Health & Nutrition:
Human Health

HEALTH EDUCATION BEHAVIOR MODELS AND THEORIES-- A REVIEW OF THE LITERATURE - PART I

Individual (Intrapersonal) Health Behavior Models/Theories

1. Health Belief Model (Rosenstock, Becker, Kirscht, et al.)

   The Health Belief Model (HBM) was one of the first models which adapted theories from the behavioral sciences to examine health problems. It is still one of the most widely recognized and used models in health behavior applications. This model was originally introduced by a group of psychologists in the 1950's to help explain why people would or would not use available preventive services, such as chest x-rays for tuberculosis screening and immunizations for influenza. These researchers assumed that people feared diseases and that the health actions of people were motivated by the degree of fear (perceived threat) and the expected fear reduction of actions, as long as that possible reduction outweighed practical and psychological barriers to taking action (net benefits).

   The HBM can be outlined using four constructs which represent the perceived threat and net benefits: 1) perceived susceptibility, a person's opinion of the chances of getting a certain condition; 2) perceived severity, a person's opinion of how serious this condition is; 3) perceived benefits, a person's opinion of the effectiveness of some advised action to reduce the risk or seriousness of the impact; and 4) perceived barriers, a person's opinion of the concrete and psychological costs of this advised action. (See Figure 1) Another concept is known as cues to action. These are events (internal or external) which can activate a person's "readiness to act" and stimulate an observable behavior. Some examples of external strategies to activate "readiness" can be delivered in print with educational materials, through any electronic mass media or in one-to-one counseling. Another concept that has been added to HBM since 1988 in order to better meet the challenges of changing unhealthy habitual behaviors (such as being sedentary, smoking or overeating) is self-efficacy. Self-efficacy, a concept originally developed by Albert Bandura in social cognitive theory (social learning theory), is simply a person's confidence in her/his ability to successfully perform an action.

   Even though the HBM was originally developed to help explain certain health related behaviors, it has also helped to guide the search for "why" these behaviors occur and to identify points for possible change. Using this framework, change strategies can be designed as referred to earlier. The HBM has been used to help in developing messages that are likely to persuade an individual to make a healthy decision. Using the HBM, messages that are suitable to health education for such topics as hypertension, eating disorders, contraceptive use, or breast self-examination have been developed.

   However, there are two main weaknesses which have been noted about the HBM. First, health beliefs compete with an individual's other beliefs and attitudes (outside of those described in modifying factors in Figure 1) which can also influence behavior. Secondly, in decades of research in the social psychology of behavioral change, it has not been shown that belief formation always precedes behavioral change. In fact, the formation of a belief may actually follow a behavior change.

2. Stages of Change Model or Transtheoretical Model (Prochaska and DiClemente)

   The Stages of Change or Transtheoretical Model was initially published in 1979 by Prochaska. In the 1980's Prochaska and DiClemente worked further on this model in outlining the stages of an individual's readiness to change, or attempt to change, toward healthy behaviors. The Stages of Change Model evolved from research in smoking cessation and also the treatment of drug and alcohol addiction. More recently it has been applied to other health behaviors, such as dietary changes. Behavior change is viewed as a process, not an event, with individuals at various levels of motivation or "readiness" to change. Since people are at different points in this process, planned interventions should match their stage.

   There are six stages that have been identified in the model: 1) Precontemplation - the person is unaware of the problem or has not thought seriously about change; 2) Contemplation - the person is seriously thinking about a change (in the near future); 3) Preparation - the person is planning to take action and is making final adjustments before changing behavior; 4) Action - the person implements some specific action plan to overtly modify behavior and surroundings; 5) Maintenance - the person continues with desirable actions (repeating the periodic recommended steps while struggling to prevent lapses and relapse; and 6) Termination - the person has zero temptation and the ability to resist relapse.

   In relapse, the person reverts back to old behavior which can occur during either action or maintenance. This model is a circular, rather than a linear model. In fact, as seen in Figure 2, it is more of a spiral as the person may go through several cycles of contemplation, action, relapse (or recycle) before either reaching termination or exiting the system without becoming free of the addictive behavior. Prochaska has used a "revolving-door schema" to explain the sequence that people pass through in their efforts to become free from addictions. People do not go through the stages and graduate; they can enter and exit at any point and often recycle several times. Other studies indicate that individuals often go through these same changes whether they use self-help or self-management techniques, seek professional counseling or attend organized programs.

3. Consumer Information Processing Model (Bettman, McGuire, et al.)

   The Consumer Information Processing (CIP) Model developed out of the study of human problem solving and information processing. Information processing has been one of the dominant paradigms in social psychology for quite a while, even though CIP is still relatively new. This model was not developed specifically for health related behavior, but it has many useful applications in the area of health education. Information is a necessary tool in health education. However, just as knowledge is necessary but not sufficient for behavior change, information is necessary but not sufficient for knowledge. There are limits to any person's information processing capacity. This is defined as the limitations upon individuals in the amount of information they can acquire, use and remember.

   By understanding the key concepts and processes of CIP, health educators can examine why people use or fail to use health information, and then design informational strategies that have better chances for success. The search for information is the process of acquiring and evaluating information. This process is affected by the person's motivation, attention and perception at that point in time. In general, consumers tend not to engage in extended information searches.

   There are two central assumptions of CIP. First, individuals are limited to how much information they can process (the information processing capacity referred to earlier). Secondly, in order to increase the usability of information, individuals combine little pieces or bits of information into "chunks" and make decision rules or heuristics to make choices faster and more easily. These are the rules of thumb which are developed and used to help consumers select more easily among alternatives.

   James Bettman created one of the best known models of CIP which is shown in Figure 3. It shows a cyclical process of information search, choice, use and learning, and feedback for future decision-making. There are several feedback loops throughout the model. The consumption and learning processes involve internal feedback based on the outcome of choices and their use in future decisions. Bettman's version of this model has now been extended to consider that the information environment affects how easily people obtain, process and use information. This includes the amount, location, format, readability, and ability to process relevant information.

   There are some basic CIP concepts that can be applied to health education. Before people will use health information, it must be: 1) available, 2) seen as useful and new, and 3) processable or in a friendly format. It is necessary to choose the most important and useful points to communicate (either verbally or in print) and place this information first and/or last in the presentation in order to be remembered best. The information should take little effort to obtain, draw the consumer's attention, and be clear. Key ways to synthesize information ("rules of thumb") that have meaning and appeal for the target population should be formulated. In the learning process, keep in mind that participants have probably made related choices before and are not necessarily starting from scratch. The information designed specifically for the target population must be placed conveniently for their use.

4. Theory of Reasoned Action (Fishbein and Ajzen)

   The Theory of Reasoned Action was designed to explain not just health behavior but all volitional behaviors. This theory is based on the assumption that most behaviors of social relevance are under volitional (willful) control. In addition, a person's intention to perform (or not perform) the behavior is the immediate determinant of that behavior. The goal is to not only predict human behavior but also to understand it.

   According to this theory, a person's intention to perform a specific behavior is a function of two factors: 1) attitude (positive or negative) toward the behavior and 2) the influence of the social environment (general subjective norms) on the behavior. The attitude toward the behavior is determined by the person's belief that a given outcome will occur if s(he) performs the behavior and by an evaluation of the outcome. The social or subjective norm is determined by a person's normative belief about what important or "significant" others think s(he) should do and by the individual's motivation to comply with those other people's wishes or desires.

   Attitudes are a function of beliefs in this theory. If a person believes that performing a given behavior will lead to on the whole positive outcomes, then s(he) will hold a favorable attitude toward performing that behavior. On the other hand, a person who believes that performing the behavior will lead to mostly negative outcomes will hold an unfavorable attitude. These beliefs that form the foundation of a person's attitude toward the behavior are referred to as behavioral beliefs.

   Subjective norms are also a function of beliefs. However, these are beliefs of a different kind. These are the person's beliefs that certain individuals or groups think (s)he should or should not perform the behavior. If the person believes that most of these significant others think s(he) should perform the behavior, the social pressure to perform it will increase the more s(he) is motivated to comply with these others. If s(he) believes that most of this reference group is opposed to performing the behavior, her/his perception of the social pressure not to perform the behavior will increase along with her/his motivation to comply with these referents. The beliefs which underlie a person's subjective norms are termed normative beliefs. The interactions among the pieces of this model are illustrated in Figure 4.

5. Social Learning Theory or Social Cognitive Theory (Rotter and Bandura)

   In Social Learning Theory, human behavior is explained using a three-way reciprocal theory in which personal factors (one's cognitive processes), behavior, and environmental influences continually interact in a process of reciprocal determinism or reciprocal causality. These are very dynamic relationships where the person can shape the environment as well as environment shaping the person. Change is bi-directional. Social Learning Theory is the result of separate research by Rotter (1954) and Bandura (1977). Bandura retitled the theory Social Cognitive Theory to emphasize the cognitive aspect. According to this theory, reinforcement contributes to learning, but reinforcement along with an individual's expectations of the consequences of behavior determine the behavior. Behavior is seen as a function of the subjective value of an outcome and the subjective probability (or expectation) that a particular action will achieve that outcome. This type of approach has been referred to as "value-expectancy theory."

   There are several constructs in Social Learning Theory (SLT) which help to explain learning. According to SLT, reinforcement can be accomplished in one of three ways: 1) direct, 2) vicarious, or 3) through self-management. Direct reinforcement is supplied directly to the person. In vicarious reinforcement the participant observes someone else being reinforced for behaving in an appropriate or inappropriate manner. This has also been called social modeling or observational learning. Reinforcement by self-management involves record-keeping by the participant of her/his own behavior. When the behavior is performed correctly, the person would reinforce or reward her/himself. The construct of self-control goes along with this type of reinforcement since it reflects the idea that individuals may gain control of their own behavior by monitoring it.

   There are several other constructs which may be applicable to learning situations in health education. Behavioral capability refers to the knowledge and skills necessary to do a behavior which influence actions. If individuals are to be able to perform specific behaviors, they must first know what the behaviors are and how to perform them. Therefore, clear instructions and/or training may be needed. Another construct mentioned earlier, expectations, refers to the ability of humans to think and, therefore, to expect certain results in certain situations. Expectancies are the values that people place on an expected outcome. The more highly valued the expected outcome, the more likely the person will perform the needed behavior to yield that outcome.

   One construct of SLT has received extra attention in health education programs. Bandura considered self-efficacy the single most important aspect of the sense of self that determines one's effort to change behavior. This self-confidence in one's ability to successfully perform a specific type of action has been so well accepted that it was also added to the Health Belief Model in 1988 as mentioned earlier in this review. This internal state is very situation specific. For example, a person may experience a high level of self-efficacy in aerobic exercise but very little when attempting to reduce the amount of fat in her/his diet. These feelings of competency have been called an individual's efficacy expectations. Even though people may have efficacy expectations, they still may not attempt the behavior because they believe the outcome of that behavior (reinforcement) is not great enough for them. These beliefs are called outcome expectations. (See Figure 5 for a diagram of the difference between efficacy and outcome expectations.) A person can increase self-efficacy through: 1) personal mastery of a task; 2) observing the performance of others (vicarious experience); 3) verbal persuasion, such as receiving suggestions from others; and 4) arousal of her/his emotional state. In the construct of emotional coping responses, a person must be able to deal with any sources of anxiety surrounding that behavior in order to learn.

Interpersonal Health Behavior Theories

1. Social Networks/Social Support Theories (Eng, Israel, et al.)

   Most health educators today recognize the critical importance of the social environment and advocate changes in the social ecology which is supportive of individual change leading to better health and a higher quality of life. However, within the community, long-term behavior change depends on the level of participation and ownership felt by those being served. In order to see how Social Networks and Social Support Theories might impact on health needs, it is first necessary to define what is meant by certain concepts.

   Social networks can be kin (extended family) or non-kin (church or work groups, friends or neighbors who regularly socialize, clubs and sporting teams). Social networks have certain types of characteristics: 1) Structural, such as size (number of people) and density (extent to which members really know one another); 2) Interactional, which include reciprocity (mutual sharing), durability (length of time in relationship), intensity (frequency of interactions between members), and dispersion (ease with which members can contact each other); and 3) Functional, such as providing social support, connections to social contacts and resources, and maintenance of social identity.

   Social support refers to the varying types of aid that are given to members of a social network. Research indicates that there are four kinds of supportive behaviors or acts: 1) Emotional support - listening, showing trust and concern; 2) Instrumental support - offering real aid in the form of labor, money, time; 3) Informational support - providing advice, suggestions, directives, referrals; and 4) Appraisal support -affirming each other and giving feedback. This social support is given and received through the individual's social network. However, it is important to remember that "some or all network ties may or may not be supportive."

   Social trends in the United States offer support for health education intervention strategies that promote lay helping. Some of these trends include: 1) the increase in chronic illnesses requiring long-term care which have tended to dominate U.S. disease patterns in the last half of this century; 2) a rapid expansion of health materials available for the lay public; 3) a wide range of medical technology now available to the public (e.g. blood pressure cuffs, glucose meters, pregnancy tests); 4) over-the-counter medications that have increased in number and potency; 5) a public that is better able to see both the beneficial and harmful effects of medical care and 6) a recognition that human behavior is an important aspect of medicine. Along with the recognition of this need for lay volunteers, a host of programs to train a core of "lay health advisors" (LHAs) has mushroomed. These LHAs are lay people to whom others in the social environment turn for advice, emotional support and/or aid. There are many terms which can be used instead of LHAs. Some of these are listed in below:

   Alternate Terms for Lay Health Advisors

   Canvasser	Home visitor
   Community health advisor	Indigenous paraprofessional
   Community health advocate	Informal helper
   Community health aide	Lay community health worker
   Community health opinion leader	Lay volunteer
   Community health representative	Natural caregiver
   Community health worker	Natural helper
   Community helper	Natural neighbor
   Family health promoter	Nonprofessional
   Health education aide	Nonprofessional neighborhood support care worker
   Health facilitator
   Health guide outreach worker	Paraprofessional
   Health promoter	Resource mother
   Health visitor	Voluntary health educator
   Health liaison

   LHAs should serve foremost as a source of help that is available within a community. Both LHAs and professionals can provide the four basic types of social support mentioned earlier--emotional, instrumental, informational and appraisal. However, the lay helping role should complement the specialized roles of the professionals as shown by some examples in Figure 7. Overall, there are three general roles in which LHA's may serve. They may: 1) link and/or negotiate agency services for their people in need, 2) counsel as a part of the natural exchange of feedback and advice to people who know and trust them; and 3) educate people and help them organize their resources to advocate for improvements in their own health care on a community-wide basis.

   There are several examples of LHA programs across the country. The Resource Mother's Project in South Carolina, the Camp Health Aid Program in Michigan, the Community Health Advocacy Program and the Save Our Sisters Project, both in North Carolina, and the Community Health Advisor Network in Mississippi are just a few. The main characteristics which are sought in these lay helpers are their willingness to help, their ties to others in their own social networks, and their ability to access resources in the local health care system.

   Eng and Young (1992) have offered a planning process model for LHA interventions that asks four major questions on needs to be considered:

   1. At what level or levels is the program outcome desired? This could include individual changes in behavior, social network changes in working with agencies, service delivery changes in the structure of agencies, or community changes in problem-solving abilities.
   2. What network intervention strategies will be used? Possibilities would be strengthening existing networks, enhancing the total network, or organizing community efforts.
   3. What existing structures (such as family and friends, religious and social organizations, civic organizations, service organizations, neighborhoods, or businesses) will be targeted to initiate any change?
   4. Which social support functions--emotional, instrumental, informational, or appraisal--will the LHAs be expected to carry out?

   This model does encourage an approach to establishing LHA programs which are adaptable to different settings and purposes within the realm of public health.

Community Level Models/Theories

1. Community Organization The phrase Community Organization has emerged from a specific field of activity within social work in the late 1800's into a much broader process which involves working with people as they attempt to "define their own goals, mobilize resources, and develop action plans" for meeting the needs they have identified collectively. Community organization has been formally defined as "the method of intervention whereby individuals, groups, and organizations engage in planned action to influence social problems." It has been viewed as an art in consensus building concerned with the enrichment, development and change of social institutions. Community organization has roots in several theoretical frameworks: ecological theory, social systems theory, and theories of social networks and social support.

   1. Three Models of Community Organization

      Rothman and Tropman (1987) considered that community organization could be categorized into three distinct models of practice: 1) locality development; 2) social planning; and 3) social action. Locality development is a very process-oriented model. Community change is sought through participation of a broad cross-section of members in the community who attempts to identify and solve their own problems. It stresses consensus, cooperation, building group identity and a sense of community. Outside practitioners (coordinators or enablers) help to coordinate this effort and enable the community to successfully address its own concerns. In the literature, a segment of this field is referred to as "community development." Some examples of an application of this model include neighborhood work programs conducted by settlement houses, Volunteers in Service to America (VISTA), and the Peace Corps. Social planning stresses a technical aspect of problem solving with community participation varying from much to little depending on the problem and the organization variables present. It is more task oriented. Expert planners are to use their technical abilities to guide complex change processes. The design and implementation of social plans and policies is the central focus of this model. Building community capacity for a community to solve its own problems or encouraging either radical or fundamental social change is not a central part of this model. The United Way, urban affairs, city planning and social planning divisions of housing authorities typify this approach to community organization. Social action is both task and process oriented. This model is used to increase the problem-solving ability of the community and also to achieve some concrete changes in order to correct social injustice that has been identified by a disadvantaged or oppressed group. Basic changes are sought in major institutions or community practices. An attempt is made to redistribute power, resources or decision-making in the community and/or to change basic policies of formal organizations. Application of this approach in the past has included the civil rights movement, some of the early black-power groups, labor unions, women's liberation and the welfare rights movement. Even though these three models have been isolated or set apart in their descriptions, in actual practice these approaches overlap.

   2. Key Concepts in Community Organization

      Even though community organization does not use a single unified model, there are several key concepts that are central to its practice to bring about change on the community level. The first of these, empowerment, has been described as a process by which individuals and communities gain mastery over their lives by becoming enabled to take power and and then to act effectively to transform or change their environments. Within community organization, this concept of empowerment operates on two levels at the same time. First, the individual who is involved in the community organizing effort may experience increased social support, a concept considered earlier in this review. This support may result in a more generalized sense of control. An increased sense of control (empowerment) could have positive benefits on one's health. Researchers have indicated that social participation can decrease the individual's susceptibility to illness. On the second and broader level, community organization can contribute to community-level empowerment which leads to increased community competence. Community competence may be thought of as the equivalent of self-efficacy and behavioral capability on a community level; both the confidence and skills to solve problems effectively are present within the community. The health practitioner or community organizer could play a crucial role in helping communities increase their problem-solving ability.

      Two principles which are important in community organization practice are the principle of participation and the principle of relevance. Dewey (1946) and Lindeman (1926) paid close attention to the principle of participation or "learn by doing" in their work within the field of adult education. Adult education was (and still is) considered a process of increasing people's understanding, activating them, and helping them make decisions for themselves. This idea fits nicely with the community organization principle of gaining true involvement and participation by community members at each stage within the process. The principle of relevance was identified by Dorothy Nyswander (1966) as one of "starting where the people are." The change agent who begins with the individual or community's felt needs rather than a personal or agency plan will experience far more success than imposing an agenda from outside. It is widely accepted that communities should identify their own needs and issues to be addressed. When an issue is chosen by the community, a sense of ownership emerges which leads to empowerment and the development of a competent community.

      However, in the concept of issue selection one must differentiate between problems, which are troublesome, and issues, which are problems the community feels strongly about. In addition, the selected issue should also be: 1) specific, 2) simple, and 3) winnable. A good issue should be able to be clearly explained in a sentence or two by any member in the group. As people begin to work on it, they should be able to remain upbeat and optimistic if the issue is "doable."

      One of the most important concepts by Brazilian educator Paulo Freire (1973) was recently added to the model of community organization. In the concept of critical consciousness, Freire spoke of entering a dialogue with illiterate peasants so that they could teach themselves how to read and write as well as how to understand the root causes of their problems.

      According to Friere, the educator's main role is to converse with the students about concrete situations and offer them the tools in order for the students to teach themselves to read and write. It is a collaborative effort. From this understanding, a person could really learn to think critically about real-life problems and and take action to change his/her world for the better. Applied to health education, communities should consider their health concerns in the broader context of their political and social situation in order to develop their own plan of action to deal with any problems collectively identified.

   3. Studies Using Models of Community Organization

      Two studies which demonstrate the application of concepts and principles in the models of community organization are the Tenderloin Senior Organizing Project (TSOP) in San Francisco's Tenderloin hotels in 1979 and the Minnesota Heart Health Program (MHHP) started in the 1980's. The TSOP was directed at the low-income elderly in Tenderloin (single room occupancy) hotels within San Francisco. In an effort to combat poor health, social isolation and helplessness, health educators attempted to encourage social support and social action among these residents. In identifying problems, a modified approach to Freire's method was used to help residents share their problems along with their causes and to create possible action plans. Next, specific and winnable issues were selected. Group members were encouraged to meet their social needs along with the political concerns of some members of the hotel group. Indicators, such a reduced crime rate in the area and qualitative changes in the health and the life satisfaction of residents, suggest that a more competent community resulted. The MHHP is a scientific project while at the same time being a community-based program. This study involves about 250,000 people in three communities with the stated goal of reducing mortality and morbidity rates due to cardiovascular disease. There have been three educational approaches used in this project: community organization, media and face-to-face education. Since the beginning of this program, a high priority has been assigned to developing community partnerships for health where community members work with the research team in making decisions and implementing programs. A community advisory board was formed early in each community to also ensure a high level of community involvement. All three of these advisory boards have now become private nonprofit organizations. The program has also moved increasingly from a social planning model toward a community development approach.

2. Diffusion of Innovations Theory (Rogers and Shoemaker)

   Diffusion of Innovations Theory provides an explanation for how new ideas, products and social practices diffuse or spread within a society or from one society to another. Diffusion can be thought of as a special type of communication in which messages are concerned about a new idea. If a health education program is viewed as an innovation, this theory could describe the pattern the target population would follow in adopting the program.

   The pattern of adoption has been represented as a bell-shaped curve. As can be seen in Figure 8, time is an important element in this diffusion process. Five adopter categories are used to classify members of a social system on the basis of their innovativeness: 1) innovators (active information seekers of new ideas); 2) early adopters (very interested in the innovation but not the first to sign up); 3) early majority (need external motivation to get involved); 4) late majority (are skeptics and will not adopt an innovation until most people in the social system have done so); and 5) laggards (last to become involved by a mentoring program or through constant exposure and have limited communication networks).

   Another aspect of time considers the rate of adoption, which is the speed in which an innovation is adopted by members of a social system. When the number of individuals adopting a new idea is plotted on cumulative number or percentage of adopters over time, the result is an s-shaped curve as illustrated in Figure 9. Most innovations have this s-shaped rate of adoption. However, the slope can be very steep, as when a new idea diffuses rapidly, or more gradual in a slower rate of adoption.

   There are certain characteristics which are associated with successful diffusion efforts. These attributes of innovations can help to explain the different rates of adoption of innovations by individuals. Some of these include: 1) Relative advantage - the level at which an innovation is perceived as better than the idea it attempts to replace; 2) Compatibility - the level at which an innovation is viewed as being consistent with the existing values, past experiences and needs of the potential adopters; 3) Complexity - the level at which an innovation is viewed as difficult to use and understand; 4) Trialability or Flexibility - the level at which an innovation can be experimented with on a limited or "trial" basis; 5) Observability - the level at which the results of an innovation can be seen by others.

   This process of diffusion of an innovation involves an innovation, someone who has knowledge or experience with using the innovation, someone else who does not yet have knowledge of the innovation, and a communication channel between the two people. The communication channel is the means by which messages get from one individual to another. Mass media channels are the most rapid and effective ways to create an awareness/knowledge about an innovation. These channels are mass media, such as radio, television, newspapers, and magazines, where one source can potentially reach an audience of many. In regards to improving health, when physicians and community leaders act to reinforce information that is also provided through mass media channels, there is a much better chance that consumers will decide to act. This goes along with the research that interpersonal channels, which involve a face-to-face exchange between two or more people, are more effective in persuading an individual to adopt a new idea.

   The innovation-decision process is a five-step procedure through which an individual passes. These steps include: 1) knowledge, 2) persuasion, 3) decision, 4) implementation, and 5) confirmation. The person has an awareness/knowledge of an innovation, forms an attitude about it, decides to accept or reject, implements the new idea, and confirms the decision. Re-invention is a concept that was added to diffusion in the 1970's and refers to the degree to which an innovation is changed or modified by a user in the process of its adoption. It is most likely to occur during the implementation stage. In the decision stage, the innovation may be adopted or rejected. However, decisions can be reversed later. Discontinuance is the decision to reject an innovation after it was adopted earlier. This may be due to dissatisfaction or to an improvement in the innovation.

   Individuals also often adopt innovations as members of organizations. Such people seldom adopt an innovation until it is first adopted by the organization. These adoptions have been referred to as contingent innovation-decisions because the adoption and implementation of an innovation by these individuals is contingent upon organizational adoption. One example of this would be a health educator using a new curriculum after it has been formally adopted by the school district.

3. Organizational Change Theories

   Organizations are complex and layered social systems. Change may be influenced at each of these levels. Health education strategies that are directed at several layers at once may be the most durable over time in producing the desired results. In terms of sociology, ecology refers to the study of human populations in terms of physical environment, spatial organization distribution, and cultural characteristics. Since organizations can be influenced at many levels in their ecology, no single theory can completely explain how and why organizations change. Among the many theories of organizational behavior, two have shown special promise in the area of public health: a) Stage Theory and b) Organizational Development.

   1. Stage Theory of Organizational Change (Lewin (1951), Zaltman, Duncan and Holbek (1973) and Beyer & Trice (1978))

      This theory helps to explain how organizations plan and implement new goals, programs, technologies and ideas. Organizations are believed to pass through a series of "stages" with each stage requiring a unique set of strategies if the innovation is to progress. A strategy that may be effective at one stage may be wrongly applied at the next. An innovation's current stage of development must be correctly assessed and the proper strategies selected in order to be successful in the application of Stage Theory.

      One shortened version of Stage Theory consists of four stages: 1) Awareness (Problems are recognized and analyzed, and solutions are suggested and evaluated); 2) Adoption (Policies are formulated, and resources for beginning change(s) are allocated); 3) Implementation (The innovation is implemented, reactions take place, and changes in roles occur); 4) Institutionalization (The policy or program becomes an integral part of the organization, and new goals and values are a part of its structure). These stages are "in sequence." However, movement can be forward, backward, or abandoned at any point in the process.

      It is also known that different actors may play leading roles at different stages of the organizational change. Senior-level administrators tend to be important at the awareness and early adoption stages. Mid-level administrators become important at the adoption and early implementation stages. Workers (e.g. teachers) are instrumental at the implementation stage. Finally, senior-level administrators again play a key role during the institutionalization stage.

      There are some criticisms of Stage Theory. First, the stages need to be better defined. Second, the stage model is not yet complete since beyond institutionalization there should be renewal, when a well-established program evolves to meet changing demands. Lastly, the factors known to contribute to the program's development at each stage need to be expanded.

   2. Organizational Development Theory (Lewin (1951) and Porras & Robertson (1987))

      Human relations and the quality of life at work are often the targets of Organizational Development Theory. It has been divided into two main sections: 1) Change Process Theories and 2) Implementation Theories. Change Process Theories deal with the underlying dynamics of change. There are only a few of these theories according to Porras and Robertson, and these have not yet been integrated into an adequate explanation of the change process. On the other hand, Implementation Theories are much better defined. These are the activities that health educators would use to make sure the change is successful. Under Implementation, there are Procedure Theories which identify the sequence of actions needed for producing change in the organization. These four steps include: 1) Diagnosis - a specially trained person, usually an outside consultant, helps the organization identify its most striking problems which interfere with its functions; 2) Action Planning - strategies are developed for addressing these diagnosed problems; 3) Intervention - the consultant usually does not offer specific solutions but will aid in problem solving among the organization's members in group interactions; 4) Evaluation - the effort of the planned changes is assessed, and these changes in the organization are allowed to settle.

      Generally speaking, Stage Theory and Organizational Development Theories have the greatest potential for creating positive health changes in organizations when used together. One example would be using consultation (Organizational Development) as the intervention in both the adoption and institutional stages (Stage Theory) in an organizational change.

4. Ecological Models

   Ecological models for health education focus attention on the individual and the social environmental factors as the targets for any interventions. Some health education professionals maintain that using such terms as "lifestyle" and "health behavior" may direct attention toward changing individuals, rather than changing the social and physical environment, which can serve to reinforce unhealthy behaviors. This emphasis on individuals and their choices can lead to the support of victim-blaming. An ecological outlook suggests a "reciprocal causation" between the individual and the environment.

   Ecological models are systems models; however, certain patterned behaviors (whether for one or many persons) are the outcomes of interest. Human behavior is viewed as being determined by the following:

   1. Intrapersonal Factors - The theory of change is one of changing characteristics of the individual, such as knowledge, attitudes, skills or intention to comply with certain behavioral norms.

   2. Interpersonal Relationships - Relationships with family, friends, neighbors, coworkers and acquaintances are important influences on the health behavior of individuals. An individual can belong to one or more social networks. Through these ties in social networks, people acquire norms.

   3. Organizational Factors - Within the ecological framework, organizational characteristics can be used to support behavioral change. Organizations, such as school, work, church, professional or neighborhood groups, may have positive or negative effects on the health of their members. Since they are important sources and transmitters of social norms and values, organizations can provide the opportunity to build social support for a desirable behavior change. Organizational changes are needed to support long-term behavioral changes among individuals.

   4. Community Factors - Community can refer to the face-to-face primary groups to which an individual can belong. These "mediating structures," such as family, church, informal social networks, and neighborhoods, may provide social identity and resources. Community can also be concerned with the relationships among organizations within a political or geographic area. Many organizations competing for scarce resources usually results in the inefficient use of these resources, unless there is coordination and coalition building among community agencies in planning health education interventions. A community can also be defined as a population which is political and has one or more power structures. These power structures play a crucial role in defining this community's health problems as well as allocating its resources. Often those with the most serious health problems in a community are also those with the least access to its power structures (e.g. poor, rural, uneducated, homeless, unemployed, minorities, handicapped).

   5. Public Policy - Within public health, the health of the population has been emphasized. Regulatory policies, procedures and laws have been passed (national, state or local) to help protect the health of communities. These policies have been traditionally focused on reducing death and disease from infectious agents. This success has now led to the development of public policy in the area of chronic diseases. As a part of the policy development process, increasing the public's awareness of health and policy issues must be included.

   An ecological model should focus attention on the environmental causes of behavior (rather than be individually focused) and should also identify environmental interventions for enhancing health. In the literature, three formal ecological models are outlined: 1) The Mandala of Health, 2) Human Development and 3) Health and the Community Ecosystem.

   The Mandala of Health is a model of the human ecosystem and presents those factors that affect health as shells or levels that extend out from the individual as seen in Figure 10. The systems which expand out from the holistic individual (mind, body, spirit) are family, community and its environment, and culture and the biosphere in the outer shell. The model also provides for the inclusion of the social sciences in the upper half of the figure and the natural sciences in the lower half. Sick care service (i.e. health care system) is only one factor of health, besides work and lifestyle, which integrate the social and physical sciences. This is described as a very dynamic and three-dimensional model in which the pieces can change in shape and size depending on the need over time and in different communities. The essence of the mandala model is the notion that for any health intervention to be successful the approaches must be "multi-level, multi-faceted, and multi-disciplinary."

   Human Development, a second model, focuses on sustainable health for all. There is a strong interrelationship between health, environment and economy as diagrammed by three interlocking circles shown in Figure 11. The economy has to be environmentally sustainable by conserving resources and controlling pollution. In addition, the economy must also be socially sustainable. This involves the concept of equity. Resources (including wealth) should be distributed so that everyone's "basic human needs" are met. In a fair and just society, humans will have an "equal" opportunity to meet their health needs. The concept of viability, at the top of Figure 11, emphasizes the environmental conditions that support human life and well-being. Environment includes both the natural environment as well as the created environment that humans build for themselves. This health-environment-economy model considers the economy as an important support to the environment and human health. Described as a "central model for healthy public policy," this model has, as its overall goal, "maximizing human rather than economic development."

   In the third model, Health and the Community Ecosystem, the central focus is health or human development (See Figure 12). There are three qualities for each of the areas of community, the environment and the economy that must be present for the highest level of human health and development to be achieved. A community needs to be: 1) convivial (have social support networks), 2) livable (provide a viable human environment), and 3) equitable (treat all with fairness and justice). The economy must be adequate; it must generate enough wealth so that its members can achieve an acceptable level of health. This implies an equitable distribution within the community. In addition, the economy must also be socially and environmentally sustainable. The environment, like economy, must be sustainable so that its diversity can be maintained. It must also be viable for humans. As discussed earlier in the Human Development model, environment includes both the natural environment and the created environment, which must be livable for the community and its individuals. All three of these models suggest a holistic approach to meeting the environmental, social, economic, land use, and health or human development needs of its members.

Prepared by:
Carol Campbell
Health Curriculum Research
Mississippi Cooperative Extension Service