Promoting healthy behavior
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Promoting Healthy Behavior. 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

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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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Maternal and child underweight

Unsafe sex

High blood pressure



Unsafe water, poor sanitation, and hygiene

High cholesterol

Indoor smoke from solid fuels

Iron deficiency

High body mass index or overweight

Ten Leading Risk Factorsfor Preventable Disease

Source: WHO, World Health Report 2002: Reducing Risk, Promoting Healthy Life (Geneva: WHO, 2002), accessed online at, on Nov. 15, 2004.

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Whose Behavior is Responsible For…

  • 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 behaviorstranslate to diseases

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Global Causes of Death


Communicable diseases, maternal and perinatal conditions, and nutritional deficiencies

Noncommunicable diseases

Source: WHO, World Health Report 2000—Health Systems: Improving Performance (Geneva: WHO, 2000).

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Health Promotion Means Changing Behavior at Multiple Levels

A Individual: knowledge, attitudes, beliefs, personality 

B Interpersonal: family, friends, peers 

C Community: social networks, standards, norms 

D Institutional: rules, policies, informal structures

E 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

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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.)






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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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Define problem

Identify solutions

Initiate action

Allocate resources



Organizational Change

Organizational Stage Theory

Organizational Development Theory

Organizational structures

Worker behavior and motivation

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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 Change

  • Gradual

  • Movement through groups

    • Pioneers

    • Early adopters

    • Masses

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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 Tools

  • 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

  • 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

  • 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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  • 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