafely?
• overeat?
• smoke cigarettes?
• drink alcohol?
• use drugs?
• fail to follow health
recommendations advises?

Why and Why is it important to
have theories?
• A theory presents a systematic way of
understanding events, behaviors and/or
situations.
• By understanding the factors that influence
our choices, we can make informed decisions
that promote our well-being.

Importance of Using Theory in Health
Education/Promotion
▪ Understand why people do or do not practice health promoting
behaviors;
▪ Theories provide direction and organizes knowledge
– Indicates reasons why people are not behaving in healthy ways
– Identifies information needed for intervention development
– Provides a conceptual framework
– Gives insight for delivery
– Identifies measurements needed for evaluation

▪ Provide insight into how to design a program so it is successful
▪ Programs based upon sound theory more likely to succeed

Evidence from research
• A growing body of evidence suggests that interventions
developed with an explicit theoretical foundation are more
effective than those lacking a theoretical base and that some
strategies that combine multiple theories and concepts have
larger effects.

• The most successful public health programs and initiatives are
based on an understanding of health behaviors of individuals
and the context in which they occur.
• Therefore, interventions to improve health behavior can be
best designed with an understanding of relevant theories of
behavior change and the ability to use them skillfully.

Definitions
• theory – “a set of interrelated concepts, definitions, and repositions
that present a systematic view of events or situations by specifying
relations among variables in order to explain and predict the events
of the situations” (Glanz et al., 2008, p. 26)

• 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, p. 4); how a construct will be measured (Glanz et al., 2008)

Health Promotion Means Changing Behavior at Multiple
Levels
Health-related behaviors are affected by, and affect,
multiple levels of influence: intrapersonal or individual
factors,
interpersonal
factors,
institutional
or
organizational factors, community factors, and public
policy factors.
▪ Individual: knowledge, attitudes, beliefs, personality traits
▪ Interpersonal: family, friends, peers
▪ Community: social networks, standards, norms
▪ Institutional: rules, policies
▪ Public Policy: laws, policies related to healthy practices

Source: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion (2003), available online at

• There are several theories and models that support
the practice of health promotion and disease
prevention.
• Theories and models are used in program planning
to understand and explain health behavior and to
guide the identification, development, and
implementation of interventions.

23

Health Belief
Model

24

Health Belief Model
• The HBM was first developed in the 1950s by social
psychologists Hochbaum, Rosenstock and Kegels working in the
U.S. Public Health Services.
• 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 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 shortterm health behaviors.

Health Belief Model
• The Health Belief Model is one of the most widely
recognized conceptual frameworks of health behavior.
• According to the model individuals conduct an internal
assessment of the net benefits of changing their behavior,
and then decide whether to act.
• Key concepts: Perceived susceptibility, perceived severity,
perceived benefits, perceived barriers, cues to action, and
self-efficacy.

Health Belief Model
– Explains the likelihood of an individual to take action to prevent a
disease or injury based upon:
▪Perceived Susceptibility: Belief about the likelihood of getting a disease.
▪Perceived Severity: Belief about the seriousness of the disease.
▪Perceived Benefits: Belief in the efficacy of the advised action to reduce
risk.
▪Perceived Barriers: Belief about the costs or obstacles to taking action.
▪Cues to actions: Triggers that prompt engagement in health-promoting
behaviors. There are two types of ‘cue to action’; internal, which in the
health context includes symptoms of ill health, and external, which
includes media campaigns or the receipt of other information. These cues
affect the perception of threat and can trigger or maintain behaviour.
▪Self-efficacy: The individual’s perceived capacity to adopt the
behaviour. Confidence in one’s ability to take action.

HEALTH BELIEF MODEL (Detailed)
Concept

Definition

Application

Perceived
Susceptibility

One’s opinion of chances of
getting a condition

Define population(s) at risk based
on a person’s features or behaviour.
Heighten perceived susceptibility
if too low

Perceived
Severity

One’s opinion of how serious a
condition and its sequelae are

Specify consequences of risk and
condition

Perceived
Benefits

One’s opinion of the efficacy of
Define action to talk: how, where,
the advised action to reduce risk or when; clarity the positive effects to
seriousness of impact
be expected

Perceived
Barriers

One’s opinion of the tangible and
psychological costs of the advised
action

Cues to Action Strategies to activate “readiness”

Self-Efficacy

Identify and reduce barriers
through reassurance, incentives,
assistance
Provide how-to information,
promote awareness, reminders

Confidence on one’s ability to take Provide training, guidance in
action
performing action

29

Health Belief Model as a predictor of preventive health behavior

Example
• Sultan is not likely to continue smoking because:
• He thinks that he will get lung cancer if he continues to
smoke (susceptibility).
• He believes that lung cancer is deadly disease and dying
from lung cancer is terrible (not worth it) (severity).
• Sultan does not find smoking to be very pleasurable
(cost/benefits).
• His family/friends are supportive of he quitting (absence of
barrier)
• He belief that people can give up smoking, as well as he has
strong belief that he can do so (self-efficacy)
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Example
• MAJED is likely to continue smoking because:
• He agrees with the tobacco industry–smoking might cause
lung cancer (Susceptibility-not quit strong).
• He believes that lung cancer is curable, and dying from lung
cancer is not any worse than any other way of dying
(Severity-not harsh).
• Majed feels that smoking is cool and relaxes him
(cost/benefits- cost over benefit).
• His best friends are smokers and offer him cigarettes
(barrier)
• He belief that it is hard to quit smoking, and most people
32
fail (low self-efficacy)

“in order for behaviour to change, people must feel

personally vulnerable to a health threat, view the
possible consequences as severe, and see that taking
action is likely to either prevent or reduce the risk at
an acceptable cost with few barriers. In addition, a
person must feel competent (have self-efficacy) to
execute and maintain the new behaviour. Some
trigger, either internal … or external …, is required to
ensure actual behaviour ensues”.
Nisbet and Gick (2008)

33

Summary

• The HBM suggests that individuals’ health
behaviors are influenced by their beliefs about
their susceptibility to a disease, the severity of
the disease, the benefits of preventive actions, the
barriers to taking action, cues to action, and their
self-efficacy.
▪First they must feel personally threatened by
disease i.e. they must feel personally susceptible
to a disease with serious or severe consequences
▪Second they must believe that the benefits of
taking the preventive action outweigh the
perceived barriers to (and/or cost of) preventive
action

• Implications for health promotion: Health
promotion interventions can be designed to
increase individuals’ perceived susceptibility and
severity, highlight the benefits of preventive
actions, address perceived barriers, and provide
cues to action.
34

Barriers, most be minimized
• So, there are no significant
psychological, financial, or
other costs or barriers to
engaging in
the healthy
behavior.

35

Theory of Reasoned
Action and Theory
of Planned Behavior
(Fishbein and Ajzen – 1975)

THE THEORY OF REASONED
ACTION
• The Theory of Reasoned Action (TRA) and the Theory of Planned Behavior
(TPB) are psychological theories that aim to predict and understand human
behavior. They are frequently used in fields like marketing, health
psychology, and social sciences.
• Unlike the Health Belief Model, this model is based on rationality and does
not provide explicitly for emotional ‘fear-arousal’ elements such as the
perceived susceptibility to illness
• Basically more emphasis is put on intention rather than attitudes. (Note:
attitudes and intention are strongly related).

TRA and TPB
• Two closely associated theories (The Theory of Reasoned Action and the Theory
of Planned Behavior) suggest that a person’s health behavior is determined by
their intention to perform a behavior.

• A person’s intention to perform a behavior (behavioral intention) is predicted
by:
• 1) a person’s attitude toward the behavior
• 2) subjective norms regarding the behavior.
• Generally, positive attitude and positive subjective norms result in greater
perceived control and increase the likelihood of intentions governing changes in
behavior.
38

THE THEORY OF REASONED
ACTION
• Developed by Martin Fishbein and Icek Ajzen in the late 1960s.
• Suggests that a person’s behavior is determined by their intention to
perform the behavior.
• Intention is influenced by two factors: Attitude and Subjective
Norms.
• Proposes that voluntary behavior is predicted by one’s intention to
perform the behavior (e.g. how likely is it that you will take up a
quit smoking programme?)
• Intention, in turn, is a function of :
– attitude towards the impending behaviour (do you feel good or
bad about quitting smoking?), and
– subjective norms (do most people who are important to you
think you should quit?)

THE THEORY OF REASONED
ACTION
▪ Attitude is a function of beliefs about the consequences of the behaviour
(how important do you think it is to quit?) weighted by an evaluation of
the importance of that outcome (how important is it to you to quit?)
▪ Subjective norms are a function of expectations of significant others (does
your friend/family member/spouse think you should quit?) weighted by
the motivation to conform (how important is it to do what your
friend/family member/spouse wants?)
❑ Behavioral Intention=Attitude+Subjective Norms

41

TRA Formula
• In its simplest form, the TRA can be expressed as the following
equation:
• BI= (AB)W + (SN)W

• where:
• BI = behavioral intention
• AB= one’s attitude toward performing the behavior
• SN = one’s subjective norm related to performing the behavior
• W = empirically derived weights

42

43

Strategies to Use with Tobacco Users
1. Assess the degree to which the client intends to change their

tobacco use behavior
2. Discuss the positive and negative expectancies the client has
for tobacco use, and provide feedback about incorrect
expectancies
3. Ask the client whether family members and friends support
tobacco use
4. Draw attention to the social pressure to quit using tobacco
5. Provide contact with others who have quit using tobacco
6. Work to build self-efficacy for quitting smoking and staying quit
in challenging situations

44

Theory of Planned Behavior
•

The Theory of Planned Behavior (TPB) started as the Theory of Reasoned
Action (TRA) to predict an individual’s intention to engage in a behavior at
a specific time and place.

•
•

An extension of TRA, introduced by Ajzen in 1985.
Adds a third element: Perceived Behavioral Control.

• People act after they’ve developed an intention, which requires
adopting a positive attitude toward the behavior, seeing it as a norm,
and believing they have the ability to act.

Theory of Planned Behavior
▪ Individuals’ intention to perform a given behavior is a function of their
attitude toward the behavior, their belief of what others think they
should do, and their perception of level of ease or difficulty of the
behavior in which they are considering action
▪ Attitude toward the behavior
▪ Subjective norm
▪ Perceived behavioral control
▪ Actual behavioral control

The TPB is comprised of six constructs that collectively represent
a person’s actual control over the behavior:
• Attitudes – This refers to the degree to which a person has a favorable or
unfavorable evaluation of the behavior of interest
• Behavioral intention – This refers to the motivational factors that influence a given
behavior where the stronger the intention to perform the behavior, the more
likely the behavior will be performed.
• Subjective norms – This refers to the belief about whether most people approve
or disapprove of the behavior. It relates to a person’s beliefs about whether peers
and people of importance to the person think he or she should engage in the
behavior.
• Social norms – This refers to the customary codes of behavior in a group or people
or larger cultural context. Social norms are considered normative, or standard, in
a group of people.
• Perceived behavioral control – This refers to a person’s perception of the ease or
difficulty of performing the behavior of interest. This construct of the theory was
added later, and created the shift from the Theory of Reasoned Action to the
Theory of Planned Behavior.
47

Theory of Planned Behavior (TPB)

Theory of Planned behaviors

49

Theory of Planned Behavior (TPB)

50

Theory of Planned behaviors

51

Theory of Planned behaviors Formula

Behavioral Intention=Attitude+Subjective Norms+Perceived Behavioral Control

52

TPB and TRA
Practical
Implications

• Policy Making: Developing
policies that consider the social
and psychological factors
influencing behavior
• Health Promotion: Designing
interventions that target attitudes,
social norms, and perceived
control to change health
behaviors.
• Marketing: Understanding how
attitudes and social norms
influence consumer behavior.

53

Transtheoretical Model/Stages of
Change (Prochaska, 1979)
•

The model identifies a number of stages which a person can go through
during the process of behavior change

•

It takes a holistic approach, integrating a range of factors such as the role
of personal responsibility and choices, and the impact of social and
environmental forces that set very real limits on the individual potential for
behavior change

•

It provides a framework for a wide range of potential interventions by
health promoters

Transtheoretical Model/Stages of Change
• Long-term changes in health behavior involve
multiple actions and adaptations over time.
• Some people may not be ready to attempt
changes, while others may have already begun
implementing changes in their smoking, diet,
activity levels, and so on.

Transtheoretical Model/Stages of Change
• The construct of “stage of change” is a key element of
The Transtheoretical Model (TTM) of behavior change,
and proposes that people are at different stages of
readiness to adopt healthful behaviors.

• The notion of readiness to change, or stage of change,
has been examined in health behavior research and
found useful in explaining and predicting changes for a
variety of behaviors including smoking, physical activity,
and eating habits.
• The TTM has also been applied in many settings.

Transtheoretical Model of Change (TMC)
– People make behavior change through a series of
different stages related to the behavior
– Stages of change:
• Precontemplation: stage people are in before they are
ready to change and are not intending to change
• Contemplation: stage when individuals are considering
making a behavior change within the next 6 months
• Preparation: stage where the individual is actively
planning change
• Action: the effort to make the change in behavior
• Maintenance: sustaining the change and resisting
relapse
• Termination: quitting , stopping change

STAGES OF CHANGE MODEL
▪ Pre-contemplation stage: The stage which precedes
entry into the change cycle. At this stage the person has not
considered changing their lifestyle or become aware of any
potential risks in their health behaviour.

▪ Contemplation stage: Although the individual is aware of
the benefits of change, they are not yet ready and may be
seeking information or help to make the decision. This stage
may last a short while or several years.

STAGES OF CHANGE MODEL

▪ Preparation stage: When the perceived benefits seem to
outweigh the costs and when the change seems possible as
well as worthwhile, the individual may be ready to change,
perhaps seeking some extra support.

▪ Action stage: The early days of change require positive
decisions by the individual to do things differently. A clear
goal, a realistic plan, support and rewards are features of this
stage.

STAGES OF CHANGE MODEL
▪ Maintenance stage: The new behaviour is sustained and
the person moves into a healthier lifestyle

▪ Relapse stage: Although individuals experience the
satisfaction of a changed lifestyle for varying amounts of time,
most of them cannot exit from the revolving door first time
around. Typically, they relapse back. Of great importance,
however, is that they do not stop there, but move back into
the contemplation stage.

STAGES OF CHANGE MODEL
(Prochaska J & DiClemente C, 1984)

62

STAGES OF CHANGE MODEL
Concept

Definition

Application

Pre-contemplation

Unaware of the problem hasn’t
though about change.

Increase awareness of need for
change, personalize
information on risks and
benefits.

Contemplation

Thinking about change, in the
near future.

Motivate, encourage to make
specific plans.

Commitment

Making a plan to change.

Assist in developing concrete
action plans, setting gradual
goals.

Action

Implementation of specific
action plans.

Assist with feedback, problem
solving, social support,
reinforcement.

Maintenance

Continuation of desirable
actions, or repeating periodic
recommended step(s).

Assist in coping, reminders,
finding alternatives, avoiding
slips/relapses (as applies).

Stages Of Change Model As Applied To Smoking

64

Stages Of Change Model As Applied To
Smoking cessation Programme
Precontemplation
Smoker young man
has heard
about lung cancer but
doesn’t think it is
relevant to his life.

Contemplation
Young man
believes that he
and his friends
are at risk and
thinks that he should
do something.

Maintenance
He successfully maintain
quitting smoking.

Decision/
Determination
Young man is
ready & plans to
Quit smoking.

Action
Young man seeks advice and
Start stopping smoking.

Summary

• The TTM suggests that individuals go
through a series of stages as they
change their behaviors.
• Health promotion interventions can be
tailored to individuals’ stage of change
to maximize their effectiveness.
• Implications for health promotion:
Health promotion interventions can
provide different types of support for
individuals at different stages of
change.

66

SLT and SCT:
• Social learning theory and social cognitive theory are theories
that try to explain learning in the social context, with the main
position being that people acquire new behaviors by observation.
• The Social Cognitive Theory (SCT) started as the Social
Learning Theory (SLT) in the 1960s by Albert Bandura.
• Is a theory of learning process and social behavior which
proposes that new behaviors can be acquired by observing and
imitating others.
• It suggests that learning occurs in a social context with a dynamic
and reciprocal interaction of the person, environment, and
behavior.

67

68

SLT and SCT:
• The word ‘social’ refers to the influence of social interactions on
how we acquire new behaviors which may not necessarily be
social in nature, and how we preserve them.
• The two are very similar in content, so similar that both are
sometimes attributed to just one man, Albert Bandura.
• Although not by much, social learning theory is a fairly older
body of knowledge while social cognitive theory has a broader
scope. And while social cognitive theory can be attributed solely
to Bandura, social learning theory is a collection of ideas from
various thinkers.
69

SLT and SCT
▪ It considers observational learning. People learn from:
1.
their own experiences
2. learn by observing the actions of others and the results of those
actions.
▪ It emphasizes behavioral capability: A person needs to know what to do
and how to do it. Thus, clear instructions and sometimes training are
needed.
▪ It considers self-efficacy as being one of the most important aspects in
bringing about healthy behaviors.

The Bobo Doll experiments
(Bandura, 1961)
• Bandura developed what famously became known as the Bobo
Doll experiments. In these studies, children watched adults model
either violent or passive behavior towards a toy called Bobo Doll;
what they saw influenced how they themselves subsequently
interacted with the doll. Specifically, children who observed
violent behavior imitated this behavior and were verbally and
physically aggressive toward the doll. Children who witnessed
nonviolent behavior behaved less aggressively toward the doll.
• Bandura concluded that children learn aggression, violence, and
other social behaviors through observation learning, or watching
the behaviors of others.
71

SCT and SLT
The first five constructs were developed as part of the SLT; the
construct of self-efficacy was added when the theory evolved
into SCT:
1.

Reciprocal Determinism – It refers to the dynamic and reciprocal
interaction of person (individual with a set of learned experiences),
environment (physical and external social context), and behavior
(responses to stimuli to achieve goals).

2.

Behavioral Capability – This refers to a person’s actual ability to
perform a behavior through essential knowledge and skills. In order to
successfully perform a behavior, a person must know what to do and
how to do it. People learn from the consequences of their behavior,
which also affects the environment in which they live.

SLT and SCT
3. Observational Learning – This asserts that people can
observe a behavior conducted by others, and then reproduce
those actions. This is often presented through “modeling” of
behaviors. If individuals see successful demonstration of a
behavior, they can also complete the behavior successfully.
4. Reinforcements – This refers to the internal or external
responses to a person’s behavior that affect the likelihood of
continuing or discontinuing the behavior. Reinforcements can
be self-initiated or in the environment, and reinforcements can
be positive or negative.

SLT and SCT
5. Expectations – This refers to the anticipated consequences of
a person’s behavior. People anticipate the consequences of
their actions before engaging in the behavior, and these
anticipated consequences can influence successful completion
of the behavior. Expectations derive largely from previous
experience.
6. Self-efficacy – This refers to the level of a person’s
confidence in his or her ability to successfully perform a
behavior. Self-efficacy is influenced by a person’s capabilities,
individual factors, and environmental factors (barriers and
facilitators).
74

Social Cognitive Theory (Bandura,
1986)
– With social cognitive theory, Bandura broadens his social learning theory
by starting with a conceptualization of humanity as having agency and
capability, that is, humans are not just shaped by their environments and
inner forces but also shape their environment and can regulate those inner
forces.
– Is a reciprocal interaction between the individual’s environment, cognitive
process, and behavior.
– Reciprocal determinism means that a person can be both an agent for
change and a responder to change.
– Thus, changes in the environment, the examples of role models, and
reinforcements can be used to promote healthier behavior.
– Media provides models for a vast array of people in many different
environmental settings.

76

Social Cognitive Theory (SCT)
• A basic idea of SCT is that people learn not only through
their own experiences, but also by observing the actions of
others and the results of those actions.
• The theory states that when people observe a model
performing a behavior and the consequences of that
behavior, they remember the sequence of events and use
this information to guide subsequent behaviors.
• Observing a model can also prompt the viewer to engage in
behavior they already learned.
• Four conditions are necessary in any form of observing
behavior: attention, retention, reproduction, and motivation.

Necessary conditions for effective
modeling
•

•

•
•

Attention — various factors increase or decrease the amount of attention
paid. Includes distinctiveness, affective valence, prevalence, complexity,
functional value. One’s characteristics (e.g. sensory capacities, arousal
level, past reinforcement) affect attention.
Retention — remembering what you paid attention to. Includes symbolic
coding, mental images, cognitive organization, symbolic rehearsal, motor
rehearsal.
Reproduction — reproducing the image. Including physical capabilities,
and self-observation of reproduction.
Motivation — having a good reason to imitate. Includes motives such as
past (i.e. traditional behaviorism), promised (imagined incentives) and
vicarious (seeing and recalling the reinforced model)

78

Implications for health promotion
•

Health promotion interventions can be designed to enhance
individuals’ self-efficacy, provide positive role models, and
help individuals develop self-regulation skills.

79

Summary
• Health education/promotion is a multidisciplinary profession.
• Many of the theories & models used in health
education/promotion have evolved from other disciplines.
• Theories in health promotion and health education provide
crucial frameworks for understanding in influencing behavior.
• By applying these theories, practitioners can develop more
effective interventions that improve public health outcomes.
• There is no absolute perfect model.

Questions

Discussion Questions
• Which health behavior theories do you find
most applicable in your field, and why?
• How can we ensure that health interventions
are culturally sensitive and effective?
• What are some strategies for sustaining longterm behavior change in individuals?

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