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
underweight
• Unsafe sex
• High blood pressure
• Tobacco
• Alcohol
• Unsafe water, poor
sanitation, and hygiene
• High cholesterol
• Indoor smoke from solid
fuels
• Iron deficiency
• High body mass index
or overweight
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…
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•
•
•
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
diseases,
maternal and
perinatal
conditions, and
nutritional
deficiencies
9%
Noncommunicable
diseases
31%
60%
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
B
C
D
E
Individual: knowledge, attitudes, beliefs,
personality 
Interpersonal: family, friends, peers 
Community: social networks, standards,
norms 
Institutional: rules, policies, informal
structures
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
Action
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Contemplation
Decision
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
Theory
Organizational
Development Theory
Define problem
Identify solutions
Organizational structures
Initiate action
Allocate resources
Implement
Institutionalize
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Worker behavior and motivation
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
• Gradual
• Movement through groups



Pioneers
Early adopters
Masses
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Change
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
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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
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•
•
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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
•
•
•
•
•
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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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