Theory-based Education
COMT 492-02
Overview

Why we need theories
 How to select a theory
 Pros & cons of theories
 Common theories
 Example
 Lessons learned
Types of theories?
Linguistic
How we word messages determines whether
people will pay attention & respond
Behavioral Decision-making
Behavior change is complex & involves a series of
stages
Affective or framing theories
Fear appeals and positive framing affect how
people respond to messages
Why do we need theories?

Guides practice
 Leads to more
effective interventions
 May save costs
 Help develop models
of change
Freudenberg, N., Eng, E., Flay, B., et al. (1995). Strengthening individual and
community capacity to prevent disease and promote health: In search of
relevant theories and principles. Health Education Quarterly, 22 (3) : 290306.
Why do we need theories?

Understanding “antecedents” to health
behavior
– Promotes better understanding of causes of
behavior…

leading to more effective programs
– Helps identify groups who are at risk…
 helping target programs
How to select a theory?
Numerous theories exist

Sociological
 Psychosocial
 Biological
Numerous theories exist

Sociological theories
– poverty, ethnicity, disorganization, structural causes

Psychosocial theories
– beliefs, personal values, perceived norms, intentions
– family education, parenting, stability

Biological theories
– genetics, hormones, and psychological (proximal)
determinants of behavior
How to select a theory?

Theories must answer:
– What are primary causes of
the health problem?
– What are links between
interventions & outcomes?
– How do community,
individual and societal
factors interact?
– What’s role of health
educator?
Links between activities &
outcomes

Understanding how
and why interventions
work enables us to
replicate effective
change.
 Evaluation research
can test whether an
intervention worked in
the way(s) a theory
predicts.
Role of health educator

An effective intervention should have a
coherent rationale – or a theoretical basis –
for goals, intervention activities, and role of
the educator.
Weaknesses of theories
Weaknesses of health
education theories

Not readily available
to practitioners
 Emphasize individual
change at expense of
societal factors

Static or unidirectional
 Not very participatory
 Don’t explain big
picture -- how
problems emerge and
how interventions
work
Common health education
theories
Psychosocial Theories

Elaboration Likelihood Model
 Health belief model
 Social cognitive theory
 Theory of reasoned action
 Theory of self-regulation & control
 Stages of Behavior Change
 Agenda-setting
Elaboration likelihood model:
Motivation to attend to health
messages

Before you get people to change their behavior,
you need to get them to attend to a message.
– Mindless/passive vs. Active/mindful
– Peripheral vs. Cognitive (central processing)

An audience involved with a topic will actively
seek, attend and process messages about that topic.
 Uninvolved audiences will process info in a
passive fashion.
Switching cognitive gears

How do you prompt active thought (Louis
& Sutton, 1991)
– Mode of presentation
 Unusual, novel or unfamiliar
– Positive affect appeals for topics usually associated with
fear (e.g., skin cancer)
– Entertainment (e.g., Amazing Spiderman Comics)
• Parasocial relationships
• Behavior modeling
Switching cognitive gears
(cont’d)

Content represents discrepancy
– When a message is inconsistent w/ what’s expected, it prompts
active thought

External or internal request for paying attention
– Verbal immediacy
– Denotative specificity
• Personalizes & simplifies a message
• “You should wear sunscreen” vs. “People should…”
– Spatial immediacy
• “This, these, here” vs. “those, that and there”
– Temporal immediacy
• Present tense verbs
– Avoid qualifiers
Health Belief Model:
Factors influencing behavior

Intention to engage in the behavior
 Environmental constraints
 Skills or ability to engage in the behavior
Factors influencing behavior

Intention
– Perceived net benefits
– Perceived social norms
– Self-efficacy
– Consistency with self-standards
– Emotional reactions
Example: Teen Pregnancy

A person is more likely to intend to use
contraception if they believe:
– Benefits outweigh costs
– Others have positive beliefs about
contraception
– They can readily obtain contraception
– Using contraception is consistent with their self
image
Antecedents of teen
pregnancy & childbearing

No one antecedent explains all variance in
behavior
 Many antecedents weakly or moderately
related
 Results can paint picture of youths most at
risk
Antecedents (cont’d)

Youths at greatest risk are more likely to:
– Live in communities w/ high turnover; low
education, high poverty, high divorce, high
rates of adolescent births
– Have parents w/ low education, poor, history of
divorce, history of teen pregnancy
– Have parents w/ poor childrearing practices,
less supervision
– Have friends who are sexually active
Implications for teen
pregnancy programs

Difficult to reduce teen pregnancy markedly
– Many factors
– Many of the factors are structural, biological or distal

Programs should not focus on any one factor alone
 Programs should focus on:
– Sexual beliefs, attitudes, perceived norms, self-efficacy,
skills & intentions
– Environmental constraints
– Structural inequities
Theories of Behavior Change

Social Learning Theory (Bandura, 1977)
 Empowerment Education (Freire, 1973)
 Agenda Setting (McCombs, 1978)
 Theory of Reasoned Action (Azjen &
Fisbein, 1980)
 Stages of Behavior Change (Prochaska &
DiClemente, 1986)
Health Belief Model
Health Belief Model

One’s attitudes, social norms and beliefs about
outcomes of a behavior determine their
behavior
– Hell-raiser may expect pregnancy or HIV, and
therefore use condoms more
– Romantic Idealist may expect loss of love if she
insists on condom use
Becker, M., 1974
Social Learning Theory
&
Social Cognitive Theory
Social Learning & Cognitive
Theories

People learn by observing role models being
rewarded or punished for a behavior
 Learning is increased if:
– Role model is:



Likeable
Similar to target audience
Credible
– Skills are clearly demonstrated
– Behavior appears easy to do
Bandura, A., 1977, 1986
Empowerment Education
Empowerment Education

Learning occurs when people are involved
in the process of education or change
 Learning is increased if:
– People participate more
– People are involved with every step of the
process
– People agree on end goal
Freire, P., 1973
Agenda-setting
Agenda-setting

Media sets the agenda for what people think
is important
 When media gives high salience to an issue,
it is reflected by popular opinion
Shaw, D. & McCombs, M., 1978
Stages of Behavior Change
Stages of Behavior Change

Behavior change is not a one-step process
 Different messages are needed for each stage
 Stages of Behavior Change Model:
 Pre-contemplation: No intention of condom use
 Contemplation: Intends to use condoms in next 6
months
 Ready-for-action: Intends to use condoms from now on
 Action: Continual condom use for less than 6 months
 Maintenance: Condoms used every time for at least 6
months
Prochaska J, et al. The transtheoretical model of change and HIV prevention: A
review. Hth Ed Quart use of condoms using the stages of change model. Public
Health Reports 1996;111(suppl 1):59-68.
Pre-contemplation to
Contemplation

Consciousness-raising: Increasing
information about oneself in relation to a
particular problem
– Dimensional models and risk comparisons
– Cumulative and one-shot probability
– Qualitative & quantitative probability terms
– Framing effect
Dimensional models & risk
comparison

Only risks with similar dimensional profiles
should be compared.
– Health communication can encourage people to
move from PC to C by increasing perceived
risk associated w. a particular behavior and by
making comparisons with activities widely
regarded by society as risky.
– Inappropriate comparisons will fail.
Cumulative & one-shot
probabilities

People underestimate cumulative risk.
– Emphasizing cumulative might move people
from PC to C more effectively than talking
about the risks of a single incident.
Qual. & Quant. Terms

People associate specific numbers with
specific terms.
 Communication designers should consult
qualitative probability literature to find the
rage of quantitative equivalents (Bryant &
Norman, 1980).
– “virtually always” = .99
– “unlikely” “low probability” = .20
Segmenting by Stage of
Behavior Change

Campaigns that target audience by risk level
are more effective than non-targeted
campaigns
– in smoking cessation, exercise adoption, dietary
fat reduction & mammography screening -why not HIV?
Prochaska JO, et al. In search of how people change. American
Psychologist 1992;47(9):1102-14.
CDC Role Models Campaign
CDC Uses Stages of
Change Theory

Campaign
– CDC’s Role Model Stories in San Francisco, 1993-96

Goal
– To change women’s HIV risk behavior & community
norms

Media
– Narrative pamphlets

Target audience
– Welfare mothers ages 17-54
Kinght K, et al. This is my story: A descriptive analysis of a peer education
HIV/STD risk reduction program. Presented at American Public Health
Association, New York City, November, 1996.
Stages of Change Campaign

Different stories were developed for each
stage of behavior change:
– Contemplation:
 Kizzy says she’ll “seriously try” to use condoms
– Ready-for Action:
 Mayeisha decides to use condoms with her next man
– Action:
 Champagne uses condoms, but not every time
Campaign Results

People who progress from one stage to next
early in campaign are more likely to change
behavior
– 3% pre-contemplators quit smoking
– 7% pre-contemplators who moved to
contemplation in 1st month quit smoking
– 20% contemplators took action
– 41% contemplators who moved to ready-foraction in 1st month took action
ASHA Teen Web Site

www.iwannaknow.org
ASHA Teen Web Site
Employs Theories

Social Cognitive Theory
– Role model similar to target audience
moderates message board

a young adult with extensive STD prevention
counseling experience
– Topics teens can relate to
 frequently asked questions from other teenagers
– Tone of voice appropriate to teenagers
ASHA Teen Web Site
Employs Theories (cont’d)

Stages of Behavior Change
– Each component of Web site addresses different
stage of readiness to protect against STD/HIV



Question-and-answer format gives knowledge
(contemplation)
Internet games build safe sex negotiation skills
(ready-for-action)
Message boards provide confidence and social
support (maintenance)
– Teens can click on topics most appropriate
What are some
lessons learned?
Lessons learned

Message tailoring
 Participant involvement
 Integrate individual & community factors
 Link health goals to broader social goals
 Use existing resources
 Build on community strengths
 Support diffusion to wider population
Bridging gaps

Work with researchers from other
disciplines
 Multidisciplinary theoretical research
 Obtain input from health ed practitioners
 Create forums with community leaders,
activists, practitioners, etc.
 Define vision of health education within
larger health care system