Health Education

Temesgen Geleta(MPH,HE & Promotion)

Public Health Department

St Paul’s Hospital Millennium Medical College
(SPHMMC)
Nov,2016
E-mail: [email protected]

1
Course content
Introduction to health education
 Definitions, concepts
 Principles, rationale, goals and objectives
 Role of HE in PHC, PH, HP

Health and human behavior

 Definitions, types of behaviors
 Factor affecting human behaviors
 Approaches to behavioral change

Theories and models in health education and promotion

 Definitions and concepts
 Importance/purpose of theory
 Common theories and models
 HBM, TRA/TPB, TTM, SCT, DIT

Health communication
• Definitions and concepts
• Communication process and elements
• Types and forms of communication
• Strategic communication

. 2
Content ….

Health education methods

Health education materials/communication materials

Assessment : ??????
1) Continues Assessment (40%)
2) 40% Final Written Exam= Mcqs & Essay
3) Attendance 10%,
4) Assignment 10%.

Teaching method and material; Lecture forum, discussion and LCD

3
Content ….

References
1. James Mckenzie. Health promotion planning, implementation and evaluation. 4 th
edition. 2005
2. Karen G., Barbara K. & Frances M (2002) Health Behavior and Health Education:
Theory, Research and Practice. 3rd edition.
3. Lawrence W. Green (1980) Health education planning a diagnostic approach
4.John Hubley (1993) Communicating health. An action guide to health education and
health promotion.
5. Getnet Mitike (2003) health education for health science students. Lecture note
series. Addis Ababa University, Ethiopia.
6. WHO (1988) Education for health. A manual on health education in PHC, WHO,
Geneva.

4
 Unit 1
Introduction to Health Education

5
 Outlines

• Definition of Health
• Determinants of health
• Definition of health education & promotion.
• Why health education
• Aims of Health education
• Principles in HE
• Challenges in HE

6
 What is Health?

Narrow definitions for health

 Absence of disease or infirmity

 Physical and physiological capabilities to perform
routine tasks

WHO definition for Health

 Health is a state of complete physical, mental,
emotional and social well-being not merely the
absence of disease or infirmity.” WHO constitution of
1948.
7
 Health definition….

• Absence of diseases or
disability or infirmity
Negative • Physical and physiological
definition/narrow
definition capabilities
• The human body as
mechanical devices

• It is broader and more

Positive definition/broad holistic concept. WHO
definition definition is the most known
of this model.

8
What is …?

1. Physical health

• absence of diseases or disability on the body parts

• It is the biological integrity and the physiological
well functioning of the human body
• It is the ability to perform routine tasks without any
physical restriction.

9
 What is …?

2. Mental health
• Cognitive component - ability of an individual to learn,
perceive and, think clearly.
3. Emotional component - ability of expressing emotions
(e.g. fear, happiness, and to be angry) in an
“appropriate” way.
• Appropriate here is to emphasis that the response of the
body should be congruent with that of the stimuli.
• It is the ability to maintain one’s own integrity in the
presence of stressful situations (tensions, depression and
anxiety).
• E.g. if somebody gets into coma during an examination.
10
What is …?

4. Social health
• Is the ability to make and maintain
“acceptable” and “proper” interaction and
communication with other people and the
social environment; satisfying interpersonal
relationship and role fulfillment.
• For example, to mourn when close family
member dies, to celebrate festivals, to create
and maintain friendship etc.

11
What is …?

Extended definition of Health

• The ability to lead socially and economically
productive life
Spiritual Health
• It is a relation of health with religion or
cultural values and beliefs and is a way of
achieving mental satisfaction in stressful or in
other ill- health conditions.

12
What is …?

Critics of WHO definition for Health

• It is an over attractive, overambitious, ideal

and unattainable definition.
• Health is a process rather than a state - health
is a dynamic process with ever-changing
stimuli and responses.
• Spiritual health is not component of WHO
definition

13
 Determinants of Health

• Health or ill health is the result of a

combination of different factors.
• There are different perspectives in expressing
the determinants of health of an individual or a
community.
• According to the “Health field” concept, there
are four major determinants of health

14
It has determinants of different classes

Genetics

Personal Physical
environm
behavior ent
Health

Social
Health
environm
care
ent

15
 Determinants of Health …

A. Human Biology
• there are factors, which are genetically transmitted from
parents to offspring
B. Environment
• is all that which is external to the individual human host.
• Environmental factors that could influence health include
 Physical factors: climate, Rain fall, temperature…
 Biological factors: microorganisms, toxins, Biological
waste…
 Psycho-social & economic factors e.g. overcrowding,
income, access to health care…
 Chemical factors: industrial wastes, agricultural wastes, air
pollution, etc
16
Determinants of Health …

C. Life style (Behavior)

• is an action that has a specific frequency, duration,

and purpose, whether conscious or unconscious.
• It is what we do and how we act.
• Life style of individuals affects their health directly or
indirectly. For ex: Cigarette smoking, unsafe sexual
practice, Eating habit…

17
Determinants of Health ..

D. Health care organization

• It is concerned with
Availability of health service
Acceptability of the service by the community
Accessibility: in terms of physical distance,
finance etc

18
 What is Health Education?

• Health education is concerned with changes in

knowledge, feelings and behavior of people. (WHO)

• Health education is any combination of learning

experiences designed to facilitate voluntary action
conducive to health (Lawrence Green )

• Combination - emphasizes on the importance of

matching multiple determinants of behaviors with
multiple learning experiences or educational
intervention

19
 Defn s of concepts in HE

• Designed - distinguishes health education from

incidental learning experiences as a systematically
planned and organized activity.
• Facilitate - creating favorable condition such as
predispose, enable, reinforce.
• Voluntary - with full understanding and acceptance of
the purpose of the action, without use of coercion or
any manipulative approaches.
• Action - behavioral steps/measures taken by individuals,
groups or community to achieve the desired health
effect.
20
 Rationale for health education (HE)
 Do we need health education ?

 Developed countries ?

 Developing countries

 Do you think health education is important in our

health care system?

21
 Rationale for health education

“We must recognize that most of the world’s major

Health problems and premature death are
preventable through changes in human behaviors
and at low cost .We have the know –how and
technology but they have to be transformed into
effective action at the community level”
Dr.Hiroshi Nakajiima, Director – General, WHO, 1998

22
 Rationale …

1. The continued existence and spread of

communicable diseases

2. About 75% of childhood illnesses are preventable

3. For some diseases health education is the only

practical choice in order to prevent the spread of
the disease or to lead a normal life

4. The tendency of increasing magnitude of chronic

conditions and other emerging agendas 23
 Rationale …
5. prevention is the best cure and the most cost
effective intervention

6. Human behaviors are almost the single causes for

the development of most health conditions .

7. Wide spread of unhealthy behaviors

8. people’s ignorance of causes of heir illnesses

24
 Ultimate goals and educational objectives of HE

A) The ultimate goals of health education

 Health education improves the health status of individuals,
families, communities, states, and the nation

 The ultimate goal of all service professionals including health

educators is to improve the quality of life.

 The highest goal in life is to die young, at as old an age is

possible .

 To promote health, prevent illness, self-adjust to live with

disabilities and decrease morbidity and mortality.
25
 B. Educational objectives of health
education

Educational objectives of health education are;

• To provide appropriate Knowledge

• To help develop positive Attitude

• To help exercise health Practice/behavior

=KAP

26
 Dimensions of Health Education
• Health education is life long process. It is not one
time affair.

• The concern caring about a child begins while the

fetus is in the mother’s womb.

• Health Education is concerned with people at all

points of health and illness continuum

27
 Dimensions & characteristics of HE

• Concerned with whole person

• Touches upon many fields
• lifelong process
• concerned with people at all points of health and illness
• It deals with helping people to help themselves and with
helping people to work towards creating healthier
conditions for everybody.
• It involves formal & informal teaching and learning using
a range of methods.
• It is concerned with a range of goals, including giving
information, attitude change, behavior change & social
change. 28
 Dimension …

No level of
Health -illness disease
prevention can
operate with no
health
Health

education
successfully

Illness Death

Figure mathematical presentation of health and illness 29

continuum
 Cont’….
• Health education covers the continuum from disease
prevention and promotion of optimal health to the
detection of illness to treatment, rehabilitation, and
long-term care.
• It includes infectious and chronic diseases, as well as
attention to environmental issues.
Health education is delivered in almost every
conceivable settings:
 Settings: communities, schools, health care, worksite
 Others: too many (eg. churches, mosques, etc..)

30
 Dimension …
Health education is not an end by itself.
Rather a way of empowering people to understand
their own problems, identifying its solution and take
appropriate action.

Health education is not limited to patients in clinical

setups.
It includes those who are apparently healthy and
who want to minimize the risk of having a problem.

31
 Principles of health education…
1. Principle of diagnosis: 7. Need based
a-behavioral 8. Culture
b-educational 9. Principle of
2. Principle of reinforcement
Participation 10.Individualization
3. Principle of multiple (educational
methods specificity)
4. Principle of planning
and organizing
5. Facts based
6. Audience segmentation
32
 Basic Principles of health education

• All health education should be need based

• Health education aims at change of behavior

• It is necessary to have a free flow of communication

• The health educator has to adjust his talk and action to suit the
group for whom he has to give health education
• Health Education should provide an opportunity for the clients
to go through the stages of identification of problems,
planning, implementation and evaluation.
• Health Education is based on scientific findings and current
knowledge
• Health educators have to make themselves acceptable 33
 Health Promotion

• A combination of educational and environmental

supports for actions and condition of living conducive to
health.” (GREEN AND KRUETR , 1991)
• Combination - refers to the necessity of matching
multiple determinants of health with multiple
intervention or sources of supports.
• Educational - refers to the communication part of
health promotion. That is health education.
• Environmental - refers to the social, political, and
economic, organizational, policy and regulatory
circumstances influence behavior or more directly
health
34
 Health promotion ….

• Elements of Health promotion,

Building healthy public policy

Reorienting the health services
Creating supportive environments
Strengthening community action
Developing personal skills

35
 Principles of health promotion,
• Empowerment - health promotion initiatives should
enable individuals and communities to assume more
power over the personal, socio-economic and
environmental factors that affect their health.

• Participative – Health promotion initiatives should

involve those concerned in all stages of planning,
implementation and evaluation.

• Holistic – Health promotion initiatives should foster

physical, mental, social and spiritual health.
36
 Principles …..
• Inter-sectoral - Health promotion initiatives should involve the
collaboration of agencies from relevant sectors.

• Equitable - Health promotion initiatives should be guided by a

concern for equity and social justice.

• Sustainable - Health promotion initiatives should bring about

changes that individuals and communities can maintain once
initial funding has ended.

• Multi-strategy – Health promotion initiatives should use a variety

of approaches in combination with one another, including policy
development, organizational change, community development,
legislation, advocacy, education and communication.

37
 Levels of HE in disease prevention

1. Primary health education

• Directed at healthy people and the primary
aim is to prevent occurrence of ill-health.
• E.g. nutrition education
2. Secondary Health Education
• Educating patients about their condition and
what to do about it. E.g. How to adjust
habits in cases of overweight

38
 Levels of HE …

3. Tertiary health education

• Used in patients whose ill - health has not been or
could not be prevented and who cannot be
completely cured.
• It is concerned with educating the person or his or
her relatives about how to make the most about the
remaining potential for healthy living and had to avoid
unnecessary hardships, restrictions & complications
• E.g. How to adjust eating and drinking habits to
ensure maximum health & minimum complications in
chronic and incurable conditions such as hypertension
39
 Historical development of HE
• HE as emerging profession is as old as about 100
years but the concept of educating about health has
been around since the down of humans.

• At the time of Alma Ata declaration of Primary

Health Care in 1978, health education was put as
one of the components of PHC.

• Ethiopia utilizes health education as a primary means

of prevention of diseases and promotion of health.

40
 The role of health education and
promotion in primary health care
• Primary health care i s a means of achieving health
for all.
• It is very much concerned with health promotion
and education.
• One of the core principles of primary health care is
community participation.
• No components of primary health care can
successfully implemented without health education.

41
 Challenges of Health Education

• Health education is not considered as important

during relatively healthy status
• Changing health behavior is conditioned by many
factors which are difficult to deal with
simultaneously.
• Health education does not have high prestige
• People are preoccupied with many daily activities
to support their life which impedes them to give
their ear to the messages of health education.
• people charged with health education programs lack
special training and are not qualified
42
Thank you!!!

43
 Unit Two
Health and Human behavior
 Outline

 Behaviors
 Definitions and concepts
 Types of behaviors

 Factors affecting human behaviors

Predisposing factors –psychosocial factors
Enabling factors
Reinforcing factors
 The role of human behaviors in disease
prevention

45
 Leaning outcome

• At the end of this session, you will be able to;

 Define correctly what behaviors mean?
 Describe determinants of human behaviors
 Discuss the role of human behaviors in disease
prevention

46
Human Behavior: Definition

What is behavior ????

Behavior- is an action that has specific

frequency, duration, and purpose,
whether conscious or unconscious. It is
both the act and the way we act.

47
 Behaviors ….
Eg.
Action – drinking/smoking

To say a person has drinking/smoking

behavior
Duration –is it for a week/month?
Frequency- how it is repeated?
Purpose –is he/she doing consciously or not

48
 Components of Behavior

Basically human behavior has 3 domains;

A) Cognitive domain (knowledge, perception )
 Encodes, stores, retrieves, processes information;
 purpose is manipulation of information

B) Affective domain= cognition +feeling

eg. Attitude, Beliefs
purpose is to create arousal
C) Psychomotor domain - Voluntary muscle
 Psycho-mind , Motor – action

49
 Behavior….

Note:

1. Involuntary (not purposeful) is not behavior

2. Voluntary (purposeful) act is behavior-In health
education we refer only to those voluntary
movements and purposive acts arising out of
decisions taken by the motor center of the brain.
3. The same words ( Behavior=Action= Practice)
50
 Behavior and health
1. Well/healthy behavior can promote health
Healthy behavior is an overt behavioral patterns, actions, and
habits that relate to health maintenance, to health restoration,
and to health improvement
Eg. Physical exercise, BF, seeking
treatment, ………..
Ill/unhealthy behavior harms
health
Smoking, chat chewing, excessive
alcohol consumption, unsafe sex,
sedentary life style etc. 51
Burden: mortality, morbidity and modifiable risk factors

• The world is experiencing a shift in

 cause of ill- health: Bacteria to Behavior
 Risk factors: traditional risk to modern risk
 Disease burden: Communicable disease to
non-communicable –double burden (for
developing countries)

 Human behaviors plays significant role as a cause

as well as a solutions for existing and emerging52
53
According to WHO, 40% of deaths
worldwide are due to these 10 risk
factors alone (behaviors).

Global life expectancy could be increased

by 5-10 years if we reduce these risks.

54
Behaviours important for health promotion are;

Preventive behaviors

Utilization behaviors

Illness behaviors

Compliance behaviors

Rehabilitation behaviors

Community action
55
 Human behaviours important for
health promotion

1) Preventive behaviors
Physical exercise , use of latrine, Child-spacing , proper disposal
of dirty water, Good nutrition, clean storage of food, Breast-
feeding , tooth cleaning, reduction/cessation of unhealthy
practices such as cigarette smoking, and excessive alcohol
consumption

56
2) Utilization behaviours – utilization of health services.
Eg. ANC service, Immunization services, Child-health service
Screening programs, FP service

3) Illness behaviours - recognition of symptoms and

prompt self-referral.
 It is what people do when they feel ill.
 aimed to seek remedy

57
4) Compliance (adherence) – following
course of prescribed medicines

5) Rehabilitation behaviours – what people

need to do after an illness/surgery to recover

A type of behavior that prevent further

disabilities after a serious illness
6) Community action - actions by
communities to change their surroundings
include community participation in health
decision-making
58
 Factors affecting human behavior

Lawrence Green identified three

categories of factors affecting
individual or collective behavior.
These are;

59
 Determinants of human behaviors
Predisposing Knowledge, attitude,
factors perception, beliefs, values,
self efficacy etc.

Cultures/
norms/traditions Behaviors Enabling factors

Availability,
affordability,
accessibility,
Peer pressure, influential
people, perceived social
resources to
pressures/significant Reinforcing accomplish the
others/discouragement/encou factors behaviors
ragement
60
 1. Predisposing factors , inside head factors
 Are antecedents or prior to behavior that provide the
rationale or motivation for the behavior to occur.
• Eg. Knowledge, Perception, Belief , Attitude, Values etc.
• They are generally referred to cognitive variables because
they are inside the mind –inside head factors and have to do
with knowing or believing
• They are also called psychosocial because they are socially
influenced
61
 Knowledge or awareness

• Knowledge is, “A clear and certain mental perception, understanding,

the fact of being aware of something, experience of acquaintance of
familiarity with information of, learning that which is known, facts
learned or study of.”

• Therefore, one`s knowledge of something include some combination of ;

1. Simple awareness of facts and

2. understanding of how these facts relate to one another.

62
 Knowledge ….

Knowledge is necessary but not sufficient in

behavior change.

It is necessary, because, without adequate

knowledge , people may unaware of and concerned
about health problem and unable to manage their
behavior.
63
 Knowledge…

• Simple logic for the specific knowledge is that before act

voluntarily people need to know,

 Why they should act?

 What actions are needed?
 When or under what circumstances?
 How to act and where?

64
Knowledge about/awareness Vs How-to/ essential knowledge

Knowledge about/awareness: Knowledge about a topic may be

important in developing interest in the topic and may even
motivate the behavior

How-to/ essential knowledge: Intentional behavior change

depends on it
It is practical/applicable

Eg. Knowing about condom, its importance and benefits less

important for behavior change than knowing proper use or how-
to use condom
65
 Knowledge …

• In general, knowledge about a problem is not as

critical to behavior change as knowledge how to
perform about the target behaviors.

• How-to or essential knowledge is the major

components of skill.

• Therefore, one of the main task in health education is

helping the learner to become knowledgeable about
some health topic and how to do th behavior
66
 Perception
Perception: a process by which
individuals organize and interpret
their sensory information in order
to give meaning it.

Perception is a means of
acquiring knowledge.

And it is highly subjective

67
Perception is subjective

68
 Perception is subjective …. And it influences
knowledge

69
 Skills
• Skills is the capability of accomplishing something with
precision and certainty.

• Skills require practical knowledge and ability

• On many occasions inappropriate or ineffective health
behavior may result from the lack of mastery of specific skills.
• Knowledge and skills are interrelated in that skills are the
practical application of essential knowledge
Thus, main of HE task: Improve/enhance skill

70
 Attitude

• Social psychologists define an attitude as an

enduring evaluation, positive or negative, of
people, objects, or ideas.
 We are not neutral observers of the
world; we evaluate what we encounter.

 Attitudes are often a matter of good or bad;

as soon as you know what something is,
you start to know whether you like it or
dislike it.
71
Mucchielli (1970) describes attitude
as “a tendency of mind or of a
relatively constant feeling
towards a certain category of
objects, people, or situation.”

72
 Characteristics of attitude

1) Predisposition- exposure related to an attitudinal

object. No exposure, no attitude
2) Has directions- polar, +ve or -ve, good or bad.
Negative ……………… positive
3) Evaluation-can be evaluated by intensity or
judgment
e.g. Favorable or unfavorable
73
 Attitude….

4) Changeability-can be changed, not static.

5) Stability or consistency
 Stability=related to time , constant over sometime
 Consistency= sameness of attitude

e.g. “Mood” changed quite often.

74
Link between knowledge(K) and Attitude (A)

Feeling/sense of
Knowledge Attitude
like or dislike

75
Link between knowledge(K) and Attitude (A)
…

• With the knowledge or information that we

have on things, the mind is able to develop a
sense of like or dislike, positiveness or
negativeness/feeling.

• It is thus, the feeling component is added to

76
 Link among knowledge(K) and Attitude (A) and
Practice (P)

Knowledge Attitude Practice

77
 Link among knowledge(K) and Attitude (A) and Practice (P)

The general trend or normal way of thinking and acting the

proper sequence and linkage among KAP is that knowledge (K)
is followed by attitude (A) and is followed by practice (P).
 But this rule is not universally applicable to every behavior
i.e. different possibilities and combinations can come across
with regard to KAP.
When P or A precedes K, it is due either to an imitation
(modeling) or compulsion
78
 Attitude measurement

Self-reported attitudes- asked direct questions about their

feelings.

The Likert Scale –is one the mostly commonly used scale to
measure attitude.
In likert scale, respondents are asked how strongly they agree
or disagree with carefully selected statements on five point
scale.
Attitude scale is usually stated in form of statement.
Eg. Contraception improves family well being.
1. Strongly disagree 2. disagree 3. undecided 4. agree 5.strongly agree
79
 strong opinion

Belief
• Beliefs are what one perceive as a true; it
may be correct or not.
• It also refers to a conviction- that a
phenomenon or object is true or real.
• It is different from knowledge in that it is
perceived whereas knowledge is
accepted objective truth. 80
 Belief…

• Beliefs are derived from parents, grand

parents, and other people we respect to
listen and are accepted as true.
• But we accept beliefs without trying to
prove that they are true or false.

81
 Difficulty index of changing beliefs

It is usually difficult to change those beliefs

that
• are held by the whole community
• Have been deep rooted in the culture
• Come from highly respected and trusted
sources
• Are part of the a religion or traditional
82
Relationship between beliefs and
attitudes

Attitude

Beliefs
83
 Beliefs Vs attitude ….

• Our beliefs about things affect our attitude towards

it.

• Our beliefs, in turn, are influenced by our attitudes.

• The judgment as good or bad and worth carrying out

a behavior will depend on the beliefs about the
consequences of performing the behavior.

84
 Beliefs Vs attitude ….

• If an individual beliefs the behaviors have good

outcomes (positive beliefs)…………………… +ve
attitude

• If an individual beliefs the behaviors have bad

outcomes (negative beliefs)…………………… -ve
attitude 85
 Value

• The relative worthy/preference/judgment individual

gives every thing around is known as value.
• value is something held to be important or worth;
and prized by an individuals or community.

86
 Examples of characteristics that can be valued by the
communities

• Being a good mother

• having many children/cattle Value exert strong
and enduring
• Being approved by friends
influence on
• masculinity and sexual prowess behaviors. It provides
• Being attractive to opposite sex general guides to
behaviors.
• Having beautiful girl friend
• academically success

• Being a man of God /Allah, success in foot ball events , being ‘modern’

* being healthy
87
These values that have
advantages for the self and for the
society are known as positive
values.
And these values that are harmful
and disadvantageous are known as
negative values.
88
 Difficult index;
In terms of difficulty of changing: KBAV

Knowledge < Beliefs < Attitude < Value

89
 2. Enabling factors

• Enabling factors are those antecedents to behavior

that facilitate a motivation to be realized.
• They help individuals to choose, decide and adopt
behaviors and may be barriers and assets to needed
changes.
• The absence of enabling conditions inhibits action.

90
 Enabling ….

• Sometimes a person may intend to perform but still

not do so. This is because of the influence of
enabling factors such as time, money, equipment,
skills and health services.

91
They includes
Availability, accessibility and affordability
health care
New skills
Resources. Eg. Time, money, transportation
etc.

1. What is enabling factors to prepare home made ORS?

2. What are the enabling factors to promote condom use?
3. What are enabling factors to promote quitting of smoking ?

92
Note: Behaviors which involve spending much
time, money, requiring new skills or conflict
with existing practices will be more difficult to
promote than those which are simple to carry
out or fit with the existing practices.

93
 Enabling …

 In behavior change communication be sure that

enabling resources are readily available in the
community of interest.

94
 3.Reinforcing factors

• Reinforcing factors are those factors subsequent to a

behavior that provide the continuing reward or
incentives for the behavior to be persistent and
repeated.
• positive or negative feedback and is support socially
or by significant others after it occur.

95
 Significant others (influential people)

• These are people who are significant (determine or

influence) the behavior of others to encourage or
discourage to do something.
Eg.
– The woman does not adopt FP because her
husband disapproves.
– The young man who starts smoking because his
friends encourage him to do so.

96
 Friends Traditional
healers

Grand Religious
parents leaders

Husband

I want to use FP,

but…
The influence of social pressure (circle of influence)

97
 Summary of factors affect human behaviors

Predisposing factors
create intention to act

Realizes the
Enabling factors
intentions

Encourage behaviors to
Reinforcing factors persist

Sustainable behavior

Remember: Any given behavior can be explained as a function of the

collective influence of these three factors 98
 Theoretical sequence to address
determinants of behaviors

Enabling
• Knowledge,
factors • Peer Behaviors
attitude, • Availability, influence &
beliefs, affordability, social
values accessibility & pressure
others
Predisposing resources Reinforcing
factors factors

In practice simultaneously
99
 Educational approaches to behavior change

Determinants • Approaches to change

of behaviors
•Direct communication with target individuals-
Predisposing factors educational approaches

• Organization change, avail services,

Enabling factors accessibility, advocacy , resource mobilization

• In direct communication with the social

Reinforcing factors environments , influential peoples

100
Our behavior changes all the time, some are natural while
others are planned changes.

• Natural changes: When changes occur because of natural

events in the community around us, we often change with out
Changes of Behavior
thinking much about it (unintentional change).

• Planned changes: When changes occur deliberately and/or

planned. E.g. quitting smoking (intentional change).

101
 Behavior change approaches
• The persuasion approach-the deliberate attempt to influence
the other person to do what we want them to do. ‘directive’ /
forcefully/coercion.

• Used in situations where there is serious treat such as

epidemics and natural disasters, and the actions needed are
clear-cut.

• The informed decision making approach- giving people

information, problem-solving and decision-making skills to
make decision but leaving the actual choice to the person
(open or ‘non-judgmental’ approach)-empowerment.

102
 Health education in level of disease prevention

• Health education can help at various

levels.

1. Primary prevention: Is the

optional point for education.
• This an education to prevent the
development of specific illness

• Health education plays

103
significant role-preventive
 2. Secondary prevention

 Once the disease occurred health education is

important to slow down the disease progression to
prevent the onset of disability.

Health education plays significant role-

appropriate illness behaviors/ early
treatment seeking, compliance behaviors

104
 3. Tertiary prevention

• At some point the disease seriously affects

the patients’ quality of life leading to
limitations in morbidity, changes in role
functioning and reduced social interactions

• Patient education efforts to avoid or lessen

major disability, lose of important roles,
premature death are classically termed as
tertiary prevention.
• Health education to promote
rehabilitative behaviors 105
 Health education is important at all levels

Role of Brs
Prevention
prevention

Healthy
behaviors
10
Decreasing health status

Early detection
prevention
20

Medication
usage & self
Mgt
prevention
30

Death
Time

106
Opportunities for prevention : source based on Kaplan
 Further reading materials

1. Lawrence W. Green et al. 1980. Health

education planning a diagnostic approach

2. Randall R. Cottrell, James T. Girvan, James F.

McKenzie 2006. Principles& foundations of
health promotion and education. Third ed.
USA.

3. BruceG, Wlter H, Nell H. Introduction to Health

education and Health promotion;2nd edition,
1984
4. Ramachandran L. and Dharmalingam. T. 1995. Health
education’s new approach. 107
 .

Thank you

108
MODULE 3: THEORIES AND MODELS IN HEALTH
EDUCATION &PROMOTION

109
 Learning objectives
After this lecture session students will be able to

• Define some terms related to theories of HE/HP.

• Describe the importance of theories/models
• Differentiate different classes of
theories/models
• Illuminate a glimpse of some theories in HE/HP
• Discuss how to select appropriate model
110
Diagrammatic representation (model) to PIE Health promotion

Public
Health Predisposing

Health
education
Behavior
Reinforcing
Quality
Health of life
Policy
regulation
organization Environment
Enabling

111
 Defining theory & model
Theory
 It is a set of interrelated concepts, definitions,
propositions that explain or predict events or
situations by illustrating the relationships
between variables. OR

 Is “A systematic explanation for the observations that

relate to a particular aspect of life. E.g screening serv. use

112
 …definitions
Concepts (preposition, definition)
are the building blocks—the primary elements—of a theory.
(generalized notion related to aspect of a phenomenon) e.g
personalized risk motivate beneficial action
Constructs/dimensions :
are concepts developed or adopted for use in a particular
theory. The key concepts of a given theory.
Variables (ensure empiricism):
 are the operational forms of constructs.
They define the way a construct is to be measured in a specific
situation.
113
 Variables: e.g HIV testing (perc.
susceptibility)
Perceived susceptibility: (Likert 5 point scale)
• i) A person may get infected with HIV in one or the other way. I
might have been infected with HIV/AIDS in some way.
• ii) My sexual behavior is safe and didn’t expose me to HIV/AIDS.
• iii) Lack of faithfulness of one’s sexual partner may expose to
HIV. I might have been susceptible to HIV due to lack of my
partner’s unfaithfulness.
• iv) I will not be infected with HIV come whatever. (etc)
• Note: a composite (latent) variable will construct from the
summation of these variables/items (score out of; 4 items *1-
5=4-20 score of perceived susceptibility)

114
 …definitions
Model:
May draw on a number of theories to help understand a
particular problem in a certain setting or context.
 Semantic/diagramatic representation of a phenomenon.
 it results from an effort to best represent or explain a
specific problem by 100 %.
At least a model should explain in part (50%).

Limitation is inevitable because of uncountable specific

problems we have.
There is no perfect model
115
 …defining
Conceptual framework
• Many theories 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.

116
 Fundamental features: Theories;

Become useful when filled with practical topics &

goals; otherwise are empty shapes with nothing
inside.
• Are dynamic; no theory is full for every situation,
setting or every case -testable
• Have different paradigms; out look on the same
issue
• Have multiple functions as predicting, spelling
points in establishing interventions, etc
117
Basic purpose of theory e.g for H/behavior

1. Describe-the behavior (what)

2. Explain- the causes of behavior (why)
3. Predict-predict the behavior(when)
4. Control/change-then we change the
behavior(how) 118
 Importance/strength of theories

i) Furnishing with outlooks at various stages of PIE

SMART perspective: a predetermined priority population
has to be segmented b/c we must satisfy the needs &
wants of each.
 MATCH: it is ecological planning perspective at many levels
PRECEDE-PROCEED: a series of logical steps for planning
ii) Help pinpoint what planners need to know before they
develop programs (to be sure for why it works well). E.g;
 indv.+ community + orgs. +policy=multilevel (?); any else?
– P+R+E=behavior (?) Can we consider any 4th dimension

119
 …Strengths & importance of theories

iii) Help explain why problems happen (explanatory

theories): e.g: find best predictor of adherence to ART.

iv) Guide dev’t of H/intervention (change theories)

 It suggests how to devise program strategies that reach
target audiences and have an impact on whole.
e.g: how we should do to innovation. PPM,DOI
 MATCH: leveled interv. for one goal (individual, org, gov’t.)
 CDCynergy: what are all possible interventions for each one
of the problem lists I want to address?

120
 Importance of theories/models in HE& HP

1. Guide the practice of health education at various Stages

2.Provides a platform for understanding why people engage in health

compromising behaviors and how People adopt health protective
behaviors

3.Help to organize our thinking about a given health problem & human
behaviors related to it. E.g: MATCH vs. PPM
In so doing
 Prevent the planner from overlooking important factors.
 Help to set priorities for health education interventions
121
Classification of theories & models
• Planning models (change/action theories)
 are theories of planning, implementation &
evaluation
– PPM, SMART, CDCynergy, PATCH, MATCH, Generalized model
of planning etc (Read them)
• Are change theories (action theory)
• Behavior change theories/models
– explanatory theory (theory of problem)
• Specify real causes of some behavior
– explicate conditions for or why the priority b/r
changes
122
– Can be continuum: relation of variable in predictive ways
 …continuum theories
• Behavior is treated as an External variables Beliefs that the

event to be predicted. Demographic

behaviour leads to
certain outcomes
Attitudes towards
variables
• constructs mix, in some
the behaviour
Age, sex, occupation
socio-economic Evaluation of the
status, religion, outcomes
way, to predict behavior. education.
Relative
Attitudes towards importance of
• They usually model targets
Attitude towards
attitudinal and
normative
components
structure for behavior
people
Attitudes towards Beliefs that specific
institutions referents think I
should not perform Intention Behaviour
the behaviour
Personality traits
Introversion- Subjective norm
• E.g HBM, TRA etc extraversion
Neuroticism
Authoritarianism
Motivation to
comply with the
specific referents.
Dominance

Possible explanations for observed relations between external variables and behaviour.
Stable theoretical relations linking beliefs to behaviour.

123
 …stage of change theories

• View behavior as habitual pattern that requires

gradual development rather than event
happening without process (e.g: TTM..1979)…
addictive b/rs
OR
• As an event requiring deliberate steps under
individual conscious awareness (e.g: PAPM-
Weinstein -1992)

• Stage theories model the necessary stages & 124

 Stages implication in theories
Stages imply:
 There are ordered set of categories into which people with in
priority population can be classified
 The movement from one categories to the other can be
induced via some sort of factor/intervention considering:
 common barrier facing people in the same stage
 different barriers facing people in different stages
NB: One can imagine that these factors will act as processes to
go up this stances.

 Remember: educational specificity (principle of HE)

125
 …Classification
Ecological Perspective in behavior change
theories:
It highlights people’s interactions with their
physical, socio-cultural & political environments.
H/behaviors embrace multiple levels of influence
Emphasizes the interaction between and
interdependence of factors within and across all
levels of a health problem.
It shows the advantages of multilevel
interventions that combine behavioral and 126
 …classification
Ecological perspective (Glanz & Rimer, 1995)
Depending on levels of influence
• Intrapersonal –individual factors theories
• interpersonal- micro social factors theories
• institutional/organizational e.g PPM, DOI
• community; E.g PATCH community
theory
• public policy e.g MATCH, Policy dev’t
127
A glimpse of theories for this class
• Intrapersonal (inside the head constructs)
Health Belief Model (HBM)
Theory of Planned Behavior (TPB)
Trans theoretical Model (TTM)
 Interpersonal (inside the head + immediate
env’t)
Social cognitive theory (SCT)-reading assignment
• Community (inside the head + broader env’t)
Diffusion Of Innovation (DOI)
128
 The Health belief Model (HBM)…model 1

• The HBM was developed initially in the 1950s in

the U.S. PHS to explain the widespread failure of
people to participate in programs to prevent and
detect disease (Hochbaum 1958, Rosenstock &
Becker, 1960/74).

• HBM hypothesizes that health related action

depends on simultaneously occurrence of three
classes of factors
– Health motivation (concerns that make health issue129
 …HBM constructs
The HBM contains primary concepts that predict
why people will take action to prevent, to screen for,
or to control illness conditions
 Perceived susceptibility
 perceived severity
 perceived benefits
 perceived barriers
 Cues to action
 Self efficacy
The constructs are summarized under in table.
130
 Key Concepts and Definitions of the HBM
Constructs Definitions Application

Perceived Belief about the Define population(s) at risk, risk levels

susceptibility chances of
experiencing a risk or Personalize risk based on a person’s
getting a condition characteristics or behavior

Make perceived susceptibility more

consistent with individual’s actual risk

Perceived Belief about how Specify consequences of risks

severity serious a condition and conditions
and its sequelae are

Perceived Belief in efficacy of the Define action to take: how,

benefits advised action to where, when; clarify the
reduce risk or positive effects to be expected
seriousness of impact

131
 …Constructs and Definitions of the HBM
Constructs Definitions Application
Perceived Belief about the Identify and reduce perceived barriers
barriers tangible and through reassurance, correction of
psychological costs of misinformation, incentive
the advised action

Cues to Strategies to activate Provide how-to information,

action “readiness” promote awareness,
use appropriate reminder systems

Self efficacy Confidence in one’s •Provide training and guidance in

ability to take action performing recommended action
•Use progressive goal setting
•Give verbal reinforcement
•Demonstrate desired behaviors
•Reduce anxiety

132
 The Health Belief Model
INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION

Demographic Variables Perceived benefits of

(age, sex, race, ethnicity, etc) preventative action
Minus
Sociopsychological variables
Perceived barriers to
preventative action

Perceived susceptibility Perceived Threat of Disease

to Disease “X” Likelihood of Taking
“X” Recommended
Perceived Seriousness Preventative Health
(Severity) of Disease “X” Action
Cues to Action
Mass Media Campaigns
Advice from others
Reminder postcards from physician
or dentist
Illness of family member or friend
Newspaper or magazine
article
Health Education Quarterly (Spring 1984) 133
 Theory of planned behavior (TPB)
…CON’T (THEORY 2)
Developed by: Fishbein & Ajzen (1970s)

…intention predicts a behavior…

134
 …TPB

• Developed by Fishbein & Ajzen in 1970’s.

• Basically rooted in cognitivism theory in which
 Human beings are usually very rational & make
systematic decisions based on available information.
 However, it is not always true that behaviors are
under volitional control

 TPB is concerned with individual motivational factors as

determinants of the likelihood of performing a specific
behavior.
135
 …constructs of TPB
• TPB assumes the best predictor of a behavior is
behavioral intention.
e.g: How can we motivate women to seek ANC, ID
when they become pregnant
• Behavioral intention (BI): is subjective perception &
report of the probability that one will perform the b/r.
 it is a readiness to engage on action

• NB: There are different levels of intention for different actions in

different Context & time.
136
 …Constructs of TPB
• TPB asserts, direct determinants of individuals’
behavioral intention are their
– Attitude toward performing the behavior (AB),
– subjective norm associated with the b/r. &
– perceived control over the behavior/PBC
• E.g institutional delivery for pregnant women in rural
areas.
– perceived level of the existence of different facilitators or
inhibitors of ID?

137
 …TPB
• Attitude towards the behavior (AB): belief of the
outcomes/attributes of a b/r (BB) weighted by
evaluations of each attribute (EB).
• Subjective Norm (SN): individuals belief of
whether important referent others
approve/disapprove (NB) weighted by motivation
to comply those referents (MC)
• Perceived behavioral control (PBC): determined
by
• perception of presence/absence of facilitators/
138
inhibitors to perform the b/r (CB) weighted by
 TPB frame work
External variables Beliefs that the
behaviour leads to
Demographic certain outcomes
Attitudes towards
variables the behaviour
Age, sex, occupation
socio-economic Evaluation of the
status, religion, outcomes
education.

Attitudes towards
targets Beliefs that specific
Attitude towards referents think I
people should not perform Intention
Behaviour
Attitudes towards the behaviour
institutions
Motivation to Subjective norm
Personality traits comply with the
Introversion- specific referents.
extraversion
Neuroticism Control beliefs
Authoritarianism Perceived
Dominance perceived Power of Behavioral control
the control

Possible explanations for observed relations between external variables and behaviour.
Stable theoretical relations linking beliefs to behaviour.
139
 Transtheoretical model (TTM)
…CONT (MODEL
developed by: 3) (1979)
Prochaska & Diclimente

…change is a process with stages not just an event…

140
 …TTM
• Developed in 1979 by Prochaska and Diclemente.

• It emerged from review of 300 therapy

outcomes (prochaska,1984).
• It evolved out of studies comparing the
experiences of smokers who quit on their own
with those of smokers receiving professional
treatment.

141
 …TTM
The model’s basic premise is that behavior
change is a process that unfolds over time, not
an event.
• It is one among stage theories.

• It uses stages of change to integrate processes

and principles of change from across major
theories of intervention.

142
 Core Constructs of TTM:
• Stages of Change: temporal dimension

• Processes of Change: covert/experiential and overt/

behavioral activities people use to progress through the
stages.

• Decisional Balance: weighing pros and cons of changing.

• Self-Efficacy: temptation & confidence

143
 C1.Stages of Change Model
Precontemplation
Awareness of need to change

Contemplation
Increasing the Pros for
Change and decreasing the
Cons

Preparation
Commitment &
Planning
Relapse and
Recycling
Maintenance
Action
Integrating Change
Implementing and
into Lifestyle
Revising the Plan

Termination 144
 …stages of change model
Stage Definition Potential change strategies
Precontemplation Has no intention of taking action within Increase awareness of need
the next six months for change; personalize
information about risks and
benefits.

Contemplation Intends to take action in the next six Motivate; encourage making
months specific plans

Préparation Intends to take action within the next Assist with developing and
30 days and has taken some behavioral implementing concrete
steps in this direction action plans; help set gradual
goals

Action Has changed behavior for less than six Assist with feedback,
months problem solving, social
support, and reinforcement

Maintenance Has changed behavior for more than six Assist with coping reminders,
months finding alternatives, avoiding
slips/relapses (as applicable)
145
 C2:Processes of change; the steps
• Processes of change are the covert experiences and overt
activities people use to progress through stages.

• Processes of change provide important guides for

intervention programs;

• Processes are like independent variables that people

need to apply to move from stage to stage.Stages
of Change in Which Change Processes Are Most Empha
...
146
 …Experiential Processes of Change

Consciousness Raising: Gaining information increasing

awareness about the current habitual or new behavior
Emotional Arousal/Dramatic relief: Experiencing emotional
reactions about the status quo and/or the new behavior
Self –Revaluation: Seeing when and how the status quo or the
new behavior fit in with or conflict with personal values
Environmental Reevaluation: Recognizing the effects the
status quo or new behavior have upon others and the
environment

Social Liberation: Noticing and increasing social alternatives and

norms that help support change in the status quo and/or initiation
of the new behavior
147
 … Behavioral Processes of Change
Self Liberation: Accepting responsibility for and committing to
make a behavior change
Stimulus Control: Creating, altering or avoiding cues/stimuli that
trigger or encourage a particular behavior
Counter-Conditioning: Substituting new, competing behaviors
and activities for the “old” behaviors
Reinforcement Management: Rewarding sought after new
behaviors while extinguishing (eliminating reinforcements) from
the status quo behavior
Helping Relationships: Seeking and Receiving support from
others (family, friends, peers)

148
 Stages of Change in Which Change Processes
Are Most Emphasized
Stages of Change
Precontemplati Contemplation Preparatio Action Maintenanc
on n e
Consciousness Raising
Dramatic relief
Environmental
reevaluation
Self-
reevaluation
Self-
liberation
Reinforcement
Management
Helping relationships
149 Counter conditioning
 C3-4 .DB & SE
• Ambivalence is a normal part of the process of change.

• Decisional balance is a balance between

– Pros= benefits of changing (New>old)
– Cons= costs of changing (<=)
• Self efficacy
 Is the confidence people have to cope with high-risk
situations such as (emotional distress, positive social
occasions & Cravings)
• These two are markers of change
150
 Theoretical and practical considerations related
to movement through the Stages of Change

Motivation Decision-Making Self-efficacy

Precontemplation Contemplation Preparation Action Maintenance

Personal Environmental Decisional Cognitive Behavioral

Concerns Pressure Balance Experiential Processes
(Pros & Cons) Processes

Recycling Relapse
.

151
 Summary of TTM constructs in use
• The TTM has general implications for all aspects of
intervention development and implementation.
• Five areas:
• Recruitment- stages for all recruitment (rate)
• Retention: matched intervention that respond to
need
• progress: cognitive & behavioral progress
• Process: different interventions through stages
• outcome: ~ impact= reach × efficacy
152
 ….summary
• Outcome is not only efficacy ( % of participants
who are engaged on action) rather impact (what
contribution in general priority population
• outcome/impact = recruitment rate * efficacy
• For high outcome we expect high recruitment
rate via various campaigns (reactive) + proactive
(interest)
• Exercise Quest: Assume that the efficacy of some intervention
resulted to 50% change in behavior you want to change, to produce 40%
contribution in adaption of the health behavior to the total priority population
in six months time period as an outcome, what should be your average 153
recruitment rate at all stages as a whole in your interventions and interpret
How individuals, behavior & environment interact:

Social cognitive theory

(Rotter & Bandura, 1954/86)

154
 SCT
• Developed by Rotter as SLT (1954)
• SLT was basically rooted in observational learning &
SR theory- the role of reinforcement in shaping
behavior (role of environment)
• Extended by Albert Bandura into SCT (1986), added
– the role of cognitivism: value-expectancy theory
– personal qualities: self efficacy, goal setting, self
control, coping

155
 …SCT

Unlike intrapersonal theories, social cognitive

theory gives due attention to the external
environment which can punish or reward the
behaviors .

In addition, it gives due attention to human

minds & qualities such as expectation, values,
confidence and self-control. 156
 …SCT

Bandura stated that there are three factors that

interact dynamically to determine human
behavior. These factors are;

1. Environmental influence: there are three major

processes by which the environment exert its
influences on behaviors, namely

157
1a)The opportunity it provides for observation
learning/modeling the behaviors after that of the other
person (observational learning)…role compulsion.

1b) The vicarious reinforcement it provides- reinforcement

occurs for the behaviors that an individuals has observed
but not yet expressed. (indirect reinforcement-IDR)

1c)The reinforcement/inhibition of behavior resulting from

the consequences for particular action (Direct Reinf’t)
158
 …SCT
2. Personal factors: mainly related to prior
history in the form of knowledge and attitude
pertaining to the issue at hand, plus
demographic, economic status etc.
(cognitive+ physical person)

3. Behavioral factors: mainly related to

individuals ability to exert self control as they
determine their response to the situation. It
includes factors such as self efficacy,
anxiety/emotions coping, goal setting etc
159
• Therefore, behaviors is explained in terms of a
triadic, dynamic, and reciprocal model in which
behavior, personal factors, and environmental
influences all interact (Triadic).

• SCT emphasizes reciprocal determinism in the

interaction between people and their environments:

160
 Main constructs of SCT
• Behavioral capability: Knowledge and skill to perform a
given behavior; (promote mastery learning through
skills training)

• Expectations: Anticipatory outcomes of a behavior;

(Model positive outcomes of healthful behavior)

• Expectancies: The values that the person places on a

given outcome, incentives; (Present outcomes of
change that have functional meaning)
161
 …SCT constructs
• Reciprocal determinism: The dynamic interaction
of the person, the behavior, and the environment
in which the behavior is performed; (consider
multiple avenues to behavioral change, including
environmental, skill, and personal change)

162
 …SCT constructs
• Observational learning: Behavioral acquisition that
occurs by watching the actions and outcomes of
others’ behavior; (Include credible role models of the
targeted behavior)
– attention, retention, production & motivation
• Reinforcements: Responses to a person’s behavior
that increase or decrease the likelihood of
reoccurrence; (Promote self-initiated rewards,
vicarious and incentives)
• Vicarious, Self, &Direct
163
 …SCT constructs
• Self-control: Personal regulation of goal-directed
behavior or performance; (Provide opportunities
for self-monitoring, goal setting, problem solving,
and self-reward)

Emotional coping responses: Strategies or tactics

that are used by a person to deal with emotional
stimuli; provide training in problem solving and
stress management
164
 …SCT
Self-efficacy: The person’s confidence in
performing a particular behavior;
Approach behavioral change in small steps to
ensure success (Goal setting)
 self efficacy increases through:
 through performance (personal mastery of task)
 through vicarious experience (observing others
performance e.g use ordinary person
performance)
 verbal persuasion (receiving suggestions from 165
 Model 4: Summary of the main
constructs of SCT
Concept Definition Application

Reciprocal Determinism Behavior changes result from Involve the individual and relevant others;
interaction between person work to change the environment, if
and environment; change is warranted
bi-directional

Behavioral Capability Knowledge and skills to Provide information and training about
influence behavior action

Expectations Beliefs about likely results Incorporate information about likely results
of action of action in advice

Self-Efficacy Confidence in ability to take Point out strengths; use persuasion

and
action and persist in action encouragement; approach behavior
change in small steps

Observational Learning Beliefs based on observing Point out others’ experience, physical
others like self and/or visible changes; identify role models to emulate
physical results

Reinforcement Responses to a person’s Provide incentives, rewards, praise;

behavior that increase or encourage self-reward; decrease
decrease the chances of possibility of negative responses that
recurrence deter positive changes

166
 …SCT
The concepts of SCT are most often used as in
designing HP interventions
SCT emphasizes the capacity for collective
action in addition to individual action.
This enables individuals to work together in
organizations and social systems to achieve
environmental changes that benefit the entire
group. (e.g look cancer risk reduction below)

167
 Example: cancer risk reduction b/r
• In a certain area HP planner looks at many risks
to cancer & develops a religious center-based
intervention to help congregation members
change their habits to meet cancer risk reduction
guidelines (behavior).

• Many members of the religious center have low

incomes, are overweight, rarely exercise, eat
foods that are high in sugar and fat, and are
uninsured (personal factors). 168
 …example
• The program offers classes that teach healthy
cooking and exercise skills (behavioral
capability).
• Participants learn how eating a healthy diet and
exercising will benefit them (expectations).
• Health advisors create contracts with
participants, setting incremental goals (self-
efficacy).
• Respected congregation members serve as role
models (observational learning). 169
 …example
• Participants receive T-shirts, recipe books, and
other incentives (reinforcement).
• As church members learn about healthy
lifestyles, they bring healthier foods to
church, reinforcing their healthy habits
(reciprocal determinism).

170
 …SCT
Applicable complex behavior & lifestyle
changes

• Try SCT in chat chewing

• regular exercise
• Alcohol
• diet modification

171
DIFFUSION OF INNOVATION THEORY (DOI)
…CON’T MODEL 5
developed by: Everett. M. Rogers, 1962/2005)

….How to deal with social systems in communicating a new product to

target audiences…
172
 Theory of Diffusion of Innovation (DOI)

 It is one of the community models

 Developed by Everett M. Rogers

(1962,1983,1995, 2003, 2005)
 Diffusion of innovation theory is a theoretical
approach which provides an explanation of how
innovation, or ideas perceived as new are
communicated (diffused) through channels
among the members of the social system.
173
 …CONT

 Diffusion is the process by which an innovation is

communicated through certain channels over time
among the members of a social system (Rogers, 2003).
 A key premise of the Diffusion of Innovations model is;
some innovations diffuse quickly and widely,
whereas others are weakly or never adopted,
and others are adopted but subsequently abandoned.
innovations are adopted by different individuals and
spread at different rates in subgroups of individuals.

174
Elements in the diffusion of innovation

 There are four main elements in the

diffusion of new ideas:
1. The innovation
2. Communication channels
3. The social system
4. Time

175
 Elements…
1. Innovation: An idea, practice, or object
that is perceived as new by an individual or
other unit of adoption
2. Communication Channels: Means by
which messages about innovation spread;
mass media, interpersonal, electronic
communications.
3. Social System: structures, norms & leadership that
provides boundary within which innovation diffuses.
4.Time dimension: involved in three ways;
adoption process, innovativeness & rate of 176
 Important factors in the diffusion
process

• There are three groups of variables which

can affect the diffusion process; namely;

1. Characteristics of the innovation

2. Characteristics of adopters, and
3. Features of the setting or environmental
context.

177
 1. Characteristics of the Innovation

 Rogers has comprehensively reviewed the

attributes or characteristics of innovations
most likely to affect the speed and extent
of the adoption and diffusion process
They include;
1) Relative advantage
2) Compatibility
3) Complexity
4) Trialability and
5) Observability
178
Characteristics of innovations
that affect diffusion

179
 2. Characteristics of Individuals

There are five segments (adopter categories) in

the diffusion process based on the amount of
time it takes to adopt an innovation. These are;
1. Innovators
2. early adopters
3. early majority
4. late majority and
5. laggards
Rogers (2003) defined the adopter categories as
“the classifications of members of a social system
on the basis of innovativeness”
180
 …CONT

• Rogers (1995, 2003) described the process

of innovation adoption by individuals as a
normal, bell-shaped distribution

181
 How to work with each category
Adopter How to work with them
categories
Innovators  Track them down and become their “first followers
 Providing support and publicity for their ideas.
 Invite keen innovators to be partners
early  Offer strong face-to-face support
adopters  make the idea more convenient, low cost and marketable.
 Promote them as fashion leaders
 Recruit and train some as peer educators.
 Maintain relationships with regular feedback.
early  Use credible, respected, similar folks.
majority  Lower the entry cost and guarantees performance.
 Redesign to maximize ease and simplicity.
 Simplify application forms and instructions.
 Provide strong customer service and support.
late  Focus on promoting social norms rather than just product benefits
majority  Keep refining the product to increase convenience and reduce costs.
and  Emphasize the risks of being left behind.
 Respond to criticisms from laggards.
laggards  Give them high levels of personal control over when, where, how and whether they do the new
behavior.
 Maximize their familiarity with new products or behaviors. 182
 Let them see exactly how other laggards have successfully adopted the innovation.
 Innovation-Decision Process (ID)

Rogers described the innovation-decision process

“an information-seeking and information-processing
activity, where an individual is motivated to reduce
uncertainty about the advantages and
disadvantages of an innovation”
For Rogers (2003),the ID process involves five steps:
1. Knowledge
2. Persuasion
3. Decision
4. implementation, and
5. confirmation.
183
Innovation-Decision Process/Stages of adoption

Aware Knowled
ness ge
Interes Persuasi
t on
Evaluat
Decision
ion
Implement
Trial ation

Adopti Confirma
on tion
184
 3. The role of settings and context in diffusion

• not just only static features of the innovation or of the

adopters affect diffusion of innovation.
• Rather, there is usually a dynamic interaction among
features of the innovation, intended adopters, and
the context or setting where the process is occurring.
• These contexts include; workplaces, schools or other
organizations
• Communication channels, norm/system of the
env’t…..(SMART perspective)

185
 Diffusion Model
Source: “Communication and Community Development for
Health Information: Constructs and Models for Evaluation” by
John E. Bowes, Review prepared for the National Network of
PRIOR
Libraries of Medicine, Pacific Northwest Region, Seattle,
CONDITIONS
December 1997. [email protected]
1. Previous practice
2.Felt needs/problems
3.Innovativeness
4.Norms of the social COMMUNICATION CHANNELS
systems

I. KNOWLEDGE II. PERSUASION III. DECISION IV. IMPLEMENTATION V. CONFIRMATION

Characteristics of
the Decision- Perceived Characteristics
Making Unit: of the Innovation 1. Adoption Continued Adoption
1. Socioeconomic 1. Relative Advantage Later Adoption
characteristics 2. Compatibility
2. Personality 3. Complexity
4. Trialability Discontinuance
variables
5. Observability 2. Rejection Continued Rejection
3. Communication
behavior
186
 limitations of theories for H/Br change

Many theoretical frameworks fail to accurately

address complexity of human health behaviors.
Localized (affluent society); requires testing &
retesting
Theories currently in vogue (popular) fall short in
their ability to accurately predict or explain much
of the variance of health behavior.
Lack of description of relationship among
variables in the theories
Poorly operationalized constructs & valid 187
 Fitting theories to the field of practice

• “There is nothing so useful as a good

theory”(Lewin,1935)
• No single theory dominates health education and
promotion, nor should it.
– Different levels of behavior influences.
– different perspectives
• Adequately addressing an issue may require more than
one theory, and no one theory is suitable for all cases.
• Selecting an appropriate theory or combination of
theories helps take into account the multiple factors
that influence health behaviors. 188
 …fitting theories
• Choosing a theory does not begin with just a
theory (e.g., the most familiar theories).
• Instead, the process starts with a thorough
assessment of the situation:
• the units of analysis or change, (indiv, org?
• the topic,
• the type of behavior to be addressed.
• Selecting a theory that “fits” should be a careful,
deliberate process based on situations.
189
 …fitting/applying…for selection
A Good Fit: Characteristics of a Useful Theory
A useful theory makes assumptions:

Logical (in terms of levels of influence, purpose)

Consistent with everyday observations;
Similar to those used in previous successful
programs; and
Supported by past research in the same area or
related ideas.
190
 …Suggestions for applying/fitting theories

1. Have a good grasp of various theories (old/new)

2. examine applicability to problem being
addressed (consider goal of a program with
levels of influence)
3. Look for evidence that which will work best in
your particular situation.
 Seldom does a single theory address all the
complexity of a problem ( Integrate theories)???
4. Final step is choosing theory that makes sense to
you given that all the theories are possible to 191
 References
• Glanz.k, Rimer.B, Health behavior & health
education. Theory, research & practice. 4th
edition.2005
• Theory at a glance. A guide to health
promotion practice. 2nd edition, U.S. National
institute of cancer.
• James Mckenzie. PIE of HP programs.4th
edition.2005

192