Introductory Unit-2.pptxIS 336 Health and Health Care Is.docx

Introductory Unit-2.pptx
IS 336 Health and Health Care Issues Introductory Unit
Welcome!
We are glad you are here!
Course Description
This course identifies and examines current issues involving the
health behaviors, health status and health care of people in the
United States. Among the specific issues included in this course
are: (1) the impact of health behaviors on health status and the
health care system, (2) the ethics of health care treatment and
decision-making, (3) the patterns of health status based on
gender, age, race and income, (4) the cost of health care, (5)
inequalities in access to health care, and (6) alternative models
of health care reform.
The objectives of the course are for students to examine:
“health” and its’ determinants, including individual health
behavior.
multiple health behaviors—prevalence, impact on the health
status of the United States collectively and of specific groups

(e.g., gender, race, age)/ United States collectively, and impact
on the United States’ health care system.
the general health status and health risks of the U.S. population
(overall in the U.S., by age, by gender, by race and ethnicity, by
income).
healthcare disparities (quality of care, access, preventive care,
acute treatment, chronic disease management) related to age,
race, ethnicity, and income in the U.S.
the effectiveness of the U.S. health system, including levels of
satisfaction of the U.S. population with the health system,
opinions concerning health care reform, and the impact of the
Patient Protection and Accordable Care Act.
Achievement of course and unit objectives will be assessed
through evaluations of performance on unit exams and selected
issue presentation
Introductory Unit Objectives
Overview course and course expectations, including accurate
citations—in-text citations to support propositions and
literature-cited (references)
Syllabus
Introductory PowerPoint
Introduce course faculty and students
Introductory discussion board posting
Begin identification of a health/healthcare issue of specific
interest
Introductory discussion board posting
Practice online exam completion within Canvas
Introductory Quiz

Unit 1
Health
Measures
Life Expectancy
Self Assessed Quality of Life
Disease Incidence
Activity Limitations
Determinants
Individual Behavior
Biology & Genetics
Psychosocial Factors
Environmental Factors
Health Services
Policy Making
Unit 2
Health
Status
IS 336 United States’ Health & Healthcare Issues Course
Overview
Unit 3
Healthcare System
Effectiveness
Measures
% Insurance Coverage
Cost control

Perceived Quality of Care
Health Outcomes
Choice
5
Course Grading
LATE PENALTY: Assignments turned in after the due date
listed will receive a 20% reduction in the grade of the
assignment. The last day that late assignments can be submitted
is Friday, July 24, 2015 (midnight).
Instructional Units
Introductory Unit Course Overview
Introductory Quiz-Untimed
Introductory Discussion Board Posting
Unit 1 Health in the United States and Determinants of Health,
including Individual Health Behaviors
Unit 1 Reading/Viewing Guide (Optional)
Unit 1 Exam-1 hour time limit
Unit 2 Health Status of People of the United States

Unit 3 United States Healthcare System
Timed Unit Exams
The Unit 1-3 Exams are timed exams.
They will become accessible 6 days prior to the due date.
Once you open the exam and read the first question, a 60 minute
timer will activate.
Time remaining will always be visible in the upper right corner
of your screen.
Each exam has a variety of question formats—multiple choice,
multiple answer, true/false, matching, and short essay.
Preparation for Unit Exams
Complete all required readings/viewing listed on the Unit
Overview page
Consider taking notes, perhaps on the provided Unit
Reading/Viewing Guides (all quiz questions are addressed
within these guides)
Selected Health/Healthcare Issue PowerPoint Presentation
Purpose:
This assignment provides you with the opportunity to
investigate a health/healthcare issue/topic of specific interest to
you and to share your findings with your classmates.

Directions:
Identify a health/healthcare issue/topic of specific interest to
you. If you select an issue/topic already addressed within the
course (e.g., required Units 1-3 PowerPoints, readings, and
videos), you must greatly expand discussion of the topic and/or
take a different approach to the topic.
Complete a preliminary search of your selected topic and begin
to gather reputable, relevant evidence. You will eventually need
at least four reputable sources.
Send an email (via Canvas course site) to course professors,
outlining your proposed health/healthcare issue/topic, no later
than midnight Sunday, June 21st.
When your topic is approved, thoroughly research your selected
topic. Gather reputable, relevant evidence that will help you
communicate the following:
Detailed description of the issue/topic
Relevance and significance of the issue/topic
Impact of the issue/topic on health, health status, and/or
healthcare in the United States
Challenges/barriers (e.g., to incidence reduction,
implementation, resolution/improvement)?
Create a PowerPoint presentation that informs your classmates
about your selected issue/topic. Describe in detail your selected
health or health care issue/topic.

Why is it relevant?
What is its significance?
How does it impact health, health status and/or healthcare in the
United States?
What are challenges/barriers (e.g., to incidence reduction,
implementation, resolution/improvement)?
Provide relevant current data and research findings.
Keep in mind that the PowerPoint presentation is to serve as an
instructional tool and not to promote your viewpoint. In other
words, this is not about your opinion or experiences, it is a
scholarly presentation of information.
Presentations are to be well-researched, informative, thought
provoking, and based on a synthesis of facts and ideas from a
variety of authoritative references. Information is to be
presented in a logical, interesting sequence.
Write in your own words. Insert citations in order to attribute
your information to original source and to add credibility to
your writing. Direct quotes are not appropriate for this
assignment. Points will be deducted for inaccurate in-text
citation format and use of verbatim direct quotes.
Cite reputable sources throughout your presentation. Give
appropriate credit for paraphrased/summarized information from
reputable sources. Provide Literature Cited (or Reference List)
slide(s) at the conclusion of the PowerPoint, which provides full
publication information for all (and only those) sources cited
within the PowerPoint. Use a formal style guide that you
familiar with, e.g. APA, MLA.

It is anticipated that your PowerPoint presentation will include
20+ slides. Your PowerPoint presentation should begin with a
title slide that identifies the topic of your presentation, your
name, and the date. Your PowerPoint presentation should
conclude with Literature Cited (or References) slide(s).
Be sure to use a consistent appropriate background, font, font
size(s) and font color combinations. Include appropriate
graphics/images/diagrams. The overall appearance of your
PowerPoint presentation should be appealing and contain no
spelling, grammar, or punctuation errors.
Create a reply to the Selected Health/Healthcare Issue
Discussion Board. Attach your developed PowerPoint
presentation to your reply. Due by midnight Sunday July 19th.
Beginning Monday July 20th, view your classmates’ PowerPoint
presentations. Post replies to at least five. Your reply should
identify what you learned from the presentation and expand the
discussion of the issue/topic. Your 5+ replies are due by
midnight Friday July 24th.
Sample Topics
Government role in health spending
Public health and prevention

Hospital organization
Electronic Health Record (EHR)
Long term care services
Managed care
Ambulatory care services
A specific chronic disease or health problem
Immunizations
Mental health services
Hospice
Home health service
Access to health care services
Population health
Concierge Medicine
Wellness care
Stress-related health problems
Depression
A specific mental illness
Emergency department use
Health care information technology
Nursing Shortage
Quality measures
Homelessness and health
Epidemic preparedness
Nurse bedside shift report
HIV/AIDS
Alzheimer’s/Dementia
A specific injury
Violence
Safe staffing levels
Building a culture of health
Interprofessional collaboration
Patient Satisfaction
Hospital Safety Scores
Hospital report cards
Physician Quality Reporting System (PQRS)
30-day Medicare Readmission penalties

Changing physician payment trends
Health Insurance portability
Quality and Safety Education for Nurses (QSEN) project
Patient centered medical homes
Nurse job dissatisfaction & burnout
Entry level RN education
PowerPoint Presentation Evaluation
See Evaluation rubric within syllabus
35% Course Points
Proposal Email (5%)
PowerPoint Presentation (25%)
Content (10%)
Writing (5%)
Design (5%)
Citations (5%)
Replies (5% course points, 1%/reply)
Student Resources
The Learning Commons, Hooley –Bundschu Library
[https://www.avila.edu/hbl/AvilaLearningCommons/index.aspx]
Professional librarian available
for database and reference searching assistance

IT Support Services
[http://transformlearning.avila.edu/ITservices/]
The IT support-desk is located next to the circulation desk in
the Learning Commons. The IT support staff can solve problems
with networks, computer-devices, software, and other types of
technology.
Send an email to [email protected] or
Call 816-501-2900
Citation Review
In Text
Literature Cited
When to cite?
All information that is not “common knowledge”
Information/ideas paraphrased/summarized from a source must
be cited (author, date)
If taken verbatim from a source, quotes are placed around the
verbatim text and cited (author, date, and page number)—Direct
quotes are NOT appropriate for the assignments in this course.
Failure to cite = Plagiarism
In Text citations allow the reader to locate the source within
Literature Cited section, which should include full publication
information.

Literature Cited – Page at end of document which lists ALL
sources cited (and only the sources cited) within the document.
Provides full publication information – reader can use to
relocate reference source.
In Text Citations
Quotations must be identical to the original, using a narrow
segment of the source. They must match the source document
word for word and must be attributed to the original author.
Direct quotes are NOT appropriate for the assignments in this
course.
Paraphrasing involves putting a passage from source material
into your own words. A paraphrase must also be attributed to
the original source. Paraphrased material is usually shorter than
the original passage, taking a somewhat broader segment of the
source and condensing it slightly.
Summarizing involves putting the main idea(s) into your own
words, including only the main point(s). Once again, it is
necessary to attribute summarized ideas to the original source.
Summaries are significantly shorter than the original and take a
broad overview of the source material.
http://owl.english.purdue.edu/owl/resource/563/1/

In Text Citations
Provide support for claims or add credibility to your writing
Refer to work that leads up to the work you are now doing
Give examples of several points of view on a subject
Call attention to a position that you wish to agree or disagree
with
Highlight a particularly striking phrase, sentence, or passage by
quoting the original
Expand the breadth or depth of your writing
A paraphrase is...
Your own rendition of essential information and ideas expressed
by someone else, presented in a new form.
One legitimate way (when accompanied by accurate
documentation) to borrow from a source.
A more detailed restatement than a summary, which focuses
concisely on a single main idea.

6 Steps to Effective Paraphrasing
Reread the original passage until you understand its full
meaning.
Set the original aside, and write your paraphrase on a note card.
Jot down a few words below your paraphrase to remind you
later how you envision using this material. At the top of the
note card, write a key word or phrase to indicate the subject of
your paraphrase.
Check your rendition with the original to make sure that your
version accurately expresses all the essential information in a
new form.
Use quotation marks to identify any unique term or phraseology
you have borrowed exactly from the source.
Record the source (including the page) on your note card so that
you can credit it easily if you decide to incorporate the material
into your paper.
MIDAC: Paraphrasing Method
In your own words after reading an article (or a section of an
article), identify:
Main idea
Important points
Delete unimportant
Analyze
Collapse (Synthesize)
In Text Citation

Signal phrase (1 Author) : According to AUTHOR LAST
NAME (year), …..
Signal phrase (2 Authors): According to AUTHOR LAST
NAME (first listed) and AUTHOR LAST NAME (second listed)
(year), …
Signal phrase (3+ authors): According to AUTHOR LAST
NAME (first listed) et al. (year),…..
Organization as Author: According to the American Heart
Association (2013)…..
EXAMPLE:
Muniz Pagan et al. (2012) found that foraging lizards use as
much as 90% of their maximal capacity when evading predators.
Literature Cited
Select a formal style guide that you familiar with, e.g. APA,
MLA
Identify type of source:
Book (one, two or more than two authors)
Journal article
Webpage
Find a sample and “mirror”
https://owl.english.purdue.edu
Make sure entries are listed in alphabetical order
Indent subsequent (second, third….) lines 5 spaces (1/2 inch)
Include ONLY sources cited in manuscript
Be sure to include ALL sources cited in manuscript
Selecting reputable Sources

Reputable Sources
“The following sources would generally be perceived as
reputable. Most are readily found in university, faculty or
departmental libraries, and many can be found on the Internet:
Journal databases, e.g, ProQuest
academic books by single or multiple authors within the
discipline or area of study or academic and professional
journals within the discipline or area of study
specialist magazines or newspapers of agreed high repute, e.g.
Nature, The Wall Street Journal, The Australian Financial
Review, The New York Review of Books, The Times Literary
Supplement
government reports
reports from known, reputable organizations, e.g. the World
Health Organization (WHO), the United Nations Educational,
Scientific and Cultural Organisation (UNESCO), the
Organisation for Economic Co-operation and Development
(OECD)
recorded TV or radio programs to which reputable figures
within the discipline have contributed
the internet, if the site has a reputable author, publisher and
domain name that show the site has the relevant credentials for
your writing purpose.”

Adapted from:
http://writesite.elearn.usyd.edu.au/m2/m2u2/m2u2s2/m2u2s2_1.
htm
“Good” vs. “Not so Good” Sources For Our Assignments
“Good Sources”
1. Google Scholar (http://scholar.google.com)
2. Avila Library databases, e.g., Academic Search Premier or
ProQuest
“Not so Good” Sources
1. Wikipedia
2. Other Wiki pages
3. Personal Experiences
4. Friends and family
Course Assignment Point
Allocation
Due Date
Introductory Quiz 4% Sunday, June 7
th
(by midnight)
Introductory Discussion Board 1% Sunday, June 7
th
(by midnight)
Unit 1 Exam 20% Sunday, June 14
th
(by midnight)
Selected Issue Presentation Topic
Proposal

5% Sunday, June 21
st
(by midnight)
Unit 2 Exam 20% Sunday, June 28
th
(by midnight)
Unit 3 Exam 20% Sunday, July 12
th
(by midnight)
Selected Issue PowerPoint Presentation 25% Sunday, July 19
th
(by midnight)
Responses to Selected Issue
Presentations (5)
5% Friday, July 24
th
(by midnight)
TOTAL 100%
Course Assignment
Point
Allocation
Due Date
Introductory Quiz
4%
Sunday, June 7th (by midnight)
Introductory Discussion Board
1%
Unit 1 Exam
20%
Selected Issue Presentation Topic Proposal
5%
Sunday, June 21st (by midnight)
Unit 2 Exam

20%
Unit 3 Exam
20%
Sunday, July 12th (by midnight)
Selected Issue PowerPoint Presentation
25%
Sunday, July 19th (by midnight)
Responses to Selected Issue Presentations (5)
5%
Friday, July 24th (by midnight)
TOTAL
100%
Day Summer Hours
Monday 8:00 AM TO 9:00PM
Tuesday 8:00 AM TO 9:00PM
Wednesday 8:00 AM TO 9:00PM
Thursday 8:00 AM TO 9:00PM
Friday 8:00 AM TO 6:00PM
Saturday 10:00 AM TO 5:00PM
Sunday CLOSED
Day
Summer Hours
Monday
8:00 AM TO 9:00PM
Tuesday
8:00 AM TO 9:00PM
Wednesday
8:00 AM TO 9:00PM
Thursday
8:00 AM TO 9:00PM
Friday
8:00 AM TO 6:00PM

Saturday
10:00 AM TO 5:00PM
Sunday
CLOSED
__MACOSX/._Introductory Unit-2.pptx
unit1/.DS_Store
__MACOSX/unit1/._.DS_Store
unit1/Health Behavior Models.pdf
The International Electronic Journal of Health Education, 2000;
3 (Special Issue): 180-193
http://www.iejhe.siu.edu
Health Behavior Models
Colleen A. Redding, PhD1; Joseph S. Rossi, PhD2; Susan R.
Rossi, PhD3;
Wayne F. Velicer, PhD4; James O. Prochaska, PhD5
1Dr. Redding is an Assistant Research Professor at the Cancer
Prevention Research Center (CPRC) at the
University of Rhode Island. She received her doctorate in 1993
at the University of Rhode Island in clinical
psychology. Her clinical internship was in Health Psychology at
UCLA Medical Center and her post-doctoral
fellowship was at the CPRC. She has fifteen years of clinical
and research experience in many medical and
reproductive health care settings, and is an investigator on many
federally funded research projects studying various
health behavior changes. She has ten years of experience in the
development and application of the

Transtheoretical Model and stage-matched interventions to
many problem behaviors.
2Dr. Joseph Rossi is a Professor in the Department of
Psychology and Director of Research at the Cancer
Prevention Research Center at the University of Rhode Island.
He received his PhD in experimental psychology
from the University of Rhode Island in 1984. He has published
in a wide range of areas including research
methodology and measurement, skin cancer prevention, smoking
cessation, exercise adoption, weight control,
diabetes self-management, HIV risk reduction, and expert
system development. A recent study conducted by the
Institute for Scientific Information and the American
Psychological Society listed him among the 10 most
influential authors in psychology.
3Dr. Susan Rossi is Diabetes Research Coordinator for
ProChange Behavior Systems, Adjunct Assistant Professor
at the College of Nursing and Coordinator of Adherence &
Education Programs for the Rhode Public Health
Partnership in Emerging Infectious Disease at the University of
Rhode Island. She received her BS in nursing at
Duke University in 1974, and an MSN in 1982 and PhD in
nursing in 1994 at the University of Rhode Island. She
has 13 years of research experience as a behavioral scientist
focusing on applying the Transtheoretical Model to
the dietary area, work which has been nationally and
internationally recognized.
4Dr. Velicer is a Principal in ProChange, Co-Director of the
Cancer Prevention Research Center, and is Professor
of Psychology, University of Rhode Island. He received his PhD
in psychology from Purdue University in 1972. He
has published more than 120 papers on a variety of topics,
including behavior change for health promotion/disease
prevention, factor and component analysis, time series analysis,
and measurement development. He was identified
as one of the highest impact authors in psychology by studies in

1992 and 1996. He is an original developer of the
Transtheoretical Model and a pioneer in the development of
expert systems. He has been PI or co-PI on more than
$40 million dollars in federal funding.
5Dr. Prochaska is President of ProChange, Director of the
Cancer Prevention Research Center, and Professor of
Psychology, University of Rhode Island. He received his PhD in
clinical psychology in 1969 from Wayne State
University. He has published more than 100 papers and 3 books
on the Transtheoretical Model of behavior change
for health promotion and disease prevention. A recent study
conducted by the Institute for Scientific Information
and the American Psychological Society listed him among the
10 most influential authors in psychology. One of
the originators of the Transtheoretical Model, he has been PI on
over $40 million in research grants on prevention
of cancer and other chronic diseases.
Corresponding author: Colleen A. Redding, Assistant Professor,
Cancer Prevention Research Center, University
of Rhode Island, 2 Chafee Road, Kingston, RI 02881-0808;
phone: 401.874.2830; email: [email protected]
Introduction
Since they define what to measure, models and
theories of health behavior change are inherently
linked to the measurement of health behavior. This
chapter reviews different models of health behavior
change as an overview, not an in-depth comparison.
Furthermore, while we aim to present other models
fairly, the authors are biased toward the
Transtheoretical model—we present best that with
which we are most familiar.
We review here only the four most commonly used
models of individual health behavior change, relying

primarily on the criteria of Glantz and colleagues.1
Their review of articles published between 1992-1994
in health education, medicine, and behavioral science
that use any theoretical framework (only 45% used a
theory)1 revealed that the most used models were the
mailto:[email protected]
Health Behavior Models Redding et al
http://www.iejhe.siu.edu 181
Health Belief Model, Theory of Reasoned
Action/Planned Behavior, Social Cognitive Theory and
The Transtheoretical Model. There are many more
theories and models relevant for health behavior
covering such important topics as: community
organization, communication, diffusion of innovations,
social marketing, information processing, stress and
coping, relapse prevention, and empowerment.
Additional materials are cited in the text and interested
readers can pursue these ideas further through these
resources. An entire book is devoted to the topics
covered in this chapter and is highly recommended for
those who want more details.1
Theoretical models fundamentally guide both our
current and future understanding of health behavior, as
well as providing direction for our research and
intervention development. As a metaphor, each model
or theory provides a different roadmap of the health

behavior territory. Of course, it is important to point
out that the map is not the territory itself, and different
maps (theories) describe the same territory differently.
Even so, when we enter new territory, we still need a
map. Even a roughly drawn or poorly scaled map is
much better than none at all. The map points out the
relevant landmarks (constructs) and how they are
connected, and, perhaps, how far it is from one
landmark to another. As different maps of the same
territory evolve over time and are compared, the
territory becomes clearer, thus allowing better maps to
evolve, perhaps integrating the clearest features of
different maps. So it goes with theoretical development
as well. There is no final or true map, only a map or
theory that best meets our needs right now. Thus, as
we evaluate these different theories, we should ask
comparable questions of them.
Evaluation and comparison of the different
theories reveals that they are not so different in terms
of their differential predictions. Most differences really
amount to emphasis on one construct over another.
Cummings and colleagues conclude that theories
which integrate ideas from other competing theories
provide more explanatory power.2 Similarly, Fishbein
and colleagues went through an unprecedented
consensus conference among theorists to outline the
most important variables to study in relation to
reducing HIV risk.3 Many constructs from each theory
are actually fairly similar. One excellent research
proposal for conducting critical tests of different
theoretical predictions is outlined by Weinstein.4 In
fact, the National Institutes of Health recently issued a
cross-agency request for funding applications to
systematically test different theoretical predictions.

The Health Belief Model
The Health Belief Model (HBM) has the longest
history of all the theories reviewed. It was originally
conceived by social psychologists in the public health
arena as a way of predicting who would utilize
screening tests and/or vaccinations.3,5_9 According to
the HBM, the likelihood that someone will take action
to prevent illness depends upon the individual's
perception that:
• they are personally vulnerable to the condition;
• the consequences of the condition would be
serious;
• the precautionary behavior effectively prevents the
condition; and
• the benefits of reducing the threat of the condition
exceed the costs of taking action.9
These four factors, which are influenced by
mediating variables, indirectly influence the
probability of performing protective health behaviors
by influencing the perceived threat of the illness and
expectations about outcome.
The HBM has been used for intervening with
health screening, illness, sick role, and precautionary
behaviors.5,8_12 The model has undergone some
modifications since its original formulation. Table 1
shows the four-construct model that is the most
commonly described form of the HBM. The model's
four key components are conceptualized as perceived:
1) susceptibility, 2) severity, 3) effectiveness, and 4)
cost.

Perceived susceptibility refers to the probability
that an individual assigns to personal vulnerability in
developing the condition. The concept of perceived
susceptibility has been found to be predictive of a
number of health-protective behaviors. From an HBM
perspective, the likelihood individuals will engage in
precautionary behaviors to prevent cancer (e.g., quit
smoking, eat a diet low in fat and high in fiber,
exercise, get a mammogram or prostate exam) depends
on how much they believe they are vulnerable to or at
risk for cancer. In general, it has been found that
people tend to underestimate their own susceptibility to
disease.
Table 1. Health Belief Model Constructs
Constructs Descriptions
Perceived
Susceptibility
One’s evaluation of chances of
getting a condition
Perceived
Severity

One’s evaluation of how serious
a condition, its treatment, and its
conseuqences would be
Perceived
Benefits
One’s evaluation of how well an
advised action will reduce risk or
moderate the impact of the
condition
Perceived
Barriers
One’s evaluation of how difficult
an advised action will be or how
much it will cost, both
psychologically and otherwise
Cues to
Action
Events or strategies that increase
one’s motivation
Self-efficacy
Confidence in one’s ability to
take action
Perceived severity refers to how serious the
individual believes the consequences of developing the
condition are. An individual is more likely to take
action to prevent cancer if s/he believes that possible
negative physical, psychological, and/or social effects

resulting from developing the disease pose serious
consequences (e.g., altered social relationships,
reduced independence, pain, suffering, disability, or
even death). Models of Health Belief frequently refer
to perceived health threats. The combination of
perceived susceptibility and perceived severity
constitute a threat.
Perceived effectiveness refers to the benefits of
engaging in the protective behavior. Motivation to take
action to change a behavior requires the belief that the
precautionary behavior effectively prevents the
condition. For example, individuals who are not
convinced that there is a causal relationship between
smoking and cancer are unlikely to quit smoking
because they believe that quitting will not protect
against the disease.
Perceived cost refers to the barriers or losses that
interfere with health behavior change. The
combination of perceived effectiveness and perceived
costs constitute the notion of outcome expectation.
Belief alone is not enough to motivate an individual to
act. Taking action involves cognitively weighing the
personal costs associated with the behavior against the
benefits expected as a result of engaging in the
behavior. Benefits have to outweigh the costs involved.
Cues to action involve stimuli that motivate an
individual to engage in the health behavior.9 The
stimulus that triggers action may be internal or
external. For example, angina may act as an internal
cue to initiate action. External cues such as a spouse's
illness or the death of a parent may also trigger health
behavior changes in an individual who was not
otherwise considering them. HBM factors also interact

to trigger action. For example, when perceptions of
susceptibility and severity are high, a very minor
stimulus may be all that is needed to initiate action.
However, more intense stimuli may be needed to
initiate action if perceived susceptibility and severity
are low.
More recent formulations of the HBM have
included self-efficacy as a key factor. Self-efficacy is
influenced by mediating variables and in turn
influences expectations. In addition, some forms of the
HBM refer to general susceptibility to illness as a key
factor in the model. However, substitution of the
general case over specific consequences is only
appropriate if the intention of the precautionary
behavior is to improve health in general.4 The value of
health, another variable which is sometimes included,
refers to interest in and concerns about general health,9
the extent to which an individual values health.6
According to this view of HBM, individuals concerned
about being healthy in general are more likely to
exercise regularly than individuals who place little
value on health. Although both cues to action and the
value of health have been included in some forms of
HBM, their importance in predicting health behavior
is unclear since neither variable has been
systematically studied.9
Mediating factors (demographic, structural, and
social variables) have also been explored in applying
the HBM. Mediating variables (e.g., educational level)
are believed to indirectly affect behavior by influencing
an individual's perceptions of susceptibility, severity,

benefits, and barriers.9 Becker and Maiman added the
concept of motivation to the HBM.6 This has also been
interpreted as readiness to change behavior.12
The Theory of Reasoned
Action/Planned Behavior
The Theory of Reasoned Action (TRA) is a widely
used behavioral prediction theory which represents a
social-psychological approach to understanding and
predicting the determinants of health-behavior.14_16
Over the years, TRA has been applied to many diverse
health-related behaviors including: weight loss,
smoking, alcohol abuse, HIV risk behaviors, and
mammography screening. The theory of reasoned
action states that the intention to perform a particular
behavior is strongly related to the actual performance
of that behavior. Two basic assumptions that underlie
the TRA are: 1) behavior is under volitional control,
and 2) people are rational beings. From the perspective
of TRA, we behave in a certain way because we choose
to do so and we use a rational decision-making process
in choosing and planning our actions. The TRA was
designed to predict behavior from intention, and
proposes quasi-mathematical relationships between
beliefs, attitudes, intentions, and behavior. A modified

version of TRA includes the addition of perceived
control over the behavior and is referred to as the
Theory of Planned Behavior (TPB).3,7 Table 2
describes the main constructs used in TRA and the
Theory of Planned Behavior
Table 2. Theory of Reasoned Action/Planned Behavior
Constructs Description
Behavioral Intention Perceived likelihood of performing the
behavior
Attitudes The product of the behavioral belief multiplied by the
evaluation of it
Behavioral Belief Evaluation of the likelihood that performance
of the behavior is associated
with certain outcomes
Evaluation of B.B. How good or how bad those outcomes would
be
Subjective Norm The product of the normative belief multiplied
by the motivation to comply
Normative Belief Perception of how much each personal contact
approves or disapproves of the
behavior
Motivation to Comply Motivation to do what each personal
contact person wants
Perceived Behavioral Control The product of the control belief
multiplied by the perceived power

Control Belief Perceived likelihood of each facilitating or
constraining condition occurring
Perceived Power Perceived effect of each condition in making
the performance of the behavior
easier or more difficult
Predicting behavior is the ultimate goal of the
TRA. According to the TRA, behavior is influenced by
the intention to perform the behavior. Intention is
influenced by three major variables: subjective norms,
attitudes, and self-efficacy. Subjective norms involve
an individual's perception of what significant others
believe about his or her ability to perform the behavior.
For example, whether or not someone intends to cut
down on dietary fat by giving up bacon and red meat
could be partly determined by what that person
believes his or her spouse's opinion would be if s/he
did. Attitudes can be conceptualized in terms of values.
That is, an individual develops particular values about
behaviors. For example, one attitude might be: eating
a healthy diet is a good way to prevent heart disease
and/or cancer. Self-efficacy is the confidence an
individual feels that s/he can successfully perform the
behavior of eating a healthy diet.

Two of the variables that influence intention,
subjective norms, and attitudes are in turn influenced
by beliefs. Two general types of beliefs are considered
in TRA: normative and behavioral beliefs. Normative
beliefs are situationally based social expectations,
which are considered the rule. Normative beliefs
influence subjective norms while beliefs about the
behavior influence attitudes. An individual's attitudes
toward a behavior are determined by his/her
expectations about the outcome of performing the
behavior, and the extent to which s/he values the
outcome. Thus, from a TRA perspective, the likelihood
that an individual will engage in health risk reduction
depends upon how much s/he is convinced that healthy
behaviors will prevent risk, and the degree to which
s/he perceives the benefits will outweigh the costs.
The majority of TRA research has focused on the
prediction of behavioral intention rather than on the
behavior itself.13 Unfortunately, because the correlation
between behavior and intention is not particularly
impressive, research on attitudes and behaviors is often
dismissed.14 Despite this shortcoming, Sonstroem has
suggested that TRA can still be a useful perspective as
long as situation-specific attitude and intention
measures are employed that specify congruent action,
target, context, and time, and that the interactions
between personal determinants and situations are
emphasized.17
Social Cognitive Theory
This theory goes well beyond individual factors in
health behavior change to include environmental and
social factors. In fact, this theory may be the most
comprehensive model of human behavior yet proposed.

Bandura's Social Cognitive Theory (SCT),18 also
referred to as Social Learning Theory, is a behavioral
Table 3. Social Cognitive Theory Constructs
Environmental Factors outside the person
Situation One’s perception of the environment
Behavioral Capability One’s knowledge and skills to perform a
behavior
Expectations One’s anticipation of the outcomes of a behavior
Expectancies How good or bad one evaluates the outcomes to be
Self-control Regulation of one’s own behavior
Observational Learning Acquiring a new behavior by watching
someone else perform it and observing
the outcomes–a.k.a. modeling
Reinforcements Responses to a person’s behavior that affect
how likely it is that the behavior
will reoccur
Self-efficacy One’s confidence in one’s own ability to perform
a behavior
Emotional Coping Responses Strategies used by someone to
deal with emotionally challenging thoughts,
events, or experiences
Reciprocal Determinism Dynamic interaction of the person, the

behavior, and his/her environment
prediction theory that represents a clinical approach to
health behavior change.3,7 This theory has been widely
applied to health behavior with respect to prevention,
health promotion, and modification of unhealthy
lifestyles for many different risk behaviors. SCT
emphasizes what people think and its effect on their
behavior.19,20 SCT proposes that behavior can be
explained in terms of triadic reciprocity between three
key concepts which operate as determinants of each
other. Reciprocal determinism forms the basic
organizing principle of SCT. This important concept
states that there is a continuous, dynamic interaction
between the individual, the environment, and behavior.
Thus, a change in one of these factors impacts on the
other two. SCT involves numerous key concepts,
which have been associated with each of the three
main constructs for the purpose of describing the SCT.
Table 3 describes all the key constructs employed by
SCT.
Bandura conceptualized influences on behavior
that involved the concept of person in terms of basic
human capacities that are cognitive in nature.18 Key
concepts associated with the person include: personal
characteristics, emotional arousal/coping, behavioral

capacity, self-efficacy, expectation, expectancies,
self-regulation, observational/experiential learning,
and reinforcement.19,20
• Personal characteristics have been
operationalized as multiple, interacting
determinants such as demographics (e.g., gender,
race/ethnicity, education), personality, cognitive
factors (e.g., thoughts, attitudes, beliefs,
knowledge), motivation, and skills.
• Emotional arousal/coping can interfere with
learning and thus influence behavior. This refers
to an individual's ability to respond to emotional
stimuli with various techniques, strategies, and
activities that help one to deal with arousing
situations (e.g., fear, anxiety).
• Behavioral capacity refers to the individual's
possession of both the knowledge and skills
necessary to perform a behavior.
• Self-efficacy refers to an individual's confidence in
his or her ability to perform a behavior in various
situations. Self-efficacy has been recognized as an
important mediating variable between knowledge,
attitudes, skills, and behavior.13
• Expectations are beliefs associated with the
outcome of a behavior. Expectancies are the value
an individual attributes to the anticipated outcome
of performing a behavior.
• Self-regulation refers to the individual's ability to
manage or control behavior. Individuals use goal
setting, self-monitoring, and self-reinforcement to

regulate performance of a behavior.
• Observational/experiential learning refers to the
acquisition of a behavior through observation and
experience. Learning can occur either through
observation of another's performance of a behavior
(modeling), or through personal experience, i.e.,
trial and error.
• Reinforcement refers to the consequences that
affect the probability a behavior will be tried
again. Individuals are motivated to perform
behaviors through rewards and incentives.20
In SCT, the relationship between behavior, person,
and environment is interactive. The stereotypic picture
of the relatively young executive who develops high
blood pressure provides an illustration of how variables
associated with person, (e.g., personal characteristics),
interact with the environment and behavior. Consider
a male in his early 40s who is obsessed with
achievement, advancement, and recognition. This
individual is a highly competitive workaholic who is
driven to get things done quickly. Such individuals are
sometimes described as being hostile and might be
found operating in a highly stressful environment.
Although simplistic and stereotypical, this picture
represents a classic example of a "Type A personality."
From an SCT perspective, this individual's
predominant personality type negatively influences his
behavior. Thus this individual is less likely to take the
time to acquire the cognitive and behavioral skills
necessary to successfully perform any risk reduction
behavior (smoking cessation, stress management, etc.).
Influences on behavior which involve the

environment can be physical, social, cultural,
economical, political in nature,21 or situational in
nature.20 In SCT, the person's perceptions of the
environment are referred to as situations; this key
variable can facilitate or inhibit behavior. In this
reciprocal, interactive scheme, in which multiple
determinants of behavior are assumed, behavior also
exerts an influence on both the environment and the
person. The environment and past experience with a
Table 4. Transtheoretical Model Constructs
Stages of Change
Precontemplation No intention to take action within the next 6
months
Contemplation Intends to take action within the next 6 months
Preparation Intends to take action within the next 30 days and
has taken some behavioral steps
in this direction
Action Has changed overt behavior for less than 6 months

Maintenance Has changed overt behavior for more than 6
months
Decisional Balance
Pros The benefits of changing
Cons The costs of changing
Self-efficacy
Confidence Confidence that one can engage in the healthy
behavior across different
challenging situations
Temptation Temptation to engage in the unhealthy behavior
across different challenging
situations
Process of Change
Consciousness Raising Finding and learning new facts, ideas,
and tips that support the healthy behavior
change
Dramatical Relief Experiencing the negative emotions (fear,
anxiety, worry) that go along with
unhealthy behavioral risks
Self-reevaluation Realizing that the behavior change is an
important part of one’s identity as a
person
Environmental
Reevaluation

Realizing the negative impact of the unhealthy behavior, or the
positive impact of
the healthy behavior, on one’s proximal social and/or physical
environment
Self-liberation Making a firm commitment to change
Helping Relationships Seeking and using social support for the
healthy behavior change
Counterconditioning Substitution of the healthier alternative
behaviors and/or cognitions for the
unhealthy behavior
Reinforcement
Management
Increasing the rewards for the positive behavior change and/or
decreasing the
rewards of the unhealthy behavior
Stimulus Control Removing reminders or cues to engage in the
unhealthy behavior and/or adding
cues or reminders to engage in the healthy behavior
Social Liberation Realizing that social norms are changing in
the direction of supporting the healthy
behavior change

particular behavior can also provide reinforcement for
acting in a particular way. For example, as Americans
have demanded the availability of healthier, lower fat,
higher fiber choices in their environment, more and
more eating establishments have changed their food
preparation procedures and menus to reduce dietary
fat. There are a wider variety of "heart healthy" menus
available now. To reduce their risk, consumers have
begun to take advantage of greater environmental
choices by: purchasing more fruits and vegetables,
substituting available lower fat products instead of
high fat ones, changing their food preparation methods
to broiling and baking instead of frying, and ordering
lower fat food choices offered by restaurants.
Interactions are also assumed to occur between
problem behaviors (e.g., eating high fat foods, lack of
exercise, smoking) and physiological factors (e.g.,
nicotine, caffeine addiction).21 An individual's
performance of associated behaviors can have an
important impact on disease prevention. Engaging in
exercise can trigger hunger, stimulating the desire for
high fat food. Finishing a meal can act as a cue that
triggers the desire for a cigarette. An individual may
use smoking to relax in a high stress environment. To
effectively prevent disease, an individual needs to
engage in multiple healthy behaviors like exercise
adoption, low fat/high fiber eating habits,
mammography screening, wearing seatbelts, etc. SCT
assumes that most behaviors are learned responses and
can be modified. Thus, learning through observing the
behavior of others (i.e., modeling) is important from a
SCT perspective. SCT also places heavy emphasis on
learning both cognitive and behavioral skills for

coping with situations and making changes in health
behavior. Thus, an individual who wants to quit
smoking but lacks the cognitive and behavioral skills
to effectively cope with stressful situations without
cigarettes is less likely to successfully change smoking
behavior in spite motivation to do so.
Self-Efficacy
The concept of self-efficacy is recognized as one of
Bandura's most important contributions to psychology
and the field of health behavior change in general.22
Self-efficacy refers to the confidence an individual has
in his or her own ability to successfully carry out a
behavior. The importance of self-efficacy for behavior
change has been widely recognized across multiple
behaviors relevant to health risk reduction.23
Furthermore, its incorporation into almost all major
theories of behavior change is further evidence of its
important role in the behavior change process.
Bandura proposed that the actual performance of
a particular behavior is highly related to an
individual's belief in his/her ability to perform that
behavior in specific situations. An individual with low
self-efficacy is likely to have lower expectations of
successfully performing the behavior and be more
affected by situational temptations that are
counterproductive to promoting and maintaining
behavior change. In contrast, an individual who has
high self-efficacy not only expects to succeed but is
actually more likely to do so. For example, the
likelihood that an individual will successfully perform
a behavior like exercise is strongly dependent upon
how confident that individual is that s/he can actually

do activities, such as walking, jogging, swimming, or
doing aerobics on a regular basis.22
Several factors influence an individual's
self-efficacy, including persuasion by others, observing
others' behavior (modeling), previous experience with
performing the behavior, and direct physiological
feedback.18 For example, individuals are more likely to
attempt to quit smoking if: 1) a physician recommends
that they do so, thus persuading them that quitting is
a good idea, 2) they have observed others who have
been able to quit and/or are coping well with trying to
quit, 3) they have had past experience with quit
attempts, and/or 4) they have been able to cope with
the physical symptoms of nicotine withdrawal.
Self-efficacy exerts such a strong influence on behavior
change that confidence has been found to outperform
past performance in predicting future behavior.24
The Transtheoretical Model
The past 20 years of Transtheoretical Model-based
research has found some common principles of
behavior change which have applied to a wide range of
health behaviors. These behaviors include: smoking
cessation, exercise adoption, sun protection, dietary fat
reduction, condom use, adherence to mammography
screening, medication adherence, stress management,
and substance abuse cessation, to name just a few.25_29
These problem behaviors are important from both a
clinical and a public health standpoint because they are
strongly associated with increased morbidity,
mortality, and with decreased quality of life. The
Transtheoretical Model (TTM) is a model of

intentional behavior change that has produced a large
volume of research and service across a wide range of
problem behaviors and populations.25_29 This model
describes the relationships among: stages of change;
processes of change; decisional balance, or the pros
and cons of change; situational confidence, or
self-efficacy in the behavior change; and situational
temptations to relapse. Table 4 describes all the
constructs that collectively comprise the TTM.
This model has several advantages over other
models. First, it describes behavior change as a
process, as opposed to an event. Then, by breaking the
change process down into stages and studying which
variables are most strongly associated with progress
through the stages, this model provides important tools
for both research and intervention development.
Secondly, its explicit focus on measurement of
constructs has provided a strong foundation for the
model. Across different problem behaviors and
populations, different variables have been associated
with stage movement for each stage of change.30
These TTM findings inform the design of
individualized, stage-matched, expert system
interventions (see below) that target those variables
most predictive of progress for individuals at each
stage of change. One aspect of this model that often

goes unrecognized is that it is the processes of change
that drive movement through the stages of change.31
Thus, although commonly referred to as the "Stages of
Change Model" since "stage" is the core construct
around which other model constructs are organized,
this is a misnomer since it focuses attention on only
one construct from this multidimensional model.
Naturally, model-based interventions are
multidimensional as well. TTM research has found
remarkable similarities across different kinds of
behavior changes. We have found repeatedly that the
stages of change have predictable relationships with
the pros and cons of behavior change, confidence in
behavior change, temptation to relapse, and the
processes of change.
Stages of Change
Individuals do not change their behavior all at once;
they change it incrementally or stepwise in stages of
change. The stages most commonly used across
research areas include: Precontemplation,
Contemplation, Preparation, Action, and Maintenance.
Individuals do not typically move linearly from stage
to stage, but often progress and then recycle back to a
previous stage before moving forward again. This
change process is conceptualized most meaningfully as
a spiral, which illustrates that even when individuals
do recycle to a stage they've been in before, they may
still have learned from their previous experiences.
Precontemplation describes individuals who for
many reasons do not intend to change within the next
six months. Some of these individuals may want to
change at some future time, but just not within the next

six months. Others may not want to change at all and,
in fact, may be very committed to their problem
behavior (e.g., a lifelong smoker or someone who
regularly cultivates a deep tan).
Contemplation describes individuals who are
thinking about changing their problem behavior within
the next six months. They are more open to feedback
and information about the problem behavior than their
counterparts in Precontemplation.
Individuals in the Preparation stage are
committed to changing their problem behavior soon,
usually within the next 30 days. These people have
often tried to change in the past and/or have been
practicing change efforts in small steps to help them
get ready for their actual change attempt.
The Action stage includes individuals who have
changed their problem behavior within the past six
months. The change is still quite new and their risk for
relapse is high, requiring their constant attention and
vigilance.
Maintenance stage individuals have changed their
problem behavior for at least six months. Their change
has become more of a habit, and their risk for relapse
is lower, but relapse prevention still requires some
attention, although somewhat less than for individuals
in Action.
Processes of Change
The processes of change describe the ten
cognitive, emotional, behavioral, and interpersonal
strategies and techniques that individuals and/or

change agents (therapists, counselors) use to change
problem behaviors.25,26 Research has demonstrated that
successful behavior change depends upon the use of
specific processes at specific stages.32_35 TTM-based
research has consistently found that different processes
are used to progress to different stages. Thus, the
processes mediate the transitions from stage to stage
and can represent important intermediate outcomes of
interventions. The processes of change are also ideal
tools for process-to-outcome research and in many
ways provide the foundation for TTM expert system
interventions (see below). The processes of change are
consistent with many SCT constructs and are quite
similar to most conceptions of coping behaviors as
well.36
Many studies across problem behaviors35,37 have
found that the ten most used processes of change are
organized into two higher order clusters of processes:
the experiential processes—Consciousness Raising,
Dramatic Relief, Self-Reevaluation, Environmental
Reevaluation, and Social Liberation; and the
behavioral processes—Helping Relationships,
Counterconditioning, Reinforcement Management,
Stimulus Control, and Self Liberation. The
experiential set of processes are most often emphasized

in earlier stages (Precontemplation, Contemplation,
and Preparation) to increase intention and motivation;
and the behavioral set of processes are most often
utilized in later stages (Preparation, Action, and
Maintenance) as observable behavior change efforts
get underway and need to be maintained.
Decisional Balance
Decisional Balance, or the pros and cons of behavior
change, describes the importance or weight of an
individual's reasons for changing or not changing. The
pros and cons relate strongly and predictably to the
stages of change.38,39 These are the decision-making
components of the TTM and also serve as two
important intervening, or intermediate outcome
variables. Individuals' decisions to move from one
stage of change to the next are based on the relative
weight given to the pros and cons of adopting the
healthy behavior. The pros are the positive aspects of
changing behavior, or the benefits of change (reasons
to change). In contrast, the cons include the negative
aspects of changing behavior, or barriers to change
(reasons not to change). These two dimensions have
been consistently supported by studies across many
different problem behaviors in TTM-based research.39
Characteristically, the pros of healthy behavior are low
in the early stages and increase across the stages of
change, and the cons of the healthy behavior are high
in the early stages and decrease across the stages of
change.
The pros and cons are particularly useful when
intervening with individuals in early stages of change.
Decisional balance is an excellent indicator of an

individual's decision to move out of the
precontemplation stage. The relationship between the
stages of change and decisional balance has been
shown to be remarkably consistent across at least 12
different problem behaviors.39 Not only has the
relationship between stage and the pros and cons been
replicated across problem behaviors, but the magnitude
of the change across the stages of change has been
replicated as well. Based on these data, the strong and
weak principles of behavior change were formulated.38
The strong principle states that in progressing from
precontemplation to action, the pros of change
generally increase by about one standard deviation,
whereas the weak principle states that correspondingly,
the cons of change tend to decrease by about one-half
of a standard deviation.
The TTM pros and cons constructs are quite
similar to those also proposed by both the HBM
(benefits/barriers) and the TRA/TPB (benefits/costs);
and the evidence presented by Prochaska and
colleagues39 across 12 problem behaviors does provide
some support for all three models. However, only the
TTM proposes the specific relationship between these
constructs and the stages of change. Also, importantly,
the TTM has gone beyond mere specification of
components to deductively hypothesize the degree of
change in the pros and cons that occurs from
Precontemplation to Action across problem
behaviors.38 This is an important, innovative step for
the TTM and for the development of the science of
behavior change in general.
Situational Confidence and
Temptations

The self-efficacy construct utilized in the TTM40
integrates the models of self-efficacy proposed by
Bandura,18,22 and the coping models of relapse and
maintenance described by Shiffman.41 These variables
have undergone considerable elaboration over time,
with situational temptation to engage in the unhealthy
behavior often viewed as an equally important
companion construct to the more commonly used
situational confidence measures. Confidence and
temptation function inversely across the stages, and
temptation predicts relapse better. Research has
demonstrated that both the confidence and temptation
constructs can be conceptualized psychometrically as
unifactorial and/or multifactorial. Structural modeling
analyses have repeatedly revealed a global higher order
construct (confidence or temptations) which is
comprised of several lower order situationally
determined components.40,42,43 The lower order
situational factors depend more strongly upon the
problem behavior than the higher order construct. A
global score is often useful as a general screening tool,
while the situational subscale scores provide useful
information for targeting intervention feedback to
individuals at different stages of change.

Confidence and temptation both vary across the
stages of change, with confidence rising and
temptation decreasing across longitudinal profiles of
smokers.30 A moderate, reciprocal relationship (r =
-.60) has been found between temptation and
confidence for both smoking cessation and safer sex
behaviors.40,43 Confidence is typically lowest in the
Precontemplation stage, since individuals have little
performance feedback and/or little interest in change.
Confidence is higher during Contemplation,
outperforming demographic variables in its ability to
predict movement into Preparation and Action stages.44
Even in the Maintenance stage where subjects have
successfully altered the problem behavior for at least
six months, temptation is one of the best predictors of
relapse and recycling to earlier stages of change.45
Expert Systems
An expert system computer program mimics or
codifies the reasoning of human experts. The program
uses standardized decision rules or algorithms for
assessment and providing feedback and applies those
algorithms consistently. A TTM expert system is an
integrated assessment and intervention delivery
computer program.46_49 Expert systems have been used
with many different populations and have been found
to be effective for smoking cessation,33,50 sun
protection,51,52 dietary fat reduction53 and
mammography screening.54 The more recent
development of multimedia expert systems provides
nearly immediate feedback to respondents, who sit at
the computer and completes a series of questions
followed by feedback. Participants respond to several
series of questions interspersed with feedback on
different TTM constructs.47,48

Measurement and Research
Foundations
What is not obvious from most descriptions of the
TTM is the careful attention to measurement
development and validation that is taught and
practiced by TTM-Model contributors and
originators.54,55 Construction of measures based on the
TTM have typically employed the sequential methods
of scale development described by Jackson56,57 and
Comrey.58 Initial item pools are generated based on
theoretical construct definitions. Many of the items are
adapted from existing instruments, but item content is
then modified to more closely reflect the problem
behavior and the language used by the population
being studied. This is necessary for intervention
development, as well as being an important foundation
for any research project. There is a large and
increasing volume of research using this model.
Summary/Future Directions
We have presented each of four models of behavior
change, with a clear emphasis on the TTM. The TTM
has an explanatory advantage since it was conceived
later than the other models. The TTM was clearly not
conceived in a vacuum. As part of their
"Transtheoretical" strategy, model originators
consciously incorporated and built upon the strengths
of their predecessors. As put so well by Isaac Newton
in his letter to Robert Hooke (February 5, 1676), "If I
have seen further …it is by standing on the shoulders
of giants." Also, importantly, the TTM is not a fixed
entity. It must grow and develop over time
incorporating and responding to new promising ideas
and new challenging data. It is a sign of our times that
other theories are now utilizing this same strategy and

drawing upon TTM variables, especially stage of
change, to integrate within their own framework.
Others are also now using various eclectic theoretical
frameworks to develop tailored feedback systems.59_62
We have made our biases clear. It is now up to the
reader to investigate the strength of the evidence
further and to keep these questions in mind as he or
she evaluates and compares competing theories:
• How well does this model describe health behavior
change?
• How parsimonious is this theory?
• How much variance is accounted for in studies
applying this model?
• How much intervention development guidance is
provided by this theory?
• How useful is this model in practice?
• How effective in practice are interventions based
on this theory?
• How well measured or how clear are theoretically
defined constructs?

• How well specified and tested are theoretically
defined mediating mechanisms?
These are the questions that the science of behavior
change will ultimately use to decide which models and
which model-based components provide the most
useful description of the health behavior territory.
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32. Marcus BH, Rossi JS, Selby VC, Niaura RS,
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Copyright IEJHE © 2000

__MACOSX/unit1/._Health Behavior Models.pdf
unit1/Unit One Reading Viewing Guide.docx
Unit One Reading/Viewing Guide
View all slides: Unit One (Health in the United States and
Determinants of Health, including Individual Health Behaviors)
PowerPoint
What is Health?
Determinants of Health
Readings:
http://www.healthypeople.gov/2020/about/foundation-health-
measures/Determinants-of-Health#individual%20behavior
Video: https://www.youtube.com/watch?v=5Lul6KNIw_8#t=112
· Policymaking
· Social Determinants
· Physical Determinants
· Health Services

· Individual Behavior
· Biology and Genetics
Leading Health Indicators
Readings: http://www.healthypeople.gov/2020/leading-health-
indicators/2020-LHI-Topics [The Overview and Impact and
Latest Data segments]
· Access to Health Services
· Clinical Preventive Services
· Environmental Quality
· Injury and Violence

· Maternal, Infant, and Child Health
· Mental health
· Nutrition, Physical Activity, & Obesity
· Oral health
· Reproductive and sexual health
· Social determinants
· Substance abuse
· Tobacco
What is Health Behavior?

Health Behavior Models
Reading: Redding, et. al. (2000). Health Behavior Models. The
International Electronic Journal of Health Education, 3: 180-
193. [see course files]
What are the constructs of each model?
· Health Belief Model
· Theory of Reasoned Action/Planned Behavior
· Social Cognitive Theory
· The Transtheoretical Model

What is self efficacy?
What is reciprocal determinism?
Application of a selected model for a selected health behavior
problem, e.g., college student alcohol consumption
Selected Health Behaviors
College Student Alcohol Consumption
Reading: Wechsler, H. & Nelson, T. (2008). What we have
learned from the Harvard school of public health college
alcohol study: Focusing attention on college student alcohol
consumption and the environmental conditions that promote it.
Journal of studies on alcohol and drugs, 69: 1-10. [see course
files]
· Reason for drinking alcohol
· Deaths per year from alcohol-related unintentional injuries,
e.g. motor vehicle crashes
· Perceptions of binge drinkers regarding ever having had a
problem with alcohol

· Features of college environment related to initiation of binge
drinking in college
· College-level factors that influence student drinking
· Environmental factor(s) associated with high rates of College
Age Binge Drinking
· Relationship between student drinking and policy (and
students’ opinions regarding)
Body Mass Index (BMI)
Video: Our Supersized Kids

· % of children who are overweight or obese?
· Likelihood of overweight children becoming obese adults?
· Significant medical complications related to being obese, now
being seen before age 20?
· BMI ranges for normal weight? overweight? obese?
· Childhood obesity levels—low income communities of color?
· Importance of making changes as a family?
· Psychosocial and emotional factors associated with being
overweight as a child?
· Portion distortion? Normal portion size?

· Pounds of sugar consumed by most kids each year?
· Connection between amount of time spent watching TV and
other media and body weight? Amount of time spent exercising?
· Importance of parent role modeling?
__MACOSX/unit1/._Unit One Reading Viewing Guide.docx
unit1/Unit_I_Health in the United States and Determinants of
Health%2C including Individual Health Behaviors.pptx
Unit 1: Health in the United States and Determinants of Health,
including Individual Health Behaviors
Upon completion of this unit, the learner will be able to:
Explore definitions of health and determinants of health,
including individual health behaviors.
Recognize the leading health indicators.

Describe the environmental, social, and psychological factors
that affect health behaviors.
Discuss impact of health determinants, including health
behaviors on the health status of the U.S. and specific groups
and on the U.S. health care system.
Identify the constructs of select health behavior change models
and use a model to promote health behavior change.
Unit 1 Objectives
According to the World Health Organization (WHO), Health is a
state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity.
Source: http://www.who.int/about/definition/en/print.html
What is “Health”?
In a study of healthcare practitioners' definitions of health
across practitioner types (sample size 73), most identified
health as the interrelatedness of physical, mental, and spiritual
factors. Many emphasized health as good functioning, absence
of disease, and chronic disease under control.
See: Julliard, K., Klimenko, E., & Jacob, M. (2006). Definitions
of health among healthcare providers.
Nursing Science Quarterly,19(3): 265-71.
Healthcare Provider Perspective of “Health”

Health is defined as a state of physical, emotional, mental,
social and legal wellness. All aspects of an individual’s life are
related to health and wellness.
Social Behavioral Science Perspective of “Health”
“A range of personal, social, economic, and environmental
factors that influence health status are known as determinants of
health. Determinants of health include such things as biology,
genetics, individual behavior, access to health services, and the
environment in which people are born, live, learn, play, work,
and age.”
Source: http://www.healthypeople.gov/2020/about/Foundation-
Health-Measures
Determinants of “Health”
Policymaking (e.g., seat belt law)
Social (e.g., wages, exposure to crime, quality of schools,
public safety)
Physical (e.g., weather, housing, exposure to toxic substances)
Health services (e.g., access to, quality of, insurance status,
barriers)

Individual behavior (e.g., smoking, substance abuse, diet,
physical activity, hand washing)
Biology and genetics (aging, inherited conditions, gender,
family history)
Determinants of Health
Access to Health Services+
Clinical Preventive Services+
Environmental Quality+
Injury and Violence-
Maternal, Infant, and Child Health+
Mental health+
Nutrition+, Physical Activity+, & Obesity-
Oral health +
Reproductive and sexual health+
Social determinants
Substance abuse -
Tobacco-
+ Positive Determinant
- Negative Determinant
Leading Health Indicators
Social and physical determinants affect a wide range of health,
functioning, and quality of life outcomes. For example:
Access to parks and safe sidewalks for walking is associated
with physical activity in adults.
Education is associated with:

Longer life expectancy
Improved health and quality of life
Health-promoting behaviors like getting regular physical
activity, not smoking, and going for routine checkups and
recommended screenings.
Discrimination, stigma, or unfair treatment in the workplace can
have a profound impact on health; discrimination can increase
blood pressure, heart rate, and stress, as well as undermine self-
esteem and self-efficacy.
Places where people live and eat affect their diet. More than 23
million people, including 6.5 million children, live in “food
deserts”—neighborhoods that lack access to stores where
affordable, healthy food is readily available (such as full-
service supermarkets and grocery stores).
Source: http://www.healthypeople.gov/2020/leading-health-
indicators/2020-lhi-topics/Social-Determinants
Health Impact of Social Determinants
Mental disorders are among the most common causes of
disability. Recent figures suggest that, in 2004, approximately 1
in 4 adults in the United States had a mental health disorder in
the past year1—most commonly anxiety or depression—and 1 in
17 had a serious mental illness.
Mental health and physical health are inextricably linked.
Evidence has shown that mental health disorders—most often
depression—are strongly associated with the risk, occurrence,
management, progression, and outcome of serious chronic
diseases and health conditions, including diabetes,
hypertension, stroke, heart disease, and cancer.

Source: http://www.healthypeople.gov/2020/leading-health-
indicators/2020-lhi-topics/Mental-Health
Health Impact of Mental Health
“Health Behavior is any activity undertaken by an individual,
regardless of actual or perceived health status, for the purpose
of promoting, protecting or maintaining health, whether or not
such behavior is objectively effective towards that end.”
Source: http://www.definitionofwellness.com/dictionary/health-
behavior.html
Definition: Health Behavior
11
Positive
Healthy eating
Regular checkups
Health screening
Safe sex
Exercise
Good hygiene
Sleep
Reducing stress
Negative

Smoking
Unhealthy eating
Use of illegal drugs
Unsafe sex
Risk taking behavior
Alcohol
Not seeking health care services
Noncompliance with health promotion/ medical treatment
Health Behavior Examples
Positive health behaviors promote health. Negative health
behaviors are correlated with health risk and/or disease
incidence. Note that non-compliance/non-use of positive health
behaviors, e.g., not seeking treatment for a medical condition
(e.g., hypertension), non-engagement in an exercise program,
poor hygiene, inadequate sleep are negative health behaviors.
12
Source: http://www.balancedweightmanagement.com/figure1.gif
Health Belief Model

The Health Belief Model is a health behavior change model. It
proposes four determinants of an individual’s likelihood of
making a health behavior change or engaging in health
protective behaviors:
Perceived susceptibility (risk of getting the condition)
Overall, people tend to underestimate their vulnerability, which
negatively effects the likelihood of health behavior change
Perceived severity (seriousness of the condition, and its
potential consequences)
Individuals are more likely to change behavior if they perceive
that serious negative consequences are possible
Perceived costs (barriers/losses that discourage adoption of the
promoted behavior)
Perceived benefits (positive consequences of adopting the
behavior)
Perceived benefits have to exceed costs for change to occur
Cues to action are internal/external stimuli that motivate health
behavior change. For example, a heart attack might stimulate an
individual to begin an exercise program.
14
Social Cognitive Theory

Transtheoretical Model (Intentional Behavior Change)
In this newer model, health behavior change is intentional and
occurs in sequential stages over time. Individuals utilize
experiential (Consciousness Raising, Dramatic Relief, Self-
Reevaluation, Environmental Reevaluation, and Social
Liberation) processes to increase motivation in the early stages
of changes (Precontemplation, Contemplation, and Preparation)
and behavioral processes (Helping Relationships,
Counterconditioning, Reinforcement Management, Stimulus
Control, and Self Liberation) in the later stages (Preparation,
Action, Maintenance) to maintain/stabilize the change.
Confidence grows across the stages of change. Temptation
poses the greatest risk of relapse.
17
Social Factors
Such as poverty status, marital status, race and ethnicity,
education level and access to health services
Psychological Factors
Such as motivation, health knowledge, and mental health status
Environmental Factors
Such as living conditions and exposure to carcinogens
Factors that Affect Health Behavior

Health Care Foundation Greater Kansas City “Social
Determinants” video—Healthy Communities Build Healthy
Individuals
What role does an individual’s home, school, workplace,
neighborhood, and community play in improving health?
What impact does each of the following have on individual and
collective health behavior?
education
stable employment
safe homes and neighborhoods
stores where affordable, healthy food is readily available
transportation
access to preventive services
Social Determinants of Health
19
There is an inextricable link between mental health and physical
health.
Evidence has shown that the risk, occurrence, management,
progression, and outcome of serious chronic diseases and health
conditions, including diabetes, hypertension, stroke, heart
disease, and cancer are strongly associated with mental health
disorders, especially depression.
Individuals (all ages) with untreated mental health disorders are
at greater risk for many unhealthy and unsafe behaviors,
including alcohol or drug abuse, violent or self-destructive
behavior, and suicide.
Source:

http://healthypeople.gov/2020/LHI/mentalHealth.aspx?tab=over
view
Health Impact of Mental Health
Mental health disorders are the leading cause of disability in the
United States and Canada, accounting for 25 percent of all years
of life lost to disability and premature mortality.
Mental illnesses, such as depression and anxiety, affect people’s
ability to participate in health-promoting behaviors.
Alzheimer’s disease is the 6th leading cause of death among
adults aged 18 years and older. Estimates vary, but experts
suggest that up to 5.1 million Americans aged 65 years and
older have Alzheimer’s disease.
People living with dementia are:
at greater risk for general disability
experience frequent injury from falls
are 3 times more likely to have preventable hospitalizations
20
Maintaining a healthy environment is essential to increasing
quality of life and years of healthy life. Globally, nearly 25
percent of all deaths and the total disease burden can be
attributed to environmental factors.
Environmental factors are diverse and far reaching. They
include:
Exposure to hazardous substances in the air, water, soil, and
food, e.g.,
3.9 billion pounds of toxic pollutants were released in to the
environment in 2008
In 2008, approximately 127 million people lived in U.S.
counties that exceeded national air quality standards
Natural and technological disasters

Physical hazards
Nutritional deficiencies
The built environment (Features that appear to impact human
health-influencing behaviors, physical activity patterns, social
networks, and access to resources)
Source:
http://healthypeople.gov/2020/topicsobjectives2020/overview.as
px?topicid=12
Environmental Health Factors
Select Health Behavior Risks of People in the
United States
22
Current cigarette smoking
SOURCE: CDC/NCHS, Health, United States, 2012, Figure 8.
Data from the National Health Interview Survey and the
National Institutes of Health/National Institute on Drug Abuse,
Monitoring the Future Study.

Health Risks associated with Cigarette Smoking:
Cancer
Heart disease
Lung diseases (including emphysema and bronchitis)
Premature birth, low birth weight, stillbirth, and infant death
Secondhand smoke causes:
heart disease and lung cancer in adults
severe asthma attacks, respiratory infections, and ear infections
in infants and children
29.8 percent of persons aged 20 years and over were at a
healthy weight in 2007-10 (age adjusted to the year 2000
standard population)
35.3 percent of persons aged 20 years and over were obese in
2007-10 (age adjusted to the year 2000 standard population)
34.6 percent was the mean percentage of total daily calorie
intake provided by solid fats and added sugars for the
population aged 2 years and older in 2001–04 (age adjusted to
the year 2000 standard population)
Unhealthy Eating

Overweight and obesity
Malnutrition
Iron-deficiency anemia
Heart disease
High blood pressure
Dyslipidemia (poor lipid profiles)
Type 2 diabetes
Osteoporosis
Oral disease
Constipation
Diverticular disease
Some cancers
Health Risks associated with Unhealthy Eating:
A healthful diet reduces an individual’s risk for development of
these diseases. A healthful diet is inclusive of nutrient-dense
foods within and across the food groups, especially whole
grains, fruits, vegetables, low-fat or fat-free milk or milk

products, and lean meats and other protein sources. Limited
caloric intake and limited intake of saturated and trans fats,
cholesterol, added sugars, sodium (salt), and alcohol are also
important to healthy eating.
28
Regular Physical Activity Reduces Adults’ Risk of:
Early death
Coronary heart disease
Stroke
High blood pressure
Type 2 diabetes
Breast and colon cancer
Falls
Depression
Physical Activity of Children & Adolescents
In a nationally representative survey, 77% of children aged 9–
13 years reported participating in free-time physical activity
during the previous 7 days.14
In 2009, only 18% percent of high school students surveyed had
participated in at least 60 minutes per day of physical activity
on each of the 7 days before the survey.3

Twenty-three percent of high school students surveyed had not
participated in 60 or more minutes of any kind of physical
activity on any day during the 7 days before the survey.3
Participation in physical activity declines as young people age.
Source: Centers for Disease Control
Improves bone health
Improves cardiorespiratory and muscular fitness
Decreases levels of body fat
Reduces symptoms of depression
For Children and Adolescents, Regular Physical Activity :
30.9 percent of students in grades 9 through 12 got sufficient
sleep (defined as 8 or more hours of sleep on an average school
night) in 2009
69.6 percent of adults got sufficient sleep (defined as ≥ 8 hours
for those aged 18 to 21 years and ≥ 7 hours for those aged 22
years and older on average during a 24-hour period) in 2008
2.7 vehicular crashes per 100 million miles traveled were due to
drowsy driving in 2008
Sources: CDC, Department of Transportation
Inadequate Sleep

Heart disease
High blood pressure
Obesity
Diabetes
All-cause mortality
Health Risks Associated with Untreated Sleep Disorders and
Chronic Short Sleep:
Teenage pregnancy
Human immunodeficiency virus/acquired immunodeficiency
syndrome (HIV/AIDS)
Other sexually transmitted diseases (STDs)
Domestic violence
Child abuse
Motor vehicle crashes
Physical fights
Crime
Homicide
Suicide

Health Risks Associated with Substance Abuse
Source:
http://www.healthypeople.gov/2020/topicsobjectives2020/overvi
ew.aspx?topicid=40
U.S. high school students surveyed in 2009 reported:
46% had ever had sexual intercourse
34% had had sexual intercourse during the previous 3 months,
and, of these
39% did not use a condom the last time they had sex
77% did not use birth control pills or Depo-Provera to prevent
pregnancy the last time they had sex
14% had had sex with four or more people during their life
An estimated 8,300 young people aged 13–24 years in the 40
states reporting to CDC had HIV infection in 2009
Nearly half of the 19 million new STDs each year are among
young people aged 15–24 years
More than 400,000 teen girls aged 15–19 years gave birth in
2009
Source: CDC
Sexual Risk Behaviors & Unintended Health Outcomes
Influenza and pneumococcal vaccination
Data from the National Health Interview Survey.

Who Gets Routine CheckUps
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447395/ta
ble/t1/
Summarized Results:
A reduced likelihood of having a checkup in the past 12 months
was associated with being between ages 25 and 64, male,
unmarried, and a daily smoker.
People who perceived medical cost barriers also were less likely
to obtain checkups.
Checkups were more likely among persons with incomes greater
than $75 000; persons with health insurance; persons whose
health status was rated as very good, fair, or poor rather than
good or excellent; persons involved in any physical activity;
and persons with chronic diseases.
Compared with nonsmokers, occasional smokers and former
smokers were more likely to have a checkup.

Health Risks associated with uncontrolled high blood pressure:
Artery damage and narrowing (atherosclerosis)
Aneurysm
Coronary artery disease
Enlarged left heart
Heart failure
Transient ischemic attack (TIA)
Stroke.
Dementia
Mild cognitive impairment
Kidney failure
Kidney scarring (glomerulosclerosis)
Kidney artery aneurysm
42
Delay or nonreceipt of needed medical care or prescription
drugs
Data from the National Health Interview Survey.

Noncompliance
30.0% Untreated High Blood Pressure
26.7% Untreated High Cholesterol
About 50% of the 2 billion prescriptions filled each year are not
taken correctly
18.8% Did not Visit a Doctor in the Past Year
26.8% Women did not have a Pap test in Past 3 years
Source: United States, National Center for Health Statistics,
2010
Studies have shown than non-compliance causes:
125,000 deaths annually in the US
23% of nursing home admissions due to noncompliance(Cost
$31.3 billion / 380,000 patients)
10% of hospital admissions due to noncompliance (Cost $15.2
billion / 3.5 million patients)
Health Risks Associated with Noncompliance

46
__MACOSX/unit1/._Unit_I_Health in the United States and
Determinants of Health%2C including Individual Health
Behaviors.pptx
unit1/What We Have Learned From the Harvard School of
Public Health College Alcohol Study-2.pdf
WECHSLER AND NELSON 1
What We Have Learned From the Harvard School
of Public Health College Alcohol Study: Focusing
Attention on College Student Alcohol Consumption and
the Environmental Conditions That Promote It*
HENRY WECHSLER, PH.D., AND TOBEN F. NELSON,
SC.D.†
Department of Society, Human Development and Health,
Harvard School of Public Health, 677 Huntington Avenue,
Boston, Massachusetts 02115
Received: October 29, 2007. Revision: January 18, 2008.
*The Harvard School of Public Health College Alcohol Study
was funded
by multiple grants from the Robert Wood Johnson Foundation.

†Correspondence may be sent to Henry Wechsler at the above
address or
via email at: [email protected] Toben F. Nelson is with the
Divi-
sion of Epidemiology and Community Health, University of
Minnesota,
Minneapolis, MN.
1
ABSTRACT. The Harvard School of Public Health College
Alcohol
Study surveyed students at a nationally representative sample of
4-year
colleges in the United States four times between in 1993 and
2001. More
than 50,000 students at 120 colleges took part in the study. This
article
reviews what we have learned about college drinking and the
implica-
tions for prevention: the need to focus on lower drink
thresholds, the
harms produced at this level of drinking for the drinkers, the
second-
hand effects experienced by other students and neighborhood
residents,
the continuing extent of the problem, and the role of the college
alco-
hol environment in promoting heavy drinking by students. In
particu-
lar, the roles of campus culture, alcohol control policies,
enforcement
of policies, access, availability, pricing, marketing, and special
promo-

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