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1 WHY THEORY MATTERS FOR EFFECTIVE HEALTH PROMOTION: A BRIEFING I could not do my job without talking about theory. (Health promotion practitioner) There is nothing so practical as a good theory (Kurt Lewin). Like an expert chef, a theoretically grounded health education professional does not blindly follow a cookbook recipe, but constantly creates it anew, depending on the circumstances. Without a theory, she or he has only the skills of a cafeteria line worker. (US National Cancer Institute, 1997) Planning is an unnatural process. It is far more fun just to do something. The really good thing about not planning is that failure comes as a complete surprise rather than being preceded by prolonged periods of worry and depression. (John Harvey Jones) CONTENTS 1. Who is this briefing for? 2. Why is theory important in promoting health? 3. What is theory? 4. Which theory? 5. What are the main theories in health promotion? 6. The importance of evaluation 7. Sources and further information The Shaping the Future Collaboration is hosted and led by the Royal Society for Public Health, in partnership with the Faculty of Public Health, the Institute of Health Promotion and Education and the UK Public Health Register. However, it should be noted that these organisations have not yet individually endorsed this briefing. This version takes account of comments made at a Shaping the Future workshop in October This is a living document which we would like to develop further. The important of theory needs continuous discussion. Please send comments to Nelly Araujo at the Royal Society for Public Health, 1

2 1. Who is this briefing for? This short briefing is intended to assist health promotion and public health practitioners in explaining the importance of theory to colleagues, such as: Those working in other disciplines of public health Commissioners of public health and health promotion interventions, including the value of theory in scoping service specifications Partnerships with the voluntary and community sector, local authorities, and businesses Programmes and interventions that are based on sound theory are more likely to help your organisation meet its key targets, for example reducing obesity, smoking and other addictive behaviours, and to ensure that health promotion is cost-effective. The capacity to select relevant health promotion theories or models, and apply them in practice, is a key competence for public health. It is included in national competence frameworks, for example the Public Health Skills and Career Framework and the standards of the UK Public Health Register. People outside of health promotion can sometimes be sceptical about the added value of theory and want to move straight to action! This briefing emphasises that theory is an important form of evidence for planning health improvement interventions. This document is a short introduction and cannot explain all the major theories. For more information, please consult a health promotion specialist or academic department, the sources of information at the end, or ask the Institute of Health Promotion and Education (www.ihpe.org.uk) or the Shaping the Future Collaboration who will seek a colleague to discuss the issues with you. 2. Why is theory important in promoting health? Theory is important in the planning and delivery of health improvement services because: Health promotion needs to be carefully planned to be efficient and effective. Theory can guide programme planning, helping to ensure that interventions actually reach and have a demonstrable impact on individuals, communities and organisations. Theories and models are an important form of evidence. Theory needs to be integrated into the evidence base, alongside evaluations and other research-based evidence, the academic literature and national policy. Planning, commissioning, implementation and monitoring processes based in theory are more likely to succeed than those developed without the benefit of a theoretical perspective 1. 1 US National Cancer Institute (2005). Theory at a Glance: A Guide for Health Promotion Practice (second edition). U.S. Department of Health and Human Services, National Institutes of Health. 2

3 Theory assists with the development of state-of-the-art interventions, by helping to answer key what, why and how questions: o What is the nature of the problem? o Who is affected? o Why does it happen o What are the causes? o What are the contextual factors? o What do we need to do to tackle it? o How should we do it? Theory provides an essential framework for studying problems, developing appropriate interventions, and evaluating their successes. Theory is particularly helpful in complex situations most situations! A simple input-output model cannot address adequately the reality of complexity. 3. What is theory? Theories offer explanations of how or why something happens by identifying key variables or issues and establishing the relationship between them. Concepts are the main elements of theories Constructs operationalise key concepts for use in building a specific theory Theories can help to explain situations or predict the ways in which change takes place in individuals, communities, organisations and societies. The application of theory allows a systematic assessment of the problem, its causes and possible solutions to be undertaken. Without theory, interventions might easily: Address wrong or inappropriate variables or issues (i.e. miss the target completely) Tackle only a proportion of the combination of variables required to have the desired effect (i.e. hit only a few of the total number of possible targets) 2 Models provide a looser, often untested, framework to help understand reality and the relationship between concepts. They may draw on one or more theories. 4. Which theory? A key decision is which theories or models fit a health problem, such as promoting exercise or healthy eating. If you are grappling with this issue, you may want to seek help from a health promotion specialist or academic department, or consult one of the sources of information at the end of this briefing. These questions may be helpful: 3 Does the theory include all relevant variables or issues? Does it exclude redundant variables? Does its use make logical sense in the particular situation? 2 Green, J. (2000) The role of theory in evidence-based health promotion practice, Health Education Research, 15(2): Tones, K. and Green, J (2004). Health Promotion Planning and Strategies. London: Sage 3

4 Has it been used by others for similar purposes? Are there any published studies that use the theory for similar purposes? Is it consistent with the values integral to the work? For example, if you are planning or commissioning a programme to reduce obesity and promote healthy eating, here are some of the theories you might find valuable: The stages of change model would assess the readiness of the community to change Learning theory, diffusion of innovations theory and communication theory would inform behavioural interventions to help people to make healthy food choices Community development theory would help in enabling the community to address barriers to having a healthy diet (for example through setting up a food co-operative) Policy theory would help with how to influence political processes (e.g. getting the council to set aside land for allotments). 5. What are the main theories in health promotion? 4 No single theory dominates health promotion. One of its strengths is that it draws from a wide range of disciplines, such as sociology, psychology, economics, geography and biology. Adequately addressing a health problem will probably require more than one theory. In addition to preventing disease, health promotion aims to be salutogenic, that is health producing. Salutogenic research asks why some people remain healthy, and links this to strengthening people s sense of coherence, rather than blaming the victims who fall sick. In the workplace, for example, people s sense of coherence will be enhanced if their work is meaningful, not over-stressful, and fosters a sense of autonomy and participation. People who stay healthy tend to have good relationships with family, friends and wider networks. There are two main types of health promotion theory that are of value in planning and commissioning programmes and interventions: explanatory theory and change theory. 5.1 Explanatory theory Explanatory theory describes the reasons why a problem exists, e.g. why young people take up smoking. It will help to ensure that all relevant factors are identified, such as the personal, environmental, social and behavioural determinants of the problem. Examples of explanatory theories that explain behaviour change in individuals include: The Health Belief Model o This is one of the oldest theories, developed by Becker in the 1970s. It suggests that behaviour change is a result of a rational process in which decisions are based on beliefs about a health action, its benefits and costs. Theories of reasoned action and planned behaviour o Developed in the 1980s by Ajzen and Fishbein and others, these theories focus on people s intentions to change their attitudes, beliefs and sense of control 4 This section is adapted from: Wills, J. and Earle, S. (2007), Theoretical perspectives on promoting public health. IN: Earle, S., Lloyd, C.E., Sidell, M., Spurr, S. Theory and research in promoting public health. Sage publications in association with the Open University. 4

5 over their lives. They highlight the need to understand a person s beliefs about a health issue, such as smoking, and are concerned with the influence of significant others such as family, friends, peers and celebrities. The Stages of Change Model o Developed in the 1980s by Prochaska and DiClemente and others, this model identifies five stages of change in behaviour: pre-contemplation, contemplation, preparation, action and maintenance. It can be used to tailor interventions to the stage people have reached in the change process, for example an individual who wants to lose weight. The Health Action Model o Developed by Tones, the Health Action Model takes account of beliefs, normative influences and motivating factors, including attitudes, along with other strong motivating forces, such as hunger, pain, pleasure and sex, in order to understand behaviour. Identity and self-esteem are also important mediating factors. The model emphasises the need for facilitating factors, such as a supportive environment or the possession of personal skills, to support the translation of behavioural intention into action. o The model illustrates that people s health behaviour is dependent, to a large extent, on the conditions of their lives, which for many are beyond their control. For example, people on low incomes and who feel socially excluded are most likely to smoke. 5.2 Communities Because health is influenced by so many factors, and in part determined by external conditions (social, economic and environmental), many projects and programmes focus on change at the community or system level. Health promotion has a strong emphasis on community development and engagement. 5 Community development itself draws on several important theories concerned with the building of groups, inter-sectoral collaboration and organisational change. To understand a community, we need to know about the motivation and capacity to respond of families, social networks, local organisations etc. Health promotion works by strengthening this capacity, by being an empowering influence. 5.3 Change theory Change theory guides the development of interventions and assists evaluation. Examples of change theories include community organisation and diffusion of innovations. The diffusion of innovations theory (developed initially by Rogers and Shoemaker in the 1970s as communication of innovations theory) helps to explain the spread and adoption of new ideas within a community: Innovators and early adopters are few in number and may be from higher socioeconomic groups Then the early majority, for whom the utility of the change must be clear 5 See the leaflet Specialised health promotion: You can t be the best without it! from the Shaping the Future Collaboration. 5

6 Then the late majority, who tend to gain information from those around them Then the laggards, who tend to be more isolated and thus traditional in behaviour Change theory also highlights the importance of: Opinion leaders, change agents and champions in the communications process and in stimulating change Peers, rather than experts, as change agents Understanding the nature of social systems, leadership and the role of change agents allows interventions to be targeted appropriately, and therefore makes them more effective. 5.4 Context and complexity For most health promotion interventions the relationship between input and outcomes is complex. The use of theory helps to unpick the complexity. The notion of realistic evaluation (developed by Pawson and Tilley) also draws attention to the importance of understanding contextual factors and the mechanisms by which interventions work. Pawson argues that programmes do not work directly in themselves, but bring resources that allow people to generate change. The extent to which change is triggered (e.g. in a school, community or workplace) will be heavily influenced by the context. This is particularly important for multi-faceted interventions. So we need to know not just does it work, but: How does it work? What components are necessary to success? Why does it work or not work in this context? 6. The importance of evaluation Empirical evidence and theory are not alternatives, but are inextricably linked. Research evidence about the effectiveness of interventions should contribute to the development of intervention theory, which will itself shape subsequent interventions and the way in which they are evaluated. For practitioners and policy-makers seeking to replicate achievements, the process of programme delivery and the identification of factors critical to success are as important if not more so than the outcomes of the intervention, but are often not included in evaluation reports. As a result, there is a dearth of published information to guide practitioners and decision-makers regarding the practical aspects of programme adoption and replication. We hope you will be able to contribute to a continuous cycle in which theory is used to direct practice, and exposed to the scrutiny of practitioners to assess its value in practice in different contexts. 7. Sources and further information Green, J. (2000). The role of theory in evidence-based health promotion practice. Health Education Research, Oxford University Press. Nutbeam, D. and Harris, E. (1998). Theory in a Nutshell. National Centre for Health Promotion, Sydney. Tones, K. and Green, J (2004). Health Promotion Planning and Strategies. London: Sage US National Cancer Institute (2005). Theory at a Glance: A Guide for Health Promotion Practice (second edition). U.S. Department of Health and Human Services, National Institutes of Health. Wills, J. and Earle, S. (2007), Theoretical perspectives on promoting public health. IN: Earle, S., Lloyd, C.E., Sidell, M., Spurr, S. Theory and research in promoting public health. Sage publications in association with the Open University. 6

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