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Chapter 7

Theories and Models Commonly Used for Health Promotion Interventions

Definitions

Theory – “a set of interrelated concepts, definitions, and propositions 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, Lewis, & Rimer, 2002, p. 25)
Model – is a subclass of theory; “draws upon a number of theories to help people understand a specific problem in a particular setting or context” (Rimer & Glanz, 2005, p. 4)
Concept – primary elements of theories or building blocks of theory (Glanz et al., 2002)
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., 2002)

Examples of the Definitions

Concept – personal belief

Construct – perceived barrier

Variable – On a scale of 1 to 10, with 1 being least important and 10 being most important, how important is wearing a safety belt to you?

Model – Health Belief Model

Theory – Social Cognitive Theory

Why use theories & models?

“A theory based approach provides direction and justification for program activities and serves as the basis for processes that are to be incorporated into the health promotion program (Cowdery et al., 1995, p. 248)

“Theories can provide answers to program developers’ questions regarding why people aren’t engaging in a desirable behavior of interest, how to go about changing their behaviors, and what factors to look at when evaluating a program’s focus” (van Ryn & Heaney, 1992, p. 326).

“Using theory…is consistent with the current emphasis on using evidence-based interventions in public health, behavioral medicine, and medicine” (Rimer & Glanz, 2005, p. 5)

An Overview of the of Theories and Models Used

Models serve as frames from which to build; structure and organization for the planning process

No perfect model and no one model dominates research or practice

Approximately 10 theories and models are used regularly to plan programs

Many different theories and models; many have common elements but may have different vocabulary

Types of Theories & Models

Planning models (or theories/models of implementation) - presented in Ch. 2

Behavior change theories (or change process theory) – “specify the relationships among causal processes operating both within and across levels of analysis (McLeroy et al., 1992, p. 3)

Behavior Change Theories

Many different change process theories

First need to decide on what level to intervene; the ecological perspective is a multilevel, interactive approach to examining the influences on health-related behaviors and conditions (Cottrell et al., 2009)

Consider the ecological perspective (McLeroy et al., 1988; Rimer & Glanz, 2005)
Intrapersonal level (individual level)
Interpersonal level (individuals exist within and are influenced by a social environment)
Community levels: Institutional factors, Community factors, Public policy

Behavior Change Theories (cont.)

Continuum theories – use an approach that identifies variables that influence action and combines them into a prediction equation (e.g., Health Belief Model, Theory of Planned Behavior)

Stage theories – are comprised of an ordered set of categories into which people can be classified, and which identifies factors that could induce movement from one category to the next (e.g., Transtheoretical Model, Precaution Adoption Process Model, Health Action Process Approach)

Behavior Change Theories - Intrapersonal Level

This group of theories focuses on factors within the individual such as knowledge, attitudes, beliefs, self-concept, mental history, past experiences, motivation, skills, and behaviors (Glanz & Rimer, 1995)

Examples

Stimulus Response, Health Belief Model, Transtheoretical Model, Precaution Adoption Process Model

Stimulus Response (SR) Theory

If the consequence is reinforcement, then there is an increase in behavior
If consequence is punishment, then there is a decrease in behavior
Reinforcement should be frequent and soon
Shape behavior in small steps
Reinforcement and punishment can be both positive and negative

Stimulus Response Consequence

2 X 2 table of the stimulus response theory

Theory of Planned Behavior (TPB)

Theory of Planned Behavior (TPB) (cont.)

The TPB is an extension of the theory of reasoned action (TRA); it addresses the problem of incomplete volitional control

Intention – “is an indication of a person’s readiness to perform a given behavior and it is considered to be an immediate antecedent of behavior” (Ajzen, 2006)

Attitude toward the behavior – “is the degree to which performance of a behavior is positively or negatively valued” (Ajzen, 2006)
Do I really think the behavior will be good for me?
How important is the behavior to me?

Theory of Planned Behavior (TPB) (cont.)

Subjective norm – “is the perceived social pressure to engage or not engage in a behavior” (Ajzen, 2006)
Do others think I should behave this way?
How much do I care what others think?

Perceived behavioral control – “refers to people’s perceptions of their ability to perform a given behavior” (Ajzen, 2006)
Do I have any control over this behavior?

Theory of Freeing

Takes a much different approach; aimed at empowering education

Empowerment – “…power to act with others to effect change” (Wallerstein & Bernstein, 1988, p. 380)

“free people so they may make health-related decisions based upon their needs and interests as long as the needs and interests do not adversely affect others” (Greenberg, 1978, p. 20)

Underlying concept: critical consciousness; determined by interaction with culture

Three stages: listening, dialogue process, and action Wallerstein & Bernstein, 1988; Wallerstein, 1994)

Health Belief Model (HBM)

Help explain the use of health services

Hypothesizes: 1) health issue salient or relevant, 2) belief that one is susceptible, and 3) benefits are worth the cost

The HBM “addresses a person’s perceptions of the threat of a health problem and the accompanying appraisal of a recommended behavior for preventing or managing a problem” (Rimer & Glanz, 2005, p. 12)

Health Belief Model (cont.)

Constructs–
Perceived susceptibility

Perceived seriousness

Perceived barriers

Perceived benefits

Cues to action

Self-efficacy

The Elaboration Likelihood Model of Persuasion (ELM)

Designed to help explain how persuasion message (aimed at changing attitudes) were perceived and processed by people

Hasn’t been used much in health promotion

Elaboration refers to the amount of effortful processing people put into receiving messages

Messages are processed centrally or peripherally

Useful in message tailoring

The Elaboration Likelihood Model of Persuasion

Transtheoretical Model (TTM)

The TTM “ is an integrative framework for understanding how individuals and populations progress toward adopting and maintaining health behavior change for optimal health” (Prochaska, Johnson, & Lee, 1998, p. 59)

Has four major constructs – 1) Stages of change (this is why some call it the “Stages of Change Model”), 2) Processes of change, 3) Self-efficacy, and 4) Decisional balance

Transtheoretical Model (cont.)

How to stage a person

Do you exercise regularly?

Yes

Do you intend to in the next 30 days?

Have you been doing so for more than 6 months?

Yes

Do you intend to in the next six months?

Yes

Precontemplation

Contemplation

Preparation

Action

Maintenance

Transtheoretical Model (TTM) (cont.)

Major constructs –
Stages of change
Decisional balance
Pros
Cons
Self-efficacy
Confidence
Temptation
Processes of change

Transtheoretical Model (cont.)

Stages of change in which processes are most emphasized

Precaution Adoption Process Model (PAPM)

TTM has been useful explaining gradual development habitual patterns, e.g., diet and exercise

PAPM explains how people come to the decision to take action, and how they translate that decision to action

Most useful when a deliberate action is required, e.g., screening or immunization

Precaution Adoption Process Model (cont.)

Stage Transition Important Issues

Stage 1 to 2 • Media message

Stage 2 to 3 • Communication from significant other

• Personal experience with hazard

Stage 3 to 4 to 5 • Beliefs about hazard likelihood & severity

• Beliefs about personal susceptibility

• Beliefs about behavior effectiveness & difficulty

• Behaviors & recommendations of others

• Perceived social norms

• Fear & worry

Stage 5 to 6 • Time, effort, & resources to act

• Detailed “how-to” information

• Reminders & other cues to action

• Assistance in carrying out action

Staging a Person Using Precaution Adoption Process Model

What are your intentions for receiving the new vaccine for shingles?
I have already gotten it. (Stage 6)
I have decided to get it. (Stage 5)
I have thought about it and decided not to get it. (Stage 4)
I am not sure. I am still trying to decide whether to get it or not. (Stage 3)
I heard there was a vaccine, but I really haven’t thought much about it. (Stage 2)
I was not aware there was a vaccine for shingles. (Stage 1)

Health Action Process Approach (HAPA)

Another stage model that applies to all health-compromising and health-enhancing behaviors (Luszczynska & Sutton, 2005)

Describes behavior change over time

Has two phases–motivation to change and self-regulatory processes– and five stages: intention, planning, initiative, maintenance, and recovery

Health Action Process Approach (HAPA) (cont.)

Change Process Theories - Interpersonal Level

This group of theories is comprised of theories that “assume individuals exist within, and are influenced by, a social environment. The opinions, thoughts, behavior, advice, and support of people surrounding an individual influence his or her feelings and behavior, and the individual has a reciprocal effect on those people” (Rimer & Glanz, 2005, p. 19)

Examples

Social learning, social power, interpersonal communication, social networks, and social support

Social Cognitive Theory (SCT)

Builds on the Stimulus Response theory

SCT describes learning as a reciprocal interaction among an individual’s environment, cognitive processes, and behavior (Parcel, 1983)

People are thinkers; expectations of consequences

Reinforcement

Direct reinforcement

Vicarious reinforcement (observational learning or social modeling)

Self-reinforcement

Often Used Constructs of the SCT

Behavior capability (knowledge and skills to perform behavior)
Expectations (beliefs about the likely outcomes of certain behaviors)
Expectancies (values on expected outcomes)
Locus of control (center of control over reinforcement)
Reciprocal determinism (behavior change results from the interaction between person and environment)
Self-control or self-regulation (gaining control over behavior through monitoring and adjusting)
Emotional coping response (ability to deal with anxiety surrounding behavior)

Often Used Constructs of the SCT (cont.)

Self-efficacy

through performance attainment (mastery of task)

through vicarious experience (observing)

as a result of verbal persuasion (suggestions from others)

through emotional arousal (interpreting one’s emotional state)

Difference Between Efficacy and Outcome Expectations

Behavior Change Theories - Community Level

This group of theories includes three of the ecological perspective levels- institutional (e.g., rules & regulations), community (e.g., social networks & norms), & public policy (e.g., legislation).

“…they explore how social systems function and change and how to mobilize community members and organizations” (Rimer & Glanz, 2005, p. 22)

Examples

Theories associated with these factors include theories of community organizing and community building

Community Readiness Model

A stage model for communities

Like individuals, communities are at various stages of readiness for change

Nine stages– 1) No awareness, 2) Denial, 3) Vague awareness, 4) Preplanning, 5) Preparation, 6) Initiation, 7) Stabilization, 8) Confirmation/Expansion, and 9) Professionalism

Cognitive-Behavioral Model of the Relapse Process (C-BMRP)

Relapse - breakdown or failure in a person’s attempt to change or modify a particular (health) behavior

Lapse - a single slip or mistake

Relapse prevention - a self control program designed to help individuals to anticipate and cope with the problem of relapse when changing (health) behavior

Relapse is triggered by high risk situations

Cognitive-Behavioral Model of the Relapse Process

Theories

Constructs

Operationalize

for use in

interventions

Relationship of theories and models to interventions

Using appropriate theory and practice greatly enhances the chances of effective health promotion practice (Glanz et al., 2002)

Barriers to Applying Theory

Failure of theory to adequately guide practice in specific settings or contexts

The lack of appropriate theories to guide community-oriented interventions

Difficulties in transferring theories from academic training context to the practice environment

Suggestions for Applying Theory to Practice

Have a basic grasp of the theories and models

Examine applicability of theories and models to the goals of the proposed program

Seldom does a single theory address all the complexities of a problem

Planners should select “a theory that makes sense to them, given their experience and what they know and believe about the world” (van Ryn & Heaney, 1992, p. 320)