MPH 541

Lecture 13:
Health Education
And
Behavior Change
Communication
Dr J. Sitali
 Lecture Outline
1. Introduction.

2. Concept of Health education.

3. Key definitions.

4. Theories of behavior change:

1. The health belief model.
2. Theory of reasoned action.
3. The stages of change model.
4. The Prerequisites of change.
 Introduction
• Revise education approach to HP

• Revise behavior change approach to HP.

• The role of environment on behavior.

• Communication, what is the aim, what are the

things to note?
• Theories explain the influence of different
variables on health related behavior.
 Introduction
• People’s behavior is partly determined by their
attitude to that behavior.
• Attitude to a specific action and the intention
to adopt it are influenced by beliefs,
motivation which comes from the person’s
values, attitudes and drives or instincts, and
the influences from social norms.
 Health Education
• Traditional view of healthcare work.

• lifestyle choices contribute to development of disease.

• Information can lead to change for a healthy lifestyle.

• Modeled on Top-down approaches.

• In HE the HP is a facilitator.

• Role is to identify need and enable an informed choice.

 Key Definitions.
Beliefs:
• A belief is based on the information a person has about
an object or action.
• It links the object to some attribute.

• Behavior is based on beliefs.

• This is called Knowledge-Attitudes-behavior (KAB)

model.
• But actual behavior is more complex.
 Key Definitions
Values:
• Emotionally charged beliefs that a person
thinks are important.
• Acquired through socialization.
• Values influence a range of feelings.
 Key Definitions
Attitudes:
• More specific than values.

• Describe relatively stable feelings towards

particular issues.
• No clear association between attitudes and
behavior.
 Key Definitions
Drives:
• Describes strong motivating factors such as
hunger, thirst, sex and pain.
• Also describes motivations which can become
drives, such as addiction.
 Key Definitions

Instinct:
• Describes behavior which is not learned but
are present at birth.
• Instincts can override attitudes and beliefs.
Note:
1. People’s views about the cause and prevention of
ill health.

2. The extent to which people feel they can control

their life and make changes.

3. Whether they believe change is necessary.

4. Whether change is perceived to be beneficial in

the long term, outweighing any difficulties and
 Theories of Behavior Change
1. Health belief model
2. Theory of reasoned action
3. Stages of change model
4. Prerequisites of change model
 The Health Belief Model
• Highlights the function of beliefs in decision-making.

• Model proposed by Rosenstock (1966) and modified

by Becker (1974).
• Used to predict protective health behavior.

• Model suggests that whether or not people change

their behavior will be influenced by an evaluation of
its feasibility and its benefits weighted against its cost.
 The health belief model
• People considering changing behavior engage
in a cost-benefit or utility analysis.
• This may include thoughts about susceptibility,
severity of illness or injury, efficacy of action
whether it will have some personal benefit or
how likely it is to protect the person.
 The health belief model
Requirements for behavior change:
1. Incentive to change.
2. Feel threatened by current behavior.
3. Feel a change will be beneficial with few adverse
consequences.
4. Feel competent to carry out the change.
Note:
• Being very frightened can also lead to denial
and an avoidance of the message.
• Protection Motivation Theory suggests that
fear only works if the threat is perceived as
serious and likely to occur if the person does
not follow the recommended advice.
 2. Theory of Reasoned Action.
Behavior is dependent on two variables:

1. Attitudes.
 Beliefs about the consequences of the behavior.
 Appraisal of the positive and negative aspects of
making a change.

2. Subjective norms.
 What ‘significant others’ do and expect and the degree
to which the person wants to conform and be like
 Theory of Reasoned Action.
• These two variables combine to form an intention.

• Behavior is not always consistent with intentions.

• Stability is determined by strength of belief, how long

it has been held, whether it is reinforced by other
groups to which the individual belongs, whether it is
related to and integrated with other attitudes and
beliefs, and how clear or structured it is.
 Theory of Reasoned Action
• Differs from the ‘health belief model’ in that it
places importance on social norms as a major
influence on behavior.
• Social pressure may be exerted through societal
norms.
• ‘significant others’ influence behavior.

• The example of peer pressure.

 Theory of Reasoned Action
Bandura (1997) suggests that choices are related
to:
 Outcome expectations (whether an action will
lead to a particular outcome).
 Self-efficacy (whether people believe they
can change).
 Theory of Reasoned Action
• Ajzen (1991) further developed the theory of
reasoned action and recast it as “The Theory
of Planned Behavior”.
• Incorporated another variable – that people’s
behavior is a consequence of their perceived
control.
• Control is either internal or external.
 3. The stages of Change Model
• Developed by Prochaska & DiClente (1984, 1986).

• It shows that any change we make is not final but a

part of an ongoing cycle of change.
• Focused on encouraging change in addictive
behaviors.
• There are stages to go through when changing
behavior.
 The stages of change model
The Stages:
1. Precontemplation.
 Those in this stage have not considered change.
 Not aware of any risk in their health behavior.
 When they become aware of a problem, they may
progress to the next stage.
 The stages of change model
2. Contemplation.
 Though aware of the benefits of change, they are
not yet ready and may seek information or help
to make decision.
 May last a short while or several years.
 Some never progress beyond this stage.
 The stages of change model
3. Preparing to change.
 When the perceived benefits seem to outweigh
the costs and when the change seems possible as
well as worthwhile, the individual may be ready
to change.
 They may seek extra support.
 The stages of change model
4. Making the change.
 The early days of change require positive
decisions by the individual to do things
differently.
 A clear goal, a realistic plan, support and rewards
are features of this stage.
 The stages of change model
5. Maintenance.
 New behavior is sustained and the person moves
into a healthier lifestyle.
 Maintaining the new behavior may be difficult
and the person may revert or ‘relapse’ back to
any of the previous stages.
 The stages of change model
• Whilst few go through each stage in an orderly way,
most will go through each stage.
• Some go both backwards and forwards through a
series of cycles of change.
• This model is different from others because it
focuses on how people change and not why people
do not change.
 4. The Prerequisites of change
1. Change must be self-initiated.
 People will only change if they want to.

2. Behavior must become salient.

 For a change to occur, that behavior or habit must
be called into question by some other activity or
event so that the behavior becomes ‘salient’.
 The Prerequisites of change
3. The salience of the behavior must appear
over a period of time.
 The habitual behavior needs to become difficult
to maintain.
 The new behavior must become part of everyday
life.
 The Prerequisites of change
4. The behavior is not part of the individual’s
coping strategies.
 People resist change to their coping strategies.
 Sometimes its possible to help them identify
alternative coping strategies.
 The Prerequisites of change
5. The individual’s life should not be problem
or uncertain.
 There is a limit to a person’s capacity to adapt
and change.
 Having to make changes in their health behavior
may be too much to expect for people whose
lives are already problematic.
 The Prerequisites of change
6. Social support is available
 The presence and interest of other people provides
reinforcement and keeps the behavior salient.
 Changing one’s behavior can be stressful and
individuals need support.
 WHO recognizes the important role of the health
promoter in stimulating and maintaining social
support for individuals and groups.
The end!