NIH Publication No. 05-3896

Printed September 2005
Theory
 at a
 Glance


A Guide For Health Promotion Practice 

(Second Edition) 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 
Foreword


Adecade ago, the first edition of Theory at a Glance was published. The guide was 

a welcome resource for public health practitioners seeking a single, concise 

summary of health behavior theories that was neither overwhelming nor superficial. 

As a government publication in the public domain, it also provided cash-strapped 

health departments with access to a seminal integration of scholarly work that was useful to 

program staff, interns, and directors alike. Although they were not the primary target audience, 

members of the public health research community also utilized Theory at a Glance, both as 

a quick desk reference and as a primer for their students. 

The National Cancer Institute is pleased to sponsor the publication of this guide, but its 

relevance is by no means limited to cancer prevention and control. The principles described 

herein can serve as frameworks for many domains of public health intervention, 

complementing focused evidence reviews such as Centers for Disease Control and 

Prevention’s Guide to Community Preventive Services. This report also complements a 

number of other efforts by NCI and our federal partners to facilitate more rigorous testing 

and application of health behavior theories through training workshops and the development 

of new Web-based resources. 

One reason theory is so useful is that it helps us articulate assumptions and hypotheses 

concerning our strategies and targets of intervention. Debates among policymakers 

concerning public health programs are often complicated by unspoken assumptions or 

confusion about which data are relevant. Theory can inform these debates by clarifying key 

constructs and their presumed relationships. Especially when the evidence base is small, 

advocates of one approach or another can be challenged to address the mechanisms by 

which a program is expected to have an impact. By specifying these alternative pathways to 

change, program evaluations can be designed to ensure that regardless of the outcome, 

improvements in knowledge, program design, and implementation will occur. 

I am pleased to introduce this second edition of Theory at a Glance. I am especially 

impressed that the lead authors, Dr. Barbara K. Rimer and Dr. Karen Glanz, have enhanced 

and updated it throughout without diminishing the clarity and efficiency of the original. We 

hope that this new edition will empower another generation of public health practitioners to 

apply the same conceptual rigor to program planning and design that these authors exemplify 

in their own research and practice. 

Robert T. Croyle, Ph.D.


Director


Division of Cancer Control and Population Sciences


National Cancer Institute


Spring 2005 
Acknowledgements


The National Cancer Institute would like to thank Barbara Rimer Dr.P.H. and 

Karen Glanz Ph.D., M.P.H., authors of the original monograph, whose knowledge of 

healthcommunications theory and practice have molded a generation of health promotion 

practitioners. Both have provided hours of review and consultation, and we are grateful to 

them for their contributions. 

Thanks to the staffs of the Office of Communications, particularly Margaret Farrell, 

and the Division of Cancer Control and Population Sciences and Kelly Blake, who guided 

this monograph to completion. We appreciate in particular the work of Karen Harris, 

whose attention to detail and commitment to excellence enhanced the monograph’s 

content and quality. 
Table of Contents


Introduction viii


Audience and Purpose 1


Contents 1


Part 1: Foundations of Theory in Health Promotion and Health Behavior 3


Why Is Theory Important to Health Promotion and Health Behavior Practice? 4


What Is Theory? 4


How Can Theory Help Plan Effective Programs? 4


Explanatory Theory and Change Theory 5


Fitting Theory to the Field of Practice 5


Using Theory to Address Health Issues in Diverse Populations 7


Part 2: Theories and Applications 9


The Ecological Perspective: A Multilevel, Interactive Approach 10


Theoretical Explanations of Three Levels of Influence 12


Individual or Intrapersonal Level 12


Health Belief Model 13


Stages of Change Model 15


Theory of Planned Behavior 16


Precaution Adoption Process Model 18


Interpersonal Level 19


Social Cognitive Theory 19


Community Level 22


Community Organization and Other Participatory Models 23


Diffusion of Innovations 27


Communication Theory 29


Media Effects 30


Agenda Setting 30


New Communication Technologies 31


Part 3: Putting Theory and Practice Together 35


Planning Models 36


Social Marketing 36


PRECEDE-PROCEED 39


Where to Begin: Choosing the Right Theories 43


A Few Final Words 44


Sources 48


References 49

Tables and Figures


Tables 

Table 1 An Ecological Perspective: Levels of Influence 11 

Table 2 Health Belief Model 14 

Table 3 Stages of Change Model 15 

Table 4 Theory of Planned Behavior 17 

Table 5 Social Cognitive Theory 20 

Table 6 Community Organization 24 

Table 7 Concepts in Diffusion of Innovations 27 

Table 8 Key Attributes Affecting the Speed and Extent of an Innovation’s Diffusion 28 

Table 9 Agenda Setting, Concepts, Definitions, and Applications 31 

Table 10 Diagnostic Elements of PRECEDE-PROCEED 42 

Table 11 Summary of Theories: Focus and Key Concepts 45 

Figures 

Figure 1 Using Explanatory Theory and Change Theory to Plan and Evaluate Programs 6 

Figure 2 A Multilevel Approach to Epidemiology 10 

Figure 3 Theory of Reasoned Action and Theory of Planned Behavior 18 

Figure 4 Stages of the Precaution Adoption Process Model 19 

Figure 5 An Integrative Model 21 

Figure 6 Sociocultural Environment Logic Framework 26 

Figure 7 An Asthma Self-Management Video Game for Children 33 

Figure 8 Social Marketing Wheel 38 

Figure 9 The PRECEDE-PROCEED Model 40 

Figure 10 Using Theory to Plan Multilevel Interventions 46 
Introduction


viii 

THEORY AT A GLANCE 

This monograph, Theory at a Glance: Application to Health Promotion and Health 

Behavior (Second Edition), describes influential theories of health-related behaviors, 

processes of shaping behavior, and the effects of community and environmental 

factors on behavior. It complements existing resources that offer tools, techniques, 

and model programs for practice, such as Making Health Communication Programs Work: 

A Planner’s Guide,

i and the Web portal, Cancer Control PLANET (Plan, Link, Act, Network 

with Evidence-based Tools).ii Theory at a Glance makes health behavior theory accessible 

and provides tools to solve problems and assess the effectiveness of health promotion 

programs. (For the purposes of this monograph, health promotion is broadly defined as the 

process of enabling people to increase control over, and to improve, their health. Thus, the 

focus goes beyond traditional primary and secondary prevention programs.) 

For nearly a decade, public health and health care practitioners have consulted the original 

version of Theory at a Glance for guidance on using theories about human behavior to inform 

program planning, implementation, and evaluation. We have received many testimonials 

about the First Edition’s usefulness, and requests for additional copies. This updated edition 

includes information from recent health behavior research and suggests theoretical 

approaches to developing programs for diverse populations. Theory at a Glance can be 

used as a stand-alone handbook, as part of in-house staff development programs, or in 

conjunction with theory texts and continuing education workshops. 

For easy reference, the monograph includes only a small number of current and applicable 

health behavior theories. The theories reviewed here are widely used for the purposes of 

cancer control, defining risk, and segmenting populations. Much of the content for this 

publication has been adapted from the third edition of Glanz, Rimer, and Lewis’ Health 

Behavior and Health Education: Theory, Research, and Practice,

1 published by Jossey-Bass 

in San Francisco. Readers who want to learn more about useful theories for health behavior 

change and health education practice can consult this and other sources that are 

recommended in the References section at the end of the monograph. 

i Making Health Communication Programs Work (http://www.nci.nih.gov/pinkbook/) describes a practical 

approach for planning and implementing health communication efforts. 

ii Cancer Control PLANET (http://cancercontrolplanet.cancer.gov) provides access to data and resources 

that can help planners, program staff, and researchers to design, implement, and evaluate evidence-based 

cancer control programs. 
Audience and Purpose 

This monograph is written primarily for public health workers in state and local health 

agencies; it is also valuable for health promotion practitioners and volunteers who work in 

voluntary health agencies, community organizations, health care settings, schools, and the 

private sector. 

Interventions based on health behavior theory are not guaranteed to succeed, but they are 

much more likely to produce desired outcomes. Theory at a Glance is designed to help users 

understand how individuals, groups, and organizations behave and change—knowledge they 

can use to design effective programs. For information about specific, evidence-based 

interventions to promote health and prevent disease, readers may also wish to consult the 

Guide to Community Preventive Services, published by the Centers for Disease Control and 

Prevention (CDC) at www.thecommunityguide.org. 

Contents 

This monograph consists of three parts. For each theory, the text highlights key concepts 

and their applications. These summaries may be used as “checklists” of important issues to 

consider when planning or evaluating programs or to prompt project teams to think about the 

range of factors that influence health behavior. 

Part 1. Foundations of Theory in Health Promotion and Health Behavior describes ways that 

theories and models can be useful in health behavior/health promotion practice and 

provides basic definitions. 

Part 2. Theories and Applications presents an ecological perspective on health 

behavior/health promotion programs. It describes eight theories and models that 

explain individual, interpersonal, and community behavior and offers approaches to 

solving problems. A brief description of each theory is followed by definitions of key 

concepts and examples or case studies. The section also explores the use of new 

communication technologies. 

Part 3. Putting Theory and Practice Together explains how theory can be used in health 

behavior/health promotion program planning, implementation, and evaluation. 

Two comprehensive planning models, PRECEDE-PROCEED and social marketing, 

are reviewed. 

1 

IN

T

RO THEORY AT A GLANCE 
Part 1

Foundations of Theory 

in Health Promotion 

and Health Behavior 

3 

PA

RT 1 THEORY AT A GLANCE 
4 

THEORY AT A GLANCE 

Why Is Theory Important to 

Health Promotion and Health 

Behavior Practice? 

Effective public health, health promotion, 

and chronic disease management programs 

help people maintain and improve health, 

reduce disease risks, and manage chronic 

illness. They can improve the well-being 

and self-sufficiency of individuals, families, 

organizations, and communities. Usually, 

such successes require behavior change at 

many levels, (e.g., individual, organizational, 

and community). 

Not all health programs and initiatives are 

equally successful, however. Those most 

likely to achieve desired outcomes are 

based on a clear understanding of targeted 

health behaviors, and the environmental 

context in which they occur. Practitioners 

use strategic planning models to develop 

and manage these programs, and 

continually improve them through 

meaningful evaluation. Health behavior 

theory can play a critical role throughout 

the program planning process. 

What Is Theory? 

A theory presents a systematic way of 

understanding events or situations. It is a 

set of concepts, definitions, and propositions 

that explain or predict these events or 

situations by illustrating the relationships 

between variables. Theories must be 

applicable to a broad variety of situations. 

They are, by nature, abstract, and don’t 

have a specified content or topic area. 

Like empty coffee cups, theories have 

shapes and boundaries, but nothing inside. 

They become useful when filled with 

practical topics, goals, and problems. 

• Concepts are the building blocks—the 

primary elements—of a theory. 

• Constructs are concepts developed or 

adopted for use in a particular theory. 

The key concepts of a given theory are 

its constructs. 

• Variables are the operational forms of 

constructs. They define the way a 

construct is to be measured in a specific 

situation. Match variables to constructs 

when identifying what needs to be 

assessed during evaluation of a theorydriven program. 

• Models may draw on a number of theories 

to help understand a particular problem in 

a certain setting or context. They are not 

always as specified as theory. 

Most health behavior and health promotion 

theories were adapted from the social and 

behavioral sciences, but applying them to 

health issues often requires that one be 

familiar with epidemiology and the biological 

sciences. Health behavior and health 

promotion theories draw upon various 

disciplines, such as psychology, sociology, 

anthropology, consumer behavior, and 

marketing. Many are not highly developed 

or have not been rigorously tested. Because 

of this, they often are called conceptual 

frameworks or theoretical frameworks; here 

the terms are used interchangeably. 

How Can Theory Help Plan 

Effective Programs? 

Theory gives planners tools for moving 

beyond intuition to design and evaluate 

health behavior and health promotion 

interventions based on understanding of 

behavior. It helps them to step back and 

consider the larger picture. Like an artist, 

a program planner who grounds health 
interventions in theory creates innovative 

ways to address specific circumstances. 

He or she does not depend on a “paint-bynumbers” approach, re-hashing stale ideas, 

but uses a palette of behavior theories, 

skillfully applying them to develop unique, 

tailored solutions to problems. 

Using theory as a foundation for program 

planning and development is consistent with 

the current emphasis on using evidencebased interventions in public health, 

behavioral medicine, and medicine. Theory 

provides a road map for studying problems, 

developing appropriate interventions, and 

evaluating their successes. It can inform the 

planner’s thinking during all of these stages, 

offering insights that translate into stronger 

programs. Theory can also help to explain 

the dynamics of health behaviors, including 

processes for changing them, and the 

influences of the many forces that affect 

health behaviors, including social and 

physical environments. Theory can also help 

planners identify the most suitable target 

audiences, methods for fostering change, 

and outcomes for evaluation. 

Researchers and practitioners use theory 

to investigate answers to the questions of 

“why,” “what,” and “how” health problems 

should be addressed. By seeking answers 

to these questions, they clarify the nature 

of targeted health behaviors. That is, theory 

guides the search for reasons why people 

do or do not engage in certain health 

behaviors; it helps pinpoint what planners 

need to know before they develop public 

health programs; and it suggests how to 

devise program strategies that reach target 

audiences and have an impact. Theory also 

helps to identify which indicators should be 

monitored and measured during program 

evaluation. For these reasons, program 

planning, implementation, and monitoring 

processes based in theory are more likely 

to succeed than those developed without 

the benefit of a theoretical perspective. 

Explanatory Theory and 

Change Theory 

Explanatory theory describes the reasons 

why a problem exists. It guides the search 

for factors that contribute to a problem (e.g., 

a lack of knowledge, self-efficacy, social 

support, or resources), and can be changed. 

Examples of explanatory theories include 

the Health Belief Model, the Theory of 

Planned Behavior, and the Precaution 

Adoption Process Model. 

Change theory guides the development of 

health interventions. It spells out concepts 

that can be translated into program 

messages and strategies, and offers a basis 

for program evaluation. Change theory 

helps program planners to be explicit about 

their assumptions for why a program will 

work. Examples of change theories include 

Community Organization and Diffusion of 

Innovations. Figure 1. illustrates how 

explanatory theory and change theory can 

be used to plan and evaluate programs. 

Fitting Theory to the Field of Practice 

This monograph includes descriptions and 

applications of some theories that are 

central to health behavior and health 

promotion practice today. No single theory 

dominates health education and promotion, 

nor should it; the problems, behaviors, 

populations, cultures, and contexts of public 

health practice are broad and varied. Some 

theories focus on individuals as the unit of 

change. Others examine change within 

families, institutions, communities, or 

cultures. Adequately addressing an issue 

may require more than one theory, and no 

one theory is suitable for all cases. 

5 

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RT 1 FOUNDATIONS OF APPLYING THEORY IN HEALTH PROMOTION PRACTICE 
Figure 1. Using Explanatory Theory and Change Theory to Plan and Evaluate Programs 

Problem 

Behavior 

or 

Situation 

ChangeTheory 

Which strategies? 

Which messages? 

Assumptions about 

how a program 

should work 

Evaluation 

Planning 

Explanatory 

Theory 

Why? 

What can 

be changed? 

6 

THEORY AT A GLANCE 

Because the social context in which 

behavior occurs is always evolving, theories 

that were important in public health 

education a generation ago may be of 

limited use today. At the same time, new 

social science research allows theorists to 

refine and adapt existing theories. A recent 

Institute of Medicine report2 observed that 

several theorists have converged in their 

views, identifying several variables as 

central to behavior change. As a result, 

some constructs, such as self-efficacy, are 

central to multiple theories. 

Effective practice depends on using 

theories and strategies that are appropriate 

to a situation. 

One of the greatest challenges for those 

concerned with behavior change is learning 

to analyze how well a theory or model “fits” 

a particular issue. A working knowledge of 

specific theories, and familiarity with how 

they have been applied in the past, 

improves skills in this area. Selecting an 

appropriate theory or combination of 

theories helps take into account the multiple 

factors that influence health behaviors. 

The practitioner who uses theory develops a 

nuanced understanding of realistic program 

outcomes that drives the planning process. 

Choosing a theory that will bring a useful 

perspective to the problem at hand does not 

begin with a theory (e.g., the most familiar 

theory, the theory mentioned in a recent 

journal article, etc.). Instead, this process 

starts with a thorough assessment of the 

situation: the units of analysis or change, 

the topic, and the type of behavior to be 

addressed. Because different theoretical 

frameworks are appropriate and practical for 

different situations, selecting a theory that 

“fits” should be a careful, deliberate process. 

Start with the steps in the box at the top of 

the next page. 
A Good Fit: 

Characteristics of a Useful Theory 

A useful theory makes assumptions about 

a behavior, health problem, target 

population, or environment that are: 

• Logical; 

• Consistent with everyday observations; 

• Similar to those used in previous 

successful programs; and 

• Supported by past research in the same 

area or related ideas. 

Using Theory to Address Health 

Issues in Diverse Populations 

The U.S. population is growing more 

culturally and ethnically diverse. An 

increasing body of research shows health 

disparities exist among various ethnic and 

socio-economic groups. These findings 

highlight the importance of understanding 

the cultural backgrounds and life 

experiences of community members, though 

research has not yet established when and 

under what circumstances targeted or 

tailored health communications are more 

effective than generic ones. (Targeting 

involves using information about shared 

characteristics of a population subgroup to 

create a single intervention approach for 

that group. In contrast, tailoring is a process 

that uses an assessment to derive 

information about one specific person, and 

then offers change or information strategies 

for an outcome of interest based on that 

person’s unique characteristics.)3 

Most health behavior theories can be 

applied to diverse cultural and ethnic 

groups, but health practitioners must 

understand the characteristics of target 

populations (e.g., ethnicity, socioeconomic 

status, gender, age, and geographical 

location) to use these theories correctly. 

There are several reasons why culture and 

ethnicity are critical to consider when 

applying theory to a health problem. First, 

morbidity and mortality rates for different 

diseases vary by race and ethnicity; second, 

there are differences in the prevalence of 

risk behaviors among these groups; and 

third, the determinants of health behaviors 

vary across racial and ethnic groups. 

What People in the Field Say About Theory 

“Theory is different from most of the tools 

I use in my work. It’s more abstract, but 

that can be a plus too. A solid grounding 

in a handful of theories goes a long way 

toward helping me think through why I 

approach a health problem the way I do.” 

— County Health Educator 

“I used to think theory was just for 

students and researchers. But now I have 

a better grasp of it; I appreciate how 

practical it can be.” 

— State Chronic Disease Administrator 

“By translating concepts from theory 

into real-world terms, I can get my staff 

and community volunteers to take a closer 

look at why we’re conducting programs 

the way we do, and how they can succeed 

or fail.” 

— City Tobacco Control Coordinator 

“A good grasp of theory is essential for 

leadership. It gives you a broader way 

of viewing your work. And it helps create 

a vision for the future. But, of course, it’s 

only worthwhile if I can translate it clearly 

and simply to my co-workers.” 

— Regional Health Promotion Chief 

“It’s not as hard as I thought it would be 

to keep up with current theories. More 

than ever these days, there are tools and 

workshops to update us often.” 

— Patient Education Coordinator 

7 

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RT 1 FOUNDATIONS OF APPLYING THEORY IN HEALTH PROMOTION PRACTICE 
Part 2

Theories and Applications


9 

PA

RT 2 THEORY AT A GLANCE 
The Ecological Perspective: A 

Multilevel, Interactive Approach 

Contemporary health promotion involves 

more than simply educating individuals 

about healthy practices. It includes efforts 

to change organizational behavior, as well 

as the physical and social environment of 

communities. It is also about developing and 

advocating for policies that support health, 

such as economic incentives. Health 

promotion programs that seek to address 

health problems across this spectrum 

employ a range of strategies, and operate 

on multiple levels. 

The ecological perspective emphasizes the 

interaction between, and interdependence 

of, factors within and across all levels of a 

health problem. It highlights people’s 

interactions with their physical and sociocultural environments. Two key concepts 

of the ecological perspective help to identify 

intervention points for promoting health: 

first, behavior both affects, and is affected 

by, multiple levels of influence; second, 

individual behavior both shapes, and is 

shaped by, the social environment 

(reciprocal causation). 

To explain the first key concept of the 

ecological perspective, multiple levels of 

influence, McLeroy and colleagues (1988)4 

identified five levels of influence for healthrelated behaviors and conditions. Defined 

in Table 1., these levels include: (1) 

intrapersonal or individual factors; (2) 

interpersonal factors; (3) institutional or 

organizational factors; (4) community 

factors; and (5) public policy factors. 

10 

THEORY AT A GLANCE 

Figure 2. A Multilevel Approach to Epidemiology 

Social and Economic Policies 

Institutions 

Neighborhoods and Communities 

Living Conditions 

Social Relationships 

Individual Risk Factors 

Pathophysiological 

Pathways 

Individual/Population 

Health 

Genetic/Constitutional 

Factors 

Environment 

Lifecourse 

Source: Smedley BD, Syme SL (eds.), Institute of Medicine. Promoting Health: Strategies from Social and Behavioral 

Research. Washington, D.C.:, National Academies Press, 2000. 
Table 1. An Ecological Perspective: Levels of Influence 

Concept 

Intrapersonal Level 

Interpersonal Level 

Community Level 

Institutional Factors 

Community Factors 

Public Policy 

Definition 

Individual characteristics that influence behavior, such as 

knowledge, attitudes, beliefs, and personality traits 

Interpersonal processes and primary groups, including 

family, friends, and peers that provide social identity, 

support, and role definition 

Rules, regulations, policies, and informal structures, which 

may constrain or promote recommended behaviors 

Social networks and norms, or standards, which exist as 

formal or informal among individuals, groups, and 

organizations 

Local, state, and federal policies and laws that regulate 

or support healthy actions and practices for disease 

prevention, early detection, control, and management 

In practice, addressing the community level 

requires taking into consideration 

institutional and public policy factors, as well 

as social networks and norms. Figure 2. 

illustrates how different levels of influence 

combine to affect population health. 

Each level of influence can affect health 

behavior. For example, suppose a woman 

delays getting a recommended 

mammogram (screening for breast cancer). 

At the individual level, her inaction may be 

due to fears of finding out she has cancer. 

At the interpersonal level, her doctor may 

neglect to tell her that she should get the 

test, or she may have friends who say they 

do not believe it is important to get a 

mammogram. At the organizational level, 

it may be hard to schedule an appointment, 

because there is only a part-time radiologist 

at the clinic. At the policy level, she may 

lack insurance coverage, and thus be 

unable to afford the fee. Thus, the outcome, 

the woman’s failure to get a mammogram, 

may result from multiple factors. 

The second key concept of an ecological 

perspective, reciprocal causation, suggests 

that people both influence, and are 

influenced by, those around them. For 

example, a man with high cholesterol may 

find it hard to follow the diet his doctor has 

prescribed because his company cafeteria 

doesn’t offer healthy food choices. To 

comply with his doctor’s instructions, he can 

try to change the environment by asking the 

cafeteria manager to add healthy items to 

the menu, or he can dine elsewhere. If he 

and enough of his fellow employees decide 

to find someplace else to eat, the cafeteria 

may change its menu to maintain lunch 

business. Thus, the cafeteria environment 

may compel this man to change his dining 

habits, but his new habits may ultimately 

bring about change in the cafeteria as well. 

11 

PA

RT 2 THEORIES AND APPLICATIONS 
12 

THEORY AT A GLANCE 

An ecological perspective shows the 

advantages of multilevel interventions that 

combine behavioral and environmental 

components. For instance, effective 

tobacco control programs often use 

multiple strategies to discourage smoking.5 

Employee smoking cessation clinics have 

a stronger impact if the workplace has a 

no-smoking policy and the city has a clean 

indoor air ordinance. Adolescents are 

less likely to begin smoking if their 

peers disapprove of the habit and laws 

prohibiting tobacco sales to minors 

are strictly enforced. Health promotion 

programs are more effective when 

planners consider multiple levels of 

influence on health problems. 

Theoretical Explanations of Three 

Levels of Influence 

The next three sections examine 

theories and their applications at the 

individual (intrapersonal), interpersonal, 

and community levels of the ecological 

perspective. At the individual and 

interpersonal levels, contemporary theories 

of health behavior can be broadly 

categorized as “Cognitive-Behavioral.” 

Three key concepts cut across 

these theories: 

1. Behavior is mediated by cognitions; that 

is, what people know and think affects 

how they act. 

2. Knowledge is necessary for, but not 

sufficient to produce, most behavior 

changes. 

3. Perceptions, motivations, skills, and 

the social environment are key influences 

on behavior. 

Community-level models offer frameworks 

for implementing multi-dimensional 

approaches to promote healthy behaviors. 

They supplement educational approaches 

with efforts to change the social and 

physical environment to support positive 

behavior change. 

Individual or Intrapersonal Level 

The individual level is the most basic one 

in health promotion practice, so planners 

must be able to explain and influence the 

behavior of individuals. Many health 

practitioners spend most of their work time 

in one-on-one activities such as counseling 

or patient education, and individuals are 

often the primary target audience for health 

education materials. Because individual 

behavior is the fundamental unit of group 

behavior, individual-level behavior change 

theories often comprise broader-level 

models of group, organizational, community, 

and national behavior. Individuals participate 

in groups, manage organizations, elect and 

appoint leaders, and legislate policy. Thus, 

achieving policy and institutional change 

requires influencing individuals. 

In addition to exploring behavior, individuallevel theories focus on intrapersonal factors 

(those existing or occurring within the 

individual self or mind). Intrapersonal 

factors include knowledge, attitudes, 

beliefs, motivation, self-concept, 

developmental history, past experience, 

and skills. Individual-level theories are 

presented below. 

• The Health Belief Model (HBM) addresses 

the individual’s perceptions of the threat 

posed by a health problem (susceptibility, 

severity), the benefits of avoiding the 

threat, and factors influencing the 

decision to act (barriers, cues to action, 

and self-efficacy). 
• The Stages of Change (Transtheoretical) 

Model describes individuals’ motivation 

and readiness to change a behavior. 

• The Theory of Planned Behavior (TPB) 

examines the relations between an 

individual’s beliefs, attitudes, intentions, 

behavior, and perceived control over 

that behavior. 

• The Precaution Adoption Process Model 

(PAPM) names seven stages in an 

individual’s journey from awareness to 

action. It begins with lack of awareness 

and advances through subsequent stages 

of becoming aware, deciding whether 

or not to act, acting, and maintaining 

the behavior. 

Health Belief Model (HBM) 

The Health Belief Model (HBM) was one 

of the first theories of health behavior, and 

remains one of the most widely recognized 

in the field. It was developed in the 1950s 

by a group of U.S. Public Health Service 

social psychologists who wanted to explain 

why so few people were participating in 

programs to prevent and detect disease. 

For example, the Public Health Service was 

sending mobile X-ray units out to 

neighborhoods to offer free chest X-rays 

(screening for tuberculosis). Despite the fact 

that this service was offered without charge 

in a variety of convenient locations, the 

program was of limited success. The 

question was, “Why?” 

To find an answer, social psychologists 

examined what was encouraging or 

discouraging people from participating in 

the programs. They theorized that people’s 

beliefs about whether or not they were 

susceptible to disease, and their 

perceptions of the benefits of trying to 

avoid it, influenced their readiness to act. 

In ensuing years, researchers expanded 

upon this theory, eventually concluding that 

six main constructs influence people’s 

decisions about whether to take action to 

prevent, screen for, and control illness. They 

argued that people are ready to act if they: 

• Believe they are susceptible to the 

condition (perceived susceptibility) 

• Believe the condition has serious 

consequences (perceived severity) 

• Believe taking action would reduce their 

susceptibility to the condition or its severity 

(perceived benefits) 

• Believe costs of taking action (perceived 

barriers) are outweighed by the benefits 

• Are exposed to factors that prompt action 

(e.g., a television ad or a reminder from 

one’s physician to get a mammogram) 

(cue to action) 

• Are confident in their ability to successfully 

perform an action (self-efficacy) 

Since health motivation is its central focus, 

the HBM is a good fit for addressing 

problem behaviors that evoke health 

concerns (e.g., high-risk sexual behavior 

and the possibility of contracting HIV). 

Together, the six constructs of the HBM 

provide a useful framework for designing 

both short-term and long-term behavior 

change strategies. (See Table 2.) When 

applying the HBM to planning health 

programs, practitioners should ground their 

efforts in an understanding of how 

susceptible the target population feels to the 

health problem, whether they believe it is 

serious, and whether they believe action 

can reduce the threat at an acceptable cost. 

Attempting to effect changes in these factors 

is rarely as simple as it may appear. 

13 

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RT 2 THEORIES AND APPLICATIONS 
14 

THEORY AT A GLANCE 

Concept 

Perceived 

susceptibility 

Perceived severity 

Perceived benefits 

Perceived barriers 

Cues to action 

Self-efficacy 

Definition 

Beliefs about the chances 

of getting a condition 

Beliefs about the 

seriousness of a condition 

and its consequences 

Beliefs about the 

effectiveness of taking 

action to reduce risk or 

seriousness 

Beliefs about the material 

and psychological costs 

of taking action 

Factors that activate 

”readiness to change” 

Confidence in one’s ability 

to take action 

Potential Change Strategies 

• Define what populations(s) are at risk and 

their levels of risk 

• Tailor risk information based on an 

individual’s characteristics or behaviors 

• Help the individual develop an accurate 

perception of his or her own risk 

• Specify the consequences of a condition 

and recommended action 

• Explain how, where, and when to take 

action and what the potential positive 

results will be 

• Offer reassurance, incentives, and 

assistance; correct misinformation 

• Provide ”how to” information, promote 

awareness, and employ reminder systems 

• Provide training and guidance in 

performing action 

• Use progressive goal setting 

• Give verbal reinforcement 

• Demonstrate desired behaviors 

Table 2. Health Belief Model 

High blood pressure screening campaigns often identify people who are at high risk for heart 

disease and stroke, but who say they have not experienced any symptoms. Because they don’t 

feel sick, they may not follow instructions to take prescribed medicine or lose weight. The 

HBM can be useful for developing strategies to deal with noncompliance in such situations. 

According to the HBM, asymptomatic people may not follow a prescribed treatment regimen 

unless they accept that, though they have no symptoms, they do in fact have hypertension 

(perceived susceptibility). They must understand that hypertension can lead to heart attacks 

and strokes (perceived severity). Taking prescribed medication or following a recommended 

weight loss program will reduce the risks (perceived benefits) without negative side effects 

or excessive difficulty (perceived barriers). Print materials, reminder letters, or pill calendars 

might encourage people to consistently follow their doctors’ recommendations (cues to 

action). For those who have, in the past, had a hard time losing weight or maintaining 

weight loss, a behavioral contract might help establish achievable, short-term goals to build 

confidence (self-efficacy). 
Stages of Change (Transtheoretical) Model 

Developed by Prochaska and DiClemente,6 

the Stages of Change Model evolved out 

of studies comparing the experiences of 

smokers who quit on their own with those 

of smokers receiving professional treatment. 

The model’s basic premise is that behavior 

change is a process, not an event. As a 

person attempts to change a behavior, he 

or she moves through five stages: 

precontemplation, contemplation, 

preparation, action, and maintenance (see 

Table 3.). Definitions of the stages vary 

slightly, depending on the behavior at issue. 

People at different points along this 

continuum have different informational 

needs, and benefit from interventions 

designed for their stage. 

Whether individuals use self-management 

methods or take part in professional 

programs, they go through the same stages 

of change. Nonetheless, the manner in 

which they pass through these stages may 

vary, depending on the type of behavior 

change. For example, a person who is trying 

to give up smoking may experience the 

stages differently than someone who is 

seeking to improve their dietary habits by 

eating more fruits and vegetables. 

The Stages of Change Model has been 

applied to a variety of individual behaviors, 

as well as to organizational change. The 

Model is circular, not linear. In other words, 

people do not systematically progress from 

one stage to the next, ultimately 

“graduating” from the behavior change 

process. Instead, they may enter the 

change process at any stage, relapse to 

an earlier stage, and begin the process 

once more. They may cycle through this 

process repeatedly, and the process can 

truncate at any point. 

15 

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Stage 

Precontemplation 

Contemplation 

Preparation 

Action 

Maintenance 

Definition 

Has no intention of taking 

action within the next 

six months 

Intends to take action in 

the next six months 

Intends to take action 

within the next thirty 

days and has taken some 

behavioral steps in 

this direction 

Has changed behavior for 

less than six months 

Has changed behavior for 

more than six months 

Potential Change Strategies 

Increase awareness of need for change; 

personalize information about risks 

and benefits 

Motivate; encourage making specific plans 

Assist with developing and implementing 

concrete action plans; help set 

gradual goals 

Assist with feedback, problem solving, 

social support, and reinforcement 

Assist with coping, reminders, finding 

alternatives, avoiding slips/relapses 

(as applicable) 

Table 3. Stages of Change Model 
16 

THEORY AT A GLANCE 

Suppose a large company hires a health educator to plan a smoking cessation program 

for its employees who smoke (200 people). The health educator decides to offer group 

smoking cessation clinics to employees at various times and locations. Several months 

pass, however, and only 50 of the smokers sign up for the clinics. At this point, the 

health educator faces a dilemma: how can the 150 smokers who are not participating 

in the clinics be reached? 

The Stages of Change Model offers perspective on ways to approach this problem. First, 

the model can be employed to help understand and explain why they are not attending 

the clinics. Second, it can be used to develop a comprehensive smoking program to help 

more current and former smokers change their smoking behavior, and maintain that 

change. By asking a few simple questions, the health educator can assess what stages 

of contemplation potential program participants are in. For example: 

• Are you interested in trying to quit smoking? (Pre-contemplation) 

• Are you thinking about quitting smoking soon? (Contemplation) 

• Are you ready to plan how you will quit smoking? (Preparation) 

• Are you in the process of trying to quit smoking? (Action) 

• Are you trying to stay smoke-free? (Maintenance) 

The employees’ responses will help to pinpoint where the participants are on the 

continuum of change, and to tailor messages, strategies, and programs appropriate to 

their needs. For example, individuals who enjoy smoking are not interested in trying to 

quit, and therefore will not attend a smoking cessation clinic; for them, a more 

appropriate intervention might include educational interventions designed to move 

them out of the “precontemplation” stage and into “contemplation” (e.g., using carbon 

monoxide testing to demonstrate the effect of smoking on health). On the other hand, 

individuals who are ready to plan how to quit smoking (the “preparation” stage) can be 

encouraged to do so, and moved to the next stage, “action.” 

Theory of Planned Behavior (TPB) 

The Theory of Planned Behavior (TPB) and 

the associated Theory of Reasoned Action 

(TRA) explore the relationship between 

behavior and beliefs, attitudes, and 

intentions. Both the TPB and the TRA 

assume behavioral intention is the most 

important determinant of behavior. 

According to these models, behavioral 

intention is influenced by a person’s attitude 

toward performing a behavior, and by beliefs 

about whether individuals who are important 

to the person approve or disapprove of the 

behavior (subjective norm). The TPB and 

TRA assume all other factors (e.g., culture, 

the environment) operate through the 

models’ constructs, and do not 

independently explain the likelihood that 

a person will behave a certain way. 

The TPB differs from the TRA in that it 

includes one additional construct, perceived 

behavioral control; this construct has to 

do with people’s beliefs that they can control 
a particular behavior. Azjen and Driver7 

added this construct to account for 

situations in which people’s behavior, or 

behavioral intention, is influenced by factors 

beyond their control. They argued that 

people might try harder to perform a 

behavior if they feel they have a high 

degree of control over it. (See Table 4.) 

It has application beyond these limited 

situations, however. People’s perceptions 

about controllability may have an important 

influence on behavior. 

Concept 

Behavioral intention 

Attitude 

Subjective norm 

Perceived behavioral 

control 

Definition 

Perceived likelihood of performing 

behavior 

Personal evaluation of the behavior 

Beliefs about whether key people 

approve or disapprove of the 

behavior; motivation to behave in a 

way that gains their approval 

Belief that one has, and can exercise, 

control over performing the behavior 

Measurement Approach 

Are you likely or unlikely to 

(perform the behavior)? 

Do you see (the behavior) as 

good, neutral, or bad? 

Do you agree or disagree that 

most people approve 

of/disapprove of (the behavior)? 

Do you believe (performing the 

behavior) is up to you, or not 

up to you? 

Table 4. Theory of Planned Behavior 

Surveillance data show that young, acculturated Hispanic women are more likely to get 

Pap tests than those who are older and less acculturated.8 A health department decides to 

implement a cervical cancer screening program targeting older Hispanic women. In 

planning the campaign, practitioners want to conduct a survey to learn what beliefs, 

attitudes, and intentions in this population are associated with seeking a Pap test. They 

design the survey to gauge: when the women received their last Pap test (behavior); how 

likely they are to seek a Pap test (intention); attitudes about getting a Pap test (attitude); 

whether or not “most people who are important to me” would want them to get a Pap 

test (subjective norm); and whether or not getting a Pap test is something that is “under 

my control” (perceived behavioral control). The department will compare survey results 

with data about who has or has not received a Pap test to identify beliefs, attitudes, and 

intentions that predict seeking one. 

17 

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Figure 3. Theory of Reasoned Action and Theory of Planned Behavior 

18 

THEORY AT A GLANCE 

Behavioral 

beliefs 

Evaluation of 

behavioral outcomes 

Attitude toward 

behavior 

Normative 

beliefs 

Motivation 

to comply 

Subjective 

norm 

Control beliefs 

Perceived power 

Perceived 

behavioral control 

Behavioral 

intention Behavior 

Note: Upper blue section shows the Theory 

of Reasoned Action; the entire figure 

shows the Theory of Planned Behavior. 

Figure 3. shows the TPB’s explanation for 

how behavioral intention determines 

behavior, and how attitude toward behavior, 

subjective norm, and perceived behavioral 

control influence behavioral intention. 

According to the model, attitudes toward 

behavior are shaped by beliefs about what 

is entailed in performing the behavior and 

outcomes of the behavior. Beliefs about 

social standards and motivation to comply 

with those norms affect subjective norms. 

The presence or lack of things that will 

make it easier or harder to perform the 

behavior affect perceived behavioral control. 

Thus, a causal chain of beliefs, attitudes, 

and intentions drives behavior. 

Precaution Adoption Process Model 

The Precaution Adoption Process Model 

(PAPM) specifies seven distinct stages in 

the journey from lack of awareness to 

adoption and/or maintenance of a behavior. 

It is a relatively new model that has been 

applied to an increasing number of health 

behaviors, including: osteoporosis 

prevention, colorectal cancer screening, 

mammography, hepatitis B vaccination, 

and home testing for radon gas. 

In the first stage of the PAPM, an individual 

may be completely unaware of a hazard 

(e.g., radon exposure, the link between 

unprotected sex and HIV). The person may 

subsequently become aware of the issue 

but remain unengaged by it (Stage 2). Next, 

the person faces a decision about acting 

(Stage 3); may decide not to act (Stage 4), 
Figure 4. Stages of the Precaution Adoption Process Model 

19 

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Stage 1: 

Unaware 

of Issue 

Stage 2: 

Unengaged 

by Issue 

Stage 3: 

Deciding 

About 

Acting 

Stage 5: 

Decided 

to Act 

Stage 6: 

Acting 

Stage 4: 

Decided 

Not to Act 

Stage 7: 

Maintenance 

or may decide to act (Stage 5). The stages 

of action (Stage 6) and maintenance (Stage 

7) follow. (See Figure 4.) According to the 

PAPM, people pass through each stage of 

precaution adoption without skipping any of 

them. It is possible for people to move 

backwards from some later stages to earlier 

ones, but once they have completed the first 

two stages of the model they do not return 

to them. For example, a person does not 

move from unawareness to awareness and 

then back to unawareness. 

The PAPM bears similarities to the Stages 

of Change model, but differs in important 

ways. Stages of Change offers insights for 

addressing hard-to-change behaviors such 

as smoking or overeating; it is less helpful 

when dealing with hazards that have 

recently been recognized or precautions 

that are newly available. The PAPM 

recognizes that people who are unaware of 

an issue, or are unengaged by it, face 

different barriers from those who have 

decided not to act. The PAPM prompts 

practitioners to develop intervention 

strategies that take into account the stages 

that precede active decision-making. 

Interpersonal Level 

At the interpersonal level, theories of health 

behavior assume individuals exist within, 

and are influenced by, a social environment. 

The opinions, thoughts, behavior, advice, 

and support of the people surrounding an 

individual influence his or her feelings and 

behavior, and the individual has a reciprocal 

effect on those people. The social 

environment includes family members, 

coworkers, friends, health professionals, 

and others. Because it affects behavior, 

the social environment also impacts health. 

Many theories focus at the interpersonal 

level, but this monograph highlights Social 

Cognitive Theory (SCT). SCT is one of the 

most frequently used and robust health 

behavior theories. It explores the reciprocal 

interactions of people and their 

environments, and the psychosocial 

determinants of health behavior. 

Social Cognitive Theory (SCT) 

Social Cognitive Theory (SCT) describes a 

dynamic, ongoing process in which personal 

factors, environmental factors, and human 

behavior exert influence upon each other. 

THEORIES AND APPLICATIONS 
20 

THEORY AT A GLANCE 

According to SCT, three main factors affect 

the likelihood that a person will change a 

health behavior: (1) self-efficacy, (2) goals, 

and (3) outcome expectancies. If individuals 

have a sense of personal agency or selfefficacy, they can change behaviors even 

when faced with obstacles. If they do not 

feel that they can exercise control over their 

health behavior, they are not motivated to 

act, or to persist through challenges.9 As a 

person adopts new behaviors, this causes 

changes in both the environment and in the 

person. Behavior is not simply a product of 

the environment and the person, and 

environment is not simply a product of the 

person and behavior. 

SCT evolved from research on Social 

Learning Theory (SLT), which asserts 

that people learn not only from their own 

experiences, but by observing the actions 

of others and the benefits of those actions. 

Bandura updated SLT, adding the construct 

of self-efficacy and renaming it SCT. 

(Though SCT is the dominant version in 

current practice, it is still sometimes called 

SLT.) SCT integrates concepts and 

processes from cognitive, behaviorist, 

and emotional models of behavior change, 

so it includes many constructs. (See Table 

5.) It has been used successfully as the 

underlying theory for behavior change 

in areas ranging from dietary change10 

to pain control.11 

Concept 

Reciprocal 

determinism 

Behavioral 

capability 

Expectations 

Self-efficacy 

Observational 

learning (modeling) 

Reinforcements 

Definition 

The dynamic interaction of the 

person, behavior, and the 

environment in which the 

behavior is performed 

Knowledge and skill to perform 

a given behavior 

Anticipated outcomes of 

a behavior 

Confidence in one’s ability to 

take action and overcome 

barriers 

Behavioral acquisition that 

occurs by watching the actions 

and outcomes of others’ 

behavior 

Responses to a person’s 

behavior that increase or 

decrease the likelihood 

of reoccurrence 

Potential Change Strategies 

Consider multiple ways to promote 

behavior change, including making 

adjustments to the environment or 

influencing personal attitudes 

Promote mastery learning through 

skills training 

Model positive outcomes of 

healthful behavior 

Approach behavior change in small 

steps to ensure success; be specific 

about the desired change 

Offer credible role models who 

perform the targeted behavior 

Promote self-initiated rewards 

and incentives 

Table 5. Social Cognitive Theory 
Reciprocal determinism describes 

interactions between behavior, personal 

factors, and environment, where each 

influences the others. Behavioral capability 

states that, to perform a behavior, a person 

must know what to do and how to do it. 

Expectations are the results an individual 

anticipates from taking action. Bandura 

considers self-efficacy the most important 

personal factor in behavior change, and it 

is a nearly ubiquitous construct in health 

behavior theories. Strategies for increasing 

self-efficacy include: setting incremental 

goals (e.g., exercising for 10 minutes each 

day); behavioral contracting (a formal 

contract, with specified goals and rewards); 

and monitoring and reinforcement (feedback 

from self-monitoring or record keeping). 

Observational learning, or modeling, refers 

to the process whereby people learn 

through the experiences of credible others, 

rather than through their own experience. 

Reinforcements are responses to behavior 

that affect whether or not one will repeat it. 

Positive reinforcements (rewards) increase 

a person’s likelihood of repeating the 

behavior. Negative reinforcements may 

make repeated behavior more likely by 

motivating the person to eliminate a 

negative stimulus (e.g., when drivers put the 

key in the car’s ignition, the beeping alarm 

reminds them to fasten their seatbelt). 

Reinforcements can be internal or external. 

Internal rewards are things people do to 

reward themselves. External rewards (e.g., 

token incentives) encourage continued 

participation in multiple-session programs, 

but generally are not effective for sustaining 

long-term change because they do not 

bolster a person’s own desire or commitment 

to change. Figure 5. illustrates how selfefficacy, environmental, and individual 

factors impact behavior. 

21 

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Figure 5. An Intergrative Model 

Behavioral beliefs 

and their 

evaluative aspects 

Normative beliefs 

and motivation 

to comply 

Efficacy beliefs 

Attitude 

Norm 

Self-efficacy 

Skills 

Intention Behavior 

Environmental 

constraints 

Other individual 

difference variables 

Personality traits 

Attitudes toward 

targets 

Demographic 

variables 

External variable 
A university in a rural area develops a church-based intervention to help congregation 

members change their habits to meet cancer risk reduction guidelines (behavior). Many 

members of the church have low incomes, are overweight, rarely exercise, eat foods that 

are high in sugar and fat, and are uninsured (personal factors). Because of their rural 

location, they often must drive long distances to attend church, visit health clinics, or 

buy groceries (environment). 

The program offers classes that teach healthy cooking and exercise skills (behavioral 

capability). Participants learn how eating a healthy diet and exercising will benefit them 

(expectations). Health advisors create contracts with participants, setting incremental 

goals (self-efficacy). Respected congregation members serve as role models (observational 

learning). Participants receive T-shirts, recipe books, and other incentives, and are taught 

to reward themselves by making time to relax (reinforcement). As church members learn 

about healthy lifestyles, they bring healthier foods to church, reinforcing their healthy 

habits (reciprocal determinism). 

22 

THEORY AT A GLANCE 

Community Level 

Initiatives serving communities and 

populations, not just individuals, are at 

the heart of public health approaches to 

preventing and controlling disease. 

Community-level models explore how 

social systems function and change and 

how to mobilize community members and 

organizations. They offer strategies that 

work in a variety of settings, such as health 

care institutions, schools, worksites, 

community groups, and government 

agencies. Embodying an ecological 

perspective, community-level models 

address individual, group, institutional, 

and community issues. 

Communities are often understood in 

geographical terms, but they can be defined 

by other criteria too. For instance, there are 

communities of shared interests (e.g., the 

artists’ community) or collective identity 

(e.g., the African American community). 

When planning community-level 

interventions, it is critical to learn about 

the community’s unique characteristics. 

This is particularly true when addressing 

health issues in ethnically or culturally 

diverse communities. 

Comprehensive health promotion programs 

often use advocacy techniques to help 

support individual behavior change with 

organizational and regulatory change. In 

recent years, innovative tools and methods 

for evaluation and measurement have been 

developed to capture the successes of 

community-level health promotion efforts.12 13 

Tobacco control/smoking prevention is one 

area where programs have been extensively 

evaluated. Local tobacco control initiatives 

typically pursue four concurrent goals: (1) 

raising the priority of smoking as a health 

concern, (2) helping community members to 

change smoking behavior, (3) strengthening 

legal and economic deterrents to smoking, 

and (4) reinforcing social norms that 

discourage smoking. This multi-level 

approach has been proven very effective. 
The conceptual frameworks in this section 

offer strategies for intervening at the 

community level: 

• Community Organization and Other 

Participatory Models emphasize 

community-driven approaches to 

assessing and solving health and 

social problems. 

• Diffusion of Innovations Theory addresses 

how new ideas, products, and social 

practices spread within an organization, 

community, or society, or from one society 

to another. 

• Communication Theory describes how 

different types of communication affect 

health behavior. 

Community Organization and Other 

Participatory Models 

Community organizing is a process through 

which community groups are helped to 

identify common problems, mobilize 

resources, and develop and implement 

strategies to reach collective goals. Strict 

definitions of community organizing assume 

that the community itself identifies the 

problems to address (not an outside change 

agent). Public health professionals often 

adapt the methods of community organizing 

to launch programs that reflect the priorities 

of community members, but may not be 

initiated by them. Community organizing 

projects that start with the community’s 

priorities, rather than an externally imposed 

agenda, are more likely to succeed. 

Community organizing is consistent with an 

ecological perspective in that it recognizes 

multiple levels of a health problem. It can be 

integrated with SCT-based strategies that 

take into account the dynamic between 

personal factors, environmental factors, 

and human behavior. Theories of social 

networks and social support (exploring the 

influence of social relationships on health 

decision making and behavior) can be 

used to adapt community organizing 

strategies to health education goals. 

Social systems theory (exploring how 

organizations in a community interact with 

each other and the outside world) is also 

useful for this purpose. 

Community organizing is not a single 

mode of practice; it can involve different 

approaches to effecting change. Jack 

Rothman14 produced the best-known 

classification of these change models, 

describing community organizing according 

to three general types: locality development, 

social planning, and social action. These 

models sometimes overlap and can 

be combined. 

• Locality development (or community 

development) is process oriented. With the 

aim of developing group identity and 

cohesion, it focuses on building consensus 

and capacity. 

• Social planning is task oriented. It stresses 

problem solving and usually relies heavily 

on expert practitioners. 

• Social action is both process and task 

oriented. Its goals are to increase the 

community’s capacity to solve problems 

and to achieve concrete changes that 

redress social injustices. 

The different approaches broadly classified 

as community organizing share in common 

several concepts that are key to achieving 

and measuring change. (See Table 6.) 

Empowerment describes a social action 

process through which individuals, 

organizations, or communities gain 

confidence and skills to improve their quality 

of life.15 Community capacity refers to 

23 

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24 

THEORY AT A GLANCE 

Term 

Empowerment 

Community 

capacity 

Participation 

Relevance 

Issue selection 

Critical 

consciousness 

Definition 

A social action process through 

which people gain mastery over 

their lives and their communities 

Characteristics of a community that 

affect its ability to identify, mobilize 

around, and address problems 

Engagement of community 

members as equal partners; reflects 

the principle, “Never do for others 

what they can do for themselves” 

Community organizing that ”starts 

where the people are” 

Identifying immediate, specific, and 

realizable targets for change that 

unify and build community strength 

Awareness of social, political, and 

economic forces that contribute to 

social problems 

Potential Change Strategies 

Community members assume 

greater power, or expand their 

power from within, to create 

desired changes 

Community members participate 

actively in community life, gaining 

leadership skills, social networks, 

and access to power 

Community members develop 

leadership skills, knowledge, and 

resources through their 

involvement 

Community members create 

their own agenda based on felt 

needs, shared power, and 

awareness of resources 

Community members participate 

in identifying issues; targets are 

chosen as part of a larger strategy 

Community members discuss the 

root causes of problems and plan 

actions to address them 

Table 6. Community Organization 

characteristics of a community that allow 

it to identify social problems and address 

them (e.g., trusting relationships between 

neighbors, civic engagement). Participation 

in the organizing process helps community 

members to gain leadership and problemsolving skills. Relevance involves activating 

participants to address issues that are 

important to them. Issue selection entails 

pulling apart a web of interrelated problems 

into distinct, immediate, solvable pieces. 

Critical consciousness emphasizes helping 

community members to identify the root 

causes of social problems. 

The social action model differs from other 

forms of community intervention in that it 

is grassroots based, conflict oriented, and 

geared to mobilizing disadvantaged people 

to act on their own behalf.16 Goals vary, but 

typically include policy and other significant 

changes that participants have identified as 

important. Largely based on the organizing 

work of Saul Alinsky and the Industrial Areas 

Foundation,17 this approach employs directaction strategies as the primary means of 

fostering change. It focuses on building 

power and encouraging community 

members to develop their capacities 

as active citizens.18 
In a social action approach to community 

organizing, self-interest is seen as the 

motivation for action: community members 

become involved when they see that it will 

benefit them to take action, and targeted 

institutions are willing to make changes 

when they believe it is in their self-interest 

to do so. Community organizing seeks to 

expand participants’ sense of self-interest 

to an ever-wider sphere, from the 

individual or family level to their block, 

neighborhood, city, state, and so on.19 

Participants grow through this process, 

learning to take an active role in shaping 

the future of their communities. 

Media Advocacy is an essential tactic in 

community organizing. It involves using the 

mass media strategically to advance public 

policies.20 Because the media bring attention 

to specific issues, they set the agenda for the 

public and policy makers. The media often 

present health information in medical terms, 

focusing on technological breakthroughs and 

personal health habits. Media advocacy 

assumes the root of most health problems is 

not that people lack information, but that they 

lack the power to change social and economic 

conditions. It seeks to balance news coverage 

by framing issues to emphasize social, 

economic, and political—rather than personal 

and behavioral—influences on health.21 

25 

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Responding to high rates of cancer among African Americans, a health department 

wishes to increase consumption of fresh fruits and vegetables in a low-income, urban 

neighborhood. The department surveys community members to find out why they do 

not eat more fruits and vegetables. They learn there are few supermarkets within easy 

walking distance, and residents shop at local stores that do not offer fresh, affordable 

produce. Many do not own cars; they must take the bus, spend money on taxis, or 

carry shopping bags for blocks to shop at the supermarket. 

The health department contacts a community-based organization that has been working 

to improve neighborhood conditions, and shares the findings with them (participation). 

The organization’s leaders invite department staff to attend a community meeting, 

where residents discuss why there are fewer supermarkets in low-income neighborhoods 

(critical consciousness). Residents say they would buy healthier, less expensive foods at 

the supermarket if they could get a ride home (relevance). The community organization 

decides to organize a campaign to convince the local supermarket to start a shuttle 

service (issue selection). 

The health department trains residents to assess the potential cost and ridership of the 

shuttle service (community capacity). Residents plan an event and invite the media. 

They line up in front of the supermarket with shopping carts and signs, and explain 

both the problem and the potential solution to reporters (media advocacy). Stories 

appear in the local newspapers. The supermarket’s management meets with community 

residents and tells them the market loses thousands of dollars each year due to stolen 

shopping carts. Residents explain that the store will have fewer shopping cart losses if 

they start a shuttle (self-interest). The supermarket agrees to give free rides to inner-city 

shoppers. Through their success, residents gain skills and confidence, and are inspired 

to think about other ways to strengthen their community (empowerment). 

THEORIES AND APPLICATIONS 
In participatory action research, the people 

who are being studied take an active role 

in some or all phases of the research. 

Participatory research builds an alliance 

between professional researchers and 

lay participants, and enables a dialogue 

between them.22 When planning and 

implementing health programs, the 

program’s beneficiaries help to direct the 

type of inquiry, collect and analyze data, 

imagine possible solutions, and evaluate 

the costs and benefits of each choice. They 

engage in a learning process, both checking 

and complementing expert knowledge. One 

example of participatory action research is 

the NCI’s COMMIT program, which explored 

whether implementing an intervention 

through community organizations would 

result in a higher “quit rate” among heavy 

smokers than in the comparison 

communities.23 24 

26 Figure 6. Sociocultural Environment Logic Framework 

Guide to Community Preventive Services: Sociocultural Environment Logic Framework 

DETERMINANTS IMMEDIATE OUTCOMES HEALTH OUTCOME 

EQUITY and 

SOCIAL JUSTICE 

1* Neighborhood Living 

Conditions

THEORY AT A GLANCE 

Community Development and 

Employment Opportunities 

2 

3 Civic Engagement and 

Participation in 

Decision-Making 

4 Prevaling Community Norms, 

Customs, and Processes 

Opportunities for Education 

and Developing Capacity 

Health Promotion, Prevention, 

and Care Opportunities 

5


6


*Links 1-6 indicate strategic 

points for intervention 

SOCIETAL 

RESOURCES 

Standard of living 

Culture and history 

Social institutions 

Built environments 

Political structures 

Economic systems 

Technology 

PHYSICAL 

ENVIROMNMENT 

Natural Resources 

SOCIETAL RESOURCES 

concerns the presence 

of essential resources 

while EQUITY and 

SOCIAL JUSTICE 

concerns the distribution 

of those resources 

within the population 

HEALTHIER 

COMMUNITIES 

HEALTHY 

POPULATION 

A pathway that will not be examined 

Source: Institute of Medicine. Speaking of Health: Assessing Health Communications Strategies for Diverse 

Populations. Washington, D.C.: National Academies Press, 2002. 
The CDC Task Force on the Guide to 

Community and Preventive Services created 

an organizing logic framework to illustrate 

how community-level factors influence health 

status. (See Figure 6.) They noted that 

disparities in access to health care; behaviors 

in response to illness; exposure to 

environmental and occupational hazards; 

health promotion and disease prevention 

behaviors; and experience of stress, societal 

support, and social cohesion all contribute 

to disparities in health status. Therefore, 

community-level interventions that address 

neighborhood conditions, employment 

opportunities, behavioral norms, opportunities 

for education and training, and access to 

health promotion, prevention, and care are 

key to addressing health disparities.25 The 

model shows elements and associations 

at play in translating theory into research 

and action. 

Diffusion of Innovations 

In public health and health promotion, 

practitioners who want to make efficient use 

of resources must attend to the reach, 

adoption, implementation, and maintenance 

of programs. It is not enough to develop 

innovative programs; to reduce the burden of 

cancer, these programs must be disseminated 

widely. Cancer control measures will not 

realize their full potential for improving 

population health until effective programs 

are broadly diffused and disseminated. 

Multiple critiques, including one by the 

National Cancer Policy Board, suggest that 

failing to implement proven methods of 

cancer prevention and early detection 

results in tens of thousands of premature 

deaths each year.

26 Diffusion expands the 

number of people who are exposed to and 

reached by successful interventions, 

strengthening their public health impact. 

Diffusion of Innovations Theory addresses 

how ideas, products, and social practices 

that are perceived as “new” spread 

throughout a society or from one society to 

another. According to the late E.M. Rogers, 

diffusion of innovations is “the process by 

which an innovation is communicated 

through certain channels over time among 

the members of a social system.”27 Diffusion 

Theory has been used to study the adoption 

of a wide range of health behaviors and 

programs, including condom use, smoking 

cessation, and use of new tests and 

technologies by health practitioners. 

Table 7. defines concepts that are central 

to this theory. 

Diffusion of innovations that prevent disease 

and promote health requires a multilevel 

change process that usually takes place in 

27 

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Table 7. Concepts in Diffusion of Innovations 

Concept 

Innovation 

Communication channels 

Social system 

Time 

Definition 

An idea, object, or practice that is thought to be new by an 

individual, organization, or community 

The means of transmitting the new idea from one person to another 

A group of individuals who together adopt the innovation 

How long it takes to adopt the innovation 
28 

THEORY AT A GLANCE 

diverse settings, through different strategies. 

At the individual level, adopting a health 

behavior innovation usually involves lifestyle 

change. At the organizational level, it may 

entail starting programs, changing regulations, 

or altering personnel roles. At a community 

level, diffusion can include using the media, 

advancing policies, or starting initiatives. 

According to Rogers, a number of factors 

determine how quickly, and to what extent, 

an innovation will be adopted and diffused. 

By considering the benefits of an innovation 

(see Table 8.), practitioners can position it 

effectively, thereby maximizing its appeal. 

Specifically: 

• The relative advantage of an innovation 

shows its superiority over whatever 

it replaces. 

• Compatibility is an appropriate fit with the 

intended audience. 

• Complexity has to do with how easy it is 

to implement the innovation. 

• Trialability pertains to whether it can be 

tried on an experimental basis. 

• Observability reflects whether the 

innovation will produce tangible results. 

Effective diffusion requires practitioners to use 

both informal and formal communications 

channels and a spectrum of strategies for 

different settings. Disseminating an innovation 

in a variety of ways increases the likelihood 

that it will be adopted and institutionalized. 

Communication usually should include both 

mass media and interpersonal interactions. 

Through the two-step flow of communication, 

information from the media moves in two 

stages. First, opinion leaders, who pay 

close attention to the media, receive the 

information. Second, they convey their own 

interpretations, as well as the media content, 

to others. This process highlights the 

value of social networks for influencing 

adoption decisions. 

Rogers described the process of adoption as 

a classic “bell curve,” with five categories of 

adopters: innovators, early adopters, early 

majority adopters, late majority adopters, and 

laggards. When an innovation is introduced, 

the majority of people will either be early 

majority adopters or late majority adopters; 

fewer will be early adopters or laggards; and 

very few will be innovators (the first people to 

use the innovation). By identifying the 

Table 8. Key Attributes Affecting the Speed and Extent of an Innovation’s Diffusion 

Attribute 

Relative advantage 

Compatibility 

Complexity 

Trialability 

Observability 

Key Question 

Is the innovation better than what it will replace? 

Does the innovation fit with the intended audience? 

Is the innovation easy to use? 

Can the innovation be tried before making a decision to adopt? 

Are the results of the innovation observable and easily measurable? 
A university designs a program to help elementary school children cultivate healthy 

lifestyle habits and avoid chronic disease. The program has many components: it 

addresses the foods that children eat by modifying the fat and sugar content of school 

lunches, it teaches important health information through a classroom-based health 

education curriculum, and it encourages physical activity through a physical education 

component. It is highly successful; follow-up studies show that children who went 

through the program in elementary school continue to have healthier habits in their 

adolescence than those who did not go through the program. 

The fact that the program is successful is not enough to ensure it will change elementary 

school practices. To achieve a broader impact, the program must diffuse to other sites. 

Program planners may seek to demonstrate the relative advantage of the program by 

emphasizing its positive outcomes. They may try to show its compatibility by 

demonstrating that state policy-makers (e.g., the state Board of Education) have 

approved its materials. The program’s complexity can be limited by creating user-friendly 

materials for teachers and cafeteria workers. By making the materials available on a 

Web site, they can enhance its trialability. Professional demonstrations of the program 

components can create an element of observability. 

characteristics of people in each adopter 

category, practitioners can more effectively 

plan and implement strategies that are 

customized to their needs. 

Communication Theory 

Communication theory explores “who says 

what, in which channels, to whom, and with 

what effects.” It investigates how messages 

are created, transmitted, received, and 

assimilated. When applied to public health 

problems, the central question theories of 

communication seek to answer is, “How do 

communication processes contribute to, or 

discourage, behavior change?” Focused on 

improving the health of communities rather 

than examining the underlying processes of 

communication, public health communications 

is the scientific development, strategic 

dissemination, and evaluation of relevant, 

accurate, accessible, and understandable 

health information, communicated to and 

from intended audiences to advance the 

public’s health.28 

Public health communications should 

represent an ecological perspective and 

foster multilevel strategies, such as tailored 

messages at the individual level, targeted 

messages at the group level, social marking 

at the community level, media advocacy at 

the policy level, and mass media campaigns 

at the population level.29 Public health 

communications can increase knowledge 

and awareness of a health issue; influence 

perceptions, beliefs, and attitudes that 

factor into social norms; prompt action; 

demonstrate or illustrate healthy skills; 

increase support for services; debunk 

misconceptions; and strengthen 

organizational relations.30 On the other 

hand, without supports in the social and 

physical environment, health communications 

alone may not be enough to sustain 

individual-level behavior changes, may 

not be effective for relaying complex 

health messages, and cannot compensate 

for lack of access to health care or 

healthy environments.31 

29 

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30 

THEORY AT A GLANCE 

Since other communication strategies are 

discussed elsewhere in this monograph, this 

section examines the role of mass media in 

public health interventions. The media are 

interconnected, large-scale organizations 

that gather, process, and disseminate news, 

information, entertainment, and advertising 

worldwide. Whether they are small 

operations, such as a neighborhood 

newspaper, or large corporations employing 

tens of thousands of people, the media 

influence almost every aspect of human life: 

economic, political, social, and behavioral. 

Media Effects 

The outcomes of media dissemination of 

ideas, images, themes, and stories are 

termed media effects. Media effects research 

investigates not only how the media influence 

the knowledge, opinions, attitudes, and 

behaviors of audience members, but also how 

audience members affect the media. Because 

audience members are active seekers and 

users of health information, the content 

transmitted through the media reflects their 

needs, interests, and preferences. Two 

questions are central to understanding the 

effects of media on audience members: 1) 

What factors affect the likelihood that a 

person will be exposed to a given message? 

2) How do media effects vary with the 

amount of exposure to that message?32 

Funding is a primary factor that determines 

whether or not audience members will be 

exposed to a message through the mass 

media, since money is needed to buy media 

time and space. Many public health programs 

do not have large budgets, so they often must 

rely on strategies for free distribution. Options 

may include public service announcements, 

embedding health messages in entertainment 

programs (e.g., soap operas), or promoting 

news coverage of public health topics in print 

and electronic media. Community institutions 

can adopt and disseminate messages, and 

social networks can also generate excitement 

about some messages, depending on 

their content.33 

How often do people need to hear a message 

before it influences their beliefs or behaviors? 

This depends on several factors. 

Characteristics of target audiences (e.g., 

their readiness for change, the ways they 

process information), the complexity of the 

health issue, the presence of competing 

messages, and the nature of the health 

message influence the relationship between 

exposure to a health message and an 

outcome effect. Repeated exposure to a 

message, especially when it is delivered 

through multiple channels, may intensify 

its impact on audience members.34 

Planners often assume that a certain 

percentage of the target audience will be 

exposed to a message and that another 

fraction of those who receive the message 

will be engaged by it. Yet there are several 

possible paths through which a health 

communications message can influence 

someone’s beliefs and/or behaviors. These 

include immediate learning (people learn 

directly from the message), delayed learning 

(the impact of the message is not processed 

until some time after it has been conveyed), 

generalized learning (in addition to the 

message itself, people are persuaded about 

concepts related to the message), social 

diffusion (messages stimulate discussion 

among social groups, thereby affecting 

beliefs), and institutional diffusion (messages 

instigate a response from public institutions 

that reinforces the message’s impact on the 

target audience.)35 

Agenda Setting 

The mass media can illuminate and focus 

attention on issues, helping to generate 

public awareness and momentum for change. 

A major focus of communications research 
has been on how the mass media influence 

public opinion, especially about politics and 

policymaking. Agenda setting involves setting 

the media agenda (what is covered), the 

public agenda (what people think about), and 

the policy agenda (regulatory or legislative 

actions on issues).36 (See Table 9.) Research 

on agenda setting has shown that the amount 

of media coverage an issue receives 

correlates strongly with the public’s opinion 

of how important that issue is. 

An axiom underlying this area of study is that 

mass media may not tell us what to think, but 

they are surprisingly effective in telling us 

what to think about. A critical construct of 

agenda setting, however, reinterprets this 

idea. Framing is a process in which someone 

tells the audience what aspect of the story is 

important. In other words, they tell the 

audience not only what to think about, but 

how to think about it. The way facts are 

packaged to tell a story creates the frame. 

By framing stories to emphasize social and 

environmental factors that affect health, 

public health advocates can use the media 

to pressure decision makers to develop 

and support healthy policies. 

New Communication Technologies 

New communication technologies have 

opened an extraordinary range of avenues 

for influencing health behavior. “E-health” 

(one element of new communication 

technologies) is the use of emerging 

information and communication technology, 

especially the Internet, to improve or enable 

31 

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Concept 

Media agenda setting 

Public agenda setting 

Policy agenda setting 

Problem definition 

Framing 

Definition 

Institutional factors and 

processes influencing how 

the media define, select, and 

emphasize issues 

The link between issues 

covered in the media and the 

public’s priorities 

The link between issues 

covered in the media and 

the legislative priorities of 

policy makers 

Factors and process leading to 

the identification of an issue 

as a “problem” by social 

institutions 

Selecting and emphasizing 

certain aspects of a story and 

excluding others 

Potential Change Strategies 

Understand media professionals’ 

needs and routines for gathering 

and reporting news 

Use media advocacy or 

partnerships to raise public 

awareness of key health issues 

Advocate for media coverage to 

educate and pressure policy 

makers about changes to the 

physical and social environment 

needed to promote health 

Community leaders, advocacy 

groups, and organizations define 

an issue for the media and 

offer solutions 

Advocacy groups “package” an 

important health issue for the 

media and the public 

Table 9. Agenda Setting, Concepts, Definitions, and Applications 
32 

THEORY AT A GLANCE 

health and health care. The term refers to an 

emerging field in the intersection of medical 

informatics, public health, and business.37 

It bridges clinical and non-clinical sectors, 

and includes both individual and population 

health-oriented tools.38 E-health 

communication strategies include, but are 

not limited to: health information on the 

Internet, online support groups, online 

collaborative communities, information 

tailored by computer technologies, 

educational computer games, computercontrolled in-home telephone counseling, 

and patient-provider e-mail contact.39 

Major benefits of e-health strategies are 

increased reach (the ability to communicate 

to broad, geographically dispersed 

audiences), asynchronous communication 

(interaction not bounded by having to 

communicate at the same time) the ability 

to integrate multiple communication modes 

and formats (e.g., audio, video, text, 

graphics), the ability to track, preserve, and 

analyze communication (computer records 

of interaction, analysis of interaction trends), 

user control of the communication system 

(the ability to customize programs to user 

specifications), and interactivity (e.g., 

increased capacity for feedback).40 

Educational and behavioral interventions 

employing new communication technologies 

are forging new ground and therefore benefit 

from the perspective provided by theories 

of health behavior. Like communications in 

other media, e-health interventions can 

address issues at the individual, group, or 

community/societal level; different theories 

may be appropriate, depending on the 

project’s goals. For example, computertailored print materials encouraging individuals 

to eat more fruits and vegetables could be 

designed using the Stages of Change Model. 

Online support groups may apply theories of 

social support and social networks. 

Community organizing approaches have 

been used to coordinate Internet-based 

campaigns through www.Meetup.com 

(a technology platform that helps people 

self-organize local gatherings). 

Innovative e-health projects are expanding 

the range of tools that planners can use to 

develop cancer control and other 

interventions. For instance, NCI’s Cancer 

Control Planet http://cancercontrolplanet. 

cancer.gov/ links public health professionals to 

comprehensive cancer control resources. NCI 

also has published data from its Health 

Information National Trends Survey (HINTS) 

on the Web at http://cancercontrol.cancer.gov/ 

hints/. The HINTS program helps survey 

researchers, program planners, and social 

scientists understand how adults 18 years 

and older are using different communication 

channels, including the Internet. For example, 

according to recent HINTS data, when asked 

where they would go first if they had a strong 

need to get information about cancer, 34 

percent of respondents said they would go 

to the Internet. 

The HINTS data illustrate consumers’ 

increasing reliance on the Internet as an 

easily accessible source of health information. 

The Internet has been characterized as a 

“hybrid technology” because it has the 

potential to reach millions of people with 

information that can be tailored to individual 

needs and preferences.41 E-health 

interventions frequently offer information, 

education, and support directly to consumers. 

For example, the Association of Online 

Cancer Resources (ACOR), a collection of 

online communities designed to provide timely 

and accurate information in a supportive 

environment, is one case in point. ACOR 

delivers 1.8 million cancer messages each 

week (http://www.acor.org/). 
Not all e-health interventions are Web-based. 

Computer applications have also allowed new 

uses of traditional health communications 

media, such as print and telephone. Tailored 

print communications (TPCs) and telephonedelivered interventions (TDIs) are two 

examples that have the potential for reaching 

linguistically and culturally diverse audiences. 

TPCs are printed materials created especially 

for an individual, based on relevant 

information about that person. Over 40 studies 

of TPCs have been conducted on a wide 

range of health topics, including diet, exercise, 

smoking cessation, mammography, and 

prostate cancer; most have found positive 

outcomes evidence. TDIs include a range 

of human-delivered counseling and reminder 

interventions delivered using the telephone 

and computer-generated voice response 

systems. Studies indicate that TDIs are 

effective across different populations and 

health topics, but do not have a broad-based 

reach. They have not been widely used by 

diverse populations.42 

Interactive games offer another vehicle for 

intervention. Lieberman et al. designed a 

series of Nintendo video games to improve 

children’s and adolescents’ prevention and 

self care behaviors for asthma, diabetes, 

smoking prevention, and other health topics 

(see Figure 7.).43 The games were based 

on well-established theories of learning and 

behavior change, such as Social Cognitive 

Theory. They reduced players’ urgent care 

and emergency medical visits by as much 

as 77 percent.44 Though research has 

demonstrated the effectiveness of some 

new communications technologies, further 

inquiry is needed into the mechanisms’ 

underlying success.45 

Opportunities are increasing for people to 

gain free access to the Internet via libraries 

and kiosks.46 Unequal access remains 

problematic, however. Significant gaps in 

Internet usage between Caucasians, African 

Americans, and Hispanics persist,47 and 

people with lower levels of educational 

attainment are also less likely to have 

Internet access. Because the Internet is 

a text-based medium, literacy issues that 

make it difficult for people to read print 

materials are also barriers to accessing 

Web-based information. There is danger 

that new computer technologies could 

worsen existing inequities in health status 

for diverse populations. It is therefore 

important to involve community members in 

planning e-health interventions and to offer 

them ongoing training and support for using 

these emerging communications tools.48 

33 

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Figure 7. 

An Asthma Self-Management 

Video Game for Children 

(Bronkie the Bronchiasaurus) 

Box art reproduction used by permission of Health Hero Network. Copyright © 1994 by Health Hero Network. All rights reserved. 
Part 3

Putting Theory And 

Practice Together 

35 

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36 

THEORY AT A GLANCE 

Planning Models 

When practitioners begin the process of 

planning an intervention to promote health 

or change health behavior, theory helps 

them interpret the situation and guides their 

decisions about what design, procedures, 

and measurement indicators to select. 

Depending on the unit of practice (e.g., 

individuals, groups, organizations, 

community) and the nature of the health 

problem, different theoretical approaches 

may be appropriate. Practitioners can find 

that using more than one theory to address 

a problem produces a stronger impact. 

This is particularly true when planning 

comprehensive health promotion 

programs that address multiple levels 

(e.g., individual, organizational, community) 

of a health problem. 

Planning models, such as PRECEDEPROCEED and social marketing, help 

practitioners develop programs step by step, 

integrating multiple theories to explain and 

address health problems. Practitioners 

begin by using theory to develop a set of 

assumptions about factors contributing to a 

health problem. They then use research to 

test, adjust, and add to these assumptions. 

Armed with a theoretical framework and 

situation-specific research findings, 

practitioners design a targeted intervention 

strategy. This includes designing an 

evaluation to gauge whether or not the 

approach is effective, and choosing realistic, 

actionable goals that define in advance 

what programmatic success will look like. 

Research (into the needs of the population, 

resources available, and the situation in 

which the health problem occurs) is a 

central feature of comprehensive planning 

models. Theory helps planners think about 

what questions to ask throughout program 

planning, implementation, and evaluation 

phases. During program planning, they 

explore the needs and resources of the 

population and learn how to design effective 

materials and strategies. During 

implementation, they seek to build and 

continually improve the program. After it 

ends, they assess what short-term and longterm effects the program has had on the 

health problem and its contributing factors. 

Both social marketing and the PRECEDEPROCEED model instruct the practitioner 

to begin the planning process by assessing 

the target audience’s needs at multiple 

levels of a health problem. In social 

marketing, this preliminary investigation 

involves conducting consumer research and 

market analysis. In PRECEDE-PROCEED, 

it includes carrying out epidemiological 

assessment; behavioral, educational, 

environmental, and organizational 

diagnosis; and administrative and policy 

assessment. Both planning models combine 

behavior change theories for greater impact 

and use them as a basis for evaluation. 

These planning models are described in 

greater detail in the sections that follow. 

Social Marketing 

Social marketing uses marketing techniques 

to influence the voluntary behavior of target 

audience members for health benefit. It 

is distinct from health education in that it 

goes beyond informing or persuading 

people to reinforcing behavior with 

incentives and other benefits. It also differs 

from commercial marketing because the 

people who gain from it are members of the 

target audience. Another difference is that 

the marketing organization defines success 

in terms of positive effects on society. 

Social marketing is not a theory, but an 

approach to promoting health behavior. 
Alan Andreason defines it as “the 

application of commercial marketing 

technologies to the analysis, planning, 

execution, and evaluation of programs 

designed to influence the voluntary behavior 

of target audiences in order to improve their 

personal welfare and that of society.”49 

This process creates a voluntary exchange 

between a marketing organization and 

members of a target audience based on 

mutual fulfillment of self-interest. In other 

words, the marketing organization exists 

to fulfill its mission (as defined by the 

organization’s leadership), and the target 

audience members act in their own interests. 

Social marketing programs are generally 

“consumer-driven,” not expert-driven. They 

are targeted to serve a defined group of 

people. To avoid delineating the target 

market in an overly broad manner, social 

marketing practitioners segment a larger, 

heterogeneous target market into smaller 

subgroups. Market segmentation is the 

process of dividing a target audience into 

these more homogenous subgroups with 

distinct, unifying characteristics and needs. 

For example, factors such as regional 

location, ethnicity, gender, exercise habits, 

readiness for change, or media habits could 

be used to segment the larger audience 

of “smokers.” Social marketing seeks to 

identify patterns that distinguish one target 

group from another to effectively target 

marketing strategies. 

The social marketing process involves 

identifying an effective “marketing mix” 

(“The four Ps”) of product, price, place, 

and promotion. The optimal marketing mix 

produces a timely exchange that heightens 

benefits, reduces barriers, and offers a 

better choice than the competition. The 

social marketer explores what benefits 

are of most interest to target market 

members and develops strategies and 

methods accordingly. The four Ps of the 

marketing mix are: 

• Product (the right kind of behavioral 

change) includes not only the behavior 

that is being promoted, but also the 

benefits that go along with it. 

• Price (an exchange of benefits and costs) 

refers to barriers or costs involved in 

adopting the behavior (e.g., money, 

time, effort). 

• Place (making new behaviors easy to do) 

is about making the “product” accessible 

and convenient. It means delivering 

benefits in the right place at the right time. 

• Promotion (delivering the message to the 

audience) is how the practitioner notifies 

the target market of the product, as well 

as its benefits, reasonable cost, 

and convenience. 

Ideally, social marketing interventions begin 

with formative research (also called 

audience or consumer research) to 

understand the target market’s perceptions, 

needs, and wants concerning the health 

behavior. Formative research includes 

learning about consumers’ current behavior, 

what enables it, and what reinforces it. 

Practitioners also conduct a second type of 

research, competitive analysis (also called 

environmental analysis), to learn about the 

environment in which members of the target 

market are making behavior decisions. 

This analysis examines competing 

behaviors that are being promoted to the 

target market. (For example, messages 

encouraging people to eat convenient, 

inexpensive fast foods compete with 

messages about eating 5 fruits and 

vegetables a day.) It also investigates how 

consumers’ decisions are shaped by 

factors such as their social and physical 

surroundings or their economic situation. 

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Evaluation is a critical and ongoing 

component of social marketing programs. 

Formative research helps practitioners to 

develop and refine concepts, messages, 

products, services, pricing, and distribution 

channels before they are fully implemented. 

Marketers often use qualitative methods, 

such as focus groups or key informant 

interviews, to pre-test marketing concepts, 

messages, and materials in a cost-effective 

manner. They may also pilot-test materials 

with individuals who share characteristics 

of the target market in order to verify their 

effectiveness, identify diverse channels 

for delivering the message, and measure 

outcomes. Process evaluation methods are 

used to track program outputs and processes 

during implementation. Social marketers also 

conduct summative research, often in the 

form of outcomes monitoring. This analysis 

Figure 8. Social Marketing Wheel 

compares the program’s program objectives 

with its immediate and long-term outcomes 

to determine what worked, what didn’t, and 

whether the program was cost-effective. 

Social marketing programs are most 

successful when they are implemented 

using a research-driven process; then 

consumer research can help to adjust 

program messages and outputs. The social 

marketing process includes four stages: 

planning and strategy development; 

development of pretesting concepts, 

messages, and materials; implementation; 

assessment of in-market effectiveness; 

and feedback to the first stage. (See 

Figure 8.) Within each stage, there is a 

constant feedback loop between research 

and planning. 

38 

THEORY AT A GLANCE 

1 

2 

3 

4 

Planning and 

Strategy 

Development 

Assesing 

Effectiveness 

and Making 

Refinements 

Developing 

and Pretesting 

Concepts, 

Messages, 

and Materials 

Implementing 

the Program 
As an approach that promotes behavior 

change through voluntary exchange and 

positive reinforcement, social marketing 

borrows substantively from behavior change 

theory. Behavioral theory offers insights 

into the current behavior of target market 

members and what might influence or 

change that behavior. For example, a social 

marketer who references Social Cognitive 

Theory might examine how self-efficacy 

and expectations about the outcome of a 

behavior factor into certain health practices 

within a target market. 

The California 5 A Day Campaign, which 

was the model for the national 5 A Day 

program,50 employs social marketing to 

increase Californians’ consumption of 

fruit and vegetables through strategies 

such as supermarket point-of-purchase 

interventions, industry promotional support, 

media outreach, and community programs.51 

Several features of this program have been 

well-received.52 First, it has a focused goal: 

to increase fruit and vegetable consumption 

by raising awareness of the health benefits. 

Second, its approach is built on an 

established theoretical framework—the 

Stages of Change model. Third, messages 

were designed and disseminated using 

consumer-driven communications 

strategies. Fourth, formative research (mall 

intercept interviews, focus groups, and 

baseline survey data) helped the planners 

to understand their audiences and improve 

messages. Lastly, the program uses the 

four Ps of social marketing: 

• Product: Consuming more fruits and 

vegetables each day to minimize the risk 

of cancer and improve health status 

• Price: The costs of eating a healthier diet 

(e.g., financial cost of buying fruits and 

vegetables, time cost of shopping for and 

preparing them, psychological cost of 

“worrying” about getting the recommended 

number of servings) 

• Place: Grocery stores and other points 

of purchase (the 5 A Day message and 

healthy foods compete against unhealthy 

products for space and attention) 

• Promotion: Branding the 5 A Day 

campaign to increase awareness (e.g., 

using a slogan and compelling images 

that are easy to recall) 

Distribution channels include mass media 

advertising, public service announcements, 

newsletters, the Internet, magazines, press 

conferences, outreach activities, special 

events, and community-based groups, such 

as churches. Regular monitoring and 

evaluation help to assess the reach and 

impact of messages; efficient use of time, 

labor, and capital resources; and program 

costs/benefits. 

PRECEDE-PROCEED 

PRECEDE-PROCEED is a planning model, 

not a theory. It does not predict or explain 

factors linked to the outcomes of interest, 

but offers a framework for identifying 

intervention strategies to address these 

factors. Developed by Green, Kreuter, 

and associates,53 PRECEDE-PROCEED 

provides a road map for designing health 

education and health promotion programs. 

It guides planners through a process that 

starts with desired outcomes and works 

backwards to identify a mix of strategies 

for achieving objectives. (See 

http://lgreen.net/index.html.) 

Because the model views health behavior 

as influenced by both individual and 

environmental forces, it has two distinct 

parts: an “educational diagnosis” 

39 

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(PRECEDE) and an “ecological diagnosis” 

(PROCEED). The PRECEDE acronym 

stands for Predisposing, Reinforcing, 

Enabling Constructs in Educational/ 

Environmental Diagnosis and Evaluation. 

Developed in the 1970s, this component 

of the model posits that an educational 

diagnosis is needed to design a health 

promotion intervention, just as a medical 

diagnosis is needed to design a treatment 

plan. PROCEDE stands for Policy, 

Regulatory, and Organizational Constructs 

in Educational and Environmental 

Development. This element was added 

to the framework later, in 1991, to take 

into account the impact of environmental 

factors on health. Together, these two 

components of the model help practitioners 

plan programs that exemplify an 

ecological perspective. 

PRECEDE-PROCEED has nine steps. The 

first five steps are diagnostic, addressing 

both educational and environmental issues. 

These include: (1) social assessment, (2) 

epidemiological assessment, (3) behavioral 

and environmental assessment, (4) 

educational and ecological assessment, and 

(5) administrative and policy assessment. 

The last four comprise implementation and 

evaluation of health promotion intervention. 

These include: (6) implementation, (7) 

process evaluation, (8) impact evaluation, 

and (9) outcome evaluation. (See Figure 9.) 

Figure 9. The PRECEDE-PROCEED Model 

40 

THEORY AT A GLANCE 

PRECEDE 

STEP 5 STEP 4 STEP 3 STEP 2 STEP 1 

Administration Educational and Behavioral and Epidemiological Social 

and Policy Ecological Environmental Assessment Assessment 

Diagnosis Assessment Assessment 

Health 

Promotion 

Health 

education 

Policy 

regulation 

organization 

Predisposing 

factors 

Reinforcing 

factors 

Enabling 

factors 

Behavior and 

lifestyle 

Environment 

Health Quality 

of life 

STEP 6 STEP 7 STEP 8 STEP 9 

Implementation Process Impact Outcome 

Evaluation Evaluation Evaluation 

PROCEED Source: Green LW, Kreuter MW, 1999. 
During the diagnostic steps of the model, 

practitioners employ various methods to 

learn about the community’s perceived and 

actual needs, as well as the regulatory 

context in which the intervention will 

operate. To conduct social assessment, the 

practitioner may use multiple data collection 

activities (e.g., key informant interviews, 

focus groups, participant observation, 

surveys) to understand the community’s 

perceived needs. Epidemiological 

assessment may include secondary data 

analysis or original data collection to 

prioritize the community’s health needs and 

establish program goals and objectives. 

Behavioral and Environmental Assessment 

identifies factors, both internal and external 

to the individual, that affect the health 

problem. Reviewing the literature and 

applying theory are two ways to map out 

these factors. 

In Educational and Ecological Assessment, 

the practitioner identifies antecedent and 

reinforcing factors that must be in place to 

initiate and sustain change. Behavior—such 

as reducing intake of dietary fat, engaging 

in routine physical activity, and obtaining 

annual mammograms—is shaped by 

predisposing, reinforcing, and enabling 

factors. Practitioners can use individual, 

interpersonal, or community-level change 

theories to classify determinants of behavior 

into one of these three categories and rank 

their importance. Because each type of 

factor requires different intervention 

strategies, classifying them helps 

practitioners consider how to address 

community needs. The three types of 

influencing factors include: 

• Predisposing factors, which motivate or 

provide a reason for behavior; they include 

knowledge, attitudes, cultural beliefs, and 

readiness to change. 

• Enabling factors, which enable persons to 

act on their predispositions; these factors 

include available resources, supportive 

policies, assistance, and services. 

• Reinforcing factors, which come into play 

after a behavior has been initiated; they 

encourage repetition or persistence of 

behaviors by providing continuing rewards 

or incentives. Social support, praise, 

reassurance, and symptom relief might all 

be considered reinforcing factors. 

In the final diagnostic step of PRECEDEPROCEED, Administrative and Policy 

Assessment, intervention strategies reflect 

information gathered in previous steps; 

the availability of needed resources; and 

organizational policies and regulations 

that could affect program implementation. 

(See Table 10.) 

The four remaining steps of PRECEDEPROCEED comprise program 

implementation and evaluation. Before 

Implementation (Step 6) begins, 

practitioners should prepare plans for 

evaluating the process (Step 7), impact 

(Step 8), and outcome (Step 9) of the 

intervention. Process Evaluation gauges the 

extent to which a program is being carried 

out according to plan. Impact Evaluation 

looks at changes in factors (i.e., 

predisposing, enabling, and reinforcing 

factors) that influence the likelihood that 

behavioral and environmental change will 

occur. Lastly, outcome evaluation looks at 

whether the intervention has affected health 

and quality-of-life indicators. 

As Table 11 shows, the individual, 

interpersonal, and community-level theories 

discussed in this monograph are most 

useful when applied to PRECEDEPROCEED’s diagnostic steps. Community 

41 

PA

RT 3 PUTTING THEORY AND PRACTICE TOGETHER 
organization relates to Step 1, which may 

entail working with communities to identify 

their own needs, strengths, resources, and 

capacities. Descriptive epidemiology is most 

pertinent to Step 2, but community-level 

theories may be relevant if the community 

helps to choose the health problem that will 

be addressed, or to set priorities among 

health problems. Theory is most directly 

useful when applied to steps 3, 4, and 5, 

since these steps call upon the practitioner 

to make strategic decisions. By using theory, 

the practitioner can make sound choices 

that are based upon more than just intuition 

and personal judgment. 

Theory should guide practitioners’ examination of predisposing, enabling, and 

reinforcing factors. For example, the Health 

Belief Model suggests that certain beliefs 

might influence women’s decisions about 

whether or not to get a mammogram, such 

as perceived chances of developing cancer 

(perceived susceptibility), or how serious 

they believe cancer would be (perceived 

severity). Both beliefs constitute 

predisposing factors. Other HBM constructs 

may identify possible perceived benefits of 

and barriers to screening. Receiving 

42 

THEORY AT A GLANCE 

Planning Step 

1. Social Assessment 

2. Epidemiological 

Assessment 

3. Behavioral/ 

Environmental 

Assessment 

4. Educational/ 

Ecological 

Assessment 

5. Administrative/ 

Policy 

Assessment 

Function 

Assesses people’s views of 

their own needs and quality 

of life 

Documents which health 

problems are most important 

for which groups in a 

community 

Identifies factors that 

contribute to the health 

problem of interest 

Identifies preceding and 

reinforcing factors that must 

be in place to initiate and 

sustain change 

Identifies policies, resources, 

and circumstances in the 

program’s context that may 

help or hinder implementation 

Examples of Relevant Theory 

Community organization 

Community building 

Community-level theories 

(If the community helps to 

choose the health problem that 

will be addressed) 

Interpersonal theories 

- Social Cognitive Theory 

Theories of organizational change 

Community organization 

Diffusion of innovations 

All three levels of change theories: 

- Individual 

- Interpersonal 

- Community 

Community-level theories: 

- Community organization 

- Organizational change 

Table 10. Diagnostic Elements of PRECEDE-PROCEED 
reassurance that they do not have cancer 

(perceived benefit) might be a reinforcing 

factor. Lack of insurance coverage for 

screening mammography (perceived 

barrier) could be a negative enabling factor. 

By exploring the degree to which each of 

these factors affects women’s behaviors, 

program planners can decide how to focus 

program messages for a communications 

campaign or strategies for an administrative 

intervention (such as providing low- or nocost screening or changing insurance 

coverage). The best way to verify and rank 

explanations offered by theory is to gather 

information directly from women in the 

target population. Another, less ideal 

approach is to learn by reading research 

literature on women who share 

characteristics with the target population. 

Where to Begin: Choosing the 

Right Theories 

Interventions that evolve from a 

comprehensive planning process, build 

on prior research, and use health behavior 

theories are more likely to be effective. 

By investigating what factors influence 

the target population’s behavior, including 

their social and physical environments, 

practitioners gain the raw materials they 

need to meet the needs of that population. 

Theory helps practitioners to interpret the 

findings of their research, making the leap 

from facts on a page to understanding the 

dynamic interactions between behavior 

and environmental context. Systematic 

approaches to tailoring, targeting, 

implementing, and evaluating programs 

provide practitioners with a framework for 

translating this insight into actions that 

improve health outcomes. 

To make appropriate use of theory in a 

given situation, practitioners must consider 

both the social or health problem at hand 

and the context in which the intervention 

will take place. Once they have identified 

a problem, they can use a planning system 

such as social marketing or PRECEDEPROCEED to identify social science 

theories that contribute to their 

understanding. These theories can guide 

them to potential points of intervention. 

Consulting the research literature helps 

practitioners to learn about the past 

successes or failures of intervention 

strategies that they consider, and reflect 

on whether those strategies are likely to 

work for the current situation. Pre-testing 

and actively discussing proposed 

strategies with the target audience can 

also help to determine whether or not they 

will be well received. 

Table 11. summarizes the focus and key 

concepts of each of the eight theories 

described in this guide. Refer to this table 

to identify theories that help explain and 

address a health problem. For example, 

several theories could be used to inform the 

design of a program to reduce tobacco use 

among adolescents. By scanning the 

“Focus” column, one can quickly gauge 

which theories might apply to a particular 

situation. For example, The Stages of 

Change model might be very useful, since it 

centers on individuals’ readiness to change. 

On the other hand, the Health Belief Model 

seems less promising, since young people 

may be less concerned about long-term 

health problems. (In fact, they may not feel 

vulnerable to disease at all!) Social 

Cognitive Theory could be helpful because it 

emphasizes the interplay between personal, 

environmental, and behavior factors. 

Likewise, Community Organization could 

offer perspective on activating young people 

43 

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RT 3 PUTTING THEORY AND PRACTICE TOGETHER 
44 

THEORY AT A GLANCE 

around tobacco control issues. Applying 

each of these theories might look like this: 

• Stages of Change: Learn more about 

readiness to change among adolescents 

who smoke in order to plan appropriate 

and effective cessation messages 

and strategies. 

• Social Cognitive Theory: Examine how 

social environment, including peer 

attitudes, influences adolescents’ tobacco 

use. What are the expectations of teens 

who experiment with tobacco, or who use 

it regularly? How do observational learning 

and reinforcement contribute to the 

reasons why they smoke? Might these 

constructs help identify someone who 

can successfully help them to quit? 

• Community Organization: Consider how 

to involve teen smokers in developing and 

carrying out the program. One idea might 

be to organize a coalition of concerned 

parents, teachers, and teens to help 

explore why teens smoke, and identify 

potential solutions. 

The examples above offer a basic 

illustration of how multiple theories might 

be combined to address a single problem. 

The resulting program would be a multifaceted, multilevel effort. 

A Few Final Words 

Once one is familiar with some 

contemporary theories of health behavior, 

the challenge is to use them appropriately 

within a comprehensive planning process. 

Planning systems, such as social marketing 

and PRECEDE-PROCEED, facilitate the 

process of developing successful programs 

because they lead practitioners through a 

step-by-step process of examining health 

and behavior at multiple levels. 

At the most basic level, an ecological 

perspective points to two approaches to 

addressing health problems: change 

people’s behavior or change the 

environment. The most powerful health 

promotion and behavior change 

interventions integrate these approaches 

and treat them both as essential. Figure 10. 

illustrates that strategies intended 

to change people’s behavior can often be 

derived from individual-level theories; those 

aimed at changing the environment draw on 

community-level theories. Theories at the 

interpersonal level (such as Social Cognitive 

Theory) lie in-between, exploring the 

reciprocal exchanges between individuals 

and their environments. 

Practitioners who are aware of reciprocal 

causation (i.e., that individual behavior 

both influences, and is influenced by, the 

environment) are more likely to design 

multidimensional, effective health promotion 

programs. A change strategy based on 

individual-level theory may indirectly lead 

to changes in the environment (e.g., when 

individuals’ improved eating habits drive 

the cafeteria to offer healthier choices). 

By the same token, a strategy based on 

community-level theory may yield improved 

individual health behaviors (e.g., when 

an individual’s involvement in a community 

organizing project to improve access to 

fruits and vegetables in the community 

inspires her to cook healthier foods for 

her family). 

Theoretical frameworks offer flexible 

guidance for applying the abstract 

concepts of theory to a vast array of real 

circumstances. By becoming familiar with 
P U T T I N G T H E O R Y A N D P R A C T I C E T O G E T H E R 45 

PA

RT 3 

Individual 

Level 

Interpersonal 

Level 

Community 

Level 

Theory 

Health Belief Model 

Stages of Change 

Model 

Theory of Planned 

Behavior 

Precaution 

Adoption Process 

Model 

Social Cognitive 

Theory 

Community 

Organization 

Diffusion of 

Innovations 

Communication 

Theory 

Focus 

Individuals’ perceptions of 

the threat posed by a health 

problem, the benefits of 

avoiding the threat, and 

factors influencing the 

decision to act 

Individuals’ motivation and 

readiness to change a 

problem behavior 

Individuals’ attitudes toward 

a behavior, perceptions of 

norms, and beliefs about the 

ease or difficulty of changing 

Individuals’ journey from 

lack of awareness to action 

and maintenance 

Personal factors, 

environmental factors, and 

human behavior exert 

influence on each other 

Community-driven 

approaches to assessing and 

solving health and social 

problems 

How new ideas, products, 

and practices spread within a 

society or from one society 

to another 

How different types of 

communication affect health 

behavior 

Key Concepts 

Perceived susceptibility 

Perceived severity 

Perceived benefits 

Perceived barriers 

Cues to action 

Self-efficacy 

Precontemplation 

Contemplation 

Decision 

Action 

Maintenance 

Behavioral intention 

Attitude 

Subjective norm 

Perceived behavioral control 

Unaware of issue 

Unengaged by issue 

Deciding about acting 

Deciding not to act 

Deciding to act 

Acting 

Maintenance 

Reciprocal determinism 

Behavioral capability 

Expectations 

Self-efficacy 

Observational learning 

Reinforcements 

Empowerment 

Community capacity 

Participation 

Relevance 

Issue selection 

Critical consciousness 

Relative advantage 

Compatibility 

Complexity 

Trialability 

Observability 

Example: Agenda Setting 

Media agenda setting 

Public agenda setting 

Policy agenda setting 

Problem identification, 

definition 

Framing 

Table 11. Summary of Theories: Focus and Key Concepts 
Figure 10. Using Theory to Plan Multilevel Interventions 

46 

THEORY AT A GLANCE 

Change Strategies 

Change 


People’s Behavior


Change 


the Environment


Examples 


of Strategies


•	 Educational sessions 

•	 Interactive kiosks 

•	 Print brochures 

•	 Social marketing 

campaigns 

Ecological 

Level 

Useful Theories 

Individual Stages of Change 

Precaution Adoption Process 

Health Belief Model 

Theory of Planned Behavior 

•	 Mentoring programs Interpersonal Social Cognitive Theory 

•	 Lay health advising 

•	 Media advocacy Community Communication Theory

campaigns Diffusion of Innovations 

•	 Advocating changes to Community Organizing 

company policy 

behavior change theories and planning 

systems, practitioners gain access to tools 

that allow them to generate creative 

solutions to unique situations. They are able 

to go beyond acting on instinct or repeating 

earlier interventions to adopt a systematic, 

scientific approach to their work. Theory 

helps practitioners to ask the right questions 

and effective planning helps them zero in on 

factors that contribute to a problem. Other 

key elements of effective programs include 

matching programs to the audience, making 

information accessible and practical, 

involving participants in active learning, 

and including elements that build skills 

and reinforce behavior change. 

Becoming comfortable with behavior change 

theory as an instrument of practice may take 

some work, but the results are well worth 

it. Behavior change theory is not simply a 

tool for academics and researchers; it 

can be applied to the problems health 

promotion practitioners face every day. 

The abstractions of theory help practitioners 

to understand the dynamics underlying real 

situations and to think about solutions 

in a new way. Armed with this resource, 

you may find yourself saying, as did 

Winston Churchill in 1898, “I pass with relief 

from the tossing sea of Cause and Theory 

to the firm ground of Result and Fact.” 
47 

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RT 3 PUTTING THEORY AND PRACTICE TOGETHER 
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Printed September 2005