Promoting Healthy Behavior

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 Behavior and Global Health
“Health is a state of complete physical, psychological,
and social well-being and not simply the absence of
disease or infirmity.” (World Health Organization, 1948)

• Physical good health eludes billions of people

• Death and disease from preventable causes
remain high
• Behavior is a key factor in determining health

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 Ten Leading Risk Factors
for Preventable Disease
• Maternal and child • High cholesterol
underweight • Indoor smoke from solid
• Unsafe sex fuels
• High blood pressure • Iron deficiency
• Tobacco • High body mass index
• Alcohol or overweight
• Unsafe water, poor
sanitation, and hygiene

Source: WHO, World Health Report 2002: Reducing Risk, Promoting Healthy Life (Geneva: WHO, 2002),
accessed online at www.who.int, on Nov. 15, 2004.
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 Whose Behavior is
Responsible For…
• Maternal and child underweight
• Smoking and alcohol abuse 
• Unsafe sex 
• Unsafe water and lack of adequate sanitation 

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Maternal and Child Underweight
• Individuals (may resist nutrition education)
• Communities (male preference norms)
• Policymakers (fail to address poverty)
• Health planners and health workers (do not
include nutrition programs for the poor)

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 Smoking and Alcohol Abuse
• Individuals (choice)
• Communities (norms regarding smoking)
• Health policymakers
• Legislators & tax assessors
• Tobacco company executives
• Decision-makers in marketing companies

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 Unsafe Sex
• Individuals (abstinence, fidelity, condoms)
• Communities (norms regarding male
dominance and multiple partners)
• Poverty (transactional sex for poor women)
• Health policymakers and health workers
(effective AIDS prevention programs)


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 Unsafe Water and
Lack of Adequate Sanitation
• Individuals (where they fetch water, boiling
water, washing hands)
• Communities (fatalism regarding diarrheal
diseases, community latrines)
• Governments (ignore or underfund safe water
and sanitation needs)

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 Risky behaviors
translate to diseases

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 Global Causes of Death
Injuries

Communicable 9%
diseases, Noncommunicable
maternal and 31% diseases
perinatal 60%
conditions, and
nutritional
deficiencies

Source: WHO, World Health Report 2000—Health Systems: Improving Performance (Geneva: WHO,
2000).
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 Behavior change reduces
risky behaviors

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 Health Promotion Means Changing
Behavior at Multiple Levels
A Individual: knowledge, attitudes, beliefs,
personality 
B Interpersonal: family, friends, peers 
C Community: social networks, standards,
norms 
D Institutional: rules, policies, informal
structures
E Public Policy: local policies related to
healthy practices
Source: Adapted from National Cancer Institute, Theory at a Glance: A Guide for Health Promotion
(2003), available online at http://cancer.gov.
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A: Individual-Oriented Models
• Individual most basic unit of health promotion
• Individual-level models components of
broader-level theories and approaches
• Models
 Stages of Change Model
 Health Belief Model

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 Stages of Change Model
• Changing one’s behavior is a process, not an
event
• Individuals at different levels of change
• Gear interventions to level of change

Source: James O. Prochaska et al., “In Search of How People Change: Application to Addictive
Behaviors,” American Psychologist 47, no. 9 (1992): 1102-14.
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Stages of Change Model (cont.)
Precontemplation

Maintenance Contemplation

Action Decision

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 Health Belief Model
• Perceived susceptibility and severity of ill
health
• Perceived benefits and barriers to action
• Cues to action
• Self-efficacy


Source: Irwin M. Rosenstock et al., “Social Learning Theory and the Health Belief Model,” Health
Education Quarterly 15, no. 2 (1988): 175-85.
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 B: Interpersonal Level:
Social Learning Theory
• Interaction of individual factors, social
environment, and experience
• Reciprocal dynamic
• Observational learning
• Capability of performing desired behavior
• Perception of self-efficacy

Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall,
1986).
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 Interpersonal Level:
Social Learning Theory (cont.)
• Three strategies for increasing self-efficacy
 Setting small, incremental goals
 Behavioral contracting: specifying goals and
rewards
 Self-monitoring: feedback can reinforce
determination to change (keep a diary)
• Positive reinforcement: encouragement helps


Source: Albert Bandura, Social Foundations of Thought and Action (Englewood Cliffs, NJ: Prentice Hall,
1986).
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 C: Community-Level Models
• Analyze how social systems function
• Mobilize communities, organizations, and
policymakers
• Use sound conceptual frameworks
 Community Mobilization
 Organizational Change
 Diffusion of Innovations Theory

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 Community Mobilization
• Encompasses wider social and political
contexts
• Community members assess health risks,
take action
• Encourages empowerment, building on
cultural strengths and involving
disenfranchised groups

Source: National Cancer Institute, Theory at a Glance: A Guide for Health Promotion: 18; Paolo Freire,
Pedagogy of the Oppressed (New York: Continuum, 1970.); Saul Alinsky, Rules for Radicals: A
Pragmatic Primer for Realistic Radicals (New York: Vintage Books, 1971; revised edition, 1989).
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 Organizational Change
Organizational Stage Organizational
Theory Development Theory
Define problem

Organizational structures
Identify solutions

Initiate action

Allocate resources Worker behavior and motivation

Implement

Institutionalize
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 Diffusion of Innovations Theory
• How new ideas, products, and behaviors
become norms
• All levels: individual, interpersonal,
community, and organizational
• Success determined by: nature of innovation,
communication channels, adoption time,
social system

Source: Everett M. Rogers, Diffusion of Innovations, 4th ed. (New York: The Free Press, 1995).

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Diffusion of Innovations (cont.)
Nature of innovation
• Relative advantage over what is being
replaced
• Compatible with values of intended users
• Easy to use
• Opportunity to try innovation
• Tangible benefits

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Diffusion of Innovations (cont.)
Communication channels
• Mass media (enhanced by listening groups,
call-in opportunities, and face-to-face
approaches)
• Peers
• Respected leaders

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Diffusion of Innovations (cont.)
Adoption time
• Awareness Intention Adoption Change
• Gradual
• Movement through groups
 Pioneers
 Early adopters
 Masses

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Diffusion of Innovations (cont.)
Social system:
• Identify influential networks to diffuse
innovation: health systems, schools, religious
and political groups, social clubs, unions, and
informal associations
• Identify opinion leaders, peers, and targeted
media channels to diffuse innovations

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 Health Promotion

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 Health Promotion Tools
• Mass media
• Social marketing
• Community mobilization
• Health education
• Client-provider interactions
• Policy communication

Source: Robert Hornik and Emile McAnany, “Mass Media and Fertility Change,” in Diffusion Processes
and Fertility Transition: Selected Perspectives, ed. John Casterline (Washington, DC: National
Academies Press, 2001): 208-39.
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 Behavior Change Successes
• Reducing malnutrition (micronutrient initiatives)
• Preventing malaria (insecticide-treated bednets)
• Helping children survive (breastfeeding)
• Improving maternal health (safe motherhood
movement, emergency obstetric care)
• Making family planning a norm (worldwide efforts)
• Combating HIV/AIDS (Uganda program)

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 Combating HIV/AIDS in Uganda
• Political support, multisectoral response
• Decentralized behavior change campaigns
• Focus on women and youth, stigma and
discrimination
• Mobilization of religious leaders
• Confidential voluntary counseling and testing
• Social marketing of condoms
• Control and prevention of STIs
Source: Edward C. Green, Rethinking AIDS Prevention: Learning from Successes in Developing
Countries (Westport, CT: Praeger Publishers, 2003).
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 Health Promotion:
Lessons Learned
• Research underlying causes
• Address contextual factors
• Identify and reach key actors at every level
• Involve stakeholders throughout process
• Use sound behavioral theories
• Monitor and evaluate

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 Conclusion
• Improving global health requires behavior
change at every level—individuals, families,
communities, organizations, and
policymaking bodies
• Evidence-based behavioral theories and
successful behavior-change case histories
point the way
• Next step: political will and sufficient
resources

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 For More Information
Elaine M. Murphy, “Promoting Healthy
Behavior,” Health Bulletin 2 (Washington, DC:
Population Reference Bureau, 2005).

Available online at www.prb.org

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