* From Theory at a Glance: A Guide for Health Promotion Practice (NIH Publication No. 97-3896), by the National Cancer Institute, 1995. Bethesda, MD. In the public domain.

Planning Systems/Frameworks

Once health communications planners identify a health problem, they can use a planning framework such as the two described below: social marketing and PRECEDE-PROCEED. These planning systems can help identify the social science theories most appropriate for understanding the problem or situation. Thus, planners use the theories and models described below within the construct of a planning framework.

Using planning systems like social marketing and PRECEDE-PROCEED increases the odds of program success by examining health and behavior at multiple levels. Planning system perspectives emphasize changing people, their environment, or both.

Social Marketing

Social marketing has been defined as "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" (Andreason, 1995). This definition encompasses several key aspects of the social marketing approach; it is seen as:

1. A key benefit to individuals and society; not focused on profit and organizational benefits as commercial marketing practices are
2. A focus on behavior, not awareness or attitude change
3. An approach centered on the target audience’s having a primary role in the process

Social marketing practices are based on commercial marketing practices that make the consumer the central focus for planning and conducting a program. The program's components address:

• Price—what the consumer must give up in order to receive the program’s benefits (these costs may be intangible [e.g., changes in beliefs or habits] or tangible [e.g., money, time, or travel])
• Product—what the program is trying to change within the intended audience and what the audience stands to gain
• Promotion—how the exchange is communicated (e.g., appeals used)
• Place—what channels the program uses to reach the intended audience (e.g., mass media, community, or interpersonal)

The formulation of price, product, promotion, and place evolves from research with the consumers to determine what benefits and costs they would consider acceptable and how they might be reached. Lessons learned from social marketing stress the importance of understanding the intended audiences and designing strategies based on their wants and needs rather than what good health practice directs that they should do.

For Further Reading
Andreason, A. (1995). Marketing social change: Changing behavior to promote health, social development, and the environment. San Francisco: Jossey-Bass.

Kotler, P., & Roberto, E. L. (1989). Social marketing: Strategies for changing public behavior. New York: Free Press.

Lefebvre, R. C., & Rochlin, L. (1997). Social marketing. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and health education: Theory, research, and practice (2nd ed.). San Francisco: Jossey-Bass.

PRECEDE-PROCEED

The PRECEDE-PROCEED framework is an approach to planning that examines the factors contributing to behavior change. These include:

• Predisposing factors—the individual’s knowledge, attitudes, behavior, beliefs, and values before intervention that affect willingness to change
• Enabling factors—factors in the environment or community of an individual that facilitate or present obstacles to change
• Reinforcing factors—the positive or negative effects of adopting the behavior (including social support) that influence continuing the behavior

These factors require that individuals be considered in the context of their community and social structures, and not in isolation, when planning communication or health education strategies.

PRECEDE-PROCEED Framework

PRECEDE

PROCEED

For Further Reading
Green, L.W., & Kreuter, M.W. (1999). Health promotion planning: An educational and ecological approach (3rd ed.). Mountain View, CA: Mayfield.

Green, L.W., & Ottoson, J. M. (1999). Community and population health (8th ed.). New York: McGraw-Hill.

Selected Social Science Theories, Models, and Constructs

Individual Level

Behavioral Intentions

Studies of behavioral intentions suggest that the likelihood of intended audiences’ adopting a desired behavior can be predicted by assessing (and subsequently trying to change or influence) their attitudes toward and perceptions of benefits of the behavior, along with how they think that their peers will view their behavior. Research by Fishbein and Ajzen supports the idea that individuals’ and society’s (perceived) attitudes are an important predecessor to action. Therefore, an important step toward influencing behavior is a preliminary assessment of intended audience attitudes, and subsequent tracking is necessary to identify any attitudinal changes.

For Further Reading
Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley.

Communications for Persuasion

William McGuire has described the steps an individual must be persuaded to pass through to assimilate a desired behavior. These steps are:

• Exposure to the message
• Attention to the message
• Interest in or personal relevance of the message
• Understanding of the message
• Personalizing the behavior to fit one’s life
• Accepting the change
• Remembering the message and continuing to agree with it
• Being able to think of it
• Making decisions based on bringing the message to mind
• Behaving as decided
• Receiving positive reinforcement for behavior
• Accepting the behavior into one’s life

To communicate the message successfully, five communication components all must work:

1. Credibility of the message source
2. Message design
3. Delivery channel
4. Intended Audience
5. Intended behavior

Paying attention to McGuire’s steps helps ensure that a communication program plan addresses all the factors that determine whether a message is received and absorbed, that the program is staged over time to address intended audience needs as they differ over time, and that progress is being made toward behavior change.

For Further Reading
McGuire, W. J. (1984). Public communication as a strategy for inducing health-promoting behavioral change. Preventive Medicine, 13(3), 299−313.

Stages of Change

The basic premise of the stages-of-change construct, the central construct of the transtheoretical model, is that behavior change is a process and not an event and that individuals are at varying levels of motivation, or readiness, to change. People at different points in the process of change can benefit from different interventions, matched to their stage at that time.

By knowing an individual’s current stage, you can help set realistic program goals.You can also tailor messages, strategies, and programs to the appropriate stage.

Five distinct stages are identified in the stages-of-change construct:

1. Precontemplation
2. Contemplation
3. Decision/determination
4. Action
5. Maintenance

It is important to note that this is a circular, not a linear, model. People don’t go through the stages and "graduate"; they can enter and exit at any point, and often recycle.

For Further Reading
Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38–48.

Health Belief Model

The health belief model (HBM) was originally designed to explain why people did not participate in programs to prevent or detect diseases. The core components of HBM include:

• Perceived susceptibility—the subjective perception of risk of developing a particular health condition
• Perceived severity—feelings about the seriousness of the consequences of developing a specific health problem
• Perceived benefits—beliefs about the effectiveness of various actions that might reduce susceptibility and severity (taken together, perceived susceptibility and severity are labeled "threat")
• Perceived barriers—potential negative aspects of taking specific actions
• Cues to action—bodily or environmental events that trigger action

More recently, HBM has been amended to include the notion of self-efficacy as another predictor of health behaviors’especially more complex ones in which lifestyle changes must be maintained over time. A wide variety of demographic, social, psychological, and structural variables may also impact people’s perceptions and, indirectly, their health-related behaviors. Some of the more important variables include educational attainment, age, gender, socioeconomic status, and prior knowledge.

For Further Reading
Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health Education Quarterly, 11, 1–47.

Strecher, V. J., & Rosenstock, I. M. (1997). The health belief model. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and health education: Theory, research, and practice (2nd ed.). San Francisco: Jossey-Bass.

Consumer Information Processing Model

The consumer information processing (CIP) model was not developed specifically to study health-related behavior, nor to be applied in health promotion programs, but it has many useful applications in the health arena. Information is a common tool for health education and is often an essential foundation for health decisions.

Information can increase or decrease people’s anxiety, depending on their information preferences and how much and what kind of information they are given. Also, illness and its treatments can interfere with information processing. By understanding the key concepts and processes of CIP, health educators can examine why people use or fail to use health information and design informational strategies to better chances for success. CIP theory reflects a combination of rational and motivational ideas. The use of information is an intellectual process; however, motivation drives the search for information and how much attention people pay to it. The central assumptions of CIP are that 1) individuals are limited in how much information they can process, and 2) to increase the usability of information, they combine bits of information into "chunks" and create decision rules, known as heuristics, to make choices faster and more easily. According to basic CIP concepts, before people will use health information, it must be 1) available, 2) seen as useful and new, and 3) processable, or format-friendly.

For Further Reading
Bettman, J. R. (1979). An information processing theory of consumer choice. Reading, MA: Addison-Wesley.

Interpersonal Level

Social Cognitive Theory

Social cognitive theory (SCT) explains behavior in terms of triadic reciprocality ("reciprocal determinism") in which behavior, cognitive and other interpersonal factors, and environmental events all operate as interacting determinants of one another. SCT describes behavior as dynamically determined and fluid, influenced by both personal factors and the environment. Changes in any of these three factors are hypothesized to render changes in the others.

One of the key concepts in SCT is the environmental variable: observational learning. In contrast to earlier behavioral theories, SCT views the environment as not just a variable that reinforces or punishes behaviors, but one that also provides a milieu where an individual can watch the actions of others and learn the consequences of those behaviors. Processes governing observational learning include:

• Attention—gaining and maintaining attention
• Retention—being remembered
• Reproduction—reproducing the observed behavior
• Motivation—being stimulated to produce the behavior

Other core components of SCT include:

• Self-efficacy—judgment of one’s capability to accomplish a certain level of performance
• Outcome expectation—judgment of the likely consequence such behavior will produce
• Outcome expectancies—the value placed on the consequences of the behavior
• Emotional coping responses—strategies used to deal with emotional stimuli, including psychological defenses (denial, repression), cognitive techniques such as problem restructuring, and stress management
• Enactive learning—learning from the consequences of one’s actions (versus observational learning)
• Rule learning—generating and regulating behavioral patterns, most often achieved through vicarious processes and capabilities (versus direct experience)
• Self-regulatory capability—much of behavior is motivated and regulated by internal standards and people’s self-evaluative reactions to their own actions

For Further Reading
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.

Lefebvre, R. C. (2000). Theories and models in social marketing. In P. N. Bloom & G. T. Gundlach (Eds.), Handbook of marketing and society. Thousand Oaks, CA: Sage.

Organization/Community/Societal Level

Organizational Change Theory

Organizations are complex and layered social systems, composed of resources, members, roles, exchanges, and unique cultures. Thus, organizational change can best be promoted by working at multiple levels within the organization. Understanding organizational change is important in promoting health to help establish policies and environments that support healthy practices and create the capacity to solve new problems.While there are many theories of organization behavior, two are especially promising in public health interventions: stage theory and organizational development (OD) theory.

Stage theory is based on the idea that organizations pass through a series of steps or stages as they change. By recognizing those stages, strategies to promote change can be matched to various points in the process of change. An abbreviated version of stage theory involves four stages:

1. Problem definition (awareness)
2. Initiation of action (adoption)
3. Implementation
4. Institutionalization

OD theory grew out of the recognition that organizational structures and processes influence worker behavior and motivation. OD theory concerns the identification of problems that impede an organization’s functioning, rather than the introduction of a specific type of change. Human relations and quality of work-life factors are often the targets of OD problem diagnosis, action planning, interventions, and evaluation. A typical OD strategy involves process consultation, in which an outside specialist helps identify problems and facilitates the planning of change strategies.

Stage theory and OD theory have the greatest potential to produce health-enhancing change in organizations when they are combined. That is, OD strategies can be used at various stages as they are warranted. Simultaneously, the stages signal the need to involve organization members and decision-makers at various points in the process.

For Further Reading
Beyer, J. M., & Trice, H. M. (1978). Implementing change: Alcoholism policies in work organizations. New York: Free Press.

Porras, J. I., & Roberston, P. J. (1987). Organization development theory: A typology and evaluation. In R.W.Woodman & W. A. Pasmore (Eds.), Research in organizational change and development (Vol. 1). Greenwich, CT: JAI Press.

Community Organization Theory

Community organization theory has its roots in theories of social networks and support. It emphasizes active participation and developing communities that can better evaluate and solve health and social problems. Community organization is the process by which community groups are helped to identify common problems or goals, mobilize resources, and develop and implement strategies for reaching their goals. It has roots in several theoretical perspectives: the ecological perspective, social systems perspective, social networks, and social support. It is also consistent with social learning theory (SLT) and can be successfully used along with SLT-based strategies. Community organization is composed of several alternative change models:

• Locality development (also called community development) uses a broad cross-section of people in the community to identify and solve its own problems. It stresses consensus development, capacity building, and a strong task orientation; outside practitioners help to coordinate and enable the community to successfully address its concerns.
• Social planning uses tasks and goals, and addresses substantive problem solving, with expert practitioners providing technical assistance to benefit community consumers.
• Social action aims to increase the problem-solving ability of the community and to achieve concrete changes to redress social injustice that is identified by a disadvantaged or oppressed group.

Although community organization does not use a single unified model, several key concepts are central to the various approaches. The process of empowerment is intended to stimulate problem solving and activate community members. Community competence is an approximate community-level equivalent of self-efficacy plus behavioral capability, which are the confidence and skills to solve problems effectively. Participation and relevance go together: They involve citizen activation and a collective sense of readiness for change. Issue selection concerns identifying "winnable battles" as a focus for action, and critical consciousness stresses the active search for root causes of problems.

Social action approaches to community organizing go beyond the traditional notion of geographic and political boundaries. Communities of people who share common health problems have coalesced to attract attention to and to obtain power to address their needs—including health services, antidiscrimination policies, and more research funding. Foremost among these groups presently are AIDS activists.Women’s health advocates have also used social action to pressure powerful institutions to address their problems; breast cancer is now a focus for action and advocacy among breast cancer survivors and their relatives. They have used media advocacy as a powerful tool in their efforts.

Media advocacy is the strategic use of mass media as a resource for advancing a social or public policy initiative. It is an important, and often essential, part of social action and advocacy campaigns because the media focus public concern and spur public action. The core components of media advocacy are developing an understanding of how an issue relates to prevailing public opinions and values and designing messages that frame the issues so as to maximize their impact and attract powerful and broad public support.

For Further Reading
Rothman, J., & Tropman, J. E. (1987). Models of community organization and macro practice: Their mixing and phasing. In F. M. Cox, J. L. Ehrlich, J. Rothman, & J. E. Tropman (Eds.), Strategies of community organization (4th ed.). Itasca, IL: Peacock.

Diffusion of Innovations Theory

Diffusion of innovations theory addresses how new ideas, products, and social practices spread within a society or from one society to another. The challenge of diffusion requires approaches that differ from those focused solely on individuals or small groups. It involves paying attention to the innovation (a new idea, product, practice, or technology) as well as to communication channels and social systems (networks with members, norms, and social structures).

A focus on the characteristics of innovations can improve the chances that they will be adopted and hence diffused. It also has implications for how an innovation is positioned to maximize its appeal. Some of the most important characteristics of innovations are their:

• Relative advantage—is it better than what was there before?
• Compatibility—fit with intended audience
• Complexity—ease of use
• Trialability—can it be tried out first?
• Observability—visibility of results

Communication channels are another important component of diffusion of innovations theory. Diffusion theories view communication as a two-way process rather than one of merely "persuading" an intended audience to take action. The two-step flow of communication—in which opinion leaders mediate the impact of mass media—emphasizes the value of social networks (or interpersonal channels) over and above mass media for adoption decisions.

For Further Reading
Green, L.W., Gottlieb, N. H., & Parcel, G. S. (1987). Diffusion theory extended and applied. In W. B.Ward (Ed.), Advances in health education and promotion. Greenwich, CT: JAI Press.

Rogers, E. M. (1983). Diffusion of innovations (3rd ed.). New York: Free Press.

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