Core Area Chapters

The social and behavioral sciences in public health address the behavioral, social, and cultural
factors related to individual and population health and to health disparities over the life course.
Research and practice in this area contributes to the development, administration, and
evaluation of programs and policies in public health and health services to promote and sustain
healthy environments and healthy lives for individuals and populations.

Competencies: Upon graduation, a student with an MPH should be able to…

1. Identify basic theories, concepts, and models from a range of social and behavioral
disciplines that are used in public health research and practice.

2. Identify the causes of social and behavioral factors that affect the health of individuals and
populations.

3. Identify individual, organizational, and community concerns, assets, resources, and deficits
for social and behavioral science interventions.

4. Identify critical stakeholders for the planning, implementation, and evaluation of public
health programs, policies, and interventions.

5. Describe steps and procedures for the planning, implementation, and evaluation of public
health programs, policies, and interventions.

6. Describe the role of social and community factors in both the onset and solution of public
health problems.

7. Describe the merits of social and behavioral science interventions and policies.

8. Apply evidence-based approaches in the development and evaluation of social and

behavioral science interventions.

9. Apply ethical principles to public health program planning, implementation, and

evaluation.

10. Specify multiple targets and levels of intervention for social and behavioral science
programs and policies.
Social and Behavioral Sciences - Overview

Written by: Lisa Ulmer, MSW, ScD, Professor and Chair, Department of Community Health and Prevention,
Drexel University School of Public Health
While the discipline of social and behavioral sciences has made key contributions to major public health
successes in the past century, the high proportion of early and unnecessary deaths caused by
behavioral risk factors highlights the importance of a public health workforce with social and behavioral
competencies to promote health across the lifespan, promote healthy communities, prevent injury,
disease, disability, and death, and eliminate health disparities.

The goal of this chapter is to guide MPH professionals through the process of preparing for the CPH
Examination in the area of social and behavioral sciences. Specific objectives include:

1. To provide an overview of social and behavioral sciences in public health.

2. To outline core principles and methods underlying social and behavioral competencies in
public health.
3. To promote mastery of social and behavioral sciences competencies by applying core
principles and methods to the solution of public health problems.

I. Overview of Social and Behavioral Sciences in Public Health

Over the past century, the global pattern of disease has shifted away from infectious disease towards
chronic disease, with chronic disease now accounting for 60% of deaths worldwide. Heart disease and
stroke are the two leading causes of death worldwide, and 80% of all chronic disease deaths occur in
developing countries. Disparities in chronic disease exist worldwide, with disadvantaged populations
experiencing a disproportionate burden of morbidity, disability, and death. In the United States, chronic
disease now accounts for 70% of deaths, a substantial proportion of morbidity, and more than 75% of
national health care costs.

Behavioral risk factors, including tobacco use, poor diet and physical inactivity, and excess alcohol
consumption, are the major determinants of early and unnecessary death. However, despite evidence
about cost-effective strategies that can modify these risk behaviors, preventable death remains a major
public health challenge of the 21st century, largely due to limited use of a broad, sustained, multi-level
approach directed at individuals, social relationships, and organizational and community environments.

The core area of social and behavioral sciences in public health represents a multidisciplinary approach
to the promotion of health and prevention of disease, drawing from the fields of psychology, sociology,
anthropology, and economics to address not only public health problems with behavioral risks -- chronic
diseases, intentional and unintentional injuries, occupational safety and health, human
immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), sexually transmitted
diseases (STDs), and tuberculosis – but the organizational, community, and societal level determinants
of health, and racial and ethnic approaches for eliminating health disparities.

Understanding and applying core principles from social and behavioral sciences can help public health
practitioners respond to the challenge of preventable death through enhanced understanding of the
social and behavioral determinants of health, theoretically-driven, evidence-based strategies for health
promotion and disease prevention, and rigorous participatory models for program planning and
evaluation.

Core principles and methods underlying the social and behavioral sciences multidisciplinary approach
to public health problem solving are shown below, and are outlined in the following section.

SOCIAL AND BEHAVIORAL SCIENCES IN PUBLIC HEALTH

Domain
Social and Behavioral Determinants of Health
Prevention Theory, Science & Practice
Program Planning and Evaluation
Core Principles and Methods
Leading Causes of Preventable Death
Health Disparities and Inequities
Social and Behavioral Epidemiology
The Social Ecological Model
Theories and Models of Change
Health Promotion and Disease Prevention
Evidence-based Prevention Programs and Policies
Community Health Practice
Ethical Issues in Planning and Evaluation
Planning Models
Evaluation Methods
Scaling Up Programs and Sustainability

II. Core Social and Behavioral Sciences Principles and Methods

Social and Behavioral Determinants of Health

Leading Causes of Preventable Death

The five leading causes of death include heart disease, cancer, stroke, chronic lower respiratory
diseases, and unintentional injuries. The leading risk factors for preventable deaths worldwide are
hypertension, tobacco use, high blood glucose, physical inactivity, and obesity. In the US, tobacco use,
poor diet and physical inactivity, and excess alcohol use account for nearly 40% of all early and
unnecessary deaths. Tobacco use increases the risk of heart disease, stroke, lung cancer, and chronic
lung disease for the smoker; heart disease and lung cancer for nonsmokers regularly exposed to
secondhand smoke; and respiratory infections and more frequent and severe asthma attacks in children
regularly exposed to secondhand smoke. Poor diet and physical inactivity increase the risk for heart
disease, diabetes, osteoporosis, and colorectal cancer. Excessive alcohol use increases the risk for
heart disease, stroke, cancer, liver disease, chronic pancreatitis, and psychiatric problems, and has
additional consequences for public health through alcohol-related motor vehicle deaths, injuries, and
violence. The National Vital Statistics System (NVSS) is the major source of mortality data in the US,
and may be used to track the leading causes of death over time.

Health Disparities and Inequities

Health disparities are differences in the incidence rate, prevalence rate, disability rate, or mortality rate
between groups. Most disparities affect specific groups in the population that are in a position of social
or economic disadvantage related to discrimination or exclusion because of gender, age, race or
ethnicity, education or income, geographic location, disability, or sexual orientation. When disparities in
health are due to systematic injustices, such as segregation and unequal treatment, the differences are
termed health inequities. The leading health inequities in the US include heart disease, cancer,
diabetes, HIV/AIDS, infant mortality, asthma, and mental health. Inequities present not only as
differential health status, but differential access to needed medical procedures and access to quality
medical care.

It is important to note that while racial inequities in health reflect factors at the level of organizations,
communities, and societies, racism, actions that place an individual or group in a subordinate position
due to race or skin color, also functions as a form of chronic stress, with concomitant physiological
effects on blood pressure and cortisol levels. Racism is conceptualized into three dimensions: (1)
Internalized Racism – Acceptance of negative messages about worth by race; (2) Personally-mediated
Racism – Differential assumptions about abilities and intentions by race; (3) Institutionalized Racism –
Differential access to benefits and opportunities because of race.

The World Health Organization report “Closing the Gap in a Generation: Health Equity Through Action
on the Social Determinants of Health,” highlights that social injustice and human rights issues are the
key contributors to health inequities worldwide. The opportunities and challenges in the social context of
individuals across income levels influence their health, with low-income populations in poorer health
than middle-income populations, and middle-income populations in poorer health than high-income
populations. The decline in health at lower relative incomes, termed the “social gradient,” is seen both
within countries and between countries. It is important to note that the social gradient exists in high-
income countries as well; when the benefits of wealth or economic growth are not distributed equitably,
health inequities persist.

There are a number of social forces that produce health inequities including: (1) Socioeconomic Status -
Neighborhood quality can affect the health of individuals directly through adverse conditions such as
poor access to nutritious food, lack of safe places to exercise, exposure to environmental toxins, lack of
access to medical care, crowding, and inadequate housing and social services; (2) Social Capital - The
level of social capital determines the level of mutual trust, social reciprocity and informal social control,
and the capacity for collective social action including community mobilization and civic action; and (3)
Collective Efficacy - The level of community efficacy determines the level of political power and
influence the community can bring to bear on problems such as access to safe and healthy
environments, access to health care, and exposure to environmental pollutants.

Environmental factors such as built environment and proximity to environmental hazards are also
related to health inequities. Within the built environment, inadequate housing exposes people to
deteriorating lead paint and asbestos insulation, cockroaches and dust mites, gas appliances, and
stress from overcrowding; the placement of major roads near homes, schools and workplaces, exposes
people to pollutants, and creates a shortage of safe places to bicycle and walk; and a high density of
fast-food outlets, convenience stores, and liquor stores, exposes people to junk food, tobacco, and
alcohol. Due a variety of factors including racial/ethnic and class inequalities in zoning, the lower cost of
land and housing in industrial areas, and the fact that many communities lack the political power to
repel the siting of hazardous facilities, there is disproportionate residential proximity to environmental
hazards among people in low-SES and predominantly minority communities. Some key strategies that
may contribute to eliminating health disparities include: (1) increased access to services for all through
financing mechanisms, organizational changes, and removal of legal and transportation barriers; (2)
culturally and linguistically competent programs; (3) improved patient-provider communication; (4)
programs to eliminate provider discrimination; and (5) increased minority representation among the
health care workforce. Major data sources for monitoring health disparities over time include the
National Health Interview Survey (NHIS), the Behavioral Risk Factor Surveillance System (BRFSS), the
National Health and Nutrition Examination Survey (NHANES), the National Vital Statistics System
(NVSS), and administrative data (Medicare, Medicaid, and hospital discharge data).

Social and Behavioral Epidemiology

Social epidemiology investigates social, economic, and environmental causal and contributing factors to
explain the distribution of disease. Behavioral epidemiology investigates lifestyle factors to explain the
distribution of disease. Social and behavioral epidemiology have identified a number of determinants of
disease including social class, housing, employment, environmental pollutants, access to health care,
access to healthy foods, built environment, stress, social support, social capital, social cohesion,
tobacco use, lack of physical exercise, poor diet, excess alcohol use, drug use, failure to use seat belts,
and failure to follow preventive guidelines. The Behavioral Risk Factor Surveillance System (BRFSS) is
a state-based telephone survey established by the Centers for Disease Control (CDC) in 1984,
collecting data on health risk factors (i.e., percent of population smoking, percent of population
overweight), protective factors (i.e., percent of population wearing seat belts, percent of population with
flu vaccination, percent of women receiving mammograms), access to care (i.e., percent of population
with health insurance, percent of population with access to a primary care provider), and health
conditions, diseases, and status (i.e., percent of population with hypertension, percent of population
with diabetes, percent of population with poor health).

The Social Ecological Model

The social ecological perspective asserts that health is a complex phenomenon that cannot be
understood from a single level of influence. The social ecological model is a framework of determinants
of health across multiple levels of influence. In the social ecological model, environments influence
individuals, and individuals influence their environments. Determinants may include risk factors, which
place an individual at increased risk for a negative health outcome, and protective factors, which
decrease the likelihood of negative consequences from exposure to risk.

Levels of influence - (1) Individual level influences include biology, knowledge, attitudes, beliefs, self-
efficacy, and skills. (2) Interpersonal level influences include role modeling, social support, and social
norms through relationships with families, friends, and peers. (3) Organizational level influences are
rules, regulations and policies and norms of institutions such as schools and workplaces. (4)
Community level influences include relationships among organizations, informal community networks,
and community norms. (5) Societal level influences are macro-level factors such as religious or cultural
belief systems, societal norms, economic or social policies, and national, state, and local laws.

Core Principles - Core principles in the social ecological perspective include: (1) Multiple factors
operate at multiple levels to influence health behavior; (2) Influences interact across levels; (3) Multi-
level interventions are more effective than interventions at a single level; and (4) Interventions are most
powerful when they address specific behaviors.

Models of Help-Seeking and Health Services Use - Models of help-seeking and health services use
inform the process linking determinants with health outcomes, and highlight the diversity in populations
that must be understood and addressed in order to have culturally competent practitioners and service
delivery systems.

Model of Help-Seeking - This model includes: (1) Health behaviors - actions to promote health,
prevent disease, or detect disease at early stages such as diet, exercise, and immunizations, and on-
time screenings; (2) Illness behaviors - help-seeking and self-care actions in response to suspected or
actual illness, including ignoring symptoms, self-help, medical care, and alternative medical care; (3)
Sick role behaviors - actions in response to diagnosed illness; and (4) Disease management behaviors -
actions in response to medical advice, such as adherence to treatment.

Socio-Behavioral Model of Health Services Use - This model predicts the use of health services with
three major types of variables: (1) Predisposing variables - demographic characteristics, coping
strategies, and health beliefs; (2) Enabling variables – personal and household resources, availability of
community resources, and access to resources through transportation, financing, language, and
literacy; and (3) Need – self perceived health status or clinician-rated health status.

III. Prevention Theory, Science & Practice

Theories and Models of Change

Definitions - A theory is a set of interrelated concepts, definitions and propositions that presents a
systematic view of events or situations. Concepts are major components of theory. Constructs are
concepts that have been developed or adapted for use in a particular theory. Variables are
operationally-defined, measurable forms of constructs. Models are a set of theories that have been
combined to explain a specific problem. The most useful theories are internally consistent,
parsimonious, plausible, pragmatic, and ecologically valid. Theories and models of change guide the
development of interventions by identifying factors within individuals, in relationships among individuals,
and in organizations and communities that are related to changes in the health behavior and health
status of individuals and populations.

Theories of Change Focusing on Factors Within Individuals - Intrapersonal theories of change are
used to understand and change individual health behaviors. These theories focus on factors within the
individual that influence health behavior, including beliefs, attitudes, and readiness to change. Major
intrapersonal theories and models include the Health Belief Model, the Theory of Reasoned
Action/Theory of Planned Behavior, and the Transtheoretical Model.

Health Belief Model - The Health Belief Model focuses on individual beliefs as determinants of
behavior. The basic premise is that health behavior is determined by perception of the threat of a health
problem, and appraisal of the recommended behavior for preventing or controlling the problem. Major
constructs include: (1) Perceived Susceptibility, belief about the chances of experiencing a risk of
getting a condition or disease; (2) Perceived Severity, belief about how serious a condition and its
related consequences are; (3) Perceived Benefits, belief in the efficacy of the advised action to reduce
the risk of seriousness of impact; (4) Perceived Barriers, belief about the tangible and psychological
costs of the advised action; (5) Cues to Action, strategies to activate an individual’s readiness to
perform the advised action; and (6) Self-efficacy, confidence in one’s ability to perform the advised
action.

Theory of Reasoned Action/Theory of Planned Behavior - These two theories focus on individual
attitudes as determinants of behavior. The basic premise is that behavioral intentions are the best
predictors of behavior, and behavioral intentions are directly influenced by the attitude about performing
the behavior and the subjective norm, the belief whether important others approve or disapprove of the
behavior. Major constructs include: (1) Behavioral Intention, the intent to enact the behavior; (2)
Attitude, the evaluation of the behavior; and (3) Subjective Norm, the perceived expectation to perform
the behavior from others. The Theory of Planned Behavior expands the Theory of Reasoned Action by
adding a construct of Perceived Behavioral Control over performance of the behaviors.
Transtheoretical Model - The Transtheoretical Model focuses on an individual’s readiness to change
as a determinant of behavior. The basic premise is that behavior change is a process, individuals differ
in their readiness to change, and intervention strategies must be tailored for each stage of readiness to
change. The model consists of six stages: (1) Precontemplation, no intention to act; (2) Contemplation,
intention to act sometime in the future; (3) Preparation, intention to act in the near future with some
steps towards action; (4) Action, behavior change for less than 6 months; (5) Maintenance, behavior
change for more than 6 months; and (6) Termination, no temptation to relapse. Moving successfully
through the stages requires Decisional Balance, weighing the benefits of changing versus the costs of
changing, and Self-efficacy, the perceived ability to engage in healthy behavior.

Theories of Change Focusing on Relationships - Interpersonal theories of change are used to

understand and change interpersonal interactions related to health behaviors and health status. These
theories focus on factors in the individual’s social relationships that influence health, including learning
processes, relationships between individuals, and coping strategies. Major interpersonal theories and
models include Social Cognitive Theory, Social Support/Social Networks, Stress and Coping, and
Social Influence.

Social Cognitive Theory - Social Cognitive Theory focuses on learning processes as a determinant of
health. The basic premise is that individuals learn both from their own experiences and vicariously, by
watching the behaviors and the attendant behavioral consequences of others. A key feature of this
theory is reciprocal determinism, in which behavior, interpersonal factors, and environmental events
interact as determinants of each other. Major concepts include: (1) Environment, social environmental
factors and physical environmental factors; (2) Outcome Expectations, beliefs about outcomes of
behaviors; (3) Outcome Expectancies, perceived value of the outcomes; (4) Self-control, regulation of
performance; (5) Behavioral Capability, knowledge and skills to perform the behavior; (6) Self-efficacy,
confidence to perform the behavior and sustain the behavior change; and (7) Emotional Coping
Response, the strategies to deal with emotional stimuli. The two major methods of behavior change
include: (1) Observational Learning, learning to perform new behaviors by observing others’ actions and
the outcomes of others’ behavior; and (2) Reinforcement, responses to an individual’s behavior that
increase or decrease the chances of recurrence.

Social Support/Social Networks - Social Support Theory and Social Network Theory focus on
relationships between individuals and how the nature of these relationships influences beliefs and
behaviors. The four types of social support include: (1) Emotional Support, empathy and caring; (2)
Instrumental Support, tangible aid; (3) Informational Support, advice and information; and (4) Appraisal
Support, information for self-evaluation, such as constructive feedback. A social network is comprised of
the relationships surrounding an individual and includes six critical components: (1) Centrality vs.
Marginality, the degree of interaction; (2) Reciprocity of Relationships, whether relationships are one-
way or two-way; (3) Complexity of Relationships, whether relationships are dense or primarily one-way;
(4) Homogeneity/Diversity, the level of difference among individuals within a network; (5) Subgroups,
Linkages, and Cliques, the level of concentration of interaction; and (6) Communication Patterns, the
credibility of communication and how information is circulated throughout the network.

Stress And Coping - Stress and Coping Theory focuses on coping strategies as determinants of
health. Stressful experiences are constructed as person-environmental transactions, where the impact
of an external stressor is mediated by the individual’s appraisal of the stressor and the psychological,
social, and cultural resources at his/her disposal. There are five types of stressors: (1) Ambient
Environment, continuous conditions in the physical environment; (2) Major Life Events, discrete events
that occurs and disrupt the individual’s normal activities; (3) Daily Hassles, ongoing minor situations or
events that irritate or distress an individual; (4) Chronic Strains, challenges that an individual
experiences over time such as poverty, discrimination, or unemployment; and (5) Cataclysmic Events,
sudden physical environmental disasters. Major constructs include: (1) Primary Appraisal, evaluation of
the significance of a stressful event; (2) Secondary Appraisal, evaluation of ability to control the stressful
event through coping; (3) Coping Efforts, strategies used to mediate a stressful event; (4) Problem
management, strategies used to change a stressful situation; and (5) Emotional Regulation, strategies
used to change thoughts or feelings about a stressful event.

Social Influence - Social influence is a process directed at behavior change through communication as
part of formal (doctor-patient) and informal (parent-child) interpersonal relationships. Behavior change
may occur from interactions with others who are similar, others who are esteemed/ valued, and others
who are considered expert. The amount of change is a function of the number of influencers, the
closeness of the influencers to the individual, and the salience of the influencers. Motivational
interviewing is a formal social influence process through which individuals identify, explore, and resolve
ambivalence about changing unhealthy behaviors, such as tobacco use, poor diet, and sedentary
lifestyle.

Theories of Change Focusing on Organizations and Communities - Organizational and community

theories of change are used to understand and change the role organizations and communities play in
supporting or inhibiting behavior change. These theories focus on factors in organizations and
communities that influence health, including organizational policies and practices; community
organization and community building; production and exchange of information; and widespread
dissemination of innovations. Major organizational and community theories and models include
Organizational Change Theory, Community Organization Theory, Communication Theory, and Diffusion
of Innovations.

Organizational Change Theory - Organizational Change Theory focuses on organizational policies

and practices as determinants of health. There are two major approaches to organizational change: a
stage approach, and an organizational development approach. The basic premise of the stage
approach is that organizations go through a set of stages as they engage in a change process,
including awareness of a problem, initiating action to solve the problem, implementing changes, and
institutionalizing changes. The basic premise of organizational development is that factors related to
organizational functioning must be identified and changed. The Organizational Development process
consists of four stages: (1) Assessing and improving group dynamics within the organization; (2)
Encouraging shared goals; (3) Identifying organizational barriers to change; (4) Identifying and
implementing new organizational policies and practices.

Community Organization Theory - Community Organization Theory focuses on community

organization and community building as determinants of health, and involves a process in which
community groups identify problems, mobilize resources, and design and implement strategies to reach
common goals. Major models include: (1) Locality Development, primarily a process-oriented model that
uses consensus and cooperation to build a sense of community and community capacity; (2) Social
Planning, primarily a task-oriented model that uses rational-empirical problem solving with the help of
an outside expert to solve immediate problems; and (3) Social Action, a confrontational, conflict-
oriented model that seeks to change imbalances of power by redistributing power and resources. Major
concepts include: (1) Empowerment, a social action process to create community mastery over
community problems; (2) Critical consciousness, awareness of social, economic, and political factors
that contribute to community problems; (3) Community capacity, community ability to identify, mobilize,
and address community problems; (4) Issue selection, community identifies immediate winnable
changes; (5) Participation, the engagement of community members as partners in the change process;
and (6) Relevance, a community agenda based on community-defined needs and resources.

Communication Theory - Communication Theory focuses on the production and exchange of

information as a determinant of health. Communication theory uses media and communications to
provide information, influence behavior change, and influence what individuals are concerned about.
The most common forms of communication in public health are interpersonal and mass communication.
The processes involved in communication include encoding, transmission, reception (decoding) and
synthesis of information and meaning. A number of factors can affect the communication process
including: (1) Context of the communication; (2) Relationship between sender and receiver; (3) Meaning
attached to the channel (i.e., newspaper, TV, interpersonal communication); and (4) Process of
encoding and decoding. Communication theory is an important tool for addressing health literacy,
cultural competency, and limited English proficiency in populations. New communication strategies
include internet-based health information, online support groups, telephone-delivered interventions, and
interactive health games.

Diffusion of Innovation - Diffusion of Innovation theory focuses on the widespread dissemination of

successful innovations as a determinant of health. The process of dissemination includes: (1)
Innovation Development, the development of the innovation; (2) Dissemination, the process to
communicate about the innovation; (3) Adoption, the “uptake” of the innovation by the target population;
(4) Implementation, the regular use of the innovation; and (5) Maintenance, a focus on sustainability
and institutionalization of the behavior. Five factors influence whether an innovation will diffuse, and the
rate of diffusion: (1) individual characteristics of the prospective adopter; (2) environmental context of
the innovation; (3) the change agent’s credibility, trust, and respect; (4) the quantity and quality of
information and communication about the innovation; and (5) characteristics of the innovation, in terms
of relative advantage (if the innovation is better than what currently exists), compatibility (if the
innovation fits with the intended audience), complexity (if the innovation is easy to use), trialability (if the
innovation can be tried before deciding to adopt it), and observability (if the results of the innovation are
observable and measurable).

Health Promotion and Disease Prevention

Health Promotion is defined by the World Health Organization (WHO) as “the process of enabling
people to increase control over their health and its determinants, and Health promotion activities focus
on changing individual knowledge, attitudes, and skills, as well as enacting laws, policies, and
regulations that address air and water quality, housing, food supply, income, and working conditions.
Prevention is defined by WHO as “approaches and activities aimed at reducing the likelihood that a
disease or disorder will affect an individual, interrupting or slowing the progress of the disorder, or
reducing disability.” Prevention approaches may be categorized based on a continuum of disease or by
population subgroup.

Prevention Categories Based on the Disease Continuum - Prevention activities occur at different
points along the disease continuum: (1) Primary Prevention Strategies are delivered prior to the onset of
disease in order to prevent the occurrence of disease. Examples of primary prevention include
immunizations, safe drinking water and food system, adequate diet and physical activity, preventing
youth access to tobacco, sunscreen and protective clothing, workplace safety regulations, and air bags.
(2) Secondary Prevention Strategies are delivered at the earliest stages of disease to identify and
detect disease and provide prompt treatment. Examples of secondary prevention include screening for
cancers, heart disease, diabetes, lead exposure, TB, HIV, mental illness, and substance abuse. (3)
Tertiary Prevention Strategies are delivered when the individual already has a disease in order to limit
disability and complications, and reduce severity or progression of disease. Examples of tertiary
prevention include retinal exams for diabetic retinopathy, stroke and post- heart attack rehabilitation
programs, cancer survival programs, and hospice programs that ensure dignity and reduce suffering in
terminal conditions.

Prevention Categories Based on Population Subgroup - Prevention activities are targeted to

different groups in the population: (1) Universal Prevention Strategies are delivered to the entire
population in order to avert the onset of disease; (2) Selective Prevention Strategies are delivered to a
subgroup in the population who are deemed “at risk” by belonging to a certain group or setting,
regardless of their individual level of risk; and (3) Indicated Prevention Strategies are delivered to the
individuals in the population who have risk factors or are exhibiting early signs of a disorder.

Multicultural Perspective and Prevention - Culture is a set of learned and shared values, beliefs,
attitudes, languages, behaviors, and customs of a group of people. Ethnicity is a classification of people
based on national origin or culture, and race is a classification of people based on physical or biological
characteristics. Cultural diversity refers to differences based on cultural, ethnic, or racial factors. Cultural
diversity impacts beliefs about health, illness, and health care. A multicultural perspective takes cultural
differences into account when developing a model of the determinants of health and when designing
prevention strategies. Examples of multicultural prevention strategies include culturally tailored dietary
guidelines, and partnering with churches to deliver prevention programs.

Harm Reduction Perspective and Prevention - The harm reduction perspective is based on the
assumption that banning certain substances is unrealistic, so the public health approach should focus
on reducing the negative consequences of high-risk behaviors. Examples of harm reduction strategies
include nicotine gum, designated driver programs, and needle exchange programs for intravenous drug
users.

Evidence-based Prevention Programs and Policies

The Task Force on Community Preventive Services produces the Community Guide, an independent
group of public health and prevention experts appointed by the Director of CDC. The Community Guide
includes Task Force recommendations about evidence-based interventions to improve public health.
The Community Guide complements the Guide to Clinical Preventive Services (The Clinical Guide)
developed by the Agency for Healthcare Research and Quality (AHRQ), which identifies evidence-
based interventions for clinical practice. The Community Guide assesses interventions aimed at
promoting healthy behaviors and reducing unhealthy behaviors, reducing diseases, injuries, and
disability, and promoting healthy behaviors in community settings. Interventions are evaluated in terms
of effectiveness, costs, barriers to use, and unintended consequences. Examples of evidence-based
primary prevention strategies directed at the four leading behavioral risk factors for preventable death
include: (1) Tobacco Use: Smoking cessation programs, school-based prevention curricula, minor
access laws, cigarette excise taxes, and smoke free environments. (2) Physical Inactivity: Moderate
amounts of low intensity physical activity, accessible stairwells and sidewalks, safe neighborhoods, and
affordable facilities for exercise. (3) Poor Diet: Include more fruits and vegetables, increase grains and
fiber-rich foods, decrease total fat and saturated fat, decrease salt and sugar, restaurants encourage
healthy eating habits, and food manufacturers lower fat content of processed food. (4) Excess Alcohol
Consumption: Alcohol reduction programs, school-based prevention curricula, minor access laws,
increasing alcohol taxes, maintaining limits on days of sale, maintaining limits on hours of sale in bars,
regulation of alcohol outlet density, sobriety checkpoints, and supervision in alcohol risk work
environments. Evidence about cultural beliefs may be used to tailor interventions to specific population
subgroups, thus producing more widespread impact. Examples of cultural tailoring include using dietary
guidelines to create healthy versions of ethnic or regional recipes, and using hip-hop music to
communicate health messages.

Community Health Practice

WHO defines a community as “A social group determined by geographic boundaries and/or common
values and interests, community members know and interact with one another, the community functions
within a particular social structure, and the community creates norms, values, and social institutions.”
Critical components of community health practice include identification of stakeholders, community
mobilization, community assessment, and community-based participatory research.

Identification of Stakeholders - Stakeholders include the program sponsor, and decision makers,
organizations, and individuals that will be affected by the program. Critical stakeholders include: (1)
Elected officials and their health policy advisors; (2) Legislators on health-related committees; (3)
Program sponsors and funders; (4) Program Managers; (5) Program Staff; (6) Key health supporters as
well as potential adversaries; (7) Representatives from a broad array of public and private agencies
including public health, private health care organizations, mental health, substance abuse,
environmental protection, criminal justice, social services, education, agriculture, transportation, and
recreation; (8) Representatives from relevant health associations (American Heart Association,
American Cancer Society, etc.); (9) Target groups and beneficiaries; and (10) Potential program
adopters.

Community Mobilization - Community mobilization involves a collective effort by groups and

community members to increase awareness about a problem and advocate for change. Key steps
include: (1) Defining the community; (2) Assessing, and working with, the community’s capacity for
mobilizing; and (3) Understanding the community agenda and selecting the right issue. Community
mobilization leads to community empowerment, i.e., the community taking charge of the issue, defining
what the goals are, and taking the necessary action. Through this process, the community gains
experience and sense of collective efficacy about resolving community problems.

Community Assessment - Basic information for community needs assessment and surveillance
includes morbidity and mortality data from the National Vital Statistics System; behavioral factors from
the Behavioral Risk Factor Surveillance System; and social, economic, and environmental indicators
from the Directory of Social Determinants of Health at the Local Level. The process of mapping
community assets Identifies community capacity for addressing community needs, and includes the
following steps: (1) Identify the skills, capacities, and experiences of community members and
organizations that can help address the problem. This assessment should include the health care
environment (hospitals, clinics, insurance companies, pharmacies), the food environment (produce
markets, quick shops, fast food restaurants), the active living environment (sidewalks, parks, recreation
center), community services (employment assistance, housing, transportation), other public institutions
(schools, libraries), private businesses, nonprofit organizations, and community or neighborhood
organizations, media representatives, community historians, and community informal leaders and role
models. (2) Identify how the assets identified in step 1 can be used to address determinants of the
problem; (3) Identify what assets are missing to address determinants of the problem.

Community-based Participatory Research - Community-based Participatory Research (CBPR) is a

collaborative approach to research that equitably involves all stakeholders in the process of defining the
problem, identifying and implementing solutions, and evaluating outcomes. CBPR is founded on the
principle that more comprehensive and participatory approaches are needed to address the complex
set of multi-level determinants underlying major public health problems. The key principles include: (1)
Start with the community as the unit of assessment and change; (2) Build on community assets and
resources in solving community problems; (3) Support equitable partnership with the community
throughout the research process; (4) Build community capacity through the research process; (5) Use
the social ecological model to understand determinants of community problems and to guide actions at
multiple levels of influence; (5) Disseminate findings through multiple channels with sensitivity to cultural
issues in communication and literacy; and (6) Balance research and action.

IV. Program Planning and Evaluation

Ethical Issues in Planning and Evaluation

The Tuskegee Study - The Tuskegee Syphilis Study involved poor African-American men in Macon
County Alabama who were offered free treatment for “Bad Blood”, a euphemism for syphilis. 600 low-
income African American males were recruited by government health workers and monitored for 40
years, while effective treatment was withheld from study participants who contracted syphilis. In 1972 a
United States Public Health Service investigator expressed concerns about the morality of the
experiment to an Associated Press reporter, and the publication of the story led to a class-action suit
against the federal government, which was settled out of court in 1974.

The National Research Act and the Belmont Report - The U.S. Congress passed the National
Research Act in 1974, creating the National Commission for the Protection of Human Subjects of
Biomedical and Behavioral Research. The goal of the Commission was to identify the basic ethical
principles guiding the conduct of research with human subjects. The Belmont Report summarizes the
work of the Commission, including the boundaries between practice and research, basic ethical
principles of respect for persons, beneficence, and justice, and informed consent, assessment of risks
and benefits, and selection of subjects.

Institutional Review Board (IRB) - An IRB is an administrative board that has the authority to approve,
modify or disapprove research involving human subjects. IRBs are federally mandated to ensure that all
research involving human subjects is conducted in accordance with federal regulations.

Planning Models

Healthy People National Health Objectives - The US Department of Health and Human Services has
developed science-based national public health objectives every 10 years since 1980, as part of the
Healthy People Initiative. The goal of Healthy People is to increase quality and years of life and
eliminate health disparities by providing a framework of public health priorities, measurable objectives
and benchmarks, which can be used to guide local health planning and to aid in monitoring progress
over time. Leading Health Indicators in Healthy People 2010 include physical activity, overweight and
obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence,
environmental quality, immunization, and access to health care.
PRECEDE-PROCEED - PRECEDE-PROCEED is a community-oriented, participatory model for
creating successful community health promotion interventions by identifying the desired outcome,
identifying determinants of the outcome, and designing an intervention to reach the desired outcome.
The initial PRECEDE component has four phases:(1) Social Diagnosis, which involves asking the
community what it wants and needs to improve community health and quality of life, resulting in
identification of a community health outcome; (2) Epidemiological Diagnosis, which involves identifying
the health behaviors, interpersonal factors, organizational factors, and community factors that influence
the community-identified outcome, determining which risk factors are most significant and malleable,
and developing program objectives; (3) Educational and Organizational Diagnosis, which involves
identifying the predisposing, enabling, and reinforcing factors that may facilitate or impede changing the
factors identified during Phase 2; and (4) Administrative and Policy Diagnosis, which involves identifying
and modifying internal administrative issues and policies and external policies as needed to generate
the funding and other resources for the intervention. Results from Phases 3 & 4 lead to the intervention
plan. The PROCEED component adds on an additional four phases (5) Implementation, which involves
starting up and conducting the intervention; (6) Process Evaluation, which involves a determination
whether the intervention is proceeding as planned, with adjustments as needed; (7) Impact Evaluation,
which involves a determination whether the intervention is changing the planned risk factors, with
adjustments as needed; and (8) Outcome Evaluation, which involves a determination whether the
intervention is producing the outcome identified in Phase 1, with adjustments as needed.

Social Marketing - Social Marketing applies the principles of marketing to planning interventions at
individual, interpersonal, organizational, community, and societal levels. The social marketing approach
includes a focus on consumer wants and needs, awareness of competition, and audience
segmentation. The goal is to influence “consumers” to “buy” a behavior change or health-related
product/technology. Social marketing campaigns are built around the “four Ps” (1) Product, the
behavior, program, technology; (2) Price, the cost of adoption; (3) Place, where the product available or
promoted; and (4) Promotion, how to promote the first three “Ps” through persuasive strategies.

Other models - Other planning models include Mobilizing for Action through Planning and Partnerships
(MAPP), Assessment Protocol for Excellence in Public Health (APEXPH), Multi-Level Approach to
Community Health (MATCH), and Planned Approach to Community Health (PATCH).

Common Elements Among Planning Models - Planning models have the following features in
common: (1) Community involvement and mobilization; (2) Needs assessment at community and
organizational levels; (3) Selection of specific target audiences; (4) Development of specific,
measurable, attainable and time-bound objectives and their indicators; (5) Action plan development and
implementation; (6) Evaluation of program processes and outcomes; and (7) Institutionalization.

Evaluation Methods

Program evaluation is a systematic process using both qualitative and quantitative methods to answer
questions about the nature of the problem the program is addressing, the program’s logic model,
program processes, program outcomes, and program efficiency. Program evaluation helps to orient
public health efforts towards outcomes, and encourages the use of scientific evidence to guide
decisions about public health programs and policies.

Needs Assessment - A needs assessment investigates the extent of the problem, the consequences
of the problem, and subgroups of people or places affected by the problem.
Logic Model - A logic model summarizes the program’s mechanism of change by identifying inputs,
activities, outputs, and a trajectory of short-term, intermediate, and long-term outcomes.

Process Evaluation - Process evaluation investigates the fidelity of program implementation (what
program activities are delivered, who delivers program activities, and when and where activities are
delivered), and investigates outputs such as number of people served.

Outcome Evaluation - Outcome evaluation investigates the effect of the program on short-term
outcomes, intermediate outcomes, and long-term outcomes. For example, short-term outcomes of a
prevention program could include increased knowledge, improved attitudes and beliefs, and increased
skills; intermediate outcomes could include behavior change; and long-term outcomes could include
decreased rates of disease, disability, death, or disparity.

Efficiency Evaluation - An efficiency evaluation compares the incremental cost of the program to its
effects (cost-effectiveness analysis) or to monetized effects (cost-benefit analysis). Efficiency
evaluations may also investigate several competing programs to determine whether alternative, less
costly programs achieve the same results as more expensive programs.

RE-AIM - The RE-AIM Model encourages program developers and evaluators to emphasize the
external validity of a program, thus increasing the likelihood of translating an effective program to
practice. The RE-AIM framework includes five components; (1) Reach of the program; (2) Effectiveness
of the program; (3) Adoption by large number of diverse settings; (4) Implementation with fidelity; and
(5) Maintenance through institutionalization or by becoming part of organizational policies and practices.

Centers for Disease Control (CDC) Evaluation Framework - The CDC established a six-step
framework for evaluating public health programs: (1) Engage Stakeholders. The first step involves
engaging stakeholders in development of the evaluation plan, conduct of the evaluation, and use of
evaluation results. Stakeholders include funders, program management and leadership, grantees,
program partners, the evaluation team, those served or affected by the program, and users of the
evaluation. (2) Describe the Program. The second step involves developing a logic model to guide the
evaluation. The model includes inputs, activities within each program component, and a trajectory of
client outcomes detectable immediately following intervention (short-term outcomes), at follow-up
(intermediate outcomes), and after a sustained period of program implementation (long-term outcomes).
Case studies may also be used to provide descriptive data about the program. (3) Focus the Evaluation
Design. Different evaluation questions are relevant for different stages of a program, with
implementation fidelity questions paramount at program initiation, short-term outcome questions
important once fidelity is assured, and long-term outcome questions appropriate once the program has
documented short-term and intermediate-term effects. Stakeholders should be involved in developing
evaluation questions at each stage of the program. (4) Gather Credible Evidence. While existing data
should be used whenever possible, evaluation tools should be developed as needed, and piloted prior
to use in the evaluation. (5) Justify Conclusions. Both quantitative and qualitative data analysis methods
may be used to analyze implementation fidelity, program processes, and program outcomes. (6) Ensure
Use and Share Lessons Learned. A communication and dissemination plan for the evaluation should
include internal communication strategies, strategies for communicating with stakeholders, and program
and provider dissemination, scientific dissemination, policy-relevant dissemination, and public access
dissemination.
Methodological Issues - Design, sampling, measurement, and analysis methods influence the internal
validity and external validity of the evaluation.

Designs - Questions about complex events, patterns and processes of a program are best answered
with qualitative designs such as case studies and focus groups. There are three quantitative designs for
measuring program impact: (1) The single subject design measures outcomes before and after program
implementation, and is appropriate for a preliminary investigation of a program. The before and after
design will not allow the evaluator to conclude if the program caused the change in outcome, as
alternative, plausible explanations for the results cannot be ruled out; (2) The quasi-experimental design
compares outcomes for a group participating in a program to the outcomes for a similar group not
receiving the program. The quasi-experimental design is appropriate when random assignment is not
feasible or ethical; (3) The experimental design, or randomized prevention trial, compares outcomes for
a group randomly assigned to participate in a program to the outcomes for a group randomly assigned
to a control condition. The experimental design is the most rigorous evaluation of impact when there are
no concerns about denial or delay of program services.

Descriptive/Exploratory Research - The purpose of descriptive research is to document

characteristics and conditions of individuals, groups, or settings. The purpose of exploratory research is
to examine the relationships among characteristics and conditions of individuals, groups, or settings.
Descriptive and exploratory research questions are typically addressed with qualitative designs (case
studies, focus groups, ethnography) or quantitative non-experimental designs (cross-sectional,
retrospective, and prospective).

Hypothesis Testing Research - The purpose of hypothesis testing research is to define a hypothesis,
operationalize the variables, and conduct a statistical test of the relationship among variables. Statistical
tests of relationships between variables are based on the null hypothesis; if the appropriate test statistic
is different enough (p<.05), the null hypothesis of no relationship between the variables is rejected.

Synergy Between Descriptive/Exploratory Research and Hypothesis Testing Research - There is

a synergy between descriptive/exploratory research and hypothesis testing research in that results from
one type of study may inform the other (i.e., results from an exploratory study may generate a
hypothesis for testing; rich details that underlie hypothesis testing study results may be revealed by an
exploratory study).

Sampling Methods - There are two major types of sampling methods: (1) Non-probability sampling
methods use human judgment to select the sample. Examples include convenience sampling, quota
sampling, and purposive sampling. Theoretical sampling is a type of non-probability sampling method
where new research cases are selected to build and elaborate theories based on data from cases
already studied. Data is collected until there is no longer any unique information, termed “data
saturation.” Non-probability samples are appropriate for qualitative designs exploring complex program
patterns. (2) Probability sampling methods draw a sample from the defined population such that each
element has a known probability of being selected. Examples include simple random sampling, stratified
random sampling, and cluster sampling. Probability samples are appropriate for quantitative designs,
with cluster sampling being most useful in situations when the program covers a large geographic area.

Measurement Methods - Data about program activities, outputs, and outcomes can be collected via
interviews with program staff and participants, direct observations of the program, and content analysis
of program records. Data collection methods should be reliable (consistency of measure) and valid
(accuracy of measure). Widespread impact of a program may be measured by using the Behavioral
Risk Factor Surveillance System (BRFSS) to examine trends in behaviors for a defined population
before and after implementation of a program.

Analytic Methods - Analysis of the effect of the program on outcomes should control for other variables
related to the outcomes. Major multivariate techniques include regression or ANOVA for continuous
outcomes, and logistic regression for categorical outcomes.

Internal Validity - Program evaluation methods have internal validity when other alternative plausible
explanations for the effect of the program on the outcome can be ruled out.

External Validity - Program evaluation methods have external validity when the results can be
generalized to other groups and settings.

Scaling Up Programs and Sustainability

Scaling Up - Scaling up refers to increasing a program’s impact while maintaining the program’s
quality. There are four categories of scaling up: (1) Quantitative, increasing the numbers of clients
reached by a program. (2) Functional, expanding program breadth. (3) Political, increasing the
organization’s ability to address barriers to effective program services; and (4) Organizational,
improving the organization’s ability to continue to support the program in an effective and sustainable
manner.

Strategies for Ensuring Program Sustainability - Strategies include: (1) Build community and
organizational capacity in management, advocacy, fundraising, and training; (2) Utilize simple, user-
friendly materials and tools; (3) Involve community members in every step of the program; (4) Develop,
implement, and institutionalize cost-recovery mechanisms; (5) Develop, implement and institutionalize
quality assurance and self assessment tools; (6) Build on pre-existing structures; 97) Develop program
leaders and “champions”; and (8) Encourage cross-community learning.

V. Mastering Social and Behavioral Sciences Competencies for Exam Success

This section includes three cases, one from each domain: (1) Social and Behavioral Determinants of
Health; (2) Prevention Theory, Science & Practice; and (3) Program Planning and Evaluation. For each
case, a problem is presented, and then solved by applying core principles and methods. Each case
ends with policy, systems and environmental changes in order to illustrate a broad, sustainable, multi-
level approach directed at individuals, social relationships, and organizational and community
environments.

Case 1: Social and Behavioral Determinants of Health

Problem: Tobacco use is the most preventable cause of chronic illness and premature death in the
world. Although the overall rate of cigarette smoking has decreased over time, smoking rates remaining
high among racial and ethnic minorities, individuals who have not graduated from high school, and
individuals living in poverty. Existing tobacco prevention and control strategies appear to have limited
reach to racial and ethnic low-income groups.

Application of Core Principles and Methods: Develop a foundation for an effective tobacco cessation
program with young men who are in employment training centers through a literature review, and by
conducting focus groups with young male smokers at employment training centers. Use the findings
from the literature review and qualitative analysis of focus group data to develop a social ecological
model that can guide the design of the tobacco cessation program.

A SOCIAL ECOLOGICAL MODEL OF TOBACCO USE AMONG YOUNG LOW-INCOME MEN ATTENDING
EMPLOYMENT TRAINING CENTERS
Level of Determinants
Influence
Individual  Nicotine addiction
 Social position – race, social class (SES, education), and ethnicity
 Tobacco-related health beliefs – severity, susceptibility, self-efficacy, and
response efficacy
 Psychological factors – depression, anxiety, and future time perspective
 Comorbid substance use – alcohol and marijuana use

Interpersonal  Family influence – family member tobacco use, perceived family approval for
tobacco use, receipt of tobacco or money to purchase tobacco from family
members, and availability of place to smoke at home
 Peer influence –peer tobacco use, perceived peer approval for tobacco use, and
receipt of tobacco from peers
 Stressors – racism (prejudice, discrimination, oppression), trauma (witnessing/
experiencing violence, sexual abuse, motor vehicle accidents), family conflict, and
arrest/probation
 Coping strategies – reliance on avoidance-oriented strategies (denial or
minimization)

Organizational  Employment training center – staff tobacco use, limited enforcement of tobacco
 restrictions, and social advantages of smoking breaks

Community  Structural disadvantage –material wealth disadvantage, employment opportunities

disadvantage, educational opportunities disadvantage, political influence disadva
ntage, racial segregation
 Easy access to tobacco, alcohol, and other drugs
 Perceived community norms around tobacco use, alcohol use, and other drug use
 Cultural beliefs about tobacco use
 Limited enforcement of tobacco and alcohol laws and regulations
 Community violence

Societal Level  Tobacco taxes

 Tobacco prices
 Racism

Policy, Systems and Environmental Changes. In addition to the tobacco cessation program that can
be designed based on the social ecological model elaborated above, the following change options may
help create a broad context for tobacco prevention and control:

 Develop a media campaign to increase awareness of cessation benefits, increase awareness

of Quitline, increase awareness of tobacco free policies and laws, and encourage cessation
attempts
 Mandate point-of-purchase counter-advertising in tobacco outlets
 Ban vending machines
 Ban sale of single cigarettes
 Limit youth sales through merchant education and enforcement
 Incentives for merchants who are in compliance
 Community mobilization to increase support for retailer compliance with youth access laws
 Enact graduated fine and suspension regulations; monitor dispositions of adjudicated cases
 Enact conditional zoning regulations for tobacco outlets in close proximity to schools
 Enact local excise tax on tobacco products
 Advocate for comprehensive cessation benefits through insurers and employers

Case 2: Using Prevention Theory to Guide Practice

Problem: Colorectal cancer is the second leading cause of cancer death in men and women. Despite
evidence of high survival rates with early screening, less than 50% of the eligible US population has
been screened, highlighting a critical need to translate scientific knowledge to practice.

Application of Core Principles and Methods: Develop an online colorectal cancer education
intervention using constructs from the Health Belief Model.
USING THE HEALTH BELIEF MODEL TO DESIGN AN ONLINE COLORECTAL CANCER EDUCATION
INTERVENTION
CONSTRUCT INTERVENTION COMPONENT
Perceived Animated graph showing rise in colorectal cancer with age
susceptibility Bullet points - Information about risk
Pop-up screen for viewers to assess their risk
Perceived severity Short movie showing growth of polyp, early death, family members missing at the table,
community members
missing from their communities (movie would use culturally diverse male and female
actors combined with voiceovers)
Perceived benefits Movie continues with alternate ending – with screening, polyp does not grow, individual
does not die,
families are whole at the table, communities are whole
A colonoscopy video explains details about screening
Interactive screen with photographs of survivors - Click on a picture to hear the survivor’s
story. Culturally diverse survivors reinforce the message that screening saves lives
Perceived barriers Colonoscopy video provides accurate information about procedure, allaying fears that
screening is embarrassing or painful
Pop-up screen with tips for colonoscopy prep and screening
Cues to action Pop-up for “how to get a colonoscopy”
Self efficacy Interactive game that reinforces lowering risk through lifestyle changes, and screening
beginning at age 50
Policy, Systems and Environmental Changes. In addition to the online colorectal cancer education
program described above, the following change options may help create a broad context for cancer
prevention and control

 Develop partnership network of health departments, providers, cancer registry, community-

based organizations, organizations representing and advocating for seniors, and cancer
prevention and control advocacy groups
 Develop large scale and targeted small media campaigns to increase awareness about CRC
and importance of screening through varied channels (TV, radio, print, internet, social media)
 Develop a quality improvement initiative with primary care professional associations to
educate providers about USPSTF screening guidelines, promote the use of provider reminder
systems, and promote the use of electronic medical records systems
 Develop local outreach partnerships with community-based groups and faith-based groups
 Develop patient navigation systems
 Advocate for coverage of CRC screening through insurers and employers
 Enroll uninsured patients into Medicaid
 Advocate for worksite policies that support time off for CRC screening
 Establish CRC screening reporting system with health insurance plans

3.3 Case 3: Developing A Logic Model for Program Evaluation

Problem: Cardiovascular disease (CVD) is the leading cause of death, worldwide, and in the US. Low-
income groups have a disproportionate burden of cardiovascular disease, disability and death,
compared to groups with higher incomes. The burden of cardiovascular disease can be reduced
through a combination of lifestyle interventions to modify tobacco use, diet, and physical activity, and
clinical interventions to manage high blood pressure, high cholesterol, and diabetes.

Application of Core Principles and Methods: A CVD Prevention Program is being initiated in urban
health centers for low-income populations, aged 40-64, to provide lifestyle interventions and screening.
Health Center staff are trained to implement an evidence-based lifestyle intervention through an initial
training session, and a quarterly learning community session. A policy and procedure manual detailing
clinical and lifestyle intervention guidelines is developed. Local partners with the capacity to provide
physical activity and diet interventions are formally affiliated with the program through memoranda of
understanding. Low-income men and women, 40-64, are recruited from the health centers, enrolled in
the program, and receive baseline screening. Those with alert or abnormal values for blood pressure,
cholesterol, or blood sugar received clinical interventions. All participants receive dietary and physical
activity counseling, and referral to the tobacco quitline, as needed. Participants are rescreened
annually. Develop a logic model to guide the program evaluation that depicts major inputs, program
development, provider professional development, and client activities, and a trajectory of client
outcomes detectable immediately following intervention (short-term outcomes), at annual rescreening
(intermediate outcomes), and after a sustained period of program implementation (long-term outcomes).

Click here to see Logic Model: CVD Prevention Program

Policy, Systems and Environmental Changes. In addition to the CVD Prevention Program described
on the previous page, the following change options may help create a broad context for CVD prevention
and control

 Develop community walking trails and bicycle trails with health messaging signage
 Develop community gardens with monthly community meal using produce from the garden
 Develop Farmers’ Markets
 Ensure that Farmers’ Markets accept WIC (Women, Infants and Children) Farmers Market
Nutrition Program vouchers and Food Stamps
 Establish grocery store tours with education on healthy food choices
 Establish Grocery store cooking demonstrations
 Develop large media – heart attack and stroke symptoms and when to call 911
 Develop small targeted media - culturally tailored recipes and meal planning; tips for healthy
food substitution; tips for increasing physical activity on daily basis
 Advocate for Chamber of Commerce to develop and conduct an information and support
program for member worksites to develop worksite wellness programs
 Advocate for sidewalks and bike lanes to be built for all new developments
 Ensure sidewalks are in compliance with Americans with Disabilities Act (ADA) requirements
 Pass bonds or levy taxes to finance trails, bike paths, and sidewalk enhancements
 Enact zoning to protect open spaces and natural resources
 Enact ordinance banning cooking with trans fats in food establishments
 Promote point-of-purchase healthy food messages in retail outlets
 Financial incentives to recruit supermarkets to underserved areas

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Communities: Expanding the Wisdom of WISEWOMAN in Intervening at the Environmental Level.
Journal of Women's Health 13(5): 644.
Social and Behavioral Sciences - Definitions

Acculturation:
A gradual process through which an individual adopts the behavioral norms, attitudes and beliefs of a
culture other than his own.

Adherence:
Closely following or sticking to a plan or protocol. In the context of health promotion, we use the term
adherence to refer to individuals taking their medications as prescribed (i.e. adherence to antiretroviral
therapy) or following program protocols (i.e. sticking to a diet and exercise plan). In the context of health
promotion, adherence can also refer to following the implementation protocol when delivering a health
promotion program, conducting interviews, etc.

Asset mapping 24-25 :

A component of community capacity assessment and community development that involves conducting
an inventory of individual, group and community resources, often physically designating them on a
geographical map. A capacity assessment offers an alternative to a needs-based approach to
community health and “is a measure of actual and potential individual, group and community resources
that can be inherent and/or brought to bear for health maintenance and enhancement.” 25 Once assets
are “mapped,” efforts are directed at mobilizing, strengthening and supplementing them while working to
achieve a common vision.

Behavioral capability 1:
An individual's knowledge and skills related to a specific health behavior. In order for an individual to
engage in a particular behavior, that individual must first know what the behavior is and how to
successfully perform it. Behavioral capability is a key construct of the Social Cognitive Theory.

Behavioral factors 7:
“The patterns of behavior of individuals and groups that protect or put them at risk for a given health or
social problem.”

Behavioral intention 7:
“A mental state in which the individual expects to take a specified action at some time in the future.”

Behavioral objective 7:
“A statement of desired outcome that indicates who is to demonstrate how much of what action by when
.”
Behavioral risk:
A typically modifiable behavior, like smoking or lack of physical activity, which puts an individual at risk
for a negative health outcome.

Best practices:
“Recommendations for an intervention, based on a critical review of multiple research and evaluation
studies that substantiate the efficacy of the intervention in the populations and circumstances in which
the studies were done, if not its effectiveness in other populations and situations where it might be
implemented.”7

Change agent 29:

In the context of Diffusion of Innovations, a change agent is “an individual who influences clients'
innovation-decisions in a direction deemed desirable by a change agency.” The change agent's
functions are often to develop a perceived need for change, facilitate information-exchange, identify a
client's problems, develop a client's intentions to change, motivate the movement from intentions to
action, support long-term adoption of the change, and help the client achieve self-reliance.

Coalition 7:
“A group of organizations or representatives of groups within a community joined to pursue a common
objective.”

Co-morbidity:
Having more than one illness or condition that compromises quality of life at the same time.

Communication theories 1:
In the context of public health, communication theories are meant to describe how communication
processes impact health behavior change and how communication strategies can be used strategically
to motivate behavior change. Although there are a number of communication theories and concepts, four
that are particularly relevant to public health include the knowledge gap, agenda setting, cultivation
studies, and risk communication . The knowledge gap refers to the fact that individuals with more
formal education tend to be more knowledgeable about many issues when compared to those with less
formal education; therefore, “an increasing flow of information into a social system is more likely to
benefit groups of higher socioeconomic status than those of lower SES,” thereby contributing to health
disparities and other inequities. Knowledge gaps can be modified by content and channel factors, social
conflict and mobilization, community structure, and individual motivational factors. Agenda-setting refers
to the ability of the mass media to influence public opinion and priorities, particularly in relation to politics
and policymaking. Cultivation studies investigate “the impact the mass media have on our perceptions of
reality.”

Community 5:
“A specific group of people, often living in a defined geographical area, who share a common culture,
values and norms, are arranged in a social structure according to relationships which the community has
developed over a period of time. Members of a community gain their personal and social identity by
sharing common beliefs, values and norms which have been developed by the community in the past
and may be modified in the future. They exhibit some awareness of their identity as a group, and share
common needs and a commitment to meeting them.”
Community-based interventions 18:
“Programs designed to focus on healthful changes in either subgroups or localized populations.”

Community-based participatory research (CBPR) 19:

“A collaborative process that equitably involves all partners in the research process and recognizes the
unique strengths that each brings. CBPR begins with a research topic of importance to the community
with the aim of combining knowledge and action for social change to improve community health and
eliminate health disparities.”

Community capacity 7:
“Combined assets that influence a community's commitment, resources, and skills used to solve
problems and strengthen the quality of life for its citizens.”

Community organization 7:
“The set of procedures and processes by which a population and its institutions mobilize and coordinate
resources to solve a mutual problem or to pursue mutual goals.”

Consciousness raising 1:
A process of “learning new facts, ideas and tips that support the healthy behavior change.” Efforts to
increase awareness about the causes and consequences of a disease or unhealthy behavior during a
media campaign would be considered consciousness raising. Consciousness raising is a process of
change included in the Transtheoretical model that is most appropriate for individuals in the earliest
stages of change (precontemplation and contemplation).

Cues to action 1:
“Strategies to activate one's readiness” to engage in a particular behavior or activity. A cue to action can
be either an internal or external stimulus that motivates a person to act. Cues to action is a key construct
in the Health Belief Model.
Cultural competence 11:
“The design, implementation, and evaluation process that accounts for special issues of select
population groups (ethnic and racial, linguistic) as well as differing educational levels and physical
abilities.”

Decisional balance 1:
The relative weight an individual places on the perceived pros and cons of changing or engaging in a
certain behavior. Typically, the pros of change need to outweigh the cons of change before an individual
will be ready to take action and maintain a behavior change. Decisional balance is a key construct in the
Transtheoretical model.

Determinants of health 5:
“The range of personal, social, economic and environmental factors which determine the health status of
individuals or populations.”

Diffusion of innovations (DOIs) 1:

A community-level theory that attempts to describe the rate and process of the adoption of new ideas
and behaviors in a specific population or between populations. An innovation is defined as “an idea,
practice or object that is perceived as new by an individual or other unit of adoption,” while diffusion is
defined as “the process by which an innovation is communicated through certain channels over time
among the members of a social system.” The process of diffusion occurs over the course of five stages:
innovation development, dissemination, adoption, implementation, and maintenance. The adoption stage
requires that an individual: 1) has knowledge of the innovation (has an awareness that the innovation
exists, knowledge of how to use the innovation and how it works); 2) goes through a process of
persuasion or attitude development, in which the individual discusses the innovation with others and
forms a favorable or negative attitude toward it; 3) decides to adopt the innovation; 4) implements, or
begins to use the innovation; and 5) goes through a process of confirmation, in which the individual
integrates the innovation into his life and recommends it to others. In general, not everyone adopts an
innovation at the same time. Diffusion of Innovations categorizes individuals into five groups, based on
when they adopt an innovation: innovators are the first to adopt, followed by early adopters , then
early majority adopters , followed by late majority adopters and finally laggards . The process of
adoption in a population over time, as described by DOI, roughly follows a standard normal distribution:
early majority adopters and late majority adopters are within one standard deviation of the mean; early
adopters and laggards are within two standard deviations; and innovators are within three standard
deviations of the mean. There are certain attributes of an innovation that determine the speed and extent
of its diffusion. These attributes include: the relative advantage of the innovation over existing
alternatives; its compatibility with the intended audience; its complexity , or ease of use; its trialability
, or whether or not someone can try the innovation before deciding whether or not to adopt it; the
observability or measurability of its results; its likely impact on social relations ; its reversibility ; its
communicability , or how easily and clearly it can be understood; the time required to adopt the
innovation; the level of risk or uncertainty associated with its adoption; the level of commitment
required to use the innovation effectively; and the modifiability of the innovation over time.

Early adopters 7:
“Those in the population who accept a new idea or practice soon after the innovators (but before the
middle majority), and who tend to be opinion leaders for the middle majority.”

Ecological approaches/levels 9:
Ecological approaches recognize the multiple levels of influence on and the varying nature of
determinants of health. They view health behavior as both affected by and affecting the physical and
social environment (reciprocal determinism). They move beyond a “victim blaming,” individual-level
approach to health promotion, emphasizing the use of multiple strategies to impact determinants of
health, partnerships between multiple sectors to enhance health promotion efforts, and targeting change
at multiple levels of intervention. The levels of an ecological approach in health promotion include
intrapersonal factors, interpersonal processes and primary groups, institutional factors, community
factors, and public policy.

Empowerment:
“A social action process that promotes participation of people, organizations and communities in gaining
control over their lives in their community and larger society. With this perspective, empowerment is not
characterized as achieving power to dominate others, but rather power to act with others to affect
change.” 6 “In health promotion, empowerment is a process through which people gain greater control
over decisions and actions affecting their health.”5

Environment/environmental factors 1:
Factors that influence an individual's behavior but are physically external to the individual. The
environment/environmental factors are explicitly important in social ecological approaches to health
education and health promotion, as well as in Social Cognitive Theory.

Ethics in health promotion and health promotion research:

Ethical principles in health education and health promotion practice and research are similar to those
outlined in the Belmont Report and earlier ethical codes and include principles of respect for persons,
beneficence, and justice. In health promotion practice and research, these ethical principles call for
informed consent and voluntary participation, a commitment to preserve participant privacy, equitable
inclusion in programs and research, a protection of vulnerable populations, and careful efforts to
maximize benefits and minimize risks for participants. A unified code of ethics for the health education
profession was adopted in 1999, outlining each health educator's responsibilities to the public, to the
profession, to employers, in delivering health education, in conducting research and evaluation, and in
professional preparation. The code of ethics is available at www.cnheo.org.

Evaluation 7:
“The comparison of an object of interest against a standard of acceptability.” In health education and
health promotion, evaluation is typically thought about in three distinct phases: formative, process and
summative.

Evidence-based practice 7:
“Program decisions or intervention selections made on the strength of data from the community
concerning needs and data from previously tested interventions or programs concerning their
effectiveness, sometimes using theory in the absence of data on the specific alignment of interventions
and population needs.”

Feedback 1:
Information provided to individuals based on their individual characteristics or based on comparisons
with others. Major types of feedback, in the context of health communication and communication
technology, include personal feedback, normative feedback, and ipsative (or iterative) feedback.
Personal feedback “refers to the information that respondents obtain about the answers they have
provided.” Normative feedback “refers to the information respondents obtain when comparing their
responses with the responses of another group.” Ipsative feedback “refers to a comparison between a
person's most recent status and that found at previous assessments.”

Focus group 31:

A focus group study is a carefully planned series of discussions designed to obtain perceptions on a
defined area of interest in a permissive, nonthreatening environment.

Formative evaluation 7-8:

“Any combination of measurements obtained and judgments made before or during the implementation
of materials, methods, activities or programs to discover, predict, control, ensure, or improve the quality
of performance or delivery.” This can include the combination of needs assessment, pilot testing,
process evaluation, etc.

Formative research 11:

“Assesses the nature of the problem, the needs of the target audience, and the implementation process
to inform and improve program design. Formative research is conducted both prior to and during
program development to adapt the program to audience needs. Common methods include literature
reviews, reviews of existing programs, and surveys, interviews, and focus group discussions with
members of the target audience.”

Gatekeeper:
An individual who formally or informally controls aspects of a community and/or access to a priority
population. Gatekeepers are typically very knowledgeable of a community and how it functions. In
community health, gaining the cooperation of the community gatekeeper(s) can improve the feasibility,
quality and acceptability of community interventions and programs.
Hardiness 21:
A positive coping influence characterized by “high levels of perceived control, commitment to succeed,
and a propensity to see stressful life events as challenging.” Challenging, in the context of hardiness,
reflects an individual's ability to view stressful situations and experiences as an opportunity for growth
and development and not as a threat. Hardy individuals are less likely to experience illness as a result of
stressful events.

Harm reduction:
An intermediate approach to behavior change that emphasizes adopting a lower risk alternative to a high
risk behavior when an individual is either unwilling or unable to stop the high risk behavior. Needle
exchange programs that facilitate the use of sterile injection equipment in order to reduce the
transmission of HIV among injection drug-users are an example of harm reduction.

Health belief model (HBM) 1:

An individual-level, value-expectancy health behavior theory developed in the 1950s by social
psychologists in the U.S. Public Health Service in efforts to explain why people did not seek preventive
health and screening services. The theory was first used in relation to a free Tuberculosis screening
program, but has since been applied to numerous health behaviors. The HMB maintains that an
individual will engage in behavior to prevent, screen for or control disease or negative health outcomes if
they 1) perceive themselves to be at risk for that disease; 2) believe that the disease has potentially
serious consequences; 3) believe that a recommended (and available) behavior is effective in reducing
their risk for or the consequences of the disease; and 4) believe that the perceived barriers or costs of
engaging in that behavior are fewer than the perceived benefits. Internal or external cues to action can
motivate a person to take action. Self-efficacy was added as a construct to the HBM in the late 1980s.

Health disparities 10:

Differences in the incidence, prevalence, mortality, burden of diseases or other adverse health
conditions that exist among specific groups within the general population. “A chain of events signified by
a difference in: (1) environment, (2) access to, utilization of, and quality of care, (3) health status, or (4) a
particular health outcome that deserves scrutiny.”

Health literacy 11:

“The degree to which individuals have the capacity to obtain, process, and understand basic health
information and services needed to make appropriate health decisions.”

Health Insurance Portability and Accountability Act (HIPAA) 14:

A statute passed in 1996 in efforts to improve the efficiency of healthcare delivery by mandating and
standardizing the electronic exchange of health information and to provide Federal protections to
preserve the privacy of protected, individually identifiable health information. Under HIPAA's Privacy
Rule, which has been effective since April, 2003, an individual has the right to see and correct his health
records, to know how information from those health records is being used and shared, and to deny
permission for those health records to be used for certain purposes. In many cases, an individual must
provide written permission for certain individuals or groups to be able to received information from his
personal health records, unless that information is needed to provide continuity of care or is required to
be reported for public health surveillance purposes.

Health status 5:
“A description and/or measurement of the health of an individual or population at a particular point in
time against identifiable standards, usually by reference to health indicators.”

Impact evaluation 7:
“The assessment of program effects on intermediate objectives including changes in predisposing,
enabling, and reinforcing factors, behavioral and environmental changes, and possibly health and social
outcomes.”

Information-motivation-behavior (IMB) 15:

A general model that holds that information, motivation, and behavioral skills are the primary
determinants of health-related behaviors. Individuals who are well informed, highly motivated, and who
have the necessary behavioral skills are more likely to engage in a specific health-related behavior. The
specific types of information, motivational strategies and behavioral skills necessary to lead to behavior
change are expected to vary between subpopulations and between behaviors. Behaviorally relevant
information is considered “a necessary but not a sufficient condition” for risk reduction behavior. In
general even a well-informed and behaviorally skilled individual must be highly motivated in order to
engage in a specific health-promoting behavior and to maintain it over time.

Institutionalization:
Involves “permanently” incorporating program activities into the routines and structure of an organization
or community in order to maximize the long-term benefits of your program and to ensure its sustainability
following staffing changes, the termination of formal activities and/or grant funding, etc.

Intervention mapping 16:

A program planning framework intended to facilitate the development of theory- and evidence-based
health promotion programs. Following a thorough review of the literature and an appropriate needs
assessment, the process of intervention mapping includes five steps: “1) creating matrices of proximal
program objectives from performance objectives and determinants of behavior and environmental
conditions; 2) selecting theory-based intervention methods and practical strategies; 3) designing and
organizing programs; 4) specifying adoption and implementation plans; and 5) generating an evaluation
plan.” In step one, a list of performance objectives are generated that define the desired behavioral and
environmental outcomes of the program; personal (internal) and external determinants of the behavioral
and environmental outcomes are specified; if determinants vary by sub-population, the target population
is differentiated; and, finally, performance objectives and determinants are linked in a matrix format,
often by level (i.e. individual vs. organizational) and by sub-population, if applicable. Each cell in the
resulting matrices will contain either a learning objective (linking a performance objective with a personal
determinant) or a change objective (linking a performance objective with an external determinant) that
defines what individuals need to learn or what changes need to take place in the environment as a result
of the program. In step 2, a list of theoretical intervention methods (i.e. community planning) and a list of
possible strategies for delivering those methods (i.e. community forums or meetings) are developed,
based on the identified proximal objectives. In step 3, the selected strategies are operationalized into
deliverable program components and delivery mechanisms (i.e. channel selection), and program
materials are developed and pre-tested. During step 4, a “linkage system” between program users and
developers is created so that the program can be modified to meet the needs of the users; adoption and
implementation performance objectives are developed; determinants of adoption and implementation are
specified; and an implementation plan is developed. Finally, step 5 involves developing an evaluation
model, including a plan for process evaluation.

Intervention message:
A program-specific message delivered to an individual or group that is designed to increase awareness
of a health problem, motivate behavior change, address perceived barriers to engaging in a health
behavior, or something else related to the goals and objectives of the program. Theory-based and
tailored intervention messages are typically the most effective.

Lay health advisor (or lay health worker or community health worker):
A member of the target community that is trained to administer health promotion messages and program
activities. Lay health advisors are often used to overcome language barriers, to enhance the cultural
relevance of health promotion programs, to facilitate access to and understanding of a community
among program planners, to help connect members of the target population with services, etc.

Levels of prevention (primary, secondary, tertiary):

Reflect the different points of prevention and intervention in health education and health promotion. See
definitions for primary prevention, secondary prevention and tertiary prevention.

Locus of control 21:

A generalized belief that circumstances and rewards are under one's own (internal locus of control) or
others' control (external locus of control).

Mediating factors 28:

A factor that partially or completely explains the relationship between a predictor and a behavior or
outcome. A mediating factor is independently related to the outcome of interest and to the predictor of
interest, thereby acting as a link between the two. For example, in the Theory of Reasoned Action, a
person's behavioral intention acts as a mediating factor between his attitude and subjective norms and
his behavior.

Mission statement 8:
A brief statement that defines the purpose and focus and sometimes the vision and values of an
organization or program. Typically, all program planning, program activities, partnerships, etc. should be
made to reflect to the mission statement to ensure that they are in line with the overall purpose and
goals of the program or organization.

Mixed methods 20:

The strategic and systematic combination of qualitative and quantitative research methods. The
combination of methods often works to overcome the limitations of quantitative or qualitative methods
used in isolation, to improve the validity of findings, and/or to provide a more comprehensive
understanding of a problem or phenomenon.

Motivational interviewing 1,17:

“A directive, client-centered counseling style for eliciting behavior change by helping clients to explore
and resolve ambivalence .” 17 Motivational interviewing emphasizes drawing out an individual's internal
motivations to change; allowing an individual to express and resolve her own ambivalence towards a
behavior; and avoiding direct persuasion, confrontation and argumentation. The individual is viewed as
the expert, while the primary role of the interviewer is to facilitate the individual's expression of goals and
the discovery of an acceptable resolution to the ambivalence. In theory, an individual's ambivalence is
the principle barrier to behavior change.

National health objectives:

The U.S. Department of Health and Human Services has coordinated a process to develop a set of
national health objectives to direct public health efforts each decade since 1980, starting with the
publication of Promoting Health/Preventing Disease: Objectives for the Nation. The current set of
national health objectives is contained in Healthy People 2010: Understanding and Improving Health .
Healthy People 2010 contains 467 national health objectives that cover 28 primary focus areas.

Needs assessment 7-8:

“The process of determining, analyzing and prioritizing needs, and in turn, identifying and implementing
solution strategies to resolve high priority needs.” 8 A needs assessment is meant to assist program
planners in identifying a priority population, their specific needs, subgroups of the population with the
greatest needs, the most significant problems facing the priority populations and subgroups, what is
currently being done and/or what has been done in the past to effectively address their needs, etc.
Needs assessment is generally viewed as the first step in health promotion program planning and
depends on both secondary and primary data collection gathered through a variety of qualitative and
quantitative methods.

Normative beliefs 1:
Reflect individuals' beliefs about whether important referent individuals, or people whose opinion they
value, approve or disapprove of a particular behavior. Normative beliefs, along with an individual's
motivation to comply with the opinions and values of the referent individuals, form a person's subjective
norms. Normative beliefs and subjective norms are constructs of the Theory of Reasoned Action/Theory
of Planned Behavior.

Opinion leaders 8:
“Individuals who are well respected in a community and can accurately represent the views of the priority
population.” They are typically demographically similar to the priority population, knowledgeable about
community issues and concerns, early adopters of innovations, and capable of persuading others to
engage in a particular behavior.

Organizational change 1:
The process through which organizations “innovate new goals, programs, technologies, and ideas” in
order to improve organizational efficiency and effectiveness. The Stage Theory of Organizational
Change is one theory that explains this process. The seven stages of the stage theory of organizational
change are: 1) Sensing unsatisfied demands on the system; 2) search for possible responses; 3)
evaluation of alternatives; 4) decision to adopt a course of action; 5) initiation of action within the system;
6) implementation of the change; and 7) institutionalization of the change.

Outcome evaluation 7: “Assessment of the effects of a program on the ultimate objectives, including
changes in health and social benefits or quality of life.”
Outcome expectations 1:
“Anticipatory outcomes of a behavior,” or what an individual perceives is the likely result of engaging in a
specific behavior. Outcome expectations develop from previous experience, through observing others,
hearing about specific behaviors or situations from others, or from emotional or physical responses to a
behavior. Outcome expectations are a construct of the Social Cognitive Theory.

Perceived barriers 1:
An individual's beliefs about the negative consequences of or challenges associated with engaging in a
particular health behavior. Perceived barriers can be physical, emotional, psychological, economic, etc.
Typically, the perceived benefits of a behavior must outweigh the perceived barriers for a person to
adopt that behavior. “Perceived barriers” is a key construct of the Health Belief Model.

Perceived benefits 1:
An individual's beliefs about the efficacy of a particular behavior in reducing the perceived threat
associated with a particular disease or outcome. An individual would not be expected to adopt a specific
health behavior without believing it would effectively reduce his perceived threat of disease. “Perceived
benefits” is a key construct of the Health Belief Model.

Perceived outcome expectations:

See outcome expectations.

Perceived Response efficacy 30:

Belief whether the recommended action is effective in preventing or reducing risk for a health problem. It
is important to note that ether low perceptions of self (self efficacy), or low perceptions of the
recommended action (response efficacy) may lead to maladaptive behavior. For example, people may
not feel confident that they can reduce their intake of fried foods (self efficacy) or they may not feel
confident that reducing their intake of fried foods will lower their risk of heart attack (response efficacy).
The implication for prevention is to ensure that health education supports both the belief in one's ability
to change lifestyle behaviors as well as the belief that lifestyle changes are effective in reducing risks.

Perceived self-efficacy 1:
An individual's beliefs about and confidence in his ability to perform a certain behavior or take action.
Self-efficacy influences what behaviors we choose to perform, the amount of effort we expend on
performing those behaviors, how long we persist in performing a behavior, and how we feel about
particular behaviors. Self-efficacy is developed through direct or vicarious experience, verbal or social
persuasion, and physiological reactions/feedback. Perceived self-efficacy is a concept common to many
theories of Health Behavior, but is most directly related to Social Cognitive Theory.

Perceived severity 1:
An individual's beliefs about how serious a disease or its physical and social consequences are.
“Perceived severity” is a key construct of the Health Belief Model.

Perceived susceptibility 1:
An individual's beliefs about how vulnerable, or at risk, he or she is to getting a particular disease or of
being affected by a particular health outcome. “Perceived susceptibility” is a key construct of the Health
Belief Model.

Perceived threat 1:
The combination of perceived severity and perceived susceptibility. An individual's beliefs about his
perceived susceptibility to a disease and the perceived severity of that disease combine to form his
overall beliefs about the level of threat that disease poses for him.

Pilot testing 8:
Involves implementing a program or program components on a smaller scale, in a setting similar to
where the program will be fully implemented and with a population similar to the planned target
population. Pilot testing allows program planners to identify and correct problems with the intervention
strategies before they are fully implemented.

Policy advocacy 2:
“The actions or endeavors individuals or groups engage in in order to alter public opinion in favor or in
opposition to a certain policy.”

Population-based 2, 23:
“ Community health methods that are used to help change behavior in groups of people.” Population-
based approaches use a defined community or population as their organizing principle for preventive
action over individuals, and they focus on addressing population-level processes that influence health.
Population-based approaches include policy development and advocacy, organizational change,
community development and empowerment.

PRECEDE-PROCEED framework 7:
The most well-known health program planning model. In PRECEDE-PROCEED a program planner
begins by identifying the desired outcome of the program and working backwards to discover strategies
for reaching that outcome. PRECEDE stands for p redisposing, r einforcing and e nabling c onstructs in
e ducational/ecological d iagnosis and e valuation, and includes various stages of assessment and
planning. PROCEED stands for p olicy, r egulatory, and o rganizational c onstructs in e ducational and e
nvironmental d evelopment and deals mainly with program implementation and evaluation. PRECEDE-
PROCEED has six main phases, followed by three phases of evaluation: Phase 1, social assessment
and situational analysis, involves engaging the target population to identify general indicators of quality
of life. Phase 2, epidemiological assessment, includes identifying specific health goals or problems that
contribute to or interact with the social goals or problems identified in phase 1. Phase 3, behavioral and
environmental assessment, involves identifying and prioritizing behavioral and environmental
determinants of the specific health problems identified in phase 2. Phase 4, educational and ecological
assessment, includes identifying and prioritizing predisposing, reinforcing and enabling factors that are
related to the behavioral and environmental determinants. “ Predisposing factors include a person's or
population's knowledge, attitudes, beliefs, values and perceptions that facilitate or hinder motivation for
change.” Reinforcing factors are “the rewards received and the feedback the learner receives from
others following adoption of a behavior.” “ Enabling factors are those skills, resources or barriers that
can help or hinder the desired behavioral changes as well as environmental changes.” Phase 5,
intervention alignment and administrative and policy assessment, involves “intervention matching,
mapping, and patching” to determine which program components and activities are needed to target the
factors identified in the previous stages and determining whether or not the program has the policy,
organizational and administrative capacity to do them. In phase 6, implementation occurs. Phase 7
includes process evaluation, phase 8 includes impact evaluation, and phase 9 includes outcome
evaluation.

Predictors:
Characteristics or variables that predict or otherwise help to explain a particular behavioral, health or
other outcome.

Primary data 2:
Data gathered directly by the individual using it to answer a specified research question or to gather
information on a specific population or health problem. This includes data collected first-hand through
survey research, focus groups, interviews, etc.

Primary prevention 2:
Refers to preventive measures that are intended to prevent or put off the onset of injury or disease.
Vaccinations, abstinence, and exercise are examples of primary prevention.

Process evaluation 8:
“Any combination of measurements obtained during the implementation of program activities to control,
assure, or improve the quality of performance or delivery.”

Processes of change 1:
“The covert and overt activities that people use to progress through the stages” 1 of change in the
transtheoretical model (TTM). There are ten processes of change that have been identified in
conjunction with the development of the TTM: consciousness raising, dramatic relief, self-reevaluation,
environmental reevaluation, self-liberation, helping relationships, counter-conditioning, contingency
management, stimulus control, and social liberation. Different processes of change are used by
individuals in different stages of change to progress towards action and maintenance. In the early
stages, people tend to rely more on the cognitive, affective and evaluative processes (consciousness
raising, dramatic relief, environmental reevaluation and self-reevaluation) while in the later stages the
emphasized processes of change focus on making commitments, seeking support, contingency planning
and other behavioral processes (counter-conditioning, helping relationship, stimulus control,
reinforcement management).

Protective factors:
Factors that decrease the likelihood of negative health outcomes and risk behaviors.

Psychosocial determinants 27:

Determinants of health that reflect the interaction between the social environment and an individual's
development, beliefs and behaviors. Psychosocial factors are thought to not only mediate the effects of
social and structural factors on individual health outcomes, but also to be influenced by the social
structures and contexts in which they develop. Coping skills or social support following a stressful
experience are examples of psychosocial determinants.

Qualitative research 12:

Utilizes methods that results in the collection of non-numeric data that are not highly categorized or
defined prior to data collection. Open-ended surveys, focus groups, in-depth interviews, observational
and case studies typically result in qualitative data.

Quality of life 7:
“The perception of individuals or groups that their needs are being satisfied and that they are not being
denied opportunities to achieve happiness and fulfillment.”

Quantitative research 12:

Utilizes methods that result in the collection of numerical and typically predefined data. Statistical
methods are employed to analyze and interpret quantitative data. Closed-ended surveys are an example
of quantitative research.

Quasi-experimental design 13:

Any research design that does not use randomization in assigning units (individuals) to conditions or
treatments. Quasi-experiments depend on self-selection or administrator selection to assign individuals
to conditions but they are otherwise structurally similar to a randomized experimental design.

Reciprocal determinism 1:
“The dynamic interaction of the person, behavior, and the environment in which the behavior is
performed.” In other words, the concept of reciprocal determinism emphasizes that health behaviors and
individuals are not only influenced by the physical and social context in which they exist, but also that
such individuals and their behavior influences the environment. Reciprocal determinism is a key
construct of the Social Cognitive Theory and in ecological approaches to health promotion.

Relapse prevention 8, 26:

“A self-control program designed to help individuals to anticipate and cope with the problem of relapse in
the habit-changing process.” According to the Relapse Prevention Model, which is based on social-
cognitive psychology, relapse is influenced by both immediate determinants and covert antecedents to
high-risk situations. Immediate determinants of relapse include high-risk situations, coping skills,
outcome expectancies, and the abstinence violation effect (the individual's emotional response to an
initial lapse and what he attributes that lapse to). Covert antecedents to high-risk situations—lifestyle
factors (i.e. stress and lifestyle imbalance) or cognitive factors such as cravings and urges—can
increase the likelihood of relapse by increasing an individual's exposure to high-risk situations and/or by
decreasing the individual's motivations to resist a lapse in behavior. The Relapse Prevention model
outlines various intervention strategies for identifying, preventing, or avoiding the determinants and
antecedent causes.

Resilience 22:
“The process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant
sources of stress—such as family and relationship problems, serious health problems, or workplace and
financial stressors. It means ‘bouncing back' from difficult experiences.”

Perceived Response efficacy :

Belief whether the recommended action is effective in preventing or reducing risk for a health problem. It
is important to note that ether low perceptions of self (self efficacy), or low perceptions of the
recommended action (response efficacy) may lead to maladaptive behavior. For example, people may
not feel confident that they can reduce their intake of fried foods (self efficacy) or they may not feel
confident that reducing their intake of fried foods will lower their risk of heart attack (response efficacy).
The implication for prevention is to ensure that health education supports both the belief in one's ability
to change lifestyle behaviors as well as the belief that lifestyle changes are effective in reducing risks.

Risk behavior 5:
“Specific forms of behavior which are proven to be associated with increased susceptibility to a specific
disease or ill-health.”
Risk communication 11:
“Engaging communities in discussions about environmental and other health risks and about
approaches to deal with them. Risk communication also includes individual counseling about genetic
risks and consequent choices.”

Screening behavior:
Seeking diagnostic (screening) tests to check for the presence of disease or precursors to disease,
typically prior to the development of outward signs and symptoms. Screenings, as a form of secondary
prevention, facilitate early diagnosis of disease and often improve disease outcomes.

Secondary data 2:
Pre-existing data collected by somebody other than the individual using it. Secondary data is often used
in conducting needs assessments and/or to supplement primary data.

Secondary prevention 2:
Preventive measures that are directed at the early diagnosis and treatment of injuries and diseases to
limit disability and prevent the development of complications and more serious disease. Screening tests
and self-exams for breast cancer are examples of secondary prevention strategies.

Self-management:
The process of taking an active responsibility for and control over managing and monitoring one's health,
including managing chronic diseases and disability.

Self-report (data) 8:
Data that are generated by having respondents report about themselves. Self-report data are common in
sociaorgal and behavioral sciences, but their validity is often questioned because of potential bias.

Social capital 5, 7:
“Social capital represents the degree of social cohesion which exists in communities. It refers to the
processes between people which establish networks , norms, and social trust, and facilitate co-
ordination and co-operation for mutual benefit.” 5 Social capital is “usually characterized by four
interrelated constructs: trust, cooperation, civic engagement, and reciprocity.” 7

Social cognitive theory (SCT) 1:

A health behavior theory that describes the reciprocal influence and dynamic interaction between an
individual's personal factors, the environment, and specific health behaviors. Major constructs of the
SCT include environments , situations (an individual's cognitive perceptions of the environment that
may affect his behavior), behavioral capability , outcome expectations , outcome expectancies (the
value an individual places on an expected outcome), self-regulation (ability to engage in goal-directed
behavior), observational learning, reinforcements, perceived self-efficacy , emotional coping
responses, and reciprocal determinism . The SCT maintains that personal factors within individuals—
their behavioral capability, self-efficacy, outcome expectations and expectancies, coping mechanisms,
and self control—are key determinants of behavior and both influence and are influenced by the
environment. The environment is important partially because it provides models for and opportunities for
observational learning and reinforcement, increasing the likelihood that certain behaviors are performed.
Based on the concept of reciprocal determinism any change in the person, environment or behavior
results in a situational change, necessitating a reevaluation of the interaction between the three.

Social ecology 1:
The “study of the influence of the social context on behavior, including institutional and cultural variables”

Social ecology framework 2,9:

“An approach to health education that goes beyond individual behavior change to examine and modify
the social, political, and economic factors impacting health behavior decisions.” The social ecological
framework (see also ecological approach/levels) recognizes the individual, interpersonal, community,
organizational and policy-level influences on health.

Social marketing 1,3,4:

“The application of commercial marketing technologies to the analysis, planning, execution, and
evaluation of programs designed to influence the voluntary behavior of target audiences in order to
improve their personal welfare and that of their society.” 4 Social marketing emphasizes the 4 P's of
product, price, place and promotion.

Social network 1:
“The web of social relationships that surround individuals.” Social network structures can be described
both in terms of dyadic characteristics and characteristics of the network as a while. Dyadic
characteristics include reciprocity, intensity, and complexity in interpersonal relationships. Network
characteristics include levels of homogeneity, geographic dispersion, and density.

Social norms 7:
“Perceived social patterns of and expectations for behavior.”

Socioeconomic factors:
Social and economic characteristics like education, income, and occupation that influence an individual's
ability to function or “compete” in society. Socioeconomic factors are often correlated with an individual's
health status.

Stages of change 1:
Refers to the temporal progression towards behavior change that individuals go through over time. The
stages of change are part of the Transtheoretical model, in which five stages of change are defined:
precontemplation (no intention to take action in the next six months); contemplation (thinking about
taking action in the next six months); preparation (intending to take action in the next month and has
taken some behavioral steps toward change); action (has adopted behavior change for less than six
months); and maintenance (has adopted behavior change for longer than six months). Although there is
technically a sixth stage of change—termination (no longer tempted to engage in old behavior and has
complete self-efficacy)—defined for use in the Transtheoretical model, very few people seem to reach
this stage.

Stakeholders 7:
“People who have an investment or a stake in the outcome of a program and therefore have reasons to
be interested in the evaluation of the program.”

Stereotyping:
Making generalizations or assumptions about an individual based on a characteristic or attribute that
individual shares with a larger group.
Stress and coping 21:
Stress is the experience of psychological or emotional distress in response to an event or experience.
Stress can produce physiological changes in the body that may be associated with illness and disease.
Coping consists of “an individual's ongoing efforts to manage specific external and internal demands that
are appraised as taxing or exceeding personal resources.”

Structural intervention:
An intervention that focuses on influencing or changing the social, political, physical or economic
environment to facilitate healthy behaviors or behavior change in large groups of people.

Subjective norm 1:
An individual's “belief about whether most people approve or disapprove” of a particular behavior.
Subjective norms directly influence a person's intentions to engage or not engage in that behavior.
Subjective norm is a key construct of the Theory of Reasoned Action/Theory of Planned Behavior. (See
also normative beliefs).

Subpopulation:
A group, or subset, of people within a population that share a common characteristic. Subpopulations
within intended audiences are often defined in order to facilitate understanding of the group and to be
able to better tailor messages to fit their needs and behaviors.

Summative evaluation:
“The application of design, measurement and analysis methods to the assessment of outcomes of a
program or specific interventions within a program.” 7 Outcome and impact evaluation are collectively
referred to as summative evaluation.

Sustainability 8:
“The maintenance and institutionalization of a program or its outcomes.”

Tailoring 7:
“The use of information about individuals to shape the message or other qualities of a communication or
other intervention so that it has the best possible fit with the factors predisposing, enabling, and
reinforcing that person's behavior.”

Target group/intended audience:

The primary population expected to receive/benefit from a specific health promotion program's
messages, activities and interventions. Typically the target group is the group of people most at risk or
most affected by a specific health problem.

Tertiary prevention 2:
Preventive measures directed at rehabilitating, training and educating an individual who has already
reached a point of disability, impairment or dependency. Tertiary prevention is the final level of
prevention and includes measures such as disease management education for diabetics or for
individuals who are recovering from a heart attack.

Theoretical construct 1:
The building blocks or primary elements of a theory that have been developed or adopted for use in that
particular theory. Constructs are understood only within the context of the theories they are associated
with. For example, perceived susceptibility, perceived severity, and perceived barriers are constructs of
the Health Belief Model.

Theory 1:
“A set of interrelated constructs, definitions, and propositions that presents a systematic view of events
or situations by specifying relations among variables in order to explain and predict the events or
situations.”

Theory of planned behavior (TPB) 1:

An extension of the Theory of Reasoned Action that takes into consideration an individual's perceived
control over engaging in a particular behavior, in addition to his attitudes towards and subjective norms
surrounding that behavior. Perceived behavioral control was added in efforts to account for factors
beyond the individual's control that potentially influence his behavioral intentions and, ultimately,
behavior. People may expend more energy and try harder to perform a behavior when they perceive that
they have high behavioral control, or are capable and have sufficient resources to engage in that
behavior and overcome any barriers. Perceived behavioral control is a function of control beliefs (beliefs
about the presence or absence of resources and barriers to performing a behavior) and perceived power
(beliefs about the influence of each perceived resource or barrier on the difficulty of engaging in the
behavior).

Theory of reasoned action (TRA) 1:

According to the Theory of Reasoned Action, the most important determinant of a behavior is an
individual's behavioral intention , or “perceived likelihood of performing the behavior.” An individual's
behavioral intention is influenced directly by that person's attitude toward the behavior and subjective
norms . Attitude toward a behavior is a function of a person's behavioral beliefs (beliefs about the likely
outcomes and attributes of a particular behavior) and his evaluation of behavioral outcomes (the value
that he places on the likely outcomes and attributes). Again, subjective norms are formed by a person's
normative beliefs and motivations to comply .

Transtheoretical model of change (TTM) 1:

A model of individual health behavior that integrates processes of change and theoretical principles from
multiple leading theories across several disciplines. The TTM is a stage-based model that takes into
account an individual's readiness to change and views behavior change as a process that occurs over
time and not as a finite event. Intervention messages and strategies are based on appropriate processes
of change and are developed and matched to an individual's readiness to change. There are five main
stages of change (see stages of change) and ten processes of change (see processes of change) that
have been empirically linked in the TTM. In addition to the concepts of stages and processes of change,
the TTM also asserts that, in order for an individual to take action and maintain a behavior change, that
person must perceive that the benefits, or pros, of change outweigh the cons ( decisional balance ).
Situational self-efficacy —the confidence one feels in his or her ability to resist relapsing and engaging in
an unhealthy or high-risk behavior in specific, tempting situations—is the final key construct of the TTM.

Voucher:
A coupon or document that can be exchanged for a service, incentive or something else as decided by
the distributor. Vouchers are used in health promotion to encourage individuals to participate in
programs, to link individuals to and to coordinate services between program partners, as incentives, etc.

References
1. Glanz K, Rimer BK, & Lewis FM (Eds). (2002). Health Behavior and Health Education: Theory,
Research and Practice, 3 rd Edition. San Francisco : Jossey-Bass.
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Education, 2nd Edition. San Francisco: Benjamin Cummings.
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4. Andreasen, A.R. (1995). Marketing Social Change . San Francisco : Jossey-Bass.
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8. McKenzie JF, Neiger BL, & Smeltzer JL. (2005). Planning, Implementing and Evaluating Health
Promotion Programs: A Primer, 4th edition. San Francisco : Benjamin-Cummings.
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promotion programs. Health Education Quarterly. 15(4): 351-377.
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426-434.
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Understanding and Improving Health. Available at www.healthypeople.gov .
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Handbook of Health Promotion and Disease Prevention. New York : Plenum Publishers.
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for Generalized Causal Inference. Boston : Houghton Mifflin Company.
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DiClemente RJ (1999). Handbook of Health Promotion and Disease Prevention. New York :
Plenum Publishers.
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Research: Implications for Public Health Funding. Am J Public Health. 93(8): 1210-1213.
20. Chen HT. (2006). A theory-driven evaluation perspective on mixed methods research. Research
in the Schools. 13(1): 75-83.
21. Clark LF, Aaron L, Littleton M, Pappas-Deluca K, Avery JB, & McKleroy VS. (1999). Stress,
coping, social support and illness. In Raczynski JM, & DiClemente RJ (1999). Handbook of
Health Promotion and Disease Prevention. New York : Plenum Publishers.
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http://www.apahelpcenter.org/dl/the_road_to_resilience.pdf .
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Management. Gaithersburg , MD : Aspen Publishers, Inc.
24. Sharpe PA, Greaney ML, Lee PR, & Royce SW. (2000). Assets-oriented community assessment.
Public Health Reports. 115: 205-211.
25. Gilmore GD, & Campbell MD. (2005). Needs and Capacity Assessment Strategies for Health
Education and Health Promotion. Boston : Jones and Bartlett Publishers, Inc.
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Cognitive-Behavioral Model. Alcohol Research & Health. 23(2): 151-160.
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29. Rogers EM. (2003). Diffusion of Innovations, 5 th Edition . New York : Simon & Schuster.
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Thousand Oaks, CA: Sage
Core Area Chapters

The texts below are among the most widely used in the field for teaching social and behavioral
sciences to MPH students. Most give an overview of the field and should contain definitions for
terms in the terminology section as well as answers to most of the sample questions. Studying all
of these texts is not recommended. Rather, one of these may be useful if a general text has not
been consulted in preparing for the examination:

• Bensley RJ, Brookins-Fisher J. Community Health Education Methods. 2 nd ed. Boston : Jones
and Bartlett Publishers; 2001:292.
• Coreil J, Bryant C, Henderson JN. Social and Behavioral Foundations of Public
Health. Thousand Oaks , Cal : Sage; 2001.
• Glanz K, Lewis FM, Rimer BK. Health Behavior and Health Education: Theory, Research, and
Practice. 3 rd ed. San Francisco : Jossey-Bass, Inc.; 2002.
• Green LW, Kreuter MW. Health Promotion Planning: An Educational and Ecological Approach.
4 th ed. New York : McGraw Hill Publishing Company; 2005. ISBN 00729854292005.
• Kettner PM, Moroney RK, Martin LL. Designing and Managing Programs: An Effectiveness-
Based Approach. Newbury Park , Cal : Sage; 2003.
• McKenzie JM, Smelter J. Planning, Implementing, and Evaluating Health Promotion Programs.
4 th edition. Boston : Allyn and Bacon; 2005.
• Nutbeam D, Harris E. Theory in a Nutshell: A Guide to Health Promotion Theory. 2 nd ed.
Sydney : McGraw-Hill Australia ; 2004.

The following texts are also widely used, but somewhat more limited in scope, as their
titles suggest:
• DiClemente RJ, Crosby RA, Kegler MC, eds. Emerging Theories in Health Promotion Practice
and Research: Strategies for Improving Public Health. San Francisco : Jossey-Bass, John
Wiley & Sons; 2002: 432 pages.
• Gilmore GD, Campbell MD. Needs and Capacity Assessment Strategies for Health Education
and Health Promotion. 3 rd ed. Sudbury , Mass: Jones and Bartlett Publishers; 2004:265.
• Israel BA, Eng E, Schulz AJ, Parker EA, eds. Methods in Community-Based Participatory
Research for Health. San Francisco : Jossey-Bass; 2005: 528 pages.
• Minkler, M., & Wallerstein, N. (Eds.). Community-based participatory research for health. San
Francisco, CA: Jossey-Bass, 2003.
• National Cancer Institute. Making Health Communications Work . Washington : National
Institutes of Health; 2001. NIH Publication No. 02-5145.
• Peterson DJ, Alexander GR. Needs Assessment in Public Health – A Practical Guide for
Students and Professionals. New York : Kluwer Academic/Plenum Publishers; 2001:139.
• Rogers EM. Diffusion of Innovations. 5 th ed. New York : Free Press; 2003. Articles/Chapters
Addressing Important Issues in the Field
• Steckler, A., & Linnan, L. (Eds.). Process evaluation for public health intervention and research.
San Francisco: Jossey-Boss, 2002.
• Windsor, R., Clark, N., Boyd, N. R., & Goodman, R. M. Evaluation of health promotion, health
education and disease prevention programs 3rd ed. New York: McGraw-Hill, 2003.

The following list is not exhaustive, but provides a starting place for reviewing some
important issues in the field of social and behavioral sciences in public health:
• Altman D, Goodman RM. Community intervention. In: Baum A, Revenson TA, Singer JE,
eds. Handbook of Health Psychology. Malwah , NJ : Lawrence Erlbaum Associates Publishers;
2001:591–612.
• Berkman LF, Glass T. Social integration, social networks, social support, and health. In:
Berkman LF, Kawachi I, eds. Social Epidemiology. New York : Oxford University Press; 2000.
• Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O. Defining cultural competence: a
practical framework for addressing racial/ethnic disparities in health and health care. Public
Health Reports. 2003; 118:293–302.
• Betancourt JR, Green AR, Carrillo JE, Park ER. Cultural competency and health care
disparities: key perspectives and trends. Health Affairs. 2005:24(2) : 499–505.
• Butterfoss FD, Goodman RM, Wandersman A. Community coalitions for prevention and health
promotion. Health Education Research. 1993; 8(3):315–330.
• Glanz K, Kegler MC, Rimer BK. Ethical issues in the design and conduct of community-based
intervention studies. In: Coughlin S, Beauchamp T, Weed D, eds. Ethics in Epidemiology. 2 nd
ed. New York : Oxford University Press; 2007.
• Hawe P, Shiell A. Social capital and health promotion: a review. Social Science & Medicine.
2000; 51: 871–885.
• Institute of Medicine (IOM). Behavioral risk factors. In: Health and Behavior: The Interplay of
Biological, Behavioral, and Societal Influences. Washington : National Academy Press; 2001.
• Kaplan SA, Garrett KE. The use of logic models by community-based initiatives. Evaluation and
Program Planning. 2005; 28:167–172.
• Kripalani S, Weiss BD. Teaching about health literacy and clear communication. Journal of
General Internal Medicine. 2006; 21(8):888–890.
• Marmot M. Social determinants of health inequalities. The Lancet. 2005; 365 (9464): 1099-
1104.
• McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective for health promotion
programs. Health Education Quarterly. 1988; 15(4).
• Putnam R. Social capital measurement and consequences. ISUMA. Spring 2001:41–51.
• Snyder LB, Hamilton MA , Mitchell EW, Kiwanuka-Tondo J, Fleming-Milici F, Proctor D. A meta-
analysis of the effect of mediated health communication campaigns on behavior change in the
United States . Journal of Health Communication. 2004; 9(suppl 1):71–96.
• Suggs LS. A 10-year retrospective of research in new technologies for health communication.
Journal of Health Communication. 2006; 11(1):61–74.

Other Sources of Important Information

• CDC Evaluation WorkingG: Framework for Program Evaluation
http://www.cdc.gov/eval/framework.htm
• CDCynergy is a multimedia CD-ROM used for planning, managing, and evaluating public health
communication programs. This innovative tool is used to guide and assist users in designing
health communication interventions within a public health framework
http://www.cdc.gov/healthmarketing/cdcynergy/
• Community tool box: http://ctb.ku.edu/en/
• Community-campus partnerships for health: transforming communities and higher education
http://depts.washington.edu/ccph/commbas.html (this provides information on CBPR)
• Deeds SG, Hayden J. The Health Education Specialist: A Study Guide for Professional
Competence. 4 th ed. Allentown , Penn: National Commission for Health Education
Credentialing (NCHEC); 2000.
• National Center for Cultural Competence. Conceptual Frameworks/Models, Guiding Values,
and Principles. Washington : Georgetown University ; 2006. Available
 at: http://www11.georgetown.edu/research/gucchd/nccc/foundations/frameworks.html.
• Wilkinson R, Marmot M, eds. Determinants of Health: The Solid Facts. 2 nd ed. Copenhagen :
World Health Organization; 2003. Available at: http://www.who.dk/document/e81384.pdf,
http://www.euro.who.int/document/e81384.pdf.
• Zaza S, Briss PA, Harris KW, eds. The Guide to Community Preventive Services: What Works
to Promote Health? Task Force on Community Preventive Services, Centers for Disease
Control and Prevention. New York : Oxford University Press; 2005. Available
at: http://www.thecommunityguide.org.
Core Area Chapters

1. Many people do not attempt to decrease unhealthy behaviors such as overeating or smoking because they lack
the confidence that they can successfully change. This is an example of:
(A) Perceived susceptibility
(B) Perceived severity
(C) Perceived self-efficacy
(D) Perceived response efficacy

2. The construct of normative beliefs is from which model/theory?

(A) Transtheoretical model
(B) Theory of reasoned action/planned behavior
(C) Social cognitive theory
(D) Social ecological model

3. Which of the following do social cognitive theory and the social ecological model have in common?
(A) Both take into consideration factors that are within the individual and factors that operate outside the individual.
(B) Both focus primarily on environmental determinants of behavior that must be addressed at the policy level.
(C) Both come out of the value expectancy paradigm that associates behaviors with valued outcomes.
(D) Both originally were developed exclusively to explain unhealthy versus healthy behaviors.

4. A population of rural women experiences a high rate of mortality related to breast cancer. Researchers at a
local u niversity implement a breast cancer screening intervention. This intervention is an example of:
(A) Tertiary prevention
(B) Advocacy
(C) Secondary prevention
(D) Primary prevention

5. All intervention messages (printed, computer-delivered, or Internet-based) must:

(A) Start with the most important information first
(B) Include graphics, pictures, and the like to attract people's attention
(C) Be written at a reading level suitable to the target population
(D) Be no longer than four sentences so that the reader does not become bored

Scenario for Questions 6–9.

Franklin 's Grove is the county seat of Franklin County , a small rural county in the So utheast. On the basis of its
demographic and economic profile, it was selected as a health improvement zone to receive Federal funds to
implement programs to improve progress toward reaching the national health objectives. Communities receiving
such funds are charged with identifying the most significant gaps betw een the current health status and national
health objectives and with putting programs in place to narrow such gaps.

6. What is the first step to take to address the goals of the funding?
(A) Consult Healthy People 2010 to identify relevant objectives
(B) Convene a group of community leaders to decide how to spend the funds
(C) Convene a group of community citizens to decide how to spend the funds
(D) Consult an expert in community health to draw up a program plan

7. Using the PRECEDE framework, the county health department has conducted a social and health
diagnosis. Some of the most severe quality-of-life problems were related to limb amputation and kidney
failure. Prevalent health problems included diabetes, hypertension, and cardiovascular disease. Which of the
 following behavioral factors are most likely responsible for the above health and quality-of-life issues in
Franklin 's Grove?
(A) Unprotected sex, early sexual initiation, use of drugs
(B) Sedentary lifestyle, high caloric consumption, low fiber intake
(C) Advanced age, low levels of education, history of racism
(D) Frequent tobacco, drug, and alcohol use

8. Given the factors presumed to be responsible for the major health problems in this scenario, what would be the
best source for community planners to use to find data on how widespread each behavioral factor is at the
state or local level?
(A) Healthy People 2010 midcourse review
(B) Behavioral Risk Factor Surveillance System (BRFSS)
(C) Community Guide to Preventive Services
(D) Morbidity and Mortality Weekly Report

9. The Franklin County health program planners intend to keep close track of the number of programs and
activities offered, the number of adults and children who participate in each program or activity, and all
feedback given by community members about the programs and activities. These actions would most
appropriately fit into which of the following evaluation categories?
(A) Cost-effectiveness
(B) Impact
(C) Outcome
(D) Process

10. Which term refers to a collective body of individuals identified by geography, common interests, concerns,
characteristics, or values?
(A) Community
(B) Population
(C) Sample
(D) Group

11. Which of the following is defined as a community's ability to define and solve its own problems?
(A) Social capital
(B) Community development
(C) Community organization
(D) Community capacity

12. Biological, environmental, behavioral, organizational, political, and social factors that contribute to the health
status of individuals, groups, and communities are commonly referred to as:
(A) Health behavior causal factors
(B) Social ecology factors
(C) Needs assessment factors
(D) Determinants of health

13. An individual's capacity to obtain, interpret, and understand basic health information and services and the
individual's competence to use such information and services in ways that enhance health are called:
(A) Medical informatics
(B) Health literacy
(C) Health education
(D) Patient education

14. Which of the following terms refers to a consumer-driven application of sales and promotional techniques to
the analysis (including the review of background information and formative work), planning, implementation,
and evaluation of programs designed to encourage positive health behaviors within intended audiences?
(A) Health communications
 (B) Health promotion
(C) Focus group testing
(D) Social marketing

15. Which of the following terms from the social cognitive theory refers to the dynamic interaction among the
person, environment, and behavior?
(A) Behavioral norms
(B) Reciprocal determinism
(C) Decisional balance
(D) Bidirectional dependence

16. A community has high rates of HIV infection among injection drug users (IDUs). The community council
decides to legalize needle exchange programs in an effort to provide clean syringes to prevent the sharing of
contaminated needles in drug-using networks. This type of program is an example of:
(A) Harm reduction
(B) Policy advocacy
(C) Community organization
(D) Behavior change

17. Theory is defined as:

(A) A branch of philosophy that deals with morality
(B) A tested set of hypotheses listed in order of importance
(C) A systematic relationship of constructs devised to analyze, predict, and otherwise explain the nature of behavior of a
specified set of phenomena
(D) A verified fact that the majority does not believe to be true

18. Which of the following is not a construct from the Health Belief Model?
(A) Susceptibility
(B) Cues to action
(C) Decisional balance
(D) Barriers

19. Which of the following processes from the Transtheoretical Model refers to substituting healthy behaviors for
unhealthy ones?
(A) Stimulus control
(B) Consciousness raising
(C) Reinforcement management
(D) Counter-conditioning

20. Which of the following is the best example of a process evaluation for a program designed to decrease
mortality from drinking and driving among high school youth?
(A) Document change in mortality associated with drinking and driving
(B) Document change in numbers of youth riding with impaired drivers
(C) Document about risks of riding with impaired drivers
(D) Document number of students who attend the school’s alcohol-free party

21. Which of the following most directly deals with the issue of internal validity in program evaluation design?
(A) Having a reliable and valid measurement instrument
(B) Having well-written process objective (s)
(C) Having a comparison group
(D) Ensuring generalizability of program effects
22. Which of the following is the best example of intrapersonal factors that affect an individual’s behavior as
outlined by the Social Ecological Model ( McLeroy et al., 1988)?
(A) National laws and policies
(B) Informal social networks
(C) Personal knowledge or skills
(D) Community partnerships

23. Which of the following is not an example of a methodology used during a social assessment?
(A) Process evaluation
(B) Focus groups research
(C) Delphi method
(D) Survey administration

24. Which of the following is not a principle/key concept in community organization and community building
practice?
(A) Critical consciousness and empowerment
(B) Critical allocation of resources and sharing among partners
(C) Principle of relevance or “start where the people are”
(D) Principle of participation

25. When a person is healthy, without signs and symptoms of disease, illness, or injury, the level of prevention
most appropriate would be:
(A) Primary prevention
(B) Secondary prevention
(C) Tertiary prevention
(D) No prevention level is needed

26. In the planning process, the group being served is referred to as the:
(A) Pilot population
(B) Key informants
(C) General population
(D) Priority population

27. The social marketing conceptual framework if known for its 4 P’s and competition. Which of the following is not
one of the 4 P’s?
(A) Price
(B) Product
(C) Population
(D) Place
Core Area Chapters

1. Many people do not attempt to decrease unhealthy behaviors such as overeating or smoking because they lack
the confidence that they can successfully change. This is an example of:
(C) Perceived self-efficacy
Perceived self-efficacy is a construct from social cognitive theory. It is defined as the level of confidence in one's ability
to undertake the recommended preventive behavior. Self-efficacy is situation specific, so a person can be very confident
in some circumstances and not in others. Additional explanations of this concept are available in several general texts
(e.g., Coriel, Glanz, Nutbeam).

2. The construct of normative beliefs is from which model/theory?

(B) Theory of reasoned action/planned behavior
The construct of normative beliefs comes from the theory of reasoned action/planned behavior. It is the belief about
whether each referent (i.e., the people important to someone) approves or disapproves of the behavior. Additional
explanations of this concept are available in several general texts (e.g., Coriel, Glanz, Nutbeam).

3. Which of the following do social cognitive theory and the social ecological model have in common?
(A) Both take into consideration factors that are within the individual and factors that operate outside the
individual.
Social cognitive theory and the social ecology model both consider factors that are within the individual and factors that
operate outside the individual (the social and physical environments). See McLeroy, et al.

4. A population of rural women experiences a high rate of mortality related to breast cancer. Researchers a t a
local university implement a breast cancer screening intervention. This intervention is an example of:
(C) Secondary prevention
Secondary prevention refers to actions taken to prevent recurrence of a previous condition or worsening of a current
condition. For instance, taking part in a cardiac rehabilitation program is secondary prevention, to stop one having
another heart attack.

5. All intervention messages (printed, computer-delivered, or Internet-based) must:

(C) Be written at a reading level suitable to the target population
Reference: National Cancer Institute (NCI). Making Health Communications Work.

Scenario for Questions 6–9.

Franklin 's Grove is the county seat of Franklin County , a small rural county in the So utheast. On the basis of its
demographic and economic profile, it was selected as a health improvement zone to receive Federal funds to
implement programs to improve progress toward reaching the national health objectives. Communities receiving
such funds are charged with identifying the most significant gaps betw een the current health status and national
health objectives and with putting programs in place to narrow such gaps.

6. What is the first step to take to address the goals of the funding?
(A) Consult Healthy People 2010 to identify relevant objectives
The first step for implementing programs that could narrow the gaps between the current health status in the county and
the national health objectives would be to consult Healthy People 2010, a national health promotion and disease
prevention initiative to increase the quality and years of healthy life and to eliminate health disparities. This action
identifies the actual national health objectives so that programs can be developed and implemented to achieve these
specific goals locally (http://www.healthypeople.gov).

7. Using the PRECEDE framework, the county health department has conducted a social and health
diagnosis. Some of the most severe quality-of-life problems were related to limb amputation and kidney
failure. Prevalent health problems included diabetes, hypertension, and cardiovascular disease. Which of the
 following behavioral factors are most likely responsible for the above health and quality-of-life issues in
Franklin 's Grove?
(B) Sedentary lifestyle, high caloric consumption, low fiber intake
The behavioral factors associated with such diseases as diabetes, hypertension, and CV disease include sedentary
lifestyle, high caloric consumption, and low fiber intake.

8. Given the factors presumed to be responsible for the major health problems in this scenario, what would be the
best source for community planners to use to find data on how widespread each behavioral factor is at the
state or local level?
(B) Behavioral Risk Factor Surveillance System (BRFSS)
The Centers for Disease Control and Prevention (CDC) operates the Behavioral Risk Factor Surveillance System
(BRFSS), a state-based system of health surveys that collects information on health risk behaviors, preventive health
practices, and health care access, primarily related to chronic disease and injury. For many states, the BRFSS is the
only available source of timely, accurate data on health-related behaviors.

9. The Franklin County health program planners intend to keep close track of the number of programs and
activities offered, the number of adults and children who participate in each program or activity, and all
feedback given by community members about the programs and activities. These actions would most
appropriately fit into which of the following evaluation categories?
(D) Process
When health programs track the number of programs, activities, and participants and also gather feedback from
community members, these actions constitute process evaluation. See: Kettner PM, Moroney RK, and Martin LL.
2003. McKenzie JM and Smelter J. 2005.

10. Which term refers to a collective body of individuals identified by geography, common interests, concerns,
characteristics, or values?
(A) Community
A “community” can be defined as “a collective body of individuals identified (or defined) by geography, common
interests, concerns, certain characteristics, or values”.

11. Which of the following is defined as a community's ability to define and solve its own problems?
(D) Community capacity
The more skills, assets, and strengths that a community has, the better prepared it is to achieve its goals
(http://www.communitycapacity.org).

12. Biological, environmental, behavioral, organizational, political, and social factors that contribute to the health
status of individuals, groups, and communities are commonly referred to as:
(D) Determinants of health
All biological, environmental, behavioral, organizational, and political, and social factors that contributes to health status
for individuals, groups, communities and beyond, are all referred to as determinants of health.

13. An individual's capacity to obtain, interpret, and understand basic health information and services and the
individual's competence to use such information and services in ways that enhance health are called:
(B) Health literacy
Health literacy includes the capability to read and comprehend the label on a prescription bottle and then to take the
medicine exactly as prescribed.

14. Which of the following terms refers to a consumer-driven application of sales and promotional techniques to
the analysis (including the review of background information and formative work), planning, implementation,
and evaluation of programs designed to encourage positive health behaviors within intended audiences?
(D) Social marketing
Reference: National Cancer Institute (NCI). Making Health Communications Work.

15. Which of the following terms refers to the dynamic interaction among the person, environment, and behavior?
(B) Reciprocal determinism
Reciprocal determinism comes from social cognitive theory (SCT) and refers to the interrelationship between a person,
her environment, and her behavior. In other words, behavior both influences, and is influenced by, the social and
physical environment.
16. A community has high rates of HIV infection among injection drug users (IDUs). The community council
decides to legalize needle exchange programs in an effort to provide clean syringes to prevent the sharing of
contaminated needles in drug-using networks. This type of program is an example of:
(A) Harm reduction
Harm reduction interventions are designed to encourage individuals to adopt a behavior that reduces risk when they are
unable or unwilling to completely eliminate their behavioral risk (e.g., reducing the number of cigarettes smoked, but not
totally quitting).

17. Theory is defined as:

(C) A systematic relationship of constructs devised to analyze, predict, and otherwise explain the nature or
behavior of a specified set of phenomena
Reference: Glanz, et al. (2002)

18. Which of the following is not a construct from the Health Belief Model?
(C) Decisional balance
Susceptibility, cues-to-action and barriers are classic HBM constructs, going back to the initial formulations of this
theory. On the other hand, decisional balance is often employed within stages of change theory, particularly in SOC’s
Strong and Weak Principles.
Reference: Glanz, et al. (2002) pp. 45-66

19. Which of the following processes from the Transtheoretical Model refers to substituting healthy behaviors for
unhealthy ones?
(D) Counter-conditioning
Within the Transtheoretical Model, stage movement is accompanied by one or more processes of change. Counter-
conditioning, that is substituting healthy behaviors for unhealthy ones, is active during action and maintenance.
Reference: Glanz, et al. (2002) pp 99-120

20. Which of the following is the best example of a process evaluation for a program designed to decrease
mortality from drinking and driving among high school youth?
(D) Document number of students who attend the school’s alcohol-free party
Process evaluation is concerned with how the program is delivered. It deals with issues such as when program activities
occur, where they occur, and who delivers them and how many people participate in those activities.
Reference: Steckler & Linnan (2002)

21. Which of the following most directly deals with the issue of internal validity in program evaluation design?
(C) Having a comparison group
Internal validity is defined as the extent to which an observed impact can be attributed to a planned intervention and not
to other factors. In order to do that, we employ evaluation designs, where in most cases, except for the one group
pretest and post-test design which is the weakest design-a comparison group is incorporated.
Reference: Windsor et al.(2003)

22. Which of the following is the best example of intrapersonal factors that affect an individual’s behavior as
outlined by the Social Ecological Model (McLeroy et al., 1988)?
(C) Personal knowledge or skills
Intrapersonal factors are defined as characteristics of the individual such as knowledge, attitudes, self-concept and
skills.
Reference: McLeroy et al (1988) pp 351-377

23. Which of the following is not an example of a methodology used during a social assessment?
(A) Process evaluation
Social assessment is the process of gathering information through multiple sources and through broad participation in
order to enhance the understanding of people regarding their own quality of life and aspirations for the common good.
Strategies to conduct social assessment include asset mapping, the nominal group process, the Delphi method, focus
groups, surveys and public service data.
Reference: Green and Kreuter (2005)

24. Which of the following is not a principle/key concept in community organization and community building
practice?
 (B) Critical allocation of resources and sharing among partners
Although there is no single model regarding community building there are several key concepts that affect and measure
change at the community level. These are: critical consciousness and empowerment, community competence, the
principles of participation and relevance, issue selection and measurement and evaluation of community organizing
efforts.
Reference: Minkler, M. (Ed.) (1999)

25. When a person is healthy, without signs and symptoms of disease, illness, or injury, the level of prevention
most appropriate would be:
(A) primary prevention
Primary prevention includes preventive measures that forestall the onset of illness or injury during the prepathogenesis
period.
Reference: McKenzie et al (2009)

26. In the planning process, the group being served is referred to as the:
(D) Priority population
The priority population is the people for whom the program is intended.
Reference: McKenzie et al (2009)

27. The social marketing conceptual framework if known for its 4 P’s and competition. Which of the following is not
one of the 4 P’s?
(C) Population
The social marketing framework includes five key concepts: the product (behavior being promoted) and its competition;
the price (social, emotional, and monetary costs exchange for the product’s benefits); place (where the exchange takes
place and/or where the target behavior is practiced); and promotion (activities used to facilitate the exchange.)
Reference: Coreil and Henderson (2001)