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Chapter 2

Health Sciences 4202A/B Chapter Notes - Chapter 2: Health Promotion, Colorectal Cancer, Mammography

Health Sciences
Course Code
HS 4202A/B
Tamara Thompson

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Chapter 2 How Theory Informs Health Promotion and Public Practice
Theory has become an indispensable tool for the development, implementation, and evaluation of
public health initiatives because it enables researched to better under and change health behavior
Chapter provides the contextual background needed to understand how public health and
specifically, health promotion programs can be designed to change a broad range of health behaviors
- provides a framework for understanding how theory can most effectively be used to inform and
guide interventions designed to reduce health risk behaviors associated with morbidity and
Key Concepts
Health Behaviors Are Diverse
To present the broad spectrum of differences among health behaviors, it has identified 3 dimensions to
health behavior: complexity, frequency, and Volitionality
The first dimension is complexity
- Behaviors may be highly complex, meaning they involve higher levels of knowledge, skill, or
resources to perform than simple behaviors
- e.g. eating a low-sodium diet and the correct use of male condoms that involves 10 steps
- Not every behavior is complex; the key lies in understanding that these behaviors are relatively
easy to perform and may be viewed as less demanding in terms of necessary knowledge, skills, or
- A critical point here is that the dimension of complexity is not always inherent in the behavior,
which may be counterintuitive
- Complexity is a function of the environment
e.g. boiling drinking water in the United States vs. resource-poor nation
- Complexity may vary as a function of the population
e.g. 50-year-old woman may have ready access to preventative health care, while another
may have no such access, thereby magnifying the complexity level of the first
Second dimension of frequency
- Health behaviors can be frequent and repetitive (diet and exercise), one time only (screening for
radon), or periodic (obtaining a mammogram or having a flu shot)
- May be highly complex but require only infrequent repetition (being screened for colorectal
cancer), or a behavior could be highly complex and require daily repetition (consuming a low-fat
Volitionality can be used to differentiate between various health behaviors
- Represents the degree of personal control over the behavior; specifically, a high volitional
behavior is one in which the person has complete control in performing the behaviour the
behavior does not require external resources, assistance or support
e.g. flossing, using seatbelts, and performing moderate exercises
- Conversely, behaviors that are low in volitionality require (to some extent) a reliance on external
resources, assistance, or support
e.g. consuming fresh fruits and vegetables
- Tied to the environment
e.g. the use of contraceptives for women can vary in terms of volitionality depending on
the environment/culture
Theory Is Relevant at Multiple Levels
Theories can be applied at several “levels” within the environment
Environmental levels represent different influences on individual behavior
The concept of environmental levels is drawn from a classic model of an ecological approach to health
promotion as popularized by Bronfenbrenner

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- This model suggests that outer levels influence inner levels all the way down to the individual (“I
in the innermost circle)
Although the “I” is often construed as the “target” of all intervention efforts, it is
important to note that making changes at any of the levels can influence individual health
- The model suggests that the outermost level influences all other levels and that the next outermost
level influences all remaining levels, and so forth
- The ultimate implication of this model is that interventions targeting multiple levels represent an
ecological approach
Ecological approaches are widely believed to be more effective compared to single-level
approaches and are representative of the new public health
A synonymous term is “multi-level approach”, meaning that 2 or more levels of
ecological influence are the targets of the planned health-promotion program
e.g. childhood obesity
Theory selection is predicated upon the composition of the applicable levels that best describe a given
health behavior
Proximal Versus Distal Influences on Health Behavior
Inner-levels are called proximal influences because these influences are in close proximity to the
level (“I” level)
Factors located in the outer levels are called distal influences because these influences do not always
directly or immediately affect the individual due to their location in the outer level in the model
- e.g. Taxes on tobacco cigarettes and tobacco smoking regulations and marketing regulations
The concept of outer levels influencing the inner levels is a key point here
- Because proximal influences demonstrate an immediate influence on health behavior, the
perception that the “cost is too high (distal influence)” would be considered a proximal influence
on smoking reduction
To streamline health-promotion efforts, programs need to be designed so that the critical constructs
(proximal and distal) are identified and the corresponding intervention methods and strategies for
modifying these constructs can be implemented
Theory keeps us from randomly attempting to change behavior
- Helps us develop an organized, systematic, and efficient approach to investigating health
- Once these investigations produce satisfactory results and are replicated the findings can be used
to inform the design of theory-based intervention programs
Getting Started: An Inductive Approach to Defining the Program
3 informal steps:
1. Your own hunch about the nature of the health behavior in question and its underlying
2. Think about the health behavior from a theoretical perspective
3. Conduct an empirical evaluation that suggests underlying causes of risk behavior and potential
antecedents to the adoption of health-protective behaviors
The 3 steps serve the central and initial goal: to identify the determinants of the specific health
Determinants influence the health behavior; they are the levels of influence shown in
Bronfenbrenner’s ecological model
- Determinants should be targeted to affect behavior change; thus, it is the determinants that
programs seek to change, not the behavior
- Theory guides the process of identifying the determinants most likely to alter and support the
long-term adoption of health-protective behaviors
- Determinants can be identified through an exercise that is best described by the phrase
“determining the theory of the problem
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