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Compose an essay with the elements listed below using information from the lectures and Chapter 4 in the textbook and examples from Episodes 2, 3, and 4 of “Unnatural Causes” that provides an explanation to the following prompts:

Explain how to value expectancy is used as a general theoretical concept using one example from the textbook and/or “Unnatural Causes.” (M4.1)

Using the example from part (a), compare and contrast the theory of reasoned action, the theory of planned behavior, and the Information-Motivation-Behavioral Skills (IMB) model as it applies to understand how beliefs, values, and expectations factor into making health behavior decisions. (M4.2)

Conclude your essay by discussing cultural competency and discuss how cultural competency factors into the example selected in part (a). Include your opinion on why cultural competency is important in assessing the health of individuals (diagnostics) and designing public health interventions.

Health Behavior Theory
for Public Health
Principles, Foundations, and Applications
Ralph J. DiClemente, PhD
Laura F. Salazar, PhD
Richard A. Crosby, PhD
Charles H. Candler Professor
Rollins School of Public Health
Emory University
Atlanta, GA
Institute of Public Health Georgia
State University
Atlanta, GA
Good Samaritan Endowed
Department of Health Behavior
College of Public Health
University of Kentucky
Lexington, KY
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Names: DiClemente, Ralph J., author. | Salazar, Laura Francisca, 1960author. | Crosby, Richard A., 1959- author.
Title: Health behavior theory for public health / Ralph DiClemente, Laura
Salazar, Richard Crosby.
Description: 2nd. | Burlington, Massachusetts: Jones & Bartlett Learning,
[2019] | Includes bibliographical references and index.
Identifiers: LCCN 2018008730 | ISBN 9781284129885 (paperback: alk. paper)
Subjects: | MESH: Public Health | Health Behavior | Health Promotion |
Models, Theoretical
Classification: LCC RA776.9 | NLM WA 100 | DDC 614.4—dc23
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To my three girls, Gina, Sahara, and Sianna. You are my
Love, my Joy, my Passion, my Hope, and my Life. RJD
To my wonderful and inspiring co-authors whose
friendship, support, and mentorship mean the world
to me and whose dedication and contribution
to public health are an inspiration to all. LFS
This book is dedicated to the next generation of public
health professionals – the future of this profession,
and the people it serves, are in your hands. RAC
Special Dedication:
James W. Curran, MD, MPH
Dean, Rollins School of Public Health, Emory University
To a friend, colleague, and public health leader. You
have made an indelible footprint on the landscape
of public health. Your leadership, passion, and
scholarship are widely respected and an inspiration
for all of us fortunate to serve with you in your effort
to champion a public health of consequence.
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Prologue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
Acknowledgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
SECTION I Overview
Chapter 1  Health Behavior in the Context
of the “New” Public Health . . . . 3
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . . 23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Chapter 2  How Theory Informs Health
Promotion and Public Health
Practice. . . . . . . . . . . . . . . . . . . . 25
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . . 39
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Planning Model. . . . . . . . . . . . . 41
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
An Applied Example. . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . . 55
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
SECTION II  Conceptual and Theoretical
Perspectives for Public
Health Research and
Chapter 4  Value–Expectancy Theories. . . . 59
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
An Applied Example. . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . . 72
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Chapter 5  Models Based on Perceived
Threat and Fear Appeals. . . . . .73
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
An Applied Example. . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . . 91
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Chapter 6  Stage Models for Health
Promotion . . . . . . . . . . . . . . . . . 94
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Global Application of the TMC. . . . . . . . . . . . . . . . 108
An Applied Example. . . . . . . . . . . . . . . . . . . . . . . . . . 113
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 113
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Chapter 7  Social Cognitive Theory
Applied to Health
Behavior �����������������������������������116
Introduction �������������������������������������������������������������������117
Key Concepts �����������������������������������������������������������������118
An Applied Example ���������������������������������������������������134
Take Home Messages �������������������������������������������������135
References ���������������������������������������������������������������������135
Chapter 8  Health Communication:
Theory, Social Marketing,
and Tailoring ���������������������������137
Introduction �������������������������������������������������������������������138
Key Concepts �����������������������������������������������������������������141
Applied Examples �������������������������������������������������������155
Take Home Messages �������������������������������������������������158
References ���������������������������������������������������������������������158
Chapter 9  Ecological and Structural
Approaches to Improving
Public Health ���������������������������160
Introduction �������������������������������������������������������������������161
Key Concepts �����������������������������������������������������������������164
Applied Examples �������������������������������������������������������175
Summary �������������������������������������������������������������������������177
Take Home Messages �������������������������������������������������177
References ���������������������������������������������������������������������178
Chapter 10 Social Network Theory. . . . . 180
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Intellectual Foundations and a Brief History. . . 181
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Three Assets of Social Network Models. . . . . . . . 186
Health Effects of Social Networks . . . . . . . . . . . . . 188
Social Network Analysis. . . . . . . . . . . . . . . . . . . . . . . 190
Application Potential of Social Network
Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
The Network-Individual-Resource Model. . . . . . 193
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 194
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Chapter 11  Diffusion of Innovations
Theory �������������������������������������197
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
An Applied Example. . . . . . . . . . . . . . . . . . . . . . . . . . 212
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 213
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
SECTION III  Application to Public
Health Research and
Chapter 12  Translating Research
to Practice: Putting
“What Works” to Work ���������217
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 238
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Chapter 13  Learning to Combine
Theories: An Introduction
to Intervention Mapping �����241
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Understanding the Intervention Mapping
Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 251
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Chapter 14  Measurement and Design
Related to Theoretically
Based Health Promotion,
Research, and Practice ���������253
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 279
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Chapter 15  Evaluating Theory-Based
Public Health Programs:
Linking Principles to
Practice �����������������������������������281
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
Key Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
A Step-by-Step Guide to Effective
Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Making the Evaluation Even Better. . . . . . . . . . . . 296
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Take Home Messages. . . . . . . . . . . . . . . . . . . . . . . . . 300
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
John S. Santelli, MD, MPH
Dr. Santelli is a Professor in the Department
of Population and Family Health and
Pediatrics in the Mailman School of Public
Health at Columbia University.
heory is essential in understanding health
behaviors and is critical in guiding health
research. Theory helps us organize and
understand information; it focuses attention on
key issues; and it helps us select constructs for
questionnaires. Theory is fundamental in designing, implementing, and evaluating interventions
and in constructing policies to improve health
and prevent disease. Thus, theory is essential to
the work of public health.
Health behaviors are influenced by factors
related to the individual but are also shaped by
the myriad of social and structural influences. For
example, to understand adolescent contraceptive
use, drug use, smoking, and drinking patterns,
one needs to understand the origins of these
behaviors and the social and environmental forces
supporting them. Physicians who work in public
health and address human behavior are well aware
of this importance; while medicine is principally
guided by a variety of biological theories, physicians rapidly come to understand that effective
pharmacologic interventions often fail unless they
address the behaviors of patients. Public health
professionals intuitively grasp the importance of
behavior change in influencing behaviors across
the lifespan—from adolescent pregnancy prevention, to injury prevention and prevention of
chronic disease, to promoting healthy aging.
The “new public health” focuses on health
promotion and the factors that enable individuals and communities to attain optimal health
­(Awofeso, 2004). In this new era, social education, and economic actions are provided to support attitudinal, behavioral, and social change.
For example, health behavior theory has been
highly influential in human immunodeficiency
virus (HIV) prevention and treatment over the
past 30 years, although the focus of interventions
and the specifics of health behavior theory have
shifted over time. In the early years of the HIV
pandemic, behavioral risk reduction—­coupled
with latex condoms and clean needles—was the
only public health tool for prevention of new HIV
infection (Lyles et al., 2007). With the advent of
highly effective pharmacologic treatments, the
new behavioral challenge became encouraging
adherence to drug regiments. And when we discovered that effective pharmacologic treatment
could be an effective HIV prevention strategy
(so-called “treatment as prevention” approach,
Cohen, McCauley, & Gamble, 2012), we realized
again that behavioral change was essential to the
success of this new biomedical strategy.
In my field, adolescent health, understanding the origins of and influences on health risk
behaviors is critical to effective health promotion.
A recent Lancet Commission report outlined the
triple dividend of investing in adolescent health:
improving the health adolescents today, across the
lifespan, and for the next generation (Patton et al.,
2016). These investments need to address the social
and structural factors (Viner et al., 2012) that influence adolescent risk behaviors. Behavioral theory
is essential to understanding these social forces
and promoting adolescent health and well-being.
Health Behavior Theory for Public Health,
­Second Edition addresses the need to provide students with a highly accessible (easy to understand)
collection of basic “tools” needed to design, implement, and evaluate health promotion programs.
The most essential of these tools is an accurate
understanding of the tenets and constructs comprising commonly used behavioral and social science theories. The selection of theories is carefully
balanced to provide students with the diverse skill
sets that are needed to design effective health promotion programs.
In this new edition, all chapters have been
updated and refined to improve the student learning experience—and new chapters added. All
chapters also now contain pull quotes to ­highlight
key points relevant to the chapter objectives.
Chapter 9 on ecological strategies has been greatly
augmented by adding two key theories commonly
used to help resolve social inequalities: minority
stress theory and intersectionality theory. The
authors have updated applied examples, with one
featuring the highly successful ­structural-level of
intervention of Citibike in New York City and a
second illustrating an ecological intervention in
a campus-based violence prevention program.
A new chapter (Chapter 13) teaches students
the value of combining multiple theories to better understand—and thus better resolve—social
inequalities in preventing disease. Using Intervention Mapping as the framework, this chapter provides an efficient set of practices that can be vital
to public health professionals who are faced with
challenges not easily addressed by the use of one
theory in isolation.
Finally, the three authors of this revised text
(Ralph, Rick, and Laura) are among the “best of
the best”, superb social and behavioral scientists
who have devoted years to improving health via
theory-driven, innovative public health interventions. Their life’s work has been dedicated to
health promotion. Their thinking in this new edition is very much aligned with modern thinking
about ecological influences. Moreover, because
it is an authored text, there is strong integration
of the chapters. Visuals, margin quotes, learning
objectives, practice questions, make the text a unified learning experience. With this second edition,
they have created a “one-stop shop” to prepare the
next generation of public health professionals to
carry on the important work of behavior change.
▸▸ References
Awofeso, N. (2004). What’s new about the “new public health”?
American Journal of Public Health, 94(5), 705–709.
Cohen, M. S., McCauley, M., & Gamble, T. R. (2012). HIV
treatment as prevention and HPTN 052. Current Opinion
in HIV and AIDS, 7(2), 99.
Lyles, C. M., Kay, L. S., Crepaz, N., Herbst, J. H., Passin, W. F.,
Kim, A. S., … Mullins, M. M. (2007). Best-evidence
interventions: Findings from a systematic review of HIV
behavioral interventions for US populations at high risk,
2000–2004. American Journal of Public Health, 97(1),
Patton, G.C., Sawyer, S. M., Santelli, J. S., Ross, D. A., Afifi, R.,
Allen, N. B., … Viner, R. M. (2016). Our future: A Lancet
commission on adolescent health and wellbeing. The
Lancet, 387(10036), 2423–2478.
Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M.,
Fatusi, A., & Currie, C. (2012). Adolescence and the social
determinants of health. The Lancet, 379(9826), 1641–1652.
ealth promotion is a cornerstone of public health practice. In turn, the primary
task of health promotion involves leveraging and sustaining long-term health-­protective
behaviors across diverse populations. Meeting
the very difficult challenges inherent in fostering
health-protective behaviors requires the wise and
parsimonious use of behavioral and social science theories. These theories can best be viewed
as the tools of the trade, and this text is designed
to help you master those all-so-­important tools.
Before you begin this learning process, it is
crucial that you understand a basic principle:
learning about the full array of currently used
theories in health promotion practice is essential
to the ultimate success of any public health program you may design and implement. In many
ways, your work in health promotion is similar
to that of a highly skilled craftsperson. You will
be crafting interventions and it is unlikely that
any two programs will be “built” in the same way.
This is true because even if you plan to change
the same behavior in a subsequent program, the
population served by that program is bound to be
markedly different than the population originally
served by the same program. So, think of yourself
as a craftsperson who can effectively assess the
needs of any population relative to their longterm adoption of health-protective behaviors.
Your theory “toolbox” will facilitate this assessment and it will also allow you to develop an
effective intervention approach.
Another important preliminary lesson is that
each of the theories in your toolbox may, at first
blush, appear to be distinctively different. As you
read this text, rest assured that the theories you
learn about each have a unique role in changing
health behavior. Learning about and using only
a few of the many theories is unlikely to lead to
successful health promotion programs. Similarly,
learning about theory in the absence of learning about core practices such as measurement,
evaluation, and planning will not be adequate if
your goal is to truly have an impact on population health. As such, the second edition of Health
Behavior Theory for Public Health will provide you
with a balanced professional education—one that
teaches you about the essential spectrum of theoretical tools as well as the core practices.
This text will open by providing you with a
firm foundation (Section I) for developing expertise in public health theory and related core practices. Please pay special attention to the concepts
and terminology, as this added effort will certainly
pay great dividends in your career. ­Section I is
focused on health, public health, health behavior,
and health promotion planning, rather than theory per se. Indeed, you will learn in this section
that there is much more to understanding and
changing health behavior than ­simply being wellversed in theory.
Section II provides you with the ability to gain
a command of the theories and approaches most
commonly applied in public health research and
programs. We have taken great strides to present
this material in a very straightforward manner
and within the context of current relevant challenges in the field. As you finish this section you
will see how theory “fits” into the larger scope of
public health research and practice as described
in Section I.
The text will close by providing you with a
diverse set of application “tools” (Section III).
These fairly advanced chapters were designed to
bring all that you have learned in Section I and
Section II into a more practical light. Here, you
will learn about the essential tasks of translation,
learning to combine theories, measurement, and
program evaluation. Again, we emphasize the
point that understanding and changing health
behavior is challenging and requires multiple
skills beyond the ability to apply theory.
Finally, we invite you to use an evaluative
eye as you read this text. By using this phrase,
we are suggesting that you should avoid the academic trap of looking at ideas as being correct or
incorrect. Instead, think of each new idea as an
opportunity to indulge in critical thinking. When
learning about various theories or core practices,
you may want to ask yourself questions such as
“Is this approach logical and can it be reasonably
translated into practice?” Learn to think in terms
that transcend the universal terms of correct or
incorrect and challenge yourself to think about
questions such as, “When would this approach
work best and when would it work poorly, or not
at all?”
Our goal for the next generation of public
health professionals is for them to develop effective programs designed to avoid premature morbidity and mortality. We recognize that this work
is as important as the work of traditional medical
professionals and that effective public health programs can make a difference that transcends the
limitation of a medical paradigm. This text will
provide you a broad acumen of knowledge and
skills that will ultimately serve your needs in the
work you do to advance health promotion practice. We trust that your dedication to preventing
disease will become greater than ever as you gain
the ability to truly have an impact on the lives of
We wish to thank Mike Brown of Jones & ­Bartlett Learning for believing in this text and encouraging us
to write this second edition. His collegiality, great humor, and dedication to quality are all greatly appreciated traits. We look forward to working with him in the future.
John Acker, BA
Department of Psychology
University of Georgia
Rita K. Noonan, PhD
Behavioral Scientist
Centers for Disease Control & Prevention
Michael T. Amlung, MS
Department of Psychology
University of Georgia
Lara Ray, PhD
Department of Psychology
University of California, Los Angeles
James G. Emshoff, PhD
EMSTAR Research, Inc.
Colleen A. Redding, PhD
Research Professor
Cancer Prevention Research Center
University of Rhode Island
James MacKillop, PhD
Department of Psychology
University of Georgia
Center for Alcohol and Addiction Studies
Brown University
James H. Walker, BA, BS
Rollins School of Public Health
Emory University
Cara M. Murphy, BS
Department of Psychology
University of Georgia
Seth M. Noar, PhD
Associate Professor
School of Journalism and Mass Communication
Lineberger Comprehensive Cancer Center
University of North Carolina at Chapel Hill
▸▸ Introduction
Above all else in life, the maintenance of health may be the one universal
value. Being healthy means being free of disease and having the resources
to take active measures to fortify the body against the onset of both chronic
and infectious diseases—this level of prevention also provides people with
a vitality that leads to productive and satisfying lives. Unfortunately, many
societies (including the United States) broadly support recovery from chronic
and infectious diseases at the expense of the more complicated task of preventing these problems in the first place. The ethic of placing prevention on
the “pedestal of medicine” is a largely unrealized vision. A more practical
vision is known as “upstream thinking,” which implies that preventing the
onset of disease or injury is the greatest priority in public health. The concept
of upstream thinking implies that nations should prioritize prevention over
treatment. Given the overarching influence of social determinants on health,
this concept also implies that social equity must become a frontline effort of
health-promotion programs.
Health equity is the obtainment of the highest level of health for all members of a population. Health inequities then are differences in health that are
avoidable and therefore unjust. To achieve health equity, we need to foster
efforts pertaining to eliminating those avoidable health inequities and their
corresponding outcomes (i.e., health disparities). Health equities pertain to
health, whereas social equities pertain to equal opportunities for all people,
regardless of race, ethnicity, gender, sexual orientation, or religious beliefs.
Social equity guarantees health equity because it promotes unfettered access
(and comparable access) to the advantages of a society that protect health and
prevent disease. Achieving social equity, however, implies that some members
of a population will need more support/access than others to bring them to
the same level of opportunity. Stated differently, social disadvantages create an
initial unequal starting point for some people—these people cannot be said to
have social equity until those deficits are made up. This means that some people will have more support/access needs than others, and thus, a need exists
for disproportionate distribution of resources before true social equity.
Upstream thinking is not always an easy paradigm. It demands an understanding of why people place themselves at risk of disease and why they adopt
health-protective behaviors. It also demands an understanding of how people
Section I Overview
manage to successfully adopt health-protective
behaviors, especially those behaviors requiring
daily repetition. Most importantly, it demands a
thorough understanding of the social determinants of health and a corresponding commitment to achieving equity on the distribution of
these determinants. Fortunately, a vast range of
theories can be used to traverse these multiple
challenges of upstream thinking. Modern theory
spans a range from those that locate the behavior
and change efforts strictly at the individual level
to ecological theories, suggesting that behavior is
a product of multiple and often interlocking environmental influences.
All theories are ultimately useful in the larger
process of changing health-risk behaviors. This
process, however, is far more involved than one
might first imagine. A central starting point is to
empirically identify the determinants of health-risk
and health-protective behaviors. Determinants that
are potentially modifiable can then be conceived as
hypothesized mediators of behavior change. Theory can be used to define specific objectives meant
to alter these hypothesized mediators in a way that
leads to effective behavior change for large numbers of people, even entire populations The wise
selection of theory is, of course, vital, because
the process just described is one that can easily
go wrong if program objectives are ill-conceived
because of a theory that poorly matches the identified health-promotion challenge at hand.
In the first two chapters, you will learn much
more about the concept of upstream thinking,
particularly with respect to the concepts of primary prevention and universal care. Some of
what you learn may challenge current beliefs
you hold regarding health and medical care, and
may even challenge the concept that apparently
simple health behaviors may be influenced by
a complex web of ecological factors. We suggest
that any challenges to your current belief systems
be embraced, as this is the first and most critical
stage of your growth as a health-promotion professional. Further, we suggest that you diligently
learn the basic vocabulary of health promotion
as shown by the bolded terms in these two chapters. You will soon become proficient at using
terms such as construct, proximal influence, distal
­influence, and multilevel intervention.
We also implore you to study Chapter 3 quite
carefully. This chapter provides you with a widely
used framework that is useful for conceptualizing
the entire process of planning a health-promotion
program. As you study Chapter 3, please bear in
mind that theory application and program planning are not synonymous. Think of theory application as a subset of program planning. Program
planning is a larger concept simply because it
includes elements related to problem assessment,
goal setting, and evaluation. Chapter 3 introduces
a long-standing and highly practical approach
known as the PRECEDE–PROCEED model. For
several decades, this planning model has served
public health effectively through its ability to
achieve targeted and judicious use of resources
and health-promotion efforts.
An important caveat is warranted before you
begin reading these three chapters: public health
practice is an activity rather than a specific discipline. This statement reflects the growing tendency
of public health practice to implicate a spectrum
of likely intervention points for any given health
behavior. Thus, public health efforts span a continuum ranging from media-based health communication programs to making products easily
accessible (e.g., condoms, low-fat foods, bicycle
helmets, exercise facilities). The continuum spans
further to include changes to public policy and
laws. It will become apparent that people from
numerous professional backgrounds are needed to
promote conditions favoring widespread and longterm adoption of health-protective behaviors.
The question you may then ask is, “What
holds all of these various professionals together in
a unified effort to promote health in an upstream
thinking paradigm?” To this question, we respectfully suggest that the concepts you will learn about
in the entire text represent a type of shared wisdom
that indeed defines the work of health promotion.
Your dedication to these chapters will have an
important influence on your ability to protect the
health of the public through prevention of disease
and conditions that would otherwise limit the
quality and longevity of people’s lives.
Health Behavior in the
Context of the “New”
Public Health
Laura F. Salazar, Richard A. Crosby, and Ralph J. DiClemente
The health of the people is really the foundation upon which all their happiness and all their powers
as a state depend.
—Benjamin Disraeli, British Politician (1804–1881)
Unhealthy behaviors contribute to the leading causes of early mortality. As such, if health-promotion efforts
can prevent people from engaging in many of these behaviors, then health-promotion can make a significant
impact on the rates of early mortality and morbidity. Using a wide range of theories in its endeavors, health
promotion seeks to change environments, settings, policies, regulations, and individuals so that optimal health
can be achieved.
1. Compare and contrast the three levels of prevention.
2. Understand the different types of health behaviors.
3. Define health promotion and understand the multidisciplinary nature of health promotion.
4. Understand the importance of multiple theories in health-promotion efforts.
5. Understand that health behavior is highly influenced by the physical, economic, legal, and social
environments that define people’s daily existence; thus, a broad range of theoretical approaches
provides increased assurance of leveraging change.
Chapter 1 Health Behavior in the Context of the “New” Public Health
▸▸ Introduction
Without question, health should be the most valuable thing in a person’s life. An old Arabic proverb
states, “He who has health, has hope; and he who has
hope, has everything.” But what, exactly, is health?
Some would argue that health is simply the absence
of disease. According to the World Health Organization (WHO), health is not merely the absence of
disease or infirmity; rather, health should encompass a state of complete physical, mental, and social
well-being. Expanding on this definition at a seminal conference in Ottawa, Ontario, Canada, the
WHO reconceptualized health, in that it should be
defined from an ecological perspective to encompass the “extent to which an individual or group
is able, on the one hand, to realize aspirations and
satisfy needs; and, on the other hand, to change or
cope with the environment. Health is, therefore,
seen as a resource for everyday life, not the objective
of living; it is a positive concept emphasizing social
and personal resources, as well as physical capacities” (World Health Organization, 1986). Using
these definitions, health would seem to transcend
an individual’s state of physical being at any given
moment to also include his or her ability to optimize
his or her health and the availability of environmental resources that enable him or her to maintain his or her health over time. Thus, to embrace
these definitions of health requires perhaps a paradigm shift in terms of conceptualizing what health
is, what the determinants of health are, and most
importantly how to promote health. A basic premise of Health Behavior Theory for Public Health:
Principles, Foundations, and Appli­ca­tions is that, as
Benjamin Disraeli so succinctly stated, an important goal for any nation
is the health of its peoHealth is not merely
ple, but we advocate
that the means to this
the absence of
end lie in adopting
disease or infirmity;
strategies that modify
rather, health should
setencompass a state
tings, and policies/
of complete physical,
regulations while also
mental, and social
targeting the many
individual factors that
influence health.
A key principle in health promotion involves
understanding the nature of the diseases that are
most likely to occur in a population. At the turn
of the 20th century (see FIGURE 1-1), the top three
causes of death were attributed to infectious disease
agents that caused pneumonia, tuberculosis, diarrhea, and enteritis (Centers for Disease Control and
Prevention [CDC], 1999). Early public health efforts
were very successful in implementing important
new biomedical advances (e.g., vaccinations and
antibiotics) and developing public health programs
that remedied many types of infectious diseases
(e.g., water sanitation to reduce cholera), eradicated
some diseases (e.g., smallpox), and mitigated many
afflictions. However, as the incidence of these diseases decreased, chronic diseases (e.g., cardiovascular disease, diabetes, and cancer) flourished.
Toward the end of the 21st century, individual lifestyle behaviors, such as smoking, poor
diet and exercise, alcohol consumption, and the
use of illicit drugs, were primary contributors to
the six leading causes of death (Mokdad, Marks,
Stroup, & Gerberding, 2004). These behaviors are
deemed “lifestyle behaviors” because they take
place within the context of individuals’ everyday
lives. These specific lifestyle behaviors have been
cited as actual causes of death because they have
been linked directly to the top five chronic diseases: heart disease, cancer, cerebrovascular disease, respiratory disease, and diabetes (McGinnis
& Foege, 1993; Mokdad et al., 2004).
Clearly, a person who contracts an infectious
disease such as cholera, pneumonia, or tuberculosis would most likely hold the perception that they
were not healthy; however, it may not be as clear to
people who smoke, eat high-fat foods, do not exercise, consume too much alcohol, or use illicit drugs
that they are unhealthy. They may hold an inaccurate perception of their health, which is most
likely due to the hidden contribution of engaging
in unhealthy lifestyle behaviors to the development
of chronic diseases, rather than the more noticeable infectious or communicable diseases.
Chronic diseases manifest over time, are not
always apparent, and may be long-lasting or recurring. In TABLE 1-1, we list various chronic diseases
that may result from engaging in several unhealthy
lifestyle behaviors and are linked to the leading
Public health issues, 1900
Pneumonia and influenza
Diarrhea and enteritis
Heart disease
Liver disease
Percentage of all deaths, 1900
Public health issues, 1997–present
Heart disease
Chronic lung disease
Unintentional injury
Pneumonia and influenza
Kidney disease
Chronic liver disease
Percentage of all deaths, 1997
FIGURE 1-1 The 10 leading causes of death, as a percentage of all deaths—the United States, 1900, 1997
Centers for Disease Control and Prevention, National Center for Health Statistics. (1999). Achievements in Public Health, 1900–1999: Control of infectious diseases,
1900–1999. Morbidity & Mortality Weekly Report, 48, 621–629.
Chapter 1 Health Behavior in the Context of the “New” Public Health
TABLE 1-1 Chronic Diseases Associated with Unhealthy Lifestyle Behaviors
SMOKING: Acute myeloid leukemia; cancers of the cervix, kidney, bladder,
esophagus, larynx, lung, mouth, pancreas, and stomach; abdominal aortic
aneurysms; cataracts; periodontitis; pneumonia; chronic lung disease; chronic
heart and cardiovascular diseases; osteoporosis; peptic ulcers; reproductive
HIGH-FAT DIET: Coronary heart disease, type 2 diabetes, cancers (endometrial,
breast, and colon), hypertension (high blood pressure), dyslipidemia (e.g., high
total cholesterol or high levels of triglycerides), stroke, liver and gallbladder
disease, sleep apnea and respiratory problems, osteoarthritis (a degeneration
of cartilage and its underlying bone within a joint), gynecological problems
(abnormal menses, infertility)
ALCOHOL: Cardiovascular disease; liver disease; chronic pancreatitis; pancreatic,
breast, liver, oral, colon, and throat cancers
ILLICIT DRUGS: Suicide, homicide, motor vehicle injury, HIV infection, pneumonia,
violence, mental illness, hepatitis
Photos from top to bottom, © Photos.com, © Digital Vision/Photodisc/Thinkstock, © SunnyS/Shutterstock © Vladimir V. Georgievskly/Shutterstock
causes of death in the United States. In viewing the
associated disease outcomes, you may surmise that
many people are unaware that these diseases are
significantly linked to these unhealthy behaviors.
Although there is no definitive answer as to exactly
how many years of unhealthy lifestyle behavior it
takes to develop some of these chronic diseases, it
is generally agreed that the time is best thought of
in terms of years. Thus, it is understandable why
so many people engaging in these lifestyle behaviors may not perceive themselves at risk for disease in the same way as a person who was recently
exposed to someone coughing on an airplane or
who may have worked in an environment that was
harmful (e.g., manufacturing of asbestos textiles).
If the consummate goal is to ensure the health
of the people, then individual perceptions of health
or what constitutes “unhealthy” may exert some
influence on whether appropriate action is taken by
society or by the individual. This text emphasizes
that public health initiatives to combat both chronic
and infectious diseases and improve the health of
the public should be multidimensional—that is,
health-promotion efforts should target systems
and political structures to affect the underlying
social determinants of health and their corresponding health behaviors. This emphasis on the
significant role of environmental influences in
shaping individual behavior and affecting health is
the driving force behind the “new public health.”
An expedient summary of the new public health is
provided by the director of the Centers for Disease
Control and Prevention, under the Obama administration. ­FIGURE 1-2 illustrates the relative strength
and education
Clinical inerventions
Long-lasting protective
Changing the context to make
individual’s default decisions healthy
Socioeconomic factors
FIGURE 1-2 Frieden pyramid
Reproduced from Frieden, Thomas. A Framework for Public Health Action: The Health Impact Pyramid. American Journal of Public Health. 2010 April; 100(4): 590–595.
of five factors influencing public health, with the
largest (i.e., strongest) contribution coming from
socioeconomic status. This is precisely why the
new public health has an emphasis on social equity.
Beyond socioeconomic status, in order of strength,
the remaining four
Public health
changes that enable
initiatives to combat
the “easy” adoption
both chronic and
of health-­protective
infectious diseases and
behaviors, the use
improve the health of
of planned interthe public should be
shown to have long-­
lasting effects on
that is, healthhealth behavior, clinpromotion efforts
should target
systems and political
education-­based prostructures to affect
grams. Noteworthy
the underlying
in this pyramid is that
clinical interventions
social determinants
occupy a relatively
of health and their
small fraction of the
corresponding health
on the health of a
This chapter provides an overview of the
importance of health behavior (i.e., reducing unhealthy behaviors while also promoting
healthy ones) in achieving optimal health. We
describe how the best approach emphasizes
prevention and targets settings where behavior takes place. You have most likely heard the
famous adage attributed to Benjamin Franklin: “An ounce of prevention is worth a pound
of cure.” He believed that it is wiser and more
cost-­effective to try and prevent a disease from
manifesting rather than to treat it. Public health,
in general, embraces this adage; its mission is
prophylaxis, or prevention, of early mortality, ­morbidity, and associated negative health
­outcomes. Changing or modifying health behaviors that are associated with morbidity and early
mortality is considered one aspect of a prevention approach. Because health behaviors can
contribute significantly to early mortality and
morbidity, understanding and changing health
behaviors and the surrounding conditions that
influence behavior are critical to achieving public health’s mission.
We also provide an overview of public health
and describe the rationale for public health
approaches that target whole populations rather
than only those individuals at heightened risk. We
Chapter 1 Health Behavior in the Context of the “New” Public Health
articulate the role of health promotion in the context of public health and the basic principles and
strategies used. We express that the field of public
health is multidisciplinary and involves a process,
rather than being a unified field, like physics or
chemistry. Finally, we highlight the role of theory in public health research and practice and the
importance of choosing the proper framework.
▸▸ Key Concepts
Why the Emphasis on Prevention?
Once one is afflicted with a disease, medical
approaches must be used for treatment. Treatment
can be very costly, not everyone has access to treatment, and furthermore, treatment is not always a
panacea; treatment cannot “fix” many health issues
(e.g., dead heart muscle tissue). In 2015, the United
States spent $3.2 trillion (representing 17.8% of the
gross domestic product) on health care or $9,990
per person (Centers for Medicaid and Medicare
Services [CMS], 2015). As shown in FIGURE 1-3, the
United States spends more on health care, both as a
proportion of gross domestic product and on a per
capita basis, than any other country in the world
(WHO, 2009). Given the enormous price tag associated with U.S. healthcare costs, you would imagine that the United States should be getting what
they pay for in terms of much lower early mortality and morbidity rates. Unfortunately, statistics
do not support this assertion. In fact, the United
States ranks 47th in terms of life expectancy, 9th in
terms of cancer death rates, 13th in heart disease
death rates, and 1st in obesity rates (http://www
.NationMaster.com). Despite its drastically smaller
population size (approximately 300 million), the
United States ranks with India (approximately
1.1 billion people) and China (approximately
The cost of a long life
United States
Average life expectancy
San Marino
New Zealand
United Kingdom
United States
Life expectancy
Per capita spending (International dollars)
FIGURE 1-3 Per capita healthcare costs and life expectancy around the world
Reproduced from UC Atlas of Global Inequality, http://ucatlas.ucsc.edu/spend.php, Health care spending.
Per capita spending
Key Concepts
1.3 billion people) in terms of the number of estimated cases of diabetes.
Diabetes is an excellent example of a prime
opportunity for improved population-based prevention. Type 2 diabetes is the most common form
of diabetes and has been linked to obesity, inactivity, and genetic factors. Ignoring the genetic component (as this is largely not amenable to change),
obesity is considered a modifiable risk factor as it
can be changed. If the rates of obesity and inactivity among the population were somehow reduced
significantly, a reduction in the prevalence of type
2 diabetes should be experienced as well, thereby
reducing the associated mortality rate. Now consider that one out of every five U.S. federal healthcare dollars is spent treating people with diabetes
(American Diabetes Association, 2008). If treating
people with diabetes represents 20% of healthcare
dollars spent, then a better approach may be to
prevent diabetes rather than treat diabetes. Unfortunately, according to former U.S. Surgeon General Dr. David Satcher, of the total dollars spent
on national health care in the year 1999, only 1%
went to population-based prevention.
Some estimates suggest that the U.S. government spends $1390 per person to treat disease,
while spending only $1.21 per person on prevention. Although this represents an enormous imbalance in the amount of money spent on treatment
versus prevention, the United States does make a
concerted effort. To combat many of the lifestyle
diseases afflicting its populace in the later part of
the 20th century and to enhance the health of its
people, the United States created a national prevention agenda. The 1979 Surgeon General’s Report on
health promotion and disease prevention, Healthy
People, outlined the tremendous gains made in
combating infectious diseases in the earlier part
of the 20th century, stating that “the health of the
American people has never been better.” However,
he also stated that further improvements could be
achieved through a “renewed national commitment to efforts designed to prevent disease and to
promote health” (U.S. Department of Health, Education & Welfare, 1979, p. 3). Healthy People laid
the foundation for a national prevention agenda
that spanned a wide range of health goals focused
on reducing early mortality and morbidity, such
as a reduction in smoking, an increase in physical
activity, and a reduction in injuries. Most important
is that Healthy People as a policy signified that the
United States must take responsibility for the health
of its people. The agenda has since been updated
and goals reexamined every 10 years. The 1980
Promoting Health/Preventing Disease: Objectives
for the Nation and Healthy People 2000: National
Health Promotion and Disease Prevention Objectives both established national health objectives and
served as the basis for the development of state and
community plans. Presently, Healthy People 2020
has built on the work of the past three decades and
has implemented a 10-year health-promotion program with four overarching goals:
Attain high-quality, longer lives free of
preventable disease, disability, injury,
and premature death.
Achieve health equity, eliminate disparities, and improve the health of all
Create social and physical environments that promote good health for all.
Promote quality of life, healthy development, and healthy behaviors across
all life stages.
The focus is on different health areas (e.g.,
sexually transmitted diseases, substance abuse,
tobacco use, diabetes, cancer, HIV), accompanied
by 600 public health objectives and leading health
indicators to measure the progress toward meeting its goals. The question remains, however, as
to whether the U.S. government will balance the
scales and devote enough funds toward prevention so that it can meet these goals. Passage of
the Affordable Care Act in 2010 created historic
strides toward shifting funds to the prevention
of disease. Whether these strides continue in the
future will be crucial to the health of U.S. citizens.
Health Behavior Is Complex
The central question, irrespective of funding, is:
how do we work toward achieving these prevention
goals? Focusing on type 2 diabetes, specifically, how
Chapter 1 Health Behavior in the Context of the “New” Public Health
do we prevent people from becoming obese? How
can we motivate and enable people to adopt better dietary habits, lose weight, and exercise more?
What systems-level changes or policy/regulations
changes can be made to promote consistent exercise behaviors and improved dietary habits among
persons most at risk of diabetes? What social inequities must be addressed and rectified to optimally
prevent diabetes? We may think that all we need to
do is tell people that they are at risk and that making people aware of their risks will result in them
changing their dietary and exercise behaviors.
Unfortunately, changing behavior is not as simple
as it seems. Persuading a person to change his or
her habits is a major challenge indeed, especially
when the behavior is viewed as enjoyable (e.g., eating a juicy hamburger) or when they may not have
complete control (e.g., a child whose parent makes
the decisions about food or a person who can only
afford high-calorie foods of low nutritional value
such as fast-food “bargains”). The reality is that
human behavior is complex and influenced by
many factors; therefore, changing it requires a thorough understanding of the range of influences. For
example, changing dietary habits such that whole
foods (i.e., foods that are unrefined and unprocessed) compose the majority of the daily caloric
intake implies understanding (1) why people prefer
processed foods; (2) what people do not like about
whole foods; (3) the benefits that people perceive
from consuming less processed foods; (4) the physical, economic, political, cultural, and social barriers
that people perceive relative to the consumption of
whole foods; (5) the barriers to stocking produce
and other whole foods among grocery stores; and
(6) the national and local policies that translate to the
of providing whole
foods. In essence,
Before we can change
reducing the obesity
health behavior, we
epidemic will involve
must understand the
h e a lt h – prom ot i on
determinants of the
efforts that address all
behavior, the nature
six of these questions,
of the behavior, and
with an emphasis on
the latter three.
the motivation for the
Before we can
change health behavior,
we must understand the determinants of the behavior, the nature of the behavior, and the motivation
for the behavior. Influencers (also referred to as
“drivers”) of behavior can theoretically be infinitesimal and can include a range of factors, such as
biological characteristics, personality characteristics,
family, peers, the community, society, and the built
environment. Moreover, the nature of health behaviors can vary along many dimensions. For example,
some health behaviors may occur once in a lifetime
(e.g., polio ­vaccine), some on a daily basis (e.g., diet,
exercise), and some are conditional to the context
(e.g., using a condom). Furthermore, motivation
for engaging in a health behavior or to stop engaging in an unhealthy behavior will also be affected by
numerous individual, environmental, and policy/
regulatory factors.
So, how do we begin to make a dent in achieving the prevention goals of Healthy People 2020 and
eventually Healthy People 2030? First, understanding what factors contribute, cause, precede, influence, and motivate health behaviors, and then how
to effectively modify those factors so that behavior
change is achieved is the basic premise of health
promotion. Health promotion is an integral part
of the “new public health” approach and involves
two aspects: research and practice. Indeed, public
health professionals are increasingly recognizing
that the mainstays of epidemiology and healthcare
service administration lack the ability to change
population-level indicators of health. The realization is that changing behaviors in a population
and creating environments conducive to healthy
behaviors are possibly the ultimate solutions to the
long-standing question of how best to improve the
health of the public. Health-promotion research is
at the forefront of understanding the underlying
individual, environmental, and policy/regulatory
factors that influence health behavior. Conversely,
health-­promotion practice is at the forefront of
designing and implementing interventions to modify those factors and to ultimately change behavior.
Thus, health promotion can be viewed as a process
for which many public health, medical, and education professionals, whether on the research side or
the practice side, have a responsibility and play an
integral role in promoting health. The tool used for
health-promotion research and practice is theory.
Key Concepts
A theory is a set of testable propositions that
is used to explain a group of facts or phenomena.
In health promotion, theory enables researchers
to better understand health behavior and make
predictions about how to change behavior. Just as
there are a multitude of health behaviors, there are
many theories that attempt to explain these health
behaviors. Unfortunately, in this text, we cannot
cover all of them; however, we do describe many
of the theories widely used today in health promotion research and practice. Before we proceed to
the description of these theories, it may be helpful
to provide a foundation of health behavior in the
context of public health.
Prevention and the Public
Health Approach
In broad terms, public health seeks to promote
health, prevent early mortality and morbidity,
and enhance or ensure quality of life. Prevention
is the basic principle underlying the public health
approach. In fact, the leading public health agency
in the United States—the Centers for Disease
Control and Prevention (CDC)—has the following mission statement: “To promote health and
quality of life by preventing and controlling disease, injury, and disability.” The CDC motto of
“Saving Lives, Protecting People” is very much
a reflection of a prevention-based orientation.
From a public health perspective, the essence of
prevention is creating healthy populations, meaning that the incidence of chronic disease, infectious disease, and injury decline dramatically. In
our experience, the implications of a prevention-­
oriented approach to public health are often difficult for students to fully comprehend without
first “divorcing” themselves from a medical orientation to public health. FIGURE 1-4 provides a
visual depiction, suggesting that the prevention
of disease entails far more than averting clinically
observable illness.
As shown in Figure 1-4, clinically observable
illness can be viewed as the midpoint of a continuum ranging from optimal wellness to extreme
illness. Coronary vascular disease serves as a
good example to illustrate this division. Clinically
observable early warning signs of a heart attack,
for example, can be diagnosed through a treadmill
stress test. Proxy measures of pending blockages
in coronary arteries include high serum cholesterol levels, high blood pressure, and high body
mass index (BMI). From a medical orientation,
the prevention of a heart attack is about defining
a threshold for high blood serum cholesterol, high
blood pressure, and a risky level of BMI. Once
these thresholds are established, any person who
exceeds any one threshold can be “treated” under
the prevailing medical paradigm. Failure to do
so will presumably result in increased coronary
occlusion followed by the eventual blockage of the
blood supply to the heart, possibly inducing death.
Prevention orientation
Medical orientation
Clinically observable problems
FIGURE 1-4 Wellness–illness continuum
Chapter 1 Health Behavior in the Context of the “New” Public Health
a second figure may be
The inherent problem
quite useful.
The public health
of intervening only at
orientation, in contrast,
the tail is that even
is perhaps best embodwhen success occurs
ied by the motto of the
and these people join
Bloomberg School of
the masses near the
Public Health at Johns
mean, more people
Hopkins University:
Protecting Health, Savwill continue to move
ing Lives—Millions
into the tail.
at a Time. This extension of the CDC motto
clearly defines health at the population level. In his
book titled The Strategy of Preventive Medicine, Geoffrey Rose, a British physician, developed the skewed
distribution curve shown in FIGURE 1-5, also known
as the Rose curve (Rose, 1992) that guides thinking
about population-level intervention.
This drawing is quite useful because it gives a
visual image of those considered “at risk” because
of their diet and the associated negative health outcomes as composing the right-end tail of the distribution; those not at risk would fall under the rest
of the area under the curve. Think of the tail in this
curve as being the portion of a population located
on the right side of the wellness–illness continuum.
It follows, then, that the remaining area under the
curve represents that portion of a population somewhere to the left of the center point in the wellness–­
illness continuum. The medical orientation can be
Percentage of population
Percentage of population
The problem with the “prevention ← medical” orientation is that it begins with a diagnosis
and is reactive, thereby restricting the arena of
the doctor–patient relationship and defining prevention in medical terms. This limits the public
health approach to changing people literally one
at a time. Conversely, the “prevention → medical”
orientation (left part of Figure 1-4) lends itself to a
­population-level approach because it is not predicated on an individual medical diagnosis. Instead,
this orientation acknowledges that defining what
levels constitute high cholesterol, high blood pressure, and high body mass is problematic and that
everyone in a population can benefit from lower
cholesterol, lower blood pressure, and less body fat.
In this orientation, prevention activities are most
often implemented before clinically defined levels
of risk are reached by people. The intent is to figuratively “pull” people further to the left of the continuum (as far away from illness as possible). Unlike
the medical approach, this orientation does lend
itself to intervening with entire populations, rather
than taking a one-at-a-time approach to public
health. Unfortunately, the one-at-a-time approach
to prevention has been frequently applied without
success to the task of changing health behaviors,
as well as changing risk factors (such as high cholesterol) through medication. This individual-level
approach to behavior change is not necessarily relegated to the right side of the wellness–illness continuum shown in Figure 1-4. Thus, at this juncture,
Low consumption
High consumption
Low consumption
Fat in diet
FIGURE 1-5 Example of a Rose curve
High consumption
Fat in diet
Key Concepts
viewed as a type of intervention that only happens
with people located in the tail of the curve. The
inherent problem of intervening only at the tail is
that even when success occurs and these people
join the masses near the mean, more people will
continue to move into the tail. This occurs because
the social inequities, system influences, and policy/
regulatory influences do not change. Thus, the
task of intervening with people who are already ill
becomes never ending. Think of Sisyphus rolling
his boulder up the hill for all of eternity! The following reference to the Multiple Risk Factor Intervention Trial (MRFIT) depicts this concept:
[E]very time we helped a man in [MRFIT]
to stop smoking, on that day, probably one to two children in a schoolyard
somewhere were taking their first tentative puffs on a cigarette . . . So, even when
we do help high-risk people to lower
their risk, we do nothing to change the
distribution of disease in the population
because, in one-to-one programs . . . we
do nothing to influence forces in society
that caused the problem in the first place
(Syme, 1996, p. 463)
As a result of the limitations that accompany
the at-risk paradigm, public health strategies have
increasingly been directed at the goal of moving the
population mean to the left of the curve shown in
Figure 1-5. By shifting the mean to the left, everyone in the distribution benefits and ultimately the
population as a whole experiences an increase in
health behavior, and perhaps a decrease in eventual morbidity and mortality (Syme, 1996). The
concept of moving the population mean to the left
of the Rose curve corresponds quite nicely with a
prevention-orientation goal—the goal is to lower
everyone’s level of risk rather than targeting only
those at greatest risk or those who have manifested
the disease. This goal allows intervention to transcend a one-at-a-time approach, thereby allowing
for change strategies that can be applied to entire
populations. This involvement at the level of entire
populations is the essence of public health.
A popular analogy to illustrate the concept
of population-based prevention versus individual
treatment is the “upstream allegory.” In this story,
fishermen fishing downstream observe streams
of people coming down the river struggling not to
drown. The fishermen must spend all their time
pulling these individuals out of the river to save
them. After exhausting their efforts, they finally
decide to move upstream to see why so many people
have fallen into the river. They quickly ascertain that
there is no protective barrier at the edge of the riverbank; thus, when people are drawn to the riverbank,
it is quite easy for them to fall into the raging waters.
Consequently, community leaders decide to put up a
railing at the edge of the riverbank, which results in
significantly fewer people falling into the water. Not
only does this benefit the people who would have
fallen in, but it also benefits the fishermen, as they
do not have to spend their time and resources rescuing people. This “intervention,” in turn, benefits the
entire community: the community has reduced rates
of early mortality; they have more fish to eat; and
they sell what is left over to the neighboring community, generating economic revenue. Thus, everyone’s
quality of life has improved in many ways.
From this story, it is easy to see why the
medical approach is considered a downstream
approach (treating individuals on a case-by-case
basis after falling in), whereas public health is
considered an upstream approach (instituting
changes to prevent large numbers of people from
ever falling in). The upstream approach equates
with primary prevention, which is one of three
levels of prevention identified by epidemiologists
Hugh Leavell and Guerney Clark (1960), with secondary prevention and tertiary prevention being
the other two levels. Using our analogy, secondary
prevention equates with saving people who perhaps have just fallen in, but well before they have
been caught up in the current and are drowning.
Tertiary prevention in public health targets people who can treat the disease and/or people who
have the disease with the goal of mitigating the
disease’s effects; thus, tertiary prevention would
equate with targeting the fishermen and teaching
them how to more effectively save drowning people or targeting the drowning people and teaching them to tread water to buy them more time
so that they can be saved. These different levels
of prevention equate with the three stages of the
Chapter 1 Health Behavior in the Context of the “New” Public Health
Tertiary prevention Secondary prevention
Universal or selected*
Primary prevention
Universally applied
* Depending on the disease/condition in question.
FIGURE 1-6 Three levels of prevention
disease, injury, or behavioral process, where each
stage may require a different prevention strategy.
A graphic depiction is provided in FIGURE 1-6.
The public health approach is predicated on
primary prevention. In primary prevention, efforts
are made to intercept the onset or occurrence of
disease, injury, or behavior. Primary prevention
examples include vaccination programs, water fluoridation, abstinence programs, motorcycle helmet
laws, bicycle helmet laws for children, mandatory
seatbelt and child safety seat laws, mandatory minimum smoking/drinking age requirements, and
antismoking media campaigns. These are just a few
examples, and many of these initiatives have been
very effective in reducing associated morbidity and
early mortality. For example, increasing price may
be the most effective way to prevent teens from
becoming daily smokers. A joint study from the
University of Illinois at
Chicago and the UniIn primary prevention,
versity of Michigan
efforts are made to
Institute for Social
intercept the onset or
Research conducted
an analysis where they
occurrence of disease,
matched price hikes
injury, or behavior.
of cigarettes with teen
smoking rates over a period of 6 years. They found
that a 10% price increase would decrease the number of children who started to smoke between 3%
and 10%, depending on their stage of smoking
(Chaloupka & ­Warner, 2000).
Moreover, analyses indicate that in addition
to preventing disease, pain, suffering, disability,
death, or loss of function, many prevention programs are also cost-effective. Primary prevention involves intervening before disease onset.
In the context of public health, it must be broad
in scope and aimed at large portions of the population. This is defined as adopting a universal
approach, and it corresponds with the notion of
intervening at the “bell” rather than the tail in
the Rose curve shown in Figure 1-5. A universal
approach is when an entire population (e.g., a
nationwide crime-prevention media campaign)
or subgroups of the population (e.g., children 16
years of age and under to enforce bicycle helmet
use) are targeted regardless of whether individuals in the group have specific risk factors. Because
whole populations are targeted, a large number of
individuals are reached and the economic benefits of prevention become substantial. Moreover,
if the focus of the preventive effort (e.g., diabetes,
Key Concepts
obesity, motor vehicle injury, alcohol abuse) corresponds to a high rate within the population,
then the universal approach is extremely cost-­
effective. However, it is important to note that if
the rate is infrequent, then an ounce of prevention
may not equate with a pound of cure (see Cohen,
Neumann, and ­Weinstein (2008) for detailed analyses on this subject).
In some situations, instead of taking a universal
approach, primary prevention efforts target those
in the population who are at heightened risk. This
type of approach is called a selective approach. Typically, those individuals are targeted on the basis of
biological, psychological, social, or environmental
risk factors known to be associated with the disease
or condition. For example, as mentioned previously,
obesity is a risk factor for type 2 diabetes. A selective primary intervention to combat type 2 diabetes
would target those individuals whose BMI is above
25, but who have not yet developed type 2 diabetes. Thus, although the focus is on those who are
at increased risk, this approach is still considered
primary prevention. Indeed, this approach was
used by Knowler et al. (2002) in their randomized
controlled trial of a primary prevention educational
intervention (curriculum to affect diet and exercise
behaviors) in preventing type 2 diabetes. They targeted clinic patients who had a BMI above 24 and
whose glucose levels were elevated but not diagnostic of diabetes. At the 2-year follow-up, they found
the educational ­intervention was nearly twice as
effective as pharmaceutical treatment (metformin)
in preventing the onset of diabetes.
Secondary and tertiary are the other two levels
of prevention identified by Leavell and Clark. Secondary prevention occurs when a disease process is
diagnosed in an early stage of progression, thereby
enhancing the odds of treatment success. The
focus of secondary prevention is to minimize consequences through early detection and intervention. Screening programs for sexually transmitted
diseases, cancer, or diabetes and smoking cessation
programs are examples of secondary prevention. A
good example is the use of mammography to diagnose localized tumors of the breast before these
tumors progress. A tumor may indeed form, but
with mammography the early diagnosis may lead
to a simple lumpectomy as opposed to what may
have become a radical mastectomy. Pap
The focus of
testing and colonossecondary prevention
copy are also common
is to minimize
forms of secondary
consequences through
prevention because
early detection and
they screen for cerviintervention.
cal dysplasia and polyps, respectively.
Tertiary prevention occurs when a disTertiary prevention
ease state is diagnosed
involves mitigating
in time to apply treatthe consequences of
ment that may prevent
further organic damdisease or an injury
age or death. Thus,
after the fact.
the difference between
secondary and tertiary
prevention can essentially be thought of as the difference between early and late diagnosis. Tertiary
prevention involves mitigating the consequences of
disease or an injury after the fact.
The goal of tertiary prevention is to provide treatment and rehabilitation so that negative
impact is reduced and function can be restored. An
indicated approach is used in tertiary prevention.
Examples of tertiary prevention would include
providing patients who have type 2 diabetes with
educational pamphlets to help them better manage
their disease, providing mental health counseling
for rape victims, and instituting outreach programs
to monitor people with mental disorders who live
in the community to ensure they are adhering to
their medication regimens. In many ways, tertiary
prevention in the public health model is similar to
treatment in the medical model.
Primary, secondary, and tertiary prevention
can be integrated with the concepts of universal,
selective, and indicated approaches. Figure 1-6
provides a visual depiction of this integration.
As shown by the wide angle of this cone, the vast
majority of health-promotion practice is primary
prevention applied on a universal basis. This
application can and should occur at the population level. Conversely, the least prevalent form
of health promotion occurs with the indicated
application of tertiary prevention—this application occurs at the individual level. This bipolar
Chapter 1 Health Behavior in the Context of the “New” Public Health
continuum therefore leaves secondary prevention in the middle of the cone, suggesting that it
is practiced less often than primary prevention
but more often than tertiary prevention. Consistent with our description of a selective approach,
secondary prevention may be universally applied
to an entire population or selectively applied to a
defined subset of a population.
Prioritizing and Conceptualizing
Health Behaviors
To fulfill the public health mission of prevention,
public health professionals must first have a clear
understanding of which diseases and types of injuries are having the greatest impact, so that efforts
are correctly positioned. Epidemiologists conduct
surveillance studies and analyze records to determine the rates of diseases and the leading causes of
death. Consequently, the causes and contributing
risk factors have been well established. Although
in the 21st century chronic diseases are at the
top of the list, there are many other public health
concerns. Injury from firearms and motor vehicle crashes are on the list, while infectious diseases such as influenza, HIV/AIDS, tuberculosis,
chlamydia, human papillomavirus (HPV), Ebola,
and methicillin-resistant Staphylococcus aureus
(MRSA), to name a few, are also responsible for
substantial morbidity and early mortality. From
a global perspective, infectious diseases still
remain a significant source of morbidity and early
mortality. Six infectious ­diseases—pneumonia,
HIV/AIDS, diarrhea, tuberculosis, malaria, and
­measles—account for half of the premature deaths
globally. The top causes of death worldwide are
listed in TABLE 1-2.
Although the etiology is quite different for
chronic and infectious diseases, as well as for sustaining injury, all can be prevented to some degree.
At a minimum, onset can be delayed and the risk
TABLE 1-2 Top Causes of Death Worldwide, 2004
Cause of Death
Number of Deaths
in Millions
Deaths (%)
Coronary heart disease
Stroke and other cerebrovascular diseases
Lower respiratory infections
Chronic obstructive pulmonary disease
Diarrheal diseases
Road traffic accidents
Prematurity and low birth weight
Reproduced from World Health Organization. (2008). The 10 leading causes of death by broad income group (2004). Retrieved from http://www.who.int
Key Concepts
of death mitigated. Many of these 21st-century
“scourges” have underlying health behaviors, and
public health efforts that target these health behaviors are integral to a comprehensive preventive
effort. For example, one in four child deaths from
malaria could be prevented if children at risk slept
under bed nets at night to avoid mosquito bites
(WHO, 1999). In the United States, motor vehicle
injuries are the leading cause of death for children
aged 4–11 years (CDC, 2008). For children aged
4–7 years, the use of belt-positioning booster seats
reduces this risk by 59%, compared with the use of
seat belts alone (Durbin et al., 2003).
“Using a bed net” and “using a booster seat”
are merely two types of health behaviors that can be
affected or modified to prevent the acquisition of
malaria or the risk of auto accident injury, respectively; however, there are other health behaviors
that could be changed to prevent malaria and injuries. When conceptualizing health behavior, many
people may not perceive that “using a bed net”
or “buying a booster seat” should be classified as
health behaviors. Generally speaking, when people think of health behavior, they think of things
like exercising or taking vitamins. They might not
consider that their decision to get a mammogram
or to get a flu shot is a health behavior. Furthermore, they might not categorize testing their home
for the presence of radon as a health behavior.
Regardless of the general public’s perceptions
of what constitutes a health behavior, it should be
defined so that health-promotion research can
be used to gain a better understanding of health
behavior, and subsequently, health-promotion
practice can be used to alter it. Behavior in the
broadest sense is the manner in which something acts, functions, responds, or reacts. This
definition can apply not only to individual people but also more broadly to collectives and systems. Along these lines, health behavior can be
defined as the actions, responses, or reactions of
an individual, group, or system that prevent illness, promote health, and maintain quality of life.
Examples of individual health behaviors would be
using a condom, buckling up the seat belt, or getting vaccinated. Collective health behaviors could
be a neighborhood association making changes
to the built environment to encourage physical
activity (e.g., putting in sidewalks, installing better lighting), initiating a safety patrol, or starting
a local co-op farmer’s market. Sociopolitical system behaviors could involve instituting a citywide
smoking ban, implementing community-wide
condom accessibility/availability programs, or
banning trans fats in restaurants. Again, we
emphasize the importance of using a multilevel
approach to promote health in a population; a
focus on only one of these levels is unlikely to be
productive. We also emphasize that any approach
taken must be made with the goal of social equity
in mind. This implies that intervention resources
and efforts will be intensified for marginalized
populations, most at risk of morbidity and early
mortality. Often, with extreme social inequities,
intervention efforts as simple as food provision
are tremendously helpful (see FIGURE 1-7).
FIGURE 1-7 Food provision is a basic part of public
health practice
Courtesy of WFP/Rein Skullerud
Chapter 1 Health Behavior in the Context of the “New” Public Health
Just as there are
different levels to
behaviors can be similarly qualified according to the nature of
the health behavior.
Most health behaviors can be classified
into three categories:
­preventive, illness, or
sick role (Gochman,
1988; Kasl & Cobb,
1966). These categories are presented in TABLE 1-3.
Generally, the health-related behaviors of healthy
people and those who try to maintain their health
are considered preventive behaviors and are
strongly tied to primary prevention. The previous examples of different health behaviors can
be viewed as preventive health behaviors. Illness
behavior is defined as any behavior undertaken
by individuals who perceive themselves to be ill
and who seek relief or definition of the illness.
Illness behaviors are linked closely to secondary
prevention as the goal is the early intervention
and control of a disease. Some examples of illness
behaviors would be seeking care from a healthcare
provider to obtain a diagnosis, turning to self-help
strategies to lose weight if overweight or to reduce
anxiety, or seeking help for a drinking problem
by going to a 12-step program. Illness behavior
stems from the perception that something may
Health behavior
can be defined as the
actions, responses,
or reactions of an
individual, group, or
system that prevent
illness, promote
health, and maintain
quality of life.
be wrong physically and/or psychologically and is
therefore subject to an individual’s interpretation
of the situation or symptoms. Furthermore, even
if people perceive that they may be sick, they may
not seek care due to lack of health insurance or
other resources.
A logical extension of illness behavior is sickrole behavior. Once an individual is diagnosed
with a disease, the treatment plan constitutes the
sick-role behavior. Sick-role behavior is denoted
as any behavior undertaken to get well. Thus,
sick-role behavior is typical of patients in clinical
settings and is related to tertiary prevention. One
example of sick-role behavior would be adherence
to a medically prescribed regimen such as antiretroviral therapy (ART) for patients diagnosed
with HIV or switching to a low-­carbohydrate/
high-fiber diet and exercise regimen for patients
diagnosed with type 2 diabetes or cardiovascular disease. Given that patient adherence with
medication regimens may be exceedingly poor,
sick-role behavior is increasingly being viewed
as necessitating individual and environmental
intervention and is fast becoming a public health
issue. Numerous behavioral, social, economic,
medical, and policy-related factors contribute to
poor adherence and must be addressed if rates
are to improve. For instance, as few as of one
of every six people living with HIV receive, and
become adherent to, the life-saving advantages
of ARTs (Gardner, McLees, Steiner, Del Rio, &
Burman, 2011). Adherence issues include lack of
TABLE 1-3 Categories of Health Behaviors and Link to Prevention Level
Type of Health
State of Person
Exercise, high-fiber diet, colonoscopy at 50
wear bicycle helmet
Perceives health
Doctor visit, alternative medicine therapies,
join Weight Watchers®, mammogram at 40
Sick role
Adherence to treatment regimen
(medication, exercise, diet, etc.)
Key Concepts
awareness among clinicians about basic adherence management principles, poor communication between patients and clinicians, operational
aspects of pharmacy and medical practice, and
professional barriers, all of which compromise
the effectiveness of therapy. Given all these
issues, it is no wonder that adherence to drugs
that decrease hypertension and lower cholesterol,
for example, is problematic even among people recovering from a heart attack (Ho, Bryson,
& Rumsfeld, 2009). As C. Everett Koop, former
surgeon general of the United States, stated succinctly, “Drugs don’t work in patients who don’t
take them.”
Health Promotion: Definition
and Background
Public health seeks to create healthful living
conditions. In the 19th century, the focus was on
creating safe and healthy environmental infrastructures to reduce the spread of infectious diseases. Early in the 20th century, the focus shifted
to the individual with large-scale immunization
programs. Beginning in the late 20th century
and continuing into the 21st century, a new public health movement emerged where both ends
of the spectrum were and are continuing to be
addressed. Public health initiatives became multidimensional by targeting individuals, systems,
and political structures to affect health behaviors. More importantly, a shift occurred that
emphasized the significant role of environmental influences in shaping individual behavior and
affecting health; the said influences included
but were not limited to culture, public policy,
areas of technology, work, energy production,
and urbanization. Also, along the same lines
as the old public health, the new public health
considered the influence of not only built environments but also the natural environment, and
thus, conservation of natural resources became
a primary goal. This shift in theoretical perspective and scope has been deemed the “new
public health” (Macdonald & Bunton, 1992).
Although in some ways the new public health
has come full circle from the early beginnings of
the old public health
The new public
(i.e., focusing on
environmental struchealth embraces the
tures to affect health
role of individuals
outcomes), the new
in changing their
public health also
health behavior while
includes an emphasis
also emphasizing
on how those relethe relevant
vant environmental
structures and influenvironmental and
ences affect individstructural elements
ual health behavior,
within their context to
which in turn is
facilitate the adoption
linked to health outof health-promoting
comes. The new pubbehaviors.
lic health embraces
the role of individuals in changing their
health behavior while also emphasizing the relevant environmental and structural elements
within their context to facilitate the adoption of
health-promoting behaviors.
Health promotion emerged as a field against
this backdrop of the new public health; it arose
out of necessity in part from the insufficiency and
costliness of biomedical approaches in improving the public’s health, but also from the inability
of medical professionals to understand fully how
to affect health behavior. In simple terms, health
promotion can be viewed as a process of enabling
people to increase control over, and to improve,
their health and the conditions that affect their
health (WHO, 1986). Thus, health promotion is
concerned not only with empowering people to
remain free from illness but also with enhancing their ability to avoid, resist, or overcome
illness—moving them to the left side of the
wellness–illness continuum shown in Figure 1-4.
By enabling people to recognize health threats
and creating conditions that facilitate protective action, health promotion can be viewed as a
“behavioral” inoculation in the same way that a
traditional vaccine inoculates against infectious
agents (Ewart, 1991).
Although there are many other definitions
of health promotion, we provide one that is more
comprehensive and also “official” in the sense
that it was used as part of legislation introduced
Chapter 1 Health Behavior in the Context of the “New” Public Health
in the U.S. Senate in
2004. Health promotion is defined as
the art and science
of motivating people
to enhance their lifestyle to achieve complete health, not just
the absence of disease. Complete health
involves a balance of
physical, mental, and
social health. As a first
impression, this definition of health promotion indicates that
objectives are diverse, broad, and complex, and
that it embraces a multifaceted and integrated
approach in achieving those objectives (e.g.,
“facilitate behavior change” and “develop supportive environments”). But the unanswered question
is: how does health promotion accomplish such
lofty and wide-ranging goals?
Health promotion
is defined as the
art and science of
motivating people to
enhance their lifestyle
to achieve complete
health, not just the
absence of disease.
Complete health
involves a balance of
physical, mental, and
social health.
Health-Promotion Strategies
In FIGURE 1-8, we depict the different strategies
that health promotion uses to achieve goals. As
you can see, the strategies are general and are
not limited to any one specific health problem
or to a specific set of behaviors. Each strategy
can be applied to a range of settings, risk factors, population groups, diseases, or negative
health outcomes. Moreover, these strategies are
not typically applied in isolation, but overlap
and are integral to achieving health-promotion
objectives. For example, research is at the forefront of any health-promotion endeavor, and it
also informs all of the other strategies shown in
the figure. Research can reveal the ­epidemiology
(i.e., the scope, causes, and risk factors of disease) of the health issue, the underlying environmental and individual determinants, and the
negative outcomes, as well as provide insight into
targeted, at-risk populations and their environments. Furthermore, research provides a valid
and reliable way to understand the health issue
from multiple theoretical perspectives and to
and evaluation
FIGURE 1-8 Health-promotion strategies
Key Concepts
inform health-promotion activities, whether
they are part of a health education program, a
social marketing program, or activities involved
in policy development.
Research is also critical in determining
whether the health-promotion initiative was
effective in reaching its goals, and, if so, research
can also show how the goals were achieved.
This type of research is critical in supporting
­evidence-based health-promotion practice so
as to improve the quality and cost-effectiveness
of health-promotion interventions. Against
this research backdrop, advocacy represents an
important and related strategy. Advocacy is necessary to gain the political commitment, policy
support, social acceptance, and systems support
for a particular health program. Advocacy may
be carried out through lobbying, social marketing, a health education program, or community
organizing. Finally, building community capacity
is a key strategy for sustaining health-­promotion
efforts. Community capacity represents the
community’s ability to do things that promote
and sustain its well-being. A number of factors
have been proposed as contributing to capacity
building, such as leadership, resources, knowledge, skills, and collaboration (Provan, Nakama,
­Veazie, Teufel-Shone, & Huddleston, 2003).
Achieving community capacity by affecting all
of these factors may not be feasible, yet many of
these factors are modifiable through the use of
other health-promotion strategies. For example,
health education can be used to convey information and knowledge and impart skills to community members and service organizations; social
marketing can also be used in tandem with health
education efforts to raise awareness of health
information or to inform community members
about resources; and research can be used to create an inventory of social organizations, agencies,
and other stakeholders within the community so
that a network of resources can be constructed.
Thus, in reviewing these strategies used in health
promotion, you can appreciate why health promotion is considered a process that employs multiple strategies in partnership to achieve its goals
of optimal health.
Theory in Health-Promotion
Research and Practice
What is missing from Figure 1-8, however, is the
inclusion of another circle that would convey that
the cornerstone of all health-promotion strategies is theory. Health-promotion researchers,
policymakers, and practitioners use theory to
guide many of their health-promotion strategies.
Theory informs what variables to measure, how
to measure them, and how they are interrelated.
Within the context of health promotion, theory is viewed as a tool for enhancing our understanding of complex situations versus something
that offers universal explanations or predictions
(Green, 2000). This more practical perspective is
grounded in praxis and acknowledges that theory should be relative to the context in which it
is used. Health Behavior Theory for Public Health
describes many of the more relevant theories used
in health promotion. We acknowledge that, like
any t…
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