Planning behaviour change programs
Task 1
Kok, G., Schaalma, H., De Vries, H., Parcel, G., & Paulussen, T. (1996) Social psychology and health
education.
Health promotion
Health education: planned activity stimulating learning through communication to promote healthy
behaviourvoluntary change. The steps of the model (example in paper):
Social diagnosis: determining people’s perceptions of their own needs or quality of life.
Epidemiological diagnosis is conducted to determine which health problems are important and
which behavioural and environmental factors contribute to the occurrence of the health
problems.
Behavioural and environmental diagnosis: analysis of the behavioural, social and
environmental factors that are linked to the goals or problems that were identified in the
previous step. Determinants of health are analyzed in terms of behaviour, lifestyle and
environment.
Educational and organizational diagnosis: analysis of the determinants of the behavioural and
environmental conditions that are linked to health status or quality-of-life concerns. 3 factors
can be distinguished: predisposing factors (provide rationale/motivation for the behaviour),
enabling factors, reinforcing factors.
Administrative and policy diagnosis: analysis of the usefulness of health education and other
potential interventions. Also refers to political, regulatory and organizatory factors that
facilitate or hinder the development and implementation of the program.
Evaluation of process, impact and outcome.
Vs. Health promotion: any planned combination of educational, political, regulatory, and
organizational supports for actions and conditions of living conducive to the health of individuals,
groups, or communitiesforced compliance.
Health promotion include 3 types of prevention: primary prevention, early detection and
treatment, and patient care and support.
A combination of various levels and means is often most effectiveeducation, control and
resources.
The role of social psychology
Application of social psychology theories within the area of health education for primary intervention.
Within the field of applied social psychology basically two activities can be distinguished theory-
driven and problem-driven applied social psychology. Theory-driven applied social psychology refers
to testing a theory in an applied setting, merely to get insight into the validity of the theory. Although
theories are tested in practice, the primary focus is on theory testing and the criteria for success are
formulated in terms of theory development. Problem-driven applied social psychology refers to
scientific activities that focus at changing or reducing a practical problem by using a transtheoretical
(social) psychological approach.
The theory-driven approach often considers problems from a mono-theoretical perspective: practical
settings are merely used for theoretical testing. This may be problematic:
1. Risk perception for example. Parents who do not use a restraint device for their children in the
car may think that the chance of them being in an accident is very low (unrealistic optimism).
So, you may want to educate parents about the risk etc. But the real problem is that often their
children become annoying and restless when put in the restraint device (but they know the
risks of not putting their child in a device). A better solution then would be to teach parents
how to handle their child in this situation or design a different restraint device.
2. Causal attribution: when people attribute an illness to external factors, they feel positive
emotions to the patient (e.g. sympathy, willing to help). However, when people attribute an
illness to internal factors, they feel negative emotions to the patient (contempt). According to
this theory, one way to tackle the stigmatization of AIDS patients, might be to advocate that
the cause of AIDS is external. This is however, in contrast with AIDS prevention programs
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, emphasizing that HIV can be prevented by taking self-responsibility. Thus, other theories
should be taken into account as well.
In conclusion considering multiple theories is useful. The selection of theories can be done in multiple
ways (merging the together might be most useful):
1. Issue-related strategy: search for theories that are specifically tailored to the problem in
question. Focus on theories directly related to the problem.
2. Concept-related strategy: translation of specific problem related concepts into more general
explaining principles. According to this strategy, researchers should start with the formulation
of preliminary explanations for the problem in question. Subsequently, abstracting from
specific problem- related concepts may lead to general concepts that are linked to theories.
3. General theories: general theories to explain the problem.
Theories of behavioural determinants
General and specific theories that can be applied in the diagnosis of behavioural determinants, options
for intervention programs and program implementation:
Health belief model: behaviour depends on the value placed by an individual on a particular
goal and on the estimate of the likelihood that a given action will achieve that goal. It consists
of 4 variables: perceived susceptibility, perceived severity, perceived benefits, and perceived
barriers. In other words, an individual’s decision to engage in a health action is determined by
his or her perceptions of personal susceptibility to, and the severity of, a particular condition
of illness. The specific action taken is based upon a kind of cost-benefit analysis of perceived
benefits and barriers. The decision-making process is triggered by a cue to action (internal
such as symptoms of a disease or external such as health education).
3 general categories of behavioural determinants can be distinguished (basically theory of
planned behaviour):
1. Attitude.
2. Social influence: subjective beliefs about social norms and expectations.
3. Self-efficacy.
Barriers and skills influence the relation between intentions and behaviour. The 3 factors can
be antecedent factors but also a consequence of behaviour.
First, the target behaviours and the target group have to be specified. Then relevant beliefs or
outcome expectations, relevant reference persons, and relevant self-efficacy expectations have
to be identified. The first phase in measuring determinants involves a survey of the available
theoretical and empirical literature on the target behaviour or related behaviours. In the second
phase, a qualitative method is used to find out the target population’s own ideas about
determinants of their behaviour, through individual open interviews, group interviews or open-
ended questionnaires. The third phase involves a quantitative method, a structured
questionnaire with questions that are based on the results of the qualitative phase and that is
administered to a large sample of the target population. The main focus of the analysis of the
questionnaire data is on finding (differences in) psychosocial behavioural determinants
distinguishing groups of the target population that do or do not perform the target behaviour.
Finally, the influence of other potentially relevant variables can be studied, such as gender,
age, SES, or experience with the behaviour.
Health education interventions
Behaviour change through communication:
Persuasion-Communication model constitutes of 7 phases: successful communication
(attention and comprehension); changes in behavioural determinants (attitude, social influence
and self-efficacy), and behaviour; and maintenance of behaviour change. Interventions may be
different for each phase. Not all receivers are however interested in the messageElaboration
likelihood model (people think less or more elaborate about the content of a message) and
heuristic systematic model.
Stages of change model distinguishes stages of change within a person: precontemplation,
contemplation, preparing for action, action, and maintenance or relapse. An important
implication of the stages-of- change model is the specific tailoring of educational efforts to
groups of people in different stages of change. Interventions based on this model normally
have completely different methods or strategies for each stage.
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, Social cognitive theory: relationships between cognitive, environmental and behavioural
variables are seen as interactive and bi-directional. Reinforcement of behaviour is a key
environmental factor studied by social cognitive theorists. Other people in the environment
can also affect behaviour because a person learns through observing others and receiving
reinforcement. The SCT cognitive variables include outcome expectations and self- efficacy
expectations. Modelling and incentives are SCT’s major intervention methods for influencing
behaviour.
Protocol for developing theory-based and data-based health education programs
Shift from explaining behaviour to changing behaviour. A number of steps have to be taken:
Formulation of educational goals in terms of determinants (e.g. enhancing self-efficacy).
Specification of learning objectiveswhat target group is supposed to learn.
Selection of appropriate methodologies.
Translation of methodologies into strategies and material.
Anticipation of implementation barriers.
Monitoring and evaluation of the process and effect.
Implementation of health education
Theories of implementation:
The determinants of institutional behaviour (e.g. the adoption of a prevention program by
organizations) is needed of the development of implementation strategies. The existing knowledge
concerning the diffusion and adoption of health promotion will be summarized from two perspectives:
features of the innovation that determine adoption, and the importance of a “linkage” system.
1. Features of the innovation that determine adoption: teachers’ planning behaviour and thought
processes and decisions with regard to an innovation process including four subsequent stages:
dissemination, adoption, implementation, and continuation. Dissemination refers to the
transfer of information about the innovation to potential users (e.g. teachers). Adoption refers
to potential users’ intentions to use the innovation. Implementation refers to the actual use of
the innovation. Continuation refers to the stage in which the innovation has become current
practice.
2. Linkage system: many health promotion innovations have failed because of “the gap that is
frequently left unfilled between the point where innovation development ends and diffusion
planning begins”, as if innovation-development barriers and diffusion barriers were aspects of
unrelated problems. To bridge this gap, there is a need for a linkage system between the
resource system that develops and promotes the intervention (e.g. the Anti-Cancer Council),
and the user system that is supposed to adopt the intervention (e.g. schools). Such a liaison
group should include representatives of the user system, representatives of the resource
system, and a change agent facilitating the collaboration.
A protocol for theory-based implementation planning
A strategy to stimulate implementation should be based on a careful analysis of the determinants of
implementation behaviour, on both the individual and organizational level. These determinants can be
measured with the same kind of protocol as is used in the determinants of behaviour analysesoften
the stages (dissemination, adoption, implementation, and continuation). The next step is the selection
of methods and strategies to stimulate implementation, recognizing the four phases: dissemination,
adoption, implementation and continuation. Again, the development of implementation strategies
follows the same protocol as the development of health education interventions: goals, objectives,
methodologies, strategies, implementation and evaluation. Adoption of health promotion interventions
is facilitated by observing other organizations adopt an intervention, as well as by reinforcement in
terms of material incentives, social status, or the achievement of objectives.
Ruiter, R.A.C. & Crutzen, R., (2020). Core Processes: How to use evidence, theories, and research in
planning behavior change interventions.
The processes of brainstorming, literature review, theory selection and application, and data collection
are “Core Processes” that can be used in different phases/steps of intervention planning—from needs
assessment to intervention design to program implementation and evaluation—and within different
planning frameworksif you have a question and don’t know the answer, use the core processes (also
if you think you have the answer, look if you have done all the steps). The Core Processes minimize
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, the likelihood of incomplete understanding and selecting ineffective solutions. Core Processes has a
fixed order of six steps, starting with asking a question, followed by first consulting with experts, then
reviewing the existing empirical evidence and finding theoretical support, and if then still needed
collect additional data.
1. Pose questions: mean of analyzing possible causes for the health behaviour. Later questions
are used to identify determinants of behaviour and environmental conditions.
2. Brainstorm possible answers: involves free association to generate as much explanations as
possible. Later, explanations that are poorly supported by the literature can be disregarded.
3. Review empirical findings from published research: support or refute provisional answers to
the questions based on a review of available empirical findings.
4. Find theoretical support using the topic, concepts and general theories approaches: There are
three approaches to finding theories: the topic, concept and general theories approaches; these
should be utilized in combination but also in that order. Limiting the pool of candidate
theories too soon may lead to inadequate answers or, worse, it may lead to conclusions being
drawn that are counterproductive.
Topic approach: refine, add to, and discard provisional answers based on theoretical
concepts from the empirical literature.
Concept approach: examine concepts that are generated during brainstorm
sessionsredefine lay terms to professional ones.
General theories approach: consider potentially useful general theories for further
extending and refining the list of explanations. Should be seen as a last resort to
prevent falling back in a theory-driven approach. When there is tension between
generalizability and utility of theories, utility should be given preference given the
applied nature of the problem-driven approach.
5. Identify and address the need for new research: all evidence and insights that are available
should be used before conducting new research.
6. Complete and assess the list of possible answers: Complete the provisional list of answers and
summarize into a working list for which the evidence is sufficient. Assess the answers in terms
of relevance and changeability.
Example of prevention of HIV and other STDs and pregnancy among adolescents.
1. What are health problems related to HIV etc.? (health problem). What are risk behaviours for
transmission of HIV? (behaviour). Why don’t adolescents males use condoms when having
sex with steady girlfriends? (determinants). What change methods relate to what
determinants? (change methods). How could such an intervention be implemented?
(implementation).
2. Free association to generate explanations. E.g. lack of knowledge about HIV, peers don’t use
condoms.
3. Review empirical findings. E.g. perceive condoms as embarrassing.
4. Topic approach: literature review identified a study on the determinants of condom use. In the
introduction the authors refer to different theories which can now also be used. Concept
approach: lack of confidenceredefined as lack of self-efficacy etc. General theories
approach: general theories such as Social Cognitive Theory.
5. More information was needed from the priority population, so a focus group was formed.
6. Provisional list of answers for which evidence is sufficient, was made. The evidence must be
relevant (strength of the association between determinant and behaviour) and changeable
(strength of the evidence suggesting that the proposed change can be realized by an
intervention).
The example used above to illustrate the Core Processes in answering questions with empirical and
theoretical support mainly concern selection of determinants (i.e., addressing “why” questions). We
would like to stress that Core Processes also need to be used to select change methods for behavior
change or to systematically plan implementation and evaluation of interventions. In other words, to
also address “how” questions.
Ruiter, R. A. C., Massar, K., Van Vugt, M. & Kok, G., (2013). Applying social psychology to
understanding social problems
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