Theory at a Glance: Comprehensive Study Notes (Second Edition)
Introduction (Overview of the Monograph)
Theory at a Glance describes influential health-related behavior theories, processes shaping behavior, and how community and environmental factors influence behavior.
Complementary resources mentioned: Making Health Communication Programs Work: A Planner’s Guide; Cancer Control PLANET (Plan, Link, Act, Network with Evidence-based Tools).
Health promotion is broadly defined as enabling people to increase control over and improve their health, extending beyond traditional primary/secondary prevention.
Use of theory is linked to planning, implementation, and evaluation; theory can guide questions of why, what, and how to address health problems.
The monograph can be used as a standalone handbook or with theory texts and continuing education.
Originally adapted content from Glanz, Rimer, and Lewis’ Health Behavior and Health Education (3rd edition, Jossey-Bass, 2002).
Readers are encouraged to consult additional sources for deeper theory understanding.
Audience: primarily public health workers at state/local levels; also useful for volunteers, community organizations, health care settings, schools, and the private sector.
CDC’s Guide to Community Preventive Services is highlighted as a related evidence-based resource.
Contents are organized into three parts: Foundations of Theory, Theories and Applications (ecological perspective), and Putting Theory and Practice Together (planning models).
Part 1: Foundations of Theory in Health Promotion and Health Behavior
Why theory matters: aging health systems, behavior change at multiple levels (individual, organizational, community) requires understanding targeted health behaviors and their environmental context.
Theory helps move beyond intuition, enabling strategic planning, evaluation, and evidence-based intervention design.
Theory provides a road map for studying problems, developing interventions, and evaluating success; guides target audiences, change methods, and outcome indicators.
Explanatory Theory vs Change Theory:
Explanatory theory explains why a problem exists and what factors can be changed (e.g., HBM, TPB, PAPM).
Change theory guides the development of interventions, translating concepts into messages and strategies, and providing a basis for evaluation (e.g., Community Organization, Diffusion of Innovations).
Diagrammatic idea: planning and evaluation are connected by Change Theory, with Evaluation as a feedback loop.
Fitting Theory to the Field of Practice:
No single theory dominates public health; problems, populations, cultures, and contexts require multiple theories; some theories focus on individuals, others on families, organizations, or communities.
Adequate addressing may require more than one theory; the process should start with situational assessment (units of analysis, topic, behavior).
A thoughtful, deliberate selection of theories helps account for multi-factor influences on health behaviors.
A Good Fit for a Theory (characteristics):
Logical, consistent with everyday observations, consistent with past successful programs, and supported by prior research.
Targeting vs Tailoring (cultural relevance):
Targeting uses subgroup characteristics to create a single intervention for a group.
Tailoring uses individual assessment to customize strategies for a specific person.
Most health behavior theories apply to diverse groups, but practitioners must understand population characteristics (ethnicity, SES, gender, age, geography) to apply theories correctly.
Practical takeaway: use a theory or combination of theories appropriate to the situation, considering several levels of influence and context.
“What people in the field say” about theory: quotes from county health educators, state chronic disease administrators, city tobacco control coordinators, regional health promotion chiefs, patient education coordinators on the practical value of theory.
Audience and purpose (Recap):
The monograph targets public health workers, with a view toward making theory a practical tool for planning, implementing, and evaluating programs.
It emphasizes using theory to understand how individuals, groups, and organizations behave and change, and to guide program design.
Structure recap (for exam orientation): three parts – Foundations, Theories and Applications, Putting Theory and Practice Together; two comprehensive planning models (PRECEDE-PROCEED and Social Marketing) discussed in Part 3; focus on selecting theories and using them to plan multilevel interventions.
Part 2: Theories and Applications
The Ecological Perspective: A Multilevel, Interactive Approach
Core idea: health behavior is influenced by multiple levels of influence and reciprocal causation among levels; behavior both affects and is affected by social and physical environments.
Levels of influence (five identified by McLeroy et al., 1988):
Intrapersonal (individual) factors: knowledge, attitudes, beliefs, personality traits.
Interpersonal: social identity, support, and role definitions from family, friends, peers.
Institutional/Organizational: rules, regulations, policies, informal structures within organizations.
Community: social networks and norms, formal or informal standards among individuals, groups, and organizations.
Public Policy (local, state, federal): policies and laws that regulate or support healthy actions.
Reciprocal causation: individuals shape environments and are shaped by them; e.g., a man with high cholesterol influenced by cafeteria options can push for healthier choices, which can, in turn, change cafeteria offerings.
Practical implications: multilevel interventions are often most effective when combining behavioral and environmental components (e.g., tobacco control programs with workplace no-smoking policies and city indoor air laws).
Example (mammography): at each level instructions/constraints to obtain a mammogram can coexist, and combined influence yields better outcomes than single-level approaches.
Multilevel advantage: addresses broader determinants of health and supports sustained behavior change.
In practice, addressing community-level issues requires considering institutional factors and public policy, along with social networks and norms.
Figure reference: A Multilevel Approach to Epidemiology shows how social/economic policies, institutions, neighborhoods, living conditions, social relationships, and individual risk factors integrate with pathophysiology to influence health outcomes.
Three key general points about the ecological approach:
It emphasizes cross-level interaction and reciprocal causation.
It supports multilevel, integrated strategies combining behavior change with environmental change.
It aligns with the idea that health promotion requires interventions at multiple levels and settings.
Examples of ecological thinking in practice: tobacco control and exercise/diet programs that align individual education with workplace/policy supports.
Theoretical explanations of the three levels of influence (summary):
Intrapersonal: cognitive-behavioral theories dominate; focus on cognition, attitudes, and skills.
Interpersonal: social influence processes (e.g., Social Cognitive Theory) operate within social networks.
Community: community-level models aim to change social systems and environments to support health.
Individual or Intrapersonal Level
The most basic unit of behavior change; many practitioners spend most time in one-on-one work (counseling, patient education).
Intrapersonal factors include knowledge, attitudes, beliefs, motivation, self-concept, past experiences, and skills.
Theories at this level (brief overview):
Health Belief Model (HBM): addresses perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy.
Stages of Change (Transtheoretical) Model: motivation/readiness to change; five stages.
Theory of Planned Behavior (TPB): beliefs, attitudes, intentions, behavior, and perceived behavioral control; includes intention as primary determinant of behavior.
Precaution Adoption Process Model (PAPM): seven stages from awareness to maintenance.
Health Belief Model (HBM)
Origin: developed in the 1950s to explain low participation in screening programs (e.g., tuberculosis X-ray campaigns).
Core idea: people act if they perceive a health threat and believe benefits of action outweigh costs.
Six core constructs:
Perceived susceptibility: beliefs about the chances of getting a condition.
Perceived severity: beliefs about the seriousness of a condition and its consequences.
Perceived benefits: beliefs about the effectiveness of taking action to reduce risk/severity.
Perceived barriers: beliefs about material/psychological costs of taking action.
Cues to action: factors that activate readiness to change (e.g., reminders).
Self-efficacy: confidence in one's ability to take action.
Use in planning: ground strategies in target population’s perceived risks, seriousness, benefits, barriers, cues, and self-efficacy; tailor interventions to these constructs.
Example: managing asymptomatic hypertension: individuals may delay action unless they perceive susceptibility/severity, believe actions reduce risk, and have cues to remind them to comply; use print materials, reminder letters, pill calendars; consider behavioral contracts for weight loss or treatment adherence.
Stages of Change (Transtheoretical) Model
Focus: individuals’ motivation and readiness to change a behavior; non-linear, circular processes.
Five stages of change (from Table 3):
Precontemplation: no intention to act within the next six months.
Contemplation: intends to act within the next six months.
Preparation: intends to take action within the next 30 days and has taken some steps.
Action: has changed behavior for less than six months.
Maintenance: has changed behavior for more than six months.
Stage-specific strategies (illustrative):
Precontemplation: raise awareness of risks/benefits; personalize information.
Contemplation: motivate and encourage concrete plans.
Preparation: assist with concrete action plans and gradual goals.
Action: provide feedback, problem-solving, social support, reinforcement.
Maintenance: help with coping, reminders, alternatives, relapse prevention.
Key notes: the model is a circular process; people can relapse and re-enter at any stage; stages vary by behavior; used for individuals and organizations.
Example in practice: smoking cessation program planning—identify what stage employees are in to tailor messaging (e.g., precontemplators vs. contemplators vs. those ready to quit).
Theory of Planned Behavior (TPB) and Theory of Reasoned Action (TRA)
Core idea: behavioral intention is the most important determinant of behavior; other factors operate through intention.
TRA/TPB constructs (Table 4):
Behavioral intention: likelihood of performing the behavior.
Attitude: personal evaluation of the behavior (good/neutral/bad).
Subjective norm: beliefs about whether important others approve of the behavior; motivation to comply.
Perceived behavioral control (TPB): belief about one’s control over performing the behavior.
Difference: TPB adds Perceived Behavioral Control to account for controllability beyond the individual’s will; TRA does not include this construct.
Application example: cervical cancer screening campaign targeting older Hispanic women; assess last Pap test (behavior), intention to seek a Pap test, attitudes, perceived norms, and perceived control; compare with actual screening data to identify predictive beliefs/attitudes.
Precaution Adoption Process Model (PAPM)
Focus: stages leading from lack of awareness to adoption/maintenance of a precautionary behavior; distinct from Stages of Change.
Seven stages (Figure 4 reference):
Stage 1: Unaware of the issue.
Stage 2: Unengaged by the issue.
Stage 3: Decide about acting.
Stage 4: Decide not to act.
Stage 5: Decide to act.
Stage 6: Acting.
Stage 7: Maintenance.
Key differences from Stages of Change:
PAPM distinguishes between stages before action (awareness/unengagement) and stages after decision; it recognizes barriers for those unaware or unengaged.
It helps tailor interventions to consider barriers before behavior change begins.
Interpersonal Level
The social environment (family, coworkers, friends, health professionals) influences behavior; reciprocal influence exists between individuals and their social surroundings.
The monograph highlights Social Cognitive Theory (SCT) as a primary framework at this level.
Social Cognitive Theory (SCT)
Core idea: a dynamic, ongoing reciprocal process among personal factors, environmental factors, and behavior.
Three key factors affecting likelihood of behavior change:
Self-efficacy: belief in one’s ability to execute actions.
Goals: clear targets and progression toward them.
Outcome expectancies: anticipated results of taking action.
Main constructs (Table 5):
Reciprocal determinism: dynamic interaction of person, behavior, and environment.
Behavioral capability: knowledge and skills to perform a behavior.
Expectations: anticipated outcomes of behavior.
Self-efficacy: most important personal factor; high self-efficacy supports action.
Observational learning (modeling): learning by watching others; credible role models.
Reinforcements: responses that affect the likelihood of repeating behavior (internal/external rewards).
Applications/strategies to increase self-efficacy: incremental goals, behavioral contracts, self-monitoring, feedback, reinforcement.
SCT’s utility across domains (e.g., diet, pain management) due to its integrative nature across cognitive, behavioral, and emotional processes.
Illustrative model: how self-efficacy, environment, and personal factors interact to influence behavior (Figure 5).
Community Level
Community-level interventions address issues beyond individuals, aiming to modify social systems, organizations, and environments to support health.
Core ideas include community organization and other participatory models, diffusion of innovations, and communication theory:
Community Organization and Other Participatory Models
Community organizing is a process by which communities identify problems, mobilize resources, and implement strategies to achieve shared goals; ideally community-identified problems (not externally imposed).
Interventions align with ecological perspective, recognizing multiple levels of influence and integrating Social Cognitive Theory strategies (e.g., social networks, support) within community actions.
Rothman’s three change models (locality development, social planning, social action) describe different approaches to community organizing:
Locality development (community development): process-oriented; builds group identity and capacity.
Social planning: task-oriented; relies on expert practitioners for problem solving.
Social action: both process and task; increases community capacity to solve problems and achieve concrete changes addressing social injustices.
Key community-level concepts (Table 6):
Empowerment: gaining power and capability to improve life.
Community capacity: resources, leadership, networks that enable action.
Participation: active engagement in community life and decision making; principle: Never do for others what they can do for themselves.
Relevance: starts with felt needs and builds from there.
Issue selection: choosing specific, manageable problems within a larger strategy.
Critical consciousness: analyzing root causes (economic, social forces) and planning actions.
Media Advocacy: a tactic to leverage mass media to advance public health goals by reframing issues and pushing policy changes; aims to widen participants’ sense of self-interest and empower communities to act.
Participatory Action Research: community members actively participate in the research process, shaping inquiry, data collection, data interpretation, and solution generation; example: COMMIT program evaluating cessation interventions within communities.
Public health application example: a tobacco control scenario showing how a department collaborates with a community organization to address supermarket access, transportation barriers, and policy changes; demonstrates empowerment and strategic action, including media engagement and capacity building.
Diffusion of Innovations
Core idea: how new ideas (innovations) spread within a social system over time via communication channels.
Definitions:
Innovation: an idea, object, or practice perceived as new by individuals or groups.
Communication channels: the means by which new ideas are transmitted.
Social system: the group among whom the innovation diffuses.
Time: the diffusion process takes place over time.
Key concepts central to diffusion (Table 7): the relative attributes of an innovation that affect its adoption and diffusion among individuals and organizations.
Attributes affecting diffusion speed and extent (Table 8):
Relative advantage: is the innovation better than what it replaces?
Compatibility: does it fit with the audience’s values and needs?
Complexity: how easy is it to use?
Trialability: can it be experimented with before full adoption?
Observability: are the results visible and measurable?
Adopter categories (Rogers’ model): innovators, early adopters, early majority, late majority, laggards (classic bell curve). Most adopt later; few are innovators.
Two-step flow of communication: media information first reaches opinion leaders, who then interpret and relay to others; highlights the importance of social networks in adoption decisions.
Communication Theory and Media Effects
Communication theory examines who says what, through which channels, to whom, and with what effects; important for shaping health messages across levels (individual to population).
Media effects research: investigates how messages affect knowledge, attitudes, beliefs, and behaviors, and how audience characteristics influence exposure and processing of messages.
Funding and exposure: budget constraints influence the likelihood of audience exposure to messages; many programs rely on low-cost options (PSAs, embedding health messages in entertainment, public/media coverage).
Key questions: exposure likelihood and variation of effects with exposure level.
Public health communications should reflect ecological thinking: tailor messages at multiple levels (individual to population) and integrate with environmental supports to sustain changes.
Agenda Setting and Framing
Agenda setting: the media agenda shapes what people think about; greater media coverage correlates with perceived importance of issues.
Framing: how media present issues; highlights certain aspects and influences interpretation and prioritization.
Public health implication: frame issues to emphasize social and environmental determinants and advocate for supportive health policies.
New Communication Technologies (E-health)
E-health: use of information and communication technologies (e.g., Internet) to improve or enable health promotion.
Benefits: broad reach, asynchronous communication, integration of multiple media, data tracking, user customization, interactivity.
Examples and applications:
MeetUp.com and community-based online organizing for health campaigns.
Cancer Control PLANET and HINTS (Health Information National Trends Survey) for data and resources.
Internet usage for health information (e.g., 34% would go to the Internet first for cancer information).
ACOR (online cancer resources) and online communities providing support.
Tailored print communications (TPCs) and telephone-delivered interventions (TDIs) to reach diverse populations.
Interactive games (e.g., Bronkie the Bronchiasaurus) for health behavior change; evidence of reductions in urgent/emergency visits in some studies.
Caveats and ethics: digital divide persists; unequal access to the Internet by race/ethnicity and education levels; literacy barriers; importance of involving community members in planning and providing training/support to use new tools.
Theory and e-health: e-health interventions can be designed using various theories (e.g., Stages of Change for tailored fruit/vegetable messages; Social Cognitive Theory for online communities and modeling).
Overall message: new tech expands the toolkit, but implementation should be theory-driven and equity-conscious.
Putting Theory and Practice Together: Part 3
Planning Models
When planning, theory helps interpret situations and informs decisions about design, procedures, and measurement indicators.
Theories can be used across units of practice (individuals, groups, organizations, communities); multiple theories may yield stronger impact, especially for multilevel problems.
Two comprehensive planning models are emphasized:
PRECEDE-PROCEED (diagnostic to evaluation) and
Social Marketing (consumer-driven, market-analysis-based approach).
Core workflow: start with theory-based assumptions about factors contributing to health problems; test/adjust using research; design targeted intervention strategies; plan evaluation with explicit goals and indicators.
Research is central to planning; it informs audience needs, resources, and context; guides intervention design and assessment.
Social Marketing
Definition: application of marketing principles to influence voluntary behavior for social good; distinct from health education because it emphasizes voluntary exchange and mutual benefit between the marketer and target audience.
Not a theory but an approach; consumer-driven and segmented to subgroups to tailor strategies.
Four Ps of the marketing mix (Product, Price, Place, Promotion):
Product: the desired behavior and its benefits.
Price: barriers or costs (money, time, effort).
Place: accessibility and convenience of adopting the behavior.
Promotion: messaging to inform and motivate.
Formative research (audience/consumer research): understand current behavior, enabling factors, and reinforcement; environmental analysis to identify competing behaviors and contextual factors.
Social marketing process stages (Figure 8): planning/strategy development; pretesting concepts/messages/materials; implementation; in-market effectiveness assessment; feedback loops to stage 1.
Evaluation: process evaluation (outputs/processes), summative outcomes monitoring (impact and cost-effectiveness).
Example: California 5 A Day Campaign; features included distribution channels (grocery stores, mass media, community groups); marketing mix elements emphasized to increase fruit/vegetable consumption; ongoing monitoring and evaluation.
Link to behavior change theory: uses concepts from SCT (self-efficacy, outcome expectations) to shape messages and strategies.
PRECEDE-PROCEED
PRECEDE-PROCEED is a planning framework, not a theory, built on the theoretical basis of health behavior and ecological diagnosis; relies on the underlying Planning and Stages of Change model.
Two components:
PRECEDE: Predisposing, Reinforcing, Enabling Constructs in Educational/Environmental Diagnosis and Evaluation.
PROCEED: Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development.
Nine steps total; first five diagnostic (educational and environmental), last four involve implementation and evaluation.
Diagnostic steps (PRECEDE):
Social assessment: understand perceived needs and quality of life.
Epidemiological assessment: identify priority health problems by groups.
Behavioral and environmental assessment: identify factors that contribute to the health problem.
Educational and ecological assessment: identify predisposing, enabling, reinforcing factors that must be in place to initiate and sustain change.
Administrative and policy assessment: identify organizational, policy, and resource factors that affect implementation.
Implementation and evaluation steps (PROCEED):
Implementation, Process evaluation, Impact evaluation, Outcome evaluation.
Enabling and reinforcing factors in educational and environmental contexts:
Enabling factors: resources, policies, services that make action possible.
Reinforcing factors: rewards or feedback that encourage ongoing performance.
The framework emphasizes aligning theory with planning steps to diagnose and address determinants of behavior across individual and contextual levels.
PRECEDE-PROCEED examples: planning for mammography uptake; identifying social and environmental barriers; designing interventions that address education, policy, and organizational supports.
Where to Begin: Choosing the Right Theories
Emphasizes a systematic approach to theory selection based on problem characteristics and context, not the popularity of a theory.
A theory-focused assessment helps identify the unit of analysis, the topic, and the behavior to be addressed; multiple theories may be appropriate for different aspects of the same problem.
Table 11 (Summary of Theories: Focus and Key Concepts) provides a concise reference for selecting theories based on focus areas and core concepts. The eight theories covered in Theory at a Glance are:
Health Belief Model (HBM)
Precaution Adoption Process Model (PAPM)
Social Cognitive Theory (SCT)
Theory of Planned Behavior (TPB)
Diffusion of Innovations
Community Organization (and related participatory models)
Communication Theory
Stages of Change (Transtheoretical Model)
Application example: to reduce tobacco use among adolescents, multiple theories can be used: Stages of Change (readiness), SCT (social environment and self-efficacy), Community Organization (youth involvement), and Diffusion of Innovations (diffusion of an intervention through schools and communities).
Theories are tools to help interpret data and guide design; the planning process (especially via PRECEDE-PROCEED and social marketing) helps integrate multiple theories for a multilevel approach.
A Final Word on Theory Application
A mature public health strategy integrates individual- and environment-focused approaches; reciprocal causation means improvements at one level can influence other levels (e.g., individual dietary changes can lead to cafeteria changes, which further reinforce individual behavior).
Theory is a flexible guide to translating abstract concepts into concrete, adaptable interventions for real-world problems.
The concluding note encourages practitioners to view theory as a tool for understanding dynamics and to translate insight into actionable, evidence-based programs that improve health outcomes.
Closing quote reference: Winston Churchill (1898): moving from the tossing sea of Cause and Theory to the firm ground of Result and Fact.
Key Takeaways for Exam Preparation
Understand the Ecological Perspective and Reciprocal Causation: health behavior is influenced by and influences multiple levels of influence (intrapersonal, interpersonal, institutional, community, public policy).
Know the major theories at the intrapersonal level: HBM (susceptibility, severity, benefits, barriers, cues to action, self-efficacy); Stages of Change (precontemplation to maintenance); TPB/TRA (attitude, norms, perceived control; intention as driver); PAPM (seven precaution stages).
Interpersonal theory spotlight: Social Cognitive Theory (reciprocal determinism, self-efficacy, observational learning, reinforcements, behavioral capability).
Community-level approaches: Community Organization (empowerment, capacity, participation, relevance, issue selection, critical consciousness); Diffusion of Innovations (relative advantage, compatibility, complexity, trialability, observability; adopter categories); diffusion processes (two-step flow, time); Communication Theory (agenda setting, framing); new tech (e-health) and related considerations (digital divide, tailoring vs targeting).
Planning models for practice: PRECEDE-PROCEED (diagnostic to evaluation) and Social Marketing (four Ps; formative research; environmental analysis; iterative evaluation).
Choosing theories: use a combination of theories fit to the problem and population; consult the focus and key concepts table to select appropriate theories; apply planning models to integrate multiple theories into a cohesive intervention and evaluation plan.
Ethical and practical implications: cultural tailoring, health disparities, and equity; need for community involvement in planning; ensure access to innovative technologies does not exacerbate existing inequities; tailor messages to diverse cultures and literacy levels; confirm feasibility and resources for implementation and sustained impact.