Applying Theories and
Models
…to Community Nutrition
Programs and Strategies
Theories & Models of Health
Behaviour
We will explore:
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Factors that influences our food choice
behaviours
Theories & models of health behaviour
Community & System level change
strategies (Community Development,
Social Marketing, Policy)
Food Choice Behaiours
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
READ
Raine, K. (2005). Determinants of
healthy eating in Canada. An
overview and synthesis. Can. J.
Public Health, 96, suppl 3, S8-S14.
Personal Food Choices
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Physiological
factors
Food Preferences
Nutritional
Knowledge
Perceptions of
Healthy Eating
Psychological
Factors
Personal Food Choices?
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Environmental Factors
Interpersonal influences
 Physical environment
 Economic environment
 Social environment
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Creating Supportive
Environments - Policy
Food Choices
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Food choices, eating behaviours and
resulting nutrional health are influenced
by a number of complex and interrelated individual, collective and policyrelated determinants.
A growing body of research is
supporting the relationship between
food preparation and cooking skills and
food choices of children and adolescents
within the family context.

Health Canada, Improving Cooking and Food
Preparation Skills, 2011
Food Choices

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Diet quality of youth related to
frequency of family meals AND
involvement in food prep
Taste, nutritional value, cost and time

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Main factors behind food choice & prep
decisions ACROSS SES groups
Low SES report cooking from ‘scratch’
more often AND use of fewer
convenience foods

Health Canada, 2011
Best Practices for
Interventions
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Theoretical basis clear
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Experiential/hands-on learning
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Or minimally based on set of
“defendable community-relevant
assumptions”
Promotes self confidence through skill
development
Include self-assessment of eating
patterns & behaviour change
tracking

Health Canada, 2011
Best Practices
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Tailored for specific population
group
Based on measurable, specific
goals
Longer vs. shorter duration
programs
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Provide reinforcement & motivation

Health Canada, 2011
What are food skills?
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Knowledge
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Planning
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Creative use of leftovers, adjusting recipes
Mechanical techniques
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Organizing menu, food prep within budget, teaching
children food skills
Conceptualizing food
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Food safety, label reading, ingredient substitution
Following recipe, chopping, mixing, etc.
Food Perception
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Using senses, when foods are cooked
Rural Restaurant Customers
Preferences
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Options most
likely to order if
available
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Broiled or baked
meat
WW bread
Fresh fruit
Steamed veg
Regular salad dsg
on side
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Options least
likely to order if
available
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Low-fat sour
cream
Low-fat salad dsg
Low-fat milk
Low-calorie
dessert
Request to hold
high fat
ingredients
Income & supplement use
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Lower income adults less likely to
consume vit/min supplements
Higher education linked to greater
supplement use
Lower income
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Food insecure & poorer diet quality
May need supplements most
Findings suggest need for improved
access to supplements for lower income

Whiting, Adolphe, & Vatanparast, Oct 2009, DC
Current Issues
Food Choice Behaviours
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Knowledge  behaviour
Food Choice Behaviours
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Values
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Beliefs
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conceptions of reality & propositions about how the
universe works
Norms
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Permeate our lives; define who we are & where we stand;
learned from socialization (Vanden Heede, et al., 2006)
conception of what is desirable & undesirable
principles, rules or standards for behavior - they are
people’s conception of what should occur in a given
situation
Culture
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a guide for behaviour
a mental map
Theory
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a set of interrelated concepts,
definitions, and propositions
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presents a systematic view of events or
situations
by specifying relationships among variables
in order to explain or predict the events of
the situations.
Theory

Used as a guide:
 WHY people are/are not following health
advice
 WHAT you need to know before
developing or organizing an intervention
program
 HOW you shape program strategies to
reach population and make an impact
 WHAT should be monitored, measured,
and/or compared in the program evaluation
Theory
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Helps us understand behavior
Explains dynamics of behavior
Explains process for change of behavior
Identifies target for programs
Identifies methods for accomplishing
change
Theories and models EXPLAIN behavior and
SUGGEST ways to achieve behavior change
Theory

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Keep in mind that more than one
theory may be used to address an
issue
No single theory dominates community
nutrition activities
Theory

Designing interventions for eating pattern
changes can best be done with understanding
of relevant theories and of dietary behaviors
change and an ability to put them into
practice
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(Glanz & Eriksen, 1993)
Theories therefore:
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Guide program development
Provide foundation for evaluation
Model
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Vehicle for applying theories
Provides plan for investigating or
addressing a phenomenon
Only represents processes; does
not attempt to explain them
Two models linking theory to
practice
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Scientific model
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Theory defined to deduce hypotheses that
are tested with experimental research
design
Requires replication by practitioners of
exact process to find the ‘truth’
Humanistic model
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Theory define to seek to clarify social values
Practitioners use theory to stimulate
dialogue about “eating habits in living the
kind of life that community members find
most valuable.” Buchanan, 2004, JNEB, 36, 146-154.
Theories and models
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Intrapersonal level (Individual)
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Interpersonal level
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Stages of Change (TTM)
The Health Belief Model
Theory of Reasoned Action
Social Cognitive Theory
Community and group level
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Diffusion of innovations
Transtheoretical Model
(TTM) – Intrapersonal
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Developed by Prochaska & Diclemente
Stages of Change Model
Transtheoretical Model
(TTM)
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Focus

Person’s readiness to change or
attempt to change toward healthy
behaviour
Transtheoretical Model
(TTM)
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Assumptions
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Behaviour change involves series of
stages or steps
Common stages across variety of
health behaviours
Tailor interventions to be most
effective
Encourages us to think about
client’s readiness to change
Transtheoretical Model
(TTM)
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Precontemplation – unaware or not
interested in making change
Contemplation – thinking about taking
action - next 6 mths
Preparation – active decision to change and
planning
Action – trying to make change for <6mths
Maintenance -has sustained change for
>6mths
Termination – no temptation and 100%
self-efficacy
TTM
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Self Efficacy
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confidence in ability to change
behaviour & to withstand temptations
to relapse
Decisional Balance
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pros and cons of change
how an individual perceives these
Decisional Balance
Pros of
Change
Pros of No
Change
Cons of
Change
Cons of No
Change
TTM Applications

Intervention strategies should be
matched with processes commonly
used in particular stage of change

cognitive processes used in pre-action
stages
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Seeking information
behavioral processes used in Prep,
Action and Maintenance
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Seeking ways to strengthen behaviour
TTM Applications

TTM originated with addictive
behaviours research
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e.g., smoking cessation
Dietary change involves complex
combination of removal of one set
of behaviours & acquisition of new
set of behaviours
Measurement of definite stage of
change is more difficult
TTM – use to increase V/F
intake in preschool children
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Low-income parents & primary
caregivers (N=238)
Incorporates staging algorithm for
increasing V/F accessibility to PS
children, decisional balance, selfefficacy
Hildebrand, & Betts, 2009;
JNEB, 41(2), 110-119
TTM – use to increase V/F
intake in preschool children
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Precontemplation/Contemplation
(43%)
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Preparation (29%)
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Best to use methods to share ideas for
planning meals and snacks to include V/F
Aim to build skills in making quick &
economical V/F
Stress parent role-modeling
Encourage goal setting
Action/Maintenance
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Hildebrand, & Betts, 2009;
To prevent relapse, build
social
support in
JNEB,in
41(2),
110-119
all learning formats
TTM with low income parents
& caregivers
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Caregivers assessed for stage of change
for increasing V/F access for PS children
43% precontemplation/contemplation
29% preparation
Those in action & maintenance
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Showed higher self efficacy u
Used more behavioral processes
Interventions should be tailored to
stage of change
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Cognitive vs. behavioural

Hildebrand, & Betts, 2009
Health Belief Model Intrapersonal
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Hochbaum, Rosenstock and Kegel 1950s
to explain why people would/would not
use health services
Health Belief Model Intrapersonal
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Focus

Person’s perception of a health
problem & appraisal of recommended
behaviour to manage or prevent the
problem
Health Belief Model –
Three Components
1. Perception of threat to health
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personal threat to health
concerned that ‘disease’ carries serious personal
consequences
2. Outcome expectations
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perceived benefits and barriers to taking specific
action
3. Self-efficacy
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belief that one can make a behaviour change
Other factors affect perceived threat, outcome
expectations & efficacy expectations
Thus, factors influence health behaviour
indirectly
Using Health Belief Model
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Include skill-building components
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Be aware of times of increased
threat perception

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increase self-efficacy
↑ likelihood of change
Identify barriers to action

develop strategies for helping clients
overcome barriers
Theory of Reasoned Action –
Intrapersonal
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Ajzen and
Fishbein
Behaviour
determined
directly by
intention to
perform the
behaviour
Theory of Reasoned Action
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Intention
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Instructions given to self to behave in
certain way
Consider behaviour outcomes & opinion of
significant others when forming opinions
Intentions influenced by attitudes and
social pressures to perform (subjective
norms)
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Perceived social pressure to perform or not
perform a behaviour
Theory of Trying Intrapersonal
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Developed by
Bagozzi
Modified Theory
of Reasoned
Action
Theory of Trying
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Added components that influence
intention to try behaviour:
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past experience (success or failure)
with behaviour
mechanisms for coping with
behaviour outcome
emotional responses to process
Application of Theories to
Practice
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Self-assurance seems linked to
successful behaviour change

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self-esteem
self-efficacy
Application of Theories to
Practice
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Could screen clients upon program
entry
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degree of readiness to change
degree of past success
degree of confidence in ability to
change
level of commitment to program
Social Cognitive Theory
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Developed by
Bandura
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to explain how
people acquire &
maintain
behaviours
SLT = Social
Learning Theory
Interpersonal Model –
Social Cognitive Theory
Internal/Personal
Factors
Environmental
Factors
Behavior
(Bandura,
1972)
Social Cognitive Theory

Strength

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focus on target behaviours rather
than attitudes & knowledge
Key concepts and their
implications

Table 15-3, page 487
Interpersonal level
applications
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Small Groups
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Social Support
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Supplement or substitute individual counseling
Interacting with positive role models and problem
solving through discussions with people with
shared problems
Peer Education
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Effective at enhancing observational learning
through role models
Youth and cultural minority groups
Interpersonal level
applications
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Point-of-purchase nutrition
information
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Guide food selections in food
establishments, i.e., supermarkets,
cafeterias, restaurants
Information during decision making
increase awareness and serve as reminder
Community & Group –
Diffusion of Innovation

Rogers and
Shoemaker,
1970s

to explain how
product/idea
becomes accepted
by majority of
consumers
Diffusion of Innovation

Focus

Addresses how new ideas, products &
social practices spread within a
society or from one society to another
Diffusion of Innovation
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Consists of 4 stages
Knowledge
Persuasion
Decision
Confirmation
Diffusion of Innovation
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Spread of innovations largely by
word-of-mouth
Speed of diffusion is a function of
number of people adopting
Consumers classified by readiness
to adopt new innovation

innovators, early adopters, early
majority, late majority, late adopters,
laggards
Application of Diffusion of
Innovation
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Diffusion process facilitated by
actions of different sectors
Barriers to adoption occur due to
disruption of habitual routines
The greater the disruption, the
slower the adoption
Knowledge-AttitudeBehaviour
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Health Information

Calorie per calorie, whole fruit has
more dietary fibre than fruit juice.

ADA position paper, Total diet approach to
communicating food and nutrition information,
2007.
Health Belief Model

Perceived benefits, threats, barriers

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Whole fruits have fibre that helps me feel full.
If I drink juice instead of eating whole fruit, I would
get less fibre and have a harder time managing my
calorie intake.
That could lead to gaining excess weight which
would make me feel less attractive.
However, I may not be able to eat whole fruit as
often as I want to because it is easier to find fruit
juice when I need something that’s fast and easy
from a vending machine or a convenience store.
Social Learning Theory
TTM, & Health Belief Model

Self-efficacy

I know that I can eat more fruit and
less juice by learning which fruits are
in season and putting those fruits on
my weekly shopping list.
Social Learning Theory

Reciprocal Determinism

If the vending machines at my office
have fruit, I will be more likely to
select it as a snack.
TTM

Stages and Processes of Change

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I realize that eating whole fruit is a
good way to help me increase my
intake of fruits & vegetables each
day.
I also realize that I have been getting
most of my fruit in the form of juice.
I will start buying more whole fruit
and less juice the next time I go to
the supermarket.
Community-level models

Frameworks for understanding
how social systems function and
change, and how communities
and organizations can be
activated
Community-level models

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Essential for comprehensive community
education
 individuals, groups, institutions, and
communities
 Embody an ecological perspective
Complement individually oriented behaviour
change goals with broad aims that include
advocacy and policy development
Suggest strategies and initiatives that are
planned and led by organizations and
institutions,

i.e., schools, worksites, health care settings,
community groups, and government agencies
Ecological Perspective

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Multiple
dimensions of
influence on
behavior
Interactions
across dimensions
Multiple levels of
environmental
influences
Environments
directly influence
behaviors
Intrapersonal
factors
Inter-personal
processes and groups
Institutional
factors
Community
factors
Public policy
Community-level models

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Community Organization Theories
Organizational Change Theory
Community-level models

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Organizational Change theory
Focus

Processes and strategies for
increasing the chances that healthy
policies & program will be adopted &
maintained in formal organizations
Community-level models

Community Organization Theories

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roots in theories of social networks and
support.
Emphasizes active participation &
development of communities that can
better evaluate and solve health and
social problems
Community Change: Key
Concepts

Empowerment


process by which individuals,
communities or organization obtain
mastery over their lives to produce
change
Community Competence

Community sectors able to
collaborate effectively to engage in
problem solving
Community Change: Key
Concepts

Participation


involvement of all community
members in planning, development, &
implementation of programs in the
community
Relevance

starting where the people are;
beginning with the community’s felt
needs
Community Change: Key
Concepts

Issue Selection


community’s ability to identify &
prioritize issues
Critical Consciousness

Developing understanding of the root
causes of a problem
Community Level
Strategies

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Community Development
Community Capacity Building
Community Based vs.
Community Development

Community based programming is the
process of health professionals and/or health
agencies

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
Defining the health problem
Developing strategies to remedy the problem
Involving local community members and groups to
assist in problem solving
Working to transfer major responsibility for
ongoing program to local community members
and groups
Labonte, 1993
Community Based vs.
Community Development

Community development is the
process of organizing and/or supporting
community groups in their identification
of important concerns and issues, and
in their ability to plan and implement
strategies to mitigate their concerns
and resolve their issues.
Labonte, 1993
Characteristics of
community-based

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The problem name is given by the
professional/institution
There are defined program timelines
Changes in specific behaviours or
knowledge levels are the desired
outcome
Decision-making rests principally with
the professional/institution
Labonte, 1993
Characteristics of
community development

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The naming of the problem starts with
the community group
Work is long term, requiring many
hours
A general increase in the group’s
capacity is the desired outcome
Power relations are constantly
negotiated
Labonte, 1993
Capacity Building

“the strengthening of the ability of
people, communities and systems to plan,
develop, implement and maintain
effective health and social approaches.”
(PPHB Atlantic, Health Canada 2001)

“an approach to the development of
skills, organizational structures,
resources, and commitment to
improvement in health and other sectors,
to prolong and multiply health gains
many times over.” (Hawe, 1999)
Capacity Building

Individual/Personal

Community

Organization

Systems
Society Level Strategies


Social Marketing
Policy Change
Social Marketing
“ the use of marketing principles and
techniques to advance a social cause,
idea, or behaviour”
Vanden Heede & Pelican, 1995
Social Marketing
“…combines the best elements of traditional
approaches to social change in an integrated
planning and action framework, and utilizes
advances in communications technology and
marketing skills. It uses marketing techniques
to generate discussion and promote
information, attitudes, values and behaviors.
By doing so, it helps to create a climate
conducive to social and behavioral change.”
(Health Canada, 2004)
Social Marketing Network http://www.hc-sc.gc.ca/english/socialmarketing/
Social Marketing


Aim: to influence the voluntary adoption of
behavior change of the target audience
Uses consumer research



i.e. demographics
Focus on conferring benefits & reducing
barriers
Primary beneficiaries are the target audience,
not the marketing body
The Marketing Mix
The 4 P’s of marketing:
 Product - the “bundle of benefits”
 Price - “cost” of the behavior change
 Place – benefits must be available at the
right place and the right time


i.e., “the how” and “the where”
Promotion – methods used to raise
awareness and provide education

i.e., “the what”
The role of research…
Market research


Developing demographic, behavioral and
lifestyle profiles
Identifying existing behaviors, actions, needs,
perceptions, attitudes and perceived
benefits/barriers of the target audience
Competitive analysis

Identifying organizational and environmental
considerations that influence behavior change
Health Canada, 2004
Social Marketing


CDC recommends social marketing to
achieve targeted public health goals
Self-guided Web course (free)



Social Marketing for Nutrition and Physical
Activity
http://www.cdc.gov/nccdphp/dnpa/socialmar
keting/training/basics
Basics, problem description, Formative
research, Strategy development, Intervention
design, Evaluation, Implementation PLUS tips,
worksheets, glossary and resources
Social Marketing Examples


Evidence that providing coupons
for nutritious food to university
students, low-income seniors, WIC
participants (US)  improved long
term nutrition status
Linking communities with local
farms & encouraging pick-yourown intitiatives


 increased V/F intake
? Reduced obesity risk
FOP Label Understanding


Low-CHO claim FOP
Only FOP claim seen



FOP claim with Nutrition facts panel


Rated low-CHO claim as more helpful to wt
management AND lower in calories than
same product without claim
Bread with low-cho claim rated more
healthful
Rated products with the same nt profile the
same with or without FOP claim
Consumers who do not use the NF panel
may misinterpret FOP claims

Labiner-Wolfe, Lin, & Verrill, 2010
Online Social Marketing
Projects

Social Marketing: Nutrition and
Physical Activity



http://www.cdc.gov/nccdphp/dnpa/
socialmarketing/training/basics/
Self-guided web course in social
marketing of health
Modules take about 15-30 minutes to
complete

Tips, worksheets, resources, glossary
Ecological theory and social
marketing
Behavior is influenced by a variety of factors.
If…
 They believe it will reduce risk (intrapersonal)
 Their family requests it (interpersonal)
 Their employers offer a nutrition education
program (organizational)
 There is an availability of foods that can
reduce risk (community)
 There is improved product labeling (policy)
Lefebvre, 1995
Milk - some facts…



Children main consumers but by teens
consumption reduced
Nearly 90% teen girls and 70% teen boys don’t get
the calcium they need
Osteoporosis affects 1.4 million Canadians




1 in 4 women and 1 in 8 men over the age of 50
$1.3 billion in health care costs
Milk viewed as high fat & associated with high fat
foods
Low fat milk perceived as lower in nutrients
Goeree 1996, Hanley and Josse 1996, NIH Consensus statements 2000
The got milk? program
History of got milk?

In 1993: California Milk Processor
Board (CMPB) formed



Aim: to make milk more competitive & to
increase consumption in California
Initial target: women aged 25-44
Initial position: skim milk was healthy
for adults
History of got milk?





1994: milk consumption in California
increased 1%
1995: the got milk? campaign was
licensed to the National Dairy Board
1996: billboard ads
1998: Birth of the milk mustache
1999: gotmilk.com born
History of got milk?




2000: ads promote chocolate milk
2002: California milk sales increase
1.6% since 2001
Californians used 746 million gallons of
milk in 2002, the highest since 1992
2003: McDonalds McHappy Meals
include milk
History of got milk?








By 10th anniversary:
Over 95% of Americans recall campaign
Spawned hundreds of got milk? rip-offs
Has become a multi-million dollar licensing property
Helped defend milk’s share of beverage consumption
in California & the US
Dairy industry spends $150 million annually to
support campaign
Industry worth $2 billion in California & $20 billion
nationally
Competition: products such as Coke and Pepsi and
more recently calcium enriched beverages
4P’s of got milk?




Product: e.g., milk provides vitamins and
minerals to aid in the prevention of
osteoporosis
Price: resources needed to drink milk
Place: magazines, billboards, TV
actual milk: stores, schools, fast food
Promotion: via ads, media campaign, web
site
Why television ads?




To reach people in their homes
Less than 5% of all milk is consumed
outside the home
Aim to get people to “reach for cookies
and milk instead of chips and soda”
Started in 1994 and in 2 years there
was a 91% awareness rating
Evidence its reaching the
public (Evaluation)

In July 2002 press release:




Milk intake increased for the first time in 6 years
Soft drink still number one for those 13-17 y
Flavored milk big hit
Per capita milk consumption among teens in
2001 was 22 gallons, 3% increase


increased to 23.5 in 2002
Teens that drink milk get 34.6% of their
beverage intake from soft drinks and 29.7%
from milk

Non-milk drinkers: soft drink-54.8%
Evidence its reaching the
public (Evaluation)

Milk Mustache Survey
 36% women said the campaign would make them
drink more milk
 70% who viewed the entire campaign now
consider milk cool and contemporary
 86% thought milk was delicious after seeing the
campaign
 1% and skim milk consumption has increased,
while 2% and whole has decreased
 The campaign got over 60% awareness in just 3
months