The document provides an overview of several theories and models used in health education, including definitions, the Health Belief Model, Trans theoretical Model, Theory of Planned Behavior, Precede-Proceed Model, and Social Cognitive Theory. The Precede-Proceed Model is an 8-phase planning model used to assess factors influencing health behaviors and guide the development, implementation and evaluation of health promotion programs.

1. Theories/Models in
Health Education
Samson Mideksa (PhD)
July, 2021
1

2. Outline
1. Definitions
2. Health Belief Model
3. Trans theoretical model
4. Theory of planned behavior
5. Precede-Proceed Model
6. Social Cognitive Theory
2

3. 1. Definitions
• Theories are about causes and effects.
• Theories answer the questions what causes a certain
effect under consideration and how these causes lead to
that effect.
• Theories in health behavior are about factors (causes)
and unhealthy situation (effects).
– Example of effects (unhealthy situations):-
• Low immunization coverage.
– Example of factors (causes):-
• Low perception of susceptibility to vaccine
preventable diseases.
3

4. Cont . . .
• All these causes bring about the effects
through their action on behavior.
– Example of behavior:- Low utilization of
health services.
•Exercise
Give examples:
– Causes/factors, health effects and health
behavior
4

5. Cont . . .
• Health related Theories/Models are about
these factors, their effects on health and how
they cause the effects to help design the
solution in Health Education or Health
Promotion.
5

6. 2. Health Belief Model (HBM)
• Health Belief Model contains several primary
concepts that predict why people will take
action to prevent, to screen for, or to control
illness conditions; these include susceptibility,
seriousness, benefits and barriers to a
behavior, cues to action, and most recently,
self-efficacy.
6

7. Cont . . .
Perceived susceptibility = Belief about the
chances of experiencing a risk or getting a
condition or disease.
Perceived Severity = Belief about how serious
a condition and its sequelae are.
The combination of susceptibility and severity
has been labeled as perceived threat.
Perceived Benefits = Belief in efficacy of the
advised action to reduce risk or seriousness of
impact.
7

8. Cont . . .
Perceived Barriers = Belief about the tangible
and psychological costs of the advised action
(The potential negative aspects of a particular
health action)
Cues to action = Strategies to activate “readiness”
( e.g. how-to disseminate information, promoting
awareness, reminder system).
Self-efficacy = Confidence in one’s ability to take
action.
8

9. Cont . . .
If individuals regard themselves as susceptible
to a condition, believe that condition would
have potentially serious consequences, believe
that a course of action available to them would
be beneficial in reducing either their
susceptibility to or severity of the condition,
and believe the anticipated benefits of taking
action outweigh the barriers to (or costs of)
action, they are likely to take action that they
believe will reduce their risks.
9

10. Models Individual of Health Behavior
Health Belief Model:
Perceived
susceptibility
Behavior
Perceived
barriers
Perceived
seriousness
Perceived
benefits
Cues to
action
10

11. 3. Trans theoretical model
• Transtheoretical Model (TTM) and Stages
of Change (SOC)
• The TTM uses stages of change to integrate
processes and principles of change across
major theories of intervention, hence the
name Transtheoretical.
• The impetus for the model arose when
Prochaska and colleagues conducted a
comparative analysis of self-changers
compared to smokers in professional
treatments.
11

12. Cont . . .
Transtheoretical Model has concentrated on
five stages of change, ten processes of change,
pros and cons of changing, self-efficacy, and
temptation.
It is also based on critical assumptions about
the nature of behavior change and
interventions that can best facilitate such
change.
12

13. Cont . . .
Stages of Change
The TTM posits behavior change as a process
progress through a series of six stages, although
frequently not in a linear manner.
1. Pre-contemplation = no intention to take
action within the next six months.
2. Contemplation = Intends to take action within
the next six months.
13

14. Cont . . .
3. Preparation = Intends to take action within the
next 30 days and has taken some behavioral
steps in this direction.
4. Action = Changed overt behavior for less than
six months.
5. Maintenance = Changed overt behavior for
more than six months.
6. Termination = No temptation to relapse and
100% confidence.
14

16. Cont . . .
Processes of Change
1. Consciousness raising = Finding and
learning new facts, ideas, and tips that
support the healthy behavior change.
2. Dramatic relief = Experiencing the negative
emotions (fear, anxiety, worry) that go along
with unhealthy behavioral risks.
3. Self-reevaluation = Realizing that the
behavior change is an important part of one’s
identity as a person.
16

17. Cont . . .
4. Environmental = Realizing the negative
impact of the unhealthy behavior
reevaluation or the positive impact of the
healthy behavior on one’s proximal social
and/or physical environment.
5.Self-liberation = Making a firm commitment
to change.
6. Helping relationships = Seeking and using
social support for the healthy behavior change.
17

18. Cont . . .
7. Counter-conditioning = Substitution of
healthier alternative behaviors and
cognitions for the unhealthy behavior.
8. Reinforcement = Increasing the rewards for
the positive behavior change management
and decreasing the rewards of the unhealthy
behavior.
18

19. Cont . . .
9. Stimulus control = Removing reminders or
cues to engage in the unhealthy behavior and
adding cues or reminders to engage in the
healthy behavior.
10. Social liberation = Realizing that the social
norms are changing in the direction of
supporting the healthy behavior change.
19

20. Cont . . .
Decisional Balance
Pros = Benefits of changing.
Cons = Costs of changing.
Self-Efficacy
Confidence = Confidence that one can engage in
the healthy behavior across different challenging
situations.
Temptation = Temptation to engage in the
unhealthy behavior across different challenging
situations.
20

21. 4. Theory of planned behavior (TPB)
• Theory of planned behavior aims to explain
rationally motivated, intentional health and
non-health behaviors.
• The TPB assumes a causal chain that links
attitudes, subjective norms, and perceived
behavioral control to behavior through
behavioral intentions.
21

22. Cont . . .
Theory of Planned Behavior:
Attitude
towards the
behavior
Subjective
norms
Behavioral
intention
Behavior
Perceived
control
22

23. Cont . . .
Attitude is determined by the individual’s beliefs
about outcomes or attributes of performing the
behavior (behavioral beliefs), weighted by
evaluations of those outcomes or attributes.
Thus, a person who holds strong beliefs that
positively valued outcomes will result from
performing the behavior will have a positive
attitude toward the behavior.
Conversely, a person who holds strong beliefs
that negatively valued outcomes will result from
the behavior will have a negative attitude.
23

24. Cont . . .
 Attitude is affected by behavioral beliefs and evaluation of
behavioral outcomes.
Attitude
towards the
behavior
Behavioral
intention
Behavior
Evaluation of
behavioral
outcomes
Perceived
control
Behavioral
beliefs
Subjective
norms
24

25. Cont . . .
Subjective norm: A person’s subjective norm
is determined by his or her normative beliefs,
that is, whether important referent
individuals approve or disapprove of
performing the behavior, weighted by his or her
motivation to comply with those referents.
 A person who believes that certain referents
think he/she should perform a behavior and
is motivated to meet expectations of those
referents will hold a positive subjective norm.
25

26. Cont . . .
 Conversely, a person who believes these
referents think he/she should not perform
the behavior will have a negative subjective
norm,
 A person who is less motivated to comply
with those referents will have a relatively
neutral subjective norm.
26

27. Cont . . .
 Subjective norms are affected by normative
beliefs and motivation to comply.
Attitude
towards the
behavior
Subjective
norms
Perceived
control
Behavioral
intention
Behavior
Behavioral
beliefs
Evaluation of
behavioral
outcomes
Normative
beliefs
Motivation
to comply
27

28. Cont . . .
Perceived control is determined by control beliefs
concerning the presence or absence of facilitators
and barriers to behavioral performance, weighted
by their perceived power or the impact of each
control factor to facilitate or inhibit the behavior.
 A person’s perception of control over behavioral
performance, together with intention, is expected to
have a direct effect on behavior, particularly when
perceived control is an accurate assessment of
actual control over the behavior.
28

29. Cont . . .
 Perceived control is affected by
control beliefs and perceived power
Behavioral
beliefs
Evaluation of
behavioral
outcomes
Normative
beliefs
Motivation
to comply
Attitude
towards the
behavior
Subjective
norms
Perceived
control
Behavioral
intention
Behavior
Perceived
power
Control
beliefs
29

30. 5. Precede-Proceed Model
(Theories/Research/Practice)
• It is a planning model for Health Education to
bring behavior change.
• It is used to link the causal assessment and the
intervention planning and evaluation
processes into one overarching planning
framework.
30

31. Cont . . .
The acronyms:
PRECEDE framework, was developed in
1970s, stands for Predisposing, Reinforcing,
and Enabling Constructs in
Educational/Environmental Diagnosis and
Evaluation.
PRECEDE stands for the four phases of
Diagnosing the problem where all factors for
the problem of interest are identified.
Problem diagnosis should precede health
education (intervention).
31

32. Cont . . .
PROCEED which stands for Policy,
Regulatory, and Organizational Constructs in
Educational and Environmental Development
was added to the framework in 1991 to
recognize the importance of environmental
factors as determinants of health and health
behaviors.
PROCEED stands for the next four phases
involving implementation of the selected
strategy
32

33. Cont . . .
Phase 1 = Social assessment, Participatory
planning and Situation analysis.
Social assessment:
Through causal assessment tailored to search
for all possible factors, the community will
be assessed to explore their understandings
of the major health problems and the causes
of the identified health problem.
 What is the most important health problem in
your area and why does it exist?
33

34. Cont . . .
The analysis will result in a list of health problems
and their causes.
Maternal mortality is the major health problem in our
kebele because ………….
Utilization of institutional delivery is low in our
kebele. This, in turn, happens because …..
Most mothers do not perceive that they are at risk of
pregnancy complications.
This is called concept mapping, but practically not
so simple. This guides where health education should
target.
34

35. Cont . . .
Phase 2 = Epidemiological, Behavioral and
Environmental assessment.
This phase identifies the health priorities and
their behavioral and environmental determinants.
Epidemiological data (primary or secondary) will
be collected and used to support or correct the
social diagnosis made in phase 1.
These data are used to prioritize the health
problems to be addressed.
It is here that the public health expert supports
the community to define their target health
problem.
35

36. Cont . . .
Example: Why is institutional delivery low in
this area?
Epidemiological findings:-
 80% of the mothers believe that they are not
susceptible to pregnancy complications.
 Health facility is more than 10kms away
from the residence.
 The skilled birth attendant is available in the
HC only for 2 days of a week.
36

37. Cont . . .
Let’s say, “Low institutional delivery
utilization due to low perceived susceptibility
to pregnancy complications by the mothers” is
selected to be addressed using the above
mentioned criteria.
37

38. Cont . . .
Phase 3 = Educational and Ecological Assessment
 After selecting the relevant behavioral and
environmental factors for intervention, the third
step is to identify the antecedent and reinforcing
factors that should be in place to initiate and
sustain the change process.
38

39. Cont . . .
These factors are classified as predisposing,
enabling, and reinforcing, and they collectively
influence the likelihood that behavioral and
environmental change will occur.
We are interested in the positively influencing
factors because our intention is to bring positive
behavior change.
39

40. Cont . . .
The intended behavior change is “high utilization of
institutional delivery”.
The factor diagnosed to cause “low utilization” is
“low perceived susceptibility to pregnancy
complications”.
The Predisposing factor is, therefore, “increased
proportion of mothers with perceived susceptibility to
pregnancy complications” because, if perceived
susceptibility is high mothers will most likely utilize
institutional delivery services.
40

41. Cont . . .
What factor can Enable? a mother to utilize
institutional delivery if “the low perceived
susceptibility” is removed?
Enabling factor = If perceived susceptibility
is raised, “availability of ambulance” may
initiate utilization of the institutional delivery
services in this situation.
41

42. Cont . . .
What factor may Re-enforce? high utilization
of institutional delivery once a mother starts
utilizing institutional delivery?
Re-enforcing factor = Once utilization is started,
“availability of quality institutional delivery
services” may sustain the utilization behavior.
How to achieve these “positive factors” is the
role of health education /or health promotion!
42

43. Cont . . .
Phase 4 = Administrative and Policy Assessment and
Intervention Alignment.
In this phase:
i. Interventions are aligned with priority determinants of
change previously identified.
ii. Theories and models that work best in the
implementation of the selected intervention are
identified.
iii. Resources, organizational barriers and facilitators,
and policies that are needed for program
implementation and sustainability are identified to
check if the suggested solutions can work in the real
world. 43

44. Cont . . .
Phase 5 = Implementation.
Plan and implement “Awareness raising on
risks of pregnancy complications.”
Who will do what and when, with whom, using
what?
Example: To increase proportion of mothers in
our kebele who believe that they are susceptible
to risks of pregnancy complications from 20%
to 100% in one year.
44

45. Cont . . .
Phase 6 = Process evaluation.
Is everything according to the plan?
If not, is it worth revising?
Is the revised plan on the right track?
who what when With whom With what
Plan a b c d e
Actual ? ? ? ? ?
45

46. Cont . . .
Phase 7 = Evaluation for short-term results.
What were the shot-term results expected?
 Proportion of mothers who believe that they
are susceptible to risks of pregnancy
complications increased from 20% to 100% in
one year.
 Are they achieved and to what extent? =
evaluation at the end of one year.
46

47. Cont . . .
Phase 8 = Evaluation long-term results.
What was the long-term result planned for?
 Reduced MMR (due to pregnancy complications)
by 50% in 5yrs.
 Is it achieved?
 Compare MMR at the beginning of
implementation and at the end of 5yrs.
47

48. The PRECEDE-PROCEED planning model
(Theories/Research/Practice)
P R E C E D E
Phase 1
Social
assessment
Phase 2
Epidemiological,
Behavioral and
Environmental assessment
Phase 3
Educational and
Ecological
assessment
Phase 4
Administrative & Policy
assessment and Intervention
Alignment
Health Promotion
Educational
strategies
Policy
Regulation
Organization
Phase 5
Implementation
P R O C E E D
Phase 6
Process Evaluation
Phase 7
Evaluation for
Short-term results
Phase 8
Evaluation for
Long-term results
Predisposing
Factors
Re-enforcing
Factors
Enabling
Factors
Behavior
Environmental
Factor
Genetic
Factor
Health
Quality
of life
48

49. 6. Social Cognitive Theory (SCT)
• Theories/Models of Health Communication
• Social Cognitive Theory emphasizes
reciprocal determinism in the interaction
between people and their environments.
• The SCT conceives that human behavior is the
product of the dynamic interplay of personal,
behavioral, and environmental influences.
49

50. Cont . . .
• Although it recognizes how environments
shape behavior, this theory focuses on
people’s potential abilities to alter and
construct environments to suit purposes they
devise for themselves.
• The SCT emphasizes the human capacity for
collective action.
50

51. Cont . . .
Societies seek to control the environmental
and social factors that influence health
behaviors and health outcomes.
This enables individuals to work together in
organizations and social systems to achieve
environmental changes that benefit the entire
group.
51

52. Cont . . .
Social Cognitive Theory Concepts
1. Reciprocal determinism = Environmental
factors influence individuals and groups, but
individuals and groups can also influence their
environments and regulate their own behavior.
2. Outcome expectations = Beliefs about the
likelihood and value of the consequences of
behavioral choices.
52

53. Cont . . .
3. Self-efficacy = Beliefs about personal ability to
perform behaviors that bring desired outcomes.
4. Collective efficacy = Beliefs about the ability of
a group to perform concerted actions that bring
desired outcomes.
5. Observational learning = Learning to perform
new behaviors by exposure to interpersonal or
media displays of them, particularly through
peer modeling.
53

54. Cont . . .
6. Incentive motivation = The use and misuse of
rewards and punishments to modify behavior.
7.Facilitation = Providing tools, resources, or
environmental changes that make new behaviors
easier to perform.
8.Self-regulation = Controlling oneself through
self-monitoring, goal-setting, feedback, self
reward, self- instruction, and mobilization of
social support.
54

55. Cont . . .
9. Moral disengagement = Ways of thinking
about harmful behaviors and the people who
are harmed that make infliction of suffering
acceptable by disengaging self-regulatory
moral standards.
55

56. Cont . . .
The nine concepts in SCT can be grouped into
five categories:
(1)Psychological determinants of behavior
(2) Observational learning
(3) Environmental determinants of behavior
(4) Self-regulation
(5) Moral disengagement
56

57. Cont . . .
Social Cognitive Theory
Behavior
Environment
Individual
Health
Observational
learning
57

58. Cont . . .
1. Psychological Determinants of Behavior
in SCT = beliefs about the likelihood of
various outcomes that might result from the
behaviors that a person might choose to
perform, and the perceived value of those
outcomes.
• The SCT builds on the idea that people’s
actions are not based solely on objective
reality but on their perceptions of it.
58

59. Cont . . .
2. Observational Learning = There are four
processes:
(1) Attention, (2) Retention, (3) Production, and
(4) Motivation.
 Different factors play a role in different processes.
 For example, access to family, peer, and media
models determines what behaviors a person is able
to observe, while the perceived functional value of
the outcomes expected from the modeled behavior
determines what they choose to attend to closely.
59

60. Cont . . .
 Cognitive retention of an observed behavior
depends on intellectual capacities such as
reading ability.
 Production, that is, the performance of the
modeled behavior, depends on physical and
communication skills and on self-efficacy for
performing, or learning to perform, the observed
behavior.
 Motivation is determined by outcome
expectations about the costs and benefits of the
observed behavior.
60

61. Cont . . .
3. Environmental Determinants of Behavior =
SCT has a reciprocally deterministic viewpoint and
hypothesizes that no amount of observational
learning will lead to behavior change unless the
observers’ environments support the new
behaviors.
One basic form of environmental change to
modify behavior is incentive motivation, through
the provision of rewards or punishments for
desired or undesired behaviors.
61

62. Cont . . .
A second basic approach to influencing behavior
through environmental change is facilitation,
which is the provision of new structures or
resources that enable behaviors or make them
easier to perform.
62

63. Cont . . .
4. Self-Regulation
The SCT emphasizes the human capacity to
endure short-term negative outcomes in
anticipation of important long-term positive
outcomes, that is, to discount the immediate costs
of behaviors that lead to a more distant goal. This
is achieved through self-regulation.
63

64. Cont . . .
The basic idea is that we can influence our own
behavior in many of the same ways we would
influence another person, that is, through rewards
and facilitating environmental changes that we
plan and organize for ourselves.
64

65. Cont . . .
There are six ways in which self-regulation is
achieved:
(1) Self-monitoring is a person’s systematic
observation of his/her own behavior
(2)Goal-setting is the identification of
incremental and long-term changes that can
be obtained
(3) Feedback is information about the quality
of performance and how it might be improved
65

66. Cont . . .
(4) Self-reward is a person’s provision of tangible
or intangible rewards for him/herself
(5) Self-instruction occurs when people talk to
themselves before and during the performance
of a complex behavior
(6) Mobilization of social support is achieved
when a person finds people who encourage
his/her efforts to exert self-control.
66

67. Cont . . .
5. Moral Disengagement = SCT describes how
people can learn moral standards for
self-regulation, which can lead them to avoid
violence and cruelty to others.
They can violate those standards through
mechanisms of moral disengagement:
1. Euphemistic labeling = which sanitizes violent
acts by using words that make them less
offensive
67

68. Cont . . .
2. Dehumanization and attribution of blame
to victims by perceiving them as racially or
ethnically different and at fault for the
punishment they will receive
3. The diffusion and displacement of
responsibility by attributing decisions to a
group or to authority figures
4. Perceived moral justification for harmful
actions by construing them as beneficial and
necessary.
68

69. The last!
Thank
you!
69