University of Applied Sciences , Utrecht, The Netherlands
Many common health problems are influenced by the lifestyle and (health) behavior of people. If we are able to change an unfavorable lifestyle and behavior in a favorable direction, then health problems can be prevented or restricted. When lifestyle or health behavior has changed in a positive direction, people can become healthier. We call this changing of lifestyle and behavior of people health promotion. Health promotion can be achieved through health education. Motivating people to change their behavior is a major task according to nursing professionals themselves, and they state that they spend a lot of time on this (Sassen et al. 2011).
This chapter provides an insight into how nursing professionals can develop health interventions and implement these health interventions, using health promotion and health education. In Sect. 4.1 we describe the difference between intentional health education and facilitating health education. Health education has a clear system, targeting, and efficiency plan, which we will describe in Sect. 4.2. The protocol of intervention mapping (IM) is explained extensively in Sect. 4.3, because this is currently the most frequently used planning model for developing health promotion and health education interventions. Using intervention mapping creates interventions that have been shown to be efficient at achieving the goals of changing lifestyle and (health) behavior.
4.1 Health Promotion and Health Education: What Is the Difference?
Health promotion and health education both aim to change unfavorable (health) behavior, in favor of the health of a person, to change a lifestyle that has a negative effect and harms health.
Health promotion comprises health education, in addition to (healthcare) facilities, laws, and regulations.
By using health promotion, health is stimulated in a positive way and negative influences on health are limited as far as possible. Health promotion and health education are both aimed at changing health-impairing behavior. Health promotion is the overarching concept and includes health education. In support of health education, we offer (health care) facilities, laws and regulations, used with the goal achieving a better effect (Kok 1993).
Health promotion is aimed at motivating people toward different, healthier behavior and changing their unfavorable lifestyles. Offering (health care) facilities and/or laws or regulations may support people, so that they are better able to achieve healthier behavior and change their lifestyle. The core of health promotion is offering health education. Health promotion is the broad, overarching concept including health education; both assume a lifestyle-oriented approach to health. In addition to this lifestyle-oriented approach, health promotion can take an environmentally oriented approach (Fig. 4.1).
Relationship between health promotion and health education
Health education, the systematic and methodical attempts to change lifestyle and (health) behavior of people, by motivating them toward, healthier behavior. These targeted changes in knowledge, attitudes, skills, and behaviors are in the interests of the person and eventually lead to an improvement in health.
Therefore, the aim of health education is that a person becomes motivated to change to healthier behavior, thus improving his health status.
What is health education? Health education can be defined as the systematic and methodical attempts to change the lifestyle and (health) behavior of people, by motivating them toward healthier behavior. These targeted changes in knowledge, attitudes, skills, and behaviors are in the interests of the person and eventually lead to an improvement in health.
Health education is used as an instrument of health promotion. Health education is specifically aimed at people’s behavior and at the health determinants lifestyle and behavior. Health education is always concerned with providing education on health to individuals or groups. Health education is useful for addressing or even “tackling” health problems. Health education includes all efforts to change people’s behavior that affects their health, by motivating them to different, healthier behavior (Kok et al. 1997). The characteristic of health education is in the statement that it is concerned with motivating people toward healthier behavior (Kok et al. 1997). According to Damoiseaux (1991), health education covers a broad range of health education interventions, it has many goals, focuses on different target populations, and is carried out on different levels; health education is a tool in health care. A characteristic of health education is that there is a systematic approach, a clear cooperation with the target group, and that there should always be careful consideration of the desired behavior that takes place (de Saan and de Haes 1993).
Motivating people to behave in a healthier way seems easier than it is. This is because people do not associate health problems with themselves, think that it will not happen to them, or that it is a problem for the long term. They think that they do not behave in a risky manner, they are not convinced of the benefits of healthier behavior, or they do not experience support from others. If people want to change, then they often do not know how to deal with problems that they may encounter. All this ensures that in such cases, people are not motivated to change (De Vries 1999).
Thus, health education is purposeful in motivating a person to undertake healthier behavior so that they develop a more favorable, healthier lifestyle. Nursing professionals want to promote people’s health and prevent or limit damage to health.
4.2 Intentional Health Education and Facilitating Health Education
Basic forms of health education:
In intentional health education, the goal is to change unfavorable, health-impairing behavior into a lifestyle that supports health.
In facilitating health education, the goal is knowledge transfer.
Nursing professionals should focus on intentional health education.
When do we call health education real health education? There are two basic forms, intentional health education and facilitating health education. The starting point for both is the importance of the recipient of the education.
What is intentional health education? By using intentional health education, an attempt is made to change the lifestyle of a person in a favorable direction. The assumption is that it is better for a person to behave in a healthier manner. The purpose of intentional education is to change unfavorably, health-impairing behavior into a lifestyle that supports health. Therefore, it is important, from the view of nursing professionals, to change behavior that has or can have an adverse effect on health.
A nursing professional uses intentional health education to ensure a conscious change in the knowledge, attitude, and behavior of a person. This from an evidence-based perspective that such changes can improve the health status. Although the person himself may not have a clear need, it is always his own choice whether he wants to change his lifestyle or (health) behavior. Patients cannot be obliged to change the way they handle their health. For example, a person cannot be obliged to take note of the advantages and disadvantages of physical activity, to develop a positive attitude toward physical activity, and to actually start moving. The obligation is not even there when the patient has a serious health problem, such as cardiovascular diseases or diabetes.
What is facilitating health education? The second fundamental form of health education is facilitating health education. The purpose is knowledge transfer, and to inform the person. The scope of this goal is limited, because it is only about providing information. Facilitating health education is about all sorts of facts around a health problem. Facilitation education meets a number of conditions. First, the information is provided without obligation; this means that a patient can choose if he wants to receive the information. Second, the information is correct and objectively formulated; the patient can build on it. Last, the information is based on the expected need of the patient to be informed. For example, the need for information on fever in children, or on regulating blood glucose levels for diabetics. With facilitating health promotion, an explanation can be given (for example, on the different activities of youth health care), a statement can be given (for example, about the importance of using folic acid before and during pregnancy), and/or a clarification can be given (for example, on the action of insulin in the body).
Facilitating health education can be offered in the form of a folder, brochure, website or app. Although facilitating education is also used to inform the patient about the importance of changing lifestyle factors and behavior, it is rarely an effective way to achieve this goal. Informing a patient leads only to a better informed patient; it does not lead to a change in lifestyle or (health) behavior. For example, when a patient with multiple risk factors for cardiovascular diseases and type 2 diabetes receives a booklet from a nursing professional containing background information on high blood pressure, high cholesterol levels, and obesity, this can lead to an increase in knowledge. If the booklet also informs the patient about the beneficial effect that an improvement in physical activity may have, nursing professionals should not expect the patient to change his lifestyle and start moving. Patients do not change their (motion) lifestyle or behavior because they are better informed. More knowledge rarely leads to healthier behavior.
What does this mean for you as a nursing professional? Within the nursing profession and practice, the focus is on intentional health education. Nursing professionals motivate their patients to change their health-impairing behavior, focusing on optimizing patients’ behavior, so that the health status may improve. Nursing professionals also use facilitating education. Facilitating health education is, for example, useful for informing patients on all issues associated with a hospital stay. Providing information, with the aim of increasing knowledge, takes place frequently, but is insufficient for behavior change without intentional education. Facilitating education within the nursing profession should only be used in support of intentional health education. Intentional health education should be used when the aim is to change lifestyle and (health) behavior.
4.3 Intervention Mapping: Planning Model Intentional Health Education
Intervention mapping is a protocol for incrementally developing and implementing a health education intervention.
Intervention mapping offers a framework for developing an intervention (Bartholomew et al. 2011, 2016; Kok et al. 2004; Schaalma et al. 2009). Intervention mapping is a protocol for incremental intervention development based on evidence (for nursing professionals) from a literature search: a health education intervention will be developed.
Intervention mapping starts by assessing a specific health problem (see step 1 in Fig. 4.2). You look at the causes of the health problem, and you look at distinguishing risk groups and risk behaviors. In step 2, you define goals, and you specify in this step what changes are necessary to achieve these goals. In step 3, you select proven effective intervention methods that can put changes in motion (in knowledge, attitudes, skills, and behavior). In step 4, you design the health intervention by combining the selected intervention methods and test your intervention as well. In step 5, you will develop an adoption and implementation plan for the intervention. Finally, you develop an evaluation plan in step 6. The evaluation is aimed at assessing both the effectiveness of the intervention and the entire process that has preceded it.
Intervention mapping protocol: design, implementation, and evaluation of a health education intervention
Intervention mapping has been shown to be an effective protocol for developing health-based interventions and then running it on the basis of the implementation plan (Bartholomew et al. 2011; Sassen et al. 2012; Alewijnse et al. 2002; Heinen et al. 2006; Wolfers et al. 2007). Intervention mapping is not a new theory or a new model, but a tool for the planning and development of a health intervention. Intervention mapping is a tool that allows you to develop a health intervention in a systematic way. By using Intervention Mapping, you apply theories and the results of earlier research (Kok et al. 2004). By applying the protocol of Intervention Mapping you work based on evidence.
The steps of Intervention Mapping:
“… provide a guide in intervention planning … to travel a common path from start to finish” … “It maps the path from recognition of a need or problem to the identification of a solution.” (Bartholomew et al. 2000)
The PRECEED–PROCEED model (Green and Kreuter 2005) is a precursor of intervention mapping. The PRECEED–PROCEED model and intervention mapping have a number of important overlaps and complement each other. Both the PRECEED–PROCEED model and the intervention mapping protocol are based on an efficiency plan being key to the success of effective health promotion and health education interventions. Both start from an analysis of a health problem and try to solve the health problem, as far as this is possible. Intervention mapping is, according to Kok et al. (2001), a process, and the concretizing of a health intervention is done by regularly going back to a previous step, because new insights have emerged from that previous step, and from that step one can go further with the protocol.
4.4 Conditions and Principles of Intervention Mapping
What is the starting point of intervention mapping? The starting point is that those who develop the intervention work together with the people who will receive and are going to use the health intervention. Bartholomew et al. (2000, 2011) call this the perspective on participation in planning. By letting people participate in the development of the health-based intervention, this increases the chance of connecting with the target audience. The intervention will be developed together with the target group, because the people in the target group know best what would fit them. The target group consists of the people with a specific health problem, in addition to the nursing or health professionals who are going to use the health intervention in a specific health care setting.
What is done in advance to intervention development? Before starting to build a health intervention, there should be a comprehensive analysis. We call this the needs assessment or the analysis of the health problem. In the needs assessment, we want to gain more of an insight into the health problem. Insight into the health problem can be obtained by the collection of data, data on the quality of life, and on epidemiological health indicators. We start from a major health problem and analyze behavioral and environmental factors related to that health problem. We explore in the needs assessment the influence that (health) behavior and social–cognitive determinants have on the health problem. We want to know the impact of lifestyle on health, and especially if behavior can be targeted to promote healthier behavior. Also, we explore in the needs assessment the influence of the environment on the health problem. We want to know the impact of the environment on health, and if the environment can be targeted at promoting healthier behavior.
In short, in the needs assessment, we collect data around the health problem, in a deductive mode. If there are not enough data available or if data are insufficiently worked out, one should not start with intervention mapping:
“the most common mistake in health education, implying poorly planned work; and, we do not need to have illusions about the results of the health education” (Kok et al. 2000).
The further description of intervention mapping assumes that nursing professionals themselves develop (parts of) the health education intervention, and that they implement and evaluate the intervention. In the steps of developing the health education intervention, it is recommended that the available research results that have been described in the literature are used. Intervention mapping should always be based on evidence from other research. To work based on evidence, do a literature search in for example PubMed, using the search terms “intervention mapping” AND “specific health problem.”
4.5 Intervention Mapping Step 1: Needs Assessment
How are you going to get started in step 1 of intervention mapping? Step 1 of intervention mapping is going to answer the questions: what is the health problem? What is the influence of the health problem on the quality of life? What is the relationship between the health problem and (health) behavior? What is the relationship between the health problem and the environment? What are the social–cognitive determinants that determine the intention and that (health) behavior can be detected? Intervention mapping step 1 is called the needs assessment.
In intervention mapping step 1, we explore whether health promotion or health education can contribute to the solution of the health problem. In this step, we first want to understand the health problem. We start from a health problem that is important in some way, for example, because the health problem is common, because it has an adverse effect on the quality of life, or because many nursing professionals see patients with this health problem. By analyzing the health problem, we obtain a numerical insight into the health problem. Because of this, we know if the health problem should be a priority and which patient (and group) needs special attention.
In intervention mapping step 1, the analysis of the health problem, there are two possible pitfalls (Kok et al. 2001). The main pitfall is that of a non-existent problem. No development of an intervention should take place for a problem that on closer inspection does not exist or hardly exists. An example is: should drinking alcohol be discouraged during pregnancy? Is it a real problem, or do most women not consume much alcohol during pregnancy? Look at the severity and scope of the health problem and work on it as if the health problem really exists. A second pitfall is that there is no relationship between the health problem and the behavior of those involved. Attention should be paid to the relationship between the health problem and the recommended behavior. If behavior is not an issue, then another approach is more obvious and one stops using intervention mapping.
Step 1 can be divided into four sub-steps, which we discuss successively.
Step 1 intervention mapping. What is the health problem? What is the influence of the health problem on the quality of life? Perform an analysis of the health problem based on health indicators. Step 1.1 of intervention mapping (Fig. 4.3) answers the following questions: what is the health problem? What is the influence of the health problem on the quality of life? an analysis of the health problem can only be carried out by using health indicators.
Intervention mapping step 1.1: needs assessment, analysis of the health problem
The starting point of the needs assessment is a health problem, but it may also be a specific group of people, for example, if we see that the quality of life is negatively evaluated by a specific group of people. If we start from a specific group we come through a small detour to the health problem that is a major cause of reduced quality of life.
What is the health problem? Start with analyzing the health problem based on health indicators. How do you get started? What is the health problem? You start by analyzing the health problem based on health indicators and defines the importance of this health issue. To indicate the impact of a health problem on the health of humans, you make use of the health indicators from the epidemiology (see Sect. 2.1 for a detailed description of health indicators). By using health indicators, you gain an insight into the size and distribution of a health problem. The size of a health problem indicates the frequency in which the health problem occurs; this requires knowledge about the incidence and prevalence of the health problem. The distribution gives the breakdown of the health problem about times, places, and people.
By using health indicators, you also look at the severity of a health problem. The severity indicates the impact of a health problem on the quality of life. Is it as a serious health problem experienced by people who have that health problem? Judge people who have that health problem, their health is worse compared with people without that health problem?
By using health indicators, you attain numerical insight into the health problem: life expectancy, number of years of life lost, possible multi-morbidity, health differences, and perceived health. Disease or morbidity is an important health indicator, in addition to the number of people who die, or mortality. When the health problem is analyzed and the health indicators are described, what do you do next? If you have an overview of the health problem based on health indicators, you go more in-depth to look at the ways in which people experience this health problem; thus, the (subjective) assessment of the health problem. How do people experience their health problem? With what eyes do they look at their health problem? For example, it might be important for nursing professionals to gain a more profound insight into how people who use daily painkillers experience their health. What would help these people to solve the problems they encounter? Another example: what is the quality of life like perceived by elderly people with depression and what solutions to their loneliness do they see themselves?
Step 1.2 of intervention mapping (Fig. 4.4) provides an insight into the relationship between the health problem and (health) behavior. What is the relationship between the health problem and (health) behavior? For most health problems, (health) behavior has an important influence. Usually, not only one behavior plays a role, but the health problem is determined by a number of behaviors. Health behaviors can be divided into health-impairing behavior and health-enhancing behavior. Health-impairing behavior has a negative effect on health (status) or has the result that a person is exposed to a health problem. Examples of health-impairing behavior are too high a level of fat consumption, or using medication not according to the prescription, but to suit your way of living. Health-enhancing behavior leads to health benefits or protects the patient against the emergence or worsening of health problems. Examples of health-enhancing behavior are being physically active or maintaining the balance between activity and rest/sleep. In health education and in promoting patient self-management, the emphasis should be on limiting health-impairing behavior and promoting health-enhancing behavior. Thus, attention should be focused on promoting a lifestyle and (health)behavior that is desired for dealing with the health problem.
Intervention mapping step 1.2: what is the relationship between the health problem and (health) behavior?
Behavioral analysis, in the inventory of the (health) behaviors that cause and aggravate a health problem. The goal is to identify (health-impairing or health-enhancing) behaviors that are related to the health problem
Environmental analysis, in the inventory of the environmental factors that cause and aggravate a health problem. The goal is to identify the relevant environmental factors that are related to the health problem
The purpose of the behavior analysis in step 1.2 of intervention mapping is to identify the relevant behaviors that are related to the health problem. If you want to motivate a patient toward different, healthier behavior and to improve patient self-management, it is important for you to understand the behaviors associated with a specific health problem. In the behavior analysis, you look at the (health) behaviors that cause and aggravate the health problem. Which health behaviors are associated with the corresponding health problem? Which health behaviors are important? Which health behaviors are specifically relevant to nursing? From the behavior analysis, it must be shown that there is a relationship between the health problem and the behavior. In addition to the influence of lifestyle and behavior on the health problem, it is important to identify the relationship with the environment.
Step 1.3 of intervention mapping (Fig. 4.5) gives an inventory of the environmental factors that cause and aggravate a health problem. The purpose of the environmental analysis is to analyze the relevant environmental factors that are related to the health problem. The environment in which we live also affects the health problem. An example of an environmental analysis is the analysis of an environment that can promote or hinder movement behavior. The questions to be answered are: what environmental factors are associated with the corresponding health problem? What environmental factors are important? What environmental factors are specifically relevant to nursing professionals? What environmental factors are under the influence of nursing professionals?
Intervention mapping step 1.3: what is the relationship between the health problem and the environment?
The environmental analysis can take place at various levels, such as at the level of a city or neighborhood. You can also visit the surroundings with a multi-structural viewpoint, such as looking at the physical environment or the socio-economic status of people. The Health Concept Lalonde ( Sect. 2.1 ), offers nursing professionals clear handles for analyzing the influence of the determinants of lifestyle and behavior and environment on the health problem. From this health concept, it is also shown that behavior and environment have a mutual effect on each other. For example, a patient with diabetes may make less healthy food choices because of the food available in the company restaurant or nearest supermarket. As a healthy food choice is easier and within reach, and if the environment provides opportunities to be physically active, this may make behavior change easier. Making changes in the physical and social environment is easier than to teach people to cope with the obstacles in their environment. The environment can invite people to eat more healthily by limiting advertisements for unhealthy foods in the media, from fast food chains around schools and hospitals, and by increasing the availability of foods with low energy values. An environment can be shaped to encourage moving behavior. The environmental analysis is about detecting conditions so that people can live healthily, conditions under which people can live healthily in line with the health policy of their Government. Health policy is integrated policy, involving different areas. For example, sports and movement, or traffic and spatial planning.
Example: assessment of a health problem
The most influential environmental factors are sports, playing facilities, and physical education. According to de Bourdeaudehuij and Rzewnicki (2001), the most influential environment variable for increasing the moving behavior of children and young people, is the availability of sports and playing facilities. Mandatory physical education classes form a second important environmental factor. Adults walk more if the environment is perceived as pleasant and women walk more if they have a pet. Children who live in neighborhoods with a lower socio-economic status, despite an increased risk of accidents and injury, are more likely to be physically active outside playing. Boys turn out to be physically more active outside if there is someone monitoring them, whereas girls are more active indoors without someone monitoring them (Baranowski et al. 2003).
Urinary incontinence is a health problem of which there are three types. People can suffer from stress incontinence of the bladder wall, of overstimulation, or a combination of both forms. Which health indicators play a role? This involuntary urine leakage is a common complaint, about 25% in men and 75% in women. The prevalence is about 25–30% of the group in relatively younger women.
What behaviors play a role? PFME therapy has been shown to be effective in women with stress incontinence or for women with the combined form of incontinence. Right after the therapy, approximately 70% is restored or improved dramatically, but this conversion rate is declining over time because of the relapse into the old, unwanted behavior. After a year the patient compliance is about 50% and after 5 years’ follow-up around 40%, whereas in the meantime, the symptoms of incontinence had returned or increased in severity.
4.6 Intervention Mapping Step 1: Analysis of Lifestyle and Behavior
Determinants of behavior, or social–cognitive determinants, the determining factors of (health) behavior.
The underlying reasons why people behave in a certain way.
Health behavior is complex behavior:
multiple (health) behaviors can play a role in one health problem;
awareness of the risk;
(health) behavior may be divided into part behaviors.
Social–cognitive determinants are the determining factors of behavior. Social–cognitive determinants are factors that make people behave in a certain way; thus, these are the underlying reasons why people undertake certain behavior. If you behave in a certain way, you do not always think about the underlying reasons, of course. For example, a patient with cardiovascular risk factors who does sports does not think constantly about why it is so important to get more exercise. However, most people are able to describe the reasons for their movement behavior if specifically asked. We call this reasoned behavior.
The behavior that has emerged from the behavior analysis as being important is crucial. Social–cognitive determinants have a clear relationship with the health problem in the sense that they contribute to the creation and maintenance of the problem.
By analyzing the (health) behavior that underlies the health problem, it is important to wonder whether people know that they are behaving healthy or that they are performing unhealthy behavior. It turns out that sometimes people have a false picture of their health behavior, especially when the behavior is complicated or not clearly visible. For example: whether someone does sport is clear, but whether anyone eats too much saturated fat is much more difficult to fix. A person may not know this for himself and the health advice “eat less saturated fat” can be more difficult to make concrete. It is possible that people are not aware of the risky behavior. Often, multiple behaviors play a role in a particular health problem. For example, in the case of cardiovascular diseases and risk factors for cardiovascular health problems, movement behavior plays a role, but so do the intake of medications and dietary behavior. These multiple behaviors may complicate the underlying reasons why people behave in a certain way. In addition to not knowing if you are behaving in a risky way and the complexity of several lifestyle factors that play a role in one health problem, there is a third factor that makes health behavior more complex. Certain behavior may be divided into part behaviors. For example, movement behavior can involve sport activities or consist of moving at work (taking the stairs) or at home (gardening). To understand the reasons why patients behave in a certain way, you should have a clear view of the specific elements of the behavior.
Behaviors are often intertwined and not easy to separate from other behaviors. Behavior is determined by a complicated interplay of factors and changing lifestyle factors and behavior is not easy. People often want to behave differently, in a healthier way, but experience all kinds of obstacles to change. Barriers can include, for example, a lack of willpower. However, experiencing pleasure because of the unhealthy behavior is a barrier to behavior change. A significant factor is the influence of other people around you. Fortunately, it is possible to untangle the interlocking aspects of (health) behavior.
Damoiseaux et al. (1993) expresses clearly that to be able to influence (health) behavior, it is necessary to know what is hidden behind certain behaviors that promote or threaten health. With health promotion and health education, we want to motivate people toward other, healthier behavior. The social–cognitive determinants are the targets for behavioral change. If we know the social–cognitive determinants and thus know what the underlying reasons for the patient’s (health) behavior, we can start to develop an intervention (Fig. 4.6).
Intervention mapping step 1.4: which social–cognitive determinants determine intention and (health) behavior?
What is hidden behind certain behavior? Patients who do not visit the diabetes clinic differ from patients who do visit it. Patients who do not visit the diabetes clinic, experience more negative feelings. The diabetes patients who do not go for a consultation, have more difficulties with diabetes care and treatment. They experience less control over the health problem and have less confidence in the effectiveness of the treatment. They also experience more side effects and have a more pessimistic view of the future.
In step 1.4 Intervention Mapping, you explore the role that (health) behaviors play in the health problem; you want to know what influence lifestyle and behavior has on health.
4.6.1 Explaining (Health) Behavior
The Theory of Planned Behavior is a model to explain (health) behavior and to obtain a clear view of the social–cognitive determinants that affect and explain people’s intention and behavior. With this model, we can explain the background of wanted and unwanted (health) behavior. What factors reward unwanted behavior? What factors hinder the desired behavior? The Theory of Planned Behavior arose from the Reasoned Action Approach Model (Fishbein and Ajzen 1975, 2010; Ajzen 1988; Bandura 1986). The Theory of Planned Behavior shows the underlying reasons why people behave in a certain way and is useful for identifying the social–cognitive determinants.
The starting point for the Theory of Planned Behavior is that people can indicate reasons why they behave in a certain way. It is not that those reasons “spin through the head” of a patient constantly when, for example, moving, taking medication or eating snacks. But if asked, the person can describe the reasons for his (healthy) behavior. The reasoning might be: “if I use less medication/eat snacks/have unsafe sex – I feel less sick/I am better able to concentrate/I am more relaxed. This is more important to me than damage to my health.” The reasons for a specific behavior may differ per person, but are often the same for people with a specific health problem. For example, patients with cardiovascular risk factors have overall the same reasons to increase movement. The same is seen in patients who personalize their medication regime although there is a health problem, or people who often eat snack food, or people who do not always have safe sex. Sometimes people are not convinced of the advantages of the behavior. An intervention should stress the benefits of the desired behavior.
The Theory of Planned Behavior (or TPB model):
“Teaches you to see where the bottlenecks to change exactly are at a certain target group. Sometimes a target is not convinced of the advantages of the behavior. … An intervention should need to stress the benefits of the desired behavior. Sometimes people do not know how they should deal with issues that they may encounter if they want to exhibit the new behavior. The intervention will have to address how you can solve these problems. Social–cognitive determinants need to get attention in an intervention” (De Vries 1999).
In Intervention Mapping step 1, the analysis of lifestyle and behavior, there is a possible pitfall (Kok et al. 2001). The pitfall that needs to be figured out is that an incorrect assessment is made of the reasons for behavior. It comes to the question of whether the real reasons why people exhibit certain behaviors are detected. For example, if women do not use folic acid before and during early pregnancy, is this due to a lack of knowledge or is it laziness?
The TPB model is shown in Fig. 4.7. The left side of the TPB model shows the external variables. External or background variables have indirect influences on people’s behavior. This influence comes through the attitudes of the social–cognitive determinants, subjective norms or social influence, and perceived behavior control or self-efficacy. External variables are individual, social or education-focused. Examples of individual external variables are personality, mood and emotion, risk perception, and earlier behavior. However, individual external variables are also endogenous determinants associated with the health problem. Examples of external variables are education, age and gender, religion, and culture. Examples of education-targeted external variables are knowledge and the availability of social media.
Theory of Planned Behavior model: social–cognitive determinants of intention and (health) behavior
The best way to understand the Theory of Planned Behavior, is if we look at the TPB model from the right to the left. We start to look at the social–cognitive determinant behavior in the TPB model. We depart from the desired behavior and want to figure out what reasons people have for exhibiting certain behavior. This can include all sorts of behaviors or lifestyle, that have a relationship with health or nothing at all to do with health. People have expectations of certain behavior, they have all kinds of thoughts, ideas, and considerations on how to perform certain behaviors that may be different for each behavior. People may even have very different expectations of similar behavior. They can have conscious and deliberate reasons for behaving in a certain way. It is also possible that there is unconscious and little elaborate “reason” for the behavior. The extremes are on the one hand to make informed, reasoned decisions and to behave accordingly, and on the other hand, routine behavior. All kinds of transitional forms are possible. The degree to which a patient behaves consciously, making reasoned choices for desired behavior, can differ from person to person.
4.6.2 Theory of Planned Behavior: Behavior and Intention
Desired behavior: figuring out what reasons people have for performing or not performing certain (health) behavior.
Intention: planning or not planning to perform certain (health) behavior.
People often have good plans for starting to behave in a healthier way.
Converting a positive intention into the desired behavior is usually not easy.
According to the TPB model, the best way to predict behavior is to look at their intention. The intention is the planning of a certain behavior. For example, a patient with cardiovascular risk factors is planning to move every day. Or, a diabetes patient is going to stick to his diet, check his blood sugars regularly and take his medication. According to the TPB model, the intention is the person planning to perform the behavior. The intention of a person can be identified by asking: do you intend to …. (the desired behavior)? It is likely that you … (the desired behavior)? For example, do you plan to exercise for 30 min every day? Is it likely that you will move 30 min every day? You ask people what the chance is that they will exhibit the desired behavior within a certain period of time, and whether they think the implementation of the desired behavior will succeed (Godin 1993). People’s intentions can be different, even for related behaviors. For example, there is a difference in intention to brush teeth and to floss teeth. The intention to brush teeth is usually more positive than that to floss teeth (Tedesco et al. 1991). People’s intentions can change through the influence of behavior. For example, the intention to participate in mammography decreases as the number of breast examinations to which the patient has already been subjected increases.
4.6.3 Theory of Planned Behavior: Barriers
People often have good intentions, good plans to behave differently, and in a healthier way. However, converting a positive intention and putting desired behavior into practice is no easy matter. The relationship between intention and eventually performing the behavior or not may be disrupted by barriers (Fig. 4.8).
Theory of Planned Behavior model: social–cognitive determinants intention, barriers, behavior
Barriers dissuade people and a person is not capable of concerting his intention into actual behavior. Barriers disrupt the relationship between the intention and the behavior of a person. A person is planning to perform the desired behavior and has a positive intention. But this person does not perform the desired behavior, because he experiences barriers. For example, patients with cardiovascular risk factors have positive intentions when it comes to moving, but when putting the plan into action they experience barriers. For example, a barrier is that moving takes up a lot of time. This means that they are not going to move on a daily basis. Or patients who are using anti-diuretics have a positive intention to take their daily medication, but the frequent need to go to the toilet is seen as a barrier, and they match their medication intake to their stay outdoors.
Converting the positive intention into the desired behavior can therefore be hampered by barriers. A person with a positive intention can plan the desired behavior to go out, but barriers can throw a spanner in the works and the person will not perform the behavior. Common barriers that people encounter are time constraints, conditions, and external circumstances that obstruct them from performing the behavior. First, a barrier may ensure that a positive intention changes over time into a negative intention. For example, a nursing professional makes an arrangement with the patient that if he is properly established on his insulin scheme, he will check his own blood sugar levels regularly when he is at home again. The patient has a positive intention, but over time back at home it turns out to be more complicated than the patient expected it to be and the intention is less positive or even negative. Second, certain conditions have been shown to be a barrier and obstruct the planned behavior. For example, the patient wants to stick to his diet, but an important condition is that his partner experiences the food they eat as tasty as well. If this is not the case, a person may adapt his intention in a negative way. Third, external circumstances may arise over which a person has no control and that stand in the way of behavioral change. For example, the patient with varying blood sugar levels should move more, and intends to do this when accompanied by a friend; if the friend is not able to attend or stops the movement behavior, the patient also stops. Barriers can obstruct the relationship between the intention and the desired behavior considerably.
4.6.4 Theory of Planned Behavior: Attitudes
In the TPB model, the intention as the predictor of behavior is affected by three social–cognitive determinants. The intention is formed by the combination of (1) attitudes, (2) the subjective norms or social influence, and (3) the perceived behavior control or self-efficacy (Fig. 4.9).
Theory of Planned Behavior model: social–cognitive determinants attitudes, subjective norms, and perceived behavioral control
Attitudes, the result of balancing the advantages and disadvantages that a person connects to the behavior.
Considerations for the desired behavior with the appreciation of whether this will be positive or negative affects the intention.
Knowledge plays a role in attitudes, but is not a social–cognitive determinant.
Attitudes are affectively “colored.”
Attitudes are the social–cognitive determinant that directly affects the intention of a person. Attitudes give insight into the pros and cons attached to the (health) behavior. People link certain advantages to the behavior and certain disadvantages to the behavior. They balance these advantages and disadvantages against each other as if on a scale, and the benefits can offset the disadvantages. The pros and cons are viewed mostly in the short term. Attitudes are formed based on considerations and appreciations.
People have certain considerations, reasons, for behaving in a certain way. Considerations are important for making a reasoned decision to perform certain behavior. These considerations reflect a person’s individual advantages and disadvantages. A consideration is: “the experienced probability that the behavior in question will have a particular result” (de Vries 2000).
An example of a consideration is that daily exercise is healthy. The person labels the consideration with a positive or negative rating. The consequences of the behavior are also given a rating. For example, I think it is important that I have a healthy, fit appearance. The attitude is the final result of the consideration of the pros and cons that are connected to the behavior for a person. The considerations for the desired behavior with the specific appreciation that this will be positive or negative affects the intention (Fig. 4.10).
Theory of Planned Behavior: social–cognitive determinants considerations and specific appreciations, attitudes, intentions
The attitudes of a person can be identified by asking: “regular exercise/three times a day brushing teeth/always having safe sex” results in my having less back-pain/not having bleeding gums/not getting HIV or a STD, and for me this is … very important/important/less important/unimportant”. But also: “if I don’t move/do not brush my teeth/do not have safe sex, I can just do what I feel like/can quickly get into bed or go to work/never have to talk about condom use, and this is for me … very important or very unimportant.”
What is the importance of knowledge in attitudes? Knowledge plays a role in the formation of the social–cognitive determinant attitudes, but is not a standalone social–cognitive determinant. The knowledge that a person has plays a role in the balancing of pros and cons, in the considerations, and the appreciations. Knowledge is just one of many factors that affect behavior. Knowledge about the considerations and consequences of certain behavior, has an important impact on the ultimate attitude. This is worded as follows: Knowledge can be a requirement for “doing,” but knowledge is rarely sufficient for people “to do” (Meertens et al. 2001).
As a rule, knowledge about the (health) risks related to behavior does not lead “spontaneously” to a change in (health) behavior. For example, although a patient with cardiovascular risk factors knows that more intensive exercise will probably have a positive effect on his blood pressure and blood cholesterol after talking with a nursing professional, he will most likely not pick up his sports bag and go to the gym the same evening.
What is the importance of affective reactions in attitudes? Apart from knowledge, the affective, emotional sensations play a role in attitudes. The attitudes might be associated with certain positive or negative emotions that arise in the implementation of behavior (Ajzen and Driver 1992). Attitudes have an affective coloring, coupled with the advantages and disadvantages, and specifically the consequences. For example, taking a brisk walk three times a day for half an hour has benefits for physical health, but can also be relaxing and can result in feelings of satisfaction. Another example, going to the gym can recall memories of the gym classes at school, with fewer positive emotions.
The attitudes described above are not to be translated into the definition of attitude within the nursing profession. According to the TPB model, attitudes are about balancing the pros and cons with regard to (health) behavior. Within professional nursing practice, attitude describes the nursing professional’s attitude toward patients and the care of patients in nursing.
Attitudes to moving behavior. Important attitudes are that moving improves fitness, improves energy levels, and increases muscle strength and muscle tone, yields social contacts, and improves mental health. It is not that people will become more physically active because they know that a lack of physical activity increases the risk of health problems (de Bourdeaudehuij and Rzewnicki 2001). For attitudes to movement, both active and inactive people think it is important to get more exercise, but above all, the active people experience movement as being more pleasurable (Jansen et al. 2002). Older people are more afraid of injuries and unpleasant sensations associated with movement (Resnick 2000).
Attitudes to brushing teeth are more positive than for flossing. For flossing, important attitudes are that flossing is healthy, useful, enjoyable, that it is rated as good preventive health behavior, that it removes dental plaque, and that it has a preventive effect on tooth loss (Tedesco et al. 1991).
Attitudes of women with regard to confidence in screening mammography is not only the experienced chance of having cancer and increasing concern about cancer, but also experiences with the use of other preventive screening activities, such as screening for cervical cancer and dental visits.
4.6.5 Theory of Planned Behavior: Subjective Norms or Social Influence
Subjective norms or social influence, the extent to which a person may or may not agree to the views of others.
Views of others around you, referent views.
Motivation to conform.
Social support and social pressure.
In addition to the social–cognitive determinant attitudes, the intention of a person is directly affected by the social–cognitive determinant subjective norms or social influence (Fig. 4.11).
Theory of Planned Behavior model: social–cognitive determinants subjective norms or social influence, intention
The social–cognitive determinant subjective norms or social influence is the extent to which a person agrees with the views of people from his social environment. This social–cognitive determinant is determined by the views of other people around you about a specific (health) behavior, and we call them referent beliefs. Intention may be influenced positively by these referent beliefs, or it may be attracted by these referent beliefs. This means that people comply with a referent to behave in a certain way, does not comply to a referent belief, or only partially comply to the referent belief. Referent beliefs are what anyone thinks that other people think. For example, “I think my partner and children belief that I must move more”. The motivation to conform is the readiness of a person to endorse or not to endorse the beliefs of others and act accordingly. An example of the corresponding motivation to comply is: “what my partner and children think about my movement behavior is important to me, because then they think I am energetic and fit”.
The groups to which a person belongs, or would like to belong, have an important influence on people’s behavior. In a group, people must comply with certain rules and people tend to adapt if they want to belong to that group. This is the social influence on people’s behavior, and this is what a patient experiences as consent or rejection of his (health) behavior. Social influence can be positive and we call this social support. Social influence can be negative and we call this social pressure. Social support includes providing information or providing emotional or material support. Social support is helpful for performing or learning certain behaviors. For example, a friend supports blood glucose checks and shows his interest with regard to injecting insulin. Another example is that the spouse reminds the patient to use his antidepressants to prevent a depressive episode in life. An example of social pressure is the negative social influence of drinking alcohol or smoking among young people.
In addition to influencing behavior in a particular direction, one can also put pressure on a person to prevent him from changing his (long-term) behavior. An example of this is the constant comments of the partner that popping too many pills is not good and that the patient’s manic behavior can be much better prevented by being “strong.”
The subjective norms or social influence can be mapped by asking: “Do most people who are important to you think that you should move more/ follow your diet/do your relaxation exercises?” This is followed by asking about the extent to which the person believes that others think that someone needs to move/follow a diet/do his relaxation exercises. Thus, asking about how often and with what intensity.
The subjective norms or social influence specific to movement behavior, inactive people experience the people in their environment as having an active lifestyle more often than active people. Active people find the people that surround them more often as less active (Jansen et al. 2002). For adults, the social support of their partner and family is important in doing physical activity under supervision. This support they think is more important than the support of friends or the support of the supervisor of the activity. Adults who have a fixed “buddy” and are physically active together with another person, are significantly more physically active than those who don’t (de Bourdeaudehuij and Rzewnicki 2001)
4.6.6 Theory of Planned Behavior: Perceived Behavioral Control and Self-Efficacy
Perceived behavior control and self-efficacy, the expectation that a person has of the feasibility of the behavior by:
Previous experience with the behavior;
Observation of the behavior of others;
Persuasion by others;
The third social–cognitive determinant that affects the intention of a person directly, in addition to attitudes and subjective norms or social influence, is the perceived behavioral control or self-efficacy (Fig. 4.12). The perceived behavioral control or self-efficacy is the estimate that a person makes of the feasibility of the behavior. This social–cognitive determinant revolves around the question: “do you think you can?” According to Bandura (1986), the self-efficacy determines the possibility of someone exhibiting behavior or not. Expectations about self-efficacy are influenced by previous experiences that are gained with that behavior. Also, expectations about self-efficacy can be created by the observation of the behavior of others. In addition to the observation of the behavior of others, expectations about self-efficacy can be created by persuasion by other people. Also, physiological limitations affect the expectations about one’s self-efficacy.
The practical skills needed to carry out the desired behavior, determines the assessment that a person makes of the feasibility of the behavior and are therefore important for the observed behavior control or self-efficacy. A person makes an estimation of the skills he needs for the behavior. If the person is going to perform or attempt to perform the behavior, he experiences whether he is actually in control. If the control is less than what is necessary to perform the behavior, then the person adjusts the perceived behavior control or self-efficacy. Skills play a role if the person attempts to perform the behavior. Just as barriers play a role in performing the desired behavior, so do the skills.
The perceived behavioral control or self-efficacy of a person can be identified by asking: “is the display of the desired behavior (more exercise, regulate blood glucose levels) extremely easy … easy … extremely difficult” and: “to be able to … (get more exercise, regulate blood glucose levels), I should learn to be able to …”
Is the TPB model often used? By using the TPB model a good insight can be obtained into the underlying reasons for people to behave in a certain way. This model is widely used to assess social–cognitive determinants and is currently the model most frequently used to determine social–cognitive determinants. This means that the model is commonly applied by others and that there are many examples accessible in the literature. Search in the literature with the search terms theory of planned behavior, self-efficacy, barriers, subjective norms, social–cognitive determinants, and combine this with the health problem you are interested in (Fig. 4.7).
Theory of Planned Behavior model: perceived behavioral control or self-efficacy, intention
Active people score higher on self-efficacy than inactive people (Jansen et al. 2002). According to de Bourdeaudehuij and Rzewnicki (2001), in many studies in adults it is shown that self-efficacy is the main social–cognitive determinant of physical activity. But: is a person more physically active because he has more confidence that he will be able to do so, or does a person have more confidence because he was physically active in the past?
In the case of physical activity, a person’s intention is more positive when experiencing control over the desired movement behavior. The greater the confidence of the person that he is able to be physically active and the greater the satisfaction about the extent to which he is physically active, the greater the participation in the exercise. Self-efficacy is an essential social–cognitive determinant for movement behavior.
4.7 Intervention Mapping Step 2: Defining Performance and Change Objectives
In step 2 of Intervention Mapping you start to give direction to solving the health problem of the patient (group). Step 2 of intervention mapping answers the questions: what is the overall purpose of the health education intervention? What are the performance objectives of the intervention, the behavioral goals of the intervention? What are the change objectives of the health education intervention? How can we change the social–cognitive determinants of intention and behavior? (Fig. 4.13).
Intervention mapping step 2: defining performance and changing objectives of the health education intervention
According to Green and Kreuter (2005), behaviors should be viewed to the extent to which they are important and whether they can be changed. Important behavior is behavior that shows higher numbers and for which the link with the health problem is clearly detectable. Less important is behavior that has lower numbers or that only has an indirect link to health problems. How changeable is the selected behavior? If behavior is still in development or newly formed (e.g., among young people), it is highly changeable. If the behavior is not deeply woven into habits, patterns, or lifestyles, there is also a high degree of changeability. The mutability is also high if the behavior is only superficially connected to certain patterns or lifestyles.