Seminar-9
Dr. M.S.Bala Vidyadhar
Date:01-01-2016
BehaviorModels In HealthPromotion

Contents
 Introduction
 Definitions
 History & Background
 Importance of Behavior models
 Behavior Theories/Models Of Health Promotion
 Oral Health Applications Of Theories in Research
 Conclusion
 References
 Previous Year Questions

Introduction
 Health education is a profession of educating people about health.
 Areas within this profession encompass environmental health,
physical health, social health, emotional health, intellectual health,
and spiritual health.
 It can be defined as the principle by which individuals and groups
of people learn to behave in a manner conducive to the promotion,
maintenance, or restoration of health.

Definitions
 WHO definition of Health
 Health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity.
 Health promotion
 Health promotion is the process of enabling people to increase
control over, and to improve, their health. It moves beyond a focus
on individual behaviour towards a wide range of social and
environmental interventions.

Definitions
 Theory:
A supposition or a system of ideas intended to explain something,
especially one based on general principles independent of the
thing to be explained.
 Model: A thing used as an example to follow or imitate.
 Patient Autonomy: The capability and right of patients to control
the course of their own medical treatment and participate in the
treatment decision making process.

Definitions
 The Joint Committee on Health Education and Promotion
Terminology of 2001 defined Health Education as
“Any combination of planned learning experiences based on
sound theories that provide individuals, groups, and
communities the opportunity to acquire information and the
skills needed to make quality health decisions.”

Definitions
 The World Health Organization defined Health Education
as “Comprising of consciously constructed opportunities
for learning involving some form of communication
designed to improve health literacy, including improving
knowledge, and developing life skills which are conducive
to individual and community health.”

History & Background
 The fundamental needs of shelter, food, water, and safety are
health related, and the writings of the Babylonians, Egyptians,
and Old Testament Israelites indicate that various health
promotion techniques were utilized.
 There were community systems to collect rain water or
otherwise provide safe drinking water.

 There were various sewage disposal methods, including the use
of earth closets. Personal cleanliness was advocated.
 Intoxication was recognized as troublesome.
 Disease, though not understood, was known to be contagious
and various forms of quarantine were used, as were herbal
medicines

 Business and industry have also been major players in health
education and health promotion programming since the Industrial
Revolution, admittedly prodded into action by labour unions.
 Early efforts to improve safety and eliminate inhumane working
conditions have evolved into comprehensive employee wellness
programs.

 President Eisenhower officially established the Department of
Health, Education and Welfare on April 11, 1953 in the USA.
 The Department of Education and the Department of Health and
Human Services were later separated.

Theories Of Health Behaviors

Health Promotion Theories and Models
 Behavior change theories provide structures that educators may
use to systematically design educational programs, and to
explain how and why a program is expected to be effective.
 No one theory can address all variables that contribute to a
person’s behavior, and not all theories are applicable to all
situations.
 But elements of different theories may be combined to create a
program tailored for a specific issue and target population.

A health behaviour theory offers a number
of benefits and can be seen:
 As a Toolbox for moving beyond intuition to designing and
evaluating health education interventions that are based on an
understanding of why people engage in certain health behaviour;
 As a Foundation for programme planning and development that
is consistent with the current emphasis on using evidence-based
interventions;
 As a Road map for studying problems, developing appropriate
interventions, identifying indicators and evaluating impacts;

A health behaviour theory offers a number
of benefits and can be seen:
 As a Guide to help explain the processes for changing health
behaviour and the influences of the many forces that affect it,
including social and physical environments;
 As a Compass to help planners identify the most suitable target
audiences, methods for fostering change and outcomes for
evaluation.

The Health Belief Model
by Hockbaum

Health Belief Model (HBM)
 The Health Belief Model (HBM) is an intrapersonal (within the
individual, knowledge and beliefs) theory used in health
promotion to design intervention and prevention programs.
 It was designed in the 1950’s by Hockbaum and continues to be
one of the most popular and widely used theories in intervention
science.
 The model was created in reaction to a failed, free tuberculosis
screening program.

Health Belief Model (HBM)
 The HBM assumes that behavior change occurs with the existence
of three ideas at the same time:
1. An individual recognizes that there is enough reason to make a
health concern relevant (perceived susceptibility and severity)
2. That person understands he or she may be vulnerable to a disease
or negative health outcome. (perceived threat)
3. Lastly the individual must realize that behavior change can be
beneficial and the benefits of that change will outweigh any costs
of doing so. (perceived benefits and barriers).

Limitations
 Research has not supported HBM to be a model that
will produce predictable changes.
 This model might help in changing beliefs but may not
be sufficient for behavior change.
 Behavior changes rarely follow a logical stepwise
pattern.

The Trans-theoretical Model And
Stages Of Change
by Prochaska, Norcross & DiClemente

The Trans-theoretical Model And
Stages Of Change
 Model inspired by smoking cessation studies
 Draws on fields of psychotherapy and behaviour change
 Seeks to help us understand behaviour change
 Model has been applied to a wide range of health behaviours:
Addiction, bullying, eating disorders, HIV/AIDS prevention,
etc.

Trans-theoretical Model Constructs
 Model consists of four core constructs:
1. Stages of Change (6 stages)
2. Processes of Change (10 processes)
3. Decisional Balance (Pros/Cons)
4. Self-Efficacy (Confidence/Temptation)

Question: Do you have any plans to begin exercising
more in the future?

Step 2

Decisional Balance
 Weighing of the pros (benefits) and cons (costs) of
changing a behaviour
 Pros should be higher than cons in order to move into
the action stage and beyond

Self-Efficacy (Confidence/Temptation)
 Confidence that one can engage in healthy behaviours across
different challenging situations.
 Temptation to engage in unhealthy behaviours across different
challenging situations

Limitations
 TTM considers Individual health behaviour change in isolation from
social and environmental factors
 TTM aims to produce individual change and not structural change,
so interventions are usually limited to the individual level
 Increased responsibility is placed on the individual-Potential for
victim-blaming.
 TTM interventions usually target people with change potential
 Model does not acknowledge that people with lower change
potential are often socially or economically disadvantaged
 Can further increase inequities.

Theory of Reasoned Action and
Theory of Planned Behavior
By Fishbein and Ajzen

History of the model
 Originated in the field of social psychology.
 The concept of “attitude” as a trigger and predictor of human
behavior.
 Value-Expectancy theory

Assumptions of the Model
 Human behavior is under the voluntary control of the individual
 People think about the consequences and implications of their
actions, then decide whether or not to do something.
 Therefore, intention must be highly correlated with behavior.
 Whether or not a person intends to perform a health behavior
should correlate with whether or not they actually DO the
behavior

Components of the Model
 Behavior is a function of 2 things:
 Attitudes toward a specific action
 What will happen if I engage in this behavior?
 Is this outcome desirable or undesirable?
 Subjective norms regarding that action
 Normative beliefs: others expectations
 Motivation to comply: do I want to do what they tell
me? How much? Why?

What ISN’T in the Model
 Other factors such as the modifying factors in the HBM
(demographics, etc.) are not directly addressed.
 They can have an indirect effect on the other components,
but are not specifically incorporated into the model.

Beliefs and
Evaluations of
Behavioral
Outcomes
Attitude
Toward
The Behavior
Behavioral
Intention
Behavior
Normative
Beliefs
Subjective
Norms

Limitations of TRA
 People who have little power over their behaviors (or
believe they have little power).
 As a result, Ajzen added a third element to the original
theory:
 Perceived Behavioral Control

Theory of Planned Behavior

Uses for TRA/TPB
 TRA works best when applied to behaviors that are under
the person’s control (or they think they are)
 TPB works best when the behavior is NOT perceived to be
under the person’s control.

Limitations
 Factors such as demographics and personality still not in model
 No clear definition of perceived behavioral control (hard to
measure)
 Assumption that perceived behavioral control predicts actual
behavioral control.
 The more time between behavioral intent and actually doing the
behavior, the less likely the behavior will happen.
 Theory assumes people are rational and make systematic decisions
based on available information. Ignores unconscious motives

Social Cognitive Theory
Of Learning
by Bandura, 1986.

Social Cognitive Theory Of Learning
 Social cognitive learning theory highlights the idea that much of
human learning occurs in a social environment.
 By observing others, people acquire knowledge of rules, skills,
strategies, beliefs, and attitudes.
 Individuals also learn about the usefulness and appropriateness
of behaviors by observing models and the consequences of
modelled behaviors and they act in accordance with their beliefs
concerning the expected outcomes of actions.

 Social cognitive theory defines learning as
“An internal mental process that may or may not be reflected in
immediate behavioral change” (Bandura, 1986).
 Assumptions / Basic Principles:
1. People learn by observing others: Modeling
2. Learning is internal.
3. Learning is goal-directed behavior.
4. There are ways to reinforce behaviors:

Behavioral Reinforcers
 There are 3 types of reinforcers of behaviors:
A. Direct reinforcement -- direct reinforcement would be directly
experienced by the learner.
B. Vicarious reinforcement -- vicarious reinforcement would be
observed to be consequences of the behavior of the model.
C. Self reinforcement -- self reinforcement would be feelings of
satisfaction or displeasure for behavior gauged by personal
performance standards.

Limitations
 No big picture of the person
 Too much focus on situations
 Ignore biological factors
 Mechanical -- No free will

Locus Of Control
By Wallston & Kaplan in 1970s

Locus of Control
Generalized Expectancies to perceive reinforcing events
One’s own behavior
Beyond control

Internal Locus of Control
 A belief that reinforcement is brought about by one’s own
behavior.

External Locus of control
 A belief that reinforcement is under the control of
other people, fate or Luck.

Scales to measure Locus of Control
 I-E Scale(1966).
 Interpersonal trust
Scale(1967).
 Situation Specific scales.
 Rotter Incomplete Sentence
Blank (1950).
 Intellectual Ascription of
responsibilty scale.(1965).
 Standford preschool I-E
Index.

Sense of Coherence
By Antonovsky

Health, Stress & Coping
 Morbidity hypothesis: at least 1/3 & possibly majority of
population is characterized by some morbidity at any point in time
 Views health as a continuum
ease → dis-ease

Salutogenesis
 Saluto (health) + genesis (origins)
 How do we stay healthy?
 Why?
 “What are the stressors in the lives of poor people that underlie
the brute fact that with regard to everything related to health,
illness & patienthood, the poor are affected?”

Stressors
 Stressor: characteristic that introduces entropy into the system; life
experience characterized by inconsistency, under- or overload, &
exclusion from decision making
 Chronic: Enduring, permanent, generalized phenomenon; primary
determinant of SOC
 Major life events: Specifiable in time & space; Strength of SOC →
outcome is noxious, neutral or salutary
 Daily hassles: No automatic adaptive response, but no impact on
SOC or health status

Sense of coherence (SOC)
 Global orientation that expresses the extent to which one has a
pervasive, enduring & dynamic feeling of confidence that one’s
internal & external environment are predictable.
 High probability that things will work out as reasonably as can be
expected.
 Generalized, long-lasting way of seeing the world & one’s position
in it.

Sense Of Coherence Contd..
 Shaped & tested, reinforced & modified
 Constant tendency towards consistency & generalization, stability
& continuity
 Weak SOC: Anticipate things will go wrong, difficulty expecting
needs to be fulfilled, lack hope
 Strong SOC: Life is complicated, but understood & in the end
things will work out

Development of SOC
 Certain individuals & social groups likely to have stronger SOC
than others.
 Social-structural & cultural-historical situations provide
developmental & reinforcing experiences → strong SOC.
 Different from internal locus of control – “I am in control” vs.
“Things are under control”.

Operationalizing SOC
 Strong SOC is salutogenic.
 Operationalize:
 Don’t commit to one methodology
 Requires exploration before it’s a systematic tool
 SOC is not dichotomous
 All problems have an answer, challenge/doubt intolerable, no
flexibility to adapt to change, claim ultimate
control/understanding, denial of sadness, incapacity to admit
uncontrollable → Fake SOC

3 components of SOC
 Comprehensibility: Extent to which one perceives stimuli as
ordered, consistent, etc.
 Manageability: Extent to which one perceives resources available
as adequate to meet demands.
 Meaningfulness: Extent to which one feels life makes sense, some
demands worth investing in, challenges welcome.

Measuring the SOC concept
 29-item questionnaire 13 item short form
 7-point Likert type scale
 Questionnaire which measures Orientation to Life.
 Should not measure scores on subscales, inconsistent with
theoretical formulation

Oral Health Applications &
Recent Research

The Application of the Health Belief Model
in Oral Health Education
 By M Solhi et.al.
 The Goal of this study was to determine the application of health
belief model in oral health education for 12-year-old children and
its effect on oral health behaviors and indexes.
 A quasi- experimental study was carried out on twelve-year-old
girl students (n-291) in the first grade of secondary school, in the
central district of Tehran, Iran.
Ref: Iranian J Publ Health, Vol. 39, No.4, 2010, pp. 114-119

 Methodology:
 First, a descriptive study was applied to individual perceptions,
oral behaviors, Oral Hygiene Index (OHI) and Decayed, Missing
and Filled Teeth Index (DMFTI).
 Then an educational planning based on the results and Health
Belief Model (HBM) was applied.
 The procedure was repeated after six months.
Ref: Iranian J Publ Health, Vol. 39, No.4, 2010, pp. 114-119

 Results:
 After education, based on HBM, all the oral health perceptions
increased (P<.05). Correct brushing and flossing are influenced by
increased perceptions.
 A low correlation between the reduction of DMFTI and increased
perceived severity and increased perceived barriers are found.
 In addition, there was a limited correlation between OHI and
increased perceived benefits .
 Conclusion:
 Using health belief model in oral health education for increasing the
likelihood of taking preventive oral health behaviors is applicable.
Ref: Iranian J Publ Health, Vol. 39, No.4, 2010, pp. 114-119

Oral hygiene behaviours and readiness to
change using the TransTheoretical Model
 By Wade KJ et.al. The aim of this study was to investigate the
Transtheoretical Model (TTM) in relation to measures of readiness to
change oral hygiene behaviours.
 A self-administered questionnaire was designed; it included four measures
related to inter-dental cleaning used for TTM staging, confidence and
frequency measures of future interdental cleaning and tooth brushing,
together with items seeking demographic details.
 Data collection occurred before a dental hygiene appointment where oral
health advice was offered, and then at three and six months afterwards, in
order to measure readiness to change post-intervention.
Ref: N Z Dent J. 2013 Jun;109(2):64-8.

 Results:
 The confidence measures for maintaining toothbrushing twice per
day and for interdental cleaning were associated with TTM staging at
baseline.
 Participants were likely to be in a higher TTM stage at 3 months
after attendance at the dental hygiene clinic and then decline to a
lower TTM stage by 6.
 Of the 31 participants who improved their TTM staging between
baseline and 3 months, 11 fell back to a lower category between 3
months and 6 months, 14 maintained their improvement, and 6
improved further.
Ref: N Z Dent J. 2013 Jun;109(2):64-8.

 Conclusions: Understanding a person's readiness to change could
improve the way in which oral hygiene interventions and advice
are given in the clinical setting.
 The TTM staging measurement tool used here provides insight
into people's readiness to change their oral hygiene behaviours,
and its use would aid practitioners in the delivery of oral health
messages.
 The initial improvement in TTM stage and subsequent regression
was consistent with the TTM's relapse phenomenon and reinforces
the concept that on-going support is crucial to maintaining
behaviour change. Ref: N Z Dent J. 2013 Jun;109(2):64-8.

The Theory Of Reasoned Action In Describing
Tooth Brushing, Dental Caries And Diabetes
Adherence Among Diabetic Patients.
 By Syrjälä AM et.al
 The aim here was to analyze the variables of Ajzen and Fishbein's
theory of reasoned action to explain the reported frequency of
tooth brushing, dental caries, HbA1c level and diabetes adherence.
 Cross-sectional data were gathered from 149 IDDM patients by
means of a quantitative questionnaire, clinical examination and
patient records.
Ref: J Clin Periodontol. 2002 May;29(5):427-32.

 Results: The results showed that a firmer intention to brush the
teeth was related to a higher reported frequency of tooth brushing.
 The attitude to and the subjective norm of tooth brushing were
related to the intention to brush and to the reported frequency of
tooth brushing.
 A better dental attitude was related to better diabetes adherence and
fewer decayed surfaces, and a firmer intention to brush the teeth
was related to a lower HbA1c level.
 Conclusion: Results suggest that in oral health promotion among
diabetic patients, both subjective norm and attitude are important
and that diabetes adherence may be influenced by promoting dental
attitude. Ref: J Clin Periodontol. 2002 May;29(5):427-32.

Applying Social Learning Theory To
Children With Dental Anxiety.
 By Catherine et.al.
 Through a review of the literature dental anxiety has been found to
be prevalent and problematic within the child population.
 This article seeks to apply Albert Bandura's social learning theory
to reduce dental anxiety in children, in a preventative nature.
 The social learning theory offers not only a preventative approach
but also easy and effective interventions that can be used with
children, in particular ranging from 4-9 years of age.
Ref: J Contemp Dent Pract. 2004 Feb 15;5(1):126-35.

 A dentist can act on his own free will to reduce disruptions in his
office by incorporating either films or live observations within
his or her practice.
 This article concluded that the collaboration between psychology
and dentistry offers both fields a better understanding of dental
anxiety and further improves the resources available to those
children that suffer with dental anxiety.
Ref: J Contemp Dent Pract. 2004 Feb 15;5(1):126-35.

Dental Fear And Locus Of Control:
A Pilot Study
 By Per Otto Neverlien et. Al.
 In a pilot study among 25 Norwegian elementary schoolchildren age
13 the external part of a Health Locus of Control (HLC) inventory,
when scored in internal direction, showed remarkably high positive
correlations with clinical anxiety (r = 0.81) and scores on Corah's
Dental Anxiety Scale (CDAS) (r = 0.77).
 The high correlation between the E-part of the HLC scale and
CDAS was upheld when HLC was given to 19 children 20 months
later.
Ref: Community Dentistry and Oral Epidemiology Volume 16, Issue 2, page 127,April 1988

A Salutogenic Perspective To Oral
Health
 By Jarno Savolainen et al
 The study verified Sense of coherence as a determinant of oral and
general health behaviours, and oral health-related quality of life.
 The present study uses data from the nationally representative
Health 2000 survey carried out in 2000–2001 by the National
Public Health Institute of Finland.
 The cross-sectional data was collected via home interviews, self-
administered questionnaires, or clinical examinations.
Ref: A Salutogenic Perspective To Oral Health By Jarno Savolainen

 Results:
 Sense of coherence was positively associated with oral health
behaviours, such as dental attendance and tooth-brushing
frequency. In addition to tooth-brushing frequency, sense of
coherence was also positively associated with the level of oral
hygiene.
 A strong sense of coherence was strongly associated with a
positive oral health-related quality of life (OHIP).
 Sense of coherence was also associated with all of the OHIP sub-
scales, and the association was most evident in the psychological
discomfort, psychological disability and handicap sub-scales.
 A strong sense of coherence was a common determinant of
healthy behaviours in general, as well as of a good subjective
health status.
Ref: A Salutogenic Perspective To Oral Health By Jarno Savolainen

 Conclusions:
 This study recognizes the sense of coherence as a common
health-promoting determinant of oral and general health
behaviours, good oral health, and a good Oral Health-related
Quality Of Life.
 The results thus suggest that the role of psycho-social factors
should not be underestimated in health promotion.
Ref: A Salutogenic Perspective To Oral Health By Jarno Savolainen

Conclusion

Conclusion
 Improving the health of individuals and communities was a concern
of the earliest civilizations and it remains a concern today.
 Indeed, health education and promotion has evolved into a
profession, and certification indicating adequacy of training and
competence is now available.
 Health promotion programming is pervasive in the private and
public sectors of most industrialized societies, and it has even been
suggested that we are in a “golden age” of health education and
promotion.

Conclusion
 Health promotion programming is pervasive in the private and
public sectors of most industrialized societies, and it has even
been suggested that we are in a “golden age” of health education
and promotion.
 Yet the question remains whether the profession will continue to
flourish (because its practice has improved) or whether it will
begin to decline (because it has not lived up to its potential).
 The answer to this question is largely in the hands of today’s
practitioners.

References
 Primary Preventive Dentistry: Norman O. Harris, 7th Edition.
 Community Oral Health: Cynthia Pine Et Al.
 Parks Textbook Of Public Health Medicine 23rd edition.
 Health Promotion Theories and Models for Program Planning and
Implementation Rowan Frost, Mel & Enid Zuckerman College of
Public Health University of Arizona.
 Health Education: Theoretical Concepts, Effective Strategies And
Core Competencies: WHO Library Cataloguing in Publication
Data

References
 Health education: www.wikipedia.com
 Evolution of Health Education, Health Promotion, and Wellness
Programs: 42376_BOOK_johnson.indb
 http://currentnursing.com/nursing_theory/health_belief_model.
html
 The Transtheoretical Model And Stages Of Change Laura
Kadowaki Gero 820
 Social Cognitive Theory Albert Bandura Stanford University

References
 Iranian J Publ Health, Vol. 39, No.4, 2010, pp. 114-119
 N Z Dent J. 2013 Jun;109(2):64-8.
 J Clin Periodontol. 2002 May;29(5):427-32.
 J Contemp Dent Pract. 2004 Feb 15;5(1):126-35.
 Community Dentistry and Oral Epidemiology Volume 16, Issue
2, page 127,April 1988
 A Salutogenic Perspective To Oral Health By Jarno Savolainen

Previous Year Questions
 Health education Models: RGUHS May 2009 (20mks).
 Behavior Modification Theories: RGUHS 2004 (20mks).
 Health Promotion Models: RGUHS 2013 (20mks).
 Motivational Models: NTRUHS May 2012 (AP)-(5mks).