University of Gondar,

College of Medicine & Health Sciences

Institute of Public Health
Department of Health promotion and Health Behavior

Course Health Education& communication

Course number
Department HI
Credit Hour 02(32 hours)

Wallelign. A (MPH/HPC)

1
Course contents
Unit 1. Introduction to Health Education
◦ 1.1. Definition of Health &Health Education
◦ 1.2 Primary health care (PHC) concepts and components
◦ 1.3. Aim & principles of Health Education
◦ 1.4 HI, HE and HP
Unit 2. Health & Human Behavior
◦ 2.1 Definition of Behavior
◦ 2.2. Factors affecting human behavior
◦ 2.3. Principles of learning 

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 Unit 3. Theories Models in Health Education
◦ 3.1. Health Belief Model (HBM)
◦ 3.2. Theory of Reasoned Action (TRA/TPB)
◦ 3.3. Trans Theoretical Model (TTM)
◦ 3.4. PRECEDE-PROCEED framework
◦ 3.5. Social learning theory/Social cognitive theory
 Unit 4. Communication
◦ 4.1. Define Communication
◦ 4.2. Components of Communication
◦ 4.3. Types of Communication
◦ 4.4. Traditional means of communication
◦ 4.5. Barrier of communication
◦ 4.6 Diffusion of an Innovation

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 Unit 5. PIE Health Promotion program
 Unit 6. Health education settings

6.1. patient education

6.2. School Health
6.3. prison health
 Unit 7. Principles of HP

7.1. Social marketing

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 Evaluation
Assignment-------------30%
Test-----------------------20%
Written Exam ---------50%

5
Assignment to be submitted(30%)
Group1. Counselling
Group 2. Health teaching methods and materials
Group 3. Application of HE in PHC
Group 4. Medical error
Group 5. Group dynamics and Health team

6
Brain exercise
 What is Health mean?
 What is the WHO definition of health?

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Introduction

 Health:- is a very abstract concept to conceptualize and

measure and it is too difficult to put in words.

 It is a broad concept and its definition also differs among
social classes, cultures, religion and ethnic groups.
 Generally, there are two opposing models concerning
the definition of health:
 Negative model
 Positive model
1. Negative model
 Health is sometimes negatively defined as the absence of
disease and injury, sometimes as a normative judgment
referring to the average state of most people, and
sometimes as a positive concept of well-being.

 Disability and illness can be distinct from health or,

together with health, represent different points on a
continuum
 This model views health as:

Absence of diseases or disability or infirmity

Biological integrity of the individual

Physical and physiological capabilities to perform

routine tasks.
 According to this definition individual is healthy if all the
body parts; cells, tissues, organs, organ systems are
functioning well.

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2. Positive Health

 It is broader and more holistic concept.

 Probably the most widely known of such models is that
of the constitution of World Health Organization
(1948), which defines health, as:
 “A state of complete physical, mental, social and
spiritual well-being not merely the absence of disease or
infirmity.”
 To more fully understand the meaning of health, it is
important to understand each components of health
This definition may seem very attractive but still has lots of
drawbacks.

It will be seen that even after having this definition it will
be difficult to conceptualize and standardize positive health
with specific clear-cut attributes and criteria for
measurement.
WHO definition…..

State, Health is not a state rather it is dynamic

Well being. It is very subjective rather to be objective

Completeness difficult to measure all the attributions

More idealistic view therefore no one can embodies the

attributions presented on the definition.

Health is not an end but a means of achieving something that

they value more highly.
 In other words, good health should not be the goal of life, but
rather a vehicle to reach one’s goal in life
Aspects of Health

1. Physical health; refers to anatomical integrity and physiological

functioning of all body parts.

To say a person is physically healthy:

 All the body parts should be there.

 All of them are in their natural place and position.

 None of them has any pathology.

 All of them are doing their physiological functions properly.

 And they work with each other harmoniously.

 Aspects of health..

2. Mental health; refers to a human individual's emotional

and psychological well-being.
 "A state of emotional and psychological well-being in
which an individual is able to use his or her cognitive
and emotional capabilities, function in society, and meet
the ordinary demands of everyday life.“

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 Components of mental health

a. Cognitive component
 It is the ability of an individual to learn, perceive and, think clearly.

E.g. A person is said to be mentally retarded if he/she cannot learn

something new at a pace in which an ordinary person learns.

b. Emotional component
 Is the ability of expressing emotions (e.g. fear, happiness, and to be
angry) in an “appropriate” way.

 Fear=ፍርሃት

 Angry=ቁጣ
3. Social health
 Is the ability to make and maintain “acceptable” and
“proper” interaction and communication with other
people and the social environment
 satisfying interpersonal relationship and role fulfillment
 The ability to lead socially and economically productive
life.
 It is a relation of health with religion or cultural values
and beliefs and is a way of achieving mental satisfaction
in stressful or in other ill- health conditions.
4. Emotional Health
 Emotional health is part of our overall health concerned with the way
we think and feel.

 It refers to our sense of well-being and our ability to cope with life
events.

 Emotional health is about our ability to acknowledge and respect our

own emotions as well as those of others.
E.g. ability to manage stress and express emotions appropriately
ability to recognize, accept, and express feelings
ability to accept one’s limitations
 The response of the body should be congruent with that of the
stimuli.

Cope=መቋቋም
Congruent=ወጥ የሆኔ
6. Spiritual health
 It is a relation of health with religion or cultural values
and beliefs and is a way of achieving mental satisfaction
in stressful or in other ill- health conditions.

belief in some force (nature, science, religion, or a

"higher power") that serves to unite human beings
and provide meaning and purpose to life

includes a person’s morals, values, and ethics

It is that innermost part that allows us to gain

strength and hope.
 Generally, the different aspects of health are interrelated
and interdependent. Physical problems could lead to
mental consequences and vice versa.

 Therefore, health is a holistic concept and wellness is

expressed through integrated mental, physical,
emotional, spiritual and social health at any point of
health and illness spectrum
Concepts of Health education, Health
Information and Health Promotion

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HE

 Any combination of learning experiences designed to facilitate

voluntary action conducive to health.

 Combination: the importance of matching multiple

determinants of behaviors with multiple learning experiences or
educational intervention

 Designed: health education is not incidental learning

experiences. It is a systematically planned and organized
activity

 Facilitate: creating favorable condition such as predispose,

enable, reinforce
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 Voluntary: with full understanding and acceptance of the
purpose of the action
 In health education we do not force the people to do
what we want them to do, instead our effort is to help
people to make decisions and choices by themselves.
[Informed decision making]
 Action: behavioral steps/measures taken by individuals,
groups or community to achieve the desired health effect
2. Health information
 It is health message disseminated to the target audience
focusing on the basic facts related to the health issue
under consideration.
 What is the difference between HE and HI?
 Generally, HI concerned on the scientific facts (e.g. the
causes, mode of transmission, prevention methods of
particular diseases) content of health education which
primarily aimed at increasing of knowledge on that
particular health problems.
 But HE address the other factors that affect health
behaviors other than knowledge such as beliefs,
attitude ,reinforcing factors etc.
 HI is not necessarily HE. But HI is certainly a basic part of
HE.
 HE is beyond HI
 3. Health promotion is the process of enabling people to
increase control over the determinants of health and thereby
improve their health.
 A combination of educational and environmental supports

for actions and condition of living conducive to health.

Educational: refers to the communication part of health

promotion. That is HE

Environmental: refers to the social, political, and economic,

organizational, policy and regulatory circumstances
influence behavior or more directly health
BASIC STRATEGIES FOR HEALTH PROMOTION
Advocacy
Enabling
Mediating

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A. Advocacy
 Is a combination of individual or social actions designed
to gain political support, social acceptance and systems
support for a particular health goal.
 Political, economic, social, cultural, environmental,
behavioral and biological factors can all favor or harm
health.
 So HP make these conditions favorable for Health
through advocacy .

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B. Enabling means

….”taking action in partnership with individuals or groups

to empower them, through the mobilization of human and
material resources, in order to take control over those
things which determine their health.

 Ensure the availability of equal opportunities and

resources to enable all people to achieve their full health
potential.

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C. Mediating
 Is a process through which the different
interests(personal, social, economic) of individuals and
communities and different sectors (private and public)
are reconciled/working together in ways that promote
and protect health.

 Health sector alone can not ensured the pre-requisites

and prospects for health. Therefore working in
collaboration with other sectors is mandatory.

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Priorities for health promotion in the 21st century

 Promote social responsibility for health

 Increase investment for health development

 Consolidate and expand partnerships for health
 Increase community capacity and empower the
individual
 Secure an infrastructure for health promotion
 Call/demand the concerned bodies for action
 Disease,
 Illness
 Sickness, which usually mean the same thing though
social scientists give them different meaning to each.

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 Disease; the existence of some pathology or abnormality
of the body, which is capable of detection using, accepted
investigation methods.
 Illness; the subjective state of a person who feels aware of
not being well.
 Sickness; a state of social dysfunction: a role that an
individual assumes when ill.

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There are four general determinants of health. These are
 Human biology
 Genetics - inheritance plays a part in
determining lifespan, healthiness and the
likelihood of developing certain illnesses
 Gender - Men and women suffer from
different types of diseases at different ages.
 Environment
 safe water and clean air, healthy workplaces,
safe houses, communities and roads all
contribute to good health


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 Lifestyle

 Healthcare Services.
 access and use of services that prevent and treat
disease influences health.
 Others
 Social support networks – greater support from families, friends
and communities is linked to better health.
 Culture - customs and traditions, and the beliefs of the family
and community all affect health

 Income and social status - higher income and social status are
linked to better health. The greater the gap between the richest
and poorest people, the greater the differences in health.

 Education – low education levels are linked with poor health,

more stress and lower self-confidence

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 Educational taxonomy

Learning domains/objectives/
 Cognitive domain: emphasizes intellectual learning and

problem solving activities and is much concerns with

knowledge comprehension and analysis.

 Affective Domains: involves behavior and educational

objectives that have some emotional overtones that deals with

attitudes, values interests, beliefs and appreciations.

 Psychomotor Domain: deals with motor and manipulative

skills. Practical applications of scientific facts in to problem

solving situations.
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A. Cognitive Domain

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Cognitive Domain…
It has its own components 6 components
 Remembering: Re-call or remembering of facts,
informations , and skills through experience or
education.
 Understanding: involves explain ideas or concepts with
our own words with out any central message change
 Application or use of general ideas, principles or
methods to new situation.

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 Analysis: - It consists the breakdown of material into its
constituent parts, and detection of the relationships of the parts
& of the way they are organized.

 Evaluating - judgments/appraisal about the works, methods, and

material, or values of something.
 Involves the use of criteria as well as standards for appraising
the extent to which particulars are accurate or satisfying.

 Creating: the learner can create new product or new point of
view

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B. Affective domain

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 Affective Domain…

There are 5 categories

 Receiving or Attending: - Sensitivity to the existence of a
certain phenomenon or stimulus, and awareness. It also
includes willingness to receive, or attention.

 Responding: - At this level the learner is sufficiently

involved in a subject, or activity that he will seek it out
& gain satisfaction from working with it or engaged in it.
/do something as a reaction to someone or something/

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 Valuing: - at this stage behavior is consistent & stable. It
involves acceptance of a value & commitment (conviction)
for a certain point of preference for a value.

 Organization: - at this level the learner constructs a value

system which guides his behavior.

 Characterization:- at this stage of internalization the values

already have a place in the individual’s value hierarchy, are
organized in to some kind of internally consistent system.

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C. Psychomotor Domain

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 Psychomotor domain…

There are 5 categories

Imitation: Observing and patterning behavior after someone else.
Performance may be of low quality.

Example: Copying a work of others.

Manipulation: Perform an action according to instruction and not

only on the bases of observation

Example: Creating work on one's own, after taking lessons, or

reading about it.

Precision: Refining, becoming more exact. Few errors are apparent.
Example: Working and reworking something, so it will be “just
right.”
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 Articulation- Involves the co-ordination of a series of acts
by the establishment of an appropriate sequence (internal
consistence)
Example: Perform Nursing Art /Catheterization/

 Naturalization- Having high level performance become

natural, without needing to think much about it.
Examples: Giving an Injection
 Level Illness/ disease prevention.
 Primordial prevention
 Primary prevention
 Secondary prevention
 Tertiary prevention
 It is the action aimed at protecting, eradicating,
eliminating or minimizing the impacts of disease
and disability.

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 Primordial prevention: Prevention of development of risk factors in a
population group, which they have not yet appeared.

• Focused on the prevention of chronic diseases/problems

• The main intervention is health education/promotion.
 Primary prevention is directed toward preventing the initial occurrence of
a disorder;
e.g. regular exercise, immunization

 Secondary prevention; aim is to reduce the impact of a disease or injury

that has already occurred.
e.g. screening

 Tertiary prevention; aims to soften the impact of an ongoing illness or

injury that has long lasting effects in order to improve as much as possible
their ability to function, their quality of life.
e.g. chronic disease management like HTN, DM, HIV/AIDS..
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 Rational for Health Education

1. Continued existence and spread of communicable diseases

such as malaria, TB, HIV/AIDS that need the involvement of
the community members

2. Nearly 3 million people die each year from TB, most of

which are in developing world.

3. About 75% of childhood illnesses are preventable

e.g. measles by immunization, malnutrition and diarrhea by
teaching mothers about good weaning foods and promoting
breast feeding up until age of two.

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4. Increasing threats to the young from new and harmful
behaviors. E.g., tobacco use, teenage
pregnancy ,substance abuse

5. Health education is the only practical option for some

diseases in order to contain the spread of disease. e. g.,
HIV/AIDS

6. The cost of health care is rising. E.g. treatment and

hospitalization costs are rising.

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7. The tendency of increasing magnitude of chronic
conditions (diseases) that require cooperation of
individuals to deal with the problem. E.g. HTN, DM, Ca.

8. Increased awareness of people on chronic health

problems and the need to know preventive actions. E.g.
prevention of cardiac complications

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Goals of Health Education

1.To provide appropriate knowledge: The goal is to give

specific knowledge and information.

2. To help develop positive attitude: concerned with

opinions of people, their feeling and beliefs.

3. To help exercise healthy practice ( behavior): is

concerned with carrying out a decision and actually doing
something about a health matter.

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4. Decision making: Involves both "knowing" and "feeling"
objectives and is concerned with deciding what to do in
the future about health or a particular aspect of health.

5. Social change: Goal of changing the physical and/or

social environment so that people are encouraged to adopt
healthier behaviour.

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Levels of Health Education in Health-illness continuum

1. Primary health education, it is an education processes

that is applied on apparently healthy peoples where the
primary aim is to prevent occurrence of illness or health
problems.
 Altering unhealthy or unsafe behaviors that can lead to
disease or injury, and increasing resistance to disease or
an injury .
 The target population is apparently healthy peoples.
E.g. Nutrition, immunization, and breastfeeding

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2. Secondary Health education, it is given after the
disease or the problem has occurred. The objective at this
level is to stop the progress of the disease to the severest
form of the problem. Targets are patients and apparently
healthy peoples.

examples
 Educating TB patients about their disease conditions
and treatment,

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3. Tertiary Health education: the main objective of health
education at this level is to prevent further disabilities,
complications, prolonging life and maintenance of normal
function.
 The target population is patients having irreversible,
incurable and chronic conditions

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Why The process of health education is often
challenging ???

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1.People are usually preoccupied with many other
important daily activities.

2. There is a failure to see the value of health teaching by

many health professionals.

3. Health education is not considered important during

normal life. People are concerned about diseases.

4. Mostly related to behavior; changing health behavior is

conditioned by many factors: social, psychological,
economic, cultural, accessibility and quality of services,
political environmental, etc.

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PRINCIPLES OF HEALTH EDUCATION
 Principle of Definite Objectives; Health education would
be more effective if we know what it is and we want to
accomplish as a result of our educational process.

 Principle of Credibility; good health education is based

on facts; and must be consistent and compatible with
scientific knowledge, local culture, educational system as
well as social goals.

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 Principle of Interest – people are unlikely to listen to
those things which are not to their interest/need

 Principle of Participation – participation is a key concept

in health education. It is based on the principle of active
learning.

 Principle of Motivation - in every person there is a

fundamental desire to learn. Awakening this desire is
called motivation.

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 Principle of Comprehension; in health education, we
must know the level of understanding, educational
status or literacy of the people to whom the teaching is
directed.

Principle of Reinforcement; few people can learn all

that is new in a single period. Therefore, in health
education repetition at interval is necessary.
 If there is no reinforcement, there is a possibility of
individuals going back to the pre awareness stage.

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 Principle of Learning by Doing – learning is an action
process; not memorizing one in a narrow sense

 Principle of Known to Unknown – in health education

we must proceed from the concrete to the abstract; from
the particular or specific to the general

 Principle of Setting an Example (using role model) -

health educator must set a good example in the things
he/she is teaching and must be a role model to his/her
clients.

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 Principle of Good Human Relations _ sharing of
information, ideas and feelings happen most easily
between people who have a good relations or
relationships.

 Principle of Leadership _ psychologists have shown and

established that we learn from people whom we respect
and regard

 Principle of Group Support- It is only when many people

support a new idea or practice that the individual
members come out for adoption.

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 Principle of Successful Experiences- people tend to adopt
those practices that give them satisfaction and reject
other ones with unhappy experiences.

 Principle of Feedback- feedback is one of the key

concepts in systematic approach. For effective
communication, feedback is of paramount importance.

 Principle of Cumulative Learning- Behavior is the sum of

a lifetime of personal and cultural experiences.

 Principle of Multiple Targets- Individuals’ knowledge,

attitudes and behavior are intermediate to the final goals
of a program.

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UNIT2: HEALTH & BEHAVIOUR

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What is behavior ?

Behavior- is an action that has specific frequency,

duration, and purpose, whether conscious or unconscious,

It is both the act and the way we act.

 Action – drinking/smoking
 Duration –is it for a week/month?
 Frequency- how it is repeated?
 Purpose –is he/she doing to attain a goal

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Human behavior is influenced by
 culture,
 attitudes,
 emotions,
 values,
 ethics, authority, rapport(relationship),
 persuasion(influence), coercion and/or genetics.
The acceptability of behavior is evaluated relative to
social norms and regulated by various means of social
control. 

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 Life style: refers to the collection of behaviors that
make up a person’s way of life-including diet, clothing,
family life, housing and work.
 Customs: It represents the group behavior. It is the
pattern of action shared by some or all members of the
society.
 Traditions: are behaviors that have been carried out for
a long time and handed down from parents to children.

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 Healthy behaviour- is an action that healthy people
undertake to keep themselves or others healthy and
prevent disease.
 Health behaviour is any activity undertaken by a person
believing him/herself to be healthy for the purpose of
preventing disease or detecting it at an early stage.
 Healthy behavior aimed to prevent disease

e.g. Physical exercise, BF, seeking treatment

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 Unhealthy behavior can harm health
e.g. Smoking, chat chewing, excessive alcohol
consumption, unsafe sex , sedentary life style etc.

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Utilization behavior: - utilization of health services such
as antenatal care, child health, immunization, family
planning…etc
Illness behavior: - recognition of early symptoms and
prompt self referral for treatment.
Compliance behavior: - following a course of prescribed
drugs/informations from health care providers
Rehabilitation behavior: - what people need to do after a
serious illness to prevent further disability.

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Study of health behaviour is based upon two
assumptions
 A substantial proportion of mortality and morbidity
is caused due to a particular pattern of behaviour
and that these behaviour patterns are modifiable.

 It is recognized that individuals are the major

producers/contributors of their health

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Category of factors affecting human behavior
1.Predisposing Factors - any characteristics of a
person or population which motivates individuals to
adopt behavior
Prior to the occurrence of that behavior
 Knowledge
 Beliefs
 Values
 Attitudes

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2. Enabling - characteristic of the environment that
facilitate action and any skill or resource required to
attain specific behavior
 accessibility
 availability
 skills
 laws (local, state, federal)

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3. Reinforcing factors: are those factors
subsequent/following to a behavior that provide the
continuing reward or incentives for the behavior to be
persistent and continual.
 Feedback and rewards from significant others such
as family, peers, teachers, employers, health
providers, community leaders, decision-makers, self
or others who control rewards.

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76
Definitions of factors affecting Behaviors
1. Knowledge

2. Attitude

3. Beliefs is a conviction/an informal declaration that a

phenomenon or an object is true or real especially without
proof.
They are usually derived from parents, grandparents and other
people we respect (accepted as true).
People usually do not know whether they are true or false and
they are often difficult to change.
e.g. belief of many people that cold may cause respiratory
problems.
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4. Values; important and lasting beliefs or ideas shared
by the members of the culture about what is good and
bad.
They are the basis justifying one’s actions in
moral or ethical terms.
They are standards.

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 Some Values in our community
 Being a good mother
 Having many children/cattle
 Academically success
 Being a man of God /Allah
 Being modern
 Being healthy

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80
5. Skills
A person’s ability to perform the tasks that constitute a
health related behavior.
6. Culture
7. Lifestyle: Consciously chosen, personal behavior of
individuals. E.g. Urban Vs rural life style

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8. Social Norms – the influence of social pressure that is
perceived by the individual (normative beliefs) to
perform or not perform a certain behaviour.

9.Perception: a process by which individuals organize

and interpret their sensory information in order to
give meaning it.
 Perception is a means of acquiring knowledge.
 And it is highly subjective

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83
10. Perceived Behavioral Control – the individual’s
belief concerning how easy or difficult performing the
behaviour will be.
 11. People who are important to us greatly influence
our behavior. Examples: parents, elders, friends,
experienced people, highly educated people, teachers,
etc.
12. Resources: facilities, money time, labor services,
skills, materials and their distribution and their location
affect behavior. Example: access to HC

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 Changes in behavior

 Natural change - our behavior changes all the time. Some

changes take place because of natural events or processes
such as age-sex related behaviors. E.g. eating clay during
pregnancy.
Planned change - we make plans to improve our lives or to
survive for that matter and we act accordingly. E.g. plan to
stop smoking or drinking, plan to become a health
professional.
Planned change in behavior can be faster or slower
depending on the response of the acceptor and adapter of the
behavior.
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Learning
 Learning is relatively permanent change in behavior
as a result of knowledge, experience or practice.
 Learning is acquiring new knowledge, behaviors,
skills, values, preferences or understanding, and may
involve synthesizing different types of information.
 The ability to learn is possessed by both in humans
and animals.

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THEORIES OF LEARNING

There are four theories which explain how learning

occurs. They are
1. Classical conditioning
2. Operant conditioning
3. Cognitive theory
4. Social learning theory

Read for details!!!

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Principles of learning
There are three principles of learning:
1. Learning by association
2. Learning by reinforcement , punishment
3. Learning by motivation
1. Learning by association - Connection between events
in time, place, etc.
 It is the most important part of the learning process.
 It is first formed in the physical environment.

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E.g.
 If we see lightening we expect thunder
 When we see a needle/syringe, we think of
injection
 When we see pregnancy we expect delivery

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2. Learning by reinforcement and punishment
 Reinforcement; is used to enhance desirable behavior;
 Punishment; is employed to minimize undesirable
behavior.
1. Positive reinforcement; add something desirable such as
praise to increase the likelihood of a behavior
2. Negative reinforcement; avoid/ withdraw something
undesirable to increase the likelihood of a behavior.
(prepare an out reach program for a distant health facility
for immunization program/
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Punishment
 Is the attempt to eliminate or weaken undesirable
behavior. It is used in two ways
 Negative punishment; subtract/taking away something
desirable to decrease the likelihood of a behavior.

e.g. a child fights with her brother and has her favorite toy
taken away.
 positive punishment; augmenting/adding something
unwanted/ undesirable/ to decrease the likelihood of a
behavior

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3. Motivation; desire or willingness to perform/attend
something/or learning process.
The concept of motivation is basic because, without
motivation learning does not take place or, at least, is not
discernible.
An individual who is not motivated will gain or learn
nothing i.e. it can affect the learning process

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3.Theories and Models of Health Behavior

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Learning objectives

After this session students will be able to

 Define theory and Model
 Describe theories at different levels
 List the most commonly used behavioural models
 Describe Health Belief model
 Describe Trans theoretical model of change
 Describe TRA/TPB
 Apply models to practical exercises
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 Introduction
What is Theory?
 A theory is a set of interrelated concepts, definitions, and
propositions that present a systematic view of events or
situations by specifying relations among variables, in order
to explain and predict the events or situations.
 In short, it is a set of interrelated concepts which defines a
phenomena/situation and the factors that affect it.
 Theories can be tested, modified, or replaced.

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Introduction

Concepts
 Are the building blocks or the primary elements of a theory

Constructs(key concepts)
 Is the term used for a concept developed for use in a
particular theory. key concepts of a given theory are its
constructs
Variables:
 are the operational forms of constructs.
 they define the way a construct is to be measured in a
specific situation.
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 Introduction

MODELS
 Are generalized, hypothetical descriptions, often based
on an analogy, used to analyze or explain something.
 It provides a plan for investigating and/or addressing a
phenomenon.
 It provides the vehicle for applying the theories.

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 Commonly used models and theories

1. Health Belief Model (HBM)

2. Trans theoretical Model of Behavior Change/TTM/

3. The Theory of Reasoned Action (TRA)

4. Theory of Planned Behavior (TPB)

5. PRECEDE/PROCEED FRAMEWORK

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1.Health Belief Model (HBM)
This model was developed to explain preventive health behaviour by

examining the extent to which an individual perceives a problem.

The HBM contains primary concepts that predict why people will take

action to prevent or to control illness conditions

Perceived susceptibility
perceived severity
perceived benefits
perceived barriers
Cues to action
Self efficacy

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HBM…
It is important to note that perception is a critical variable in
HBM construct.
 Perceived Threat: Consists of two parts: perceived
susceptibility and perceived severity of a health condition.
 Perceived Susceptibility: One's subjective perception of the
risk of contracting a health condition,
 Perceived Severity: Feelings concerning the seriousness of
contracting an illness (including evaluations of both medical
and clinical consequences and possible social
consequences).
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HBM..
Perceived Benefits: The believed effectiveness of
strategies/actions designed to reduce the threat of illness.
Perceived Barriers: The potential negative consequences
that may result from taking particular health actions,
including physical, psychological, and financial demands.
Cues to Action: Events, either bodily (e.g., physical
symptoms of a health condition) or environmental (e.g.,
media publicity) that motivate people to take an action.

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HBM…
Exercise
If this model was used to shape a public education
programme for HIV/AIDS prevention, what beliefs
would it be necessary for people to adopt so as to
minimize their risk of infection?

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HBM…

Solution for exercise

Individuals would need to:

 believe that they are at risk of HIV infection
 believe that the consequences of infection are serious
 receive supportive cues for action which may
trigger/activate/ a response (such as targeted media publicity)
 believe that risk minimization practices (such as safe sex or
abstinence) will greatly reduce the risk of infection

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HBM…
Solution for exercise….
 believe that the benefits of action to reduce risk will
outweigh potential costs and barriers, such as reduced
enjoyment and negative reactions of their partner
 believe in their ability to take effective action, such as
following and maintaining safe sex behaviors

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2.THE TRANS-THEORETICAL MODEL (TTM)
(PROCHASKA & DICLEMENTE, 1979)

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

look the concern of stage theories

105
 The model describes how people modify unhealthy
behavior or acquire a positive behavior.
 The central organizing construct of the model is the
Stages of Change.
 Views as the behavior is a habitual pattern that requires
gradual development rather than event happening
without process.
 The model’s basic premise/argument/ is that behavior
change is a process that unfolds over time, not an event.

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 Stage of change theories
 It is one among stage theories.
 It uses stages of change to integrate processes and
principles of change from across major theories of
intervention.

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TTM…principles of change

 People change voluntarily only when they

Become concerned about the need for change

Become convinced that the change is in their best

interests or will benefit them more than cost them

Intend/motivated to take action in some context & time.

Organize a plan of action that they are committed to

implementing

Take the actions that are necessary to make the change

and sustain the change
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 Core Constructs of TTM
 Stages of Change:
 Processes of Change:
 Decisional Balance:
 Self-Efficacy: temptation & confidence

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1.Stages of change construct
 Spiral than linear
Pre-contemplation

 contemplation

 preparation

 action

 maintenance

 termination

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111
 Stages of Change Model
Pre contemplation
Awareness of need to change

Contemplation
Increasing the Pros for Change
and decreasing the Cons

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

Termination 112
2. Processes of change; the steps
 Processes of change are the covert and overt activities
people use to progress through stages.
 Processes of change provide important guides for
intervention programs;
 Processes are like independent variables that people need
to apply to move from stage to stage.

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Processes of Change

A. Experiential Processes

Concern the person’s thought processes and generally seen in the early Stages.

1.Consciousness raising

2.Dramatic relief

3.Environmental reevaluation

4.Social liberation

5.Self reevaluation

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B. Behavioral Processes
 Action oriented and usually seen in the later stages
1.Stimuli control

2.Helping relationship
3.Counter conditioning
4.reinforcement management

5.Self liberation

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Process of change

 Consciousness Raising; Finding and learning new facts,

ideas, and tips that support the healthy behavior change
 Dramatic Relief; Experiencing the negative emotions
(fear, anxiety, worry) that go along with unhealthy
behavioral risks
 Self-reevaluation; Realizing that the behavior change is
an important part of one’s identity as a person. Assess an
individual themselves readiness to act on the new
healthier behavior
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Process of change

 Environmental reevaluation; Realizing the negative impact of

the unhealthy behavior or the positive impact of the healthy
behavior on one’s proximal social and/or physical
environment
 Self-liberation; Making a firm commitment to change their
behavior.
 Counter conditioning ;Substitution of healthier alternative
behaviors and cognitions for the unhealthy behavior

 Reinforcement management ;Increasing the rewards for the

positive behavior change and decreasing the rewards of the
unhealthy behavior
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 Stimulus control; Removing reminders/cues/motivators
to engage in the unhealthy behavior and adding cues or
reminders to engage in the healthy behavior
 Social liberation; Realizing that the social norms are
changing in the direction of supporting the healthy
behavior change.
 Helping relationships; Seeking and using social support
for the healthy behavior change

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119
3. Decisional Balance

 Decisional balance is derived via a comparison of the

strength of perceived pros of the target behavior with
the perceived cons.
 Pros= benefits of changing
 Cons= costs of changing
 Using this “conflict” to promote positive change
 Increasing Discrepancy…towards pros of new b/r

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4. Self-Efficacy

 Confidence; a state of mind that one can engage in the

healthy behavior across different challenging situations
 Temptation; engage in the unhealthy behavior across
different challenging situations
 Self-efficacy; one’s confidence in ability to take an
action.

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 Critical Assumptions of TTM

 No single theory can account for all the complexities of

behavioral change.
 Behavioral change is a process that unfolds over time
through a sequence of stages.
 There are a common set of change processes that people
apply across a broad range of behaviors.
 Without planned interventions, populations will remain
stuck in the early stages.

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 Critical Assumptions

 Specific processes and principles of change need to be

applied at specific stages: intervention programs must be
matched to each individual’s stage of change.
 Stage-matched interventions have been designed
primarily to enhance self-control.

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Stages ( in Tobacco cessation program)
Precontemplation stage
 Smoking is not a problem. I do not want to quit.
 Consider brief interventions
 Educate on the negative effects of Tobacco
 Recommend quitting smoking
 List cessation options (e.g. Nicotine replacement)
 Discuss patient's reaction to recommendations
 Reinforce at follow-up visits
 Physician example
 Most people agree that Tobacco use is harmful
 What do you think about this?
 I am concerned about your health
 How can I help you quit?

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Contemplation stage
 Smoking is a problem. I want to quit.
 Continue to discuss benefits of quitting smoking
 Avoid negative long-term effects of Tobacco use
 Improved health and positive self-image
 Financial cost savings
 Physician example (Your morning cough will improve
off Tobacco )

125
Preparation stage

 Set a definite quit date (I will quit smoking on January 1)

 Facilitation measures
 Encourage social support
 Tobacco cessation program
 Friends and relatives provide support
 Provide a no-fail environment
 Remove Tobacco, ashtrays and other related items
 Others should not smoke around patient
 Be aware of Tobacco use triggers (rituals)
 Consider habit substitutions in place of Tobacco
 Avoid provocative behaviors (e.g. alcohol use)
 Offer Tobacco cessation pharmacologic measures
 Nicotine replacement
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Action stage

 I stopped smoking today.

 Provide behavior support
 Smoking Cessation program
 Follow-up contact (e.g. Troubleshoot triggers)
 Weekly during first month of cessation
 At time of stopping pharmacologic measures
Maintenance stage
 I only smoked on one stressful day in the last month.
 Continue behavior support
 Offer additional interventions if relapse occurs

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3.Theory of Reasoned Action/ Planned
Behavior (TRA/TPB
(Fishbein & Ajzen, 1970’s)

128
 The TRA focus on theoretical constructs concerned with
individual motivational factors as determinants of the
likelihood of performing a specific behavior.

 TRA assume that the best predictor of a behavior is

behavioral intention, which in turn is determined by
attitude toward the behavior and social normative
perceptions regarding it.

 Direct determinants of individuals’ behavioral intention

are their attitude toward performing the behavior and
their subjective norm associated with the behavior.

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TRA…

 TRA and TPB have been used successfully to predict and

explain a wide range of health behaviors and intentions,
including ;
 smoking,

 drinking,

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 TRA
 Attitudes - This refers to the degree to which a person has a
favorable or unfavorable evaluation of the behavior of interest.

 Behavioral intention - This refers to the motivational factors

that influence a given behavior/an indication of a person's
readiness to perform the new behavior/ where the stronger the
intention to perform the behavior, the more likely the
behavior will be performed.

 Subjective norms - This refers to the belief about whether

most people approve or disapprove of the behavior.

 Perceived behavioral control - This refers to a person's

perception of the ease or difficulty of performing the behavior
of interest
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THE THEORY OF REASONED ACTION (TRA)

132
4.Theory of Planned Behavior (TPB)

 It is an extension of theory of reasoned action.

 It includes Perceived behavioral control as construct.

133
TPB

Key Variables

Attitude Toward Behavior. Is the degree to which performance of

the behavior is positively or negatively valued

 Subjective Norm. the perceived social pressure to perform or not

to perform the behavior

 Perceived Behavioral Control. Perception of the ease or

difficulty of performing the particular behavior

Behavioral intention. subjective probability that he or she will

engage in a given behavior

134
 Beliefs
Regarding
Behaviour Attitude
toward
Behaviour
TRA Evaluation
of outcomes

Beliefs that
Important
Others have
Subjective Intention BEHAVIOUR
Motivation to Norm
Comply with
Important Others

Control
Variables
Perceived
TPB Behavioral
Power over Control
Control
Factors
135
5. PRECEDE/PROCEED FRAMEWORK
Health planning Model

136
Many different kind of planning models have
been developed to guide planning process

 PRECED-PROCEED
 MATCH
 PATCH
 SMART
 CDCynergy

Models serve as frames from which to build;

Provide structure & organization for the
planning process

137
• The PRECEDE-PROCEEDE model is a framework
for the process of systematic development and
evaluation of health education programs

• It is the well known and most frequently used

model to plan, implement and evaluate health
education and promotion programs.

138
The model rests on two principles:

1. The principle of participation, which states that

success in achieving change is enhanced by the
active participation of members of the target
audience.

2. The important role of the environmental factors

as determinants of health and health behavior

139
 PRECEDE

Predisposing, Reinforcing, Enabling, Causes in,

Educational ,Diagnosis and Evaluation.

 PROCEED
Policy, Regulatory, Organizational Constructs in
Educational and Environmental Development.

140
DESCRIPTION OF THE MODEL

PRECEDE - the first 5 phases(diagnostic phase)

Phase 1 - Social Diagnosis
Phase 2 - Epidemiological Diagnosis
Phase 3 - Behavioral & Environmental Diagnosis
Phase 4 - Education & Organizational Diagnosis
Phase 5 - Administrative & Policy Diagnosis
PROCEED - the second 4 phases(Implementation &
evaluation phase)
Phase 6 - Implementation
Phase 7 - Process Evaluation
Phase 8 - Impact Evaluation
Phase 9 - Outcome Evaluation

141
Phase 1 - Social Diagnosis/social assessment
The focus of this phase is;
 Identify social problems that impact quality of life
 That is important understand of the social problems
which affects the quality of life of the
individuals/communities
 Self assessment of the needs & Health issues from people
point of view
Identify social problems that impact quality of life

142
Methods used for social diagnosis may be one or more of
the following:
Community Forum
 Focus Groups
 Surveys
 Interviews

143
Phase 2 - Epidemiological Diagnosis
Determine health issues associated with the quality of life.
Review Epidemiological data
e.g. morbidity, mortality, risk factors, disability,
incidence, prevalence of disease
Objective data is gathered, usually from secondary data

144
Examples of Epidemiological data:
 vital statistics
 disability
 prevalence
 morbidity
 incidences
 mortality
 Program objectives are created - that is the goal you
hope to achieve as a result of implementing this
program

145
• Once a list of problems identified in phase 1 &
2, priority should be set among these problems

• For the selected health problem, develop

program goals and objectives

• Suppose, malaria is the health problem

identified in phase 1 & 2, then develop program
goal and health objective for malaria.

146
• Goal : To reduce the burden of malaria in
gilgel gibe by 2010.

• Objective: To reduce the prevalence of malaria

in gilgel gibe field research center community
from 45% to 10% by the end of 2010

147
Phase 3 - Behavioural and Environmental Diagnosis
Asses social problems that affect the quality of life it
might be behavioral causes or environmental causes
Behavioral causes such as poor wasting disposal, poor
personal hygiene, poor diet/ eating habit or low coverage
of EPI
Environmental factors like low access to safe water,
We need to prioritize the problems based on changeability

148
149
 •Presence of stagnant water
•Lack of ITN
•Lack of services

Envi
Beh
ron Pers Mal
avio
men onal aria
ral
•Not properly using
tal
ITN
•Staying outside at
evening
•Not seeking treatment
early
•Not following course
of prescribed drugs
150
151
 Just follow the same procedure to identify
environmental factors and prioritize it in terms of
changeability and importance
AND

• Write SMART, objectives for the identified factors

152
Phase 4 - Educational and organizational Diagnosis
 Identifies causal factors that must be changed to initiate
and sustain the process of behavioral and environmental
change identified in Phase 3
Three kinds of causes are identified.
 Predisposing factors; knowledge, attitudes…
 Enabling factors; resource, access..
 Reinforcing factors; social support

153
• In phase 3, two broad factors could be
identified

Previous example
 Behavior factors : Improper use of ITN….What
is the cause of improper use??????
 Non-behavior factor….

154
Phase 5 - Administrative and Policy Diagnosis
This phase focuses on the administrative and organizational
concerns which must be addressed prior to program
implementation.

This includes the assessment of resources, budget

development and allocation, development of an
implementation time table, organization or personnel
within programs, and coordination of the program with all
other departments, and institutional organizations and the
community.
155
Administrative Diagnosis - the analysis of policies,
resources and circumstances prevailing organizational
situations that could hinder or facilitate the development of
the health program.
Policy Diagnosis - to assess the compatibility of your
program goals and objectives with those of the organization
and its administration; does it fit into the mission
statements, rules and regulations.

156
 Phase 6 - Implementation of the Program
Phase 7 - Process Evaluation is used to evaluate the process
by which the program is being implemented.
Phase 8 - Impact Evaluation measures the program
effectiveness in terms of intermediate objectives and
changes in predisposing, enabling, and reinforcing factors.
Phase 9 – Outcome Evaluation; measures change in terms
of overall objectives and changes in health and social
benefits or the quality of life.
 It takes a very long time to get results and it may take
years before an actual change in the quality of life is seen.
157
6. THEORY OF DIFFUSION OF INNOVATION(DOI)

 Diffusion of innovation theory is a theoretical approach

which provides an explanation how innovation, or ideas
perceived as new are communicated (diffused) through
channels among the members of the social system.
 Diffusion is the process by which an innovation is

communicated through certain channels over time among the

members of a social system

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 Elements of in the diffusion of an innovations

There are four main elements in the diffusion

of new ideas:

1. The innovation
2. Communication channels
3. The social system

4. Time

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 Innovation: An idea, practice, or object that is perceived as new
by an individual or other unit of adoption.
 Communication Channels: Means by which messages are
spread, including mass media, interpersonal channels, and
electronic communications.

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3. Social System: Set of interrelated units that are engaged in
joint problem solving to accomplish a common goal.
 Social systems have structure, including norms and
leadership.
 The social system constitutes a boundary within which an
innovation diffuses.
• 4. Time: time dimension is involved in diffusion

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Important factors in the diffusion process
1.The characteristics of the innovation;
2.The characteristics of potential adopters;
3.The rate of adoption
4.Change Agents: An individual who influences
clients innovation decision

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1.The characteristics of the innovation;
The characteristics which determine an innovation's rate of adoption
are:
1.Relative Advantageous - the degree of perception /merits better than the
standard for the innovation.
2.Compatibility - capable of fitting with existing systems, ideas to this
innovation.
3.Complexity - systems how easy it to the people to understand the new
idea.
4.Trialability - how easily can try the new idea that interact to the
audience.
5.Observability – noticeable results of the trying idea.
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2.CHARACTERISTICS OF ADOPTERS

1. Innovator(2.5%)
 Are first to adapt an innovation (they want to be first to do
something)
 They Risk takers even if the innovation is unprofitable.
2.Early adopter (13.5%)
 They are very interested in innovation, but they do not want to be
first to be involved.
 Opinion leaders/respected by peers
 Serve as role model for other members or society
3- Early majority(34%)
 Their motto/saying might be “Be not the last to lay the old aside, nor
the first by which the new is tried”
 May be interested in innovation, but will need some external
motivation to get involved.
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4- Late majority (34%) - reluctant to change until benefits of
innovation have been clearly proven.
5- Laggards (16%)
 Will be the last to get involved in an innovation
 Tend to decide after looking at whether the innovation is
successfully adopted by other members of the social
system in the past.

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 3.Stages in the Adoption of Innovation

1.Stage of awareness (Cognitive - knowledge) : the individual learns the

existence of an event/idea (innovation).
 Decisions to adopt an innovation are made only after multiple
contacts with a variety of communication channels over a long
period.
2.Stage of interest (concern, acceptance) : the individual develops
interest in the idea(innovation). – he/she seeks more information
about it and considers its general merits/advantage.
3.Evaluation (appraisal, assessment, costing): the individual makes
mental application of the idea and weighs its merit for his own
situation (pros and cons of the idea).
11/21/2022 166
 Cont,d
4. Trial (testing in practice) : actual application of idea, usually on
a small scale/ pre- test the innovation.
5. Adoption ( implementation, agreement, maintenance):
acceptance leading to continual use of the idea with out
relapse.

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 THANKS!!!

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