HEALTH EDUCATION RESEARCH
Theory & Practice
Vol.12 no.l 1997
Pages 143-150
POINT OF VIEW
Behavioral science theory and principles for practice
in health education
Abstract
The value of health education practice lies
in its effectiveness. Behavioral science theories
have greater potential to enhance the effectiveness of practice than is currently realized.
Many have called for development of strategies
to overcome current barriers to the use of theory
in the field. Such strategies should explicate the
potential of commonly taught behavioral science
theories to facilitate practice and assist practitioners in using such theories. This paper presents one such strategy: a set of principles
for practice, derived from multiple behavioral
science theories and having many direct implications for practice. Health educators who are
knowledgeable of these principles may be better
prepared to consolidate their knowledge of multiple theories and better prepared to derive
implications for practice from their theoretical
knowledge. To the extent that health educators
are proficient at synthesizing theoretical
information and distilling from this information
implications for practice, the utility of theory
in practice should be enhanced.
Introduction
Whether and how to conduct theory-informed
practice is an issue of central importance to
public health education. The value of health
Department of Health Behavior and Health Education,
School of Public Health, University of North Carolina at
Chapel Hill, Chapel Hill, NC 27599-7400, USA
© Oxford University Press
education practice lies in its effectiveness, and
at issue is the potential of theory to increase
program effectiveness and the capacity of practitioners to take advantage of this potential.
Discourse on this issue has been extensive and
has identified several potential advantages of
conducting theory-informed practice. The literature also identifies several barriers to theoryinformed practice and emphasizes the need for
strategies to overcome these barriers (McQueen,
1991; Hochbaum and Long, 1992). This paper
presents one such strategy: a framework intended
to assist efforts to integrate and apply behavioral
science theories relevant to health education
practice. The paper begins by briefly summarizing
the benefits of and barriers to using theory in
practice. The paper then presents a set of
principles for practice, derived from multiple
behavioral science theories relevant to health
education. Knowledge of these principles would
not supplant the study of individual theories.
Rather, it may facilitate the study of multiple
theories by making clear the fundamental assumptions about human behavior which underlie many
theories and, thus, by making clear that many
of the apparent differences between theories are
in fact variations of these basic assumptions.
Making the underlying assumptions salient should
facilitate comparison and synthesis of theories
and the application of theories in practice.
Theory-informed practice: benefits
and barriers
The basic argument for theory-informed practice
is that behavioral science theories constitute the
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Christine Jackson
C. Jackson
There are substantial barriers to applying
theory in the field. The vast and growing array of
behavioral science theories is imposing, such that
the process of identifying, sorting, learning and
integrating multiple theories can be a daunting
task (Hochbaum et al, 1992). Also, the terms
used to label behavioral science variables have
144
been described as practically a foreign language
(Hochbaum et al., 1992; van Ryn and Heaney,
1992)—a language that those already in the field
have limited time to master. Another category of
barriers arises from how theory is taught. Students
of health education are often briefly exposed to a
broad array of theories which results in insufficient
learning of single theories, and insufficient understanding to integrate multiple theories (Hochbaum
etal, 1992; D'Onofrio, 1992). Also, students often
receive inadequate training in how to use theories
in program development and evaluation, and they
experience difficulty in transferring theories from
the academic training context to the practice
environment (Hochbaum et al., 1992; D'Onofrio,
1992).
In sum, barriers to theory-informed practice
include the quantity of relevant theories, the nature
of theoretical information, the way theory courses
are taught, and the perspective on theory held by
health education students and practitioners. The
infrequency of theory-informed practice indicates
that these barriers are sufficient to offset the
potential benefits of such practice.
Strategies for enhancing theory-informed
practice
Several strategies have been proposed to enable
health educators to more frequently use theory in
the field. Van Ryn and Heaney (1992) propose
guidelines for choosing a theory, including
selecting theories that are specific to the unit
of practice (e.g. individuals, organizations), and
selecting theories that have been tested in populations and settings similar to those the practitioner
is working with. Similarly, Hochbaum et al. (1992)
encourage practitioners to select theories that match
the unit of practice and are consistent with the
attributes of the target behavior. These authors
also encourage mutual respect and recognition of
common goals between academicians and practitioners. To address the barrier imposed by the
generality of theories, McLeroy et al. (1993) propose that health educators develop 'theories of
the problem' that summarize the field's current
knowledge of intervention for specific public
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best available information on why people behave
the way they do and practitioners aiming to change
health-related behavior would do well to take
advantage of this information (Burdine and
McLeroy, 1992; Hochbaum et al, 1992; van Ryn
and Heaney, 1992). More specifically, behavioral
science theories identify several attributes of
individuals and their surroundings that are
causally related to behavior, and, thus, theories
can guide practitioners' selection of psychological,
behavioral, social and environmental targets for
intervention. Use of theory can facilitate development of a coherent and comprehensive health
education program, and by doing so increase the
likelihood that the program will affect behavior
change (Glanz et al., 1990; van Ryn and Heaney,
1992). Theory does this by assisting practitioners
in answering the question 'What am I trying to
change by implementing this program?'. When
theory is used to respond to this question, practitioners are more likely to identify program objectives that are causally related to one another and to
the health behaviors of interest, and they are more
likely to develop effective programs. Theories are
equally applicable to designing a comprehensive
and informative program evaluation, since the
factors identified as program objectives can also
be measured to evaluate the process and effects of
program implementation (Glanz et al, 1990; van
Ryn and Heaney, 1992). Additionally, theory can
help practitioners predict the consequences of
various interventions in populations or situations
not experienced before (Hochbaum et al, 1992).
In sum, as noted by Glanz et al. (1990), the task
of health education is to understand health behavior
and to transform knowledge about behavior into
useful strategies for health enhancement. Many
would argue that the application of behavioral
science theory is fundamental to this task.
Principles for practice
Principles for practice
This section describes eight principles for practice
in health education. These principles were derived
from behavioral science theories and models
commonly used in health education research
and frequently taught in graduate curricula in
health behavior and health education (Edwards,
1961; Kelley, 1973; Becker, 1974; Rogers,
1975;
Bandura, 1977; Ajzen and Fishbein,
1980; Cummings, et ai, 1980; Prochaska and
DiClemente, 1983; Becker and Maiman, 1983;
Rogers, 1983; Janz and Becker, 1984; Ajzen,
1985; Bandura, 1986; McQuire, 1990; Ronis,
1992;Weinstein, 1993). This approach was used
because the aim of this paper is to consider
theory from the perspective of a health education
student or practitioner. Specifically, the paper
aims to address this question: given a set of
theories such as those taught in graduate programs
in health education, what basic tenets can
be identified that would assist students in
synthesizing and using this information?
A qualitative approach was used to develop the
principles. Specifically, the author's knowledge of
behavioral science theories and their application
in behavior change programs were used to identify
principles relevant to health education practice.
Over a period of 2 years, the principles were
presented in graduate courses in health education
and at professional conferences. The feedback
obtained during this process lead to a refinement
of the principles presented here.
Principle 1: acquiring new behaviors is a
process, not an event, and often entails
learning by performing successive
approximations of the behavior
The first principle underscores the utility of conceptualizing interventions as a series of highly
specific behavior change objectives and of
delivering interventions so that individuals have
the opportunity to begin 'where they are' in the
process, and proceed incrementally from there.
Behavioral science theories provide much
guidance in identifying steps in the behavior
change process, in understanding inter- and intraindividual variation in the change process, and
in developing support activities, such as guided
practice, that facilitate progression from one step
to the next. Some of the many implications for
practice of this principle follow:
• Expect individual differences in readiness to
change.
• Emphasize gradual change.
• Develop program elements specific to each step
in the behavior change process.
• Teach the psychological and behavioral skills
necessary for successful performance.
• Use direct experience (e.g. guided practice; role
playing) to activate performance and strengthen
attitude-behavior consistency.
• Teach goal setting to enable participants to set
their own pace for change.
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health problems. Such 'mini-intervention theories'
would provide a comprehensive assessment of
the antecedents and causal processes for a given
problem, and would identify the social science
theories most appropriate for designing interventions targeting that problem.
A complementary approach, presented here, is
to identify theoretically informed principles for
practice—derived not from any single theory, but
from multiple behavioral science theories relevant
to health education. Contemporary behavioral science theories, implicitly or explicitly, share basic
assumptions about variables that influence human
behaviors. Health educators who are knowledgeable of these shared assumptions may be better
prepared to consolidate their knowledge of multiple
theories and they may be better prepared to derive
implications for practice from their theoretical
knowledge. To the extent that health educators
have been trained to synthesize theoretical information and distill from this information implications
for practice, the utility of theory in practice should
be enhanced. Specifically, practitioners who are
developing or evaluating behavior change programs may benefit from utilizing theory-based
principles for practice.
C. Jackson
• Teach self-monitoring skills so participants can
chart their own progress.
Principle 2: psychological factors, notably
beliefs and values, influence how people
behave
• Develop program components that target beliefs
such as perceived personal risk, self-efficacy,
response efficacy and perceived social norms.
• Develop program components that target values,
such as perceived personal benefits, perceived
costs and perceived social relevance.
• Instilling new beliefs or values is but one of
several strategies; programs may aim to modify
existing beliefs or values, or they may aim to
146
Principle 3: the more beneficial or
rewarding an experience, the more likely
it is to be repeated; the more punishing or
unpleasant an experience, the less likely it
is to be repeated
The positive or negative aspect of any experience,
whether psychological or behavioral, is subjectively defined. Thus, application of the third
principle requires practitioners to determine
whether seemingly rewarding experiences are
perceived as such by their constituents. In addition, there are many health recommendations for
which health educators are hard pressed to identify
reinforcing factors. One approach to this problem
is to develop program components specifically to
engender positive perceptions of compliance (or
negative perceptions of non-compliance) and to
implement such components prior to making
behavioral recommendations. Campaigns to
modify the perceived benefits of condom use
could, for example, precede recommendations
to purchase and use condoms. Implications for
practice of this principle include:
• Program components that cause participants
to experience personal control, success, social
recognition or other positive states are reinforcing.
• Direct incentives or rewards are also generally
perceived as positive and so reinforce behaviors.
• Developing individuals' capacity to be selfreinforcing, as when individuals learn goalsetting, self-monitoring or self-statement skills,
is a more internalized and potentially more
durable change strategy.
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A key contribution of behavioral science theories
to practice is the specification of beliefs and values
relevant to understanding or trying to change health
behaviors. An important corollary to the second
principle is to know the conceptual and practical
differences between beliefs and values. Beliefs
involve consequential or probabilistic thinking
about the relationships between objects or events.
For example, individuals make attributions about
the causes of specific events; they have expectations about the likelihood of certain outcomes.
Values are evaluative judgments about outcomes
or events. Individuals may perceive events as
good or bad, as desirable or undesirable. These
constructs, which constitute the cognitive and
affective components of attitudes, are the principal
explanatory variables of many behavioral science
theories. In the Theory of Planned Behavior (Ajzen
and Fishbein, 1980; Ajzen, 1985), for example, the
attitudinal component is determined by beliefs that
a behavior leads to certain outcomes, and evaluative
judgments regarding the outcomes. Understanding
the relationships between beliefs and values, as well
as their relationships with behavioral variables,
is key to understanding some of the important
differences between behavioral science theories.
Moreover, it is easier to develop programs to
change relevant beliefs and values when one is clear
on the distinctions between them. Implications for
practice of this principle include:
enhance the salience and perceived relevance
of existing beliefs or values.
• Recognize that multiple beliefs and values
generally underlie each belief and value of
primary interest; develop program elements to
modify these underlying beliefs and values. For
example, the belief 'I am not likely to get
AIDS' could have several underlying beliefs
including 'AIDS is a gay disease' and 'my
partner is not likely to be infected.'
Principles for practice
Principle 4: behavioral experience can
influence individuals' expectancies and
values
The fourth principle makes the point that individuals can modify their beliefs and values as a
result of behavioral experience. This principle
challenges health educators to develop strategies
for increasing opportunities for constituents to
try new behaviors and strategies for involving
constituents in activities that are consistent with,
but do not entail adopting, new health practices.
The former objective calls for developing intervention elements that enhance the convenience,
feasibility and affordability of trying recommended
actions. The latter objective calls for developing
intervention components that engage participants
as agents of change rather than as targets for
change. Media advocacy and policy change interventions exemplify this approach. Implications for
practice of this principle include:
• Program planners should not feel compelled to
conform to the knowledge-attitudes-intention—
behavior change framework for intervention.
• An alternative strategy for change begins with
direct involvement in a health protective
behavior; such involvement may then affect
attitudes and motivation about the behavior.
• A related strategy is one that begins by getting
participants actively and publicly involved in a
health issue without challenging them to change
their health behaviors. Often this will entail
working with participants to change elements
of their environment to increase resources or
support for practicing a health behavior.
Principle 5: individuals are not passive
responders, but have a proactive role in
the behavior change process.
The proactive role of constituents described by
the fifth principle affects the health education
process in multiple ways. Most fundamentally, it
is constituents, not health educators, who control
the process of change. Constituents selectively
attend to educational resources, they assign meaning to educational recommendations, they choose
to accept new information or adopt recommended
actions and they evaluate the consequences of
their experiences. The primary implication of the
proactive role of constituents is that health educators should both analyze their intended audience
and involve audience members in the process of
developing health education messages or programs.
The objective of such analysis and involvement
is to accurately anticipate audience responses to
program components. Behavioral science theories
can facilitate meeting this objective by identifying
variables that predict how audience members will
perceive program components and recommendations. Implications for practice of this principle
include:
• Increase individual motivation to change by
ensuring that all facets of program participation
and response are perceived as volitional.
• Avoid using health education messages or interventions that are perceived as coercive or selfserving; they are likely to be ignored.
• Involve members of the target audience in
developing health education messages, programs and intervention strategies.
• Individuals evaluate health education programs
using existing beliefs and values to determine
whether programs are relevant to them. Effective health behavior change begins with an
assessment to identify the relevant beliefs and
values held by members of the target group.
Principle 6: social relationships and social
norms have a substantial and persistent
influence on how people behave
Several behavioral science theories, including
Social Learning Theory (Bandura, 1977; Bandura,
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• Participants respond more favorably to programs that use fear, anxiety, or threat of loss
when such programs also have an effective
'threat resolution' component (because resolving a threat is reinforcing).
• Alternative versions of program content are
usually needed to account for individual differences in perceptions of what is rewarding or
punishing.
C. Jackson
• Modeling of behaviors by significant others is
effective in initiating and maintaining behavior
change.
• People have different social motives for
making a recommended behavior change; to be
effective, program recommendations must be
consistent with participants' underlying social
motives for change.
• Activate normative influence processes by
making shared social norms salient, and by
using methods which create social pressure,
such as social contracts or public commitments.
• Changing health practices within social groups
increases the potential for sustained behavior
change.
Principle 7: behavior is not independent
of the context in which it occurs; people
influence, and are influenced by, their
physical and social environments
This principle underscores the fact that health
behaviors are influenced by an array of biologic,
psychological, social, physical, economic and
regulatory factors. The multi-disciplinary nature
of effective public health practice requires that
knowledge of behavioral science theories be
integrated with knowledge from other disciplines
widely used to inform public health practice—
148
sociology, political science, economics, medicine
and epidemiology, among others. Implications for
practice of this principle include:
• It is not enough to promote individual behavior
change; environmental changes are needed
which promote and facilitate individual change
efforts.
• Comprehensive, ecological interventions are
needed which occur at multiple levels and
settings in the community, employ multiple
change strategies and maximize synergy
between intervention components.
• Comprehensive interventions can have added
impact when they engage community members
in changing their physical and social environments, as well as changing their own behaviors
and circumstance.
Principle 8: the process of applying
behavioral science theories in practice
situations should be guided by research
and evaluation methods
As illustrated by several of the preceding
principles, behavioral science theories identify
many specific intra- and interpersonal factors
thought to explain variation in health behaviors.
Conducting theory-informed practice often
requires measuring such factors, and designing
evaluations that will determine whether programs
are effective in changing them. Practitioners therefore need to utilize research and evaluation methods
to correctly apply behavioral science theory in
practice situations. If, for example, a practitioner
wants to assess the existing levels of self-efficacy
and response-efficacy in a target population,
research methods are needed to obtain reliable,
valid assessments of these concepts. Similarly, if
a program is intended to change social norms
regarding condom use, a research design is needed
that will determine whether any change in norms
has occurred and whether such change can be
attributed to the program. In brief, research and
evaluation methods are critical tools for linking
theory and practice. The general implications of
this principle include:
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1986) and the Theory of Planned Behavior (Ajzen
and Fishbein, 1980; Ajzen, 1985), explain how
social norms and social influence processes affect
individual behavior. Social norms are naturally
occurring standards of behavior that exert a
powerful influence of members of a social group
(e.g. a family, peer group or work group). The
stronger one's affiliation with (or desire for
affiliation with) a specific social group, the more
responsive one is to the normative expectations
of that group. Consistent with the theoretical
models of normative influence, health education
programs that have social groups as the unit of
intervention and aim to change group norms may
achieve substantial and sustainable change in health
practices. Implications for practice of this principle include:
Principles for practice
Conclusion and implications
Hochbaum et al. (1992) state that practitioners
who doubt the usefulness of theories basically
question the existence of a link between the
abstract formulations that are theories and the
realities of practice. Explicating principles for
practice is a means of demonstrating such a link,
of demonstrating the implications of theory for
health education. Most importantly, the principles
may facilitate synthesis of theoretical knowledge, and, thus, application of an integrated body
of knowledge rather than selection and application
of single theories. It is widely acknowledged that no
single theory is adequate for developing effective
behavior change strategies. Practitioners need a
framework for applying multiple theories. To the
extent that these principles for practice are valid
summaries of the behavioral tenets of the theories
from which they are derived, they may constitute
such a framework.
Applying the principles in the framework does
present certain challenges. First, as previously
noted, the principles do not supplant the need to
study behavioral science theories. Because the
principles generalize across theories they do not
specify in sufficient detail the theoretical constructs which practitioners could apply. For
example, the second principle describes the link
between beliefs and behavior. One would need
knowledge of the Health Belief Model (Janz and
Becker, 1984), the Theory of Planned Behavior
(Ajzen, 1985) and other theories to determine what
specific beliefs to address in a program or to
determine how to measure beliefs in a program
evaluation.
Second, practitioners must determine which
principles to apply in a given practice situation.
Application of the first principle assumes, for
example, that practitioners know where members
of their target group are as regards the phases of
behavior change and what behavioral skills might
facilitate progress to the next phase. Similarly,
practice situations vary with regard to the viability
of using direct involvement as a change strategy
(per the fourth principle) or using normative influence factors to achieve behavior change (per the
sixth principle).
A third challenge is that resources are needed
to collect information pertinent to the application
of the principles. For example, application of
the second principle requires information about
participants' current beliefs and values; application
of the third principle requires information on
participants' perceptions of rewards and incentives,
and application of the sixth principle requires
information on social group members whom participants hold in high regard. Practitioners may use
focus groups, small group surveys or other brief
measures to obtain such information. In sum, the
challenges of applying the principles are to link
the principles with the set of theories one finds
relevant to practice, determine which principles
one can apply in a given practice situation and
obtain the information necessary to take advantage
of the relevant principles.
The notion that behavioral science and other
disciplines can inform health education practice
does not exclude or discount the equally important
role of experience in informing practice decisions.
Experience engenders knowledge of the people,
knowledge of the problem, and knowledge of
the social system in which the problem occurs.
Experience engenders trust, familiarity, cultural
sensitivity and political awareness—all essential
to successful intervention. Optimally, practitioners
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• Knowledge of the empirical literature underlying a theory is a useful foundation for determining whether and how theoretical concepts
are relevant to specific practice situations.
• To apply theory in needs assessments, formative
evaluations for program planning and other
practice activities, research methods should be
used to define, operationalize and measure the
theoretical concepts of interest.
• To determine whether programs affect change
in the psychological, social and other theorybased determinants of behavior, research
designs are needed that eliminate rival explanations and provide evidence of a cause-effect
relationship.
C. Jackson
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Received on August II, 1995: accepted on April 10. 1996
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can draw upon their theoretical and experiential
knowledge as they plan, implement and evaluate
health education programs.
Controversy about the role of theory in health
education practice continues (McLeroy et ai, 1993;
Green et ai, 1994; Buchanan, 1994). The debate
is multi-faceted, raising questions about the role
of existing theories and models (McLeroy et ai,
1993; Green et ai, 1994), and even broader questions about the nature of social science theory and
its capacity to explain human behavior (Buchanan,
1994). The present paper is one response to this
debate. It assumes that health educators who recognize the utility of theoretical constructs would
choose to conduct theory-informed practice. It
assumes that the burden of proof regarding the
utility and methods of applying theory rests with
theoreticians. It also assumes that while behavioral
science theories do not approach the explanatory
power of natural science theories, they constitute
the best available explanatory knowledge about
variables influencing behavior. Guided by these
assumptions, the present paper is not aligned with
one position in the debate, but specifically aims to
get beyond the debate by proposing a method for
narrowing the gap between theory and practice.