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Theory at a

Glance A Guide For Health Promotion Practice

(Second Edition)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

Foreword

A decade ago, the first edition of Theory at a Glance was published. The guide was a welcome resource for public health practitioners seeking a single, concise summary of health behavior theories that was neither overwhelming nor superficial. As a government publication in the public domain, it also provided cash-strapped

health departments with access to a seminal integration of scholarly work that was useful to program staff, interns, and directors alike. Although they were not the primary target audience, members of the public health research community also utilized Theory at a Glance, both as a quick desk reference and as a primer for their students.

The National Cancer Institute is pleased to sponsor the publication of this guide, but its relevance is by no means limited to cancer prevention and control. The principles described herein can serve as frameworks for many domains of public health intervention, complementing focused evidence reviews such as Centers for Disease Control and Prevention’s Guide to Community Preventive Services. This report also complements a number of other efforts by NCI and our federal partners to facilitate more rigorous testing and application of health behavior theories through training workshops and the development of new Web-based resources.

One reason theory is so useful is that it helps us articulate assumptions and hypotheses concerning our strategies and targets of intervention. Debates among policymakers concerning public health programs are often complicated by unspoken assumptions or confusion about which data are relevant. Theory can inform these debates by clarifying key constructs and their presumed relationships. Especially when the evidence base is small, advocates of one approach or another can be challenged to address the mechanisms by which a program is expected to have an impact. By specifying these alternative pathways to change, program evaluations can be designed to ensure that regardless of the outcome, improvements in knowledge, program design, and implementation will occur.

I am pleased to introduce this second edition of Theory at a Glance. I am especially impressed that the lead authors, Dr. Barbara K. Rimer and Dr. Karen Glanz, have enhanced and updated it throughout without diminishing the clarity and efficiency of the original. We hope that this new edition will empower another generation of public health practitioners to apply the same conceptual rigor to program planning and design that these authors exemplify in their own research and practice.

Robert T. Croyle, Ph.D. Director Division of Cancer Control and Population Sciences National Cancer Institute

Spring 2005

Acknowledgements

The National Cancer Institute would like to thank Barbara Rimer Dr.P.H. and Karen Glanz Ph.D., M.P.H., authors of the original monograph, whose knowledge of healthcommunications theory and practice have molded a generation of health promotion practitioners. Both have provided hours of review and consultation, and we are grateful to them for their contributions.

Thanks to the staffs of the Office of Communications, particularly Margaret Farrell, and the Division of Cancer Control and Population Sciences and Kelly Blake, who guided this monograph to completion. We appreciate in particular the work of Karen Harris, whose attention to detail and commitment to excellence enhanced the monograph’s content and quality.

Tables and Figures Table of Contents

Introduction viii Audience and Purpose 1

Contents 1

Part 1: Foundations of Theory in Health Promotion and Health Behavior 3 Why Is Theory Important to Health Promotion and Health Behavior Practice? 4

What Is Theory? 4 How Can Theory Help Plan Effective Programs? 4

Explanatory Theory and Change Theory 5 Fitting Theory to the Field of Practice 5

Using Theory to Address Health Issues in Diverse Populations 7

Part 2: Theories and Applications 9 The Ecological Perspective: A Multilevel, Interactive Approach 10

Theoretical Explanations of Three Levels of Influence 12 Individual or Intrapersonal Level 12

Health Belief Model 13 Stages of Change Model 15

Theory of Planned Behavior 16 Precaution Adoption Process Model 18

Interpersonal Level 19 Social Cognitive Theory 19

Community Level 22 Community Organization and Other Participatory Models 23

Diffusion of Innovations 27 Communication Theory 29

Media Effects 30 Agenda Setting 30

New Communication Technologies 31

Part 3: Putting Theory and Practice Together 35 Planning Models 36 Social Marketing 36

PRECEDE-PROCEED 39 Where to Begin: Choosing the Right Theories 43

A Few Final Words 44

Sources 48

References 49

Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11

Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10

Tables

An Ecological Perspective: Levels of Influence 11 Health Belief Model 14

Stages of Change Model 15 Theory of Planned Behavior 17

Social Cognitive Theory 20 Community Organization 24

Concepts in Diffusion of Innovations 27 Key Attributes Affecting the Speed and Extent of an Innovation’s Diffusion 28

Agenda Setting, Concepts, Definitions, and Applications 31 Diagnostic Elements of PRECEDE-PROCEED 42

Summary of Theories: Focus and Key Concepts 45

Figures

Using Explanatory Theory and Change Theory to Plan and Evaluate Programs 6 A Multilevel Approach to Epidemiology 10

Theory of Reasoned Action and Theory of Planned Behavior 18 Stages of the Precaution Adoption Process Model 19

An Integrative Model 21 Sociocultural Environment Logic Framework 26

An Asthma Self-Management Video Game for Children 33 Social Marketing Wheel 38

The PRECEDE-PROCEED Model 40 Using Theory to Plan Multilevel Interventions 46

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Introduction

T his monograph, Theory at a Glance: Application to Health Promotion and Health Behavior (Second Edition), describes influential theories of health-related behaviors, processes of shaping behavior, and the effects of community and environmental factors on behavior. It complements existing resources that offer tools, techniques,

and model programs for practice, such as Making Health Communication Programs Work: A Planner’s Guide, i and the Web portal, Cancer Control PLANET (Plan, Link, Act, Network with Evidence-based Tools).ii Theory at a Glance makes health behavior theory accessible and provides tools to solve problems and assess the effectiveness of health promotion programs. (For the purposes of this monograph, health promotion is broadly defined as the process of enabling people to increase control over, and to improve, their health. Thus, the focus goes beyond traditional primary and secondary prevention programs.)

For nearly a decade, public health and health care practitioners have consulted the original version of Theory at a Glance for guidance on using theories about human behavior to inform program planning, implementation, and evaluation. We have received many testimonials about the First Edition’s usefulness, and requests for additional copies. This updated edition includes information from recent health behavior research and suggests theoretical approaches to developing programs for diverse populations. Theory at a Glance can be used as a stand-alone handbook, as part of in-house staff development programs, or in conjunction with theory texts and continuing education workshops.

For easy reference, the monograph includes only a small number of current and applicable health behavior theories. The theories reviewed here are widely used for the purposes of cancer control, defining risk, and segmenting populations. Much of the content for this publication has been adapted from the third edition of Glanz, Rimer, and Lewis’ Health Behavior and Health Education: Theory, Research, and Practice, 1 published by Jossey-Bass in San Francisco. Readers who want to learn more about useful theories for health behavior change and health education practice can consult this and other sources that are recommended in the References section at the end of the monograph.

i Making Health Communication Programs Work (http://www.nci.nih.gov/pinkbook/) describes a practical approach for planning and implementing health communication efforts.

ii Cancer Control PLANET (http://cancercontrolplanet.cancer.gov) provides access to data and resources that can help planners, program staff, and researchers to design, implement, and evaluate evidence-based cancer control programs.

Audience and Purpose

This monograph is written primarily for public health workers in state and local health agencies; it is also valuable for health promotion practitioners and volunteers who work in voluntary health agencies, community organizations, health care settings, schools, and the private sector.

Interventions based on health behavior theory are not guaranteed to succeed, but they are much more likely to produce desired outcomes. Theory at a Glance is designed to help users understand how individuals, groups, and organizations behave and change—knowledge they can use to design effective programs. For information about specific, evidence-based interventions to promote health and prevent disease, readers may also wish to consult the Guide to Community Preventive Services, published by the Centers for Disease Control and Prevention (CDC) at www.thecommunityguide.org.

Contents

This monograph consists of three parts. For each theory, the text highlights key concepts and their applications. These summaries may be used as “checklists” of important issues to consider when planning or evaluating programs or to prompt project teams to think about the range of factors that influence health behavior.

Part 1. Foundations of Theory in Health Promotion and Health Behavior describes ways that theories and models can be useful in health behavior/health promotion practice and provides basic definitions.

Part 2. Theories and Applications presents an ecological perspective on health behavior/health promotion programs. It describes eight theories and models that explain individual, interpersonal, and community behavior and offers approaches to solving problems. A brief description of each theory is followed by definitions of key concepts and examples or case studies. The section also explores the use of new communication technologies.

Part 3. Putting Theory and Practice Together explains how theory can be used in health behavior/health promotion program planning, implementation, and evaluation. Two comprehensive planning models, PRECEDE-PROCEED and social marketing, are reviewed.

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Foundations of Theory in Health Promotion and Health BehaviorPart 1

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Why Is Theory Important to Health Promotion and Health Behavior Practice?

Effective public health, health promotion, and chronic disease management programs help people maintain and improve health, reduce disease risks, and manage chronic illness. They can improve the well-being and self-sufficiency of individuals, families, organizations, and communities. Usually, such successes require behavior change at many levels, (e.g., individual, organizational, and community).

Not all health programs and initiatives are equally successful, however. Those most likely to achieve desired outcomes are based on a clear understanding of targeted health behaviors, and the environmental context in which they occur. Practitioners use strategic planning models to develop and manage these programs, and continually improve them through meaningful evaluation. Health behavior theory can play a critical role throughout the program planning process.

What Is 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. Theories must be applicable to a broad variety of situations. They are, by nature, abstract, and don’t have a specified content or topic area. Like empty coffee cups, theories have shapes and boundaries, but nothing inside. They become useful when filled with practical topics, goals, and problems.

• 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.

Most health behavior and health promotion theories were adapted from the social and behavioral sciences, but applying them to health issues often requires that one be familiar with epidemiology and the biological sciences. Health behavior and health promotion theories draw upon various disciplines, such as psychology, sociology, anthropology, consumer behavior, and marketing. Many are not highly developed or have not been rigorously tested. Because of this, they often are called conceptual frameworks or theoretical frameworks; here the terms are used interchangeably.

How Can Theory Help Plan Effective Programs?

Theory gives planners tools for moving beyond intuition to design and evaluate health behavior and health promotion interventions based on understanding of behavior. It helps them to step back and consider the larger picture. Like an artist, a program planner who grounds health

interventions in theory creates innovative ways to address specific circumstances. He or she does not depend on a “paint-by­ numbers” approach, re-hashing stale ideas, but uses a palette of behavior theories, skillfully applying them to develop unique, tailored solutions to problems.

Using theory as a foundation for program planning and development is consistent with the current emphasis on using evidence- based interventions in public health, behavioral medicine, and medicine. Theory provides a road map for studying problems, developing appropriate interventions, and evaluating their successes. It can inform the planner’s thinking during all of these stages, offering insights that translate into stronger programs. Theory can also help to explain the dynamics of health behaviors, including processes for changing them, and the influences of the many forces that affect health behaviors, including social and physical environments. Theory can also help planners identify the most suitable target audiences, methods for fostering change, and outcomes for evaluation.

Researchers and practitioners use theory to investigate answers to the questions of “why,” “what,” and “how” health problems should be addressed. By seeking answers to these questions, they clarify the nature of targeted health behaviors. That is, theory guides the search for reasons why people do or do not engage in certain health behaviors; it helps pinpoint what planners need to know before they develop public health programs; and it suggests how to devise program strategies that reach target audiences and have an impact. Theory also helps to identify which indicators should be monitored and measured during program evaluation. For these reasons, program planning, implementation, and monitoring processes based in theory are more likely

to succeed than those developed without the benefit of a theoretical perspective.

Explanatory Theory and Change Theory

Explanatory theory describes the reasons why a problem exists. It guides the search for factors that contribute to a problem (e.g., a lack of knowledge, self-efficacy, social support, or resources), and can be changed. Examples of explanatory theories include the Health Belief Model, the Theory of Planned Behavior, and the Precaution Adoption Process Model.

Change theory guides the development of health interventions. It spells out concepts that can be translated into program messages and strategies, and offers a basis for program evaluation. Change theory helps program planners to be explicit about their assumptions for why a program will work. Examples of change theories include Community Organization and Diffusion of Innovations. Figure 1. illustrates how explanatory theory and change theory can be used to plan and evaluate programs.

Fitting Theory to the Field of Practice

This monograph includes descriptions and applications of some theories that are central to health behavior and health promotion practice today. No single theory dominates health education and promotion, nor should it; the problems, behaviors, populations, cultures, and contexts of public health practice are broad and varied. Some theories focus on individuals as the unit of change. Others examine change within families, institutions, communities, or cultures. Adequately addressing an issue may require more than one theory, and no one theory is suitable for all cases.

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Fig

Explanatory Theory

Why? What can

be changed?

ure 1. Using Explanatory Theory and Change Theory to Plan and Evaluate Programs

Evaluation

ChangeTheory Problem Behavior Which strategies?

Which messages? or Assumptions about

Situation how a program should work

Planning

A Good Fit: 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.

Using Theory to Address Health Issues in Diverse Populations

The U.S. population is growing more culturally and ethnically diverse. An increasing body of research shows health disparities exist among various ethnic and socio-economic groups. These findings highlight the importance of understanding

Because the social context in which behavior occurs is always evolving, theories that were important in public health education a generation ago may be of limited use today. At the same time, new social science research allows theorists to refine and adapt existing theories. A recent Institute of Medicine report2 observed that several theorists have converged in their views, identifying several variables as central to behavior change. As a result, some constructs, such as self-efficacy, are central to multiple theories.

Effective practice depends on using theories and strategies that are appropriate to a situation.

One of the greatest challenges for those concerned with behavior change is learning to analyze how well a theory or model “fits” a particular issue. A working knowledge of specific theories, and familiarity with how

they have been applied in the past, improves skills in this area. Selecting an appropriate theory or combination of theories helps take into account the multiple factors that influence health behaviors. The practitioner who uses theory develops a nuanced understanding of realistic program outcomes that drives the planning process.

Choosing a theory that will bring a useful perspective to the problem at hand does not begin with a theory (e.g., the most familiar theory, the theory mentioned in a recent journal article, etc.). Instead, this process starts with a thorough assessment of the situation: the units of analysis or change, the topic, and the type of behavior to be addressed. Because different theoretical frameworks are appropriate and practical for different situations, selecting a theory that “fits” should be a careful, deliberate process. Start with the steps in the box at the top of the next page.

the cultural backgrounds and life experiences of community members, though research has not yet established when and under what circumstances targeted or tailored health communications are more effective than generic ones. (Targeting involves using information about shared characteristics of a population subgroup to create a single intervention approach for that group. In contrast, tailoring is a process that uses an assessment to derive information about one specific person, and then offers change or information strategies for an outcome of interest based on that person’s unique characteristics.)3

Most health behavior theories can be applied to diverse cultural and ethnic groups, but health practitioners must understand the characteristics of target populations (e.g., ethnicity, socioeconomic status, gender, age, and geographical location) to use these theories correctly.

There are several reasons why culture and ethnicity are critical to consider when applying theory to a health problem. First, morbidity and mortality rates for different diseases vary by race and ethnicity; second, there are differences in the prevalence of risk behaviors among these groups; and third, the determinants of health behaviors vary across racial and ethnic groups.

What People in the Field Say About Theory

“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

“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

“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

“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

“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

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The Ecological Perspective: A interactions with their physical and socio­ cultural environments. Two key concepts Multilevel, Interactive Approach of the ecological perspective help to identify intervention points for promoting health:Contemporary health promotion involves first, behavior both affects, and is affected

Concept Definition

Intrapersonal Level Individual characteristics that influence behavior, such as knowledge, attitudes, beliefs, and personality traits

Interpersonal Level Interpersonal processes and primary groups, including family, friends, and peers that provide social identity, support, and role definition

Community Level Institutional Factors Rules, regulations, policies, and informal structures, which

may constrain or promote recommended behaviors

Community Factors Social networks and norms, or standards, which exist as formal or informal among individuals, groups, and organizations

Public Policy Local, state, and federal policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control, and management

by, multiple levels of influence; second,

Table 1. An Ecological Perspective: Levels of Influence

more than simply educating individuals about healthy practices. It includes efforts

individual behavior both shapes, and isto change organizational behavior, as well

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shaped by, the social environment as the physical and social environment of communities. It is also about developing and (reciprocal causation).

advocating for policies that support health, such as economic incentives. Health promotion programs that seek to address health problems across this spectrum employ a range of strategies, and operate on multiple levels.

The ecological perspective emphasizes the interaction between, and interdependence of, factors within and across all levels of a health problem. It highlights people’s

To explain the first key concept of the ecological perspective, multiple levels of influence, McLeroy and colleagues (1988)4

identified five levels of influence for health- related behaviors and conditions. Defined in Table 1., these levels include: (1) intrapersonal or individual factors; (2) interpersonal factors; (3) institutional or organizational factors; (4) community factors; and (5) public policy factors.

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Figure 2. A Multilevel Approach to Epidemiology

Social and Economic Policies

Institutions

Neighborhoods and Communities

Living Conditions

Social Relationships

Individual Risk Factors

Pathophysiological Pathways

Individual/Population Health

Genetic/Constitutional Factors

Envir onm

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Li fe

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In practice, addressing the community level requires taking into consideration institutional and public policy factors, as well as social networks and norms. Figure 2. illustrates how different levels of influence combine to affect population health.

Each level of influence can affect health behavior. For example, suppose a woman delays getting a recommended mammogram (screening for breast cancer). At the individual level, her inaction may be due to fears of finding out she has cancer.

At the interpersonal level, her doctor may neglect to tell her that she should get the test, or she may have friends who say they do not believe it is important to get a mammogram. At the organizational level, it may be hard to schedule an appointment, because there is only a part-time radiologist at the clinic. At the policy level, she may lack insurance coverage, and thus be

unable to afford the fee. Thus, the outcome, the woman’s failure to get a mammogram, may result from multiple factors.

The second key concept of an ecological perspective, reciprocal causation, suggests that people both influence, and are influenced by, those around them. For example, a man with high cholesterol may find it hard to follow the diet his doctor has prescribed because his company cafeteria doesn’t offer healthy food choices. To comply with his doctor’s instructions, he can try to change the environment by asking the cafeteria manager to add healthy items to the menu, or he can dine elsewhere. If he and enough of his fellow employees decide to find someplace else to eat, the cafeteria may change its menu to maintain lunch business. Thus, the cafeteria environment may compel this man to change his dining habits, but his new habits may ultimately bring about change in the cafeteria as well.

Source: Smedley BD, Syme SL (eds.), Institute of Medicine. Promoting Health: Strategies from Social and Behavioral Research. Washington, D.C.:, National Academies Press, 2000.

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An ecological perspective shows the advantages of multilevel interventions that combine behavioral and environmental components. For instance, effective tobacco control programs often use multiple strategies to discourage smoking.5

Employee smoking cessation clinics have a stronger impact if the workplace has a no-smoking policy and the city has a clean indoor air ordinance. Adolescents are less likely to begin smoking if their peers disapp

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