Ethics and Health EducationPromotionChapter 5Copyright

Ethics and Health Education/Promotion
Chapter 5
Copyright © 2018 Pearson Education, Inc.
1
Chapter Objectives - 1
Identify and define the three major areas of philosophy
Define ethics
Explain the difference between ethics and morality
Explain why it is important to act ethically
Define professional ethics
Explain and briefly describe the two major categories of ethical
theories
Identify principles that create a common ground for all ethical
theories
Outline a guide for making ethical decisions
Identify ethical issues associated with the profession of health
education/promotion

Explain how a profession can ensure that its professionals will
act ethically
Define code of ethics and identify the source of the code
available for health education specialists
Key Terms and Origins
Major areas of philosophy
Ethics (the study of morality)
Epistemology (the study of knowledge)
Metaphysics (the study of the nature of reality)
Ethics dates back to 470–399 B.C.
Ethos and Mores – both mean character
Ethics – the science of how choices are made
Morality – the activity of making choices and of deciding,
judging, justifying, and defending those actions
People use terms such as good, right, bad, and wrong when
referring to ethical judgments about human behaviors
Why Should People Act Ethically? - 1
Ethics provide a standard by which we live
Ethical behavior brings meaning and purpose to life
Ethical behavior leads to a healthier and more satisfying life

Why Should People Act Ethically? - 2
Professional ethics
Focuses on the “actions that are right and wrong in the
workplace and are of public matter”
Professional ethics guide individual behavior in the work
setting
Professional socialization – coming to an understanding of what
behaviors are appropriate in a professional role
Research ethics – subset of professional ethics
“Comprises principles and standards that, along with underlying
values, guide appropriate conduct relevant to research
decisions”
Voluntary participation is the foundation of research ethics
Ethical Theories
Provide frameworks to evaluate whether human actions are
acceptable
Major categories of theories
Deontological (formalism or non-consequentialism)
Looking at the act; the end does not justify the means
Theories “that claim that certain actions are inherently right or
wrong without regard to their consequences” (Reamer, 2006)
Teleology (consequentialism)

Looking at the consequences; the end does justify the means
Evaluate the moral status of an act by the goodness or the
consequences (Reamer, 2006)
Neither category of ethical theory can be used for all moral
issues
Ethical questions are answered through philosophical thought,
using reason, logic, & argument
Basic Principles for Common Moral
Ground - 1
Five principles
Value of Life – First & most basic principle
Goodness (or rightness) – Subdivided into two related
principles
nonmaleficence – First duty is to do no harm
beneficence (or benevolence) – Doing good; actions that
provide for the greater good of the community
Justice (or fairness) – just in distributing goodness & badness;
subdivided into two area
procedural justice – fair procedures followed
distributive justice – allocation of resources
Basic Principles for Common Moral

Ground - 2
Honesty
At the heart of any moral relationship is communication; telling
the truth
Autonomy (or individual freedom)
People must have the freedom to choose their own way of being
ethical within the framework of the other principles
Making Ethical Decisions - 1
Ethical decision making
Requires practitioner to make choices when the circumstances
involve conflicting principles
Requires people to rely on their values, principles, and ethical
thinking
Should begin before any ethical problem surfaces
Figure 5.2 Steps in ethical decision making
Sources: Adapted from: Balog et al., (1985); Mellert (1995);
Nelson (2005); Reamer (2006); Remley & Herlihy (2007);
Svara, (2007).

Importance of moral sensitivity
Be aware of the context in which an ethical decision is made
Consider
Place
Time
Identity
Social relationships
The ideal
The concrete
Seriousness
Ethical Issues & Health Education/Promotion - 1
Ethical issues interface with all aspects of our professional lives
Obligations of professions & professionals (Bayles, 1989)
Obligations & availability of services
Obligations between professionals and clients
Obligations to third parties
Obligations between professionals and employers
Obligations to the profession
Ethical dilemmas (Penland & Beyrer, 1981)
Must be an issue (a controversy); two sides
Must involve a question of right and wrong

Major categories of issues (McLeroy et al., 1993)
Assigning individual responsibility
Changing behavior vs. social environment
Use of public policy or coercive strategies
Overemphasizing behavior change
Overemphasizing the importance of health
Educating the public on the concept of risk
Underemphasizing professional behavior
Major categories of issues (McLeroy et al., 1993) (continued)
Ethical issues to be considered with community interventions
Confidentiality
Consent
Disclosure
Competence
Conflict of interest
Grossly unethical behavior
General ethical responsibilities
Ensuring Ethical Behavior - 1

Professionals act unethically for specific reasons
Profession can put into place procedures that help to ensure
ethical behavior by all
Selective admissions into academic programs
Retention standards for students in academic programs
Graduation from an academic program
Completion of internships
Becoming credentialed
Continuing education unit or update of credentials
Once individuals have been admitted to the profession
Expected to behave according to professional norms
Code of ethics
Considered the professional norm
Principal function is to “organize in a systematic way basic
ethical standards, rules, and principles of professional conduct”
(Pritchard, 2006)
Types of statement found in codes of ethics
Don’t statements
Obligations and responsibilities
Virtues, personal qualities, and/or values
Aspirations

Professions should have a means to discipline individuals that
violate the code of ethics
Sanctions based upon a variety of factors
Type of violation
Number of prior violations
Willfulness of the violation
Level of responsibility of the professional
Ensuring ethical behavior in the health education/promotion
profession
Health education/promotion has unclear standards for admission
into the profession
The profession of health education/promotion has a code of
ethics
Society for Public Health Education (1976)
Association of the Advancement of Health Education (1994)
[now know as the American Association of Health Education]
Current code of ethics is recognized by the Coalition of
National Health Education Organizations [CNHEO]

Summary - 1
Ethical questions impact all aspects of life
Health education specialists are constantly being confronted
with ethical dilemmas, thus must have a basic understanding of
how to make an ethical decision
Key terms: philosophy, ethics, & morals
Professionals should work from an ethical base
Two major categories of ethical theories: deontology &
teleology
Summary - 2
Principles to guide ethical behavior: value of life, goodness
(nonmaleficence & beneficence), justice (procedural &
distributive) truth telling, & individual freedom
Ten step process for making ethical decisions
Ethical issues facing health education specialists in just about
every aspect of the job
Ensure that professionals act ethically by: admission to the
professional preparation program, retention in the program,
appropriate education, internships, code of ethics &
enforcement

Ethics and Health Education/Promotion
Chapter 5: The End
Theories and Planning Models
Chapter 4
1
Define and explain the difference among theory, concept,
construct, variable, and model
Explain the importance of theory to health education/promotion
Explain what is meant by behavior change theories and planning
models
Describe how the concept of socio-ecological approach applies
to using theories
Explain the difference between continuum theories and stage
theories
Identify and briefly explain the behavior change theories, and

their components, used in health education/promotion:
Health Belief Model
Theory of Planned Behavior
Elaboration Likelihood Model of Persuasion
Information-Motivation-Behavioral Skills Model
Transtheoretical Model of Change
Precaution Adoption Process Model
Social Cognitive Theory
Social Network Theory
Social Capital Theory
Diffusion Theory
Community Readiness Model
Identify and briefly explain the planning models, and their
components, used in health education/promotion:
PRECEDE-PROCEED
Multilevel Approach to Community Health (MATCH)
Intervention Mapping
CDCynergy
Social Marketing Assessment and Response Tool (SMART)
Mobilizing for Action through Planning and Partnerships
(MAPP)
Generalized Model (GM)
Definitions
theory – “a set of interrelated concepts, definitions, and
propositions that present a systematic view of events or
situations by specifying relations among variables in order
to explain and predict the events of the situations” (Glanz et al.,

2008, p. 26)
concept – primary elements of theories (Glanz et al., 2008)
construct – a concept developed, created, or adopted for
use with a specific theory (Kerlinger, 1986)
variable – the operational (practical use) form of a construct;
(Rimer & Glanz, 2005, p. 4); how a construct will be measured
(Glanz et al., 2008)
model – is a composite, a mixture of ideas or concepts
taken from any number of theories and used together
(Hayden, 2009, p. 1)
Importance of Using Theory in Health Education/Promotion
Theories provide direction and organizes knowledge
Theories can help in planning, implementing, and evaluating
programs
Indicates reasons why people are not behaving in healthy ways
Identifies information needed for intervention development
Provides a conceptual framework
Gives insight for delivery
Identifies measurements needed for evaluation
Help provide focus and infuses ethics and social justice into
practice
Programs based upon sound theory more likely to succeed
Behavior Change Theories

Multiple theories to design interventions
Levels of influence are key parts of socio-ecological approach
Socio-ecological approach helps to recognize importance of the
larger social system of behaviors and social influences
Figure 4.1 The socio-ecological model
Source: Simons-Morton, B. G., McLeroy, K. R., & Wendel, M.
L. (2012). Behavior theory in health promotion practice and
research. Burlington, MA: Jones & Bartlett Learning. p. 45.
Focus on factors within individuals (e.g. knowledge, attitudes,
beliefs, self-concept, developmental history, past experiences,
motivation, skills, and behaviors)
Health Belief Model (HBM), Theory of Planned Behavior
(TPB), Elaboration Likelihood Model of Persuasion (ELM),
Information-Motivation-Behavior Skills Model (IMB),
Transtheoretical Model of Change (TMC), Precaution Adoption,
Process Model (PAPM)
Continuum theories identify variables that influence action and

combine them in a prediction equation
Intrapersonal (Individual) Theories - 1
Stage Theory
Comprised of ordered set of categories into which people can be
classified
Identifies factors that could induce movement from one stage to
another
Four principle elements
Category system to define stages
Ordering of stages
Barriers to change that are common among people in same stage
Different barriers to change, facing people in different stages
Health Belief Model (Rosenstock)
Explains the likelihood of an individual to take action to
prevent a disease or injury based upon:
Sufficient motivation to make the issue relevant (perceived
susceptibility and perceived seriousness)
The perceived threat of the health issue
The perceived benefits of a given action
The perceived barriers to taking the necessary action
Cues to actions may also impact on the individual’s likelihood
of taking action
Self-efficacy – to feel competent to overcome perceived barriers
to take action

Figure 4.2 Health Belief Model as a predictor of preventive
health behavior
Source: Becker, M. H., et al., from “A new approach to
explaining sick-role behavior in low income populations,”
American Journal of Public Health 64, March 1974: 205–216,
Fig 1. Used by permission of Sheridan Press.
Theory of Planned Behavior (Fishbein & Ajzen, 1975)
Individuals’ intention to perform a given behavior is a function
of their attitude toward the behavior, their belief of what others
think they should do, and their perception of level of ease or
difficulty of the behavior in which they are considering action
Attitude toward the behavior
Subjective norm
Perceived behavioral control
Actual behavioral control

Figure 4.3 Theory of Planned Behavior (TPB)
Source: “Theory of Planned Behavior Diagram” (TPB Diagram)
by Dr. Icek Ajzen,
http://www.people.umass.edu/aizen/tpb.diag.html. Reprinted by
permission.
Elaboration Likelihood Model of Persuasion
Developed to explain inconsistencies in research results from
the study of attitudes (Petty, Barden, & Wheeler, 2009)
Attitudes form via two routes
The two routes usually leads to attitudes with different
consequences
The model specifies how variables have an impact on
persuasion
elaboration – refers to the amount of cognitive processing (i.e.,
thought) that a person puts into receiving messages
Figure 4.5 The Elaboration Likelihood Model of Persuasion
(ELM)
Source: From Petty, R. E., Barden J., & Wheeler, S. C., “The
Elaboration Likelihood Model of Persuasion: Developing health

promotions for sustained behavioural change” in Emerging
theories in health promotion practice and research, 2nd ed.;
DiClemente, R. J., Crosby, R. A., & Kegler, M. (Eds.), p. 196.
Copyright © 2009 John Wiley & Sons, Inc. Reproduced with
permission of John Wiley & Sons, Inc.
Information-Motivation-Behavioral Skills Model
Created to address the critical need for a strong theoretical basis
for HIV/AIDS prevention efforts
Information
Motivation
Behavioral skills
Preventive behaviors
Figure 4.6 The Information-Motivation-Behavioral Skills Model
of HIV Prevention Health Behavior
Source: From Fisher, J. D., & Fisher, W. A., “Changing AIDS
risk behavior,” Psychological Bulletin 111 (3), 455–474, 1992.
Published by American Psychological Association (APA).
Reprinted by permission.
Transtheoretical Model of Change (TMC)
(Prochaska, 1979)
People make behavior change through a series of different
stages related to the behavior
Stages of change
Precontemplation—stage people are in before they are ready to
change and are not intending to change
Contemplation—stage when individuals are considering making

a behavior change within the next 6 months
Preparation—stage where the individual is actively planning
change
Action—the effort to make the change in behavior
Maintenance—sustaining the change and resisting relapse
Termination
Precaution Adoption Process Model (PAPM) (Weinstein &
Sandman, 2002)
Explains how a person comes to the decision to take action, and
how the decision is translated into action
Figure 4.7 Stages of the Precaution Adoption Process Model
(PAPM)
Source: From Weinstein, N. D., Sandman, P. M., & Blalock, S.
J., “The Precaution Adoption Process Model” in Health
behavior and health education: Theory, research, and practice,
4th ed., K. Glanz, B. K. Rimer, and K. Viswanath, (Eds.), p.
127. Copyright © 2008 John Wiley & Sons, Inc. Reproduced
with permission of John Wiley & Sons, Inc.
Interpersonal Theories - 1
Theories that “assume individuals exist within, and are

influenced by, a social environment. The opinions, thoughts,
behavior, advice, and support of people surrounding an
individual influence his or her feelings and behavior, and the
individual has a reciprocal effect on those people” (Rimer &
Glanz, 2005, p. 19)
These theories help to explain
Social norms
Social learning
Social power
Social integration
Social networks
Social support
Social capital
Interpersonal communication
Social Cognitive Theory (Bandura, 1986)
Learning is a reciprocal interaction between the individual’s
environment, cognitive process, and behavior
Behavioral capability
Expectations
Expectancies
Locus of control
Reciprocal determinism
Observational learning
Reinforcement
Self-control
Self-efficacy
Emotional coping response

Social Network Theory
Explains the web of social relationships that surround people
Key component – relationship between and among individuals
and how those relationships influences beliefs and behaviors
When assessing a network’s role, considers –
Centrality vs. Marginality
Reciprocity of relationships
Complexity or intensity of relationships in the network
Homogeneity or diversity of people in the network
Subgroups, cliques, and linkages
Communication patterns in the network
Social Capital Theory
Does not provide theories of change
Does not guarantee empirical outcomes
Does have an impact on health
Type of network resources
Bonding
Bridging
Linking
Trust and reciprocity
Norms and expectations
Figure 4.9 Social capital

Source: From Hayden, J., Introduction to Health Behavior
Theory, 1st ed., Fig 9-3, p. 125. Copyright © 2009, Jones and
Bartlett Publishers, Sudbury, MA. http://www.jblearning.com.
Reprinted by permission.
Community Theories - 1
Group of theories includes three of the ecological perspective
levels
Institutional (e.g., rules & regulations)
Community (e.g., social norms)
Public policy (e.g., legislation)
Diffusion Theory (Rogers, 1983)
Explains diffusion of innovations in a population
Categorizes individuals based upon when they adopt a new
behavior, idea, or program
Innovators – first to adopt.
Early adopters – influential and open to trying innovations, but
are more grounded than innovators
Early majority individuals – wary and watchful about their
involvement in new ideas
Late majority – get involved through peers or mentors programs
and more skeptical and adopt after most people
Laggards – last to be involved and interested in change
Health educators will need to modify marketing strategies to
attract individuals from each of the different categories

Figure 4.10 Bar chart depicting percentages of persons adopting
an innovation over time
Community Readiness Model (Edwards et al., 2000)
Stage model to explain the nine stages of community readiness
to change
No awareness
Denial
Vague awareness
Preplanning
Preparation
Initiation
Stabilization
Confirmation/expansion
Professionalism

Table 4.3 Community readiness stages and goals
Planning Models - 1
Sound health promotion programs are organized around a well -
thought-out and well-conceived model
Models serve as frames from which to build; structure &
organization for the planning process
Many models
Many have common elements but may have different labels
No perfect model
Planning Models - 2
PRECEDE-PROCEED (Green & Kreuter, 1991)
Best known & often used model
Developers: Larry W. Green & Marshall W. Kreuter
PRECEDE—predisposing, reinforcing, and enabling constructs
in educational / ecological diagnosis & evaluation
PROCEED—policy, regulatory, and organizational constructs in
educational & environmental development
Planning Models - 3
PRECEDE

Social assessment
Epidemiological assessment
Educational and ecological assessment
Intervention alignment and administrative and policy
assessment
PROCEED
Implementation
Process evaluation
Impact evaluation
Outcome evaluation
Planning Models - 4
Figure 4.14 PREDEDE-PROCEED model for health program
planning
Source: From Green, L. W., & Kreuter, M. W., Health program
planning: An educational and ecological approach, 4th ed., p.
17, Fig 1.5. Copyright © 2005 The McGraw-Hill Companies,
Inc. Reprinted by permission.
Planning Models - 5
Multilevel Approach to Community Health (MATCH)
(Simons-Morton et al., 1995)
Ecological planning perspective
Recognizes that intervention activities should be aimed at a
variety of objectives and individuals

Phases
Phase 1: health goal selection
Phase 2: intervention planning
Phase 3: program development
Phase 4: implementation
Phase 5: evaluation
Planning Models - 6
Intervention Mapping (Bartholomew et al.,1998)
Based upon the importance of theory and evidence in the
development of health promotion programs
Step 1: needs assessment
Step 2: matrices of change objectives
Step 3: theory-based methods and practical strategies
Step 4: program development
Step 5: adoption and implementation
Step 6: evaluation planning
Planning Models - 7
CDCynergy (CDC, 1998)
Developed for public health professionals at the Centers for
Disease Control and Prevention
Used by professionals who have responsibilities for health
communication
Six phases
Phase 1: describe problem

Phase 2: analyze problem
Phase 3: plan intervention
Phase 4: develop intervention
Phase 5: plan evaluation
Phase 6: implement plan
Content specific editions of the software are available
Planning Models - 8
Social Marketing Assessment and Response Tool (SMART)
(Neiger, 1998)
Central focus is the consumer
Composed of seven phases:
Phase 1: preliminary planning
Phase 2: consumer analysis
Phase 3: market analysis
Phase 4: channel analysis
Phase 5: develop intervention, materials, and pretest
Phase 6: implementation
Phase 7: evaluation
Planning Models - 9
Mobilizing for Action through Planning and Partnerships
(MAPP) (NACCHO, 2001)
Blends the strengths of other planning models
Six phases
Phase 1: organizing for success and partnership development

Phase 2: visioning
Phase 3: conducting the four MAPP assessments
Phase 4: identify strategic issues
Phase 5: formulate goals and strategies
Phase 6: the action cycle
Planning Models - 10
Figure 4.13 Mobilizing for Action through Planning and
Partnerships (MAPP) model
Source: National Association of Country and City Health
Officials, “Mobilizing for Action through Planning and
Partnerships (MAPP) Model” from http://www.naccho.
org/topics/infrastructure/mapp/upload/
MAPP_Handbook_fnl.pdf. Reprinted by permission.
Generalized Model for Program Planning (GMPP) (McKenzie et
al., 2009).
Five tasks:
Assessing needs
Setting goals and objectives
Developing interventions
Implementing interventions
Evaluating results

Figure 4.14 Generalized model
Source: From McKenzie, J. F., Neiger, B. L., & Thackery, R.,
Planning, implementing and evaluating health promotion
programs: A primer, 6th ed., p. 45, Fig. 3.1. Copyright © 2013.
Reproduced by permission of Pearson, Boston, MA.
Summary
Health education/promotion is a multidisciplinary profession
& has evolved from the theory & practice of other disciplines
Many of the theories & models used in health
education/promotion also have evolved from these
other disciplines
Key terms: theory, concept, construct, variable, & model
There are many behavior change theories that can be
categorized using the five levels (intrapersonal, interpersonal,
institutional, community, & public policy) of the socio-
ecological approach
There is a distinction between continuum theories & stage
theories
Planning models provide a framework on which to build
programs
Theories and Planning Models
Chapter 4: The End

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