If we want more evidence-based practice, we need more practice-based evidence.*

Chapter 4
Human Behavior and Community and
Population Health Education

Table of Contents

REFERENCES - since publication of 8th edition


To achieve the objectives stated at the beginning of this chapter, we introduce another of the scientific foundations in community health, namely the behavioral and social sciences. Our philosophy is that most of the gains to be made in community health depend in democratic societies on the enlightened participation or support of the public. Technological and environmental maneuvers can only succeed if the public accepts them. Health education is the means to facilitate voluntary adaptation of behavior conducive to health in individuals, families, and communities. 


A model for analyzing the behavioral factors contributing to community health is presented with examples from maternal and child health--the subject of the next chapter. Thus, this chapter helps to bridge the foundations of community health presented in Part 1 of the book with the life span considerations of Part 2. Specific principles and steps in planning, organizing, implementing and evaluating a community health education program are offered in this chapter, using the PRECEDE framework for health education planning (Green & Kreuter, 1999). This limited introduction to the PRECEDE model presents health education as a systematic approach to problem solving in community health without going as far as a course in health education. 


Pennsylvania: Schools see promising results from obesity campaign “School district shows early success in fighting childhood obesity” (Associated Press, Jan 1, 2005 )    

California: Cities and towns make effort to keep tobacco from minors. “Fee helps snuff out tobacco sales to minors.” Monterey County Herald   Jan 1, 2005.  M.S. Enkoji

Zerhouni Says Brain Research Is Key To Future Health Behavior Success (Health Behavior News Service, March 3, 2003) - National Institutes of Health Director Elias Zerhouni predicts that brain and behavior studies, along with efforts to target disease at the molecular level, are the future of medical research that emphasizes prevention as much as cures.

Doctor Fights for Warnings On Viagra's Ads and Labels (Wall Street Journal, March 3, 2003) - Since last year, 43 new cases of syphilis and 14 new HIV infections have been diagnosed in Viagra users in San Francisco.  This occurrence has provides evidence that Viagra use may be associated with unsafe sexual behavior.

Britain To Ban Most Tobacco Ads.    (Sources: Lucy Fardon, "British Agency To Ban Majority Of Tobacco Ads," Wall Street Journal, June 18, 1999, p. A19 <http://www.wsj.com>; Edna Fernandes, "UK Moves To Stub Out Tobacco Advertising," Reuters, June 17, 1999; Alan Cowell, "Tobacco Ads Banned," New York Times, June 18, 1999, p. C3 http://www.nyt.com) Tobacco advertisements were banned from all billboards, newspapers and magazines in Britain beginning December 10, 1999, according to the country's Department of Health. The new rule took effect 18 months before a similar European Union ban is implemented. In addition to banning tobacco ads, the department's goal is to phase out the vast majority of tobacco sponsorships by 2003. The extension of three years was given to global sports such as Formula One racing, snooker, darts and perhaps fishing, provided they reduce tobacco sponsorship and advertising by one-fifth in each year of the extension. These sports were cited as having to rely heavily on tobacco funds in order to remain in existence. The tobacco industry claimed the new ban will result in thousands of lost jobs. Clive Bates, director of Action on Smoking and Health, said, "If the cigarette companies are unhappy then we can be sure that it is a good day for long life and healthy living." http://www.hc-sc.gc.ca/english/media/releases/1999/99_65e.htm

Hygiene Behaviour Research . (Hygiene Behaviour Network Newsletter, no. 4, January 1999)- The latest issue of the Hygiene Behaviour Network Newsletter includes an overview of recent hygiene behavior research, programs and publications. http://info.lut.ac.uk/departments/cv/wedc/garnet/hybnews4.html

Just Say Life Skills

Just Say Life Skills (Time November 11, 1996) Life skills training has efficacy in providing students with the ability to deal with drugs pressures from peers.

Sunburn Scare has Faded Like an Old Tan (Southam News July 18, 1996) Many youth do not associate the incidence of sunburn with the complication of skin cancer later in life. Strategies need to be developed to increase awareness and change behaviors.

Harm Reduction or Zero Tolerance: Which is a Better Weapon Against Drug Abuse in Hawaii ( Pam Lichty, The Honolulu Advertiser September 26, 1996) Harm reduction is proving to be a more effective tool against drug abuse than law enforcement approaches, such as the "zero tolerance" attitude that dominates US policy today.

 For related news stories, please click here.  


National Conference on Health Info-Structure

(3 September 1998)  http://www.hc-sc.gc.ca/english/media/releases/1999/99_65e.htm


The purpose of the conference was to advance the development of a national strategy on using information and communication technologies to modernize the health system. Minister Rock took the opportunity to announce the National Telehealth Research Project for First Nations communities. The final conference report is available to the public.

Centers for Disease Control and Prevention
Public Health Service

Centers for Disease Control and Prevention
Public Health Service
Department of Health and 
Human Services
1600 Clifton Road, NE
Atlanta, GA 30333

The CDC website for "Programs that Work" was discontinued by the current administration (see
http://www.house.gov/reform/min/politicsandscience). ETR Associates in California are
preserving this research on their ReCAPP website at: http://www.etr.org/recapp/programs/index.htm

Maintains a database of health education/health promotion literature. It serves as a dissemination vehicle for the growing body of published and non-published works in health education, including citations and annotations to current journal articles monographs, conference proceedings and reports.

Consumer Information Center
Department TD
Pueblo, CO 81009

Maintains a consumer information catalog of 200 free and inexpensive federal consumer publications to increase public awareness. Published quarterly for educators, libraries, consumer and other nonprofit groups.

Federal Information Center (KJF)
U.S. General Services Administration
Washington, DC 20405

Addresses and telephone numbers of 37 federal information centers are listed. To help consumers get information accurately and quickly on more than 125 agencies and departments in the federal government.

Planning guide for National Health Education Week (Oct 19-23)


Requests for single copies should be directed to the National Center for Health Education at 212/334-9470.

National Health Information Center



If you work with another special population and do not know where to look for information, there's the National Health Info Center.  This site provides a searchable database of Federal government and private clearinghouses - so you can find all those toll-free numbers and websites in one place.  

Journal Writing, from Education World




Teachers of grades 2-12 generally agree that journal writing is a powerful teaching tool, but something they dread because of the many excuses students give them. This site contains not only ideas for prompting the student writer but also teacher-tested ideas that have worked with students.

CDC's Office on Smoking and Health. (OSH) Go to: http://www2.cdc.gov/nccdphp/osh/state/

OSH announced in June 1999 that its STATE System (State Tobacco Activities Tracking and Evaluation System) is now active on the internet. This system is a one-stop electronic source for state-specific tobacco data

Social Marketing


 Some websites with search capacity for social marketing analyses of audience characteristics ("psychographics") relevant to message development.

The Communication Initiative Website




  Journal References

Bauman, A. Commentary on the VERB campaign – perspectives on social marketing to encourage physical activity among youth. Preventing Chronic Disease (serial online) 2004 July. 

Dole, L. R., Elkins, D. B., Boonjear, K., Phiensrithom, S., Maticka-Tyndale, E. (1998).  Cattle markets and local festivals: Development of HIV/AIDS prevention interventions for specific risk situations in rural Northeast Thailand. HEALTH AND PLACE 4: 265-272. 

Green, L. W. (1999). Health Education's Contributions to Public Health in the Twentieth Century: A Glimpse Through Health Promotion's Rear-View Mirror. ANNUAL REVIEW OF PUBLIC HEALTH 20: 67-88.
    ABSTRACT/Full-Text: Abstract.

Hale, J. F (1998). Application of the PRECEDE-PROCEED Model for comprehensive community assessment, education programming, and evaluation in a combat hospital community during the Gulf War. HOME HEALTH CARE MANAGEMENT & PRACTICE 11(1): 52-65.
    ABSTRACT: "This article describes the Persian Gulf combat hospital community of the 410th [Evacuation Hospital of the US Army Reserve] as it evolved, dissolved, and was evaluated in terms of the PRECEDE-PROCEED model as a community that attained and maintained a high quality of life for both community members and patients during its 'life' in the barren desert of Saudi Arabia..."(p.52). This article supports use of this framework for not only nursing interventions, but also for interdisciplinary community-based interventions and interactions as well. The author has found it to be invaluable in both an academic setting for teaching graduate students a process for and application of an advanced level of community assessment, planning, and evaluation both nationally and internationally when one needs to look at the targeted population or setting from the 'ground up'.

Reisen, C. A., & Poppen, P. J. Partner-specific risk perception: A new conceptualization of perceived vulnerability to STDs. JOURNAL OF APPLIED SOCIAL PSYCHOLOGY 29 (4): 667-684.
    ABSTRACT: Two studies were conducted to test a new conceptualization of risk perception, focusing on the risk posed by a specific sexual partner at a specific time rather than a generalized perception of vulnerability to HIV or sexually transmitted diseases. Study 1 used a cross-sectional design and found support for a model with the following domains as antecedents of partner-specific risk perception (PSRP): generalized perception of HIV risk, partner's sexual history, and characteristics of relationship with the partner. However, PSRP was not associated with condom use in Study 1. Study 2, which used a longitudinal design, replicated the domains predictive of PSRP and also demonstrated the influence of PSRP on condom use 4 weeks later while controlling for past condom use. The findings support the utility of this conceptualization of risk perception in lieu of the Health Belief Model and other models in sexually-transmitted disease control.

Robison, J. I. (1998). To Reward...Or Not to Reward?: Questioning the Wisdom of Using External  Reinforcement in Health Promotion Programs. AMERICAN JOURNAL OF HEALTH PROMOTION 13 (1): 1-3.
The journal's website is:

Oldenburg, B., Glanz, K., & Ffrench, M. (1999). The application of staging models to the understanding of health behavior change and the promotion of health. PSYCHOLOGY & HEALTH 14 (3): 503-516.
    ABSTRACT: Health behavior change programs should be based not only on relevant and demonstrably effective strategies, but also on relevant theories or models. Models such as Social Learning Theory/Social Cognitive Theory and the Transtheoretical Model of Change, for example, may be applied independently or together in a way that may lead to improved intervention outcomes. This paper examines staged approaches to health behavior change and promoting health, and illustrates how key concepts and variables from other models can be used in conjunction with such a framework to develop more tailored and targeted strategies. An overview of the literature in this field is provided, as well as a description of several case studies where interventions based on matching of theories or models have been successful. The potential for extension of the application of such theories from an individual framework to multiple levels, and at an organizational level or environmental level are explored, whereby the potential reach of intervention programs beyond a relatively small number of individuals is increased while still maintaining acceptable program exposure.



The following questions and activities draw on the planning model discussed in this chapter and summarized in Figure 4-5. By working through the model, using the maternal and child health example in the chapter, you will have a greater understanding of how the foundational sciences and determinants of health interact in planning for community and population health. Having worked through the model with this example, you may wish to apply it to an area of health interest to you and your community.

1. Epidemiological diagnosis. The first boxed issue addresses the use of health statistics to identify health problems in the epidemiological diagnosis phase. For each of the health problems associated with elevated maternal mortality, infant death rates and fetal death ratio: 1) assess the incidence, prevalence, distribution, intensity and duration of the problem, and its potential for change to find out which health problem affects the greatest number of people and has effective intervention techniques available; and 2) set program goals, health objective(s) and behavioral objective(s) by asking who will benefit by how much of what outcome by when?

2. Behavioral diagnosis. The second boxed issue examines the behavioral and nonbehavioral (genetic and environmental) causes of the specific health problem. It is important to note that non-behavioral factors contribute to the problem, but are not controlled by the individual. You should select behaviors that will be the subject of the behavioral objective(s) and the focus of the intervention. By using a scale of 1 to 3 (1 = no evidence, 2 = tenuous evidence, 3 = definite evidence), you can rate each behavior by asking the following questions: Importance - How clearly does the evidence link this behavior to the health problem? Changeability - How much supporting evidence is there to change this behavior? With the behaviors ranked by importance and changeability, you can use a matrix of health behavior to select the behavior(s) that will be the focus of the educational intervention:



Not (Less) Important


1. High priority for program focus and political purposes

3. Low priority except to demonstrate change for political purposes

Not (Less) Changeable

2. Priority for innovative program; evaluation

4. No program justified

High priority programs focus on those behaviors that are most important and most directly related to the health problem and have good evidence that the behavior can be changed. Identify the highest priority for program focus from those health problems associated with maternal mortality, infant mortality and fetal death.

3. Educational diagnosis. This boxed issue on page 100 identifies three factors to work on in order to change a behavior (predisposing, enabling and reinforcing). Identify predisposing, enabling and reinforcing factors for the priority behavior previously identified as important and changeable.

(a) Predisposing factors include knowledge, attitudes, beliefs, values and perceptions. The following factors from the Health Belief Model might be addressed: beliefs in one's susceptibility and belief in the seriousness of the health problem, and beliefs in benefits of and barriers to the behavior recommended. The following questions serve as an example:
    1. How likely is it that I will become pregnant?
    2. How likely is it that I would have a problem pregnancy?
    3. How likely is it that my child would suffer the health consequences of a problem pregnancy?

(b) Enabling factors include availability and accessibility to services and skills in achieving the behavior.

(c) Reinforcing factors include incentives and ways to maintain the behavioral change. These could include both positive and negative reinforcers.

4. The final boxed issue looks at program objectives and more specifically at behavioral objectives, by asking the following questions: who is expected to achieve or become how much or what by when. As a concluding activity, formulate behavioral objectives for health programs of choice. 

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