MBA 580 Power BI User Manual Introduction1Accessing Power B

MBA 580 Power BI User Manual
Introduction1
Accessing Power BI via the VDI1
Importing Files to Power BI2
Working on the Module Six Milestone Two Assignment4
Creating a Pie Chart4
Exporting Files from Power BI8
Uploading Image Files to OneDrive10
Introduction
Power BI is a tool that enables its users to visualize data and
present it in a manner that is easy to understand and analyze.
Accessing Power BI via the VDI
1. Open the virtual desktop interface (VDI) on your machine.
2. On the VDI home screen, select Power BI Desktop. The
Power BI homepage is displayed.
Importing Files to Power BI
Once Power BI opens, close out of any message windows that
may pop up. On the Power BI homepage, to select the type of
file you want to import:
1. Go to File, then choose Get Data, and then choose Text/CSV.

Note: For the steps to access Power BI via the VDI, refer to
Accessing Power BI via the VDI.
The Open window is displayed.
2. Go to Desktop, then click on Business Analytics Course
Content Folder, and then choose MBA-580. Select the CSV file
to be imported and click Open. The preview window with the
data set content is displayed.
3. Click Load. The data is imported in Power BI. You can now
perform your analysis.
Working on the Module Six Milestone Two Assignment
In MBA 580, you will access Power BI using the VDI in the
Module Six Milestone Two assignment. In this assignment, you
will create four pie charts and perform your analysis.
Creating a Pie Chart
1. Access Power BI and import the required CSV file.
Note: To learn the process for importing files into Power BI,
refer Importing Files to Power BI.
2. In the right pane, under Visualizations, click the pie chart
icon.

In the center pane, the pie chart placeholder is displayed.
Note: To view the name of the icon, place your cursor over the
icon. For example, to view the name pie chart, place your cursor
over the following icon.
3. Using the resizing tool, resize the pie chart placeholder so
that it fits the screen.
The placeholder is resized. You can now move ahead and plot
the pie chart per the required attributes.
4. To add an attribute, in the right pane, under Fields, drag an
attribute and place it under Visualizations in Legend, Details,
Values, or Tooltips.
For example, let’s move the attributes Markets and Competitors
and Market share percentage for cars and trucks now from
Fields to Legend and Values in Visualizations.
This will provide us with the pie chart for analyzing the
existing market share of cars and trucks category for the

companies VW, Toyota, BMW, and your car company.
The fields are then displayed in the boxes under the Legend and
Values, under Visualizations.
5. After moving the two attributes, the pie chart is displayed in
the center pane.
Similarly, plot the pie chart for market share percentage for cars
and trucks in 2030 and compare the two pie charts displaying
the market share percentage for cars and trucks now and the
market share percentage for cars and trucks in 2030.
Later, plot the pie charts for market share percentage for
connected cars and trucks now and market share percentage for
connected cars and trucks in 2030. On plotting the pie charts,
compare them and write your analysis.
Exporting Files from Power BI
Note: We cannot export an individual file from Power BI in the
VDI. All graphs can be exported all at once. You can later take
the screenshots from the downloaded file to add to your
assignments.
1. In the upper left corner of the virtual desktop interface (VDI)
screen, click File.
2. In the displayed list, select Export and then Export to PDF.

3. The charts are opened in one PDF document.
4. Take a screenshot of the chart pages and save it in the VDI.
Once the screenshots are taken, you can upload them to
OneDrive.
Uploading Image Files to OneDrive
1. In the VDI, open the OneDrive-SNHU application.
The Google Chrome browser is opened and the OneDrive login
page is displayed.
2. Enter your SNHU login ID email and click Next. The
Password page is displayed.
3. Enter your SNHU password and click Sign in. The OneDrive
user homepage is displayed.
4. In the top pane, click + New.

5. In the displayed list, click Folder. The Create a Folder dialog
box is displayed.
6. Enter a name for the folder and click Create. The new folder
is created and displayed in OneDrive.
7. Open the new folder.
8. In the top pane, click Upload.
9. In the displayed options, select Files. The Open window is
displayed.
10. Navigate to the saved graphs image files. Select them and
click Open.
The image files are uploaded to OneDrive. A success message
indicating successful upload of the files is displayed.
2

Planning, Implementing,
and Evaluating Health
Promotion Programs
A Primer
SeVenth edition
James F. McKenzie, Ph.d., M.P.h., M.C.h.e.S.
Ball State University
Brad L. neiger, Ph.d., M.C.h.e.S.
Brigham Young University
Rosemary thackeray, Ph.d., M.P.h.
Brigham Young University
Senior Acquisitions Editor: Michelle Cadden
Project Manager: Lauren Beebe
Program Manager: Susan Malloy
Editorial Assistant: Heidi Arndt
Program Management Team Lead: Mike Early
Project Management Team Lead: Nancy Tabor
Production Management: Charles Fisher, Integra
Compositor: Integra
Design Manager: Marilyn Perry
Cover Designer: Yvo Riezebos, Tandem Creative, Inc.
Rights & Permissions Project Manager: William Opaluch
Rights & Permissions Management: Rachel Youdelman
Senior Procurement Specialist: Stacey J. Weinberger
Executive Product Marketing Manager: Neena Bali
Senior Field Marketing Manager: Mary Salzman

Cover Photo Credit: Edhar Shvets / Shutterstock
Copyright ©2017, 2013, 2009 Pearson Education, Inc. All
Rights Reserved. Printed in the United States of America.
This publication is protected by copyright, and permission
should be obtained from the publisher prior to any
prohibited reproduction, storage in a retrieval system, or
transmission in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise. For
information regarding permissions, request forms and
the appropriate contacts within the Pearson Education Global
Rights & Permissions department, please visit www
.pearsoned.com/permissions/.
Unless otherwise indicated herein, any third-party trademarks
that may appear in this work are the property
of their respective owners and any references to third-party
trademarks, logos or other trade dress are for
demonstrative or descriptive purposes only. Such references are
not intended to imply any sponsorship,
endorsement, authorization, or promotion of Pearson’s products
by the owners of such marks, or any
relationship between the owner and Pearson Education, Inc. or
its affiliates, authors, licensees or distributors.
Library of Congress Cataloging-in-Publication Data
McKenzie, James F.
Planning, implementing, and evaluating health promotion
programs: a primer/
James F. McKenzie, Brad L. Neiger, Rosemary Thackeray.—7th
ed.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-13-421992-9—ISBN 0-13-421992-9
I. Neiger, Brad L. II. Thackeray, Rosemary. III. Title.

[DNLM: 1. Health Promotion—United States. 2. Health
Education—United States.
3. Health Planning—United States. 4. Program Evaluation—
United States. WA 590]
613.0973—dc23
2015044450
ISBN-10: 0-13-421992-9
ISBN-13: 978-0-13-421992-9
1 2 3 4 5 6 7 8 9 10—V355—20 19 18 17 16
www.pearsonhighered.com
Acknowledgments of third party content appear on pages 477–
478, which constitutes an extension of this
copyright page.
http://www.pearsonhighered.com
www.pearsoned.com/permissions/
This book is dedicated to seven special people—
Bonnie, Anne, Greg, Mitchell, Julia, Sherry,
and Callie Rose
and to our teachers and mentors—
Marshall H. Becker (deceased), Mary K. Beyer, Noreen Clark
(deceased),
Enrico A. Leopardi, Brad L. Neiger, Lynne Nilson, Terry W.
Parsons,
Glenn E. Richardson, Irwin M. Rosenstock (deceased),
Yuzuru Takeshita, and Doug Vilnius

This page intentionally left blank
Preface xiii
Acknowledgments xvii
Chapter 1 health education, health Promotion, health education
Specialists, and Program Planning 1
Health Education and Health Promotion 4
Health Education Specialists 4
Assumptions of Health Promotion 9
Program Planning 10
Summary 13
Review Questions 13
Activities 13
Weblinks 14
PART I Planning a HealtH Promotion Program 15
Chapter 2 Starting the Planning Process 17
The Need for Creating a Rationale to Gain the Support
of Decision Makers 18
Steps in Creating a Program Rationale 20
Step 1: identify Appropriate Background information 20
Step 2: title the Rationale 26
Step 3: Writing the Content of the Rationale 26
Step 4: Listing the References Used to Create the Rationale 30
Planning Committee 33

Parameters for Planning 36
Summary 37
Review Questions 37
Activities 37
Weblinks 38
Chapter 3 Program Planning Models in health Promotion 41
Evidence-Based Planning Framework for Public Health 43
Mobilizing for Action Through Planning and Partnerships
(MAPP) 45
Contents
v
vi Contents
MAP-IT 46
PRECEDE-PROCEED 48
the eight Phases of PReCede-PRoCeed 48
Intervention Mapping 50
Healthy Communities 51
SMART 53
the Phases of SMARt 55
Other Planning Models 57
An Application of the Generalized Model 58
Final Thoughts on Choosing a Planning Model 62
Summary 63
Review Questions 63
Activities 64

Weblinks 64
Chapter 4 Assessing needs 67
What to Expect from a Needs Assessment 70
Acquiring Needs Assessment Data 71
Sources of Primary data 71
Sources of Secondary data 82
Steps for Conducting a Literature Search 87
Using technology to Map needs Assessment data 88
Conducting a Needs Assessment 90
Step 1: determining the Purpose and Scope of the needs
Assessment 91
Step 2: Gathering data 91
Step 3: Analyzing the data 93
Step 4: identifying the Risk Factors Linked to the health
Problem 96
Step 5: identifying the Program Focus 97
Step 6: Validating the Prioritized needs 98
Application of the Six-Step needs Assessment Process 98
Special Types of Health Assessments 100
health impact Assessment 100
organizational health Assessment 101
Summary 102
Review Questions 102
Activities 103
Weblinks 103
Chapter 5 Measurement, Measures, Measurement instruments,
and Sampling 105
Measurement 106

the importance of Measurement in Program Planning and
evaluation 107
Levels of Measurement 108
types of Measures 111
Contents vii
Desirable Characteristics of Data 111
Reliability 112
Validity 114
Bias Free 117
Measurement Instruments 117
Using an existing Measurement instrument 117
Creating a Measurement instrument 118
Sampling 121
Probability Sample 123
nonprobability Sample 126
Sample Size 127
Pilot Testing 127
Ethical Issues Associated with Measurement 129
Summary 130
Activities 131
Weblinks 131
Chapter 6 Mission Statement, Goals, and objectives 133
Mission Statement 134
Program Goals 135
Objectives 136
different Levels of objectives 136

Consideration of the time needed to Reach the outcome
of an objective 138
developing objectives 139
Questions to be Answered When developing objectives 139
elements of an objective 139
Goals and Objectives for the Nation 142
Summary 148
Activities 149
Weblinks 150
Chapter 7 theories and Models Commonly Used for health
Promotion interventions 151
Types of Theories and Models 154
Behavior Change Theories 154
intrapersonal Level theories 157
interpersonal Level theories 176
Community Level theories 182
Cognitive-Behavioral Model of the Relapse Process 186
Limitations of Theory 187
Summary 188
viii Contents
Activities 189
Weblinks 190
Chapter 8 interventions 191
Types of Intervention Strategies 193

health Communication Strategies 194
health education Strategies 203
health Policy/enforcement Strategies 206
environmental Change Strategies 210
health-Related Community Service Strategies 211
Community Mobilization Strategies 212
other Strategies 215
Creating Health Promotion Interventions 225
intervention Planning 225
Adopting a health Promotion intervention 226
Adapting a health Promotion intervention 226
designing a new health Promotion intervention 228
Limtations of Interventions 233
Summary 234
Activities 235
Weblinks 236
Chapter 9 Community organizing and Community Building 237
Community Organizing Background and Assumptions 238
The Processes of Community Organizing and Community
Building 241
Recognizing the issue 244
Gaining entry into the Community 244
organizing the People 245
Assessing the Community 248
determining Priorities and Setting Goals 252
Arriving at a

Solution
and Selecting intervention Strategies 254
Final Steps in the Community organizing and Building
Processes 254
Summary 255
Activities 255
Weblinks 256
PART II imPlementing a HealtH Promotion Program 259
Chapter 10 identification and Allocation of Resources 261
Personnel 264
internal Personnel 264
Contents ix
external Personnel 265

Combination of internal and external Personnel 266
items Related to Personnel 267
Curricula and Other Instructional Resources 272
Space 275
Equipment and Supplies 276
Financial Resources 276
Participant Fee 277
third-Party Support 277
Cost Sharing 278
Cooperative Agreements 278
organization/Agency Sponsorship 278
Grants and Gifts 279
Combining Sources 282
Preparing and Monitoring a Budget 282
Summary 287
Activities 287
Weblinks 288
Chapter 11 Marketing: developing Programs that Respond
to the Wants and needs of the Priority Population 291
Marketing and Social Marketing 291

The Marketing Process and Health Promotion Programs 293
exchange 293
Consumer orientation 294
Segmentation 296
Marketing Mix 301
Pretesting 310
Continuous Monitoring 312
Summary 314
Activities 315
Weblinks 316
Chapter 12 implementation: Strategies and Associated
Concerns 319
Logic Models 321
Defining Implementation 322
Phases of Program Implementation 322
Phase 1: Adoption of the Program 323
Phase 2: identifying and Prioritizing the tasks to Be Completed
323
Phase 3: establishing a System of Management 326
Phase 4: Putting the Plans into Action 331

Phase 5: ending or Sustaining a Program 335
Implementation of Evidence-Based Interventions 335
x Contents
Concerns Associated with Implementation 336
Safety and Medical Concerns 336
ethical issues 338
Legal Concerns 340
Program Registration and Fee Collection 341
Procedures for Record Keeping 341
Procedural Manual and/or Participants’ Manual 341
Program Participants with disabilities 342
training for Facilitators 342
dealing with Problems 345
documenting and Reporting 345
Summary 346
Activities 347
Weblinks 348

PART III evaluating a HealtH Promotion Program 349
Chapter 13 evaluation: An overview 351
Basic Terminology 352
Purpose of Evaluation 354
Framework for Program Evaluation 356
Practical Problems or Barriers in Conducting an Evaluation 358
Evaluation in the Program Planning Stages 360
Ethical Considerations 360
Who Will Conduct the Evaluation? 361
Evaluation Results 362
Summary 362
Activities 363
Weblinks 363
Chapter 14 evaluation Approaches and designs 365
Formative Evaluation 366
Pretesting 373
Pilot testing 373
Summative Evaluation 374
Selecting an Evaluation Design 375
Experimental, Control, and Comparison Groups 376

Evaluation Designs 378
Internal Validity 381
External Validity 382
Contents xi
Summary 383
Activities 384
Weblinks 384
Chapter 15 data Analysis and Reporting 387
Data Management 388
Data Analysis 389
Univariate data Analyses 390
Bivariate data Analyses 391
Multivariate data Analyses 392
Applications of data Analyses 393
Interpreting the Data 394
Evaluation Reporting 396

designing the Written Report 397
Presenting data 397
how and When to Present the Report 398
Increasing Utilization of the Results 399
Summary 400
Activities 400
Weblinks 401
Appendix A Code of ethics for the health education Profession
403
Appendix B health education Specialist Practice Analysis
(heSPA 2015)–
Responsibilities, Competencies and Sub-competencies 409
Glossary 419
References 433
Name Index 459
Subject Index 465

Text Credits 477
this book is written for students who are enrolled in a
professional course in health
promotion program planning. It is designed to help them
understand and develop the skills
necessary to carry out program planning regardless of the
setting. The book is unique among
the health promotion planning textbooks on the market in that it
provides readers with both
theoretical and practical information. A straightforward, step-
by-step format is used to make
concepts clear and the full process of health promotion planning
understandable. This book
provides, under a single cover, material on all three areas of
program development: planning,
implementing, and evaluating.
Learning Aids

Each chapter includes chapter objectives, a list of key terms,
presentation of content,
chapter summary, review questions, activities, and Weblinks. In
addition, many of the
key concepts are further explained with information presented
in boxes, figures, and
tables. There are also two appendixes: Code of Ethics for the
Health Education Profession
and Health Education Specialist Practice Analysis 2015—
Responsibilities, Competencies, and
Sub-competencies; an extensive list of references; and a
Glossary.
Chapter Objectives
The chapter objectives identify the content and skills that
should be mastered after read-
ing the chapter, answering the review questions, completing the
activities, and using
the Weblinks. Most of the objectives are written using the
cognitive and psychomotor
(behavior) educational domains. For most effective use of the
objectives, we suggest that
they be reviewed before reading the chapter. This will help

readers focus on the major
points in each chapter and facilitate answering the questions and
completing the activi-
ties at the end.
Key Terms
Key terms are introduced in each chapter and are important to
the understanding of the
content. The terms are presented in a list at the beginning of
each chapter and are printed
in boldface at the appropriate points within the chapter. In
addition, all the key terms are
presented in the Glossary. Again, as with the chapter objectives,
we suggest that readers skim
PrefaCe
xiii
xiv Preface
the key terms list before reading the chapter. Then, as the

chapter is read, particular attention
should be paid to the definition of each term.
Presentation of Content
Although each chapter could be expanded—in some cases,
entire books have been written
on topics we have covered in a chapter or less—we believe that
each chapter contains the
necessary information to help students understand and develop
many of the skills required
to be successful health promotion planners, implementers, and
evaluators.
Responsibilities and Competencies Boxes
Within the first few pages of all except the first chapter, readers
will find a box that contains
the responsibilities and competencies for health education
specialists that are applicable to
the content of the chapter. The responsibilities and
competencies presented in each chapter
are the result of the most recent practice analysis—the Health
Education Specialist Practice
Analysis 2015 (HESPA 2015), which is published in A

Competency-Based Framework for Health
Education Specialists—2015 (NCHEC & SOPHE, 2015). These
boxes will help readers under-
stand how the chapter content applies to the responsibilities and
competencies required of
health education specialists. In addition, these boxes should
help guide candidates as they
prepare to take either the Certified Health Education Specialist
(CHES) or Master Certified
Health Education Specialist (MCHES) exam. A complete listing
of the Responsibilities,
Competencies, and Sub-competencies are presented in Appendix
B.
Chapter Summary
At the end of each chapter, readers will find a one- or two-
paragraph review of the major con-
cepts covered in the chapter.
Review Questions
The questions at the end of each chapter provide readers with
some feedback regarding their
mastery of the content. These questions also reinforce the

objectives and key terms presented
in each chapter.
Activities
Each chapter includes several activities that allow students to
use their new knowledge and
skills. The activities are presented in several different formats
for the sake of variety and to ap-
peal to the different learning styles of students. It should be
noted that, depending on the ones
selected for completion, the activities in one chapter can build
on those in a previous chapter
and lead to the final product of a completely developed health
promotion program plan.
Weblinks
The final portion of each chapter consists of a list of updated
links on the World Wide Web.
These links encourage students to explore a number of different
Websites that are available
to support planning, implementing, and evaluating programs.

Preface xv
new to this edition
In revising this textbook, we incorporated as many suggestions
from reviewers, colleagues, and
former students as possible. In addition to updating material
throughout the text, the follow-
ing points reflect the major changes in this new edition:
⦁ Chapter 1 has been updated to include information about the
revised areas of
responsibility, competencies, and subcompetencies based on the
Health Education
Specialist Practice Analysis (HESPA 2015) (NCHEC & SOPHE,
2015), and the implications
of HESPA 2015 for the Health Education Profession.
⦁ Chapter 2 has been expanded to include additional
information on sources of evidence
to support a program rationale, additional information on
determining the financial
burden of ill health, a new example of a written program
rationale, and information on

the importance of partnering with others when creating a
program.
⦁ Chapter 3 has been restructured to place more emphasis on
the prominent planning
models used in health promotion. The chapter also now includes
the Evidence-
Based Planning Framework in Public Health, the CHANGE tool
used to plan healthy
community initiatives, and more evidence-based examples of
how planning models are
used in practice.
⦁ Chapter 4 has new information on the importance of needs
assessment in the accredita-
tion of health departments and the IRS requirement for not-for-
profit hospitals, new
information on using technology while conducting a needs
assessment, and a new
section on organizational health assessments.
⦁ Chapter 5 includes new information on wording questions for
different levels of
measurement, how to present data in charts and graphs, how to
write questions and

response items for data collection instruments, and guidelines
for the layout and visual
presentation of data collection instruments.
⦁ Chapter 6 now includes a new section on short-term,
intermediate, and long-term
objectives, and a new SMART objective checklist.
⦁ Chapter 7 includes additional information on the expansion of
the socio-ecological
approach, additional information on the constructs of the social
cognitive theory,
the inclusion of the diffusion of innovations theory which was
previously found in
Chapter 11, and a new section on the limitations of theory.
⦁ Chapter 8 features new information on motivational
interviewing, new content on
the built environment, new content on behavioral economics,
information on the
Affordable Care Act and its impact on incentives, and new
content on the limitations
of interventions.
⦁ Chapter 9 includes new information on the renaming of

community organizing
strategies and updated figures on community organizing and
community building
typology and on mapping community capacity.
⦁ Chapter 10 now includes expanded information on using
volunteers as a program
resource, and program funding by governmental agencies.
⦁ Chapter 11 has been reworked and now has several new boxes
and tables that include a
social marketing planning sheet, factors to consider when
selecting pre-testing methods,
a 4Ps marketing mix example, types of questions to ask for
formative research, and
examples of segmentation.
xvi Preface
⦁ Chapter 12 content includes expanded information on logic
models, new content on
professional development including a template for a
professional development plan, new

content on monitoring implementation, and new content on the
implementation of an
evidence-based intervention.
⦁ Chapter 13 now includes updated information on CDC’s
Framework for Program
Evaluation and new information on CDC’s characteristics of a
good evaluator. In
addition, new information has been added to support the
importance of evaluation and
the use of evaluation standards.
⦁ Chapter 14 includes updated terminology and context for
internal and external validity,
and updated context for experimental, quasi-experimental, and
non-experimental
evaluation designs.
⦁ Chapter 15 includes updated information for data
management, data cleaning, and
the transition to data analysis. In addition, new information is
presented to show
the relationship between levels of measurement and the
selection of statistical tests
including parametric and non-parametric tests.

⦁ All chapters include more practical planning examples and,
where appropriate, new
application boxes have been added to chapters.
⦁ A new appendix has been added that contains all of the
Responsibilities, Competencies,
and Sub-competencies that resulted from the Health Education
Specialist Practice
Analysis 2015.
⦁ To assist students, the Companion Website
(https://media.pearsoncmg.com/bc/bc_
mckenzie_health_7) has been updated and includes chapter
objectives, practice quizzes,
Responsibilities and Competencies boxes, Weblinks, a new
example program plan, the
Glossary, and flashcards.
⦁ To assist instructors, all of the teaching resources have been
updated by Michelle LaClair,
Pennsylvania State College of Medicine. These resources are
available for download on
the Pearson Instructor Resource Center. Go to
http://www.pearsonhighered.com and

search for the title to access and download the PowerPoint®
presentations, electronic
Instructor Manual and Test Bank, and TestGen Computerized
Test Bank.
Students will find this book easy to understand and use. We are
confident that if the
chapters are carefully read and an honest effort is put into
completing the activities and
visiting the Weblinks, students will gain the essential
knowledge and skills for program
planning, implementation, and evaluation.
https://media.pearsoncmg.com/bc/bc_mckenzie_health_7
https://media.pearsoncmg.com/bc/bc_mckenzie_health_7
http://www.pearsonhighered.com
A project of this nature could not have been completed without
the assistance and
understanding of many individuals. First, we thank all our past
and present students, who
have had to put up with our working drafts of the manuscript.
Second, we are grateful to those professionals who took the

time and effort to review
and comment on various editions of this book. For the first
edition, they included Vicki
Keanz, Eastern Kentucky University; Susan Cross Lipnickey,
Miami University; Fred Pearson,
Ricks College; Kerry Redican, Virginia Tech; John Sciacca,
Northern Arizona University;
and William K. Spath, Montana Tech. For the second edition,
reviewers included Gordon
James, Weber State; John Sciacca, Northern Arizona University;
and Mark Wilson, University
of Georgia. For the third edition, reviewers included Joanna
Hayden, William Paterson
University; Raffy Luquis, Southern Connecticut State
University; Teresa Shattuck, University
of Maryland; Thomas Syre, James Madison University; and
Esther Weekes, Texas Women’s
University. For the fourth edition, reviewers included Robert G.
LaChausse, California
State University, San Bernardino; Julie Shepard, Director of
Health Promotion, Adams
County Health Department; Sherm Sowby, California State
University, Fresno; and William
Kane, University of New Mexico. For the fifth edition, the
reviewers included Sally Black,

St. Joseph’s University; Denise Colaianni, Western Connecticut
State University; Sue Forster-
Cox, New Mexico State University; Julie Gast, Utah State
University; Ray Manes, York
College CUNY; and Lois Ritter, California State University
East Bay. For the sixth edi-
tion, reviewers included Jacquie Rainey, University of Central
Arkansas; Bridget Melton,
Georgia Southern University; Marylen Rimando, University of
Iowa; Beth Orsega-Smith,
University of Delaware; Aimee Richardson, American
University; Heather Diaz, California
State University, Sacramento; Steve McKenzie, Purdue
University; Aly Williams, Indiana
Wesleyan University; Jennifer Banas, Northeastern Illinois
University; and Heidi Fowler,
Georgia College and State University. For this edition,
reviewers included Kimberly A. Parker,
Texas Woman’s University; Steven A. Branstetter, Pennsylvania
State University; Jennifer
Marshall, University of South Florida; Jordana Harshman,
George Mason University; Tara
Tietjen-Smith, Texas A & M University, Commerce; Amy L.
Versnik Nowak, University of
Minnesota, Duluth; Amanda Tanner, University of North

Carolina, Greensboro; Deric R.
Kenne, Kent State University; and Deborah J. Gibson,
University of Tennessee, Martin.
Third, we thank our friends for providing valuable feedback on
various editions of
this book: Robert J. Yonker, Ph.D., Professor Emeritus in the
Department of Educational
Foundations and Inquiry, Bowling Green State University;
Lawrence W. Green, Dr. P. H.,
Professor, Department of Epidemiology and Biostatistics,
School of Medicine, University
aCknowledgments
xvii
xviii Acknowledgments
of California, San Francisco (UCSF); Bruce G. Simons-Morton,
Ed.D., M.P.H., Senior
Investigator, Eunice Kennedy Shriver National Institute of
Child Health and Human

Development, National Institutes of Health; and Jerome E.
Kotecki, H.S.D., Professor,
Department of Physiology and Health Science, Ball State
University. We would also like to
thank Jan L. Smeltzer, Ph.D., coauthor, for her contributions to
the first four editions of
the book.
Fourth, we appreciate the work of the Pearson employees
Michelle Cadden, Senior
Acquisitions Editor for Health, Kinesiology, and Nutrition who
has been very supportive
of our work, and Susan Malloy, Program Manager, whose hard
work and encouragement
ensured we created a quality product. We also appreciate the
careful work of Allison
Campbell and Charles Fisher from Integra–Chicago.
Finally, we express our deepest appreciation to our families for
their support, encourage-
ment, and understanding of the time that writing takes away
from our family activities.
J. F. M.
B. L. N.

R. T.
1
1
Chapter Health Education, Health Promotion,
Health Education Specialists, and
Program Planning
Chapter Objectives
After reading this chapter and answering the
questions at the end, you should be able to:
⦁ ⦁ Explain the relationship among good health
behavior, health education, and health promotion.
⦁ ⦁ Explain the difference between health education
and health promotion.
⦁ ⦁ Write your own definition of health education.

⦁ ⦁ Explain the role of the health educator as
defined by the Role Delineation Project.
⦁ ⦁ Explain how a person becomes a Certified
Health Education Specialist or a Master
Certified Health Education Specialist.
⦁ ⦁ Explain what the Competencies Update
Project (CUP), Health Educators Job Analysis
(HEJA-2010), and Health Education Specialists
Practice Analysis (HESPA-2015) have in common.
⦁ ⦁ Explain how the Competency-Based Framework
for Health Education Specialist is used by colleges
and universities, the National Commission for
Health Education Credentialing, Inc. (NCHEC),
Council for the Accreditation of Educator
Preparation (CAEP), and the Council on
Education for Public Health (CEPH)
⦁ ⦁ Identify the assumptions upon which health
education is based.
⦁ ⦁ Define the term pre-planning.

Key Terms
Advanced level
1-health education
specialist
Advanced level-2
health education
specialist
community
decision makers
entry-level health
education
specialist
Framework
health behavior
health education
health education
specialist

health promotion
Healthy People
pre-planning
primary prevention
priority population
Role Delineation
Project
secondary
prevention
stakeholders
tertiary prevention
2 Chapter 1
History has shown that much progress was made in the health
and life expectancy
of Americans since 1900. During these 116+ years, we have
seen a sharp drop in infant
mortality (NCHS, 2015); the eradication of smallpox; the
elimination of poliomyelitis in
the Americas; the control of measles, rubella, tetanus,

diphtheria, Haemophilus influenzae
type b, and other infectious diseases; better family planning
(CDC, 2001); and an increase
of 31.5 years in the average life span of a person in the United
States (CDC, 2015e). Over
this same time, we have witnessed disease prevention change
“from focusing on reducing
environmental exposures over which the individual had little
control, such as providing
potable water, to emphasizing behaviors such as avoiding use of
tobacco, fatty foods, and
a sedentary lifestyle” (Breslow, 1999, p. 1030). Yet, even with
this change in focus we, as a
society, have done little to encourage health community design,
and as individuals, most
Americans have not changed their lifestyle enough to reduce
their risk of illness, disability,
and premature death. As a result, unhealthy lifestyle
characteristics have lead to the United
States ranking 94th (out of 225 countries) in crude death rate;
42nd (out of 224 countries) in
life expectancy at birth; and 1st in health care spending (CIA,
2015).
Today in the United States, much of the death and disability of

Americans is associated with
chronic diseases. Seven out of every 10 deaths among
Americans each year are from chronic
diseases, while heart disease, cancer, and stroke account for
approximately 50% of deaths
each year (CDC, 2015b). In addition, more than 86% of all
health care spending in the United
States is on people with chronic conditions (CDC, 2015b).
Chronic diseases are not only the
most common, deadly, and costly, they are also the most
preventable of all health problems
in the United States (CDC, 2105b). They are the most
preventable because four modifiable
risk behaviors—lack of exercise or physical activity, poor
nutrition, tobacco use, and exces-
sive alcohol use—are responsible for much of the illness,
suffering, and early death related to
chronic diseases (CDC, 2015b) (see Table 1.1). In fact, one
study estimates that all causes of
mortality could be cut by 55% by never smoking, engaging in
regular physical activity, eating
a healthy diet, and avoiding being overweight (van Dam, Li,
Spiegelman, Franco, & Hu, 2008).
TablE 1.1 Comparison of Most Common Causes of Death and

Actual Causes of Death
Most Common Causes of Death, United States, 2013* Actual
Causes of Death, United States, 2000**
1. Heart disease 1. Tobacco
2. Cancer 2. Poor diet and physical inactivity
3. Chronic lower respiratory diseases 3. Alcohol consumption
4. Unintentional injuries 4. Microbial agents
5. Stroke 5. Toxic agents
6. Alzheimer’s disease 6. Motor vehicles
7. Diabetes 7. Firearms
8. Influenza and pneumonia 8. Sexual behavior
9. Kidney disease 9. Illicit drug use
10. Suicide
*Kochanek, Murphy, Xu, & Arias (2014).
**Mokdad, Marks, Stroup, & Greberding (2004, 2005).
Health Education, Health Promotion, Health Education

But modifying risk behaviors does not come easy to Americans.
One study (Reeves &
Rafferty, 2005) has shown that only 3% of U.S. adults adhere to
four healthy lifestyle
characteristics (not smoking, engaging in regular physical
activity, maintaining a healthy
weight, and eating five fruits and vegetables a day). If moderate
alcohol use were included
in the healthy lifestyle characteristics the percentage would be
even lower (King, Mainous,
Carnemolla, & Everett, 2009). Now in the second decade of the
twenty-first century, behav-
ior patterns continue to “represent the single most prominent
domain of influence over
health prospects in the United States” (McGinnis, Williams-
Russo, & Knickman, 2002, p. 82).
Though the focus on good health, wellness, and health behavior
(those behaviors that
impact a person’s health) seem commonplace in our lives today,
it was not until the last
fourth of the twentieth century that health promotion was
recognized for its potential to
help control injury and disease and to promote health.

Most scholars, policymakers, and practitioners in health
promotion would pick 1974 as the
turning point that marks the beginning of health promotion as a
significant component of
national health policy in the twentieth century. That year
Canada published its landmark
policy statement, A New Perspective on the Health of Canadians
(Lalonde, 1974). In the United
States, Congress passed PL 94-317, the Health Information and
Health Promotion Act, which
created the Office of Health Information and Health Promotion,
later renamed the Office of
Disease Prevention and Health Promotion (Green 1999, p. 69).
This paved the way for the U.S. government’s Healthy People:
The Surgeon General’s Report
on Health Promotion and Disease Prevention (USDHEW, 1979),
which brought together much
of what was known about the relationship of personal behavior
and health status. The docu-
ment also presented a “personal responsibility” model that
provided Americans with a pre-
scription for reducing their health risks and increasing their
chances for good health.

It may not have been the content of Healthy People that made
the publication so sig-
nificant, because several publications written before it provided
a similar message. Rather,
Healthy People was important because it summarized the
research available up to that
point, presented it in a very readable format, and made the
information available to the
general public. Healthy People was followed by the release of
the first set of health goals and
objectives for the nation, titled Promoting Health/Preventing
Disease: Objectives for the Nation
(USDHHS, 1980).
These goals and objectives, now in their fourth generation
(USDHHS, 2015c), have de-
fined the nation’s health agenda and guided its health policy
since their inception. And, in
part, they have kept the importance of good health visible to all
Americans.
This focus on good health has given many people in the United
States a desire to do some-
thing about their health. This desire, in turn, has increased the
need for good health informa-

tion that can be easily understood by the average person. One
need only look at the Internet,
current best-seller list, read the daily newspaper, observe the
health advertisements delivered
via electronic mass media, or consider the increase in the
number of health-promoting facilities
(not illness or sickness facilities) to verify the interest that
American consumers have in health.
Because of the increased interest in health and changing health
behavior, health professionals
are now faced with providing the public with information.
However, obtaining good informa-
tion does not mean that those who receive it will make healthy
decisions and then act on those
decisions. Good health education and health promotion
programs are needed to assist people
in reducing their health risks in order to obtain and maintain
good health.
4 Chapter 1
⦁ Health Education and Health Promotion

There is more to health education than simply disseminating
health information (Auld et al.,
2011). Health education is a much more involved process. Two
formal definitions of health
education have been frequently cited in the literature. The first
comes from the Report of the
2011 Joint Committee on Health Education and Promotion
Terminology (Joint Committee on
Health Education and Promotion Terminology [known hereafter
as the Joint Committee
on Terminology], 2012). The committee defined health
education as “[a]ny combination
of planned learning experiences using evidence-based practices
and/or sound theories that
provide the opportunity to acquire knowledge, attitudes, and
skills needed to adopt and
maintain healthy behaviors” (Joint Committee on Terminology,
2012, p. S17). The second
definition was presented by Green and Kreuter (2005), who
defined health education as “any
planned combination of learning experiences designed to
predispose, enable, and reinforce
voluntary behavior conducive to health in individuals, groups,
or communities” (p. G-4).

Another term that is closely related to health education, and
sometimes incorrectly used
in its place, is health promotion. Health promotion is a broader
term than health education. In
the Report of the 2011 Joint Committee on Health Education
and Promotion Terminology (Joint
Committee on Terminology, 2012, p. S19) health promotion is
defined as “[a]ny planned
combination of educational, political, environmental,
regulatory, or organizational mecha-
nisms that support actions and conditions of living conducive to
the health of individuals,
groups, and communities.” Green and Kreuter (2005) offered a
slightly different definition
of health promotion, calling it “any planned combination of
educational, political, regulatory
and organizational supports for actions and conditions of living
conducive to the health of
individuals, groups, and communities” (p. G-4).
To help us further understand and operationalize the term health
promotion, Breslow (1999)
has stated, “Each person has a certain degree of health that may
be expressed as a place in a spec-
trum. From that perspective, promoting health must focus on

enhancing people’s capacities
for living. That means moving them toward the health end of the
spectrum, just as prevention
is aimed at avoiding disease that can move people toward the
opposite end of the spectrum”
(p. 1031). According to these definitions of health promotion,
health education is an important
component of health promotion and firmly implanted in it (see
Figure 1.1). “Health promotion
takes into account that human behavior is not only governed by
personal factors (e.g., knowl-
edge, expectancies, competencies, and well-being), but also by
structural aspects of the environ-
ment” (Vogele, 2005, p. 272). However, “without health
education, health promotion would be
a manipulative social engineering enterprise” (Green & Kreuter,
1999, p. 19).
The effectiveness of health promotion programs can vary
greatly. However, the success
of a program can usually be linked to the planning that takes
place before implementation
of the program. Programs that have undergone a thorough
planning process are usually the
most successful. As the old saying goes, “If you fail to plan,

your plan will fail.”
⦁ Health Education Specialists
The individuals best qualified to plan health promotion
programs are health education special-
ists. A health education specialist has been defined as “[a]n
individual who has met, at a
minimum, baccalaureate-level required health education
academic preparation qualifications,
who serves in a variety of settings, and is able to use
appropriate educational strategies and
methods to facilitate the development of policies, procedures,
interventions, and systems
conducive to the health of individuals, groups, and
communities” (Joint Committee on
Terminology, 2012, p. S18). Today, health education specialists
can be found working in a vari-
ety of settings, including schools (K–12, colleges, and

universities), community health agencies
(governmental and nongovernmental), worksites (business,
industry, and other work set-
tings), and health care settings (e.g., clinics, hospitals, and
managed care organizations). (Note:
Prior to the term health education specialists being used by the
health education profession,
health education specialists were referred to as health educators.
Throughout the remainder of
this book the term health education specialist will be used
except when the term health educator is
part of a title or when the term carries historical relevance.)
The role of the health education specialist in the United States
as we know it today
is one that has evolved over time based on the need to provide
people with educational
interventions to enhance their health. The earliest signs of the
role of the health educa-
tion specialist appeared in the mid-1800s with school hygiene
education, which was
closely associated with physical activity. By the early 1900s,
the need for health educa-
tion spread to the public health arena, but it was the writers,
journalists, social workers,

and visiting nurses who were doing the educating—not health
education specialists as
we know them today (Deeds, 1992). As we gained more
knowledge about the relationship
between health, disease, and health behavior, it was obvious
that the writers, journal-
ists, social workers, visiting nurses, and primary caregivers —
mainly physicians, dentists,
other independent practitioners, and nurses—were unable to
provide the needed health
Environ-
mental
Environ-
mental
E
nv
iro
n-

m
en
ta
l
E
nviron-
m
entalE
nv
iro
n-
m
en
ta
l
E
nviron-

m
ental
Policy Social
Regulatory Organi-
zational
Political Economic
HEA
LTH PROMOTION
HEALTH PROMOTIO
N
Health
Education
⦁ ▲ Figure 1.1 Relationship of Health Education and Health
Promotion

6 Chapter 1
education. The combination of the heavy workload of the
primary caregivers, the lack of
formal training in the process of educating others, and the need
for education at all levels
of prevention—primary, secondary, and tertiary—(see Table
1.2) created a need for
health education specialists.
As the role of the health educator grew over the years, there was
a movement by those
in the discipline to clearly define their role so that people inside
and outside the profession
would have a better understanding of what the health education
specialist did. In January
1979, the Role Delineation Project began (National Task Force
on the Preparation and
Practice of Health Educators, 1985). Through a comprehensive
process, this project yielded
a generic role for the entry-level health educator—that is,
responsibilities for health
education specialists taking their first job regardless of their
work setting. Once the role of
the entry-level health educator was delineated, the task became

to translate the role into a
structure that professional preparation programs in health
education could use to design
competency-based curricula. The resulting document, A
Framework for the Development of
Competency-Based Curricula for Entry Level Health Educators
(NCHEC, 1985), and its revised
version, A Competency-Based Framework for the Professional
Development of Certified Health
Education Specialists (NCHEC, 1996), provided such a
structure. These documents, simply
referred to as the Framework were comprised of the seven major
areas of responsibility,
TablE 1.2 Levels of Prevention
Level of Prevention Health Status Example Interventions
Primary prevention –
measures that forestall the
onset of a disease, illness,
or injury
Healthy, without signs and
symptoms of disease, illness

or injury
Activities directed at
improving well-being
while preventing
specific health problems,
e.g., legislation to
mandate safe practices,
exercise programs,
immunizations, fluoride
treatments
Secondary prevention –
measures that lead to early
diagnosis and prompt
treatment of a disease,
illness, or injury to minimize
progression of health
problem
Presence of disease, illness,
or injury
early diagnosis, referral,

and prompt treatment,
e.g., mammograms,
self-testicular exam,
laboratory tests to
diagnosis diabetes,
hypercholesterolemia,
hypothyroidism,
programs to prevent
reinjury
Tertiary prevention –
measures aimed at
rehabilitation following
significant disease, illness,
or injury
Disability, impairment, or
dependency
rehabilitation to return
a person to maximum
usefulness, e.g., disease
management programs,
support groups, cardiac

rehabilitation programs
which defined the scope of practice, and several different
competencies and subcompeten-
cies, which further delineated the responsibilities.
Even though the seven areas of responsibility defined the role
of the entry-level health
educator, they did not fully express the work of the health
education specialist with an
advanced degree. Thus, over a four-year period beginning in
1992, the profession worked
to define the role of an advanced-level practitioner. By July
1997, the governing boards of
the National Commission for Health Education Credentialing,
Inc. (NCHEC), the American
Association of Health Education (AAHE), and the Society for
Public Health Education
(SOPHE) had endorsed three additional responsibilities for the
advanced-level health educa-

tor. Those responsibilities revolved around research,
administration, and the advancement
of the profession (AAHE, NCHEC, & SOPHE, 1999).
The seven entry-level and three additional advanced-level
responsibilities served the
profession well, but during the mid- to late-1990s it became
obvious that there was a need
to revisit the responsibilities and competencies and to make sure
that they still defined
the role of the health educator. Thus in 1998, the profession
launched a six-year multi-
phase research study known as the National Health Educator
Competencies Update Project
(CUP) to reverify the entry-level health educator
responsibilities, competencies, and
subcompetencies and to verify the advanced-level competencies
and subcompetencies
(Airhihenbuwa et al., 2005).
What became obvious from the analysis of the CUP data was
that the seven respon-
sibilities and many of the competencies and subcompetencies
identified in the earlier
Role Delineation Project were still valid. However, the wording

of the responsibilities was
changed slightly, some competencies and subcompetencies were
dropped, and a few new
ones were added. Also, certain subcompetencies were reported
as more important and per-
formed more regularly by health education specialists who had
both more work experience
and academic degrees beyond the baccalaureate level. Thus, the
CUP model that emerged
included responsibilities, competencies, and subcompetencies
and the development of a
three-tiered (i.e., Entry, Advanced Level-1, and Advanced
Level-2) hierarchical model
reflecting the role of the health educator. The results of the
CUP, which were published
approximately 20 years after the initial role delineation proje ct,
lead to the creation of
a revised framework titled A Competency-Based Framework for
Health Educators (NCHEC,
SOPHE, & AAHE, 2006).
To keep the role of the health education specialist contemporary
and to meet best practice
guidelines of the National Commission for Certifying Agencies
(NCCA), a third national

research study known as the Health Educator Job Analysis
(HEJA-2010) was conducted. The
results of this study generated a new Framework titled A
Competency-Based Framework for
Health Education Specialist–2010 (NCHEC, SOPHE, AAHE,
2010). The NCCA, the agency that
accredits the Certified Health Education Specialist (CHES) and
the Master Certified Health
Education Specialist (MCHES) exam programs, has a standard
that requires periodic updates
of a job/practice analysis to keep the practice of the profession
contemporary.
The most recent edition of the Framework titled A Competency-
Based Framework for Health
Education Specialist–2015 (NCHEC & SOPHE, 2015) is the
result of the Health Education
Specialist Practice Analysis (HESPA-2015). Over the years, the
number of Areas of Responsibility
outlined in the Framework have remained fairly consistent (see
Box 1.1). What has changed
over the years is the wording of the Areas of Responsibilities
and the number and wording

8 Chapter 1
of the competencies and subcompetencies found under the Areas
of Responsibility. In the
2015 Framework, there are 36 competencies and 258
subcompetencies (141 Entry-level, 76
Advanced 1-level, and 41 Advanced 2-level ) (NCHEC &
SOPHE, 2015).
In reviewing the current seven areas of responsibility, it is
obvious that four of the seven
are directly related to program planning, implementation, and
evaluation and that the other
three could be associated with these processes, depending on
the type of program being
planned. In effect, these responsibilities distinguish health
education specialists from other
professionals who try to provide health education experiences.
The importance of the defined role of the health education
specialist is becoming greater
as the profession of health promotion continues to mature. This
is exhibited by its use in
several major professional activities. First, the Framework has

provided a guide for all colleges
and universities to use when designing and revising their
curricula in health education to
prepare future health education specialists. Second, the
Framework was used by the National
Commission for Health Education Credentialing, Inc. (NCHEC)
to develop the core criteria for
certifying individuals as health education specialists (Certified
Health Education Specialists,
or CHES). The first group of individuals (N=1,558) to receive
the CHES credential did so be-
tween October 1988 and December 1989, during the charter
certification period. “Charter
certification allows qualified individuals to be certified based
on their academic training, work
experience, and references without taking the exam” (Cottrell,
Girvan, McKenzie & Seabert,
2015, p. 171). In 1990, using a criterion-referenced examination
based on the Framework, the
nationwide testing program to certify health education
specialists was begun by NCHEC, Inc.
In 2011, again using a criterion-referenced examination based
on the Framework,
NCHEC began offering an examination to certify advanced-

level health education spe-
cialists. Those who passed the examination were awarded the
Master Certified Health
Education Specialist (MCHES) credential. Prior to the first
MCHES examination, this new
certification was made available to those who had held active
CHES status since 2005 and
who could demonstrate that they were practicing health
education at an advanced-level.
This process was known as the Experience Documentation
Opportunity (EDO). All those
1.1
Box Areas of Responsibility for Health Education Specialists
AREA oF RESponSiBiliTy i: Assess Needs, Resources, and
Capacity for Health Education/
Promotion
AREA oF RESponSiBiliTy ii: Plan Health Education/Promotion
AREA oF RESponSiBiliTy iii: Implement Health
Education/Promotion

AREA oF RESponSiBiliTy iV: Conduct Evaluation and
Research Related to Health
Education/Promotion
AREA oF RESponSiBiliTy V: Administer and Manage Health
Education/Promotion
AREA oF RESponSiBiliTy Vi: Serve as a Health
Education/Promotion Resource Person
AREA oF RESponSiBiliTy Vii: Communicate, Promote, and
Advocate for Health, Health
Education/Promotion, and the Profession
Source: A Competency-Based Framework for Health Education
Specialists—2015. Whitehall, PA: National Commission for
Health Education Credentialing, Inc.
(NCHEC) and the Society for Public Health Education
(SOPHE). Reprinted by permission of the National Commission
for Health Education Credentialing, Inc.
(SOPHE).

who successfully completed the EDO were granted the MCHES
credential in April 2011.
Currently, both the CHES and MCHES examinations are given
twice a year—once in April
and once in October—at approximately 130 college-campus
locations around the United
States. Both examinations are composed of 165 questions (150
are scored and 15 are pi-
lot questions) and are offered in a paper-and-pencil format
(NCHEC, 2015). Information
about eligibility for the examinations and the percentage of
questions from each Area of
Responsibility are available on the NCHEC Website (see the
link for the Website in the
Weblinks section at the end of the chapter).
Third, the Framework is used by program accrediting bodies to
review college and uni-
versity academic programs in health education. Both the
Council for the Accreditation
of Educator Preparation (CAEP), which accredits teacher
education programs, and the

Council on Education for Public Health (CEPH), which
accredits public health programs,
use components of the Framework when accrediting programs
that have a focus on health
education. The accrediting processes used by both CAEP and
CEPH are based on programs
conducting a self-study by comparing components of their
program to accrediting body
criteria or standards. After the self-study is completed, peer
external reviewers visit the cam-
pus of the college or university seeking accreditation to verify
the contents of the self-study.
The governing boards of CAEP and CEPH review the findings
of the self-study and external
reviewers report and vote on awarding accreditation.
The use of the Framework by the profession to guide academic
curricula, provide the
core criteria for the health education specialist examinations,
and form the basis of pro-
gram accreditation processes has done much to advance the
health education profession.
“In 1998 the U.S. Department of Commerce and Labor formally
acknowledged ‘health
educator’ as a distinct occupation. Such recognition was

justified, based to a large extent,
on the ability of the profession to specify its unique skills”
(AAHE, NCHEC, & SOPHE,
1999, p. 9). In 2010, in its most recent update, the U.S.
Department of Labor Bureau
of Labor Statistics (BLS) described the work of health educators
(Standard Occupation
Classification [SOC] 21-1091) using the following language:
Provide and manage health education programs that help
individuals, families, and their
communities maximize and maintain healthy lifestyles. Collect
and analyze data to identify
community needs prior to planning, implementing, monitoring,
and evaluating programs
designed to encourage healthy lifestyles, policies, and
environments. May serve as resource
to assist individuals, other health professionals, or the
community, and may administer fiscal
resources for health education programs (USDOL, BLS, 2015,
para. 1).
⦁ Assumptions of Health Promotion
So far, we have discussed the need for health, what heal th

education and health promotion
are, and the role health education specialists play in delivering
successful health promotion
programs. We have not yet discussed the assumptions that
underlie health promotion—all
the things that must be in place before the whole process of
health promotion begins. In the
mid-1980s, Bates and Winder (1984) outlined what they saw as
four critical assumptions of
health education. Their list has been modified by adding several
items, rewording others,
and referring to them as “assumptions of health promotion.”
This expanded list of assump-
tions is critical to understanding what we can expect from
health promotion programs.
10 Chapter 1
Health promotion is by no means the sole answer to the nation’s
health problems or, for
that matter, the sole means of getting a smoker to stop smoking
or a nonexerciser to exercise.
Health promotion is an important part of the health system, but

it does have limitations.
Here are the assumptions:
1. Health status can be changed.
2. “Health and disease are determined by dynamic interactions
among biological,
psychological, behavioral, and social factors” (Pellmar, Brandt,
& Baird, 2002, p. 217).
3. “Behavior can be changed and those changes can influence
health” (IOM, 2001, p. 333).
4. “Individual behavior, family interactions, community and
workplace relationships and
resources, and public policy all contribute to health and
influence behavior change”
(Pellmar et al., 2002, p. 217).
5. “Interventions can successfully teach health-promoting
behaviors or attenuate risky
behaviors” (IOM, 2001, p. 333).
6. Before health behavior is changed, the determinants of
behavior, the nature of the

behavior, and the motivation for the behavior must be
understood (DiClemente,
Salazar, & Crosby, 2013).
7. “Initiating and maintaining a behavior change is difficult”
(Pellmar et al., 2002, p. 217).
8. Individual responsibility should not be viewed as victim
blaming, yet the importance of
health behavior to health status must be understood.
9. For health behavior change to be permanent, an individual
must be motivated and
ready to change.
The importance of these assumptions is made clearer if we refer
to the definitions of
health education and health promotion presented earlier in the
chapter. Implicit in those
definitions is the goal of having program participants
voluntarily adopt actions conducive
to health. To achieve such a goal, the assumptions must indeed
be in place. We cannot ex-
pect people to adopt lifelong health-enhancing behavior if we
force them into such change.

Nor can we expect people to change their behavior just because
they have been exposed to
a health promotion program. Health behavior change is very
complex, and health educa-
tion specialists should not expect to change every person with
whom they come in contact.
However, the greatest chance for success will come to those
who have the knowledge and
skills to plan, implement, and evaluate appropriate programs.
⦁ Program Planning
Because many of health education specialists’ responsibilities
are involved in some way with
program planning, implementation, and evaluation, health
education specialists need to
become well versed in these processes. “Planning an effective
program is more difficult than
implementing it. Planning, implementing, and evaluating
programs are all interrelated, but
good planning skills are prerequisite to programs worthy of
evaluation” (Minelli & Breckon,
2009, p. 137). All three processes are very involved, and much
time, effort, practice, and on-
the-job training are required to do them well. Even the most

experienced health education
specialists find program planning challenging because of the
constant changes in settings,
resources, and priority populations.
Hunnicutt (2007) offered four reasons why systematic planning
is important. The first is
that planning forces planners to think through details in
advance. Detailed plans can help
to avoid future problems. Second, planning helps to make a
program transparent. Good
planning keeps the program stakeholders (any person,
community, or organization with
a vested interest in a program; e.g., decision makers, partners,
clients) informed. The plan-
ning process should not be mysterious or secretive. Third,
planning is empowering. Once
decision makers (those who have the authority to approve a
plan; e.g., administrator of
an organization, governing board, chief executive officer) give

approval to the resulting
comprehensive program plan, planners and facilitators are
empowered to implement the
program. Without an approved plan, planners will spend a great
deal of time waiting for
the “next step” to be approved and risk losing program
momentum. And fourth, planning
creates alignment. Once the decision makers have approved the
program, all organization
members have a better understanding of where it “fits” in the
organization and the impor-
tance that the plan carries.
A general understanding of all that is involved in creating a
health promotion program
can be obtained by reviewing the Generalized Model (see Figure
1.2). (A more in-depth
explanation of this model can be found in Chapter 3.) This
model includes the five major
steps involved in planning a program. However, prior to
undertaking the first step in the
Generalized Model, it is important to do some pre-planning.
Pre-planning allows a core
group of people (or steering committee) to gather answers to
key questions (see Box 1.2)

that are critical to the planning process before the actual
planning process begins. It also
helps to clarify and give direction to planning, and helps
stakeholders avoid confusion as
the planning progresses.
Also prior to starting the actual planning process, planners need
to have a very good
understanding of the “community” where the program will be
implemented. When we
say community, do not think of just a geographic area with
specific boundaries like a
neighborhood, city, county, or state. Community should be
defined as “a collective body
of individuals identified by common characteristics such as
geography, interests, experi-
ences, concerns, or values” (Joint Committee on Terminology,
2012, p. S15). For example,
a community could be a religious community, a cancer-survivor
community, a workplace
community, or even a cyber community. Understanding the
community means finding
out as much as possible about the priority population (those for
whom the program
is intended to serve) and the environment in which it exists.

Each setting and group is
unique with its own nuances, resources, and culture. These are
important to know at the
beginning of the process. Planners should never assume they
“know” a community. The
more background information that planners secure, the better
the resulting program can
be. However, it is not enough to understand the community,
planners also need to engage
members of the priority population. Engaging the priority
population means involving
Assessing
needs
Setting
goals and
objectives
Developing
an
intervention
Implementing
the

intervention
Evaluating
the
results
⦁ ▲ Figure 1.2 Generalized Model
12 Chapter 1
those in the priority population or a representative group from
the priority population in
the planning process.
Finally, before the actual planning begins thought must be given
to “when the best time
is to plan such a program, what data are needed, where the
planning should occur, what
resistance can be expected, and generally, what will enhance the
success of the project”
(Minelli & Breckon, 2009, p. 138).
The remaining chapters of this book present a process that

health education specialists
can use to plan, implement, and evaluate successful health
promotion programs and will
introduce you to the necessary knowledge and skills to carry out
these tasks.
1.2
Box Example Key Questions to Be Answered in the pre-
planning process
purpose of program
⦁ ⦁ How is the community defined?
⦁ ⦁ What are the desired health outcomes?
⦁ ⦁ Does the community have the capacity and infrastructure to
address the problem?
⦁ ⦁ Is a policy change needed?
Scope of the planning process
⦁ ⦁ Is it intra- or inter-organizational?

⦁ ⦁ What is the time frame for completing the project?
planning process outcomes (deliverables)
⦁ ⦁ Written plan?
⦁ ⦁ Program proposal?
⦁ ⦁ Program documentation or justification?
leadership and structure
⦁ ⦁ What authority, if any, will the planners have?
⦁ ⦁ How will the planners be organized?
⦁ ⦁ What is expected of those who participate in the planning
process?
identifying and engaging partners
⦁ ⦁ How will the partners be selected?
⦁ ⦁ Will the planning process use a top-down or bottom-up

approach?
identifying and securing resources
⦁ ⦁ How will the budget be determined?
⦁ ⦁ Will a written agreement (i.e., MOA—memorandum of
agreement) outlining
responsibilities be needed?
⦁ ⦁ If MOA is needed, what will it include?
⦁ ⦁ Will external funding (i.e., grants or contracts) be needed?
⦁ ⦁ Are there community resources (e.g., volunteers, space,
donations) to support the
planned program?
⦁ ⦁ How will the resources be obtained?
Fo
cu
s
O

n
Summary
The increased interest in personal health and behavior change,
and the flood of new health
information have expanded the need for quality health
promotion programs. Individuals are
seeking guidance to enable them to make sound decisions about
behavior that is conducive
to their health. Those best prepared to help these people are
who complete a curriculum based upon the role defined by the
profession. Properly trained
health education specialists are aware of the limitations of the
discipline and understand the
assumptions on which health promotion is based. They also
know that good planning does
not happen by accident. Much time, effort, practice, and on-the-

job training are needed to
plan an effective program. The planning process begins with
pre-planning.
Review Questions
1. Explain the role Healthy People played in the relationship
between the American people
and health.
2. How is health education defined by the Joint Committee on
Terminology (2012)?
3. What are the key phrases in the definition of health education
presented by Green and
Kreuter (2005)?
4. What is the relationship between health education and health
promotion?
5. Why is there a need for health education specialists?
6. What is the Role Delineation Project?
7. How is the Competency-Based Framework for Health

Education Specialists used by colleges
and universities? By NCHEC? By CAEP? By CEPH?
8. How does one become a Certified Health Education Specialist
(CHES)?
9. How does one become a Master Certified Health Specialist
(MCHES)?
10. What are the seven Areas of Responsibilities of health
education specialists?
11. What is the National Health Educator Competencies Update
Project (CUP)?
12. What is the Health Educator Job Analysis – 2010 (HEJA-
2010)?
13. What is the Health Education Specialist Practice Analysis –
2015 (HESPA-2015)?
14. What assumptions are critical to health promotion?
15. What are the steps in the Generalized Model?

16. What is meant by the term pre-planning? Why is it
important? What are some questions
that should be answered during the pre-planning process?
17. How have stakeholders, decision makers, and community
been defined in this chapter?
Activities
1. Based on what you have read in this chapter and your
knowledge of the profession of
health education, write your own definitions for health, health
education, health promotion,
and health promotion program.
14 Chapter 1
2. Write a response indicating what you see as the importance
of each of the nine
assumptions presented in the chapter. Write no more than one
paragraph per
assumption.

3. With your knowledge of health promotion, what other
assumptions would you add to
the list presented in this chapter? Provide a one-paragraph
rationale for each.
4. If you have not already done so, go online
(http://profiles.nlm.nih.gov/ps/access
/NNBBGK.pdf) or to the government documents section of the
library on your campus
and read Healthy People: The Surgeon General’s Report on
Health Promotion and Disease
Prevention (USDHEW, 1979).
5. Say you are in your senior year and will graduate next May
with a bachelor’s degree
in health education. What steps would you have to take in order
to be able to take the
CHES exam in April prior to your graduation? (Hint: Check the
Website of the National
Commission for Health Education Credentialing, Inc.)
6. In a one-page paper describe the differences and similarities
in the two credentials—
CHES and MCHES—available to health education specialists.
(Hint: Check the Website of

the National Commission for Health Education Credentialing,
Inc.)
7. In a one-page paper describe what the job outlook is
projected to be for health education
specialists for the next ten years. (Hint: Check the Website of
the Bureau of Labor
Statistics Occupational Outlook Handbook.)
Weblinks
1. http://www.healthypeople.gov
Healthy People
This is the Webpage for the U.S. government’s Healthy People
initiative including
a complete presentation of Healthy People 2020.
2. http://www.nchec.org/
National Commission for Health Education Credentialing, Inc.
(NCHEC)
The NCHEC, Inc. Website provides the most current
information about the CHES
and MCHES credentials.

3. http://www.bls.gov/ooh/community-and-social-
service/health-educators.htm
Occupational Outlook Handbook
This is a Webpage provided by the Bureau of Labor Statistics
that describes the
occupation outlook for health educators and community health
workers.
http://profiles.nlm.nih.gov/ps/access/NNBBGK.pdf
http://profiles.nlm.nih.gov/ps/access/NNBBGK.pdf
http://www.healthypeople.gov
http://www.nchec.org/
http://www.bls.gov/ooh/community-and-social-service/health-
educators.htm
The chapters in this section of the book provide the basic
information needed to plan a health promotion program.
Each chapter presents readers with the information they
will need to build the knowledge to develop the skills to
create a successful program in a variety of settings.
Part I Planning a HealtH
Promotion Program

Chapter 2 17
Starting the Planning Process
Chapter 3 41
Program Planning Models
in Health Promotion
Chapter 4 67
assessing Needs
Chapter 5 105
Measurement, Measures,
Measurement Instruments,
and Sampling
Chapter 6 133
Mission Statement, Goals,
and Objectives
Chapter 7 151

theories and Models
Commonly Used for Health
Promotion Interventions
Chapter 8 191
Interventions
Chapter 9 237
Community Organizing
and Community Building
17
As noted earlier (Chapter 1), planning a health promotion
program is a multistep
process that begins after doing pre-planning. “To plan is to

engage in a process or a proce-
dure to develop a method of achieving an end” (Minelli &
Breckon, 2009, p. 137). However,
because of the many different variables and circumstances of
any one setting, the multistep
process of planning does not always begin the same way. There
are times when the need for
a program is obvious and there is recognition that a new
program should be put in place. For
example, if a community’s immunization rate for its children is
less than half the national
average, a program should be created. There are other times
when a program has been suc-
cessful in the past but needs to be changed or reworked slightly
before being implemented
again. And, there are situations where planners have been given
the independence and
authority to create the programs that are needed in a community
in order to improve the
health and quality of life. However, when the need is not so
obvious, or when there has
not been successful health promotion programming in the past
or decision makers want
“proof” (i.e., evidence) that a program is needed and will be
successful, the planning process

often begins with the planners creating a rationale to gain the
support of key people in or-
der to obtain the necessary resources to ensure that the planning
process and the eventual
implementation proceed as smoothly as possible.
literature
organizational
culture
planning committee
planning parameters
planning team
program ownership
return on investment
(ROI)
social math
steering committee
Key Terms
advisory board
cost-benefit analysis

(CBA)
doers
epidemiology
evidence
evidence-based
practice
Guide to Community
Preventive Services
influencers
institutionalized
Chapter Objectives
⦁ ⦁ Develop a rationale for planning and
implementing a health promotion program.
⦁ ⦁ Explain the importance of gaining the support
of decision makers.
⦁ ⦁ Identify the individuals who could make up a

planning committee.
⦁ ⦁ Explain what planning parameters are and the
impact they have on program planning.
Starting the Planning Process
2
Chapter
18 Part 1 Planning a Health Promotion Program
This chapter presents the steps of creating a program rationale
to obtain the support of
decision makers, identifying those who may be interested in
helping to plan the program,
and establishing the parameters in which the planners must
work. Box 2.1 identifies the
responsibilities and competencies for health education
specialists that pertain to the mate-
rial presented in this chapter.
The Need for Creating a Rationale to Gain the Support

of Decision Makers
No matter what the setting of a health promotion program—
whether a business, an in-
dustry, the community, a clinic, a hospital, or a school —it is
most important that the
program have support from the highest level (e.g., the
administration, chief executive
2.1
Box Responsibilities and Competencies for Health Education
Specialists
The content of this chapter includes information on several
tasks that occur early in
the program planning process. These tasks are not associated
with a single area of
responsibility, but rather five areas of responsibility of the
health education specialist:
RESponSiBility i: Assess Needs, Resources, and Capacity for
Health Education/
Promotion

Competency 1.2: Access existing information and data related
to health
Competency 1.6: Examine factors that enhance or impede the
process of health education/promotion
RESponSiBility ii: Plan Health Education/Promotion
Competency 2.1: Involve priority populations, partners, and
other
stakeholders in the planning process
RESponSiBility V: Administer and Manage Health
Education/Promotion
Competency 5.3: Manage relationships with partners and other
stakeholders
Competency 5.4: Gain acceptance and support for health
education/
promotion
Competency 5.5: Demonstrate leadership
RESponSiBility Vi: Serve as a Health Education/Promotion

Resource Person
Competency 6.1: Obtain and disseminate health-related
information
Competency 6.3: Provide advice and consultation on health
education/ promotion issues
RESponSiBility Vii: Communicate, Promote, and Advocate for
Health and Health
Education/ Promotion, and the Profession
Competency 7.2: Engage in advocacy for health
education/promotion
Competency 7.3: Influence policy and/or systems change to
promote
health and health education/promotion

(SOPHE).
officer, church elders, board of health, or board of directors) of
the “community” for
which the program is being planned (Allen & Hunnicutt, 2007;
Chapman, 1997, 2006;
Hunnicutt & Leffelman, 2006; Ryan, Chapman, & Rink, 2008).
It is the individuals in
these top-level decision-making positions who are able to
provide the necessary resource
support for the program.
“Resources” usually means money, which can be turned into
staff, facilities, materials, supplies,
utilities, and all the myriad number of things that enable
organized activity to take place over
time. “Support” usually means a range of things: congruent
organizational policies, program
and concept visibility, expressions of priority value, personal
involvement of key managers, a

place at the table of organizational power, organizational
credibility, and a role in integrated
functioning (Chapman, 1997, p. 1).
There will be times when the idea for, or the motivating force
behind, a program comes
from the top-level people. When this happens, it is a real boon
for the program planners
because they do not have to sell the idea to these people to gain
their support. However,
this scenario does not occur frequently.
Often, the idea or the big push for a health promotion program
comes from someone
other than one who is part of the top-level of the “community.”
The idea could start with
an employee, an interested parent, a health education specialist
within the organization, a
member of the parish or congregation, or a concerned individual
or group from within the
community. The idea might even be generated by an individual
outside the “community,”
such as one who may have administrative or oversight
responsibilities for activities in a
community. An example of this arrangement is the employee of

a state health department
who provides consultative services to a local health department.
Or it may be an individual
from a regional agency who is partnering with a group within
the community to carry out a
collaborative project. When the scenario begins at a level below
the decision makers, those
who want to create a program must “sell” it to the decision
makers. In other words, in order
for resources and support to flow into health promotion
programming, decision makers
need to clearly perceive a set of values or benefits associated
with the proposed program
(Chapman, 2006). Without the support of decision makers, it
becomes more difficult, if
not impossible, to plan and implement a program. A number of
years ago, Behrens (1983)
stated that health promotion programs in business and industry
have a greater chance for
success if all levels of management, including the top, are
committed and supportive. This
is still true today of health promotion programs in all settings,
not just programs in busi-
ness and industry (see Box 2.2).

If they need to gain the support of decision makers, program
planners should de-
velop a rationale for the program’s existence. Why is it
necessary to sell something that
everyone knows is worthwhile? After all, does anyone doubt the
value of trying to help
people gain and maintain good health? The answer to these and
similar questions is that
few people are motivated by health concerns alone. Decisions
by top-level management
to develop new programs are based on a variety of factors,
including finances, policies,
public image, and politics, to name a few. Thus to sell the
program to those at the top,
planners need to develop a rationale that shows how the new
program will help decision
makers to meet the organization’s goals and, in turn, to carry
out its mission. In other
words, planners need to position their program rationale
politically, in line with the
organization.

Steps in Creating a Program Rationale
Planners must understand that gaining the support of decision
makers is one of the most
important steps in the planning process and it should not be
taken lightly. Many program
ideas have died at this stage because the planners were not well
prepared to sell the program
to decision makers. Thus, before making an appeal to decision
makers, planners need to have
a sound rationale for creating a program that is supported by
evidence that the proposed pro-
gram will benefit those for whom it is planned.
There is no formula or recipe for writing a rationale, but
through experience, the authors have
found a logical format for putting ideas together to help guide
planners (see Figure 2.1). Note
that Figure 2.1 is presented as an inverted triangle. This
inverted triangle is symbolic in design to
reflect the flow of a program rationale beginning at the top by
identifying a health problem in
global terms and moving toward a more focused solution at the
bottom of the triangle.

Step 1: identify Appropriate Background information
Before planners begin to write a program rationale, they need to
identify appropriate sources
of information and data that can be used to sell program
development. The place to begin
the process of identifying appropriate sources of information
and data to support the devel-
opment of a program rationale is to conduct a search of the
existing literature. Literature
includes the articles, books, government publications, and other
documents that explain
the past and current knowledge about a particular topic. By
conducting a search, planners
gain a better understanding of the health problem(s) of concern,
approaches to reducing or
eliminating the health problem, and an understanding of the
people for whom the program
is intended (remember these individuals are referred to as the
priority population). There are a
number of different ways that planners can carry out a review of
the literature (see Chapter 4
for an explanation of the literature search process).

2.2
Box
Though the importance of decision
makers’ support to the success of
health promotion programs has been
known for a number of years, it is only
recently that efforts have been put forth
to actually measure decision makers’
support for health promotion programs.
Della, DeJoy, Goetzel, Ozminkowski, and
Wilson (2008) created a valid instrument
to assess leadership support for health
promotion programs in work settings.
The measurement tool, referred to as the
Leading by Example (LBE) Instrument,
is a four-factor scale. The four factors
are (1) business assignment with health
Measuring Decision Makers’ Support for Health promotion
promotion objectives, (2) awareness
of the economics of health and worker
productivity, (3) worksite support for

health promotion, and (4) leadership
support for health promotion (Della et al.,
2010). Della and colleagues feel that the
LBE could be used in two ways. The first
would be through a single administration
“to assess specific areas in which the
health promotion climate might support/
hinder programmatic efforts” (p. 139).
The second would be to administer
the LBE two different times to monitor
change in support for health promotion
programs over time.
Fo
cu
s
O
n

In general, the types of information and data that are useful in
writing a rationale in-
clude those that (1) express the needs and wants of the priority
population, (2) describe
the status of the health problem(s) within a given population,
(3) show how the potential
outcomes of the proposed program align with what the decision
makers feel is important,
(4) show compatibility with the health plan of a state or the
nation, (5) provide evidence
that the proposed program will make a difference, and (6) show
how the proposed program
will protect and preserve the single biggest asset of most
organizations and communities—
the people. Though many of these types of information and data
are generated through
a review of the literature, the first one discussed below —needs
and wants of the priority
population—is not.
Information and data that express the needs and wants of the
priority population can be gen-
erated through a needs assessment. A needs assessment is the
process of identifying, analyzing,
and prioritizing the needs of a priority population. Needs

assessments are carried out through
a multiple-step process in which data are collected and
analyzed. The analysis generates a
Title the work “A rationale for the development of . . .” and
indicate who is submitting
the work.
Identify the health problem in global terms, backing it up with
appropriate
(international, national, or state) data. If possible, also include
the economic costs of the problem.
Narrow the health problem by showing its relationship to the
proposed priority population. Create a problem statement.
State why it is a problem and why it should be dealt with.
Again, back up the statement with appropriate data.
State a proposed solution to the problem (name
and purpose of the proposed health promotion
program). Provide a general overview of
the program.

State what can be gained from such a
program in terms of the values and
benefits to the decision makers.
State why the program will
be successful.
Provide the
references
used in
preparing
the
rationale.
⦁ ▲ Figure 2.1 Creating a rationale
prioritized list of needs of the priority population (see Chapter 4

for a detailed explanation of the
needs assessment process). Even though information and data
that express the needs and wants
of the priority population can be very useful in generating a
rationale for a proposed program,
more than likely at this point in the planning process, a formal
needs assessment will not have
been completed. Often, a complete needs assessment does not
take place until decision mak-
ers give permission for the planning to begin. However, the
review of literature may generate
information about a needs assessment of another related or
similar program. If so, it can provide
valuable information and data that can help to develop the
rationale.
Information and data that describe the status of a health
problem within a population can
be obtained by analyzing epidemiological data. Epidemiologic
data are those that result from
the process of epidemiology, which has been defined as “[t]he
study of the occurrence and
distribution of health-related events, states and processes in
specific populations, including
the study of determinants influencing such processes, and the

application of this knowledge
to control relevant health problems” (Porta, 2014, p. 95).
Epidemiological data are available
from a number of different sources including governmental
agencies, governmental health
agencies, non-governmental health agencies, and health care
systems. table 2.1 provides
some examples of useful sources of epidemiological data.
taBle 2.1 example Sources of epidemiological Data
Source example Data
International
World Health organization World Health Statistics Report
(http://www.who.int/gho/publications/
world_health_statistics/en/)
Country Statistics
(http://www.who.int/gho/countries/en/)
National
Centers for Disease Control
and Prevention

National Center for Health
Statistics
National Health and Nutrition Examination Survey (NHANES)
(http://www.cdc.gov/nchs/nhanes.htm)
National Health Interview Survey (NHIS)
(http://www.cdc.gov/nchs/nhis.htm)
State
and Prevention
Behavioral Risk Factor Surveillance System (BRFSS)
(http://www.cdc.gov/brfss/about/index.htm)
Youth Risk Behavior Surveillance System (YRBSS)
http://www.cdc.gov/healthyyouth/data/yrb s/index.htm
Pennsylvania Department
of Health
Health Statistics
(http://www.portal.state.pa.us/portal/server.pt/community/

health_statistics/14136)
Local
Robert Wood Johnson
Foundation & University of
Wisconsin Population Health
Institute
County Health Rankings & Roadmaps
(http://www.countyhealthrankings.org/)
http://www.who.int/gho/publications/world_health_statistics/en/
http://www.who.int/gho/publications/world_health_statistics/en/
http://www.who.int/gho/countries/en/
http://www.cdc.gov/nchs/nhanes.htm
http://www.cdc.gov/nchs/nhis.htm
http://www.cdc.gov/brfss/about/index.htm
http://www.cdc.gov/healthyyouth/data/yrbs/index.htm
http://www.portal.state.pa.us/portal/server.pt/community/health
_statistics/14136
http://www.portal.state.pa.us/portal/server.pt/community/health
_statistics/14136
http://www.countyhealthrankings.org/

Epidemiologic data gain additional significance when it can be
shown that the described
health problem(s) is(are) the result of modifiable health
behaviors and that spending money
to promote healthy lifestyles and prevent health problems makes
good economic sense. Here
are a couple examples where modifiable health behaviors and
health-related costs have been
connected. The first deals with smoking. Approximately 17.8%
of U.S. adults 18 years of age
and older are cigarette smokers (CDC, 2015g). It has been
estimated that the cost of ill effects
from smoking in the United States totals approximately $300
billion per year. Almost equal
amounts are spent on direct medical care ($170 billion) and
productivity losses due to pre-
mature death and exposure to secondhand smoke ($156 billion)
(CDC, 2015g). The second
example deals with diabetes. It has been estimated that annual
costs associated with diabetes
are approximately $245 billion; $176 billion from direct
medical costs and $69 billion indirect
costs related to disability, work loss, and premature death

(CDC, 2014a). We know that not all
cases of diabetes are related to health behavior, but it is known
for people with prediabetes,
lifestyle changes, including a 5%–7% weight loss and at least
150 minutes of physical activity
per week, can reduce the rate of onset of type 2 diabetes by 58%
(CDC, 2012b). In addition,
we know people with diagnosed diabetes have medical
expenditures that are about 2.3 times
higher than medical expenditures for people without diabetes
(CDC, 2012b). When a ratio-
nale includes an economic component it is often reported based
on a cost-benefit analysis
(CBA). A CBA of a health promotion program will yield the
dollar benefit received from the
dollars invested in the program. A common way of reporting a
CBA is through a metric called
return on investment (ROI). ROI “measures the costs of a
program (i.e., the investment)
versus the financial return realized by that program” (Cavallo,
2006, p. 1) (see Box 2.3 for
formulas to calculate ROI). An example of ROI is a study that
examined the economic impact
of an investment of $10 per person per year in a proven
community-based program to in-

crease physical activity, improve nutrition, and prevent smoking
and other tobacco use. The
results of the study showed that the nation could save billions
of dollars annually and have an
ROI in one year of 0.96 to 1, 5.6 to 1 in 5 years, and 6.2 to 1 in
10–20 years (TFAH, 2009).
However, it should be noted that “proving” the economic impact
of many health pro-
motion programs is not easy. There are a number of reasons for
this including the multiple
2.3
Box Return on investment
In general, ROI compares the dollars invested in something to
the benefits produced by
that investment:
ROI =
(benefits of investment - amount invested)
amount invested

In the case of an investment in a prevention program, ROI
compares the savings
produced by the intervention, net cost of the program, to how
much the program cost:
ROI =
net savings
cost of intervention
When ROI equals 0, the program pays for itself. When ROI is
greater than 0, then the
program is producing savings that exceed the cost of the
program.
Source: Copyright © 2009 by Trust for America’s Health.
Reprinted with permission.
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causes of many health problems, the complex interventions
needed to deal with them, and
the difficulty of carrying out rigorous research studies.
Additionally, McGinnis and col-
leagues (2002) feel that part of the problem is that health
promotion programs are held
to a different standard than medical treatment programs when
cost-effectiveness is being
considered.
In a vexing example of double standards, public investments in
health promotion seem to
require evidence that future savings in health and other social
costs will offset the investments
in prevention. Medical treatments do not need to measure up to
the standard; all that is
required here is evidence of safety and effectiveness. The cost-
effectiveness challenge often is
made tougher by a sense that the benefits need to accrue
directly and in short term to the payer

making investments. Neither of these two conditions applies in
many interventions in health
promotion (p. 84).
A helpful tool for calculating the financial burden of chronic
diseases has been the
Chronic Disease Cost Calculator Version 2 created by the
Centers for Disease Control and
Prevention and RTI International (see the link for the Website
in the Weblinks section
at the end of the chapter). For those planners interested in using
economic impact and
cost-effectiveness of health promotion programs as part of a
program rationale, we recom-
mend that the work of the following authors be reviewed:
Centers for Disease Control and
Prevention (CDC, 2015f), Chapman (2012), Cohen, Neumann,
and Milton (2008), Goetzel
and Ozminkowski (2008), Laine et al. (2014), McKenzie (1986),
O’Donnell (2014), and
Miller & Hendrie (2008).
Other information and data that are useful in creating a
rationale are those that show
how the potential outcomes of the proposed program align with

what decision makers feel is
important. Planners can often get a hint of what decision makers
value by reviewing the orga-
nization’s mission statement, annual report, and/or budget for
health-related items. Planners
could also survey decision makers to determine what is
important to them (Chapman, 1997).
table 2.2 provides a list of values or benefits that can be derived
from health promotion pro-
grams, while table 2.3 provides a list of sources where
information about values or benefits
could be found.
taBle 2.2 Values or Benefits from Health Promotion Programs
Value or Benefit for: types of Values or Benefits
Community Establishing good health as norm; improved quality
of life; improve
the economic well-being of the community; provide model for
other communities
Employee/Individual Improved health status; reduction in health
risks; improved health
behavior; improved job satisfaction; lower out-of-pocket costs

for
health care; increased well-being, self-image, and self-esteem
Employer Increased worker morale; enhanced worker
performance/
productivity; recruitment and retention tool; reduced
absenteeism
and presenteeism; reduced disability days/claims, reduced
health
care costs; enhanced corporate image
Sources: Adapted from ACS (2009); CDC (2014c); and
Chapman (1997).
A fourth source of information for a rationale is a comparison
between the proposed
program and the health plan for the nation or a state. Comparing
the health needs of the
priority population with those of other citizens of the state or of
all Americans, as outlined in
the goals and objectives of the nation (USDHHS, 2015c), should

enable planners to show the
compatibility between the goals of the proposed program and
those of the nation’s health
plan (see Chapter 6 for a discussion of the Healthy People 2020
goals and objectives).
A fifth source of information and data is evidence that the
proposed program will be ef-
fective and make a difference if implemented. By evidence we
mean the body of data that
can be used to make decisions when planning a program. Such
data can come from needs
assessments, knowledge about the causes of a health problem,
research that has tested the
effectiveness of an intervention, and evaluations conducted on
other health promotion
programs. When program planners systematically find, appraise,
and use evidence as the
basis for decision making when planning a health promotion
program, it is referred to as
evidence-based practice (Cottrell & McKenzie, 2011).
Various forms of evidence can be placed on a continuum
anchored at one end by objec-
tive evidence (or science-based evidence) and subjective

evidence at the other of the contin-
uum (Chambers & Kerner, 2007). Others (Howlett, Rogo, &
Shelton, 2014) have organized
the various forms of evidence as a hierarchy within an evidence
pyramid with the objective
evidence at the top of the pyramid and the more subjective
evidence at the base of the
pyramid. Irrespective of format for aligning and presenting the
various forms of evidence,
“[m]ore objective types of evidence include systematic reviews,
whereas more subjective
data involve personal experience and observations as well as
anecdotes” (Brownson, Diez
taBle 2.3 Selected Sources of information about Values or
Benefits of Health
Promotion Programs
Source location of information
American Heart Association
http://www.heart.org/HEARTORG/GettingHealthy
/WorkplaceWellness/Workplace-Wellness_UCM_460416
_SubHomePage.jsp

Centers for Disease Control and Prevention
National Center for Health Statistics http://www.cdc.gov/nchs/
Worklife http://www.cdc.gov/niosh/twh/default.html
Workplace Health Promotion
http://www.cdc.gov/workplacehealthpromotion/
The Community Tool Box http://ctb.ku.edu/en
National Committee for Quality Assurance http://www.ncqa.org
National Business Group on Health
https://www.businessgrouphealth.org/preventive
/businesscase/index.cfm
Prevention Institute http://www.preventioninstitute.org/
Robert Wood Johnson Foundation http://www.rwjf.org/e n.html
Trust for America’s Health (TFAH)
http://healthyamericans.org/reports/
U.S. Department of Health & Human Services
Office of Assistant Secretary for Planning &
Evaluation
http://aspe.hhs.gov
Wellness Council of America (WELCOA)
http://www.welcoa.org/resources/
http://www.heart.org/HEARTORG/GettingHealthy/WorkplaceW

ellness/Workplace-Wellness_UCM_460416_SubHomePage.jsp
http://www.cdc.gov/nchs/
http://www.cdc.gov/niosh/twh/default.html
http://www.cdc.gov/workplacehealthpromotion/
http://ctb.ku.edu/en
http://www.ncqa.org
https://www.businessgrouphealth.org/preventive/businesscase/in
dex.cfm
http://www.preventioninstitute.org/
http://www.rwjf.org/en.html
http://healthyamericans.org/reports/
http://aspe.hhs.gov
http://www.welcoa.org/resources/
Roux, & Swartz, 2014, p. 1). Because it is derived from a
scientific process, objective evi-
dence is seen as a higher quality of evidence. Planners should
strive to use the best evidence
possible but also understand that “evidence is usually
imperfect” (Brownson, Baker, Leet,
Gillespie, & True, 2011, p. 6) and, as planners, they will often
be faced with having to use

the best evidence available (Muir Gray, 1997). Over the years,
the number of organizations/
agencies that have worked to identify evidence of various types
of health-related programs
(i.e., health care, disease prevention, health promotion) has
increased (see Box 2.4 for ex-
amples). A most useful source for those planning health
promotion programs is the Guide
to Community Preventive Services, referred to simply as The
Community Guide (CDC,
2015c). The Community Guide summarizes the findings from
systematic reviews of public
health interventions covering a variety of topics. The systematic
reviews are used to answer
several questions (CDC, 2015c, para. 1):
⦁ ⦁ “Which program and policy interventions have been proven
effective?
⦁ ⦁ Are there effective interventions that are right for my
community?
⦁ ⦁ What might effective interventions cost; what is the likely
return on investment?”

The Community Guide was developed and is continually
updated by the nonfederal Task
Force on Community Preventive Services. The Task Force,
which is comprised of public
health experts who are appointed by the director of the CDC, is
charged with reviewing and
assessing the quality of available evidence and developing
appropriate recommendations.
Finally, when preparing a rationale to gain the support of
decision makers, planners
should not overlook the most important resource of any
community—the people who make
up the community. Promoting, maintaining, and in some cases
restoring human health
should be at the core of any health promotion program.
Whatever the setting, better health
of those in the priority population provides for a better quality
of life. For those planners
who end up practicing in a worksite setting, the importance of
protecting the health of em-
ployees (i.e., protecting human resources) should be noted in
developing a rationale. “Labor
costs typically represent 60% to 70% of total annual operating
costs for most organizations”

(Chapman, 2006, p. 10); thus people are a company’s single
biggest asset. “Fit and healthy
people are more productive, are better able to meet extra
ordinary demands and deal with
stress, are absent less, reflect better on the company or
community as exemplars, and so
forth” (Chapman, 2006, p. 29).
Step 2: title the Rationale
Once planners have identified and are familiar with the sources
of information and data that
can be used to sell program development, they are ready to
begin the process of putting a ra-
tionale together. Thus, the next step is giving a title to the
rationale. This can be quite simple
in nature, such as “A Rationale for (Title of Program): A
Program to Enhance the Health of
(Name of Priority Population).” Immediately following the title
should be a listing of who
contributed to the authorship of the rationale.
Step 3: Writing the Content of the Rationale
The first paragraph or two of the rationale should identify the

health problem from a
“global perspective.” By global perspective we mean presenting
the problem using informa-
tion and data at the most macro level (whether it be
international, national, regional, state,
2.4
Box
the Campbell Collaboration
Type of evidence: Produces systematic
reviews on the effects of social
interventions in crime and justice,
education, international development,
and social welfare.
Website: http://www
.campbellcollaboration.org/

Centre for Reviews and Dissemination;
the University of york
Type of evidence: Synthesized research
evidence on various topics including
health technology assessment, public
health, and child health.
Website: http://www.york.ac.uk/crd/
Cochrane
Type of evidence: Synthesized research
evidence on health and health care. Can
be searched using various terms including
health education and health promotion.
Website: http://www.cochrane.org/
Canadian task Force on preventive
Health Care
Type of evidence: Practice guidelines
that support primary care providers in
delivering preventive health care. Also,

has information for general public.
Website: http://www.canadiantaskforce.ca
Health Evidence, McMaster University,
Canada
Type of evidence: Effectiveness of public
health interventions in Canada.
Website: http://healthevidence.org
national Cancer institute
Document: Research-tested Intervention
Programs
Type of evidence: A searchable database
of cancer control interventions and
program materials that are designed to
provide program planners and public
Examples of Sources of Evidence
health practitioners easy and immediate

access to research-tested materials.
Website: http://rtips.cancer.gov/rtips
/index.do
Substance Abuse and Mental Health
Services
Document: National Registry of Evidence-
based Programs and Practices
Type of Evidence: Searchable online
registry of substance abuse and mental
health interventions.
Website: http://nrepp.samhsa.gov
task Force on Community preventive
Services
Document: Guide to Community
Preventive Services
Type of evidence: Programs and policies
to improve health and prevent disease in

communities.
Website: http://www.thecommunityguide
.org
U.S. preventive Services task Force
Document: The Guide to Clinical
Preventive Services
Type of evidence: Recommendations on
the use of screening, counseling, and
other preventive services that are typically
delivered in primary care settings.
Website: http://www.ahrq.gov
/professionals/clinicians-providers
/guidelines-recommendations/uspstf
/index.html
World Health organization
Document: Health Evidence Network (HEN)
Type of evidence: Summarized evidence

for public health, health care, and health
systems policymakers.
Website: http://www.euro
.who.int/en/data-and-evidence
/evidence-informed-policy-making
/health-evidence-network-hen
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http://www.campbellcollaboration.org/
http://www.york.ac.uk/crd/
http://www.cochrane.org/
http://www.canadiantaskforce.ca
http://healthevidence.org
http://rtips.cancer.gov/rtips/index.do
http://nrepp.samhsa.gov
http://www.thecommunityguide.org
http://www.ahrq.gov/professionals/clinicians-

providers/guidelines-recommendations/uspstf/index.html
http://www.euro.who.int/en/data-and-evidence/evidence-
informed-policy-making/health-evidence-network-hen
http://www.campbellcollaboration.org/
http://rtips.cancer.gov/rtips/index.do
http://www.euro.who.int/en/data-and-evidence/evidence-
informed-policy-making/health-evidence-network-hen
http://www.ahrq.gov/professionals/clinicians-
providers/guidelines-recommendations/uspstf/index.html
or local) possible. In other words, begin the rationale by
presenting the problem at the most
macro level for which supporting data are available. So, if there
is international informa-
tion and data on the problem, say for example HIV/AIDS, begin
describing the problem at
that level. If data are not available to present the problem at the
international level, say for
example people without health insurance, move down to next
level where the presentation
can be supported with data. If available, also include the

economic costs of such a problem;
it will strengthen the rationale. “Much of the decision-making
that occurs, for change to
take place in an organization is based on financial
considerations, and any change within
an organization typically must be supported by a positive return
on investment. Lacking
sound financial support or a firm understanding of the financial
implications, a good idea
may not be realized in practice” (Gambatese, 2008, p. 153).
Most health problems are also
present at other levels. Presenting the problem at these higher
levels shows decision makers
that dealing with the health problem is consistent with the
concerns of others.
Showing the relationship of the health problem to the “bigger
problem” at the interna-
tional, national, and/or state levels is the next logical step in
presenting the rationale. Thus,
the next portion of the rationale is to identify the health
problem that is the focus of the
rationale. This declaration of the health problem is referred to
as the problem statement or
statement of the problem. The problem statement should begin

with a concise explanation of
the issue that needs to be addressed (WKKF, 2004). The
statement should also include why it
is a problem and why it should be dealt with (see Box 2.5). If
available, the statement should
also include supporting data for the problem. Such data may
come from a needs assessment
if it has already been completed or from related literature.
2.5
Box Examples of problem Statements
For a local-level program
The number of children entering kindergarten who have not
received two doses of the
measles-mumps-rubella (MMR) vaccine in Mitchell County
continues to increase. In
the 2011–12 school year, 95% of the children who entered
kindergarten had received
two doses, while only 91% were immunized properly in 2015–
16. Because the number
of cases of MMR does not seem too high to parents/guardians,
many do not feel it is

necessary to subject their children to immunizations. Infectious
diseases remain a major
cause of illness, disability, and mortality. “Vaccines are among
the most cost-effective
clinical preventive services and are a core component of any
preventive services package.
Childhood immunization programs provide a very high return on
investment” (USDHHS,
2015c, para. 6).
For a state-level program
Overweight and obesity are critical health threats facing the
state of ABC. Between 2012
and 2015, the percentage of overweight adults in ABC increased
from 34% to 35%, while
the percentage of obese adults increased from 30% to 32%.
Overweight and obesity
are caused by an imbalance in the calories consumed vs.
calories burned ratio. Both
overweight and obesity increase the risks for heart disease,
stroke, diabetes, and cancer.
The annual costs (direct and indirect) of these diseases to the
state have been estimated
at $25 billion. There is good evidence that shows both the

physical and financial costs of
overweight and obesity are preventable.
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In presenting the problem statement you may find it useful to
use the technique of
social math. Social math has been defined as “the practice of
translating statistics and
other data so they become interesting to the journalist, and
meaningful to the audience”
(Dorfman, Woodruff, Herbert, & Ervice, 2004, p. 112). In other
words, data, especially large
numbers, are presented in such a way that makes them easier to
grasp by putting them in

a context that gives instant meaning. “It is critical to select a
social math fact that is 100
percent accurate, visual if possible, dramatic, and appropriate
for the target audience”
(NCIPC, 2008, 17). For example, $2.9 trillion was spent on
health in 2013 in the United
States (CMS, 2015b); 2.9 trillion is a large number and hard “to
put our heads around.”
But equating that number with spending $9,255 for every person
in the United States
(CMS, 2015b) that year makes the number more
comprehensible. Or, we could present the
$2.9 trillion in social math terms by saying if every dollar
equaled one second, then $2.9
trillion would equal 92,211 years! (See Box 2.6 for other
examples.)
2.6
Box Examples of Social Math
⦁ ⦁ Break the numbers down by time.
If you know the amount over a year, what does that look like
per hour? Per minute?

For example, the average annual salary of a childcare worker
nationally is $15,430,
roughly $7.42 per hour. While many people understand that an
annual salary of
$15,430 is low, breaking the figure down by the hour reinforces
that point—and
makes the need for some kind of intervention even more clear.
⦁ ⦁ Break down the numbers by place.
Comparing a statistic with a well-known place can give people a
sense of the statistic’s
magnitude. For instance, approximately 250,000 children are on
waiting lists for
childcare subsidies in California. That’s enough children to fill
almost every seat in
every Major League ballpark in California. Such a comparison
helps us visualize the
scope of the problem and makes a solution all the more
imperative.
⦁ ⦁ Provide comparisons with familiar things.
Providing a comparison to something that is familiar can have
great impact. For

example, “While Head Start is a successful, celebrated
educational program, it is so
underfunded that it serves only about three-fifths of eligible
children. Applying that
proportion to social security would mean that almost a million
currently eligible seniors
wouldn’t receive benefits.”
⦁ ⦁ Provide ironic comparisons.
For example, the average annual cost of full-time, licensed,
center-based care for
a child under age 2 in California is twice the tuition at the
University of California
at Berkeley. What’s ironic here is how out of balance our public
conversation is.
Parents and the public focus so much on the cost of college
when earlier education is
dramatically more expensive.
⦁ ⦁ Localize the numbers.
Make comparisons that will resonate with community members.
For example, saying,
“Center-based childcare for an infant costs $11,450 per year in

Seattle, Washington,”
is one thing. Saying, “In Seattle, Washington, a father making
minimum wage would
have to spend 79 percent of his income per year to place his
baby in a licensed care
center,” is much more powerful because it illustrates why it is
nearly impossible.
Source: National Center for Injury Prevention and Control
(2008; revised 2010). Adding Power to Our Voices: A Framing
Guide for Communicating About
Injury. Atlanta, GA: Author. Retrieved May 14, 2015, from
http://www.cdc.gov/injury/pdfs/cdcframingguide-a.pdf
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http://www.cdc.gov/injury/pdfs/cdcframingguide-a.pdf

At this point in the rationale, propose a solution to the problem.
The solution should
include the name and purpose of the proposed health promotion
program, and a general
overview of what the program may include. Since the writing of
a program rationale often
precedes much of the formal planning process, the general
overview of the program is often
based upon the “best guess” of those creating the rationale. For
example, if the purpose of a
program is to improve the immunization rate of children in the
community, a “best guess”
of the eventual program might include interventions to increase
awareness and knowledge
about immunizations, and the reduction of the barriers that limit
access to receiving immu-
nizations. Following such an overview, include statements
indicating what can be gained
from the program. Do your best to align the potential values and
benefits of the program
with what is important to the decision makers.
Next, state why this program will be successful. This is the

place to use the results of
evidence-based practice to support the rationale. It can also be
helpful to point out the similarity
of the priority population to others with which similar programs
have been successful. And
finally, using the argument that the “timing is right” for the
program can also be useful. By
this we mean that there is no better time than now to work to
solve the problem facing the
priority population.
Step 4: listing the References Used to Create the Rationale
The final step in creating a rationale is to include a list of the
references used in preparing
the rationale. Having a reference list shows decision makers
that you studied the available
information before presenting your idea. (See Box 2.7 for an
example of a program rationale.)
2.7
Box Example program Rationale
A Rationale for a Comprehensive tobacco Control program in

philadelphia
County, pennsylvania
The World Health Organization (WHO) has noted that
tobacco “is one of the biggest
public health threats the world has ever faced, killing nearly six
million people a year.
More than five million of those deaths are the result of direct
tobacco use while more
than 600,000 are the result of non-smokers being exposed to
second-hand smoke.
Approximately one person dies every six seconds due to
tobacco, accounting for one in
10 adult deaths” (WHO, 2014, para. 4). In addition, it has been
estimated that up to 50%
of current users will die of a tobacco-related disease (WHO,
2014). To further quantify
the burden of tobacco on the people of the world is to note that
six million deaths is the
equivalent of losing the entire population of the state of
Maryland each year.
The impact of tobacco use and secondhand smoke exposure has
also been a problem
in the United States. In 2013, the percentage of adult (> 18

years of age) smokers in
United States was 17.8%, which is the lowest it has ever been,
but it still totals 42.1
million people. Tobacco is the single most preventable cause of
disease, disability,
and death in the United States (CDC, 2014), and accounts for
approximately 480,000
deaths per year. It has been estimated that 41,000 of those
deaths are of non-smokers
exposed to secondhand smoke (CDC, 2015b). In total, tobacco
use and secondhand
smoke exposure are responsible for 20% of all deaths in the
United States each year. In
addition, more than 16 million Americans are living with a
disease caused by smoking
(CDC, 2015b). That means for every person who dies because of
smoking, at least
A
pp
lic
at
io

n
2.7
Box
continued
30 people live with a serious smoking-related illness. Smoking
causes cancer, heart
disease, stroke, lung diseases, diabetes, and chronic obstructive
pulmonary disease
(COPD), which includes emphysema and chronic bronchitis, and
it also increases risk
for tuberculosis, certain eye diseases, and problems of the
immune system, including
rheumatoid arthritis (CDC, 2015d).
In addition to the costly physical burden of tobacco use and
secondhand smoke
exposure in the United States, there is also a significant
economic cost. The total

financial burden of tobacco to the United States is more than
$300 billion per year.
This includes $170 billion in direct medical costs and more than
$156 billion in lost
productivity due to premature death and exposure to secondhand
smoke (CDC, 2015c).
Tobacco use and secondhand smoke exposure are also concerns
for the residents
of Pennsylvania. While the current national percentage of adult
cigarette smokers is
17.8%, the current percentage of smokers in Pennsylvania is
21.0% (CI 19.9-22.0%)
(CDC, 2015a). In addition, just over 4% of those residing in
Pennsylvania use chewing
tobacco, snuff, or snus (CDC, 2015a). Locally, the burden of
tobacco use is even greater.
Philadelphia County Pennsylvania, which is conterminous with
the City of Philadelphia,
is home to more than 1.5 million people. The current percentage
of adult smokers in
Philadelphia County is 23% (CI 22-25%) (University of
Wisconsin [UW], 2015), which
is clearly above both the state and national averages. In fact,
Philadelphia has the

highest rate of adult smoking among the 10 largest U.S. cities
(CDC, 2013). Further,
Philadelphia County is ranked last out of the 67 counties in
Pennsylvania in both
health outcomes and health factors (UW, 2015). The three
leading causes of death in
Philadelphia County are heart diseases, cancer, and stroke. All
three of these causes
have a common risk factor—smoking. Philadelphia County has
implemented several
interventions to reduce smoking including a public education
program to encourage
adults to quit, a clean indoor air ordinance, an ordinance to
eliminate smoking at the
city-owned outdoor recreational facilities, and compliance
checks to ensure retailers
are properly checking for identification before selling tobacco
products (CDC, 2013).
Although each of these efforts can contribute to the reduction in
smoking, more needs
to be done.
To reduce the prevalence of smoking in a community the CDC
has recommended a
comprehensive approach, which it has outlined in a document

titled Best Practices for
Comprehensive Tobacco Control Programs–2014 (CDC, 2014).
The program includes five
components: 1) state and community interventions, 2) mass-
reach health communication
interventions, 3) cessation interventions, 4) surveillance and
evaluation, and 5)
infrastructure administration and management.
The goals of such a program are to:
⦁ ⦁ “Prevent initiation among youth and young adults.
⦁ ⦁ Promote quitting among adults and youth.
⦁ ⦁ Eliminate exposure to secondhand smoke.
⦁ ⦁ Identify and eliminate tobacco-related disparities among
population groups”
(CDC, 2014, p. 9).
This approach is not without its merits, it is recommended based
on solid evidence.
“The Community Preventive Services Task Force recommends
comprehensive tobacco

control programs based on strong evidence of effectiveness in
reducing tobacco use
and secondhand smoke exposure. Evidence indicates these
programs reduce the
prevalence of tobacco use among adults and young people,
reduce tobacco product
consumption, increase quitting, and contribute to reductions in
tobacco-related diseases
2.7
Box
and deaths. Economic evidence indicates that comprehensive
tobacco control programs
are cost-effective, and savings from averted healthcare costs
exceed intervention costs”
(CPSTF, 2014, para. 1).
After reviewing the data, it is clear that there is a significant
smoking problem

in Philadelphia County Pennsylvania. In order to deal with this
problem, it is
recommended that the Coalition for a Smokefree Philadelphia
County build a
comprehensive tobacco control program based on Best Practices
for Comprehensive
Tobacco Control Programs– 2014 but adapt it to fit the
population of Philadelphia
County. The National Association of County and City Health
Officials has created the
“Guidelines for Comprehensive Local Tobacco Control
Programs” (CDC, 2014) to show
how the best practice guidelines can be adapted to a local level.
It is also recommended
that the Coalition begin its work by reviewing the existing
tobacco prevention programs
in the county. Those current activities that are in line with best
practices should be
keep, and those that are not should either be modified to be in
line with the best
practices or be dropped.
A comprehensive tobacco program has great potential for
success in Philadelphia
County for several reasons. First, it would be an evidence-based

program with solid
science to back it up. Second, similar programs in other large
cities in the United States
have been successful (CDC, 2014). And third, the program will
be well planned and
tailored to the residents of Philadelphia County. There is no
better time than now to
invest in the health of the people of Philadelphia County
Pennsylvania!
References
Centers for Disease Control and Prevention. (2015a).
Behavioral risk factor surveillance system:
Prevalence and trends data, Pennsylvania – 2013. Retrieved
May 16, 2015 from http://apps.nccd
.cdc.gov/brfss/page.asp?cat=TU&yr=2013&state=PA#TU
Centers for Disease Control and Prevention. (2014). Best
practices for comprehensive tobacco control
programs–2014. Atlanta, GA: U.S. Department of Health, CDC,
National Center for Chronic Disease
Prevention and Health Promotion, Office of Smoking and
Health. Retrieved May 16, 2015 from
http://www.cdc.gov/tobacco/stateandcommunity/best_practices/

pdfs/2014/comprehensive.pdf
Centers for Disease Control and Prevention. (2013). Community
profile: Philadelphia,
Penn-sylvania. Retrieved May 16, 2015 from
http://www.cdc.gov/nccdphp/dch/programs
/CommunitiesPuttingPreventiontoWork/communities/profiles/bo
th-pa_philadelphia.htm
Centers for Disease Control and Prevention. (2015b). Current
cigarette smoking among adults in
the United States. Retrieved May 16, 2015 from
http://www.cdc.gov/tobacco/data_statistics
/fact_sheets/adult_data/cig_smoking/
Centers for Disease Control and Prevention. (2015c). Economic
facts about U.S. tobacco production
and use. tobacco use: Retrieved May 16, 2015 from
http://www.cdc.gov/tobacco/data_statistics
/fact_sheets/economics/econ_facts/index.htm#costs
Centers for Disease Control and Prevention. (2015d). Smoking
and tobacco use: Fast facts. Retrieved
May 16, 2015 from
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_fact

s/index.htm
Community Preventive Services Task Force (CPSTF). (2014).
Reducing tobacco use and secondhand
smoke exposure: Comprehensive tobacco control programs.
Retrieved May 16, 2015 from http:
//www.thecommunityguide.org/tobacco/comprehensive.html
University of Wisconsin Population Health Institute (2015).
County health rankings & roadmaps.
Retrieved May 16, 2015 from
World Health Organization. (2014). Tobacco. Retrieved May 16,
2015 from http://www.who.int
/mediacentre/factsheets/fs339/en/
World Health Organization. (2015). WHO global report on
trends in prevalence of tobacco smoking 2015.
Retrieved May 16, 2015 from
http://apps.who.int/iris/bitstream/10665/156262/1/97892415649
22
_eng.pdf?ua=1
continued

http://apps.nccd
http://www.cdc.gov/tobacco/stateandcommunity/best_practices/
pdfs/2014/comprehensive.pdf
http://www.cdc.gov/nccdphp/dch/programs/CommunitiesPutting
PreventiontoWork/communities/profiles/both-
pa_philadelphia.htm
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_da
ta/cig_smoking/
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economi
cs/econ_facts/index.htm#costs
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_fact
s/index.htm
http://www.thecommunityguide.org/tobacco/comprehensive.htm
l
http://www.who.int/mediacentre/factsheets/fs339/en/
22_eng.pdf?ua=1
http://www.cdc.gov/nccdphp/dch/programs/CommunitiesPutting
PreventiontoWork/communities/profiles/both-
pa_philadelphia.htm
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_da
ta/cig_smoking/
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economi

cs/econ_facts/index.htm#costs
http://www.who.int/mediacentre/factsheets/fs339/en/
22_eng.pdf?ua=1
Planning Committee
The number of people involved in the planning process is
determined by the resources and
circumstances of a particular situation. “One very helpful
method to develop a clearer and
more comprehensive planning approach is to establish a
committee” (Gilmore, 2012, p. 35).
Identifying individuals who would be willing to serve as
members of the planning com-
mittee (sometimes referred to as a steering committee or
advisory board or planning
team) becomes one of the planner’s first tasks. Because an
effective planning committee is
usually composed of interested and well-respected individuals,
it is important to establish it
carefully (Chapman, 2009).

When composing a planning committee it is also a good time to
consider the concept of
partnering to meet the eventual goals of the program that will be
planned. Partnering can
be defined as the association of two more entities (i.e.,
individuals, groups, agencies, organi-
zations) working together on a project of common interest. Such
associations usually means
sharing of resources and tasks to be completed. There are a
number of reasons to partner and
include things such as: 1) meeting the needs of a priority
population which could not be
met by the capacities of an individual partner, 2) sharing of
financial and other resources, 3)
solving a problem or achieving a goal that is a priority to
several partners, 4) bringing more
stakeholders to the “table,” 5) bringing more credibility to the
program, 6) working with oth-
ers that have the same values (Picarella, 2015), 7) seeing and
solving a problem from multiple
perspectives and thus creating different effects (Schiavo 2014),
and 8) creating a greater re-
sponse to a need because there is strength in numbers.

In looking for partners (sometimes referred to as collaborators)
planners should consider
these questions: 1) Who is also interested in meeting the needs
of the priority population?
2) Who also sees the unmet need of a priority population as a
problem? 3) Who has unused
resources that could help solve a problem? and 4) Who would
benefit from being your part-
ner? The Prevention Institute has created an interactive
framework and tool for analyzing
collaborative efforts. The framework/tool, called the
Collaborator Multiplier, is “based on
the understanding that sectors often have different
understandings of issues and divergent
reasons for engaging in the same effort” (Prevention Institute,
2011, para. 2) (see the link for
the Website in the Weblinks section at the end of the chapter).
Here are some examples of
groups who could become partners: two non-governmental
health agencies who are both
interested in seeing the reduction in smoking rates, a local
service organization (i.e., Lions
Club, Kiwanis) and a school-based clinic to improve student
health, an employer and a
health insurance carrier to improve the quality of life for

employees, and a local health de-
partment and pro-environmental group working to improve the
air quality in a community.
After consideration is given to forming partnerships, thought
needs to be given to the
size of the planning committee. The number of individuals on a
planning committee can
differ depending on the setting for the program and the size of
the priority population. For
example, the size of a planning committee for an obesity
program in a community of 50,000
people would probably be larger than that of a committee
planning a similar program for a
business with 50 employees. There is no ideal size for a
planning committee, but the follow-
ing 10 guidelines, which have been presented earlier
(McKenzie, 1988) and are given here in
a modified form with updates, should be helpful in setting up a
committee.

1. The committee should be composed of individuals who
represent a variety of
subgroups within the priority population. To the extent possible,
the committee
should have representation from all segments of the priority
population (e.g.,
administrators/students/teachers, age groups, health behavior
participants/
nonparticipants, labor/management, race/ethnic groups,
different genders,
socioeconomic groups, union/nonunion members). The greater
the number of
individuals who are represented by committee members, the
greater the chance of
the priority population developing a feeling of program
ownership. With program
ownership there will be better planned programs, greater
support for the programs,
and people who will be willing to help sell the program to
others because they feel it
is theirs (Strycker et al., 1997).
2. If the program that is being planned deals with a specific
health risk or problem, then it
would be important that someone with that health risk (e.g.,

smoker) or problem (e.g.,
diabetes) be included on the planning committee (Bartholomew,
Parcel, Kok, Gottlieb &
Fernández, 2011).
3. The committee should include willing individuals who are
interested in seeing the
program succeed. Select a combination of doers and influencers.
Doers are people
who will be willing to “roll up their sleeves” and do the
physical work needed to see
that the program is planned and implemented properly.
Influencers are those who
with a single phone call, email, or signature on a form will
enlist other people to
participate or will help provide the resources to facilitate the
program. Both doers
and influencers are important to the planning process.
4. The committee should include an individual who has a key
role within the organization
sponsoring the program—someone whose support would be
most important to ensure
a successful program and institutionalization.

5. The committee should include representatives of other
stakeholders (any person
or organization with a vested interest in a program) not
represented in the priority
population. For example, if health care providers are needed to
implement a health
promotion program they need to be represented on the planning
committee.
6. The committee membership should be reevaluated regularly
to ensure that the
composition lends itself to fulfilling program goals and
objectives.
7. If the planning committee will be in place for a long period
of time, new individuals
should be added periodically to generate new ideas and
enthusiasm. It may be helpful
to set a term limits for committee members. If terms of office
are used, it is advisable
to stagger the length of terms so that there is always a
combination of new and
experienced members on the committee.
8. Be aware of the “politics” that are always present in an

organization or priority
population. There are always some people who bring their own
agendas to
committee work.
9. Make sure the committee is large enough to accomplish the
work, but small enough
to be able to make decisions and reach consensus. If necessary,
subcommittees can be
formed to handle specific tasks.
10. In some situations there might be a need for multiple layers
of planning committees.
If the priority population is highly dispersed geographically
and/or broken into
decentralized subgroups (e.g., various offices of the same
corporation, or several
different local groups within the same state, or different
buildings within a school
corporation), these various subgroups may need their own local

planning committee
that operates with some latitude but maintains and complements
the core planning
committee as the base of the program (Chapman, 2009).
The actual means by which the committee members are chosen
varies according to the
setting. Five commonly used techniques are:
1. Asking for volunteers by word of mouth, a newsletter, a
needs assessment, or some
other widely distributed publication
2. Holding an election, either throughout the community or by
subdivisions of the
community
3. Inviting/recruiting people to serve
4. Having members formally appointed by a governing group or
individual
5. Having an application process then selecting those with the
most desirable characteristics

Once the planning committee has been formed, someone must
be designated to lead it.
This is an important step (Strycker et al., 1997). The leader
(chairperson) should be interested
and knowledgeable about health promotion programs, and be
organized, enthusiastic, and
creative (McKenzie, 1988). One might think that most planners,
especially health education
specialists, would be perfect for the committee chairperson’s
job. However, sometimes it is
preferable to have someone other than the program planners
serve in the leadership capacity.
For one thing, it helps to spread out the workload of the
committee. Planners who are not good
at delegating responsibility may end up with a lot of extra work
when they serve as the lead-
ers. Second, having someone else serve as the leader allows the
planners to remain objective
about the program. And third, the planning committee can serve
in an advisory capacity to
the planners, if this is considered desirable. Figure 2.2
illustrates the composition of a balanced
planning committee.
Once the planning committee has been organized and a leader is

selected, the com-
mittee needs to be well organized and well run to be effective.
The committee should
meet regularly, have a formal agenda for each meeting, and
keep minutes of the meet-
ings (Hunnicutt, 2007). Further, the committee meetings should
be efficient, not long
and boring (Johnson & Breckon, 2007). In other words,
meetings should be productive
and represent a good use of the committee members’ time. In
addition, it is important for
the committee to communicate frequently both with the decision
makers and those in
the priority population so that all can be kept informed. By
communicating regularly, the
committee has the unique opportunity to educate and inform
others about health and the
specific priorities of the program (Hunnicutt, 2007).
Representatives
of all segments of
priority population
Representative
of sponsoring

agency
Good
leadership
Doers Influencers+ + + +
Other
stakeholders
+
Solid
committee
=
⦁ ▲ Figure 2.2 Makeup of a Solid Planning/Steering Committee
Parameters for Planning
Once the support of the decision makers has been gained and a
planning committee formed,

the committee members must identify the planning parameters
within which they will
work. There are several questions to which committee members
should have answers before
they become too deeply involved in the planning process. In an
earlier work (McKenzie,
1988), several such questions were presented, using the example
of school-site health pro-
motion programs. The questions are modified for presentation
here. It should be noted,
however, that not all of the questions would be appropriate for
every program because of the
different circumstances of each setting and the answers to some
of the questions may have
already been obtained during pre-planning.
1. What is the decision makers’ philosophical perspective on
health promotion
programs? What are the values and benefits of the programs to
the decision
makers (Chapman, 1997)? Do they see the programs as
something important or
as “extras”?
2. What type of commitment are decision makers willing to

make to the program?
Are they interested in the program becoming institutionalized?
That is, are
they interested in seeing that the “program becomes imbedded
within the host
organization, so that the program becomes sustained and
durable” (Goodman et al.,
1993, p. 163)? Or are they more interested in providing a one-
time or pilot program?
(Note: Goodman and colleagues [1993] have developed a scale
for measuring
institutionalization.)
3. What type of financial support are decision makers willing to
provide? Does it include
personnel for leadership and clerical duties? Released/assigned
time for managing the
program and participation? Space? Equipment? Materials?
4. Are decision makers willing to consider changing the
organizational culture so
that there is a culture of health (Terry, 2012)? That is, are
decision makers interested
in establishing a health supporting culture (Golaszewski, Allen,
& Edington,

2008) that is based on health-related values, beliefs, and
practices? Among other
things, such a culture might include health-supporting policies,
services, and
facilities. For example, are they interested in “well” days
instead of sick days?
Are they as interested in presenteeism—that is, showing up for
work even if one
is too ill, stressed, or distracted to be productive—as much as
they are interested
in absenteeism? Would they like to create employee
nonsmoking and safety belt
policies? Change vending machine selections to more nutritious
foods? Set aside
an employee room for meditation? Develop a health promotion
page on the
organization’s Website?
5. Will all individuals in the priority population have an
opportunity to take advantage
of the program, or will it be available to only certain
subgroups?
6. What type of committee will the planning committee be? Will
it be a permanent or a

temporary (ad hoc) committee (Hitt, Black, & Porter, 2012)? A
permanent committee
would indicate that decision makers want the planning
committee to be a part of the
ongoing structure of the organization.
7. What is the authority of the planning committee? Will it be
an advisory group or
a programmatic decision-making group? What will the chain of
command be for
program approval?
After the planning parameters have been defined, the planning
committee should under-
stand how the decision makers view the program, and should
know what type and number
of resources and amount of support to expect. Identifying the
parameters early will save the
planning committee a great deal of effort and energy throughout
the planning process.

Summary
Creating a program rationale to gain the support of decision
makers is an important initial
step in program planning. Planners should take great care in
developing a rationale for
“selling” the program idea to these important people. The
rationale should show how the
benefits of the program align with the values of the decision
makers, address the potential
return on investment, and be backed by the best evidence
available. A program rationale can
be written using the following four steps: (1) Identify
appropriate background information,
(2) title the rationale, (3) write the content of the rationale, and
(4) list the references used to
create the rationale. A planning committee can be most useful in
helping with some of the
planning activities and in helping to sell the program to the
priority population. When the
planning committee is being formed consider potential
collaborating partners. Planning
committee members should include program stakeholders
including interested individuals,
doers and influencers, and others who are representative of the

priority population. If the
planning committee is to be effective, it will need to work
efficiently and to know the plan-
ning parameters set for the program by the decision makers.
Review Questions
1. What is the reason for creating a program rationale?
2. Why is the support of decision makers important in planning
a program?
3. What kinds of reasons should be included in a rationale for
planning and
implementing a health promotion program?
4. How important is selling the idea of a program to decision
makers?
5. What items should be addressed when creating a program
rationale?
6. What is a problem statement? What does it include?
7. What is social math? Give an example of how it could be

used in a program rationale.
8. Who would make good planning partners?
9. Who should be selected as the members of a planning
committee?
10. What are planning parameters? Give a few examples.
11. Why is it important to know the planning parameters at the
beginning of the
planning process?
Activities
1. Write a two-page rationale that sells a program you are
planning to decision makers,
using the guidelines presented in this chapter.
2. Write a two-page rationale for beginning an exercise program
for a company with 200

employees. A needs assessment of this priority population
indicates that the number
one cause of lost work time in this cohort is back problems and
the number one cause of
premature death is heart disease.
3. Select a disease (e.g., diabetes, cancer, heart disease) or a
health behavior (e.g., physical
inactivity, smoking) and write a paragraph describing the health
problem using social math.
4. Visit the Websites of the Community Preventive Services
Task Force (CPSTF) and U.S.
Preventive Services Task Force (USPSTF)—see Box 2.4 for
URLs of the Websites. At the
two sites, find out what the recommendations are for clinical
skin cancer screenings and
educational programs for skin cancer. Summarize your findings
in one to two paragraphs.
Based on the recommendations, write another one to two
paragraphs describing what
advice you would give with regard to future health promotion
programming to a
community coalition that is trying to reduce the number of cases
of skin cancer in its

community.
5. For a program you are planning, write a two-page description
of the individuals (by
position/job title, not name) who will be asked to serve on the
planning committee, and
provide a rationale for asking each to serve. Also, list any other
agencies/organization
who you believe would make good partners.
6. Provide a list (by position/job title, not name) and a rationale
for each of the 10
individuals you would ask to serve on a community-wide safety
belt program. Use the
town or city in which your college/university is located as the
community.
7. Read the example rationale presented in Box 2.7 and then
critique it using the guidelines
presented in this chapter. Critique by describing the following:
(a) the strengths of the
rationale, (b) the weaknesses, and (c) how you would change the
rationale to make it
stronger. Be critical! Closely examine the content, reasoning,
and references.

Weblinks
1. http://www.thecommunityguide.org
Guide to Community Preventative Services
This Webpage includes evidence-based recommendations for
programs and policies to
promote population-based health from the Community
Preventive Services Task Force
(CPSTF).
2. https://new.wellsteps.com/
WellSteps
This is the home page for WellSteps, a company that helps other
companies create
worksite wellness programs. At the site you will find a number
of different resources and
tools that can assist you as you begin the planning process. One
tool found at this site is
the return on investment (ROI) calculator for health care costs
[https://www.wellsteps
.com/roi/resources_tools_roi_cal_health.php] that can help you
determine if a health
promotion for a company would make good economic sense.

3. http://www.countyhealthrankings.org
County Health Rankings
At this Website you will find a set of reports that rank the
overall health of every county
in the United States. If you are planning county-wide programs
you will find this to be a
https://new.wellsteps.com/
https://www.wellsteps.com/roi/resources_tools_roi_cal_health.p
hp
https://www.wellsteps.com/roi/resources_tools_roi_cal_health.p
hp
http://www.countyhealthrankings.org
valuable resource when creating rationales. The County Health
Rankings are a part of the
a collaboration between the Robert Wood Johnson Foundation
and the University of
Wisconsin Population Health Institute.

4. http://www.astho.org
Association of State and Territorial Health Officials (ASTHO)
ASTHO is the national nonprofit organization representing the
state and territorial public
health agencies of the United States, the U.S. Territories, and
the District of Columbia.
This Website has links to all the state and territorial health
departments. If you are
planning a program for the community setting, this site contains
a lot of information
that could help you develop a rationale for your program.
5. http://www.preventioninstitute.org/index.php
Prevention Institute
This Website is the home page of the Prevention Institute, a
California-based
organization that works from the approach of what can be done
before people become
ill or injured.
6. http://www.cdc.gov/chronicdisease/calculator/index.html
Chronic Disease Cost Calculator, Version 2
This Webpage presents background information and download
links to the user guide

and Chronic Disease Cost Calculator, Version 2.
http://www.astho.org
http://www.preventioninstitute.org/index.php
http://www.cdc.gov/chronicdisease/calculator/index.html
41
A key role, if not the central role, of the health education
specialist is planning,
implementing, and evaluating programs. Box 3.1 identifies the
responsibilities and com-
petencies for health education specialists that pertain to the
material presented in this
chapter. Good health promotion programs are not created by
chance; they are the product
of coordinated effort and are usually based on a systematic
planning model or approach.
Planning models, which are visual representations and
descriptions of steps or phases in the

planning process are the means by which structure and
organization are given to the suc-
cessful development and delivery of health promotion programs.
Models provide planners
with direction and a framework from which to build
interventions that can improve the
health of individuals and communities.
Through the years, various planning models have been
developed and presented for
health promotion with varying degrees of acceptance and use.
Although these models
share common elements, they often label and describe these
elements differently, giving
the impression that something unique and meaningful has been
offered. However, when
new models emerge and appear novel, they are usually quite
similar to the existing models.
For this reason, we use what we call the Generalized Model to
teach basic principles of plan-
ning and evaluation emphasized in most planning models. With
this as a backdrop, it is
3

Chapter Program Planning Models
in Health Promotion
Chapter Objectives
⦁ ⦁ Explain the value of using a model in planning
a program.
⦁ ⦁ Explain the value of the Generalized Model in
particular.
⦁ ⦁ Identify key models in planning health
promotion programs and briefly describe each.
⦁ ⦁ Identify the basic components of the planning
models presented and how they relate to the
Generalized Model.
⦁ ⦁ Apply a model to a program you are planning.
Key Terms

CHANGE tool
community context
ecological framework
enabling factors
evidence-based
planning
framework for
public health
formative research
Generalized Model
Healthy Communities
Model
Intervention Mapping
Model
MAP-IT Model
MAPP Model
population-based
approach
PRECEDE-PROCEED

Model
predisposing factors
reinforcing factors
SMART Model
three Fs of program
planning
important to note that the Generalized Model is not a new or
unique model either but rather
a simple composite of what is represented in most, if not all
other models. It is presented here
as both a teaching model and framework for professional
practice.
As illustrated in Figure 3.1, the Generalized Model consists of
five basic phases or steps:
(1) assessing needs; (2) setting goals and objectives; (3)
developing interventions; (4) imple-
menting interventions; and (5) evaluating results. In addition,

pre-planning is a quasi-phase
in the model but is not included formally since it involves
actions that occur before plan-
ning technically begins. The first phase in the Generalized
Model, assessing needs, is the
process of collecting and analyzing data to determine the health
needs of a population and
usually includes priority setting and the identification of a
priority population. Setting goals
and objectives identifies what will be accomplished while
interventions or programs are the
means by which the goals and objectives will be achieved (i.e.,
the how). Implementation is
the process of putting interventions into action and evaluation
focuses on both improving
P
r
e
-
p
l
a
n
n

i
n
g
Assessing
needs
Setting goals
and objectives
Developing
interventions
Implementing
interventions
Evaluating
results
Collecting and analyzing data to determine
the health needs of a population; setting
priorities; and selecting a priority population
Improving quality and

determining effectiveness
Putting interventions into action
How goals and objectives
will be achieved
What will be accomplished
⦁ ▲ Figure 3.1 The Generalized Model
3.1
Specialists
This chapter covers planning models as well as other
considerations and criteria
necessary to develop a planning sequence from start to finish.
Responsibilities and
competencies related to the credentialing of health education
specialists in this chapter
include the following:
Area II: Plan Health Education/Promotion

other stakeholders in
the planning process
Competency 2.4: Develop a plan for the delivery of health
education/promotion
(SOPHE).
Chapter 3 Program Planning Models in Health Promotion 43
the quality of interventions (formative evaluation) as well as
determining their effective-
ness (summative evaluation). Collectively, these phases define
planning and evaluation at

its core. To illustrate how planning models in general are
aligned with the phases outlined
in the Generalized Model, we briefly describe seven prominent
models used in health pro-
motion settings. As you read the following descriptions, also
note the many similarities
these models have in common.
Evidence-Based Planning Framework for Public Health
The ultimate goal of any planning effort is to improve health
outcomes. To help ensure
that health outcomes are improved, it is important to use
evidence-based (i.e. effective or
proven) approaches in all phases of planning. Ross Brownson,
one of the premier authori-
ties in evidence-based public health, and by association, health
promotion, has written
extensively on evidence-based outcomes (Brownson, Baker,
Leet, Gillespie, & True, 2011;
Brownson, Fielding, & Maylahn, 2009). Brownson and
associates at the Prevention Research
Center (PRC) at Washington University in St. Louis have
developed a set of seven skills
that collectively serve as an evidence-based planning framework

for public health
(Washington University Prevention Research Center, 2015).
This framework, while not devel-
oped as a planning model per se, is in fact, very similar to most
planning models, including
the Generalized Model. Box 3.2 displays the seven skills or
phases of this framework.
Phases 1–2, community assessment and quantifying the issue,
essentially represent a needs
assessment common to most planning models. In this
framework, community assessment
requires planners to understand the community context, or the
characteristics and cir-
cumstances that define the community, and also understand the
health concerns of com-
munity members and how to implement programs most
effectively to them. Most often, this
requires collecting new data, including a process defined in the
framework as community
audits (i.e. documenting observations about the community).
The community assessment
also involves organizing and examining existing data (e.g.
mortality, morbidity, risk factor
data, etc.). Quantifying the issue (Phase 2), closely related to

Phase 1, is the process of using
descriptive epidemiology (i.e., occurrence and distribution of
disease by person, place, and
time) derived from surveillance systems and other secondary
data sets (i.e., existing data) to
3.2
Box Evidence-Based Planning Framework for Public Health
PHaSE 1 Community Assessment
PHaSE 2 Quantifying the Issue
PHaSE 3 Developing a Concise Statement of the Issue
PHaSE 4 Determining What is Known using Scientific
Literature
PHaSE 5 Developing and Prioritizing Program and Policy
Options
PHaSE 6 Developing an Action Plan and Implementing
Interventions

PHaSE 7 Evaluating the Program or Policy
Source: Washington University Prevention Research Center
(2015). Evidence based public healthcourse. Retrieved from
http://prcstl.wustl.edu/training
/Pages/EBPH-Course-Information.aspx
H
ig
hl
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ht
s
http://prcstl.wustl.edu/training
analyze and display disease frequencies. In this step, data are
also presented in tables and fig-
ures as prevalence or incidence rates, or as percentages, to help
stakeholders make decisions

about health concerns in the community. Combined with data
from community members,
the most significant health problems in the community begin to
emerge (Washington
University Prevention Research Center, 2015).
Phase 3, developing a concise statement of the issue,
summarizes an analysis of root causes
of the most significant health problems in the community. For
example, root causes may
include lack of interventions that address primary risk factors
related to a health problem
or inadequate policies to protect the community from a known
threat. Root causes may
also take the form of social determinants (i.e. inadequate
education, low employment,
high crime, etc., related to health disparities). This analysis
leads to a concise written
statement of root causes, or statement of the issue (Washington
University Prevention
Research Center, 2015).
Phase 4, determining what is known using scientific literature,
directs planners to identify
evidence-based solutions related to the root causes and related

problems identified in the
statement of the issue (Phase 3). Planners search resources such
as the Guide to Community
Preventive Services (CDC, 2015), or scientific journals, books,
government reports, etc.,
and categorize potential solutions as recommended with strong
evidence, recommended
with sufficient evidence, insufficient evidence, and not
recommended (no evidence).
This process leads planners to various interventions that may
effectively address the root
causes of the health problems identified (Washington University
Prevention Research
Center, 2015).
Once potential interventions are examined, Phase 5, developing
and prioritizing program
and policy options, directs planners to prioritize specific
interventions or actions steps using
methods such as the Delphi technique, Nominal Group
technique, Basic Priority Rating
model, multi-level voting, or any other process that is
systematic, objective, and allows for
standardized comparisons (see Chapter 4 for descriptions of
these methods). Planners are

encouraged to identify priorities related to actions that lead to
improved health outcomes
(Washington University Prevention Center, 2015).
Phase 6, developing an action plan and implementing
interventions, is what most plan-
ners would call implementation. In this step, goals and
objectives are developed and action
strategies (i.e. interventions) are planned. Logic models are
developed to visually display
the relationship between inputs (resources) and outputs (what
will be accomplished).
Management of action strategies, personnel, and communication
with partners and
community members are also addressed in this step (Washington
University Prevention
Center, 2015).
Finally, in Phase 7, evaluating the program or policy, planners
take measures to improve the
existing program or policy (i.e. formative evaluation) as well as
measure effectiveness (i.e.
summative, or impact and outcome evaluation). Basic decisions
are made such as whether
to conduct quantitative or qualitative evaluation and whether to

use descriptive or infer-
ential statistics (see Chapter 15 for descriptions). Planners
decide on appropriate outcomes
to measure, then decide how to collect, record, analyze and
disseminate data (Washington
University Prevention Center, 2015). A close examination of the
planning approach used by
Brownson and associates, who are clearly well respected in the
field of evidence-based strate-
gies, not only validates steps used in the Generalized Model,
but also supports the argument
that most planning models are composed of the same basic
elements.
Mobilizing for Action Through Planning
and Partnerships (MAPP)
In 1997, the CDC and the National Association of County and
City Health Officials (NACCHO)
collaborated on the development of a new model and released
the MAPP model—Mobilizing

for Action through Planning and Partnerships in 2000
(NACCHO, 2001). While the MAPP
model was presented as a foundational approach to planning and
evaluation in public health
settings, particularly among local (i.e. city or county) health
departments, it has broad relevance
to all health promotion settings. In fact, the MAPP model is
considered a very robust model in
practice today. Hershey (2011) provides an in-depth case study
of how MAPP can be used suc-
cessfully at the local level.
Use of the MAPP model is intended to improve health and
quality of life through mobi-
lized partnerships and taking strategic action (NACCHO, 2001).
Figure 3.2 displays the six
phases of MAPP as well as the four MAPP assessments.
In the first phase of MAPP, organizing for success and
partnership development, planners
assess whether the MAPP process is timely, appropriate, or even
possible. This involves as-
sessing resources (including budgets), the expertise of available
personnel, support of key
decision makers and other stakeholders, and the general interest

of community members.
If resources are not available, the process is not undertaken. If
the decision is made to pro-
ceed with a MAPP process, the following work groups are
created: (1) a core support team,
which prepares most, if not all of the material needed for the
planning process; (2) the
MAPP committee, composed of key sponsors (usually
influential people or organizations
Organize
for success
Partnership
development
Visioning
Four MAPP assessments
Identify strategic issues
Formulate goals and strategies
Evaluate Plan

Implement
Action
C
om
munity themes and
str
eng
ths assessment
Local p
u
b
lic h
e
a
lth

system
a
sse
ssm
e
nt
status assessmen
t
Community health
F
o
rc
e
s
o
f
ch

a
n
g
e
a
ss
e
ss
m
e
n
t
⦁ ▲ Figure 3.2 Display of the Six Phases of MAPP and the Four
MAPP
Assessments
Source: Achieving Healthier Communities through MAPP: A
User’s Handbook. Copyright © 2009
by the National Association of County and City Health
Officials. Reprinted with permission.

from the private sector who lend support and other resources)
and stakeholders who guide
and oversee the process; and (3) the community itself, which
provides input, representa-
tion, and decision making. This phase answers basic questions
about the general feasibil-
ity, resources, and appropriateness of the MAPP process
(NACCHO, 2001).
Phase 2 of the MAPP process, visioning, guides the communit y
through a process that re-
sults in a shared vision (what the ideal future looks like) and
common values (principles and
beliefs that will guide the remainder of the planning process)
(NACCHO, 2001). Generally,
a facilitator conducts the visioning process and involves
anywhere from 50 to 100 partici-
pants including the advisory committee, the MAPP committee,
and key community leaders
(NACCHO, 2001). This process is typical of what should occur
in pre-planning (see the
Generalized Model).

Phase 3, the four MAPP assessments, represents the defining
characteristic of the
MAPP model. The four assessments include (1) the community
themes and strengths
assessment (community or consumer opinion), (2) the local
public health assessment
(general capacity of the local health department and the local
health system), (3) the
community health status assessment (measurement of the health
of the community by
use of mortality, morbidity, risk factor and other related data,
etc.), and (4) the forces of
change assessment (forces such as legislation, technology, and
other environmental or
social phenomena that do or will impact the community).
Collectively, the MAPP assess-
ments provide insight on the gaps that exist between current
status in the community
and what was learned in the visioning phase as well as strategic
direction for goals and
strategies (NACCHO, 2001). The MAPP assessments provide an
excellent framework for
the types of data collection that should be part of any
comprehensive needs assessment

(see Chapter 4).
In Phase 4 of MAPP, identify strategic issues, planners develop
a prioritized list of the
most important issues facing the health of the community. Only
issues that jeopardize
the vision and values of the community are considered.
Important tasks in this phase
include consideration of what would happen if certain issues
were not addressed, un-
derstanding why an issue is strategic, consolidating overlapping
issues, and identifying
a prioritized list. In Phase 5, formulate goals and strategies,
planners create goals related
to the vision and prioritize strategic issues then select strategies
to accomplish the goals.
Finally, Phase 6, the action cycle, is similar to implementation
and evaluation phases in
other planning models. In this phase, implementation details are
considered, evaluation
plans (i.e. gathering credible evidence) are developed, and plans
for disseminating results
are made (NACCHO, 2001).
MAP-IT

More recently, in December 2010, Healthy People 2020, a
national planning framework, was
released to help guide public health and health promotion
planning efforts for the next
decade (USDHHS, 2015c). MAP-IT (Mobilize, Assess, Plan,
Implement and Track) was intro-
duced as a planning model to assist communities in
implementing their own adaptations of
Healthy People 2020. A few case studies have demonstrated
how this can transpire (Offiong,
Oji, Bunyan, Lewis, Moore, Olusanya, 2011; Devito-Staub,
2014). The phases in MAP-IT are
displayed in Box 3.3.
MAP-IT starts by mobilizing key individuals and organizations
into a coalition that can
work together to improve the health of the community
(USDHHS, 2011c). Once partners
are identified and the coalition is organized, roles are
established for each partner and re-

sponsibilities are assigned. These responsibilities may include
facilitating community input
through meetings and other events, developing and presenting
educational and/or training
programs, leading fundraising or policy initiatives, and
providing technical assistance in
planning or evaluation (USDHHS, 2011c). In essence, the
mobilize phase of MAP-IT is the
same thing as pre-planning in the Generalized Model.
The second phase of MAP-IT, assess, is the equivalent of a
needs assessment. This
phase directs planners to ask and answer questions such as: (1)
Who is affected by key
health problems in our community? (2) What resources do we
have to address the prob-
lems that we identify? And (3) What resources are required to
have a meaningful impact?
This phase of the model examines both the problems as well as
the assets within a com-
munity to help planners focus on what the community can do
versus what it would like
to do (USDHHS, 2011c).
In the assess phase, both state and local data are collected and

analyzed to help coalition
members set priorities. In addition, the MAP-IT model directs
planners to examine the social
determinants, or root causes of the problems associated with the
data collected. This might
include an investigation of how the physical or social
environments affect the health of the
community, how a lack of access to health services contributes
to death and illness, and how
individual behavior as well as biology and genetics affect the
health issues identified as pri-
orities (USDHHS, 2011c).
The third phase of MAP-IT, plan, involves developing goals and
objectives, measures,
baselines, and targets. This means that as part of the objectives
that are developed, planners
determine what will be measured (e.g., a decrease in smoking
among adults), the baseline
(e.g., percent of adults in the community who smoke), and the
targeted decrease (e.g., a
decrease of three percent in five years). In this phase, planners
also identify the specific inter-
ventions that will be used to accomplish the identified goals and
objectives. This means ad-

dressing the following questions: (1) What do we need to do to
reach our goals? And (2) How
will we know when we have reached our goals? This phase is
the equivalent of developing
goals and objectives as well as interventions.
The fourth phase in MAP-IT, implement, involves organizing
the coalition so it can put
the plan into action. Here, a detailed work plan, including all of
the information devel-
oped in Phase 3, is assembled to identify clear action steps,
describe who is responsible for
3.3
Box Phases of MaP-IT
PHaSE 1 Mobilize
PHaSE 2 Assess
PHaSE 3 Plan
PHaSE 4 Implement

PHaSE 5 Track
H
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completing the action steps, and display a timeline with related
deadlines. A communication
plan is also produced in this phase to outline how program
partners will reach and recruit
participants and communicate the benefits of engaging in the
program.
The final phase of MAP-IT, track, is the equivalent of
evaluation. Here, coalition partners
ask and answer specific questions such as: (1) Are we

evaluating our work appropriately
(i.e., formative evaluation)? (2) Did we follow the plan (i.e.,
process evaluation)? (3) What
did we change (i.e., impact evaluation)? And, (4) Did we reach
our goal (i.e., outcome eval-
uation) (USDHHS, 2011c)? MAP-IT encourages regular
evaluations to measure and track
progress over time and draws special attention to the quality of
data being collected, the
limitations of self-reported data, and the validity and reliability
of data collected (USDHHS,
2011c). Progress on the impact of related interventions is shared
often with stakeholders
(USDHHS, 2011c).
PRECEDE-PROCEED
“PRECEDE is an acronym for predisposing, reinforcing, and
enabling constructs in
educational/ecological diagnosis and evaluation” (Green &
Kreuter, 2005, p. 9). “PROCEED
stands for policy, regulatory, and organizational constructs in
educational and environmen-
tal development” (Green & Kreuter, 2005, p. 9). The model is
very robust with hundreds of

published papers citing evidence of its usefulness in improving
health outcomes. It is per-
haps one of the oldest and most enduring planning models used
in health promotion. In
the last few years it has been cited as integral in better
understanding women’s decisions to
seek clinical breast exams (Hayes-Constant, Winkler, Bishop, &
Taboada-Palomino, 2014),
designing an oral health strategy (Binkley & Johnson, 2013),
developing an intuitive eating
approach to weight management (Cole & Horacek, 2009) and
improving the quality of life in
elders (Mazloomymahmoodabad, Masoudy, Fallahzadeh, &
Jalili, 2014).
The first half of the model, PRECEDE, “consists of a series of
planned assessments that
generate information that will be used to guide subsequent
decisions” (Green & Kreuter,
2005, p. 8). The second half of the model, PROCEED, “is
marked by the strategic implemen-
tation of multiple actions based on what was learned from the
assessments in the initial
phase” (Green & Kreuter, 2005, p. 9).

The Eight Phases of PRECEDE-PROCEED
As displayed in Figure 3.3, PRECEDE-PROCEED is composed
of eight phases. The underly-
ing approach of this model is to begin by identifying the desired
outcome, to determine what
causes it, and finally to design an intervention aimed at
reaching the desired outcome. In
other words, PRECEDE-PROCEED begins with the final
consequences and works backward to
the causes. Once the causes are known, an intervention can be
designed.
Phase 1 in the model is called social assessment and situational
analysis and seeks to
subjectively define the quality of life (problems and priorities)
of those in the priority
population while involving individuals in the priority
population in an assessment of their
own needs and aspirations. Social indicators of quality of life
include achievement, alien-
ation, comfort, crime, discrimination, happiness, self-esteem,
unemployment, and welfare
(Green & Kreuter, 2005).

In Phase 2, epidemiological assessment, planners use data to
identify and rank the
health goals or problems that may contribute to or interact with
problems identified in
Phase 1. These data include traditional indicators analyzed in
needs assessments (e.g.,
mortality, morbidity, and disability data) as well as genetic,
behavioral, and environ-
mental factors (Green & Kreuter, 2005). It is important to note
that ranking the health
problems in this phase is critical, because there are rarely, if
ever, enough resources to
deal with all or even multiple problems. Also, this phase of the
model is used to plan
health programs. Note that in Figure 3.3, arrows work backward
to connect the genetics,
behavior, and environment boxes of Phase 2 with the health box
and with the quality of
life box of Phase 1.
Once identified, the risk factors or conditions related to broader

health problems need to be
prioritized. This can be accomplished by first ranking these
factors by importance and change-
ability and then using a 2 × 2 matrix with “more important” and
“less important” on the
horizontal axis and “more changeable” and “less changeable”
along the vertical axis (Green
& Kreuter, 2005). The risk factors that fall into the “more
important” and “more changeable”
quadrant in the matrix will be the highest priorities.
Phase 3, educational and ecological assessment, identifies and
classifies the various factors
that have the potential to influence a given behavior into three
categories: predisposing,
reinforcing, and enabling. Predisposing factors include
knowledge and many affective
traits such as a person’s attitude, values, beliefs, and
perceptions. These factors can facilitate
or hinder a person’s motivation to change and can be altered
through direct communica-
tion. Barriers or facilitators created mainly by societal forces or
systems make up enabling
factors, which include access to health care facilities or other
health-related services, avail-

ability of resources, referrals to appropriate providers,
transportation, negotiation and prob-
lem-solving skills, among others. Reinforcing factors involve
the different types of feed-
back and rewards that those in the priority population receive
after behavior change, which
may either encourage or discourage the continuation of the
behavior. Reinforcing behaviors
Phase 1 –
Social
Assessment
Phase 2 –
Epidemiologi-
cal
Assessment
Phase 3 –
Educational &
Ecological
Assessment

Phase 4 –
Administrative
& Policy
Assessment
and
Intervention
Alignment
Phase 5 –
Implementa-
tion
Phase 6 –
Process
Evaluation
Phase 7 –
Impact
Evaluation

Phase 8 –
Outcome
Evaluation
⦁ ▲ Figure 3.3 PRECEDE-PROCEED Model for Health
Promotion Planning and Evaluation
can be delivered by, but not limited to, family, friends, peers,
teachers, self, and others who
control rewards (Green & Kreuter, 2005).
Phase 4 is composed of two parts: (1) intervention alignment;
and (2) administrative and
policy assessment. The intent of intervention alignment is to
match appropriate strategies
and interventions with projected changes and outcomes
identified in earlier phases (Green
& Kreuter, 2005). In administration and policy assessment,
planners determine if the capa-

bilities and resources of existing personnel and participating
organizations are available to
develop and implement the program. It is between Phases 4 and
5 that PRECEDE (the assess-
ment portion of the model) ends and PROCEED
(implementation and evaluation) begins.
However, there is no distinct break between the two phases;
they actually run together, and
planners can move back and forth between phases.
The four final phases of the model—Phases 5, 6, 7, and 8—
make up the PROCEED por-
tion. In Phase 5—implementation—with appropriate resources
secured, planners select in-
terventions and strategies and implementation begins. Phases 6,
7, and 8 address process,
impact, and outcome evaluation (see Chapter 13 for
definitions), respectively, and are based
on the earlier phases of the model, when objectives were
outlined in the assessment process.
Whether all three of these final phases are used depends on the
evaluation requirements of
the program. Usually, the resources needed to conduct
evaluations of impact (Phase 7) and
outcome (Phase 8) are much greater than those needed to

conduct process evaluation (Phase
6) (Green & Kreuter, 2005).
Intervention Mapping
Intervention mapping was designed to fill a gap in health
promotion practice by trans-
lating data collected in the PRECEDE phases of PRECEDE-
PROCEED (i.e., social, epidemio-
logical, educational, ecological, administrative, organizational,
and policy assessments)
into theoretically based and otherwise appropriate interventions
(Green & Kreuter, 2005).
Once planners identify program objectives, they are guided by
diagrams and matrices
that incorporate outputs of the assessment process with relevant
theory (Green & Kreuter,
2005). Intervention Mapping as a planning model has been
refined and described more
comprehensively by Bartholomew, Parcel, Kok, Gottlieb, and
Fernandez (2011). The model
has been used to develop a breast and cervical cancer screening
program for Hispanic farm-
workers (Fernandez, Gonzales, Tortolero-Luna, Partida, &
Bartholomew, 2005), to develop

a worksite physical activity intervention (McEachan, Lawton,
Jackson, Conner, & Lunt,
2008), to explore the development of existing sex education
programs for people with
intellectual disabilities (Schaafsma, Joke, Kok, & Curfs, 2012),
and in reducing heavy drink-
ing among college students (Voogt, Poelen, Kleinjan, Lemmers,
& Engels, 2014).
Box 3.4 outlines the six phases of Intervention Mapping. The
first phase, conduct a needs
assessment, is conducted by using the PRECEDE phases of the
PRECEDE-PROCEED model
and includes establishing a participatory planning group,
assessing community capacity,
and linking the needs assessment to health outcomes and quality
of life goals (Bartholomew
et al., 2011). Phase 2, create matrices of change objectives,
specifies who and what will change as
a result of the intervention (Bartholomew et al., 2011).
Although the identification of goals
and objectives is common to all planning models, intervention
mapping makes a signifi-
cant contribution in this regard and is considered the basic tool
of the model. In this phase,

planners create a matrix of change objectives which “state what
needs to be achieved in order
to accomplish performance objectives that will enable changes
in behavior or environmen-
tal conditions that will in turn improve the health and quality of
life program goals identi-
fied in Step 1” (Bartholomew et al., 2011, p. 239). This is
perhaps the defining strength and
unique contribution of the model.
Phase 3, theory-based intervention methods and practical
applications, guides the planner
through a process of selected theory-based interventions and
strategies that hold the great-
est promise to change the health behavior(s) of individuals in
the priority population.
Phase 4, organize methods and applications into an intervention
program, describes the scope
and sequence of the intervention, the completed program
materials, and program protocols

(Bartholomew et al., 2011). In addition, program materials are
pretested with the priority
population prior to implementation.
Phase 5 of intervention mapping is plan for adoption,
implementation, and sustainabil-
ity of the program. This phase requires the same development of
matrices as in Phase 2,
except in these matrices, the focus is on adoption and
implementation of performance
objectives (Bartholomew et al., 2011). In other words, instead
of focusing on who and
what will change within the priority population, the focus is on
what will be done by
whom among planners or program partners. Finally, Phase 6 is
generate an evaluation
plan. In this phase, planners decide if determinants were well
specified, if strategies were
appropriately matched to methods, what proportion of the
priority population was
reached, and whether or not implementation was complete and
executed as planned
(Bartholomew et al., 2011).
Healthy Communities

Healthy Communities (or Healthy Cities) is a movement that
began in the 1980s in
Canada and, with the assistance of the World Health
Organization, spread to various lo-
cations throughout Europe. As a result, organizations like
California Healthy Cities and
Indiana Healthy Cities were created in the United States. The
movement is characterized by
community ownership and empowerment and driven by the
values, needs, and participa-
tion of community members with consultation from health
professionals. Another charac-
teristic of Healthy Communities is diverse partnership. It is not
uncommon to see partners
3.4
Box Phases of Intervention Mapping
PHaSE 1 Conduct a Needs Assessment
PHaSE 2 Create Matrices of Change Objectives
PHaSE 3 Select Theory-Based Intervention Methods and

Practical Applications
PHaSE 4 Organize Methods and Applications into an
Intervention Program
PHaSE 5 Plan for Adoption, Implementation, and Sustainability
of the Program
PHaSE 6 Generate and Evaluation Plan
Source: Bartholomew, L.K., Parcel, G.S., Kok, G., Gottlieb,
N.H., & Fernandez, M.E. (2011). Planning Health Promotion
Programs: An Intervention
Mapping Approach (3rd ed.). San Francisco, CA: Jossey-Bass.
H
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from business or labor, transportation, recreation, public safety,
or even politicians partici-
pate in the Healthy Communities process.
In the past few decades, the Centers for Disease Control and
Prevention (CDC) has
worked intensively with hundreds of communities to cultivate
Healthy Communities
and has reported that the following factors predict success: (1)
local investment in com-
munities; (2) providing a venue for local communities to learn
about effective strategies;
(3) mobilizing networks for change; and (4) providing tools to
communities to achieve
health equity and prevent chronic disease (Giles, Holmes-
Chavez, & Collins, 2009). One
of the lessons learned from Healthy Communities is the idea
that the pursuit of shared
values in the context of ownership and empowerment is a viable
approach to improving
health in the community. The Healthy Communities Program at
the CDC has created the

CHANGE (Community Health Assessment aNd Group
Evaluation) tool to enable
stakeholders and community team members to gather data on
community strengths
and assets as well as provide opportunities to create policy,
systems, and environmental
change through a community action plan (CDC, 2010a). This
tool or model represents a
viable planning framework for organizations and communities
engaging in the Healthy
Communities approach.
Box 3.5 displays the eight phases (described as action steps by
CDC) of the CHANGE
tool. Phase 1, assemble the community team, organizes 10-12
individuals, including key
decision makers, representing diverse sectors from the
community who are willing to
collect and analyze data, translate data to an action plan, and
oversee implementation of
related interventions (CDC, 2010a). Phase 2, develop a team
strategy, directs the community
team to make decisions about how to operate most efficiently
and effectively. This might
include reorganizing the larger team into smaller work groups

with specific tasks. It also
includes creating decision-making procedures, including how to
reach consensus (CDC,
2010a). Phase 3, review all five CHANGE sectors, divides the
work of data collection and
analysis into five sectors: (1) the community at large sector; (2)
the community institu-
tion/organization sector (i.e. institutions or organizations in the
community that provide
human services and access to facilities); (3) the health care
sector; (4) the school sector; and
3.5
Box Phases of the CHaNGE Tool
PHaSE 1 Assemble the Community Team
PHaSE 2 Develop a Team Strategy
PHaSE 3 Review All Five CHANGE Sectors
PHaSE 4 Gather Data
PHaSE 5 Review Data Gathered

PHaSE 6 Enter Data
PHaSE 7 Review Consolidated Data
PHaSE 8 Build the Community Action Plan
Source: Centers for Disease Control and Prevention (2010a).
Community Health Assessment aNd Group Evaluation Action
Guide: Building a Foundation
of Knowledge to Prioritize Community Needs. Atlanta: U.S.
U.S. Department of Health and Human Services.
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Chapter 3 Program Planning Models in Health Promotio n 53

(5) the worksite sector. Each sector contains specific questions
with related data elements
associated with policy, systems, or environmental change that
need to be addressed (CDC,
2010a). Phase 4, gather data, begins the assessment phase. Here,
“sites” or locations that
have data related to the questions associated with each sector
are identified and specific
data collection strategies such as observations, interviews,
focus groups and surveys are
used to gather new or existing data (CDC, 2010a). In Phase 5,
review data gathered, team
members discuss what was discovered and “rate” (or rank) each
item (specific questions
related to each sector) using a five-point scale. This involves
making judgments about
whether the condition of each item (e.g. condition and safety of
sidewalks that increase or
decrease the likelihood of physical activity, or structured
physical activity classes in grades
9-12, etc.) is improving, getting worse, or staying the same
(CDC, 2010a). Phase 6, enter
data, incorporates CHANGE Sector Excel files, which organizes
data for analysis. Phase

7, review consolidated data, transfers data into “CHANGE
summary statements for quick
reference of all sites with related ratings across all five sectors
(CDC, 2010a). In essence, this
step summarizes data to accommodate prioritization and
decision making. Finally, Phase
8, building the community action plan, involves translating
prioritized data from the sum-
mary statements to measurable objectives and action steps with
assignments, and creates
strategies for evaluation and reassessment (CDC, 2010a). The
CHANGE action guide (CDC,
2010a) provides adequate instructions on how to complete the
eight phases of this process.
But in general, it includes pre-planning and visioning, needs
assessment, priority setting,
selecting appropriate policy, systems, or environmental
interventions, and evaluating the
quality and effectiveness of interventions.
SMART
Although most planning models try to involve members of the
priority population in
the planning process at some level and some go so far as to

incorporate consumer data
(see MAPP for a good example), planning models such as
SMART (Social Marketing
Assessment and Response Tool [Neiger & Thackeray, 1998]),
with a social marketing
focus, generally do a better job of orienting program
interventions to the preferences of
consumers throughout the entire planning process (see Chapter
11 for more informa-
tion on marketing/social marketing). Consumer data are
collected continually, first to
understand the wants and needs of consumers and then to test
all aspects of interven-
tion and communication strategies. There is some evidence to
suggest that this planning
approach may be more effective than traditional approaches
used in health promotion
(Neiger & Thackeray, 2002). SMART is one of the more robust
social marketing mod-
els currently in practice; the other being the Community Based
Prevention Marketing
Model (Bryant, Forthofer, McCormack-Brown, Landis, &
McDermott, 2000). Within the
last few years, the SMART Model has been used in service-
learning to teach community

health (Buckner, Ndjakani, Banks, & Blumenthal, 2010), in the
development of an edu-
cational intervention to treat schizophrenia (Bradshaw, Lovell,
Bee, & Campbell, 2010),
and in developing a support program for patients with diabetic
kidney disease (Pagels,
Hylander, & Alvarsson, 2015).
The SMART model, influenced primarily by Walsh and
colleagues (1993), is also a com-
posite of several social marketing planning frameworks but
differs from most planning
models used in health promotion settings due to its multistep
focus on the consumer. Unlike
some social marketing planning models, SMART has been used
from start to finish in success-
ful social marketing interventions (Neiger & Thackeray, 2002).
As displayed in Box 3.6, SMART is composed of seven phases.
Like other social market-

ing planning models, the central focus of SMART is consumers.
The heart of this model,
composed of Phases 2 through 4, directs planners to acquire a
broad understanding of
the consumers who will be the recipients of a program and its
interventions. These three
phases seek to understand consumers before interventions are
developed or implemented.
Though these phases (2–4) are displayed in linear fashion, and
for clarity will be described
in sequence, they are typically performed simultaneously with
members of the priority
population.
3.6
Box
Phase 1: Preliminary Planning
⦁ ⦁ Identify a health problem and name it in
terms of behavior
⦁ ⦁ Develop general goals

⦁ ⦁ Outline preliminary plans for evaluation
⦁ ⦁ Project program costs
Phase 2: Consumer analysis
⦁ ⦁ Segment and identify the priority
population
⦁ ⦁ Identify formative research methods
⦁ ⦁ Identify consumer wants, needs, and
preferences
⦁ ⦁ Develop preliminary ideas for preferred
interventions
Phase 3: Market analysis
⦁ ⦁ Establish and define the market
mix (4Ps)
⦁ ⦁ Assess the market to identify
competitors (behaviors, messages,
programs, etc.), allies (support systems,

resources, etc.), and partners
Phase 4: Channel analysis
⦁ ⦁ Identify appropriate communication
messages, strategies, and channels
⦁ ⦁ Assess options for program distribution
⦁ ⦁ Identify communication roles for
program partners
⦁ ⦁ Determine how channels should be used
The SMaRT Model
Phase 5: Develop Interventions,
Materials, and Pretest
⦁ ⦁ Develop program interventions and
materials using information collected
in consumer, market, and channel
analyses
⦁ ⦁ Interpret the marketing mix into

a strategy that represents exchange
and societal good
⦁ ⦁ Pretest and refine the program
Phase 6: Implementation
⦁ ⦁ Communicate with partners and clarify
involvement
⦁ ⦁ Activate communication and
distribution strategies
⦁ ⦁ Document procedures and compare
progress to timelines
⦁ ⦁ Refine the program
Phase 7: Evaluation
⦁ ⦁ Assess the degree to which the priority
population is receiving the program
⦁ ⦁ Assess the immediate impact on the
priority population and refine the

program as necessary
⦁ ⦁ Ensure that program delivery is
consistent with established protocol
⦁ ⦁ Analyze changes in the priority
population
Source: Adapted from Walsh et al. (1993) by Neiger &
Thackeray (1998).
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The Phases of SMaRT

Phase 1, preliminary planning, is critical for any type of health
promotion program and
in this model includes the planning elements of pre-planning
and needs assessment as
described earlier. Preliminary planning allows program planners
to objectively assess all
health problems and determine which one is most appropriate to
address. This is most often
accomplished through analysis of epidemiologic data, including
various mortality and mor-
bidity rates and associated risk factor data. It also includes
objective priority setting with
predetermined criteria. Sometimes planners do not undergo a
process to select a priority
health problem because the decision has already been made or
the organization is dedicated
to a specific health problem (e.g., the American Heart
Association focuses on heart disease).
Once a single health problem is determined, it is defined in
terms of behaviors. Risk factors,
or contributing factors, then become the focus of the social
marketing process. This is simi-
lar to most health promotion programs.

Some social marketing practitioners and those who engage in
community-based partici-
patory research would argue that the priority population itself
should determine the focus of
an intervention or program. Good arguments can be made for
this approach, including the
idea that priority populations are capable of identifying their
own problems and solutions
and that they will be more vested in long-term involvement if
they have ownership in the
process. The SMART model suggests that planners, as trained
health professionals, have both
the expertise and responsibility to use various data sets to
oversee and determine priority
health problems within a community in partnership with
members of the priority popula-
tion. Once a priority or priorities are identified, the remainder
of the process becomes almost
exclusively consumer-driven.
While health professionals may determine initial program
direction, the SMART model
directs that consumers drive the development and
implementation of interventions.
This is not unlike most ventures in commercial marketing where

a product or service is
developed internally then tested with consumers and modified
prior to distribution. For
example, a company such as Coca-Cola develops its own
identity and mission and creates
the basic essence of its products. But it engages in complex
marketing campaigns to better
understand how to modify, improve, position, and deliver these
products to its consumers
in a way that offers benefits at reasonable costs.
Although goals are outlined in Phase 1, objectives are not. This
makes sense from a social
marketing perspective, since consumer research has not yet been
performed. The goals are
general statements of intent or direction, but they do not specify
program components or
direct the planner into specific courses of action.
Another task in Phase 1 is to develop preliminary plans for
evaluation. Theoretically, it will
make sense to most planners to consider evaluation early in the
planning process. In reality,
evaluation is too often an afterthought. Preliminary decisions
regarding evaluation outcomes

must be made early in the planning process in order to account
for personnel, time, and bud-
get requirements. Therefore, it is also important to determine
how baseline and post-program
(posttest) data will be collected and to identify valid survey or
data collection instruments.
Planners can also control for various kinds of bias or error in
data collection if these basic
evaluation concepts are considered before the program is
implemented.
Finally, program costs need to be projected before the social
marketing project begins.
Social marketing can be an expensive proposition in terms of
staff costs and direct expenses.
When performed correctly, a social marketing project can take
several months or up to a year
before implementation even begins. Program planners and
organizations must decide if they
are ready to make these kinds of time and financial

commitments.
At the end of Phase 1, the social marketing planners have (1)
identified the focus of in-
terest in terms of modifiable behaviors, (2) developed goals that
provide general direction,
(3) outlined preliminary plans for evaluation, and (4) estimated
total project costs. Based
on this information, the planners and organizations can make an
informed decision
about the potential costs and benefits of the project as well as
the application of social
marketing.
Phase 2 of SMART is consumer analysis. In social marketing
language, the process of per-
forming consumer analysis is called formative research, defined
as a process that identi-
fies differences among subgroups within a population, identifies
a subgroup, determines the
wants and needs of the subgroup, and identifies factors that
influence its behavior, including
benefits, barriers, and readiness to change (Bryant, 1998).
It is important to remember that no single type of data

collection technique is necessarily
best in performing formative research. To the contrary, it is
helpful to use multiple methods
to gain a better perspective of the priority population. It is a
mistake for those who engage in
social marketing to perform one or two focus groups in the
name of formative research and
claim they understand their consumers. Ordinarily, however,
formative research will involve
the use of focus groups, in-depth interviews, and surveys, and
so on, to understand consumer
preferences.
At the conclusion of Phase 2, a priority population is also
identified. Adequate formative
research has been performed yielding data about major themes,
directions, and consumer
preferences related to the health problem and related
interventions. Although Phases 2
through 4 are often performed simultaneously, information
collected in Phase 2 can provide
context for the other two phases. For example, knowing about
consumer preferences related
to some type of behavior change allows planners to more
effectively understand consumer

preferences related to the market mix and communication
strategies.
Phase 3, market analysis, examines the fit between the focus of
interest (desired behavior
change) and important market variables within the priority
population. Marketing mix is
a term that is often used in both commercial and social
marketing. It is composed of four
components, also known as the 4Ps: product, price, place, and
promotion (see Chapter 11 for
more on the 4Ps).
At the conclusion of this phase, consumer analysis is enriched
by a better understanding
of important market variables that influence consumers.
Combined with consumer analysis
and channel analysis, market analysis provides a powerful
combination of useful informa-
tion about consumers, the environment they live in, and
strengths and weakness associated
with potential social marketing interventions.
The fourth phase of SMART is channel analysis. Although
communication may not be

the focal point of a social marketing campaign, it will play a
secondary role in communicat-
ing important messages about the product. In addition to
messages and related strategies,
formative research includes specific questions about the type of
communication channels
consumers believe are most appropriate for the behavior change
being addressed.
At the conclusion of Phase 4, communication channels are
identified that are consistent
with preliminary messages, and product distribution points and
potential communication
and intervention partners are identified.
Phase 5 of SMART is develop interventions, materials and
pretesting. Once formative research
is performed, it is critical that the data are transferred or
infused adequately into the design of
programs, interventions, and communication strategies. To do
this, data must be analyzed

and categorized appropriately to assure that planners understand
what they have seen, heard,
and observed. As planners meet to design programs and
materials, they should keep formative
research data in front of them and refer to them often.
Discussion and decisions should reflect
all data and represent a consensus among all planners. In other
words, materials and methods
should represent what was learned in formative research.
Once a program prototype is developed, it is imperative to
return to the priority popula-
tion and test the concepts before implementing a widespread
campaign. In fact, social mar-
keting represents a process of continually returning to the
consumers until the program and
all its support mechanisms are consistent with their views and
preferences. Several mecha-
nisms are available to perform pretesting. One example is a
pilot test where the program can
be implemented with the priority population on a smaller, less
expensive scale. Phase 6 of
SMART is implementation. This phase is concerned with
clarifying everyone’s role, including
external partners. This means that procedures are communicated

and documented, and that
timelines are developed and followed. In this phase, the
communication and distribution
plans are activated and the actual program and its interventions
are offered. In addition, the
program is refined continually, based on consumer feedback.
The seventh and final phase of SMART is evaluation. The
preliminary evaluation strate-
gies that were identified in Phase 1 now take effect. Evaluation
always has at least two ma-
jor objectives: improve the quality of the program and
determine the effectiveness of the
program. With respect to quality, program planners assess the
degree to which the priority
population is actually receiving the program or interventions.
Planners also assess the im-
mediate impact the program is having and whether the
interventions and related support
strategies are acceptable and engaging to the priority
population. In addition, planners
ensure that program delivery is consistent with program
protocol or at least consistent with
developed timelines.

Ultimately, social marketing, and all its related work, is of little
value unless behavior
change occurs and health is improved. Evaluation also concerns
itself with measuring these
outcomes. Effective planners and evaluators also make sure that
evaluation results are folded
back into the program so that it can be improved before it is too
late. This requires communi-
cating evaluation results effectively to stakeholders.
Other Planning Models
The Evidence-Based Planning Framework for Public Health,
MAPP, MAP-IT, PRECEDE-
PROCEED, Intervention Mapping, Healthy Communities
(CHANGE tool), and SMART are all
theoretically good models and can each be used to successfully
plan, implement, and evaluate
programs. While these specific models may be used more
commonly in health promotion
settings, still other models have been useful in various settings
including Community-Based
Prevention Marketing (Bryant, Forthofer, McCormack-Brown,
Landis, & McDermott, 2000),
PATCH (Lancaster & Kreuter, 2002), the Health

Communication Model (National Cancer
Institute, n.d.), Healthy Plan-It (Centers for Disease Control and
Prevention, 2000), and SWOT
(Strengths, Weaknesses, Opportunities, and Threats)
(Panagiotou, 2003), which is more of a
decision-making strategy than a traditional planning model.
Technically, its use should be
limited to the preliminary stages of decision making in
preparation for more comprehensive
strategic planning (Bartol & Martin, 1991; Johnson, Scholes, &
Sexty, 1989).
An Application of the Generalized Model
In practice, planners will often encounter situations where it is
not feasible to use a model
in its entirety or where it is necessary to combine parts of
different models to meet specific
needs. For this reason, the Generalized Model is used in this
book to help you adapt and

respond to complex planning challenges you will experience in
professional practice.
With planning expertise associated with your working
knowledge of the Generalized
Model, you will be able to more quickly assimilate and interpret
varying or competing
stakeholder preferences for planning into a guiding paradigm
that will generally keep you
on track. Although there is nothing unique about the
Generalized Model itself, its prin-
ciples are the building blocks for all other planning models.
This likely became apparent
to you as you reviewed the preceding planning models and
noticed their many similari-
ties. Each of these models in one form or another includes: pre-
planning, assessing needs,
setting goals and objectives, developing interventions,
implementing interventions and
evaluating results.
Another benefit of understanding the Generalized Model is an
increased ability to apply
an important process closely related to program planning—grant
writing. Requirements
listed in requests for applications (RFAs) or requests for

proposals (RFPs) related to grant an-
nouncements will be developed by the funding
agency/organization and include their
preferences for language and terminology. But the steps or
requirements related to requests
for health funding often relate back to the steps displayed in the
Generalized Model.
For example, funding requests from the CDC and other federal
or national organizations
generally require applicants to organize proposals with the
following types of sections:
background and statement of need; work plan; management
plan; evaluation; and budget.
These sections parallel closely with the Generalized Model: the
background and statement
of need relate to the needs assessment; the work plan includes
goals and objectives as well as
a description of interventions; and the management plan
generally includes requirements
for program implementation. The Community Tool Box (see
Weblinks at the end of this
chapter), a Website designed to assist health professionals with
various tasks, outlines the
standard components of a grant proposal. Sections include the

statement of the problem/
needs assessment; project description (goals and objectives and
methods/activities); the
evaluation plan; and the budget request and justification
(University of Kansas, 2015b).
To help you better understand how the Generalized Model might
work in practice, we will
use a hypothetical example to walk you through its five steps.
Of course, in practice, stake-
holders may choose a different approach than what is presented
here. But at least you can
see how the steps in the model build upon each other. While this
example is hypothetical in
nature, it is drawn from the 96 years of combined experience we
as authors have with plan-
ning and evaluation in health promotion settings. In other
words, it represents a realistic
accumulation of our experience.
Let’s assume Jane Doe, CHES, a recent health promotion
graduate, has just been hired
by a medium-sized county health department in California. She
has been asked to lead a

planning process to identify a health problem that will become
the health department’s key
priority for the next three years.
The first thing Jane decides to do is some pre-planning. She sets
out to identify key stake-
holders who can help guide the process as well as partners who
will help her carry out the
work. She organizes a few meetings with stakeholders to discuss
the collective vision for the
process including purpose, scope, and deliverables as well as
the leadership structure (i.e.,
authority, roles, and responsibilities). She ensures that a few
partners are community resi-
dents who have volunteered previously with the health
department and can help represent
the community in general. Jane begins discussions with her
partners to identify and secure
resources to be able to implement a program once a priority
health problem and priority pop-
ulation have been identified. Although Jane realizes she does

not need to spend months or
even weeks pre-planning, she understands the value of getting
all stakeholders on the same
page with respect to vision, leadership, and resources. This will
help ensure a more positive
and successful planning approach.
The actual planning and evaluation process begins with a needs
assessment.
Stakeholders determine together that they will collect data in
three main categories:
chronic diseases, infectious diseases, and injuries. Three teams
are assembled to address
each of the categories and each team is charged with identifying
8–10 leading health
problems or diseases within the three categories. Teams agree to
use a recent data report
produced by the California Department of Health Services
(organized by county) that
describes leading causes of mortality, morbidity, and
hospitalizations to select the 8–10
health problems for each of the categories. Stakeholders further
determine that they will
collect the following types of data for each of the 8–10 health
problems: county-specific

mortality and morbidity data; hospital discharge data; economic
data; years of potential
life lost; disability data; data on disparities; social determinants
and risk factors for each
health problem; and evidence of successful interventions that
relate to the preventable
nature of each health problem. The planning team decides on a
presentation template
for each health problem that includes graphs as well as brief
descriptions for each of the
predetermined criteria. The three planning teams decide to
allow two months to collect
and organize all the data.
After two months have passed, all three teams come together to
compile their work in
a single report and to make an oral presentation of their
findings. Afterward, Jane and the
community residents are given the assignment to use the basic
priority rating (BPR) model
2.0 (Neiger, Thackeray, & Fagen, 2011) to narrow the list of
health problems within each
category to five (see Chapter 4 for BPR). Jane serves as the
moderator of priority setting to
make sure everyone understands the process. Within a week,

five chronic diseases (heart dis-
ease, breast cancer, lung cancer, diabetes, and arthritis), five
infectious diseases (HIV/AIDS,
pneumonia, chlamydia, E.coli, and meningitis), as well as five
unintentional injuries (falls,
drownings, motor vehicle injuries, bicycle crashes, and auto-
pedestrian injuries) surface as
leading health problems in the county.
After preliminary priority setting, the group of stakeholders
decides it would like to
supplement its needs assessment with a series of focus groups
throughout the county to de-
termine what community residents feel are the most significant
health problems among the
initial priorities. Stakeholders decide to hire an evaluation firm
to conduct 20 focus groups
across the county and prepare a report. The final bid for
services is $8,500, which the com-
munity outreach office of a local hospital agrees to pay.

As the evaluation firm begins to organize and conduct focus
groups, stakeholders use
the BPR model to further prioritize the remaining 15 health
problems. Jane leads all discus-
sions but is assisted by a program coordinator from the local
chapter of the American Cancer
Society who has years of experience in health promotion and
some experience with the BPR
model. It takes the group two additional meetings to develop a
list of their top five priorities:
(1) motor vehicle injuries; (2) heart disease; (3) breast cancer;
(4) chlamydia; and (5) diabetes.
Within a month, the contracted evaluation team returns with its
findings from the focus
groups. Data indicate that the community believes effective
prevention should start with
children and adolescents and that the county should focus on
childhood obesity as a risk fac-
tor for heart disease as well as the prevention of sexually
transmitted diseases (i.e., chlamydia)
among adolescents.
With these findings, Jane and her stakeholders are faced with a
difficult decision. The

BPR model and process produced a convincing case that motor
vehicle injuries should be
the county’s top priority. But community residents are not in
agreement. After thought-
ful deliberation, stakeholders decide to develop a safe driving
program among high school
students throughout the county as well as a childhood obesity
prevention program among
elementary and junior high students. They further decide to
create two planning teams for
each of the priorities, with each team taking responsibility for
grant writing and funding in
general. The teams are also tasked to identify appropriate
partners with specific expertise and
resources in each of the two priority areas.
With health problems and priority populations identified, each
newly formed team de-
velops goals and objectives for each of the two priorities. Using
Healthy People 2020 as a starting
point, the teams develop general goals for each of the priorities
as well as process, impact, and
outcome objectives. The teams carefully develop their baseline
measurements (i.e., starting
points) for each objective based on the data collected in the

needs assessment. Again, using
the targets in Healthy People 2020, each team develops its own
targets for each objective, en-
suring that each one is specific, measurable, achievable,
realistic, and time-phased.
With goals and objectives developed, the planning teams turn to
developing the interven-
tions, the third step in the Generalized Model. Here, planners
need to determine if they will
use existing programs and tailor them to their priority
population or develop their own
programs. Jane remembers from her undergraduate coursework
that interventions need to
be evidence-based. She works with both teams to ensure that the
interventions selected will
offer a high probability of success. In the end, the childhood
obesity team decides to adapt
a program from Utah titled Gold Medal Schools. This program
is selected for its successful
track record and its multifaceted approach combining
educational components with poli-
cies leading to healthy school environments. The safe driving
team selects a program called
Driving School Home, a successful defensive driving course

involving high school students
from Illinois. Both teams then begin the process of fully
understanding their programs and
drafting budgets, including an analysis of how many staff
members and volunteers would
be required to implement each program, how much funding
would be required to purchase
program materials or capital equipment, and how much money
might be required for con-
sultants. Program protocols are available for each program and
in a matter of weeks, both
teams feel they understand the basic sequence of tasks and
activities required to implement
each program.
The fourth phase of the Generalized Model, implementing
interventions, is focused on
delivering interventions to the community. Before
implementation occurs however, both
teams begin to lay the necessary groundwork with school

personnel to establish partner-
ships and to receive approval to proceed as planned. This
becomes more complicated than
Jane had anticipated. However, protocols and policies
previously developed by the various
school districts need to be observed. For example, one thing all
school districts require is that
each program be implemented on a pilot basis first to determine
whether the likelihood of
success is high enough to justify full implementation of the
programs on a broader basis. In
total, this process takes three months. But afterward, strong
partnerships are established and
implementation is approved for each program.
Implementation is equivalent to program management. In this
phase, program partners
ensure that programs are implemented as per predetermined
protocol. Regular meetings are
held to ensure that everyone is doing his/her job as planned.
Managers follow up with their
staff and make sure that timelines are carefully followed and
that monies from approved
budgets are accessible for program support. Implementation also
focuses on marketing and

communication. It is important that an adequate number of
members from the priority
population is reached and that enough people actually
participate in the programs. Jane and
her teams conduct in-depth interviews with school
administrators to understand how to best
communicate the purpose of the programs to potential
participants (e.g., schools, students,
and parents).
Jane helps to coordinate all the work of implementation and
discovers that it takes a great
deal of assertiveness and diplomacy to keep people moving
forward on schedule. She also
learns that certain aspects of both programs need to be modified
in the process of imple-
mentation in order to increase the likelihood of their success.
Toward the end of year one of
implementation, Jane realizes that while neither program was
implemented perfectly, both
programs are running smoothly with continued enthusiasm and
support.
During program implementation, Jane, along with two
colleagues from the county health

department conduct formative evaluation to ensure that the
quality of program compo-
nents and implementation are being presented as planned and
that modifications are made
continually to improve the likelihood of success. This also
proves to be a challenge for Jane.
During the course of implementing the Driving School Home
program, she has to replace an
ineffective teacher. As the Gold Medal Schools program is
evaluated, Jane discovers that the
kick-off assembly is too long and that both teachers and
students are losing attention. When
the assembly is shortened by 20 minutes and more incentives
and small prizes are distrib-
uted, everyone feels more energized. These come to represent
just a few of the many program
improvements that are made during year one.
In addition, both teams had decided prior to implementation that
outcome evalua-
tion, which would measure both changes in behavior as well as
decreases in the actual
health problems, would be conducted by faculty and graduate
students from a nearby
university. University personnel were willing to conduct the

research at no cost, provid-
ing they could use all data for publications in scientific
journals. While the researchers
required certain things of Jane and her partners, it became a
win-win situation in the end.
The researchers collected data immediately after the programs
concluded and then again
at three months after the conclusion of the programs. Data
indicated that the Gold Medal
Schools program was moderately effective and that the Driving
School Home program was
moderately to highly effective. Jane communicated to
stakeholders that the programs
were more likely to experience higher levels of success in
future implementations based
on continual improvements as part of formative and process
evaluation. After data had
been collected and analyzed, Jane made several presentations to
stakeholders reporting
on what went well and what went poorly. These presentations

helped ensure continued
funding for both programs.
To reiterate, the preceding example could have played out in
many different ways
based on the vision and competency of those leading the
planning efforts. The purpose
of the example was to describe how the phases in the
Generalized Model might unfold.
In practice, selecting a specific planning model to apply will be
based on many factors:
(1) the preferences of stakeholders (e.g., decision makers,
program partners, consum-
ers); (2) how much time and funding are available for planning
purposes; (3) how many
resources are available for data collection and analysis; (4) the
degree to which clients are
actually involved as partners in the planning process or the
degree to which your planning
efforts will be consumer oriented (i.e., planning is largely based
on the wants and needs of
consumers or the planning process is owned by the community
itself); and (5) preferences
of a funding agency (in the case of a grant or contract award).
Planners must have the

capacity to not only lead a planning process, but also negotiate
these important issues
among a diverse set of stakeholders.
Final Thoughts on Choosing a Planning Model
Three important criteria, or the three Fs of program planning:
fluidity, flexibility, and
functionality, should also help guide the selection of your
model and govern the application
of its use. Fluidity suggests that steps in the planning process
are sequential, or that they
build on one another. It is usually a problem if certain steps in
the planning process are
performed out of sequence as diagrammed in the Generalized
Model. For example, a plan-
ner cannot develop goals and objectives until a needs
assessment has been performed and a
priority health problem has been identified.
Flexibility means that planning is adapted to the needs of
stakeholders. Due to various
circumstances, planning is usually modified as the process
unfolds. For example, some
health problems, such as an outbreak of influenza, require a

rapid assessment and scan of the
environment. Strict adherence to a model in light of unique and
pressing circumstances will
generally lead to frustration among partners and a less-than-
desirable outcome. Functionality
means that the outcome of planning is improved health
conditions, not the production of
a program plan itself. A plan is only a tool to help planners
accomplish their real work—to
improve health and decrease disease and disability.
In addition to the three Fs, when deciding on a planning model,
it is also important to
ensure that the model is conducive to planning a population-
based approach and that
it uses an ecological framework. Whereas systematic and
strategic planning efforts can
address smaller populations such as those found in a small
community or worksite, many
planning processes pertain to large population segments of even
larger populations—thus
the term population-based approach.
Planners must also understand the interaction between a priority
population and the

communities in which they live. The ecological framework
helps planners better appreciate
that families, schools, employers, social networks,
organizations, communities, and societies
exert an influence on individuals and priority populations as
they attempt to change health
behaviors and improve their health (Bartholomew et al., 2011).
Thus, planners must work
with priority populations within the context of broad
environments.
In addition, during pre-planning, planners need to determine the
extent to which
members of the priority population will be involved in the
planning process and in
decision making. This varies widely in practice and may range
from no community
involvement on one end of a continuum to an approach like
community-based partici-
patory research where the community itself owns the program

and is the unit of identity,
solution, and practice involved in all aspects of program
development and delivery
(Trickett, 2011). Ideally, planning efforts in health promotion
should use a partnership-
based approach in the context of community empowerment and
mobilization where
professionals work in unison with community members in
taking actions to improve
health and reduce disease.
Summary
A model can provide the framework for planning a health
promotion program. Several differ-
ent planning models have been developed and revised over the
years. The planning models
for health promotion presented in this chapter have included:
1. The Generalized Model
2. Evidence-Based Planning Framework for Public Health
3. MAPP (Mobilizing for Action through Planning and
Partnership)

4. MAP-IT (Mobilize, Assess, Plan, Implement, Track)
5. PRECEDE-PROCEED
6. Intervention Mapping
7. Healthy Communities (CHANGE tool)
8. SMART (Social Marketing Assessment and Response Tool)
The Generalized Model is recommended as the template for
learning the basic principles
of planning and evaluation: (1) assessing needs; (2) setting
goals and objectives; (3) develop-
ing interventions; (4) implementing interventions; and (5)
evaluating results. Several other
models used in health promotion also continue to make valuable
contributions typically
using these same elements.
Review Questions
1. How does an understanding of the Generalized Model help
you understand other

planning models?
2. What are the elements or steps in the Generalized Model that
are common in most,
if not all, other planning models?
3. Why is it important to use a model when planning?
4. How does pre-planning relate to most of the models presented
in this chapter?
5. Explain the degree to which you believe consumers or
members of the community
should be involved in the planning process. Do you believe they
should own or control
the process?
Activities
1. After reviewing the models presented in this chapter, create
your own model by

identifying what you think are the common components of the
models. Provide a
rationale for including each component. Then draw a diagram of
your model so that
you can share it with the class. Be prepared to explain your
model.
2. In a one-page paper, defend what you believe is the best
planning model presented in
this chapter.
3. Using a hypothetical health problem for a specific priority
population, write a paper
explaining the steps/phases for one of the models presented in
this chapter.
4. Identify a health promotion program reported as successful in
a scientific journal. What
elements of the Generalized Model are described in the paper?
Could you engage in an
effective planning process based on the amount of information
provided in the article?
Summarize your comments in a one-page paper.
Weblinks

1. http://www.healthypeople.gov/2020/default.aspx
Healthy People
At this Website, Healthy People 2020 is outlined with several
helpful links including:
(1) About Healthy People (background and general
information); (2) Healthy People 2020
topics and objectives; (3) Data Search; (4) Leading Health
Indicators (measurement and
progress); (5) Healthy People in Action (the Healthy People
2020 consortium and stories
from the field); and (6) Tools and Resources. This is a site with
which planners in health
promotion should be familiar.
2. http://prcstl.wustl.edu/training/Pages/EBPH-Course-
Information.aspx
Evidence-Based Planning for Public Health
This Website displays the evidence-based planning framework
for public health
described in this chapter. PowerPoint presentations are provided
for each skill and phase
associated with this framework.

3. http://www.naccho.org/topics/infrastructure/mapp/index.cfm
National Association of County and City Health Officials
At this Website, the MAPP model is comprehensively
diagrammed and explained.
The four MAPP assessments are described, including how they
are implemented, how to
use subcommittees for each assessment, and how to make
linkages between assessments.
4. http://www.healthypeople.gov/2020/tools-and-
resources/Program-Planning
MAP-IT: A Guide to Using Healthy People 2020 in Your
Community
http://www.healthypeople.gov/2020/default.aspx
http://prcstl.wustl.edu/training/Pages/EBPH-Course-
Information.aspx
http://www.naccho.org/topics/infrastructure/mapp/index.cfm
http://www.healthypeople.gov/2020/tools-and-
resources/Program-Planning
This Website provides a valuable resource to assist health

promotion professionals in
implementing Healthy People 2020. The site includes field
notes for each of the phases in
MAP-IT with examples or case studies from various health
organizations, as well as other
resources and tool kits for each planning phase.
5.
http://www.cdc.gov/nccdphp/dch/programs/healthycommunities
program/tools/change.htm
CHANGE Model (Community Health Assessment aNd Group
Evaluation)
This Website provides a detailed description of CDC’s
CHANGE model associated with
the implementation of the Healthy Communities Approach.
6. http://ctb.ku.edu/
Community Tool Box
This Website is an indispensable tool for all planners in health
promotion. According to
the site, “The Tool Box offers more than 300 educational
modules and other tools, many
of which pertain to planning steps and phases discussed in this
chapter.

7.
http://www.communityhlth.org/communityhlth/resources/hlthyc
ommunities.html
Association for Community Health Improvement
This Website provides additional information on the Healthy
Communities Initiative
including current projects and links.
8. http://www.cdc.gov/healthcommunication/
Gateway to Health Communication and Social Marketing
Practice, Centers for Disease
Control and Prevention
This Website provides an overview of health communication
and social marketing
practice including how to develop programs, segmenting an
audience, and selecting
appropriate channels and tools for program delivery.
http://www.cdc.gov/nccdphp/dch/programs/healthycommunities
program/tools/change.htm
http://ctb.ku.edu/
http://www.communityhlth.org/communityhlth/resources/hlthyc
ommunities.html
http://www.cdc.gov/healthcommunication/

67
Once the planning committee is in place and a planning model
has been selected,
the next step in the planning process is to identify the needs of
those in the priority popu-
lation. Gilmore (2012) has defined need as “the difference
between the present situation
and a more desirable one” (p. 8). These needs can be expressed
in many different ways.
For example, there may be a need for better health, or a need for
more knowledge, or a
need to possess a certain skill, to name a few. Whether a need
of the priority population is
4
Chapter Assessing Needs
Chapter Objectives

⦁ ⦁ Define need and needs assessment.
⦁ ⦁ Define capacity, community capacity, and capacity
building.
⦁ ⦁ Explain why a needs assessment is an important
part of the planning process.
⦁ ⦁ Explain what should be expected from a needs
assessment.
⦁ ⦁ Differentiate between primary and secondary
data sources.
⦁ ⦁ List the various methods for collecting
primary data.
⦁ ⦁ Locate secondary data sources that are in print
and on the World Wide Web.
⦁ ⦁ Explain how a needs assessment can be

completed.
⦁ ⦁ Explain what is meant by health impact
assessment.
⦁ ⦁ Conduct a needs assessment within a given
population.
Key Terms
action research
basic priority rating
(BPR)
bias
BPR model 2.0
capacity
capacity building
categorical funds
community capacity
community forum
Delphi technique
focus group
health assessments

(HAs)
health impact
assessment (HIA)
HIPAA
key informants
mapping
need
needs assessment
networking
nominal group
process
observation
obtrusive observation
opinion leaders
participatory data
collection
participatory research
photovoice
primary data
proxy measure
random-digit dialing

(RDD)
secondary data
self-assessments
self-report
significant others
single-step survey
unobtrusive
observation
walk-through
windshield tour
actual (true need) or perceived (reported need) does not matter
(Gilmore, 2012). What mat-
ters is being able to identify all needs, actual and perceived, so
that they can be addressed
through appropriate program planning.
From an epidemiologic viewpoint, a needs assessment has been
defined as “[a] systematic

procedure for determining the nature and extent of problems
experienced by a specific
population that affect their health either directly or indirectly”
(Porta, 2014, p. 195). From a
program planning viewpoint, a needs assessment is defined as
the process of identifying,
analyzing, and prioritizing the needs of a priority population.
Other terms that have been
used to describe the process of determining needs include
community analysis, community
diagnosis, and community assessment. Conducting a needs
assessment may be the most critical
step in the planning process because it “provides objective data
to define important health
problems, sets priorities for program implementation, and
establishes a baseline for evaluat-
ing program impact” (Grunbaum et al., 1995, p. 54).
There are many reasons why a needs assessment should be
completed before the other
steps of the planning process begin. First, it is a logical place to
start (Gilmore, 2012). Before
a need can be met, it first must be identified and measured.
Second, a needs assessment
can help ensure that scarce resources are allocated where they

can give maximum health
benefit (Rowe, McClelland, & Billingham (2001). Without
determining and prioritizing
needs, resources can be wasted on unsubstantiated
programming. Third, a needs assessment
allows planners to “apply the principles of equity and social
justice in practice” (Rowe et al.,
2001) by focusing on those in greatest need. Fourth, failure to
perform a needs assessment
may lead to a program focus that prevents or delays adequate
attention directed to a more
important health problem. For example, a health problem that
tends to create a high emo-
tional response, particularly among parents, is the trauma
associated with bicycle injuries
in children. Of course, it is a tragedy when a preventable death
occurs. In 2013, 7% of the
743 bicyclists killed in the United States were children age 15
and under (NHTSA, 2015). But
an even more significant determinant of childhood injury and
death in the United States is
the inadequate use of safety belts or car seats involved with
motor vehicle crashes. In fact,
motor vehicle crashes are the leading cause of death among
children in the United States

(Sauber-Schatz, West, & Bergen, 2014). A needs assessment
that examined both bicycle
and motor vehicle crashes would lead planners to determine in
most locations, in most in-
stances, that restraining children in motor vehicles with safety
belts or approved car seats is
a more important issue.
Fifth, a needs assessment can determine the capacity of a
community to address specific
needs. Capacity refers to the individual, organizational, and
community resources, such
as leadership, relationships, operations, structures,
infrastructure, politics, and systems, to
name a few, that can enable a community to take action
(Brennan Ramirez, Baker, & Metzler,
2008; Gilmore, 2012). In other words, when related to health
promotion, community
capacity is the “characteristics of communities that affect their
ability to identify, mobilize,
and address social and public health problems” (Goodman et al.,
1998, p. 259) (see Chapter 9
for mapping community capacity). “Assessing community
capacity helps you think about
existing community strengths that can be mobilized to address

social, economic, and envi-
ronmental conditions affecting health inequities. In general, you
should look at the places
(e.g., parks, libraries) and organizations (e.g., education, health
care, faith-based groups,
social services, volunteer groups, businesses, local government,
law enforcement) in various
Chapter 4 Assessing Needs 69
sectors of the community” (Brennan Ramirez et al., 2008, p.
54). “It is also important to
identify the nature of the relationships across these sectors
(e.g., norms, values), with the
community (e.g., civic participation), and among various
subgroups within the community
(e.g., distribution of power and authority, trust, identity)”
(Sampson & Raudenbush, 1999,
and Trachim, 1989, as cited in Brennan Ramirez et al., 2008, p.
54).
Sixth, a needs assessment can provide a focus for developing an
intervention to meet the

needs of the priority population. And finally, knowing the needs
of a priority population
provides a reference point to which future assessments can be
compared.
Having just stated several reasons why a needs assessment
should be completed, it may
seem odd that there are a few planning scenarios in which a
needs assessment would not be
used. The first would be if another needs assessment had been
conducted recently, possibly
for another related program, and the funding or other resources
to conduct a second needs
assessment in such a short period of time were not available. A
second scenario in which
a needs assessment may not be used is one where the program
planners are employed by
an agency that deals only with a specific need that is already
known (e.g., cancer and the
American Cancer Society), or the agency for which they work
has received categorical
funds that are earmarked or dedicated to a specific disease (e.g.,
HIV/AIDS), health determi-
nant (e.g., risk factor), or program (e.g., immunization).

Although a needs assessment has long been an important step in
health promotion
process, two recent events have made the public more aware of
the importance of a needs
assessment. In 2003, the Institute of Medicine (2003)
recommended examination of health
department accreditation as a means of improving public health
agency performance. After
such an examination, the Public Health Accreditation Board
(PHAB) was created in 2007
to create an accreditation process for governmental public
health departments operated by
tribes, states, local jurisdictions, and territories (PHAB, 2013b).
In July 2011, PHAB released
the Accreditation Standards and Measures. In order for a health
department to become ac-
credited, it must show its work meets the standards and
measures that are spread over 12 do-
mains. The first domain, which is a needs assessment, is stated
as “Conduct and Disseminate
Assessments Focused on Population Health Status and Public
Health Issues facing the
Community” (PHAB, 2013a, p. 13).
The second event that has made needs assessments more visible

to the public was the
passing of the Patient Protection and Affordable Care Act
(PPACA also known as the ACA)
that added section 501(r) to the Internal Revenue Code. Under
section 501(r) of the code,
501(c)(3) organizations that operate one or more hospitals (i.e.,
non-profit hospitals) must
meet four general requirements in order for the organization to
maintain its 501(c)(3) tax-
exempt status. One of the four general requirements is to
conduct a community health needs
assessment (CHNA) and adopt an implementation strategy for
addressing the needs at least
once every three years (CDC, n.d.b). Further, the IRS guidelines
require that these organiza-
tions partner with a public health agency in conducting the
CHNA. Each of these events that
require community needs assessments will add to improving the
community’s health.
The remaining portions of this chapter will present discussions
on what to expect from
a needs assessment, the types and sources of data used to
conduct a needs assessment, and a
suggested process for conducting a needs assessment. Box 4.1

identifies the responsibilities
and competencies for health education specialists that pertain to
the material presented in
this chapter.
What to Expect from a Needs Assessment
Several authors have provided lists of questions that should be
answered after completing a
needs assessment. They include:
1. Who makes up the priority population? (Petersen &
Alexander, 2011)
2. What are the needs of the priority population? (Petersen &
Alexander, 2011)
3. Why do these needs exist? (NACCHO, n.d.)
4. What factors create or determine the need? (NACCHO, n.d.)

5. Which subgroups within the priority population have the
greatest need? (Petersen &
Alexander, 2011)
6. Where are these subgroups located geographically? (Petersen
& Alexander, 2011)
7. What resources are available to address the needs?
(NACCHO, n.d.)
8. What is currently being done to resolve identified needs?
(Petersen & Alexander, 2011)
9. How well have the identified needs been addressed in the
past? (Petersen & Alexander, 2011)
Indirectly, getting answers to the latter three questions, numbers
7, 8, and 9, provides some in-
formation about the community capacity and whether part of the
identified needs may include
the need to build capacity. Capacity building refers to activities
that enhance the resources
of individuals, organizations, and communities to improve their
effectiveness to take action.

No matter how needs assessment is defined, the concept
embedded in the definitions is the
same: identifying the needs of the priority population and
determining the degree to which
the needs are being met. If needs are not being met, there may
also be a need to enhance capac-
ity of the community.
4.1
Specialists
The content of this chapter is associated with a single area of
responsibility. That
responsibility and related competencies include:
Health Education/Promotion
Competency 1.1: Plan assessment process for health
education/promotion
to health

Competency 1.3: Collect primary data to determine needs
Competency 1.4: Analyze relationships among behavioral,
environmental,
and other factors that influence health
Competency 1.5: Examine factors that influence the process by
which
people learn
process of
health education/promotion
Competency 1.7: Determine needs for health
education/promotion based
on assessment findings
for Health Education Credentialing, Inc. (NCHEC)

and the Society for Public Health Education (SOPHE).
Acquiring Needs Assessment Data
Two types of data are generally associated with a needs
assessment: primary data and
secondary data. Primary data are those data you collect
yourself (via a survey, a focus
group, in-depth interviews, etc.) that answer unique questions
related to your specific needs
assessment. Most methods of collecting primary data are ones in
which those collecting
the data interact with (e.g., interviewing) or minimally interact
with (e.g., windshield tour)
those from whom the data are being collected. Such methods
have been labeled as interac-
tive contact methods or minimal contact observational methods
(Marti-Costa & Serrano-Garcia
as cited in Hancock & Minkler, 2012). Secondary data are those
data already collected by
somebody else and available for your use. Thus, the methods to

collect these data have been
labeled as no contact methods (Marti-Costa & Serrano-Garcia as
cited in Hancock & Minkler,
2012). The advantages of using secondary data are that (1) they
already exist, and thus
collection time is minimal, and (2) they are usually fairly
inexpensive to access compared
to primary data. Both of these advantages are important to
planners because programs
are often planned when both time and money are limited.
However, a drawback of using
secondary data is that the information might not identify the
true needs of the priority
population—perhaps because of how the data were collected,
when they were collected,
what variables were considered, or from whom the data were
collected. A good rule is to
move cautiously and make sure the secondary data are
applicable to the immediate situa-
tion before using them.
Primary data have the advantage of directly answering the
questions planners want
answered by those in the priority population. However,
collecting primary data can be

expensive and when done correctly, take a great deal of time.
An overview of the means of acquiring primary and secondary
data are presented in the
following pages.
Sources of primary Data
Primary data can be collected using a variety of methods. Those
most commonly used in
planning health promotion programs are presented in Box 4.2.
SinglE-StEp oR CRoSS-SECtional SuRvEyS
Single-step surveys, or as they are often called cross-sectional
(point-in-time) surveys, are a
means of gathering primary data from individuals or groups
with a single contact—thus, the
term single-step. Such surveys often take the form of written
questionnaires and interviews.
When individuals or groups (also sometimes called respondents
or participants) are answering
questions about themselves, the information that is provided is
referred to as self-report
data. Thus, respondents are asked to recall (e.g., “When was

your last visit to your dentist?”)
and report accurate information (e.g., “On average, how many
minutes do you exercise
each day?”). Self-report measures are essential for many needs
assessments and evaluations
because of the need to obtain subjective assessments of
experiences (e.g., feelings about
available programs, self-assessments of health status, and health
behavior, such as eating
patterns) (Bowling, 2005). “For some behaviors, such as safer
sex behaviors, this is the only
way one can measure behavior” (Sharma & Petosa, 2014, p.
100). Even marketing data (e.g.,
the best location for a program, the best time to offer a
program, and willingness to pay for a
program) and capacity data (e.g., “What resources are needed to
make this change?) can be
collected through these assessments. In addition, self-report
measures have a broad appeal
to those who need to collect data, because “they are often quick

to administer and involve
little interpretation by the investigator” (Bowling, 2005, p. 15).
However, planners should
be aware that self-report data do have limitations. One such
limitation is bias (Windsor,
2015)—those data that have been distorted because of the way
they have been collected.
(See the section in Chapter 5 on bias free data.) To overcome
some of these limitations and
to maximize the usefulness of self-report, Baranowski (1985)
has developed eight steps to
increase the accuracy of this method of data collection:
1. Select measures that clearly reflect program outcomes.
2. Select measures that have been designed to anticipate the
response problems and that
have been validated.
3. Conduct a pilot study with the priority population. (See
Chapter 5 for pilot studies.)
4. Anticipate and correct any major sources of unreliability.
5. Employ quality-control procedures to detect other sources of

error.
6. Employ multiple methods.
7. Use multiple measures.
8. Use experimental and control groups with random assignment
to control for biases in
self-report.
By following these steps, planners can enhance the accuracy of
self-report, making this a more
effective method of data collection.
For a variety of reasons, there are times when those in the
priority population cannot re-
spond for themselves or do not want to respond. For example,
children who have not learned
how to read yet or people with dementia (Streiner, Norman, &
Cairrney, 2015). In such
situations, planners will have to collect data indirectly by
asking another (i.e., proxy reporter)
(Streiner et al., 2015) or looking for indications of a behavior.
Such a method is referred to

4.2
Box
Single-Step or Cross-Sectional Surveys
From priority population—self-report
written questionnaires
telephone interviews
face-to-face interviews
electronic interviews
group interviews
Proxy measures
From significant others
From opinion leaders
From key informants

Multistep Survey: Delphi Technique
Sources of primary Data
Community Forum (Town Hall Meeting)
Meetings
Focus Group
Nominal Group Process
Observation
Direct observation
Indirect observation (proxy measures)
“Windshield” or walk-through (walking
tours)
Photovoice and videovoice
Self-Assessments

Fo
cu
s
O
n
as a proxy (or indirect) measure. A proxy measure is an
outcome measure that provides
evidence that a behavior has occurred. Or as Dignan (1995)
stated, “indirect measures are
unmistakable signs that a specific behavior has occurred” (p.
103). Examples of proxy mea-
sures include (1) lower blood pressure for the behavior of
medication taking, (2) body weight
for the behaviors of exercise and dieting, (3) cotinine in the
blood for tobacco use, (4) empty
alcoholic beverages in the trash for consumption of alcohol, or
(5) another person reporting

on the compliance of his/her partner (Cottrell & McKenzie,
2011). Proxy measurements of
skills or behavior usually require more resources and
cooperation to obtain than self-report
or direct observation (Dignan, 1995). The greatest concern
associated with proxy measures is
making sure that the measure is both valid and reliable (Cottrell
& McKenzie, 2011).
In addition to surveying the priority population, there are other
groups of individuals
who are commonly asked to respond to single-step surveys for
the purpose of collecting
primary needs assessment data. They include significant others
of the priority population,
community opinion leaders, and key informants. Significant
others may include family
members and friends. Collecting data from the significant others
of a group of heart disease
patients is a good example. Program planners might find it
difficult to persuade heart disease
patients themselves to share information about their outlook on
life and living with heart
disease. A survey of spouses or other family members might
help elicit this information so

that the program planners could best meet the needs of the heart
disease patients.
Opinion leaders are individuals who are well respected in a
community and who can
accurately represent the views of the priority population. These
leaders are:
1. Discriminating users of the media
2. Demographically similar to the priority group
3. Knowledgeable about community issues and concerns
4. Early adopters of innovative behavior (see Chapter 11 for an
explanation of these terms)
5. Active in persuading others to become involved in innovative
behavior
Opinion leaders include political figures, chief executive
officers (CEOs) of companies, union
leaders, administrators of local school districts, and other
highly visible and respected indi-
viduals. (See Figure 4.1 for a form for tallying opinion leader

survey data.)
Key informants are individuals with unique knowledge about a
particular topic. For
example, it may be a person who has had a specific problem like
losing weight being able to
talk about the barriers of such an experience, or a person who
has tried to get health insur-
ance through an exchange only to be denied coverage. Because
their information may only
represent a single experience and thus be biased, planners need
to be careful not to base an
entire needs assessment on the data generated from a key
informant survey.
Single-step surveys of those in the priority population,
significant others, opinion leaders,
and key informants can be administered, as noted earlier,
several different ways. The primary
means of collecting data from these individuals include written
questionnaires, telephone
interviews, face-to-face interviews, electronic interviews, and
group interviews. A discussion
of each follows.

WRittEn QuEStionnaiRES
One of the most often used methods of collecting self-reported
data is the written
questionnaire. It has several advantages, notably the ability to
reach a large number of
respondents in a short period of time, even if there is a large
geographic area to be covered.
This method offers low cost with minimum staff time needed.
However, it often has the
lowest response rate.
With a written questionnaire, each individual receives the same
questions and instruc-
tions in the same format, so that the possibility of response bia s
is lessened. The corre-
sponding disadvantage, however, is the inability to clarify any
questions or confusion
on the part of the respondent. As mentioned, the response rate
for mailed questionnaires

tends to be low especially if respondents cannot remain
anonymous, but there are several
ways to overcome this problem. One way is to include with the
questionnaire a postcard
that identifies the person in some way (such as by name or
identification number). The in-
dividual is asked to return the questionnaire in the envelope
provided and to send the post-
card back separately. Anonymity is thus maintained, but the
planner/evaluator knows who
has returned a questionnaire. The planner/evaluator can then
send a follow-up mailing
(including a letter indicating the importance of a response and
another copy of the ques-
tionnaire with a return envelope) to the individuals who did not
return a postcard from the
first mailing. The use of incentives also can increase the
response rate. For example, some
hospitals offer free health risk appraisals to those who return a
completed needs assessment
instrument.
The appearance of the questionnaire is also extremely important
when collecting data.
It should be attractive, easy to read, and offer ample space for

the respondents’ answers. It
should also be easy to understand and complete, because written
questionnaires provide no
opportunity to clarify a point while the respondent is
completing the questionnaire. In addi-
tion, all mailed questionnaires should be accompanied by a
cover letter, to help clarify direc-
tions for completion (see Chapter 5 for more information on
questionnaire design).
__________________________________________
Number of interviewersData collection method
______________________________
To: _____From: ______ Total number of people interviewed
Date Collected ________
Number of Persons
Identifying Problem
Percentage of Persons
Identifying ProblemRank Health Problem
1.

2.
3.
4.
5.
6.
7.
8.
9.
10.
⦁ ▲ Figure 4.1 Form to Tally Opinion Leader Survey Data
Source: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention (no date), p. A3–12.
Short questionnaires that do not take a long time to complete
and questionnaires that
clearly explain the need for the information are more likely to
be returned. Planners/evaluators
should give thought to designing a questionnaire that is as easy
to complete and return as pos-

sible. For other strategies to increase response rates to wri tten
questions delivered via the postal
service see the systematic review conducted by Edwards et al.
(2009).
FaCE-to-FaCE intERviEWS
At times, it is advantageous to administer the instrument to the
respondents in a face-to-face
interview setting. This method is time consuming because it
may require not only time for
the actual interview but also travel time to the interview site
and/or waiting time between
interviews. The interviewer must be carefully trained to conduct
the interview in an unbi-
ased manner. It is important to explain the need for the
information in order to conduct the
needs assessment/evaluation and to accurately record the
responses. Methods of probing, or
eliciting additional information about an individual’s responses,
are used in the face-to-face
interview, and the interviewer must be skilled at this technique.
This method of self-report allows the interviewer to develop
rapport with the respondent.

The flexibility of this method, along with the availability of
visual cues, has the advantage of
gaining more complete data from respondents. Smaller numbers
of respondents are included
in this method, but the rate of participation is generally high. It
is important to establish
and follow procedures for selecting the respondents. There are
also several disadvantages
to the face-to-face interview. It is more expensive, requiring
more staff time and training of
interviewers. Variations in the interviews, as well as differences
between interviewers, can
influence the results.
tElEpHonE intERviEWS
Compared to mailed surveys or face-to-face interviews, the
telephone interview offers a
relatively easy method of collecting self-reported data at a
moderate cost. But it is not as easy
and inexpensive as it once was “due in part to the increasing use
of cell phones” (SHADAC,
2009, p. 1). The number of households in the United States that
do not have landline tele-
phone service, known as wireless-only households, continues to

grow. It has been estimated
that more than two out of five American homes (44.0%) have
only wireless telephones and
another 2.6% do not have any phone service (Blumberg & Luke,
2014). The prevalence of
such ‘wireless-only’ households now markedly exceeds the
prevalence of households with
only landline telephones (8.5%), and this difference is expected
to grow (Blumberg & Luke,
2014). Those most likely to live in wireless-only households are
younger, living with other
nonrelated adults, renting their residence, and being non-white
(Blumberg & Luke, 2014).
Therefore, depending on whom planners/evaluators are trying to
interview and how they
plan to select the participants for interviews, some individuals
may not have a chance of
being selected and/or contacted.
Prior to so many people living in wireless-only households,
participants who were to be
interviewed by telephone were selected using some type of
random process. One method
was to randomly select people from a “list.” For example, a
program participants’ list, a local

telephone book, student directory, church directory, or
employee directory. However, select-
ing people randomly from a list misses people with unlisted
telephone numbers and/or cell
phones. One way to overcome this problem is a method known
as random-digit dialing
(RDD), in which telephone number combinations are chosen at
random. This method would
include businesses as well as residences and nonworking as well
as valid numbers, making it
more time consuming. The numbers may be obtained from a
table of random numbers or
generated by a computer. The advantage of random-digit dialing
is that it includes the entire
survey population with a telephone in the area, including people
with unlisted numbers and
cell phones. However, there are several drawbacks to using
RDD. The first is that those with
cell phones may not have a telephone number with an area code
in which they live. This is

a problem because in order to use the RDD technique both the
area codes and the exchanges
(i.e., the first three digits of the seven-digit telephone number)
must be known. Another draw-
back is some peoples’ resistance to answering questions over
the telephone or resentment
about being interrupted with an unwanted call. And finally,
those conducting the interviews
may also have a difficult time reaching individuals because of
unanswered phones or answer-
ing machines.
Like face-to-face interviews, telephone interviewing requires
trained interviewers; without
proper training and use of a standard questionnaire, the
interviewer may not be consistent
during the interview. Explaining a question or offering
additional information can cause a
respondent to change an initial response, thus creating a chance
for interviewer bias. The
interviewer does have the opportunity to clarify questions,
which is an advantage over the
written questionnaire, but does not have the advantage of visual
cues that the face-to-face
interview offers.

ElECtRoniC intERviEWS
With more and more individuals having access to the Internet
and email [87% of U.S. adults
use the Internet, and 72% of Internet users say they looked
online for health information
during the past year (Pew Research Center, 2014)], it was only a
matter of time until planners/
evaluators used them to conduct interviews. Advantages to
using this type of interviewing
compared to using a written questionnaire include the reduced
response time, cost of materi-
als, ease of data collection, flexibility in the design and format
of the questionnaire, control
over the administration such as distribution to the recipients all
at the same time on the
same day, and recipient familiarity with the format and
technology (Neutens & Rubinson,
2014). In addition, responses received can be formatted to enter
directly into a spreadsheet/
statistical package eliminating manual data entry or scanning
(Cottrell & McKenzie, 2011).
However, there are several drawbacks to using the Internet for
interviewing: not everyone

has access to the Internet, obtaining email addresses of the
possible respondents can be diffi-
cult, and some people’s lack of comfort in using a computer. To
date, studies in the literature
on the response rate to electronic interviews has been mixed,
with some studies reporting
good results and others reporting lower rates similar to written
questionnaires sent via the
U.S. mail (Cottrell & McKenzie, 2011).
With the expanded use of the Internet has come an increase in
the number of commer-
cial companies (e.g., FluidSurveys, Qualtrics, QuestionPro,
SurveyMonkey, surveygizmo,
Zoomerang) that offer services to assist those in using this
method of interviewing. This is
how they work. Customers sign up and pay a fee. For the most
part, the fee is based on the
amount of service provided and the length of time the service is
used. Typical services of-
fered include design and preparation of the questionnaire,
translation of the questionnaire
into another language, customizing the questionnaire with
organization logo/branding,
personalized email cover letter introducing the questionnaire,

personalized email thank-you
letters for those who complete the instrument, data tallying and
analysis, various trainings,
and customer support. The costs of the services vary depending
on the type of customer, but
most companies provide a discount for not-for-profit and
educational organizations. Some
companies provide free options for limited use. One drawback
of such commercial services
is that they may not meet the security policies of some potential
users (e.g., medical centers).
gRoup intERviEWS
Interviewing individuals in groups provides for economy of
scale. That is, data can be col-
lected from several people in a short period of time. But there
are some drawbacks of such
data collection that primarily revolve around one or more group
members’ influencing

the response of others. A specific form of group interview
discussed later in this chapter is
focus groups. Focus groups are useful in collecting information
for a needs assessment, but
can also be used to determine if programs are being
implemented effectively or determine
program outcomes.
MultiStEp SuRvEy
As its title suggests, a multistep survey is one in which those
collecting the data contact those
who will provide the data on more than one occasion. The
technique that uses this process
is called the Delphi technique. It is a process that generates
consensus through a series of
questionnaires, which are usually administered via mail or
electronic mail. The process be-
gins with those collecting the data asking the priority
population to respond to one or two
broad questions. The responses are analyzed, and a second
questionnaire with more specific
questions based on responses to the first questionnaire, is
developed and sent to the priority
population. The answers to these more specific questions are

analyzed again, and another
new questionnaire is created and sent out, requesting additional
information. If consensus is
reached, the process may end here; if not, it may continue for
another round or two (Gilmore,
2012). Most often, this process continues for five or fewer
rounds.
CoMMunity FoRuM
The community forum, also sometimes referred to as a town hall
meeting, approach brings
together people from the priority population to discuss what
they see as their group’s problems/
needs. It is not uncommon for a community forum to be
organized by a group representing the
priority population, in conjunction with the program planners.
Such groups include labor,
civic, religious, or service organizations, or groups such as the
Parent Teacher Association
(PTA). Once people have arrived, a moderator explains the
purpose of the meeting and then
asks those from the priority population to share their concerns.
One or several individuals
from the organizing group, called recorders, are usually given

the responsibility for taking notes
or recording the session to ensure that the responses are
documented accurately. However,
when moderating a community forum, it is important to be
aware that the silent majority may
not speak out and/or a vocal minority may speak too loudly. For
example, an individual par-
ent’s view may be wrongly interpreted to be the view of all
parents.
At a community forum, participants may also be asked to
respond in writing (1) by answer-
ing specific questions or (2) by completing some type of
instrument. Figure 4.2 is an example
of an instrument that could be used to collect data from
participants in a community forum.
MEEtingS
Meetings are a good source of information for a preliminary
needs assessment or various
aspects of evaluation. For example, if a health department is
planning to conduct a needs

assessment and would like some direction on what health topics
to key in on, planners may
meet with a small group from the priority population to find out
what they see as health issues
in the community.
The meeting structure can be flexible to avoid limiting the
scope of the information
gained. The cost of this form of data collection is minimal.
Possible biases may occur when
meetings are used as the sole source of data collection. Those
involved may give “socially
acceptable” responses to questions rather than discussing actual
concerns. There also may
be limited input if relatively few participants are included, or if
one or two participants
dominate the discussion.
FoCuS gRoup
The focus group is a form of qualitative research that grew out
of group therapy. Focus

groups are used to obtain information about the feelings,
opinions, perceptions, insights,
beliefs, misconceptions, attitudes, and receptivity of a group of
people concerning an idea
or issue. Focus groups are rather small, compared to community
forums, and usually include
only 8 to 12 people. If possible, it is best to have a group of
people who do not know each
other so that their responses are not inhibited by acquaintance.
Participation in the group
is by invitation. People are invited about one to three weeks i n
advance of the session. At
the time of the invitation, they receive general information
about the session but are not
given any specifics. This precaution helps ensure that responses
will be spontaneous yet ac-
curate. Once assembled, the group is led by a skilled moderator
who has the task of obtaining
candid responses from the group to a set of predetermined
questions. In addition to elicit-
ing responses to the questions, the moderator may ask the group
to prioritize the different
Directions: Please rank the need for each program in the
community by placing a number in the

space to the left of the programs. Use 1 to rank the program of
greatest need, 2 for the next
greatest need, and so forth, until you have ranked all seven
programs. The program with the
highest number next to it should be the one that, in your
opinion, is least needed. If you feel that
a program should not be considered for implementation in our
community, please place an X in
the space to the left of the program instead of a numb er. Please
note that the number you place
next to each program represents its need in the community, not
necessarily your desire to par-
ticipate in it. After ranking the program, place an X to the right
of the program in the column(s)
that represent the age group(s) to which you feel the program
should be targeted.
Children
5–12
Teens
13–19
Adults
20–64

Older
adults 65�Program All ages
_______ Alcohol education: ________ ________ ________
________ ________
_______ Exercise/�tness: ________ ________ ________
________ ________
_______ Nutrition education: ________ ________ ________
________ ________
_______ Safety belt use: ________ ________ ________
________ ________
_______ Smoking cessation: ________ ________ ________
________ ________
_______ Smoking education: ________ ________ ________
________ ________
_______ Weight loss: ________ ________ ________ ________
________
⦁ ▲ Figure 4.2 Instrument for Ranking Program Need
Source: Instrument for Ranking Program Need. Amy L. Bernard.
Copyright © 2011 by Amy L. Bernard. Reprinted with
permission.

responses. As in a community forum, the answers to the
questions are recorded through
either written notes and/or audio or video recordings, so that at
a later date the interested
parties can review and interpret the results.
Focus groups are not easy to conduct. Special care must be
given to developing the ques-
tions that will be asked. Poorly written questions will yield
information that is less than use-
ful. In addition, the moderator should be one who is skilled in
leading a group. As might be
surmised, the level of skill needed to conduct a focus group
increases as the topic of discus-
sion becomes more controversial.
Although focus groups have been shown to be an effective way
of gathering data, they
do have one major limitation. Participants in the groups are
usually not selected through a
random-sampling process. They are generally selected because
they possess certain attributes

(e.g., individuals of low income, city dwellers, parents of
disabled children, or chief executive
officers of major corporations). Participants may not be
representative of the priority popula-
tion. Therefore, the results of the focus group are not
generalizable (CDC, 2008a). For more
detail and information about preparing for and conducting focus
groups, see Gilmore (2012),
National Cancer Institute (n.d.), and Teufel-Shone & Williams
(2010).
noMinal gRoup pRoCESS
The nominal group process is a highly structured process in
which a few knowledgeable
representatives of the priority population (5 to 7 people) are
asked to qualify and quantify
specific needs. Those invited to participate are asked to record
their responses to a question
without discussing it among themselves. Once all have recorded
a response, participants
share their responses in a round-robin fashion. While this is
occurring, the facilitator is
recording the responses on a computer screen, chalkboard or
flipchart for all to see. The

responses are clarified through a discussion. After the
discussion, the participants are asked
to rank-order the responses by importance to the priority
population. This ranking may be
considered either a preliminary or a final vote. If it is
preliminary, it is followed with more
discussion and a final vote.
oBSERvation
Observation, defined as “notice taken of an indicator” (Green &
Lewis, 1986, p. 363), can also
be an effective means of collecting data. Not only can people be
observed, but the environment
(i.e., those things around the priority population) can be
observed as well. Because those doing
the observation can “see” but do not interact with those in the
priority, observation has been
labeled a minimal-contact method of data collection.
Observation can be direct or indirect. Direct observation means
actually seeing a situation
or behavior. For example, direct observation may include
watching the eating patterns of
children in a school lunchroom, observing workers on an

assembly line to see if they are
wearing their protective glasses, checking the smoking behavior
of employees on break, and
observing drivers for safety belt use. This method is somewhat
time consuming, but it seldom
encounters the problem of people refusing to participate in the
data collection, resulting in a
high response rate.
Observation is generally more accurate than self-report, but the
presence of the observer
may alter the behavior of the people being observed. For
example, having someone ob-
serve smoking behavior may cause smokers to smoke less out of
self-consciousness due to
their being under observation. When people know they are being
observed it is referred
to as obtrusive observation. Unobtrusive observation means just
the opposite; the
persons being studied are not aware they are being measured,

assessed, or tested. Typically,
unobtrusive observation provides less biased data, but some
question whether unobtrusive
observation is ethical.
Differences among observers may also bias the results, because
different observers may
not observe and report behaviors in the same manner. Some
behaviors, such as safety belt
use, are very easy to observe accurately. Others, such as a
person’s degree of tension, are more
difficult to observe. This method of data collection requires a
clear definition of the exact
behavior to observe and how to record it (i.e., having an
observation checklist), in order to
avoid subjective observations. Observer bias can be reduced by
providing training and by
determining rater reliability. If the observers are skilled,
observation can provide accurate
needs assessment or evaluation data at a moderate cost.
As noted earlier in this chapter, indirect observation (or proxy
measure) can also be used to
determine whether a behavior has occurred. This can be
completed by either “observing” the

outcomes of a behavior (e.g., pills left in a bottle) or by asking
others (e.g., spouse) to report
on such outcomes (see the earlier discussion on proxy
measures). In addition, these measures
can be used to verify self-reports when observations of the
actual changes in behavior cannot
be observed.
Some specific methods of observation that have been useful in
collecting data for
health promotion programs are windshield tours or walk-
throughs and photovoice. When us-
ing a windshield tour or walk-through, the person(s) doing the
observation “walks or
drives slowly through a neighborhood, ideally on different days
of the week and at differ-
ent times of the day, ‘on the lookout’ for a whole variety of
potentially useful indicators of
community health and well-being” (Hancock & Minkler, 2012,
p. 164). Potentially useful
indicators may include: “(A) Housing types and conditions, (B)
Recreational and commercial
facilities, (C) Private and public sector services, (D) Social and
civic activities, (E) Identifiable
neighborhoods or residential clusters, (F) Conditions of roads

and distances most travel, (G)
Maintenance of buildings, grounds and yards” (Eng &
Blanchard, 1990–1991, p. 96–97).
Photovoice (formerly called photo novella) is the creation of
Wang and Burris (1994,
1997). It is a form of participatory data collection (i.e., those in
the priority population
participate in the data collection) in which those in the priority
population are provided
with cameras and skills training (on photography, ethics, data
collection, critical discussion,
and policy), then use the cameras to convey their own images of
the community problems
and strengths (Kramer et al., 2010; Minkler & Wallerstein,
2012). “Photovoice has 3 main
goals: (1) to enable people to record and reflect their
community’s strengths and concerns;
(2) to promote critical dialogue and enhance knowledge about
issues through group discus-
sions of the photographs; and (3) to inform policy makers”
(FYVPC, 2006, para. 2).
Photovoice has been used a lot with “marginalized groups of
various ages that want their

perspective seen and heard by those in power” (WCPH, 2009, p.
1). More recently it has been
receiving increased attention because of its application to health
promotion. There are a
number of reports of its use in the literature that have resulted
in successful policy and envi-
ronmental changes (e.g., Goodhard et al., 2006; Kramer et al.,
2010; Wang, Morrel-Samuels,
Hutchinson, Bell, & Pestronk, 2004). It has also been used with
a variety of community and
public health problems.
The process for using photovoice involves the following steps:
(1) defining the goals
and objectives of the project; (2) identifying the community
participants; (3) providing
participants with the purpose and philosophy behind
photovoice; (4) providing partici-
pants with training to carry out the project; (5) providing a
theme for taking the pictures

(e.g., “show what is unhealthy about our community”); (6)
letting the participants take the
pictures; (7) selecting the photographs that reflect the concerns
of the project; (8) in groups,
engaging in meaningful dialogue about the significance of each
photograph; (9) contextu-
alizing the photographs by writing captions based on the
mnemonic SHOWeD created by
Wallerstein (1987) (i.e., What do you See here? What’s really
Happening here? How does
this relate to Our lives? Why does this problem or this strength
exist? What can we Do
about this?); (10) codifying the results by identifying the issues,
themes, or theories that
emerge; (11) identifying the stakeholders and venues to present
the results; (12) making
the presentation(s) to the community stakeholders (e.g., policy
makers, decision makers)
and the public; and (13) taking action based on results of the
photovoice process (Downey,
Ireson, Scutchfield, 2009; Kramer et al., 2010; STEPS Centre,
2015; University of Kansas,
2014; Wang & Burris, 1997; Wang, Morrel-Samuels, et al.,
2004; Wang, Yi, Tao, & Carovano,
1998; WCPH, 2009).

For those interested in learning more about photovoice please
see reviews by Catalani and
Minkler (2010) and Hergenrather, Rhodes, and Bardhoshi
(2009).
SElF-aSSESSMEntS
Data can also be collected by those in the priority population
through self-assessments.
“A majority of these approaches address primary prevention
issues, such as the assessment
of risk factors and protective factors in one’s lifestyle pa ttern,
and the secondary prevention
process of the early detection of disease symptoms” (Gilmore,
2012, p. 179). Examples of
such assessments include breast self-examination (BSE),
testicular self-examination (TSE),
self-monitoring for skin cancer, and health assessments (HAs).
“Health assessments in-
clude instruments known as health risk appraisals or health risk
assessments (HRAs), health
status assessments (HSAs), various lifestyle-specific (e.g.,
nutrition, stress, and physical activ-
ity) assessment instruments, wellness and behavioral/habit

inventories” (SPMBoD, 1999,
p. xxiii), and disease/condition status assessments (e.g.,
chances of getting heart disease or
diabetes). HAs, specifically HRAs, have been used more in
worksite health promotion pro-
grams than in other settings.
Of the different self-assessments, it is the HAs that have been
most useful in the needs
assessment process, because from such assessments planners
can obtain “group data which
summarize major health problems and risk factors” (Alexander,
1999, p. 5). And of the HAs,
it is the HRAs that are most often included in the needs
assessment process. HRAs are instru-
ments that estimate “the odds that a person with certain
characteristics will die from selected
causes within a given time span” (Alexander, 1999, p. 5). Even
though HRAs are used as part
of needs assessments, this was not their original intent. The
original purpose of HRAs was to
engage family physicians and their patients in conversation
about risks of premature death
and preventive health behaviors (Robbins & Hall, 1970).

To use an HRA as part of a needs assessment, planners would
have those in the prior-
ity population complete a questionnaire. The instruments
include questions about health
behavior (e.g., smoking, exercise), personal or family health
history of diseases (e.g., can-
cer, heart disease), demographics (e.g., age, sex), and usually
some physiological data (e.g.,
height, weight, blood pressure, cholesterol). The resulting risk
appraisals, in most cases,
are calculated by computers, but some HRAs are hand-scored by
the participant or health
professional (Alexander, 1999). Most HRAs generate both
individual and group reports. Thus
planners can use the individual reports as part of an educational
program for the priority
population and use the group reports as another source of
primary needs assessment data.
There are many HA instruments on the market. Before using

one, you need to review
information about the instruments that are available. Hunnicutt
(2008a) created 10 critical
questions that need to be asked when a health risk appraisal is
purchased from a vendor: (1)
How long has the vendor been in business? (2) How many other
clients have used the instru-
ment? (3) Who was behind the development of the HRA? (4)
What is the best price? (5) Is
the vendor willing to share the names of other clients who have
used the HRA? (6) Is there
any litigation pending against the vendor? (7) Is the vendor
Health Insurance Portability
and Accountability Act (HIPAA) compliant? (8) Will the vendor
store the HRA data at a site
outside the United States? (9) Is customer service/technical
assistance included with the pur-
chase of the HRA? (10) Who is the key contact within the
company of the vendor and what is
his/her emergency number?
Although this discussion has revolved around the use of HRAs
as means of providing
information for a needs assessment, they have also been used to
help motivate people to:

act on their health, measure health status, increase productivity,
increase awareness, serve
as cues to action, and to contribute to program design and
evaluation (Simpson, Hyner, &
Anderson, 2013) (see Hunnicutt, 2008b, for benefits of using
personal health assessments
in a worksite). However, it should be noted that the Community
Preventive Services Task
Force (CPSTF) has conducted two separate reviews on the use
of HRAs among employees.
In the first review, it was found that there was insufficient
evidence to recommend the
use of HRAs with appropriate feedback to achieve
improvements in health behavior. In
the second review, it was found that there was sufficient
evidence to recommend the use
of HRAs with appropriate feedback when combined with health
education programs, and
with or without additional interventions for improving health
behaviors of employees
(CPSTF, 2006 & 2007).
table 4.1 summarizes the advantages and disadvantages of the
various methods of col-
lecting primary data.

Sources of Secondary Data
Several sources of secondary needs assessment data are
available to planners. The main
sources include data collected by government agencies at
multiple levels (federal, state, or
local), data available from nongovernment agencies and
organizations, data from existing
records (e.g., medical records), and data or other evidence that
are presented in the literature
(see table 4.2).
Data CollECtED By govERnMEnt agEnCiES
Certain government agencies collect data on a regular basis.
Some of the data collection is
mandated by law (e.g., census, births, deaths, notifiable
diseases), whereas other data are
collected voluntarily (e.g., usage rates for safety belts). Because
the data are collected by the
government, program planners can gain free access to them by
contacting the agency that
collects the data, or by finding them on the Internet, or in a
library that serves as a United

States government depository. Many college and university
libraries and large public librar-
ies serve as such depositories.
TAbLe 4.1 Methods of Collecting Primary Data
Method Advantages Disadvantages
Self-Report
Written questionnaire
via mail
Large outreach
No interviewer bias
Convenient
Low cost
Minimum staff time required
Easy to administer
Quick
Standardized

Possible low response rate
Possible problem of representation
No clarification of questions
Need homogenous group if response
is low
No assurance addressee was
respondent
Wait time for returns**
Telephone interview Moderate cost
Relatively easy to administer
Permits unlimited callbacks
Can cover wide geographic areas
Faster than mail or interview
techniques**
Respondent can hang up**
Telemarketers have made it harder**
Possible problem of representation
Possible interviewer bias
Requires trained interviewers

Wireless-only households
Unlisted number households
Face-to-face interview High response rate
Flexibility
Gain in-depth data
Develop rapport
Can observe nonverbal behavior**
No help from others in answering**
Expensive
Requires trained interviewers
Possible interviewer bias
Limits sample size
Time-consuming
Electronic interview Low cost
Ease and convenience
Almost instantaneous
Commercial companies’ services
Wide geographic coverage**
Must have Internet access
Self-selection
May lack anonymity

Respondent can easily delete request
to participate**
Email addresses hard to get sometimes
Group interview High response rate
Efficient and economical
Can stimulate productivity of others
May intimidate and suppress individual
differences
Fosters conformity
Group pressure may influence
responses
Delphi technique* Pooled responses
Spans time and distance
High motivation and commitment
Reduced influence of others
Enhanced response quality and
quantity
Equal representation

Consistent participant contact
High cost and time commitment
Reduced clarification opportunities
Reduced immediate reinforcement
(continued)
Data availaBlE FRoM nongovERnMEnt agEnCiES
anD oRganizationS
In addition to the data available from government agencies,
planners should also consult
with nongovernment agencies and groups for data. Included
among these are health care
systems, voluntary health agencies, business, civic, and
commerce groups. For example,
most of the national voluntary health agencies produce yearly
“facts and figures” booklets
that include a variety of epidemiological data. In addition, local
agencies (e.g., local health

department), health care facilities (e.g., non-profit hospitals)
and organizations (e.g., United
Way) often have data they have collected for their own use.
Method Advantages Disadvantages
Community forum
(town hall meeting)*
Relatively straightforward to
conduct
Relatively inexpensive
Access to a broad cross-section
of the community
People participate on own terms
Can identify most interested
Often difficult to achieve good
attendance
Participants in the community forum
may tend to represent special interests

Forum could degenerate into
gripe session
Data analysis can be time consuming
Meetings Good for formative evaluation
Low cost
Flexible
Possible result bias
Limited input from participants
Focus groups* Low cost
Convenience
Creative atmosphere
Ease of clarification
Flexibility
Qualitative information
Limited representativeness
Dependence on moderator skill
Preliminary insights
Participant involvement
Nominal group

process*
Direct involvement of priority
groups
Planned interactivity
Diverse opinions
Full participation
Creative atmosphere
Recognition of common ground
Time commitment
Competing issues
Participant bias
Segmented planning involvement
observation Accurate behavioral data
Can be obtrusive
Moderate cost
Requires trained observers
May bias behavior
Possible observer bias
May be time-consuming

Self-assessments Convenient
No interviewer bias
Moderate cost
Minimum staff time required
Easy to administer
Flexibility
Possible low response rate
Possible problem of representativeness
Self-selection
*From Gilmore (2012); **From Neutens & Rubibson (2014)
TAbLe 4.1 Continued
TAbLe 4.2 Sample Sources of Secondary Data Available from
Governmental
and Nongovernmental Agencies and Organizations
Type of Agency/Organization Type of Data URL (Web Address)

Government Agencies
U.S. Bureau of Census Demographic
U.S. Census Statistical
Abstract of the United
States
http://www.census.gov
http://www.census.gov/prod/www/
statistical_abstract.html
and Prevention (CDC)
Health and Vital Statistics
National Center for Health
Statistics (NCHS)
Morbidity Mortality Weekly
Report (MMWR)
CDC WoNDER

http://www.cdc.gov/mmwr/
http://wonder.cdc.gov
Behavioral Risk Factors
Behavioral Risk Factor
Surveillance System
(BRFSS)
Youth Risk Behavior
Surveillance System
(YRBSS)
http://www.cdc.gov/brfss/
http://www.cdc.gov/healthyyouth
/data/yrbs/index.htm
Food & Drug Administration
(FDA)
Food, Drugs and Medical

Device Data
http://www.fda.gov
Environmental Protection
Agency (EPA)
Environmental Data
and Statistics
http://www.epa.gov
Substance Abuse & Mental
Health Services Administration
(SAMHSA)
Substance & Mental Health
Statistical Information
http://www.samhsa.gov
National Cancer Institute Cancer Statistics
http://www.cancer.gov
Nongovernmental Agencies and Organizations

American Cancer Society Cancer Information and
Statistics
http://www.cancer.org
American Heart Association Heart Disease and Stroke
Information and Statistics
http://www.heart.org/HEARToRG/
County Health Rankings Health Data by U.S. Counties
Henry J. Kaiser Family
Foundation
Health Data by States http://kff.org/statedata/
Data FRoM ExiSting RECoRDS
These are health data that are often collected as a part of normal
operations of an organiza-
tion. These data can also serve as useful secondary needs
assessment data. Using such data
may be an efficient way to obtain the necessary information for

a needs assessment (or an
evaluation) without the need for additional data collection. The
advantages include low cost,
minimum staff needed, and ease in randomization. The
disadvantages include difficulty in
gaining access to the necessary records and the possible lack of
availability of all the informa-
tion needed for a needs assessment or program evaluation.
http://www.census.gov
http://www.census.gov/prod/www/statistical_abstract.html
http://www.cdc.gov/mmwr/
http://www.cdc.gov/brfss/
http://www.cdc.gov/healthyyouth/data/yrbs/index.htm
http://www.fda.gov
http://www.epa.gov
http://www.samhsa.gov
http://www.cancer.gov
http://www.cancer.org
http://www.heart.org/HEARToRG/
http://kff.org/statedata/

Examples of the use of existing records include checking
medical records to monitor
blood pressure and cholesterol levels of participants in an
exercise program, reviewing
insurance usage of employees enrolled in an employee health
promotion program, and
comparing the academic records of students engaging in an
after-school weight loss pro-
gram with those who are not. In these situations, as with all
needs assessments using ex-
isting records, the cooperation of the agencies that hold the
records is essential. At times,
agencies may be willing to collect additional information to aid
in the needs assessment for
(or an evaluation of) a health promotion program. Keepers of
records are concerned about
confidentiality and the release of private information. The
importance of privacy for those
planners working in health care settings was further emphasized
in 2003 with the enact-
ment of the Standards for Privacy of Individually Identifiable
Health Information section (The

Privacy Rule) of the Health Insurance Portability and
Accountability Act of 1996 (officially
known as Public Law 104-191 and referred to as HIPAA,
pronounced “hip-a”). The rule sets
national standards that health plans, health care clearinghouses,
and health care providers
who conduct certain health care transactions electronically must
implement to protect and
guard against the misuse of individually identifiable health
information. Failure to imple-
ment the standards can lead to civil and criminal penalties
(USDHHS, OCR, n.d.). Planners
can deal with these privacy issues by getting permission from
all participants to use their
records or by using only anonymous or de-identified (i.e.,
information removed so individu-
als cannot be identified) data.
Data FRoM tHE litERatuRE
Planners might also be able to identify the needs of a priority
population by reviewing any
available current literature about that priority population. An
example would be a planner
who is developing a health promotion program for individuals

infected by the human immu-
nodeficiency virus (HIV). Because of the seriousness of this
disease and the number of people
who have studied and written about it, there is a good chance
that present literature could
reflect the need of a certain priority population.
The best means of accessing data from the literature is by using
the available literature
databases. Most literature databases today are available in
several different forms, including
electronic databases and the Internet. Depending on the
database used, planners can expect
to find comprehensive listings of citations for journal articles,
book chapters, and books,
and, in some databases, abstracts of the literature. Within the
listings, most databases cite
sources by both author and subject/title. Figure 4.3 provides an
example of what planners
might find when searching a database.
Many literature databases are available to planners. Next is a
short discussion of those
databases that have proved helpful to health promotion
planners.

pSyCinFo
PsycINFO®, which is produced by the American Psychological
Association (APA), is an abstract-
ing (not full-text) “and indexing database with more than 3
million records devoted to peer-
reviewed literature in the behavioral sciences and mental health
(APA, 2015, para. 1)
MEDlinE
Medline, the primary component of and accessed through
PubMed®, is the U.S. National
Library of Medicine’s® (NLM) premier bibliographic database
that contains over 22 million
references from more than 5,600 journals covering the life
sciences with a concentration on
biomedicine. “A distinctive feature of Medline is that the
records are indexed with NLM’s

Medical Subject Headings (MeSH®)” (U.S. NLM, 2015, para.
1).
EDuCation RESouRCE inFoRMation CEntER (ERiC)
ERIC is an online digital library of education literature
sponsored by the Institute of
Education Sciences (IES) of the U.S. Department of Education.
ERIC provides free access to
educational journal articles and other education-related
materials.
CuMulativE inDEx to nuRSing & alliED HEaltH litERatuRE
(CinaHl)
The CINAHL, which is updated monthly, provides indexing of
journals from the fields of
nursing and other allied health disciplines. It also provides
indexing for healthcare books,
dissertations from the field of nursing, selected conference
proceedings, and standards of
practice. Subject headings follow the NLM’s MeSH® structure.
puBMED

PubMed includes “more that 24 million citations from
biomedical literature from MEDLINE,
life science journals, and online books” U.S. NLM (n.d.). Some
of the citations provide links
to full-text content.
Steps for Conducting a literature Search
gEnERal SEaRCH pRoCEDuRES
The process of searching a database is not difficult, and with
the exception of a few indi-
vidual differences, most indexes are arranged in a similar
format. As Figure 4.3 indicated,
most indexes include both an author and a subject/title index.
An item that is specific to
each index is its thesaurus, a listing of the key words the
indexes used to index the subject/
Author Citation
Authors Article title
T T
Neiger, B. L., Thackeray, R., & Fagan, M. C. Basic priority
rating model 2.0: current

applications for priority setting in health promotion practice.
Health Promotion Practice.
2011; 12(2), 166–171.
c c c
Journal Volume Pages Journal
(number)
Subject/Title Citation
Article title
T
Basic priority rating model 2.0: current applications for
priority setting in health
promotion practice. Neiger, B. L., Thackeray, R., & Fagan,
M. C., Health Promotion Practice.
2011; 12(2), 166–171.
⦁ ▲ Figure 4.3 Sample Citations

titles. Planners can find the thesauri online or in a separate
volume with or near a hard
copy of the indexes.
Figure 4.4 provides planners with a literature search strategy in
the form of a flowchart. The
chart begins by identifying the need of the priority population
or topic to be searched. At this
point, planners can search either by subject/title or by author. If
planners know of an author
who has done work on their topic, they can search the database
using the author’s last name.
If they do not have information on authors, they will need to
match their topic with the key
words presented in the thesaurus. Since there are times when a
topic is not expressed in the
same terms used in the thesaurus, planners will need to look for
related terms. Once they have
a list of key words, they need to search the database for possible
matches. In conducting this
search, they need to ensure that they are using the database that
covers the years of literature
in which they are interested. This search should identify
possible sources and citations.

Once sources are identified, planners may review abstracts (or
entire documents) online
or locate a hard copy of the document. Then, planners must
determine the quality and use-
fulness of the publication in the needs assessment process. One
means by which planners
can judge the quality of the literature is to examine the
references at the end of the publica-
tions. First, this reference list may lead planners to other
sources not identified in the original
search. Second, if the sources found in the database include all
those commonly cited in the
literature, this can verify the exhaustiveness of the search.
SEaRCHing via tHE WoRlD WiDE WEB
The continued development of the World Wide Web (WWW)
has enhanced the opportuni-
ties for planners to obtain a variety of needs assessment data
with the “touch of a button”
from their home or office. Many of the government and
nongovernment agencies and orga-
nizations, as well as the databases, discussed in this chapter
have Websites that planners can
access if they have the Web address, also known as the uniform

resource locator (URL). If the
Web address is unknown, planners can use a search engine to
identify appropriate Websites.
Popular search engines include Yahoo, DuckDuckGo, Ask,
AOL, Google, and bing.
Planners can experiment with and select the sites that best fit
their needs. If planners are us-
ing a term that has more than one word (i.e., heart disease), it is
best to use quotation marks
around the term when entering it on the search engine. “This
will let the search engine know
that the exact phrase, as contained in the quotation marks, is to
be used when seeking sites
that match. If the quotation marks are not used, the search
engine will find sites that contain
any of the words in the query” (Cottrell et al., 2015, p. 300) and
thus many of the sites found
may not be of use.
As with any data source, planners need to be aware that not all
data found via the Web
are valid and reliable. Thus planners need to scrutinize sources
just as they would data
found in hard copies. Librarians at Meriam Library at California

State University, Chico
created the Currency, Relevance, Authority, Accuracy, Purpose
(CRAAP) Test that is most
useful for evaluating information obtained via the Internet (see
the link for the Website in
the Weblinks section at the end of the chapter).
using technology to Map needs assessment Data
As has already been mentioned in this chapter, more and more
needs assessment data are
being obtained through the use of technology (i.e., electronic
interviews, computerized
searchers of the World Wide Web and databases).
Also look to match topic with
related key words not
originally considered
Search the database for the
years in which interested

Identify need or topic
Match topic with key words
in the thesaurus
Subject/Title search
Locate sources
Identify possible sources
Judge quality and quantity
of sources
Organize literature into
useable form
Search database for known
authors using last names for
the years in which interested
Author search
⦁ ▲ Figure 4.4 Literature Search Strategy Flowchart

Source: Adapted from Deeds (1992) and Marcarin (1995).
One other process that is being used more frequently is the use
of geographic infor-
mation systems (GIS) to help provide meaning to collected data.
“GIS helps us analyze
spatially referenced data and make well-informed decisions
based on the association
between data and the geography” (CDC, 2006). In other words,
the data are mapped.
Mapping “is the visual representation of data by geography or
location, linking informa-
tion to a place to support social and economic change on a
community level. Mapping is a
powerful tool for two reasons: (1) it makes patterns based on
place much easier to identify
and analyze, and (2) it provides a visual way of communicating
those patterns to a broad
audience, quickly and dramatically” (Kirschenbaum & Corburn,
2012, p. 444). The process
of mapping involves (1) identifying the geographic area that

the map will cover, (2) col-
lecting the necessary data, (3) importing the data into GIS
software so that the data can be
placed on maps, and (4) analyzing what is found in the maps.
Mapping has taken on more
meaning recently because it has been noted that “when it comes
to your health, your zip
code is more important than your genetic code” (Iton, 2014,
para. 8). Mapping has been
used to address a number of different health problems. Some
examples include blood pres-
sure (Mendy, Perryman, Hawkins, & Dove, 2014), cancer
(Beyer & Rushton, 2009; Richards
et al., 2010), diabetes (Ruberto & Brissette, 2014), fruit and
vegetable consumption (Lucan,
Hillier, Schechtner, & Glanz, 2014), and lead screening (Graff,
2013). The use of GIS in the
needs assessment process will continue to grow as the
development of such software be-
comes more widely available and easier to use.
Conducting a Needs Assessment
A number of different approaches can be used to determine the
needs of the priority

population. “Need assessments range from informal approaches,
using educated and in-
formed observations to formal, comprehensive research
projects. However, the informal
approaches are less reliable than a planned and scientifically
developed research approach”
(Timmreck, 2003, p. 89). Often, informal approaches are used
because of limited resources,
usually time, personnel, and money. However, as noted in the
beginning of this chapter,
needs assessment may be the most critical step in the planning
process and should not be
taken lightly. Resources used on need assessments usually pay
dividends many times over.
Therefore the authors present a six-step process that is more
formal in nature: (1) determin-
ing purpose and defining the scope of the needs assessment, (2)
gathering data, (3) analyz-
ing the data, (4) identifying the risk factors linked to the health
problem, (5) identifying
the program focus, and (6) validating the need before
continuing on with the planning
process (see Figure 4.5).
Step 1

Determining the
purpose and
scope
Step 2
Gathering
data
Step 3
Analyzing
data
Step 4
Identifying risk
factors linked to
health problem
Step 5
Identifying
the program

focus
Step 6
Validating
the need
⦁ ▲ Figure 4.5 Steps in Conducting a Needs Assessment
Step 1: Determining the purpose and Scope of the needs
assessment
The initial step in the needs assessment process is to determine
the purpose and the scope of
the needs assessment. In other words, what is the goal of the
needs assessment? What does the
planning committee hope to gain from the needs assessment?
How extensive will the needs
assessment be? What kind of resources will be available to
conduct the needs assessment?
In reality, the first challenge associated with conducting a needs

assessment is determining
whether an assessment should even be performed, and if so,
what type of needs assessment
is appropriate. As noted earlier in the chapter a comprehensive
needs assessment may not be
warranted because a need may be obvious or an
agency/organization has received categorical
funding to address a specific health problem. However, a more
focused needs assessment may
be appropriate to gather more specific information about the
need or health problem. For
example, if the priority health problem is breast cancer, it is
still necessary to collect current
information on the degree to which women are either dying or
suffering from the disease. It
will be important to know how prevalent breast cancer is and
where it is most prevalent in the
population, as well as the high-risk subpopulations, economic
costs, and general trends over
time. The extent to which a needs assessment is necessary and
appropriate should be deter-
mined by stakeholders, including key decision makers.
In other cases, a planner may be in a situation where a needs
assessment has never been

performed, not been performed for a long period of time, or
where categorical funding does
not dictate what health problem(s) should be addressed. This
will require planners and
their partners to collect a wide range of data, compare the
importance of multiple health
problems, and set priorities. In a general sense, this is the
process that is often referred to as a
community health needs assessment (CHNA). This implies that
all significant health problems
are examined to assess their relative significance. Stakeholders
and planning groups will
also usually determine how many health problems will be
analyzed in the needs assess-
ment. This will be influenced by how much time, and how many
resources, can be directed
to the needs assessment.
Another important decision that must be made is the extent to
which those in the
community where the needs assessment is being conducted will
be involved in the needs
assessment process. The term participatory or action research
has gained popular-
ity in recent years, though it is often misunderstood or used

inappropriately. Participatory
research has been “defined as systematic inquiry, with the
collaboration of those affected
by the issue being studied, for the purposes of education and of
taking action or effecting
change” (Mercer et al., 2008, p. 409).
Once the basic purpose and scope of the needs assessment is
identified, planners may pro-
ceed to data collection. However, planners must not take this
first step too lightly. Although
a natural tendency is to move forward quickly, an understanding
of why a needs assessment
is being performed will give proper direction to all other steps
that follow.
Step 2: gathering Data
The second step in the needs assessment process is gathering
data. As noted earlier in this
chapter, there are many different sources of needs assessment
data. A part of the art of
conducting a needs assessment is to be able to identify the most
relevant data possible. By
relevant data, we mean those data that are most applicable to

the planning situation and
that will do the best job of helping planners to identify the
actual needs of the priority
population. Because of the cost and availability, it is
recommended that planners begin the
data-gathering process by trying to locate relevant secondary
data. For example, if a national
program is being planned, then national secondary data should
be sought from appropriate
national government and nongovernment agencies. If a local
program is being planned,
then appropriate local data should be sought. When planning a
local program, it is not un-
usual to find that local data do not exist. If that is the case,
planners may need to use state,
regional, or national data (in that order) and apply them to the
local area. For example, let’s
assume diabetes mellitus mortality data are needed for local
planning and the only data
available are national level data. Planners could use national

data (e.g., 21.2 per 100,000
people died of diabetes in 2013) to estimate the number of
deaths in a local community.
If the population of a local city is 250,000, planners could infer
that the number of deaths
due to diabetes in the city during 2013 totaled 53 (i.e., 21.2 ×
2.5). If the city’s population
were older, 53 deaths could be viewed as a low estimate because
diabetes deaths are more
prevalent in older populations. Conversely, if the population
were younger, 53 deaths could
be viewed as a high estimate. Obviously, as noted at the
beginning of this chapter, there are
disadvantages of using secondary data, but good planners use
and interpret them in light of
their limitations (McDermott & Sarvela, 1999).
Once relevant secondary data have been identified, planners
need to turn their attention to
gathering the appropriate primary data in order to fill in the
“data gaps” to better understand
the needs of the priority population. For example, if secondary
data show that there is a need for
cancer education programming, but does not specifically
identify the type of cancer or segment

the priority population by useful demographic characteristics
(e.g., age or sex), then efforts
should be made to collect such data. Or, it may be that all the
secondary data are quantitative
data such as how frequently a service is used, and thus it might
be very useful to collect primary
data that are qualitative in nature such as detailed explanations
of why a service was not used. It
should be noted that primary data collection could have a dual
purpose. Not only do primary
data collections provide valuable information about the specific
planning situation that cannot
be obtained from secondary data, they also provide an
opportunity to get those in the priority
population actively involved and contributing to the program
planning process. Thus, planners
need to decide what primary data are needed, from whom they
should be collected (e.g., All?
Some? Just certain demographic groups?), and what methods
(e.g., Interviews? Questionnaires?
Focus groups? Photovoice?) would be best for not only
collecting the needed information but
also in getting active participation from the priority population.
It should also be noted that the planning model used to develop

a program might also
drive the types of data collected for the needs assessment. For
example, when the Social
Marketing Assessment and Response Tool (SMART) model is
used planners would be inter-
ested in collecting data that would assist with Consumer
Analysis (Phase 2), Market Analysis
(Phase 3), and Channel Analysis (Phase 4). When the
Mobilizing for Action through Planning
and Partnerships (MAPP) model is being used planners should
be collecting data that would
provide information for the Assessments (Phase 3) which yield
a list of challenges and oppor-
tunities in a community (see Chapter 3 for more information
about SMART and MAPP).
In addition to using a planning model to help guide the types of
data to be collected, plan-
ners may also want to use theoretical constructs to help guide
data collection. For example, it
may be important for planners to know what stages of change
(see Chapter 7 for information
on the Transtheoretical Model) the priority population is in for
a specific health behavior
(i.e., exercise) in order to create a more focused intervention.

As planners conclude the second step in the needs assessment
process, they must remember
that each planning situation is different. It is desirable to have
both primary and secondary
needs assessment data in order to gain a clear picture of needs;
however, depending on the
resources and circumstances, planners may have access to only
one or the other. In addition,
there is usually a trade-off between quality and quantity of data.
Planners must use the best
data available under the challenges and constraints facing them.
Step 3: analyzing the Data
At this point in the needs assessment process, planners must
analyze all the data collected,
with the goal of identifying and prioritizing the health
problems. The goal of data analysis
is easily stated, but this step may be the most difficult to
complete. There are those rare

occasions when the data analysis is not very complicated
because the need is obvious. For
example, the data may clearly show that breast cancer rates
have continued to rise in a
community, while the number of breast screenings has dropped,
and those in the priority
population recognize the problem. Or, in another setting the
data analysis shows a very
clear correlation between the health status of the priority
population and the lack of pri-
mary health care received. However, not all analyses of data
yield such obvious needs. More
often than not, planners are faced with trying to compare data
that are not easily compared.
The data may be mixed (i.e., apples and oranges) or confusing.
For example, they may have
mortality data for one health problem, morbidity data for
another, and perhaps behavioral
risk factor data for yet another. Or, if planners are working with
a multicultural priority pop-
ulation, data analysis may even be more confusing, because
health concepts held by one
culture may be very different than the health concepts held by
the planners. When work-
ing with diverse communities, it is important to find “out more

information about what is
going on and why and how cultural issues may or may not
influence a health problem or
related risk behaviors” (Vaughn & Krenz, 2014, p. 178). A
failure to understand and appreci-
ate these differences in the priority population can have serious
implications for success of
any health promotion/disease prevention effort (Kline & Huff,
1999).
One systematic way to analyze the data is to use the first few
phases of the PRECEDE-
PROCEED model for guidance. Start by asking and answering
the following questions:
1. What is the quality of life of those in the priority population?
2. What are social conditions and perceptions shared by those in
the priority population?
3. What are the social indicators (e.g., absenteeism, crime,
discrimination, performance,
welfare, etc.) in the priority population that reflect the social
conditions and
perceptions?

4. Can the social conditions and perceptions be linked to health
promotion? If so, how?
5. What are the health problems associated with the social
problems?
6. Which health problem is most important to change?
The last question in this list is really asking the question:
Which problem/need should get
priority? The problems/needs must be prioritized not because
the lowest-priority problems/
needs are not important, but because organizations have limited
resources to deal with all
identified problems/needs. Thus, “priority setting is critical in
narrowing the scope of ac-
tivity to reflect the availability of resources within the context
of stakeholders’ values and
preferences. In addition, priority setting helps health promotion

practitioners stay focused on
problems that actually affect the health status of the population”
(Neiger, Thackeray, & Fagen,
2011, p. 166). There are several benefits to effective priority
setting. They include: (a) building
consensus among the stakeholders for the allocation of
resources in areas most likely to yield
positive and sustainable outcomes; (b) clarifying expectations
for the use of resources in a con-
strained environment, (c) helping to establish focus on issues
based on objective criteria, and
(d) helping establish a chain of accountability for the
stakeholders (Barnett, 2012).
Priority setting is not easy and planners should be aware that
there might be conflict
among stakeholders. “Obstacles to the effective implementation
of priority setting include,
but are not limited to the following; (a) lack of quality data, (b)
conflicting political dynam-
ics and agendas, (c) stakeholder fatigue with assessment
process, (d) poorly developed and/
or understood criteria, and (e) lack of equity in stakeholder
participation and processes”
(Barnett, 2012, p. 46).

When setting priorities, the planners should seek answers to
these questions:
1. What is the most pressing need? Why?
2. Are there resources adequate to deal with the problem?
3. Can the problem best be solved by a health promotion
intervention, or could it be
handled better through another means?
4. Are effective intervention strategies available to address the
problem?
5. Can the problem be solved in a reasonable amount of time?
The actual process of setting priorities can take many different
forms and can range from
subjective approaches such as simple voting procedures, forced
rankings, and the nominal
group process with stakeholders to more objective but time-
consuming processes such as the
Delphi technique (Gilmore, 2012) and the basic priority rating
(BPR) model. The BPR

model, which was first known as the “priority rating process,”
was introduced more than
60 years ago (Hanlon, 1954) in an attempt to prioritize health
problems in developing coun-
tries. During this span of time, the BPR has been most useful to
program planners. Although
the BPR model has provided basic direction in priority setting,
it does not represent the broad
array of data available to decision makers today (Neiger et al.,
2011). In addition, “elements in
the model give more weight to the impact of communicable
diseases as compared to chronic
diseases” (Neiger et al., 2011, p. 166). As such, Neiger and hi s
colleagues have proposed
changes to the BPR model and suggested a new name for the
model; BPR Model 2.0. To
provide both background and currency, both the BPR model
(Pickett & Hanlon, 1990) and the
BPR model 2.0 (Neiger et al., 2011) are presented here.
BpR MoDEl
The BPR model requires planners to rate four different
components of the identified needs
and insert the ratings into a formula in order to determine a

priority rating between 0 and
100. The components and their possible scores (in parenthesis)
are:
A. size of the problem (0 to 10)
B. seriousness of the problem (0 to 20)
C. effectiveness of the possible interventions (0 to 10)
D. propriety, economics, acceptability, resources, and legality
(PEARL) (0 or 1)
The formula in which the scores are placed is:
Basic Priority Rating (BPR) =
(A + B)C
3
* D

Component A, size of the problem, can be scored by using
epidemiological rates or deter-
mining the percentage of the priority population at risk. The
higher the rate or percentage,
the greater the score.
Component B, seriousness of the problem, is examined using
four factors: economic loss
to community, family, or individuals; involvement of other
people who were not initially
affected by the problem, as with the spread of an infectious
disease; the severity of the prob-
lem measured in mortality, morbidity, or disability; and the
urgency of solving the problem
because of additional harm. Because the maximum score for this
component is 20, raters can
use a 0 to 5 score for each of the four factors.
Component C, effectiveness of the interventions, is often the
most difficult of the four
components to measure. The efficacy of some intervention
strategies is known, such as im-
munizations (close to 100%) and smoking cessation classes
(around 30%), but for many, it
is not. Planners will need to estimate this score based upon the

work of others or their own
expert opinions. In scoring this component, planners should
consider both the effective-
ness of intervention strategies in terms of behavior change, as
well as the degree to which
the priority population will demonstrate interest in the
intervention strategy.
Component D, PEARL, consists of several factors that
determine whether a particular inter-
vention strategy can be carried out at all. The score is 0 or 1;
any need that receives a zero will
automatically drop to the bottom of the priority list because a
score of zero (a multiplier) for this
component will yield a total score of zero in the formula.
Examples of when a zero may result
are if an intervention is economically impossible, unacceptable
to the priority population or
planners, or illegal. Ideally, some of these assessments will be
made before a health problem is
considered in the priority setting process.
Once the score for the four components is determined, an
overall priority rating for each
need can be calculated, and the prioritizing can take place.

BpR MoDEl 2.0
Building on the BPR model, Neiger and his colleagues (2011)
offered the following adapta-
tions to the model and suggested calling the revised model the
BPR model 2.0.
A. Size of the problem. “Depending on the availability of data
and preferences of the
stakeholders use one of the following:
1. Use incidence and prevalence data and score each on a scale
of 0 to 5 for a total of
10 points (it is recognized that incidence represents a proportion
of prevalence).
2. Use incidence or prevalence data and score each health
problem on a scale of
0 to 10 points.
3. Use age-adjusted cause-specific mortality rates and
proportional mortality ratios for
each health problem and score each on a scale of 0 to 5 for a
total of 10 points.

4. Use age-adjusted cause-specific mortality rates or
proportional mortality ratios and
score each health problem on a scale of 0 to 10 points” (p. 168).
B. Seriousness of the problem. Both the definitions for the
components of “seriousness”
and the scoring for the components be changed as follows:
1. Urgency—defined “as the degree to which a health problem
is increasing, stabilizing,
or decreasing and that 5-year mortality trend data be used to
score it” (p. 168). Scores
should be assigned as follows: increasing trend data (5 or 4
points); stabilized trend
data (3 or 2 points); and decreasing trend data (1 or 0 points).
2. Severity—expand the definition of the criterion to include:
(a) the lethality of a
health problem (as measured by five-year survival rate), (b)

premature mortality (as
measured by years of potential life lost or years of productive
life lost), and (c) disability
(as measured by disability-adjusted life years [DALYs]). Scores
should be assigned as
follows: 0- to 5-point scale (i.e., 5–4 is high, 3–2 is medium,
and 1–0 is low).
3. Economic loss—defined as the accumulation of costs (direct
and indirect) borne
by society associated with the health problem. Scores should be
assigned as follows:
0- to 5-point scale (i.e., 5–4 is high, 3–2 is medium, and 1–0 is
low).
4. Impact on others—expand the definition of the criterion to
include: “(a) as
the communicable nature of the health problem (particularly
when analyzing
communicable diseases); (b) the behavioral effects related to
the health problem
on others (e.g., secondhand smoke, driving while under the
influence of alcohol or
other drugs, violence perpetrated on others, etc.); or (c) the
emotional and physical

impact the health problem (with attendant disabilities) has on
others with respect
to care giving” (p. 169). Scores should be assigned as follows:
0- to 5-point scale
(i.e., 5–4 is high, 3–2 is medium, and 1–0 is low).
C. Effectiveness of the possible interventions. Limit the
definition of “effectiveness” to
evidence of a successful intervention and not rate the “reach” of
the intervention.
The scoring of effectiveness should be based on the typology of
evidence developed
by Brownson, Fielding, and Maylahn (2009). Scores should be
assigned as follows:
0- to 10-point scale (i.e., 10–9 reflect evidence-based
interventions, 8–7 reflect effective
programs, 6–5 reflect promising interventions, 4–3 reflect
emerging interventions, and
2–0 reflect unproven interventions).
D. PEARL. The calculation of PEARL should remain the same.
However, if secondary data
are available to calculate the PEARL it should be calculated
prior to collecting primary
data so that the needs assessment may be more focused.

For an example application of the BPR model 2.0 readers should
refer to Neiger
et al. (2011).
Finally, how will planners know when they have completed Step
3 (Analyzing the Data)
of the needs assessment process? Planners should be able to list
in rank order the problems/
needs of the priority population.
Step 4: identifying the Risk Factors linked to the Health
problem
Step 4 of the needs assessment process is parallel to the second
part of Phase 2 of the PRECEDE-
PROCEED model: epidemiological assessment. In this step,
planners need to identify the
determinants of the health problem identified in the previous
step. That is, what genetic, be-
havioral, and environmental risk factors are associated with the
health problem? Because most
genetic determinants either cannot be changed or interact with
the behavior and/or environ-
ment, the task in this step is to identify and prioritize the

behavioral and environmental factors
that, if changed, could lessen the health problem in the priority
population. Also, it should be
noted that the term environmental factors applies to more than
just the physical environment
(e.g., clean air and water, proximity to facilities). Environment
is multidimensional and can
include economic environment (e.g., affordability, incentives,
disincentives); service environ-
ment (e.g., access to health care, equity in health care, barriers
to health care); social environ-
ment (e.g., social support, peer pressure); psychological
environment (e.g., emotional learning
environment); and the political environment (e.g., health
policy). In essence then, modifyi ng
behavioral and/or environmental factors or determinants is the
real work of health promotion.
Thus, if the health problem is lung cancer, planners should
analyze the health behaviors and
environment of the priority population for known risk factors of

lung cancer. For example,
higher than expected smoking behavior may be present in the
priority population, and the
people may live in a community where smokefree public
environments are not valued. Once
these risk factors are identified, they too need to be prioritized
(see Figure 3.4 for a means of
prioritizing these risk factors).
Step 5: identifying the program Focus
The fifth step of the needs assessment process is similar to the
third phase of the PRECEDE-
PROCEED model: educational and ecological assessment. With
behavioral, environmental,
and genetic risk factors identified and prioritized, planners need
to identify those predispos-
ing, enabling, and reinforcing factors that seem to have a direct
impact on the risk factors. In
the lung cancer example, those in the priority population may
not have (1) the skills necessary
to stop smoking (predisposing factor), (2) access to a smoking
cessation program (enabling
factor), or (3) people around them who support efforts to stop
smoking (reinforcing factor).

“Study of the predisposing, enabling, and reinforcing factors
automatically helps the planner
decide exactly which of the factors making up the three classes
deserve the highest priority as
the focus of the intervention. The decision is based on their
importance and any evidence that
change in the factor is possible and cost-effective” (Green &
Kreuter, 1999, p. 42).
In addition, when prioritizing needs, planners also need to
consider any existing health
promotion programs to avoid duplication of efforts. Therefore,
program planners should
seek to determine the status of existing health promotion
programs by trying to answer as
many questions as possible from the following list:
1. What health promotion programs are presently available to
the priority population?
2. Are the programs being utilized? If not, why not?
3. How effective are the programs? Are they meeting their
stated goals and objectives?

4. How were the needs for these programs determined?
5. Are the programs accessible to the priority population?
Where are they located? When are
they offered? Are there any qualifying criteria that people must
meet to enroll? Can the
priority population get to the program? Can the priority
population afford the programs?
6. Are the needs of the priority population being met? If not,
why not?
There are several ways to seek answers to these questions.
Probably the most common way
is through networking with other people working in health
promotion and the health care
system—that is, communicating with others who may know
about existing programs. (See
Chapter 9 for a more detailed discussion of networking.) These
people may be located in the
local or state health department, in voluntary health agencies, or
in health care facilities, such
as hospitals, clinics, nursing homes, extended care facilities, or
managed care organizations.

Planners might also find information about existing programs by
checking with some-
one in an organization that serves as a clearinghouse for health
promotion programs or by
using a community resource guide. The local or state health
department, a local chamber
of commerce, a coalition, the local medical/dental societies, a
community task force, or a
community health center may serve as a clearinghouse or
produce such a guide. Another
avenue is to talk with people in the priority population.
Although they may not know about
all existing programs, they may be able to share information on
the effectiveness and acces-
sibility of some of the programs. Finally, some of the
information could be collected in Step 2
through separate community forums, focus groups, or surveys.
Step 6: validating the prioritized needs

The final step in the needs assessment process is to validate the
identified need(s). Validate
means to confirm that the need that was identified is the need
that should be addressed.
Obviously, if great care were taken in the needs assessment
process, validation should be a
perfunctory step. However, there have been times when a need
was not properly validated;
much energy and many resources have thereby been wasted on
unnecessary programs.
Validation amounts to “double checking,” or making sure that
an identified need is the
actual need. Any means available can be used, such as (1)
rechecking the steps followed in
the needs assessment to eliminate any bias, (2) conducting a
focus group with some indi-
viduals from the priority population to determine their reaction
to the identified need (if a
focus group was not used earlier to gather the data), and (3)
getting a “second opinion” from
other health professionals.
application of the Six-Step needs assessment process

In the previous sections, a six-step approach for conducting a
needs assessment was pre-
sented. Now we would like to present an example of how this
process may be applied. Let’s
assume that a committee has been appointed by the health
administrator of a local health
department to plan a cancer prevention program for the county,
and that the composition of
the committee closely represents the greater community. Let’s
also assume that the param-
eters for the authority of the planning committee have also been
set. Here is how this needs
assessment may be carried out.
Step 1: Determining the Purpose and Scope of the Needs
Assessment—After an organi-
zational meeting and a couple subsequent meetings, the
planning committee decided that
the purpose of the needs assessment was fourfold. To determine
(1) what types of cancers
were of greatest concern in the county, (2) which
subpopulations within the county were at
the greatest risk for the cancers identified, (3) what the most
common risk factors were for
the cancer(s) and subpopulation(s) identified, and (4) the focus

of the proposed program.
The committee members also decided that the scope of the
needs assessment would be
defined by the collection of both primary and secondary data,
and that they wanted part
of the primary data collection to be participatory in nature. That
is, they wanted some of
those in the priority population to participate in the data
collection process.
Step 2: Gathering Data—The committee members decided to
begin data collection by
identifying available sources of secondary data. Initially they
gathered secondary data
for the past five years for both the state and the county in which
they lived from the state
health department for the incidence of invasive cancer; cancer
mortality rates (i.e., crude
and age-adjusted); mortality rates for various types of cancer
broken down by sex, age, and
race/ethnicity; and behavioral risk factors that were known to
contribute to or cause the
various types of cancer. In addition, committee members were
able to get secondary data

from the state environmental agency regarding the levels of air
and water pollution in all
92 counties of the state.
The secondary data were good but they did not present a
complete picture of the cancer issue
in their county. What was not available in the secondary data
were information and data related
to cancer education programs, cancer screening programs,
access to health care providers that
specialized in cancer care, and the county residents’ interest in
taking part in activities that would
reduce the incidence and prevalence in their community.
Therefore, the committee created three
different questionnaires to be administered via single-step
surveys. The three questionnaires dealt
with cancer prevention activities (i.e., education and
screenings), cancer treatment, and attitudes
toward and willingness to participate in cancer programs if
offered in the community.

To make part of the primary data collection a participatory
process the committee sought
out two groups of volunteers from the county who were
interested in cancer control. The
first group was asked to assist in data collection by
administering the surveys to various indi-
viduals in the county by visiting places where residents were
likely to gather such as service
group meetings, religious organizations (i.e., churches,
mosques, and synagogues), services,
worksites, and neighborhood meetings. The second group of
volunteers was asked to collect
data via a photovoice process with a theme of “identify those
unhealthy areas of the county
that contribute to cases of cancer.”
Step 3: Analyzing the Data—The committee members decided
to analyze the data compar-
ing their county data versus the state data using the informal
technique of “eye-balling”
the data. To help make sense of some of the data they created a
few cross-tabulation tables
comparing county data to state data. The analysis of the
secondary cancer data from the state
health department, the County Health Rankings (University of

Wisconsin Population Health
Institute, 2015), and the Kaiser Family Foundation’s state
health facts (KFF, 2015) showed:
•⦁ higher county incidence rate for invasive cancers
(501/100,000 vs. 426/100,000)
•⦁ both higher county cancer crude mortality rates
(177/100,000 vs. 157/100,000) and
age-adjusted mortality rates (170.0/100,000 vs. 161.2/100,000)
•⦁ higher county prevalence rates for colorectal, lung, and
pancreas cancers
•⦁ lower county prevalence rates for breast, cervix, and
prostate cancers
The analysis of the secondary behavior risk data from the
state’s Behavior Risk Factor
Surveillance System data showed:
•⦁ higher percentage of county residents who had not had either
a sigmoidoscopy or
colonoscopy in the recommended time period
•⦁ higher percentage of county women who had either a clinical
breast examination

(77.1% vs. 74.5%) or mammogram (76.3% vs. 73.1%) in the
recommended time period
•⦁ higher percentage of county women who had a Papanicolaou
smear (82.6% vs. 77.4%)
in the recommended time period
•⦁ higher percentage of county residents who were physically
inactive (55.7% vs. 48.9%)
•⦁ higher prevalence of county residents who smoked (25.3%
vs. 21.0%)
The analysis of the primary data from the three surveys
conducted by the committee showed
county residents:
•⦁ would participate in free and/or inexpensive cancer
screenings if they were convenient
•⦁ were in favor of creating more smokefree public areas
•⦁ felt, and the data showed, that there were too few health care
providers in the county
who dealt with cancer.

The analysis of the photovoice process identified two major
themes in the county:
•⦁ many of the county residents were physically inactive and
appeared to be either
overweight or obese, and
•⦁ there were few smokefree public places in the county
Based on all the available primary and secondary data the
committee prioritized the list
of cancers using the BPR model 2.0. Those calculations yielded
the following BPR scores:
breast (38.7), colorectal (56.8), lung (51.8), cervix (30.4),
pancreas (24.0), and prostate (41.7).
Therefore, the committee decided to work to reduce the
incidence of colorectal and lung
cancers in the county.
Step 4: Identifying the Risk Factors Linked to the Health
Problem—The risk factors associ-
ated with colorectal cancer include age (> 50 years), personal

history of colorectal polyps or
cancer, personal history of inflammatory bowel disease (IBD),
family history of colorectal
cancer, diets high in red meats, physical inactivity, obesity,
smoking, heavy alcohol use, and
type 2 diabetes (ACS, 2015). The risk factors associated with
lung cancer include smoking,
exposure to radon, exposure to asbestos, high levels of arsenic
in the drinking water, personal
or family history of lung cancer, and air pollution (ACS, 2015).
Step 5: Identifying the Program Focus—Based on the analysis
of the data and the risk factors
associated with identified priority cancers the planning
committee decided to focus the cancer
prevention program on two areas: working to offer more cancer
screening programs in the
county, and working toward a nonsmoking ordinance in the
county in order to create smoke-
free public places.
Step 6: Validating the Prioritized Needs—Before moving
forward with the planning for the
cancer prevention programs to deal with colorectal and lung
cancer, the committee had

representatives from both the state department of health’s
cancer prevention program and
the American Cancer Society review their needs assessment to
validate their findings. Both
groups agreed with the program focus.
Special Types of Health Assessments
Before leaving the topic of needs assessment we need to
introduce two specific types of
health assessments that have gained special attention in the last
few years. They are health
impact assessment and organizational health assessment.
Health impact assessment
Health impact assessment (HIA) is an important topic because a
HIA could impact
the focus of a needs assessment and it is “a rapidly emerging
practice” (CDC, 2015d,
para. 6) in the United States (see NRC, 2011, for examples of
its use). A HIA has been
defined as “a systematic process that uses an array of data
sources and analytic methods
and considers input from stakeholders to determine the potential

effects of a proposed
policy, plan, program, or project on the health of a population
and the distribution of
those effects within the population. HIA provides
recommendations on monitoring and
managing those effects” (NRC, 2011, p. 5). In other words, a
HIA is an “approach that can
help to identify and consider the potential—or actual—health
impacts of a proposal on a
population. Its primary output is a set of evidence-based
recommendations geared to in-
forming the decision-making process. These recommendations
aim to highlight practical
ways to enhance the positive aspects of a proposal, and to
remove or minimise [sic] any
negative impacts on health, well-being and health inequalities
that may arise or exist”
(Taylor & Quigley, 2002, pp. 2–3).
The World Health Organization (2015) has noted that HIAs are

based on four values.
They include 1) democracy (i.e., all who are impacted by the
proposed change get to partici-
pate in the assessment), 2) equity (i.e., all who will be impacted
by the proposed change are
treated fairly in the assessment), 3) sustainable development
(i.e., both short- and long-term
impacts of the proposed change are considered are part of the
assessment), and 4) ethical
use of evidence (i.e., evidence used in the assessment includes
both qualitative and quanti-
tative evidence and is collected using best practices).
There are a number of different frameworks (i.e., guides) that
can be used to conduct a HIA
(see Mindell, Boltong, & Forde, 2008 for a review of guides)
and they “can range from simple,
fairly easy-to-conduct analyses to more in-depth, complex
analyses” (Brennan Ramirez et al.,
2008, p. 46), but most of these guides include the following
major steps:
1. Screening (identify plans, projects, or policies for which an
HIA would be useful)

2. Scoping (identify which health effects to consider)
3. Assessing risks and benefits (identify which people may be
affected and how they may
be affected)
4. Developing recommendations (suggesting changes to
proposals to promote positive
health effects or minimize adverse health effects)
5. Reporting (present the results to decision makers), and
6. Monitoring and evaluating (determining the effect of the HIA
on the decision) (CDC,
2015d, para. 3)
As planners prepare for a needs assessment they must also
consider whether an HIA
should be a part of the process.
organizational Health assessment
Earlier in this chapter mention was made of the impact that the
Patient Protection and
Affordable Care Act had on non-profit hospitals and the

requirement that the hospitals
had to conduct a CHNA once every three years. Another section
(i.e., 1201) of the same law
amended Section 2705 of the Public Health Service Act that
encourages employers to imple-
ment comprehensive worksite health promotion programs for
their employees. Under the
new law, employers can offer incentives (up to 30% of the total
cost of coverage) to encour-
age participation. The program must be reasonably designed to
promote health or prevent
disease. A program complies with the reasonably designed
provision “if it 1) has a reasonable
chance of improving the health of, or preventing disease in,
participating individuals; (2) is
not overly burdensome; (3) is not a subterfuge for
discrimination based on a health factor;
and (4) is not highly suspect in the method chosen to promote
health or prevent disease”
(CMS, 2015a, p. 2). “Critics of this provision have voiced
concern about the broad defini-
tion of a ‘ reasonably designed’ wellness program” (Goetzel et
al., 2013, p. TAHP-2). To deal
with this issue, in recent years several organizational health
assessments have been created

to determine if best-practices are in place in employer-
sponsored worksite health promotion
programs (Goetzel et al., 2013). These organization health
assessments can be thought of as
needs assessments for reasonably designed employee-sponsored
worksite health promotion
programs. Three of these organizational health assessments—
the HERO Employee Health
Management Best Practices Scorecard (Health Enhancement
Research Organization, 2014),
the Wellness Impact Scorecard (WISCORE®) (National
Business Group on Health, 2015),
Optimal Healing Environment (OHE) Assessment™ (Samueli
Institute, 2015) —have been
reviewed by Goetzel et al. 2013.
Summary
This chapter presented definitions of needs assessment and a
discussion of primary and

secondary data. The sources of these data along w ith their pros
and cons were discussed at
length. Also, presented in this chapter was a six-step approach
that planners can follow in
conducting a needs assessment on a given group of people. It is
by no means the only way of
conducting an assessment, but it is one viable option. No matter
what procedure is used to
conduct a needs assessment, the end result should be the same.
Planners should finish with a
clearly defined program focus. Finally, the terms health impact
assessment and organization
health assessment were introduced.
Review Questions
1. What is a need? What does needs assessment mean?
2. What is meant by the terms capacity, community capacity,
and capacity building?
3. What should program planners expect from a needs
assessment?
4. What is the difference between primary and secondary data?

5. Name several different sources of both primary and
secondary data.
6. What advice might you give to someone who is interested in
using previously collected
data (secondary data) for a needs assessment?
7. What is the difference between a single-step (cross-sectional)
and a multistep survey?
8. Explain the difference between a community forum and a
focus group.
9. What are the steps in the photovoice process?
10. What is a health assessment (HA)?
11. Describe the steps used to conduct a literature search.
12. What are the six steps in the needs assessment process, as
identified in this chapter?
What is the most difficult step to complete?
13. What is the difference between the BPR model and the BPR

model 2.0?
14. What is health impact assessment (HIA) and how could it
affect a needs assessment?
15. What is an organizational health assessment? What
relationship does it have to the
Affordable Care Act?
Activities
1. Assume a local health department (LHD) that serves a rural
population of about
100,000 people has hired you. After a few months on the job,
your supervisor has given
you the task of conducting a needs assessment. The last one
completed by this LHD was
15 years ago. Based on the annual reports of the LHD over the
past 5 years, it has been
determined that the needs assessment should focus on the needs
of the elderly. For the

purpose of this needs assessment, the LHD has defined elderly
as those 65 years of age
and older. Working with the six-step approach to needs
assessment presented in this
chapter, complete the first two steps. Complete Step 1 by
writing a purpose and scope
for the needs assessment. Complete the first part of Step 2 by
identifying at least four
sources of relevant secondary data. Also, describe what you
think would be the best
way to go about collecting primary data and defend your choice.
Then complete this
activity by creating a list of things you would like to find out by
gathering primary data.
2. Visit the Website of a commercial company (e.g.,
FluidSurveys, Qualtrics, QuestionPro,
SurveyMonkey, surveygizmo, Zoomerang) that is in the
business of helping others collect
primary data via the Internet. Once at the site, find out as much
as you can about using the
service. What specific services does the company offer? How
much do the services cost?
What group of program planners do you think would most
benefit from using the services?

Summarize the results of your fact-finding experience in a one-
page paper.
3. Using secondary data provided by your instructor or obtained
from the World Wide
Web (such as data from a Behavioral Risk Factor Surveillance
System, state or local
secondary data, or data from the National Center for Health
Statistics), analyze the
data and determine the health problems of the priority
population.
4. Using data from the County Health Rankings Website
(http://www.countyhealthrankings
.org), examine the data presented for the county in which you
grew up or currently live.
After reviewing the data, prepare a written response that
summarizes the general health
status of the county.
5. Administer an HHA/HRA to a group of 25 to 30 people.
Using the data generated,
identify and prioritize a collective list of health problems of the
group.

6. Plan and conduct a focus group on an identified health
problem on your campus.
Develop a set of questions to be used, identify and invite people
to participate in the
group, facilitate the process, and then write up a summary of the
results based on your
written notes and/or an audiotape of the session.
7. Using the data (paper-and-pencil instruments, clinical tests,
and health histories)
generated from a local health fair, identify and prioritize a
collective list of health
problems of those who participated.
Weblinks
1. http://ctb.ku.edu/en
The Community Tool Box
This site provides excellent resources on community
assessment, conducting surveys,
identifying problems, and assessing community needs and
resources. Topic sections
include step-by-step instruction, examples, checklists, and
related resources.

2. http://www.csuchico.edu/lins/handouts/eval_websites.pdf
CRAAP Test– Meriam Library, California State University,
Chico
This link takes you to a handout that presents the CRAAP Test
for evaluating materials
found on the World Wide Web.
3. http://www.cdc.gov/nchs/surveys.htm
National Center for Health Statistics
This Webpage of the National Center for Health Statistics
(NCHS) provides an overview
of all of the surveys and data collections systems of the NCHS.
In addition, it provides
the results of many of the surveys and examples of the
questionnaires used to collect
the data.
4. http://www.kff.org/statedata/

Kaiser Family Foundation State Health Facts
This site contains current state-level data on demographics and
the economy, health
costs and budgets, health coverage and uninsured, health
insurance and managed care,
health reform, health status, HIV/AIDS, Medicaid and CHIP,
Medicare, minority health,
providers and service use, and women’s health. Planners can
access information as tables,
trend graphs, or color-coded maps.
5. http://wonder.cdc.gov
CDC WONDER
This is the home page for the Centers for Disease Control and
Prevention’s (CDC)
Wide-ranging Online Data for Epidemiologic Research
(WONDER). CDC WONDER
is an easy-to-use, menu-driven system that provides access to a
wide array of secondary
public health information.
http://www.csuchico.edu/lins/handouts/eval_websites.pdf
http://www.cdc.gov/nchs/surveys.htm
http://www.kff.org/statedata/

105
5
Chapter Measurement, Measures,
Measurement Instruments,
and Sampling
Chapter Objectives
questions that follow, you should be able to:
⦁ ⦁ Define measurement.
⦁ ⦁ Explain the difference between quantitative
and qualitative measures.
⦁ ⦁ Explain the reasons that measurement is such
an important process as it relates to program
planning and evaluation as well as research.
⦁ ⦁ Briefly describe the four levels of measurement.

⦁ ⦁ List the variables that are often measured by
health education specialists.
⦁ ⦁ List the four desirable characteristics of data.
⦁ ⦁ Explain the various types of validity.
⦁ ⦁ Define reliability and explain why it is important.
⦁ ⦁ Define bias in data collection and discuss how it
can be reduced.
⦁ ⦁ Briefly describe the steps to identify, obtain, and
evaluate existing measurement instruments.
⦁ ⦁ Be able to develop questions and response
options for a data collection instrument.
⦁ ⦁ Briefly describe the process for creating
appropriate presentation for a data collection
instrument.
⦁ ⦁ Describe how a sample can be obtained from
a population.

⦁ ⦁ Differentiate between probability and
nonprobability samples.
⦁ ⦁ Describe how a pilot test is used.
Key Terms
bias
census
cluster sampling
cognitive pretesting
concurrent validity
construct validity
content validity
convergent validity
criterion-related validity
discriminant validity
equivalence reliability
face validity
instrumentation
internal consistency
inter-rater reliability
interval level measures
intra-rater reliability

levels of measurement
measurement
measurement
instrument
nominal level
measures
nonprobability
samples
nonproportional
stratified random
sample
ordinal level
measures
parallel forms
pilot testing
population
predictive validity
preliminary review

pre-pilots
probability sample
proportional stratified
random sample
psychometric qualities
public domain
qualitative measures
quantitative measures
random selection
rater reliability
ratio level measures
reliability
sample
sampling
sampling frame
sampling unit
sensitivity
simple random
sample (SRS)
specificity
stability reliability
strata
stratified random

sample
survey population
systematic sample
universe
validity
In this chapter, we will examine critical concepts necessary to
maximize the quality of
data, whether for a needs assessment or a program evaluation.
Specifically, we will examine
the (1) term measurement, (2) types of data generated from
measurement, (3) importance of
measurement, (4) levels of measurement, (5) types of measures,
(6) desirable characteristics
of measures, (7) measurement instruments, (8) sampling, and
(9) the importance of pilot
testing in the data collection process.
Box 5.1 identifies the responsibilities and competencies for

that pertain to the material presented in this chapter.
Measurement
Measurement can be defined as the process of applying
numerical or narrative data from
an instrument (e.g., a questionnaire) or other data-yielding tools
to objects, events, or people
(Windsor, 2015). For example, if researchers collect data on
height and weight from a group
of people then translate those data to body mass index (BMI)
values (weight in kilograms
divided by height in meters squared), they can classify
participants as either underweight
(usually a BMI of < 18.50), normal (18.50-24.99), overweight
(25-29.99) or obese (> 30). In
order to measure something then, planners and evaluators
(hereafter referred to collectively
as planners) need to identify what instrument or tool will be
used to collect data, how data
5.1
Specialists

Because of the importance of measurement to program planning
and evaluation,
the content of this chapter cuts across two different areas of
responsibility. Those
responsibilities and related competencies include the following:
to health
Competency 1.3: Collect primary data to determine needs
environmental,
and other factors that influence health
process of
Competency 1.7: Determine needs for health
education/promotion based

on assessment findings
RESponSiBility iV: Conduct Evaluation and Research Related
to Health Education/
Promotion
Competency 4.3: Select, adapt and/or create instruments to
collect data
Competency 4.4: Collect and manage data
Competency 4.6: Interpret results
Competency 4.7: Apply findings
Health Education
Credentialing, Inc. (NCHEC) and the Society for Public Health
Education (SOPHE). Reprinted by permission of the National
Commission for Health
Education Credentialing, Inc. (NCHEC) and the Society for
Public Health Education (SOPHE).

Chapter 5 Measurement, Measures, Measurement Instruments,
and Sampling 107
will be categorized using numbers or words, and how these
categories of data will be clas-
sified (e.g., for BMI: high risk, medium risk, low risk or
excellent health, good health, poor
health, etc.).
The data generated by measurements can be classified into two
broad categories, depend-
ing on the method by which they are collected. Quantitative
measures “are numeri-
cal data collected to understand individuals’ knowledge,
understanding, perceptions, and
behavior” (Harris, 2010, p. 208). Examples of quantitative data
could include the mortal-
ity rates for diabetes over the last five years, the
aforementioned BMIs of participants in a
weight loss program, the prevalence of cigarette smoking among
adolescents, the ratings on
a patient satisfaction survey, and the pretest and posttest scores
on a HIV knowledge test.
Qualitative measures are “data collected with the use of

narrative and observational ap-
proaches to understand individuals’ knowledge, perceptions,
attitudes and behaviors” (Harris,
2010, p. 208). Qualitative data are usually represented as words
that are organized into codes
and themes. Examples of qualitative data could include notes
generated from observational
studies, transcripts from focus groups, and taped recordings of
in-depth interviews with key
informants. Quantitative and qualitative measures both have
their individual strengths and
weaknesses, yet their greatest utility may occur when both are
used together in the measure-
ment process. While quantitative data with adequate sample
sizes can accurately represent
entire populations, qualitative data can provide rich contextual
understanding of those same
populations. One way to think about the difference is that
quantitative data is like looking at a
picture that is just black and white; all you see are the numbers.
Qualitative data adds color and
texture, or richness to those numbers. table 5.1 provides a
comparison of many of the qualities
and characteristics of quantitative and qualitative measures.

the importance of Measurement in program planning and
Evaluation
As noted earlier in the chapter (see Box 5.1), health education
specialists are expected to
have the knowledge and skills to plan and carry out the
processes associated with mea-
surement; for example, (1) when reviewing literature in order to
justify a program, health
education specialists need to be able to understand the data
generated by measurement in
order to determine if they have adequate and appropriate
evidence for a proposed program;
(2) when conducting a needs assessment, health education
specialists must understand
Table 5.1 Comparison of Quantitative and Qualitative Measures
Source: Cottrell & McKenzie (2011, p. 228) from Debus (1988).
Quantitative Measures Qualitative Measures
Measures level of occurrence Provides depth of understanding
Asks how often? and how many? Asks why?
Studies actions Studies motivations

Is objective Is subjective
Provides proof Enables discovery
Is definitive
Measures levels of actions and trends, etc.
Is exploratory
Allows insights into behavior and trends, etc.
Describes Interprets
the basic principles of measurement in order to select and use
appropriate data collection
instruments; (3) when health education specialists are planning
an evaluation to measure
whether program objectives have been met, they need to be abl e
to measure related program
outcomes; (4) when a funding agency wants evidence that a
program it funds is making a dif-
ference in a community, health education specialists must apply
appropriate measurement
techniques to generate the needed evidence; or (5) when health

education specialists are
asked to interpret the results of a program evaluation to a group
of stakeholders, they need
to be competent in determining and communicating whether
program components actually
produced the identified results. Each of these examples
demonstrates the need for a sound
understanding of the processes associated with measurement. In
other words, measurement
is an integral part of program planning, implementation, and
evaluation.
levels of Measurement
A fundamental question of measurement is deciding how
something should be measured
(McDermott & Sarvela, 1999). For example, consider a scenario
in which planners need data
on the income levels of program participants. They could ask
about the participants’ income
level in any of the following three ways:
1. Which of the following categories most closely corresponds
with your overall
household income: poor, lower middle class, upper middle

class, or wealthy?
2. What income category best describes your annual household
income? $0 to 10,000;
$10,001 to 25,000; $25,001 to 40,000; $40,001 to 55,000;
$55,001 to 70,000; $70,001+
3. What is your annual household income? $ ____________ per
year
Although these questions all pertain to household income, each
question generates a
different type and level of data. Seventy years ago, Stevens
(1946) proposed that four levels
of measurement—nominal, ordinal, interval, and ratio—were the
basis for all scientific
measurement. In fact, these four levels of measurement are
widely accepted in social and
behavioral research. The four levels of measurement are
considered “hierarchical” in nature.
In other words, they progress from more simple or basic to more
complex.
1. Nominal level measures constitute the lowest level in the
measurement hierarchy

and use names or labels to categorize people, places, or things.
While nominal data
represent different categories, they do not represent any
particular value or order (i.e.,
they are simply grouped by name). “The two requirements for
nominal measures are
that the categories have to be mutually exclusive so that each
case fits into one of the
categories, and the categories have to be exhaustive so that
there is a place for every
case” (Weiss, 1998, p. 116). For example, a question that would
generate nominal data
is, “What is your current student status?” The possible answers
include the categories
of “undergraduate student” and “graduate student.” These
answers are exhaustive
(contain all possible answers) and mutually exclusive (the
respondent has to be one
or the other, but not both). We can then assign numbers to these
categories according
to a particular rule we create (e.g., 1 = undergraduate, 2 =
graduate).
2. Ordinal level measures, like nominal level measures, allow
planners to put data

into categories that are mutually exclusive and exhaustive, but
also permit them to
rank-order the categories. The different categories represent
relatively more or less
of something. However, the distance between categories cannot
be measured. For
example, the question “How would you describe your level of
satisfaction with your
and Sampling 109
health care? (select one) very satisfied—satisfied—not
satisfied” creates categories (very
satisfied—satisfied—not satisfied) that are mutually exclusive
(the respondent cannot
select two categories) and exhaustive (there is a category for all
levels of satisfaction),
and the categories represent more or less of something ( amount
of satisfaction), thus
there is a rank order. We cannot, however, measure the distance
(or difference) between
the levels of satisfaction. Is the distance between very satisfied

and satisfied the same
distance between satisfied and not satisfied? Ordinal data
categories are not necessarily
an equal distance apart. Another example is when a patient is
asked how much pain
he or she is experiencing on a scale from 1 to 10. While 7 is
more severe than 5, this
difference may not be the same as the difference between 3 and
1.
3. Interval level measures enable planners to put data into
categories that
are mutually exclusive and exhaustive, and rank-orders the
categories, and are
continuous. Furthermore, the widths or differences between
categories must all be
the same (Hurlburt, 2003), which allows for the distance
between the categories to
be measured. There is, however, no absolute zero value. For
example, a question that
generates interval data is, “What was the high temperature
today?” We know that a
temperature of 70ºF is different than a temperature of 80ºF, that
80º is warmer than
70º, that there is 10ºF difference between the two, and if the

temperature drops to 0º F
there is still some heat in the air (though not much) because 0ºF
is warmer than –10ºF.
Examples of health-related variables that are commonly
measured on the interval level
include weight, cholesterol, height, blood pressure, age and so
forth.
4. Ratio level measures, the highest level in the measurement
hierarchy, enable
planners to do everything with data that can be done with the
other three levels of
measures; however, those tasks are accomplished using a scale
with an absolute zero.
Example questions that generate ratio data include the
following: “During an average
week, how many minutes do you exercise aerobically?” “How
much money did you
earn last month?” and “How many hours of sleep did you get
last night?” An absolute
zero “point means that the thing being measured actually
vanishes when the scale
reads zero” (Hurlburt, 2003, p. 17).
Table 5.1 shows the type of questions on a data collection

instrument that result in different
levels of measurement. Figure 5.1 shows how different levels of
data may be presented as charts
after data analysis has been completed.
Because interval and ratio data are continuous and rank-ordered
values with equal distance
between them, and because most statistical procedures are the
same for both types of data
(Valente, 2002), some have combined them into a single level of
measurement and refer to
the resulting data as numerical data.
The type of data gathered dictates the type of statistical
analyses that can be used. Generally
speaking, nominal and ordinal measures are associated with
nonparametric tests (less likely
to assume a normal distribution of data, i.e., bell shaped curve)
while interval and ratio data
are more often associated with parametric tests (more likely to
assume a normal distribution
of data). Parametric statistics are often more powerful in
detecting differences between groups
and are therefore preferred by researchers and evaluators
(Siegel & Castellan, 1988). Thus,

when planners begin to think about measurement and data
collection, they need to consider
both the wording of their questions and the response options
and how that wording will im-
pact the data analysis (see Chapter 15).
As presented earlier, many different methods can be used to
collect both primary and
secondary data (see Chapter 4). Any method selected will
require a measurement instrument
to collect the data. By measurement instrument, we mean the
item used to measure
the variables (e.g., demographic, psychosocial, behavioral) of
interest. Measurement in-
struments are also sometimes referred to as tools or data
collection instruments. The term
instrumentation is “a collective term that describes all
measurement instruments used”
(Cottrell & McKenzie, 2011, p. 146).

Measurement instruments can take many different forms and
sizes. They can range from
the very simple, like a ruler or yardstick, to a questionnaire, to
a very complicated piece of
Percent of respondents who have heard of
cytomegalovirus
Number of children currently living
at home
How likely child care providers are
to clean hands with soap and water
or hand sanitizer after serving food
yes
17%
no
83%
300
200

100
0
0 1 2 3 4 5
Nominal data
Ratio/Interval data
Ordinal data
Extremely Likely
Extremely Unlikely
0 50 100 150 200 250
Neutral
⦁ ▲ Figure 5.1 How to Present Various levels of Data
and Sampling 111

machinery that performs DNA sequencing. Although at times
may use machines or equipment as instruments (e.g., to check
blood cholesterol), more
commonly they employ a sequence of questions to measure
variables of interest (Windsor,
2015). These sequences of questions most often take the form of
tests, questionnaires, and
scales. The term test is most often used in the context of
educational measurement (DiIorio,
2005), such as an HIV/AIDS knowledge test. Questionnaires
(sometimes called survey instru-
ments) are instruments that gather information about a variety
of factors (e.g., awareness,
skills, behaviors, health status) related to one or more specific
topics. For example, a ques-
tionnaire may be developed about sleep habits and include
questions about the average
number of hours slept per night, what time a person typically
goes to sleep, use of sleep aids,
and techniques used to fall a sleep. A questionnaire can include
questions about several
concepts or one or more scales. A scale is a set of questions that
asks about one concept or
construct, often related to a psychosocial variable like attitudes,

beliefs, or opinions. For
example, health education specialists may be interested in
collecting data about attitudes
related to water fluoridation in the priority population. The
attitude scale would be a set of
questions related to attitudes. In scales, often the response
choice for every question is the
same (e.g., always, sometimes, never). Sometimes the word
scale is used in a general sense to
refer to an entire questionnaire or instrument; however, it is not
a technically correct use of
the term.
Depending on the nature of the questions being asked, the
instrument can vary in length.
Some instruments can be as short as a single question, rating, or
item to measure the vari-
able, while others may be multipage instruments. There are
advantages and disadvantages to
various instrument lengths. Obvious advantages of a shorter
instrument are the time for the
participants to complete it and for the planners to organize and
analyze the data. However,
longer instruments may do a better job of measuring less stable
(i.e., change over time) vari-

ables like attitudes (DiIorio, 2005), and longer instruments may
be more suitable for statisti-
cal calculations (Bowling, 2005).
types of Measures
Many different types of measures are used to conduct needs
assessments or evaluate
programs. Typically, health promotion programs focus on one or
more of the following
types of measures (also called variables) related to:
demographics, awareness, knowledge,
psychosocial characteristics, skills, behaviors, environmental
attributes, health status,
and quality of life indicators. table 5.2 illustrates some of these
variables and the level of
measurement.
Desirable Characteristics of Data
The results of a needs assessment or program evaluation are
only as good as the data that
are collected and analyzed. If a questionnaire is filled with
ambiguous questions and the
respondents are not sure how to answer, it is highly unlikely

that the data will reflect the
true knowledge, attitudes, and so on, of those responding.
Therefore, it is of vital impor-
tance that planners and evaluators make sure that the data they
collect are reliable, valid,
and unbiased. Collectively, these characteristics—reliability and
validity—are referred to as
an instrument’s psychometric qualities (Cottrell & McKenzie,
2011).
Table 5.2 Examples of Questions and Levels of Measurement
Source: Centers for Disease Prevention and Control, 2015a
Variable Question Stem Response Options Level of
Measurement
Demographic Height About how tall are you without
shoes?
__/__

ft/inches
Interval
Awareness
Awareness of
smoking cessation
quitlines
A telephone quitline is a free telephone-
based service that connects people who
smoke cigarettes with someone who
can help them quit. Are you aware of
any telephone quitline services that are
available to help people quit smoking?
Yes
No
Nominal
Knowledge
Knowledge of heart
attack symptoms

Do you think pain or discomfort in
the arms or shoulder are symptoms
of a heart attack?
Yes
No
Nominal
Psychosocial
Social and emotional
support
How often do you get the social
and emotional support you
need?
Always
Usually
Sometimes
Rarely
Never
ordinal

Depression During the past 30 days, for about
how many days have you felt sad,
blue, or depressed?
__ __ days Ratio
Behaviors
Visit to healthcare
provider
About how many times in the past
12 months have you seen a doctor,
nurse, or other health professional
for your diabetes?
__ __ times Ratio
Health status
Arthritis diagnosis Has a doctor, nurse, or other health
professional EVER told you that you
had some form of arthritis, rheumatoid
arthritis, gout, lupus, or fibromyalgia?
Yes

No
Nominal
Quality of life
overall measure
of health
Would you say that in general
your health is—
Excellent
Very good
Good
Fair
Poor
ordinal
Reliability
Reliability refers to consistency in the measurement process.
That is, reliability “is an
empirical estimate of the extent to which an instrument
produces the same result (measure

or score), applied once or two or more times” (Windsor, 2015,
p. 196). However, no instru-
ment will ever provide perfect accuracy in measurement because
there will always be error.
Reliability coefficients are highest if no error exists (r = 1.0)
and lowest when there is only
and Sampling 113
error or no association (r = 0.0) between two measures
(Windsor, 2015). Error can come from
many sources as will be discussed in the next section about
reliability estimates. Planners
need to strive to collect data under the best conditions that will
produce reliable data. Several
methods of estimating reliability are available.
Internal consistency is one of the most commonly used
reliability estimates (Windsor
et al., 2004). It refers to the intercorrelations among the
individual items on a scale, that is,
whether items on the scale are measuring the same domain. This

can be done by examining
the scale to ensure that the items reflect what is to be measured
and that the level of difficulty
of all items is consistent. Statistical methods can also be used to
determine internal consis-
tency by correlating the items on the test with the total score. A
Cronbach’s alpha reliability
coefficient measures internal consistency and ranges from 0 to 1
with scores of greater than
0.70 typically classified as acceptable and scores of 0.80
classified as good (George & Mallery,
2003). While alpha coefficients of 0.90 or greater are generally
considered to be excellent,
scores this high can also indicate there is redundancy in the
instrumentation (i.e., too many
questions may be asking the same thing). If Cronbach’s alpha is
low that means there are
errors due to item or content sampling, meaning all the
questions on the scale are not in-
terrelated. For example a researcher asked three questions
related to people’s perceptions
about weight control (“The health and strength of my body are
more important to me than
how much I weigh;” “I honestly don’t care how much I weigh as
long as I am physically fit,

healthy, and can do the things I want;” “I mostly exercise
because of how it makes me feel
physically”). The three items had a Cronbach alpha of 0.597.
The item correlation matrix
showed that last of the three items was not like the others and
this contributed to the low
reliability estimate. By removing the last item, the alpha
increased to 0.633. This was still not
at the .70 level, but it was improved.
Stability reliability estimates look for consistency over a period
of time (Crocker & Algina,
1986). To establish this type of reliability, the same instrument
is used to measure the same group
of people under similar, or the same conditions, at two different
points in time, and the two sets
of data generated by the measurement are used to calculate a
correlation coefficient (Cottrell &
McKenzie, 2011). This is referred to as test-retest. An adequate
amount of time should be allowed
between the test and retest so that individuals are not
responding on the basis of remember-
ing responses they made the first time, but not be so long that
other events could occur in the
intervening time to influence their responses. To avoid the

problems of retesting, parallel forms
(equivalent forms) of the test can be administered to the
participants and the results can be cor-
related. While a Cohen’s kappa coefficient (Cohen, 1960) equal
to or greater to than 0.70 is gen-
erally acceptable, a coefficient of 0.80 is ideal and should be
documented (Harris, 2010; Windsor,
2015). There are many sources of error that can contribute to
inconsistent scores over time
including changes within the person (they did not get enough
sleep the night before), or “errors
due to administration, scoring, guessing, mismarking by
examinees, and other temporary fluctu-
ations in behavior” (Crocker & Algina, 1986, p. 133). Stability
is important when implementing
interventions over a long period of time and success is
evaluated using pre and posttests. If there
should be no change in the variables being measured among
participants from pre- to posttest
(i.e., the control group), then stability will be an important
reliability estimate.
Rater reliability focuses on the consistency between individuals
who are observing or
rating the same item or when one individual is observing or

rating a series of items. If two or
more raters are involved, it is referred to as inter-rater
reliability. If only one individual
is observing or rating a series of events, it is referred to as
intra-rater reliability. There
are several different ways to calculate rater reliability. In a
research study, most researchers
would use Cohen’s kappa to calculate rater reliability. However,
a quicker and easier method
is to calculate it as a percentage of agreement between/among
raters or within an individual
rater (DiIorio, 2005). An example of inter-rater reliability
would be the percent of agreement
between two observers who are observing passing drivers in
cars for safety belt use. If raters
observe 10 cars and the raters agree 8 out of 10 times on
whether the drivers are wearing their
safety belts, the inter-rater reliability would be 80%. Intra-rater
reliability would be the de-
gree to which one rater agrees with himself or herself on the

characteristics of an observation
over time. For example, when a rater is evaluating the CPR
skills of participants in his or her
program, the rater should be consistent while observing and
evaluating participants.
Estimates of equivalence reliability focus on whether different
forms of the same mea-
surement instrument, when measuring the same subjects, will
produce similar results (means,
standard deviations, and inter-item correlations). The method
used to establish equivalence
is often referred to as parallel forms, equivalent forms, or
alternate-forms reliability. One
group is given both versions of an instrument and then the
scores are correlated. The useful-
ness of having measurement instruments that possess parallel
forms reliability is being able to
test the same subjects on different occasions (e.g., using a
pretest-posttest evaluation design)
without concern that the subjects will score better on the second
administration (posttest)
because they remember questions from the first administration
(pretest) of the instrument.
Another time equivalent forms are used is when a researcher is

trying to determine if a shorter
form of a scale is just as reliable as a longer form. For example,
the International Physical
Activity Questionnaire (IPAQ) has both a short version (9
items) and a long version (31 items;
Craig et al., 2003). If these instruments have equivalence it
would not matter if a person filled
out the short or long form, both instruments would give the
same estimate of physical activity
levels. If the forms are not equivalent, there is error due to item
or content sampling.
Validity
When designing a data collection instrument, planners must
ensure that it measures what
it is intended to measure. This refers to validity. Using an
instrument that produces valid
results increases the chance that planners are measuring what
they want to measure, thus
ruling out other possible explanations for the results.
Face validity is the lowest level of validity. A measure is said
to have face validity if, on
the face, it appears to measure what it is supposed to measure

(McDermott & Sarvela, 1999).
Face validity differs from the other forms of validity in that it
lacks some form of systematic
logical analysis of the content (Hopkins, Stanley, & Hopkins,
1990). An example of face valid-
ity is when a planner/evaluator asks a group of colleagues to
look over a series of questions
to see whether they seem reasonable to include on a
questionnaire about the risk for heart
disease. Face validity is a good first step toward creating a valid
measurement instrument, but
is not a replacement for the other means of establishing validity
Content validity refers to “the assessment of the correspondence
between the items
composing the instrument and the content domain from which
the items were selected”
(DiIorio, 2005, p. 213). This means that all essential elements
of a domain or area are included
in the instrument. For example, a person takes the certification
exam to become a health edu-
cation specialist (CHES) they want to be sure that the questions
ask about everything a pesron
should know and be able to do as a CHES certified health

educator, and not just research and
evaluation or another area of responsibility.
and Sampling 115
Content validity is usually established by using a group (jury or
panel) of experts to review
the instrument. After such a group is identified, they would be
asked to review each element
of the instrument for appropriateness. The collective opinion of
the experts is then used to
determine the content of the instrument. McKenzie and
colleagues (1999) present a method
of establishing content validity that includes both qualitative
and quantitative steps.
With criterion-related validity we are interested in the
usefulness of the score as an
indicator of specific trait or behavior presently or in the future.
To establish criterion valid-
ity for a scale, there must be a “gold standard” for the
comparison with the scale. A gold

standard is a measure that everyone agrees upon is the most
accurate and valid measure of a
trait, attribute, or behavior.
Concurrent validity means that the score on a measure (a scale)
can predict the pres-
ent standing or status of a trait, attribute or behavior, or even
disease status. For example,
a person fills out a survey about mental health and their score
on that survey shows they
have major depression. If the instrument has high concurrent
validity that score is highly
correlated with a counselor’s diagnosis (the gold standard) of
major depression. Predictive
validity means that the score on a measure is able to predict
future standing or status. For
example, in prenatal screening a physician wants the
amniocentesis test to accurately predict
whether or not a baby will have (or not have) a birth defect
when he or she is born. In physi-
cal activity measurement the gold standard is an accelerometer
(think Fitbit or Fuel Band).
When establishing validity for a new self-reported measure for
how much physical activity a
person got in the last 3 days, the score on the measure would be

compared to the results from
the accelerometer the person wore during the same time. If there
is good concurrent validity
then the scores from the self-report measure are highly
correlated with the accelerometer re-
sults. Both measures are in agreement about a person’s
physically activity level.
Construct validity is concerned with whether the instrument is
measuring the underly-
ing construct. A construct is a label that we assign a set of
attributes or behaviors; it is often
abstract and sometimes theoretical. Examples of constructs in
public health and the social sci-
ences are: depression, body-image satisfaction, self-efficacy,
worry, social support, perceived
severity, religiosity, chronic disease self-management, anxiety,
hopelessness, perceived stress,
school satisfaction, job satisfaction, and so forth (see here for
examples of more constructs
http://cancercontrol.cancer.gov/brp/constructs/).
We cannot measure constructs with a simple question or an
observation. That is we cannot
ask a person “Are you depressed?” But if a person answers a set

of questions (a scale) about their
attitudes, behaviors, thoughts, and so forth, then the construct
of depression can be measured.
For example, a person answers the 21-item Beck Depression
Inventory (BDI; Beck, Steer, &
Carbin, 1988) and based on their score it can be determined
whether or not they are depressed.
If we have construct validity then we can say that the scores
from the scale represent the
construct. We are confident that we are actually measuring what
we said we are measuring.
For example, we are confident the score on the BDI indicates a
person has depression and is
not a measure of a related (or unrelated) construct such as high
social anxiety (i.e., the fear of
negative evaluation by others).
Convergent validity is a type of construct validity evidence. It
“is the extent to
which two measures which purport to be measuring the same
topic correlate (that is, con-
verge)” (Bowling, 2005, p. 12). For example, researchers
developing the Reynolds Adolescent
Depression (RAD) scale (Krefetz, Steer, Gulab, & Beck, 2002)

gave the RAD and the well-
established BDI to a group on inpatient psychiatric adolescents.
The scores revealed high
http://cancercontrol.cancer.gov/brp/constructs/
correlation between the RAD and the BDI measures. This
provided evidence that the RAD was
in fact measuring depression. Discriminant validity “requires
that the construct should
not correlate with dissimilar (discriminant) variables” (Bowling,
2005, p. 12). The BDI is able
to discriminate or distinguish between depression and anxiety
(Beck, Steer, & Carbin, 1988).
Again, this gives planners confidence that they are measuring
what they intended to measure.
SEnSitiVity and SpECiFiCity
When speaking about validity, planners should also be familiar
with the terms sensitivity and
specificity. These terms are used in health care settings as well

as epidemiology to express the
validity of screening and diagnostic tests (Cottrell & McKenzie,
2011). Sensitivity is defined
as the ability of the test to identify correctly those who actually
have the disease (Friis & Sellers,
2009). It is recorded as the proportion of true positive cases
correctly identified as positive on
the test (Timmreck, 1997). The better the sensitivity, the fewer
the false positives. Specificity
is defined as “the ability of the test to identify only non-
diseased individuals who actually
do not have the disease” (Friis & Sellers, 2009, p. 24). It is
recorded as the proportion of true
negative cases correctly identified as negative on the test
(Timmreck, 1997). And the better
the specificity, the fewer the number of false negatives. “An
ideal screening test would dem-
onstrate 100% sensitivity and 100% specificity. In practice this
does not occur; sensitivity and
specificity are usually inversely related” (Mausner & Kramer,
1985, p. 217).
Both validity and reliability are important. If an instrument does
not measure what it is sup-
posed to, then it does not matter if it is reliable (Windsor,

2015). If it is reliable planners may
consistently get the same results, but the results will be of little
value. Box 5.2 summarizes the
different types of reliability and validity.
5.2
Box types of Reliability and Validity
Reliability—“an empirical estimate of the extent to which an
instrument produces the same
result (measure or score), applied once or two or more times”
(Windsor, 2015, p. 196).
internal consistency—the intercorrelations among individual
items on the instrument,
that is, whether all items on the instrument are measuring part
of the same domain.
Stability—used to generate evidence of consistency over time”
(Crocker & Algina, 1986).
Rater (or observer)—associated with the consistent
measurement (or rating) of an
observed event by the same or different individuals (or judges

or raters) (McDermott &
Sarvela, 1999).
Equivalence—focuses on whether different forms of the same
instrument, or a shorter
version of an instrument, when measuring the same participants
will produce similar
results. Also referred to as parallel, equivalent or alternate
forms reliability.
Validity—whether an instrument correctly measures what it is
intended to measure.
Face—if, on the face, the measure appears to measure what it is
supposed to measure
(McDermott & Sarvela, 1999).
Content—“the assessment of the correspondence between the
items composing the
instrument and the content domain from which the items were
selected” (DiIorio, 2005,
p. 213).
Criterion-related—if the score is an indicator of specific trait or
behavior presently

(concurrent), in the future (predictive).
Construct—scores on the instrument are measuring the
underlying construct. There
can be convergent and discriminant construct validity evidence.
Fo
cu
s
O
n
and Sampling 117
Bias Free
Biased data are those data that do not accurately reflect the true
level of a measure because of
errors in the measurement process including how data were
collected. In addition, bias can

be introduced due to error in the selection of the study
participants, in the study’s design, or
in the intervention phase which includes how participants were
exposed to the treatment
(Hartman, Forsen, Wallace, & Neely, 2002). In order to
effectively plan and evaluate health
promotion programs, planners must work to control bias.
Windsor (2015) describes ways in
which bias can occur in data collection—for example, when
participants do not feel comfort-
able answering a sensitive question, when participants act
differently because they know
they are being watched, when certain characteristics of the
interviewer influence a response,
when participants answer questions in a particular way
regardless of the questions being
asked, or when a biased sample has been selected from the
priority population (see informa-
tion later in this chapter on sampling).
There are a number of steps planners can take to limit bias. For
example, if data are being
collected via observation, the observation should be as
unobtrusive as possible. If sensitive
questions are being asked of respondents, then those collecting

such data need to ensure
that the data are being collected in a confidential way (the
identity of the respondent can
be determined but not released), and consider collecting the
data via an anonymous means
(there is no way of identifying the respondent). No matter how
data are collected, the use of
techniques to reduce bias will increase the accuracy of the
results.
Measurement Instruments
Using an Existing Measurement instrument
Before planners create their own measurement instrument, they
should search for an exist-
ing instrument that will produce valid and reliable data and that
meets their needs. As you
will discover in the next section, it takes a great deal of time,
effort, and resources to create a
measurement instrument with good psychometric qualities. The
main advantages of using an
existing instrument include less planning time and thus lower
costs. The major disadvantage—
one that prevents the use of many existing instruments—is that

the items on the existing
instrument may not be relevant or appropriate for the program
being planned or evaluated.
Cottrell and McKenzie (2011) offer four steps for identifying,
obtaining, and evaluating exist-
ing measurement instruments.
Step 1: Identifying measurement instruments. Start by searching
the literature to see
what others have used. You may not find an actual copy of the
measurement instruments
in the literature, but you may find a reference to the original
source. As you are aware by
now, the U.S. government has created many health-related data
collection instruments.
Conducting a search of applicable Websites (e.g., National
Center for Health Statistics) can
be useful. Remember, government publications are in the public
domain (available for
anyone to use) and thus free of charge and need no permission
to use. Also, be aware that
a number of commercial companies sell measurement
instruments [e.g., Psychological
Assessment Resources, Inc. (PAR)]. In addition, you may not
find a measurement instru-

ment that you can use in whole, but you may find specific
questions or a scale that may
work for you.
Step 2: Getting your hands on the instrument. Once you have
identified potential
measurement instruments, you then have to obtain a hard copy.
Unless an instrument is
copyrighted, or there are plans to do so in the future, most
sources are willing to share their
measurement instruments. A phone call, letter, or email
requesting a copy of an instrument
is usually all that it takes to get a copy. Once the source of the
measurement instrument is
known, be aware that you may have to pay for an instrument,
and have to meet certain cri-
teria (e.g., being a licensed psychologist, or agree to certain
terms) to be able to obtain and
use some measurement instruments.
Step 3: Is it the right instrument? Here are some questions to

ask to determine whether an
instrument is the right one for your purposes:
(1) Is there sufficient evidence of the psychometric qualities
(validity and reliability) of
the instrument? (2) Has it been used with participants similar to
yours? (3) Are standard
or normative scores available for various participants? (4) Is the
instrument culturally
appropriate for your participants? (5) Has the reading level of
the instrument been deter-
mined? (6) Is there a cost to administer or have the instrument
scored? Can you afford it?
(Cottrell & McKenzie, 2011, p. 164)
Step 4: Final steps before proceeding. If you think you have
found the right instrument,
before proceeding make sure you have done everything
necessary to be able to use it.
Remember, for instruments that are not in the public domain,
“you need the permission
of the author for any use of the instrument, usually in writing,
and particularly if you need
to make any changes” (Dignan, 1995, p. 67). You also may need
to fulfill other conditions

placed on the use of the instrument by the owner of the
copyright before you use it.
Creating a Measurement instrument
Only when planners are unable to use or adapt another
instrument for their use should they
undertake the process of developing their own (Janz, Champion,
& Strecher, 2002). The
process for creating an instrument, particularly scales, with
good psychometric qualities that
will yield valid and reliable data is complex and beyond the
scope of this text. For a detailed
discussion of steps in this process, see Cottrell and McKenzie
(2011) or Crocker and Algina
(1986). However, often planners and evaluators will need to
create questions for an instru-
ment to conduct formative research or to measure program
success. Next we will present a
general discussion about the wording, sequencing, and
presentation of questions on a mea-
surement instrument.
WoRding QUEStionS

The way in which questions are worded is extremely important
in gaining the needed infor-
mation. The result of a poorly worded question was evident to
one health promotion planner
who was planning a smoking cessation program for employees.
When asked “Do you feel we
need a smoking cessation program?” most employees said yes.
The planner realized later that
he should have also asked the question, “If offered, would you
attend a smoking cessation
program?” since very few employees participated. In general,
always try to avoid questions
that can be answered with a simple yes or no.
The following are guidelines to help you in wording structured
questions, referred to as
the question stem, with fixed response options.
and Sampling 119
First, avoid leading questions that guide the respondent’s
answer or suggest that you are

looking for a specific type of response. For example, “Most
people choose to get their health
care at Intermountain Health Care. Where do you go when you
need to get health care?”
Second, ask only about one thing at a time. Two-part questions,
also called double-
barreled, should also be avoided (e.g., “Do you brush and floss
your teeth?”). The respon-
dent may brush their teeth, but not floss.
Third, avoid jargon or use of words that people do not
understand. (e.g., “What cardiovas-
cular benefits do you feel are gained from aerobic exercise?”).
If you need to use a technical
term, like “cardiovascular” or “aerobic” define it before asking
the question. For example,
“The next questions will as about aerobic exercise. By aerobic
we mean activities that are
done for at least 30 minutes at a time, use large muscles, and
cause you to breathe harder
than normal.”
Fourth, be specific. For example instead of asking, “How
helpful was the diabetes education

class,” ask “How helpful were the classes in teaching you how
to test your blood sugar.” The first
question is too broad and general. There may be many things
about the class that was helpful.
The second question asks about specific aspect of the class.
RESponSE optionS
In addition to the question stem, planners must determine the
format for response options.
Planners must give consideration to whether the type of
question and the response options
will generate the needed data. For example, assume planners
were interested in identifying
the ages of those in the priority population. A question like
“How old are you?” could gener-
ate the best data (i.e., ratio level data), but some may not want
to share their actual age and
thus planners may not collect enough data to describe the
priority population. In this case,
a question that generates ordinal level data with response
options such as: 15–24 years old;
25–44 years old; 45–64 years old; 65+ years old” may be a
better choice.

For ease of data entry and analysis, close-ended or fixed
response are the best. The draw-
backs are that these types of questions do not allow individuals
to elaborate on their answers.
They may also force a person into a choice because of the
limited number of responses to each
question. One way to ensure that the most common responses to
questions are included in
the possible choices is to involve several individuals (especially
those in the priority popula-
tion) in the formation of the instrument and in pilot testing,
discussed later in this chapter.
Common forced response options often include Likert scales.
Likert scales allow respon-
dents to select an answer choice along a continuum, generally
ranging from a 5- to a 7-point
scale. Likert scales can measure agreement, likelihood,
frequency, importance, quality, and
so forth. For example, responses to the question “How much do
you agree with the following
statement: I feel that it is important to limit my use of salt”
might be rated on a 5-point scale
ranging from “strongly disagree” (1) to “strongly agree” (5).

Always make sure that the question and the response options
match. For example, if a
question asks “How likely are you to attend another exercise
class in the next month” the
response options should not be “yes” and “no.” Instead options
should be on a Likert-type
scale from very unlikely (1) to very likely (5) as the question is
asking about “how likely” they
are to do a behavior.
Response options should be mutually exclusive and exhaustive.
By mutually exclusive
we mean that the options do not overlap and only one can be
selected. For example, “Do
you currently live in a: house, condo, or apartment?” Someone
may live in a basement
apartment of a house and thus select both house and apartment
as response options. These
options are not mutually exclusive. The list could be expanded
to make it exhaustive.

Exhaustive response options means that all the possible choices
have been included. For
example, if a question asked about race and only included Black
and White, the list would
not be exhaustive.
pRESEntation
A survey instrument can have good questions, but if they are
not presented in a way that is
easy to read and understand there may be errors in the data or
the response rate may be low.
Therefore, presentation is just as important as wording of
questions.
Every survey, whether administered in-person, by mail, or via
the Internet should have
the following six components.
1. A cover page. The cover page should include the title of the
survey, indicate the survey
sponsor, and contain an image that reflects the survey topic.
2. A survey title. The title should tell the reader what the survey
is about. For example:

“Live for Life Weight Loss Class Evaluation”
3. A purpose statement. This tells the respondent the reason for
the survey. Do not be too
specific so as to bias participant responses. For example, “The
purpose of this survey is
to learn about your experience with the Live for Life classes” is
better than “The purpose
of this survey is to find out about how often you eat fruit and
vegetables and how often
you exercise.”
4. A statement about confidentiality of answers. This means that
nobody will know what
they put as answers and their responses will not be linked to
them as a person.
5. Instructions for how they should fill out the survey. For
example, “For each question,
mark the one box that best reflects your opinion.” These
instructions may also
appear throughout the survey before a set of questions. In that
case, they are called
“transition statements.” For example, “The next group of
questions asks about your

opinion on the Live for Life curriculum. Mark whether you
agree or disagree with
each statement.”
6. Instructions for what they are to do with the survey once they
are completed. For
example, “When you are finished with the survey, please place
it in the box at the front
of the room.”
The visual appearance of the survey is very important. This
allows respondents to easily
answer the questions increasing accuracy and response rates.
Here are six basic guidelines:
1. Allow for ample white space. There should be plenty of white
space between response
options and between the question stem and the response options.
2. Indent the response options from the question stem. This sets
the responses apart from
the question stem and makes them easy to identify.
3. Bold the question stem. This will make the question stem
stand out from the response

options.
4. Indicate skip patterns. Skip patterns are words that direct
them to go to a specific
question based on how they respond.
5. List all questions and response options vertically, from top to
bottom. Our eyes naturally
scan top to bottom, so it is easier and faster to read the options.
Do not try to fit a lot of
and Sampling 121
questions on one page. Remember, white space is good. Layout
can include two columns
on a page, but make sure to separate the columns with a line.
6. Group related questions together. For example, when asking
about foods a person
eats, place all the food questions together. Also, group all
questions that have similar
response options together. For example, if there are several

questions on a Likert scale
of strongly agree to strongly disagree, place them together in
the survey.
Lastly, ensure that the survey is designed and coded for easy
data entry and analysis. If the
survey is Internet-based many of these things will be done
automatically. Specifically:
1. Use check boxes next to response options. It is better to have
a box that they check
rather than a “circle” your answer to reduce error due to mis -
marking.
2. Code the response options. Coding means that there is a
number associated with every
response option. It is usually a number using 6-8 point font (or
superscript or subscript
number) to the left of the check box. Numbers are better than
letters, because data entry
can be done using the number key pad on a computer keyboard;
it is much faster!
3. Never ask respondents to “check all that apply.” Rather have
them answer yes or no for

each response option. This makes them evaluate each response
option individually and
again makes data entry and analysis much easier.
The first questions on an instrument should be ones that capture
the respondent’s at-
tention, are easy to answer, and get them interested in
answering the rest of the questions.
For example, it is better to ask: “Which of the following did you
like best about the Live for
Life program?” than to ask, “How much do you currently
weigh?” Questions that deal with
sensitive topics should be posed at the end of the questionnaire
or interview. Answers to
questions about drug use, sexuality, or even demographic
information, such as income level,
are more readily answered when the respondents understand the
need for the information,
are assured of confidentiality or anonymity, and feel
comfortable with the interviewer or the
questionnaire. If the respondent ends the interview or does not
complete the instrument
when asked sensitive questions, the other information collected
can still be used. To reduce
the number of questions on an instrument, ask “is this a nice-to-

know question or a need-
to-know question?” Planners may be interested many questions
but the answers to those
questions do not fit the purpose for why the data are being
collected. For example, it might
be nice to know if people thought the chairs in the classrooms
were comfortable but that an-
swer does not help evaluate the success of the program.
Figure 5.2 includes sample survey questions and illustrates the
key points for questions,
response options, and presentation.
Sampling
The need to select participants from whom data will be
collected can occur at several times
during the process of program planning or evaluation.
Depending on the size of the priority
population, planners may want to collect data from all
participants, a census, or from only
some of the participants, a sample. Each of the participants is
referred to as a sampling unit. A
sampling unit is the element or set of elements considered for
selection as part of a sample

(Babbie, 1992). A sampling unit “may be an individual, an
organization, or a geographical
area” (Bowling, 2005, p. 166).
122 Part 1 Planning a Health Promotio n Program
1. Have you ever heard of the following viruses,
bacteria, or parasites? (Choose yes or no for
each one)
4. On a typical day, for how many children does your
child care facility provide care?
(Include in your count children that are unrelated
and related to you)
5. Not including yourself, do you employ another staff
member (full-time or part-time) at your facility?
6. How many years have you been working as a
child care provider?
7. What is your age?

8. What is the highest level of education that you have
attained?
2. In your opinion, how likely is it that you will
be exposed to the cytomegalovirus at your
child care facility?
3. As far as you know, when should the diaper
changing surface be sanitized? (Choose one)
a. Adenovirus Yes No
Yes No
1−4
5−8
9−12
13−16
Yes No
Yes No− Go to

1
1
1
1
2
2
2
2
b. Enterovirus
c. Giardia
d. Cytomegalovirus
1
2

3
4
Yes
No
1
2
Less than 1 year1
1−5 years2
6−10 years3
18−191
20−292
30−393

40−494
50−595
60 or older6
High school diploma/GED, or less1
Some college2
Associate’s degree3
Bachelor’s degree or higher4
More than 10 years4
Extremely unlikely1
Somewhat unlikely2
Unlikely3
Likely4
Somewhat likely5

Extremely likely6
During the day, as needed1
At the end of the day2
Once a week3
Once a month4
As needed5
After every child6
Question 3
Line separates
columns
Plenty of white
space
Coding number to
the left of each

box
Use italics or
underline for
emphasis
Use “Yes” or “No” and
not “check all that apply”
Skip
pattern
noted
Questions that go on
to two lines are
aligned flush left
Indent response
options
Bold question
stem
Age categories are
mutually exclusive

⦁ ▲ Figure 5.2 example of Survey Questions, Response
Options, and Presentation
Figure 5.3 illustrates the relationship between groups of
individuals. All individuals, un-
specified by time or place, constitute the universe—for
example, all U.S. citizens, regardless
of where they reside in the world. Within the universe is a
population of individuals speci-
fied by time or place, such as all U.S. residents in the 50 states
on January 1, 2016. Within this
and Sampling 123
Universe
Population
Su
rve

y population
Sample
⦁ ▲ Figure 5.3 Relationship of Study Populations
population is a survey population, composed of all individuals
who are accessible to the
researchers. The key term here is accessible. For example, all
U.S. citizens who are accessible and
can be reached by telephone would be a survey population.
Obviously, this would not include
those without telephones, such as those who choose not to own
them, those institutionalized,
and the homeless.
A survey population may still be too large to include in its
entirety. For this reason, a sample
is chosen from the survey population, a process called sampling.
Those in the sample are the
individuals who will be included in the data collection process.
Using a sample rather than an
entire survey population helps contain costs. For example, using
a sample reduces the amount
of staff time needed to conduct interviews, the cost of postage

for written questionnaires, and
the time and cost of travel to conduct observations.
How the sample is chosen is critical to the result of the needs
assessment or evaluation:
Does the information gained from the sample reflect the
knowledge, attitudes, and behav-
iors of the survey population? According to Green and Lewis
(1986), the sampling bias is the
difference between the sampling estimate and the actual
population value. Sampling bias
can be reduced by controlling the sampling procedure—that is,
how the sample is chosen.
Furthermore, the ability to generalize the results to the survey
population is greater when the
sampling bias is reduced.
probability Sample
Increasing the likelihood that the sample is representative of the
survey population is achieved
by random selection. Randomness minimizes the likelihood that
a systematic source of
selection bias will occur among the sample, thereby influencing
the degree of representativeness

of the population (Windsor, 2015). When random selection is
used, each person in the survey
population has an equal chance or probability of being selected,
thus creating a probability
sample.
There are a number of different methods for selecting a
probability sample. The most
basic of the probability sampling methods is selecting a simple
random sample (SRS).
In order to select an SRS, or for that matter any probability
sample, the planner must have a
list or “quasi-list” (Babbie, 1992) of all sampling units in the
survey population. This list is re-
ferred to as the sampling frame. Oftentimes, sampling frames
have the names and contact
information for everyone in the survey population such as with
membership lists, patients
of a clinic, and parents of children enrolled in a certain school
or program. Other times the

frame may simply be the title of an individual or organization,
such as the director of envi-
ronmental services in the 92 local health departments in
Indiana, or a list of all the voluntary
health agencies in the county (Cottrell & McKenzie, 2011).
Once the sampling frame has been identified, the planner can
proceed with the process
of selecting an SRS. It begins with assigning a number with an
equal number of digits to
each sampling unit in the frame. Suppose, for example, we have
a frame of 200 individuals.
The first person in the frame would be given the number 000.
The rest of the individuals in
the frame would be assigned consecutive numbers and the last
person in the frame would
be assigned the number 199. Once it is decided how large the
sample should be, the sample
can be selected. For the purpose of this example let’s suppose a
sample size of 20 is desired.
To select these 20 individuals, a computer could be used to
randomly select 20 numbers
between 000 and 199, or it could be done manually by using a
table of random numbers
(Cottrell & McKenzie, 2011) (see table 5.3).

In order to use a table of random numbers, the manner in which
the table will be used
needs to be set forth. Since these tables are generated randomly
(by computer), it really does
not matter which way one moves through the table as long as it
is done in a consistent man-
ner. For example, the process set forth could be to (1) use the
first three digits in the columns
of numbers (because all individuals in the example frame have a
three-digit number, that is,
000 to 199); (2) proceed down the columns (as opposed to up or
across the rows); (3) at the
Table 5.3 Abbreviated Table of Random Numbers
Row/Column A B C D E
1 75 51 02 17 71 04 33 93 36 60
2 42 75 76 22 23 87 56 54 84 68
3 00 47 37 59 08 56 23 81 22 42
4 74 01 23 19 55 59 79 09 69 82
5 66 22 42 40 15 96 74 90 75 89
6 09 24 34 42 00 68 72 10 71 37
7 89 22 10 23 62 65 78 77 47 33

8 51 27 23 02 13 92 44 13 96 51
9 17 18 01 34 10 98 37 48 93 86
10 02 28 54 60 01 11 28 35 54 32
and Sampling 125
bottom of the column proceed to the top of the next column to
the right; and (4) proceed in
this same manner until the 20 individuals are selected. To
ensure that this process is indeed
random, the process must begin with a random start. That is, the
planner cannot just pick
the first number at the top of column one and proceed down
through the column because
every individual in the survey population would not have an
equal chance of being selected.
The planner can accomplish the random start by closing his or
her eyes and pointing to a
place on the table of random numbers then proceeding through
the table in the way that was
set forth above (Cottrell & McKenzie, 2011).

A systematic sample also uses a frame and takes every Nth
person (determined by
dividing the survey population size by the sample size, N/n),
beginning with a randomly
selected individual. For example, suppose that we want to
choose a sample of 10 people from
a survey population of 100. We start by randomly choosing a
number between 001 and 100,
such as 026, using a table of random numbers. We then choose
every tenth (N/n = 100/10 =
10) person (036, 046, 056, 076, 086, 096, 006, 016) until we
have the 10 subjects for the sam-
ple. In this way, everyone in the survey population has an equal
chance of being selected. A
simple random sample or systematic sample can also be used to
select “naturally occurring
groups or clusters, such as schools, clinics, worksites, or census
tracks” (Gilmore, 2012, p. 74).
When this occurs, it is called cluster sampling.
If it is important that certain groups be represented in a sample,
a stratified random
sample can be selected. Such a method would be used if the
planners felt that a certain

independent variable (e.g., size, income, or age, etc.) might
have an influence on the data
collected from the participants. A stratified random sample
might also be used if it is believed
that, due to small numbers of a certain group in the survey
population, representatives from
that group may not be selected using a simple random sample.
That is, you may have a sur-
vey population of 100 participants and in that 100 there are only
8 of one group. If you were
to select a sample of 10 from the 100, there is a good chance
that none of the 8 from the small
group might be selected (Cottrell & McKenzie, 2011).
Here is an example of the use of a stratified random sample. To
begin, the planner first
must divide the survey population into subgroups, or strata, then
select a simple random
sample from each stratum. Suppose we were interested in
collecting data from companies
within a particular state concerning the number of health
education programs offered for
employees. Based on past experience, we suspect the size of the
business (i.e., number of
employees) would affect the data we want to collect. That is,

small companies might have
fewer health education programs in general than large
companies. Also, we know that
relatively few companies in the state have a large number of
employees. We could then
divide the companies into strata by size, for example small (1–
100 employees), medium
(101–1,000), and large (1,001+). Once the planners decide how
many to select from each
stratum, they next decide whether to conduct a proportional
stratified random sample
or nonproportional stratified random sample. A proportional
stratified random
sample would be used if the planners wanted the sample to
mirror, in proportion, the
survey population. That is, draw out the companies in the same
proportions that they are
represented in the survey population. Say our example has 600
small companies, 350 me-
dium companies, and 50 large companies, and the desired
sample size is 100. Planners
would then select simple random samples of 60 small, 35
medium, and 5 large companies

A nonproportional stratified random sample may be used if the
planners want
equal representation from the different strata within the survey
population. For example,
suppose we want to collect information about the opinions of
college students on a medium-
size regional campus (the survey population) about a new
alcohol use policy that was put in
place by the administration and we want to hear equally from
the different levels of students
(freshmen [n = 4,000], sophomores [n = 3,000], juniors [n =
2,000], and seniors [n = 1,000])
because it is thought that the policy will affect each class
differently. If a sample size of 200 is
desired, we would randomly select (using a simple random
sample method) 50 students from
each of the classes (Cottrell & McKenzie, 2011). (See table 5.4
for a summary of probability
sampling procedures.)
nonprobability Sample

There are times when a probability sample cannot be obtained
or is not needed. In such
cases, planners can take nonprobability samples in which all
individuals in the survey
population do not have an equal chance or probability of being
selected to participate in the
needs assessment or evaluation. Participants can be included on
the basis of convenience
(because they have volunteered, are available, or can be easily
contacted) or because they
possess a certain characteristic.
Nonprobability samples have limitations in the extent to which
the results can be
generalized to the total survey population. Bias may also occur
because those who are not
included in the sample may differ in some way from those who
are included. For example,
including only the individuals who complete a health promotion
program may bias the
results; the findings might be different if all participants,
including those who attended but
did not complete the program, were surveyed.

Nonprobability samples can be used when planners are unable
to identify or contact all
those in the survey population. These samples can also be used
when resources are limited and
Table 5.4 Summary of Probability Sampling Procedures
Source: Adapted from E. R. Babbie, The Practice of Social
Research, 6th ed. (Belmont, CA: Wadsworth, 1992); P. C.
Cozby, Methods in Behavioral Research, 3rd ed.
(Palo Alto, CA: Mayfield, 1985); P. D. Leedy, Practical
Research: Planning and Design, 5th ed. (New York: Prentice
Hall); and R. J. McDermott and P. D. Sarvela,
Health Education Evaluation and Measurement: A Practitioner’s
Perspective, 2nd ed. (New York: McGraw-Hill, 1999).
Sample Primary Descriptive Elements
Simple Random Each subject has an equal chance of being
selected if table
of random numbers and random start are used.
Systematic Using a list (e.g., membership list or telephone
book), subjects
are selected at a constant interval (N/n) after a random start.

Nonproportional Stratified The population is divided into
subgroups based on key
characteristics (strata), and subjects are selected from the
subgroups at random to ensure representation of the
characteristic.
Proportional Stratified Like the nonproportional stratified
random sample, but
subjects are selected in proportion to the numerical strength
of strata in the population.
Cluster or Area Random sampling of groups (e.g., teachers’
classes) or areas
(e.g., city blocks) instead of individuals.
and Sampling 127
a probability sample is too costly or time consuming. It is
important that planners understand
the limitations of this type of sample when reporting the results.
(See table 5.5 for a summary

of nonprobability sampling procedures.)
Sample Size
An often-asked question associated with sampling involves how
many individuals are
needed for planners to feel confident that sampling error is
within an acceptable range so
that reasonable conclusions can be drawn from the data
collected. There is no easy answer
to this question. Appropriate sample size is determined by both
practical and statistical con-
siderations. From a practical standpoint, often the resources
(e.g., personnel, financial) avail-
able to collect data are the determining factor on how large the
sample will be. Asked another
way, is the desired sample size affordable?
When analyzing sample size from a statistical standpoint, three
major theoretical consid-
erations are used: central limit theorem (CLT), precision and
reliability, and power analysis
(Norwood, 2000). The CLT can provide the quickest answer to
the sample size question.
Mathematically, it has been shown that when a sample size

approaches 30 in number, char-
acteristics of that group approach the normal distribution of the
group from which it was
drawn. Thus, while a sample size of 30 may not properly
estimate a research parameter or
distinguish research results between groups, a general rule for
comparison purposes is, no
group should be smaller than 30.
Determining sample size using precision and reliability, or
power analysis, is much more
complicated (and is not within the scope of this book). table 5.6
is offered as an example
of the application of these considerations. Detailed explanations
of these concepts are pre-
sented in many statistics textbooks.
Pilot Testing
Pilot testing (sometimes referred to as piloting or a pilot study)
is a set of procedures used
by planners to try out the program on a small group of
participants prior to actual imple-
mentation. In other words, pilot testing can be thought of as a
dress rehearsal for planners

Table 5.5 Summary of Nonprobability Sampling Procedures
Sample Primary Descriptive Elements
Convenience Selecting people who are readily available and
easy to reach; may be
members of an intact group or people present at public location.
Homogeneous People are selected who share similar
characteristics or traits of interest.
Snowball Method by which respondents are asked to identify
others who fit study
criteria; often used with difficult to find priority populations or
to find
information-rich respondents.
Quota Choosing people based on whether they meet pre-
established criteria;
aiming to have certain number of respondents with specific
characteristics.
Maximum
variation

Ensuring diverse representation of the priority population by
selecting a
wide variety of people possessing characteristics or
experiences.
(McDermott & Sarvela, 1999). The purpose of using pilot
testing is to identify and, if nec-
essary, correct any problems prior to implementation with the
priority population. Thus,
pilot testing permits a thorough check of all planned processes
to help increase the chances
of having a successful program. Throughout the program
planning process, planners may
use pilot testing to detect any problems with sampling, data
collection instruments, data
collection procedures, data analysis procedures, interventions,
curricula, and program
evaluation (McDermott & Sarvela, 1999). Because this chapter
has focused on measure-
ment and measures, the remaining portions of this discussion

will focus on the pilot test-
ing of data collection. Pilot testing will be discussed in later
chapters, as it relates to the
implementation of a program as well as its role in formative
evaluation (see Chapter 12 and
Chapter 14).
Once the data collection method has been determined and the
instrument has been
selected or created, a trial run of the instrument, data collection
procedures, and analyses
should be conducted. During the piloting process, it would not
be uncommon for the
planners to find problems, such as ambiguous questions,
difficulty with coding sheets,
and misunderstood directions. Further, the data collected during
pilot testing should be
statistically analyzed or compiled to make sure there is no
difficulty with this step in the
data collection process. Revising the data collection process
using the information gained
from the pilot testing helps ensure that the actual data collection
will proceed smoothly.
Several authors have suggested processes for pilot testing (Borg

& Gall, 1989; McDermott
& Sarvela, 1999; Parkinson & Associates, 1982; Stacy, 1987).
They have been combined
here into a single process. Several of the preceding authors have
presented hierarchies for
pilot testing: preliminary review, pre-pilot, and pilot tests. The
first and lowest level in the
pilot testing hierarchy is a preliminary review. A preliminary
review is conducted when
those responsible for the data collection process ask colleagues,
not people from the prior-
ity population, to review the data collection instrument. At a
minimum, all data collec-
tion instruments should be subjected to this type of review.
Specifically, in a preliminary
review, colleagues would be asked to complete the instrument
as if they were participants
in hopes of identifying problems, and also respond to several
other questions about the
instrument, such as the appropriateness of (1) the instrument’s
title, (2) the introductory
statement explaining the purpose of the data collection, (3) the
directions, (4) the order or
Table 5.6 Sample Sizes for Studies Describing Population

Proportions When
the Population Size Is Known
* = In these cases the assumption of normal approximation is
poor, and the formula used to derive them does not apply.
Source: Statistics: An Introductory Analysis. Taro Yamane.
Copyright © 1973 by Pearson Education. Adapted with
permission.
Population Size
95% Confidence Interval Sample Size for Precision of
∙1 ∙3 ∙5
500 * * 222
1,000 * * 286
5,000 * 909 370
10,000 5,000 1,000 385
100,000 9,091 1,099 398
S ∞ 10,000 1,111 400

and Sampling 129
grouping of the questions, (5) the questions (e.g., unclear or too
personal), (6) the length of
the instrument, and (7) the method of returning the instrument,
to name a few.
Next, pretesting is completed with members of the priority
population. Respondents fill
out the survey and then give feedback either orally or in writing
about which questions and
response options they found confusing. When you invite
someone to come meet with you and
fill out the survey this process is referred to as cognitive
pretesting (Collins, 2003). In this
process you ask the participant to talk out loud as they take the
survey, tell you what they are
thinking as they read the question and the responses. For
example, if a question asked “How
many residences have you lived in since you were born.” The
respondent might say, “I am
thinking whether residences means houses or cities. I think it
means cities, so I am going to
write down five.” You may actually be looking for number of

houses, so you know you need to
change the wording of that question. The same cognitive
pretesting process can be used after
a respondent fills out the survey instead of during the process.
The planner holds a debriefing
session after the respondent completes the instrument where
inquiries are made about word-
ing of questions, understanding, response options and so forth.
Pre-pilots (or mini-pilots) are used by planners with five or six
members of the priority
population to assess the quality of materials, instruments, and
data collection techniques. The
pilot test requires the actual implementation of the instrument.
A representative sample of
the priority population is used to determine the quality of the
instrument. If enough subjects
are used during the pilot study, it may be possible to check the
validity and reliability of the
instrument. If at all possible, the use of this sequence of pilot
testing techniques is desirable,
but planners are often limited by time and resources, and so not
all the steps may be reasonable
to complete.

Ethical Issues Associated with Measurement
Whenever people are being measured as part of a needs
assessment or an evaluation, plan-
ners need to be aware that many of their decisions made and
actions taken throughout these
processes could have ethical ramifications. Further, planners are
obligated by law—via the
Health Insurance Portability and Accountability Act of 1996—
to guard against the misuse of
individual identifiable health information.
Ethical issues associated with measurement begin with getting
people to voluntarily par-
ticipate in the process. Before people get involved they should
be well informed about the
nature of the process and what is expected when they do
participate. Further, potential par-
ticipants should not be coerced or deceived to participate. And,
once participation has begun,
planners should make it clear that participants have the right to
discontinue participation at
any time without penalty. A second issue is that of private
and/or sensitive data. If planners
need to ask questions that reveal private and sensitive data, they

need to ensure anonymity or
confidentiality. During data collection, planners may hear about
illegal acts, such as drug use
or other crimes, or they may be provided with access to
confidential data. The planners must
consider the ethical issues and the legal ramifications of such
issues.
Once the data have been collected, several ethical issues could
arise when the data are an-
alyzed and reported. Inappropriate data analyses can lead to
personal harm to participants,
the continuation of inappropriate programs, policies or
procedures, and the waste of time,
effort, and resources (Cottrell & McKenzie, 2011). Regardless
of the purposes for which the
analyzed data are used, planners have an ethical obligation to
ensure they do not mislead
anyone who relies on them (Dane, 1990). Finally, when the
results of a needs assessment

or an evaluation are reported, planners must ensure not to reveal
the identity of those who
participated, or individual results of participants, without their
permission.
Summary
This chapter focused on helping you understand the terms
measurement, measures, measure-
ment instruments, sampling, and pilot testing. A brief overview
of measurement and measures
was provided, along with the four levels of measurement:
nominal, ordinal, interval, and
ratio. Several different examples of questions used at each of
the levels were also presented.
Next, desirable characteristics of data were discussed, including
reliability, validity, and
the importance of being bias free. Background information was
provided to assist you with
processes to identify existing measurement instruments and
create new ones. Information
was also presented on writing measurement instrument
questions. This was followed by a
discussion of techniques used to draw the various probability
and nonprobability samples,

and when the various sampling techniques might be most useful.
The chapter concluded
with short presentations on the importance of using pilot testing
and the ethical issues as-
sociated with measurement.
Review Questions
1. What is meant by measurement, and qualitative and
quantitative measures?
2. What are the reasons that measurement is such an important
process when it comes to
program planning and evaluation?
3. Name and give an example of each of the four levels of
measurement.
4. What are the most common types of measures (variables)
used in needs assessments
and evaluations? Give an example of each type of variable.
5. What are sources of validity evidence? What are the different
types of reliability
estimates? What are reasons that validity and reliability are

important to measurement?
6. What is bias in data collection? Name three ways in which it
can be controlled.
7. What are the steps one can follow when identifying,
obtaining, and evaluating existing
measurement instruments?
8. What are the advantages and disadvantages of using an
existing measurement
instrument?
9. What are the guidelines for wording questions and response
options?
10. What are the guidelines for presentation when designing a
data collection instrument?
11. Define census, sample, sampling, and sampling frame.
12. Using a table of random numbers, explain how a simple
random sample is selected.
13. Describe three types of probability samples.

and Sampling 131
14. When, if ever, should nonprobability samples be used?
15. What is the purpose of a preliminary review, a pre-pilot (or
mini-pilot), a pilot test,
and cognitive pretesting? How is each conducted?
16. What ethical issues are associated with measurement?
Activities
1. Assume that your college or university has hired you to
conduct a needs assessment on
the student body for a new health promotion program. Because
there are few secondary
data on this group of people, other than national data on college
students, you have
decided to survey a random sample of students using a written
instrument. Your
task now is to develop the instrument. Create a draft of an

instrument that includes
questions that will collect data about the students’ health
behavior and demographic
characteristics. Follow the guidelines in this chapter for
wording questions as well as
presentation.
2. Conduct a cognitive pretesting of your instrument developed
in activity 1 on five or
six of your friends, colleagues, or classmates. Make changes
based on the feedback you
receive. Next, pilot test the survey by asking 5–10 people to fill
it out. Identify any flaws
you see in the questionnaire or data collection process.
3. Assume that you are charged with the responsibility of
collecting data from all the
students on your campus who are interested in taking non-
traditional physical activity
classes such as yoga, spinning, or kickboxing. You do not have
access to a list of students
on campus that you can use as a sampling frame. Explain how
you would obtain a
representative sample from this population. Would probability
or non-probability

sampling be best? What are drawbacks and advantages of the
method you selected?
4. Look in the peer reviewed literature or the Websites listed in
this chapter to find a scale
to measure a construct such as physical activity, social support,
self-efficacy for stopping
smoking, resilience, or something similar. Evaluate the quality
of the scale by looking for
evidence of validity and reliability in the scholarly literature
(start with Google Scholar).
Write a recommendation as to whether or not it would be an
appropriate scale to use for
a program evaluation or needs assessment.
Weblinks
1. http://ctb.ku.edu/tools/en/sub_main_1044.htm
Community Toolbox
This page from the Community Toolbox Website, created and
maintained by the Work
Group on Health Promotion and Community Development at the
University of Kansas,
defines and describes the process of developing baseline
measures.

2. http://www.cdc.gov/nchs
National Center for Health Statistics (NCHS)
The NCHS Website is a rich source of data and measurement
instruments used to collect
the data about America’s health.
http://ctb.ku.edu/tools/en/sub_main_1044.htm
http://www.cdc.gov/nchs
3. http://www.surveysystem.com/resource.htm
Creative Research Systems
The Creative Research Systems Website includes a lot of
information about survey
instrument development data collection and includes a
calculator for determining
appropriate sample size.
4. http://www.socialresearchmethods.net/
Web Center for Social Research Methods
This Website is designed for people involved with social
science research. Topics covered

include measurement, statistics, study design, sampling, and
more. There are several easy
to understand examples provided.
5. http://www.qualtrics.com
Qualtrics
Qualtrics is one of the leading firms for conducting online
surveys. You can set up an
account and practice creating surveys.
6. http://www.eval.org/
American Evaluation Association
The American Evaluation Association is a professional
association dedicated to
improving the practice of evaluation in various sectors. There is
an annual conference,
an email list-serv, and several online resources. Student
membership is relatively
inexpensive.
7. http://cancercontrol.cancer.gov/brp/constructs/
Health Behavior Constructs: Theory, Measurement and Research
This Website provides definitions and measurement sources for
major theoretical
constructs related to behavioral research. This is a good place to

start looking for
measurement instruments.
http://www.surveysystem.com/resource.htm
http://www.socialresearchmethods.net/
http://www.qualtrics.com
http://www.eval.org/
http://cancercontrol.cancer.gov/brp/constructs/
133
To plan, implement, and evaluate effective health promotion
programs, planners must
have a solid foundation in place to guide them through their
work. The mission statement,
goals, and objectives of a program can provide such a
foundation. If prepared properly, a mis-
sion statement, goals, and objectives should not only give the
necessary direction to a pro-
gram but also provide the groundwork for the eventual program
evaluation (Box 6.1). There
are two old sayings that help express the need for a mission
statement, goals, and objectives.
The first is: If you do not know where you are going, then any

road will do—and you may
end up someplace where you do not want to be, or you may
eventually end up where you
want to be, but after wasted time and effort. The second is: If
you do not know where you are
going, how will you know when you have arrived? Without a
mission statement, goals, and
objectives, a program may lack direction, and at best it will be
difficult to evaluate. Figure 6.1
shows the relationship between a mission statement, goals, and
objectives. The size of the
6
Chapter Mission Statement, Goals,
and Objectives
Chapter Objectives
⦁ ⦁ Explain what is meant by the terms mission
statement and vision statement.

⦁ ⦁ Define goals and objectives and distinguish
between the two.
⦁ ⦁ Identify the different levels of objectives as
presented in the chapter.
⦁ ⦁ Describe a SMART objective.
⦁ ⦁ State the necessary elements of an objective as
presented in the chapter.
⦁ ⦁ Specify an appropriate criterion for objectives.
⦁ ⦁ Write program goals and objectives.
⦁ ⦁ Describe the use for Healthy People 2020.
Key Terms
attitude objectives
awareness objectives
behavioral objectives
condition
criterion
environmental

objectives
goal
impact objectives
knowledge objectives
learning objectives
mission statement
objectives
outcome
outcome objectives
process objectives
skill development
objectives
SMART objectives
vision statement
rectangles presented in Figure 6.1 has special meaning. The
rectangle that represents the mis-
sion statement is the largest, while the rectangle representing

the objectives is the smallest,
meaning that ideas presented go from broad to narrow in scope.
Goals ObjectivesMission
statement
⦁ ▲ Figure 6.1 Relationship of Mission Statement, Goals, and
Objectives
6.1
Specialists
The content of this chapter focuses on the mission, goals, and
objectives of a program.
Because the mission, goals, and objectives provide the
foundation on which programs
are developed and the criteria used to evaluate the programs, the
information presented
in this chapter is applicable to three areas of responsibility:
Competency 2.2: Develop goals and objectives

Competency 2.3: Select or design strategies/interventions
RESponSiBility iii: Implement Health Education/Promotion
Competency 3.2: Train staff members and volunteers involved
in
implementation of health education/promotion
Competency 3.4: Monitor implementation of health
education/promotion
to Health Education/Promotion
Competency 4.1: Develop evaluation plan for health
education/promotion
Health Education

Mission Statement
Sometimes referred to as a program overview or program aim, a
mission statement is a short
narrative that describes the purpose and focus of the program.
The statement not only describes
the current focus of a program but also may reflect the
philosophy behind it. The mission state-
ment also helps to guide planners in the development of
program goals and objectives. table 6.1
presents examples of mission statements for programs offered in
several different settings.
Some people mistake a vision statement for a mission statement.
They are different.
Whereas a mission statement provides a description of the
current efforts of a program, a
vision statement is a brief description of where the program will
be in the future; typi-
cally, in three to five years. A vision statement answers the
questions, “What do we want
to be?” and “What will we look like in three to five years?”
Vision statements are often part

of a strategic planning process in which organizations define a
strategy or direction for the
Chapter 6 Mission Statement, Goals, and Objectives 135
future. Items that are considered when creating a vision
statement are future products (i.e.,
information, ideas, goods, services, events, and behavior),
markets, customers, location, and
staffing. Most programs do not include a vision statement.
However, if a vision statement
were added to Figure 6.1, it would be found in a larger
rectangle to the left of the mission
statement rectangle.
Program Goals
Although some individuals use the terms goals and objectives
interchangeably, they are not
the same: There are important differences between them. Goals
are broad statements that
describe the expected outcomes of the program. They are less
specific than objectives and

are used to explain the general intent of a program to those not
directly involved in the pro-
gram (Cottrell & McKenzie, 2011; Neiger & Thackeray, 1998).
“Goals set the fundamental,
long-range direction” (NCCDPHP, n.d., p. 1). “Objectives break
the goal down into smaller
parts that provide specific, measurable actions by which the
goal can be accomplished”
(NCCDPHP, n.d., p. 1). In comparison to objectives, goals are
expectations that: provide
overall direction for the program, are more general in nature, do
not have a specific deadline,
usually take longer to complete, and are often not measured in
exact terms.
Program goals are not difficult to write and need not be written
as complete sentences.
They should, however, be simple and concise, and should
include two basic components:
who will be affected, and what will change as a result of the
program. Goals typically include
verbs such as evaluate, know, improve, increase, promote,
protect, minimize, prevent, reduce, and
understand (Jacobsen, Eggen, & Kauchak, 1989). A program
need not have a set number of

stated goals. It is not uncommon for some programs to have a
single goal while others have
several. Box 6.2 presents some examples of goals for health
promotion programs.
Table 6.1 Examples of Mission Statements
Setting Mission Statement
Community Setting The mission of the Walkup Health
Promotion Program is to provide
a wide variety of primary prevention activities for residents of
the
community.
Heath Care Setting This program is aimed at helping patients
and their families
to understand and cope with physical and emotional changes
associated with recovery following cancer surgery.
School Setting School District #77 wants happy and healthy
students. To that end,
the district’s personnel strive, through a Whole School, Whole
Community, Whole Child model program, to provide students
with experiences that are designed to motivate and enable them

to improve or maintain their health.
Worksite Setting The purpose of the employee health promotion
program is
to develop high employee morale. This is to be accomplished
by providing employees with a working environment that is
conducive to good health and by providing an opportunity for
employees and their families to engage in behavior that will
improve and maintain good health.
Objectives
Objectives are precise statements of intended outcome (Gilbert,
Sawyer, & McNeill, 2015).
Objectives represent smaller steps than program goals—steps
that, if completed, will lead
to reaching the program goal(s) (Ross & Mico, 1980). Stated
another way, objectives specify
intermediate accomplishments or benchmarks that represent
progress toward a goal (CDC,
2003). Objectives outline in measurable terms the specific

changes that will occur in the pri-
ority population at a given point in time as a result of exposure
to the program. “Objectives
are crucial. They form a fulcrum, converting diagnostic data
into program direction and
resource allocation over time” (Green & Kreuter, 2005, p. 100).
Objectives can be thought of
as the bridge between needs assessment and a planned
intervention. Knowing how to con-
struct objectives for a program is a most important skill for
planners.
Different levels of objectives
Several different levels of objectives are associated with
program planning. The different
levels are sequenced or placed in a hierarchical order to allow
for more effective plan-
ning (Cleary & Neiger, 1998; Deeds, 1992; Parkinson &
Associates, 1982). Objectives are
created at each level in order to help attain the program goal.
The “objectives should
also be coherent across levels, with objectives becoming
successively more refined and
more explicit, and usually multiplied from one level to the next”

(Green & Kreuter, 2005,
p. 102). Achievement of the lower-level objectives will
contribute to the achievement of
the higher-level objectives and goals. table 6.2 presents the
hierarchy of objectives and
indicates their relationship to program outcomes and evaluation.
Because the hierarchy
of objectives was created from the work of several , the labels
(names) given to the different
levels of objectives have not been consistent. Thus, as we
present the description of each
type of objective, we identify various labels that have been
used.
pRoCESS oBjECtiVES
The process objectives are the daily tasks, activities, and work
plans that lead to the ac-
complishment of all other levels of objectives (Deeds, 1992).
They help shape or form the
program and thus focus on all program inputs/resources (all that
are needed to carry out a
program), implementation activities (actual presentation of the
program), and stakeholder
reactions. More specifically, these objectives focus on such

things as program resources
6.2
Box Examples of program Goals
⦁ ⦁ Reduce the incidence of cardiovascular disease in the
employees of the Smith Company.
⦁ ⦁ Eliminate all cases of measles in the City of Kenzington.
⦁ ⦁ Prevent the spread of HIV in the youth of Indiana.
⦁ ⦁ Reduce the cases of lung cancer caused by exposure to
secondhand smoke in
Elizabethtown, PA.
⦁ ⦁ Reduce the incidence of influenza in the residents of the
Delaware County Home.
⦁ ⦁ Increase the survival rate of breast cancer patients through
the optimal use of
community resources.
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(materials, funds, space); appropriateness of intervention
activities; priority population
exposure, attendance, participation, and feedback; feedback
from other stakeholders such
as the funding and sponsoring agencies; and data collection
techniques, to name a few.
They also form the groundwork for process evaluation (see the
last column in Table 6.2).
impaCt oBjECtiVES
The second level of objectives in the hierarchy is impact
objectives. This level of objectives
comprises three different types of objectives: learning

objectives, behavioral objectives, and
environmental objectives. They are called impact objectives
because they describe the imme-
diate observable effects of a program (e.g., changes in
awareness, knowledge, attitudes, skills,
behaviors, or the environment) and they form the groundwork
for impact evaluation (see
the last column in Table 6.2).
Learning Objectives. Learning objectives are the educational or
learning tools needed
in order to achieve the desired behavior change. They are based
upon the analysis of educa-
tional and ecological assessment of the PRECEDE-PROCEED
model.
Within this category of objectives, there is another hierarchy
(Parkinson & Associates,
1982). This hierarchy includes four types of objectives,
beginning with the least complex
and moving toward the most complex. Complexity is defined in
terms of the time, effort,
and resources necessary to accomplish the objective. The
learning objectives hierarchy be-
gins with awareness objectives and moves through knowledge,

attitude, and skill
development objectives. This hierarchy indicates that if those in
Table 6.2 Hierarchy of Objectives and Their Relation to
Evaluation
Source: Adapted from Deeds (1992), Cleary & Neiger (1998),
and Parkinson & Associates (1982).
Type of Objective Program Outcomes Possible Evaluation
Measures Type of Evaluation
Process objectives Activities presented
and tasks completed
Number of sessions held,
exposure, attendance,
participation, staff performance,
appropriate materials, adequacy
of resources, tasks on schedule
Process (form
of formative)

Impact objectives
Learning
objectives
Change in awareness,
knowledge, attitudes,
or skills
Increase in awareness,
knowledge, attitudes, or skill
development/ acquisition
Impact (form
of summative)
Behavioral
objectives
Change in behavior Current behavior modified or
discontinued, or new behavior
adopted
Impact (form
of summative)

Environmental
objectives
Change in the
environment
Measures associated with
economic, service, physical,
social psychological, or political
environments, e.g., protection
added to, or hazards or barriers
removed from, the environment
Impact (form
of summative)
Outcome objectives Change in quality of life
(QOL), health status, or
risk, and social benefits
QOL measures, morbidity data,
mortality data, measures of risk
(e.g., HRA)
outcome (form

of summative)
are going to adopt and maintain a health-enhancing behavior to
alleviate a health concern
or problem, they must first be aware of the health concern.
Second, they must expand their
knowledge and understanding of the concern. Third, they must
attain and maintain an
attitude that enables them to deal with the concern. And fourth,
they need to possess the
necessary skills to engage in the health-enhancing behavior.
Behavioral Objectives. Behavioral objectives describe the
behaviors or actions in which
the priority population will engage that will resolve the health
problem and move you to-
ward achieving the program goal (Deeds, 1992). Behavioral
objectives are commonly written
about adherence (e.g., regular exercise), compliance (e.g.,
taking medication as prescribed),
consumption patterns (e.g., diet), coping (e.g., stress-reduction

activities), preventive actions
(e.g., brushing and flossing teeth), self-care (e.g., first aid), and
utilization (e.g., appropriate
use of the emergency room).
Environmental Objectives. Environmental objectives outline the
nonbehavioral causes of
a health problem that are present in the social, physical,
psychological, economic, service, and/
or political environments. Environmental objectives are written
about such things as the state
of the physical environment (e.g., clean air or water, proximity
to facilities, removal of physical
barriers), the social environment (e.g., social support, peer
pressure), the psychological environ-
ment (e.g., the emotional learning climate), the economic
environment (e.g., affordability,
incentives, disincentives), the service environment (e.g., access
to health care, equity in health
care), and/or the political environment (e.g., health policy).
outComE oBjECtiVES
Outcome objectives are the ultimate objectives of a program and
are aimed at changes in health

status, social benefits, risk factors, or quality of life. “They are
outcome or future oriented” (Deeds,
1992, p. 36). If these objectives are achieved, then the program
goal will be achieved. These objec-
tives are commonly written in terms of health status such as the
reduction of risk, physiologic
indicators, signs and symptoms, morbidity, disability, mortality,
or quality of life measures.
Consideration of the time needed to Reach the outcome of an
objective
In addition to objectives being written at different levels within
the hierarchy, they can also
be written with consideration to the amount of time needed to
reach the objective. Thus,
the terms short-term objective, intermediate objective, and long-
term objective have been used.
Short-term objectives include a time frame in which an outcome
is “expected immediately
and can occur soon after the program or intervention is
implemented, very often within a
year” (NCCDPHP, n.d., p. 2). “Intermediate objectives result
from and follow short-term
outcomes” (NCCDPHP, n.d., p. 2), while “long-term objectives

state the ultimate expected
impact of the program or intervention” (NCCDPHP, n.d., p. 2).
As an example, a short-term
objective may be a process objective that focuses on capacity
building indicating the num-
ber of health care providers would be increased. A
corresponding intermediate objective
may be written as an impact objective focusing on the number
of people screened because
of the increase in providers. And, the long-term objective, an
outcome objective, could fo-
cus on risk reduction based on individuals being treated for a
problem that was identified
via the screening.
Developing objectives
Does every program require objectives from each of the levels
just described? The answer is
no! However, too often, health promotion programs have too
few objectives, all of which

fall into one or two levels. Many planners have developed
programs hoping solely to change
the health behavior of a priority population. For example, a
smoking cessation program may
have an objective of getting 30% of the participants to stop
smoking. Perhaps this program
is offered, and only 10% of the participants quit smoking. Is the
program a failure? If the
program has a single objective of changing behavior, its
sponsors would have a good case
for saying that the program was not effective. However, it is
quite possible that as a result of
participating in the smoking cessation program, the participants
increased their awareness of
the dangers of smoking. They probably also increased their
knowledge, maybe changed their
attitudes, and developed skills for quitting or cutting back on
the number of cigarettes they
smoke each day. These are all very positive outcomes—and they
could be overlooked when
the program is evaluated, if the planner did not write objectives
that cover a variety of levels.
Questions to be answered When Developing objectives

In addition to making sure that the objectives are written in an
appropriate manner, plan-
ners also need to be consistent with other planning parameters.
In this section we present six
questions that planners should consider when writing
objectives:
1. Can the objective be realized during the life of the program
or within a reasonable time
thereafter? It would be quite realistic to assume that a certain
number of people will
not be smoking one year after they have completed a smoking
cessation program, but
it would not be realistic to assume that a group of elementary
school students could be
followed for life to determine how many of them die
prematurely due to inactivity.
2. Can the objective realistically be achieved? It is probably
realistic to assume that 30%
of any smoking cessation class will stop smoking within one
year after the program has
ended, but it is not realistic to assume that 100% of the
employees of a company will
participate in its fitness program.

3. Does the program have enough resources (personnel, money,
and space) to obtain a
specific objective? It would be ideal to be able to reach all
individuals in the priority
population, but generally there are not sufficient resources to do
so.
4. Are the objectives consistent with the policies and procedures
of the sponsoring agency? It
may not be realistic to expect to incorporate a no-smoking
policy in a tobacco company.
5. Do the objectives violate any of the rights of those who are
involved (participants or
planners)? Right-to-know laws make it illegal to withhold
information that could cause
harm to a priority population.
6. If a program is planned for a particular ethnic/cultural
population, do the objectives
reflect the relationship between the cultural characteristics of
the priority group and the
changes sought? It would not be realistic to have an objective
that eliminates the use of

tobacco in a priority population that is comprised of Native
Americans because of the
ceremonial pipe use in the Native American culture.
Elements of an objective
For an objective to provide direction and be useful in the
evaluation process, it must be
written in such a way that it can be clearly understood, states
what is to be accomplished,
and is measurable. To ensure that an objective is indeed useful,
it should include the
following elements:
1. The outcome to be achieved, or what will change
2. The conditions under which the outcome will be observed, or
when the change will occur
3. The criterion for deciding whether the outcome has been

achieved, or how much change
4. The priority population, or who will change
The first element, the outcome, is defined as the action,
behavior, or something
else that will change as a result of the program. In an objective
written as a sentence,
the outcome is usually identified as the verb of the sentence.
Thus words such as apply,
argue, build, compare, demonstrate, evaluate, exhibit, judge,
perform, reduce, spend, state,
and test would be considered outcomes (see Box 6.3 for a more
comprehensive listing of
6.3
Box outcome Verbs for objectives
abstract copy gather offer round
accept count (information) order score
adjust create generalize organize seek
adopt criticize generate pair select
advocate deduce group participate separate
analyze defend guess partition share

annotate define hypothesize perform show
apply delay (response) identify persist simplicity
approximate demonstrate illustrate plan simulate
argue derive imitate practice solve
(a position) describe improve praise sort
ask design infer predict spend
associate determine initiate prepare (money)
attempt develop inquire preserve state
balance differentiate integrate produce structure
build discover interpolate propose submit
calculate discriminate interpret prove subscribe
categorize dispute invent qualify substitute
cause distinguish investigate query suggest
challenge effect join question summarize
change eliminate judge recall supply
choose enumerate justify recite support
clarify estimate keep recognize symbolize
classify evaluate label recommend synthesize
collect examine list record tabulate
combine exemplify locate reduce tally
compare exhibit manipulate regulate test
complete experiment map reject theorize
compute explain match relate translate
conceptualize express measure reorganize try
connect extend name repeat unite

construct extract obey replace visit
consult extrapolate object represent volunteer
contrast find (to an idea) reproduce weigh
convert form observe restructure write
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appropriate outcome words). It should be noted that not all
verbs would be considered
appropriate outcomes for an objective; the verb must refer to
something measurable and
observable. Words such as appreciate, know, internalize, and
understand by themselves do
not refer to something measurable and observable, and therefore
are not good choices

for outcomes. Some verbs work better than others for specific
types of objectives. For
example, the verb list is an appropriate verb for an awareness -
level objective, but not for a
knowledge-level objective. The verb explain would be much
better suited for a knowledge-
level objective.
The second element of an objective is the condition under which
the outcome will
be observed, or when it will be observed. “Typical” conditions
found in objectives might
be “upon completion of the exercise class,” “as a result of
participation,” “by the year
2020,” “after reading the pamphlets and brochures,” “orally in
class,” “when asked to
respond by the facilitator,” “by year two of the program,” “by
May 15th,” or “during the
class session.”
The third element of an objective is the criterion for
determining when the outcome
has been achieved, or how much change will occur. The purpose
of this element is to
provide a standard by which the planners/evaluators can

determine if an outcome has
been performed in an appropriate and/or successful manner.
Examples might include “to
no more than 105 per 1,000,” “by 10% over the baseline,” “300
pamphlets,” “33% of the
county residents,” “75% of the motor vehicle occupants,” “at
least half of the participants,”
“according to CDC guidelines,” or “all people who
preregistered.” One of the most dif-
ficult parts of creating appropriate objectives for a program is
to determine what would be
the appropriate criterion for an objective. Should program
planners expect a 10% increase
over baseline? Should they anticipate half of the employees to
participate? What should
be expected? There is no hard-and-fast rule for determining the
criterion, but remember
the criterion should be realistic and based on evidence whenever
possible. Several different
criterion-(target)-setting methods have been used in writing the
objectives for the Healthy
People initiative over the past three plus decades. Box 6.4
provides a brief description of the
target-setting methods used.

The last element that needs to be included in an objective is
mention of the priority popu-
lation, or who will change. Examples are “teachers of Smith
Elementary,” “employees of the
company,” “the people who participated in the program,” and
“those residing in the Muncie
and Provo areas.” Figure 6.2 summarizes the key elements of a
well-written objective. There
is one exception to the priority population always being the who
of an objective. That excep-
tion applies to process-level objectives. Because some of these
objectives guide the work of the
program planners and/or implementers. In those cases, the who
is the staff or group entrusted
with instituting the program instead of the priority population
(See Box 6.5 for examples of objectives that would include the
four primary elements.)
Objectives that include the elements described in this section
are referred to as SMART.
SMART stands for specific, measurable, achievable, realistic,
and time-phased (CDC, 2003).
Every objective planners write for their programs should be
SMART! (See Box 6.6 for a SMART

Objectives Checklist.)
In summary, well-written objectives will always answer the
question “WHO is going to
do WHAT, WHEN, and TO WHAT EXTENT?” (NCCDPHP,
n.d., p. 2). Although it is easy to
describe the components of well-written objectives, it is not
always easy to write them. Box 6.7
provides a template to help program planners write objectives.
6.4
Box
⦁ ⦁ Better than best—When no baseline
data were available, target was set
based on a comparison to racial/
ethnic group with best, or most
favorable rate.
⦁ ⦁ Consistent with another program—

Target was set based on the results
of an already completed program.
⦁ ⦁ Consistent with national strategy—
Target was set based on the national
strategy to improve health.
⦁ ⦁ Consistent with regulations/policies/
laws—Target was set based on data
included in the regulations/policies/
laws.
⦁ ⦁ Evidence-based approach—Target
set based on results of completed
research.
⦁ ⦁ Expert opinion—If no other data were
available, the target was set based on
the opinion of experts.
⦁ ⦁ Minimal statistical significance—
Target was set using the smallest
improvement that results in a
statistically significant difference when
tested against the baseline value.

target Setting methods for the objectives of the Healthy People
initiative
⦁ ⦁ Modeling/projection of trend (or trend
analysis)—Target was set using a
model or based on trend data.
⦁ ⦁ No increase from baseline (maintain
baseline)—Target was set based on
the belief there would be no change
from baseline.
⦁ ⦁ One state per year—Target was set
based on getting one state (or the
District of Columbia) to meet a criterion
each year.
⦁ ⦁ Percent improvement—Target was
based on a reasonable expected percent
change in the priority population
compared to previous improvement.
⦁ ⦁ Retain previous set of objectives
target—Target was retained if the

previous target was not reached and
was still appropriate.
⦁ ⦁ Threshold analysis—Target was set
after analyzing at what point change
would begin to produce an effect.
⦁ ⦁ Total coverage or elimination—Target
was set based on the belief that a
criterion of 100% could be achieved.
Sources: Gurley (2007, April), USDHHS (2007), USDHHS
(2015c).
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Goals and Objectives for the Nation
A chapter on goals and objectives would not be complete

without at least a short discussion
of the health goals and objectives of the nation. These goals and
objectives have been most
helpful to planners throughout the United States.
The goals and objectives of the nation, which have been
referred to as the health agenda
or the blueprint of public health planning for the United States,
are the primary component
of the U.S. Healthy People initiative. The Healthy People
initiative was launched in 1978 and
a year later released the publication of Healthy People: The
Surgeon General’s Report on Health
Outcome
(what)
+
Priority
population
(who)
+ Conditions
(when)

+ Criterion
(how much)
= A well-written
objective
⦁ ▲ Figure 6.2 elements of a Well-Written Objective
6.5
Box Examples of objectives to Support the program Goal “to
Reduce
the prevalence of Heart Disease in the Residents of Franklin
County”
process objectives
a. By 2020, the program planners will increase the number of
heart healthy educational
sessions offered to the county residents from the baseline of 15
to 25 per year.

Outcome (what): Increase the number of heart healthy
educational sessions
Priority Population (who): Program planners
Conditions (when): By 2020
Criterion (how much): From the baseline of 15 to 25 per year
B. By August 4, the volunteers will distribute the informational
brochure to 33% of
the county residents.
Outcome (what): Will distribute the informational brochure
Priority Population (who): Volunteers
Conditions (when): By August 4
Criterion (how much): 33% of the county residents
C. During the pilot testing, the program facilitators will receive
a “good” rating from
at least half of the participants.

Outcome (what): Will receive a “good” rating
Priority Population (who): Program facilitators
Conditions (when): During the pilot testing
Criterion (how much): At least half of the participants
D. Prior to the start of the program, the program staff will
deliver the program notebooks
to all people who preregistered for the program.
Outcome (what): Will deliver the program notebooks
Priority Population (who): Program staff
Conditions (when): Prior to the start of the program
Criterion (how much): All people who preregistered
impact – learning objectives
a. Awareness level: After the American Heart Association’s
pamphlet on cardiovascular

health risk factors has been placed in grocery bags, at least 20%
of the shoppers will
be able to identify two of their own risks.
Outcome (what): Identify their own risks
Priority population (who): Shoppers
Conditions (when): After distribution of the pamphlet
Criterion (how much): 20%
B. Knowledge level: When asked over the telephone, one out of
three viewers of
the heart special television show will be able to explain the four
principles of
cardiovascular conditioning.
Outcome (what): Able to explain the four principles of
cardiovascular conditioning
Priority population (who): Television viewers
Conditions (when): When asked over the telephone

Criterion (how much): One out of three
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6.5
Box
continued
C. Attitude level: During one of the class sessions, 50% of the
participants will defend
their reason for regular exercise.
Outcome (what): Defend their reason for regular exercise

Priority population (who): Class participants
Conditions (when): During one of the class sessions
D. Skill development level: After viewing the video “How to
Exercise,” half of those
participating will be able to locate their pulse and count it every
time they are asked
to do it.
Outcome (what): Locate their pulse and count it
Priority population (who): Those participating
Conditions (when): After viewing the video
Criterion (how much): Half of those participating
impact—Behavioral objectives
a. One year after the formal exercise classes have been
completed, 40% of those
who completed a majority of the classes will still be involved in

a regular aerobic
exercise program.
Outcome (what): Will still be involved
Priority population (who): Those who completed a majority of
the classes
Conditions (when): One year after the classes
B. During the telephone interview follow-up, 50% of the
residents will report having
had their blood pressure taken during the previous six months.
Outcome (what): Will report having their blood pressure taken
Priority population (who): Residents
Conditions (when): During the telephone interview follow -up
impact—Environmental objectives

a. By the year 2020, 10% of the clinic patients will have been
able to schedule an
appointment either after 5 p.m. or on a Saturday.
Outcome (what): Will have been able to schedule
Priority Population (who): Clinic patients
Conditions (when): By the year 2020
B. By the end of the year, all senior citizens who want it will be
provided transportation
to the congregate meals.
Outcome (what): Provided transportation
Priority population (who): Senior citizens
Conditions (when): By end of year
Criterion (how much): All who want it

6.5
Box
continued
outcome objectives
a. By the year 2020, heart disease deaths will be reduced to no
more than 100 per 100,000
in the residents of Franklin County.
Outcome (what): Reduce heart disease deaths
Priority population (who): Residents of Franklin County
Conditions (when): By the year 2020
Criterion (how much): To no more than 100 per 100,000
B. By 2020, increase to at least 25% the proportion of men in
Franklin County with

hypertension whose blood pressure is under control.
Outcome (what): Blood pressure under control
Priority population (who): Men in Franklin County with
hypertension
Conditions (when): By 2020
Criterion (how much): At least 25%
C. Half of all those in the county who complete a regular,
aerobic, 12-month exercise
program will reduce their “risk age” on their follow -up health
risk assessment by
a minimum of two years compared to their preprogram results.
Outcome (what): Will reduce their “risk age”
Priority population (who): Those who complete an exercise
program
Conditions (when): After the 12-month exercise program
Criterion (how much): Half

D. Two-thirds of those who participate in a formal exercise
program will use 10% fewer
sick days during the life of the program than those who do not
participate.
Outcome (what): Use 10% fewer sick days
Priority population (who): Those who participate
Conditions (when): During the life of the program
Criterion (how much): Two-thirds
6.6
Box
Criteria to assess objectives
yes no
1. Is the objective SMART?
⦁ ⦁ Specific: Who? (priority population

and persons doing the activity)
and What? (action/activity)
⦁ ⦁ measurable: How much change
is expected
⦁ ⦁ achievable: Can be realistically
accomplished given current
resources and constraints
SmaRt objective Checklist
⦁ ⦁ Realistic: Addresses the
scope of the health problem
and proposes reasonable
programmatic steps
⦁ ⦁ time-phased: Provides a timeline
indicating when the objective will
be met
2. Does it relate to a single result?
3. Is it clearly written?

Source: CDC (2009b).
A
pp
lic
at
io
n
6.7
Box template for Writing objectives for Health promotion
programs
(Insert one when from list A here), (insert one how much from
list B here)
of the (insert one who from list C here), will (insert one what
from list D here).

Column a—When? Column B—How much?
⦁ ⦁ By December 2020 ⦁ ⦁ 10% improvement
⦁ ⦁ After the program ⦁ ⦁ half
⦁ ⦁ By year two of the program ⦁ ⦁ a majority
⦁ ⦁ One year after the classes ⦁ ⦁ at least 25
Column C —Who? Column D—What?
⦁ ⦁ participants ⦁ ⦁ be able to demonstrate how to prepare a
low-fat meal
⦁ ⦁ employees
⦁ ⦁ adolescents
⦁ ⦁ university students
⦁ ⦁ be able to explain the difference between exercise
and physical activity
⦁ ⦁ have stopped smoking
⦁ ⦁ list the risk factors for skin cancer

A
pp
lic
at
io
n
Promotion and Disease Prevention (USDHEW, 1979). Shortly
thereafter, the first set of goals
and objectives, Promoting Health/Preventing Disease:
Objectives for the Nation (USDHHS, 1980)
were published. The goals and objectives were written to cover
the 10-year period from 1980
to 1990 and were divided into three main areas—preventive
services, health protection, and
health promotion—and included a total of 226 objectives. Since
the creation of the first
set of goals and objectives, three additional sets have been
developed and published under
the titles of Healthy People 2000: National Health Promotion
and Disease Prevention Objectives
(USDHHS, 1990), Healthy People 2010 (USDHHS, 2000), and

Healthy People 2020 (USDHHS,
2015c). Formal reviews (i.e., measured progress) of these
objectives are conducted both at
midcourse half way through the 10-year period (i.e., “The
Midcourse Review”) and again
at the end of 10 years. The midcourse review provides an
opportunity to measure progress
towards the 10-year targets and determine whether there are
trends that need to be reversed.
For example, in Healthy People 2010, a number of objectives
were changed, updated, or
deleted because of the events 9/11 and Hurricanes Katrina and
Rita. Both the results of the
midcourse and end reviews along with other available data are
used to help create the next
set of goals and objectives. Each set of goals and objectives has
become more detailed than
the previous. “The evolution from the first decade’s objectives
to each subsequent set of
objectives reflected changing societal concerns, evidence-based
technologies, theories, and
discourses of those decades. Such accommodations changed the
contours of the initiative
over time in attempts to make it more relevant to specific
partners and other stakeholders”

(Green & Fielding, 2011, p. 451). At the time this text was
being revised the “Healthy People
2020” midcourse review was just beginning.
Healthy People 2020, which was released at the end of 2010,
will guide U.S. public health
practice and health education specialists through 2020. Healthy
People 2020 includes a vision
statement, a mission statement, four overarching goals, and
almost 1,200 science-based
objectives (see Box 6.8) spread over 42 different topic areas
(see Box 6.9) (USDHHS, 2015c).
On the Healthy People.gov Website each topic has its own
Webpage. At a minimum each
page contains a concise goal statement, a brief overview of the
topic that provides the back-
ground and context for the topic, a statement about the
importance of the topic backed up
by appropriate evidence, and references.

The importance of the Healthy People initiative serving as a
blueprint for the nation’s
health agenda is evidenced by their widespread use. Since the
publication of the first
Healthy People goals and objectives in 1980, a number of other
documents have been cre-
ated that can help planners develop or adopt appropriate goals
and objectives for their
programs. A number of states and U.S. territories have taken the
national objectives and
created similar documents specific to their own residents. In
addition, a number of agen-
cies/organizations have taken similar steps to create documents
that could be used by their
members and clients in various planning efforts.
The national goals and objectives have been important
components in the process of
health promotion planning since 1980. It is highly recommended
that planners review these
objectives before developing goals and objectives for programs.
The national objectives may
also be helpful in providing a rationale for a program and in
focusing program goals and objec-
tives toward the areas of greatest need, as planners work toward

the year 2020.
6.8
Box Example Goal and objectives from Healthy People 2020
Educational and Community-Based programs (ECBp)
Goal: Increase the quality, availability, and effectiveness of
educational and community-
based programs designed to prevent disease and injury, improve
health, and enhance
quality of life.
objective: ECBp-10 Increase the number of community-based
organizations (including
local health departments, tribal health services,
nongovernmental organizations, and state
agencies) providing population-based primary prevention
services in the following areas
ECBp 10.8 nutrition
Target: 94.7%.

Baseline: 86.1% of community-based organizations (including
local health
departments, tribal health services, nongovernmental
organizations, and state
agencies) provided population-based primary prevention
services in nutrition in 2008
Target setting method: 10% improvement.
Data source: National Profile of Local Health Departments
(NPLHD), National
Association of County and City Health Officials (NACCHO)
ECBp 10.9 physical activity
Target: 88.5%.
Baseline: 80.5% of community-based organizations (including
local health
departments, tribal health services, nongovernmental
organizations, and state
agencies) provided population-based primary prevention
services in physical activity
in 2008.

Target setting method: 10% improvement.
Data source: National Profile of Local Health Departments
(NPLHD), National
Association of County and City Health Officials (NACCHO)
Source: USDHHS (2015c).
Fo
cu
s
O
n
6.9
Box
1. Access to Health Services

2. Adolescent Health
3. Arthritis, Osteoporosis, and Chronic
Back Conditions
4. Blood Disorders and Blood Safety
5. Cancer
6. Chronic Kidney Disease
7. Dementias, Including Alzheimer’s
Disease
8. Diabetes
9. Disability and Health
10. Early and Middle Childhood
11. Educational and Community-Based
Programs
12. Environmental Health

13. Family Planning
14. Food Safety
15. Genomics
16. Global Health
17. Health Communication and Health
Information Technology
18. Health-Related Quality of Life and
Well-Being
19. Healthcare-Associated Infections
20. Hearing and Other Sensory or
Communication Disorders
Healthy People 2020 topic areas
21. Heart Disease and Stroke
22. HIV

23. Immunization and Infectious
Diseases
24. Injury and Violence Prevention
25. Lesbian, Gay, Bisexual, and
Transgender Health
26. Maternal, Infant, and Child Health
27. Medical Product Safety
28. Mental Health and Mental Disorders
29. Nutrition and Weight Status
30. Occupational Safety and Health
31. Older Adults
32. Oral Health
33. Physical Activity

34. Preparedness
35. Public Health Infrastructure
36. Respiratory Diseases
37. Sexually Transmitted Diseases
38. Sleep Health
39. Social Determinants of Health
40. Substance Abuse
41. Tobacco Use
42. Vision
Source: USDHHS (2015c).
Fo
cu
s
O

n
Summary
The mission statement provides an overview of a program and is
most useful in the develop-
ment of goals and objectives. It should not be confused with a
vision statement. The terms
goals and objectives are sometimes used interchangeably, but
they are quite different. Together,
the two provide a foundation for program planning and
evaluation. Goals are more general in
nature and often are not measurable in exact terms, whereas
objectives are more specific and
consist of the steps used to reach the program goals. Objectives
can and should be written for
several different levels. For objectives to be useful, they should
be written so as to be observable
and measurable. At a minimum, an objective should include the
following elements: a stated
outcome (what), conditions under which the outcome will be
observed (when), a criterion
for considering that the outcome has been achieved (how much),
and mention of the prior-

ity population (who). If an objective is written with the above
stated elements it will conform
to the SMART format. As planners develop their goals and
objectives for their programs, they
should find the Healthy People 2020 document and other
information at its Website very useful.
Review Questions
1. What is a mission statement? Why is it important? How is it
different from a vision
statement?
2. What is (are) the difference(s) between a goal and an
objective?
3. What is the purpose of program goals and objectives?
4. What are the different levels of objectives?
5. What are the four different types of objectives found in

“learning objectives
hierarchy”?
6. What are the necessary elements of an objective?
7. What are the characteristics of a SMART objective?
8. Briefly explain the Healthy People initiative.
9. What are the goals and objectives for the nation? How can
they be used by program
planners?
10. How can planners use the Healthy People 2020 goals and
objectives in their program
planning efforts?
Activities
1. Write a mission statement, a goal, and eight supporting
objectives (one of each of the
different types) for a program you are planning.
2. Which of the following statements include all four elements
necessary for a complete

objective? Revise those objectives that do not include all the
elements.
a. After the class on objective writing, the students will know
the difference between
a goal and an objective.
b. The students will understand how a skinfold caliper works.
c. After completing this chapter, the students will be able to
write objectives for each of
the levels based on the four elements outlined in the chapter.
d. Given appropriate instruction, the employees will be able to
accurately take blood
pressure readings of fellow employees.
e. Program participants will be able to list the reasons why
people do not exercise.
3. Using data available from the County Health Rankings
(http://www
.countyhealthrankings.org) for the county in which you
currently reside, write
a goal aimed at improving a health behavior and write one
process, three impact

(i.e., one each for knowledge, behavior, and environment), and
one outcome objective
to help reach the goal.
4. Using data available from the Kaiser State Health Facts
Website (http://kff.org
/statedata) for the state in which you currently reside, write a
goal aimed at improving
a health status topic and write one process, three impact (i.e.,
one each for awareness,
skill, and environment), and one outcome objective to help
reach the goal.
http://kff.org/statedata
http://kff.org/statedata
5. Assume that you are a health education specialist working in
a primary care clinic.
Based on some data provided by personnel at the local hospital
regarding birth

outcomes for the clinic patients, your supervisor has asked that
you create a new
program to decrease the percentage of female patients of
childbearing age who smoke.
After completing a needs assessment you have found that the
highest rate of smokers
was among those patients who were 18–24 years of age, covered
by a health insurance
plan, and have more than one child. In addition, the average
number of cigarettes
smoked per day by the patients was 22. Write a mission
statement, a goal, and at least
six objectives to help reach the stated goal.
Weblinks
1.
http://www.cdc.gov/phcommunities/resourcekit/evaluate/index.h
tml
Communities of Practice (CoP) for Public Health: Evaluate a
CoP
On this page of the Centers for Disease Control and Prevention
Website, you will find
more information about SMART objectives and some related
resources that provide

templates for writing SMART objectives.
2. http://www.healthypeople.gov/2020/default
Healthy People 2020
This is the home page for Healthy People 2020. At this site you
can navigate to
background information about Healthy People 2020, a listing of
the 42 topic areas and
the objectives, and suggestions for implementing Healthy
People 2020.
3. http://ctb.ku.edu/en
Community Tool Box
On the home page of the Community Tool Box (CTB), you can
use the “Search” function
to locate information on creating mission statements, goals, and
SMART objectives.
http://www.cdc.gov/phcommunities/resourcekit/evaluate/index.h
tml
http://www.healthypeople.gov/2020/default

151
7
Chapter Theories and Models Commonly
Used for Health Promotion
Interventions
Chapter Objectives
⦁ ⦁ Define theory, model, constructs, concepts, and
variables.
⦁ ⦁ Explain why health promotion interventions
should be planned using theoretical frameworks.
⦁ ⦁ Describe how the concept of the ecological
perspective applies to using theories.
⦁ ⦁ Explain the difference between a continuum
theory and a stage theory.

⦁ ⦁ Briefly explain the theories and models
presented in this chapter.
Key Terms
action stage
attitude toward the
behavior
aversive stimulus
behavior change theories
behavioral capability
collective efficacy
community readiness
concepts
construct
contemplation stage
continuum theory
decisional balance
diffusion theory
direct reinforcement
early adopters
early majority
efficacy expectations
elaboration

emotional–coping
response
expectancies
expectations
innovators
intention
laggards
lapse
late majority
likelihood of taking
recommended
preventive health
action
locus of control
maintenance stage
model
negative punishment
negative reinforcement
outcome expectations
perceived barriers
perceived behavioral

control
perceived benefits
perceived seriousness/
severity
perceived susceptibility
perceived threat
planning models
positive punishment
positive reinforcement
precontemplation stage
preparation stage
processes of change
punishment
recidivism
reciprocal determinism
reinforcement
relapse
relapse prevention (RP)
self-control
self-efficacy
self-regulation
self-reinforcement
social capital

social context
social network
socio-ecological approach
(ecological perspective)
stage
stage theory
subjective norm
temptation
termination
theory
variable
vicarious reinforcement
Whenever there is a discussion about the theoretical bases for
health education and
health promotion, we often find the terms theory and model
used. We begin this chapter with
a brief explanation of these terms to establish a common
understanding of their meaning.

One of the most frequently quoted definitions of theory is one
in which Glanz, Lewis,
and Viswanath (2008b) modified an earlier definition written by
Kerlinger (1986). It states,
“A theory is a set of interrelated concepts, definitions, and
propositions that presents a
systematic view of events or situations by specifying relations
among variables in order to
explain and predict the events of the situations” (p. 26). In other
words, “a theory presents a
systematic way of understanding events, behaviors and/or
situations” (Glanz, n.d., p. 5). For
health education specialists, theory helps “to develop an
organized, systematic, and efficient
approach to investigating health behaviors. Once these
investigations produce satisfactory
results and are replicated the findings can be used to inform the
design of theory-based inter-
vention programs” (Crosby, Salazar, & DiClemente, 2013, p.
32).
Nutbeam and Harris (1999) have stated that a fully developed
theory would be character-
ized by three major elements: “It would explain:

⦁ ⦁ the major factors that influence the phenomena of interest,
for example those factors
which explain why some people are regularly active and others
are not;
⦁ ⦁ the relationship between these factors, for example the
relationship between knowledge,
beliefs, social norms and behaviours [sic] such as physical
activity; and
⦁ ⦁ the conditions under which these relationships do or do not
occur: the how, when, and
why of hypothesised [sic] relationships, for example, the time,
place and circumstances
which, predictably lead to a person being active or inactive” (p.
10).
In comparison, a model “is a composite, a mixture of ideas or
concepts taken from any
number of theories and used together” (Hayden, 2014, p. 2).
Stated a bit differently: “Models
draw on a number of theories to help understand a specific
problem in a particular setting
or content. They are not always as specific as theory” (Rimer &
Glanz, 2005, p. 4). Unlike

theories, models do “not attempt to explain the processes
underlying learning, but only to
represent them” (Chaplin & Krawiec, 1979, p. 68).
Though we just went to some effort to make a distinction
between the words theory and
model, when the terms theory-based, theory-driven, and theory-
informed are used (such as in
theory-based/driven/informed planning, theory-
based/driven/informed practice, or theory-based/
driven/informed research), it is commonly understood in our
profession that the word theory
is used in a general way to mean either theory or model. In fact,
some of the best-known and
often used theories in health education/health promotion use the
word model in their title
(e.g., Health Belief Model). Goodson (2010) provides an
explanation for the discrepancy in
the use of term model for things we refer to as “theory.” She
has indicated that when some of
these models were created they were properly titled as models.
They were created using theo-
retical constructs to explain specific phenomena. They had little
empirical testing to prove
their worth. Over time, these models have been tested and

refined and thus have gained
theory status. Goodson (2010) concludes by saying in our work
“because we tend to borrow
the theories we employ from other disciplines and fields and
because our concern usually
centers in applying these theories (or models) to practice or
research, it seems to matter little
to us whether we deal with theories or with models; it seems to
matter even less what labels
Chapter 7 Theories and Models Commonly Used for Health
Promotion Interventions 153
we attach to them” (p. 228). Thus, as we use the terms theory
and theory-based/driven/informed
throughout the remainder of this book, we use them to be
inclusive of endeavors based on
either a theory or a model.
Concepts are the primary elements or building blocks of a
theory (Glanz et al., 2008b).
When a concept has been developed, created, or adopted for use
with a specific theory, it is

referred to as a construct (Kerlinger, 1986). “The key concepts
of a theory are its constructs”
(Rimer & Glanz, 2005, p. 4). The operational (practical use)
form of a construct is known as a
variable. Variables “specify how a construct is to be measured
in a specific situation” (Glanz
et al., 2008b, p. 28). Thus, variables need to be matched “to
constructs when identifying
what needs to be assessed during evaluation of a theory-driven
program” (Rimer & Glanz,
2005, p. 4).
Consider how these terms are used in practical application. A
personal belief is a concept related
to various health behaviors. For example, people are more likely
to behave in a healthy way—
say exercise regularly—if they feel confident in their ability to
actually engage in a healthy form
of exercise. Such a concept is captured in a construct of the
Social Cognitive Theory (SCT) called
self-efficacy. (See the discussion of the SCT later in this
chapter.) If health education specialists
want to develop an intervention to assist people in exercising,
the ability to measure the
peoples’ self-efficacy toward exercise will help create the

intervention. The measurement may
consist of a few questions that ask people to rate their
confidence in their ability to exercise.
This measurement, or operational form, of the self-efficacy
construct is a variable. However,
because of the complexity of getting a non-exerciser to become
an exerciser, the health
education specialist may need to use a model, composed of
constructs from several theories, to
plan the intervention (Cottrell et al., 2015, p. 98).
Based on these descriptions, it seems logical to think of theories
as the backbone of the
processes used to plan, implement, and evaluate health
promotion interventions. They
can help by (1) identifying why people behave as they do and
why they are not behaving in
healthy ways, (2) identifying information needed before
developing an intervention, (3) pro-
viding a conceptual framework for selecting constructs to
develop the intervention, (4) pro-
viding direction and justification for program activities, (5)
providing insights into how best
to deliver the intervention, (6) identifying what needs to be
measured to evaluate the impact

of the intervention, and (7) helping to guide research
identifying the determinants of health
behavior (Cowdery et al., 1995; Crosby, Kegler, & DiClemente,
2009; Glanz et al., 2008b;
Simons-Morton, McLeroy, & Wendel, 2012). Theory also
“provides a useful reference point
to help keep research and implementation activities clearly
focused” (Crosby et al., 2009,
p. 11), and it infuses ethics and social justice into practice
(Goodson, 2010). In addition,
“[u]sing theory as a foundation for program planning and
development is consistent with
the current emphasis on using evidence-based interventions in
public health, behavioral
medicine, and medicine” (Rimer & Glanz, 2005, p. 5). Getting
people to engage in health
behavior change is a complicated process that is very difficult
under the best of conditions.
Without the direction that theories provide, planners can easily
waste valuable resources in
trying to achieve the desired behavior change. Therefore,
program planners should ground
their planning process in the theories that have been the
foundation of other successful
health promotion efforts.

There are many theories that health education specialists can
use to guide their practice
however, there is no best theory. “The ‘best theory’ is a
function of how well it serves the
objectives that must be met to achieve sustainable protective
behaviors among a specified
population. In essence, the range of behavioral and social
science theories available for both
health promotion practice and research affords the practitioner
and researcher an oppor-
tunity to select the theories that are the most appropriate,
feasible, and practical for a par-
ticular setting or population” (Crosby et al., 2009, p. 15). In
addition, “No single theory or
conceptual framework dominates research or practice in health
promotion and education
today” (Glanz et al., 2008b, p. 31). In a review of 10 leading
health, medicine, and psychology
journals, Painter, Borba, Hynes, Mays, and Glanz (2008) found

that “dozens of theories and
models” (Glanz, 2008b, p. 31) had been used in the reported
literature. We have no intention
of introducing all of them. However, approximately 10 theories
and models are used regu-
larly to plan programs. In the remaining sections of this chapter,
and parts of several other
chapters, we present an overview of the theories that are most
often used in creating health
promotion interventions. As you read about and study the
various theories, you will find
that some express the same general ideas, but employ “a unique
vocabulary to articulate the
specific factors considered to be important” (Glanz et al.,
2008b, p. 28). Also, be aware that the
presentation of theories that follows is by no means
comprehensive in nature. For those read-
ers who would like to examine these and other theories in more
depth, we would recommend
eight books: Health Behavior and Health Education: Theory,
Research and Practice (Glanz, Rimer,
& Viswanath, 2008a); Emerging Theories in Health Promotion
Practice and Research: Strategies
for Improving Public Health (DiClemente, Crosby, & Kegler,
2009); Theory in Health Promotion

Research and Practice (Goodson, 2010); Behavior Theory in
Health Promotion Practice and Research
(Simons-Morton et al., 2012); Theoretical Foundations of
Health Education and Health Promotion
(Sharma & Romas, 2012); Health Behavior Theory for Public
Health (DiClemente, Salazar,
& Crosby, 2013); Introduction to Health Behavior (Hayden,
2014); and Essentials of Health
Behavior: Social and Behavioral Theory in Public Health
(Edberg, 2015). Box 7.1 identifies the
responsibilities and competencies for health education
specialists that pertain to the material
presented in this chapter.
Types of Theories and Models
There are several ways of categorizing the theories and models
associated with health
education/promotion practice. One way of doing so is to divide
them into two groups.
The first group includes those theories and models used for
planning, implementing, and
evaluating health promotion programs. This group has been
called planning models.
The planning models were presented earlier (Chapter 3). The

second group is referred
to as behavior change theories. Behavior change theories help
explain how change
takes place.
Behavior Change Theories
As noted earlier, there are many behavior change theories that
could use to plan programs. Because of the peculiarities of the
theories and multitude of
factors that could impact a specific planning situation, some
theories work better in some
situations than others. Before we present the theories focusing
on behavior change, it is im-
portant to introduce the concept of the socio-ecological
approach.
The socio-ecological approach, which is grounded in the work
of development psychologist

Urie Bronfenbrenner (1979), gained traction in health promotion
in the 1980s with the move-
ment toward using a systems-approach for interventions. The
underlying concept of the socio-
ecological approach (sometimes referred to as the ecological
perspective) is that human
behavior shapes and is shaped by multiple levels of influences.
“Individuals influence and are
influenced by their families, social networks, the organizations
in which they participate (work-
places, schools, religious organizations), the communities of
which they are a part, and the
society in which they live” (IOM, 2001, p. 26). In other words,
the health behavior of individuals
is shaped in part by the social context in which they live. Social
context has been “defined as the
sociocultural forces that shape people’s day-to-day experiences
and that directly and indirectly
affect health and behavior (Burke, Joseph, Pasick, & Barker,
2009, p. 56S). Therefore, a central con-
clusion of the socio-ecological approach is that interventions
must be aimed at multiple levels of
influence in order to achieve substantial changes in health
behavior (Sallis, Owen, & Fisher, 2008).

McLeroy, Bibeau, Steckler, and Glanz (1988) identified five
levels of influence: (1) intra-
personal or individual factors, (2) interpersonal factors, (3)
institutional or organizational
factors, (4) community factors, and (5) public policy factors.
More recently, Simons-Morton
et al. (2012, p. 45) added two additional levels “(6) the physical
environment and (7) culture.”
Table 7.1 defines each of the seven levels, and Box 7.2 provides
an example of how the levels
can impact health behavior.
7.1
Responsibilities and Competencies for Health Education
Specialists
The content of this chapter focuses on theories and models used
in the practice of health
promotion. Specifically, theories and models provide a “road
map” for planners to use
when creating interventions and evaluating the effectiveness of
those interventions. The
responsibilities and competencies related to these tasks include:

RESponSiBiliTy i: Assess Needs, Resources, and Capacity for
Health Education/
Promotion
Competency 1.1: Plan assessment process for health education/
promotion
RESponSiBiliTy ii: Plan Health Education/Promotion
education/
promotion
RESponSiBiliTy iii: Implement Health Education/Promotion
Competency 3.3: Implement health education/promotion plan
RESponSiBiliTy iV: Conduct Evaluation and Research Related
to Health Education/
Promotion
Competency 4.1: Develop evaluation plan for health education/
promotion

RESponSiBiliTy Vii: Communicate, Promote, and Advocate for
Health and Health
Education/Promotion, and the Profession
Competency 7.1: Identify, develop, and deliver messages using
a
variety of communication strategies, methods, and techniques
Health Education
Box
Table 7.1 An Ecological Perspective: Levels of Influence

Sources: Rimer & Glanz (2005, p. 11); Simons-Morton et al.,
(2012, p. 45)
Concept Definition
Intrapersonal Level Individual characteristics that influence
behavior, such as
knowledge, attitudes, beliefs, and personality traits
Interpersonal Level Interpersonal processes and primary groups,
including family,
friends, and peers that provide social identity, support, and role
definition
Community Level
Institutional Factors Rules, regulations, policies, and informal
structures that may
constrain or promote recommended behaviors
Community Factors Social networks and norms, or standards,
that exist as formal or
informal among individuals, groups, and organizations
Public Policy Local, state, and federal policies and laws that

regulate or support
healthy actions and practices for disease prevention, early
detection,
control, and management
Physical Environment Natural and built environment
Culture Shared beliefs, values, behaviors and practices of a
population
7.2
Box Application of the Socio-Ecological Approach
A good example of the use of the socio-ecological approach
(ecological perspective) is
the comprehensive method used to reduce cigarette smoking in
the United States. At
the intrapersonal (or individual) level, a large majority of
smokers know that smoking is
bad for them and a slightly smaller majority have indicated they
would like to quit. Many
have tried—some have tried on many occasions. At the
interpersonal level, many smokers
are encouraged by their physician and/or family and friends to

quit. Some smokers may
attempt to quit on their own or join a formal smoking cessation
group to try to quit. At
the institutional (or organizational) level, a number of
institutions (e.g., churches and
worksites) have developed policies that prohibit smoking in
and/or on institution property
(i.e., buildings and grounds). At the community level, a number
of towns, cities, and
counties have passed ordinances that prohibit smoking in public
places. At the public
policy level, a number of states have passed clean indoor air
acts that limit smoking, and
have passed laws increasing the tax on a package of cigarettes.
Also at this level, the
U.S. government has spent many dollars for public service
announcements (PSAs) and
other forms of media advertising the dangers of tobacco use. At
the physical environment
level new structures have been built to eliminate exposure to
secondhand smoke with
appropriate filtration systems and separate structures have been
built to physically
separate the smokers from the non-smokers. At the culture level
a focus has been placed

on establishing and reinforcing non-smoking as the cultural
norm. Attacking the smoking
problem from all levels has contributed to the decrease in the
percentage of smokers in
the United States.
A
pp
lic
at
io
n
Because of the underlying concepts that are captured in the
constructs of individ-
ual theories, certain theories are more useful in developing
programs aimed at spe-
cific levels of influence. For example, some theories were
developed to help explain
behavior change in individuals, while others were developed to
help explain change

at the community level. To assist program planners with
matching theories appropriate to
level of influence, we present our discussion of the theories
using the simplified version of the
socio-ecological model that condensed the multiple levels into
three—intrapersonal, interper-
sonal, and community (Glanz & Rimer, 1995; Rimer & Glanz,
2005). “In practice, addressing
the community level requires taking into consideration
institutional and public policy factors,
as well as social networks and norms” (Rimer & Glanz, 2005, p.
11). To this community level
we add the sixth and seventh levels of influence –– physical
environment and culture.
In addition to theories being placed into a level of influence at
which they may be most use-
ful, theories can also be categorized by the approach—
continuum or stage theories—they use
to explain behavior. Continuum theories are those behavior
change theories that identify

variables that influence actions (e.g., beliefs, attitudes) and
combine them into a single equa-
tion that predicts the likelihood of action (Weinstein, Rothman,
& Sutton, 1998; Weinstein,
Sandman, & Blalock, 2008). “These theories acknowledge
quantitative differences among
people in their positions on different variables” (Weinstein et
al., 2008, p. 124) and “thus, each
person is placed along a continuum of action likelihood”
(Weinstein et al., 1998, p. 291).
A stage theory is one that is comprised of an ordered set of
categories into which people can
be classified, and which identifies factors that could induce
movement from one category to the
next (Weinstein & Sandman, 2002a). More specifically, stage
theories have four principal ele-
ments: (1) a category system to define the stages, (2) an
ordering of stages, (3) common barriers
to change facing people in the same stage, and (4) different
barriers to change facing people in
different stages (Weinstein et al., 1998; Weinstein & Sandman,
2002a). Advocates of stage theories
“claim that there are qualitative differences among people and
question whether changes in health

behaviors can be described by a single prediction equation”
(Weinstein et al., 2008, pp. 124–125).
Table 7.2 lists the theories presented in this book by level of
influence and theory approach.
intrapersonal level Theories
The theories presented in this section of the chapter focus
primarily on individual health
behavior. The intrapersonal or “individual level is the most
basic one in health promotion
practice, so planners must be able to explain and influence the
behavior of individuals”
(Rimer & Glanz, 2005, p. 12). Intrapersonal theories focus on
factors within the individual
such as knowledge, attitudes, beliefs, self-concept, feelings,
past experiences, motivation,
skills, and behavior. Many health education specialists will use
the theories we discuss in this
section to assist individuals with behavior change, But be aware
that some of these theories
do not take into account social context and thus they may need
to be combined with theo-
ries found in other levels of influence to reach their program
goals.

STimuluS RESponSE (SR) THEoRy
One of the theories used to explain and modify behavior is the
stimulus response, or SR,
theory (Thorndike, 1898; Watson, 1925; Hall, 1943). This
theory reflects the combination
of classical conditioning (Pavlov, 1927) and instrumental
conditioning (Thorndike, 1898)
theories. These early conditioning theories explain learning
based on the associations
among stimulus, response, and reinforcement (Parcel &
Baranowski, 1981; Parcel, 1983). “In
simplest terms, the SR theorists believe that learning results
from events (termed ‘reinforce-
ments’) which reduce physiological drives that activate
behavior” (Rosenstock, Strecher, &
Becker, 1988, p. 175). The behaviorist B. F. Skinner believed
that the frequency of a behavior
was determined by the reinforcements that followed that
behavior.

In Skinner’s view, the mere temporal association between a
behavior and an immediately
following reward is sufficient to increase the probability that
the behavior will be repeated.
Such behaviors are called operants; they operate on the
environment to bring about changes
resulting in reward or reinforcement (Rosenstock et al., 1988).
Stated another way, operant
behaviors are behaviors that act on the environment to produce
consequences. These conse-
quences, in turn, either reinforce or do not reinforce the
behavior that preceded.
There are two broad categories of environmental consequences:
reinforcement or punish-
ment (McDade-Montez, Cvengros, & Christensen, 2005):
Individuals can learn from both.
Reinforcement has been defined by Skinner (1953) as any event
that follows a behavior,
which in turn increases the probability that the same behavior
will be repeated in the future.
Stated differently, reinforcement has “a strengthening effect
that occurs when operant be-
haviors have certain consequences” (Nye, 1992, p. 16).

Behavior has a greater probability of
occurring in the future: (1) if reinforcement is frequent and (2)
if reinforcement is provided
soon after the desired behavior. This immediacy clarifies the
relationship between the rein-
forcement and appropriate behavior (Skinner, 1953). Simons-
Morton and colleagues (2012)
Table 7.2 Theories by Level of Influence and Category
Level of Influence Where Found in This Book
• Intrapersonal Level
Continuum Theories
Stimulus Response Theory Chapter 7
Theory of Planned Behavior Chapter 7
Health Belief Model Chapter 7
Protection Motivation Theory Chapter 7
Elaboration Likelihood Model of Persuasion Chapter 7
Information-Motivation-Behavioral Skills Model Chapter 7
Stage Theory
Transtheoretical Model Chapter 7
Precaution Adoption Process Model Chapter 7
• Interpersonal Level
Continuum Theories

Social Cognitive Theory Chapter 7
Social Network Theory Chapter 7
Social Capital Theory Chapter 7
• Community Level
Continuum Theories
Communication Theory Chapters 8 & 11
Community organizing Chapter 9
Community Building Chapter 9
Diffusion of Innovations Chapter 7
Stage Theory
Community Readiness Model Chapter 7
have stated that when a behavior is sufficiently reinforced it
tends to recur. If a behavior
is complex in nature, smaller steps working toward the desired
behavior with appropriate
reinforcement will help to shape the desired behavior. This was
found to be true in getting pi-
geons to play Ping-Pong, and it can be useful in trying to
change a complex health behavior

like smoking or exercise. Whereas reinforcement will increase
the frequency of a behavior,
punishment will decrease the frequency of a behavior. However,
both reinforcement and
punishment can be either positive or negative. The terms
positive and negative in this context
do not mean good and bad; rather, positive means adding
something (effects of the stimulus)
to a situation, whereas negative means taking something away
(removal or reduction of the
effects of the stimulus) from the situation.
If individuals act in a certain way to produce a consequence that
makes them feel good or
that is enjoyable, it is labeled positive reinforcement (or
reward). Examples of this would
be an individual who is involved in an exercise program and
“feels good” at the end of the
workout, or one who participates in a weight loss program and
receives verbal encourage-
ment from the facilitator, again making that person “feel good.”
Stimulus response theorists
would note that in both of these situations, the pleasant
experiences (internal feelings and
verbal encouragement, respectively) should occur right after the

behavior, which in turn
increases the chances that the frequency of the behavior will
increase.
While positive reinforcement helps individuals learn by shaping
behavior, behavior
that avoids punishment is also learned because it reduces the
tension that precedes the
punishment (Rosenstock et al., 1988). “When this happens, we
are being conditioned by
negative reinforcement: A response is strengthened by the
removal of something from the situ-
ation. In such cases, the ‘something’ that is removed is referred
to as a negative reinforcer or
aversive stimulus (these two phrases are synonymous)” (Nye,
1979, p. 33). A good example
of negative reinforcement is a weight loss program that
requires weekly dues. When
participants stop paying dues because they have met their goal
weight, this removal of an
obligation should increase the frequency of the desired
behavior (weight maintenance). Or
in the case of exercise, “negative reinforcements would include
decreased poor self-image
and decreased fatigue” (McDade-Montez et al., 2005, p. 64).

Some people think of negative reinforcement as a form of
punishment, but it is not.
While negative reinforcement increases the likelihood that a
behavior will be repeated,
punishment typically suppresses behavior. Skinner suggested
“two ways in which a response
can be punished: by removing a positive reinforcer or by
presenting a negative reinforcer (aversive
stimulus) as a consequence of the response” (Nye, 1979, p. 43).
Punishment is usually linked
to some uncomfortable (physical, mental, or otherwise)
experience and decreases the fre-
quency of a behavior. An aversive smoking cessation program
that circulates cigarette smoke
around those enrolled in the program as they smoke is an
example of positive punishment. It
decreases the frequency of smoking by presenting (adding) a
negative reinforcer or aversive
stimulus (smoke) as a consequence of the response. Examples of
negative punishment
(removing a positive reinforcer) would include not allowing
employees to use the employees’
lounge if they continue to smoke while using it, or reducing the
health insurance benefits

of employees who continue to participate in health-harming
behavior such as not wearing
a safety belt. Stimulus response theorists would note that taking
away the privilege of using
the employees’ lounge or reducing health insurance benefits
would decrease the frequency
of smoking among the employees and increase the wearing of
safety belts, respectively.
Figure 7.1 illustrates the relationship between reinforcement
and punishment.
Finally, if reinforcement is withheld—or, stating it another way,
if the behavior is
ignored—the behavior will become less frequent and eventually
will not be repeated.
Skinner (1953) refers to this as extinction. Teachers frequently
use this technique with dis-
ruptive children in the classroom. If a child is acting up in
class, the teacher may choose to
ignore the behavior in hopes that the nonreinforced behavior
will go away.

THEoRy oF plAnnEd BEHAVioR (TpB)
The theory of planned behavior (TPB) is the first of several
value-expectancy theories presented
in this section. Value-expectancy theories were developed to
explain how individuals’ be-
haviors were influenced by beliefs and attitudes (Simons-
Morton et al., 2012). Thus, the ten-
dency to perform a particular act is a function of the expectancy
that the act will be followed
by certain consequences (e.g., ‘How vulnerable am I to the
danger?’) and the value of those
consequences (e.g., ‘How severe is the danger?’)” (Prentice-
Dunn & Rogers, 1986, p. 157).
The theory of planned behavior has its foundation in the theory
of reasoned action (TRA)
(Fishbein, 1967). The TRA was developed to explain volitional
behaviors, “that is, behaviors
that can be performed at will” (Luszczynska & Sutton, 2005, p.
73). The TRA has proved to
be useful when dealing with purely volitional behaviors, but
complications are encountered
when the theory is applied to behaviors that are not fully under

volitional control. A good
example of this is a smoker who intends to quit but fails to do
so. Even though intent is high,
nonmotivational factors—such as lack of requisite
opportunities, skills, and resources—
could prevent success (Ajzen, 1988).
The TPB (see Figure 7.2) is an extension of the TRA that
addresses the problem of incom-
plete volitional control. Both the TRA and the TPB focus on
determinants of behavioral
intentions. In the TRA, Fishbein and Ajzen (1975) distinguished
among attitude, belief, inten-
tion, and behavior. Intention “is an indication of a person’s
readiness to perform a given
behavior, and it is considered to be an immediate antecedent of
behavior” (Ajzen, 2006).
According to this theory, individuals’ intentions to perform
given behaviors are functions of
their attitudes toward the behavior and their subjective norms
associated with the behaviors.
Attitude toward the behavior “is the degree to which
performance of the behavior is
positively or negatively valued. According to the expectancy-
value model, attitude toward a

behavior is determined by the total set of accessible behavioral
beliefs linking the behavior to
various outcomes and other attributes” (Ajzen, 2006). Thus a
person who has strong beliefs
about positive attributes or outcomes from performing the
behavior will have a positive
Positive
(adding to)
Negative
(taking away)
Positive
reinforcement
(reward)
Negative
reinforcement
Positive
punishment
Increase in frequency

Decrease in frequency Negative
punishment
Consequences
B
e
h
a
v
io
r
⦁ ▲ Figure 7.1 2 × 2 Table of the Stimulus Response Theory
attitude toward behavior (Montaño & Kasprzyk, 2008). For
example, if a person feels strongly
about exercise being able to help control weight, then that

person will have a positive at-
titude toward exercise. The converse is true as well. Weak
beliefs about the outcomes or at-
tributes of exercise will produce a negative attitude toward it.
Subjective norm “is the perceived social pressure to engage or
not engage in a behavior”
(Ajzen, 2006). For many health behaviors, the social pressure
comes from a person’s peers,
parents, partner, close friends, teachers, role models, boss, and
co-workers, as well as experts
or professionals like physicians or lawyers. Thus individuals
who believe that certain people
think they should perform a behavior and are motivated to meet
the people’s expectations
will hold a positive subjective norm (Montaño & Kasprzyk,
2008). Similar to behavioral be-
liefs, the converse is also true. An example of a positive
subjective norm are employees who
see their co-workers as important people in their lives and
believe that these people approve
of them participating in a company exercise program.
The major difference between TPB and TRA is the addition of a
third (the first being atti-

tude toward the behavior and the second being subjective norm),
conceptually independent de-
terminant of intention—perceived behavioral control. Perceived
behavioral control is similar to
the Social Cognitive Theory’s concept of self-efficacy.
Perceived behavioral control “re-
fers to people’s perceptions of their ability to perform a given
behavior” (Ajzen, 2006). Stated
differently, perceived behavioral control refers to the perceived
ease or difficulty of perform-
ing the behavior and is assumed to reflect past experience as
well as anticipated impediments
and obstacles. As a general rule, the more favorable the attitude
and subjective norm with
respect to a behavior, and the greater the perceived behavioral
control, the stronger should
be the individual’s intentions to perform the behavior under
consideration (Ajzen, 1988).
Figure 7.2 illustrates two important features of this theory.
First, perceived behavioral
control has motivational implications for intentions. That is,
without perceived control,
intentions could be minimal even if attitudes toward the
behavior and subjective norm were

Behavioral
beliefs
Attitude
toward the
behavior
Control
beliefs
Perceived
behavioral
control
Normative
beliefs
Subjective
norm
Intention Behavior
Actual

behavioral
control
⦁ ▲ Figure 7.2 Theory of Planned behavior Diagram
Source: Theory of Planned Behavior Diagram. Icek Ajzen.
Copyright © 2006 by Icek Ajzen. Reprinted with permission.
strong. Second, there may be a direct link between perceived
behavioral control and behav-
ior. Behavior depends not only on motivation but also on actual
control. Actual behavioral
control “refers to the extent to which a person has the skills,
resources, and other prerequi-
sites needed to perform a given behavior. Successful
performance of the behavior depends
not only on a favorable intention but also on a sufficient level
of behavioral control. To the
extent that perceived behavioral control is accurate, it can serve
as a proxy of actual control
and can be used for the prediction of behavior” (Ajzen, 2006).

To use the example of smoking
once again as a behavior not fully under volitional control, TPB
predicts that individuals will
give up smoking if they:
⦁ ⦁ Have a positive attitude toward quitting
⦁ ⦁ Think others whom they value believe it would be good for
them to quit
⦁ ⦁ Perceive that they have control over whether they quit
HEAlTH BEliEF modEl (HBm)
The health belief model (HBM) is also a value-expectancy
theory. It was developed in the 1950s
by a group of psychologists at the U.S. Public Health service to
help explain why people
would or would not use health services (Rosenstock, 1966). The
HBM is based on Lewin’s
decision-making model (Lewin, 1935, 1936; Lewin et al., 1944).
Since its creation, the HBM
has been used to help explain a variety of health behaviors
(Becker, 1974; Janz & Becker,
1984; Jones, Smith, & Llewellyn, 2014).

The HBM hypothesizes that health-related action depends on the
simultaneous occur-
rence of three classes of factors:
1. The existence of sufficient motivation (or health concern) to
make health issues salient
or relevant.
2. The belief that one is susceptible (vulnerable) to a serious
health problem or to the
sequelae of that illness or condition. This is often termed
perceived threat.
3. The belief that following a particular health recommendation
would be beneficial
in reducing the perceived threat, and at a subjectivel y
acceptable cost. Cost refers
to the perceived barriers that must be overcome in order to
follow the health
recommendation; it includes, but is not restricted to, financial
outlays (Rosenstock
et al., 1988, p. 177). In fact, the lack of self-efficacy is also
seen as a perceived barrier
to taking a recommended health action (Strecher & Rosenstock,

1997).
In recent years, self-efficacy has become a more meaningful
concept in the perceived
barriers construct of the HBM. When the HBM was first
conceived, self-efficacy was not
explicitly a part of it. “The original model was developed in the
context of circumscribed
preventive health actions (accepting a screening test or an
immunization) that were not per-
ceived to involve complex behaviors” (Champio n & Skinner,
2008, p. 49). However, when
program planners want to use the HBM to plan health promotion
interventions for priority
populations in need of lifestyle behaviors requiring long-term
changes, self-efficacy must be
included in the model. Therefore, “[f]or behavior change to
succeed, people must (as the orig-
inal HBM theorizes) feel threatened by their current behavioral
patterns (perceived suscepti-
bility and severity) and believe that change of a specific kind
will result in a valued outcome
at acceptable cost. They must also feel themselves competent
(self-efficacious) to overcome
perceived barriers to taking action” (Champion & Skinner,

2008, p. 50) (see Figure 7.3).
Here is an example of the HBM applied to exercise. Someone
watching television sees
an advertisement about exercise. This is a cue to action that
starts her thinking about her
own need to exercise. There may be some variables
(demographic, sociopsychological, and
structural) that cause her to think about it a bit more. She
remembers her college health
course that included information about heart disease and the
importance of staying active.
She knows she has a higher than normal risk for heart disease
because of family history, poor
diet, and slightly elevated blood pressure. Therefore, she comes
to the conclusion that she is
susceptible to heart disease (perceived susceptibility). She also
knows that if she develops
heart disease, it can be very serious (perceived
seriousness/severity). Based on these fac-

tors, the individual thinks that there is reason to be concerned
about heart disease (perceived
threat). She knows that exercise can help delay the onset of
heart disease and can increase the
chances of surviving a heart attack if one should occur
(perceived benefits). But exercise
takes time from an already busy day, and it is not easy to
exercise in the variety of settings in
which she typically finds herself, especially during bad weather
(perceived barriers). Her con-
fidence in being able to overcome the barriers and exercise
regularly will also be important
(self-efficacy). She must now weigh the threat of the disease
against the difference between
benefits and barriers. This decision will then result in a
likelihood of exercising or not exer-
cising (likelihood of taking recommended preventive health
action).
pRoTECTion moTiVATion THEoRy (pmT)
The third value-expectancy theory presented in this section is
the protection motivation theory
(PMT). It was originally created by Rogers (1975) and
“proposed to provide explanations of

the effects of fear appeals on health attitudes and behavior”
(Floyd, Prentice-Dunn, & Rogers,
2000, p. 409). The PMT was later revised and extended (Rogers,
R., 1983) to a more general
theory of persuasive communication that included reward and
self-efficacy components.
The PMT has some similarities to the HBM. Both contain a
cost-benefit analysis in which the
individual weighs the costs of taking a precautionary action
against the expected benefits of
taking action, and both share an emphasis on cognitive
processes mediating attitudinal and
behavioral change (Floyd et al., 2000; Prentice-Dunn & Rogers,
1986).
As explained by the PMT, inputs come from environmental
sources of information such
as verbal persuasion and observational learning, and from
intrapersonal sources such as
Perceived
benefits less
perceived
barriers

Perceived
threat
Behavior
Perceived
seriousness
Perceived
self-efficacy
Perceived
susceptibility
Cues to
action
Age
Sex/gender
Race/ethnicity
Personality
Socioeconomics
Knowledge
Personal
experiences

⦁ ▲ Figure 7.3 Health belief Model
one’s personality and feedback from personal experiences
associated with the targeted mal-
adaptive and adaptive responses (Floyd et al., 2000). Based on
these inputs people make a
cognitive assessment of whether there is a threat to their health.
Information about a threat
to one’s health arouses two cognitive mediating processes:
threat appraisal and coping ap-
praisal (Floyd et al., 2000; McClendon & Prentice-Dunn, 2001).
The threat appraisal process is addressed first because a threat
to one’s health must be
perceived or identified before there can be an assessment of the
coping options (Floyd et al.,
2000). Threat appraisal assesses maladaptive behaviors (e.g.,
physical inactivity, smoking,
overeating, binge drinking). The assessment includes (1) a
review of intrinsic (e.g., physical

and psychological pleasure such as feeling “good”) and
extrinsic (e.g., peer approval such as
receiving attention) rewards; and (2) a review of the perceived
severity of and the perceived
vulnerability to the threat. “Rewards increase the probabi lity of
selecting the maladaptive
response (not to protect self or others), whereas threat will
decrease the probability of select-
ing the maladaptive response” (Floyd et al., 2000, p. 410).
“Thus the rewards minus the sum
of severity and vulnerability indicate the amount of threat
experienced by the individual”
(McClendon & Prentice-Dunn, 2001, p. 322).
Coping appraisal assesses adaptive behaviors (e.g., health
enhancing behaviors). This type
of assessment includes (1) a review of response efficacy ( e.g.,
belief that the coping action
will avert the threat) and self-efficacy (i.e., belief that the
person is capable of completing
the coping action); and (2) a review of the response costs (e.g.,
“inconvenience, expense,
unpleasantness, difficulty, complexity, side effects, disruption
of daily life, and overcoming
habit strength” [Rogers, 1984, p. 104]). “Response efficacy and

self-efficacy will increase the
probability of selecting the adaptive response, whereas response
costs will decrease the prob-
ability of selecting the adaptive response” (Floyd et al., 2000, p.
411). In sum, the amount of
coping appraisal experienced is indicated by the sum of
response efficacy and self-efficacy
minus the response costs” (McClendon & Prentice-Dunn, 2001,
p. 322).
When the results of the threat appraisal and coping appraisal
processes are combined it is
the protective motivation that an individual possesses. Stated a
bit differently, “The output
of these appraisal-mediating processes is the decision (or
intention) to initiate, continue,
or inhibit the applicable adaptive responses (or coping modes)”
(Floyd et al., 2000, p. 411).
When using the PMT to design an intervention protection
motivation has been measured us-
ing behavioral intentions (Floyd et al., 2000).
Prentice-Dunn and Rogers (1986, p. 156) offered the following
summary of the PMT:

PMT assumes that protection motivation is maximized when: (i)
the threat to health is severe;
(ii) the individual feels vulnerable; (iii) the adaptive response is
believed to be an effective means
for averting the threat; (iv) the person is confident in his or her
abilities to complete successfully
the adaptive response; (v) the rewards associated with the mal -
adaptive behavior are small; and
(vi) the costs associated with the adaptive response are small.
Such factors produce protection
motivation and, subsequently, the enactment of the adaptive, or
coping, response.
Since its development, the PMT has been successfully used to
create program interven-
tions for a number of different health behaviors (Floyd et al.,
2000). Some of the more
recent applications of the theory have included: adolescent drug
use intention (Wu et al.,
2014), exercise among various groups (Bui, Mullan, &
McCaffery, 2013; Gaston &
Prapavessis, 2012), living wills (Allen, Phillips, Whitehead,
Crowther, & Prentice-Dunn,
2009), pro-environmental behavior (Bockarova & Steg, 2014),
social networks (Salleh et al.,

2012), sun protection behavior/skin cancer (Prentice-Dunn,
McMath, & Cramer, 2009), and
weight loss and bariatric surgery (Boeka, Prentice-Dunn, &
Lokken, 2010).
ElABoRATion likEliHood modEl oF pERSuASion (Elm)
The Elaboration Likelihood Model of Persuasion, or the
Elaboration Likelihood Model (ELM) for
short, was initially developed to help explain inconsistencies in
the results from research
dealing with the study of attitudes (Petty, Barden, & Wheeler,
2009). Specifically, the model
was designed to help explain how persuasion messages
(communication) aimed at changing
attitudes were received and processed by people. Though not
created specifically for health
communication, since its development the ELM has been used
to help interpret and predict

the impact of health messages (Petty & Briñol, 2012) (see
Figure 7.4).
The utility of the ELM is that it does four essential things. First,
the ELM proposes that
modifying attitudes or other judgments can be formed as a
result of a high degree of thought
(i.e., central process route) or a low degree of thought (i.e.,
peripheral and processing route)
(Petty et al., 2009). “That is, the elaboration continuum’ ranges
from low to high” (Petty &
Briñol, 2012, p. 226). The distinction among the places on the
continuum is the amount of
elaboration. Elaboration refers to the amount of cognitive
processing (i.e., thought) that a
person puts into receiving messages.
Second, the ELM postulates that there are numerous specific
processes of change that
operate along the elaboration continuum (Petty & Briñol, 2011).
The continuum stretches
from one end anchored with processes requiring no thinking,
like classical conditioning (see
discussion on stimulus response theory earlier in the chapter),
to processes requiring some

effortful thinking such as inferences based on one’s
experiences, to processes requiring care-
ful consideration (see value-expectancy theories presented
earlier in the chapter) (Petty et al.,
2009). The peripheral route processes involve minimal thought
and rely on superficial cues
or mental shortcuts (called heuristics) about issue-relevant
information as primary means for
attitude change (Petty et al., 2009). For example, people may
form an attitude after hearing
a persuasive message simply because the person delivering the
message is someone that they
admire. On the other hand, central route processes involve
thoughtful consideration (or
effortful cognitive elaboration) of issue-relevant information
and one’s own cognitive re-
sponses as the primary bases for attitude change (Petty et al.,
2009). “Two conditions are nec-
essary for effortful processing to occur—the recipient of the
message must be both motivated
and able to think carefully” (Petty et al., 2009, p. 188). An
example of central route processing
would be a motorcyclist’s formation of an attitude about
wearing a helmet based on thought-
ful consideration of a message about the pros and cons of

helmet use along with recalling
knowledge gained in a motorcycle safety class and possibly the
results of a motorcycle crash
in which his or her cousin was involved.
It should be clear that the distinction between the peripheral and
central routes is the amount
of consideration given to the issue-relevant information and
how the information is processed,
not the type of information itself (Petty, Wheeler, & Bizer,
1999). “Of course, much of the time,
persuasion is determined by a mixture of these processes” (Petty
& Briñol, 2012, p. 226).
Third, when comparing the consequences of the two routes there
are times when the re-
sult is similar. However, the two routes usually lead to attitudes
with different consequences.
“High effort central route processes are more likely to lead to
attitudes that are persistent over
time, resistant to counterattack, and influential in guiding
thought and behavior than are
peripheral process” (Petty et al., 2009, pp. 207–208).

PERSUASIVE COMMUNICATION
MOTIVATED TO PROCESS?
(personal relevance,
need for cognition, etc.)
ABILITY TO PROCESS?
(distraction, repetition,
knowledge, etc.)
WHAT IS THE NATURE
OF THE PROCESSING?
(argument quality,
initial attitude, etc.)
ARE THE THOUGHTS
RELIED UPON?
(ease of generation,

thought rehersal, etc.)
Changed attitude is relatively
enduring, resistant to
counterpersuasion, and
predictive of behavior.
CENTRAL
POSITIVE
ATTITUDE
CHANGE
CENTRAL
NEGATIVE
ATTITUDE
CHANGE
RETAIN
INITIAL ATTITUDE
IS A PERIPHERAL
PROCESS OPERATING?
(identification with

source, use of heuristics,
balance theory, etc.)
Attitude does not
change from
previous position.
MORE
FAVORABLE
THOUGHTS
THAN BEFORE?
YES
YES
(Favorable)
YES
(Unfavorable)
YES

NO
NO
YES
YES
NO
NO
YES
NO
MORE
UNFAVORABLE
THOUGHTS
THAN BEFORE?
PERIPHERAL ATTITUDE SHIFT
Changed attitude is relatively
temporary, susceptible to

counterpersuasion, and
unpredictive of behavior.
⦁ ▲ Figure 7.4 The elaboration likelihood Model of Persuasion
(elM)
Source: “The Elaboration Likelihood Model of Persuasion” by
R. E. Petty, J. Barden, and G. R. Alexander, from Emerging
Theories in Health
Promotion Practice and Research: Strategies for Improving
Public Health, 2e, Ed. J. R. DiClemente, R. A. Crosby, and M.
C. Kegler. Copyright
© 2009 by Jossey-Bass. Reprinted with permission.
Fourth, and arguably the “most useful thing that the ELM does
is to organize the many
specific processes by which variables can affect attitudes into a
finite set that operate at dif-
ferent points along the elaboration continuum” (Petty & Briñol,
2012, p. 226). The variables
can have an influence on people’s motivation to think or ability

to think, as well as the va-
lence of people’s thought or the confidence in the thoughts
generated (Petty et al., 2009). For
example, variables that have an impact on how a message is
processed are the source of the
message (e.g., friend, expert), the message itself (e.g., funny,
serious), the context (e.g., de-
livered person-to-person, on the Internet), and various
characteristics of the recipient (e.g.,
intelligence, age, attentiveness).
The ELM has been used to develop a variety of interventions for
health promotion pro-
grams. The one area where the ELM has been most useful in
health promotion has been
with message tailoring. Tailored messages are those that are
“crafted for and delivered to each
individual based on individual needs, interests, and
circumstances” (NCI, n.d., p. 251). In
other words, tailored messages are matched to the needs,
interests, and circumstances of the
intended recipient. It has been found that the more tailored the
persuasive communication,
the more relevant it is to the recipient, and the more likely the
message will be processed

through the central route. And, if a message is processed
through the central route the more
likely it will impact attitude and behavior change.
inFoRmATion-moTiVATion-BEHAVioRAl (imB) SkillS modEl
The information-motivation-behavioral (IMB) skills model (see
Figure 7.5) was initially created
to address the critical need for a strong theoretical basis for
HIV/AIDS prevention efforts
(Fisher & Fisher, 1992). Since its development, there is
evidence to support its usefulness
with HIV/AIDS prevention (Fisher, Fisher, & Shuper, 2009) as
well as other intervention
strategies (Chang, Choi, Kim, & Song, 2014) including the
management of diabetes (Osborn
& Egede, 2010). According to the IMB model, the constructs of
information, motivation, and
behavioral skills are the fundamental determinants of preventive
behavior. The information
provided needs to be relevant, easily enacted based on the
specific circumstances, and serve
as a guide to personal preventive behavior. “In addition to facts
that are easy to translate into
behavior, the IMB model recognizes additional cognitive

processes and content categories
HIV prevention
motivation
HIV prevention
behavior skills
HIV prevention
information
HIV prevention
behavior
⦁ ▲ Figure 7.5 The Information-Motivation-behavioral Skills
Model of HIV Prevention
Source: “Changing AIDS-Risk Behavior.” J. D. and W. A.
Fisher from Psychological Bulletin 111(3). Copyright © 1992
by the American Psychological
Association.

that significantly influence performance of preventive behavior”
(Fisher et al., 2009, p. 27).
Such as the simple decision rules a person may hold, like “if my
best friend is willing to ride a
motorcycle without a helmet, it must be okay.”
Even though people are well informed about a particular health
issue, they may not be
motivated to act. According to the IMB model, prevention
motivation includes both per-
sonal motivation to act (i.e., one’s attitude toward a specific
behavior) and social motivation
to act (is there social support for the preventive behavior?)
(Sharma, 2012). Both types of
motivation are necessary for action to occur.
In addition to people being well informed and motivated to act,
the IMB model also as-
serts that people must possess behavioral skills to engage in the
preventive behavior. The
behavioral skills component of the IMB model includes an
individual’s objective ability and
his or her perceived self-efficacy to perform the preventive
behavior.

In applying the IMB model, health education specialists cannot
simply use their own
judgment to determine what information to provide, how best to
motivate, and what be-
havioral skills to teach to a given population. The process
should begin by eliciting informa-
tion from a subsample of the priority population to identify
deficits in their health-relevant
information, motivation, and behavior skills. Next health
education specialists need to
design and implement “conceptually-based, empirically-
targeted, population-specific” (p. 29)
interventions, constructed on the bases of the elicited findings
(Fisher et al., 2009). Then,
after the implementation of the intervention, health education
specialists must evaluate the
intervention to determine if it had significant and sustained
effects on the information, mo-
tivation, and behavioral skill determinants of the preventive
behavior and on the preventive
behavior itself (Fisher et al., 2009).
THE TRAnSTHEoRETiCAl modEl (TTm)
The transtheoretical model (TTM), someti mes referred to as the

Stages of Change Model, was
developed to help explain how individuals and populations
progressed toward adopting and
maintaining health behavior change. The model uses stages of
change to integrate processes
and principles of change from across major theories, hence the
name ‘Transtheoretical’”
(Prochaska, Johnson, & Lee, 1998). The model has its roots in
psychotherapy and was devel-
oped by Prochaska (1979) after he completed a comparative
analysis of therapy systems and
a critical review of therapy outcome studies. From the analysis
and review, Prochaska found
that some common processes were involved in change.
As this model has evolved, researchers have applied it to many
different types of health
behavior change, including but not limited to alcohol and
substance abuse, anxiety and
panic disorders, delinquency, eating disorders and obesity,
exercise, high-fat diets, hand-
washing, HIV/AIDS prevention, immunizations/vaccinations,
mammography screening,
medication adherence/compliance, unplanned pregnancy
prevention, pregnancy and

smoking, sedentary lifestyles, weight control, sun exposure, and
physicians practicing pre-
ventive medicine (Angus et al., 2013; Prochaska, Redding, &
Evers, 2008; Spencer, Adams,
Malone, Roy, & Yost, 2006).
The core constructs of the TTM include the stages of change,
the processes of change, deci-
sional balance (i.e., the pros and cons of changing), self-
efficacy, and temptation (see Table 7.3).
In addition, this model is “based on critical assumptions about
the nature of behavior change
and interventions that can best facilitate change” (Prochaska et
al., 1998, p. 60). A discussion of
these constructs and assumptions follows.
Table 7.3 Transtheoretical Model Constructs
Source: SPM Handbook for Health Assessment Tools. Colleen
A. Redding, Joseph S. Rossi, S. R. Rossi, W. F. Velicer, and J.

O. Prochaska. Copyright © 1999 by the Society of
Prospective Medicine. Reprinted with permission from the
authors.
Constructs Description
Stages of change
Precontemplation No intention to take action within the next 6
months
Contemplation Intends to take action within the next 6 months
Preparation Intends to take action within the next 30 days and
has taken some
behavioral steps in this direction
Action Has changed overt behavior for less than 6 months
Maintenance Has changed overt behavior for more than 6
months
Decisional balance
Pros The benefits of changing
Cons The costs of changing
Self-efficacy
Confidence Confidence that one can engage in the healthy
behavior across

different challenging situations
Temptation Temptation to engage in the unhealthy behavior
across
different challenging situations
Processes of change
Consciousness raising Finding and learning new facts, ideas,
and tips that support the healthy
behavior change
Dramatic relief Experiencing the negative emotions (fear,
anxiety, worry) that go with
unhealthy behavioral risks
Self-reevaluation Realizing that the behavior change is an
important part of one’s
identity as a person
Environmental reevaluation Realizing the negative impact of
the unhealthy behavior, or the positive
impact of the healthy behavior, on one’s proximal social and/or
physical environment

Self-liberation Making a firm commitment to change
Helping relationships Seeking and using social support for the
healthy behavior change
Counterconditioning Substitution of healthier alternative
behaviors and/or cognitions for
the unhealthy behavior
Reinforcement management Increasing the rewards for the
positive behavior change and/or
decreasing the rewards of the unhealthy behavior
Stimulus control Removing reminders or cues to engage in the
unhealthy behavior and/
or adding cues to reminders to engage in the healthy behavior
Social liberation Realizing that social norms are changing in
the direction of supporting
the healthy behavior change
Behavioral change does not occur overnight. A person does not
go to bed at night as a
nonexerciser and wake up the next morning as an exerciser.
Behavior change occurs over
time. Thus, the stage construct, the core construct of the model,

is comprised of categories
of change (i.e., stages) along a continuum of motivational
readiness to change a problem
behavior (URI, 2015). On this continuum “people move from
precontemplation, not intend-
ing to change, to contemplation, intending to change within 6
months, to preparation, actively
planning change, to action, overtly making changes, and into
maintenance, taking steps
to sustain change and resist temptation to relapse” (Prochaska,
Redding, Harlow, Rossi, &
Velicer, 1994). The precontemplation stage is defined as a time
in which “people do not
intend to take action in the near term, usually measured as the
next six months. The outcome
interval may vary, depending on behavior. People may be in this
stage because they are un-
informed or under-informed about the consequences of their
behavior. Or they may have
tried to change a number of times and become demoralized

about their abilities to change”
(Prochaska et al., 2008, p. 100). People in this stage “tend to
avoid reading, talking, or thinking
about their high-risk behaviors” (Prochaska et al., 1998). The
second stage, contemplation
is the stage in which “people intend to change their behaviors in
the next six months”
(Prochaska et al., 2008, p. 100). It occurs when people are
aware that a problem exists and
are seriously thinking about a behavior change but have not yet
made a commitment to take
action. They are more open to feedback and information about
the problem behavior than
those in the precontemplation stage (Redding et al., 1999). For
example, most smokers know
that smoking is bad for them and consider quitting, but are not
quite ready to do so. The third
stage is called preparation and combines intention and
behavioral criteria. In this stage,
“people intend to take action soon, usually measured as the next
month. Typically, they have
already taken some significant step toward the behavior in the
past year. They have a plan of
action, such as joining a health education class, consulting a
counselor, talking to their physi-

cian, buying a self-help book, or relying on a self-change
approach” (Prochaska et al., 2008,
p. 100). “These are the people we should recruit for such action-
oriented programs as smoking
cessation, weight loss, or exercise” (Prochaska et al., 1998, p.
61).
People are in the fourth stage, the action stage, when they have
made overt changes
in their behavior, experiences, or environment in order to
overcome their problems within
the past six months. This stage of change reflects a consistent
behavior pattern, is usually
the most visible, and receives the greatest external recognition
(Prochaska, DiClemente,
& Norcross, 1992). Since the behavior change is very new in
this stage and the chance of
relapse is high, considerable attention still must be given to
relapse prevention (Redding
et al., 1999). Also, “not all modifications of behavior count as
action in this model. People
must attain a criterion that scientists and professionals agree is
sufficient to reduce risks of
disease” (Prochaska et al., 2008, p. 102). For example, in
smoking, reduction in the number

of cigarettes smoked does not count, only total abstinence
(Prochaska et al., 1998). If those
making changes continue with their new pattern of behavior,
they will move into the fifth
stage, maintenance.
Working to prevent relapse is the focus of the maintenance
stage. People in this stage
have made specific, overt modifications in then lifestyles for at
least six months and are
increasingly more confident that they can continue their
changes (Prochaska et al., 2008;
Prochaska et al., 1998; Redding et al., 1999). The person’s
change has become more of a habit
and the chance of relapse is lower, but it still requires some
attention (Redding et al., 1999).
The final stage is termination. This stage is defined as the time
when individuals who
have changed have zero temptation to return to their old
behavior and they have 100%
self-efficacy—that is, a lifetime of maintenance. No matter
what their mood, they will not
return to their old behavior (Prochaska et al., 2008). This is a
stage that few people reach with

certain behaviors (e.g., drinking for alcoholics). Since this may
not be a practical goal for the
majority of people, it has been given less attention in the
research (Prochaska et al., 2008).
Figure 7.6 provides a summary of the stages of change.
The second major construct of the TTM is the processes of
change (see Table 7.3 for an
explanation of the 10 processes). “These are the covert and
overt activities that people use to
progress through the stages” (Prochaska et al., 2008, p. 101).
Studies over the years have indi-
cated that some of the processes are more useful at specific
stages of change. The experimen-
tal set of processes (consciousness raising, dramatic relief, self-
reevaluation, environmental
reevaluation, and social liberation) are most often emphasized
in earlier stages (precontem-
plation, contemplation, and preparation) to increase intention
and motivation, whereas

the behavioral set of processes (helping relationships,
counterconditioning, reinforcement
management, stimulus control, and self-liberation) are most
often utilized in the later stages
(preparation, action, maintenance) as observable behavior
change efforts get underway and
need to be maintained (Redding et al., 1999) (see Table 7.4).
The construct of decisional balance refers to the pros and cons
of the behavioral
change. That is, individuals’ decisions to move from one stage
to the next are based on the
relative importance (pro), or the lack thereof (con), of the
behavior change for the individu-
als. “Characteristically, the pros of healthy behavior are low in
the early stages and increase
across the stages of change, and the cons of the healthy
behavior are high in the early stages
and decrease across the stages of change” (Redding et al., 1999,
p. 90).
The fourth construct of the TTM is self-efficacy. The
developers of this model see self-ef-
ficacy as it was defined by Bandura (1977), as people’s
confidence in their ability to perform a

certain behavior or task. The final construct of the TTM is
temptation. Temptation “reflects
the converse of self-efficacy—the intensity of urges to engage
in a specific behavior when in
Precontemplation
Contemplation
Relapse Preparation
Maintenance Action
Termination
⦁ ▲ Figure 7.6 The Stages of Change
Source: Models for Provider-Patient Interaction: Applications to
Health Behavior Change. M. G.
Goldstein from The Handbook of Health Behavior Change by
Shumaker, Sally Reproduced with
permission of SPRINGER PUBLISHING COMPANY,
INCORPORATED via Copyright Clearance Center.

difficult situations. Typically, three factors reflect the mos t
common types of temptations:
negative affect or emotional distress, positive social situations,
and craving” (Prochaska
et al., 2008, p. 102). As one might guess, temptation decreases
as one moves through the
stages; however, even in the maintenance stage temptation is
still present.
As noted at the beginning of this discussion, the TTM not only
includes the five core con-
structs but it is also based on five critical assumptions
(Prochaska et al., 2008):
1. No single theory can account for all the complexities of
behavior change. A more
comprehensive model will most likely emerge from an
integration across major
theories.
2. Behavior change is a process that unfolds over time through a
sequence of stages.

3. Stages are both stable and open to change just as chronic
behavioral risk factors are
stable and open to change.
4. The majority of at-risk populations are not prepared for
action and will not be served by
traditional action-oriented behavior change programs.
5. Specific processes and principles of change should be
emphasized at specific stages to
maximize efficacy (p. 103).
Since its development, the TTM has been useful in several
different ways. The first is
that it makes program planners aware that not everyone is ready
for change “right now,”
even though there is a program that can help them modify their
behavior. People proceed
through behavior change at different paces. Second, if
individuals are not ready for action
right now, then other programs can be developed to help them
become ready for action.
Box 7.3 provides an example how to “stage” a person with a
series of TTM type questions.
With such information, planners can match a person’s stage to a

specific intervention,
which in turn can increase the chances that the intervention will
have an effect.
Table 7.4 Progressing Through the Stages of the
Transtheoretical Model
Stage Transitions
Precontemplation
to Contemplation
Contemplation
to Preparation
Preparation
to Action
Action to
Maintenance
P
ro
ce

ss
e
s
Consciousness raising x
Dramatic relief x
Environmental
reevaluation
x
Self-reevaluation x
Self-liberation x
Counterconditioning x
Helping relationships x
Reinforcement
management
x
Stimulus control x
Source: Based on “The Transtheoretical Model and Stages of
Change.” J. O. Prochaska, C. A. Redding, K. E. Evers, in Health

Behavior and Health Education: Theory, Research, and
Practice. K. Glanz, B. K. Rimer, and K. Viswanath (eds.).
Copyright © 2008 by Jossey-Bass.
pRECAuTion AdopTion pRoCESS modEl (pApm)
The precaution adoption process model (PAPM) is more recent
than the TTM (Weinstein, 1988;
Weinstein & Sandman, 1992) and is based on decision theory
(Simons-Morton et al., 2012).
Its goal “is to explain how a person comes to the decision to
take action, and how he or she
translates that decision into action” (Weinstein et al., 2008, p.
126). Though the TTM and
PAPM are both stage models and appear similar, “it is mainly
the names that have been
given to the stages that are similar. The number of stages is not
the same in the two theories,
and those with similar names are defined quite differently”
(Weinstein & Sandman, 2002a,

p. 125). The PAPM is most applicable for use with the adoption
of a new precaution (e.g.,
getting an immunization), or the abandonment of a risky
behavior (e.g., not using a safety
belt or not wearing a motorcycle helmet) that requires a
deliberate action. It can also be used
to explain why and how people make deliberate changes in
habitual patterns. It is not appli-
cable for actions that require the gradual development of
habitual patterns of behavior such
as exercise and diet (Weinstein et al., 2008). It is also different
from the TTM in that its stages
are defined without reference to arbitrary time periods (Sutton,
n.d.).
The PAPM includes seven stages along the full path from
ignorance about a specific
behavior to taking action to engaging in the behavior.
At some initial point in time, people are unaware of the health
issue (Stage 1) [Unaware].
When they first learn something about the issue, they are no
longer unaware, but they are not
yet engaged by it either (Stage 2) [Unengaged]. People who
reach the decision-making stage

(Stage 3) [Deciding about acting] have become engaged by the
issue and are considering their
response. This decision-making process can result in one of
three outcomes: they may suspend
judgment, remaining in Stage 3 for the moment; they may
decide to take no action, moving
to Stage 4 [Decide not to act] and halting the precaution
adoption process, at least for the time
being; or they may decide to adopt the precaution, moving to
Stage 5 [Decide to act]. For those
who decide to adopt the precaution, the next step is to initiate
the behavior (Stage 6) [Acting].
A seventh stage, if relevant, indicates that the behavior has been
maintained over time (Stage 7)
7.3
Box An Example of using Questions Based on the
Transtheoretical model
to “Stage” a person
1. Do you eat at least five servings of fruits and vegetables each
day?
Yes—Move to question #2

No—Skip to question #3
2. Have you been doing so for more than six months?
Yes—Maintenance stage
No—Action stage
3. Do you intend to in the next 30 days?
Yes—Preparation stage
No—Move to question #4
4. Do you intend to in the next six months?
Yes—Contemplation stage
No—Precontemplation stage
A
pp
lic

at
io
n
[Maintenance]. (Weinstein et al., 2008, p. 126; note: names of
the stages were inserted by
McKenzie, Neiger, & Thackeray.)
Figure 7.7 provides an example of the application of the PAPM
to deciding whether or
not to get the shingles vaccine. You will note in this example
that Stage 7 is not applicable
because only a single dose of the shingles vaccine is needed.
However, if the flu vaccine was
used as the example Stage 7 would read “Get the flu vaccine
once a year, usually starting in
September.” As with the TTM, the usefulness of this model is
its ability to identify various
stages of the behavior change process (see Box 7.4). Once it is
known what stage the program

participants are in, then the program planners can develop a
stage-specific intervention to
move the participants toward action. Table 7.5 presents the
important issues that need to be
addressed to move participants from one stage to the next.
Stage 6: Got the
shingles vaccine
Stage 7: Not applicable
Stage 5: Decided to get the
shingles vaccine
Stage 3: Deciding about getting
the shingles vaccine
Stage 4: Decided not to get the
shingles vaccine
Stage 2: Never thought about
the shingles vaccine
Stage 1: Unaware there is a
shingles vaccine

⦁ ▲ Figure 7.7 application of the Precaution adoption Process
Model to shingles vaccine
7.4
Box An Example of using a Question Based on the precaution
Adoption
process model to “Stage” a person
What are your intentions for receiving the new vaccine for
shingles?
⦁ ⦁ I have already gotten it. (Stage 6)
⦁ ⦁ I have decided to get it. (Stage 5)
⦁ ⦁ I have thought about it and decided not to get it. (Stage 4)
⦁ ⦁ I am not sure. I am still trying to decide whether to get it or

not. (Stage 3)
⦁ ⦁ I heard there was a vaccine, but I really haven’t thought
much about it. (Stage 2)
⦁ ⦁ I was not aware there was a vaccine for shingles. (Stage 1)
A
pp
lic
at
io
n
Table 7.5 Progressing Through the Stages of the Precaution
Adoption Process Model
Source: Based on Health Behavior and Health Education:
Theory, Research, and Practice, by Karen Glanz, Barbara K.
Rimer, and K. Viswanath. Copyright © 2008a
by John Wiley & Sons, Inc.
Stage Transitions

Stage 1:
(unaware of
issue) to
Stage 2:
(unengaged
by issue)
Stage 2:
(unengaged by
issue) to
Stage 3:
(Deciding to act)
Stage 3:
(Deciding to act)
to
Stage 4:
(Decided not to

act) or to Stage 5:
(Decided to act)
Stage 5:
(Decided to
act) to
Stage 6:
(Acting)
Im
p
o
rt
a
n
t
In
fo
rm

a
ti
o
n
f
o
r
St
a
g
e
-S
p
e
ci
fi
c

In
te
rv
e
n
ti
o
n
s
Information about hazard
and precaution
x x
Communication with
significant other about
hazard and precaution
x
Previous experience with

hazard
x
Beliefs about hazard
likelihood, severity and
personal susceptibility
x
Perceived social norms
and behaviors and
recommendations of others
x
Personal fear and worry x
Time, effort, and resources
(including assistance) to act
x
“How to” information and
cues to action

x
interpersonal level Theories
Health behavior theories that focus on the interpersonal level
assume individuals exist within,
and are influenced by, a social environment (i.e., the people
with whom they interact). That is
to say, that an individual’s attitudes and behaviors will be
influenced by the actions, opinions,
thoughts, attitudes, behavior, advice, and support of others.
Further, an individual has a re-
ciprocal effect on those people who make up their social
environment (Rimer & Glanz, 2005).
The individuals who have the greatest influence on others
include spouse/partner, other
family members, friends, peers (i.e., fellow students and
coworkers), fellow members of social
groups, health care providers, religious leaders, and others
(Rimer & Glanz, 2005).

Although social relationships can have an impact on many
different human behaviors,
research has shown that they can be a powerful influence on
health and health behaviors
(Heaney & Israel, 2008). Therefore a number of theories have
been created to explain concepts
such as social learning (learning that occurs in a social context),
social power (ability to influence
others or resist activities of others), social integration (structure
and quality of relationships), social
networks (“web of social relationships and the structural
characteristics of that web”) (IOM, 2001,
p. 7), social support (“aid and assistance exchanged through
social relationships and interpersonal
transactions” [Heaney & Israel, 2008, p. 191]), social capital
(“relationships between community
members including trust, reciprocity, and civic engagement”
[Minkler, Wallerstein, & Wilson,
2008, p. 294]), and interpersonal communication. In the
sections that follow, we present a detailed
description of a well-established interpersonal theory—the
social cognitive theory, and we
present brief overviews of two newer theories—the social
network theory and the social capital
theory. These latter two theories may be theories in name only.

Earlier in this chapter we made a
distinction between theories and models. You may remember we
said that there are some theo-
ries that have the term “model” in their title because that is the
way they were initially identified
and now that there is empirical evidence to call them theories
the “model title” has remained
because that is what we have gotten used to calling them. We
believe that the social network and
the social capital theories may have been prematurely called
theories and are probably more in
the model stage. But again as Goodson (2010) stated, “. . . it
seems to matter little to us whether
we deal with theories or with models; it seems to matter even
less what labels we attach to them”
(p. 228). Therefore, the important point of presenting the social
network and social capital theo-
ries (or models) is to make you aware of the important concepts
contained in each.
SoCiAl CogniTiVE THEoRy (SCT)
The social learning theories (SLT) of Rotter (1954) and Bandura
(1977)—or, as Bandura
(1986) relabeled them, the social cognitive theory (SCT) —

combine SR theory and cognitive
theories. Stimulus response theorists emphasize the role of
reinforcement in shaping behav-
ior and believe that no “thinking” or “reasoning” is needed to
explain behavior. However,
Bandura (2001) stated, “If actions were performed only on
behalf of anticipated external
rewards and punishments, people would behave like weather
vanes, constantly shifting di-
rections to conform to whatever influence happened to impinge
upon them at the moment”
(p. 7). Cognitive theorists believe that reinforcement is an
integral part of learning, but em-
phasize the role of subjective hypotheses or expectations held
by the individual (Rosenstock
et al., 1988). In other words, reinforcement contributes to
learning, but reinforcement along
with an individual’s expectations of the consequences of
behavior determine the behavior.

“Behavior, in this perspective, is a function of the subjective
value of an outcome and the
subjective probability (or ‘expectation’) that a particular action
will achieve that outcome.
Such formulations are generally termed ‘value-expectancy’
theories” (Rosenstock et al.,
1988, p. 176). In brief, SCT explains human functioning in
terms of triadic reciprocal causa-
tion (Bandura, 1986). “In this model of reciprocal causality,
internal personal factors in the
form of cognitive, affective, and biological events, behavioral
patterns, and environmental
influences all operate as interacting determinants that influence
one another bidirection-
ally” (Bandura, 2001, pp. 14–15). The constructs of the SCT
that have been most often used
in designing health promotion interventions will be presented
here.
As already noted, reinforcement is an important component of
SCT. According to SCT,
reinforcement can be accomplished in one of three ways:
directly, vicariously, or through self-
reinforcement (Baranowski, Perry, & Parcel, 2002). An example
of direct reinforcement is

a group facilitator who provides verbal feedback to participants
for a job well done. Vicarious
reinforcement is having the participants observe someone else
being reinforced for behav-
ing in an appropriate manner. This has been referred to as
observational learning (Baranowski
et al., 2002) or social modeling. In a system of reinforcement by
self- reinforcement, the par-
ticipants would keep records of their own behavior, and when
the behavior was performed in
an appropriate manner, they would reinforce or reward
themselves.
If individuals are to perform specific behaviors, they must know
first what the behaviors are
and then how to perform them. This is referred to as behavioral
capability. For example,
if people are to engage in cardiovascular (i.e., “cardio”)
exercise, first they must know that car-
diovascular exercise exists, and second they need to know how
to do it properly. Many people
begin exercise programs, only to quit within the first six months
(Dishman, Sallis, & Orenstein,
1985), and some of those people quit because they do not know
how to exercise properly. They

know they should exercise, so they decide to run a few miles,
have sore muscles the next day,
and quit. Skill mastery is very important. The construct of
expectations refers to the ability
of human beings to think, and thus to anticipate certain things
to happen in certain situa-
tions. For example, if people are enrolled in a weight loss
program and follow the directions of
the group facilitator, they will expect to lose weight.
Expectancies, not to be confused with
expectations, are the values that individuals place on an
expected outcome. “Expectancies
influence behavior according to the hedonic principle: if all
other things are equal, a person
will choose to perform an activity that maximizes a positive
outcome or minimizes a negative
outcome” (Baranowski et al., 2002, p. 173). Someone who
enjoys the feeling of not smoking
more than that of smoking is more likely to try to do the things
necessary to stop. The construct
of self-regulation or self-control states that individuals may
gain control of their own be-
havior through monitoring and adjusting it (Clark et al., 1992).
In writing about this construct,
Bandura (1991) believed that self-regulation systems could have

a big influence on behavior
change. Later (Bandura, 1997) he expanded his thoughts about
the construct and identified six
methods for achieving self-regulation. They include (1) self-
monitoring (i.e., self-observation)
of one’s behavior, (2) setting both incremental and long-term
goals, (3) obtaining feedback on
the quality of a behavior and how it can be improved, (4)
rewarding self (or self-reinforcement)
for meeting goals, (5) self-instructing both before and as the
behavior is being performed, and
(6) gaining social-support for the behavior. These six methods
have been used extensively in
health promotion programs. For example, when helping
individuals to change their behavior
(i.e., a goal of losing weight, quitting smoking, or exercising
more), it is a common practice to
have them monitor their behavior over a period of time, say
through 24-hour diet or smoking
records or exercise diaries, analyze their behavior based on data

recorded, and then to have
them reward (reinforce) themselves based on meeting their
goals.
One construct of SCT that has received special attention in
health promotion programs is
self-efficacy (Strecher et al., 1986), which refers to the internal
state that individuals experi-
ence as “competence” to perform certain desired tasks or
behavior, “including confidence in
overcoming the barriers to performing that behavior”
(Baranowski et al., 2002, p. 173). “Unless
people believe they can produce desired results and forestall
detrimental ones by their actions,
they have little incentive to act or to persevere in the face of
difficulties” (Bandura, 2001, p. 10).
Self-efficacy is situation specific; that is, individuals may be
self-efficacious when it comes to
regular exercise but not so when faced with reducing the amount
of fat in their diet. People’s
competency feelings have been referred to as efficacy
expectations. Thus, people who
think they can exercise on a regular basis no matter what the
circumstances have efficacy ex-
pectations. Even though people have efficacy expectations, they

still may not want to engage
in a behavior because they may not think the outcomes of that
behavior would be beneficial to
them. Stated another way, they may not feel that the reward
(reinforcement) of performing the
behavior is great enough for them. These beliefs are called
outcome expectations. For ex-
ample, in order for individuals to quit smoking for health
reasons (behavior), they must believe
both that they are capable of quitting (efficacy expectation) and
that cessation will benefit
their health (outcome expectation) (I. M. Rosenstock, personal
communication, April 1986).
Individuals become self-efficacious in four main ways:
1. Through performance attainments (personal mastery of a
task)
2. Through vicarious experience (observing the performance of
others)
3. As a result of verbal persuasion (receiving suggestions from
others)

4. Through emotional arousal (interpreting one’s emotional
state)
Not only can individuals be self-efficacious, so can groups of
people. The term given
to groups or organizations being efficacious is collective
efficacy. Collective efficacy has
been defined as the people’s shared belief in their collective
ability to act to produce specific
changes. Like self-efficacy, collective efficacy is situation
specific. It is a construct that has ap-
plication when people seek to alter social systems (e.g.,
neighborhood watches and commu-
nity organizing (see Chapter 9), but also has application in
health promotion with regards to
health policy (McAlister et al., 2008). Bandura (1982, p. 143)
noted that “[p]erceived collec-
tive efficacy will influence what people choose to do as a
group, how much effort they put
into it, and their staying power when group efforts fail to
produce results.”
The construct of emotional–coping response states that for
people to learn, they must
be able to deal with the sources of anxiety that may surround a

behavior. For example, fear is
an emotion that can be involved in learning; according to this
construct, participants would
have to deal with the fear before they could learn the behavior.
The construct of reciprocal determinism states, unlike SR
theory, that there is an
interaction among the person, the behavior, and the
environment, and that the person can
shape the environment as well as the environment shape the
person. All these relationships
are dynamic. Glanz and Rimer (1995) provide a good example
of this construct:
A man with high cholesterol might have a hard time following
his prescribed low-fat diet
because his company cafeteria doesn’t offer low-fat food
choices that he likes. He can try to
change the environment by talking with the cafeteria manager or

the company medical or
health department staff, and asking that healthy food choices be
added to the menu. Or, if
employees start to dine elsewhere in order to eat low-fat
lunches, the cafeteria may change its
menu to maintain its lunch business (p. 15).
Finally, there is one other construct that grew out of the social
learning theory of Rotter
(1954) that needs to be mentioned because of its association
with health behavior. “Rotter
posited that a person’s history of positive or negative
reinforcement across a variety of situa-
tions shapes a belief as to whether or not a person’s own actions
lead to those reinforcements”
(Wallston, 1994, p. 187). Rotter referred to this construct as
locus of control. He felt that
people with internal locus of control perceived that
reinforcement was under their control,
whereas those with external locus of control perceived
reinforcement to be under the control
of some external force. In the 1970s, Wallston and his
colleagues at Vanderbilt University
began testing the usefulness of this construct in predicting
health behavior (Wallston, 1994).

They explored the concept of whether individuals with internal
locus of control were more
likely to participate in health-enhancing behavior than those
with external locus of control.
They began their work by examining locus of control as a two-
dimensional construct (inter-
nal versus external), then moved to a multidimensional
construct (i.e., Multidimensional
Health Locus of Control [MHLC]) when they split the external
dimension into “powerful
others” and “chance” (Wallston, Wallston, & DeVellis, 1978).
Since developing the MHLC
scale, a health/medical condition specific scale (Wallston,
Stein, & Smith, 1994) and a re-
ligion and health scale (Wallston, 2007) for locus of control
have been created. (Note: All
scales are in the public domain and available from Wallston,
2007).
After a number of years of work by many different researchers,
Wallston has come to the
conclusion that locus of control accounts for only a small
amount of the variability in health
behavior (Wallston, 1992). The internal locus of control belief
about one’s own health status

is a necessary but not sufficient determinate of health-
enhancing behavior (Wallston, 1994).
Since the rise of the construct of self-efficacy, Wallston (1994)
feels that self-efficacy is a bet-
ter predictor of health-promoting behavior than locus of control.
This is not to say that locus
of control is not a useful construct in developing health
promotion programs. Knowing the
locus of control orientation of those in the priority population
can provide planners with
valuable information when considering social support as part of
a planned intervention.
Table 7.6 provides a summary of the constructs of the SCT and
an example of how each con-
struct might be operationalized.
SoCiAl nETwoRk THEoRy (SnT)
The term social network (“web of social relationships that
surround people and the struc-
tural characteristics of that web” [IOM, 2001, p. 7]) arose in the
1950s from the work of a
sociologist who studied Norwegian villages. Barnes (1954)
created the term to describe social
relationships and characteristics of the villagers that could not

be described through tradi-
tional social units such as families (Edberg, 2015; Heaney &
Israel, 2008). Since that time, the
concept has continued to be used and studied by sociologists
and professionals in various
other disciplines including health education/health promotion.
One primary reason for the
growth in its use in recent years is that researchers have become
dissatisfied with many of the
other theories presented in this chapter. “For example, theories
that show attitudes toward a
behavior are associated with the behavior often do not help us
to understand how to change
those attitudes” (Valente, 2010, p. 7). To support the work of
Table 7.6 Often-used Constructs of the Social Cognitive Theory
and Examples of Their
Application
Source: Principles and Foundations of Health Promotion and

Education. Randall R. Cottrell, James T. Girvan, James F.
McKenzie, and Denise M. Seabert. Copyright © 2015 by
Pearson Education. Reprinted with permission.
Construct Definition Example
Behavioral
capability
Knowledge and skills necessary to
perform a behavior.
If people are going to exercise
aerobically, they need to know what it
is and how to do it.
Expectations Beliefs about the likely outcomes
of certain behaviors.
If people enroll in a weight-loss
program, they expect to lose weight.
Expectancies Values people place on expected
outcomes.

How important is it to people that they
become physically fit?
Locus of control Perception of the center of control
over reinforcement.
Those who feel they have control over
reinforcement are said to have internal
locus of control. Those who perceive
reinforcement under the control of an
external force are said to have external
locus of control.
Reciprocal
determinism
“Environmental factors influence
individuals and groups, but individuals
and groups can also influence their
environments and regulate their own
behavior” (McAlister, Perry, & Parcel,
2008, p. 171).
Lack of use of vending machines could
be a result of the choices within the

machine. Notes about the selections
from the nonusing consumers to the
machine’s owners could change the
selections and change the behavior of
the nonusing consumers to that of users.
Reinforcement
(directly, vicariously,
self-management)
Responses to behaviors that increase
the chances of recurrence.
Giving verbal encouragement to those
who have acted in a healthy manner.
Self-control, or
self-regulation
Gaining control over one’s own
behavior through monitoring and
adjusting it.
If clients want to change their eating
habits, have them monitor their current

habits for seven days.
Self-efficacy People’s confidence in their ability
to perform a certain desired task or
function
If people are going to engage in a
regular exercise program, they must
feel they can do it.
Collective efficacy Beliefs about the ability of the group
to perform concerted actions that bring
desired outcomes (McAlister et al.,
2008, p. 171).
If a group of people is going to work to
change a community’s culture toward
healthy behavior, they must feel that
they can do it.
Emotional-coping
response
For people to learn, they must be able
to deal with the sources of anxiety that

surround a behavior.
Fear is an emotion that can be involved
in learning, and people would have to
deal with it before they could learn a
behavior.
there is now evidence from social epidemiological observational
studies that have clearly
documented the beneficial effects of supportive networks on
health status (Heaney & Israel,
2008; Valente, 2010). But is there enough evidence to suggest
there is such a thing as a social
network theory (SNT)? Heaney and Israel (2008) feel that the
social network, and the closely
related concept of social support, “do not connote theories per
se. Rather, they are concepts
that describe the structure, processes, and functions of social
relationships” (p. 193). They
feel that intervention studies are “needed to identify the most
potent causal agents and criti-
cal time periods for social network enhancement” (p. 197). For
example, it is not known how

much social networking is enough to enhance health or how
much is too much. It is also not
known what are the characteristics of “good networks” that
result in positive health behav-
ior (e.g., regular exercise) versus “bad networks” that lead to
negative health behavior (e.g.,
smoking). But what is known is that people who are part of
social networks are as a whole
healthier than those who are not involved in networks.
One person who has written about SNT is Edberg (2015). He
has described different types of
social networks (e.g., ego-centered networks and full relational
networks) and indicated that the
key components to SNT are the relationships between and
among individuals and how the na-
ture of those relationships influences beliefs and behaviors. He
further states that those who use
the SNT need to consider the items on the following list when
assessing the role of a network on
the health behavior of individuals who are part of the network

(Edberg, 2015):
⦁ ⦁ Centrality versus marginality of individuals in the
network—how much involvement
does the person have in the network?
⦁ ⦁ Reciprocity of relationships—are relationships one-way or
two-way?
⦁ ⦁ Complexity or intensity of relationships in the network—
are the relationships between
two people or are they multiplexed?
⦁ ⦁ Homogeneity or diversity of people in the network—do all
members of the network have
similar characteristics or are they different?
⦁ ⦁ Subgroups, cliques, and linkages—are there concentrations
of interactions among some
members and do they interact or are they isolated from others?
⦁ ⦁ Communication patterns in the network—how does
information pass between the
members in the network?

In summary, we know that social networks can impact health,
but the specifics of who is
most impacted and how best to set up and use social networks
are unknown. Nevertheless,
because of the impact of social networks, health education
specialists planning interventions
need to consider if social networks should be a part of the
strategy they use to bring about
change. And finally, with the power of the Internet and social
networking, the impact of so-
cial networks in the work of health education specialists will to
continue to grow.
SoCiAl CApiTAl THEoRy
The often-quoted definition of social capital is “the
relationships and structures within a
community, such as civic participation, networks, norms of
reciprocity, and trust, that promote
cooperation of mutual benefit” (Putnam, 1995, p. 66). More
recently, it has been defined as
“the degree of social connectedness” (Simons-Morton et al.,
2012, p. 410). “Social capital is a
collective asset, a feature of communities rather than the
property of individuals. As such, indi-

viduals both contribute to it and use it, but they cannot own it”
(Warren, Thompson, & Saegert,
2001, p. 1). The term got its start in political science and has
been used in the health education/
promotion field since the mid-1990s. The influence of social
capital is well documented (Crosby
et al., 2009). There are epidemiological studies that show that
greater social capital is linked to
several different positive outcomes (i.e., reduced mortality,
some access to health care). There
are also correlational studies that show that lack of social
capital is related to poorer health out-
comes (e.g., Kawachi, Subramanian, & Kim, 2008). But as with
social networks, a cause-effect
relationship has not been established between social capital and
better health. Social capital is
an important descriptor of community wellness, but it is not a
strategy and requires community
organizing and capacity building in order to be strengthened
(Minkler & Wallerstein, 2012).

Figure 7.8 provides a graphic representation of the social
capital. This particular figure
includes the key concepts of Putman’s (1995) definition of
social capital and three different
types of network resources—bonding, bridging, and linking
social capital. These three types
are differentiated based on the strength of the relationships
between/among those people in
the social network (Hayden, 2014). Originally, bonding social
capital (sometimes referred to
as exclusive social capital) was defined as “the type that brings
closer together people who
already know each other” (Gittell & Vidal, 1998, p.15), but
since then it has been expanded
to encompass people who are similar or people who are
members of the same group. Bonding
social capital would come from those who are members in a
service organization (e.g., Lions,
Elks, American Legion) or religious community, for example.
Bridging social capital (some-
times referred to as inclusive social capital), was originally
defined as “the type that brings
together people or groups who previously did not know each
other” (Gittell & Vidal, 1998,
p. 15), though now bridging social capital is seen more as the

resources that people obtain
from their interaction with people from outside their group,
oftentimes from people with
different demographic characteristics. An example would be
people from different parts of a
community working to create a community park.
The most recently recognized, and weakest, network resource is
linking social capital
(Hayden, 2014). In this type of network social capital comes
from relationships between/
among individuals with institutions and individuals who have
relative power over them
(Szreter & Woolcock, 2004). An example would be when a boss
and an employee work to-
gether on a project.
Again, as with social networks it is important that health
education specialists be aware of
the concept of social capital when planning interventions. It is
not an intervention in itself,
but it is a concept that needs to be considered and monitored.
Community level Theories

As noted earlier in this chapter, the community level theories
include any theory that would
apply to the last five levels of the ecological perspective —
institutional, community, public
policy, environmental, and culture. Community level theories
“explore how social systems
Networks Resources
(Bonding, Bridging, Linking)
Trust & Reciprocity
Norms & Expectations
Social Capital
E
n
vi
ro
n
m
e

n
t
⦁ ▲ Figure 7.8 Social Capital
Source: Based on Introduction to Health Behavior Theory, by J.
Hayden. Copyright © 2014 by Jones & Bartlett Learning.
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” (Rimer
& Glanz, 2005, p. 22).
Like the other levels already discussed in this chapter, a number
of different community-
level theories are available for health planners. Several
community level theories involve
community organizing and developing (see Chapter 9). The
following section presents a
discussion of two community level theories–– diffusion theory

and the community readi-
ness model.
diFFuSSion THEoRy
Diffusion theory (Rogers, 1962) provided an explanation for the
spread of innovations
(something new, such as a product, service, or program) in
populations; stated another way,
it provides an explanation for the pattern of adoption of the
innovations. Like other pro-
cesses discussed in this chapter, adoption is situation specific
and it results from people going
through a series of stages. Rogers (2003) outlined the following
five stages: (1) knowledge (ac-
quisition of about the innovation), (2) persuasion (i.e., attitude
concerning the innovation);
(3) decision (about adopting or not adopting); (4)
implementation (beginning to use the in-
novation); and (5) confirmation (commitment to use, continue to
use, or discontinue use of
the innovation). If one thinks of a health promotion program as
an innovation, the theory
describes a pattern the priority population will follow in
adopting the program.

The pattern of adoption can be represented by the normal bell -
shaped curve (Rogers,
2003) (see Table 7.7). Those individuals who fall in the portion
of the curve to the left of mi-
nus 2 standard deviations from the mean (this would be between
2% and 3% of the priority
population) would probably become involved in the program
just because they had heard
about it and wanted to be first. These people are called
innovators. They are venturesome,
independent, and daring. They want to be the first to do things,
although others in the social
system may not respect them.
The second group of people to adopt something new includes
those represented on the
curve between minus 2 and minus 1 standard deviations. This
group, which composes about
14% of the priority population, is called early adopters. These
people are very interested
in the innovation, but they are not the first to sign up. They wait
until the innovators are
already involved to make sure the innovation is useful. Early
adopters are respected by others

in the social system and looked upon as opinion leaders.
The next two groups are the early majority and the late
majority. They fall between
minus 1 standard deviation and the mean and between the mean
and plus 1 standard
Table 7.7 Diffusion of Innovations
Group % of Population Place on a Bell-shaped Curve
Innovators ~2-3 Less than minus 2 standard deviations
Early Adopters ~14 Between minus 2 and minus 1 standard
deviations
Early Majority ~34 Between minus 1 standard deviation and the
mean
Late Majority ~34 Between the mean and plus 1 standard
deviation
Laggards ~16 Greater than plus 1 standard deviation
deviation on the curve, respectively. Each of these groups

comprises about 34% of the pri-
ority population. Those in the early majority may be interested
in the health promotion
program, but they will need external motivation to become
involved. Those in the early
majority will deliberate for some time before making a decision.
It will take more work to get
the late majority involved, because they are skeptical and will
not adopt an innovation until
most people in the social system have done so. Planners may be
able to get them involved
through a peer mentoring program, or through constant exposure
about the innovation.
The last group, the laggards (16%), is represented by the part of
the curve greater than
plus 1 standard deviation. They are not very interested in
innovation and would be the last
to become involved in new health promotion programs, if at all.
They are very traditional
and are suspicious of innovations. Laggards tend to have limited
communication networks,
so they really do not know much about new things.
Because diffusion occurs over time, the cumulative prevalence

of adopters at successive
points can be represented by a S-shaped curve. At first, only a
few people adopt (innovators).
However, over time, the curve begins to climb as additional
individuals decide to adopt the
innovation (early adopters, early majority, and late majority).
The curve then levels off as
adoption of the innovation ceases, leaving a few who have not
adopted (laggards) (Goldman,
1998; Rogers, 2003).
One of the more useful application of the diffusion theory is
when marketing a health
promotion program because “the distinguishing characteristics
of the people who fall into
each category of adopters from ‘innovators’ to ‘early adopters’
to middle majority categories
to ‘late adopters’ [laggards] tend to be consistent across a wide
range of innovations” (Green,
1989). Therefore, different marketing techniques can be used
depending on the type of
people the planners are trying to reach with a program. For
example, program planners want
rapid diffusion of innovations. They know that although
innovators will adopt the program

or product first, the key subgroups of the priority population are
the early adopters and early
majority. It is especially important to identify the early adopters
(opinion leaders) as soon as
possible in the implementation process since, according to
diffusion theory, the sooner they
adopt the innovation the sooner the rest of the population will
follow. The challenge is how
to identify and reach the early adopters.
The diffusion of innovations theory has been applied to many
different types of health
promotion programs. One of the more interesting uses of
diffusion theory has been to
“conceptualize the transference of health promotion programs
from one locale to another”
(Steckler, Goodman et al., 1992). Steckler, Goodman, and
colleagues (1992) developed a
series of six questionnaires to measure the extent to which
health promotion programs are
successfully disseminated. Planners should refer to this work if
they are interested in using
and measuring diffusion.
CommuniTy REAdinESS modEl (CRm)

Community readiness “is the degree to which a community is
willing and prepared
to take action on an issue” (Tri-Ethnic Center for Prevention
Research at Colorado State
University, 2014, p. 4). Like with individuals, communities are
in different levels of readi-
ness for change. The community readiness model (CRM) is a
stage theory for communities.
The concept of community readiness got its start back in the
early 1990s, growing out of
the need to understand the problems associated with developing
and maintaining com-
munity programs. (See Edwards, Jumper-Thurman, Plested,
Oetting, & Swanson, 2000, for a
description of the origin of the CRM.) What was evident from
the beginning is that few com-
munities were alike. They may have had similar problems, but
the dynamics in each com-

munity did not mean that the starting point for dealing with the
problem could be the same.
“Communities are fluid—always changing, adapting, growing”
(Edwards et al., 2000, p.
291), and like individuals, communities are in various stages of
readiness for change. Yet, the
stages of change for communities are not the same as for
individuals. “The stages of readiness
in a community have to deal with group processes and group
organization, characteristics
that are not relevant to personal readiness” (Edwards et al.,
2000, p. 296–297). Though the
model was developed initially to deal with alcohol and drug
abuse, it has been useful in help-
ing with a variety of health and nutrition topics (e.g., AIDS
awareness, elimination of heart
disease, depression awareness, reduction of sexually transmitted
diseases), environmentally
centered programs (e.g., air quality and recycling), and social
programs (e.g., intimate part-
ner violence programs) (Edwards et al., 2000).
The CRM defines nine stages:
1. No Awareness. The problem is not generally recognized by

the people in the community
or the leaders of the community.
2. Denial. There is little or no recognition in the community
that there is a problem; if so,
the feeling is nothing can be done about it.
3. Vague Awareness. Feeling among some in the community
that there is a problem and
something should be done, but no motivation or leadership to do
so.
4. Preplanning. The clear recognition by some that there is a
problem and something
should be done. There are leaders for action, but no focused or
detailed planning.
5. Preparation. There is planning going on but it is not based on
collected data. There is
leadership, resources are being sought, and there is modest
support for efforts.
6. Initiation. Information is available to justify and begin
efforts. Staff is in, or has just
completed, training. Leaders are enthusiastic and there is

usually little resistance and
involvement from the community members.
7. Stabilization. Program is running, staffed, and supported by
community and decision
makers. Program is perceived as stable with no need for change.
May include routine
tracking, but no in-depth evaluation.
8. Confirmation/Expansion. Standard efforts are in place and
supported by the community
and decision makers. Program has been evaluated and modified,
and efforts are in place
to seek resources for new efforts. Data are collected on an
ongoing basis to link risk
factors and problems.
9. Professionalism. Much is known about prevalence, risk
factors, and cause of
problems. Highly trained staff runs effective programs, aimed at
general population
and appropriate subgroups. Programs have been evaluated and
modified.
Community is supportive but should hold programs accountable
(Edwards et al.,

2000).
A community’s readiness for addressing an issue can be
assessed through a process in
which interviews are conducted and scored with key informants.
The interviews are based on
five key dimensions of community readiness (i.e., community
knowledge of efforts, leader-
ship, community climate, community knowledge of the issue,
and resources). Once the stage
of readiness is known, like the other stage theories, there are
suggested processes for moving
a community from one stage to the next. Table 7.8 presents the
nine stages and the goal
for each stage. A handbook for using this model has been
created and is available from the
Tri-Ethnic Center for Prevention Research at Colorado State
University (2014).
Cognitive-Behavioral Model of the Relapse Process

For most people, relapse is a part of change. Relapse “refers to
the breakdown or failure
in a person’s attempt to change or modify a particular habit
pattern, such as stopping ‘bad
habits’ or developing new, optimal health behaviors” (Marlatt
& George, 1998, p. 33).
Marlatt and George (1998) differentiate between relapse (an
indication of total failure) and
a lapse (a single slip or mistake). The first drink or cigarette
following a period of abstinence
would be considered a lapse. It has been said that getting people
to change behavior is hard,
but having them maintain the behavior is much harder. This is
nicely illustrated by the
old saying, “Giving up smoking is easy; I’ve done it a hundred
times.” At one time, it was
enough for program planners just to get people to change their
behavior; now they need to
do more. Because of the difficulty of maintaining a new
behavior, program planners need
to give special attention to helping those in the priority
population avoid slipping back to
their previous behaviors.

Although much of the early research dealing with this concept
of slipping back was con-
ducted using addictive behaviors, such as substance abuse and
gambling, the concept applies
to all behavior change, including preventive health behaviors.
Marlatt (1982) indicates that
a high percentage of individuals who enter programs for health
behavior change relapse to
their former behaviors within one year. More specifically,
researchers have warned program
planners of recidivism problems with participants in exercise
and diet (Gaesser, Angadi, &
Sawyer, 2011), oral health care treatment (McCaul et al., 1990),
weight loss (Grattan, &
Connolly-Schoonen, 2012), and smoking cessation (Leventhal &
Cleary, 1980) programs.
Therefore, planners need to make sure that program
interventions include the skills necessary
for dealing with those difficult times during behavior change.
Table 7.8 Community Readiness Stages and Goals
Source: “Community readiness: Research to practice.” Ruth W.
Edwards, Pamela Jumper-Thurman, Barbara A. Plested, Eugene
R. Oetting, Louis Swanson, in Journal

of Community Psychology 28(3). Copyright © 2000 by John
Wiley & Sons, Inc.
Stage Goal
1. No awareness Raise awareness of the issue
2. Denial Raise awareness that the problem or issue exists in the
community
3. Vague awareness Raise awareness that the community can do
something
4. Preplanning Raise awareness with the concrete ideas to
combat condition
5. Preparation Gather existing information to help plan
strategies
6. Initiation Provide community-specific information
7. Stabilization Stabilize efforts/programs
8. Confirmation/expansion Expand and enhance service
9. Professionalism Maintain momentum and continue growth
Marlatt (1982) refers to the process of trying to prevent slipping

back as relapse prevention.
Relapse prevention, which is based on the social cognitive
theory, combines behavioral skill-
training procedures, cognitive therapy, and lifestyle rebalancing
(Marlatt & George, 1998).
Relapse prevention (RP) is “a self-control program designed to
help individuals to antici-
pate and cope with the problem of relapse in the habit-changing
process” (Marlatt & George,
1998, p. 33). Relapse is triggered by high-risk situations. “A
high-risk situation is defined broadly
as any situation (including emotional reactions to the situation)
that poses a threat to the in-
dividual’s sense of control and increases the risk of potential
relapse” (Marlatt & George, 1998,
p. 38). Cummings, Gordon, and Marlatt (1980), in a study of
clients with a variety of prob-
lem behaviors (e.g., drinking, smoking, heroin addiction,
gambling, and overeating), found
high-risk situations tend to fall into two major categories:
intrapersonal and interpersonal
determinants. They found that 56% of the relapse situations
were caused by intrapersonal
determinants, such as negative emotional states (35%), negative
physical states (3%), positive

emotional states (4%), testing personal control (5%), and urges
and temptations (9%). The
44% of the situations represented by interpersonal determinants
included interpersonal con-
flicts (16%), social pressure (20%), and positive emotional
states (8%). These determinants can
be referred to as the covert antecedents of relapse. That is to
say, these high-risk situations do not
just happen; instead, they are created by what Marlatt (1982)
calls lifestyle imbalances.
People who have the coping skills to deal with a high-risk
situation have a much greater
chance of preventing relapse than those who do not. Marlatt has
developed both global
and specific self-control strategies for relapse intervention.
Specific intervention proce-
dures are designed to help participants anticipate and cope with
the relapse episode itself,
whereas the global intervention procedures are designed to
modify the early antecedents of
relapse, including restructuring of the participant’s general style
of life. A complete applica-
tion of the relapse prevention model would include both specific
and global interventions

(Marlatt, 1982).
Limitations of Theory
The major foci of this chapter have been to present an overview
and the major constructs
of the theories that are commonly used to design interventions
for health promotion pro-
grams. Although all the theories presented have been found to
be useful in certain situations
and settings, no one theory has been shown to be useful in all
situations and settings. In
fact, each of the theories presented has its limitations. For
example, the SR theory focuses on
consequences (i.e., reinforcement or punishment) that resul t
from behaviors acting on the
environment. These consequences either increase or decrease
the probability of the behav-
ior being repeated but they do not take into consideration that
thinking and reasoning also
impact behavior. The value-expectancy theories presented in
this chapter (i.e.,TPB, HBM,
PMT) focus on cognitive variables but fail to suggest that
change takes place over time in
stages. Yet the stage theories have been criticized because a

number of psychologists feel that
behavior is much more complex and that behavior change
cannot be neatly placed within a
stage. Several different author groups have reviewed the various
theories and identified their
weaknesses. Three sources (Angus et al., 2013; Boston
University School of Public Health,
2013; Munro, Lewin, Swart, & Volmink, 2007) present
limitations of many of the theories
presented in this chapter. If you are interested in limitations of
other theories not noted in
these sources or are interested in other view points about
limitations of a theory simply type
the words “limitations of” and add the name of the theory into a
Internet search engine and
a number of sources will appear.
Summary
Many theories are available to program planners, and it is

important to remember that no
one theory is best. This chapter presented an overview of the
theories that are most often
used in health promotion programs. These theories are
important for planners because they
provide information about why people are, or are not, engaging
in health-enhancing behav-
iors; what factors to consider when creating interventions; and
what factors to look for when
evaluating a program. Theories can be categorized in a number
of ways. This chapter presents
two categories. The first categorizes theories by the level of
influence at which it is most effec-
tive; the second classifies theories as either the continuum or
stage theories. Finally, a brief
explanation is provided about the limitations of theory.
Review Questions
1. Define theory, using your own words.
2. How is a theory different from a model?
3. How do concepts, constructs, and variables relate to theories?

4. Why is it important to use theories when planning and
evaluating health promotion
programs?
5. How can the socio-ecological approach be used to select a
theory for use?
6. What makes stage theories different from continuum
theories?
7. What is the underlying concept for each of the following
theories?
a. Stimulus response theory
b. Social cognitive theory
c. Theory of planned behavior
d. Health belief model
e. Protection motivation theory
f. Elaboration likelihood model of persuasion
g. Information-motivation-behavioral skills model
h. Transtheoretical model
i. Precaution adoption process model
j. Social network theory
k. Social capital theory
l. Diffusion of innovations

m. Community readiness model
8. What is the major difference between the transtheoretical
model and the precaution
adoption process model?
9. How is the community readiness model different from the
other stage models?
10. How can program planners help to prepare those in the
priority population for relapse
prevention?
Activities
1. Assume that you have identified a prioritized need for a
given priority population. In a
two-page paper:

a. State who the priority population is and what the need is.
b. Select a theory to use as a guide in developing an
intervention to address the problem.
c. Explain why you chose the theory that you did.
d. Defend why you think this is the best theory to use.
e. Show how the problem “fits into” the theory.
2. In a two-page paper, identify a theory that you plan to use in
developing the intervention
for the program you are planning. Explain why you chose the
theory, and why you think
it is a good fit for the problem you are addressing.
3. Write a paragraph on each of the following:
a. Using the stimulus response theory, explain why a person
might smoke.
b. Using the social cognitive theory (SCT), explain how you
could help people change
their diets.
c. Explain how the SCT construct of behavioral capability
applies to managing stress.
d. Explain the differences between, and the relationshi p of, the
SCT constructs of expec-

tations and expectancies.
e. Explain what would have to take place for individuals to be
self-efficacious with regard
to taking their insulin.
f. Use the information-motivation-behavioral skills model to
explain how to encourage
a person to eat a healthy diet.
g. Use the theory of planned behavior to explain how a smoker
stops smoking.
h. Use protection motivation theory to explain how you could
create a public service
announcement to encourage people to exercise.
i. Apply the health belief model to getting a person to get a flu
shot.
j. Apply the transtheoretical model to get a person to change
any health behavior.
k. Using the precaution adoption process model, explain how a
person decides to get
screened for blood cholesterol.
l. Explain how a social network could be used to encourage

people to adopt a healthy
behavior.
m. Explain how you might increase the social capital of a
community.
n. Explain who and when those in a priority population may join
a new exercise program.
o. Explain how the community readiness model could be used
by planners who are
interested in getting a citywide smoking ordinance passed.
4. Your supervisor at the local health department has asked you
to create a new program to
encourage people in your county to get the influenza vaccine.
After conducting a needs
assessment it was found that the priority population for the
program would be senior
citizens who to seem lack enabling factors for getting
vaccinated. Which theory/model

do you feel would be the best to use as the foundation for the
intervention you will
create? Write a brief rationale defending your choice.
5. You have been asked to create a brief education program to
prepare outpatients for a
screening colonoscopy for the gastroenterology department at
the hospital where you
work. The request was made because feedback from a
significant number of patients who
received the screening last year indicated that they wished they
would have known what
to expect in advance. Which theory/model do you feel would be
the best to use to plan
the education program around? Write a brief rationale defending
your choice.
6. After tallying the results of an employee satisfaction survey,
the director of the human
resources (HR) department in the company where you work
wants to begin an incentive
program to encourage more people to participate in the
employee health promotion
program. The HR director would like you to create the
incentive-based intervention for

the program. Which theory/model do you feel would be the best
to use to create the
incentive-based intervention? Write a brief rationale defending
your choice.
Weblinks
1. http://web.uri.edu/cprc/about-ttm/
Cancer Prevention Resource Center (CPRC), University of
Rhode Island
CPRC is the home of the Transtheoretical Model. At this
Website, you can obtain
information about the model, as well as measures that can be
used to “stage” a person.
2. http://www.cdc.gov/Violencepre vention/overview/social-
ecologicalmodel.html
National Center for Injury Prevention and Control, Division of
Violence Prevention,
Centers for Disease Control and Prevention
This Website provides an application of the socio-ecological
approach to violence prevention.
3. http://sbccimplementationkits.org/demandrmnch/ikitresources
/theory-at-a-glance-a-guide-for-health-promotion-practice-

second-edition/
Health Communication Capacity Collaborative National Cancer
Institute (NCI)
At this Website you will be able to download a copy of the
National Cancer Institute’s
publication Theory at a Glance: A Guide for Health Promotion
Practice. This volume presents a
single, concise summary of health behavior theories that is both
easy to read and practical.
4. http://people.umass.edu/aizen/tpb.html
Theory of Planned Behavior
This is part of the Website of Dr. Icek Ajzen, creator of the
theory of planned behavior.
The site provides great detail about the theory, as well as
sample questionnaires to show
how data can be collected using this theory.
5. http://cancercontrol.cancer.gov/brp/constructs/index.html
Cancer Control and Population Sciences, National Cancer
Institute (NCI)
This page at the NCI’s Cancer Control and Population Sciences
Website presents
definitions, background information, references, published

examples, and information
about the best measures of a number of theoretical constructs
used in health promotion
practice and research.
http://web.uri.edu/cprc/about-ttm/
http://www.cdc.gov/Violencepreve ntion/overview/social-
ecologicalmodel.html
http://sbccimplementationkits.org/demandrmnch/ikitresources
http://people.umass.edu/aizen/tpb.html
http://cancercontrol.cancer.gov/brp/constructs/index.html
191
Once the goals and objectives have been developed, planners
need to decide on the
most appropriate means of reaching or attaining those goals and
objectives. The planners must
adopt, adapt, or design an activity or set of activities that would
permit the most effective (leads
8
Chapter Interventions

Chapter Objectives
⦁ ⦁ Define the word intervention and apply it to a
health promotion setting.
⦁ ⦁ Provide a rationale for selecting an intervention
strategy.
⦁ ⦁ Explain the advantages of using a combination
of several intervention strategies rather than a
single intervention strategy.
⦁ ⦁ List and explain the different categories of
intervention strategies.
⦁ ⦁ Briefly explain motivational interviewing.
⦁ ⦁ Explain the terms curriculum, scope, sequence,
units of study, lessons, lesson plans, health
advocacy, health literacy, and health numeracy.

⦁ ⦁ Briefly explain the modified framework for
instructional design.
⦁ ⦁ Explain how behavioral economics might shape
incentives.
⦁ ⦁ Explain the difference between adopting and
adapting an evidence-based intervention.
⦁ ⦁ Describe how to adapt an evidence-based
intervention.
⦁ ⦁ Create a new intervention for a health
promotion program.
Key Terms
behavioral economics
best experience
best practices
best processes
built environment
communication
channel

community advocacy
community building
community
organization
contest
contingencies
contract
cultural audit
culturally sensitive
curriculum
disincentives
dose
GINA
health advocacy
health communication
health literacy
health numeracy
incentive
intervention
lessons
lesson plan
literacy
motivational

interviewing
multiplicity
numeracy
penetration rate
scope
segmenting
sequence
social media
strategy
tailoring
unit plans
to desired outcome) and efficient (uses resources in a
responsible manner) achievement of the
outcomes stated in the goals and objectives. These planned
activities make up the intervention, or
what some refer to as treatment. When applied to the planning
of health promotion programs,
an intervention can be defined as the planned actions that are
designed to prevent disease or

injury or promote health in the priority population. For
example, let’s say that you want the
employees of Company S to increase their use of safety belts
while riding in company-owned
vehicles. You can measure their safety belt use before doing
anything else, by observing them
driving out of the motor pool. This would be a pre-program
measure. Then you can intervene in
a variety of ways. For example, you could provide an incentive
by stating that all employees seen
wearing their safety belts would receive a $10 bonus in their
next paycheck. Or you could put in
each employee’s pay envelope a pamphlet on the importance of
wearing safety belts. You could
institute a company policy requiring all employees to wear
safety belts while driving company-
owned vehicles. Each of these activities for getting employees
to increase their use of safety belts
would be considered part of an intervention. After the
intervention, you would complete a post-
program measurement of safety belt use to determine the
success of the program. In the case of
the example just given, health education specialists could use an
incentive by itself and call it an
intervention, or they could use an incentive, pamphlets, and a

company policy all at the same
time to increase safety belt use and refer to the combination as
an intervention.
The above discussion about the number of activities that make
up an intervention in part
speaks to the size of an intervention. Two terms that relate to
the size of an intervention are
multiplicity and dose. Multiplicity refers to the number of
components or activities that make
up the intervention. We have known for a number of years
(Erfurt et al., 1990; Kline & Huff,
1999; Shea & Basch, 1990) that interventions that include
several activities are more likely to
have an effect on the priority population than are those that
consist of a single activity. What
has become more apparent in recent years is that these
intervention activities are more likely to
be effective if they are aimed at multiple levels of influence
that affect individuals’ and popula-
tions’ behaviors and health status (Glanz & Bishop, 2010). In
other words, they have a greater
chance of being successful if they use a socio-ecological
approach. Some refer to this as a systems
approach. Few people change their behavior based on a single

exposure; instead, multiple ex-
posures are generally needed to change most behaviors. It
stands to reason that “hitting” the
priority population at multiple levels or through multiple means
should increase the chances of
making an impact. Although research has shown that using
several activities is better than one,
it has not identified an exact number of activities or a specific
combination of activities that will
ensure the most effective results (Kline & Huff, 1999). The
right combination of activities will
depend on the needs of those in the priority population and the
specific planning situation.
When speaking about the dose of an intervention, we are
referring to the number of pro-
gram units delivered. For example, say that it was decided that
the intervention for a skin cancer
program would consist of multiple activities (multiplicity) and
those activities would include an
educational class for the public, distribution of text messages to
those at high risk, and radio
and television public service announcements (PSAs). The dose
questions related to these activi-
ties would be: How many times would the class be offered?

How many text messages would be
distributed? And, how many times would the PSAs run? Again,
like multiplicity, we know that
the greater the dose of an intervention, the greater the chance
for change. (Chapter 14 includes
additional information about multiplicity and dose as they relate
to process evaluation.)
Box 8.1 identifies the responsibilities and competencies for
that pertain to the material presented in this chapter.
Chapter 8 Interventions 193
Types of Intervention Strategies
As mentioned earlier, there are many different types of
activities that planners can use as
part of an intervention. Most activities can be placed in larger
categories called strategies. By
strategy, we mean “a general plan of action for affecting a
health problem” (CDC, 2003, glos-
sary). Here, we present several categories of intervention

strategies based on a modification of
the Centers for Disease Control and Prevention’s (2003)
terminology for intervention strate-
gies. These categories cover the more common strategies used
by planners, but in actuality
the variety of strategies is limited only by the planners’
imagination. Irrespective of the types
of strategies used, health education specialists should seek to
use strategies that are evidence-
based. Note that the categories presented here are not always
mutually exclusive—that is,
some of the examples that we use to help explain the strategies
could be used in more than
one category. Even with this limitation, the strategies have been
categorized into the follow-
ing seven groups:
1. Health communication strategies
2. Health education strategies
8.1
Specialists

The content of this chapter focuses on the creation or adaptation
of the intervention
that will be used in the program. The intervention is really the
heart of a program. It is
the component of the program that will cause the change in the
priority population. The
responsibilities and competencies related to the tasks of
creating an intervention include:
Health Education/
Promotion
process of health education/promotion
education/
promotion

Resource Person
Competency 6.2: Train others to use health
education/promotion
skills
Health, Health Education/
Promotion, and the Profession
a
variety of communication strategies, methods, and techniques.
Competency 7.2: Engage in advocacy for health
education/promotion
promote
health education
Health Education Credentialing,

Inc. (NCHEC) and the Society for Public Health Education
for Health Education
Education (SOPHE).
Box
3. Health policy/enforcement strategies
4. Environmental change strategies
5. Health-related community service strategies
6. Community mobilization strategies
7. Other strategies
Health Communication Strategies
Health communication has been defined as “the study and use of

communication
strategies to inform and influence individual and community
decisions that affect health”
(USDHHS, 2015a, para. 1). It can also be defined by the form it
takes in health promotion
programs (e.g., mass media, media advocacy, risk
communication, public relations, enter-
tainment education, print material, electronic communication).
Of the various interven-
tion strategies used in health promotion, we present health
communication strategies first
for several reasons. First, almost all health promotion
interventions include some form of
communication ranging from simple, such as speaking and
listening, to the more complex
communication campaigns delivered through various forms of
media. Second, communica-
tion strategies are useful in reaching many of the goals and
objectives of health promotion
programs. They have been shown to create awareness of an
issue, change attitudes toward a
health behavior, encourage and motivate individuals to follow
recommended health behav-
iors, reinforce attitude and behavior change, increase demand
and support for services, and

build social norms (Ammary-Risch, Zambon, & Brown, 2010;
NCI, n.d.). Third, communica-
tion strategies probably have the highest penetration rate
(number in the priority popu-
lation exposed or reached) of any of the intervention strategies.
And fourth, they are much
more cost effective and less threatening than most other types
of strategies. But be aware that
health communication also has its limitations. For example,
health communication alone is
rarely sufficient to change behavior and reduce the risk of
disease.
Although communication has always been an important strategy
in health promotion
programs, the means by which communication takes place has
changed. In the traditional
communication model, a sender relays a message through a
channel to receivers (i.e.,
consumers)—a vertical or top-down process. In such a model,
the sender is the gatekeeper
of the information, while the consumers play a less active,
almost passive, role in receiving
the message (Thackeray & Neiger, 2009). An example is when a
health department posts

information on its Website for public consumption. However,
with the enhanced capabili-
ties of the Internet and the development of other emerging
communication technologies,
the means of delivering health communications have been
greatly expanded and blurred
the strict roles of the sender and receiver. With the new
technology has come a new commu-
nication model: the multidirectional communication (MDC)
model (Thackeray & Neiger,
2009) (see Figure 8.1). In the MDC model, communication
occurs through a combination
of: (1) sender top-down (vertical) messages, (2) consumer
created bottom-up messages, (3)
consumer shared horizontal (side-to-side) messages, and (4)
consumers seeking information.
Thus in the MDC model consumers not only receive information
but also actively seek, de-
velop, and share information (Thackeray & Neiger, 2009).
An underlying concept of the MDC model is that the
sophistication with which health
information is communicated has changed dramatically in recent
years due in large part to

new technology. To compete for the attention and participation
of consumers, those who
plan health promotion programs must either develop a working
knowledge of these com-
munication technologies or have the foresight to access those
who can provide the necessary
expertise. A key characteristic of effective health
communication campaigns is that they are
people- (or audience-) centered (Schiavo, 2014). This requires
that planners understand con-
sumer tendencies, needs, and preferences before designing
campaigns and messages.
There are literally hundreds of communication activities that
could be used with a health
communication strategy. Communication channels is one way to
subdivide these activities.
A communication channel is the route through which a message
is disseminated to the
priority population. “Understanding communication channels is
imperative to conducting

strategic, effective and user-centric health interventions,
campaigns and outreach” (CDC,
2014b, para. 1). Selecting appropriate channels for a priority
population is often related to,
or in some cases limited by, the setting where the
communication will be delivered (Kreps,
Barnes, Neiger, & Thackeray, 2009). “For example, if the home
is identified as the prime
Tradition
al
m
ed
ia
c
ha
n
n
e
ls

New media channels
Horizontal side-to-side
information sharing
Informationseeking
Bottom-
up
user-
generated
messages
Vertical
expert-
generated
messages
Consumer
⦁ ▲ Figure 8.1 A Multidirectional Communication Model
Source: Thackeray, R., & Neiger, B. L. (2009). A
multidirectional communication model: Implications for social

marketing practice. Health
Promotion Practice, 10(2), 171–175. © 2009 Sage Publications.
setting, appropriate channels could include one-on-one home
visits, technology via the tele-
phone, or mass media via television or radio” (Kreps et al.,
2009, p. 91). The four traditional
communication channels include intrapersonal (one-on-one
communication), interper-
sonal (small group communication), organization and
community, and mass media. These
channels are hierarchical in nature with regards to the number
of people they reach. The
intrapersonal channel typically reaches the fewest number of
people, while the mass media
channel reaches the largest number of people.
Because of the Internet and the other emerging technologies we
are adding social media as
a fifth communication channel. Social media, or interactive
media, is an overarching term

for any type of media that uses the Internet and other
technologies to enhance social inter-
action for sharing and discussing information. Unlike the other
four communication chan-
nels, social media does not have a set place in the hierarchy
because it “cuts across” several
different levels. That is, depending on the type and purpose of
social media, it can be used to
generate social interaction at any of the levels of the traditional
communication channel hi-
erarchy. After we address each of the four traditional
communication channels found in the
hierarchy, we will present information on social media.
Over the years, the intrapersonal channel has most often been
used, but by no means exclu-
sively, in health care settings when the health care provider and
patient interact. This is a fa-
miliar channel for most people and one they trust. It is typically
an effective communication
channel, but it is also typically the most time and resource
intensive channel for the number
of people reached. This is especially true when the health
communication messages have
some level of personal relevance. Means of creating personal

relevance in a message include
personalizing (i.e., placing the recipient’s name on/in the
communication), targeting (i.e., pro-
viding standardized information to a segmented group like
Asian American adolescent girls),
or tailoring it for the recipient. Tailoring has been defined as
“any combination of informa-
tion or change strategies intended to reach one specific person,
based upon characteristics
that are unique to that person, related to the outcome of interest,
and have been derived
from an individual assessment” (Kreuter & Skinner, 2000, p. 1).
Tailoring takes more effort
and resources than personalizing or targeting communication
because it requires obtaining in-
dividual information on each member of the priority population
(Kreuter, Farrell, Olevitch,
& Brennan, 1999; Schmid, Rivers, Latimer, & Salovey, 2008;
Suggs & McIntyre, 2009).
Tailoring is best for helping to change complex behaviors,
targeting is best when behavior is
relatively simple (e.g., a one time behavior like getting a
vaccination) (Schmid et al., 2008),
while personalizing a message helps to get an individual’s
attention.

In more recent years, the tailoring of intrapersonal
communication has been greatly en-
hanced by the use of technology. Tailoring of messages has
been used with electronic mail
messages (Kreuter et al., 1999) and with information delivered
through Websites (Suggs &
McIntyre, 2009). Another example involves the use of
telephones. Although most people no
longer think of the telephone, when it is used to talk with
another person, as “technology,” it
too is used for health promotion interventions via the
intrapersonal channel. Planners have
used it for “gathering information, disseminating information,
providing health education
and counseling, promoting health education programs, offering
cues to action and social
support” (Soet & Basch, 1997, p. 760) on a variety of health
topics ranging from asthma
management (e.g., Raju, Soni, Aziz, Tiemstra, & Hasnain,
2012), to diabetes and hyperten-
sion (e.g., Goode et al., 2011), to weight management (e.g.,
Terry, Seaverson, Grossmeier, &
Anderson, 2011). Health education delivered by telephone “can
be classified into two broad

categories: individual initiated, whereby the individual must
actively seek contact and as-
sistance from a health information hotline; and outreach,
whereby the individual is called”
(Soet & Basch, 1997, p. 760). Individual-initiated health
information hotlines or help lines
usually provide information, and sometimes education and
counseling, whereas outreach
activities range from brief, one-time preappointment reminders
to long-term interactive pro-
fessional health counseling (Soet & Basch, 1997) or coaching.
Soet and Basch (1997) present
a generic process for developing a telephone intervention
activity that includes: (a) design-
ing the intervention protocol, (b) selecting and training those
delivering the intervention,
and (c) developing the documentation and data collection
protocol.
Within the intrapersonal channel, one health communication

activity in particular that
has received much attention is health coaching. Health coaching
is the process by which a
trained health coach, using the results from some type of
personal health assessment (e.g.,
health risk appraisal), assists a client/consumer in identifying
health-enhancing goals and uses
behavioral psychology principles to help motivate the client to
work toward the goals. This
confidential communication relationship often takes place via a
series of telephone conversa-
tions but can be conducted in face-to-face sessions. There are a
number of commercial com-
panies that offer health coaching services. Such services have
been used as part of employee
health promotion programs for a number of years (e.g.,
Chapman, Lesch, & Baun, 2007;
Harris, Hannon, Beresford, Linnan, & McLellan, 2014) to help
enhance employee health and
reduce health care costs, and more recently in clinical settings
to assist patients with health
behavior change and management of chronic diseases (e.g.,
Willard-Grace et al., 2015).
A technique that is often used in health coaching is motivational

interviewing. Motivational
interviewing (MI) “is a collaborative, person-centered form of
guiding to elicit and
strengthen motivation for change (Miller & Rollnick, 2009, p.
137). Miller (1983) first used
MI with individuals who had drinking problems. Since that time
it has been used to help indi-
viduals with a wide variety of health problems in which a
behavior change was needed (Rubak,
Sandbaek, Lauritzen, & Christensen, 2005). At the heart of MI
is helping a person explore and
resolve the ambivalence associated with behavior change. “The
operational assumption in MI
is that ambivalent attitudes or lack of resolve is the primary
obstacle to behavioral change, so
that the examination and resolution of ambivalence becomes its
key goal” (SAMHSA, 2015,
para. 1). MI is not a process where a trained professional “gives
advice” or “tells a person what
to do,” but rather is a process in which the trained professional
helps guide an individual to
identify internal motivation for change. Box 8.2 presents the
four principles of MI.
Examples of the interpersonal channel are support groups and

small classes. This channel
has many of the same characteristics of the intrapersonal
channel, but reaches larger num-
bers of people with fewer resources.
Many people receive a lot of information through organization
and community channels.
Often health promotion programs have priority populations that
are part of or entirely
comprise already existing groups (e.g., workers of a particular
company, social groups, or
members of a religious organization), or who may participate in
a community activity. As such,
organizational and community channels provide excellent ways
to reach priority populations.
Thus church bulletins, company or agency newsletters,
organizations or community bulletin
boards, and community activities are often used as a part of
communication activities.
Probably the most visible communication channel to most
people is the mass media chan-
nel. Mass media interventions can seek to influence people
either directly or indirectly. When
done directly the intervention identifies a problem of concern

and targets the people who can
8.2
Box principles of Motivational interviewing
The four principles of MI are presented below. Each is followed
by bulleted points that
provide more detail about the principle and an example
application of the principle. Note:
The participant is the person who could benefit from a behavior
change and the trained
professional is the one providing the motivational interviewing.
Principle 1: Express Empathy – Expressing empathy towards a
participant shows
acceptance and increases the chance of the trained professional
and the
participant developing a rapport.
⦁ ⦁ Acceptance enhances self-esteem and facilitates change.

⦁ ⦁ Skillful reflective listening is fundamental.
⦁ ⦁ Ambivalence is normal.
— Example statement from the trained professional: “I
understand that is has been
difficult for you to quit smoking. Many people with whom I
work find this to be difficult.
It is still important for us to try to identify ways for you to work
on this. What do you
think you can do to stop smoking?”
Principle 2: Develop Discrepancy – Developing discrepancy
enables a participant to see
that his/her present situation does not necessarily fit into his/her
values and
what he/she would like in the future.
⦁ ⦁ The participant rather than the trained professional should
present the
arguments for change.
⦁ ⦁ Change is motivated by a perceived discrepancy between
present

behavior and important personal goals and values.
— Example statement from the trained professional: “You have
told me that you would
like to feel better. I think you know quitting will improve your
health. Why do you think
it has been hard for you to quit once and for all?”
Principle 3: Roll with Resistance – Rolling with resistance
prevents a breakdown in
communication between a participant and a trained professional
and allows
the participant to explore his/her views.
⦁ ⦁ Avoid arguing for change.
⦁ ⦁ Do not directly oppose resistance.
⦁ ⦁ New perspectives are offered but not imposed.
⦁ ⦁ The participant is a primary resource in finding answers and
solutions.
⦁ ⦁ Resistance is a signal for the trained professional to
respond differently.

— Example statement from the trained professional: I know you
have tried to quit “cold turkey”
in the past, would you like to know how some others have been
successful at quitting?,
Principle 4: Support Self-Efficacy
⦁ ⦁ Self-efficacy is a crucial component to facilitating change.
If a participant
believes that he/she has the ability to change, the likelihood of
change
occurring is greatly increased.
⦁ ⦁ A participant’s belief in the possibility of change is an
important motivator.
⦁ ⦁ The participant, not the trained professional, is responsible
for choosing
and carrying out change.
⦁ ⦁ The trained professional’s own belief in the participant’s
ability to change
becomes a self-fulfilling prophecy.

— Example statement from the trained professional: “I know
that it must seem like an
impossible task to stop smoking, but now that we have
discussed some options that
have helped others stop, which ones do you think might work
for you?
Source: Adapted from United States Department of Agriculture
(n.d.).
Fo
cu
s
O
n
change it while, when it is done indirectly, the interventions
seek to influence people by creat-
ing beneficial changes in the places or environments (e.g.,

homes, schools, worksites, roads,
grocery stores, cities) in which people live and work (Abroms &
Maibach, 2008). For example,
to increase the number of children who are immunized properly
a direct mass media interven-
tion would target the parents/guardians of the children. A mass
media intervention to counter
the advertising of unhealthy foods and drinks in a specific
neighborhood would be an exam-
ple of indirect mass media intervention. The mass media
channel includes both print and elec-
tronic (e.g., distribution via the Internet) formats, such as
billboards; direct mail; daily papers
with national or local circulation; local weekly newspapers;
local, public, and network televi-
sion, including cable television; public and commercial radio
stations; and magazines with
either a broad readership or a narrow focus. There are many
ways to convey a message using
the mass media. These include news coverage, public affairs
coverage, talk shows, public ser-
vice roundtables, entertainment, public service announcements
(PSAs), paid advertisements,
editorials, letters to the editor, comic strips, and columnists’
commentaries (Arkin, 1990).

With the growth of and the developments in technology, the
social media channel has
significantly changed the way people communicate both
formally and informally. Social
media, sometimes referred to as interactive media or Web 2.0,
has several characteristics that
set it apart from the other communication channels already
discussed. The unique character-
istics of social media include 1) it is user or consumer
generated, organized, and distributed;
(2) information can be revised or updated almost immediately;
(3) it is typically low cost in
terms of creation and maintenance; (4) it can reach broader,
more diverse audiences, and (5)
it is generally entertaining to use. There are many different
forms of social media that allow
for content management (collaborative writing, e.g., wikis),
content sharing (e.g., podcasts,
Webinars, widgets, eCards), social bookmarking (i.e., tagging,
saving, searching, and rating
Websites, e.g., Digg), social gaming, social journaling (e.g.,
blogs), social networking (e.g.,
Facebook, MySpace, LinkedIn, Twitter, text messaging), social
news (i.e., tagging, voting

for, and commenting on news articles, e.g., Newsvine), social
video and photo sharing (e.g.,
YouTube, Flickr), and syndication (e.g., real simple syndication
[RSS] feeds).
Though the use of social media in health promotion
interventions may be limited only
by planners’ creativity, we feel that its greatest potential lies in
three uses: (1) the Internet as
a platform to deliver behavior change interventions (e.g., weight
loss programs; see Bennett
& Glasgow, 2009); (2) the Internet to promote health promotion
programs (e.g., viral mar-
keting; see Thackeray, Neiger, Hanson, & McKenzie, 2008);
and (3) the Internet and mobile
devices for community mobilization or advocacy (e.g.,
organizing youth to get involved in
civic affairs; see Thackeray & Hunter, 2010). However, as with
other channels of communica-
tion, when using social media planners need to think
strategically about what they are trying
to accomplish and then decide how to use technology to
accomplish the program’s goals.
In other words, planners need to focus on the relationship
between themselves and those in

the priority population, and the ways people connect with each
other, because social media
is really all about developing relationships. Thackeray and
Bennion (2009) have adapted the
strategic thinking acronym POST, found in a book by Li and
Bernoff (2008), to assist program
planners in creating health promotion interventions that include
social media (see table 8.1).
The CDC has created two publications that provide information
about and best practices
for the use of social media. They include: CDC’s Guide to
Writing Social Media (CDC, 2012a)
and The Health Communicator’s Social Media Toolkit (CDC,
2011b). (Note: See the references
for location of these publications.)
Regardless of the communication channel used in creating a
communication intervention,
planners need to consider the literacy level of those in the
priority population. Literacy “is

the ability to use printed and written information to function in
society, to achieve one’s goals,
and to develop one’s knowledge and potential” (White &
Dillow, 2005, p. 4). “Literacy can be
thought of as currency in this society. Just as adults with little
money have difficulty meeting
their basic needs, those with limited literacy skills are likely to
find it more challenging to pursue
their goals—whether these involve job advancement, consumer
decision making, citizenship,
or other aspects of their lives” (Kirsch, Jungeblut, Jenkins, &
Kolstad, 1993, p. xix). The last na-
tional assessment of adult literacy in the United States was
conducted in 2003. That study, called
the National Assessment of Adult Literacy (NAAL), assessed a
representative sample of over
19,000 adults age 16 and older on prose (the knowledge and
skills to perform prose tasks such as
reading and comprehending a news story), document (the
knowledge and skills to perform docu-
ment tasks such as completing a job application), and
quantitative literacy, sometimes referred
to as numeracy (the knowledge and skills to perform
quantitative tasks such as balancing a
checkbook or calculating a tip) (USDE, n.d.). Results of the

2003 NAAL were reported using four
literacy levels: below basic (indicates no more than the most
simple and concrete literacy skills,
e.g., searching a short, simple text to find out when to show up
for an appointment), basic (skills
necessary to perform simple and everyday literacy activities,
e.g., finding specific information
in a pamphlet), intermediate (skills necessary to perform
moderately challenging literacy activi-
ties, e.g., consulting reference materials to determine which
foods contain a particular vitamin),
and proficient (skills necessary to perform more complex and
challenging literacy activities, e.g.,
comparing viewpoints in two editorials). Figure 8.2 provides a
comparison of the percentage of
adults in each literacy level for the two most recent national
literacy assessments.
The 2003 NAAL included the first-ever national health literacy
assessment of adults in the
United States. The health literacy scale used in the assessment
and the tasks that the adults
were asked to perform were guided by the following definition
of health literacy: “the
capacity to obtain, process, and understand basic health

information and services to make
appropriate health decisions” (USDHHS, 2015b, para 1).
Like the general literacy assessment, health literacy results from
the NAAL were reported
using the same four literacy categories: below basic, basic,
intermediate, and proficient. The re-
sults showed that 14% had below basic health literacy, 22% had
basic health literacy, 53% had
intermediate health literacy, and 12% had proficient health
literacy (Kutner, Greenberg, Jin, &
Paulsen, 2006). Stated a bit differently, this study showed that
“nearly 9 out of 10 adults have
TAble 8.1 Using POST to Think Strategically About Social
Media
PoST Li & Bernoff (2008) Thackeray & Bennion (2009)
People What are they ready for? What technology do they use?
Why?
objectives Why do you want to pursue the
groundswell?
What do you want to happen (i.e., a

change in attitudes, knowledge, and/or
behavior)?
Strategy How do you want relationships to change
(e.g., customers to carry your messages;
customers to become engaged)?
How will you use the marketing mix (i.e.,
product, price, place, promotion)?
Technology What technology to use? What technology will you
use, given what
you are trying to accomplish?
difficulty using the everyday health information that is
routinely available in our health care
facilities, retail outlets, media, and communities” (USDHHS,
2010, p. 1). Though the problem
of limited health literacy affects people of all ages, races,
incomes, and education levels, it dis-
proportionately affects lower socioeconomic and minority

groups (Kutner et al., 2006).
Though the NAAL assessment of health literacy included a
quantitative component,
in recent years health numeracy has emerged as a separate and
important issue (Golbeck,
Ahlers-Schmidt, Paschal, & Dismuke, 2005). As with health
literacy, health numeracy is not
at the levels it should be and may have a significant impact on
health status (Estrada, Martin-
Hryniewicz, Peek, Collins, & Byrd, 2004). Health numeracy has
been defined as “the degree
to which individuals have the capacity to access, process,
interpret, communicate, and act on
numerical, quantitative, graphical, biostatistical, and
probabilistic health information needed
to make effective health decisions” (Golbeck et al., 2005, p.
375). This definition recognizes
that there are degrees of health numeracy that fall along a
continuum, and “that health nu-
meracy is not simply about understanding (processing and
interpreting), but also functioning
(communicating and acting) on numeric concepts in terms of
health” (Golbeck et al., 2005,
p. 375). Further, Golbeck and her colleagues (2005) suggested

that health numeracy consists
of four skills: basic (e.g., counting the number of pills),
computational (e.g., determining the
number of calories consumed using a nutritional label),
analytical (e.g., determining if test
results are in the normal range), and statistical (e.g., determine
risk with probability).
Because of the lack of health literacy and health numeracy in
the United States, health
education specialists need to work to ensure that the health
communication interventi ons
are appropriate for their priority population and consistent with
the National Action Plan
to Improve Health Literacy (USDHHS, 2010). The CDC has
created a publication–Simply Put:
⦁ ▲ Figure 8.2 Percentage of Adults in each literacy level: 1992
and 2003
Source: White & Dillow (2005). White, S., & Dillow, S. (2005).
Key concepts and features of the 2003 National Assessment of
Adult Literacy
(NCES 2006-471). Washington, DC: National Center for
Education Statistics, U.S. Department of Education.

70 60 50 40 30 20 10 0 10 20 30 40 50 60 70 80 90 100
14 28 42
44
49
58∗
29
22
22
14
14
12∗
22∗
26 32

33 33∗
30
Literacy scale
and year
Prose
1992
2003
Document
1992
2003
Quantitative
1992
2003
Percent below basic Percent basic above

Below basic Basic Intermediate Proficient
15
15
13∗
13∗
13
13
*Significantly different from 1992
Note: Detail may not sum to totals because of rounding. Adults
are defined as people 16 years of age and older living in
households or
prisons. Adults who could not be interviewed due to language
spoken or cognitive or mental disabilities (3 percent in 2003
and 4 percent in
1992) are excluded from this figure.

A guide for creating easy-to-understand materials (CDC, 2009a)
(Note: See the references for
location of this publication.)– that provides many useful ideas
for creating health commu-
nication materials.
As noted in the Simply Put (CDC, 2009a) document, making
sure written materials are
presented at the appropriate reading level for the priority
population is an important con-
cept. Americans, on average, read at the 7th grade reading level
(Mishoe, 2008). Therefore,
when writing for the general public you should try to write at
the 6th grade reading level.
Reading levels can be checked using a readability test such as,
the Fog-Gunning Index,
Flesch-Kincaid Grade Level Readability Formula, the Fry
Readability Formula, or the
SMOG (stands for Simple Measure of Gobbledegook). Today
many computer word-pro-
cessing programs include a tool that can be used to check the
reading level. In case yours

does not, Box 8.3 presents the steps in the process of testing
readability using the SMOG.
the SMoG Readability Formula
To calculate the SMOG reading grade level, begin with the
entire written work that is
being assessed, and follow these four steps:
1. Count off 10 consecutive sentences near the beginning, in the
middle, and near the
end of the text.
2. From this sample of 30 sentences, circle all of the words
containing 3 or more syllables
(polysyllabic), including repetitions of the same word, and total
the number of words
circled.
3. Estimate the square root of the total number of polysyllabic
words counted. This is
done by finding the nearest perfect square, and taking its square
root.
4. Finally, add a constant of 3 to the square root. This number

gives the SMOG grade,
or the reading grade level that a person must have reached if he
or she is to fully
understand the text being assessed.
A few additional guidelines will help to clarify these
directions:
⦁ ⦁ A sentence is defined as a string of words punctuated with a
period (.), an exclamation
point (!), or a question mark (?).
⦁ ⦁ Hyphenated words are considered as one word.
⦁ ⦁ Numbers that are written out should also be considered, and
if in numeric form in the
text, they should be pronounced to determine if they are
polysyllabic.
⦁ ⦁ Proper nouns, if polysyllabic, should be counted, too.
⦁ ⦁ Abbreviations should be read as unabbreviated to determine
if they are polysyllabic.
Not all pamphlets, fact sheets, or other printed materials contain

30 sentences. To test
a text that has fewer than 30 sentences:
1. Count all of the polysyllabic words in the text.
2. Count the number of sentences.
3. Find the average number of polysyllabic words per sentence
as follows:
Average =
Total # polysyllabic words
Total # of sentences
4. Multiply that average by the number of sentences short of 30.
A
pp
lic
at
io
n

8.3
Box
Source: The SMOG Readability Formula from “SMOG
grading—a new reading formula” by H.G. McLaughlin, The
Journal of Reading 12, 639-646.
Copyright © 1969 by John Wiley & Sons. Reprinted with
permission.
Health Education Strategies
Earlier (Chapter 1) health education was defined as “any
planned combination of learning
experiences designed to predispose, enable, and reinforce
voluntary behavior decisions con-
ducive to health in individuals, groups, or communities” (Green
& Kreuter, 2005, p. G-4).
You may be asking, “How is this definition different from the
definition presented in the

earlier section for health communication strategies?” There are
some health communication
strategies, because of the way they are designed, that could be
classified as health education
strategies. And, there are some health education strategies that
could meet the definition of
health communication strategies. There is no clear dividing line
between these two catego-
ries of intervention strategies. That is, they are not mutually
exclusive categories. In fact, it
is for this reason that some authors have included health
education strategies as part of the
health communication strategies category or vice versa. Yet, we
have decided to separate
the two types of strategies. In general, we see health
communication strategies as those that
inform people (e.g., a brochure on skin cancer or a mass media
campaign on preventing
HIV), while health education strategies are those that are
planned learning experiences that
provide knowledge and skills to the learners in a more formal
educational setting. We see
SMoG Conversion table*

total polysyllabic
Word Counts
Approximate Grade level
(±1.5 Grades)
0–2 4
3–6 5
7–12 6
13–20 7
21–30 8
31–42 9
43–56 10
57–72 11
73–90 12
91–110 13

111–132 14
133–156 15
157–182 16
183–210 17
211–240 18
*Developed by Harold C. McGraw, Office of Educational
Research, Baltimore County
Schools, Towson, Maryland.
5. Add that figure to the total number of polysyllabic words.
6. Find the square root and add the constant of 3.
Perhaps the quickest way to administer the SMOG grading test
is by using the SMOG
conversion table. Simply count the number of polysyllabic
words in your chain of 30
sentences and look up the appropriate grade level on the chart.

8.3
Box
continued
health education strategies as those usually associated with
settings such as classes, semi-
nars, workshops, and courses, both face-to-face and online.
Some examples include prenatal
classes for expectant parents, a workshop for parents on how to
better communicate with
their teenager, or a first aid and CPR course for potential
babysitters.
Prior to presenting information about creating health education
interventions it is
important to have some background in how people learn. Many
theories/models have been
put forth to help explain how people learn. While many of the
theories/models include com-
ponents that are unique to the theory/model, there is also much

overlap in the content. Space
does not allow for the review of those theories/models here.
However, we are fortunate that
other authors (Bryan, Kreuter, & Brownson, 2009; Minelli &
Breckon, 2009) have reviewed
those theories/models. Those reviewers have identified many of
the common components
and created lists of learning principles. Their lists can help
guide planners as they create health
education interventions. We present their lists here. Minelli and
Breckon (2009) refer to their
list as the 10 general principles of learning. For them, learning
is facilitated: (1) if several of
the senses (e.g., seeing, hearing, speaking) are used; (2) if the
learner is actively involved in the
process, rather than a passive participant; (3) if the learner is
not distracted by discomfort or
extraneous events; (4) if the learner is ready to learn; (5) if that
which is to be learned is rele-
vant to the learner and that relevance is perceived by the
learner; (6) if repetition is used; (7) if
the learning encountered is pleasant, if progress occurs that is
recognizable by the learner, and
if that learning is recognized and encouraged; (8) if the material
to be learned starts with what

is known and proceeds to the unknown, while concurrently
moving from simple to complex
concepts; (9) if application of concepts to several settings
occurs, which generalizes the mate-
rial; and (10) if it is paced appropriately for the learner.
The principles offered by Bryan and colleagues (2009) are
specific to adult learners. The
principles represent a synthesis of recurring themes that the
authors found when reviewing
existing theories/models related to adult education. Their adult
learning principles include:
1. “Adults need to know why they are learning.
2. Adults are motivated to learn by the need to solve problems.
3. Adults’ previous experience must be respected and built
upon.
4. Adults need learning approaches that match their background
and diversity.
5. Adults need to be actively involved in the learning process.”
(p. 559)

With this brief overview of learning principles, let’s look at the
makeup of a health edu-
cation intervention. Though health communication strategies
may be the most frequently
used health promotion intervention strategy, health education
strategies are the ones that
provide the opportunity for the priority population to gain in-
depth knowledge about
a particular health topic. Well-designed health education
strategies take an understand-
ing of the educational process and take a great deal of effort to
create. In order to better
understand this process, several terms must be defined. The first
is the word curriculum.
Curriculum refers to “a planned set of lessons or courses
designed to lead to competence
in an area of study” (Gilbert, Sawyer, & McNeill, 2015, p. 437).
Examples include the
health education curriculum of a school district or the
curriculum for a hospital’s diabe-
tes education program. To further define a curriculum it is
important to understand the
terms scope and sequence. Scope refers to the breadth and depth
of the material covered in

a curriculum, whereas sequence defines the order in which the
material is presented. To
Resources & References Content
Introduction:
Conclusion:
Evaluation:
Body:
1.
2.
3.
Teaching Method

Unit: Lesson No.:
Priority Population: Length of Lesson:
Title of Program: Title of Lesson: Page of
⦁ ▲ Figure 8.3 example lesson Plan Format
further clarify these definitions, scope has been referred to as
the horizontal organization
of the substance of the curriculum (Goodlad & Su, 1992), while
the sequence is the vertical
relationship among the curricular areas (Ornstein & Hunkins,
1998). It is not unusual for
the scope of a health education curriculum to be presented as
unit plans. A unit plan is de-
fined as “an orderly, self-contained collection of activities
educationally designed to meet
a set of objectives. Other terms for this are curriculum plans,
modules, and strands” (Gilbert
et al., 2015, p. 202). Thus, a school health curriculum may have
units on exercise, nutri-
tion, chronic diseases, communicable diseases, and so forth,
while the diabetes education
curriculum might include units on self-management, working
with a health care profes-

sional, and avoiding emergencies. And finally, units of study
are further subdivided into
lessons—the amount of material that can be presented during a
single educational en-
counter, say for example the amount of material that can be
presented in a one-hour class.
The written outline of a lesson is referred to as a lesson plan
and typically includes three
components—introduction, body, and conclusion. The
introduction provides an over-
view of what will be covered, the body presents the health
content, and the conclusion
reviews what was presented. There is an old saying that
summarizes these three parts that
states tell them what you are going to tell them [introduction],
tell them it [body], and tell them
what you told them [conclusion]. (See Figure 8.3 for an example
lesson plan format.)
The heart of any lesson is the body or the content portion of the
lesson. Gagne (1985)
has created a framework, called the Nine Events of Instruction,
for designing educational ex-
periences that provides a nice outline for creating the body of a
lesson. More recently, Kinzie

(2005) modified Gagne’s framework for application to health
promotion applications. The
modified framework includes five stages instead of the original
nine created by Gagne: (1)
gain attention (convey health threats and benefits); (2) present
stimulus material (target or
tailor the message to audience knowledge and values,
demonstrate observable effectiveness,
make behaviors easy to understand and do); (3) provide
guidance (use trustworthy models to
demonstrate); (4) elicit performance and provide feedback (to
enhance trailability, and develop
TAble 8.2 Application Instructional Design Framework for a
Lesson on Breast Cancer
Stage Content Covered Method of Presentation
Gain attention • Help participants identify
personal risk to breast cancer

• Use breast cancer risk appraisal
or breast cancer pretest
• Share benefits of doing
breast self-examinations
(BSE), regular breast exams by
physicians, and mammograms
• Present a case study of women
finding a lump in the breast
early
Present stimulus material
Target/tailor message
to knowledge and values
• Using information from
risk appraisal or pretest,
target/tailor breast cancer
information
• Lecture/discussion
Demonstrate
observable

effectiveness
• Explain importance of early
diagnosis
• Use peer educators to
role-play interaction with
physician
Make desired
behaviors easy
to understand
• Present steps in BSE and
making appointment
with physician and for
mammogram
• Use video showing correct
steps for BSE or peer
educators to demonstrate on
models
Provide guidance • Have others share experiences
on how exams are conducted

• Use guest speakers who
perform regular BSE and
radiographers who do
mammograms
Elicit performance and
provide feedback
• Repeat steps in BSE and let
participants practice BSE
• Use breast models for practice
and provide critique
Enhance
retention and transfer
• Encourage participants to
share information learned
with others and ways to
remember to act
• Lecture/discussion
• Brainstorm reminder ideas

• Distribute BSE shower cards
that explain importance
of regular action for
participants to place in their
bathrooms
proficiency and self-efficacy); and (5) enhance retention and
transfer (provide social support
and deliver behavioral cues) (Kinzie, 2005). table 8.2 provides
an example of how these five
stages can be applied to a health topic.
There are many different ways of presenting health education
such as lecture, discussion,
group work, audiovisual materials, computerized instruction,
laboratory exercises, and writ-
ten materials (books and periodicals). Box 8.4 provides a more
complete listing of educational
activities, and Gilbert et al. (2015) have provided a detailed
discussion of these activities.
Health policy/Enforcement Strategies
Health polices/enforcement strategies include executive orders,

laws, ordinances, judicial
decisions, policies, regulations, rules, and position statements.
Though each of the differ-
ent types of policy/enforcement strategies has its own
definition, common to all of them is
a decision made by an authoritative person,
agency/organization, or body and that is pre-
sented in a statement or guidelines intended to direct or
influence the actions or behaviors
8.4
Commonly Used Educational Activities
A. Audiovisual materials and equipment
1. Audiotapes, records, and CDs
2. Bulletin, chalk, cloth, flannel, magnetic, and peg boards
3. Charts, pictures, and posters

4. Films and filmstrips
5. Instructional television
6. Opaque projector or Elmo
7. Slides and slide projectors
8. Transparencies, PowerPoint® slides, and overhead projector
9. Video (DVDs and tapes)
B. Technology-assisted instruction
1. World Wide Web
2. Desktop publishing
3. Photo and video voice
4. Presentation programs
5. Individualized learning programs

6. Video conferencing (e.g., Skype)
7. Social media
C. Printed educational materials
1. Displays and bulletin boards
2. Instructor-made handouts and worksheets
3. Pamphlets
4. Study guides (commercial and instructor-made)
5. Text and reference books
6. Workbooks
D. Teaching strategies and techniques for the classroom
1. Brainstorming
2. Case studies
3. Cooperative learning

4. Debates
5. Demonstrations and experiments
6. Discovery or guided discovery
7. Discussion
8. Group discussion
9. Guest speakers
10. Lecture
11. Lecture/discussion
12. Newspaper and magazine articles
13. Panel discussions
14. Peer group teaching/coaching
15. Personal improvement projects

16. Poems, songs, and stories
17. Problem solving
Fo
cu
s
O
n
Box
8.4
Box
18. Puppets
19. Questioning

20. Role playing and plays
21. Simulation, games, and puzzles
22. Tutoring
23. Values clarification activities
24. Word games
E. Teaching strategies and techniques for outside of the
classroom
1. Community resources
2. Field trips
3. Health fairs
4. Health museums
5. Health education centers
continued

of others. Another way to think about them is as strategies that
are mandated or regulated.
Such strategies revolve around establishing some type of
standard or requirement, some-
times associated with incentives or disincentives, to encourage
or discourage actions by
groups of individuals or society as a whole (Riegelman, 2014).
This type of intervention
strategy can regulate the behavior of individuals (e.g., use of
safety belts and motorcycle
helmets), organizations (e.g., paying taxes for certain
activities), institutions (e.g., school
board adopting a position statement that a district will only
provide well-balanced meals
in the cafeteria), or communities (e.g., housing codes for rental
properties) (Brennan
Ramirez et al., 2008). This type of intervention strategy can
also be used to “affect the built
environment, such as zoning related to new grocery stores or
fast food restaurants, mainte-
nance of sidewalks and streetscapes, or architectural design
features such as neighborhood
signage addressing the history and culture of the community”
(Brennan Ramirez et al.,
2008, p. 70).

Health policy/enforcement strategies may be controversial.
Some have criticized this type
of strategy because it mandates a particular response from those
governed by it. It takes away
individual freedoms and sometimes plays on a person’s pride,
“pocketbook,” and psyche.
Stated a bit differently, “it runs counter to a fundamental
emphasis on property rights, eco-
nomic individualism, and competition in American political
culture. The exceptionalism
of the United States lies in its antistatist beliefs: Americans are
less concerned with what
government will do to benefit individuals than what government
might do to control them”
(Oliver, 2006, p. 196). This type of strategy must be based on
sound evidence and must be
sold on the basis of “common good.” That is, the justification
for this type of societal action
is to protect the public’s health. Health policy/enforcement
strategies exist for the protection
of the community and of individual rights. For example, in
order to establish herd immunity
most in a population need to be immunized, thus the reasoning
behind immunizing chil-

dren prior to entering school.
Some would say that health policy/enforcement strategies do not
allow for the “voluntary
behavior conducive to health” suggested by Green and Kreuter
(2005, p. G-4) in their defini-
tion of health education. But, at the same time, this kind of
activity can get people to change
their behavior when other strategies have failed. Brownson,
Chriqui, and Stamatakis (2009)
have pointed out that if we review the 10 great public health
achievements of the 20th century
(CDC, 1999b), we will find that each of them was influenced by
policy. For example, before the
passage of safety belt laws, a national study showed that about
11% of drivers and front-seat
passengers of automobiles were observed using a safety belt
(Goodwin et al., 2013). Now that
safety belt laws are in effect, national safety belt use is 86%; in
states where the law permits law
enforcement officers to stop and cite a safety belt violator

independent of any other traffic be-
havior (i.e., primary enforcement belt use law), usage rates
average 90% (Goodwin et al., 2013).
Policymaking is complex and each setting in which policy is
created has its own char-
acteristics. For example, a state legislature where a law for
smokefree public places is being
debated would have many different characteristics from a
boardroom of a private company
where a no smoking policy is being created. Regardless of the
setting, Block (2008) has identi-
fied six phases of policymaking—agenda setting, policy
formulation, policy adoption, policy
implementation, policy assessment, and policy modification—
that we feel can be adapted
and applied to the creation of any of the health
policy/enforcement strategies for a health
promotion program. The first phase, agenda setting, deals with
determining what the health
problem is, analyzing whether the cause of the problem can best
be solved with a policy/
enforcement strategy, and identifying evidence to show that
such a strategy will work. Phase
2, policy formulation, is the phase in which the policy or

mandated action is actually devel-
oped. The actual wording of the policy is not easy work. It is
difficult to move from a concept
or idea to wording that effectively carries out the intent of the
concept or idea and creates
the most good for the most people. The simplest language
possible should be the goal. If the
policy being created is a legal document (e.g., law, ordinance),
it is not unusual for various
interest groups to try to influence those writing the document so
that the resulting work
best represents their interests. In other words, there are likely to
be both pro and con feelings
toward the policy and thus this phase can be very political. The
third phase, policy adoption or
approval, takes place when the authoritative individual or group
“approves” the formulated
policy. Again, depending on the policy being considered,
politics can impact the outcome.
Once the policy has been approved it must be implemented.
This is the fourth phase of
the process. In this phase, the necessary human and financial
resources must be assembled
to make the policy work. As a part of this phase, it is important

that those who are imple-
menting the new policy use good judgment and show respect for
others when doing so.
Depending on the policy and its complexity there may be a need
for education programs to
ensure that the priority population understands the policy.
Consideration may also need to
be given to the enforcement of the policy. The fifth phase of the
process, policy assessment,
entails making sure that the policy is being carried out as
written and that it is indeed work-
ing to solve the problem it was intended to solve. Based on the
results of the policy assess-
ment, the authoritative individual or group must consider the
sixth and final phase—policy
modification. In this phase some judgment and possible action
must be made to determine
whether the policy should be maintained, modified, or
eliminated (Dunn, 1994). Box 8.5
provides a list of questions that need to be considered when
determining whether or not
policy should be the or part of the health promotion
intervention.

Environmental Change Strategies
Another group of strategies that has been used in meeting the
goals and objectives of health
promotion programs is environmental change strategies. Such
strategies have been most use-
ful in providing “opportunities, support, and cues to help people
develop healthier behav-
iors” (Brownson, Haire-Joshu, & Luke, 2006, p. 342). As such,
they help remove barriers in
the environment. “Environmental barriers in a community can
make modifying unhealthy
behaviors challenging. Poor environmental quality; inadequate
access to affordable, nutri-
tious food; and safety issues often make healthy living
impractical” (Flores, Davis, & Culross,
2007, para. 4). In other words, environmental change strategies
are about creating health-
enhancing environments (Hunnicutt & Leffelman, 2006). In the
1986 Ottawa Charter for
Health Promotion, it was stated that the healthier choice should
be the easier choice (WHO,

2009). Friedan (2010) stated it a bit differently when he said
that the content of the envi-
ronment should be changed to make healthy options the default
choice so that individuals
would have to expend significant effort not to benefit from
them. Removing environmental
barriers often helps to make the healthier choice the easier
choice.
Environmental change strategies are characterized by changes
“around” individuals and
are not limited to the physical environment. Other environments
include the economic envi-
ronment (e.g., financial costs, affordability), service
environment (e.g., accessibility to health
care or patient education), social environment (e.g., social
support, peer pressure), cultural
environment (e.g., traditions of ethnic group), psychological
environment (e.g., emotional
learning environment), and political environment (e.g., support
for healthy environments).
Environmental change strategies have a close relationship to
health policy/enforcement
strategies because there are times when a policy change may be
needed to make a change in

the environment, for example a city or county ordinance that
creates smokefree workplaces.
Other examples of such strategies include equipping
automobiles with safety belts, air bags,
and child safety seats; placing speed bumps in parking lots by
playgrounds to slow traffic
where children are present; or installing fire and safety doors in
apartment buildings to make
8.5
Questions to Consider When Creating policy
⦁ ⦁ Is policy the best way to deal with the problem? Is it
necessary?
⦁ ⦁ Is there evidence to show that the proposed policy has the
potential to be effective?
⦁ ⦁ Is the proposed policy based on ethical principles that
balance rights, interests, and
values?
⦁ ⦁ Is the proposed policy stated clearly?

⦁ ⦁ Will the proposed policy include implementation and
enforcement language?
⦁ ⦁ Is the policy culturally appropriate for the priority
population?
⦁ ⦁ Has a representative group from the priority population
been engaged and involved in
the policy making process?
⦁ ⦁ Is there support for the proposed policy?
⦁ ⦁ Is there a need for the public to discuss/debate the proposed
policy?
⦁ ⦁ What are the potential barriers to getting the policy
enacted, implemented, sustained,
and evaluated? Opposition? Resources? Political climate?
⦁ ⦁ Would it be useful to phase-in the policy overtime?
Fo
cu
s

O
n
Box
them safer for the residents. Often environmental change
strategies do not necessarily require
action on the part of the priority population (CDC, 2003) as
noted in the examples above. Yet,
some of these strategies provide a “forced choice” situation, as
when the selection of foods
and beverages in vending machines or cafeterias are changed to
include only healthful foods.
If people want to eat foods from these places, they are forced to
eat certain types of foods.
Other activities in this category may provide those in the
priority population with health
messages and environmental cues for certain types of behavior.
Examples would be post-
ing of no-smoking signs, eliminating ashtrays, providing lockers

and showers, using role
modeling by others, playing soft music in a work area,
organizing a shuttle service or some
other type of transportation system to get seniors to congregate
for meals or to a health care
provider, and providing point-of-purchase education, such as a
sign on a vending machine
or food labeling on the food options in the cafeteria.
One “environment” that has received increased attention in
recent years is the built en-
vironment. The term built environment “generally refers to an
interdisciplinary area of
focus that describes the design, construction, management, and
land use of human-made
surroundings as an interrelated whole, as well as their
relationship to human activities
over time” (Coupland, Rikhy, Hill, & McNeil, 2011, p. 6). It
includes, but is not limited to:
transportation systems (e.g., mass transit); urban design features
(e.g., bike paths, sidewalks,
adequate lighting); parks and recreational facilities; land use
(e.g., community gardens, loca-
tion of schools, trail development); building with health
enhancing features (e.g., green roofs,

stairs); road systems; and housing free from environmental
hazards (Coupland et al., 2011;
Davidson, 2015; IOM, 2005). The built environment can be
structured to give people more or
fewer opportunities to behave in health enhancing ways. Earlier
(see Chapter 4) we discussed
the use of health impact assessments (HIAs) as a special type of
needs assessment process “to
determine the potential effects of a proposed policy, plan,
program, or project on the health
of a population and the distribution of those effects within the
population” (NRC, 2011, p. 5).
Although the major focus of an HIA is to make sure change is
not made that could harm the
health of a population, the results of a HIA could also lead to
the modifications or additions to
the built environment that provide more opportunities for
enhancing health.
Finally, like so many of the other intervention strategies,
environmental change strate-
gies often are more effective when combined with intervention
strategies from the other
categories. An example of such multiplicity is combining the
mandating of safety belts in

automobiles, which is important alone, with strict enforcement
of safety belt laws (a health
policy/enforcement strategy), which makes for a much more
effective intervention.
Health-Related Community Service Strategies
Health-related community service strategies include services,
tests, treatments, or care to
improve the health of those in the priority population (CDC,
2003). Examples of this type
of intervention strategy include, but are not limited to,
completing a health risk assessment
(HRA) form (see Chapter 4 for a discussion of HRAs); offering
low-cost flu shots or child im-
munizations; providing clinical screenings (sometimes called
biometric screenings) for diabe-
tes, blood pressure, or cholesterol; and providing professional
health checkups and exami-
nations. Because a health-related community service strategy
requires action on the part of
those in the priority population, an important component of this
type of strategy is to reduce
the barriers to obtaining the service. Thus planners must be
mindful of the affordability and

accessibility of such services. Also, planners must weigh the
consequences of including this
type of strategy in an intervention. For example, if abnormal
readings are found during a
screening, those conducting the screening have an ethical
obligation to follow up and make
sure appropriate referrals for care are made. Chapman (2003)
has provided a nice review of
many of the concerns associated with biometric screening.
Health-related community service strategies are often carried
out by partnering organiza-
tions and are offered in a variety of settings including grocery
stores, pharmacies, shopping
malls, health fairs, worksites, personal residencies, mobile units
(e.g., vans equipped with
mammography units), and easily accessible health care
facilities. Such strategies usually have
high credibility with priority populations because of their link
with health care providers.

Community Mobilization Strategies
“Community mobilization strategies involve helping
communities identify and take ac-
tion on shared concerns using participatory decision making,
and include such methods as
empowerment” (Barnes, Neiger, & Thackeray, 2003, p. 60).
There is increasing evidence to
support population-wide, community-level interventions to
change health behaviors when
community mobilizing strategies are combined with other
strategies (Karwalajtys et al.,
2013). In this book we present two subcategories of community
mobilization strategies: (1)
community organization and community building, and (2)
community advocacy.
CoMMUnity oRGAnizAtion AnD CoMMUnity BUilDinG
Other than defining the terms community organization and
community building, little will be pre-
sented here about these terms because more information is
presented elsewhere (Chapter 9).
Community organization has been defined as “the process by

which community groups
are helped to identify common problems or change targets,
mobilize resources, and develop
and implement strategies to reach their collective goals”
(Minkler & Wallerstein, 2012, p. 37).
Community building is “an orientation to practice focused on
community, rather than a
strategic framework or approach, and on building capacities, not
fixing problems” (Minkler,
2012, p. 10).
CoMMUnity ADVoCACy
Community advocacy is a process in which the people of the
community become in-
volved in the institutions and decisions that will have an impact
on their lives. It has the
potential for creating more support, keeping people informed,
influencing decisions, activat-
ing nonparticipants, improving service, and making people,
plans, and programs more re-
sponsive (Checkoway, 1989). Some individuals often confuse or
use the words advocacy and
lobbying interchangeably. There is a distinction. Lobbying is
when individuals/organizations

attempt to influence a specific piece of pending legislati on by
contacting elected officials or
their representatives, while advocacy is trying to affect
generalized change (e.g., healthier
school lunches) by expressing opinions for or against causes or
positions. Community advo-
cacy can have a big impact on social change issues, including
those dealing with health. The
community advocacy that deals with health issues is called
health advocacy. This type of
advocacy has been defined as “the processes by which the
actions of individuals or groups at-
tempt to bring about social, environmental, and/or
organizational change on behalf of a par-
ticular health goal, program, interest, or population” (Joint
Committee on Health Education
and Promotion Terminology, 2012, p. 17). Galer-Unti, Tappe,
and Lachenmayr (2004) have
identified seven different ways of advocating for health and
health education: (1) influenc-

ing voting behavior, (2) electioneering, (3) direct lobbying, (4)
integrating grassroots lob-
bying into direct lobbying efforts, (5) using the Internet, (6)
media advocacy—newspaper
letters to the editor and opinion-editorial (op-ed) articles, and
(7) media advocacy—acting
as a resource person. They have further organized these seven
advocacy strategies in a three-
tiered approach to show the varying levels of involvement in the
advocacy process. These
levels and examples of each are presented in table 8.3.
As noted in our earlier discussion of health communication
strategies, the Internet and
emerging technologies can be effective means to enhance
advocacy efforts. Thackeray and
Hunter (2010) have suggested that cell phones and social
networking sites (SNS) on the
Internet can be used for: (1) recruiting people to join the cause,
(2) organizing collective ac-
tion, (3) raising awareness and shaping attitudes, (4) raising
funds to support the cause, and
(5) communicating with decision makers. While both cell
phones and SNS can be used for
these advocacy-related purposes there are advantages and

disadvantages to using one over
the other in various situations. table 8.4 outlines the
comparative qualities of each.
TAble 8.3 Advocacy Strategies: Good, Better, Best
Source: Galer-Unti, R. A., Tappe, M. K., Lachenmayr, S.
(2004). Advocacy 101: Getting Started in Health Education
Advocacy. Health Promotion Practice Vol 5(3) pp. 280-288.
Copyright © 2004 by Society for Public Health Education.
Reprinted by permission of SAGE Publications, Inc.
Strategy Good Better Best
Voting behavior Register and vote Encourage others to
register and vote
Register others to vote
Electioneering Contribute to the
campaign of a
candidate friendly to
public health and
health education

Campaign for a
candidate friendly to
public health and
health education
Run for office or seek a
political appointment
Direct lobbying Contact a policy maker Meet with your
policy makers
Develop ongoing
relationships with your
policy makers and their
staff
Integrate grassroots
lobbying into direct
lobbying activities
Start a petition drive
to advocate a specific
policy in your local
community

Get on the agenda
for a meeting of a
policy-making body
and provide
testimony
organize a community
coalition to enact changes
that influence health
Use the Internet Use the Internet to
access information
related to health
issues
Build a Webpage that
calls attention to a
specific health issue,
policy, or legislative
proposal
Teach others to use
the Internet for
advocacy activities

Media advocacy:
Newspaper letters to
the editor and op-ed
articles
Write a letter to the
editor
Write an op-ed piece Teach others to write
letters and op-ed
pieces for media
advocacy
Media advocacy:
Acting as a resource
person
Respond to requests by
members of the media
for health-related
information
Issue a news release Develop and
maintain ongoing
relationships

with the media
personnel
TAble 8.4 Comparative Qualities of Social Networking Sites
and Cell Phones in Advocacy
Source: “Empowering Youth: Use of Technology in Advocacy
to Affect Social Change.” R. Thackeray and M. Hunter, from
the Journal of Computer–Mediated Communication,
Volume 15, pp. 575–591. Copyright © 2010 by John Wiley &
Sons, Inc. Reprinted with permission.
Technology Advantages for Advocacy Disadvantages for
Advocacy
Social Networking Sites Message sent on SNS can be
stored indefinitely
Not all advocates may be able to
attend in-person events because
of geographic distances inherent

in an online community
Easy to invite friends and fans to
join the advocacy cause
older decision makers may not give
as much credence to this form of
communication
Can organize events and post
specifics about location, time,
and purpose
Requires Internet access
Reach a large number of people
quickly
one central location for advocates
to find information about the
advocacy cause
Can post videos or photos
Unlimited space to post

information
Can update posts from a
Web-enabled cell phone or
mobile device
Can check posts from a
Web-enabled cell phone or
mobile device
Cell Phones Reach a large number of people
quickly in real-time
A text or video message may be
quickly erased
Text or video message will be
received immediately
Decision makers may not be able
to answer the phone when in a
meeting
Can use phones to take photos Have to limit messages to 160
characters

Decision maker can read a text
message while in a meeting
Advocates’ cell phone calling plans
may be limited by the number of
text messages they can send
Can be used to send quick, brief
reminders of events
Not all advocates may own a cell
phone
No need for Internet access Cell phone numbers may be
changed and contact with
advocates is lost.
Can talk to the other individual in
person.
Can forward text or video messages
to friends and other advocates

For planners interested in improving their knowledge and skills
related to community
advocacy activities, the Society for Public Health Education
(SOPHE) and the American
Public Health Association (APHA) have created useful guides.
SOPHE’s document is titled
Guide to Effectively Educating State and Local Policymakers
(available at: http://www.sophe.
org/CDP/Ed_Policymakers_Guide.cfm), while APHA’s is titled
APHA Legislative Advocacy
Handbook: A Guide for Effective Public Health Advocacy
(available at: http://www.iowapha.org/
resources/Documents/APHA Legislative Advocacy
Handbook1.pdf).
other Strategies
The other strategies category includes a variety of intervention
activities that do not fit
neatly into one of the six categories discussed above.
BEHAVioR MoDiFiCAtion ACtiVitiES

Behavior modification activities, often used in intrapersonal -
level interventions, include
techniques intended to help those in the priority population
experience a change in be-
havior. Behavior modification is usually thought of as a
systematic procedure for changing a
specific behavior. The process is based on the stimulus response
and social cognitive theories.
As applied to health behavior, emphasis is placed on a specific
behavior that one might want
either to increase (such as exercise or stress management
techniques) or to decrease (such as
smoking or consumption of fats). Particular attention is then
given to changing the events
that are antecedent or subsequent to the behavior that is to be
modified.
In changing a health behavior, the behavior modification
activity often begins by having
those trying to make a change keep records (diaries, logs, or
journals) for a specific period
of time (24 to 48 hours, one week, or one month) concerning the
behavior (such as eating,
smoking, or exercise) they want to alter. Using the information

recorded, one can plan an ac-
tivity to modify that behavior. For example, facilitators of
smoking cessation programs often
will ask participants to keep a record of all the cigarettes they
smoke from one class session
to the next (see Figure 8.4 for an example of such a record).
After keeping the record, partici-
pants are asked to analyze it to see what kind of smoking habit
they have. They may be asked
questions such as: “What three cigarettes seem to be the most
important of the day to you?”
“In what three places or activities do you find yourself smoking
the most?” “With whom do
you find yourself smoking most often?” “Is there a primary
reason or mood for your smok-
ing?” “When during the day do you find yourself smoking the
most and the least?” Once
the participant has answered these questions, appropriate
interventions can be designed to
deal with the problem behavior. For example, if participants say
they smoke only when they
are by themselves, then activities would be planned so that they
do not spend a lot of time
alone. If other participants seem to do most of their smoking
while drinking coffee, an activ-

ity would be developed to provide some type of substitute. If
participants seem to smoke the
most while sitting at the table after meals, activities could be
planned to get them away from
the table and doing something that would occupy their hands.
Another way of leading into a behavior modification activity is
through a health status
evaluation, or what is often referred to as a health screening.
Such screenings could happen
at home (e.g., BSE, TSE, hemocult), at a community health fair
(e.g., blood pressure, cho-
lesterol), or in the office of a health care professional (e.g.,
breast examination). Like record
keeping via diaries, logs, or journals, health screenings can
“grab the attention” (develop
awareness) of those in the priority population to begin the
behavior modification process.
http://www.sopheorg/CDP/Ed_Policymakers_Guide.cfm
http://www.iowapha.org/resources/Documents/APHA
Legislative Advocacy Handbook1.pdf
http://www.sopheorg/CDP/Ed_Policymakers_Guide.cfm
http://www.iowapha.org/resources/Documents/APHA
Legislative Advocacy Handbook1.pdf

Name ____________________
Date _____________________
Number of
Cigarettes Need Place With Mood
During the Day Time of Day Rating* of Activity Whom or
Reason
1. ___________ 1 2 3 ___________ ___________
_____________
2. ___________ 1 2 3 ___________ ___________
_____________
3. ___________ 1 2 3 ___________ ___________
_____________
4. ___________ 1 2 3 ___________ ___________
_____________

5. ___________ 1 2 3 ___________ ___________
_____________
6. ___________ 1 2 3 ___________ ___________
_____________
7. ___________ 1 2 3 ___________ ___________
_____________
8. ___________ 1 2 3 ___________ ___________
_____________
9. ___________ 1 2 3 ___________ ___________
_____________
10. ___________ 1 2 3 ___________ ___________
_____________
11. ___________ 1 2 3 ___________ ___________
_____________
12. ___________ 1 2 3 ___________ ___________
_____________

13. ___________ 1 2 3 ___________ ___________
_____________
14. ___________ 1 2 3 ___________ ___________
_____________
15. ___________ 1 2 3 ___________ ___________
_____________
16. ___________ 1 2 3 ___________ ___________
_____________
17. ___________ 1 2 3 ___________ ___________
_____________
18. ___________ 1 2 3 ___________ ___________
_____________
19. ___________ 1 2 3 ___________ ___________
_____________
20. ___________ 1 2 3 ___________ ___________
_____________
21. ___________ 1 2 3 ___________ ___________

_____________
22. ___________ 1 2 3 ___________ ___________
_____________
23. ___________ 1 2 3 ___________ ___________
_____________
24. ___________ 1 2 3 ___________ ___________
_____________
25. ___________ 1 2 3 ___________ ___________
_____________
26. ___________ 1 2 3 ___________ ___________
_____________
27. ___________ 1 2 3 ___________ ___________
_____________
28. ___________ 1 2 3 ___________ ___________
_____________
29. ___________ 1 2 3 ___________ ___________
_____________

30. ___________ 1 2 3 ___________ ___________
_____________
*Need rating: How important is the cigarette to you at this
time?
1 = Most important; I would miss it very much
2 = Average
3 = Least important; I would not miss it
⦁ ▲ Figure 8.4 Twenty-Four-Hour Cigarette Count
oRGAnizAtionAl CUltURE ACtiVitiES
Closely aligned with environmental change strategies are
activities that affect organizational
culture. Culture is usually associated with norms and traditions
that are generated by and
linked to a “community” of people and reflects the group’s
values, beliefs, and practices.
Organizations, which are made up of people, also can have their

own culture. The culture of
an organization can be thought of as its personality. The culture
expresses what is and what
is not considered important to the organization. “Cultural norms
are not statistical averages,
but instead are related to social standards of appropriate
behavior. Cultural norms are accepted
and expected practice” (Golaszewski et al., 2008, p. 7). The
nature of the culture depends on
the type of organization—corporation, school, or nonprofit
group and the importance that the
organization’s leadership places on it. Thus, the leadership of
an organization could advance
a culture that supports health, or stated a bit differently, could
advance a culture that includes
health-related values, beliefs, and practices (Terry, 2012). For
example, if organizational deci-
sion makers believe exercise is important, they may provide
employees with an extra 20 min-
utes at lunchtime for exercise. Similarly, it is surprising to see
how many young executives will
use a corporation’s exercise facility because the chief executive
officer does. Other examples of
organizational culture activities that support health might
include changing the types of foods

found in vending machines, closing the “junk food” machines
during lunch periods at school,
offering discounts on the health foods found in the company
cafeteria, and getting retailers to
change the way they have done things in the past, such as
moving their tobacco products from
in front of a counter to behind a counter, so that an employee
has to get them for the customer.
For organizational culture activities to be effective in
supporting a culture of health there
must be a consistency about the importance of health throughout
the organization. It must
be system-wide and delivered through multiple channels (Terry,
2014). For example, if a
culture of health is to be achieved, if an organizational culture
activity is associated with em-
ployee benefits (e.g., regular free health screenings), it would
be counter productive to stock
the organization’s vending machines with unhealthy snack
choices.
Like other health promotion strategies, the use of organizational
culture activities should
begin with an assessment. The term that has been given to

assessments associated with or-
ganizational culture is a culture (or cultural) audit. A cultural
audit is an evaluation of the
assumptions, values, normative philosophies, and cultural
characteristics of an organization
in order to determine whether they support or hinder that
organization’s central mission
(BusinessDictionary.com, 2015b). When applied to health, the
audit would help determine
whether the culture hinders or supports health. There are
companies that will perform
health culture audits for organizations (Note: search the Internet
with key words “health cul-
ture audit” for sources). In addition, the Wellness Council of
America (WELCOA) has created
a free WELCOA Quick-Inventory (Hunnicutt, 2009) as a means
to help assess the environ-
ment of a workplace.
Once the status of the organizational culture has been
determined there are several steps
that can be taken to work toward a health supporting culture.
Golaszewski and his colleagues
(2008) have identified the following influences on an
organization’s health supporting

culture: (1) shaping cultural health values (e.g., raise the
visibility of benefits of healthy
lifestyles, raise the visibility of leadership promoting healthy
lifestyles, encourage employee
forums where they can discuss health, showcase the
organization’s involvement in health
promotion); (2) shaping cultural health norms (e.g., identify key
norms for health promo-
tion in the organization, conduct interviews of those in the
priority population to determine
support or lack thereof for a healthy culture, evaluate idea
versus actual norm levels); (3)
use cultural touch points (e.g., mechanisms that support a
healthy culture like committing
resources to health, leaders’ modeling healthy lifestyles,
rewards and recognitions for health,
include health promoting ideas in organizational recruitment,
orientation, training, com-
munication, relationships, and rites, symbols, and rituals); (4)
encourage peer support (e.g.,

mobilize existing support systems, develop mutual support
systems); and (5) building a sup-
portive cultural climate for health (e.g., foster a sense of
community, foster a shared vision,
foster a positive outlook, and foster cultural climate with health
promotion).
inCEntiVES AnD DiSinCEntiVES
The use of incentives (sometimes referred to as “carrots”) and
disincentives (sometimes re-
ferred to as “sticks”) to influence health behaviors is a common
type of activity, especially in
worksite settings. However, it has also been applied to
community and public health settings
(Ashraf, 2013). An incentive is “an anticipated positive or
desirable reward designed to
influence the performance of an individual or group” (Chapman,
2005, p. 6). An incentive
can increase the perceived value of an activity (Patton et al.,
1986), motivate people to get
involved, encourage health service use behavior (Chapman,
2005), encourage compliance
with professional health advice (Chapman, 2005), remind
program participants of their

commitment to and goals for behavior change (Wilbur, 1983),
promote short-term behavior
change (French, Jeffery, & Oliphant, 1994; Robison, 1998), and
maintain behavior change
over time (Ashraf, 2013; Pescatello et al., 2001; Poole,
Kumpfer, & Pett, 2001). Incentives can
work because they make good health decisions easier and poor
ones more difficult (Ashraf,
2013). The key to motivating people with incentives, either
intrinsic or extrinsic, is knowing
what will incite them to action. Thus for this type of activity to
work, the planners need to
match the incentives with the needs, wants, or desires of the
priority population. However,
this is not easy, for what is an incentive for one person may be
a deterrent for another, and
vice versa. If planners are not in touch with what program
participants want, there is a
chance of losing participant interest in the program (Hunnicutt,
2001). Therefore, incentives
work best when they are tailored to the individual
characteristics of the participants. For
example, a financial incentive will typically generate less
response from wealthy participants
than lower income participants (Haveman, 2010).

Because incentives are used to assist individuals in making
decisions about their health,
it is important to better understand what influences decision
making. We only need to look
around us to see that individuals do not always make good
health choices. Consider indi-
viduals who continue to smoke even though they know it is bad
for their health. To help un-
derstand the reasoning behind such decisions, the concept of
behavioral economics can help.
Behavioral economics has been called “the hybrid offspring of
economics and psychology”
(Lambert, 2006, p. 53). Neoclassical economics or traditional
economics assumes individuals
make decisions based on rational thinking by weighting the
gains (pros) and losses (cons) as-
sociated with the decision. Behavioral economics is a method of
analysis that applies psy-
chological insights into decision making. Thus, behavioral
economists believe that decisions
are not based solely on rational thinking but that they are highly
dependent on the context
in which the decision is made (Samson, 2014; Zimmerman,
2009). Here are some behavioral

economic insights that help explain decision making.
Individuals: (1) are more concerned
about avoiding losses than acquiring gains, (2) are comfortable
with status quo and do not
want to change, (3) are aware of social norms and want to
conform, (4) experience decision
fatigue (i.e., choice overload) and put off difficult choices, (5)
use heuristics (i.e., shortcuts or
quick answers) because of decision fatigue, (6) have trouble
evaluating probabilities associ-
ated with health decisions, and (7) overvalue the present
outcomes of decision and discount
the future outcomes (i.e., present bias) (Arhraf, 2013; Riedel &
Calao, 2014). (See Box 8.6 for
an application of behavioral economics.)
For program planners, the task becomes one of matching the
needs of the program par-
ticipant or potential program participant with available
incentives. A couple of different

approaches can be used to accomplish this. The first is to
include questions about incen-
tives as part of any needs assessment conducted in program
planning keeping in mind the
insights from behavioral economics. For example, a needs
survey or focus group might in-
clude a question on incentives, such as “What incentives would
entice you to participate in
the exercise program?” or “What would it take to get you to
participate in this program?” or
“What would it take to keep you involved in a health promotion
program?” or “Would you
continue to participate in an exercise program if you knew you
were going to be given a nice
T-shirt after logging 100 miles running or walking, or
participating for 50 days in a yoga class
or swimming program?” The responses to these questions
should provide some indication of
the type of incentives that would be most appropriate for this
priority population.
A second approach would be to conduct an “experiment” with
different incentives. This
could be accomplished via a pilot study with a small group from

using different incentives. In such a pilot study, half of the
participants would receive one
incentive, while the other half would receive another. The
outcomes at which the incentives
were aimed would then be compared to determine which
incentive was more useful. A third
approach would be use the most promising incentive based on
previous experience or the
experience reported by others (see discussion on best
experiences later in the chapter). This
third approach might be used when program resources are
limited.
Based on the idea that incentives should meet the individual
needs of those in the prior-
ity population, the possibility of different types of incentives i s
almost endless. Incentives
are usually grouped into two major categories: material (i.e.,
financial) and nonmaterial.
Behavioral Economics
To address some of the insights from behavioral economics
program planners have used
several different techniques to assist people to making good

health decision. One of these
techniques is message framing. Planners who frame their health
promotion programs
by emphasizing the “program benefits” versus “program
obligations” have had better
results in getting people to make good health decisions. For
example, a smoking cessation
program framed as “You are not alone in your battle to quit,
come see what a smokefree
life can mean for you,” has a much better chance of resulting in
a good health decision
than one framed as “This smoking cessation program is science-
based and has shown
good results for those who stick with it.” Another technique
used to help people make
good health decisions and sustain change overtime has been
commitment devices. An
example of a commitment device related to a weight loss
program would have enrollees
put up a bond, say $500, at the beginning of the program and
would not be returned until
their goal weight was reached. In addition, the bond could also
be donated to a charity
if the goal weight was not reached in a reasonable period of
time. Such a program takes

advantage of people’s tendency to prefer avoiding losses to
acquiring gains.
H
ig
hl
ig
ht
s
8.6
Box
Some examples of material incentives include providing any
material item (e.g., food,
clothing) of worth to those in the priority population, or actual
money in the form of extra
pay, bonuses, or rebates (Ashraf, 2013; Chapman 2005;

Haveman, 2010; Pescatello et al.,
2001; Poole, Kumpfer, & Pett, 2001); paying membership fees
to health-related facilities
(Chapman, 2005); giving gift certificates; or reducing health
insurance premiums or deduct-
ibles. Examples of nonmaterial incentives include altruistic
feeling like after giving blood
(Ashraf, 2013; Serxner, 2013), giving special attention or
recognition (e.g., name mentioned
in a newsletter) (Chapman, 2005; Haveman, 2010), social
support, or providing additional
vacation days or “well” days (Chapman, 2005; Haveman, 2010).
Terry and Anderson (2011) noted that incentives should be safe,
effective, participant-
centered, timely, and equitable. In addition, Haveman (2010)
has offered six principles that
can assist program planners in creating effective incentives. His
principles were intended for
use with incentives associated with the delivery of health care,
but we have adapted them to
health promotion. Principle one is identifying the desired
outcome or, stated a different way,
what is the problem that needs to be addressed. This may seem
obvious but is often overlooked.

For example, if the desired outcome is to have program
participants stop smoking, the incen-
tives should be tied to quitting or the steps to quitting. The
second principle is identifying the
behavior change that will lead to the desired outcome. In the
smoking cessation example, par-
ticipants need to come up with a strategy to quit smoking,
actually stop, and stay off cigarettes
for a specified period of time. Principle three is determining the
potential effectiveness of the
incentive in achieving the behavior change. This is not easy
because responsiveness to incen-
tives varies greatly. “Understanding this response involves
determining the extent to which the
behavior targeted is amenable to change through the incentive”
(Haveman, 2010, p. 2). The
“size” of the incentive should be appropriate to the effort
required. If the perceived benefit of
the action is exceeded by its perceived cost, the incentive will
be ineffective (Haveman, 2010).
(See Box 8.7 for a list of factors that determine the
effectiveness incentives.) The fourth principle
is to link the incentive directly to the desired outcome or
behavior. In the smoking cessation ex-
ample, any incentive should be linked to either the final

outcome—no smoking for one year af-
ter the quit date—or to the actions leading up to it, for example,
setting a quit date, deciding on
a strategy to quit, actually quitting, not smoking for six months,
and not smoking for one year.
If the second option is used, an incentive could be attached to
each step. Further if this second
option is used the incentives could be graduated so that
incentives are worth more than the
one given at the previous step. Principle five is identifying any
possible adverse effects of the
incentive. In the smoking cessation example, nonsmokers may
say that they have no chance
to receive a smoking cessation incentive. So how could those
creating the incentive deal with
this situation? The sixth, and final, principle is to evaluate and
report changes in the behavior
or outcome in response to the incentive. If a case is going to be
made for using incentives as part
of health promotion programs in the future, planners will need
to document their work and
show that the incentives, at least in part, were responsible for
the outcomes or desired behavior.
Just as incentives can be used to get people involved in

behavior change, disincentives can
be used to discourage a certain behavior. More formally,
disincentives have been defined
as “an anticipated negative or undesirable consequence designed
to influence the perfor-
mance of an individual or group” (Chapman, 2005, p. 6). For
example, “[s]ustained increases
in excise taxes, constraining advertising and marketing,
constricting use in public places,
and penalizing the sale and distribution to minors have all
worked to help drive down the
use of tobacco” (McGinnis et al., 2002, pp. 88–89).
One final note that we need to mention before leaving this topic
is the impact that federal
legislation has had on incentives and disincentives. As we noted
at the beginning of this sec-
tion, though incentives and disincentives have been used in
health promotion programs in
a variety of settings, they have been used with great favor in
worksite settings. Up until 1996,

there were few limitations on how incentive and disincentives
were structured (Chapman,
2005) and because of this some employers were creatively tying
incentives and disincentives
associated with health to individual and group health insurance
plans. However, Congress
was concerned that employers were being unfair to some
employees in order to reduce their
health care costs. Accordingly, Congress has now enacted three
pieces of legislation that
have impacted the way incentives and disincentives can be used.
They include the Health
Insurance Portability & Accountability Act of 1996 (more
commonly referred to as HIPAA),
the Genetic Information Nondiscrimination Act of 2008
(officially known as Public Law 110-
233 and referred to as GINA), and the Affordable Care Act
(ACA) (ACA actually refers to two
separate pieces of legislation—the Patient Protection and
Affordable Care Act [P.L. 111-148]
and the Health Care and Education Reconciliation Act of 2010
[P.L. 111-152].
HIPAA created provisions in it that make it illegal for
employers to discriminate against

their employees because of a “health status related factor” with
the outcome of affecting
coverage or cost to the employee under a group or individual
health plan (Chapman, 2005).
That is, those who offer and administer health insurance plans
cannot deny health care
claim expenses, charge some employees more for their health
insurance premiums, or place
a surcharge on their premiums because of health status related
conditions like high blood
Factors that Determine the Effectiveness of incentives
MAjoR FACtoRS MinoR FACtoRS
⦁ ⦁ Dollar value of the reward(s)
⦁ ⦁ Convertibility into item of personal value
⦁ ⦁ Amount of effort needed to qualify
⦁ ⦁ Clarity of messaging
⦁ ⦁ Timing and repetition of messaging

⦁ ⦁ Extent of distrust in employers’ motives
⦁ ⦁ Supporting messages from management
⦁ ⦁ Ease of enrollment
⦁ ⦁ Perceived complexity of requirements
⦁ ⦁ Fairness and defensibility of requirements
⦁ ⦁ Group or competitive nature
⦁ ⦁ Desirability of required behavior
⦁ ⦁ Readiness composition of population
⦁ ⦁ Combination of pay values
⦁ ⦁ Spousal eligibility
⦁ ⦁ Compatibility of incentives with culture
⦁ ⦁ Past wellness incentive performance
⦁ ⦁ Importance to supervisor

⦁ ⦁ Degree of fun experienced
⦁ ⦁ Language compatibility
⦁ ⦁ Convenience of record keeping
⦁ ⦁ Amount of change in benefits
⦁ ⦁ Availability of alternative standards
⦁ ⦁ Credibility of wellness staff
⦁ ⦁ Use of outside vendor
⦁ ⦁ Adequacy of FAQs
⦁ ⦁ Availability of FAQs
⦁ ⦁ Treatment of “gamers”
⦁ ⦁ Utility of program documents
⦁ ⦁ Tax implications

⦁ ⦁ Option to ask questions
⦁ ⦁ Time of the year
⦁ ⦁ Generational effects
⦁ ⦁ Reporting back to employees
8.7
Box
Fo
cu
s
O
n
Source: “The Changing role of incentives in health promotion
and wellness.” L. S. Chapman, D. Whitehead, and M. C.
Connors, from The Art of Health
Promotion. Copyright © 2008 by American Journal of Health
Promotion. Reprinted with permission.

pressure, high blood cholesterol, or poor vision. For example,
an employer cannot require
employees to pay higher premiums than their coworkers because
they have high blood pres-
sure. However, the law does not preclude offering incentives—
in the form of premium dis-
counts or rebates or modifying applicable co-payments or
deductibles—to those who partici-
pate in health promotion programs. So an employer could
reduce employees’ co-payment on
a visit to a doctor or on the cost of a prescription medication if
the employees participated in
the company’s employee health promotion program.
GINA, which amends portions of HIPAA by treating genetic
information as protected health
information (PHI), prohibits discrimination in health coverage
and employment based on ge-
netic information. GINA went into effect for health care plans
starting on or after December 7,

2009. Though the bulk of GINA is aimed at health care
coverage provided by employers, it also
impacts health promotion/wellness programs. The area of health
promotion programming
that it most affected is the use of health risk assessments
(HRAs). HRAs cannot request genetic
information prior to enrollment in a health care “plan, and no
rewards or penalties may be
offered in conjunction with an HRA that requests genetic
information, even if the request is
made after the enrollment” (Grudzien, 2009, para. 6). As a
result of these regulations, planners
“should review all wellness and disease management plans to
determine how a HRA is used
and what information is requested; remove any financial
incentives or penalties if genetic
information is collected in the HRA; and remove any genetic
information from the HRA if
financial incentives or penalties want to be offered” (Grudzien,
2009, para. 6).
The ACA further refined rules associated with how incentives
could be used in programs
that are a part of group health insurance plans. These new rules
apply to health plans that

began on or after January 1, 2014. The ACA continued to
support employee wellness pro-
grams but also included rules to ensure the programs would not
discriminate based on health
status. It did so by making a distinction between participatory
wellness programs and health-
contingent wellness programs. A participatory wellness program
is one that does not provide an
incentive or does not tie an incentive to a health factor.
Examples of participatory program
incentives include: fitness center membership reimbursements;
paying employees who
complete a health risk assessment without requiring them to
take further action, or waiving
an out-of-pocket cost for attending a smoking cessation program
that is not contingent on
quitting.
A health-contingent wellness program is one that requires
individuals to meet a specific
health-related standard to obtain an incentive. Examples include
programs that provide an in-
centive to those who do not use, or decrease their use of
tobacco, or programs that provide an
incentive to those who achieve a specified cholesterol or blood

pressure level (USDOL, n.d.).
Because health-contingent wellness programs have the potential
to discriminate based on
health status, the ACA also includes the following:
1. Programs must give those covered by the health insurance
plan an opportunity to
qualify for the incentive at least once per year.
2. Programs must be designed to have a reasonable chance of
improving health or
preventing disease and not be overly burdensome for
individuals.
3. Programs must be reasonably designed to be available to all
similarly situated
individuals (i.e., those with same problems or circumstances).
4. Programs must include a reasonable alternative standard or
waiver to qualify for the
incentive for individuals whose medical conditions make it
unreasonably difficult, or

for whom it is medically inadvisable, to meet the specified
health-related standard. In
addition, individuals must be given notice of the opportunity to
qualify for the same
incentive through other means.
5. The incentives for wellness program participants may not
exceed 30% of the cost of
health insurance coverage.
SoCiAl ACtiVitiES
The importance of social support for behavior change and its
relationship to health have
been known for a number of years (e.g., IOM, 2001). Many
people find it much easier to
change a behavior if those around them provide support or are
willing to be partners in the
behavior change process. Social support can be provided in a
variety of ways. “There are at
least four types of social support: (1) emotional, (2)
instrumental, (3) informational, and

(4) appraisal” (Valente, 2010, pp. 36-37). Emotional support is
assistance from people close
to a person that focuses on the person’s feelings. Instrumental
support deals with providing
material items and services to people. Informational support
comes in the format of provid-
ing various forms of information such as advice, knowledge,
and suggestions to people.
Appraisal support includes analysis and feedback that allows
people to evaluate their situa-
tion (Valente, 2010). A discussion of several different types of
social support activities that
can provide these different types of social support follows.
SUppoRt GRoUpS AnD BUDDy SyStEM
The importance of support groups as part of comprehensive
interventions has been well
established. One need only look to the 12-step programs (e.g.,
Alcoholics Anonymous,
Overeaters Anonymous, and Gamblers Anonymous) and
commercial programs (e.g., Weight
Watchers) to realize the importance of people coming together
to share their experiences
and support one another’s efforts. A support group need not be

large; it might be as small as
just two people. A buddy system is an example of a two-person
group. A buddy system can
take one of two different forms. In the first, both individuals are
trying to change a behavior.
In such a relationship, the two individuals support each other,
whether this means helping
each other stay on a special diet or meeting each other at 6 A.M.
for exercise. In the other
form, only one of the two is trying to change a behavior. The
one not changing the behavior
may have already changed (e.g., has already quit smoking or is
exercising regularly) and is
acting as a mentor to the one trying to change, or may not be
trying to change but provides
support at regular intervals or as problems arise.
To enhance the motivation provided by support groups and
buddy systems it is not un-
common for these activities to also use a contest (also referred
to competitions or challenges)
or a contract. A contest can be described as a challenge between
two individuals/groups in
which the object is to outperform the competitor. Examples of
contests include the com-

petition between two individuals to see who can lose the most
weight, who can walk/run
the most miles, or who can go the longest without a cigarette.
Contests could also be based
on teams within the priority population (such as two different
companies, two schools, or
departments within an organization), using similar criteria but
now based on group total
figures (pounds, miles, or cigarettes). Contests have been useful
in introducing and promot-
ing health promotion programs and achieving significant initial
participation rates, but they
have not been as useful as an ongoing recruitment tool (Wilson,
1990).
A contract is an agreement between two or more parties that
outlines the future be-
havior of those parties. Contracts are a common part of
everyday living. People enter into
contracts when they sign a lease for an apartment or a residence
hall agreement, take out an

insurance policy, borrow money, or buy something over a
period of time. The same concept
can be applied to getting and keeping people motivated in
health promotion programs.
Program participants would enter into a contract with another
person (the program facilita-
tor, a significant other, or a fellow participant) and then work
toward an objective or agree-
ment specified in the contract. The contract would also specify
contingencies—that is,
what happens as a result of the contract’s term either being met
or not being met.
For an exercise program, this system might work as follows:
The program participant and
program facilitator would draw up a contract based on the
participant’s present status in the
program (e.g., exercising for 30 minutes once a week) and on
what would be a reasonable
goal for the near future (e.g., eight weeks). Thus the contract
might state that the participant
will exercise for 30 minutes twice a week for the first week, 30
minutes three times a week
for the second week, and so forth, building up gradually to the
final goal of exercising for

30 minutes most days of the week at the end of eight weeks. The
outcome should focus on a
behavior that can be maintained at the end of the contract
period. For a weight loss program,
the goal might be written as eliminating snacking in the
evening, increasing fruits and veg-
etables in the diet to five servings per day, and walking for 30
minutes three times a week.
These are behaviors that can reasonably be maintained after the
weight loss.
The parties to the contract then decide on what the
contingencies will be. Thus the partici-
pant might offer to make a contribution to some local charity or
state that she will continue
in the program for another eight weeks if she does not meet the
contract goal. The facilitator
might promise the participant a program T-shirt if she fulfills
the contract during the specified
eight-week period. Other ideas for contingencies might include
granting a kickback on fees for
completing a certain percentage of the classes, or earning points
toward products or services.
No matter what the contingencies are, it seems to help if the
contract is completed in writing.

SoCiAl GAtHERinGS
Social gatherings can be an important type of social
intervention. Bringing together people
who may be confronting similar problems for the purpose of
purely social interaction not
related to the problem can indirectly help them deal with the
problem. Examples of such
activities might be single parents having a cookout or a group of
senior citizens attending a
play. Although these gatherings do not deal directly with these
people’s common problems,
they do help fill voids in their lives and thus indirectly help
with the problem.
SoCiAl nEtWoRkS
Social networks are another type of social intervention. A social
network is the “web of social
relationships and the structural characteristics of that web”
(IOM, 2001, p. 7). The nature of
the structural characteristics can be quite varied, consisting of
almost anything that creates
a special feeling: need, concern, loyalty, frustration, power,

affection, or obligation, to name
just a few. When people are “networking,” they are said to be
looking for relationships that
would be useful in helping them with their concerns, such as
problem solving, program de-
velopment, resource identification, and others. As part of a
health promotion intervention,
social networking may take many different forms and can range
from informal networking
where participants create relations on their own to more formal
networking where program
participants are “assigned” others with whom to network. The
actual networking itself may
take place face-to-face, via the telephone, or through some type
of social media. An example
would be when program smoking cessation participants trade
contact information (e.g.,
email address, telephone numbers, or “friend” another) for the
purpose of connecting when
trying to resist a cigarette or trying to locate a needed resource

to solve a problem.
It should also be noted that although most social support and
buddy systems take place
between individuals, they can also be established at the
institutional level. Like individu-
als, institutions can be paired up to help one another. For
example, if two companies are
interested in establishing health promotion programs, they could
work together on their
programs and share information and resources where
appropriate. Or, if one company has
a well-established program in place, then that company could
mentor another company in
setting up a program.
Creating Health Promotion Interventions
Once program planners have completed a needs assessment,
written program goals and
objectives, and considered different types of intervention
strategies, they are in a position to
begin identifying an appropriate intervention. Identifying an
intervention is not as straight-
forward as taking a new medical procedure from one hospital to

the next. Most health pro-
motion problems result from the interaction of complicated
social dynamics that must be
accommodated (Runyan & Freire, 2007). There is no one best
way of intervening to accom-
plish a specific program goal that can be generalized to all
priority populations. Each priority
population has unique needs and wants that must be addressed,
and each setting has its own
peculiarities. Nevertheless, well planned and successful health
promotion programs have
common characteristics such as: (1) addressing one or more risk
factors of the priority popu-
lation, (2) being theory-driven, (3) being based on the best
possible evidence (see the discus-
sion of scientific evidence later in the chapter), (4) adhering to
professional ethical standards,
(5) being culturally appropriate, (6) being consistent with
professional criteria, guidelines, or
codes of practice (e.g., America College of Sports Medicine’s
guidelines for exercise programs
(ACSM, 2014)), (7) using resources efficiently, and (8)
including an evaluation component.
Such characteristics help standardize and ensure the quality of
the program, give credibility

to a program, help with program accountability, provide a legal
defense if a liability situation
might arise, and identify ethical concerns that need to be
addressed as a part of planning,
implementing, and evaluating programs.
intervention planning
When deciding on how best to intervene to reach the program
goals and objectives, program
planners have three possible avenues available to them. They
could adopt an existing inter-
vention that is supported by evidence showing that the
intervention was effective when used
elsewhere. They could adapt an existing intervention that is
supported by evidence showing
it was effective elsewhere but the circumstances or setting in
which it was used were differ-
ent that the proposed setting. Or, the planners could design a
new intervention. Irrespective
of the avenue used to identify an intervention, interventions
should be based on a sound
rationale backed by the best available evidence as opposed to
chance; a strategy should not
be selected just because the planners think it “sounds good” or

because they have a “feeling”
that it will work. Too often, intervention decisions are “based
on perceived short-term op-
portunities, lacking systematic planning and review of the best
evidence regarding effective
approaches” (Brownson, Fielding, & Maylahn, 2009, p. 175). As
mentioned earlier, planners
should choose or create an intervention that will be both
effective and efficient.
Adopting a Health promotion intervention
In order for program planners to adopt an intervention for use in
their program there are sev-
eral questions they must be able to respond to with a “Yes”
answer. The questions include: (1)
Is there sufficient evidence to show that the intervention has
been successful in dealing with
the problem in question? (2) Is there sufficient evidence to
show that the intervention has

been successful in dealing with the problem in question in a
population with similar char-
acteristics (e.g., age, sex, culture, racial/ethnic make-up, social
circumstances) to the popula-
tion in the new setting? (3) Is there evidence to show that the
intervention was successful in
more than one setting? (4) Are there similar resources available
in the new setting to ensure
the fidelity of the intervention? and (5) Is the new environment
setting similar to the envi-
ronmental setting identified in the evidence? If “No” is the
answer to any of these questions
then planners should consider either adapting the existing
intervention or developing a
new intervention. If the answers to the questions are not clearly
“Yes” or “No” Runyan and
Freire, (2007) have noted that planners might “benefit from
discussion among several people
knowledgeable about the problem, the setting, and program
planning” (p. 423).
Adapting a Health promotion intervention
If the evidence supporting the successful use of an intervention
is different (e.g., social context

or other unique characteristics) than the one in which the
planners are currently working, the
question becomes “Can the intervention that was successful in
another setting (i.e., evidence-
based intervention [EBI]) be adapted to work in the new
setting?” That is, can an intervention be
adapted to the circumstance in which the priority population
lives? To help answer this question,
the CDC’s Division of HIV/AIDS, along with some external
partners, developed draft guidance to
adapt EBIs (McKleroy et al., 2006). The approach of this
framework emphasizes both the planners’
experience working with the priority population and the
resources available for adaption and im-
plementation, while still maintaining fidelity to the core
elements of the intervention, the theory
on which it was based, and internal logic of the original
intervention (McKleroy et al., 2006).
The adaptation framework is a five-step approach that is
presented graphically in a linear
format (see Figure 8.5). However, like other planning models
presented in this book, the
steps are interconnected and thus overlap in terms of their
timing and ordering. McKleroy et

al. (2006) have presented the following description of the five
steps.
The first action step, assess, involves assessing the target
population, the EBIs being considered
for implementation, and the agency’s capacity to implement the
intervention. The second,
select, is determining whether to adopt the intervention without
adaptation, implement the
intervention with adaptation, or choose another intervention and
repeating the assess action
step before moving forward. The third action step, prepare, falls
within the preparation phase
and involves actually adapting the intervention materials, pre-
testing the adapted materials
with the target population, and increasing agency capacity and
developing collaborative
partnerships when necessary to implement the intervention. The
fourth action step, pilot, is
pilot testing the adapted intervention or its components if it is
not feasible to pilot the entire
Phases Action steps Feedback

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227
intervention and developing an implementation plan. The fifth,
implement, is conducting
the entire adapted intervention with minor revision as needed.
Additionally, the guidance
includes feedback loops and checkpoints to ensure each action
step is addressed adequately,
and to provide an opportunity to revisit earlier action steps
should difficulties occur.
Process monitoring and evaluation, and routine supervision and
quality assurance are also
important considerations for the guidance. Credible evidence
collected during the adaptation
process should be evaluated to determine the success of the

adaptation process as well as the
effectiveness of the adapted intervention (p. 64).
If you are interested in adapting an EBI, we strongly
recommend that you review McKleroy
et al. (2006) for a more in-depth description and practical
examples of the five-step framework.
Designing a new Health promotion intervention
If there is not sufficient evidence to support the adoption or
adaptation of an intervention
to a new setting then planners are faced with creating a new
intervention. Although no pre-
scription for an appropriate intervention has been developed,
experience has indicated that
the results of some interventions are more predictable than
others. In this section, we present
eight major questions that planners need to consider when
creating new health promotion
interventions. Figure 8.6 summarizes these major
considerations.
1. What needs to change? And, where is the change needed?
Designing an appropriate

intervention begins by going back to the early steps in the
program planning process
and examining the results of the needs assessment and
reviewing the goals and
What needs to change? Where is change needed?
What level of prevention?
What level(s) of influence?
Single or multiple
strategies?
Appropriate fit for
priority population?
Planned intervention
Resources
available?
Any guide for intervention selection?
Best practices or Best experiences

if not then
Best processes
⦁ ▲ Figure 8.6 Items to Consider When Creating a Health
Promotion Intervention
objectives of the proposed program. The needs assessment
identified the behavioral,
environmental, and genetic determinants or risk factors of the
health problem. (Note:
Remember that because genetic determinants either cannot be
changed or often
interact with behavior and environment, the planners’ focus
should be on behavioral
and environmental factors.) For example, after identifying the
determinants of a health
problem, planners then determine the predisposing, enabling,
and reinforcing factors
that need to be addressed in their proposed program. These

factors should be reflected
in the program goals and objectives. If the single purpose of a
program were to increase
the awareness of the priority population, the intervention would
be very different from
what it would be if the purpose were to change behavior.
Knowing what must be changed is critical to creating an
intervention, but
just as critical is understanding the context in which the change
will take place.
Understanding the context has been referred to as the settings
approach (Baric, 1993)
to health promotion. More specifically, a settings approach
means addressing the
contexts (physical, organizational, and social) “within which
people live, work, and
play and making these the object of inquiry and intervention as
well as the needs and
capacities of the people found in the different settings” (Poland,
Krupa, & McCall,
2009, p. 505). Therefore when creating an intervention,
planners need to analyze the
setting—“who is there; how they think or operate; implicit
social norms, hierarchies

of power; accountability mechanisms; local moral, political, and
organizational
culture; physical and psychosocial environment; broader
sociopolitical and economic
context, etc.” (Poland et al., 2009, p. 506)—to make sure the
intervention is a good
“fit” for those in the priority population. For those interested in
more of what to
consider when analyzing the setting, we recommend the
questions posed by Poland
et al. (2009).
2. At what level of prevention will the program be aimed?
Because of the needs and wants
of those in the priority population, planners need to consider at
which level or levels
of prevention—primary, secondary, and tertiary—the program
will be aimed. For
example, a program aimed at increasing the level of exercise is
likely to be received
differently by asymptomatic nonexercisers (primary prevention)
than by a patient
recovering from a heart attack (tertiary prevention).
3. At what level(s) of influence will the intervention be

focused? Program planners must recognize
that those in the priority population “live in social, political,
and economic systems
that shape behaviors and access to the resources they need to
maintain good health”
(Pellmar et al., 2002, p. 210). As such, planners need to decide
at what level or levels of
influence they can best obtain the goals and objectives of the
program. For example, if
the goal of the program is to increase safety belt use, can that
be best accomplished by
trying to intervene at an intrapersonal level with an individual
education program, at the
institutional level with a company policy, at the public policy
level with an enhanced
state safety belt law, or at multiple levels? Though it is possible
that an intervention can
be aimed at a single level of influence, the evidence is mounting
that there is a greater
chance of changing and maintaining health behaviors if
interventions are aimed at
multiple levels of influence (Glanz & Bishop, 2010). Therefore,
planners need to ask and
answer the question, “What levels of influence should be
addressed to provide the best

chances of achieving the program goal and objectives?”
4. What types of intervention strategies are known to be
effective (i.e., have been successfully used in
previous programs) in dealing with the program focus? In other
words, what does the evidence
show about the effectiveness of various interventions to deal
with the problem that the
program is to address? (Refer back to Chapter 2 for the
definition of and available sources
of evidence.) Using evidence does not mean finding a specific
intervention to deal with
the problem but rather going through a process of decision
making that is based on the
evaluation of reliable data and previous work (Baker,
Brownson, Dreisinger, McIntosh,
& Karamehic-Muratovic, 2009). To assist planners in
identifying the best available
evidence, Green and Kreuter (2005) and Brownson and
colleagues (2009) have put forth

typologies for classifying interventions based on the level of
scientific evidence. Green
and Kreuter (2005) have suggested three sources of guidance for
selecting intervention
strategies—best practices, best experiences, and best processes.
Best practices refer to
“recommendations for an intervention, based on critical review
of multiple research and
evaluation studies that substantiate the efficacy of the
intervention in the populations
and circumstances in which the studies were done, if not its
effectiveness in other
populations and situations where it might be implemented” (p.
G-1).
When best practice recommendations are not available for use,
planners need to
look for information on best experiences. Best experience
intervention strategies are
those of prior or existing programs that have not gone through
the critical research
and evaluation studies and thus fall short of best practice
criteria but nonetheless show
promise in being effective. Best experiences can be found by
networking with other

professionals and by reviewing the literature.
If neither best practices nor best experiences are available to
planners, then the
third source of guidance for selecting an intervention strategy is
using best processes.
Best processes intervention strategies are original interventions
that the planners
create based upon their knowledge and skills of good planning
processes including the
involvement of those in the priority population and appropriate
theories and models
(see Chapter 7). (See table 8.5 for a matrix of aligning
objectives, program outcomes,
methods, theory, intervention strategies, and activities.)
Whereas the Green and Kreuter (2005) typology for classifying
interventions has
three levels, the typology put forth by Brownson and colleagues
(2009) has four—
evidence-based, effective, promising, and emerging. The first
level, evidence-based, includes
interventions that are peer reviewed via a systematic or
narrative review (e.g., those
contained in the Guide to Community Preventive Services

[CDC, 2015c]). This first level is
parallel to the best practices level of Green and Kreuter (2005).
The interventions found
in the second level, effective, have been peer reviewed but are
not part of a systematic or
narrative review (e.g., article that appears in the scientific
literature). Those interventions
that are deemed effective via a program evaluation but without
formal peer review make
up the third level, promising (e.g., state or federal government
reports that have not gone
through peer review). Levels two and three, effective and
promising respectively, are
parallel to the best experiences described by Green and Kreuter
(2005). The fourth and
final level is emerging. This level includes ongoing works,
practice-based summaries, or
evaluation works in progress (e.g., pilot studies).
5. Is the intervention an appropriate fit for the priority
population? Intervention strategies need
to be designed to “fit” the priority population. Each priority
population has certain
characteristics that impact how it will receive an intervention.
Two processes that help

to “fit” an intervention to the priority population are tailoring
and segmenting. The
rationale for tailoring an intervention activity is based on
research that shows people
pay more attention to information that is personally relevant to
them (NCI, n.d.).
Because we presented information on tailoring earlier in the
chapter in our discussion
of health communication section, we will use this space to
present information
on segmenting. Segmenting is the process of dividing a broader
population into
smaller groups with similar characteristics that are likely to
exhibit similar behavior/
reaction to an intervention (see information in Chapter 11 about
segmenting a priority
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ti
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•
In
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•
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R
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—
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•
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ro

ch
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k
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w
a

re
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xp
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e
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ic
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n
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ct
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rn
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T
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p
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it
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e
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lt
h
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d
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ca
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n
•
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la
ss
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s,

s
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rs
,
w
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rk
sh
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p
s
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—
p
e
rc
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iv
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d
se
ri
o
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sn
e
ss
•

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ri
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te
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ls
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rc

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iv
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ts
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rr
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g
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s
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ic
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la
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ce
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ss
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tr

a
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te
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h
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fo
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t
IM
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re
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m
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ti
va
ti

o
n
•
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il
ls
Sk
il
ls
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ra
in
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g
a
n
d

p
ra
ct
ic
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SC
T
/H
B
M
/T
T
M
—
se
lf

-e
ff
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cy
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lt
h
c
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m
m
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ic

a
ti
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n
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n
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la
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co
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tr
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l
•
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m
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la
ti
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n

s
SC
T
—
se
lf
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o
n
tr
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l
B
e
h
a
vi

o
r
m
o
d
if
ic
a
ti
o
n
231
A
bb
re
vi

at
io
ns
fo
r t
he
or
ie
s:
C
-B
M
RP
=
c
og

ni
tiv
e-
be
ha
vi
or
m
od
el
o
f r
el
ap
se
p
re

ve
nt
io
n;
C
RM
=
c
om
m
un
ity
re
ad
in
es
s

m
od
el
; E
LM
=
e
la
bo
ra
tio
n
lik
el
ih
oo

d
m
od
el
o
f p
er
su
as
io
n;
H
BM
=
h
ea
lth

b
el
ie
f m
od
el
;
IM
B
=
in
fo
rm
at
io
n—
m

ot
iv
at
io
n—
be
ha
vi
or
al
s
ki
lls
m
od
el

; P
A
PM
=
p
re
ca
ut
io
n
ad
op
tio
n
pr
oc
es

s
m
od
el
; P
M
T
=
p
ro
te
ct
io
n
m
ot
iv

at
io
n
th
eo
ry
; S
CT
=
s
oc
ia
l c
og
ni
tiv

e
th
eo
ry
; S
N
T
=
s
oc
ia
l n
et
w
or
k
th

eo
ry
;
SR
T
=
s
tim
ul
us
re
sp
on
se
th
eo
ry

; T
PB
=
th
eo
ry
o
f p
la
nn
ed
b
eh
av
io
r;

TT
M
=
tr
an
st
he
or
et
ic
al
m
od
el
.
Ty
pe

o
f
o
bj
ec
ti
ve
Pr
og
ra
m
o
ut
co
m

e
M
et
ho
d
Th
eo
ry
—
C
on
st
ru
ct
*
In
te

rv
en
ti
on
St
ra
te
gy
Po
ss
ib
le
A
ct
iv

it
ie
s
M
o
d
e
li
n
g
SC
T
—
re
in
fo
rc

e
m
e
n
t
C
o
p
in
g
r
e
sp
o
n
se
C

-B
M
R
P
—
se
lf
-c
o
n
tr
o
l
•
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e
n

a
ri
o
s,
r
o
le
p
la
yi
n
g
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e
h

a
vi
o
ra
l
•
B
e
h
a
vi
o
r
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e
in
fo
rc

e
m
e
n
t
H
B
M
—
cu
e
s
to
a
ct
io

n
In
ce
n
ti
ve
s
•
D
e
te
rm
in
e
a
n
d

p
ro
vi
d
e
i
n
ce
n
ti
ve
s
SR
T
—
p
u

n
is
h
m
e
n
t/
re
in
fo
rc
e
m
e
n

t
B
e
h
a
vi
o
r
m
o
d
if
ic
a
ti
o
n

•
2
4
-h
o
u
r
b
e
h
a
vi
o
r
re
co
rd
s

C
o
u
n
te
rc
o
n
d
it
io
n
in
g
T
T
M

—
p
ro
ce
ss
e
s
o
f
ch
a
n
g
e
H
e
a
lt

h
c
o
m
m
u
n
ic
a
ti
o
n
a
n
d
e

d
u
ca
ti
o
n
•
K
e
e
p
in
g
j
o
u
rn

a
ls
o
rg
a
n
iz
a
ti
o
n
a
l
cu
lt
u
re

•
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la
ss
e
s,
s
e
m
in
a
rs
,
w
o
rk
sh
o

p
s
M
o
d
e
li
n
g
SC
T
—
re
in
fo
rc
e

m
e
n
t
•
P
e
e
r
e
d
u
ca
ti
o
n
E
n

vi
ro
n
m
e
n
ta
l
•
P
h
ys
ic
a
l
e
n

vi
ro
n
m
e
n
t
Fa
ci
li
ta
ti
o
n
SC
T
—

re
ci
p
ro
ca
l
d
e
te
rm
in
is
m
H
e
a
lt

h
p
o
li
cy
/
e
n
fo
rc
e
m
e
n
t
•
R
e

g
u
la
ti
o
n
s/
o
rd
in
a
n
ce
s
B
a

rr
ie
rs
H
B
M
—
p
e
rc
e
iv
e
d
b
a

rr
ie
rs
E
n
vi
ro
n
m
e
n
ta
l
ch
a
n
g

e
C
-B
M
R
P
—
h
ig
h
-r
is
k
si
tu
a

ti
o
n
o
rg
a
n
iz
a
ti
o
n
a
l
b
u
il

d
in
g
C
R
M
—
st
a
g
e
s
C
o
m
m
u

n
it
y
m
o
b
il
iz
a
ti
o
n
•
C
re
a
te

a
c
o
a
li
ti
o
n
•
So
ci
a
l
e
n
vi
ro
n

m
e
n
t
So
ci
a
l
su
p
p
o
rt
T
P
B
—
su

b
je
ct
iv
e
n
o
rm
So
ci
a
l
a
ct
iv
it

ie
s
•
C
re
a
te
n
e
tw
o
rk
s/
b
u
d
d
ie

s
SN
T
—
e
g
o
/a
lt
e
r
So
ci
a
l
N
e

tw
o
rk
s
T
A
b
l
e
8
.5
c
on
tin
ue
d

232
population). Segmentation allows planners to create an
intervention to fit the needs
and characteristics of a priority population (Pasick, D’Onofrio,
& Otero-Sabogal, 1996).
Following are a few examples of how priority population
segmentation can be applied.
If program planners are developing written materials as part of
their intervention, they
need to make sure that the materials are written at an acceptable
reading level for the
priority population. From a developmental stage perspective, it
is not reasonable to
expect kindergartners to sit still for a one-hour lesson.
Interventions also need to “fit”
culturally within the priority population (Pérez & Luquis, 2014)
and be culturally
sensitive. Culturally sensitive interventions are those “that are
relevant and acceptable
within the cultural framework of the population to be reached”

(Frankish, Lovato, &
Shannon, 1998). In attempts to be culturally sensitive, because
culture is often context
specific, planners need to be careful not to perpetuate harmful
cultural stereotypes.
One final item to consider when thinking about the
appropriateness of an
intervention strategy for the priority population is to ask if there
is any chance that the
strategy could cause any unintended effects in the priority
population. For example,
could the strategy threaten the physical safety or raise undue
anxiety in the priority
population (CDC, 2003)?
6. Are the necessary resources available to implement the
intervention selected? Obviously some
intervention strategies require more money, time, personnel, or
space to implement
than others. For example, it may be prudent to provide each
person in the priority
population with a $100 incentive for participating in the health
promotion program,
but it may not be possible because of budget limitations.

7. Would it be better to use an intervention that consists of a
single strategy or one that is made
up of multiple strategies? Again, we refer to the principle of
multiplicity. A single-strategy
intervention would most likely be easier and less expensive to
implement and easier to
evaluate. There are, however, some real advantages to using
several strategies at multiple
levels of influence: (1) “hitting” the priority population with a
message in a variety of ways
from multiple levels of influence; (2) appealing to the variety of
learning styles within
any priority population; (3) keeping the health message
constantly before the priority
population; (4) hoping that at least one strategy appeals enough
to the priority population
to help bring about the expected outcome; (5) appealing to the
various senses (such as
sight, hearing, or touch) of each individual in the priority
population; and (6) increasing
the chances that the combined strategies would help reach the
goals and objectives of the
program (e.g., communication used to publicize a policy
change) (CDC, 2003). When

interventions include multiple strategies offered at multiple
levels of influence to multiple
groups, they often include several interacting components or
“active ingredients.” Such
interventions are now being referred to as complex
interventions (Hawe, 2015). Probably the
biggest drawback to using complex interventions is the
difficulty of separating the effects
of one strategy from the effects of others in evaluating the
impact of the total program and
of individual components. However, Glasgow, Vogt, and Boles
(1999) have developed an
evaluation model titled RE-AIM (acronym for reach, efficacy,
adoption, implementation,
and maintenance) for use with multi-strategy interventions.
Limtations of Interventions
Finally, before leaving this chapter on interventions we would
be negligent if we did not
mention that even well-planned interventions are not always
successful in achieving the
expected outcomes. That is, most interventions come with some
limitations. In a keynote

address on the impact of injuries as a public health problem,
Sleet (2015) identified some of
the limitations associated with the three major approaches to
intervening to prevent injuries
namely—innovations in engineering and technology, legislation
and enforcement, and
education for behavior change. Sleet (2015) noted in order for
engineering and technology
innovations to be successful in preventing injuries they must
be: effective and reliable; ac-
ceptable to those for whom they were intended; easy to use; and
used properly. Consider
how these criteria apply to child-resistant cigarette lighters and
medicine bottles, bicycle
helmets, smoke and carbon monoxide detectors, and microwave-
safe baby bottles.
In order for legislative and enforcement interventions to prevent
injuries the laws must:
be widely known to the people; be fair and acceptable to the
people; insure that the prob-

ability of being caught for not obeying is high; and outline
punishment that is swift and
certain if the law is broken. Think about how these criteria
might limit laws associated with
child-safety restraints for motor vehicles, safety belts,
motorcycle helmets, and speeding.
In order for educational interventions to be effective in
preventing injuries people must: be
exposed to the information; understand and believe the
information; have the resources to
make the necessary changes; and be reinforced when they make
the changes. Reflect on how
these criteria may limit educational programs on smoke detector
maintenance, drinking and
driving, and texting while operating a motor vehicle. Although
Sleet’s (2015) examples were
restricted to injury prevention and three major intervention
strategies, the same or similar
limitations could be applied to the other categories of
intervention strategies presented in
this chapter.
Summary
Interventions are those actions that are designed to prevent

disease or injury or promote
health in the priority population. Interventions are also
sometimes referred to as treatments.
Although many times an intervention is made up of a single
strategy, it is more common
for planners to use a variety of strategies aimed at multiple
levels of influence to make up
an intervention for a program. In this chapter, intervention
strategies were categorized into
the following groups: (1) Health communication strategies; (2)
Health education strategies;
(3) Health policy/enforcement strategies; (4) Environmental
change strategies; (5) Health-
related community service strategies; (6) Community
mobilization strategies, and (7) Other
strategies. Additionally, this chapter presented three avenues for
designing health promo-
tion interventions including adopting, adapting, or creating a
new intervention. And, fi-
nally, the chapter provided some limitations of interventions.
Review Questions
1. What is an intervention?

2. What are the advantages of using a multistrategy intervention
(i.e., principle of
multiplicity) over one that includes a single strategy? Are there
any disadvantages? If
so, what are they?
3. What does dose mean in terms of an intervention?
4. What are the major categories of interventions? Explain each.
5. Define each of the following terms as they relate to health
education strategies:
curriculum, scope, sequence, unit of study, lessons, and lesson
plans.
6. What is motivational interviewing? How can it best be used
in a health promotion
program?
7. State and briefly describe the five stages of Kinzie’s (2005)
modified framework for

instructional design.
8. Define health literacy and health numeracy and explain how
they impact health
promotion programs.
9. What is health advocacy?
10. What special issues are there related to incentives with
which planners working in the
worksite setting need to be concerned? How can behavioral
economics be used to shape
incentives?
11. Why should program planners be concerned with program
guidelines that have been
developed by professional organizations and other groups?
12. What is the difference between adopting and adapting an
evidence-based intervention?
13. Identify and briefly explain the five steps in the framework
for adapting an evidence-
based intervention for a new setting.

14. Briefly discuss the questions set forth in this chapter that
should be considered before
creating a new intervention.
15. What are some of the limitations associated with
interventions?
Activities
1. Create a multi-strategy intervention for a program you are
planning.
2. Create a multi-strategy intervention for a program that has as
its goal “to get third-
grade students to wear helmets while riding their bicycles.”
3. Using evidence found at the Guide to Community Preventive
Services, adapt a multi-
strategy intervention for a setting of your choice.
4. Create a multi-strategy intervention for a program that has as
its goal “the rehydration
of young children in the small village of Y in the developing
country of Q.”
5. Design and present on an 8½” 3 11” piece of paper a bulletin

board that could be used
as part of the multi-activity intervention you are planning.
Divide the piece of paper
that represents the bulletin board into six equal sections and
indicate what you will
include in each section.
6. Interview a classmate to find out information about his or her
health risks. Then,
assuming you are a patient educator in a health clinic, create a
one-page tailored letter
to the person, urging him or her to seek an appropriate
screening for the health risk(s).
7. Develop a three-fold pamphlet that can be used as an
informational piece for a program
you are planning.
8. With other students in your class, write a PSA script for a
program you are planning.
Then rehearse the script and record it.

9. Write a two-page, double-spaced news release that describes
a program you are
planning.
10. Write a letter to your state or federal senators or
representatives and request their
support of a piece of health-related legislation that is currently
being considered.
Weblinks
1. http://www.cdc.gov/socialmedia/
Social Media at CDC
This page on the CDC’s Website deals with the use of social
media. From here you can
link to the various social media tools of CDC and to a page that
provides guidelines that
have been developed to provide critical information on lessons
learned, best practices,
clearance information, and security requirements.
2. http://nccc.georgetown.edu
National Center for Cultural Competence (NCCC)
At this site you will find a lot of resource material dealing with

cultural competence
including a listing of publications, self-assessments, and current
projects and initiatives.
3. http://www.cdc.gov/healthliteracy/
Health literacy
This page on the CDC’s Website focuses on health literacy. The
site provides
information, tools, and links on health literacy research,
practice, and evaluation. It also
provides links to the National Action Plan to Improve Health
Literacy, CDC’s Action Plan
to Improve Health Literacy, and the federal Plain Writing Act.
4. http://www2a.cdc.gov/phlp/
Public Health Law Program
This page on the CDC’s Website focuses on public health law
and policy. From here you
can link to public health law news and other materials and
resources that examine the
authority of the government at various jurisdictional levels to
improve the health of the
general population within societal limits and norms.
5. http://www.thecommunityguide.org/index.html

Guide to Community Preventive Services
This Webpage includes evidence-based recommendations for
programs and policies to
promote population-based health.
6. http://www.cdc.gov/healthcommunication/index.html
Gateway to Health Communication & Social Marketing Practice
This page on the CDC’s Website provides resources to help
build health communication
or social marketing campaigns and programs. It includes tips for
analyzing and
segmenting an audience, choosing appropriate channels and
tools, and evaluating the
success of messages or campaigns.
http://www.cdc.gov/socialmedia/
http://nccc.georgetown.edu
http://www.cdc.gov/healthliteracy/
http://www2a.cdc.gov/phlp/
http://www.thecommunityguide.org/index.html
http://www.cdc.gov/healthcommunication/index.html
237

There are a number of different processes involved in planning
health promotion
programs and those processes vary based upon the
circumstances of the planning situation.
The processes selected and used to plan programs are in part
predicated on the level of the
influence (i.e., intrapersonal, interpersonal, and/or community),
and the level of influence
is often predicated on the size of the priority population. For
example, certain processes
are more useful when planning programs for relatively small
groups or communities of
people such as those found in worksites, clinics, and schools,
whereas other processes must
be considered when working with larger communities. By
community, we do not mean only
those groups of people within a certain geographic area, though
that could define a com-
munity, but more specifically, a community is defined as “a
collective body of individuals
identified by common characteristics such as geography,
interests, experiences, concerns,
or values (Joint Committee on Health Education and Promotion
Terminology, 2012, p. 15).
Israel and colleagues (1994) have stated that communities are

characterized by the follow-
ing elements: (1) membership—a sense of identity and
belonging; (2) common symbol
systems—similar language, rituals, and ceremonies; (3) shared
values and norms; (4) mutual
influence— community members have influence and are
influenced by each other; (5) shared
needs and commitment to meeting them; and (6) shared
emotional connection—members
share common history, experiences, and mutual support. Thus
communities can be defined
by location, race, ethnicity, age, occupation, interest in
particular problems (e.g., domestic
9
Chapter Community Organizing
Chapter Objectives
⦁ ⦁ Define community, community organizing,

community building, task forces, and coalitions.
⦁ ⦁ Outline the processes for organizing and
building a community.
⦁ ⦁ Explain the term mapping community capacity.
Key Terms
active participants
bottom-up
citizen-initiated
coalition
community
community building
community organizing
executive participants
gatekeepers
grassroots
mapping community
capacity
occasional
participants

ownership
potential building
blocks
primary building
blocks
secondary building
blocks
supporting
participants
task force
violence), outcomes (e.g., breast cancer survivors), or other
common bonds (e.g., people with
a disability) (Turnock, 2012). Today, we can also talk about a
cyber community (Minkler,
Wallerstein, & Wilson, 2008).

Although many of the planning processes are applicable
regardless of the size of the com-
munity, when working with large communities an additional
process is needed in order to
have a successful program. This additional process is organizing
those in the community to
come together to work as a group to deal with the needs of the
community. This chapter ad-
dresses the fundamental elements of organizing communities for
action. Box 9.1 identifies
the responsibilities and competencies for health education
specialists that pertain to the
material presented in this chapter.
Community Organizing Background and Assumptions
In recent years, there has been a shift in the focus of the work
of planners and others in the
helping professions. Where once the work of planners focused
almost solely on the indi-
vidual, today the focus is on broadening to the community.
Community-based, community
empowerment, community participation, community
partnerships and systems change are among

the many terms that are being used more frequently by health
agencies, outside funders, and
policy makers (Minkler, 2012). There are good reasons for the
use of these terms and most
revolve around the need for communities to organize.
With the evidence to show that interventions aimed at the
community level (also
referred to as population-based approaches) can have a positive
affect on the health of a
community, it is important that health education specialists have
community organiz-
ing skills. In the early history of the United States, a sense of
community was inherent in
everyday life (Green, 1989). It was natural for communities to
pool their resources to deal
with shared problems. More recently, the need to organize
communities has seemed to
increase. “Advances in electronics (e.g., handheld digital
devices) and communications
(multifunction cell phones and Internet), household upgrades
(e.g., energy efficiency),
and increased mobility (e.g., frequency of moving and ease of
worldwide travel) have
resulted in a loss of a sense of community. Individuals are much

more independent than
ever before. The days when people knew everyone on their
block are past. Today, it is not
uncommon for people to never meet their neighbors” (McKenzie
& Pinger, 2015, p. 135).
Because of these changes in community social structure and the
resources necessary to
meet the needs of communities, it now takes a concerted effort
to organize a community
to act for the collective good.
“The term community organization was coined by American
social workers in the late 1880s
to describe their efforts to coordinate services for newly arrived
immigrants and the poor”
(Minkler & Wallerstein, 2012, p. 38). More recently,
community organization has been used
by a variety of professionals, including health education
specialists, and refers to various
methods of intervention to deal with social problems.
“Community organization is impor-
tant in fields like health education and social work partially
because it reflects one of their
fundamental principles, that of ‘starting where the people are’
(Nyswander, 1956)” (Minkler

& Wallerstein, 2012, p. 37-38). “The health education
professional who begins with the com-
munity’s felt needs, is more likely to be successful in the
change process and in fostering true
community ownership of programs and actions” (Minkler et al.,
2008, p. 288).
Chapter 9 Community Organizing and Community Building 239
9.1
Specialists
This chapter focuses on the fundamental elements of organizing
communities. As such, the
content presented cuts across several different areas of
responsibility for health education
specialists. The responsibilities and competencies related to
these tasks include:

Competency 1.1: Plan assessment process for health education/
promotion
to health
environmental, and other factors that influence health
other
stakeholders in the planning process
Competency 2.2: Develop goals and objectives
education/
promotion
Competency 2.5: Address factors that influence implementation

of
RESponSiBility iii: Implement Health Education/Promotion
Competency 3.3: Implement health education/promotion plan
to Health Education/Promotion
Competency 4.1: Develop evaluation plan for health
education/promotion
RESponSiBility V: Administer and Manage Health
Education/Promotion
Competency 5.3: Manage relationships with partners and other
stakeholders
Competency 5.4: Gain acceptance and support for health
education/
promotion programs
Competency 5.5: Demonstrate leadership

Competency 5.6: Manage human resources for health
education/
promotion
Resource Person
Competency 6.2: Train others to use health
education/promotion skills
Competency 6.3 Provide advice and consultation on health
education/
promotion issues
Health, Health Education/
Promotion, and the Profession
a
variety of communication strategies, methods, and techniques
Competency 7.2: Engage in advocacy for health and health
education/
promotion

promote
health and health education
Health Education
Box
Community organizing has been defined as “the process by
which community groups
are helped to identify common problems or change targets,
mobilize resources, and develop
and implement strategies to reach their collective goals”

It is not a science but rather an art of building consensus within
the democratic process (Ross,
1967). (See Box 9.2 for definitions of related terms.) Although
community organization may
not be as “natural” as it once was, communities can still
organize to analyze and solve problems
through collective action. In working toward this end, those
who assist communities with orga-
nizing must make several assumptions. Ross (1967, pp. 86–92)
has stated these as follows:
1. Communities of people can develop the capacity to deal with
their own problems.
2. People want to change and can change.
3. People should participate in making, adjusting, or controlling
the major changes taking
place in their communities.
9.2
terms Associated with Community organizing

Citizen Participation The bottom-up, grassroots mobilization of
citizens for
the purpose of undertaking activities to improve the
condition of something in the community.
Community Capacity “Community characteristics affecting its
ability to
identify, mobilize, and address problems” (Minkler &
Wallerstein, 2012, p. 45).
Community Development “A process designed to create
conditions of
economic and social progress for the whole
community with its active participation and the
fullest possible reliance on the community’s
initiative” (United Nations, 1955, p. 6).
Empowerment “Social action process for people to gain mastery
over
their lives and the lives of their communities” (Minkler
& Wallerstein, 2012, p. 45).
Grassroots Participation “Bottom-up efforts of people taking
collective actions
on their own behalf, and they involve the use of a

sophisticated blend of confrontation and cooperation in
order to achieve their ends” (Perlman, 1978, p. 65).
Macro Practice The methods of professional change that deal
with
issues beyond the individual, family, and small group
level.
Participation and Relevance
Social Capital
“Community organizing that ‘starts where the people
are’ and engages community members as equals”
“The processes and conditions among people and
organizations that lead to their accomplishing a
goal of mutual social benefit, usually characterized
by interrelated constucts of trust, cooperation,
civic engagement, and reciprocity, reinforced by
networking” (Last, 2007, p. 347)
Fo
cu

s
O
n
Box
4. Changes in community living that are self-imposed or self-
developed have a meaning
and permanence that imposed changes do not have.
5. A “holistic approach” can deal successfully with problems
with which a “fragmented
approach” cannot cope.
6. Democracy requires cooperative participation and action in
the affairs of the
community, and that the people must learn the skills that make
this possible.

7. Frequently communities of people need help in organizing to
deal with their needs, just
as many individuals require help in coping with their individual
problems.
The Processes of Community Organizing
There is no single unified model of community organizing or
community building (Minkler
& Wallerstein, 2012). In fact, Rothman and Tropman (1987, pp.
4–5) have stated, “We should
speak of community organization methods rather than the
community organization method.”
The early approaches to community organization used by social
workers emphasized the use of
consensus and cooperation to deal with community problems
(Garvin & Fox, 2001). However,
the best known categories of community organization were the
three put forth by Rothman
(2001) and include locality development, social planning, and
social action. More recently, the
strategies have been renamed planning and policy practice,
community capacity development, and
social advocacy (Rothman, 2007). At the heart of the planning

and policy practice strategy are
data. By using data, community/public health workers generate
persuasive rationales that lead
toward proposing and enacting particular solutions (Rothman,
2007).
The community capacity development strategy is based on
empowering those impacted by a
problem with knowledge and skills to understand the problem
and then work cooperatively
together to deal with the problem. Group consensus and social
solidarity are important
components of this strategy (Rothman, 2007). The third
strategy, social advocacy, is used to
address a problem through the application of pressure, including
confrontation, on those
who have created the problem or stand as a barrier to a solution
to the problem. This strategy
creates conflict (Rothman, 2007). Although each of these
strategies has unique components,
each of the strategies can be combined with the others to deal
with a community problem. In
fact, Rothman has offered a 3 3 3 matrix to help explain the
combinations (Rothman, 2007).
Regardless of whether one talks about the “old models” or the

“new models,” they all revolve
around a common theme: The work and resources of many have
a much better chance of
solving a problem or meeting a goal than the work and
resources of a few.
Minkler and Wallerstein (2012) have done a nice job of
summarizing the newer perspec-
tives of community organizing with the older models by
presenting a typology that incorpo-
rates both needs- and strength-based approaches. That typology
is presented in Figure 9.1.
Their typology is divided into four quadrants with strength-
based and needs-based on the
vertical axis and consensus and conflict on the horizontal axis.
Though this typology sepa-
rates and categorizes the various methods of community
organizing and building, Minkler
and Wallerstein (2012) point out that when they
. . . look at primary strategies, we see that the consensus
approaches, whether needs based
or strengths based, primarily use collaboration strategies,
whereas conflict approaches use
advocacy strategies and ally building to support advocacy

efforts. Several concepts span these
Social Action
(Alinsky Model)
Community
Development
Community Building
and Capacity Building
(Power With)
Community Capacity
Leadership
Development
Critical Awareness
Empowerment-Oriented
Social Action

(Challenging Power Over)
Grassroots organizing
Organizing coalitions
Lay health workers
Building community identity
Political and legislative actions
Culture relevant practice
ConflictConsensus
Strategies
Collaboration Advocacy
Needs based
Strengths based

⦁ ▲ Figure 9.1 Community Organization and Community-
Building Typology
Source: Minkler, M., & Wallerstein, N. (2012). Improving
health through community organization and community
building: Perspectives from health education
and social work. In M. Minkler (Ed.). Community organizing
and community building for health and welfare (3rd ed., p. 43).
New Brunswick, NJ: Rutgers
University Press.
two strengths-based approaches, such as community
competence, leadership development, and
multiple perspectives on gaining power. Again, as with the
Rothman model, many organizing
efforts use a combination of these strategies at different times
throughout the life of an
organizing campaign and community building process (p. 44).
Because the purpose of this chapter is to provide an overview of
the community organiz-
ing and community-building processes, and at the risk of
oversimplifying the processes, we
would like to present a very general or generic approach to
community organizing and com-
munity building (see Figure 9.2). It does not include everything

planners need to know about
community organizing and community building, but it does
present the basic elements.
For further information about community organizing, refer to
any of several references
(Minkler, 2012; Minkler et al., 2008; Ross, 1967; Rothman
2007; Snow, 2001) that are de-
voted entirely to the subject. Also, there are several works that
deal specifically with the ap-
plication of community organization to health promotion
activities (Karwalajtys et al., 2013;
Minkler, 2012; Minkler et al., 2008).
Before presenting the generic process for community organizing
and community build-
ing, we would like to comment on the role of the planner in this
process. For many years,
the planner was seen as a “leader” of the community organizing
effort. However, more often

Determining the priorities and setting goals
Arriving at a solution and selecting intervention strategies
Implementing the plan
Evaluating the outcomes of the plan of action
Maintaining the outcomes in the community
Looping back
Assessing the community
Organizing the people
Gaining entry into the community
Recognizing the issue
⦁ ▲ Figure 9.2 Summary of the Steps in Community Organizing
and Building

than not, the planner is an “outsider” with regard to the
community being organized and, as
such, has trouble gaining the credibility to serve as a leader.
Yes, he or she may work in the
community (remember that a community is often defined by
something other than geo-
graphical boundaries) but often lives outside the community in
which the organizing effort
is needed. Thus, the role that the planner should take is that of a
facilitator or assistant rather
than the leader. Experience has shown that it is best if the
leaders come from within the com-
munity. Keep this thought in mind as you read through the
general model.
Recognizing the issue
The processes of community organizing and building begin
when someone recognizes that
an issue exists in the community and that something needs to be
done about it. This recogni-
tion may occur as a result of someone reviewing health data on
the community and seeing a

need (e.g., an unusually high number of teenage pregnancies),
by someone actually observ-
ing a specific situation in the community that needs attention
(e.g., injuries at a particular in-
tersection), or as the result of a community crisis (e.g., lack of
resources to deal with a natural
disaster). “This person (or persons) is referred to as the initial
organizer. This individual may
not be the primary organizer throughout the community
organizing/building process. He or
she is the one who gets things started” (McKenzie & Pinger,
2015, p. 138). For the purposes
of this discussion, assume that the concern is a health problem,
but remember that the com-
munity organization process may be used with any type of
problem found in a community.
Concerns can be as specific as trying to get a certain piece of
legislation passed or as general as
advocating for a drug-free community.
The recognition of an issue can occur from inside or outside the
community. A citizen or
a church leader from within the community may identify the
issue, or it may first be iden-
tified by someone outside the community, such as an employee

of a local or state health
department, a state legislator, a politically active group, or
someone from a local voluntary
health agency. However, the community organizing efforts that
have been most successful
have been those that are recognized from the inside. The
primary reason for this is that those
within the community are much more likely to take ownership
of the effort. It is difficult
for someone from the outside coming in and telling community
members that they have
problems or issues that need to be dealt with and they need to
organize to take care of them.
When there is internal recognition of the issue or concern, it is
referred to as grassroots,
citizen-initiated, or bottom-up organizing.
Gaining Entry into the Community
The second step of this generic process of community
organizing and community building
may or may not be needed. If the issue identified in the previous
step is recognized by some-
one from within the community, then this step of the process
will, more than likely, not be

needed. We say “more than likely” because those within a
community do not need to gain
entry into it. But there may be some cases when someone from
within a community may
identify the issue but has not lived in the community long
enough, lacks the political power,
or does not know enough about the interactions of the
community to proceed with the pro-
cess. In these later cases, the person may be treated or feel like
an “outsider” and may have to
proceed as an outsider would.
If the issue is identified by someone from outside the
community this becomes a most
critical step in the process. Recognition of a concern does not
mean that people should
immediately set about correcting it. Instead, they should follow
a set of steps to deal with
it; gaining proper “entry” into the community is the first step.
Braithwaite and colleagues
(1989) have stressed the importance of tactfully negotiating

entry into a community with
the individuals who control, both formally and informally, the
“political climate” of the
community. These individuals are referred to as gatekeepers.
The term infers that one must
pass through the “gate” in order to get at the people in the
community (Wright, 1994). These
“power brokers” know their community, how it functions, and
how to accomplish tasks
within it. Longtime residents are usually able to identify the
gatekeepers of their community.
They may include people such as business leaders, education
leaders, heads of law enforce-
ment agencies, leaders of community activist groups, parent and
teacher groups, clergy,
politicians, and others. Their support is absolutely essential to
the success of any attempt to
organize a community.
Organizers must approach the gatekeepers on the gatekeepers’
terms and “play” the
gatekeepers’ “game.” However, before making this contact,
organizers must first be famil-
iar with the community with which they are working. “They
must be culturally sensitive

and work toward cultural competence. That is, they must be
aware of the cultural differences
within a community and effectively work with the cultural
context of the community”
(McKenzie & Pinger, 2015, p. 139). Tervalon and Garcia (1998)
stress the need for cultural
humility—openness to others’ culture. In other words,
community organizers must have
a thorough knowledge of the community and the people living
there before they try to
enter the informal boundaries of the community (Braithwaite et
al., 1989). Having a thor-
ough understanding of the community and tactfully approaching
its gatekeepers will help
community organizers develop credibility and trust w ith those
in the community, and, as
noted earlier, it is not easy to bring a concern to the attention of
those in the community.
Few people are glad to know they have a problem, and fewer
still like others to tell them
they have a problem. Move with caution, and do not be too
aggressive!
When people from outside the community are working to
facilitate the organizing efforts,

they will find it advantageous to enter the community through
an already established, well-
respected organization or institution in the community, such as
a church, a service group, or
another successful local group. If those who make up an
existing organization/institution in
the community can see that a problem exists and that solving
the problem will improve the
community, it can help smooth the way to gaining entry and
achieving the remaining steps
in the process.
organizing the people
Obtaining the support of the community members to deal with
the concern is the next
step in the process. It is best to begin with those individuals
who are already interested
in addressing the concern. This is not the time to try to convert
people to the cause or to
make sure that all the key players of the community are
involved. The initial group must
be made up of those people most affected by the problem and
who want to see change
occur. For example, if the identified problem is teenage drug

use, then teens needed to
be included in the group. If the issue is housing for individuals
with low-incomes, then
those individuals need to be included. If the problem is
something that a community
agency or organization (e.g., the local health department or a
social service agency) has
dealt with for a period of time but is unable to solve, then this
group should be involved.
Or, if a group of parents, or another defined group, has been
struggling with the problem
without resolution, then its leaders should be invited to
participate. More often than not,
this core group will be small and consist of people who are
committed to the resolution
of the concern, regardless of the time frame. Brager and
colleagues (1987) have referred
to this core group as executive participants. From among the
core group, a leader
or coordinator must be identified. If at all possible, the leader

should be someone with
leadership skills, good knowledge of the concern and the
community, and most of all,
someone from within the community. One of the early tasks of
the leader will be to help
build group cohesion.
Not everyone is cut out to be an organizer or a leader.
Researchers have found that good
organizers are successful because of a combination of skills and
attributes. These skills and at-
tributes fall into three main areas: change vision attributes,
technical skills, and interactional
or experience skills. Change vision attributes are closely
aligned with an organizer’s view of the
world political terms. These people see a need for change and
are personally dedicated and
committed to seeing the change occur—so much so that they are
willing to put other priori-
ties aside to see the project through (Mondros & Wilson, 1994).
Technical skills include two areas: those related to efficacy on
issues and those related to
organizational health and effectiveness. The former includes
being able to analyze issues,

opponents, and power structure; develop and implement change
strategies; achieve goals;
and possess outstanding communication and public relation
skills. Organizational health
and effectiveness skills include building structures for the
recruitment and involvement of
others, forming and maintaining task groups, and implementing
skills of fundraising and
organizational management (Mondros & Wilson, 1994).
The third characteristic of a good organizer is possessing
interactional or experience skills.
These include an ability to respond with empathy, to assess and
intervene with individuals
and groups, and to be able to identify, develop, educate, and
maintain organizational mem-
bers and leaders (Mondros & Wilson, 1994).
With the core group and leader in place, the next step is to
expand the group to build
support for dealing with the concern—that is, to broaden the
constituency. Brager and col-
leagues (1987) have noted that other group participants will
include active, occasional, and
supporting participants. The active participants (who may also

be executive participants)
take part in most group activities and are not afraid to do the
work that needs to be done.
The occasional participants become involved on an irregular
basis and usually only
when major decisions are made. The supporting participants are
seldom involved but
help swell the ranks and may contribute in nonactive ways or
through financial contribu-
tions. When expanding the group, look for others who may be
interested in helping, and
ask current group members for names of people who might be
interested. Look for people
who may already be dealing with the concern, affected by the
problem through their pres-
ent work, or who have resources to contribute. This search
should include existing social
groups, such as voluntary health agencies, agricultural
extension services, religious orga-
nizations, hospitals, health care providers, political
officeholders, policy makers, police,
educators, lay citizens, or special interest groups. (See Box 9.3
on tips for understanding the
diversity in a working group.)

9.3
Understanding Diversity
Members of a group come from many different backgrounds.
Some members may be
much older or much younger than other members; some may
represent different cultural,
racial, or ethnic groups; some may represent different
educational levels and abilities.
Extra awareness and flexibility are required for the facilitator
and other group members
to remain sensitive to different backgrounds. Below we suggest
a few ways to improve
your awareness of differences. In general, new information is
acquired so that different
perspectives can be understood and appreciated.
⦁ ⦁ Become aware of differences in the group by asking
questions and getting involved in
small group discussions.

⦁ ⦁ Seek involvement and input and listen to persons of
different backgrounds without
bias, and avoid being defensive.
⦁ ⦁ Learn the beliefs and feelings of specific groups about
particular issues.
⦁ ⦁ Read about current and emerging issues that concern
different groups, and read
literature that is popular among different groups.
⦁ ⦁ Learn about the language, humor, gestures, norms,
expectations, and values of
different groups.
⦁ ⦁ Attend events that appeal to members of specific groups.
⦁ ⦁ Become attuned to cultural clichés, stereotypes, and
distortions you may encounter in
the media.
⦁ ⦁ Use examples to which persons of different cultures and
backgrounds can relate.

⦁ ⦁ Learn the facts before you make statements or form
opinions about different groups.
Source: Centers for Disease Control and Prevention, USDHHS,
(no date), p. A2–15.
Fo
cu
s
O
n
Box
Over the last 50 years, in many communities the number of
people interested in volunteer-
ing their time has decreased. Today, if you ask someone to
volunteer, you may hear the reply,
“I’m already too busy.” There are two primary reasons for this
response. First, there are many
families in which both husband and wife work outside the home.
Second, there are more
single-parent households. (See Box 9.4 for tips on working with
volunteers.)

Sometimes these expanded community groups become task
forces or coalitions. A task
force has been defined as “a self-contained group of ‘doers’ that
is not ongoing. It is con-
vened for a narrow purpose over a defined timeframe at the
request of another body or com-
mittee” (Butterfoss, 2013, p. 7). A coalition is “a formal
alliance of organizations that come
together to work for a common goal” (Butterfoss, 2007, p. 30) —
often, to compensate for
deficits in power, resources, and expertise. Coalitions “develop
an internal decision-making
and leadership structure that allows member organizations to
speak with a united voice and
engage in shared planning and implementation activities. Links
to outside organizations
and communication channels are formal. Member organizations
are willing to pull resources
from existing systems, as well as seek new resources to develop
a joint budget. Agreements,
benchmarks, roles, and assignments are often written”
(Butterfoss, 2007, p. 30). The under-
lying concept behind coalitions is collaboration; for several
individuals, groups, or orga-

nizations with their collective resources have a better chance of
solving the problem than
any single entity. “Building and maintaining effective coalitions
have increasingly been
recognized as vital components of much effective community
organizing and community
building” (Minkler, 2012, p. 20). Much has been written about
the importance and use of co-
alitions. Aitaoto, Tsark, and Braun (2009) found that the key to
sustaining coalitions include
having a champion, a supportive organizational home, and
access to technical assistance
and resources. Woods and colleagues (2014) presented a case
study on the importance of
training and technical assistance on coalition functioning and
sustainability. Butterfoss
(2009) has created a longer list of characteristics of successful
coalitions (see Box 9.5), while
Kegler and Swan (2011) have tested the community coalition
action theory (CCAT) for

consistency of its constructs with working community
coalitions. Brown, Feinberg, and
Greenberg (2012) have created a Web-based, self-report
questionnaire that can be used to
provide feedback to coalitions and technical assistance
providers about coalition function-
ing. For those who want more information about coalition
development, Butterfoss (2007,
2009, 2013), Butterfoss and Kegler (2012), and Goldstein
(1997), provide nice overviews of
the processes of building and sustaining coalitions.
Assessing the Community
Earlier in this chapter we noted that there were a numb er of
strategies that have been used
for community organizing. Many of those community
organizing strategies operate “from
the assumption that problems in society can be addressed by
helping the community be-
come better or differently organized, and each strategy
perceives the problems and how or
whom to organize somewhat differently” (Walter, 2005, p. 66).
In contrast to those strategies

tips on Working with Volunteers
Volunteers work for self-satisfaction, personal growth, fun, and
other intangible rewards.
Each volunteer should be treated as a colleague and recognized
as an official part of the
team. However, offer volunteers more flexibility than you can
to employees, and adjust
your expectations accordingly. For example, because volunteers
cannot contribute as much
time as paid, full-time workers do, they cannot complete tasks
as quickly. When scheduling
activities, be realistic about how long a busy participant will
need to complete it.
Get to know each volunteer personally so that you can learn
about special abilities
and limitations and match responsibilities to skills. Vary
responsibilities as desired by
volunteers.
Be sure to assign specific and clearly defined tasks and to
explain procedures and
expectations. Develop a work plan or job description for the
volunteer to help ensure that

roles and responsibilities are understood. Provide training and
give credit for work done.
Give lots of feedback, encouragement, and signs of
appreciation. Be willing to change
the placement of volunteers, if that seems appropriate, or even
dismiss a volunteer if
necessary.
Keep in mind the following key points of working with
volunteers. They want to be:
⦁ ⦁ appreciated for the work that they do.
⦁ ⦁ busy with worthwhile and varied tasks.
⦁ ⦁ provided with clear communication about tasks and
expectations.
⦁ ⦁ developed through training.
Source: Centers for Disease Control and Prevention (no date), p.
A2–17.
H
ig

hl
ig
ht
s
Box
9.4
Characteristics of Successful Coalitions
⦁ ⦁ Continuity of coalition staff, in particular the coordinator
position
⦁ ⦁ Ownership of the problem by coalition members and the
community
⦁ ⦁ Community leaders support the coalition and its efforts

⦁ ⦁ Active involvement of community volunteer agencies
⦁ ⦁ High level of trust and reciprocity among members
⦁ ⦁ Frequent and ongoing training for coalition members and
staff
⦁ ⦁ Benefits of membership outweigh the costs
⦁ ⦁ Active involvement of members in developing coalition
goals, objectives, and
strategies
⦁ ⦁ Development of a strategic action plan rather than a
project-by-project approach
⦁ ⦁ Consensus is reached on issues instead of voting
⦁ ⦁ Productive coalition meetings
⦁ ⦁ Large problems are broken down into smaller, solvable
pieces
⦁ ⦁ Steering committee of elected leaders and staff guides
coalition

⦁ ⦁ Task or work groups of members design and implement
strategies
⦁ ⦁ Rules and procedures are formalized
⦁ ⦁ Local media are actively involved
⦁ ⦁ Coalition and its activities are evaluated continuously
Source: “Building and Sustaining Coalitions.” F. D. Butterfoss,
from Community Health Education Methods: A Practical Guide.
R. J. Bensley and J. Brookins-Fisher
(Eds.). Copyright © 2009 by Jones & Bartlett Learning.
Reprinted with permission.
Fo
cu
s
O
n
Box

9.5
is community building. Community building “is an orientation
to practice focused on
community, rather than a strategic framework or approach, and
on building capacities, not
fixing problems” (Minkler, 2012, p. 10). Community building is
intended to affirm strong
community-rooted traditions, and to build on the good work
already going on in commu-
nities (Kretzmann & McKnight, 1993). One of the major
differences between community
organization and community building is the type of assessment
that is used to determine
where to focus the community’s efforts. In the community
organization approach, the as-
sessment is focused on the needs of the community, whereas in
community building, the
assessment focuses on the assets and capabilities of the
community. A clearer picture of the
community will be revealed, and a stronger base will be
developed for change, if the assess-
ment includes the identification of both the needs and assets,
and involves those who live in
the community.

You may recall (in Chapter 4) we outlined the procedures for
conducting a needs as-
sessment and described how the resulting needs could be placed
on a map (i.e., mapping)
to provide a visual representation of the needs of a community.
Figure 9.3 provides an ex-
ample of such a map. However, an assessment that focuses
entirely on needs/deficiencies
presents only half of the information that is needed in
community organizing and building
(McKnight & Kretzmann, 2012). Organizers also need to know
the capacities and assets.
McKnight and Kretzmann (2012) point out “communities have
never been built upon their
deficiencies. Building community has always depended on
mobilizing the capacities and as-
sets of a people and a place” (p. 183).
In order to map community assets—a process referred to as
mapping community

capacity—McKnight and Kretzmann (2012) have categorized
assets into three different
groups based on their availability to the community and refer to
them as building blocks.
Primary building blocks are the most accessible assets (see
Figure 9.4). They are located in
the neighborhood and are largely under the control of those who
live in the neighborhood.
Primary building blocks can be organized into the assets of
individuals and those of organiza-
tions or associations. (See Box 9.6 for examples of each.) The
next most accessible building
blocks are secondary building blocks, which are assets located
in the neighborhood but
largely controlled by people outside. The least accessible assets
are referred to as potential
building blocks. They are resources originating outside the
neighborhood and controlled
by people outside. Figure 9.4 presents an example of an asset
map using the three types of
building blocks. Knowing both the needs and assets of the
community, organizers can work
to identify the true concerns of the community and the capacity
to deal with them.

Slum housing
S
lu
m
h
o
u
si
n
g
T
ru
a
n
cy
Crime
Mental
illness

Rat
bites
Drug
abuseTeenage
pregnancy
Lead
poisoning
Welfare
dependency
Domestic
violence
Alcoholism
AIDS
Dropouts
Pollution

Unemployment
Boarded-up
buildings
Broken
families
Child abuse
Homelessness
Abandonment
Illiteracy
Gangs
⦁ ▲ Figure 9.3 Neighborhood Needs Map
Source: Kretzman, John P. and John L. McKnight. “Figure 10.1:
Neighborhood Needs Map,” “Mapping Community Capacity” in
and Community Building for Health and Welfare. Copyright ©
2012 by Meredith Minkler. Reprinted by permission of Rutgers
University Press.

Public information
P
u
b
lic
in
fo
rm
a
tio
n
LIBRARIES
FIRE
DEPTS.

PARKSPersonal
incomePUBLIC
SCHOOLS
Cultural
organizations
Associations
of business
Capital
improvement
expenditures
POLICE
VACANT
BLDGS.,
LAND,
ETC.
SOCIAL
SERVICE

AGENCIES
Gifts of
labeled
people
Religious
organizations
Citizens
associations
HIGHER
EDUCATION
INSTITUTIONS
Home-based enterprise
ENERGY/
WASTE RESOURCES
Welfare expenditures

Individual
capacities
Individual
businesses
H
O
S
P
I
T
A
L
S
Primary Building Blocks:
Legend
Secondary Building Blocks:
Potential Building Blocks:
Assets and capacities in the neighborhood,

largely under neighborhood control.
Assets in the community, largely controlled by
outsiders.
Resources outside the neighborhood, controlled
by outsiders.
⦁ ▲ Figure 9.4 Neighborhood Assets Map
Source: Kretzman, John P. and John L. McKnight. “Figure 10.2:
Neighborhood Assets Map,” “Mapping Community Capacity” in
and Community Building for Health and Welfare. Copyright ©
2012 by Meredith Minkler. Reprinted by permission of Rutgers
University Press.
9.6
Building Blocks (Assets) of Communities
primary Building Blocks

Individual assets
⦁ ⦁ Skills and abilities of residents
⦁ ⦁ Individual businesses
⦁ ⦁ Home-based enterprises
⦁ ⦁ Personal income
⦁ ⦁ Gifts of labeled (disabled) people
Organizational assets
⦁ ⦁ Associations of businesses (e.g., chamber of commerce)
⦁ ⦁ Citizens’ associations (e.g., neighborhood watch)
⦁ ⦁ Cultural organization (e.g., Old West End Festival, British
Club)
⦁ ⦁ Communications organizations (e.g., newspapers, TV,
radio)

⦁ ⦁ Religious organizations
⦁ ⦁ Financial institutions
Secondary Building Blocks
Private and nonprofit organizations
⦁ ⦁ Higher education institutions
⦁ ⦁ Hospitals
⦁ ⦁ Social service groups (e.g., Rotary, Kiwanis)
Public institutions and services
⦁ ⦁ Public schools
⦁ ⦁ Police and fire departments
⦁ ⦁ Libraries
⦁ ⦁ Parks
Physical resources

⦁ ⦁ Vacant land, vacant commercial and industrial structures,
vacant housing
⦁ ⦁ Energy and waste resources
potential Building Blocks
Welfare expenditures
Public capital-information expenditures
Public information
Source: “Mapping Community Capacity” by J. L. McKnight and
J. P. Kretzmann from Community Organizing and Community
Building for Health,
Ed. M. Minkler. Copyright © 2005 by Rutgers, the State
University Press.
Fo
cu
s
O

n
Box
Determining priorities and Setting Goals
Once the community has been assessed, the community group is
ready to develop its
goals. The goal-setting process includes two phases. The first
phase consists of identifying
the priorities of the group—what the group wants to accomplish.
The priorities should be
determined through consensus rather than through formal
voting. (See Box 9.7 for tips on
how to reach consensus.) The second phase consists of using the
priority list to write the
9.7
Reaching Consensus

Groups sometimes find it hard to reach a consensus, or general
agreement. Remind
participants of the following guidelines to group deci sion
making.
⦁ ⦁ Avoid the “one best way” attitude; the best way is that
which reflects the best
collective judgment of the group.
⦁ ⦁ Avoid “either, or” thinking; often the best solution
combines several approaches.
⦁ ⦁ A majority vote is not always the best solution. When
participants give and take,
several viewpoints can be combined.
⦁ ⦁ Healthy conflict, which can help participants reach a
consensus, should not be
smoothed over or ended prematurely.
⦁ ⦁ Problems are best solved when participants try to both
communicate and listen.
If a group has trouble reaching consensus, consider using some
special techniques such

as brainstorming, the nominal group process, and conflict
resolution.
Source: Centers for Disease Control and Prevention (no date), p.
A2–12
Fo
cu
s
O
n
Box
goals. To help ensure that the ideals of community organization
take hold, the stakehold-
ers (those in the community who have something to gain or lose
from the community
organizing and building efforts) must be the ones to establish
priorities and set goals. This
may sound simple, but in fact it may be the most difficult part
of the process. Getting the
stakeholders to agree on priorities takes a skilled group
facilitator because there is sure to be

more than one point of view.
When working with coalitions and task forces, one is likely to
face some challenges
(Clark, Friedman, & Lachance, 2006). One challenge that may
surface when determining
priorities and setting goals is turf struggles (disagreements over
the control of resources
and responsibilities). Even though individuals or representatives
of their organizations
have come together to solve a problem, many people will still
be concerned with finding
specific solutions to the problems faced by their organizatio n.
For example, in the case
of drug abuse in the community, consensus may indicate that
the majority of people
believe the solutions lie in the educational system, but people
who work in drug treat-
ment centers may believe that they lie in the treatment of drug
abuse. The facilitator
will need special skills to keep these treatment center people
involved after the priority-
setting process does not identify their concern as a problem the
group will attack. One
means of dealing with this is to have subgoals that can be

worked on by special interest
subcommittees. Such an arrangement will allow the
subcommittee to have a feeling of
ownership in the process.
Miller (2009) and Staples (2012) have identified criteria that
community organizers need
to consider when determining priorities and setting goals. The
concern/issue/problem: must
be winnable, ensuring that working on it does not simply
reinforce fatalistic attitudes and
beliefs that things cannot be improved; must be simple and
specific so that any member of
the organizing group can explain it clearly in a sentence or two;
must unite members of the
organizing group; and must involve them in a meaningful way
in achieving concern/issue/
problem resolution.
254 Part 1 Planning a Health Promotio n Program
Arriving at a

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